Brief
family
therapists responded to this and made the transition to the psychoeducational model.
Reports
The
Therapist
Elizabeth Sarah Dana
Patricia
as Psychoeducator
Ph.D. M.S.W.
Pollen,
who provide care for nelawith long-term mental illness. We describe some of the successes of the approach as we!! as complex issues and problems that arose, and we discuss our conclusion that psychodynamic understanding and skills need to be integrated into psychoeducation. tives
Nemser, M.S.W. Nuzzola, R.N.,
Lenore
families
M.D.
Gingerich, Golden, Holley,
J oan
advocacy
M.S.
M.S.W.
Clinicians providing psychoeducation give information and support to family members in a nonjudgmental, educational format (1). To improve the ftmily’s understanding of their relative’s overall treatment, psychoeducation embraces evolving biological theories of mental illness and promotes a sense of “cognitive mastery” (1) of the family member’s illness and its management. The efficacy of the psychoeducational approach has been supported by early research demonstrating that it decreased on forestalled patients’ relapse and nehospitalization (1 ,2). In recent years, the theory of expressed emotion has been formulated, which suggests that psychoeducation improves outcome by decreasing the family’s emotional intensity and creating a more benign attitude toward the patient (3). This paper is based on six cliicians’ collective experience doing psychoeducational group work with
Ms. Pollen are affiliated with Cambridge Hospital, Harvard Medical School. Dr. Golden and Ms. Pollen are at Metropolitan State Hospital in Waltham, Massachusetts.
Background Family therapy evolved in the 1950s, shifting the focus of treatment from internal dynamics and introjects to the influence of the social environment on the individual (4). Concepts such as the “schizophrenogcic mothen” (5) and communication theory, which offered explanations of family etiology of schizophrenia, also arose in the 1950s. These ideas implied that reversal of family dysfunction might also reverse the patient’s symptomatology. The family therapist took a removed and critical stance toward the family as patient; the therapist had knowledge and skill, and the “sick” family needed to struggle toward self-understanding and insight. With the reform movement of deinstitutionalization in the 1960s and 1970s, families were expected to take greater and more enduring nesponsibility for their relatives while they continued to be held responsible for causing and perpetuating the illness (6). The National Alliance for the Mentally Ill emerged in 1979 as an expression of families’ outrage at being seen as pathological rather than being given assistance. Families wanted real help in the form of information on mental illness and its management, as well as more research on the actual causes and effective treatments. Some traditional
928
September
Dr. Ms. the
Gingerich, Nuzzola Somerville
Clinic, vile,
63 College
are
Ms. Holley, and affiliated with Mental Health Avenue,
Massachusetts
Gingerich, ley, Ms.
Dr. Nernser,
Sorner-
02144.
Golden, and
Ms.
Dr. Ho!-
1992
Vol. 43
No.9
Our experience Our work with groups of families took place over a period ofeight years in three different settings: a state hospita! inpatient unit, a community hospital inpatient unit, and a community mental health outpatient clinic. Two- to four-session seminars were given at each site, with an emphasis on biological explanations of heritability, etiology, symptoms, and treatment of major mental illnesses, particularly shizophrenia and major depression. The clinicians involved met togetherduring that time for discussion, support, and crossreferral. Effects on families. The families in our programs benefited from information and social support by gaining ne!iefand comfort, greater objectivity, and a degree of mastery over their situations. They experienced validation of their feelings by listening to others’ stories and recognizing that they were not alone with their struggles and frustrations. They frequently expressed relief at knowing that their feelings of anger, disappointment, disbelief, and guilt were normal. Families in the programs began to face the chronicity of the illness and their ongoing grief. The family members in our groups shared complaints about withholding and unresponsive profcssionals: “I’ve never been told a diagnosis.” “When I try to get information, I’m seen as intrusive.” “They don’t listen to us.” “They won’t hospitalize patients until it’s too late. Why do we have to wait until someone gets hurt?” The family members encouraged each other to be assertive when dealing with professionals. After they entered our programs, families reported increased tolerance for patients’ residual symptoms, which had not previously been identificd as part of the illness. Their responses to patients’ aggravating behaviors such as excessive sleeping, poor hygiene, and dropped cigarette ashes often became less emotional and more effective. They frequently acknowledged the gratification they received from helping other families
Hospital
and Community
Psychiatry
deal
with the devastation expeniduring the initial stages of loss and confusion. Families of inpatients became more involved in decisions about patients’ home visits and holiday plans, which improved the success of the visits. Visits to inpatients became easier for families, and their increased comfort with staff was also noted by nursing staff. Several ftmilies returned or were referred to another site for additional seminars. An ongoing family psychoeducation group was started at the outpatient clinic in response to families’ requests for continuing education and support. Some family members entered more traditional family therapy or individual therapy. Others became more involved in advocating for improvements through the legal system and the National Alliance for the Mentally Ill. Effects on clinicians. Clinicians learned to respect and appreciate the enormous strengths and abilities of family members. This process allowed us to join families as allies and demystified clinician authority. However, our early experiences became complicated by the emergence of conflict in several areas. In the seminars we had difficulty completing our reviews of educational matcrial because ofthe families’ pressure for discussion. We began to feel caught in a split between families and professionals in which one side devalued the other: “The doctors don’t understand or care about what
