Group Therapy

Group therapy varies with each of the three phases in the psychotherapy of substance abusers: achieving abstinence, early Sobriety, and late sobriety (achieving intimacy).

Early Phase: Achieving Abstinence. In the first phase of psychotherapy, the type of group utilized will depend on the treatment setting: hospital, residential, intensive outpatient (also termed partial hospitalization), or limited outpatient.

In hospital settings, educational groups are an essential part of the early treatment process, and the subjects covered in these groups are quite similar to those in educational family groups (described in the first section of this article). The major difference of emphasis in patient educational groups is on the physiological aspects and risk factors of drugs and alcohol. Other important didactic groups cover in detail issues such as (1) Assertiveness Training; (2) other compulsive behaviors, such as sexuality, eating, working, and Gambling; (3) Relapse Prevention; (4) the prolonged abstinence syndrome; (5) leisure skills; and (6) cross addiction. All educational groups include appropriate coping strategies, some of which are developed from the experiences of recovering members.

One advantage of 28-day residential programs (now more often 7 to 21 days, followed by an intensive 6-hours-a-day outpatient program) is that group therapy can be started immediately after drinking or drug use stops. In the first few sober days, the addict or alcoholic is so needy that his/her resistance to groups is low. At this stage, the therapist and the group should show the substance abuser how to borrow the confidence that life without alcohol or drugs is possible and better than life with it. This hope is best offered by a therapist or cotherapist who is a recovering substance abuser with solid sobriety. Therapeutic groups in these settings will also deal with appropriate expressions of feelings, relationships with significant others, childhood molestation and abuse, building self-esteem, and development of strategies for self-care.

A critical aspect of early group therapy is for the patient to experience the sharing of a group of individuals struggling against their addiction. This helps to overcome the feelings of isolation and shame that are so common in these patients. The formation of a helping, sober peer group that provides support for a lifetime, in and out of twelve-step groups, is very helpful and dramatic when it occurs.

In outpatient programs there is less of an opportunity to perform uncovering therapy in the early phases because there is less protection and less of a holding environment than in residential settings.

Others, particularly Woody et al. (1986), have developed detailed group therapy techniques for methadone patients. Also, Brown and Yalom (1977) and Vanicelli (1992), with alcoholics, and Khantzian et al. (1990), with cocaine addicts, have adapted psychodynamic techniques for group work.

Ex-addicts and recovering alcoholics are valuable as cotherapists, or even as primary or sole therapist, particularly in the early stages of groups. Commonality of experience with the client, by itself, does not qualify an individual to be a therapist. Recovering persons should have at least two years of sobriety before they are permitted to function as group therapists. The techniques that help ex-addicts become experienced therapists are best learned gradually and under close supervision, preferably by experienced paraprofessionals and professionals.

Also helpful in cotherapy is male-female pairing, which provides a balance of male and female role models and transference.

During the early sessions of group therapy with substance abusers, the focus is on the shared problem of drinking or drug use, and its meaning to each individual. The therapist should be more active in this phase, which should be instructional and informative as well as therapeutic.

Alcoholics tend toward confessionals and monologues about prior drinking. These can be politely interrupted or minimized by a ground rule of ''no drunkalogues.'' Romanticizing past use of drugs or alcohol is strongly discouraged. Outpatient Groups. The desire to drink or use drugs and the fear of slipping are pervasive, early concerns in outpatient groups. The patient's attitude is one of resistance and caution, combined with fear of open exploration. Members are encouraged to participate in AA and other relevant twelve-step groups, yet the ''high support, low conflict, inspirational style ' of AA may inhibit attempts at interactional therapy. Therapists should not be overly protective and prematurely relieve the group's anxiety because this fosters denial of emotions. On the other hand, the members' recognition of emotions and responsibility must proceed slowly because both are particularly threatening to substance abusers. Patients are superficially friendly, but do not show real warmth or tenderness. AA-type hugs are an easy way to begin to show physical support. They are afraid to express anger or to assert themselves. However, sudden irritation, antipathy, and anger toward the leaders and other members inevitably begin to become more overt as the group progresses.

Gradually, tentative overtures of friendship and understanding become manifest. There may be a conspiracy of silence about material that members fear could cause discomfort or lead to drug use or drinking. The therapists can point out to the members that they choose to remain static and within comfortable defenses rather than expose themselves to the discomfort associated with change. Patients usually drop out early if they are still committed to using drugs or drinking. Other patients who drop out early do so because they grow increasingly alarmed as they become aware of the degree of discomfort that any significant change requires.

