INTERNATIONAL JOURNAL OF GROUP PSYCHOTHERAPY, 51(1) 2001

GALANTER THERAPY
NETWORK AND BROOK
FOR ADDICTION

Network Therapy for Addiction:

Bringing Family and Peer Support
Into Office Practice

MARC GALANTER, M.D.

DAVID BROOK, M.D.

ABSTRACT
Network therapy was developed as a specialized type of combined individual and group
therapy to ensure greater success in the office-based treatment of addicted patients by using
both psychodynamic and cognitive-behavioral approaches to individual therapy while en-
gaging the patient in a group support network composed of family members and peers.
This article outlines the role of group cohesiveness as a vehicle for engaging patients in this
treatment; the patient’s family and peers are used as a therapeutic network, joining the pa-
tient and therapist at intervals in therapy sessions. This network is managed by the thera-
pist to provide cohesiveness and support, to undermine denial, and to promote compliance
with treatment. The author presents applications of the network technique designed to sus-
tain abstinence and describes means of stabilizing the patient’s involvement. Some specific
techniques discussed include ambulatory detoxification, disulfiram and naltrexone ad-
ministration, relapse prevention, and contingency contracting. Also discussed are recent
research on the use of psychiatric residents and counselors for treatment, and use of the
Internet in dissemination.

T he challenges of treating substance abusers in groups call for innova-

tive and creative approaches. Substance abusers are often difficult to
treat, with primitive defenses; poor affect control; inadequate object rela-
tions; and compulsive, self-destructive behavior. Their difficulties in af-
fect regulation and self-care have particularly been noted by Khantzian,
Halliday, and McAuliffe (1990). A number of authors have studied the
difficulties substance abusers have with attachments, both in the family
of origin with parents (Brook, Brook, Whiteman, Gordon, & Cohen,

Marc Galanter, M.D., is a Professor of Psychiatry and Director of the Division of Alcohol-
ism and Drug Abuse at New York University Medical Center.
David Brook, M.D., is on the faculty of Mount Sinai School of Medicine.

101
102 GALANTER AND BROOK

1990) and later in other relationships. Although group therapy has been
increasingly seen as the treatment of choice for these patients, many diffi-
culties block the path to successful group treatment (Vannicelli, 1982).
A number of group approaches have been devised with the goals of
helping substance abusers both achieve abstinence and prevent relapse
(Brook & Spitz, in press). These approaches, including harm reduction
approaches, have been based on cognitive-behavioral, psychodynamic,
attachment object relations, and family interactional theories, and have
been applied in both long- and short-term groups, time-limited groups,
and medication groups in a variety of inpatient and outpatient settings. A
number of therapists have used the work of Prochaska and DiClemente
(1985) on stages of change to model stepwise approaches to treatment.
Most authors have emphasized the therapeutic importance of develop-
ing and maintaining group cohesion and of working in the group’s pres-
ent (Flores, 1997; Yalom, 1985).
Because of the constraints of managed care, there has been an on-go-
ing effort to develop group approaches that are both therapeutically ef-
fective and cost-effective. There has been emphasis on outpatient treat-
ment and the application of specific methods and techniques to treat
appropriately patients along the spectrum of substance abuse and addic-
tion, from those needing detoxification to those requiring relapse pre-
vention and the maintenance of abstinence.
It has become clear that the more support an addict or abuser can mus-
ter, the greater the likelihood of achieving and maintaining abstinence,
as well as the possibility of achieving deeper characterological changes.
This understanding has been incorporated into the work of family thera-
pists (Kaufman & Kaufman, 1992; Liddle, Dakof, & Diamond, 1992),
who have used the family as a supportive and therapeutic group to
achieve positive change.
Multiple family group therapy (Kymissis & Halperin, 1996) has also
been useful in the treatment of adolescent substance abusers. Pressman
and Brook (1999) have used a multiple-group–based approach in the day
treatment of such difficult-to-treat adolescents. Of course, many sub-
stance abusers and addicts have either never established families or been
unable to maintain ongoing family structures because of their great diffi-
culties in relationships and in affect regulation. Such patients are often
said to have substituted relating to a substance of abuse for relating to
people. Because of the need to find healing relationships in groups for
 NETWORK THERAPY FOR ADDICTION 103

