ALCOHOLISM AND DRUG DEPENDENCY
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- Title
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ALCOHOLISM
AND
DRUG DEPENDENCY - extracted text
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ALCOHOLISM
AND
DRUG DEPENDENC
An Advanced Master Guide
for Professionals
Issues and Treatment Procedures
In
After-Care
L
ALCOHOLISM AND DRUG DEPENDENCY
AN ADVANCED MASTER GUIDE
FOR PROFESSIONALS
I
■
Issues and Treatment Procedures in After-care
i
I
Copyright © 1992,
T.T. RANGANATHAN CLINICAL
RESEARCH FOUNDATION
IV Main Road
Indira Nagar
Madras 600 020
India
/?< LIBRARY
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DOCUMENTATION
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This publication is
Sponsored by
Ministry of Welfare, Government of India
New Delhi 110 001
&
Produced by
T.T. RANGANATHAN CLINICAL RESEARCH FOUNDATION
17, IV MAIN ROAD, INDIRA NAGAR, MADRAS 600 020
iii
ACKNOWLEDGEMENTS
I would like to express my gratitude to the many people who have put in
enormous time and effort in producing this Advanced Masterguide.
RUKMANI JAYARAMAN, our Honorary Consultant, wrote the core
chapters of this manual including Relapse Prevention Planning and Counselling
Techniques. Rukmani has been working on this manual for over two years.
She has gathered extensive materials covering case studies, interviews,
implementation tools, methodologies and research references and has
condensed and presented them in a well structured format.
Counsellor JAYASHREE VENKATARAMAN wrote some of the techniqueoriented chapters including Assertiveness Training. She took the trouble of
meeting fellow professionals and specialists working in other institutions to
seek their valuable suggestions on the text.
RAVI MENON went through the complete text several times over to improve
the language and presentation.
Producing such a detailed manual involves tremendous volume of secretarial
work. GEETHA SUNDARAM did the job single handed putting in late hours
on the word processor. She took the initiative of making first level draft
corrections and saved a lot of time for the authors.
Dr. S RAJARAM Lecturer at the National Institute of Mental Health and
Neurological Sciences, Bangalore and Dr. RAYMOL RACHEL CHERIAN,
Research Co-ordinator, Addiction Research Centre, Madras, were most kind
and gracious in sparing much of their valuable time to go through the
manuscript and provide suggestions for improvement.
SHANTHI RANGANATHAN
HONORARY SECRETARY
T T RANGANATHAN CLINICAL RESEARCH FOUNDATION
17, IV MAIN ROAD, INDIRA NAGAR, MADRAS 600 020
V
INTRODUCTION
This book is for
*
*
*
*
Counsellors
Psychologists
Social Workers
Medical Professionals
Working in the field
of Addiction Treatment
It is a guide to understanding
*
Organisational and Administrative requirements of setting up an
After-Care Centre.
* Special treatment procedures and methodologies to manage patients
prone to frequent relapses.
* The need for qualitative life-style changes to effect long-term recovery.
We wrote it because
* Even experienced professionals, quite unnecessarily, tend to feel angry
and guilty when a patient relapses despite their committed efforts
towards his recovery and well being.
* Many professionals are still unaware of the positive role of AfterCare services in helping the patient towards recovery.
This book will
*
Provide the specialist with a deeper insight into the Relapse Dynamic.
* Empower the treatment professional with special tools, methodologies
and step by step analysis of treatment procedures.
♦ Enable the Counsellor to derive greater job satisfaction in addition
to professional development and growth.
vii
A BRIEF NOTE TO THE COUNSELLOR
We have adopted some standardisations with regard to the terminology used
in this manual. This is largely to ensure simplicity of presentation and clarity
in understanding. The following notes will therefore be of use to you.
* This manual covers chemical dependency in general. However, expressions
like addiction to alcohol, drug addiction, drug dependency have been used
in specific contexts where appropriate. These may, therefore, be understood
within the overall theme of chemical dependency.
* At the end of some key chapters, there is a place for ADDITIONAL
INFORMATION. In this place, we have some of the following:
i) Implementation Tools
ii) Case Studies
Case Studies are authentic. But the names and references have been altered
to maintain confidentiality.
♦ The Counsellor is referred to as HE. You may also find expressions like
therapist, professional, etc., in place of Counsellor.
♦ The word HE is used to denote the chemically dependent person. Again,
this expression ‘Chemical dependent’ may rind its near equivalent in
alcoholic, addict, patient and client.
* The ‘Family Member’ is represented by the ‘wife’ and, therefore, referred
to as SHE. Actually, it could also be a husband, father, mother or a
guardian.
* The real value of this manual lies in the fact that a large part of it has been
drawn out of our own experience both at the After-care Centre and our
main Hospital in treating over 5,000 patients so far.
* Chemical dependency has now become an intense and pervasive social
problem with a major social impact. Consequently, management of this
problem, as also the methods of approach and treatment — all require
continuous updating and tuning up.
The After-care Centre of the T T Ranganathan Clinical Research Foundation
would therefore welcome any information by way of feedback from
professionals which may be relevant and useful in meeting this objective.
ix
CONTENTS
Pages
1. What is After-Care?
2. Rules and Regulations of the Centre
3. After-care Centre and After-care Services
4. Medical Complications Related to Drug Abuse
5. Resolving Guilt and Shame
6. Working Through Grief
7. Healing the Hurts
8. Anger Management
9. Understanding Powerlessness and Unmanageability
10/ Relapse Prevention Planning
11. Addiction — Its Impact on the Family
12. Sexual Problems in Recovery
13. Coping with Stress
14. Understanding Values
...
15. Compulsive Gambling
16. Improving the Quality of Life
17. Spirituality
18. Assertiveness Training
19f Group Therapy
20^The Role of the Counsellor and Counselling Techniques
..
21. Vocational Rehabilitation
..
22. Some more Implementation Tools
xi
1
6
14
38
44
52
62
71
87
97
116
127
136
142
150
154
163
170
180
199
227
230
\ /
1______________________
WHAT IS AFTER-CARE?
Management of chemical dependency is a complex issue which has
to be handled by professionals specialised in various disciplines.
These specialists work together in the common task of treating and
rehabilitating the dependent. Addiction treatment goes through three
distinctly defined phases.
Detoxification
Detoxification, a process supervised by medical professionals, aims at
withdrawing the person safely from physiological drug dependence.
Primary treatment
This includes a gamut of rehabilitation efforts through individual, group
and family therapy, and can be a residential or an out-patient
programme. Primary treatment aims at total abstinence from mood
altering drugs. It emphasises the need for a qualitative change in the
life-style of the patient.
After-care services
After-care includes any service offered to the patient after the goals
of primary treatment have been largely met in order to help him to
continue his sobriety. The package would be, follow-up counselling,
self-help through Alcoholics Anonymous (A.A.) and Narcotics
Anonymous (N.A.), referral to adjuncture services like vocational
counselling, After-care centres or Half-way homes. After-care services
reinforce the need to make positive life-style changes.
The need for after-care services
Recovery is not just the cessation of drug use; it also demands
adjustment to a new way of life. The chemical dependent has to
K I
2
ALCOHOLISM AND DRUG DEPENDENCY
rebuild each and every area of his life — family relationship,
employment, finances, education etc. These activities can also impose
new stresses and therefore require new coping skills. Recovering patients
need hope and determination in the phase of change. To make a truly
new way of life, chemical dependents need much more than grit — they
must have guidance to acquire new skills and make new contacts for
total recovery.
Following are a few problems they must learn to handle.
- There is the crucial issue of relapse. Relapse can be painful and can
confuse the patient, his family and friends.
- Getting back to the same environment may pose a threat to sobriety.
- The negative emotions which the patient experiences lead to problems
in recovery. Therefore, feelings of ‘Guilt’, ‘Shame’, ‘Hurt’, ‘Anger’
and ‘Grief’ have to be resolved.
The recovering person may have to handle high risk situations and
therefore has to learn to say ‘NO’ to drugs.
- He must also learn to respond safely to stress.
- Patients have to relearn new ways of life and start rebuilding their
values.
- Recovering persons have to learn to lead a fulfilling life without
resorting to chemicals.
- The patient should establish spiritual recovery by coming to believe
in a Power greater than himself which can give him strength and
confidence to manage the variety of challenges he is likely to face.
- Also the family may find it difficult for sometime to accept the
person back into its system.
Hence, the family has to be helped to recover*.
Goals of after-care services
To manage the challenges, the after-care services have certain specific
goals. Researchers have suggested four reasonable goals for after-care
services.
* Methods to handle the above challenges have been discussed in detail in the various chapters of this
Manual.
/
WHAT IS AFTER-CARE?
'UH 1 • ‘i
3
1. After-care should increase family and other social support for
successful living in the community without dependence on drugs and
should seek to eliminate patterns of interaction with family and peers
that contribute to relapses. In short, after-care should seek to develop
or enhance social supports in the community.
2. After-care should seek to increase involvement in productive roles
in the community, whether in work, school or at home.
3. After-care should facilitate the person’s involvement in active
recreational and leisure activities that do not involve the use of drugs.
4. After-care should assist the patient to recognise his negative emotions
and deal with them appropriately.
Process in after-care services
The process by which change occurs in the recovering chemical
dependent, begins with providing the patient with a drug free
environment, which will help in his recovery. At the first instance, the
patient seeks to replace his dependency on drugs with dependency on
the After-care Centre. This can later on be shifted to make the patient
depend on himself. Ultimately, the after-care programme aims at
returning the patient to the community as a competent, functional, more
or less independent person.
What is after-care centre?
The After-care Centre is one of the treatment modalities which was
evolved in the late 1950’s, largely as an outgrowth of the practice of
Alcoholics Anonymous. After-care Centres did not typically offer
‘formal treatment’ for addiction as was commonly provided in an in
patient or out-patient treatment facility. Few or no medical services
were offered. It began as a supportive environment to the patients for
a period ranging from several weeks to several months. It was viewed
as a vehicle for providing shelter to the homeless recovering patient who
had lost supportive family attachments. This group often could not
adapt to or cope with the demands of independent living and social
functioning following primary treatment. The After-care centre was a
place for the person to initiate and stabilise his recovery process.
4
ALCOHOLISM AND DRUG DEPENDENCY
Definition of After-care Centre
The definition of an After-care Centre depends on the nature of services
offered. A few definitions have been given below:
Source
Association of Half-way House
Alcoholism Programmes of America
‘AHHAP’. 1975.
National Institute on Alcohol Abuse
and Alcoholism (NIAAA), 1977.
National Drug and Alcoholism Treatment
Utilisation Survey (NDATUS), 1982.
Definition
Community-based, group oriented,
residential facilities that provide food,
shelter and service in a supportive non
drinking environment for the ablebodied and mentally competent
recovering alcoholic.
A transitional facility that bridges the
gap between the Hospital and
community living. Its purpose is to
provide preventive and after-care
services for alcoholics who do not need
to be institutionalised, but would benefit
from a supportive living arrangement.
A community based, peer group
oriented, residential facility that
provides food, shelter and supportive
services (including vocational, rec
reational, social services) in a suppor
tive, non-drinking environment for
ambulatory and mentally competent
recovering alcoholics who may be re
entering the work force. It also provides
or arranges for provision of appropriate
treatment services.
Characteristics of an After-care Ce itre
The primary thrust of all After-care Centres revolves around the creation
of an alcohol/drug free therapeutic environment that emphasises group
living. More specifically, the centres share some common characteristics
which have been outlined by Rubington E. (1979) and Noble E P (1977):
' /
WHAT IS AFTER-CARE?
5
They are small in size, ranging in capacity from 10 to 20 beds.
They promote a strong A.A. orientation that attempts to provide
the tools and support for recovery.
They provide insulation from alcohol/drugs.
They provide an informal, family-like environment and emphasise
mutual help with a built-in group of acquaintances with similar
problems.
Therapeutic benefits
Over a period of time, the effectiveness of the existing after-care services
has been evaluated, and a number of research studies have consistently
established the following positive outcomes.
After-care services help in prevention of relapses.
★ They equip the patient with alternative ways to deal with his emotions
and manage the stresses of life.
★ They enable the patient to get back to productive employment.
★ They allow him to smoothly reintegrate into his family structure
and consequently into the society at large.
★
Bibliography
1. Addict After-care: Recovery Training and Self-help by Fred Zackow,
William E. McAuliffe and James M.N. Chien — National Institute
on Drug Abuse, USA 1985.
2. Treatment Services for Adolescent Substance Abusers by Alfred
S. Friedman and G 3orge M. Beschner — National Institute on Drug
Abuse, USA 1985.
2____________________ __
RULES AND REGULATIONS
OF THE CENTRE
The After-care centre has certain specific goals and objectives. In order
to help patients achieve these goals, certain policies are set. This chapter
throws light on the rules and regulations to be followed by patients
during their stay at the Centre. Rules can be modified according to the
need of the specific centres.
Admission policy
Patients who have a diagnosis of chemical dependency and have already
undergone primary treatment for the same are eligible for admission.
Admission is done through an interview by the Counsellor.
Admission requirements
1. Should be abstinent from all mood altering drugs at the time of admission.
2. Should express willingness to get admitted.
3. Should have accepted all rules and regulations of the centre.
4. Should be between 20-40 years of age.
5. Should not suffer from any major physical illness.
6. Should have no severe physical disability/handicap.
7. Should not suffer from any major psychiatric illness.
Prior to admission, the patient is given a detailed account of the
treatment policies, procedures, rules and regulations.
Length of stay
Each patient is expected to stay for a period of three to six months.
Patient’s length of stay is also based on his cooperation, and progress
so far as the treatment programme is concerned. This includes both
extension as well as discharge before stipulated time.
RULES AND REGULATIONS OF THE CENTRE
7
Rules/regulations
1. Gambling is strictly prohibited.
2. Borrowing or lending money is not allowed.
3. Violence in any form is not permitted and will not be tolerated.
4. Sexual relationships are strictly prohibited.
5. Patients should not form groups to tease, fight with or deliberately
trouble peers or bully them in any way.
6. No inmate is allowed to go out without a pass issued by the authorities.
7. The new comer is not given an outpass for a period of 15 days from
the day of admission, and will have to remain within the premises.
After completion of 15 days, patients are allowed to go home/relatives’
house for the weekend.
8. Patients are not allowed to bring other drug taking peers to the premises.
Medication policy
1. At the time of admission, all medicines have to be handed over to
the Warden.
2. Patients are expected to take their prescribed medicines under staff
supervision.
3. Patients are expected to meet the doctor when he visits the centre.
Free time
During free time patients can avail 'of all recreational facilities.
Both indoor and outdoor games are available. Patients play games like
table tennis, carrom and chess. Out door games include volley ball,
badminton, dodge ball etc. Patients are permitted to watch T.V.
programmes. They are allowed to watch films on video on Sundays.
A library is open to them and they are encouraged to read books and
periodicals. The patients are given an opportunity to utilise their free
time meaningfully, so that they will continue to make proper use of
it after their discharge.
V I
ALCOHOLISM AND DRUG DEPENDENCY
8
Outpasses
Patients are eligible for out pass only on completion of two weeks.
The Counsellor uses his discretion and the patients are allowed to leave
the premises only when they have obtained out-passes from their
respective Counsellors. The Counsellor issues out-passes also according
to the number of *tokens each person has. If the patient has not returned
to the After-care Centre at the stipulated time, his family/friends/
persons responsible are informed immediately.
Policy to deal with relapses
1. Patients are not allowed to use alcohol/drugs in the premises.
2. When patients return from an outing, they will be searched for
possession of alcohol/drugs each time they enter the premises.
3. If a patient has used chemicals in the premises or returned after an outing
under the influence of chemicals, he will not be allowed to stay inside.
4. Patients who are under the influence of chemicals will be sent
immediately for detoxification. (It is useful to have a liaison with
a local detoxification facility/unit.)
5. If a patient has had one relapse during his stay in the centre, he is
given a warning and subsequently his out passes will be curtailed
for 15 days. If the patient continues to use/possess drugs/ alcohol,
he will be discharged from the centre.
Any
other patient who is found to be involved/helping in malpractice
6.
or being aware, does not disclose it, will also have to face similar
consequences.
7. During the patient’s stay, the staff retain the right to check the
patient’s self or belongings periodically.
Discharge policy
Discharge on disciplinary grounds
- The patient is discharged when he uses drugs or alcohol for the
second time on the premises or outside. On first relapse, a warning
is given and on second relapse, the patient is discharged.
* ‘Token Economy System’ explained in detail on page numbers 21 & 22.
RULES AND REGULATIONS OF THE CENTRE
9
The patient is discharged on disciplinary grounds if he indulges in
violence, presents a danger to other patients, or resorts to stealing
anything from the premises.
If a patient does not show any involvement in the programme or
if he is not willing to follow the rules and regulations, his out-passes
are withheld. Repeated failure to comply will result in his discharge.
Planned discharges
Each patient will usually be ready for discharge when he has completed
3 to 4 months of stay. However, it can be shortened or extended
according to his progress. Discharges are determined by the Counsellor
in consultation with the patient. Prior to discharge, the Counsellor
ensures the emotional and physical stability of the patient. He
- reviews the goals the patient has achieved
— plans future goals and determines follow-up steps
- makes sure that social support has been created and strengthened
— reviews relapse prevention methods and plans for management ol
warning signs.
On the day of discharge, a small get-together is planned, wherein the
patient gives his feedback about the programme and the steps he is going
to take after his discharge. The Counsellors and peers provide support
and encouragement.
\ >
ALCOHOLISM AND DRUG DEPENDENCY
10
Additional Information
A model time table of programme
Phase I
10.00 10.30
10.30 12.00
06.30.06.45
06.45 07.00
07.00 07.30
07.30 09.30
Monday
Physical
Workout
Prayer
(Though't
for the day)
Home
Main
tenance
Community Reeducative
Bath/
session
Meeting
Washing/
Breakfast
Tuesday
Physical
Workout
. Prayer
(Thought
for the day)
Home
Main
tenance
Community Assignment
Bath/
on reedu
Meeting
Washing/
cative topic
Breakfast
Wednesday
Physical
Workout
Prayer
(Thought
for the day)
Home
Main
tenance
Community Reeducative
Bath/
topic
Meeting
Washing/
Breakfast
Thursday
Physical
Workout
Prayer
(Thought
for the day)
Home
Main
tenance
Community Assignment
Bath/
on reedu
Meeting
Washing/
cative topic
Breakfast
Friday
Physical
Workout
Prayer
(Thought
for the day)
Home
Main
tenance
Community Reeducative
Bath/
topic
Meeting
Washing/
Breakfast
Saturday
Physical
Workout
Prayer
(Thought
for the day)
Home
Main
tenance
Community Assignment
Bath/
on reedu
Meeting
Washing/
cative topic
Breakfast
Week Days
Sunday
FREE
* Assignments on each Reeducative topic given on Pages 230 to 235.
/
11
RULES AND REGULATIONS OF THE CENTRE
Phase I
04.00 05.00
05.00 06.00
06.00 06.30
07.00 08.00
Tea
Coun
selling
Games
Tea
AA
Meeting
Group
Therapy
Tea
Coun
selling
Games
Tea
Reeducative
topic
Lunch
Group
Therapy
Tea
Relaxation
Therapy
Games
Tea
NA
Meeting
Ind. Coun
selling
Lunch
Group
Therapy
Tea
Coun
selling
Games
Tea
Reeducative
topic
Individual
Assignment
Lunch
(jroup
Tea
Coun
selling
Games
Tea
Life History
sharing
Family
Counselling
Lunch
Tea
Coun
selling
Games
Tea
Life History
sharing
03.30 -
12.00 01.00
01.00 02.00
02.00 03.30
04.00
Ind. Coun
selling
Lunch
Group
Therapy
Supportive
Group
Lunch
Group
Assignment
Therapy
Group
Therapy
FREE*
12
ALCOHOLISM AND DRUG DEPENDENCY
Additional Information
Phase II
Week Days
06.30 -
06.45
06.45 07.00
07.00 07.30
07.30 -
10.00 -
10.30 -
09.30
10.30
12.00
Monday
Physical
Workout
Prayer
(Thought*
for the day)
Home
Main
tenance
Bath/
Community Therapeutic
Washing/
Meeting
Games
Breakfast
Tuesday
Physical
Workout
Prayer
(Thought
for the day)
Home
Main
tenance
Bath/
Community Assignment
Washing/
Meeting
Breakfast
Wednesday
Physical
Workout
Prayer
(Thought
for the day)
Home
Main
tenance
Bath/
Community Therapeutic
Washing/
Meeting
Games
Breakfast
Thursday
Physical
Workout
Prayer
(Thought
for the day)
Home
Main
tenance
Bath/
Community Therapeutic
Washing/
Meeting
Games
Breakfast
Friday
Physical
Workout
Prayer
(Thought
for the day)
Home
Main
tenance
Bath/
Community Review of
Washing/
Meeting
the Week
Breakfast
Saturday
Physical
Workout
Prayer
(Thought
for the day)
Home
Main
tenance
Bath/
Community Review of
Washing/
Meeting
the Week
Breakfast
Sunday
FREE
13
RULES AND REGULATIONS OF THE CENTRE
Phase II
04.00 05.00
05.00 06.00
06.00 06.30
07.00 08.00
Tea
Coun
selling
Games
Tea
AA
Meeting
Group
Therapy
Tea
Coun
selling
Games
Tea
Reeducative
topic
Lunch
Group
Therapy
Tea
Relaxation
Therapy
Games
Tea
NA
Meeting
Therapeutic
Group
Activities
Lunch
Group
Therapy
*Tea
Coun
selling
Games
Tea
Reeducative
topic
Therapeutic
Game
Lunch
Role Play
Tea
Coun
selling
Games
Tea
Family
Counselling
Lunch
Free
Tea
Coun
selling
Free
Tea
01.00 02.00
02.00 -
03.30 -
03.30
04.00
Ind. Coun
selling
Lunch
Group
Therapy
Supportive
Group
Lunch
Therapeutic
Group
Activities
12.00 01.00
FREE »
Games include outdoor (Shuttle, Volley Ball)
indoor (Table Tennis, Carrom, Chess)
Once in three months tournaments will be held and prizes will be given
to the winners.
3__________________________
AFTER-CARE CENTRE AND
AFTER-CARE SERVICES
After-care Centre provides supportive environment in a home like
atmosphere to persons who have completed primary treatment for their
chemical dependency. The After-care Centre is an important component
of the continuum of addiction treatment services. This section gives
an overall picture of the After-care Centre and discusses in detail all
the therapeutic issues that go into the development of the After-care
programme.
Description of an After-care Centre
Physical Structure-Residential facility
- Situated in a residential area
- Spacious house with adequate living amenities, good ventilation
and light
- Rooms for therapeutic activities
- Space for out-door recreations
Appointment of staff
- Programme coordinator
The Programme coordinator is in charge of all the activities (both
administrative and therapeutic). He should have completed post
graduation in Social Work or Psychology.
— Psychiatrist/Medical officer
A psychiatrist or a medical officer works on a part-time basis and
reviews the physical condition of the patients atleast thrice a week.
AFTER-CARE CENTRE AND AFTER-CARE SERVICES
15
- Counsellors
The minimum number of Counsellors required to run an after-care
programme of 20 beds is 3. All the Counsellors should be post
graduates in Social Work or Psychology. They should have undergone
specialised training in addiction treatment.
- Warden
The Warden should necessarily be a middle-aged man and the post
is a residential one. He should be a graduate in humanities or should
be an active A.A. member with a history of qualitative sobriety
for a minimum period of 5 years.
V) i » 'i
- Occupational Therapist
The occupational therapist should be a graduate, with a diploma
or degree in rehabilitation science. He should be familiar with the
community resources available to help the clients in vocational
rehabilitation.
- Ward Boy
1
The Ward Boy should be an energetic young man, and should have
passed S.S.L.C. or its equivalent.
Cook
The cook should be literate with sufficient experience in cooking
food and proper maintenance of kitchen.
- Security
To ensure round the clock service,.reliable security staff are recruited.
In the selection of staff for the After-care Centre, certain specific issues
must be looked into. The person
- Should not use alcohol/drugs.
- Should not have too many unresolved conflicts.
- Should not gamble.
- Should not be susceptible to bribes.
- Should not be involved in illicit sexual relationships.
16
ALCOHOLISM AND DRUG DEPENDENCY
Before appointing the staff, a thorough investigation of the candidate,
especially with regard to the above issues should be carried out. Stability in
work record/married life and good interpersonal relationship are essential
prerequisites of the candidates.
Therapeutic programme
Goals
- Strengthen the motivation to lead an alcohol and drug free life
Provide an atmosphere that will sustain the individual’s desire for
recovery.
- Help patients identify and manage relapse warning signs.
- Guide them to be assertive and say ‘NO’ to drugs.
- Help them to relearn skills necessary to cope with ordinary stresses
of social interaction.
- Provide vocational skills training/opportunities for employment
continuation.
- Make them realise the need to strengthen family relationships.
- Expose them to new positive ways of having fun.
- Provide model and peer experience that will enhance and improve
inter-personal relationships.
- Create an awareness about the personal defects of character and
a need to make positive changes.
- Help them reorganise their value system.
- Guide them to express and deal with emotions appropriately.
- Teach methods of managing finances.
- Provide opportunities to learn responsible living.
Programme
The therapeutic programme is conducted in two phases.
First phase
The duration of this phase is one month. During this period, the patient
attends re-educative sessions on various topics related to chemical
AFTER-CARE CENTRE AND AFTER-CARE SERVICES
17
dependency. After each session, he is given assignments related to his
problems. Individual counselling, based on an individual treatment plan
is given to each patient.
Group therapy is also conducted every day. Patients are provided
opportunities to participate in recreational activities. They learn
relaxation methods to manage stress. They also attend A.A./N.A.
meetings.
The process adopted to carry out these activities of the therapeutic
programme is discussed below in detail.
w i >
Prayer, community meeting, thought for the day
This meeting is where the patients get together and share their feelings,
thoughts and experiences along with the Counsellor.
At 10.00 a.m., a bell is rung for the patients to assemble. They sit in
a circle. The day starts with this meeting and it lasts for half-an-hour
to 45 minutes. All therapeutic staff participate in thb meeting.
The meeting begins with the Counsellor asking someone to volunteer
and say a prayer or sing a song. The Counsellor reads a thought for
the day. Patients are asked to reflect on that thought and are given
an opportunity to express their own experiences or views relating to
that particular thought. Patients are encouraged to talk only about
themselves - use T and not ‘We’ or ‘You’.
A person sometimes may not have anything to say. He must however
introduce himself and say that he has got nothing to communicate.
The Counsellor discourages him from just nodding his head or gesturing
to say ‘no.’
The staff also introduce themselves and say a word or two. This should
be an honest expression of self and is not meant to be a preaching session
to patients.
At the close of the meeting, everybody meditates for a few minutes.
The Community meeting is an opportunity for the Counsellors and
patients to share their feelings and get to know one another.
The Community meeting instills faith in a Higher Power and provides
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ALCOHOLISM AND DRUG DEPENDENCY
an opportunity for the patients to start the day on a right note.
The thought for the day* makes the patients think meaningfully and
plan their day better.
Re-educative sessions
The re-educative lecture sessions are held everyday for the patients.
It lasts for 45 minutes to one hour. The lectures focus on the problems
faced by chemical dependents and offer guidelines and methods to deal
with those problems.
*
The lecture sessions are conducted by the Coordinator and Counsellors.
In the first phase, the following lectures are covered.
Disease concept
Denial
Understanding values
Relapse prevention planning
Overcoming grief
Steps towards sober living
Anger
Hurt feelings
Grief and fear
Shame and guilt
Dry-drunk syndrome
Assertiveness
Human needs
Stress management
Problems in sobriety
Personality defects
These lectures are not theoretical. They provide information and are
followed by discussions. These interactions centre on the patients’
problems and focus on realistic methods to deal with them. Specialists
may be invited, to give lectures on topics relevant to the patient’s
recovery (for example, Nutrition, Budgeting).
Assignments
After each session, the patients are given assignments related to the
lecture topics. Assignments help the patients to think, reflect on and
analyse the facts presented during the lecture sessions. These strengthen
their knowledge and give them an opportunity to look at their personal
experiences/problems. They become aware of the methods they could
adopt to manage their problems.
* A few thoughts that could be read in the community meeting are given as additional information.
AFTER-CARE CENTRE AND AFTER-CARE SERVICES
19
Group therapy
The other important component of the therapeutic programme is group
therapy. Group therapy may be held every day between 2.00 and
3.30 p.m. Group therapy is conducted by the same Counsellor for
one week.*
Counselling
Chalking out an individual treatment plan and offering individual
counselling based on it are the important components of this
programme.®
Family programme
Involvement of family members is crucial in recovery. Family members
visit the After-care Centre once a week. They have individual and
combined counselling sessions.
Life history sharing
Patients are encouraged to share their life experiences. The new comers
share their life history on completion of 15 days, so that they are familiar
with others and feel comfortable enough to share openly. A few
guidelines which may be given are
— start from your childhood, stating any significant event from your
childhood to your adolescence.
— say when and how you started using alcohol or drugs, and the pattern
of use.
— share about the damages caused, by drugs to your physical,
emotional, occupational, social and family life.
— share how you came to this centre, the initial feelings with which
you entered the centre and your present feelings.
Supportive group
The Counsellor conducts the supportive group once a week. Here any
complaints to be made, any grievances, suggestions are brought forth
* For further details refer Chapter 19.
• More information on this is given in Chapter 20.
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ALCOHOLISM AND DRUG DEPENDENCY
and discussed. Interpersonal problems are also handled. The ground
rules to be followed are
— no accusation to be made.
— no judgements to be passed.
- complaints to be descriptively and specifically stated.
Relaxation therapy
Stress management is part of the programme. The Jacobsons progressive
relaxation methods* can be followed. In case the Counsellor is familiar
with any other methods, he could make use of them. A weekly session
would be adequate.
Therapeutic games
In order to help the patients relax, a few games are also introduced.
These games not only help patients fulfill their recreational needs but
also enable them to understand themselves better in the process.
Recreatipnal/Leisure time activities
Throughout their 3 months’ stay at the After-care Centre, patients are
encouraged to spend their leisure time constructively. Facilities to play
indoor gajnes (Chess, Chinese Checker, Table Tennis, Carrom, etc.)
and out door games (Shuttle Badminton, Volley Ball, Dodge Ball, etc.)
are provided. Tournaments are held every 3 months and prizes
distributed. Patients are also encouraged to utilise the library during
their free time.
Participation in A.A./N.A. meetings
Patients are expected to attend A.A./N.A. meetings regularly. This helps
them to strengthen their recovery.
Second phase
This phase of treatment lasts for two months. During this phase also,
patients attend re-educative lecture sessions which focus on improving
their quality of life. Intensive group therapy and individual counselling
* For more details refer ‘Alcoholism & Drug Dependency - A Professional’s Master Guide’.
AFTER-CARE CENTRE AND AFTER-CARE SERVICES .
21
are provided. The individual treatment is restructured after feed back
and review. Opportunities are provided for vocational training. Patients
start attending office during day time. During this phase also,
opportunities to participate in recreational activities are provided.
Patients continue to attend A.A./N.A. meetings.
