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Group treatment for substance use disorder in adults: A systematic review and
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DOI: 10.1016/j.jsat.2019.01.016

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 Contents lists available at ScienceDirect

Journal of Substance Abuse Treatment

journal homepage: www.elsevier.com/locate/jsat

Group treatment for substance use disorder in adults: A systematic review

and meta-analysis of randomized-controlled trials
Gianluca Lo Cocoa, ,1, Francesco Melchiorib,1, Veronica Oienid, Maria Rita Infurnab,
⁎

Bernhard Straussc, Dominique Schwartzec, Jenny Rosendahlc, Salvatore Gulloa

a
University of Palermo, Department of Psychology, Educational Sciences and Human Movement, Palermo, Italy
b
University Niccolò Cusano, Faculty of Psychology, Rome, Italy
c
University Hospital Jena, Friedrich Schiller University Jena, Institute of Psychosocial Medicine and Psychotherapy, Jena, Germany
d
ANDROS clinic, Psychology Unit, Palermo, Italy

A R TIC L E INFO A B S TR A C T

Keywords: Background and aims: From residential programs to outpatient services, group therapy permeates the clinical
Group psychotherapy field of substance misuse. While several group interventions for substance use disorders (SUDs) have demon-
Substance use disorder strated effectiveness, the existing evidence on group therapy has not been systematically reviewed. The current
Abstinence meta-analysis aims to provide estimates of the efficacy of group therapy for SUDs in adults using rigorous
Systematic review
methods.
Meta-analysis
Methods: We included studies comparing group psychotherapy to no treatment control groups, individual psy-
chotherapy, 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 dif-
ferent 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.

1. Introduction physiological symptoms indicating that an individual continues to use a

Substance use is a problem affecting a large portion of the global
population (Degenhardt & Hall, 2015; Gowing et al., 2015; Griffiths &
Meacham, 2008), and the World Health Organization assumes the
global burden of disease related to drug and alcohol issues to be 5.4%
worldwide (WHO, 2014). In the U.S., the National Survey on Drug Use
and Health estimated that 21.5 million Americans aged 12 and older
battled a substance use disorder in 2014 (Center for Behavioral Health
Statistics and Quality, 2015). Substance use disorder (SUD) is defined in
the DSM-5 (APA, 2013) by a cluster of cognitive, behavioral, and
substance despite experiencing significant substance-related problems.
In many cases there is a comorbidity between substance use disorders
and psychiatric or personality disorders in adults (Conner, Pinquart, &
Gamble, 2009; van Dam, Ehring, Vedel, & Emmelkamp, 2013; Weiss
et al., 2007). The prevalence of psychiatric comorbidity has been esti-
mated between 30% and 45% for individuals with alcohol and drug
dependence, respectively (Farrell et al., 1998; Worley, Trim, Tate, Hall,
& Brown, 2010), and individuals with co-occurring disorders typically
have a prolonged course of substance dependence (Hasin et al., 2002).
High rates of co-occurrence of drug and alcohol problems were also

⁎
Corresponding author.
E-mail address: gianluca.lococo@unipa.it (G. Lo Coco).
1
Contributed equally.

