Substance Abuse Treatment:

Group Therapy

Inservice Training

Based on Treatment 

Improvement 

Protocol

TIP

41

Substance Abuse Treatment:
 

Group Therapy
 

Inservice Training
 

Based on Treatment 


Improvement 


Protocol
 

TIP
 

41
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

1 Choke Cherry Road 

Rockville, MD 20857 
Acknowledgments 

This training manual, based on Treatment Improvement Protocol (TIP) 41, Substance Abuse Treatment: 

Group Therapy, was prepared by the Southeast Addiction Technology Transfer Center for the Substance 

Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human 

Services (HHS). Catherine D. Nugent, LCPC, served as the Government Project Officer. 

The manual was produced under the Knowledge Application program (KAP), contract number 270-09-0307, 

a joint venture of The CDM Group, Inc., and JBS International, Inc., for SAMHSA, HHS. Christina Currier 

served as the KAP Contracting Officer’s Representative. 

Disclaimer 

The views, opinions, and content expressed herein are those of the expert panel and do not necessarily 

reflect the views or policies of SAMHSA or HHS. No official support of or endorsement by SAMHSA or HHS for 

these opinions or for particular instruments, software, or resources is intended or should be inferred. 

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. 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 Copies of Publication 

This publication may be ordered from the SAMHSA Store at http://www.store.samhsa.gov. Or, please call 

1-877-SAMHSA-7 (1-877-726-4727) (English and Español). 

The document and accompanying PowerPoint slides can be downloaded from the KAP Web site at http:// 

www.kap.samhsa.gov. 

Recommended Citation 

Substance Abuse and Mental Health Administration. Substance Abuse Treatment: Group Therapy Inservice 

Training. HHS Publication No. (SMA) SMA-11-4664. Rockville, MD: Substance Abuse and Mental Health 

Services Administration, 2012. 

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) 11-4664 

Printed 2012 
Contents 

Training and Manual Overview...................... v
 

Module 1: Groups and Substance Abuse Treatment .. 1-1
 

Module 2: Types of Groups Used in 

Substance Abuse Treatment ..................... 2-1
 

Module 3: Criteria for the Placement 

of Clients in Groups............................. 3-1
 

Module 4: Group Development 

and Phase-Specific Tasks ........................ 4-1
 

Module 5: Stages of Treatment ................... 5-1
 

Module 6: Group Leadership, Concepts, 

and Techniques ................................ 6-1
 

Module 7: Supervision .......................... 7-1
 

iii 

v 

Training and Manual 

Overview 

Training Purpose 

This inservice training manual provides counselors and other clinical 

staff members with scripted modules to use in trainings for Treatment 

Improvement Protocol (TIP) 41, Substance Abuse Treatment: Group 

Therapy, published by the Substance Abuse and Mental Health Services 

Administration’s (SAMHSA’s) Center for Substance Abuse Treatment (CSAT). 

The seven training modules will assist program staff in understanding and 

implementing the evidence-based practices described in TIP 41. 

A TIP is the end result of careful consideration of relevant research findings 

and experiences in clinical settings. For each TIP, a panel of expert clinical 

researchers, clinical providers, and program administrators (the consensus 

panel) discusses the issues relevant to the specific TIP. The product of 

the panel represents the combined and collaborative input of the various 

viewpoints and provides recommendations for specific best-practice 

guidelines. The panel’s work is reviewed by expert field reviewers. Revisions 

suggested by these reviewers are incorporated into the final document. 

TIP 41 and this training manual present an overview of the role and efficacy 

of group therapy in substance abuse treatment. The goal of both documents 

is to offer the latest research and clinical findings and to distill them into 

practical guidelines for group therapy leaders in the field of substance abuse 

treatment. The documents describe effective types of group therapy and 

offer a theoretical basis for group therapy in the treatment of substance use 

disorders. The information will be a useful guide to supervisors and trainers 

of beginning counselors, as well as to experienced counselors. 

Training Design 

The training manual is designed as a seven-module continuing education 

workshop for substance use disorder counselors and other professionals. 

Senior staff members and clinical supervisors can easily lead the training 

sessions. 

The modules are between 45 minutes and 1 hour and 45 minutes in length. 

They can be delivered as stand-alone training sessions or as elements 

within a large training program. Experienced trainers are encouraged to 

adjust the schedules based on external factors such as participant skill 

levels, facility amenities, and other factors that affect training delivery. 

Trainers should read the corresponding TIP chapters to familiarize 

themselves with the full content of TIP 41 before presenting a training 

module. 

The primary goal of this training package is to provide a quick, easy, and 

user-friendly way to deliver the content of TIP 41 to substance abuse 
vi 

TIP 41 Curriculum 

treatment providers. The manual covers the types of groups used, criteria 

for placement in a group, group development, stages of treatment, and 

group leadership issues, such as leadership styles and strategies for 

therapy. The trainer should be cognizant of participants’ needs and adapt 

the material to meet these needs. Trainer’s notes and suggested talking 

points are provided to allow flexibility. 

Instructional Approach 

An experienced substance abuse treatment provider should serve as the 

trainer for these modules, but no training experience is required to use 

the materials. The success of the training depends on the willingness of 

the trainer to use the trainer’s notes and PowerPoint slides to enhance 

discussions to ensure that participants grasp the modules’ objectives. 

The training generally follows the flow of the TIP. The training can be 

conducted in small- to medium-sized groups (10–25 people). 

Materials and Equipment 

Each module provides trainer’s notes and suggested talking points. 

Thumbnail copies of the PowerPoint slides that reinforce the topics are 

provided in the left column. The PowerPoint slides, available at http:// 

www.kap.samhsa.gov/products/trainingcurriculums/index.htm, require a 

personal computer; they can be saved as presentations or, if necessary, 

printed to make overhead slides. The training room should be set up to 

accommodate small groups and comfortable viewing of the PowerPoint 

slides. 

TIP 41 is used as a reference throughout the training. The trainer should 

order enough copies of TIP 41 to distribute one to each participant. Copies 

can be ordered free of charge from the SAMHSA Store by telephone at 

1-877-SAMHSA-7 (1-877-726-4727) or electronically at http://www.store. 

samhsa.gov. TIPs can also be downloaded from the Knowledge Application 

Program (KAP) Web site at http://www.kap.samhsa.gov. A Quick Guide for 

Clinicians based on TIP 41 can also be ordered from the SAMHSA Store or 

downloaded from the KAP Web site. 

References in the TIP have been deleted from the training manual. Trainers 

and participants should refer to TIP 41 for original sources. 

Trainers must have the following materials for all modules: 

• Computer 

• LCD projector for PowerPoint slides 

• Newsprint paper, easel, and colorful markers 

• Tape for affixing newsprint to the walls 
vii 

Training and Manual Overview 

Manual Format 

The start of each module presents the module’s learning overview, 

sections, and objectives. A new discussion topic or activity is designated by 

a section title and the approximate time needed to complete the section. 

The left column of the module page displays the following icons to assist 

the trainer: 

Time to complete Trainer’s PowerPoint 

the section note slide 

25 minutes 

PP 7-1 

Passages in Roman typeface are scripted talking points, which are based 

on text taken directly from TIP 41. This text can be read verbatim or 

modified by the trainer. Text in italics typeface provides notes to the trainers 

such as cues on when to begin a new section. 

Learning Objectives 

After completing this training, participants will be able to: 

•		Discuss the use of group therapy in substance abuse treatment. (Module 1) 

•		Explain five group therapy models and three specialized group therapy 

models used in substance abuse treatment. (Modules 1 and 2) 

•		Explain the advantages of group therapy. (Module 1) 

•		Modify group therapy to treat substance abuse. (Module 1) 

•		Explain the stages of change. (Module 2) 

•		Match clients with substance abuse treatment groups. (Module 3) 

• Assess clients’ readiness to participate in group therapy. (Module 3) 

• Determine clients’ needs for specialized groups. (Module 3) 

•		Distinguish differences between fixed and revolving membership groups. 

(Module 4) 

•		Prepare clients for groups. (Module 4) 

•		Describe the tasks for each of the three phases of group development. 

(Module 4) 

•		Discuss the importance of making clinical adjustments in group therapy. 

(Module 5) 
viii 

TIP 41 Curriculum 

•		Explain the three stages of treatment. (Module 5) 

•		Describe the conditions of the early, middle, and late stages of 

treatment. (Module 5) 

•		Identify leadership characteristics in the early, middle, and late stages of 

treatment. (Modules 5 and 6) 

•		Describe concepts and techniques for conducting substance abuse 

treatment group therapy. (Module 6) 

•		Identify training opportunities. (Module 7) 

•		Appreciate the value of clinical supervision. (Module 7) 
1-1 

10 minutes 

PP 1-1
 

Module 1: Groups and 

Substance Abuse Treatment 

Module 1 Overview 

The goal of Module 1 is to provide participants with an overview of the 

training and an overview of group therapy in substance abuse treatment. 

The information in Module 1 covers Chapter 1 of Treatment Improvement 

Protocol (TIP) 41, Substance Abuse Treatment: Group Therapy. This module 

takes 1 hour to complete and is divided into three sections: 

•	 Welcome, Training Objectives, and Ground Rules (10 minutes) 

•	 Presentation: Overview of Groups in Substance Abuse Treatment (45 

minutes) 

•	 Summary (5 minutes) 

Welcome, Training Objectives, and Ground Rules 

After participants have taken their seats, the trainer introduces 

himself or herself and asks participants to introduce themselves 

by stating their names, what they do, and one skill they hope to 

gain from the training. 

The trainer distributes copies of TIP 41 to participants, asks them 

to turn to the table of contents (p. iii) of TIP 41, and instructs them 

to bring TIP 41 to each training session. 

This training is based on the Substance Abuse and Mental Health Services 

Administration (SAMHSA)/Center for Substance Abuse Treatment (CSAT) 

TIP 41, Substance Abuse Treatment: Group Therapy. TIP 41 is part of a 

series of best-practices guidelines developed by SAMHSA/CSAT to assist in 

providing practical, up-to-date, evidence-based information on important 

topics in substance abuse treatment. The table of contents for the TIP 

provides an overview of the training curriculum, which roughly follows the 

order of the chapters. 
TIP 41 Curriculum 

 

PP 1-2
 

PP 1-3
 

PP 1-4
 

PP 1-5
 

The group therapy training is divided into seven modules. Module 1 covers 

Chapter 1 of TIP 41. After completing all seven modules, you will be able to: 

•		Discuss the use of group therapy in substance abuse treatment. 

(Module 1) 

•		Explain five group therapy models and three specialized group therapy 

models used in substance abuse treatment. (Modules 1 and 2) 

•		Explain the advantages of group therapy. (Module 1) 

•		Modify group therapy to treat substance abuse. (Module 1) 

•		Explain the stages of change. (Module 2) 

•		Match clients with substance abuse treatment groups. (Module 3) 

• Assess clients’ readiness to participate in group therapy. ( Module 3) 

• Determine clients’ needs for specialized groups. (Module 3) 

•		Distinguish differences between fixed and revolving membership groups. 

(Module 4) 

•		Prepare clients for groups. (Module 4) 

•		Describe the tasks for each of the three phases of group development. 

(Module 4) 

•		Discuss the importance of making clinical adjustments in group therapy. 

(Module 5) 

•		Explain the three stages of treatment. (Module 5) 

•		Describe the conditions of the early, middle, and late stages of 

treatment. (Module 5) 

•		Identify leadership characteristics in the early, middle, and late stages of 

treatment. (Modules 5 and 6) 

•		Describe concepts and techniques for conducting substance abuse 

treatment group therapy. (Module 6) 

•		Identify training opportunities. (Module 7) 

•		Appreciate the value of clinical supervision. (Module 7) 

1-2 
1-3 

Module 1: Groups and Substance Abuse Treatment 

PP 1-6
 

PP 1-7
 

45 minutes 

The trainer reviews the ground rules, asks participants whether 

they would like to add any rules to the list, and writes additional 

rules on newsprint. 

• Begin and end sessions and breaks on time. 

