Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain—they change its structure and how it works. These brain changes can be long lasting, and can lead to the harmful behaviors seen in people who abuse drugs.
Reasons For Why People Take Drugs
In general, people begin taking drugs for a variety of reasons:
- To feel good. Most abused drugs produce intense feelings of pleasure. This initial sensation of euphoria is followed by other effects, which differ with the type of drug used. For example, with stimulants such as cocaine, the “high” is followed by feelings of power, self-confidence, and increased energy. In contrast, the euphoria caused by opiates such as heroin is followed by feelings of relaxation and satisfaction.
- To feel better. Some people who suffer from social anxiety, stress-related disorders, and depression begin abusing drugs in an attempt to lessen feelings of distress. Stress can play a major role in beginning drug use, continuing drug abuse, or relapse in patients recovering from addiction.
- To do better. The increasing pressure that some individuals feel to chemically enhance or improve their athletic or cognitive performance can similarly play a role in initial experimentation and continued drug abuse.
- Curiosity and “because others are doing it.”In this respect adolescents are particularly vulnerable because of the strong influence of peer pressure; theyare more likely, for example, to engage in “thrilling”and “daring” behaviors.
Problems Of Drug Abuse
At first, people may perceive what seem to be positive effects with drug use. They also may believe that they can control their use; however, drugs can quickly take over their lives.
Consider how a social drinker can become intoxicated, put himself behind a wheel and quickly turn a pleasurable activity into a tragedy for him and others. Over time, if drug use
continues, pleasurable activities become less pleasurable, and drug abuse becomes necessary for abusers to simply feel “normal.” Drug abusers reach a point where they seek and take drugs, despite the tremendous problems caused for themselves and their loved ones. Some individuals may start to feel the need to take higher or more frequent doses, even in the early stages of their drug use.
The initial decision to take drugs is mostly voluntary. However, when drug abuse takes over, a person’s ability to exert self control can become seriously impaired. Brain imaging studies
from drug-addicted individuals show physical changes in areas of the brain that are critical to
judgment, decision making, learning and memory, and behavior control. Scientists believe that these changes alter the way the brain works, and may help explain the compulsive and destructive behaviors of addiction.
Why do some people become addicted to drugs, while others do not?
As with any other disease, vulnerability to addiction differs from person to person. In general, the more risk factors an individual has, the greater the chance that taking drugs will lead to abuse and addiction. “Protective” factors reduce a person’s risk of developing addiction. Individual’s genes, age when started taking drugs, and family and social environment all play a role in addiction. Risk factors that increase individual’s vulnerability include:
- Family history of addiction
- Abuse, neglect, or other traumatic experiences in childhood
- Mental disorders such as depression and anxiety
- Early use of drugs
Factors Increase Risk Of Addiction:
No single factor determines whether a person will become addicted to drugs. The overall risk for addiction is impacted by the biological makeup of the individual—it can even be influenced by gender or ethnicity, his or her developmental stage, and the surrounding social environment (e.g., conditions at home, at school, and in the neighborhood).
Scientists estimate that genetic factors account for between 40 and 60 percent of a person’s vulnerability to addiction, including the effects of environment on gene expression and function. Adolescents and individuals with mental disorders are at greater risk of drug abuse and addiction than the general population.
I. Home and Family. The influence of the home environment is usually most important in childhood. Parents or older family members who abuse alcohol or drugs, or who engage in criminal behavior, can increase children’s risks of developing their own drug problems.
II. Peer and School. Friends and acquaintances have the greatest influence during adolescence. Drug-abusing peers can sway even those without risk factors to try drugs for the first time. Academic failure or poor social skills can put a child further at risk for drug abuse.
I. Early Use. Although taking drugs at any age can lead to addiction, research shows that the earlier a person begins to use drugs the more likely they are to progress to more serious abuse. This may reflect the harmful effect that drugs can have on the developing brain; it also may result from a constellation of early biological and social vulnerability factors, including genetic susceptibility, mental illness, unstable family relationships, and exposure to physical or sexual abuse. Still, the fact remains that early use is a strong indicator of problems ahead, among them, substance abuse and addiction.
II. Method of Administration. Smoking a drug or injecting it into a vein increases its addictive potential. Both smoked and injected drugs enter the brain within seconds, producing a powerful rush of pleasure. However, this intense “high” can fade within a few minutes, taking the abuser down to lower, more normal levels. It is a starkly felt contrast, and scientists believe that this low feeling drives individuals to repeated drug abuse in an attempt to recapture the high pleasurable state.
