Substance Abuse Treatment:

Group Therapy

A Treatment 

Improvement 

Protocol

TIP

41
Substance Abuse Treatment:

Group Therapy

A Treatment 

Improvement 

Protocol 

TIP 41 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Rockville, MD 20857
Acknowledgments

This publication was produced under the

Knowledge Application Program (KAP) contract

number 270-99-7072 with the Substance Abuse

and Mental Health Services Administration

(SAMHSA), U.S. Department of Health and

Human Services (HHS). Karl D. White, Ed.D.,

and Andrea Kopstein, Ph.D., M.P.H., served as

the Center for Substance Abuse Treatment

(CSAT) Government Project Officers. Christina

Currier served as the CSAT TIPs Task Leader.

Disclaimer

The opinions expressed herein are the views

of the consensus panel members and do not

necessarily reflect the official position of

SAMHSA or HHS. No official support of or

endorsement by SAMHSA or HHS for these

opinions or for the instruments or resources

described are intended or should be inferred.

The guidelines presented should not be considered substitutes for individualized client

care and treatment decisions. 

Public Domain Notice

All materials appearing in this volume except

those taken directly from copyrighted sources

are in the public domain and may be reproduced or copied without permission from

SAMHSA or the authors. Citation of the

source is appreciated. However, this publication may not be reproduced or distributed for

a fee without the specific, written authorization of the Office of Communications, 

SAMHSA, HHS.

Electronic Access and 

Printed Copies

This publication may be ordered from or

downloaded from SAMHSA’s Publications

Ordering Web page at http://store.samhsa.gov.

Or, please call SAMHSA at 1-877-SAMHSA-7

(1-877-726-4727) (English and Español).

Recommended Citation

Center for Substance Abuse Treatment.

Substance Abuse Treatment: Group Therapy.

Treatment Improvement Protocol (TIP)

Series, No. 41. HHS Publication No. (SMA)

15-3991. Rockville, MD: Substance Abuse

and Mental Health Services Administration,

2005.

Originating Office

Quality Improvement and Workforce

Development Branch, Division of Services

Improvement, Center for Substance Abuse

Treatment, Substance Abuse and Mental

Health Services Administration, 1 Choke

Cherry Road, Rockville, MD 20857.

HHS Publication No. (SMA) 15-3991

Printed 2005

Revised 2009, 2011, 2012, 2014, and 2015

ii Acknowledgments
Contents 

What Is a TIP?............................................................................................................vii

Consensus Panel...........................................................................................................ix

KAP Expert Panel and Federal Government Participants ....................................................xi

Foreword ..................................................................................................................xiii

Executive Summary .....................................................................................................xv

Chapter 1—Groups and Substance Abuse Treatment ...........................................................1

Overview......................................................................................................................1 

Introduction .................................................................................................................1 

Defining Therapeutic Groups in Substance Abuse Treatment ....................................................2 

Advantages of Group Treatment ........................................................................................3 

Modifying Group Therapy To Treat Substance Abuse..............................................................6 

Approach of This TIP .....................................................................................................8 

Chapter 2—Types of Groups Commonly Used in Substance Abuse Treatment ..........................9

Overview......................................................................................................................9 

Introduction .................................................................................................................9 

Five Group Models  .......................................................................................................12 

Specialized Groups in Substance Abuse Treatment................................................................29 

Chapter 3—Criteria for the Placement of Clients in Groups................................................37

Overview ....................................................................................................................37 

Matching Clients With Groups .........................................................................................37 

Assessing Client Readiness for Group ................................................................................38 

Primary Placement Considerations ...................................................................................40 

Stages of Recovery ........................................................................................................43 

Placing Clients From Racial or Ethnic Minorities .................................................................44 

Diversity and Placement.................................................................................................52 

Chapter 4—Group Development and Phase-Specific Tasks .................................................59

Overview ....................................................................................................................59 

Fixed and Revolving Membership Groups...........................................................................59 

Preparing for Client Participation in Groups.......................................................................61 

Phase­Specific Group Tasks ............................................................................................72 

Chapter 5—Stages of Treatment ....................................................................................79

Overview ....................................................................................................................79 

Adjustments To Make Treatment Appropriate......................................................................79 

The Early Stage of Treatment ..........................................................................................80 

The Middle Stage of Treatment ........................................................................................85 

The Late Stage of Treatment............................................................................................88 

iii
Chapter 6—Group Leadership, Concepts, and Techniques..................................................91

Overview ....................................................................................................................91 

The Group Leader ........................................................................................................92 

Concepts, Techniques, and Considerations ........................................................................105 

Chapter 7—Training and Supervision............................................................................123

Overview...................................................................................................................123 

Training....................................................................................................................123 

Supervision................................................................................................................131 

Appendix A: Bibliography ..........................................................................................137

Appendix B: Adult Patient Placement Criteria................................................................149

Appendix C: Sample Group Agreement .........................................................................151

Appendix D: Glossary ................................................................................................153

Appendix E: Association for Specialists in Group Work Best Practice Guidelines..................159

Appendix F: Resource Panel .......................................................................................165

Appendix G: Cultural Competency and Diversity Network Participants ...............................167

Appendix H: Field Reviewers.......................................................................................169

Appendix I: Acknowledgments.....................................................................................175

Index ......................................................................................................................177

SAMHSA TIPs and Publications...................................................................................183

iv Contents
Figures 

1­1  Differences Between 12­Step Self­Help Groups and Interpersonal Process Groups ...................4 

2­1  Groups Used in Substance Abuse Treatment and Their Relation to Six Group Models .............11 

2­2  Characteristics of Five Group Models Used in Substance Abuse Treatment ...........................13 

2­3  Group Vignette: Joe’s Argument With His Roommate.......................................................26 

2­4  Joe’s Case in an Individually Focused Group .................................................................27 

2­5  Joe’s Case in an Interpersonally Focused Group.............................................................28 

2­6  Joe’s Case in a Group­As­A­Whole Focused Group..........................................................29 

2­7  The SageWind Model for Group Therapy......................................................................33 

3­1  Eco­Map ...............................................................................................................38 

3­2  Client Placement by Stage of Recovery .........................................................................43 

3­3  Client Placement Based on Readiness for Change............................................................44 

3­4  What Is Culture? ....................................................................................................45 

3­5  Diversity Wheel ......................................................................................................46 

3­6  When Group Norms and Cultural Values Conflict ...........................................................48 

3­7  Three Resources on Culture and Ethnicity ....................................................................48 

3­8  Guidelines for Clinicians on Evaluating Bias and Prejudice ...............................................49 

3­9  Self­Assessment Guide ..............................................................................................50 

3­10 Preparing the Group for a New Member From a Racial/Ethnic Minority..............................54 

3­11 Culture and the Perception of Conflict ........................................................................57 

4­1  Characteristics of Fixed and Revolving Membership Groups..............................................62 

4­2  The Family Care Program of the Duke Addictions Program ..............................................66 

4­3  SageWind..............................................................................................................67 

4­4  Examples of Agreements About Time and Attendance ......................................................69 

4­5  Examples of Agreements About Group Participation........................................................71 

4­6  Reminders for Each Group Session .............................................................................74 

6­1  Shame ..................................................................................................................95 

6­2  Confidentiality and 42 C.F.R., Part 2 .........................................................................110 

6­3  Jody’s Arm ..........................................................................................................121 

7­1  How Important Is It for a Substance Abuse Group Leader To Be in Recovery?.....................126 

7­2  Does Online Communication Impede Attachment? .........................................................132 

7­3  Group Experiential Training ....................................................................................133 

Contents v

What Is a TIP?

Treatment Improvement Protocols (TIPs) are developed by the Substance Abuse and Mental Health

Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS).

Each TIP involves the development of topic-specific best-practice guidelines for the prevention and treatment of substance use and mental disorders. TIPs draw on the experience and knowledge of clinical,

research, and administrative experts of various forms of treatment and prevention. TIPs are distributed

to facilities and individuals across the country. Published TIPs can be accessed via the Internet at

http://store.samhsa.gov.

Although each consensus-based TIP strives to include an evidence base for the practices it recommends,

SAMHSA recognizes that behavioral health is continually evolving, and research frequently lags behind

the innovations pioneered in the field. A major goal of each TIP is to convey "front-line" information

quickly but responsibly. If research supports a particular approach, citations are provided. When no

citation is provided, the information is based on the collective clinical knowledge and experience of the

consensus panel. 

vii

Consensus Panel

Note: The information given indicates each participant's affiliation during the time the panel was

convened and may no longer reflect the individual's current affiliation.

Chair

Philip J. Flores, Ph.D., COP, FAGPA 

Adjunct Clinical Supervisor

Department of Psychology

Georgia State University

Atlanta, Georgia

Co­Chair

Jeffrey M. Georgi, M.Div., CGP, CSAC, 

LPC, CCS 

Clinical Director

Department of Behavioral Science

Duke School of Nursing and Duke University

Medical Center

Senior Clinician

Duke Addictions Program

Duke University Medical Center

Durham, North Carolina

Workgroup Leaders

David W. Brook, M.D., CGP 

Department of Community and Preventive

Medicine

Mount Sinai Medical Center

New York, New York

Frederick Bruce Carruth, Ph.D., LCSW 

Private Practice

Boulder, Colorado

Sharon D. Chappelle, Ph.D., M.S.W., LCSW 

President

Chief Executive Officer

Chappelle Consulting and Training

Services, Inc.

Middletown, Connecticut

David E. Cooper, Ph.D. 

Psychologist/Psychoanalyst

Chestnut Lodge Hospital

Chevy Chase, Maryland

Charles Garvin, Ph.D. 

Professor of Social Work

School of Social Work

University of Michigan

Ann Arbor, Michigan

Panelists

Marilyn Joan Freimuth, Ph.D. 

Psychologist/Faculty Member

The Fielding Institute

Bedford, New York

Barbara Hardin-Perez, Ph.D. 

Director

Student Health and Mental Health Services

St. Mary’s University

San Antonio, Texas

Frankie D. Lemus, Jr., M.A. 

Clinical Director

SageWind (Oikos, Inc.)

Reno, Nevada

Marilynn Morrical, CCDN, NCACII 

(Deceased 2002) 

Alcohol, Tobacco, and Drug Consultant

Marilynn Morrical Consulting and

Rehabilitation

Reno, Nevada

Tam K. Nguyen, M.D., LMSW, CCJS, 

DVC, MAC 

President

Employee & Family Resources

Polk City, Iowa

Candace M. Shelton, M.S., CADAC 

Clinical Director

Native American Connections, Inc.

Tucson, Arizona

Darren C. Skinner, Ph.D., LSW, CAC 

Director

Gaudenzia, Inc.

Gaudenzia House West Chester

West Chester, Pennsylvania

ix
Judith S. Tellerman, Ph.D., MAT, M.Ed., Marsha Lee Vannicelli, Ph.D., FAGPA 

CGP Associate Clinical Professor

Assistant Clinical Professor Department of Psychiatry

College of Medicine Harvard Medical School

University of Illinois Belmont, Massachusetts

Chicago, Illinois

x Consensus Panel
KAP Expert Panel and Federal

Government Participants

Note: The information given indicates each participant's affiliation during the time the panel was

convened and may no longer reflect the individual's current affiliation.

Barry S. Brown, Ph.D. 

Adjunct Professor

University of North Carolina at Wilmington

Carolina Beach, North Carolina

Jacqueline Butler, M.S.W., LISW, LPCC, 

CCDC III, CJS 

Professor of Clinical Psychiatry

College of Medicine

University of Cincinnati

Cincinnati, Ohio

Deion Cash 

Executive Director

Community Treatment and Correction

Center, Inc.

Canton, Ohio

Debra A. Claymore, M.Ed.Adm. 

Owner/Chief Executive Officer

WC Consulting, LLC

Loveland, Colorado

Carlo C. DiClemente, Ph.D. 

Chair

Department of Psychology

University of Maryland Baltimore County

Baltimore, Maryland

Catherine E. Dube, Ed.D. 

Independent Consultant

Brown University

Providence, Rhode Island

Jerry P. Flanzer, D.S.W., LCSW, CAC 

Chief, Services

Division of Clinical and Services Research

National Institute on Drug Abuse

Bethesda, Maryland

Michael Galer, D.B.A., M.B.A., M.F.A. 

Independent Consultant

Westminster, Massachusetts

Renata J. Henry, M.Ed. 

Director

Division of Alcoholism, Drug Abuse,

and Mental Health

Delaware Department of Health and Social

Services

New Castle, Delaware

Joel Hochberg, M.A. 

President

Asher & Partners

Los Angeles, California

Jack Hollis, Ph.D. 

Associate Director

Center for Health Research

Kaiser Permanente

Portland, Oregon

Mary Beth Johnson, M.S.W. 

Director

Addiction Technology Transfer Center

University of Missouri—Kansas City

Kansas City, Missouri

Eduardo Lopez, B.S. 

Executive Producer

EVS Communications

Washington, DC

Holly A. Massett, Ph.D. 

Academy for Educational Development

Washington, DC

Diane Miller 

Chief

Scientific Communications Branch

National Institute on Alcohol Abuse

and Alcoholism

Bethesda, Maryland

xi
Harry B. Montoya, M.A. 

President/Chief Executive Officer

Hands Across Cultures

Espanola, New Mexico

Richard K. Ries, M.D. 

Director/Professor

Outpatient Mental Health Services

Dual Disorder Programs

Seattle, Washington

Gloria M. Rodriguez, D.S.W. 

Research Scientist

Division of Addiction Services

NJ Department of Health and Senior Services

Trenton, New Jersey

Everett Rogers, Ph.D. 

Center for Communications Programs

Johns Hopkins University

Baltimore, Maryland

Jean R. Slutsky, P.A., M.S.P.H. 

Senior Health Policy Analyst

Agency for Healthcare Research & Quality

Rockville, Maryland

Nedra Klein Weinreich, M.S. 

President

Weinreich Communications

Canoga Park, California

Clarissa Wittenberg 

Director

Office of Communications and Public Liaison

National Institute of Mental Health

Kensington, Maryland

Consulting Members

of the KAP Expert Panel

Paul Purnell, M.A. 

Vice President

Social Solutions, L.L.C.

Potomac, Maryland

Scott Ratzan, M.D., M.P.A., M.A. 

Academy for Educational Development

Washington, DC

Thomas W. Valente, Ph.D. 

Director, Master of Public Health Program

Department of Preventive Medicine

School of Medicine

University of Southern California

Alhambra, California

Patricia A. Wright, Ed.D. 

Independent Consultant

Baltimore, Maryland

xii KAP Expert Panel and Federal Government Participants
Foreword

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the

U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral

health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on

America’s communities.

The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s mission to reduce the impact of substance abuse and mental illness on America's communities by providing evidence-based and best practices

guidance to clinicians, program administrators, and payers. TIPs are the result of careful consideration

of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and

patient advocates debates and discusses their particular area of expertise until they reach a consensus on

best practices. Field reviewers then review and critique this panel’s work.

The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory

process have helped bridge the gap between the promise of research and the needs of practicing clinicians

and administrators to serve, in the most scientifically sound and effective ways, people in need of behavioral health services. We are grateful to all who have joined with us to contribute to advances in the

behavioral health field.

Pamela S. Hyde, J.D.

Administrator

Substance Abuse and Mental Health Services Administration

Daryl W. Kade

Acting Director

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services Administration

xiii

Executive Summary 

With the recognition of addiction as a major health problem in this country, demand has increased for

effective treatments of substance use disorders. Because of its effectiveness and economy of scale, group

therapy has gained popularity, and the group approach has come to be regarded as a source of powerful

curative forces that are not always experienced by the client in individual therapy. One reason groups

work so well is that they engage therapeutic forces—like affiliation, support, and peer confrontation—and

these properties enable clients to bond with a culture of recovery. Another advantage of group modalities

is their effectiveness in treating problems that accompany addiction, such as depression, isolation, and

shame.

Groups can support individual members in times of pain and trouble, and they can help people grow in

ways that are healthy and creative. Formal therapy groups can be a compelling source of persuasion,

stabilization, and support. In the hands of a skilled, well­trained group leader, the potential healing powers inherent in a group can be harnessed and directed to foster healthy attachments, provide positive peer

reinforcement, act as a forum for self­expression, and teach new social skills. In short, group therapy can

provide a wide range of therapeutic services, comparable in efficacy to those delivered in individual therapy.

Group therapy and addiction treatment are natural allies. One reason is that people who abuse substances are often more likely to stay sober and committed to abstinence when treatment is provided in

groups, apparently because of rewarding and therapeutic benefits like affiliation, confrontation, support,

gratification, and identification. This capacity of group therapy to bond patients to treatment is an important asset because the greater the amount, quality, and duration of treatment, the better the client’s prognosis (Leshner 1997; Project MATCH Research Group 1997).

The primary audience for this TIP is substance abuse treatment counselors; however, the TIP should be

of interest to anyone who wants to learn more about group therapy. The intent of the TIP is to assist

counselors in enhancing their therapeutic skills in regard to leading groups.

The consensus panel for this TIP drew on its considerable experience in the group therapy field. The

panel was composed of representatives from all of the disciplines involved in group therapy and substance

abuse treatment, including alcohol and drug counselors, group therapists, mental health providers, and

State government representatives.

This TIP comprises seven chapters. Chapter 1 defines therapeutic groups as those with trained leaders

and a primary intent to help people recover from substance abuse. It also explains why groups work so

well for treating substance abuse.

xv
Chapter 2 describes the purpose, main characteristics, leadership, and techniques of five

group therapy models, three specialty groups,

and groups that focus on solving a single

problem.

Chapter 3 discusses the many considerations

that should be weighed before placing a client

in a particular group, especially keying the

group to the client’s stage of change and stage

of recovery. This chapter also concentrates on

issues that arise from client diversity.

Chapter 4 compares fixed and revolving types

of therapy groups and recommends ways to

prepare clients for participation: pregroup

interviews, retention measures, and most

important, group agreements that specify

clients’ expectations of each other, the leader,

and the group. Chapter 4 also specifies the

tasks that need to be accomplished in the early,

middle, and late phases of group development.

Chapter 5 turns to the stages of treatment. In

the early, middle, and late stages of treatment,

clients’ conditions will differ, requiring different therapeutic strategies and approaches to

leadership.

Chapter 6 is the how­to segment of this TIP. It

explains the characteristics, duties, and concepts important to promote effective group

leadership in treating substance abuse, including how confidentiality regulations for alcohol

and drug treatment apply to group therapy.

Chapter 7 highlights training opportunities

available to substance abuse treatment professionals. The chapter also recommends the

supervisory group as an added measure that

improves group leadership and gives counselors

in the group insights about how clients may

experience groups.

Throughout this TIP, the term “substance

abuse” has been used to refer to both substance abuse and substance dependence (as

defined by the Diagnostic and Statistical

Manual of Mental Disorders, 4th edition, Text

Revision [DSM­IV­TR] [American Psychiatric

Association 2000]). This term was chosen partly because substance abuse treatment professionals commonly use the term “substance

abuse” to describe any excessive use of addictive substances. In this TIP, the term refers to

the use of alcohol as well as other substances of

abuse. Readers should attend to the context in

which the term occurs in order to determine

what possible range of meanings it covers; in

most cases, however, the term will refer to all

varieties of substance use disorders described

by DSM­IV.

The sections that follow summarize the content

in this TIP and are grouped by chapter.

Groups and Substance

Abuse Treatment

Because human beings by nature are social

beings, group therapy is a powerful therapeutic

tool that is effective in treating substance

abuse. The therapeutic groups described in this

TIP are those groups that have trained leaders

and a specific intent to treat substance abuse.

This definition excludes self­help groups like

Alcoholics Anonymous and Narcotics

Anonymous.

Group therapy has advantages over other

modalities. These include positive peer support; a reduction in clients’ sense of isolation;

real­life examples of people in recovery; help

from peers in coping with substance abuse and

other life problems; information and feedback

from peers; a substitute family that may be

healthier than a client’s family of origin; social

skills training and practice; peer confrontation;

a way to help many clients at one time; structure and discipline often absent in the lives of

people abusing substances; and finally, the

hope, support, and encouragement necessary

to break free from substance abuse.

xvi Executive Summary
Groups Commonly

Used in Substance

Abuse Treatment

Five group models are common in substance

abuse treatment:

•Psychoeducational groups, which educate

clients about substance abuse

•Skills development groups, which cultivate

the skills needed to attain and sustain abstinence, such as those needed to manage anger

or cope with urges to use substances

•Cognitive–behavioral groups, which alter

thoughts and actions that lead to substance

abuse

•Support groups, which buoy members and

provide a forum to share pragmatic information about maintaining abstinence and managing day­to­day, chemical­free life

•Interpersonal process groups, which delve

into major developmental issues that contribute to addiction or interfere with recovery

Three other specialized types of groups that do

not fit neatly into the five­model classification

nonetheless are common in substance abuse

treatment. They are designed specifically to

prevent relapse, to bring a specific culture’s

healing practices to bear on substance abuse,

or to use some form of art to express thoughts

that otherwise would be difficult to communicate. Groups also can be formed to help clients

who share a specific problem, such as anger or

shyness, that contributes to their substance

abuse.

Criteria for the

Placement of Clients

in Groups

Not everyone is suited to every kind of group.

Moreover, because recovery is a long, nonlinear process, the type of therapy chosen always

should be subject to re­evaluation.

Appropriate placement begins with a thorough

assessment of the client’s needs, desires, and

ability to participate. Evaluators rely on forms

and interviews to determine the client’s level of

interpersonal functioning, motivation to

abstain, stability, stage of recovery, and expectation of success in the group.

Most clients can function in a group that is heterogeneous, that is, members may be mixed in

age, gender, culture, and so on. What is essential, however, is that all clients in a group

should have similar needs. Some clients, such

as those with a severe personality disorder, will

need to be placed in homogeneous groups, in

which members are alike in some way other

than their dependence problem. Such groups

may include people of a particular ethnicity, all

women, or a particular age group.

Some clients probably are not suitable for

certain groups, or group therapy in general,

including

•People who refuse to participate

•People who cannot honor group agreements,

including preserving privacy and confidentiality of group members in accordance with

the Federal regulations (42 C.F.R., Part 2)

•People who make the therapist very uncomfortable

•People who are prone to dropping out or who

continually violate group norms

•People in the throes of a life crisis

•People who cannot control impulses

•People who experience severe internal

discomfort in groups

Professional judgment is also essential and

should consider characteristics such as substances abused, duration of use, treatment

setting, and the client’s stage of recovery. For

example, a client in a maintenance stage may

need to acquire social skills for interacting in

new ways, address emotional difficulties, or

become reintegrated into a community or

culture of origin.

Ethnicity and culture can have a profound

effect on treatment. The greater the mix of

Executive Summary xvii
ethnicities in a group, the more likely it is that

biases will emerge and require mediation.

Special attention may be warranted, too, if

clients do not speak English fluently because

they may be unable to follow a fast­flowing

discussion. Programs should ensure that group

members are fluent in the language for their

specific demographic area, which may or may

not be English. Further, while it might be desirable to match the group leader and all group

members ethnically, the reality is that it is seldom feasible. Thus, it is crucial for the group

leader to understand how ethnicity affects

substance abuse and group participation.

Group Development

and Phase­Specific

Tasks

Group membership may be fixed, with a stable

and relatively small number of clients.

Alternatively, membership may revolve, with

new members entering a group when they are

ready for the service it provides. Either type

can run indefinitely or for a set time.

The preparation of clients for group participation commences when the group leader meets

individually with each prospective group member to begin to form a therapeutic alliance,

reach consensus on what is to be accomplished

in therapy, educate the client about group therapy, allay anxiety related to joining a group,

and explain the group agreement. In these pregroup interviews, it is important to be sensitive

to people who differ significantly from the rest

of the group whether by age, ethnicity, gender,

disorder, and so on. It is important to assure

clients that a difference is not a deficit and can

be a source of vitality for the group.

Selection of group members is based on the

client’s fit with a specific group modality.

Considerations include the client’s

•Level of interpersonal functioning, including

impulse control

•Motivation to abstain from drug or alcohol

abuse

•Stability

•Stage of recovery

•Expectation of success

Throughout the initial group therapy sessions,

clients are particularly vulnerable to relapse

and discontinuation of treatment. The first

month appears to be especially critical

(Margolis and Zweben 1998). Retention rates

in a group are enhanced by client preparation,

maximum client involvement, feedback,

prompts to encourage attendance, and the provision of wraparound services (such as child

care and transportation). The timing and

duration of groups also affect retention.

While group leaders have many responsibilities

in preparing clients for participation in groups,

clients have obligations, too. A group agreement establishes the expectations that group

members have of each other, the leader, and

the group itself. It specifies the circumstances

under which clients may be barred from group

and explains policies regarding confidentiality,

physical contact, substance use, contact outside

the group, group participation, financial

responsibility, and termination. A group member’s acceptance of the contract prior to entering a group has been described as the single

most important factor contributing to the success of outpatient therapy groups.

The tasks in the beginning phase of a group

include introductions, review of the group

agreement, establishment of an emotionally

safe environment and positive group norms,

and focusing the group toward its work. In the

middle phase, clients interact, rethink their

behaviors, and move toward productive

change. The end phase concentrates on reaching closure.

Stages of Treatment

As clients move through different stages of

recovery, treatment must move with them. That

is, therapeutic strategies and leadership roles

will change with the condition of the clients.

In the early phase of treatment clients tend to

be ambivalent about ending substance use,

xviii Executive Summary
rigid in their thinking, and limited in their ability to solve problems. Resistance is a challenge

for the group leader at this time.

The art of treating addiction in the early phase

is in the defeat of denial and resistance. Groups

are especially effective at this time since people

with dependencies often have had adversarial

relationships with people in authority. Thus,

information from peers in a group is more

easily accepted than that from a lone therapist.

People with addictions remain vulnerable

during the middle phase of treatment. Though

cognitive capacity usually begins to return to

normal, the mind can still play tricks. Clients

may remember distinctly the comfort of their

past use of substances, yet forget just how bad

the rest of their lives were. Consequently, the

temptation to relapse remains a concern.

Because people with dependencies usually are

isolated from healthy social groups, the group

helps to acculturate clients into a culture of

recovery. The leader draws attention to positive developments, points out how far clients

have traveled, and affirms the possibility of

increased connection and new sources of

satisfaction.

In the late phase of treatment clients are stable

enough to face situations that involve conflict

or deep emotion. A process­oriented group may

become appropriate for some clients who finally are able to confront painful realities, such as

being an abused child or an abusive parent.

Other clients may need groups to help them

build a healthier marriage, communicate more

effectively, or become a better parent. Some

may want to develop new job skills to increase

employability.

Group Leadership,

Concepts, and

Techniques

Effective group leadership requires a

constellation of specific personal qualities and

professional practices. The personal qualities

necessary are constancy, active listening, firm

identity, confidence, spontaneity, integrity,

trust, humor, and empathy.

Leaders should be able to

•Adjust their professional styles to the

particular needs of different groups

•Model group­appropriate behaviors

•Resolve issues within ethical dimensions

•Manage emotional contagion

•Work only within modalities for which they

are trained

•Prevent the development of rigid roles in the

group

•Avoid acting in different roles inside and outside the group

•Motivate clients in substance abuse treatment

•Ensure emotional safety in the group

•Maintain a safe therapeutic setting (which

involves deflecting defensive behavior without shaming the offender, recognizing and

countering the resumption of substance use,

and protecting physical boundaries according

to group agreements)

•Curtail emotion when it becomes too intense

for group members to tolerate

•Stimulate communication among group

members

Key concepts and techniques used in group

therapy for substance abuse follow.

Interventions are any action by a leader to

intentionally affect the processes of the group.

Interventions may be used, for example, to

clarify understanding, redirect energy, or stop

a damaging sequence of interactions. Effective

leaders do not overdo intervention. To do so

would result in a leader­centered group, which

is undesirable because in therapy groups, the

healing comes from the connections forged

between group members. One type of intervention, confrontation, deftly points out inconsistencies in clients’ thinking.

Confidentiality restricts the information that

providers can reveal about clients and that

clients may reveal about each other. Group

Executive Summary xix
leaders and clients should understand the exact

provisions of this important boundary.

Diversity plays a highly important role in

group therapy, for it may affect critical aspects

of the process, such as what clients expect of

the leader and how clients may interpret other

clients’ behavior. Clinicians should be open to

learning about other belief systems, should not

assume that every person from a specific group

shares the same characteristics, and should

avoid appearing as if they are trying to persuade

clients to renounce their cultural characteristics.

Many people in treatment for substance abuse

have other complex problems, such as cooccurring mental disorders, homelessness, or

involvement with the criminal justice system.

For many clients, group therapy may be one

element in a larger plan that also marshals

biopsychosocial and spiritual interventions to

address important life issues and restore faith

or belief in some force beyond the self.

Integrated care from diverse sources requires

cooperation with other healthcare providers.

For example, it is critical that all providers

working with clients with multiple disorders

know what medications they are taking and why.

Two aspects of group management relate to

conflict and subgroups. Properly managed,

conflict can promote learning about respect for

different viewpoints, managing emotions, and

negotiation. Part of the therapist’s job as a

conflict manager is to reveal covert conflicts

and expose repetitive and predictable arguments. The therapist also reveals covert subgroups and intervenes to reconfigure negative

subgroups that threaten the group’s progress.

Various types of disruptive behavior may

require the group leader’s attention. Such

problems include clients who talk nonstop,

interrupt, flee a session, arrive late or skip sessions, decline to participate, or speak only to

the problems of others. The leader also should

have skills to handle people with psychological

emergencies or people who are anxious about

disclosing personal information.

Training and

Supervision

National professional organizations are a rich

source of training. Through conferences or

regional chapters, national associations provide

training—both experiential and direct instruction—geared to the needs of a wide range of

persons, from graduate students to highly experienced therapists. More training options are

usually available in large urban areas. It is

likely, however, that online training will make

some types of professional development accessible to a greater number of counselors in remote

areas.

Clinical supervision as it pertains to group

therapy often is best carried out within the context of group supervision. Group dynamics and

group process facilitate learning by setting up a

microcosm of a larger social environment. Each

group member’s style of interaction will

inevitably show up in the group transactions.

As this process unfolds, group members, guided by the supervisor, learn to model effective

behavior in an accepting group context.

Supervisory groups reduce, rather than escalate, the level of threat that can accompany

supervision. In place of isolation and alienation, group participation gives counselors a

sense of community. They find that others

share their worries, fears, frustrations, temptations, and ambivalence. This reassurance is of

particular benefit to novice group counselors.

xx Executive Summary
1 Groups and Substance

Abuse Treatment

In This 

Chapter... 

Introduction 

Defining 

Therapeutic 

Groups in 

Substance Abuse 

Treatment 

Advantages of 

Group Treatment 

Modifying Group 

Therapy To Treat 

Substance Abuse 

Approach of 

This TIP 

Overview

The natural propensity of human beings to congregate makes group

therapy a powerful therapeutic tool for treating substance abuse, one

that is as helpful as individual therapy, and sometimes more successful.

One reason for this efficacy is that groups intrinsically have many

rewarding benefits—such as reducing isolation and enabling members

to witness the recovery of others—and these qualities draw clients into

a culture of recovery. Another reason groups work so well is that they

are suitable especially for treating problems that commonly accompany

substance abuse, such as depression, isolation, and shame.

Although many groups can have therapeutic effects, this TIP concentrates only on groups that have trained leaders and that are designed to

promote recovery from substance abuse. Great emphasis is placed on

interpersonal process groups, which help clients resolve problems in

relating to other people, problems from which they have attempted to

flee by means of addictive substances. While this TIP is not intended

as a training manual for individuals training to be group therapists, it

provides substance abuse counselors with insights and information that

can improve their ability to manage the groups they currently lead.

Introduction

The lives of individuals are shaped, for better or worse, by their experiences in groups. People are born into groups. Throughout life, they join

groups. They will influence and be influenced by family, religious, social,

and cultural groups that constantly shape behavior, self­image, and both

physical and mental health.

Groups can support individual members in times of pain and trouble,

and they can help people grow in ways that are healthy and creative.

However, groups also can support deviant behavior or influence an

individual to act in ways that are unhealthy or destructive.

1
Because our need for human contact is biologically determined, we are, from the start, social

creatures. This propensity to congregate is a

powerful therapeutic tool. Formal therapy

groups can be a compelling source of persuasion, stabilization, and support. Groups organized around therapeutic goals can enrich

members with insight and guidance; and during

times of crisis, groups can comfort and guide

people who otherwise might be unhappy or

lost. In the hands of a skilled, well­trained

group leader, the potential curative forces

inherent in a group can be harnessed and

directed to foster healthy attachments, provide

positive peer reinforcement, act as a

forum for selfexpression, and

teach new social

skills. In short,

group therapy can

provide a wide range

of therapeutic services, comparable

in efficacy to those

delivered in individual therapy. In some

cases, group therapy

can be more beneficial than individual

therapy (Scheidlinger

2000; Toseland and

Siporin 1986).

Groups provide

positive peer

support and

pressure to abstain

from substances

of abuse.

Group therapy and addiction treatment are

natural allies. One reason is that people who

abuse substances often are more likely to

remain abstinent and committed to recovery

when treatment is provided in groups, apparently because of rewarding and therapeutic

forces such as affiliation, confrontation, support, gratification, and identification. This

capacity of group therapy to bond patients to

treatment is an important asset because the

greater the amount, quality, and duration of

treatment, the better the client’s prognosis

(Leshner 1997; Project MATCH Research

Group 1997).

The effectiveness of group therapy in the treatment of substance abuse also can be attributed

to the nature of addiction and several factors

associated with it, including (but not limited to)

depression, anxiety, isolation, denial, shame,

temporary cognitive impairment, and character pathology (personality disorder, structural

deficits, or an uncohesive sense of self).

Whether a person abuses substances or not,

these problems often respond better to group

treatment than to individual therapy (Kanas

1982; Kanas and Barr 1983). Group therapy is

also effective because people are fundamentally

relational creatures.

Defining Therapeutic

Groups in Substance

Abuse Treatment

All groups can be therapeutic. Anytime someone becomes emotionally attached to other

group members, a group leader, or the group

as a whole, the relationship has the potential to

influence and change that person. Identifying a

group as “therapy” does not imply that other

groups are not therapeutic. In preparing this

TIP, the consensus panel debated at length

what constitutes “group therapy” and what

distinguishes therapy groups from other types

of groups.

Although many types of groups can have therapeutic elements and effects, the group types

included in this TIP are based on the goals and

intentions of the groups, as well as the intended

audience of the TIP (especially substance abuse

treatment counselors and other substance

abuse treatment professionals). Thus, this TIP

is limited to groups that (1) have trained leaders and (2) intend to produce some type of

healing or recovery from substance abuse. This

TIP describes (in chapter 2) five models of

group therapy currently used in substance

abuse treatment:

•Psychoeducational groups, which teach about

substance abuse.

2 Groups and Substance Abuse Treatment
•Skills development groups, which hone the

skills necessary to break free of addictions.

•Cognitive–behavioral groups, which rearrange patterns of thinking and action that

lead to addiction.

•Support groups, which comprise a forum

where members can debunk each other’s

excuses and support constructive change.

•Interpersonal process group psychotherapy

(referred to hereafter as “interpersonal process groups” or “therapy groups”), which

enable clients to recreate their pasts in the

here­and­now of group and rethink the relational and other life problems that they have

previously fled by means of addictive substances.

Treatment providers routinely use the first four

models and various combinations of them. The

last is not as widely used, chiefly because of the

extensive training required to lead such groups

and the long duration of the groups, which

demands a high degree of commitment from

both providers and clients. All the same, many

people enter substance abuse treatment with a

long history of failed relationships exacerbated

by substance use. In these cases, an extended

period of therapy is warranted to resolve the

client’s problems with relationships. The reality

that extended treatment is not always feasible

does not negate its desirability.

This TIP does not discuss multifamily and multicouple groups, which are discussed in TIP 39,

Substance Abuse Treatment and Family

Therapy (Center for Substance Abuse

Treatment 2004). Even though multifamily and

multicouple groups typically are made up of

unrelated groups of families, they focus on

family relations as they affect and are affected

by a member with a substance use disorder.

This TIP concentrates on therapy groups,

which have a distinctively different focus.

Also outside the scope of this TIP is the use of

peer­led self­help groups such as Alcoholics

Anonymous (AA) or group activities like social

events, religious services, sports, and games.

Any or all may have one or more therapeutic

effects, but are not specifically designed to

achieve that purpose. Figure 1­1 (see p. 4)

shows other differences between self­help

groups and interpersonal process groups. In

most aspects, the comparison would apply to

the other four group models as well.

Advantages of Group

Treatment

Treating adult clients in groups has many

advantages, as well as some risks. Any treatment modality—group therapy, individual

therapy, family therapy, and medication—can

yield poor results if applied indiscriminately or

administered by an unskilled or improperly

trained therapist. The potential drawbacks of

group therapy, however, are no greater than

for any other form of treatment.

Some of the numerous advantages to using

groups in substance abuse treatment are

described below (Brown and Yalom 1977;

Flores 1997; Garvin unpublished manuscript;

Vannicelli 1992).

•Groups provide positive peer support and

pressure to abstain from substances of abuse.

Unlike AA, and, to some degree, substance

abuse treatment program participation,

group therapy, from the very beginning, elicits a commitment by all the group members to

attend and to recognize that failure to attend,

to be on time, and to treat group time as special disappoints the group and reduces its

effectiveness. Therefore, both peer support

and pressure for abstinence are strong.

•Groups reduce the sense of isolation that

most people who have substance abuse disorders experience. At the same time, groups

can enable participants to identify with others who are struggling with the same issues.

Although AA and treatment groups of all

types provide these opportunities for sharing,

for some people the more formal and deliberate nature of participation in process group

therapy increases their feelings of security

and enhances their ability to share openly.

•Groups enable people who abuse substances

to witness the recovery of others. From this

Groups and Substance Abuse Treatment 3
Figure 1­1

Differences Between 12­Step Self­Help Groups 

and Interpersonal Process Groups

Self-Help Group Interpersonal Process Group 

Size Unlimited (often large) Small (8–15 members)

Leadership 

• Peer leader or individual in recovery

• Leadership is earned over time

• Implicit hierarchical leadership

structure

• Trained professional

• Appointed leader

• Formal hierarchical leadership

structure

Participation Voluntary Voluntary and involuntary

Group 

Government Self­governing Leader governed

Content 

• Environmental factors, no

examination of group interaction

• Emphasis on similarities among

members

• Here­and­now focus

• Examination of intragroup behavior

and extragroup factors

• Emphasis on differences and

similarities among members

• Here­and­now focus plus

historical focus

Screening 

Interview None Always

Group 

Processes 

Universality, empathy, affective sharing,

self­disclosure (public statement of

problem), mutual affirmation, morale

building, catharsis, immediate positive

feedback, high degree of persuasiveness

Cohesion, mutual identification,

education, catharsis, use of group

pressure to encourage abstinence

and retention of group membership,

outside socialization (depending on

the group contract or agreement)

Group 

Goals 

• Positive goal setting, behaviorally

oriented

• Focus on the group as a whole and

the similarities among members

• Ambitious goals: immediate problem

plus individual personality issues

• Individual as well as group focus

Leader 

Activity 

• Educator/role model, catalyst

for learning

• Less member­to­leader distance

• Responsible for directing

therapeutic group experience

• More member­to­leader distance

Use of 

Psychodynamic 

Techniques 

No Yes

Confidentiality Anonymity preserved

Anonymity strongly emphasized and

includes everything that occurs in the

group, not just the identity of group

members

4 Groups and Substance Abuse Treatment
           

           

       

           

         

             

         

           

           

             

     

             

           

         

         

         

             

           

               

       

         

         

         

           

         

             

               

   

         

           

       

             

       

         

           

         

             

           

             

             

         

       

     

           

           

             

           

       

 

     

 

             

       

     

       

           

   

         

               

           

Self-Help Group Interpersonal Process Group 

Sponsorship 

Program Yes (usually same sex) None

Determination of Time 

in Group 

• Members may leave group at their own

choosing

• Members may avoid self­disclosure or

discussion of any subject

• Predetermined minimal term of group

membership

• Avoidance of discussion seen as

possible “resistance”

Involvement 

in Other 

Therapies 

Yes Yes—eclectic models

No—psychodynamic models

Time 

Factors 

Unlimited group participation possible

over years

Often time­limited group experiences

Frequency 

of Meetings 

Active encouragement of daily

participation

Meets less frequently (often once or

twice weekly)

Source: Adapted from Spitz 2001. Used with permission.

inspiration, people who are addicted to

substances gain hope that they, too, can

maintain abstinence. Furthermore, an interpersonal process group, which is of long

duration, allows a magnified witnessing of

both the changes related to recovery as well

as group members’ intra­ and interpersonal

changes.

• Groups help members learn to cope with

their substance abuse and other problems by

allowing them to see how others deal with

similar problems. Groups can accentuate this

process and extend it to include changes in

how group members relate to bosses, parents,

spouses, siblings, children, and people in

general.

•Groups can provide useful information to

clients who are new to recovery. For example, clients can learn how to avoid certain

triggers for use, the importance of abstinence

as a priority, and how to self­identify as a

person recovering from substance abuse.

Group experiences can help deepen these

insights. For example, self­identifying as a

person recovering from substance abuse can

be a complex process that changes significantly during different stages of treatment

and recovery and often reveals the set of

traits that makes the system of a person’s self

as altogether unique.

•Groups provide feedback concerning the

values and abilities of other group members.

This information helps members improve

their conceptions of self or modify faulty,

distorted conceptions. In terms of process

groups in particular, as specific themes

emerge in a client’s group experience, repetitive feedback from multiple group members

and the therapist can chip away at those

faulty or distorted conceptions in slightly

different ways until they not only are

correctable, but also the very process of

correction and change is revealed through

the examination of the group processes.

•Groups offer family­like experiences. Groups

can provide the support and nurturance that

may have been lacking in group members’

families of origin. The group also gives members the opportunity to practice healthy ways

of interacting with their families.

Groups and Substance Abuse Treatment 5
•Groups encourage, coach, support, and

reinforce as members undertake difficult or

anxiety­provoking tasks.

•Groups offer members the opportunity to

learn or relearn the social skills they need to

cope with everyday life instead of resorting to

substance abuse. Group members can learn

by observing others, being coached by others, and practicing skills in a safe and supportive environment.

•Groups can effectively confront individual

members about substance abuse and other

harmful behaviors. Such encounters are

possible because groups speak with the combined authority of people who have shared

common experiences and common problems.

Confrontation often plays a part of substance

abuse treatment groups because group

members tend to deny their problems.

Participating in the confrontation of one

group member can help others recognize and

defeat their own denial.

•Groups allow a single treatment professional

to help a number of clients at the same time.

In addition, as a group develops, each group

member eventually becomes acculturated to

group norms and can act as a quasi­therapist

himself, thereby ratifying and extending the

treatment influence of the group leader.

•Groups can add needed structure and discipline to the lives of people with substance use

disorders, who often enter treatment with

their lives in chaos. Therapy groups can

establish limitations and consequences, which

can help members learn to clarify what is

their responsibility and what is not.

•Groups instill hope, a sense that “If he can

make it, so can I.” Process groups can

expand this hope to dealing with the full

range of what people encounter in life,

overcome, or cope with.

•Groups often support and provide encouragement to one another outside the group setting. For interpersonal process groups,

though, outside contacts may or may not be

disallowed, depending on the particular

group contract or agreements.

Modifying Group

Therapy To Treat

Substance Abuse

Modifying group therapy to make it applicable

to and effective with clients who abuse substances requires three improvements. One is

specific training and education for therapists so

that they fully understand therapeutic group

work and the special characteristics of clients

with substance use disorders. The importance

of understanding the curative process that

occurs in groups cannot be underestimated.

Most substance abuse counselors have responded by adapting skills used in individual therapy.

Counselors have also sought direction, clinical

training, and practical suggestions. Despite

individual efforts, however, group therapy often

is conducted as individual therapy in a group.

Individual therapy is not equivalent to group

therapy. Some principles that work well with

individuals are inappropriate for group therapy.

Using the wrong approach may lead to several

undesirable results. First, the rich potential of

groups––self­understanding, psychological

growth, emotional healing, and true intimacy––

will be left unfulfilled. Second, group leaders

who are unfamiliar with and insensitive to

issues that manifest themselves in group therapy may find themselves in a difficult situation.

Third, therapists who think they are doing

group therapy when they actually are not may

observe the poor results and conclude that

group therapy is ineffective. Compounding all

these difficulties is the fact that group therapy

is so ubiquitous. Thus, poorly conceived

approaches are being used frequently.

Group therapy also is not equivalent to 12­Step

program practices. Many therapists who lack

full qualifications for group work have adapted

practices from AA and other 12­Step programs

for use in therapeutic groups. To say that this

borrowing is inadvisable is not to say that the

principles of AA are inadequate. On the contrary, many people seem to be unable to recover from dependency without AA or a program

6 Groups and Substance Abuse Treatment
similar to it. For this reason, most effective

treatment programs make attendance at AA or

another 12­Step program a mandatory part of

the treatment process. By the same token, AA

and other 12­Step programs are not group

therapy. Rather, they are complementary components to the recovery process. Twelve­Step

programs can help keep the individual who

abuses substances abstinent while group therapy provides opportunities for these individuals

to understand and explore the emotional and

interpersonal conflicts that can contribute to

substance abuse.

Progress toward optimal group therapy has

also been hindered by the misconception that

group therapy with clients who have addictions

does not require specially qualified leaders.

This notion is false. Therapy groups cannot

just take care of themselves. Group therapy,

properly conducted, is difficult. One reason

that it is challenging has to do with the nature

of the clients; an addicted population poses

unique problems for the group therapy leader.

A second reason is the complexity of group

therapy; the leader requires a vast amount of

specialized knowledge and skills, including a

clear understanding of group process and the

stages of development of group dynamics. Such

mastery only comes with extended training and

experience leading groups.

Many groups led by untrained or poorly

trained leaders have not fulfilled their potential

and may even have had negative effects on a

client’s recovery. It matters little whether the

inadequately trained group therapist is a person who once abused substances or someone

who developed knowledge in a traditional

course of academically based training. Where

problems exist, they usually relate to one of two

deficiencies: a lack of effective group therapy

training or use of a group therapy model that is

inadequate for clients who are chemically

dependent. Additional training and education

is needed to produce therapists who are well

qualified to lead therapy groups composed primarily of individuals who are chemically

dependent.

A second major improvement needed if people

who have addictions are to benefit from group

therapy is a clear answer to the question,

“Why is group therapy so effective for people

with addictions?” We already have part of the

answer, and it lies in the individual with addiction, a person whose character style often

involves a defensive posture commonly referred

to as denial. Addiction is, in fact, frequently

referred to as a disease of denial.

Groups instill

hope, a sense that

“If he can make it,

so can I.” 

The individual who is

chemically dependent

usually comes into

treatment with an

uncommonly complex

set of defenses and

character pathology.

Any group leader who

intends to help people

who have addictions 

benefit from treatment should have a

clear understanding 

of each group member’s defensive process and character 

dynamics. More than 

20 years ago, John Wallace (1978) wrote about 

this important issue in an informative essay on 

the defensive style of the individual who is 

addicted to alcohol. He referred to these character­related defensive features as the preferred defense system of the individual addicted to alcohol. 

A third major modification needed is the adaptation of the group therapy model to the treatment of substance abuse. The principles of 

group therapy need to be tailored to meet the 

realities of treating clients with substance use 

disorders. 

For the most part, group therapy has been 

based on a model derived from outpatient therapy for clients whose problems may or may not 

include substance abuse. The theoretical 

underpinnings and practical applications of 

general group therapy are not always applicable to individuals who abuse substances. 

Groups and Substance Abuse Treatment 7
Substance abuse treatment sometimes is implemented as a grab bag of strategies, approaches,

and techniques that were not tailored for people with substance use disorders. Further, the

common characteristics and typical dynamics

seen in this population have not always been

evaluated adequately, and this lapse has inhibited the development of effective methods of

treatment for these clients.

This model suitability problem is further complicated by the fact that clients with substance

use disorders, and even staff members, often

become confused about the different types of

group treatment modalities. For instance, in

the course of their treatment, clients may

engage in AA, Narcotics Anonymous, other

12­Step groups, discussion groups, educational

groups, continuing care groups, and support

groups. Given this mix, clients often become

confused about the

purpose of group

therapy, and the

treatment staff sometimes underestimates

the impact that

group therapy can

make on an individual’s recovery.

This TIP will help

counselors expand

their awareness

and comprehension of dynamics

occurring in their

treatment groups.	 

The upshot of these

problems has been

partial or complete

failure; that is, the

techniques and

strategies that usually work with the general psychiatric population often do not

work with people

abusing substances.

A further negative result is that the clients who

have addictions may be unfairly viewed as poor

treatment risks—people resistant to treatment

and unmotivated to change.

Time also is an important factor in a person’s

recovery. What a group leader does in group

therapy with clients in an inpatient setting in a

hospital during the first few days or weeks of

recovery will differ dramatically from what

that same group therapist will do with the same

recovering person in a continuing care group 6

months into abstinence with the expectation

that the person will remain in the group at least

another 6 to 12 months.

Approach of This TIP

While this TIP does not provide the training

needed to become an interpersonal process

group therapist, the point of view, attitudes,

and considerations of these group therapists

infuse the discussions throughout this TIP. The

panel hopes that this TIP will help counselors

expand their awareness and comprehension

of dynamics that might be going on in their

current substance abuse treatment groups.

These insights will help counselors become better prepared to manage their groups and their

individual members, inform group members’

individual therapists of possible issues that

need resolution, record dynamics and issues

for use in treatment during later stages of

recovery, and improve retention by appropriately acknowledging issues that are outside the

scope of the group. The TIP will achieve its

purpose to the extent that it assists counselors

as they juggle immediate client needs, interactions in groups, tasks leading to recovery, and

sheer human complexity.

8 Groups and Substance Abuse Treatment
2 Types of Groups

Commonly Used in

Substance Abuse

Treatment

In This 

Chapter... 

Five Group Models

Psychoeducational Groups 

Skills Development Groups 

Cognitive–Behavioral 

Groups

Support Groups

Interpersonal Process

Group Psychotherapy

Specialized Groups

in Substance Abuse

Treatment

Relapse Prevention

Communal and

Culturally Specific Groups

Expressive Groups

Groups Focused on 

Specific Problems 

Overview

This chapter presents five models of groups used in substance abuse

treatment, followed by three representative types of groups that do not

fit neatly into categories, but that, nonetheless, have special significance

in substance abuse treatment. Finally, groups that vary according to

specific types of problems are considered. The purpose of the group,

its principal characteristics, necessary leadership skills and styles, and

typical techniques for these groups are described.

Introduction

Substance abuse treatment professionals employ a variety of group

treatment models to meet client needs during the multiphase process of

recovery. A combination of group goals and methodology is the primary

way to define the types of groups used. This TIP describes five group

therapy models that are effective for substance abuse treatment:

• Psychoeducational groups

• Skills development groups

• Cognitive–behavioral/problemsolving groups

• Support groups

• Interpersonal process groups

Each of the models has something unique to offer to certain populations;

and in the hands of a skilled leader, each can provide powerful therapeutic experiences for group members. A model, however, has to be

matched with the needs of the particular population being treated; the

goals of a particular group’s treatment also are an important determinant of the model that is chosen.

This chapter describes the group’s purpose, principal characteristics,

leadership requisites, and appropriate techniques for each type of

group. Also discussed are three specialized types of groups that do not fit

9
into the five model categories, but that function

as unique entities in the substance abuse treatment field:

•Relapse prevention treatment groups

•Communal and culturally specific treatment

groups

•Expressive groups (including art therapy,

dance, psychodrama)

Figure 2­1 lists some groups commonly used in

substance abuse treatment and classifies them

into the five­model framework used in this TIP.

This list of groups is by no means exhaustive,

but it demonstrates the variety of groups found

in substance abuse treatment settings.

Occasionally, discussions in this TIP refer to

the stages of change delineated by Prochaska

and DiClemente (1984). They examined 18 psychological and behavioral theories of how

change occurs, including the components of a

biopsychosocial framework for understanding

substance abuse. Their result was a continuum

of six categories for understanding client motivation for changing substance abuse behavior.

