The most powerful factor deterring psychiatrists and other mental health professionals from intervening in problems concerning alcoholism is undoubtedly the certainty that one's efforts will initially be met by anger and denial. Yet if "prevention of chronicity" in alcoholism is to be achieved, action is necessary. In this article we will describe some of the approaches used in the alcoholism program of the Cambridge-Somerville Mental Health and Retardation Center in Massachusetts to diagnose and treat alcoholism.
In our experience, only caregivers (or friends or family members) who are totally convinced that alcoholism is an illness with a natural downward and sometimes fatal progression and who care enough to take the risk of losing a relationship with the alcoholic can summon the courage to open a discussion about another's problem with alcohol.1
The notion is pervasive that alcoholics cannot be helped until they are ready for help or "hit bottom." This widespread conviction on the part of professionals militates against taking the initiative in an identification and referral process. The rationale for nonintervention runs something like this: I know my patient has a drinking problem. He does not profess a drinking problem. If I broach the subject, he will become insulted and angry and may refuse further contact. Therefore, I will not be able to continue to help in any way.
This dilemma is common to the range of human service workers - including public health nurses, clergy, physicians, and mental health professionals - who see their primary helping role dependent on a continuing relationship with the client.
There is an urgent need to train caregivers to take an active role in reducing the human suffering associated with undiagnosed alcoholism. Some typical examples of how this can be done will illustrate the effect that a caregiver can have on the diagnosis and treatment of the alcoholic.2
Joseph F. is a 55-year-old black alcoholic. He has now been sober for 15 years. He marks the beginning of his recovery process with a phone call made by his wife to their clergyman. The clergyman responded by visiting the family and recommending Al-Anon to the wife. He confronted the husband with his drinking problem and exacted a promise that he would attend an Alcoholics Anonymous meeting. The clergyman called the following evening to accompany Joe to his first A.A. meeting. The husband maintained his sobriety through regular attendance at A.A.; the wife is an active member of Al-Anon.
Judith K. is the 37-year-old wife of an alcoholic who has been sober for the past 1 0 years. They are the parents of seven children. She initially sought help from a family service agency, and the social worker identified her husband's behavior as alcoholism. The wife terminated casework contact, since the husband was unwilling to come in for treatment.
Judith, however, was relieved to learn that her husband was an alcoholic; she had assumed that his behavior at home meant that he no longer cared for either her or their children. Only when she made up her mind to leave him unless he did something about his problem did he seek treatment at an alcoholism clinic. Today - 10 years later - she still associates the recovery of her husband and her family with that initial single interaction with the family-agency social worker.
Betty M. is now 45, married, and engaged in professional work. Her problem with alcohol began during her senior year in high school. By the time she was 21 she was seeing a psychiatrist, and she subsequently underwent years of intensive psychotherapy and psychoanalysis. She says that she repeatedly told her internists and her psychiatrists that she drank too much, but that - with one exception - they either ignored what she said or simply told her to cut down on her drinking (something she had been trying desperately to do, she says, for many years without success).
After about 15 years of her heavy drinking, which included one hospitalization, a psychoanalyst finally identified her problem to her as alcoholism. But he told her he could not help her - that Only she could solve the problem. Finally, close to suicide, she came by herself to a meeting of Alcoholics Anonymous, which she had read about.
The starting point of the recovery process in each of these alcoholics was the ability öf a professional not only to recognize alcoholism as an entity in the patient but also to verbalize the diagnosis so that the alcoholic or his spouse understood it. We are convinced that it is of critical importance for the physician (as well as other caregivers) to be able to communicate the diagnosis of alcoholism to their patients when they recognize it.
GOALS OF REFERRAL
Referral is essentially an educational process in which it is important to set realistic expectations. Failure should be expected if the goal is defined in terms of the client's accepting the diagnosis and seeking immediate help. Seeking treatment is more often the ultimate result of a series of confrontations. For the person with alcoholism to seriously consider giving up alcohol, many communications are needed over a period of time from both family members and persons outside the family. This cumulative process is needed before clients can begin to associate their drinking as the source, not the result, of major problems in their lives - a key issue in the recovery process. The passage of time is often needed for the building of crises that will force the decision that life without alcohol, painful though it may be, is preferable to one with alcohol.
