Complexities with group therapy facilitation in substance use disorder specialty treatment settings

A pilot study of twice-weekly group-based written exposure therapy for veterans in residential substance use treatment: effects on PTSD and depressive symptoms

BACKGROUND

Posttraumatic stress disorder (PTSD) is highly comorbid with substance use disorders (SUDs), resulting in high prevalence of PTSD among individuals in residential SUD care. However, there is limited research on integrating trauma treatment into residential SUD care settings. The aim of the present project was to conduct an initial evaluation of the effects of group-based Written Exposure Therapy (WET) on PTSD and depressive symptoms that was integrated into programming for individuals in residential SUD treatment.

METHODS

Participants were 48 Veterans with comorbid PTSD-SUD from a 28 day residential SUD program at a Veterans Affairs Medical Center. Eligible participants were enrolled in 5 sessions of WET, delivered twice-weekly in an adapted group format. PTSD symptoms and depressive symptoms were assessed at each session with the Posttraumatic Stress Disorder Checklist, DSM-5 version (PCL-5) and the Patient Health Questionnaire (PHQ-9).

RESULTS

Over 5 months, 76.2% of the target population were successfully enrolled. Of the enrolled sample, 48 participants, 92% (n = 44) completed 3 sessions, while 56% (n = 28) completed 5 sessions. Generalized Estimating Equations (GEE) showed significant within-person reductions in PTSD symptoms over time, with an average decrease of 3.18 per session (χ² = 23.21, p = .006) and moderate effect sizes (d = 0.46 and d = 0.51 at mid- and post-treatment). In addition, there were significant reductions in depressive symptoms within-persons over time, with an average per-session reduction of 1.13 (χ² = 23.10, p = .006).

CONCLUSION

Findings demonstrate that brief, group-delivered WET is feasible and shows promise for addressing PTSD and depressive symptoms in residential SUD treatment. Results of the present evaluation could inform further efficacy testing and implementation of PTSD treatment into residential SUD settings.

A Pilot Study of Twice-Weekly Group-Based Written Exposure Therapy for Veterans in Residential Substance Use Treatment: Effects on PTSD and Depressive Symptoms

Background

Posttraumatic stress disorder (PTSD) is highly comorbid with substance use disorders (SUDs), resulting in high prevalence of PTSD among individuals in residential SUD care. However, there is limited research on integrating trauma treatment into residential SUD care settings. The aim of the present project was to conduct an initial evaluation of the effects of group-based Written Exposure Therapy (WET) on PTSD and depressive symptoms that was integrated into programming for individuals in residential SUD treatment.

Methods

Participants were 48 Veterans with comorbid PTSD-SUD from a 28-day residential SUD program at a Veterans Affairs Medical Center. Eligible participants were enrolled in 5 sessions of WET, delivered in twice-weekly in a group format. PTSD symptoms and depressive symptoms were assessed at each session with the Posttraumatic Stress Disorder Checklist, DSM-5 version (PCL-5) and the Patient Health Questionnaire (PHQ-9).

Results

Of the enrolled sample of 48 participants, 92% (n = 44) completed 3 sessions, while 56% (n = 28) completed 5 sessions. Dependent samples t-tests showed significant reductions from baseline in PTSD symptoms within-persons at both the 3-session (t(43) = 4.77, p < .001, d = .72) and 5-session mark (t(27) = 4.36, p < .001, d = .82). In addition, there were significant reductions in depressive symptoms after 3 sessions (t(38) = 3.01, p < .01, d = .48) and after 5 sessions (t(23) = 2.97, p < .01, d = .61).

Conclusion

Findings demonstrate that brief, group-delivered WET shows promise for addressing PTSD and depressive symptoms in residential SUD treatment. Results of the present evaluation could inform further efficacy testing and implementation of PTSD treatment into residential SUD settings.

Implementation and Preliminary Evaluation of a 12-Week Cognitive Behavioural and Motivational Enhancement Group Therapy for Cannabis Use Disorder

Background

The purpose of this paper is to provide a preliminary evaluation of treatment outcomes, retention and client satisfaction following a 12-week combined cognitive behavioural therapy (CBT) and motivational enhancement therapy (MET) group treatment for cannabis use disorder (CUD) delivered in an outpatient setting. Implementation of the program is also described.

