Excerpts from Must Read Books & Articles on Mental Health Topics
Books, Part XII

Group Psychotherapy with Addicted Populations
Philip Flores
Chapter 9- Early Stage Treatment Issues, pp. 339-64

Early stage treatment issues deal primarily with precontemplation, contemplation, and preparation stages of change that have been outlined by Prochaska and DiClemente (1992). Most of the therapist's energy will be directed toward getting alcoholics and addicts to recognize, admit, and move past their high levels of ambivalence and denial. Beginning group leaders soon discover that few alcoholics and addicts enter treatment of their own free will. Consequently, when these patients are initially introduced to treatment and group, usually they are either under extreme external pressure from their family, their employer, or a judge, or they are compelled by serious physical health problems related to their chemical use. Group leaders find that many of their group members are in a severe emotional state characterized by guilt, shame, and depression or are extremely obstinate and angry because others have forced them to comply with demands that seem to them to be unjust, unfair, and punitive. Even if chemically dependent individuals agree that they need treatment, they usually harbor wishes to be able to drink and use drugs in a safe and normal way. Their compliance to treatment is motivated more by their remorse and wish to avoid further condemnation than it is by their desire to actively learn ways to ensure that their treatment will be successful. Thus, the group leader is faced with the difficult task of dealing with resistant patients on two different levels. If the group members are not actively rebellious and resistant to treatment, they usually are working very hard to give the staff and group leader the impression that they are actively engaged in their recovery and treatment. This presents the group leader with a delicate problem because those group members who are actively resistant are usually easier to treat than those who are passively compliant.
    Their facade of voluntary compliance must be exposed as a manipulation of the treatment process or their recovery will be motivated only by their desire to be free from external distress and pressure. In either case, the patient's postures need to be confronted and altered quickly, usually within twenty-eight days, the length of a normal inpatient program. Unless this is accomplished, the AA program will not be internalized and they will never be able to make the shift to personal responsibility for their recovery and abstinence. Although group psychotherapy can be a significant adjunct to alcoholics' and addicts' treatment, group leaders also discover that few patients are completely willing to do everything necessary to ensure the successful treatment of their addiction. Most alcoholics and addicts possess varying levels of motivation to abstain from alcohol and drug use. This is especially true during the early initial stages of treatment when their level of alcohol- and drug-induced cognitive impairment is most severe and they are more rigid and limited in their ability to explore alternative solutions to old problems. Even when addicts and alcoholics enter treatment completely of their own free will and possess a strong innate desire to stop their use of chemicals, many of these patients will have difficulty doing the things necessary to ensure their recovery because of the various degrees of character pathology they possess. This condition is also made more severe by the recency of their chemical use, which usually leaves them more rebellious, suspicious, and manipulative.
    The art of treating addiction is to overcome the enormous denial and resistance--whether it be passive or active--that most alcoholics and addicts possess. Such a stance in treatment raises many important ethical and therapeutic issues. Confrontation, if done too punitively or if motivated by a group leader's countertransference issues, can severely damage the therapeutic alliance. However, the group leader cannot afford to stand back and take a stance of therapeutic neutrality, because time, the severity of the chemically dependent patient's condition, and his or her lack of motivation interferes with the normal evolution of psychotherapy that usually takes place with most non-addicted patients. Treating the chemically dependent patient requires group leaders to make a dramatic shift in focus and utilize techniques with which they usually have had little training or experience. Confrontation, intervention, coercion, and the use of therapeutic leverage are techniques that can have damaging effects on an individual or a group if they are applied inappropriately and indiscriminately. Such an approach to treatment is often completely contrary to most contemporary forms of psychotherapy, and many group leaders are either uncomfortable with its use or do not understand its proper application. Consequently, these methods are frequently misused, ignored, or overzealously applied. In some cases, group leaders who are unfamiliar with the proper utilization of these methods apply them indiscriminately to all group members with equal intensity all of the time. They fail to realize that some alcoholics and addicts require a little less and some require a little more. They fail to treat their group members as individuals, and these techniques become ends unto themselves. What would be an appropriate confrontation for an alcoholic at the beginning of treatment would be completely destructive for that same alcoholic later in treatment.
    It is important to remember that defensive operations organize the self not only for effective normal functioning, but also to avoid anxiety. Therefore, confrontational techniques used solely as tools to hammer away at the rigid defenses of alcoholics and addicts are likely to increase anxiety and thereby precipitate avoidance responses and denial. Withdrawal, avoidance, or placating responses can be triggered by such techniques and will, in turn, reinforce rigid patterns of thought and behavior, thereby increasing resistance to change. In many cases, treatment can be enhanced with a more indirect use of confrontation. Also, any tendencies toward passive compliance (agreement with the staff and group leader to avoid the anxiety of confrontation) are amplified by direct attacks. Thus, indirect confrontation also decreases the likelihood of passive compliant forms of resistance.
    This brings us to the purpose of this chapter. Each of these techniques--coercion, the use of therapeutic leverage, confrontation, and intervention--will be explored in an attempt to define the limits of its usefulness and applicability. Usually, if not always, these techniques are much more appropriate during the early part of treatment. They should be utilized either to get chemically dependent individuals to realize the extent of their difficulty in the hope that they will enter treatment or once they are in treatment help them to truly understand the severe disparity between their actions and feelings. In short, these techniques can help individuals take a more honest look at themselves and hopefully recognize that their self-deceptions are a significant contributing factor to the severity of their condition.

Special Problems of the Addicted Patient
The basic thrust of treatment for addicted patients is to get them to perceive and understand the relationship between their present difficulties in life and their alcohol and drug use. When this is accomplished, patients must be made to see the advantage of not drinking or doing drugs compared to the problems resulting from the continual use of chemicals. This choice must be weighed by each patient and a personal decision must be made. However, left to rely on their own resources, most addicts and alcoholics will cling to the belief that one day they can attain normal and healthy use of drugs and alcohol. While most therapists have been taught that it is important not to make decisions for patients and that a therapeutic alliance must never be compromised at any cost, the group leader must carefully evaluate such a stance when leading a group composed of members who are currently struggling with these decisions in the early stages of their recovery. As Shore states, "Therapists who remain inflexibly supportive while alcoholics continue to kill themselves by drinking need to reconsider the moral repercussions of their position".
    Alcoholics and addicts consequently present group leaders with new and unique problems in group. Working with this population requires group leaders to evaluate many of their conventional and unquestioned assumptions about treatment. An approach that is very effective with a non-addicted patient might be totally inappropriate for someone who is currently addicted or is in the early stages of recovery. The group leader must also be aware that many alcoholics and addicts have rather sophisticated defenses and are usually adept at applying these defenses in an effort to defeat the therapist. Unlike neurotics or non-addictive patients, who come to treatment of their own free will and are actively seeking help in the relief of their symptoms, most addicted patients want to convince the group leader and the treatment staff that there has either been a horrible mistake made in their referral for treatment or that they need the staff and group leader to focus on their real problem. This problem is often formulated in the patients' minds as the root cause of their pathological use of chemicals. Secretly, the patient hopes that once this root cause is discovered, he or she will be able to return to the normal use of chemicals. Chemically dependent individuals will emphasize this issue because drinking or drug use is frequently the only pleasure they feel they derive out of life--a pleasure that must be protected at all costs.



Defense Mechanisms

   Alcoholics' and addicts' common misconceptions about alcohol and drugs are often the result of an elaborate set of defense mechanisms. Neo-Freudians were the first to make the distinction between healthy ego-defenses, such as sublimation and intellectualization, and unhealthy ego-defenses, such as denial and suppression. Group leaders should understand that repression and ego-defenses are a normal, healthy process that reflects an individual's tendency to selectively forget negative experiences that may be too painful or uncomfortable. Repression and ego-defenses are utilized by all of us in our attempts to cope with day-to-day problems. It is only when the degree of repression reaches such proportions as to deny reality that symptoms of illness are manifested. When ego-defenses are utilized with such frequency and intensity that reality-testing becomes compromised, individuals must be encouraged to face the inappropriateness of their defensive position. Confronting these misconceptions is crucial in treating the alcoholic and addict because inappropriate ego-defenses and repression are the key misconceptions that the group leader must recognize and deal with before any progress in treatment can be made. Borowitz (1964) hypothesized that the basic psychological effect of alcohol is to modify ego function, which involves a decrease in perceptual activity. In fact, alcoholics and addicts are generally thought to possess poorly developed egos with inadequate defenses. Vernon Johnson (1973) agrees, and he believes alcoholics are unable to perceive what exactly is happening to them because the dynamics of the illness are so complicated. Addiction is an intricate process that involves an interplay of repression, cortical deterioration, and impaired judgment. While it is not important that the group leader know why individuals are alcoholics or addicts in order to counsel and help them, it is important to have an understanding of the dynamics involved in the addiction process.
    Alcoholics or addicts are individuals with a chronic disease that becomes progressively worse. This is important to remember because as their condition deteriorates, their ego strength weakens and their self-image deteriorates. Guilt, shame, and remorse are factors that frequently cause them to set up elaborate defenses to control these uncomfortable emotions. As the emotional pain becomes greater, their defenses become more rigid. Eventually, they become victim of their own psychological defense mechanisms.
    Marty Mann (1973), among others, stressed the importance of straightening out the patient's misconceptions and fallacies about the disease of alcoholism. Alcoholics, Mann felt, share the view of society that alcoholism is a moral deficiency. Alcoholics and addicts generally do not view themselves as physically dependent, and this is one of the reasons why they make every effort to deny that addiction is their problem. The guilt and remorse they feel because of their drinking and drug use leads them to refuse to acknowledge or accept help. The disease concept convinces them that they are not bad, but rather, ill. This relieves their guilt. Any modality of treatment that helps addicts and alcoholics to accept themselves as individuals with some worth will help their recovery. Increased self-esteem and self-worth are important factors in treatment. 
    Ruth Fox sums up this position when she writes,

