Group Therapy and Treatment of Compulsive and Addictive Behaviors

¶ … Group Addiction TX

Theory Selection

The Psychodynamic Model

The Behaviorists

The Cognitive Model

The Humanistic Model

Theory Analysis

Ethical and Cultural Considerations

Group Development

Personal Model

Psychology has a long tradition of interpreting human behavior across different paradigms. The current paper investigates a method of incorporating four main psychological paradigms: psychoanalytic, behaviorist, cognitive, and humanist, into group counseling treatment for addictions and compulsive behaviors. Each paradigm is briefly discussed then the integration of aspects from theoretical models that spring from the paradigms is examined. This integration is based on previous empirically-based findings that support the use of a specific facet or an approach to treatment and counseling. The integration of these paradigms is discussed in terms of the ethical and cultural considerations, the development of groups, and a model developed specifically to avoid recidivism in addictive or compulsive behaviors.

Psychology has a long tradition of interpreting human behavior across different paradigms. The specific paradigm used defines what methods, hypotheses, and explanations will be accepted in describing behavior. Thus, the same behavior can be explained differently depending of the core propositions of each paradigm (Mcleod, 2007). Counseling also follows this approach. The specific counseling methods are derived from the major psychological paradigms. The five major perspectives in psychology are: the psychodynamic perspective, the behaviorist perspective, the humanist perspective, the cognitive perspective, and the biological perspective (McGraw-Hill, 2008). As the biological perspective is most often associated with the use of medications and psychiatry there will be no discussion specifically of that model in this paper, although counseling interventions are believed to have neurobiological effects.

The other four paradigms have direct applications to therapy and counseling for a number of different conditions. Psychotherapy or counseling for addictions has often been considered a difficult enterprise (Wurmser, 1978), but if approached from an integrative manner counseling for addictions and compulsive behaviors in a group or individual format can be effective. The current paper examines some of the aspects of each of the four remaining paradigms that this writer believes can be helpful in a group counseling approach to these issues and to forming a holistic approach to treatment.

Theory Selection

The Psychodynamic Model

The psychodynamic paradigm was originated by Sigmund Freud and advanced by other famous psychologists, most from a clinical psychology or psychiatry background such as Carl Jung, Karen Horney, and Alfred Adler (Hall, Lindzey, & Campbell, 1998). In essence, the psychodynamic paradigm views the mind as a composite of three interacting and sometimes competing structures that were originally named by Freud as the id (the unconscious instinctual aspect composed of drives), the ego (the mostly conscious aspect that mediates reality with drives and rules), and the superego (the conscience, mostly unconscious but learned from parents). Most dynamically- oriented theorists/methods retain Freud's structural motif, although differing emphasis was placed on the role and importance of the ego and of personal (object) relations with others by later theorists. In a dynamic model much of human behavior is attributed to instinctual drives (for Freud these were sexual or procreative drives) and much of motivation is unconscious in nature. Thus, the person often has little insight and little conscious control over many or most (if not all) of their actions. Behavior is fueled by drives and needs that are innate and psychological problems result when drives are blocked or when anxiety occurs as a result of unconscious conflicts that transpire due to the interactions of the three structures of the mind. Often the anxiety is blocked by defenses mechanisms such as repression that protects the ego from the anxiety associated with id impulses gone awry. For most of the psychodynamic theorists the crucial time in the development of one's personality occur the first six or so years of life, although there are some exceptions such as the theories of Erik Erickson (Hall, Lindzey, & Campbell, 1998). Psychodynamic counseling relies on three main techniques: free association (the client just speaking what is on their mind at the time), transference (the projection of inner conflicts on the therapist), and interpretation (when the time is right the counselor provides limited insight into the meanings of associations and transference). Sometimes dream analysis can be used if appropriate.