Middle Phase: Early Sobriety. In the middle phase of group therapy, the emphasis is quite similar to that of individual therapy. Therapists should continue to focus on cognitive behavioral techniques to maintain sobriety. Intensive affects are abreacted toward significant persons outside of the group but are minimized and modulated between group members. In this stage there evolves a beginning awareness of the role of personality and social interactions in the use of drugs and alcohol. Alcoholics are ambivalent about positive feedback. They beg for it, yet reject it when it is given. They repeatedly ask for physical reassurance, such as a warm hug, but may panic when they receive it because of fear of intimacy and a reexperiencing of their unmet past needs. There is a fear of success and a dread of competing in life as well as in the group. Success means destroying the other group members (siblings) and loss of therapist (parent).

Alcoholics are reluctant to explore fantasies because the thought makes them feel as guilty as the act. They view emotions as black or white. This makes them withhold critical comments because they fear their criticism will provoke upset and the resumption of drinking in other members. This withholding may be conscious or unconscious. Rage has been expressed either explosively or not at all. Its expression in the middle phase of group should be encouraged, but gradually and under slowly releasing controls.

The other crucial affect that must be dealt with is depression. There is an initial severe depression, which occurs immediately after detoxification. It appears to be severe but usually remits rapidly, leaving the substance abuser with a chronic, low-grade depression—frequently expressed by silence, lack of energy, and vegetative signs. These patients should be drawn out slowly and patiently. Ultimately, they are encouraged to cry or mourn, and a distinction is made between helping them deal with despair as opposed to rushing to take it away from them.

The success of the middle phase of group therapy with substance abusers depends on the therapist's and the group's ability to relieve anxiety through support, insight, and the use of more adaptive, concrete ways of dealing with anxiety. Alcohol and drugs must become unacceptable solutions to anxiety. In this vein, it is important not to end a session with members in a state of grossly unresolved conflict. This can be avoided by closure when excessively troubling issues are raised. Closure can be achieved by the group's concrete suggestions for problem solution. When this is not possible, group support, including extragroup contact by members, can be offered. Brown and Yalom (1977) utilize a summary of the content of each group that is mailed to members between sessions and helps provide closure and synthesis.

Final Phase: Late Sobriety. In the final phase of therapy, substance abusers express and work through feelings, responsibility for behavior, interpersonal interactions, and the functions and secondary gain of drugs and alcohol. In this phase, reconstructive group techniques as practiced by well-trained professionals are extremely helpful and essential if significant shifts in ego strength are to be accomplished. Here, the substance abuser will become able to analyze defenses, resistance, and transference. The multiple transferences that develop in the group are recognized as ''old tapes'' that are not relevant to the present. Problems of sibling rivalry, competition with authority, and separation anxiety become manifest in the group, and their transference aspects are developed and interpreted. Conflicts are analyzed on both the in-trapsychic and interpersonal levels. Ventilation and catharsis take place, and may be enhanced by group support. Excessive reliance on fantasy is abandoned.

Alcoholics who survive a high initial dropout rate stay in groups longer than neurotic patients, and thus a substantial number of middle-phase alcoholics will reach this final phase. By the closing phase, the alcoholic has accepted sobriety without resentment and works to free himself or herself from unnecessary neurotic and character problems. He or she has developed a healthy self-concept, combined with empathy for others, and has scaled down inordinate demands on others for superego reassurance. He or she has become effectively assertive rather than destructively aggressive and has developed a reasonable sense of values. More fulfilling relationships with spouse, children, and friends can be achieved.

When members leave the group, the decision to leave should be discussed for several weeks before a final date is set. This permits the group to mourn the lost member and for the member to mourn the group. This is true regardless of the stage of the group, but the most intense work is done in the later phases. In open-ended groups, the leadership qualities of the graduating member are taken over by others, who then may apply these qualities to life outside the group.

By the time substance abusers have reached this phase, they act like patients in highly functioning neurotic groups. Other forms of group treatment combine the principles of group and family work, such as multiple family group treatment and couples groups.

Multiple Family Group Treatment (MFGT). This is a technique that can be used in any treatment setting for substance abusers but is most successful in hospital and residential settings, where family members are usually more available. In a residential setting, the group may be composed of all of the families or separated into several groups of three or four closely matched families. Most MGFTs now include the entire community because this provides a sense of the entire patient group as a supportive family. In residential settings these groups are held weekly for two or three hours. In hospitals, a family week or weekend is often offered as an alternative or adjunct to a weekly group.

