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Orchowski L.M., Johnson, J.E.
Current Drug Abuse Reviews: 2012, 5(2), p.148–157
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Orchowski at Lindsay_Orchowski@Brown.edu.
Treating patients in groups rather than individually seems to promise cost savings and perhaps too more effective treatment, but according to this review, research has yet to show treating problem drinkers together is clearly and consistently beneficial.
Summary Most of the research into treatments for alcohol problems assesses interventions that are delivered individually – to one person at a time – yet group interventions are actually the most commonly used type of treatment, at least in the United States. Researchers reviewed the evidence on the effectiveness of group treatments for alcohol problems, with the aim of discovering whether these might prove a cost-effective way to disseminate treatment across many different types of health care settings. This literature review examined studies that evaluated group interventions using cognitive-behavioural approaches, interactional group therapy, combined pharmacological and group interventions and group cue exposure treatments. Further information on what these treatments entailed is given below.
To conduct the review, a search of databases of scientific journals was first performed to identify the relevant research. To be included in the review, studies had to have randomly allocated patients to a group treatment conducted according to a manual versus some other approach, which might have been another group treatment, an individual treatment, or no specific treatment, the patients had primarily to be in treatment for their drinking problems (abuse or dependence), and these had to have been diagnosed by interviewing the patient. This left 15 articles eligible for review, with 120 otherwise relevant articles excluded for not meeting the criteria.
The review grouped the studies together and assessed their findings in different categories for several different types of group intervention.
No studies that met inclusion criteria were found which directly compared group versus individual interventions for treating alcohol problems, although a meta-analysis A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. of cognitive-behavioural therapy interventions for substance users found no difference in effectiveness between group and individual therapy.
Cognitive-behavioural group therapies used for treating alcohol problems are similar to those used for other psychological disorders, and involve an emphasis on learning and implementing coping skills which are intended to help people manage triggers that might lead them to drink,to prevent relapse and to maintain abstinence. Teaching includes coping with cravings, social skills, an understanding of patterns of drinking, managing negative thoughts, planning for emergencies and increasing engagement in pleasant activities. One specific form of cognitive-behavioural treatment is termed coping skills training, which involves training sessions with therapist presentations, practice and homework based around problem solving, interpersonal, relaxation and coping skills. One study of group coping skills training compared it to another form of treatment called interactional group therapy, and there appeared to be no difference in the effectiveness of the two interventions following 26 weeks of treatment. Another study found that giving group cognitive-behavioural therapy and group coping skills training to people with drinking problems had a similar effect on their abstinence rates, both better than the standard practice of referral to outpatient care.
Coping skills training was also evaluated in combination with another intervention called cue exposure treatment, which involves repeatedly exposing people to triggers for their alcohol use until corresponding urges to drink are reduced, whilst also teaching cognitive and behavioural coping strategies. Patients given the combined group coping skills training and group cue exposure treatment intervention relapsed less, had fewer heavy drinking days, used their coping skills more and felt fewer urges to drink compared to people given a control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. intervention of only education and relaxation.
Another model of group treatment in the cognitive-behavioural family uses a therapeutic approach called relapse prevention, which involves education on substance use, how to identify situations and warning signs that risk relapse, development of coping skills and new lifestyle behaviours that reinforce abstinence, self-efficacy at coping with risky situations and how to reframe relapses as learning experiences rather than failure. One group of problem drinkers given eight hour-long sessions of group relapse prevention alongside normal treatment finished with greater self-efficacy than people given either just normal treatment or a form of the relapse prevention involving only discussion groups and not role-play. They were also more likely to be abstinent from alcohol six months after treatment, but there was no difference after 12 months. A drinking and life-skills treatment similar to relapse prevention was also found to have patchy results.
These two group therapies focus on interaction and communication within the group, using unstructured discussion. Pyschodynamic therapy aims to improve control over urges to drink by increasing self-knowledge, enhancing a sense of identity and reflecting on feelings and impulses. Interactional group therapy aims to examine participants' relationships with other people as shown by their interactions with others in the group, intending to increase self-knowledge and reduce impulsiveness. Unlike cognitive-behavioural approaches, interactional group therapy features little direct teaching of skills or information by the therapist. One group of moderately dependent drinkers had on average more days free from drinking 15 months after 15 weeks of 90-minute psychodynamic group therapy sessions than a comparison group offered group cognitive-behavioural therapy. Another two studies (1 2) showed that groups of problem drinkers and dependent drinkers did not differ in their drinking after being given interactional group therapy compared to group coping skills training.
Three reviewed studies examined the effectiveness of group cognitive-behavioural therapy combined with medications. The results were again very patchy, with one trial showing that people assigned group cognitive-behavioural therapy did no differently if they were given naltrexone as well or not – as both groups were given the group therapy, we learn little about what effect, if any, this had – and another appearing to show that people given group cognitive-behavioural therapy and nefazodone did no differently after 12 weeks than those given group cognitive-behavioural therapy and a placebo, non-directive group counselling and nefazodone, or non-directive group counselling and a placebo. Again all these options included a form of group treatment so we cannot tell if these were effective or not, only that they were not significantly different to each other. At a year after the treatments, the group given a combination of non-directive group counselling and nefazodone were drinking more than any of the other groups.
