Bringing Up the Touchy Subject of a Patient’s Drinking

Broaching the subject of alcohol with a patient or client who shows signs of a drinking problem can be awkward. Drinkers often feel ashamed of their problem, at the same time that they downplay its seriousness. Directly confronting them may do no more than provoke a flat denial. For these reasons professionals very often steer clear of the matter. But to wait for that patient or client to bring up the subject amounts to giving up on the issue, according to some with first-hand experience in the matter.

“In 30 years of practice it almost never happens that someone comes in and announces that they have a problem with alcohol,” says Carvel Taylor-Valentine, a licensed clinical social worker.

“Patients would rather that their problems are about anything other than alcohol or drugs. They would rather admit to some kind of mental illness, even schizophrenia, than to call themselves an alcoholic.”

The reason for this, says Ms. Taylor-Valentine, who is a certified addictions counselor, is simple: “They don’t want to stop drinking. Alcohol is a feel-good substance, and they are afraid of giving it up.”

Marsha Epstein, M.D., medical director, Tucker Health Center, a unit of the Los Angeles Department of Public Health, agrees.

“No one is quick to admit to current problems with alcohol or drugs. When I was in private practice years ago, I saw about 2,000 patients over four and a half years and none ever admitted current heavy drinking.”

Dr. Epstein, who also has a master’s degree in public health, remembers a phone call from the daughter of a woman patient disclosing that the mother drank alcoholically. “I believed the daughter, but I never brought up any problem with alcohol to her mother. I did not know how.”

Both Dr. Epstein and Ms. Taylor-Valentine have found that the information forms filled out by new patients are the best place to introduce questions about drinking problems, especially if the questions are about alcohol abuse in a patient’s family.

“It was at a medical conference that I was introduced to a woman who was a member of Al-Anon and who told me about that program,” says Dr. Epstein. [Al-Anon is a Twelve Step program for those who have problem drinkers in their lives.] “When I returned from that conference, I added a question about drinking problems among family members to the medical history forms filled out by patients.”

Happy to Discuss Anyone Else’s Drinking

Whereas practically no patient would talk about their drinking problem, “lots admitted that they had family members who drank too much,” says Dr. Epstein. Nowadays, when the conversations get to a patient’s drinking, Dr. Epstein says, “instead of asking if someone has a problem with alcohol, I ask when was the last time they overdid it. Not asking specific questions is a mistake.”

When a patient opens up about their alcohol abuse, Dr. Epstein steers them to Alcoholics Anonymous. “Here’s the number for A.A. meetings – just go. You don’t have to say anything, and you can sit in the back.”

Back in her time in private practice, Dr. Epstein also made use of Al-Anon. “If they checked ‘yes’ on that question about a family drinking history, I would suggest they go to an Al-Anon meeting and come back and tell me how it was.”

What Dr. Epstein discovered was that some of her patients found their way to Alcoholics Anonymous through Al-Anon.

“Over the course of a few years, five patients who had gone to Al-Anon returned to tell me that they discovered in that program that they had a problem with alcohol. I suspect there were many others who got to A.A. through Al-Anon. It never occurred to me that it would work this way.”

From; About AA; A newsletter for professionals, Spring 2007. www.AA.org

Dilemma of the Alcoholic Marriage

Brief-TSF Goals and Objectives

Brief-TSF seeks to facilitate three general goals in individuals with alcoholism:

1. acceptance (of the need for abstinence from alcohol),
2. surrender, or the willingness to participate actively in 12-Step fellowships as a means of sustaining sobriety, and
3. taking action to address the disease or malady.

These goals are in turn broken down into a series of cognitive, emotional, relationship, behavioural, social, and spiritual objectives.

Spiritual But Never ‘Religious’

The A.A. Program – Spiritual But Never ‘Religious’

One of the most common misconceptions about Alcoholics Anonymous is that it is a religious organization. New members especially, confronted with A.A.’s emphasis on recovery from alcoholism by spiritual means, often translate “spiritual” as “religious” and shy away from meetings, avoiding what they perceive as a new and frightening set of beliefs.

By the time they walk into their first meeting, many alcoholics have lost what faith they might once have possessed; others have tried religion to stop drinking and failed; still others simply want nothing to do with it.