The six stages are:

•Precontemplation. Clients are not thinking

about changing substance abuse behavior

and may not consider their substance abuse

to be a problem.

•Contemplation. Clients still use substances,

but they begin to think about cutting back or

quitting substance use.

•Preparation. Clients still use substances, but

intend to stop since they have recognized the

advantages of quitting and the undesirable

consequences of continued use. Planning for

change begins.

•Action. Clients choose a strategy for discontinuing substance use and begin to make the

changes needed to carry out their plan. This

period generally lasts 3–6 months.

•Maintenance. Clients work to sustain

abstinence and evade relapse. From this

stage, some clients may exit substance use

permanently.

•Recurrence. Many clients will relapse and

return to an earlier stage, but they may move

quickly through the stages of change and may

have gained new insights into problems that

defeated their former attempts to quit substance abuse (such as unrealistic goals or

frequenting places that trigger relapse).

For a detailed description of the stages of

change, see TIP 35, Enhancing Motivation for

Change in Substance Abuse Treatment (Center

for Substance Abuse Treatment [CSAT] 1999b).

The client’s stage of change will dictate which

group models and methods are appropriate at a

particular time. If the group is composed of

members in the action stage who have clearly

identified themselves as substance dependent,

the group will be conducted far differently

from one composed of people who are in the

precontemplative stage. Priorities change with

time and experience, too. For example, a group

of people with substance use disorders on their

second day of abstinence is very different from

a group with 1 or 2 years of sobriety.

Theoretical orientations also have a strong

impact on the tasks the group is trying to

accomplish, what the group leader observes

and responds to in a group, and the types of

interventions that the group leader will initiate.

Before a group model is applied in treatment,

the group leader and the treating institution

should decide on the theoretical frameworks to

be used, because each group model requires

different actions on the part of the group leader. Since most treatment programs offer a variety of groups for substance abuse treatment, it

is important that these models be consistent

with clearly defined theoretical approaches.

In practice, however, groups can, and usually

do, use more than one model, as shown in

Figure 2­1. For example, a therapy group in an

intensive early recovery treatment setting might

combine elements of psychoeducation (to show

how drugs have ravaged the individual’s life),

skills development (to help the client maintain

abstinence), and support (to teach individuals

how to relate to other group members in an

honest and open fashion). Therefore, the

10 Types of Groups Commonly Used in Substance Abuse Treatment
Figure 2­1

Groups Used in Substance Abuse Treatment 

and Their Relation to Six Group Models

Source: Consensus Panel. *See “Specialized Groups in Substance Abuse Treatment” on p. 29.

Group Types æ Group Model or Combination of Models 

Skills 

Development 

Cognitive– 

Behavioral 

Therapy 

Interpersonal 

Process 

Support Specialized 

Group* 

Psychoeducational 

Anger/feelings management • • •

Co­occurring disorders • •

Skills­building • •

Conflict resolution • • •

Relapse prevention • • • •

12­Step psychoeducational • •

Psychoeducational •

Trauma (abuse, violence) • • •

Early recovery • • • •

Substance abuse education •

Spirituality­based •

Cultural • •

Psychodynamic • •

Ceremonial healing practices •

Support •

Family roles (psychoeducational) •

Expressive therapy •

Relaxation training •

Meditation •

Multiple­family • • •

Gender specific • •

Life skills training • •

Health and wellness •

Cognitive–behavioral • • •

Psychodrama •

Adventure­based •

Marathon •

Humanistic/existential • •

Types of Groups Commonly Used in Substance Abuse Treatment 11
descriptions of the groups in this chapter are of

ideal, pure forms that rarely stand alone in

practice. It must be acknowledged, too, that

the terms used to describe groups are not altogether clear­cut and consistent. In different

treatment settings, programs, and regions of

the country, a term like “support group” may

be used to refer to different types of treatment

groups, including a relapse prevention group.

Despite such discrepancies between neat theory

and untidy practice, little difficulty will arise if

the group leader exercises sound clinical judgment regarding models and interventions to be

used. One exception to this assurance, however,

should be noted. Close adherence to the theory

that dictates the way an interpersonal process

group should be conducted has crucial implications for its success.

Five Group Models

Figure 2­2 summarizes the characteristics of

five therapeutic group models used in substance abuse treatment. Variable factors

include the focus of group attention, specificity

of the group agenda, heterogeneity or homogeneity of group members, open­ended or

determinate duration of treatment, level of

facilitator or leader activity, training required

for the group leader, length of sessions, and

preferred arrangement of the room.

Psychoeducational Groups

Psychoeducational groups are designed to educate clients about substance abuse, and related

behaviors and consequences. This type of group

presents structured, group­specific content,

often taught using videotapes, audiocassette, or

lectures. Frequently, an experienced group

leader will facilitate discussions of the material

(Galanter et al. 1998). Psychoeducational

groups provide information designed to have a

direct application to clients’ lives—to instill

self­awareness, suggest options for growth and

change, identify community resources that can

assist clients in recovery, develop an understanding of the process of recovery, and

prompt people using substances to take action

on their own behalf, such as entering a treatment program. While psychoeducational

groups may inform clients about psychological

issues, they do not aim at intrapsychic change,

though such individual changes in thinking and

feeling often do occur.

Purpose. The major purpose of psychoeducational groups is expansion of awareness about

the behavioral, medical, and psychological consequences of substance abuse. Another prime

goal is to motivate the client to enter the recovery­ready stage (Martin et al. 1996; Pfeiffer et

al. 1991). Psychoeducational groups are provided to help clients incorporate information

that will help them establish and maintain

abstinence and guide them to more productive

choices in their lives.

These groups also can be used to counteract

clients’ denial about their substance abuse,

increase their sense of commitment to continued treatment, effect changes in maladaptive

behaviors (such as associating with people who

actively use drugs), and supporting behaviors

conducive to recovery. Additionally, they are

useful in helping families understand substance

abuse, its treatment, and resources available

for the recovery process of family members.

Some of the contexts in which psychoeducational groups may be most useful are

•Helping clients in the precontemplative or

contemplative level of change to reframe the

impact of drug use on their lives, develop an

internal need to seek help, and discover

avenues for change.

•Helping clients in early recovery learn more

about their disorders, recognize roadblocks

to recovery, and deepen understanding of the

path they will follow toward recovery.

•Helping families understand the behavior of

a person with substance use disorder in a

way that allows them to support the individual in recovery and learn about their own

needs for change.

•Helping clients learn about other resources

that can be helpful in recovery, such as

12 Types of Groups Commonly Used in Substance Abuse Treatment
Figure 2­2

Characteristics of Five Group Models Used in Substance Abuse Treatment

Group model Group/ 

leader focus 

Specificity of the 

group agenda 

Heterogeneous 

or homogeneous 

Open-ended/ 

determinate 

Level of facili- tator activity 

PsychoeducationalLeader

focused

Specific Either Either High

Skills

development

Leader

focused

Specific Either Either

(depending

on topic)

High

Cognitive–

behavioral

Mixed/

balanced

Either Either Either High

Support Group focus Nonspecific Either Open Low to

moderate

Interpersonal

process

Group focus Nonspecific Heterogeneous Open Low to

moderate

Group 

model 

Level of facilitator activity Duration of 

treatment 

Length of 

session 

Space and 

arrangement 

Leader 

training 

PsychoeducationalHigh Limited by

program

requirements

15 to 90

minutes

Horseshoe

or circle

Basic

Skills

development

High Variable 45 to 90

minutes

Horseshoe

or circle

Basic with

some specialized training

Cognitive–

behavioral

High Variable and

open­ended

60 to 90

minutes

Circle Specialized

training

Support Low to

moderate

Open­ended 45 to 90

minutes

Circle Specialized

training

with processoriented skills

Interpersonal

Process

Low to

moderate

Open­ended 1 to 2 hours Circle Specialized

training in

interpersonal

process groups

meditation, relaxation training, anger 

management, spiritual development, and 

nutrition. 

Principal characteristics. Psychoeducational

groups generally teach clients that they need to

learn to identify, avoid, and eventually master

the specific internal states and external circumstances associated with substance abuse. The

coping skills (such as anger management or the

use of “I” statements) normally taught in a

skills development group often accompany this

learning.

Psychoeducational groups are considered

a useful and necessary, but not sufficient, component of most treatment programs. For

instance, psychoeducation might move clients

Types of Groups Commonly Used in Substance Abuse Treatment 13
in a precontemplative or perhaps contemplative stage to commit to treatment, including

other forms of group therapy. For clients who

enter treatment through a psychoeducational

group, programs should have clear guidelines

about when members of the group are ready

for other types of group treatment.

Often, a psychoeducational group integrates skills development into its program. As part of a

larger program,

psychoeducational

groups have been

used to help clients

reflect on their own

behavior, learn new

ways to confront

problems, and

increase their selfesteem (La Salvia

1993).

Psychoeducational

groups should work

actively to engage

participants in the group discussion and

prompt them to relate what they are learning to

their own substance abuse. To ignore group

process issues will reduce the effectiveness of

the psychoeducational component.

Psychoeducational

groups are highly

structured and

often follow a

manual or a	 

preplanned

curriculum.

Psychoeducational groups are highly structured and often follow a manual or a preplanned curriculum. Group sessions generally

are limited to set times, but need not be strictly

limited. The instructor usually takes a very

active role when leading the discussion. Even

though psychoeducational groups have a format different from that of many of the other

types of groups, they nevertheless should meet

in a quiet and private place and take into

account the same structural issues (for

instance, seating arrangements) that matter in

other groups.

As with any type of group, accommodations

may need to be made for certain populations.

Clients with cognitive disabilities, for example,

may need special considerations. Psychoeducational groups also have been shown to be

effective with clients with co­occurring mental

disorders, including clients with schizophrenia

(Addington and el­Guebaly 1998; Levy 1997;

Pollack and Stuebben 1998). For more information on making accommodations for clients

with disabilities, see TIP 29, Substance Use

Disorder Treatment for People With Physical

and Cognitive Disabilities (CSAT 1998b).

Leadership skills and styles. Leaders in psychoeducational groups primarily assume the

roles of educator and facilitator. Still, they

need to have the same core characteristics as

other group therapy leaders: caring, warmth,

genuineness, and positive regard for others.

Leaders also should possess knowledge and

skills in three primary areas. First, they should

understand basic group process—how people

interact within a group. Subsets of this knowledge include how groups form and develop,

how group dynamics influence an individual’s

behavior in group, and how a leader affects

group functioning. Second, leaders should

understand interpersonal relationship dynamics, including how people relate to one another

in group settings, how one individual can influence the behavior of others in group and some

basic understanding of how to handle problematic behaviors in group (such as being withdrawn). Finally, psychoeducational group leaders need to have basic teaching skills. Such

skills include organizing the content to be

taught, planning for participant involvement in

the learning process, and delivering information

in a culturally relevant and meaningful way.

To help clients get the most out of psychoeducational sessions, leaders need basic counseling

skills (such as active listening, clarifying, supporting, reflecting, attending) and a few

advanced ones (such as confronting and terminating) (Brown 1998). It also helps to have

leadership skills, such as helping the group

get started in a session, managing (though not

necessarily eliminating) conflict between group

members, encouraging withdrawn group members to be more active, and making sure that

14 Types of Groups Commonly Used in Substance Abuse Treatment
all group members have a chance to participate.

As the group unfolds, it is important that group

leaders are nondogmatic in their dealings with

group members. Finally, the group leader

should have a firm grasp of material being

communicated in the psychoeducational group.

During a session, the group leader should be

mindful both of the group’s need and the specific needs of each member. The group leader

will need to understand group member roles

and how to manage problem clients. Except in

unusual circumstances, efforts should be made

to increase members’ comfort and to reduce

anxiety in the group. Leaders will use a variety

of resources to impart knowledge to the group,

so each session also requires preparation and

familiarization with the content to be delivered.

Group leaders should have ongoing training

and formal supervision. Supervision benefits

all group leaders of all levels of skill and training, as it helps to assure them that people in

positions of authority are interested in their

development and in their work. If direct supervision is not possible (as may be the case in

remote, rural areas), then Internet discussions

or regular telephone contact should be used.

Techniques. Techniques to conduct psychoeducational groups are concerned with (1) how

information is presented, and (2) how to assist

clients to incorporate learning so that it leads to

productive behavior, improved thinking, and

emotional change. Adults in the midst of crises

in their lives are much more likely to learn

through interaction and active exploration than

they are through passive listening. As a result, it

is the responsibility of the group leader to

design learning experiences that actively engage

the participants in the learning process. Four

elements of active learning can help.

First, the leader should foster an environment

that supports active participation in the group

and discourages passive note taking.

Accordingly, leader lecturing should be limited

in duration and extent. The leader should concentrate instead on facilitating group discussion,

especially among clients who are withdrawn and

have little to say. They need support and understanding of the content before expressing their

views. Techniques such as role playing, group

problemsolving exercises, and structured experiences all foster active learning.

Second, the leader should encourage group

participants to take responsibility for their

learning rather than passing on that responsibility to the group leader. From the outset of

the group, the leader can emphasize group selfownership by allowing members to participate

in setting agreements and other group boundaries. The leader can emphasize member

responsibility for honest, respectful interaction

among all members and can de­emphasize the

leader role in determining group life.

Third, because many people have pronounced

preferences for learning through a particular

sense (hearing, sight, touch/movement), it is

essential to use a variety of learning methods

that call for different kinds of sensory experience. Excellent material on adapting instruction to learning styles is available through the

Association for Supervision and Curriculum

Development Web site. To access the many articles and book chapters, enter “learning styles”

into the search function and click the “Go”

button.

Most people, at one time or another, have had

unpleasant experiences in traditional, formal

classroom environments. The resulting shame,

rejection, and self­deprecation strongly motivate people to avoid situations where these

experiences might be brought back into awareness. Therefore it is critically important for the

group leader to be sensitive to the anxiety that

can be aroused if the client is placed in an environment that replicates a disturbing scene from

the past. To allay some of these concerns, leaders can acknowledge the anxieties of participants, prevent all group participants from

mocking others’ comments or ideas, and show

sensitivity to the meaning of a participant’s

withdrawal in the group. Overall, leaders

should create an environment where participants who are having difficulty with the

psychoeducational group process can express

their concerns and receive support.

Types of Groups Commonly Used in Substance Abuse Treatment 15
Fourth, people with alcoholism and other

addictive disorders are known to have subtle,

neuropsychological impairments in the early

stage of abstinence. Verbal skills learned long

ago (that is, crystallized intelligence) are not

affected, but fluid intelligence, needed to learn

some kinds of new information, is impaired. As

a result, clients may seem more able to learn

than they actually are. Therapists who are

teaching new skills should be mindful of

this difficulty.

Skills Development Groups

Most skills development groups operate from a

cognitive–behavioral orientation, although

counselors and therapists from a variety of

orientations apply skills development techniques in their practice. Many skills development groups incorporate psychoeducational

elements into the group process, though skills

development may remain the primary goal of

the group.

Purpose. Coping skills training groups (the

most common type of skills development group)

attempt to cultivate the skills people need to

achieve and maintain abstinence. These skills

may either be directly related to substance use

(such as ways to refuse offers of drugs, avoid

triggers for use, or cope with urges to use) or

may apply to broader areas relevant to a

client’s continued sobriety (such as ways to

manage anger, solve problems, or relax).

Skills development groups typically emerge

from a cognitive–behavioral theoretical

approach that assumes that people with substance use disorders lack needed life skills.

Clients who rely on substances of abuse as a

method of coping with the world may never

have learned important skills that others have,

or they may have lost these abilities as the

result of their substance abuse. Thus, the

capacity to build new skills or relearn old ones

is essential for recovery.

Since many of the skills that people with

substance abuse problems need to develop are

interpersonal in nature, group therapy

becomes a natural treatment of choice for skills

development. Members can practice with each

other, see how different people use the same

skills, and feel the positive reinforcement of a

peer group (rather than that of a single professional) when they use skills effectively.

Principal characteristics. Because of the

degree of individual variation in client needs,

the particular skills taught to a client should

depend on an assessment that takes into

account individual characteristics, abilities,

and background. The suitability of a client for

a skills development group will depend on the

unique needs of the individual along with the

skills being taught. Most clients can benefit

from developing or enhancing certain general

skills, such as controlling powerful emotions or

improving refusal skills when around people

using alcohol or illicit drugs. Skills might also

be highly specific to certain clients, such as

relaxation training.

Skills development groups usually run for a

limited number of sessions. The size of the

group needs to be limited, with an ideal range

of 8 to 10 participants (perhaps more, if a

cofacilitator is present). The group has to be

small enough for members to practice the skills

being taught.

While skills development groups often incorporate elements of psychoeducation and support,

the primary goal is on building or strengthening

behavioral or cognitive resources to cope better

in the environment. Psychoeducational groups

tend to focus on developing an information base

on which decisions can be made and action

taken. Support groups, to be discussed later in

this chapter, focus on providing the internal and

environmental supports to sustain change. All

are appropriate in substance abuse treatment.

While a specific group may incorporate elements

of two or more of these models, it is important to

maintain focus on the overall goal of the group

and link methodology to that goal.

Leadership skills and styles. In skills development groups, as in psychoeducation, leaders

need basic group therapy knowledge and skills,

such as understanding the ways that groups

16 Types of Groups Commonly Used in Substance Abuse Treatment
grow and evolve, knowledge of the patterns

that show how people relate to one another in

group, skills in fostering interaction among

members, managing conflict that inevitably

arises among members in a group environment,

and helping clients take ownership for the

group.

In addition, group leaders should know and be

able to demonstrate the set of skills that the

participants are trying to develop. Leaders also

will need significant experience in modeling

behavior and helping others learn discrete elements of behavior. Other general skills, such as

sensitivity to what is going on in the room and

cultural sensitivity to differences in the ways

people approach issues like anger or assertiveness, also will be important. Depending on the

skill being taught, there may be certain educational or certification requirements. For example, a nurse might be needed to teach specific

health maintenance skills, or a trained facilitator may be needed to run certain meditation or

relaxation groups.

Techniques. The specific techniques used in a

skills development group will vary greatly

depending on the skills being taught. (For more

information on the techniques used in cognitive–behavioral coping skills training see chapter 4 of TIP 34, Brief Interventions and Brief

Therapies for Substance Abuse Treatment

[CSAT 1999a].)

It is useful to keep in mind that most skills,

such as riding a bicycle or swimming, seem relatively simple, straightforward, and easy once

incorporated into one’s repertoire of behavior.

The process of learning and incorporating new

skills, however, may be difficult, especially if

the previous approach has been used for a long

time. For instance, individuals who have been

passive and nonassertive throughout life may

have to struggle mightily to learn to stand up

for themselves. As a consequence, it is crucial

for leaders of skills development groups to be

sensitive to the struggles of group participants,

hold positive expectations for change, and not

demean or shame individuals who seem overwhelmed by the task.

Furthermore, many

behavioral changes

that seem straightforward on the surface

have powerful effects

at deeper levels of

psychological functioning. For instance,

assertiveness may

touch feelings of

shame and unworthiness. Thus, new 

assertive competence

may be incompatible 

with and overwhelmed by deep feelings of inadequacy 

and low self­esteem. As a result, a client may 

learn a new behavior, but be unable to incorporate it into a repertoire of positive action. 

Counselors should not automatically assume, 

therefore, that a newly learned skill inevitably 

will translate into action. Feedback from participants on their progress since the last group 

is a good way to assess both learning and the 

incorporation of skills. 

Skills development

groups typically

emerge from a cognitive–behavioral

approach. 

An often unstated and underrecognized difficulty in leading skills groups is that a leader 

teaching the same material week after week can 

become bored with the content. In due course, 

the boredom will creep into the teaching. To 

retain energy and teaching effectiveness, leaders can switch topics, or one leader can teach 

different topics over time. When feasible, it 

also may help to provide feedback to leaders 

by making video or audio recordings of their 

presentations. 

Other specific techniques for skills development groups depend on the nature of the 

group, topic, and approach of the group leader. Before undertaking leadership of a skills 

development group, it is wise for the leader to 

have previously participated in the specific 

kind of skills development group to be led. 

Often special training programs are available 

for leaders of these kinds of groups. 

Types of Groups Commonly Used in Substance Abuse Treatment 17
Cognitive–Behavioral Groups

Cognitive–behavioral groups are a wellestablished part of the substance abuse treatment field and are particularly appropriate in

early recovery. The term “cognitive–behavioral

therapy group” covers a wide range of formats

informed by a variety of theoretical frameworks, but the common thread is cognitive

restructuring as the basic methodology of

change.

Purpose. Cognitive–behavioral groups conceptualize dependency as a learned behavior that

is subject to modification through various

interventions, including identification of conditioned stimuli associated with specific addictive

behaviors, avoidance of such stimuli, development of enhanced contingency management

strategies, and response­desensitization

(McAuliffe and Ch’ien 1986). The etiologies of

dependency include neurobehavioral factors

(Rawson et al. 1990), biopsychosocial (NunesDinis and Barth 1993; Wallace 1990), and the

disease model (Miller and Chappel 1991), in

which the key etiological determinants of

dependency are genetic and physiological factors, ones that the person with dependency

cannot control.

Cognitive–behavioral therapy groups work to

change learned behavior by changing thinking

patterns, beliefs, and perceptions. The groups

also work to develop

social networks that

support continued

abstinence so the

person with dependency becomes

aware of behaviors

that may lead to

relapse and develops

strategies to continue in recovery

(Matano et al. 1997).

Cognitive–	 

behavioral groups

are particularly

appropriate in

early recovery. Cognitive processes

include a number of

different psychological elements, such as

thoughts, beliefs,

decisions, opinions, and assumptions. A number of thoughts and beliefs are affected by an

individual’s substance abuse and addiction.

Some common errant beliefs of individuals

entering recovery are

•“I’m a failure.”

•“I’m different.”

•“I’m not strong enough to quit.”

•“I’m unlovable.”

•“I’m a (morally) bad person.” The word

“morally” carries the implication of a “shame

script” and feeling defective as a person.

“Bad” alone refers more to behavior, or

doing “bad things.”

Changing such cognitions and beliefs may lead

to greater opportunities to maintain sobriety

and live more productively.

Principal characteristics. In cognitive– 

behavioral groups for people who abuse 

substances, the group leader focuses on providing a structured environment within which

group members can examine the behaviors,

thoughts, and beliefs that lead to their maladaptive behavior. Treatment manuals—

providing specific protocols for intervention

techniques—may be helpful in some, though

not all, cognitive–behavioral groups. In any

case, most cognitive–behavioral groups

emphasize structure, goal orientation, and a

focus on immediate problems. Problem

solving groups often have a specific protocol

that systematically builds problemsolving

skills and resources.

One example is a model cognitive–behavioral

group for women with posttraumatic stress disorder (PTSD) and substance abuse designed to

•Educate clients about the two disorders

•Promote self­control skills to manage overwhelming emotions

•Teach functional behaviors that may have

deteriorated as a result of the disorders

•Provide relapse prevention training (Najavits

et al. 1996)

18 Types of Groups Commonly Used in Substance Abuse Treatment
The group format is an important element of

the model, given the importance of social support for PTSD and substance use disorders. In

addition, group treatment is a well­established,

relatively low­cost modality, so it can successfully reach a large number of clients. Some key

characteristics of this program are that it

•Uses a model designed for 24 sessions, in

which 3–10 members meeting twice each week

for 3 months in 90­minute group meetings

•Is early­recovery–oriented, with a strong

focus on coping skills to gain control over

symptoms

•Has homogeneous membership (for example,

all women)

•Includes a six­session unit on relationships

and themes, such as Safety and Selfprotection and Reaching Out for Help

•Uses educational devices to promote rapid

and sustained learning of material, such as

visual aids, role preparation, memory

improvement techniques, written summaries,

review sessions, homework, and audiotapes

of each session

•Focuses on both disorders, with instruction

on stages of recovery to motivate members to

achieve abstinence and control over PTSD

symptoms (Najavits et al. 1996)

Another cognitive–behavioral model was

employed to reduce the anger that can trigger

renewed use of cocaine among 59 men and 32

women diagnosed with cocaine dependence.

The model assumed that angry responses are

learned behavior that can be changed. Clients

in the pilot program were taught to gauge their

anger levels and to use anger management

strategies like time­outs and conflict resolution.

During the 12 weeks of treatment, participants

were able to reduce and control their anger

more effectively than they had in the past, and

these gains held at the follow­up 3 months after

treatment. Violent behavior also decreased significantly (Reilly and Shopshire 2000).

Leadership skills and styles. Cognitive–behavioral therapies encompass a variety of methodological approaches, all focused on changing

cognition (beliefs, judgments, and perceptions)

and the behavior that flows from it. Some

approaches focus more on behavior, others on

core beliefs, still others on developing problemsolving capabilities. Regardless of the particular focus, the group therapist conducting cognitive–behavioral groups should have a solid

grounding in the broader theory of

cognitive–behavioral therapy. This basis is the

framework from which specific interventions

can be drawn and implemented. Training in

cognitive–behavioral theory is available in

many workshops on counseling skills and in

many alcohol and drug training programs for

counselors. For instance, over a 2­week period

in 2002, the Rutgers Summer Schools of

Alcohol and Drug Studies offered seven weeklong courses that concentrated specifically on

cognitive counseling theory and methods. Many

books are available on the theory of cognitive–behavioral therapy (Beck 1976; Ellis and

MacLaren 1998; Glasser 2000; Leahy 1996) as

well as self­help manuals with a cognitive–

behavioral focus (Burns 1999; Greenberger

and Padesky 1995). See chapter 7 for more

information about training sources.

The level of interaction by the therapist in cognitive–behavioral groups can vary from very

directive and active to relatively nondirective

and inactive. It also can vary from highly confrontational with group members to relatively

nonconfrontational demeanor. Perhaps the

most common leadership style in cognitive–

behavioral groups is active engagement and a

consistently directive orientation.

A cautionary note: In cognitive–behavioral

groups, the leader may be tempted to become

the expert in how to think, how to express that

thinking behaviorally, and how to solve problems. It is important not to yield to such a

temptation, but instead to allow group members to use the power of the group to develop

their own capabilities in these areas.

Techniques. Specific techniques may vary

based on the particular orientation of the leader, but in general, techniques include those

which (1) teach group members about selfTypes of Groups Commonly Used in Substance Abuse Treatment 19
destructive behavior and thinking that leads to

maladaptive behavior, (2) focus on problemsolving and short­ and long­term goal setting,

and (3) help clients monitor feelings and behavior, particularly those associated with drug use.

More experienced leaders will have a wider

range of specific techniques to engage participants and more comfort with a wider range of

client needs and expectations.

An important element of conducting cognitive–

behavioral groups is recognizing that behavioral change and intellectual insight gained in

the group can be provocative and upsetting for

clients with a poor sense of self, low selfesteem, and fear of emotional and interpersonal inadequacy. As a result, resistance to change

inevitably will occur as the group evolves and

behavioral changes begin to become routine.

Experienced leaders learn to recognize,

respect, and work with the resistance instead of

simply confronting it. Clinical supervision is

quite beneficial in learning a variety of styles of

working with resistance generated by growth

and change.

Many specific approaches to cognitive–behavioral therapy, including rational emotive therapy (Ellis 1997), reality therapy (Glasser 1965)

and the work of Aaron Beck and colleagues

(1993), incorporate various techniques specific

to each approach. Substance abuse treatment

counselors may find it useful to explore these

approaches for techniques appropriate to their

specific client populations.

Support Groups

The widespread use of support groups in the

substance abuse treatment field originated in

the self­help tradition in the field. These groups

also have roots in the realization that significant lifestyle change is the long­term goal in

treatment and that support groups can play a

major role in such life transitions. Self­help

groups share many of the tenets of support

groups—unconditional acceptance, inward

reflection, open and honest interpersonal interaction, and commitment to change. These

groups attempt to help people with dependencies sustain abstinence without necessarily

understanding the determinants of their dependence (Cooper 1987).

The focus of support groups can range from

strong leader­directed, problem­focused groups

in early recovery, which focus on achieving

abstinence and managing day­to­day living, to

group­directed, emotionally and interpersonally focused groups in middle and later stages of

recovery.

Purpose. Support groups bolster members’

efforts to develop and strengthen the ability to

manage their thinking and emotions and to

develop better interpersonal skills as they

recover from substance abuse. Support group

members also help each other with pragmatic

concerns, such as maintaining abstinence and

managing day­to­day living. These groups are

also used to improve members’ general selfesteem and self­confidence. The group—or

more often, the group leader—provides specific

kinds of support, such as being sure to help

clients avoid isolation and finding something

positive to say about each participant’s contribution. In some programs, support groups

might be considered process (therapy) groups,

but the main interest of support groups is

not in the intrapsychic world, and the goal

is not character change. Process issues may

be involved, but support groups are less

complex, more direct, and narrower in focus

than process groups.

Principal characteristics. Many people with

substance use disorders avoid treatment

because the treatment itself threatens to

increase their anxiety. Because of support

groups’ emphasis on emotional sustenance

providing a safe environment, these groups are

especially useful for apprehensive clients,

indeed, for any client new to abstinence. The

adjective “support” itself may be a way of

destigmatizing the activity. For this reason, a

“support” group may be more attractive to

someone less committed to recovery than a

“therapy” group.

Not all support groups, however, are intended

just for clients new to recovery. Support groups

20 Types of Groups Commonly Used in Substance Abuse Treatment
can be found for all stages of treatment in all

sorts of settings (inpatient, outpatient, continuing care, etc.). While a support group always

will have a clearly stated purpose, the purpose

varies according to its members’ motivation

and stage of recovery. Many of these groups are

open­ended, with a changing population of

members. As new clients move into a particular

stage of recovery, they may join a support

group appropriate for that stage until they are

ready to move on again. Groups may continue

indefinitely, with new members coming in and

old members leaving, and occasionally, returning. Program differences will also alter how this

type of group is used. A support group will be

different in a 4­ to 6­week daily treatment program from the way it is used in a 1­year treatment community.

In a support group, members typically talk

about their current situation and recent problems that have arisen. Discussion usually focuses on the practical matters of staying abstinent;

for example, ways to deal with legal issues or

avoid places that tempt people to use substances. Group members are encouraged to

share and discuss their common experiences.

Issues that do not specifically relate to the

focus of the group are often considered extraneous, so discussion of them is limited. Support

groups provide guidance through peer feedback, and group members generally require

accountability from each other. The group

leader, however, will try to minimize confrontation within the group so as to keep anxiety levels low. In cohesive, highly functioning support

groups, member­to­member or leader­to­member confrontation does occur.

Support groups can work from a variety of theoretical positions. Many reflect the 12­Step tradition in the substance abuse field, but other

recovery tools, such as relapse prevention, can

form the basis of a support group. Some support groups are based on theoretical frameworks such as cognitive therapies or spiritual

paths. Programs may even design a support

group by combining theories or philosophies.

Leadership skills and styles. Some support

groups may be peer­generated or peer­led, but

this TIP is mainly concerned with groups led

by a trained, professional group leader.

Support group leaders need a solid grounding

in how groups grow and evolve and the ways

in which people interact and change in groups.

It is also critical that group leaders have a

theoretical framework for counseling (such as

cognitive–behavioral therapy) that informs

their approach to support group development,

the therapeutic goals for group members, the

guidance of group members’ interactions, and

the leader’s implementation of specific

intervention methods.

Since the leader

should help build connections between

members and emphasize what they have in

common, it is useful

for the leader to have

participated in a support group and to

have been supervised

in support group

work before undertaking leadership of

such a group.

Training and supervision focused on how

individuals develop

psychologically, typical psychological conflicts, and the way these conflicts may appear

in group therapy settings also may help the

support group leader function more effectively,

since such considerations help the leader

understand individual members’ behavior in

the group.

In a support

group, members

typically talk

about their current situation and

problems that

have recently

arisen.

The leadership style for someone running a

support group typically will be less directive

than for psychoeducational, skills development, or cognitive–behavioral groups because

the support group is generally group­focused

rather than leader­focused. The leader’s primary role is to facilitate group discussion, helping group members share their experiences,

grapple with their problems, and overcome difficult challenges. The group leader also provides positive reinforcement for group memTypes of Groups Commonly Used in Substance Abuse Treatment 21
bers, models appropriate interactions between

individuals in the group, respects individual

and group boundaries, and fosters open and

honest communication in the group setting. In

a most general way, the leader is active but not

directive.

Techniques. The techniques of leading support

groups vary with group goals and member

needs. In general, leaders need to actively

facilitate discussion among members, maintain

appropriate group boundaries, help the group

work though obstacles and conflicts, and provide acceptance of and regard for members. In

a support group, the leader exercises the role

of modeler of appropriate behaviors. In this

way, the leader helps members grow and

change.

Specific group techniques may appear to be

less important for the leader of a support

group, since the leader is usually less active in

group direction and leadership. The techniques

used in support groups, however, are simply

less obvious.

Interventions, for example, are likely to be

more interpretive and observational and less

directive than in many other groups. The

observations are generally limited to support

for the progress of the group and facilitating

supportive interaction among group

members. The goal

is not to provide

insight to group

members, but to

facilitate the evolution of support within the group.

Process­oriented	 

group therapy

uses the process of

the group as the

primary change

mechanism.

The support group

leader is also responsible for monitoring

each individual’s

progress in group

and ensuring that

individuals are participating (in their

own way) and benefiting from the group

experience. Understanding some of the history

of each person in the group, the leader also

watches to see whether the group is providing

each individual with emotional and interpersonal experiences that build success and skills

that apply to life arenas outside the group. In

addition to monitoring individuals in the

group, the leader also monitors the progress of

the group as a whole, making sure that group

development proceeds through its predictable

stages and does not become blocked at any

stage of its evolution.

Finally the leader is responsible for recognizing

interpersonal blocks or struggles between

group members. It is not necessarily the

responsibility of the leader to resolve these

blocks, or even to point them out to group

members, but to ensure that such struggles

do not hinder the development of the group or

any member of the group.

Interpersonal Process Group

Psychotherapy

The interpersonal process group model for

substance abuse treatment is grounded in an

extensive body of theory (Brown 1985; Brown

and Yalom 1977; Flores 1988; Flores and

Mahon 1993; Khantzian et al. 1990; Matano

and Yalom 1991; Vannicelli 1992; Washton

1992). Even this sharply defined area of process­oriented group therapies is widely diverse.

Psychodynamic group therapies can be thought

of as a generic name encompassing several ways

of looking at the dynamics that take place in

groups. Originally, these dynamics were considered in Freudian psychoanalytic terms that

placed a heavy emphasis on sexual and aggressive drives, and conflicts and attachments

between parents and children. Over the past

half century many researchers, such as Jung,

Adler, Bion, Noreno, Rogers, Perls, Yalom,

and others, expanded or changed the Freudian

emphasis. As a result, current dynamic conceptualizations include heavy emphasis on the

social nature of human attachment, rivalry and

social hierarchies, and cultural and spiritual

concerns (i.e., existential issues and questions

22 Types of Groups Commonly Used in Substance Abuse Treatment
of faith). This therapeutic approach focuses on

healing by changing basic intrapsychic (within

a person) or interpersonal (between people)

psychological dynamics.

Thus, a student of process­oriented group therapy, a group treatment approach that uses the

process of the group as the primary change

mechanism, soon learns that the way Bion

(1961) taught group therapy will be far different from the way other recognized authorities,

such as Wolf and Schwartz (1962), taught.

These theorists in turn differ from the processorientation exemplified by Durkin (1964) or

Glatzer (1969). The many theoretical variants

differ in what they pay most of their attention

to as group members interact.

Purpose. Interpersonal process groups use

psychodynamics, or knowledge of the way people function psychologically, to promote change

and healing. The psychodynamic approach recognizes that conflicting forces in the mind,

some of which may be outside one’s awareness,

determine a person’s behavior, whether healthy

or unhealthy. Attachment to others is one of

the contending forces. From a psychodynamic

point of view, starting in early childhood,

developmental issues are a key concern, as are

environmental influences, to which certain people are particularly vulnerable because of their

genetic and other biological characteristics. For

those people who have been drawn to substance

abuse, the interpersonal process group raises

and re­examines fundamental developmental

issues. As faulty relationship patterns are perceived and identified, the group participant

can begin to change dysfunctional, destructive

patterns. The group member becomes increasingly able to form mutually satisfying relationships with other people, so alcohol and drugs

lose much of their power and appeal.

Basic tenets of the psychodynamic approach

include the following

•Early experience affects later experience.

Individuals bring their histories—personal,

cultural, psychological, and spiritual—to

therapy.

•Sometimes perceptions distort reality. People

often draw generalizations from their life

experiences and apply the generalizations to

the current environment, even when doing so

is inappropriate or counterproductive. These

“cognitive distortions” may serve to maintain

habits people would otherwise like to change.

•Psychological and cognitive processes outside

awareness influence behavior. As clients

become conscious of some formerly subconscious processes supporting a behavior they

want to change, this information can be used

to alter dysfunctional relationships.

•Behaviors are chosen to adapt to situations

and protect people from harm. A specific

behavior is a person’s best effort to adapt to

a particular situation given individual makeup, environment, and personal history. In a

sense, people come to therapy because of

their solutions, not their problems.

Within the interpersonal process model, the

objects of interest are the here­and­now interactions among members. Of less importance is

what happens outside the group or in the past.

All therapists using a “process­oriented group

therapy” model continually monitor three

dynamics:

•The psychological functioning of each group

member (intrapsychic dynamics)

•The way people are relating to one another in

the group setting (interpersonal dynamics)

•How the group as a whole is functioning

(group­as­a­whole dynamics)

A group leader conducting an interpersonal

process group, however, will tend to pay more

attention to the interpersonal dynamics and

concentrate less on each member’s individual

psychological dynamics and the workings of the

group as a whole. The section that follows

includes illustrations (Figures 2­3 to 2­6) of how

groups might differ according to their focus on

intrapsychic, interpersonal, and group­as­awhole dynamics.

The experienced group leader knows that the

intervention chosen at any moment in the group

will have an impact on all three dynamics and

Types of Groups Commonly Used in Substance Abuse Treatment 23
that a delicate balance must be struck in the

attention given to each. A too­intense focus on

group members’ interaction, to the exclusion of

attention to individual psychological needs or

the needs of the group as a whole, blunts the

effectiveness and relevance of group development.

Principal characteristics. Interpersonal process group therapy delves into major developmental issues, searching for patterns that contribute to addiction or interfere with recovery.

The group becomes a microcosm of the way

group members relate to people in their daily

lives.

The Interpersonal Process Group Psychotherapy (IPGP) model links the abstinence­based

treatment approach with current psychological

principles of treatment, while still remaining

compatible with 12­Step theory and practice.

IPGP and substance abuse treatment both recognize that a person’s capacity for healthy

interpersonal relationships supports solid

recovery from substance abuse. IPGP is easy to

understand and adapt because it is

•Pragmatic. IPGP is a practical, nuts and

bolts, hands­on type of group treatment. It

focuses on results, not abstract concepts and

all­encompassing theories, and its results­oriented nature is especially satisfying to a population that needs some swift, positive outcomes. This feature is especially important

during the early phases of treatment, when

the window of opportunity for influencing

clients is small and open only briefly.

•Applicable. IPGP is a very adaptable model.

Because it can so readily be modified, it can

be applied in diverse sets of difficulties and

under various circumstances. IPGP furnishes the group leader with a set of strategic

tools that are easy to acquire and use. The

IPGP model provides enough structure to

prevent unproductive discussion. This is

especially desirable because few will tolerate a

passive group leader who waits for issues to

evolve out of the flow of the group. On the

other hand, many people who abuse substances will react negatively to a domineering

or authoritarian leader. The IPGP model permits a group experience that is neither leaderdependent nor leader­centered. This generally egalitarian setting helps to reduce resistance.

•Synergistic. IPGP and substance abuse treatment complement each other, reciprocally

setting the scene for the establishment of the

crucial components of effective treatment.

The combination of IPGP and substance

abuse treatment allows the client to experience treatment as emotionally supportive.

This sparing of the client’s self­image enables

the client to identify positively with treatment

and mutes any strong reactions to the counselor. Further, the combination of these two

treatment approaches can ease the client’s

handling of shame, the need to change

aspects of self, the uncomfortable newness of

the recovery period, and the therapeutic

experience itself. Recovery can proceed as

clients experience and re­experience deep

attachment dynamics and use the experience

to craft major changes in character and

behavior.

Leadership skills and styles. In interpersonal

process groups, content is a secondary concern. Instead, leaders focus on the present,

noticing signs of people recreating their past in

what is going on between and among members

of the group. If, for example, a person has a

problem with anger, this problem eventually

will be re­enacted in the group. When an angry

group member, “George,” explodes at

“Charlie,” the therapist might say, “George,

you seem to be having a strong response to

Charlie right now. Who does Charlie remind

you of? Does this feel familiar? Has anything

like this happened to you before?”

On one hand, the interpersonal process group

leader monitors how group members are relating, how each member is functioning psychologically or emotionally, and how the group as a

whole is functioning. On the other hand, the

interpersonal process group leader observes a

variety of group dynamics, such as the stages of

group development, how leadership is emerging

in the group, the strengths each individual is

24 Types of Groups Commonly Used in Substance Abuse Treatment
bringing to the group as a whole, and how individual resistances to change are interacting

with and influencing group functioning. The

interventions of the leader are dependent on

his or her perceptions of this mix.

Since the group leader’s theoretical persuasion,

training, experience, and personality determine

the level of intervention that takes priority at a

particular time, it is rare to find two interpersonal process group leaders who will conduct a

group in exactly the same manner. Even so,

leaders in this type of group are not fonts of

information, skill builders, problemsolving

directors, or client boosters. In interpersonal

process group therapy, the leader’s job is to

promote and probe interactions that carry

a point.

Most group leaders who apply a process­oriented approach to group therapy with people who

abuse substances recognize the theoretical

influence of the Interactional Model (Yalom

1975). Yalom recommends an adaptable

approach to group treatment, one that allows

easily applied modifications across the continuum of the recovery needs of an individual who

abuses substances. His model can be tightened

(to have more structure) early in treatment and

can subsequently be loosened (to relax structure) as more abstinent time passes, recovery is

solidified, and the danger of relapse decreases.

Techniques. In practice, group leaders may use

different models at various times, and may

simultaneously influence more than one focus

level at a time. For example, a group that

focuses on changing the individual will also

have an impact on the group’s interpersonal

relations and the group­as­a­whole. Groups

will, however, have a general orientation that

determines the focus the majority of the time.

This focus is an entry point for the group leader, helping to provide direction when working

with the group.

Specific techniques of the process group leader

will vary, not only with the type of process

group, but also with the developmental stage of

the group. Early on in group development,

process group leaders might consciously decide

to be more or less

active in the group

life. They might also

choose, based on the

needs of the group, to

make more or fewer

interpretations of

individual and group

dynamics to the group

as a whole. Likewise

they might choose to

show more warmth

and supportiveness

toward group members or take a more

aloof position. For

instance, in contrast to leading a support

group, where the leader is likely to be unconditionally affirming, the process leader might

make a conscious decision to allow clients to

struggle to affirm themselves, rather than

essentially doing it for them.

In interpersonal

process groups,

leaders focus on

the present.

Such choices should be based on the needs of

group members and the needs of the group as a

whole, rather than the style that is most comfortable for the group leader. Obviously such

tactical decisions require a high degree of

understanding and insight about group dynamics and individual behavior. For this reason,

almost all leaders of process groups will seek

supervision and consultation to guide them in

making the best tactical decisions on behalf of

the group and its members.

Three group dynamics 

in practice 

When deciding on a model for a substance

abuse treatment group, programs need to consider their resources, the training and theoretical orientation of group leaders, and the needs

and desires of clients in order to determine

what approaches are feasible. While it is

beyond the scope of this TIP to provide

detailed instruction on how to run each of the

different models of groups, the following figures

do illustrate the basic differences among the

psychodynamic emphases. Figure 2­3 describes

an argument drawn from a problem­focused

Types of Groups Commonly Used in Substance Abuse Treatment 25
group, which assists people in resolving a specific problem in their lives. (For additional

information on this type of group, see the last

section in this chapter. The reader also may

refer to appendix B of TIP 34, Brief

Interventions and Brief Therapies for

Substance Abuse [CSAT 1999a], for a list of

resources that can provide further training and

information about the theoretical orientations

that influence these groups.)

Figure 2­3

Group Vignette: Joe’s Argument With His Roommate

Source: Adapted from Flores 1997.

Before the first meeting of a new problem­focused group, Joe had been arguing

with his roommate because the roommate had forgotten to pay the phone bill the

previous month. Joe had told his roommate, Mike, that he might remember to

pay the bills on time if he were not smoking pot every day, and they began an

angry discussion about the roommate’s drug use. Joe tells the group that he wants

to talk about his distrust of his roommate. Joe is not currently using drugs, but

he is still struggling with attempts to control his drinking. Group members are

generally supportive of Joe in his argument with his roommate. They express

concern that he is living with someone who is actively using marijuana and other

drugs. One group member, Jane, voices strong objections, however, to Joe’s lack

of trust for his roommate. Jane is struggling with her own abuse of prescription

tranquilizers, and she is typically rather quiet and anxious in group.

Nonetheless, she attacks Joe verbally with uncharacteristic vehemence.

Individually focused groups

The individually focused group concentrates on

individual members of the group and their distinctive internal cognitive and emotional processes. How the client interacts in the world at

large is not on the agenda. The group instead

strives to modify clients’ behavior. This model

is used with a range of technical and theoretical

approaches to group therapy, including cognitive therapy, expressive therapies, psychodrama, transactional analysis, redecision therapy,

Gestalt, and reality therapy (see section below

for further discussion of expressive therapies

and psychodrama as well as the glossary in

appendix D).

The group is conceived as an aggregate of individuals in which the group leader generally

works sequentially with one group member at

a time. While one individual’s issues are

addressed, the other group members serve as

observers, contributors, alter egos, or significant others. Generally, however, more than

one group member will be involved in the conversation at one time, and all group members

will be encouraged to actively help each other

and learn from each other’s experiences. This

model of group does not require a client to

have insight into a problem but does require

awareness of behavior and its immediate causes and consequences. Some individually oriented approaches will use group members in a

structured/directive way, such as in a roleplaying exercise.

In the more cognitively oriented approaches,

clients will focus on their behaviors in relation

to thoughts. The more expressive form of individually oriented groups is particularly bene26 Types of Groups Commonly Used in Substance Abuse Treatment
ficial for clients who need a structured environment or have so much contained, powerful

emotion that they need some creative way of

releasing it.

Individually focused groups are useful to identify the first concrete steps in coping with substance abuse. They can help clients become

more aware of behavior and its causes, and at

the same time, they increase the client’s range

of options as to how to behave. The ideal end

result is the client’s freedom from an unproductive or destructive behavior.

Figure 2­4 describes how an individually

focused group might respond to the conflict

described in Figure 2­3.

Interpersonally focused

groups

Interpersonally focused groups generally work

from a theory of interactional group therapy,

most often associated with the work of Irving

Yalom (1995). Other examples of this model of

group include sensitivity training, or T­groups

(Bradford et al. 1964), and L. Ormont’s

Modern Analytic Approach (Ormont 1992). In

groups that follow this model, emphasis is

placed primarily on current interactions

between and among group members. Clients

are urged to explore how they behave, how this

behavior affects others, and how

others’ behavior affects them.

In interpersonally focused groups, the group

leader serves as a role model, but does not

explicitly assess the clients’ behavior. That task

is left to other group members, who evaluate

each other’s behavior. The group leader monitors the way clients relate to one another, and

reinforces therapeutic group norms, such as

members responding to each other in an

emphatic way. The leader also steps in to

extinguish contratherapeutic norms that might

damage group cohesion or to point out behavior that could inhibit empathic relationships

within the group.

Figure 2­4

Joe’s Case in an Individually Focused Group

Source: Adapted from Flores 1997.

The group leader in an individually focused group might work first with Joe and

then Jane (or vice versa, depending on who seemed to have the more pressing

issues). The group leader might ask Joe to tell the group more about his anger

and how he experiences it and might ask him to say why he has difficulty trusting his roommate. Joe could be urged to see how this situation might relate to

other circumstances and how his reaction to his roommate’s substance abuse

might help him understand his own problems with drinking. The leader might

use role­playing techniques with Joe so that he can practice how he will interact

with his roommate and better understand his reaction to his roommate’s behavior. Jane might be asked why Joe’s reaction to his roommate made her so angry.

The group leader could try to help her see if Joe reminded her of anyone and

whether she identified with the roommate because she too had been judged. Her

fears of being judged might be related to her own substance abuse, and the

group could explore that possibility.

Types of Groups Commonly Used in Substance Abuse Treatment 27
Figure 2­5

Joe’s Case in an Interpersonally Focused Group

Source: Adapted from Flores 1997.

A group leader working from an interpersonally focused group model would

direct the group’s attention to what is going on between Joe and Jane. The leader might ask Jane if she can tell Joe directly how his statements have made her

feel, and then ask Joe to say how he feels about what she said. The group leader

might also ask Joe if he sees any parallel in his response to both his roommate

and Jane. The leader might ask him if Jane could have reported what she felt in

a way that would make him feel less defensive. Jane might tell Joe that she is

reacting to his judgmental behavior toward his roommate and his evasiveness

about his own drinking. This interaction confronts Joe’s denial. If Jane discloses

the reasons behind her response to Joe, namely that her husband distrusts her

in a similar manner, the group leader would turn the issue over to the group,

perhaps asking Jane how she thinks Joe feels about her. Another group member

who has worked on issues concerning trust may interpret what is really going on

between Joe and Jane. The goal is to help Joe and Jane deal authentically and

realistically with one another, and strengthen the attachment between them.

This analysis of relationships within the group may ultimately transfer to settings outside the group and improve Joe’s and Jane’s relationships with others

outside the group.

Figure 2­5 describes how an interpersonally

focused group might respond to the conflict

described in Figure 2­3. 

Group­as­a­whole focused

groups	 

The theoretical approaches most often associated with the group­as­a­whole orientation are

Tavistock’s Group­as­a­Whole (Bion 1961; Rice

1965), Agazarian Systems­Centered Therapy

for Group (Agazarian 1992), Bion’s primary

assumption groups (Bion 1961), and the focal

conflict model (Whitaker and Lieberman

1965). As the name suggests, in this model, the

group leader focuses on the group as a single

entity or system. While model variations may

recognize the group as an aggregate of individuals (the Systems­Centered Therapy does, for

instance), the emphasis remains on the group

as a single unit with its own ways of operating 

in the world. 

This model generally is inappropriate for

clients with substance use disorders—at least

as the sole approach to treatment. It can be

harmful, especially to clients new to recovery,

and can add to their problems without helping

them manage their substance abuse. Certain

techniques taken from this approach, however,

may be used productively in an eclectic treatment group. For example, when the entire

group seems to be sharing a mood, behavior, or

viewpoint, a group leader may choose to use

mass group process comments, such as “You all

seem quiet today” or “Almost everyone is ganging up on Jim.”

Figure 2­6 describes how a group­as­a­whole

focused group might handle Joe’s problem.

28 Types of Groups Commonly Used in Substance Abuse Treatment
Figure 2­6 

Joe’s Case in a Group­As­A­Whole Focused Group

Source: Adapted from Flores 1997.

A group leader with a Bion orientation would notice a lot of conflict swirling 

around this incident and that the group is in a “fight mode.” The point of interest would be the source of the tension and how it interferes with the work of the 

group, which is the recovery process. The leader might note that the group has 

become very involved in this discussion as a way of evading issues of trust common to the whole group. Is the group perhaps fleeing from dealing directly with 

trust? Looking at Jane’s response, the group leader would consider whether 

Jane’s response is carrying something for the group, that is, representing a 

group concern about whether the group will judge members for what they have 

to say. The discussion might be redirected toward how the group is coping with 

feelings of uncertainty about continued substance use. 

Three cautionary notes	 

These vignettes illustrate the different interventions available. No single approach necessarily

is more appropriate than any other. The

critical question is always, “Is this approach

the most likely to succeed with this particular

group in substance abuse treatment?”

In addition to making the right strategic choice

of approach, the interventions should be done

at the right time. Treatment as a time­dependent process should be the guiding principle

when working with people with addictions 

in group.

