about half the ward’s patients are

involved in SAGE at any one time.

Using Group Therapy to Persuade Patients
soon after
are assigned
admission
to the group
to maximize
Dual-Diagnosis Patients to Seek their exposure.
for membership
The
other
only
than
criteria
a cer-

Substance Abuse Treatment tam or possible

stance abuse
diagnosis
is a requirement
of sub-
that
participants refrain from making
overt threats or engaging in major
Lial Kofoed, M.D. patient psychiatric ward. Prelimi- disruptions.
Alice Keys, M.D. nary data on the group’s effective-
ness in persuading patients to ac- Group structure
Patients with a substance abuse cept ongoing substance abuse ther- The group meets twice a week.
disorder and a coexisting psychiat- apy are presented. Each meeting consists of two half-
nc iblness respond poorly to pni- The group, which was estab- hour sessions, with a 15-minute
mary substance abuse treatment lished in 1983, capitalizes on the break after the first half hour. The
and often become the responsibil- unique opportunities presented by format is well tolerated by acutely
ity ofgeneral psychiatric units (1,2). psychiatric hospitalization to per- ill inpatients. The break allows the
Psychiatric hospitalization, how- suade substance abusers to seek patients to talk and discover com-
ever, cannot provide definitive treat- treatment. During hospitalization mon issues that otherwise might
ment for these dual-diagnosis pa- patients do not use drugs or alco- not emerge and gives staff an op-
tients ( 1). In fact, when treating hol, and their disruptive psychiat- portunity to consult with each
substance abusers, general psychi- nc symptoms are controlled. By other during the session.
atric wards are most effective when assuming a “sick role,” patients The group is co-led by a staff
they limit their goals to providing become amenable to being influ- member of the substance abuse
detoxification and psychiatric sta- enced (3). program and a staff member from
bilization and to persuading the The hospital setting also facili- the psychiatric ward. Joint leader-
patient to accept recovery-oriented tates peer group discussion of sub- ship by the programs combats the
outpatient care. stance abuse. Discussion with peers misperception by program staff
offers the substance abusers a more that treatment planning is influ-
Treatment acceptance among sub-
acceptable source of support and enced by turf issues between the
stance abusers may be improved
confrontation than is usually avail- two programs (5). Collaboration
by specific persuasive efforts (3,4).
able to them on general psychiat- between the departments mini-
The use of persuasion is particu-
nc wards. It also provides them mizes opportunities for patients
barmy critical for dual-diagnosis pa-
with an opportunity to experience to cause conflict within staff
tients, as coexisting thought or af-
a group format similar to the kind through a process called splitting,
fective disorders may exacerbate
used by many substance abuse treat- an ego mechanism that is com-
denial of substance abuse. This
ment programs, a process called monly a feature of the dual-
paper describes the use of a per-
robe induction. diagnosis patient’s learned manipu-
suasion group for dual-diagnosis
patients on a general hospital in- lativeness (1,6).
The persuasion group At hospitals without substance
Setting and patients abuse treatment units, a therapist
Dr. Kofoed is assistant profes- The setting for the group, called with experience in substance abuse
sor of clinical psychiatry at Dart- the substance abuse group experi- and self-help recovery groups may
mouth Medical School and di- ence, or SAGE, is a 23-bed inpa- serve as co-leader (7). Psychiatric
rector of outpatient psychiatry tient psychiatric ward at a VA residents also help lead SAGE,
at the Veterans Administration medical center. Participation is bim- which presents a unique training
Medical Center in White River ited to patients on the ward who opportunity.
Junction, Vermont. Dr. Keys is “have, have had, or someone thinks The group leaders open each
assistant professor of psychiatry might have a problem with abuse session by explaining criteria for
in the School of Medicine at of alcohol or other drugs.” Pa- admission to the group and the
Oregon Health Sciences Univer- tients in the hospital’s specialized group rules. Staff explain that
sity and inpatient staff psychia- substance abuse program, located SAGE is not a lecture but a group
trist at the VA Medical Center in a separate building in the medi- in which members learn from each
in Portland, Oregon. Address cal center, do not participate in other’s experience. They counsel
correspondence to Dr. Kofoed the group. the group members to maintain
at Psychiatry Service (1 16A), Dual-diagnosis patients make up confidentiality. The introduction
VA Medical Center, White a significant proportion of the encourages peer discussion, mini-
River Junction, Vermont 05001. ward’s population, and usually mizes defensiveness, and promotes

