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Brain-mapping studies (Braun et al., 2000), in vivo neurochemistry, and studies of brain receptors (Insel & Quirion, 2005), and state-of-the-art neuroimaging techniques (functional magnetic resonance imagery (fMRI) and other imagery techniques such as PET scans) make it possible to actu- ally visualize changes in brain function or neuron pathways that are the re- sult of attachment, substance use, dysphoria, satisfaction, and even psycho- therapy. Terms such as cortical rerouting, neurogenesis, intensive operant shaping, and brain neuronal reorganization reflect mounting evidence that the brain remains plastic throughout the lifespan. They dislodge the pre- 1980s’ notion that the brain is hardwired at birth and not subject to alter- ation in adulthood (Taub & Uswatte, 2000; Morris et al., 2001; Weis et al., 2000). Sharon Begley (2004) captured the implications of these new dis- coveries when she wrote about “the brain’s recently discovered ability to change its structure and function in particular by expanding or strengthen- ing circuits that are used and by shrinking or weakening those that are rarely engaged. [Although] the science of neuroplasticity has mostly documented brain changes that reflect physical experience and input from the outside world” (2004, p. 1), more recent research in the area of meditation has shown that altering the structure of the brain is not limited to only external physical rehearsal. The brain can also change in response to purely internal 4 GROUP PSYCHOTHERAPY WITH ADDICTED POPULATIONS mental signals, similar to those practiced in meditation. Furthermore, those individuals who have the most practice at it are the ones who demonstrate the most alteration in brain circuitry. “This opens the tantalizing possibility that the brain, like the rest of the body, can be altered intentionally. Just as aerobics sculpt the muscles, so mental training sculpts the gray matter in ways scientists are only beginning to fathom” (Begley, 2004). These advancements also provide attachment theory with concrete evi- dence that helps explain not only how the brain becomes addicted, but also how it responds to psychological interventions. For instance, single posi- tron-emission tomography (SPET) was used to compare two men with sim- ilar diagnosis and age. One man received psychotherapy for a year while the other did not. Pre-treatment SPET imaging revealed reduced serotonin up- take in the medial forebrain bundle when compared with ten healthy indi- viduals. After a year of therapy, the treated individual’s SPET pattern had returned to normal. The untreated patient stayed the same. Preliminary studies also showed that functional magnetic resonance imaging (fMRI) can predict with high accuracy whether an individual will relapse following treatment for methamphetamine abuse (Paulus, Tapert, & Schuckit, 2005). An equally startling discovery is that this new evidence about the ad- dicted brain does not lead to the need for the development of new treatments for addiction, but actually validates many current methods already being utilized. The field of “interpersonal neurobiology” has validated the vener- able notion that talking with someone—especially if the encounter is mean- ingful and occurs within the context of emotional arousal, attunement, and a strong emotional bond—will alter neural pathways and synaptic strength. All forms of psychotherapy, from psychoanalysis to cognitive behavioral therapy (CBT), are successful to the degree to which they accomplish this and enhance growth in relevant neuron circuitry. The use of communicative language and emotional attunement provides the best medium for neuronal growth and integration. The false separation that exists between biology and psychology is grad- ually diminishing thanks to the contributions of attachment theory and the neurosciences. Research has revealed a number of erroneous conclusions about the brain and psychotherapy that should be changed. Recent scien- tific discoveries revealed the following six facts: 1. Attachment and psychotherapy can alter brain chemistry. 2. Learning-based experiences alter neuronal connectivity. 3. Potentiation requires activation (environmental stimulation), which alters the strength and autonomous patterns of brain functioning. 4. Synaptic strength is an experience-dependent phenomenon. Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 5 5. Speaking in a meaningful way, paying attention, and attachment alters brain biochemistry and changes in synaptic transmission, strength, and numbers. 6. Attachment can alter gene expression

