Alcoholics in Interactional An Outcome Irvin D.
Study
Yalom, MD; Sidney Bloch, MB, PhD; Gary Bond, PhD; Erik Zimmerman, MD; Brandon Qualls, MD
therapy groups of alcoholic patients 20) were formed, and treatment outcome after eight months and again after 12 months of therapy was compared with the outcome of 17 neurotic patients in comparable therapy. Outcome assessment was obtained from three sources: patient, therapist, and independent judge, using both nomothetic and ideographic measures. The results indicated that although more alcoholic than neurotic patients terminated therapy within the first six sessions, a higher percentage of alcoholic patients remained in therapy for 12 months. At the end of 12 months, both samples had improved along a wide variety of variables, and there were no significant differences between the alcoholic and neurotic population in degree of improvement. (Arch Gen Psychiatry 35:419-425, 1978) \s=b\ Three interactional
(N
Group Therapy
=
long-term the chronic alcoholic patient? Not Howforeffective would is
interactional group therapy very, most psychotherapists agree. For many years, clinicians have assumed that the chronic alcoholic patient is not a suitable candidate for uncovering long-term psychothera¬ py in general and group therapy in particular. Many group therapists have found that the alcoholic patient not only fails to obtain personal benefit but so clogs the working of the group that the other members suffer as well. The alcoholic patient's attendance is poor, he disrupts the group by arriving at meetings intoxicated, his presumptive underlying orality results in a consumption of a dispropor¬ tionately high percentage of the group time and energy, he cannot tolerate the frustration inherent in the formative stages of group therapy, he cannot bind anxiety and thus
publication March 3, 1977. Department of Psychiatry, Stanford (Calif) University Medical Center (Dr Yalom); the Department of Psychiatry, Warneford Hospital, University of Oxford (England) (Dr Bloch); the Department of Behavioral Sciences, University of Chicago (Dr Bond); the Department of Psychiatry, Yale University, New Haven, Conn (Dr Zimmerman); and the Butler Hospital, Providence, RI (Dr Qualls). Reprint requests to Department of Psychiatry, Stanford University Medical Center, Stanford, CA 94305 (Dr Yalom). Accepted
From the
for
tends to act out, generally through drinking. Thus, most psychotherapists, whether or not they are familiar with the Alcoholics Anonymous (AA) approach, are glad to leave the treatment of the alcoholic patient to AA, even though they realize that there is little systematic knowledge about either the efficacy of AA or the types of patients most and least likely to be helped by AA. Despite these widespread assumptions, a review of the
literature reveals that there have been few clinical reports of long-term interactional group therapy with the alcoholic patient, and no systematic outcome evaluation of this approach. We attempted, first, to develop methods that would enable the alcoholic patient to work effectively in long-term, interactionally based group therapy, and then, using a variety of assessment techniques, to evaluate the effects of this therapy. We have described our clinical approach fully in other publications.'"' To summarize briefly, we began our group therapy work with a number of a priori assumptions and procedural guidelines but also with a psychological set that as the situation demanded, we would modify our approach. One main assumption was that the group would be inter¬ actionally based, ie, the primary task of the group members would be to explore in depth their interpersonal style of relating to the leaders and to the other members. We hoped to build an effective, cohesive group, sufficiently supportive and trusting so that, as time passed, the members would be willing to engage in considerable selfdisclosure and affective expression. The basic clinical approach is fully described in the group therapy text written by the senior author.' Our first step was to form an experimental group, using no selection criteria, in which we would try out various technical modifications we hoped might facilitate therapy. After we had obtained sufficient experience and expertise, we planned to form two other groups to test these techniques further and to evaluate outcome. The first six months of the experimental group was an
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of New South Wales User on 04/16/2016
unstable period, with five patients dropping out after only a brief stay. Gradually, with the use of anxiety-reducing techniques such as a written summary of each meeting mailed to the patients before the subsequent meeting,' improved selection, and interruption of disruptive subgrouping, the group soon passed into a more stable phase. At this point, using what we had learned from this first group, we formed two other groups of alcoholics and
proceeded
to evaluate outcome.
METHOD Our basic research plan was to compare the outcome of alcoholic and neurotic patients both engaged in interactional group ther¬ apy. We collected our sample over a six-month period and included every patient who entered either an alcoholic group or a general therapy group in Stanford (Calif) University's Department of Psychiatry outpatient clinic. Typical group therapy screening procedures were used': excluded were patients who were psychotic, psychopathic, poorly motivated, in severe external crisis, or uncon¬ trollable drinkers. Our sample consisted of 20 chronic alcoholic and 17 neurotic patients. The 20 alcoholic patients entered one of three alcoholic groups (the original experimental group adding new members, and two newly formed groups); the 17 neurotic patients entered one of three neurotic groups (also one established and two newly formed
groups). All six groups were led by cotherapy teams. One therapist—a psychologist and recovered alcoholic-was a cotherapist in all three alcoholic groups. Her three cotherapists were a senior faculty member, a junior faculty member, and a first-year psychiatric resident. The three neurotic groups were led by two faculty members and four advanced psychiatric residents. The groups met weekly for an hour and a half. They were open groups in that new patients could be introduced as members terminated. (The length of the alcoholic groups was predetermined by the research grant, and no new patients were added during the last six months of their functioning.) All therapists, aside from the two led by senior faculty, were supervised by experienced supervi¬ sors who met with the cotherapist teams weekly. The alcoholic groups were supported by a research grant and the patients were charged no fee; the neurotic patients were charged on a sliding scale (according to income) ranging from $2 to $15 per session.
