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Help your clients find the path to overcoming their addiction
Alcoholics are one of the most difficult client groups to treat effectively. To preserve their way of life, they may lie about their problem or deny that one exists; that is the nature of this profoundly powerful disease. Yet if you can guide each of your clients through their own resistance towards the truth, not only will you be rewarded with starting them on the road to recovery, you will no doubt have saved their life as well. Achieving such a victory goes to the heart of being an addiction counselor; it is the experience of healing on a direct and tangible level.
Treating Alcoholism provides a complete road map for assessing, diagnosing, and treating this multifaceted and tenacious illness. Detailed clinical information on the disease accompanies ready-to-use tools for practice. With a special emphasis on the 12 Steps of Alcoholics Anonymous, the author walks you through the first five steps of this established methodology in comprehensive detail, showing how to easily apply each one to treatment.
Other useful resources in Treating Alcoholism include:
* A sample treatment plan
* Copies of alcohol screening tests (SMAST and CAGE questionnaires)
* Tests for other potentially related problems such as gambling and sexual addiction
* A sample behavioral contract for use with adolescents
* Listings of additional resources
The treatment of alcoholism is fraught with struggles and hazards for both client and caregiver. Written in a lively tone that resonates with the author's compassion for his own clients, Treating Alcoholism gives you reliable, up-to-date, and practice-tested information and materials you need to successfully confront this deadly disease and start your clients on the path to recovery.
1. Recognizing Alcohol Problems.
2. Critical Concepts.
3. Treatment Planning.
4. The Tools of Recovery.
5. The Steps.
6. Dual Diagnosis.
7. Adolescent Treatment.
8. Terminating Treatment and Preventing Relapse.
9. The Recovery Community.
10. Into the Future.
Appendix 1: CAGE Questionnaire.
Appendix 2: Short Michigan Alcoholism Screening Test (SMAST).
Appendix 3: Alcohol Involvement Scale.
Appendix 4: Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA).
Appendix 5: DSM-IV®-TR Psychoactive Substance Use Disorder.
Appendix 6: Cognitive Capacity Screening Examination.
Appendix 7: The Biopsychosocial Interview.
Appendix 8: Helping Patients with Alcohol Problems: A Health Practitioner’s Guide—National Institute on Alcohol Abuse and Alcoholism (NIAAA).
Appendix 9: Barriers in Thinking: Blueprint for Change.
Appendix 10: National Council on Problem Gambling: 10 Questions about Gambling Behavior.
Appendix 11: Hamilton Anxiety Scale.
Appendix 12: The Behavioral Contract.
Appendix 13: The Sexual Addiction Screening Test (SAST).
Appendix 14: Yale-Brown Obsessive Compulsive Scale (Y-BOCS).
Appendix 15: Fetal Alcohol Behavior Scale.
Appendix 16: Liebowitz Social Anxiety Scale.
Appendix 17: Personal Recovery Plan.
You know something is wrong with your patient, but you don't know what it is. He looks depressed and anxious. His face is red and swollen, his eyes watery and red. If you look closely at his cheeks, you might see little red spider lines called spider angiomas that signal a failing liver. Something is wrong and it nags at you. That uncomfortable feeling inside you grows, and you don't like it.
You have been a natural born healer all of your life. When you were a kid, you cared a little more about injured puppies and kittens than others did. You didn't want to squash bugs. People in school talked to you when they wouldn't talk to anyone else. People recognize a healer when they see one.
There is another side of you that is different, though. It has been in trouble with patients like this before. Sometimes this healing thing is not what it's cracked up to be. Sometimes you have to tell people the truth when they don't want to hear it. They rebel against you and get angry. You have learned that sometimes it is best to let the truth go or to change it to make it more palatable. You hate that part of yourself, but you have learned how to live with it. After all, you live in a world full of litigation and managed care. Fear has overcome your best judgment many times.
Andthere's that patient over there, crying out to the healer in you. This time if you let the problem go, if you take the easy way out, the patient could die. Ninety-five percent of alcoholics die of their addiction, and the average alcoholic dies 26 years earlier than he or she would otherwise. To let this patient out of your office without confronting the truth is to be potentially responsible for the patient's death.
Yet, you have confronted alcoholics before. Alcoholic patients have two sides: One side knows they are drinking themselves to death while the other side knows they can drink safely. You and your patients are in a war of lies, battling the truth. The trick is to help the patients win. You are up against a great enemy. The Big Book of Alcoholics Anonymous (2001) says this illness is "cunning, baffling and powerful" (pp. 58-59). At every AA meeting, someone reads how it works, which is the fifth chapter in the Big Book. The chapter ends with this statement:
Our description of the alcoholic, the chapter to the agnostic, and our personal adventures before and after make clear three pertinent ideas: (a) that we were alcoholic and could not manage our own lives, ( b) that probably no human power could have relieved our alcoholism, and (c) that God could and would if He were sought. (Alcoholics Anonymous, 2001, p. 60)
So the battle lines are drawn. The enemy, the disease, is confident of victory. It thinks that you will probably take the easy way out. You will handle the acute problem and let the patient go home. You will not ask the questions that could lead to the truth.
