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The Heart of Treatment for Alcoholism
by James J. Hinrichsen, Ph.D.
years ago I was principal investigator on a massive, Federally-funded
study of alcoholism in the elderly. A variety of research
approaches were used to address questions that ranged in
level and focus from government policy to individual case-handling.
While a tremendous amount of useful and important information
was developed in that study, none of it is as important
or useful as what you are about to read in this article.
Health and social service providers who work with elderly
people need to realize that about 10% of the elderly are
likely to manifest varying degrees of health, psychological
and social dysfunctions related to the excessive use of
alcohol. The difficulty associated with detecting excessive
alcohol use is inversely related to the chronicity and severity
of the problem. About two-thirds of elderly alcoholics are
severe, chronic alcoholics whose symptoms tend to be both
obvious and profound. These symptoms are likely to include
physical signs of intoxication (e.g. dysarthria, ataxia,
impaired motor skills, attention and memory deficits, inappropriate
behavior) alcohol withdrawal (e.g. tremulousness, nausea,
vomiting, anxiety, tachycardia, hypertension, sweating,
insomnia, loss of appetite, mild disorientation), medical
problems (e.g. gastritis, cancers of the digestive tract,
especially esophagus and stomach, pancreatitis, fatty liver,
hepatitis, cirrhosis, organic brain syndrome, peripheral
neuropathy, blackouts, atherosclerosis, hypertensive heart
disease, cardiomyopathy, muscle pain and deterioration,
weakness), abnormal laboratory tests (e.g. elevated uric
acid, low levels of platelets and clotting proteins, decreased
production of red and white blood cells, SGPT and SGOT elevations,
low magnesium and potassium), and psychiatric and emotional
problems (e.g. anxiety and depression, suicidal ideation,
sleep disturbances, confusion and disorientation, frequent
life crisis, disturbed interpersonal relations, and marked
change in personality when drinking).
remaining one-third of cases are likely to be less obvious.
These people generally started drinking excessively later
in life and their dependence on alcohol has no yet resulted
in profound debilitation. Regardless of the obviousness
or chronicity of the alcohol problem, "patients"
are far more likely to present themselves as having medical
problems than to walk in and announce that they have a drinking
problem. Denial is the most basic and frequent psychological
response to the suggestion that one has an alcohol problem.
Thus, while you are well-advised to get some training in
the recognition of alcohol problems, it is not likely to
help you much unless you also have some idea about what
to do with older people who drink excessively once you have
found them. This is where we get into the areas of intervention
and referral for treatment the most delicate aspects of
handling alcoholic clients.
A major difficulty in making referrals for alcoholism treatment
is resistance on the part of the client. This may be augmented
in elderly problem drinkers who were the youth and teens
of the Prohibition era and who hold very negative and moralistic
attitudes about alcoholics. This population is also poorly
educated about alcohol and alcoholism, and their denial
of alcohol problems is likely to be supported by their observations
that they do not drink or act as their stereotype of an
may thus be the first step in the referral process. Ideally,
the counselor will have established a collaborative relationship
with the client, and a mutual rapport. Generally, the best
approach is for the confronting person to share his or her
concerns, using the client's presenting complaints to bring
up the subject of excessive drinking. The counselor may
wish to point out destructive patterns of alcohol use; the
relationship between drinking and symptom manifestation;
or educate the client as to future problems he or she can
expect if drinking is continued. The counselor should avoid
the label "alcoholic" as well as judgmental, blaming,
or punitive statements.
the client has accepted the need for, or the reality of
the referral, it will be necessary for the counselor to
explore with the client his or her perceptions about treatment,
and needs and preferences in regard to treatment. Fear is
a common response to the idea of entering alcohol treatment,
and the counselor should allow the client to express fears
of being "locked up," socially ostracized, or
financially ruined as a result of entering an alcohol treatment
program. When the client has overcome the initial shock
and its attendant anxieties, the counselor can explore those
issues pertaining to the type of facility which is acceptable
to the client.