• Respect others and their opinions. 

• Allow one person to speak at a time. 

• Maintain confidentiality. 

• Participate in each training session. 

• Have fun. 

The goal of Module 1 is to provide an overview of group therapy used in 

substance abuse treatment. By the end of the session, you will be able to: 

• Discuss the use of group therapy in substance abuse treatment. 

• Define five group therapy models used in substance abuse treatment. 

• Explain the advantages of group therapy. 

• Modify group therapy to treat substance abuse. 

Presentation: Overview of Group Therapy in Substance Abuse 

Treatment 

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 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 especially suitable for treating 

problems that commonly accompany substance abuse, such as depression, 

isolation, and shame. 

Although many groups can have therapeutic effects, TIP 41 concentrates 

only on groups that have trained leaders and that are designed to promote 

recovery from substance abuse. 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. This course does not train individuals to be group 

therapy leaders. Rather, it provides substance abuse counselors with 
1-4 

TIP 41 Curriculum 

insights and information that can improve their ability to manage the groups 

they currently lead. 

The lives of individuals are shaped by their experiences in groups. People 

are born into groups; they join groups; they will influence and be influenced 

by family, social, and cultural groups that constantly shape behavior, selfimage, and both physical and mental health. 

PP 1-8 

PP 1-9
 

Group therapy can support members in times of pain and trouble. A group’s 

therapeutic goals can enrich members with insight and guidance. Group 

therapy and addiction treatment are natural allies. The effectiveness of 

group therapy in substance abuse treatment can be attributed to several 

factors associated with addiction such as depression, anxiety, and denial. 

Can you name others? 

The trainer encourages participants to name other factors and 

writes them on newsprint. 

Most groups in substance abuse treatment have trained leaders. In 

addition, their goal is to produce healing or recovery from substance abuse. 

Five group therapy models are frequently used in substance abuse treatment: 

•		Psychoeducational groups teach about substance abuse. 

•		Skills development groups help members hone skills necessary to break 

free of addiction. 

•		Cognitive–behavioral groups encourage members to rearrange patterns 

of thinking and action that lead to addiction. 

•		Support groups provide a forum where members can debunk excuses 

and support constructive change. 

•		Interpersonal process groups enable members to re-create their past 

and rethink problems and solutions that led to their substance abuse. 

Treatment counselors routinely use the first four models and various 

combinations of them. The interpersonal process group model is not widely 

used in substance abuse treatment because of the extensive training 

required to lead such groups and the long duration of the groups; these 

groups demand a high degree of commitment from both counselors and 

clients. 

Module 2 provides more details about each type of group. 

Treating adult clients in groups has many advantages but can yield poor 

results if applied indiscriminately or administered by an unskilled or 

improperly trained leader. There are numerous advantages to using groups 

in substance abuse treatment. For example: 
1-5 

Module 1: Groups and Substance Abuse Treatment 

PP 1-10 

PP 1-11 

PP 1-12	 

•		Groups provide positive peer support and pressure for abstinence from 

substances of abuse. Group therapy elicits 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 group members and 

reduces the group’s effectiveness. 

•		Groups reduce the sense of isolation that most people who have 

substance use disorders experience. They enable participants to identify 

with others who are struggling with the same issues. 

•		Groups enable members who abuse substances to witness the recovery 

of others. From this inspiration, people who are addicted gain hope that 

they too can maintain abstinence. 

•		Groups help members learn to cope with their substance use problems 

by allowing them to see how others deal with similar problems. 

•		Groups can provide useful information to clients who are new to 

recovery. Members can learn how to avoid triggers for use, the 

importance of abstinence, and how to self-identify as a person 

recovering from substance abuse. 

•		Groups provide feedback on the values and abilities of other group 

members. This information helps members improve their conception of 

self or modify faulty, distorted conceptions. 

•		Groups offer family-like experiences that support and nurture group 

members. These experiences may have been lacking in the group 

members’ families of origin. 

•		Groups encourage, coach, support, and reinforce as members undertake 

difficult or anxiety-provoking tasks. 

Some modifications are needed to make group therapy applicable to and 

effective with clients who abuse substances. 

First, group therapy leaders may need specific training and education 

so that they fully understand therapeutic group work and the special 

characteristics of clients with substance use disorders. Group therapy is not 

individual therapy done in a group, nor is it equivalent to 12-Step program 

practices. Group therapy requires that individuals understand and explore 

the emotional and interpersonal conflicts that can contribute to substance 

abuse. The group leader requires specialized knowledge and skill, including 

a clear understanding of group process and the stages of development of 

group dynamics. 

Second, the individual who is chemically dependent usually comes to 

treatment with a complex set of defenses and is frequently in denial. The 
1-6 

TIP 41 Curriculum 

group leader should have a clear understanding of each group member’s 

defensive process and character dynamics. 

Third, the theoretical underpinnings and practical applications of general 

group therapy are not always applicable to individuals who abuse 

substances. Clients and even staff members often become confused about 

the different types of group therapy modalities. For instance, the course 

of treatment may include 12-Step groups, discussion groups, educational 

groups, continuing care groups, and support groups. Clients can become 

confused about the purpose of group therapy, and staff can underestimate 

the impact that group therapy can have. Therefore, the principles of group 

therapy need to be tailored to meet the realities of treating clients with 

substance use disorders. 

5 minutes 

Summary 

The trainer: 

•	 Responds to participants’ questions or comments. 

•	 Encourages participants to review Chapter 1 of TIP 41. 

•	 Instructs participants to read Chapter 2 and reminds them to 

bring TIP 41 to the next training session. 

•	 Reminds participants of the date and time of the next training 

session. 
2-1 

	 	 	 	 	 	 	 	 	

5 minutes 

PP 2-1
 

Module 2: Types of Groups 

Used in Substance Abuse 

Treatment 

Module 2 Overview 

The goal of Module 2 is to provide participants with an overview of the 

group therapy models used in substance abuse treatment. The information 

in Module 2 covers Chapter 2 of Treatment Improvement Protocol (TIP) 41, 

Substance Abuse Treatment: Group Therapy. This module takes 1 hour and 

45 minutes to complete and is divided into five sections:

•	 Module 2 Goal and Objectives (5 minutes) 

•	 Presentation: Stages of Change (10 minutes) 

•	 Presentation: Five Group Therapy Models in Substance Abuse Treatment 

(60 minutes) 

•	 Presentation: Three Specialized Group Therapy Models in Substance 

Abuse Treatment (25 minutes) 

•	 Summary (5 minutes) 

Module 2 Goal and Objectives 

After participants have taken their seats, the trainer instructs 

them to turn to Chapter 2 (p. 9) of TIP 41. 

Module 2 covers Chapter 2 of TIP 41. 
TIP 41 Curriculum 

PP 2-2
 

10 minutes 

PP 2-3
 

The goal of Module 2 is to provide details about the group therapy models 

used in substance abuse treatment. The module also explores specialized 

groups and groups that focus on specific problems. By the end of the 

session, you will be able to: 

•		Explain the stages of change. 

•		Describe the five group therapy models used in substance abuse 

treatment. 

•		Discuss the three specialized group therapy models used in substance 

abuse treatment. 

Presentation: Stages of Change 

The client’s stage of change dictates which group models and methods are 

appropriate at a particular time. 

Six stages of change have been identified for individuals with substance 

use disorders: 

•		Precontemplation. Individuals are not thinking about changing 

substance use behaviors and may not consider their substance use a 

problem. 

•		Contemplation. Individuals still use substances, but they begin to think 

about cutting back or quitting substance use. 

•		Preparation. Individuals still use substances but intend to stop because 

motivation to quit has increased and the consequences of continued use 

have become clear. Planning for change begins. 

•		Action. Individuals choose a strategy for discontinuing substance use 

and begin to make the changes needed to carry out their plan. 

•		Maintenance. Individuals work to sustain abstinence and avoid relapse. 

•		Recurrence. Many 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. 

A group comprising members in the action stage who have clearly identified 

themselves as substance dependent will be far different from the one 

comprising people who are in the precontemplative stage. Priorities change 

with time and experience, too. For example, a group of people in their 

second day of abstinence is very different from a group with 2 years in 

recovery. 

Theoretical orientations also have an impact on the tasks the group is trying 

to accomplish, what the group leader observes and responds to in group, 

and the types of interventions that the group leader initiates. Before a group 

2-2 
2-3 

Module 2: Types of Groups Used in Substance Abuse Treatment 

model is used in treatment, the group leader and treatment program should 

decide on the theoretical framework to be used. Each group model requires 

different actions from the group leader. Because 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. 

60 minutes 

PP 2-4
 

Presentation: Five Group Therapy Models in Substance Abuse 

Treatment 

For each type of group, the trainer allows participants to share 

experiences they have had as members or leaders of that 

particular group before moving on to the next group. 

Substance abuse treatment programs use a variety of group therapy 

models to meet client needs during the multiphase process of recovery. 

TIP 41 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 model has something unique to offer to certain populations, and 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 are important determinants of 

the model chosen. 

Before beginning the discussion on the types of group models, 

the trainer asks participants to share their experiences working 

with different types of groups. 
2-4 

TIP 41 Curriculum 

PP 2-5 

PP 2-6	 

Variable factors for the five group models include: 

•		Group or leader focus 

• Specificity of the group agenda 

•		Heterogeneity and homogeneity of group members 

•		Open ended or determinate duration of treatment 

• Level of leader activity 

•		Training required for the group leader 

•		Duration of treatment and length of each session 

•		Arrangement of room 

The trainer instructs participants to turn to Figure 2-2 in TIP 41 

(p. 13) and reviews the figure with participants. 

We will now take a look at the purpose, principal characteristics, leadership 

skills and styles, and techniques of each of the five groups. 

Psychoeducational groups educate clients about substance abuse 

and related behaviors and consequences. This type of group presents 

structured, group-specific content, often using videotapes, audiocassettes, 

and lectures. These groups: 

•		Assist individuals in the precontemplative and contemplative stages of 

change. Clients learn to reframe the impact of substance use on their 

lives, develop an internal need to seek help, and discover avenues for 

change. 

•		Help clients in early recovery learn about their disorder. Clients recognize 

roadblocks to recovery and begin on a path toward recovery. 

•		Provide family members with an understanding of the behavior of the 

person in recovery. Families learn how to support their loved one and 

about their own need for change. 

•		Advise clients about other resources and skills that can help in recovery. 

Clients can become familiar with other services such as mutual-help 

programs and learn skills such as meditation, relaxation, and anger 

management. 
2-5 

Module 2: Types of Groups Used in Substance Abuse Treatment 

PP 2-7 

PP 2-8	 

Psychoeducational groups teach clients that they need to learn to identify, 

avoid, and eventually master the specific internal states and external 

circumstances associated with substance use. The coping skills normally 

taught in skills development groups often accompany this learning. 

Psychoeducational groups: 

• Work to engage participants in the group discussion and prompt them to 

relate what they learn to their own substance abuse. 

•		Are highly structured and often follow a manual or curriculum. The leader 

usually takes a very active role in discussions. 

Leaders in psychoeducational groups primarily assume the roles of 

educator and facilitator. They also have the same core characteristics of 

other group leaders: caring, warmth, genuineness, and positive regard for 

others. Leaders of psychoeducational groups: 

•		Understand basic group processes—how people interact within a group. 

They should know how groups form and develop, how group dynamics 

influence an individual’s behavior in group, and how a leader affects 

group functioning. 

•		Understand interpersonal relationship dynamics, including how people 

relate to one another in group settings, how one individual can influence 

the behavior of others, and how to handle problem group behavior (such 

as being withdrawn). 

•		Have basic teaching skills. Such skills include organizing the content, 

planning for participant involvement in the learning process, and 

delivering information in a culturally relevant and meaningful way. 

