Int J Ment Health Addiction (2014) 12:470–476

DOI 10.1007/s11469-014-9478-1

Narrative Group Therapy for Alcohol Dependent Patients

József Szabó & Szilvia Tóth &

Annamária Karamánné Pakai

Published online: 14 February 2014

# Springer Science+Business Media New York 2014

Abstract A group therapy method was developed based on the results of previous
research using narrative psychological approaches. Our primary technique was narra-
tive restructuring. Alcohol addicted patients treated at our department were instructed
to restructure their autobiography in a way that their linguistic expressions become
more similar to those of recovering patients’. We presumed that it would have
positive therapeutic effects, which could be measured with the Hopelessness Scale
(HS) and the Means-Ends Problem Solving Procedure (MEPS). We recorded the tests
before and after the group therapy sessions and the changes in results were compared
(t-test) to those of control persons, who participated in other types of group therapy.
We found significant difference between the case and control groups. Our therapeutic
method reduced hopelessness and increased problem solving ability more effectively
than other group therapies.

Keywords Alcohol dependency . Autobiography . Autobiographical memory . Linguistic code .

Narrative . Social words . Hopelessness . Problem solving ability . Recovery

Narrative psychological approaches, which started to develop in the second part of

the last century but are still considered progressive nowadays, have also gained
ground in clinical psychology and its frontier areas, and made their debut in
addictology as well. Our paper describes a group therapy technique that was based
on the results of mostly narrative psychological and some cognitive psychological
research.

Background

The widespread presence of narrative approaches that developed on the basis of cognitive
psychology by combining the methods and results used in applied linguistics, communication
theories, cultural anthropology and social psychology soon resulted in their introduction in

J. Szabó (*) : A. Karamánné Pakai

Faculty of Health Sciences, University of Pécs, Zalaegerszeg Campus, Landorhegyi u. 33,
8900 Zalaegerszeg, Hungary
e-mail: testudo@zalaszam.hu

S. Tóth
Department of Psychiatry, Zala County Hospital, Zrínyi u. 1, 8900 Zalaegerszeg, Hungary
Int J Ment Health Addiction (2014) 12:470–476 471

addictology research and practice. Several studies identified expressions and linguistic codes
characteristic of addicts (Hanninen and Koski-Jannes 1999). Others considered the techniques
of narrative psychology as a good means for depicting and describing the process of recovery
from addiction (Mohatt et al. 2004; Keane 2001; Cerclé 2002). In the opinion of some experts
narrative techniques can facilitate the identification of effective factors in self-help communi-
ties (Rafalovich 1999; Klaw and Humpreys 2000). Several studies dealt with the use and
therapeutic restructuring of autobiographies as self-representations of differential diagnostic
and predictive value (Carricaburu and Pierret 1995; Meichenbaum 1999). As regards the group
therapy technique to be introduced, the publication that analysed the digitised autobiography
of 96 deceased psychologists and 220 late fine literature writers and introduced the definition
of social words is of significant importance. The authors of the study used archived data to
collect the writers’ sex, date and place of birth and death, their age at the time of writing their
autobiography and the date of its publication. They found that the more frequent use of words
suggesting social roles and integration (e.g.: father, sister, neighbour, colleague, etc.) correlated
with a longer lifespan in both groups. Expressions specific for family roles (e.g.: aunt, family,
sibling, etc.) and reference to other individuals (e.g.: they, we, us, everybody, etc.) also
predicted a longer lifespan; however, only in case of the psychologists. According to their
conclusions, the analysis of the frequency of social words in autobiographies provides an
indirect way of measuring social relationships and the anticipated lifespan. The authors
recommend their method, i.e. computerised content analysis for the research of archived
documents as well as for the indirect examination of social relationships, as completing
structured questionnaires and participating in interviews may generate a need for acceptance,
which can distort the information gained. On the other hand, the content analysis of autobi-
ographies can reveal the spontaneous indicators of important social relationships (Pressman
and Cohan 2007). Using their aspects we compared the autobiography of recovered and
relapsed alcohol abusers who participated in an earlier study of ours and we had very similar
results (Szabó and Gerevich 2009) and we managed to detect linguistic codes characteristic of
alcohol addicts in another previous study of ours (Szabó and Gerevich 2007). On developing
our method we also relied on some studies revealing and emphasizing the role of autobio-
graphical memory that found a relationship between pathological behaviour/mental disorders
and lack of problem-solving ability caused by impaired autobiographical memory (Perczel
Forintos and Poós 2008). Apart from the examination of depression, crises and suicidal acts
the same phenomenon was described by the researchers of addictions (Eiber et al. 1999) and
post-traumatic stress disorder. They identified characteristic patient narratives which described
the patient as a victim, while healthy people who suffered a similar crisis put themselves in the
role of a survivor when describing their trauma (Sutherland and Bryant 2008). According to
some psychotherapists, the process of recovery in such patients means getting from the
position of the “victim”, “sufferer” to the position of the “fighter”, “survivor”, which has to
be facilitated purposefully during the therapy (Meichenbaum 1999).

