PURPOSE AND BENEFITS
The purpose of the Co-Occurring Disorders Group (hereafter referred to as “The Group”) is to provide a safe, positive, and therapeutic environment for patients with a substance abuse disorder and at least one co-occurring mental illness. The Group will empower its members to a) learn coping skills vital to their recovery from active addiction and b) learn to appropriately manage the symptoms of their own individual mental illnesses. Through directive techniques and activities led by the group leader as well as interaction with other members, each participant will learn to take an active role in his or her own recovery.
One of the reasons why patients with co-occurring disorders will benefit from group therapy is that Twelve-Step Programs, commonly used as an adjunct for recovering addicts and alcoholics, inadvertently exclude individuals with accompanying mental illness. The following are three issues that patients with co-occurring disorders face in Twelve Step Programs:
- Narcotics Anonymous considers any use of mind altering substances to be in conflict with their program of recovery. This includes any and all psychotropic medications used for the treatment of mental illness such as anxiety, depression, PTSD, and bipolar disorder.
- Both NA and AA believe that “the therapeutic value of one addict (or alcoholic) helping another is without parallel.” This implies that a regulated group is by definition inferior. It also implies that a group leader who is not an addict themselves is somehow unfit.
- Mental illness is seen as an “outside issue” in both NA and AA. Both organizations do not recognize therapy as a legitimate means to recovery, nor do they address any form of mental illness other than addiction and/or alcoholism. AA, for example, specifically addresses alcohol as the core problem of the alcoholic.
While these programs do not seek to intentionally exclude patients suffering from mental illness, the reality is that many addicts and alcoholics end up feeling isolated and alone when they attempt to associate with the very programs that are supposed to provide them with fellowship and a sense of belonging (Doughty & Hunt, 1999).
Popovic & Starcher (1995) suggest that group therapy offers twelve distinct benefits for patients with co-occurring disorders. These include group education, support, identification of relapse triggers, honesty, changes in lifestyle, the effects of stress, taking personal responsibility, the importance of confidentiality, and the need for spirituality, among others (1-2). It is clear that the need for such a group exists, and that its effectiveness is backed up by current research.
GROUP ORGANIZATION AND SELECTION
The proposed Group will be voluntary in nature, and will not exclude anyone based on race, gender, age, creed, religion, sexual identity, or ethnicity. There will only be two requirements for entrance into the group:
1. Each member must have a substance abuse disorder and a co-occurring mental illness. Patients suffering from depression, anxiety, bipolar disorder, and/or PTSD will constitute the bulk of the group. Patients who suffer from more severe personality disorders, such as Schizoid-Affective Disorder, will need to be referred to a more intensive group setting.
2. Patients must have the desire to cease their substance abuse and to manage their mental illness in a way that affords them the opportunity to be productive and responsible members of society.
The group will be closed and consist of no more than 15 persons. It will meet for 90 minutes twice a week for a total of ten sessions or five weeks. The group should remain closed so that individual members can form intimate relationships with one another and grow as a single cohesive unit. While outside groups such as AA and NA can theoretically last a life time, the realities of our healthcare system dictate a finite number of sessions. To that end, the group leader will always keep an eye on termination as the ultimate goal of the group. The purpose of the group is to learn skills to cope with substance abuse and mental illness. The objective of the group is to empower the group to thrive as individuals long after the last session ends.
TWELVE STEP COMPONENT
As is the case with so many patients with a substance abuse disorder, group members will inevitably have a certain familiarity with Twelve-Step jargon and what can be called “the culture of recovery.” This group is by no means a critical response of Twelve Step Programs. Rather, it is a group designed to empower patients with co-occurring disorders to thrive in all walks of life, including participation in groups such as AA and NA. The Group provides an extra layer of therapy, geared towards the challenges that patients with co-occurring disorders face. Involvement in Twelve Step programs will be encouraged, but with the understanding that those programs only address half of the issues with which the patients are faced. From the group, they will learn coping skills and strategies that would otherwise not be afforded to them in a traditional Twelve Step forum. Having said that, the Twelve Step Model can be extremely effective, and many aspects of it are quite useful. For example:
- Spiritual principles such as honesty, integrity, brotherly love, justice, open mindedness, and willingness are integral to the therapeutic process.
- The emphasis on fellowship, personal accountability, and service.
- The manner in which Twelve Step Groups promote sharing experience, strength and hope to other members of the Fellowship. This is extremely helpful in a group setting.
- Twelve Step Programs place a high premium of personal security and anonymity.
RULES AND STRUCTURE
Confidentiality is enforced by each member; as a result, members feel comfortable. Unlike most Twelve Step Programs, which are open to the public, this group will Be closed, and will be by referral or invite only. In order to preserve group cohesion, the group leader will populate the group with members that he or she believes are most likely to participate and contribute to the group as a whole. The group leader will rely on recommendations and referrals from mental health therapists, psychologists, and substance abuse counselors. An effort needs to be made to ensure that group members are appropriate, in that they have co-occurring disorders, but also the willingness to make positive change in their lives. It is also important to ensure that patients with extreme conditions, such as schizophrenia, be referred to a setting where they can get more individualized therapy.