•		Have basic counseling skills (e.g., active listening, clarifying, supporting, 

reflecting, attending) and a few advanced counseling skills (e.g., 

confronting, terminating). 
2-6 

TIP 41 Curriculum 

PP 2-9
 

PP 2-10
 

PP 2-11
 

Techniques to conduct psychoeducational groups address how the 

information is presented and how to assist clients in incorporating learning 

so that it leads to productive behavior, improved thinking, and emotional 

change. Techniques: 

•		Foster an environment that supports participation. Lecturing should be 

limited, and group discussion should be encouraged. 

•		Encourage participants to take responsibility for their learning. Leaders 

should emphasize honest, respectful interactions among all members. 

•		Use a variety of learning methods that require sensory experiences (e.g., 

hearing, sight, touch/movement). 

•		Are mindful of cognitive impairments caused by substance use. People 

with addictive disorders are known to have subtle, neuropsychological 

impairments in the early stage of abstinence. 

Most skills development groups operate from a cognitive–behavioral 

orientation. Many skills development groups incorporate psychoeducational 

elements into the group process, though skills development may remain the 

primary goal of the group. These groups: 

•		Cultivate skills people need to achieve and maintain abstinence. 

•		Assume clients lack needed life skills. 

•		Allow clients to practice skills. Clients see how others use the skills 

and receive positive reinforcement from the group when skills are used 

effectively. 

•		May be either directly related to substance use or may apply to broader 

areas relevant to recovery. 

The suitability of a client for a skills development group depends on the 

unique needs of the individual and the skills being taught in the group. 

Skills development groups: 

•		Have a limited number of sessions and a limited number of participants. 

The group must be small enough to allow members to practice the skills 

being taught. 

•		Strengthen behavioral and cognitive resources. 

•		Focus on developing an information base on which decisions can be 

made and actions taken. 
2-7 

Module 2: Types of Groups Used in Substance Abuse Treatment 

PP 2-12
 

PP 2-13
 

Leaders in skills development groups: 

•		Need basic group therapy knowledge and skills, such as understanding 

the ways that groups grow and evolve, knowledge of the patterns that 

show how people relate to one another in groups, skills in fostering 

interaction among members, and ability to manage conflicts that arise 

among members in a group environment. 

•		Know and can demonstrate skills that clients are trying to develop. 

Leaders need experience in modeling behavior and helping others learn 

discrete elements of behavior. 

•		Are aware of the different ways people approach issues and problems 

such as anger or assertiveness. 

The specific techniques used in a skills development group depend on the 

skills being taught. The process of learning and incorporating new skills 

may be difficult. Individuals who have been passive and nonassertive may 

struggle to learn to stand up for themselves. Many changes that seem 

straightforward have powerful effects at deeper levels of psychological 

functioning. Techniques: 

•		Vary depending on the skills being taught. 

• Are sensitive to clients’ struggles. 

•		Hold positive expectations for change and do not shame individuals who 

seem overwhelmed. 

•		Depend on the nature of the group, topic, and approach of the group 

leader. Before undertaking leadership of a skills development group, the 

leader should have participated in the specific skills development group 

to be led. 
2-8 

TIP 41 Curriculum 

PP 2-14 

PP 2-15 

Cognitive–behavioral groups are a well-established part of the substance 

abuse treatment field and are particularly appropriate in early recovery. 

Cognitive–behavioral groups use 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. Cognitive–behavioral 

groups: 

•		Conceptualize dependence as a learned behavior that is subject to 

modifications through various interventions, including identification 

of conditioned stimuli associated with specific addictive behaviors, 

avoidance of such stimuli, development of enhanced contingency 

management strategies, and response desensitization. 

•		Work to change learned behavior by changing thinking patterns, beliefs, 

and perceptions. 

•		Develop social networks that support continued abstinence so that the 

person with dependence becomes aware of behaviors that may lead to 

relapse and develops strategies to continue in recovery. 

•		Include a number of different psychological elements, such as thoughts, 

beliefs, decisions, opinions, and assumptions. Changing such cognitions 

and beliefs may lead to greater opportunities to maintain recovery. 

Cognitive–behavioral groups are often used to address ways a client deals 

with issues and problems that may be reinforcing substance abuse. These 

groups: 

•		Provide a structured environment within which group members can 

examine the behaviors, thoughts, and beliefs that lead to maladaptive 

behavior. 

•		Sometimes follow a treatment manual that provides specific protocols 

for intervention techniques. 

•		Emphasize structure, goal orientation, and a focus on immediate 

problems. Problemsolving groups often have a specific protocol that 

systematically builds problemsolving skills and resources. 

•		Use educational devices (e.g., visual aids, role preparation, memory 

improvement techniques, written summaries, review sessions, 

homework, audiotapes) to promote rapid and sustained learning. 

•		Encompass a variety of methodological approaches that focus on 

changing cognition (beliefs, judgments, and perceptions) and the 

behavior that flows from it. Some approaches focus on behavior, others 

on core beliefs, and still others on problemsolving abilities. 
2-9 

Module 2: Types of Groups Used in Substance Abuse Treatment 

PP 2-16
 

PP 2-17
 

Leaders in cognitive–behavioral groups: 

•		Have a solid grounding in the theory of cognitive–behavioral therapy. 

Training in cognitive–behavioral therapy is available. Chapter 7 in TIP 41 

provides information on training resources. 

•		Are actively engaged in the group and have a consistently directive 

orientation. 

•		Allow group members to use the power of the group to develop their 

own capabilities. Leaders 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 temptation. 

•		Recognize, respect, and work with resistance. Experienced leaders 

realize that resistance to change is inevitable and can address it without 

confrontation. TIP 35, Enhancing Motivation for Change in Substance 

Abuse Treatment, has numerous examples of rolling with resistance. 

The specific techniques used in cognitive–behavioral groups vary depending 

on the particular orientation of the leaders. In general, techniques: 

•		Teach group members about self-destructive behavior and thinking that 

lead to maladaptive behavior. 

•		Focus on problemsolving and short- and long-term goal setting. 

•		Help clients monitor feelings and behavior, particularly those associated 

with substance use. 
2-10 

TIP 41 Curriculum 

PP 2-18
 

PP 2-19
 

The widespread use of support groups originated in the self-help tradition of 

the substance abuse treatment field. These groups realize that significant 

lifestyle change is the long-term goal in treatment and that support groups 

can play a major role in such life transitions. The focus of support groups 

can range from strong leader-directed, problem-focused groups in early 

recovery, which focus on achieving abstinence and managing day-to-day 

living, to group-directed, emotionally and interpersonally focused groups in 

later stages of recovery. Support groups: 

•		Are useful for apprehensive clients who are looking for a safe 

environment. 

• Bolster members’ efforts to develop and strengthen their ability to 

manage thinking and emotions and to improve interpersonal skills as 

they recover from substance abuse. 

•		Address pragmatic concerns, such as maintaining abstinence and 

managing day-to-day living. 

• Improve members’ self-esteem and self-confidence. The group members 

and group leader provide specific kinds of support, such as helping 

members avoid isolation and finding something positive to say about 

other members’ contributions. 

Support groups always have clearly stated purposes that depend on the 

members’ motivation and stage of recovery. Support groups: 

•		Often are open ended, 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. Groups 

may continue indefinitely, with new members coming and old members 

leaving and occasionally returning. 

• Encourage discussion about members’ current situations and recent 

problems. Discussion usually focuses on staying abstinent. 

•		Provide peer feedback and require members to be accountable to one 

another. In cohesive, highly functioning support groups, member-tomember or leader-to-member confrontation can occur. 
2-11 

Module 2: Types of Groups Used in Substance Abuse Treatment 

PP 2-20
 

PP 2-21
 

Some support groups may be peer generated or led. Leaders are active but 

not directive. Leaders: 

•		Need solid grounding in how groups grow and evolve and the ways in 

which people interact and change in groups. 

•		Have a theoretical framework in counseling (e.g., cognitive–behavioral 

therapy) that informs their approach to support group development, 

therapeutic goals for group members, guidance of group members’ 

interactions, and implementation of specific interventions. 

•		Build connections among members and emphasize what members have 

in common. It is useful for leaders to have participated in a support 

group and to have been supervised in support group work before 

undertaking leadership of such a group. 

•		Are usually less directive than they are for other types of groups. The 

leader’s primary role is to facilitate group discussion and help group 

members share their experiences, grapple with their problems, and 

overcome difficult challenges. 

•		Provide positive reinforcement, model appropriate interactions, 

respect individual and group boundaries, and foster open and honest 

communication. 

Specific group techniques are less important in support groups than they 

are in other groups, so the leader usually has a less active role in group 

direction. The goal is to facilitate the evolution of support within the group. 

Techniques: 

• Vary with group goals and members’ needs. 

•		Facilitate discussion among members, maintain appropriate group 

boundaries, help the group work through obstacles and conflicts, and 

provide acceptance of and regard for members. 

•		Ensure that interpersonal struggles among group members do not 

hinder the development of the group or any members. 
2-12 

TIP 41 Curriculum 

PP 2-22
 

PP 2-23
 

PP 2-24
 

Interpersonal process groups should be led only by well-trained 

professionals. Today’s training provides only an overview. The therapeutic 

approach of interpersonal process groups focuses on healing by 

changing basic intrapsychic (within a person) and interpersonal (between 

people) dynamics. For those people who have become dependent on 

substances, the interpersonal process group raises and reexamines 

fundamental developmental issues. As faulty relationship patterns 

are identified, participants begin to change dysfunctional, destructive 

patterns. Participants become increasingly able to form mutually satisfying 

relationships with other people. Interpersonal process groups: 

•		Recognize that conflicting forces in the mind, some of which may be 

outside one’s awareness, determine a person’s behavior, whether 

healthful or unhealthful. 

•		Address developmental influences, starting in early childhood, and 

environmental influences, to which people are particularly vulnerable 

because of their genetic and other biological characteristics. 

Interpersonal process groups: 

•		Delve 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 lives. 

•		Use psychodynamics, or the way people function psychologically, to 

promote change and healing. 

•		Rely on here-and-now interactions of members. Of less importance is 

what happens outside the group or what happened in the past. 

Leaders must be trained in psychotherapy. Leaders: 

•		Focus on the present, noticing signs of people re-creating their past 

in what is going on between and among members of the group. For 

example, if a person has a problem with anger, this problem eventually 

will be reenacted in the group. 

•		Monitor how group members relate to one another, how each member 

is functioning psychological or emotionally, and how the group is 

functioning. 
2-13 

Module 2: Types of Groups Used in Substance Abuse Treatment 

PP 2-25
 

25 minutes 

PP 2-26 

PP 2-27
 

In practice, group leaders may use different models at various times and 

may focus on more than one aspect at a time. For example, a group that 

focuses on changing the individual will also have an impact on the group’s 

interpersonal relationships and the group as a whole. Techniques: 

•		Vary depending on the type of process group and the developmental 

stage of the group. 

•		Are based on the needs of group members and the needs of the group 

as a whole. 

•		Require a high degree of understanding about and insight into group 

dynamics and individual behavior. 

Presentation: Three Specialized Group Therapy Models in Substance 

Abuse Treatment 

For each type of group, the trainer allows participants to share 

experiences they have had as members or leaders of that 

particular group before moving on to the next group. 

Three specialized groups, which do not fit into the five model categories, 

function as unique entities in the substance abuse treatment field: 

•		Relapse prevention groups 

•		Communal and culturally specific groups 

•		Expressive groups (art therapy, dance, psychodrama) 

Relapse prevention groups focus on helping a client maintain abstinence or 

recover from relapse. Clients need to achieve a period of abstinence before 

joining a relapse prevention group. This kind of group is appropriate for 

clients who are abstinent but cannot necessarily maintain a drug-free state. 

Relapse prevention groups: 

•		Help clients maintain their recovery by providing them with skills to 

identify and manage high-risk situations. 

• Upgrade the clients’ abilities to manage risky situations and stabilize 

clients’ lifestyles through changes in behavior. 

•		Focus on activities, problemsolving, and skills building. 

• Increase clients’ feelings of self-control. 