The stigma of alcoholism, with its accompanying denial and self-hatred, makes alcoholic patients particularly difficult to deal with. The need to deny stems from their conviction that life is essentially impossible without alcohol. They know they are hooked in the same way that an addict is hooked on heroin. Although the concept is a difficult one for the nonalcoholic person to incorporate, for the alcoholic, life without alcohol is equated with suicide.
Also at work is the stereotype of an alcoholic that the alcoholic himself initially is likely to share with the rest of the population: The alcoholic is a skid-row bum, therefore the patient is not alcoholic. To be alcoholic means to be homeless, unemployed, and physically sick. In addition, the common conviction that alcoholism is a hopeless illness does not help the alcoholic to accept the idea of treatment.
KNOWING TREATMENT RESOURCES
The psychiatrist should have basic information about Alcoholics Anonymous and its affiliate organizations, Al-Anon and Alateen, as well as other alcoholism treatment resources that might be useful for one's patients.3,4 We have found that there is no substitute for firsthand experience in attending open meetings of A.A., AI-Anon, and (on invitation) Alateen. One can hardly refer clients and expect them to attend meetings when he has no personal experience to share in allaying the alcoholic's apprehensions.
It is our experience that most professionals will not attend meetings of these self-help groups unless they are accompanied by someone they know. We must remember that patients have at least an equal amount of fear. Patients should be accompanied to an introductory meeting, either by the caregiver or by an A.A., Al-Anon, or Alateen contact. It is especially helpful if caregivers have personal contacts in these groups - members who can facilitate the referral process by accompanying patients to at least their first few meetings. It is equally important to visit other community alcoholism facilities - to become familiar with their staffs by name, as well as with their services.
Caregivers generally have some understanding of how alcoholism treatment facilities function; they need to understand equally well how and why self-help groups work, especially since they are apparently our most effective single treatment resource. Self-help groups provide patients with a round-theclock availability of people as a substitute for alcohol - at no cost. They also provide patients with the necessary tools to alter their life style so that they can live without alcohol. People learn that they are not alone, that their suffering is not unique, that it is possible to recover, and that others are there to help them in the process of recovery.
PRECIPITATING THE CRISIS
The psychiatrist must recognize that referral to a treatment resource will probably "fail" if one defines success as having the patient seek immediate treatment. An alcoholic will usually fail to seek immediate treatment, and the physician may be tempted to ascribe his failure to "lack of motivation." But in dealing with the alcoholic, the concept of motivation has to be examined more critically. One must understand that alcohol controls alcoholics in every aspect of their lives. Until the pain associated with use of alcohol becomes greater than the expected pain of its loss, alcoholics will be driven by the overwhelming motivational force in their lives - alcohol. Thus, caregivers, family members, and friends can only hope that an accumulation of painful communications from a variety of sources will ultimately outweigh the alcoholic's fear of trying to cope with life without alcohol.
"Motivation" is an irrelevant concept in discussing the dynamics of alcohol dependence. Except for the rare case (and there occasionally is one), the alcoholic seeking treatment is usually choosing what he perceives to be the lesser of two evils. They present themselves to him as "Stop drinking or lose your spouse," "Stop drinking or lose your life," "Stop drinking or lose your job," or variations of these notions. Often, when the alcoholic is referred for treatment, he himself is not trying to do anything other than to appease the person in his life who precipitated his immediate crisis. As an alcoholic, he still nurtures the secret hope that he can continue to drink without further harassment once the spouse or boss or caregiver is assured that treatment is being pursued. Thus precipitation of crises, not motivation, is useful in getting patients to avail themselves for treatment.
The decision to confront the patient with alcoholism is probably most difficult for the mental health caregiver. The alcoholic patient's depressions, phobias, and often expressed suicidal impulses engross therapists' attention. The conviction is strong in most dynamically oriented, trained professionals that the patient's need to escape pain in alcohol will disappear if one can only find the underlying causes of the emotional disorder that leads the patient to drink.
