The Decision Group.• Weginning Treatment in an Al lcoholism Clinic VALERIE R. LEVINSON
HEALTH AND SOCIAL WORK,
Vol. 4, No. 4, November 1979
0360-7283/79/0404-0199 $0.50 C 1979 National Association of Social Workers, Inc. Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
The Decision Group was designerf to fill the needs of individuals applying for treatment at an alcoholism outpatient clinic and to reduce time lost to the clinic as a result of broken appointments. The group succeeded in engaging patients in treatment, motivating them to accept identification as alcoholics, and maintaining high attendance. The author describes the group's accomplishments and suggests ways that future groups could avoid certain problems the Decision Group encountered.
alcoholT ics describes much innovation. In outpatient clinics HE LITERATURE ON GROUP TREATMENT Of
alone, the kinds of groups created and the techniques utilized are impressive. In addition to the conventional group which is insight oriented and open ended, group treatment for alcoholism includes the following: multiple conjoint family therapy, therapy with couples, large groups with thirty-five members, psychodrama, marathon encounters, relaxation training, assertiveness training, a format in which each member takes a turn being questioned by other members, a format in which the therapist presents a question at the beginning and each member takes a turn answering, a procedure for sharing records of drinking episodes, thematic group therapy in which patients rotate as leader, and, of course, many 200 Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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versions of the educational lecture and discussion format. 1 And these do not include various efforts to engage and help family members apart from the alcoholic's treatment. There is agreement in the field that, in general, groups are good for recovering alcoholics. A number of formats have been developed specifically for the initial stage of treatment. One method has individuals go through the intake process in a group. 2 Patients must wait at most only forty-eight hours after first making contact with a clinic before beginning with this group. Intake sessions enable the therapist to elicit material for evaluation and to formulate a treatment plan with the patient. Some education and motivational counseling may also occur in these brief first meetings and can be done by the patients themselves, for themselves. Another format consists of time-limited (ten sessions) directive group treatment. 3 The purpose of this group is to foster abstinence and to give the newly sober alcoholic substitute emotional support. Everyone in the group starts and ends at the same time, however, which means that certain individuals who are ready to begin the group immediately must wait for a period of time. ADVANTAGE OF GROUP THERAPY
Among the benefits of group therapy, Yalom identifies instillation of hope through ongoing observation of others' improvements; altruism, or receiving through giving; development of socializing techniques such as helpful responsiveness to others, effective abilities to resolve conflict, capacity for experiencing and expresring accurate empathy, and awareness of one's impact on others; imitative behavior, which helps expand the Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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individual's repertoire of responses as well as solidify a sense of self; interpersonal learning, ultimately "enabling . . . the individual to participate collaboratively with others [and] to obtain interpersonal satisfactions in the context of realistic, mutually satisfying interpersonal relationships"; catharsis, in the sense of becoming able to express feelings and work with them, rather than just ventilating them; imparting information, which helps allay anxieties that stem from uncertainty regarding the source, meaning, and seriousness of symptoms; and universality, which counters the individual's sense of alienation, unacceptability, and personal isolation. 4 These "curative factors" are particularly suited to combating the effects of alcoholism. Yalom repeatedly cites Alcoholics Anonymous (AA), for example, as an effective group that demonstrates these benefits. Some people refer to alcoholism as "the disease of loneliness." If an individual did not begin drinking feeling personally isolated already, he or she always ends up isolated. Besides losing friends, jobs, and family from crises caused by drinking behavior, alcoholics also lose the ability to relate in a meaningful way. Anyone not drinking at a party who has watched other people getting tipsy is well aware of how disconnected drinkers become, in spite of their perception that they are confident, astute, gregarious, and witty. That distorted sense of self is the creation of the anesthetic haze provided by alcohol. Alcohol replaces relationship, and instead of talking, the alcoholic uses drinking as his or her primary coping mechanism. The newly sober alcoholic, even with family still intact, feels great self-loathing. The feeling results from a glimmering recognition of the personal and interpersonal havoc he or she created while drinking. This loathing is intensified by the perception Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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that he or she is the only person in the world who has ever behaved in such a "sinful manner," as one patient put it. Therefore, the universalization that occurs in group work, the recognition that members share similar situations, is an important first step in the alcoholic's struggle to scrape together some shreds of self-esteem. 5 Newly sober, the alcoholic may begin to feel overpowered by loneliness, depression, periods of mental disorganization, impairment of memory and concentration, a sense of powerlessness, and diffuse anxiety. He or she may experience an uneasiness that can escalate to terror about insomnia and "empty time" now that the hours are not filled with drinking. The alcoholic is as-
saulted, whether prepared or not, by the real everyday problems and by fears associated with experiencing a wide range of feelings. Sexual and aggressive impulses, which have been masked by the sedating effect of alcohol, are particularly threatening, since many alcoholics are not sure they can control the urge to act on them. If lucky, they will be able to deny, rationalize, project unacceptable feelings onto others, or minimize the extent of the problem. 6 But usually sober alcoholics sense that they are in a vulnerable psychological position. They have good reason to feel hopeless. Extreme discomfort must be managed with brittle, shaky tools. Hearing others say that they are not drinking and surviving, that such experiences are normal in early sobriety, that the alcoholic is not alone, that alternative ways of coping exist, that talking helps relieve tension as well as connects with other human beings, can be tremendously reassuring and may forestall another drinking episode. One of Yalom's factors, imparting information, is also important. Through lectures and talking with others, Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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"The newly sober alcoholic, even with family stilt intact, feels great self-loathing, which results from a recognition of the personal and interpersonal havoc that he or she created while drinking."