•		Explore the problems of daily life and recovery. 
2-14 

TIP 41 Curriculum 

	 	 	 	 	 	 	

PP 2-28
 

PP 2-29 

PP 2-30
 

Leaders of relapse prevention groups need a set of skills that are similar 

to those needed for the skills development group, as well as experience 

working in relapse prevention. Group leaders: 

•		Monitor client participation for risk of relapse, signs of stress, and need 

for a particular intervention. 

•		Know how to handle relapse and help the group work through such an 

event in a nonjudgmental, nonpunitive way. 

•		Understand the range of consequences clients face because of relapse. 

•		Draw on techniques used in cognitive–behavioral, psychoeducational, 

skills development, and process-oriented groups. 

Communal and culturally specific groups use a specific culture’s healing 

practices and adjust therapy to cultural values. These groups: 

•		Build personal relationships with clients before turning to treatment 

tasks. 

•		Can be integrated into a therapeutic group. 

•		Show respect for a culture and its healing practices. 

Leaders: 

•		Strive to be culturally competent, avoid stereotypes, and allow clients to 

self-identify. 

•		Are aware of cultural attitudes. 

SAMHSA has published several books on topics that help counselors 

become culturally competent, including TIP 29, Substance Abuse Treatment 

for People With Physical and Cognitive Disabilities; TIP 51, Substance 

Abuse Treatment: Addressing the Specific Needs of Women; and A 

Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, 

Bisexual, and Transgender Individuals. These books are available from the 

SAMHSA Store at http://www.store.samsha.gov. Other resources are listed 

in Figure 3-7 (p. 48) of TIP 41. 
2-15 

Module 2: Types of Groups Used in Substance Abuse Treatment 

PP 2-31
 

PP 2-32
 

5 minutes 

Expressive groups use therapeutic activities that allow clients to express 

feelings and thoughts that may be difficult to communicate orally. 

Expressive groups: 

•		Foster social interaction as group members engage in a creative activity. 

•		Help clients explore their substance abuse, its origins (e.g., trauma), the 

effect it has had on their lives, and new options for coping. 

•		Depend on the form of expression clients are asked to use. 

Leaders: 

•		Need to be trained in the specific modality being used (e.g., art therapy, 

drama therapy). 

•		Can recognize signs related to histories of trauma and can help clients 

find the resources they need to work through powerful emotions. 

• Are sensitive to a client’s ability and willingness to participate in the 

activity. 

Summary 

The trainer: 

•	 Responds to participants’ questions or comments. 

•	 Encourages participants to review Chapter 2 of TIP 41. 

•	 Instructs participants to read Chapter 3 and reminds them to 

bring TIP 41 to the next training session. 

•	 Reminds participants of the date and time of the next training 

session. 

3-1 

	 	 	

5 minutes 

PP 3-1
 

Module 3: Criteria for the 

Placement of Clients in 

Groups 

Module 3 Overview 

The goal of Module 3 is to provide participants with an overview of how to 

match clients with groups depending on clients’ readiness to change and 

their ethnic and cultural experiences. The information in Module 3 covers 

Chapter 3 of Treatment Improvement Protocol (TIP) 41, Substance Abuse 

Treatment: Group Therapy. This module takes 1 hour to complete and is 

divided into five sections:

•	 Module 3 Goal and Objectives (5 minutes) 

•	 Presentation: Matching Clients With Groups (5 minutes) 

•	 Presentation: Assessing Client Readiness for Group (25 minutes) 

•	 Presentation: Ethnic and Cultural Experiences in Groups (20 minutes) 

•	 Summary (5 minutes) 

Module 3 Goal and Objectives 

After participants have taken their seats, the trainer instructs 

them to turn to Chapter 3 (p. 37) of TIP 41. 

Module 3 covers Chapter 3 of TIP 41. 
TIP 41 Curriculum 

PP 3-2 

PP 3-3
 

5 minutes	 

25 minutes 

PP 3-4
 

The goal of Module 3 is to provide an overview of how to match clients with 

groups, depending on clients’ readiness to change and their ethnic and 

cultural experiences. By the end of the session, you will be able to: 

• Match clients with substance abuse treatment groups. 

• Assess clients’ readiness to participate in group therapy. 

• Determine clients’ needs for specialized groups. 

Presentation: Matching Clients With Groups 

Matching each individual with the right group is critical for success in group 

therapy. Before placing a client in a particular group, the counselor 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 client’s ethnic and cultural experiences 

Placement choices are constantly subject to change. Clients may need to 

move to different groups as they progress through treatment, encounter 

setbacks, or become more or less committed to recovery. A client can 

move from a psychoeducational group to a relapse prevention group to an 

interpersonal process group. The client can also participate in more than 

one group at the same time. 

Presentation: Assessing Client Readiness for Group 

Placement begins with a thorough assessment of the client’s ability to 

participate in the group and the client’s needs and desires for treatment. 

This assessment begins when the client enters treatment and continues 

during the initial interview and through as long as the first 4 to 6 weeks of 

group participation. 

The assessment should inquire about all drugs used and look for crossaddictions. The client should be asked about his or her social network and 

experiences with and roles in groups in the past. 

Clinical observation and judgment, information from collateral resources, 

and findings of assessment instruments should contribute to the decision 

on a client’s readiness and appropriateness for group therapy. Either the 

group leader or another trained staff person should meet with the client 

before assignment to a group to evaluate how the client reacts to the group 

leader and to assess interpersonal relationship experiences. The client can 

also be observed in a waiting room with other clients to gain insight into 

how he or she relates to others. 

3-2 
3-3 

Module 3: Criteria for the Placement of Clients in Groups 

The counselor pays careful attention to a client’s relationships at the 

current stage of recovery because these relationships can reveal the 

client’s ability to participate in groups. Clients need to be able to engage 

with others. 

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 are in the process of 

resolving practical life problems. A person who is in the throes of acute 

withdrawal from crack cocaine does not belong in a group with people who 

have been abstinent for 3 months. Groups usually can be demographically 

heterogeneous (e.g., men and women, young and old clients, people of 

different races and ethnicities), but clients should be placed in groups with 

people with similar needs. 

PP 3-5 

Some clients may be inappropriate for group therapy: 

•		Clients who refuse to participate. No one should be forced to participate 

in group therapy. 

•		Clients who cannot honor group agreements. Sometimes, clients can 

have disqualifying pathologies such as personality disorders or paranoia. 

In other instances, clients cannot attend groups for logistical reasons 

such as a conflicting work schedule. 

•		Clients who are unsuitable for group therapy. Such people might be 

prone to dropping out or acting in ways contrary to the interests of the 

group. 

•		Clients in the throes of a life crisis. Such clients require more 

concentrated attention than groups can provide. 

•		Clients who cannot control impulses. Such clients may be suitable for 

homogeneous groups. 

•		Clients whose defenses would clash with the dynamics of the group. 

These people include those who cannot tolerate strong emotions or get 

along with others. 

•		Clients who experience severe internal discomfort in groups. 

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

suited to meet their needs. Client evaluators should review completed forms 

and meet with each candidate for group placement. The evaluator should 

listen carefully to determine the client’s hopes, fears, and preferences. 

After specifying the appropriate treatment level, a counselor meets with 

the client to identify options consistent with this level of care. More specific 

screens are needed to determine whether the client is appropriate for 

treatment in a group modality. 
3-4 

TIP 41 Curriculum 

PP 3-6
 

20 minutes 

PP 3-7
 

TIP 41 identifies several primary placement considerations: 

•		Women. Studies have shown that women do better in women-only 

groups than in mixed-gender groups. Women are more likely than men to 

have experienced traumatic events. Women are less willing to disclose 

their victimization in mixed-gender groups. 

•		Adolescents. Local, State, and Federal laws related to confidentiality; 

infectious disease control; parental permission and notification; child 

abuse, neglect, and endangerment; and statutory rape are important 

factors when substance abuse treatment services are delivered to 

minors. Other complications include school scheduling and the need to 

include family in the treatment process. 

•		Level of interpersonal functioning, including impulse control. Two 

questions to consider when determining a client’s level of functioning in 

a group setting include: 

–	 Does the client pose a threat to others? 

–	 Is the client prepared to engage in the give and take of groups dynamics? 

•		Motivation to abstain. Clients with low levels of motivation should be 

placed in psychoeducational groups, which can help them make the 

transition to the recovery-ready stage. 

•		Stage of recovery. Different types of groups are appropriate for clients 

at the different stages of recovery. Figure 3-2 in TIP 41 (p. 43) indicates 

client placement in specific groups based on the client’s stage of 

recovery. Figure 3-3 in TIP 41 (p. 44) indicates client placement in 

groups based on the readiness for change model discussed in Module 2. 

•		Expectation of success. Clients are expected to succeed in the groups. A 

poor match can be identified early through group monitoring. The group 

cannot succeed unless each member of the group gets something out of 

the experience. 

Presentation: Ethnic and Cultural Experiences in Groups 

Ethnic and cultural diversity issues take on added importance in a 

therapeutic group composed of many different kinds of people. 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 the 

counselor who is different. 

Diversity in TIP 41 means differences that distinguish an individual from 

others and that affect how an individual identifies himself or herself and 

how others identify him or her. It includes consideration of age, gender, 

cultural background, sexual orientation, ability level, social class, education 

level, spiritual background, parental status, and justice system involvement. 
3-5 

Module 3: Criteria for the Placement of Clients in Groups 

PP 3-8
 

A culturally homogeneous group tends to adopt roles and values from 

its culture of origin. However, group leaders should be aware that these 

roles may conflict with treatment requirements. If a group leader believes 

that cultural traditions might be a factor in a client’s participation or in 

misunderstandings among group members, the leader should check the 

accuracy of that perception with the client involved. However, individuals 

cannot always perceive or articulate their cultural assumptions. 

Group leaders should anticipate a particular group’s characteristics without 

automatically assigning them to all individuals in that group. For instance, 

it is a mistake for a program to assign all immigrants to a single group and 

assume they would be comfortable together. 

Leaders should be open and ready to learn all they can about their clients’ 

cultures. Ethnicity and culture have a profound effect on many aspects of 

treatment. 

Group leaders should be conscious of how their own backgrounds affect 

their ability to work with particular populations. For example, a group 

therapy leader who has survived domestic violence may have difficulties 

working with spouse abusers. 

The greater the mix of ethnicities in a group, the more likely that biases will 

emerge and require mediation. A client should not be asked to give up any 

cultural beliefs, feelings, or attitudes. The client should be encouraged to 

share these beliefs even though they may upset other members. Although 

group leaders may be uncomfortable when a member talks about racism 

and bigotry, such expressions may be an important part of a person’s 

recovery process. 
3-6 

TIP 41 Curriculum 

PP 3-9 
 

Before placing a client in a particular group, the counselor needs to 

understand the influence of culture, family structure, language, identity 

processes, health beliefs and attitudes, political issues, and stigma 

associated with minority status for each client who is a potential candidate 

for the group. The counselor needs to: 

•		Address the substance use problem in a manner that is congruent with 

the client’s culture. For instance, some cultures use substances as part 

of rituals. This entwinement of substance use and culture does not 

mean that the counselor cannot discuss the issue of this substance use 

with a client. Some clients 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 social occasions. A culturally sensitive 

discussion of this issue with clients may result in individual decisions to 

abstain on these occasions, despite cultural pressure to use. 

•		Assess the behaviors and attitudes of current group members to 

determine whether a new client would match the group. 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. Nevertheless, potential problems between a candidate 

and existing group members should be identified and counteracted to 

prevent dropout and promote engagement cohesion among members. 

•		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 prejudices 

and other sensitive topics. 
3-7 

Module 3: Criteria for the Placement of Clients in Groups 

PP 3-10
 

PP 3-11
 

Four major processes that occur within multiethnic groups have been 

identified: 

•		Symbolism and nonverbal communication. In some cultures, direct 

expression of thoughts and feelings is considered unseemly; symbolic 

gestures or nonverbal signals communicate indirectly and acceptably. 

The group leader should intervene if nonverbal communications are 

misinterpreted. 