patients with poor family or social supports, a number of additional inno-

vative approaches have emerged.
One such approach is network therapy, in which the patient’s family
and peers form the group and act as the substrate for therapeutic change.
The group processes are similar to those occurring in the course of other
group approaches, but group cohesion and the use of the present in the
group take place in a specified step-wise fashion. Network therapy inte-
grates a variety of techniques from group and family approaches in its ef-
fort to use a practical method of office-based treatment for substance
abusers. This method of treatment has been in use for some time and re-
cently has been standardized and evaluated in a clinical research setting.
It attempts to achieve the cost-effective, as well as therapeutically effec-
tive, treatment of substance abusers, using an innovative group-based ap-
proach.
Managing addicted patients in office practice may, in fact, be less
costly than inpatient care, but reports on the relative effectiveness of
standard office practice have not been positive. In an early survey of psy-
chiatrists in practice, Hayman (1956) found that very few professed an
appreciable degree of success in treating alcoholics in office practice. No
difference in outcome was found when outpatients were offered individ-
ual therapy as a treatment added to medical monitoring alone
(Braunstein, Powell, McGowan, & Thoreson, 1983), nor was insight-ori-
ented therapy found to enhance the effectiveness of outpatient milieu
treatment for alcoholism (Olson, Ganley, Devine, & Dorsey, 1981). In
commenting on alcoholism treatment, Vaillant (1981) was similarly pessi-
mistic about the effectiveness of individual psychotherapy. As conven-
tionally practiced, individual therapy does not appear to be an effective
tool for addiction rehabilitation.
A number of issues, however, can be considered in formulating a new
approach to augment office-based therapy. Recent years have witnessed
both research-based and clinically based support for the importance of
securing abstinence as an initial step in addiction treatment rather than
awaiting results of an exploratory therapy (Gallant, 1987; Gitlow &
Peyser, 1980; Nathan & McCrady, 1986/87). This position has been
strengthened by the widespread acceptance of Alcoholics Anonymous
(AA), itself strongly oriented toward abstinence. To implement a regi-
men of abstinence, clinical researchers have developed a number of
structured techniques, focusing on cognitive-behavioral change (Annis,
1986; Marlatt & Gordon, 1985) and interpersonal support from family
104 GALANTER AND BROOK

and peers (Galanter, 1993; Kaufman & Kaufman, 1979; Stanton &
Thomas, 1982). These approaches can be adapted to an office practice
oriented toward individual therapy so as to secure abstinence and effec-
tive rehabilitation.
This integrated approach is called network therapy because it draws on
the supportive role of a group of family and peers introduced into ther-
apy sessions. It uses aspects of multiple family therapy as the members
come from different (but often related) family systems. Group and indi-
vidual interventions are based on the interactions among the different
network members, and employ primarily cognitive-behavioral tech-
niques. The term network derives from the work of Speck and Attneave
(1974), who used a large support group drawn from the patient’s family
and social network as a tool for psychiatric management. They used these
networks for both psychological and practical aid in addressing acute psy-
chiatric illness, so as to avert a hospitalization until the acute symptoms
remitted. Once mobilized, the network was then available to aid in ambu-
latory rehabilitation as well. Network therapy may be viewed as a special-
ized type of time-limited group therapy, addressing issues at the interface
of group and family therapies. To define what this approach must accom-
plish, though, it is first necessary to examine some unique characteristics
of the substance dependence syndrome.

CONDITIONING AND CONDITIONED CUES

For many clinicians, the problem of relapse and loss of control, embodied
in the first two criteria for substance dependence in DSM-IV (American
Psychiatric Association, 1994), epitomize the pitfalls inherent in addiction
treatment. Because addicted patients are typically under pressure to re-
lapse and ingest alcohol or drugs, they are seen as poor candidates for sta-
ble treatment. Loss of control has been used to describe addicts’ inability
to limit reliably consumption once an initial dose is taken.
These clinical phenomena are generally described anecdotally but can
be explained mechanistically as well by recourse to the model of condi-
tioned withdrawal, one that relates the pharmacology of depend-
ency-producing drugs to the behaviors they produce.
Wikler (1973) studied addicts maintained with morphine and then
thrown into withdrawal with a narcotic antagonist. After several trials of
precipitated withdrawal, he found that a full-blown withdrawal response
could be elicited in his subjects when a placebo antagonist was adminis-
 NETWORK THERAPY FOR ADDICTION 105