the alcoholic learns that much of what he or she is attributing to personal failings is in fact a symptom of the disease of alcoholism and not a fault. "Fault" must be differentiated from "responsibility." Alcoholics are prone to blame themselves for their disease. Such self-abuse only further decreases self-esteem and does not contribute to recovery and growth. Taking responsibility, on the other hand, enables them to think in terms of choices, which are under their control (for example, whether to pick up a drink or not). Alcoholics cannot help being alcoholics and losing control of drinking once they begin, but they can decide whether to touch the first drink. In early sobriety one can expect to experience anxieties, sleeping problems, and other symptoms. Knowing this allays the panic that arises simply from not expecting these feelings. This knowledge gives the sober alcoholic a degree of control over what otherwise would be experienced as a chaotic universe both internally and externally Group work can successfully engage the patient in treatment. Alcoholics may fear, avoid, or oppose the individual therapist who is perceived as an authority figure. The patient may automatically fear receiving disapproval or criticism, as well as demands for more maDownloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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ture behavior, from the individual therapist. In group work, however, authority is given over to the group itself; less guilt is aroused since everyone shares the same problem, and support can be accepted more easily than from the individual therapist. The individual therapist, as the authority figure, may need to be opposed in order for the alcoholic to maintain a sense of identity not to oppose the therapist would be feit as submission, or worse, loss of identity. Alcoholism is a natural bond which helps group members identify with one another. This positive attachment to the group enhances a member's commitment to abstinence. 7
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The idea of the Decision Group arose from a problem at an alcoholism clinic. No more openings were available for new patients in need of structure, education, and intensive treatment. Moreover, many patients applying for treatment appeared only once or twice for sessions with therapists on a one-to-one basis. This was especially true of patients coerced into treatmentthrough threat of loss of benefits—by public assistance programs. Once this population received the required proof-of-attendance letter, they often were never seen again. One or two individual sessions even with a therapist skilied in dealing with the alcoholic's characteristic resistances still could not engage the individual in treatment. In the one-to-one encounter the alcoholic is more likely to feel guilty and ashamed regarding his or her drinking behavior (and is perhaps too frightened to stop drinking), and therefore he or she needs to deny the problem completely. Doubting or denying the problem, or uncertain what to do about it or how to cope if he or Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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she chooses abstinence, the alcoholic is certainly not inclined to make a commitment to treatment, especially for an undetermined period of time. The Decision Group was designed to provide group services to patients who needed structure, education, and an opportunity to identify with others and become less isolated, to reduce the defensiveness that occurs in one-to-one situations, and to provide services to all who applied for treatment, with minimal financial loss to the clinic as a result of broken appointments. The Decision Group was so named because of the decisions required by all persons who are in conflict about their drinking. Are they alcoholics? Must they stop drinking? Once stopped, they must still decide whether to pick up a drink as the impulse recurs over and over again. Even if successful in deciding not to drink again and again, they must still decide what to do instead. These are only immediate problems. Newly sober alcoholics are rarely carefree. All the problems postponed by drinking also must be handled, and decisions about these, including whether to try to deal with them right away, have to be made. To meet the needs of newly sober alcoholics and help them with their "decisions," the following structure was designed. The Decision Group met twice a week for an hour at a time. Following a brief intake session to identify those in need of inpatient treatment, a new member could enter the group at any time and could attend eight consecutive sessions. In addition, patients were expected to attend two educational lectures about alcoholism. The lectures introduced the concept of alcoholism as a disease and discussed its characteristic symptoms, including its progressive nature, and stressed the need for total abstinence from Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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alcohol and other mood-altering drugs. Newly sober alcoholics were told which sedative medications are addictive. Each group session focused on one topic. The leader began by explaining the name of the group and introducing the topic for the day. Topics could be repeated in the course of the eight sessions and were geared to issues raised as new members introduced themselves. For example, when one member briefly described what led him to the clinic, sounding very depressed and mentioning several suicide attempts, the topic for the day became "Handling Depression." When two new people came in, feeling angry about social agencies coercing them into treatment by threatening to cut off welfare payments or not returning their children, the topic was "Do I Really Need to Be Here?" The leader encouraged all group members to acknowledge negative und ambivalent feelings. Other topics included "Handling Loneliness" (which also dealt with "empty time"), "Handling Nervousness" (which included problems with sleeping), "Dealing with Frustration" (which related to situations in which individuals feit they must control the uncontrollable—usually other people), and "What's the Use of AA?" (which was directed to members who had not attended meetings or who had negative attitudes or fears about AA). Concrete suggestions, giving advice, and socializing outside the group were encouraged here, unlike more sophisticated, longterm, insight-oriented groups.
SCREENING The screening process consisted of a fifteen-minute "orientation" for potential new members immediately Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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prior to their first session. At the orientation, potential members introduced themselves and the leader handed each new person a sheet listing the guidelines for the group. The leader read and discussed the guidelines, which covered the following points: 1. The day, time, and length of meetings were stated. 2. The only requirement for attendance was that a member be off alcohol and pills for twenty-four hours. Members were asked in a matter-of-fact way whether they had had any alcohol or pills within the last twentyfour hours. If they had, they were permitted to hear the rest of the guidelines, but were asked to leave before the group started. They were invited back to the next group. If individuals found they were not able to abstain for twenty-four hours, they were asked to arrange an individual session to formulate an alternate plan, usually detoxification. It was further explained that in an earlier session, the group had decided a maximum of two absences would be permitted. Members feit more than two absences would reduce too greatly the benefit a person might receive from the group. 3. Members were to report anticipated absences, or in an emergency were to call the group leader. It was explained that group members would naturally worry about an absent member unless they knew where he or she was. 4. Payment was required prior to each session. Working people paid fees ranging from $7 to $17, the average being about $12. Individuals receiving public assistance were covered by Medicaid. People were also asked not to smoke during the meetings because the room became stuffy. It was interesting that, in a group of newly sober, anxious alcoholics, no one ever obDownloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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jected to this stipulation or left the room to smoke during a session. People were then asked what questions they had about the group. Invariably, they asked what happened after their eight sessions were up, a possible indication of a developing commitment to treatment since the question was usually raised by people who were attending voluntarily. They were told that after their four weeks were over they would meet individually with the leader to have a "wrap-up" session and to plan for the next step. They were told briefly of options, which ranged from a long-term, less-structured group to a few individual sessions to termination from the clinic to continue or initiate AA attendance. If a member could not stay within the structure of the group but kept going into the details of personal problems, the leader might suggest one or two individual sessions. If an individual seemed to be under a lot of pressure but was managing within the group format and asked about individual sessions, the person was assured that time was available. It was found that just knowing a therapist was available reduced anxiety. If someone repeatedly arrived drunk, he or she was asked not to enter the group room but to remain in the waiting-room until the end of the session. The leader then suggested detoxification and discussed arrangements for hospitalization. The group's composition was heterogeneous, accommodating a wide range of differences. The fortyfive members who attended over the two and one-half months studied ranged in age from 20 to 67. The group was mixed racially and included men and women, "gays" and "straights," and one transvestite. It also included individuals who had never worked, two doctors, Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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a business executive, several homemakers, two writers, and a hairdresser, as well as others. The group tolerated a range of emotional problems and differences. At least three people communicated in a loose, tangential, almost incoherent fashion. The group responded with some anxiety to those with whom they could not easily identify, but nevertheless they kept everyone in the group. ACCOMPLISHMENTS