https://doi.org/10.1016/j.jsat.2019.01.016
Received 25 July 2018; Received in revised form 21 January 2019; Accepted 22 January 2019
G. Lo Coco et al.
reported, for example, alcohol use disorders are detected in 38% and
45% of opiate and stimulant-using treatment seekers, respectively
(Hartzler, Donovan, & Huang, 2010; Hartzler, Donovan, & Huang,
2011).
SUDs are chronic or long-term disorders for a significant proportion
of adult patients (McLellan, Lewis, O'Brien, & Kleber, 2000;
Morgenstern & McKay, 2007). Standard remission rates have been re-
ported to vary considerably between 19.6% and 95.7%, with a pooled
mean estimate of 51.7%, 54%, and 60.0% for alcohol, heroin and
polysubstance use disorders, respectively (Fleury et al., 2016). Notably,
individuals with mental health problems and SUD co-morbidity are said
to be more difficult to treat than individuals with either condition
alone, and poor retention in treatment programs and poorer treatment
adherence have been reported (Broome, Flynn, & Simpson, 1999).
A number of psychosocial interventions for SUDs in adults have
demonstrated effectiveness, including coping skills training, relapse
prevention, contingency management, motivational interviewing, be-
havioral couple therapy and motivational enhancement therapy
(Carroll & Onken, 2005; Gates, Sabioni, Copeland, Le Foll, & Gowing,
2016; Knapp, Soares, Farrell, & Silva de Lima, 2007; Magill & Ray,
2009; Powers, Vedel, & Emmelkamp, 2008). Most of these SUD-specific
treatments are provided in a group format and have received wide-
spread clinical acceptance in the last decades (Wendt & Gone, 2017).
Reasons for the clinical predominance of group therapy are the in-
creased focus on cost containment (Spitz, 2001) as well as the influence
of mutual support groups such as Alcoholics Anonymous, Cocaine
Anonymous, and Twelve-Step Facilitation Therapy in treatment pro-
grams for substance use (Brown, Seraganian, Tremblay, & Hannis,
2002; Donovan & Wells, 2007). There are also some important clinical
reasons for the adoption of the group format in SUD treatment facilities.
A group setting provides a basis for influencing patient's behavior in
terms of social support and social pressure to change (Sobell & Sobell,
2011). Furthermore, patients with SUDs can benefit from developing
interpersonal relationships with others, learning to identify and com-
municate psychological needs and identifying maladaptive patterns of
behavior (Weiss, Jaffee, de Menil, & Cogley, 2004).
A great variety of group treatments for SUD with different formal
change approaches have been included in the literature under the
umbrella term “group therapy.” For example, group drug counseling is
designed to educate patients about the concept of addiction recovery
and to provide a supportive group climate (Crits-Christoph et al., 1999).
Relapse prevention groups aim to instruct patients about substance use
and focus on situations that represent a high risk for relapse, while
communication skills training focuses on communication and beha-
vioral skills that can be used to handle risky situations (Monti &
Rohsenow, 1999). Motivational groups help patients tip the balance in
favor of changing addictive behavior by finding more motivating al-
ternatives (Sobell & Sobell, 2011), while mindfulness group programs
such as Mindfulness-Based Relapse Prevention (MBRP, Bowen et al.,
2009) enhance coping abilities for relapse triggers and interrupting the
previous cycle of automatic substance use behavior (Grant et al., 2017).
Twelve-Step Facilitation Therapy (TSF) was adapted from that used in
project MATCH (Project MATCH Research Group, 1997) and for de-
livery in a group format (Donovan et al., 2013). It promotes abstinence
from substances by helping participants better understand the core
principles of Twelve-Step approaches, facilitating acceptance and sur-
render of their addiction (Timko, DeBenedetti, & Billow, 2006). In
contrast to TSF, Twelve-Step meetings are not therapist-led and include
group discussion of the Twelve-Step philosophy (Wells, Peterson,
Gainey, Hawkins, & Catalano, 1994).
Adoption of the group format in SUD treatment facilities is also
supported by clinical evidence for effectiveness (Burlingame, Strauss, &
Joyce, 2013; Weiss et al., 2004). Weiss et al. (2004) narratively re-
viewed 24 studies of group treatment outcomes for SUD and provided
support for the effectiveness of the group approach. It was found that
group therapy can be effective when added to treatment-as-usual or
compared to a wait-list control condition, but very few differences were
found between group and individual therapy. Moreover, some studies
included in that review highlighted limitations such as the absence of a
well-defined SUD diagnosis and a lack of randomized-controlled trials
(RCTs). Sobell and Sobell (2011) updated the review by Weiss and
colleagues and consistently found that there were no differences be-
tween the group and individual treatment formats, despite patients
significantly improved in their substance use. Another recent narrative
review by Burlingame et al. (2013) found that group treatments for
substance use show positive effects with minor differences in effec-
tiveness between specific formal change theories. In sum, previous
narrative reviews suggested that group treatments produced positive
results compared to no treatment, whereas the results were mixed when
groups were compared to other active control conditions. However, the
great majority of these reported studies on the effectiveness of group
treatment are clinical trials with closed groups and the issue regarding
the dissemination of results from RCTs to routinely practice which
mostly adopts open groups is an ongoing challenge (Wendt & Gone,
2017). It is noteworthy that several SUD-specific treatments were pri-
marily developed for individual therapy and only later the therapeutic
components of these individual therapies were effectively extended and
validated into a group format, such as the Twelve-Step Facilitation, the
Guided Self-Change treatment and the group motivational interviewing
(Donovan et al., 2013; Santa Ana, Wulfert, & Nietert, 2007; Sobell &
Sobell, 2011).
Although the number of well-conducted RCTs on the efficacy of
group therapy for SUDs is increasing at a rapid pace, a meta-analysis of
the existing evidence on experimental research of group therapy with
adult SUD patients is still missing (Wendt & Gone, 2017). A meta-
analysis on the efficacy of group treatments for SUDs can allow for an
accurate estimation of the effect of group interventions and to examine
whether the effects of group therapy differ among specific subgroups of
studies. More quantitative evidence regarding the size of these group
effects, the possibility of reaching such effects in the short or long term,
and the stability of these effects at follow-up and their potential su-
periority compared to various control conditions is required. The cur-
rent meta-analysis aims to shed light on these clinically relevant issues
in a field characterized by a massive heterogeneity of treatment mod-
alities and a mismatch between research and real-world practice.
The primary goal of this meta-analysis is to provide an updated and
comprehensive overview of the existing evidence on group therapy for
SUDs in adults. It additionally provides an analysis of all available RCTs
comparing group treatments for SUDs to no treatment, individual
therapy, and other active treatment. We excluded tobacco and nicotine
dependence from the current meta-analysis given that the great ma-
jority of studies on this substance recruited only individuals without a
psychiatric disorder.
2. Methods
2.1. Protocol and registration
This systematic review is part of a larger research project sum-
marizing the evidence on group psychotherapy for various mental
disorders which was registered at the PROSPERO international register
of systematic reviews (CRD42013004419). Results of this research have
recently been published for social anxiety disorder (Barkowski et al.,
2016), obsessive-compulsive disorder (Schwartze, Barkowski,
Burlingame, Strauss, & Rosendahl, 2016), panic disorder with/without
agoraphobia (Schwartze, Barkowski, Strauss, Burlingame, et al., 2017),
and post-traumatic stress disorder (Schwartze, Barkowsky, Strauss,
Knaevelsrud, & Rosendahl, 2017), as well as for comparisons of group
and individual psychotherapy across various mental disorders
(Burlingame et al., 2016).
G. Lo Coco et al.
2.2. Eligibility criteria
Study inclusion criteria were specified according to the PICOS
guideline, proposed by the PRISMA statement for preferred reporting
items for systematic reviews and meta-analyses (Moher, Alessandro,
Tetzlaff, & Altman, 2009). All randomized-controlled trials (RCTs)
published after 1990 that examined adult patients with substance use
disorder (substance abuse or substance dependence) as the primary
diagnosis based on the Diagnostic and Statistical Manual of Mental
Disorders (DSM) or the International Classification of Diseases (ICD)
were eligible. There were no restrictions related to comorbidity. Eli-
gible interventions were group treatments consisting of at least 3 pa-
tients and a therapist who meet regularly for a minimum of 5 sessions
with the primary goal of either reducing or eliminating substance use or
addressing behaviors related to substance use (see Weiss et al., 2004).
Additional treatments were allowed in the case where the group
therapy was the primary treatment. Group therapy was compared to
either no treatment control groups, individual psychotherapy, or other
active treatments such as Twelve-Step Facilitation Therapy, medication
or self-help therapy. Although self-help groups are usually conducted
by leaders without any professional training who do not apply psy-
chotherapeutic techniques, this intervention modality incorporates
some nonspecific elements of treatment such as the interpersonal
learning, guidance and altruism (Humphreys et al., 2004). Conse-
quently, self-help therapy was included as “other treatment” compar-
ison in this review.
The primary outcome was abstinence, and secondary outcomes
were frequency of substance use as a continuous measure, symptoms of
SUD as measured with a common questionnaire such as the Addiction
Severity Index, anxiety, depression, general psychopathology, and
treatment attrition. Treatment attrition was defined as the number of
subjects completing treatment divided by number of subjects that were
randomized, with completion as defined by the study authors (for ex-
ample, a certain percentage of attended sessions). Outcomes were as-
sessed at post-treatment and follow-up, and the latest assessment oc-
curred within 12 months of the post-treatment measure.
2.3. Information sources and search
An electronic search was conducted in Medline, Web of Science,
CENTRAL, and PsycInfo. The search strategy was initially developed for
Medline (Supplementary Table 1) and was subsequently adapted for the
other databases. We also manually searched for eligible trials by
screening the reference lists of the included studies, existing systematic
reviews and meta-analyses, and published clinical treatment guidelines
(i.e., Carroll & Onken, 2005; Gates et al., 2016; Magill & Ray, 2009;
McHugh, Hearon, & Otto, 2010; Roberts, Roberts, Jones, & Bisson,
2016). We used a broad search strategy and also included search terms
for smoking cessation and tobacco use, as the search was a part of a
larger project (see funding).
2.4. Study selection
A team of reviewers first independently screened potential studies
by title and abstract based on the inclusion criteria using a conservative
approach, with ambiguous studies left included. The full texts of the
identified studies were then independently screened for eligibility by
reviewers in pairs of two. Disagreements were resolved by discussion
within the research team.
2.5. Data collection
Data were extracted by independent reviewers and validated by a
second reviewer. A third party was consulted in case of disagreements.
Consistently with the aforementioned eligibility criteria, the following
major groups of data were extracted from the included studies: patient
information (gender, age, substance used, comorbidity), intervention
(type of group therapy, number of patients per group, number and
length of sessions, sessions attended), comparator (type of control
group, number and length of sessions, sessions attended), outcomes
(type of outcome, assessment, measure used), statistical parameters
(means, standard deviations, frequencies, p-values), and risk of bias
indicators. A hierarchical approach was used in cases of multiple
measures for one reported outcome, for example urinalysis data was
preferred over self-reported abstinence. Therefore, only one effect size
per outcome and study was extracted. Intent-to-treat (ITT) data were
preferred over completer data.
2.6. Risk of bias in individual studies
The Cochrane Risk of Bias Tool (Higgins, Altman, & Sterne, 2011)
has been used to judge the internal validity of the included studies.
Selection bias refers to inadequate randomization procedure and allo-
cation concealment, reporting bias may be introduced by incomplete
reporting of the findings, and attrition bias can be caused by incomplete
outcome data. Risk of bias was rated as low, high, or unclear for each
study following the recommendations of the Cochrane Collaboration
(Higgins et al., 2011). We also evaluated bias introduced by the im-
plementation quality of the group treatment. Bias was considered low if
RCTs ensured treatment completion according to the protocol, either by
therapists receiving specific training and regular supervision, or ver-
ified by conducting adherence checks for fidelity to a treatment manual
or a session by session structure with a precise description of treatment
methods (Barkowski et al., 2016).
2.7. Summary measures
Between-group effect sizes were computed together with 95%
confidence intervals. Relative risks (RR) were provided for dichotomous
outcomes, and we calculated Hedges' g, a standardized mean difference
corrected for small sample bias, for continuous outcomes (Hedges,
1981).
2.8. Synthesis of results
Study results were aggregated within the following comparisons: 1)
group therapy vs. no treatment, 2) group therapy vs. individual
therapy, and 3) group therapy vs. other treatments. Because the number
of included studies was rather limited, the effects of anxiety, depres-
sion, and general psychopathology were pooled into a single effect size
of mental state per study. We used random effects models to aggregate
effect sizes across studies, and heterogeneity in effect sizes across stu-
dies was quantified using Q-statistics. We also calculated I2, re-
presenting the proportion of the total variance in effect sizes due to true
differences among treatments above those expected by chance (Higgins,
Thompson, Deeks, & Altman, 2003). I2 values of 25%, 50%, and 75%
are commonly interpreted as low, moderate, and high heterogeneity,
respectively.
2.9. Risk of bias across studies
Reporting bias and small study effects were visually assessed in
funnel plots, and Egger's regression test was run to statistically analyze
the relationship between study effect size and standard error (Egger,
Davey Smith, Schneider, & Minder, 1997).
2.10. Additional analyses
We conducted sensitivity analyses to prove the robustness of the
findings by excluding approximated effect sizes and effect sizes set to
zero because of insufficient statistical information in the studies, by
excluding studies that allowed for comorbidity of mental disorders
G. Lo Coco et al.

