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THE GUILFORD PRESS
Group Therapy for Substance use Disorders
Group Therapy
for Substance Use
Disorders
A Motivational
Cognitive-Behavioral Approach
Linda Carter Sobell

Mark B. Sobell
THE GUILFORD PRESS

New York London
© 2011 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com
All rights reserved
Except as noted, no part of this book may be reproduced, translated, stored in a retrieval
system, or transmitted, in any form or by any means, electronic, mechanical, photocopying,
microfilming, recording, or otherwise, without written permission from the publisher.
Printed in the United States of America
This book is printed on acid-free paper.
Last digit is print number: 9 8 7 6 5 4 3 2 1
LIMITED PHOTOCOPY LICENSE
These materials are intended for use only by qualified professionals.
The publisher grants to individual purchasers of this book nonassignable permission to

reproduce all materials for which photocopying permission is specifically granted in a
footnote. This license is limited to you, the individual purchaser, for personal use or use
with individual clients. This license does not grant the right to reproduce these materials
for resale, redistribution, electronic display, or any other purposes (including but not
limited to books, pamphlets, articles, video- or audiotapes, blogs, file-sharing sites,
Internet or intranet sites, and handouts or slides for lectures, workshops, webinars, or
therapy groups, whether or not a fee is charged). Permission to reproduce these materials
for these and any other purposes must be obtained in writing from the Permissions
Department of Guilford Publications.
The authors have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the standards of practice that are
accepted at the time of publication. However, in view of the possibility of human error or
changes in behavioral, mental health, or medical sciences, neither the authors, nor the editor
and publisher, nor any other party who has been involved in the preparation or publication
of this work warrants that the information contained herein is in every respect accurate or
complete, and they are not responsible for any errors or omissions or the results obtained from
the use of such information. Readers are encouraged to confirm the information contained in
this book with other sources.
Library of Congress Cataloging-in-Publication Data

Sobell, Linda C.
Group therapy for substance use disorders : a motivational cognitive-behavioral approach /
Linda Carter Sobell, Mark B. Sobell.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-60918-051-5 (pbk.: alk. paper)
1. Substance abuse—Treatment. 2. Group psychotherapy. 3. Motivational
interviewing. 4. Cognitive therapy. I. Sobell, Mark B. II. Title.
[DNLM: 1. Substance-Related Disorders—therapy. 2. Psychotherapy, Group—
methods. WM 270 S677g 2011]
RC564.S567 2011
616.89′152—dc22
2010025130
This book is dedicated to four very special people in our lives.
First, to Mark’s mother, Mollie, and to Linda’s grandmother, Sadie,

who had a major influence on each of our lives.
We only wish they were still here so we could share this with them.
Second, to our daughters and special friends, Stacey and Kimberly,

who have enriched our lives in so many ways.
About the Authors
Linda Carter Sobell, PhD, ABPP, is Professor and Associate Director of Clinical Training at
the Center for Psychological Studies at Nova Southeastern University (NSU) in Fort Lauder-
dale, Florida. She is also Co-Director of the Guided Self-Change Clinic at NSU. For 17 years
she was a Senior Scientist at the Addiction Research Foundation (Canada) and a Professor at
the University of Toronto. A Fellow of the American Psychological Association, a Motivational
Interviewing Trainer, and a Diplomate in Cognitive and Behavioral Psychology of the American
Board of Professional Psychology, Dr. Sobell is nationally and internationally known for her
research in the addictions field, particularly brief motivational interventions, the process of self-
change, and the Timeline Followback. She has given more than 300 invited presentations and
workshops, published more than 275 articles and book chapters, authored seven books, serves
on several editorial boards, and for over three decades has been the recipient of grants from
several federal agencies. She is past president of the Association for Behavioral and Cognitive
Therapies and of the Society of Clinical Psychology of the American Psychological Association.
Among Dr. Sobell’s awards are the Betty Ford Award from the Association for Medical Educa-
tion and Research in Substance Abuse, the Norman E. Zinberg Memorial Award from Harvard
University, the Distinguished Scientific Contribution Award from the Society of Clinical Psy-
chology of the American Psychological Association, the Lifetime Achievement Award from the
Addictions Special Interest Group of the Association for Behavioral and Cognitive Therapies,
the Brady/Schuster Award for outstanding behavioral science research in psychopharmacology
and substance abuse from Division 28 of the American Psychological Association, and the 2008
Charles C. Shepard Science Award for the most outstanding peer-reviewed research paper on
prevention and control published by Centers for Disease Control and Prevention/Agency for
Toxic Substances and Disease Registry scientists.
Mark B. Sobell, PhD, ABPP, is Professor and Co-Director of the Guided Self-Change Clinic at
the Center for Psychological Studies at NSU. For 16 years he was a Senior Scientist at the Addic-
tion Research Foundation (Canada) and a Professor at the University of Toronto. A Diplomate
vii
viii About the Authors
in Cognitive and Behavioral Psychology of the American Board of Professional Psychology, Dr.
Sobell is nationally and internationally recognized for his work in the area of addictive behav-
iors, particularly brief motivational interventions, the process of self-change, and the Timeline
Followback. He has given more than 200 invited presentations and workshops, published more
than 275 articles and book chapters, authored six books, serves on several editorial boards, and
for over three decades has been the recipient of grants from several federal agencies. He was
Acting Editor of the Journal of Consulting and Clinical Psychology and is currently Associate
Editor of Psychology of Addictive Behaviors and the Journal of Consulting and Clinical Psy-
chology. Among Dr. Sobell’s awards are the Distinguished Scientific Contribution Award from
the Society of Clinical Psychology of the American Psychological Association, the 2008 Charles
C. Shepard Science Award, the Lifetime Achievement Award from the Addictions Special Inter-
est Group of the Association for Behavioral and Cognitive Therapies, and the Jellinek Memorial
Award for outstanding contributions to knowledge in the field of alcohol studies.
Preface
This book emerges from a study we conducted comparing our Guided Self-Change (GSC) treat-
ment model (M. B. Sobell & Sobell, 1993a, 2005) delivered in a group with individual therapy
(L. C. Sobell, Sobell, & Agrawal, 2009). Although our initial intent was to develop, validate, and
successfully extend the GSC treatment model used in individual therapy to a group setting, as
discussed in Chapter 1, that extension presented some unexpected challenges.
Our objectives in writing this book were (1) to describe how to effectively conduct and
manage the dynamics of interpersonal interactions in groups (e.g., structure of groups, develop-
ing cohesion, handling difficult clients) with clients with substance use disorders; (2) to dem-
onstrate how to integrate the basic principles of cognitive-behavioral therapy and motivational
interviewing into group therapy; (3) to discuss how to manage difficult and challenging clinical
situations and issues that arise when conducting groups; and (4) to present a brief overview of
the treatment outcome results of our randomized clinical trial comparing the GSC treatment
model in group and individual formats. In the latter regard, this book provided an opportunity
to update the GSC treatment that was presented in our earlier book (M. B. Sobell & Sobell,
1993a).
The terms patient and client are used interchangeably throughout this book, as both terms
are used in clinical psychology and behavioral health. When presenting clinical examples, we
have removed all identifying information, and for consistency we refer to male clients as Bill and
to female clients as Mary.
Integration of Clinical Material and Dialogue

into the Text
Almost all of the clinical materials and questionnaires, as well as therapist and client handouts,
are integrated into the chapters rather than included as appendices. This makes the clinical
material more user friendly, clinically useful, and easier to access. Chapter 3 describes the
assessment with a discussion of the clinical utility of the measures and instruments used, includ-
ing sample therapist dialogues illustrating how to discuss the assessment with clients. Chapter
ix
x Preface
4 discusses the GSC treatment delivered in an individual format and provides session outlines
for therapists that include objectives, procedures, and materials and handouts needed. Chapter
5 similarly presents session outlines for therapists for each group session. In addition, Chapter 5
includes sample round-robin discussions. Clinical examples are included throughout the book,
and particularly in Part II, that demonstrate (1) how to implement the GSC treatment model
in both individual and group therapy and (2) how to integrate cognitive-behavioral and moti-
vational interviewing strategies and techniques into group therapy, including the assessment
measures and questionnaires and associated motivational interviewing feedback materials.
Intended Audience
This book has two intended audiences. The first is practitioners and clinicians who are already
treating individuals with substance use problems and who want to learn how to successfully
integrate cognitive-behavioral and motivational interviewing techniques into group therapy.
The second audience is practitioners and clinicians not in the substance abuse field who want
to learn more about how to conduct and manage the dynamics of interpersonal interactions in
groups and how to integrate cognitive-behavioral and motivational interviewing principles and
techniques into group therapy. We hope that those reading this book will come away with an
appreciation that, although group therapy is more complex and challenging than individual
therapy, it is also extremely rewarding and can accomplish things not easily achieved in indi-
vidual treatment.
Acknowledgments
This book is based on a randomized clinical trial that evaluated the Guided Self-Change (GSC)
treatment model in a group- versus an individual-therapy format. It was conducted when we
directed the GSC Unit at the Addiction Research Foundation in Toronto, Canada. We wish to
thank Dr. Joan Marshman, who at the time was the Foundation President, and the GSC staff,
who contributed to the success of the study (in alphabetical order): Sangeeta Agrawal, Margaret
Beardwood, Diane Benedek, Curtis Breslin, Joanne Brown, Barbara Bruce, Giao Buchan, Car-
ole Bush, Virginia Chow, Pat Cleland, John Cunningham, Judy Dobson, Doug Gavin, Joanne
Jackson, Lisa Johnson-Young, Mel Kahan, Even Kwan, Gloria Leo, Eric Rubel, Lorna Sagorsky,
Kathy Sdao-Jarvie, Peter Selby, Jennifer-Ann Shillingford, Joanne Spratt, Kathy Voros, Peter
Voros, Lynn Wilson, and Kim Zynck. In addition, we want to thank all our doctoral students
at the Center for Psychological Studies at Nova Southeastern University in Fort Lauderdale,
Florida, who, as part of their training, were supervised by us in the conduct of group therapy.
Because of that supervision over the past 12 years, we have continued to refine our approach
to conducting group therapy and to applying motivational interviewing techniques in a group
setting.
Several years ago, we attended two workshops presented by Dr. Robert Dies that greatly
influenced our approach to group therapy. As will be evident after reading this book, what
influenced us most were the concepts of Think Group, the Music Comes from the Group, and
Therapists as Conductors. Furthermore, his suggestions for handling difficult and challenging
clients and group situations have proven invaluable. A special thanks to Anaeli Ramos, Jessica
Ruiz, Rachael Silverman, and Andrew Voluse for their help with the preparation of the book
manuscript. Thanks to Sir Meowy for keeping us company and sitting on the manuscript pages
late at night. In addition, we want to thank the many clients who over the years participated in
our groups, as they taught us a great deal about groups and group processes. Dr. Beverly Thorn’s
book Cognitive Therapy for Chronic Pain (2004) also provided some very useful ideas about how
to present the clinical materials in this book.
xi
xii Acknowledgments
We also are indebted to William R. Miller, a consummate scientist/clinician, who master-

fully formalized the major elements of motivational interviewing. Motivational interviewing
has been an increasingly important component of our approach and is an important pillar of the
treatment approach in this book.
Last, we are indebted to Jim Nageotte, our editor at The Guilford Press, for his patience
and support. Although, from our perspective, the final product was never in doubt, it took far
longer to complete than we anticipated. In this regard, we want to thank Jim for not abandoning
this project. Finally, a special thanks to an anonymous reviewer of the book manuscript whose
detailed comments led to a more reader-friendly and clinically useful book.
Contents
List of Figures, Tables, and Therapist and Client Handouts xvii
Part I. Rationale, Research, and Assessment
Chapter 1. Guided Self-Change Treatment and Its Successful Extension 3

to Group Therapy
Influences on the Development of the GSC Treatment Model 4
The GSC Treatment Model Compared with Other Cognitive-Behavioral
Interventions for SUDs 4
Brief Review of Studies Comparing Group and Individual Treatments for SUDs 5
General Framework of the GSC Treatment Model 9
Extending the GSC Treatment Model to a Group Format 9
How Well Does GSC Work? 10
Dissemination of the GSC Treatment Model: From Bench to Bedside 21
Overview of This Book 23
Chapter 2. Overview of Motivational Interviewing Strategies and Techniques 25

Historical Development of Motivational Interviewing 25
What Is Motivational Interviewing? 26
Motivational Interviewing Strategies and Techniques 29
Summary 41
Chapter 3. Assessment: A Running Start for Treatment 42

Using a Motivational Interviewing Approach to Start the Assessment 42
Assessment Measures and Questionnaires: Description and Utility 43
Utility of Homework Exercises 49
Homework Assignments Given to Clients at the Assessment Session 50
Ending the Assessment Session: What Stood Out? 54
Summary 54
xiii
xiv Contents
Part II. Guided Self-Change: A Motivational Cognitive-Behavioral

Intervention for Individual and Group Therapy
Chapter 4. Guided Self-Change Treatment in an Individual Format 81

Session 1 81
Session 2 88
Session 3 96
Session 4 97
Summary 100
Chapter 5. Integrating Motivational Interviewing and Cognitive-Behavioral Techniques 148

into Group Therapy
The Power of the Group: Capitalizing on Group Processes 149
Adaptation of the GSC Treatment Model 150
Round-Robin Discussions 153
Integrating Motivational Interviewing Strategies and Techniques into a Group
Format Using Round-Robin Discussions 157
Preparing Potential Group Members during the Assessment 162
Group Therapy Can Be Limited by Cultural or Other Factors 163
Summary 163
PART III. Conducting and Managing Groups: Pregroup Planning,

Group Cohesion, and Difficult Situations and Clients
Chapter 6. Building Group Cohesion: Music Comes from the Group 189
Group Preparation and Planning 189
Group: A Living, Learning Hall of Mirrors 191
Music Comes from the Group: Therapists as Orchestra Conductors 191
Cohesion: A Potent Force in Group Therapy 192
Summary 195
Chapter 7. Managing Groups: Structural Issues 196

Assembling Groups 197
Session Structure: Length and Size 199
The Role of Cotherapists/Group Leaders 199
Selecting Group Members: Composition and Balance 200
Other Significant Group Issues 200
Termination of Groups 202
Summary 202
Chapter 8. Managing Difficult Clients in Groups 203

Think Group: Interrupting Clients for the Greater Good 203
Balancing Voices in the Group 205
Managing Conflict and Calling Timeouts 206
Self-Disclosure 207
Personalizing Problems Using Affect 209
Summary 209
Contents xv
Chapter 9. The Way Ahead 210

Putting Cost-Effective Treatments into Practice 210
Are Groups Cost-Effective? 212
Where Is the Training? 212
Group Therapy: The Wave of the Future 213
Summary 213
APPENDICES
Appendix A. AUDIT Questionnaire 217
Appendix B. Drug Use Questionnaire (DAST-10) 219
Appendix C. Drug Use History Questionnaire 221
Appendix D. Brief Situational Confidence Questionnaire (BSCQ) 222
References 225
Index 235
List of Figures, Tables, and Therapist
and Client Handouts
Figures
FIGURE 1.1. Percent of days abstinent during pretreatment, within treatment, and 13
posttreatment for problem drinkers assigned to individual- and group-
treatment conditions.
FIGURE 1.2. Mean number of standard drinks per drinking day during pretreatment, 14
within treatment, and posttreatment for problem drinkers assigned to
individual- and group-treatment conditions.
FIGURE 1.3. Percent of days drinking at different levels during pretreatment, within 15
treatment, and posttreatment for problem drinkers.
FIGURE 1.4. Percent of days abstinent from drugs during pretreatment, within treatment, 16
and posttreatment for all drug abusers, and separately for cocaine and
cannabis abusers.
FIGURE 4.1. Cognitive components of the relapse prevention model. 89
FIGURE 4.2. Sample graphs of the six BSCQ profiles. 92
FIGURE 9.1. Stepped-care model of treatment. 211
Tables
TABLE 1.1. Major Ways the GSC Treatment Model Differs from Other 5
Cognitive-Behavioral Interventions for SUDs
TABLE 1.2. RCTs of the Same Treatment Delivered in Group versus Individual Formats 7
for SUDs
TABLE 1.3. Summary of Outcome Studies Evaluating the GSC Treatment Model 12
for Clients with Alcohol Problems
xvii
xviii List of Figures, Tables, and Therapist and Client Handouts
TABLE 1.4. Clients’ End-of-Treatment Ratings of Treatment by Condition (Individual 17

or Group) and by Primary Substance Problem (Alcohol or Drug)
TABLE 1.5. Clients’ Evaluations of Treatment at the 12-Month Follow-Up by Condition 19

(Individual or Group) and by Primary Substance Problem (Alcohol or Drug)
TABLE 1.6. Therapists’ Evaluations of Clients by Condition (Individual or Group) 22

and by Primary Substance Problem (Alcohol or Drug)
TABLE 2.1. Benefits of Quitting Smoking Timeline 37
TABLE 3.1. Measures and Questionnaires Used in GSC Treatment for Individual 44
and Group Therapy
TABLE 4.1. Personalized Feedback Materials Given to Clients during Sessions 1–4 82
TABLE 4.2. BSCQ: Eight Categories of High-Risk Situations and Shorthand Names 91
of Profiles
TABLE 5.1. Round-Robin Discussion Topics Used in the GSC Group Treatment 154
TABLE 5.2. Ways to Bring Different Members and Topics into Group Discussions 155
TABLE 5.3. Group Rules and Their Rationales 167
TABLE 6.1. Tasks for Cotherapists Prior to Each Group Therapy Session 190
TABLE 6.2. Empirically Supported Principles Regarding the Therapeutic Relationship 194
in Group Treatment
TABLE 7.1. Advantages and Disadvantages of Group versus Individual Therapy 196
TABLE 8.1. Suggestions for Responding to Difficult Clients in Groups 204
Therapist Handouts
Therapist Handout 3.1. Objectives, Materials Needed, Procedures, and Client 55