Finally, what works for the client without	 

addictions will not always work with a client	 

with addictions. Consequently, the rest of this	 

TIP will be dedicated to exploring the modifications in group technique that need to be

made when treating people with substance

use disorders.	 

Specialized Groups in

Substance Abuse

Treatment

A variety of therapeutic groups that do not

fit in the already­described group models may

be employed in substance abuse treatment

settings. Some of these specialized groups are

unique to substance abuse treatment (like

relapse prevention), and others are unique in

format, group membership, or structure (such

as culturally specific groups and expressive

therapy groups). It would be impossible to

describe all of the types of special groups that

might be used in substance abuse treatment.

The three that follow represent a cross­section

of special groups.

Relapse Prevention

Relapse prevention groups focus on helping a

client maintain abstinence or recover from

relapse. This kind of group is appropriate for

clients who have attained abstinence, but who

have not necessarily established a proven track

record indicating they have all the skills to

maintain a drug­free state. Relapse prevention

Types of Groups Commonly Used in Substance Abuse Treatment 29
also can be helpful for people in crisis or who

are in some way susceptible to a return to substance use.

Purpose. Relapse prevention groups help

clients maintain their sobriety by providing

them with the skills and knowledge to “anticipate, identify, and manage high­risk situations”

that lead to relapse into substance use “while

also making security preparations for their

future by striving for broader life balance”

(Dimeff and Marlatt 1995, p. 176). Thus,

relapse prevention is a double­level initiative.

It aims both to upgrade a client’s ability to

manage risky situations and to stabilize a

client’s lifestyle through changes in behavior

(Dimeff and Marlatt 1995).

Principal characteristics. Relapse prevention

groups focus on activities, problemsolving, and

skills­building. They also may take the form of

psychotherapy. For instance, Khantzian et al.

(1992) assert that, because the same traits in

personality and character predispose people

to use substances initially and to relapse during recovery, psychodynamic approaches can

mitigate psychological vulnerabilities. Because

relapse prevention groups may use techniques

drawn from all of these types of groups, they

are considered a special type of group in

this TIP.

The different models

for relapse prevention groups

(Donovan and

Chaney 1985)

include those developed by Annis and

Davis (1988), Daley

(1989), Gorski and

Miller (1982), and

Marlatt (1982). All

of these models are

derived from principles of cognitive

therapy. Some, such

as that of Marlatt,

classify relapse prevention as a form of

skills development; other models tend to

emphasize support.

Relapse

prevention groups

focus on activities,

problemsolving,

and skillsbuilding.	 

These approaches share a number of basic elements, including teaching clients to recognize

high­risk situations that may lead to relapse,

preparing them to meet those high­risk situations, and helping them develop balance and

alternative ways of coping with stressful situations. Many of these approaches also increase

group members’ feelings of selfcontrol, so they feel capable of resisting

relapse. (More information on the techniques

of relapse prevention appears in TIP 34, Brief

Interventions and Brief Therapies for

Substance Abuse [CSAT 1999a].)

Research has demonstrated that relapse is common and to be expected during the process of

recovery (Project MATCH 1997). In a metaanalysis of 24 controlled clinical trials evaluating relapse prevention programs delivered in

both group and individual formats, Carroll

(1996) found that relapse prevention groups

were effective in comparison to no­treatment

controls for many substances of abuse; the

groups were most effective for smoking cessation. Carroll also notes that relapse prevention

groups seem to reduce the intensity of relapse

when it occurs. Groups also appear to be more

effective than other approaches for clients who

have “more severe levels of substance use,

greater levels of negative affect, and greater

perceived deficits in coping skills” (1996, p. 52).

Research also suggests that relapse prevention

can be conducted in both group and one­onone formats, with little measurable difference

in outcomes. Schmitz and colleagues (1997)

compared relapse prevention for cocaine abuse

delivered in group and individual formats.

Both demonstrated favorable outcomes; no

significant difference was detected in cocaine

use as measured by urine tests. Clients treated

in groups, however, reported fewer cocainerelated problems than those treated in individual sessions. Further, McKay et al. (1997)

found that 6 months after intensive outpatient

treatment for cocaine abuse, subjects treated 

in a group setting displayed higher rates 

30 Types of Groups Commonly Used in Substance Abuse Treatment
of sustained abstinence than those treated

individually.

Relapse prevention carried out in group settings enables clients to explore the problems of

daily life and recovery together and to work

collaboratively to isolate and overcome problems. Because of these dual goals, relapse prevention groups may improve clients’ quality of

life. However, as Schmitz and colleagues note,

it may also be the case that the group experience makes members less willing to report the

severity of their problems or cause them to feel

that their problems are less severe by comparison to those of others (Schmitz et al. 1997).

Leadership skills and styles. Leaders of

relapse prevention groups need to have a set of

skills similar to those needed for a skills development group. However, they also need experience working in relapse prevention, which

requires specialized training, perhaps in a particular model of relapse prevention. Leaders

also

need a well­developed ability to work on group

process issues.

Group leaders need to be able to monitor client

participation to determine risk for relapse, to

perceive signs of environmental stress, and to

know when a client needs a particular intervention. Above all, group leaders should know how

to handle relapse and help the group process

such an event in a nonjudgmental, nonpunitive

way—clients, after all, need to feel safe in the

group and in their recovery. Leaders should

know how to help the group manage the abstinence violation effect, in which a single lapse

leads to a major recurrence of the addiction.

Additionally, the leader of a relapse prevention

group should understand the range of consequences a client faces because of relapse. These

consequences can be culturally specific

responses, criminal justice penalties, child

protective services actions, welfare­to­work

setbacks, and so on. The group leader, like any

counselor, should know the confidentiality

rules (42 C.F.R. Part 2) and the legal reporting

requirements relating to client relapse.

Techniques. Relapse prevention groups draw

on techniques used in a variety of other types

of groups, especially the cognitive–behavioral,

psychoeducational, skills development, and

process­oriented groups. Because the purpose

of a relapse prevention group is to help members develop new ways of living and relating to

others, thereby undercutting the need to return

to substance use or abuse, potential group

members need to achieve a period of abstinence

before joining a relapse prevention group.

Communal and Culturally

Specific Groups

Restoring lost cultural ties or providing a sense

of cultural belonging can be a powerful therapeutic force in substance abuse treatment, and

in important ways, substance abuse is intimately intertwined with the cultural context in

which it occurs. Cultural prohibitions against

substance use and cultural patterns of permissible use define, in part, what is reasonable use

and what is abuse of substances (Westermeyer

1995). Risk factors such as cultural displacement or discrimination cause substance abuse

rates to rise drastically for a given population.

Problems that pervade particular cultures,

such as racism, poverty, and unemployment,

have an impact on the incidence of substance

abuse and are appropriate focuses for intervention in substance abuse treatment (Taylor

and Jackson 1990; Thornton and Carter 1988).

Communal and culturally specific wellness

activities and groups include a wide range of

activities that use a specific culture’s healing

practices and adjust therapy to cultural values.

For instance, Hispanics/Latinos generally share

a value of personalismo, a preference for person­to­person contact. Effective substance

abuse treatment providers thus build personal

relationships with clients before turning to the

tasks of treatment. Also, at the outset of treatment, personal relationships do not yet exist.

At this point, a client’s hesitation should not

be mistaken for resistance (Millan and Ivory

1994).

Types of Groups Commonly Used in Substance Abuse Treatment 31
Three common ways to integrate such

strengths­focused activities into a substance

abuse treatment program are

•Culturally specific group wellness activities

may be used in a treatment program to help

clients heal from substance abuse and problems related to it.

•Culturally specific practices or concepts can

be integrated into a therapeutic group to

instruct clients or assist them in some aspect

of recovery. For example, a psychoeducational group formed to help clients develop a balance in their lives might use an American

Indian medicine wheel diagram or the seven

principles of Kwanzaa. The medicine wheel

represents four dimensions of wellness:

belonging, independence, mastery, and generosity. These four concepts promote wellness

for the individual and collective good of the

American­Indian tribal group and humanity/environments. Kwanzaa is based on a

value system of seven principles called the

Nguzo Saba. The Kwanzaa paradigm is a

nonreligious, nonheroic ritual that has been

widely embraced by the national AfricanAmerican community. The Nguzo Saba and

other Kwanzaa symbols and practices can be

used therapeutically in the regrounding and

reconnecting process for African­American

clients.

•Culturally or community­specific treatment

groups may be developed within a services

program or in a substance abuse treatment

program serving a heterogeneous population

with a significant minority population of a

specific type. Examples might include a

group for people with cognitive disabilities,

or a bilingual group for recent immigrants.

Such groups typically are process­ or support­oriented, though they also may have

psychoeducational components. The groups

help minority group members understand

their own background, cope with prejudice,

and resolve other problems related to minority status. Groups described in this TIP fall

into this category.

Purpose. Groups and practices that accentuate

cultural affinity help curtail substance abuse

by using a particular culture’s healing practices

and tapping into the healing power of a communal and cultural heritage. Many have

commented on the usefulness of these types of

groups (Trepper et al. 1997; Westermeyer

1995), and clinical experience supports their

utility. As this TIP is written, little researchbased evidence has accumulated to confirm the

effectiveness of this approach. Research is

needed to evaluate the effectiveness of culturally specific groups and ascertain the primary

indications for their use.

Principal characteristics. Different cultures

have developed their own views of what constitutes a healthy and happy life. These ideas may

prove more relevant and understandable to

members of a minority culture than do the values of the dominant culture, which sometimes

can alienate rather than heal. All cultures also

have specific processes for promoting wellness

among their members.

In using a culture’s healing practices or group

activities, whether in heterogeneous or homogeneous groups (that is, all one culture or a mix

of cultures), treatment providers should be

careful to show respect for the culture and its

healing practices. As long as respect and

awareness are evident, the use of such practices will not harm the members of a particular

culture.

Leadership characteristics and style. Group

leaders always need to strive to be culturally

competent with members of the various populations who enter their programs.1 Substance

1 See chapter 3 of this TIP and the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment

(SAMHSA in development a) for more information on cultural competence. TIP 29, Substance Use Disorder Treatment

for People With Physical and Cognitive Disabilities (CSAT 1998b), contains information on being sensitive and responsive to the needs of people with disabilities, and A Provider’s Introduction to Substance Abuse Treatment for Lesbian,

Gay, Bisexual, and Transgender Individuals (CSAT 2001) has information on working with gay and lesbian populations.

32 Types of Groups Commonly Used in Substance Abuse Treatment
abuse treatment counselors first need to be

aware of the demographics in their program

areas, and to be aware as well that there are

many people from mixed ethnic backgrounds

who do not necessarily know or recognize their

cultural heritage. Clinicians should actively

avoid stereotyping clients based on their looks,

and instead allow them to self­identify. Clients

should be asked what it means to them to

belong to a particular group. Clinicians also

should be sensitive to self­identification issues

such as sexual orientation, gender identification, and disability. When in doubt, clinicians

should discuss the issue privately with the

client.

A group leader for a culturally specific group

will need to be sensitive and creative. How

much authority leaders will exercise and how

interactive they will be depends on the values

and practices of the cultural group. The group

leader should pay attention to a number of factors, all of which should be considered in any

group but which will be particularly important

in culturally specific groups. Clinicians should

•Be aware of cultural attitudes and resistances

toward groups.

•Understand the dominant culture’s view of

the cultural group or community and how

that affects members of the group.

•Be able to validate and acknowledge past and

current oppression, with a goal of helping to

empower group members.

•Be aware of a cultural group’s collective grief

and anger and how it can affect countertransference issues.

Figure 2­7 

The SageWind Model for Group Therapy

In programs that have the resources, the capacity to offer a variety of types of

groups addressing a range of client needs is preferred. SageWind in Reno,

Nevada, offers more than 100 groups each week.

To assess each client’s unique needs, SageWind’s comprehensive biopsychosocial

assessment evaluates the severity of a client’s substance abuse. In addition, the

clinical team, the client, and any others concerned (such as probation or parole

officers, parents or legal guardians, or social workers) determine the best course

of group therapy formats.

Group intervention ranges in intensity from one group per week to more than

20. The large number of weekly groups offered in SageWind’s menu of options

covers a continuum of treatment options from psychoeducational to skills­building to experiential to process­oriented. In a structured program similar to that

of a university, where fundamental courses are required before more advanced

ones may be taken, clients attend the groups they need, then change to others

and progress through the program. Clients complete groups, moving to more

advanced formats until they have met discharge criteria based on the American

Society of Addiction Medicine (ASAM) Patient Placement Criteria­2R (PPC­2R)

(ASAM 2001).

Types of Groups Commonly Used in Substance Abuse Treatment 33
•Focus on what is held in common among

members of the group, being sensitive to

differences.

The SageWind Model for group therapy,

discussed in Figure 2­7 (see p. 33), provides

individually tailored interventions for its

clients.

Techniques. Different cultures have specific

activities that can be used in a treatment

setting. Some common elements in treatment

include storytelling, rituals and religious practices, holiday celebrations, retreats, and rites

of passage practice (these may be particularly

useful for adolescent clients).

Culturally specific groups work best if all members of the population become involved in the

activity, even the clients who are not familiar

with their cultural heritage. In fact, the reasons

for that lack of familiarity can become a topic

of discussion. Helping clients understand what

they have lost by being separated from their

cultural heritage, whether because of substance

abuse or societal forces, can provide one more

reason to continue in sobriety.

Expressive Groups

This category includes a range of therapeutic

activities that allow clients to express feelings

and thoughts—conscious or unconscious—that

they might have difficulty communicating with

spoken words alone.

Purpose. Expressive therapy groups generally

foster social interaction among group members

as they engage either together or independently

in a creative activity. These groups therefore

can improve socialization and the development

of creative interests. Further, by enabling

clients to express themselves in ways they might

not be able to in traditional talking therapies,

expressive therapies can help clients explore

their substance abuse, its origins, the effect it

has had on their lives, and new options for coping. These groups can also help clients resolve

trauma (like child abuse or domestic violence)

that may have been a progenitor of their substance abuse. For example, Glover (1999)

states that play therapy and art therapy are

particularly useful for substance abuse treatment clients who have been incest victims.

Play and art therapies enable these clients to

work through their trauma and substance

abuse issues using alternatives to verbal

communication (Glover 1999).

Although a number of articles have theorized

about the usefulness of various types of expressive therapy for clients with substance use disorders, little study on the subject has used rigorous research methods. Clinical observation,

however, has suggested benefits for female

clients involved in dance therapy (Goodison

and Schafer 1999). Client self­reports suggest

the value of psychodrama for female clients in

treatment for alcoholism, particularly for highly educated women and those who are inclined

to be extroverted and verbally expressive

(Loughlin 1992).

As Galanter and colleagues note, expressive

therapy groups—which they called “activity

groups”—often can be “the source of valuable

insight into patients’ deficits and assets, both of

which may go undetected by treatment staff

members concerned with more narrowly

focused treatment interventions” (Galanter et

al. 1998, p. 528).

Principal characteristics. The actual characteristics of an expressive therapy group will

depend on the form of expression clients are

asked to use. Expressive therapy may use art,

music, drama, psychodrama, Gestalt, bioenergetics, psychomotor, play (often with children)

games, dance, free movement, or poetry.

Leadership characteristics and style. 

Expressive group leaders generally will have a

highly interactive style in group. They will need

to focus the group’s attention on creative activities while remaining mindful of group process

issues. The leader of an expressive group will

need to be trained in the particular modality to

be used (for example, art therapy).

Expressive therapies can require highly skilled

staff, and, if a program does not have a trained

staff person, it may need to hire an outside

consultant to provide these services. Any con34 Types of Groups Commonly Used in Substance Abuse Treatment
sultant working with the group should be in

regular communication with other staff, since

expressive activities need to be integrated into

the overall program, and group leaders need to

know about each client if they are to understand their work in the group.

Expressive therapies can stir up very powerful

feelings and memories. The group leader

should be able to recognize the signs of reactions to trauma and be able to contain clients’

emotional responses when necessary. Group

leaders need to know as well how to help clients

obtain the resources they need to work though

their powerful emotions.

Finally, it is important to be sensitive to a

client’s ability and willingness to participate in

an activity. To protect participants who may be

in a vulnerable emotional state, the leader

should be able to set boundaries for group

members’ behavior. For example, in a movement therapy group, participants need to be

aware of each other’s personal space and

understand what types of touching are not

permissible.

Techniques. The techniques used in expressive

groups depend on the type of expressive therapy being conducted. Generally, however, these

groups set clients to work on an activity.

Sometimes clients may work individually, as in

the case of painting or drawing. At other times,

they may work as a group to perform music.

After clients have spent some time working on

this activity, the group comes together to discuss the experience and receive feedback from

the group leader and each other. In all expressive therapy groups, client participation is a

paramount goal. All clients need to be involved

in the group activity if the therapy is to exert

its full effect.

Groups Focused on Specific

Problems

In addition to the five models of therapeutic

groups and three specialized types of groups

discussed above, groups can be classified by

purpose. The problem­focused group is a specific form of cognitive–behavioral group

used to eliminate or

modify a single particular problem, such

as shyness, loss of a

loved one, or substance abuse. In

sheer numbers, these

groups are the most

widespread.

Additionally, problemsolving groups are

directed from a cognitive–behavioral

framework. They

focus on problems of

daily life for people in

early and middle

recovery, helping

group members learn

problemsolving skills, cope with everyday difficulties, and develop the ability to give and

receive support in a group setting. As clients

discuss problems they face, these problems are

generalized to the experience of group members, who offer support and insight.

Expressive

therapy groups

foster social

interaction as

members engage

in a creative

activity.

Purpose. Problem­focused groups’ primary

purpose is to “change, alter, or eliminate a

group member’s self­destructive or self­defeating target behavior. Such groups are

usually short­term and historically have been

used with addictive types of behavior (smoking,

eating, taking drugs) as well as when the focus

is on symptom reduction...or behavioral

rehearsal” (Flores 1997, p. 40).

Principal characteristics. Problem­focused

groups are short (commonly 10 or 12 weeks),

highly structured groups of people who share a

specific problem. This type of group is not

intended to increase client insight, and little or

no emphasis is placed on self­exploration.

Instead, the group helps clients develop effective coping mechanisms to enable them to meet

social obligations and to initiate recovery from

substance abuse. The group’s focus, for the

most part, is on one symptom or behavior, and

they use the cohesiveness among clients to

Types of Groups Commonly Used in Substance Abuse Treatment 35
increase the rate of treatment compliance and

change. A problem­focused group commonly is

used in the early stages of recovery to help

clients engage in treatment, learn new skills,

and commit to sobriety. This kind of group is

helpful particularly for new clients; its homogeneity and simple focus help to allay feelings

of vulnerability and

anxiety.

Leadership characteristics and styles. 

The group leader

usually is active and

directive.

Interaction within

the group is limited

typically to

exchanges between

individual clients

and the group leader; the rest of the

group acts to

confront or support

the client according to the leader’s guidance.

The leader in a

problem­focused

group usually	 

is active and

directive.

Techniques. Many traditional recovery groups

fall into the problem­focused category, which

includes abstinence maintenance, relapse prevention, support, behavior management, and

many continuing care groups. Other examples

are groups that help support people with a specific problem or loss (such as breast cancer or

suicide in the family), help people alter a particular behavior or trait (like overeating or shyness), or learn a new skill or behavior (for

instance, conflict resolution or assertiveness

training).

In practice, group leaders may use different

models at various times, and may simultaneously influence more than one focus level at a

time. For example, a group that focuses on

changing the individual will also have an

impact on the group’s interpersonal relations

and the group­as­a­whole. Groups will, however,

have a general orientation that determines the

focus the majority of the time. This focus is an

entry point for the group leader, helping to

provide direction when working with the group.

When deciding on a model for a substance

abuse treatment group, programs will need

to consider their resources, the training and

theoretical orientation of group leaders, and

the needs and desires of clients in order to

determine what approaches are feasible. The

reader may also refer to appendix B of TIP 34,

Brief Interventions and Brief Therapies for

Substance Abuse (CSAT 1999a), for a list of

resources that can provide further training and

information about the theoretical orientations

that influence these groups.

36 Types of Groups Commonly Used in Substance Abuse Treatment
3  Criteria for the

Placement of Clients 

in Groups

In This 

Chapter... 

Matching Clients 

With Groups 

Assessing Client 

Readiness for 

Group 

Primary Placement 

Considerations 

Stages of Recovery 

Placing Clients 

From Racial or 

Ethnic Minorities 

Diversity in a Broad Sense 

Leader Self­Assessment 

Diversity and Placement 

Ethnic and Cultural 

Matching 

Other Considerations for 

Practice 

Overview

Before any client is placed in a group, readiness for particular groups

must be assessed. Techniques such as eco­maps and resources like

American Society of Addiction Medicine (ASAM) criteria (see the

“Primary Placement Considerations” section of this chapter) can be

very helpful. The clinician must also determine the client’s current stage

of recovery and stage of change.

Culture and ethnicity considerations also are of primary importance.

This chapter explains ways to facilitate the placement of people from

minority cultures and ease such clients into existing groups. From this

discussion, clinicians can also assess their readiness to deal with other

cultures and become aware of processes that occur in multiethnic

groups.

Matching Clients With Groups 

Therapy groups, designed to treat substance abuse by resolving persistent life problems, are used frequently, but the individual success of this

group experience depends in important respects on appropriate placement. Matching each individual with the right group is critical for success. Before placing a client in a particular group, the provider should

consider

•The client’s characteristics, needs, preferences, and stage of recovery

•The program’s resources

•The nature of the group or groups available

The placement choice, moreover, should be considered as constantly

subject to change. Recovery from substance abuse is an ongoing process

and, if resources permit, treatment may continue in various forms for

some time. Clients may need to move to different groups as they progress

through treatment, encounter setbacks, and become more or less committed to recovery. A client may move, for example, from a psychoeducational group to a relapse prevention group to an interpersonal process

group. The client also may participate in more than one group at the

same time.

37
Assessing Client

Readiness for Group

Placement should begin with a thorough assessment of the client’s ability to participate in the

group and the client’s needs and desires regarding treatment. This assessment can begin as

part of a general assessment of clients entering

the program, but the evaluation process should

continue after the initial interview and through

as long as the first 4 to 6 weeks of group.

Assessment should inquire about all drugs used

and look for cross­addictions. It also is important to match groups to clients’ current needs.

In addition to these and other assessment considerations, clients should be asked about the

composition of their social networks, types of

groups they have been in, their experience in

those groups, and the roles they typically have

played in those groups (Yalom 1995).

To help assess clients’ relationships and their

ability to participate productively in a group,

the clinician can have the client draw an

eco­map (see an example in Figure 3­1). An

eco­map (sometimes called a sociogram) is a

graphic representation that depicts interpersonal relationships (Garvin and Seabury 1997;

Hartman 1978). The client occupies the center

of the page. Then, circles are added to show

each significant relationship. The closer the

relationship, the closer it is to the center circle.

A solid line between circles indicates a strong,

nurturing relationship, while a dotted line

depicts a conflicted connection. Arrows drawn

on the lines can represent the direction of the

relationship. An arrow from the center out

means “I care about this person.” An incoming

arrow means “This person cares about me.”

Clients who are inarticulate or withdrawn may

welcome the opportunity to present information visually, and clinicians can gather useful

information from these diagrams. If the diagram indicates few, distant, and conflicted relationships, the client may require a group that is

very structured.

The eco­map is indicative, but not comprehensive. It only provides the client’s viewpoint.

Though it is a useful tool, leaders should be

Figure 3­1

Eco­Map

Source: Adapted from Garvin and Seabury 1997; Hartman 1978.

Used with permission.

Mother Boss

Sister

Drinking

Buddy Joe Brother

#2

Client

Father

Brother

Wife

Ex­wife

38 Criteria for the Placement of Clients in Groups
wary of basing placement decisions on this or

any other single source of information. Clinical

observation and judgments, information from

collateral resources, and other assessment

instruments all should contribute to a decision

on a client’s readiness and appropriateness for

group treatment. Either the group leader or

another trained staff person should meet with a

client before assignment to a group. In this

interview, it is important to evaluate how the

client reacts to the group leader and to assess

current and past interpersonal relationships.

The group leader also may hold an orientation

group (perhaps educational in nature) to

observe how the client relates to others. The

client also may be observed in a waiting room

with other clients or in a similar social situation

to gain insight into how each person relates

to others.

The clinician pays such careful attention to the

relationships clients can manage at their current stage of recovery because this capacity has

everything to do with how able the client is to

participate in a group. Whatever their diagnosis, clients in groups—especially interpersonal

process groups—need to be able to engage with

other people. They need motivation to change,

creativity, and dogged perseverance (Brown

1991). Furthermore, the group leader should

continue to assess clients as treatment progresses. The clients’ needs and abilities are apt to

change––change is part of successful treatment––and the appropriate type of group or

the suitability for group in general may shift

dramatically.

Not all clients are equally suited for all kinds of

groups, nor is any group approach necessary

or suitable for all clients with a history of substance abuse. For instance, a person who

relapses frequently probably would be inappropriate in a support group of individuals

who have attained significant abstinence and

who have moved on to resolving practical life

problems. It would be equally disadvantageous

to place a person in the throes of acute withdrawal from crack cocaine in a group of people

with alcoholism who have been abstinent for 3

months. A group usually can be heterogeneous

in demographic composition, including men

and women, younger and older clients, and

people of different races and ethnicities, but

clients should be placed in groups with people

with similar needs.

People with significant character pathology (for

example, a personality disorder) placed in a

group of people who do not have a similar disorder almost certainly would violate the boundaries of the group and of individuals in the

group. As a result, both the clients who have

and who lack the character disorder would

have a negative group experience and limited

opportunity for growth. Clients with a personality disorder generally need a group that can

place significant limits on their behavior both

in and beyond the group setting. In groups

treating clients with active psychoses, special

adaptations would need to be made for possible

psychotic symptoms, delusions, and paranoia.

Once such adaptations in technique are made

to fit the special circumstances of the population being treated, group therapy—in the

hands of a skilled group leader—can be an

effective, appropriate form of treatment.

Other types of clients who may be inappropriate for group therapy include

• Clients who refuse to participate. No one

should be forced to participate in group

therapy.

• People who can’t honor group agreements.

Sometimes, as noted, these clients may have a

disqualifying pathology. In other instances,

they cannot attend for logistical reasons,

such as a work schedule that conflicts with

that of regular group meetings.

• Clients who, for some reason, are unsuitable

for group therapy. Such people might be

prone to dropping out, getting and remaining

stuck, or acting in ways contrary to the interests of the group.

• People in the throes of a life crisis. Such

clients require more concentrated attention

than groups can provide.

Criteria for the Placement of Clients in Groups 39
• People who can’t control impulses. Such

clients, however, may be suitable for

homogeneous groups.

• People whose defenses would clash with the

dynamics of a group. People who can’t tolerate strong emotions or get along with others

are examples.

• People who experience severe internal

discomfort in groups.

Primary Placement

Considerations

A formal selection process is essential if clinicians are to match clients with the groups best

suited to their needs and wants. For each

group, different filters are appropriate. Some

groups may require only that members be participants in a particular program. Others may

require a multidisciplinary panel review of the

client’s case history. For many groups, especially interpersonal process groups, pregroup

interviews and client preparation are essential.

Client evaluators should not rely solely on the

review of forms, but should meet with each

candidate for group placement. The interviewer should listen carefully to the client’s hopes,

fears, and preferences. Ideally, clients should

be offered a menu of appropriate options, since

people will be more likely to remain committed

to courses of treatment that they have chosen.

Client choice also may strengthen the therapeutic alliance and thereby increase the likelihood

of a positive treatment outcome (Emrick 1974,

1975; Miller and Rollnick 1991). Naturally,

appropriate clinical guidance should also play

a part in placement decisions.

After specifying the appropriate treatment

level, a therapist meets with the client to identify options consistent with this level of care.

More specific screens are needed to determine

whether, within the appropriate level of care,

the client is appropriate for treatment in a

group modality. If so, further screens are needed to determine the most helpful type of group.

Considerations include the following.

Women. Recent studies have shown that

women do better in women­only groups than in

mixed gender groups. When women have singlegender group therapy, retention is improved

(Stevens et al. 1989). They also are more likely

to complete their treatment programs (Grella

1999), use more services during the course of

their treatment, and are more likely to feel they

are doing well in treatment (Nelson­Zlupko et

al. 1996).

The primary reason same­sex groups are more

effective for women is that women have distinct

treatment needs that are different from those

of men. Women are more likely than men to

have experienced traumatic events, which often

lead to depression, anxiety, and posttraumatic

stress disorder. About three­quarters of the

women in treatment have been child or adult

victims of sexual, physical, or emotional abuse

(Roberts 1998). Statistically, women with substance use disorders also have experienced

more severe types of abuse (such as incest),

and perpetrators have abused them for longer

periods of time in comparison to women without substance use disorders. The perpetrators

are most often male partners, male family

members, or male acquaintances. Women

are less willing to disclose and discuss their

victimization in mixed­gender groups (Hodgins

et al. 1997).

Women further are more likely to be caretakers

for minor children or elderly parents and need

to balance these family responsibilities with

their own treatment needs. They face greater

challenges in securing employment, are more

likely to have co­occurring mental illness, and

encounter greater stigma for their substance

use disorders than men.

Because women are relational by nature and

develop a sense of self and self­worth in relation to others (Miller 1986), groups specifically

for women are advisable, particularly in early

treatment. Gender­specific treatment groups

provide both the safety women often need to

resolve the problems that fuel their substance

use disorders and the healing environment they

40 Criteria for the Placement of Clients in Groups
need to develop a healthier development of self

and connections to other women.

It is important to help female clients make the

transition from an environment supportive of

their specific needs to one that is less sensitive

to them. Following treatment, they will need an

effective support network in their communities

to help them sustain the gains of treatment.

(See the forthcoming TIP Substance Abuse

Treatment: Addressing the Specific Needs of

Women [Center for Substance Abuse

Treatment (SAMHSA) in development b].)

Adolescents. Planning, designing, and operating group therapy services for adolescent

clients is a complex undertaking. Adolescents

are strikingly different from adults, both psychosocially and developmentally, and require

decidedly different services. Local, State, and

Federal laws related to confidentiality; infectious disease control; parental permissions and

notifications; child abuse, neglect, and endangerment; and statutory rape all can come into

play when substance abuse treatment services

are delivered to minors. Add the complications

related to scheduling around school and the

need to include family in the treatment process,

and it is no surprise that most group therapy

for teens occurs in the context of an overall

treatment program or as part of highly specialized, targeted programs (e.g., see the discussion

of Cognitive Behavioral Therapy group sessions

in Sampl and Kadden 2001). Indeed, to serve

as a substance abuse counselor or clinician in

the delivery of group therapy to adolescents

typically requires prior training and experience

with the particular age group to be served.

The complexities related to adolescents and

group therapy lie outside the scope of the TIP.

Suggested reading for those interested in the

rationale for group therapy with adolescents

includes, but is not limited to, Sampl and

Kadden 2001 or textbooks such as Group

Therapy with Children and Adolescents

(Kymissis and Halperin 1996), including the

chapter by Spitz and Spitz on adolescents who

abuse substances, or Adolescent Substance

Abuse: Etiology, Treatment, and Prevention

(Lawson and Lawson

1992), especially the

chapter on group psychotherapy with adolescents by Shaw.

Last, a journal article

(Pressman et al. 2001)

relates the special difficulties group psychotherapy presents

for adolescents with

both psychiatric

and substance abuse

problems—another

common complexity

of providing group

therapy for adolescents with substance

abuse disorders.

In placement,

both the client’s

and the group’s

best interests need

to be considered.

The client’s level of interpersonal functioning, including impulse control. Does the client

pose a threat to others? Is the client prepared

to engage in the give and take of group dynamics? The client’s “level of psychological functioning and integration” should be considered,

as should “the kinds of defenses [used] to

maintain abstinence, and the rigidity of [those]

defenses” (Vannicelli 1992, p. 31). A client who

has not moved beyond sloganism, including

“avoid strong feelings,” may not do well in a

group that has evolved more sophisticated ways

to maintain abstinence (Vannicelli 1992).

Motivation to abstain. Clients with low levels

of motivation to abstain should be placed in

psychoeducational groups. They can help the

client make the transition into the recoveryready stage.

Stability. In placement, both the client’s and

group’s best interests need to be considered.

For example, bringing a new member who is in

crisis into treatment may tax the group beyond

its ability to function effectively, yet the group

might easily manage a person in similar crisis

who already is part of the group (Vannicelli

1992). Group stability counts as well. An ongoing group of clients who have gained insight

into the management of their feelings can supCriteria for the Placement of Clients in Groups 41
port a new member,

helping that person

solve problems without getting caught

up in feelings of crisis themselves.

Stage of recovery. 

The five stages of

Prochaska and

DiClemente’s transtheoretical model of

change (discussed

briefly in chapter 2

and in greater detail

in TIP 35,

Enhancing

Motivation for

Change in

Substance Abuse

Treatment [CSAT 1999b]) map the route that a

person abusing substances must travel during

the transition from abuse to recovery. The

stages of change are best conceived as a cycle,

but movement through the cycle is not always a

tidy, forward progression. Clients can––and

often do––move backward as they struggle with

dependence. Varying types of groups will be

appropriate for clients at different stages of

recovery. For example, an interpersonal process group might be overstimulating for some

clients in early stages of recovery, particularly

those undergoing detoxification. They would

benefit most from a group with a strong primary focus on achieving and maintaining abstinence. Once abstinence and attachment to the

recovery process are established, the client is

ready to work on such issues as awareness and

communication of feelings, conflict resolution,

healthy interdependence, and intimacy.

Every effort	 

should be made to

place the client in

a group in which

the client can

succeed.

Expectation of success. Every effort should be

made to place the client in a group in which the

client, and therefore, the program, can succeed.

A poor match between group and client is not

always apparent at the outset. Monitoring can

ensure that clients are in groups in which they

can learn and grow without interfering with the

learning and growth of others. Although the primary factor to consider regarding continued

participation in group should be a client’s ability to get something out of the experience, it is

also important to determine how each person’s

participation affects the group as a whole. A

client who, for whatever reason, cannot participate may have a profoundly adverse effect on

the group’s ability to coalesce and function

cohesively. If a client does not interfere with

group progress, however, sometimes it is appropriate to keep a nonparticipant in the group

and simply allow that person to sit and listen.

A number of different assessment models can be

used to allow meaningful dialog between client

and program representatives during the screening and placement phase, even when resources

are limited. The ASAM PPC­2R treatment criteria (ASAM 2001) commonly are used for client

placement. The criteria are arranged in two

sets, one for adults and one for adolescents.

Each set covers five levels of service:

• Level 0.5 Early Intervention

• Level I Outpatient Treatment

• Level II Intensive Outpatient Treatment/

Partial Hospitalization

• Level III Residential/Inpatient

Treatment

• Level IV Medically Managed Intensive

Inpatient Treatment

On each level of care ASAM’s criteria

describe appropriate treatment settings, staff

and services, admission, continued service, and

discharge criteria for six “dimensions”:

•Potential for acute intoxication or withdrawal

•Biomedical conditions and complications

•Emotional and behavioral conditions or

complications

•Treatment acceptance or resistance

•Relapse and continued use potential

•Recovery environment

On the five levels of care, ASAM also provides

a brief overview of the services available for

particular severities of addiction and related

42 Criteria for the Placement of Clients in Groups
problems. Another commonly used assessment

tool, the Addiction Severity Index, can be

found in appendix D of TIP 38, Integrating

Substance Abuse Treatment and Vocational

Services (CSAT 2000).

Some States require providers to use the ASAM

PPC­2R for patient placement, continuing stay,

and discharge decisions. For placement in

group therapy, a provider can also consider

•A client’s stage of recovery (see next section)

•The progression of the disease

•The client’s stage of readiness for change

Although no single set of criteria is sufficient to

evaluate a client’s proper placement, this document presents a chart (see Figure 3­2) that

summarizes the types of group treatment most

appropriate for clients at different stages of

recovery. Clinicians can use the chart as a

guide to determine the type of group most

appropriate for a client.

When different dimensions of evaluation conflict in their placement indications, the clinician will need to break the impasse with clinical

judgment. Actual client placement should take

into account characteristics such as substances

abused, duration of use, treatment setting, and

the client’s stage of change. For example, a

client in a maintenance stage may need to

acquire social skills to interact in new ways,

may need to address emotional difficulties, or

may need to be reintegrated into a community

and culture of origin. Only an additional level

of assessment will determine which of these

groups (or combination of groups) is best for

the client.

Stages of Recovery 

A number of classification systems have been

applied to the stages of recovery from substance abuse. The most common, however,

classifies clients as being in an early, middle, or

late stage of recovery:

• Early recovery. The client has moved into

treatment, focusing on becoming abstinent

and then on staying sober. Clients in this

stage are fragile and particularly vulnerable

to relapse. This stage generally will last from

1 month to 1 year.

Figure 3­2 

Client Placement by Stage of Recovery

Key: 

Blank Generally not appropriate

+ Sometimes necessary

++ Usually necessary

+++ Necessary and most important

Source: Consensus Panel.

Psycho- educa- tion 

SkillsBuilding Cognitive– 

Behavioral 

Support Inter- personal 

Process 

Relapse 

Preven- tion 

Ex- pressive CultureSpecific 

Early +++ ++ + +++ + + *

Middle + ++ ++ ++ +++ +++ + *

Late and

Maintenance

++ + +++ *

Criteria for the Placement of Clients in Groups 43
Figure 3­3

Client Placement Based on Readiness for Change

Psycho

Source: Consensus Panel; Prochaska and DiClemente 1984.

- educa- tion SkillsBuilding 

Cognitive– 

Behavioral 

Support Inter- personal 

Process 

Relapse 

Preven- tion 

Ex- pressive CultureSpecific 

Precontemplation + + + +

Contemplation + + + + + + +

Preparation + + + + + + +

Action + + + + + + + +

Maintenance + + + + + + +

Recurrence + + + + + + +

•Middle recovery. The client feels fairly secure

in abstinence. Cravings occur but can be

recognized. Nonetheless, the risk of relapse

remains. The client will begin to make significant lifestyle changes and will begin to change

personality traits. This stage generally will

take at least a year to complete, but can last

indefinitely. Some clients never progress to

the late recovery/maintenance stage. Sometimes they relapse and revert to an early

stage of recovery.

• Late recovery/maintenance. Clients work to

maintain abstinence while continuing to make

changes unrelated to substance abuse in their

attitudes and responsive behavior. The client

also may prepare to work on psychological

issues unrelated to substance abuse that have

surfaced in abstinence. Since recovery is an

ongoing process, this phase has no end.

Figure 3­3 uses Prochaska and DiClemente’s

stages of change model to relate group

placements to the client’s level of motivation

for change.

Placing Clients From

Racial or Ethnic

Minorities

Diversity in a Broad Sense

In all aspects of group work for substance abuse

treatment, clinicians need to be especially mindful of diversity issues. Such considerations are

key in any form of substance abuse treatment,

but in a therapeutic group composed of many

different kinds of people, diversity considerations can take on added importance. As group

therapy proceeds, feelings of belonging to an

ethnic group can be intensified more than in

individual therapy because, in the group process, the individual may engage many peers who

are different, not just a single therapist who is

different (Salvendy 1999).

While the word “diversity” often is used to

refer to cultural differences, it is used here in a

broader sense. It is taken to mean any differences that distinguish an individual from others

and that affect how an individual identifies

himself and how others identify him.

Considerations such as age, gender, cultural

44 Criteria for the Placement of Clients in Groups
background, sexual orientation, and ability

level are all extremely important, as are less

apparent factors such as social class, education

level, religious background, parental status,

and justice system involvement. Figure 3­4

provides several definitions around culture.

To help clinicians understand the range of diversity issues and the importance of these issues,

this volume adapts a diversity wheel from Loden

and Rosener (1991) (see Figure 3­5 on p. 46).

The wheel depicts two kinds of characteristics

that can play an important role in understanding client diversity: The inner wheel includes

permanent characteristics such as age or race;

the outer wheel lists a number of secondary

characteristics that can be altered. Note that

primary characteristics are not necessarily

more important than secondary ones and that

this figure does not include a comprehensive

list of secondary characteristics.

It is important for clinicians to realize that

diversity issues affect everyone. All individuals

have unique characteristics. Further, how

people view themselves and how the dominant

culture may view them are frequently different.

In any event, no one should be reduced to a single characteristic in an attempt to understand

that person’s identity. All people have multiple

characteristics that define who they are.

While ideas of difference are social constructions, they do have a real­world effect. For

example, members of groups tend to act in different ways when with members of their own

group than they would in a heterogeneous

group. Further, the dominant culture’s attitudes and beliefs about people (based on age,

race, sexual preference, and so on) influence

everyone.

A culturally homogeneous group quite naturally will tend to adopt roles and values from its

Figure 3­4

What Is Culture?

Source: Giachello 1995; Office of Minority Health 2001.

Culture: Integrated patterns of human behavior that include the language,

thoughts, communications, actions, customs, beliefs, values, and institutions

of a racial, ethnic, religious, or social group.

Cultural knowledge: Familiarity with selected cultural characteristics, history,

values, belief systems, and behaviors of the members of another ethnic group.

Cultural awareness: Developing sensitivity to and understanding of another

ethnic group. This usually involves internal changes of attitudes and values.

Awareness and sensitivity also refer to the qualities of openness and flexibility

that people develop in relation to others. Cultural awareness should be

supplemented with cultural knowledge.

Cultural competence: A set of congruent behaviors, attitudes, and policies that

come together in a system, agency, or among professionals that enable them to

work effectively in cross­cultural situations.

Criteria for the Placement of Clients in Groups 45
Figure 3­5

Diversity Wheel

Source: Adapted from Loden and Rosener 1991. Used with permission.

PRIMARY 

CHARACTERISTICS 

race, gender, ethnicity, age,

sexual orientation,

physical/mental

ability

religion,

socioeconomic

class,

education

level of accultaration,

learning style,

language,

accent,

criminal justice

system involvement

geographic location, time orientation,

appearance, marital status,

parental status, military status,

immigrant status

SECONDARY 

CHARACTERISTICS 

46 Criteria for the Placement of Clients in Groups
culture of origin (Tylim 1982). These ways

should be understood, accepted, respected,

and used to promote healing and recovery.

However, group leaders should also be aware

of the possibility that these group roles and values might conflict with treatment requirements,

and therefore clinicians need to be prepared to

provide more direction to group members when

required (Salvendy 1999). For example, a

group composed of Southeast Asian refugees

might give authority to older men in the group,

who may never be challenged, contradicted, or

disagreed with because to do so would show

disrespect (Kinzie et al. 1988). These older,

adult males can assist in group leadership.

However, the opinions of female group members, particularly younger ones, might be

ignored, and a group leader should be able to

compensate for this tendency. As another

example, many Hispanics/Latinos may be suspicious of rules and the people who enforce

them. Consequently, group leaders regarded as

authority figures (that is, not compadres)

unwittingly may represent discrimination and

encroachments on freedom (Torres­Rivera et

al. 1999).

Cultural practices also affect communication

among group members. Many traditionally

raised Asians, for example, will be reluctant to

disagree openly with their elders or even voice

a personal opinion in their presence (Chang

2000). Gender­specific cultural roles, too, may

be played out in groups. For example, women

may hold emotional energy for men or nurture

them. Therapists should be alert to assumptions and roles that may inhibit the development of individuals or the group as a whole.

Unfortunately, little research reveals how

group therapy should be adapted to meet such

differences, and many of the findings that do

exist are contradictory. Further, any generalizations about cultural groups may not apply to

individuals because of variance in levels of

acculturation and other experiential factors. A

particular Latino youth, for example, may

identify with the dominant culture and not

think of himself as Latino. The client is always

to be considered the expert on what culture,

ethnicity, and gender identity mean to that

person. If a leader believes that cultural traditions might be a factor in a client’s participation

in group or in misunderstandings among group

members, the leader should check the accuracy

of that perception with the client involved.

Therapists should be aware, however, that individuals may not always be able to perceive or

articulate their cultural assumptions.

Group leaders should be able to anticipate a

particular group’s characteristics without automatically assigning them to all individuals in

that group. It would be a mistake, for instance,

if an institution assigned all immigrants or people of color to a single group, assuming they

would be more comfortable together. Members

of such groups may not have anything in common. An Asian­American woman assigned to

the only Asian­American therapist in the institution might resent her placement and protest

in strong terms. She would want the best therapist for her, not an automatic matchmaking

based on ethnicity.

Clinicians working primarily with other cultural or ethnic groups should be open and ready

to learn all they can about their clients’ culture. For example, a therapist working with

Salvadoran immigrants should be prepared to

learn not only about the country and culture of

El Salvador, but also about all the events and

influences that have shaped this population’s

experience, including social conditions in El

Salvador and the experience of immigration.

Accommodating cultural and ethnic characteristics is not a simple matter. These adaptations

should be made, however, because ethnicity

and culture can have a profound effect on

many aspects of treatment. For instance,

pressures to conform to the dominant culture

represented in the group can be intense. The

norms of the group may also be in painful

conflict with an individual’s traditional cultural

values. An example is shown in Figure 3­6 (see

p. 48). Figure 3­7 (see p. 48) provides three

suggested resources on culture and ethnicity;

however, this list is by no means exhaustive.

Criteria for the Placement of Clients in Groups 47
Figure 3­6

When Group Norms and Cultural Values Conflict

Source: Adapted from Salvendy 1999, p. 441.

A middle­aged, single professional woman of Philippine background who, in one

group session, recounted death wishes toward an elder sister whom she perceived

as domineering, remained silent the following week in the group. When other

members tried to engage her, wanting her to follow up, she complained of debilitating migraines and refused to talk. Months later, she was able to share with the

group that she felt ashamed and disloyal to her sister, a great transgression in

her culture. The client believed she was punished for her “naughtiness” with

crippling headaches.

Figure 3­7

Three Resources on Culture and Ethnicity

Culture and Psychotherapy: A Guide to Clinical Practice is a resource for mental health professionals treating people of widely varying cultural backgrounds.

Case studies include the story of an American­Indian woman who could not

escape her “spirit song,” a Latina who feared “losing her soul,” and an Arab

woman whose psychological conflicts were related to cultural changes in her society that involved the social status of women. Other chapters describe treatment

techniques for various racial and ethnic groups and models of therapy (Tseng

and Streltzer 2001).

Ethnic Sensitivity in Social Work provides a section on cross­cultural orientation

and one on specific cultures, including African­American, Hispanic/Latino,

American­Indian, and Asian and Pacific Island cultures. The second part of the

book is a psychocultural overview of several major ethnic groups in the United

States. For each group, the authors discuss work and economic systems, family

life and kinships, political structures and stratification, intergroup relations and

ideological structures, identity, social interaction rules, and health behaviors

(Winkelman 1995).

Readings in Ethnic Psychology contains several chapters on substance abuse and

treatment among several ethnic and racial groups and describes culturally

appropriate interventions used in therapy, including group therapy (Organista

et al. 1998).

48 Criteria for the Placement of Clients in Groups
Leader Self­Assessment

Group leaders should be aware that their own

ethnicities and standpoints can affect their

interpretation of group members’ behavior.

The group leader brings to the group a sense of

identity, as well as feelings, assumptions,

thoughts, and reactions. Leaders should be

conscious of how their own backgrounds affect

their ability to work with particular populations. For example, a female therapist who has

survived domestic violence may have severe

difficulties working with spouse abusers.

Another example is that male group leaders

may be inclined to call on male members more

often than female members of the group. If so,

they need to make a conscious effort to call on

all members equally, regardless of gender.

Clinicians also need to evaluate how competent

they are managing issues of cultural diversity.

In cases where cultural or language barriers are

very strong, a group leader may need to refer a

client to another group or make special accommodations to allow the client to participate.

Reed and her colleagues (1997) have developed

a list of principles for group leaders to evaluate their own attitudes about diversity (see

Figure 3­8). Figure 3­9 (see pp. 50–52) is a selfassessment guide for group counselors working

with diverse populations.

Figure 3­8

Guidelines for Clinicians on Evaluating Bias and Prejudice

Source: Adapted from Reed et al. 1997. Used with permission.

• The processes of gaining knowledge about the workings of discrimination and

oppression and for guarding against bias should be ongoing and lifelong.

• Clinicians should learn about their own culturally shaped assumptions so as to

refrain from unconsciously imposing them on others and should exhibit a professional’s values, standards, and actions.

• Clinicians should work harder to recognize institutionalized racism than they

do to perceive individual prejudice; that is, they should recognize how bias is

structured into policies, practices, and norms in program relations.

• Clinicians should question the knowledge base and theories that underlie their

practice in order to eliminate prejudice and bias in that practice.

• Clinicians should look at their own feelings and reactions and listen to the feedback of others to recognize how their own ideas have been unconsciously

shaped by discriminatory social dynamics.

• Clinicians can use their knowledge of how their personal characteristics are

likely to affect a range of others to reduce communication problems and disputes between group members.

Criteria for the Placement of Clients in Groups 49
Figure 3­9

Self­Assessment Guide

The questions that follow can serve as a guide and self­assessment for group

leaders working with clients of diverse cultures.

Are you familiar with a broad range of special populations, particularly those in

your community?

• What cultural customs and health beliefs, practices, and attitudes of

ethnic/racial groups would affect treatment in a group situation?

• Would tensions within any broad cultural group––say one that includes

Cubans, Mexicans, and Puerto Ricans––pose problems in therapy?

• What languages are spoken within the community?

• What are the typical communication styles, including body language, of various

racial/ethnic groups? Are clients likely to speak in a group setting? Would they

speak only with others of their same culture? Would they speak in an ethnically

mixed group?

• How do clients think about the cultures of the world? Do they have pronounced

prejudices? How do they understand the major and minor cultural subgroups

that make up the community?

• How do language, social class, race/ethnicity, and gender affect the outward

signs and symptoms of substance abuse, emotional distress, and mental illness?

• In any local cultures, do specific social stresses, such as homelessness or uncertain immigration status, complicate the problem of coping with substance abuse

and psychiatric disorders?

• What are community views about different kinds of substances? Is alcohol more

acceptable than marijuana? Marijuana more acceptable than cocaine? Are

males with addictions tolerated more than females?

• How do various cultural subgroups perceive women in the community? The

elderly? Lesbian, gay, and bisexual persons?

Do you understand your own thoughts, feelings, and experiences regarding other

cultures?

• With what cultural groups other than your own do you have frequent contact?

• With what ethnic groups do you have contact? How frequently?

• What are some of the key characteristics of these groups?

• What do you know about the principal cultural groups in the country? In your

community?

• What are the main ethnic groups in the United States?

• What are the important characteristics of your own culture?

• How does your culture affect the way you interact with others? What is your

culture’s style of interaction?

50 Criteria for the Placement of Clients in Groups
Figure 3­9

Self­Assessment Guide (continued)

• Do you have a personal style that differs from your culture’s norms?

• Toward which cultural groups do you feel positive?

Which groups make you feel uneasy or uncomfortable?

• Are you comfortable counseling persons with sexual orientations different

from yours?

• Have you worked with a variety of age groups?

• Do you have substantial knowledge of any particular population’s key

attributes and values regarding child rearing, marriage, financial matters,

and other major matters of life?

• Do you know any other group’s social and political history well enough to

predict its impact on group dynamics around a given issue?

What resources in the community are available to meet the needs of special

populations?

• Are cofacilitators with special expertise, such as fluency in other languages,

available to assist with groups?

• Are services available in other languages? Have support groups been designed

for racial/ethnic groups? Lesbians and gay men? Women? Elderly people?

• What State­ and community­based organizations provide social services for

people from nonmainstream cultures?

What systemic barriers and staff attitudes and beliefs inhibit cultural sensitivity

and competence in your programs?

• Is cross­cultural training available to group leaders?

• Are any staff members fluent in languages spoken by potential clients in group?

• Is there someone in your agency or organization who assists clients with social

services support, including Medicaid?

What are the characteristics of the person about to be placed?

• Are the client’s language skills adequate to permit participation in this group?

• To what degree is the client acculturated? For example, how long has a

Salvadoran been in this country?

• Is the client discriminated against?

• Does this client share traits (for example, educational attainment, socioeconomic status, motivation level) with others in the group who are not from the same

population?