Records idenfied through Addional records idenfied

database searching through other sources

Idenficaon
(n = 7873) (n = 26)

Records a!er duplicates removed

(n = 7612)
Screening

Records screened Records excluded a!er

(n = 7612) screening tles and abstracts
(n = 6778)

Full-text arcles assessed Full-text arcles excluded,

for eligibility (n = 834) with reasons
n = 801
Eligibility

Not meeng inclusion criteria:

532
- No SUD diagnosis 106
- No group therapy 205
- No eligible control group 81
- No available outcome 28
- No RCT design 98
- Secondary publicaon 14
Inclusion

Relevant data for the analysis

Studies included in
quantave synthesis
(meta-analysis)
(n = 31)
(+ 2 follow-up reports)
not found (a!er contacting
authors): 9
Smoking cessaon arcles
excluded from the analysis of
this study: 260

Fig. 1. Flow chart of the study selection process.

(dual diagnosis), and by excluding studies that did not apply a baseline
treatment to all patients. We also tested whether results change when
only studies comparing equivalent treatment approaches were con-
sidered and when studies with a high or unclear risk of bias were ex-
cluded. Subgroup analyses were not executed because of the small
number of included studies and the low heterogeneity found in the
majority of analyses. We further conducted post-hoc power analyses to
test if our meta-analyses have sufficient power to detect differences
between group psychotherapy and control groups with α = 0,05 (two-
tailed) considering average group sizes of the included studies and the
degree of heterogeneity across studies (Hedges & Pigott, 2001).
3. Results
3.1. Study selection
Our electronic search revealed 7873 records. After screening all
records and assessing the relevant full texts for eligibility, 31 primary
studies and two secondary publications reporting follow-up results met
our inclusion criteria (Fig. 1).
3.2. Study characteristics
The characteristics of the included studies are summarized in
Table 1. The included studies allowed for 34 comparisons between
group therapy and a control group. Group therapy was compared to no
treatment control groups in nine studies, to individual therapy in seven
trials, and to other treatments in 18 studies. Cognitive-behavioral group
therapy was investigated in 21 comparisons, behavioral group therapy
in two comparisons, and mindfulness-based programs in three com-
parisons. Other group treatment approaches such as dialectic beha-
vioral group therapy or integrated treatment were used in eight com-
parisons. The median number of patients per group was 8, and the
median number of sessions was 14, with patients attending an average
of 60.9% of the sessions. The median length of a session was 90 min,
provided once a week. Group therapy was applied in an inpatient set-
ting in six studies, in an outpatient setting in 21 trials, and within a day
treatment program in three studies. Group therapy was part of an acute
treatment in 17 studies, it was used within aftercare treatment (relapse
prevention) in nine trials, and it was included in acute treatment and
relapse prevention in five studies. A baseline treatment was additionally
applied to patients in both intervention and control groups in 14 trials
(7 treatment as usual, 4 pharmacotherapy, 2 individual therapy, 1
Twelve-Step group).
In total, 3951 patients were randomized with 2103 in intervention
groups and 1848 in control groups. The mean age of the patients was
38.2 years and 36.2% of the patients were female. SUD was related to
alcohol in seven studies, to cocaine in six, to heroin or opioids in three,
and to cannabis in one trial. Eleven studies considered patients using
mixed substances, while another three studies did not specify the sub-
stances used. The included patients had comorbid mental disorders in
nine studies, including borderline personality disorder, psychosis, and
major depressive disorder.
Table 1
Characteristics of the included studies.
Author(s) and publication Country Population Group treatment n No. of No. of Comparison treatment n Baseline Outcomes
G. Lo Coco et al.

