SUMMARY - 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.

INTRODUCTION

According to most international literature and clinical experience, overcoming dependence by rehabilitation is the most important goal in the treatment of alcoholism.
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 life"^1-5.
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 program^6-12.
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 group therapies.
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 alcoholism"¹⁴.
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 symptomatic therapy.
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:

• restoring physical health
• reducing craving
• becoming aware of being an alcoholic
• clearing motivation to treatment
• learning to express opinions and feelings and to bear comparison and disagreement
• learning to be honest with oneself and others
• gaining motivational skills to change one's lifestyle
• restoring self-identity
• achieving the assertive motivation to sobriety
• re-establishing intra-familial and inter-personal relations
• restore family roles
• learning to accept and to help each other.

To 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).

WHY THE THEMATIC DISCUSSION GROUPS?

The 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:

• a) awareness by the whole family of the alcoholism problem and what it means to be an alcoholic
• b) researching and explicating the self-motivations to sobriety, different for each patient
• c) 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
• d) reactivating the relational and constructive dialogue in the family and consequently restoring family roles
• e) lastly, excluding from the family milieu discussion about alcohol and getting drunk and coming back to speak to each other about family life problem

However 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 alcoholic^15-20. 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 therapy²¹ and the principles of Marlatt's rehabilitation cognitive behavioural therapy^22,23. The practical models were inspired by the experiences of the Alcohol and Drug Abuse Treatment Center Of the University of Connecticut (USA)²⁴ 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 (Fig. 1).

Figure 1. Pattern of points and modalities of thematic intervention.

PROBLEM SOLVING GROUP

This 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 past.
The technical method we use is the "cooperative problem-solving"²⁶ a program divided into 6 phases:

1. problem 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;
2. problem definition: dividing the problem into all its separate parts and working out how the same problem can be evaluated by others, not directly involve;
3. problem analysis: identifying the problem causes and evaluating which situation elements support a positive change and which interfere with it;
4. production 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;
5. solution evaluating: all the members are invited to evaluate the solutions considering cost/effectiveness ratio for the subject;
6. choice 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.

Beginning 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.

COGNITIVE EMOTIONAL EXPERIENCE GROUP

Reconsidering 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 self-esteem.
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.

PLANNING WEEK-END GROUP

The 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.

MEDICAL EDUCATION GROUP

The 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:

• hepatic and gastroenteric complications;
• cardiovascular complications;
• neuro-psychiatric complications and sleeping disorders;
• sexual disorders and pregnancy complications;
• heredity, genetics and pathogenesis of alcoholism;
• alcohol and driving, alcohol and therapeutic drugs;
• alcohol and nutrition: the deficiency-induced troubles;
• prejudices and myths on alcohol effects.

The 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.