Group Psychotherapy with Addicted Populations

An Integration of Twelve-Step and Psychodynamic Theory, Third Edition

Philip J. Flores

• Publisher: Routledge
• Year: 2007
• ISBN:
  9781136782114
• Edition: 1
• Topic: Psychologie
• Subtopic: Santé mentale en psychologie

Be more effective in group therapy with addicted clients Group Psychotherapy with Addicted Populations: An Integration of Twelve-Step and Psychodynamic Theory, Third Edition is the newly revised edition of the classic text, that provides you with proven strategies for defeating alcohol and drug addiction through group psychotherapy. Philip J. Flores, a highly regarded expert in the treatment of alcoholism and in group psychotherapy brings together practical applications of 12-step programs and psychodynamic groups. This updated book explores the latest in constructive benefits of group therapy to chemically dependent individuals, providing opportunities to share and identify with others who are going through similar problems, to understand their own attitudes about addiction by confronting similar attitudes in others, and to learn to communicate their needs and feelings more directly. Topics in Group Psychotherapy with Addicted Populations: An Integration of Twelve-Step and Psychodynamic Theory, Third Edition include:

• alcoholism, addiction, and psychodynamic theories of addiction
• alcoholics anonymous and group psychotherapy
• use of confrontational techniques in the group
• inpatient group psychotherapy
• characteristics of the leader
• transference in the group
• resistance in groups
• preparing the chemically dependent person for group
• the curative process in group therapy
• integrating a modern analytic approach
• a discussion of object relations theory
• group psychotherapy, AA, and twelve-step programs
• diagnosis and addiction treatment
• treatment issues at early, middle, and late stages of treatment
• a discussion of guidelines and priorities for group leaders
• countertransference
• special considerations of resistance to addiction
• termination of treatment

Professionals working in group therapy and addictions will find Group Psychotherapy with Addicted Populations: An Integration of Twelve-Step and Psychodynamic Theory, Third Edition an invaluable resource emphasizing the positive and constructive opportunities group psychotherapy brings to the chemically dependent individual.

Part I:

Theoretical Models

Chapter 1

Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective

The world of addiction treatment and group psychotherapy has evolved and changed since the first edition of this book appeared in 1988. The growing impact that the neurosciences have had on the way we understand addiction and the proliferation of ways addictive behavior now pervades our society have been foremost among these changes. Addiction is no longer limited to psychoactive substances such as alcohol, cocaine, heroin, and other central nervous system (CNS) depressants and stimulants, but has been expanded to include the so-called “process addictions” such as sex, gambling, work, shopping, exercise, and even the Internet (Freimuth, 2005). Because these new addictions have nothing to do with substances that are ingested or injected into the body, the “disease model” of addiction must be expanded, with a new paradigm put forth that better captures the fundamental similarities shared by these diverse conditions. Since it is now recognized that addiction has more to do with a person’s habitual and compulsive behaviors than with the substances introduced into the body, a more thorough and comprehensive theoretical perspective is required. Such a perspective must elucidate the multitude of diverse conditions that predispose some to become addicted to almost anything, while others use substances recreationally but do not develop an addiction. Without inclusion of more recent discoveries in the neurosciences, outdated genetic explanations are incomplete. Countless twin adoptee studies conducted over the past fifty years account for only 20 percent of the variance when predicting who will become addicted (Goodwin, 1979). Recent advances in the neurosciences—along with a complementary allegiance to attachment theory— provide a more thorough and satisfying paradigm for the understanding of the dynamics involved in addiction. Most important for this book, these advances also furnish new, cogent reasons why group psychotherapy and the group format of twelve-step programs such as Alcoholics Anonymous are the most potent formats for the treatment of addiction.