Handouts: Assessment Session for Group and Individual
Therapy
Therapist Handout 3.2. Timeline Followback Instructions and Sample Calendar 57

for Alcohol Use
Therapist Handout 3.3. Timeline Followback Instructions and Sample Calendar 59

for Drug Use
Therapist Handout 4.1. Objectives, Procedures, Client Handouts, and Clinical 101
Guidelines and Dialogues: Individual Session 1
List of Figures, Tables, and Therapist and Client Handouts xix
Therapist Handout 5.1. Objectives, Procedures, Client Handouts, Pregroup Planning, 164
and Sample Round-Robin Discussions: Group Session 1
Client Handouts
Client Handout 3.1. Decisional Balance Exercise 61
Client Handout 3.2. Self-Monitoring Logs for Alcohol Use 64
Client Handout 3.3. Self-Monitoring Logs for Drug Use 69
Client Handout 3.4. Abstinence Goal Evaluation for Alcohol or Drugs 73
Client Handout 3.5. Goal Choice Evaluation for Alcohol Use 75
Client Handout 3.6. Where Are You Now Scale 78
Client Handout 4.1. Personalized Feedback: Where Does Your Alcohol Use Fit In?: 115
Individual and Group Session 1
Client Handout 4.2. Personalized Feedback: Where Does Your Drug Use Fit In?: 118
Individual and Group Therapy Session 1
Client Handout 4.3. Example of Personalized Alcohol Use Feedback Pretreatment 133
to Session 4: Individual and Group Session 4
Client Handout 4.4. Example of Personalized Drug Use Feedback Pretreatment 134
to Session 4: Individual and Group Session 4
Client Handout 4.5. Reading on Identifying Triggers: Individual and Group Session 2 135
Client Handout 4.6. Exercise on Identifying Triggers: Individual and Group Session 2 138
Client Handout 4.7. Sample BSCQ Alcohol or Drug Use Profile from the Assessment: 141
xx List of Figures, Tables, and Therapist and Client Handouts
Client Handout 4.8. Exercise on Developing New Options and Action Plans: 142
Client Handout 4.9. Sample BSCQ Alcohol or Drug Use Profile from the Assessment 146
and Session 3: Individual and Group Session 4
Client Handout 4.10. Request for Additional Sessions: Individual and Group Session 4 147
Client Handout 5.1. Introduction to Groups 185

Part I
Rationale, Research, and Assessment

Chapter 1
Guided Self-Change Treatment and Its

Successful Extension to Group Therapy
A persuasive body of outcome research has demonstrated unequivocally that

group therapy is a highly effectively form of psychotherapy and that it is at least
equal to individual psychotherapy in its power to provide meaningful benefit.
—Yalom and Leszcz (2005, p. 1)
This chapter lays the foundation for the rest of this book by (1) reviewing the development of the
Guided Self-Change (GSC) treatment model and the several lines of research that influenced
the model; (2) comparing the GSC treatment model with other cognitive-behavioral interven-
tions for substance use disorders; (3) discussing how the GSC treatment model was successfully
disseminated throughout the community in which it was originally developed; and (4) present-
ing the results of the randomized controlled trial (RCT) that successfully extended the GSC
treatment model developed as an individual treatment to a group therapy format.
The GSC treatment model was an outgrowth of our earlier research on outpatient treatment
of problem drinkers. In comparison with more severely dependent drinkers, problem drinkers
are not physiologically dependent on alcohol, tend to have had a problem for fewer years, are
usually employed, have a supportive environment, and are very resistant to traditional labels
such as alcoholic or drug addict. These differences are described in detail in our earlier book,
Problem Drinkers: Guided Self-Change Treatment (M. B. Sobell & Sobell, 1993a). Although
the GSC treatment model was developed for English-speaking problem drinkers, it has been
extended to and evaluated with drug abusers whose problems are not severe (L. C. Sobell et
al., 2009; L. C. Sobell, Wagner, Sobell, Agrawal, & Ellingstad, 2006) and to Spanish-speaking
alcohol abusers (Ayala, Echeverría, Sobell, & Sobell, 1997, 1998; Ayala-Velazquez, Cardenas,
Echeverría, & Gutierrez, 1995). The findings of our study comparing GSC delivered in a group
versus an individual-treatment format and extending the GSC treatment model to drug abusers
are presented in this chapter, as is a summary of a previous review of several studies that evalu-
ated the GSC treatment model and adaptations of that model (M. B. Sobell & Sobell, 2005).
3
4 RATIONALE, RESEARCH, AND ASSESSMENT
Influences on the Development of the GSC Treatment Model
As reviewed elsewhere (M. B. Sobell & Sobell, 1993a, 2005), several lines of research influ-
enced the development of the GSC treatment model. The first major influence derived from
epidemiological research conducted in the 1970s showing that many individuals had alcohol
problems that were not severe (e.g., Cahalan & Room, 1974; Schuckit, Smith, Danko, Bucholz,
& Reich, 2001; M. B. Sobell & Sobell, 1993b). Consistent with other health problems, it seemed
reasonable to think such individuals might benefit from a less intense, briefer intervention com-
pared with individuals with more severe alcohol problems. Related to this was research on
problem drinkers’ preferences for moderation goals (Heather & Robertson, 1981; Marlatt et al.,
1985; Miller, 1986–1987).
Another important influence on the development of the GSC treatment model was a study
by Edwards and his colleagues (1977) that found that one session of advice or counseling pro-
duced the same outcomes as a comprehensive treatment. Furthermore, individuals randomly
assigned to either condition generally showed considerable improvement. Although the major-
ity of cognitive-behavioral studies until that time had emphasized skills training, improvement
following a single session could not be explained by skills training. Rather, the most likely expla-
nation was that many individuals have the capacity to change their substance abuse problem
if sufficiently motivated and that the single session catalyzed their motivation. Such thinking
is supported by research on the phenomenon of self-change (i.e., natural recovery) that has
shown that many people with alcohol and drug problems can successfully change on their own
(reviewed in Klingemann & Sobell, 2007).
Bandura’s (1977, 1986) social cognitive theory was another influence on the development
of the GSC treatment model, as it suggested that self-efficacy, outcome expectations, and goal
choice might be important determinants of motivation. Many individuals with substance use
disorders (SUDs), especially those whose problems are not severe, are ambivalent about the need
to change. In this regard, another influence was the development of motivational interviewing, a
therapeutic approach put forth by Miller and his colleagues to minimize resistance and increase
clients’ motivation to change (Miller, 1983; Miller & Rollnick, 1991, 2002). The motivational
interviewing approach was consistent with Prochaska and DiClemente’s (1984) transtheoretical
model of change that conceptualized motivation as a state and targeted increasing motivation
for change as a focus of therapy. For these reasons, motivational interviewing has become the
recommended counseling style for developing a therapeutic alliance with clients (Kazdin, 2007;
Meier, Barrowclough, & Donmall, 2005; Moyers, Miller, & Hendrickson, 2005).
The GSC Treatment Model Compared

with Other Cognitive-Behavioral Interventions for SUDs
The GSC intervention reflects a synergy of time-tested cognitive-behavioral strategies that are
delivered using motivational interviewing techniques (e.g., rolling with resistance, decisional
balance exercise, readiness ruler). Although the GSC treatment model has several unique fea-
tures, it also shares many features with other cognitive-behavioral interventions, including the
use of functional analysis (M. B. Sobell, Sobell, & Sheahan, 1976); self-monitoring of alcohol and
drug use (L. C. Sobell & Sobell, 1973); problem-solving skills to develop alternative responses to
GSC Treatment and Group Therapy 5
drinking or drug use situations (D’Zurilla & Goldfried, 1971); and homework assignments, includ-
ing a decisional balance exercise (Janis & Mann, 1977; Kazantzis, Deane, & Ronan, 2000).
Table 1.1 highlights the major differences between the GSC treatment model and other
cognitive-behavioral interventions for SUDs. Factors unique to the GSC treatment model
include (1) incorporating cognitive elements of the relapse prevention model (Marlatt & Dono-
van, 2005; Marlatt & Gordon, 1985; M. B. Sobell & Sobell, 1993a); (2) allowing alcohol clients
to self-select their treatment goals (i.e., moderation or abstinence; M. B. Sobell & Sobell, 1995);
(3) using the Timeline Followback (TLFB) to provide clients with feedback about their pretreat-
ment alcohol or drug use and related risks (Agrawal, Sobell, & Sobell, 2008; L. C. Sobell &
Sobell, 2003); (4) allowing clients to request additional sessions after the four semistructured
GSC sessions (M. B. Sobell & Sobell, 1993a); and (5) using a motivational interviewing style
throughout the delivery of the intervention.
Before we further describe the GSC treatment model and its extension to group therapy, it
is important to briefly review the findings of studies that compared the same treatment deliv-
ered in individual and group formats with substance abusers. As will be apparent, such studies
are few in number.
Brief Review of Studies

Comparing Group and Individual Treatments for SUDs
With a long and rich history (Bernard & MacKenzie, 1994; Scheidlinger, 1994; Yalom & Leszcz,
2005), group therapy is a popular form of treatment across many clinical disciplines (e.g., psy-
chology, psychiatry, social work) and across a wide range of clinical problems (e.g., anxiety and
mood disorders, posttraumatic stress disorder, obesity) (Barlow, Burlingame, Nebeker, & Ander-
TABLE 1.1. Major Ways the GSC Treatment Model Differs from Other Cognitive-
Behavioral Interventions for SUDs
•• Provides goal choice that includes low-risk drinking and accepts harm-reduction alternatives for
clients not willing to seek abstinence.
•• Clients functionally analyze their own substance use (i.e., identify high-risk trigger situations and
associated consequences for use) and develop their own treatment plans.
•• Emphasizes the application of problem-solving skills.
•• Incorporates cognitive elements of the relapse prevention model into the treatment. Rather than
providing skills training, a relapse management approach is used to generate a dialogue about taking
a realistic perspective on change and to discuss the need to construe slips as learning experiences.
•• Uses the Timeline Followback to gather pretreatment substance use data that are then used
to generate personalized feedback for clients about their level of substance use, risks, and
consequences.
•• Incorporates flexibility in scheduling, explicitly soliciting client input as the main determinant for
additional sessions.
•• As a brief intervention, it includes an aftercare telephone call 1 month after the last scheduled
session that is intended to provide support for clients’ functioning and to facilitate resumption of
treatment if needed.
•• Uses motivational interviewing as a communication style throughout the intervention, in addition
to incorporating various motivational interviewing strategies and techniques (e.g., readiness ruler,
advice feedback, decisional balancing).
son, 2000; Guimon, 2004; Humphreys et al., 2004; Panas, Caspi, Fournier, & McCarty, 2003;
Satterfield, 1994; Scheidlinger, 1994; Weiss, Jaffee, deMenil, & Cogley, 2004). In the substance
abuse field it is the “most common treatment modality” (Weiss et al., 2004, p. 339). The popular-
ity of groups relates in large part to two factors: (1) the provision of social support to clients and
(2) the ability to treat multiple clients concurrently and at a lower cost than individual therapy.
The term group therapy has been used to describe a wide variety of therapeutic activities
(e.g., educational, didactic, interactional, process, support, aftercare, codependency), including
self-help groups. Although self-help groups, a widely used group format in the substance abuse
field, incorporate and resemble some aspects of group therapy, there are several major differ-
ences, the most significant being that leaders need no professional training (Scheidlinger, 1994;
Yalom & Leszcz, 2005). Consequently, self-help groups are not included in this review.
Group therapy has a long tradition in the treatment of SUDs (Center for Substance Abuse
Treatment, 2005; Institute of Medicine, 1990; Panas et al., 2003; Vannicelli, 1992; Weiss et al.,
2004), especially with adolescents (D’Amico et al., 2011; Kaminer, 2005). Given this history, one
might expect to find considerable research supporting the efficacy of group therapy with SUDs.
To the contrary, RCTs of group versus individual treatment are sparse and lack appropriate
controls (Institute of Medicine, 1990; Weiss et al., 2004).
In one of the first reviews of the group therapy literature with alcohol abusers, Brandsma
and Pattison (1985) found 30 studies. Based on their review, they concluded that it was impos-
sible to evaluate the efficacy of group therapy, as the research was plagued with multiple prob-
lems (e.g., inadequate designs, inadequate specification of procedures, lack of controls, poor
measures, lack of replications), including that most of the group treatments had been combined
with other program components (e.g., individual therapy, aftercare, self-help meetings). Despite
these problems, the studies reported abstinence or improvement rates ranging from 15 to 53%,
comparable to those for individual treatments.
A similar review conducted two decades later (Weiss et al., 2004) found that little has
changed from the Brandsma and Pattison (1985) review. In this recent review, 24 comparative
trials of group therapy with SUDs were found. The authors classified these studies into six
distinct categories: (1) group therapy versus no group therapy (e.g., Stephens, Roffman, & Cur-
tin, 2000); (2) group therapy versus individual therapy (e.g., Marques & Formigoni, 2001); (3)
group therapy plus individual therapy versus group therapy alone (e.g., Linehan et al., 1999); (4)
group therapy plus individual therapy versus individual therapy alone (e.g., McKay et al., 1997);
(5) group therapy versus another group therapy with different content or theoretical orienta-
tion (e.g., Kadden, Cooney, Getter, & Litt, 1989); and (6) more group therapy versus less group
therapy (e.g., Coviello et al., 2001). The two major conclusions from this review were that no
significant outcome differences existed between group and individual treatments and that no
single type of group therapy was superior.
RCTs of the Same Treatment Delivered in a Group versus Individual

Format for SUDs
Because the RCT of the GSC treatment model involved an evaluation of the same treatment
in an individual versus a group format (L. C. Sobell et al., 2009), the following review includes
only RCTs that compare the same treatment delivered in a group versus an individual format.
Consequently, studies comparing different types of groups (e.g., Abrams & Wilson, 1979; Miller
& Taylor, 1980; Oei & Jackson, 1980) or different group and individual treatments (e.g., McKay
et al., 1997; Stephens et al., 2000) are not included. In addition, family and marital studies are
excluded, as they have no individual-treatment component.
Of the 24 studies in the Weiss and colleagues (2004) review, only 3 (12.5%) addressed
the efficacy of group compared with individual therapy for SUDs (Graham, Annis, Brett, &
Venesoen, 1996; Marques & Formigoni, 2001; Schmitz et al., 1997). Although not in the Weiss
and colleagues review, a fourth study (Duckert, Johnsen, & Amundsen, 1992) using an RCT
compared the same treatment in group and individual formats for alcohol abusers. To facilitate
comparisons among these four RCTs, the major characteristics of each study are listed in Table
1.2. Thus only details not in Table 1.2 are discussed subsequently.
In the Graham and colleagues (1996) study, alcohol and drug abusers were randomized
to 12 sessions of relapse prevention aftercare treatment delivered in either a group or an indi-
vidual format. At the follow-up, there were no significant differences between the two treatment
conditions on any alcohol or drug use outcome measures. However, prior to randomization, all
clients had participated in one of two treatment programs for SUDs (12-step 26-day residen-
tial program or 1-year outpatient eclectic group). Because other interventions (mainly groups)
immediately preceded this study’s comparison of group and individual aftercare, it does not
allow a true comparison of the efficacy of the two aftercare treatment modalities.
TABLE 1.2. RCTs of the Same Treatment Delivered in Group versus Individual Formats
for SUDs
Author (year)
Marques &
Duckert et Graham et al. Formigoni Schmitz et al.
Study characteristic al. (1992) (1996) (2001) (1997)
Country Norway Canada Brazil United States
Sample size 135 192 155 32
% Male 60.0 66.9 92.0 50.0
Type of substance abuse problem Alcohol Alcohol and Alcohol and Cocaine
other drugs other drugs
Treatment type Cognitive- Relapse Cognitive- Cognitive-

behavioral prevention behavioral behavioral relapse
aftercare prevention
aftercare
No. of scheduled sessions 12 12 17 12
Length (min) of group sessions 90 60–90 — 60
Follow-up period (mo) 21 12 15 6
% Found for follow-up 57.7 74.0 68.4 84.0
Self-reports confirmed Yes No Yes Yes
Significant outcome differences

Pre- versus posttreatment Yes Yes Yes Yes
Group versus individual No No No No
Note. Dash indicates that data were not reported.

