TIP 41: Substance Abuse Treatment: Group Therapy

“This guide helps counselors improve their skills in leading group therapy sessions for substance use treatment. The guide discusses types of group therapy, confidentiality, client placement, group development, stages of treatment, how-to tips, training, and supervision.”

Background

Treatment Improvement Protocols (TIPs) are developed by the Center for Substance Abuse Treatment (CSAT), of the Substance Abuse and Mental Health Services Administration (SAMHSA) at the U.S. Department of Health and Human Services (HHS), and are the results of efforts to develop topic-specific best-practice guidelines for behavioral health providers. TIP manuals represent the consensus of a panel of clinical, research, and administrative experts who draw upon their experience and knowledge to “convey ‘front-line’ information quickly but responsibly” and provide citations for research that supports approaches. Tip manuals are updated periodically to reflect new research in the field. Research is ongoing in any field and updates may not necessarily keep pace with research.

Treatment Improvement Protocol (TIP) 41, Substance Abuse Treatment: Group Therapy was published in 2005. Although the Consensus Panel has not reconvened for the purpose of reviewing and updating its clinical information, a literature review for 2005-mid-2017 did not reveal significant new research that would warrant changes in treatment recommendations, and it is still a very relevant document today  (Center for Substance Abuse Treatment, 2017). TIP 41 provides guidance for providers of substance use disorder treatment who want to improve their therapeutic skills. It is also a useful document for anyone wanting to learn more about group therapy.

Overview

Group therapy remains an effective and economical treatment modality. Some aspects of treatment found through group therapy cannot be found in other approaches, such as the bonding that occurs through mutual support, connection, and accountability found through group process. Treatment and recovery groups are effective in addressing depression, isolation, and shame. To sum up, “group therapy can provide a wide range of therapeutic services, comparable in efficacy to those delivered in individual therapy” (Center for Substance Abuse Treatment, 2005).

Tip 41 contains seven chapters. The chapters are briefly described in the executive summary:

“Chapter 1 defines therapeutic groups as those with trained leaders and a primary intent to help people recover from substance abuse. It also explains why groups work so well for treating substance abuse.

Chapter 2 describes the purpose, main characteristics, leadership, and techniques of five group therapy models, three specialty groups, and groups that focus on solving a single problem.

Chapter 3 discusses the many considerations that should be weighed before placing a client in a particular group, especially keying the group to the client’s stage of change and stage of recovery. This chapter also concentrates on issues that arise from client diversity.

Chapter 4 compares fixed and revolving types of therapy groups and recommends ways to prepare clients for participation: pre-group interviews, retention measures, and most important, group agreements that specify clients’ expectations of each other, the leader, and the group. Chapter 4 also specifies the tasks that need to be accomplished in the early, middle, and late phases of group development.

Chapter 5 turns to the stages of treatment. In the early, middle, and late stages of treatment, clients’ conditions will differ, requiring different therapeutic strategies and approaches to leadership.

Chapter 6 is the how to segment of this TIP. It explains the characteristics, duties, and concepts important to promote effective group leadership in treating substance abuse, including how confidentiality regulations for alcohol and drug treatment apply to group therapy.

Chapter 7 highlights training opportunities available to substance abuse treatment professionals. The chapter also recommends the supervisory group as an added measure that improves group leadership and gives counselors in the group insights about how clients may experience groups” (Center for Substance Abuse Treatment, 2005).

The Appendices provide a bibliography, adult patient placement criteria, a sample group agreement, a glossary, guidelines for the Association for Specialists in Group Work Best Practice (ASGW), information on resource panel participants and their affiliations at the time it convened, participants of the cultural competency and diversity network, a list of the field reviewers, and acknowledgements. The impact of technological advances, patient and treatment criteria, and other advances or changes is pronounced in the topics in the appendices and are, therefore, outlined below.

Updates Impacting TIP 41

In the Editor’s Note for TIP 41, acknowledgement of advances in topical areas provides new information and resources to that found in TIP 41 (Center for Substance Abuse Treatment, 2017). While the basic premise and theoretical foundations for group therapy still form the basis for group treatment modalities, behavioral health providers must also keep current with development in related areas to maintain or improve effectiveness. The areas that changed significantly between 2005 and 2017 are as follows:

Technological Advances in informational technology such as advanced internet programs, text messaging, and smartphone applications were documented. The effect of those still-developing technologies is to enable clinicians and clients to be involved with group therapy sessions from separate and different physical locations (2017). One example of such technological advances is avatar-assisted therapy (AAT), where both clients and clinicians are represented by animated figures that interact in real time in a three-dimensional virtual environment through use of a secure server. A pilot study examining whether clients would be interested in AAT and looking for factors that increased treatment success, found higher treatment attendance rates and fewer positive urine drug screens for participants who completed treatment using AAT (Gordon, et al., 2017).

Patient and Treatment Criteria was expanded and revised by the American Society of Addiction Medicine (ASAM) in 2013 when it was renamed The ASAM Criteria. This collaborative effort defines one national set of criteria for providers that helps standardize outcome-oriented and results-based addiction treatment by using separate placement criteria for adolescents and adults. Patient assessment (six dimensions of multidimensional assessment) and five levels of treatment are based on “the degree of medical management provided,  the structure, safety and security provided and the intensity of treatment services provided” (asam.org, 2019). The ASAM Criteria reflect a continuum of care that addresses patient needs, obstacles, liabilities, and patient strengths, assets, resources, and support structure. To fully educate providers on the new ASAM Criteria, the Association for Addiction Professionals (NAADAC) produced a free NAADAC Webinar in 2015. The webinar updates participants on changes to the ASAM Criteria and also highlights compatibility with the DSM-5 and new sections on older adults, criminal justice clients, parents with children and people in safety sensitive occupations. A CE certificate is available upon completion of the webinar.

The Revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013 is documented and the changes explained very completely in fact sheets published by the American Psychiatric Association. Five fact sheets provide information on Cultural Concepts, DSM-5 and Diagnoses for Children, Integrated Assessment, Mixed Features Specifier, Section III. Fact sheets for updated disorders in the DSM-5 are available, with the fact sheet on Substance-Related and Addictive Disorders being particularly applicable to TIP 41.

Professional Updates include development or revision of best practice guidelines or principles of multicultural competence for facilitating therapy groups. Information about those changes and the documents are as follows:

• “The Association for Specialists in Group Work (ASGW), a division of the American Counseling Association, originally developed and published best practice guidelines in 1998. The document, ASGW Best Practice Guidelines, was revised in 2007 to address changes made in the 2005 version of the association’s code of ethics. These changes were largely prompted by advances in the use of technology in counseling and an increasing focus on multicultural issues.
• The ASGW Best Practice Guidelines define the scope of practice and the responsibilities of group-work professionals in planning, performing, and processing group work. In addition to the best practice guidelines, ASGW has developed two other guidance documents: Professional Standards for the Training of Group Workers and Multicultural and Social Justice Competence Principles for Group Workers.
• In 2004, the American Group Psychotherapy Association (AGPA) established a Science to Service Task Force to develop practice guidelines for AGPA members that would “bridge the gap” between research and practice in the field of group psychotherapy. The association published Practice Guidelines for Group Psychotherapy in 2007” (Center for Substance Abuse Treatment, 2017).

Statistical Updates that impact TIP 41 include changes in the percentage of treatment facilities offering special programs or groups for them, and many categories experienced increase percentages of special programs or groups, such as Adult Men, Adult Women, Clients with co-occurring disorders, Criminal justice clients, LGBT populations, Older adults, people with HIV/AIDS, and Pregnant or postpartum women (Center for Substance Abuse Treatment, 2017).

Regulatory Updates included changes to 42 CFR Part 2, regarding confidentiality of patient records for people with substance use disorders, published as a Final Rule (82 FR 6052; effective date February 17, 2017). The standards are different for group members and for counselors or therapists, with only the latter being legally obligated to maintain confidentiality (with exceptions for child or dependent adult abuse and the threat of harm to others). Professionals should keep current on laws governing confidentiality for the states in which they practice (Center for Substance Abuse Treatment, 2017).

Resource Updates have been included in the Editor’s Note for TIP 41 and include the AK Rice Institute as a resource and listed its location as Jupiter, FL. The organization is now known as the AK Rice Institute for the Study of Social Systems and is based in Portland, OR (Center for Substance Abuse Treatment, 2017).

Strengths of TIP 41

The most important value of TIP 41 is as a basic document that covers a broad range of group therapy topics and issues with enough depth so that behavioral health providers who read it will have a global perspective of this treatment modality. What TIP 41 is not, is a document to read once to know all that is needed to effectively use group therapy. What it is, is a document to refer to time and again to search out topics for professional development opportunities that will help providers to obtain in-depth knowledge and understanding of the many aspects of group therapy, and to know what types of training opportunities to attend in order to hone the variety of skills needed to be effective.

With ongoing and future changes in technology, The ASAM Criteria, state and federal regulations, and professional guidelines, further training and education is imperative to keep current in order to understand and implement new dynamics that are inevitably created in therapy groups.

One such opportunity for behavioral health providers in Nevada and surrounding states is Groups and Group Processing Skills, an in-person training being provided on September 25, 2019 by CASAT Training at the UNR Cooperative Extension Southern Area, 8050 Paradise Road, Las Vegas 89123; and on October 11, 2019 at UNR Redfield Campus, 18600 Wedge Parkway, Reno, NV 89511. The presenter is Richard Shannon, NCC, MFT, LCADC. This workshop will consider strategies presented by TIP 41, Irvin Yalom’s The Theory and Practice of Group Psychotherapy, and current research, with an emphasis on application to substance use disorder treatment in group settings. In addition, the role that the stages of change model and motivational interviewing can play in group therapy will be considered.

Learning objectives for this workshop:

• Participants will consider how they can apply principles of effective group processes in their specific work environment.
• Participants will consider their perspective and the perspective of group participants.
• Participants will consider what makes group work effective and what may reduce group work effectiveness.
• Participants will consider group stages and how they can effectively respond to them.
• Participants will consider Yalom’s view of “problem group members” and potential strategies to respond to these group members.

For additional information and to register for the workshop, visit the CASAT Training website.

TIP 41 and the Editor’s Note for TIP 41 and additional related documents can be downloaded from the CASAT OnDemand Resources and Downloads section of the website.

References

Center for Substance Abuse Treatment. Substance Abuse Treatment: Group Therapy. Treatment Improvement Protocol (TIP)Series, No. 41. HHS Publication No. (SMA)15-3991. Rockville, MD: Substance Abuse and Mental Health Services Administration,2005.

Center for Substance Abuse Treatment. Editor’s Note on Substance Abuse Treatment: Group Therapy. Treatment Improvement Protocol (TIP)Series, No. 41. HHS Publication No. (SMA)15-3991. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2017.

Gordon, M. S., Carswell, S. B., Schadegg, M., Mangen, K., Merkel, K., Tangires, S., & Vocci, F. J. (2017). Avatar-assisted therapy: A proof-of-concept pilot study of a novel technology-based intervention to treat substance use disorders. American Journal of Drug and Alcohol Abuse, 43(5), 518–524.

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