• How familiar is the client with the goals of therapy? With group therapy?

Criteria for the Placement of Clients in Groups 51
Figure 3­9

Self­Assessment Guide (continued)

Source: Adapted from Winkelman 1995. Used with permission.

• How does the client currently relate to the therapist? To treatment in general?

• How would the client fit into an existing group? Would the client be the only

representative of that culture in the group? What is the current makeup of the

group with respect to cultural diversity? What views do current members hold

toward the prospective member’s culture?

• How long has the person been a resident of your community? Is the client traveling from another community for therapy? How long has the person been a

resident of this geographical area?

• Would the client fit in better with a homogeneous group; for example, a singlesex group for a woman who has been a victim of sexual abuse or incest?

• How does the client’s family handle issues of power and control? Independence

and autonomy? Trust? Communication of feelings?

• Does the culture of origin provide traditional healing practices that could be

used in the group?

• Might specific cultural issues affect the recovery process?

• To what extent will the new client adapt to an existing group’s norms?

• Will changes that satisfy the group’s norms alienate the client from the culture

of origin?

• What are the alternatives to placing the person in a specific group? What

accommodations may have to be made?

Diversity and Placement

In many groups, the composition of members

will be heterogeneous; for example, a majority

of Caucasians placed with a minority of ethnically or racially different members. The

greater the mix of ethnicities, the more likely

that biases will emerge and require mediation

(Brook et al. 1998). Whatever a client’s belief

system or origin, “neither the therapist nor the

group should ask any group member to give up

or renounce any ethnic/cultural beliefs, feelings, or attitudes. Rather, group members are

encouraged to share these feelings and beliefs

verbally and overtly, even if this may be upsetting to some or all of the group’s members”

(Brook et al. 1998, p. 77). Although therapists

may be uncomfortable when group members

talk about subjects like racism and discrimination, such expression sometimes is an important part of an individual’s recovery process.

First­generation immigrants who speak little or

no English usually are underrepresented in

52 Criteria for the Placement of Clients in Groups
group therapy because of their limited fluency.

While an immigrant may be able to communicate adequately in individual therapy with a

single healthcare professional, that newcomer

may be unable to follow a fast­flowing group

discussion.

As previously mentioned, before placing a

client in a particular group, the therapist needs

to understand the influence of culture, family

structure, language, identity processes, health

beliefs and attitudes, political issues, and the

stigma associated with minority status for each

client who is a potential candidate for a group.

In addition, the therapist will need to do the

following:

Address the substance abuse problem in a manner that is congruent with the client’s culture.

Each culture incorporates beliefs and values

that guide the behavior of everyone identified

with the culture and that govern experiences

related to the use of substances. Some cultures,

for instance, use chemical substances as part of

rituals, some of them religious. This entwinement of substance use and culture does not

mean that the therapist cannot discuss the issue

of this substance use with a client. Some

clients, of their own volition, will reduce or

eliminate the use of substances once they examine their beliefs and experiences.

Appreciate that particular cultures use substances, usually in moderation, at specified

types of social occasions. For many people,

occasional, moderate use of substances might

be part of a meaningful social/cultural ritual,

but for people with substance use disorders

such use, even when culturally accepted, is

contraindicated because it might provoke

relapse, binges, or other destructive reactions.

Again, a culturally sensitive discussion of this

issue with clients may result in individual decisions to abstain on these occasions, despite considerable cultural pressure to use substances of

abuse. In contrast, some cultures have beliefs

in direct opposition to the client’s use of substances. Helping the client redirect behavior to

come into accord with these beliefs may be an

important treatment approach.

Assess the behaviors

and attitudes of current group members

to ascertain whether

the new client would

match the group.

From the start of a

multicultural therapy

group, members

should feel that race is

a safe topic to discuss

(Salvendy 1999).

Because group members are less restricted

to their usual social

circles and customary

ethnic and cultural

boundaries, the group

is potentially a social

microcosm within

which members may

safely try out new ways of relating (Matsukawa

2001). Even so, potential problems between a

candidate and existing group members should

be identified and counteracted to prevent

dropout and promote engagement cohesion

among members.

Understanding the

cultural characteristics of major

racial and ethnic

populations will

permit betterinformed decisions

about placement.

Understand personal biases and prejudices

about specific cultural groups. A group leader

should be conscious of personal biases to be

aware of countertransference issues, to serve as

a role model for the group, and to create group

norms that permit discussion of prejudice and

other topics relevant to a multicultural setting.

Understanding the cultural characteristics of

major racial and ethnic populations—particularly their history, acculturation level, family

and community roles and relationships, health

beliefs, and attitudes toward substance abuse—

will permit better­informed decisions about the

placement of individuals from these populations into existing therapy groups. Naturally,

no group leader can know everything about

every culture, but a good counselor can be

aware of major characteristics of cultural

groups. This knowledge can guide the placement of clients into appropriate groups and

Criteria for the Placement of Clients in Groups 53
help a leader anticipate relationships and tensions that may arise within a group.

Figure 3­10

Preparing the Group for a New Member 

From a Racial/Ethnic Minority

To promote cohesion, a positive group quality stemming from a sense of

solidarity within the group, the group leader should

• Inform the group members in advance that people from a variety of backgrounds and racial and ethnic groups will be in the group.

• Discuss the differences at appropriate times in a sensitive way to provide an

atmosphere of openness and tolerance.

• Set the tone for an open discussion of differences in beliefs and feelings.

• Help clients adapt to and cope with prejudice in effective ways, while maintaining their self­esteem.

• Integrate new clients into the group slowly, letting them set their own pace.

• When new members start to make comments about others or to accept feedback, encourage more participation.

Figure 3­10 provides tools to prepare both the

group and the minority client for the client’s

entry and integration into an established therapeutic group.

One researcher cites four major dynamic processes that occur within a multiethnic group

(Matsukawa 2001). Identifying these processes

as they function in a group may help a therapist predict whether a possible placement will

support a cohesive social microcosm or create a

threatening and disruptive environment.

1.	 Symbolism and nonverbal communication.

In some cultural groups, direct expression

of thoughts and feelings is considered

unseemly. Matsukawa (2001) points out that

among the Japanese, a highly valued trait is

the ability to sense what another person

wants without explicitly stated cues. In such

a culture, symbolic gestures (a gift, perhaps)

or nonverbal signals (the author describes a

woman who showed her craft work without

comment) are used to communicate indirectly and acceptably. In such a situation,

Matsukawa says, the therapeutic approach

is modified to perceive and permit a

Japanese­American woman to present

herself tacitly without pressing for verbal

elaboration. Therapists also should

intervene if nonverbal communications are

misinterpreted.

2.	 Cultural transference of traits from one person of a certain culture to another person of

that culture. If a group member has had

experiences (usually negative) with people of

the same ethnicity as the therapist, the

group member may transfer to the therapist

the feelings and reactions developed with

others of the therapist’s ethnicity. In short,

Matsukawa (2001) says, the group member

jumps to conclusions and assigns traits to

the therapist based on ethnicity alone. The

therapist first should detect these miscon54 Criteria for the Placement of Clients in Groups
ceptions and then reveal them for what they

are to dispel them.

3.	 Cultural countertransference, the therapist’s (often subconscious) emotional reaction to a client. Therapists also can jump to

conclusions. Countertransference of culture

occurs when a therapist’s response to a current group member is based on experience

with a former group member of the same

ethnicity as the new client. Matsukawa

(2001) cautions therapists to exercise

restraint when in the middle of a “countertransference storm.”

4.	 Ethnic prejudice. “Stereotypes become prejudice,” Matsukawa (2001, p. 256) writes,

“when they are hard to modify and when

one’s interactions, or lack thereof, with

another person are based on preconceived

feelings and judgments about the person’s

race, without enough knowledge, understanding, or experience.” In multiethnic

groups, it is vital to develop an environment

in which it is safe to talk about race. Not to

do so will result in scapegoating or division

along racial lines (Matsukawa 2001).

In practice, people connect and diverge in ways

that cannot be predicted solely on the basis of

ethnic or cultural identity. Two people from

different ethnic backgrounds may share many

other common experiences that provide a basis

for identification and mutual support. All the

same, it is possible to rule out some combinations. For example, two elderly men, one

Korean and the other Japanese, may not blend

well since their cultures have clashed in the

past many times. Similarly, a single 17­year­old

girl would not mix well with a group made up

primarily of middle­aged males. Potentially

undesirable and distracting group dynamics

could easily be foreseen. Leaders are responsible for considering carefully the positions of

people who are different in some way, especially when planning fixed­membership groups.

Ethnic and Cultural Matching

Although arguments for matching the ethnicity

of the therapist with that of the group members

treated may have some merit, the reality is that

such a course seldom is feasible. Health care

providers from culturally and linguistically

diverse groups are underrepresented in the

current service delivery system, so it is likely

that a group leader will be from the mainstream culture (Cohen and Goode 1999). While

it might be ideal to match all participants by

ethnicity in a therapeutic group, the most

important determinants of success are the values and attitudes shared by the therapist and

group members (Brook et al. 1998).

It should be noted that recent research suggests

that an ethnic match between therapist and

client does not “consistently improve outcomes” (Salvendy 1999, p. 437). Other

research (Atkinson and Lowe 1995) suggests

that, while the ethnicity of the therapist is a

factor that can influence treatment, it is by no

means the most important factor. Culturally

specific homogeneous groups should be used

only when someone’s “cultural, religious, or

political beliefs are very different from the

mainstream and they are not open to adjustments,” as, for example, with recent immigrants or refugees (Brook et al. 1998; Ivey et

al. 1993; Salvendy 1999, p. 457; Silverstein

1995; Takeuchi et al. 1995; Yeh et al. 1994).

If less acculturated people with limited language skills are treated in groups, the program

should provide bilingual clinicians who are sensitive to gender and culture. Therapists should

focus on problem­oriented, short­term treatment; should consider employing a proactive

therapeutic style; and should be aware that

clients may view them as authority figures

(Brook et al. 1998).

In culturally specific groups, a member of the

focus culture usually runs the group, although

this ideal situation is not always possible. If a

trained clinician who also belongs to the group

is not available, it may be advantageous to add

a cofacilitator who belongs to the population,

understands the population’s specific problems

and strengths, and can serve as a role model to

assist the clinician. Of course, if the program is

not specifically focused on cultural or communiCriteria for the Placement of Clients in Groups 55
ty issues and is simply incorporating some cultural elements, the staffing requirements are

not as stringent. In such cases, the presence of a

member of the culture that developed the practice or knowledge is desirable, but not vital.

“Children often accompany their parents to

therapeutic encounters to translate and provide

support” for immigrant parents, but relying on

“the children in this way actually perpetuates

isolation and decreases pressure to build a network of supports. Finding an interpreter who

not only speaks the language but also who may

share the values and the migration experience is

crucial to further the acculturation and therapy

process” (Nakkab and Hernandez 1998, p. 98).

Other Considerations for

Practice

Groups may include people who have varying

• Expectations of leaders

• Experience in decisionmaking and conflict

resolution

• Understanding of gender roles, families, and

community

• Values

All these differences, and many others, will

affect individual and group experiences. Group

leaders should be keenly aware of ways in

which ethnicity and culture can affect participation in interactive therapy. One of the most profound ways that different cultural backgrounds

may affect individuals in groups is in expectations of the leader. For example, many African

Americans look to leaders as problemsolvers. In

Hispanic/Latino culture, people are equals until

proven otherwise––roles do not automatically

constitute a supervisor/subordinate relationship

(Wilbur and Roberts­Wilbur 1994).

Differences that may influence an individual’s

perception of a leader’s role should be explored

in the pregroup interview. The interviewer can

explain how the leader’s role may differ from

what the client might expect. Later, in group,

leaders need to be alert to unexpected differences in interpretation of their actions. For

example, a group member who expects the

leader to exercise authority might view a leader’s attempt to empower the group as shirking

responsibility. The leader can help by being

explicit about his or her role and responsibilities in the group.

Group leaders also should be aware that people

manage conflict in culturally diverse ways. A

native New Yorker might have an in­your­face

approach to conflict, while some Asian

Americans may find a raised voice offensive.

Cultural factors may frame a client’s perception of conflict in a way not readily apparent to

the group. For an example, see Figure 3­11.

For more detailed information on cultural

diversity in client placement, see the forthcoming TIP Improving Cultural Competence

in Substance Abuse Treatment (SAMHSA in

development a).

Once placement decisions are completed, group

development begins. Chapter 4 explains this

process.

56 Criteria for the Placement of Clients in Groups
Figure 3­11

Culture and the Perception of Conflict

Source: Adapted from Salvendy 1999, p. 451.

A 33­year­old single, second­generation Chinese­Canadian woman joined a group

after proper preparation. She was one of two non­Caucasians in this long­term,

interpersonally focused, slow­turnover group. Unfortunately, in her first session,

the group forcefully confronted an elderly man, who was emotionally abusive to

his spouse and shirked responsibility for it. The new member froze throughout

the session and was clearly very anxious. The therapist acknowledged her discomfort and the stressfulness of the situation for her. Nevertheless, the following

day this client wanted to discontinue group, feeling very threatened by the

directness of the confrontation and its target, the elderly father figure. Her anxiety was accepted as genuine and not seen as resistance by the therapist, who provided several individual sessions parallel to the group to clarify that this was not

an attack on all fathers (including her own) in the group, and that it was done to

help the elderly group member. This Chinese­Canadian client also was reassured

that the other group members would be informed about the sociocultural reasons

for her being upset, and that they would be empathic to her feelings on this matter. This intervention facilitated her integration in the group and her perception

of the therapist as culturally credible and competent.

Criteria for the Placement of Clients in Groups 57

4 Group Development

and Phase­Specific Tasks

In This 

Chapter... 

Fixed and 

Revolving 

Membership 

Groups 

Fixed Membership Groups 

Revolving Membership 

Groups 

Preparing for

Client Participation

in Groups

Pregroup Interviews 

Increasing Retention 

Identifying the Need for 

Wraparound Services 

Group Agreements 

Phase­Specific 

Group Tasks 

Beginning Phase— 

Preparing the Group To 

Begin 

Middle Phase—Working 

Toward Productive 

Change 

End Phase—Reaching 

Closure 

Overview 

This chapter begins by discussing the varying uses of fixed or revolving

groups. Fixed groups generally stay together for a long time, while

members in revolving groups remain only until they accomplish their

goals. Each is used for different purposes, and each requires different

leadership.

As treatment and recovery have stages, group development also changes

over time. The first phase pays attention to orientation and establishing

safe, effective working relationships. In the middle (and longest) phase,

the actual work of the group is done. The end phase is a deliberate,

positive termination of group business. Each phase requires attention to

specific tasks.

Fixed and Revolving Membership

Groups

The way groups are developed varies by the type of group. A wide range

of therapeutic groups may be used with people who have substance use

problems. For the purpose of this discussion, however, groups have been

classified into two broad categories, each with the same two

subcategories:

1. Fixed membership groups

A. Time­limited

B. Ongoing

2. Revolving membership groups

A. Time­limited

B. Ongoing

59
Fixed Membership Groups

Fixed membership groups are relatively small

(not more than 15 members); membership is

relatively stable. Typically, the therapist

screens prospective members, who then receive

formal preparation for participation. Any

departure from the group occurs through a

well­defined process. Two variations of this

category are

•A time­limited group, in which the same

group of people attend a specified number of

sessions, generally starting and finishing

together

• An ongoing group, in which new members fill

vacancies in a group that continues over a

long period of time

In time­limited groups with fixed membership,

learning builds on what has taken place in

prior meetings. Thus, members need to be in

the group from its start. New members are

admitted only in the earliest stages of group

development (for example, only during the first

week for a daily group or during the first

month for a group that meets weekly). Ongoing

fixed membership groups may be used for

short­term therapy, skill building, psychoeducation, and relapse prevention.

In ongoing groups

with fixed membership, the size of the

group is set; new

members enter only

when there is a

vacancy. The leader

generally is less

active than is the

leader of a time­limited group, since the

interaction among

group members is

more important than

leader­to­member

interactions. To conduct this type of

group, the leader

needs substantial

training in group dynamics (such as individuals’ boundaries and the roles different members assume) and leadership along with excellent supervisory skills. Examples in this category include interpersonal process groups and

some psychoeducational therapy groups.

Fixed groups are rare because they demand a

long­term commitment of resources. Most outpatient programs provide only 8–20 sessions,

and most inpatient programs are limited to

2–4 weeks.

New members

enter a revolving

membership group	 

when they become

ready for the service it provides.

Revolving Membership

Groups

New members enter a revolving membership

group when they become ready for the service

it provides. Revolving membership groups frequently are found in inpatient treatment programs. As clients are admitted and discharged,

people come and go in the group. Consequently, revolving groups must adjust to frequent, unpredictable membership changes.

The two variations of revolving membership

groups are

•A time­limited group that members generally

join for a set number of sessions

•An ongoing group that clients join until they

accomplish their goals

Revolving membership groups can be larger

than fixed membership groups. The temptation

to have many members often is strong due to

insufficiently trained staff and shortages of

funding. While revolving membership groups

have no absolute limit on the number of members, it is prudent to keep the group small

enough (about 15 or fewer) for participants to

feel heard and understood, for the leader to

know each of them, and for members to feel a

sense of connection and belonging to the group.

If a group becomes too large (more than 20),

group interaction breaks down and the clients

become a class made up of individuals, rather

than a single, cohesive, therapeutic body.

Revolving membership groups generally are

more structured and require more active lead60 Group Development and Phase­Specific Tasks
ership than fixed membership groups.

Participation and

learning are not highly

dependent on attendance at previous sessions. In some settings,

new members may be

brought in at fixed 

intervals. In a daily 

group, for instance, 

new members might

enter once a week.

Members who have

been in the group for a

substantial number of

meetings often help to

orient newer members.

One advantage to

revolving membership

groups is the stimulation that new members

provide. A potential problem is that new group

members may dread joining a group, feeling

themselves to be at a disadvantage because

existing members already know each other,

how the group operates, and what has been discussed in previous sessions. For its part, the

group itself may be apprehensive about the new

member (Rasmussen 1999).

One advantage to

revolving membership groups is the	 

stimulation that

new members

provide.

A related possible problem is the adverse effect

that membership changes can have on group

cohesion. For these reasons, preparation for

revolving groups is of paramount importance:

Group leaders need to pay special attention to

helping new members become acclimated to the

group, and clients chosen to fill a group vacancy should have the capacity to observe and

adjust to the dynamics of the group

(Rasmussen 1999).

In time­limited groups, each member generally

is expected to attend a certain number of sessions for a certain number of weeks or months.

A psychodrama group (one kind of expressive

therapy group), for example, might be offered

every spring. Other common examples include

psychoeducational groups and some skillsbuilding groups.

Several possible varieties of ongoing groups

have revolving membership. Such groups may

be (1) open­ended, with clients staying for as

many sessions as they wish; (2) repeating sets of

topics, with clients staying only until they have

completed all of the topics; or (3) a durationspecific format, with clients attending for a set

number of weeks (either consecutively or nonconsecutively). An interpersonal process group

as part of an intensive outpatient program is an

example of an ongoing group with revolving

membership. Clients enter this treatment group

and attend until the work specified in the treatment plan has been completed.

Other examples of revolving membership

groups include inpatient unit groups, continuing care drop­in groups, transition groups for

inpatients leaving and moving to outpatient

care, psychoeducational groups, expressive

therapy groups, and long­term support groups,

such as ongoing continuing care groups and

maintenance groups. Figure 4­1 (see p. 62) provides the characteristics of fixed and revolving

membership groups.

Preparing for Client

Participation in Groups

Pregroup Interviews

Research shows a strong tendency toward

relapse early in the substance abuse treatment

process. A person early in recovery is at

greater risk for returning to use than someone

with 3, 6, or even 18 months of abstinence

(Johnson 1973; Project MATCH 1997). The

better clients are prepared for treatment, however, the longer they stay in treatment. If clinicians ensure that clients come to the group with

appropriate expectations, both clinicians and

clients can expect a greater degree of success.

Group leaders should conduct initial individual

sessions with the candidate for group to form a

therapeutic alliance, to reach consensus on

what is to be accomplished in therapy, to educate the client about group therapy, to allay

anxiety related to joining a group, and to

Group Development and Phase­Specific Tasks 61
Figure 4­1 

Characteristics of Fixed and Revolving Membership Groups

Entry Group Development Examples 

Fixed Membership Groups 

Time- •New members admitted •Learning built on what •Short­term therapy groups

limited only in earliest stages of has happened in prior •Skills­building and

group development meetings psychoeducational groups

•Groups begin and end with •Relapse prevention groups

same membership

Ongoing •Group size fixed

•New members enter

only after vacancy or

graduation

•Members expected to stay

for a substantial period of

time

•Dynamics of group process

(such as individuals’

boundaries and the roles

different members assume)

are the primary source

of learning, healing for

participants

•Ongoing interpersonal

process groups

•Long­term supportive

therapy groups

Revolving Membership Groups 

Time- •Number of sessions •Learning at each session •Expressive therapy

limited usually fixed relatively independent of

previous group sessions

groups (dance therapy,

psychodrama)

•Psychoeducational groups

•Some skills­building

groups

Ongoing •Clients may (1) stay as

long as they wish, (2) be

required to attend sessions

with set topics, or (3) be

required to attend set

number of weeks

•Usually a set maximum

number of participants

•More structured

•Active leadership

•Client hall groups

•Day hospital check­in

groups

•Continuing care drop­in

groups

•Transition groups for

clients leaving inpatient

and moving to outpatient

care

•Psychoeducational groups

•Expressive therapy groups

•Long­term supportive

groups, such as ongoing

continuing care groups

and maintenance groups

62 Group Development and Phase­Specific Tasks
explain the group agreement. These activities

may take as little as one meeting or as long as

several weeks (Rutan and Stone 2001).

Normally, the longer the expected duration of

the group, the longer the preparation phase.

Clients should have an opportunity to air any

concerns, especially if they are apprehensive

about their cultural status within the group.

During this time, the group facilitator should

learn how the client handles interpersonal

functions on a day­to­day basis, how the

client’s family functions, and how the client’s

culture perceives the substance abuse problem.

The process of preparing the client for participation in group therapy begins as early as the

initial contact between the client and the program. Clients’ preconceptions about the group,

their expectation of how the group will benefit

them, their understanding of how they are

expected to participate, and whether they have

experienced a motivational session prior to the

group will all influence members’ participation.

Preparation meetings serve a dual purpose.

First, they ensure that clients understand

expectations and are willing and able to meet

them. Second, these meetings help clients

become familiar with group therapy processes.

Where in­depth, one­on­one meetings are

impractical because of group size or other considerations, at least some form of orientation

should be provided, perhaps in the form of

readings, videotape, group preparation meeting, or discussion with the primary counselor

prior to attending a group.

Pregroup interviews are widely used to gather

useful information about clients and prepare

them for what they can expect from a group.

The pregroup interview should cover clients’

goals for treatment, the group contract, client

behaviors that might present an obstacle to

group work, and any other information that

clients feel may be pertinent (Vannicelli 1992).

Clients should be thoroughly informed about

what group therapy will be like. In addition,

client preparation should address the following:

Explain how group interactions compare to

those in self­help groups, such as Alcoholics

Anonymous (AA). Clients should be informed

that group therapy differs from 12­Step or

other similar recovery groups. In particular,

the member­to­member “cross­talk” discouraged in 12­Step groups is an essential part of

interactive therapy (Margolis and Zweben

1998). Although clients sometimes perceive a

conflict between their AA or Al­Anon experience and group therapy due to these different

formats, the therapist should know with certainty that the two are not mutually exclusive,

but that they serve different functions and provide support in distinct, complementary ways

(Vannicelli 1992). Therapists also should be

careful to distinguish treatment groups from

AA’s self­help approach, which, having no formal leadership, cannot provide meaningful

accountability (Vannicelli 1992; Zweben 1995).

Emphasize that treatment is a long­term process. Participants should know in advance that

in group therapy, each person’s attendance at

each session is vital. They should also recognize

that while the first 3 months of treatment after

detoxification are critical, fully effective treatment takes much longer.

Let new members know they may be tempted to

leave the group at times. It should be emphasized that although the work is difficult and

even upsetting at times, clients gain a great deal

from persistent commitment to the process and

should resist any temptation to leave the group.

Clients also should be encouraged to discuss

thoughts about leaving the group when they

arise so that the antecedents of these thoughts

can be examined and resolved.

Give prospective and novice members an

opportunity to express anxiety about group

work, and help allay their fears with information. For some prospective members, group

process work may need to be demythologized.

Misperceptions should be countered to keep

them from interfering with group participation.

Some providers conduct a short­term group to

prepare clients for upcoming participation in

other kinds of groups. This approach enables

Group Development and Phase­Specific Tasks 63
leaders to assess clients’ suitability for various

types of group work.

Recognize and address clients’ therapeutic

hopes. With help, clients can explain how they

think group work can help them, identify their

preferences, and articulate realistic goals.

Leaders can use this information to be sure

that clients are placed in groups most likely to

fulfill their aspirations.

For a sample dialog that takes place in a preparation interview, see “Preparing the Patient for

Group Psychotherapy” (Hoffman 1999).

In preparing prospective members for a group

experience, it is important to be sensitive to

people who are different from the majority of

the other participants in some way. Such a person may be much older or younger than the

rest of the group, the lone woman, the only

member with a particular disorder, or the person from a distinctive ethnic or cultural minority. The leader should consult privately with

people who stand out in the group to determine

from their unique perspective how they are

experiencing the group. They should always be

allowed to be the experts on their own situation. Further, clients should be encouraged to

define the extent of their identification with the

groups to which they belong and to determine

what that identification implies.

The fixed membership format provides more

time to discuss issues of difference prior to

joining a group. A person unlike the rest of

the group may be asked by the other group

members:

•How do you think you would feel in a

group in which you differ from other group

members?

•What would it be like to be in a group where

everyone else is a strong believer in something, such as AA, and you are not?

Such questions might be coupled with positive

comments that stress the benefits that a unique

perspective may bring to the group.

It is important to explore issues of difference in

advance of group placement. It similarly is

important to acknowledge cultural or ethnic

backgrounds and to emphasize that differences

can be strengths that can contribute to the

group. If a client believes that a particular

group situation would be uncomfortable, however, the counselor may offer the client other

treatment options.

The counselor also is responsible for raising the

level of group members’ sensitivity and empathy. It is important at times, for instance, to

prepare group members for situations in which

others have symptoms that could offend or

repel them. The therapist can initiate discussion by asking questions such as, “What would

it be like for you to be with people who sometimes cut themselves?”

While group leaders have many responsibilities

to prepare clients for participation in groups,

the clients have obligations, too. Their responsibilities are specified in group agreements, discussed later in this chapter.

Increasing Retention

Throughout the initial sessions of therapy,

clients are particularly vulnerable to return to

substance use and to discontinue treatment.

The first month appears to be especially critical

(Margolis and Zweben 1998). Yalom (1995)

writes that premature termination usually

“stems from problems caused by deviancy, subgrouping, conflicts in intimacy and disclosure,

the role of the early provocateur, external

stress, complications of concurrent individual

and group therapy, inability to share the leader, inadequate preparation, and emotional contagion” (p. 315) (a concept discussed later in

chapter 6).

Retention rates are affected positively by client

preparation, maximum client involvement during the early stages of treatment, the use of

feedback, prompts to encourage attendance,

and the provision of wraparound services (such

as child care and transportation) to make it

possible or easier for clients to attend regularly.

64 Group Development and Phase­Specific Tasks
Consideration needs to be given to the timing

and length of groups, too, because these factors

affect retention.

To achieve maximum involvement in group

therapy during this period, motivational

techniques, such as psychoeducation and

attendance prompts, may be used to engage the

client. Evidence suggests that if people are selfmotivated, they will persist longer in behaviors

consistent with recovery, and will attach more

value to their quest than they would in

response to external pressure. Incorporating

motivational elements in pregroup preparation

or offering groups that focus on motivation is

likely to increase compliance with continuing

care requirements (Foote et al. 1999).

Some pretreatment techniques that appear to

reduce the incidence of dropping out include

the following:

•Role induction uses formats such as interviews, lectures, and films to educate clients

about the reasons for therapy, setting realistic

goals for therapy, expected client behaviors,

and so on.

•Vicarious pretraining using interviews, lectures, films, or other settings demonstrates

what takes place during therapy so the client

can experience the process vicariously.

•Experiential pretraining uses group exercises

to teach client behaviors like self­disclosure

and examination of emotions.

•Motivational interviews use specific listening

and questioning strategies to help the client

overcome doubt about making changes

(Walitzer et al. 1999).

Prompts to remind clients of upcoming group

sessions are another important way to engage

group members during the first 3 months of

treatment (Lash and Blosser 1999). One successful strategy increased the number of clients

who began continuing care group therapy and

nearly doubled the attendance at group sessions

(Lash and Blosser 1999). The plan included:

•An explanation to each client of the importance of continuing care in maintaining

sobriety and the use of a continuing care

participation contract.

•An appointment card and an automated

telephone message reminder of each upcoming group session.

•A note from the therapist following the first

session saying that he was glad the client

chose to attend the group and was looking

forward to seeing the client at upcoming

sessions.

•At least two follow­up phone calls after

missed sessions (Lash and Blosser 1999).

Yalom (1995) notes that it is common practice

for therapists to try to forestall premature termination by persuading clients who plan to

leave group to attend just one more session.

The hope is that other group members will

persuade the restless member not to drop out.

This tactic rarely works, however. Instead,

during the preparation of clients for group,

Yalom suggests emphasizing that periods of discouragement are likely to occur during therapy.

Another effective way to retain clients can be

used in groups that have a few veteran members. When new members join, the old members are asked to predict which new member

will be the first to drop out. This prediction

paradoxically increases the probability that it

will not be fulfilled (Yalom 1995).

To achieve maximum involvement

in group therapy 

during this period, 

motivational

techniques may

be used.

Researchers note that

these simple initiatives, which make so

much difference in

continuing care

engagement, and the 

outcomes of treatment, “required minimal clinical and clerical time to conduct”

(Lash and Blosser 

1999, p. 58). 

However, while automated phone

reminders might be

useful for highly

structured skillsbuilding groups early

Group Development and Phase­Specific Tasks 65
in recovery or for groups of low­functioning

clients, in interpersonal process groups with

higher functioning clients, the prompts might

set up norms that place too much responsibility

on the leader and too little on group members.

Identifying the Need for

Wraparound Services

Practical problems, such as a lack of suitable

childcare or transportation, deter many clients

from participation in substance abuse counseling services. Many programs find that when

they provide wraparound services to meet these

and other practical needs, they retain clients in

therapy longer. As a result, clients are more

likely to develop new behaviors and thought

processes that enable them to remain abstinent.

Two examples of programs that provide such

services are described in Figures 4­2 and 4­3.

The first step toward wraparound services is to

document the need for them. The next step is

to recognize that wraparound services seldom

flourish in isolation. A thorough search of

existing community resources may identify services already in place that could meet some

Figure 4­2 

The Family Care Program of the Duke Addictions Program

Source: Jeffrey M. Georgi, Senior Clinician, Duke Addictions Program.

The Family Care Program (FCP) at Duke University in Durham, North

Carolina, is a substance abuse program for women who abuse substances and

are pregnant and/or mothers of young children. Transportation is a major difficulty for many of the women and should be provided if their group experience is

to be consistent. Using vans supplied by the county and the State, FCP uses

Medicaid funding to provide transportation to and from approved medical interventions. The program schedules appropriate transportation for the mother and

her children on days that therapy is provided at the Duke Addictions Program.

Viewing the mother and child dyad as the client, FCP provides wraparound services to support the involvement of the woman and her children in treatment.

FCP works closely with the Department of Social Services, the Child Protection

Team at Duke University Medical Center, Head Start, and Vocational Rehabilitation, thus providing a wide range of services, all coordinated through FCP.

Because women are encouraged to bring their infants to group, changing tables

and diapers are available within the group space. For the physical comfort of

pregnant women, particularly those in the later stages of pregnancy, rooms are

furnished with chairs that move into a variety of positions.

Older children who are not yet in school are also included in the treatment program. Because these children could be upset by the subject matter that can arise

in the group, they are not present when women are discussing sensitive issues.

Instead, they have their own treatment programs, supported by a specially trained

child treatment and intervention specialist, who works with the children on issues

of self­esteem, life skills, overall adjustment, and academic performance.

66 Group Development and Phase­Specific Tasks
Figure 4­3 

SageWind

Source: A Consensus Panel member.

SageWind in Reno, Nevada, provides a variety of wraparound services to support clients in recovery. First, it has a working agreement with the local school

district’s alternative high school education program, under which two teachers

help clients acquire high school credits that can be transferred to other schools

in the district. SageWind pays the salary of one teacher and the district pays the

other. SageWind also hires two summer school teachers in order to offer clients

year­round schooling. Throughout the year, college students and other adult

volunteers provide tutoring.

SageWind has a full­time wellness coordinator who is a licensed substance abuse

counselor. The wellness program includes a wide range of recreational activities

designed to teach clients to enjoy alcohol­ and drug­free experiences. Clients

participate in such activities as woodshop projects, along with basketball, pool,

bowling, baseball, and volleyball games.

Through a Qualified Service Organization Agreement with the county health

department, SageWind offers onsite mandatory tuberculosis testing and counseling and voluntary HIV and pregnancy testing and counseling. A registered nurse

teaches a weekly health class on issues ranging from communicable diseases to

nutrition. Treatment technicians can provide transportation, picking up clients

for treatment and returning them to work or home. When necessary, SageWind

also offers bus passes.

An onsite mental health and family clinic at SageWind addresses co­occurring

disorders and strengthens the family unit. Multifamily group counseling, family

support groups, couples counseling, and family therapy help develop skills needed for the survival and growth of the family.

All of SageWind’s primary counselors also function as case managers. If a client

or the client’s family needs housing, food, clothing, or medical care, counselors

will provide referral information and assistance. SageWind receives donated

returned items from two of the area’s largest retailers. The agency maintains a

clothes closet and can also help clients obtain household furnishings and similar

necessities. Any remaining items are donated to other nonprofit organizations in

nearby areas.

Finally, a full­time career counselor at SageWind facilitates a career track. The

counselor provides individual and group services, as well as onsite monitoring of

clients’ job performance. The goal is to assist clients not only to gain employment, but to perform well consistently in their jobs.

Group Development and Phase­Specific Tasks 67
needs. Services still needed can be provided by

initiating cooperative ventures with organizations that have similar interests and complementary capabilities. Note all the cooperation

between and among organizations described in

Figures 4­2 and 4­3.

Group Agreements

A group agreement establishes the expectations

that group members have of each other, the

leader, and the group itself. For example,

many leaders require that group members

entering long­term fixed membership groups

commit to remain in the group for a set period.

Another common provision of group contracts

stipulates that sessions will start and end at

specific times. The leader should make sure

that these time boundaries are observed, both

by clients and the leader. Group members cannot be expected to abide by the group agreement if the leader does not.

A group member’s acceptance of the contract

before entering a group has been described as

the single most important factor contributing to

the success of outpatient therapy groups

(Flores 1997). Consequently, it is important to

present the contract

in a way that causes

clients to view it as a

true commitment

and not a mere formality. Particularly

with people referred

to treatment through

the criminal justice

system, it is important to make therapeutic contracts that

are explicit and

clear, and that carry

a firm expectation

that the agreement is

to be honored by all

members of the

group.

It is important to

present the contract in a way that	 

causes clients to

view it as a true

commitment and

not a mere

formality. To reinforce the

importance of the

agreement as the basis for group activities,

group members can be asked to recall specific

agreements during the first session. To an

appropriate response, the leader can reply,

“Yes, that’s an important one.” Responses that

are distorted may be referred to the group to

determine how others recall the agreement

(Vannicelli 1992).

The agreement provides for “a mutual understanding of the common task and the conditions

under which it will be pursued. It is through

the contract that the leader derives his authority to work: to propose activities, to confront a

member, to make interpretations. And it is by

virtue of the contract that certain other activities can be declared ‘out of bounds’ by either

leader or member” (Singer et al. 1975, p. 147).

Sometimes, obtaining compliance to the group

agreement requires flexibility and ingenuity. In

some cultures, for example, time is a process,

not a concept represented by a number. Of

course, it remains important to maintain time

boundaries. However, when many group members share a culture or ethnicity with a markedly relaxed attitude toward time, it may be

appropriate to design and adhere to a structure

appropriate for that group. For example,

SageWind accommodates its Hispanic/Latino

clients’ flexible view of time and traditions of

sociability. One model moves clients from a

shared lunch to group. By the time group starts,

all its members have arrived and are ready to

begin group work. Another tactic is to schedule

longer group times that enable members to move

into group work from a socializing phase, usually including rituals of food or music.

The group agreement is intended to inspire

clients to accept the basic rules and premises of

the group and to increase their determination

and ability to succeed. These agreements are

not meant to provide a basis for excluding or

punishing anyone. On the contrary, the leader

should understand that few group members are

able to meet all stipulations in the agreement

throughout their recovery. When provisions of

the group agreement are violated, the leader

should avoid assuming an authoritarian role

68 Group Development and Phase­Specific Tasks
Figure 4­4

Examples of Agreements About Time and Attendance

Source: Vannicelli 1992, p. 295. Source: Philip J. Flores.

Regular and timely attendance at all

sessions is expected. As a member, it is

your responsibility to notify the group

in advance when you know that you

will be away or late for group.

To emphasize the importance of each

person to the group, members are also

required to notify the leader when

they are unable to attend.

Members joining long­term groups

remain as long as they find the group

useful in working on important issues

in their lives. We recommend at least 1

year’s participation.

Members are required to make an initial 3­month commitment in order to

determine the usefulness of this particular group for them.

In the event of an unexpected absence,

group members are expected to notify

the group at least 24 hours in advance

to avoid being charged for the missed

session.

Attendance. Regular attendance and

punctuality increase the value of the

group for each member. Such cohesiveness creates a climate of work,

support, and success. In the event of a

member’s inability or decision not to

attend a session, a telephone call to

this effect is expected. Group will

begin and end promptly at the designated times. Group members will

agree to be in group at the time it

starts and stay until it finishes.

Commitment. Members are allowed to

join the group only if they are willing

to make a 6­month commitment.

This agreement ensures that the group

process will not be disrupted by members “dropping in” for one or two sessions and then dropping out of the

group. The agreement also ensures

that any person who joins the group

will be making enough of a commitment to benefit from the group.

and instead ask questions that refer infractions

to the group. The violation becomes important

and useful material for group members to discuss as part of the group process. The errant

behavior should be understood as a meaningful

deviation and approached with interest and

curiosity, not with an air of reproach. See

Figures 4­4 and 4­5 (see p. 71) for examples of

group agreement stipulations.

Communicating grounds for

exclusion 

The terms under which clients will be excluded

from the group should be made explicit in the

group agreement, so exclusion does not come as

a surprise. Some stipulations in the group

agreement might have to incorporate legal

requirements since court­mandated treatment

groups may have attendance criteria set by the

State. If so, the State will set forth the consequences for failure to attend the requisite number of sessions.

Group Development and Phase­Specific Tasks 69
Confidentiality 

Group members should be asked not to discuss

anything outside the group that could reveal

the identity of other members. The leader

should emphasize that confidentiality is critical

and should strongly encourage group members

to honor their pledge of confidentiality. The

principle that “what is said in the group stays

in the group” is a way of delineating group

boundaries and increasing trust in the group.

This atmosphere of trust is essential for group

members to feel safe enough to disclose their

feelings and problems.

Though group members are precluded from

identifying other members of the group or discussing anything they say, members can discuss

the themes of the group and what they personally have said. In fact, talking about the group

with a significant other or therapist in a way

that does not violate the confidentiality of others can be important to a client’s growth.

Under some circumstances, as defined by the

Federal confidentiality regulation or by more

stringent State regulation, certain information

may be shared.

However, the information shared without consent is

restricted by the

minimum necessary

clause. Refer to 42

C.F.R., Part 2,

Confidentiality of

Alcohol and Drug

Abuse Patient

Records to identify

the specific circumstances under which

these exceptions

apply. Group members should know

what information

about them might be

shared and why,

how, and when this

sharing occurs, so

they do not feel

betrayed when someone outside the group

knows about something said within the group.

Except in situations specified in Federal law,

programs may not disclose information about

the services a client receives without the client’s

written consent. The law is explained in detail

in Confidentiality of Patient Records for

Alcohol and Other Drug Treatment (Lopez

1994).

Group leaders

need to be familiar

with confidentiality requirements

in their programs

and their States.

The leader should emphasize how to structure

consent and disclosure, especially through discussion of the minimum necessary principle.

Only specific information can be disclosed.

Legal requirements commonly require, for

example, that the therapist report instances of

elder or child abuse and take action when

clients threaten to harm themselves or others.

Actions might include the hospitalization of the

prospective perpetrator and/or a warning to

the intended victim. Group leaders need to be

familiar with confidentiality requirements in

their programs and their States. See chapter 6

for a discussion of confidentiality.

Physical contact 

Touch in a group is never neutral. People have

different personal histories and cultural backgrounds that lead to different interpretations of

what touch means. Consequently, the leader

should evaluate carefully any circumstance in

which physical contact occurs, even when it is

intended to be positive. In most groups, touch

(handholding or hugs) as part of group rituals

is not recommended, though in others (such as

an expressive therapy or dance group), touch

may be acceptable and normative. Naturally,

group agreements always should include a

clause prohibiting physical violence.

Use of mood­altering 

substances 

Some programs, especially ones connected to

the judicial system, have policies that require

expulsion of group members who are using

drugs of abuse. Counselors are required to

report these violations. Part of client prepara70 Group Development and Phase­Specific Tasks
tion and orientation is to explain all legally

mandated provisions and consequences for

failure to comply with group and treatment

guidelines.

Many in the substance abuse treatment field

believe that such rules lead to withholding of

information (Vannicelli 1992). They reason that

clients cannot be open and honest about substance use if their candor is punished. A reasonable requirement, many believe, is that

clients “must be in an appropriate condition to

participate in order to be at the group. This

allows the therapist to make a clinical judgment

on a case­by­case basis, as to whether or not a

client who has slipped may benefit from being

in the group that night” (Vannicelli 1992, pp.

59–60). Members also should pledge to discuss

a return to use promptly after it occurs (providing that group rules permit and encourage

such disclosures).

Contact outside the group

Generally speaking, the group agreement

should discourage personal contact outside the

group. The reality is, however, that clients who

have bonded in group are likely to communicate outside the group and may encounter each

other on occasions like AA meetings. Under

some circumstances, it may even be desirable

to encourage individuals who support each

other’s efforts to abstain from substance abuse.

The group members need to be told and

reminded that new intimate relationships are

hazardous to early recovery and are therefore

discouraged. Further, any contacts outside the

group should be discussed openly in the group.

Figure 4­5 

Examples of Agreements About Group Participation

Source: Vannicelli 1992, p. 295. Source: Philip J. Flores.

Members will have a commitment to

talk about important issues in their

lives that cause difficulty in relating to

others or in living life fully.

Members will have a commitment to

talk about what is going on in the

group itself as a way of better understanding their own interpersonal

dynamics.

To help you benefit most from your

group experience, you will agree to:

Talk about the issues and problems

that prompted you to join the group.

Tell the emotionally meaningful stories

of your life.

Verbally communicate your immediate

thoughts and feelings about yourself,

the group leaders, and the group

members.

Take an equal share of the total talking time.

Not leave the group before you complete or resolve what you came to the

group to address.

Group Development and Phase­Specific Tasks 71
Participation in the life of 

the group 

The group agreement should specify what

group members are expected to divulge. For

example, group members should be willing to

discuss, in an honest way, the issues that

brought them to the group. Instructions to participants should emphasize that they are

responsible for maintaining their personal

boundaries, and they should participate at the

pace and level they find comfortable. They

should not be required to share personal information until they feel safe enough to do so.

Financial responsibility

In the group agreement, members agree to pay

their bills at a specified time. The agreement

also may specify (1) a commitment to discuss

any problems that occur in making payments

(Vannicelli 1992) and (2) the circumstances

under which a group member will be held

responsible for payments. For example, group

members should know ahead of time that they

will be financially responsible for missed sessions if that is the agency policy.

Termination

Group agreements should specify how group

members should handle termination or occasions when they are

considering termination. Sometimes, a

group member close

to an emotionally

charged issue may

decide to terminate

rather than to confront the uncomfortable feelings.

Because group members often are tempted to leave the group

prematurely instead

of working toward

the necessary

changes in their

lives, the agreement

should emphasize the need to involve the group

in termination decisions. Ultimately, however,

the group members should make their own

choice about discontinuing treatment.

Premature termination (dropping out) may

have serious consequences for some clients.

Court­referred clients (those on parole, probation, and so on) must be reported if they drop

out of treatment. The group agreement should

clearly state all requirements for reporting and

all consequences established by the referring

agency. Members of the group should all clearly understand what behaviors might lead to a

premature termination.

Premature

termination

(dropping out)

may have serious

consequences for

some clients.	 

Phase­Specific Group

Tasks

Every group has a beginning, middle, and end.

These phases occur at different times for different types of groups. One or two sessions of a

particular revolving membership group may

cover all three stages of group therapy for a

particular client, while for a long­term fixed

membership group, several sessions may be

only part of the beginning phase. Whatever the

type or length of a group, the group leader is

responsible for attending to certain key elements at each of these points. (Note that this

discussion focuses on phases of group development, not phases of treatment.)

Beginning Phase––Preparing

the Group To Begin

During the beginning phase of group therapy,

issues arise around topics such as orientation,

beginners’ anxiety, and the role of the leader.

The purpose of the group is articulated, working conditions of the group are established,

members are introduced, a positive tone is set

for the group, and group work begins. This

phase may last from 10 minutes to a number

of months. In a revolving group, this orientation will happen each time a new member joins

the group.

72 Group Development and Phase­Specific Tasks
Introductions

Even in short­term revolving membership

groups, it is important for the leader to connect

with each member. This joining can be as simple as a friendly smile and a one­word welcome. At this time, all members, at the very

least, should have an opportunity to give their

names and say something about themselves.

Some leaders ask members to introduce themselves. Others let the group figure out how to

get acquainted. One cautionary note, however,

is that many clients treated for substance abuse

also have histories of emotional and physical

abuse. Merely directing attention toward them

can trigger feelings of shame. Thus, while it is

extremely important to make connections

between and among group members and to

involve them in the process, the sensitive leader

will not insist on recitations. Emotional safety

always should be foremost in the group

leader’s mind.

At the first meeting of a fixed membership

group, group members also may be asked if

they know anyone else in the group. If there

are connections that might cause difficulties,

they will be discovered at the start.

Each new member who joins the group is entering the beginning phase of the group—for that

individual. It is not easy to find one’s place in

an already established group. The leader can

help build bridges between old and new members by pointing out that it is difficult to be the

new member and by encouraging old members

to help the new one join the group. In longterm fixed membership groups, the group will

require careful preparation to receive a new

member graciously. Even in revolving membership groups, which provide less opportunity for

preparation, the leader should let members

know when to expect membership changes,

introduce new members, and help build

bridges—for example, by inviting existing

members to say something about the group and

how it works.

Ideally, membership changes should be held to

a minimum, especially in fixed membership

groups, though as members graduate, new

members will need to enter to ensure survival

of the group. In contrast, revolving membership groups may have frequent changes

because of the demands of treatment payment

guidelines or admission and discharge procedures. Careful thought should be given to the

pace and timing of membership changes for

particular group types.

Group agreement review

The group agreement should be reviewed in an

interactive way, involving the group members in

discussion of the

terms. The

group leader

should ask

members if they

are aware of

concerns that

might require

additional group

agreement provisions to make

the group a safe

place to share

and grow.

Group members

should have an

opportunity to

suggest and discuss further

stipulations. In

addition, the

group agreement should be reviewed periodically. 

Ideally, membership changes

should be held to

a minimum,

especially in fixed

membership

groups.

Providing a safe, cohesive

environment

During the beginning phase of the group, all

members should feel that they have a part to

play in the group and have something in common with other members. This cohesion, both

among clients and between the clients and the

group leader, will affect the productivity of

work throughout the therapeutic process.

Among the many components of group cohesion

are “connectedness of the group demonstrated

by working toward a common therapeutic goal;

Group Development and Phase­Specific Tasks 73
acceptance, support, and identification with

the group; affiliation, acceptance, and attractiveness of the group; and engagement”

(Marziali et al. 1997, p. 476).

In the beginning phase, the leader ordinarily

needs to be more supportive and active than

will be necessary once the group gets underway. If particular members have spoken very

little, it helps to let them know that their contributions are welcome. The leader might say

something like, “We haven’t heard much from

you tonight, Jane, but perhaps next week the

group will have a chance to get to know you a

little bit more” (Vannicelli 1992, p. 48).

To help group members bond with each other,

the leader should encourage the connections

members begin to make on their own and

should point out similarities. The leader might

say, for instance, “It seems that Sue and Bob,

and perhaps others in here as well, are struggling with very similar problems with their

anger” (Vannicelli 1992, pp. 48–49).

The leader also is responsible for ensuring that

early in the group, emotional expression stays

at a manageable level. Otherwise, members

quickly may feel emotionally overloaded and

begin to withdraw. Care always should be

taken not to shame group members or to allow

others in the group to engage in shaming

behaviors.

The leader also should bear in mind that in the

beginning phase, the group is unable to withstand much conflict. Before the group develops

trust and cohesion, conflict is likely to disrupt

proceedings or even to threaten a group’s existence, so it is unwise to permit confrontation.

Instead the group leader should encourage

interaction that minimizes aggression and hostility. Later, when the group is more stable,

group members may be urged to risk more

provocative positions (Flores 1997).

Establishing norms 

It is up to the leader to make sure that healthy

group norms are established and that counterproductive norms are precluded, ignored, or

extinguished. The leader shapes norms not only

through responses to events in the group, but

also by modeling the behavior expected of others. For example, norms to be encouraged in a

process group include honesty, spontaneity, a

high level of attentive involvement, appropriate

Figure 4­6

Reminders for Each Group Session

Open. 

Announcements: Who will be late? Absent? Does the leader plan any absences? 

If there are new members, welcome them. Then explain the goals of the group. 

Encourage new members to express their goals. 

Track process. 

To refocus the direction of the group, ask: 

•How are things going (or feeling) in the group?

•What is happening right now?

•Does it feel as if we are on track?

74 Group Development and Phase­Specific Tasks
Figure 4­6

Reminders for Each Group Session (continued)

Don’t fight what is hard––use it!

Capitalize on the energy of resistance (the client’s defense against the pain of

self­examination) by

•Noticing it

•Validating it by welcoming honesty

•Linking it to group goals 

Connect before tackling. Ally before confronting or stopping behavior. 

Note the speaker’s positive intentions or efforts. Then ask the speaker to examine his behavior or change course. 

Encourage mutual connections among members. 

Underscore resonating responses, either verbal or nonverbal. Ask how others 

are reacting to what is being shared. 

Share the work. 

Use the group to help you when the going gets rough: 

•Share your conflict and ask the group to help with it.

•When a problem occurs, ask the group members to share their thoughts

about how to proceed. For example, “Max clearly has a lot on his mind. Do

we go with that issue or stick to where we were headed a few minutes ago?”

Close. 

Note that the time is up, or soon will be. 

As you state the end boundary, ask if it is a hard time to end. 

Source: Vannicelli, unpublished manuscript.

self­disclosure, the desire for insight into one’s

own behavior, nonjudgmental acceptance of

others, and the determination to change

unhealthy practices (Flores 1997). Unhealthy

norms that could hamper a process group

include a tendency to become leader­centered,

one­dimensional (that is, all­loving or allattacking), or so tightly knit that the group is

hostile to new members (Flores 1997). The

leader should respond quickly and clearly to

habits that impede group work and that threaten to become normative.

Group Development and Phase­Specific Tasks 75
Initiating

the work

of the

group 

The leader

facilitates the

work of the

group,

whether by

providing

information in

a psychoeducational group

or by encouraging honest

exchanges

among members in other

types of

groups. Most leaders strive to keep the focus on

the here and now as much as possible. The

leader also may need to prompt a new group

with questions such as, “You seem to be

responding to what Jane was sharing. Can you

tell us something about what was going on for

you as she was talking?” (Vannicelli 1992, p. 50).