In the Schmitz and colleagues (1997) study, cocaine-dependent clients who had recently
completed an inpatient chemical dependency treatment program were subsequently randomly
assigned (by cohorts) to a 12-session manualized cognitive-behavioral relapse prevention treat-
ment delivered in either a group or individual format. At the follow-up, there were no signifi-
cant differences between the two conditions. As with the Graham and colleagues (1996) study,
because all participants had received other substance abuse treatment before the RCT, a pure
test of the efficacy of the two aftercare treatments is not possible.
In the Marques and Formigoni (2001) study, alcohol and drug abusers were randomly
assigned to a 17-session cognitive-behavioral treatment delivered in either a group or an individ-
ual format. The first treatment session, which was conducted individually for both conditions,
consisted of reviewing assessment data and presenting educational information about alcohol
and drugs. Abstinence was required of all participants for the first 3 months, after which alcohol
clients could select a moderation goal. Although the two conditions did not have significantly
different outcomes at the follow-up, 7% of participants had dropped out after the first session,
and only 54% completed 8 of the 17 sessions. Although there were no significant differences in
dropout rates between the group and individual conditions, drug clients attended significantly
fewer sessions than did alcohol clients.
In the Duckert and colleagues (1992) study, alcohol abusers were recruited through news-
paper advertisements, matched pairwise, and then randomly assigned to a 12-session cognitive-
behavioral treatment delivered in either a group or an individual format. Groups were of a single
gender, and all participants were allowed to select an abstinence or moderation drinking goal.
Besides the format, the two conditions differed in the number of hours spent in sessions (indi-
vidual: 7 hours; group: 25 hours). At follow-up no significant differences were found between
the group and individual conditions on a number of outcome variables, including alcohol con-
sumption. When asked at the follow-up, a larger number of group than individual participants
reported that they wanted more contact with their therapists. This may reflect the feeling that
group participants had received proportionately less personal attention from their therapists
than they would have if they had been assigned to individual therapy.
In summary, RCTs comparing the same treatment delivered in a group versus an indi-
vidual format for clients with SUDs are rare. Of the four published studies, two (Graham et al.,
1996; Schmitz et al., 1997) were not pure comparisons, as clients had received other treatment
immediately prior to being randomized. The most striking and consistent finding across all four
studies, however, was that, although clients demonstrated significant improvements in their
substance use, there were no differences between the group- and individual-treatment formats.
Last, none of the four studies reported any cost-effectiveness evaluations of group versus indi-
vidual treatment.
Research Issues in Conducting RCTs of Group versus Individual Therapy

Several issues make it difficult to conduct research studies comparing group with individual
therapy. One serious problem that can threaten the validity of such treatment comparisons is
differential attrition (Piper, 1993; Piper & Joyce, 1996). In this regard, studies have shown that
a greater number of clients drop out when assigned to group than to individual therapy (Bud-
man et al., 1988; Hofmann & Suvak, 2006). The Budman and colleagues (1988) study, an RCT
of group versus individual therapy with psychiatric clients, illustrates the importance of imple-
menting strategies to minimize dropouts. The great majority of the 29 patients who dropped
out after being informed of their assignment had been assigned to group rather than individual
therapy (89.7%, n = 26; 10.3%, n = 3, respectively). Therefore, although significant improve-
ments occurred in both conditions, it was impossible to draw firm conclusions about the relative
efficacy of group versus individual therapy because of differential attrition. Another issue con-
cerns recruiting a sufficient number of participants to randomize to group and individual treat-
ment, particularly in closed groups (i.e., those to which no new members are added after the
first session), which can be difficult. Other complicating factors involve group characteristics
(e.g., gender composition) and different session lengths for group and individual therapy. Last,
a critical issue that must be addressed in any comparative evaluation of group versus individual
treatment is whether the study is a pure comparison in which there are no other concurrent or
preceding treatment components (e.g., treatments preceding aftercare, self-help groups, phar-
macotherapy) that could provide alternative explanations for the findings.
Several conclusions about the role and utility of group therapy can be drawn based on this
chapter: (1) group processes play an important role in the efficacy of groups; (2) because of their
inherent structure, groups offer important advantages that do not exist in an individual therapy
setting; (3) groups that incorporate group processes have reported comparable outcomes to indi-
vidual therapy; and (4) groups can treat multiple patients at one time, thereby reducing the
financial burden on the payer. Given the widespread use of group therapy in clinical practice
with SUDs, the only curious issue is why there is a paucity of research (particularly RCTs) eval-
uating the same type of treatment (e.g., theoretical orientation, procedures, number of sessions)
delivered in a group versus an individual setting. With these caveats in mind, we now return to
a consideration of GSC and how it was adapted to a group format.
General Framework of the GSC Treatment Model
The general framework for the GSC treatment model is an assessment and four semistructured
sessions, with additional sessions available as needed. The major components of a GSC assess-
ment and four-session treatment program for substance abusers, whether delivered in an indi-
vidual or a group format, are described in detail in Chapters 4 and 5, respectively. These chap-
ters include therapist handouts for each individual therapy (4.1–4.4) and each group therapy
(5.1–5.4) session. Each handout contains detailed session guidelines, objectives, procedures,
and homework exercises. In addition, each group therapist handout contains guidelines on how
to conduct several round-robin discussions, which is the format used to conduct the clinical
intervention in a group format. Round-robin discussions were designed so that support, feed-
back, and advice emanate primarily from group members rather than from the group leaders.
Extending the GSC Treatment Model to a Group Format
The primary empirical support for the cognitive-behavioral, motivational interviewing group
therapy approach that is the subject of this book derives from an RCT that compared a GSC
intervention delivered in a group versus an individual format (L. C. Sobell et al., 2009). For two
decades starting in the mid-1970s, our clinical research focused on developing and validating
individual therapies for those with SUDs. However, by the early 1990s the substance abuse
field as well as the agency where we were then employed, the Addiction Research Foundation
in Toronto, Canada, had developed waiting lists for clients requesting individual therapy. At
this same time, both in the United States and in Canada, there were serious concerns about
health care cost containment as well as cost-effective treatments (Rosenberg & Zimet, 1995;
Spitz, 2001; Steenberger & Budman, 1996). Consequently, we decided to extend and validate
the GSC treatment model in a group format. The group-versus-individual study, also known as
GRIN (GRoup vs. INdividual), was an RCT that evaluated the GSC treatment model delivered
in a group versus an individual format with 264 alcohol and drug abusers voluntarily seeking
treatment. This was also the first study to evaluate the GSC treatment model with drug abusers
whose problems were not severe (e.g., no intravenous drug users participated). Although discus-
sion of the group treatment procedures and details occupies much of this book, it will be helpful
to first discuss how the GRIN study evolved and to present the results of the RCT of GSC used
in group and individual therapy.
All of the therapists who participated in the GRIN study were trained in conducting GSC
treatment, a time-limited cognitive-behavioral motivational intervention (M. B. Sobell & Sobell,
1993a, 2005), with individual clients, and most had some, albeit limited, experience in conduct-
ing groups. However, early during a pilot study intended to precede the formal study, it became
clear that the integration of cognitive-behavioral procedures (e.g., homework, self-monitoring,
functional analyses of behaviors, relapse prevention) and motivational interviewing techniques,
vital elements of the GSC individual treatment model, would require careful thought and atten-
tion if they were to be successfully incorporated into a group setting. The major concern was
addressing the needs and problems of multiple clients while capitalizing on group processes
without a loss of therapeutic effectiveness. To address this concern, we stopped the pilot study
and spent several months reviewing the group psychotherapy literature to determine how to
best integrate the GSC intervention into a group format. Our goal was to retain the curative
elements of the GSC intervention delivered individually while addressing the constraints and
opportunities intrinsic to group therapy.
After stopping the initial pilot study and providing the GSC staff with training in group
skills and how to integrate them with their cognitive-behavioral and motivational interview-
ing skills, a second pilot study was conducted, followed by the completion of the GRIN study.
We believe that the success of the GRIN study, and especially the high level of group cohesion
achieved, demonstrates that we were able to successfully integrate cognitive-behavioral and
motivational interviewing principles and techniques with group processes.
How Well Does GSC Work?
As reviewed elsewhere (M. B. Sobell & Sobell, 2005), the GSC treatment model has been evalu-
ated in multiple settings (e.g., outpatient alcohol treatment programs, primary care centers),
with different populations (adults, adolescents, alcohol and drug abusers, gamblers), and with
both English and Spanish speakers. A summary of the main findings of studies evaluating the
GSC treatment model for clients with alcohol problems that also had 1 year or more of follow-up
appears in Table 1.3. This table lists the outcome variables assessed in each study and shows
the percentage change for those variables from pretreatment to posttreatment. For proportion
of days abstinent, a positive change indicates improvement, whereas for mean drinks per drink-
ing day (or mean drinks per week), a negative change indicates improvement. The amount of
change demonstrated in these studies is similar to that shown in other studies of brief interven-
tions (Babor et al., 2006) and primary care interventions (Fleming, Barry, Manwell, Johnson, &
London, 1997).
There are two additional published studies, involving adolescents, that used the GSC treat-
ment model, but because they did not meet the 1-year follow-up criterion, they are not listed in
Table 1.3. In one study (Breslin, Li, Sdao-Jarvie, Tupker, & Ittig-Deland, 2002), at the 6-month
follow-up, 50 adolescent substance users treated with an adaptation of GSC were found to
have reduced their substance use by about 44%. The second study, also an adaptation of GSC,
involved 213 African American and Hispanic adolescents. Preliminary follow-up results around
11 weeks found that clients’ self-reported marijuana and alcohol use had decreased about 55%
and 47%, respectively (Gil, Wagner, & Tubman, 2004). The findings from these two studies are
consistent with those in Table 1.3 that have a 1-year follow-up, but they showed greater change
scores, possibly because of their shorter follow-up intervals. Although studies using motivational
interviewing in groups with adolescents are few in number, D’Amico and her colleagues have
offered compelling arguments (D’Amico et al., 2011) and support (D’Amico, Osilla, & Hunter, in
press) for motivational interviewing is particularly suited (e.g., taking a collaborative approach,
addressing ambivalence about changing, avoiding labels, allowing youths to give voice to the
need to change rather than being told what to do) for at-risk youths and particularly those from
disadvantaged/marginalized or cultural minority backgrounds.
Because this book is intended as a clinical guide, the studies in Table 1.3 are not further
discussed. The evidence, however, shows that the GSC treatment model has consistently been
associated with substantial and significant gains over the course of treatment and that these
changes are maintained following treatment.
How Well Does GSC Work in Groups?

Findings from the GRIN study are briefly summarized here, as they have been reported in
detail elsewhere (L. C. Sobell et al., 2009). The participants had voluntarily sought treatment
for an alcohol or drug problem at the Addiction Research Foundation in Toronto, Ontario,
Canada. When the study was conducted, the Addiction Research Foundation was the largest
outpatient service provider in the province of Ontario. The GRIN study was designed for prob-
lem drinkers and for drug abusers voluntarily seeking treatment (drug abusers who used drugs
intravenously or who used heroin were excluded). The major procedural details of the GRIN
study (i.e., session dialogues, forms, exercises, round-robin discussions) are described in other
places throughout this book. Chapter 3 discusses assessment measures and materials used in
both the GSC individual and group sessions and Chapters 4 and 5 present the GSC treatment
model in terms of its application to the conduct of the individual and group therapy, respec-
tively. Also included in these chapters are the therapist and client handouts, clinical examples,
and sample therapist and client dialogues. The details of the statistical analyses of the GRIN
are reported elsewhere (L. C. Sobell et al., 2009). What follows is a summary of the important
findings and also some insights into the study that go beyond what can be communicated in
journal articles.
The most important result of the GRIN study was that participants in both the individual-
and group-treatment conditions showed sizeable and significant improvement across treatment
and follow-up. There were, however, no significant differences between the two treatment for-
mats. That is, although clients in both treatment conditions significantly reduced their alcohol
or drug use, it did not matter whether they were in individual or group therapy.
TABLE 1.3. Summary of Outcome Studies Evaluating the GSC Treatment Model for Clients
with Alcohol Problems
Study and group Variable Pretreatment Posttreatment Change
Andréasson, Hansagi, & Oesterlund
(2002)
4GSCS (n = 30) Mean drinks/DD 5.2 4.5 –13%
1GSCS (n = 29) Mean drinks/DD 6.3 4.7 –25%
Ayala et al. (1998)

INDIV (n = 177) Prop abstinent 0.73 0.82 +9%
INDIV (n = 177) Mean drinks/DD 9.2 6.5 –29%
Breslin et al. (1998)

SC (n = 33) Prop abstinent 0.28 0.45 +17%
NSC (n = 36) Prop abstinent 0.24 0.37 +13%
M. B. Sobell, Sobell, & Gavin (1995)

BC (n = 36) Prop abstinent 0.32 0.61 +29%
RP (n = 33) Prop abstinent 0.33 0.50 +17%
BC (n = 36) Mean drinks/DD 6.7 4.2 –37%
RP (n = 33) Mean drinks/DD 5.1 3.6 –29%
M. B. Sobell, Sobell, & Leo (2000)

DSS (n = 19) Prop abstinent 0.23 0.47 +24%
NSS (n = 24) Prop abstinent 0.21 0.44 +23%
DSS (n = 19) Mean drinks/DD 6.3 4.3 –21%
NSS (n = 24) Mean drinks/DD 5.8 4.6 –20%
L. C. Sobell et al. (2009)

INDIV (n = 107) Prop abstinent 0.30 0.58 +28%
GRP (n = 105) Prop abstinent 0.30 0.53 +23%
INDIV (n = 107) Mean drinks/DD 6.4 4.1 –36%
GRP (n = 105) Mean drinks/DD 6.7 4.6 –31%
L. C. Sobell et al. (2002)

ME/PF (n = 321) Prop abstinent 0.21 0.35 +14%
B/DG (n = 336) Prop abstinent 0.23 0.34 +11%
ME/PF (n = 321) Mean drinks/DD 5.9 4.7 +20%
B/DG (n = 336) Mean drinks/DD 5.9 4.7 +20%
Note. All studies had to have a minimum of 1 year of follow-up. Study and group designations: 4GSCS, 4 GSC sessions; 1GSCS, 1
GSC session; INDIV, individual treatment; SC, supplemental care; NSC, no supplemental care; BC, behavioral counseling; RP,
behavioral counseling plus cognitive relapse prevention; DSS, directed social support; NSS, natural social support; GRP, group
treatment; ME/PF, motivational enhancement/personalized feedback; B/DG, bibliotherapy/drinking guidelines. Prop abstinent,
proportion of days abstinent; Mean drinks/DD, mean number of drinks consumed per drinking day. Change is defined as the
percentage of change pretreatment to posttreatment. From M. B. Sobell and L. C. Sobell (2005, p. 205). Copyright 2005 by the
Springer Publishing Company. Reprinted by permission.
Validity of Self-Reports and Treatment Integrity Checks

As part of the study, each participant provided the name of a collateral informant who could
be contacted to corroborate the participant’s self-reports of posttreatment alcohol or drug use.
Results showed that collaterals confirmed participants’ self-reports of alcohol and drug use (L.
C. Sobell et al., 2009). A treatment integrity check on therapists’ compliance with the study
protocol found that compliance was uniformly high for both the individual and group treatment
conditions (L. C. Sobell et al., 2009).
Outcomes for Alcohol Clients

Figure 1.1 shows that for clients who had a primary alcohol problem, the percentage of abstinent
days for those in the individual and group treatment conditions were similar at all three time
points. Furthermore, for clients in both conditions, the percentage of abstinent days showed a
large increase over treatment that was sustained over the 12-month follow-up. Figure 1.2 shows
similar results but for mean number of standard drinks consumed per drinking day. Again,
the data for clients in both treatment conditions were very similar. Because some reports in
the alcohol literature have noted that females have shown better outcomes than males in brief
cognitive-behavioral interventions (Sanchez-Craig, Leigh, Spivak, & Lei, 1989; Sanchez-Craig,
Spivak, & Davila, 1991), we explored whether there were any gender differences. However, no
significant differences related to gender or relating gender to treatment conditions were found
for this study.
100
90
80 Individual Treatment
70 Group Treatment
Percent of Days Abstinent
60
50
40
30
20
10
0
Pretreatment Within Treatment Posttreatment
FIGURE 1.1. Percent of days abstinent during pretreatment, within treatment, and posttreatment for
problem drinkers assigned to individual- and group-treatment conditions.
10
Mean Number of Standard Drinks per Drinking Day

9
8
Individual Treatment
7 Group Treatment
0
FIGURE 1.2. Mean number of standard drinks per drinking day during pretreatment, within treatment,
and posttreatment for problem drinkers assigned to individual- and group-treatment conditions.
For clients with alcohol problems, an interesting pattern of improvement was observed. As
in other studies involving problem drinkers, approximately three-quarters of the clients chose
to work on reducing rather than stopping their drinking (Sanchez-Craig, Annis, Bornet, & Mac-
Donald, 1984; M. B. Sobell, Sobell, & Gavin, 1995). However, in terms of drinking outcomes,
as shown in Figure 1.3, the main change over the course of treatment and follow-up was that
alcohol clients greatly reduced their percentage of heavy drinking days (i.e., five or more stan-
dard drinks), and concurrently increased their percentage of abstinent days. In contrast, their
frequency of limited drinking days (i.e., one to four standard drinks) stayed almost constant from
pre- to posttreatment. This phenomenon, in which clients chose a low-risk, limited-drinking
goal but then increased their abstinent days, is consistent with another study (Sanchez-Craig,
1980) that found that those assigned to a low-risk drinking goal were significantly better able to
abstain for the first 3 weeks of treatment (they were requested to do so putatively to facilitate the
assessment) than those randomly assigned to an abstinence goal. These findings strongly suggest
that the way clients view their ability to manage their drinking can be an important variable
affecting their drinking decisions.
Outcomes for Cocaine and Cannabis Clients

In addition to providing a demonstration that the GSC intervention delivered in groups was
as effective as the same intervention delivered individually, the GRIN study also extended
the GSC treatment model to individuals with drug problems other than alcohol, most notably
cocaine and cannabis. Figure 1.4 shows how the percentage of days abstinent from drug use
changed from pretreatment through treatment and follow-up. Because there were no significant
100
90
80
Pretreatment
70 Within Treatment
Percent of Days Drinking
Posttreatment
60
50
40
30
20
10
0
Abstinence 1–4 Drinks 5–9 Drinks ≥ 10 Drinks
FIGURE 1.3. Percent of days drinking at different levels during pretreatment, within treatment, and
posttreatment for problem drinkers. Because the individual- and group-treatment conditions did not dif-
fer significantly, they were combined.
differences at any point between clients in the group or individual conditions, data from both
conditions were combined in Figure 1.4. As can be seen, clients with a primary cocaine prob-
lem improved considerably over treatment and continued to improve over follow-up. For clients
for whom cannabis was the primary problem, although substantial gains over treatment were
made, some regression over the follow-up year occurred. At the end of follow-up, however, they
still were using far less than prior to treatment.
Therapist Time Ratio Analysis of GSC Group versus Individual Treatment

When treatments that require different amounts of resources are compared, the key question is
not whether one treatment is as effective as another but whether a more expensive or demand-
ing treatment (from the patient’s perspective) produces sufficiently superior outcomes to war-
rant the added cost or personal investment. In evaluating the GSC treatment in a group versus
an individual format, we calculated a therapist time ratio comparing the time spent providing
group compared with individual treatment. This evaluation showed that there was a 41.4% sav-
ings in therapists’ time when conducting group therapy (L. C. Sobell et al., 2009).
Clients’ Evaluations of the GSC Intervention at the End of Treatment