Characteristics of the Clinical Sample A study of the demographic characteristics of the alcoholic and neurotic samples shows some differences. There were 13 men and seven women in the alcoholic sample, while the neurotic sample had seven men and ten women. The alcoholics were older, with a mean age of 41 (range, 29 to 55 years) compared to a mean age of 28 (range, 21 to 44 years) for the neurotic sample. Fifteen of the 20 alcoholic patients were married, as contrasted to three of the 17 neurotic patients. Most patients in both samples came from a middle socioeconomic class. All the neurotic patients and 18 of the 20 alcoholic patients had had some college education. Five of the neurotics were graduate students, whereas only one alcoholic was a full-time student. Most of the patients in both groups had had considerable exposure to previous therapy: only two of the neurotic and seven of the alcoholic patients had had no previous psychotherapy experience. (However, three of these seven alco¬ holic patients had previously attended AA meetings.) Approxi¬ mately equal numbers of the two samples had received over six months of
prior psychotherapy.
12 months of the study, six neurotic patients and three of the alcoholic patients were concurrently receiving indi¬ vidual therapy. Furthermore, nine alcoholic patients attended some AA meetings.
During the
Assessment of Outcome Each patient's outcome was assessed over the 12-month obser¬ vation period, using an individualized approach and several stan¬ dard outcome measures. There were three sources of outcome measurement: patients, therapists, and independent judges. The Patient as Source.-Each patient was interviewed by the same researcher three times: before the onset of therapy, at eight months, and at 12 months after beginning therapy. The patient constructed a list of the chief problems for which he had entered therapy and rated each one on a nine-point "distress" scale. The patient formulated an associated goal for each problem. ("If therapy were to be successful for you, in which way would you like to see this problem changed?") At each subsequent interview, he rated each of his problems on the "distress" scale, and also on a nine-point scale that reflected the extent to which he thought he had achieved his goal with respect to that problem. At 12 months, he completed three global scales reflecting the degree of change he believed he had accomplished, the extent to which his complaints had changed over the year, and his overall satisfaction with the results of therapy. Before therapy and at eight and 12 months, the patient completed a Hopkins symptom checklist, modified to increase its relevance to our clinical population (unpublished material). The Therapist as Source.—At the onset of therapy, the therapists listed the patients' major problems (both symptomatic and characterological) and formulated a therapeutic goal for each problem. Eight and 12 months later, the therapists rated each problem on the degree to which they thought the patient had achieved the associated goal. They also rated the patient on a nine-point global measure of change at the end of the 12 months (1, "worst possible outcome"; 5, "unchanged"; 7, "moderately improved"; 9, "best
possible outcome").
Independent Judge
as
Source.—The interviews mentioned above,
therapy and after eight and 12 months of therapy, were videotaped. Each was a 50 to 60-minute interview in which the interviewer explored each of the patient's main problems in as much depth as possible. The independent judge method has been described in detail in another publication1 and shall be only briefly described here. Teams of experienced psychotherapists from the Stanford Univer¬ sity Department of Psychiatry clinical faculty (psychiatrists, psychologists, and social workers, most with more than ten years of clinical practice) viewed these tapes. Each team consisted of three judges who viewed all three tapes (two tapes for those patients who dropped out of therapy between eight and 12 months) in a single four-hour sitting. After the pretherapy tape, each of the three judges constructed a list of the major problems of the patients as he saw them. The three resultant problem lists were written on a blackboard and, through a process of consensus, shaped into one problem list. The team then developed a goal for each problem. The tape of the eight-month interview was then viewed and, using the goal as a standard, each judge indepen¬ dently rated the degree of change for each of the consensus problems on nine-point scale ranging from 1 ("worst possible outcome") through 5 ("unchanged") to 9 ("best possible outcome"). The judges also rated the overall outcome of the patient on a 17point global improvement scale (1, "worst possible outcome"; 9, "unchanged"; 13, "moderately improved"; 17, "best possible outcome"). before
RESULTS Nature and
Severity
of
Psychopathology
Several types of data were collected that permit us to compare the nature and severity of the psychopathology of the alcoholic and the neurotic samples, (t tests were used
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of New South Wales User on 04/16/2016
drinking but had brief periods of abstinence, one was mainly abstinent but had brief periods of drinking, and five were abstinent (three for only a few weeks and two for over a year). The major problems listed before therapy by the 29 patients who continued in therapy at least eight months were sorted into 12 categories. Table 1 indicates that, except for alcohol and marital problems (many more alcoholics than neurotic patients were married), there were no significant differences in the type of problems. Each patient rated each problem for degree of distress (on a nine-point scale with 9 indicating maximal distress): there were no significant differences for distress on any of the categories between the alcoholic and neurotic sample. The mean distress for all categories was 6.36 for the alcoholic patients and 6.65 for the neurotic patients, a difference not reaching statistical significance. Therapists and Independent Judges.—The problem lists constructed by the independent judges (after watching the videotape of the pretherapy interviews) and by the thera¬ pists before therapy were also categorized (Table 2). The only consistent difference between alcoholics and neurotics that both therapists and judges cited (aside from the expected differences in "alcoholism" and "marital prob¬ lems") was in the category of "dependency," a character trait much more likely to be noted in the alcoholic sample. The therapists' pretherapy severity ratings (nine-point scale) for all problems showed no significant differences in the mean ratings between alcoholics (6.20) and neurotics (6.26). The initial mean severity ratings of the independent judges (nine-point scale) also showed no significant differ¬
severity levels.) Dropouts (patients who termi¬ nated therapy before the 8-month follow-up) are excluded from this statistical comparison, leaving a sample of 14 neurotic and 14 alcoholic patients. Hopkins Symptom Checklist.—All patients completed a modified Hopkins checklist (unpublished material) con¬ taining the following subscales: somatization, depression, anxiety, cognitive functioning, affect isolation, affect expression, self-esteem, hostility, alcohol and drug depen¬ dency, and an additional target symptom scale (the five items chosen from the questionnaire by the patient as most significant in his case). There were no significant differ¬ ences between the alcoholic and neurotic patients in initial levels on any of these scales (except, of course, on the to compare
alcohol
scale).
