Mixed-methods exploration of group therapy for substance use disorders
By Dennis C. Wendt
For my dissertation (Wendt, 2015) I used mixed methods to explore complexities related to group therapy facilitation for substance use disorder (SUD) treatment. Here, I briefly describe the process that led to this project, its general research design, and its broad conclusions and implications. (Manuscripts reporting results are in preparation or under review.)
As part of my graduate training in clinical psychology at the University of Michigan, I worked in an intensive-outpatient SUD treatment program at a VA hospital. As part of this experience I helped to revamp the program's psychosocial curriculum—consisting entirely of group therapies—using evidence-based treatments (EBTs; i.e., standardized treatments based on randomized clinical trials). This predominance of group therapy is typical among SUD specialty treatment programs—a reflection of cost considerations, a historical connection to mutual-support groups (e.g., Alcoholics Anonymous), and therapeutic factors that are unique to group settings (e.g., support and accountability from others with similar problems; Crits-Christoph, Johnson, Connolly Gibbons, & Gallop, 2013; Weiss, Jaffee, de Menil, & Cogley, 2004).
What I soon discovered, though, is that existing EBTs for SUDs have focused predominantly on individual therapy. A likely reason for this focus is that clinical trials for individual therapy are easier to conduct and analyze than are clinical trials for group therapy ( Morgan-Lopez & Fals-Stewart, 2008). Nonetheless, as I came to appreciate, this treatment modality mismatch is not trivial. Individual therapies do not translate easily into group format, and additional skills and training are generally required of clinicians (e.g., due to groups being more unpredictable as a function of consisting of several clients; American Group Psychotherapy Association, 2007; Sobell & Sobell, 2011; Yalom & Leszcz, 2005) . A further complexity is that SUD treatment settings typically utilize open groups, in which clients begin and terminate treatment on a rolling basis (making it difficult if not impossible to deliver therapeutic content that builds on itself conceptually over multiple sessions).
Overview of Dissertation
For my dissertation I took preliminary steps to narrow this treatment modality mismatch, with an aim to explore, document, and analyze common practices and complexities for group therapy facilitation in real-world SUD treatment settings. Questions guiding this investigation included:
- In what ways do SUD clinicians facilitate groups?
- What practices are most likely to be used?
- What organizational factors influence group therapy curricula (including use of EBTs)?
- How do clinicians balance structure with group process?
- How are open groups managed?
To answer these questions, I utilized a mixed-methods approach consisting of a quantitative survey and qualitative semi-structured interviews. This approach is best categorized as a QUAL + quan mixed-methods design, meaning that qualitative data are a more substantive part of the data collection and analysis than are quantitative data, and that the relationship between the two types of data collection/analysis is simultaneous rather than sequential (Palinkas & Soydan, 2012).
I surveyed 566 clinicians who facilitated SUD group therapy within the past two years in the U.S., recruited from the membership of NAADAC (Association for Addiction Professionals; formerly called the National Association of Alcoholism and Drug Abuse Counselors), the nation's largest addiction health care professional organization. Respondents were surveyed online about their most commonly used group therapy practices (1-5 Likert scale), using an adaptation of the “Clinical Practices Survey for Substance Use Disorders” (Gifford et al., 2012), in addition to demographic items. Survey results confirmed the widespread use of group therapy in SUD treatment settings, including the predominant use of open groups. Clinicians also reported high utilization of EBT components, especially for motivational interviewing and cognitive behavioral therapy, but with varying use of specific components and moderate use of questionable practices.
Semi-Structured Interviews (Qualitative)
I conducted semi-structured interviews (one to two hours) with 13 clinicians and three clinical directors at three outpatient SUD specialty clinics located in the same Midwestern U.S. metropolitan area: (a) a non-profit 12-step oriented community clinic, (b) a state medical school clinic, and (c) a VA intensive-outpatient clinic. I analyzed the organizational structure and group therapy curricula at the three clinics, as well as explored complexities and barriers for group therapy facilitation (including use of EBTs). Questions addressed organizational characteristics, services provided, group therapy curricula, and use of manualized and/or evidence-based treatments. Interviews were audio-recorded, transcribed verbatim, coded, and interpreted according to principles of thematic content analysis; to maximize methodological rigor, I adhered to a 15-point checklist for thematic content analysis (Braun & Clarke, 2006) and a 32-item checklist for reporting qualitative research (consolidated criteria for reporting qualitative research; COREQ; Tong, Sainsbury, & Craig, 2007). For part of this analysis, brief summaries of each clinic's organizational factors (e.g., operational structure, treatment philosophy, and group therapy curriculum) were compared with logistical and structural aspects of three prominent psychosocial EBT manuals for SUDs: cognitive behavioral therapy, motivational enhancement therapy, and 12-step facilitation.
Based on the clinic descriptions, the three clinics differed substantially in terms of their operational structure, funding, socioeconomic status of clientele, professional experience of clinicians, and use of EBTs. In spite of these differences, I concluded that all three clinics had, or would have, significant challenges with implementing each of the three manualized EBTs, as evidenced by the clinics' (a) exclusive or predominant use of open groups, (b) reliance on certain treatment structures (e.g., session length, number, and duration) that are not readily compatible with existing EBTs, and (c) insufficient coordination between group therapy and individual care.
Based on themes generated from interviews, clinicians emphasized the importance of flexibility in group treatment delivery in order to provide individualized, relevant, and engaging care. However, clinicians also had challenges with group facilitation (including difficulties in adoption and use of EBTs), as evidenced by their reports of (a) complex group dynamics, (b) limited group therapy experience and training, (c) predominant use of educational groups, and (d) limited attention to clients' demographic diversity.
This research has several implications for improved innovation and implementation of evidence-based group therapies. In terms of clinical research, researchers could potentially reduce the research-practice gap by collaborating with clinics and clinicians to adapt existing EBTs and best practices in a manner in which they could be more flexibly utilized in group formats. For clinicians and administrators, greater recognition ought to be given that group therapy requires specialized training as a distinctive treatment modality. In general, greater attention to clinician training and quality control appears to be sorely needed.
In addition, my dissertation is an example of how exploratory mixed-methods inquiry can bridge gaps between research and clinical practice. Such an approach allowed for in-depth investigation of widely utilized therapy processes that have been neglected by researchers. In particular, the qualitative data suggest that clinical settings and clinicians are frequently ill-equipped to use existing EBTs in group format and therefore greater attention needs to be given to this treatment modality mismatch. Assuming that group therapy will remain a mainstay of SUD specialty treatment, it behooves researchers and clinicians to collaboratively address these challenges. I hope that this research can serve as a springboard for this collaboration, ideally towards the creation, adaptation, implementation, and assessment of clinically-relevant EBTs for group therapy.
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Wendt, D. C. (2015). Mixed-methods exploration of group therapy for substance use disorders: Prospects for evidence-based practice (Doctoral dissertation). University of Michigan. Retrieved from http://deepblue.lib.umich.edu/handle/2027.42/113429
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