tered. He concluded that the withdrawal had been conditioned and was
later elicited by a conditioned cue, in this case the syringe used to admin-
ister the placebo. This hypothesized mechanism was later confirmed by
O’Brien, Testa, O’Brien, Brady, and Wells (1977), who elicited condi-
tioned withdrawal by using sound tones as conditioned cues. This con-
ception helps to explain addictive behavior outside the laboratory. A po-
tential addict who has begun to drink or use another drug heavily may be
exposed repeatedly to an external stimulus (such as a certain mood state)
while drinking; subsequent exposure to these cues may produce condi-
tioned withdrawal symptoms, subjectively experienced as craving.
This is why relapse is such a frequent and unanticipated aspect of ad-
diction treatment. Exposure to conditioned cues, ones that were repeat-
edly associated with drug use, can precipitate reflexive drug craving dur-
ing the course of therapy, and such cue exposure can also initiate a
sequence of unconditioned behaviors that lead addicts to relapse unwit-
tingly into drug use.
Loss of control can be the product of conditioned withdrawal, de-
scribed by Ludwig, Bendfeldt, Wikler, and Cain (1978) and long recog-
nized on a practical level by members of AA. The sensations associated
with the ingestion of an addictive drug, such as the odor of alcohol or the
euphoria produced by opiates, are temporally associated with the phar-
macologic elicitation of a compensatory response to that drug and can
later produce drug-seeking behavior. For this reason, the “first drink”
can serve as a conditioned cue for further drinking. Patients, therefore,
have a very limited capacity to control consumption once a single does of
drug has been taken.
A number of therapists have applied the principles of cognitive-behav-
ioral group therapy to the treatment of substance abusers (Beck, Wright,
Newman, & Liese, 1993; Liese, 1994). Cognitive-behavioral groups use
very specific methods to focus on the disturbed thinking patterns that
perpetuate substance abuse, helping patients to restructure the way they
think about their patterns of use, and to examine and change
maladaptive cognitive structures that lead to drug use.
Changes in mood state can become conditioned stimuli for drug seek-
ing, and the substance abuser can become vulnerable to relapse through
reflexive response to a specific affective state. Such phenomena have
been described clinically by Khantzian (1985) as self-medication. Such
mood-related cues, however, are not necessarily mentioned spontane-
ously by the patient in conventional therapy. This is because the trigger-
106 GALANTER AND BROOK

ing feeling may not be associated with a memorable event, and the drug
use may avert emergence of memorable distress.

GROUP COHESIVENESS AS A VEHICLE

FOR REINFORCING ABSTINENCE

Group cohesiveness is defined as the sum of all forces that act on members
of a group to keep them engaged (Cartwright & Zander, 1968). It can be an
important factor in binding a patient to the therapy context, even when
the patient is inclined to drop out. The concept of the curative effects of
group cohesion is well known in group therapy (Budman, & Gurman,
1988; Flores, 1997; Yalom, 1985). In relation to addiction rehabilitation,
group cohesion is particularly important as it is often the principal vehicle
for retaining the addicted patient in therapy when relapse is threatening. It
plays an important role in peer-led and established professional programs
for addiction, as well as in office-based addiction rehabilitation.
In studies of the emergence of cohesiveness in AA, emotional engage-
ment leads to an improvement in emotional wellbeing. This enhanced
wellbeing stabilizes conformity with the group’s norms, as compliance is
also operantly reinforced by a positive affective response to involvement
in the group (Galanter, 1990; Galanter, Talbott, Gallegos, & Rubenstone,
1990). Drug-free therapeutic communities also promote intense related-
ness among members as a vehicle for addiction rehabilitation (De Leon,
1989), as do the close ties within a given subculture.
AA in particular provides an example of how large group cohesiveness
can be highly influential in addiction rehabilitation. At AA meetings, re-
inforcements for group involvement and cohesion are regularly pro-
vided as members are given structured chances for interaction and ap-
proval by the group, both when they speak informally and when they
recount their histories at anniversaries of their sobriety. An individual
member develops close ties to a member who serves as a sponsor to su-
pervise recovery, and this relationship is a predictor of good outcome
(Emrick, 1989). Importantly, AA also illustrates the feasibility of combin-
ing strong cohesive ties with cognitive-behavioral techniques. For exam-
ple, members are inculcated to avoid the “persons, places and things”
that are cues to drinking; they also learn mottos and phrases that serve as
cognitive labels (Ludwig et al., 1978) for avoidance of problem attitudes
and situations. These aspects of the 12-step approach illustrate how the
labeling of cues for conditioned withdrawal can be wedded to a social
therapy, thereby enhancing the addict’s motivation to apply such label-
 NETWORK THERAPY FOR ADDICTION 107