Almost all of the participants (209 of 213: 106 individual treatment; 103 group treatment) who
completed the fourth and last structured treatment session also completed an assessment of
100
90
80
70
Percent of Days Abstinent
60
50
40
30
20 All Drugs
Cocaine
10 Cannabis
0
FIGURE 1.4. Percent of days abstinent from drugs during pretreatment, within treatment, and posttreat-
ment for all drug abusers, and separately for cocaine and cannabis abusers.
treatment, rating several aspects of their treatment on 5-point scales (with lower scores reflect-
ing more favorable ratings). Table 1.4 shows clients’ end-of-treatment ratings for group and indi-
vidual conditions and for clients with primary alcohol problems or primary drug problems.
Some of the differences, as noted in Table 1.4, are statistically significant.
Overall, clients in both the individual- and the group-treatment conditions rated the pro-
gram very positively, with mean ratings near the favorable end of the scale (1.42 and 1.56,
respectively). Several other aspects of the intervention were also highly rated: quality of service,
self-change component, therapists, self-monitoring logs, and the program atmosphere. In fact,
with the exception of the length of the treatment and the difficulty of the homework, all mean
ratings were positive. With regard to treatment length, group clients were more likely to rate
the treatment as being “too little” (mean = 3.55) than individual clients (mean = 3.17), although
the mean ratings for this variable suggested that clients in both conditions would have liked
the treatment to be longer. Because this study was an RCT, the length of treatment was kept
constant. However, in practice the GSC treatment model is flexible and allows for additional
sessions. Clients in the group condition also rated the readings and the homework exercises as
more useful than clients in the individual condition. One reason this may have occurred is that
in the group condition the homework assignments formed the basis of round-robin discussions
and, as such, received more attention and talk time because they were discussed by multiple
clients. Last, and very important, clients were highly satisfied with being assigned to the group
condition (mean = 1.55, with 1 = very satisfied). With regard to the statistically significant dif-
ferences shown in Table 1.4, they were small in absolute magnitude, and there was no consistent
direction of difference.
TABLE 1.4. Clients’ End-of-Treatment Ratings of Treatment by Condition (Individual or Group)

and by Primary Substance Problem (Alcohol or Drug)
Treatment condition
Individual (n = 107) Group (n = 106)
Variable Mean (SD) Mean (SD)
Satisfied with treatment (1 = very, 5 = not at all) 1.42 (0.74)a 1.56 (0.76)b
Quality of service (1 = excellent, 5 = poor)* 1.23 (0.46)a 1.43 (0.59)c
Program length (1 = too much, 5 = too little)* 3.17 (0.64)a 3.55 (0.73)d
Satisfied with self-change component (1 = very, 5 = not at all) 1.91 (0.93) a 1.84 (0.97)b
Satisfied with therapist (1 = very, 5 = not at all)* 1.16 (0.44)a 1.42 (0.69)b
Readings useful (1 = very, 5 = not at all)* 2.25 (0.99)e 1.86 (0.93)b
Homework useful (1 = very, 5 = not at all)* 2.03 (0.96) e 1.68 (0.89)d
Homework difficulty (1 = too easy, 5 = too hard) 2.78 (0.62)f 2.86 (0.73)d
Self-monitoring useful (1 = very, 5 = not at all) 1.66 (0.83)e 1.65 (0.93)b
Decisional balance exercise useful (1 = very, 5 = not at all)* 2.23 (0.98)e 1.93 (0.89)b
Satisfied with program atmosphere (1 = very, 5 = not at all) 1.50 (0.75)e 1.69 (0.89)b
Program was helpful (1 = very much, 5 = not very much) 1.43 (0.66)e 1.52 (0.73)d
Recommend program to friend (1 = definitely, 5 = definitely not) 1.23 (0.50)a 1.27 (0.61)g
Satisfied with being in group (1 = very, 5 = not at all) 1.55 (0.76)h
Primary substance problem
Alcohol (n = 180) Drugs (n = 33)
Satisfied with treatment (1 = very, 5 = not at all) 1.49 (0.76)h 1.53 (0.76)i
Quality of service (1 = excellent, 5 = poor) 1.34 (0.54) j 1.26 (0.51)k
Program length (1 = too much, 5 = too little) 3.34 (0.67) j 3.44 (0.91)d
Satisfied with self-change component (1 = very, 5 = not at all) 1.89 (0.98) j 1.81 (0.78)i
Satisfied with therapist (1 = very, 5 = not at all) 1.30 (0.60)h 1.22 (0.55)i
Readings useful (1 = very, 5 = not at all) 2.01 (0.99)l 2.34 (0.90)i
Homework useful (1 = very, 5 = not at all) 1.80 (0.94)l 2.16 (0.92)i
Homework difficulty (1 = too easy, 5 = too hard) 2.84 (0.68)l 2.71 (0.82)k
Self-monitoring useful (1 = very, 5 = not at all)* 1.58 (0.84) j 2.06 (0.98)i
Decisional balance exercise useful (1 = very, 5 = not at all) 2.09 (0.96) j 2.03 (0.90)i
Satisfied with program atmosphere (1 = very, 5 = not at all) 1.58 (0.81)l 1.66 (0.83) j
Program was helpful (1 = very much, 5 = not very much) 1.46 (0.68)l 1.53 (0.76)i
Recommend program to friend (1 = definitely, 5 = definitely not) 1.25 (0.55)h 1.25 (0.62)i
Satisfied with being in group (1 = very, 5 = not at all) 1.57 (0.76) m 1.47 (0.77) n
Note. Ratings made on 5-point scales (1–5) with end points shown for each variable.
a n, 106; b n, 103; c n, 101; d n, 102; en, 105; f n, 104; gn, 100; hn, 177; i n, 32; jn, 176; kn, 31; ln, 175; m n, 81; n n, 19;
* p < .05, two-tailed independent sample t-tests.
Clients’ Evaluations of the GSC Intervention at the 12-Month Follow-Up

At the end of the 12-month follow-up, clients again rated their treatment experiences. Table
1.5 shows clients’ evaluations of treatment at the 12-month follow-up for both the group and
individual conditions and for clients with primary alcohol and primary drug problems. A total
of 230 clients completed the follow-up questionnaires. Similar to their evaluations at the end
of treatment, clients’ overall evaluations of their treatment at the follow-up were positive, with
more than 90% suggesting that the GSC program should continue and over 80% reporting
that their substance use was either no longer a problem or less of a problem than before they
entered treatment. Interestingly, and consistent with the end-of-treatment evaluations, 42.1%
felt that the GSC treatment was not long enough. In this regard, there is substantial evidence
that many alcohol and drug abusers with less severe problems show great improvement in brief
treatment (e.g., Marijuana Treatment Project Research Group, 2004; Moyer, Finney, Swearin-
gen, & Vergun, 2002; Stephens et al., 2000; Stern, Meredith, Gholson, Gore, & D’Amico, 2007).
For example, in a multicenter RCT that compared two 12-session treatments delivered over
12 weeks (12-Step Facilitation and Cognitive-Behavioral Coping Skills) with a 4-session treat-
ment (Motivational Enhancement treatment) delivered over 12 weeks, there were no impor-
tant differences in outcomes between the treatments (Project MATCH Research Group, 1998).
This finding is consistent with other studies showing that a sizeable proportion of individuals
with various psychiatric disorders achieve successful outcomes after a few treatment sessions
(Wilson, 1999). Thus, although clients in the present study felt that they would have liked more
treatment, whether a longer treatment would have yielded better outcomes remains an empiri-
cal question. Finally, at the end of follow-up, 82.5% of individual and 81.0% of group clients felt
that treatment goals should be self-selected. In addition, 87.7% of individual and 87.1% of group
clients said that choosing their own goals was a good thing.
Clients’ Evaluations of Group Treatment at Follow-Up

As discussed earlier, the literature shows that when given a choice most clients say they would
prefer individual over group therapy. Thus it was decided that at the end of the 12-month follow-
up and after all the outcome data had been collected, clients would again be asked to rate their
treatment experience, this time including what treatment condition they would have chosen if
they had been given a choice at the start of the study. Although it was a retrospective evaluation,
significantly more group (38.2%) than individual (5.8%) clients stated at their 12-month follow-
up that if given their choice they would have selected group treatment. This suggests that there
was a preexisting bias against group therapy that to some extent was lessened by the clients’
experience in the groups. At the end of the follow-up, 59.2% of the group clients and 75.6% of
all clients still said they would have chosen individual treatment if given a choice. Consistent
with the literature, these findings suggest that if group therapy is to be offered, providers need
to include pregroup induction procedures to explain the benefits of group therapy and to attend
to questions that potential group members may have about group therapy and its effectiveness.
Finally, 75.4% of the individual and 65.5% of the group clients said they would prefer to be
given the choice between individual and group treatment rather than being assigned to a treat-
ment condition.
TABLE 1.5. Clients’ Evaluations of Treatment at the 12-Month

Follow-Up by Condition (Individual or Group) and by Primary
Substance Problem (Alcohol or Drug)
Treatment condition
Individual (IT) Group (GT)
Question (n = 114) (n = 116)
Amount of treatment
% too little 36.3 a 47.8 b
% sufficient 62.8 51.3
% too much 0.9 0.9
Drinking status
% no longer a problem 30.7 31.0
% less of a problem 50.0 52.6
% unchanged 16.7 14.7
% more of a problem 2.6 1.7
Choose own goal

% good thing 87.7 87.1
% bad thing 4.4 5.2
% no opinion 7.9 7.8
Who should select goal?

% self-select 82.5 81.0
% therapist select 10.5 12.1
Program should continue

% yes 90.4 93.9 b
% no 2.6 0.9
If assigned to GT, would have participated

% yes 61.4
% no 33.3
% do not know 5.3
If assigned to IT, would have participated

% yes 92.2
% no 6.0
% do not know 1.7
If given choice, would have chosen**

% IT 91.9 c 59.2d
% GT 5.8 38.2
(cont.)
TABLE 1.5. (cont.)

Alcohol Drugs
Question (n = 189) (n = 41)
Amount of treatment
% too little 40.1e 51.2
% sufficient 58.8 48.8
% too much 1.1 0.0
Drinking status
% no longer a problem 31.2 29.3
% less of a problem 52.4 46.3
% unchanged 14.8 19.5
% more of a problem 1.6 4.9
Choose own goal

% good thing 88.9 80.5
% bad thing 3.7 9.8
Who should select goal*

% self-select 86.2 61.0
% therapist select 9.0 22.0
Program should continue

% yes 92.1 92.5f
% no 1.6 2.5
If assigned to GT, would have participated

% yes 60.4 g 66.7h
% no 33.3 33.3
% do not know 6.3 0.0
If assigned to IT, would have participated

% yes 91.4 i 95.7j
% no 7.5 0.0
% do not know 1.1 4.3
If given choice, would have chosen

% IT 74.4 k 86.2 l
% GT 22.6 13.8
Note. At the last follow-up (12 months), GT participants were asked, “If you had been assigned to
individual treatment rather than group, would you have continued to participate in this study?”
and IT clients were asked, “If you had been assigned to group treatment rather than individual,
would you have continued to participate in this study?”
a n, 113; b n, 115; c n, 86; d n, 76; en, 187; f n, 40; gn, 96; hn, 18; i n, 93; jn, 23; kn, 133; ln, 29.
* p < .01; ** p < .001.
Therapists’ Evaluation of Clients at the End of Treatment

Another unique aspect of this study was that at the end of the fourth treatment session therapists
completed a form evaluating their clients’ participation and progress in treatment. Table 1.6 dis-
plays therapists’ evaluations of clients for group and individual conditions and for clients with
primary alcohol and primary drug problems. There were no significant differences between
treatment conditions. Only 1 of 13 differences between alcohol and drug clients was statistically
significant, with therapists rating alcohol clients as more likely to be on time for sessions than
drug clients. What is striking about these evaluations is that irrespective of clients’ treatment
condition (group vs. individual) or their primary substance abuse problem (alcohol or drug),
the therapists’ evaluations were uniformly high, reflecting their views that their clients were
responsive to treatment, participated actively, and completed their homework assignments.
Dissemination of the GSC Treatment Model:

From Bench to Bedside
We developed the GSC treatment model when we were at the Addiction Research Founda-
tion in Toronto, Canada. As a government-funded agency in a country with government-funded
universal health care, the dissemination of effective and efficient treatments was a priority. The
story of how the GSC treatment mode was effectively disseminated throughout the province
of Ontario, which is the largest province in Canada, has been described in detail elsewhere
(Martin, Herie, Turner, & Cunningham, 1998; L. C. Sobell, 1996) but is summarized here as it
provides an illustration of the challenges of going from bench to bedside. At the outset of the dis-
semination effort, we were struck by the fact that although the Addiction Research Foundation
was a well-known and internationally respected center for addiction research, evidence-based
treatment was not widely used in the community. It was clear that the usual methods of dissemi-
nation (e.g., workshops, publications) had not been particularly effective and that, if we wanted
to successfully disseminate the GSC treatment model, we would have to think outside the box.
In this case, the “box” was the traditional way of attempting to disseminate clinical science, and
“outside the box” meant to learn from the experience of others (i.e., business organizations) for
which successful dissemination is a matter of survival.
In business, establishing new products requires a substantial and long-term investment in
resources (once the product is launched the company must be prepared to respond to demand
if sales skyrocket). Failure to obtain buyers for a product can have dire economic consequences.
Such research has been described in detail in Diffusion of Innovations by Rogers (1995), who is
considered the father of dissemination research. Rogers’s book was the starting point in devel-
oping our efforts to get community treatment providers to adopt the GSC approach.
As described elsewhere (L. C. Sobell, 1996), we successfully partnered with practitioners
in the community to disseminate the GSC treatment model. One of the key factors was hav-
ing a flexible and adaptable product that we could use to train practitioners in the province of
Ontario. Before this project, our dissemination efforts typically would have involved offering
practitioners a 1-day workshop and handing out treatment materials. In contrast, we engaged in
a carefully planned effort that unfolded over time, involving gaining a buy-in from community
providers, which brought with it a responsibility on our part to provide continued training and
consultation.
TABLE 1.6. Therapists’ Evaluations of Clients by Condition

(Individual or Group) and by Primary Substance Problem (Alcohol
or Drug)
Treatment condition
Individual (n = 109) Group (n = 106)
Responsive to treatment 4.48 (0.73)a 4.38 (0.79)
Completed homework 4.61 (0.82) 4.67 (0.70)
Participated actively 4.70 (0.59) 4.52 (0.62)
Punctual for sessions 4.60 (0.81) 4.70 (0.57)
Appeared satisfied with sessions 4.53 (0.62) 4.50 (0.62)
Understood homework 4.54 (0.73) 4.72 (0.60)
Appeared ready to change 4.27 (0.93) 4.31 (0.94)
Read handouts 4.73 (0.63) 4.83 (0.47)
Resistant to the treatment 1.40 (0.81) 1.39 (0.76)
program
Unresponsive to feedback 1.50 (0.89) 1.40 (0.71)
Worked on self-selected goals 4.63 (0.63) 4.58 (0.80)
Good rapport with therapist 4.60 (0.60) 4.50 (0.56)
Alcohol (n = 182) Drugs (n = 33)
Responsive to treatment 4.43 (0.75)b 4.45 (0.79)
Completed homework 4.65 (0.73) 4.55 (0.91)
Participated actively 4.60 (0.62) 4.67 (0.54)
Got along with others in the 4.65 (0.53)c 4.75 (0.55)d
group
Punctual for sessions* 4.72 (0.55) 4.24 (1.17)
Appeared satisfied with sessions 4.51 (0.62) 4.58 (0.61)
Understood homework 4.62 (0.69) 4.67 (0.60)
Appeared ready to change 4.29 (0.92) 4.27 (1.04)
Read handouts 4.80 (0.52) 4.67 (0.74)
Resistant to the treatment 1.40 (0.79) 1.39 (0.75)
program
Unresponsive to feedback 1.48 (0.83) 1.27 (0.67)
Worked on self-selected goals 4.62 (0.69) 4.55 (0.91)
Good rapport with therapist 4.53 (0.59) 4.67 (0.48)
Note. Ratings were made on 5-point scales (1 = never, 5 = always).

a n, 108; b n, 181; c n, 85, group only; d n, 20, group only.
* p < .01.
Target systems for the treatment were carefully selected through a market analysis and
community forums, with the first target system being assessment/referral centers (Martin et al.,
1998). Ten workshops were conducted to train center staff in how to conduct GSC treatment
in group and individual formats. Of the 42 total assessment/referral centers in the province of
Ontario, 39 participated in the training, involving more than 200 staff members.
An important element in creating a favorable response to GSC treatment among commu-
nity service providers was encouraging them to tailor the procedures to fit their needs. That is,
they were encouraged to integrate aspects of the GSC treatment approach that they felt were
effective into their existing practices rather than totally discarding one approach for another.
Another important element was the provision of ongoing clinical support. A toll-free number was
established from our GSC program in Toronto to provide consultation to the field sites. A train-
ing videotape demonstrating the GSC intervention was also produced (L. C. Sobell & Sobell,
1995). These efforts resulted in wide-scale adoption of the GSC treatment model throughout the
province of Ontario (Martin et al., 1998; L. C. Sobell, 1996).
Our experience in disseminating the GSC treatment model in Ontario has had a lasting
influence on our work, including how we have gone about preparing this book. Although we
cannot approach the task of writing a book with the same resources, time commitment, or
personal involvement that went into the community dissemination effort, we hope that the con-
tents of this book demonstrate a sensitivity to clinicians’ and clients’ needs and to the context in
which cognitive-behavioral group therapy using motivational interviewing is likely to success-
fully occur.
Overview of This Book
In setting the stage for the remainder of this book, this chapter has reviewed the development
of the GSC treatment model and research that influenced its development, compared the GSC
treatment model with other cognitive-behavioral therapy for substance use disorders, reviewed
the few published RCTs of group versus individual treatment for substance use disorders, and
presented the results of the RCT that successfully extended the GSC individual treatment
model to a group therapy format.
The remainder of this book presents the details of GSC treatment and how to integrate and
implement it in a group setting. It also addresses a plethora of issues and challenges that face
therapists who conduct groups (e. g., failure to systematically use group processes, failure to
integrate cognitive-behavioral techniques with group processes). Chapter 2, a general overview
of motivational interviewing, describes and presents examples of motivational interviewing
strategies and techniques and their utility. The strategies and techniques reviewed in Chapter 2
have been an integral part of the GSC treatment model for many years, including the study that
compared GSC treatment in a group versus an individual format.
Chapter 3 contains a detailed discussion of how to conduct the GSC assessment, which is
the same whether the treatment is delivered in an individual or a group format. This chapter
also describes the clinical utility of the assessment measures and instruments that are used in
GSC sessions. The therapist dialogues included in Chapter 3 are presented as examples of how
topics might be initiated and probed rather than as clinical scripts. Chapters 4 and 5 describe
the detailed application of the GSC model to the conduct of individual and group therapy,
respectively. Descriptions of each of the four individual treatment sessions and each of the four
group treatment sessions include (1) therapist and client handouts, (2) clinical examples, and (3)
sample therapist–client dialogues. In addition, both chapters present session outlines for thera-
pists (i.e., objectives, procedures, materials and handouts needed) for each of four individual
sessions (Therapist Handouts 4.1–4.4) and each of the four group sessions (Group Therapist
Handouts 5.1–5.4). The session outlines for group therapists also include sample round-robin
discussions for each group session. Last, Chapter 5 contains a detailed discussion of how to inte-
grate motivational interviewing and cognitive-behavioral strategies and techniques into group
therapy using round-robin discussions.
Chapter 6 discusses the importance of group preparation and planning, managing the
group, and building group cohesion. This chapter also presents specific examples of how to
successfully conduct cognitive-behavioral motivational group therapy using group processes.
In this chapter we use two phrases that we feel are key to understanding how to successfully
manage groups. The first, Think Group, is intended to help group leaders remember that groups
have multiple members and that the group itself should be the agent of change. The second
phrase, Music Comes from the Group, is used to communicate that group therapists can be
viewed as conductors and that to achieve high group cohesion, which is related to successful
treatment outcomes, the majority of interactions within the group need to come from the mem-
bers (i.e., the music comes from the group).
Chapters 7 and 8 discuss two central aspects of how to manage groups. Chapter 7 addresses
a multitude of structural issues (e.g., composition, attendance, role of cotherapists, breaking
eye contact) that are critical for therapists to understand when conducting group therapy. Also
included is a brief discussion of the major advantages and disadvantages of conducting group
therapy compared with individual therapy. Chapter 8 discusses how to deal with challenging
clients and difficult situations in groups. Specific examples for dealing with such situations are
provided throughout the chapter.
Chapter 9, the concluding chapter, presents a discussion of the likely place of group psy-
chotherapy in the health care system of the future. This chapter suggests that, as interest in and
popularity of group therapy continues to grow, a major challenge will be to ensure that practi-
tioners are competently trained to provide group therapy.
Finally, because the inclusion of clinical materials that could be freely copied and used by
clinicians was successfully received in our 1993 book, Problem Drinkers: Guided Self-Change
Treatment (M. B. Sobel & Sobell, 1993), we have again included a variety of materials that can
be reproduced and used by practitioners and, where appropriate, given to clients. These materi-
als include individual and group session outlines, clinical assessment materials, questionnaires,
therapist and client handouts, homework exercises, and motivational feedback materials used
during both group and individual sessions. With the exception of the group session outlines, all
of the assessment and clinical materials can be used when applying the GSC treatment model
in either group or individual therapy.
Chapter 2
Overview of Motivational Interviewing

