Full length articleGroup therapy for women with substance use disorders: Results from the Women's Recovery Group Study
Introduction
Substance use disorders (SUDs) are a growing health problem among women in the United States (Substance Abuse and Mental Health Services Administration (SAMHSA, 2009). For example, since the late 1980's there has been a narrowing of the gender gap in the male to female prevalence ratio of alcohol use disorders in the U.S., and levels of abstaining have decreased in women in birth cohorts born after versus before World War II, while these rates remained stable in men (Grucza et al., 2008). Gender-specific SUD treatment approaches for women are informed by research highlighting the importance of co-occurring psychiatric disorders, histories of trauma, and relationships with children and significant others that are important in women's recovery (Greenfield and Pirard, 2009). Nevertheless, there are few therapies developed for women with SUDs, and fewer empirical studies on the relative effectiveness of these therapies versus standard treatments for this population (Greenfield et al., 2007a, Tang et al., 2012), or in comparison with mixed-gender SUD treatment (Bride, 2001, Greenfield et al., 2007a, Kaskutas et al., 2005, Orwin et al., 2001). Those that do exist were designed for specific subpopulations of women with SUDs, such as pregnant women (Reynolds et al., 1995), methadone maintained mothers (Luthar and Suchman, 2000), women with co-occurring post-traumatic stress (Hien et al., 2004, Najavits et al., 1998), women in correctional settings (Messina et al., 2010), among others (Greenfield et al., 2007a, Kelly et al., 2000, Linehan et al., 1999). However, women in community treatment programs often use multiple substances, have various co-occurring psychiatric disorders, are of different ages and may or may not be pregnant or parenting (Greenfield et al., 2007a, SAMHSA, 2012). Although SUD treatment is most frequently offered in groups (Hodgins et al., 1997, Kominars and Dornheim, 2004, Morgan-Lopez and Fals-Stewart, 2006, Stinchfield et al., 1994), there has been no manual-based, empirically-tested group therapy designed for this heterogeneous population of treatment-seeking women with SUDs.
Based on this treatment gap, we used the Stage Model of Behavioral Therapies research (Rounsaville et al., 2001) to develop and test the Women's Recovery Group (WRG). As defined by Rounsaville et al. (2001), Stage I consists of manual writing and pilot and feasibility testing, and Stage II involves randomized controlled trials to investigate the efficacy of a manualized treatment that has shown promise in pilot testing. Therefore, in a Stage I behavioral therapy development trial, we developed and tested the effectiveness of the WRG compared with a standard mixed-gender group therapy (Greenfield et al., 2007b). The WRG is a manual-based group therapy for women heterogeneous with respect to their substance dependence, co-occurring psychiatric disorders, trauma history, and age and stage of life. The WRG is a 12-session, structured relapse-prevention group therapy that utilizes a cognitive behavioral approach and includes gender-specific content and single-gender group composition. Individual session content was derived from research on gender-specific substance abuse antecedents, consequences, and treatment outcomes (Greenfield et al., 2007a, Grella, 2008, Hernandez-Avila et al., 2004, Piazza et al., 1989). The content areas translated into 14 specific session topics (e.g., violence and abuse, partners and recovery, caretaking and recovery, co-occurring disorders, women's reproductive health, effects of drugs on women's health, disclosure) that could be flexibly implemented in any order for a 12-week sequence of groups.
In the Stage I trial (45), women were randomized to WRG (n = 16) or a mixed-gender control condition, Group Drug Counseling (GDC, n = 7; Crits-Christoph et al., 1999, Daley et al., 2002). No significant differences in outcomes emerged between WRG and GDC during the 12 week group sequence. However, in the 6 months post-treatment, WRG participants showed a pattern of continued reductions in substance use while GDC participants did not (Greenfield et al., 2007b).
While these results were promising, the Stage I trial utilized a small, relatively homogeneous pilot sample and a Stage II trial was warranted to test the WRG in a larger, more diverse sample. Moreover, the WRG and GDC groups in the Stage I trial were conducted in semi-open format (i.e., enrollment continued until a maximum of 6–8 subjects were entered per group and then enrollment was closed until the end of the sequence). The design of the Stage I trial was essential for treatment development and testing (Carroll and Onken, 2005). However, most group treatment is delivered in open enrollment (or “rolling”) group format in which patients can enter at any time in the group sequence and exit the group after 12 weeks are completed (Morgan-Lopez and Fals-Stewart, 2006, Washton, 2005) rather than starting and ending with a cohort of other participants. Because the WRG is intended to be a manual-based treatment ready for dissemination into clinical practice if demonstrated to be effective (Greenfield et al., 2014), the Stage II trial was designed to be implemented in an open group format at two clinical sites. The aim of this clinical trial was to investigate the effectiveness of the WRG relative to GDC in reducing days of use of any substance from baseline in a sample of women heterogeneous with regard to drugs of abuse, co-occurring disorders, trauma histories, and age and stage of life, as well as to demonstrate the feasibility of implementing the WRG in open-enrollment group format.
Section snippets
Participant recruitment
Participants were recruited through treatment programs and private practices, websites, and advertisements (for detailed recruitment information see Greenfield et al., 2014). Inclusion criteria were: (1) current DSM-IV diagnosis of substance dependence for at least one substance besides nicotine; (2) age 18 years or older; (3) used substances within the past 60 days; (4) available during the follow-up period; (5) interested in group treatment; (6) gave consent for study personnel to communicate
Baseline statistics
Demographic, substance use, psychiatric diagnoses, and other clinical data for the women randomized to treatment are represented in Table 1. There were no significant baseline differences between women randomized to WRG and GDC in sociodemographic characteristics, Axis I or Axis II diagnoses, days in a controlled environment, or ASI alcohol and drug composite scores. However, there were statistically significant differences between women in WRG and GDC with regard to two of the substance use
Discussion
In this Stage II trial, women in both the WRG and the GDC conditions had significant reductions of approximately 75% fewer days of substance use during the 12-week group treatment and these reductions were sustained during the 6-month post-treatment follow-up period. This study provides evidence that women with alcohol and drug dependence, with or without co-occurring psychiatric disorders, can have significant reductions in their substance use through treatment in weekly outpatient group
Role of funding source
Support for this study was provided by the National Institute on Drug Abuse grants R01 DA015434, K24 DA019855, and U10 DA015831 to McLean Hospital. NIDA had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors
All authors had substantial contributions to the conception and design, or the analysis and interpretation of data; made substantial contributions to drafting the article or reviewing for critical content; and all authors have approved the final manuscript.
Conflict of interest statement
Dr. Bailey provides the following disclosures: Dr. Bailey's institution has received grant support from NIDA, Titan Pharmaceuticals, Inc., Alkermes, Inc., BioDelivery Sciences International, Inc. and Orexo. Dr.Bailey has received travel support from Titan Pharmaceuticals, Inc. and is on the advisory boards of Braeburn Pharmaceuticals, BioDelivery Sciences International, Inc. and Camurus AB. All other authors declare that they have no conflicts of interest.
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