It is probably unrealistic at this primitive stage of knowledge about the etiology of alcoholism to expect widespread acceptance of the "illness concept of alcoholism" on the part of mental health professionals.5 But at least the conviction grows stronger that it is useless to engage an alcohol-dependent patient in psychotherapy until that person gains some sobriety. It appears to us that to attempt psychotherapy in dealing with patients' confilicts and problems while they are drinking is like trying to teach them to play PingPong in a hurricane. It does not mean that you might not try to teach them to play Ping-Pong ultimately, but the patient's sobriety is a primary requisite.
That the layers of denial in alcoholism run deep and present an almost impenetrable wall has discouraged many clinicians. However, understanding the futility of psychotherapy while persons are still drinking should strengthen those so timid that they fear they will lose the patient if they confront the drinking. It is difficult to accept the basic reality that the only useful help one can give is to identify the drinking as a source of serious problems for the patient no matter what the consequences. To arrive at this acceptance, one must realize that no matter how strong a therapist-patient relationship might appear to be, without focusing on the alcohol, that relationship has no chance of paying off in any meaningful way.
Consequently, one has little to losé even if the confrontation process leads to the patient's breaking off the therapeutic alliance. Only the experience of dealing with numbers of alcoholic patients and following the recovery process can make this confrontation process "feel right" at more than a intellectual level.
That the denial more often than not continues throughout the patient's life, without therapeutic intervention, is borne out in the following brief sketches of three patients who were seen at the state hospital in Massachusetts that serves as the backup hospital for the Cambridge-Somerville area. One of the five wards in the Cambridge-Somerville unit, the largest and the busiest, serves alcoholic persons whose illness is complicated by a psychosis, brain deterioration, or violent behavior unmanageable on open wards. Some are persons usually diagnosed, following suicide attempts, as depressed.
The three cases described below are classic examples of the thousands of late-stage alcoholism patients who spend time in our mental institutions throughout the country. The caregiver can take heart in knowing that the expected anger and denial with which early interventions are often met are of the same magnitude whether clients are in the early, middle, or late stage of alcoholism. Again, the argument for early confrontation is strengthened by the knowledge that acceptance of the diagnosis is achieved only by a gradual erosion of the mass of denial, coupled with evidence that the earlier the recovery process is initiated, the greater the patient's chances of a successful outcome. One can conclude only that, without intervention, the shell of denial does not soften and the alcoholism visibly worsens.
Jean B., a single 38-year-old woman, cannot recall a time since she was a teenager when she has not had from a half pint to a pint of whiskey a day - except for a stretch of several months when she was in a mental hospital. The daughter of a chronic alcoholic, she was admitted to a private psychiatric hospital two years ago following a hallucinatory episode, but alcoholism was not focused on as a major problem. She had been seeing a psychiatrist during the two subsequent years, but he had not been concentrating on her alcoholism.
The patient has been a teacher. She has had a number of affairs, all of which - to her disappointment - ended without marriage. She described two recent visits to Cape Cod, during which her drinking behavior became intolerable to her friends. She came to the State Hospital via the Cambridge Hospital emergency room when the police discovered her very drunk, walking the streets of Cambridge. Also, within the previous two or three weeks, she had been arrested for drunk driving.
After a week at the state hospital, she is able to acknowledge that she has a drinking problem. But she still cannot admit that she must give up drinking entirely. The idea, in fact, upsets her greatly. "Others can drink socially, so why can't I?" she asks.
She uses alcohol to obliterate all emotional pain, so the idea of giving it up presents itself to her as an extreme loss. She asks again - is she really so bad off that she must give up drinking even socially? She once went to an A.A. meeting for course credit as a part of a teacher's workshop she attended, but she does not see herself as fitting into A.A. or really belonging.
When she is confronted head-on with the knowledge that she is an alcoholic, she seems relieved. She says it is the first time in her life that anyone has taken the responsibility of talking to her about her drinking problem.
