Therapeutic Factors in Group Psychotherapy: A Study of Egyptian Drug Addicts

Abstract

The effect of group therapy on substance-dependent patients has been demonstrated in several studies emphasizing the cost-effectiveness of this intervention. However, little research was conducted on how group therapy can help these patients. The objective of this article is to study the therapeutic factors of group therapy among a group of substance-dependent patients and to study the relation between the therapeutic factors of group therapy with these patients and clinical outcome of relapse or continuing abstinence. The study includes 80 patients divided into two groups. Group I includes 40 substance-dependent patients attending group therapy sessions. Group II is a comparison group of 40 substance-dependent patients who did not attend group therapy. Both groups received the same treatment except for group therapy. All subjects were diagnosed according to a structured interview applying the International Classification of Diseases-10th Revision. Fifteen-session group therapy was conducted for Group I, and subjects were subjected to the Yalom test for assessing group therapeutic factors. The relapse/sobriety outcome was assessed and compared between the two groups 1 year after the intervention. All subjects have been subjected to drug screening before and after 1 year follow-up. The relation between choice of the therapeutic factor and outcome was studied. Group I patients cited the most helpful therapeutic factor in group therapy as catharsis, followed by group cohesiveness and interpersonal learning (output). Identification is perceived as the least helpful factor in group therapy. One year into the study, 52.5 % of Group I remained sober in comparison to 22.5 % of Group II. No significant statistical relation was found between the choice of therapeutic factor and the outcome in Group I subjects. The most helpful factor perceived by addicts in group therapy is catharsis, followed by group cohesiveness and interpersonal learning (output). Patients who received group therapy had a significantly more favorable outcome rate than those who received other modes of treatment.

KEYWORDS:

• substance dependence
• abuse
• addiction
• psychotherapy
• Addiction Severity Index (ASI)
• group therapy
• therapeutic factors relapse
• sobriety
• abstinence

INTRODUCTION

The cost-saving qualities and the effectiveness of group interventions have produced clear expectations for an increased use of therapy groups (Pollack, 2001), but how does group therapy help patients? Irvin Yalom's view (1985) is that if we can answer this seemingly naïve question with some measure of precision and certainty, we shall have at our disposal a central organizing principle by which we can approach the most vexing and controversial problems of psychotherapy. Once identified, the crucial aspects of the change process will constitute a rational basis upon which the therapist may base tactics and strategy. Yalom suggests that therapeutic change is an enormously complex process and occurs through an intricate interplay of various guided human experiences, which he refers to as “therapeutic factors” (Yalom).

Our efforts to evaluate and integrate the therapeutic factors will always remain conjectural to some extent. There is little truly definitive research demonstrating the efficacy of any of the therapeutic factors and even less research bearing on the question of their comparative value or their interrelation among the substance-dependent patients (Yalom, 1985).

Objective

Stemming from the hypothesis that the choice of therapeutic factors in group therapy for addicts is related to the outcome of such patients, this study aims to assess the outcome of group therapy for substance-dependent patients and the relation of this outcome to the choice of specific therapeutic factors.

Study Design

This is a comparative interventional study involving Egyptian substance-dependent patients in group therapy compared with substance-dependent patients who have undergone treatments other than group therapy. All subjects were recruited from the addiction units of two private psychiatric hospitals having separate addiction services. The study was carried out during a period of 2 to 3 years from February 2004 to June 2006. All patients were subjected to drug screening before and after a 1-year period. Patients who had group therapy (Group I) were asked to evaluate the therapeutic factors of group therapy through answering the Yalom questionnaire of therapeutic factors (Yalom, 1985). Group I patients participated in a therapy group for 15 sessions. The group was led by a senior psychiatrist with 10 years of experience in group therapy. The Yalom test was applied as soon as the participant was recruited to Group I (pregroup assessment). The same test was applied on Group I at the end of the therapy group experience.

Sampling

The sample includes opiates or poly-substance-dependent patients from both sexes with age ranging from 18 to 40 years. Patients with significant active medical illness, physically handicapped patients, and those with mental subnormalities were excluded from the study. Subjects fulfilling the inclusion criteria were consecutively allocated to one of the two studied groups. The first recruited patient was located in Group I, the second in Group II, and so on until the required number for each group was reached.

SUBJECTS

The study sample was allocated to the two research groups as follows.

Group I

Seventy-one subjects were asked to participate in the study, but only 49 accepted. Nine subjects dropped out during the study period. Thus, Group I consists of 40 participants who fulfilled the criteria of the International Classification of Diseases-10th Revision (ICD-10) for substance dependence and attended 15 group therapy sessions.