Couples Groups. There are two types of couples groups: one for the parents of young substance abusers and one for the significant other and the substance abuser.

Couples often have difficulty dealing with the role of their own issues in family or other couple therapy dysfunction when the children are present. This boundary is generally appropriate, and thus ongoing couples groups should be an integral part of any family-based treatment program.

When the presenting problem of substance abuse is resolved, content shifts to marital problems. It is often at this point that parents want to leave the MFGT and attend a couples group. In a couples group, procedures are reversed. Couples should not speak about their children but, rather, focus on the relationship between themselves. If material is brought up about the children, it is allowed only if it is relevant to problems that the couples have.

Couples must support each other while learning the basic tools of communication. When one partner gives up substance misuse, the nonusing partner must adjust the way he or she relates to the formerly using partner. There are totally new expectations and demands. Sex may have been used for exploitation and pacification so often that both partners have given up hope of resuming sexual relations and have stopped serious efforts toward mutual satisfaction. In addition, drugs and alcohol may have physiologically diminished the sex drive. Sexual communication must be slowly redeveloped. Difficulties may arise because the recovering abuser has given up the most precious thing in his or her life (drugs or alcohol) and expects immediate rewards. The spouse has been "burned" too many times (and is unwilling to provide rewards when sobriety stabilizes the spouse) to trust one more time; at the same time the recovering abuser is asked to reevaluate expectations for trust.

Couples groups in an adult or an adolescent program provide a natural means for strengthening intimacy. Spouses are encouraged to attend Al-Anon, Naranon, Coanon, and Coda to help diminish their reactivity and enhance their coping and self-esteem.

Couples groups have been used even more widely with alcoholics than with drug abusers, and the techniques are similar to those described above. Spouses of alcoholics are encouraged to attend Al-Anon, which facilitates an attitude of loving detachment.

Many studies have demonstrated that spousal involvement facilitates the alcoholic s participation in treatment and aftercare. It also increases the incidence of sobriety and enhanced function after treatment. Further, the greater the involvement of the spouse in different group modalities (Al-Anon, spouse groups, etc.), the better the prognosis for treatment of the alcoholic.

(See also: Causes of Substance Abuse; Comorbidity and Vulnerability; Contingency Con tracts; Families and Drug Use; Sobriety;



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MINUCHIN, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.

Noel, N. E. & McCRADY, B. (1984). Behavioral treatment of an alcohol abuser with a spouse present. In E. Kaufman (Ed.), Power to change: Family case studies in the treatment of alcoholism. New York: Gardner.

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Woody, G. E., et al. (1986). Psychotherapy for substance abuse. Psychiatric Clinics North America, 9, 547-562.

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Edward Kaufman

Hypnosis Hypnosis is a normal state of attentive, focused concentration with a relative suspension of peripheral awareness, a shift in attention mechanisms in the direction of focus at the expense of the periphery. Being hypnotized is something like looking through a telephoto lens. What is seen, is seen in great detail, but at the expense of context. The use of hypnosis has been associated with inducing a state of relaxation and comfort, with enhanced ability to attend to a therapeutic task, with the capacity to reduce pain and anxiety, and with heightened control over somatic function. For these reasons, hypnosis has been used with some benefit as an adjunct to the treatment of certain kinds of Drug and Alcohol Abuse and Addiction.

Therapeutic approaches involving hypnosis include using it as a substitute for the pleasure-inducing substance, taking a few minutes to induce a self-hypnotic state of relaxation (for example, by imaging oneself floating in a bathtub or a lake, or visualizing pleasant surroundings on an imaginary screen). In this strategy the hypnosis is a safe substitute for the pleasure-inducing effects of the drug. A second approach involves ego-enhancing techniques, providing the subject with encouragement, picturing himself or herself living well without the substance and able to control the desire for it. A third approach involves instructing subjects to reduce or eliminate their craving for the drug. A fourth involves cognitive restructuring, diminishing the importance of the craving for the drug by focusing instead on a commitment to respect and protect the body by eliminating the damaging drug. One widely used technique for smoking control, for example, has people in hypnosis repeat to themselves three points: (1) For my body, smoking is a poison; (2) I need my body to live; (3) I owe my body respect and protection. This approach places an emphasis on a positive commitment to what the person is for, rather than paying attention to being against the drug, thereby keeping attention on protection rather than on abstinence.

Hypnosis has been most widely used in the treatment of Nicotine dependence, and although the results vary, a number of large-scale studies indicate that even a single session of training in self-hypnosis can result in complete abstinence of six months or more by approximately one out of four smokers.