Hospital and Community Psychiatry November 1988 Vol. 39 No. 11 1209

continuity in the face of rapid turn- the question to assure themselves its own effectiveness. Once their
over (8). they do not meet thecriteria, thus symptoms are controlled and their
SAGE meetings are held on the perpetuating their denial, they al- preferred psychological defenses
psychiatric ward rather than in the ways harbor fear about the an- are once again operative, patients
substance abuse program, both to swer. Rather than providing an say “Thanks a lot, Doc. I feel
emphasize the role substance abuse immediate definition, SAGE lead- much better. I was drinking too
plays in psychiatric illness (9) and ers have found they are more suc- much, but I can handle it now.”
to minimize excuses for missing cessfuj in penetrating denial if they They believe that once their symp-
group. The group serves as an encourage patients to examine toms are gone, so are their prob-
adjunct to Alcoholics Anonymous their substance use in a step-by- lems. The group format is effec-
or Narcotics Anonymous, which step process. tive in confronting that mistaken
tend to inappropriately minimize First, the group leaders poll belief, especially if other group
psychiatric illness. AA and NA group members about their defi- members have experienced both
groups are variably tolerant of psy- nition of addiction. Most patients abstinence and relapse.
chiatnic symptoms and medications, soon realize that they define an Opening the group to patients
which limits their usefulness in addict as the person who has one with a history of substance abuse
persuading patients to seek sub- more problem related to substance who are not currently using sub-
stance abuse treatment. However, abuse than they do. For example, stances has been valuable. Through
AA and NA are valuable in the the group member who has lost the group, recently recovering pa-
long-term rehabilitation of dual- his wife due to substance abuse, tients find support for their strug-
diagnosis patients (10). but not his job, defines an addict gle to remain sober, share their
as someone whose substance abuse experience with sobriety, and con-
Group process has caused him to lose his job. vey information about actual treat-
The main goals of the group are Next, group leaders ask whether ment episodes.
to persuade patients to acknowl- substance use has interfered in ma-
edge their drug addiction and to jot areas of the patients’ lives. Preliminary results
seek continued substance abuse They have found it useful to ask The 1 19 treatment plans of the
treatment. Because patients in the patients whether they have expe- 109 patients discharged from the
early stage of recovery may as- nienced the CAGE criteria of sub- psychiatric ward from January to
sume a passive stance toward per- stance abuse-having tried to Cut July 1986 were compared with
sons of authority, the group’s lead- down, being Annoyed by criticisms the 1 16 discharge treatment plans
ers avoid lecturing. They attempt of use, having Guilty feelings about of 109 patients discharged during
to answer questions directly (eva- substance use, or needing a morn- the same period from another psy-
sion is easily spotted by patients ing Eye opener (1 1). chiatric unit in the medical center.
who have made a career of it) but Finally, SAGE leaders define sub- (The number of treatment plans
not before exploring what stance use disorder as a loss of exceeded the number of patients
prompted the question and what consistent control over substance because some patients were read-
the group members think about it. use (3), a definition they have mitted during the study period
Frequently patients ask the theta- found to be the most useful and and were given two discharge
pists about their own substance durable. They ask patients whether plans.) The analysis consisted of
use, which serves as an indirect they have ever used alcohol or comparing the number of patients
way of testing the therapists’ credi- drugs in greater quantities than in each ward who received a treat-
biity. Without becoming defen- they intended to or used them ment plan that included substance
sive, the leaders remind the group when they had not intended to. abuse treatment and the number
that their job is to help the mem- Reminding patients that sub- who accepted those plans.
bets help each other and empha- stance abuse contributed to their The comparison and the study
size that they have had experience hospitalization can help them con- wards were similar in size, staff-
with patients who have success- front denial. The leaders often ing, and patient mix and drew pa-
fully recovered. They encourage find, as did Safer (9), that many tients from the same sources, but
the patients to share their per- patients escalated their use of sub- the comparison ward did not use
sonal experiences with substance stances just before their hospitali- a persuasion group. Substance
abuse aiid the pain and loss they zation or were intoxicated at the abuse was mentioned in the dis-
have suffered as a result. Such time of hospitalization. Emphasiz- charge summaries of 7 1 patients
exchanges among peers mean more ing the role of substance abuse in on the study ward, or 65 percent,
to the patients than does prose!y- their need for hospitalization helps and of 74 patients on the compari-
tizing by staff. patients realize they have two dis- son ward, or 68 percent. A total
The most common question tinct but interacting problems, both. of 56 patients on the study ward,
asked of the therapists is “Doctor, of which require treatment (6,8). or 5 1 percent, were discharged
just what is an alcoholic (or ad- Psychiatric hospitalization of sub- with a diagnosis of substance abuse,
dict)?” Though the patients ask stance abusing patients suffers from compared with 52 patients on the