tween our tendency to generalize in order to teach coherently and a need to address the individuality of patients and their symptoms. Overall, it seemed that education was a palatable way for stressed families to come into the mental health system, yet the format did not sufficiently allow for expression of intense feelings ofgriefand guilt. The ongoing family psychoeducation group became a cohesive group resistant to the addition of new peopie. The members had difficulty absorbing and using ideas presented in the educational format because of
their own personality styles and defenses. Due to the nature of the psychoeducation-support group model, there was no explicit contract with group members that their own problems might be the focus of therapeutic endeavor, nor was there any discussion of members’ commiting to the group or paying a fee. We became stuck about how actively to address the characterological patterns of the family members themselves, since they appeared to be important determinants of families’ ability to cope with patients. Family members in both the seminars and the ongoing group presented a spectrum ranging from the concerned and insightful to those who were themselves mentally ill. Facilitating group discussions therefore challenged our therapeutic skills. We drew on group, family, and individual therapy techniques as well as teaching skills. All the psychoeducation programs were set up as separate from other clinical services, but referrals from fellow clinicians dropped off. This decrease occurred in the outpatient setting partly because an original pool of families most receptive to the programs had been served, and it appeared that other families required considerable preparation and support from a clinician in order to be referred successfully. Institutiona! supports in the form of money and clinical time were not forthcoming in any of the settings, as direct care priorities and new unrelated programs competed for shrinking economic resources. In addition, as the National Alliance for the Mentally Ill gained numbers and political recognition, it seemed that we might be duplicating programming. Thus the nature and role of our psychoeducation programs were called into question, goals were reexamined, and new ideas were formulated. Changingexplanations. Psychoeducation practitioners experience in a microcosm what the mental health field struggles with. Clinicians have found that neither a biological nor a dynamic explanation alone is sufficient to explain or manage the full range ofproblems facing people who deal with the mental illness of family members. We observed that dy-
Hospital
September
enced
we live with every day” as opposed
to
“The family is enmeshed him get better.”
let
We
experienced
and
Community
and can’t
a tension
Psychiatry
be-
1992
Vol.
43
No.9
namic understanding of these families may have been sacrificed in an effort to compensate for the damage done by dynamic theories of etiology of mental illness. Our findings and recommendations drawn from our collective expenicncc are summarized below. . Facilitating any educational or support group requires use of a range of clinical skills, including group, family, and individual techiques. Practitioners may enhance their ability to educate by acknowledging the extent to which they must use their clinical skills and thus regain the freedom to use them. S Psychoeducational group work involves a natural tension between family members’ need to gain information and their need to express complex feelings and beliefs, a tension that should be anticipated and balanced by group leaders. . The state of the art and science of treating mental illness requires teaching what is known in the context of honest acknowledgment of what is not known. Generalizations must be balanced with recognition ofthe uniqueness ofthc individual patient and family. . The needs of families, mdividually and as a group, change and evolve in response to changes in the patient and the care system and require continual reassessment. . Clinicians need to maintain a dialogue about changing needs with each other and with patients and families, institutions for patient care, and local advocacy groups. This dialogue may include issues such as group versus individualized modalitics for providing education and support, the changing needs of families oven the course ofdealing with longterm mental illness, the overlap between psychoeducation programs offered by professionals and by the National Alliance for the Mentally Ill, and the possibilities for professionals and advocacy groups to interact more effectively. Conclusions Families ofmentally ill patients have become more educated, assertive, and politically involved. The patient care system has become more nesponsivc to families’ needs and more
929
oriented toward biological models of treatment for major mental illness. The original psychoeducation model has been useful, but no longer needs to remain “pure. As with many new movements, psychoeducation can now be practiced more effectively through integration with other models rather than in isolation. “
References 1.