Early psychoanalytic formulations of substance abuse and compulsive behaviors proposed that these behaviors stemmed from the unconscious self-destructive instincts of the id resulting in a "slow suicide" (Khantzian, 1980). These early dynamic treatments focused on these tendencies of the id as actions that were merely manifest symptoms of a repressed idea that leaks into consciousness. The actual repressed idea is unrecognizable, it appears on the surface as compulsive behavior or addiction but it is distorted by psychological defense mechanisms. Compulsive behaviors and addiction were initially thought of as a compromises resulting from the conflict of a repressed idea and the defenses against that idea (Morgenstern & Leeds, 1996). However, as psychoanalytic thought began to move away from drive reduction models of behavior and more towards the ego functions the conceptualization of psychodynamic models altered its focus. More contemporary psychodynamic approaches maintain that compulsive behaviors like addictions are the defense mechanism themselves (e.g., Khantzian, 2012). Addicts and those with other compulsive behaviors use those actions to protect themselves from depression, anxiety, shame, and other negative emotions. That is to say that these behaviors are attempts at "self-medication" (Khantzian, 1980). So in the more contemporary analytical thinking these negative affective states are not the consequences of addiction or compulsive behaviors, but instead are the causes of them (Khantzian, 2012). One of the early originators of this idea, Wurmser (1978) believed that the greater the legal penalties or social stigma associated with a specific drug or behavioral compulsion, the more severe the psychopathology that was involved in driving it. The logical conclusion would be that drug control laws or laws against certain compulsive acts and many forms of drug treatment miss the point because they merely focus on the acts themselves and not the underlying pathology. If indeed the self-medication hypothesis is true, then it would follow that different psychopathological states would result in different compulsions or dugs of choice. This also led to a large body of research aimed at being able to predict the type of drug addiction or compulsion one has or one will have as a result of their underlying psychopathology. There has been extensive research starting in the 1980's up to the present time attempting to predict a specific drug of choice from psychological data. For example, Suh et al. (2008) attempted to predict specific drug addiction/abuse in a large sample of drug users and nonusers based on the Minnesota Multiphasic Personality Inventory-2 special scales using logistic regression analyses. The results indicated that repression directly and the depression subscales indirectly predicted membership in the alcoholic group, psychomotor acceleration was a predictor of the cocaine abuse group, and cynicism predicted preference for heroin, partially supporting the self-medication hypothesis.

Group psychodynamic therapy would still follow many of the same principles that individual therapy follows. By focusing group therapy on particular issues the clients are directed to introspect on specific events regarding their behaviors and feelings and are given insight about their interpersonal relationships and transferences in the group. By listening to each others' introspections, conflicts, and transference behaviors the process of insight into psychodynamic therapy is can be significantly increased in the group process.

Behaviorism

Behaviorists, like psychodynamic theorists agree that much behavior occurs beneath ones' conscious awareness, but in contrast the psychodynamic theorists, the behaviorists took a different approach to designing their theories. The bulk of early psychodynamic thought was derived from their observations and cases histories of clinical cases of people with psychological problems (in some instances very severe psychological problems) but the behaviorists developed their ideas initially from the experimental studies with animals (Hall, Lindzey, & Campbell, 1998). The early influential studies that formed the core theme of the behaviorists came from experiments by Pavlov, Thorndike, and Watson. Essentially the behaviorists took the view that what was externally observable was important and human behavior was based on the reinforcement or punishment of like behaviors in the past. In its most extreme form behaviorism viewed the mind as a "black box" from which little useful information could be derived (Skinner, 1966). In a sense then, behaviorism is the antithesis of the psychodynamic model in that it did not theorize about unconscious drives but instead relied on empirical evidence, measureable behaviors, and experimental models to derive their ideas B.F. Skinner, probably the most influential of all the behaviorists, took this notion to the extreme developing models of how schedules of reinforcement could be provided and offering a look at how behavioral theories could be applied to everything from education to psychotherapy to a model for developing society.

McAuliffe and Gordon (1980) proposed that addiction and compulsive behaviors are operantly conditioned responses that strengthen as a function of the quality, number, and size of the reinforces, which can be either positive (rewards like euphoria or peer acceptance) or negative (like anxiety reduction, pain management, or the reduction of withdrawal symptoms). For strict behaviorists addiction or compulsion are simply a terms for an operantly conditioned behavior. Other compulsive behaviors follow the same line of reasoning. The inability to refrain from using a drug or engaging in a compulsion merely indicates that a sufficient history of reinforcement has been acquired to drive a high rate of the behavior. Therefore, physical dependence, as in the DSM-IV-TR diagnostic criteria, is neither sufficient nor necessary to result in a diagnosis of an addiction (American Psychiatric Association [APA], 2000). Physical dependence is just a result of the overuse of certain drugs according to this view (McAuliffe & Gordon, 1980).