The group helped strengthen members' capacities to cope without alcohol in a variety of ways. The following examples illustrate how the group encouraged individuals to respond to situations positively and exercise control over their lives. Identification as an Alcoholic
One outstanding characteristic of the Decision Group was its capacity to deal rapidly with the members' entrenched resistances to identifying themselves as alcoholica. For example, Ralph, a new member, began by asserting with great hostility that he was there only at the behest of the welfare office, and he challeneged the leader to try to tell him to stop drinking. After listening to less recalcitrant members talk, he suddenly asked for a definition of seizure or convulsion, which he had confused with blackout or memory lapse. Once he had obtained a clear definition, he realized, with no assault to his ego, that he frequently suffered this serious symptom of chronic alcoholism. The power struggle he attempted to set up with the leader was avoided, and the real issue was addressed. In discussing seizures, another member, Jerry, postuDownloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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lated that they resulted from overwork. Several members smiled wryly. When asked to explain their response, they described their own tendencies to rationalize, and identified Jerry's theory as a similar rationalization. Again, the group was able to educate, reduce denial, and point out rationalization without any member losing face. Reality-testing and Group Support
Erna had been sober for one month, the longest period in twenty years. Her doctor said she would die if she had even one more drink. She told the group in a rambling, almost incoherent way of her plan to go out West to visit her 21-year-old son, whom she had not seen for several years. Erna wanted to "save" him from his father, from whom she was estranged. She feit his father was going to "corrupt" him by involving him in illegal activities. She acknowledged she could not tell her son how to live his life, but she thought that her presence might convey something to him about what he should do. It was difficult for group members to understand what was going on, but they took Erna seriously. She could not be dissuaded from going, so they questioned her briefiy about what she wished to accomplish regarding her son, reiterating the difficulty of trying to control a grown child. They brought up the issue of her sobriety, suggesting gently that the situation would be stressful, and asking what she could do to take care of herself if she feit like drinking. With the group's help she formulated a plan to continue to attend AA meetings out West and identified several people she could talk to about her alcoholism during the trip. Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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Alternative Methods of Coping
Juan spoke about a frustrating encounter with his new landlord. After Juan moved into his new apartment, the landlord tried to get rid of him and then raised the rent. Although Juan acknowledged that the incident had been frightening and frustrating, he denied that he had had any emotional reaction. Bill had been with Juan at the time the rent was raised and described how angry he would have been if he had been in Juan's shoes, and how cool Juan had in fact appeared. A third member, Raul, became excited and raid he would have "punched the guy out." This sharing enabled Juan to understand and verbalize some of his own feelings and at the same time allowed the group to consider what the most effective response might have been—appearing cool, drinking, fighting, checking the legality of what the landlord did, or making contingency plans to move. Managing the Desire to Drink
Several members insisted during one session that they had had no desire to drink in the preceding week. The subject was mentioned so of ten and with such vehemence that it became clear they were barely managing to control the powerful impulse to drink. They feared that the slightest acknowledgment of thinking, wishing, or even dreaming of a drink would instantly be translated into action. The leader proceeded to ask the group to imagine, within the safe confines of the meeting room, a favorite drink. At first a few people became uneasy. Most members, however, were able to conjure up an image almost immediately. Maureen imagined sipping a dry vodka martini with a twist of lemon in luxurious Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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comfort by a fire, draped across a chaise lounge in a sumptuous gown. As she described it she became more and more relaxed, draping herself across her chair, leaning back against the walt, sighing with pleasure. Ed said how frightening it was for him to have his fantasy at first, that he could feel the fear in the pit of his stomach, but then the fear had gone away, and he enjoyed his phantom "ice-cold six-pack" in peace. Fay reported that nothing had come to mind. She passed. Greg also had no image. He stated firmly that he did not want to drink and could not drink any more. The leader asked him to imagine his favorite drink with a big X across it, the X coming between him and the drink. He grinned, a gin-and-tonic fantasy coming freely to mind The group talked about his using the X whenever it occurred to him to drink. Then Fay, who had passed, imagined a bottle of Beefeater gin sitting in front of her that was so large it completely camoufiaged her from the group. Gaining Control over Acting Impulsively As the leader painted a picture of Raul's "beer," Raul suddenly jumped up, saying he was thirsty and was leaving to get a glass of water. The leader asked if he would stay and talk about his feelings. Raul thought that was ridiculous, pulled uncomfortably at his sweater, and said how hot the room had become. The group tried to find out why the impulse had occurred when it did and how it felt, but Raul decided he had to get a drink of water and left the room. Animated conversation ensued as members argued with each other about the leader's "psychologizing" and whether the incident involved a glass of water in a warm Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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room or anxiety over a discussion of drinking. The leader pointed out that the feelings experienced in the meeting room were no different from those that members would encounter in other places, especially when alcohol was actually present—at parties, at the neighborhood bar, or in a liquor store. People ‘, ,to had been silent jumped in with their opinions. Maureen said she was annoyed that the leader was so "picky." Then she said she was proud to say how she feit rather than "bottle it up." The leader asked at the end of the session how many people planned to go out and drink from "the problems she gave them" and would not return to the group. Members scoffed at the question and remained behind for the first time to talk with each other. Everyone returned to the next session, an unprecedented event for a group so transient and ambivalent about treatment. -
Reducing Isolation and Fear of Insanity In panicky tones Irene talked about her sleepless night and the fear that her insomnia would never end. She said she tried and tried but could not get to sleep all night. Her mind was racing and it would not stop. She feit hopeless and despondent. Most members reassured her that they were experiencing the same thing, that it does get better, and that bodies do not die from lack of sleep. Members offered numerous home remedies for insomnia besides the familiar booze and pills—warm milk with honey, a hot bath, relaxation exercises, reading, television, and, above all, not forcing it. She was exhorted to get out of bed and do the laundry, clean the apartment, or bake a cake. Irene talked about her suicidal feelings, her loneliness, her anxiety over Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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empty time: "I wake up in the morning and wonder what to do now. How will I make it through a whole day? I can't get out of bed." Again members identified with her feelings. They suggested ways of filling time, and especially mentioned AA meetings. Her tone lightened and she said she feit better. The other members gained from sharing her experiences also. Dealing with Resistance to AA Members in favor of or with experience in AA were able to break the ice for others who were afraid of their first AA meeting or who had misconceptions about what went on in AA. Members shared their knowledge of alcoholism and at the same time helped to set up specific AA meetings with specific days, times, and locations for new participants. Group members often offered to take newer members to AA meetings. Increasing Participation Although it is too early to obtain complete statistics, available data seem to indicate a much higher return and completion rate for Decision Group clients than for similar clients seen individually. Approximately 50 percent of the forty-five members who entered the group during the two and one-half months completed their eight sessions, as contrasted with a return rate of approximately 25 percent for clients seen individually for a comparable eight sessions. PROBLEMS Many problems existed in a group like this, although more for the leader than for the members. The main Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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"Sexual and aggressive impulses, which have been masked by the sedating effect of alcohol, are particularly threatening, since many alcoholics are not sure they can control the urge to act on them."