Role play
Role play is intended to help patients handle high risk situations which
they may be required to face after leaving the centre. High risk situations
include both internal and external cues. These are enacted and discussed
in role play sessions. Internal cues would include craving, anger,
resentment, loneliness, depression, anxiety, fear of failure, boredom,
etc. External cues would include a drinking party, meeting an old
drinking/drug taking companion, friends calling for a drink or taking
drugs, suspicion from others, excessive money in hand etc.*
Duties
Therapeutic duties are allotted to each patient. One person will be
selected as a monitor to ensure that duties are carried out properly.
Duties include all activities essential to maintain the centre. For example
— ringing the bell, filling water jugs, dusting, cleaning ash trays,
washing vessels, cutting vegetables, watering plants, maintaining the
recreation room, prayer hall, etc. New comers are allotted easier tasks
to help them get acclimatized to the routine. Any problem faced, any
patient not doing his duty etc., are handled either in the supportive group
or when duties are changed. The duty roster is put up on the Notice
Board every week. To encourage participation, the Token Economy
System is implemented here.
Behaviour therapy - token economy system
The Token Economy System has been found useful in increasing patient
participation in the programme and to bring about desirable behaviour
changes. It is introduced in the first week itself. Participation in various
activities, physical work out, doing allotted duties, attending lectures,
group meetings etc., help patients earn their tokens and rewards.
The following format will serve as an example:
* The chapter on ‘Assertiveness Training’ deals exclusively with these issues and offers meaningful methods
to tackle them.
V )
22
ALCOHOLISM AND DRUG DEPENDENCY
Specifications
Tokens
Reporting on time and being
Green
regular for physical work out.
Executing duties with
involvement
Taking initiative to do extra
work
White
Rewards
Out pass for two hours
OR
Allowing him to watch the
weekly special programme
‘World This Week’ on the T.V.
OR
Preparing a dish of his choice
Submitting assignments on time Out pass for week ends
OR
Allowing him to see a movie
Open and honest sharing in
of his choice
group therapy
OR
Permitting him to possess
Being supportive and under
and
use ‘Walkman’ during
standing towards new comers
weekends
Therapeutic group activities
The activity hour is a vital component of the therapeutic programme.
It is an informal meeting of patients and Counsellors, who engage
themselves in discussions, games, activities etc.
Thus the After-care programme aims at helping the patients lead a long
term, drug-free, qualitative life. This goal can be achieved through a
carefully planned treatment programme which effectively combines in
itself the various methodologies described so far.
AFTER-CARE CENTRE AND AFTER-CARE SERVICES
23
Additional information
I. A few thoughts for the day
Just for today
I feel weighed down and depressed when I think that I have to
lead a changed life pattern for the rest of my life. I have tried this
so many times in the past and failed miserably.
I am reminded of a clock that came to know it had a 2 year guarantee
period. The very thought of striking 6,30,72,000 seconds made it
absolutely tired and so it stopped. Another clock noticed this and
pointed out that it was happy it had to tick only once every second.
I learn a lesson from this and tell myself that I will concentrate
on living a new way of life ‘Just for today’. This ‘Today’
programme applies to all areas of my life. If I find executing my
plans for 24 hours difficult — if I find myself going back to my
old ways of thinking — I will plan for 10 hours. If I feel even this
too much, I will plan for one hour...one more hour..and so on.
All that I really have is ‘Now’. Yesterdays are gone; I have to forget
them. Tomorrow has still not come. Therefore, I need not worry
-1 plan for today - JUST FOR TODAY. When I implement this
24 hours plan, I obtain peace, assurance and happiness.
I pray to God to help me work the ‘One day at a time’ programme
to the best of my ability.
The first drink does the damage
After treatment, do I want to drink a little alcohol? With that,
all my problems start again. This is a fact which I have learnt from
experience. Before I realised this, I had made several attempts to
become a controlled drinker and failed.
When a stone rolls down a mountain, even if the mountain wishes,
that stone cannot be stopped from rolling. Similarly, the first drink
will inevitably lead me to excessive drinking. Even if I wish, it will be
difficult for me to stop. If I start drinking, I will get caught in many
24
ALCOHOLISM AND DRUG DEPENDENCY
problems without my knowledge. In the end, I would be at cross
purposes with my career, family, friends etc. This is the bitter truth.
So what do I do when I experience a craving to drink? I have to
recollect in detail all the problems I had encountered - the job I lost,
the lack of love from my children, the problems in my marital relation
ship. When I recollect these, I will experience anxiety and fear. The
thought of drinking would automatically be removed from my mind.
I clearly understand the truth. I start with the intention of having
only one peg. I plan, but am unable to stop with that first drink.
I lose control. So, I have to avoid that first drink.
I pray to God to keep me away from the self-deception that I might
gain control again.
Developing patience
Some happy children sowed a few seeds in the garden and poured
water. After doing this, they went back home. All of them were
so happy and excited that they hardly slept that night. They waited
for sunrise, and came running to the garden. They expected the
garden to be filled with blossoms, and were disappointed. Not even
one plant had grown; not even one flower. The children were very
upset, disappointed, and sad. They went back home and did not
come back to the garden afterwards. They did not pour water and
so all the seeds dried up.
If, like these children, we expect immediate results, we will only
be disappointed. Sometimes, even after repeated efforts, we may
not be able to get the results we want. When we stop drinking and
want to lead a sober life, there may be many problems threatening
us. We cannot expect to set right all these problems immediately.
If I expect to solve all the problems immediately, I am going to
be disappointed. I have to plan one day at a time and start building
my sobriety. For this, I need patience and self determination. I pray
to God to give me the strength to develop patience.
Sharing with others
When I was drinking, I was always thinking only about myself.
I had no other thought. When I got up in the morning, with a bad
V )
AFTER-CARE CENTRE AND AFTER-CARE SERVICES
25
hangover, my only thought would be how to get rid of this
hangover. So what did I do? I started drinking again. I did not
remember or think of anybody else other than me and my bottle.
Living for others, was a value which was of no meaning to me.
A male elephant and a female elephant were very thirsty and were
searching for water in a forest. Suddenly, they found water in a
small pond. Immediately, the female elephant requested the male
elephant to drink, but the male elephant insisted that only if the
female drank, would he drink. After a few minutes, the two
elephants decided that they would each go to one end of the pond
and drink half the water. Both the elephants put their trunks into
the pond and stood, but the level of water never came down. Why?
The female elephant waited for the male elephant to drink whereas
the male elephant waited for the female elephant to drink.
What does this story tell us? Life becomes meaningful only with
sharing. When I give in and sacrifice a few things for others, I find
a meaning for mj existence. Thus, I should avoid thinking only
about myself and must start being concerned about my family and
friends. I pray to God to give me the strength to stop being selfish
and start living for others.
Seeing good in others
A little boy, not familiar with the echo, went to a forest. He thought
he heard the voice of another boy not very far off.
He shouted, “Hello, there!” and the voice shouted back, “Hello,
there!”
He cried at the top of his voice, “You are a mean fellow!” and
the cry came back, “You are a mean fellow!”
The boy got upset, went home and told his mother that there was
a bad boy in the woods. The mother understood that it was an
echo, and said, “Ramu! speak kindly to him, and he will also be
kind to you!”
The little boy went back to the woods and shouted, “You are a
good boy!” Out came the echoing reply, “You are a good boy!”
“I love you” - he shouted happily.
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ALCOHOLISM AND DRUG DEPENDENCY
“I love you” - replied the faithful echo.
The story of echo is exactly the story of our lives. We receive only
what we give. If we show love and understanding to others, they
give back care and concern. On the other hand, if we show anger
and resentment, we will receive only negative criticism and hatred.
I pray to God to give me the strength to see all the good qualities
of others, which, in turn, will help me to be more loving, kind
and balanced.
IL A few therapeutic activities
a) Completing developmental tasks
Following is an activity which the Counsellor can ask the patients
to participate in. This will create an awareness in them as to what
tasks they have failed to complete in their different ‘life-stages’ as
a result of their chemical dependency. If an awareness is created
they can be guided to complete the tasks from then on.
There are a series of developmental “tasks” appropriate to different
stages in a person’s life. A developmental task is one which arises
at or about a certain period of the life of the individual. Achievement
of the task leads to happiness and to success with later tasks, while
failure leads to unhappiness in the individual, disapproval by society
and difficulty with later tasks. A chemical dependent would not have
completed most of these developmental tasks. So it is essential that
he becomes aware of the tasks he is expected to complete.
Description of the activity
In the beginning of the session, the patients are divided into three
groups. The first group comprises patients between 18-26 years,
the second, 26-38 years, and the third, 38 years and above.
The Counsellor writes down on the board the developmental tasks
for the respective age groups.
a) Tasks for the age group 18-26 years are:
Completion of school education and entry into college.
Completing college education.
AFTER-CARE CENTRE AND AFTER-CARE SERVICES
27
Selecting and preparing for an occupation.
Developing the ability to make decisions.
Achieving Socially acceptable behaviour.
Understanding values and living by them.
Preparing for marriage and family life.
Building a good relationship with family members.
Managing finances responsibly.
b) The tasks for the age group 26-38 years are :
Getting started and settling down in an occupation.
Selecting a life partner.
Having a good relationship with the marriage partner.
Starting a family.
Rearing children.
Managing a home.
Finding a congenial social group.
Learning healthy recreational activities.
Managing to save money.
c) The tasks for the age group 38 years and above are:
Maintaining or improving one’s standard of living.
Assisting children to become responsible happy adults.
Relating well with the spouse.
Planning and saving for the future.
Establishing a satisfactory residential living arrangement.
Developing trust in God.
Learning to do activities with the family members.
Patients are given 10 minutes to read the tasks. Then a patient from
the first group sits facing the three groups and the patients from the
other group ask him questions with regard to the tasks mentioned on
the board. (Questions such as “How educated are you?”, “Did you
complete your studies?”, “Are you married?’ etc.) The group
supportively helps the patient realise the tasks he has not completed.
The patient is helped to prioritise and establish a goal to be achieved.
The group members then help the person chalk out a plan of how to
achieve it. Every patient has his turn.
At the end of the session, the Counsellor educates the patients on the
importance of developmental tasks and their completion. He makes
them understand that they enhance one’s quality of life.
28
ALCOHOLISM AND DRUG DEPENDENCY
b) Living by Values
Values form the core of a person’s life. They are learnt and followed
from childhood, and they determine the quality of a person’s life.
During the different stages of his dependency, the chemical dependent
would have broken all the values he had previously learnt. So, during
recovery, it is essential for him to understand the necessity to rebuild
his value system, and start living by it. The following activity will help
in creating an awareness in him and providing him with a structured
plan to start living by values.
The Counsellor may ask the chemical dependent to list the values he
wants to follow in the order Of his priorities. After the prioritising is
done, he may be asked to explain each value as given below:
1. Loving
- Showing care, concern and understanding of others’ needs and
emotions.
2. Being Honest
- What the person thinks, says and does - all the three are in a straight
line. They are in perfect harmony with each other.
3. Disciplined
- In thought, speech and actions. Discipline applies not only with regard
to overcoming craving for and consumption of alcohol/drugs. It means
discipline in every area of life.
4. Being Responsible
- In every area of his life (occupation, duties to family, society etc.).
5. Drug-free life
- Leading a life free from all mood altering chemicals.
6. Hard working
- Working with involvement, interest, enthusiasm - working to the
best of one’s abilities.
7. Open mindedness
- Listening whole heartedly.
- Sharing one’s feelings openly.
- Accepting and acknowledging good things in others.
. I h'1
AFTER-CARE CENTRE AND AFTER-CARE SERVICES
29
Now he should explain to the Counsellor as to what steps he is going
to take to practise that value. For example, if his first priority is ‘hard
work’, he should state as follows
- I will clean vessels regularly
- I will do all the jobs assigned to me
- I will participate with involvement in the therapy classes and so on.
The person should start practising the value he has prioritised, and share
with the group members and the Counsellors as to how exactly he displayed
that value in his life during that week. Group members provide a feedback.
It will be a repeat exercise for every week. This will be a constant reminder
and a conscious practice for him so that when he leaves the After-care
Centre, it will become a permanent habit.
1 'th i • 'j
c) ‘Strengthening Self-esteem’
Self-esteem is actually our assessment of our own self. It is essentially
a measure of self worth and importance. Only a person with a strong
self-esteem will be able to build meaningful relationships and find himself
successful. A chemical dependent, during the different stages of his disease,
would have felt incapable, unworthy and low. His self assessment would
have been a negative one.
So, during recovery, it is very important for him to strengthen his selfesteem and improve the quality of his life. He has to understand that
self-esteem is a quality that can be strengthened at any point of life
regardless of age, educational background and social standing.
The ‘self-esteem’ game is a useful exercise to help the patients strengthen
their ‘self-esteem’. Each patient during his turn sits in front of the others.
Each member of the group is expected, fo state atleast one good quality
which he had noticed in that person. While sharing or giving the positive
stroke, it should be ensured that the member
- maintains eye contact
- feels comfortable
- is genuine about what he is sharing.
The game proceeds, and as each member of the group is focused on,
all others give positive strokes to that member. This activity helps the
clients to receive and give positive strokes comfortably.
30
ALCOHOLISM AND DRUG DEPENDENCY
Some therapeutic games
1) ‘Sober living’ game
This activity helps patients to discuss various methods to stay sober.
Description
At the beginning of the game, every patient is given a piece of paper
in which one of the methods to stay sober is written. Twenty pieces
of paper each containing one method are distributed among the patients.
Some methods are
Staying away from the first 'drink/drug.
Living one day at a time.
Diverting the mind.
Postponing the first drink.
Going to a place where drugs cannot be used. (Library, temple,
prayer hall).
Remembering happy moments sobriety has brought forth.
Getting active physically.
Contemplating on the serenity prayer.
Changing old routines.
Availing a sponsor.
Fending off loneliness.
Recognising anger and resentments.
Remembering the worst drinking episode.
Eliminating self-pity.
Staying away from friends who are continuing to use drugs/drinks.
Keeping regular contact with the treatment centre.
Taking antabuse everyday.
Regular eating habits.
Involving in healthy activities (e.g. going to temple, playing games).
Sharing with someone trustworthy.
The patients sit in a circle. Anybody can start. Each patient reads aloud
the method given to him and shares his experiences about it. Others
ask questions, and they discuss the method in detail.
This game teaches clients practical tips for sobriety. A sense of hope
is instilled, and some clarity is achieved with regard to management
of ‘high risk’ situations.
*
A
AFTER-CARE CENTRE AND AFTER-CARE SERVICES
31
2) ‘Seif expression’ Games
As the name indicates these games help the patient to talk about his
emotions comfortably, meaningfully and in depth.
i) Ungame
This is a board game similar to ludo/snakes and ladders. The dice
is thrown and each player moves his coin that many squares.
At particular intervals each square would have particular feelings
written on it.
2
If the player’s coin lands on this special square with the name of
a feeling written on it - say anger, resentment, happiness, anxiety,
fear etc., he will have to share an event from his life which involves
the feeling during that day or week. Ungame facilitates patients to
express their feelings openly.
Rules and Regulations
1. Determine the length of playing time. For optimum results,
45 minutes to 1 hour is suggested. Extra time may be desired at
the conclusion of the game for talking about the experience.
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ALCOHOLISM AND DRUG DEPENDENCY
2. Players agree to REMAIN SILENT except during their turn.
To encourage LISTENING and UNDERSTANDING and to
discourage probing and challenging.
3. Players should have pencil and paper to jot down their personal
thoughts and/or questions to ask other players, to be used at the
appropriate time, (see 7 & 8 below)
4. Select the Deck to be used. Deck 1 contains LIGHTHEARTED
topics. A great ice breaker or fun way to get acquainted. Deck 2
deals with more SERIOUS subjects. This deck works better after
a group is acquainted and has practised sharing, listening and
responding to deck 1.
Note: Blank squares are included, so players can write questions of
their own design and insert them on the board.
5. Each player selects a marker and places it on the
QUESTION/COMMENT space nearest to him.
6. After determining who will go first, a player rolls the dice and moves
his marker in the direction the spaces indicate. Player to the left
takes the next turn.
7. A player landing on an UNGAME space should read the feeling
aloud and answer in 2 or 3 sentences.
Remember, no other player can comment at this time! Thoughts and
ideas can be jotted down on scratch paper and shared when landing
on a QUESTION/ COMMENT space.
8. When landing on a QUESTION/COMMENT space, a player may
(a) Ask another player a question regarding something noted on scratch
paper, something previously shared, or anything that comes to mind.
Examples: “What do you like to do in your spare time?”
“Why did you answer that question the way you did?”
“How do you feel about---------------------- ?”
The question may be answered at this time.
(b) Make a comment on ANY subject.
Player has the opportunity to say whatever is on his mind OR refer
to what has been noted on scratch paper.
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AFTER-CARE CENTRE AND AFTER-CARE SERVICES
,>
’ 'll) t • h
Examples: “This is how I feel regarding---“I think I understand the way you feel.”
“How I would answer that last question is_
“I really appreciate you!’’
The other players listen without responding.
9. When landing on an “IF YOU
” space, the player should read
the statement aloud and respond by moving to the corresponding
“EMOTION” area if it applies OR staying on the space if it does
not apply. Player should share his reasons.
On the next turn, the player in the Emotion area starts his/her move
on the space indicated by the EXIT arrow.
10. If the player lands on a CHOICE space, he may choose whether
to draw a card, ask a question or make a comment.
Note: This game can be obtained from — The UNGAME CO.,
Anaheim, California — 92806, USA. Alternatively, this can be made
on your own.
ii) The Stamps Game
Purpose: The purpose of the STAMP GAME is to help players to
identify, clarify and discuss feelings.
Embarrassment
Sadness
Confusion
Anger
34
ALCOHOLISM AND DRUG DEPENDENCY
Leader: THE STAMP GAME requires that one person acts as a
facilitator and does not participate in playing the game. This is an
emotionally-charged game, and so the facilitator must be a warm, caring
person, comfortable with his own feelings and the feelings of others.
In this case, the Counsellor will be the facilitator.
Players: The game can be played with one to six players, with the
facilitator moving among the groups.
Time Frame: A group of six players will take approximately 60 to
90 minutes to play the game. Allow 90 minutes if feedback is utilised.
The STAMP GAME may be ongoing, in that, participants may play
a portion of the game during each session.
Results:
- Players will be able to relate more honestly to others when they have
learnt to express feelings.
- Players will begin to respond appropriately to situations when they
become more aware of their feelings.
- As a result, players will become increasingly more effective problem
solvers.
Setting: Game can be played on a large table or on the floor (more fun).
To Begin:
1. Players sit in a circle.
2. Counsellor places stamps in the centre of the circle, in piles according
to their colour and explains which colour represents what feelings.
RED STAMPS — Any form of anger such as rage, frustration,
irritation, disgust, etc.
BLUE STAMPS — any form of sadness such as disappointment,
loss etc.
BLACK STAMPS — Fear.
ORANGE STAMPS — Guilt
GREEN STAMPS — Embarrassment
YELLOW STAMPS — Any form of happiness, such as joy,
warmth, Idve etc.
)
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AFTER-CARE CENTRE AND AFTER-CARE SERVICES
LIGHT BROWN STAMPS — Confusion.
WHITE STAMPS (Wild card) — Any feeling not listed above, which
the player wants to identify, e.g., loneliness, helplessness.
* "
' llh t > '?•
Embarrassm en t
Wild Card
A
Sadness
Fear
Confusion
Guilt
7
Anger
Happiness
3. Ask participants to think back and bring to mind what it was like
when they were young children and teen-agers growing up in their
family. Then ask them to pick up stamps which represent that
particular feeling they had as youngsters and adolescents.
4. Explain that the stamps represent the feelings they had. It does not
matter whether other people in their family were aware of the fact
36
ALCOHOLISM AND DRUG DEPENDENCY
that they had these feelings. Participants should select a number of
stamps representing the intensity of each fueling. Example: If a
participant experienced a great deal of anger, he might take 5 to
10 red-anger stamps, compared to feeling a small amount of fear,
where he might take 2 or 3 black-fear stamps.
If participants are not able to immediately identify the particular feeling,
give them some more time.
(This process usually takes approximately 5-8 minutes)
5. When all group members have selected their stamps,instruct them
to arrange the stamps, in an order beginning with the feelings
expressed the most as a child, to feelings shown next, to those shown
the least. Example: the person who knows that he hid his anger,
yet found it easier to show sadness might position his blue-sadness
stamp(s) before his red-anger stamp(s). The person who was afraid
and showed that fear, will have his black-fear stamps in front of
his orange-guilt stamps if he seldom or never showed guilt.
There is no one correct way to position stamps; arrangement is left up
to each player.
Do not give any further instructions until players have completed the
positioning of the game.
To Play:
As sharing is very personal, it is suggested that there is no break after
the sharing has begun.
Tell participants that each one has approximately 10 minutes to share.
1. The Counsellor leaves it open for anyone to start, and when a person
volunteers, asks that person to talk about his stamps with the group.
It is easier for participants to begin by talking about the feelings
they expressed the most, then feelings they felt but expressed less.
2. The participant tells the group the source of his feelings, rather than
simply identifying them, e.g., “this anger is with my mother for all
her screaming” vs. “this is my anger-red”.
3. As each participant shares, members may become aware of more
feelings and quietly add to their piles. Also, while the participant
I
AFTER-CARE CENTRE AND AFTER-CARE SERVICES
.
37
is sharing, he may become aware of having more of one feeling than
he originally thought and may add to his pile while speaking.
4. After the first player has shared his feelings, ask him to reflect on
how the stamps are different today as an adult. Ask him to represent
that change by adding to or substracting from his collection and/or
repositioning the order. While he is changing his stamps, instruct
him to tell the group why he is making the changes. When completed,
next person takes his turn. Allot approximately 8 to 10 minutes per
person for this sharing for a group of six.
5. After the last player has shared and if time permits, the Counsellor
may want to ask if the first player would like to say more, as the
first player to speak is often more inhibited.
6. Be sure to thank participants for their sharing and attentiveness.
It is suggested that the group ends with a quick self-reflection or self
image exercise. The following are a few suggestions:
Ask the group to quickly express to each other
A. What is it that you are particularly glad you shared?
B. What did you learn about yourself during this game?
C. What did you learn that would be helpful for you to work on?
Again, thank the participants for being honest.
Note: This Game can be obtained from — MAC Publishing a division
of CLAUD J A, inc 5005, East 39th Avenue Denver, COLORADO —
80207, USA. Alternatively, this can be made on your own.
3) Memory game
A few items are kept on the table and after observation for three
minutes, patients are asked to close their eyes and write down the objects
they had seen, on a piece of paper. This game can be played frequently
to help patients work on memory deficits which might have been caused
due to alcohol/drug use. This exercise helps in developing ‘new learning’
as well as retention.
4
MEDICAL COMPLICATIONS
RELATED TO DRUG ABUSE
Excessive and prolonged use of chemicals leads to medical complications
specific to the drug abused. An awareness of the complications related
to specific drugs is a must for the therapist working at the After-care
Centre. As a detailed coverage of all the complications is beyond the
scope of this Manual, it will be helpful for the therapist to get exhaustive
information from relevant literature.
By the time a patient reaches the After-care Centre, painful withdrawal
symptoms following the cessation of drug intake would have been
handled and dealt with. Even then it would be a fallacy to assume that
all is normal with the patient. He may need a few weeks or even months
to totally recover from the damages that drug abuse has caused. In this
chapter, we have dealt with the problems associated with cannabis and
brown sugar addiction because these are the most commonly abused
drugs in India.
Medical Complications
Respiratory ailments
Chronic cannabis and brown sugar users frequently suffer from
respiratory ailments like pneumonia, bronchitis or even tuberculosis.
Poor health condition, poor nutritional status combined with frequent
inhalation of drugs that are irritants to the respiratory system are
responsible for this. Repeated infection of the tubes in the lungs
(bronchioles) damage the walls of the tubes leaving them permanently
dilated. This leads to a condition called ‘bronchiectasis’. All these
conditions require appropriate medical treatment. With cannabis, the
reduction of the white blood corpuscles in the blood lowers immunity,
making the patient more susceptible to infection.
!
MEDICAL COMPLICATIONS RELATED TO DRUG ABUSE
39
Cardio-vascular problems
Brown sugar intake leads to reduction in blood pressure and heart rate
while cannabis lowers blood pressure (by vaso-dilation) and increases
heart rate as much as 50%. Frequent interference with the natural
balance in the body that maintains these vital signs can lead to
complications.
Sexual problems
Narcotic use has been frequently associated with reduced libido. Studies
have shown that the sex hormone level correspondingly declines with
the increase of THC (the mood changing chemical in cannabis) in the
blood. Thus sterility and impotence can accompany drug abuse.
Problems with memory
Memory is the ability to recall past experiences or information stored
in the brain. Memory is of three types.
1) Immediate memory (dialling a telephone number after a glance at
the directory) Here the information is retained for a very short time
and then forgotten. Recall within this time frame is instantaneous.
2) Short-term memory involves remembering newly learnt material. The
information is stored in the brain and needs a few minutes for recall.
3) Long-term memory involves memory relating to events dating back
for many years and is stored. The information is retained life long.
The recall time is immediate.
All the three patterns of memory and recall depend on the functioning
of the pathways in different parts of the brain. Use of drugs can and
does affect memory by affecting the integration, interpretation, storage
and retrieval of information. In addition to this, deficiency of Vitamin
B-l (due to poor nutrition) complicates matters further.
Of the three, short-term memory is the worst affected. So, there is
difficulty in learning new material and in storing new information.
This becomes significant because the drug dependent person finds it
difficult to cope with expectations at school/college. In vocational
training also, learning a new skill becomes difficult.
40
ALCOHOLISM AND DRUG DEPENDENCY
Poor short-term memory persists for a few months following cessation
of drug use. Since there is little that can be done medically for the
patient, reassurance by the Counsellor becomes very important.
These deficiencies that are threatening during the early days of recovery,
gradually disappear as abstinence continues. Exercises to improve
memory and concentration are quite helpful.
Sleep disturbances and poor appetite are the most common complaints
of drug dependent people. Sleep disturbances are most upsetting to the
patient. This condition may be an indication of an underlying psychiatric
problem and therefore this possibility has to be ruled out first. In the
absence of such problems, a structured life style with adequate physical
exercises is enough to handle this problem.
Lack of appetite is the result of the chemical dependent’s poor eating
habits. Providing input to the patient on the need to reorganise his food
habits, along with the use of some enzymatic preparations to increase *
appetite, often help.
Complications with intravenous drug use
a) Sharing of unsterile needles can lead to infective hepatitis (jaundice
— loss of appetite, vomiting and malaise). Medication, adequate
rest and diet control are required. If special arrangements cannot
be made for this patient, he may be temporarily sent home until his
medical condition improves.
b) Acquired Immuno Deficiency Syndrome (AIDS): Sharing of needles
with HIV positive drug abusers can lead to infection that later on
results in AIDS. Sharing of needles accounts for one fifth of all AIDS
cases. If facilities are available, the Counsellor should convince the
intravenous user to take the ELISA screening test to rule out HIV
infection. If the result proves negative, the potential risks involved
in drug use should be clearly explained to the patient. If results are
positive, supportive counselling, reassurance and information on
preventing the spread of infection to others are necessary.
c) Repeated use on same injection sites or use of unsterile needles can
lead to injection abcesses at the site, lung abcesses or abcess in the
brain. It should be left to the discretion of the physician to decide
if the patient can be treated while at the After-care Centre itself or
if he has to be shifted to a Hospital.
MEDICAL COMPLICATIONS RELATED TO DRUG ABUSE
41
Overdose
If the patient has a relapse, he may unwittingly take an overdose of
heroin. The body may become cold, blue and moist. Fits, shock and
coma can follow. Respiratory arrest is a possibility. Immediate medical
help is necessary to prevent death.
Psychiatric complications
In most cases, it is difficult to ascertain if the psychiatric condition
preceded or followed drug abuse. Whatever be the origin, it is clear
that such complications can exist in the recovering person. Often, these
problems are secondary to the main problem of addiction. With low
doses of medication and a period of abstinence, improvement is seen.
Sometimes, the psychiatric problem may be primary and addiction, only
a secondary problem. With these patients, regular and continued use
of psychiatric medicines becomes absolutely important.
Given below are some problems that may co-exist with addiction.
A few characteristic symptoms along with methods to handle them are
also stated.
Anxiety
Anxiety states and panic attacks are more often associated with cannabis
use than with other drugs. The patient complains of palpitation,
constricted feeling in the chest, breathlessness and excessive sweating.
Mild anti-anxiety agents, use of relaxation therapy and counselling on
trigger factors, help.
Depression
Patient seems dull, and shows little or no interest in interacting with
others, in eating and in personal appearance. Poor or excessive sleep
and lethargy are also reported. Suicidal thoughts may be present.
The patient will need medications (anti-depressants) for three to six
months depending on the severity of his problem. If suicidal thoughts
are present, it will be advisable to shift the patient to a hospital where
24-hour close supervision is possible.
ALCOHOLISM AND DRUG DEPENDENCY
42
Manic-Depressive psychosis
1 to 2% of drug abusers may have manic or depressive features.
While most of these patients have only manic or depressive features,
some go through swings from a depressive state to a manic state and
revert back.
Restlessness, sleeplessness, excessive / rapidity of speech, jumping from
one topic to another, grandiose talk, extravagant spending, dressing
in bright flashy colours are some of the main indicators of the
manic state.
,
Psychiatric consultations and continued use of medications are extremely
important.
Major psychosis
Paranoid features are most frequently seen. The symptoms may range
in their severity from a single paranoid delusion to a full blown paranoid
schizophrenic state.
Delusions and hallucinations can also set in.
With such conditions, medical intervention is the first line of treatment.
Regular use of medications for a continued period of time and
supervision to ensure smooth progress are important.
Psychological testing
It would be helpful for the Psychologist/Psychiatric Social Worker to
run a mental status examination on every patient admitted to the After
care Centre. It is advisable to avoid admitting patients with psychiatric
disorders. The main areas to check would be:
appetite, sleep, weight change, personal hygiene, psycho-motor
activity, thought (content, relevance and coherence, delusional
ideas, delusions), perception (hallucination), affect (subjective,
objective), cognitive functions (memory, attention, concentration)
and insight.
Simple Psychological tests to identify depression, and screening for other
problems (like MMPI, MPQ) may be used.
MEDICAL COMPLICATIONS RELATED TO DRUG ABUSE
43
Ongoing medical assessment should be part of the treatment programme
at the After-care Centre. Even if the patient’s problem is purely a
medical one, medication alone will not suffice. Reassurance and support
from the Counsellor who understands the condition and its future
implications, aid in speedy, sustained recovery.
Bibliography
The Pharmer’s Almanac — Pharmacology of Drugs, Anthony
Redcliffe, Peter Rush, Carol Forrer Sites, Joe Cruse, MAC Printing
and Publications, Colorado, 1985.
