discussion groups as a multimodal remedial
instrument in an alcohol addiction treatment program
- Gruppo Informativo Motivazionale per i Familiari di alcolisti e farmaco-dipendenti
(Informative-Motivational Group for Relatives of alcoholics and drug addicts)
Nursing Home "Le Betulle" in Appiano Gentile (CO), Italy.
Past-Head of Alcohol Addiction Service,
San Raffaele Hospital, Milan, Italy.
- The aim of this paper is to show the motivations, characteristics,
scope and goals of a new group psychotherapy, Thematic Discussion
Group, for the rehabilitation of alcoholics used for a year at our
Alcohol Addiction Service. Planned and implemented by us, such groups
focus on the following points: alcohol-related cognitive emotional
experiences, problem solving on a daily basis, weekend planning
and alcohol-related medical education. They are discussion meetings
on prefixed topics, run by cognitive-behavioural techniques and
led, in account with the topic, by the most appropriate member of
the multidisciplinary team. They are intended to constitute short-term
psychotherapy and they are very useful in the early intensive treatment
period at the beginning of the de-addiction therapy. Our experience
with the Thematic Discussion Groups shows that this psychotherapeutic
strategy can accelerate and develop a change in cognitive style
and the emotive response to stressful events.
to most international literature and clinical experience, overcoming
dependence by rehabilitation is the most important goal in the treatment
The main focus of such remedial action is group therapy, with or
without family presence and participation, carried out both as self-help
group and as a psychotherapeutic group which can be run by different
techniques: psychodynamic, behavioural-cognitive or systematic methods.
The common goal of all groups is an action aimed to motivate abstinence
to the point of "sobriety", to rebuild self identity,
restore the family roles and finally to change the "way of
The bio-psycho-social approach to alcoholism is generally believed
today to be the most suitable for tackling a phenomenon whose complexity
lies in its multifactorial pathogenesis and its various clinical
manifestations (psycho-behavioural disorders and internal, neurologic
or psychiatric alcohol-related diseases). To be fruitful, this approach
needs a multimodal medical integrated treatment program6-12.
By "multimodal medical integrated intervention" we mean
taking care of the addicted subject in all the causes and consequences
of him being an alcoholic, i.e. medical, psychological and background
aspects. It is very important for the team in charge to have some
specific and effective psychotherapeutic strategies available, particularly
Our Alcohol Addiction Service is part of the Neuro-Psychic Science
Department of S. Raffaele General Hospital for Scientific Research
and thus it sets itself a dual clinic task: treatment and research.
Our multidisciplinary team consists of two psychiatrists, the chief
and an assistant, one psychologist, one social worker and some nurses.
There is a close daily interaction with other medical specialists.
The main program of our Service is the intensive treatment of the
early critical phase of de-addiction from alcohol dependence. At
the same time, we deal with detoxication and minor alcohol-related
diseases. This treatment lasts 4-5 weeks and continues with the
out-patient clinical follow-up and with long-term group therapy.
Early intensive treatment is fundamental, in our opinion, to lay
the foundations of the subsequent maintenance treatment. We only
admit patients with a diagnosis of "abuse" or "alcoholic
dependence" in accord with the indications of the Diagnostic
and statistical manual of mental disorders13
and, prevalently, also in accord with clinical criteria of "primary
Diagnostic screening is made at the first encounter on taking charge
of the subject and his/her family in our out-patients' service,
where they voluntarily presented looking for specific therapy for
an alcohologic problem.
The central level of our intervention is a part-time daily treatment
unit (27 hours a week on 5 days). This modality was chosen in order
not to sever links between the subject and his social and family
background. Besides, in this way, we can interact with behaviour,
emotions and life experiences stressed by the usual way of life
in the outside milieu. Moreover, if the alcoholic is to give a daily
account and discuss his behaviour during the out-of hospital half-day,
he is more inclined to choose sobriety. In our opinion, the cognitive
and behavioural changes obtained in that way are much more easily
and firmly transferred to the after-cure.