Interpersonal Neurobiology

The neurosciences have taught us the astounding fact that the most efficient way to change one’s brain is not to give him or her drugs that mimic, block, or substitute for endogenous neurotransmitters, but rather to provide the person with an ongoing opportunity for novel experiences and optimal emotional arousal within the context of a safe, supportive, interpersonal relationship and affective bond. In short, if you want to change someone’s mind, become emotionally attuned with the individual and talk with him or her in a meaningful, caring manner. State-of-the-art neuroimaging techniques have confirmed this to be so. Schore’s (2003a) review of hundreds of neuroimaging studies demonstrated the importance of the implicit, bodybased, nonverbal affective communication that occurs within the critical component of the intersubjective field of the therapeutic alliance. This critical process accounts for the greatest structural changes in the brain during effective therapy. The neurosciences have led the way to an understanding of human behavior that is moving beyond the limits of the mind-body dualism, which has dominated medical science for the past 300 years. This emerging evidence has prompted Lewis, Amini, & Lannon (2000) to write, “Dividing the mind into ‘biological’ and ‘psychological’ is as fallacious as classifying light as a particle or a wave” (p. 167).

Brain-mapping studies (Braun et al., 2000), in vivo neurochemistry, and studies of brain receptors (Insel & Quirion, 2005), and state-of-the-art neuroimaging techniques (functional magnetic resonance imagery (fMRI) and other imagery techniques such as PET scans) make it possible to actually visualize changes in brain function or neuron pathways that are the result of attachment, substance use, dysphoria, satisfaction, and even psychotherapy. Terms such as cortical rerouting, neurogenesis, intensive operant shaping, and brain neuronal reorganization reflect mounting evidence that the brain remains plastic throughout the lifespan. They dislodge the pre-1980s’ notion that the brain is hardwired at birth and not subject to alteration in adulthood (Taub & Uswatte, 2000; Morris et al., 2001; Weis et al., 2000). Sharon Begley (2004) captured the implications of these new discoveries when she wrote about “the brain’s recently discovered ability to change its structure and function in particular by expanding or strengthening circuits that are used and by shrinking or weakening those that are rarely engaged. [Although] the science of neuroplasticity has mostly documented brain changes that reflect physical experience and input from the outside world” (2004, p. 1), more recent research in the area of meditation has shown that altering the structure of the brain is not limited to only external physical rehearsal. The brain can also change in response to purely internal mental signals, similar to those practiced in meditation. Furthermore, those individuals who have the most practice at it are the ones who demonstrate the most alteration in brain circuitry. “This opens the tantalizing possibility that the brain, like the rest of the body, can be altered intentionally. Just as aerobics sculpt the muscles, so mental training sculpts the gray matter in ways scientists are only beginning to fathom” (Begley, 2004).

These advancements also provide attachment theory with concrete evidence that helps explain not only how the brain becomes addicted, but also how it responds to psychological interventions. For instance, single positron-emission tomography (SPET) was used to compare two men with similar diagnosis and age. One man received psychotherapy for a year while the other did not. Pre-treatment SPET imaging revealed reduced serotonin uptake in the medial forebrain bundle when compared with ten healthy individuals. After a year of therapy, the treated individual’s SPET pattern had returned to normal. The untreated patient stayed the same. Preliminary studies also showed that functional magnetic resonance imaging (fMRI) can predict with high accuracy whether an individual will relapse following treatment for methamphetamine abuse (Paulus, Tapert, & Schuckit, 2005).

An equally startling discovery is that this new evidence about the addicted brain does not lead to the need for the development of new treatments for addiction, but actually validates many current methods already being utilized. The field of “interpersonal neurobiology” has validated the venerable notion that talking with someone—especially if the encounter is meaningful and occurs within the context of emotional arousal, attunement, and a strong emotional bond—will alter neural pathways and synaptic strength. All forms of psychotherapy, from psychoanalysis to cognitive behavioral therapy (CBT), are successful to the degree to which they accomplish this and enhance growth in relevant neuron circuitry. The use of communicative language and emotional attunement provides the best medium for neuronal growth and integration.

The false separation that exists between biology and psychology is gradually diminishing thanks to the contributions of attachment theory and the neurosciences. Research has revealed a number of erroneous conclusions about the brain and psychotherapy that should be changed. Recent scientific discoveries revealed the following six facts:

1. Attachment and psychotherapy can alter brain chemistry.
2. Learning-based experiences alter neuronal connectivity.
3. Potentiation requires activation (environmental stimulation), which alters the strength and autonomous patterns of brain functioning.
4. Synaptic strength is an experience-dependent phenomenon.
5. Speaking in a meaningful way, paying attention, and attachment alters brain biochemistry and changes in synaptic transmission, strength, and numbers.
6. Attachment can alter gene expression.