third step in the referral process is assisting the client
in contacting the referral agency. This might include arranging
transportation to the agency; contacting directly the person
who will meet the client there; arranging a specific time
for the appointment; obtaining signed releases for the transfer
of information; and arranging for follow-up report(s) from
the referral agency. Referrals to agencies with long waiting
lists should be avoided, as research shows that the longer
an alcoholic waits before entry into the treatment system,
the less likely he or she is to enter or succeed in treatment.
are a variety of existing programs for the treatment of
alcoholism, ranging from in- patient, hospital-based programs
to out-patient clinics and half-way houses. In choosing
a referral for an elderly alcoholic or problem drinker,
a number of factors must be considered. First is an assessment
of the person's physical condition. Does he or she require
detoxification or immediate medical attention? If this is
judged to be the case, then referral to a hospital's alcohol
program or to a detoxification center may be appropriate.
Does the client have special health-care needs or disabilities
which would bear on his or her eligibility of treatment?
Before referring a client to any institution it is advisable
to be aware of the organization's requirements and the scope
of its services.
Most Important Things
You Need to Know about
variety of approaches to the treatment of alcoholic patients
is mind-boggling in its diversity and this diversity constitutes
a testimonial to the frustration and lack of success which
caregivers have experiences. Once you move beyond standard
medical remedies for the physical maladies associated with
alcohol dependence, you enter the realm of actually treating
the disease of alcoholism. After 20 years of clinical and
research experience, I am convinced that the program provided
by Alcoholics Anonymous (A.A.) has provided more help to
more people than any other approach. Furthermore, I see
no evidence that this reality is likely to change in the
foreseeable future. The most important information in this
article is what you are now going to read about A.A. and
how it works.
caregivers in the elderly services network have only a superficial
awareness of A.A. Unless they are members of A.A. or have
a close relationship with an A.A. member, their knowledge
of A.A. is likely to be deficient and their attitudes toward
A.A. may be distorted. The notion that A.A. is a "religious
program" which "has twelve steps" and "requires
a lot of meetings in smoke-filled rooms“ fails to
do justice to a vast, sophisticated and free alcoholism
majority of alcoholism treatment programs in the U.S., including
hospital-based in-patient programs, out-patient programs,
and long-term residential care programs use the A.A. philosophy
and encourage patients to become actively involved with
A.A. While a period of hospitalization may be necessary
for many alcoholics to detoxify safely and to stabilize
medically, the real test of the efficacy of treatment does
not occur until the patient is back out in the world and
independently faces the challenges of abstaining from alcohol.
Data from the AoA-funded study clearly indicated that elderly
alcoholics who became actively involved with A.A. were far
more likely to remain sober than those who did not. This
research also clearly showed that group therapy and social
support, whether related to A.A. or not, were the most important
and effective elements of treatment.
The A.A. approach to recovery incorporates a "medical"
model of alcoholism and a "moral-spiritual" model
of recovery. The medical model of alcoholism asserts that
alcoholism is a disease which, if not treated, is progressive
and may lead to premature illness and death. The fundamental
medical problem is that some people respond physically to
alcohol in an abnormal way which leads to excessive use,
dependence, "craving" and an inability to control
The medical model of alcoholism has received some persuasive
research support in recent years as evidence has been generated
in support of the assertion that there may exist, in some
people, a genetically inherited predisposition to become
alcoholic. While it is true that there is a continuing scientific
debate over the characterization of alcoholism as a disease,
this debate has proven to be of more scientific interest
than therapeutic value. In my opinion, the medical model
of addiction has been valuable in therapeutic practice largely
because it is more acceptable to the "patient"
and to society to view addictions as illnesses rather than
as reflections of a personal failure of will-power or some
other equally humiliating characterization.
A.A. 12-step program of recovery begins with the practical
observation that, for whatever reason, the individual has
lost the power of choice with respect to alcohol consumption.
The alcoholic's capacity to drink moderately is so impaired
as to render the notion of "free-will" a fiction.
Along with the inability to control alcohol consumption
is a diminished capacity to manage one's health and life
in general. The recognition and acceptance of this reality
constitutes an enormously important psychological change
from denial to awareness. It's like walking from darkness
into light and it constitutes the foundation on which a
program of recovery can be built. It is part of the wisdom
of A.A. to know that this "awakening" is very
much an individual matter which will not happen until the
individual is "ready." Getting to the point of
readiness may require that the individual "hit bottom"
through considerable suffering. Sadly, some alcoholics never
do reach a state of readiness and, other than intervention
through some sort of confrontation, there seems to be little
that outside agents can do to assist the process.