Surveys indicate some children arealready abusing drugs by age 12 or 13.
Drug abuse starts early and peaks in teen years.
DRUG ABUSE VS. DRUG DEPENDENCE(ADDICTION)
Signs And Symptoms Of Drug Abuse
|Health And Behavior|
|Financial And Legal|
|Family And Friends|
|Signs And Symptoms Of Cannabis Use (Marijuana And Hashish)|
Signs And Symptoms Of Drug Dependence (Addiction)
|Cravings and relapse|
|Effects on memory and|
Drug Use Can Lead To Addiction
People with conditions such as Attention-Deficit/Hyperactivity Disorder (ADHD) or mood disorders such as depression and anxiety may find that a street drug makes them feel less jumpy, depressed or anxious.
The line between substance abuse and drug dependence is defined by the role drugs play in your life. Addiction and drug dependence occurs when drugs become so important that you are willing to sacrifice your work, home and even family. Once individual’s brain and body get used to the substances individual is taking, he begin to require increasingly larger and more frequent doses, in order to achieve the same effect.
Drugs such as Heroin, a painkiller, over-stimulate the pleasure centers of the brain producing euphoric effects which cause compulsive drug-seeking behaviors and affect self-control and judgment. These drugs are highly addictive and require a medical detoxification (detox) to cleanse the chemicals from your system. The severity of withdrawal symptoms such as chills,
shakes, muscle pain, nausea, vomiting, headaches, and cravings can be reduced in detox with prescribed medications that can be slowly decreased over time. Withdrawal affects you physically and emotionally resulting in sadness, depression and exhaustion.
This table is a representation of the people who tried a drug once, the fraction that
|Drug||Fraction Addicted after 1 use|
The Last Forty Years Have Seen An Explosion In Drug Use
In 1962, 4 million people reported having tried drugs, however by 1992, this figure
jumped to 80 million.
In the 1960’s the drugs of choice were primarily marijuana and the psychedelics. 1975-
1990 saw an increase in the use of cocaine, and in the past couple decades heroin use has
Some Recent Statistics On Drug Use
Nicotine – 50 million users (greatest cause of preventable deaths in the US)
Nicotine use has stabilized over the past few years, and the increase in adolescent use has
Alcohol – 12-18 million
Alcohol use is stable to declining with some increase in binge drinking.
Marijuana – 5 million use it weekly
Currently, 24% of high school seniors use marijuana. This figure is a slight decrease from
Cocaine – 2-3.5 million
Cocaine use has been declining, however the decrease in the number of cocaine addicts
has been slow because cocaine treatment is very difficult.
Heroin – 810,000 addicts
Heroin use has been increasing. Cheap, pure heroin has replaced cocaine on the drug
market. Additionally, this purer heroin is easier to use (since it is so potent, it does not
have to be injected; snorting or smoking produces the same high).
Commonly abused drugs
|Hallucinogens and Psilocybin|
|Drugs for increasing muscle|
Drugs And The Brain
Introducing the Human Brain
The human brain is the most complex organ in the body. This three-pound mass of gray and white matter sits at the center of all human activity—you need it to drive a car, to enjoy a meal, to breathe, to create an artistic masterpiece, and to enjoy everyday activities. In brief, the brain regulates your basic body functions; enables you to interpret and respond to everything you experience; and shapes your thoughts, emotions, and behavior.
The brain is made up of many parts that all work together as a team. Different parts of the brain are responsible for coordinating and performing specific functions. Drugs can alter important brain areas that are necessary for life-sustaining functions and can drive the
compulsive drug abuse that marks addiction. Brain areas affected by drug abuse—
- The brain stem controls basic functions critical to life, such as heart rate, breathing, and sleeping.
- The limbic system contains the brain’s reward circuit—it links together a number of brain structures that control and regulate our ability to feel pleasure. Feeling pleasure motivates us to repeat behaviors such as eating—actions that are critical to our existence. The limbic system is activated when we perform these activities— and also by drugs of abuse. In addition, the limbic system is responsible for our perception of other emotions, both positive and negative, which explains the mood-altering properties of many drugs.