Group II

Sixty-eight subjects were asked to participate in the study. Fifty-nine agreed to join, 19 dropped out throughout the study period, and 40 continued the assessment procedure. Group II consists of 40 patients who fulfilled the ICD-10 criteria for drug dependence. Group II subjects did not participate in group psychotherapy.

Both groups received similar modes of treatment (hospitalization, rapid detoxification, symptomatic treatment of withdrawal symptoms), except for the intervention group therapy for Group I.

METHOD

The following procedure was adopted in the organization of the research.

Ethical Consideration

Each subject was informed about the nature and aims of the study and given the option to participate or refrain. Written and verbal consent were obtained from each participant. Strict confidentiality was offered to all participants in regards to joining the study and the results of the tests. A structured sheet was created to assess age, education, occupation, marital status, family history, past history, onset, and duration of substance use and trials to quit.

Assessing Severity of Substance Dependence

Addiction Severity Index (ASI; American Society of Addiction Medicine [ASAM], 2003)

The ASI is a widely used semistructured interview designed to elicit information about areas of the patient's life, which may contribute to and/or be affected by his or her substance use problem. The ASI assesses seven dimensions that typically are of foremost concern to patients with substance dependence. These are medical status, employment/support status, drug/alcohol and drug use, legal status, family history, family/social relationships, and psychiatric status.

Group Therapy and Therapeutic Factors

Three rotations of the intervention group sessions were needed to complete the 40 participants of group. Each rotation included 15 sessions with a rate of 3 sessions per week. Every session lasted 90 minutes. Each group consisted of 8 to 15 participants. In every session, a theme was adopted as a trigger for discussion. The group relies on the leader, who is the same in all study groups. The approach to therapy applies mainly gestalt, and transactional principles placed emphasis on “I–thou” and “here and now.” Subjects who were not able to attend the 15 sessions of the study were excluded from analysis. Subjects who wished to continue as outpatients while in group therapy were still given the option to attend the three-time weekly therapy:

Session 1

“Am I an addict?”:

Definition of addiction: tolerance, craving, and loss of control.

Session 2

“Price of pleasure”:

Consciousness rising: physical, academic, occupational, social, financial, legal, and psychological negative consequences.

Session 3

“Breaking the denial”:

Dramatic relief, emotional arousal about one's current situation and the relief that can come from changing. Fear, inspiration, guilt, and hope are some of the emotions that moved participants to contemplate changing. Psychodrama and personal testimonies as well as gestalt technique were the used techniques selected to move participants emotionally.

Session 4

“Wheel of change”:

Understanding the process of change, self reevaluation and identification of the current stage of participants (e.g., “Why does he think of himself in the precontemplation or in the contemplation phase?)

Session 5

“I’m not criminal, I’m not indecent, I’m ill”:

Acceptance of addiction as a disease; motivation to change; discussion and sharing of motivational struggles.

Session 6

“Choosing to be responsible”:

Exploration of pros and cons of change and pros and cons of abstinence.

Session 7

“Dropping masks”:

Denial, minimization, projection, dramatization, suppression, and other defenses are uncovered and confronted in a safe, accepting, controlled setting of therapeutic alliance.

Session 8

“It is not the drug; it is the lifestyle”:

Other addictions—sex, gambling, work, relationships, games, and eating—were the most common pictures of other addictive behavior used to illustrate the addictive lifestyle and personality.

Session 9

“The road map 1”

This session allows participants to discuss and share their expectations about the phases and domains of recovery. Storytelling and workshop techniques were used to train participants on different problematic situations along the way to recovery.

Session 10

“The road map 2”

Continuation of the above theme with use of role-playing and drama techniques to enhance behavior change.

Session 11

“Relapse prevention 1”:

Managing high-risk people, places, instruments, and events.

Session 12

“Relapse prevention 2”:

Each participant makes a profile of his or her own high-risk situations, high-risk people, and high-risk events.

Session 13

“My family is part of the team”:

Effects of addiction on family and interpersonal relationships; expectation about the time needed for the subsidence of family suspiciousness and lack of confidence; ideas about resolving marital or family conflicts.

Session 14

“Stress management”:

Description of the process of stress and its relation with substance abuse, enhancing the engagement in healthy leisure interests and addressing social and relationship problems or deficits.

Session 15

“We are all in the same boat”:

Discussion of how to cope with negative emotions, how to resist social pressures to drink alcohol or use other drugs, how to face or to avoid interpersonal conflicts, how to ask for support and help, the value of love and intimacy, and the value of joining self-help groups in recovery.

Being hostile, help-rejecting complainers, narcissistic, borderline, or playing therapists, some of the group participants were extremely challenging. As they could affect the group as a whole, the researcher and his supervisors prepared a variety of strategies to address any dynamic that might arise in the course of group sessions.