Behaviorists offer many different techniques that can applied to group counseling. Typically contingency management (CM) techniques are applicable behavioral for group counseling involved with addiction or compulsive behaviors (Higgins & Petry, 1999). CM initially begins with a functional analysis to determine antecedents and consequences of the behavior. By understanding the antecedent conditions and reinforcers for the behavior other more adaptive behaviors can be substituted for the addiction or the compulsion. In the early CM approaches Dustin and George (1973) specified three phases of CM that can be applied to group counseling. The first phase is problem specification which incorporates a functional analysis and defines terms as they have relevance for the client. The second phase is making a commitment to change. In addictions and compulsive behaviors the client is often in treatment at the bequest of others; the client needs to commit to change and believe that change is needed. Incentives to generate and maintain the clients' motivation are crucial to identify. The third phase is specifying goals where the group and the client specify the client's goals and the means to achieve them. The contingencies are delivered based on the client's maintenance of abstinence and on their attendance. Some groups use vouchers or reinstatement of privileges, whereas other contingences can be more internalized. In some cases punishment may be used to maintain treatment adherence, but the preferred way is to use positive reinforcement.

The Cognitive Model

According to the strict behaviorists all learning was a result of reinforcement (or punishment); however, as might be clear from the above description of CM behavioral therapies benefit from the addition of the recognition of the importance of thoughts and attitudes. Cognitive models of behavior have been extremely influential in counseling. The cognitive paradigm got its start when in 1946 Edward Tolman, in order to discredit a pure behavioral explanation of behavior, performed an experiment where completely sated rats were allowed to explore a T-maze. At one end of the maze was water, at the other end food. Later when half the rats were deprived of food and the other half were deprived of water they returned to the spot in the maze that would allow then to satisfy their needs. According to behaviorist theory since the rats were never reinforced for learning they should not have been able to find food or water later; however, Tolman had argued that the rats had made "cognitive maps" of the maze and this is why they knew where the food (or water) was (Tolman, 1948). Tolman's views would later be adopted by other psychologists such as Uric Neisser to develop the cognitive perspective of psychology (Neisser, 1967). The cognitive paradigm holds that people's mental states, thoughts, perceptions, and beliefs shape and mold their behaviors. Modern cognitive psychological principles have likened humans to complex information processing systems that input, analyze, and manipulate information in order to make decisions. Thus, cognitive psychologists acknowledge the presence of inner mental states like the psychodynamic and humanist models and still adhere to the rigid empirical and methodological approach of the behaviorist school. Cognitive psychology principles have been applied to all areas of psychological applications and in other fields such as economics and decision making theory.

Bandura's (1977) social learning theory (SLT) is an obvious cognitive application that fits in with group models of counseling. SLT indicates that learning (hence behavior) can occur via the modeling of another's actions. This is an obvious advantage to the group counseling process whereas individuals learn, relate, and share from each other's experiences. Motivational interviewing (Miller & Rollnick, 2002) is an empirically supported cognitive behavioral treatment for addiction, substance abuse, and compulsive behaviors. Motivational interviewing works by positively reinforcing treatment relevant cognitive behaviors such as "change talk" by means of an interpersonal process in the therapy session (e.g., the use of support, empathy and contingent feedback to the members of the group).