Strategies and Techniques
There has been considerable interest shown in motivational interviewing

(MI), since Miller (1983) initially presented it as an alternative and potentially
more effective way of working with problem drinkers, particularly those
individuals who may have been perceived as being resistant or in denial.
—Britt, Blampied, and Hudson (2003, p. 193)
[From] humble beginnings two decades ago, MI has been widely adopted and
adapted for use with a diverse range of clients.
—A llsop (2007, p. 343)
Historical Development of Motivational Interviewing
This chapter provides a general overview of motivational interviewing and its rationale. In the
mid-1980s, dissatisfaction with confrontational alcohol treatment approaches, coupled with the
conceptualization of motivation as a state (Prochaska & DiClemente, 1982) led William Miller
in the United States and Steve Rollnick in the United Kingdom (Miller, 1985; Miller & Rollnick,
1991) to develop motivational interviewing. In their seminal book Motivational Interviewing,
Miller and Rollnick (1991) noted that there is “no persuasive evidence that aggressive confron-
tational tactics are even helpful, let alone superior or preferable strategies in the treatment of
addictive behavior or other problems” (p. 7). They felt that confrontational approaches, such as
insisting that clients label themselves as “alcoholics” or “addicts,” served iatrogenically to evoke
resistance and could even be counterproductive. For example, individuals who are not severely
dependent (e.g., problem drinkers, marijuana abusers, adolescents) may respond to labeling with
counterarguing whereby they generate reasons why the label is not applicable to them (Perloff,
2008). In contrast, motivational interviewing does not use labels and deliberately avoids con-
frontation or other approaches likely to be perceived by the client as judgmental or coercive.
25
Motivational interviewing has been characterized as a client-centered, directive, noncon-

frontational, and nonjudgmental way of interacting with clients that prompts them to give voice
to the need for change (Center for Substance Abuse Treatment, 1999; Miller & Rollnick, 2002;
Rollnick, Miller, & Butler, 2008). The motivational interviewing strategies and techniques
reviewed in this chapter are those that have been an integral part of the GSC treatment model
for many years and were used in the study described throughout this book. For clinical guide-
lines and a detailed discussion of how to use motivational interviewing in a group format, read-
ers are referred to Chapter 6.
Studies comparing motivational interviewing with traditional confrontational treatment
approaches for SUDs have found motivational interviewing to result in less resistance, increased
compliance, lower dropout rates, better attendance during treatment, and better overall treat-
ment outcomes (Harper & Hardy, 2000; Martino, Carroll, O’Malley, & Rounsaville, 2000;
Swanson, Pantalon, & Cohen, 1999).Twenty-five years after its development, motivational inter-
viewing has been evaluated in diverse settings (e.g., health, mental health, medical, health pro-
motion) and with a wide variety of health and mental health problems. These studies, like those
for SUDs, have also have found increased compliance, reduced resistance, decreased dropouts,
and better treatment outcomes (Britt et al., 2003; Burke, Arkowitz, & Menchola, 2003; Dunn,
Deroo, & Rivara, 2001; Knight, McGowan, Dickens, & Bundy, 2006; Miller, 1985, 2005; Miller
& Rollnick, 2002; Resnicow et al., 2002; Rollnick & Allison, 2001; Rollnick et al., 2008; Santa
Ana, Wolfert, & Nietert, 2007).
Further evidence of the widespread adoption of motivational interviewing is demonstrated
by the following figures: (1) the first edition of Miller and Rollnick’s book, Motivational Inter-
viewing: Preparing People to Change Addictive Behavior (Miller & Rollnick, 1991), sold over
55,000 copies; (2) the second edition (Miller & Rollnick, 2002), according to the publisher (Guil-
ford Press), has as of this writing sold over 180,000 copies and was voted one of the 10 most
influential books by Psychotherapy Networker readers; and (3) the Motivational Interview-
ing Network of Trainers (www.motivationalinterview.org) reports getting over 41,000 hits per
month on their website.
What Is Motivational Interviewing?
Motivational interviewing, an amalgamation of principles and techniques culled from different

treatment models and principles of behavior change (e.g., stages of change, Rogerian client-
centered therapy, social cognitive learning theory), is a goal-directed, client-centered coun-
seling style. It is designed to elicit intrinsic motivation to change by exploring and resolving
a client’s ambivalence about changing risky/problem behaviors. Rather than being prescrip-
tive (i.e., telling clients what to do), a motivational interviewing approach uses reflections and
other strategies to get clients to verbalize their need to change. Motivational interviewing also
helps clients resolve ambivalence by identifying discrepancies between their current behaviors
(e.g., continuing to engage in a risky/problem behavior) and their desired goals (e.g., wanting to
change a risky/problem behavior) while minimizing resistance. Although motivational inter-
viewing is particularly useful during the early phases of treatment, when resistance is often
high, it can be used throughout all phases of treatment, as it is a style conducive to a positive
therapeutic relationship.
Motivational Interviewing Strategies and Techniques 27
Ambivalence: A Normal Occurrence

Part of a motivational interviewing approach is recognition by therapists that ambivalence is a
normal everyday occurrence, which makes change difficult. Ambivalence is not a reluctance to
do something. Rather, it is a conflict about choosing between two courses of action (e.g., con-
tinuing to smoke cigarettes vs. quitting; staying in a marriage vs. getting a divorce; doing regular
finger pricks to assess one’s blood sugar levels vs. not doing them regularly), each of which typi-
cally has costs and benefits. In many ways, ambivalence is a battle between conflicting emo-
tions. This is consistent with the Latin origin of the word ambivalence, where ambi- means both
and valence is derived from valentia- meaning strength.
Empathy: A Key Element in Motivational Interviewing

Empathy is one of the most important elements of a motivational interviewing approach. An
empathic style (1) communicates respect for and acceptance of clients and their feelings, (2)
encourages a nonjudgmental, collaborative relationship between the therapist and client, (3)
establishes a safe and open environment for the client that is conducive to examining issues and
eliciting reasons for change, (4) compliments rather than denigrates, and (5) allows clients to
make choices rather than having therapists or practitioners telling them what to do.
The key to expressing empathy is to use reflective listening, in which therapists listen care-
fully and then reflect back to the client what they think the client has said. By using reflective
listening, therapists validate that they understand the client’s feelings and concerns (e.g., “It
sounds like you are ambivalent about changing”). High levels of empathy are associated with
positive treatment outcomes for clients with SUDs (Connors, Carroll, DiClemente, Longabaugh,
& Donovan, 1997; Miller & Brown, 1997), as well those with psychiatric problems (Horvath &
Luborsky, 1993).
Motivational Interviewing:
An Intervention or an Interactional Counseling Style?
In the literature, motivational interviewing has been defined and presented both as an inter-
vention and as an interactional counseling style (e.g., Resnicow et al., 2002). In part, the confu-
sion has arisen from Project MATCH (Heather, 1999; Project MATCH, 1993; Project MATCH
Research Group, 1997), a multisite study of treatments for alcohol problems. In Project MATCH
a treatment utilizing motivational interviewing was designed as an intervention referred to as
Motivational Enhancement Therapy. The first to comment on this were Saunders and Wilkin-
son (1990), who several years ago said, “Motivational interviewing is not a treatment in itself, but
is rather one component in the counseling process” (p. 139). Comments from others, including
Miller and Rollnick, support the view that motivational interviewing is an interactional counsel-
ing style rather than an intervention: (1) “Rather, it is an interpersonal style, not at all restricted
to formal counseling settings. It is a subtle balance of directive and client-centered components
shaped by a guiding philosophy and understanding of what triggers change” (Rollnick & Miller,
1995, p. 325, emphasis added); (2) “Motivational interviewing has become widely adopted as
a counseling style for promoting behavior change” (Markland, Ryan, Tobin, & Rollnick, 2005,
p. 118, emphasis added); and (3) “Motivational interviewing (MI) is a counseling style that has
been shown to reduce heavy drinking among college students” (Walters, Vader, Harris, Field, &
Jouriles, 2009, p. 64, emphasis added).
Focus and Tone of Motivational Interviewing

In motivational interviewing the focus is on the clients’ concerns and beliefs about changing
their risky/problem behaviors. A client’s ambivalence is explored in a manner that increases
motivation to change without eliciting resistance. Motivational interviewing does not attempt
to convince or coerce clients into changing. Rather, the intent is to get clients to give voice to
the need to change. Using motivational interviewing strategies and techniques, as shown in the
following example, allows therapists to guide clients through the change process with clients
doing much of the work.
Example of Having the Client Give Voice to Changing
Therapist: “You mentioned that your drinking has started to cause you more problems in the
last year, especially with your family. What will happen if you continue to drink over the
next year?”
Client: “If I don’t stop drinking I think it is just a matter of time until my wife and kids leave
me.”
The tone of a motivational interviewing approach is empathic, nonjudgmental, nonconfron-

tational, and supportive, such that clients feel comfortable discussing the good and less good
things about their risky/problem behavior(s). Therapists who use a motivational interviewing
tone avoid (1) moralizing (e.g., “You should . . . ”), (2) sounding judgmental (e.g., “You are wrong
to think that you can quit by reducing your drinking”), (3) being stigmatizing (e.g., using labels
such as addict), and (4) being confrontational (e.g., “Can’t you see that you are going to kill your-
self if you don’t stop doing drugs?”).
Content of Motivational Interviewing

While a motivational interviewing style is designed to minimize resistance, the content of moti-
vational interviewing interactions is intended to elicit dialogue and change talk from clients.
Content relates to what is said. As reflected in the following examples, there are huge differ-
ences between a nonmotivational and a motivational way of asking clients about their behavior
(i.e., content).
Content reflecting a nonmotivational Content reflecting a motivational

interviewing style interviewing style
• “Do you have a drug problem?” • “Do you mind if we talk about your
recent drug use?”
• “Are you an alcoholic?” • “What are the good and less good things
about your alcohol use?”
Exploring the Variety of Random
Documents with Different Content
be dissolved, but only to be penetrated, with conservation of their
forms, as they were when put in, and, without any diminution, to be
transmuted into better Metals; which in ♄ is most easy to be done.
Yet any Aqua Fortis, although you add to it thrice so much common
Water, will prey upon and dissolve ♄, ♃, ♀, and ♂, which is a thing
to be studiously avoided. Into the aforesaid Gradatory Water, in
which the fixed 🜍 is, cast a little common Salt, then the Aqua Fortis
becomes Enemy to the Lead, and assaults it, but indeed only to
penetrate, (not to dissolve the same) and to introduce the fixed 🜍.
After the Lead hath lain in such Water about 14 Days, it will swell
and wax white, leaving one half of it self upon the Cupel. But the
longer it shall lye in the Gradatory Water, so much the more
amended will it be.
If fixed 🜍 could as easily be turned into Gradatory Waters, the
same may easily be fixed; assuredly in the whole World there would
be no one particular more desirable than this, by the help of which,
great Riches might be acquired. For this same humid Graduation
requires almost no trouble or labour, more than putting filed or
rasped Lead for some time into the Gradatory Water, and after
Gradation, to take it out and cupellate it; being such a kind of Work,
as by Chymists is accounted a Childish Labour.
But to know and be able to convert fixed 🜍 into a Gradatory Water,
is the principal Artifice; and to participate of that, all diligence must
be used by him, whosoever he be, that is desirous to reap pleasant
and profitable Fruits from Chymistry. What do you desire? All things
needful to be spoken, cannot clearly be explained with a Pen; yet if
any one shall acquire the Salt of Metals, he may easily so far
introduce fixed 🜍 into Metals by that, as they shall be amended
thereby. Hitherto I have plainly enough described the Fixation of 🜍,
and prolixly demonstrated, how ingress may be procured to it, as
well by the Humid, as by the Dry way. Wherefore, whosoever shall
think himself concerned herein, let him follow these Prescripts, until
he find so much Good, as the favour of G O D will grant to him. For
the All of our hope depends on the blessing of G O D.
In the mean while, I am not willing to conceal from the Searcher
of Art, this one only Artificial Manual Compendium, of converting 🜍
easily into a Gradatory Water. We above said, Aqua Fortis could find
no ingress for it self to the fixing of 🜍, before it was procured to it by
the help of Sal Mirabile. Therefore, since the way of preparing Sal
Mirabile is various, and one Salt is always more constant than
another; great Caution must be used, that the Sulphur be so
handled and accommodated, as it may be suddenly dissolved by the
sharp Aqua Fortis, and so not be precipitated into a white Powder.
For if this be not done, it will indeed be fixed by the Aqua Fortis, but
become very difficult to be dissolved. If it be well dissolved the first
time, after Fixation it will be easily dissolved. Which is a thing worthy
and profitable to be observed: For the whole hinge of Art consists
here. Therefore, if any one be well Skilled in Spagyrick Labours of
Fire, he will easily bring this Prescript to a good Effect; but if he be
not such, he will Labour in vain, and lose his Charges; and that not
without the good Pleasure of G O D, who Wills not, that every Man
should be made Rich. Nevertheless, if any one, with an indefatigable
study and patience of Search, shall hit the Mark, he will give thanks
to G O D and to me: If not, let him impute the Error to his own
unhappiness, since I have writ so openly and clearly, as no Man
before me ever did. My purpose is in this place to discover one most
excellent Secret; by the benefit of which, fixed 🜍 may easily be
changed into a Gradatory Water, and that the following way.
Choose such 🜍, as unto which Nature hath given greater Efficacy,
than to the common 🜍; such, I say, as is in a sort Mercurial, and in
which such beginnings of the Operation of Nature discover
themselves, as thence may be made a Metal of a Golden Disposition.
Such a Mercurial 🜍 you shall scarcely find in all the Metallurgy of
Gold; and that naturally Red, both internally and externally; and is
otherwise called by Paracelsus Embryonate Sulphur, or Cinnabarine
Sulphur, or immature mineral Electrum; but by Miners vulgarly called
the Flower of Gold: Also you may perceive it to have a great
Communion and similitude with Auripigment and Antimony. This
Sulphur is Mercurial, and toucheth Metals with a more near Affinity,
than vulgar simple 🜍, because after Fixation it is easie to be
dissolved, and before Fixation better to be wrought upon than
common 🜍, which partakes of no Mercury. And this 🜍 in the
abstraction of Aqua Fortis gives forth more of a beautiful Tincture
than any other common 🜍. Also this pure Soul may much better be
used in Medicine and in Alchymy, because it is both Mercurial and of
greater Efficacy, than the Soul of any common 🜍.
Note: Common 🜍 is not so easily prepared for Solution, as this;
because it is Mercurial, and therefore, hath more Communion with
Aqua Fortis, to be dissolved by help of it. And after it is dissolved, in
the Distillation it gives forth more Soul, and the fixed 🜍, which
remains in the bottom, is of greater Virtue in Medicine, than the
other of common 🜍. For by how much the more pernicious Venome
it was before Fixation so much the more Efficacious Medicine doth it
become, after the Venome is inverted by Fixation, and converted or
prepared into an Antidote or Treacle. Such 🜍 may also another way,
more commodious, than by Sal Mirabile, be prepared for easie
Solution: Which indeed is a thing of great moment, and worthy to be
observed.
This short, but necessary, Admonition I thought good to subjoyn
for the sake of the Searchers of Art; to the end it might be known,
that one 🜍 is better than another for preparing the aforesaid
Gradatory Water. Nevertheless, the known common Sulphur, as well
as that of Wood, is sufficiently conducible to be washed and fixed.
More at this time I have not to advise. In the mean while, if any one
be desirous to Labour, he may ingeniously search out all things fit for
his Invention, and earnestly strive for Riches. For I, without Envy, or
close Concealment, have so openly spoke my mind, as the least
blame cannot justly be imputed to me. But to prevent the Infelicity
of thy Error, my Reader, I could not do better, than I have here done
by Writing. Let it not be tedious to Thee to tread in our Footsteps,
and in the Footsteps of others, so long, as until you can attain to a
fortunate and desirable End; which will Crown your Work: Which
Work, by Idleness and sloath, together with Supine Ignorance, can
never be accomplished.
Having communicated these Gratis, every Man may hence satisfie
his Desires so, as not to trouble me further with his Inquiries.
A C O R O L L A R Y.
W e, in this small Treatise, have plainly shewed the Way or

