Professionals' perspectives on interventions to reduce problematic alcohol use in older adults: a realist evaluation of working elements

OBJECTIVES

This study set out to understand how (which elements), in what context and why (which mechanisms) interventions are successful in reducing (problematic) alcohol use among older adults, from the perspective of professionals providing these interventions.

DESIGN

Guided by a realist evaluation approach, an existing initial programme theory (IPT) on working elements in alcohol interventions was evaluated by conducting semistructured interviews with professionals.

SETTING AND PARTICIPANTS

These professionals (N=20) provide interventions across several contexts: with or without practitioner involvement; in-person or not and in an individual or group setting. Data were coded and links between contexts, elements, mechanisms and outcomes were sought for to confirm, refute or refine the IPT.

RESULTS

From the perspective of professionals, there are several general working elements in interventions for older adults: (1) pointing out risks and consequences of drinking behaviour; (2) paying attention to abstinence; (3) promoting contact with peers; (4) providing personalised content and (5) providing support. We also found context-specific working elements: (1) providing personalised conversations and motivational interviewing with practitioners; (2) ensuring safety, trust and a sense of connection and a location nearby home or a location that people are familiar with in person and (3) sharing experiences and tips in group interventions. Furthermore, the mechanisms awareness and accessible and low threshold participation were important contributors to positive intervention outcomes.

CONCLUSION

In addition to the IPT, our findings emphasise the need for social contact and support, personalised content, and strong relationships (both between client and practitioner, and client and peers) in interventions for older adults.

The relationships among working alliance, group cohesion and homework engagement in group cognitive behaviour therapy for social anxiety disorder

OBJECTIVE

Few studies have investigated the role of generic relational factors, such as group cohesion and working alliance, in group cognitive behaviour therapy (CBT) for social anxiety disorder (SAD). The aim of this study was to examine the temporal associations among working alliance, group cohesion, and an index of a CBT-specific factor, homework engagement, as correlates of fear of negative evaluation and symptoms of social anxiety in group CBT for SAD.

METHOD

There were 105 participants with a diagnosis of social anxiety disorder who were randomly assigned to 12 sessions of group imagery-enhanced or standard CBT. Participants completed measures at various time points during the 12-session interventions, and the relationship among variables was examined through random-intercept cross-lagged panel models.

RESULTS

Group cohesion was significantly associated with social anxiety symptoms at the end of treatment, however there was no significant relationship with working alliance. Greater homework engagement predicted lower social interaction anxiety, but only during mid-treatment.

CONCLUSION

The results highlight the importance of supporting group cohesion and maximising homework engagement during core components of social anxiety treatment such as behavioural experiments.

A framework for the evidence-based practice of therapeutic jurisprudence: A legal therapeutic alliance

This paper provides a theoretical rationale for using the constructs of procedural justice, trust and self-determination as a framework to guide the evidence-based practice of therapeutic jurisprudence (TJ). The overarching purpose of TJ is to provide therapeutic outcomes to all participants in the legal system. This paper proposes that in legal decision-making, running a procedurally just process that generates trust amongst participants and allows the parties to experience self-determination, creates a dynamic akin to the therapeutic alliance, which, in therapy, is a reliable predictor of therapeutic outcomes. The paper argues that when a legal therapeutic alliance forms in a legal decision-making process then positive therapeutic outcomes are possible, and the process can be classified as one that accords with the philosophy of TJ. A subsequent argument is that a therapeutic court can be defined as one that enacts such a process. The paper concludes by explaining how the framework can provide both a guide to courts in designing TJ processes and an assessment framework to analyse legal decision-making processes for their therapeutic value.

The influence of members’ attachment style on group cohesion in substance use therapy groups

Group cohesion is an important factor in group therapy as it influences treatment outcomes and group processes. One’s attachment style has been found to impact experiences of group cohesion, however research into this relationship in substance use disorder (SUD) group treatment is lacking. This is of particular concern as insecure attachment presentations are more prevalent in this clinical population and group therapy is often treatment of choice. The current study sought to determine whether attachment style significantly predicted group cohesion. It also provided a qualitative exploration of factors that promote group cohesion in SUD group treatment. Participants (N = 38) attending a SUD therapy program completed self-report measures. Attachment avoidance was a significant negative predictor of positive bonding and positive working, and a significant positive predictor of negative relationships. Attachment anxiety was a significant negative predictor of negative relationships, however, unexpectedly did not significantly predict positive bonding or positive working. The current findings highlight the importance of group therapists tailoring group treatment to meet the attachment needs of individuals to promote a group therapy environment conducive to recovery.