As Siegel (2006) points out, we are at an exciting moment in the history of psychotherapy as neuroscience has shown us the way to integrate the clinical field of psychotherapy with the independent field of neuroscience. No longer is the simple “single-skull” view of the mind appropriate since recent research findings from the neurosciences have now altered completely how we define the mind. The old reductionistic perspective that the mind is nothing more than the end result of the accumulation of the molecular and biochemical functioning of the brain is clearly outdated. This obsolete view fostered the belief that the best way to change someone’s mind was to give the person a pill or alter synaptic connections in some way. The mind is much more than just the activity of the brain. The mind uses the brain to cultivate itself or as Siegel (2006) says, “The brain is the plaything of the mind.” No longer is the mind viewed as a singular encapsulated organ enclosed within an individual. The new perspective reconciles this misconception when it defines the mind as the flow of energy and information within the brain as well as the flow of energy and information between brains. The interpersonal neurobiological perspective enables group therapists to embrace the findings of the neurosciences and use these findings to understand how the mind is altered through group psychotherapy, primarily through the experience of being with others.

The mind develops as the genetically programmed maturation of the brain is shaped by ongoing experience, and the experience that sculpts the brain the most is not drugs, but relationships. As Siegel reminds us, one of the most powerful relationships is a properly conducted and managed therapy relationship (2006). No form of psychotherapy is effective unless it changes the brain, and long-lasting changes to the mind require changes in the brain. Most important, a pill is not needed to accomplish this goal. A recent pilot study (Siegel, 2006) with attention-deficit hyperactivity disorder (ADHD) patients confirmed this hypothesis, demonstrating that individuals can be taught how to alter the ingrained tendencies of their mind to be easily distracted. More than sixty subjects with ADHD were taught to eliminate and inhibit their impulses by utilizing mindfulness techniques practiced during meditation. When Siegel first showed the results from his study to his colleagues, the first question was “What was the dosage of the medication you used?”

Siegel (2006) explained how experience can actually activate genes to stimulate synaptic growth. Neural stem cells, which are uncommitted blobs of neuroplasma in our brains, divide spontaneously every twenty-four hours or so. When they divide, one remains with the stem cell line, and the other waits for a novel experience to be inspired to grow into an integrated neuron in the brain—no novel experience, no neuronal growth. However, provide that experience repeatedly and interesting things start to happen. It takes about a month for the neuron to get inspired and another two or three months to get established. After 90 to 120 days, massive changes will occur in the integrative functions of the brain related to new stem cell division and differentiation.

The implications from these findings are profound. As Siegel suggests, scientific evidence now exists confirming every psychotherapist’s dream. Psychotherapy does not just change one’s mind; it alters the brain. One especially important parallel from this research for addiction treatment is the recognition that changing one’s behavior and mind, as well as one’s brain, requires a certain commitment of time. AA’s intuitive recognition and recommendation of “ninety meetings in ninety days” takes on added authority when the implication of Siegel’s work is carefully examined. AA got it right: To produce the desired change toward sobriety, an alcoholic’s brain will require at least ninety days before it can make the massive changes in stem cell differentiation and division Siegel describes. The neurosciences are confirming that effective therapy requires three essential components:

1. A novel experience
2. An optimal amount of emotional arousal to prime the brain for neuronplasticity:
   • new synaptic connections
   • modification of old synaptic connections
   • stimulate stem cells to differentiate into fully integrated neurons
3. Support

The Neurophysiology of Attachment

As data from the neurosciences accumulated, researchers searched for a theoretical framework to help translate their discoveries into an explanation that would have both clinical relevance and practical application for treatment. The emergence of this accumulative information from diverse perspectives required a comprehensive cohesive theory to integrate and explain this shared phenomenon. Attachment theory provided this needed paradigm. In effect, attachment theory can be viewed as an attempt to update psychoanalytic theory in light of the newer discoveries in developmental neurobiology and the neurosciences (Diamond & Marrone, 2003). Furthermore, attachment theory has evolved into a body of knowledge that provides a translation of findings from numerous domains of study into a common language and conceptual framework that includes psychoanalysis, genetics, memory, evolutionary psychology, child development, and interpersonal neurobiology. This integration enables researchers and scientists from a wide range of traditionally independent fields of research to coalesce into a unified perspective. Another refreshing feature of attachment theory and its associated influence in the interdisciplinary sciences is how much it naturally inspires, informs, and confirms child development studies, the neurosciences, treatment outcome studies, animal studies, and modern psychodynamic theory.