The model of intervention we selected is the multimodal medical
integrated approach made as personalized as possible. It is implemented
initially by concomitant group therapy and pharmacotherapy against
craving and then by pharmacotherapy of withdrawal syndrome and medical
Psychological and physical assessment is made during the same period.
The task of our intensive treatment is twofold. Firstly it is necessary
to produce an effective change in the subject during the early very
important stage of the de-addiction run, equipping him/her for a
global physical and psychologic detachment from dependence. Secondly,
the need for psychoactive drugs must be reduced to a minimum.
The aims of our therapeutic program are those of other similar alcohologic
centers. They can be summarized in the following targets:
aware of being an alcoholic
motivation to treatment
to express opinions and feelings and to bear comparison and disagreement
to be honest with oneself and others
motivational skills to change one's lifestyle
the assertive motivation to sobriety
intra-familial and inter-personal relations
to accept and to help each other.
make the psychotherapeutic strategy of our program of de-addiction
and rehabilitation from primary alcoholism more affective, we set
out to find a group instrument which would increase and fulfil the
therapeutic action of the motivational group and work particularly
on critical points of the emotional and relational life experience
of the alcoholic, allowing for different modes of intervention.
The technique devised was the "Thematic Discussion Groups"
tested positively for one year (cfr: Vittadini M., Alietti M.:
I gruppi di incontro tematici come strumento riabilitativo multimodale
della dipendenza alcolica. Relazione presentata al XI Congresso
Nazionale della S.I.A., Bari, 1993).
THE THEMATIC DISCUSSION GROUPS?
traditional core of our psychotherapeutic intervention is the multifamilial
motivational group, also open to after-cure patients. This group,
run with a cognitive-behavioural approach by the psychiatrist, focuses
on the following points:
awareness by the whole family of the alcoholism problem and
what it means to be an alcoholic
researching and explicating the self-motivations to sobriety,
different for each patient
offering an assertive boost both from the comparison with the
experience of the other members who are at different levels
of rehabilitation and from the solidarity of the group
reactivating the relational and constructive dialogue in the
family and consequently restoring family roles
lastly, excluding from the family milieu discussion about alcohol
and getting drunk and coming back to speak to each other about
family life problem
our clinical experience with this group led us to regard such intervention
as wasteful on account of the many aims and points of therapeutic
action too weak to modify the cognitive and behavioural aspects
of the alcohol addiction in a limited time like our intensive program.
So we aimed to develop a therapeutic group instrument able to seize
the various levels of the existential experience of the alcoholic.
We began from a review of the international literature on the most
remarkable and frequent personality traits in alcoholic15-20.
We particularly took into consideration the egotistical trait characterized
by low endurance to stressful life situations and great difficulty
in postponing gratification. Moreover we considered the emotive-instinctive
impulsiveness and the rarely expressed insight into inadequacy.
This insight is motivated by the clash between the great ideal self-image
and the "dissatisfaction" with one's personal realization.
Consequently there is either a desire to escape from reality or
the self attribution of negative and devalued traits, both moods
making people drown themselves in alcohol.
We also took into account the clinical note that the alcoholic's
life is poor in interpersonal relations and planning capacity, only
focussed on the need and search for the drug and that he/she has
difficulty in asserting ideas without argument.
On the ground of these findings we designed and implemented the
Thematic Discussion Groups focussed on the following points: alcohol
related cognitive emotional experiences, problem solving of daily
events, week-end planning and alcohol-related medical education.
The theoretical aspects were based on the principles of Beck's cognitive
and the principles of Marlatt's rehabilitation cognitive behavioural
The practical models were inspired by the experiences of the Alcohol
and Drug Abuse Treatment Center Of the University of Connecticut
and the Countess of Chester Regional Alcohol Dependence Unit (GB)25.
The groups are discussion meetings on a prefixed constant theme
and they are led, depending on the topic, by the most appropriate
member of the multidisciplinary team, i.e.: psychiatrist, psychologist
or social worker. They are intended as short-term psychotherapy
aimed at identifying and controlling emotions modifying the typical
cognitive-behavioural stereotypes of the alcoholic and developing
the skills to face stress and disagreements. Besides they aim to
combat the prejudices and the myths about alcohol and ignorance
of the various harmful consequences of abuse.