There has been little research into motivational interviewing as a group therapy despite its prominence as an individual treatment, and no studies met the inclusion criteria for the review, with some excluded for failing to use a treatment manual and others for not including participants diagnosed by interviewers as having alcohol use disorder. [Editor's note: Whilst manualisation is meant to improve the accuracy of research findings by making sure the treatment being given is properly standardised, there is evidence that motivational interviewing actually works best without a manual]. The studies, although not meeting inclusion criteria, were reported as showing mixed results that perhaps suggested group motivational interviewing was no different from individual motivational interviewing, group cognitive-behavioural therapy or even a control group, although other research suggested that group motivational interviewing was better than control at reducing some measures of drinking. One study did directly compare the effects of group versus individual motivational interviewing, finding no difference between the two treatments, although there was no control group who received neither treatment. Another compared group motivational interviewing with group cognitive behaviour therapy and found similar results, also without a control group. One small study did compare group motivational interviewing with an assessment-only control, finding that group motivational interviewing resulted in fewer drinks per drinking occasion and fewer episodes of intoxication. These results show some promise of effectiveness, and more research should be conducted in this area.
Four studies were included in the review that focussed on co-occuring alcohol problems and mental health or behavioural conditions. One was a comparison between group cognitive-behavioural therapy and an enhanced group cognitive-behavioural therapy that included an extra relationship component. The effects on drinking outcomes after the two treatments were no different, whether for people with just alcohol problems or those with both alcohol problems and antisocial personality disorder. A study with people who had alcohol problems and anxiety disorders found that adding six two-hour group cognitive-behavioural sessions to a four-week inpatient alcohol treatment programme did not improve drinking or anxiety outcomes. Another trial of intensive group relapse prevention – 25 hours of treatment per week for 12-16 weeks – for people with alcohol problems and agoraphobia or social phobia found that adding eight one-hour sessions of individual cognitive-behavioural therapy did not affect alcohol outcomes. Two other studies that combined anxiety treatment, in groups or individually, with group alcohol treatment showed no additional benefits. Comparing group cognitive-behavioural therapy that specialised in both substance use and violence for perpetrators of domestic violence with alcohol problems versus just twelve-step treatment found no differences six months after treatment.
Using one set of criteria for assessing the strength of research evidence, group cue exposure treatment when combined with group coping skills training is found to be modestly supported by the evidence. Group coping skills training itself might have modest or strong support depending on which studies are allowed to be counted, although two other studies found no difference between group coping skills training and interactional group therapy. General group cognitive-behavioural therapy is modestly supported in one study but found to do no better or even worse than other options by more studies. Group relapse prevention has modest support, as does interactional group therapy with psychodynamic therapy. Grouping various types of group cognitive-behavioural therapy together gives strong support, but along with it many studies that found no evidence of effectiveness. Viewed as a whole, these group treatments probably have an effect on improving alcohol outcomes in problem drinkers.
Group treatments are generally under-researched, especially compared to individual treatments, and most of the treatments mentioned have only one or two studies supporting their effectiveness, and some negative findings too. It is not known whether giving group therapy alongside medication is more effective than medication alone. Little is known too about which people group treatments might be most effective for, although the research suggests that the more structured group treatments may be better for people with anti-social personality disorder, and less structured treatments better for people with neuropsychological problems – that is more broadly, impaired brain functioning.
commentary The patchy and unclear findings about so many different types of group alcohol treatment demonstrate how much work is still to be done before we know the truth about whether any of these treatments are effective at combating alcohol use and related problems. Not a single type of group alcohol treatment in the review was found to be clearly and uncontroversially effective – the great majority were shown, even according to the most sympathetic research, to have only moderate evidence of effectiveness, usually combined with contradictory evidence of a similar strength. The reviewers’ underlying view appears to be that these treatments are nonetheless promising on the whole, and that the patchiness of the evidence is due to a lack of high quality research rather than the treatments simply being ineffective. This optimistic view might turn out to be right, but purely from the review may not be justified, with so few positive and unambiguous impacts being clutched from among the large number of impacts tested for.
It is important, if unfortunate, that this review does not get us any closer to knowing the answers to the two key questions: are group treatments better than individual treatments, and are they better than doing nothing? The second of these questions is not trivial, given that it seems some group treatments do actually result in worse outcomes.
Setting aside self-help and 12 step groups, there is little mention of group alcohol treatments in UK guidance from the National Institute for Health and Care Excellence, which only states “Intensive community programmes following assisted withdrawal should consist of a drug regimen supported by psychological interventions including individual treatments, group treatments, psychoeducational interventions, help to attend self-help groups, family and carer support and involvement, and case management”. The seeming lack of interest in group treatments is curious given that it seems fair to assume they could be significantly less expensive than individual treatments – provided of course that they actually work. Indeed, one aim of this review was to discover whether group treatments were not only effective but might also be cost-effective, an ambition that presumably fell at the first hurdle when effectiveness could not be proved. Despite this potential saving, from this review the most that can be said for group treatments is it still unknown whether or not they useful in helping people with alcohol problems, regardless of cost.
Last revised 09 June 2014. First uploaded 02 June 2014
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