Methods

A retrospective observational cohort study was conducted using data collected from medical records and self-report assessments. Participants were treatment-seeking cannabis users at the Centre for Addiction and Mental Health, Toronto. Cannabis use, cannabis-related problems, craving, withdrawal symptoms, self-efficacy for remaining abstinent, depression and anxiety were assessed pre- and post-treatment. Treatment retention was calculated by inspecting clinic attendance records, and client satisfaction was evaluated using an anonymous feedback survey. Potential predictors of treatment outcomes and retention were investigated in exploratory analyses.

Results

Cannabis use was lower and days of abstinence higher post-treatment (vs pre-treatment). Post-treatment improvements in cannabis-related problems, craving, withdrawal symptoms, self-efficacy and mood were also observed. Completion of group treatment (⩾75% of sessions attended) was 57% and moderate levels of treatment satisfaction were reported.

Conclusions

This study provides preliminary evidence that a 12-week combined CBT and MET treatment for cannabis use disorder delivered in a novel group setting improves cannabis use outcomes. Potential predictors of reduced cannabis use and retention were identified. Future controlled studies are warranted, and strategies for increasing retention should be explored.

Assessing the Fidelity of an Affirmative Cognitive Behavioral Group Intervention

PURPOSE

Support implementation fidelity in intervention research with lesbian, gay, bisexual, transgender, queer, and sexual and gender diverse (LGBTQ+) populations, this study explores the systematic development of a fidelity process for AFFIRM, an evidence-based, affirmative cognitive behavioral therapy group intervention for LGBTQ+ youth and adults.

METHOD

As part of a clinical trial, the AFFIRM fidelity checklist was designed to assess clinician adherence. A total of 151 audio-recorded group sessions were coded by four trained raters.

RESULTS

Adherence was high with a mean fidelity score of 84.13 (SD = 12.50). Inter-rater reliability was 81%, suggesting substantial agreement. Qualitative thematic analysis of low-rated sessions identified deviations from the manual and difficulties in group facilitation, while high-rated sessions specified affirmative and effective clinical responses.

DISCUSSION

Findings were integrated into clinical training and coaching. The fidelity process provides insights into the challenges of implementing social work interventions effectively with LGBTQ+ populations in community settings.

Trust and collaboration between patients and staff in SUD treatment: A qualitative study of patients’ reflections on inpatient SUD treatment four years after discharge

Background and aim: Substance use disorder (SUD) is multifactorial, complex, and involves the severe problematic use of alcohol, prescription drugs, and other substances. People with SUD have long histories of perceived stigma, marginalisation, exclusion, social isolation, and shame. Moreover, patients with SUD are often treated as untrustworthy and incapable of actively participating in their treatment planning, even by healthcare and social services workers. Methods: Through in-depth interviews with former patients who have undergone SUD treatment, we explored their reflections on the treatment content. Interpretative phenomenological analysis revealed that some informants experienced aspects of the treatment as valuable, whereas others considered the same treatment useless or harmful. Results: Essential aspects of treatment were developing self-esteem and optimism about the future, developing strategies for coping with stress and challenging emotions and situations, developing relationships with family and friends, and preparing for life after inpatient treatment. Relationships with staff were described as crucial in all parts of the treatment. Conclusion: In conclusion, we suggest that a transition to a more collaborative treatment philosophy would be ethically and professionally valuable for providing support and treatment and enhancing patients’ perceptions of empowerment, inclusion, participation, and well-being on their terms, in cooperation with supportive others.

The use of Australian SMART Recovery groups by people who use methamphetamine: Analysis of routinely-collected nationwide data

INTRODUCTION

Mutual support groups (e.g. SMART Recovery) are an important source of support for people experiencing addictive behaviours. Little is known about the use of mutual support groups by people who use methamphetamine, or the factors that may influence group cohesion.