- The cerebral cortex is divided into areas that control specific functions. Different areas process information from our senses, enabling us to see, feel, hear, and taste. The front part of the cortex, the frontal cortex or forebrain, is the thinking center of the brain; it powers our ability to think, plan, solve problems, and make decisions.
Communication System Of Brain
The brain is a communications center consisting of billions of neurons, or nerve cells. Networks of neurons pass messages back and forth to different structures within the brain, the spinal column, and the peripheral nervous system. These nerve networks coordinate and regulate everything we feel, think, and do.
Each nerve cell in the brain sends and receives messages in the form of electrical impulses. Once a cell receives and processes a message, it sends it on to other neurons.
- Neurotransmitters—The Brain’s Chemical Messengers
The messages are carried between neurons by chemicals called neurotransmitters. (They transmit messages between neurons.)
- Receptors—The Brain’s Chemical Receivers
The neurotransmitter attaches to a specialized site on the receiving cell called a receptor. A neurotransmitter and its receptor operate like a “key and lock,” an exquisitely specific mechanism that ensures that each receptor will forward the appropriate message only after interacting with the right kind of neurotransmitter.
- Transporters—The Brain’s Chemical Recyclers
Located on the cell that releases the neurotransmitter, transporters recycle these neurotransmitters (i.e., bring them back into the cell that released them), thereby shutting off the signal between neurons.
The Way How Drugs Work In The Brain
Drugs are chemicals. They work in the brain by tapping into the brain’s communication system and interfering with the way nerve cells normally send, receive, and process information. Some drugs, such as marijuana and heroin, can activate neurons because their chemical structure mimics that of a natural neurotransmitter. This similarity in structure “fools” receptors and allows the drugs to lock onto and activate the nerve cells. Although these drugs mimic brain chemicals, they don’t activate nerve cells in the same way as a natural neurotransmitter, and they lead to abnormal messages being transmitted through the network. Other drugs, such as amphetamine or cocaine, can cause the nerve cells to release abnormally large amounts of natural neurotransmitters or prevent the normal recycling of these brain chemicals. This disruption produces a greatly amplified message, ultimately disrupting communication channels. The difference in effect can be described as the difference between someone whispering into your ear and someone shouting into a microphone.
Drugs Work In The Brain To Produce Pleasure
All drugs of abuse directly or indirectly target the brain’s reward system by flooding the circuit with dopamine. Dopamine is a neurotransmitter present in regions of the brain that regulate movement, emotion, cognition, motivation, and feelings of pleasure. The overstimulation of this system, which rewards our natural behaviors, produces the euphoric effects sought by people who abuse drugs and teaches them to repeat the behavior.
Stimulation Of The Brain’s Pleasure Circuit Teach Us To Keep Taking Drugs
Our brains are wired to ensure that we will repeat life-sustaining activities by associating those activities with pleasure or reward. Whenever this reward circuit is activated, the brain notes that something important is happening that needs to be remembered, and teaches us to do it again and again, without thinking about it. Because drugs of abuse stimulate the same circuit, we learn to abuse drugs in the same way.
Drugs More Addictive Than Natural Rewards
When some drugs of abuse are taken, they can release 2 to 10 times the amount of dopamine that natural rewards do. In some cases, this occurs almost immediately (as when drugs are smoked or injected), and the effects can last much longer than those produced by natural rewards. The resulting effects on the brain’s pleasure circuit dwarfs those produced by naturally rewarding behaviors such as eating and sex. The effect of such a powerful reward strongly motivates people to take drugs again and again. This is why scientists sometimes say that drug abuse is something we learn to do very, very well.
Keep Taking Drugs Lead To Tolerance
Just as we turn down the volume on a radio that is too loud, the brain adjusts to the overwhelming surges in dopamine (and other neurotransmitters) by producing less dopamine or by reducing the number of receptors that can receive and transmit signals. As a result, dopamine’s impact on the reward circuit of a drug abuser’s brain can become abnormally low, and the ability to experience any pleasure is reduced. This is why the abuser eventually feels flat, lifeless, and depressed, and is unable to enjoy things that previously brought them pleasure. Now, they need to take drugs just to bring their dopamine function back up to normal. And, they must take larger amounts of the drug than they first did to create the dopamine high—an effect known as tolerance.
