By themselves, therapists have only marginal potential for influencing patients outside the office. If a patient has a slip into drug abuse the therapist may not be apprised, and if he knows, he can bring little influence to bear. Therapists on their own are limited in the degree to which they can make demands on the patient's life, and the patient is free to walk away from the therapeutic situation if it is uncomfortable for him—that is to say, if it challenges a serious relapse to addiction. All these factors make the engagement and orchestration of family and friends into the therapy with a substance-abusing patient an invaluable resource, one which offers remarkable opportunity for the modification of traditional psychotherapeutic techniques to treat the substance abuser.
The Network
A social network is very important in altering addictive behavior. In the public alcoholism clinic I once directed, patients without families to support them had to be repeatedly confronted with the realities of the addiction in group therapy by their peers so as to assure that denial did not erode their capacity to deal with reality. A social network is apparently a necessary vehicle to stabilizing the cognitive components of patients' recovery, to allow them to deal with the reality they need to see, and to provide the support essential for accepting the new reality. I realized that because of the social ties in a cohesive network, a patient in a therapist's office might be reluctant to run out on his treatment.
Inpatient rehabilitation facilities, by contrast, often disrupt family and social ties while the patients are hospitalized. They also remove patients from the opportunity of learning to deal with the conditioned cues for drinking while treatment supports are greatest; the real temptations to drinking do not present themselves in the hospital.
A person's immediate network might draw on his spouse, some friends, or his family of origin. Components of the network are only parts of the natural support systems that usually operate without professional involvement. But, brought to act in concert, the strength of their social influence can serve as a therapeutic device.
A number of forces shape the network:
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Cohesiveness
Social cohesiveness has been defined as the product of all forces that act to keep members engaged in a group, and it can be an important therapeutic instrument. It is generally evident and well-focused in indigenous mental healing rituals in preindustrial societies—and among members of groups like the Moonies and Hare Krishna. Colleagues and I have actually measured the emotional well-being experienced by members of these groups and found it to be directly proportional to the intensity of their respective feelings of cohesiveness toward the group. The relationship between emotional well-being and cohesiveness apparently served as an implicit motivation for persons to stay close to the group and promoted their compliance with its expectations.
Although community ties in our society are generally weak, the kinds of intimacy and social support that characterize traditional societies can potentially be generated by engaging a small network of persons close to the patient. If the relationship between cohesiveness and emotional being is harnessed within the therapeutic context, and the patient comes to experience closeness to the therapy network as a vehicle toward well-being, then the resulting social forces can move the patient toward accepting the group's expectations, as abstinence becomes the ticket to sustaining closeness.
The purpose of network therapy is then to create an atmosphere that will allow an alcohol or drug abuser to experience relief from distress by participating, and moving towards a drug-free outlook. After initial sobriety has been achieved, network sessions often acquire a social quality. The group becomes friendly and close-knit, and stories and even jokes may carry over from one session to the next.
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Cognition
In order to act out a pattern of behavior that is clearly self-destructive, addicts must adopt a pattern of denial. This denial is supported by a variety of distorted perceptions: persecution at the hands of employers, failings of his distraught spouse, a presumed ability to control the addiction if he wants. This cognitive set is not only unfounded, but it is also at variance with the common sense views of his drug-free family and friends. Because of this, intimate and positive encounters with them in the network produce an inherent conflict between addicts' views and the views of network members. The addict must resolve this conflict, or cognitive dissonance, in order to feel accepted in the group. The network therefore creates an ongoing pressure on the addict to relinquish the trappings of denial.
Typically, addicts deal with this conflict by defensive withdrawal, but if their network is properly managed, cohesive ties in the group will engage them and draw them into an alternative outlook. Gradually, they come to accept that their distress can be relieved by a change in attitude, as denial and rationalization are confronted in a supportive way. Over time, engagement in the network allows an addict to restructure the perspective in which the addiction has been couched.
For addicts, both healthy and faulted attitudes have long coexisted in conflict with each other, and the cognitive dissonance produced by these contradictions has driven them into a defensive stance, fending off any attack on this awkward balance. On the other hand, in a proper supportive context, a constructive view premised on abstinence and on acknowledgment of the harmful nature of drug use can emerge. Addicts can experience a "conversion" of sorts, perhaps gradual, but real nonetheless.
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