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U sing G roup T he rapy to P ersu adeD ual-D iagno sis P a tien ts to S eekSub stance A bu se T rea tm en t

H osp ital an d C omm unity P sych ia try N ovem ber 1 988 V o l. 39 N o . 11 1209

L ia l K ofo ed , M.D .A lice K eys, M .D .Pa tien ts w ith a su bstance ab used iso rde r an d a coex is ting p sych ia t-n c ib lness re spo nd poo rly to pn i-m ary su bstance abu se trea tm en tand o ften becom e the resp ons ib il-it y ofg ene ra l psych ia tric un its (1 ,2 ) .P sy ch iatr ic h osp italiza tion , how -eve r , can no t p ro v ide d efin itiv e trea t-m en t fo r th e se d ua l-d iag nosis pa -tien ts ( 1) . In fac t, w hen trea tingsu bstance abu sers , g en era l psych i-a tric w ards a re m ost e ffec tive w henth ey lim it th eir goa ls to p ro v id in gd eto x ifica tion an d psych ia tric sta -b iliz a tion an d to pe rsuad in g th ep atien t to accep t reco ve ry -o rien tedo u tpa tien t care .

T rea tm en t accep tan ce am ong sub-stance abusers m ay be im pro vedby sp ec if ic p ersuasiv e e ffo rts (3 ,4 ) .T he use o f pe rsu asion is p articu -ba rm y critica l fo r d ua l-d iag nos is pa -tien ts , a s coex istin g th ough t o r af-fec tive d iso rde rs m ay ex ace rb ateden ia l o f su bstance abu se. Th isp ap er d escr ibe s th e use o f a p er-suasio n grou p fo r du a l-d iagn osisp atien ts on a g ene ra l h osp ital in -

D r. K ofoed is ass istan t p rofes-so r of c lin ica l p sych ia try a t D ar t-m outh M ed ica l S choo l and d i-rector o f ou tp atien t p sych ia tryat the V eterans A dm in istra tionM ed ica l C en ter in W hite R iverJunction , V erm ont. D r. K eys isassis tan t p ro fe sso r o f psych ia tryin the S choo l o f M ed ic ine atO regon H ea lth S ciences U n iv er-sity an d in pa tien t sta ff psych ia -tr is t a t the V A M edical C en te rin Po rtland , O reg on . A ddres sco rre sp ond en ce to D r. K ofoeda t P sych ia try Serv ice (1 16 A),VA M edica l C en ter , W h iteR iver Jun ction , V erm ont 05001 .

pa tien t psych ia tric w ard . P re lim i-n ary d ata on the g ro ups e ffec tive -n es s in pe rsu ad ing p a tien ts to ac -cep t on go in g subs tan ce ab use the r-ap y are p re sen ted .

T he g ro up , w h ich w as estab -lished in 1 983 , cap ita lize s on theun iq ue o ppo rtun ities p re sen ted b ypsy ch ia tric hosp ita liza tion to pe r-suade su bstance abusers to seektreatm en t. D uring hosp ita liza tionpa tien ts d o no t use d rugs o r alco -ho l, and th eir d isrup tiv e p sych ia t-nc sym ptom s a re con tro lled . B yassum in g a sick ro le, p atien tsbecom e am en ab le to be ing in flu -en ced (3 ) .

T he ho sp ita l se tting a lso fac ili-tate s peer g rou p d iscussio n o f su b-stan ce abuse. D iscus sion w ith pee rso ffe rs the sub stance ab use rs a m oreaccep tab le sou rce o f sup port andco nfron tatio n than is usua lly ava il-ab le to th em on gen era l p sych ia t-nc w ards . I t a lso p rov ides themw ith an o ppo rtu n ity to expe rien cea g roup fo rm a t sim ilar to the k in dused by m any substance abuse trea t-m en t p rog ram s, a p rocess ca lledro be in du ctio n.

The p ersua sion groupSe ttin g and pa tien tsT he settin g fo r the g roup , ca lledthe su bstance ab use g rou p expe ri-ence, o r SAG E , is a 2 3-bed in pa -tien t psych ia tric w ard a t a VAm edica l cen te r . P a rticip atio n is b im -ited to pa tien ts on the w ard w hohave , have h ad , o r som eone th in ksm ig h t h ave a pro b lem w ith abuseo f a lcoho l o r o the r d ru gs. P a -tien ts in th e ho sp ita ls specia lizedsubs tan ce ab use p rog ram , lo ca tedin a sep ara te bu ild ing in the m ed i-cal cen te r, do n o t pa rtic ip ate inthe g ro up .