The alcoholic needs to be reassured that alcoholism is truly viewed by the medical profession and other health authorities as an illness, not a moral failing or a wicked self-indulging weakness. The usual immediate result of this assurance is a draining off of the emotions which constrict and distort the alcoholic's self-image and view of the problem, and a release from the enormous guilt feelings which paralyze the patient's ability to take steps toward recovery. (1967)

Fox's position is consistent with the psychoanalytic belief that when the cause of repression is discovered, the repressed material rapidly emerges into the patient's consciousness. In other words, if the threat is eliminated, it becomes safe for the repressed material to return to awareness. It is at this stage of recovery that alcoholics and addicts can look at their illness realistically.
    The return to consciousness of repressed feelings is a crucial step in the recovery process for a number of reasons. Alcoholics and addicts can now become reacquainted with themselves at a more meaningful level. Admittance of one's illness and addiction is a significant first step in AA's twelve steps. Johnson suggests,

The effect of this new degree of self-awareness has been to create the need for a reduction of the burden of moral anxiety and guilt which it has brought into conscious focus .... In some fashion, the alcoholic begins now to see the truth that these defects of character are the signs of his sickness, and that upon their removal, his recovery depends. (I 973)

Psychoanalytic theory generally supports Johnson's contention that an emotional component to this awareness is a prerequisite for recovery. In a similar fashion, Nemiah (1961) concludes,

The pain is further heightened to an unbearable intensity by the anger that stems from their ambivalence. To protect themselves from pain, they employ abnormal mechanisms of defense: denial of loss leads to a blocking of the process of grief... resulting in a variety of somatic complaints, violent self-castigation, and suicide.

It is through the process of pain and grief that alcoholics' and addicts' awareness of their condition is realistically faced and accepted. Only through an emotional catharsis and crisis will alcoholics and addicts finally admit to God and to others that their life is hopeless in the face of their chemical use. This is the stage AA recognizes as the surrender to the acknowledgement that the alcoholic is ill. This process cannot be an intellectual awareness alone. It also requires understanding at an emotional and spiritual level.
    For treatment to continue on at this point, it is important that the group leader not be manipulated into trying to perform insight psychotherapy with a patient who continues to drink or use drugs. The group leader must make it clear to the patient that abstinence will have to come first. Even when addiction is accompanied by an underlying psychopathology, the pathological drinking can kill long before its cause is found. Very often, abstinence brings about amelioration of most of the conditions previously blamed by alcoholics and addicts as the reasons for their drinking and drug use.
    Johnson (1973) sees the removal and alleviation of guilt and remorse as an important factor in treatment. This only occurs after abstinence is attained. "Our most startling observation has been that alcoholism cannot exist unless there is a conflict between the values and the behavior of the drinker." Johnson goes on to conclude, "Very simply, the treatment involves a therapy designed to bring the patient back to reality." It is through the group leader's confrontation of repression and denial that the establishment of reality-testing takes place with an associated emotional catharsis.
    Albrecht (1969) summed up this position when he concluded, "During this phase of heavy drinking, the individual becomes very skillful at using denial, rationalization, and projection to avoid full confrontation with his drinking problem. He denies that he has a problem; he finds a multitude of reasons for his drinking and he blames others for his drinking." Not only are alcoholics and addicts unaware of their highly developed defense system, they are also unaware of the powerful feelings of self-hate buried behind it. Their defense systems continue to grow, so that they can survive in the face of their problems. The greater the pain they suffer, the higher and more rigid the defenses become. Alcoholics and addicts therefore become more rigid in their defensive processes as time goes by. Consequently, this adds to the group leader's difficulty as he or she struggles to get alcoholics and addicts to see their situation more realistically. As alcoholics and addicts succumb more to their rigid defense systems, they become more and more out of touch with their feelings. Given these circumstances, the group leader's task during the early stages of treatment becomes clearly defined. He or she must help alcoholics and addicts to (1) discover themselves and others as feeling persons, and (2) identify the defenses that prevent this discovery.
    Getting alcoholics and addicts to recognize their feelings is important for two reasons. First, feelings and spontaneous expressions tend to be much more honest. It is more helpful to be revealing than to be right. A spontaneous expression may release both positive and negative emotions that must be recognized and dealt with. This is the only way the alcoholics' and addicts' rigid defenses and repressions can be altered and reality testing can be restored. Second, it is essential to know one's own feelings at a given moment, for it is necessary to sense with equal accuracy the feelings of another person. If alcoholics and addicts are to return to the world of the "living," they must be able to deal with other people accurately and empathetically.
    Because of chemically dependent individuals' addiction, confrontation is often the only way to alter their self-destructive and rigid defenses. However, the way confrontation is utilized is crucial. There are constructive and destructive forms of confrontation. Alcoholics need someone who will call a spade a spade in a realistic fashion without adopting a punitive, moralistic, or superior attitude. As Vernon Johnson illustrates, attacking the individual is often mistaken for confrontation. Attacking serves only to raise defenses. Confrontation, on the other hand, can be defined as describing individuals in a way that is most likely to be received by them. Johnson states that, "We are most useful as confronters when we are not so much trying to change another person as we are trying to help him see himself more accurately."

Coercion
   However, before confrontive techniques can be applied in group, alcoholics or addicts must seek treatment. In many, if not most, cases, this is the single largest obstacle to treatment. Pre-treatment strategies must be established and managed to ensure that reluctant patients are adequately coerced to seek treatment, especially when they are unable or unwilling to see the reality of their condition. Coercion to seek therapy, however, is a controversial issue having many ethical, legal, and practical implications. Questions concerning individuals' rights and freedom to refuse treatment even though their behavior may prove to be a menace to themselves and society are not easily resolved or answered (Wald, 1974). Aside from the crucial and currently popular issues of infringement of rights and invasion of privacy is the problem of the efficacy of forcing someone to seek treatment when cooperation and motivation to be treated are absent. An axiom in the field of psychotherapy and counseling is that clients must invest a large part of themselves in the treatment process if therapy is to be successful (Perls, 1969; Schultz, 1969; Rogers, 1942; Carkhuff, 1969). However, evidence is now mounting that perhaps this is not necessarily true, especially for alcoholics (Boume and Fox, 1973; Johnson, 1973).
    Ruth Fox (1967) announced that it is not necessary to wait for alcoholics to hit bottom or motivate themselves into treatment before taking therapeutic measures. Steme and Pittman (1965) demonstrated plainly that it is often the psychotherapist or group leader, rather than the addict or alcoholic, who needs the motivating. Chaftez, Blane, and Hill (1970) showed that helping professionals can motivate reluctant patients to undergo treatment by promptly meeting patients' obvious dependency needs, by communicating through action, concern for the patient's low self-esteem, and by continuity of care. As Alcoholics Anonymous and Al-Anon have consistently illustrated, a new or changed attitude surrounding the problem drinker frequently motivates such a patient to seek help of his or her own volition (Bailey and Leach, 1965).



Denial

There is now a general consensus among theorists and practitioners in the field of addiction that alcoholics and addicts generally possess especially poor ego defenses (Johnson, 1973; Boume and Fox, 1973; Jellinek, 1960; Weinberg, 1976). Rationalization and denial are such frequent components of an alcoholic's and addict's illness that these ego defenses have become synonymous with the addiction process. Most theorists recognize the necessity of identifying and breaking through this denial system before successful recovery can be initiated (Hazelden Foundation, Johnson Institute, etc.). Denial is frequently a progressive part of the alcoholic's and addict's illness. It becomes overdeveloped, more rigid, and increasingly difficult to penetrate in its later stages until the alcoholic is almost completely out of touch with reality (Jellinek, 1960). Late stage alcoholics and addicts minimize, rationalize, and deny any problem with alcohol or drugs, usually projecting the cause of their problems onto others. Guilt, remorse, and deteriorating judgment perpetuate the drinking cycle until alcoholics and addicts totally reject any responsibility for their plight (Johnson, 1973). Weinberg (1976) saw the tendency on the part of family, friends, and helping professionals to avoid this issue when dealing with alcoholics and addicts in the earlier stage of their illness as providing a social environment that encourages denial. Until changes in cultural attitudes occur, Weinberg contended, professionals will continue to be frustrated by a stubborn resistance to change.
    Other theorists disagree and suggest strategies for effectively dealing with this problem. It is understandable how alcoholics' and addicts' elaborate ego defenses and strong denial systems often lead many counselors, judges, and other helping professionals to erroneously assume that alcoholics or addicts must hit bottom before they can be helped. Evidence suggests that this is not the case (Boume and Fox, 1973; Johnson, 1973). Fox (1967) contended that alcoholics will not consider giving up alcohol until the suffering it causes them is greater than the pleasure it gives them. The general consensus is that, alcoholics and addicts must lose something important to them or at least be threatened with such a loss (Boume and Fox, 1973; Johnson, 1973).
    Vernon Johnson (1973) maintained that it is dangerous to wait for an alcoholic or addict to hit bottom. He sees the need to train counselors to recognize an alcoholic's and addict's "cry for help" and "defiant dependence" as components of the treatment process that the counselors can use to their advantage once they are identified. Evidence from industrial programs indicates that a crisis induced by individuals with the authority to confront and back up their accusations can be an effective alternative to previous modes of treatment.