Yalom Test of Irvin (Yalom, 1985)

The test was applied by the group therapist to assess the therapeutic factors. Yalom (1985) offers an understandable and useful approach to the study of group therapy. Yalom and colleagues studied the therapeutic factors mainly among therapy patients. All 20 subjects completed a therapeutic factor Q-sort and were interviewed by the team of three investigators. The 12 therapeutic factors identified by Yalom were assessed along 20 years of collaborative work and many group therapy interventions. However, these factors were studied mainly among psychiatric patients. Few studies were found to assess such therapeutic factors among substance-dependent patients.

In this study, 12 categories of therapeutic factors were constructed from the sources outlined throughout the above procedure; five items describing each category were written. The items made a total of 60 that are listed in Appendix 1. These items were translated into Arabic and then back to English by a professor and an associate professor of psychiatry at Cairo University. Each item was typed on a 3 × 5-inch card. The patient was given the stack of random cards and asked to place a specified number of cards into seven piles labeled as “most helpful” (2 cards), “extremely helpful” (6 cards), “very helpful” (12 cards), “helpful” (20 cards), “barely helpful” (12 cards), “less helpful” (6 cards), and “least helpful” (2 cards). The number of the cards chosen was selected according to Yalom's work and suggestions.

E- Relapse Rate Assessment (Drug Screening)

Drug screening was carried out on the participants in both groups at the beginning of the study. For the duration of the group therapy sessions, drug screening for cannabis, opiates, amphetamines, benzodiazepines, barbiturates, and alcohol was carried out on participants of the study to detect or exclude relapse. One year after the end of group therapy, both groups were screened again to confirm the findings on their relapse/sobriety rate. The purpose of screening was to assess the quality of data collected.

STATISTICAL ANALYSIS

The resultant data were analyzed as follows: (1) description of demographic data of the studied groups to verify the matching between demographics in the two groups; (2) level and types of drugs used; (3) distribution of the studied groups according to the scores of ASI; (4) distribution of the studied groups according to their choice of therapeutic factors; and (5) distribution of the studied groups according to the sobriety/relapse status. The chi-squared Test of Association allows the comparison of two attributes in a sample of data to determine if there is any relationship between them. The idea behind this test is to compare the observed frequencies with the expected ones if the null hypothesis of no association/statistical independence were true. By assuming the variables are independent, we can also predict an expected frequency for each cell in the contingency table. Statistical Package for the Social Sciences (SPSS) 12 was used to analyze the entered data. Probability value was identified as p ≤ .05. Logistic regression analysis was used to study the relationship between perception of therapeutic factors and clinical status outcome at the time of the study, whether using drugs or abstinent. Only the most helpful, extremely helpful, and least helpful choices are entered in a binary logistic regression analysis using SPSS 16.

RESULTS

Description of the Study Participants

Group I and Group II were matched according to age, sex, residency, education, and socioeconomic levels (Table 1). The majority of the sample group was male; their age ranged from 19 to 36 years. There was a statistical significance in the difference of occupational level between the two groups (p < .02): Group I had more “never worked” subjects (72.5% vs. 42%) and fewer subjects with skilled jobs (10% vs. 30%) compared with Group II.

TABLE 1 Comparison of Demographic Data between Group I and Group II

	Group I		Group II
	No.	%,	No.	%	Significance
Age	25.7	4.1	25.8	4.7	p > .005
<20	1	2.5	3	7.5
20–30	34	85	30	75
>30	5	12.5	77	17/5
Sex
Males	38	95	39	97.5	p > .05
Females	2	5	1	2.5
Residence
Urban	40	100	39	97.5	p > .05
Rural	0	00	1	2.5
Educational level
Primary	0	0	3	7.5	p > .05
General Secondary	10	25	10	25
Technical	6	15	10	25
University**	24	60	17	42.5
Occupation
Professional	3	7.5	5	12.5	p < .02*
Skillful job	4	10	12	30
Semi-skillful job	4	10	6	15
Never worked	29	72.5	17	42.5
Socioeconomic level
High	11	27.5	4	10	p > .05
Middle	24	60	25	62.5
Low	5	12.5	11	27.5
*Statistically significant value.
**University education category involves students who were currently in university education and students who were graduated.

Type of Substance Used

Of the total sample, 82.5% used opiates (N = 66), 60% used cannabis (N = 48), 17.5% used opioid analgesic medications (N = 14), 15% used sedatives (N = 12), 11. 25% (N = 9) used alcohol, and 13.75% (N = 11) used other substances like inhalants. No statistically significant difference was found between the two groups regarding the type of substance used (Table 2).