Hypothesis

We based our research hypothesis on the above mentioned scientific literature results. We
thought that the therapeutically controlled restructuring of alcohol abusers’ autobiography
(which serves as self-representation) has measurable therapeutic effects and facilitates their
recovery. (Restructuring means identifying the linguistic codes characteristic of alcohol
abusers and transforming them, as well as the controlled presentation of social relationships
and recalling previous situations and events that necessitated fighting.) Confirming the
472 Int J Ment Health Addiction (2014) 12:470–476

hypothesis offered us a therapeutic opportunity that could be exploited in various fields of

treating alcohol abusers and applied in several professions. The method was named autobi-
ography reconstruction group.

Materials and Methods

Our study group included 30 patients treated at our rehabilitation ward (Department of
Psychiatry, County Hospital of Zala) with the admission diagnosis of Alcohol dependence
(F10.2, ICD-10). In order to confirm this diagnosis and make it more accurate we had our
patients fill in the Severity of Alcohol Dependence Questionnaire (SADQ) (Stockwell et al.
1983). Regarding age, sex and educational background we tried to select a sample represen-
tative of our patient population. The selected patients completed the Hopelessness Scale (HS)
(Beck et al. 1974) and the Means-Ends Problem Solving Procedure (MEPS) both before and
after the group-based transformation and restructuring of their autobiography. Our hypothesis
was that we were going to experience a decrease in the Hopelessness Scale and an increase in
the Means-Ends Problem Solving Procedure.
In order to prove that the measured changes were not merely the results of 3 weeks’
abstinence and that of other therapeutic interventions applied at our department we established
two control groups. The first control group included alcohol dependent patients treated at our
Department who met the diagnostic criteria of the cases and received some kind of group
therapy; the only difference being that they did not get selected into the case group. The second
control group included other group therapy patients treated at our department with unspecified
anxiety disorders (F40.0-F41.9) who did not get selected into the autobiography reconstruction
group either. We administered both above mentioned tests in all control patients and repeated
them in 3 weeks’ time. Our hypothesis was that we were going to experience less significant
changes in the case of both tests.

Group Therapy Procedure

The therapy was divided into 12 sessions (4 sessions per week for 3 weeks) with the
participation of 6–8 patients at one time. The therapy had 4 important steps:

1. Writing the autobiographies. During the first group therapy session besides the usual
formal procedures we asked the participants to write their autobiography, the story of their
life for the next session.
2. Sharing and discussing autobiographies with the group. Usually 2 autobiographies
were shared in every session; the other members of the group had to reflect on what was said.
3. Writing new, guided autobiographies based on the instructions provided. The process
of rewriting the autobiographies had 4 phases, based on the written instructions provided.
4. Sharing and discussing the new autobiographies. Again with the active participation of
2 members, while the others commented on what they heard.