Termination is

a particularly

important

opportunity for

members to honor

the work they

have done.	 

Middle Phase––Working

Toward Productive Change

The group in its middle phase encounters and

accomplishes most of the actual work of therapy. During this phase, the leader balances content, which is the information and feelings

overtly expressed in the group, and process,

which is how members interact in the group.

The therapy is in both the content and process.

Both contribute to the connections between and

among group members, and it is those connections that are therapeutic.

Many new leaders focus strongly on content,

but thoughtful attention to group process is

extremely important. Even in an educational

group, tension in the room, rolling eyes, or side

conversations can interfere with messages that

need attention. In a process group, these cues

are part of the work and need to be explored

actively, but even in more content­oriented

groups, nonverbal cues are indicative and

should not be ignored.

The group, then, is a forum where clients interact with others. In this give and take of therapy, clients receive feedback that helps them

rethink their behaviors and move toward productive changes. The leader helps group members by allocating time to address the issues

that arise, by paying attention to relations

among group members, and by modeling a

healthy interactional style that combines honesty with compassion. Figure 4­6 (p. 74) suggests some ways in which a group leader can

help the group accomplish its middle­phase

tasks.

End Phase––Reaching Closure

Termination is a particularly important opportunity for members to honor the work they

have done, to grieve the loss of associations and

friendships, and to look forward to a positive

future. Group members should learn and practice saying “good­bye,” understanding that it is

necessary to make room in their lives for the

next “hello.”

“Termination,” Yalom (1995, pp. 361–362)

observes, “is more than the end of therapy; it is

... an important force in the process of change

... a stage in the individual’s career of growth.”

The group begins this work of termination

when the group as a whole reaches its agreedupon termination point or a member determines that it is time to leave the group. In

either case, termination is a time for

•Putting closure on the experience

•Examining the impact of the group on each

person

•Acknowledging the feelings triggered by

departure

•Giving and receiving feedback about the

group experience and each member’s role

in it

•Completing any unfinished business

76 Group Development and Phase­Specific Tasks
•Exploring ways to carry on the learning the

group has offered

Departing clients have been classified into three

groups. Completers have finished the work

they came into group to do. Plateauers are not

really finished, but their progress has slowed or

stopped for the time being. Fleers feel an irresistible need to escape as rapidly as possible,

often because they have encountered an upsetting reality in the group or in their lives outside

the group (Vannicelli 1992).

The group may be invited to explore the proposal that a member leave the group. In addition, the leader might ask clients about to terminate to classify themselves as completers,

plateauers, or fleers. If the client is a fleer, that

person might be asked a hypothetical question:

If you remained in group, what do you think

you might work on? Such a query might bring

to light the issue the fleer wants very much to

avoid. To dissuade a person departing prematurely, it may also help to comment, “One of

the characteristics of a good decision is that it

remains a good decision even after consideration a few weeks later” (Vannicelli 1992, p.

179). Then ask the client if, by that standard,

his decision to leave will be a good one.

Whatever attempts are made to dissuade premature termination, some people with substance abuse problems inevitably will leave

groups abruptly, for a variety of reasons.

Groups should be forewarned that sudden

changes may take place, and leaders should be

prepared to help group members cope with

these changes.

Completing a group successfully can be an

important event for group members, when they

see the conclusion of a difficult but successful

endeavor (Flores 1997). The termination of a

group also is an opportunity for clients to practice parting, with the understanding that a

departure leads to the next opportunity for

connection.

Even positive, celebrated departures, however,

can raise strong feelings, so soon­to­depart

members of an ongoing group should give

ample advance notice (perhaps 4 weeks) to give

the group time to process the feelings associated

with the leave­taking (Flores 1997). Group

members should be given permission to examine existential issues like loss, growth, death,

the shortness of time, the unfairness of life, and

other thoughts that can prey on the mind

(Yalom 1995). So often, clients who used drugs

or alcohol to anesthetize their grief over losses

come to confront their grief in early sobriety.

Every group facilitator working with substance

abuse therefore should understand the grief

process and should be prepared to deal with

grieving clients.

It is natural for individuals and groups to try

to hold onto each other. “Some isolated

patients may postpone termination because

they have been using the therapy group for

social reasons rather than as a means for developing the skills to create a social life for themselves in their home environment. The therapist should help these members focus on transfer of learning and encourage risk taking outside the group” (Yalom 1995, p. 363).

Alternatively, groups

(and therapists) may

subtly pressure a particular group member

to remain because

they value the departing member’s contributions and will miss

him or her. When a

senior member leaves,

however, another

ordinarily will assume

the role just vacated

(Yalom 1995).

In general, the

longer members

have been with the

group, the longer

they may need

to spend on termination.

Some client feelings

may concern parting

from the therapist.

Some clients who are

exquisitely sensitive to

abandonment, for

example, may deny

the gains they have

made. They need reassurance that, once they

improve, they no longer will need the therapist.

Group Development and Phase­Specific Tasks 77
In other reluctant clients, symptoms may

recur. These people need help seeing the

apparent setback for what it really is: fear of

termination (Yalom 1995).

Under no circumstances should the therapist

“collude in the denial of termination” (Yalom

1995, p. 365). The client has to come to grips

with the reality of leaving and not routinely

returning. The departing client and the balance

of the group should face the fact that “the

group will be irreversibly altered; replacements

will enter the group; the present cannot be

frozen; time flows on cruelly and inexorably”

(Yalom 1995, p. 365).

In general, the longer members have been with

the group, the longer they may need to spend

on termination. The group leader plays an

important role in termination, either facilitating an individual’s good­bye to the group or the

group’s good­bye to itself (if the group is ending). Although group leaders cannot say goodbye for the group, they can encourage the

group to fashion its own farewell.

78 Group Development and Phase­Specific Tasks
5 Stages of Treatment 

In This 

Chapter... 

Adjustments To 

Make Treatment 

Appropriate 

The Early Stage of 

Treatment 

Condition of Clients in 

Early Treatment 

Therapeutic Strategies in 

Early Treatment 

Leadership in Early 

Treatment 

The Middle Stage of 

Treatment 

Condition of Clients in 

Middle­Stage Treatment 

Therapeutic Strategies in 

Middle­Stage Treatment 

Leadership in MiddleStage Treatment 

The Late Stage of 

Treatment 

Condition of Clients in 

Late­Stage Treatment 

Therapeutic Strategies in 

Late­Stage Treatment 

Leadership in Late­Stage 

Treatment 

Overview

This chapter describes the characteristics of the early, middle, and

late stages of treatment. Each stage differs in the condition of clients,

effective therapeutic strategies, and optimal leadership characteristics.

For example, in early treatment, clients can be emotionally fragile,

ambivalent about relinquishing chemicals, and resistant to treatment.

Thus, treatment strategies focus on immediate concerns: achieving abstinence, preventing relapse, and managing cravings. Also, to establish a

stable working group, a relatively active leader emphasizes therapeutic

factors like hope, group cohesion, and universality. Emotionally charged

factors, such as catharsis and reenactment of family of origin issues, are

deferred until later in treatment.

In the middle, or action, stage of treatment, clients need the group’s

assistance in recognizing that their substance abuse causes many of their

problems and blocks them from getting things they want. As clients

reluctantly sever their ties with substances, they need help managing

their loss and finding healthy substitutes. Often, they need guidance in

understanding and managing their emotional lives.

Late­stage treatment spends less time on substance abuse per se and

turns toward identifying the treatment gains to be maintained and risks

that remain. During this stage, members may focus on the issues of living, resolving guilt, reducing shame, and adopting a more introspective,

relational view of themselves.

Adjustments To Make Treatment

Appropriate

As clients move through different stages of recovery, treatment must

move with them, changing therapeutic strategies and leadership roles

with the condition of the clients. These changes are vital since interventions that work well early in treatment may be ineffective, and even

harmful, if applied in the same way later in treatment (Flores 2001).

79
Any discussion of

intervention adjustments to make treatment appropriate at

each stage, however,

necessarily must be

oversimplified for

three reasons. First,

the stages of recovery and stages of

treatment will not

correspond perfectly

for all people.

Clients move in and

out of recovery

stages in a nonlinear

process. A client

may fall back, but

not necessarily back

to the beginning.

“After a return to

substance use,

clients usually revert to an earlier change

stage—not always to maintenance or action,

but more often to some level of contemplation.

They may even become precontemplators

again, temporarily unwilling or unable to try to

change . . . [but] a recurrence of symptoms

does not necessarily mean that a client has

abandoned a commitment to change” (Center

for Substance Abuse Treatment 1999b, p. 19).

See chapters 2 and 3 for a discussion of the

stages of change.

With guidance, 

clients can learn 

to recognize 

the events and 

situations that 

trigger renewed 

substance use. 

A return to drug use, properly handled, can

even be instructive. With guidance, clients can

learn to recognize the events and situations that

trigger renewed substance use and regression to

earlier stages of recovery. This knowledge

becomes helpful in subsequent attempts leading

to eventual recovery. Client progress­regressprogress waves, however, require the counselor

to constantly reevaluate where the client is in

the recovery process, irrespective of the stage

of treatment.

Second, adjustments in treatment are needed

because progress through the stages of recovery

is not timebound. There is no way to calculate

how long any individual should require to

resolve the issues that arise at any stage of

recovery. The result is that different group

members may achieve and be at different stages

of recovery at the same time in the lifecycle of

the group. The group leader, therefore, should

use interventions that take the group as a

whole into account.

Third, therapeutic interventions, meaning the

acts of a clinician intended to promote healing,

may not account for all (or any) of the change

in a particular individual. Some people give up

drugs or alcohol without undergoing treatment.

Thus, it is an error to assume that an individual is moving through stages of treatment

because of assistance at every point from institutions and self­help groups. To stand the best

chance for meaningful intervention, a leader

should determine where the individual best fits

in his level of function, stance toward abstinence, and motivation to change. In short,

generalizations about stages of treatment may

not apply to every client in every group.

The Early Stage of

Treatment 

Condition of Clients in Early

Treatment

In the early stage of treatment, clients may be

in the precontemplation, contemplation, preparation, or early action stage of change, depending on the nature of the group. Regardless of

their stage in early recovery, clients tend to be

ambivalent about ending substance use. Even

those who sincerely intend to remain abstinent

may have a tenuous commitment to recovery.

Further, cognitive impairment from substances

is at its most severe in these early stages of

recovery, so clients tend to be rigid in their

thinking and limited in their ability to solve

problems. To some scientists, it appears that

the “addicted brain is abnormally conditioned,

so that environmental cues surrounding drug

use have become part of the addiction”

(Leshner 1996, p. 47).

80 Stages of Treatment
Typically, people who abuse substances do not

enter treatment on their own. Some enter treatment due to health problems, others because

they are referred or mandated by the legal system, employers, or family members (Milgram

and Rubin 1992). Group members commonly

are in extreme emotional turmoil, grappling

with intense emotions such as guilt, shame,

depression, and anger about entering treatment.

Even if clients have entered treatment voluntarily, they often harbor a desire for substances

and a belief that they can return to recreational use once the present crisis subsides. At first,

most clients comply with treatment expectations more from fear of consequences than

from a sincere desire to stop drinking or using

illicit drugs (Flores 1997; Johnson 1973).

Consequently, the group leader faces the challenge of treating resistant clients. In general,

resistance presents in one of two ways. Some

clients actively resist treatment. Others passively resist. They are outwardly cooperative and

go to great lengths to give the impression of

willing engagement in the treatment process,

but their primary motivation is a desire to be

free from external pressure. The group leader

has the delicate task of exposing the motives

behind the outward compliance.

The art of treating addiction in early treatment

is in the defeat of denial and resistance, which

almost all clients with addictions carry into

treatment. Group therapy is considered an

effective modality for

...overcoming the resistance that characterizes addicts. A skilled group leader

can facilitate members’ confronting

each other about their resistance. Such

confrontation is useful because it is difficult for one addict to deceive another.

Because addicts usually have a history

of adversarial relationships with authority figures, they are more likely to

accept information from their peers

than a group leader. A group can also

provide addicts with the opportunity for

mutual aid and support; addicts who

present for treatment are usually well

connected to a dysfunctional subculture

but socially isolated from healthy contacts (Milgram and Rubin 1992, p. 96).

Emphasis therefore is placed on acculturating

clients into a new culture, the culture of recovery (Kemker et al. 1993).

Therapeutic Strategies in Early

Treatment

In 1975, Irvin Yalom elaborated on earlier

work and distinguished 11 therapeutic factors

that contribute to healing as group therapy

unfolds:

•Instilling hope—some group members exemplify progress toward recovery and support

others in their efforts, thereby helping to

retain clients in therapy.

•Universality—groups enable clients to

see that they are not alone, that others have

similar problems.

•Imparting information—leaders shed light on

the nature of addiction via direct instruction.

•Altruism—group members gain greater selfesteem by helping each other.

•Corrective recapitulation of the primary

family group—groups provide a family­like

context in which long­standing unresolved

conflicts can be revisited and constructively

resolved.

•Developing socializing techniques—groups

give feedback; others’ impressions reveal how

a client’s ineffective social habits might

undermine relationships.

•Imitative behavior—groups permit clients to

try out new behavior of others.

•Interpersonal learning—groups correct the

distorted perceptions of others.

•Group cohesiveness—groups provide a safe

holding environment within which people feel

free to be honest and open with each other.

•Catharsis—groups liberate clients as they

learn how to express feelings and reveal what

is bothering them.

Stages of Treatment 81
•Existential factors—groups aid clients in

coming to terms with hard truths, such as

(1) life can be unfair; (2) life can be painful

and death is inevitable; (3) no matter how

close one is to others, life is faced alone; (4) it

is important to live honestly and not get

caught up in trivial matters; (5) each of us is

responsible for the ways in which we live.

In different stages of treatment, some of these

therapeutic factors receive more attention than

others. For example, in the beginning of the

recovery process, it is extremely important for

group members to experience the therapeutic

factor of universality. Group members should

come to recognize that although they differ in

some ways, they also share profound connections and similarities, and they are not alone in

their struggles.

The therapeutic factor of hope also is particularly important in this stage. For instance, a

new member facing the first day without drugs

may come into a revolving membership group

that includes people who have been abstinent

for 2 or 3 weeks. The mere presence of people

able to sustain abstinence for days––even

weeks––provides the new member with hope

that life can be lived without alcohol or illicit

drugs. It becomes possible to believe that abstinence is feasible because others are obviously

succeeding.

Attention to group

cohesiveness is

important early in

treatment.

Imparting information often is needed

to help clients learn

what needs to be

done to get through

a day without chemicals. Psychoeducation also allows

group members to

learn about addiction, to judge their

practices against this

factual information,

and to postpone

intense interaction

with other group

members until they

are ready for such highly charged work.

Attention to group cohesiveness is important

early in treatment because only when group

members feel safety and belonging within the

group will they be able to form an attachment to

the group and fully experience the effects of new

knowledge, universality, and hope.

Therapeutic factors such as catharsis, existential factors, or recapitulation of family groups

generally receive little attention in early treatment. These factors often are highly charged

with emotional energy and are better left until

the group is well established.

During the initial stage of treatment, the therapist helps clients acknowledge and understand

how substance abuse has dominated and damaged their lives. Drugs or alcohol, in various

ways, can provide a substitute for the give­andtake of relationships and a means of surviving

without a healthy adjustment to life. As substances are withdrawn or abandoned, clients

give up a major source of support without having anything to put in its place (Brown 1985;

Straussner 1997).

In this frightening time, counselors need to

ensure that the client has a sense of safety. The

group leader’s task is to help group members

recognize that while alcohol or illicit drugs may

have provided a temporary way to cope with

problems in the past, the consequences were

not worth the price, and new, healthier ways

can be found to handle life’s problems.

In early­stage treatment, strong challenges to a

client’s fragile mental and emotional condition

can be very harmful. Out of touch with unmedicated feelings, clients already are susceptible

to wild emotional fluctuations and are prone to

unpredictable responses. Interpersonal relationships are disturbed, and the effects of substances leave the client prone to use “primitive

defensive operations such as denial, splitting,

projective identification, and grandiosity”

(Straussner 1997, p. 68).

This vulnerable time, however, is also one of

opportunity. In times of crisis, “an individual’s

attachment system opens up” and the therapist

82 Stages of Treatment
A Note on Attachment Theory and

Substance Abuse Treatment

Attachment theory provides a comprehensive meta­theory of addiction that

not only integrates diverse mental health models with the disease­concept, but

also furnishes guidelines for clinical practice that are compatible with existing

addiction treatment strategies including an abstinence basis and alignment with

12­Step treatment philosophy.

Attachment theory (Bowlby 1979) and self psychology (Kohut 1977b) provided

the first compelling theories that offered a practical alternative rationale for the

addiction cycle that is not only compatible with the disease concept, but expands

it by providing a more complete and intellectually satisfying theoretical explanation why Alcoholic Anonymous (AA) works as it does.

According to the theory, attachment is recognized as a primary motivational

force with its own dynamics, and these dynamics have far­reaching and complex

consequences (Bowlby 1979). In clients with substance use disorders there is an

inverse relation between their substance abuse and healthy interpersonal attachments. A person who is actively abusing substances can rarely negotiate the

demands of healthy interpersonal relationships successfully.

Using this theoretical model, substance abuse can be viewed as an attachment

disorder. Individuals who have difficulty establishing intimate attachments will

be more inclined to substitute substances for their deficiency in intimacy.

Because of their difficulty maintaining emotional closeness with others, they

are more likely to substitute various behaviors (including substance abuse) to

distract them from their lack of intimate interpersonal relations.

The use of substances may initially serve a compensatory function, helping those

who feel uncomfortable in social situations because of inadequate interpersonal

skills. However, substances of abuse will gradually compromise neurophysiological functioning and erode existing interpersonal skills. Managing relationships

tends to become increasingly difficult, leading to a heightened reliance on substances, which accelerates deterioration and increases abuse and dependence.

Eventually, the individual’s relationship with substances of abuse becomes both

an obstacle to and a substitute for interpersonal attachments. If problems in

attachment are a primary cause of substance abuse, then a therapeutic process

that addresses the client’s interpersonal relations will be effective for long­term

recovery (Flores 2001; Straussner 1993). Treatment concentrates on removing

stress­inducing stimuli, teaching ways to recognize and quell environmental cues

that trigger inappropriate behaviors, providing positive reinforcement and support, cultivating positive habits that endure, and developing secure and positive

attachments.

Stages of Treatment 83
has a chance to change the client’s internal

dynamics (Flores 2001, p. 72). Support networks that can provide feedback and structure

are especially helpful at this stage. Clients also

need reliable information to strengthen their

motivation.

At this time, clients are solidifying their “new

identity as an alcoholic with the corresponding

belief in loss of control.” They develop “a new

logical structure” with which to assail their

“former logic and behavior.” They also can

develop a “new story . . . the Alcoholics

Anonymous drunkalogue,” which recalls their

experiences and compares previous events with

what life is like now (Brown 1985).

Whether information is offered through skills

groups, psychoeducational groups, supportive

therapy groups, spiritually oriented support

groups, or process groups, clients are most

likely to use the information and tools provided

in an environment alive with supportive human

connections. All possible sources of positive

forces in a client’s life should be marshaled to

help the client manage life’s challenges instead

of turning to substances or other addictive

behaviors.

During early treatment, a relatively

active leader seeks

to engage clients in

the treatment

process.

Painful feelings,

which clients are not

yet prepared to face,

can sometimes trigger relapse. If

relapses occur in an

outpatient

setting––as they

often do, because

relapses occur in all

chronic illnesses,

including addiction––the group

member should be

guided through the

regression. The leader encourages the

client to attend selfhelp groups,

explores the

sequence of events

leading to relapse,

determines what cues led to relapse, and suggests changes that might enable the client to

manage cravings better or avoid exposure to

strong cues.

For some clients, chiefly those mandated into

treatment by courts or employers, grave consequences inevitably ensue as a result of relapse.

As Vannicelli (1992) points out, however, clinicians should view relapse not as failure, but as

a clinical opportunity for both group leader

and clients to learn from the event, integrate

the new knowledge, and strengthen levels of

motivation. Discussion of the relapse in group

not only helps the individual who relapsed

learn how to avoid future use, but it also gives

other group members a chance to learn from

the mistakes of others and to avoid making the

same mistakes themselves.

Leadership in Early Treatment

Clients usually come to the first session of

group in an anxious, apprehensive state of

mind, which is intensified by the knowledge

that they will soon be revealing personal information and secrets about themselves. The therapist begins by making it clear that clients have

some things in common. All have met with the

therapist, have acceded to identical agreements, and have set out to resolve important

personal issues. Usually, the therapist then suggests that members get to know each other. One

technique is to allow the members to decide

exactly how they will introduce themselves. The

therapist observes silently—but not impassively—watching how interaction develops (Rutan

and Stone 2001).

During early treatment, a relatively active leader seeks to engage clients in the treatment process. Clients early on “usually respond more

favorably to the group leader who is spontaneous, ‘alive,’ and engaging than they do to the

group leader who adopts the more reserved

stance of technical neutrality associated with

the more classic approaches to group therapy”

(Flores 2001, p. 72). The leader should not be

overly charismatic, but should be a strong

enough presence to meet clients’ dependency

needs during the early stage of treatment.

84 Stages of Treatment
During early treatment, the effective leader will

focus on immediate, primary concerns: achieving abstinence, preventing relapse, and learning

ways to manage cravings. The leader should

create an environment that enables clients to

acknowledge that (1) their use of addictive substances was harmful and (2) some things they

want cannot be obtained while their pattern of

substance use continues. As clients take their

first steps toward a life centered on healthy

sources of satisfaction, they need strong support, a high degree of structure, positive

human connections, and active leadership.

In process groups, the leader pays particular

attention to feelings in the early stage of treatment. Many people with addiction histories are

not sure what they feel and have great difficulty communicating their feelings to others.

Leaders begin to help group members move

toward affect regulation by labeling and mirroring feelings as they arise in group work.

The leader’s subtle instruction and empathy

enables clients to begin to recognize and own

their feelings. This essential step toward managing feelings also leads clients toward empathy

with the feelings of others.

The Middle Stage of

Treatment 

Condition of Clients in

Middle­Stage Treatment

Often, in as little as a few months, institutional

and reimbursement constraints limit access to

ongoing care. People with addiction histories,

however, remain vulnerable for much longer

and continue to struggle with dependency.

They need vigorous assistance maintaining

behavioral changes throughout the middle, or

action, stage of treatment.

Several studies (Committee on Opportunities in

Drug Abuse Research 1996; London et al.

1999; Majewska 1996; Paulus et al. 2002;

Strickland et al. 1993; Volkow et al. 1988,

1992) have observed decreased blood flow

and metabolic changes rates in the brains of

subjects who abused

stimulants (cocaine

and methaphetamine).

The studies also found

that deficits persisted

for at least 3 to 6

months after cessation

of drug use. Whether

these deficits predated

substance abuse or

not, treatment personnel should expect

to see clients with

impaired decisionmaking and impulse

control manifested by

difficulties in attending, concentrating,

learning new material, remembering things

heard or seen, producing words, and integrating visual and motor cues. For the clinician,

this finding means that clients may not have the

mental structures in place to enable them to

make the difficult decisions faced during the

action stage of treatment. If clients draw and

use support from the group, however, the

client’s affect will re­emerge, combine with new

behaviors and beliefs, and produce an increasingly stable and internalized structure (Brown

1985).

Cognitive capacity

usually begins to

return to normal

in the middle stage

of treatment.

Cognitive capacity usually begins to return to

normal in the middle stage of treatment. The

frontal lobe activity in a person addicted to

cocaine, for example, is dramatically different

after approximately 4–6 months of nonuse.

Still, the mind can play tricks. Clients distinctly

may remember the comfort of their substance

past, yet forget just how bad the rest of their

lives were and the seriousness of the consequences that loomed before they came into

treatment. As a result, the temptation to

relapse remains a concern.

Therapeutic Strategies in

Middle­Stage Treatment

In middle­stage recovery, as the client experiences some stability, the therapeutic factors

Stages of Treatment 85
of self­knowledge and altruism can be

emphasized. Universality, identification,

cohesion, and hope remain important as well.

Practitioners have stressed the need to work in

alliance with the client’s motivation for change.

The therapist uses whatever leverage

exists––such as current job or marriage concerns––to power movement toward change.

The goal is to help clients perceive the causal

relationship between substance abuse and

current problems

in their lives.

Counselors should

recognize and

respect the client’s

position and the

difficulty of change.

The leader who

leaves group members feeling that they

are understood is

more likely to be in a

position to influence

change, while sharp

confrontations that

arouse strong emotions and appear

judgmental may

trigger relapse

(Flores 1997).

The goal is to help

clients perceive the

causal relationship

between substance

abuse and current	 

problems in

their lives.

Therapeutic strategies also should take into

account the important role substance abuse has

played in the lives of people with addictions.

Often, from the client’s perspective, drugs of

abuse have become their best friends. They fill

hours of boredom and help them cope with difficulties and disappointments. As clients move

away from their relationship with their best

friend, they may feel vulnerable or emotionally

naked, because they have not yet developed

coping mechanisms to negotiate life’s inevitable

problems. It is crucial that clients recognize

these feelings as transient and understand that

the feeling that something vital is missing can

have a positive effect. It may be the impetus

that clients need to adopt new behaviors that

are adaptive, safe, legal, and rewarding.

As the recovering client’s mental, physical, and

emotional capacities grow stronger, anger, sadness, terror, and grief may be expressed more

appropriately. Clients need to use the group as

a means of exploring their emotional and interpersonal world. They learn to differentiate,

identify, name, tolerate, and communicate feelings. Cognitive–behavioral interventions can

provide clients with specific tools to help modulate feelings and to become more confident in

expressing and exploring them. Interpersonal

process groups are particularly helpful in the

middle stage of treatment, because the authentic

relationships within the group enable clients to

experience and integrate a wide range of emotions in a safe environment.

When strong emotions are expressed and discussed in group, the leader needs to modulate

the expression of emerging feelings, delicately

balancing a tolerable degree of expression and

a level so overwhelming that it inhibits positive

change or leads to a desire to return to substance use to manage the intensity. It also is

very important for the group leader to “sew the

client up” by the end of the session. Clients

should not leave feeling as if they are “bleeding” emotions that they cannot cope with or

dispel. A plan for the rest of the day should be

developed, and the increased likelihood of

relapse should be acknowledged so group members see the importance of following the plan.

Leadership in Middle­Stage

Treatment

Historically, denial has been the target of most

treatment concepts. The role of the leader was

primarily to confront the client in denial,

thereby presumably provoking change. More

recently, clinicians have stressed the fact that

“confrontation, if done too punitively or if motivated by a group leader’s countertransference

issues, can severely damage the therapeutic

alliance” (Flores 1997, p. 340). Inappropriate

confrontation may even strengthen the client’s

resistance to change, thereby increasing the

rigidity of defenses.

86 Stages of Treatment
When it is necessary to point out contradictions

in clients’ statements and interpretations of

reality, such confrontations should be welltimed, specific, and indisputably true. For

example, author Wojciech Falkowski had a

client whose medical records distinctly showed

abnormal liver functions. When the client

maintained that he had no drinking problem,

Falkowski gently suggested that he “convince

his liver of this fact.” The reply created a ripple of amusement in the group, and “the client

immediately changed his attitude in the desired

direction” (Falkowski 1996, p. 212). Such caring confrontations made at the right time and

in the right way are helpful, whether they come

from group members or the leader.

Another way of understanding confrontation is

to see it as an outcome rather than as a style.

From this point of view, the leader helps group

members see how their continued use of drugs

or alcohol interferes with what they want to get

out of life. This recognition, supported by the

group, motivates individuals to change. It

seems that people who abuse substances need

someone to tell it like it is “in a realistic fashion

without adopting a punitive, moralistic, or

superior attitude” (Flores 1997, p. 340).

In the middle stage of treatment, the leader

helps clients join a culture of recovery in which

they grow and learn. The leader’s task is to

engage members actively in the treatment and

recovery process. To prevent relapse, clients

need to learn to monitor their thoughts and

feelings, paying special attention to internal

cues. Both negative and positive dimensions

may be motivational. New or relapsed group

members can remind others of how bad their

former lives really were, while the group’s

vision of improvements in the quality of life is a

distinct and immediate beam of hope.

The leader can support the process of change

by drawing attention to new and positive developments, pointing out how far clients have

traveled, and affirming the possibility of

increased connection and new sources of satisfaction. Leaders should bear in mind, however,

that people with addictions typically choose

immediate gratification over long­range goals,

so benefits achieved and sought after should be

real, tangible, and quickly attainable.

The benefits of recovery yield little satisfaction

to some clients, and for them, the task of staying on course can be difficult. Their lives in

recovery seem worse, not better. Many experience depression, lassitude, agitation, or anhedonia (that is, a condition in which formerly

satisfying activities are no longer pleasurable).

Eventually, their lives seem devoid of any

meaningful purpose, and they stop caring

about recovery.

These clients may move quickly from “I don’t

care” to relapse, so the group leader should be

vigilant and prepared to intervene when a

client is doing all that should be done in the

recovery process, yet continues to feel bleak.

Such clients need attention and accurate

diagnosis. Do they have an undiagnosed cooccurring disorder? Do they need antidepressants? Do they need more intensive, frequent,

adjuncts to therapy, such as more Alcoholics

Anonymous or Narcotics Anonymous meetings

and additional contacts with a sponsor?

Leaders need to help group members understand and accept that many forms of therapy

outside the group can promote recovery. Group

members should be

encouraged to support each other’s

efforts to recover,

however much their

needs and treatment

options may differ.

In the middle stage

of treatment, the

leader helps clients

join a culture of

recovery in which

they grow

and learn.

The leader helps

individuals assess the

degree of structure

and connection they

need as recovery

progresses. Some

group members find

that participation in

religious or faith

groups meets their

needs for affiliation

and support. For

Stages of Treatment 87
long­term, chronically impaired people with

addictive histories, highly intensive participation in 12­Step groups is usually essential for

an extended period of time.

The Late Stage of 

Treatment 

Condition of Clients in 

Late­Stage Treatment 

During the late (also referred to as ongoing or

maintenance) stage of treatment, clients work

to sustain the attainments of the action stage,

but also learn to anticipate and avoid tempting

situations and triggers that set off renewed substance use. To deter relapse, the systems that

once promoted drinking and drug use are

sought out and severed.

Despite efforts to forestall relapse, many

clients, even those who have reached the late

stage of treatment, do return to substance use

and an earlier stage of change. In these cases,

the efforts to guard against relapse were not all

in vain. Clients who return to substance abuse

do so with new information. With it, they may

be able to discover and acknowledge that some

of the goals they set are unrealistic, certain

strategies attempted

are ineffective, and

environments

deemed safe are not

at all conducive to

successful recovery.

With greater insight

into the dynamics of

their substance

abuse, clients are

better equipped to

make another

attempt at recovery,

and ultimately, to

succeed.

During the late

stage of treatment,

clients work to

sustain the attainments of the

action stage. As the substance

abuse problem fades

into the background,

significant underlying issues often emerge, such as poor selfimage, relationship problems, the experience of

shame, or past trauma. For example, an

unusually high percentage of substance and

alcohol abuse occurs among men and women

who have survived sexual or emotional abuse.

Many such cases warrant an exploration of dissociative defenses and evaluation by a knowledgeable mental health professional.

When the internalized pain of the past is

resolved, the client will begin to understand

and experience healthy mutuality, resolving

conflicts without the maladaptive influence of

alcohol or drugs. If the underlying conflicts are

left unresolved, however, clients are at

increased risk of other compulsive behavior,

such as excessive exercise, overeating, gambling, or excessive sexual activity.

Therapeutic Strategies in LateStage Treatment

In the early and middle stages of treatment,

clients necessarily are so focused on maintaining abstinence that they have little or no capacity to notice or solve other kinds of problems.

In late­stage treatment, however, the focus of

group interaction broadens. It attends less to

the symptoms of drug and alcohol abuse and

more to the psychology of relational interaction.

In late­stage treatment, clients begin to learn to

engage in life. As they begin to manage their

emotional states and cognitive processes more

effectively, they can face situations that involve

conflict or cause emotion. A process­oriented

group may become appropriate for some clients

who are finally able to confront painful realities, such as being an abused child or abusive

parent. Other clients may need groups to help

them build a healthier marriage, communicate

more effectively, or become a better parent.

Some may want to develop new job skills to

increase employability.

Some clients may need to explore existential

concerns or issues stemming from their family

of origin. These emphases do not deny the continued importance of universality, hope, group

88 Stages of Treatment
cohesion and other therapeutic factors. Instead

it implies that as group members become more

and more stable, they can begin to probe deeper into the relational past. The group can be

used in the here and now to settle difficult and

painful old business.

Leadership in Late­Stage

Treatment

The leader plays a very different role in latestage treatment, which refocuses on helping

group members expose and eliminate personal

deficits that endanger recovery. Gradually, the

leader shifts toward interventions that call

upon people who are chemically dependent to

take a cold, hard look at their inner world and

system of defenses, which have prevented them

from accurately perceiving their self­defeating

behavioral patterns. To become adequately

resistant to substance abuse, clients should

learn to cope with conflict without using chemicals to escape reality, self­soothe, or regulate

emotions (Flores 1997).

As in the early and middle stages, the leader

helps group members sustain abstinence and

makes sure the group provides enough support

and gratification to prevent acting out and

premature termination. While early­ and

middle­stage interventions strive to reduce

or modulate affect,

late­stage interventions permit more

intense exchanges.

Thus, in late treatment, clients no

longer are cautioned

against feeling too

much. The leader no

longer urges them to

apply slogans like

“Turn it over” and

“One day at a time.”

Clients finally should

manage the conflicts

that dominate their

lives, predispose them

to maladaptive behaviors, and endanger their

hard­won abstinence. The leader allows clients

to experience enough anxiety and frustration to

bring out destructive and maladaptive characterological patterns and coping styles. These

characteristics provide abundant grist for the

group mill.

As group members

become more and

more stable, they

can begin to probe

deeper into the

relational past.

Stages of Treatment 89

6 Group Leadership,

Concepts, and Techniques

In This 

Chapter... 

The Group Leader

Personal Qualities 

Leading Groups 

Concepts, 

Techniques, and 

Considerations 

Interventions 

Transference and 

Countertransference 

Resistance in Group 

Confidentiality 

Biopsychosocial and 

Spiritual Framework— 

Treating the Whole Person 

Integrating Care 

Management of the Group 

Managing Other Common 

Problems 

Overview

This chapter describes desirable leader traits and behaviors, along with

the concepts and techniques vital to process groups––though many of the

ideas can apply in other types of groups. Most of the ideas seem perfectly logical, too, once they are brought to mind.

For instance, consistency in manner and procedure helps to provide a

safe and stable environment for the newly recovering person with a substance use disorder. When the upheaval in the lives of people recovering

from addictions is considered, it becomes clear how important it is to

keep as many factors as possible both constant and predictable.

The pages that follow discuss issues such as

•How to convert conflict and resistance into positive energy that powers

the group

•How to deal with disruptive group members, such as clients who talk

incessantly or bolt from a session

•How to cool down runaway affect or turn a crisis into an opportunity

People who abuse substances are a broad and diverse population, one

that spans all ages and ethnic groups and encompasses people with a

wide variety of co­occurring conditions and personal histories. In working with people who have substance use disorders, an effective leader

uses the same skills, qualities, styles, and approaches needed in any

kind of therapeutic group. The adjustments needed to treat substance

abuse are simply that—adjustments within the bounds of good practice.

The particular personal and cultural characteristics of the clients in

group also will influence the therapist’s tailoring of therapeutic strategies

to fit the particular needs of the group.

91
The Group Leader

Personal Qualities

Although the attributes of an effective interpersonal process group leader treating substance

abuse are not strikingly different from traits

needed to work successfully with other client

populations, some of the variations in

approach make a big difference. Clients, for

example, will respond to a warm, empathic,

and life­affirming manner. Flores (1997) states

that “many therapists do not fully appreciate

the impact of their personalities or values on

addicts or alcoholics who are struggling to identify some viable alternative lifestyle that will

allow them to fill up the emptiness or deadness

within them” (p. 456). For this reason, it is

important for group leaders to communicate

and share the joy of being alive. This lifeaffirming attitude carries the unspoken message that a full and vibrant life is possible without alcohol or drugs.

In addition, because many clients with substance abuse histories have grown up in homes

that provided little protection, safety, and

support, the leader should be responsive and

affirming, rather than distant or judgmental.

The leader should recognize that group members have a high

level of vulnerability

and are in need of

support, particularly

in the early stage of

treatment. A discussion of other essential characteristics

for a group leader

follows. Above all, it

is important for the

leader of any group

to understand that

he or she is responsible for making a

series of choices as

the group progresses.

The leader chooses

how much leadership

to exercise, how to structure the group, when to

intervene, how to effect a successful intervention, how to manage the group’s collective anxiety, and the means of resolving numerous other

issues. It is essential for any group leader to be

aware of the choices made and to remember

that all choices concerning the group’s structure and her leadership will have consequences

(Pollack and Slan 1995).

Excellent listening

skills are the

keystone of any

effective therapy.	 

Constancy 

An environment with small, infrequent changes

is helpful to clients living in the emotionally

turbulent world of recovery. Group facilitators

can emphasize the reality of constancy and

security through a variety of specific behaviors.

For example, group leaders always should sit in

the same place in the group. Leaders also need

to respond consistently to particular behaviors.

They should maintain clear and consistent

boundaries, such as specific start and end

times, standards for comportment, and ground

rules for speaking. Even dress matters. The

setting and type of group will help determine

appropriate dress, but whatever the group

leader chooses to wear, some predictability is

desirable throughout the group experience.

The group leader should not come dressed in a

suit and tie one day and in blue jeans the next.

Active listening 

Excellent listening skills are the keystone of any

effective therapy. Therapeutic interventions

require the clinician to perceive and to understand both verbal and nonverbal cues to meaning and metaphorical levels of meaning. In

addition, leaders need to pay attention to the

context from which meanings come. Does it

pertain to the here­and­now of what is occurring in the group or the then­and­there history

of the specific client?

Firm identity 

A firm sense of their own identities, together

with clear reflection on experiences in group,

enables leaders to understand and manage

their own emotional lives. For example,

92 Group Leadership, Concepts, and Techniques
therapists who are aware of their own capacities and tendencies can recognize their own

defenses as they come into play in the group.

They might need to ask questions such as: “Am

I cutting off discussions that could lead to verbal expression of anger because I am uncomfortable with anger? Have I blamed clients for

the group’s failure to make progress?”

Group work can be extremely intense emotionally. Leaders who are not in control of their

own emotional reactions can do significant

harm—particularly if they are unable to admit

a mistake and apologize for it. The leader also

should monitor the process and avoid being

seduced by content issues that arouse anger

and could result in a loss of the required professional stance or distance. A group leader

also should be emotionally healthy and keenly

aware of personal emotional problems, lest

they become confused with the urgent issues

faced by the group as a whole. The leader

should be aware of the boundary between personal and group issues (Pollack and Slan 1995).

Confidence 

Effective group leaders operate between the

certain and the uncertain. In that zone, they

cannot rely on formulas or supply easy answers

to clients’ complex problems. Instead, leaders

have to model the consistency that comes from

self­knowledge and clarity of intent, while

remaining attentive to each client’s experience

and the unpredictable unfolding of each session’s work. This secure grounding enables the

leader to model stability for the group.

Spontaneity 

Good leaders are creative and flexible. For

instance, they know when and how to admit a

mistake, instead of trying to preserve an image

of perfection. When a leader admits error

appropriately, group members learn that no

one has to be perfect, that they––and

others––can make and admit mistakes, yet

retain positive relationships with others.

Integrity 

Largely due to the

nature of the material

group members are

sharing in process

groups, it is all but

inevitable that ethical

issues will arise.

Leaders should be

familiar with their

institution’s policies

and with pertinent

laws and regulations.

Leaders also need to

be anchored by clear

internalized standards

of conduct and able to

maintain the ethical

parameters of their profession.

Good leaders are

creative and

flexible.

Trust 

Group leaders should be able to trust others.

Without this capacity, it is difficult to accomplish a key aim of the group: restoration of

group members’ faith and trust in themselves

and their fellow human beings (Flores 1997).

Humor 

The therapist needs to be able to use humor

appropriately, which means that it is used only

in support of therapeutic goals and never is

used to disguise hostility or wound anyone.

Empathy 

Empathy, one of the cornerstones of successful

group treatment for substance abuse, is the

ability to identify someone else’s feelings while

remaining aware that the feelings of others are

distinct from one’s own. Through these “transient identifications” we make with others, we

feel less alone. “Identification is the antidote to

loneliness, to the feeling of estrangement that

seems inherent in the human condition”

(Ormont 1992, p. 147).

For the counselor, the ability to project empathy is an essential skill. Without it, little can be

Group Leadership, Concepts, and Techniques 93
accomplished. Empathic listening requires

close attention to everything a client says and

the formation of hypotheses about the underlying meaning of statements (Miller and Rollnick

1991). An empathic substance abuse counselor

•Communicates respect for and acceptance of

clients and their feelings

•Encourages a nonjudgmental, collaborative 

relationship 

•Is supportive and knowledgeable

•Sincerely compliments rather than denigrates

or diminishes another person

•Tells less and listens more

•Gently persuades, while understanding that

the decision to change is the client’s

•Provides support throughout the recovery 

process (Center for Substance Abuse 

Treatment [CSAT] 1999b, p. 41) 

One of the great benefits of group therapy is

that as clients interact, they learn from one

another. For interpersonal interaction to be

beneficial, it should be guided, for the most

part, by empathy. The group leader should be

able to model empathic interaction for group

members, especially since people with substance use disorders

often cannot identify

and communicate

their feelings, let

alone appreciate the

emotive world of

others. The group

leader teaches group

members to understand one another’s

subjective world,

enabling clients to

develop empathy for

each other (Shapiro

1991). The therapist

promotes growth in

this area simply by

asking group members to say what they

think someone else is

feeling and by pointing out cues that indicate what another person

may be feeling.

One of the feelings that the group leader needs

to be able to empathize with is shame, which is

common among people with substance abuse

histories. Shame is so powerful that it should

be addressed whenever it becomes an issue.

When shame is felt, the group leader should

look for it and recognize it (Gans and Weber

2000). The leader also should be able to

empathize with it, avoid arousing more shame,

and help group members identify and process

this painful feeling. Figure 6­1 discusses shame

and group therapy.

The group leader

should be able to

model empathic	 

interaction for

group members.

Leading Groups

Group therapy with clients who have histories

of substance abuse or dependence requires

active, responsive leaders who keep the group

lively and on task, and ensure that members

are engaged continuously and meaningfully

with each other. Leaders, however, should not

make themselves the center of attention. The

leader should be aware of the differing personalities of the group members, while always

searching for common themes in the group.

Themes to focus on, for example, might include

loss, abandonment, and self­value (Pollack and

Slan 1995).

Leaders vary therapeutic

styles with the needs of

clients

As explained in chapter 5, group leaders

should modify their styles to meet clients’ needs

at different times. During the early and middle

stages of treatment, the therapist is more

active, becoming less so in the late stage.

Moreover, during the late stage of treatment,

the therapist should offer less support and

gratification. This keeps the group at an “optimal level of anxiety,” one that would be intolerable and counterproductive in the early or

middle stages of treatment (Flores 1997).

To determine the type of leadership required to

support a client in treatment, the clinician

94 Group Leadership, Concepts, and Techniques
Figure 6­1

Shame

Source: Consensus Panel.

Often failed attachments in childhood and failed relationships thereafter result

in shame, an internalized sense of being inferior, not good enough, or worthless.

Shame flares whenever clients encounter the discrepancy between their drugaffected behavior and personal or social values. In group therapy, feelings of

shame may be intensified because feelings of self­consciousness are elevated and

other group members are present. The presence of other group members “often

stimulates regressive longings” (Gans and Weber 2000, p. 385). Furthermore,

group members have a marked tendency to compare themselves with one another (Gans and Weber 2000). In the past, when group facilitators used highly confrontational efforts to break through denial and resistance, an undesirable side

effect was intensified shame, which increased the likelihood that group members

would relapse or leave treatment. Shame interferes dramatically with attempts

to heighten a client’s self­esteem, which in turn is important to recovery (Alonso

and Rutan 1988).

Clients with addictions often are exquisitely sensitive and prone to project their

shame onto relationships within the group. Often, at an unconscious level, they

anticipate disapproval or hostility when none was intended. In this way, clients

may demote themselves to the role of secondary player in the group.

One way to neutralize unintentionally shame­provoking comments is to reframe

member­to­member communications. For example, if a group member asks,

“Sally, where were you last week? You didn’t come to group.” Sally may interpret the question as a criticism or even an implication that she has returned to

active use. The group facilitator may choose to reframe this member­to­member

communication by speaking to the concern that the questioner really has for

Sally’s well­being.

This reframing would begin with the group leader asking why the group member

wanted to know where Sally had been, adding something like, “I suspect your

question reflects the feeling that you missed Sally last week and find group more

enjoyable when she is here.”

By focusing on positive interactions that reveal competency, the group facilitator

helps move clients from shame to an affirmative image of themselves. The group

leader should pay attention to member­to­member interaction, looking for

instances of relational competence and support. The leader’s supportive interactions eventually develop into group norms that combat the shame attached to

addictive illness.

Group Leadership, Concepts, and Techniques 95
should consider the client’s capacity to manage

affect, level of functioning, social supports, and

stability, since these factors have some bearing

upon alcohol or illicit drug use. These considerations are essential to determine the type of

group best suited to meet the client’s needs. For

example, a client at the beginning stage of

treatment who is

high functioning and

used to working in

groups generally will

require a less active

therapist and less

structure. On the

other hand, a lowerfunctioning client

who has little or no

group experience

and is just beginning

treatment would best

be placed in a structured, task­oriented

group. Such a person also would benefit from a clinician

who more actively

expresses warmth

and acceptance, thus

helping to engage the client.

Cotherapy is	 

extremely powerful when carried

out skillfully.

Leaders model behavior 

It is more useful for the therapist to model

group­appropriate behaviors than to assume

the role of mentor, showing how to “do recovery.” For example, the therapist can model the

way to listen actively, give accurate feedback,

and display curiosity about apparent discrepancies in behavior and intent.

Therapists should be aware that self­disclosure

is always going on, whether consciously or

unconsciously. They intentionally should use

self­disclosure only to meet the task­related

needs of the group, and then only after

thoughtful consideration, perhaps including a

discussion with a supervisor.

Both therapists and their institutions should

have a thoughtful policy about self­disclosure,

including disclosure of a therapist’s past experiences with substance abuse or addiction. Too

often, self­disclosure occurs to meet the therapist’s own needs (for example, for affiliation

and approval) or to gratify clients. When personal questions are asked, group leaders need

to consider the motivation behind the question.

Often clients are simply seeking assurance that

the therapist is able to understand and assist

them (Flores 1997).

Leaders can be cotherapists 

Cotherapy is an effective way to blend the

diverse skills, resources, and therapeutic

perspectives that two therapists can bring to

a group. In addition, cotherapy is beneficial

because, if properly carried out, it can provide

•The opportunity to watch “functional,

adaptive behavior in the co­leader pair”

•Additional opportunities for family

transferences when the leaders are of

different genders

•An opportunity for “two sets of eyes to view

the situation” (Vannicelli 1992, p. 238)

Cotherapy, also called coleadership, is extremely

powerful when carried out skillfully. A male–

female cotherapy team may be especially

helpful, for a number of reasons. It allows

clients to explore their conscious and subconscious reactions to the presence of a parental

dyad, or pair. It shows people of opposite sexes

engaging in a healthy, nonexploitative relationship. It presents two different gender role

models. It demonstrates role flexibility, as

clients observe the variety of roles possible for

a male or a female in a relationship. It provides

an opportunity for clients to discover and work

through their gender distortions (Kahn 1996).

Frequently, however, cotherapy is not done

well, and the result is destructive. At times, a

supervisor and a subordinate act as cotherapists, and power differentials result. Alternatively, cotherapists are put together out of

convenience, rather than their potential to

work well together and improve and facilitate

group process. True cotherapy takes place

96 Group Leadership, Concepts, and Techniques
between clinicians of equal authority and

mutual regard. (Naturally, the foregoing does

not apply to training opportunities in which a

trainee sits in with a seasoned group therapist.

In such a setting, the trainee functions as an

observer, not a cotherapist.)

Problems also may arise because institutions

and leaders fail to allow enough time for

cotherapists to prepare for group together and

to process what has happened after the group

has met. Some suggest that cotherapists confer

for as much time outside the group as the

length of the group itself, that is, 45 minutes of

consultation for each 45­minute group session.

While this amount of time may be ideal, the

realities of most organizations do not make this

level of commitment feasible. At the least, however, cotherapists should have a minimum of 15

minutes before and after each group meets.

Personal conflict or professional disagreements

can be a third source of negative effects on the

group. Thus, cotherapists should carefully

work out their own conflicts and develop a

leadership style suitable for the group before

engaging in the therapeutic process. Cotherapists also should work out important theoretical differences before taking on a group, reaching full agreement on their view of the group

and appropriate ways to facilitate the group’s

development (Wheelan 1997). Achieving a

healthy, collaborative, and productive cotherapy team will require a “(1) commitment of time

and sharing, (2) the development of [mutual]

respect...and (3) use of supervision to work out

differences and identify...problems” (Kahn

1996, p. 443).

Inevitably, cotherapist relationships will grow

and evolve over time. The relationship between

the cotherapists and the group, too, will evolve.

Both the cotherapists and the group should

recognize this process and be ready to adapt to

constant change and growth (Dugo and Beck

1997). The most successful cotherapy is carried

out “by partners who make a commitment to

an ongoing relationship, who reason with each

other, and who accept responsibility to work on

the evolution of their relationship” (Dugo and

Beck 1997, p. 2). The development of a healthy

relationship between cotherapists will have a

positive effect on their relationship to the

group, relationships among members of the

group, and on individuals within the group as

they experience the continuous changes and

growth of the group (Dugo and Beck 1997).

Leaders are sensitive to 

ethical issues 

Group therapy by nature is a powerful type of

intervention. As the group process unfolds, the

group leader needs to be alert, always ready to

perceive and resolve issues with ethical dimensions. Some typical situations with ethical concerns follow.

Group agreements

give the group definition and clarity,

and are essential

for group safety.

Overriding group agreements 

Group agreements give the group definition

and clarity, and are essential for group safety.

In rare situations, however, it would be unethical not to bend the rules to meet the needs of

an individual. For example, group rules may

say that failure to call in before an absence

from group is cause for reporting the infraction

to a referring agency. If the client can demonstrate that an unavoidable emergency prevented calling in, the group leader may agree that

the offense does not merit a report. Furthermore, the needs of the

group may sometimes

override courtesies

shown to an individual. For example, a

group may have made

an agreement not to

discuss any group

member when that

member is not present. If, however, a

member should

relapse, become seriously ill, or experience some other dire

problem, the no­discussion rule has to be

set aside if the group

leader is to allow the

Group Leadership, Concepts, and Techniques 97
members to express their concerns for the missing member and to consider how that person’s

problem affects the group as a whole.

Informing clients of options 

Even when group participation is mandated,

clients should be informed clearly of the

options open to them. For example, the client

deserves the option to discuss with program

administrators any forms of treatment or

leadership style that the client believes to be

inappropriate. In such an instance, issues of

cultural competence should be kept in mind,

because what is appropriate for an individual

or a group is by no means universal.

Preventing enmeshment 

Leaders should be aware that the power of

groups can have a dark side. Although cohesion is a positive outcome to be sought and

supported, the strong desire for affiliation also

can place undue pressure on group members

who already are in

the throes of a major

transition from substance abuse to

abstinent lives. The

need to belong is so

strong that it can

sometimes cause a

client to act in a way

that is not genuine

or consistent with

personal ethics.

Regardless of the

kind of group, the

leader needs to be

aware of this possibility and to monitor

group sharing to

ensure that clients

are not drawn into

situations that violate their privacy or integrity. The leader is

obligated to foster cohesion while respecting the

rights and best interests of individuals.

The leader is obligated to foster

cohesion while

respecting the

rights and best

interests of individuals.