ing in avoiding relapse. AA members are reinforced when they discuss

the avoidance of cues at AA meetings or with their sponsors in the organi-
zation. The 12-step approach of AA provides members with the opportu-
nity for personality change, as they “work the steps” to rebuild their lives
and relationships and help others following the admission of being pow-
erless to control their drinking.
Unfortunately, however, many addicted patients reject the option of
involvement in AA, and others have been found to drop out after their
initial meetings (Brandsma, Maultsby, & Welsh, 1980). Because of this,
there is a strategic advantage in a therapeutic approach that draws on pre-
existing cohesive ties—those of family and close friends—as a starting
point in treatment. This latter approach can also protect against early
dropping out, which might take place in a self-help group setting popu-
lated by relative strangers. It can also help the therapist encourage a re-
luctant patient to continue attendance at AA meetings.
Professionals can also draw on a network of cohesive relationships in
naturally occurring groups to enhance the outcome of treatment. For ex-
ample, an evaluation of the outcome of Speck and Attneave’s network
therapy for psychotic patients demonstrated that considerable benefit
derived from use of existing social ties to a family and friends
(Schoenfield, Halevey, & Hemley-van-der Velden, 1986). Enhanced out-
come was reported as well when the community reinforcement tech-
niques developed by Hunt and Azrin (1973) were augmented by greater
social relatedness in a club-like setting (Mallams, Godley, Hall, Meyers,
1982). Similarly, Galanter, Castaneda, and Salamon (1987) achieved
higher rates of retention and social recovery by integrating a peer-led for-
mat into a professionally directed alcohol treatment program.
Not surprisingly, the cohesiveness and support offered by group and
family therapy has been found effective in rehabilitating substance-abus-
ing patients. Yalom, Bloch, Bond, and Zimmerman (1978) reported on
the benefits derived when interactional group therapy was used as an ad-
junct to recovery techniques. According to Yalom (1985), these benefits
included a focus on understanding maladaptive interpersonal relation-
ships, an increase in cohesion, decreased symptoms, and decreased anxi-
ety. The curative factors in the group therapy of substance abusers have
been described by Flores (1997), who has stated that group therapy helps
build psychic structure and enhances an individual’s sense of self by pro-
viding “optimal frustration.” Curative factors that accomplish this goal
include cohesion, universality, hope building, mutual learning, altruism,
108 GALANTER AND BROOK

identification and feedback, catharsis, and self-understanding. These cu-

rative factors can play a role in treating addicts in a family or marital con-
text. Brook (1996) has written about the use of group cohesion to change
the balance between psychosocial risk and protective factors in a positive
direction to achieve therapeutic changes with these patients.
These approaches can be used in marital and family treatment set-
tings as well as in group approaches to the treatment of substance
abusers and addicts. Couples group therapy has also been shown to
benefit alcoholics and to diminish the likelihood of treatment drop-
out (Gallant, Rich, Bey, & Terranova, 1970; McCrady, Stout, Noel,
Abrams, & Fisher-Nelson, 1991). Even the counseling of spouses of al-
coholics in the absence of their alcoholic partners ultimately yielded
more effective treatment (Dittrich & Trapold, 1984). Observations
like these have led experienced clinicians to develop addiction reha-
bilitation techniques based on expertise in the practice of family ther-
apy and have yielded a number of clinical monographs on the use of
established family therapy techniques in addiction (Kaufman &
Kaufman, 1979; Stanton & Thomas, 1982; Steinglass, Bennett, Wolin,
& Reiss, 1987).

NETWORK THERAPY IN OFFICE PRACTICE

The model of network therapy for addiction (Galanter, 1987, 1993)

which introduces behavioral techniques and group cohesion into the on-
going treatment of the addicted patient, offers a pragmatic approach to
enhance the effectiveness of office management. It is based on the use of
family members, friends, and colleagues to form a supportive system, or
network, rather like a large extended family working together as an inter-
active and supportive group. As cohesion develops among the members
of the network, the members’ interventions and interactions in the con-
text of the network system help the addict break down denial, rationaliza-
tions, and projections that interfere with self-understanding and the
development of relationships with people to replace those with the ad-
dicting substance.
A cohabiting couple will provide the first example of how the natural
affiliative ties in a small (marital) network can be used to develop a secure
basis for rehabilitation. Couples therapy for addiction has been de-
scribed in both ambulatory and inpatient settings, and good marital ad-
justment has been found to be associated with a diminished likelihood of
 NETWORK THERAPY FOR ADDICTION 109

