Why ’not drinking’?

We members of Alcoholics Anonymous see the answer to that question when we look honestly at our own past lives. Our experience clearly proves that any drinking at all leads to serious trouble for the alcoholic, or problem drinker. In the words of the American Medical Association:

Alcohol, aside from its addictive qualities, also has a psychological effect that modifies thinking and reasoning. One drink can change the thinking of an alcoholic so that he feels he can tolerate another, and then another, and another.

The alcoholic can learn to completely control his disease, but the affliction cannot be cured so that he can return to alcohol without adverse consequences.

And we repeat: Somewhat to our surprise, staying sober turns out not to be the grim, wet-blanket experience we had expected! While we were drinking, a life without alcohol seemed like no life at all. But for most members of A.A., living sober is really living-a joyous experience. We much prefer it to the troubles we had with drinking.

One more note: anyone can get sober. We have all done it lots of times. The trick is to stay and to live sober. That is what this booklet is about.

Living Sober, 1975, Alcoholics Anonymous World Services, Inc

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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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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What are drug users looking for in treatment; abstinence or harm reduction?

Within the UK and in many other countries two of the most significant issues with regard to the development of health and social care services for drug users has been the growth of the consumer perspective and the philosophy of harm reduction.

In this paper we look at drug users’ aspirations from treatment and consider whether drug users are looking to treatment to reduce their risk behavior or to become abstinent from their drug use.

The paper is based on interviews using a core schedule with 1007 drug users starting a new episode of drug treatment in Scotland. Participants were recruited from a total of 33 drug treatment agencies located in rural, urban and inner-city areas across Scotland.

Our research has identified widespread support for abstinence as a goal of treatment with 56.6% of drug users questioned identifying ‘abstinence’ as the only change they hoped to achieve on the basis of attending the drug treatment agency.

By contrast relatively small proportions of drug users questioned identified harm reduction changes in terms of their aspiration from treatment, 7.1% cited ‘reduced drug use’, and 7.4% cited ’stabilization’ only.

Less than 1% of respondents identified ’safer drug use’ or ‘another goal’, whilst just over 4% reported having ‘no goals’.

Drug user’s desires;

• Abstinence - 56.6%
• Reduce drug use - 7.1%
• Stabilization - 7.4%
• Safer drug use or other goal (Grouped) – Less than 1%
• No goals - 4%

The prioritization of abstinence over harm reduction in drug users treatment aspirations was consistent across treatment setting (prison, residential and community) gender, treatment type (with the exception of those receiving methadone) and severity of dependence.

Neil McKeganey, Zoë Morris, Joanne Neale & Michele Robertson. What are drug users looking for when they contact drug services: abstinence or harm reduction? Drugs: Education, Prevention & Policy, Volume 11, Number 5 / October 2004, Pages: 423 - 435

TSF ASSESSMENT

The assessment session in TSF runs 1-1/2 hours. The goals are to:

• Establish client-facilitator rapport.
• Conduct a collaborative assessment of alcohol and other drug abuse(history).
• Discuss the client’s prior efforts to stop or control use.
• Discuss negative consequences associated with use.
• Share a diagnosis with the client and attempt to have it be a collaborative decision.
• Outline the TSF program.
• Attempt to get a commitment from the client to give TSF and AA/NA and try and to keep an open mind.

Assessment within the TSF model has both an informational and a motivational goal.

It is recommended that periodic alcohol tests be done either randomly or when the facilitator suspects that the client may have been drinking or using.

Consistent with 12-step philosophy, no client is excluded from treatment as a consequence of drinking or using, although with some clients it may become appropriate to discuss inpatient treatment. Sessions with clients who are found to be (or who admit to being) drunk or high are terminated, and arrangements are made to get the client home safely.

TSF CLIENT-COUNSELOR RELATIONSHIP

What Is the Counselor’s Role?

The facilitator’s role in TSF is broadly defined as including education and advocacy, guidance and advice, and empathy and motivation. Each of these broad goals is broken down further into a series of specific guidelines or objectives. For example, guidance and support include monitoring client involvement in AA/NA, encouraging clients to volunteer for basic service work, identifying appropriate social events the client might participate in, locating appropriate meetings, and clarifying the role of a sponsor.

Who Talks More?

Clients and facilitators talk about equally in effective TSF sessions. Since TSF is an active intervention, facilitators who are passive may not succeed in maintaining focus or accomplishing basic goals. At the same time, success in TSF is dependent on monitoring client activity and reactions, which requires soliciting active client involvement in sessions.

How Directive Is the Counselor?