TABLE 2 Type of Substance Used: Comparison Between Group I and Group II

Type of	Group I		Group II		Total
substance	No.	%	No.	%	No.	%	Significance X^2 /p
Illicit opiates	32	80	34	85.5	66	82.5	X^2 = 3.043
Cannabis	31	77.5	17	42.5	48	60	p > .05
Opioid analgesic medications	8	20	6	15	14	17.5
Sedatives	7	17.5	5	12.5	12	15
Alcohol	6	15	3	7.5	9	11.25
Others	4	10	7	17.5	11	13.75

Addiction Severity Index

ASI results reveal that the majority of subjects in both groups had mild-to-moderate medical deterioration, occupational deterioration, legal problems, psychiatric problems, and family history of substance dependence and/or psychiatric illness. Of the total sample, 82.5% had moderate social problems due to substance dependence, while only 10% had mild social problems. No statistically significant difference between Group I and Group II was found on ASI scores except for social problems (p < .027), where Group I had a higher degree of social problems than Group II (Table 3).

TABLE 3 Distribution of the Studied Groups According to the ASI

		Group I		Group II		Total		Significance
ASI	Severity	No.	%	No.	%	No.	%	X ^2	p
Medical problems	Mild	34	85	31	77.5	65	81.3
	Moderate	6	15	7	17.5	13	16.3	0.30	>.330
	Severe	0	0	2	5	2	2.5
Occupational deterioration	Mild	13	32.5	14	35	27	33.8
	Moderate	25	62.5	25	62.5	50	62.5	0.37	> 831
	Severe	2	5	1	2.5	3	3.8
Drug and alcohol use	Moderate	11	27.5	17	42.5	28	35	1.978	>.16
	Severe	29	72.5	23	57.5	52	65
Legal problems	Mild	26	65	25	62.5	51	63.8
	Moderate	14	35	12	30	26	32.5	3.173	>.205
	Severe	0	0	3	7.5	3	3.8
Family history	Mild	21	52.5	22	55	43	53.8
	Moderate	17	42.5	14	35	31	38.8	0.98	>.613
	Severe	2	5	4	10	6	7.5
Social problems	Mild	1	2.5	7	17.5	8	10
	Moderate	34	85	32	80	66	82.5	7.227	<.027*
	Severe	5	12.5	1	2.5	6	7.5
Psychiatric problems	Mild	14	35	14	35	28	35
	Moderate	21	52.5	26	65	47	58.8	5.532	>.063
	Severe	5	12.5	0	0	5	6.3
*Statistically significant value.

Group II received the same treatment measures as Group I except for group therapy. These include hospitalization, rapid detoxification using opioid agonists, antagonists, and symptomatic treatment of withdrawal symptoms.

As for the therapeutic factors chosen by Group I patients, catharsis comes first in rank as the most and extremely helpful factor (N = 13, 16.2%; and N = 46, 19.2%, respectively). It was followed by group cohesiveness and interpersonal learning (output; N = 11; 13.8% for both factors) in ranking of the most helpful factor. However, group cohesiveness has higher frequency among the extremely helpful factors than interpersonal learning (output; 11.7% vs. 10.8%). As the most helpful factor, self-understanding comes next, selected nine times (11.2%), followed by existential factor, universality, and instillation of hope, each selected eight times (10%). Existential factor was selected by 15% of Group I, universality by 7.9%, and instillation of hope by 6.2% as extremely helpful factors. Altruism, interpersonal learning (input), guidance, family reenactment, and identification come latest in rank among the most and extremely helpful therapeutic factors with a score of less than 7% in both rankings. The cards referring to identification were not chosen between the most helpful factors (Table 4).

TABLE 4 Therapeutic Factors According to Their Subjective Helpfulness to Group I

	Most Helpful*		Extremely Helpful*		Least Helpful*
Therapeutic factor	No.	%	No.	%	No.	%
Catharsis	13	16.2	46	19.2	5	6.2
Group cohesiveness	11	13.8	28	11.7	2	2.5
Interpersonal learning (output)	11	13.8	26	10.8	4	5.0
Self-understanding	9	11.2	25	10.4	0	00
Existential	8	10.0	36	15	7	8.8
Universality	8	10.0	19	7.9	3	3.8
Instillation of hope	8	10.0	15	6.2	0	00
Altruism	5	6.2	7	2.9	13	16.2
Interpersonal learning (input)	3	3.8	10	4.2	6	7.5
Guidance	3	3.8	15	6.2	7	8.8
Family reenactment	1	1.2	6	2.5	7	8.8
Identification	00	00	7	2.9	26	32.5
Total**	80	100.00	240	100.00	80	100.00
*Helpfulness of the therapeutic factor as chosen by Group I subjects.
**Group I patients (40 subjects) chose two cards as most helpful therapeutic factors, six cards as extremely helpful, and two cards as least helpful.