Siegel (1999), for instance, provides convincing evidence that attachment not only influences a child’s developing neurophysiology, but can also stimulate neurogenesis in an adult. Cox (2006) supports this view when he points out that an attachment experience causes neurons to fire, neuronal activity causes gene expression to change, and the resulting stimulation of new proteins promotes new brain structure. In the following outline Siegel describes the way the attachment system works to alter brain activity (1999, p. 67). His description has been expanded so parallels can be drawn between a child’s developing mind and an addict’s addicted brain.

1. Attachment is an inborn system in the brain that evolves in ways that influence and organize motivational, emotional, and memory processes with respect to significant caregiving figures, whether those caregivers are parents, sponsors, or group members.
2. The attachment system motivates infants (and adults) to seek proximity to parents (and other primary caregivers such as friends, spouses, therapists, and fellow members of AA for instance), increasing the potential for meaningful communication with them.
3. At the most basic evolutionary level, this behavioral system improves our chances for survival. As Bowlby implies, just as we are more likely to survive on the plains of the Serengeti in Africa if we have a companion, our chances for survival increase if we have a companion when we are battling a serious case of cancer or even taking a walk down a dark alley. Recovering from an addiction is more likely to be successful if someone is not trying to do it alone.
4. At the level of the mind, attachment establishes an interpersonal relationship (an alliance) that helps the immature brain (or the addicted brain) use the mature functions of the parent’s (or group leader’s) brain to organize its own processes.
5. The emotional transactions of secure attachment involve a parent’s (or group’s) responses to the child’s (or addict’s) verbal and nonverbal signals, which can serve to amplify the child’s (or addict’s) positive emotional states and to modulate negative states.
6. In particular, the aid parents (or group members) can give in reducing uncomfortable emotions such as fear, anxiety, or sadness enables children (or other group members) to be soothed and gives them a haven of safety when they are upset.
7. Repeated experiences become encoded in implicit memory as expectations and then as mental models or schemata of attachment which serve to help the child (or addict) feel an internal sense of Secure Base.

Interdisciplinary Research and Attachment Theory: A Source for Informing Addiction Treatment

The contributions that attachment theory (Bowlby, 1988) has to offer on addiction and treatment have not been appreciated or recognized for their far-reaching implications. Until the sheer magnitude of accumulated evidence from developmental neurobiology (Siegel, 1999), the neurosciences (Schore, 2003a; Sroufe, 1996), and developmental psychoanalysis (Stern, 1985) forced the psychoanalytic community to embrace Bowlby’s work, attachment theory had been exiled to the fringes of psychoanalytical theory and judged to only have relevance for social psychology and child development. Diamond and Marrone (2003) and Cortina and Marrone (2003), utilizing Kuhn’s (1962) concept of the difficulty of all sciences accepting paradigm shifts, suggests that the resistance to attachment theory within the psychoanalytic community is because Bowlby’s theories were not just a matter of offering a slight revision of psychoanalysis, but in actuality, “attachment theory proposes a completely new framework from which to understand clinical and developmental phenomena” (Cortina & Marrone, 2003, p. 14).

The potential impact of attachment theory’s contributions to treatment is not limited to just addiction. Bowlby’s original ideas (1958, 1973) have evolved into a body of knowledge that furnishes a translation of findings from numerous domains of study, providing a common language and conceptual framework. This integration enables researchers and scientists from a wide range of traditionally independent fields of research to coalesce into a unified perspective. Another refreshing feature of attachment theory and its associated influence in the interdisciplinary sciences is how much it naturally inspires, informs, and confirms child developmental studies, the neurosciences, treatment outcome studies, animal studies, and modern psychodynamic theory. (These sentences are repeats of sentences a few paragraphs prior to this paragraph.) Each of these different streams of research will be briefly covered to help illustrate attachment theory’s relevance to group treatment and addiction.

Addiction As a Brain Disease

This section aims to integrate knowledge gathered from several disciplines about interpersonal experiences, mental processes, child development, attachment, stress, and substance use to help provide a conceptual framework for desc...