Yet with rare exceptions, once A.A. members achieve any length of sobriety, they have found a source of strength outside themselves – a Higher Power, by whatever name – and the stumbling block has disappeared.

FAQ – AA – A Newsletter for Professionals Fall 2003; www.aa.org

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My own experience

By an AA member

I first came into contact with Alcoholics Anonymous 20 years ago. I had just been discharged from mental hospital after a suicide attempt and after losing two jobs within a few weeks. AA was the main thing which kept me going over the following months, although I also got help from family, friends, my doctor and my therapist. I have not had an alcoholic drink since my first AA meeting. I have had many problems getting my life together since then, not least with depression.

With the benefit of hindsight depression was probably one of the reasons why I drank, but the drinking was more a cause than an effect of my problems.

I still attend AA meetings regularly. I do not want to drink again and I still value the support I get in maintaining sobriety, among other things by listening to people who have had a harder time than I have, have only just stopped drinking or are still trying to stop. AA is also part of my social life.

Carrying the AA message

The 12th step of the AA programme encourages its members to carry the AA message to other alcoholics. The proposition that helping others helps you to stay sober has support in peer-reviewed scientific literature as well as in the practical experience of AA groups. In London, where I live, current initiatives include AA members speaking to school children about their experiences, giving presentations at magistrates courts, working with the probation service and supporting AA meetings at prisons. A seminar about the work of AA was held at the Houses of Parliament in March 2005 and a repeat of this is due in May 2006.

AA has been particularly successful in working with some leading hospitals which provide treatment for alcohol dependence. AA meetings are held in the hospitals and AA members give separate talks to the patients to help them to think about becoming members too.

In other hospitals AA meetings may be held in the premises without such a close working relationship. There may be a clash of cultures. There are sometimes strong contrasts in general approach and language between AA members and those who work professionally in the field of addiction, although both sides are usually trying to achieve what is essentially the same thing.

Working with AA

A doctor in charge of an alcohol treatment unit once told me that I was the first AA member he had met. Others may strongly encourage their clients to try AA without having any direct contact with the fellowship themselves.

Professionals who want to make optimal use of AA as a resource may sometimes need to make a greater effort to understand its programme, meet with members involved in outreach activities and attend a few “open” meetings (which should usually be done far enough away from where you work to ensure that you do not meet your own clients). This is surely not a disproportionate time commitment. It can enable the professional, for instance, to tell his or her patients or clients at first hand what they should expect. You do not have to become an alcoholic yourself (or apply the ‘Minnesota Model’, which involves integrating the AA programme within treatment) to get to this point.

Why should you make the effort? Partly because there is now a sound body of scientific evidence suggesting that AA does work for a significant number of people with drink problems. It operates at no cost to the taxpayer and is paid for entirely by voluntary contributions from those members who can afford to make them. It is also most active outside normal working hours and thus complements the help that can be provided at a professional level.

The need for AA to adjust

AA members actively involved in its public relations activities may need to make an equivalent effort to understand other people’s points of view and find common ground. Involvement in AA outreach activities helps to achieve this up to a point as does, for instance, reading some scientific literature, contact with professionals, attending conferences focusing on alcohol problems and involvement in working groups at a local level.

One of the co-founders of AA, William Wilson, acknowledged that some AA members ‘decry every attempt at therapy except our own’ but the majority ‘don’t care too much whether new and valuable knowledge issues from a test tube, a psychiatrist’s couch or revealing social studies’.

AA has changed considerably over the 20 years I have been a member. There are, for instance, more people under 30 and more women. There are meetings focused on the needs of young people, women, gays and lesbians and some provision in Central London (although still not nearly enough) for child care. It was rare in the 1980s to see anyone from racial minorities at meetings. Now it is rare not to see them. The fellowship is making every effort to provide help to people whose first language is not English or who may have other communication problems or disabilities.

The Internet and email has also helped to spread the AA message. For instance the basic ‘Alcoholics Anonymous’ textbook is now available online in full text in English, French and Spanish as well as being available in hard copy in many other languages.

The anonymity tradition

There is sometimes a tendency to over-interpret the AA anonymity tradition. It only requires members to maintain anonymity at the level of press, radio, film etc. The second cofounder of AA, Dr Robert Smith, argued that maintaining anonymity at any other level and in particular “being so anonymous you can’t be reached by other drunks” was itself a breach of the anonymity tradition. He also considered that AA members should let themselves be known as such in the community.

