Treatment issues in the group psychotherapy of addicted physicians.

For the most part, physician-addict patients are affable, cooperative and tend to be bright, verbal and engaging. However, on a deeper level they experience significant internal obstacles to truly using treatment. The role of the healer adopted after years of training and work experience is not easily exchanged for the role of patient. Furthermore, the armour of defenses and character style that have been built up over a lifetime is resistant to modification. Additionally, most of these patients have not chosen to change. They have been ordered into treatment under considerable duress and are aware that retaining their hard-earned careers is dependent on their successful performance in treatment. Given all these difficulties it is striking that the vast majority of these patients gradually come to experience a genuine and meaningful connection to the group and the therapeutic process. They develop close relationships with their fellow group members and come to use them as a support system, even at times when the group is not in session. They report looking forward to group and missing it when it does not meet. In this context they begin to take risks by sharing on a deeper level and slowly bring to the group issues in their life other than addiction. Their devotion to group is reflected by the fact that when no longer mandated, many continue voluntarily and maintain that the experience is central to their recovery. One of the major reasons recovering physicians are able to make this connection is that behind their fear of interpersonal relationships is a tremendous wish to join with others. Many report profound relief at discovering they are not alone and are able to use group to address their deeply felt sense of shame. For many this is their first experience of such strong feelings of attachment and affiliation to a group of peers. Their prior professional experience did not routinely allow for such relationships and as Smith (1978) has observed, their experience has been characterized by extraordinary isolation even as compared to the general population of addicts. There are no communities of drug-using doctors and no romanticized antics shared amongst fellow addicted physicians. A doctor's addiction is at its core an activity of secrecy and solitude. This investment to group can only develop in an environment that feels fundamentally safe. It is the creation of such an environment that is the central task for the therapist working with addicted physicians. The patient must come to learn that he can say whatever is on his mind without being criticized, ridiculed or punished. To a large extent this is accomplished by highlighting the commonality between the group members which diminishes the sense of isolation and shame. In addition, the therapist must maintain an accepting and non-judgmental stance so that the patient is free to fully experience the ambivalence inherent in the decision to get sober.