Employee Assistance Programs

Substantial opinion and research evidence support a strategy of "constructive coercion" (Minovitz, 1973) or "forceful coercion" (Murray, 1973) as a viable alternative for inducing a crisis in an alcoholic's life. Lew (1973), in research conducted on industrial treatment programs, believed that alcoholics are motivated to change when they are in crisis, and that if they do not have to accept the consequences of their behaviors, they are not ready to be motivated toward recovery. Other research (Umere, 1958; Gerard, 1962; Fiebout, 1961) indicated that the importance of employee assistance programs lies in the employer's right to bring about a job-related crisis in the alcoholic's or addict's life while he or she is still on the job. Because of the deteriorating effects of addiction, a written company policy confronting the individual's poor job performance and attendance, while directly avoiding accusations of his or her alcoholism or addiction, is generally successful in inducing treatment Often, job security is the individual's chief vehicle for denial. Once that job security is challenged, his or her denial begins to crumble.
    The strength of the employer and supervisor in confrontation centers in the intrinsic makeup of a supervisory role. Supervisors are trained to be more ready to act and have more power at their disposal than the alcoholic's spouse, friends, clergyman, or physician. Previous attempts to use the family as the locus for identifying the developing problem drinker have been unfruitful because of the diffused emotional relationships that characterize family structure and process (Department of Health, Education, and Welfare, 1974).
    Independent research by the National Institute on Alcohol Abuse and Alcoholism (1962) indicates that the 70 percent success rate in industrial programs is often unparalleled, even by Alcoholics Anonymous. Most other treatment facilities report success rates that rarely reach above the 20 percent level. This suggests that the highly confrontational nature of industrial programs and AA produces an atmosphere that facilitates successful treatment for alcoholics. The court, too, has the power to bring about a crisis through confrontation.
    The constructive confrontation strategy makes specific assumptions. Coercion, in some form, is necessary in human behavior (Simmel, 1950). Because society provides few clear norms about alcohol and drug use, developing alcoholics and addicts rarely face consistent sanctions; thus, they have few internal controls for managing this behavior (Inkeles, 1968). Enforced cooperation relieves alcoholics or addicts of the burden of developing motivation for themselves. The strategy activates and uses existing social controls within the system rather than moving the deviant from the system into a specialized control setting.



Coercion, Attitudes and Motivation in Treatment

   It appears that one of the problems in motivation of the alcoholic or addict to accept treatment is that reluctance on the part of the patient to seek or accept help is psychological in nature. This is particularly true if the procedure is unknown and possibly threatening. Canter (1969) tested this hypothesis and concluded that it is important to inform alcoholics and addicts about various treatment approaches to enhance their receptivity to treatment. Rossi (1972) reached a similar conclusion and suggested that the motivation of the alcoholic and addict to accept treatment is not only internal, but is related to the characteristics of the social environment and the personality of the helping professional. Rossi further suggested that the patient's motivation to recovery be seen as a multidimensional interaction of the patient the setting, and the psychotherapist Devito's research (1969) results were similarly encouraging and lend credence to the hypothesis of the value of firm external controls in the successful treatment of alcoholics and addicts.
    Zax (1961) demonstrated that significant relationships in the counseling process enhance the tendency to remain in treatment longer. Wedel (1965), in a similar study, concluded that the efforts of social workers had great personal significance to some individuals. Wedel found that few alcoholics and addicts in his study had sufficient ego strength to stop drinking; the motivation had to come from other sources, such as religious faith, group involvement, or family considerations. Steme and Pimm (1965) examined the concept of motivation to determine to what extent it was crucial to recovery. They concluded that the majority of individuals in the helping professions excessively rely on the belief that client motivation is essential for success in treatment. Failure to accept an alcoholic or addict as a client and the lack of success in treatment are often conveniently explained by the lack of motivation on the client's part. Their findings suggest a need for improvement of professional training. They also concluded that systematic research is needed to isolate factors that contribute to alcoholics' and addicts' acceptance of treatment.
    While it sometimes is crucial for the legal system or employer to initiate the treatment process through coercion, there is research to indicate that addicts and alcoholics do not need pressures to keep them actively involved in the recovery process (Heitier, 1976). Other research, however, cites the importance of force as an essential part of treatment (Sexias, 1976). Other evidence suggests that individuals coerced into treatment do as well--no better, no worse--as those who presumably enter treatment on their own. Bibb's (1970) research concluded with the findings that outpatient treatment as a contingency of probation can yield results comparable to those of voluntary patients, as long as someone other than the therapist polices the terms of the probation.
    Typically, these studies show that negative expectancies and attitudes on the part of the psychotherapists and group leaders frequently have an adverse effect on the success rate of the treatment. Effectively dealing with reluctant patients may be the most important overall competency that group leaders and psychotherapists can develop. Involuntary clients may account for the majority of a group leader's or psychotherapist's caseload and failure to learn how to deal adequately with hostility and reluctance on a patient's part may be the single largest contributing factor to failure in treatment. It is true that many professionals have simply not had sufficient training to deal skillfully and easily with reluctant patients.
    It is important to point out that coercion takes many subtle forms and does not necessarily have to be so obvious as when practiced by the employer or court. Unhappy spouses, worried friends, concerned doctors, and disgruntled bosses all make up a contingency that often uses subtle pressure to force individuals with many different types of problems into counseling when those individuals do not agree that they have a problem. It is suggested here that individuals who seek psychotherapy completely of their own free will may be more the exception than the rule. Dealing with such patients requires that group leaders know how to utilize their therapeutic leverage to ensure maximum benefit from treatment.



The Use of Therapeutic Leverage

Group leaders must be aware that alcoholics and addicts will not give up their alcohol or drugs until the pain and dysphoria they experience outweighs the pleasure and euphoria they derive from its use. Consequently, alcoholics and addicts must be made to see the way alcohol and drugs affect important areas of their lives. Group leaders must also learn early in individuals' treatment what is significantly important to the addicts or alcoholics that continued drinking and drug use might threaten. For some individuals, it is their job. For others, it is their spouse, health, family, or self-respect. In some cases, it might even be the threat of incarceration. Such knowledge is important since it can be used to encourage and even coerce individuals to utilize the tools of treatment, group, or AA. Since alcohol and drug use affects judgment and in most cases of chronic use causes temporary but severe levels of cognitive impairment, many patients are unable to accurately understand, interpret, and perceive the true nature of their condition, much less make clear, rational decisions that will have profound effects on their life, family, health, and job. It is important for the group leader to understand the necessity of utilizing therapeutic leverage to guide alcoholics and addicts through the early stages of their treatment. This is required until patients are more capable of making rational choices for themselves. Convincing patients to try it the group leader's way under threat of loss of spouse, job, health, or incarceration can be tempered by telling group members that if they do not like this way after one year they can then try it their own way.
    Group members who are concerned about their physical condition should have frequent laboratory testing and have ready access to a physician. Liver functioning tests and neurological examinations are particularly important. CAT scan evidence of cerebral atrophy, though costly and difficult, can be a very important source of therapeutic leverage, particularly with the abundance of recent research evidence demonstrating reversability of this condition if sobriety is maintained. Psychological testing, especially with an emphasis on neuropsychological assessment, can provide similar evidence to the patient at a much reduced cost. Evidence presented from psychological and neuropsychological testing can be even more powerful, since it is concrete and concerns specific demonstrable behavior. Showing alcoholics or addicts that their IQ and abstract reasoning scores are markedly low can have a powerful influence on their motivation to abstain from further chemical use, especially if they are cautioned that further chronic use might produce permanent and irreversible brain damage.
   If the alcoholic or addict is married, or involved in a significant relationship, the group leader will discover that there are usually multiple difficulties in the marriage or the relationship. In many cases, the spouse has either threatened divorce, is in the process of divorce, or is separated from the patient. If the marriage or relationship is important to the patient, and especially if the spouse is not also addicted, this can be a source of important therapeutic leverage. The alcoholic's or addict's spouse or significant other should be involved in the treatment process. This is especially true if the patient is hospitalized and being treated at a twenty-eight day inpatient program. Involvement in Al-Anon and conjoint therapy sessions will ensure that the spouse or significant other does not engage in self-defeating behavior that might threaten the therapeutic leverage. The input from this individual can be helpful to treatment if utilized properly. He or she can be supportive of the alcoholic and addict and can contribute information and observations that can help strengthen the therapeutic leverage. However, spouses or significant others must be taught not to make idle threats. They must be encouraged only to threaten separation or divorce if they intend to follow through with such threats. Such a stance by the spouse or significant other can often serve as a powerful motivating force in the chemically dependent person's recovery.
   Patients who are suffering job-related difficulties because of their drinking or drug use can be under extreme pressure to remain abstinent. This is especially true if the referral comes from the employer. Under these circumstances, contact with the employer, the EAP (employee assistance program) representative, or the medical department of the company should be maintained. This, of course, will require that the group leader have a signed consent of release of information. This ensures that the group leader is protected legally, but, just as important, it is a clear therapeutic contract that defines the goals, motives, and intentions of the group leader. The purpose of this contract should be explained to patients not just as a threat to their job but as a clear message that the treatment program is serious about their recovery and expects them to face the consequences of their behavior. Patients should be told that the specifics of their personal sharing in treatment or group will not be discussed, but only their progress related to their drinking or drug use. This assures the group members that their confidentiality concerning matters unrelated to their progress with abstinence from drugs and alcohol will be maintained. For many alcoholics and addicts, the therapeutic leverage related to their job security and work performance is the most powerful motivating force in their recovery.
    A very similar position can be taken with alcoholics or addicts if they are referred by a court. This is especially true if they have two or more convictions for public intoxication or driving while intoxicated (DWI) or driving under the influence (DUI). A therapeutic contract established through the court or a probation officer can serve as a powerful incentive in an individual's recovery. Utilizing a group therapy format for referrals requires special adaptations of the group format. However, if this adaptation is accomplished successfully, group is the treatment of choice for court referrals. Later in this chapter, such a format will be presented and described in detail because such a format will contain the utilization of all the techniques (i.e., confrontation, intervention, coercion, therapeutic leverage) to be described in this chapter.
    Certainly, the use of therapeutic leverage as outlined here raises many important considerations concerning the therapeutic contract. Trust is a crucial factor in all forms of psychotherapy and treatment. In many cases, trust and the therapeutic alliance will be severely compromised because of the nature of the disease of addiction and the circumstances leading the patient to enter group or treatment. There are a couple of ways that group leaders might avoid the pitfalls associated with the use of leverage in treatment. If the patient is in group under the auspices of a treatment facility or hospital, it would be beneficial to have someone other than the patient's primary therapist or group leader serve as the enforcer of this policy. This will allow group leaders to avoid compromising the therapeutic alliance too severely. However, group leaders should be definite in outlining the limits of the therapeutic contract. They should tell the group members explicitly that they must convey information concerning the members' progress to the rest of the staff at the hospital. After patients have completed the initial part of their treatment, group leaders could then establish a new contract with the group and its members. This will be especially important if the group is to be an ongoing, long-term, after-care group. However, it may be difficult, if not impossible, for some individuals to trust their group leader once they have felt coerced or manipulated into treatment--no matter how much it may have helped them. Trust and a therapeutic alliance may be impossible to establish or reestablish in such cases. Referral of the group or individual group members to other group leaders might be in order in these circumstances.
    While the utilization of therapeutic leverage may create some difficulties for the group leader, the gains from its application usually outweigh its costs in terms of treatment effectiveness. Zimberg (1980) outlines the advantages of such an approach if it is carried out in a well-planned and therapeutic manner:

When used judiciously, appropriately, nonpunitively and nonjudginentally, therapeutic leverage can be very effective in directing the alcoholic into a more responsive therapeutic status. If used, however, by a therapist with serious countertransference problems, including anger and frustration at the patient, it can destroy the therapeutic relationship. One must be constantly self observing when treating an alcoholic to ensure that the therapeutic leverages are designed to facilitate the alcoholic's recovery and not to satisfy one's need for successful treatment or as retaliation and punishment for the alcoholic's provocative behavior.

Confrontation
Before group leaders can effectively apply the use of therapeutic leverage in group, they must understand the intricate interplay between the purpose of an alcoholic's and addict's defenses and the confrontive techniques necessary to alter them. Defenses are always there for a reason. They must not be stripped away too quickly and confronted too severely just for the sake of confrontation. It is a general axiom in psychotherapy that defenses should not be altered until patients completely understand their purpose and have developed enough ego strength and alternative resources to allow them to substitute more constructive ways of defending themselves from painful affective states. However, alcoholics or addicts can kill themselves or completely destroy their support system while the group leader allows them the necessary time it may require for them to figure this out by themselves. This is one instance where the group leader has to alter his or her normal stance of support and unconditional acceptance. Confrontation is one method that the group leader can utilize in dealing with the alcoholic's or addict's rigid, self-destructive defensive process. However, the parameters and limits of confrontation must be understood and appreciated first.
    In contrast to empathic clarifications and interpretations, both of which are directed at what patients say and present to the group leader, confrontations address something that patients are unaware of or denying. Confrontations are more effective when they are directed toward something that patients could or should be addressing, but are not because they are either consciously or unconsciously avoiding it. Patients who describe incidents while omitting feelings, or whose description of an incident is notably similar to previous episodes in their lives, or who present a discrepancy between their thoughts, feelings, and actions are prime candidates for a confrontation, which might help them progress past their stuck position.
    If, as the group leader, you only empathize with alcoholics' or addicts' pain and suffering, you run the risk of reinforcing their denial or delusional system. You must also be able to empathize with their denial that their suffering and pain is determined in a large part because of their refusal to give up their use of chemicals. The group leader must remember that empathy is not compliance and doing or saying what the patient wants or hopes to hear. Inevitably, there are critical moments in the group process when, in order to facilitate a significant step in the change process, responsible group leaders will take a well-timed risk by confronting a member with a painful truth, sensitively monitoring their own counter-transferential feelings. In truth, the risk is a calculated one insofar as the group leader is implicitly saying with conviction, "In my judgment you are ready to face this issue, this truth about yourself at this time. I accept my responsibility as a group leader by confronting you and have confidence in the strength of our relationship and in your ability to face it." If the confrontation is delivered in the context of this attitude and not motivated by the group leader's frustration or anger, it is likely to be effective. As Louis Ormont (1985) said, "If you love your patients and they feel it, you can say anything to them."
    Applied from this perspective, confrontations differ significantly from the way they have been used historically in addiction treatment. Historically, the use of confrontation in group therapy evolved out of the work of drug-free therapeutic communities such as Day-Top and Synanon and was in large part directed by ex-addicts. The original intent was to convey the message that if we did not care or if we were not concerned about you, we would not bother to point out something that might save your life. However, like any therapeutic technique applied overzealously, confrontation can have anti-therapeutic consequences, especially when it becomes attack therapy (Rachman and Heller, 1974).
    As Rachman and Heller caution, confrontation becomes "attack therapy" when:

1. In a confrontational atmosphere, individuals are often psychologically assaulted. Individuals who are rehabilitated from substance abuse can pay the price of losing their dignity, their freedom to disagree, or their sense of independence and opportunity to think, feel, or behave in a unique manner.
2. The mandate is to conform to a strict, inflexible code of behavior and philosophy known as the "concept."
3. Confrontation is often used before a working alliance is developed.
4. There is a lack of therapeutic flexibility, so that a variety of helpful interventions are not integrated along with confrontation.
5. A ritualistic interaction develops in which individuals confront each other over and over again without genuine internal change occurring.

As Rachman and Heller (1974) warn, members learn to "cop-to-the-game" in response to attack. They adapt by admitting to transgression in behavior in order to get the staff and group leaders off their backs. The use of confrontation exclusively promotes an increase of tension, anger, hostility, and resentment to the exclusion of empathy, concern, and caring.
    In contrast to this position, Raubolt (1974) recommends that an atmosphere of "caring confrontation" be established under the following guidelines:

I . Confrontation and limit-setting are necessary when an individual's impulsiveness is out of control. Confrontation is used to peel away layers of defenses against the awareness of destructive effect of substance abuse.
2. The use of peers as agents of change rather than traditional authority figures.
3 . The realization that addiction often involves a lifestyle and an identity that frequently consumes the individual.
4. Insistence that before personality change can occur, abstinence and a focus on alcohol- and substance-taking behaviors must occur.
5. Insistence that individuals take responsibility for their self-destructive and chemical-oriented behavior.
6. The use of nontechnical language in discussing psychological issues and personality functioning.

Confrontations are not usually delivered exclusively by the group leader. Peers and other members of the group are likely to be confrontational to each other, especially when the atmosphere established by the group leader permits and even fosters confrontation. This can have either beneficial or damaging consequences depending on whether the climate is one of "attack therapy" or "caring confrontation." Washton (1992) suggests presenting group members with the following guidelines to help them both understand the purpose of confrontation and become more receptive to its delivery.

Guidelines for Effective Confrontation

I . Confrontation is defined as giving someone realistic feedback about their behavior as you see it--it is a process by which you attempt to "hold up a mirror" to let a person know how he/she appears to others--it is not an attempt at "character assassination."
2. Confrontation is most useful when spoken with empathy, concern, and caring in a respectful tone of voice.
3. Confrontation is descriptive of what you have observed, giving examples of the behavior in question; it excludes guesses, explanations, interpretations, advice, and criticisms about the person's behavior.
4. Confrontation includes a statement of your concern about the person's dangerous, self-defeating behavior and, if possible, an example of similar self-defeating behavior from your own experience.