As for the substance abuse disorders, clients need to be completely clean from all drugs, and pledge to abstain from mind altering substances not prescribed by a licensed physician. Should a group member relapse during the course of group therapy, they will be asked to refrain from participating until they are no longer high. Twelve Step programs suggest that relapse is often a part of recovery, so no group member should be arbitrarily dismissed from the group for a relapse. However, they may be asked to return only if they are free from drugs and alcohol.
TECHNIQUES AND INTERVENTIONS
Smock, et al. (2008) and Wager & McMahan 2004) have both published articles about the efficacy of solution-focused group therapy for patients with co-occurring disorders including substance abuse. Wagner & McMahon (2004) examined the benefits of motivational interviewing in a group setting. A client’s motivation plays a huge role in their recovery. It is essential to change, and to learning to cope effectively with co-occurring disorders. Motivational Interviewing, as the authors identify it, focus on the following areas:
- The importance of change;
- Confidence that change is possible;
- Readiness to make changes (152).
As such, motivational interviewing will play a key role in the group. Patients must learn
that change is both possible and preferable. Smock, et al (2008) found similar findings in their study, which showed that patients exposed to solution focused therapy made significant gains, as measured by the Beck Depression Inventory and the Outcome Questionnaire (107).
RISKS AND SAFEGUARDS
Patients with co-occurring disorders, just like any other patient, must accept certain risks associated with group therapy. It is also the group leader’s responsibility to minimize those risks. A sample of risks are as follows, with the safeguards to be used:
- Confidentiality. Both mental illness and substance abuse carry with them a societal stigma that can cause patients to lose their jobs, their marriages, their children, and their standing in the community. To that end, all group members will sign an Informed Consent detailing the limits of confidentiality, and they will pledge to keep all group discussions confidential.
- Psychological risks. Change is often a byproduct of effective therapy. As patients begin to become more and more self-aware, it is possible that they will dislike the person they have become, or regret the things they have done in the past. To that end, the group leader will incorporate the Twelve Step process of writing a fearless and moral inventory (Step 4) and admitting to themselves, God, and another person the nature of their wrongdoings (Step 5). In a positive, supportive environment, group members will have the opportunity to make sense of their past behaviors and learn how to live a life free of drugs and alcohol.
- Conflict with other members. The spiritual principle of tolerance, open mindedness, and willingness will act as a backbone of recovery for the group. While group members are free to speak their minds, the group leader will reserve the right to challenge any faulty thinking that prevents the recovery of the group.
EVALUATION AND FOLLOW UP PROCEDURES
Evaluation of the group will be an on-going and collaborative process, requiring the input and feedback of all members of the group. Corey (2010) suggests two forms of evaluation: member-specific, and group-specific. The latter addresses changes in beliefs and attitudes among individual members. The former assesses changes common to all members of the group, such as increased self-awareness, a lessening of anxiety, managing of symptoms, and improved personal relationships (126).
Corey (2010) also recommends a follow up group session after the group is terminated. Such a follow up can provide accountability for group members, as they know they will have to “answer” to their fellow group members even after the group has officially ended. Group members will also be encouraged to support one another and perhaps exchange contact information, much the same way as NA and AA operate. At the follow up sessions, group members will have an opportunity to discuss any problems they have encountered, how the group impacted their own personal recovery, and they may share any personal strategies they have learned to be an effective means for positive change. The Coreys (2010) suggest that group members write a letter to themselves at the end of the last session, to be read six months after the last meeting and then again one year later. The purpose of this exercise is to help members remember their experiences and to help them feel accountable for their actions.
Corey, Marianne, Corey, Gerald, & Corey, Cindy. (2010) Groups: process and practice, 8th Ed. Belmont: Brooks/Cole, pp 454.
Courbasson, Christine M. (2010). Cognitive behavioral group therapy for patients with co-existing social anxiety disorder and substance use disorders: a pilot study. Cognitive
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Doughty, Jhan & Hunt, Brandon. (1999). Counseling clients with dual disorders: information for rehabilitation counselors. Journal of Applied Rehabilitation Counseling. 30: 3, 3-10.
Panas, Lee, et al. (2003). Performance measures for outpatient substance abuse services: group versus individual counseling. Journal of Substance Abuse Treatment, 25:4, 271-279.
Popovic, Sveto & Starcher, Margaret. (1995) Group therapy offers 12 ways to manage dual diagnosis. Addiction Letter, 11:10, 1-2.
Smock, Sara A., et al. (2008). Solution-focused group therapy for level 1 substance abusers. Journal of Marital and Family Therapy, 34:1, 107-20.
Timko, Christine. (2005). Treatment for dual diagnosis patients in the psychiatric and substance abuse systems. Mental Health Services Research, 7:4, 229-242.
Wagner, Christopher & McMahan, Brian. (2004). Motivational interviewing and rehabilitation counseling practice. Rehabilitation Counseling Bulletin, 47:3, 152-161.
Weiss, R.D., et al. (2007). A randomized trial of integrated group therapy versus group drug counseling with patients with bipolar disorder and substance dependents. The American Journal of Psychiatry, 164:1, 100-7.