Integrating psychological paradigms in group counseling for addictions

¶ … 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.

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.

The fourth stage (Performing) is the stage where group can focus on the tasks and reach goals as a unit. Senior members of the group here learn by listening, sharing, and teaching; newer members learn mostly by listening, asking, and sharing. In an open group the newer members are able to move quicker through the stages than their predecessors as they have the benefit of experience. Members at this stage develop a string sense of group cohesiveness, the feeling of an awareness of belonging or being a member of the group. Members in this stage can go beyond simple behavioral interventions and CM and begin to explore an in-depth examination of their thinking processes, motivations, and focus on bringing desirable changes in behavior.

The fifth stage, adjourning, occurs after the client, the group, and the counselor concur that a member has "graduated" for lack of a better term is ready to function outside the group. The counseling group itself is likely to be ongoing, unlike the groups that Tuckman envisioned. However, closed groups may have a group adjournment. Twelve-step groups never formally acknowledge this step as adjourning and hard-core "12-steppers" consider group attendance a lifelong endeavor.

A good counselor would also plan for follow-up meetings with members that leave the group to allow for booster sessions and in cases of legal involvement for accountability purposes so that the members will continue their programs. Group members "graduating" should be encouraged to return to the group from time to time if they so desire.

Personal Model

This writer has come to believe that an integrative therapy/counseling approach is the best approach for the treatment of addictions and compulsive behaviors. The difference between integrative psychotherapy and eclectic psychotherapy is that integrative therapy ties together at least two different elements from at least two different schools of thought into a unified theoretical approach, whereas eclectic approaches combine different techniques from different schools on a case by case basis (Palmer & Woolfe, 1999). I do not believe that a competent counselor will just use a trial and error approach in much the same way the psychiatrists prescribe medications.

Using and integrative approach the client, counselor, and group should first identify the situations in which group members he/she may experience difficulty coping and increased desire to return to the addictive or compulsive behavior. Since most addicts and those with compulsions have tried to stop on their own reviewing past relapses and discussing fantasies of using would allow for identification of such situations. For clients who are still engaging in their behaviors a self-monitoring system that records situations, feelings, and interpersonal factors associated with urges could be developed (this could be useful for all clients).

Next, the members of the group need to learn to recognize the situations associated with relapse so risky situations can be addressed. Learning and practicing more effective coping skills in these situations should be undertaken. This allows for the development of motivation, self-efficacy, and strengthening of the ability to delay gratification and adopt more distal goals. For many of the clients in the group assessing and developing these last two aspects are very important.

For long-term success identifying individual aspects of addictive and compulsive behaviors, cognitive restructuring, and teaching would be important factors of successful treatment in several ways. These could follow some basic guidelines such as:

A. Reviewing the client's expectations of their behaviors. Addictions and compulsions are driven by expectations of the client. Something is expected from the behavior. These clients concentrate on the immediate effects of their behavior and not the long-term effects. An effective treatment regime should include having them weigh their expectancies for both immediate and delayed consequences their behavior. This allows for the identification of the drive of the behavior and can help them to identify and strive for longer-term outcomes. Practice here is the key to learn to use higher-order mental processes (social cognition).

B. The group can jointly develop recovery maps which are analyses of high-risk situations that emphasize the different choices available to cope in these situations. A solid therapy system should actively address these issues.

C. As discussed above these behaviors are not just specific problems themselves but are often symptoms of bigger issues. Other needs often have to be addressed on many levels. By discussing mood, relationships, and occupational issues and using reframing strategies in these areas a person can achieve greater lifestyle balance and develop coping mechanisms for triggers of use and relapse.

D. Return to activities that were previously enjoyable or identifying new activities and goals can help establish more positive behaviors (so-called positive addictions).

E. Relapses are not uncommon in recovery, wanting to go out and return to one's old ways is common. Counselors should be assisting in the reframing of such episodes. What is driving this desire and how else can the drive be addressed? This can help decrease the tendency of the person to view relapses as the result of a personal failing and reduce the potential of the notion that a slip will inevitably lead to relapse

F. Finally, other issues such as depression or other psychiatric problems should be addressed in their own right.

Table one displays the mechanics of the group:

By to adhering to these main points one can integrate the important paradigms and work towards a positive outcomes with these difficult clients. The style will be democratic, with the counselor's role being less prominent as the group develops over time. In early sessions the counselor will provide didactics and structure; however, as the group develops more and more structure will be provided by the group members. The counselor will allow the group format to be determined by all of the members of the group. All individuals in the group will be able to participate and structure the group's direction.