Working together: An investigation of the impact of working alliance and cohesion on group psychotherapy attendance

OBJECTIVES

Group psychotherapy holds considerable potential for cost-effective treatment delivery. However, issues with client attendance can compromise the efficacy of such treatments. To date, client specific factors are amongst the most researched predictors of attendance in psychotherapy, with much less of a focus given to process factors, particularly in the group therapy context. This study aimed to determine which process factors influenced attendance in the context of a group therapy programme for adults with anxiety. It was hypothesized that (1) the working alliance and group cohesion would be moderately correlated, (2) both the working alliance and group cohesion would explain unique variance in session attendance, and (3) the working alliance would act as a moderator for attendance, when group cohesion was low.

DESIGN

The study utilized a within participants design.

METHODS

Participants were 91 adults (aged 18-74 years) who took part in a 9-week, transdiagnostic cognitive behavioural group therapy programme for the treatment of anxiety disorders.

RESULTS

Working alliance and group cohesion were significantly, but only moderately correlated (rs ranging .41 to .55). Together, working alliance and group cohesion significantly predicted total session attendance (17.70% variance explained). Working alliance did not moderate the relationship between group cohesion and session attendance.

CONCLUSIONS

The importance of individual and group processes in influencing group therapy engagement is highlighted, including the role of fostering bonds within the group and between clients and therapists.

PRACTITIONER POINTS

A complex array of process factors has been argued to influence treatment outcomes in group therapy The quality of the relationship between group therapy clients, as well as the relationship between a client and the therapist, predict session attendance. The quality of the relationship between the client and the therapist may be the most important predictor of session attendance. Therapists should foster positive relationships between each client and the therapist in group therapy, as well as assisting each client to foster positive relationships with other group members.

Therapeutic Factors and Member Satisfaction in an Online Group Intervention During the COVID-19 Pandemic

The purpose of the present study was to evaluate members' perceptions of the therapeutic factors during a group intervention that was designed to mitigate the adverse psychological effects of the coronavirus pandemic and the imposition of restrictive measures, their satisfaction with the online format of the intervention, and how these are associated with the intervention's outcomes. The participants (N = 44, M _age  = 31.93, SD = 8.09) were Greek adults who attended a 2-week, voluntary, online group intervention. To assess the effectiveness of the intervention, 1 week before and 1 week after implementation, participants completed several questionnaires measuring their demographic characteristics, empathy, resilience, affectivity, feelings of loneliness, depression and anxiety levels, and feelings of fear regarding the outbreak. One week after the intervention, they also completed two questionnaires evaluating the therapeutic factors and their satisfaction and impressions regarding telemental health counseling. Analyses showed that the most frequently cited therapeutic factor was guidance, followed by acceptance, self-disclosure, universality, and instillation of hope. Therapeutic factors of catharsis, self-disclosure, guidance, self-understanding, vicarious learning, and therapeutic alliance correlated with elements of empathy, resilience, loneliness, positive emotions, symptoms of anxiety and depression, and fear of the coronavirus. Satisfaction with the online format of the intervention was associated to universality, elements of empathy, and symptoms of depression. More specifically, member satisfaction was negatively correlated with improvement in personal distress and depression, an unexpected finding that may be attributed to the brief duration of the present intervention. The practical value of the results for the development and implementation of online psychological interventions during a crisis is discussed.

Measuring Perceptions of the Therapeutic Alliance in Individual, Family, and Group Therapy from a Systemic Perspective: Structural Validity of the SOFTA-s

This study examined the multidimensional structure of the client and therapist versions of the self-report measure, System for Observing Family Therapy Alliances (SOFTA-s; Friedlander, Escudero, & Heatherington, Therapeutic alliances in couple and family therapy: An empirically informed guide to practice. Washington, DC: American Psychological Association, 2006) across three distinct therapeutic modalities (individual, family, group). Specifically, we investigated whether the originally theorized model of four first-order factors (Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System, and Shared Sense of Purpose within the Family) would be reflected in a second-order factor (Therapeutic Alliance). The sample included 105 therapists who worked with 858 clients (165 individuals, 233 families, and 43 groups) in several Spanish community agencies. To control for dependent data, we used multilevel modeling. Results of the multilevel confirmatory factor analyses showed adequate reliabilities, fit indices, and factor loadings across the three therapy contexts for both versions of the measure (client and therapist). Adequate measurement invariance was also found across respondents and therapy modalities. Taken together, these results support the structural validity of the SOFTA-s, a brief and flexible self-report alliance measure that can be used reliably in clinical practice as well as in studies of individual, family, and group therapy.

