Group therapy vs individual therapy: Is process group therapy better?
The importance of group therapy has been discussed on several occasions on our recovery podcast. Group therapy for substance abuse, also referred to as Process group therapy, is a form of treatment in which a therapist acts as a group facilitator with a small therapy group. Even the best rehab centers in the world are known for including process group therapy.
Often, the group members sit in chairs arranged in a circle. With this arrangement, members of the group session can listen to another participant while seeing their expressions and body language.
Everyone in the group therapy session feels as if they are equals in the circle. No one gets to hide out in the back row.
Group psychotherapy is implemented in most rehab programs, from residential rehab to private detox to outpatient programs, such as PHP, IOP, and OP. Because the 12-step Alcoholics Anonymous program is so thoroughly integrated into many rehab programs, you might think that the rehab psychotherapy group originated in AA and was borrowed from that program.
Interestingly, the concept of the process group was developed at least a few years before the founding of Alcoholics Anonymous. A group of psychiatrists developed the idea well before the first AA meeting took place.
In fact, it is more likely that AA borrowed the idea of group participants meeting together to share their common experience from the work of these psychiatrists. It does make sense that the founders of AA would want to include in their program what was considered cutting edge therapy for mental illness at the time, in the 1930s, when AA was founded.
Still, since 12-step facilitation is considered to be evidence-based treatment and employed by many rehabs, the influence of 12-step programs on rehab curriculums clearly exists.
Group treatment started out in the realm of psychiatry and psychology, was popularized by 12-step programs, and became a cornerstone of rehab counseling.
In the interpersonal process group, there is always a group leader. The group leader may be a certified addiction counselor or even a doctor of psychology or psychiatry.
In the group setting, the group therapist will help by facilitating the conversation. They may point out interesting topics that arise and encourage other members to share about those particular topics.
Or, the group facilitator may moderate disagreements and hostilities, preventing the escalation of arguments that may arise among the group participants in the therapeutic group. Public 12-step meetings also typically involve a chairperson who acts as a group leader, but with a less hands-on approach.
Unlike a group counseling leader in a residential center for addiction treatment, a 12-step meeting chairperson does not have to have any special credentials to lead a meeting. Their main responsibility is to open and close the meeting and call on members to raise their hands so that they may share.
What is the purpose of the process group?
Why would a rehab include group therapy at all? Why not focus solely on individual therapy?
The idea of the process group is to give participants an opportunity to share similar experiences and similar issues with the group. When one member hears that another member has a similar problem, it can help by seeing that they are not alone in their experience.
Addiction can be terrifying. People who experience active addiction may believe that they are going through something that is impossible to escape. They may believe that other people in recovery have it easier.
During substance abuse treatment, a patient may be given hope when they hear that a real person, just like them, has gone through similar situations. This group — sharing relationship can give rehab patients hope, that if another person in their situation can recover, that they can recover as well.
In facilities that employ highly trained addiction psychologists to moderate groups, they may use more advanced therapies in group sessions. Cognitive behavioral therapy (CBT) is often used in top rehab programs in the group setting.
CBT can be applied in treating addiction or any mental health condition where the patient is capable of participating in the therapy. Inpatient dual diagnosis treatment centers often employ CBT as a part of individual and group therapy. CBT can even be used in online therapy.
SMART Recovery is a non-12-step program that uses CBT in group meetings. Group leaders are trained in using CBT as a part of the program.
What other benefits are there to the psychoeducational group meetings in rehab?
In active addiction, many people start to avoid any social interactions. Drug or alcohol misuse becomes the complete focus of their lives, and they choose to engage in substance use alone.
In order to improve social skills, the ability to form interpersonal relationships, and to reduce anxiety, groups can be a gentle reintroduction back to engaging in social interactions. By addressing social anxiety and other issues that are present as a result of active addiction, there is an opportunity for personal growth.
A rehab client may learn in a group to see their personal challenges differently, learning to have a better distress tolerance when faced with adversity. A group may even practice important skills such as mindfulness, focusing on what is happening in the group in the present moment.