Identification has the highest score of the least helpful factors in (32%), followed by altruism (16.2%), guidance, family reenactment, and existential factor (8.8% each). Interpersonal learning (input) comes next, with a score of 7.5%, followed by catharsis (6.2%). Interpersonal learning (output), universality, and group cohesiveness come next. None of the cards referring to self-understanding and instillation of hope were selected as the least helpful factor in group therapy (Table 4).

A statistically significant difference between the two groups was found regarding their relapse/sobriety outcome (p < .01). Table 5 shows that 52.5% of Group I remained sober after 1 year of the first assessment study, compared with 22.5% of Group II.

TABLE 5 Distribution of the Studied Groups According to Abstinence/Relapse Rate After 1 Year of the Study

	Group I		Group II
	No.	%	No.	%	Significance
Abstinent	21	52.5	9	22.5	X^2 = 7.68
Relapsed	19	47.5	31	77.5	p < .01*
Total	40	100.0	40	100.0
*Statistically significant value.

TABLE 6 Relation Between Perception of Therapeutic Factors and Outcome

Chosen card*	B	SE	Wald	df	Sig.	Exp (B)
Most helpful, 1st card	–.19	0.104	0.032	1	.858	0.981
Most helpful 2nd card	–.043	0.121	0.128	1	.720	0.958
Extremely helpful 1	–.030	0.114	0.069	1	.794	0.971
Extremely helpful 2	.123	0.121	1.032	1	.310	1.131
Extremely helpful 3	–.075	0.138	0.299	1	.584	0.928
Extremely helpful 4	–.167	0.128	1.708	1	.191	0.846
Extremely helpful 5	–.025	0.146	0.029	1	.865	0.976
Extremely helpful 6	.037	0.896	0.146	1	.702	1.037
Least helpful 1	.037	0.119	0.497	1	.756	1.038
Least helpful 2	.196	0.131	1.414	1	.234	1.169
Constant	.214	2.453	0.908	1	.930	1.231
*Cards chosen by Group I subjects according to their subjective helpfulness in group therapy. Two cards were selected as most helpful, six cards as extremely helpful, and two cards as least helpful factors in group therapy.

When we studied the relationship between perception of therapeutic factors and the patients’ clinical outcome (relapse or abstinence), the two most helpful, six extremely helpful, and two least helpful factors were entered in a logistic regression analysis using the clinical state as a dependent variable. As revealed in Table 6, no evident significant relationship was detected. This means that the patients’ perception of usefulness of a certain therapeutic factor rather than the others has no significant bearing on the outcome of treatment (i.e., there are no preferred therapeutic factors).

DISCUSSION

When the therapeutic factors were ranked in a descending order, as perceived by Group I subjects, catharsis received the highest rank among the most and extremely helpful factors. This goes along with Khantzian, Golden, and McAuliffe's findings (1999). Yalom (1985) as well views that seven of the first eight therapeutic factors represent some form of catharsis or insight. Yalom uses “insight” in the broadest sense (gaining an objective perspective of one's interpersonal behavior). “This finding lends considerable weight to the principle, that therapy is a dual process, consisting of emotional experience and of reflection upon that experience … The open expression of affect is without question vital in the group therapeutic process, in its absence a group would degenerate into a sterile academic exercise. Yet it is only a part process and must be complemented by other factors” (pp. 75–80, 85) Rakhawy (1979) states that expressing or even experiencing positive and negative feelings alone are not essentially of positive value; the ultimate therapeutic value depends on other intermingling factors. In this sense, Marziali, Munroe, and McClearly (1999) view that the high learners in group therapy showed a profile of catharsis in addition to some form of cognitive learning.

It seems that catharsis in a group setting is not simply a tension releaser. It could be much more related to what Yalom (1985) considered “first level of insight” (i.e., gaining an objective perspective of one's interpersonal behavior). With addicts, this seems particularly so, allowing unblocking, rather than simple evacuation.

Group cohesiveness comes second in rank as the most and extremely helpful factor. Group membership acceptance and approval are of the utmost importance in the individual's developmental sequence (Yalom, 1985). We suppose that problems in belonging to a group can be hidden or overcome by the use of substances. Moreover, group cohesiveness is a basic phenomenon in addicts’ gatherings, whether negative and destructive or positive and constructive. The shift from negative to positive is ready through the different techniques of group therapy. Guided by the therapist, the group therapy gives an appropriate opportunity for such shift.