If these guidelines are followed, they can help the group leader avoid some of the difficulties that can be experienced with overly hostile group members who hold the mistaken idea that humiliation and aggression are acceptable ways to force resistant members to face reality. Washton, writing about the possible abuses of excessive confrontation, cautions the group leader to monitor its application in group:

Group members typically have less tolerance for negative attitudes and "b.s." than do group leaders, especially when these attitudes are reminiscent of their own. Likely targets for attack are members who relapse repeatedly, who remain defiant, superficial, or insincere, and who minimize their problems and fail to affiliate genuinely with other members of the group.
    Sometimes group leaders feel ambivalent about stopping attacks on group members who have thorny problems that have been overlooked and are long overdue for being addressed. The group leader must never allow unpopular, frustrating, resistant, or severely troubled group members to be scapegoated and bludgeoned by their peers, even when the content of what is being said is entirely accurate. Harsh excessive confrontation must not be used as a means to push selected members out of the group and to discourage them from coming back. (1992, p. 514)

If confrontations are done properly, they will bring new understanding to the patient's awareness. However, if they are punitive or attacking, they will only raise defenses and increase resistance. In some cases, as with the passive compliant patient, there is some benefit to this tactic because it makes overt what would otherwise be kept covert by the patient, making it clear that what is hidden is an essential ingredient and component of effective confrontation. Consequently, group leaders are more effective when they limit their confrontations to observable events that will be obvious to the patient once they are pointed out. If group leaders do not keep their facts straight or misjudge the accuracy of their observations, their confrontations will lose their potency and impact. Confrontations are much more powerful as factual statements and should never be confused with a hypothesis about a patient's motives or behavior.
    For instance, a confrontation by a group leader who tells an alcoholic, "I think you are an alcoholic because you drink too much" is offering a subjective opinion that at best suggests a plausible hypothesis about a person's behavior. It is a relative statement open to debate since what may be heavy drinking for one person may be moderate consumption for another. Such a statement is not based on observable facts and is likely to cause the confronted individual to counter with his or her own subjective opinion. However, group leaders can make a much more credible confrontation if they focus their observations on demonstrable facts. For instance, the group leader in this same instance could have said,

It might be helpful for you to carefully and realistically assess the consequences of your drinking. Your wife is divorcing you because she finds you intolerable when you drink. You have two DUI arrests that have cost you a tremendous amount of money because of lawyers' fees and raised insurance premiums. Your boss is threatening to fire you because your work efficiency and attendance have been severely compromised by your weekend binges. This is certainly not normal drinking. Such a pattern of difficulties does suggest that you may be an alcoholic, or if you are uncomfortable with that word, someone who has a severe problem with his drinking.

The difference between the two confrontations is obvious. The first can be interpreted as subjectively biased and opinionated. The second deals with observable and undeniable facts. Even though the second statement is highly confrontational, it does not transmit an attitude of anger or disrespect. Confrontations should never come at the expense of a patient's integrity or respect. If done properly, they will not injure the person although the confrontation may trigger a painful awareness. Group leaders who "blast away" at patients "for their own good" need to carefully explore alternatives to such a stance. In most instances, they will discover that there are more effective ways to convey the same information without taking anything away from the impact of the message. An example will help clarify this point.

John, a thirty-one-year-old, poly-drug abuser, had entered treatment because of mounting difficulties and concerns related to his escalating drug and alcohol use. His second wife had just filed for divorce and he was beginning to experience severe physical complications (i.e., memory loss, shakes, D.Ts and convulsions) relating to his drug and alcohol use. Two weeks into a therapy group that met daily, he began to become more and more verbal after sitting quietly and passively while his thinking cleared and physical condition stabilized. As he gained strength and sobriety, his typical defensive maneuvers returned. He began to dominate the group meetings with his excessive rambling about extraneous events and circumstances in his life. The group leader carefully determined that this issue needed to be dealt with and corrected because, not only was it damaging to the group, it was a defensive maneuver that alienated others from John and was a significant complaint of his wife. Left to his own resources, John might have taken months to come to this awareness. At the start of the next session, John started into an elaborate explanation of his sister, describing her as a "big bullshitter," and appeared on the way to repeat his performances in the last two meetings. In the middle of his explanation, the group leader interrupted John briefly to say, "John, excuse me a second, but before you go on any further, I would like to ask you a question." John promptly stopped, his curiosity raised by the group leader's inquisitiveness. At this point the group leader gently confronted John with, "I ask this question in all respect John, and hope not to offend you, but does bullshitting run in the family?" John stopped and thought for a second, laughed out loud, and with a smile triggered by the awareness of his behavior said, "Yeah, now that you mention it, I guess that it does." The rest of the group laughed along with John and began to share that they, too, had noticed his tendency to ramble on in a nonproductive manner, but they had not wanted to say anything because he had been so quiet for the two previous weeks, and they feared that if they said anything, it might lead him to retreat once again into his shell. Further exchanges among other group members led to the awareness of the manner in which he and others often used words to cover over their real feelings. A productive exploration of fears and defenses by the group members accrued during the remainder of the session as a consequence of this confrontation.

In this example, the group leader could have easily confronted John earlier or more directly. A statement such as, "That's bullshit," would have certainly been more provocative and to the point. However, such a statement would have likely offended John, angered him and led to his retreat from the group. It would have also set a tone for the group that might have had far-reaching, dire consequences concerning openness, trust and safety. Also, as this example clearly demonstrates, confrontations need not be made punitively or in anger. A judiciously applied intervention mixed with a touch of humor and irony can be as, if not more, productive as one presented in an overly firm, provocative, or dogmatic manner.
    The targeted intent of a confrontation needs to be cautiously assessed before it is delivered in a group composed of alcoholics and addicts. Since alcoholics or addicts usually utilize their defenses as a means of protecting themselves against painful affective states related to deep feelings of shame, low self-esteem, and overly intro-punitive self-loathing and hate, confronting these defenses prematurely or inappropriately can be counter-productive to their recovery. Group leaders will avoid the dangers associated with a "shotgun type, hit-everything-that-moves" approach if they limit their confrontations to the alcoholic's drinking or drinking-related behavior during the early or beginning stages of that individual's treatment. Group leaders will keep their feet on more solid theoretical ground if they follow the axiom of treating newly recovering or actively using addicts' and alcoholics' defenses differently from non-addicted individuals. While it is necessary to vigorously confront drug and alcohol use and all defensive operations related to their use, it will prove more beneficial not to confront other defenses while demonstrating empathic understanding and supportive soothing of feelings separate from patients' drinking or drug-using behavior. Many obvious inconsistencies and rigid defenses in newly recovering or actively using alcoholics and addicts may have to be tolerated by the group leader until these individuals are ready to look at these issues more realistically and honestly. This requires that group leaders temper many of their confrontations until they feel more confident that the addicts or alcoholics are able to tolerate the confrontation without relapsing and retreating into further alcohol or drug use.
    Group leaders must maintain a delicate balance between confrontation and support when working with this population. Too much support for some individuals will only reinforce continued alcohol and drug use. Premature and inappropriate confrontation, on the other hand, may trigger a relapse or increased defiant resistance for other patients. Unfortunately, inappropriate and poorly timed confrontations do not always come from the group leader. Therefore, it is important that the group leader be adept at handling and managing confrontations between group members. Sometimes an accurate and empathic confrontation from someone else in the group can have a much more dramatic effect on the patient. However, a confrontation from another group member usually has a greater chance of being destructive because it is frequently triggered by anger at the individual. If the group leader can respond quickly when such a confrontation occurs, he or she can guide the interaction so it is not completely devoid of caring and support. An example will help illustrate this point.

Fred, an immature and arrogantly defiant nineteen-year-old veteran had been required by the U.S. Army to enter an inpatient drug rehabilitation program in the VA hospital. A few months earlier, he had been given an early discharge on honorable conditions because of repeated disciplinary problems related to his drug use. In the three weeks he had been on the hospital unit, he had remained consistently oppositional, defiant, and angry. During the tenth meeting of a daily inpatient group, the group leader noticed Dave, another group member, shaking his head and glaring as Fred continued one of his frequent harangues about the innate badness and unfairness of the staff, the doctors, and the entire U.S. Army. At the end of Fred's daily tirade, the group leader quietly asked Dave, who was a rather large, burly, well-respected but feared, thirty-eight-year-old Vietnam veteran, what he was feeling as Fred talked. Dave, never one to mince words, replied, "Man, I see a bunch of self-pitying bullshit!" Since Dave, an IV heroin addict, was widely respected and feared by all of the other veterans on the unit, Fred was somewhat taken aback by his comment. Rather than leave the confrontation set at this point, the group leader asked Dave whom Fred reminded him of. Although initially startled by the question, Dave quickly responded, "You sound like me nineteen years ago and, man, if you do not change your attitude, you're going to end up like me--a junkie--or dead, or in jail." As the group leader explored Dave's exchange with Fred, it became more apparent that there was a great deal of concern underneath Dave's angry confrontation. Although it was somewhat uncharacteristic for Dave, he proceeded to demonstrate a soft, caring side of himself to Fred and the group. This softened the initial harshness of his confrontation and made it much more palatable to Fred. Such a confrontation would have lost much of its effectiveness if it had come from the group leader or if the confrontation had just been left with Dave's opening statement. Explorations of the reasons behind the confrontation led Fred to an awareness of himself that he had not previously possessed.