K
5
RESOLVING GUILT AND SHAME
The emotional response to addictive illness has its roots in feelings of
guilt and shame. Both guilt and shame lead to feeling bad — feeling
bad about one’s actions in the case of guilt, feeling bad about one’s
self in the experience of shame. Guilt results from a violation, a
transgression, a fault of doing something. Guilt leads to a feeling of
wrong doing, a sense of wickedness (“not good”)
Shame is the fear of being exposed, the fear of being found out. It is
the fear of appearing vulnerable, of being imperfect, of having one’s
secrets and flaws revealed. When the chemical dependent feels ashamed,
he feels intensely, painfully guilty about being himself. And feelings
of not being good enough, of not doing enough, of not being right or
doing the right thing are common among them.
Shame results from a failure, a falling short, a fault of being. Shame
leads to a feeling of inadequacy, a sense of worthlessness (“no good”).
Guilt and shame are accented differently. Feelings of guilt place
emphasis on the act committed.
“How could I have done that?”
Shame, on the other hand, focuses on the person who committed the act.
“How could I have done that?
How worthless I am!”
Guilt and shame are ultimately self-induced anxiety states that reinforce
the chemical dependent’s old feelings of unworthiness.
Unresolved guilt and shame often lead to feelings of depression and a low
self-esteem. Guilt and shame are often intermingled. Guilt is the feeling
of extreme regret for the past behaviour. It arises from breaking or
twisting some ‘rule’. Shame occurs when a self-expectation is not reached.
RESOLVING GUILT AND SHAME
45
Many chemical dependents feel worthless and lacking because they have
fallen short of their personal code of ethics. This results in a sense of
self-inadequacy. They may intellectualise their feelings and will make
it appear that their reaction is a result of someone else’s fault.
Shankar had borrowed money from almost all possible
sources. He did not know how he was going to repay.
He blamed his wife and held her responsible for his
indebtedness. His argument was that she had unnecessarily
shifted her son to a more expensive school, as a result of which
he had to borrow money.
He got irritated because his wife did not bother about the crisis
he was facing. He even threatened her that if she continued
to be unhelpful, he had no other option but to go back to
drinking.
Many chemical dependents see themselves as victims of others’
behaviour. Parents may be blamed for being too strict; wives may be
charged with not making the effort to understand. Stress at work or
boredom due to unemployment are other alibis used. They will keep
on blaming others and also become highly sensitive to others’ criticism
and a small trigger, like somebody calling them a ‘drunkard’, will be
reason enough for them to get provoked and go back to drinking.
Addiction would not be a problem for most patients if they did not
suffer from any guilt, because then there would tye no conflict.
It is this feeling, resulting from a niggling awareness of pain caused
to others, that often brings reality to the fore, and instigates recovery.
Many chemical dependents feel guilty during abstinence because it is
only then that they realise that during their drinking pr drug taking
days, they had behaved in ways which were not acceptable to them now.
The chemical dependent’s behaviour under the influence of drugs can
be embarrassing, worrying and extreme. Mood altering chemicals lower
inhibitions, and the person behaves in totally unacceptable ways.
He breaks promises, forgets about appointments, his work is sporadic.
He is not dependable. He becomes self-centred, insensitive to others,
irresponsible, manipulative and dishonest.
46
ALCOHOLISM AND DRUG DEPENDENCY
Arun was abusing Ganja for the past five years. He was living
with his aged mother who was struggling to run the family.
She had problems with her vision. She was hesitant to consult
a doctor since she did not have enough money. One day,
someone told her that there was going tp be a free eye camp
in the village on a Sunday after two weeks.
Arun's mother passed on the information to her son and
requested him to lake her to the camp for treatment. Arun
agreed to accompany her on the day of the camp. She kept
reminding him everyday. . *
On Saturday night, she again reminded Arun, that they had
to visit the camp the next day. Arun promised that he would
take her the next morning. But when the day dawned, Arun
was not found inside the house. He had gone out to the ‘den'
to meet his old friends. They smoked ganja together and he
totally forgot the word he had given to his mother. He reached
home only in the night and did not bother about how he
had behaved.
Because of Arun's total irresponsibility his mother had to
suffer for one more year, since the next free eye camp would
be held only in the following year.
During abstinence, when he is no more under the influence of
anaesthetizing drugs, he is able to see the reality of his actions, reactions
and all the consequences of his appalling behaviour in the past. This is
an extremely painful discovery for him and he is thoroughly shocked
and ashamed. He experiences shame and guilt in magnified proportions.
Actions done under intoxication, harm done to family members, friends
and relatives, acts of violence, and secret guilt feelings arising out of
deviations from normal values, like having extra-marital relationships,
acts of dishonesty - these literally shake him.
“Oh God! How cruel had I been!
What am I going to do now?
How am I going to make amends?"
The load of guilt and shame, is too heavy for him to bear. He finds
only two options before him. He starts using drugs again to anaesthetize
I
RESOLVING GUILT AND SHAME
47
emotional pain and escape from reality, and climbs back on the painful
round about of lies, deceit, theft, hurting others, fear of not being able
to maintain his habit, of being caught, and persistent feelings of guilt.
In case he decides not to go back to drugs, acute stress arising out of
these two major feelings may even drive him to attempt suicide.
Helping the patients resolve guilt and shame
For long term recovery, it is very important that the patient takes
remedial measures to resolve his feelings of guilt and shame. Maturity
comes through facing those hurt feelings and working through them.
All along, he has escaped from reality through the use of drugs and
this has stunted his emotional growth. Recovery from addiction is an
exploration; it is a process of discovering one’s feelings, values, and
beliefs. It is coming to accept and understand whatever he has done
under the influence of chemicals in all its depth and intensity.
The Counsellor should make him understand that he just cannot change
his past and he has to stop feeling guilty and ashamed about the many
things over which he had absolutely no control. His ‘If only’ thinking
(‘If only I had been different
If only I hadn’t drunk so much........ ’,
etc.) is non-productive.
The first step in resolving shame is in understanding his total
powerlessness over alcohol/drugs and accepting himself with this
‘limitation’. All along, he drank in an effort to escape from this reality
- to try to become more relaxed, more capable, more ‘whatever’. As a
result of those efforts, he ended up just the opposite — got sick, passed
out, and made a fool of himself.
“Why did I behave in such a shameful manner?”
The simple answer is
“You didn’t want to, but you did!
You did because you are a chemical dependent. The answer to your
‘why’ is not in your will power or your strength or weakness, but in
the fact that you have no power over drugs!”
Acceptance of the reality of powerlessness leads to forgiving oneself
for shameful acts done under intoxication, and rectifying those by
48
ALCOHOLISM AND DRUG DEPENDENCY
feeling them to their depth. He may have to own up his secrets and
talk about them. In doing so, he may discover that other people also
have the very same or similar secrets. That is the only way to overcome
the isolation and the self-hate that guilt and shame produce.
The Counsellor should clarify that after admitting his past mistakes,
he has to forgive himself and see to it that such acts are not repeated.
He can thus draw comfort, strength and forgiveness from other people.
Although fear and pride may discourage him from sharing his secrets,
he should be made to recognise that as long as he holds on to his secret
shame, he will continue to fe£l alone and miserable.
Also during recovery, he has to take responsibility to make amends for
whatever he had done earlier. He can definitely resolve guilt if he starts
making a list of the persons he had hurt, with an honest intention to
make amends to them all. Making amends for the past behaviour starts
with wholeheartedly apologising to those he had hurt. This is only the
starting point. It however, calls for a total change in the attitude and
behaviour of the chemical dependent. The recovering person has to take
the responsibility of consistently keeping a caring, understanding and
helping attitude towards those he had hurt. This is an on-going process
which will help him ‘let go’ of his feelings of guilt and shame, and
thereby enable him to feel worthy.
Forgiving himself, puts an end to the guilt and shame that perpetuate
past attitudes, emotions and behaviour. Making amends to others signals
the end of grief, his willingness to put the past behind him. Before he
can accept the past and let it go, he should be able to forgive all past
offences — his own and others’.
To sum up, recovery from addiction is a discovery of a feeling of
wholeness. The chemical dependent can start resolving his guilt and
shame during recovery by
★
understanding and accepting his powerlessness over addiction and
over his past behaviour
★
wholeheartedly forgiving himself for his past actions and
★
making amends to those he had hurt
RESOLVING GUILT AND SHAME
49
Additional information
A real life story
Let us listen to Vikram, a recovering alcoholic narrating his own
1
\ Ufe story- ■
“I was in my + 2 when my father died. He was an honest
worker in a press, and soon after his death I was offered a
job in the same press on sympathetic grounds.
I had been drinking very heavily for the past five years. I used
to come to the office drunk in the morning and there were
several occasions when I had quarrelled with my co-workers
and supervisors. Under the influence of alcohol, I had
threatened my supervisor and one day shouted at my boss
using indecent language. I had borrowed money from all my
colleagues; and whenever they refused to lend money,
I became spiteful. I was abusive.
My mother was struggling hard to run the family. She had
chronic health problems; there was practically no support for
her, I being her only son. Whenever she asked for money
I used to shout at her and on several occasions even kicked
her. I was violent and abusive. She was almost always in tears.
By now, my drinking had considerably increased. I tried
several methods; but could not control the quantity, time or
place of drinking. I was always thinking only of alcohol.
My mother, my sister — no one had any meaning for me.
I feel terribly upset whenever I recall the 21st of October when
my sister was about to be engaged. Even now I remember
clearly how both my mother and sister pleaded, asking me
not to drink just for that day. I shouted at my mother and
went out. When I entered home, I was heavily drunk. The boy
who was to propose to my sister, was already there with his
parents. They saw me and were visibly shocked — their cold
stares, their silent withdrawal from our house — nothing had
any impact on me. What was remaining, was only the sight
of my crying mother and sister which irritated me again.
50
ALCOHOLISM AND DRUG DEPENDENCY
The lime came when 1 lost my job; was threatened by people
who had given me loans. I was in a real financial crisis. I could
not manage. Still 1 reassured myself that "the situation is not
that bad", until one day I ended up in a treatment centre with
pancreatitis brought on by heavy drinking.
I was afraid, guilt ridden, totally asham. d of myself when
I shared my experiences at the treatment centre. I had to take
extended treatment. I got myself admitted after a month in
the After-care Centre and regularly started attending
A. A meetings also. I felt terribly guilty over my unforgivable
past actions; thoroughly ashamed of myself.
How am I going to make amends to those I have hurt?
How am I going to get out of my shame?
I have to — positively have to — make amends to them all.
I was told by my Counsellor that I will not be able to change
whatever had happened in the past. Alcohol had taken
absolute control, and I was not even aware of what I was
doing. I need not continue to feel ashamed of the acts I had
done under the influence of alcohol. Instead, I can plan my
life from now onwards — plan for my present and work
towards the future.
The A. A. members told me that I had to first forgive myself,
accept myself, and improve myself. I took the next step.
I immediately went to my mother, then to my sister, and whole
heartedly apologised for whatever wrongs I had done. It was
painful but I was determined io do it. They were so good that
they accepted me for what I was. It did not end there. I decided
that I had to support them, show care and understanding
towards them till my last day. I started helping them in the
household chores. I gave an advertisement in the paper, and
looked out for a suitable alliance for my sister. I had to get
her married. Yes! 1 had to see her enjoy life.
I met my supervisor, my boss, my co-workers — met each
one in person and wholeheartedly apologised for my past
51
RESOLVING GUILT AND SHAME
■p i»n
misbehaviour. I had got my Provident Fund money by then;
so I was able to repay most of the debts I had incurred.
After doing all these, Ifelt really light. I was confident I would
be able to make amends to those whom I had hurt. It is one
year since I stopped drinking. I have got a job, my sister is
married to a gentleman in Bangalore; my mother's smile has
come back and I am happy about myself.
On the day I completed my first year of sobriety, I arranged
for a small get-together, invited all my previous co-workers,
my mother, sister and all whom I had abused. After the tea
party was over, I shared my feelings, genuinely feeling sorry
for whatever I had done under the influence of alcohol.
I reassured them that I was a totally changed man and will
remain so.
I can now tell you with all conviction that negative feelings
of guilt and shame have to be recognised and resolved. I was
helped to recognise my own and benefit from it. My experience
can positively help you recognise and resolve yours. "
p/s sso
(
t
0ocU’
o’4'1
y
r
6
___
WORKING THROUGH GRIEF
Grief pervades the life of the chemical dependent. Unfortunately grief
is rarely considered in most recovery programmes intended for the
addict. Grief is a normal reaction to the total aspects of addiction an
is therefore something that has to be understood and plans made for
working to overcome it.
What exactly is grief?
Grief is a normal reaction to the loss of a cherished person or a thing.
The loss can be
material — any object of value
physical — part or function of body
psychological — self-esteem/self-respect/self-confidence/
reputation
significant person in one’s life — through death or separation
If grief occurs due to any of these losses, the grieving person must be
allowed to experience grief and helped through it with the most
appropriate means available to him. Each society and culture has its
own process of working through grief, and persons must be permitieci
to express their grief.
When Balan was 14, his father died. It was a rude shock to
him, to his brothers, and above all, to his young mother.
His mother was terribly upset, shocked, afraid, totally shaken.
“This is not true. My husband cannot be dead.
No! this cannot happen to me. ”
She was filled with resentment; got angry; became thoroughly
disappointed and disillusioned. Initially, she could not even
accept the fact that her husband was no more — dead and
gone for ever.
u
I
WORKING THROUGH GRIEF
53
As this case study shows, grief passes through distinctly defined stages.
The initial and immediate reaction is one of shock and denial. Events
often seem unreal. At first there is a tendency to deny the loss,
“This can ft be true. He is not dead. It can ft happen to me.
This is followed by anger and fear. The degree varies according to the
loss and may not be apparent to others.
“I haven ft done any harm to anybody. Why does God punish
me like this? I am wronged.,f
Anger may be directed at anyone, whether he is a factor in the loss
or not. Anger is often directed at oneself in the form of “If I had (or
had not) done this or that, then the loss would not have occurred.”
This anger is often repressed and the “If” statements are often thought
of, but not spoken. If this repression occurs, it leads to guilt feelings.
The bereaved person suffers from a feeling of responsibility for the loss.
This response is followed by a feeling of hopelessness, despair and
utter loneliness.
“I can't cope. I have to suffer the pain all alone. My God!
there is practically nobody for me! I wish I were dead!"
Emotional responses to any loss
Grief
(Resulting from a loss)
Anger
Hopelessness
Shock
4-
Denial
+
+
Fear
+
Despair *
Guilt
+
Loneliness
Grief of the alcoholic*
Alcoholism has long been identified as a disease which results in
numerous losses to the individual and to his family members. Alcoholics
most often enter treatment in response to a loss or threat of a loss —
threat of separation or divorce, loss of job, friends, financial security
etc. The alcoholic who is actively drinking is involved in a perpetual
* The same applies to drug dependents also.
u
54
ALCOHOLISM AND DRUG DEPENDENCY
state of grief — a response to many losses that are experienced over
the years of uncontrolled drinking. As the alcoholic progresses through
treatment, he experiences yet another loss — the loss of alcohol, a major
loss which needs to be grieved for. Total abstinence is the only solution
to his sickness. He can never go back to social or controlled drinking.
As a result, the grief he goes through will be no different from Balan s
mother’s condition. He is experiencing a deep personal loss — the death
of alcohol.
For the past so many years, alcohol had always been his trusted fiiend.
When he was unhappy or depressed, he drank and became happy.
When he was disappointed and lonely, alcohol seemed to relieve him
of his tension. To him, it was a trusted friend. It never let him down.
The gratification it gave, had always been immediate. To put it plainly,
he was tied to the bottle with an invisible chain. To him, it was all in
all; nothing else in the world mattered to him
family relationship,
job, finances, friends — everything receded to the background.
He unconsciously erected a wall around himself — he and his bottle.
Such a person has to now give up alcohol totally; he has to permanently
sever himself from his closest associate. The very thought will be frightening
to him. He will be shocked, angry, resentful, guilt ridden, desperate
and lonely. These phases of grief must be followed by a realistic insight
and reconstruction. This consists in recognising the loss, accepting it,
sharing the feelings involved with another person and making
readjustments to carry on meaningfully inspite of the loss. He has to
be helped to recognise and accept this loss, strengthen meaningful
relations and seek new relationships to replace that which is lost.
It will be appropriate at this juncture to hear what Balan has got to say.
(<When my mother was dazed, confused and grief stricken,
a number ofpeople came to console her — some were known,
while a few others were just acquaintances.
(It is just unbelievable. He was so young. How could this ever
happen?"
The same statements were repeated by each and every visitor.
My mother cried and described the details to everyone she
WORKING THROUGH GRIEF
55
was never tired of repeating the same again and again. She did
not talk about anything else.
I noticed that many who came, shared their personal grief.
There were young widows who had similar experiences.
They talked as to how they were initially shocked and shaken
and how they got back to living again without their partners.
They actually spoke of methods they adopted in dealing with
their loss.
After 10 days of sharing and repeating, I saw a visible change
in my mother. She could now accept the fact that my father
was really dead and gone — that she could see or feel him
no more. She also seemed to have gained some confidence
in dealing with the loss.9 9
The first step in overcoming grief is to share these losses with others
who are understanding and can appreciate the intensity of grief. At this
point in time, love, comfort and reassurance are needed — not advice.
For an alcoholic, sharing with AA members and fellow sufferers helps
a lot because they have also suffered the same loss.
The recovering alcoholic may experience feelings of depression and anger
and may not even be able to relate these feelings to the loss of alcohol.
It is important that the loss be identified so that he can begin the grief
process. He may express his anger in self-destructive thoughts or actions.
As he begins to face reality, overwhelming feelings of guilt will be
experienced. Self-blame and guilt lead to frustration, which when
internalised, will turn into depression. In the past, he would have dealt
with these feelings by drinking alcohol, an option which is no longer
available to him. Since new coping skills have not yet been developed,
anxiety will result. He will lack direction and may not know which
way to turn.
The recovering alcoholic may be reluctant to recall past drinking
experiences, and will most often feel uncomfortable while abstaining.
The resulting anxiety may be expressed or experienced in psychosomatic
symptoms such as insomnia, irritability, agitation, nervousness
or headaches.
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ALCOHOLISM AND DRUG DEPENDENCY
John says, “At the treatment centre, when I attended lectures,
when I talked to Counsellors and when I went to AA meetings,
everyone was talking only about alcohol and the need to lead
a life without it. All conversation centred on drinks. I got
impatient. I shouted, ‘You preach abstinence; ask us to forget
alcohol; but at the same time, you talk only about drinking
and keep constantly reminding us of alcohol. Don’t you have
anything else to tell us?’
Albert, another recovering, alcoholic, patted me on my
shoulder and calmly explained to me, ‘Now it is very important
to talk about alcohol, about the problems associated with
drinking, about leading a life without alcohol etc. This is the
only way of getting rid of fear and sorrow. This is the most
crucial turning point in our life. You keep sharing your sorrow,
and grief with us because we have also suffered the same loss.
Sharing with AA members and Counsellors is the only way of accepting
grief, confirming it, and learning to lead a meaningful life without it.
He will slowly begin to understand his realistic equation with alcohol
— that it can no more give him pleasure; drinking will lead to pain
and only pain from now on.
This reminds us again of Balan’s reaction.
“Even today I remember, that on the 13th day of my father s
death, new dresses were bought, a feast was arranged and a
visit to the temple was planned. I resented this custom.
I honestly felt that people were celebrating my father s death.
My mother told me, ‘There is nothing wrong in wearing new
clothes; eating a good meal or going to the temple today. This
social sanction is given only with a purpose. After all, father
is dead and is not going to come back to us. It is our
misfortune. In spite of this, our life has to go on. This
ceremony signifies the need for leading a productive and
meaningful life even in his permanent absence. We have cried
enough, and there is no point in clinging on to sorrow.
At some point in time, we have to start doing our duties and
begin to live again.
a
WORKING THROUGH GRIEF
57
Sharing helps the alcoholic slowly realise that there is no point in
permanently lamenting about something which cannot be changed —
his powerlessness over alcohol. Talking about his grief and about the
feelings associated with it, gives him relief. The solution to the pain
is in recognising it, owning it, feeling it to its fullest and laying it to
rest by sharing.
If one goes through each phase of grief and completes the process, he
will be able to go on with his life. If, on the other hand, he skips one
or more of the phases, he will suffer from unresolved grief and will
later have to come back and complete the grief process. If he does not,
the future loss will bring with it not only that loss, but also all the
unresolved feelings resulting from the former loss. This will inevitably
lead him back to drinking.
What are the other losses suffered by the alcoholic?
He suffers from the loss of the bottle; loss of drinking friends; loss
of a routine involved in drinking; loss of self-esteem; loss of self
confidence; loss of respect from family members and loss of personal
dignity. These losses are also subject to the grief process and therefore
must be dealt with.
How can his grief be resolved?
As the alcoholic starts accepting the loss and begins to cope with the
resulting stress, resolution of the loss can be achieved. New coping skills
must be learnt and developed. As the individual’s self-esteem begins
to increase, as anger and depression decrease, internal resources can
be built.
A structured practical plan alone can help the alcoholic to become
balanced and happy - happy that it is possible for him to lead a
comfortable life without drinking.
‘A Working through grief provides a chance to say goodbye to the old
memories and the old drinking friends and an opportunity to bring
new people close together in a mutually supportive environment.
These new relationships can be developed with persons who are
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ALCOHOLISM AND DRUG DEPENDENCY
recovering from alcoholism, and it will be very helpful for him to
attend AA meetings and other therapeutic groups. New relationships
should be developed only with persons who will have a positive
impact on the recovering person’s abstinence from alcohol.
★ Readjustment starts with getting a job. Applying his mind to the
work will make it interesting and productive.
★ He should strengthen his family relationship by spending time with
his wife and communicating with his children.
★ He should find out new recreational activities and resort to new ways
of having fun. If he has any idle time, he can spend it in pursuing
old hobbies.
★ The foundation to recovery is in the realisation of his total
powerlessness and surrendering to a Higher Power which alone will
give him lot of mental strength to lead the new life.
I
Role of the counsellor in ‘Grief work’
It is necessary for the Counsellor to be patient and supportive. He should
recognise and respect the feelings of each person. The Counsellor should
avoid statements like,
''You have had enough of problems. Even after that it is
strange you haven't learnt a lesson."
These reactions inhibit grief.
The Counsellor should also avoid becoming defensive if, by chance,
the alcoholic’s anger is directed towards him.
The recovering alcoholic may need help in identifying the loss and in
verbalising what the loss means to him. The Counsellor should allow the
individual to approach this in his own time schedule. It is important
that the Counsellor should on no account attempt to accelerate the
grief process.
For the alcoholic, losses will be cumulative. Past losses like loss of job,
loss of finances, loss of relationships etc. would not have been resolved.
These losses will now return to the individual’s awareness. As the person
has been unsuccessful in resolving losses, he is not likely to deal with
present losses and resolve them without proper support and assistance.
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WORKING THROUGH GRIEF
59
Apart from these, some deaths might have even occurred in the family
during the alcoholic’s drinking days. The alcoholic would not have
mourned; instead he would have escaped the pain by using chemicals
to numb himself. During recovery, however, he may deeply regret and
feel guilty. This grief which is not resolved, does not go away. It should
be put to rest through a process of re-experiencing earlier losses so that
they become real. The Counsellor should allow him to talk over the
pain so that these long-repressed, long-denied feelings come into his
consciousness once again. He may open up wells of hidden anger along
with his disappointments and deprivations. Fear, guilt and anxiety may
also surface when he begins to talk about the past. However painful,
he should be allowed to ventilate his feelings, because mourning is
necessary for his personal recovery.
The grieving person also needs to have his feelings validated — to know
that they are real, normal and expected. He should be encouraged to
explore his feelings and assisted, if necessary, in assigning them meaning.
He may need help in acknowledging the loss and exploring feelings in
relation to the loss. Therefore the loss should be identified, examined,
and its significance defined.
In short, in a supportive environment, the Counsellor should allow the
alcoholic to ventilate his fears and feelings that accompany his loss.
He should be allowed to acknowledge his pain and ultimately release
it. Unless he admits his anger, bitterness, depression, self-pity and
loneliness, he will never be able to let them go. And these buried feelings
can consume him, making it impossible for him to move beyond these
losses towards recovery.
Sharing his feelings in group therapy and individual counselling sessions
leads him to slowly accept the loss and plan a new life style, structuring
his day-to-day activities. This, along with recreation and prayer, will
help him in successfully dealing with his loss.
Within the family system, healing is as contagious as sickness. When
one member of the family seeks help and overcomes grief and remains
in that condition of healing without changing back to the old methods
of dealing with problems, it is highly possible that others in the family
also move towards recovery. Everyone has a choice to overcome grief
with the help of those who bear the scars of the same wound.
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ALCOHOLISM AND DRUG DEPENDENCY
Once a person recognises grief and begins to talk about it and the feelings
involved with another person, he will begin to find relief from the pain.
Any attempt to cover these feelings with alcohol or other chemicals will
not meet with success. He has to deal with grief through the definite
phases, make readjustments by effecting qualitative changes in his life
style, and only then can his life go on unencumbered.
WORKING THROUGH GRIEF
61
Additional information
Following is a record of several stages of grief as explained by researchers
over the years. This may be used as a reference by the Counsellor.
The Stages of Grief
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2. developing awareness
Lindemann, 1944
3. restitution
1. shock and disbelief
4. resolution
2. developing awareness
3. resolving the loss
Kubler-Ross, 1969
1. denial and isolation
Bowlby, 1961
3. bargaining
2.
anger
1. weeping and anger
4. depression 5. acceptance
2. disorganisation
3. reorganisation
Parkes, 1972
2. pining
1. numbness
Westberg, 1962
4.
recovery
3.
depression
1. shock
Kavanaugh, 1972
2. emotional release
3. depressed and lonely
1. shock
4. physical symptoms of distress 2. disorganisation
5. panic
3. volatile emotions
6. guilt
4. guilt
7- anger and resentment
5. loss and loneliness
8. resist returning
6. relief
9. hope
7. re-establishment
10. affirm reality
Colgrove, 1976
Engle, 1962
1. shock and denial
1. apprehending the loss
2. anger and depression
2. attempting to deal with the loss 3*. understanding and acceptance
3. final restitution and
Baker and Kelly, 1978 Tasks
resolution of the loss
related to loss
Engle, 1964
2. healing
1. surviving
1. shock and disbelief
3. growth
Bibliography
1. 'Alcoholism Treatment Quarterly’, Volume — 1, Number — 1, Mary
Ann F Friedman, Spring 1984. Published by Haworth Press, Inc.,
New York.
7:_____________
HEALING THE HURTS
A chemical dependent harbours lots of frustrations, resentments and
hurt feelings. During the process of his dependency, he would have hurt
a lot of people. They, in turn, would have hurt him back. In order to
escape from these hurt feelings, previously he would have abused
chemicals. Now during recovery, these accumulated unresolved hurts
lead to stress, negative feelings and growing problems. Added to that,
during recovery, he may be experiencing fresh wounds of hurt.
Emotional pain can be very deep and destructive. If hurts are not
resolved, they can interfere with relationships and also hinder the
recovery process.
How do hurts happen?
Can they be avoided?
Relationships are a source of strong feelings — both positive and
negative. Happy and hurtful moments come from them. The closer
the relationship, the stronger the feelings it gives rise to. Hurts
and disappointments are as deep or as slight as the person’s
involvement in the relationship. Following are a few reasons why
hurts happen.
When the chemical dependent’s views are
not regarded/respected
Family members and significant others frequently act or speak in ways
that are very different from the way the recovering person would like
them to. Even when he is abstaining, they may not always function
in accordance with his expectations. He often interprets their
disagreement with his views as a rejection of himself, and their actions
are therefore seen as deliberate moves to hurt him.
HEALING THE HURTS
63
Arvind was a brown sugar addict who went home on an
outpass when he was at the After-care Centre. On that
particular day, a few of his relatives visited his house. Arvind’s
mother immediately called him aside and said that he need
not see the visitors or talk to them.
Arvind was deeply hurt because he thought that his mother
was ashamed of him, and that was the reason why she had
sent him upstairs.
w t »i?
The fact was Arvind’? mother thought that it was too early
to expose him to the relatives. She felt he was not as yet open
about his problems, and she really wanted to give him some
more time to settle down. She had a lot of care and concern
for Arvind and that wps the reason why she asked him not
to see them.
But Arvind’s opinion was that his mother thought that he was
not worthy enough and that she was too ashamed of him.
Arvind had loaded the situation with his negative
interpretation and turned it into a cause for hurt.
If the chemical dependent refrains from adding his judgement to others’
behaviour, he will be able to see their point of view better. Then it will
become easier for Arvind to see his mother’s act as a sign of love and
warmth rather than as a mark of shame and hatred.
In short,
★ When situations are interpreted to form generalised opinions, hurt
is created.
★ Objectively viewing and stating the facts of the situation, aids
understanding.
When the patient’s legitimate needs
are not taken care of
When others fail to meet his needs, the chemical dependent feels
thoroughly disappointed. He immediately comes to the conclusion that
they do not care.
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ALCOHOLISM AND DRUG DEPENDENCY
During recovery, Mohan felt that his wife did not have any
regard for him. He had the following complaints about her.
- She does not iron his clothes properly.
- Does not take pains to make good food for him.
— Did not visit his parents or provide moral support to them.
Mohan was upset and deeply hurt; but he never expressed his
feelings.
Mohan shared his problems with one of his peers at the After
care Centre. His friend suggested that he openly tell his wife
whatever he expected of her. Mohan was initially reluctant.
His friend insisted that he should give it a try.
With a lot of hesitation, Mohan told his wife that he would like
to look clean and her ironing his shirt would be very helpful.
He told her how hungry he felt and how he longed for good
food. He also conveyed to her that he was worried about his
father's health and that he would be very happy if she took
care of his parents. To his surprise, she was very receptive,
and from then on, their relationship changed for the better.
When hurt sets in, “Why?”, “How could she?” and similar self- pitying
responses crowd the mind. These do not lead to the resolution of the
problem, but only keep the person running in circles.
Asking himself “What do I do now?” rather than “Why did this happen
to me?”, will take him closer towards solving the problem. Meaningful
relationships call for openness from both sides. Unexpressed needs run
the risk of remaining unfulfilled, giving scope for hurt.
Therefore, it is necessary that
★ The person explicitly states what he wants the other person to do.
★ Being able to express needs, brings people closer and strengthens
relationships.
When negative criticisms flow freely
When negative feedback far exceeds positive feedback, the person feels
rejected by the other. If this painful feeling is not handled, it weakens
his self-esteem.
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HEALING THE HURTS
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Vikram felt his mother was being very difficult. Her choice
of words, her suspicious nature, her constant comparison with
his friends, her talking about his past behaviour in front of
his brothers — everything hurt him. Vikram was upset and
angry. This led to further problems and a vicious cycle was
in progress.
After talking to the Counsellors and his peers at the After
care Centre, slowly Vikram learnt to cope. How did he manage
that? What brought about the change in him?
<’
■■
They actually made him look at the problem from his mother’s
angle. They made him see the fact that his mother had
arranged for his treatment thrice during the past two years.
She had not hesitated to spend money, and in spite of her
health problems always made it a point to visit the hospital
everyday. In spite of her repeated efforts, Vikram’s problems
did not seem to have totally disappeared, and that was
probably the reason behind her frustration.