“Therapy is broadly interpersonal, both in its goals and in its means” (Sullivan, 1938). Interpersonal learning (output) is ranked third among the most helpful factors in group therapy. While the interpersonal learning (input) factor was not very prized by Group I subjects, the output factor was highly appreciated. This can be explained in the light of the self-centered attitude of addicts. Addicts focus more on what they acquired in their relating with the group (skills in getting along with the group, learning to approach others, way of relating to others, etc.), which is included in the output factor, rather than on others’ views and impression toward them, emphasized in the input factor (Appendix 1).

Self-understanding as introduced by this test extends beyond intellectual insight. It was noticeably ranked among the most and extremely helpful therapeutic factors. According to Yalom (1985), group therapy offers an opportunity for participants to discover “positive areas of themselves.” We presume that most addicts are self-explorers via a faulty way. The “trip,” as some addicts call it, seems to be a trial to discover or uncover one's self. Group therapy could offer some healthy alternative to fulfill such a goal. Self-understanding is relevant to self and other's acceptance, tolerance, and objectivity. Using multichannel means of communications and frequent emphasis on the here and now in the group therapy provides a real chance for such comprehensive awareness, rather than conceptual understanding.

The existential factor follows self-understanding in ranking. We are inclined to agree that the existential factor is more ready to be uncovered in attitudes and modes of relating rather than in self-judgment and declared ideological standpoint. Perhaps this is behind Yalom's idea (1985) that existential factors play an important but generally unrecognized role in group therapy. Beck and Lewis (2000) noticed the unlikeliest to choose the existential factors and tried to interpret this phenomenon as: “The items in the Q-sort that struck meaningful chords in patients reflected some of these painful truths about existence. Patients realized that there were limits to the guidance and support they could receive from others, and that the ultimate responsibility for the conduct of their lives was theirs alone” (pp. 3–19). However, in the case of addicts, we presume that some existential challenges lay behind the psychopathology of their craving. Other genuine modes of existence such as group therapy may allow such opportunity at some integrated comprehensive level in contrast to the aborted trials through addictive behavior. Addicts seem more able to grasp this difference as much as observers.

From the literature and researchers’ experience, it seems that existential factors play a great role in cure. This role is seen by the therapists but not necessarily consciously perceived or verbally explained by patients. This would raise a question: Why in this study were existential factors appreciated by patients and selected as one of the extremely helpful therapeutic factors? Culturally, we may assume that group therapy gives some better chance for visiting such existential area, which is usually considered as a taboo in our society at large.

The fifth factor ranked as most and extremely helpful to subjects in the therapy is universality. This was explained by Yalom (1985) as: “In the therapy group, especially in the early stages, the disconfirmation of a patient's feelings of uniqueness is a powerful source of relief. After hearing other members disclose concerns similar to their own, patients report feeling more in touch with the world and describe the process as a ‘welcome to the human race’ experience or ‘we’re all in the same boat’; or perhaps more typically, ‘misery loves company’” (p. 8). In this sense, Despland, Roten, and Despars (2001) view that with rare exceptions, patients express great relief at discovering that they are not alone and that others share the same dilemmas and life experiences. This may be much more feasible with the psychopathology of addicts who tend, via their addiction, to break through the boring alienated closed-circuit stereotyped mode of living prevailing in their societies.

The importance of instillation of hope (ranked as the sixth among the most helpful factors) for addicts is strongly emphasized by self-help groups. “One of the great strengths of Alcoholics Anonymous is the fact that the leaders are all ex-alcoholics—living inspirations to the others” (Lieberman & Borman, 1979, pp. 202–205). Considering that hopelessness is a strong underlying psychopathological factor that leads to perpetuation of the addictive behavior, we believe that group therapy, via the diverse used mechanisms, offers a milieu where such perpetuation can be broken up.

Altruism was not very praised among the significantly helpful therapeutic factors (Table 4). This can be explained by the difficulty the addict finds to appreciate the value of the intrinsic act of giving, with respect to his relatively self-centered core of existence. However, altruism can be responsible for maintenance of sobriety among ex-addicts by helping who needs them.

