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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Co-Occurring Disorders:
Integrated Dual Disorders Treatment

Integrated Dual Disorders Treatment Workbook

Chapter 13: Group Treatment for Dual Disorders

INTRODUCTION
Group treatment for substance abuse problems is often highly effective. In a group setting, people with dual disorders can learn from and be supported by others who have had experiences similar to their own. A peer network develops that can increase social support and enhance the recovery process. Many types of groups can be helpful for persons with mental illness and substance use disorders. This chapter presents a woman with bipolar disorder and alcohol abuse who used a group to learn more about how alcohol was affecting her life and to develop motivation to stop using. Groups can be helpful both for people who are in the persuasion phase of treatment and for those who are in the action phase of treatment.

VIGNETTE
Vicky is a 23-year-old African-American woman who has been diagnosed with bipolar disorder and alcohol dependence. Vicky has shown symptoms of bipolar disorder since she was 17 years old and reports that she started drinking alcohol around the same time. She had a full-blown manic episode at age 21, when she stayed awake for several days studying for courses she was taking in college. She became convinced she was teaching the courses and acted this way in class, resulting in her dismissal. After two months of hospitalization and medication, she did not return to college.

Vicky worked at a series of jobs. She started drinking alcohol daily, however, and her moods became unpredictable with wild ups and downs. She was often unable to work and lost several jobs. She experienced another manic episode and was hospitalized again. When she was able to think clearly, she realized that her landlord had given her notice of eviction because she hadn't paid her rent. She had no way to pay the hospital either. The hospital social worker referred her to the mental health center.

For the next 12 months, the assertive community treatment team worked with Vicky to engage her into treatment, to stabilize her living situation, and to help her stay on medication. After they developed a good relationship with her, they began talking with her about how alcohol seemed to be interfering with her personal goal of holding down a steady job and returning to college some day. Vicky was in the persuasion stage, and the team felt it would be appropriate for Vicky to attend the team's dual diagnosis group. They suggested that she could meet people struggling with issues similar to hers.

At first Vicky was reluctant to attend the group. She wasn't sure she would fit in and she didn't want strangers knowing about her troubles. She was afraid she would be the only African American person in the group. Vicky did come into the mental health center once a week, so the team suggested she give the group a try for a month because she was already at the center, and she could meet with her case manager after the group. Her case manager let her know that there were other people of color in the group, and that one of the leaders was African American.

Vicky agreed to try it for one month. She was surprised to see that popcorn and soda were served and that people seemed pretty nice. At first when people were talking about their substance use, she felt nervous and passed when it was her turn. She was shocked at how bad some of the other people's problems were. The group leader let Vicky's case manager know that she wasn't talking in the group, and her case manager then talked with her about her fears of "people knowing my business." The group members reviewed the policy of confidentiality. After the third week, she began to talk about how much she enjoyed drinking alcohol. She also talked some about how much her father used to drink, and how badly he acted when he was "really bad drunk." She heard about how other people had parents who abused substances, and how substance use disorders are biological diseases that can run in families. She was impressed when another group member announced that she was planning to start attending AA with her brother, who had stopped drinking a year ago, and that that group member was going to stop drinking. She told her case manager that she felt she might have something in common with some of the people in the group. She really liked one of the group leaders, and would stay after the group to talk with her.

During the group there were many discussions about how substance use interacted with mental illness. Another person in the group had bipolar disorder. Vicky learned from the discussions about how she and the others were more sensitive to the effects of alcohol than someone without a mental illness, and how drinking can worsen mania or depression. As people talked about their substance use, the group facilitators would start a discussion about the similarities for group members and help people examine some of the negative consequences of their use. Vicky talked about how alcohol helped her feel better when she was feeling like a failure in her life. This led to a discussion with her doctor about depression and whether alcohol prevented her medications from helping as much as they could.

Over time Vicky began to see that her daily alcohol use was interfering with her ability to keep a job. With the help of the group, she decided to try a period of drinking only on nights when she didn't have to work the next day. Group members helped her come up with ideas about what to do on the nights she didn't drink. A few of them offered to get together with her to watch TV or play cards. Vicky stuck with this plan for several months and remained in her job for over a year. She eventually chose to stop drinking completely.

GROUP INTERVENTIONS
Groups can be a powerful way for clients to learn about themselves, to learn new skills, to find models of recovery, to develop new values, to develop social supports, and to have the experience of helping others. Feedback from peers is often more valued than the opinions of treatment providers. Groups are also a cost-effective way of providing education and treatment to several people (usually 6-12) at the same time.

Many types of groups are used for clients with dual disorders. Self-help groups like Alcoholics Anonymous and Narcotics Anonymous are described in the next chapter. Skills training groups can help people learn particular skills, such as social skills or work skills. Educational groups usually focus on a specific topic, such as the effects of substance use. Stage-wise treatment groups focus on helping people who are in the same stage of treatment to move toward recovery from their substance use disorder. Persuasion groups are for clients who do not yet see that their substance use is a problem; they are in the late engagement and persuasion stages of treatment. Active treatment groups are for clients who have decided that substance use is a problem they want to change. Active treatment groups are for people in the active treatment and relapse prevention stages of treatment.

