Psychiatric Annals

COMPREHENSIVE ALCOHOLISM PROGRAM

Raymond A Ransom, MD

Abstract

11. Provision of consultation and education to community agencies and organizations.

Staff:

1. One psychiatrist half time (director)

2. One psychiatrist half time (clinical)

3. Two social workers

4. Two alcoholism counselors

5. One internist

6. One nurse, RN

7. Two mental health aides

8. Two clerk-typists

9. One messenger

The Harlem Hospital Alcoholism Clinic gave direct and indirect services to persons, who, without such help, would have continued to lead aimless, unproductive lives with frequent hospitalizations. It provided direct services to approximately 1,000 persons registered in the clinic.

Program evaluation from 1967 through 1971 and an Alcoholism Prevalence Study at Harlem Hospital confirmed a very obvious need for an expanded and more comprehensive program.

A broad range of treatment components must be considered in any attempt to provide comprehensive treatment. These are: Detoxification; Residential Treatment; Outpatient Care,- 24-hour Emergency Services; Vocational Rehabilitation; Training; and Consultation, Education, Information and Referral Service.

In the spring of 1973, an Inpatient Detoxification Unit and Halfway House were included as parts of a new comprehensive Alcoholism Program, and the existing outpatient services were expanded. With the existing outpatient service (to be expanded), the three units formed a comprehensive treatment system under a unified administration.

A physician director and a program administrator are responsible for supervising the activity of all three program components. Flexible staffing patterns allow the professional and paraprofessional staff of the outpatient clinic to provide liaison between treatment units, general hospital, and community agencies. The system is set up to facilitate patient transfer from one treatment sequence to another.

A. The Detoxification Unit16 beds (5 female, 11 male):

A large proportion of the patients enter the program through the Detoxification Unit. This unit admits patients from a number of sources. They come from the hospital's emergency room, the medical and surgical wards of the hospital, the alcoholism clinic and other hospital clinics, from community agencies, and from alcoholism programs of other hospitals.

Any person residing in the Harlem community, from 16 years of age, who voluntarily desires detoxification from alcohol can request admission to the detoxification unit. The person may not have an associated acute medical, surgical, obstetrical, gynecological, etc. problem. We consider impending delirium tremens to be a condition which makes the person admissible for detoxification. A fine line in judgment is used.

Preliminary screening is usually done by social service in the clinic. The client is then referred to the physician for a thorough medical evaluation and decision to admit or not.

If a person gives a history of multiple addiction he is carefully evaluated to determine if there is true alcohol abuse together with other addiction. If such candidates meet the admission criteria, and are addicted to drugs other than methadone, they will be withdrawn from alcohol and the other drug.

Patients enrolled in Methadone Maintenance Treatment Programs are detoxified from alcohol, maintained on methadone as determined by direct contact with their treatment program, and subsequently referred back to the Methadone Maintenance Program. There is no follow-up of these patients.

B. The Outpatient Clinic (800 patient population):

Outpatient care is an appropriate form of long-term treatment for many patients. Two important guidelines governing treatment in the Clinic are comprehensiveness of services and continuity of care. The goal of the Center's outpatient treatment program is to provide treatment modalities for alcoholics which lead to the patient's most complete social functioning. Because alcoholism represents a combination of social, psychiatric and medical problems, improved functioning can only come with multi-service treatment. Outpatient clinics offering a broad range of services provided on a quality basis have been demonstrated to be extremely effective for…

The Alcoholism Program's inception in 1967 was designed to develop an effective approach to treating alcoholism in the Harlem community. The program was supported by a grant from the New York State Department of Mental Hygiene. It was organized as a pilot project to evaluate two approaches to the treatment of alcoholism.

One approach, outpatient care, involved weekly, brief, supportive sessions plus medication provided by an internist. The other approach was called "The Comprehensive Approach."

Patients with delirium tremens or other serious medical problems were referred to the emergency room or medical clinics. Also, any patient with grossly psychotic symptoms was referred to the psychiatric clinic.

The patients were characterized by chronic diseases and social and psychological maladaptation. However, they were not so acutely ill or sufficiently debilitated to require institutionalization. Many were living alone subsequent to periods of family strife that led to rejection by family.