D ua l-d iagno sis pa tien ts m ake upa sign ifican t p rop ortio n of th ew ard s p opu la tio n , and usua lly

abou t h alf th e w ard s pa tien ts a reinv o lved in SAGE at an y one tim e.P a tien ts a re a ssign ed to the g roupso on a fter adm issio n to m ax im izethe ir ex posu re . Th e o n ly c rite r iafo r m em bersh ip o the r than a cer-tam o r poss ib le d iag nosis o f su b -stance abuse is a requ irem en t tha tpa rticip an ts re fra in from m ak ingov ert th rea ts o r eng ag ing in m ajo rd isrup t ions.

G roup stru ctu reThe gro up m eets tw ice a w eek .E ach m ee ting con sists o f tw o h alf-ho ur sess ions, w ith a 15 -m inu teb reak a fter the firs t h alf hou r. Th efo rm a t is w e ll to le ra ted by acu te lyill in pa tien ts . T he break allow s thep atien ts to talk and d isco ve r com -m on issues tha t o the rw ise m ig h tno t em erge and g ives staff an op-p ortun ity to consu lt w ith eacho the r du rin g the se ssion .

T he gro up is co -led by a sta ffm em ber o f the sub stance ab usep rog ram and a sta ff m em ber fromthe p sych ia tric w ard . Jo in t lead er-sh ip by the p ro gram s com ba ts th em ispe rcep tion by pro gram s tafftha t trea tm en t p lann in g is in f lu -enced by tu rf issu es b etw een thetw o pro gram s (5 ) . C o llabo ra tionbe tw een the depa rtm en ts m in i-m izes op portun ities fo r pa tien tsto cause con flic t w ith in sta ffth rou gh a process ca lled sp litting ,an eg o m ech an ism th at is com -m only a fea tu re o f the d ua l-d iagn osis pa tien ts lea rned m an ipu-la tiveness (1 ,6 ) .

A t hosp ita ls w ithou t su bstanceabuse trea tm en t un its , a th erap istw ith expe rien ce in su bstance ab useand self-h elp reco ve ry g ro ups m ayse rv e as co -leade r (7 ). P sy ch iatr icresid en ts a lso h elp lead SAG E ,w hich presen ts a u n iqu e tra in ingopportun i ty .

T he gro up leade rs op en eachsessio n by exp lain ing c rite ria fo radm ission to the g rou p and th eg roup ru le s . S ta ff exp lain tha tSA GE is no t a lec tu re bu t a g ro upin w hich m em bers learn from eacho the rs expe rien ce . T hey coun se lthe g ro up m em bers to m ain taincon fid en tiality . Th e in tro duc tionencou rages pee r d iscussio n , m in i-m izes de fensiv eness, and prom o tes

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1210 Novem ber 19 88 V ol. 39 N o . Ii Hospita l and C omm unity P sych ia try

co n tinu ity in th e face o f rap id tu rn -ov er (8 ) .

SA GE m eetin gs a re he ld on thepsych ia tric w ard rath er th an in thesub stan ce abuse p ro gram , b o th toem ph as ize the ro le substance abu sep lays in p sych ia tr ic illne ss (9 ) an dto m in im ize excuses fo r m issin gg rou p . T he grou p se rv es as anad junc t to A lco ho lic s A nonym ousor N arco tic s A nonym ous, w h ichtend to in ap propria tely m in im izepsy ch iatr ic illne ss . AA and NAgroups a re va riab ly to le ran t o f psy -ch iatn ic sym ptom s an d m ed icatio ns,w h ich lim its th eir use fu lness inp e rsu ad ing p atien ts to seek sub -stance abu se trea tm en t. H ow ev er ,AA and NA are va luab le in th elo ng-term rehab ilita tion of du al-d iag nosis p a tien ts (1 0 ).

G roup proces sThe m ain g oa ls o f the g roup a reto pe rsuade pa tien ts to ackn ow l-edg e the ir d rug ad d ic tion an d toseek co n tinu ed sub stance ab usetrea tm en t. B ecau se pa tien ts in th eea rly stage o f recov ery m ay as-sum e a passiv e stance tow ard p er-son s o f au tho rity , th e g rou ps lead -e rs av o id lec tu r ing . T hey attem p tto an sw er question s d irec tly (ev a-sion is easily spo tted b y pa tien tsw ho have m ad e a ca ree r o f it ) bu tno t be fo re ex p lo ring w hatp rom pted th e q uestion an d w hatthe g ro up m em bers th in k abou t it.