Long-Term Drug Abuse Impairs Brain Function
We know that the same sort of mechanisms involvedin the development of tolerance can eventually lead toprofound changes in neurons and brain circuits, with thepotential to severely compromise the long-term health ofthe brain. For example, glutamate is another neurotransmitterthat influences the reward circuit and the ability tolearn. When the optimal concentration of glutamate isaltered by drug abuse, the brain attempts to compensatefor this change, which can cause impairment in cognitivefunction. Similarly, long-term drug abuse can trigger adaptations in habit or nonconscious memory systems. Conditioningis one example of this type of learning, whereby environmentalcues become associated with the drug experience and can triggeruncontrollable cravings if the individual is later exposed to these cues,even without the drug itself being available. This learned “reflex” isextremely robust and can emerge even after many years of abstinence.
Chronic exposure to drugs of abuse disrupts the way critical brain structures interact to control behavior—behavior specifically related to drug abuse. Just as continued abuse may lead to tolerance or the need for higher drug dosages to produce an effect, it may also lead to addiction, which can drive an abuser to seek out and take drugs compulsively. Drug addiction erodes a person’s self-control and ability to make sound decisions, while sending intense impulses to take drugs.
Medical Consequences Of Drug Addiction
Individuals who suffer from addiction often have one or more accompanying medical issues, including lung and cardiovascular disease, stroke, cancer, and mental disorders. Imaging scans, chest x-rays, and blood tests show the damaging effects of drug abuse throughout the body. For example, tests show that tobacco smoke causes cancer of the mouth, throat, larynx, blood, lungs, stomach, pancreas, kidney, bladder, and cervix. In addition, some drugs of abuse, such as inhalants, are toxic to nerve cells and may damage or destroy them either in the brain or the peripheral nervous system.
Treatment And Recovery
Addiction is a treatable disease. Discoveries in the science of addiction have led to advances in drug abuse treatment that help people stop abusing drugs and resume their productive lives. Addiction need not be a life sentence. Like other chronic diseases, addiction can be managed successfully. Treatment enables people to counteract addiction’s powerful disruptive effects on brain and behavior and regain control of their lives.
The chronic nature of the disease means that relapsing to drug abuse is not only possible, but likely, with relapse rates similar to those for other well-characterized chronic medical illnesses such as diabetes, hypertension, and asthma, which also have both physiological and behavioral components. Treatment of chronic diseases involves changing deeply imbedded behaviors, and relapse does not mean treatment failure. For the addicted patient, lapses back to drug abuse indicate that treatment needs to be reinstated or adjusted, or that alternate treatment is needed.
The Basics Of Effective Addiction Treatment
Research shows that combining treatment medications, where available, with behavioral therapy is the best way to ensure success for most patients. Treatment approaches must be tailored to address each patient’s drug abuse patterns and drug-related medical, psychiatric, and social problems.
- Medications For Treatment Of Drug Addiction
Different types of medications may be useful at different stages of treatment to help a patient stop abusing drugs, stay in treatment, and avoid relapse.
I. Treating Withdrawal. When patients first stop abusing drugs, they can experience a variety of physical and emotional symptoms, including depression, anxiety, and other mood disorders; restlessness; and sleeplessness. Certain treatment medications are designed to reduce these symptoms, which makes it easier to stop the abuse.
II. Staying in Treatment. Some treatment medications are used to help the brain adapt gradually to the absence of the abused drug. These medications act slowly to stave off drug cravings, and have a calming effect on body systems. They can help patients focus on counseling and other psychotherapies related to their drug treatment.
III. Preventing Relapse. Science has taught us that stress, cues linked to the drug experience (e.g., people, places, things, moods), and exposure to drugs are the most common triggers for relapse. Medications are being developed to interfere with these triggers to help patients sustain recovery.
- Behavioral Therapies For Treatment Of Drug Addiction
Behavioral treatments help engage people in drug abuse treatment, modifying their attitudes and behaviors related to drug abuse and increasing their life skills to handle stressful circumstances and environmental cues that may trigger intense craving for drugs and prompt another cycle of compulsive abuse. Moreover, behavioral therapies can enhance the effectiveness of medications and help people remain in treatment longer.
I. Cognitive Behavioral Therapy. Seeks to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs.
II. Motivational Incentives. Uses positive reinforcement such as providing rewards or privileges for remaining drug free, for attending and participating in counseling sessions, or for taking treatment medications as prescribed.
III. Motivational Interviewing. Employs strategies to evoke rapid and internally motivated behavior change to stop drug use and facilitate treatment entry.