When activities such as prayer and mindfulness are introduced into the group setting, the experience can become spiritual. However, the spiritual experience in group meetings may be more appropriate in public 12-step meetings rather than in the clinical setting of a center for addiction treatment. Yet, in a religious-based program, such as a Christian rehab, prayer and spiritual experience may be an important part of the program.
Is process group therapy appropriate in psychedelic treatment for addiction?
At this time, psychedelic therapy for addiction and other forms of mental illness is still a new field in the US, only practiced in research settings. Psychedelic drugs are, for the most part, still not legal for use in medical therapy in the US.
However, in other countries, there are ibogaine treatment centers that use psychedelic drugs such as ibogaine and its derivative, 18-MC. While treatment is often provided in a very private setting, there may be instances where group therapy is employed.
Outside the clinical setting, there are groups that meet, led by a shaman, who uses psychedelic drugs such as ayahuasca to induce an experience to help people to overcome issues such as addiction, dependence, or chronic pain. Ayahuasca is a natural drug from which the drug DMT is derived.
In these sessions led by a religious shaman out in the deserts of Central or South America, group sessions may be an important part of the shared spiritual experience. Some participants have described feeling a sense of oneness with others. They may develop a new perspective on the universe and on their lives.
There are also, in these countries, clinics that offer ayahuasca therapy as well. Some people complain that using this drug in a clinical setting is a form of cultural appropriation and that the only proper setting is with an experienced shaman.
Of course, I am not recommending psychedelic therapy in other countries with more lax regulations or any drug-related therapy that involves following a shaman out into the desert. While there may be usefulness in these therapies when properly implemented and supervised by professionals, they are also highly dangerous.
People have died seeking ibogaine therapy outside the US. The drug is known to be cardio toxic. Also, while there may be reputable shamans out in the deserts south of the border, how can you be certain that you are safe?
So, while it may seem romantic to seek group therapy in a spiritual group under the stars in far off Mexico, out in the desert, vomiting up ayahuasca tea in front of the other group members, you may be putting yourself at serious risk of permanent injury or death. You could possibly develop a serious permanent mental health condition as a result of unregulated group psychedelic therapy.
Is group therapy in rehab always a good idea?
The idea that patients in rehab can only benefit from the experience of others by attending a group session is not completely true. If you are under the care of a doctor with experience of treating addiction, you can also benefit greatly from the experience of others.
For example, if you are seeing a private doctor for addiction treatment, your doctor will be able to share with you statistics and data about the success of medical treatment for the type of addiction that you are working to overcome. Additionally, the doctor can share case studies of other patients who have gone through similar experiences.
Of course, your addiction doctor is not going to give information that identifies the other patient in any way. Privacy is of the utmost importance for all addiction treatment patients.
Yet, hearing about success stories from your doctor can be inspirational, motivating, and give you great hope for your future in overcoming your addiction. Hearing about others who have passed before you and had success is a great motivator.
In fact, learning about past success stories may be a better way to motivate a patient and give them hope than sitting in a group of rehab clients who are at the same stage in treatment. If you are addicted to heroin and hear another group member state that they are addicted to heroin in the same way, how does that help to let you know that you have hope of getting past your addiction?
A patient once expressed this exact concern to me, about the feeling of hopelessness in rehab when sitting in a group session. He told me that he repeatedly shared with the group that he did not feel as if he would ever get past the intense drug cravings that haunted him throughout the day, every day.
Other members of the group shared that they felt the same way. The group leader encouraged other participants to share the topic and share how they felt about their hopelessness.
The patient told me that he felt even worse, as if there was no hope for him at all after hearing that other group members felt the same way. In fact, the group leader then told the group that the chance of success in overcoming addiction was fairly low, so they better dedicate themselves to the recovery process so that they might be in the very small percentage that succeeds.
Needless to say, this speech was not motivating in the way that the group leader intended. Telling a group that 1 in 10 might make it does not necessarily make anyone feel better or more hopeful.
After the patient told me this story, I asked him how he would feel about the odds of success being at least 1 in 2. He agreed that it was much better than what his group leader had told the group in rehab.