But the enemy doesn't know you. The enemy doesn't know that you are a natural born healer. You will not lie. You are not going to let the patient go home to die. You are going to fight. This is who you are inside, and it is who you will always be.
THE MOTIVATIONAL INTERVIEW
Your patient is sick and doesn't want to know the reason. Your job is to go with the patient toward the truth. It does no good to go against the patient. Arguing with the patient will not work because the alcoholic is an expert at giving every excuse in the world for abnormal behavior. If you argue, the patient will win because he or she will leave your office convinced you are a bad person. You need to gently walk with the patient toward the truth-patient -centered, not self-centered. You must connect with that gentle voice of reason inside patients that is telling them they are sick. That voice is there and your job is to connect with it, empathize with it, and pull for more. The other voice in patients' heads says something else is to blame. They might have a problem, but it has nothing to do with alcohol.
As a professional, you are used to your patients being honest with you, but this one is going to lie. The patient is not a bad person; he or she is a good person with a bad disease. The disease of alcoholism lives and grows in the self-told lie. Patients must lie to themselves and believe the lie, or the illness cannot continue. Patients have a long list of excuses for their behavior. My spouse has a problem. The police have a problem. The school has a problem. My boyfriend has a problem. I have a physical problem. I'm depressed. I'm anxious. I have a stomachache. I can't sleep. The excuses go on and on, and they will confuse you if you get caught up in them. They are all part of a tangled web of deceit. Remember, your job is to walk with the patient toward the truth, not against the patient toward the truth. You are going to spend most of your time agreeing with the patient. When the patient is honest, you are going to agree with the patient. When the patient is dishonest, you are going to probe for the truth. If the patient is listening to you, you can work with him or her. If the patient is not listening to you, anything you say is worthless. Watch the patient's nonverbal behavior very carefully. You are a healer, and you have been given the gift of supersensitivity. Your intuition will tell you whether the patient is going with you or resisting. When patients are going with you, you feel peace. When they are going against you, you feel fear. When the patient is ready, you will educate him or her about the disease. This is a gentle, loving process and it takes time. If you are in a hurry, it's not going to work.
The patient has been using alcohol for a long time and trusts it. All drugs of abuse tell the brain, "Good choice!" All organisms have an instinctive way of finding their way in a complicated world. What foods are good and what are bad? What is the best way through the jungle? What is safe and what is dangerous? We all learn these things deeply in the brain. What is good becomes quickly imprinted. If it is very good, it can become imprinted after one trial. Alcohol has been good to this patient for many years, and now it is destroying him or her. The very thing that gave the patient joy now gives nothing but pain. The patient is so fooled by this process that direct evidence of alcohol's harmful consequences are denied. Remember, alcohol has always said, "Good choice!" So how can it now be a bad choice? You are fighting with this patient's basic understanding of the world, and he or she will be convinced that you are wrong. You must help the patient see that alcohol is no longer a good choice-it's a deadly choice. The alcoholic cannot see this alone, but AA has an old saying: "What we cannot do alone, we can do together." The patient cannot discover the truth without your help. You must guide the patient toward a destiny he or she finds impossible. You need to help patients see that they need to stop drinking.
What you are looking for is the truth. The patient will rarely tell you accurate symptoms. You have to look for signs of the disease. You will continue to investigate-testing, smelling the air, ordering laboratory studies, and talking to family, friends, court workers, school personnel, and anyone else who can help you until you uncover the truth.
Your patient cannot tell you the truth because the patient doesn't know the truth. Addiction hijacks patients' spirit, mind, and body. They are trapped in a web of self-deception. They cannot tell you the truth even if they try because they don't know what it is. Remember, you are the healer. You love your patients even if they hate themselves. You are going to love them even though they are being nasty and deceptive. You are going to help them even though they don't understand what you are doing.
DEVELOPING THE THERAPEUTIC ALLIANCE
From the first contact, your patients are learning some important things about you. You are friendly. You are on their side. You are not going to beat them up, shame, or blame them. You answer any questions. You are honest and you hold nothing back. You are committed to do what is best for them. You provide the information and they make the decisions. They see you as a concerned professional. In time, they begin to hope that you can help them. The therapeutic alliance is built from an initial foundation of love, trust, and commitment.
You show the patient that he or she does not have to feel alone. Neither of you can do this alone. You must cooperate with each other to solve the mystery. Your patients know things that you don't know. They know themselves better than anyone else, and they need to learn how to share themselves with you. Likewise, you have knowledge that they don't have. You know the tools of recovery.
Your patients must develop trust in you. To establish this trust, you must be honest and consistent. You must prove to them, time and time again, that you are going to be actively involved in their individual growth. When you say you are going to do something, you do it. When you make a promise, you keep it. You never try to get something from patients without using the truth. You never manipulate, even to get something good. The first time your patients catch you in a lie, even a small one, your alliance is weakened.