year Age patients sessions/

% female per group length in
minutes

Bellack, Bennet, Gearon, USA Patients with SUD Behavioral group therapy 103 5 52/n.r. Supportive group discussion 72 No Attrition,
Brown, and Yang (cocaine, heroin, abstinence,
(2006) marijuana) and severe substance use
persistent mental
illness
Age: 43
34% female
Bowen et al. (2009) USA Patients with SUD Mindfulness-Based Relapse 93 8 8/120 TAU (Twelve-Steps) 75 No Attrition,
(alcohol only or Prevention (MBRP) Substance use,
polysubstance use) SUD-symptoms
Age: 41
36% female
Bowen et al. (2014) USA Patients with SUD a) Cognitive-behavioral relapse 88 8 8/120 TAU (Twelve-Steps) 95 No Attrition,
(alcohol only or prevention abstinence,
polysubstance use) b) Mindfulness-based relapse 103 8 8/120 substance use
Age: 38 prevention
20% female
Brown et al. (2002) Canada Patients with SUD Cognitive-behavioral relapse 126 6 10/90 TSF (Twelve-Step Facilitation 140 No Attrition,
(alcohol only or prevention aftercare program Therapy; therapist-guided) frequency, SUD-
polysubstance use) symptoms
Age: 38
31% female
Brown et al. (2006) USA Veterans with SUD Cognitive-behavioral group 48 n.r. 36/60 TSF (Twelve-Step Facilitation 42 Standard pharmacotherapy Attrition,
Lydecker et al. (2010) (alcohol, cannabinol or therapy combining treatment Therapy; therapist-guided) abstinence, mental
stimulants) and major for depression and coping Skills state, SUD-
depressive disorder training for SUD symptoms
Age: 49
8% female
Burtscheidt et al. (2002) Germany Patients with SUD a) Cognitive-behavioral group 40 6 26/100 TAU 40 No Attrition,
(alcohol) therapy abstinence
Age: 42 b) Coping skills training 40 6 26/100
30% female
Easton et al. (2007) USA Men with SUD Cognitive-behavioral group 40 10 12/90 TSF (Twelve-Step Facilitation 38 No Attrition,
(alcohol) and co- therapy Therapy; therapist-guided) abstinence, SUD
occurring symptoms
interpersonal violence
Age: 38
0% female
Epstein, Hawkins, Covi, USA Patients with SUD Cognitive-behavioral group 48 n.r. 12/90 Social-support group 49 No Attrition,
Umbricht, and Preston (cocaine) therapy abstinence,
(2003) Age: 39 substance use
43% female
Estopiñán, Poza, Martín, Spain Patients with SUD Cognitive-behavioral group 14 14 7/90 TAU 10 No Attrition,
and Garcia (2009) (alcohol) therapy abstinence
Age: 45
29% female
Garland, Gaylord, USA Patients with SUD Mindfulness-based group 27 10 10/120 Social-support group 26 No Attrition, mental
Boettiger, and (alcohol) living in a therapy state, SUD
Howard (2010) therapeutic symptoms,
community for
> 18 months
(continued on next page)
Table 1 (continued)

Author(s) and publication Country Population Group treatment n No. of No. of Comparison treatment n Baseline Outcomes
year Age patients sessions/
G. Lo Coco et al.

% female per group length in

minutes

Age: 40
21% female
Gouzoulis-Mayfrank et al. Germany Patients with SUD Integrated treatment including 50 n.r. n.r./120 TAU 50 No Attrition,
(2015) (mixed substances) and disorder-specific group therapy abstinence,
Psychosis substance use
Age: 31
16% female
Hien et al. (2009) USA Women with SUD Cognitive-behavioral group 176 n.r. 12/75–90 Women's health education 177 Standard SUD treatment Attrition,
(mixed substances) and therapy (Seeking Safety) group abstinence,
PTSD substance use
Age: 39
100% female
Hunter et al. (2012) USA Patients with SUD and Cognitive-behavioral group 47 n.r. 18/120 No (additional) treatment 26 TAU based on Twelve-Steps and Matrix Attrition,
depressive symptoms therapy Model abstinence, mental
Age: 35 state
48% female
Kushner et al. (2013) USA Patients with SUD Cognitive-behavioral group 171 3 6/60 Progressive relaxation training 173 Residential TAU (Twelve-Steps) Attrition,
(alcohol) and anxiety therapy abstinence, mental
disorder state, substance
Age: 39 use
40% female
Lanza, Garcia, Lamelas, Spain Incarcerated women a) Cognitive-behavioral group 18 n.r. 16/90 No treatment (Waitlist 13 No Abstinence, SUD
and Gonzalez- with SUD therapy (Acceptance and control) symptoms, mental
Menendez (2014) Age: 33 Commitment therapy) state
100% female b) Cognitive-behavioral group 19 n.r. 16/90
therapy (traditional program)
Lehman, Herron, USA Patients with SUD Supportive group therapy 29 n.r. n.r./60 No (additional) treatment 25 TAU (usual mental health center and SUD symptoms
Schwartz, and Myers (alcohol, cannabis) and (Being sober rehabilitation services)
(1993) severe mental illness group) + intensive case
Age: 31 management
26% female
Li, Armstrong, Chaim, Canada Patients with SUD Multiple couples therapy 30 8 8/90 Individual couple therapy 24 No Attrition, SUD
Kelly, and Shenfeld (mixed substances) and (integrated treatment) (integrated treatment) symptoms
(2007) their partners
Age: 42
26% female
Linehan et al. (1999) USA Women with SUD Dialectical behavior group 12 n.r. n.r./120 TAU 15 No Attrition,
(mixed substances) and therapy abstinence
borderline personality
disorder
Age: 30
100% female
Linehan et al. (2002) USA Women with SUD Dialectical behavior group 11 n.r. n.r./150 Individual comprehensive 12 Pharmacotherapy (opiate agonist Attrition,
(heroin) and therapy validation medication) abstinence
borderline personality therapy + Twelve-Steps
disorder groups
Age: 36
100% female
Madigan et al. (2013) Ireland Patients with SUD Cognitive-behavioral group 59 n.r. 12/n.r. No (additional) treatment 29 TAU (care from a multidisciplinary team in Attrition,
(cannabis) and therapy and motivational the local service) substance use,
Psychosis interviewing mental state
(continued on next page)
Table 1 (continued)