IV. Group Therapy. Helps patients face their drug abuse realistically, come to terms with its harmful consequences, and boost their motivation to stay drug free. Patients learn effective ways to solve their emotional and interpersonal problems without resorting to drugs.
The natural propensity of human beings to congregate makes group therapy a powerful therapeutic tool for treating substance abuse, one that is as helpful as individual therapy, and sometimes more successful. One reason for this efficacy is that groups intrinsically have many rewarding benefits—such as reducing isolation and enabling members to witness the recovery of others—and these qualities draw clients into a culture of recovery. Another reason groups work so well is that they are suitable especially for treating problems that commonly accompany substance abuse, such as depression, isolation, and shame.
Although many groups can have therapeutic effects, this TIP concentrates only on groups that have trained leaders and that are designed to promote recovery from substance abuse. Great emphasis is placed on interpersonal process groups, which help clients resolve problems in relating to other people, problems from which they have attempted to flee by means of addictive substances. While this TIP is not intended as a training manual for individuals training to be group therapists, it provides substance abuse counselors with insights and information that can improve their ability to manage the groups they currently lead.
Defining Therapeutic Groups in Substance Abuse Treatment
Advantages of Group Treatment
Modifying Group Therapy To Treat Substance Abuse
Approach of This TIP
The lives of individuals are shaped, for better or worse, by their experiences in groups. People are born into groups. Throughout life, they join groups. They will influence and be influenced by family, religious, social, and cultural groups that constantly shape behavior, self‐image, and both physical and mental health.
Groups can support individual members in times of pain and trouble, and they can help people grow in ways that are healthy and creative. However, groups also can support deviant behavior or influence an individual to act in ways that are unhealthy or destructive.
Because our need for human contact is biologically determined, we are, from the start, social creatures. This propensity to congregate is a powerful therapeutic tool. Formal therapy groups can be a compelling source of persuasion, stabilization, and support. Groups organized around therapeutic goals can enrich members with insight and guidance; and during times of crisis, groups can comfort and guide people who otherwise might be unhappy or lost. In the hands of a skilled, well‐trained group leader, the potential curative forces inherent in a group can be harnessed and directed to foster healthy attachments, provide positive peer reinforcement, act as a forum for self‐expression, and teach new social skills. In short, group therapy can provide a wide range of therapeutic services, comparable in efficacy to those delivered in individual therapy. In some cases, group therapy can be more beneficial than individual therapy (Scheidlinger 2000; Toseland and Siporin 1986).
Group therapy and addiction treatment are natural allies. One reason is that people who abuse substances often are more likely to remain abstinent and committed to recovery when treatment is provided in groups, apparently because of rewarding and therapeutic forces such as affiliation, confrontation, support, gratification, and identification. This capacity of group therapy to bond patients to treatment is an important asset because the greater the amount, quality, and duration of treatment, the better the client’s prognosis (Leshner 1997; Project MATCH Research Group 1997).
The effectiveness of group therapy in the treatment of substance abuse also can be attributed to the nature of addiction and several factors associated with it, including (but not limited to) depression, anxiety, isolation, denial, shame, temporary cognitive impairment, and character pathology (personality disorder, structural deficits, or an uncohesive sense of self). Whether a person abuses substances or not, these problems often respond better to group treatment than to individual therapy (Kanas 1982; Kanas and Barr 1983). Group therapy is also effective because people are fundamentally relational creatures.
Defining Therapeutic Groups in Substance Abuse Treatment
All groups can be therapeutic. Anytime someone becomes emotionally attached to other group members, a group leader, or the group as a whole, the relationship has the potential to influence and change that person. Identifying a group as “therapy” does not imply that other groups are not therapeutic. In preparing this TIP, the consensus panel debated at length what constitutes “group therapy” and what distinguishes therapy groups from other types of groups.
Although many types of groups can have therapeutic elements and effects, the group types included in this TIP are based on the goals and intentions of the groups, as well as the intended audience of the TIP (especially substance abuse treatment counselors and other substance abuse treatment professionals). Thus, this TIP is limited to groups that (1) have trained leaders and (2) intend to produce some type of healing or recovery from substance abuse. This TIP describes (in chapter 2) five models of group therapy currently used in substance abuse treatment:
Psychoeducational groups, which teach about substance abuse.