by defi¬ self-labeled alcoholics. When started nition, they therapy, ten were drinking continuously and heavily, four were Patients' Problems Lists.—All 20 alcoholics were,
Table 1.—Patients' Own Problem Lists: Comparison Between Alcoholics and Neurotics in the Nature of Presenting Problems No. of Patients
Listing Problems _A_
Alcoholics
Category
of Problems
(N
=
14)
Neurotics
(N
=
14)
Lack of
autonomy Conflicts in intimacy
10
12
Isolation from affect
Marital conflicts Conflicts with parents Existential (lack of
meaning
and
purpose)
between alcoholics (5.51) and neurotics (5.45). In summary, the two samples, apart from alcoholic addiction, were similar in the nature and severity of their psychopathology with only these differences: the alcoholics were older, more likely to be married, and more often ence
Self-esteem
Alcohol, drugs Somatic
Anxiety Depression Work/school
functioning
Table
pathologically dependent.
2.—Comparison of Problem Areas
Formulated by Independent for Neurotic and Alcoholic Patients
Judges
and
No. of Times Mentioned
as a
Therapists Problem
Therapists
Independent Raters Alcoholics
(N
=
13)
Neurotics
(N
=
12)
13
Depression Passive-aggressive Anxiety
10
10
Loneliness, social isolation, few friends Marital problems Sexual problems
10
10
Anger (abrasive, hostile) Passive, unassertive, submissive Affect (awareness Lack of intimacy
or
(N
=
10 12
Dependency Alcoholism Self-esteem
Alcoholics
expressivity)
Lack of trust
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of New South Wales User on 04/16/2016
13)
Neurotics
(N
=
12)
Clinical Course All six psychotherapy groups involved in this study were hard-working, cohesive groups. Although the alcoholic groups occasionally focused on the current drinking of one of the members, this was only a minor theme. Over the course of the year, patients in the alcoholic groups arrived intoxicated at meetings on only nine occasions. From their very first meeting, the alcoholic groups were oriented away from the explicit discussion of alcohol. The therapists emphasized that they did not think that the group's task was to help members achieve or maintain sobriety-they would need ancillary aid, either AA or medical (disulfirum
[Antabusej), for this. Nor was the group a substitute for AA. Instead, the group's primary task was to help each member understand and work through underlying person¬ ality conflicts that contributed to the alcohol dependency. Within a short period, all three alcoholic groups were working at a level of interpersonal and intrapersonal exploration, which made them virtually indistinguishable from the three neurotic groups. An instrument that offers corroboration for the similar
functioning of the alcoholic and neurotic groups is the Curative Factor Questionnaire,'1 which was administered after eight and 12 months of therapy. This questionnaire contains 19 items that are effective mechanisms of change in group therapy: each patient is asked to indicate on a five-point scale that importance of each item to him in his therapy. The items include such factors as feedback, catharsis, self-disclosure, acceptance by others, altruism, direct advice, different types of insight, universality, and existential factors. Different types of therapy groups accent different factors, and even within one group different patients may select various change pathways through the therapeutic process. If, therefore, the neurotic and the alcoholic groups functioned differently, or if the patients used therapy in different ways (eg, supportive, relationship therapy compared to self-exploration), these differences would be reflected in the
answers
to the
questionnaire.