Author(s) and publication Country Population Group treatment n No. of No. of Comparison treatment n Baseline Outcomes
year Age patients sessions/
G. Lo Coco et al.

% female per group length in

minutes

Age: 28
22% female
Marlowe et al. (2003) USA Patients with SUD Cognitive-behavioral group 40 n.r. n.r. No (additional) treatment 39 Individual cognitive-behavioral addiction Attrition,
(cocaine) oriented day treatment counseling + interpersonal problem solving abstinence
Age: 34 groups
22% female
Marques and Formigoni Brazil Patients with SUD Cognitive-behavioral group 78 7 17/n.r. Cognitive-behavioral 77 No Attrition,
(2001) (alcohol or drugs) therapy individual therapy abstinence,
Age: 32 substance use,
8% female SUD symptoms
Maude-Griffin et al. USA Veterans with SUD Cognitive-behavioral group 59 n.r. 36/n.r. TSF (Twelve-Step Facilitation 69 Individual counseling Abstinence
(1998) (cocaine) therapy Therapy; therapist-guided)
Age: n.r.
2% female
Milby et al. (1996) USA Homeless persons with Group oriented day treatment 89 n.r. 24/n.r. TAU (Twelve-Steps, individual 87 No Attrition,
SUD (multimodal) and group counseling) abstinence
Age: 31
19% female
Min et al. (2011). China Men with SUD (heroin) Cognitive-behavioral relapse 50 12 20/90 No (additional) treatment 50 TAU (rehabilitation program) Attrition,
Age: 36 prevention abstinence, SUD
0% female symptoms, mental
state
Monras et al. (2000) Spain Patients with SUD Motivational enhancement 45 10 nr/60 No (additional) treatment 43 TAU (individual visits + pharmacological Attrition,
(alcohol) group therapy treatment if necessary) abstinence
Age: n.r.
24% female
O'Farrel, Schumm, USA Patients with SUD Group behavioral couples 50 8 11/90 Individual behavioral couples 51 Twelve-Steps Group (without partner) Attrition,
Dunlap, Murphy, and (alcohol) and their therapy therapy abstinence,
Muchowsky (2016) heterosexual partners substance use
without SUD
Age: 48
30% female
Rawson et al. (2001) USA Patients with SUD Cognitive-behavioral group 40 n.r. n.r./90 No (additional) treatment 41 TAU: Detoxification + Pharmacotherapy Abstinence, SUD
(opioid) therapy + individual sessions (naltrexone) symptoms, mental
Age: 33 state
40% female
Rawson et al. (2002) USA Patients with SUD Cognitive-behavioral group 30 6 48/90 No (additional) treatment 30 Pharmacotherapy (standard methadone tx) Abstinence
(cocaine) therapy
Age: 44
48% female
Schmitz et al. (1997). USA Patients with SUD Cognitive-behavioral group 24 5 12/60 Cognitive-behavioral 23 No Attrition,
(cocaine) therapy individual therapy abstinence,
Age: 35 substance use,
50% female SUD symptoms,
mental state
Weinstein, Gottheil, and USA Patients with SUD Integrated group treatment 142 n.r. 36/180 Individual counseling 144 No Attrition,
Sterling (1997); (cocaine) including behavioral, abstinence,
Gottheil, Weinstein, Age: n.r. exploratory, supportive, and substance use,
Sterling, Lundy, and % female n.r. expressive techniques SUD symptoms,
Serota (1998) Mental state