METHODS

This study uses post-group data reported by SMART Recovery facilitators in Australia between 2018 and 2020. Group cohesion was indexed by facilitator ratings of The Group Entitativity measure (GEM-GP). Participant characteristics (gender, age, new or returning group member, voluntary or mandated attendance) and group location (major city vs. regional/remote vs. online) were used to (a) compare methamphetamine and non-methamphetamine related attendances; and (b) explore relationships to group cohesion within groups where the majority attended for methamphetamine.

RESULTS

Methamphetamine use was the second most common reason for attending SMART Recovery groups (n = 4929; 22.2 % service occasions). Methamphetamine-related service occasions were more likely amongst men, people aged <45 years, returning attendees and regional/rural groups (allp < .05). GEM-GP scores were high (signalling strong cohesion), and did not significantly differ according to proportion of participants attending for methamphetamine (F(1,2) = 0.482, p = .618). Group cohesion increased with larger group size, proportion of women and proportion of younger people (F(4, 504) = 11.058, p < .001)).

DISCUSSION AND CONCLUSIONS

This study improves current understanding of service utilisation by people who use methamphetamine. SMART Recovery groups offer an avenue for supporting a diverse range of people who use methamphetamine, outside the formal treatment system. This provides an important foundation for improving community support options for people who use methamphetamine.

Randomized controlled trial of group motivational interviewing for veterans with substance use disorders

BACKGROUND

Motivational interviewing delivered in a group format is understudied yet promising as a treatment for substance use disorders (SUD). We evaluated the efficacy of group motivational interviewing (GMI) relative to a treatment-control (TCC) for enhancing treatment and self-help engagement and decreasing alcohol and drug use among veterans with SUD and co-existing psychiatric disorders.

METHOD

Veterans (n = 118) with alcohol use disorder were recruited within an outpatient SUD treatment program and randomized to GMI or TCC upon program entry. Alcohol use, SUD treatment, and 12-step session attendance were primary outcomes. Drug use days was the secondary outcome. Participants were assessed at baseline and at one-and three-month follow-up.

RESULTS

Significant differences were observed between GMI and TCC for binge drinking at both one (RR = .74; 95 % CI [.58, .94]) and three-month follow-up (RR = .74; 95 % CI [.59, .91]). At three-month follow-up, significant differences between treatment conditions were observed for alcohol use days (RR = .79; 95 % CI [.67, .94]), number of SUD treatment sessions (RR = 2.53; 95 % CI [1.99, 3.22]), and 12-step sessions attended (RR = 1.64; 95 % CI [1.35-1.98]). Similarly, we observed significant effects for GMI on reducing alcohol consumption in standard drinks (RR = .49; 95 % CI [.25, .95]). Drug use days declined at each follow-up, with no significant differences between treatment conditions.

CONCLUSIONS

GMI delivered at SUD treatment program entry enhanced treatment session and 12-step group attendance and lowered alcohol consumption among outpatient Veterans. Future research should study how GMI works and its effectiveness in SUD treatment settings.

Utilizing patient perception of group treatment in exploring medication adherence, social support, and quality of life outcomes in people who inject drugs with hepatitis C

People who inject drugs (PWID) have a high prevalence of hepatitis C virus (HCV). Group treatment is a practical option for addressing barriers to treatment in this population. Prior research on group treatment has resulted in mixed conclusions about its effectiveness in addressing barriers to treatment. A patient's perception of the group environment may help to explain this variability. This study sought to explore the association between indicators of group treatment environment and improved outcomes in HCV-infected PWID. This secondary analysis of a randomized controlled trial exploring different models of treatment for HCV in a PWID population consisted of 42 participants randomized to the group treatment branch of the trial. Independent variables consisted of group sessions attended and group climate constructs of engagement, conflict, and avoidance. Dependent variables consisted of medication adherence, social support, and health-related quality of life. The study implemented generalized estimating equations to assess associations with the outcomes at the end of treatment. Factors indicative of group treatment environment were related to medication adherence and other barriers to health for HCV-infected PWID: social support and health-related quality of life. Perceptions of conflict or avoidance were associated with worse outcomes, while increased session attendance was generally associated with better outcomes. The study attests to the importance of examining group environment factors during treatment interventions. Although preliminary, the study provides specific indicators of treatment success for HCV-infected PWID and practical implications to improve patients' health outcomes and better tailor treatment to the patient.