The day care program was established to provide a therapeutic alcohol-free environment. Also, ambulatory detoxification could be carried out in a day care program. The program provided an opportunity for the patients to develop a strong identification with the program and its staff. This was in keeping with the philosophy of the clinic, that one of the important factors in the alcoholic's path to recovery is his ability to accept the reality of his dependency and to develop other methods of meeting these needs.

Medication, including antidepressant and anti-anxiety drugs and disulfiram, was given the patients by a psychiatric nurse. Medication was found to be quite effective for patients unable to control their drinking.

The buddy system was developed whereby patients would telephone or visit each other over the weekend. This evolved from the patient government group that began to plan various activities and establish rules and regulations to govern itself in the day care program.

The use of recovered alcoholics as members of staff was an integral part of the philosophy of the clinic. It was felt that they served as role models, thereby assisting the alcoholic in developing creative use of other people.

The Alcoholism Clinic's philosophy was carried out in three rather comprehensive approaches:

1. Alcoholism rehabilitation and counseling.

2. Family and individual therapy.

3. Community education and training.

A range of treatment and rehabilitative services and activities was provided. The patients were assigned to specialized treatment programs according to their needs.

Services Provided:

1. Complete medical and psychiatric evaluation.

2. Ambulatory detoxification.

3. Medical follow-up and referral to special chnics in Harlem Hospital as needed.

4. Day Care (Monday through Friday 9 a.m. to 5 p.m.).

5. Group activities, including an educational program regarding alcohol use and abuse, therapeutic meetings, recreational activities and AA groups.

6. Psychiatric treatment, including chemotherapy, individual psychotherapy and group therapy.

7. Counseling to help with problems in housing, welfare, education and employment.

8. Home visiting.

9. lob referral and placement in training program.

10. Family counseling.

11. Provision of consultation and education to community agencies and organizations.

Staff:

1. One psychiatrist half time (director)

2. One psychiatrist half time (clinical)

3. Two social workers

4. Two alcoholism counselors

5. One internist

6. One nurse, RN

7. Two mental health aides

8. Two clerk-typists

9. One messenger

The Harlem Hospital Alcoholism Clinic gave direct and indirect services to persons, who, without such help, would have continued to lead aimless, unproductive lives with frequent hospitalizations. It provided direct services to approximately 1,000 persons registered in the clinic.

Program evaluation from 1967 through 1971 and an Alcoholism Prevalence Study at Harlem Hospital confirmed a very obvious need for an expanded and more comprehensive program.

A broad range of treatment components must be considered in any attempt to provide comprehensive treatment. These are: Detoxification; Residential Treatment; Outpatient Care,- 24-hour Emergency Services; Vocational Rehabilitation; Training; and Consultation, Education, Information and Referral Service.

In the spring of 1973, an Inpatient Detoxification Unit and Halfway House were included as parts of a new comprehensive Alcoholism Program, and the existing outpatient services were expanded. With the existing outpatient service (to be expanded), the three units formed a comprehensive treatment system under a unified administration.

A physician director and a program administrator are responsible for supervising the activity of all three program components. Flexible staffing patterns allow the professional and paraprofessional staff of the outpatient clinic to provide liaison between treatment units, general hospital, and community agencies. The system is set up to facilitate patient transfer from one treatment sequence to another.

A. The Detoxification Unit16 beds (5 female, 11 male):

A large proportion of the patients enter the program through the Detoxification Unit. This unit admits patients from a number of sources. They come from the hospital's emergency room, the medical and surgical wards of the hospital, the alcoholism clinic and other hospital clinics, from community agencies, and from alcoholism programs of other hospitals.

Any person residing in the Harlem community, from 16 years of age, who voluntarily desires detoxification from alcohol can request admission to the detoxification unit. The person may not have an associated acute medical, surgical, obstetrical, gynecological, etc. problem. We consider impending delirium tremens to be a condition which makes the person admissible for detoxification. A fine line in judgment is used.

Preliminary screening is usually done by social service in the clinic. The client is then referred to the physician for a thorough medical evaluation and decision to admit or not.

If a person gives a history of multiple addiction he is carefully evaluated to determine if there is true alcohol abuse together with other addiction. If such candidates meet the admission criteria, and are addicted to drugs other than methadone, they will be withdrawn from alcohol and the other drug.

Patients enrolled in Methadone Maintenance Treatment Programs are detoxified from alcohol, maintained on methadone as determined by direct contact with their treatment program, and subsequently referred back to the Methadone Maintenance Program. There is no follow-up of these patients.