Acting in each client’s best interest 

It is possible that the group collectively may

validate a particular course of action that may

not be in a client’s best interest. For example,

if there is stress in one group member’s marriage, other group members might support a

course of action that could have dangerous or

harmful consequences. Similarly, the group

might engage in problem solving in some area

of a member’s life and recommend a course of

action that would clearly be undesirable.

It is the responsibility of the group facilitator to

challenge the group’s conclusions or recommendations when they deny individual autonomy

or could lead to serious negative consequences.

Any such challenge, however, should come in a

nonshaming fashion, primarily through the

review of other options.

Handling emotional 

contagion 

Another’s sharing, such as an agonized account

of sexual abuse, can stir frightening memories

and intense emotions in listeners. In this powerful and emotional atmosphere, the spreading

excitement of the moment, or emotional contagion, requires the leader to

•Protect individuals. The group leader should

guard the right of each member to refrain

from involvement. The leader makes it clear

that each group member has a right to private emotions and feelings. When the group

pressures a member to disclose information,

the leader should remind the group that

members need only reveal information about

themselves at levels with which they are comfortable.

•Protect boundaries. Group pressure or the

group leader’s interest should not obligate

anyone to disclose intimate details that the

client prefers not to share. At the same time,

clients are responsible for managing their

feelings in the face of the group’s power and

deciding what they will and won’t share.

•Regulate affect. At all times, the therapist

should be mindful of the need to modulate

98 Group Leadership, Concepts, and Techniques
affect (emotionality), always keeping it at a

level that enables the work of the group to

continue. Yalom (1995) suggests an intervention that group leaders could use to limit conflict or almost any unacceptable escalation of

affect: “We’ve been expressing some intense

feelings here today....To prevent us from

overload, it might be valuable to stop what

we’re doing and try together to understand

what’s been happening and where all these

powerful feelings come from” (p. 350).

Working within professional

limitations 

Group leaders never should attempt to use

group techniques or modalities for which they

are not trained. When new techniques are used

with any group, leaders should be certain to

have appropriate training and the supervision

of experts familiar with the techniques to be

employed. Therapists likewise should decline to

work with any population or in any situation

for which they are unprepared. For example,

an addiction counselor who has never run a

long­term therapy group and has not learned

how to do so should not accept an assignment

to lead such a group. Further, a counselor cannot read about psychodrama and, using a

workbook, successfully apply this highly

charged technique with clients in an early stage

of treatment. Such a misguided effort could

have serious psychological consequences.

Ensuring role flexibility 

Different group members may assume particular

roles within the group. Natural leaders may

emerge, as may a member who expresses anger

for the group and someone who provides support. One client may take on a scapegoat role

and then blame the group.

Playing different roles and examining their

dynamics can provide a corrective emotional

and interpersonal experience for the group. On

the other hand, rigid roles can restrict group

work. If, for example, a group consistently

places individuals in particular roles, they may

use their placements as defense mechanisms,

thereby avoiding powerfully charged issues. 

It is easier, for example, to deal with the 

problems of being a

scapegoat than it is to 

work on recovery

from addiction. 

While it is natural for

group members to

assume certain

roles––there are, after

all, natural leaders––

individual members

benefit from the

opportunity to experience different aspects

of themselves. Role

variation also keeps

the group lively and

dynamic. These benefits will be lost if the same

group members consistently assume the same

roles in group. It is important for the group

facilitator to support role sharing within the

membership.

In all therapeutic 

settings, the 

clinician should

be sensitive to

issues of dual

relationships.

Avoiding role conflict

In all therapeutic settings, the clinician should

be sensitive to issues of dual relationships. A

group leader’s responsibilities outside the

group that place him in a different relationship

to group participants should not be allowed to

compromise the leader’s in­group role. For

example, a client’s group leader should not also

be that client’s Alcoholics Anonymous (AA)

sponsor. Both roles and functions are important, but should not be performed by the same

person. If the leader happens to be in recovery

and is attending self­help meetings at which

group members are present, this possible role

conflict should be discussed with supervisors.

Ethical behavior is absolutely essential to group

leadership. As the best practice guidelines

(1998) from the Association for Specialists in

Group Work (ASGW) declare, “ASGW views

ethical process as being integral to group work

and views Group Workers as ethical agents.”

Group Leadership, Concepts, and Techniques 99
The ASGW statement is regarded as so

important that the entire text is reproduced in

appendix E.

Leaders improve motivation 

Client motivation is a vital factor in the success

of treatment for substance use disorders.

Motivation­boosting techniques have been

shown to increase both treatment participation

and outcomes (Chappel 1994; Easton et al.

2000; Foote et al. 1999). Motivation generally

improves when

•Clients are engaged at the appropriate stage

of change.

•Clients receive support for change efforts.

•The therapist explores choices and their

consequences with the client.

•The therapist honestly and openly communicates care and concern for group members.

•The therapist points out the client’s competencies.

•Steps toward positive change are noted

within the group and further encouragement

is provided.

The therapist helps clients enjoy their triumphs

with questions such as, “What’s it like, Bill, to

communicate your thoughts so clearly to Claire

and to have her understand you so well?” or

“What was it like to be able to communicate

your frustration so directly?”

One effective motivational tool is the FRAMES

approach, which uses the six key elements of

Feedback, Responsibility, Advice, Menus (of

change options), Empathic therapy, and Selfefficacy (Miller and Sanchez 1994). This

approach engages clients in their own treatment and motivates them to change in ways

that are the least likely to trigger resistance.

The FRAMES approach is discussed in detail

in chapter 2 of TIP 35, Enhancing Motivation

for Change in Substance Abuse Treatment

(CSAT 1999b).

When this kind of supportive technique is

employed, however, a client’s stage of change

should be taken into account (see chapters 2

and 3 for more detailed discussions of the

stages of change). Techniques to enhance

motivation that are appropriate at one stage of

change may not be useful at another stage and

may even trigger treatment resistance or noncompliance (CSAT 1999b). For example, clients

in the contemplation stage are weighing the

pros and cons of continued substance abuse.

An intervention for the action stage is appropriate for a client who has already made a

commitment to change. If such an intervention

is used too early, the client understandably

may fail to cooperate.

Leaders overcome resistance

Resistance is especially strong among clients

referred by the courts. It generally arises as a

defense against the pain that therapy and

examining one’s own behavior usually brings.

In group therapy, resistance appears at both

the individual and the group level. The group

leader should have a repertoire of means to

overcome the resistance that prevents successful substance abuse treatment in groups

(Milgram and Rubin 1992).

The group therapist should be prepared to

work effectively against intense resistance to

“experiencing, expressing, and understanding

emotions” (Cohen 1997, p. 443). In order to

overcome resistance to the experience of emotion, “the group members should experience

feelings at a level of arousal wherein feelings are

undeniable, but not to the extent that the group

member is overcome” (Cohen 1997, p. 445).

Leaders defend limits 

Providing a safe, therapeutic frame for clients

and maintaining firm boundaries are among

the most important functions of the group leader. For many group members, a properly conducted group will be the first opportunity to

interact with others in a safe, supportive, and

substance­free environment.

The boundaries established should be mutually

agreed upon in a specific contract. When

leaders point out boundaries and boundary

violations, they should do so in a nonshaming,

100 Group Leadership, Concepts, and Techniques
nonjudgmental, matter­of­fact way. Some possible ways of dealing with this situation might be

•“This is a hard place to end, but . . .”

•“I know how angry you’re feeling, but we

have agreed . . .”

When boundary violations occur, group members should be reminded of agreements and

given an opportunity to discuss the meaning

and implication of the limit­breaking behavior

as they see it. For example, if three group

members are coming in late, the leader might

say, “It’s interesting that although everyone

who joined the group agreed to arrive on time,

many members are having a difficult time meeting this agreement.” Or the leader might ask,

“How would this group be different if everyone

came on time?”

The group members may respond, for example,

that they would not be obliged to repeat what

already has been said to help latecomers catch

up and, thus, get more out of each session.

This group involvement in limit setting is crucial. It transmits power and responsibility to

the group, and the leader avoids the isolated

role of enforcer. While leaders inevitably will

be regarded as authority figures, they certainly

want to avoid creating the image of an insensitive, punitive authority.

Leaders maintain a safe 

therapeutic setting 

Emotional aspects of safety 

Group members should learn to interact in positive ways. In the process, leaders should

expect that people with substance abuse histories will have learned an extensive repertoire of

intimidating, shaming, and other harmful

behaviors. Because such conduct can make

group members feel unsafe, the leader should

use interventions that deflect the offensive

behavior without shaming the shamer.

Shame is not a point, but a range, some

researchers argue. “Healthy” shame “helps to

regulate a person’s behavior in the service of

preserving self­esteem, values, and personal

connection” at one

end of the continuum

(Gans and Weber

2000, p. 382). At the

other end is “unmetabolized shame,” or

shame that “in a narcissistically vulnerable

person produces its

pathological variants...Whereas guilt

is a response to a

thought or deed,

shame connotes a 

more pervasive (self) 

condemnation” (Gans 

and Weber 2000, p. 

382). It is thus potentially harmful to group members who are 

struggling to be honest with themselves and 

with the other group members. 

The boundaries

established should

be mutually

agreed upon in a

specific contract.

The group needs to feel safe without blaming or 

scapegoating an individual member. If a member makes an openly hostile comment, the leader’s response should state clearly what has happened and set a firm boundary for the group 

that makes clear that group members are not to 

be attacked. Sometimes, the leader simply may 

need to state what has occurred in a factual 

manner: “Debby, you may not have intended 

this effect, but that last remark came across as 

really hurtful.” 

When group members’ responses lack empathy 

or treat one group member as a scapegoat, this 

targeted individual represents “a disowned 

part of other members of the group.” Members 

may fault Sally repeatedly for her critical 

nature and lack of openness. The leader may 

intervene with a comment such as, “We’ve 

taken up time dealing with Sally’s problems. 

My guess is that part of the reason the group is 

so focused on this is that it’s something everybody in here knows a little about and that this 

issue has a lot of meaning for the group. 

Perhaps the group is trying to kick this characteristic down and beat it out because it’s too 

close to home and simply cannot be ignored” 

(Vannicelli 1992, p. 125). 

Group Leadership, Concepts, and Techniques 101
When individual

group members are

verbally abusive and

other group members are too intimidated to name the

problem, the leader

should find a way to

provide “a safe environment in which

such interactions can

be productively processed and understood—not only by

the attacking group

member but also by

the other members

(who need to understand what is motivating their reluctance to respond)” (Vannicelli

1992, p. 165). To accomplish this goal, the

leader may intervene with statements such as:

•To the group as a whole: “John has been

pretty forthright with some of his feelings

this evening. It seems as if others in here are

having more difficulty sharing their feelings.

Perhaps we can understand what it is about

what John has shared or the way in which he

shared it that makes it hard to respond”

(Vannicelli 1992, p. 165).

•To John: “John, how do you suppose Mary

might be feeling just now about your

response to her?” or “If you had just

received the kind of feedback that you gave

to Mary, how do you suppose you’d be feeling

right now?” (Vannicelli 1992, pp. 165–166).

Whatever intervention is used should show the

group “that it is appropriate to let people know

how you feel, and that people can learn in the

group how to do this in a way that doesn’t push

others away” (Vannicelli 1992, p. 166).

A client can be severely damaged by emotional

overstimulation. It is the therapist’s responsibility to maintain the appropriate level of emotion

and stimulation in the group. This will “prevent

a too sudden or too intense mobilization of feeling that cannot be adequately expressed in language” (Rosenthal 1999a, p. 159). The therapist

can achieve this control by warning potential

group members of the emotional hazards of

revealing their feelings to a group of strangers

and by helping new members regulate the

amount of their self­disclosure.

It is the therapist’s

responsibility to

maintain the

appropriate level

of emotion and

stimulation in the

group.	 

Substance use 

In a group of people trying to maintain

abstinence, the presence of someone in the

group who is intoxicated or actively using illicit

drugs is a powerful reality that will upset many

members. In this situation, the leader should

intervene decisively. The leader will make it as

easy as possible for the person who has

relapsed to seek treatment, but a disruptive

member should leave the group for the present.

The leader also will help group members

explore their feelings about the relapse and

reaffirm the primary importance of members’

agreement to remain abstinent. Some suggestions follow for situations involving relapse:

•If clients come to sessions under the influence

of alcohol or drugs, the leader should ensure

that the individual does not drive home.

Even a person walking home sometimes

should be escorted to prevent falls, pedestrian accidents, and so on.

•If a client obviously is intoxicated at the

beginning of the group, that person should be

asked to leave and return for the next session

in a condition appropriate for participation

(Vannicelli 1992).

Vannicelli (1992) addresses several other

situations that commonly occur:

Signs indicate that the client is not abstinent,

but the client will not admit using alcohol or

drugs. When signs (such as bloodshot eyes)

indicate that the client is using substances

repeatedly before coming to the group, but

the client does not admit the infraction, the

leader might:

•Use empathy to join with the client, letting

the member know that the leader understands why it’s hard to acknowledge

substance use to the group.

102 Group Leadership, Concepts, and Techniques
•Describe the impasse, namely, that it is

important that both client and therapist feel

that they are in a credible relationship, but

the way things are shaping up, it must be

increasingly difficult for the client to come in

week after week knowing that the therapist

doubts him.

•Brainstorm, permitting the group to solve the

problem and get past the impasse (Vannicelli

1992).

A client has been using alcohol or drugs, but

will not acknowledge it. If other group members do not confront clients who are using substances, the leader should raise the issue in an

empathic manner designed to encourage honesty, such as, “It must be hard for you, Sandy,

to find yourself in a group in which you don’t

feel safe enough to talk about your drinking”

(Vannicelli 1992, p. 65).

A client defiantly acknowledges using substances. A client who uses substances and

clearly has no intention of stopping should be

asked to leave the group. In contrast, a client

who slips repeatedly needs an intervention that

invites the group’s help in setting conditions for

continued participation: “It is clear, Maria,

that you feel it is appropriate for you to stop

using and yet, so far, the ways that you have

been dealing with the problem have not been

adequate. Since it is important that your

behavior, as well as your words, support the

group norm, we need to find ways that will be

more effective in supporting abstinence.” The

group may then help set up specific requirements for Maria that will help her maintain

abstinence. Suggestions might include increased

AA participation, the development of a relapse

prevention plan, increased supportive social

contact, or the use of medications (like

Antabuse for alcoholism) (Vannicelli 1992,

p. 68).

Many outpatient groups have mandated clients

who are required to submit to urine tests. The

counselor is required to report infractions or

test failures. These stipulations should appear

in the group agreement, so they do not come as

a surprise to anyone.

Boundaries and physical contact 

When physical boundaries are breached in the

group, and no one in the group raises the issue,

the leader should call the behavior to the

group’s attention. The leader should remind

members of the terms of agreement, call attention to the questionable behavior in a straightforward, factual way, and invite group input

with a comment such as, “Joe, you appear to

be communicating something nonverbally by

putting your hand on Mary’s shoulder. Could

you please put your actions into words?”

Most agencies have policies related to violent

behavior; all group leaders should know what

they are. In groups, threatening behavior

should be intercepted decisively. If necessary,

the leader may have to stand in front of a

group member being physically threatened.

Some situations require help, so a lone leader

should never conduct a group session without

other staff nearby. On occasion, police intervention may be necessary, which could be

expected to disrupt the group experience

completely.

The leader should not suggest touching, holding

hands, or group hugs without first discussing

this topic in group. This tactic will convey the

message that strong feelings should be talked

about, not avoided. In general, though, group

members should be

encouraged to put

their thoughts and

feelings into words,

not actions. A group may need

to set up specific

requirements

to help a member

maintain

abstinence.

Whenever the therapist invites the group

to participate in any

form of physical contact (for example, in

psychodrama or

dance therapy), individuals should be

allowed to opt out

without any negative

perceptions within the

group. All members

uncomfortable with

Group Leadership, Concepts, and Techniques 103
physical contact should be assured of permission to refrain from touching or having anyone

touch them.

Leaders also should

make sure that suggestions to touch are

intended to serve the

clients’ best interests

and not the needs of

the therapist. Under

no circumstances

should a counselor

ask for or initiate

physical contact.

Like their clients,

counselors need to

learn that such

impulses affect them

as well. Nothing is

wrong with feeling attracted to a client. It is

wrong, however, for group leaders to allow

these feelings to dictate or influence their

behavior.

Group leaders

carefully monitor

the level of emotional intensity in

the group.

Leaders help cool down

affect 

Group leaders carefully monitor the level of

emotional intensity in the group, recognizing

that too much too fast can bring on extremely

uncomfortable feelings that will interfere with

progress––especially for those in the earlier

stages of recovery. When emotionally loaded

topics (such as sexual abuse or trauma) come

up and members begin to share the details of

their experiences, the level of emotion may

rapidly rise to a degree some group members

are unable to tolerate.

At this point, the leader should give the group

the opportunity to pause and determine

whether or not to proceed. The leader might

ask, “Something very powerful is going on right

now. What is happening? How does it feel? Do

we want to go further at this time?”

At times, when a client floods the room with

emotional information, the therapist should

mute the disturbing line of discussion. The

leader should not express discomfort with the

level of emotion or indicate a wish to avoid

hearing what was being said. Leaders can say

something such as

•“As I ask you to stop, there’s a danger that

what you hear is, ‘I don’t want to hear you.’

It’s not that. It’s just that for now, I’m concerned that you may come to feel as if you

have shared more than you might wish.”

•“I’m wondering how useful it would be for

you to continue with what you’re doing right

now.” This intervention teaches individuals

how to regulate their expression of emotions

and provides an opportunity for the group to

comment.

•“Let’s pause for a moment and every few

minutes from now. How are you feeling right

now? Let me know when you’re ready to

move on.”

A distinction needs to be made whether the

strong feelings are related to there­and­then

material or to here­and­now conduct. It is far

less unsettling for someone to express anger—

even rage—at a father who abused her 20 years

ago than it is to have a client raging at and

threatening to kill another group member.

Also, the amount of appropriate affect will

differ according to the group’s purpose. Much

stronger emotions are appropriate in psychodrama or gestalt groups than in psychoeducational or support groups.

For people who have had violence in their

lives, strong negative emotions like anger can

be terrifying. When a group member’s rage

adversely affects the group process, the leader

may use an intervention such as

•“Bill, stop for a moment and hear how what

you’re doing is affecting other people.”

•“Bill, maybe it would be helpful for you to

hear what other people have been thinking

while you’ve been speaking.”

•“Bill, as you’ve been talking, have you

noticed what’s been happening in the

group?”

104 Group Leadership, Concepts, and Techniques
The thrust of such interventions is to modulate

the expression of intense rage and encourage

the angry person and others affected by the

anger to pay attention to what has happened.

Vannicelli (1992) suggests two other ways to

modulate a highly charged situation:

•Switch from emotion to cognition. The leader

can introduce a cognitive element by asking

clients about their thoughts or observations

or about what has been taking place.

•Move in time, from a present to a past focus

or from past to present.

When intervening to control runaway affect,

the leader always should be careful to support

the genuine expressions of emotion that are

appropriate for the group and the individual’s

stage of change.

Leaders encourage communication within the group

In support and interpersonal process groups,

the leader’s primary task is stimulating communication among group members, rather than

between individual members and the leader.

This function also may be important on some

occasions in psychoeducational and skillsbuilding groups. Some of the many appropriate

interventions used to help members engage in

meaningful dialog with each other are

•Praising good communication when it happens.

•Noticing a member’s body language, and

without shaming, asking that person to

express the feeling out loud.

•Building bridges between members with

remarks such as, “It sounds as if both you

and Maria have something in common . . .”

•Helping the group complete unfinished business with questions such as, “At the end of

our session last time, Sally and Joan were

sharing some very important observations.

Do you want to go back and explore those

further?”

•When someone has difficulty expressing a

thought, putting the idea in words and asking, “Have I got it right?”

•Helping members

with difficulty verbalizing know that

their contributions

are valuable and

putting them in

charge of requesting

assistance. The

leader might ask, “I

can see that you are

struggling, Bert. My

guess is that you are

carrying a truth 

that’s important for 

the group. Do you 

have any sense of 

how they can help 

you say it?” 

In general, group

leaders should speak

often, but briefly,

especially in time­limited groups. In group, the best interventions

usually are the ones that are short and simple.

Effective leadership demands the ability to

make short, simple, cogent remarks.

In support and

interpersonal

process groups,

the leader’s primary task is stimulating communication

among group

members.

Concepts, Techniques,

and Considerations

Interventions

Interventions may be directed to an individual

or the group as a whole. They can be used to

clarify what is going on or to make it more

explicit, redirect energy, stop a process that is

not helpful, or help the group make a choice

about what should be done. A well­timed,

appropriate intervention has the power to

•Help a client recognize blocks to connection

with other people

•Discover connections between the use of

substances and inner thoughts and feelings

•Understand attempts to regulate feeling states

and relationships

•Build coping skills

Group Leadership, Concepts, and Techniques 105
•Perceive the effect of substance abuse on

one’s life

•Notice meaningful inconsistencies among

thoughts, feelings, and behavior

•Perceive discrepancies between stated goals

and what is actually being done

Any verbal intervention may carry

important nonverbal

elements. For example, different people

would ascribe a

variety of meanings

to the words, “I am

afraid that you have

used again,” and the

interpretation will

vary further with the

speaker’s tone of

voice and body language. Leaders

should therefore

be careful to avoid

conveying an observation in a tone of voice that

could create a barrier to understanding or

response in the mind of the listener.

A process group

that remains

leader focused limits the potential for

learning and

growth.	 

Avoiding a leader­centered

group 

Generally a counselor leads several kinds of

groups. Leadership duties may include a psychoeducational group, in which a leader usually takes charge and teaches content, and then a

process group, in which the leader’s role and

responsibilities should shift dramatically. A

process group that remains leader­focused limits the potential for learning and growth, yet all

too often, interventions place the leader at the

center of the group. For example, a common

sight in a leader­centered group is a series of

one­on­one interactions between the leader and

individual group members. These sequential

interventions do not use the full power of the

group to support experiential change, and

especially to build authentic, supportive interpersonal relationships. Some ways for a leader

to move away from center stage:

•In addition to using one’s own skills, build

skills in participants. Avoid doing for the

group what it can do for itself.

•Encourage the group to learn the skills necessary to support and encourage one another

because too much or too frequent support

from the clinician can lead to approval seeking, which blocks growth and independence.

Supporting each other, of course, is a skill

that should develop through group phases.

Thus, in earlier phases of treatment, the

leader may need to model ways of communicating support. Later, if a client is experiencing loss and grief, for example, the leader

does not rush in to assure the client that all

will soon be well. Instead, the leader would

invite group members to empathize with each

other’s struggles, saying something like,

“Joanne, my guess is at least six other people

here are experts on this type of feeling. What

does this bring up for others here?”

•Refrain from taking on the responsibility to

repair anything in the life of the clients. To a

certain extent, they should be allowed to

struggle with what is facing them. It would be

appropriate, however, for the leader to

access resources that will help clients resolve

problems.

Confrontation 

Confrontation is one form of intervention. In

the past, therapists have used confrontation

aggressively to challenge clients’ defenses of

their substance abuse and related untoward

behaviors. In recent years, however, clinicians

have come to recognize that when “confrontation” is equivalent to “attack,” it can have an

adverse effect on the therapeutic alliance and

process, ultimately leading to failure. Trying to

force the client to share the clinician’s view of a

situation accomplishes no therapeutic purpose

and can get in the way of the work.

A more useful way to think about confrontation

is “pointing out inconsistencies,” such as disconnects between behaviors and stated goals.

William R. Miller explains:

106 Group Leadership, Concepts, and Techniques
The linguistic roots of the verb “to confront” mean to come face to face. When

you think about it that way, confrontation is precisely what we are trying to

accomplish: to allow our clients to come

face to face with a difficult and often

threatening reality, to “let it in” rather

than “block it out,” and to allow this

reality to change them. That makes confrontation a goal of counseling rather

than a particular style or technique. . .

[T]hen the question becomes, What is

the best way to achieve that goal?

Evidence is strong that direct, forceful,

aggressive approaches are perhaps the

least effective way to help people consider new information and change their

perceptions (CSAT 1999b, p. 10).

Confrontation in this light is a part of the

change process, and therefore part of the helping process. Its purpose is to help clients see

and accept reality so they can change accordingly (Miller and Rollnick 1991). With this

broader understanding of what interventions

that “confront” the client really mean, it is not

useful to divide therapy into “supportive” and

“confrontative” categories.

Transference and

Countertransference

Transference means that people project parts

of important relationships from the past into

relationships in the present. For example,

Heather may find that Juan reminds her of her

judgmental father. When Juan voices his suspicion that she has been drinking, Heather feels

the same feelings she felt when her father criticized all her supposed failings. Within the

microcosm of the group, this type of incident

not only relates the here­and­now to the past,

but also offers Heather an opportunity to learn

a different, more self­respecting way of

responding to a remark that she perceives as

criticism.

The emotion inherent in groups is not limited

to clients. The groups inevitably stir up strong

feelings in leaders. The therapist’s emotional

response to a group member’s transference is

referred to as countertransference. Vannicelli

(2001) describes three forms of countertransference:

•Feelings of having been there. Leaders with

family or personal histories with substance

abuse have a treasure in their extraordinary

ability to empathize with clients who abuse

substances. If that empathy is not adequately

understood and controlled, however, it can

become a problem, particularly if the therapist tries to act as a role model or sponsor, or

discloses too much personal information.

•Feelings of helplessness when the therapist is

more invested in the treatment than the client

is. Treating highly resistant populations, such

as clients referred to treatment by the courts,

can cause leaders to feel powerless, demoralized, or even angry. The best way to deal

with this type of countertransference may be

to use the energy of the resistance to fuel the

session. (See “Resistance in Group,” next

section.)

•Feelings of incompetence due to unfamiliarity

with culture and jargon. It is helpful for leaders to be familiar with 12­Step programs, cultures, and languages. If a group member uses

unfamiliar terms, however, the leader should

ask the client to

explain what the

term means to that

person, using a

question like,

“‘Letting go’ means

something a bit different to each person. Can you say a 

little more about 

how this relates to 

your situation?” 

(Vannicelli 2001,

p. 58).

The therapist’s

emotional

response to a

group member’s

transference is

referred to

as countertransference.

When countertransference occurs, the

clinician needs to

bring all feelings associated with it to

Group Leadership, Concepts, and Techniques 107
awareness and manage them appropriately.

Good supervision can be really helpful.

Countertransference is not bad. It is inevitable,

and with the help of supervision, the group

leader can use countertransference to support

the group process (Vannicelli 2001).

Resistance in Group

Resistance arises as an often unconscious

defense to protect the client from the pain of

self­examination. These processes within the

client or group impede the open expression of

thoughts and feelings, or block the progress of

an individual or group. The effective leader

will neither ignore resistance nor attempt to

override it. Instead, the leader helps the individual and group understand what is getting in

the way, welcoming the resistance as an opportunity to understand something important

going on for the client or the group. Further,

resistance may be viewed as energy that can be

harnessed and used in a variety of ways, once

the therapist has helped the client and group

understand what is happening and what the

resistant person or persons actually want

(Vannicelli 2001).

In groups that are mandated to enter treatment, members often have little interest in

being present, so

strong resistance is

to be expected. Even

this resistance, however, can be incorporated into treatment.

For example, the

leader may invite the

group members to

talk about the difficulties experienced

in coming to the

session or to express

their outrage at having been required to

come. The leader

can respond to this

anger by saying, “I

am impressed by

how open people

have been in sharing their feelings this evening

and in being so forthcoming about really speaking up. My hope is that people will continue to

be able to talk in this open way to make our

time together as useful as possible” (Vannicelli

2001, p. 55).

For the group	 

leader, strict

adherence to confidentiality regulations builds trust.

Leaders should recognize that clients are not

always aware that their reasons for nonattendance or lateness may be resistance. The most

helpful attitude on the clinician’s part is curiosity and an interest in exploring what is happening and what can be learned from it. Leaders

need not battle resistance. It is not the enemy.

Indeed, it is usually the necessary precursor to

change.

It would be a serious mistake, however, to

imagine that resistance always melts away once

someone calls attention to it. “Resistance is

always there for a reason, and the group members should not be expected to give it up until

the emotional forces held in check by it are sufficiently discharged or converted, so that they

are no longer a danger to the safety of the

group or its members” (Flores 1997, p. 538).

When a group (rather than an individual) is

resistant, the leader may have contributed to

the creation of this phenomenon and efforts

need to be made to understand the leader’s role

in the problem. Sometimes, “resistance can be

induced by leaders who are passive, hostile,

ineffective, guarded, weak, or in need of constant admiration and excessive friendliness”

(Flores 1997, p. 538).

Confidentiality

For the group leader, strict adherence to

confidentiality regulations builds trust. If the

bounds of confidentiality are broken, grave

legal and personal consequences may result. All

group leaders should be thoroughly familiar

with Federal laws on confidentiality (42 C.F.R.

Part 2, Confidentiality of Alcohol and Drug

Abuse Patient Records; see Figure 6­2) and relevant agency policies. Confidentiality is recognized as “a central tenet of the practice of psychotherapy” (Parker et al. 1997, p. 157), yet a

108 Group Leadership, Concepts, and Techniques
vast majority of States either have vague

statutes dealing with confidentiality in group

therapy or have no statutes at all. Even where

a privilege of confidentiality does exist in law,

enforcement of the law that protects it is often

difficult (Parker et al. 1997). Clinicians should

be aware of this legal problem and should warn

clients that what they say in group may not be

kept strictly confidential. Some studies indicate

that a significant number of therapists do not

advise group members that confidentiality has

limits (Parker et al. 1997).

One set of confidentiality issues has to do with

the use of personal information in a group session. Group leaders have many sources of

information on a client, including the names of

the client’s employer and spouse, as well as any

ties to the court system. A group leader should

be clear about how information from these

sources may and may not be used in group.

Clinicians consider the bounds of confidentiality as existing around the treatment enterprise,

not around a particular treatment group.

Clients should know that everyone on the treatment team has access to relevant information.

In addition, clinicians should make it clear to

clients that confidentiality cannot be used to

conceal continued substance abuse, and the

therapist will not be drawn into colluding with

the client to hide substance use infractions.

Clinicians also should advise clients of the exact

circumstances under which therapists are legally required to break confidentiality (see Figure

6­2).

A second set of confidentiality issues has to do

with the group leader’s relationships with

clients and clients with one another. When

counseling a client in both individual therapy

and a group context, for example, the leader

should know exactly how information learned

in individual therapy may be used in the group

context. In almost every case, it is more beneficial for the client to divulge such information

than for the clinician to reveal it. In an individual session, the therapist and the client can

plan how the issue will be brought up in group.

This preparation gives clients ample time to

decide what to say

and what they want

from the group. The

therapist can prompt

clients to share information in the group

with a comment like,

“I wonder if the group

understands what a

hard time you’ve been

having over the last 2

weeks?” On the other

hand, therapists

should reserve the

right to determine

what information will

be discussed in group.

A leader may say

firmly, “Understand

that whatever you tell me may or may not be

introduced in group. I will not keep important

information from the group, if I feel that withholding the information will impede your

progress or interfere with your recovery.”

Clinicians should

warn clients that

what they say in

group may not

be kept strictly

confidential.

Still other confidentiality issues arise when

clients discuss information from the group

beyond its bounds. Violations of confidentiality

among members should be managed in the

same way as other boundary violations; that is,

empathic joining with those involved followed

by a factual reiteration of the agreement that

has been broken and an invitation to group

members to discuss their perceptions and feelings. In some cases, when this boundary is violated, the group may feel a need for additional

clarification or addenda to the group agreement. The leader may ask, both at the beginning of the group or when issues arise, whether

the group feels it needs additional agreements

in order to work safely. Such amendments,

however, should not seek to renegotiate the

terms of the original group agreement. See

Figure 6­2 (see p. 110) for helpful information

on confidentiality and the law.

Because a group facilitator generally is part of

the larger substance abuse treatment program,

it is recommended that the group facilitator

take a practical approach to exceptions. This

Group Leadership, Concepts, and Techniques 109
Figure 6­2 

Confidentiality and 42 C.F.R., Part 2

Source: Consensus Panel.

Confidentiality is both an ethical and a legal issue. Federal law (Title 42, Part 2

or 42 C.F.R., Part 2, Confidentiality of Alcohol and Drug Abuse Patient

Records) guarantees strict confidentiality of information about all people receiving substance abuse prevention and/or treatment services. Clients should be

fully informed regarding issues of confidentiality, and group leaders should do

all they can to build respect for confidentiality and anonymity within groups.

There are six conditions under which limited disclosure is permitted under the

regulations. These exceptions are

•The group member has signed a Release of Information document that allows

the group facilitator to communicate with another professional and/or agency.

•A group member threatens imminent harm to him­ or herself, and the group

facilitator believes that the client may act on this threat.

•A client threatens imminent harm to another named person, and the group

facilitator believes that there is a reasonable likelihood that the client will act

on the threat.

•A medical emergency requires that a client’s drug and alcohol status be

revealed in order to ensure that the client gets appropriate medical attention.

•A client is suspected of child neglect and/or abuse, as defined by the laws of the

State in which the substance abuse treatment services are being provided.

•A direct court order mandates the release of specific information related to a

client’s history and/or treatment. However, an authorizing court order alone

does not compel disclosure—for example, if the person authorized to disclose

confidential information does not elect to make the disclosure, he or she cannot be forced to do so unless there is a valid subpoena (i.e., the subpoena has

not expired) or other compulsory process introduced that would then compel

disclosure. An appropriate judge issues a court order. It specifies the exact

information to be provided about a particular client and is properly signed

and dated.

More detailed discussions of confidentiality can be found in TIP 25, Substance

Abuse Treatment and Domestic Violence (CSAT 1997b); TIP 8, Intensive

Outpatient Treatment for Alcohol and Other Drug Abuse (CSAT 1994a); TAP

13, Confidentiality of Patient Records for Alcohol and Other Drug Treatment

(Lopez 1994); and TAP 18, Checklist for Monitoring Alcohol and Other Drug

Confidentiality Compliance (CSAT 1996).

110 Group Leadership, Concepts, and Techniques
practical approach is to have the group facilitator discuss the potential application of the

exceptions with the program director or member of the program staff who is the lead on the

confidentiality regulation.

Biopsychosocial and Spiritual

Framework—Treating the

Whole Person

Substance use disorders include a wide range

of symptoms with different levels of associated

disability. Clients always bring into treatment

vulnerabilities other than their alcohol or illicit

drug dependencies. Group interventions may

be needed to resolve psychological problems,

physical ailments, social stresses, and perhaps,

spiritual emptiness or bankruptcy. In short,

successful treatment for substance use disorders should address the whole person, including that person’s spiritual growth.

While the group experience is a powerful tool

in the treatment of substance use disorders, it

is not the only tool. Other interventions, such

as individual therapy, psychological interventions, pharmacological supports, and intensive

case management, may all be necessary to

achieve long­term remission from the symptoms

of addictive disorders.

For example, people who are homeless with a

co­occurring mental disorder have three complicated sets of problems that require a continuous and comprehensive care system—one that

integrates or coordinates interventions in (1)

the mental health system, (2) the addiction system, and (3) the social service system for homeless persons. In group therapy, each condition

should be regarded as a primary interactive

problem; that is, one in which each problem

develops independently but contributes to both

of the others (Minkoff and Drake 1992).

One model offered for treating homeless persons with substance use disorder is a modified

training group designed to accommodate a

large number of members whenever a traditional small group is not possible. In this

model, participants meet in a large group with

the clinician and then

break into smaller

groups to discuss,

practice, or role­play

the particular topic.

Each group has a

client leader, and the

clinician circulates

among the groups to

ensure that the topic

is understood and

that discussion is proceeding. The clinician

does not participate in

the groups. Researchers describing this

model note that

because the clinicians

step back from assuming leadership roles in the

groups, the clients become empowered to take

group sessions in the necessary direction and

demonstrate feelings and insights that might

not occur in a group formally led by a clinician

(Goldberg and Simpson 1995).

Successful treatment for substance

use disorders

should address the

whole person.

It is well known that 12­Step programs are an

important part of many therapeutic programs

(Page and Berkow 1998). While 12­Step programs have a proven record of success in helping people overcome substance use disorders,

there is a basic conflict inherent in them that

group therapists need to reconcile. In the 12­

Step program, people are urged to cede control

to a higher power. Yet, in group, the clinician

is prompting clients to take control of their

emotions, behavior, and lives.

As a result, some researchers have stated that

it is “impossible to integrate psychotherapy and

AA approaches dealing with addictions without

compromising one approach or the other”

(Page and Berkow 1998, pp. 1–2). Another

researcher has argued that “the AA approach

is consistent with existential philosophy”

because both stress that people should accept

their “human limitations and security­seeking

behaviors” (Page and Berkow 1998, p. 2).

Although the literature currently has few

straightforward discussions of spirituality and

Group Leadership, Concepts, and Techniques 111
its role in the

dynamics of group

therapy, most clinicians would agree

that the spiritual

well­being of the

client is essential to

breaking free of substance abuse.

When clients join

self­help groups,

they sometimes hear

from individuals

who strongly oppose

the use of any medication. Some people

in 12­Step programs

erroneously believe,

for example, that the

use of pharmacological adjuncts to therapy is a violation of the program’s principles.

They consequently oppose methadone maintenance, the use of Antabuse, or the use of medications needed to control co­occurring disorders.

Recent research

has clearly demonstrated the ability

of self­help groups	 

to improve outcomes.

Clinicians should be prepared to handle these

misapprehensions. One way to help would be

to refer apprehensive clients to the pamphlet,

The AA Member—Medications and Other

Drugs: A Report from a Group of Physicians

in AA (Alcoholics Anonymous World Services

1984). It stresses the value of appropriate

medication prescribed by a physician who

understands addictive disorders and reassures

clients that such use of medication is wholly

consistent with AA and Narcotics Anonymous’

12­Step programs.

Many clients enrolled in a process group for

persons with substance use disorders are likely

participating in a 12­Step program or other

self­help groups as well. On occasion, apparently conflicting messages can be an issue. For

instance, many people with addiction histories

try to use AA and its jargon as material for

resistance. Such problems can readily be managed, provided the therapist is thoroughly

familiar with the self­help group. Matano and

Yalom (1991) strongly recommend that group

leaders become thoroughly familiar with AA’s

language, steps, and traditions because misconceptions about the program, whether by

the client or therapist, can raise barriers to

recovery.

Recent research has clearly demonstrated the

ability of self­help groups to improve outcomes

(Tonigan et al. 1996). Research also has shown

that clients receiving mental health services as

well as participating in 12­Step meetings have

an even better prognosis (Ouimette et al. 1998).

Marilyn Freimuth’s research on integrating

group psychotherapy and 12­Step work has

shown that “if mere co­participation in psychotherapy and 12­Step groups supports a

client’s recovery, it is reasonable to expect that

a more integrated approach will provide further benefits” (Freimuth 2000, p. 298). Both

activities “support abstinence and emotional

growth” (Freimuth 2000, p. 301). Together,

the two modalities supply multiple relationship

models, potentially of immense value to the

client.

Some suggestions for maximizing the therapeutic potential of participation in both process

and 12­Step groups follow:

Orientation should prepare new group members who are also members of 12­Step groups

for differences in the two groups. A key difference will be the fact that members interact with

each other. Such “cross talk” is discouraged at

12­Step meetings. “The new psychotherapy

group member may need to be told that the

topic of conversation is much wider than the

12­Step meeting’s focus on addiction and recovery, and that it includes feelings and reactions

toward other group members” (Freimuth

2000, p. 300; see also Vannicelli 1992).

During early recovery, it is particularly important to avoid making the 12­Step program’s

encouragement of “unquestioning acceptance”

a focus of analysis in group therapy. Too

critical an interpretation offered too early may

disrupt the 12­Step program’s status as an

“ideal object,” belief in which “is critical to

112 Group Leadership, Concepts, and Techniques
maintaining early abstinence” (Dodes 1988;

Freimuth 2000, p. 305).

Sometimes clients experience “splitting”—

seeing “the [12­Step] program as the all­good

parent and all others, including the

therapist/group as the all­bad/ambivalent

object.” Later, the split may be just the opposite (Freimuth 2000). The group leader should

be attuned to this potential and should be prepared to work through these perceptions and

the feelings underlying them. Further, when

the process group is perceived as the “less

than” modality and the client enthusiastically

quotes insights from a 12­Step group, the therapist should watch for possible countertransference and bear in mind the benefits the client

is receiving from both programs.

Sponsors of 12­Step members may distrust

therapy and discourage group member from

continuing in treatment. The leader should be

prepared to respond to a variety of potential

issues in ways that avoid appearing to compete

with the self­help group. For example, if a

client says, “In my AA group, they say I don’t

need to be here. As long as I’m not drinking,

my life is fine.” The therapist might acknowledge the importance of continued sobriety, but

remind the client of depression experienced

before the onset of heavy drinking.

Group leaders should beware of their possible

biases against 12­Step groups that may be

based on inaccurate information. For example,

it is not true that the 12­Step philosophy opposes therapy and medication, as AA World

Service pamphlets clarify. It also is a misconception that 12­Step programs encourage people to abdicate responsibility for substance use.

AA, however, does urge people with addiction

problems to attend meetings in the early stages

of recovery, even though they may still be using

alcohol or illicit drugs. Finally, some clinicians

believe that 12­Step programs discourage

strong negative emotions. On the contrary,

“there is no unilateral discouragement of negative affects within [12­Step] program philosophy; only when anger threatens sobriety is it

considered necessary to circumvent negative

feelings” (Freimuth 2000, p. 308).

The following vignette illustrates a typical

intervention intended to clarify and harmonize

appropriate participation in 12­Step and

process groups:

The group leader knew that Henry, who

was well along in recovery but new to

group, had not expressed his anger at

Jenna for having cut him off for the

third time. When asked how he experienced Jenna, he simply replied that

according to the program you are not to

take another person’s inventory. The

leader took the opportunity to say that

in group therapy it is important to consider one’s feelings about what others

say and do even if [the feelings] are

negative. Expressing one’s own feelings

is different from focusing on another’s

character (taking his inventory)

(Freimuth 2000, p. 308).

No matter what the modality, however, group

therapy is sure to remain an integral part of

substance abuse treatment.

Addressing life issues 

Substance abuse affects every aspect of life:

home, family, friends, job, health, emotional

well­being, and beliefs. As clients move into

recovery, the wide range of issues they should

face may overwhelm them. Leaders need to

help clients rank the

importance of the

challenges, taking

care to make the best

possible use of the

resources the client

and the leader can

bring to bear.

Naturally, clients

will vary in their

ability to address

many concerns

simultaneously.

Naturally, clients will

vary in their ability to

address many concerns simultaneously;

capacity for change

also is variable. For

example, some individuals with cognitive

impairments will have

a much harder time

Group Leadership, Concepts, and Techniques 113
than others engaging

in a change process.

In the early stage of

treatment, such

clients need simple

ideas, structures,

and principles.

As the client moves

forward, the clinician can keep in

mind the issues that

a client is not ready

or able to manage.

As this process goes

on, the leader should

remember that the

client’s priorities

matter more than

what the leader

thinks ought to come next. Unless both client

and leader operate in the same motivational

framework the leader will not be able to help

the client make progress.

The leader should

explore the importance of spiritual	 

life with the group.

No matter what is missing—even if it is a roof

over the client’s head—it is possible to engage

the client in treatment. A client never should be

told to come back after problems other than

substance abuse have been resolved. On some

front, constructive work can always be done.

Of course, this assertion does not mean that

critical needs can be ignored until treatment

for substance abuse is well underway. The

therapist should recognize that a client preoccupied with the need to find a place to sleep

will not be able to engage fully in treatment

until urgent, practical needs are met.

Life issues facing the client provide two powerful points of therapeutic leverage that leaders

can use to motivate the client to pursue recovery. First, group leaders should be aware that

people with alcoholism and other addictions

will not give up their substance use until the

pain it brings outweighs the pleasure it produces. Consequently, they should be helped to

see the way alcohol and drugs affect important

areas of their lives. Second, early in treatment,

group leaders should learn what is important to

each client that continued substance abuse

might jeopardize. For some individuals, it is

their job. For others, it is their spouse, health,

family, or self­respect. In some cases, it might

be the threat of incarceration. Such knowledge

can be used to encourage, and even coerce,

individuals to utilize the tools of treatment,

group, or AA (Flores 1997).

Incorporating faith 

While spirituality and faith may offer to some

the hope, nurturing, sense of purpose and

meaning, and support needed to move toward

recovery, people obviously interpret spiritual

matters in diverse ways. It is important not to

confuse spirituality with religion. Even if

clients are not religious, their spiritual life is

important. Some clinicians mistakenly conclude

that their own understanding of spirituality will

help the client. Other clinicians err in the

opposite direction and are overly reluctant to

address spiritual beliefs. Actually, a middle

ground is preferable. The leader should

explore the importance of spiritual life with the

group, and if the search for spiritual meaning

is important, the clinician can incorporate it

into group discussions.

For clients who lack meaningful connection to

anything beyond themselves, the group may be

the first step toward a search for meaning or a

feeling of belonging to something greater than

the self. The clinician’s role in group therapy

simply is to create an environment within

which such ego­transcending connections can

be experienced.

Integrating Care

Interaction with other health

care professionals 

Professionals within the entire healthcare network need to become more aware of the role of

group therapy for people abusing substances.

To build the understanding needed to support

people in recovery, group leaders should educate others serving this population as often as

opportunities arise, such as when clinicians

114 Group Leadership, Concepts, and Techniques
from different sectors of the healthcare system

work together on a case. Similar needs for

understanding exist with probation officers,

families, and primary care physicians.

Integration of group therapy

and other forms of therapy 

It is common for a client to be in both individual and group therapy simultaneously. The dual

relationship creates both problems and opportunities. Skilled therapists can use what they

discover in group about the client’s style of

relatedness to enhance individual therapy.

Conversely, the individual alliance can help the

client use the group effectively. So long as the

therapist does not collude consciously or

unconsciously with the client to keep what is

said as a secret between them, most obstacles

can be overcome.

In conjoint treatment, that is, a situation in

which one therapist sees a client individually

while another therapist treats the same client in

a group, the therapists should be in close communication with each other. Clinicians should

coordinate the treatment plan, keeping important interpersonal issues alive in both settings.

The client should know that this collaboration

routinely occurs for the client’s benefit.

Medication knowledge base

Clinicians need general knowledge of common

medications used to assist in recovery, relapse

prevention, and co­occurring disorders. Group

leaders should be aware of various medication

needs of clients, the type of medications prescribed, and potential side effects. Prescribing

medication involves striking a balance between

therapeutic and detrimental pharmacological

effects. For example, benzodiazepines can

reduce anxiety, but they can be sedating and

might lead to dependency.

The pregroup interview for long­term groups

should ask what medications group members

are taking and the names of prescribing physicians so cooperative treatment is possible. For

example, if a client is awake all night with drug

cravings, the therapist

might talk with the

physician to determine whether appropriate medication

could help the client

through the difficult

period following

substance abuse

cessation. Therapists

should be wary, however. From former

days of active substance abuse, clients

may have ties to careless physicians who

enabled addiction by

providing cross­addictive medications. If an

evaluation of prescription medications

is needed, counselors

should refer the client to a consulting physician

working with the agency or to a physician

knowledgeable about chemical dependency.

Attention needs to be paid to medications prescribed for physical illnesses as well. For example, it would be important for the group leader

to know that a group member has diabetes and

requires medication.

Conflict in group

therapy is normal,

healthy, and

unavoidable.

Management of the Group

Handling conflict in group 

Conflict in group therapy is normal, healthy,

and unavoidable. When it occurs, the therapist’s task is to make the most of it as a learning opportunity. Conflict can present opportunities for group members to find meaningful

connections with each other and within their

own lives.

Handling anger, developing empathy for a different viewpoint, managing emotions, and

working through disagreements respectfully are

all major and worthwhile tasks for recovering

clients. The leader’s judgment and management are crucial as these tasks are handled. It

is just as unhelpful to clients to let the conflict

Group Leadership, Concepts, and Techniques 115
go too far as it is to

shut down a conflict

before it gets worked

through. The therapist must gauge the

verbal and nonverbal reactions of

every group member

to ensure that everyone can manage the

emotional level of

the conflict.

After a conflict, it

is important for

the group leader to

speak privately

with group members and see how

each is feeling.

The clinician also

facilitates interactions between members in conflict and

calls attention to

subtle, sometimes

unhealthy patterns.

For example, a

group may have a member, Mary, who frequently disagrees with others. Group peers

regard Mary as a source of conflict, and some

of them have even asked Mary (the scapegoat)

to leave so that they can get on with group

work. In such a situation, the therapist might

ask, “Do you think this group would learn

more about handling this type of situation if

Mary left the group or stayed in the group?”

An alternative tack would be, “I think the

group members are avoiding a unique opportunity to learn something about yourselves.

Giving in to the fantasy of getting rid of Mary

would rob each of you of the chance to understand yourself better. It would also prevent you

from learning how to deal with people who

upset you.”

Conflicts within groups may be overt or covert.

The therapist helps the group to label covert

conflicts and bring them into the open. The

observation that a conflict exists and that the

group needs to pay attention to it actually

makes group members feel safer. The therapist

is not responsible, however, for resolving conflicts. Once the conflict is observed, the decision to explore it further is made based on

whether such inquiry would be productive for

the group as a whole. In reaching this decision,

the therapist should consider the function the

conflict is serving for the group. It actually may

be the most useful current opportunity for

growth in the group.

On the other hand, as Vannicelli (1992) points

out, conflicts can be repetitive and predictable.

When two members are embroiled in an endless loop of conflict, Vannicelli suggests that the

leader may handle the situation by asking,

“John, did you know what Sally was likely to

say when you said X?” and “Sally, did you

know what John was likely to say when you

said Y?” “Since both participants are likely to

answer, ‘Yes, of course,’ the therapist would

then inquire what use it might serve for them to

engage in this dialogue when the expected outcome is so apparent to both of them (as well as

to other members of the group). This kind of

distraction activity or defensive maneuver

should come to signal to group members that

something important is being avoided. It is the

leader’s task to help the group figure out what

that might be and then to move on” (Vannicelli

1992, p. 121).

Group leaders also should be aware that many

conflicts that appear to scapegoat a group

member are actually displaced anger that a

member feels toward the therapist. When the

therapist suspects this kind of situation, the

possibility should be forthrightly presented to

the group with a comment such as, “I notice,

Joe, that you have been upset with Jean quite a

bit lately. I also know that you have been a little annoyed with me a since couple weeks ago

about the way I handled that phone call from

your boss. Do you think some of your anger

belongs with me?”

Individual responses to particular conflicts can

be complex, and may resonate powerfully

according to a client’s personal values and

beliefs, family, and culture. Therefore, after a

conflict, it is important for the group leader to

speak privately with group members and see

how each is feeling. Leaders also often use the

last 5 minutes of a session in which a conflict

has occurred to give group members an opportunity to express their concerns.

116 Group Leadership, Concepts, and Techniques
Subgroup management 

In any group, subgroups inevitably will form.

Individuals always will feel more affinity and

more potential for alliance with some members

than with others. One key role for the therapist

in such cases is to make covert alliances overt.

The therapist can involve the group in identifying subgroups by saying, “I notice Jill and

Mike are finding they have a good deal in common. Who else is in Jill and Mike’s subgroup?”

Subgroups can sometimes provoke anxiety,

especially when a therapy group is made up of

individuals acquainted before becoming group

members. Group members may have used

drugs together, slept together, worked together,

or experienced residential substance abuse

treatment together. Obviously, such connections are potentially disruptive, so when groups

are formed, group leaders should consider

whether subgroups would exist.

When subgroups somehow stymie full participation in the group, the therapist may be able

to reframe what the subgroup is doing. At

other times, a change in the room arrangement

may be able to reconfigure undesirable combinations. On occasion, however, subtle

approaches fail. For instance, adolescents talking among themselves or making obscene gestures during the session should be told factually

and firmly that what they are doing is not permissible. The group leader might say, “We

can’t do our work with distractions going on.

Your behavior is disrespectful and it attempts

to shame others in the group. I won’t tolerate

any abuse of members in this group.”