problem for the members was the transient nature of the group. At each session new people were entering and others were graduating. The composition of the group was constantly in flux. Since the sessions lasted only one month for each person, there was not much time for members to form a cohesive group. Each meeting resembled a first session. There were always strangers to get to know, which provoked anxiety, and always people to bid farewell to. Members had just begun to establish connections, and it was disruptive and sad to say good-bye. The leader had a difficult task. Numerous people were moving through the group with many intense individual needs. It was difficult to keep track of everything, especially with minimal screening for the group. Because everyone in the group was newly sober, they had all the physical, emotional, and social problems of individuals in extreme crisis. Physically, most people were still in some stage of withdrawal, even if they had been detoxified. They were extremely nervous and often still shook. They had trouble sleeping. A certain degree of brain damage had occurred, mostly reversible, which hindered clear thinking, concentration, memory, and organization. Emotionally, people were frightened, even panicky. Some were depressed. Some denied they were alcoholics. Some were so overwhelmed with problems they could not stop talking. They threatened to overDownloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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whelm the others with their neediness. Others in the group were shy, self-deprecating, and without social skills. They were afraid to talk unless called on. The difficulty of asserting oneself in the group was exacerbated by its transient nature, which was not conducive to building trust. The group was set up on an experimental basis with limited screening procedures to eliminate many of the usual barriers to entry that discourage people from continuing treatment in the clinic, especially when their tolerance for frustration is low. Some members, therefore, turned out to be actively psychotic, or arrived intoxicated. Anyone who denied drinking but who ap-
peared to have been drinking was asked to leave the session and call the leader for an individual appointment. Screening was redone at that time and the need for detoxification, psychiatric consultation, or antipsychotic medication determined. Another problem for the leader was, in a sense, administrative. The date of each member's graduation had to be monitored, and plans made for continuing services. Dropouts had to be followed up also. In addition, the leader or other therapists in the clinic had to have time available for crises that required individual sessions. Newly sober individuals have more crises than those who have been sober for a long time. Participating in the group was a stressful experience itself. The collective anxieties of all the members created an atmosphere of potential chaos. The leader was constantly active because each session was, in effect, the start of a new group, composed of narcissistic people who, by the nature of their situation, were especially needy and not used to relating to other people. The leader had to be aware of each member at every moDownloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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ment and had to entourage each person to talk. It was important, especially in a short-term group, that everyone had a chance to speak. Although people seemed to be intimidated at first, a word of acknowledgment from the leader or another member was sufficient to bring them into the group. Once they started, they were never at a loss for words. Some members were lost to the group because they returned to alcohol. Participants established enough contact with one another to sense when someone was drinking. The loss of a member was upsetting to the whole group, close as they all were to picking up a drink themselves. People moved through the group so quickly that openings for individual and group services had to be available in the clinic for graduaten who had become committed to treatment. The clinic had to absorb large numbers of people because the group was indeed effective in engaging people in treatment. CONCLUSIONS The Decision Group was an effective format for engaging newly sober alcoholic patients in time-limited treatment. The group was also effective in fostering members' identification as alcoholics and in mitigating some of the pain caused by their low self-esteem, sense of being different, loneliness, and fear that the symptoms of early sobriety were symptoms of insanity. The group also reduced the amount of money lost to the clinic when patients broke appointments. The transient nature of the group precluded much cohesion among members, however, and added to the anxiety of individuals already living chaotic lives. Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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The rapid flow of members in and out of the group made it difficult, if not impossible, for the leader always to know who was ready to leave, to be alert to individual needs and problems, and to formulate well-thoughtout treatment plans for graduating members. One solution might have been to extend the group to two months instead of one, and perhaps to have had everyone start and finish the group at the same time. A cotherapist might have been added to treat people individually as needed and to handle drunk or disruptive members outside the group while the meeting was going on.
Further experimentation should be encouraged in the treatment of alcoholism. The particular physical, emotional, and social problems caused by this disease demand that alcoholism treatment veer off the beaten path of traditional psychotherapy. 8
About the Author Valerie R. Levinson, MSW, was, at the time of writing, Social Worker, Smithers Alcoholism Treatment and Training Center, The Roosevelt Hospi tal, New York, New York. She is presently Alcoholism Treatment Supervisor, Brooklyn—Staten Island Mental Health Service, Health Insurance Plan of Greater New York, Brooklyn, New York, and in private practice.
Notes and References 1. See, for example, K. K. Berman, "Multiple Conjoint Family Groups in the Treatment of Alcoholism," Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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Journal of the Medical Society of New Jersey, 65 (1968),
pp. 6-8; Donald M. Gallant, A. Rich, E. Bey, and L. Terranova, "Group Psychotherapy with Married Couples: A Successful Technique in New Orleans Alcoholism Clinic Patients," Journal of the Louisiana Medical Society, 122 (1970), pp. 41-44; J. D. Armstrong and R. J. Gibbons, "A Psychotherapeutic Technique with Large Groups in the Treatment of Alcoholism," Quarterly Journal of Studies on Alcohol, 17 (1956), pp. 461-478; B. J. Speroff, "Psychodrama with Alcoholics: Two Brief Paradigms," Group Psychotherapy, 19 (March—April 1966), pp. 214-219; Marvin Dichter, Genevra Z. Driscoll, Donald J. Ottenberg, and Alvin Rosen, "Marathon Therapy with Alcoholics," Quarterly Journal of Studies on Alcohol, 32 (March 1971), pp. 66-77; C. H. Hartman, "Group Relaxation Training for Control of Impulsive Behavior in Alcoholics," Behavior Therapy, 4 (1973), pp. 173-174; A. A. Adinolfi, W. F. McCourt, and S. Geoghegan, "Group Assertiveness Training for Alcoholics," Journal of Studies on Alcohol, 37 (1976), pp. 311-320; P. H. Esser, "Group Psychotherapy with Alcoholics," British Journal of Addiction, 57 (1961), pp. 105-114; Edward M. Scott, "A Special Type of Group Therapy and its Application to Alcoholics," Quarterly Journal of Studies on Alcohol, 17 (1956), pp. 288-290; L. C. Sobell and M. B. Sobell, "A Self-Feedback Technique to Monitor Drinking Behavior in Alcoholics," Behaviour Research and Therapy, 11 (1973), pp. 237-238; and F. Schual, H. Salter, and M. G. Paley, "Thematic Group Therapy in the Treatment of Hospitalized Alcoholic Patients," International Journal of Group Psychotherapy, 21 (1971), pp. 226-233. 2. Donald M. Gallant, Melvin D. Bishop, B. Stoy, M. S. Faulkner, and L. Paternoster, "The Value of a First Contact Group Intake Session in an Alcoholism Outpatient Clinic: Statistical Confirmation," Psychosomatics, 7 (November—December, 1966), pp. 349-351; and "The Walkin Clinic: A Group Approach to Treatment Planning," Alcohol Health and Research World (Winter 1975), pp. 25-27. 3. Martha Brunner-Orne and Martin T. Orne, "DirecDownloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
DECIS1ON GROUP 221 tive Group Therapy in the Treatment of Alcoholics: Technique and Rationale," International Journal of Group Psychotherapy, 4 (1954), pp. 293-302. 4. Irwin D. Yalom, The Theory and Practice of Group Psychotherapy (New York: Basic Books, 1975), pp. 3-84. 5. Brunner-Orne and Orne, op. cit., p. 301. 6. John Wallace, Tactical and Strategie Use of the Preferred Defense Structure of the Recovering Alcoholic
(New York: National Council on Alcoholism, 1974). 7. See L. P. Dolan, "An Intake Group in the Alcoholism Outpatient Clinic," Journal of Studies on Alcohol, 36 (1975), pp. 996-999; Arnold Pfeffer, Philips Friedland, and S. Bernard Wortis, "Group Psychotherapy with Alcoholics," Quarterly Journal of Studies on Alcohol, 10 (1949), pp. 198-216; Larson 0. Martenson, "Group Psychotherapy with Alcoholics in Private Practice," International Journal of Group Psychotherapy, 6 (1956), pp. 2837; Max M. Glatt, "Group Therapy in Alcoholism," British Journal of Addiction, 54 (1958), pp. 133-147; and John Clancy, "The Use of Intellectual Processes in Group Psychotherapy with Alcoholics," Quarterly Journal of Studies on Alcohol, 23 (1962), pp. 432-441. 8. See, for example, Valerie R. Levinson and Shulamith Ashenberg Straussner, "Social Workers as Tnablers' in the Treatment of Alcoholics," Social Casework, 59 (January 1978), pp. 14-21; and Christine H. Fewell and LeClair Bissell, "The Alcoholic Denial Syndrome: An Alcohol-Focused Approach," Social Casework, 59 (January 1978), pp. 6-13.