The therapist, the group and I: how therapeutic alliance moderates the effect of group cohesion on outcomes

Purpose

This study aims to investigate whether the influence of group cohesion on the outcomes depended on the levels of the therapeutic alliance.

Design/methodology/approach

Sixteen individuals with a substance use disorder who were undergoing treatment in a therapeutic community responded to therapeutic alliance, group cohesion, craving and outcomes measures after every therapeutic small group session for a period of six weeks. Data analysis was performed using hierarchical linear modeling.

Findings

Results indicate that the effect of group cohesion is stronger when there is a high therapeutic alliance between resident and therapist.

Originality/value

Even on group interventions, to enhance group cohesion effects on outcomes, therapists must foster higher therapeutic alliance levels. The findings point out the importance of studying the effect of common factors on outcomes.

Effective factors of addiction treatment communities in Peru, Nicaragua and Czechia

Purpose

This paper aims to explore the effective factors that influence the treatment of drug addiction in therapeutic communities (TCs) and to determine its essential elements in the Peruvian, Nicaraguan and Czech context.

Design/methodology/approach

The qualitative data were collected during semi-structured interviews with inpatients/clients of seven TCs based in Peru (Takiwasi), Nicaragua (Centro de Especialiades en Adicciones, Centro de Rehabilitación del Alcohólico y Adicto a Otras Drogas and Albergue de Miembros Adictos en Recuperación) and the Czech Republic (Renarkon, Sejrek and Kladno-Dubi). All 90 interviews were manually transcribed, and content analysis was performed. Codes were created using the grounded theory method.

Findings

The effective factors of TC, treatment in Peru, Nicaragua and Czechia are identical in conditions such as the presence of a personal therapist, the use of psychotherapy and the importance of group cohesion. In Peru, the administration of medicinal plants and diet was perceived as a principal part of the treatment. Nicaraguan TCs were specific for practicing 12 steps. In Czechia, an emphasis is put on the therapeutic program, workshops and leisure activities. Spirituality and religion play a main role in the Peruvian and Nicaraguan TCs only.

Originality/value

The current study presents a unique insight into the factors considered effective by inpatients/clients of TCs in different socio-cultural contexts.

High retention in an opioid agonist therapy project in Durban, South Africa: the role of best practice and social cohesion

Background

Moral conservatism within government and communities has resulted in a reluctance to support the provision of opioid agonist therapy for people with opioid use disorders in South Africa. In April 2017, South Africa’s first low-threshold opioid agonist therapy demonstration project was launched in Durban. The project provided 54 low-income people with heroin use disorders methadone and voluntary access to psychosocial services for 18 months. At 12 months, retention was 74%, notably higher than the global average. In this paper, we aim to make sense of this outcome.

Methods

Thirty semi-structured interviews, two focus groups, ten oral histories and ethnographic observations were done at various project time points. These activities explored participants’ pathways into drug use and the project, their meaning attributed to methadone, the factors contributing to project success and changes they experienced. Recordings, transcripts, notes and feedback were reviewed and triangulated. Key factors contributing to retention were identified and analysed in light of the existing literature.

Results

The philosophy and architecture of the project, and social cohesion were identified as the main factors contributing to retention. The use of a harm reduction approach enabled participants to set and be supported to achieve their treatment goals, and was shown to be important for the development of trusting therapeutic relationships. The employment of a restorative justice paradigm provided a sense of acceptance of humanity and flaws as well as an imperative to act responsibly towards others, fostering a culture of respect. Social cohesion was fostered through the facilitation of group sessions, a peace committee and group sport (soccer). In concert, these activities provided opportunities for participants to demonstrate care and interest in one another’s life, leading to interdependence and care, contributing to them remaining in the project.