The instructions for writing the new autobiographies concentrated on 4 important matters:

1. Cessation of negative coding. We tried to decrease the negative linguistic codes of

hopelessness and impotence described by Balázs Kézdi (Kézdi 1995), which is also
characteristic of alcohol addicts (Szabó and Gerevich 2009). The specific instruction
Int J Ment Health Addiction (2014) 12:470–476 473

was to avoid the use of negation and negative prefixes/suffixes. One simple but illustrative
sample for such changes:

A sentence from the first, spontaneous autobiography: “My study average at school was
never below 4.6”. The same piece of information from the second autobiography: “I always
had very good results at school”.

2. Increasing the frequency of social words. Based on the work of Pressman and Cohan as
well as our previous work we instructed our patients to include characters and social
relationships that might be part of the story but failed to appear in the first, spontaneous
version. We also instructed them to use words suggesting social interactions such as like,
get, give, help or their conjugated forms. According to the above mentioned studies, the
more frequent appearance of these words predicts a longer lifespan (Pressman and Cohan
2007), or recovery (Szabó and Gerevich 2009) in the case of alcohol addicts.
3. Stimulating autobiographical memory. We encouraged the recall of previous situations
and crises that needed fighting by asking our patients to mention the most important difficulty
or turning point in their life. By recalling a successful fight or at least “survival” we hoped to
decrease their feeling of hopelessness and activate their blocked problem-solving ability
(Perczel Forintos and Poós 2008; Eiber et al. 1999; Sutherland and Bryant 2008).
4. Decreasing the frequency of “and”-type connecting words and increasing the fre-
quency of “so”-type connecting words. We instructed our patients to use connecting
words suggesting a causative relationship instead of ones that merely suggest the chrono-
logical order of certain events. Through this we wanted to emphasize that certain things do
not just “happen to them”, but they are also active participants in the story whose actions have
consequences. This way we were trying to decrease the feeling of “drifting” and hopeless-
ness, and emphasize their own role in influencing their life (Szabó and Gerevich 2007).
5. Guided inclusion of the future tense. Once more, our aim was to decrease hopelessness
(Szabó and Gerevich 2007).
6. Forming sentences with “I decided, I chose, I could” instead of saying “I must, I had
to”. Our aim was to get our patients through the different stages of recovery described by
Alain Cerclé (from expressions like “had to” through “I would like to, I want” to “I may, I
am allowed to”.) (Cerclé 2002). Our specific instruction was to use “I decided, I chose, I
could” instead of saying “I must, I had to”.

Throughout the process of restructuring the autobiographies it was emphasized several

times that the patients should stick to the original story. Fortunately, our fear that the very
specific, definite instructions will make it more difficult for the patients to identify themselves
with the new autobiography, thereby losing its therapeutic effect, was not realised. When asked
if they could identify themselves with the restructured story they always said they could,
sometimes adding that the new version was more about them, as several important but first
forgotten people and events could find their way into the story. None of the patients felt that the
new version was not about them. The majority of the participants found the task interesting and
useful in spite of its difficulty, and they expressed their satisfaction during the last session.

Results

The changes in the variables measured before and after the group therapy are as follows: the
rate of hopelessness decreased in 80 % of the participants, did not change in 10 % and
474 Int J Ment Health Addiction (2014) 12:470–476