dropping out and a positive overall outcome (Dittrich & Trapold, 1984;
Galanter, 1987; Kaufman & Kaufman, 1979; McCrady et al., 1991; Noel,
McCrady, Stout, & Fisher-Nelson, 1987; Moos & Moos, 1984; Stanton &
Thomas, 1982).
Appropriate constructive engagement should be distinguished from a
co-dependent (Cermak, 1986) or overly involved interaction, which is
thought to be a problem in recovery. Indeed, couples managed with a be-
havioral orientation showed greater improvement in alcoholism than
those treated with interactional therapy, where attempts were made to
engage them in relational change (O’Farrell, Cutter, & Floyd, 1985).
Each member of the couple should have an appropriated and differenti-
ated role, so that the spouse is not placed in a position of pressing the pa-
tient to comply with treatment. One behaviorally oriented way for mak-
ing use of the marital relationship involves working with a couple to
change the nature of their relationship to enhance the effectiveness of
disulfiram therapy.
The use of disulfiram has yielded relatively little benefit overall in con-
trolled trials when patients are solely responsible for taking their doses,
largely because this agent is effective only when it is ingested as in-
structed, typically on a daily basis. Alcoholics who forget to take required
doses will likely, in time, resume drinking. Indeed, such forgetting often
reflects the initiation of a sequence of conditioned drug-seeking behav-
iors. The involvement of a spouse in observing the patient’s consumption
of disulfiram yields a considerable improvement in outcome (Azrin,
Sissan, Meyers, & Godley, 1982; Galanter, 1989; Keane, Fay, Nunn, &
Rychtarick, 1984). Patients alerted to taking disulfiram each morning by
this external reminder are less likely to experience conditioned drug
seeking when exposed to addictive cues and are more likely to comply on
subsequent days with the dosing regimen.
The technique also helps in clearly defining the roles in therapy of
both the alcoholic and spouse, typically the wife, by avoiding the spouse’s
need to monitor drinking behaviors she cannot control. The spouse does
not actively remind the alcoholic to take each disulfiram dose. She merely
notifies the therapist if she does not observe the pill being ingested on a
given day. Decisions about managing compliance are then shifted to the
therapist, and the couple does not become entangled in a dispute over
the patient’s attitude and the possibility of secret drinking. By means of
this technique, a majority of alcoholics in one clinical trial experienced
110 GALANTER AND BROOK

marked improvement and sustained abstinence over the period of treat-

ment (Galanter, 1993).
Spouses can also be engaged in history taking at the outset of treat-
ment to minimize the introduction of denial into the patient’s repre-
sentation of the illness (Liepman, Nierenberg, & Begin, 1989). The
initiation of treatment with such a technique is illustrated in the fol-
lowing case report.

Case Example

A 39-year-old alcoholic man was referred for treatment. Both the patient and his
wife were initially engaged by the psychiatrist in a telephone exchange so that all
three could plan for the patient to remain abstinent on the day of the first session.
They agreed that the wife would meet the patient at his office at the end of the
work day on the way to the appointment. This would ensure that cues presented
by his friends going out for a drink after work would not lead him to drink. In the
session, an initial history was taken both from the wife as well as from the patient,
allowing her to expand on the negative consequences of the patient’s drinking
thereby avoiding his minimizing of the problem. A review of the patient’s medical
status revealed no evidence of relevant organ damage, and the option of initiat-
ing his treatment with disulfiram at that time was discussed. The patient, with the
encouragement of his wife, agreed to take his first dose that day, continue under
her observation, and then be evaluated by his internist within a few days. Subse-
quent sessions with the couple were dedicated to dealing with implementation of
this plan, and concurrent individual therapy was initiated as well.

It is important to clarify certain aspects of engaging a collateral person

in the treatment, particularly a spouse. Long-standing conflicts between
members of an alcoholic couple should not be allowed to interfere with
the disulfiram monitoring. For example, the spouse should not be placed
in the marital network in a role demanding compliance. This is why the
patient is vested with the responsibility of ingesting the disulfiram so that
he is clearly seen by his spouse; her role is only to notify the therapist in a
telephone message if she does not see him taking his pill on a given morn-
ing. Discussions of compliance per se are therefore initiated by the thera-
pist and not by the spouse. In this way, the role of the spouse as enforcer
is eliminated, a role compatible with the approach suggested by Al-Anon,
which encourages the spouse to avoid responsibility for managing the
partner’s drinking problem.
 NETWORK THERAPY FOR ADDICTION 111

LARGER NETWORKS

In an evaluation of family treatment for alcohol problems reported by

the Institute of Medicine, McCrady concluded that research supported
superior outcomes for family-involved treatment and the modal ap-
proach should involve family members and carefully planned interven-
tions (Institute of Medicine, 1990). Indeed, the idea of the therapist’s
intervening with family and friends to start treatment was introduced by
Johnson (1986) as one of the early ambulatory techniques in the addic-
tion field (Gallant, 1987; Gitlow & Peyser, 1980). More broadly, the avail-
ability of greater social support to patients has been shown to be an
important predictor of positive outcome in addiction (McLellan, Woody,
Luborsky, O’Brien, & Druly, 1983).
The demonstrated utility of directive and behaviorally oriented ap-
proaches for preventing relapse might protect against an unstructured
exploration of the family as a system. There are, however, two options for
stabilizing abstinence: the ecologic and the problem-solving family treat-
ment. The ecologic approach, developed by Minuchin, Montalvo,
Guerney, Rusman, and Schumer (1967) and others, emphasizes the en-
gagement of resources from the patient’s family and social environment.
It presumes that the pathology is embedded in the broader social context
and acknowledges that this context must be used to effect recovery. Prob-
lem-solving family therapy, developed by Haley (1977) and others, relies
on an initial assessment of the principal presenting symptom; subse-
quent treatment using the family is directed at the problem itself rather
than primarily at restructuring the family relations. By means of these ap-
proaches, the therapist can develop an option for network treatment that
parallels the community reinforcement behavioral approach used in
multimodality clinics (Hunt & Azrin, 1973), using the power of group co-
hesion to effect behavioral change.