Conclusions

We believe that the high retention was achieved through attraction. We argue that opioid agonist therapy programmes should take the principles of harm reduction and restorative justice into consideration when designing low-threshold opioid agonist therapy services. Additionally, ways to support cohesion amongst people receiving agonist therapy should be explored to support their effective scale-up, both in low-middle income countries and in high-income countries.

Group Cohesion and Climate in Cognitive Behavioral Therapy for Individuals with a First-Time DUI

Few studies have examined group cohesion and climate in the substance use disorder treatment literature. We examined whether group cohesion and climate are associated with increased self-efficacy outcomes and reduced drinks per week, binge drinking and DUI behaviors, in a sample of individuals with a first-time DUI receiving either cognitive behavioral therapy (CBT) or usual care. Additionally, we examined whether CBT moderates these relationships. Group measures and drinking outcomes were not significantly associated. This study is the first to provide an in-depth analysis on group processes in DUI settings, and as such, provides important insights into how group processes may differ in a mandated DUI context.

The Influence of Retention, Turnover, and Alliance on Process and Outcomes in Rolling Group Psychotherapy for Cocaine Disorder

A longitudinal repeated measures design was used to investigate the influence of treatment retention, and membership turnover on individual outcomes, and the relationship between individual-level and group-level therapeutic alliance in rolling group psychotherapy for individuals with cocaine abuse disorder. Eighteen patients were studied; data were collected prior to therapy and then monthly for 24 months. Patient outcomes and process were assessed. Improvements in symptoms and psychological functioning were associated with retention in psychotherapy. Membership turnover had a negative influence on symptoms. Development of an individual alliance was affected by the development of group-level therapeutic alliance, but not by time spent in therapy.

Beyond Cohesiveness

Despite a general consensus that cohesiveness promotes positive outcomes in group psychotherapy, the empirical evidence for this notion is limited. In this article the literature on group cohesiveness and its relation to clinical outcomes is reviewed. Three interrelated problems with this literature are highlighted: A lack of consensus as to how to conceptualize cohesiveness, inconsistent measurements of cohesiveness, and lack of attention to possible mediators of the cohesiveness-outcome relationship. The authors argue that the term cohesiveness is too vague and amorphous to be useful as a unitary construct and that the field could benefit by identifying more specific group processes that facilitate—or impede—clinical outcomes. They review social psychological research on group processes, and discuss how three constructs— group identification, independence, and homogeneity—might be applied to the clinical literature. Furthermore, in an attempt to stimulate a closer examination of mediational paths in the literature on group psychotherapy, they discuss possible mechanisms through which group processes affect clinical outcomes.

Level of Alliance, Pattern of Alliance, and Outcome in Short–term Group Therapy

This study investigated the relationships between initial level of alliance, pattern of alliance over sessions, and outcome in a sample of 107 patients who completed short-term group therapy for complicated grief. Both patient-rated alliance and therapist-rated alliance were studied. For patient-rated alliance, both the initial level of alliance and the linear pattern of alliance were directly and significantly related to favorable outcome. For therapist-rated alliance, no significant direct relationships with outcome were found. Instead, significant interaction effects were found. For patients with relatively high initial alliance, the greater the increase in alliance over sessions, the better the outcome. For patients with relatively low initial alliance, the greater the decrease in alliance over sessions, the better the outcome. Explanations for the findings are considered as well as possible clinical implications.

Group Process in the single-gender Women's Recovery Group compared with mixed-gender Group Drug Counseling

Enhanced affiliation among members is thought to provide increased support for women in single-gender compared with mixed-gender group therapy for substance use disorders (SUDs) and to provide a potential mechanism of action for its efficacy. In a Stage I trial of single-gender versus mixed-gender group therapy for SUDs we examined affiliative statements made by members in two group treatments, single-gender Women's Recovery Group (WRG) and mixed-gender Group Drug Counseling (GDC). Twenty-eight WRG and 17 GDC group therapy tapes were coded and compared for five types of affiliative statements. Three types of affiliative statements (agreement, supportive, and completing a thought) were highly correlated and were more frequent in WRG than GDC (D=0.882, p=0.27). In GDC, women were more likely to provide an affiliative statement to a male group member than any other combination of directionality (p<0.01). Compared with mixed-gender, single-gender group therapy for SUDs may enhance support through greater frequency of affiliative statements.