PART I: THEORETICAL MODELS Chapter 1. Interpersonal Neurobiology and Addiction: An Attachment Theory Perspective 3 Interpersonal Neurobiology 4 The Neurophysiology of Attachment 7 Interdisciplinary Research and Attachment Theory: A Source for Informing Addiction Treatment 9 Contributions from Child Development Studies 10 Contributions from the Neurosciences 19 Reward Deficiency Syndrome 19 Attachment and Animal Research 37 Contributions of the Relational Perspective to Group Psychotherapy 38 Chapter 2. Attachment Theory As a Theoretical Basis for Understanding Addiction 43 Attachment Theory and Self-Psychology 45 Attachment Styles and Secure Attachment 46 Ainsworth and the Strange Situations 47 Implications for Treatment 48 Implications for Addiction Treatment 60 Summary of Treating Addiction As an Attachment Disorder 62 Chapter 3. The Disease Concept and Group Psychotherapy 65 Abstinence: Is it Necessary? 66 Paradigm Shift 74 Specific Implications of Group Therapy and the Disease Concept 81 Addiction, Abstinence, and the Disease Concept 84 Chapter 4. Psychodynamic Theory and the Relational Models 97 Character Pathology and Addiction 99 Contributions of Object-Relations Theory and Self-Psychology 101 Margaret Mahler’s Theory of Normal Development 106 Ego Psychology and Object-Relations Theory 107 Mahler’s Stages of Normal Development 112 Beyond the Ego: Kohut’s Self-Psychology 126 Definition of Terms 134 The Self-Medication Hypothesis and Affect Regulation 138 Application for Therapy: Corrective Emotional Expression 143 Addiction As an Attempt at Self-Repair 152 Self-Esteem Vulnerabilities 154 The Reparative Approach 160 Chapter 5. Alcoholics Anonymous and Twelve-Step Programs 163 Misconceptions About Alcoholics Anonymous 164 Values, Science, and AA 167 Philosophy of Science and the Limits of Rationality 173 The Self-Help Movement 177 Alcoholics Anonymous: Its Historical Roots 178 AA—Why and How It Works: An Interpretation of AA 182 Pragmatism: Its Influence on AA 185 Existential View of AA 188 AA—How it Works: A Phenomenological Perspective 196 The Self-Attribution of Alcoholism 201 Honesty, Denial, and the Need for Others 204 AA: A Self-Psychology Perspective 207 AA: A Treatment for Shame and Narcissism 209 Higher Power As an Attachment Object 214 PART II: ADDICTION TREATMENT IN THE GROUP Chapter 6. Different Models of Group Psychotherapy 221 Some Models of Group Psychotherapy 222 Psychological Levels of Intervention 223 Specific Applications for Addictions Treatment 250 Chapter 7. Preparing the Chemically Dependent Person for Group Therapy 257 Selection and Composition 259 Implications of Research Findings 261 Therapeutic Alliance and Cohesion in Group 262 Pre-Group Preparation: Increasing Treatment Retention and Reducing Dropouts 267 Recommendations for Entry into a Therapy Group 269 Present and Gain Acceptance of the Contract 282 Chapter 8. Interactional Group Psychotherapy 287 Yalom’s Basic Tasks 288 The Model-Setting Participant 291 Interpersonal Honesty and Spontaneity 295 Establishment of the Group Norms 298 The Norm of Self-Disclosure 299 Procedural Norms and Antitherapeutic Norms 302 Importance of Group 303 The Here-and-Now Activation and Process Illumination 305 Interpersonal Theory of Behavior 316 Sullivan’s Interpersonal Theory of Psychiatry 317 Examples of Yalom’s Here-and-Now Focus 324 Integration of Modern Analytic Approach 332 Conclusion 348 Chapter 9. Modifications of Yalom’s Interactional Model 351 Treatment Considerations and Group Therapy 353 Recommendations for Group Psychotherapy 356 Protocol 356 Early and Later Stage Treatment 361 Therapist Attributes and Special Considerations for Affect Attunement 364 Careseeking, Affect Attunement, and Psychotherapy 368 Group Therapy and ACOA 370 Addiction and the Family 371 Common Identified Characteristics of ACOA 372 ACOA and Shame 375 Alcoholics Anonymous and Group Psychotherapy 376 Chapter 10. Co-Occurring Disorders and Group Psychotherapy: An Attachment Theory Perspective 379 Addiction—The Cart or Horse of Mental Illness? 