•		Cultural transference of traits from one person of a certain culture 

to another person of that culture. If a member has had experiences 

(usually negative) with people of the same ethnicity as the group leader, 

the group member may transfer to the leader feelings and reactions 

developed with others of the leader’s ethnicity. To dispel such feelings 

and reactions, the group leader should detect these misconceptions and 

reveal them for what they are. 

• Cultural countertransference, the group leader’s (often subconscious) 

emotional reaction to a client. Countertransference of culture occurs 

when a leader’s response to a current group member is based on 

experience with a former group member of the same ethnicity as the 

new client. Group leaders should exercise restraint in these situations. 

•		Ethnic prejudice. In multiethnic groups, it is vital to develop an 

environment in which it is safe to talk about race. Not to do so results in 

scapegoating or division along racial lines. 

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. Leaders are 

responsible for considering carefully the positions of people who are 

different in some way, especially when planning fixed-membership groups. 

To promote group cohesion and welcome new members, the group leader 

should: 

•		Inform members in advance that people from a variety of racial and 

ethnic backgrounds 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. 
3-8 

TIP 41 Curriculum 

PP 3-12
 

PP 3-13
 

5 minutes 

•		Help clients adapt to and cope with prejudice in effective ways, while 

maintaining their self-esteem. 

•		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. 

Although arguments for matching the ethnicity of a group leader with that of 

the group members being treated may have some merit, the reality is that 

such a course seldom is feasible. Healthcare providers from culturally and 

linguistically diverse groups are underrepresented in the current service 

delivery system, so the group leader will likely be from the mainstream 

culture. Although it might be ideal to match all participants by ethnicity in 

a therapeutic group, the most important determinants for success are the 

values and attitudes shared by the group leader and group members. 

Groups may include people who have varying: 

•		Expectations of leaders (Some cultures might consider leaders 

problemsolvers, whereas in other cultures leaders might be considered 

equals until proven otherwise.) 

•		Experience in decisionmaking and conflict resolution 

•		Understanding of gender roles, families, and community 

•		Values 

Summary 

The trainer: 

•	 Responds to participants’ questions or comments. 

•	 Encourages participants to review Chapter 3 of TIP 41. 

•	 Instructs participants to read Chapter 4 and reminds them to 

bring TIP 41 to the next training session. 

•	 Reminds participants of the date and time of the next training 

session. 
4-1 

	 	 	 	 	 	 	 	 	 	 	 	 	 	

5 minutes 

PP 4-1
 

Module 4: Group 

Development and Phase– 

Specific Tasks 

Module 4 Overview 

The goal of Module 4 is to provide participants with an overview of the uses 

of fixed and revolving groups and an overview of the tasks for the three

phases of group development. The information in Module 4 covers Chapter 

4 of Treatment Improvement Protocol (TIP) 41, Substance Abuse Treatment: 

Group Therapy. This module takes 1 hour to complete and is divided into 

five sections:

•	 Module 4 Goal and Objectives (5 minutes) 

•	 Presentation: Fixed and Revolving Membership Groups (10 minutes) 

•	 Presentation: Preparing for Client Participation in Groups (25 minutes) 

•	 Presentation: Phase-Specific Group Tasks (15 minutes) 

•	 Summary (5 minutes) 

Module 4 Goal and Objectives 

After participants have taken their seats, the trainer instructs 

them to turn to Chapter 4 (p. 59) of TIP 41. 

Module 4 covers Chapter 4 of TIP 41. 
TIP 41 Curriculum 

PP 4-2 

10 minutes 

PP 4-3
 

PP 4-4
 

The goal of Module 4 is to provide an overview of fixed and revolving 

membership groups and an overview of the tasks for the three phases of 

group development. By the end of the session, you will be able to: 

•		Distinguish the differences between fixed and revolving membership groups. 

•		Prepare clients for groups. 

•		Describe the tasks for each of the three phases of group development. 

Presentation: Fixed and Revolving Membership Groups 

Members of fixed membership groups generally stay together for a long 

time. Members in revolving membership groups remain in the group only 

until they accomplish their goals. Each is used for different purposes, and 

each requires different leadership. 

Fixed membership groups are small (not more than 15 members) and 

membership is stable. The group leader usually screens prospective members, 

who are prepared for participation. Fixed membership groups can be: 

•		Time limited. The same group of people attends a specified number 

of sessions, generally starting and finishing together. Learning builds 

on what has taken place in prior meetings. Members need to be in the 

group from its start. New members are admitted only in the earliest 

stages of group development. Time-limited groups are used for skillbuilding, psychoeducational, and relapse prevention groups. 

•		Ongoing. New members fill vacancies in a group that continues over a 

long period. The size of the group is set. The leader generally is less active 

than is the leader of a time-limited group because interaction among 

group members is more important than leader-to-member interactions. 

Leaders need substantial training in group dynamics. Ongoing groups are 

used for interpersonal process and some psychoeducational groups. 

Fixed groups are rare in substance abuse treatment because they demand 

a long-term commitment of resources. 

New members enter a revolving membership group when they become 

ready for the services it provides. Revolving groups must adjust to frequent 

unpredictable changes. Revolving groups are also: 

•		Time limited. Each member attends a specified number of sessions, 

generally starting and finishing at his or her own pace. 

•		Ongoing. The member remains until he or she has accomplished his or 

her specified goals. 

These groups are frequently found in inpatient treatment programs. 

Revolving member groups tend to be larger than fixed membership groups. 

However, if they are larger than 20 members, group interactions break down. 

4-2 
4-3 

Module	 	 	 4: Group Development	 	 and Phase–Specific Tasks

 

25 minutes 

PP 4-5
 

PP 4-6
 

Revolving membership groups are structured and require active leadership. 

Participation and learning are not highly dependent on previous sessions. 

Members who have been in the group for several meetings often help orient 

new members. 

Figure 4-1 in TIP 41 (p. 62) provides a comparison of the characteristics of 

fixed and revolving membership groups. 

Presentation: Preparing for Client Participation in Groups 

The process of preparing the client for participation in group therapy begins 

as early as the initial contact between the client and the program. Group 

leaders should conduct an initial individual session 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 explain the group agreement. 

The longer the expected duration of the group, the longer the preparation 

phase. During this time, the group leader learns how the client handles 

interpersonal functions, how the client’s family functions, and how the 

client’s culture perceives the substance use problem. 

Preparation meetings ensure that clients understand expectations and will 

be able to meet them, and they help clients become familiar with the group 

therapy process. Client preparation should: 

•		Explain how group interactions compare with those in self-help groups. 

Clients should be informed that member-to-member “cross-talk,” which is 

discouraged in 12-Step groups, is essential in interactive group therapy. 

•		Emphasize that treatment is a long-term process. Clients should know that 

each person’s attendance at each session is vital during this process. 

•		Let new members know they may be tempted to leave the group at times. 

Clients gain a great deal from persistent commitment to the process 

and should resist temptations to leave the group. Clients should be 

encouraged to discuss thoughts about leaving the group as they arise. 

•		Give prospective members an opportunity to express anxiety about group 

work. Misperceptions should be countered to keep them from interfering 

with group participation. 

• Recognize and address clients’ therapeutic hopes. Leaders can use this 

information to place clients in groups most likely to fulfill their aspirations. 

Leaders should be sensitive to people who are different from the majority of 

other participants in some way. Clients should always be allowed to be the 

experts on their own situations. 

Leaders are responsible for raising the level of the group members’ sensitivity 

and empathy. They must sometimes prepare group members for a situation 

in which others have symptoms that could offend or repel them. 
4-4 

TIP 41 Curriculum 

PP 4-7
 

PP 4-8
 

PP 4-9
 

Retention rates are affected positively by client preparation, maximum 

client involvement during the early stage of treatment, the use of feedback, 

prompts to encourage attendance, and the provision of wraparound 

services to make it possible to attend sessions regularly. Consideration 

needs to be given to the timing and length of groups. To achieve maximum 

involvement in group therapy, motivational techniques may be used to 

engage clients. 

Techniques that increase retention include the following: 

•		Role induction uses 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 uses interviews, lectures, films, and other settings 

to demonstrate what takes place during therapy so that the client can 

experience the process vicariously. 

•		Experiential pretraining uses group exercises to teach client behaviors 

such as self-disclosure and examination of emotions. 

•		Motivational interviewing uses specific listening and questioning 

strategies to help clients overcome doubts about making changes. 

•		Prompts remind clients that upcoming group sessions are important in 

engaging members during the first 3 months of treatment. 

A group agreement establishes the expectations that group members 

have for one another, the leader, and the group. Many leaders require that 

group members entering a long-term fixed membership group commit to 

remaining in the group for a set period. 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. 

A group agreement should include at least eight elements. 

•		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 

because court-mandated treatment groups may have attendance criteria 

set by the State. 

•		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 

encourage members to honor their pledge of confidentiality. The 

principle that “what’s said in the group stays in the group” is a way of 

delineating group boundaries and increasing trust. 
4-5 

Module	 	 	 4: Group Development	 	 and Phase–Specific Tasks

•		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 as part of 

a group ritual is not recommended. Group agreements always should 

include a clause prohibiting violence. 

•		Use of mood-altering substances. Some programs, such as those 

connected to criminal justice systems, have policies that require 

expulsion of members who are using drugs of abuse. Counselors 

are required to report these violations. Part of client preparation 

and orientation is to explain all legally mandated provisions and 

consequences for failure to comply with treatment guidelines. Members 

also should pledge to discuss a return to use promptly after it occurs, 

providing the group rules permit and encourage such disclosures. 

•		Contact outside the group. Clients who have bonded in group are likely 

to communicate outside the group and may encounter one another at 

self-help meetings. Group members need to be told and reminded that 

new intimate relationships are hazardous to early recovery. Any contacts 

outside the group should be discussed openly in the group. 

•		Participation in the group. The agreement should specify what group 

members are expected to divulge. Group members should be willing 

to discuss the issues that brought them to group. They should not be 

required to share personal information until they feel safe enough to 

do so. 

•		Financial responsibility. The agreement may specify a commitment 

to discuss any problems that occur in making payments and the 

circumstance under which a group member is held responsible for 

payment. For example, 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 

handle termination. Because group members often are tempted to leave 

the group prematurely, the agreement should emphasize the need to 

involve the group in termination decisions. However, members make 

their own choices about discontinuing treatment. 
4-6 

TIP 41 Curriculum 

15 minutes 

PP 4-10
 

Presentation: Phase-Specific Group Tasks 

Every group has a beginning, middle, and end. These phases occur at 

different times for different types of groups. 

During the beginning phase, the purpose of the group is articulated, 

working conditions of the group are established, members are introduced, 

a positive tone is set, 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. Five activities are 

conducted in the beginning phase: 

•		Introductions. Even in short-term revolving membership groups, it is 

important for the leader to connect with each member. All members 

should give their names and say something about themselves. The 

leader can build bridges between the old and new members by 

encouraging old members to help new members join. 

•		Group agreement review. The group members should review and discuss 

the group agreement. The leader should ask members whether they 

have concerns that might require additional provisions to make the 

group safe. The agreement should be reviewed periodically during the 

course of the group. 

•		Providing a safe, cohesive environment. All members should feel that they 

have a part to play in the group and have something in common. This 

cohesion affects the productivity of work throughout the therapeutic process. 

•		Establishment of norms. The group leader is responsible for ensuring 

that healthful norms are established and that counterproductive norms 

are precluded, ignored, or extinguished. The leader shapes norms 

through responses to events in the group and by modeling the behavior 

expected of others. 

•		Initiation of group work. The leader facilitates group work by providing 

information or encouraging honest exchanges among members. Most 

leaders strive to keep the group focused on the here and now. 

PP 4-11	 

The group in the middle phase encounters and accomplishes most of the 

therapy work. 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 both the content and 

the process. Both contribute to the connections between and among group 

members. 

The group is the forum where clients interact with others. Through give and 

take, clients receive feedback that helps them rethink their behaviors and 

move toward productive changes. Leaders allocate time to address issues 

that arise, pay attention to relations among group members, and model a 

healthful interactional style that combines honesty with compassion. 
4-7 

Module	 	 	 4: Group Development	 	 and Phase–Specific Tasks

PP 4-12
 

5 minutes 

Termination is an 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 learn and practice saying 

“good-bye,” understanding that it is necessary to make room in their lives 

for the next “hello.” 