Skills development groups, which hone the skills necessary to break free of addictions.
Cognitive–behavioral groups, which rearrange patterns of thinking and action that lead to addiction.
Support groups, which comprise a forum where members can debunk each other’s excuses and support constructive change.
Interpersonal process group psychotherapy (referred to hereafter as “interpersonal process groups” or “therapy groups”), which enable clients to recreate their pasts in the here‐and‐now of group and rethink the relational and other life problems that they have previously fled by means of addictive substances.
Treatment providers routinely use the first four models and various combinations of them. The last is not as widely used, chiefly because of the extensive training required to lead such groups and the long duration of the groups, which demands a high degree of commitment from both providers and clients. All the same, many people enter substance abuse treatment with a long history of failed relationships exacerbated by substance use. In these cases, an extended period of therapy is warranted to resolve the client’s problems with relationships. The reality that extended treatment is not always feasible does not negate its desirability.
This TIP does not discuss multifamily and multi‐couple groups, which are discussed in TIP 39, Substance Abuse Treatment and Family Therapy (Center for Substance Abuse Treatment 2004). Even though multifamily and multicouple groups typically are made up of unrelated groups of families, they focus on family relations as they affect and are affected by a member with a substance use disorder. This TIP concentrates on therapy groups, which have a distinctively different focus.
Also outside the scope of this TIP is the use of peer‐led self‐help groups such as Alcoholics Anonymous (AA) or group activities like social events, religious services, sports, and games. Any or all may have one or more therapeutic effects, but are not specifically designed to achieve that purpose. Figure 1-1 shows other differences between self‐help groups and interpersonal process groups. In most aspects, the comparison would apply to the other four group models as well.
Figure 1-1. Differences Between 12‐Step Self‐Help Groups and Interpersonal Process Groups
View in own window
|Self‐Help Group||Interpersonal Process Group|
|Size||Unlimited (often large)||Small (8–15 members)|
|Participation||Voluntary||Voluntary and involuntary|
|Group Government||Self‐governing||Leader governed|
|Group Processes||Universality, empathy, affective sharing, self‐disclosure (public statement of problem), mutual affirmation, morale building, catharsis, immediate positive feedback, high degree of persuasiveness||Cohesion, mutual identification, education, catharsis, use of group pressure to encourage abstinence and retention of group membership, outside socialization (depending on the group contract or agreement)|
|Use of Psychodynamic Techniques||No||Yes|
|Confidentiality||Anonymity preserved||Anonymity strongly emphasized and includes everything that occurs in the group, not just the identity of group members|
|Sponsorship Program||Yes (usually same sex)||None|
|Determination of Time in Group|
|Involvement in Other Therapies||Yes||Yes—eclectic models |
|Time Factors||Unlimited group participation possible over years||Often time‐limited group experiences|
|Frequency of Meetings||Active encouragement of daily participation||Meets less frequently (often once or twice weekly)|
|Source: Adapted from Spitz 2001. Used with permission.|
Advantages of Group Treatment
Treating adult clients in groups has many advantages, as well as some risks. Any treatment modality—group therapy, individual therapy, family therapy, and medication—can yield poor results if applied indiscriminately or administered by an unskilled or improperly trained therapist. The potential drawbacks of group therapy, however, are no greater than for any other form of treatment.
Some of the numerous advantages to using groups in substance abuse treatment are described below (Brown and Yalom 1977; Flores 1997; Garvin unpublished manuscript; Vannicelli 1992).
Groups provide positive peer support and pressure to abstain from substances of abuse. Unlike AA, and, to some degree, substance abuse treatment program participation, group therapy, from the very beginning, elicits a commitment by all the group members to attend and to recognize that failure to attend, to be on time, and to treat group time as special disappoints the group and reduces its effectiveness. Therefore, both peer support and pressure for abstinence are strong.
Groups reduce the sense of isolation that most people who have substance abuse disorders experience. At the same time, groups can enable participants to identify with others who are struggling with the same issues. Although AA and treatment groups of all types provide these opportunities for sharing, for some people the more formal and deliberate nature of participation in process group therapy increases their feelings of security and enhances their ability to share openly.
Groups enable people who abuse substances to witness the recovery of others. From this inspiration, people who are addicted to substances gain hope that they, too, can maintain abstinence. Furthermore, an interpersonal process group, which is of long duration, allows a magnified witnessing of both the changes related to recovery as well as group members’ intra‐ and interpersonal changes.