Case Example

Friends of a 46-year-old alcohol-dependent man sought out consultation to se-

cure his abstinence. On the therapist’s suggestion, they brought him along with
them to a conjoint session, where he avowed that he could stop drinking on his
own. An agreement was made among the network members, the patient, and the
psychiatrist that they would maintain contact so they could act together in case
112 GALANTER AND BROOK

the patient’s suggested approach did not succeed. Two months later, after the pa-
tient had required brief hospitalization for detoxification following a relapse into
drinking, members of the network prevailed on him to come for treatment. The
patient and network members then agreed that he would participate in individual
therapy and would meet with the network and therapist at regular intervals. The
patient suffered a relapse six months later; one of the network members con-
sulted the therapist and then stayed with the patient in his home for a day to en-
sure that he would not drink. He and other network members then brought the
patient to the psychiatrist’s office to reestablish a plan for abstinence.

This case illustrates how members of the network can help counter the
patient’s inclination to deny his drinking problem in the initial stages of
engagement and during relapse as well. It shows the value of the network
in providing the therapist with the means of communicating with a re-
lapsing patient and of assisting in reestablishment of abstinence.

Case Example

An alcoholic began one of his early network sessions by reporting a minor lapse
in abstinence. This was disrupted by an outburst of anger from his older sister
who said that she had “had it up to here” with his frequent unfulfilled promises of
sobriety. The therapist addressed this source of conflict by explaining in a didac-
tic manner how behavioral cues affect vulnerability to relapse. This didactic ap-
proach was adopted to defuse the assumption that relapse is easily controlled and
to relieve consequent resentment. He then led members in planning concretely
with the patient how he might avoid further drinking cues in the period preced-
ing their next conjoint session.

This case illustrates the importance of maintaining an appropriate

therapeutic milieu in the network sessions. In volunteering to partici-
pate, members agree to help the patient but not to subject their own mo-
tives to scrutiny. In this, the network format differs materially from the
systemic family therapy approach as it avoids subjecting network mem-
bers to the demand of addressing their own motives. The didactic or in-
tellectualized approach can therefore be helpful in neutralizing excessive
anger that may be felt toward the patient without scrutinizing the reasons
for a member’s anger.
In addition, the patient is expected to help maintain amicable rela-
tions with network members to protect the supportive milieu; this is
made explicit in both network and individual sessions. For example, if a
network member is absent for a few sessions, the patient is expected to
discuss the matter with that member and resolve any outstanding issues
 NETWORK THERAPY FOR ADDICTION 113

to promote the member’s return. Any difficulty the patient may experi-
ence in carrying out this role is viewed as an issue that acts as a resis-
tance to treatment and should be addressed in individual sessions.
The network is therefore conceived of as an active collaboration in
which conflicts are minimized through the use of a cognitive approach to
the group structure to ensure optimal function, as they would be on the
work site or in a sports team. Dealing with critical issues as they arise in
the present of the network group enhances group cohesion and team-
work. When led effectively, members are inclined to be effective team
members. They develop a positive transference toward the therapist and
are willing to support the therapist’s views.
It should be noted that related to the often primitive defenses used by
these patients (i.e. denial, projection), significant transference and
countertransference difficulties can arise. Group members can join to-
gether against the therapist to oppose the network structure. The thera-
pist must avoid becoming involved with the group members in a destruc-
tive way because of overprotective or punitive feelings elicited in
response to interactions in the group. Generally speaking, transference
issues should not be dealt with directly but should be responded to in the
context of the holding structure of the group. The group members
should be encouraged and helped to deal with such issues themselves to
minimize conflicts, whether between the group members themselves or
between a group member and the therapist.

THE CONTINGENCY CONTRACT

Contingency contracting, as used in behavioral treatment (Hall, Cooper,

Burmaster, & Polk, 1977), stipulates that an unpalatable contingency will
be applied if a patient carries out a prohibited symptomatic behavior.
Crowley (1984) successfully applied this technique to rehabilitating co-
caine addicts by preparing with each patient a written contact that stated
that a highly aversive consequence would be initiated for any use of the
drug. For example, for an addicted physician, a signed letter in which the
physician admitted addiction was prepared for mailing to the state licens-
ing board. The approach can be adapted to the network setting as well.