This phase begins when the group reaches its agreed-on termination point 

or a member determines it is time to leave the group. 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 

•		Exploring ways to continue learning about topics discussed in the group 

Completing a group successfully can be an important event for group 

members when they see the conclusion of a difficult but successful 

endeavor. The longer members have been with the group, the longer they 

may need to spend on termination. 

Summary 

The trainer: 

•	 Responds to participants’ questions or comments. 

•	 Encourages participants to review Chapter 4 of TIP 41. 

•	 Instructs participants to read Chapter 5 and reminds them to 

bring TIP 41 to the next training session. 

•	 Reminds participants of the date and time of the next training 

session. 

5-1 

5 minutes 

PP 5-1
 

Module 5: Stages 

of Treatment 

Module 5 Overview 

The goal of Module 5 is to provide participants with an overview of 

adjustments that can be made in the early, middle, and late stages of 

treatment. The information in Module 5 covers Chapter 5 of Treatment 

Improvement Protocol (TIP) 41, Substance Abuse Treatment: Group 

Therapy. This module takes 1 hour to complete and is divided into four 

sections: 

•	 Module 5 Goal and Objectives (5 minutes) 

•	 Presentation: Adjustments To Make Treatment Appropriate (5 minutes) 

•	 Presentation: The Stages of Treatment (45 minutes) 

•	 Summary (5 minutes) 

Module 5 Goal and Objectives 

After participants have taken their seats, the trainer instructs 

them to turn to Chapter 5 (p. 79) of TIP 41. 

Module 5 covers Chapter 5 of TIP 41. 
TIP 41 Curriculum 

PP 5-2
 

PP 5-3
 

5 minutes 

The goal of Module 5 is to provide an overview of adjustments that can 

made in the early, middle, and late stages of treatment. By the end of the 

session, you will be able to: 

•		Discuss the importance of making clinical adjustments in the group 

therapy. 

•		Explain the three stages of treatment. 

•		Describe the conditions of the early, middle, and late stages of 

treatment. 

•		Identify leadership characteristics in the early, middle, and late stages of 

treatment. 

Presentation: Adjustments To Make Treatment Appropriate 

Treatment has three stages: 

•		In the early stage of treatment, clients can be emotionally fragile, 

ambivalent about relinquishing chemicals, and resistant to treatment. 

Treatment strategies focus on immediate concerns: achieving 

abstinence, preventing relapse, and managing cravings. In this stage 

leaders emphasize hope, group cohesion, and universality. 

• In the middle 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 the things they want. As clients sever their 

ties with substances, they need help managing their loss and finding 

healthful substitutes. 

•		In the last stage of treatment, clients spend less time on their substance 

abuse issues and turn toward identifying the treatment gains to be 

maintained and risks that remain. Clients focus on the issues of living, 

resolving guilt, reducing shame, and adopting a more introspective view 

of themselves. 

Therapeutic strategies change as clients move through the different stages. 

Interventions that worked well early in treatment may be ineffective and 

even harmful later in treatment. 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. 

Adjustments in treatment are needed because progress through the stages 

is not time bound. There is no way to calculate how long an individual will 

require to resolve the issues that arise in any stage of recovery. 

Therapeutic interventions may not account for all of the changes in a 

particular individual. Generalizations about stages of treatment may not 

apply to every client in every group. 

5-2 
5-3 

Module 5: Stages of Treatment 

45 minutes 

PP 5-4
 

PP 5-5
 

Presentation: The Stages of Treatment 

Typically, people who abuse substances do not enter treatment on their 

own. Some enter treatment because of health problems; others begin 

treatment because they are referred or mandated by the criminal justice 

system, employers, or family members. Group members commonly are in 

extreme emotional turmoil, grappling with intense emotions such as guilt, 

shame, depression, and anger about entering treatment. Consequently, the 

group leader faces the challenge of treating resistant clients. Emphasis is 

placed on acculturating clients into a new culture, the culture of recovery. 

Eleven therapeutic factors contribute to healing as group therapy unfolds: 

1.	 Instilling hope. Some group members exemplify progress toward 

recovery and support others in their efforts. 

2.	 Universality. Groups enable clients to see that they are not alone and 

that others have similar problems. 

3.	 Imparting information. Leaders shed light on the nature of addiction 

via direct instruction. 

4.	 Altruism. Group members gain greater self-esteem by helping one 

another. 

5.	 Corrective recapitulation of the primary family group. Groups provide 

a family-like context in which longstanding unresolved conflicts can 

be revisited and constructively resolved. 

6.		 Developing socializing techniques. Groups give feedback; others’ 

impressions reveal how a client’s ineffective social habits might 

undermine relationships. 

7.	 Imitative behavior. Groups permit clients to try out behaviors of others. 

8.	 Interpersonal learning. Groups correct the distorted perceptions of 

others. 

9.	 Group cohesiveness. Groups provide a safe environment within 

which people feel free to be honest and open with one another. 

10. Catharsis. Groups liberate clients as they learn how to express 

feelings and reveal what is bothering them.
 

11. Existential factors. Groups aid clients in coming to terms with hard 

truths such as life can be unfair; life can be painful, and death is 

inevitable; no matter how close one is to others, life is faced alone; it 

is important to live honestly and not get caught up in trivial matters; 

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. 
5-4 

TIP 41 Curriculum 

PP 5-6
 

PP 5-7
 

PP 5-8 

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 be revealing personal information and secrets about themselves. The 

leader begins by stressing that clients have some things in common. 

During early treatment, a leader actively engages clients in the treatment 

process. Clients early on usually respond to group leaders who are 

spontaneous and engaging. The leader should not be overly charismatic 

but should be a strong enough presence to meet clients’ dependence 

needs during the early stage of treatment. During early treatment, effective 

leaders focus on immediate primary concerns: 

• Achieving abstinence 

• Preventing relapse 

• Learning ways to manage cravings 

Cognitive capacity usually begins to return to normal in the middle stage 

of treatment. A person addicted to cocaine, for example, is dramatically 

different after 4 months of nonuse. Still, the mind can play tricks. 

Clients may remember distinctly the comfort of their past substance 

use yet forget how bad the rest of their lives were and the seriousness 

of the consequences that loomed before they came into treatment. The 

temptation to relapse remains a concern. 

In the middle stage of treatment, as the client experiences some stability, 

the therapeutic factors of self-knowledge and altruism can be emphasized. 

Universality, identification, cohesion, and hope remain important.
	

As the recovering client’s mental, physical, and emotional capacities grow 

stronger, emotions of 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. 
5-5 

Module 5: Stages of Treatment 

PP 5-9	 

PP 5-10	 

When pointing out contradictions in clients’ statements and interpretations 

of reality, leaders should ensure that confrontations are well timed, specific, 

and indisputably true. 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. In the middle stage, 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 attention to internal cues. 

The leader can support the process of change by drawing attention to 

new and positive developments and affirming the possibility of increased 

connections and new sources of satisfaction. The leader helps individuals 

assess the degree of structure and connection they need as recovery 

progresses. 

In the late (also referred to as ongoing or maintenance) stage of treatment, 

clients work to sustain the achievements of previous stages, but also learn 

to anticipate and avoid tempting situations and triggers that set off renewed 

substance use. To deter relapse, the lifestyle that once promoted drinking 

and drug use are sought out and severed. 

Many clients, even those who have reached the late stage of treatment, do 

return to substance use and an earlier stage of change. 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 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. 

As the substance use problem fades into the background, significant 

underlying issues often emerge, such as poor self-image, relationship 

problems, the experience of shame, or past trauma. 

When the internalized pain of the past is resolved, the client will begin to 

understand and experience healthful 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, overspending, gambling, 

and excessive sexual activity, among others. 
5-6 

TIP 41 Curriculum 

PP 5-11
 

PP 5-12
 

5 minutes 

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 late-stage 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 interactions. 

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 emotion. A process-oriented group may become appropriate 

for some clients who can confront painful realities, such as being abused as a 

child or being an abusive parent. Other clients may need groups to help them 

build healthier relationships, communicate more effectively, or become better 

parents. Some may want to develop job skills. As group members become 

increasingly stable, they can begin to probe deeper into the relational past. The 

group can be used to settle difficult and painful old business. 

The leader plays a very different role in the late stage of treatment, which 

refocuses on helping group members expose and eliminate personal deficits 

that endanger recovery. Gradually, the leader shifts toward interventions that 

call on clients to take a clear-headed 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 substances to 

escape reality, self-soothe, or regulate emotions.
 

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. Late-stage interventions 

permit more intense exchanges. Thus, in late treatment, clients are no longer 

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 should manage the 

conflicts that dominate their lives, predispose them to maladaptive behaviors, 

and endanger their hard-won abstinence. The leader allows clients to experience 

enough anxiety and frustration to identify destructive and maladaptive patterns. 

Summary 

The trainer: 

•	 Responds to participants’ questions or comments. 

•	 Encourages participants to review Chapter 5 of TIP 41. 

•	 Instructs participants to read Chapter 6 and reminds them to 

bring TIP 41 to the next training session. 

•	 Reminds participants of the date and time of the next training 

session. 
6-1 

5 minutes 

PP 6-1
 

Module 6: Group Leadership, 

Concepts, 

and Techniques
 

Module 6 Overview 

The goal of Module 6 is to provide participants with an overview of 

desirable leader traits and behaviors and an overview of the concepts and 

techniques vital to process groups. The information in Module 6 covers 

Chapter 6 of Treatment Improvement Protocol (TIP) 41, Substance Abuse 

Treatment: Group Therapy. This module takes 1 hour to complete and is 

divided into four sections: 

•	 Module 6 Goal and Objectives (5 minutes) 

•	 Presentation: The Group Leader (20 minutes) 

•	 Presentation: Concepts and Techniques (30 minutes) 

•	 Summary (5 minutes) 

Module 6 Goal and Objectives 

After participants have taken their seats, the trainer instructs 

them to turn to Chapter 6 (p. 91) of TIP 41. 

Module 6 covers Chapter 6 of TIP 41. 
TIP 41 Curriculum 

PP 6-2 

20 minutes 

PP 6-3
 

PP 6-4
 

The goal of Module 6 is to provide an overview of desirable leader traits and 

behaviors and an overview of the concepts and techniques vital to process 

groups. By the end of the session, you will be able to: 

•		Discuss the characteristics of group leaders. 

• Describe concepts and techniques for conducting substance abuse 

treatment group therapy. 

Presentation: The Group Leader 

When 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 particular personal and cultural 

characteristics of the clients in the group also influence the leader’s 

tailoring of therapeutic strategies to fit the particular needs of the group. 

Clients typically respond to a warm, empathic, and life-affirming manner. 

Group leaders should communicate and share the joy of being alive. This 

life-affirming attitude carries the unspoken message that a full and vibrant 

life is possible without alcohol or drugs. The leader 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 

• The means of resolving numerous other issues 

It is essential for the leader to be aware of the choices made and to 

remember that all choices concerning his or her leadership and the group’s 

structure have consequences. 

TIP 41 identifies nine personal qualities of leaders: 

•		Constancy. An environment with small, infrequent changes is helpful 

to clients living in the emotionally turbulent world of recovery. Group 

leaders can emphasize the reality of constancy and security through 

their behavior. For example, group leaders should always sit in the same 

place in group, maintain consistent start and end times and ground rules 

for speaking, and even dress in a consistent manner. 

•		Active listening. Excellent listening skills are the keystone of any effective 

therapy. Therapeutic interventions require the leader to perceive 

and to understand both verbal and nonverbal cues to meaning and 

metaphorical levels of meaning. 

6-2 
6-3 

Module 6: Group Leadership, Concepts, and Techniques 

 

•		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, leaders who are aware of 

their own capacities and tendencies can recognize their own defenses as 

they come into play in the group. Group work can be intensely emotional. 

Leaders who are not in control of their own reactions can do significant 

harm—particularly if they cannot admit to a mistake or apologize for it. 