Method, by which, every black Volatile and Combustible 🜍
may in the space of one day be converted, by washing, into a Snow-
like Candor, fixed and rendred constant in Fire.
Also how, in Fixation, the Aqua Fortis, being abstracted from the
Sulphur, carries with it self the most pure Soul of the Sulphur,
renders it fixed and durably permanent in Fire; and besides, that it is
not only a present Remedy for expelling Diseases most grievous in
the humane Body; but also, that it is endued with the Power of
transmuting imperfect Metals into ☉ and ☽, yet particularly only,
being destitute of such ☿, as can sufficiently extend it self in Efficacy.
Likewise we have taught, how to the more gross part of the 🜍,
which remains in the bottom, ingress may be procured for the
amending of Metals with Profit, both in the humid and the dry way.
Lastly, we shewed, how much one 🜍 excels another, and such 🜍
was to be accounted more excellent which contained in it self pure
☿; and that especially to be the most excellent, which before Fixation
was judged most venemous; and that for this Reason, viz. because
every Supream Venome, after Preparation, will become the highest
Medicament; and that the Melioration of such Sulphur is much more
Efficacious, than common Sulphur. Wherefore in this place, I am
willing, again and again, earnestly to commend to the Lovers of Art
Antimony, Red Arsenick, Yellow Auripigment, Ash-coloured
Cobaltum, Cakimia and Zinck, with Bismuth; because all these are
more excellent than common Sulphur. But he, that elaborates such
Subjects, so venemous, must studiously beware of the evil Fumes
arising from them. For as such a Subject before Preparation is mere
Venome, so, in preparing, its venomous Disposition is more and
more increased; but after Preparation, that which was deadly, now
becomes a most Salubrious Antidote or Treacle, and present Remedy
against all kinds of Poisons.
Note: Whosoever is desirous to be securely freed from all Peril,
him I would advise, to learn the way of fixing some common 🜍,
before he rashly attempts to invade the Fort of such noxious
Venoms.
Therefore, whatsoever we have hitherto taught are not vulgar
Matters, or Arts well known before, but merely great Arcanum’s, and
those very lately invented. For, who could believe, that common 🜍, a
Substance easily inflameable and burnable, should in one day be so
fixed, as to be able to remain unhurt against all the force of Vulcan?
Who could have persuaded himself, that the most venemous
Venoms, as Cobalt, Arsenick and the like, may in one day be
Artificially inverted, and their mortal Venoms converted into
Salubrious Antidotes? Lastly, who could ever have thought, that of
the most Volatile Mineral Subjects, as 🜍, Antimony, Arsenick,
Auripigment and others of that kind, in the space of one day may be
prepared a Tincture (constant in Fire) for humane and Metallick
Bodies? No Man, if we had not in this small Treatise so evidently
demonstrated that, as it may be plainly understood. Wherefore, as I
have formerly said, so I am now ready to affirm, that I, in this small
Treatise, have revealed so great and admirable Arcanum’s, as no
Man (as far as the Memory of Man can tell) hath publish’d any thing
more clearly than I, touching such Secrets.
If any one is desirous to Learn, whence so swift a Fixation of
combustible Sulphur, or so sudden Metamorphosis of most deadly
Venoms, ariseth; to him, I will now discover the Cause. It is
sufficiently manifest, that Spirit of Nitre, as well as Aqua Fortis
distilled from Vitriol and Salt Nitre, possess such a fiery Disposition,
by which all combustible and Volatile Minerals are ripened. And
being ripened, they are also fixed; as if fixed things must of
necessity be Mature, and consequently no more noxious or deadly to
Mortals. For whatsoever is rough, crude and immature, the Stomach
of Man cannot digest, but rejects and casts out that, (by which it
may be injured) as Venome: According as is easily discerned in all
Catharticks, either Vegetable, Animal or Mineral, which, by reason of
their Crudity, are so great an offence to the Stomach of Man, as it
frees it self from them, either by Vomit or Seidge. And the more
crude and immature Purgers be, the more strongly do they Operate.
Hence usually (by the Prescript of Physicians) Purgers that are too
violent, before they be taken into the Body, are amended by Fire. As
for Example. Squills and Diagridium, which too vehemently Purge,
are covered over with Dough and baked in an Oven, for correcting
the excessive Purging property in them, that they may cause
Evacuations more moderate and more safe. Antimony immoderately
Purging, is excocted, or melted in an open Fire with common Nitre
and Tartar, by which it is so far corrected, as it Purgeth without
vehemency. The same also is so corrected by spirit of Nitre, as it
loseth its purging Property, and instead of its Cathartick Virtue,
acquires to it self a Diaphoretick and Diuretick Property.
Common Tartar, taken into the Body, performs the Office of a
Cathartick: But the same, when the ripening Heat of the Sun, in the
more hot Regions of the World, hath took from it, its Acidity, and it,
in the Fermentation of Wine, becomes a fiery Spirit, it no more
exerciseth a purging Property, but rather hinders Purgers, and so
amends them, as they cannot Purge with so great vehemence, as
they were wont to manifest, before Correction; as is already
demonstrated by Us, where we treat of the Extraction of purging
Vegetables. Therefore if the common Fire of Coals, and Spirit of
Wine, correct Vegetables and Animals immoderately purging; why
should not the most strong Fire of Salt, such as Aqua Fortis is,
correct the most venomous Mineral Subjects, and be able to
transmute the same (deposing their noxious Qualities) into an
Antidote or Treacle?
From all which, it is sufficiently manifest, that in correcting even
the most venomous Subjects, Mineral Spirits of Salt are sufficient;
being such, as can deprive them of all their pernicious Venome, and
change them into salutary Medicaments. Wherefore, I doubt not, but
that the ingenious Reader, by these few things demonstrated, will
sufficiently understand the cause of this sudden Correction or
Fixation of all Volatile and venomous Mineral Subjects. When Ancient
Philosophers, by Poetical Parables, described the laborious
Navigation of Jason to the Island Colchos, where resided an huge
Dragon vomiting Fire, which, with Eyes never closed, diligently
watched the Golden Fleece; they added this, viz: that Jason was
taught by his Wife Medea, to cast to this waking Dragon an edible
Medicine to be swallowed, whereby he should be killed and burst;
and that Jason should presently take the Dragon (thus slain) and
totally submerge him in the Stygian Lake. Jason, in this ingenious
Fable, Hieroglyphically represents the Philosophers; Medea, accurate
Meditations; the laborious and perillous Navigation, signifies
manifold Chymical Labours; the watching Dragon vomiting Fire,
denotes Salt Nitre and Sulphur; and the Golden Fleece is the
Tincture or Soul of Sulphur, by the help of which, Jason restored
Health to his Aged Father, and acquired to himself immense Riches.
By the Pills of Medea is understood the Preparation of Sulphur and
Sal Mirabile. By the total submersion of the Dragon in the Stygian
Lake, is intimated the Fixation of Sulphur by Stygian Water, that is,
Aqua Fortis. Whence, it is sufficiently clear, how obscurely the
Ancient Philosophers did describe their Fixation of 🜍 by Nitre, and
how secretly they hid it from the Eyes of the unworthy. But, since I,
in this Treatise, do as clearly as is possible discover all things, know,
that I do it not without Reason. It will be enough for any one, if he
rightly understand the Method of performing such a Fixation.
After any combustible 🜍 hath been fixed by Aqua Fortis, or Aqua
Regis, and ☉ and ☽ added to it in Fixation, then will that no more be
vulgar ☉ or ☽, being such as cannot again be dissolved in Aqua
Fortis, or Aqua Regis, nor upon a Cupel have Ingress into ♄, but
passeth as it were into a dry Earth, which can neither be reduced by
Borax, nor any other common fluxing Powders into a ductile Body. If
any one be desirous to know this by Experience, let him dissolve 🝳
of ☉ in Aqua Regis, and pour this Solution upon a Pound of Aqua
Regis, and also put this Aqua Regis upon ℥iiij of Butter of Antimony,
and abstract the Aqua Regis thence, Then he will find, that Gold,
which was in the Aqua Regis, to have mixed it self Radically with the
Sulphur and Mercury of Antimony; so as not only the Butter of
Antimony becomes fixed and irreducible, but it also renders the Gold
so irreducible, as thenceforth it can no more be separated from the
Antimony, but remains adhering to it in every Examen: And can only
be subduced by our Secret Salt of Metals, volatilized, or rendred
fusile, and so be introduced into other Metals for their Amendment.
Therefore, if such a destruction of ☉ can be made by Antimony,
less than the half of which is 🜍, but the greatest part ☿; how should
the same not be better performed by common 🜍, which is void of all
Mercury? I, in all those places where I have taught the Fixation of
Sulphur, did always advise, that Aqua Regis to be carefully kept,
which was abstracted from the Sulphur; but especially what
contained Gold; because together with the Aqua Fortis, the most
pure Soul of Gold and Sulphur ascends, and is as much fixed, (I
might say, more) as that which remains in the bottom. Wherefore, if
what I have here imparted be observed by any Reader, or by none,
it shall not trouble me, but I shall remain well contented, that I have
done my Part, and performed so much, as no Man before me ever
did; because I have openly taught the Method of extracting in a few
hours (by the help of Distillation) from ☉ and 🜍, or from ☉ and
Antimony, a fixed Tincture. And these I do willingly communicate to
the Searchers of Art.
Some write, that Miriam the Prophetess, and Sister of Moses,
knew the Art of elaborating the Tincture in three days, which seems
incredible to many Skilful Writers. But what will envious Persons
judge, when they shall hear, that GLAUBER, by a publick Writing,
without any manner of Concealment, hath taught the Method of
extracting a fixed Tincture out of ☉ and Antimony, fit to expel all
desperate Diseases out of the humane Body; and this work to be
compleated in one day? Undoubtedly they will exclaim and say: All
are Lyes, and such things are impossible to be done. The ignorance
and wickedness of these Men were much more tolerable, if, to their
Calumnies, they should also add, Our ignorant Brains persuade
amiss. For did they rightly know themselves they never would so
basely condemn and reprove the Experience of Others. But what
shall I write against such? Nothing, but the Old Proverb, Effeminate
Men, Effeminate Words; according to the Verse,
Each Bird so sings, as formed is his Bill;

And such as is the Man, so speak he will.
Indeed I would willingly have published more Examples, of the

Method of swiftly fixing Sulphur, but I am kept back by very weighty
Reasons. Yet I cannot chuse, but Commemorate these few things
thereabout; viz. that every 🜍, without the help of external Fire, by a
Secret invisible Fire only, which is added to the combustible 🜍, and
left with it for a small space of Time, in a cold place, becomes as
white and fixed, sustaining all force of Fire, as well as that Fixation,
which is made by Aqua Fortis, or his abstraction from the 🜍.
Wherefore this cold Fixation of Sulphur, by our Secret cold, and
humid Fire (because it needs no common Fire, no Body, and Head,
no Retort with its Receiver, and the like) is to be preferred before
the other Fixation by Aqua Fortis. Therefore for this, we give
Immortal Praises and Thanks to the most wise G O D.
If any Reader thinks, I have been too brief, or too obscure in this
Treatise, he may more amply satisfie his Desires from the two
following Tracts, where we treat of the Mercury and Salt of
Philosophers; whereunto we refer every one, that is a studious
Inquisitor of Art.
OF THE
M E R C U RY of Philosophers.
M
ercury may easily be extracted not only from all Metals and
Minerals, but also from Animals, and Vegetable Subjects,
and of the same (by the help of Gold) be prepared a true
Tincture for all the three Kingdoms.
We, from the Consent of all true Philosophers, do certainly know,
that ☿ is the most pure part of the three Principles of Metals, and
therefore doth spontaneously adhere to most pure Metals, and
always embraceth them with greater affection, than the impure
Metals. As for Example, Mercury most willingly adheres to its own
like ☿; next to ☉; then to ☽; afterwards to ♃, and ♄; and lastly to ♀;
but to ♂ most unwillingly, only because it chooseth rather to mix it
self with its like, than with its unlike. For it is wholly Homogeneal,
void of all Heterogeneal parts; such also are ☉ and ☽. The greatest
part of all other Metals is Heterogeneal, although there is found no
imperfect Metal, which hath not in it self some part Homogeneal; yet
so, as the Metal participates more of the one, than of the other;
according to the Writings of Philosophers. Wherefore, a true
Philosopher will scarcely affirm, that, by the benefit of the Tincture,
the whole Body of imperfect Metals can be transmuted into ☉ or ☽,
since so great Virtue is not insited, even in the Philosophers Stone it
self. For the immature, foul, stinking, combustible and superfluous 🜍
of ♃, ♂ or ♀, cannot, in so short time, as Projection is wont to be
made in, be converted into ☉, although you cast in more than
enough of the Tincture: But as much as the Metal hath of
Homogeneity, that is, of Mercury, in it self, so much only is tinged
and fixed into Gold, the Residue not so. Because the Stone separates
the Heterogeneal parts, that is, the superfluous 🜍 burning it self (in
the form of Scoria) from the Mercury, which it only tingeth into Gold;
because it hath no Communion with those Heterogeneities; as I
have daily found, and in the following Part, where we treat of the
Salt of Philosophers, I purpose to demonstrate more at large.
Now let us see the Method, by which Metallick ☿ may with little
Labour be extracted, not only from
Metals and Minerals, but also from all Animals and Vegetables. I
said, With little Labour, in respect of experienced Men. For in respect
of the Unskilful, it is not a Work of small Labour; but in the Memory
of all Ages it hath been accounted (by all the most experienced
Lovers of our Art) the Secret of Secrets, and the nearest way to
come to the Attainment of the true Universal Medicine. Nor will it
ever be of less Esteem, since in the whole Nature of things, a more
pure matter cannot be found, (whereof to make the Stone of
Philosophers) than this only Mercury of Metals. In the mean while, it
is easie to judge, that the Mercuries of Metals differ in themselves
notably, and that one of them is better, and more conducible than
another, for preparing thence a Tincture for Humane and Metalline
Bodies. For one is always better in Colour and Tincture than another.
Indeed, by the external Face, almost no Man is able certainly to
know, from what Metal or Mineral the best Mercury may be had: Yet
according to the general Opinion of Philosophers, the most excellent
☿ is wont to be prepared of the Vitriol of ♂ and ♀ ; because these
two Metals do most abound with Tinctures. I, being taught by
Experience, am assured, that out of black Ash-coloured ♄ may be
acquired a ☿, as excellently tinged, as from both those Red Metals, ♂
and ♀. Yet in the mean while I do not deny, that the ☿ of ♂ and ♀,
is impregnated with 🜍, tinging in the highest degree; as Ancient
Philosophers, in these few words, have compendiously expressed.
VITRIOLUM.
Visitaris Interiora Terræ, Rectificando Invenies
Occultum Lapidem, Veram Medicinam. By which Words,
VITRIOLUM [or Vitriol] is expressed; which process is no other, than
a Solution of Mars and Venus prepared by the Labour of Nature. But
Vitriol prepared thus by Nature, is never found so pure and clean, as
that which is prepared of good Steel, and pure ♀, by the help of Oyl
of Sulphur, or instead of that, Oyl of Vitriol: Because the Native
contains more Earthiness, than that which is made by Art. Now let
us return to our Mercury.
I think good here, to advise all the Lovers of our Art, not to bend
their thoughts so much upon vulgar ☉ and ☽, as to endeavour out of
them to extract their ☿ and 🜍. Because common ☉ and ☽ are
altogether Homogeneal, and have nothing of Heterogeneity in them;
and therefore difficult to be wrought on. And although they were as
easie to be wrought on as ♂ and ♀; yet it would be no Profit to use
them; because of their greater Price, and also because there is much
more Tincture contained in vile and contemptible ♂, than in ☉ it self.
It is true, this Tincture is not yet fixed, but is volatile, and may easily
be fixed. Wherefore I advise every one to seek ☿ in ♄, and 🜍 in ♂.
Upon ☉, in times past, through my Ignorance, I consumed much
without any Profit, and laboured Fruitlesly, until I had consumed
some Pounds of it, to find out for others a more safe Way; which if
any one had shewed me, I would never have laboured in vain. But I
was hard to believe, that they, who were unwilling to use common ☉
and ☽, could prepare an apt Tincture, for tinging imperfect Metals
into Gold. Yet since vulgar ☉ and ☽, do not only give easie Ingress
to those Tinctures, which draw their Original from the 🜍 and ☿ of
Philosophers; but do also further the Fixation of volatile Mercury;
therefore we cannot well be without them, in the Composition of the
Stone of Philosophers. Let the Lovers of Art take Cognizance of
these few things for their Information.
Now it is necessary to be known, by what Method the ☿ of
Philosophers may most commodiously be extracted from Metals and
Minerals, and by the help of ☉, be duly fixed by Art, into a Tincture
for humane and metallick Bodies.
First, we are not ignorant, that the purest part of Metals, viz.:
Homogeneal Mercury, is tyrannically held Captive in a certain
obscure Prison, by his most inveterate Enemy, superfluous burning
Sulphur. Therefore, if any one would unbolt his Chains, and set him
free, he hath necessity to mortifie and annihilate his Enemies, by
which he is so fast bound and imprisoned, before he breaks down
the Prison Walls, and delivers Mercury from Captivity: Which ☿ will
also bring forth with him his natural Brother, viz. tinging 🜍. These
being at Liberty, nothing will be wanting to fix them into a Tincture,
but the help of vulgar ☉. But if any one be not satisfied with this
short Paraphrase, let him read either Sandivogius, who hath writ an
intire Treatise of such a freeing of Captives; or Paracelsus, who, no
less eminently than plainly, hath discovered his mind touching the
same.
Now follows my own Experience, Way and Method, By which I

have several times freed the forementioned Captive, and set
him at Liberty.
Although I have my self extracted the Mercury of Philosophers
from Metals, by such divers Methods, as I mean here to discover;
yet I always found some better than other some. Therefore out of
such Processes, some of which we here subjoyn, every Man may, as
best pleaseth him, take which he thinks most conducible, and
proceed in Operating according to that, until he finds, what G O D
shall be pleased to bestow on him.
Mercury is never to be extracted from hard Metals, before they be
dissolved and unlocked. Unlocked more commodiously they cannot
be, than by the Corrosive Spirits of Salt. Yet since all Corrosives are
most inimical to ☿, they have no Power of making either Living or
Running Mercury. Therefore, after Solution, the Corrosives must be
mortified by contrary Salts; such are, Salt of Tartar, Spirit of Urine,
Sal Armoniack, &c. This being done, the Corrosives changing their
Nature wax gentle, and in Distillation permit the ☿ to ascend: Which
otherwise, without Mortification of the Corrosive, would not happen,
as you will learn by the following Processes.
Therefore, since it is most certain, that Metals are to be dissolved,
before ☿ (by the help of Resusoitating Salts) can be distilled thence;
we will first exhibit the Method, by which ☿ may be extracted from
such Metals, as Nature presents to us already dissolved; viz. Vitriol,
which is no other than Mars or Venus, or ♂ and ♀ together,
dissolved by the Universal Acidity. Hence, whosoever will use (in his
intended Work) such Vitriol, in which both those Metals are found
highly tinged and dissolved by Nature; he will not need by tedious
Labours to seek out a new Method of dissolving Metals, but may
spare both his Time and Charges. Therefore, now it will be
expedient to teach, how Mercury may be prepared of any common
Vitriol.
The Process follows.