There are fewer systematic data regarding use of hypnosis with Cocaine, Opiate, or alcohol addiction. The success of the approach is complicated by the fact that the acute effects of substance intoxication and/or the chronic effects on cognitive function of alcohol and other drug abuse hampers hypnotic responsiveness, thereby diminishing the potential of addicted individuals to enter this state and benefit from it. Nonetheless, there may be occasional individuals who are sufficiently hyp-notizable and motivated to use this approach as an adjunct to other treatment, diminishing the dysphoria and discomfort that can accompany Wlthdrawal and abstinence while enhancing and supporting their commitment to a behavior change. Hypnosis can be used by licensed and trained physicians, psychologists, dentists, and other healthcare professionals who have special training in its use. The treatment is employed in offices and clinics as well as in hospital settings. It should always be used as an adjunct to a broader treatment strategy.

Hypnosis is a naturally occurring mental state that can be tapped in a matter of seconds and mobilized as a means of enhancing control over behavior, as well as the effects of withdrawal and abstinence, in motivated patients supervised by appropriately trained professionals.


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David Spiegel

Long-term Versus Brief For many medical and psychiatric disorders that, like substance use disorders, have a chronic course, longer-term treatments are usually found to be much more effective than short interventions. For example, most patients with disorders such as hypertension, elevated cholesterol, diabetes, or schizophrenia have the best clinical course if they maintain lifestyle modifications and remain on their medications for extended periods of time. One would therefore think that individuals with substance use disorders who seek treatment would have better outcomes if they received longer, as opposed to shorter, episodes of care. However, research findings in the addictions have indicated that the relationship between length of treatment and outcome is not particularly straightforward.

There is considerable evidence that patients who stay in treatment longer have better outcomes. That is, when patients with similar demographic characteristics and pretreatment substance-use severity all enter the same treatment program, those who stay in treatment longer will on average have better treatment outcomes that those who leave early. The dividing line that predicts good versus poor outcome has frequently been retention for at least 90 days in treatment. However, it is not clear how much the better outcomes should be attributed to longer stays in treatment or to individual characteristics such as motivation and initial success in treatment. The most direct way to untangle treatment from motivation effects is to conduct studies in which patients are randomized to different lengths or intensities of treatment, and their outcomes examined over time. Studies of this sort have produced very little evidence to indicate that longer or more intense treatments produce better substance-abuse outcomes than shorter or less intense treatments. For example, a recent random assignment study compared 6- and 12-month therapeutic community programs, and 3- and 6-month residential programs with a relapse prevention focus. In both cases, the long and short versions of the same program did not differ in rates or patterns of drug use during six-month posttreatment followup periods. This suggests that the relationship between longer treatments and better outcomes is probably more a function of motivation and other patient characteristics than duration of treatment received.

However, it should also be stressed that many substance abuse treatment programs feature a continuum of care, in which patients spend a certain amount of time in an initial higher intensity treatment and then ''step down'' to a lower intensity level of care, such as aftercare. Perhaps participation in and completion of aftercare following initial treatment has greater prognostic significance than the duration of a single level of care? Surprisingly, research suggests it does not. In the majority of the relatively few studies that have examined this issue, patients who were randomly assigned to active aftercare treatments did not have better substance use outcomes than those who were randomized to either no aftercare or minimal aftercare conditions.

Is it therefore the case that duration of substance use treatment, whether in one level of care or a continuum of care, is not related to substance use outcome? Despite the results from randomized studies described here, duration might still be of some importance. For example, monitoring substance abusers with low-cost, low-intensity interventions over long periods of time and arranging for more intensive treatments if they appear to have resumed use or be at risk might produce better outcomes than simply discharging patients following an initial episode of care and maintaining no contact after that. However, this approach has yet to be evaluated in controlled research studies.

Although the research literature does not strongly support the use of longer-term treatment interventions, there is consensus among clinicians and clinical researchers that sustained recoveries from substance use disorders generally require ongoing efforts by those who have these disorders. Some of the behaviors that have been associated with good long-term outcomes include regular attendance at self-help groups such as Alcoholics Anonymous, treatment for family or marital problems, employment, involvement with religion, and commitment to new interests or hobbies. These findings are consistent with the notion that formal treatment, whether of short or long duration, is useful for beginning a process of change that must be sustained over long periods of time in order to be successful and that ultimately involves many areas of functioning.