Subgroups are not always negative. The leader

for example may intentionally foster a subgroup that helps marginally connected clients

move into the life of the group. This gambit

might involve a question like, “Juanita, do you

think it might help Joe if you talked some

about your experience with this issue?”

Further, to build helpful connections between

group members, a group member might be

asked, “Bob, who else in this group do you

think might know something about what you’ve

just said?”

Responding to disruptive

behavior 

Clients who cannot stop talking 

When a client talks on and on, he or she may

not know what is expected in a therapy group.

The group leader might ask the verbose client,

“Bob, what are you hoping the group will learn

from what you have been sharing?” If Bob’s

answer is, “Huh, well nothing really,” it might

be time to ask more experienced group members to give Bob a sense of how the group

works. At other times, clients tend to talk more

than their share because they are not sure what

else to do. It may come as a relief to have their

monolog interrupted (Vannicelli 1992, p. 167).

If group members

exhibit no interest in

stopping a perpetually

filibustering client, it

may be appropriate to

examine this silent

cooperation. The

group may be all too

willing to allow the

talker to ramble on,

to avoid examining

their own past failed

patterns of substance

abuse and forge a

more productive

future. When this

motive is suspected,

the leader should

explore what group

members have and

have not done to signal the speaker that it is time to yield the floor.

It also may be advisable to help the talker find

a more effective strategy for being heard and

understood (Vannicelli 1992).

In managing

subgroups, one

key role for the

therapist is to

make covert

alliances overt.

Clients who interrupt 

Interruptions disrupt the flow of discussion in

the group, with frustrating results. The client

who interrupts is often someone new to the

group and not yet accustomed to its norms and

rhythms. The leader may invite the group to

comment by saying, “What just happened?” If

Group Leadership, Concepts, and Techniques 117
the group observes,

“Jim seemed real

anxious to get in

right now,” the leader might intervene

with, “You know,

Jim, my hunch is

that you don’t know

us well enough yet to

be certain that the

group will pay adequate attention to

your issues; thus, at

this point, you feel

quite a lot of pressure to be heard and

understood. My

guess is that when

other people are

speaking you are

often so distracted

by your worries that

it may even be hard to completely follow what

is going on” (Vannicelli 1992, p. 170).

Sometimes, clients

are unable to

participate in ways

consistent with	 

group agreements.

Clients who flee a session 

Clients who run out of a session often are acting on an impulse that others share. It would

be productive in such instances to discuss these

feelings with the group and to determine what

members can do to talk about these feelings

when they arise. The leader should stress the

point that no matter what is going on in the

group, the therapeutic work requires members

to remain in the room and talk about problems

instead of attempting to escape them (Vannicelli

1992). If a member is unable to meet this

requirement, reevaluation of that person’s

placement in the group is indicated.

Contraindications for continued participation in group 

Sometimes, clients are unable to participate in

ways consistent with group agreements. They

may attend irregularly, come to the group

intoxicated, show little or no impulse control,

or fail to take medication to control a co­occurring disorder. Though removing someone from

the group is very serious and should never be

done without careful thought and consultation,

it is sometimes necessary. It may be required

because of a policy of the institution, because

the therapist lacks the skills needed to deal

with a particular problem or condition, or

because an individual’s behavior threatens the

group in some significant and insupportable

way.

Though groups do debate many issues, the

decision to remove an individual is not one the

group makes. On the contrary, the leader

makes the decision and explains to the group in

a clear and forthright manner why the action

was taken. Members then are allotted time to

work through their responses to what is bound

to be a highly charged event. Anger at the

group leader for acting without group input or

acting too slowly is common in expulsion situations, and should be explored.

Managing Other Common

Problems

Coming late or missing 

sessions 

Sometimes, addiction counselors view the client

who comes to group late as a person who, in

some sense, is behaving badly. It is more productive to see this kind of boundary violation

as a message to be deciphered. Sometimes this

attempt will fail, and the clinician may decide

the behavior interferes with the group work too

much to be tolerated.

Silence 

A group member who is silent is conveying a

message as clearly as one who speaks. Silent

messages should be heard and understood,

since nonresponsiveness may provide clues to

clients’ difficulties in connecting with their own

inner lives or with others (Vannicelli 1992).

Special consideration is sometimes necessary

for clients who speak English as a second language (ESL). Such clients may be silent, or

respond only after a delay, because they need

118 Group Leadership, Concepts, and Techniques
time to translate what has just been said into

their first language. Experiences involving

strong feelings can be especially hard to translate, so the delay can be longer. Further, when

feelings are running high, even fluent ESL

speakers may not be able to find the right

words to say what they mean or may be unable

to understand what another group member is

saying about an intense experience.

Tuning out 

When the group is in progress and clients seem

present in body but not in mind, it helps to

tune into them just as they are tuning out. The

leader should explore what was happening as

an individual became inattentive. Perhaps the

person was escaping from specific difficult

material or was having more general difficulties

connecting with other people. It may be helpful

to involve the group in giving feedback to

clients whose attention falters. It also is possible, however, that the group as a whole is

sidestepping matters that have to do with connectedness. The member who tunes out might

be carrying this message for the group

(Vannicelli 1992).

Participating only around the

issues of others 

Even when group members are disclosing little

about themselves, they may be gaining a great

deal from the group experience, remaining

engaged around issues that others bring up. To

encourage a member to share more, however, a

leader might introduce the topic of how well

members know each other and how well they

want to be known. This topic could be explored

in terms of percentages. For instance, a man

might estimate that group members know about

35 percent about him, and he would eventually

like them to know 75 percent. Such a discussion would yield important information about

how much individuals wish to be known by others (Vannicelli 1992).

Fear of losing control 

As Vannicelli (1992) notes, sometimes clients

avoid opening up because they are afraid they

might break down in front of others––a fear

particularly common in the initial phases of

groups. When this restraint becomes a barrier

to clients feeling acute pain, the therapist

should help them remember ways that they

have handled strong feelings in the past.

For example, if a

female client says she

might “cry forever”

once she begins, the

leader might gently

inquire, “Did that

ever happen?” Clients

are often surprised to

realize that tears generally do not last very

long. The therapist

can further assist this

client by asking,

“How were you able

to stop?” (Vannicelli

1992, p. 152).

When a client’s fears

of breaking down or

becoming unable to

function may be

founded in reality (for example, when a client

has recently been hospitalized), the therapist

should validate the feelings of fear, and should

concentrate on the strength of the person’s

adaptive abilities (Vannicelli 1992).

A group member

who is silent is

conveying a message as clearly as

one who speaks.

Fragile clients with psychological emergencies 

Since clients know that the group leader is

contractually bound to end the group’s work

on time, they often wait intentionally until the

last few minutes of group to share emotionally

charged information. They may reveal something particularly sad or difficult for them to

deal with. It is important for the leader to recognize they have deliberately chosen this time

to share this information. The timing is the

Group Leadership, Concepts, and Techniques 119
client’s way of

limiting the group’s

responses and avoiding an onslaught of

interest. All the

same, the group

members or leader

should point out

this self­defeating

behavior and

encourage the client

to change it.

Clients may feel

great anxiety after

disclosing something important.

Near the end of a

session, for example,

a group leader has

an exchange with a group member named Lan,

who has been silent throughout the session:

Leader: Lan, you’ve been pretty quiet today. I

hope we will hear more about what is happening with you next week.

Lan: I don’t think you’ll see me next week.

Further exploration reveals that Lan intends to

kill herself that night. In view of the approaching time boundary, what should the leader do?

In such a situation, the group leader has dual

responsibilities. First, the leader should

respond to Lan’s crisis. Second, the incident

should be handled in a way that reassures

other group members and preserves the integrity of the group. Group members will have a

high level of anxiety about such a situation.

Because of their concern, some group leaders

are willing to extend the time boundary for that

session only, provided that all members are

willing and able to stay. Others feel strongly

that the time boundary should be maintained

and that the leader should pledge to work with

Lan individually right after the session.

Whatever the decision and subsequent action,

the leader should not simply drift casually and

quietly over the time boundary. The important

message is that boundaries should be honored

and that Lan will get the help she needs. The

group leader can say explicitly that Lan’s needs

will be addressed after group.

Figure 6­3 shows that group leaders should

be prepared to deal not only with substance

abuse issues, but with co­occurring psychiatric

concerns as well.

Anxiety and resistance after

self­disclosure 

Clients may feel great anxiety after disclosing

something important, such as the fact that they

are gay or incest victims. Often, they wonder

about two possibilities: “Does this mean that I

have to keep talking about it? Does this mean

that if new people come into the group, I have

to tell them too?” (Vannicelli 1992, p. 160).

To the first question, the therapist can respond

with the assurance, “People disclose in here

when they are ready.” To the second, the

member who has made the disclosure can be

assured of not having to reiterate the disclosure

when new clients enter. Further, the disclosing

member is now at a different stage of development, so the group leader could say, “Perhaps

the fact that you have opened up the secret a

little bit suggests that you are not feeling that it

is so important to hide it any more. My guess is

that this, itself, will have some bearing on how

you conduct yourself with new members who

come into the group” (Vannicelli 1992, p. 160

& p. 161).

120 Group Leadership, Concepts, and Techniques
Figure 6­3

Jody’s Arm

A long­term outpatient interpersonal process group meets in 90­minute sessions

to support sustained recovery. The group, which includes five women and four

men, is relatively stable and successfully abstinent. Many of the clients, however,

still struggle with profound psychological concerns that require ongoing

attention.

In one group session, all members are present except Jody, a 43­year­old client

who is opioid­dependent and has co­occurring psychiatric difficulties. Jody

walks in approximately 35 minutes late, apologizing for her lateness. The group

facilitator makes a mental note that Jody is wearing several sweatshirts, despite

weather too mild to justify the need for layered clothing.

Approximately 15 minutes before the close of group, blood seeps through the top

layer of clothing covering Jody’s left arm. The group leader asks Jody if her

injured arm is making some statement to the group members. Is there something

specific that she wants from the group at this particular moment? The leader is

confident that Jody is saying something very important not only to, but for, the

group as a whole.

Jody indicates that the previous week she felt diminished by comments from a

number of members in the group. In an effort to deal with the anxiety and

shame associated with returning to the group, she has cut herself before

attending.

A number of group members quickly share their concern for her and hopes that

their comments of the previous week could be revisited and revised to be more

supportive. Jody shows the group the cut on her forearm, which has all but

stopped bleeding. She explains how deep her pain is and her desire for the

group not to judge her for that pain.

Because Jody appears to be in no imminent danger, the leader chooses to continue with the group process, ending it at the regularly scheduled time. The group

meets at a major medical center, so the leader is able to walk with Jody to the

emergency room. The leader assures the group that Jody will receive the medical

attention she needs.

The next week, the entire group makes substantial gains. They carefully examine their judgment and willingness to allow Jody to be the primary spokeswoman

for the profound emotional pain that each of them feels. The dramatic and

unexpected situation the previous week has not interrupted the group process. It

has instead been used adroitly to make the group even more productive.

Group Leadership, Concepts, and Techniques 121

7 Training and

Supervision

In This 

Chapter... 

Training

Training Opportunities 

Training Opportunities in 

Types of Group Therapy 

Supervision

The Supervisor’s Essential 

Skills 

The Supervisory Alliance 

Funding for Training and 

Supervision Programs 

Overview

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

• Administrative

• Evaluative

• Clinical

•Supportive

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 top­flight group clinician or supervisor of clinicians.

Training

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)

123
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 cross­knowledge; and (2) an ever

younger pool of

clients is presenting

with more cognitive deficits, abuse issues, and

co­occurring disorders.

A group leader for

people in substance abuse treatment requires

competencies in	 

both group work

and addiction.

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

12­Step 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 co­occur 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 self­help 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, self­help 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,

cognitive–behavioral 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 one­way mirrors

as experienced therapists lead groups.

124 Training and Supervision
• 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 process­oriented), 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 first­hand 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

client––and not be duped by agreeable, but

false, façades.

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.

Supervision in a

group enables

therapists to

obtain first­hand

experience.

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

Training and Supervision 125
good judgment and leadership skills (see Figure

7­1). Helping the group explore why the recovery status of the group leader is important can

be discussed if and when the issue is raised.

Training Opportunities

National professional organizations are a rich

source of training. Through conferences or

regional chapters, national associations provide

training—both experiential and direct instruction—geared to the needs of a wide range of

professionals, from the novice to the highly

experienced therapist. More training options

are usually available in large urban areas. It is

likely, however, that online training will make

some types of professional development accessible to a greater number of counselors in

remote areas. A number of professional

organizations that provide a variety training

settings are listed below. Inclusion in the list

does not imply endorsement by the Substance

Abuse and Mental Health Services Administration (SAMHSA). Note that not all of these

organizations approach substance abuse

treatment through group therapy.

Professional associations 

American Group Psychotherapy

Association (AGPA) 

AGPA, founded in 1942, has more than 4,000

members and 33 local and regional affiliate

societies, which provide a broad range of professional, educational, and social support for

group therapists in the United States and

abroad. The organization publishes The

International Journal of Group Psychotherapy

and The Group Circle.

AGPA’s Special Interest Groups (SIGs) share

ideas and knowledge through interaction with

colleagues. Some SIGs focus on substance

abuse; children and adolescents; cotherapy;

diversity; gay, lesbian, and bisexual clients; the

medically ill; the severe and persistent mentally

ill; and women in group therapy. SIGs are open

to nonmembers of AGPA.

At its annual conferences, AGPA offers training institutes for individuals. Three of these

institutes focus on substance abuse training.

The association can also provide in­house

training to agency staff at a very low cost.

Further, AGPA has developed basic and

Figure 7­1

How Important Is It for a Substance Abuse Group Leader To Be

In Recovery?

Source: Consensus Panel.

A leader who is in recovery will probably elicit trust more quickly from group

members, especially people with hard­core addictive backgrounds, because such

clients often assume––correctly or not––that a person in recovery can empathize

with the pain of addiction. Such group leaders, as success stories, have the

added advantage of serving as role models for group members struggling against

temptations and cravings in the early stages of recovery.

A leader having personally recovered, however, does not automatically make

that person an effective therapist. Many counselors in recovery cannot make the

switch from self­ to client­centered approaches and hold rigid views of how to

manage the recovery process.

126 Training and Supervision
advanced core courses. They tend to be practical in nature, and they contribute to certification. The certified group therapy program is

available through the regional affiliates.

American Psychiatric Association

(APA)

The American Psychiatric Association is a medical specialty society recognized world­wide. Its

more than 35,000 U.S. and international member physicians work together to ensure humane

care and effective treatment for all persons

with mental disorder, including mental retardation and substance­related disorders. To its

members, the APA offers board certification

and continuing medical education from online

sources as well as at annual meetings.

American Psychological Association

(APA) 

The APA College of Professional Psychology

offers a Certificate of Proficiency in the

Treatment of Alcohol and Other Psychoactive

Substance Use Disorders. This certificate is a

uniform nationally recognized credential

offered exclusively to licensed psychologists

who meet specific criteria related to experience

in substance abuse treatment, including completion of an APA examination.

Two of APA’s 55 subgroups may be of special

interest. Division 49, Group Psychology and

Group Psychotherapy, serves psychologists’

interest in research, teaching, and the practice

of group psychology and group therapy.

Division 50, Addictions, centers on research,

professional training, and clinical practice

dealing with a broad range of addictive behaviors. Both divisions publish a newsletter and

journal, and both have annual meetings and

award programs.

APA has extensive resources on cultural diversity and ethnic/racial issues related to therapy,

including online brochures, a quarterly journal, Cultural Diversity and Ethnic Minority

Psychology, and an Office of Ethnic Minority

Affairs that provides publications and information. Recent APA books on this topic describe

relationships among Asian­American women

and health­promoting and health­compromising behaviors among minority adolescents.

American Society of Addiction

Medicine (ASAM) 

One of ASAM’s goals is educating health professionals about addiction. The organization

develops credentialing guidelines and publishes

the comprehensive and influential volume,

Principles of Addiction Medicine (Graham et

al. 2003), among other books and journals.

The society has also developed patient placement criteria called PPC­2R (published in

2001), as well as screening and assessment

tools. Each year, ASAM hosts several conferences and training meetings on various aspects

of addiction medicine. ASAM offers audiotapes

of its conferences for continuing medical education credit. Physicians certified by the society

in addiction medicine are listed in an ASAM

directory.

Association for the Advancement

of Social Work with Groups

(AASWG)

This international professional organization

has developed standards that reflect the distinguishing features of group work, as well as the

unique perspective that social workers bring to

their practice with groups. These standards are

applicable to the types of groups that social

workers encounter in the various settings in

which they practice and allow the practitioner

to apply a variety of relevant group work models. AASWG has also collected a 29­page bibliography of books, monographs, and videos

available for practitioners, educators, and

researchers.

Training and Supervision 127
Association for Specialists in Group

Work (ASGW) 

A division of the American Counseling

Association, the ASGW was founded to

promote high quality in group work training,

practice, and research, both nationally and

internationally. The organization has developed Best Practice Guidelines, Principles for

Diversity­Competent Group Workers, and

Professional Standards for the Training of

Group Workers. These criteria are available

on the organization’s Web site: http://asgw.org.

The Web site also provides resources, including

products, institutes, and links to other Web

pages, along with a calendar describing upcoming conferences and professional development

activities of interest to a broad spectrum of

group leaders.

National Association of Alcohol

and Drug Abuse Counselors

(NAADAC)

NAADAC is the largest national organization

for alcoholism and drug abuse professionals

across the country. The association offers

opportunities for professional development,

such as workshops, seminars, and education

programs for members. In addition to a

bimonthly magazine, The Counselor, NAADAC

provides an Educational Resources Guide that

lists colleges and universities offering degree

and certification programs in addiction counseling and a listing of approved education

providers for trainers in each State. Through

its national certification program, including the

National Certified Addiction Counselor and the

Masters Addiction Counselor designation,

NAADAC recognizes counselors with advanced

skill levels.

National Association of Black Social

Workers (NABSW)

NABSW offers national and international

education conferences, as well as projects and

mentoring programs to support the work of

African­American social workers.

National Association of Social

Workers (NASW) 

NASW is the world’s largest organization of

professional social workers. The association

has developed practice standards and clinical

indicators, a credentialing program, continuing

education courses on national and State levels,

and numerous publications for members and

nonmembers.

Distance learning courses are listed on NASW’s

Web site. Many topics are relevant to addiction

counselors, such as Chemical Dependency and

the African American: Counseling Strategies

and Community Issues, Dual Diagnosis,

HIV/AIDS and Substance Abuse, and

Multicultural Counseling—The New Paradigm

for Substance Abuse Professionals.

National Registry of Certified

Group Psychotherapists 

In an effort to maintain the highest standards

for group therapy practice, the National

Registry certifies group therapists according to

nationally accepted criteria and promotes these

criteria among mental health professionals,

employers, insurers, education personnel, and

clients. The registry has developed guidelines

that are clinically based, client­focused service

indicators to be used in discussions with

accrediting organizations regarding appropriate standards of quality. The guidelines also

apply in discussions with employers regarding

delivery of mental health services in groups, as

well as managed care and health maintenance

organizations. The registry’s newsletter, The

Group Solution, provides up­to­date information on the use of group therapy in the current

behavioral health care atmosphere.

128 Training and Supervision
Frequent continuing education seminars are

given by local affiliate societies and at the

annual meeting of the parent group, AGPA.

Other sources of training 

Many agencies mandate a certain number of

trainings each year and provide in­house

training that draws on the resources of credentialed senior management. Each of the

States has a department of alcohol and drug

abuse services, and some may provide substance abuse training for group therapy.

Training in mental health issues is often

available through the mental health division

of government agencies, professional associations, and psychological and psychiatric

organizations. Most colleges, universities,

and community colleges offer relevant

courses, many of them certified by professional organizations.

Several Federal entities offer resources for

training. SAMHSA provides a number of

resources, including publications for substance abuse treatment professionals. These

include the Technical Assistance Publication

(TAP) series. TAP 21 is relevant to training:

Addiction Counselor Competencies: The

Knowledge, Skills, and Attitudes of

Professional Practice (CSAT 1998a).

In addition, SAMHSA’s Treatment

Improvement Protocol (TIP) series includes

more than 40 publications to assist therapists and counselors in treating people with

substance abuse problems. To view TAPs

and TIPs online, go to

http://www.kap.samhsa.gov and click on

“Publications.”

These publications also are available free

through the SAMHSA Store at 1­877­726­

4727. The SAMHSA Store can also provide

a catalog of other resources and publications on addiction counseling and treatment.

One of them, for example, is the National

Institute on Drug Abuse, which provides

information on research and treatment.

The National Mental Health Information

Center (NMHIC) at SAMHSA provides a

wealth of information for the public and

for treatment professionals. A search for

“training” on its Web site resulted in a list of

numerous opportunities for training and

technical assistance on a variety of topics as

well as bibliographies, publications, and

links.

Training Opportunities in

Types of Group Therapy

Experiential learning 

For the therapist in training, the experience

of being in a group is particularly important

for both the development of skills and the

level of comfort with one’s developing leadership style. Whether this experience is

acquired through a process group, a supervision group, or experiences offered through

organizations like the AGPA, experiential

opportunities afford learners not only

insight into their personal growth, but a

first­person appreciation for the healing

power of group therapy.

SAMHSA

provides a number

of resources,

including

publications for

substance abuse

professionals.

Experienced group therapists are able to

lead process groups

because training in

this area is part of

the preparation program for mental

health professionals.

In these groups,

members study their

own behavior to

learn about group

dynamics, individual

dynamics, boundaries, and interpersonal communications. In addition,

Training and Supervision 129
leadership of process groups provides one of

the best continuing education tools available

to senior clinicians (Swiller et al. 1993). One

experienced supervisor of training groups for

therapists in training has found that “one of

the most striking aspects of the supervision of

group therapists in the group setting is its effectiveness in bringing about the identification,

emotional recognition, and resolution

of...untherapeutic behaviors, which we term

counterresistances” (Rosenthal 1999b, p. 201).

A great many institutions and individuals offer

workshops and courses in conducting group

therapy. One of these is the A.K. Rice Institute

and its affiliate societies, which provides group

relations training based on the Tavistock

model, which originated at the Tavistock

Institute in England. The training, offered in

weekend or longer conferences, is a model of

experiential training that focuses exclusively on

group­level dynamics.

The A.K. Rice Institute

Anne­Marie Kirkpatrick, R.N., Administrator

P.O. Box 1776

Jupiter, Florida 33468­1776

Phone: (561) 744­1350

Fax: (561) 744­5998

Expressive therapies

A wide range of expressive therapies (therapy

based on an artist’s working process) is often

used in substance abuse treatment. Expressive

therapy groups may use dance, music, art,

writing, psychodrama, drama, role playing,

adventure, and gestalt. Training in these areas

is available through AGPA, ASGW, and APA.

The Gestalt Institute has training centers in

most large cities and offers a certification in

psychodrama.

The National Institute of Expressive Psychotherapy offers a 2­year online program for

those who have participated annually in the

institute’s 2­day residency. Professionals are

required to participate as a member of a roleplaying or drama group before attending

classes in techniques and learning how to apply

them with a population that has substance

abuse problems. The National Expressive

Therapy Association offers conferences,

professional education, and in affiliation with

the National Institute of Expressive Therapy,

continuing education units, credentialing, and

board certification.

Cross­training 

Though group therapists work in the field of

mental health, they generally have little training in the specifics of substance abuse treatment. This situation will have to change if the

fields of substance abuse treatment and mental

health are to integrate their activities.

To supplement courses that professional organizations offer individuals, agencies can use a

case study approach. Case studies that include

educational materials on diagnosis, symptoms,

and treatment serve as a good foundation for

cross­training. The cases that cause counselors

to struggle the most could be analyzed. What

strategies were used? What were the outcomes?

What alternatives did other staff recommend?

Case conferences can be conducted at weekly

staff development sessions, as part of regular

meetings, or (more quickly) at morning feedback meetings on clinical topics. A case conference might involve counselors, social workers,

and psychologists.

Legal issues

It is important for therapists to know Federal

regulations and the laws of their States, especially those concerning “duty to warn” stipulations regarding the abuse of children or elders,

commitment procedures for psychiatric clients,

and confidentiality laws pertaining to HIV/

AIDS, adolescents, and managed care.

Practitioners should be familiar with the

Federal confidentiality regulation, 42 C.F.R.

Part 2, Confidentiality of Alcohol and Drug

Abuse Patient Records. In addition, there are

State laws that also guide the confidentiality of

130 Training and Supervision
alcohol and drug abuse information, and

whichever is more restrictive (i.e., State law or

Federal law) governs. Professional and legal

organizations usually address these topics in

their coursework. It is best to find such courses

at the regional or State level, so that attendees

can grasp the laws governing residents in their

specific geographical areas.

Videos 

While impersonal media cannot replace the

relationships between supervisors and trainees,

videos can be used to explain theoretical principles, provide information on various types of

drugs, and support skills­building activities.

Distance learning 

Distance learning systems, which often communicate via cable or satellite, can assist with

explaining concepts, theories, and case studies.

Like videos, distance learning may lack the

close personal relationship with a supervisor,

but interactive forms of distance learning do

permit questions, comments, and requests for

clarification.

Group therapy for trainees using an online

chat room is an interesting possibility and

could be especially helpful to people in remote

settings. Licensing boards, however, would first

need to resolve any potential legal issues

regarding confidentiality. Also, some critics

have worried that computerized communication would interfere with attachment (one of

the most powerful therapeutic factors). This

problem does not seem to occur in educational

seminars conducted online (see Figure 7­2 on

p. 132).

Every State has a credentialing process for

substance abuse treatment professionals, and

NAADAC lists all the particulars at

http://www.NAADAC.org.  At the same address,

NAADAC posts training calendars and a

great deal of other information on training

opportunities.

The 14 regional Addiction Technology Transfer

Centers (ATTCs), launched by SAMHSA’s

CSAT in 1993, connect substance abuse

treatment professionals to a wide variety of

useful information. ATTCs

• Provide State­by­State credentialing

information

• Post news in the field

• List new resources, including publications

• Translate technical and academic journal

articles into easy­to­read language

• List alcohol and other drug treatment programs in each State

•Provide a worldwide catalog of online courses

To tap into ATTC’s lode of professional

development information, log onto

http://www.nattc.org.

Supervision

Supervisory oversight is a significant training

requirement for group therapists. Powell

(1993) defines clinical supervision as “a disciplined, tutorial process wherein principles

are transformed into practical skills with

four overlapping foci—administrative, evaluative, clinical, and supportive.” Powell’s

description points out that the clinical supervisor has an administrative task, namely the

development of an appropriate supervision

plan for clinician trainees. This task includes

planning, coordination, and delegation of

responsibilities; determining appropriate

staff assignments; and helping to define

administrative polcies and procedures.

Every State has a

credentialing process for substance

abuse treatment

professionals.

In addition, the clinical supervisor has

duties in the sphere

of evaluation. As the

skills and knowledge

of new group facilitators begin to grow,

they need consistent,

useful feedback that

will direct their work

and will support professional growth. In

the early stages of 

Training and Supervision 131
Figure 7­2

Does Online Communication Impede Attachment?

Source: A Consensus Panel member.

As a faculty member with the Fielding Graduate Institute, a distance learning

program, I teach psychology in both on­ and offline formats. In many of the

online seminars, students post their papers and comment on the contributions of

others. The students are dispersed around the country, so few (if any) know

each other prior to the seminar.

Even though the students’ interactions are asynchronous (that is, not in real

time; a lag separates comment and response), a group of learners develops that

is indistinguishable from learners sitting in the same room together. Alliances

develop between students who share similar ideas, and disagreements take place

between opposing positions. The attachments that develop through the written

word outside of real time seem as genuine as any other relationships.

In the online seminars, some students find in cyberspace a safer format than

traditional classes. Not having to confront all the verbal cues that may distract

people in a face­to­face conversation, learners are freer to be genuine. Several of

my students who were involved in a seminar with in­person and online components were more interactive and spontaneous in the online segment.

I don’t see why these dynamics would be different in supervisory groups. I don’t

know of any online therapy groups, but some AA meetings are conducted online.

Further, Haim Weinberg operates a discussion list that includes about 400 group

therapists from more than 30 countries. This arena for exchanging ideas about

group therapy behaves very much like any large group, with a few surprising

departures. Among them:

• In this highly diverse group representing many schools of thought, conflicts do

not arise over differing theoretical stances or the appropriateness of interventions. Instead, “word wars,” (commonly called “flaming”) break out due to

impatience or personal attitudes and exchanges. One member wrote, for example, “I thought you either have to be very young and inexperienced or very

rude and insulting.” Some of the flaming seems to stem from misunderstandings that in turn result from having only words as cues. What is meant in jest,

for example, may be taken seriously (Weinberg 2002).

•Traditionally, the larger the group, the more impersonal it was, but Weinberg

finds startling self­disclosure and intimacy over the Internet. For example, a

man whose newborn son had died wrote, “My heart is broken. Words can’t

convey the grief, and I realize only now that the depth of this pain is beyond

comprehension. I feel waves of horrible sadness and utter bewilderment.”

Messages of condolence flooded back to the distraught father (Weinberg 2002).

132 Training and Supervision
group facilitation, answers to the question,

“How am I doing?” are extremely important,

but unfortunately, the question often goes

unanswered. Appropriate clinical supervision

will not only keep this question in mind, but

also provide clear, cogent responses to trainees.

Figure 7­3 gives an example of group experiential training.

Figure 7­3

Group Experiential Training

Source: A Consensus Panel member.

Through the Mountain Area Health Education Center in Asheville, North

Carolina, I conducted an 18­month intensive group training and supervision

experience, which is one of many ways to provide clinicians with an expanded

knowledge base and the opportunity to sense the power of group therapy. The

group met one Saturday a month from 9:00 a.m. to 6:00 p.m.

The model had three main components. The first, conducted in a direct instruction format, communicated basic, intermediate, and eventually advanced group

skills. It also highlighted the role of failed attachment in the expression of addictive disease and the theoretical means by which groups address these concerns.

The trainees’ experiential group process, the second component, took place

three times throughout the day. In these 1­hour sessions, trainees participated in

a training group. From the outset, it was made clear that this training group was

not therapy. Although personal information inevitably was shared, the primary

purpose of the experience was trainees’ encounter with the here­and­now

aspects of interpersonal group process, while being exposed to the same anxieties, excitement, and achievements that clients feel within the context of group.

At the end of each experiential group process, trainees evaluated not only the

group process, but also reflected on aspects of the supervisor’s leadership style,

commenting on its facilitation of the process or difficulties it presented.

The third aspect of this training and supervision experience was an in­depth

evaluation of the clinical experiences of the trainees. At each session, group

members brought in clinical issues that occurred in their practice for comment,

discussion, and review. They received information not only from the group

supervisor, but also from peers. This opportunity enabled trainees to integrate a

theory base with practice, thus satisfying one of Powell’s key components of clinical supervision, that is, “a tutorial process wherein principles are transformed

into practical skills” (Powell 1993).

After leading this intensive experience, as well as many less intensive 30­hour

training courses in group therapy, the need for such continuing training opportunities is clear to us. We can say with some authority that the continued

advancement of one’s personal skills is essential, from initiation into the field

throughout the trajectory of a professional’s career.

Training and Supervision 133
The clinical function

that the supervisor

fulfills is the development of a basic 

core of knowledge 

and skills, which 

includes an in­depth

understanding of

addictive disease, an

integrated model of

group process,

group dynamics, and

the stages of group

development.

The interaction

between supervisory

personnel and

trainees has a supportive function,

which is vital to the

growth of trainees.

When they begin to apply their newly acquired

knowledge is the time that they need the most

support and the most discerning supervision.

The supervisory	 

alliance is needed

to teach the

trainee the skills

and knowledge

required to lead

groups effectively.

Clinical supervision, as it pertains to group

therapy, often is best carried out within the

context of group supervision. Group dynamics

and group process facilitate learning by setting

up a microcosm of a larger social environment.

Each group member’s style of interaction will

inevitably show up in the group transactions.

Given enough time, all the people in the supervisory group will interact with group members

just as they interact with others in wider social

and clinical spheres, and every person will

create in the group the same interpersonal

universe inhabited outside the group. As this

process unfolds, group members, guided by the

supervisor, learn to model effective behavior in

an accepting group context.

For the beginning counselor, supervisory

groups reduce, rather than escalate, the level

of threat that can accompany supervision. In

place of isolation and alienation, group participation gives counselors a sense of community.

They find that others share their worries,

fears, frustrations, temptations, and ambivalence. This reassurance is especially beneficial

to novice counselors. Further,

• Group disclosure increases the potential for

self­disclosure and confirmation, creating

opportunities for growth.

• Empathy and sharing of interests are available to a greater extent than in individual

supervision.

• Working together over time, a group can

reinforce its members’ personal growth.

• Alternative clinical approaches and methods

of helping are available to a far greater

extent than in dyadic supervision. As a

result, group members acquire a broad

perspective on counseling styles.

• Each counselor can do reality testing,

presenting perceptions for peer scrutiny, and

possibly, validation.

•The potential for critique is greatly expanded

(Powell 1993).

For treatment facilities, group supervision is

attractive in its efficiency and effectiveness:

• It provides a cost­effective way of supervising

more people in the same amount of time.

• The diversity of people in the group increases

opportunities for learning. The number of

group members (up to the desired limit of

four to six members) exponentially expands

the range of learning opportunities.

• Group supervision creates a working alliance

among counselors, engendering a sense

of psychological safety and reducing selfdefeating behavior (Powell 1993).

The Supervisor’s Essential

Skills

A supervisor should be competent in several

content areas, including substance abuse treatment, group training, cultural competence, and

diagnosis of co­occurring conditions. A supervisor may be an administrator, an in­house trainer, or a therapist from another agency.

A recent survey of members of NAADAC

indicates that many counselors receive and are

134 Training and Supervision
satisfied with weekly clinical supervision.

However, a significant percentage of the

respondents (who were not differentiated as to

whether they work with individuals or groups)

indicated they receive no clinical supervision

(Culbreth 1999). This finding is disturbing considering the benefits of clinical supervision for

the delivery of high­quality service to clients

and the professional development of counselors.

Other findings from the NAADAC survey have

clear implications for supervisory training. For

example, respondents preferred a supervisor

who is a knowledgeable professional in the field

and supervision that is more proactive and

intentional than reactive (Culbreth 1999).

The Supervisory Alliance

Some training experts believe the key to effective group therapy supervision is the development of the supervisory alliance. This positive

working relationship between the supervisor

and trainee is a unique and appropriate setting

within which a new therapist can develop skills

in group analysis and refine an ability to develop appropriate treatment strategies.

The supervisory alliance is needed to teach the

trainee the skills and knowledge required to

lead groups effectively and to make sure that

the group accomplishes its purpose. The supervisor helps by establishing an open and collaborative climate, identifying the unique learning

needs and styles of the supervisory group

members, formulating a responsive supervisory

contract, and pinpointing any problems that

emerge within the alliance (Kleinberg 1999).

Supervision also includes encouraging and

mentoring students from specific cultural

groups, since it is difficult to locate well­trained

therapists to treat certain populations.

Assessment of trainee skills 

The supervisor should be able to assess the

various domains that trainees are required

to master.

• Clinical skills (from selecting prospective

group members and designing treatment

strategies to planning and managing

termination)

• Comprehensive knowledge of substance abuse,

which, depending upon the treatment setting,

could entail broad general knowledge of, or a

thorough facility with, a particular field

• Knowledge of the preferred theoretical

approach

• Knowledge of psychodynamic theory

• Knowledge of group dynamics theory

• Knowledge of the institution’s preferred

theoretical approaches

• Diagnostic skills for determining co­occurring

disorders

• Capacity for self­reflection, such as recognizing one’s own vulnerability and, when this

problem arises, the ability to monitor and

govern behavioral and emotional reactions

• Consultation skills, such as the ability to

consult with a referring therapist, provide

feedback, and coordinate treatment in both

individual and group modes

•Capacity to be supervised; for example,

openness in supervision, setting goals for

training, and discussing with supervisor one’s

learning style and preferences (Kleinberg

1999)

Planning ways to train new

counselors

In planning a training approach, a supervisor

needs to consider the characteristics of the

supervisory team, that is, the supervisor plus

the trainees. Variables to be considered include

• The sophistication of trainees’ knowledge

and skills

• The supervisory setting

• The characteristics of the client population

• The nature of the supervised treatment

• The personality fit of the members on the

supervisory team

• The format of the supervision

•The theoretical compatibility of the supervisory team (Kleinberg 1999)

Training and Supervision 135
After weighing all these variables, the supervisor discusses the focus and goals of the work

with the team. The particulars will take shape

as the supervisory contract. The necessary

mastery of specified clinical subjects, as well as

the skills associated with them, can be developed through reading assignments, video presentations, written assessments, and both

direct and indirect supervision.

Funding for Training and 

Supervision Programs 

Given the time and financial resources needed

to create formal academic preparation programs, it is a challenge to provide extended

training (beyond 1­ and 2­day seminars) that is

well grounded in theory and application and

that addresses the needs of substance abuse

counselors, especially those leading therapy

groups. The best way to fund such training is

to incorporate it into an agency or organization

budget. These outlays should be viewed as

investments that pay handsome dividends. For

instance, opportunities for training can help

attract new, highly motivated employees.

It is a challenge to

provide extended

training that is

well grounded in

theory and

application.	 

One alternative source of funding is a Federal

or State grant. Such funds are often available,

though frequently they require a great deal of

administrative work

and strict adherence

to specific guidelines

for project direction,

staffing, and evaluation. Grants are also

available to agencies

and individuals

through certain professional and training organizations.

For example, AGPA

gives scholarships to

students who wish to

attend its annual

meetings and training conferences.

Other options can be found through the

Foundation Center, a nonprofit library system

that

• Collects and disseminates information on

sources of funding

• Conducts and promotes research on trends in

philanthropy

• Provides education on grant seeking

•Publishes The Foundation Directory, available on CD­ROM through The Foundation

Center

The five foundation libraries (located in

Atlanta, Cleveland, New York, San Francisco,

and Washington) provide many resources with

information on grants for projects related to

health and education. The center has recently

designed a virtual classroom to assist in

• Researching philanthropy

• Writing proposals

• Identifying nearby corporations, government

agencies, and other sources of funds in specific geographical areas

• Training in fundraising

• Online fundraising

The Foundation Center can be reached at

http://www.fdncenter.org. The Frequently

Asked Questions section on this Web site is a

useful introduction to the center’s services.

As with training, an inherent cost is associated

with high­quality clinical supervision, both in

financial commitment and clinical time. Despite

the positive returns that stem from good, better, or best clinical supervision, staff resources,

agency or organizational requirements, and the

needs of the leader in training often dictate the

specific type of supervision available.

Every agency providing services to clients

abusing substances should take clinical supervision seriously and direct appropriate

resources toward constant improvement

through the clinical supervision process.

136 Training and Supervision
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Appendix B: Adult Patient

Placement Criteria

Adult Patient Placement Criteria For the Treatment

of Psychoactive Substance Use Disorders

Levels of Care 

Criteria 

g

i

Dimensions Level I

Outpatient

Treatment

Level II

Intensive Outpatient

Treatment

Level III

Medically

Monitored Intensive

Inpatient Treatment

1 

Acute 

Intoxication 

and/or 

Withdrawal 

Potential 

Level IV Medically Managed

Intensive Inpatient

Treatment

No withdrawal risk. Minimal withdrawal

risk.

2 Severe withdrawal Severe None or very None or nondistractBiomedical risk but manageable withdrawal risk. stable. ing from addiction

Conditions and in Level III. treatment and manComplications ageable in Level II.

3 Requires medical Requires 24­hour Mild severity with Moderate severity Emotional and monitoring but not medical, nursing potential to distract needing a 24­hour

Behavioral intensive treatment. care. from recovery. structured setting. Conditions and 

Complications None or very stable.

4 Severe problems Willing to cooperate Resistance high Resistance high

Treatment requiring 24­hour but needs motivat­ enough to require despite negative

Acceptance psychiatric care ing and monitoring structured program, consequences and

and Resistance with concomitant

addiction treatment.

strategies. but not so high as to

render outpatient

treatment ineffective.

needs intensive

motivating strategies

in 24­hour structure.

(continued on next page)

149
Adult Patient Placement Criteria For the

Treatment of Psychoactive Substance Use

Disorders (continued)

Source: American Society of Addiction Medicine 2001.

Levels of Care Level I Level II Level III Level IV

Criteria 

Outpatient Intensive Outpatient Medically Medically Managed g Treatment Treatment Monitored Intensive Intensive Inpatient

Dimensions i Inpatient Treatment Treatment

5 Able to maintain Intensification of Unable to control Problems in this

Relapse abstinence and addiction symp­ use despite active dimension do not

Potential recovery goals toms and high participation in qualify patient

with minimal likelihood of less intensive care for Level IV treatsupport. relapse without and needs 24­hour ment.

close monitoring structure.

and support.

6 Supportive recov­ Environment Environment dan­ Problems in this

Recovery ery environment unsupportive but gerous for recovery dimension do not

Environment and/or patient has

skills to cope.

with structure or

support, the

patient can cope.

necessitating

removal from the

environment;

logistical impediments to outpatient

treatment.

qualify patient

for Level IV treatment.

150 Adult Patient Placement Criteria
Appendix C: Sample

Group Agreement

Appleton Outpatient Psychotherapy Group Ground Rules

The following is excerpted from Vannicelli 1992, pp. 295–296.

The behavior and feelings of members of the therapy group mirror in

important ways behavior and feelings in other important relationships.

Consequently, the group provides a setting in which to examine patterns

of behavior in relationships. The group also provides a context in which

members learn to identify, understand, and express their feelings. The

therapist’s role is to facilitate this group process.

To foster these goals, we believe that several group ground rules are

important. These are as follows:

1.	 Members joining long­term groups remain as long as they find the

group useful in working on important issues in their lives. We

recommend at least a year. Members are required to make an initial

3­month commitment in order to determine the usefulness of this

particular group for them.

2.	 Regular and timely attendance at all sessions is expected. As a

member, it is your responsibility to notify the group in advance when

you know that you will be away or late for group. In the event of an

unexpected absence, you should notify the group at least 24 hours in

advance to avoid being charged for the missed session.

3.	 Members of Appleton substance abuse groups are committed to

maintaining abstinence. If a relapse does occur, it must be discussed

promptly in the group—as must thoughts or concerns about resuming

drug/alcohol use. Members of ACOA (Adult Children of Alcoholics)

and family groups are asked to be reflective about their own substance use and to bring up changes in patterns of use or concerns that

may be associated with use.

151
4.	 Members will notify the group if they are

considering leaving the group. Because leaving the group is a process, just as joining is,

members are expected to see this process

through for at least 3 weeks following notification of termination.

5.	 Members will have a commitment to talk

about important issues in their lives that

cause difficulty in relating to others or in

living life fully.

6.	 Members will also have a commitment to

talk about what is going on in the group

itself as a way of better understanding their

own interpersonal dynamics.

7.	 Members will treat matters that occur in the

group with utmost confidentiality. To that

end, members are expected not to discuss

what happens in the group with people who

are not members of the group.

8.	 Outside­of­group contact often has considerable impact on the group’s therapeutic

effectiveness. Therefore, any relevant interactions between members which occur outside the group should be brought back into

the next meeting and shared with the entire

group.

9.	 What you share in the group will be shared

with other members of the treatment team

when we feel that it is important to your

treatment to do so.

10. Payments for group are due at the last

meeting of the month unless other arrangements are discussed and explicitly worked

out in the group. If for any reason timely

payment becomes problematic, members

are expected to discuss this in the group.

152 Sample Group Agreement
Appendix D: Glossary 

AA

Alcoholics Anonymous, the best known of the 12­Step self­help

organizations.

ASAM

The American Society of Addiction Medicine is a national specialty

society of the American Medical Association and is dedicated to educating physicians and improving the treatment of individuals with

alcoholism and other addictions. ASAM publishes the Patient

Placement Criteria for the Treatment of Substance­Related

Disorders: ASAM PPC­2R (2001), a widely used system of criteria

for placing clients in appropriate treatment settings.

Basic teaching skills

Organizing the content to be taught, planning for participant

involvement in the learning process, and delivering information in

a culturally relevant and meaningful way.

Cognitive–behavioral groups

Groups formed to change learned patterns of thinking and behavior

that lead to substance abuse or other psychological and interpersonal disorders.

Cognitive therapy

Attempts to modify maladaptive behavior by influencing a client’s

beliefs, schemas, self­statements, and problemsolving strategies.

Assumes that emotional problems are largely caused by irrational or

maladaptive thinking and that restructuring these cognitions will be

therapeutic.

Cohesion

A positive quality of groups denoting a sense of enthusiastic solidarity within the group; Yalom (1995, p. 48) notes that cohesive groups

“have a higher rate of attendance, participation, and mutual support,” and that members “will defend the group standards much

more than groups with less esprit de corps.”

153
Communal and culturally

specific groups

Groups formed to use the sense of belonging to a culture to reduce or eliminate drug

abuse and other negative behaviors.

Conflict

A basic dynamic in groups in which members have opposing views, beliefs, or emotions; conflict can be constructive by (1)

assisting members to consider and respect

other opinions, (2) generating energy and

investment in the group, and (3) creating a

variety of options for change; conflict is

detrimental when (1) it distracts members’

attention or allows them to avoid issues in

the group, (2) any group member feels his

or her beliefs or world views are not understood or viewed as valid, or (3) the conflict

leads to destructive behaviors, such as

denigration or other verbal abuse.

Confrontation

A form of intervention that literally means

“coming face to face” or “pointing out

inconsistencies” that keep clients from

facing unpleasant realities (CSAT 1999b,

p. 10).

Content

Information and feelings expressed in

group; its complement is process.

Culture

Integrated patterns of human behavior that

include the language, thoughts, communications, actions, customs, beliefs, values,

and institutions of a racial, ethnic, religious, or social group (Giachello 1995;

Office of Minority Health 2001).

Eco­map, or sociogram

A graphic that clients construct to represent their important social relationships.

Expressive groups

Groups formed to use some kind of creative

activity (such as painting, dance, play therapy, or psychodrama) to help clients

explore their substance abuse, its origins

and effects, and new coping options;

expressive groups may be especially

effective for clients who have difficulty

verbalizing thoughts and feelings.

Diversity

As used in this TIP, diversity refers to any

difference that distinguishes one individual

from another and that affects how clients

identify themselves and are identified by

others.

Emotional contagion

Rapid and intense escalation of excitement

in a group, which if uncontrolled, can

threaten boundaries and an individual’s

sense of well­being, potentially leading to

premature termination of treatment.

Fixed membership groups

Relatively small group with a set number of

members who stay together over a long

period of time; people in time­limited fixed

membership groups start and stay together,

while ongoing fixed membership groups

bring in new members if a vacancy occurs.

Gestalt therapy

Developed by Friedrich S. and Laura

Perls, gestalt therapy aims to enhance

clients’ awareness, which frees them to

grow in their own consciously guided ways.

It seeks to reestablish stalled growth processes by helping clients become aware of

feelings they have disowned but that are a

genuine part of them, and recognize feelings

and values that they think are a genuine

part of them but are borrowed from other

people.

Group agreement

A contract between provider and client

stipulating the responsibilities of clients and

their expectations of other group members,

the leader, and the group; group agreements

typically specify grounds for exclusion from

group, expectations of confidentiality,

restrictions on physical contact, consequences for returns to substance use,

boundaries on contact outside the group,

expectations for participation in group,

financial responsibilities, and procedures

for termination (leaving the group).

154 Glossary
Group dynamics

Forces at work among small groups of

interacting people; collectively, group

dynamics are a complex amalgam of individual personalities and actions combined

with the overarching properties of the

group as a whole; put another way, group

dynamics are the collective impact of individual members on the group and the

impact the group has on each individual.

Group process

How events take place in group, in contrast

to content, which is what takes place; if, for

example, a question is raised, a process­oriented group leader might silently note circumstances such as voice quality, facial

expression, what came before and after the

question, and how the question was directed (to the leader? the group? to an individual? away from someone?); overall, process

concerns include (1) the impact and quality

of interaction among group members, (2)

the impact of group on individuals, and (3)

the life phases of the group.

Heterogeneous groups

Groups made up of a mixture of clients

whose only similarity is the need they share

for a particular kind of group.

Homogeneous groups

Groups made up of clients who are alike in

some respect other than a common substance use problem; homogeneous groups

may include, for example, only women,

only adolescents or elderly people, or only

people from a certain cultural heritage.

IPGP

Interpersonal process group psychotherapy, shortened in this TIP to interpersonal

process groups.

Interpersonal process groups

Formed to use group interactions to promote change and healing; such groups are

used after abstinence is well established;

they delve into major developmental issues

that contribute to addiction and interfere

with recovery; the primary interest is how

clients recreate past experiences in the

here­and­now microcosm of the group;

interpersonal process groups attend more

to process (how people act and talk) and

less to content (what people do and say).

Interpersonal relationship dynamics

How people relate to one another in group

settings and how one individual can influence the behavior of others in group, such

as by giving and receiving feedback from

each other.

Interventions

Words or actions with a therapeutic purpose; interventions may clarify what is

happening in group, redirect energy, stop

unhelpful processes, or present the group

with a choice.

Intrapsychic

Relating to events occurring within the psyche, mind, or personality; that is, internally

without reference to any external factors.

Leadership skills

Include helping the group get started in a

session, managing (though not necessarily

eliminating) conflict between group members, helping withdrawn members of the

group become more active, and making

sure that all group members have a roughly

equal chance to participate.

Problem­focused groups

Groups formed to address a particular

problem that contributes to substance

abuse or limits recovery options; problemfocused groups also look at the process of

problemsolving so members can generalize

their experience in group to other life areas.

Process

How members interact in the group; its

complement is content.

Process­oriented therapy

An approach to group therapy that emphasizes group interaction as the healing agent;

the role of the leader is the promotion of

interaction among group members.

Glossary 155
Projective identification

Involves projecting one’s disowned

attributes onto another person (Yalom

1995).

Psychodynamic emphases

The dynamic interplay of psychological

forces conceptualized using psychodynamic

theories. Within an individual these forces

influence behavior, interaction with others,

and emotions.

Psychodynamic therapy,

psychodynamic approach

An approach to psychological growth and

change that emphasizes the evolution and

adaptation of the psychological structure

within an individual. Psychodynamic therapy often focuses on changing behavior in

the present by re­examining and revising a

person’s understandings and reactions to

events in the past.

Psychotherapy (or therapy) groups

Groups formed to reduce or eliminate substance abuse or other problematic behaviors by changing long­standing relational

and intrapsychic difficulties. Psychotherapy groups differ from other groups

traditionally used for substance abuse

treatment, such as problem­solving or support groups, in that the group (1) has a relatively long­term contract; (2) focuses more

on psychodynamic issues (rather than education, support, or problem solving); (3)

begins in later stages of treatment and

recovery; (4) tolerates the expression of

more emotion; and (5) stresses process over

content.

Psychoeducational groups

Groups formed to educate clients about

substance abuse, related behaviors, and

the behavioral, medical, and psychological

consequences of use, abuse, and dependency; psychoeducational groups provide

information important for achieving abstinence and maintaining recovery.

Reality therapy

Developed by William Glasser, the basic

principle of reality therapy is that we are

responsible for what we choose to do.

Reality therapy focuses on solving problems and on coping with the demands of

reality in society by making more effective

choices.

Redecision therapy

Is aimed at helping people challenge themselves to discover ways in which they perceive themselves in victimlike roles and to

take charge of their lives by deciding for

themselves how they will change.

Relapse prevention groups

Groups formed to help clients maintain

abstinence or minimize the impact and

duration of relapse.

Resistance to therapy

An often subconscious defense against the

pain of examining one’s own behavior, perceptions, beliefs, and feelings; resistance

can appear in many disguises: continual

claims to be too upset to work on issues in

group, missing group or coming late, or

aversion to strong emotions, such as anger.

Resistance is a natural part of any change

process, but if it is not dealt with, it

impedes growth and blocks the progress of

individuals and groups.