Distil from common Vitriol, in the usual manner, an Acid Spirit, and
fiery Oyl, with strong fire, according to Art. For in the Spirit is latent
the ☿ of ♂ and ☿, which by Mortifying the Corrosive, may be brought
to light, and made Visible, as follows.
℞. Of Tartar, calcined unto Whiteness ℔ i, or ij, which reduced to
Powder, put into a Glass Body, on which set an Head with its Hole
and Tunnel in it, well luted; then apply a Receiver, and lute the
Junctures exactly. When the Body and Head is placed in warm Sand,
through the Tunnel, at one time pour on about one or two Lotones
of the sharp Spirit of Vitriol, upon the Tartar calcined; whence will be
caused so great Ebullition, as by its own proper Power the Spirit will
ascend from it. This Duel or Fermentation being ended, again pour
in some Ounces of that Spirit; which also leave, till all the Ebullition
ceaseth. Afterward reiterate the like injection, until that Acidity
contends no more with the Tartar: Which will be an Argument, that
the Salt of Tartar is sufficiently mortified. When you see this,
administer Fire, and by Degrees draw forth all Humidities, untill the
Vessel and Matter is Red hot. The Water that ascended (which in
Taste will be almost like Spirit of Urine) must be rectified; in which
Rectification the ☿ of the Vitriol ascending, is rendred more subtile
and more pure. This pure Mercurial Water bears in it self invisibly
contained, a living Metallick Mercury, which is made conspicuous
thus,
The Conjunction of Philosophick Mercury with Gold.

Dissolve common ☉ in a sharp Aqua Regis, and separate the
dissolved from the undissolved. Then leisurely, and at times, drop
after drop, pour of your subtile Mercurial Water upon the Solution of
☉, so long, as until the Spirit of the Mercury hath no more Action
upon the Solution of Gold, but ceaseth, and all the ☉ shall be
precipitated from the Water. In which Precipitation, the ☉ attracts to
its self the Mercury of the Vitriol, from the Mercurial Water, in such a
manner, as it settles to the bottom of the Vessel, in the form of
Slime, or a yellow Powder. Let the Precipitate be filtred through
brown Paper, that the Saline Water may pass through; and the
precipitate ☿ remain in the Filter mixt with the Gold; which must be
very well washed with sweet Water, and, being edulcorated, dryed.
This being done, you will have the ☿ of Vitriol united with the ☉:
Both which will suffer themselves to be fixed into a true Tincture, for
Humane and Metallick Bodies, as follows.
The Fixation of Mercury with Gold.

Note: Before the Mercury is put in to be fixed with the Gold, it
must be proved, whether it be duly prepared, or not. For if the
Mercurial Water was rightly prepared, it will contribute Mercury
enough to the Gold; by which ☿ the precipitated Gold is so
augmented, as tis no more common ☉. But if the Mercurial Water
was not legitimately prepared, and consequently could not
contribute much ☿ to the ☉, the Gold will remain poor, and, as soon
as it is sensible of any heat, will fulminate, like any other fulminating
Gold, and so be altogether unfit for Fixation, being destitute of a
tinging ☿, which should have converted the whole Body of ☉ into
Tincture. Wherefore, after Precipitation of the ☉ and ☿, you must
make a small part of the Precipitate hot, in a very small Crucible, for
Tryal, whether it be fit to be fixed. For if it fulminates, like
fulminating ☉, it is a sign your Mercurial Water was not perfect, and
could not give unto the Gold ☿ enough. But if after it shall be Red
hot in the Fire, it comes forth with a delicate purple Colour; it is to
be supposed, the ☉ hath imbibed ☿ enough, and they both be fixed
together into one Tincture.
Note: Beware of too strong a Fire. For this way the Mercury will
leave the Gold untouched, and fly away; so as, thence you can have
no certain Tryal. Therefore, in all parts of the Work proceed Warily
and Prudently. The Fixation of ☿ with ☉ is thus made:
The Fixation of the Mercury of ♂ and ♀, into one Tincture.

℞. So much as you have ready prepared of this our Mercury
impregnated with Gold, although there be no more of it, than half a
Loton: For here no great quantity is desired. Put it into a small Glass
Phial, which place in hot Sand; yet take heed, you give no stronger
Fire, than your Volatile Bird can bear. This Fire you must continue in
a moderate degree for some Weeks: For by that means, your
Mercury will by little and little, be able to brook the Fire, adhere to
the Gold, and convert the same into Tincture. But if any one,
contrary to the serious Interdiction of all Philosophers, make too
much haste, and persuade himself, he may in a shorter space of
time acquire the Tincture; his Mercury will fly away, and leave the
Gold pale behind it; because the ☿ in its flight substracts the Colour
of the ☉, and carries it away with it self. Therefore, in Fixing there is
need of Patience. Hence all Philosophers advise, not to be hasty. For
Festination proceeds from the Devil. Wherefore, let every one so far
study his own Good, as to be obedient to this Admonition.
Note: There are also other ways, or Methods, of fixing ☿ with ☉;
but he doth very foolishly, who, when no necessity urgeth, will
prostrate all things together and at once, at the feet of Swine.
Whomsoever G O D will be pleased to assist, he may triumph in the
highest help; but whom G O D doth not assist, even the most plainly
prescribed Method cannot help him. For all our help depends on the
divine Blessing.
How to prove, whether Mercury be Legitimately prepared, and

whether it can give forth the Tincture of Metals.
℞. Of the Mercurial Water above described, and mortifie it by a
contrary Acidity, as Oyl of Vitriol, or Spirit of Salt. Then the Mercury
will precipitate it self, in the form of an Ash-coloured Powder, which
if you edulcorate, and grind with Oyl of Tartar, you will vivifie. If any
one be minded, he may also distil the same by Retort, and so
examine it.
A Tryal, or Proof, whether the Mercury of Metals be so well

prepared, as of it with ☉ may be made a Tincture.
℞. A little of that, viz. the quantity of a Pea, and put it upon a
Silver Plate, then over the Fire permit the Mercury to be evaporated.
If it tinge the Silver well with a purple Colour, it is fit for the Work,
otherwise it will be of no Value. Also, this ☿ may be digested with the
filings of ☉, in a due measure or proportion mixed, and so fixed. But
this Fixation, as well as the former, require along time, and so much
Patience, as all Festination must be laid aside. Whosoever is so
covetous, as he cannot wait till the Fruits are Ripe; he would be
better advised, if he abstained from so great a Work, than to set
about it to his own Damage. I have often prepared this Mercury, and
put it to be fixed; but because I could not look to it my self with my
own Eyes, I was constrained to commit the Governance of the Fire,
to the Industry of another, and then it succeeded unhappily. And
when by reason of my Age, and imbecillity of Body, I was wholly
uncapable to take in hand a Work of so great moment, I
communicated the Method to some of my intimate Friends, with this
Condition, viz. that they should elaborate it themselves. But because
in that Operation, they could not acquire so much ☿ as they desired,
they desisted, and would not proceed to the Compleatment of the
Work. Hence I was moved rather, by Printing, to divulge so Royal a
Work, than to let it be buried with me: Although I was difficultly
brought to an hearty Assent, to yeild to the Revelation of Arcanum’s,
of so great moment, to this Malignant and unfaithful World.
The way of Preparing a tinging Mercury out of Antimony.

℞. Of Antimony, Saltpeter, and Tartar, of each ℔ j. Which, first
pulverized and mixed, put into a Crucible, and kindle the Mixture
with a Coal; when the Fulmination ceaseth, melt it, and pour it out
into a Cone. After it is cooled, separate the Regulus from the
Scoria’s; which reduce to Powder, and dissolve by boyling in Water.
So doing, you will have a Red Lixivium; upon which if you add
(about half its own weight of) Salarmoniack pulverized, and put the
Mixture into a Glass Body, (which must not be above half full,
because it riseth easily) with it’s Head and Receiver well luted, and
then subminister Fire for Distillation; a certain most subtile volatile
Spirit will ascend, in which the ☿ of Antimony is latent: Which, in a
Solution of ☉ may be precipitated, edulcorated, dryed, and then
proved and fixed, as above we taught of the Mercury of Vitriol.
Antimony yeilds much more ☿, than Vitriol; and it is also made more
easily than it; and therefore to be preferred far before it; but
especially, because the Ancient Philosophers did for the most part
use this ☿ of Antimony, for preparing their Tincture.
Note: If any one desire a more excellent ☿ of Vitriol, than That
above described by Us; he, instead of the Lixivium of Antimony, may
use a Lixivium of Salt of Tartar, and thence extract Mercury by the
help of Oyl of Vitriol; so he will have some thing more excellent,
than can be made of a Common Lixivium.
The way of Preparing out of ♂ and ♀ a tinging Mercury, by the

help of Resuscitative Salts only, without any Corrosives.
Among all Resuscitative Salts, Tartar obtains the principal place;
the next to which is Salt of Urine, which is no other, than such a
Volatile Tartar as passeth into this kind of Salt, from Wine, Beer,
Bread and other Foods taken into the humane Body. Almost of the
same kind, is the Soot of Chimneys, being the Volatile Salt of Wood.
Also a like Volatile Salt you shall find in Blood, Hairs, Horns and
Hoofs of Animals. Even so, almost a like Salarmoniack is prepared of
Blood, Urine and Soot. In like manner, in Eggshels is insited an
efficacious Resuscitative Salt. These and the like Salts are endued
with a Virtue converting Metals into Mercury, after they are
dissolved. For volatile Salts are not so efficacious, as to dissolve
Metals: Yet Tartar is endued with so great Power, as it can dissolve
some Metals easie to be dissolved, as ♂, ♀ and ♄, and thence may
the Mercury be extracted by Distillation; especially if a little Kitchin
Salt be added, or (which is more conducent) Salarmoniack, to
comfort it. Also instead of ♂ and ♀ , common Vitriol only may be
used; and thence Mercury distilled by the help of volatile Salts.
Now follows the Process.

℞. ℔ vj. Of Vitriol, to which, dissolved in Urine, add of
Salarmoniack ℔ j. Crude Tartar ℔ ij. Salt of Tartar ℔ iiij. Distil from
these, in a strong Glass Body, a subtile Mercurial Water; which,
according to the Method prescribed, may be made Corporeal, and
with Gold be fixed into a Tincture. This way of proceeding is very
easie, and of little Charge; so as it will fully satisfie the desire of
those, who are contented with so much only, as may be acquired by
the benefit of Glass Bodies. But those, whose greedy desire cannot
be satisfied with little, may distill this Mixture in a Brass or Copper
Vesica, untill they have quantity enough to suffice them: Yet with
this Caution, that they use no Alembick, or Refrigeratory made of
Copper, but of Lead, or (which is better) of Tin; and that because
our Mercurial Water easily corrodes the Copper, and thence contracts
to it self a Greenness: But in ♄ or ♃ doth not so. But if any one
refuseth to be at the Charge of a Tin Refrigeratory, he may use his
Copper Vessels. For although the Spirit corrodes the Copper, and
contracts a blewish Colour, yet this Colour in Rectifying abides in the
bottom, and the ☿ is nothing the worse. Indeed, this way a greater
quantity is acquired, than needs; unless the Operator be more
greedy than a Wolf. But it is not the part of a good Philosopher, to
covet more than is needful. If any one be desirous to prepare an
abundance of Mercurial Water, either by some such way as this, or
by another certain Mixture of Salts, him we have now, as it were, led
by the hand, through Processes more difficult, to proceed in these.
For Tartar alone will be sufficient for such an Use. What seek you?
The Feces of Wine burnt will do the same; so as the Lover of Art,
with almost no other Trouble and Charge, may extract the Mercury
of Metals by Resuscitative Salts.
The way of Preparing Mercury out of Metals and Minerals, by

the benefit of Tartar only, without any other Salts.
℞. Filings of Steel ℔ j. Tartar ℔ ij. Common Water ℔ xx. If by
strong boyling by Alembick in Sand, you distil thence all the Water;
the Tartar in that boyling dissolves the ♂ , and so will Volatilize the
Mercury set at Liberty, in such wise, as it will ascend with the Water,
like a subtile Spirit; which, (concentrated and made fit by
Rectification) either by a Solution of ☉, or by some other contrary
Acidity, is rendred Corporeal, according to the Method above
shewed. If any one, to as much Tartar as he hath, take half so much
Salarmoniack, the Tartar so much the more readily preys upon the ☿,
also much more Mercury issueth thence, than by Tartar only.
Note: But since this way, in one Distillation, but little Mercury
ascends, such an Operation may be performed in a large Vesica; yet
with this Caution, viz. that the Alembeck and Refrigeratory be not
made of Copper, but of Tin or Lead. This way of Operating by a
Vesica will be of great use, especially for such covetous Men, as
cannot be content with few things; but always labour with the
perpetual Poverty of an unsatiable Spirit; although, they more than
sufficiently abound with the fulness of all desireable things. For he is
only Rich, who is always content with his present Fortune.
The way of Preparing Mercury of Saturn, by Tartar only.

℞. One or two ℔. of the Raspings or Filings of Saturn, upon which
pour fifteen, or twenty ℔. of strong Vinegar of Wine, and mix
therewith a little pulverized Tartar. But the Vinegar per se should be
impregnated with no small quantity of Tartar. Which Tartar, if you
distil with the Mixture, the Phlegm in Distillation carries over with it
self a subtile Mercurial Spirit; which must be separated from the
Phlegm, in manner as we above taught. The Solution of ♄ will
remain in the bottom. Thence also, by the help of Salt of Tartar, ☿
may be extracted by Retort; yet it is not so good as the other, which
ascended in the form of a subtile Spirit.
The way of Preparing Mercury of Antimony, by the help of Tartar

only.
℞. Some Pounds of strong Antimonial Red Lixivium, (made of
Antimony duly, decrepitate and melted with Tartar and Nitre) which
put into a Glass Body set in Sand, as we above taught, in treating of
the Fixation of 🜍: Afterward, through the Tunnel, leisurely and at
times, pour upon the Lixivium most strong Wine Vinegar, until both
(viz. the Lixivium and Vinegar) cease to Act upon each other. This
being done, if by Distillation you separate all the Humidity, the
Sulphureous Spirit of Antimony, will ascend in the form of a subtil
Spirit, smelling like Sulphur: Which after Rectification, either with a
Solution of ☽ or ☉, becomes Corporeal, and so habile, as it may be
converted into a fixed Tincture.
The Method of Distilling a tinging Mercurial Spirit from Metals

another way.
We above shewed, that from Metals most firmly compact, a
tinging 🜍 and ☿ could not be extracted, unless the Metals be first
dissolved, or mortified; and that in such Mortification, there is a
Spirit so apt to be associated, as, in the very hour of Mortification, it
lays hold of, and carries up with it self, the ascending Spirit, or Soul
of Metals. Yet among all, pure Spirit of Wine well dephlegmated, I
judge best; because in abstraction it carries over with it self the
most pure 🜍 and ☿ of Metals, and leaves the Gross dead Body
behind in the bottom; so as, such Mercury, as you shall draw forth in
distilling by Spirit of Wine, will be much purer, and more Virtuous in
Tinging, than the other, which you distil off by common Water only;
and that for this especially, viz. because this Spirit, which is
extracted by Spirit of Wine, from more pure is rendred most pure by
Rectification. Which is a thing impossible to be effected, where the
Sulphureous ☿ of Metals shall ascend by the help of common Water;
because then the Water only, in Rectification, is distilled off, but the
🜍 remains in the bottom, in form of a Red Powder: And the other,
which is sublimed by Spirit of Wine, and afterward by Rectification
subtilized to an higher degree, and meliorated in its tinging Virtue, is
not only in Medicine, but also in the Melioration of Metals, Gems,
and the more ignoble pretious Stones, an hundred fold more
efficaciously conducent to tinge them to a Constancy, than the
former, which, in distilling, ascends by Water only; and by
Rectification cannot be exalted, or multiplyed in its Virtue, so well as
the other, made by Spirit of Wine. That Sulphureous ☿, which
ascends by help of Spirit of Wine, is endued with so subtil and
penetrative Power, as to it in the Vessel is given such Ingress, by
which Metals and Gems are tinged with a more constant and durable
Red, or Yellow Colour, than can be annihilated or impaired by any
Corrosive Waters, or by the violence of Fire; especially if it be
distilled from apt tinging Subjects, as the Vitriol of ♂ and ♀, or from
Antimony. Of which I suppose enough is now spoken.
Therefore, if any one be desirous of knowing more touching this
Matter, him (for his further and more clear Information of the same)
I refer to the Seventh Part of our Spagyrick Pharmacopœa; where
he will find, we have prolixly taught, touching the extraction of
Tinctures, from Red Corals, and other tinging Subjects.
The way of making good Mercury of Saturn and Luna.