The Humanistic Model

The use of empathy, being able to take the client's perspective, is often regarded as a key component in fostering change. This component was popularized by the "third force" in psychology, the humanistic movement. This movement was fueled primarily by Carl Rogers, although certain other theorists like Abram Maslow were also instrumental in promoting the humanist perspective (Mcleod, 2007). This perspective came about as a reaction to the mechanistic and deterministic stances of the psychodynamic and behavioral models, hence the third force tag. Humanists strongly believe in choice, free will, and self-determination (or self-actualization as characterized by Maslow) as the important determinants of behavior and personality. Their ideas are reaction to the psychodynamic notion that instincts direct behavior and the behaviorist notion that the environment shapes personality. Therefore the humanistic model sought to put the control of people's lives back in their own hands and concentrated on issues such as the need to meet basic human needs such as food and shelter, but also the human need to strive for other more abstract goals such as a sense of belongingness, creativity, and becoming more in tune with the greater meanings of life. Motivation was then not also due to instincts or environmental pulls, but was also fueled by the need to become something more than a cog in a machine and a need to find deeper meanings to life and existence, something not well explained by the previous two paradigms. The humanistic paradigm was also extremely accomplished in the area of psychotherapy thanks to Carl Rogers being the first therapist to apply experimental methodologies to psychotherapy outcomes (Barry, 2002). Given their views the humanists are often considered to have the most positive outlook on behavior and personality compared to the previous paradigms.

Using the Rogerian ideals of therapist empathy, genuineness, and unconditional positive regard will enhance any group counseling format (Okiishi, Lambert, Nielsen, & Ogles, 2003). However, there are some other principles that Rogers explored that are also important in group counseling for compulsive behaviors or addictions. Rogers believed that every person had a drive towards self-actualization, but this drive was hindered by the "shoulds" which are attitudes people accept as being valid, but are actually based on false perceptions of what the person believes will validate them as a person (Rogers, 1965). We incorporate these values from others. In addiction and compulsive behaviors these "shoulds" can be important to identify and challenge.

Theoretical Analysis of the Paradigms

Which of the above paradigms is correct? There is no easy answer to that question; however, the most parsimonious answer is that all of the influences described by these paradigms play an important part in human behavior (Fava & Sonino, 2008).

The accomplished psychoanalyst Wurmser (1974) believed that addicts were not suitable clients for analysis. Moreover, the psychodynamic notion of addictive or compulsive behavior as a form of "self-medication" while long accepted in lay circles, has not stood up to empirical efforts to test its validity. Most of the research forecasting group membership by pathology is ad hoc, and not predictive. For example, even as far back as 1985 Cox found that those subjects who later developed addictions demonstrated the traits of independence, nonconformity, and impulsivity but no significantly difference levels of psychopathology than those who did not become abusers or addicts. In fact the opposite appears to be true: the comorbidity of depression, anxiety, etc. appears to result after significant abuse/addictive problems have occurred with the lone exception being personality disorders, but none of these predicted substance abuse problems better than the other (Grant et al., 2004). The self-medication hypothesis then may explain the maintenance and increasing intensity of compulsions or addictions, but not their etiology. Nonetheless the model can still be a useful consideration in treatment. The psychoanalytic notion of conscious and unconscious components of behavior has recently been popularized by models of social cognition that have divided cognition into automatic and controlled cognitive processes is relevant to understanding compulsive behaviors and addiction and can be applied in a cognitive behavioral model.

CM has solid empirical support to its effectiveness in the treatment of compulsive behaviors and addictions and meta-analyses of treatment studies indicate robust effect sizes (e.g., Dutra et al., 2008). However, the use of behavioral techniques is enhanced significantly by including cognitive therapy techniques. The principles of motivational interviewing have been empirically supported as valid methods to treat addictions and compulsive behaviors and are compatible in CM individual and group sessions (Moyers & Martin, 2006). Cognitive behavioral therapy has been used to treat a wide variety of issues and is often the preferred therapy for substance abuse, addiction, and compulsive behaviors (Miller & Rollinck, 2002; Moyers & Martin, 2006). However, all psychosocial interventions include common and unique factors in their conceptualization and implementation. There has been a long history of discussing the common factors in therapy and counseling which often include the educating clients, giving them a rationale for treatment, developing expectations of improvement, providing encouragement and support, and what is often considered crucial is the quality of the therapeutic relationship (Okiishi et al., 2002). The humanistic paradigm focuses on improving the therapeutic outcome via the therapeutic relationship. Moreover, the Rogerian notion of the "shoulds" and trying to conform to what we think others think we should is very similar to the cognitive model of counseling and implanting change. Therefore in group counseling the combination of these factors can bring together a viable counseling environment.

Ethical and Cultural Issues

There are several important issues to consider here (Pope & Vasquez, 2010):

1. Getting Informed Consent. Getting informed consent from clients for group therapy is of fundamental importance as it to assure the client's independence in entering and following the guidelines of counseling as well as informing them of the group procedures including roles, rights and responsibilities of all parties.