Confrontations conducted in this manner can be effective. But the group leader must remember that a confrontation is not an end in itself. It should be applied strategically, and when used in conjunction with other clinical skills and knowledge, it can enhance working with the alcoholic's and addict's denial and resistance to treatment. Confrontation need not always be direct or lacking in warmth and caring. Paradoxical interventions which take advantage of metaphors, humor, irony, and the use of counter-force, allow the group leader to assume a warm, empathic stance while placing the responsibility for change squarely on the shoulders of the alcoholic and addict--where it belongs--thus lessening the group leader's frustration and making treatment more effective. Sobriety and abstinence are impossible unless the alcoholic and addict are prepared to assume responsibility for that change. Confrontations only work if they are motivational and facilitative in nature. The group leader cannot and should not force or attempt to force the alcoholic or addict to change. In such a power struggle, no one wins. The addict or alcoholic has another excuse to continue his or her use of chemicals, and the group leader only becomes increasingly discouraged and frustrated.
    The discussion of confrontation in this chapter has hopefully made clear criticisms and misunderstanding about the nature and appropriate use of confrontation in group psychotherapy. Confrontations, like good interpretations and clarifications, are attempts to make patients aware of behavior of which they had not previously been aware. As they develop more of an accurate and realistic understanding of themselves, the defenses they use and the reasons for these defenses can be examined. When working with alcoholics or addicts, the shift from an accurate awareness of their drinking and drug use to an understanding of their defenses and the reasons underlying the use of these defenses may take months, and in many cases, even years. With many alcoholics and addicts, the unconscious motives for their behavior should not be explored until they have enough sobriety and emotional stability in their life to handle this awareness. This is the most significant and important difference that must be learned by the group leader who is working with addicted patients.
    The shift from confrontations, which are limited to behavior, attitudes, and actions that have a direct influence and connection with maintaining sobriety, to a more explorative examination of the unconscious motives behind all defensive operations, is a strategic decision that must be carefully assessed for each individual patient. Some will be ready for such a shift in treatment rather quickly; others will require much more time. Once the group leader feels that the recovering addict or alcoholic is capable of managing a more explorative form of psychotherapy, the leader can then transfer the addict or alcoholic to a more advanced group or shift the focus of the group.

The Yellow Wallpaper
Charlotte Perkins Stetson Gilman
1892
From "Out of Her Mind: Women Writing on Madness"

After seeking treatment from a well-known Philadelphia "nerve specialist," Charlotte Perkins Stetson wrote her autobiographical short story, "The Yellow Wallpaper." Magazine editors initially rejected her work, with rebuffs such as Horace Scudder's of the Atlantic Monthly: "I could not forgive myself if I made others as miserable as I have made myself!" Eventually published by the New England Magazine in 1892, "The Yellow Wallpaper" is now considered a classic portrayal of the mental anguish suffered by oppressed nineteenth-century women. Gilman, a poet, editor, and writer of fiction and nonfiction, also lectured widely on women's rights. After divorcing her first husband, she married her cousin George H. Gilman in 1900. Ailing from breast cancer, she committed suicide in 1935.

It is very seldom that mere ordinary people like John and myself secure ancestral halls for the summer.
    A colonial mansion, a hereditary estate, I would say a haunted house, and reach the height of romantic felicity--but that would be asking too much of fate!
    Still I will proudly declare that there is something queer about it.
    Else, why should it be let so cheaply? And why have stood so long untenanted?
    John laughs at me, of course, but one expects that in marriage.
    John is practical in the extreme. He has no patience with faith, an intense horror of superstition, and he scoffs openly at any talk of things not to be felt and seen and put down in figures.
    John is a physician, and perhaps--(I would not say it to a living soul, of course, but this is dead paper and a great relief to my mind)--perhaps that is one reason I do not get well faster.
    You see he does not believe I am sick!
    And what can one do?
    If a physician of high standing, and one's own husband, assures friends and relatives that there is really nothing the matter with one but temporary nervous depression--slight hysterical tendency--what is one to do?
    My brother is also a physician, and also of high standing, and he says the same thing.
    So I take phosphates or phospites--whichever it is, and tonics, and journeys, and air, and exercise, and am absolutely forbidden to "work" until I am well again.
    Personally, I disagree with their ideas.
    Personally, I believe that congenial work, with excitement and change, would do me good.
    But what is one to do?
    I did write for a while in spite of them; but it does exhaust me a good deal--having to be so sly about it, or else meet with heavy opposition.
    I sometimes fancy that in my condition if I had less opposition and more society and stimulus--but John says the very worst thing I can do is to think about my condition, and I confess it always makes me feel bad.
    So I will let it alone and talk about the house.
    The most beautiful place! It is quite alone, standing well back from the road, quite three miles from the village. It makes me think of English places that you read about, for there are hedges and walls and gates that lock, and lots of separate little houses for the gardeners and people.
    There is a delicious garden! I never saw such a garden--large and shady, full of box-bordered paths, and lined with long grape-covered arbors with seats under them.
    There were greenhouses, too, but they are all broken now.
    There was some legal trouble, I believe, something about the heirs and coheirs; anyhow, the place has been empty for years.
    That spoils my ghastliness, I am afraid, but I don't care--there is something strange about the house--I can feel it.
    I even said so to John one moonlight evening, but he said what I felt was a draught, and shut the window.
    I get unreasonably angry with John sometimes. I'm sure I never used to be so sensitive. I think it is due to this nervous condition.
    But John says if I feel so, I shall neglect proper self-control; so I take pains to control myself--before him, at least, and that makes me very tired.
    I don't like our room a bit. I wanted one downstairs that opened on the piazza and had roses all over the window, and such pretty old-fashioned chintz hangings! But John would not hear of it.
    He said there was only one window and not room for two beds, and no near room for him if he took another.
    He is very careful and loving, and hardly lets me stir without special direction.
    I have a schedule prescription for each hour in the day; he takes all care from me, and so I feel basely ungrateful not to value it more.
    He said we came here solely on my account, that I was to have perfect rest and all the air I could get. "Your exercise depends on your strength, my dear," said he, "and your food somewhat on your appetite; but air you can absorb all the time." So we took the nursery at the top of the house.
    It is a big, airy room, the whole floor nearly, with windows that look all ways, and air and sunshine galore. It was nursery first and then playroom and gymnasium, I should judge; for the windows are barred for little children, and there are rings and things in the walls.
    The paint and paper look as if a boys' school had used it. It is stripped off--the paper--in great patches all around the head of my bed, about as far as I can reach, and in a great place on the other side of the room low down. I never saw a worse paper in my life.
    One of those sprawling flamboyant patterns committing every artistic sin.
    It is dull enough to confuse the eye in following, pronounced enough to constantly irritate and provoke study, and when you follow the lame uncertain curves for a little distance they suddenly commit suicide--plunge off at outrageous angles, destroy themselves in unheard of contradictions.
    The color is repellent, almost revolting; a smouldering unclean yellow, strangely faded by the slow-turning sunlight.
    It is a dull yet lurid orange in some places, a sickly sulphur tint in others.
    No wonder the children hated it! I should hate it myself if I had to live in this room long.
    There comes John, and I must put this away,--he hates to have me write a word.

* * *

We have been here two weeks, and I haven't felt like writing before, since that first day.
    I am sitting by the window now, up in this atrocious nursery, and there is nothing to hinder my writing as much as I please, save lack of strength.
    John is away all day, and even some nights when his cases are serious.
    I am glad my case is not serious!
    But these nervous troubles are dreadfully depressing.
    John does not know how much I really suffer. He knows there is no reason to suffer, and that satisfies him.
    Of course it is only nervousness. It does weigh on me so not to do my duty in any way!
    I meant to be such a help to John, such a real rest and comfort, and here I am a comparative burden already!
    Nobody would believe what an effort it is to do what little I am able,--to dress and entertain, and order things.
    It is fortunate Mary is so good with the baby. Such a dear baby!
    And yet I cannot be with him, it makes me so nervous.
    I suppose John never was nervous in his life. He laughs at me so about this wall-paper!
    At first he meant to repaper the room, but afterwards he said that I was letting it get the better of me, and that nothing was worse for a nervous patient than to give way to such fancies.
    He said that after the wall-paper was changed it would be the heavy bedstead, and then the barred windows, and then that gate at the head of the stairs, and so on.
    "You know the place is doing you good," he said, "and really, dear, I don't care to renovate the house just for a three months' rental."
    'Then do let us go downstairs," I said, "there are such pretty rooms there."
    Then he took me in his arms and called me a blessed little goose, and said he would go down to the cellar, if I wished, and have it whitewashed into the bargain.
    But he is right enough about the beds and windows and things.
    It is an airy and comfortable room as any one need wish, and, of course, I would not be so silly as to make him uncomfortable just for a whim.
    I'm really getting quite fond of the big room, all but that horrid paper.
    Out of one window I can see the garden, those mysterious deep-shaded arbors, the riotous old-fashioned flowers, and bushes and gnarly trees.
    Out of another I get a lovely view of the bay and a little private wharf belonging to the estate. There is a beautiful shaded lane that runs down there from the house. I always fancy I see people walking in these numerous paths and arbors, but John has cautioned me not to give way to fancy in the least. He says that with my imaginative power and habit of story-making, a nervous weakness like mine is sure to lead to all manner of excited fancies, and that I ought to use my will and good sense to check the tendency. So I try.
    I think sometimes that if I were only well enough to write a little it would relieve the press of ideas and rest me.
    But I find I get pretty tired when I try.
    It is so discouraging not to have any advice and companionship about my work. When I get really well, John says we will ask Cousin Henry and Julia down for a long visit; but he says he would as soon put fireworks in my pillow-case as to let me have those stimulating people about now.
    I wish I could get well faster.
    But I must not think about that. This paper looks to me as if it knew what a vicious influence it had!
    There is a recurrent spot where the pattern lolls like a broken neck and two bulbous eyes stare at you upside down.
    I get positively angry with the impertinence of it and the everlastingness. Up and down and sideways they crawl, and those absurd, unblinking eyes are everywhere. There is one place where two breadths didn't match, and the eyes go all up and down the line, one a little higher than the other.
    I never saw so much expression in an inanimate thing before, and we all know how much expression they have! I used to lie awake as a child and get more entertainment and terror out of blank walls and plain furniture than most children could find in a toy-store.
    I remember what a kindly wink the knobs of our big, old bureau used to have, and there was one chair that always seemed like a strong friend.
    I used to feel that if any of the other things looked too fierce I could always hop into that chair and be safe.
    The furniture in this room is no worse than inharmonious, however, for we had to bring it all from downstairs. I suppose when this was used as a playroom they had to take the nursery things out, and no wonder! I never saw such ravages as the children have made here.
    The wall-paper, as I said before, is torn off in spots, and it sticketh closer than a brother--they must have had perseverance as well as hatred.
    Then the floor is scratched and gouged and splintered, the plaster itself is dug out here and there, and this great heavy bed which is all we found in the room, looks as if it had been through the wars.
    But I don't mind it a bit--only the paper.
    There comes John's sister. Such a dear girl as she is, and so careful of me! I must not let her find me writing.
    She is a perfect and enthusiastic housekeeper, and hopes for no better profession. I verily believe she thinks it is the writing which made me sick!
    But I can write when she is out, and see her a long way off from these windows.
    There is one that commands the road, a lovely shaded winding road, and one that just looks off over the country. A lovely country, too, full of great elms and velvet meadows.
    This wall-paper has a kind of sub-pattern in a different shade, a particularly irritating one, for you can only see it in certain lights, and not clearly then.
    But in the places where it isn't faded and where the sun is just so--I can see a strange, provoking, formless sort of figure, that seems to skulk about behind that silly and conspicuous front design.
    There's sister on the stairs!