Dorothy M. is a 40-year-old married woman who was admitted to the hospital after taking an excessive dose of Librium. She has two teenage daughters, 14 and 15, and a younger daughter, aged seven. Her husband acknowledges that he has two jobs in order to avoid dealing with family problems. She readily admits that she turns to alcohol in order to deal with her pain, especially the loss of her father, but she finds that "in the long run, alcohol makes it all worse." She is even able to describe in detail the drinking of her 14-year-old daughter and an episode in which they both physically struggled for possession of a bottle of wine. She said the conflict occurred because she wanted the bottle of wine for herself, but her daughter was able to get it away. She cannot come to terms with the fact that alcohol is destroying both her own and her daughter's life.
Despite the degree of recognition of the important role alcohol plays in her life, she is afraid that she will become too depressed if she really looks at her drinking. She clings to the rationalization that she needs alcohol to deal with her many problems and resents putting herself in a situation where she might ultimately have to give up the alcohol.
Irene L. is a divorced woman in her 40s with chronic phobic illness who has had several hospitalizations in which she has been incorrectly diagnosed as depressed or schizophrenic. She lives with her father and a 21year-old son. The court has awarded custody rights to her three younger children to her husband, and she has been fighting the action.
Irene says she really does not like drinking because it makes her feel worse in the long run, but then she volunteers that "it's great for about two hours." She fails to see herself as an alcoholic, but we were able to establish that she used alcohol to overcome feelings of panic. Her response to that was that she would never become an alcoholic like her friend Mary, who had lost everything. It was brought to her attention that she had lost her marriage, has had several hospitalizations, and will lose the custody fight for her children unless she can strengthen her case for being a responsible parent by remaining sober.
She has attended A.A. meetings and admits: "1 can't control the booze; it controls me."
The therapists supported her efforts to get her drinking under control. It was pointed out that she still has friends and many other strengths and that she can reverse the course of her life and has a good chance of being with her children, who are in need of mothering.
She acknowledges that this is the first time in her life that a real diagnosis of her drinking problem has been made.
THE PHYSICIAN'S ATTITUDE
In our experience, attitudes are the key element in any successful interaction between caregiver and an alcoholic or a caregiver and a family member. Attitudes and understandings that we believe to be helpful in dealing with alcoholics and their family members are shown in Table 1.
Just as some attitudes and understandings help the treatment process, others may delay it or even make it impossible. Some of these unhelpful attitudes are listed in Table 2.
There are many signs of possible alcoholism that may come to caregivers' attention - among them alcohol on the breath in the morning; overt drunkenness behavior (staggering); slurred speech; disorientation; broken appointments; empty bottles; an unkept household; uncared-for, withdrawn, or overly compulsive children; missing time from work or school; evidence of physical abuse; and recurring accidents.
We believe that the initial confrontation of the patient with the fact that he is an alcoholic is the step that plants the seed for him to seek treatment sometime in the near future. (As mentioned above, the future is seldom immediately foreseeable.)
The secret to successful confrontation lies in setting realistic expectations. Understanding the nature of the alcoholic's illness at a "gut level" can keep the therapist from becoming angry with the denial process that is almost always associated with alcohol dependence.
HELPFUL ATTITUDES AND UNDERSTANDINGS IN TREATING ALCOHOLICS
UNHELPFUL ATTITUDES IN TREATING ALCOHOLICS
It may help if one looks at the initial communication between alcoholic patient and caregiver as an educational exchange. Regardless of what the patient says, does, or does not do, the physician can consider his goal achieved if the interaction includes these six elements:
1. An expression of warmth and concern for the patient.
2. A description of the patient's observable problem-drinking behavior.
3. An explanation that drinking is the source of the person's problems (or at least many of them) rather than the result.
4. An explanation that alcoholism is an illness and a discussion of some of the common signs.
5. An expression of hope about the illness, knowledge of persons who have recovered, etc.
6. Knowledge that outside help is needed and a description of several options, including personnel A.A. and Al-Anon contacts as well as alcoholism clinics.
A successful confrontation will require the physician or other health-care professional to avoid letting the client rationalize his behavior and to place the drinking behavior into the larger context of alcoholism. The patient must also be given hope, led to understand that outside help is needed, and offered several options.