2. Counselor Competence. Counselors have an ethical responsibility only to practice within the scope of their professional competence as judged by education, training, and experience. Moreover, counselors should base treatments on established methods backed by sound theory. The counselor should be able to describe the theoretical basis for providing a counseling service or using a particular method.

3. Confidentiality. Counselors need to carefully guard against the unauthorized disclosure of client information. This issue should be explained to the group and to new members. Several other concerns associated with this are: Counselors have a duty to warn/protect individuals whom a client places in imminent danger, such sharing of needles, STDs, relapses, etc. Counselors should know the statues relating to these situations. Minors in the groups need to have a clearly established understanding of the extent to which their parents will be informed of issues surfacing in sessions. Counselors should be familiar with state and federal laws regarding minors and substance abuse.

4. The maintenance of appropriate boundaries during the sessions and after the groups are over should be discussed with the group and new members.

Another important concern is the counselor's and group's need to honor diverse values. It can be a challenge to guide change in individuals without undermining their autonomy. It is inevitable that counselors with encounter views that are different from their own and that group members will also have such differences. When the counselor holds a fundamentally incompatible value with a client, it is up to the counselor to either refer the client out or to attempt to help the client achieve their goals within the context of their value system. However, some clients with alcohol issues and other substance abuse issues will attempt cling to their alcohol use as form of cultural expression. In these cases if the counselor finds it necessary to make an effort to modify these values, it should be done no more than is necessary to address the particular focus of the treatment.

It can be beneficial to discuss differing values in group as long as it is done respectfully. Of course this does not mean values regarding substance abuse and continued use while in treatment, as sobriety should be stressed, but instead related to personal and cultural differences. If a counselor cannot practice tolerance and respect for certain individuals then the counselor should refer them to another treatment provider. Group members who cannot demonstrate tolerance and respect for others or if they become too disruptive and will not attempt to change or demonstrate respect for others should also be referred to another provider.

Group Development

Tuckman's (1965) model has been applied to the development of groups that can serve as a guideline for the development of the addiction counseling group. There are a few considerations however. First, Tuckman's model applied to closed groups that basically were oriented towards a goal and would disband when the goal was achieved. Many counseling groups are open, continuing, and allow new members to join at anytime. Some of the dynamics of these groups will change slightly because members can be at different stages, but the main concepts of Tuckman's model are still applicable.

Stage one (Forming) involves development of the group, briefing members as to the purpose, rules, ethics, etc. Many counseling groups are not static and new members may come in at anytime so this may be an ongoing or repetitive stage for the group. In substance abuse or compulsive behavior group there will be the need for self-disclosure and many members will feel uncomfortable at first. The stage can be comfortable and it is up to the counselor to provide the empathy and acceptance for all members so this is modeled across the group. This is also the best time for didactics and teaching, setting up CM plans for individuals, and working on the behavioral aspects of the treatment. In open groups newer members can benefit from the experience of more senior members and should be encouraged to listen closely to them, ask questions, and discuss issues with them.

In stage two (Storming) where different ideas, different needs, different views will start to compete. Individuals will experience difficulties in maintaining their sobriety or behavioral plan, or will have cravings and feel helpless. Here a counselor needs to be able to assist the different members in the development and maintenance of the CM plan that was originally agreed upon. Other group members should also be able to share and contribute. The counselor is responsible for trying to keep members focused and engaged in treatment. This is the phase where many relapses will occur (but relapse can occur at any stage) and the counselor should approach these as a learning experience for the client and not a failure. This is the stage where confidence in the ability to engage in treatment will begin to wane and the counselor is crucial in working with clients and using Rogerian principles to strengthen the therapeutic alliance and keep the client on track.

The third stage (Norming) occurs when the group has achieved a sense of purpose and can focus on the group goals. Counseling groups are often able to benefit from the flow of members in and out of groups as these groups are often open. Thus, there will be members at differing stages of development and those in the early stages can benefit from the experience of those that have been in the group. So there will always be some members in the storming phase and some in this phase some in the next two phases. The empathetic counselor will let the group benefit from this situation.