Group Work with People with Substance Use Disorders

In this entry, I present a discussion on group work with people with Substance Use Disorders. This entry has been selected for publication in The Encyclopedia of Social Work with Groups edited by Alex Gitterman and Robert Salmon published by the Haworth Press. The entry is presented here in accordance with the publication contract's section on preprint distribution rights. Stay tuned for more information about the Encyclopedia as it becomes available. Haworth Press can be reached at this link, Haworth Press Homepage.


Group treatment is the cornerstone of most abstinence based programs in the United States (Stinchfield et al, 1994). The popularity of group treatment for people with Substance Use Disorders (SUDs) can be best explained by the resonance of mutual aid with the demands of achieving and maintaining abstinence. The power of mutual aid processes, including the combined effect of mutual support and demand, in helping people get sober was phenomenologically discovered by the originators of Alcoholics Anonymous, whose success is likely to have lent credence to early efforts at providing group treatment with this population (Blume, 2002; Flores, 1997). Furthermore, collaborative, non-exploitive, mutual aid based relationships assuage the isolation, shame and stigma experienced by people with SUDs. Quite simply, mutual aid heals! At the same time, people with SUDs are likely to experience difficulty in trusting others and forming healthy attachments, a point which should inform the interventions of the worker. This entry will apply concepts and practice principles drawn from the Mutual Aid Model which can be integrated with a variety of group approaches with this population (Gitterman, 2004; Shulman, 2006).

Tasks of Early Recovery
Substance Use Disorders are best conceptualized as chronic, relapsing brain diseases with biopsychosocial antecedents and consequences (Leshner, 1999). Recovery from SUDs is an ongoing, perhaps life-long process with discrete developmental tasks and challenges to be found in early, middle, and ongoing stages. Typically clients in agency based substance abuse treatment are in the early or middle stage of recovery. The primary goals of the early and middle stages of recovery include achieving and maintaining abstinence. The nature of the work is primarily cognitive and behavioral, as opposed to being insight oriented (SAMHSA, 2005).

Common early recovery tasks include enhancing motivation for behavior change; learning about SUDs and recovery; identifying and verbalizing feelings; strengthening coping skills; cultivating self-esteem and self-care; and developing a sober support network (SAMHSA, 2005). Additional work exists for group members who have been mandated to treatment, which can be characterized as ‘transforming to clienthood’ (Rooney & Chovanec, 2004).

Orienting Knowledge
The effectiveness of group work is enhanced when the worker possesses knowledge both about group work as well as substance use disorders. Salient orienting knowledge includes an understanding of the biopsychosocial implications of SUDs; the concepts, principles and structure of 12 Step Fellowships; the Transtheoretical Model of the Stages of Change; and the principles and skills of motivational interviewing (Flores, 1997; Miller & Rollnick, 1991; Prochaska, DiClemente, & Norcross, 1992; SAMHSA, 2005).

Strengths and Resiliencies
Empowerment oriented practice necessitates that the worker view the group member from a strengths perspective. Furthermore, the mutual aid based group provides an opportunity for members to identify and experience their own and each others strengths. The opportunities that exist in group work to experience mutual aid both strengthen self-esteem and affirm the value of a sober network of peers. Members should be encouraged to view their capacity to share feelings, life experiences and taboo topics as individual and collective strengths. Furthermore, the quality of mutual aid becomes enriched as members move through the recovery process and draw upon their accumulated experience in navigating ‘life on life’s terms’ sober.

Recommendations for Helping
Preparation is enhanced when the worker tunes in to the members needs and feelings regarding both their being in treatment and in recovery. The stage of change model provides a useful framework for conceptualizing the needs of members as they engage with the change process. Accurately tuning in to these factors will help the worker identify topics that need to be addressed in early group sessions.

Workers should plan to respond to queries about their own recovery status. However, worker disclosure is secondary to the sub-text of such a query. Often members are really wondering if the worker will be helpful, trustworthy and non-judgmental. Additionally, such a request for self disclosure provides an opportunity for the worker to clarify worker role and member role. Of note, evidence indicates that worker recovery status has no impact on treatment outcome (Culbreth, 2000).