1210 November 1988 Vol. 39 No. Ii Hospital and Community Psychiatry

comparison ward, or 48 percent. patients (6,10). The potential bene- of Group Psychotherapy, 3rd ed. New
York, Basic Books, 1985
Sixty-six of the 7 1 patients on fits of a persuasion group, which
9. Safer DJ: Substance abuse by young
the study ward with a history of appears to enhance the use of and adult chronic patients. Hospital and
substance abuse, or 93 percent, acceptance of discharge plans that Community Psychiatry 38:511-514,
carried additional axis I diagnoses, include substance abuse treatment, 1987
are therefore substantial. The re- 10. Kofoed L, KaniaJ, Walsh T, et a!: Out-
compared with 65 patients on the
patient treatment of patients with sub-
comparison ward, or 88 percent. suits reported here should encour-
stance abuse and coexisting psychiatric
Schizophrenia was the most com- age further examination of the ef- disorders. American Journal of Psychia-
mon additional axis I diagnosis on ficacy of similar methods of per- try 143:867-872, 1986
suasion. 1 1. Mayfield D, McLeod G, Hall P: The
both wards. About half the pa-
CAGE questionnaire: validation of a
tients on both wards also carried new alcoholism screening instrument.
an axis II diagnosis. American Journal of Psychiatry
References
As Table 1 indicates, patients 131:1121-1123, 1974
on the wand in which the pensua- 1. Pinsker H: Addicted patients in hospi-
sion group was used more fre- ta.L psychiatric units. Psychiatric Annals

quently received and more fre- 13:619-623, 1983

2. McLellan AT: Psychiatric severity as
quently accepted treatment plans
a predictor of outcome from substance Letters
specifically addressing substance abuse treatments, in Psychopathology
abuse. The differences in the two and Addictive Disorders. Edited by
groups may be due to the study Meyer RE. New York, Guilford, 1986
Letters from readers are wel-
ward’s use of SAGE, which pro- 3. Atkinson R.M: Persuading alcoholic pa-
tients to seek treatment. Comprehen-
comed. They will be published
moted peer discussion, clarity of at the discretion of the editor as
siveTherapy 11:16-24, 1985
treatment goals, and increased staff 4. Stark MJ, Kane BJ: General and spe- space permits and will be subject
awareness of substance abuse cific psychotherapy role induction with to editing. They should be a maxi-
among patients. No significant dif- substance-abusing clients. International
mum of 500 words with no more
Journal of the Addictions 20:1135-
ferences were found in the num- than five references and should
1141, 1985
ben of patients who received in- 5. Turner JA, Kofoed L: Decision- be submitted in duplicate, typed
regular discharges (patients dis- making, professional discipline, and pro- double-spaced. Writers’ affili-
charged against medical advice or gram affiliation: selection of an inpa- ations will be published.
absent without leave) or in the tient treatment alternative. Journal of
Clinical Psychology 40:858-865, 1984
number who were readmitted
6. Hellerstein DJ, Meehan B: Outpatient
within the study period. group therapy for schizophrenic sub- Accreditation Surveys
stance abusers. American Journal of Psy-
Conclusions chiatry 144:1337-1339, 1987 To the Editor: In his commentary
Appropriate postdischarge treat- 7. O’Connell V: Alcoholism counseling on accreditation surveys, Dr. James
in the psychiatric hospital setting. Al-
ment for dual-diagnosis patients Barter (1) oversimplifies. In doing
coholism Treatment Quarterly 1:115-
may lead to markedly bower rates 119, 1984 so, he obscures rather than clan-
of hospital utilization among these 8. Yalom ID: The Theory and Practice fies a very complex problem: what
is the most effective way to en-
sure that every patient receives
Table 1
at beast a minimally acceptable level
Comparison of patients on two psychiatric wards that did or did not use group
of care? Dr. Barter states that sun-
therapy to persuade patients to accept substance abuse treatment at discharge’
veys, though “allegedly” empha-
Ward with Ward without sizing quality assurance, “are nit-
persuasion group persuasion group picking excursions to control
Substance Non- Substance Non- costs.” This is simply wrong. There
abusers abusers abusers abusers is a relationship between quality
Variable (N=71) (N38) (N74) (N35) assurance and cost control (utiliza-
tion review), but they are far from
Received irregular
being the same.
discharge2 14 1 8 1
Readmitted3 8 2 6 1 In principle, utilization review
Given treatment plan is intended to avoid misapplica-
for substance abuse 45 - 35 - tion of resources-too few as well
Accepted treatment plan as too many. Admittedly, how-
for substance abuse 28 - 16 - ever, it often becomes simply cost
I The two wards differed significantly in the proportions of patients who were given cutting. Therefore, without some
treatment plans for substance abuse and who accepted them (25.92, df2, p.O5).
measure to protect quality, such
2 Includes patients discharged against medical advice and patients away without leave as the quality assurance process
3 Includes patients who were readmitted during the seven-month study period Dr. Barter thinks so little of, there

Hospital and Community Psychiatry November 1988 Vol. 39 No. 11 1211