Keep the alcoholic from rationalizing his behavior. When he says, "I drink because of my wife" (or because of his job, because he has no money, or because of poor health), you can answer: "I understand that things are bad for you and know how easy it is for you to drink when you feel that way. A lot of people use alcohol to make them feel better when they have problems like yours. But ..." Most alcoholics will be likely to have a myriad of responses of denial or resistance to each of the six points mentioned above.
Put drinking behavior into the larger context of alcoholism. You might use the third person to do this: "A lot of people who drink because of problems they have find that they sometimes drink more than they mean to or get drunk when they didn't expect to . . ." (find they have done things they never would have done while sober, discover they have forgotten things that happened to them while drinking, etc.). You should point out several signs of alcoholism in the patient's behavior as he has described, it to you. You might say, for example: "No matter how bad things are for you now, a lot of your problems would get better if your drinking stopped." Later you might add: "I wonder if you understand what alcoholism is? It's when alcohol begins to make serious problems in your life." One can try to give some more signs in the hope that one or more might strike home. A simple booklet listing signs of alcoholism can be left with the patient.6
Give your patient hope. Tell him more about alcoholism as an illness, and express some optimism about the favorable prognosis for many alcoholics. "I know it's hard for you to understand that the things you are doing are signs of an illness called alcoholism," you might say, "because it's an illness that many people get through no fault of their own. It can happen to anyone. But there are lots of things people can do, and they recover."
Explain that outside help is needed. Find out what the patient knows about resources. Explain to him that, while he can recover, he will not be able to do it alone. "You can't just say, Tm going to quit drinking,' and do it. No one can, without outside help. You may already realize that because you've tried to quit before. That's just the nature of the illness. But there are several places where you can get help."
Tell him about specific agencies in his area. If he has sought help from one or more of them before, suggest that he try again. It is especially important to deal with the patient who says that he has tried A.A. once and did not like it. We believe that A.A. should not be written off until the alcoholic has attended the meetings of at least three different A.A. groups.*
Leave several options open for action in the future. For example, you can say: "Maybe you're not ready to do anything right now if you like your life the way it is. But if you decide you want to be different, remember that it is possible. Tm going to give you something you may want to read. If you decide you'd like to do something about your drinking later on, I'd be happy to talk to you about it or arrange for you to talk to someone who has recovered from this illness. If you are interested, they can tell you about A.A. and what the meetings are all about. They might take you to one later if you want to go. Meanwhile, here's my name and telephone number. Give me a call whenever you feel like it.
Do not forget family members. Denial in both spouse and children often is as difficult to penetrate as that of the alcoholic. Sometimes it is more difficult. We believe that caregivers should try to get family members to get support for themselves. The family members should be encouraged to attend Al-Anon or a clinic - not to motivate their alcoholic father or spouse but to help themselves. Family members thus can learn the nature of alcoholism and can feel less guilty about their own behavior in relationship to the alcoholic's drinking. They will learn to life for themselves rather than for the alcoholic.
By learning more about alcoholism, the spouse or children will learn some of the do's and don'ts of dealing with alcoholic behavior. They will learn to stop covering up for the alcoholic and will thereby let the alcoholic accept the full negative consequences of his antisocial behavior. Often the crisis thus precipitated will speed up the process of "hitting the bottom" and result in earlier treatment and recovery.
NEED FOR TRAINING
The unconstructive attitudes of many caregivers toward alcoholics have been welldocumented, and the literature711 indicates that physicians' attitudes unfortunately are little different from those of the general public. Alcoholics are viewed as derelicts, immoral persons, irresponsible hedonists, persons with character disorders, or depressed persons bent on suicide. While lip service may be paid to the fact that alcoholism is a treatable illness, we believe that this concept has little meaning for the many clergymen, physicians, nurses, and social workers who have experienced little success in prevention of chronicity in the alcoholic.
