The keystone of medical treatment is the adoption of a psychological approach which relies on discussion between patient and doctor. Someone who has become dependent on alcohol invariably has conflicts and problems which call for psychological measures. Individual psychotherapy, where the doctor and patient meet alone and regularly, is designed to help the latter appreciate the basis of the difficulties he has in his social relationships. Psychological treatments seek to identify the patient’s misconceptions, and enable him to modify his behaviour. The patient may have used alcohol expressly to relieve distressing symptoms: anxiety experienced when required to speak in work discussions or meetings, lack of confidence in ability to do his job adequately, insecurity in relation to more senior people, conflicts in the marriage relationship. Instead of needing to relieve the symptoms with alcohol the patient is enabled to understand and control them.
The more long-term aim of psychological treatment is to bring about personality change. The patient gradually defines the personality problems which he had sought to alleviate by the use of alcohol. The psychiatrist helps the patient to grasp the distortion in his attitudes which bring about the difficulties. The patient then can himself go about restoring his affairs to order. If he fears that he is going to lose his job the psychiatrist does not intervene by going to see the employer. Instead, the patient and he study the patient’s inadequacy feelings, his dependence on more forceful men in place of reliance on his own abilities, and irrational fears of punishment for supposed errors. The insights gained permit him to distinguish the realities of his situation from irrational fears that arise from past experiences but are currently distorting his personal relationships.
Many alcoholics are not responsive to the concept that their drinking is an attempt to repair a deep-seated personality disturbance; they fight shy of an individual treatment relationship with a psychiatrist. From them an alternative method of treatment must be sought.
An interesting development during recent years has been the finding1 that group psychotherapy is effective with alcoholic patients. The members of a treatment group, generally about ten alcoholics, meet with one psychiatrist for sessions of an hour and a half each week, for about a year. The psychiatrist who has chosen patients whom he considers suitable to form a particular group conducts the meetings so as to evoke group interactions which bring about personality changes.
A group session consists of the descriptions by members of their recent experiences, each one speaking as he wishes, when he considers he has an idea to contribute to the discussion.
As the weeks pass, the members of the group report and pool their experiences; small triumphs are noted and disasters are shared, not only with interested attention but with responsible concern, because any member’s setback is thoroughly understood and had perhaps even been anticipated. When a member has a lapse and begins to drink, the skills developed by the
Some contributions of group therapy in the treatment of chronic alcoholism’. In Problems of Addiction and Habituation, ed. Hoch, P. H. and Zubin, J. New York: Grune & Stratton. Also: Walton, H. J. (1961). ‘ Group methods in the psychiatric treatment of alcoholism’. American Journal of Psychiatry, 118, 410. group are put to the test; understanding, firmness in reaching sound decisions, and skill in communicating them often help the drinking member to recover rapidly without incurring serious harm.
The alcoholic in a group is able to try out new ways of approaching people, secure in the knowledge that the reactions of fellow members, whether appreciative or critical, will never be scornful or humiliating. They can tell him things that he will not tolerate hearing from non-alcoholics, because of their personal experience of the illness. Moreover, he knows that the psychiatrist conducting the group will control the development of individual or group emotions too threatening or too disruptive for the members themselves to handle. The psychiatrist trained in group methods conducts the meetings so as to foster therapeutic interactions, and to ensure that harmful developments are recognized in time and counteracted. His role does not call for domination of the group nor for giving advice. The group collectively works through the conflicts of opinion between members which arise as private preoccupations are disclosed and discussed.
As he gains in self-confidence, the unassertive alcoholic discovers that to express himself forcefully does not incur the catastrophes he had previously feared. In this way patients learn to understand the motives for their behaviour and develop ways of modifying them when they are unrealistic. Their chances of remaining abstinent are greatly strengthened even when difficulties supervene.