COMPLEMENTING INDIVIDUAL THERAPY

Even after the patient’s abstinence is apparently stable, it is important to

examine in therapy the patient’s thoughts about drinking, dreams related
114 GALANTER AND BROOK

to substance use, and responses to environmental drinking cues. They

alert the patient to the need to be aware of the long-term risk of relapse; in
addition, they provide revealing clues to ongoing conflicts, which may be
apparent only in their expression in the symbolism of addiction.
Although network sessions may be terminated before long-term indi-
vidual therapy comes to an end, it is essential to make clear that the net-
work members should be available if the patient experiences difficulties
in the future, as illustrated in the next case vignette.

Case Example

An alcoholic woman had been seen in network and individual sessions for 16
months and had been abstinent for a year. Because of her stability, a final network
session was scheduled with her husband and two friends. Discussion there ini-
tially focused on her successful recovery, evidenced by her beginning employ-
ment in the previous month. Those present then agreed that any of the network
members could contact the therapist if the patient relapsed in the future. The pa-
tient herself indicated that she herself would discuss any lapse in abstinence with
both the network members and therapist.

RECENT RESEARCH ON NETWORK THERAPY

An initial evaluation (Galanter, 1993) reviewed the treatment of 60 pa-

tients managed by him for dependence on various substances, primar-
ily alcohol, cocaine, and heroin. Ninety-two percent of the patients
were treated with a network, and a majority of the networks included
significant others (62%) and friends (51%). Parents, siblings, and chil-
dren participated less often. A large majority of the patients (77%)
achieved major or full improvement, meaning that they were abstinent
or had virtually eliminated substance use and that their life circum-
stances were materially improved and stable. Using this criterion for
improvement and DSM-IV diagnostic criteria, patients with mild or
moderate severity of drug use were found to be more likely to achieve
success than those with severe dependence (93% vs. 61%). Neither a
patient’s choice of drug, nor regular AA attendance, was associated
with relative success. A majority of patients (16 of 21) whose primary
drug was alcohol were offered disulfiram (Antabuse), observed by a
network member. Acceptance of disulfiram was significantly associ-
ated with major or full improvement in almost all cases (14 of the 16)
relative to refusal to take the disulfiram, which was more often associ-
ated with only moderate improvement (4 of 6).
 NETWORK THERAPY FOR ADDICTION 115

Given the treatment’s relative success in this trial, a more extensive de-
velopmental study was supported by the National Institute on Drug
Abuse (Galanter, Keller, & Dermatis, 1997). The technique was standard-
ized for inter-rater reliability and distinction from a systematic treatment
approach. A 122-page training manual was then developed and
post-graduate year 3 residents in psychiatry naive to ambulatory addic-
tion treatment were given a 13-session seminar on network therapy.
Their treatment was videotaped to monitor compliance with the tech-
nique; the outcome of the patients, chosen for dependence on cocaine,
was evaluated. The average length of treatment was 15.4 weeks, and pa-
tients participated in an average of 9.5 network sessions and 11.3 individ-
ual sessions. Of the total of 262 random observed urinalyses, 79% were
negative for cocaine; 67% of the subjects produced three consecutive
weekly urines free of cocaine; and 42% of subjects produced cocaine-free
urines in their last three urines prior to termination. In reviewing compa-
rable studies in the medical literature on the outcome of outpatient care
for cocaine dependence, these novice addiction therapists were found to
perform as well or better than experienced practitioners employing dif-
ferent techniques (Carroll et al., 1994; Higgins, Budney, Bickel, Hughes,
Georg, & Badger, 1993; Schoptaw, Rawson, McCann, & Olbert, 1994).
In another study (Keller & Galanter, 1999), treatment was conducted
by counselors in a community-based program. Patients managed with or
without network therapy were compared. A greater portion of the net-
work-treated urines were negative for drugs of abuse (94 of 107) than
were those of the controls (54 of 82). Furthermore, there was a trend to-
ward longer retention in treatment for the network patients (13.9 weeks)
than for the controls (10.7 weeks). This suggests that the approach is ap-
plicable for community-based nondoctoral counselors.
Astudy is now being conducted on the efficacy of network therapy for
heroin addicts for promoting induction onto buprenorphine and later
discontinuation from maintenance. Subjects treated with conventional
counseling and subjects receiving network therapy will be compared in
terms of effectiveness of achieving a drug-free state.