Since alcoholism is treated only cursorily in medical school, on-the-job and continuing educational activities must fill the gap. Our experience in the Cambridge-Somerville alcoholism program convinces us that carefully designed experiential training programs can help physicians and others in treating alcoholic patients and make them more successful in the all-important confrontation with the alcoholic. When professionals learn about alcoholism at both a cognitive and a "gut" level, they become convinced that the threatened loss of a client relationship is irrelevant. The life-threatening nature of the illness guarantees that, without intervention, the patient will deteriorate and suffer a premature death. Once the caregiver grasps this basic truth, he or she overcomes an emotional hurdle that makes the painful confrontation of denial appear as a lifesaving process.
Much of our education effort in the alcoholism program of the CambridgeSomerville Mental Health and Retardation Center is devoted to workshops for caregivers - usually five or six weekly two-hour sessions, with 12 to 15 participants. Every workshop provides role plays based on typical situations described by caregivers that occurred with their alcoholic patients. These sessions allow subjects to examine the attitudes that block them from constructive interactions. Role plays also enable participants to practice the educational confrontation exchange described in this article. In our catchment area, approximately 900 caregivers in 60 agencies have participated in eight-to- 10-hour workshops over the past six years,12"14 Alcoholism treatment facilities are just beginning to experience the effects of successful early intervention in the lives of alcoholics - as evidenced by drunk-driving programs, for example. We look forward to an acceleration of professional training efforts both in and out of school so that the denial that has so often prevented alcoholics from seeking early treatment in the past will be confronted with increasing skill and understanding on the part of caregivers.
The traditional training both of clinicians and of community caregivers teaches them to proceed gently with patients' problems and to avoid the dangers of confrontation. In treating the alcoholic patient, such an approach will only give support to the denial and rationalization process that is associated with the illness.
By understanding the denial mechanism in alcoholism and adapting strategies for dealing with it, the clinician can help many patients from remaining chronic problem drinkers and in the process avoid the frustration and discouragement all too often associated with attempts to treat alcoholics. ®
1. DiCicco, L M.. and Unterberger, H. Cultural and professional avoidance: a dilemma In alcoholism training. J. Alcohol Drug Educ. 22 (Winter. 1977). 28-38.
2. Unterberger. H., and DiCicco, L. M. Planning alcoholism services. Contemporary Drug Problems, a Law Quarterly ( 1 973). 697-71 6.
3. Alcoholics Anonymous, Third Edition. New York: A.A. World Services. 1976.
4. Al-Anon Faces Aieohofem. New York: Al-Anon Family Group Headquarters, Inc., 1973.
5. Mack. J. E. The governance of self: medieval and modern perspectives. The Freud Lectures at Yale University. May. 1978.
6. What Are the Signs of Alcoholism? New York: National Council on Alcoholism.
7. Knox. W, J. Attitudes of psychiatrists and psychologists toward alcoholism, Am. J. Psychiatry 127 (1971), 1675-1679.
8. Knox. W. J. Attitudes of social workers and other professional groups toward alcoholism. Q. J. Stud. Alcohol 34 (1974). 1270-1278.
9. Pittman. D. J,. and Sterne, M.W. Report on alcoholism: community agency attitudes and their impact on treatment services. Public Health Service Pubi. No. 1273. Washington, DC. U.S. Government Printing Office, 1965.
10 Wolf. I.. Chafetz. M. E., Blane, H. T., and Hill. M. J. Social factors in the diagnosis of alcoholism. II. O. J. Stud, Alcohol31 (1965), 72-79.
11. Bailey, M. B. Attitudes toward alcoholism before and after a (raining program for social caseworkers. O. J. Stud. Aicohoi. 31 (1970), 669-683.
12. DiCicco, L. M" and Unterberger, H. Does alcohol follow drugs? Bull. Natl. Assoc. Secondary. School Principals 57 (1973). 85-91.
13. Unterberger. H., and DiCicco, L. M. Alcohol education reevaluated. Bull. Natl. Assoc. Secondary School Principals 52 (1968), 15-29.
14. Williams. A. E,. DiCicco, L. M.. and Unterberger. H. Philosophy and evaluation of an alcohol education program. O. J. Stud. Alcohol 29 (1968), 685-702.
HELPFUL ATTITUDES AND UNDERSTANDINGS IN TREATING ALCOHOLICS
UNHELPFUL ATTITUDES IN TREATING ALCOHOLICS