Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

520 V. TREATMENTS FOR ADDICTIONSinsight-oriented, or directive, they all focus on the concerns of a relativelysmall number of patients involved in the therapy group (typically 6 to 10), tothe exclusion of other program participants. Second, it is generally agreed thatsuch small-group therapy for alcoholics offers a better outcome when conductedin the context of a multimodal program. Such a program may integrate treatmentcomponents to implement a carefully structured plan, as described byHunt and Azrin (1973).These two aspects of small-group therapy may be considered in relation toa self-help–oriented treatment program such as the one described previously.With regard to group size, such a program introduces the option of the patients’strong identification with and sense of cohesion in a treatment network ofmany more than 6 to 10 patients. In fact, it encourages affiliative feelingsamong the full complement of self-help patients, providing an experience of alarge, zealous group (Galanter, 1989). This cohesion is promoted by therapeuticcontact with a number of senior patients who are involved in the therapygroups; by programwide patient-run activities, such as the orientation groupsopen to patients in crisis; and in monthly large-group meetings, also open to allpatients. This broader identification forms the bulwark of a self-help orientation.Self-Help Groups and the ClinicianThe relationship between professional treatment and membership in a 12-stepgroup has been less than systematically addressed. Clark (1987) proposed guidelinesto orient the clinician. Clearly, acquaintance with 12-step programs isessential for the clinician to orient patients regarding their needs and torespond to possible conflicts between the nature and goals of professional careand the demands of participation in self-help organizations. Clinicians treatingaddicts can learn about 12-step programs by attending local meetings, bybecoming familiar with the fellowship’s literature, and by exploring theirpatients’ experiences in the context of their membership in these organizations.One point deserving emphasis is that physicians should be aware of the dangerof prescribing habit-forming substances to addicts because of not only theinherent dangers involved in the use of these substances but also the goals of programsthat demand complete avoidance of chemical solutions for life’s problems(Zweben, 1987). When psychotropic medication is strongly recommended, thebenefits and risks involved in their use should be carefully discussed with thepatient in the context of the goals of 12-step programs. An occasional sponsormay be opposed to any medication, even when a patient clearly needs pharmacologicaltreatment to alleviate disabling behavioral or physical conditions. In thissituation, the clinician has to address the nature of the conflict involved in thetreatment by making the needed medical treatment compatible with the programphilosophy. This desirable goal can only be achieved when the clinician is wellinformed about the nature of 12-step programs and can help the patient to inte-