This may be feasible in North America, but in Europe it is perhaps more an ideal to be strived for. I am a professional myself, although I do not practise in the field of addictions. I do not tell my colleagues at work (whom I have only known for about 18 months) about my past drinking problems and my membership of AA. When I get to know them better, and if it were to serve a useful purpose, I might perhaps do so.

References

1 2 See Zemore SE, Kaskutas, LE and Ammon LN (2004) ‘In 12-step groups, helping helps the helper’, Addiction 99, 1015.  4 See, for instance: Vaillant, GE (2003) ‘A 60-year follow-up of alcoholic men’ Addiction, 98, 1043- 1051. Gossop M, Harris, R, Best D, Man L-H et al, ‘Is attendance at Alcoholics Anonymous meetings after inpatient treatment related to improved outcomes? A 6 month follow-up study’ Alcohol and Alcoholism, Vol 38 No 5 421-426. Project MATCH Research Group (1997) ‘Matching alcoholism treatments to client heterogeneity: Project MATCH post treatment outcomes’. Journal of Studies on Alcohol 58, 7-29. 5 ‘Let’s be friendly with our friends’,AA Grapevine March 1958. 6 www.aa.org/bigbookonline/. 7 ‘Doctor Bob and the Good Oldtimers’, page 264, 1980 AA World Services inc. Alcohol Alert (2006) is published by The Institute of Alcohol Studies an initiative of the Alliance House Foundation, www.ias.org.ukwww.alcoholicsanonymous.org.uk/geninfo/05steps.shtml

On completion of BriefTSF, you will be able to use Brief-TSF as adjunctive therapy and;

Understand and use questionnaires for assessing alcohol use.

• Separate the differences between alcoholics and problem drinkers
• Guide alcoholics to self-assessment and acceptance of their condition
• Gauge suitability of alcoholics for Alcoholics Anonymous

Understand the barriers to alcoholics acceptance of their condition

• Understand alcoholism as an illness
• Help an alcoholic to work through denial, and self defeating thinking and emotions
• Understand the stages of change in recovery from alcoholism
• Understand the impaired thinking and behaviour of alcoholics
• Foster rational and spiritual responses to dangerous drinking reminders and situations
• Help the alcoholic understand the key remedies to craving and compulsive thinking.

Understand the self help methods of Alcoholics Anonymous, Alateen and Al-anon

• Be able to work with recovering members of self help groups such as AA, Al Anon and Alateen.
• Help and support prospective members in contacting an AA or Al-anon Peer Sponsor

Understand the ‘tools of recovery’ and practices of the AA program and culture.

• Support prospective and new members of AA in their quest for sobriety using AA meetings, slogans and AA members.
• Detect the barriers to ‘doing the program’ in AA
• Discuss remedies for dangerous actions and thinking with the alcoholic
• Promote relapse prevention and better responses to relapse
• Support an alcoholic in using the tools of relapse prevention
• Help alcoholics gain new motivation, hope and action after a relapse

Partners of Alcoholics

• Understand the thinking and actions of partners, children and parents of alcoholics
• Help with understanding of alcoholic family forces and the enabling of alcoholism
• recognise symptoms of child, youth and adult abuse within alcoholic families
• Recognize impaired and healthy caring actions of significant others
• Guide partners of alcoholics to self assessment and acceptance of their condition
• Judge suitability of partners and children of alcoholics for self help groups such as Al-anon or Alateen

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Alcoholics Anonymous is self-help, not treatment

Alcoholics Anonymous is not really a treatment for alcoholism but a community resource for those wishing to stop drinking. Uncontrolled studies of AA have shown that people who affiliate with AA tend to stop drinking and find that their lives improve in many respects (Emrick et al. 1993).

However, evaluating AA alongside professionally delivered interventions presents problems and perhaps should not be done.

AA, the original 12 Step program, is not a fixed form of “treatment” and people are free to participate in different ways. Some go a few times and then drop out. Others go more often, but do not actively participate in meetings or “work the program.”