Examination of the data at eight months (12 alcoholics and 12 neurotics completed the instrument) and at 12 months (13 alcoholics and eight neurotics) indicated no significant differences (using t tests) on any of the 19 items. We then examined the responses of only those patients who were rated as highly improved by the inde¬ pendent judges. There was again, no difference between the highly improved alcoholic and the highly improved neurotic patient. These findings corroborate the clinical impressions of observers who had the opportunity to watch both the alcoholic and neurotic groups: a similar type of therapy was offered to both samples. Duration of
Therapy
Our objective outcome measures were gathered at two points in this study: eight and 12 months after the onset of therapy. Four alcoholics and two neurotics dropped out in the first three months of therapy; two alcoholic patients and no neurotic patients dropped out between the third and eighth month. Thus, we have complete eight-month
data on 14 (70%) of the alcoholic patients and 14 (88%) of the neurotic patients (one neurotic patient is excluded because of missing data). Between eight and 12 months, six neurotics and one alcoholic terminated therapy; therefore, we have 12-month data on 13 (65%) of the alcoholic patients and eight (47%) of the neurotic patients. Early Dropouts.—Data on patients who dropped out early in therapy is less systematic and trustworthy. The assumption generally made by group therapists about patients who drop out after a very short period of interac¬ tional group therapy is that they rarely obtain much therapeutic benefit.7 Our clinical data substantiate that view. First, consider the six patients who dropped out of therapy within the first 12 sessions. Of the four who were alcoholics, three were clearly errors of selection: all entered therapy drinking heavily and, on a few occasions, arrived at meetings intoxicated. One attended only a single meet¬ ing, another was hospitalized for alcoholism after three meetings, another-an explosive, manipulative, poorly motivated patient—attended six meetings, seemed threat¬ ened by the group task, and terminated without benefit. The fourth alcoholic attended ten meetings, but according to the therapists was a nonworking, guarded member of the group. Her impulsive decision to live with a new alcoholic boyfriend was challenged by the group, and she abruptly terminated therapy without apparent benefit. Two neurotic patients terminated after six meetings. One was an aggressive, manipulative "early provocateur"7 in the group who was deeply involved with a heroin-addict boyfriend. She refused to examine this relationship in therapy and left after inciting much group anger toward her. The other, an isolated individual, was threatened by the intense level of interaction and left without ever becoming involved in the group. Neither patient benefited from their six sessions. Later Dropouts.—Once a patient survives the early group meetings, he generally commits himself to the group for at least several months.7 This held true for our sample: only two alcoholics and no neurotic patients terminated therapy between three and eight months. Both of these dropouts made some progress in therapy but, according to their therapists, left the group because they were threatened by the implications of change. One patient had had a 20-year, stormy homosexual relationship with an alcoholic partner (who resisted personal involvement in therapy); she reached a point at which she thought that further personal growth would necessitate termination of the relationship. The other patient, who was virtually silent for six months, had finally begun to work in the group but, threatened at her emerging strong feelings of anger and warmth, precip¬ itously terminated treatment. Patients
Terminating
Between
Eight
and 12 Months.—
Although roughly proportion of alcoholic and neurotics completed eight months of therapy, there was a sharp falloff of the latter between eight and 12 months. Of the eight patients who terminated therapy during that period, seven were neurotics and only one an alcoholic. Thus, at the 12th month there were more alcoholic patients (65% of the original sample) than neurotic patients (47%) receiving therapy. the
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of New South Wales User on 04/16/2016
same
eight patients terminate therapy? The 29-year-old woman, was clearly a failure in therapy. Her therapists and the independent judges all agreed that she not only failed to improve but deteriorated during therapy. She was faced with considerable environ¬ mental stress: a dying mother and a disintegrating marriage. She attempted to control the group by engen¬ dering guilt via such self-destructive behavior as drinking and sexual promiscuity. When the group wrenched itself free from its guilt and confronted her, she withdrew and finally so dreaded the meetings that she terminated ther¬
Why
did these
alcoholic,
apy.
Of the seven neurotic patients who terminated therapy between eight and 12 months, three left the group because of circumstances beyond their control (two moved to another city because of job shifts, and one was in a group that terminated when she had been in therapy for 11 months). (The residents completed their training.) These three patients had made satisfactory progress, and thera¬ pists and independent judges rated them as slightly to moderately improved. The other four terminated the group with varying degrees of dissatisfaction. One patient, a 20year-old sociopathic drug addict, was heavily involved in illicit drug sales: she was a peripheral group member, highly secretive and irregular in attendance. The group therapists asked her to leave because she was not only making no personal progress but was retarding the rest of the group. The therapists thought that she did not improve—in fact, that she may have deteriorated (she required hospitalization two months after termination). She, however, rated herself as mildly improved. Another patient never resolved strong negative transference prob¬ lems and dropped out of the group. The independent judges rated him as unchanged, while the rating of both patient and therapist indicated that he had made slight to moderate improvement. The other two patients made definite but limited gains in therapy; neither used the group fully, and, though improved, did not "graduate."
Ratings
of
Change
After
Eight
Months of
Therapy
Ratings from patients, therapists, and independent judges are available for the 14 alcoholic patients and 14 of the 15 neurotic patients who completed eight months of therapy. Tables 3 through 6 present data on outcome from the three sources: patient (mean achievement of patientdetermined goals for their self-selected problems and reduction of distress in these problem areas), independent judges (mean achievement on all problems), and therapist (mean achievement on all problems). Differences between the samples were tested by t tests on achievement and global ratings from the three sources. In addition, reduction in distress for each sample was assessed by testing pretherapy-posttherapy differences (using t tests) on the target problems and the Hopkins symptom checklist. Two findings are evident: (1) the entire sample under¬ went considerable improvement as a result of eight months of group therapy; (2) there were no significant differences in improvement between the alcoholic and the neurotic
samples.
Table 3.—Mean Achievement of Goals at
a
Alcoholics
(N Source of Patient"
Rating
=
(N
=
Mean 4.63
1.65
Mean 4.84
5.77 6.44
0.77 1.00
5.78 6.38
Therapistt Independent judges!
Months
Neurotics
14) SD
Eight 14) SD 1.07 0.72
0.40 0.03
(NS) (NS)
0.80
0.17
(NS)
•Patients used a nine-point scale for rating achievement of goals they set before therapy for their self-selected problems: 1, not at all; 3, a little; 5, pretty much; 7, very much; 9, totally. tBoth therapists and independent judges used a nine-point scale: 1,
worst possible outcome; worse; 5, unchanged; 6, possible outcome.