* * *

Well, the Fourth of July is over! The people are all gone and I am tired out. John thought it might do me good to see a little company, so we just had mother and Nellie and the children down for a week.
    Of course I didn't do a thing. Jennie sees to everything now. But it tired me all the same.
    John says if I don't pick up faster he shall send me to Weir Mitchell in the fall.
    But I don't want to go there at all. I had a friend who was in his hands once, and she says he is just like John and my brother, only more so!
    Besides, it is such an undertaking to go so far.
    I don't feel as if it was worth while to turn my hand over for anything, and I'm getting dreadfully fretful and querulous.
    I cry at nothing, and cry most of the time.
    Of course I don't when John is here, or anybody else, but when I am alone.
    And I am alone a good deal just now John is kept in town very often by serious cases, and Jennie is good and lets me alone when I want her to.
    So I walk a little in the garden or down that lovely lane, sit on the porch under the roses, and lie down up here a good deal.
    I'm getting really fond of the room in spite of the wall-paper. Perhaps because of the wall-paper.
    It dwells in my mind so!
    I lie here on this great immovable bed--it is nailed down, I believe--and follow that pattern about by the hour. It is as good as gymnastics, I assure you. I start, we'll say, at the bottom, down in the corner over there where it has not been touched, and I determine for the thousandth time that I will follow that pointless pattern to some sort of a conclusion.
    I know a little of the principle of design; and I know this thing was not arranged on any laws of radiation, or alternation, or repetition, or symmetry, or anything else that I ever heard of.
    It is repeated, of course, by the breadths, but not otherwise.
    Looked at in one way each breadth stands alone, the bloated curves and flourishes--a kind of "debased Romanesque" with delirium tremens-- waddling up and down in isolated columns of fatuity.
    But, on the other hand, they connect diagonally, and the sprawling outlines run off in great slanting waves of optic horror, like a lot of wallowing seaweeds in full chase.
    The whole thing goes horizontally, too, at least it seems so, and I exhaust myself in trying to distinguish the order of its going in that direction.
    They have used a horizontal breadth for a frieze, and that adds wonderfully to the confusion.
    There is one end of the room where it is almost intact, and there, when the crosslights fade and the low sun shines directly upon it, I can almost fancy radiation after all,--the interminable grotesques seem to form around a common centre and rush off in headlong plunges of equal distraction.
    It makes me tired to follow it. I will take a nap I guess.
    I don't know why I should write this.
    I don't want to.
    I don't feel able.
    And I know John would think it absurd. But I must say what I feel and think in some way--it is such a relief!
    But the effort is getting to be greater than the relief.
    Half the time now I am awfully lazy, and lie down ever so much.
    John says I mustn't lose my strength, and has me take cod liver oil and lots of tonics and things, to say nothing of ale and wine and rare meat.
    Dear John! He loves me very dearly, and hates to have me sick. I tried to have a real earnest reasonable talk with him the other day, and tell him how I wish he would let me go and make a visit to Cousin Henry and Julia.
    But he said I wasn't able to go, nor able to stand it after I got there; and I did not make out a very good case for myself, for I was crying before I had finished.
    It is getting to be a great effort for me to think straight. Just this nervous weakness I suppose.
    And dear John gathered me up in his arms, and just carried me upstairs and laid me on the bed, and sat by me and read to me till it tired my head.
    He said I was his darling and his comfort and all he had, and that I must take care of myself for his sake, and keep well.
    He says no one but myself can help me out of it, that I must use my will and self-control and not let any silly fancies run away with me.
    There's one comfort, the baby is well and happy, and does not have to occupy this nursery with the horrid wall-paper.
    If we had not used it, that blessed child would have! What a fortunate escape! Why, I wouldn't have a child of mine, an impressionable little thing, live in such a room for worlds.
    I never thought of it before, but it is lucky that John kept me here after all, I can stand it so much easier than a baby, you see.
    Of course I never mention it to them any more--I am too wise,--but I keep watch of it all the same.
    There are things in that paper that nobody knows but me, or ever will.
    Behind that outside pattern the dim shapes get clearer every day.
    It is always the same shape, only very numerous.
    And it is like a woman stooping down and creeping about behind that pattern. I don't like it a bit. I wonder--I begin to think--I wish John would take me away from here!
    It is so hard to talk with John about my case, because he is so wise, and because he loves me so.
    But I tried it last night.
    It was moonlight. The moon shines in all around just as the sun does.
    I hate to see it sometimes, it creeps so slowly, and always comes in by one window or another.
    John was asleep and I hated to waken him, so I kept still and watched the moonlight on that undulating wall-paper till I felt creepy.
    The faint figure behind seemed to shake the pattern, just as if she wanted to get out.
    I got up softly and went to feel and see if the paper did move, and when I came backjohn was awake.
    "What is it, little girl?" he said. 'Don't go walking about like that--you'll get cold."
    I thought it was a good time to talk, so I told him that I really was not gaining here, and that I wished he would take me away.
    "Why, darling!" said he, "our lease will be up in three weeks, and I can't see how to leave before.
    "The repairs are not done at home, and I cannot possibly leave town just now. Of course if you were in any danger, I could and would, but you really are better, dear, whether you can see it or not. I am a doctor, dear, and I know. You are gaining flesh and color, your appetite is better, I feel really much easier about you."
    "I don't weigh a bit more," said I, "nor as much; and my appetite may be better in the evening when you are here, but it is worse in the morning when you are away!"
    "Bless her little heart!" said he with a big hug, "she shall be as sick as she pleases! But now let's improve the shining hours by going to sleep, and talk about it in the morning!'
    "And you won't go away?" I asked gloomily.
    "Why, how can I, dear? It is only three weeks more and then we will take a nice little trip of a few days while Jennie is getting the house ready. Really dear you are better!"
    "Better in body perhaps--" I began, and stopped short, for he sat up straight and looked at me with such a stern, reproachful look that I could not say another word.
    "My darling," said he, "I beg of you, for my sake and for our child's sake, as well as for your own, that you will never for one instant let that idea enter your mind! There is nothing so dangerous, so fascinating, to a temperament like yours. It is a false and foolish fancy. Can you not trust me as a physician when I tell you so?"
    So of course I said no more on that score, and we went to sleep before long. He thought I was asleep first, but I wasn't, and lay there for hours trying to decide whether that front pattern and the back pattern really did move together or separately.