Vikram could see his mother’s plight and thought to himself
that he would try not to get provoked by his mother’s words
from then onwards.
If he had really put this thought into practice, it would not
only contribute to his peace of mind but also help him in
improving his relationship with his mother.
In short,
★ Understanding the problem from the other person’s position helps
in resolving hurt feelings.
When the recovering person lets
trivial instances provoke him
Misery loves company. When hurt, the person starts looking out for
further hurts to add to his collection. He waits for one wrong move
from the other person, quickly converts it into a hurt and adds it to
his collection of hurts.
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ALCOHOLISM AND DRUG DEPENDENCY
Mithun was upset again with his wife. He was very angry
with her and reflected on her words that hurt him the
previous week.
On Monday, when he was leaving for the office, she said,
ftCome back early today.iy
(She is waiting to find fault. She thinks I may go out and
drink.)
When he brought his salary home, she dsked, Got only so
much of money this month?'3
(What does she mean by this? Does she think I have kept some
money in reserve for drinks?)
Why is it that any remark from his wife upsets Mithun?
Possibly because he is already experiencing stress arising out
ofphysical discomfort he is putting up with during abstinence.
This stress makes him uncomfortable and he exaggerates every
remark and converts it into a cause for hurt.
Mithun would not have been hurt if he had paused for a
moment and recollected all the positive qualities of his wife.
He could recall instances when she had made so many
sacrifices, had taken so much of his burden and had been so
very patient. These thoughts would have definitely changed
his entire perception.
When hurt feelings are not properly handled, they weaken the
relationship. Piling up hurts destroys fine relationships. Weeds,
if left unchecked, can ruin the most beautiful garden. Hurt grows
bigger and bigger, making healing more and more difficult and
complicated.
So,
★ Even minor issues are likely to upset the person when he is handling
stressful situations.
★ When hurt, the chemical dependent should recollect all the positive
qualities of the person and not harp on just one discordant remark
of the present.
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HEALING THE HURTS
67
When the person keeps decade old hurts alive
Many chemical dependents carry a huge load of hurts of the distant
past. Pulled down by the sheer weight of negative feelings, they cannot
relate to the present. They willingly lie chained and stay stuck to the past.
Sanjeev had been carrying a lot of hurt feelings arising out
of his wife’s behaviour in the past. She had been staying with
her father when he was drinking heavily and she was unable
to cope. But when he decided to take treatment, she dame back
to him and extended lot of support and was really helping him
in his recovery.
Sanjeev never appreciated her help, but was always clinging
to his past resentments. He could not forgive her because
- she left him and went away.
- his father-in-law made an adverse comment about his
behaviour in the presence of his friends.
- she refused to borrow money from her Provident Fund
to pay back his debts.
Carrying the hurt, and keeping painful memories alive, the person reacts
only from that level and reacts negatively. The reasons for their long
standing hurts are unchangeable. They no more have any relevance.
Still, they give so much of their present life to nurse the hurt and keep
the past alive. When a person is not willing to ‘let go’, the hurt
grows and eats up more and more relationships, leaving him distraught
and lonely.
Therefore,
★ Old hurts keep the person chained'to the past and come in the way
of other relationships too.
★ “Letting go” has to be done — not for the sake of others, but for
themselves.
Blocks which prevent hurt feelings
from getting resolved
What are the usual thinking patterns which prevent the chemical
dependent from resolving his hurt feelings?
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ALCOHOLISM AND DRUG DEPENDENCY
He usually waits for the other person to take the initiative. Normally
the chemical dependent’s arguments will be
‘‘After all I have given up drugs; let her start showing love and
affection.”
- “She knows just as well as I do. After all these are issues which
affect both of us; let her change first.”
- “I have sacrificed; have done so much for them; let them make the
first move.”
Sometimes, the recovering person believes that just ignoring hurts, will
work. But, this is not true. In close relationships, ignoring hurts and
pretending that nothing is amiss, is like a volcano waiting to erupt. Hurts
add on quickly and turn trivial instances into major issues. Even in
formal relationships, time heals only if the person allows it to.
The therapist should make the recovering person understand that he
is not losing or giving in when he takes the first step to resolve his hurt.
On the other hand, by doing so, he is only proving that he cares more.
When he hits out at other people with words, they will do the same with
ease. Instead, if he stops and says, “Come on! let us do something and
work on our relationship!”, they will find it difficult to turn him away.
Hurts can be healed
Given below are some techniques and tools. These are based on authentic
experiences of recovering people. They do work. Among these, the
chemical dependent can try one or two ideas or techniques which he
feels may be useful and relevant. He is sure to be immensely benefited.
However, the Counsellor should appreciate the fact that healing of hurts
takes time since they have got accumulated over a period of time.
He should never try to accelerate the process; instead he should let the
patient take his own time to resolve them.
Tools to heal hurts
★ The chemical dependent may be asked to maintain a diary of his
feelings. At the end of the week, say, on a Sunday, he can record
two instances when he felt good about himself.
HEALING THE HURTS
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It can be
- somebody at the After-care Centre expressing his gratitude for
the timely support.
- the peers’ comment that he was very neat and clean.
- the Counsellor appreciating his ‘honest sharing*.
He can record one instance when he felt hurt or unhappy. It may be
- a remark from the Counsellor for being late.
- wife going to her mother’s house without informing.
Over a period of time, the recovering person will get to see so many
positive things in his life, and also the common triggers that cause hurt,
and he will probably find his own unique ways of dealing with them.
★ If one issue is repeatedly giving rise to hurts, he should be encouraged
to list the options he has. With each option, he should record the
result he anticipates.
To give an example,
When Jayakar was recovering, his wife always talked about how
shameful his behaviour was, how many times he broke promises,
the amount of opportunities he missed, the way he carried on in an
irresponsible manner — all during his drinking days. Jayakar got
annoyed; but tried to put up with it patiently. He found it very
difficult. So he decided to resolve the matter.
What did he do?
Jayakar listed the options and the possible outcomes.
Options___________________ Outcomes_________________
Leave the place without making any May be able to cope for some more
time; but definitely not permanently.
comment.
Shout at her and release angry feelings. Wiff may resent and shout back.
Relationship will become more strained.
Order wife not to speak in that manner. She may not listen and this will show
on their relationship.
Discuss issue openly focusing on how he She may argue and and try to justify
is affected and how intensely he feels or
she may agree to stop talking about
about it.
the past
or
some solution can be identified.
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ALCOHOLISM AND DRUG DEPENDENCY
Jayakar decided to try the last option which seemed the least hurtful
and the most likely to succeed.
Studying options, clarifies the recovering person’s thoughts and needs.
By carefully considering his course of action, he will act constructively
rather than react impulsively.
★ When the hurt is threatening to break a long standing relationship,
the chemical dependent may be asked to list two qualities that he
likes in the other person.
It may be his wife
- taking lot of interest in cooking and serving good food.
- helping children in their studies and giving the) a emotional support.
- always looking neat and clean.
★ Write two situations in which the other person had been supportive.
It can be
- managing the house efficiently when he was financially broke.
- taking care of his father when he was hospitalised.
This helps the chemical dependent to see the other person with
understanding and gives him assurance that with so many strong points
supporting her, he can rebuild the relationship.
★ Strong relationships mean better communication and less hurt.
To facilitate this in the family, the chemical dependent may be
educated to do the following, whenever there is an opportunity.
- Encourage each member to appreciate some nice deed or act of
one other member.
- Help each member talk about his or her personal achievements
in the recent past.
They can do such things in an informal, natural manner, say, over
dinner, or while eating out. Being able both to give and receive positive
strokes, leads to a strong self-esteem. A strong self-esteem helps in
handling hurts easily.
Recovery from chemical dependency will be secure only if relationships
are strong. For any relationship to be strong, hurt feelings have to be
resolved. Therefore, whenever hurt, the chemical dependent should
★ ask himself — ‘"Why am I feeling hurt?”
★ check his options — ‘‘What can I do about it now?”
★ initiate action based on the analysis.
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ANGER MANAGEMENT
Anger is a normal human emotion. Still, chemical dependents have
special problems with anger. In their families, anger is often expressed
in extreme ways through emotional abuse and neglect, violence, sexual
abuse or through abandonment. When they express anger, they may
be overwhelmed by feelings of guilt. Fear, anger, guilt — for them these
emotions are all tied together in a negative way.
They try to ignore their angry feelings, hoping that these will go away
on their own. But they don’t. They usually get worse. Then they feel
guilty and end up abusing chemicals once again and behaving in ways
that can hurt them as also the people around.
This is a chapter on anger, specifically about how it hinders the process
of recovery from chemical dependency. Abstinence does not make anger
disappear. The fact is sometimes abstinence does make anger worse,
both for the dependent and his family. For instance, when the alcoholic
is drinking, the family members have something to blame his anger
on
the bottle; the booze; the drunkenness. During abstinence, the
bottle is taken away and what is left is just the anger with nothing to
blame it on. They end up confused.
Anger is an emotion that lasts long after the chemical abuse has stopped.
Even after abstinence is achieved, aggression may continue unless the
chemical dependent learns to channelise aggressive feelings in
less dangerous ways. He becomes angrier when under pressure.
Learning to ventilate anger in a positive manner is an important part
of the recovery process.
Unresolved anger, whether it is openly discussed or not, can hinder the
recovery process. When anger is loud, explosive and frightening, it can
be recognised. We can see it, hear it, and feel it. But there is another
kind of anger — controlled, quiet, ice-cold. It can take many forms —
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ALCOHOLISM AND DRUG DEPENDENCY
depression, manipulation, suicide and so on. These varied responses
can mask what is really going on under the surface — unrecognised
rage. They may not yell or scream or kick at each other, but the anger
is there in the clenched jaws, the cold stares, the slammed doors and
the subtle threats. This kind of anger often builds in families where
a chemical dependent is abstinent, but neither the patient nor his family
is working on the recovery process. Abstinence by itself is no guarantee
for happiness. For a chemical dependent, it is the starting point, the
single most important thing necessary to begin the process of recovery.
And this process calls for committed work.
For positive recovery to take place, anger needs to be acknowledged,
dealt with and resolved. The recovering person has to be made aware
that there are healthy ways to express anger and that the management
of anger can contribute a great deal in the process of recovery, making
it less stressful and reducing the chance of a relapse.
Indirect expressions of anger
Anger can manifest itself in disguised ways, unrecognised both by the
angry person and his target.
Mahesh says, “After treatment, I had been totally staying
away from alcohol, I went back to my office, from where I
had received a suspension order before I took treatment. I
was filled with hopes that they would take me back
immediately. This did not happen. They made me come the
next day. ...the next week
and so on. After about a month,
they bluntly told me that they could not take me back. Why
did they make me run from pillar to post? Could they not
have said this earlier?
I was thoroughly disgusted and heart broken! I was totally
disappointed!.... Upset!
I told my friend, Peter, T am so depressed that I wish I were
dead! I feel like committing suicide!"
Peter immediately asked me, Are you angry?"
I said, (No, I am only depressed."
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ANGER MANAGEMENT
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73
He replied, ‘You feel hopeless; you are convinced nothing is
going right for you; future looks bleak and you are not
enjoying anything — look at yourself and see ifyou are angry
about something. ’
He was right; I was angry at my own self. ”
Many chemical dependents learn to be passive and silent, while
underneath, they seethe. Even when they are shouted at, they may not
open their mouth or react.
Ramu says, “Whenever my wife shouted, I kept quiet, I had
learnt to control and stifle my temper and sit on it. But inside
I would be boiling. I couldn’t admit I was angry — not even
to myself. I was well brought up, which meant I had to pretend
— I had to act. ”
When Ramu swallows his anger, pretending it does not exist, he is sure
to explode, over reacting to any minor irritant. When pushed, down
and hidden, anger can be like slow acting acid splashed on one s selfesteem. It gnaws, eats, burns, corrodes, until nothing is left but a raw
edged hole, an empty pit of despair. Sometimes, suicide may look like
the only way out. Ramu may start craving for a drink again. For him,
anger management should be an essential part of his recovery plan.
Sarcasm and biting humour are also displays of anger.
“One day I came home early to take my wife out for a movie.
It was already late and she was not yet ready. 1 smiled and
said, ‘How smart you are! You are always ready on time!’”
Even though he was smiling, he was actually boiling with resentment
and anger.
Those who suffer from chemical dependency have another majoi
problem that does not always look like it is related to anger, but it is.
It is self-pity, caused by negative self thought. They feel so sorry for
themselves, because their family, friends, co-workers, the whole world
does not give them what they want, need, and feel they deserve.
They wallow in self-pity and seldom stop to consider whether what they
want from their family and friends is reasonable. They make
unreasonable demands and are angry when they are not met.
ALCOHOLISM AND DRUG DEPENDENCY
74
To complicate things, some of their demands are not even voiced.
They just expect other people to know what they want. They are angry
that life is not fair, that it is full of hardship and disappointment.
They often think of themselves as victims tossed around by an uncaring
world. They strongly believe in luck — always bad luck for them and
good luck for everyone else. Whom do they blame? — anyone who
is handy — wife, children, subordinates etc.
A disturbing manifestation of hidden anger is the reaction of body to
it. Unrecognised anger can contribute to many physical disabilities like
migraine head ache, pain in the neck, sleeplessness, nervousness,
heaviness in body etc. Anger is a form of energy, which, if repressed,
must come out somewhere and it can harm almost any part of the body
or influence the emotions in a negative manner.
One outlet of repressed anger is accidents.
<(When I am angry, I slam the door; get into my car and continu
ously blow the horn. I drive so fast that I often run into some
accident. One day, when I was watching a tennis match on
the TV, my wife insisted on my hanging a picture on the wall
right away. I was so angry that I hit my fingers with the
hammer. 1 must have been angry earlier, but did not realise it. ”
So far, we have seen that anger may be disguised in many ways, some
easy to recognise, some not. It may appear in language, action or body
reaction. One may get aches and pains; injure himself or others; become
withdrawn or depressed.
Hidden anger
Feelings
Expressions
Disappointment
“I am upset
1 am heart broken.”
“I feel like killing myself”
“I wish I were dead.”
(Quiet)
“Ah! very smart!”
(meaning the opposite)
“Poor me!”
“Only I suffer.”
Depression
Silent Resentment
Sarcasm
Self-pity
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75
ANGER MANAGEMENT
Outcome
Physical signs
Psychological signs
Loneliness
Headache
Depression
Stiffness
Lack of appetite
Sleep disorder
Being tense all the time
Behavioural signs
Verbal abuse
Violence
Unnecessary arguments
Isolation from Society
Silent brooding
Return to
drug/alcohol use
Why do chemical dependents get so angry?
There are two main reasons for quick, open expressions of anger.
The first is they have accumulated so much anger in them, that it
requires only the slightest provocation to set them off.
During abstinence, they want a quick change in the attitude of all
others around. But to their disappointment, there is always tension
in the air, mixed with the memories of yesterday’s pain. When the
chemical dependent sobers up, initially there is not much of a
change in the family dynamics. Anxiety, tension and mistrust lurk
constantly in the air, even on problem-free days. Everyone recalls
with burning resentment every injustice, every offence, every wrong
committed. The memory is embedded deep and it festers.
During recovery, the chemical dependents are also hiding wounds
that have not been allowed to heal — resentment wounds — the gashes,
the trauma and lacerations of bitter anger. The resentments can
very often affect their jobs, marriages and friendships; and, ofcourse,
their recovery.
The second reason is that, over a period of time, they had found
that anger works, and they are therefore conditioned to continue
its use. Since people dislike and fear displays of temper, they give
in to the angry person. Thus, for them, anger becomes a pattern
of behaviour.
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ALCOHOLISM AND DRUG DEPENDENCY
What happens as a result of the chemical
dependent’s anger?
Anger is a strong impediment to recovery and if left unchecked, their
chemical abuse will creep in. They try to balance their emotions like
a child. The child cries. They do not cry, but go back to chemical abuse.
If something does not happen the way they want, the time scale in which
they want it to happen, they become impatient. They cannot wait.
They want to seek immediate gratification and therefore get back to
drinking/drug abuse.
For positive recovery to take place, anger needs to be acknowledged,
dealt with and resolved. However, the Counsellor should make the
patient understand that there is no ‘quick fix’ for this problem; no simple
solutions and no set formula to deal with this complex issue.
However, there are a few steps, which, if followed, may lead to a
reasonable solution.
A few steps in dealing with anger
Learning to deal with anger and resentments, learning to forgive people,
and learning to forgive themselves for the wrongs they have committed
are the most important elements of their recovery.
The first step for the chemical dependent in dealing with anger, is to
recognise that he is angry and admit it to himself. Anger, of which one
is aware, is.much less harmful than unrecognised anger. If the person
is tense and does not know why, or has any of its disguised
manifestations, he should be allowed to explore the possibility that he
is angry and not aware of it. If he feels depressed, he should introspect
and find out the reason for his anger. If he is feeling sad, fed-up, hurt,
frustrated or disappointed, the question he has to ask himself is,
“Am I angry with myself? Am I afraid of facing the situation?
Anger may not always be reasonable; but that does not mean it does,
not exist. Anger is an emotional response, and can be dealt with only
if he is aware of it as an emotion.
The next step is to identify the source of anger. Once he has recognised
that he is angry, he has taken the most difficult step. Then the problem
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ANGER MANAGEMENT
77
iji i • n
is to understand where his anger is coming from. It may be very obvious
or very subtle.
He may be frustrated as a result of his inability to pay off his debts.
His body may be aching and paining. Since it is not possible for him
to shout at anybody else, he may show his anger on his wife. A few
minutes’ delay on her part in bringing coffee, is reason enough for him
to blow up. When he reasons this out, he will understand'that his anger
is out of proportion to the cause. It is misplaced anger — an outlet
for anger generated by someone or something else. The chemical
dependent should be made to understand that if anger is repeatedly
misplaced, meaningful relationships are likely to become sour.
The next step is to determine whether anger is realistic or not. If he
has recognised that he is angry, and identified the source of anger,
he should proceed to find out whether it is realistic or not.
Gopal narrates,
“When I came from the office, 1 found that my wife had not
ironed my shirts. I was terribly upset because I was leaving
for Bombay the next morning. She had not packed my
things
, not even kept them ready. I shouted at her.
‘You were so busy that you didn't find time to keep my things
ready....Is it?'
She shouted back, ‘Do you expect me to read your mind?
You never told me you were leaving for Bombay tomorrow.
You don't say things properly
, you know only to shout
at me!'
This shouting continued and in my rage, I went away without
eating.
I thought for sometime andfinally realised that my anger was
not realistic. I had not told her that I was leaving station the
next day, and that I wanted her to pack my things.
My expectations were not expressed, and therefore I had no
reason to feel upset. It was not fair on my part to expect
something when the other person was not aware of my needs. "
When the fact that he is angry, the source, and the reason have all been
brought into the open, the question is how to deal with it realistically.
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ALCOHOLISM AND DRUG DEPENDENCY
In a chemical dependent’s home, there is a set pattern in which angei
shows itself. The patient is extremely angry and shouts throughout the
night His wife shouts the next morning. In either case, the other person
does not listen at all. Neither of them feels guilty for having shouted.
As each one shouts in turn, their anger gets ‘evened out’.
The first step the chemical dependent has to take, is to break this evened
out’ cycle. He has to stop reacting immediately. Instead of shouting in
rage, he should try other methods, to break down anger. Alter this, he will
be in a proper frame of mind to communicate or talk about his feelings.
Sunil underwent treatment for his alcoholism. After a month s
abstinence, he went back to his office. He was expecting a
promotion. To his utter disappointment, he learnt that many
others had got their promotion whereas he did not get one.
He was sulking in the office and as soon as he entered home,
he shouted at his wife complaining that tea was very cold.
He had a headache, pain in the neck and was feeling depressed.
He was raising his voice and arguing unnecessarily. Suddenly^
it occurred to him that he could try Anger Management’
methods which he learnt at the After-care centre. The follow
ing steps which he adopted, helped him to understand,
recognise and deal with anger in constructive ways.
What did he do?
He recognised his angry feelings
How did his anger show up? Physical signs included headache
and pain in the neck. Psychological signs showed themselves
in his feeling of depression. Behavioural sign was his
unnecessary arguments. Now he realised that he was angry
and admitted it to himself.
He identified the cause of his anger
What was the situation which triggered his anger?
He expected a promotion, but he did not get it. So he was
angry with his boss.
Was his anger misplaced or properly placed?
It was quite obvious that his anger was misplaced. He was
unable to shout at his boss; therefore, he shouted at his wife.
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ANGER MANAGEMENT
79
Was his anger realistic?
To him, it seemed realistic, because he felt he deserved a
promotion.
He decided to deal with his anger realistically.
What did he do?
He fixed up an appointment with his boss, the next day.
An open discussion revealed that his boss’ expectations were
different. He noted down whatever the boss said was a pre
requisite for the promotion; and after he came home, he
chalked out a practical plan. His action plan included:
★ The amount of work he had to put in for the next six
months.
★ Ways in which he had to develop his professional skills.
★ Plans he had to make to manage his time.
Once he jotted down everything in detail, he felt he would
be able to get his promotion in the course of the next few
months. Surprisingly, he found that he was not half as angry
as he was a few hours before.
What is it he can do before shouting in rage?
Anger produces a lot of energy. This force can be used constructively.
Physical activity is a healthy outlet for getting rid of anger. Active sports,
gardening or cleaning the house are alternatives for the release of pent
up energy. May be, he can go out for a small walk in the open.
Now he will be in a position to communicate. Improving the
communication with family members hNps in better understanding of
one another in the family, thus giving no scope for misplaced or
unrealistic anger. It is important for the couple to discuss their feelings
in an effort to arrive at a reasonable solution. If the husband or wife
has been accumulating anger without recognising it, this anger can
interfere with their communication and make it extremely difficult to
understand the real problem.
Given below are certain tips which can be followed by the chemical
dependent while making or receiving a complaint. The Counsellor can
ALCOHOLISM AND DRUG DEPENDENCY
80
educate him as to how these can be effective. To make it convenient
to use, the presentation is in direct narrative - as though the Counsellor
is directly talking to the recovering person.
While making a complaint
- Talk directly to the person who has hurt you. Direct eye contact
is a must.
- Talk to the person when he is alone.
- Make your ,complaint as earl^ as possible. Never try to postpone.
- Do not minimise or exaggerate the problem. Be descriptive and not
judgemental.
- Under no circumstance should you compare.
- Avoid using words like ‘always’ or ‘never’. This will dilute the
seriousness of the problem.
- Make only one complaint at a time.
- Do not sound apologetic. Do not use any preface to justify
your stand.
- Do not repeat a point once you have made it and the other person
has understood it.
- Compliment the person if you have anything to appreciate in
him. This will enable him to remain open to your criticism.
Appreciation and criticism should always be in the proportion of
atleast 2:1.
To give an example.
Ram was very hungry when he came home and expected a
good meal. To his utter disappointment, when he sat down
to eat, he found that food was not well prepared. He felt upset
and wanted to convey his feelings to his wife. He communi
cated properly, and at the end, his wife, Latha felt sorry for
the bad job done. Let us now see how Ram conveyed his
feelings effectively; let us also know how ineffective he would
have been if he had conveyed it the wrong way.
ANGER MANAGEMENT
81
Right way
Wrong way
“I am very disappointed... I was
eagerly looking forward to a
sumptuous meal.”
“You were so busy that you didn’t
have the time to cook well, is it?”
“Today curry is burnt; and sambar is
salty.”
‘T have dined so many times at
Rajesh’s house. You should learn
from his wife. How well she cooks!”
While receiving a complaint
- Make eye contact when you are being criticised.
- Listen carefully without interrupting at any point. Your motto
should be ‘Listen, Listen, Listen.’
- Do not find fault with the person who is criticising you.
- Do not rationalise or make use of your intelligence to cover up your
mistake.
- Communicate to the other person that you have understood his
point.
If anger is not recognised and ventilated properly, it will accumulate
in the same manner as pressure gets collected in the pressure cooker.
The safety valve prevents the cooker from bursting by releasing excess
pressure. Relaxation will prove to be a good safety valve for the angry
person. The chemical dependent has to find out what gives him peace
and balance, and resort to that activity every day atleast for some time.
This will prove to be an effective^ measure in releasing anger
positively.
Anger which is a strong impediment to recovery, can be successfully
channelised, if only the chemical dependent can be trained to identify
the cause of anger and see whether it is justified or not. Pent up anger
can be easily diffusea by taking up constructive physical activities,
relaxation methods and open communication. The Counsellor can
reassure him that proper recognition, understanding, and channelising
of this emotion can change his entire way of life, making it more
productive, more comfortable and more balanced.
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ALCOHOLISM AND DRUG DEPENDENCY
Additional information
Violence and chemical dependency
A certain percentage of chemical dependents are often the initiators
of violence within the family. Domestic violence is a crime that is
committed behind closed doors in the privacy of the family. It is a
problem that tends to be denied, tolerated or ignored by our society
which has always viewed abuse within the family as a private matter
rather than as a social problem. An effective method for handling
the issue of domestic violence is necessary. The guidelines given
below have been designed to help Counsellors in chemical dependency
settings deal more effectively with the problem of violence within
the family.
I
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Characteristics of abusive men
- Belief that men have more rights than women
- Low self-esteem. Afraid of losing the woman.
- Fearful of losing control. Possessive/jealous.
- Difficulty in identifying and expressing any feeling other than
anger.
- Total dependency on the woman. Few other support systems.
- Poor stress management and conflict resolution skills.
- Threat of suicide or homicide if woman leaves.
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Characteristics of battered women
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- Filled with fear of the abuser.
- Ashamed to let others know of the abuse.
- Feelings of guilt.
- Socially isolated. Lack of support systems.
- Low self-esteem; distorted self-image.
- Emotionally and often financially dependent on the abuser.
- Belief that men have more rights than women.
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ANGER MANAGEMENT
83
— Unaware of existing support services.
- Hope that violence will not happen again.
In the home of a chemical dependent, violence always takes place in
a particular cycle.
2
K
Guilt
3RemorsezJ
EXPLOSION
FIGHT
“HONEYMOON”PHASE
Anger Fear
“It will never
r happen again.”
1
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low self-esteem
<J[t:nsion builds
stress, frustration^---- y
poor communication
Cycle of Violence
1. Tension — Arguments, increasing criticism and building of stress.
2. Violence — ‘Tension release’ by batterer through physical violence/
or humiliation of the wife. Severity often increases in successive
cycles.
3. Honey-moon Phase’ — Marked by apologies, gift-giving and
promises. Initially, these are ignored by both spouses as violence
is viewed as a ‘freak event’.
In the course of time, the wife is able to see that violence does not
disappear with time. On the other hand, its frequency only increases.
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ALCOHOLISM AND DRUG DEPENDENCY
If so, what is it that can be done to help the battered woman?
Tue following is a list of the therapeutic issues that may be worked
on in counselling a battered woman.
Battered women find it very difficult to deal with emotions like fear,
anger, guilt, depression and grief. A special concern here is that of
suicide, as the overwhelming negative emotions felt by battered
women may result in suicidal thoughts and attempts.
★ These battered women would have had little chance to develop problem
solving/assertiveness/decision making skills. They are almost always
afraid of making decisions or standing up for their rights.
★ Many battered women are isolated, with few friends and no
information about helping institutions. Without the ability to use
available help, the task of rebuilding becomes strenuous.
★
Special tips for counsellors dealing with battered women.
★ Helping her to understand the cycle of violence, and the processes
that perpetuate violent relationships; information on how to
recognise potentially violent and destructive relationship patterns.
This will be very helpful for a woman who is trying to explore
whether the relationship can be saved, improved or must be ended.
★ Give supportive help and be willing to accept setbacks. The decision
of how to respond, is very complicated for the woman. So she may
move forward, then draw back. Reflect her strengths and fears and
deal with both.
★ Provide areas to explore to help build self concept, such as
accomplishments and personality strengths.
★ Help her explore options — therapy programmes, family help units,
emergency shelter, legal aid, employment possibilities — so that she
can consider plans realistically.
★ Women who have been battered by an alcoholic or a chemical
dependent will benefit from experience in Al-Anon or similar groups.
If addiction is the reason, they may need help in seeing all the
damages caused by chemical dependency, while still being aware
that this does not justify what has happened to them.
ANGER MANAGEMENT
85
Special tips for counsellors dealing with abusive men
• Make him understand his violence cycle.
• If he had been a victim of abuse in the past, these emotions should be
explained in depth. The family member who had been abusive should
be made to attend therapy sessions so that the patient forgives and
forgets the past which is important for his recovery from addiction.
• Make him realise that he has taken the role model of father or any
other significant person in his life. This helps in his recalling his
own bitter experiences of abuse in the past.
• Help him learn and explore alternative coping skills to deal with anger.
An implementation tool for the counsellor
Anger management during abstinence
A ready to use questionnaire for the patient
Chemical dependents state that one of the issues difficult for them to
cope with, is anger. Many attribute relapses to an inability to
constructively handle anger. Mismanaged anger can pose a threat to
sobriety; it can also lead to problems in relationship with others.
During the patient’s str y at the After-care Centre, the Counsellor can
- conduct group sessions on anger management
- express appreciation whenever the patient is able to resolve his anger
appropriately.
The following steps may help the patient learn to understand, recognise
and deal with anger in constructive ways.
Step - I
Recognise angry feelings
How does your anger show up? Look for anger clues.
1. Physical signs
a)
b)
c)
ALCOHOLISM AND DRUG DEPENDENCY
86
2. Psychological signs
a)
b)
c)
3. Behavioural signs
a)
b)
c)
•m
Step - II
Identify possible causes of your anger
Examine all the contributing factors related to your anger, by identifying
the situation which triggered your anger, who else is involved, and why
you feel angry at this particular time. List below the causes of your anger.
Step - III
Identify effects of your anger on your self and others
Examine your usual responses to your angry feelings.
For example:
a) Do you do nothing and allow anger to build up inside?
b) Do you shout at others and get into arguments or fights?
c) Do you try to ignore the situation or do you talk about your anger?
d) How does your method of handling anger affect you?
e) How does your method of handling anger affect others?
Step - IV
Decide on the best method of handling your anger
Decide first if your anger is really justified. It may be an over reaction to
a situation or a result of self anger which you misplace on others. If your
anger does not seem justified, try to talk yourself o at of it. What are the
methods you are going to adopt while communicating your angry feelings?
Bibliography
Anger — How to recognise and cope with it. By Leo Madow, M.D.
Published by Charles Scribner’s Sons, New York.
9__________________________________
UNDERSTANDING POWERLESSNESS
AND UNMANAGEABILITY
For a chemical dependent, true recovery from addiction starts with an
understanding of his powerlessness over his addiction and
unmanageability in almost all areas of his life.
What is powerlessness?
Understanding powerlessness over addiction is the foundation to
recovery from chemical dependency. A thorough understanding of
powerlessness must be solidly and firmly established; otherwise addiction
cannot be arrested.
We hear alcoholics say,
“If I can set right the problems in my life, I will be okay...
My only problem is my job. I am not getting promoted fast
enough. My boss is too prejudiced... My wife is too
demanding; too critical; the family does not understand me. ”
With such rationalisations, the alcoholic is failing to see his physical
and psychological powerlessness over addiction.
For a chemical dependent, there is a physical dependency on drugs.