Anderson Schizophrenia
CM,
Guilford, 2.
Falloon
Reiss and
DJ,
Hogarty
the Family.
GE:
New York,
1986 IRH,
Boyd
L, McGill
CW,
et al:
Cocaine Arthur
I. Alterman, Droba, M.D. A. Thomas McLellan,
Ph.D.
Marian
Ph.D.
Day hospital treatment is an effective intervention in the treatment of scveral psychiatric disorders (1 ). Day hospital treatment for alcoholism compares favorably with inpatient
ic director scientific
rnent
is associate scientifDr. McLellan is
and director
ofVeterans
at the
Depart-
Affairs-Univer-
sity ofPennsy!vania Addiction Research Center at the Veterans Affairs Medical Center (1 16), Uiversity and Woodland Avenues, Philadelphia,
Pennsylvania
19104.
Drs. Alterman and McLellan are professors and Dr. Droba is cliical assistant professor in the departrnent versity
ofpsychiatry of Pennsylvania
Medicine Droba trist
vania
930
in is also
at the Hospital.
3.
Beels
C, McFarlane
W:
Family
treatments
ofschizophrenia: background and state of the art. Hospital and Community Psychiatry 33:541-549, 1982 4. Haley J: A review of the family therapy field, in Changing Families: A Family Therapy Reader. Edited by Haley J. New York, Grune & Stratton, 1971 5. Fromm-Reichmann F: Notes on the development oftneatment of schizophnenics by psychoanalytic psychotherapy. Psychiatry 11:263-273, 1948 6. McGill CW, Lee E: Family psychoeducational intervention in the treatment of schizophrenia. Bulletin ofthe Menninger Clinic
50:269-286,
1986
to Day Hospital by Patients With and Alcohol Dependence
Response Treatment
Dr. Alterman
Family management in the prevention of exacerbations ofschizophrenia. New England Journal of Medicine 306:14371449, 1982
at the UiSchool of
Philadelphia. Dr. attending psychiaInstitute of Pennsyl-
treatment (2,3). The Philadelphia Veterans Affairs Medical Center has been treating low-income alcoholdependent men in a day hospital program with good results for more than 1 5 years. When an increasing number ofcocaine-dependcnt individuals began seeking treatment at our facility several years ago, we had no specific interventions in place for them, although they appeared to require intensive treatment (4). We attempted to treat them in the same day hospital program used for the alcoholic patients. The purpose ofthc study reported here was to compare the treatment response of the cocaine-dependent patients in the day hospital program with that of the alcohol-dependent patients in the program. Measures of treatment response included the amount oftreatmcnt patients in each group reported receiving, the two groups’ treatment completion rate, the duration oftreatment for patients who did and did not complete treatment, and within-treatment urine toxicology data for the cocaine-dcpendent patients. Many cocaine-dc-
September
1992
Vol.
43
No.9
pendent without
patients the benefit
enter treatment of detoxification. We therefore felt it important to determine the extent to which patients with a positive initial urine toxicology screen are likely to complete treatment.
Methods Subjects. Sixty cocaine-dependent men and 67 alcohol-dependent men undergoing day hospital treatment in the Philadelphia VA Medical Centen were selected between September 1987 and August 1990. Substance abuse diagnoses were based on a dinical diagnostic interview by a program psychiatrist who used DSMIII-R criteria (5). Patients over 59 years ofage, those with a history of a psychotic disorder or dementia, those medically inappropriate for outpatient treatment, or those who met criteria for a substance abuse diagnosis involving a substance other than alcohol, cocaine, or marijuana were not included in the study. Treatment program. The day hospital treatment program is available to both alcoholand cocaine-dcpendent veterans. Its goal is to providc a structured setting in which patients can initiate abstinence from all drugs of abuse. The program provides 27 hours of treatment each week for about a month, including daily group therapy focusing on cognitive and behavioral patterns of addiction, educational sessions on the biopsychosocia! aspects of addiction, supervised group recreation, and family therapy when indicated. Individual counseling is available as needed. Maintenance and preventive medical care is available. Ancillary psychotropic medication (usually for depression) is occasionally prescribed. Twice-weekly urine toxicology screens arc used to monitor patients’ abstinence. Other indicators of progress monitored by program staff are attendance, participation in group and educational sessions, and participation at least three times a week in Alcoholics Anonymous or Narcotics Anonymous groups. Evidence ofcontinued cocaine or alcohol use, mdicated by three successive positive
Hospital
and
Community
Psychiatry
family
therapists responded to this and made the transition to the psychoeducational model.