2, markedly worse; 3, moderately worse; 4, slightly slightly improved; 7, moderately improved; 9, best
Eight
Table 4.—Reduction in Distress of Problems at Months* 0 mo 6.36 6.64
Patient as Source Alcoholics (N 14) Neurotics (N 14) =
=
8 mo Reduction 4.48 1.88 4.87 1.77
4.26
Study
Yalom, MD; Sidney Bloch, MB, PhD; Gary Bond, PhD; Erik Zimmerman, MD; Brandon Qualls, MD
therapy groups of alcoholic patients 20) were formed, and treatment outcome after eight months and again after 12 months of therapy was compared with the outcome of 17 neurotic patients in comparable therapy. Outcome assessment was obtained from three sources: patient, therapist, and independent judge, using both nomothetic and ideographic measures. The results indicated that although more alcoholic than neurotic patients terminated therapy within the first six sessions, a higher percentage of alcoholic patients remained in therapy for 12 months. At the end of 12 months, both samples had improved along a wide variety of variables, and there were no significant differences between the alcoholic and neurotic population in degree of improvement. (Arch Gen Psychiatry 35:419-425, 1978) \s=b\ Three interactional
(N
Group Therapy
=
long-term the chronic alcoholic patient? Not Howforeffective would is
interactional group therapy very, most psychotherapists agree. For many years, clinicians have assumed that the chronic alcoholic patient is not a suitable candidate for uncovering long-term psychothera¬ py in general and group therapy in particular. Many group therapists have found that the alcoholic patient not only fails to obtain personal benefit but so clogs the working of the group that the other members suffer as well. The alcoholic patient's attendance is poor, he disrupts the group by arriving at meetings intoxicated, his presumptive underlying orality results in a consumption of a dispropor¬ tionately high percentage of the group time and energy, he cannot tolerate the frustration inherent in the formative stages of group therapy, he cannot bind anxiety and thus
publication March 3, 1977. Department of Psychiatry, Stanford (Calif) University Medical Center (Dr Yalom); the Department of Psychiatry, Warneford Hospital, University of Oxford (England) (Dr Bloch); the Department of Behavioral Sciences, University of Chicago (Dr Bond); the Department of Psychiatry, Yale University, New Haven, Conn (Dr Zimmerman); and the Butler Hospital, Providence, RI (Dr Qualls). Reprint requests to Department of Psychiatry, Stanford University Medical Center, Stanford, CA 94305 (Dr Yalom). Accepted
From the
for
tends to act out, generally through drinking. Thus, most psychotherapists, whether or not they are familiar with the Alcoholics Anonymous (AA) approach, are glad to leave the treatment of the alcoholic patient to AA, even though they realize that there is little systematic knowledge about either the efficacy of AA or the types of patients most and least likely to be helped by AA. Despite these widespread assumptions, a review of the
literature reveals that there have been few clinical reports of long-term interactional group therapy with the alcoholic patient, and no systematic outcome evaluation of this approach. We attempted, first, to develop methods that would enable the alcoholic patient to work effectively in long-term, interactionally based group therapy, and then, using a variety of assessment techniques, to evaluate the effects of this therapy. We have described our clinical approach fully in other publications.'"' To summarize briefly, we began our group therapy work with a number of a priori assumptions and procedural guidelines but also with a psychological set that as the situation demanded, we would modify our approach. One main assumption was that the group would be inter¬ actionally based, ie, the primary task of the group members would be to explore in depth their interpersonal style of relating to the leaders and to the other members. We hoped to build an effective, cohesive group, sufficiently supportive and trusting so that, as time passed, the members would be willing to engage in considerable selfdisclosure and affective expression. The basic clinical approach is fully described in the group therapy text written by the senior author.' Our first step was to form an experimental group, using no selection criteria, in which we would try out various technical modifications we hoped might facilitate therapy. After we had obtained sufficient experience and expertise, we planned to form two other groups to test these techniques further and to evaluate outcome. The first six months of the experimental group was an
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of New South Wales User on 04/16/2016
unstable period, with five patients dropping out after only a brief stay. Gradually, with the use of anxiety-reducing techniques such as a written summary of each meeting mailed to the patients before the subsequent meeting,' improved selection, and interruption of disruptive subgrouping, the group soon passed into a more stable phase. At this point, using what we had learned from this first group, we formed two other groups of alcoholics and
proceeded
to evaluate outcome.
METHOD Our basic research plan was to compare the outcome of alcoholic and neurotic patients both engaged in interactional group ther¬ apy. We collected our sample over a six-month period and included every patient who entered either an alcoholic group or a general therapy group in Stanford (Calif) University's Department of Psychiatry outpatient clinic. Typical group therapy screening procedures were used': excluded were patients who were psychotic, psychopathic, poorly motivated, in severe external crisis, or uncon¬ trollable drinkers. Our sample consisted of 20 chronic alcoholic and 17 neurotic patients. The 20 alcoholic patients entered one of three alcoholic groups (the original experimental group adding new members, and two newly formed groups); the 17 neurotic patients entered one of three neurotic groups (also one established and two newly formed
groups). All six groups were led by cotherapy teams. One therapist—a psychologist and recovered alcoholic-was a cotherapist in all three alcoholic groups. Her three cotherapists were a senior faculty member, a junior faculty member, and a first-year psychiatric resident. The three neurotic groups were led by two faculty members and four advanced psychiatric residents. The groups met weekly for an hour and a half. They were open groups in that new patients could be introduced as members terminated. (The length of the alcoholic groups was predetermined by the research grant, and no new patients were added during the last six months of their functioning.) All therapists, aside from the two led by senior faculty, were supervised by experienced supervi¬ sors who met with the cotherapist teams weekly. The alcoholic groups were supported by a research grant and the patients were charged no fee; the neurotic patients were charged on a sliding scale (according to income) ranging from $2 to $15 per session.