He probably started drinking/using drugs to relax, to have fun, to be
part of a group, to be accepted. But now, a time has come when
his body has become so much dependent upon drugs that if he stops
using it, he develops severe withdrawal symptoms. He is totally
powerless over it.
Moreover, he is unable to exercise control over the quantity, time and
place of drinking/drug taking. He has reached a point where he cannot
keep away from drugs or control the amount consumed. Drug abuse has
become compulsive. He tries several methods to quit on his own — to
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ALCOHOLISM AND DRUG DEPENDENCY
give up drugs — not for ever, but for a specific period of time. He is able
to stay away from chemicals for a period of time he has set, a week,
a month or whatever — but then, his compulsion for drugs makes him
either shorten the period of time he has set for himself, or he is able
to abstain for the said period. In either case, after this stretch,
he inevitably goes back to obsessive drinking/drug use. He attempts
to change his drinking/drug taking pattern, to convince himself and
show others that he can start using again without experiencing the same
old problems. For example, the alcoholic changes drinks or shifts the
place and time of drinking. But no matter how many changes he makes,
if it is alcohol he is drinking, he is not able to exercise any control.
In short, he is powerless over alcohol.
The chemical dependent lives in compulsive slavery, as drugs provide
the only means he knows by which life is made bearable, or by which
he can quieten his jittery nerves. Reluctance to examine his physical
dependence is as much a symptom of his disease as liver damage, or any
of his other drug- related physical problems. As far as chemicals are
concerned, he has also developed psychological dependence. The urge
to repeat the experience of becoming high is so strong that he forsakes
many of his responsibilities and values. He has thrown away things that
are most important to him — his family, his job, his personal welfare,
his respect and integrity — in order to go after and satisfy the urge
to drink/use drugs. This further demonstrates powerlessness in his life.
Acceptance of powerlessness
Understanding and accepting powerlessness is a way to freedom.
The chemical dependent will be releasing himself from the insanity,
the morning shakes, the loss of respect and the loss of interest in
activities that have been important in his life. He will be able to get
over the physical problems induced by alcohol and chemicals on his
nervous system. He will not be subject to the moral deterioration and
the loss of regard for his individual value systems. He should ask
himself, “What am I really giving up?” — he is really giving up misery,
pain, discomfort and a fight for mere existence in life.
Social pressures centred on the myth that “Will power is all that is
needed to control a drinking or drug problem” can result in the chemical
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UNDERSTANDING POWERLESSNESS AND UNMANAGEABILITY
89
dependent’s unwillingness to accept his powerlessness. He should be
made to understand that he cannot exercise his will power, only with
regard to alcohol/drugs. In all other areas of life, he is absolutely
capable of being in control. He has the will power to put the rest of
his life back in order. He has absolute power to rebuild family
relationships, to excel in his job, to have fun and lead a productive
and meaningful life. So far as these areas are concerned, he could be
in control, provided he totally gives up drinking/drug taking.
Initially, it will be hard for anyone to admit that he is powerless. It is
infinitely difficult for the chemical dependent to admit that he is an addict.
But unless and until he does, he will continue to hit his head against
the wall, and his addiction will progress. Even to start recovering, it is
absolutely essential that this admission is made, totally believed and totally
accepted. It is the doorway to a new way of life — it means life itself.
When does the chemical dependent totally accept his powerlessness?
— when he is encumbered with too many problems which he is unable
to handle. He is afraid and feels terribly guilty. He slowly comes to
understand and accept he cannot exercise any control over chemicals.
With total acceptance, he feels relieved. He knows he suffers from a
disease and consoles himself saying that his problems were the result
of his addiction. Once he accepts his powerlessness, he is in a position
to take steps to resolve his guilt, shame, fear etc.
Helplessness is not hopelessness
The chemical dependent is helpless with regard to drugs. Helplessness
without hope could be utterly shattering.. But for him, there is, however,
lot of hope — a bright, shining hopfc, exemplified by thousands of
recovering persons around the world, whose recovery began when they
learnt and totally accepted that they had a disease. In other words, there
should be absolute recognition of the fact that he is powerless over drugs
and he will not be able to exercise any control over his drug use. In short,
there should be total acceptance.
The first essential part of recovery is to stop using chemicals completely.
If he begins to use again, he risks his health, his sanity and his life.
The chemical dependent who recovers is the one who has accepted
u
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ALCOHOLISM AND DRUG DEPENDENCY
himself as an addict. By accepting himself, he can change his own self
image from “drinker” to a “non-drinker”. It is necessary to go further
than to admit his powerlessness. He must completely, absolutely and
whole heartedly accept it (surrender). He must make it a part of himself,
just as the shape of his skull or the colour of his eyes. He will be able
to rebuild his life only if he accepts his disease and its permanence.
Accepting this, is not a sign of weakness. On the contrary, it is indicative
of one’s strength to be honest, realistic and to recognise one’s own
limitations. He will learn that he will not be able to adapt his life unless
he has a thorough, ongoing programme of recovery in the same way
as a diabetic or a heart patient has, to keep his disease in check.
Let us think about a person who has lost his leg. The leg is
completely severed and gone for ever. This person can do one
of the two things — he can tear himself apart wishing he had
his leg back, or he can face facts and accept the loss.
If he chooses the first way of dealing with the situation, he will
feel sorry for himself and resent people, who are walking on
both their legs. He will envy and hate them, curse his fate,
indulge in self-pity and drive himself to the brink of insanity.
In other words, he will not face reality.
The other option he has, is to face facts. He can tell himself,
<fI have to live the rest of my life with one leg. I cannot change
this fact; so I will accept it and make the best of it.”
By accepting it, he opens up ways of dealing with his problem.
He will learn to use crutches or an artificial leg and will be
able to get along and do things that make him happy.
The chemical dependent, like the amputee, has two options. He can
refuse to accept the fact that he is powerless over drugs. He can try
again and again, to use drugs with control. He will not succeed and
will end up in total destruction.
The other option is to accept himself to be totally helpless with regard
to chemicals. He can then go about living with hope and contentment
forgoing only chemicals. The chemical dependent can acquire physical
and mental health, gain respect and the ability to function as any other
efficient person. Actually, a recovering person can make his life infinitely
better, richer and more rewarding than he had ever believed possible.
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UNDERSTANDING POWERLESSNESS AND UNMANAGEABILITY
91
Unmanageability
Unmanageability is related to powerlessness. What helps the chemical
dependent to identify powerlessness, is taking an honest look at what
drinking or using drugs had done to him. Instead of living a free and
natural life, he is reduced to fighting for survival in life.
Addiction directly affects every area of his life, and he is unable to
manage anything properly.
Physical unmanageability
i
He develops physical problems and his body is affected. For an
alcoholic, the blood stream and body cells are first affected, then the
brain, as he compulsively substitutes alcohol for the nutrition necessary
for normal growth. Complications like gastritis, liver dysfunction,
polyneuritis and even cirrhosis occur. His physical deterioration is quite
obvious.
Emotional unmanageability
His emotions and behaviour get affected. He experiences extreme fear
and anxiety. He feels intensely lonely. There are moments when he is
totally depressed. He gets angry and frustrated for no proper reason
and shows his resentment towards others. In other words, he is not able
to exercise any control over his emotions.
Occupational unmanageability
In the area of job, lost hours and shirking responsibility are directly
related to the abuse of chemicals. He loses the respect of co-workers;
receives memos, and suspension orders. Sometimes, his drinking/drug
taking leads to his even losing his job.
Unmanageability in family relationship
There is a total breakdown in his family relationship. As a result of
the enormous problems experienced, there is lack of communication,
and lack of care and warmth from the family members. Children also
move away from him. Addiction results in torn family relationships.
ALCOHOLISM AND DRUG DEPENDENCY
92
Social unmanageability
This inevitably follows the act of drinking or taking other drugs.
He becomes aggressive, gets involved in fights and even displays anti
social behaviour. To give an example, there b little doubt that for
an intoxicated person driving his vehicle down the street, the situation
is unmanageable.
Financial unmanageability
As a result of uncontrolled drinking/drug use, the chemical dependent
is almost always unable to live within the available income. He borrows
from all possible sources and is unable to repay them. So far as finances
are concerned, he is totally ‘broke’ and his financial life becomes
unmanageable.
Legal unmanageability
Unmanageability is obvious in arrests for disorderly conduct, violent
fights and breaking of laws.
Recovery from addictioji, the disease which was responsible for his
unmanageable life, can be accomplished only when he stops using
chemicals and simultaneously makes changes to improve the quality
of his life.
How does an understanding of powerlessness
and unmanageability help?
★
It makes the chemical dependent honest in evaluating his true
physical condition.
★
It makes him humble so that he willingly stops rationalising and
promising that he can stop taking drugs, using his will power.
★
It awakens him to the need for getting help through treatment and
A.A./N.A.
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UNDERSTANDING POWERLESSNESS AND UNMANAGEABILITY
93
Additional information
An implementation tool for the counsellor to help the
patient understand his powerlessness and unmanageability
A ready-to-use assignment for the patients
If you have admitted to yourself, that you are powerless over alcohol
and other drugs, and that your life has become unmanageable, it is
possible that you are sad right now. Such a feeling of pain is normal.
It is important to talk over feelings you are having as you look at your
drug use. Talking about it, is part of accepting your disease.
Not knowing the cause and not having a permanent cure does not
matter. What matters is recovery.
Now that you know what the problem is, you can do something about
it. You don’t have to keep living in the mess your disease has created.
Your decision can lead to recovery. You are not alone. You don’t have
to set right your whole life at once. Recovery starts when you begin
to surrender to the fact that you are powerless over chemicals. You have
already begun. You have taken the first step.
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Acceptance of powerlessness
1. What was the drug you were regularly using?
2. What other drugs have you used?
a)
b)
c)
3. Do you keep a secret supply of money to buy drugs/alcohol?
4. What times of the day do you usually ‘get high’?
a)
b)
c)
ALCOHOLISM AND DRUG DEPENDENCY
94
5. Give examples of moments your mind was on chemicals when it
should have been on something else.
a)
b)
c)
d)
6. Have you ever tried to control your drug use, if so, when and how?
7. What happened each time? , *
a)
b)
c)
d)
Realisation of the fact that life has become unmanageable
Effects on the body
1. How many times have you passed out after using chemicals?
2. Do you have any disease which is caused by your drug use?
3. Did you suffer from sleeplessness, tremors or loss of appetite?
4. Has your drug use had any effect on how well you can solve problems
or concentrate on your work?
Effects on emotional life
1. Have you ever felt like committing suicide? If so, when?
2. Part of recovery is learning to know and talk about youi feelings.
Do you feel guilty or ashamed over any of your past actions? If so,
list them.
a)
b)
i
c)
d)
3. Even when people are around, do you ever feel intensely lonely?
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UNDERSTANDING POWERLESSNESS AND UNMANAGEABILITY
95
Effects on the job
1. Have you received warning letters/suspension orders from your
workplace? If so, how many times and for what?
2. How many jobs have you changed during the past 5 years?
3. Have you ever been asked to quit your job?
4. Have there been periods when you were unemployed? If so,
give details.
Effects on family life
1. Has your wife left you or ever threatened to leave you?
2. Have you ever suffered from lack of love/trust or rejection by your
wife/parents?
3. How do your children behave when you are around?
Effects on social life
1. How many friends have you dropped or drifted away from, because
they don’t use drugs?
2. Some other friends may have dropped you as your use grew heavier.
Who are the people who went away from you?
a)
b)
c)
3. List some names or terms people have used when they refer to
you? (which relate to your drug use).
a)
b)
c)
Effects on finances
1. List the number of times you had borrowed money and from whom.
a)
b)
c)
ALCOHOLISM AND DRUG DEPENDENCY
96
2. Go back to your days of drug use and figure out approximately how
much money you have spent on drugs.
Illegal behaviour
1. Have you ever been arrested? What is the reason?
2. Are there times you have done things you could have been arrested
for but you were not caught? List them.
a)
b)
c)
d)
Bibliography
1. The Foundation of Recovery — Step — 1. By William Springborn.
2. Henwood lecture series — September 1983.
3. Step-1 for young adults by Della Van Dyke and Jane Nakken.
A Hazelden publication.
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RELAPSE PREVENTION PLANNING*
Relapse and Recovery are closely related. A chemical dependent cannot
recover from addiction without experiencing a tendency towards relapse.
Relapse tendencies are a normal and natural part of the recovery process.
However, clear and accurate thinking helps to overcome relapse tendencies.
Recovery from chemical dependency starts with the acceptance of the
fact that the person cannot safely use alcohol or any other mood altering
chemicals. Abstinence from mood altering drugs allows the recovery
process to begin. Total recovery, however, requires much more than
mere abstinence. It is necessary to correct the physical, psychological
and social damages caused by addiction. It is also necessary to learn
to live a healthy and productive life without feeling the need for alcohol
dr other drugs.
Recovery from addiction goes through
distinctly defined stages
Developmental Period
Goal
1. Pretreatment
2. Stabilisation
Recognition of Addiction
Handling withdrawal symptoms and
,' Crisis Management
Recovery from Post Acute
Withdrawal
Balanced Living
Positive Personality Changes
Growth and Development
3. Early Recovery
4. Middle Recovery
5. Late Recovery
6. Maintenance
* RELAPSE’ and ‘RECOVERY’ are dealt with in great detail in our earlier publication, “Alcoholism
and Drug Dependency - The Professional’s Master Guide’’. This chapter will be more meaningful and
complete if it is viewed as an extension of the above mentioned chapters and read along with them.
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ALCOHOLISM AND DRUG DEPENDENCY
One of the major problems in recovery from chemical dependency is
relapse, or a return to alcohol or drug use after a period of abstinence
following treatment. The dependent must be made aware that relapse
is a distinct possibility which could happen to him. Recovery from
addiction is an ongoing process requiring both abstinence from mood
altering substances and a change in thinking patterns, attitudes,
behaviour and life style.
I
Recovery from addictive disease is not a
process of straight line growth*
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Recovery does
not progress like this!
It progresses like this!
There are certain specific problems experienced during abstinence.
When these abstinence-based problems become severe the person begins
to become dysfunctional even though he is not using chemicals.
These episodes of dysfunction constitute the Relapse Syndrome.
When these symptoms of the relapse syndrome make life painful, many
chemical dependents choose to use drugs to gain temporary relief from
the pain. Some others do not drink/take drugs; but develop serious
problems related to the relapse syndrome.
■
* Diagram reproduced from ‘Staying Sober’ by Terence T. Gorski and Merlene Miller
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RELAPSE PREVENTION PLANNING
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What are the problems experienced during
the initial stages of abstinence?
The relapse syndrome*
Internal and external dysfunction
- Thought Process Impairment
- Emotional Process Impairment
- Problems with remembering things
- High level of Stress
- Difficulty in sleeping restfully
- Difficulty with physical coordination
- Denial Returns
- Avoidance and Defensiveness
- Crisis Building
- Immobilisation
- Confusion and Over-reaction
Loss of control
- Depression
- Loss of Behavioural Control
- Recognition of Loss of Control
- Option Reduction
- Relapse Episode
Thus, relapse is not merely the act of taking a drink or using drugs.
It is a process or progression that creates an overwhelming need for
the use of alcohol or drugs.
* A close look at ‘Alcoholism & Drug Dependency - A Professional’s Master Guide’ will give better
clarity about the problems associated with Relapse Syndrome.
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ALCOHOLISM AND DRUG DEPENDENCY
What are the different stages in
the progression of reiapse?
The relapse progression*
Change
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Stress
‘
1
5
\
Denial
\
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Post Acute Withdrawal'
1
Behaviour Change
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Breakdown in Social Structure
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Loss of control of judgement
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Loss of Behavioural Control
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Option Reduction
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Acute Degeneration
1
Addictive Use
It is possible to interrupt the relapse progression before serious
consequences occur by bringing the warning signs of relapse into
the chemical dependent’s conscious awareness. This is Relapse
Prevention Planning.
The Relapse Prevention Plan includes educating the patient about the
relapse process and devising a plan to help him understand the warning
signs of relapse so that he can prevent a return to drug use.
* This is dealt with in great detail in ‘Alcoholism & Drug Dependency - The Professional’s Master Guide’.
(Reproduced from ‘STAYING SOBER’. A guide for Relapse Prevention by Terence T. Gorski and
Merlene Miller)
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RELAPSE PREVENTION PLANNING
The chemical dependent can be in a relapse before he actually uses
alcohol or drugs. It is possible to build up to a relapse over a period
of days, weeks or even months. Many alcoholics and chemical
dependents have reviewed their relapse experiences and identified clues
which preceded their return to the use of chemicals.
Relapse clues or warning signs may relate to changes in attitude,
thoughts, feelings, behaviour, or a combination of these. The dependent
should be made to understand that he must be on the alert when changes
occur so that he can avoid a return to chemical use. The following are
some examples of “relapse clues”.
1. Changes in attitude
- Not caring about sobriety
— Becoming too negative about life
2. Changes in thought
- Thinking that he “deserves” drugs because he had been sober
for quite some time.
- Thinking that he can use substitute drugs.
- Thinking that his problem is “cured” since he had been
abstaining for sometime.
3. Changes in feelings
- Increased moodiness or depression
- Strong feelings of anger and resentment
— Increased feelings of boredom and loneliness
4. Changes in behaviour
Increased episodes of arguing with others
“Forgetting” to take Antabuse
Skipping AA/NA meetings
Stopping in a bar just to socialise and drink soda or other soft
drinks
- Increased stress symptoms such as smoking more cigarettes
- Threatening to use drugs to have his way
- Talking repeatedly about the pleasures associated with chemicals
These are just a few examples. The important point to remember is
that negative changes in attitude, thoughts, feelings and behaviour
indicate that the relapse process is set in motion.
-
36^9—
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ALCOHOLISM AND DRUG DEPENDENCY
After the identification of warning signs, the chemical dependent should
be helped to explore healthier ways to replace them. He should be helped
to lower the risk of experiencing relapse through guided focus, structured
exercises, relapse prevention planning and contracts. Planning for
relapse prevention minimises its destructive potential. This planning will
give him a sense of security. He will be able to identify early warning
signs and develop a plan for interrupting the relapse syndrome if it
appears. Relapse Prevention Planning should be an essential part of
his recovery programme.
Various steps in relapse prevention planning
★ Stabilisation
‘T must get back in control of myself and my behaviour.”
Stabilisation is the method of regaining control over thoughts, emotions,
judgement and behaviour, when a person is in the relapse process.
This will be a time of crisis for him and his family. He may feel
frightened, angry, disappointed and guilty. At this point he needs help.
Vitamins and other medicines to help him regain his normal physical
health may be his immediate requirements in the process of getting
physically stabilised. This is the time the Counsellor could reassure him
and help him take necessary steps to re-establish his sobriety.
★ Assessment
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“I must find out with the help of others, what is causing my
relapse episodes.”
The second step in Relapse Prevention Planning is to identify the factors
that set his relapse in motion. This can be traced by reviewing his history
of addictive use, as well as finding out the specific warning signs that
occurred during each period of attempted abstinence. This information
will provide valuable clues as to what went wrong and how it can be
rectified to improve chances of the dependent’s permanent sobriety.
Suraj, 40 years old, was running his own departmental stores.
He underwent treatment for his alcoholism. He was
responding well during the initial phase and maintained
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RELAPSE PREVENTION PLANNING
abstinence for one year. After 12 months, he went back to
drinking again. He was again detoxified and treated. This one
year mark became his relapse pattern. On the third year, after
three relapses, he started thinking - ((My God! what is
happening to me? Why is it I am not able to abstain? I should
definitely do something about this. ”
He approached the Counsellor and an open discussion and
analysis revealed that his drinking was triggered by the stress
he experienced during every ‘year-end* on the period of closing
of accounts. Now that he identified the episode which caused
his return to drinking, he was able to work out a practical
plan with the help of the Counsellor and start implementing
it straight away.
★ Relapse Education
“I must learn about the process of relapse, and methods to prevent it.”
The more information the chemical dependent gets about addiction,
recovery and relapse, the more tools he will have to maintain sobriety.
He has to understand post acute withdrawal symptoms, what puts him
in high-risk of developing them, what might trigger them and what it
takes to prevent or manage them. The Counsellor should help him
review and apply this information. The education programme will be
complete only when he is capable of honestly and openly applying
information to his own life and his current life circumstances. Addiction
is a disease of denial; and his denial may prevent him from recognising
what is really happening to him.
Lakshmanan was a 35 year old ganja addict with a history
of heavy drug taking and related problems for the past 8 years.
He had been hospitalised quite a number of times and
participated in many recovery programmes. While reviewing
his relapse history, he stated that he usually built up to
drug taking over a period of about 5 weeks. His relapse
clues included
1) Decreased interest in taking care of his nutritional needs
which was evident when he skipped breakfasts and dinners.
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ALCOHOLISM AND DRUG DEPENDENCY
2) Increased thoughts of smoking ganja such as (tI can have
a few puffs. ”
3) Stopping in the den where he used to smoke ganja in order
to “see old friends. ”
The following relapse prevention plan was devised by Lakshmanan with
the help of the Counsellor.
★ When I notice that my food habits are changing, I must
find out why this is happening and whether something is
bothering me which needs attention.
★ I must see my Counsellor/N.A. sponsor to review my
current feelings.
★ I must go regularly to gymnasium to regain my physical
fitness.
★ I must write in detail why stopping in the den is not in
my interest.
★ I must review the benefits of sobriety which I have already
written, in order to reinforce the importance of my recovery.
★ Warning sign identification
“I must make a list of my personal relapse warning signs.”
Relapse warning sign identification is the process of identifying the
problems and symptoms that can lead to a return to chemical use.
Problems may be situations outside of the chemical dependent or within.
Symptoms may be health problems, thought problems, emotional
problems, memory problems or problems with judgement and behaviour.
It is necessary for the patient to develop a list of personal warning signs
from past relapse experiences. He should be helped to develop a list
of clear and specific indicators that denote that he is beginning to move
towards drug use again.
Anil, 50 year old, alcoholic, widower, employed, has had sober
periods upto 2 years. However, since his wife died, he had
been drinking very heavily with only short periods of
abstinence. His high risk situation was his painful memories”
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RELAPSE PREVENTION PLANNING
105
of his wife’s untimely death and related feelings of sadness
and depression. Anil usually experienced these memories and
feelings on certain holidays, the anniversary of his marriage,
and sometimes during the weekend when he was at home
all alone.
In working out his relapse prevention plan, Anil decided to
utilise professional counselling to assist him in working
through his sadness, depression and grief. Should painful
memories or feelings regarding his wife make him feel like
drinking alcohol, he will discuss these immediately with his
Counsellor/A.A member or his sister. Prior to the holidays
and other times associated with his negative feelings, he
decided to make plans to become more active in A.A. and
visit his elder sister and her family and take their children out.
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★ Warning sign management
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“I must have concrete plans to interrupt the warning signs before
I lose control.”
Addiction is a disease with a tendency towards relapse. Once the
chemical dependent knows and accepts that fact, he can plan for the
inevitable. Each warning sign is a problem he has to solve once it occurs.
He will need to review each warning sign and answer the question,
“How can I prevent this problem from happening?”
The chemical dependent should keep a daily record to review his
recovery process and monitor for relapse warning signs. This will help
him see whether he is making progress in his recovery. Just knowing
what the warning signs are, may not necessarily help him. It is essential
for him to establish new responses to the identified warning signs.
He has to be guided to determine what he is going to do when he
recognises a specific warning sign which shows itself again and again
in his life. He should be helped to get clarity on the following questions:
“How can the relapse syndrome be interrupted?”
“What positive action can I take to deal with the warning sign?”
He should list several options or possible solutions for tackling these
problems in his life. Listing several alternatives will give him better
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ALCOHOLISM AND DRUG DEPENDENCY
chance of choosing the best solution and provide him with alternatives
in case his first choice does not work. The chemical dependent should
be made to understand that he has to practise each new response until
it becomes a habit. If the new response is to be applied in times of high
stress, he can practise it in times of low stress. If the new response fails
to interrupt the warning sign, he has to establish a more effective plan.
He cannot afford to put off developing a plan to interrupt his warning
signs as and when they occur. If he does not have a ready plan, he will
not be able to interrupt any warning sign at all.
Here is a chart prepared by Madhan, a recovering addict.
Warning signs
Management techniques
Meeting a drug user
Immediately leave the place and
meet an N.A member
Get involved in activities like
going with the children for a
walk
Visit a temple
Get something to eat
Postpone use of drug till the
next day
This method can be renewed
again the following day
Go through the already
prepared list of all the bad
things that happened during my
active drug taking days
Think of how good I feel and
how people respect me when I
do not use drugs
Think of slogans like “Easy
does it” or “This too will
Loneliness
Boredom
An urge to take drugs
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RELAPSE PREVENTION PLANNING
107
★ Inventory Training
“I must do an inventory twice daily, so that I can notice the first warning
signs and correct the problems before they go out of control.”
Any successful recovery programme involves a daily inventory. This is
necessary to help him identify relapse warning signs before his denial
gets reactivated. Any relapse warning sign is serious because it can be
the first step towards his getting back to drug use. Without a daily
inventory, the chemical dependent is likely to ignore early warning signs,
and then be unable to interrupt the relapse syndrome when it
becomes obvious.
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The chemical dependent should be helped to develop a way to
incorporate this inventory system into his day-to-day living. In order
for the daily inventory to become a habit, the establishment of two daily
inventory systems can be recommended to him. The first can take place
in the morning. He should plan activities for the 24 hours of that day.
He should ask himself whether he is prepared for that day and what
action he is going to take to physically and emotionally meet the
challenges of that day and maintain sobriety.
The second inventory can take place in the evening. Now he has to
review the tasks he had undertaken and identify those which he handled
well and those which needed improvement. He can list the strengths
he displayed in meeting the challenges and find out methods to reinforce
and build upon his strengths. He can also think about his weaknesses
and find out methods to overcome his shortcomings.
L
Arjun, a 35 year old employed man, got treated for his
alcoholism. Six months after completing the programme, four
of his old friends’ came to meet him. In the course of
conversation, one of them suggested that they go on a picnic
to a nearby place on the New Year eve. Arjun was immediately
thrilled with the idea and enthusiastically said he would join
them. When they had left, after about an hour, he suddenly
realised he was getting into their trap. “My God! How silly
I have been! Their only source of enjoyment is drinking.
How is it that Iforgot about it and got thrilled with their idea!
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ALCOHOLISM AND DRUG DEPENDENCY
No! 1 will not go. If I go, I may not be able to resist the
temptation of drinking. He decided to inform them that he
would not be able to accompany them. How could he do it?
He thought of a few ways.
— State straight out that I have a problem with alcohol.
— Politely refuse to come, without giving any explanation.
— Offer an alternative activity. For example tell them ‘"I am
not drinking, let us enjoy going to a temple.
He finally decided that the second option was the best and
immediately rang them up and politely declined their offer.
★ A review of the recovery programme
“I must review my current recovery programme to make sure that I am
managing my warning signs well.”
4
The Counsellor can help the chemical dependent find out whether his
previous recovery programme had been working for him or whether
it can be improved upon. For every problem, symptom or warning sign
that he had identified, he should ensure that there is something in his
recovery programme to help him cope with it.
★ Involvement of significant others
“I must get feedback from others as to whether they are able to identify
any warning signs of relapse in me.”
It is not possible for a chemical dependent to recover in isolation. Total
recovery involves the help and support of a variety of people. As the
relapse process, sometimes happens at the unconscious level, in spite
of the daily inventory, the chemical dependent may not be able to see
what is actually happening to him. That is why it is important to involve
other people in Relapse Prevention Planning. Family members, co
workers and fellow AA/NA members can be extremely helpful in
recognising warning signs.
Sometimes people even when they recognise the warning signs, may
find it difficult to tell the recovering person that he is relapsing. They
may be afraid that in case they openly tell him, he will become angry
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RELAPSE PREVENTION PLANNING
109
and show his resentment by drinking. They will be more comfortable
in informing the Counsellor so that the Counsellor, in turn, tells the
patient without arousing his resentment. In order to facilitate this, the
Counsellor may hold weekly meetings with the family members and
other significant people so that they openly discuss the relapse warning
signs which they have observed in the chemical dependent.
The chemical dependent must be made aware that he should allow the
network of significant people to participate in his recovery. He should
encourage them to verbalise their feed back as to whether he is showing
any warning signs.
★ Follow-up and Reinforcement
“I must revise my Relapse Prevention Plan as I grow and develop in
my recovery.”
Chemical dependency is a life long chronic condition; and recovery
from addiction is a way of life. Since Relapse Prevention Planning
is a part of recovery, it too must become a way of life. This
planning should be integrated into his entire life, and must be
compatible with AA/NA and other support groups he is using to
maintain sobriety.
The recovering person has the freedom to carefully choose methods
that will help him grow and develop. He must be willing to revise and
update his plans at regular intervals and be willing to recognise new
problems that pose a threat to his sobriety. In short, Relapse Prevention
Planning is a process that should become an integral part of his recovery.
For him, the outcome will be freedom'to’enjoy a comfortable sobriety
and assurance that he has an action plan to manage any warning sign
if it develops.
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ALCOHOLISM AND DRUG DEPENDENCY
Additional information
A model relapse prevention planning programme
Following is a treatment model which allows the Counsellor and
client to recognise forces that maximise the potential for recovery.
This can be done by
- obtaining information about the patient’s current level of functioning
- identifying positive and negative forces in relation to sobriety
- identifying problems and developing goals
- treatment strategies
- evaluation
This model is applicable within any treatment facility where there is
an emphasis on individualised treatment planning.
Bharath, a 25 year old electrician, married, had problems with
Brown Sugar for the past 5 years. His drug taking was stress
related and occurred when peers were around. Bharath s wife
refused to allow him to live in the house when he was using
drugs. During those days, he stayed with his old drug taking
friends’. Bharath recognised his problem and got admitted
in the After-care Centre since he wished to achieve sobriety
and was afraid of losing his wife. After discharge, Bharath
had several periods of abstinence ranging from 3 to 6 months
with N.A. participation.
Recently, Bharath had some problem at the office which
demanded overwork and this caused stress. As a result, he
could not attend N.A. meetings. When he met one of his drug
taking friends’, he was almost on the verge of going back
to drugs. He immediately consulted the Counsellor at the
After-care Centre to prevent a relapse.
Obtaining Information
The purpose of this step is to gather information about the chemical
dependent in order to assess his current level of functioning. A compre
hensive assessment is obtained by gathering information about
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RELAPSE PREVENTION PLANNING
Ill
the client’s behaviour in different areas — emotional, environmental,
family, vocational, physical and interpersonal.
»ii <, > it
Such information can be obtained through interviewing, psychological
testing etc. In this case, the counsellor should spend time with Bharath,
his wife, parents and employer. During this process, the counsellor
establishes a therapeutic relationship with Bharath and explains the
purpose of obtaining this information. Once this information is
obtained, Bharath and his counsellor will begin to organise information
into a system that allows them to understand the impact of various forces
on his sobriety.