Guidance or “imparting information” was ranked 10th among the most and extremely helpful factors and 3rd among the least helpful factors. Ranking of guidance among unappreciated helpful factors in the group can be understood by the postulation that didactic information and advice are not valued retrospectively in group therapy (Jones, 1944). In other words, the educational process in group therapy is implicit; most group therapists do not offer explicit didactic instruction in interaction group therapy. There are, however, some other group therapy approaches in which formal instruction is an important part of the group. This is obviously met in the self-help addictive groups where imparting of information is strongly emphasized and used. Yalom (1985) suggested that direct advice is related to the age of the group. It is invariably part of the early stages of the group and occurs with such regularity that it can be used to estimate the age of the group. In this context, Rakhawy, Shaalan, and Abdel Gawad (1974, p. 24) stated: “If we observe or hear a tape of a group in which the patients with some regularity say, ‘I think you ought to …’ or, ‘What you should do is …’ or, ‘Why don't you …,’ then we can be reasonably certain either that the group is young or that it is an older group facing some difficulty that has either impeded its development or effected temporary regression. Despite the fact that advice giving is common in early interactional group therapy, specific suggestion concerning some problem was of direct benefit to any patient. Indirectly, however, advice giving serves a purpose; the process, rather than the content of the advice, may be beneficial, since it implies and conveys mutual interest and caring.”

The fact that family reenactment is not cited by patients among the main helpful factor is not surprising. Yalom (1985) views that family reenactment operates at a different level of awareness from such explicit factors as catharsis or universality. However, this factor is highly appreciated by therapists. Kooiman, Spinhoven, Trisjsburg, and Rooijmanans (1998) view that “the group can be a time machine which flings patients back several decades and evokes deeply etched ancient memories and ancient feelings. The patient reenacts early family scripts in group and, if therapy is successful, is able to experiment with new behavior, and to break free from the family role into which he or she has long been locked.”

It is very obvious in the results of this study that patients are inclined not to acknowledge identification or imitative behavior as a helpful factor in group therapy. None of the cards related to identification were selected as the most helpful factor, and identification received the highest score as a least helpful factor (Table 4). It seems that this factor declares some sort of frank follower attitude usually denied by addicts. Rosenthal (1955) stated that “group therapy patients rate imitative behavior as one of the least helpful of the twelve therapeutic factors. However, in retrospect, the five items in this category seem to have tapped only a limited sector of this therapeutic mode. They failed to distinguish between mere mimicry, which apparently has only a restricted value for patients, and the acquisition of general modes of behavior, which may have considerable value.”

Findings of the Studied Groups According to the Sobriety/Relapse Outcome

The outcome of Group I, who received at least 1.5-month hospitalization containing 15 sessions of group therapy, was more favorable than Group II, who received modes of treatment other than group therapy. In Group I, 52.5 % remained sober after 1 year of the study in comparison to 22.5% of Group II. The difference in the relapse/sobriety outcome between the two groups is of a statistical significance (p < .01). Krampe et al. (2006) view comprehensive programs where active components are forms of psychotherapy as more effective in treatment of substance abuse. ASAM's literature (2003) asserts that detoxification, however successful, does not affect the natural history of substance abuse disorder. Detoxification is associated with relapse rate so high that they have little long-term effect on addiction. Kissen (2006) highlighted Freud's view that the talking cure was developed due to the rather primitive nature of neuroscientific knowledge, with regard to the brain. The recent work of neuroscientists, according to Kissen, may allow for empirical demonstrations of benign changes in brain functions following an effective course of treatment. Hence, brain studies and their correlation with the relapse/sobriety outcome can be considered in future studies.

Relation Between Therapeutic Factors and Relapse/Sobriety Outcome

Despite our assumption that correlation of sobriety/relapse outcome with independent therapeutic factor(s) may invite some sort of splitting hairs, which is inconsistent with the basic concept of holistic interaction between most such factors, we have tried to find the relation between individual therapeutic factors and outcome. No significant correlation was found between the choice of the therapeutic factor and the outcome after 1 year of the study. The logistic regression analysis of the therapeutic factors, using the clinical state as a dependent variable did not reveal any evident significant relationship. This supports the view that the group therapy experience is perceived as a whole. Looking at any therapeutic factors separately is not enough for actualizing therapeutic goals. This also suggests that therapeutic factors interact together, working on different levels of awareness, consciousness, and existence to lead to the ultimate change desired from therapy. Besides, therapeutic factors are presumed to change across the stages of group therapy. Mahfouz, Hanaa, and Mohamed (2002) reported that the nature of a single therapeutic factor can also change across the stages of the group factors, and altruism can change from simple help at the beginning of the group to “being with” at later stages. Global consideration of factors in the group seems to be more understandable than a reductionist perspective focusing on single therapeutic factors.

Study Challenges and Limitation

• As many studies on psychotherapeutic interventions, the small sample size is a relative limitation that can be overcome by further future studies in the same field.

• A considerable number of Group II participants refused to do any psychometric studies and accepted only drug screening as a follow-up assessment. So relapse/sobriety was only assessed by drug screening. Further qualitative assessment, as via the ASI, would add to the value of the results.