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HEALTH AND SOCIAL WORK,
Vol. 4, No. 4, November 1979
0360-7283/79/0404-0199 $0.50 C 1979 National Association of Social Workers, Inc. Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
The Decision Group was designerf to fill the needs of individuals applying for treatment at an alcoholism outpatient clinic and to reduce time lost to the clinic as a result of broken appointments. The group succeeded in engaging patients in treatment, motivating them to accept identification as alcoholics, and maintaining high attendance. The author describes the group's accomplishments and suggests ways that future groups could avoid certain problems the Decision Group encountered.
alcoholT ics describes much innovation. In outpatient clinics HE LITERATURE ON GROUP TREATMENT Of
alone, the kinds of groups created and the techniques utilized are impressive. In addition to the conventional group which is insight oriented and open ended, group treatment for alcoholism includes the following: multiple conjoint family therapy, therapy with couples, large groups with thirty-five members, psychodrama, marathon encounters, relaxation training, assertiveness training, a format in which each member takes a turn being questioned by other members, a format in which the therapist presents a question at the beginning and each member takes a turn answering, a procedure for sharing records of drinking episodes, thematic group therapy in which patients rotate as leader, and, of course, many 200 Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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versions of the educational lecture and discussion format. 1 And these do not include various efforts to engage and help family members apart from the alcoholic's treatment. There is agreement in the field that, in general, groups are good for recovering alcoholics. A number of formats have been developed specifically for the initial stage of treatment. One method has individuals go through the intake process in a group. 2 Patients must wait at most only forty-eight hours after first making contact with a clinic before beginning with this group. Intake sessions enable the therapist to elicit material for evaluation and to formulate a treatment plan with the patient. Some education and motivational counseling may also occur in these brief first meetings and can be done by the patients themselves, for themselves. Another format consists of time-limited (ten sessions) directive group treatment. 3 The purpose of this group is to foster abstinence and to give the newly sober alcoholic substitute emotional support. Everyone in the group starts and ends at the same time, however, which means that certain individuals who are ready to begin the group immediately must wait for a period of time. ADVANTAGE OF GROUP THERAPY
Among the benefits of group therapy, Yalom identifies instillation of hope through ongoing observation of others' improvements; altruism, or receiving through giving; development of socializing techniques such as helpful responsiveness to others, effective abilities to resolve conflict, capacity for experiencing and expresring accurate empathy, and awareness of one's impact on others; imitative behavior, which helps expand the Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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individual's repertoire of responses as well as solidify a sense of self; interpersonal learning, ultimately "enabling . . . the individual to participate collaboratively with others [and] to obtain interpersonal satisfactions in the context of realistic, mutually satisfying interpersonal relationships"; catharsis, in the sense of becoming able to express feelings and work with them, rather than just ventilating them; imparting information, which helps allay anxieties that stem from uncertainty regarding the source, meaning, and seriousness of symptoms; and universality, which counters the individual's sense of alienation, unacceptability, and personal isolation. 4 These "curative factors" are particularly suited to combating the effects of alcoholism. Yalom repeatedly cites Alcoholics Anonymous (AA), for example, as an effective group that demonstrates these benefits. Some people refer to alcoholism as "the disease of loneliness." If an individual did not begin drinking feeling personally isolated already, he or she always ends up isolated. Besides losing friends, jobs, and family from crises caused by drinking behavior, alcoholics also lose the ability to relate in a meaningful way. Anyone not drinking at a party who has watched other people getting tipsy is well aware of how disconnected drinkers become, in spite of their perception that they are confident, astute, gregarious, and witty. That distorted sense of self is the creation of the anesthetic haze provided by alcohol. Alcohol replaces relationship, and instead of talking, the alcoholic uses drinking as his or her primary coping mechanism. The newly sober alcoholic, even with family still intact, feels great self-loathing. The feeling results from a glimmering recognition of the personal and interpersonal havoc he or she created while drinking. This loathing is intensified by the perception Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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that he or she is the only person in the world who has ever behaved in such a "sinful manner," as one patient put it. Therefore, the universalization that occurs in group work, the recognition that members share similar situations, is an important first step in the alcoholic's struggle to scrape together some shreds of self-esteem. 5 Newly sober, the alcoholic may begin to feel overpowered by loneliness, depression, periods of mental disorganization, impairment of memory and concentration, a sense of powerlessness, and diffuse anxiety. He or she may experience an uneasiness that can escalate to terror about insomnia and "empty time" now that the hours are not filled with drinking. The alcoholic is as-
saulted, whether prepared or not, by the real everyday problems and by fears associated with experiencing a wide range of feelings. Sexual and aggressive impulses, which have been masked by the sedating effect of alcohol, are particularly threatening, since many alcoholics are not sure they can control the urge to act on them. If lucky, they will be able to deny, rationalize, project unacceptable feelings onto others, or minimize the extent of the problem. 6 But usually sober alcoholics sense that they are in a vulnerable psychological position. They have good reason to feel hopeless. Extreme discomfort must be managed with brittle, shaky tools. Hearing others say that they are not drinking and surviving, that such experiences are normal in early sobriety, that the alcoholic is not alone, that alternative ways of coping exist, that talking helps relieve tension as well as connects with other human beings, can be tremendously reassuring and may forestall another drinking episode. One of Yalom's factors, imparting information, is also important. Through lectures and talking with others, Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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"The newly sober alcoholic, even with family stilt intact, feels great self-loathing, which results from a recognition of the personal and interpersonal havoc that he or she created while drinking."