Characteristics of the Clinical Sample A study of the demographic characteristics of the alcoholic and neurotic samples shows some differences. There were 13 men and seven women in the alcoholic sample, while the neurotic sample had seven men and ten women. The alcoholics were older, with a mean age of 41 (range, 29 to 55 years) compared to a mean age of 28 (range, 21 to 44 years) for the neurotic sample. Fifteen of the 20 alcoholic patients were married, as contrasted to three of the 17 neurotic patients. Most patients in both samples came from a middle socioeconomic class. All the neurotic patients and 18 of the 20 alcoholic patients had had some college education. Five of the neurotics were graduate students, whereas only one alcoholic was a full-time student. Most of the patients in both groups had had considerable exposure to previous therapy: only two of the neurotic and seven of the alcoholic patients had had no previous psychotherapy experience. (However, three of these seven alco¬ holic patients had previously attended AA meetings.) Approxi¬ mately equal numbers of the two samples had received over six months of
prior psychotherapy.
12 months of the study, six neurotic patients and three of the alcoholic patients were concurrently receiving indi¬ vidual therapy. Furthermore, nine alcoholic patients attended some AA meetings.
During the
Assessment of Outcome Each patient's outcome was assessed over the 12-month obser¬ vation period, using an individualized approach and several stan¬ dard outcome measures. There were three sources of outcome measurement: patients, therapists, and independent judges. The Patient as Source.-Each patient was interviewed by the same researcher three times: before the onset of therapy, at eight months, and at 12 months after beginning therapy. The patient constructed a list of the chief problems for which he had entered therapy and rated each one on a nine-point "distress" scale. The patient formulated an associated goal for each problem. ("If therapy were to be successful for you, in which way would you like to see this problem changed?") At each subsequent interview, he rated each of his problems on the "distress" scale, and also on a nine-point scale that reflected the extent to which he thought he had achieved his goal with respect to that problem. At 12 months, he completed three global scales reflecting the degree of change he believed he had accomplished, the extent to which his complaints had changed over the year, and his overall satisfaction with the results of therapy. Before therapy and at eight and 12 months, the patient completed a Hopkins symptom checklist, modified to increase its relevance to our clinical population (unpublished material). The Therapist as Source.—At the onset of therapy, the therapists listed the patients' major problems (both symptomatic and characterological) and formulated a therapeutic goal for each problem. Eight and 12 months later, the therapists rated each problem on the degree to which they thought the patient had achieved the associated goal. They also rated the patient on a nine-point global measure of change at the end of the 12 months (1, "worst possible outcome"; 5, "unchanged"; 7, "moderately improved"; 9, "best
possible outcome").
Independent Judge
as
Source.—The interviews mentioned above,
therapy and after eight and 12 months of therapy, were videotaped. Each was a 50 to 60-minute interview in which the interviewer explored each of the patient's main problems in as much depth as possible. The independent judge method has been described in detail in another publication1 and shall be only briefly described here. Teams of experienced psychotherapists from the Stanford Univer¬ sity Department of Psychiatry clinical faculty (psychiatrists, psychologists, and social workers, most with more than ten years of clinical practice) viewed these tapes. Each team consisted of three judges who viewed all three tapes (two tapes for those patients who dropped out of therapy between eight and 12 months) in a single four-hour sitting. After the pretherapy tape, each of the three judges constructed a list of the major problems of the patients as he saw them. The three resultant problem lists were written on a blackboard and, through a process of consensus, shaped into one problem list. The team then developed a goal for each problem. The tape of the eight-month interview was then viewed and, using the goal as a standard, each judge indepen¬ dently rated the degree of change for each of the consensus problems on nine-point scale ranging from 1 ("worst possible outcome") through 5 ("unchanged") to 9 ("best possible outcome"). The judges also rated the overall outcome of the patient on a 17point global improvement scale (1, "worst possible outcome"; 9, "unchanged"; 13, "moderately improved"; 17, "best possible outcome"). before
RESULTS Nature and
Severity
of
Psychopathology
Several types of data were collected that permit us to compare the nature and severity of the psychopathology of the alcoholic and the neurotic samples, (t tests were used
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of New South Wales User on 04/16/2016
drinking but had brief periods of abstinence, one was mainly abstinent but had brief periods of drinking, and five were abstinent (three for only a few weeks and two for over a year). The major problems listed before therapy by the 29 patients who continued in therapy at least eight months were sorted into 12 categories. Table 1 indicates that, except for alcohol and marital problems (many more alcoholics than neurotic patients were married), there were no significant differences in the type of problems. Each patient rated each problem for degree of distress (on a nine-point scale with 9 indicating maximal distress): there were no significant differences for distress on any of the categories between the alcoholic and neurotic sample. The mean distress for all categories was 6.36 for the alcoholic patients and 6.65 for the neurotic patients, a difference not reaching statistical significance. Therapists and Independent Judges.—The problem lists constructed by the independent judges (after watching the videotape of the pretherapy interviews) and by the thera¬ pists before therapy were also categorized (Table 2). The only consistent difference between alcoholics and neurotics that both therapists and judges cited (aside from the expected differences in "alcoholism" and "marital prob¬ lems") was in the category of "dependency," a character trait much more likely to be noted in the alcoholic sample. The therapists' pretherapy severity ratings (nine-point scale) for all problems showed no significant differences in the mean ratings between alcoholics (6.20) and neurotics (6.26). The initial mean severity ratings of the independent judges (nine-point scale) also showed no significant differ¬
severity levels.) Dropouts (patients who termi¬ nated therapy before the 8-month follow-up) are excluded from this statistical comparison, leaving a sample of 14 neurotic and 14 alcoholic patients. Hopkins Symptom Checklist.—All patients completed a modified Hopkins checklist (unpublished material) con¬ taining the following subscales: somatization, depression, anxiety, cognitive functioning, affect isolation, affect expression, self-esteem, hostility, alcohol and drug depen¬ dency, and an additional target symptom scale (the five items chosen from the questionnaire by the patient as most significant in his case). There were no significant differ¬ ences between the alcoholic and neurotic patients in initial levels on any of these scales (except, of course, on the to compare
alcohol
scale).