Revolving membership groups

Somewhat larger than fixed membership

groups, revolving membership groups

acquire new members when they become

ready for its services; time­limited revolving membership groups keep a member for

a specified period of time, while ongoing

revolving membership groups may have

clients who (1) stay as long as they wish, (2)

enter a group with a repeating cycle of topics and stay until they have completed all

the topics, or (3) attend for a set time

(either consecutively or nonconsecutively).

156 Glossary
Skills development groups

Groups formed to bring about or improve

the skills needed to achieve and maintain

abstinence; such skills may relate directly

to substance abuse (such as ways to refuse

drugs or cope with urges to use them), or

they may be designed to reduce or eliminate general life problems that imperil

recovery (such as inadequate anger management or an inability to relax).

Splitting

A divide­and­conquer tactic used to come

between cotherapists (Yalom 1995).

Stages of change

Prochaska and DiClemente’s (1984) continuum that describes the stages a client

moves through to achieve lasting recovery:

precontemplation, contemplation, preparation, action, maintenance, and recurrence

(for definitions, see chapter 2); the stage a

client is in helps to determine what group

treatment models and methods are appropriate for that person.

Stages (or phases) of group

development

In the beginning phase, the group is prepared to begin its work. Tasks in this period

involve introductions, a review of the group

agreement, and the establishment of a safe

environment and healthy norms. The middle phase, or actual work of the group, is

the time for here­and­now interactions that

help clients rethink behaviors and undertake changes. The end phase is a mixture of

recognition and celebration of work done

and goals achieved, mourning for the loss of

the attachments formed in group, and

reorientation toward the future.

Stages of recovery

In early recovery, clients establish abstinence. During this period, they are fragile

and highly prone to relapse. In middle

recovery, abstinence becomes stable

enough so that the client can begin to work

on life problems. In late recovery, clients

continue working to maintain abstinence

and make life changes, but may also confront and modify deeply ingrained relational problems and other psychological issues.

A client’s stage of recovery is one determinant of placement.

Stages of treatment

In early treatment, clients are ambivalent

about relinquishing substance abuse, so

heavy emphasis is placed on drawing clients

into a culture of recovery and helping them

get through each day without substances.

Strong challenges to the mental and emotional state are set aside until later in treatment. In the middle stage, clients’ mental

and emotional condition improves, but they

have an acute need for satisfying new directions that can fulfill the role that substance

abuse once played in their lives. In late

treatment, clients sustain earlier gains, but

learn to anticipate temptations and triggers

for relapse. Also, the client may need to

address issues like poor self­image, relationship problems, shame, or trauma.

Support groups

Groups formed to (1) develop and strengthen clients’ abilities to manage their own

thinking and emotions (2) improve interpersonal skills, (3) manage day­to­day life

more effectively, and (4) boost self­esteem

and self­confidence.

Transactional analysis

Is both a theory of personality and an

organized system of interactional therapy.

Its basic assumption is that people make

current decisions based on past premises

that were at one time appropriate to

survival but may no longer be valid.

Transactional analysis emphasizes the

cognitive, rational, and behavioral aspects

of the therapeutic process.

Transference and countertransference

Transference is a perceptual distortion in

which the characteristics of one person are

attributed to another; in other words,

parts of past relationships are projected

onto relationships in the present; if, for

example, group member A reminds member B of a dour, narrow­minded father,

Glossary 157
member B may transfer the attributes of

his father to member A and react to him in

group with extraordinary and irrational

hostility. In a narrow sense, countertransference occurs when clients’ transference

evokes (often unconscious) emotional

responses in therapists. In recent years, the

concept has widened to include any emotional reaction in a therapist brought on by

a client.

12­Step programs

Self­help programs that are based on mastering a set of steps to achieve and maintain

abstinence; they are often loosely organized

around a drug of abuse: Alcoholics

Anonymous (alcohol), Narcotics

Anonymous (opioids and illicit drugs),

Cocaine Anonymous.

158 Glossary
Appendix E: Association

for Specialists in Group

Work Best Practice

Guidelines

Approved by the ASGW Executive Board, March 29, 1998

Prepared by: Lynn Rapin and Linda Keel, ASGW Ethics

Committee Co­Chairs

The Association for Specialists in Group Work (ASGW) is a division

of the American Counseling Association whose members are interested in

and specialize in group work. We value the creation of community;

service to our members, clients, and the profession; and leadership as a

process to facilitate the growth and development of individuals and

groups.

The Association for Specialists in Group Work recognizes the commitment of its members to the Code of Ethics and Standards of Practice (as

revised in 1995) of its parent organization, the American Counseling

Association (ACA), and nothing in this document shall be construed to

supplant that code. These Best Practice Guidelines are intended to clarify the application of the ACA Code of Ethics and Standards of Practice

to the field of group work by defining Group Workers’ responsibility

and scope of practice involving those activities, strategies, and interventions that are consistent and current with effective and appropriate

professional ethical and community standards. ASGW views ethical

process as being integral to group work and views Group Workers as

ethical agents. Group Workers, by their very nature in being responsible

and responsive to their group members, necessarily embrace a certain

potential for ethical vulnerability. It is incumbent upon Group Workers

to give considerable attention to the intent and context of their actions

because the attempts of Group Workers to influence human behavior

through group work always have ethical implications. These Best

Practice Guidelines address Group Workers’ responsibilities in planning,

performing, and processing groups.

159
Section A: Best Practice in

Planning 

A.1. Professional Context and

Regulatory Requirements 

Group Workers actively know, understand,

and apply the ACA Code of Ethics and

Standards of Best Practice, the ASGW

Professional Standards for the Training of

Group Workers, these ASGW Best Practice

Guidelines, the ASGW diversity competencies,

the ACA Multicultural Guidelines, relevant

State laws, accreditation requirements, relevant National Board for Certified Counselors

Codes and Standards, their organizations’

standards, and insurance requirements impacting the practice of group work.

A.2. Scope of Practice and

Conceptual Framework 

Group Workers define the scope of practice

related to the core and specialization competencies defined in the ASGW Training

Standards. Group Workers are aware of personal strengths and weaknesses in leading

groups. Group Workers develop and are able

to articulate a general conceptual framework to

guide practice and a rationale for use of techniques that are to be used. Group Workers

limit their practice to those areas for which

they meet the training criteria established by

the ASGW Training Standards.

A.3. Assessment 

a. Assessment of self. Group Workers actively

assess their knowledge and skills related to

the specific group(s) offered. Group Workers

assess their values, beliefs, and theoretical

orientation and how these impact upon the

group, particularly when working with a

diverse and multicultural population.

b. Ecological assessment. Group Workers

assess community needs, agency or organization resources, sponsoring organization mission, staff competency, attitudes regarding

group work, professional training levels of

potential group leaders regarding group

work, client attitudes regarding group work,

and multicultural and diversity considerations. Group Workers use this information as

the basis for making decisions related to their

group practice, or to the implementation of

groups for which they have supervisory, evaluation, or oversight responsibilities.

A.4. Program Development and

Evaluation 

a. Group Workers identify the type(s) of

group(s) to be offered and how they relate to

community needs.

b. Group Workers concisely state in writing the

purpose and goals of the group. Group

Workers also identify the role of the group

members in influencing or determining the

group goals.

c. Group Workers set fees consistent with the

organization’s fee schedule, taking into consideration the financial status and locality of

prospective group members.

d. Group Workers choose techniques and a

leadership style appropriate to the type(s) of

group(s) being offered.

e. Group Workers have an evaluation plan consistent with regulatory, organization and

insurance requirements, where appropriate.

f. Group Workers take into consideration current professional guidelines when using technology, including but not limited to Internet

communication.

A.5. Resources 

Group Workers coordinate resources related to

the kind of group(s) and group activities to be

provided, such as: adequate funding; the

appropriateness and availability of a trained coleader; space and privacy requirements for the

type(s) of group(s) being offered; marketing and

recruiting; and appropriate collaboration with

other community agencies and organizations.

160 Association for Specialists in Group Work Best Practice Guidelines
A.6. Professional Disclosure

Statement 

Group Workers have a professional disclosure

statement which includes information on confidentiality and exceptions to confidentiality, theoretical orientation, information on the nature,

purpose(s) and goals of the group, the group

services that can be provided, the role and

responsibility of group members and leaders,

qualifications to conduct the specific group(s),

specific licenses, certifications and professional

affiliations, and address of licensing/credentialing body.

A.7. Group and Member

Preparation 

a. Group Workers screen prospective group

members if appropriate to the type of group

being offered. When selection of group members is appropriate, Group Workers identify

group members whose needs and goals are

compatible with the goals of the group.

b. Group Workers facilitate informed consent.

Group Workers provide in oral and written

form to prospective members (when appropriate to group type): the professional disclosure statement; group purpose and goals;

group participation expectations including

voluntary and involuntary membership; role

expectations of members and leader(s); policies related to entering and exiting the

group; policies governing substance use;

policies and procedures governing mandated

groups (where relevant); documentation

requirements; disclosure of information to

others; implications of out­of­group contact

or involvement among members; procedures

for consultation between group leader(s) and

group member(s); fees and time parameters;

and potential impacts of group participation.

c. Group Workers obtain the appropriate consent forms for work with minors and other

dependent group members.

d. Group Workers define confidentiality and

its limits (for example, legal and ethical

exceptions and expectations, waivers implicit

with treatment plans, documentation and

insurance usage). Group Workers have the

responsibility to inform all group participants of the need for confidentiality, potential consequences of breaching confidentiality

and that legal privilege does not apply to

group discussions (unless provided by

State statute).

A.8. Professional Development 

Group Workers recognize that professional

growth is a continuous, ongoing, developmental

process throughout their career.

a. Group Workers remain current and increase

knowledge and skill competencies through

activities such as continuing education, professional supervision, and participation in

personal and professional development

activities.

b. Group Workers seek consultation and/or

supervision regarding ethical concerns that

interfere with effective functioning as a

group leader. Supervisors have the responsibility to keep abreast of consultation, group

theory, process, and adhere to related ethical guidelines.

c. Group Workers seek appropriate professional assistance for their own personal problems

or conflicts that are likely to impair their

professional judgment or work performance.

d. Group Workers seek consultation and

supervision to ensure appropriate practice

whenever working with a group for which all

knowledge and skill competencies have not

been achieved.

e. Group Workers keep abreast of group

research and development.

A.9. Trends and Technological

Changes 

Group Workers are aware of and responsive to

technological changes as they affect society and

the profession. These include but are not limited to changes in mental health delivery systems; legislative and insurance industry

reforms; shifting population demographics and

Association for Specialists in Group Work Best Practice Guidelines 161
client needs; and technological advances in

Internet and other communication and delivery

systems. Group Workers adhere to ethical

guidelines related to the use of developing

technologies.

Section B: Best Practice in

Performing 

B.1. Self Knowledge 

Group Workers are aware of and monitor their

strengths and weaknesses and the effects these

have on group members.

B.2. Group Competencies 

Group Workers have a basic knowledge of

groups and the principles of group dynamics,

and are able to perform the core group competencies, as described in the ASGW Professional

Standards for the Training of Group Workers.

Additionally, Group Workers have adequate

understanding and skill in any group specialty

area chosen for practice (psychotherapy, counseling, task, psychoeducation, as described in

the ASGW Training Standards).

B.3. Group Plan Adaptation 

a. Group Workers apply and modify knowledge, skills, and techniques appropriate to

group type and stage, and to the unique

needs of various cultural and ethnic groups.

b. Group Workers monitor the group’s

progress toward the group goals and plan.

c. Group Workers clearly define and maintain

ethical, professional, and social relationship

boundaries with group members as appropriate to their role in the organization and

the type of group being offered.

B.4. Therapeutic Conditions and

Dynamics 

Group Workers understand and are able to

implement appropriate models of group development, process observation, and therapeutic

conditions.

B.5. Meaning 

Group Workers assist members in generating

meaning from the group experience.

B.6. Collaboration 

Group Workers assist members in developing

individual goals and respect group members as

co­equal partners in the group experience.

B.7. Evaluation 

Group Workers include evaluation (both formal and informal) between sessions and at the

conclusion of the group.

B.8. Diversity 

Group Workers practice with broad sensitivity

to client differences including but not limited to

ethnic, gender, religious, sexual, psychological

maturity, economic class, family history, physical characteristics or limitations, and geographic location. Group Workers continuously seek

information regarding the cultural issues of the

diverse population with whom they are working

both by interaction with participants and from

using outside resources.

B.9. Ethical Surveillance 

Group Workers employ an appropriate ethical

decisionmaking model in responding to ethical

challenges and issues and in determining courses of action and behavior for self and group

members. In addition, Group Workers employ

applicable standards as promulgated by ACA,

ASGW, or other appropriate professional organizations.

Section C: Best Practice in

Group Processing 

C.1. Processing Schedule 

Group Workers process the workings of the

group with themselves, group members, supervisors, or other colleagues, as appropriate.

This may include assessing progress on group

and member goals, leader behaviors and techniques, group dynamics and interventions,

162 Association for Specialists in Group Work Best Practice Guidelines
developing understanding, and acceptance of

meaning. Processing may occur both within

sessions and before and after each session, at

time of termination, and later follow up, as

appropriate.

C.2. Reflective Practice 

Group Workers attend to opportunities to synthesize theory and practice and to incorporate

learning outcomes into ongoing groups. Group

Workers attend to session dynamics of members and their interactions and also attend to

the relationship between session dynamics and

leader values, cognition, and affect.

C.3. Evaluation and Follow­Up 

a. Group Workers evaluate process and outcomes. Results are used for ongoing program

planning, improvement and revisions of

current group, and/or to contribute to

professional research literature. Group

Workers follow all applicable policies and

standards in using group material for

research and reports.

b. Group Workers conduct follow­up contact

with group members, as appropriate, to

assess outcomes or when requested by a

group member(s).

C.4. Consultation and Training

With Other Organizations 

Group Workers provide consultation and

training to organizations in and out of their

setting, when appropriate. Group Workers

seek out consultation as needed with competent

professional persons knowledgeable about

group work.

Source: ASGW 1998. Reprinted with

permission.

Association for Specialists in Group Work Best Practice Guidelines 163

Appendix F: 

Resource Panel

Note: The information given indicates each participant's affiliation during the time the panel was

convened and may no longer reflect the individual's current affiliation.

Candace Baker

Clinical Affairs Manager

Lesbian, Gay, Bisexual, and Transgender

Special Interest Group

National Association of Alcohol and Drug

Abuse Counselors

Alexandria, Virginia

Nancy Bateman, LCSW­C, CAC

Senior Staff Associate

Division of Professional Development and

Advocacy

National Association of Social Workers

Washington, DC

Carole Chrvala, Ph.D.

Senior Program Officer

Board on Neuroscience and Behavioral

Health

Institute of Medicine

Washington, DC

Peggy Clark, M.S.W., M.P.A.

Center for Medicaid and State Operations

Centers for Medicare and Medicaid

Services

Baltimore, Maryland

Sandra M. Clunies, M.S., ICADC

Derwood, Maryland

Cathi Coridan, M.A.

Senior Director for Substance Abuse

Programs and Policy

National Mental Health Association

Alexandria, Virginia

Edwin M. Craft, Dr.P.H.

KAP Alternate Project Officer

Office of Evaluation, Scientific Analysis

and Synthesis

Center for Substance Abuse Treatment

Rockville, Maryland

Christina Currier

Public Health Analyst

Office of Evaluation, Scientific Analysis

and Synthesis

Center for Substance Abuse Treatment

Rockville, Maryland

Dorynne Czechowicz, M.D.

Medical Officer

Treatment Development Branch

Division of Treatment Research and

Development 

National Institute on Drug Abuse 

Bethesda, Maryland 

Jennifer Fiedelholtz

Public Health Analyst

Office of Policy and Program Coordination

Substance Abuse and Mental Health

Services Administration 

Rockville, Maryland 

Hendree E. Jones, Ph.D.

Assistant Professor

Department of Psychiatry and Behavioral

Sciences 

Johns Hopkins University Center 

Baltimore, Maryland 

165
Edith Jungblut

Project Officer

Center for Substance Abuse Treatment

Rockville, Maryland

Tom Leibfried, M.P.A.

Vice President of Government Relations

National Council for Community

Behavioral Healthcare 

Rockville, Maryland 

Emeline Otey, Ph.D.

Program Official

Adult Psychotherapy and Prevention

Resource Branch

National Institute of Mental Health

Bethesda, Maryland

Anne Pritchett, M.P.A.

Policy Analyst

Executive Office of the President

Office of National Drug Control Policy

Washington, DC

Elizabeth Rahdert, Ph.D.

Program Administrator

National Institute on Drug Abuse

Bethesda, Maryland

Stanley Smith, M.A., TEP

Clinical Director

Mid­Atlantic Chapter

American Society of Group Psychotherapy

and Psychodrama

c/o Adolescence and Family Growth

Center, Inc.

Springfield, Virginia

Richard T. Suchinsky, M.D.

Associate Chief for Addictive Disorders

and Psychiatric Rehabilitation

Mental Health and Behavioral Sciences

Services 

Department of Veterans Affairs 

Washington, DC 

Jan Towers, Ph.D., CRNP

Director

Health Policy

American Academy of Nurse Practitioners

Washington, DC

166 Resource Panel
Appendix G: Cultural

Competency and Diversity

Network Participants

Note: The information given indicates each participant's affiliation during the time the network 

was convened and may no longer reflect the individual's current affiliation.

Elmore T. Briggs, CCDC, NCAC II

Program Manager

Adolescent Recovery Center

Vanguard Services, Unlimited

Arlington, Virginia

African American Work Group

Maxine F. Carpenter, M.S.

President/Chief Executive Officer

McKinley Group, Inc.

Atlanta, Georgia

African American Work Group

Magdalen Chang

Center Manager

Bill Pone Memorial Unit

Haight Ashbury Free Clinic

San Francisco, California

Asian and Pacific Islanders Work Group

Marty Estrada

Career Services Specialist

General Relief Team

Ventura Intake and Eligibility Center

Ventura, California

Hispanic/Latino Workgroup

Adelaida Hernandez, M.S., LCDC

M.U.H.E.R.E.S. Program Director

S.C.A.N., Inc.

Laredo, Texas

Hispanic/Latino Workgroup

Ford H. Kuramoto, D.S.W.

National Director

National Asian Pacific American Families

Against Substance Abuse

Los Angeles, California

Asian and Pacific Islanders Work Group

Frank Lemus, Jr., M.A.

Clinical Director

SageWind (Oikos, Inc.)

Reno, Nevada

Hispanic/Latino Workgroup

Ting­Fun May Lai, M.S.W., CSW, CASAC

Director

Chinatown Alcoholism Center

Hamilton­Madison House

New York, New York

Asian and Pacific Islanders Work Group

Tam K. Nguyen, M.D., LMSW, CCJS, DVC,

MAC

President

Employee & Family Resources

Polk City, Iowa

Asian and Pacific Islanders Work Group

Rick Rodriguez

Manager/Counselor

Services United

Santa Paula, California

Hispanic/Latino Work Group

167
Candace Shelton, M.S., CADAC

Clinical Director

Native American Connections, Inc.

Tucson, Arizona

Lesbian, Gay, Bisexual, and Transgender

Workgroup

Mariela C. Shirley, Ph.D.

Assistant Professor

Department of Psychology

University of North Carolina at

Wilmington 

Wilmington, North Carolina 

Hispanic/Latino Workgroup 

Antony P. Stephen, Ph.D.

Executive Director

Mental Health & Behavioral Sciences

New Jersey Asian American Association

for Human Services, Inc.

Elizabeth, New Jersey

Asian and Pacific Islanders Workgroup

Ednita Wright, Ph.D., M.S.W., CSW

Independent Consultant/Counselor

Therapist

Garnett Health Center, Counseling

Psychological Service

Ithaca, New York

Lesbian, Gay, Bisexual, and Transgender

Workgroup

168 Cultural Competency and Diversity Network Participants
Appendix H: Field Reviewers 

Note: The information given indicates each participant's affiliation during the time the review was

conducted and may no longer reflect the individual's current affiliation.

Rosie Anderson­Harper

Mental Health Manager/Treatment

Coordinator

Division of Alcohol and Drug Abuse

Missouri Department of Mental Health

Jefferson City, Missouri

Nancy Bateman, LCSW­C, CAC

Senior Staff Associate

Division of Professional Development and

Advocacy

National Association of Social Workers

Washington, DC

Michele W. Beck, M.S.W., LSBCAC, ICRC

Acting Director of Treatment

Office for Addictive Disorders

State of Louisiana

Baton Rouge, Louisiana

Marion A. Becker, R.N., Ph.D.

Associate Professor

Department of Community Health

Louis de la Parte Florida Mental Health

Institute

Tampa, Florida

Janice S. Bennett, M.S., CSAC

Program Coordinator

Hawaii Drug Court Program

Honolulu, Hawaii

Elmore T. Briggs, CCDC, NCAC II

Program Manager

Adolescent Recovery Center

Vanguard Services Unlimited

Arlington, Virginia

David W. Brook, M.D., CGP

Department of Community and Preventive

Medicine 

Mount Sinai Medical Center 

New York, New York 

Nina W. Brown, Ed.D.

President

Mid­Atlantic Group Psychotherapy Society

Virginia Beach, Virginia

Barry S. Brown, Ph.D.

Professor (Adjunct)

University of North Carolina at

Wilmington 

Carolina Beach, North Carolina 

Maxine F. Carpenter, M.S.

President/Chief Executive Officer

McKinley Group, Inc.

Atlanta, Georgia

Bruce Carruth, Ph.D., LCSW

Private Practice

Boulder, Colorado

Annabelle Casas, B.A.

Family Drug Court Coordinator

65th District Court Family Drug Court

Program 

El Paso, Texas 

Magdalen Chang

Center Manager

Bill Pone Memorial Unit

Haight Ashbury Free Clinic

San Francisco, California

169
Sharon D. Chappelle, Ph.D., M.S.W., LCSW

President/Chief Executive Officer

Chappelle Consulting and Training

Services, Inc. 

Middletown, Connecticut 

David E. Cooper, Ph.D.

Psychologist/Psychoanalyst

Former Director of the Lodge Day

Program 

Chestnut Lodge Hospital 

Private Practice 

Chevy Chase, Maryland 

Cathi Coridan, M.A.

Senior Director for Substance Abuse

Programs and Policy

National Mental Health Association

Alexandria, Virginia

Eric Denner

Clinical Social Worker

San Francisco General Hospital

San Francisco, California

Janice M. Dyehouse, Ph.D., R.N., M.S.N.

Professor and Department Head

College of Nursing

University of Cincinnati

Cincinnati, Ohio

Marty Estrada

Career Services Specialist General Relief

Team

Ventura Intake and Eligibility Center

Ventura, California

Arthur C. Evans, Ph.D.

Deputy Commissioner

Connecticut Department of Mental Health

and Addiction Services 

Hartford, Connecticut 

Kathleen J. Farkas, Ph.D., LISW, ASCW

Associate Professor

Case Western Reserve University

Cleveland, Ohio

Saul Feldman, Ph.D.

Chairman/Chief Executive Officer

United Behavioral Health

San Francisco, California

Philip J. Flores, Ph.D., COP, FAGPA

Adjunct Clinical Supervisor

Department of Psychology

Georgia State University

Atlanta, Georgia

Marilyn Joan Freimuth, Ph.D.

Bedford, New York

Byron N. Fujita, Ph.D.

Senior Psychologist

Clackamas County Mental Health Center

Oregon City, Oregon

Michael Galer, D.B.A., M.B.A., M.F.A.

Westminster, Massachusetts

Charles Garvin, Ph.D.

Professor of Social Work

School of Social Work

University of Michigan

Ann Arbor, Michigan

Jeffrey M. Georgi, M.Div., CGP, CSAC,

LPC, CCS 

Clinical Director 

Department of Behavioral Science 

Duke School of Nursing and Duke 

University Medical Center 

Senior Clinician 

Duke Addictions Program 

Duke University Medical Center 

Durham, North Carolina 

170 Field Reviewers
Mary M. Gillespie, Psy.D., CASAC

Psychologist

Private Practice

Saratoga Springs, New York

Paolo Giudici, LPCC, LADAC

Clinical Director

AYUDANTES, INC.

Santa Fe, New Mexico

Paula R. James, M.A.

Department of Psychiatry

Community Support Services

Bellevue Hospital Center

New York, New York

Kathryn P. Jett

Director

California Department of Alcohol and

Drug Programs 

Sacramento, California 

Michael W. Kirby, Jr., Ph.D.

Chief Executive Officer

Arapahoe House, Inc.

Thornton, Colorado

Ford H. Kuramoto, D.S.W.

National Director

National Asian Pacific American Families

Against Substance Abuse 

Los Angeles, California 

Ting­Fun May Lai, M.S.W., CSW, CASAC

Director

Chinatown Alcoholism Services

Hamilton­Madison House

New York, New York

Marlana Lalli

Program Manager

Ft. Des Moines OWI Program

Des Moines, Iowa

Barry Levy

Executive Director

Community Resource Council

Long Beach, California

Margaret Mattson, Ph.D.

Staff Collaborator

National Institute on Alcohol Abuse and

Alcoholism 

Bethesda, Maryland 

Robert Meyer

Chief Executive Officer/President

Rainbow Recovery Center, Inc.

Des Moines, Iowa

Stacia Murphy

President

National Council on Alcoholism and Drug

Dependence, Inc. 

New York, New York 

Ethan Nebelkopf, Ph.D., MFCC

Clinic Director

Family and Child Guidance Center

Native American Health Center

Oakland, California

Thomas E. Nightingale

Director

Bureau of Addiction Treatment Centers

New York State Office of Alcoholism and

Substance Abuse Services 

Albany, New York 

Marlene O’Connell, R.N., M.S.N., LCPC,

NCC, CCDC 

Manager 

Behavioral Health Services Benefits 

Healthcare 

Great Falls, Montana 

Gwen M. Olitsky, M.S.

Chief Executive Officer

The Self­Help Institute for Training and

Therapy 

Lansdale, Pennsylvania 

Jerry M. Owens, M.S., LMHC, LMFT

Wadle and Associates

Des Moines, Iowa

Field Reviewers 171
Thomas A. Peltz, M.Ed., LMHC, CAS

Therapist

Private Practice

Beverly Farms, Massachusetts

Nancy A. Piotrowski, Ph.D.

Associate Scientist

Alcohol Research Group

Berkeley, California

Jeffrey David Roth, M.D., FASAM, FAGPA

Independent Consultant

Chicago, Illinois

Marvena A. Simmonds, M.P.A.

Public Health Advisor

Division of State and Community

Assistance

Center for Substance Abuse Treatment

Rockville, Maryland

Darren C. Skinner, Ph.D., LSW, CAC

Director

Gaudenzia, Inc.

Gaudenzia House West Chester

West Chester, Pennsylvania

Antony P. Stephen, Ph.D.

Executive Director

Mental Health and Behavioral Sciences

New Jersey Asian American Association

for Human Services, Inc. 

Elizabeth, New Jersey 

Richard T. Suchinsky, M.D.

Associate Chief for Addictive Disorders

and Psychiatric Rehabilitation

Mental Health and Behavioral Sciences

Services

Department of Veterans Affairs

Washington, DC

Judith S. Tellerman, Ph.D., M.Ed., MAT,

CGP 

Assistant Clinical Professor 

College of Medicine 

University of Illinois 

Chicago, Illinois 

Jocelyn Thevenote, B.A.

Outreach Director

Office for Addictive Disorders

Pineville Alexandria Clinic

Pineville, Louisiana

Ernie Turner

Director

Division of Alcoholism and Drug Abuse

Alaska Department of Health and Social

Services 

Juneau, Alaska 

Judy Tyson, Ph.D., CGP

Mid­Atlantic Group Psychotherapy Society

Bethesda, Maryland

Karen Urbany

Public Health Advisor

Treatment and Systems Improvement

Branch 

Division of Practice and Systems 

Development

Center for Substance Abuse Treatment

Rockville, Maryland

Marsha Lee Vannicelli, Ph.D., FAGPA

Associate Clinical Professor

Department of Psychiatry

Harvard Medical School

Belmont, Massachusetts

Ralph Varela, M.S.W.

Chief Executive Officer

Pinal Hispanic Council

Eloy, Arizona

Albert J. Villapiano, Ed.D.

Director of Substance Abuse Product Line

Inflexxion

Newton, Massachusetts

Iris Wilkinson, Ed.D.

Associate Professor

Human Services Department

School of Applied Studies

Washburn University

Topeka, Kansas

172 Field Reviewers
William H. Williams, Jr., M.A., LCADC

Substance Abuse Program Manager

Clinical Plans and Management

Bureau of Medicine and Surgery

Department of Navy

Washington, DC

Ednita Wright, Ph.D., M.S.W., CSW

Independent Consultant/Counselor

Therapist

Garnett Health Center, Counseling

Psychological Service

Cornell University

Ithaca, New York

Janet Zwick

Deputy Director

Division of Substance Abuse and Health

Promotion

Iowa Department of Public Health

Des Moines, Iowa

Field Reviewers 173

Appendix I:

Acknowledgments

Numerous people contributed to the development of this TIP, including

the TIP Consensus Panel (see page ix), the KAP Expert Panel and

Federal Government Participants (see page xi), the Federal Resource

Panel (see Appendix F), the Cultural Competency and Diversity

Network Participants (see Appendix G), and the TIP Field Reviewers

(see Appendix H).

This publication was produced under KAP, a Joint Venture of The CDM

Group, Inc. (CDM), and JBS International, Inc. (JBS), for the

Substance Abuse and Mental Health Services Administration, Center for

Substance Abuse Treatment.

Christina Currier served as the SAMHSA TIPs Task Leader. Rose M.

Urban, M.S.W., J.D., LCSW, CCAC, CSAC, served as the CDM KAP

Executive Deputy Project Director. Shel Weinberg, Ph.D., served as the

CDM KAP Senior Research/Applied Psychologist. Other CDM KAP personnel included Raquel Witkin, M.S., Deputy Project Manager; Susan

Kimner, Managing Editor; James Girsch, Ph.D., Editor/Writer; Michelle

Myers, Quality Assurance Editor; and Sonja Easley, Editorial Assistant.

In addition, Sandra Clunies, M.S., I.C.A.D.C., served as Content

Advisor. Jonathan Max Gilbert, M.A., Susan Hills, Ph.D., and Mary

Lou Rife, Ph.D., were writers.

Acknowledgments 175

Index

Notes: Because the entire volume is about substance abuse treatment and group therapy, the

use of these terms as entry points has been minimized in this index. Reference locators for

information contained in figures appear in italics.

12­Step groups, 111–113

as different from interpersonal process 

groups, 4, 6–7, 63

42 C.F.R. Part 2, 31, 70, 108–109, 110, 130

A

AA. See Alcoholics Anonymous

AASWG. See Association for the

Advancement of Social Work with Groups

action stage, overview of, 10

active listening, 92

adaptation 

of group therapy to substance abuse 

treatment, 7–8

of instruction to learning style, 15

Addiction Technology Transfer Centers, 131

adolescents, 41

adult patient placement criteria, 149–150

advantages of group treatment, 3–6

affect, 86, 98–99, 102, 104–105

Agazarian Systems­Centered Therapy for

Group, 28

AGPA. See American Group Psychotherapy

Association

agreements, group, 68–69, 69, 71, 73, 97,

151–152

A.K. Rice Institute, 130

Alcoholics Anonymous, 6–7, 63, 112

American Group Psychotherapy Association,

126–127

American Psychiatric Association, 127

American Psychological Association, 127

American Society of Addiction Medicine, 127.

See also ASAM PPC­2R

anger reduction, 19

anxiety alleviation, 15, 20, 63, 120

APA. See American Psychiatric Association,

American Psychological Association

ASAM PPC­2R, 42–43

ASGW. See Association for Specialists in

Group Work

assessment, 38–40

of trainee skills, 135

Association for the Advancement of Social

Work with Groups, 127

Association for Specialists in Group Work,

99, 128

best practice guidelines, 159–163

Association for Supervision and Curriculum

Development, 15

attachment theory, 83

ATTCs. See Addiction Technology Transfer

Centers

B

beginning phase of group, 72–76

behavior modeling by leaders, 96

benefits of groups, 1

best practice guidelines, 159–163

Bion’s primary assumption groups, 28

biopsychosocial issues, 111–114

boredom, group leader, 17

boundaries, 100–101, 103, 118

Index 177
C

characteristics of group models, 13 

cognitive–behavioral groups, 18–19 

communal and culturally specific 

groups, 32 

expressive groups, 34 

fixed and revolving membership 

groups, 62 

problem­focused groups, 35 

psychoeducational groups, 13–14 

relapse prevention groups, 30 

skills development groups, 16 

support groups, 20–21 

client 

defensive features, 7 

not suited for group, 39–40, 118 

motivation, 65, 100 

retention, 64–66 

client placement, 37, 96 

based on readiness for change, 44 

cognitive–behavioral groups, 3 

characteristics of, 18–19 

leadership skills and styles, 19 

purpose of, 18 

techniques used in, 19 

cognitive capacity, 85 

cognitive restructuring, 18 

cohesion, 73–74, 82 

communal and culturally specific treatment 

groups, 10, 31–34 

characteristics of, 32 

leadership characteristics and styles, 

32–33 

purpose of, 32 

techniques used in, 34 

communication among group members, 105 

confidentiality, 31, 41, 70, 108–109, 110, 130 

conflict, 48, 57, 74, 97, 99, 115–116 

confrontation, 6, 86–87, 106–107

constancy, 92 

contact outside the group, 71–72 

contemplation stage 

overview of, 10 

and psychoeducational groups, 12, 14 

cotherapy, 96–97 

countertransference, 107–108 

cultural sensitivity, 33, 98 

culture 

definitions of, 45 

of recovery, 81, 87 

resources on, 48 

D

defensive features of clients, 7 

disruptive behavior, 117–118 

distance learning, 131, 132 

diversity, 44–48 

diversity wheel, 46 

dual relationships, 99–100 

E

early recovery stage, 43, 80–85 

eco­map, 38 

emotionality, 86, 98–99, 102, 104–105 

empathy 

of group members, 64 

of leaders, 85, 93–94 

end phase of group, 76–78 

enmeshment, 98 

ethical issues, 97–98 

ethnicity, 47, 48 

matching client and counselor, 55–56 

etiologies of dependency, 18 

exclusion from group, 69 

experiential learning, 129–130, 133 

experiential pretraining, 65 

expressive groups, 10, 34–35, 130 

178 Index
F

faith in a group setting, 114 

families and psychoeducational groups, 12 

Family Care Program of the Duke Addictions 

Program, The, 66 

feedback, 17, 76 

financial responsibility, 72 

fixed membership groups, 60, 62 

focal conflict model, 28 

Foundation Center, 136 

FRAMES, 100 

Freudian psychoanalysis, 22–23 

funding for training programs, 136 

G

gender­specific groups, 40 

group­as­a­whole 

dynamics, 23 

focused groups, 28–29, 29 

group 

advantages of, 3–6

agreements, 68–69, 69, 71, 73, 97, 

151–152

benefits of, 1 

cohesion, 73–74, 82 

contact outside of, 71–72

exclusion from, 69 

influence of, 1–2

model characteristics, 13, 13–14, 16 

stability, 41–42

types not covered, 3 

types related to models, 11 

guidelines to evaluating leader bias and prejudice, 49 

H

hope as a therapeutic factor, 82 

I 

impulse control, 41 

inappropriate placement of clients, 39–40 

individually focused groups, 26–27, 27 

Institute of the American Group 

Psychotherapy Association, 125 

integrating care, 114–115 

Interactional Model, 25 

interpersonal dynamics, 23 

interpersonal process groups, 3, 22–25 

characteristics of, 24 

as different from self­help groups, 4–5 

leadership skills and styles, 24–25 

purpose of, 22–23 

techniques used in, 25 

theoretical approaches, 22–23 

Interpersonal Process Group Psychotherapy, 

24 

interpersonally focused groups, 27–28, 28 

interventions, 25–29, 105–107, 111 

interviews, pregroup, 63 

intrapsychic dynamics, 23 

IPGP. See Interpersonal Process Group 

Psychotherapy 

K

Kwanzaa, 32 

L

late recovery/maintenance stage, 44, 88–89

leader 

avoiding a leader­centered group, 106 

boredom, 17 

personal qualities of, 92–94 

self­assessment for cultural issues, 49, 

50–52 

who is in recovery, 125, 126 

leadership 

cognitive–behavioral group, 19 

communal and culturally specific 

group, 32–33 

early treatment, 84–85 

expressive group, 34–35 

interpersonal process group, 24–25 

late­stage treatment, 89 

middle­stage treatment, 86–88 

Index 179 
problem­focused group, 36 

psychoeducational group, 14–15 

relapse prevention group, 31 

skills development group, 16–17 

support group, 20–21 

levels of care, ASAM, 42 

life issues, 113–114 

listening skills, 92 

M

maintenance stage, overview of, 10 

matching client and counselor ethnicity, 

55–56 

middle phase of group, 76 

middle recovery stage, 44, 85–88 

models related to group types, 11 

Modern Analytic Approach, 27 

mood­altering substances, 70–71 

motivation, client, 65, 100 

motivational interviews, 65 

N

NAADAC. See National Association of 

Alcohol and Drug Abuse Counselors 

NABSW. See National Association of Black 

Social Workers 

NASW. See National Association of Social 

Workers 

National Association of Alcohol and Drug 

Abuse Counselors, 128, 131 

National Association of Black Social Workers, 

128 

National Association of Social Workers, 128 

National Clearinghouse for Alcohol and Drug 

Information, 129 

National Mental Health Information Center, 

129 

National Registry of Certified Group 

Psychotherapists, 128–129 

NCADI. See National Clearinghouse for 

Alcohol and Drug Information 

neuropsychological issues, 16 

NMHIC. See National Mental Health

Information Center

norms, 74–75

P

participant feedback, 17, 76 

peer support, 3 

physical contact, 70, 103–104 

placement considerations, 37, 40–43, 96 

for adolescents, 41 

criteria, 42–43 

and cultural issues, 47, 52–53, 54 

for women, 40–41 

posttraumatic stress disorder, 18–19

precontemplation stage 

overview of, 10 

and psychoeducational groups, 12, 14 

pregroup interviews, 63 

premature termination, 72 

forestalling, 65, 89 

preparation stage, overview of, 10 

preparing clients for group, 63–64 

pretreatment techniques, 65 

problem­focused groups, 35 

problemsolving exercises, 15 

psychodynamics, 23 

psychoeducational groups, 9, 12 

characteristics of, 13–14 

leadership skills and styles of, 14–15 

purpose of, 12 

techniques used in, 15–16 

psychological emergencies, 119–120

PTSD. See posttraumatic stress disorder

Q

qualities needed in a group leader, 92–94

R

recurrence stage, overview of, 10 

refusal skills, 16 

180 Index
relapse, 102

relapse prevention groups, 10, 29–31 

characteristics of, 30 

leadership skills and styles, 31 

purpose of, 30 

techniques used in, 31 

resistance, 20, 81, 100, 108 

retention of clients in group, 64–66 

revolving membership groups, 60–61, 62 

role 

induction, 65 

flexibility, 99 

playing, 15, 26 

S

safety, 101–104 

SageWind, 33, 67, 68 

same­sex groups, 40 

scapegoating, 55, 99, 101, 116 

self­disclosure, 96 

self­help groups, 111–112 

as different from group therapy in 

general, 63 

as different from interpersonal process 

groups, 4–5 

as different from support groups, 20 

sensitivity training, 27 

shame, 74, 94, 95, 101 

silence, 118–119 

skills development groups, 3 

characteristics of, 16 

leadership skills and styles, 16–17 

purpose of, 16 

techniques used in, 17 

smoking cessation, 30 

spirituality, 114 

stability of groups, 41–42 

stages of change, 42, 80, 100 

and client placement, 44 

overview of, 10 

stages of recovery, 43–44, 80 

subgroups, 117 

supervision, 125, 131, 134–135 

support groups, 3, 12, 20 

characteristics of, 20–21

as different from interpersonal process

groups, 20 

leadership skills and styles, 21–22 

purpose of, 20 

techniques used in, 22 

T

Tavistock’s Group­as­a­Whole, 28 

techniques used 

in cognitive–behavioral groups, 19–20

in communal and culturally specific 

treatment groups, 34 

in expressive groups, 35 

in interpersonal process groups, 25 

in problem­focused groups, 36 

in psychoeducational groups, 15–16 

in relapse prevention groups, 31 

in skills development groups, 17 

in support groups, 22 

termination, 72, 76–78 

T­groups, 27 

theoretical approaches, 10–11, 27, 28 

therapeutic groups, definition, 2 

therapeutic factors 

in early recovery, 81–84 

in late recovery, 88–89 

in middle recovery, 85–86 

therapeutic services, 2 

therapeutic styles of leaders, 94–96 

time as a factor in recovery, 8 

TIPs cited 

Brief Interventions and Brief Therapies 

for Substance Abuse Treatment 

(TIP 34), 17, 26, 30, 36 

Index 181 
Enhancing Motivation for Change in 

Substance Abuse Treatment (TIP 35), 

42, 100 

Guide to Substance Abuse Services for 

Primary Care Clinicians (TIP 24), 

A, 124 

Improving Cultural Competence in 

Substance Abuse Treatment (in 

development), 32, 56 

Integrating Substance Abuse Treatment 

and Vocational Services (TIP 38), 43 

Intensive Outpatient Treatment for 

Alcohol and Other Drug Abuse 

(TIP 8), 110 

Screening and Assessing Adolescents for 

Substance Use Disorders (TIP 31), 

124 

Simple Screening Instruments for 

Outreach for Alcohol and Other 

Drug Abuse and Infectious 

Diseases (TIP 11), 124 

Substance Abuse Treatment: Addressing

the Specific Needs of Women (in

development), 41 

Substance Abuse Treatment and Domestic 

Violence (TIP 25), 110 

Substance Use Disorder Treatment for 

People With Physical and Cognitive 

Disabilities (TIP 29), 14, 32 

training and education, 6–7, 99, 124–126, 

129–130 

funding for, 136 

transference, 107–108

treatment criteria, ASAM, 42–43

U

universality as a therapeutic factor, 82, 86 

V 

vicarious pretraining, 65 

W

women, and placement considerations, 40–41

wraparound services, 66 

182 Index
SAMHSA TIPs and Publications Based on TIPs

What Is a TIP?

Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians, researchers,

program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art treatment practices. TIPs

are developed under the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Knowledge Application Program (KAP)

to improve the treatment capabilities of the Nation’s alcohol and drug abuse treatment service system.

What Is a Quick Guide?

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized booklet. Each Quick Guide is

divided into sections to help readers quickly locate relevant material. Some contain glossaries of terms or lists of resources. Page

numbers from the original TIP are referenced so providers can refer back to the source document for more information.

What Are KAP Keys?

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening in-struments, checklists, and

summaries of treatment phases. Printed on coated paper, each KAP Keys set is fastened together with a key ring and can be kept

within a treatment provider’s reach and consulted fre-quently. The Keys allow you, the busy clinician or program administrator, to

locate information easily and to use this information to enhance treatment services.

Ordering Information

Publications may be ordered or downloaded for free at http://store.samhsa.gov. To order over the phone, please call 

1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

TIP 1 State Methadone Treatment Guidelines—Replaced by

TIP 43

TIP 2 Pregnant, Substance-Using Women—Replaced by

TIP 51

TIP 3 Screening and Assessment of Alcohol- and Other

Drug-Abusing Adolescents—Replaced by TIP 31

TIP 4 Guidelines for the Treatment of Alcohol- and Other

Drug-Abusing Adolescents—Replaced by TIP 32

TIP 5 Improving Treatment for Drug-Exposed Infants

TIP 6 Screening for Infectious Diseases Among Substance

Abusers—Archived

TIP 7 Screening and Assessment for Alcohol and Other

Drug Abuse Among Adults in the Criminal Justice

System—Replaced by TIP 44

TIP 8 Intensive Outpatient Treatment for Alcohol and

Other Drug Abuse—Replaced by TIPs 46 and 47

TIP 9 Assessment and Treatment of Patients With

Coexisting Mental Illness and Alcohol and Other

Drug Abuse—Replaced by TIP 42

TIP 10 Assessment and Treatment of Cocaine- Abusing

Methadone-Maintained Patients—Replaced by TIP 43

TIP 11 Simple Screening Instruments for Outreach for

Alcohol and Other Drug Abuse and Infectious

Diseases—Replaced by TIP 53

TIP 12 Combining Substance Abuse Treatment With

Intermediate Sanctions for Adults in the Criminal

Justice System—Replaced by TIP 44

TIP 13 Role and Current Status of Patient Placement

Criteria in the Treatment of Substance Use

Disorders

 Quick Guide for Clinicians 

 Quick Guide for Administrators 

 KAP Keys for Clinicians

TIP 14 Developing State Outcomes Monitoring Systems for

Alcohol and Other Drug Abuse Treatment

TIP 15 Treatment for HIV-Infected Alcohol and Other Drug

Abusers—Replaced by TIP 37

TIP 16 Alcohol and Other Drug Screening of Hospitalized

Trauma Patients 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 17 Planning for Alcohol and Other Drug Abuse

Treatment for Adults in the Criminal Justice

System—Replaced by TIP 44

TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues

for Alcohol and Other Drug Abuse Treatment

Providers—Archived

TIP 19 Detoxification From Alcohol and Other Drugs—

Replaced by TIP 45

TIP 20 Matching Treatment to Patient Needs in Opioid

Substitution Therapy—Replaced by TIP 43

TIP 21 Combining Alcohol and Other Drug Abuse

Treatment With Diversion for Juveniles in the

Justice System 

 Quick Guide for Clinicians and Administrators 

183
TIP 22 LAAM in the Treatment of Opiate Addiction—

Replaced by TIP 43

TIP 23 Treatment Drug Courts: Integrating Substance Abuse

Treatment With Legal Case Processing 

 Quick Guide for Administrators 

TIP 24 A Guide to Substance Abuse Services for Primary

Care Clinicians 

 Concise Desk Reference Guide 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 25 Substance Abuse Treatment and Domestic Violence 

 Linking Substance Abuse Treatment and Domestic

Violence Services: A Guide for Treatment Providers 

 Linking Substance Abuse Treatment and Domestic

Violence Services: A Guide for Administrators 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 26 Substance Abuse Among Older Adults 

 Substance Abuse Among Older Adults: A Guide for

Treatment Providers 

 Substance Abuse Among Older Adults: A Guide for

Social Service Providers 

 Substance Abuse Among Older Adults: Physician’s

Guide 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

TIP 27 Comprehensive Case Management for Substance

Abuse Treatment

 Case Management for Substance Abuse Treatment: A

Guide for Treatment Providers 

 Case Management for Substance Abuse Treatment: A

Guide for Administrators 

 Quick Guide for Clinicians 

 Quick Guide for Administrators

TIP 28 Naltrexone and Alcoholism Treatment—Replaced by

TIP 49

TIP 29 Substance Use Disorder Treatment for People With

Physical and Cognitive Disabilities

 Quick Guide for Clinicians

 Quick Guide for Administrators 

 KAP Keys for Clinicians 

TIP 30 Continuity of Offender Treatment for Substance Use

Disorders From Institution to Community 

 Quick Guide for Clinicians

 KAP Keys for Clinicians

TIP 31 Screening and Assessing Adolescents for Substance

Use Disorders

 See companion products for TIP 32.

TIP 32 Treatment of Adolescents With Substance Use

Disorders 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 33 Treatment for Stimulant Use Disorders

 Quick Guide for Clinicians

 KAP Keys for Clinicians

TIP 34 Brief Interventions and Brief Therapies for Substance

Abuse 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 35 Enhancing Motivation for Change in Substance Abuse

Treatment

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 36 Substance Abuse Treatment for Persons With Child

Abuse and Neglect Issues

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

 Helping Yourself Heal: A Recovering Woman’s Guide to

Coping With Childhood Abuse Issues 

 Also available in Spanish

 Helping Yourself Heal: A Recovering Man’s Guide to

Coping With the Effects of Childhood Abuse 

 Also available in Spanish

TIP 37 Substance Abuse Treatment for Persons With

HIV/AIDS

 Quick Guide for Clinicians

 KAP Keys for Clinicians 

 Drugs, Alcohol, and HIV/AIDS: A Consumer Guide 

 Also available in Spanish

 Drugs, Alcohol, and HIV/AIDS: A Consumer Guide for

African Americans

TIP 38 Integrating Substance Abuse Treatment and

Vocational Services

 Quick Guide for Clinicians 

 Quick Guide for Administrators 

 KAP Keys for Clinicians 

TIP 39 Substance Abuse Treatment and Family Therapy

 Quick Guide for Clinicians

 Quick Guide for Administrators

 Family Therapy Can Help: For People in Recovery

From Mental Illness or Addiction

184
TIP 40 Clinical Guidelines for the Use of Buprenorphine in

the Treatment of Opioid Addiction

 Quick Guide for Physicians 

 KAP Keys for Physicians 

TIP 41 Substance Abuse Treatment: Group Therapy

 Quick Guide for Clinicians 

TIP 42 Substance Abuse Treatment for Persons With CoOccurring Disorders

 Quick Guide for Clinicians 

 Quick Guide for Administrators 

 KAP Keys for Clinicians 

TIP 43 Medication-Assisted Treatment for Opioid Addiction

in Opioid Treatment Programs

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 44 Substance Abuse Treatment for Adults in the

Criminal Justice System

 Quick Guide for Clinicians

 KAP Keys for Clinicians 

TIP 45 Detoxification and Substance Abuse Treatment

 Quick Guide for Clinicians

 Quick Guide for Administrators

 KAP Keys for Clinicians 

TIP 46 Substance Abuse: Administrative Issues in

Outpatient Treatment

 Quick Guide for Administrators

TIP 47 Substance Abuse: Clinical Issues in Outpatient

Treatment

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

TIP 48 Managing Depressive Symptoms in Substance Abuse

Clients During Early Recovery

TIP 49 Incorporating Alcohol Pharmacotherapies Into

Medical Practice

 Quick Guide for Counselors 

 Quick Guide for Physicians 

 KAP Keys for Clinicians 

TIP 50 Addressing Suicidal Thoughts and Behaviors in

Substance Abuse Treatment

 Quick Guide for Clinicians 

 Quick Guide for Administrators

TIP 51 Substance Abuse Treatment: Addressing the Specific

Needs of Women

 KAP Keys for Clinicians

 Quick Guide for Clinicians

 Quick Guide for Administrators

TIP 52 Clinical Supervision and Professional Development

of the Substance Abuse Counselor

 Quick Guide for Clinical Supervisors

 Quick Guide for Administrators

TIP 53 Addressing Viral Hepatitis in People With Substance

Use Disorders

 Quick Guide for Clinicians and Administrators

 KAP Keys for Clinicians 

TIP 54 Managing Chronic Pain in Adults With or in

Recovery From Substance Use Disorders

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

 You Can Manage Your Chronic Pain To Live a Good

Life: A Guide for People in Recovery From Mental

Illness or Addiction

TIP 55 Behavioral Health Services for People Who Are

Homeless

TIP 56 Addressing the Specific Behavioral Health Needs of

Men 

 Quick Guide for Clinicians

 KAP Keys for Clinicians

TIP 57 Trauma-Informed Care in Behavioral Health

Services 

 Quick Guide for Clinicians

 KAP Keys for Clinicians

TIP 58 Addressing Fetal Alcohol Spectrum Disorders

(FASD)

TIP 59 Improving Cultural Competence

185

Substance Abuse Treatment:

Group Therapy

This TIP, Substance Abuse Treatment: Group Therapy, presents an

overview of the role and efficacy of group therapy in substance

abuse treatment planning. This TIP offers research and clinical findings and distills them into practical guidelines for practitioners of

group therapy modalities in the field of substance abuse treatment.

The TIP describes effective types of group therapy and offers a theoretical basis for group therapy’s effectiveness in the treatment of substance use disorders. This work also will be a useful guide to supervisors and trainers of beginning counselors, as well as to experienced

counselors. Finally, the TIP is meant to provide researchers and clinicians with a guide to sources of information and topics for further

inquiry.

Collateral Products

Based on TIP 41

Quick Guide for Clinicians

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

HHS Publication No. (SMA) 15-3991

Printed 2005

Revised 2009, 2011, 2012, 2014, and 2015