the alcoholic learns that much of what he or she is attributing to personal failings is in fact a symptom of the disease of alcoholism and not a fault. "Fault" must be differentiated from "responsibility." Alcoholics are prone to blame themselves for their disease. Such self-abuse only further decreases self-esteem and does not contribute to recovery and growth. Taking responsibility, on the other hand, enables them to think in terms of choices, which are under their control (for example, whether to pick up a drink or not). Alcoholics cannot help being alcoholics and losing control of drinking once they begin, but they can decide whether to touch the first drink. In early sobriety one can expect to experience anxieties, sleeping problems, and other symptoms. Knowing this allays the panic that arises simply from not expecting these feelings. This knowledge gives the sober alcoholic a degree of control over what otherwise would be experienced as a chaotic universe both internally and externally Group work can successfully engage the patient in treatment. Alcoholics may fear, avoid, or oppose the individual therapist who is perceived as an authority figure. The patient may automatically fear receiving disapproval or criticism, as well as demands for more maDownloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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ture behavior, from the individual therapist. In group work, however, authority is given over to the group itself; less guilt is aroused since everyone shares the same problem, and support can be accepted more easily than from the individual therapist. The individual therapist, as the authority figure, may need to be opposed in order for the alcoholic to maintain a sense of identity not to oppose the therapist would be feit as submission, or worse, loss of identity. Alcoholism is a natural bond which helps group members identify with one another. This positive attachment to the group enhances a member's commitment to abstinence. 7
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DECISION GROUP
The idea of the Decision Group arose from a problem at an alcoholism clinic. No more openings were available for new patients in need of structure, education, and intensive treatment. Moreover, many patients applying for treatment appeared only once or twice for sessions with therapists on a one-to-one basis. This was especially true of patients coerced into treatmentthrough threat of loss of benefits—by public assistance programs. Once this population received the required proof-of-attendance letter, they often were never seen again. One or two individual sessions even with a therapist skilied in dealing with the alcoholic's characteristic resistances still could not engage the individual in treatment. In the one-to-one encounter the alcoholic is more likely to feel guilty and ashamed regarding his or her drinking behavior (and is perhaps too frightened to stop drinking), and therefore he or she needs to deny the problem completely. Doubting or denying the problem, or uncertain what to do about it or how to cope if he or Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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she chooses abstinence, the alcoholic is certainly not inclined to make a commitment to treatment, especially for an undetermined period of time. The Decision Group was designed to provide group services to patients who needed structure, education, and an opportunity to identify with others and become less isolated, to reduce the defensiveness that occurs in one-to-one situations, and to provide services to all who applied for treatment, with minimal financial loss to the clinic as a result of broken appointments. The Decision Group was so named because of the decisions required by all persons who are in conflict about their drinking. Are they alcoholics? Must they stop drinking? Once stopped, they must still decide whether to pick up a drink as the impulse recurs over and over again. Even if successful in deciding not to drink again and again, they must still decide what to do instead. These are only immediate problems. Newly sober alcoholics are rarely carefree. All the problems postponed by drinking also must be handled, and decisions about these, including whether to try to deal with them right away, have to be made. To meet the needs of newly sober alcoholics and help them with their "decisions," the following structure was designed. The Decision Group met twice a week for an hour at a time. Following a brief intake session to identify those in need of inpatient treatment, a new member could enter the group at any time and could attend eight consecutive sessions. In addition, patients were expected to attend two educational lectures about alcoholism. The lectures introduced the concept of alcoholism as a disease and discussed its characteristic symptoms, including its progressive nature, and stressed the need for total abstinence from Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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alcohol and other mood-altering drugs. Newly sober alcoholics were told which sedative medications are addictive. Each group session focused on one topic. The leader began by explaining the name of the group and introducing the topic for the day. Topics could be repeated in the course of the eight sessions and were geared to issues raised as new members introduced themselves. For example, when one member briefly described what led him to the clinic, sounding very depressed and mentioning several suicide attempts, the topic for the day became "Handling Depression." When two new people came in, feeling angry about social agencies coercing them into treatment by threatening to cut off welfare payments or not returning their children, the topic was "Do I Really Need to Be Here?" The leader encouraged all group members to acknowledge negative und ambivalent feelings. Other topics included "Handling Loneliness" (which also dealt with "empty time"), "Handling Nervousness" (which included problems with sleeping), "Dealing with Frustration" (which related to situations in which individuals feit they must control the uncontrollable—usually other people), and "What's the Use of AA?" (which was directed to members who had not attended meetings or who had negative attitudes or fears about AA). Concrete suggestions, giving advice, and socializing outside the group were encouraged here, unlike more sophisticated, longterm, insight-oriented groups.
SCREENING The screening process consisted of a fifteen-minute "orientation" for potential new members immediately Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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prior to their first session. At the orientation, potential members introduced themselves and the leader handed each new person a sheet listing the guidelines for the group. The leader read and discussed the guidelines, which covered the following points: 1. The day, time, and length of meetings were stated. 2. The only requirement for attendance was that a member be off alcohol and pills for twenty-four hours. Members were asked in a matter-of-fact way whether they had had any alcohol or pills within the last twentyfour hours. If they had, they were permitted to hear the rest of the guidelines, but were asked to leave before the group started. They were invited back to the next group. If individuals found they were not able to abstain for twenty-four hours, they were asked to arrange an individual session to formulate an alternate plan, usually detoxification. It was further explained that in an earlier session, the group had decided a maximum of two absences would be permitted. Members feit more than two absences would reduce too greatly the benefit a person might receive from the group. 3. Members were to report anticipated absences, or in an emergency were to call the group leader. It was explained that group members would naturally worry about an absent member unless they knew where he or she was. 4. Payment was required prior to each session. Working people paid fees ranging from $7 to $17, the average being about $12. Individuals receiving public assistance were covered by Medicaid. People were also asked not to smoke during the meetings because the room became stuffy. It was interesting that, in a group of newly sober, anxious alcoholics, no one ever obDownloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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jected to this stipulation or left the room to smoke during a session. People were then asked what questions they had about the group. Invariably, they asked what happened after their eight sessions were up, a possible indication of a developing commitment to treatment since the question was usually raised by people who were attending voluntarily. They were told that after their four weeks were over they would meet individually with the leader to have a "wrap-up" session and to plan for the next step. They were told briefly of options, which ranged from a long-term, less-structured group to a few individual sessions to termination from the clinic to continue or initiate AA attendance. If a member could not stay within the structure of the group but kept going into the details of personal problems, the leader might suggest one or two individual sessions. If an individual seemed to be under a lot of pressure but was managing within the group format and asked about individual sessions, the person was assured that time was available. It was found that just knowing a therapist was available reduced anxiety. If someone repeatedly arrived drunk, he or she was asked not to enter the group room but to remain in the waiting-room until the end of the session. The leader then suggested detoxification and discussed arrangements for hospitalization. The group's composition was heterogeneous, accommodating a wide range of differences. The fortyfive members who attended over the two and one-half months studied ranged in age from 20 to 67. The group was mixed racially and included men and women, "gays" and "straights," and one transvestite. It also included individuals who had never worked, two doctors, Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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a business executive, several homemakers, two writers, and a hairdresser, as well as others. The group tolerated a range of emotional problems and differences. At least three people communicated in a loose, tangential, almost incoherent fashion. The group responded with some anxiety to those with whom they could not easily identify, but nevertheless they kept everyone in the group. ACCOMPLISHMENTS