The worker in the beginning phase should actively attend to enhancing motivation for change and issues related to trust and safety. Members are likely to have ambivalent feelings about getting sober (Milgram & Rubin, 1992). The use of the mutual aid process, the dialectic process, is resonant with principles of motivational interviewing. Members can be encouraged to discuss the pros and cons of being in treatment and of getting sober. As the worker responds empathically and points out member commonalties organic opportunities arise to foster safety and trust as well as enhance motivation for change.

The work of the group is enhanced when member strengths and contributions are both encouraged and recognized. In an outpatient setting the worker stimulated the strengths in numbers phenomenon when the group agreed to accompany one member to his first A.A. meeting as he had been afraid to go on his own. In a residential setting, as members began looking for apartments in the community they often were shown dilapidated apartments in drug-infested neighborhoods. In one session, Francis shared her despair and stated, “I felt like getting high; I got sober to live in a crack-house!? But instead of getting high, I called my sponsor”. In the next session another member recounted the same experience but added, “I thought of you Francis. I thought to myself I couldn’t let you or the group down. So, I followed your lead and instead of getting high I called my sponsor.” The worker asked Francis what she felt in knowing that she had helped someone protect their sobriety. Her eyes welled up with tears as she said, “it feels good to help. All my life I had no help to offer anyone; if anything I was a taker”.

As most groups in substance abuse treatment settings are open-ended, typically members leave but the group continues. Variations on endings exist when members relapse and prematurely leave the program against medical advice. Ample time should be allotted for members to express their feelings and for the member who is leaving to consider their ongoing relapse prevention plan.

Finally sessional work is enhanced when the worker helps the group review the purpose and format of the group in each session, in part because of the short-term memory loss associated with early recovery and to help distinguish the work of one group from that of another. Sessional endings provide an opportunity for members to identify the salience of the group encounter with their own recovery process.

References
Blume, S. (2002). Group psychotherapy in the treatment of addictive disorders: Past, present and future. In Brook, D.W. and Spitz, H.I. (Eds.) (2002). The group therapy of substance abuse (pp. 411-428). Binghamton, NY: The Haworth Medical Press.

Culbreth, JR, (2000). Substance abuse counselors with and without a personal history of chemical dependency: A review of the literature. Alcoholism Treatment Quarterly, 18(2), 67-82.

Flores, P.J. (1997). Group psychotherapy with addicted populations: An integration of twelve-step and psychodynamic theory (2cnd edition). New York: The Haworth Press.

Gitterman, A. (2004). The mutual aid model. In C. Garvin, L. Gutierrez, and M. Galinsky (Eds.), Handbook of social work with groups (pp. 93-110). New York and London: The Guilford Press.

Leshner, A.I. (1999). Science-based views of drug addiction and its treatment. JAMA: The Journal of the American Medical Association, 282(14), 1314-1316.

Milgram, D. and Rubin, J. (1992). Resisting the resistance: Involuntary substance abuse group therapy. Social Work with Groups, 15(1), 95-110.

Miller, W.R. and Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behaviors. New York: The Guilford Press.

Prochaska, J.O., DiClemente, C.C., Norcross, J. (1992). In search of how people change: applications to addictive behaviors. American Psychologist, 47(9), 1102-1114.

Rooney, R. and Chovanec, M. (2004). Involuntary groups. In C. Garvin, L. Gutierrez, and M. Galinsky (Eds.), Handbook of social work with groups (pp. 212-226). New York and London: The Guilford Press.

Shulman, L. (2006). The skills of helping individuals, families, groups, and communities (Fifth edition). Belmont. CA: Thompson.

Stinchfield, R., Owen, P. and Winters, K.C. (1994). Group therapy for substance abuse: A review of the empirical research. In A. Fuhriman and G. Burlingame (Eds.) Handbook of group psychotherapy: An empirical and clinical synthesis (pp. 458-488). New York: John Wiley and Sons, Inc

Substance Abuse and Mental Health Services (2005). Substance abuse treatment: Group therapy. (Treatment Improvement Protocol No. 41). Department of Health and Human Services Publication No. (SMA) 05-3991. Rockville, MD: Department of Health and Human Services.