℞. Of ♄, or ☽, ℔ j. which, dissolved in Aqua Fortis, precipitate with
Salt-water, edulcorate the Calx with Sweet-water, and dry it. When
dryed, mix with it a fourth part of our 🜍 fixed unto Whiteness. Distil
from the Mixture in a coated Retort its ☿ with strong Fire; which
notwithstanding will not be living ☿, but, in the form of a Sublimate,
will adhere to the Neck of the Retort, in weight heavy, and to the
Taste of the Tongue very sharp. Indeed there will not be so great a
quantity of it, as some may desire, yet it is worthy of the highest
Estimation. For in a Cold Cellar it is easily dissolved, and becomes a
strong Mercurial Water, which dissolves all Metals. This Water
prepared of ♄ joyns it self (with an incredible Love) with the Soul of
♂ ; and suffers it self to be fixed with it into Tincture; This Water
prepared of ☽ readily dissolves Gold, and with it passeth into
Tincture. The Reason, why, I in Distillation, mix fixed 🜍 with the ♄ or
☽, is this: Since both these Subjects, precipitated, as we above
mention, with Salt-water, are very fusile and penetrating, easily melt
together into one, and in Distillation yeild no ☿. Nor can Sand or
Earth prevent this Fluxion. Wherefore, I could find nothing more
conducible, than our white fixed Sulphur.
The way of Preparing Mercury of Jupiter.

Jupiter gives forth from it self, a most excellent Mercury, in form
of a subtil Spirit; which, above all other Mercuries, is most earnestly
beloved and attracted by Gold. For if but a very small quantity of it
be put into any Solution of Gold, it in a moment draws to it self all
the Gold from the sharp Aqua Regis, and together with it settles to
the bottom, like a purple Powder. This is the best Precipitation of ☉,
when you shall extract it with Aqua Regis from Sand and Stones:
Because, by this Precipitation, the Aqua Regis may be used again for
extracting ☉ from Sand and Stones, as you may more amply read in
our Seventh Part of the Prosperity of Germany, where we have
plainly writ touching this kind of Extraction. But in another manner,
may be prepared as powerful a Mercurial Water from all Metals, by
the help of my Secret Sal Armoniack, which, by Paracelsus and
Helmont, is called the Liquor Alcahests touching which, I have
largely treated in the Seventh Part of my Spagyrick Pharmacopæa,
where he who loves so great Gifts of G O D, may satisfie his Appetite
to the full.
Behold, I present thee another way, by which, without any

Charge or Expense of Money, you may easily prepare as much
of the Philosophick ☿, as you will.
I would not have you to suppose, I here insert this so stinking a
Process, to the end you should follow this, rather than the before-
mentioned; but I add this, that the common sort of Men, simple and
poor, may see, that they may, by such a Method as this, suppress
their Poverty, and attain to the Acquisition of so noble an universal
Medicine, as well as any other of the great and mighty Men of the
World, by their ample Fortunes.
Whosoever is but a little Skilled in Chymistry, well knows, that
every 🜍 and ☿ arise from one only Original; and that the Sulphur in
Herbs, and also that in Animals, is of no less Virtue, than the other
in Metals, Fixation only excepted. For as this in Metals is found more
fixed than that in Minerals, so the Mineral 🜍 is more fixed than the
Animal, and Vegetable. The same is to be judged of Mercury. But
that we may wander no further, but return again to our Purpose, and
clearly prescribe the Method of Preparing an universal Medicine, of
Humane Urine and Dung, I will very briefly discover the Process in
these following Words.
℞. A good quantity of humane Dung and Urine, collected in some
capacious Vessel, and (after they have stood together about a
Month, and when the Salt shall be exactly united with the Sulphur,
and Mercury by Fermentation) from thence, by an Alembick in
Balneo, distil the Mercurial Sulphureous Spirit; which indeed will be
very subtil, but smell strong. Yet after Rectification, as we have
taught, it may be conjoyned with a Solution of Gold, and, by
moderate heat, be gradually fixed into an universal Medicine, for
Humane and Metallick Bodies.
Note: The aforesaid Stink vanisheth so soon as the Aqua Regis
hath Access. Wherefore, those Philosophers who have laboured in
Matters of evil and strong Smells, did always speak of suffocating
their venemous Dragon in Stygian Waters. But among all
Philosophers, that ever I read, I find no Man more excellently to
have writ, touching this matter, than the Philosopher Neusementius,
in a certain small Treatise of his, intituled, Of the Salt and Spirit of
the World; where he so explains the Table of Hermes, as he renders
it most worthy to be Read; because he hath so very prolixly, and
largely, with exquisit study and diligence, explained all things
whatsoever, the laudable Hermes, in very few Words, left to Posterity
in his Smaragdine Table.
A C O R O L L A R Y.
A lthough I have, in this small Tract, so largely and clearly treated

of Preparing the Mercury of Philosophers, as it seems
altogether needless to trouble the Reader, with a further Paraphrase;
since from him, I have not concealed any Methods of manual
Operation, but have so revealed all things necessary to be known, as
he (who, only seeking the bare Letter of the prescribed Method,
knows not how to elaborate his own intended Work) may rather be
accounted a Man of a dull Capacity, than a Chymical Operator: Yet
since unto all insatiable Sons of Avarice, according to this my
Description, there seems to be too small a part of Mercury extracted,
I (for the sake of those also) will demonstrate yet another Method,
by which they may obtain a larger quantity of good tinging ☿, than
from Metals can be gained. But first it is required, that every one,
who will exercise himself in this kind of Labour, should shew himself
a diligent Operator, shunning no Pains: Know, that Vulgar Mercury
may easily be so prepared by Art, as to be as much conducent for
Tinging, as the Mercury of Metals. Yet they must first procure
Tincture to it, by tinging Metals, as by ♂, ♀ and Antimony. For, of its
own proper Nature, it hath no Tincture at all in it self; but it must
necessarily receive the same from other Metals, (in which G O D and
Nature cooperating have insited it) before it can exercise the Power
and Faculty of Tinging. But which way such a Tincture may
commodiously be taken, and acquired from certain Stones tinged by
Nature, or from certain Metallick, and Mineral Subjects, hath been by
me, in various places of my Writings, so frequently mentioned, as I
judge it not necessary to Discourse further thereabout in this place.
But here, I will freely expose to publick view the way of Preparing
vulgar ☿ so, as it may be able to extract Tinctures from Metals,
Minerals and Stones.
℞. Common Mercury ℔ j. Which as soon as you have dissolved in
Aqua Fortis, mortifie the Aqua Fortis by pouring on Spirit of Urine,
and when you shall by Retort, in hot Sand, have abstracted thence
all the unprofitable Water, and administred a stronger Fire, the
Mercury will sublime it self in the Neck of the Retort, white in Colour,
but discovering no singular Acrimony upon the Tongue. Such a
sublimate as this, is easily dissolved by help of common Water. This
Mercurial Water is endued with a power of extracting Tinctures from
Metals, Gems, and other more ignoble Stones. In which very Work,
even Proserpina, the Wife of Pluto, will scarce elaborate any thing
more excellent: Therefore, when this ☿ hath drawn so much Blood
from the Red Lyon, as it no longer remains White, but becomes
totally Red; then indeed it hath acquired the Melioration of one
higher degree; but as yet, it is able to work no Miracles in Tinging.
Now, that it may be exalted to so great Perfection, as to be
admirably efficacious in Transmutation; this Red Mercury must again
be vivified, and again (as we taught above) mortified; and if this
Labour be repeated seven, nine, or twelve times, it will be
sufficiently impregnated with Tincture. This being done, you have
nothing else to do, but to fix this tinging Mercury into a fusile Red
Stone, which will thenceforth perform the same (yea perhaps more)
in the Transmutation of Metals, than the Mercury of Metals it Self.
Although, I have here revealed the Melioration of common
Mercury; yet, I am fully persuaded, no Man will readily set himself
about its Preparation, nor adventure, by Tryal, to experience the
truth of this. For commonly, every good thing is disesteemed, if it
want external Splendor. Some years ago, I did earnestly, and highly
commend to some of my most loving Friends, the Exaltation of
common Mercury; yet no one of them took so much notice thereof,
as ever to set his hand to the Work. Wherefore no Man needs to
fear, that Art will be made too common, although I had published
the same, described even with a Solar Ray. Indeed, I intended to
have divulged more, touching such sublimate Mercury, as may be
dissolved with common Water, viz. how many other famous Works
may be performed with it, besides the Transmutation of Metals; but
for brevity sake, I here desist at present: Yet after a little while, (if
G O D permit) I will elsewhere treat of the same. In the mean time,
let the loving Reader kindly accept of these: For hence he may be
assured of the possibility of exalting common ☿ so far, as to be equal
in Virtue to the Mercury of Metals: In which Assertion every studious
Artist may safely confide, and persuade himself, that I here give no
other Testimony, than I have learned by my own Experience
oftentimes.
OF THE
Salt of P H I L O S O P H E R S.
How, and whence, That is Prepared, and of what
use It is in Medicine and Chymistry.
T
hose our venerable Ancestors, the ancient Philosophers, have
indeed copiously written many things, touching this Third
Part of the Principle of Metals, viz. Salt: Yet so very obscurely,
as it is almost impossible for a Man to learn thence, Fundamentally,
any thing of moment: Yea, I might say, it hath happened to very
few, to know how, to prepare the Salt of Philosophers, but on the
contrary, six hundred have ruined themselves, and lost all their
Fortunes in labouring thereabout. After, I also had, for some years
together, expended great Labour and Cost, besides what I spent in
acquiring both the other Principles, viz. Sulphur and Mercury, (which
were understood by me, about two years since) it pleased the most
wise G O D at length, also to reveal to me this most famous Salt.
Wherefore, I could not refrain from communicating some thing of it
to Posterity, for the Glory of my G O D, and for divulging his
wonderous Works, not doubting, but that this my Revelation may be
of great Concern, to open the Eyes of this blind World. Because,
they may be helped by such a Salt, of which, so incredible Works
may be prepared, as I am now about to write, and are already
sufficiently known to me.
I can unto every Man safely, surely and truly affirm, that
whatsoever I here write, are not the idle Dreams of a vain Man, nor
patched together out of other Books, but true and solid Experiments,
which I my self, with the help of these my hands, have found out.
Indeed, I do not here say, that I could give no credit at all to him,
who no long time before discovered something to me, touching such
Arcanum’s; but I thought his Words intimated Paradoxes and
Impossibilities; although I had read Philosophers, who writ: He that
hath the Salt of Metals, hath the Stone of Philosophers. I also well
know, that the Salts of Metals, according as they been hitherto every
where fraudulently presented by Pseudo-Chymists, having no solid
Foundation, do not indeed deserve the name of Salts; being no
other, than such Vitriols, as by the sharp Spirits of Salts, are
prepared of Metals; and are not at all efficacious to meliorate any of
the more vile Metals. On the contrary, we certainly know, that our
more true Salts do so amend all imperfect Metals, as great and
gainful Fruit may be reaped thence, as by the following shall be
clearly made appear. But before we write any thing of the Use, of
this Royal Salt, it will be worth while to premise something briefly,
and truly, touching the Preparation of the same.
Of the Preparation of the Salt of Philosophers.

Now, that I may, without any wandring Ambages, describe the
Method of Preparing this Salt, which is incomparable and Royal,
know in very deed, that this Salt is no other, than common (but
rightly prepared) Oyl of Vitriol, Coagulated by white fusible Sulphur
into a sweet Salt, which impresseth not on the Tongue, the least
Saline savour; but rather seems to be a Stone than Salt, although
fusible, like any other liquid Salt. But how that Oyl of Vitriol, or
Universal Acidity, may be changed into such a wonderful Stone, not
Corrosive, I purpose not to divulge. It is enough for me positively to
affirm, it may be done.
Whosoever desires to know more of it, let him implore the help of
G O D, and peruse the Writings of Philosophers, that if he be worthy
of this divine Gift, he may be helped; if he be not worthy, I cannot
help him. For as I acquired that, not without praying and seeking; so
also, must every other Man resolve to do: Because, no Man shall
ever get more out of me, than what I here have willingly discovered
for publick Good. Now follows
The incredible Virtue and Efficacy, which this wonderful Salt
manifests in Preparation of Tinctures, for exalting all Metals
and Minerals to the perfection of Gold.
Although it is before said, that Salt, or the Stone of Philosophers,
is only prepared of Acid Vitriol; yet I thought it necessary also, here
to publish, that Oyl of Vitriol may be prepared divers ways, so as one
or another may prepare it this way or that way, as he pleaseth. For
the common and vulgarly known Oyl of Vitriol, suffers it self (by the
help of Sulphur) to be easily transmuted into a Sweet Stone:
Because Sulphur alone is endued with Power of edulcorating all
Corrosives, and of Coagulating them into such a Stone, or Salt, by
the benefit of which, Wonders may be done, both in Medicine and
Alchymy. Philosophers do indeed persuade us, that, out of Vitriol, an
Oyl of a Blood-Red-Colour may be extracted by Art, with which,
White Metals may be tinged into Red: But the way of Preparing this,
they described not. This is that, which is most studiously sought by
the Adorers of the Chymical Art, but hath hitherto been found by
very few; and therefore is generally thought, by almost all
Inquisitors, to be impossible, whatsoever Philosophers have writ
thereabout, and how clearly, and plainly soever described it. Basil
Valentine doth, with Paracelsus, call this our Oyl of Vitriol tinged with
a Red Colour, the Blood of the Green Lyon; but Bracesus, the Wood,
or Tree of Life; Virgil, a Bough, or Branch, plucked by Proserpina’s
help from the concealed Tree: Also, Ovid useth divers other
Expressions, in the Description of this Tincture.
This Red Oyl suffers it self to be Coagulated into a Stone, not
Corrosive, as well as the Common Oyl: But this Coagulate is totally
Red, and the other is White only. Therefore, there is a necessity, that
the difference of both be known. For of both these, what the White
is able to do, the Red cannot do; and what the Red can effect, is
impossible to be performed by the White. That Red Oyl tingeth white
Metallick Bodies into Gold, and so tingeth white Chrystals into Gems
of all kind of Colours, (according to the Operators Pleasure) as, in
Elegancy, they become altogether like to the Native. But the White
tingeth not, because it self wanteth Tincture, which notwithstanding

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A Contemporary Approach to Substance Use Disorders and

Motivational Cognitive Behavioural Therapy Distinctive

Overcoming Insomnia A Cognitive Behavioral Therapy

Managing Social Anxiety Therapist Guide A Cognitive

Cognitive behavioral therapy for bipolar disorder 2nd ed

Cognitive Therapy For Personality Disorders A Guide For

Innovations in Cognitive Behavioral Therapy Strategic

Cognitive Behavioral Therapy for Smoking Cessation A

Linda Carter Sobell

THE GUILFORD PRESS

All rights reserved

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

LIMITED PHOTOCOPY LICENSE

These materials are intended for use only by qualified professionals.

The publisher grants to individual purchasers of this book nonassignable permission to

Library of Congress Cataloging-in-Publication Data

First, to Mark’s mother, Mollie, and to Linda’s grandmother, Sadie,

Second, to our daughters and special friends, Stacey and Kimberly,

Integration of Clinical Material and Dialogue

We also are indebted to William R. Miller, a consummate scientist/clinician, who master-

List of Figures, Tables, and Therapist and Client Handouts xvii

Part I. Rationale, Research, and Assessment

Chapter 1. Guided Self-­Change Treatment and Its Successful Extension 3

Chapter 2. Overview of Motivational Interviewing Strategies and Techniques 25

Chapter 3. Assessment: A Running Start for Treatment 42

Part II. Guided Self-­Change: A Motivational Cognitive-­Behavioral

Chapter 4. Guided Self-­Change Treatment in an Individual Format 81

Chapter 5. Integrating Motivational Interviewing and Cognitive-­Behavioral Techniques 148

PART III. Conducting and Managing Groups: Pregroup Planning,

Chapter 7. Managing Groups: Structural Issues 196

Chapter 8. Managing Difficult Clients in Groups 203

Chapter 9. The Way Ahead 210

FIGURE 4.1. Cognitive components of the relapse prevention model. 89

FIGURE 4.2. Sample graphs of the six BSCQ profiles. 92

FIGURE 9.1. Stepped-care model of treatment. 211

TABLE 1.4. Clients’ End-of-Treatment Ratings of Treatment by Condition (Individual 17

TABLE 1.5. Clients’ Evaluations of Treatment at the 12-Month Follow-Up by Condition 19

TABLE 1.6. Therapists’ Evaluations of Clients by Condition (Individual or Group) 22

TABLE 2.1. Benefits of Quitting Smoking Timeline 37

TABLE 5.3. Group Rules and Their Rationales 167

TABLE 8.1. Suggestions for Responding to Difficult Clients in Groups 204

Therapist Handout 3.1. Objectives, Materials Needed, Procedures, and Client 55

Therapist Handout 3.2. Timeline Followback Instructions and Sample Calendar 57

Therapist Handout 3.3. Timeline Followback Instructions and Sample Calendar 59

Client Handout 3.1. Decisional Balance Exercise 61

Client Handout 3.2. Self-Monitoring Logs for Alcohol Use 64

Client Handout 3.3. Self-Monitoring Logs for Drug Use 69

Client Handout 3.4. Abstinence Goal Evaluation for Alcohol or Drugs 73

Client Handout 3.5. Goal Choice Evaluation for Alcohol Use 75

Client Handout 3.6. Where Are You Now Scale 78

Client Handout 5.1. Introduction to Groups 185

Rationale, Research, and Assessment

Guided Self-­Change Treatment and Its

A persuasive body of outcome research has demonstrated unequivocally that

Influences on the Development of the GSC Treatment Model

Chapter 1. Guided Self-Change Treatment and Its Successful Extension 3

Part II. Guided Self-Change: A Motivational Cognitive-Behavioral

Chapter 4. Guided Self-Change Treatment in an Individual Format 81

Chapter 5. Integrating Motivational Interviewing and Cognitive-Behavioral Techniques 148

Guided Self-Change Treatment and Its

Validity of Self-Reports and Treatment Integrity Checks

Motivational interviewing has been characterized as a client-centered, directive, noncon-

Content reflecting a nonmotivational Content reflecting a motivational