Groups help members learn to cope with their substance abuse and other problems by allowing them to see how others deal with similar problems. Groups can accentuate this process and extend it to include changes in how group members relate to bosses, parents, spouses, siblings, children, and people in general.
Groups can provide useful information to clients who are new to recovery. For example, clients can learn how to avoid certain triggers for use, the importance of abstinence as a priority, and how to self‐identify as a person recovering from substance abuse. Group experiences can help deepen these insights. For example, self‐identifying as a person recovering from substance abuse can be a complex process that changes significantly during different stages of treatment and recovery and often reveals the set of traits that makes the system of a person’s self as altogether unique.
Groups provide feedback concerning the values and abilities of other group members. This information helps members improve their conceptions of self or modify faulty, distorted conceptions. In terms of process groups in particular, as specific themes emerge in a client’s group experience, repetitive feedback from multiple group members and the therapist can chip away at those faulty or distorted conceptions in slightly different ways until they not only are correctable, but also the very process of correction and change is revealed through the examination of the group processes.
Groups offer family‐like experiences. Groups can provide the support and nurturance that may have been lacking in group members’ families of origin. The group also gives members the opportunity to practice healthy ways of interacting with their families.
Groups encourage, coach, support, and reinforce as members undertake difficult or anxiety‐provoking tasks.
Groups offer members the opportunity to learn or relearn the social skills they need to cope with everyday life instead of resorting to substance abuse. Group members can learn by observing others, being coached by others, and practicing skills in a safe and supportive environment.
Groups can effectively confront individual members about substance abuse and other harmful behaviors. Such encounters are possible because groups speak with the combined authority of people who have shared common experiences and common problems. Confrontation often plays a part of substance abuse treatment groups because group members tend to deny their problems. Participating in the confrontation of one group member can help others recognize and defeat their own denial.
Groups allow a single treatment professional to help a number of clients at the same time. In addition, as a group develops, each group member eventually becomes acculturated to group norms and can act as a quasi‐therapist himself, thereby ratifying and extending the treatment influence of the group leader.
Groups can add needed structure and discipline to the lives of people with substance use disorders, who often enter treatment with their lives in chaos. Therapy groups can establish limitations and consequences, which can help members learn to clarify what is their responsibility and what is not.
Groups instill hope, a sense that “If he can make it, so can I.” Process groups can expand this hope to dealing with the full range of what people encounter in life, overcome, or cope with.
Groups often support and provide encouragement to one another outside the group setting. For interpersonal process groups, though, outside contacts may or may not be disallowed, depending on the particular group contract or agreements.
Modifying Group Therapy To Treat Substance Abuse
Modifying group therapy to make it applicable to and effective with clients who abuse substances requires three improvements. One is specific training and education for therapists so that they fully understand therapeutic group work and the special characteristics of clients with substance use disorders. The importance of understanding the curative process that occurs in groups cannot be underestimated.
Most substance abuse counselors have responded by adapting skills used in individual therapy. Counselors have also sought direction, clinical training, and practical suggestions. Despite individual efforts, however, group therapy often is conducted as individual therapy in a group.
Individual therapy is not equivalent to group therapy. Some principles that work well with individuals are inappropriate for group therapy. Using the wrong approach may lead to several undesirable results. First, the rich potential of groups—self‐understanding, psychological growth, emotional healing, and true intimacy—will be left unfulfilled. Second, group leaders who are unfamiliar with and insensitive to issues that manifest themselves in group therapy may find themselves in a difficult situation. Third, therapists who think they are doing group therapy when they actually are not may observe the poor results and conclude that group therapy is ineffective. Compounding all these difficulties is the fact that group therapy is so ubiquitous. Thus, poorly conceived approaches are being used frequently.
Group therapy also is not equivalent to 12‐Step program practices. Many therapists who lack full qualifications for group work have adapted practices from AA and other 12‐Step programs for use in therapeutic groups. To say that this borrowing is inadvisable is not to say that the principles of AA are inadequate. On the contrary, many people seem to be unable to recover from dependency without AA or a program similar to it. For this reason, most effective treatment programs make attendance at AA or another 12‐Step program a mandatory part of the treatment process. By the same token, AA and other 12‐Step programs are not group therapy. Rather, they are complementary components to the recovery process. Twelve‐Step programs can help keep the individual who abuses substances abstinent while group therapy provides opportunities for these individuals to understand and explore the emotional and interpersonal conflicts that can contribute to substance abuse.