Reports
The
Therapist
Elizabeth Sarah Dana
Patricia
as Psychoeducator
Ph.D. M.S.W.
Pollen,
who provide care for nelawith long-term mental illness. We describe some of the successes of the approach as we!! as complex issues and problems that arose, and we discuss our conclusion that psychodynamic understanding and skills need to be integrated into psychoeducation. tives
Nemser, M.S.W. Nuzzola, R.N.,
Lenore
families
M.D.
Gingerich, Golden, Holley,
J oan
advocacy
M.S.
M.S.W.
Clinicians providing psychoeducation give information and support to family members in a nonjudgmental, educational format (1). To improve the ftmily’s understanding of their relative’s overall treatment, psychoeducation embraces evolving biological theories of mental illness and promotes a sense of “cognitive mastery” (1) of the family member’s illness and its management. The efficacy of the psychoeducational approach has been supported by early research demonstrating that it decreased on forestalled patients’ relapse and nehospitalization (1 ,2). In recent years, the theory of expressed emotion has been formulated, which suggests that psychoeducation improves outcome by decreasing the family’s emotional intensity and creating a more benign attitude toward the patient (3). This paper is based on six cliicians’ collective experience doing psychoeducational group work with
Ms. Pollen are affiliated with Cambridge Hospital, Harvard Medical School. Dr. Golden and Ms. Pollen are at Metropolitan State Hospital in Waltham, Massachusetts.
Background Family therapy evolved in the 1950s, shifting the focus of treatment from internal dynamics and introjects to the influence of the social environment on the individual (4). Concepts such as the “schizophrenogcic mothen” (5) and communication theory, which offered explanations of family etiology of schizophrenia, also arose in the 1950s. These ideas implied that reversal of family dysfunction might also reverse the patient’s symptomatology. The family therapist took a removed and critical stance toward the family as patient; the therapist had knowledge and skill, and the “sick” family needed to struggle toward self-understanding and insight. With the reform movement of deinstitutionalization in the 1960s and 1970s, families were expected to take greater and more enduring nesponsibility for their relatives while they continued to be held responsible for causing and perpetuating the illness (6). The National Alliance for the Mentally Ill emerged in 1979 as an expression of families’ outrage at being seen as pathological rather than being given assistance. Families wanted real help in the form of information on mental illness and its management, as well as more research on the actual causes and effective treatments. Some traditional
928
September
Dr. Ms. the
Gingerich, Nuzzola Somerville
Clinic, vile,
63 College
are
Ms. Holley, and affiliated with Mental Health Avenue,
Massachusetts
Gingerich, ley, Ms.
Dr. Nernser,
Sorner-
02144.
Golden, and
Ms.
Dr. Ho!-
1992
Vol. 43
No.9
Our experience Our work with groups of families took place over a period ofeight years in three different settings: a state hospita! inpatient unit, a community hospital inpatient unit, and a community mental health outpatient clinic. Two- to four-session seminars were given at each site, with an emphasis on biological explanations of heritability, etiology, symptoms, and treatment of major mental illnesses, particularly shizophrenia and major depression. The clinicians involved met togetherduring that time for discussion, support, and crossreferral. Effects on families. The families in our programs benefited from information and social support by gaining ne!iefand comfort, greater objectivity, and a degree of mastery over their situations. They experienced validation of their feelings by listening to others’ stories and recognizing that they were not alone with their struggles and frustrations. They frequently expressed relief at knowing that their feelings of anger, disappointment, disbelief, and guilt were normal. Families in the programs began to face the chronicity of the illness and their ongoing grief. The family members in our groups shared complaints about withholding and unresponsive profcssionals: “I’ve never been told a diagnosis.” “When I try to get information, I’m seen as intrusive.” “They don’t listen to us.” “They won’t hospitalize patients until it’s too late. Why do we have to wait until someone gets hurt?” The family members encouraged each other to be assertive when dealing with professionals. After they entered our programs, families reported increased tolerance for patients’ residual symptoms, which had not previously been identificd as part of the illness. Their responses to patients’ aggravating behaviors such as excessive sleeping, poor hygiene, and dropped cigarette ashes often became less emotional and more effective. They frequently acknowledged the gratification they received from helping other families
Hospital
and Community
Psychiatry
deal
with the devastation expeniduring the initial stages of loss and confusion. Families of inpatients became more involved in decisions about patients’ home visits and holiday plans, which improved the success of the visits. Visits to inpatients became easier for families, and their increased comfort with staff was also noted by nursing staff. Several ftmilies returned or were referred to another site for additional seminars. An ongoing family psychoeducation group was started at the outpatient clinic in response to families’ requests for continuing education and support. Some family members entered more traditional family therapy or individual therapy. Others became more involved in advocating for improvements through the legal system and the National Alliance for the Mentally Ill. Effects on clinicians. Clinicians learned to respect and appreciate the enormous strengths and abilities of family members. This process allowed us to join families as allies and demystified clinician authority. However, our early experiences became complicated by the emergence of conflict in several areas. In the seminars we had difficulty completing our reviews of educational matcrial because ofthe families’ pressure for discussion. We began to feel caught in a split between families and professionals in which one side devalued the other: “The doctors don’t understand or care about what