n.r. = not reported; PTSD = posttraumatic stress disorder; SUD = substance use disorder; TAU = treatment as usual; TSF = Twelve-Step Facilitation Therapy.
G. Lo Coco et al.
3.3. Risk of bias within studies
The random allocation was adequate in 13 studies (low risk of bias),
two studies were evaluated as high risk, and 18 studies had an unclear
risk of bias. The risk of selection bias due to inadequate allocation
concealment was judged as low in eight studies, while it was unclear in
25. The risk of reporting bias was rated as low in six studies, high in one
study, and unclear in 26 trials. We determined that the risk of bias due
to lack of implementation quality was low in 23 studies, while it was
unclear in 10 studies because of missing information (Supplementary
Table 2). The risk of attrition bias due to incomplete outcome data was
judged as low for 53% of the outcomes, while it was rated as high for
37%, and as unclear for 10%. Finally, none of the primary studies ac-
counted for the dependence of data, such as the correlation of data
within groups by considering the intraclass correlation coefficient (ICC)
in the analysis (Baldwin, Murray, & Shadish, 2005).
3.4. Results of individual studies and synthesis of results
3.4.1. Post-treatment
The results of the included studies on the primary and secondary
outcomes as well as the pooled results (Hedges' g with 95% confidence
intervals) according to the type of control group are shown in Table 2.
We found significant, small effects of group therapy on abstinence in
each comparison, classified as group therapy compared to either no
treatment, individual therapy, or other treatments. While study results
were homogeneous for comparisons against no treatment and in-
dividual therapy, moderate effects were seen when group therapy was
compared to other treatments. The effects on frequency of substance
use and symptoms of SUD were non-significant. We found a significant
medium effect for mental state when group therapy was compared to no
treatment, but the effects for comparisons against individual therapy
and other treatments were small and non-significant. Attrition in group
therapy was 32%, and 34% in control groups. Differences in attrition
between group psychotherapy and control treatments were non-sig-
nificant for all of the subgroups: vs. no treatment, RR = 0,96, 95% CI
[0,83; 1,12], k = 5; vs. individual therapy, RR = 1,01, 95% CI [0,82;
1,23], k = 5; and vs. other treatments, RR = 1,03, 95% CI [0,94; 1,13],
k = 15.
3.4.2. Follow-up
We considered results of the latest reported follow-up assessment
within 12 months of treatment completion. The results are summarized
in Supplementary Table 3. Results for the primary outcome abstinence
increased over time for comparisons against no treatment but decreased
for comparisons against individual and other treatments. The number of
studies reporting follow-up results for the other outcomes was small,
preventing a clear interpretation of the effects.
3.5. Risk of bias across studies
We examined the risk of bias across studies by including all studies
in one analysis because of the small number of included studies within
the three types of comparisons. A visual inspection of the funnel plot for
the primary outcome abstinence did not reveal any substantial asym-
metry (Supplementary Fig. 1). Egger's regression test also indicated no
significant evidence of small-study effects (p = 0,403). We did not run
the Egger test for the other outcomes because it should be used only
when there are at least 10 studies included in the meta-analysis (Sterne,
Egger, & Moher, 2011).
3.6. Additional analyses
Results of sensitivity analyses demonstrated the robustness of the
findings on abstinence at post-treatment. The effects and conclusions
remained stable when excluding outliers, approximated effect sizes, or
studies with dual diagnoses (Supplementary Table 4). Results for stu-
dies comparing equivalent treatment approaches and for trials with low
risk of bias were similar to findings including all studies. Results
dropped to zero when we included only trials applying a baseline
treatment to all patients for comparisons of group therapy and no
treatment. Post-hoc power analyses revealed that for the primary out-
come abstinence all meta-analyses are adequately powered with
1 − β = 0,81 for comparisons against no treatment control groups,
0,93 for comparisons against individual therapy, and 0,98 for com-
parisons against other active treatments. Since effects and/or number of
studies were smaller for analyses on the secondary outcomes, these
analyses are mainly underpowered (1 − β < 0,80) except for mental
state in comparisons against no treatment control groups
(1 − β = 0,99) and frequency of use in comparisons against individual
therapy (1 − β = 0,95).
4. Discussion
Little is known about the efficacy of psychosocial treatment for
substance-related disorders conducted in the group format, despite the
widespread implementation of group therapy in most treatment facil-
ities (Crits-Christoph, Johnson, Connolly Gibbons, & Gallop, 2013;
Fletcher, 2013). The current meta-analysis examined 33 studies in-
cluding 34 treatment conditions and 3951 patients.
The results indicated that the pooled effect sizes for short-term ef-
ficacy were significant but small on the primary outcome abstinence in
each comparison. Group intervention effects remained evident for ab-
stinence at post-treatment when studies with a high risk of bias, without
a baseline treatment, or with dual diagnosis were excluded. A visual
inspection of the funnel plot for the primary outcome suggested no
indication of publication bias. Taken together, these findings provide
some evidence for the general efficacy of group treatment on abstinence
at post-treatment. The observed effect sizes ranged from the small to
moderate level and are consistent with the results of previous meta-
analyses (for example, Burke, Arkowitz, & Menchola, 2003; Magill &
Ray, 2009) as well as with research suggesting that the public nature of
group therapy can represent a more powerful incentive to avoid relapse
by providing a robust source of external control that can counter-
balance a disorder characterized by the breakdown of internalized
control mechanisms (Khantzian, 2004). A moderate heterogeneity in
effect sizes was found when group treatment was compared to other
treatments. In the reviewed studies, various “other treatments” were
contrasted with group therapy by including both therapist-led and not
therapist-led interventions, such as the mutual self-help groups. Thus,
this statistical heterogeneity seems to reflect the variety of helpful ap-
proaches for SUDs, with the challenge of crafting an effective treatment
tailored to the specific need of the patient (Mack, Brady, Miller, &
Frances, 2016).
It is often argued that a limited number of included studies in the
single analyses might be related to a lack of statistical power. Therefore,
we conducted post-hoc power analyses. Although the number of studies
was small in most analyses, for the primary outcome abstinence all
meta-analyses were adequately powered to detect differences between
study groups. This refers to one of the primary aims of meta-analyses:
increasing statistical power that is usually not given in the primary
studies, particularly when active treatment groups are compared
(Cuijpers, 2016).
It is worth noting that group therapy performed well at mental state
improvement (defined as improvement in symptoms of depression,
anxiety, or overall distress) with a moderate effect when compared to
no treatment. However, there was no significant effect on mental state
outcome when group treatment was compared to individual psy-
chotherapy or other active treatments. Additionally, group therapy was
not effective in reducing the frequency of substance use and symptoms
of SUD across all comparisons. This may be due to a higher hetero-
geneity and the small number of analyzed studies reporting frequency
G. Lo Coco et al.

Table 2
Meta-analytic results for different comparisons at post-treatment.
Study Abstinence Frequency of use SUD symptoms Mental state