Progress toward optimal group therapy has also been hindered by the misconception that group therapy with clients who have addictions does not require specially qualified leaders. This notion is false. Therapy groups cannot just take care of themselves. Group therapy, properly conducted, is difficult. One reason that it is challenging has to do with the nature of the clients; an addicted population poses unique problems for the group therapy leader. A second reason is the complexity of group therapy; the leader requires a vast amount of specialized knowledge and skills, including a clear understanding of group process and the stages of development of group dynamics. Such mastery only comes with extended training and experience leading groups.
Many groups led by untrained or poorly trained leaders have not fulfilled their potential and may even have had negative effects on a client’s recovery. It matters little whether the inadequately trained group therapist is a person who once abused substances or someone who developed knowledge in a traditional course of academically based training. Where problems exist, they usually relate to one of two deficiencies: a lack of effective group therapy training or use of a group therapy model that is inadequate for clients who are chemically dependent. Additional training and education is needed to produce therapists who are well qualified to lead therapy groups composed primarily of individuals who are chemically dependent.
A second major improvement needed if people who have addictions are to benefit from group therapy is a clear answer to the question, “Why is group therapy so effective for people with addictions?” We already have part of the answer, and it lies in the individual with addiction, a person whose character style often involves a defensive posture commonly referred to as denial. Addiction is, in fact, frequently referred to as a disease of denial.
The individual who is chemically dependent usually comes into treatment with an uncommonly complex set of defenses and character pathology. Any group leader who intends to help people who have addictions benefit from treatment should have a clear understanding of each group member’s defensive process and character dynamics. More than 20 years ago, John Wallace (1978) wrote about this important issue in an informative essay on the defensive style of the individual who is addicted to alcohol. He referred to these character‐related defensive features as the preferred defense system of the individual addicted to alcohol.
A third major modification needed is the adaptation of the group therapy model to the treatment of substance abuse. The principles of group therapy need to be tailored to meet the realities of treating clients with substance use disorders.
For the most part, group therapy has been based on a model derived from outpatient therapy for clients whose problems may or may not include substance abuse. The theoretical underpinnings and practical applications of general group therapy are not always applicable to individuals who abuse substances. Substance abuse treatment sometimes is implemented as a grab bag of strategies, approaches, and techniques that were not tailored for people with substance use disorders. Further, the common characteristics and typical dynamics seen in this population have not always been evaluated adequately, and this lapse has inhibited the development of effective methods of treatment for these clients.
This model suitability problem is further complicated by the fact that clients with substance use disorders, and even staff members, often become confused about the different types of group treatment modalities. For instance, in the course of their treatment, clients may engage in AA, Narcotics Anonymous, other 12‐Step groups, discussion groups, educational groups, continuing care groups, and support groups. Given this mix, clients often become confused about the purpose of group therapy, and the treatment staff sometimes underestimates the impact that group therapy can make on an individual’s recovery.
The upshot of these problems has been partial or complete failure; that is, the techniques and strategies that usually work with the general psychiatric population often do not work with people abusing substances. A further negative result is that the clients who have addictions may be unfairly viewed as poor treatment risks—people resistant to treatment and unmotivated to change.
Time also is an important factor in a person’s recovery. What a group leader does in group therapy with clients in an inpatient setting in a hospital during the first few days or weeks of recovery will differ dramatically from what that same group therapist will do with the same recovering person in a continuing care group 6 months into abstinence with the expectation that the person will remain in the group at least another 6 to 12 months.
Approach of This TIP
While this TIP does not provide the training needed to become an interpersonal process group therapist, the point of view, attitudes, and considerations of these group therapists infuse the discussions throughout this TIP. The panel hopes that this TIP will help counselors expand their awareness and comprehension of dynamics that might be going on in their current substance abuse treatment groups. These insights will help counselors become better prepared to manage their groups and their individual members, inform group members’ individual therapists of possible issues that need resolution, record dynamics and issues for use in treatment during later stages of recovery, and improve retention by appropriately acknowledging issues that are outside the scope of the group. The TIP will achieve its purpose to the extent that it assists counselors as they juggle immediate client needs, interactions in groups, tasks leading to recovery, and sheer human complexity.