F requen tly pa tien ts ask th e th eta -p ists ab ou t the ir ow n sub stan ceuse , w h ich se rv es as an in d irec tw ay o f tes ting th e the rap ists cred i-b iity . W ithou t b ecom ing d efen -sive , the leade rs rem in d th e g rouptha t th eir jo b is to h elp th e m em -be ts he lp each o th er and em pha-size tha t they h av e had exp eriencew ith p atien ts w ho have success -fu lly recov ered . T hey enco urageth e pa tien ts to sh are the ir pe r-sona l exp eriences w ith substan ceab use aiid the pa in and lo ss th eyh av e su ffe red as a re su lt. S u chex changes am ong peers m ean m oreto the pa tien ts th an does p rose!y -tiz ing by staff.

T he m os t com m on questio nasked of the the rap ists is D oc to r ,ju s t w ha t is an a lco ho lic (o r ad -d ict)? Though the pa tien ts ask

the qu estion to assu re th em se lvesthey do no t m ee t the c riter ia , th usp erpe tu a ting the ir d en ial, they al -w ays ha rbo r fea r abou t the an -sw er. R a the r than prov id ing animm ed ia te de fin ition , SA GE lead -e rs have foun d th ey a re m o re suc -cess fu j in p en e tra ting d en ial if theyencou rage p atien ts to exam in ethe ir su bstance use in a step -by -step p rocess.

F irs t, th e g ro up lead e rs p o llg ro up m em bers abo u t the ir de fi-n itio n of ad d ic tion . M ost pa tien tssoo n rea lize tha t they d efine anaddic t as the pe rson w ho has on em o re p ro b lem re la ted to substan ceabuse th an they d o . F or exam ple ,the g roup m em ber w ho h as losth is w ife d ue to su bstance ab use ,bu t no t h is job , d e fines an add ictas som eone w hose sub stance abuseh as cau sed h im to lose h is job .

N ex t, g rou p leade rs a sk w he the rsu bstance use has in te rfe red in m a-jo t areas o f the pa tien ts live s.T hey have fo und it u se fu l to a skpa tien ts w h eth er they h ave expe -n ien ced the C AG E crite ria o f sub -stan ce abuse-hav in g tr ied to C u td ow n , be ing A nnoy ed by c ritic ism sof use, hav in g G uilty fee ling s ab ou tsu bstance u se, o r need ing a m orn -in g E ye opene r (1 1 ) .

F inal ly , SAGE le ade rs de fin e su b-stan ce use d iso rde r a s a loss o fcon sisten t con tro l ov e r subs tan ceu se (3 ) , a d efin itio n they havefou nd to be the m o st u sefu l an ddurab le. T hey ask pa tien ts w he the rthey have eve r used alcoh o l o rd ru gs in g rea te r quan titie s thanthey in tended to o r u sed themw hen they had no t in tended to .

R em ind ing pa tien ts th at su b -stance ab use co n tr ib u ted to th eirho sp ita lizatio n can h e lp them con-fron t den ia l. T h e leade rs o ftenfin d , a s d id S afe r (9 ) , tha t m anyp atien ts e sca lated the ir use o f sub -stances just be fo re the ir hosp ita li-za tio n o r w ere in tox ica ted a t thetim e of hosp ita liza tion . Em ph asiz -ing the ro le o f su bstance abu se inthe ir need fo r ho sp ita lizatio n he lpspa tien ts rea lize they have tw o d is -tinc t bu t in teractin g prob lem s, bo th .o f w h ich req u ire trea tm en t (6 ,8 ).

P sy ch iatr ic h osp italiza tion o f su b -stan ce abusin g pa tien ts su ffers from

its ow n effec tiveness. O nce the irsym ptom s are con tro lled and the irp re fe rred psy ch o log ica l de fensesa re o nce aga in ope rativ e, pa tien tssay T hank s a lo t, D oc . I feelm u ch be tter . I w as d rink ing toom uch , b u t I can hand le it now .T hey be lieve th at once the ir sym p -tom s are g one , so a re th eir p ro b -lem s. The g ro up fo rm at is e ffec -tive in confro n ting tha t m istakenbe lie f, e sp ec ia lly if o the r g ro upm em bers have ex pe rienced b o thabstinence and re lap se.

O pen ing the g ro up to p a tien tsw ith a h isto ry o f sub stance abu sew ho a re no t cu rren tly usin g su b-stances has been va luab le . T hroughth e g ro up , recen tly recov ering p a-tien ts f ind su ppo rt fo r the ir s tru g -g le to rem a in sob er , sha re the irexpe rien ce w ith sob rie ty , an d co n-vey in fo rm atio n abou t actu al treat-m en t ep isod es .