The groups consisting of 8-10 participants , meet for one hour and
each meeting is held once a week. The team operator sets the theme
and leads the discussion but the patients develop the lively part
of the debate themselves. Groups attendance begins on the first
days of treatment and lasts as long as the intensive treatment period
of five-six weeks, i.e. recently abstinent subjects are involved
Figure 1. Pattern of points and modalities
of thematic intervention.
day life events
meeting aims to strengthen the patient's ability to recognize problematic
life situations that can induce an uncontrolled consumption of alcohol,
evaluating the real importance of the problem. It also provides
the patient with the ability to develop alternative and more adequate
solutions to the problem.
The psychologist leads the group. One patient for each sitting is
invited to recount a "standard day" of his life with particular
attention to the problematic aspects linked with alcohol abuse in
The technical method we use is the "cooperative problem-solving"26
a program divided into 6 phases:
identification: evaluating whether the trouble the patient
feels is really a problem and, at the same time, verifying whether
the group agrees to work on it;
dividing the problem into all its separate parts and working
out how the same problem can be evaluated by others, not directly
analysis: identifying the problem causes and evaluating
which situation elements support a positive change and which
interfere with it;
of all possible solutions to the problem: each patient of
the group is invited to think about the possible solutions and
to propose them during the discussion;
evaluating: all the members are invited to evaluate the
solutions considering cost/effectiveness ratio for the subject;
of the best solution: the group has to choose the solution
that seems to be the best one. As the program is a cooperative
one, the decision should reflect the universal consent.
the meeting, the conductor reminds participants of the aims and
the rules of cooperative problem solving and the need for both the
active participation of all those present and of making no judgements
on solutions until the fifth or sixth phase. During all six phase,
the psychologist helps the group to analyze the problem thoroughly
and to find adequate solutions. At the end of the process, he/she
points to the best solution chosen by the group27.
The final aim is the development of more specific and suitable coping
abilities that help patients to react better to stressful events
and achieve a more functional life.
EMOTIONAL EXPERIENCE GROUP
and discussing one's own and other's life events concerning existential
situations linked with alcohol behaviour, experienced by each patient,
the psychologist running the group tries to evince the importance
of such cognitive emotional aspects as triggers of craving and of
drinking. So we stimulate everyone's capacity to spring out of and
recognize their sensitive moods and the related at risk situations.
This helps the patient to become aware of his/her feelings, favouring
in every subject the consciousness of one's/others' responsibility
and the development of self-observation, self-control and consequently
According to our strategy, we chose to focus patients' attention
on relapse experiences, because it is one of the most hazardous
and crucial steps on the pathway from alcohol dependence to sobriety.
At every sitting a patient recounts his/her experience of a relapse
then the other present have to say how they feel when they relapse.
So, with regard to the cognitive aspects of relapse22,
each patient is invited to analyze his/her personal ideas of relapse
- both from the physical and psychological point of view - in order
to correct the cognitive dysfunctions supporting alcoholics' behaviour,
the determinant triggers (negative moods, social pressure and so
on) and the self-attribution phenomenon27.
The latter interferes greatly with maintained abstinence because
it leads the subject to attribute the causes of relapse to his own
weakness and to his personal unchangeable inadequacy.
During the meeting the group members are led to think about the
most critical components of the relapse and about their related
emotional feelings. So the subject is led both to recognize these
wrong evaluations about self and the world which led him to drink
abuse and to change them with other more adaptive assessments. At
the same time, those present are induced to pay attention to the
emotional aspects of relapse in order to develop the ability to
recognize, distinguish and express the emotions and sensations,
which are too often not considered by the alcoholics. The patients
are invited to point out some situations which they, before or after
an episode of abuse, felt emotions in. Emotions like anger, sadness,
fear and so on. Then people discuss the adequacy of the emotion,
of everyone's capacity or incapacity to express moods and the related
significance of resorting to alcohol. So subjects learn to discriminate
the different emotions and their significance and to express them
in a controlled way, without drinking.