Long-term treatment retention in West Virginia's comprehensive opioid addiction treatment (COAT) program

BACKGROUND

The United States continues to experience an opioid epidemic of unprecedented proportions despite FDA approval of life saving medications, such as buprenorphine. This paper describes a novel group-based buprenorphine treatment model and summarizes patient characteristics and treatment retention. This model, known as the Comprehensive Opioid Addiction Treatment (COAT) program, was developed in West Virginia, the epicenter of the opioid epidemic.

METHODS

Data on 454 patients actively enrolled in the COAT program were extracted from an administrative clinical data set and electronic medical records and analyzed using descriptive and quantitative analysis to determine long-term retention in treatment using frequencies and means.

RESULTS

The characteristics of the 454 patients are as follows: average age of 39, 53% female, predominantly white (94%) and Medicaid was the primary insurance provider (68%). Analysis of retention showed 37.8% of patents were retained less than one year and 14.7% were retained 10 or more years. Initiating treatment at a younger age was associated with long-term retention.

CONCLUSION

Opioid use disorder is a chronic relapsing disease and treatment models that retain patients long-term have the greatest benefit. The COAT model has been successful in retaining patients long-term in a rural setting where barriers to treatment are many.

Group treatment for substance use disorder in adults: A systematic review and meta-analysis of randomized-controlled trials

BACKGROUND AND AIMS

From residential programs to outpatient services, group therapy permeates the clinical field of substance misuse. While several group interventions for substance use disorders (SUDs) have demonstrated effectiveness, the existing evidence on group therapy has not been systematically reviewed. The current meta-analysis aims to provide estimates of the efficacy of group therapy for SUDs in adults using rigorous methods.

METHODS

We included studies comparing group psychotherapy to no treatment control groups, individual psychotherapy, medication, self-help groups, and other active treatments applying no specific psychotherapeutic techniques for patients with substance use disorder. The primary outcome was abstinence, and the secondary outcomes were frequency of substance use and symptoms of substance use disorder, anxiety, depression, general psychopathology, and attrition. A comprehensive search was conducted in Medline, Web of Science, CENTRAL, and PsycINFO, complemented by a manual search. Random-effects meta-analyses were run separately for different types of control groups.

RESULTS

Thirty-three studies were included. Significant small effects of group therapy were found on abstinence compared to no treatment, individual therapy, and other treatments. Effects on substance use frequency and SUD symptoms were not significant, but significant moderately sized effects emerged for mental state when group therapy was compared to no treatment. There were no differences in abstinence rates between group therapy and control groups. These results were robust in sensitivity analyses and there was no indication of publication bias.

CONCLUSIONS

The current findings represent the best available summary analysis of group therapy for SUDs in adults, however cautious interpretation is warranted given the limitations of the available data.

Group Psychotherapy in Specialty Clinics for Substance Use Disorder Treatment:The Challenge of Ethnoracially Diverse Clients

Minimal research has explored how clinicians address race and ethnicity considerations in the context of group psychotherapy within substance use disorder (SUD) specialty treatment settings. This article is an exploratory qualitative study in an effort to narrow this gap, using data from semi-structured interviews with 13 group clinicians at three outpatient SUD specialty clinics in the United States. Results are drawn from the portion of coded material pertaining to ethnoracial considerations. A predominant theme from the interviews was the importance of individualized care in terms of "meeting clients where they are at." However, minimal attention appears to have been given to addressing clients' demographic diversity. Overall, ethnoracial considerations were minimally addressed in groups, with clinicians framing such primarily in terms of "cultural" factors relevant to clinics' treatment philosophies. Moreover, limited attention was reportedly given to acknowledgment of social inequities faced by ethnoracial minority clients (e.g., racial discrimination), even though a few clinicians reported concern that minority clients were less engaged in treatment. Clinical implications of these findings and recommendations for future research are discussed.