* * *

    On a pattern like this, by daylight, there is a lack of sequence, a defiance of law, that is a constant irritant to a normal mind.
    The color is hideous enough, and unreliable enough, and infuriating enough, but the pattern is torturing.
    You think you have mastered it, but just as you get well underway in following, it turns a back-somersault and there you are. It slaps you in the face, knocks you down, and tramples upon you. It is like a bad dream.
    The outside pattern is a florid arabesque, reminding one of a fungus. If you can imagine a toadstool in joints, an interminable string of toadstools, budding and sprouting in endless convolutions--why, that is something like it.
    That is, sometimes!
    There is one marked peculiarity about this paper, a thing nobody seems to notice but myself, and that is that it changes as the light changes.
    When the sun shoots in through the east window--I always watch for that first long, straight ray--it changes so quickly that I never can quite believe it.
    That is why I watch it always.
    By moonlight--the moon shines in all night when there is a moon--I wouldn't know it was the same paper.
    At night in any kind of light, in twilight, candle light, lamplight, and worst of all by moonlight, it becomes bars! The outside pattern I mean, and the woman behind it is as plain as can be.
    I didn't realize for a long time what the thing was that showed behind, that dim sub-pattern, but now I am quite sure it is a woman.
    By daylight she is subdued, quiet. I fancy it is the pattern that keeps her so still. It is so puzzling. It keeps me quiet by the hour.
    I lie down ever so much now. John says it is good for me, and to sleep all I can.
    Indeed he started the habit by making me lie down for an hour after each meal.
    It is a very bad habit I am convinced, for you see I don't sleep.
    And that cultivates deceit, for I don't tell them I'm awake--O no!
    The fact is I am getting a little afraid of John.
    He seems very queer sometimes, and even Jennie has an inexplicable look.
    It strikes me occasionally, just as a scientific hypothesis,--that perhaps it is the paper!
    I have watched John when he did not know I was looking, and come into the room suddenly on the most innocent excuses, and I've caught him several times looking at the paper! And Jennie too. I caught Jennie with her hand on it once.
    She didn't know I was in the room, and when I asked her in a quiet, a very quiet voice, with the most restrained manner possible, what she was doing with the paper--she turned around as if she had been caught stealing, and looked quite angry--asked me why I should frighten her so!
    Then she said that the paper stained everything it touched, that she had found yellow smooches on all my clothes and John's, and she wished we would be more careful!
    Did not that sound innocent? But I know she was studying that pattern, and I am determined that nobody shall find it out but myself!

* * *

    Life is very much more exciting now than it used to be. You see I have something more to expect, to look forward to, to watch. I really do eat better, and am more quiet than I was.
    John is so pleased to see me improve! He laughed a little the other day, and said I seemed to be flourishing in spite of my wall-paper.
    I turned it off with a laugh. I had no intention of telling him it was because of the wall-paper--he would make fun of me. He might even want to take me away.
    I don't want to leave now until I have found it out. There is a week more, and I think that will be enough.

    I'm feeling ever so much better! I don't sleep much at night, for it is so interesting to watch developments; but I sleep a good deal in the daytime.
    In the daytime it is tiresome and perplexing.
    There are always new shoots on the fungus, and new shades of yellow all over it. I cannot keep count of them, though I have tried conscientiously.
    It is the strangest yellow, that wall-paper! It makes me think of all the yellow things I ever saw--not beautiful ones like buttercups, but old foul, bad yellow things.
    But there is something else about that paper--the smell! I noticed it the moment we came into the room, but with so much air and sun it was not bad. Now we have had a week of fog and rain, and whether the windows are open or not, the smell is here.
    It creeps all over the house.
    I find it hovering in the dining-room, skulking in the parlor, hiding in the hall, lying in wait for me on the stairs.
    It gets into my hair.
    Even when I go to ride, if I turn my head suddenly and surprise it--there is that smell!
    Such a peculiar odor, too! I have spent hours in trying to analyze it, to find what it smelled like.
    It is not bad--at first, and very gentle, but quite the subtlest, most enduring odor I ever met.
    In this damp weather it is awful, I wake up in the night and find it hanging over me.
    It used to disturb me at first. I thought seriously of burning the house to reach the smell.
    But now I am used to it. The only thing I can think of that it is like is the color of the paper! A yellow smell.
    There is a very funny mark on this wall, low down, near the mopboard. A streak that runs round the room. It goes behind every piece of furniture, except the bed, a long, straight, even smooch, as if it had been rubbed over and over.
    I wonder how it was done and who did it, and what they did it for. Round and round and round--round and round and round--it makes me dizzy!

* * *

    I really have discovered something at last.
    Through watching so much at night, when it changes so, I have finally found out.
    The front pattern does move--and no wonder! The woman behind shakes it!
    Sometimes I think there are a great many women behind, and sometimes only one, and she crawls around fast, and her crawling shakes it all over.
    Then in the very bright spots she keeps still, and in the very shady spots she just takes hold of the bars and shakes them hard.
    And she is all the time trying to climb through. But nobody could climb through that pattern--it strangles so; I think that is why it has so many heads.
    They get through, and then the pattern strangles them off and turns them upside down, and makes their eyes white!
    If those heads were covered or taken off it would not be half so bad.

* * *

    I think that woman gets out in the daytime!
    And I'll tell you why--privately--I've seen her!
    I can see her out of every one of my windows!
    It is the same woman, I know, for she is always creeping, and most women do not creep by daylight.
    I see her on that long road under the trees, creeping along, and when a carriage comes she hides under the blackberry vines.
    I don't blame her a bit. It must be very humiliating to be caught creeping by daylight!
    I always lock the door when I creep by daylight. I can't do it at night, for I know John would suspect something at once.
    And John is so queer now, that I don't want to irritate him. I wish he would take another room! Besides, I don't want anybody to get that woman out at night but myself.
    I often wonder if I could see her out of all the windows at once.
    But, turn as fast as I can, I can only see out of one at one time.
    And though I always see her, she may be able to creep faster than I can turn!
    I have watched her sometimes away off in the open country, creeping as fast as a cloud shadow in a high wind.

* * *

    If only that top pattern could be gotten off from the under one! I mean to try it, little by little.
    I have found out another funny thing, but I shan't tell it this time! It does not do to trust people too much.
    There are only two more days to get this paper off, and I believe John is beginning to notice. I don't like the look in his eyes.
    And I heard him ask Jennie a lot of professional questions about me. She had a very good report to give.
    She said I slept a good deal in the daytime.
    John knows I don't sleep very well at night, for all I'm so quiet!
    He asked me all sorts of questions, too, and pretended to be very loving and kind.
    As if I couldn't see through him!
    Still, I don't wonder he acts so, sleeping under this paper for three months.
    It only interests me, but I feel sure John and Jennie are secretly affected by it.

* * *

    Hurrah! This is the last day, but it is enough. John to stay in town over night, and won't be out until this evening.
    Jennie wanted to sleep with me--the sly thing! but I told her I should undoubtedly rest better for a night all alone.
    That was clever, for really I wasn't alone a bit! As soon as it was moonlight and that poor thing began to crawl and shake the pattern, I got up and ran to help her.
    I pulled and she shook, I shook and she pulled, and before morning we had peeled off yards of that paper.
    A strip about as high as my head and half around the room.
    And then when the sun came and that awful pattern began to laugh at me, I declared I would finish it today!
    We go away tomorrow and they are moving all my furniture down again to leave things as they were before.
    Jennie looked at the wall in amazement, but I told her merrily that I did it out of pure spite at the vicious thing.
    She laughed and said she wouldn't mind doing it herself, but I must not get tired.
    How she betrayed herself that time!
    But I am here, and no person touches this paper but me,--not alive!
   She tried to get me out of the room--it was too patent! But I said it was so quiet and empty and clean now that I believed I would lie down again and sleep all I could; and not to wake me even for dinner--I would call when I woke.
    So now she is gone, and the servants are gone, and the things are gone, and there is nothing left but that great bedstead nailed down, with the canvas mattress we found on it.
    We shall sleep downstairs tonight, and take the boat home tomorrow.
    I quite enjoy the room, now it is bare again.
    How those children did tear about here!
    This bedstead is fairly gnawed!
    But I must get to work.
    I have locked the door and thrown the key down into the front path.
    I don't want to go out, and I don't want to have anybody come in, till John comes.
    I want to astonish him.
    I've got a rope up here that even Jennie did not find. If that woman does get out, and tries to get away, I can tie her!
    But I forgot I could not reach far without anything to stand on!
    This bed will not move!
    I tried to lift and push it until I was lame, and then I got so angry I bit off a little piece at one corner--but it hurt my teeth.
    Then I peeled off all the paper I could reach standing on the floor.
    It sticks horribly and the pattern just enjoys it! All those strangled heads and bulbous eyes and waddling fungus growths just shriek with derision!
    I am getting angry enough to do something desperate. To jump out of the window would be admirable exercise, but the bars are too strong even to try.
    Besides I wouldn't do it. Of course not. I know well enough that a step like that is improper and might be misconstrued.
    I don't like to look out of the windows even--there are so many of those creeping women, and they creep so fast.
    I wonder if they all come out of that wallpaper as I did?
    But I am securely fastened now by my well-hidden rope you don't get me out in the road there!
    I suppose I shall have to get back behind the pattern when it comes night, and that is hard!
    It is so pleasant to be out in this great room and creep around as I please!
    I don't want to go outside. I won't, even if Jennie asks me to.
    For outside you have to creep on the ground, and everything is green instead of yellow.
    But here I can creep smoothly on the floor, and my shoulder just fits in that long smooch around the wall, so I cannot lose my way.
    Why there's John at the door!
    It is no use, young man, you can't open it!
    How he does call and pound!
    Now he's crying for an axe.
    It would be a shame to break down that beautiful door!
    "John dear!" said I in the gentlest voice, "the key is down by the front steps, under a plantain leaf!"
    That silenced him for a few moments.
    Then he said very quietly indeed, "Open the door, my darling!"
    "I can't," said I. "The key is down by the front door under a plantain leaf!"
    And then I said it again, several times, very gently and slowly, and said it so often that he had to go and see, and he got it of course, and came in. He stopped short by the door.
   "What is the matter?" he cried. "For God's sake, what are you doing!"
    I kept on creeping just the same, but I looked at him over my shoulder
    I've got out at last," said I, "in spite of you and Jane. And I've pulled off most of the paper, so you can't put me back!"
    Now why should that man have fainted? But he did, and right across my path by the wall, so that I had to creep over him every time!