It is possible that both dropouts and passive participants gain some benefit from the AA experience, but this has not been adequately researched. Only a minority of those ever exposed to AA seem to become full, active members over a long period and consistently “work” all the steps.

There is evidence that certain types of people may be more likely to fully affiliate with AA than others (Ogborne and Glaser, 1981; Emrick et al., 1993), but more research is needed and some studies may no longer be relevant given the current range and diversity of AA groups. However, it seems likely that AA would appeal to those who have experienced serious alcohol-related problems and who can accept the need for abstinence and the term “alcoholic”.

When professionals refer clients to AA, as adjunctive therapy, on the assumption that they will benefit from such referrals, it is reasonable to ask about the outcomes of these referrals and to compare these outcomes with those achieved by other means.

Project MATCH (1997) included a 12-step facilitation intervention and results showed that those who were encouraged to go to AA did as well as those provided with other interventions.

What symptoms of alcoholism does Brief-TSF address?

Many signs and symptoms of alcohol abuse may not be apparent even to a close relative or friend.

However, some can be easily seen and some may be hidden by other symptoms; or denied by the drinker.

The Brief-TSF course describes the signs and symptoms of alcohol abuse and alcoholism and provides ways of uncovering them.

Medical symptoms of alcoholism.

The medical symptoms of alcoholism are;

• Hangovers,
• blackouts,
• injuries,
• lethargy,
• weight gain or loss,
• poor coordination,
• high blood pressure,
• impotence,
• vomiting,
• nausea,
• cirrhosis of the liver,
• pancreas disease,
• brain damage, and
• tolerance to alcohol.

Psychological signs of alcohol dependence.

The psychological symptoms of alcohol dependence are;

• Poor concentration,
• sleep problems,
• cloudy thinking,
• depression,
• anxiety/stress,
• aggression,
• loss of control of drinking and
• denial of the effects of alcohol.

Social aspects of alcohol abuse

The social aspects of alcohol abuse are;

• Difficulties and arguments with family or friends,
• difficulties performing at work or home,
• unemployment,
• withdrawal from friends and social activities,
• legal problems and
• financial insecurity.

Spiritual affects of alcohol addiction.

The spiritual affect of alcohol addiction are;

• Dysthymia or mild chronic depression,
• restlessness,
• irritability,
• discontentment,
• self-centeredness,
• insecurity,
• self-pitying,
• resentful,
• fearful and
• feeling useless.

Partner Brief-TSF

Brief-TSF includes intervention with significant others in an alcohol dependents life. Significant others may be

• partners of alcoholics,
• children of alcoholics,
• adult children of alcoholics,
• parents of alcoholics,
• grand parents of alcoholics and
• work colleagues.

Partner Brief-TSF has similar goals and methods to Brief-TSF. The overall goal is referral of the significant other to Al-anon or Alateen.

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Self-help and other supports bolster treatment success

Combining treatment with self-help programs, such as the Alcoholics Anonymous 12-step program, also improves outcomes, and is more effective than either treatment or self-help participation alone.

Attendance at Alcoholics Anonymous meetings is significantly related to post-treatment abstinence. Although mandated AA attendance alone, without treatment, has not been proven effective, one major study showed AA to be as effective as treatment.

Research report; Runder the Influence Part 2: Treating Addictions, Reducing Corrections Costs. Katherine Merrow & Richard A. Minard , Jr. February 5, 2003. New Hampshire Center for Public Policy Studies in association with the Institute for Policy and Social Science Research, University of New Hampshire

BriefTSF can be used successfully in the correction setting

Variety of AA Groups Reflects a Diverse Fellowship

Alcoholics Anonymous is known for the diversity of its membership, with A.A. members from every walk of life sitting side by side in the approximately 60,000 A.A. groups in the United States and Canada. Over the years, though, professionals-doctors, lawyers, airplane pilots, and others-have established a few A.A. groups for those in their field.

Given their common concerns and issues, these members have found A.A. meetings with peers useful. Such groups, which are autonomous along with every other A.A. group, are usually found in large metropolitan areas. They function as any other A.A. meeting.

Among their other purposes, these groups can allay the fears of new A.A. members who may feel more comfortable in a meeting of their peers. The preamble read at “Birds of a Feather” A.A. meetings, which are attended by airline cockpit crew members, refers to the “occupational sensitivity of its members.”