The target the alcoholic has to achieve, is to become both the master
of his emotional life, face stressful events and build a better,
conceptual view of living and self.
aim of this meeting is to offer the patient the opportunity to learn
and apply the modalities of behaviour chancing. It aims to modify
the behavioural pattern of alcohol dependence acting on its cognitive-planning
component. As the alcoholic gets accustomed to putting his/her life
in order planning relaxation, hobbies and interpersonal relations,
he/she must think of an unalcoholic weekend without changing habits.
The meetings are held on Fridays and Mondays; the social worker
and the psychologist lead the discussion.
On Friday, each patient is invited to think about and to plan the
weekend he/she will spend at home. Then all the members have to
discuss with the others the practical implications of their plans
and pay attention to some habitual situations at risk for drinking
or particularly stressful. The team operators, if necessary, suggest
effective alternatives. So that everyone can learn to think and
live their lives without alcohol.
On the following Monday the planning realization is examined and
if any project has not been successful, everyone has to look for
the causes of failure or to think about the true motivation because
he has to change the program.
Attention is focussed on the need to plan specifically to avoid
the dangerous empty moments during the week-end, so that patients
become able to spend their free time in a more constructive way
and, what is more important, they become the "markers"
of their time.
The alcoholic must lead a normal life, he must not suddenly change
the habits he had before de-addiction, besides the alcoholic habits.
In this way everyone can learn personally that the required change,
for the program to be effective, must not be only the change of
the background (family, friends, work, etc.) but the modification
of his reaction/adaptation to such background.
aim of our educational meeting is to inform patients about alcohol-induced
pathologies and their being caused by drinking too much. Further,
it intends to train them in a correct mixed diet, to debunk the
cultural prejudices about alcohol and to teach them the multifactorial
genesis of alcohol toxicomanic behaviour up to addiction.
It consists in a lesson and discussion. The psychiatrist is the
speaker, with the aid of a nurse.
The theory is reduced to the bare minimum, many practical examples
and pictures are used. Once the matter has been explained, the way
is open for patients' questions; thus a lively dialogue arises,
above all, from the personal experience of the presents.
The topics we explain are the following:
and gastroenteric complications;
complications and sleeping disorders;
disorders and pregnancy complications;
genetics and pathogenesis of alcoholism;
and driving, alcohol and therapeutic drugs;
and nutrition: the deficiency-induced troubles;
and myths on alcohol effects.
goals are both to make our patients aware of taking care of themselves,
their bodies, their psycho-physical health and destroy their belief
in alcohol as not being a dangerous and toxic drug.
To be really fruitful this meeting must be managed not only as an
informative encounter but also as a therapeutic one.
one year's experience with the Thematic Discussion Groups has shown
that this psychotherapeutic strategy accelerates the change in cognitive
behaviour and the emotional response to stressful events. Clinical
follow-up interviews and active patient participation in the after-cure
groups proved that our alcoholics have gained a greater awareness
both of their own inner evolution and of the reason why they will
remain sober. Also, we found that they were better able to manage
the controlling strategies of the emotional and cognitive triggering
events. Moreover, they were better able to take care of themselves
and their bodies, and, at the same time, become masters of their own
This clinical finding leaves open the problem of gauging the size
and the quality of the change and its long-term effectiveness. It
has yet to be established what changes occur, to what extent and,
if possible, which therapeutic strategies or instruments are really
effective in this change.
This research must be carried out at two levels either examining the
subjects' response by rating scales and questionnaires or looking
for which factors in the therapeutic strategy the patient feels effective
We propose, in the near future, to rate by ad hoc instruments (SCS;
drinking related internal-external locus of control scale of Keyson;
problem solving inventory and others) the modifications gained and
perceived by the patients during the period of our intensive treatment
In conclusion, a specific psychotherapeutic strategy like the Thematic
Discussion Groups during the early period of the intensive de-addiction
treatment improves the likelihood of alcoholics making a successful
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