Modeling group process constructs at three stages in group psychotherapy

This study examined the relationships among group therapy processes measured by the Working Alliance Inventory-Short Form, the Therapeutic Factors Inventory Cohesiveness subscale, and the Group Climate Questionnaire-Short Form in a sample of 145 patients attending 18 psychodynamic groups. Five hypothesized models were tested early in therapy (Sessions 3 and 4) using multilevel confirmatory factor analysis. Two three-factor models approached conventional standards of model fit. By merging these two models, a three-factor model consisting of member-leader alliance, positive bonding relationship, and negative relationship fit the data well. Later in therapy, member-leader bonding was no longer important to member-group cohesion, indicating that cohesion and alliance and the member-leader versus member-group bonding represent different processes.

A randomized controlled study of a web-based performance improvement system for substance abuse treatment providers

We report here the results of a randomized, controlled trial evaluating the efficacy of a semiautomated performance improvement system ("patient feedback") that enables real-time monitoring of patient outcomes in outpatient substance abuse treatment clinics. The study involved 118 clinicians working at 20 community-based outpatient substance abuse treatment clinics in the northeast United States. Ten clinics received 12 weeks of the patient feedback performance improvement intervention, and 10 clinics received no intervention during the 12 weeks. More than 1,500 patients provided anonymous ratings of therapeutic alliance, treatment satisfaction, and drug/alcohol use. There was no evidence of an intervention effect on the primary drug and alcohol use scales. There was also no evidence of an intervention effect on secondary measures of therapeutic alliance. Clinician-rated measures of organizational functioning and job satisfaction also showed no intervention effect. Possible insights from these findings and alternative methods of utilizing feedback reports to enhance clinical outcomes are proposed.

Perceived Group Climate as a Predictor of Long-Term Outcome in a Randomized Controlled Trial of Cognitive-Behavioural Group Therapy for Patients with Comorbid Psychiatric Disorders

Background: Research on group therapy indicates that various dimensions of the helpful relationship qualities (cohesion, climate, empathy, alliance) are associated with outcome. However, the use of a wide variety of empirical scales makes comparisons between studies as well as generalizations somewhat difficult. Although a generic, trans-theoretical measure such as the Group Climate Questionnaire-Short Form (GCQ-S; MacKenzie, 1983) is available and applicable to most treatment conditions, it has never been tested with cognitive-behavioural group therapy. Aims: To investigate perceived dimensions of group climate (engagement, avoidance and conflict) as predictors of long-term (1 year) follow-up in a manualized, structured time-limited cognitive-behavioural group therapy (CBGT) for out-patients with comorbid psychiatric disorders. Methods: Data from 27 patients were analysed using hierarchical multiple regression analyses. Outcome measures used were general symptomatic complaints (SCL-90-R), interpersonal problems (IIP-64), specific mood- and anxiety symptoms (BDI; BAI) and early maladaptive schemas (YSQ). After controlling for scores on the relevant dependent variables at both intake and treatment termination, dimensions of group climate measured close to termination were entered as predictors in separate analyses. Results: Higher ratings of engagement were associated with reduced scores on all outcome measures at follow-up, except for anxiety symptoms (BAI). Higher ratings of avoidance were associated with lower anxiety symptoms at follow up, whereas ratings of conflict were unrelated to all follow-up scores. Conclusions: The results provide partial support for the use of the GCQ-S as a predictor of long-term follow-up in CBGT, and highlights perceived engagement as the most important dimension. Clinical implications are discussed.

Is therapist alliance or whole group cohesion more influential in group psychotherapy outcomes?

This study examined the differential ability of early in treatment measures of therapeutic alliance (Working Alliance Inventory), group cohesion (California Psychotherapy Alliance Scale for Group) and group climate (Group Climate Questionnaire) to predict outcome in a 16-session dynamic group psychotherapy for adults with major depression. Six successful therapy groups with 30 patients receiving psychodynamic group therapy were studied. Patient perceptions of the therapist alliance was not related to outcome, however, perceptions of levels of conflict and group members' ability to work actively and purposefully in treatment did predict outcome. Future research should further investigate how patients' perceptions of the whole group influence their clinical improvement.

Predictors of the therapeutic alliance in group therapy for individuals with treatment-resistant auditory hallucinations

OBJECTIVES

This study hypothesized that several baseline client characteristics (i.e. age, symptoms, insight, social functioning) would significantly predict client-rated group alliance in out-patients with schizophrenia spectrum disorders.