•		Confidence. Effective 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 self-knowledge 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. 

• Integrity. 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. 

•		Trust. Leaders should be able to trust others. 

•		Humor. Leaders need 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. One of the cornerstones of successful group therapy for 

substance abuse, empathy is the ability to identify someone else’s 

feelings while remaining aware that the feelings of others are distinct 

from one’s own. For the counselor, the ability to project empathy is an 

essential skill. An empathic leader: 

–	 Communicates respect for and acceptance of clients and their feelings. 

–	 Encourages in a nonjudgmental, collaborative relationship. 

–	 Is supportive and knowledgeable. 

–	 Sincerely compliments rather than denigrates or diminishes another 

person. 

–	 Tells less and listens more. 

–	 Gently persuades but understands that the decision to change is the 

client’s. 

–	 Provides support throughout the recovery process. 

One of the feelings that the leader needs to empathize with is shame, 

which is common among people with substance use histories. Shame is so 

powerful that it should be addressed whenever it becomes an issue. 

Group therapy with clients who have histories of substance abuse requires 

active, responsive leaders who keep the group lively and on task and ensure 

that members are engaged continuously and meaningfully with one another. 
6-4 

TIP 41 Curriculum 

PP 6-5
 

•		Leaders vary therapeutic styles to meet the needs of clients. During the 

early and middle stages of treatment, the leader is active, becoming 

less so in the late stage. To determine the type of leadership required 

to support a client in treatment, the leader should consider the client’s 

capacity to manage affect, level of functions, social supports, and 

stability. These considerations are essential to determine the type of 

group best suited to meet the client’s needs. 

•		Leaders model behavior. It is more useful for the leader to model groupappropriate behaviors than to assume the role of mentor. Leaders 

should be aware that self-disclosure is always occurring, whether 

consciously or subconsciously. They should use self-disclosure only 

to meet the task-related needs of the group and only after thoughtful 

consideration. When personal questions are asked, leaders need to 

consider the motivation behind the question. Often clients are seeking 

assurance that the leader understands and can assist them. 

•		Leaders can be cotherapists. Cotherapy (also called coleadership) is 

an effective way to blend diverse skills, resources, and therapeutic 

perspectives that two therapists can bring to the group. It provides an 

opportunity to watch adaptive behavior. A male–female cotherapy team 

may be especially helpful; it shows people of opposite sexes engaging in 

a healthful, nonexploitative relationship. 

•		Leaders are sensitive to ethical issues. As the group process unfolds, 

the leader needs to be alert, always ready to perceive and resolve issues 

with ethical dimensions. Typical situations with ethical concerns include: 

–	 Overriding group agreement. 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. Sometimes the needs of the group 

override courtesies shown to an individual. For example, if a member 

becomes seriously ill and must miss sessions, other members may 

want to express their concerns for the missing member in the group 

even though they have agreed not to discuss absent members. 

–	 Informing clients of options. Even when group participation is 

mandated, clients should be informed of options open to them. 

For example, a member deserves the option to discuss with an 

administrator a leader’s behavior that the client finds inappropriate. 

–	 Preventing enmeshment. Leaders should be aware that the power of 

groups can have a dark side. 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. The leader needs to monitor group 

sharing to ensure that clients are not drawn into situations that 

violate their privacy or integrity; the leader is obligated to respect the 

rights and best interests of individuals. 
6-5 

Module 6: Group Leadership, Concepts, and Techniques 

–		 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. The leader is responsible for challenging 

conclusions or recommendations that deny individual autonomy or 

could lead to serious negative consequences. 

PP 6-6
 

PP 6-7
 

• Leaders handle emotional contagion. Another’s sharing can stir 

frightening memories and intense emotions in listeners. In this 

atmosphere, leaders are required to: 

–	 Protect individuals. The leader should guard the right of each member 

to refrain from involvement, making it clear that each member has 

the right to private emotions and feelings. 

–	 Protect boundaries. No one should be obligated to share intimate 

details. 

–	 Regulate affect. The leader needs to modulate affect (emotionality), 

always keeping it at a level that enables the work of the group to 

continue. 

•		Leaders work within professional limitations. Leaders should never 

attempt to use techniques for which they are not trained or with 

populations or in situations for which they are unprepared. When new 

techniques are used or new populations are being served, leaders 

should have appropriate training and supervision. 

• Leaders ensure flexibility in clients’ roles. Although it is natural for 

members to assume certain roles (one client may naturally take on the 

role of a leader, whereas another may assume the role of scapegoat), 

individual members benefit from experiencing aspects of themselves in 

different roles. Role variation keeps the group lively and dynamic. 

•		Leaders avoid role conflict. Leaders should be sensitive to issues of dual 

relationships. A leader’s responsibilities outside the group that place him or 

her in a different relationship to group participants should not be allowed to 

compromise the leader’s in-group role. For example, leaders should avoid 

attending self-help meetings at which group members are present. 

•		Leaders improve motivations. Motivation generally improves when: 

–	 Members are engaged at the appropriate stage of change. 

–	 Members receive support for change efforts. 

–	 The leader explores choices and their consequences with members. 

–	 The leader communicates care and concern for members. 

–		 The leader points out members’ competencies. 

–	 Positive changes are noted in and encouraged by the group. 
6-6 

TIP 41 Curriculum 

PP 6-8
 

•		Leaders work with, not against, resistance. Resistance generally arises 

as a defense against the pain that therapy and examining one’s behavior 

usually brings. In group therapy, resistance is at the individual and 

group levels. The leader should have a repertoire of means to overcome 

resistance that prevents success. 

•		Leaders protect against boundary violations. Providing a safe, 

therapeutic frame for clients and maintaining firm boundaries are 

among the most important functions of the leader. The boundaries 

established should be mutually agreed on and specified in a group 

agreement or the ground rules. Boundary violations should be pointed 

out in a nonjudgmental, matter-of-fact way. 

•		Leaders maintain a safe, therapeutic setting: 

–	 Emotional aspects of safety. Members should learn to interact in 

positive ways. They need to feel safe without blaming or scapegoating 

others. If a member makes an openly hostile comment, the leader 

should clearly state that members are not to be attacked. 

–	 Substance use. The presence of an intoxicated group member will 

upset many members. The leader should ask the person who has 

relapsed to leave the current session. After the person has left, group 

members can explore feelings about the relapse and affirm their 

abstinence. 

–	 Boundaries and physical contact. When physical boundaries are 

breached in the group and no one in the group raises the issue, the 

leader should remind the members of the terms of the agreement 

and call attention to the questionable behavior in a straightforward 

way. A leader should know the agency’s policies regarding violent 

behavior. Members should be allowed to opt out of activities that 

involve physical contact. 

•		Leaders help cool down affect. Leaders carefully monitor the level of 

emotional intensity in the group, recognizing that too much too fast can 

bring on extremely uncomfortable feelings that interfere with progress. 

When intervening to control runaway affect, leaders should be careful to 

support the genuine expressions of emotions that are appropriate for the 

group and the individual’s stage of change. 

• Leaders encourage communication within the group. Leaders’ primary 

task is stimulating communication among group members, rather than 

between individual members and the leader. Leaders can do this by 

praising good communication, noticing a person’s body language and 

asking the person to express the feeling, and helping members know 

that their contributions are important. Leaders should speak often 

but briefly. 
6-7 

Module 6: Group Leadership, Concepts, and Techniques 

30 minutes 

PP 6-9
 

PP 6-10
 

PP 6-11 

Presentation: Concepts and Techniques 

Interventions may be directed to an individual or the group. They can be 

used to clarify what is going on, redirect energy, stop a process that is 

not helpful, or help the group decide what should be done. A well-timed, 

appropriate intervention has the power to: 

•		Help a client connect with other people. 

•		Discover connections between the use of substances and inner thoughts 

and feelings. 

•		Understand attempts to regulate feelings and relationships. 

•		Build coping skills. 

• Perceive the effect of substance use on one’s life. 

•		Notice meaningful inconsistencies among thoughts, feelings, and 

behavior. 

•		Perceive discrepancies between stated goals and what is actually being 

done. 

To move away from the center stage, leaders can: 

•		Build skills in members; 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. Too much or too frequent support from 

the leader can lead to approval seeking, which blocks growth and 

independence. Supporting one another is a skill that should develop 

through group phases. 

•		Refrain from overresponsibility for clients. Clients should be allowed to 

struggle with what is facing them. 

Group leaders 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. A more useful way 

to think about confrontation is pointing out inconsistencies such as 

disconnects between behaviors and stated goals. Confrontation used this 

way is part of the change process and part of the helping process. It helps 

clients see and accept reality, so they can change accordingly. 
6-8 

TIP 41 Curriculum 

PP 6-12
 

PP 6-13
 

PP 6-14
 

Transference means that people project parts of important past 

relationships into present relationships. 

Emotions inherent in groups are not limited to clients. The groups inevitably 

stir up strong feelings in leaders. Countertransference is the group therapy 

leader’s emotional response to a group member’s transference. Examples 

include: 

•		Feelings of having been there. Leaders with histories of substance 

abuse have an extraordinary ability to empathize with clients who abuse 

substances. If that empathy is not understood or controlled, it can 

become a problem if the group leader tries to act as a role model or 

discloses too much personal information. 

•		Feelings of helplessness when the leader is more invested in the 

treatment than the clients are. 

•		Feelings of incompetence because of unfamiliarity with culture and 

jargon. The leader should ask clients to explain terms and expressions 

that can be misunderstood. 

The leader needs to manage all feelings associated with 

countertransference. With the help of supervision, the leader can use 

countertransference to support the group process. 

Resistance arises as a client’s subconscious defense to protect himself 

or herself from the pain of self-examination and change. 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 or group understand what is getting in the 

way, welcoming the resistance as an opportunity to understand something 

important for the client or the group. 

Leaders should recognize that members are not always aware of their 

reasons for resistance. They should explore what is happening and what 

can be learned from it, not battle the resistance. Leaders may have 

contributed to the resistance, and efforts need to be made to understand 

the problem. 

Strict adherence to confidentiality regulations builds trust. If the bounds 

of confidentiality are broken, serious legal, personal, and professional 

consequences may result. All group leaders should be thoroughly familiar 

with Federal laws on confidentiality and relevant agency policies. Leaders 

should warn clients that what they say in group may not be kept strictly 

confidential. 

Group leaders have many sources of information on a client, including 

the client’s employers and spouse. Leaders should clearly explain how 

information from these sources may and may not be used in group. 
6-9 

Module 6: Group Leadership, Concepts, and Techniques 

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. 

PP 6-15 

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 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. 

It is common for a client to be in both individual and group therapy 

simultaneously. The dual relationship creates both problems and 

opportunities. Skilled counselors can use what they discover in group about 

the client’s style of relatedness to enhance individual therapy. In situations 

in which one counselor sees a client individually and another treats the 

same client in group, the counselors should be in close communication with 

each other. They 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. 

Leaders should be aware of various medication needs of clients, the 

types of medications prescribed, and potential side effects. The pregroup 

interview for long-term groups should ask each group member what 

medications he or she is taking and the names of prescribing physicians 

so cooperative treatment is possible. (Consent forms for the sharing 

of information should be signed when appropriate.) 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 dependence. Attention needs to be paid to 

medications prescribed for physical illnesses as well. 
6-10 

TIP 41 Curriculum 

PP 6-16
 

PP 6-17
 

Conflict in group therapy is normal, healthful, and unavoidable. It can 

present opportunities for group members to find meaningful connections 

with one another and within their lives. 

Handling anger, developing empathy for a different viewpoint, managing 

emotions, and working through disagreements respectfully are 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 go too far as it is to shut down a conflict before 

it gets worked through. The group leader must gauge the verbal and 

nonverbal reactions of every group member to ensure that everyone can 

manage the emotional level of the conflict. 

The leader facilitates interactions between members in conflict and calls 

attention to subtle, unhealthful patterns. Conflicts within groups may be 

overt or covert. The leader helps the group bring covert conflicts 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 decision to 

explore the conflict further is made based on whether such inquiry would 

be productive. 