increased in 10 % of the patients. The same indices in case of the alcohol addict control group
were 54 %, 13 % and 33 % respectively. The latter results may be caused by the fact that they
meet many relapsed alcohol addicts after being hospitalised, which can readily suggest
hopelessness. Furthermore, we are aware that the Hungarian population significantly under-
estimates the risk of alcohol consumption, and besides their own personal condition they have
to face other difficulties and hazards in the psychoeducational group. In short, they have to
face the fact that their situation is more difficult than they thought. The rate of hopelessness
decreased in 53 % of the participants in the anxiety group, did not change in 30 % and
increased in 17 % of the patients. The score of problem-solving ability increased in 97 % of
patients in the case group, and did not change in 3 %. In the alcohol addict control group the
same figures were 76 % and 7 % respectively, and 7 % of the patients had a lower score on
completing the test for the second time. As for the results of the anxiety control group, 73 %
did better, 7 % received the same score and 20 % had lower results.
The mean rate of change considering the Hopelessness Scale was the highest in the case
group, the decrease in the feeling of hopelessness was the most significant in this group
(Fig. 1). We performed a t-test to compare the rate of changes and to detect the significance of
the changes. Comparing the case group and the alcohol addict control group we received a
significant difference (p=0.0016). When comparing the same findings of the case and the
anxiety control group we also proved significant difference (p=0.0026) (Fig. 1).
The changes in results gained from the Means-Ends Problem Solving Procedure were
compared in a similar way. We detected significant difference (p=0.0003) between the case
and the alcohol addict control group, and we had the same results (p=0.0001) when comparing
the case and the anxiety control group. This difference is well visible in the bar graph
illustrating the mean rate of changes (Fig. 2). Comparing the results of the control groups
yielded no significant difference in either case. Based on these results we consider our
hypothesis justified.

Discussion

We can conclude that the group therapy based on narrative psychological approaches has
proved to be effective and successful, and it has met the approval and satisfaction of our
patients as well. As a result, it has become part of our standard therapeutic repertoire. The best
interpretation of the therapeutic effect experienced can be found in the framework of cognitive

Fig. 1 The mean rate of change in

hopelessness in the case and con-
trol groups
Int J Ment Health Addiction (2014) 12:470–476 475

Fig. 2 The mean rate of change in

problem solving ability in the case
and control groups

psychological approaches. According to their followers, in the background of mental disorders

and pathological behaviour you can find cognitive distortions, negative thoughts, dysfunc-
tional attitudes as well as maladaptive schemata, which refer to some fixed, highly influential
opinions, “labels”. The schemata are of 2 types usually; they either refer to the self or to the
world. Schemata referring to the self cover the likeability and the competence of the individual.
Increasing the frequency of social words and expressions suggesting social interactions
probably weakens the schemata affecting sociability, therefore the feeling of loneliness
decreases, the subjective feeling of security increases and the self-esteem is strengthened.
Replacing “and”-type connecting words (which suggest drifting, passive participation in one’s
life, playing the role of the victim) with ones that suggest causality facilitates the process
described by Cerclé. Using words like I chose, I decided weakens the maladaptive schemata
affecting competence, thereby strengthening the subjective feeling of competence and having
control over one’s own life. This makes events and the whole world more predictable, safe and
enjoyable.
The changes we achieved or can be achieved via guided restructuring are more or less the
same as the ones that become apparent in the linguistic expressions of people who spend years
in self-help communities. Naturally, this does not mean that our method could substitute for
years of self-help community participation (or it could serve as a self-help depot product); we
think that it makes you more sensitive, prepares you for that work, which is necessary to retain
the achieved changes and develop them.
The weakness of our method is that the impaired writing and reading skills that can
frequently be seen in alcohol addicts makes it more difficult for them to get selected into the
group and impairs their willingness to participate. Therefore the target population for its
application is narrow, compared to behaviour therapy and psychoeducational methods.
However, it does not replace other group therapies, so it cannot be applied as monotherapy.
We recommend its use in (any phase of) the rehabilitation of alcohol addicts, as an adjunct to
other established therapies.
Our method could be further developed and supplemented by examining the linguistic
expressions characteristic of alcohol addicts and identifying new linguistic codes. We plan to
perform further narrative psychological research at our department. As a way of self-
destruction, alcohol dependence shows significant similarity to suicidal behaviour, their shared
features can be identified through narratives as well. Therefore we can assume that our method
could be successfully applied in those who have already attempted to commit a suicide or are
at a higher risk, but this could only be proved in further studies.
476 Int J Ment Health Addiction (2014) 12:470–476

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