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James R. McKay

Minnesota Model Origins of the Minnesota Model of drug abuse treatment are found in three independent Minnesota treatment programs: Pioneer House in 1948, Hazelden in 1949, and Wilmar State Hospital in 1950. The Hazelden Clinics are still in existence and are located in Minnesota and Florida. The original treatment programs recognized Alcoholics Anonymous (AA) as having success in bringing about recovery from Alcoholism. Unique to this early stage of the Min nesota Model was the blending of professional behavioral science understandings with AA's principles. Important in the development of the Minnesota Model is the way treatment procedures emerged from listening to alcoholics, from trial and error, from acknowledgment of the mutual help approach of AA, and from the use of elementary assumptions rather than either a well-developed theoretical position or a generally accepted therapeutic protocol. In many ways, the Minnesota Model may be seen as having come about in a grassroots, pragmatic manner.

Because of its evolutionary, noncentralized development, the Minnesota Model is not a standardized set of procedures but an approach organized around a shared set of assumptions. These assumptions have been articulated by Dan Anderson, the former president of Hazelden Foundation and one of the early professionals working with the Minnesota Model at Wilmar State Hospital. They are the following: (1) Alcoholism exists in a consolidation of symptoms; (2) alcoholism is an illness characterized by an inability to determine time, frequency, or quantity of consumption; (3) alcoholism is non-volitional—alcoholics should not be blamed for their inability to drink ethanol (alcohol); (4) alcoholism is a physical, psychological, social, and spiritual illness; and (5) alcoholism is a chronic primary illness—meaning, that once manifest, a return to nonproblem drinking is not possible. Although these assumptions are phrased as pertaining to alcoholism, early experience with the Minnesota Model demonstrated that drug abuse other than alcoholism can also be understood and treated within these assumptions. Chemical dependency is the term generally used by clients and treatment providers when referring to substance abuse. The Minnesota Model provides treatment for chemical dependency—for both alcohol and other drugs.

A twenty-four to twenty-eight day inpatient treatment stay, or approximately eighty-five hours in outpatient rehabilitation, characterizes the Minnesota Model treatment. Inpatient treatment may occur in hospital settings or free-standing facilities and may be run by for-profit or nonprofit organizations. Different treatment settings have different mixes of staff positions, but the multidisciplinary team of medical and psychological professionals plus clergy and focal counselors are frequently found—either in a close interacting network or a more diffuse working arrangement.

Primary focal counselors have either received specific training in the Minnesota Model approach to treatment or have learned their counseling skills in an apprenticelike placement. Most counselors are neither mental-health-degreed professionals nor holders of medically related degrees, but they are commonly working on their own twelve-step programs because of life experience with chemical dependency or other addictions. As in AA, this shared personal experience of both clients and counselors is important for the client/counselor relationship and the behavior modeling the counselor provides for the client.

Minnesota Model treatment programs vary in the centrality of counseling staff and the programmed autonomy of the treatment experience. Some treatment programs have the counselor facilitating the majority of the groups and visibly directing the treatment experience. Other programs have the treatment groups carrying out the treatment experience where the activity follows a prescribed format, but the group members are the visible actors while the counseling staff maintains a low profile as they seek to empower clients to acquire the insights and resources necessary for their recovery. Treatment also varies in the amount of confrontation, the presence of a family program requirement, the extent of assigned reading, the detail of client record documentation, and other attributes.

What Minnesota Model treatment has without exception is the use of AA principles and understandings (steps and traditions) as primary adjuncts in the treatment experience. Clients are provided with the AA ''Big Book'' (Alcoholics Anonymous) and The TWELVE STEPS and Twelve Traditions. Both of these books are required reading. Spirituality is emphasized as important to recovery, which is consistent with the AA understanding. AA group meetings occur in the schedule of rehabilitation activities, and clients may visit a community AA meeting as part of their treatment experience. Clients will work on AA steps during their treatment experience; some programs focus on the first five steps while others emphasize all twelve steps.

Treatment it not just an intensive exposure to AA. It motivates treatment participants to develop mutual trust and to share and be open about how the use of chemicals has come to control their lives. Clients are told that they have the disease of chemical dependency. Their behavior has been directed by the disease, but they have been unable to see the reality of their behavior and the consequences because of the disease characteristic of denial. Treatment plans are individualized based on assessments by the multidisciplinary staff. Generally, the first goal of treatment is to break the client's denial and the second goal is for the client to accept the disease concept. Because treatment has clients ranging from new admissions to those ready to complete their program, senior peers are very influential in helping clients who are in the early stages of treatment to understand denial and

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