I was able to share with him statistics about medication assisted treatment and case studies about what qualities helped patients to be more successful. For example, sticking with medical treatment long enough is a great predictor of success. Another proven way to be successful in medical addiction treatment is to not let other people get involved in your medical treatment, telling you that you should stop your medication or take less without discussing it with your doctor.
Can group therapy help patients who are receiving medication-assisted treatment (MAT) for opioid use disorder or alcohol use disorder?
Group therapy as a part of medical treatment for addiction may be helpful, but it can also possibly be harmful in some situations. In a group setting where MAT is not accepted, a group member who sees a doctor for MAT may feel very uncomfortable.
For example, the Narcotics Anonymous 12-step program has an official position against what they refer to as “replacement medications.” If a patient takes Suboxone, they may be asked not to share in a meeting because the rest of the group does not consider them to be “clean.”
In addition to not being able to count clean time and celebrate milestones in their recovery with the group, they will also not be allowed to participate in service positions in the group. Hence, a person who takes Suboxone and functions perfectly well in society, at work and at home, may be made to feel like a second-class citizen in the NA program.
The problem is that, over time, the influence of group opinion can wear on a person until they finally give in and decide to act as their group wants them to act. They may make the decision to terminate medical treatment early.
So, where the best chance of success with MAT requires at least a year of treatment, a patient may quit after a few weeks or a few months, due to social pressure from a group. In this situation, the group “therapy” was definitely not helpful.
Early termination of MAT has frequently led to relapse, and sometimes tragic outcomes. It is important that people surround themselves with people who support them in their success, not people who undermine them with criticism and differing opinions that are not in line with medical science.
Is process group therapy good or bad?
While I have presented a case here for avoiding group therapy in some situations, it does not mean that it is always bad. Group sessions can be very helpful for providing a sense of community and shared experience.
Narcotics Anonymous meetings can be spiritual and inspirational, yet they may be best suited for people completing their MAT treatment. Also, it is important to note that MAT patients have no obligation to share with anyone the details of their medical treatment.
There are issues of privacy in any group therapy setting. In rehab, it is interesting that privacy laws are so highly respected when someone calls inquiring about a client.
For example, I was once contacted by one of my patients when he was in rehab. I returned his call by calling the main number for the facility. The receptionist told me that she could neither confirm nor deny the presence of my patient in their facility due to privacy laws.
This was in spite of the fact that it was clearly documented that I was the patient’s physician! I pointed out to the receptionist that it was interesting that she would protect the patient’s privacy from his own doctor, but then place him in a circle of complete strangers and encourage him to divulge the most intimate, private details of his life to them.
What if someone in the group knows someone else, personally or by reputation?
What if a celebrity is in a group with a member of the paparazzi? Invasive photographers who stalk celebrities sometimes end up in rehab with addiction problems as well.
Or, what if a member of the group is a prominent lawyer or a person who believes they were harmed by another group member? Or, they are members of the same profession, where addiction issues are frowned upon.
The possibility of privacy violations in group sessions in rehab is endless. When someone is in a state of hopelessness, just coming out of active addiction, they may not care who is in the group or what they share with the group. Yet, it is possible that what they share with strangers might come back to haunt them later.
On the other hand, putting the concerns of professionals and celebrities aside, many people have nothing to fear in sharing with the group. Being open in the group process can be very helpful in opening up about difficult issues.
They say, in the pop psychology of addiction group therapy, that a person is only as sick as their secrets. It is true that the condition of addiction motivates individuals to keep things to themselves.
A secret might be that a person has a secret plan to get high again after rehab. Maybe they still have a secret stash of drugs, or money to buy drugs. Maybe they are still keeping the phone numbers or social media contacts of their drug dealers.
Getting these secrets out in the open in front of a group can be therapeutic. There can be a feeling that sharing such secrets with a group of multiple people is even better than just sharing them with a single person in individual therapy.
For people who find group therapy to be beneficial for them, there is no reason to discourage them. Everyone is different, and there is no one-size-fits-all solution to addiction treatment. Process group therapy does help many people and should be made available to those who will most benefit from it.