DESIGN

Hierarchical linear modeling (HLM) was used to evaluate the contributions of selected baseline individual client characteristics and group level characteristics to client-rated group alliance at the sixth session of group therapy. The effect of treatment type (CBT vs. ST) on group alliance and interaction with predictor variables were also analysed. Finally, correlations were computed to explore the relationship between group alliance, attendance, and treatment engagement.

METHODS

Sixty-three out-patients who had treatment-resistant auditory hallucinations were randomly assigned to either group CBT, which targeted reduction of distress associated with hallucinations, or group ST, which focused on improving social integration.

RESULTS

Results indicate that a stronger group alliance at the mid-point of treatment was associated with overall higher levels of group insight, and lower individual autistic preoccupation and social functioning at the baseline assessment. In addition, stronger group alliance was significantly correlated with higher attendance rates and therapists' ratings of treatment compliance.

CONCLUSIONS

These findings have implications for determining group composition and identifying clients low in therapeutic engagement. Suggestions for future research on group alliance are also discussed.

Therapeutic alliance and cohesion variables as predictors of outcome in short-term group psychotherapy

The current study explored the relative ability of aggregate therapeutic alliance and cohesion variables to predict short-term group therapy outcome. Data were collected from a comparative trial of two forms of time-limited group psychotherapy for complicated grief (Piper, McCallum, Joyce, Rosie, & Ogrodniczuk, 2001). The therapeutic alliance and elements of the cohesion construct were measured from the perspectives of each patient and the group therapist at intervals during the groups; scores were aggregated across assessments. Hierarchical multiple regression analyses, adjusting for the effects of treatment approach (interpretive vs. supportive) and specific group membership, demonstrated that the patient-rated alliance was a consistent predictor of outcome. Two cohesion measures, reflecting other participants' (therapist, other members) views of the patient's "fit" with the group, also accounted for variation in outcome. Implications of the findings for research and clinical practice, and the limitations of the measurement approach taken in this study, are considered.

A feasibility study of a web-based performance improvement system for substance abuse treatment providers

We report here on the feasibility of implementing a semiautomated performance improvement system-Patient Feedback (PF)-that enables real-time monitoring of patient ratings of therapeutic alliance, treatment satisfaction, and drug/alcohol use in outpatient substance abuse treatment clinics. The study was conducted in six clinics within the National Institute on Drug Abuse Clinical Trials Network. It involved a total of 39 clinicians and 6 clinic supervisors. Throughout the course of the study (consisting of five phases: training period [4 weeks], baseline [4 weeks], intervention [12 weeks], postintervention assessment [4 weeks], sustainability [1 year]), there was an overall collection rate of 75.5% of the clinic patient census. In general, the clinicians in these clinics had very positive treatment satisfaction and alliance ratings throughout the study. However, one clinic had worse drug use scores at baseline than other participating clinics and showed a decrease in self-reported drug use at postintervention. Although the implementation of the PF system proved to be feasible in actual clinical settings, further modifications of the PF system are needed to enhance any potential clinical usefulness.

Group cohesion in cognitive-behavioral group therapy for social phobia

Cognitive-behavior therapy (CBT) for Social Phobia is effective in both group and individual formats. However, the impact of group processes on treatment efficacy remains relatively unexplored. In this study we examined group cohesion ratings made by individuals at the midpoint and endpoint of CBT groups for social phobia. Symptom measures were also completed at the beginning and end of treatment. We found that cohesion ratings significantly increased over the course of the group and were associated with improvement over time in social anxiety symptoms, as well as improvement on measures of general anxiety, depression, and functional impairment. In conclusion, findings are consistent with the idea that changes in group cohesion are related to social anxiety symptom reduction and, therefore, speak to the importance of nonspecific therapeutic factors in treatment outcome.

Performance measures for outpatient substance abuse services: Group versus individual counseling

Most substance abuse treatment programs employ various models of group therapy. Empirical evidence, however, of the benefits of group vs. individual treatment is scarce. This study examined the impact of type of treatment, defined as individual or group counseling, on treatment performance, as measured by treatment completion and goal achievement. Data on clients treated in publicly funded substance abuse outpatient treatment programs were drawn from the Massachusetts Substance Abuse Information System. A larger proportion of group to individual therapy was strongly and positively associated with increased likelihood for improved measures of treatment performance. State data systems can provide useful insights into the development and application of performance measurement.