Group, Group, and More Group
The classic visual for addiction treatment is a circle of chairs, like so:
As little as most people know about our world, pop culture has this one right! Just about everything is done in groups—same for other intensive mental health services, including hospitalization. And it’s absolutely for reasons of efficiency. Individual no-shows cost much less in a group program, and group treatment has served as a solution for short-staffing dating back at least to the 1930s. Yes, there are some clinical advantages to group modalities, and some patients like a group setting. But there’s no evidence for taking individual counseling entirely off the menu, which is what many agencies have done.
The problem is not, and is never, the patients. They’re just taking what treatment is available to them. Patients may have no choice at all in enrolling in groups, especially if they are mandated to treatment, using Medicaid, or uninsured. The problem is agencies shaping treatment to financial and administrative goals. Quality of care is not being “compromised,” it’s being completely ignored.
For those inclined to defend the group model, let’s look at how it is actually implemented.
1) Groups are nearly always “open,” meaning members join and leave on a rolling basis. (A “closed” group begins together and proceeds together, with no newcomers along the way.) Agencies want to be able to admit anyone at any time, but evidence for effective group therapy points to trust and cohesion in the group. That’s very hard to sustain when membership is constantly changing.
2) Confidentiality is hit-or-miss. As you likely know, the majority of people who might benefit from substance use treatment never pursue it. One of the major deterrents people cite, with good reason, is concern about who might find out. But providers have no way to stop group patients sharing each other’s information; all we can do is tell them not to do it. Didn’t I say patients are never the problem? They’re still not. No one should expect communal buy-in to rules, in a group, when the group itself is not necessarily consensual. That is…
3) Groups may have any proportion of mandated members. Mandated referrals are great for agencies because they represent guaranteed revenue. Mandated patients don’t need to be appealed to, nor do they need to be satisfied with the care they get. But both providers and patients express wariness of too many people in group treatment who do not want to be there.
In an ethnography of therapeutic communities (TCs) for substance use, staff say the TCs cannot function as intended if more than half of members are mandated—but the study’s typical percentage of mandated members was up to 80%. In Inside Rehab, a substance use patient who herself is mandated says she doesn’t want to be in treatment with too many mandated peers. Even patients forced to attend, in other words, want to be surrounded by voluntary participants. But the solution is not a cap on mandated referrals or a separate care setting for mandated patients (which they would likely resent even more, understandably). The solution is to end treatment mandates!
Everyone should be able to access the kind of treatment they want. In my experience with substance use patients, that is almost always individual counseling. But even for those who do want a group approach, what they get is not what it’s supposed to be.
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