Identifying positive and negative forces
in relation to sobriety
<
Forces are feelings, thoughts, needs or behaviour of the chemical
dependent and/or in the person’s environment which enhance sobriety
(positive forces) or those forces which jeopardize his sobriety (negative
forces). It is necessary to understand these forces operating for or against
a client so as to maximise successful rehabilitation outcome. Once these
forces are identified, positive forces can be strengthened to facilitate
sobriety; negative forces may be weakened to enhance the person’s
potential for achieving sobriety.
A review of Bharath’s experience indicates the following
positive and negative forces:
Positive
Negative
Previous N.A. participation
.Difficulty in handling stress
Previous periods of abstinence
Drug-taking influenced by peers
Recognition of the drug problem
Desire to achieve sobriety.
Identifying problems and developing goals
When each problem is clearly stated, specific goals can be formulated.
The following format which can be applied to each significant force,
is presented as a guide for the development of problem statements, goals,
and counselling activities.
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ALCOHOLISM AND DRUG DEPENDENCY
112
Let us examine Bharath’s case.
Problem statement
Bharath did not maintain and follow through his N.A. meetings.
Force which can
bring about the change
Goal
Counselling activities
«
Previous N.A.
involvement
Bharath will become reinvolved
with N.A. on a regular basis.
a) Explore with his help,
previous involvement with
N.A. and the nature of
assistance he gained from it.
b) Discuss with Bharath the
reasons why he stopped
going to N.A. meetings.
c) Help him identify a sponsor
in N.A.
d) Discuss with Bharath the
number of weekly N.A.
meetings he feels he needs
to attend.
e) Explore with Bharath
reinforcers which would
assist him in following
through with N.A.
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Treatment strategies
xix^ purpose ofr this
-1-1- -l-J
The
step is to identify strategies so that the goal is
accomplished. These strategies should be realistic and attainable.
In Bharath’s case, the following can be the treatment strategies.
a) Meet Bharath twice a week for individual sessions to explore
goal areas.
b) Establish a written contract with Bharath for his weekly
attendance of N.A.
RELAPSE PREVENTION PLANNING
113
c) Talk with Bharath’s wife and parents to determine their
interest and willingness to attend Al-Anon and Family
Counselling sessions in order to increase their understanding
of how to help Bharath.
Goals and treatment strategies need to be established to address his
stresses. It will be helpful to involve him in group therapy sessions.
After Bharath has established a stable period of sobriety and
his wife has received help for herself, marital counselling
may be necessary to improve their communication and
support system.
Evaluation
The final step evaluates the process and outcome of the assessment,
goal setting and treatment planning. The following questions may be
used as an evaluative measure to assure the comprehensiveness and
quality of treatment efforts.
1) Is the assessment information comprehensive, and clear?
2) Have all the positive and negative forces been identified?
Are those the correct forces?
3) Are the specific problem statements, goals, and counselling
activities for each force realistic and attainable?
4) Have effective treatment strategies been outlined to
accomplish goals?
This model allows the Counsellor and client to become actively involved
in a process to maximise the potential fpr recovery. This process includes
identifying the forces, enhancing sobriety and the forces jeopardizing
sobriety, and utilising the counselling process to develop action plans
necessary to increase and decrease appropriate forces. This Relapse
Prevention planning model can be easily integrated into the existing
treatment structure of any After-care treatment facility.
ALCOHOLISM AND DRUG DEPENDENCY
114
An implementation tool for the Counsellor
Following is a tool which can be effectively used by the Counsellor when
he is guiding the chemical dependent towards relapse prevention.
The purpose of this questionnaire is to help the chemical dependent
understand relapse as it relates to his situation. This will
★ Provide him information on important topics related to relapse.
★ Give him some practical ideas which will help him minimise the
chances of relapse.
★ Help him take responsibility fon identifying specific high risk relapse
factors which could lead to his abuse again.
★ Help him begin to make specific prevention plans based on his life
situations.
Following are questions, which the Counsellor can ask the chemical
dependent to answer, so that he is assisted in devising his own relapse
prevention plans.
I. Understanding the relapse process
If you have experienced a period of recovery in the past, prior to a
relapse, answer the following:
1. What specific clues or warning signs preceded your relapse?
a)
b)
c)
d)
e)
2. How much time lapsed between the emergence of relapse clues and
the actual use, of alcohol or drugs?
3. If these warning signs were to occur again, what specific steps will
you take to prevent a return to drug/alcohol use?
a)
b)
c)
d)
e)
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RELAPSE PREVENTION PLANNING
IL Identifying and managing the warning signs
During recovery, especially during the initial stages, it is very
common to experience an uncontrollable urge to use alcohol or
drugs. Have you experienced such urges? If so, think over and
answer the following:
1. What triggered your urge to take alcohol/drugs?
2. What was the physical discomfort which made you think of going
back to drinking/drug use?
3. Describe briefly your mental condition which triggered your thought
of drinking/drug taking again?
4. List the specific steps you have decided to take from now on to
prevent a return to alcohol/drug use.
a)
b)
cy
d)
III. Involving significant others
It is difficult to achieve sobriety without the help of others. Therefore
it becomes essential to get others seriously involved in your Relapse
Prevention Planning. Have you planned such a network? If so, answer
the following:
1) Who are the sponsors you have identified?
2) Are those significant people aware of all the relapse warning signs?
3) In case they identify any warning signs in you, what is the method
by which they are going to bring it to your notice?
J
Bibliography
1. Counselling for Relapse Prevention by Terence T Gorski and Merlene
Miller, Herald House — Independence Press.
2. Alcoholism Treatment Quarterly, Volume 1, No-4, Richard C
Washousky, Patricia Muchowski-Conley, Donald E Shrey, Winter
1984, published by Haworth Press Inc., Binghamton NY 13904.
3. Staying Sober A guide for relapse prevention by Terence T. Gorski
and Merlene Miller, Herald House, Independence press.
I
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ADDICTION — ITS IMPACT
ON THE FAMILY
Addiction is a ‘family disease’ in every sense of the term. Treatment
professionals should recognise that addiction cannot be treated in
isolation; improving patient’s relationship with wife and other family
members is an essential element in treatment.
Parents, wives and sometimes even children believe that it is their duty
to try to control the chemical dependent, and stop his use of drugs.
This results in those involved in close relationships becoming as
preoccupied with the individual, as he is with drugs. When those who
have concern for the patient ‘cover up’ for him, they unwittingly enable
him to progress further into the disease by becoming his care-takers.
Addicted people take advantage of the vulnerability of their families
or friends, and manipulate them. Without that protective support
system, they would not be able to continue with their drug use and
survive. When the wife or parent covers up, pampers, pays back the
debts, pretends nothing traumatic has happened, she does it because
she wants to protect the dignity of the family and also because she does
not want that person to be upset. She does not want to rock the boat
in case it provokes the use of more drugs. Unknowingly, by doing this,
she is allowing the dependent to continue behaving in an irresponsible
way and endorsing what his denial system is already telling him —
that the situation is not that bad.
The family’s reaction to the chemical dependent
In coping with the tension and confusion which surrounds the disease,
the family members experience feelings and display behaviour patterns
similar to the chemical dependent’s. The family members sometimes
let their preoccupation with the chemical dependent cause pain to
themselves and destroy their lives.
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ADDICTION — ITS IMPACT ON THE FAMILY
117
Denial
The family of the chemical dependent deny the existence of the problem
in order to avoid humiliation and embarrassment. What is obvious to
others, is flatly denied by those who live on intimate terms with the
dependent. The family becomes quite adept at shielding the dependent,
making excuses for his behaviour, helping him out of tight spots,
covering up for him with his employers and others. To the outside world,
the wife or parent acts as though every thing in life is normal. They fail to
see their own dependency — their dysfunctional behaviour. The mini
mising and rationalising of the family member is often deeply ingrained
and truly believed — ingrained and believed in much the same way as
the minimising and rationalising of the addicted person. As a result,
the family member protects the person, denies that the relationship is
troubled, and denies the addiction of the person to whom she is attached.
They try to cope with the pain and trauma by putting up a brave front.
But inside, they are torn apart with the agony of shame, despair, fear
and a feeling of worthlessness. Even to themselves, they may minimise
the extent of the problem. The chemical dependent may be abusing his
family while under the influence of drugs; yet, the parent or wife
reassures herself that “things are not really that bad” or “I don’t think
he has become addicted, yet.”
Blaming
Unfortunately, the family members start blaming each other. Very often,
the chemical dependent, who is trying to take the focus off himself,
uses the situation to his advantage and sets one family member off
against another. For example, he may tell his mother that he is using
drugs because he is unhappy in his marriage. He may say that his wife
nags him continuously and he can’t stand it. To his wife, the same person
complains bitterly about his domineering mother who never made any
effort to understand him as a child and sent him away to a boarding
school. This results in more pain and tension in the family because the
two women start blaming each other for his addiction. In so doing,
the family is kept f-om coming together and addressing the most
important issue of how to help the chemical dependent recover from
the disease.
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ALCOHOLISM AND DRUG DEPENDENCY
Preoccupation
The preoccupation of family members with the chemical dependent is
similar to his obsession for drugs. Their entire thinking revolves around
the dependent and they forget to take care of their needs. Their lives
are modified to suit the needs of the chemical dependent. Acute stresses
drive the wife or parent to some behaviour or activity which she
compulsively performs. For example, she may be tracking down the
movements of the dependent all through the day, even though she might
be aware that by doing this, she could not control his drug use.
Her compulsive preoccupation drives her to waste her energy in
unproductive ways, and the result is that she fails to perform her duties
like cooking, looking after the children etc. She finally ends up in a
self-destructive trap, controlled and manipulated. She tries all possible
methods to make him give up drugs. But none of the methods work.
Worry takes over the family — worrying about over dosing, about his
physical health, about his being caught by the police and about what
to expect next. Family members become so tense, afraid and angry that
they begin to question their own sanity.
Bargaining
Bargaining also comes into play as the wife and parents try to cope
with this threat that has invaded their home.
<(I will do whatever you want if only you quit smoking ganja.
I will ring up your college and tell them that you are sick,
provided you stop using ganja from now onwards.”
The goal of bargaining is to offer the chemical dependent something
in return for his desired behaviour. But such bargaining does not work
at all. Instead, it leads to their frustration and depression.
Depression
Eventually after so many promises, bargains and perhaps even sober
periods which have raised hopes and expectations, only to have them
dashed repeatedly in new rounds of drug taking, those who are closest
to the chemical dependent may plunge into depression, a feeling of
ADDICTION — ITS IMPACT ON THE FAMILY
119
complete and utter hopelessness — “Is there no answer to the problem?’’
This is the stage that may be entered any number of times during one’s
relationship with the chemical dependent. The family may suddenly
realise that loss of income and consequent problems are imminent or
they may be saddened by the thought that his health is deteriorating
and death is more or less inevitable.
i
Suppressed anger
The wife/parent’s efforts to control the chemical dependent do not pay
off. And as attempts to control increase, the dependent becomes less
and less controllable and she feels frustrated and angry.
i
She suppresses her anger. As time passes, her mind becomes a storehouse
of pent up memories, hidden resentments, hurt feelings and unresolved
conflicts. Eventually, the chronic stress of unresolved emotional hurts
become manifest in serious health problems — ulcers, hypertension,
heart disease, etc. Her energy and vitality diminish.
Her repressed anger leads to a temper that explodes over trifles, frequent
feelings of disappointment in others and a feeling of being let down.
She avoids relatives and friends. Suppressed anger does not protect,
it does not make life run more smoothly. On the other hand,
relationships become more difficult to handle. It destroys everything
that the family hopes it will protect.
Isolation
Living with a chemical dependent,can be a very lonely existence.
The wife and parents believe that no one else would understand their
problem and that no other family has been through such pain and
conflict. Repeatedly hurt and rejected, she has learnt to keep sensitive
feelings inside. She keeps herself cut off from all sources of potential
support. The result is that her loneliness increases and gets intensified.
With loneliness and isolation, come fear and anxiety. She feels totally
powerless. Yet she compulsively tries to handle all situations. Feeling
the need to take charge, and at the same time feeling powerless, she
lives with a great deal of ambiguity, uncertainity and fear — fear of
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ALCOHOLISM AND DRUG DEPENDENCY
abandonment, loneliness, and rejection. As a result of these feelings
of alienation, of low self-esteem, together with the lack of
communication and bitterness in the family, the family members feel
deeply alone.
Change of Personality
The disease of addiction can bring about changes in the personalities
of members of the chemical dependent’s family as well. People who
had been loving, tolerant and patient, suddenly find themselves
becoming aggressive and bitter as they struggle to cope with addiction.
Many parents and wives have coped with difficult problems in life, yet
the traumatic experience of living with the addicted individual leaves
them depressed, disorganised and disillusioned.
Co-dependency of family members
As a result of living in a problematic environment, the family members
unconsciously develop ‘co-dependency behaviour patterns’.
What is co-dependency?
“Co-dcpcndcncy is a specific condition that is characterised by
preoccupation and extreme emotional dependence on a person.
Eventually, this dependence on another person becomes a pathological
condition that affects the,co-dependent in all other relationships.
Sharon Wegscheider-Cruse.
The family members of the chemical dependent become preoccupied
with trying to sort out his life in a meaningful way. In many respects,
their frantic efforts to change the chemical dependent become as
compulsive as the behaviour of the dependent person. “Co-dependency
is a pattern of living, coping and problem solving created and maintained
by a set of dysfunctional rules within the family system. These rules
interfere with healthy growth and make constructive change very
difficult, if not impossible.”
Co-dependents suffer from a set of emotional problems. Their strategies
of minimising, protecting, controlling, bargaining, appealing are classic
ADDICTION — ITS IMPACT ON THE FAMILY
121
coping reactions to the chemical dependent’s maladaptive behaviour.
The co-dependent suffers from
- Difficulty in accurately identifying and expressing feelings.
“I decided not to get angry when he entered home. But I could not
help shouting. What is wrong with me? Am I going crazy?”
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- Difficulty in maintaining close relationships.
“I know I’ll feel lighter if I share my problems with my mother.
But I am unable to open up!”
- Unrealistic expectations for self and others.
“Somehow or the other my son should get into a professional
college. I don’t know how he is going to do it! But he can’t afford
to let me down. ”
- An exaggerated need for others’ approval in order to feel good.
“My friend said, ‘You must be a saint. I don’t know how you put
up with him. If I were you, I would not have tolerated him.’I should
live upto this image. ”
- Difficulty in making decisions.
“I need a change. I want to go to my parents’ place for just one
evening. Should I go? Is it right? My God! I am unable to decide. ”
- Anxiety about making changes.
“I have got a/ >b. I need money. Should I accept it? Will I be able
to go? I’m scared. ”
- Feeling responsible for others’ behaviour.
“He is going out. He may stdrt drinking again. I should send
someone to watch him.”
- Fear of abandonment.
“What can I do if he leaves me and goes out of the house?”
- Avoidance of conflict.
“He has hot given me any money this month. How am I going to
manage? Anyway I’ll not ask him. He may get upset and start using
ganja again. ”
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ALCOHOLISM AND DRUG DEPENDENCY
- A sense of shame and a low self-esteem.
“Icannot talk well. I’m inefficient. I don’t want to meet anyone.
Co-dependents appear to be self-sufficient, strong and in control of
their lives. But beneath the public image of strength and security, often
lie the opposite feelings of insecurity, self-doubt and confusion.
Thus, the people who are close to the chemical dependent do suffer
a lot due to his addiction. Although the chemical dependent experiences
emotional turmoil, his awareness is numbed by the drugs he has
in his system. On the other h'and, family members have to bear
the pain of reality. So they really need a lot of help, support and
understanding.
Help for the family
During recovery, the family members should be made to feel the need
to detach themselves from the problem which had all along been the
sole focus of their lives. If they want peace of mind, they have to be
prepared to work through this process. They will find it a great relief
when they stop denying the problem and pretending all is well. In course
of time it will help both the dependent and the family member if they
start facing the problem by doing the following.
— Stop trying to convince themselves that “if only he decides, he can
always give up drugs.” They have to accept that it is a serious
problem which requires professional help.
— Start talking calmly and factually to the chemical dependent about
his drug use and subsequent behaviour when he is drug free.
The more open they are, the more uncomfortable they will make
him feel, about his use of drugs. He should be made to understand
that he has a disease and that he can recover.
— Start communicating honestly and openly to the other members in
the family about their concerns.
— Start accepting that they are not alone; they have choices and they
need the support of Al-Anon and similar self-help groups to cope
with the problem. Self-help groups will help them find ways of
changing and building up their self-esteem.
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ADDICTION — ITS IMPACT ON THE FAMILY
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- Start looking after their own needs and the needs of their children.
They should realise that they have to start doing their duties which
they have neglected so far.
- Identify positive methods of diversion like going to temple, spending
time with children, pursuing hobbies etc. Good experiences will give
them the energy to face problems.
- Plan one day at a time and start executing their plans.
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Problems experienced during recovery
Recovery of the chemical dependent brings a great deal of joy to
everyone concerned. The family members may hope that life is going
to take a turn for the better at once. They may feel that all their tension
will disappear. In a supportive environment, the Counsellor should make
them understand that it would be very unrealistic to expect that
everything is going to be wonderful immediately. They should be made
aware of the fact that there are certain problems which they may face
during the patient’s recovery. An understanding will help them handle
the problems effectively.
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★ During recovery, it is possible for the family members to experience
great relief over his abstinence and yet miss the old, familiar life
style. Although it was painful, there had always been some
predictability. They knew how he was going to behave, what
situations they would be required to handle, etc. But now the
recovering person is likely to be more independent and more
demanding. This can leave family members resentful. All along, the
chemical dependent would not have reacted to anything happening
at home. Now he may expect his wife to make tasty dishes, keep the
house clean, help the children in their studies etc. The family may
not be able to view his expectations as justified.
★ Friends and relatives would all along have admired the tolerance
of the family member and would have praised her for bearing the
brunt all alone. When the chemical dependent stops taking drugs,
the positive comments are likely to be transferred to him. They may
even pick on her. “Now that he has given up drugs, why don’t you
be more understanding? Why do you unnecessarily get angry and
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ALCOHOLISM AND DRUG DEPENDENCY
shout like this?” These remarks hurt them and it is very common
tor the close family members to experience extreme bitterness and
resentment, especially if they had coped with addiction by
suppressing all their feelings.
★ Certain actions that would not stir a second thought if displayed
by others, may set off alarms in the minds of loved ones when
exhibited by the recovering person. It is virtually impossible for the
family not to harbour doubts when, for example, they find some
cash missing or when they fin'd the recovering person moody, tired
or notice him remaining extra long behind a locked door or getting
phone calls at unusual hours.
★ The family members may treat the recovering person as a
“brittle doll”. This is the result of a continuing fear and a
prolonged belief that anything they might say could cause conflict
and make him go back to drugs. To give an example, the recovering
person may come home in an autorickshaw. His mother may feel
that he need not extravagantly spend money like that, when they
could ill afford even the basic necessities. But she will not open her
mouth for fear that it might upset her son, and he might get back
to drugs. As a result, there is no communication, no clarity of roles
and they work according to his expectations because they are afraid
of upsetting him. There is no chance of mutual trust developing
in this kind of relationship because it continues to be dominated
by fear. On the other hand, it will only result in lot of stress
for the family.
★ Family members may continue to have a resentment towards the
patient tor being a drug abuser. Brothers may have a negative
attitude towards the patient and criticisim is likely to flow freely.
Repeated remarks about money wasted on drugs and on treatment
will be voiced by family members.
★ After many years of embarrassment and humiliation, the family may
have few outside interests or friends. All other adjustment problems
will be intensified by the family’s lack of social contacts and
shared pleasures.
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ADDICTION — ITS IMPACT ON THE FAMILY
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125
★ Family members will find it very difficult to listen to the recovering
person or relate to him in a meaningful way. Even though he may
be making positive changes, they may not acknowledge; instead they
may expect him to make changes according to their expectations.
For instance, they may make plans for his future. They may ask
him to go for work in the mornings, attend classes in the evenings,
etc., without discussing the issues with him. They are likely to feel
that they have solutions to all his problems.
★ The family members may have conflicting views if it comes to the
question of giving him responsibilities. The recovering person may
be willing to take up certain responsibilities; but the family may find
it comfortable to assign him certain other responsibilities. They may
not be able to trust him with the responsibilities he wants to carry
out. For instance, they will find it comfortable to entrust him with
insignificant jobs like carrying vegetables, participating in physical
work, etc., whereas more important (and to the dependent,
significant) jobs like drawing money from the bank, paying bills
etc., will be entrusted to other members.
The Counsellor must help the family realise that the family support
system surrounding the recovering person will require some changing.
Parents/wife need to alter their attitudes and behaviour towards the
recovering person. Even if one person in the family network is willing
to change, it will have very positive results. The Counsellor should make
the family member understand that she need not continue suffering
constant emotional pain. She has-to give up her preoccupation and
obsession with the chemical dependent and, while still caring, leave him
free to face reality and make some choices of his own. Initially it may
not be easy for them and they will probably need on-going help. AlAnon and similar self-help groups for relatives of chemical dependents
will provide a good deal of constructive advice and support. There they
will meet people who have gone through situations similar to their own.
They will understand and identify with the fear, the feelings of
helplessness and despair, the worry and guilt and the problems in
learning to ‘let go’ of the chemical dependent. The family members
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ALCOHOLISM AND DRUG DEPENDENCY
really need and deserve help to recover from this extremely painful
family addiction. If they change, it is much more likely that the chemical
dependent will want to change too.
Bibliography
1. ‘Choice Making’ by Sharon Wegscheider-Cruse, Health
Communications Inc. Pompano Beach, Florida.
2. ‘Kick Heroin’ by Liz Cutland' — Sky books, London in association
with Gateway Books, Bath.
3. ‘Lost in the Shuffle’ by Robert Subby. Health Communications Inc,
Deerfield beach, Florida.
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SEXUAL PROBLEMS IN RECOVERY
The inter relationship between chemical use and sexual activity has been
established over a period of time. Sexual problems in chemical
dependents are multifaceted, and call for its management, an inter
disciplinary approach.
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What is sexuality?
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Sexuality is in the broadest sense, the Psychic energy which finds physical
and emotional experience in the desire for contact, warmth, tenderness
and love. Sexual response can be divided into three phases — the desire
phase, the excitement phase and the orgasm phase. The first phase or the
desire phase is the libido, or the drive. These drives are influenced by
hormones and are dependent upon the physical health, emotional state
and presence of a suitable partner. The second phase is the excitement
phase. In men, this will reveal itself in the erection of the penis, and in
women, it is the vasocongestion. With continued stimulation, the reflex
response resulting in regular contractions of pelvic area muscles in women
and ejaculation in men will follow. This reflex action is called orgasm.
Alcohol, drugs and sex
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With chemical abuse, sexual problems occur in all three phases of the
response cycle. As the disease of chemical dependency progresses,
damage to the brain cells and internal organs occur. Thus sexual
responsiveness will first be hindered and later destroyed. Frequent
depression, and troubled relatipnships brought on by chemical
dependency will hinder sexual desire from an emotional level.
Chemicals affect the excitement phase by either sedating or ‘burning
out’ the necessary nervous system reactions for erection in the male
and eventually put such a high strain on the nervous system that
ALCOHOLISM AND DRUG DEPENDENCY
128
once again, responsiveness is lost. Finally, the loss of ability to become
aroused often brings about low self-esteem and depression, which,
in turn, serve to further lower sexual desire. In the orgasm phase,
the nervous system reflex response gets blunted and often eliminated
by ongoing chemical use. The most important issue is that in the
relentless progression of chemical dependency, chemicals eventually
destroy ability to enjoy sex.
Effects of alcohol on sexual functioning
Early phase
Small dose
Release of
inhibition
Increased
aggression
Increased desire
Increased
arousal
Control of
premature
ejaculation
Decreased penile
tumescence
Chronic phase
Middle phUse
Chronic alcoholism
Large dose
Moderate dose
Decreased
Impotence both
Longer fore-play
testosterone
erectile and
ejaculatory
Increased time for Disregard for social Loss of sexual
satisfaction
erection
norms
Erectile
Difficulty in main Upleasant
Impotence
ejaculation
taining erection
Loss of libido
Aggressiveness
Uncertain
orgasm
Breast development
Decreased penile
tumescence
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Decreased body hair
Shrivelled testicles
Effect of drugs on sexual functioning
Type of Drug
Narcotic Analgesics
Stimulants
Depressants
Cannabis
Problems due to abuse
Reduced libido, erectile problems
Impotence
Erectile problems, reduced libido
Sterility, prolonged use causes reduced sperm
count and decreased sperm motility.
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129
Assessment of sexual problems
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In order to deal with sexual problems and to formulate a treatment
plan, the counsellor should make an attempt to assess the exact nature
of the problem.
Some individuals due to lack of knowledge, anxiety and inexperience,
may exaggerate their problems. Support, information and reassurance
may be adequate to resolve their problems. Some others who do have
problems, may not disclose. In such cases, an empathetic and*caring
Counsellor after gaining the patient’s confidence can probe in a
supportive manner and help him to come out with his problems.
The key questions in diagnosing are
1. What stage of the sexual response cycle is impaired — desire,
excitement or orgasm phase?
2. What is the degree/extent/nature and severity of the impairment?
3. How does that affect the individual? The couple?
4. Is the problem organic or psychological?
Primary vs secondary to a psychiatric problem
It is useful to assess if the patient has a psychiatric disorder. If the
problem is found to be secondary to a psychiatric problem, then success
of treatment depends on eliminating the psychiatric problem. Most of
the antipsychotics and lithium lead to sexual problems — supportive
counselling becomes necessary.
What are the relational issues?
Chemical dependency leads to poor marital relationships. Therefore,
it is important to assess whether the patient has problems with intimacy,
communication etc.
Sexual problems in recovery
Impotence
Sexual dysfunction, especially erectile problems (impotence), is one of
the frequently noted side effects of chemical dependency. This sexual
problem can have an abrupt onset while the individual is using chemicals
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inability to get erection and finally sexual avoidance. The exact cause
of cue problem has not been scientifically established, with both
physiological and psychological factors having a bearing on it.
Since sexuality is not readily discussed, the individual has limited sources
of information. So during recovery, the patient may firmly believe that
he has only two choices — the choice of being a ‘potent drunk’ or an
‘impotent abstainer’ and choose the former. For him, the idea of
impotence connotes more than a (difficulty in getting and maintaining
erection; it is perceived as loss of power and masculinity. The person
may relapse in an effort to regain potency. This is self defeating and
does not solve his sexual problem.
In clinical practice, when confronted with this situation, the first step is
to reduce the patient’s anxiety by reassurance. It involves providing
information and education on sex and erectile functioning. Men think
that erection is automatic, and that to be a real man, one should be able to
get an erection with any woman, any time. He should be made aware that
erection is a complex psycho-physiological response requiring a relaxed
mental state and a comfortable, cooperative relationship with the partner.
Most chemical dependents would have learnt to enjoy sex only under
the influence of chemicals. They use chemicals to lower inhibitions,
reduce anxiety and increase self confidence. In essence, their sexual
learning would have been a state dependent upon chemical use.
Now they have to relearn to be comfortable and confident in the new
sober state. This transition can cause temporary erectile difficulty.
If they overreact to this temporary problem, they will become more
self conscious and may settle into a chronic performance anxiety
resulting in erectile dysfunction. It has to be reemphasised that the
transition is temporary, and that going back to chemicals will not solve
the problem. However, if the problem persists or worsens for over three
months, referral to a sex Counsellor would be appropriate.
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Inhibited sexual desire (ISD)
This disorder is defined as persistent and pervasive inhibition of sexual
desire. The patient complains of a lack of interest in sex. The reasons
for ISD may be both medical and psychological. The more frequent
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SEXUAL PROBLEMS IN RECOVERY
131
psychological causes are boredom in the relationship and depression.
When the Counsellor plans management, he should first look into the
medical reasons. The patient should be sent to a medical professional
for a-thorough investigation. As an adjunct, psychological counselling
will be helpful. The patient should be reassured that ISD is only a
temporary phase and with time, definite improvement is possible.
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Premature ejaculation
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Premature ejaculation is ejaculation occurring before or soon after
penetration. It is actually ejaculation occurring before the individual
wishes. The management of premature ejaculation can be done by
teaching the client the ‘squeeze technique’, otherwise known as the
‘stop and start technique’, evolved by Masters & Johnson in 1970.
First the couple must be educated about normal sex and all their
misinformation should be removed. Then they could be guided to
involve themselves in non-demanding but pleasure seeking ways like
touching the non-genital and subsequently genital areas of the partner.
The emphasis is not on sexual performance but on mutual enhancement
of non-orgasmic erotic pleasures. Erection and intercourse are not
expected. The couple learn that erection can occur spontaneously when
not impaired by pressure and anxiety. The next stage is the most
important stage i.e. dispelling the fear of failure because the client
anticipates failure as far as ejaculation and orgasm go. The ‘squeeze
technique’ involves the female placing her thumb on the interior surface
of the penis and the first and second fingers at the exterior penis surface
immediately adjacent to one another on either side of the coronal ridge.
Pressure is applied by squeezing steadily the thumb and the two fingers
together for three to four seconds.-this would immediately result in
the loss of urge to ejaculate. He may also lose 10 to 30 percent of his
full erection. The wife should allow an interval of 15 to 30 seconds after
releasing the applied pressure to the coronal ridge area of the penis and
then return to active penile stimulation. Again when full erection is
achieved the squeeze technique is reinstituted. Alternating between
periods of specifically applied pressure and reconstitution of sexually
stimulative techniques, a period of 15 to 20 minutes of sex play may
be experienced without a male ejaculatory episode, something unknown
to the marital unit in prior sexual performance.
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ALCOHOLISM AND DRUG DEPENDENCY
Extra-marital relationships
Having sexual affairs with women (married or unmarried) other than
their marriage partner is extra marital sex. This is found to be relatively
high among chemical dependents. These affairs would have taken place
when the chemical dependent was abusing chemicals, when judgment
and reasoning had been poor, or when there had been relationship
difficulties with the wife. Society does not permit extra marital
relationships. This leads to a value conflict in the chemical dependent
who has been having extra marital affairs. Guilt is induced and it is
prominent during recovery. Past guilt feelings related to such sexual
behaviours have to be dealt with in individual counselling sessions.
PLISSIT model
PLISSIT model is found to be useful in offering sexual counselling to
chemical dependents in After-care Centres. PLISSIT is a simplified
approach to dealing with sexual problems in chemical dependents.
‘PLISSIT’ stands for
P — permission giving
LI — limited information
SS — specific suggestions
IT — intensive therapy
Permission giving
In ‘permission giving’, the Counsellor encourages the client to discuss
issues related to his sexual life. The Counsellor should maintain a
reassuring climate for the client to talk about intimate issues without
hesitation or embarrassment. Also, ‘permission giving’ establishes an open
climate for discussion and sharing of feelings, thoughts, fantasies and
behaviours. ‘Permission giving’ can occur in a treatment unit in two ways.
1. A re-educative session on ‘issues related to sex’ can be handled by
the Counsellor.
2. Literature on ‘sexuality and chemicals’ can be made available at the
After-care Centre library.
These two techniques pave the way for open communication about sex
and enable clients to discuss sexual problems without inhibitions.