P re lim ina ry re su ltsT he 1 19 trea tm en t p lans o f the109 pa tien ts d ischa rg ed from thepsy ch iatr ic w ard from Jan ua ry toJu ly 1 986 w ere com pared w ithth e 1 16 d isch arge trea tm en t p lan so f 1 09 pa tien ts d is ch arged d urin gth e sam e pe riod from ano the r psy -ch iatr ic un it in the m ed ica l cen te r .(Th e num ber o f trea tm en t p lansexceeded th e n um ber o f pa tien tsb ecause som e pa tien ts w ere read -mitted du rin g the s tudy p eriodand w ere g iven tw o d ischa rgep lans.) Th e ana lysis cons is ted o fcom parin g the num ber o f p atien tsin each w ard w ho rece ived a treat-m en t p lan tha t inc luded sub stan ceabu se trea tm en t an d the num berw ho accep ted tho se p lans .

Th e com pariso n and the stud yw ard s w ere sim ila r in size , s ta ff-ing , and p atien t m ix an d drew p a-tien ts from the sam e so urces, bu tthe com pariso n w ard d id n o t usea p ersuasio n group . S ubs tan ceabuse w as m en tio ned in th e d is-cha rg e summ aries o f 7 1 pa tien tson th e study w ard , o r 6 5 pe rcen t,and of 74 p atien ts on the com pari-son w ard , o r 68 pe rcen t. A to talo f 56 pa tien ts o n th e stud y w ard ,o r 5 1 p ercen t, w e re d ischa rgedw ith a d iag nosis o f su bstance abu se ,com pared w ith 5 2 pa tien ts on th e

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C om parison o f pa tien ts on tw o p sych ia tric w ards tha t d id or d id no t use groupth erapy to p e rsu ad e p atien ts to accep t sub stance ab use trea tm en t a t d ischa rge

W ard w ithp ersuas ion g rou p

W ard w ith ou tp ersuas ion gro up

Sub stance N on - Sub stance Non -abu sers abu sers abu sers ab users

V ariab le (N = 71) (N 38) (N 74) (N 35 )R ece ived irregu la rd ischarge2

Readm i t t ed 3148

12

86

11

G iven trea tm en t p lanfo r subs tan ce ab use 45 - 35 -

A ccep ted trea tm en t p lanfo r su bsta nc e abu se 28 - 16 -

I Th e tw o w ard s d iffered s ign ific an tly in th e p rop ort ion s of pat ien ts w ho w ere g iventrea tm en t p lans fo r su bstance abu se and w ho accep ted them ( 25 .92 , d f2 , p .O 5).2 In clu des pa tien ts d is cha rged aga ins t m edic al ad v ic e and patien ts aw ay w ithou t leav e

3 In clu des pat ien ts w ho w ere readm itte d du ring th e seven -m onth stu dy pe riod

Hosp ita l and C omm unity P sy ch ia try N ovem ber 19 88 V o l. 39 N o . 11 1211

com parison w ard , o r 48 p ercen t.S ix ty -six o f th e 7 1 pa tien ts on

th e stu dy w ard w ith a h is to ry o fsubstan ce ab use , o r 93 pe rcen t,ca rr ied add itiona l ax is I d iagn oses,com pared w ith 6 5 p atien ts on thecom parison w ard , o r 88 p e rcen t.S ch izoph ren ia w as the m ost com -m on add itio na l ax is I d iag nos is onb o th w ard s. A bou t ha lf th e p a-tien ts on b o th w ards also ca rr iedan ax is II d iagno sis .

A s T ab le 1 ind ica tes , pa tien tso n th e w and in w hich the pensu a-sio n gro up w as u sed m ore fre-q uen tly receiv ed and m ore fre -q uen tly accep ted trea tm en t p lansspec if ica lly addressing su bstanceab use . Th e d iffe ren ces in the tw ogrou ps m ay be due to the s tudyw ard s u se o f SAG E , w hich pro -m oted peer d iscuss ion , c la rity o ftrea tm en t go als , and inc rea sed sta ffaw areness o f sub stance abuseam ong pa tien ts . N o sig n if ican t d if-ferences w ere foun d in the num -b en of p atien ts w ho receiv ed in -reg u la r d is ch arges (p atien ts d is-ch arged aga ins t m ed ica l ad v ice o rabsen t w ithou t leav e ) o r in thenum ber w ho w ere readm ittedw ith in the stu dy p eriod .