The group helped strengthen members' capacities to cope without alcohol in a variety of ways. The following examples illustrate how the group encouraged individuals to respond to situations positively and exercise control over their lives. Identification as an Alcoholic
One outstanding characteristic of the Decision Group was its capacity to deal rapidly with the members' entrenched resistances to identifying themselves as alcoholica. For example, Ralph, a new member, began by asserting with great hostility that he was there only at the behest of the welfare office, and he challeneged the leader to try to tell him to stop drinking. After listening to less recalcitrant members talk, he suddenly asked for a definition of seizure or convulsion, which he had confused with blackout or memory lapse. Once he had obtained a clear definition, he realized, with no assault to his ego, that he frequently suffered this serious symptom of chronic alcoholism. The power struggle he attempted to set up with the leader was avoided, and the real issue was addressed. In discussing seizures, another member, Jerry, postuDownloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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lated that they resulted from overwork. Several members smiled wryly. When asked to explain their response, they described their own tendencies to rationalize, and identified Jerry's theory as a similar rationalization. Again, the group was able to educate, reduce denial, and point out rationalization without any member losing face. Reality-testing and Group Support
Erna had been sober for one month, the longest period in twenty years. Her doctor said she would die if she had even one more drink. She told the group in a rambling, almost incoherent way of her plan to go out West to visit her 21-year-old son, whom she had not seen for several years. Erna wanted to "save" him from his father, from whom she was estranged. She feit his father was going to "corrupt" him by involving him in illegal activities. She acknowledged she could not tell her son how to live his life, but she thought that her presence might convey something to him about what he should do. It was difficult for group members to understand what was going on, but they took Erna seriously. She could not be dissuaded from going, so they questioned her briefiy about what she wished to accomplish regarding her son, reiterating the difficulty of trying to control a grown child. They brought up the issue of her sobriety, suggesting gently that the situation would be stressful, and asking what she could do to take care of herself if she feit like drinking. With the group's help she formulated a plan to continue to attend AA meetings out West and identified several people she could talk to about her alcoholism during the trip. Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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Alternative Methods of Coping
Juan spoke about a frustrating encounter with his new landlord. After Juan moved into his new apartment, the landlord tried to get rid of him and then raised the rent. Although Juan acknowledged that the incident had been frightening and frustrating, he denied that he had had any emotional reaction. Bill had been with Juan at the time the rent was raised and described how angry he would have been if he had been in Juan's shoes, and how cool Juan had in fact appeared. A third member, Raul, became excited and raid he would have "punched the guy out." This sharing enabled Juan to understand and verbalize some of his own feelings and at the same time allowed the group to consider what the most effective response might have been—appearing cool, drinking, fighting, checking the legality of what the landlord did, or making contingency plans to move. Managing the Desire to Drink
Several members insisted during one session that they had had no desire to drink in the preceding week. The subject was mentioned so of ten and with such vehemence that it became clear they were barely managing to control the powerful impulse to drink. They feared that the slightest acknowledgment of thinking, wishing, or even dreaming of a drink would instantly be translated into action. The leader proceeded to ask the group to imagine, within the safe confines of the meeting room, a favorite drink. At first a few people became uneasy. Most members, however, were able to conjure up an image almost immediately. Maureen imagined sipping a dry vodka martini with a twist of lemon in luxurious Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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comfort by a fire, draped across a chaise lounge in a sumptuous gown. As she described it she became more and more relaxed, draping herself across her chair, leaning back against the walt, sighing with pleasure. Ed said how frightening it was for him to have his fantasy at first, that he could feel the fear in the pit of his stomach, but then the fear had gone away, and he enjoyed his phantom "ice-cold six-pack" in peace. Fay reported that nothing had come to mind. She passed. Greg also had no image. He stated firmly that he did not want to drink and could not drink any more. The leader asked him to imagine his favorite drink with a big X across it, the X coming between him and the drink. He grinned, a gin-and-tonic fantasy coming freely to mind The group talked about his using the X whenever it occurred to him to drink. Then Fay, who had passed, imagined a bottle of Beefeater gin sitting in front of her that was so large it completely camoufiaged her from the group. Gaining Control over Acting Impulsively As the leader painted a picture of Raul's "beer," Raul suddenly jumped up, saying he was thirsty and was leaving to get a glass of water. The leader asked if he would stay and talk about his feelings. Raul thought that was ridiculous, pulled uncomfortably at his sweater, and said how hot the room had become. The group tried to find out why the impulse had occurred when it did and how it felt, but Raul decided he had to get a drink of water and left the room. Animated conversation ensued as members argued with each other about the leader's "psychologizing" and whether the incident involved a glass of water in a warm Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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room or anxiety over a discussion of drinking. The leader pointed out that the feelings experienced in the meeting room were no different from those that members would encounter in other places, especially when alcohol was actually present—at parties, at the neighborhood bar, or in a liquor store. People ‘, ,to had been silent jumped in with their opinions. Maureen said she was annoyed that the leader was so "picky." Then she said she was proud to say how she feit rather than "bottle it up." The leader asked at the end of the session how many people planned to go out and drink from "the problems she gave them" and would not return to the group. Members scoffed at the question and remained behind for the first time to talk with each other. Everyone returned to the next session, an unprecedented event for a group so transient and ambivalent about treatment. -
Reducing Isolation and Fear of Insanity In panicky tones Irene talked about her sleepless night and the fear that her insomnia would never end. She said she tried and tried but could not get to sleep all night. Her mind was racing and it would not stop. She feit hopeless and despondent. Most members reassured her that they were experiencing the same thing, that it does get better, and that bodies do not die from lack of sleep. Members offered numerous home remedies for insomnia besides the familiar booze and pills—warm milk with honey, a hot bath, relaxation exercises, reading, television, and, above all, not forcing it. She was exhorted to get out of bed and do the laundry, clean the apartment, or bake a cake. Irene talked about her suicidal feelings, her loneliness, her anxiety over Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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empty time: "I wake up in the morning and wonder what to do now. How will I make it through a whole day? I can't get out of bed." Again members identified with her feelings. They suggested ways of filling time, and especially mentioned AA meetings. Her tone lightened and she said she feit better. The other members gained from sharing her experiences also. Dealing with Resistance to AA Members in favor of or with experience in AA were able to break the ice for others who were afraid of their first AA meeting or who had misconceptions about what went on in AA. Members shared their knowledge of alcoholism and at the same time helped to set up specific AA meetings with specific days, times, and locations for new participants. Group members often offered to take newer members to AA meetings. Increasing Participation Although it is too early to obtain complete statistics, available data seem to indicate a much higher return and completion rate for Decision Group clients than for similar clients seen individually. Approximately 50 percent of the forty-five members who entered the group during the two and one-half months completed their eight sessions, as contrasted with a return rate of approximately 25 percent for clients seen individually for a comparable eight sessions. PROBLEMS Many problems existed in a group like this, although more for the leader than for the members. The main Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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"Sexual and aggressive impulses, which have been masked by the sedating effect of alcohol, are particularly threatening, since many alcoholics are not sure they can control the urge to act on them."