If you work in a facility, the patient must learn that all of your staff works as a team. What patients tell you, even in confidence, they tell the whole team. Patients occasionally test this. They tell you that they have something to share but they can share it only with you. They want you to keep it secret. This is a trap that many early professionals fall into. The truth is that all facts are friendly and all accurate information is vital to uncovering the truth. You must explain to patients that if they feel too uncomfortable sharing certain information, they should keep it secret for the time being. Maybe they can share this information later, when they feel more comfortable.
Patients must understand that you are committed to their recovery, but you cannot recover for them. You cannot do the work by yourself. You must work together, cooperatively. You can only teach the tools of recovery. The patients must use the tools to stay sober.
CONDUCTING A MOTIVATIONAL INTERVIEW
In the first interview, you begin to motivate patients to see the truth about their problem. Questions about alcohol and other drug use are most appropriately asked as a part of the history of personal habits, such as use of tobacco products and caffeine ingestion. Questions should be asked candidly and in a nonjudgmental manner to avoid defensiveness. Remember, this is patient-centered interviewing, not professional-centered, and the interview should incorporate the following elements (Delbanco, 1992; Graham & Fleming, 1998; W. Miller & Rollnick, 1991; Ockene et al., 1988; Prochaska, 2003; Rollnick, Heather, Gold, & Hall, 1992):
The patient should be alcohol-free at the time of the screening. Offer empathic, objective feedback of data. Work with ambivalence.
Meet the patient's expectations.
Assess the patient's readiness for change.
Assess barriers and strengths significant to recovery efforts.
Reinterpret the patient's experiences in light of the current problem.
Negotiate a follow-up plan.
Example of a Motivational Interview
Professional: "Hello, Mr. Smith. I'm __________ (your name). Why did you decide to come in to see me today?" [The professional wants to understand what the patient expects from the initial visit.]
Patient: "My wife told me I had to talk to you."
Professional: "Why did she do that?"
Patient: "I don't know."
Professional: "I talked to your wife on the phone yesterday, and she said she was concerned about your drinking."
Patient: [Looking irritated] "She's always concerned about something I'm doing."
Professional: "Things are not going well at home?" [Professional mirrors the patient's feelings and facial expression. When you mirror a person's expression, you validate his or her worldview. Connecting with what the patient feels is empathy, which gives the patient hope that he or she is being understood.]
Patient: "Oh, its okay. It's just that she gets all worked up about little things."
Professional: "Your wife said you have been drinking heavily every day, and she is worried about you."
Patient: "I don't drink every day. I drink once in a while, like most people. I work hard, and I like to come home and relax. Is anything wrong with that?" [The patient is obviously irritated with the interview, and the professional needs to listen and go with his or her feelings. So far, the patient is saying, "My wife has a lot of problems."]
Professional: [Reflecting the patient's point of view] "There's nothing wrong with relaxing. How do you relax?"
Patient: "I have a couple of beers."
Professional: "Your wife says you have been drinking a 12-pack of beer a day."
Patient: "It's not that much."
Professional: "Is it more than a couple?"
Patient: "Yeah, maybe a little more."
Professional: "Is it around 12?"
Patient: "So what if it is? I work hard and I deserve to relax." [The patient is resisting, and the professional knows to back off a little. It's important to keep the patient's ears open. Be empathic and understanding. Try to see the problem from the patient's point of view. Once you enter the patient's world and understand his or her point of view, you will get clues about what will motivate the patient to change. This patient is angry with his wife, and he needs some help with that, but what is his real problem?]
Professional: "I like to relax after a hard day, too. Everybody likes to do that."
Patient: "You're right about that. My wife just sits around all day and watches television while I'm working my tail off."
Professional: "So you really need to relax when you come home, particularly if you feel like you are pulling the load all by yourself?"
Patient: "Yeah, she sits around and thinks about things to argue with me about. That's her job."
Professional: "Do you think your wife loves you?"
Patient: [Visibly softening] "Yes, I think she does."
Professional: [Reinterpreting the patient's experience in light of the alcohol problem] "It's great to have a wife that loves you. If you are drinking too much, she should be worried." Patient: "But I'm not drinking too much. I'm just drinking a few beers."
Professional: "What's the most beer you have ever drunk in a full day?"
Patient: "Oh, I don't know."
Professional: "Give me a guess."
Excerpted from Treating Alcoholism by Robert R. Perkinson Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Posted September 20, 2004
As a physician I kept my alcoholic patients happy by being quiet about their addiction. This left me feeling guilty and responsible for their death. Using this book I have changed my stratagy and now move every addict toward recovery. Remarkably, they all love me for telling the truth I was so afraid to share before. The trick was to know how to intervene at their level not mine. Once I understood how to talk to addicts everything changed and now my patients are working toward recovery. This is a wonderful book full of hope and inspiration.Was this review helpful? Yes NoThank you for your feedback. Report this reviewThank you, this review has been flagged.