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SEXUAL PROBLEMS IN RECOVERY
133
Limited Information
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‘Limited information’ provides the client with specific factual data
directly relevant to his particular sexual concern. The common areas
of individual concerns centre on myths about genital size, sexual
interest/appetite, responsiveness, orgasmic potential, masturbation,
sexual frequency etc. In a treatment unit, ‘limited information should
be focused on the chemical dependent’s concern for impotence, rapid
ejaculation, inhibited sexual desire, many of which occur in his sexual
life. This can be done via:
1. A presentation/re-educative session on specific sexual dysfunctions
and their relationship with chemical dependency.
2. Structured group therapy sessions on sexual problems.
3. Individual counselling sessions aimed at each client’s specific needs.
4. Couple/family counselling sessions dealing with intimacy/sexuality.
Specific suggestions
Collecting data regarding sexual problems is the first step towards
developing a therapeutic plan. It is this record which forms the basis
for specific suggestions. Suggestions are targeted to each individual
client’s needs. Some of these suggestions are — ‘graded sexual
responses’, ‘sensate focus technique’, ‘squeeze technique etc.
Information on these skills can be obtained from specific books,
as detailed discussion on each of these techniques is beyond the scope
of this chapter.
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Intensive therapy
Based on the client’s sexual history, therapy has to be planned. Some
patients may need intensive therapy which may not be available at the
After-care Centre. It is essential for the centre to have a list of sex
Counsellors in the community who can provide intensive therapy, so
that patients can be referred there, if necessary.
Intimacy and recovery
The issues discussed so far have been related to sexual dysfunction.
Apart from these, what is more often seen in the recovering chemical
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ALCOHOLISM AND DRUG DEPENDENCY
dependents, is fear related to intimacy. These chemical dependents may
have normal sexual functioning but may feel inadequate due to reasons
such as
- Resentment/anger towards the partner.
- Guilt feelings.
- Lack of communication.
- Lack of trust.
- Ambivalence to marital relationship.
The Counsellor must emphasise that intimacy does not necessarily mean
physical intimacy. The client must be encouraged to explore various
other ways of being intimate.
Probably the first step in developing intimacy would be to take steps
in revealing oneself to another. This could be initiated by the Counsellor
in the combined sessions, wherein the couple learns to forgive and
forget whatever has happened between them in the past. This under
standing helps in developing trust which is primary to building an
intimate relationship. Also while sharing they learn to respect each
other’s feelings.
Marital partners can develop intimacy in different areas Intellectual — Share ideas and thoughts.
Emotional
Communicate feelings.
Aesthetic
Appreciate beauty in art, music, literature and
environment.
Recreational — Share common hobbies.
Physical
— Express love and affection through physical
contact.
Such intimacy can be developed only over a period of time. The couple
need not feel anxious or frustrated if they are not able to achieve
everything immediately. It is a process, and by constant effort, it can
be definitely developed.
Sexual problems are common among chemical dependents. Though they
may deny it, it is a major issue which cannot be overlooked. However,
proper management of this issue will lead to a satisfying and meaningful
marital relationship, which in turn will strengthen recovery.
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SEXUAL PROBLEMS IN RECOVERY
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Bibliography
1. Now About Sex, Bandhuin John, Hazelden Publications, USA 1985.
2. The Integration of Sexuality into Alcoholism Treatment, Fewell Huff
Christine, Alcoholism Treatment Quarterly, Vol. 2, No. 1, 1985 —
pp 47-60.
3. Sexuality and Recovery, Mcfarland Barbara, Hazelden Publications,
USA 1984.
4. Alcoholism and Sexual Dysfunction : Issues in Clinical Management,
Powell J David, Alcoholism Treatment Quarterly, Vol. 1, No.3.
The Haworth Press, New York, Fall 1984.
5. Sex and Recovery, Weinberg R Jon, Recovery Press, Minneapolis 19.
6. Human Sexual Response — Bantam Books, Masters M William and
Johnson E Virginia, USA June 1980.
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13
COPING WITH STRESS
Stress is the reaction of mind and body to change. This definition
includes all kinds of changes — pleasant, unpleasant, exciting and
boring. Most people think that stress is synonymous with distress.
This is not true. Two kinds of stresses have been identified — Distress
and Eustress.
Distress is negative stress. It can be caused by as trivial an event as
travelling in a crowded bus, or appearing for an examination, or as
serious a matter as a couple’s marriage falling apart or a family member
facing a serious illness.
There is also a positive kind of stress, called Eustress. It can be felt
by an athlete who is geared up for a competition, a father getting his
daughter married or a boy getting a seat in a professional college.
Thus stress can also be a resource for a person to develop the capacity
to meet new challenges.
Stress reaction
Whenever a person is faced with stress (the cause of which can be
physical or psychological), there are certain changes that take place in
his body and mind. This unique set of changes is called stress reaction.
It consists of a complex chain of physical and bio-chemical changes
involving the reactions of the nervous system, and the other organs to
different chemicals. As a result of this, the body goes on ‘full alert’.
In response to stress, there is an increase in the production of hormones
such as adrenalin. This, along with increased heart rate, oxygen intake
and blood flow to the muscles, combine to provide the individual with
the strength, energy and clear thinking necessary to give his ‘best’.
When the challenge has been fully met, all the organs begin to relax,
and return to normalcy.
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COPING WITH STRESS
137
Normally there are three stages through which the entire system tries
to respond to a stressful situation.
Stage 1 :
The arousal state. The body prepares itself by mobilisation
of biochemical resources.
Stage 2 :
All available energy mobilised and this energy utilised to
cope with the stress.
The challenge met, the body returns to normalcy. If the
challenge is not met, the body reverts to stage 1. (prolonged
stress).
Stage 3 :
I
Normally people adjust their behaviour to the strains of life, dealing
as best as they can. Yet stresses can sometimes pile up and push the
individual to a condition which he is unable to manage. This prolonged
stress can lead to the development of stress disorder. Four distinct stages
have been identified in this process.
1. Psychic phase
The excessive trauma makes the individual’s Central Nervous System
overactive, as a result of which he experiences psychological changes.
He becomes irritable, anxious and his sleep is disturbed. He looks
worried, and is always thinking of some impending disaster.
2. Psychosomatic phase
If the same situation continues, along with the above stated
functional disturbances, certain generalised changes such as
hypertension, tremors, palpitation etc. are noticed.
3. Somatic phase
The human body is equipped to deal with stress — but only to a
certain level. As the individual’s adaptive resources become
overworked and exhausted, the body ceases to function smoothly.
Different organs become stress targets and symptoms of dysfunction
manifest themselves. For example, the person may develop stomach
ache, burning sensation in the stomach, etc. if the target organ is
the stomach.
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ALCOHOLISM AND DRUG DEPENDENCY
4. Organic phase
As arousal continues, the body finds it difficult to adapt to the
biochemical changes under increasing strain and pressure.
Eventually it breaks down. Exhaustion is expressed through a variety
of illnesses. This happens as the lesion settles in the target organ,
and the symptoms of the diseases become more pronounced.
The stress-induced disease usually settles in one particular organ
depending on the sufferer’s hereditary background and environ
mental factors. These are the target organs, and one can notice a
dysfunction of these organs — the stomach (gastritis, peptic ulcer),
respiratory system (asthma), Central Nervous System (migraine).
Symptoms of stress
The effects of stress are insidious and the individual often fails to notice
them. Signals of stress have been classified below. Early identification
helps in effective coping.
Nervous reflexes
Mood changes
Biting nails, clenching fists, clenched jaw,
drumming fingers, grinding teeth,
hunching shoulders, picking at facial
skin, picking at skin around fingernails,
tapping feet, touching hair.
Anxiety, depression, frustration,
inappropriate anger or hostility,
helplessness, hopelessness, impatience,
irritability, excessive worrying or
excessive day dreaming or fantasising —
always wishing he was elsewhere.
(Prolonged brooding)
Illnesses
Behaviour changes
Backpain, headache, migraine, muscular
aches and pains, skin disorders, insomnia
(disturbed sleep patterns), digestive
disorders, asthma, sexual disorders and
hypochondria
Aggression, not eating/eating too much,
doing several things at once/leaving jobs
undone, emotional outbursts, over
reaction, talking too fast or too loud,
constant harping on personal failures or
short-comings, constant reference to
death or suicide, missing appointments
and deadlines, confusion, difficulty in
getting along with other people
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COPING WITH STRESS
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Individuals undergoing stress definitely need to utilise extra resources
of help and support. This support should be appropriate and healthy
(family, close friends, spouse, counsellors etc.). Some people resort to
unhealthy props like alcohol, drugs, cigarettes etc., to get relief.This
method is dangerous and should necessarily be avoided. Researchers
studying the relationship between stress and chemicals have postulated
that chemicals are initially used to reduce tension (to provide relief).
However, this in turn, reinforces the individual to continue to see
chemicals as an emotional prop. Whenever that individual feels helpless
to cope with a stressful situation, his alternative way of coping will be
chemicals — inevitably leading him to abuse chemicals.
During recovery, it is very clear that clients should be taught alternative
healthy ways to cope with stress. There are various high risk factors
that can precipitate a relapse in the client who is abstaining from drugs.
Some of them are:- Negative Physical States
- Negative Emotional States
- Interpersonal conflicts
- Social pressures
Negative Emotional Negative Physical
States
States
Low self-esteem
Guilt, Shame
Resentment
Hurt feelings
Grief, Depression
Anxiety
Interpersonal
Conflicts
Social
Pressures
Sleep disturbances Difficulty in com No job
munication
Not accepted by
Poor health
Difficulty in sexual Lack of trust of others society
Others’ unwilling- Pressure from friends
performance
to use drugs
mess to give
responsibilities
Suspicion
Criticism from others
If clients lack adequate coping skills, they have to be specifically trained
to anticipate stress and taught methods to cope effectively with the same.
Stress reduction
Given below are some guidelines to help the client handle stress during
recovery:
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ALCOHOLISM AND DRUG DEPENDENCY
Examine oneself
Before one can reduce stress or make it work, one must recognise its
signs and identify its sources. The client must learn to monitor his
physical and psychological condition. Various signs and symptoms of
stress which have been listed out earlier can be given to the client as
a checklist.
Ensure physical well-being
The Client should make all efforts to maintain good general health.
Regular eating habits with a well balanced diet should be developed.
Regular exercises will help the individual to develop optimal health to
cope with stress. He should develop regular sleeping habits and take
adequate rest. Relaxation techniques also will be useful.
Ventilate feelings
Accumulated stress eats away one’s energy and health. One must express
how he feels, even if nothing can be done about it. To whom a person
ventilates, depends on the level of trust. Clients should be encouraged
to join support groups. Support groups like the Alcoholics Anonymous
and Narcotics Anonymous help them to ventilate feelings. When a client
is under stress, solutions of others provide options for him to mentally
review what he has done or what he can do when faced with a
stressful situation.
Identify a goal and develop a plan
The level of stress is more when the client does not find a goal or purpose
for his life. Helping the client choose short term as well as long term
goals, reduces his helplessness. This should be followed by a structured
programme for each day, which would help the client work towards
his goal. Adequate time for every activity, including recreation should
be spelt out.
Procrastination should be avoided as it increases stress. To organise
better, clients can be encouraged to establish a routine. A routine will
help establish priorities and decrease wasting of time.
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COPING WITH STRESS
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To conclude, stress and chemicals are closely related and stress can lead
to relapses. Therefore stress has to be effectively managed, and one
must learn healthy ways to cope with it.
Bibliography
1. Krista Alix, The book of stress survival — How to relax and live
positively, Rajendra Publishing House Pvt. Ltd., Bombay, India,
1989.
2. New Perspectives in Stress Management, Nagendra H R and
Nagarathna R, Vivekananda Kendra, Bangalore, India, 1988.
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3. Tanner Odgen, Stress — Time Life Books, Alexandria, Virginia,
1976.
14
UNDERSTANDING VALUES
What is a value?
A ‘Value’ indicates the regard fqr a quality, or an attitude which, for
some reason, is esteemed by the Value-holder. A person’s norm for what
is ‘proper’ behaviour or a ‘good’ attitude is based on the way he wishes
others to treat or view him. Behaviour norms such as humility, taking
responsibility, being helpful, are all based upon the same consideration
of how one would like others to treat him. Thus, ethical norms or values
are not just arbitrary, man-made rules but stem from an inherent,
common regard for one’s own interest and comfort. Values are
universal. There may be some cultural variations in degree or emphasis,
but the basic standards have a certain universality.
Values form an integral part of one’s life. They form the thread which
connects the colourful beads of experiences to create the garland of
life. They actually determine the quality of a person’s life. A man is
normally known and acknowledged only by his values. (“An honest
person;”.... “A disciplined person;”.... “He is educated, but does not
have integrity”). Values are generally passed on from one generation
to another. When children trust and hold their parents in high esteem,
they automatically follow and adopt the values upheld by the parents.
For example, when parents show respect and courtesy to others, children
take them as their role model and even without conscious knowledge
they extend courtesy and respect to the people whom they meet.
Punctuality and cleanliness are examples of other values which children
directly learn from their parents.
'Merely stated’ values
These are beliefs which a person claims to hold but never follows.
In other words, these are values which are preached but not practised.
Sometimes one may not even be conscious that there is a disparity
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UNDERSTANDING VALUES
143
between what he says and what he does. Such a person will never be
able to make others follow or see any value in what he is preaching.
They will follow only what he does, and not what he states. For a
value to be effective, it is not enough if it is merely ‘stated’; it has got
to be ‘lived’. The alcoholic father tells lots of lies; slyly takes money
from the ‘Hundi’ in the Pooja Room, but does not hesitate to punish
his child when he speaks a lie or steals something from the school.
The father is not even able to see that it is his own behaviour that has
been observed and followed by his child. The child is really confused
when he is punished because he does not see anything wrong with
stealing or telling lies. Similarly, the mother who shows disrespect to
her mother-in-law, is not able to see the absurdity when she gets angry
at the defiance of her daughter. The mother may preach and talk a
lot about the val re of ‘respect to elders’ but will carry no conviction
whatsoever because the child will only see what the mother is doing
and not what she is stating.
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Lived values
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These are beliefs which an individual upholds and follows. When values
are put into action and practised, they develop into a way of life.
When beliefs become part of the person, they never change. For such
a person, what he thinks and what he does are in perfect harmony with
each other. In other words, the knower and the doer are the same.
For the expression of a value to become spontaneous, one must see its
real value in his personal life. He must recognise the worth of the values.
Only then would it be possible for him to implement them in his life.
In other words, a value becomes a value for a person only when he
sees the benefit of the value. For example, the child who is convinced
about the benefits he is going to derive as a result of his education,
recognises the value of ‘knowledge and education’. He puts in hard
work, reads a lot, updates his knowledge, etc.
For a person with lived values, life becomes very simple. No conflicts
cloud his mind. He does not have to ever feel guilty, because there is
no discrepancy between his thoughts and actions. Such a person also
becomes a good role model for his children. Gandhiji is an example
of a person with ‘lived values.’ Gandhiji advocated non-violence and
simple living. He also practised non violence and led a simple life.
ALCOHOLISM AND DRUG DEPENDENCY
144
Assimilated values
In course of time, ‘lived’ values become a part of the person. The child
who sees the mother going to the temple every day, starts doing the
same thing without questioning. He may not even be aware of the
benefits he is going to derive from the particular value which he has
imbibed. “Trust in God” becomes a deep rooted value for this child,
and when he grows up, he derives lot of comfort and strength from
this value which he has imbibed from his mother without conscious
knowledge. As an adult, when he feels the power he gets and the
confidence he acquires, he comes to have a well understood, well
assimilated personal value for “Trust in God”.
Any value, when it leads to a sense of ‘feeling good’, automatically
becomes a natural, spontaneous, personal, assimilated value.
The conduct mandated by one’s personal values, becomes what he does
without reflection or thinking. Matters of hygiene are everyday examples
of personal assimilated values. Even though one may be quite hungry,
he does not consider picking up and eating an apple found in a garbage
heap. One does not have a daily debate with himself over whether to
brush his teeth or comb his hair. Conforming to these values creates
no conflicts whatsoever for him.
Value enrichment
Constant practice enriches values. New experiences and environment
provide an opportunity to exhibit the value in all its dimensions — not
with mere ‘better sameness’, but ‘with a difference’.
The resident physician of an 'Addiction treatment centre'
discovered a cyst in the pancreas of an alcoholic.
This treatment was beyond the scope of the addiction centre.
The doctor's responsibility in such a case was to refer the
patient to a specialist in the Government Hospital.
The physician made an assessment and felt that if the patient
was given a choice, he would neither go to the Government
Hospital nor get back to the Addiction treatment centre.
He was an extremely poor patient. So the physician put up
a case for special funds for the patient's incidental expenses
at the Government Hospital. She took the trouble of talking
UNDERSTANDING VALUES
145
personally to the concerned surgeon, She took enormous
personal care and kept in touch with his family to ensure that
the patient reported back to the Addiction centre for treatment.
As per the job requirement of the doctor, she was not required
to do anything more than the following
- tell the patient about the problem he has
- refer him to the Government hospital
- leave the choice entirely to him as to what he wants to do.
In this case, the care and concern shown by the physician takes her
well beyond the boundaries of her job specification and enables her
to provide wholesome and meaningful treatment to the patient.
Sticking to her terms of reference, she might still have displayed the
value of ‘care and concern.’ But in doing what she did in this instance,
she has enriched that value by performing well beyond those ‘narrow’
frames of reference.
Value enrichment leads to greater job satisfaction and gratification.
It provides wholesome meaning to human existence. The person
practising enriched values feels happy, contented and successful in life.
For such a person, each and every experience contributes towards
personal development and enlightenment.
Addiction leading to breakdown of values
Whenever, due to some reason, the behaviour of an individual does
not coincide with his values, it leads to conflicts. Such conflicts occur
when a person is unable to live up to his values. When there is such
a conflict, the person suffers from guilt, self-condemnation, remorse,
a feeling of worthlessness, extreme regret etc. This is a common
condition among chemical dependents. Drug-related behaviour like
violence, aggression, grandiosity, dishonesty, irresponsibility, selfishness
etc. become a part of the chemical dependent’s life style, even though
they could be totally contrary to the values which the person might have
previously adhered to.
Ram recalls events which happened during the period when
he was taking brown sugar. On a'day when he did not have
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ALCOHOLISM AND DRUG DEPENDENCY
money for his drug, he decided to somehow get it from his
office. He told his boss that his mother was seriously ill and
that he needed money for her hospitalisation. His boss gave
him Rs. 500 which he took and disappeared. For the next
10 days, he was with his friends at the ‘den "and never attended
office.
His boss wanted to find out whether something was seriously
wrong with his mother. So he sent a couple of his assistants
to Ram's house to ensure that she was okay. When they
entered, to their shock and surprise, Ram's mother was
carrying water from the well. She was looking normal with
no indication of anything having gone wrong with her health.
Ram had been dishonest, and he was not even bothered about
the fact that he had to face his boss the next day. During the
different stages of his dependency, Ram was breaking all the
values he had learnt in his childhood.
During the chronic stage of addiction, the chemical dependent does not
hesitate to beg, borrow or even steal to maintain his supply of chemicals.
He becomes totally self-centred and irresponsible.
Shanmugham almost always came home drunk. Even when
he was not drunk, he was highly irritable. His only son had
been of late complaining that he had severe stomach ache and
was unable to eat. Whenever the child complained of nausea,
Shanmugham thrashed the child. The child was getting beaten
every time he said he had no appetite. The child was looking
sickly, and was unable even to walk.
One week later, the child got up from bed and collapsed.
Shanmugham's wife took him to the doctor and she was told
that the child's condition was critical and that he needed
immediate treatment and hospitalisation. He was in the
advanced stage ofjaundice. Shanmugham's wife went home;
borrowed some money from her friends, and asked
Shanmugham to accompany her to the hospital for admission.
Shanmugham promised to bring an auto. On his way, he met
a few of his friends' and decided to go to an arrack shop with
UNDERSTANDING VALUES
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them to ‘calm down his nerves'. He started drinking; lost
control; spent all his money and reached home at night in an
auto. He was too drunk to feel guilty or ashamed over his
total irresponsibility and utter selfishness.
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During abstinence, he gets exposed to his appalling behaviour and he
is shocked to see the way he had broken his values. This leads to an
intense inner turmoil, resulting in feelings of extreme guilt and shame.
Sometimes he decides to run away from these emotions by resorting
to drugs, and again the vicious cycle starts. Until this cycle is broken,
recovery from addiction is not possible. He has to give up drugs/drinks,
and at the same time, make conscious efforts to improve his behaviour
and rebuild the values which he has lost.
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Understanding values and living by them
For the chemical dependent, priorities have got to change. Changes take
place slowly, through various life experiences, through the influence
of people one lives and associates with, the books he reads, the things
he observes and so on. Close friends and associates have a significant
influence on a person’s values and value system.
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Following are a few methods which will help the chemical dependent
change his old way of life and build a proper value system which will
enable him to live in peace. Senior A.A./N.A. members and Counsellors
at the After-care Centre can be taken as a role-model by the recovering
person. The chemical dependent perceives the ‘lived values’ of the
Counsellor and other peers. The care and concern shown by the Counsellor
will reinforce the values of being helpful and loving. He imbibes values
of punctuality, trust in God, honesty and compassion.
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The environment at the After-care Centre provides an opportunity for
the chemical dependent to get back the values he has lost during the
various stages of his dependency. He should be made to see the benefit
of each value to him. He will make situational choices only when he
thinks that such choices will make him feel good.
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Nikhil recalls,
“During my ‘brown sugar days', I had been almost brutal in
my behaviour towards my mother. I had been showing
disrespect to her and was unconcerned when she was struggling
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ALCOHOLISM AND DRUG DEPENDENCY
to work in spite of her sickness. With a lot of effort, she had
saved a small sum of money. Unhesitatingly I stole the money
and spent it on drugs. I did not even regret it. There were so
many other instances when I had behaved in ways totally
unacceptable to me now.
It was only during recovery that I realised the extent of
damages I had done. I was shocked to see the level to which
I had stooped. At the After-care Centre, I realised the
tremendous impact of the values of care, understanding and
being helpful to others. I decided I should make amends
for my past behaviour by showing genuine love and
affection to my mother. I did this in all earnestness. What
did I do?
- I took a loan from my provident fund money and took
my mother to a doctor
- I admitted her in a hospital and spent the entire month
with her
- I took efforts to satisfy each and every need of hers
- I wrote letters to all the people to whom she wanted to
communicate
When I saw my mother feeling happy, I realised that care and
concern shown by me to my mother, has, in turn, given me
fulfilment and satisfaction which I never dreamt I would ever
experience.
Whenever the recovering person makes an honest attempt to rebuild
his values, the Counsellor should encourage him and assist him if
necessary, to reinforce the value. The chemical dependent should be
made aware that long-term sobriety can be achieved only if he becomes
aware of his shortcomings and starts leading a meaningful life, living
by values. He will not be able to get back his values without conscious
effort. However, with continuous, committed effort, he is sure to get
back to living by proper values. In course of time, they will
spontaneously express themselves in his life, making it more meaningful,
more productive and wholesome.
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UNDERSTANDING VALUES
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Additional information
Methods suggested to start living by values
Sometimes patients may find it difficult to name and identify the values
they want to follow. Here is a list of values for their reference. It is
certainly not a comprehensive list. They can add to it and make it more
complete.
Honesty
Care and concern
Responsibility
Discipline
Punctuality
Followi ig family traditions
Spending money wisely
Helpful
Trust in God
Listening
Open mindedness
Hard work
Respect for elders
Giving importance to education
Good health
Alcohol/drug free life
Gratitude
Cleanliness
Patience
Orderliness
After making this list, the Counsellor may ask the patient to list 5 values
he wants to follow in the order o£ his priority. He should separately
prioritise 5 values which he expects his children/siblings/peers to follow.
After the patient completes both the list’s, the Counsellor may see whether
his values coincide with the values he wants his children/siblings/peers
to follow. If there is a disparity, he should be explained the importance
of ‘lived values’. He should be made to see the need for him to follow
the values he wants his children/siblings/peers to adopt.
Bibliography
1. 'The Value of Values’ — Swami Dayananda.
15
COMPULSIVE GAMBLING
Chemical dependents may present themselves with other addictive
behaviour patterns also, and of these, gambling is the most common
one. This is a problem which needs to be handled in therapy
simultaneously with alcohol/drug problem, as gambling too is
compulsive in nature and can trigger a relapse in the recovering person.
Compulsive gambling is listed as a psychiatric disorder and it assumes
alarming proportions since it is progressive in nature.
Gambling has been defined as a progressive impulse disorder in which
an individual is chronically and uncontrollably preoccupied with
gambling, and with the urge to gamble.
DSM III R calls it ‘pathological gambling’ and lists nine specific features.
To make a diagnosis of ‘pathological gambling’, it is essential to identify
at least four of the following symptoms:
i) frequent preoccupation with gambling or with obtaining money
to gamble.
ii) frequent gambling with larger amounts of money or over a longer
period of time than intended.
iii) feeling a need to increase the size or frequency of bets to achieve
the desired excitement.
iv) restlessness or irritability if unable to gamble.
v) repeated loss of money through gambling and returning another
day to win back losses (“chasing”).
vi) repeated efforts to reduce or stop gambling.
vii) frequent gambling when expected to meet social or occupational
obligations.
viii) giving up some important social, occupational, or recreational
activity in order to gamble.
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COMPULSIVE GAMBLING
ix) continuation of gambling despite inability to pay mounting debts,
or despite other significant social, occupational, or legal problems
that the person knows to be exacerbated by gambling.
Gamblers basically fall into two categories:
1. A person who gambles.
2. A sick gambler
Who is a ‘person who gambles?’ He is the occasional bettor who does
it for fun and sociability (playing cards during special days like
Deepavali, marriages, buying lottery tickets, etc.)
The ‘sick gambler’s’ life is controlled by gambling. His time, efforts
and financial situation are determined by the status of his gambling.
Usually there is little chance that the compulsive gambler is “spotted”
by his friends, associates, colleagues, fellow workers, etc. Sometimes,
the nature of the disorder lends itself to privacy and lack of detection.
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Compulsive gambling has been defined as a “progressive behavioural
disorder”. ‘Progressive’ is the key word. The progression usually goes
unnoticed until the behaviour (gambling) has become a disorder (illness).
One of the more insidious aspects of the problem is the fact that the
gambler doesn’t mean to harm anybody. His generous intentions block
the reality that gambling is a big-money business, and that in the long
run, he cannot win (DENIAL). The sick gambler really believes he will
make that one big “win” which will enable him to pay back everybody
and also give his family, friends and relatives all that they want.
The important issue is that he believes that the big “win” is just around
the corner. The sick gambler is so persuasive that his family also believes
in his fantasies of success, and this.enables him to get deeper into the
problem.
The family’s role
Typically, a compulsive gambler’s wife does not initially recognise the
problem. In the beginning, she too enjoys the excitement of the gambling
life — the fantasies of winning — the dreams of luxury. But when
repeated loss of money affects their standard of living and becomes
a point of concern, she wakes up to what is taking place. Later, when
she realises that gambling is causing serious financial problems,
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ALCOHOLISM AND DRUG DEPENDENCY
she protests, and seeks help. The typical enabling behaviour seen
in a chemical dependent’s family is seen here also, with the same
intensity.
Guidelines to handle compulsive
gambling in chemical dependents
For any professional help, a clear history is essential. A history covering
all aspects — how it started, its progression, the predominant mode
of gambling, damages in several'areas — is to be obtained. As discussed
earlier, in a gambler, denial may be very high, since there are no obvious
symptoms of addiction (especially physical addiction). Therefore, it is
essential for the Counsellor to supportively confront the client.
For successful recovery, breaking of denial is essential. All the
guidelines given in the chapter on ‘Handling Denial’* should be kept
in mind.
The client should be helped to identify activities to substitute ‘gambling
time’. The activities can be varied — from hobbies, recreational
interests, to more serious work like joining a new course, etc.
The essential goal is to learn to handle the ‘urge’ to gamble during the
‘prime time’.
Gamblers Anonymous (GA) is in its infancy in India. GA is again based
on the 12 steps of AA, and therefore, recommends two important
ideologies:
1. Belief in a Higher Power
2. Living one day at a time
It is also essential to involve the family in therapy and educate
them on facts regarding the compulsive traits of the chemical
dependent, the need to break the family’s enabling behaviour and work
out their own recovery plans. Gambling, if not handled properly, will
be a major hurdle to sobriety, and therefore, requires prompt
attention.
* Refer “Alcoholisip and Drug Dependency - The Professional’s Masterguide.”
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COMPULSIVE GAMBLING
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Bibliography
)
1. American Psychiatric Association, Diagnostic criteria from DSM
III R, Washington, USA, 1988.
2. Compulsive Gambling — Manipulating the family — Focus on family
and chemical dependency, Fulcher Gerry, Vol 9, No. 2, March/April
1986, pp 12.
3. The Psychology of Gambling, Halliday Jon and Fuller Peter (Editors)
Harper Colophon Books, London, 1974.
4. Drinks, Drugs and Gambling. Gandhi M K, Navajivan Publishing
House, Ahmedabad, India, 1952.
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16
IMPROVING THE QUALITY OF LIFE
Recovery from chemical dependency begins with staying away from
drugs totally for life. But abstinence is only the starting point of
recovery. Long-term sobriety'can be achieved only if the chemical
dependent consciously makes improvements in the quality of his life.
What is quality of life?
The answer rests on what is meant by the word ‘Life’. What do we
associate the word ‘Life’ with? ‘Life’ means activity. It may be defined
as a series of actions or a series of experiences. Each experience becomes
a unit of life just as a brick is the unit of a wall. The strength or weakness
of the wall depends on the quality and nature of the bricks constituting
it. Similarly, the types of experiences that each one goes through,
determine the quality of his life.
Addiction has led to severe damages in several areas of the chemical
dependent’s life. So during recovery, he has to consciously take steps
to set right those damages. Working towards a concrete goal will make
a qualitative improvement in his ‘new’ life and make it purposeful.
Following are a few suggestions which will make the chemical
dependent’s life more meaningful and add to its quality. The therapeutic
environment of the After-care Centre will facilitate the patients to
implement these in a phased out manner.
Identifying a goal
Finding out a goal and working towards achieving that, will make the
life of the recovering person really meaningful. Initially, the chemical
dependent, struggling to get over the pain of addiction, may have no
other goal except to abstain and ‘stay clean’. For a person who is clean and
sincere about staying clean, some of the main challenges to recovery have
to be identified and short-term goals planned to manage those challenges.
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- There may be ‘drug craving’ which can remain strong for many months
following physiological withdrawal and which may even renew itself
upon one’s discharge from a drug-free environment. Craving may
be stimulated by a host of settings and events that a recovering person
must gradually learn to handle or avoid altogether. It is very important
for him to learn to assert himself and say ‘NO’ if it is offered.
- There is a need for a new social network. This calls for socialising
regularly in ways unfamiliar to him so far.
- There are the adjustments to drug-free activities and satisfactions.
These adjustments constitute a learning process, as old forms of
fun must be discarded and replaced by new ones.
- While learning new forms of pleasures, the recovering person must
also learn to respond safely to physical pain and stress without resorting
to drugs.