380 Cross-Addiction 381 The Relationship Between Mental Health and Addiction 384 Axis I Disorders 386 Axis II: Character Pathology and Addiction 386 Borderline Personality Organization and Pathological Narcissism 388 Kernberg’s Borderline Pathology 390 Kernberg’s Description of Supportive Psychotherapy 391 Narcissistic Personality Disorder 395 Dynamics of Multiple Addictions 404 Integration of Divergent Treatment Philosophies 407 The Relational Models: An Integration 410 Chapter 11. The Leader in Group Therapy 413 Values of the Group Leader 414 The Therapist As a Person 417 Qualities of the Group Leader 417 Guidelines and Priorities for the Group Leader 431 Roles of the Group Leader 431 Focus of the Group Leader 434 Characteristics of the Group Leader 438 The Therapeutic Process: Therapists’ and Patients’ Contributions 443 The Alliance and Addiction: Special Considerations 452 Group Leadership Functions 454 The Implications for Conducting a Successful Therapy Group 456 Alcoholism Treatment Outcome Studies 458 Patient Characteristics Related to Types of Therapy 460 Specific Group Strategies and Requirements 463 Recommendations 466 Convergence of Therapist and Patient Characteristics 467 PART III: CLINICAL APPLICATIONS Chapter 12. Diagnosis and Addiction Treatment 473 Avoidant Society: Cultural Roots of Impaired Attachment 475 Criterion Definitions of Addiction 478 Drug Groups 480 Drug Dependence and the Drug Groups 481 Neuropsychological Impairment 483 Stages of Change Model 490 Relapse Prevention 492 Interpersonal Neurobiology, Motivation, and Stages of Change Model and Brain Impairment 493 Chapter 13. Early Stage Group Treatment: Confrontation, Intervention, and Relapse 495 Special Problems of the Addicted Patient 496 The Use of Therapeutic Leverage 498 Confrontation 501 Intervention 512 Relapse and Recovery 525 Early Stage versus Later Stage Relapse 528 Therapist versus Patient’s Contributions to Relapse 530 Later Stage Relapses 532 Relapse Prevention 534 Chapter 14. Inpatient Groups and Middle Stage Treatment 535 Yalom’s Recommendations for Inpatient Groups 544 Composition of the Inpatient Groups 547 Yalom’s Strategies and Techniques of Leadership 549 Agenda Rounds 552 Difficulties with Agenda Rounds 557 The Special Circumstances of Inpatient Therapy Groups Within the Hospital 558 Leader’s Transparency About Alcohol and Drug Use 559 The Group Contract 560 Simultaneous Membership in Other Groups 562 The Special Problems of Confidentiality on an Inpatient Unit 564 Active Outreach 567 Group Members Who Relapse and Come to Group 568 Attending Group Under the Influence 569 Summary Recommendations for Inpatient Group Therapy 572 Chapter 15. Late Stage Group Treatment: Conflict, Repair, and Reunion 575 Paradigm Shift 577 The Concurrent Treatment of Addiction and Character Pathology 580 Later Stage Treatment Strategies 583 Yalom’s Model and Self-Psychology 584 Treatment of Internal Structural Deficits 587 Treatment of Introjections 589 Later Stage Treatment: Conflict, Repair, and Reunion 593 Attachment, Addiction, and the Working Alliance 597 Research and the Therapeutic Alliance 601 The Alliance: What Is it and Why Is it Important? 603 Attachment, the Therapeutic Alliance, and Negative Process 608 Chapter 16. Transference in Groups 613 Definition of Transference 614 Transference Possibilities in Group 618 Modification of Transference Distortions in Groups 621 Types of Transference in Groups 623 Common Types of Acting Out Transference 625 Abuse of Transference 631 Countertransference 631 Projective Identification 636 Pathways for Psychological Change 640 Addiction and Countertransference 641 Chapter 17. Resistance in Group 647 Resistance: A Definition 648 Group Resistance and the Work of Wilfred Bion 651 The Leader’s Influence on the Basic Assumptions 654 Resistance to Intimacy in Groups 658 Resistance to Immediacy 663 Resistance to Feelings in Group 665 Special Considerations of Resistance to Addiction 669 The Group Leader’s Effect on Group Resistance 672 Chapter 18. The Curative Process in Group Therapy 677 Yalom’s Curative Factors 679 Curative Factors in Group 679 Existential Factors 682 Curative Factors in AA 687 Curative Factors Operating in Different Types of Therapy Groups 689 Mechanisms of Change and Cure in Group Therapy 689 The Curative Process 694 Working Through with the Addicted Patient 698 Stages of Cure in a Therapy Group 699 Addiction and Goals of Termination 704 Conclusion 707 References 711 Index

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