problem for the members was the transient nature of the group. At each session new people were entering and others were graduating. The composition of the group was constantly in flux. Since the sessions lasted only one month for each person, there was not much time for members to form a cohesive group. Each meeting resembled a first session. There were always strangers to get to know, which provoked anxiety, and always people to bid farewell to. Members had just begun to establish connections, and it was disruptive and sad to say good-bye. The leader had a difficult task. Numerous people were moving through the group with many intense individual needs. It was difficult to keep track of everything, especially with minimal screening for the group. Because everyone in the group was newly sober, they had all the physical, emotional, and social problems of individuals in extreme crisis. Physically, most people were still in some stage of withdrawal, even if they had been detoxified. They were extremely nervous and often still shook. They had trouble sleeping. A certain degree of brain damage had occurred, mostly reversible, which hindered clear thinking, concentration, memory, and organization. Emotionally, people were frightened, even panicky. Some were depressed. Some denied they were alcoholics. Some were so overwhelmed with problems they could not stop talking. They threatened to overDownloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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whelm the others with their neediness. Others in the group were shy, self-deprecating, and without social skills. They were afraid to talk unless called on. The difficulty of asserting oneself in the group was exacerbated by its transient nature, which was not conducive to building trust. The group was set up on an experimental basis with limited screening procedures to eliminate many of the usual barriers to entry that discourage people from continuing treatment in the clinic, especially when their tolerance for frustration is low. Some members, therefore, turned out to be actively psychotic, or arrived intoxicated. Anyone who denied drinking but who ap-
peared to have been drinking was asked to leave the session and call the leader for an individual appointment. Screening was redone at that time and the need for detoxification, psychiatric consultation, or antipsychotic medication determined. Another problem for the leader was, in a sense, administrative. The date of each member's graduation had to be monitored, and plans made for continuing services. Dropouts had to be followed up also. In addition, the leader or other therapists in the clinic had to have time available for crises that required individual sessions. Newly sober individuals have more crises than those who have been sober for a long time. Participating in the group was a stressful experience itself. The collective anxieties of all the members created an atmosphere of potential chaos. The leader was constantly active because each session was, in effect, the start of a new group, composed of narcissistic people who, by the nature of their situation, were especially needy and not used to relating to other people. The leader had to be aware of each member at every moDownloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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ment and had to entourage each person to talk. It was important, especially in a short-term group, that everyone had a chance to speak. Although people seemed to be intimidated at first, a word of acknowledgment from the leader or another member was sufficient to bring them into the group. Once they started, they were never at a loss for words. Some members were lost to the group because they returned to alcohol. Participants established enough contact with one another to sense when someone was drinking. The loss of a member was upsetting to the whole group, close as they all were to picking up a drink themselves. People moved through the group so quickly that openings for individual and group services had to be available in the clinic for graduaten who had become committed to treatment. The clinic had to absorb large numbers of people because the group was indeed effective in engaging people in treatment. CONCLUSIONS The Decision Group was an effective format for engaging newly sober alcoholic patients in time-limited treatment. The group was also effective in fostering members' identification as alcoholics and in mitigating some of the pain caused by their low self-esteem, sense of being different, loneliness, and fear that the symptoms of early sobriety were symptoms of insanity. The group also reduced the amount of money lost to the clinic when patients broke appointments. The transient nature of the group precluded much cohesion among members, however, and added to the anxiety of individuals already living chaotic lives. Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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The rapid flow of members in and out of the group made it difficult, if not impossible, for the leader always to know who was ready to leave, to be alert to individual needs and problems, and to formulate well-thoughtout treatment plans for graduating members. One solution might have been to extend the group to two months instead of one, and perhaps to have had everyone start and finish the group at the same time. A cotherapist might have been added to treat people individually as needed and to handle drunk or disruptive members outside the group while the meeting was going on.
Further experimentation should be encouraged in the treatment of alcoholism. The particular physical, emotional, and social problems caused by this disease demand that alcoholism treatment veer off the beaten path of traditional psychotherapy. 8
About the Author Valerie R. Levinson, MSW, was, at the time of writing, Social Worker, Smithers Alcoholism Treatment and Training Center, The Roosevelt Hospi tal, New York, New York. She is presently Alcoholism Treatment Supervisor, Brooklyn—Staten Island Mental Health Service, Health Insurance Plan of Greater New York, Brooklyn, New York, and in private practice.
Notes and References 1. See, for example, K. K. Berman, "Multiple Conjoint Family Groups in the Treatment of Alcoholism," Downloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
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Journal of the Medical Society of New Jersey, 65 (1968),
pp. 6-8; Donald M. Gallant, A. Rich, E. Bey, and L. Terranova, "Group Psychotherapy with Married Couples: A Successful Technique in New Orleans Alcoholism Clinic Patients," Journal of the Louisiana Medical Society, 122 (1970), pp. 41-44; J. D. Armstrong and R. J. Gibbons, "A Psychotherapeutic Technique with Large Groups in the Treatment of Alcoholism," Quarterly Journal of Studies on Alcohol, 17 (1956), pp. 461-478; B. J. Speroff, "Psychodrama with Alcoholics: Two Brief Paradigms," Group Psychotherapy, 19 (March—April 1966), pp. 214-219; Marvin Dichter, Genevra Z. Driscoll, Donald J. Ottenberg, and Alvin Rosen, "Marathon Therapy with Alcoholics," Quarterly Journal of Studies on Alcohol, 32 (March 1971), pp. 66-77; C. H. Hartman, "Group Relaxation Training for Control of Impulsive Behavior in Alcoholics," Behavior Therapy, 4 (1973), pp. 173-174; A. A. Adinolfi, W. F. McCourt, and S. Geoghegan, "Group Assertiveness Training for Alcoholics," Journal of Studies on Alcohol, 37 (1976), pp. 311-320; P. H. Esser, "Group Psychotherapy with Alcoholics," British Journal of Addiction, 57 (1961), pp. 105-114; Edward M. Scott, "A Special Type of Group Therapy and its Application to Alcoholics," Quarterly Journal of Studies on Alcohol, 17 (1956), pp. 288-290; L. C. Sobell and M. B. Sobell, "A Self-Feedback Technique to Monitor Drinking Behavior in Alcoholics," Behaviour Research and Therapy, 11 (1973), pp. 237-238; and F. Schual, H. Salter, and M. G. Paley, "Thematic Group Therapy in the Treatment of Hospitalized Alcoholic Patients," International Journal of Group Psychotherapy, 21 (1971), pp. 226-233. 2. Donald M. Gallant, Melvin D. Bishop, B. Stoy, M. S. Faulkner, and L. Paternoster, "The Value of a First Contact Group Intake Session in an Alcoholism Outpatient Clinic: Statistical Confirmation," Psychosomatics, 7 (November—December, 1966), pp. 349-351; and "The Walkin Clinic: A Group Approach to Treatment Planning," Alcohol Health and Research World (Winter 1975), pp. 25-27. 3. Martha Brunner-Orne and Martin T. Orne, "DirecDownloaded from https://academic.oup.com/hsw/article-abstract/4/4/199/628857 by Rutgers University Libraries user on 12 January 2018
DECIS1ON GROUP 221 tive Group Therapy in the Treatment of Alcoholics: Technique and Rationale," International Journal of Group Psychotherapy, 4 (1954), pp. 293-302. 4. Irwin D. Yalom, The Theory and Practice of Group Psychotherapy (New York: Basic Books, 1975), pp. 3-84. 5. Brunner-Orne and Orne, op. cit., p. 301. 6. John Wallace, Tactical and Strategie Use of the Preferred Defense Structure of the Recovering Alcoholic
(New York: National Council on Alcoholism, 1974). 7. See L. P. Dolan, "An Intake Group in the Alcoholism Outpatient Clinic," Journal of Studies on Alcohol, 36 (1975), pp. 996-999; Arnold Pfeffer, Philips Friedland, and S. Bernard Wortis, "Group Psychotherapy with Alcoholics," Quarterly Journal of Studies on Alcohol, 10 (1949), pp. 198-216; Larson 0. Martenson, "Group Psychotherapy with Alcoholics in Private Practice," International Journal of Group Psychotherapy, 6 (1956), pp. 2837; Max M. Glatt, "Group Therapy in Alcoholism," British Journal of Addiction, 54 (1958), pp. 133-147; and John Clancy, "The Use of Intellectual Processes in Group Psychotherapy with Alcoholics," Quarterly Journal of Studies on Alcohol, 23 (1962), pp. 432-441. 8. See, for example, Valerie R. Levinson and Shulamith Ashenberg Straussner, "Social Workers as Tnablers' in the Treatment of Alcoholics," Social Casework, 59 (January 1978), pp. 14-21; and Christine H. Fewell and LeClair Bissell, "The Alcoholic Denial Syndrome: An Alcohol-Focused Approach," Social Casework, 59 (January 1978), pp. 6-13.
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