ConclusionsA pp ro pria te po std ischa rge trea t-m en t fo r dua l-d iagno sis pa tien tsm ay lead to m ark ed ly bow er rate so f h osp ital u tiliz a tion am ong th ese

Tab le 1

pa tien ts (6 ,10 ). The p o ten tia l b en e-fits o f a pe rsuasion g ro up , w h ichap pears to enh ance the use o f an daccep tance o f d is ch arge p lans th atinc lude sub stance ab use trea tm en t,are th ere fo re sub stan tia l. T he re-su its repo rted h ere sho u ld en co ur-ag e fu rthe r ex am ina tion of th e ef-ficacy o f sim ila r m e thod s o f pe r-suasion .

Re fe r en ces1 . P in ske r H : A ddicted pa tien ts in ho sp i-

ta .L psych iatric u n its. P sy ch iatric A nn als13 :619 -623 , 1983

2 . M cLe llan AT : P sych ia tric seve rity a sa pred ic to r o f ou tcom e from substanceabuse tre atm en ts, in Psych op atho lo gyand Addic tive D iso rde rs. Ed ited byM eyer RE . N ew Y o rk , G uilfo rd , 1986

3. A tk inson R .M : Persuad ing a lcoho lic pa-t ien ts to seek trea tm ent . C om p reh en -s iveT herapy 11 :16-24 , 1 985

4 . S ta rk M J, K ane B J : G en eral and sp e-c ific psych oth erapy ro le in duc tion w ithsubs tan ce-abu sin g clien ts . In tern atio na lJou rna l o f the A ddic tio ns 20 :11 35-1141, 1985

5. Tu rner JA , K ofoed L : D ec ision -m ak ing , p ro fession al d isc ip lin e, and pro -g ram affilia tion : se lec tio n of an inpa-t ien t tre atm en t al tern ative . Journal ofC lin ica l P sy ch o logy 40 :858 -865 , 1984

6 . H e lle rste in D J, M eehan B : O utp atien tg rou p the rap y fo r sch izop hren ic sub -s tan ce ab use rs. A m e rican Journal of P sy -c hi at ry 1 44 :1 33 7- 13 39 , 1 98 7

7. O Conne ll V : A lcoho lism counse lingin the p sych ia tric h osp ita l se ttin g . A l-coh olism T rea tm ent Q u arterly 1 :1 15-1 19 , 1 98 4

8 . Y alom ID : Th e Th eo ry an d P rac tic e

of G roup Psycho therapy , 3 rd ed . N ewY ork , B as ic B ooks , 1985

9. S afer D J: Su bstance abuse by youngadult chron ic pa tien ts. H o sp ita l a ndComm unity Psych ia try 38 :5 11-51 4 ,1987

10 . K ofo ed L , K an iaJ, W alsh T , e t a !: O u t-pa tien t treatm en t of p atien ts w ith sub-stanc e ab use and co existin g psych iatricd isorders. A m eric an Journal o f P sy ch ia -try 1 43 :8 67 -8 72 , 1 98 6

1 1. M ay fie ld D , M cL eod G , H a ll P : Th eCA G E qu es tionna ire : va lida tion of anew alcoh o lism screen in g instrum en t.Am erican Jo urna l o f Psych ia try131:112 1-1123, 1974

Let ters

Le tte rs from readers are w e l-com ed . T h ey w ill b e pub lish eda t th e d isc re tion o f the ed ito r a sspace perm its and w ill be sub jec tto e ditin g. They shou ld b e a m ax i-m um o f 500 w o rds w ith no m o reth an five refe rences and shouldb e subm itted in dup lica te , typ eddoub le -spaced . W rite rs a ffili-a tion s w ill b e publish ed .

Accred ita tion SurveysTo th e E d ito r: In h is com menta ryon acc red ita tion su rv ey s, D r. Jam esB arter (1 ) ove rs im p lif ie s . In do ingso , h e obscu re s ra the r than c lan -fie s a ve ry com p lex p ro b lem : w h atis the m ost e ffectiv e w ay to en -su re tha t eve ry pa tien t rece ivesat beast a m in im ally accep tab le leve lo f ca re? D r. B a rte r sta te s tha t sun -veys, thou gh a lleg ed ly em pha-siz in g q ua lity a ssu rance , are n it-p ick ing excursions to co n tro lco sts . T h is is sim p ly w rong . T he reis a re latio nsh ip be tw een qu alityas su ran ce an d cost con tro l (u tiliza -tion rev iew ), b u t they a re fa r frombe ing the sam e.

In p rinc ip le , u tiliz atio n rev iewis in ten ded to avo id m isap p lica-tion of re so u rces- too few as w e lla s too m any . A dm itted ly , h ow -ever , it o ften becom es sim ply cos tcu tting . T he re fo re , w ith ou t som em easu re to p ro tect qu ality , suchas the qu ality as su ran ce p rocessD r. B a rte r th in ks so little o f , th ere