CONCLUSION

The outcome of Group I subjects, who received 15 sessions of group therapy, was more favorable, with a lower relapse rate than Group II subjects, who received the same modes of treatment except for group therapy. The most helpful factors perceived by addicts in the group therapy are catharsis, followed by group cohesiveness and interpersonal learning (output). It is insufficient to look at independent therapeutic factors in group therapy as contributing to the desired change, as it seems that therapeutic factors interact together along the stages of the therapeutic process.

APPENDIX 1

Table

1. Altruism	1. Helping others has given me more self-respect.
	2. Putting others’ needs ahead of mine.
	3. Forgetting myself and thinking of helping others.
	4. Living part of myself to others.
	5. Helping others and being important in their lives.
2. Group Cohesiveness	6. Belonging to and being accepted by a group.
	7. Continued close contact with other people.
	8. Revealing embarrassing things about myself and still being accepted by the group.
	9. Feeling alone no longer.
	10. Belonging to a group of people who understood and accepted me.
3. Universality	11. Learning I’m not the only one with my type of problem—“We’re all in the same boat.”
	12. Seeing that I was just as well off as others.
	13. Learning that others have some of the same “bad” thoughts and feelings that I do.
	14. Learning that others had parents and background as unhappy or mixed up as mine.
	15. Learning that I’m not very different from other people gave me a “welcome to the human race” feeling.
4. Interpersonal Learning (Input)	16. The group's teaching me about the type of impression I make on others.
	17. Learning how I come across to others.
	18. Other members honestly telling me what they think of me.
	19. Group members pointing out some of my habits or mannerisms that annoy other people.
	20. Learning that I sometimes confuse people by not saying what I really think.
5. Interpersonal Learning (Output)	21. Improving my skills in getting along with people.
	22. Feeling more trustful of groups and of other people.
	23. Learning about the way I related to the other group members.
	24. The group is giving me an opportunity to learn to approach others.
	25. Working out my difficulties with one particular member in the group.
6. Guidance	26. The doctor's suggesting or advising something for me to do.
	27. Group members suggesting or advising something for me to do.
	28. Group members telling me what to do.
	29. Someone in the group is giving me definite suggestions about a life problem.
	30. Group members advising me to behave differently with an important person in my life.
7. Catharsis	31. Getting things off my chest.
	32. Expressing negative and/or positive feelings toward another member.
	33. Expressing negative and/or positive feelings toward the group leader.
	34. Learning how to express my feelings.
	35. Being able to say what was bothering me instead of holding it in.
8. Identification	36. Trying to be like someone in the group who was better adjusted than I am.
	37. Seeing that others could reveal embarrassing things and take other risks and benefit from it helped me to do the same.
	38. Adopting mannerisms or the style of another group member.
	39. Admiring and behaving like my therapist.
	40. Finding someone in the group I could pattern myself after.
9. Family reenactment	41. Being in the group was, in a sense, like reliving and understanding my life in the family in which I grew up.
	42. Being in the group somehow helped me to understand old hang-ups that I had in the past with my parents, brothers, sisters, or other important people.
	43. Being in the group was, in a sense, like being in a family, only this time a more accepting and understanding family.
	44. Being in the group somehow helped me to understand how I grew up in my family.
	45. The group was something like my family—some members or the therapists being like my parents and others being like my relatives. Through the group experience, I understand my past relationships with my parents and relatives (brothers, sisters, etc.).
10. Self-understanding	46. Learning that I have likes or dislikes for a person for reasons which may have little to do with the person and more to do with my hang-ups or experiences with other people in my past.
	47. Learning why I think and feel the way I do (that is, learning some of the causes and sources of my problems).
	48. Discovering and accepting previously unknown or unacceptable parts of myself.
	49. Learning that I react to some people or situations unrealistically (with feelings that somehow belong to earlier periods in my life).
	50. Learning that how I feel and behave today is related to my childhood and development (there are reasons in my early life why I am how I am).
11. Instillation of hope	51. Seeing others getting better was inspiring to me.
	52. Knowing others had solved problems similar to mine.
	53. Seeing that others had solved problems similar to mine.
	54. Seeing that other group members improved encouraged me.
	55. Knowing that the group had helped others with problems like mine encouraged me.
12. Existential Factors	56. Recognizing that life is sometimes unfair and unjust.
	57. Recognizing that ultimately there is no escape from some of life's pain and from death.
	58. Recognizing that no matter how close I get to other people, I must still face life alone.
	59. Facing the basic issues of my life and death, and thus living my life more honestly and being less caught up in trivialities.
	60. Learning that I must take ultimate responsibility for the way I live my life, no matter how much guidance and support I get from others.