B. The Outpatient Clinic (800 patient population):

Outpatient care is an appropriate form of long-term treatment for many patients. Two important guidelines governing treatment in the Clinic are comprehensiveness of services and continuity of care. The goal of the Center's outpatient treatment program is to provide treatment modalities for alcoholics which lead to the patient's most complete social functioning. Because alcoholism represents a combination of social, psychiatric and medical problems, improved functioning can only come with multi-service treatment. Outpatient clinics offering a broad range of services provided on a quality basis have been demonstrated to be extremely effective for many alcoholics. This modality offers the least expensive form of long-term therapy.

Far too often, the debilitated alcoholic is omitted when we discuss treatment modalities. There is no question that the clinic setting is important. But equally important is a facility and services to handle the needs of the debilitated alcoholic. The debilitated alcoholic requires the creation of new services and greater utilization of some existing services. The services required are a sobering-up station, detoxification service and a residential rehabilitation program.

C. The Therapeutic Halfway House (35 beds):

This third component of the Comprehensive Alcoholism Program is not operational at this time. We are approximately three months away from opening this unit. A residential rehabilitation and resocialization program will be provided in the Therapeutic Halfway House. This unit will be the main focus for those community agencies primarily interested in alcoholism who accept our invitation to utilize the program's facilities for their activities.

The Rehabilitation Services will include vocational, occupational and activity therapy, which will be utilized by all three components of the programs. However, the major thrusts of those services will be in the clinic and halfway house. It is recognized that vocational rehabilitation services should be available for those alcoholics who require such services because they are unemployed, inappropriately employed or underemployed. Therefore, this service will work closely with the patients, community agencies, and city and state agencies. We feel that these services must be a part of the treatment program, because of the socioeconomic plight of this urban ghetto and its citizens.

As the program expands and begins to provide more services for persons employed inside and outside the home for whose treatment vocational rehabilitative services are less necessary, other program components will gain emphasis.

Integral to the program is its involvement with: Alcoholics Anonymous, Al-Anon and Ala-Teen, very useful resources for the alcoholic and his family; consultation and education utilizing the skills of a public health educator; information and referral services through a network of multidisciplinary teams of professionals and paraprofessionals. It was very apparent as we looked at our program and at others that training and multi-service expertise were lacking. It is necessary to establish an inservice educational program for the Alcoholism Program staff and the general hospital community.

The criteria for admission to the program have changed as we observed an increase in certain kinds of alcoholics. We are seeing an increasing number of multiple drug abusers.

1. Alcohol plus opiate (heroin and methadone).

2. Alcohol plus other drugs, including LSD, mescaline, and peyote.

3. Alcohol plus soft drugs, including tranquilizers, sedatives and amphetamines.

Those in the first group need to be treated in a methadone maintenance program with consultation from an alcoholism service. Those in the second group are usually younger than the former age limit of 21. We have lowered the age to 14 for admission to the program. We are establishing consultation services to programs designed for adolescents when we feel the diagnosis is unclear and treatment in an alcoholism program is inappropriate. The third group usually belongs in the alcoholism program unless the psychopathology is so severe that they warrant psychiatric hospitalization.

The staffing pattern for the Comprehensive Alcoholism Program includes physicians (psychiatrists and internists), addiction specialists (recovered alcoholics), addiction counselors, community liaison workers, occupational and activity therapists, vocational rehabilitation counselors, security officers, data coordinators, health educators, a halfway house manager, and administrative and clerical staff.

We must continuously remember that alcoholism is a disease that is complex and whose etiology is currently not understood. The individual may be unduly exposed to a combination of the several factors that lead to the development of this condition, including psychological, physiological, genetic and socio-cultural factors. Recognizing this, our view is that approach to treatment, rehabilitation and prevention must be via the many avenues mentioned. One very significant aspect of treatment frequently overlooked by providers is the need to recognize and understand the sociocultural context within which alcoholic patients live. We have to see people within the context of their realities. One means of meeting this need is to develop staffing patterns which include persons of backgrounds similar to those of our patients, who have, in addition, the awareness and sensitivity to be able to understand and work effectively within that context for the benefit of the patients. This means seeking the involvement of nuclear and extended families, employers, supervisors, spiritual leaders and any additional people that have an effect on the specific person, through staff selected for their appropriateness in this regard and trained for effectiveness in the task.

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10.3928/0048-5713-19740501-10

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