by defi¬ self-labeled alcoholics. When started nition, they therapy, ten were drinking continuously and heavily, four were Patients' Problems Lists.—All 20 alcoholics were,
Table 1.—Patients' Own Problem Lists: Comparison Between Alcoholics and Neurotics in the Nature of Presenting Problems No. of Patients
Listing Problems _A_
Alcoholics
Category
of Problems
(N
=
14)
Neurotics
(N
=
14)
Lack of
autonomy Conflicts in intimacy
10
12
Isolation from affect
Marital conflicts Conflicts with parents Existential (lack of
meaning
and
purpose)
between alcoholics (5.51) and neurotics (5.45). In summary, the two samples, apart from alcoholic addiction, were similar in the nature and severity of their psychopathology with only these differences: the alcoholics were older, more likely to be married, and more often ence
Self-esteem
Alcohol, drugs Somatic
Anxiety Depression Work/school
functioning
Table
pathologically dependent.
2.—Comparison of Problem Areas
Formulated by Independent for Neurotic and Alcoholic Patients
Judges
and
No. of Times Mentioned
as a
Therapists Problem
Therapists
Independent Raters Alcoholics
(N
=
13)
Neurotics
(N
=
12)
13
Depression Passive-aggressive Anxiety
10
10
Loneliness, social isolation, few friends Marital problems Sexual problems
10
10
Anger (abrasive, hostile) Passive, unassertive, submissive Affect (awareness Lack of intimacy
or
(N
=
10 12
Dependency Alcoholism Self-esteem
Alcoholics
expressivity)
Lack of trust
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of New South Wales User on 04/16/2016
13)
Neurotics
(N
=
12)
Clinical Course All six psychotherapy groups involved in this study were hard-working, cohesive groups. Although the alcoholic groups occasionally focused on the current drinking of one of the members, this was only a minor theme. Over the course of the year, patients in the alcoholic groups arrived intoxicated at meetings on only nine occasions. From their very first meeting, the alcoholic groups were oriented away from the explicit discussion of alcohol. The therapists emphasized that they did not think that the group's task was to help members achieve or maintain sobriety-they would need ancillary aid, either AA or medical (disulfirum
[Antabusej), for this. Nor was the group a substitute for AA. Instead, the group's primary task was to help each member understand and work through underlying person¬ ality conflicts that contributed to the alcohol dependency. Within a short period, all three alcoholic groups were working at a level of interpersonal and intrapersonal exploration, which made them virtually indistinguishable from the three neurotic groups. An instrument that offers corroboration for the similar
functioning of the alcoholic and neurotic groups is the Curative Factor Questionnaire,'1 which was administered after eight and 12 months of therapy. This questionnaire contains 19 items that are effective mechanisms of change in group therapy: each patient is asked to indicate on a five-point scale that importance of each item to him in his therapy. The items include such factors as feedback, catharsis, self-disclosure, acceptance by others, altruism, direct advice, different types of insight, universality, and existential factors. Different types of therapy groups accent different factors, and even within one group different patients may select various change pathways through the therapeutic process. If, therefore, the neurotic and the alcoholic groups functioned differently, or if the patients used therapy in different ways (eg, supportive, relationship therapy compared to self-exploration), these differences would be reflected in the
answers
to the
questionnaire.