g 95% CI g 95% CI g 95% CI g 95% CI

Group vs. no treatment

Hunter 2012 0,26 −0,34; 0,86 0,42 −0,15; 0,99
Lanza 2014 0,63 −0,63; 1,88 0,28 −0,42; 0,97 0,82 0,08; 1,55
Lehman 1993 −0,26 −0,97; 0,45
Marlowe 2003 0,09 −0,34; 0,53
Min 2011 0,67 0,26; 1,07
Monras 2000 0,17 −0,37; 0,72
Rawson 2001 0,58 −0,06; 1,23 0,71 0,22; 1,20 0,68 0,17; 1,19
Rawson 2002 0,43 −0,18; 1,03
Total effect 0,28 0,04; 0,52 0,29 −0,28; 0,86 0,64 0,38; 0,90
Heterogeneity I2 0% 59,32% 0%
Group vs. individual therapy
Linehan 2002 −0,09 −0,88; 0,70
O'Farrel 2016 0,36 −0,03; 0,75 0,10 −0,29; 0,49
Schmitz 1997 0,29 −0,49; 1,07 0,94 0,23; 1,66 0,00 −0,67; 0,68 0,74 0,04; 1,44
Weinstein 1997 0,53 −0,02; 1,09 0,16 −0,39; 0,71 0,00 −0,55; 0,55 −0,05 −0,60; 0,49
Total effect 0,34 0,06; 0,62 0,52 −0,25; 1,28 0,06 −0,23; 0,34 0,31 −0,46; 1,09
Heterogeneity I2 0% 65,64% 0% 67,33%
Group vs. other active treatments
Bellack 2006 0,64 0,26; 1,03 0,00 −0,37; 0,37
Bowen 2009 0,10 −0,24; 0,44 0,40 0,01; 0,80
Bowen 2014 0,33 0,01; 0,65 0,16 −0,13; 0,44
Brown 2006 −0,55 −1,11; 0,01 −0,30 −0,89; 0,28
Burtscheidt 2002 0,06 −0,38; 0,50
Calvo Estopinan 2008 0,31 −0,57; 1,19
Easton 2007 0,54 0,07; 1,01 0,00 −0,48; 0,48
Epstein 2003 −0,43 −0,82; −0,03
Garland 2010 −0,35 −0,98; 0,29 0,45 −0,18; 1,09
Gouzoulis-Mayfrank 2015 0,18 −0,26; 0,61 0,02 −0,95; 0,99
Hien 2009 −0,02 −0,25; 0,21 0,04 −0,16; 0,25
Kushner 2013 0,19 −0,06; 0,43
Linehan 1999 0,48 −0,26; 1,21
Maude-Griffin 1998 0,29 −0,11; 0,68
Milby 1996 0,86 0,45; 1,26
Total effect 0,29 0,07; 0,50 0,01 −0,14; 0,16 0,07 −0,34; 0,49 0,13 −0,21; 0,46
Heterogeneity I2 65,09% 16,15% 53,44% 38,19%

SUD = substance use disorder.