tween our tendency to generalize in order to teach coherently and a need to address the individuality of patients and their symptoms. Overall, it seemed that education was a palatable way for stressed families to come into the mental health system, yet the format did not sufficiently allow for expression of intense feelings ofgriefand guilt. The ongoing family psychoeducation group became a cohesive group resistant to the addition of new peopie. The members had difficulty absorbing and using ideas presented in the educational format because of
their own personality styles and defenses. Due to the nature of the psychoeducation-support group model, there was no explicit contract with group members that their own problems might be the focus of therapeutic endeavor, nor was there any discussion of members’ commiting to the group or paying a fee. We became stuck about how actively to address the characterological patterns of the family members themselves, since they appeared to be important determinants of families’ ability to cope with patients. Family members in both the seminars and the ongoing group presented a spectrum ranging from the concerned and insightful to those who were themselves mentally ill. Facilitating group discussions therefore challenged our therapeutic skills. We drew on group, family, and individual therapy techniques as well as teaching skills. All the psychoeducation programs were set up as separate from other clinical services, but referrals from fellow clinicians dropped off. This decrease occurred in the outpatient setting partly because an original pool of families most receptive to the programs had been served, and it appeared that other families required considerable preparation and support from a clinician in order to be referred successfully. Institutiona! supports in the form of money and clinical time were not forthcoming in any of the settings, as direct care priorities and new unrelated programs competed for shrinking economic resources. In addition, as the National Alliance for the Mentally Ill gained numbers and political recognition, it seemed that we might be duplicating programming. Thus the nature and role of our psychoeducation programs were called into question, goals were reexamined, and new ideas were formulated. Changingexplanations. Psychoeducation practitioners experience in a microcosm what the mental health field struggles with. Clinicians have found that neither a biological nor a dynamic explanation alone is sufficient to explain or manage the full range ofproblems facing people who deal with the mental illness of family members. We observed that dy-
Hospital
September
enced
we live with every day” as opposed
to
“The family is enmeshed him get better.”
let
We
experienced
and
Community
and can’t
a tension
Psychiatry
be-
1992
Vol.
43
No.9
namic understanding of these families may have been sacrificed in an effort to compensate for the damage done by dynamic theories of etiology of mental illness. Our findings and recommendations drawn from our collective expenicncc are summarized below. . Facilitating any educational or support group requires use of a range of clinical skills, including group, family, and individual techiques. Practitioners may enhance their ability to educate by acknowledging the extent to which they must use their clinical skills and thus regain the freedom to use them. S Psychoeducational group work involves a natural tension between family members’ need to gain information and their need to express complex feelings and beliefs, a tension that should be anticipated and balanced by group leaders. . The state of the art and science of treating mental illness requires teaching what is known in the context of honest acknowledgment of what is not known. Generalizations must be balanced with recognition ofthe uniqueness ofthc individual patient and family. . The needs of families, mdividually and as a group, change and evolve in response to changes in the patient and the care system and require continual reassessment. . Clinicians need to maintain a dialogue about changing needs with each other and with patients and families, institutions for patient care, and local advocacy groups. This dialogue may include issues such as group versus individualized modalitics for providing education and support, the changing needs of families oven the course ofdealing with longterm mental illness, the overlap between psychoeducation programs offered by professionals and by the National Alliance for the Mentally Ill, and the possibilities for professionals and advocacy groups to interact more effectively. Conclusions Families ofmentally ill patients have become more educated, assertive, and politically involved. The patient care system has become more nesponsivc to families’ needs and more
929
oriented toward biological models of treatment for major mental illness. The original psychoeducation model has been useful, but no longer needs to remain “pure. As with many new movements, psychoeducation can now be practiced more effectively through integration with other models rather than in isolation. “
References 1.