Leaders should be aware that many conflicts that appear to scapegoat a 

group member are actually misplaced anger that a member feels toward 

the group leader. When the leader suspects this situation, the possibility 

should be forthrightly presented to the group. 

Individual responses to particular conflicts can be complex and can 

resonate powerfully according to a client’s values. After a conflict, it is 

important for the group leader to speak privately with members and 

determine how each feels. Leaders 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. 

In any group, subgroups inevitably will form. Individuals will feel more 

affinity and more potential alliance with some members than they feel with 

others. One key role for the leader is to make covert alliances overt. 

Subgroups can sometimes provoke anxiety, especially when a therapy 

group comprises individuals who were acquainted before becoming group 

members. Such connections are potentially disruptive. When groups are 

formed, leaders should consider whether subgroups would exist. 

When subgroups stymie full participation, the group leader can reframe 

what the subgroup is doing. At other times a change in room arrangement 

may be able to reconfigure undesirable combinations. 

Subgroups are not always negative. The leader may intentionally foster a 

subgroup that helps marginally connected clients move into the life of 

the group. 
6-11 

Module 6: Group Leadership, Concepts, and Techniques 

PP 6-18
 

PP 6-19
 

TIP 41 identifies three types of disruptive behaviors: 

•		Clients who cannot stop talking. When a client talks on and on, he or she 

may not know what is expected in a group. At other times, a client may 

talk more than his or her share because he or she is not sure of what 

else to do. If group members exhibit no interest in stopping a compulsive 

talker, it may be appropriate to examine this silent cooperation. Group 

members may be avoiding examining their own past patterns of 

substance abuse and forging 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 

may also be advisable to help the talker find a more effective strategy for 

being heard. 

•		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. 

•		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. The leader should stress 

that the therapeutic work requires members to remain in the room and 

talk about problems instead of attempt to escape them. 

Sometimes, clients are unable to participate in ways consistent with group 

agreements. They may attend irregularly, come to group intoxicated, show 

little or no impulse control, or fail to take medications to control a cooccurring disorder. Removing someone from group is serious and should 

never be done without careful thought and consultation. 

The decision to remove an individual is not one the group makes. The 

leader makes the decision and explains to the group 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 leader for acting 

without group input or acting too slowly is common in expulsion situations 

and should be explored. 
6-12 

TIP 41 Curriculum 

PP 6-20 

TIP 41 briefly addresses seven common problems in group: 

•		Coming late or missing sessions. Sometimes leaders view the client 

who comes to group late as a person who is behaving badly. It is more 

productive to see this kind of boundary violation as a message to be 

deciphered. 

• Silence. Nonresponsiveness may provide clues to clients’ difficulties with 

connecting with their inner lives or with others. Special consideration 

is sometimes necessary for clients who speak English as a second 

language (ESL). Experiences involving strong feelings can be hard to 

translate. 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 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. 

•		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 on issues that 

others bring up. To encourage a member to share more, a leader might 

introduce the topic of how well members know one another and how well 

they want to be known. 

•		Fear of losing control. Sometimes clients avoid opening up because 

they may become tearful in front of others. When this restraint becomes 

a barrier, the leader should help them remember ways that they have 

handled strong feelings in the past. When a client cries or breaks down, 

the leader should validate the feelings and should concentrate on the 

person’s adaptive abilities. 

•		Fragile clients with psychological emergencies. Because clients know that 

the leader is bound to end the group’s work on time, they often wait until 

the last few minutes to share emotionally charged information. The leader 

should recognize that the client has deliberately chosen this time to share 

this information. The timing could be the client’s way of limiting the group’s 

response and avoiding an onslaught of interest. The group should point out 

this self-defeating behavior and encourage the client to change it. 

•		Anxiety and resistance after self-disclosure. Clients may feel great 

anxiety after disclosing something important. Leaders should assure 

clients that people disclose information when they are ready and that 

they do not have to reiterate the disclosure when new clients enter 

the group. 
6-13 

Module 6: Group Leadership, Concepts, and Techniques 

5 minutes 

Summary 

The trainer: 

•	 Responds to participants’ questions or comments. 

•	 Encourages participants to review Chapter 6 of TIP 41. 

•	 Instructs participants to read Chapter 7 and reminds them to 

bring TIP 41 to the next training session. 

•	 Reminds participants of the date and time of the next training 

session. 

7-1 

5 minutes 

PP 7-1
 

Module 7: Supervision 

Module 7 Overview 

The goal of Module 7 is to provide participants with an overview of the skills 

group therapy leaders need, the purpose and value of clinical supervision, 

and necessary training. The information in Module 7 covers Chapter 7 of 

Treatment Improvement Protocol (TIP) 41, Substance Abuse Treatment: 

Group Therapy. This module takes 45 minutes to complete and is divided 

into four sections: 

•	 Module 7 Goal and Objectives (5 minutes) 

•	 Presentation: Training (15 minutes) 

•	 Presentation: Supervision (10 minutes) 

•	 Summary (15 minutes) 

Module 7 Goal and Objectives 

After participants have taken their seats, the trainer instructs 

them to turn to Chapter 7 (p. 123) of TIP 41. 

Module 7 covers Chapter 7 of TIP 41. 
TIP 41 Curriculum 

PP 7-2 

15 minutes 

PP 7-3
 

PP 7-4
 

The goal of Module 7 is to provide an overview of the skills group therapy 

leaders need, the purpose and value of clinical supervision, and necessary 

training. By the end of the session, you will be able to: 

•		Identify training opportunities. 

•		Appreciate the value of clinical supervision. 

Presentation: Training 

Many substance abuse treatment counselors have not had specific training 

and supervision in the special skills needed to be an effective group leader. 

Common errors that counselors make include: 

• Impatience with clients’ slow pace of dealing with changes 

•		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 

Training and education for group leaders working in the substance abuse 

treatment field can alleviate or eliminate such errors. Simultaneously, 

additional training is becoming even more critical because the traditionally 

separate fields of mental health and substance abuse counseling 

increasingly overlap, requiring more and more cross-knowledge, and 

because an ever-younger pool of clients is presenting with more cognitive 

deficits, abuse issues, and co-occurring disorders. 

A group leader for people in substance abuse treatment requires 

competencies in both group work and addiction. Before leading a group, a 

leader needs training in: 

•		Theories and techniques. Theories may include traditional 

psychodynamic methods, cognitive–behavioral modes, and systems 

theory. Applications that pertain to a wide variety of settings and 

particular client populations are drawn from these theoretical bases. 

•		Observation. The observer can sit in on group therapy sessions, study 

videotapes of group sessions (ordinarily followed by a discussion), or 

watch groups live through one-way mirrors. 

•		Experiential learning. The leader can participate in a training group offered 

by an agency, become a member of a personal therapy group (these are 

often process-oriented groups), or join in group experiences at conferences. 

7-2 
7-3 

Module 7: Supervision 

•		Supervision. Training is ongoing with groups under the supervision 

of an experienced leader. Supervision in a group enables leaders to 

obtain first-hand experiences and helps them better understand what is 

happening in groups that they will eventually lead. 

In group therapy with clients with substance use disorders, establishing and 

maintaining credibility with all group members can be challenging. Leaders 

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. However, leaders in recovery 

may tend to focus too much on themselves. Group leaders emotionally 

invested in acting as models of recovering perfection are setting themselves 

up for negative group dynamics. 

The main issue is not whether the leader is in recovery. What matters most 

is whether the leader is trained in group therapy and addiction treatment 

and has good judgment and leadership skills. Helping the group explore 

why the recovery status of the group leader is important can be discussed 

when members raise the issue. 

PP 7-5	 

National professional organizations are a rich source of training. Through 

conferences or regional sessions, national associations provide both 

experiential and didactic training geared to the needs of a wide range 

of professionals, from the novice to the highly experienced counselor. 

Professional organizations that provide a variety of training include: 

•		American Group Psychotherapy Association (AGPA) has more than 4,000 

members who provide professional, educational, and social support for 

group counselors: http://www.agpa.org. 

•		American Psychiatric Association has more than 35,000 U.S. and 

international member physicians who work to ensure humane and 

effective treatment for all persons with mental disorders: 

http://www.psych.org. 

•		American Psychological Association offers a certificate of proficiency 

in the treatment of alcohol and other psychoactive substance use 

disorders: http://www.apa.org. 

•		American Society of Addiction Medicine (ASAM) educates health 

professionals about addiction: http://www.asam.org. 

•		Association for Specialists in Group Work (ASGW) is a division of the 

American Counseling Association and was founded to promote highquality training, practice, and research: http://asgw.org. 
7-4 

TIP 41 Curriculum 

PP 7-6	 

PP 7-7 

10 minutes 

PP 7-8
 

Association for the Advancement of Social Work with Groups (AASWG) 

is an international organization that develops standards to reflect the 

distinguishing features of group work: http://www.aaswg.org. 

•		NAADAC—National Association for Addiction Professionals is the largest 

organization for alcoholism and drug abuse professionals and offers 

workshops, seminars, and education programs for members: 

http://www.naadac.org. 

•		National Association of Black Social Workers (NABSW) offers 

conferences and mentoring programs to support the work of AfricanAmerican social workers: http://www.nabsw.org. 

•		National Association of Social Workers (NASW) has developed practice 

standards and clinical indicators, a credentialing program, continuing 

education courses, and publications: http://socialworkers.org. 

Many agencies mandate a certain number of trainings each year and 

provide in-house training that draws on the resources of credentialed senior 

management. Each State has a department of alcohol and drug abuse 

services, and some States 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. 

Two Federal entities offer resources for training. The Substance Abuse and 

Mental Health Services Administration (SAMHSA) provides a number of 

resources, including the TIP Series and Technical Assistance Publications 

(TAPs). Publications in these series can be ordered from the SAMHSA Store 

at 1-877- SAMHSA-7 (1-877-726-4727) or at http://www.store.samhsa. 

gov. Publications can also be downloaded from the Knowledge Application 

Program Web site at http://www.kap.samhsa.gov. The SAMHSA Store also 

provides a wealth of information on mental health issues. The National 

Institute on Drug Abuse provides materials at http://www.nida.nih.gov. 

Presentation: Supervision 

Clinical supervision, as it pertains to group therapy, 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. 

The supervisor should be competent in several content areas, including 

substance abuse treatment, group training, cultural competence, and 

diagnosis of co-occurring disorders. A supervisor may be an administrator, 

an in-house trainer, or a counselor from another agency. 

The key to effective group therapy supervision is the development of the 

supervisory alliance. In this working relationship, the counselor develops 
7-5 

Module 7: Supervision 

skills in group analysis and refines abilities to develop appropriate 

treatment strategies. The supervisory alliance is needed to teach the 

counselor the skills needed to lead groups effectively and to make sure that 

the group accomplishes its purposes. 

PP 7-9
 

PP 7-10
 

15 minutes 

The supervisor should be able to assess the domains that leaders are 

required to master. These include: 

•		Clinical skills (from selecting prospective group members and designing 

treatment strategies to planning and managing termination) 

•		Comprehensive knowledge of substance abuse, which 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 the institution’s preferred theoretical approaches 

•		Diagnostic skills for determining co-occurring disorders 

• Capacity for self-reflection, such as recognizing one’s own vulnerability 

and ability to monitor and govern behavioral and emotional reactions 

•		Consultation skills, such as the ability to consult with the referring 

therapist, provide feedback, and coordinate both individual and group 

treatment 

•		Capacity to be supervised, including openness in supervision, setting 

goals for training, and discussing with a supervisor one’s learning style 

and preferences 

Summary 

In this last session, the trainer: 

•	 Responds to participants’ questions or comments. 

•	 Asks participants for feedback on the course in general and any 

modules that they found particularly interesting. 

•	 If using feedback/course evaluation forms, asks participants to 

complete forms before they leave. 

•	 Thanks participants for attending the training and encourages 

them to explore further the issues raised during the training. 

HHS Publication No. (SMA) 11-4664

Printed 2012