One of the hurdles facing those seeking help in A.A. may be fear of exposure or the shameful sense that their problem is unique to them. Local A.A. offices-called central offices or intergroups- sometimes have lists of A.A. members willing to talk one-on-one with a person seeking information about Alcoholics Anonymous. On these lists are representatives of many professions who will be able to reassure a prospective A.A. member that they are not alone.

There are also A.A. groups for women, men, gays, lesbians, and young people, among others. Information on where to find these groups or any other local meetings is available at A.A. offices around the country.

Al-Anon offers new life to families of alcoholics

Alcoholism touched every aspect of Brenda’s family life. She lost a father to alcoholism, and her brother developed the disease. She also married a problem drinker. They had a large family, and her husband left the job of parenting to her.

"I had out-of-control children at home," she says. "There was no structure–no rules, no bedtime schedules. It was just chaos." Brenda tried to structure the household but found that she couldn’t do it alone. Some of her children developed behavior problems at school and eventually abused alcohol themselves.

For nearly a decade, Brenda searched for support. She went to parent meetings at school. She went to marriage counseling. She went to churches and Bible study groups. Finally, a therapist suggested Al-Anon.

"I remember listening to people at my very first Al-Anon meeting and thinking, this is where I belong,"

"I remember listening to people at my very first Al-Anon meeting and thinking, this is where I belong," Brenda recalls. "The stories I was hearing there were about the very kinds of things happening in my life."

Al-Anon offers free and confidential support for anyone affected by an alcoholic or problem drinker. This includes parents, grandparents, spouses, partners, coworkers, and friends. Alateen, a part of Al-Anon, is a recovery program for young people impacted by a loved one’s alcoholism.

Founded in 1951 by the wives of two Alcoholics Anonymous members, Al-Anon is based on AA’s Twelve Steps. There are no dues and no fees. Rather than relying on mental health professionals, members lead self-help meetings in a spirit of mutual help. The purpose is to share their hope, strength, and experience in dealing with an alcoholic loved one.

It works. Today more than 26,000 Al-Anon groups exist in 115 countries.

Al-Anon begins with the principle that alcoholism is a family disease. And those who care most about the alcoholic are affected the most.

Al-Anon literature compares life with an alcoholic to a drama where people develop stereotyped, almost scripted, roles. Their behaviors center on the alcoholic and are dominated by:

• Obsession–going to great lengths to stop the alcoholic’s drinking, such as searching the house for hidden stashes of liquor, secretly pouring drinks down the drain, or listening continually for the sound of opening beer cans.
• Anxiety–worrying constantly about the effects of the alcoholic’s drinking on the children, the bills, and the family’s future.
• Anger–feelings of resentment that result from being repeatedly deceived and hurt by the alcoholic.
• Denial–ignoring, making excuses for, or actively hiding the facts about the alcoholic’s behavior.
• Guilt–family members’ belief that they are somehow to blame for the alcoholic’s behavior.
• Insanity–defined in Al-Anon as "doing the same thing over and over and expecting different results."

With help from their peers, Al-Anon members learn an alternative–detachment with love. This happens when family members admit that they did not cause their loved one’s alcoholism; nor can they control or cure it. Sanity returns to family life when members focus on taking care of themselves, changing the things that they can, and letting go of the rest.

As a result, alcoholic family members are no longer shielded from the consequences of their own behavior. This, more than anything else, can help them face the facts about their addiction and admit their need for help.

"Since I’ve been in Al-Anon, my life has totally changed," says Brenda. "I filed for divorce and set up my own household. Now my children are getting a lot more of their needs met with a lot more stability in their lives, and I’m a much happier parent. Since I moved out, my son has been on the honor roll at school and my daughter has had the best two years of her life."

To learn more about Al-Anon go online to http://www.al-anon-alateen.org/. A basic text, "How Al-Anon Works for Families and Friends of Alcoholics," explains the Al-Anon program in detail.

Alive & Free is a health column that provides information to help prevent substance abuse problems and address such problems. It is created by Hazelden, a nonprofit agency based in Center City, Minn. "Copyright © 2003 Hazelden Foundation. All rights reserved."

How Al-Anon Works for Families & Friends of Alcoholics