PERSUASION GROUPS
Persuasion groups are supportive, educational groups for people in the early stages of substance abuse treatment. Participants are encouraged to explore how their substance use affects their lives, with the goal of helping them to see how substance use interferes with reaching their own goals. Like Vicky, most clients are anxious about attending a group for the first time. Case managers or therapists need to explain that the purpose of the group is NOT for the client to give up using substances, but is just to learn about substances in a supportive environment with other people like themselves. Case managers should help people start the group by asking them just to attend for a short time to see what it is like. Group leaders need to be in contact with team members so that individual and group treatment can be coordinated.

Persuasion groups are long-term and have group members coming and going all the time. They may be co-led by an addiction professional and a mental health professional, and often one or both leaders are recovering persons. Consumers in recovery may be very helpful co-facilitators. The groups meet weekly and last forty-five minutes or an hour. They often have a break in the middle for snacks and socializing to keep people's attention up.

Leaders of persuasion groups expect that group members are currently abusing substances. They offer an open, non-judgmental opportunity for people to talk about how they use substances and how their lives are going. Each group begins with everyone sharing how their week went and what their substance use was like. The leaders use this information to begin a discussion about common problems people are having and to encourage peer-to-peer interaction. Motivational interviewing techniques are also used to point out how people's substance use is interfering with taking steps towards their goals. Vicky was able to learn from others in the group, and was able to get help from them when she was ready to consider cutting back on her alcohol use. Like many clients, she trusted the opinions of her peers because she believed they knew what living with dual disorders is really like.

Many clients are initially resistant to participating in groups but subsequently become very attached to the group. Leaders try to maintain attendance by making the group low-key, supportive, and fun. They make sure that every client feels valued by checking in with each person. They do not confront people about their substance abuse, and they keep the group safe and positive for everyone. Refreshments are usually served. Some groups will have a weekly drawing for a prize, such as tickets to the movies. Sometimes groups will have structured activities or group outings that help keep clients interested in attending the group. One often hears that helping people to connect with the group initially is the most difficult step. Once they become a regular member and feel part of the group, almost everyone benefits. Excellent programs are able to engage about two-thirds of their clients with dual disorders in group interventions.

ACTIVE TREATMENT GROUPS

When consumers make a decision to reduce their substance use or try a period of abstinence, they are ready for active treatment groups. Vicky was ready for an active treatment group at the end of the vignette. The goal of active treatment groups is to help people stop using substances and to learn new skills to maintain abstinence. These weekly groups are also co-led by a substance abuse specialist and a mental health specialist who encourage peer-to-peer interactions and support. They last 60-90 minutes, in addition to a break in the middle. Because clients in this stage are motivated to stop all substance abuse, the expectation is that clients will attend regularly without group leaders needing to use engagement activities.

Active treatment groups are offered on a long-term basis, with people participating for as long as they feel they need for support. People further along in recovery act as role models for people still trying to achieve abstinence. When a person in the group relapses, members help them get back on track. Group leaders help the group use the relapse as a learning experience. If a client is unable to stop using substances within a few weeks after relapse, they may need to return to a persuasion group. When people are ready to graduate from active treatment groups, they may want to go on with a self-help group to continue to get social support for sobriety.

In active treatment groups, leaders provide education about how to reduce and stop using substances. They provide training for skills that will help people achieve their goals for recovery. These skills include being able to recognize high risk situations as well as internal and external cues that lead to substance use. Leaders help people learn and practice communication skills for assertiveness and for refusing substances. Group leaders also help clients explore new ways of coping with stress. They might teach clients stress management skills such as relaxation techniques or imagery to deal with cravings. Self-help materials are often used, and participants are encouraged to try self-help groups in the community.

Active treatment groups usually start with clients taking turns describing how their week went and any challenges they faced in staying sober. Group leaders decide which problems may be relevant to focus on that week and encourage group members to become involved in offering concrete suggestions and participating in role plays that permit practicing a particular skill or confronting a particular situation. Clients give feedback and support to those who do a role play.

COMBINED GROUPS
In many treatment settings, clients in the persuasion and active treatment stages are invited to participate in one combined substance abuse treatment group. Mental health centers may choose to run a single substance abuse group when they feel there are not enough clients to attend two separate groups. The challenge in running a combined group is meeting the varied needs of all group members. Clients in the persuasion stage of treatment need to explore the effects of substance use on their lives, while those in the active treatment stage need to learn new skills to stop using substances, to remain abstinent, and to go on with their lives. The advantage of a combined group is the opportunity for clients in the engagement stage to have peer role models that are abstinent. The disadvantage of combined groups is that issues relevant for clients in the persuasion stage may not be relevant for active treatment, so some active treatment clients lose interest and drop out. Ideally, groups for both stages should be offered.

Recommended reading
Many books and articles discuss specific types of groups. We recommend the following chapter, which describes different types of groups: Mueser,K.T., & Noordsy,D.L. Group treatment for dually diagnosed clients. In R.E. Drake & K.T. Mueser (Eds.), Dual Diagnosis of Major Mental Illness and Substance Abuse Disorder II: Recent Research and Clinical Implications (pp.33-51). San Francisco: Jossey-Bass, 1996.

For Social Skills Training, see Social Skills Training for Schizophrenia, A Step by Step Guide by Alan Bellach and others (Guilford, 1997).

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