The second step of A.A. further reflects the genius of the
program in that it provides hope and strength to replace
despair and weakness. In this step the alcoholic acknowledges
the existence of a power greater than self which can restore
"sanity." The acceptance of a "Higher Power
" is both a source of strength and inspiration to some
people and an obstacle to be dealt with for others. The
concept of a Higher Power in A.A. refers to "God"
as we understood "Him" and it is the cornerstone
of the spiritual foundation of A.A. Unfortunately, the "religious"
nature of the A.A. program has been used by many alcoholics
to justify their avoidance of the program. They complain
or argue that this is a "turn-off" or that they
can't relate to it. So profound is this phenomenon that
in Alcoholics Anonymous, the A.A. "Big Book" which
describes how the program works, there is an entire chapter
entitled "We Agnostics" which deals with this
issue. For some, A.A. becomes the higher power. For now,
suffice to say that it is a gross distortion of the A.A.
program to assert that one must be a highly religious person
to benefit from the program.
remaining 10 steps of the A.A. program also reflect the
wisdom of those who have struggled to recover from alcoholism
and while space limitations preclude an examination of each
of them here, I will address a few points which they cover.
In A.A. it is accepted that the cessation of drinking does
not constitute recovery - it merely makes recovery possible.
The need for profound life-style change is reflected by
the individual's conscious decision to lead a less self-centered
life and to accept one's place in the broader scheme of
life. The alcoholic is asked to make "a searching and
fearless moral inventory of self" and to share this
with another person. Sound psychology is represented here
in that exposure of the truth is consistent with a healthy
orientation to reality and the emotional catharsis associated
with relief from guilt and shame represents an unburdening
of the self from negative, depressive emotions. Confession
really does seem to be good for the soul.
Additional steps in the A.A. program instruct and encourage
the individual to take actions, both practical and spiritual,
to facilitate the recovery process. Expansion of personal
awareness, acceptance of personal responsibility, and sharing
the program with others all serve to reinforce and integrate
the process which the recovering person has made. Recovery
is seen as being a life-long process which must be protected
at all times. There is no " cure" for addiction
to alcohol, only an ongoing program of recovery.
A number of features of A.A. make it especially appropriate
for elderly people. First, it's free. Given limited funds
and weak Medicare or other insurance coverage A.A. represents
an appealing alternative. Moreover, all the gold in Fort
Knox cannot buy the support and commitment which is given
freely by A.A. members. In A.A. you "work your program"
with the help of a sponsor - a person who has "good
sobriety" and who understands how the A.A. program
works. Usually, these sponsors agree to be available 24
hours a day to assist you in case of crisis. Also, many
A.A. meeting rooms are always open and this safe haven can
be used by those who need it.
The support provided by A.A. goes beyond sponsorship in
"working the program." It includes the provision
of a sense of belonging, of being part of a group. This
sense of connectedness can serve as a powerful antidote
to the loneliness and isolation which is common among the
elderly. If you need a ride to a meeting, someone will provide
it - freely. Also, you can travel to just about any part
of the country and many parts of the globe and you can find
an A.A. meeting, a safe haven, a place where you know you
will be welcome. You can't buy this.
closing, it should be noted that A.A. is not the "answer"
for all people - nor does it claim to be. Some alcoholics
stop drinking with no assistance whatsoever but they are
the minority and it is questionable whether their psychological
and spiritual growth continues merely because they are abstinent.
Some alcoholics find that they want or need psychotherapy
or medical treatment for other psychological problems. Sometimes
A.A. is only the beginning of the recovery process but it
is the best program I know of and no one can argue about
its cost effectiveness. If you really want to be helpful
to elderly alcoholics, learn about A.A. Get a copy of Alcoholics
Anonymous, get a copy of a "Where and When" booklet
so you know the location and times of local meetings. Find
out if there are any meetings in your area especially for
older adults. Share what you learn.
Aging, Fall ,1990.)