Anderson Schizophrenia
CM,
Guilford, 2.
Falloon
Reiss and
DJ,
Hogarty
the Family.
GE:
New York,
1986 IRH,
Boyd
L, McGill
CW,
et al:
Cocaine Arthur
I. Alterman, Droba, M.D. A. Thomas McLellan,
Ph.D.
Marian
Ph.D.
Day hospital treatment is an effective intervention in the treatment of scveral psychiatric disorders (1 ). Day hospital treatment for alcoholism compares favorably with inpatient
ic director scientific
rnent
is associate scientifDr. McLellan is
and director
ofVeterans
at the
Depart-
Affairs-Univer-
sity ofPennsy!vania Addiction Research Center at the Veterans Affairs Medical Center (1 16), Uiversity and Woodland Avenues, Philadelphia,
Pennsylvania
19104.
Drs. Alterman and McLellan are professors and Dr. Droba is cliical assistant professor in the departrnent versity
ofpsychiatry of Pennsylvania
Medicine Droba trist
vania
930
in is also
at the Hospital.
3.
Beels
C, McFarlane
W:
Family
treatments
ofschizophrenia: background and state of the art. Hospital and Community Psychiatry 33:541-549, 1982 4. Haley J: A review of the family therapy field, in Changing Families: A Family Therapy Reader. Edited by Haley J. New York, Grune & Stratton, 1971 5. Fromm-Reichmann F: Notes on the development oftneatment of schizophnenics by psychoanalytic psychotherapy. Psychiatry 11:263-273, 1948 6. McGill CW, Lee E: Family psychoeducational intervention in the treatment of schizophrenia. Bulletin ofthe Menninger Clinic
50:269-286,
1986
to Day Hospital by Patients With and Alcohol Dependence
Response Treatment
Dr. Alterman
Family management in the prevention of exacerbations ofschizophrenia. New England Journal of Medicine 306:14371449, 1982
at the UiSchool of
Philadelphia. Dr. attending psychiaInstitute of Pennsyl-
treatment (2,3). The Philadelphia Veterans Affairs Medical Center has been treating low-income alcoholdependent men in a day hospital program with good results for more than 1 5 years. When an increasing number ofcocaine-dependcnt individuals began seeking treatment at our facility several years ago, we had no specific interventions in place for them, although they appeared to require intensive treatment (4). We attempted to treat them in the same day hospital program used for the alcoholic patients. The purpose ofthc study reported here was to compare the treatment response of the cocaine-dependent patients in the day hospital program with that of the alcohol-dependent patients in the program. Measures of treatment response included the amount oftreatmcnt patients in each group reported receiving, the two groups’ treatment completion rate, the duration oftreatment for patients who did and did not complete treatment, and within-treatment urine toxicology data for the cocaine-dcpendent patients. Many cocaine-dc-
September
1992
Vol.
43
No.9
pendent without
patients the benefit
enter treatment of detoxification. We therefore felt it important to determine the extent to which patients with a positive initial urine toxicology screen are likely to complete treatment.
Methods Subjects. Sixty cocaine-dependent men and 67 alcohol-dependent men undergoing day hospital treatment in the Philadelphia VA Medical Centen were selected between September 1987 and August 1990. Substance abuse diagnoses were based on a dinical diagnostic interview by a program psychiatrist who used DSMIII-R criteria (5). Patients over 59 years ofage, those with a history of a psychotic disorder or dementia, those medically inappropriate for outpatient treatment, or those who met criteria for a substance abuse diagnosis involving a substance other than alcohol, cocaine, or marijuana were not included in the study. Treatment program. The day hospital treatment program is available to both alcoholand cocaine-dcpendent veterans. Its goal is to providc a structured setting in which patients can initiate abstinence from all drugs of abuse. The program provides 27 hours of treatment each week for about a month, including daily group therapy focusing on cognitive and behavioral patterns of addiction, educational sessions on the biopsychosocia! aspects of addiction, supervised group recreation, and family therapy when indicated. Individual counseling is available as needed. Maintenance and preventive medical care is available. Ancillary psychotropic medication (usually for depression) is occasionally prescribed. Twice-weekly urine toxicology screens arc used to monitor patients’ abstinence. Other indicators of progress monitored by program staff are attendance, participation in group and educational sessions, and participation at least three times a week in Alcoholics Anonymous or Narcotics Anonymous groups. Evidence ofcontinued cocaine or alcohol use, mdicated by three successive positive
Hospital
and
Community
Psychiatry