of use and SUD symptoms. However, there is promising evidence for
reduced SUD symptoms at follow up when the group format was
compared with the no treatment condition.
Additional long-term effects were evaluated, and significant
medium effects on abstinence were found in studies comparing group
treatment to no treatment, a finding that is consistent with previous
randomized trials examining the effectiveness of group therapy for SUD
patients (Litt, Kadden, Cooney, & Kabela, 2003; McKay et al., 1997).
However, studies comparing group therapy against other active treat-
ments did not yield significant differences on abstinence in the long-
term. Overall, our findings on abstinence are promising, given the
chronic-relapsing nature of addiction problems highlighted by previous
research (McLellan et al., 2000). It is worth noting that we found only a
few studies reporting follow-up results for the secondary outcomes.
No differences in secondary outcomes were found when group
therapy was compared to individual therapy or other active treatments
such as Twelve-Step Facilitation Therapy or TAU. This result is con-
sistent with previous research reporting no differences between the
outcomes of group and individual therapy in general (Burlingame et al.,
2016), and specifically for patients with SUD (Irvin, Bowers, Dunn, &
Wang, 1999; Schmitz et al., 1997; Sobell & Sobell, 2011; Weiss et al.,
2004) as well as between group therapy and any active therapy com-
parators for various mental disorders (panic disorder and PTSD:
Schwartze et al., 2016, Schwartze, Barkowski, Strauss, Burlingame,
et al., 2017, Schwartze, Barkowski, Strauss, Knaevelsrud, et al., 2017;
social anxiety disorder: Barkowski et al., 2016). However, this result
represents a promising outcome considering that there are several ad-
vantages to the group format in substance use treatment (Flores, 2007)
and the efficient use of therapist time achieved by group therapy
(Marques & Formigoni, 2001).
No differences in attrition were found between group psy-
chotherapy and control treatments. However, the overall attrition rate
was high at 34%, especially when compared to previous meta-analyses
of psychotherapy efficacy studies (Swift & Greenberg, 2012). This is
particularly important considering the increased likelihood of achieving
abstinence or intervals of greatly reduced substance use for patients
who are able to maintain active participation in formalized treatment
(Kleber et al., 2007). Patients with SUD are known to frequently report
high rates of treatment discontinuation (Wells, Saxson, Calsyn, Jackson,
& Donovan, 2010) and attendance can be poor even when group
therapy is mandated such as in methadone or rehab clinics (Joe,
Simpson, Greener, & Rowan-Szal, 1999). Further research is needed to
determine which group therapeutic strategies can effectively improve
treatment adherence. There is some evidence for the efficacy of con-
tingency management procedures such as abstinence-based incentives
for reinforcing cocaine abstinence and group therapy attendance (Petry,
Martin, & Simcic, 2005) as well as attendance at motivational en-
hancement and treatment readiness group sessions for opioid-depen-
dent patients (Kidorf et al., 2009).
Interestingly, the effects for comparisons against individual therapy
and other treatments on abstinence remained significant and moderate
once the studies examining patients with dual diagnoses in the sensi-
tivity analysis were excluded. This result confirms the robustness of the
findings on the effectiveness of group treatment for SUDs and suggests
that group therapy can be implemented and sustained for patients with
both a SUD and a comorbid psychiatric disorder. Although previous
G. Lo Coco et al.
research found evidence regarding certain well-supported treatment
methods for adult patients with SUDs (Miller & Wilbourne, 2002; Sobell
& Sobell, 2011), the greater efficacy of a single type of treatment
modality over another for patients with co-occurring substance use and
mental health problems is still a matter of debate (Drake, O'Neal, &
Wallach, 2008; Roberts et al., 2016). Our findings suggest that group
therapy can be effective for the difficult-to-treat patients. However, this
is a preliminary conclusion, given the small number of studies included
in the meta-analysis. More studies are needed in order to draw defini-
tive conclusions about the efficacy of group treatment approaches for
patients with comorbidities. Nonetheless, the pattern of findings seen in
the currently available research is encouraging.
To sum up, the current meta-analysis suggests that integrating the
results on the efficacy of group therapy RCTs can allow both researchers
and clinicians to make an accurate estimation of the effect of group
treatment for SUDs. At the same time, we are aware that the “real-
world” group treatments for SUDs are often different from those re-
ported in the RCTs. For example, the open-enrolling groups are likely
the most frequent modality of group therapy in SUD specialty clinics
and are rarely examined in controlled trials (Weiss et al., 2004; Wendt
& Gone, 2017) because of methodological difficulties. In the current
review none of the 31 studies have explicitly mentioned the inclusion of
open-enrolling groups. However, some recent and powerful tools for
analyzing data from rolling groups were developed (Tasca et al., 2010)
and could be effectively adopted in research with SUDs. Furthermore,
there is still a gap in the literature associated with the mismatch be-
tween the use of group manualized therapies and the need for high
degree of flexibility in treatment delivery to address the complex nature
of addiction (Wendt & Gone, 2018). RCTs and meta-analyses have ex-
tensively relied on manualized/structured treatments. Although strict
treatment adherence is necessary for a well-controlled study, con-
siderable flexibility within structured group therapies is likely required
within real-world treatment settings (Wendt & Gone, 2018). Finally, the
results of the current meta-analysis provide compelling evidence for the
effects of group treatment for SUDs and can help both policy makers
and stakeholders to allocate financial resources for improving effective
group interventions in SUDs specialty treatments. A precise estimation
of the effect of group interventions can improve the evidence-based
ground of group therapies, given that most of previous research efforts
heavily focused on individual therapy for SUDs (Wendt & Gone, 2017).
4.1. Limitations
Various limitations related to the characteristics of the included
studies may have impacted our findings. Firstly, some studies relied
almost entirely on patient self-reports to clinicians, and numerous
questions have been raised about their reliability and validity in sub-
stance use research (Richter & Johnson, 2001). Secondly, although
there was some breadth in the range of included intervention types, the
majority of the group therapies implemented in the included studies
could be classified as taking the cognitive-behavioral approach (58%).
Furthermore, in the present meta-analysis the eligible interventions
were group treatments consisting of at least 3 patients and a therapist
who meet regularly for a minimum of 5 sessions, consistently to recent
reviews on evidence-based group treatments (Burlingame et al., 2013;
Weiss et al., 2004). Thus, the estimation of the effect size of group in-
terventions in this meta-analysis excluded some very brief group
therapies which are usually delivered in one, two or four sessions such
as the motivational enhancement therapy (Miller & Rollnick, 2002) or
group motivational interviewing (Santa Ana et al., 2007). Further stu-
dies are needed to estimate the effects of these brief group treatments
which showed to be viable treatment modalities in clinical settings to
enhance treatment outcome for SUDs. Additionally, a number of in-
cluded studies did not report the number of patients per group or the
number of group sessions. We believe it was reasonable to include those
studies because it seemed very unlikely for us that groups had < 3
patients when the N ranged between 50 and 150. Furthermore, we used
a conservative approach by including those studies with a lack of re-
ported number of sessions because in the worst case we would under-
estimate the real treatment effect as it is quite unlikely to reach a high
treatment effect with a small (< 5) number of sessions. The next gen-
eration of empirical research on group therapy should consistently re-
port more details concerning the group structure, such as open or closed
format or number of patients per each group. In the reviewed studies,
the included participants were typically white males. The applicability
of the treatments to females, older adults, and non-white individuals is
less clear. Few included trials were conducted outside the USA (32%),
leaving the applicability of treatments to other countries similarly un-
clear. We focused on studies of adult individuals with SUD and con-
sidered adolescents as a special population that deserved a distinct
analysis. Although the diagnostic criteria for drug use are similar for all
types of substances and across all ages, the epidemiology and nature of
adolescent substance use is related to the unique developmental period
of adolescence (Fisher & Roget, 2009). Our findings therefore cannot
apply to adolescent substance users, although the behavioral treatment
of adolescent substance use is an important area to pursue (Hogue,
Henderson, Ozechowski, & Robbins, 2014). To date, the results from
controlled studies of treatment for adolescents with SUDs fall well short
of yielding definitive conclusions about the treatment approaches that
are most effective for this clinical population. However, the recent
meta-analytic results on the advantages of group counseling treatment
seem promising, with positive and statistically significant improve-
ments in substance use over time (Tanner-Smith, Wilson, & Lipsey,
2013) and tested in a wide array of group interventions including
psychoeducation, social learning and motivational interviewing
(Burlingame et al., 2013). Finally, we were unable to investigate
whether effect sizes differed by specific SUD diagnoses due to the
limited number of studies available for inclusion in some subgroup
analyses. In the current study, eleven RCTs included patients using
mixed substances, which appear to reflect the complexity of group
delivery in clinical contexts.
4.2. Conclusions
The term group therapy has been used by both clinicians and re-
searchers to describe very different approaches to the treatment of
SUDs, with some adopting well-validated group therapy principles and
processes (e.g., Yalom & Leszcz, 2005) and others simply promoting
dyadic interactions in a group context. Although there are different
meanings of the term “group therapy” in the field (Weiss et al., 2004), a
large majority of programs for SUDs report that group therapy is a
useful treatment modality due to its empirical effectiveness (Weiss
et al., 2004; Wendt & Gone, 2018). The current meta-analysis re-
presents an effort to narrow the gap between research and practice in
the SUD literature, given that no meta-analyses quantitatively sum-
marizing the efficacy of group therapy for SUDs are currently available.
The results of the present meta-analysis provide preliminary evidence
that group treatment leads to improved abstinence when compared to
either no treatment, individual therapy, or other treatments. However,
the effect sizes are small and there are few studies reporting follow-up
results. The main findings in this study are supported by sensitivity
analyses and a low level of heterogeneity. Although the current findings
represent compelling summary analysis of group therapy for SUDs,
further research is needed to determine the influence of socio-
demographic, psychiatric, and general medical characteristics as well as
patient treatment preferences on treatment attrition and outcome
(Kadden, Litt, Cooney, Kabela, & Getter, 2001; Sofin, Danker-Hopfe,
Gooren, & Neu, 2017). Group studies with long-term prospective de-
signs are also needed, given that only a third to a half of individuals
with SUDs achieve remission, occurring after a mean follow-up period
of 17 years (Fleury et al., 2016).
The current findings could facilitate group clinicians in improving
G. Lo Coco et al.
their attitudes toward group therapies by further supporting the effi-
cacy of group treatment protocols, and, at the same time, could help
researchers to further address the complexities with group facilitation
which are usually under-examined in RCTs with this difficult-to-treat
patient population.
Funding
This study was funded by the German Academic Exchange Service
(grant number 57214281).
Acknowledgements
We kindly thank Gary Burlingame for his helpful suggestions in the
process of this review.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.jsat.2019.01.016.
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