TSF is similar to many cognitive-behavioral therapies in that it is focused and requires the facilitator to be fairly directive while still maintaining good rapport. The TSF facilitator is directive in the following ways:

• The focus of therapy is on early recovery. The facilitator does not allow the focus to drift onto other issues (e.g., relationship or work problems) even if these are significant. The facilitator validates other concerns and helps the client develop an overall treatment plan to deal with them but maintains the focus of TSF.
• The client’s reactions to assignments and meetings are considered very important. In TSF the facilitator needs to solicit specific feedback from the client.
• Each TSF session has a specific topic (core, elective, or conjoint) that includes a specific agenda to be covered. Although a given topic may require more than one session to cover, and while the facilitator needs to be somewhat flexible in his or her agenda, the facilitator must also take responsibility for controlling the content and flow of sessions.
• Each TSF session follows a set format that the facilitator is responsible for following. Again, there is some flexibility, but the facilitator does not simply follow the client’s agenda.
• Every TSF session ends with the facilitator making specific suggestions to the client (recovery tasks). In addition, the facilitator is expected to make specific suggestions (e.g., which meetings to attend, how to ask for a sponsor) throughout treatment.

Therapeutic Alliance

In TSF, the facilitator is seen as an expert in interpersonal counseling techniques and as knowledgeable in the principles and practicalities of 12-step fellowships.

However, in TSF the facilitator is not regarded as the primary agent of change; rather, it is the 12-step fellowship (AA or NA) that is seen as the agent of change.

Accordingly, the TSF facilitator needs to conceptualize treatment as the product of a collaborative relationship and should assume responsibility for doing the best he or she can to establish that collaborative relationship.

However, it is not the facilitator’s goal to breakdown the client’s denial, to provide all support needed to stay sober, to take the client to meetings, and so forth. Even in emergencies, the facilitator’s role and responsibilities are limited in the TSF model. For this reason the word "facilitator" was chosen rather than therapist or counselor, as it seems to describe the role better than those labels.

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.

Drinking and Biting

It’s a problem Mike Tyson knows well: fights that escalate into men biting other men. And researchers say that most human-bite cases involve males who have been drinking, the CanWest News Service reported June 20.

Irish researchers say that 86 percent of human-bite cases involve alcohol, and that men are bitten 12 times more often than women. Most bites occur on the face — particularly the ears, nose and cheek — as well as the fingers and forearm. Sixty-five percent of all bites involve the ear.

"I think a lot of people wouldn’t know this happens, or to the extent that it happens," said study co-author Patricia Eadie, a plastic surgeon at St. James’s Hospital in Dublin. "There’s a lot of person-on-person violence that can be due to alcohol and drugs." Many such incidents go unreported because victims don’t seek medical attention, she added.

The study was published in the July 2007 issue of the Emergency Medicine Journal.

Research Reference: Henry, F.P., Purcell, E.M., Eadie, P.A. (2007) The human bite injury: a clinical audit and discussion regarding the management of this alcohol fuelled phenomenon. Emergency Medicine Journal, 24: 455-458.

Reduction in heavy drinking as a treatment outcome in alcohol dependence.

This article, published in a prestigious journal, suggests that controlled drinking should return to the public health arena. This, even though this policy has been dismissed, about 2 decades ago, as being unworkable and dangerous to the individuals, their families and society as a whole.

Alcoholics who have tried controlled drinking will attest to the futility of such a policy and goal.

Reduction in heavy drinking for ‘problem drinkers’ is a viable goal but not for alcoholics.

The only valuable suggestion made in the article is the final one

“outcomes be individualized to patients’ goals”.

There is no clinical benefit in trying to get an alcoholic to control their drinking.

Abstract; In the field of clinical alcohol disorders treatment in North America, abstinence continues to be largely viewed as the optimal treatment goal; however, there is a growing awareness of limitations when abstinence is considered the only successful outcome.

Although this issue has been discussed in research settings, new studies on the public health significance of heavy drinking (defined as five or more standard drinks per drinking day in men, and four or more standard drinks per drinking day in women) in the past 10 years suggest that clinical providers should consider the value of alternative outcomes besides abstinence.

A focus on abstinence as the primary outcome fails to capture the impact of treatment on reduction in the pattern and in the frequency of alcohol consumption.

In addition, evaluating reduction in drinking as “positive” has value for patients as an indicator of clinical progress. Measurement of continuous variables, such as the quantity and the frequency of alcohol consumption, has provided a clearer understanding of the scope of alcohol-related morbidity and mortality at the societal level, and of the relationship between individual patient characteristics and the naturalistic course of alcohol use, abuse, and dependence.

A review of these characteristics suggests that there are clinical benefits associated with reducing heavy drinking in alcohol-dependent patients.

Given the significant public health consequences associated with heavy drinking and the benefits associated with its reduction, it is proposed that researchers, public health professionals, and clinicians consider using reduction in heavy drinking as a meaningful clinical indicator of treatment response, and that outcomes be individualized to patients’ goals and readiness to change.

Research report; David R. Gastfriend, James C. Garbutt, Helen M. Pettinati and Robert F. Forman. Reduction in heavy drinking as a treatment outcome in alcohol dependence. Journal of Substance Abuse Treatment. Volume 33, Issue 1, July 2007, Pages 71-80

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 www.alcoholicsanonymous.org.uk/geninfo/05steps.shtml 2 See Zemore SE, Kaskutas, LE and Ammon LN (2004) ‘In 12-step groups, helping helps the helper’, Addiction 99, 1015. 3 See www.hazelden.org/servlet/hazelden /go/INFO_MNMODEL 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.uk