A former accountant in a group found employment as timekeeper on a building site. He had taken care to let his employers know of his alcoholism. His foreman told him to mark as present a man whom he was using elsewhere illicitly. This happened repeatedly. The patient discussed his difficulty in his treatment group; as he saw it, he would have to refuse. He was certain the foreman would see to it that he lost his hard-found job. The group members sympathetically agreed that here was a perplexing problem; but although individual members offered particular advices the consensus was that he should do what the foreman instructed. He did the opposite. His rebellion against the group’s opinion was a try-out for subsequent rebellion against the foreman. He said to the foreman he was not happy about marking the absentee present. ‘You do as I tell you,’ said the foreman threateningly. Very unhappily he obeyed. But his protest was successful. The foreman never again asked him to be dishonest. This achievement gave him the confidence he needed to tell his employers that he was really capable of a more exacting job.
During the course of a group session problems will be focused upon, generally arising out of a recent situation related by one member, who also tells how he reacted to it. This becomes a theme in the discussion and it is worked upon from all sides. A patient described a lapse into drinking: ‘I fell away last week. I’m having trouble with my daughter. I’d finished my antabuse and intended to get more at last week’s meeting.’ His wife, he said, had urged him to take their daughter to task. At first she had supported him when he began to reprimand the girl but then, ‘as she usually does when she thinks I become too harsh with the children, my wife changed over and sided with my daughter. I couldn’t stand that. I went out, had a couple of whiskies, and then came home to continue the brawl.’
Mr Peel said that he also had difficulty with his children because he was not sure how to deal with them.
‘You can’t dictate to young people today,’ said Mr Fox. ‘ They think for themselves. You can’t tie them down, especially the girls.’
Mr Walpole, the original speaker, could not accept this: ‘I’m not going to stand for it. If she comes back home late again she’ll find the door shut.’ ‘What right have we to judge our children ?’ asked Mr Fox, and the group went on to consider, some of them for the first time, how their children might understandably be confused by not knowing what value to place upon admonitions and controls exercised by a parent who until recently had been disorganized by drinking.
Mr Walpole admitted reflectively that his daughter had indeed been concerned about him when he was drinking. ‘ But,’ he went on, ‘a father has to exercise control. Once you let the children get on top of you, that’s it.’
The group continued to discuss the position of the alcoholic parent. ‘ When you were drinking it didn’t matter what time your daughter came in.’ ‘The child thinks: “He didn’t care before, why should hecare now ? ” ’ They insisted to Mr Walpole that aggressive handling of his daughter would fail. ‘If you come the heavy father, she’ll just go off.’ A woman member, Mrs Holland, introduced a new note when she talked about her own youth. ‘At sixteen I used to stay out late.’ She said that, like Mr Walpole’s wife, ‘I want my husband to chastise the children if they do wrong, but when he does I take their side against him.’ Several of the men then said that their wives also placed them in this false position. Mrs Holland, by identifying herself with Mr Walpole’s wife, had taken on the role of all the missing spouses. But she was herself an alcoholic, so she could express the group’s problem, which she did precisely: ‘I tell my boy to be in by ten o’clock or there will be a row, and he answers back, “You weren’t in by ten when you were in the pubs.” Then there is chaos.’
Each member of the group had become enabled to see how his own actions in a common situation appeared to others, to wives and to children. Relationships in particular between parents and children were no longer seen as one-sided. Now they were putting themselves imaginatively in the posidon of their children, trying to see themselves from the outside. This led Mr Peel, whose father was also an alcoholic, to conclude with feeling: ‘I mean to be different to my children than my father was to me.’ The group had done its work for that session but the psychiatrist had registered a possible clue to Mr Walpole’s intractable harshness to his daughter; he decided that he would provide an opportunity in a later session for Mr Walpole to discuss the treatment he had received from his father, which might be serving as a model for his own behaviour as a parent.
The group process does three things. It supports the recovering alcoholic in his abstinence by letting him see that he is wrong to think that an alcoholic is sinful and degenerate. When he perceives the strengths and positive capacities of his fellow patients, his disgust with himself also diminishes. When he sees that others accomplish what he feared was impossible for him he begins to believe that he can himself reorganize his life to exclude alcohol. Secondly it shows him the situations in which he repeatedly involves himself and which he characteristically mismanages so that he learns to deal with them more effectively. Lastly, the group member, by examining his and other members’ ways of reacting and by exploring the origins of those ways, can in time modify his self-defeating patterns of behaviour.