PRINCIPLES OF NETWORK TREATMENT

Listed below is an abstract for applying Network Therapy in practice. It

can be adapted to the needs of a given patient and to the relative availabil-
ity of potential network members.
116 GALANTER AND BROOK

Start a Network as Soon as Possible

1. It is important to see the alcohol or drug abusers promptly because the window
of opportunity for openness to treatment is generally brief. A week’s delay can
result in a person’s reverting back to drunkenness or losing motivation.
2. If the person is married, engage the spouse early on, preferably at the time of
the first phone call. Point out that addiction is a family problem. For most
drugs, you can enlist the spouse in ensuring that the patient arrives at your
office with a day’s sobriety.
3. In the initial interview, frame the exchange so that a good case is built for the
grave consequences of the patient’s addiction, and do this before the patient
can introduce his or her system of denial. That way you are not putting the
spouse or other network members in the awkward position of having to con-
tradict a close relation.
4. Make it clear that the patient needs to be abstinent, starting now. (A tapered
detoxification may be necessary sometimes, as with depressant pills.)
5. When seeing an alcoholic patient for the first time, begin disulfiram treat-
ment as soon as possible, in the office if you can. Have the patient continue
taking disulfiram under observation of a network member.
6. Start arranging for a network to be assembled at the first session, generally
involving a number of the patient’s family or close friends.
7. From the very first meeting, consider how to ensure sobriety until the next
morning, and plan that with the network. Initially, their immediate company,
a plan for daily AA attendance, and planned activities may all be necessary.

Manage the Network with Care

1. Include people who are close to the patient, have a longstanding relationship
with him or her, and are trusted. Avoid members with substance problems,
because they will let you down when you need their unbiased support. Avoid
superiors and subordinates at work, because they have an overriding rela-
tionship with the patient independent of friendship.
2. Get a balanced group. Avoid a network composed solely of the parental gen-
eration or of younger people or of people of the opposite sex. Sometimes a
nascent network selects itself for a consultation if the patient is reluctant to
address his or her own problem. Such a group will later supportively engage
the patient in the network with your careful guidance.
3. Make sure that the mood of meetings is trusting and free of recrimination.
Avoid letting the patient or the network members be made to feel guilty or
angry in meetings. Explain issues of conflict in terms of the problems pre-
sented by addiction—do not get into personality conflicts.
4. The tone should be directive. That is to say, give explicit instructions to sup-
port and ensure abstinence. A feeling of teamwork should be promoted,
with no psychologizing or impugning members’ motives.
5. Meet as frequently as necessary to ensure abstinence, perhaps once a week
for a month, every other week for the next few months, and every month or
two by the end of a year.
 NETWORK THERAPY FOR ADDICTION 117

6. The network should have no agenda other than to support the patient’s ab-
stinence. But as abstinence is stabilized, the network can help the patient
plan for a new drug-free adaptation. The network does not exist to work on
family relations or to help other members with their problems, although it
may do this indirectly.

Keep the Network’s Agenda Focused

1. Maintaining abstinence. At the outset of each session, the patient and the net-
work members should report any exposure of the patient to alcohol and
drugs. The patient and network members should be instructed on the nature
of relapse and plan with the therapist how to sustain abstinence. Cues to con-
ditioned drug-seeking should be examined.
2. Supporting the network’s integrity. Everyone has a role in this. The patient is
expected to make sure that network members keep their meeting appoint-
ments and stay involved with the treatment. The therapist sets meeting times
and summons the network for any emergency, such as relapse; the therapist
does whatever is necessary to secure stability of the membership if the pa-
tient is having trouble doing so. Network members’ responsibility is to at-
tend network sessions, although they may be asked to undertake other
supportive activity with the patient.
3. Securing future behavior. The therapist should combine any and all modalities
necessary to ensure the patient’s stability, such as a stable, drug-free resi-
dence; the avoidance of substance abusing friends; attendance at 12-step
meetings; medications, such as disulfiram or blocking agents; observed uri-
nalysis; and ancillary psychiatric care. Written agreements, such as mutually
acceptable contingency contract with penalties for violation of understand-
ings, may be handy.

Make Use of AA and Other Self-Help Groups

1. Patients should be expected to go to AA meetings or related groups at least

two to three times, with follow-up discussion in therapy.
2. If patients have reservations about these meetings try to help them under-
stand how to deal with them. Issues like social anxiety should be explored if
they make a patient reluctant to participate. Generally, resistance to AA can
be related to other areas of inhibition in a person’s life as well as to the denial
of addiction.
3. As with other spiritual involvements, do not probe the patients’ motivation
or commitment to AA once engaged. Allow them to work out things on their
own, but be prepared to listen.

CONCLUSIONS

The model of addictive behavior and office-based group treatment pre-

sented here deals with the influence of pharmacologically conditioned
118 GALANTER AND BROOK

drinking cues on relapse into substance dependence, and it uses a cogni-

tive-behavioral group approach to averting relapse. To engage addicted
patients while treatment is applied and to motivate them to overcome the
effect of addictive cues, a network of persons close to the patient can be
brought into the therapy sessions and augment the individual treatment.
Specific network techniques draw on the variety of relationships among
the patient, family, and peers.

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Marc Galanter, M.D. Received: July 15, 1999

550 First Avenue Revision Received: May 2, 2000
New York, NY 10016 Accepted: May 4, 2000