Examination of the data at eight months (12 alcoholics and 12 neurotics completed the instrument) and at 12 months (13 alcoholics and eight neurotics) indicated no significant differences (using t tests) on any of the 19 items. We then examined the responses of only those patients who were rated as highly improved by the inde¬ pendent judges. There was again, no difference between the highly improved alcoholic and the highly improved neurotic patient. These findings corroborate the clinical impressions of observers who had the opportunity to watch both the alcoholic and neurotic groups: a similar type of therapy was offered to both samples. Duration of
Therapy
Our objective outcome measures were gathered at two points in this study: eight and 12 months after the onset of therapy. Four alcoholics and two neurotics dropped out in the first three months of therapy; two alcoholic patients and no neurotic patients dropped out between the third and eighth month. Thus, we have complete eight-month
data on 14 (70%) of the alcoholic patients and 14 (88%) of the neurotic patients (one neurotic patient is excluded because of missing data). Between eight and 12 months, six neurotics and one alcoholic terminated therapy; therefore, we have 12-month data on 13 (65%) of the alcoholic patients and eight (47%) of the neurotic patients. Early Dropouts.—Data on patients who dropped out early in therapy is less systematic and trustworthy. The assumption generally made by group therapists about patients who drop out after a very short period of interac¬ tional group therapy is that they rarely obtain much therapeutic benefit.7 Our clinical data substantiate that view. First, consider the six patients who dropped out of therapy within the first 12 sessions. Of the four who were alcoholics, three were clearly errors of selection: all entered therapy drinking heavily and, on a few occasions, arrived at meetings intoxicated. One attended only a single meet¬ ing, another was hospitalized for alcoholism after three meetings, another-an explosive, manipulative, poorly motivated patient—attended six meetings, seemed threat¬ ened by the group task, and terminated without benefit. The fourth alcoholic attended ten meetings, but according to the therapists was a nonworking, guarded member of the group. Her impulsive decision to live with a new alcoholic boyfriend was challenged by the group, and she abruptly terminated therapy without apparent benefit. Two neurotic patients terminated after six meetings. One was an aggressive, manipulative "early provocateur"7 in the group who was deeply involved with a heroin-addict boyfriend. She refused to examine this relationship in therapy and left after inciting much group anger toward her. The other, an isolated individual, was threatened by the intense level of interaction and left without ever becoming involved in the group. Neither patient benefited from their six sessions. Later Dropouts.—Once a patient survives the early group meetings, he generally commits himself to the group for at least several months.7 This held true for our sample: only two alcoholics and no neurotic patients terminated therapy between three and eight months. Both of these dropouts made some progress in therapy but, according to their therapists, left the group because they were threatened by the implications of change. One patient had had a 20-year, stormy homosexual relationship with an alcoholic partner (who resisted personal involvement in therapy); she reached a point at which she thought that further personal growth would necessitate termination of the relationship. The other patient, who was virtually silent for six months, had finally begun to work in the group but, threatened at her emerging strong feelings of anger and warmth, precip¬ itously terminated treatment. Patients
Terminating
Between
Eight
and 12 Months.—
Although roughly proportion of alcoholic and neurotics completed eight months of therapy, there was a sharp falloff of the latter between eight and 12 months. Of the eight patients who terminated therapy during that period, seven were neurotics and only one an alcoholic. Thus, at the 12th month there were more alcoholic patients (65% of the original sample) than neurotic patients (47%) receiving therapy. the
Downloaded From: http://archpsyc.jamanetwork.com/ by a University of New South Wales User on 04/16/2016
same
eight patients terminate therapy? The 29-year-old woman, was clearly a failure in therapy. Her therapists and the independent judges all agreed that she not only failed to improve but deteriorated during therapy. She was faced with considerable environ¬ mental stress: a dying mother and a disintegrating marriage. She attempted to control the group by engen¬ dering guilt via such self-destructive behavior as drinking and sexual promiscuity. When the group wrenched itself free from its guilt and confronted her, she withdrew and finally so dreaded the meetings that she terminated ther¬
Why
did these
alcoholic,
apy.
Of the seven neurotic patients who terminated therapy between eight and 12 months, three left the group because of circumstances beyond their control (two moved to another city because of job shifts, and one was in a group that terminated when she had been in therapy for 11 months). (The residents completed their training.) These three patients had made satisfactory progress, and thera¬ pists and independent judges rated them as slightly to moderately improved. The other four terminated the group with varying degrees of dissatisfaction. One patient, a 20year-old sociopathic drug addict, was heavily involved in illicit drug sales: she was a peripheral group member, highly secretive and irregular in attendance. The group therapists asked her to leave because she was not only making no personal progress but was retarding the rest of the group. The therapists thought that she did not improve—in fact, that she may have deteriorated (she required hospitalization two months after termination). She, however, rated herself as mildly improved. Another patient never resolved strong negative transference prob¬ lems and dropped out of the group. The independent judges rated him as unchanged, while the rating of both patient and therapist indicated that he had made slight to moderate improvement. The other two patients made definite but limited gains in therapy; neither used the group fully, and, though improved, did not "graduate."
Ratings
of
Change
After
Eight
Months of
Therapy
Ratings from patients, therapists, and independent judges are available for the 14 alcoholic patients and 14 of the 15 neurotic patients who completed eight months of therapy. Tables 3 through 6 present data on outcome from the three sources: patient (mean achievement of patientdetermined goals for their self-selected problems and reduction of distress in these problem areas), independent judges (mean achievement on all problems), and therapist (mean achievement on all problems). Differences between the samples were tested by t tests on achievement and global ratings from the three sources. In addition, reduction in distress for each sample was assessed by testing pretherapy-posttherapy differences (using t tests) on the target problems and the Hopkins symptom checklist. Two findings are evident: (1) the entire sample under¬ went considerable improvement as a result of eight months of group therapy; (2) there were no significant differences in improvement between the alcoholic and the neurotic
samples.
Table 3.—Mean Achievement of Goals at
a
Alcoholics
(N Source of Patient"
Rating
=
(N
=
Mean 4.63
1.65
Mean 4.84
5.77 6.44
0.77 1.00
5.78 6.38
Therapistt Independent judges!
Months
Neurotics
14) SD
Eight 14) SD 1.07 0.72
0.40 0.03
(NS) (NS)
0.80
0.17
(NS)
•Patients used a nine-point scale for rating achievement of goals they set before therapy for their self-selected problems: 1, not at all; 3, a little; 5, pretty much; 7, very much; 9, totally. tBoth therapists and independent judges used a nine-point scale: 1,
worst possible outcome; worse; 5, unchanged; 6, possible outcome.
2, markedly worse; 3, moderately worse; 4, slightly slightly improved; 7, moderately improved; 9, best
Eight
Table 4.—Reduction in Distress of Problems at Months* 0 mo 6.36 6.64
Patient as Source Alcoholics (N 14) Neurotics (N 14) =
=
8 mo Reduction 4.48 1.88 4.87 1.77
4.26