- There is a need for intimacy in family relationships. This might have
been deeply damaged. Family members who were once close will
still be available, but may be difficult to approach. Intimacy can
be vital but especially problematic for a person whose self-esteem
is often fragile.
All these challenges must be managed and therefore, it is very important
for the recovering person to have clear cut short-term goals which will
help him manage the immediate challenges
But abstinence cannot long remain an end in itself. It must soon become
the opportunity to do something more with life, lest all these efforts
seem pointless. In short, recovery from addiction can be secure only
if the person has found new life goals and has begun to work towards
their achievement.
While short-term goals are oriented towards specific recovery needs,
the future, however, means wider opportunities. Every patient should
be encouraged to identify atleast a few attractive and meaningful
possibilities. These goals should necessarily be realistic, achievable and
meaningful. If the chemical dependent is able to complete a few short
term goals on the time-frame needed to complete the tasks, he will feel
good about himself. This will also give him confidence and help him
to undertake more difficult long-term goals. Goals help him find footholds
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ALCOHOLISM AND DRUG DEPENDENCY
and paths on the slippery slopes. They shape his energies. They give
him hope.
Here is what Naveen, a recovering alcoholic has got to say:
“When I came out of the After-care Centre, I decided to
rebuild my workshop which I had totally neglected during my
drinking days. Yes! I had to somehow do it. I listed out all
the things I had to do towards building it up; met a few people
who had initially helped me in my endeavour.
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Even they laughed at me. ‘Are you really serious or are you
joking?" — they had no confidence in me.
Still I was very clear about my goal. I was ready to put in any
amount of hard work. It is my workshop. I am rebuilding
it
Yes, I will enjoy the process of doing it. I planned step
by step, and in the end, I did achieve my goal! I felt really
good about myself. The amount of thrill and pleasure I derived
when I completed each step
Oh! it cannot be expressed
through mere words!”
To others, Naveen’s goal was unrealistic. They laughed at him. But Naveen
had a lot of clarity in his thinking. His sincerity and hard work did
pay him dividends. He achieved his goal and was immensely happy.
The goal will definitely differ from person to person. It may be anything
— its sole purpose is to add value to life. For one individual, a new
professional career may be a viable objective; someone else may
recognise meaning in providing support to his children in their studies....
to save money for the daughter’s wedding.,
no matter what the
goal is, real satisfaction is derived once he starts working in a committed
manner towards achieving that goal.
However, these goals should be periodically evaluated by people who are
interested in the recovery of the chemical dependent. These can be discussed
with the family members, the wife, parents, a friend or a Counsellor.
Working towards the goal
Once the person has identified a goal, the next step is to make a daily
structured plan which will enable him to proceed towards achieving
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that goal. Commitment, sincerity and hard work are the prerequisites.
There are no substitutes.
Every day activities should be directed towards achieving that goal.
The recovering person should be helped to list out the priorities in his
life so that he can set goals according to his priorities. In order to achieve
each goal, he will be listing sub-goals or tasks to be executed towards
achieving that goal. He should also have a time scale for the completion
of every task. At the end of every day, he can make a list, on a paper,
of the items to be accomplished the next day. As they are completed,
he can cross them off. On a good day, he may find himself crossing
off nearly all the items and feel really happy.
Krishnan, a tailor who had been abusing ganja says,
“When I came for treatment, I was in shambles. I had lost
all my three shops and had even pawned my last sewing
machine.
During my two months’ stay at the After-care Centre, I
decided on two things
- I’ll not touch ganja again.
- I’ll get back one of my shops.
When I talked about this, my relatives ignored me. Some of
them made fun of me. I didn’t bother. I planned all the things
I had to do. I worked under another tailorfor a month; earned
some money and hired a sewing machine. I carried the
machine, walked across to several houses, sat there and
stitched for them.
There were moments when I felt really depressed. “Why
should I slog like this? Why not smoke ganja again?”
Immediately I would stifle such thoughts. No. I’ll surely get
back my shop. I worked all through the day, saved enough
money and bought my own sewing machine.
My family was very happy and helped me in all possible ways.
I took a contract with two schools to stitch their students’
uniforms. Everyday I noted down my schedule and always
delivered the uniforms on the promised date.
ALCOHOLISM AND DRUG DEPENDENCY
158
This brought me a 'good name" and orders piled up. In one
year's time, I got back my first shop. This motivated me to
work harder and within two years, I got back all my shops.
You will be surprised if I tell you that my third shop was
'opened' by a famous film star."
Working with gusto and enthusiasm
Enjoying the work he is doing, will be a new and delightful experience
for the recovering person. However, this calls for a positive change in*
the attitude of the chemical dependent. All along, he had been seeking
happiness and gratification through drugs. Now he would have realised
that drug taking is no more a pleasurable experience for him. So he
has to replace it by other ways of deriving joy. Are there any changes
he has to consciously make towards enjoying life? Ofcourse, yes.
The disinterested person should start getting interested in all the activities
of life. His depression should be replaced by enthusiasm. All along he
might have been dishonest, selfish and unconcerned about others.
Now during recovery, he should get involved in and committed to
whatever he is doing. Whatever be the nature of work he is
performing, if it is done with total involvement, it will surely give him
immense satisfaction. Once he is back home, he may be helping his
children in their homework;
assisting his wife in house
hold chores;
cleaning the house;
buying vegetables for the
family etc. The job per se may be a simple one, but the fact that
he has done it to the best of his abilities, will definitely give him
satisfaction.
Joseph says:
"Only now when I am off Ganja, do I realise that there are
so many little pleasures around me. The early morning with
its cool breeze, refreshes me. Today I am able to enjoy each
and every dish that my mother prepares for me. I personally
go to the market to buy vegetables. I know what my son, wife
and mother like. I take special care to buy what each one
enjoys... Today I am able to help my son with his homework,
and both of us enjoy the experience. Whatever I do, gives me
lot of joy and satisfaction."
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IMPROVING THE QUALITY OF LIFE
159
Exercising the freedom of choice
Unlike animals, man has the right to choose. Animals are governed
by their inborn instincts and their urge to survive. For example, a tiger
instinctively fulfills the need to nourish its body by eating other animals.
It does not and cannot choose to be a vegetarian and start eating grass.
But man has an intellect, a thinking faculty, and unlike animals, mere
bodily survival does not constitute his life. He not only wants to continue
living, but to live in a meaningful way.
Time and again, the chemical dependent should ask himself,
“Have I understood the importance of making choices in my life?’’
“Am I aware of the choices given to me or do I lead a life which is
governed by impulses?”
He can make the best out of his life, rebuild meaningful relationships,
provide financial support for the family, excel in his job, have lots of
fun and derive real happiness by giving up only one thing — he has
to stop drinking/using drugs totally for life. His powerlessness over
chemicals will no more be a handicap for him, provided he takes
necessary steps to put back his life in perfect order.
If we go through the careers of people of achievement, we will be firmly
convinced that a large number of them succeeded because they started
out with handicaps that spurred them on to great endeavour and great
rewards. Milton wrote his immortal poetry when he was blind, and the
great Beethoven composed everlasting music when he was deaf. Helen
Keller’s brilliant career was inspired and made possible in spite of her
blindness and deafness. Wilma Rudolph till the age of 11 was afflicted
with polio, and yet, went onto become an Olympic Gold Medallist in
the 100 metres.
The reason behind the success of these great people, is they exercised
their freedom of choice in a positive manner. They turned all their
handicaps into achievements by looking forward instead of backward.
Their positive thoughts released creative energies which made them get
so busy that they neither had the time nor the inclination to mourn
over what was past and forever gone.
With the help of the staff and other residents, it is possible for the
chemical dependent too, to exercise his choice and rebuild his life.
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Making meaningful changes
The present status of the chemical dependent is a result of his past life
and experiences. However, he need not harp upon the past because it
cannot be changed. That he is powerless over chemicals, is a reality
which cannot be changed. The actions he had done under the influence
of chemicals, cannot be changed. Whatever has happened, has
happened. He cannot do anything about them. Instead, he can
concentrate on the present — on the things which he can change, which
he can repair. He should exercise his self-effort and make
meaningful changes in all areas of his life. He can change his attitude
towards himself and towards the world. He can strive to make amends
to those he had hurt. He can set right the financial damages. He can
rebuild meaningful relationships
and so on. What one meets in
life, might have been pre-determined, but how one meets it, is
self-effort. The future lies under the control of the recovering
person since he has the capacity to change- it by regulating his
self-effort from now on. The future, therefore, is a continuity of the
past, modified by the present. The freedom to modify the effects of
the past and create a meaningful future is the result of nothing but
self-effort. .
Arun, a recovering alcoholic speaks his mind:
After treatment, Ifelt terribly guilty,., thoroughly ashamed.
When I was drinking, I had refused to pay my son's school
fees. So he had to discontinue his studies. My God! How cruel
had I been! I decided to do something now! What do I do?
How do I give him a good future?
I called my son and discussed with him. He was very keen
to continue his studies. He said he would join a postal course
and finish his schooling without any break.
I immediately enrolled my son in a correspondence course...,
started working overtime to pay his tuition fees..., spent a lot
of time helping him during his exams.
I made these changes with total commitment; and the result
was he became qualified to enter college. ”
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IMPROVING THE QUALITY OF LIFE
161
Being aware of personal strengths
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The chemical dependent has a normal tendency to belittle his abilities
or discount his strengths. He constantly keeps comparing himself with
others and feels inadequate. He should be made to understand that the
purpose of his life is to discover his potential so that it can be moulded
and channelised in such a way that it enables him to discover a meaning
for life and make it productive.
Prakash recalls, “When I entered the After-care Centre, I was
feeling inadequate.... unworthy. After one month, we were
asked to play the ‘self-esteem ’ game. Others were asked to
point out all the positive qualities they found in me. To my
surprise, they identified so many of my personal strengths,
which, all along I was not even aware of.
Four people said that I was very good at cleaning vessels and
washing the clothes. One of them commented that when he
was depressed, I was very warm to him and gave him lot of
emotional support.
I felt extremely happy because for once I realised I was a
worthy person. ”
In short,
★ Recovery is an opportunity to set new goals and new life directions;
and working towards worthwhile goals in life is important for
keeping recovery strong.
The
recovering person’s goals, both short-term and long- term,
★
should be realistic and compatible with the needs of recovery.
★ He should make appropriate choices and take necessary steps to
put back his life in order.
★ He should concentrate on making meaningful changes in his life
and focus on setting right all the damages.
★ He should develop a strong self-esteem by being aware of his
personal strengths.
★ No matter who the recovering person is, or where he started from,
with commitment, patience, perseverance and hardwork he can
definitely improve the quality of his life, and thereby achieve success
and satisfaction.
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ALCOHOLISM AND DRUG DEPENDENCY
Additional information
A ready-to-use questionnaire for the patients
Addiction might have caused you a lot of suffering. But recovery gives
you special wisdom and also a very special opportunity to set a new
course for your life. As you define your goals for the near future
and beyond, think about the following:
★ Are your goals consistent with the needs of recovery, and will they
lead you in safe directions?,'
★ Are your day to day activities consistent with your goals?
★ Do you have some goals that will be relatively simple to achieve
and fun to work on?
★ What are the new activities you have taken up? How do you feel
after completing them?
★ What are the damages that have happened in your life as a result
of your addiction? What are the steps you are taking to rectify them?
Specify with examples.
★ What are your good qualities? How do you exhibit them? Specify
with examples.
Although we can’t make life go exactly as we plan, we can certainly
make plans that help us enjoy life. Make your plans realistic and execute
them well. Keep them growing with your own progress. Recognise your
strengths — they express who you are and who you can be.
Bibliography
1. Addict After-care: Recovery Training and Self-help, Fred Zackow,
William E McAuliffe and James M N Ch’ien — National Insititute
on Drug Abuse, USA 1985.
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SPIRITUALITY
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What is spirituality?
What is the role of spirituality in recovery?
Following are the responses pf a few well known people who have
specialised in the field of addiction treatment.
Vernon Johnson — Minneapolis, Minnesota.
“A very difficult word. It is not religion, although it expresses itself
that way. It is not morality, although it expresses itself that way. It is
a quality through which the individual is identified. It is an activating
principle which motivates. The way a person looks at himself implies
his spirituality. We look in the mirror and see ourselves as being either
useless or worthwhile. Chemical dependency destroys spirit. It replaces
feelings of self-worth with self-loathing and hate. Recovery means
recovery of the spirit.”
Linda Smith — Chattanooga, Tennessee:
“It is a process of defining me through the recovery steps of awareness,
honesty, surrender, acceptance, gratitude, allowing me to be free from
the past,
finding balance, becoming whole........ living m the here
and now, feeling my feelings, owning responsibilities, making choices,
and having serenity. From this ptOcess, I find my identity, that is, who
I am, and what I am all about”.
Dave Mills — Fort Lauderdale, Florida:
“It is a partnership. But I have to hold up my end of the bargain. I can’t
just lay back and say, ‘Okay, God, do it.’ The God of my understanding
provides opportunity and it is up to me to take advantage of those.
Wayne Kritsberg — Austin, Texas:
“There is a certain improvement in recovery, or a certain quality, for
which spirituality is necessary. There is no depth of recovery without
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a spiritual anchoring — that is primary. My personal belief is that once
a decision is made that there is a God, then everything becomes a
manifestation of God — consciousness.”
The chemical dependent tried to experience short lived joys, and ended
up feeling cheated and betrayed because the hoped for and promised
joys of the drug resulted in pain and disaster. This led to an awakening
in him. In order to free himself completely from dependency on the
drug, a replacement was necessary for him and this is the role of the
spiritual.
Spirituality is experiencing whatever it is that makes life worth living.
It refers to getting in touch with the meaningful and long-lasting values
of life while going beyond the superficial. It means waking up to what
is really important in life.
Spirituality is a simple way of living. There are four basic movements
that recovering people need to make to put their lives on a positive
spiritual basis. The first is a movement from fear to trust; the second
from self-pity to gratitude; the third from resentment to acceptance;
and the fourth, from dishonesty to honesty.
Discovering the meaning of life
Spirituality is really getting at the spirit of life. It is this that enables
the recovering person to unlock the secrets of life which contain both
suffering and happiness. This happens when looking through into
themselves, they discover not only themselves but all that is outside as
well. In fact, the power to discover life’s secrets lies within the man.
Spirituality is the power within man to discover life’s meaning.
The notion of God or Higher Power is a part of spirituality.
The following example will clarify this statement.
OTHERS — PROBLEM — AWARE
ME
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The chemical dependent did not know about his problem first.
Who knew about it? — may be his wife, his friend, or his boss. Usually
someone outside of himself was aware of the problem before he came
to realise. In order to gain awareness, what did he do? He opened up
and allowed the awareness to enter into him.
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OTHERS - PROBLEM - AWARE
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AWARE ME
Only then did he become aware of his problem. This awareness,
however, was not the solution to his problem. Then where did the
solution lie? He opened another door and went out of himself and asked
for help from others.
others _ pROBLEM _ AWARE
OTHERS HELP 4
AWARE ME
These others indicated for him as to what could be done; in other words,
they helped him. But even here, his cooperation was needed. What did
he do? He opened still another door and allowed the help to enter into
him and become a part of himself:
OTHERS - PROBLEM - AWARE
OTHERS HELP
AWARE
ME
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ALCOHOLISM AND DRUG DEPENDENCY
166
To the extent the chemical dependent relies only on himself, he can never
recover from addiction. To the extent he allows the help to become
part of him, he can be sure of recovery. In other words, spirituality
enables him to realise that he requires much more than his own resources.
He needs outside help. If a person does recover, it is due to his own
efforts and he deserves the credit. It is also equally true that he needed
all the outside help to recover. The Higher Power works this way.
OTHERS - PROBLEM - AWARE?
HIGHER POWER
AWARE ME
OTHERS HELP
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Rarely does the Higher Power offer direct help. Instead, He works
through the outside help influencing the person requesting help.
This then is what people mean when they say that their Higher Power
is A.A., their Counsellor, their family or their religion. That is the
outside influence and help through which the Higher Power comes to
the individual.
Let us hear what Sailesh, an alcoholic has got to say.
“I do believe that there is a Power that is greater than me,
that has guided and helped me throughout my life. During
my drinking days, I had enormous problems. I was really
unable to cope. I wanted somebody to help me. I didn *t know
which way to turn; whom to approach for help; what sort of
help I needed — I was confused.
Then the miracle happened. As usual, I came home with a
small packet of peanuts to munch along with my drinks.
The peanut was packed in the portion of a newspaper.
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167
When I opened the packet, I was thrilled. The piece ofpaper
carried an advertisement of a treatment centre for addiction
— the information I longed for. At that point in time, I really
felt the presence of the Higher Power in that portion of the
newspaper. It was so very valuable to me. ”
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Ravi remarks,
“There were several occasions when I had really felt the
presence of the Higher Power. To give you one example, one
month after treatment, I stopped taking Antabuse, convincing
myself that I will not get tempted at all. I didn ft buy the
medicine.
One day, when I was walking along the street, I came across
an arrack shop and immediately felt a deep craving to have
a drink. I was desperate. I found it very difficult to resist.
I was too restless. I put my hand in my pocket to take the
money to buy one glass of arrack. To my astonishment, what
came to my hand was not money, but a tablet of Antabuse.
I swallowed the medicine and really felt in my heart of hearts
that that was not mere medicine but the Higher Power Itself.,f
Recognising the need for outside help is basically what Higher Power
should imply. To stay with his own resources is to shrink and decay.
To reach out for help, is to blossom and grow. To ask for help is not
a sign of weakness; on the other hand it requires enormous strength
to acknowledge one’s limitations in order to develop and grow.
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Faith in a Higher Power
Many chemical dependents do feef that at a point in time when they
had used up all resources of family, friends and even professionals,
there was still one source of help. It is the one that never fails, never
gives up, and is always available and willing. When all help failed, they
grabbed a rope and hung on.
Every recovering person believes and knows from experience that a
Power Greater than Himself can remove his obsession, straighten out
his thinking and restore him to sane thought and behaviour. What he
calls this Power, is a matter of his own choice. Naming It is unimportant.
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ALCOHOLISM AND DRUG DEPENDENCY
The important thing is that he believes in It; that he uses It to
restore him to health and fitness. Thus faith in a Higher Power is the
basic law of recovery. It is always evident in the lives of recovering
people.
The chemical dependent need not call this Higher Power, God. He can
call this Power as he understands Him. That Power may be a Supreme
Force, that designed this vast complex Universe, so far beyond our
capacity to understand, of which we are only an insignificant part.
We need not understand how the Universe or the Higher Power works.
It is like electricity — we do not know what it is, but it is there to use
and we use it.
A person walking into a dark room does not worry about understanding
electricity. He just looks for the switch and turns on the light. In the
same manner, a chemical dependent can turn on the switch of spirituality
by simply asking the Higher Power each morning for another day of
sobriety and thanking Him at night for another sober day. He should
start doing it mechanically even if initially he does not believe in it.
In course of time, he will be able to feel the strength and courage he
derives from it.
In other words, his understanding starts with blind faith, which open
to conviction, grows into “conscious contact with God.” A sure way
of increasing this help and improving contact with Higher Power, is
possible through simple prayers of sincere appreciation. He can start
acknowledging the help He has given and be genuine in his thanks for
His understanding of the ‘problem’ and the strength He has given to
overcome it.
Prayers of appreciation are good for chemical dependents. They remove
egoism and awaken them to life’s true values. They act as stabilizers
to the restless nature of the chemical dependent.
The serenity prayer
“God grant me the serenity
To accept the things I cannot change..
Courage to change the things I can.
And the wisdom to know the difference.”
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The recovering person must first accept the fact that he is a chemical
dependent. There are certain things he can deal with successfully, but
there are certain other things which he just cannot change.
The recovering person cannot use mood altering drugs of any nature
because that would bring back the negative attitudes and make the
positive sense of self worth disappear. He cannot change the situations
or happenings of the past when the drugs were in full control and had
taken absolute charge. There is no point in clinging to the past and
worrying about things which cannot be changed.
There are several things which the recovering person can change. He can
correct his past mistakes and make amends to those he had harmed
or hurt. He can change his attitude towards himself, his family and
friends. He can change his resentful attitudes and replace them with
tolerance and forgiveness. He can change his entire personality and start
practising honesty, humility, appreciation, forgiveness, promptness in
admitting wrongs, making amends and rendering service to others.
The recovering person should not waste his time harping on things which
cannot be changed, but rather direct his time and energy in helpful,
constructive activities where satisfactory results are possible.
Each worthy thought put into practice brings the recovering person a
step nearer to the Higher Power. They are the stepping stones over which
the person slowly progresses to greater awareness of His presence.
They are the means by which he makes a conscious contact with Him.
By constant practice, the chemical dependent can gain the priceless
reward of contented sobriety.
Bibliography
1. Henwood Lecture Series - 1983.
2. Changes (For and about Children of Alcoholics), Nov-Dec 1986,
Published by the U.S. Journal of Drug and Alcohol Dependence
Inc., Florida, USA.
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ASSERTIVENESS TRAINING
‘Assertiveness’ is the ability to act in harmony with one’s values, and
self esteem, without hurting others. It is a direct and honest expression
of one’s feelings towards others' without violating their dignity.
Assertive behaviour, in practice, is a socially appropriate, inter
personal behaviour which includes the ability
- To express one’s feelings
- To decide how one will act
- To speak up for one’s rights when it is appropriate
- To disagree when one thinks it is necessary
- To carry out plans for modifying one’s own behaviour
- To help others to change their inappropriate behaviour
As a result of this, one’s self-esteem gets enhanced and self confidence
gets strengthened.
Thus, when a person conducts himself in an “assertive manner”, he
is stating positively, assuredly and strongly his own feelings, while at
the same time taking into account, others’ feelings also.
Each one of us can think and act in three different styles. A close look
at these three styles, will clarify what assertiveness really means.
Passive
A passive person fails to stand up for his rights, and does not express
his thoughts, feelings and beliefs. In case he does, he expresses them
so apologetically, that they are ignored.
Aggressive
An aggressive person stands up for his rights and expresses his thoughts,
feelings and beliefs in such a way that other’s rights are violated.
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ASSERTIVENESS TRAINING
An aggressive person hurts others in order to get his way. He ignores
others’ feelings, needs and opinions. In short, aggressive behaviour is
characterised by domination.
Assertive
An assertive person stands up for his rights in ways which do not violate
the rights of others. He is clear regarding his own feelings and goals
and also knows what he wants to accomplish by asserting himself.
t ■
The characteristic traits which dominate each type of personality, are
given in the following table
PASSIVE
1
AGGRESSIVE
ASSERTIVE
Behaviour
Doesn’t stand up for Stands up for his Stands up for his
rights but violates own fights in such a
his rights.
way that Others rights
others’
are not violated
Puts himself down Puts down others, Expresses needs,
and is apologetic ignores or dismisses opinions and feelings
about his feelings, feelings, needs and in direct, honest and
needs and opinions. opinions of others. appropriate ways.
Expresses himself in
rude ways.
Attitude
You’re okay, I am I’m okay, you’re not I’m okay, you’re
okay
okay
not okay
Thinks that others’ Thinks that his needs Thinks that just as he
needs are more are always more has his own rights,
than others also have
important than his important
theirs.
others’.
own.
Thinks that only Thinks that others Thinks that everyone
others can exercise don’t have rights has something to
contribute.
their rights.
Thinks that others
don’t have anything
to contribute.
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172
PASSIVE
AGGRESSIVE
ASSERTIVE
Feelings
Feels
helpless, May feel good Feels good about
frustrated and angry temporarily because himself.
with himself and he has got his way,
resentful towards but is full of remorse,
guilt and self-hatred
others.
because of hurting
others.
Aim
To avoid conflict, To win at any cost To maintain selfpleases others at any even if it means harm respect and dignity.
to others.
cost.
Why do people lack assertiveness?
A major deficit area which has been identified is LOW SELF-ESTEEM.
People with low self-esteem typically place three large obstacles between
themselves and the goal of assertiveness
— poor communication skills. Inability to stand, look, or talk in a
confident manner.
— inability to handle/control their emotions; poor coping skills in
stressful situations.
— negative image of themselves. They feel inadequate and experience
fear of rejection.
The therapeutic technique by which assertiveness is taught to or
enhanced in clientele is called ‘assertiveness training’. Therapy goals
include an increased ability to express negative feelings (resentment,
fear, guilt) and positive feelings (j°y, love, appreciation) appropriately.
‘Assertiveness training’ is also helpful in dealing with issues relating
to interpersonal conflicts and problem solving.
Assertiveness will benefit the client in two ways. First, behaving in an
assertive way will instil in the client a greater feeling of well being. Secondly
the client will be able to achieve significant social rewards (dignity, respect,
recognition) and thus obtain more satisfaction from life.
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ASSERTIVENESS TRAINING
173
In this, the Counsellor functions as a teacher, with the aim of helnuvthe client understand what is wrong or lacking in his behavioural and
communication styles and how to change or improve upon them.
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Assertiveness training lays emphasis on two factors
1. Identification of the target behaviour that needs change.
2. Planning with the patient a systematic programme to a 'b'O'result.
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Goals of assertiveness training
Assertiveness training aims at teaching the client the to,, ".vim.,
★ Everyone has basic rights
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★ Each one is responsible for himself and his behavioui
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It is often appropriate to bring about a change in one-elf than in
others.
When
an individual changes his behaviour, others will automatically
★
start responding differently to him.
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Techniques of assertiveness training
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By far the most commonly used assertiveness training technique
role play. This technique requires that the client and the r omv-e.
act out relevant interpersonal interactions along with other pati* :
Part of the time the client (who wants to change) plays the role himsen,
with the Counsellor and other group members assuming the --ole ol
significant person in the client’s life such as a parent, employe,
spouse. In carrying out this role, the Counsellor must poitiay m
person’s role in a realistic manner. The following is a summm. . ■
technique of role play as applied to a specific area of interpc... difficulty.
1. The client enacts the behaviour as he would in his real life.
2'. The Counsellor provides specific verbal feedback, stressing positive
features and presenting inadequacies in a friendly, nou-pmut*.
fashion.
3. The Counsellor models more desirable behaviour, with the client
assuming the other person’s role when appropriate.
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ALCOHOLISM AND DRUG DEPENDENCY
4. The client then attempts the response again.
5. The Counsellor rewards (praise, appreciation) improvement. Steps
3 and 4 are repeated until both the Counsellor and the client are
satisfied with their responses, and the client is confident of
responding with little or no anxiety in real life.
6. The interaction, if lengthy, should be broken up into small segments
and dealt with sequentially. Then the client and Counsellor can run
through the entire interaction for the purpose of consolidation.
7. The Counsellor should also'monitor the choice of words used by
the client and the accompanying expression of feelings.
8. The Counsellor may gradually fade out from modelling assertive
responses and have the client assume more and more of the
responsibility for generating assertive tactics.
‘Assertiveness training’ indicates that small changes in one s behavioural
pattern may bring about a large and wholesome impact. Assertiveness
training is carried out in stages.
In the first level, deficits in the following areas can be handled - eye
contact, posture, tone of voice etc.
The second level involves the basic skills of assertion - ability to say
‘no’ and ‘yes’ when one wants to say ‘no’ and ‘yes respectively, ask
for favours and make requests, communicate feelings and thoughts in
an open, direct way, and handle criticism.
The third level pertains to more complex interactions with others adaptive behaviour in job situations, ability to form and maintain a
social network, achievement of close personal relationships.
Types of assertive responses
An assertive person would display the following emotional/behavioural
responses:-
Non-verbal
- Greet others with warmth
- Smile and respond'in a friendly manner
- Maintain an adequate, comfortable, erect body posture.
ASSERTIVENESS TRAINING
175
- Establish adequate eye contact. The individual learns to look into
the eyes of the person he is talking to.
- Talk in a clear tone so as to be heard by others.
- Use facial expressions that normally go with different emotions.
- Use appropriate natural gestures.
Verbal
Expressing One’s Feelings
To express one’s personal likes and dislikes explicitly rather than state
things in a neutral fashion.
Communicating About Oneself
This does not mean monopolising conversation, but mentioning
accomplishments wherever appropriate.
Accepting Compliments
Accepting compliments gracefully rather than disagreeing with and
rejecting them.
Practising the use of “I”
Using “I” in situations like admitting a mistake or accepting responsibility.
Disagreeing Appropriately
Not pretending to agree for the sake of maintaining peace.
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Asking for Clarification
If someone gives confusing directions, instructions or explanations, the
courage to ask that person to restate them more clearly.
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Asking Why
■
If requested to do something that does not seem reasonable, the ability
to ask ‘why’.
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Being Persistent
To restate a legitimate complaint.
Avoiding Justification
The strength to avoid giving excuses, alibis, reasons for one’s own or
others’ behaviour.
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ALCOHOLISM AND DRUG DEPENDENCY
Chemical dependency and assertiveness
Clinical and experimental studies on chemical dependency have indicated
that interpersonal situations which require assertive responses are
stressful for chemical dependents and frequently set the occasion for
a relapse. Feelings of social inadequacy or an inability to express
emotions can both lead to frustration and serve as potent cues for drug
taking. Research has proved that ‘social pressures’ to drink, and peer
pressure to take drugs are the most stressful interpersonal situations
faced by the recovering chemical dependent. This finding has stimulated
a number of behaviour therapists to advocate that the chemical
dependent should be taught to say “NO” effectively. A study by Miller
and Eishler (1977) indicates that alcoholics (when sober) showed less
ability to express negative feelings such as resentr tent or irritation and
those who were unable to express their negative feelings subsequently
consumed alcohol whereas those who did express their negative feelings
were able to abstain. Thus a correlation was noted between lack of
assertiveness and alcohol consumption.
Typically in the After-care Centre, assertiveness training for a chemical
dependent can take the following forms:-
(1) Discussing actual incidents wherein the client had been under
tremendous social pressure to consume drugs/alcohol.
(2) Discussing hypothetical situations where the client needs to convince
a party otherwise.
After identifying the situation, role play technique can be used to
enhance assertiveness.
The situations which can be enacted are:—
— Client attending a party where alcohol is served
— Family members suspecting that the client has taken drugs
— Wife insisting that she will spend on something that the client feels
is not of immediate priority
— Boss requesting the client to stay after office hours (overtime) while
the client has another important commitment.
— Expressing feelings of anger, anxiety, fear, and depression.
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179
n
4. ‘Don’t Say Yes when you want to say No’, Fensterheim Herbert and
Baer Jean, Futura Publications Limited, Great Britain, 1976.
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5. Assertion Therapy: Skill Training or Cognitive Restructuring,
Behaviour Therapy, Linehan, Golfried and GolfriCd, Vol. 40,,1979,
pp 372 - 388.
'
.
... ...
6. Assertive Behaviour for Alcoholics, A descriptive analysis, Behaviour
Therapy, Miller Peter and Richard M Fishier, Vol. 8, No. 2, 1977,
pp 146 - 149.
19
GROUP THERAPY
Group Therapy has been acclaimed over the years as by far the most
effective method of treatment for addiction. The gains of group therapy
are now well established. Following are a few therapeutic gains that
are unique to group therapy.
— Provides an opportunity to share and identify with others who are
going through similar problems. Groups help in the development
of a sense of belonging.
— The spontaneous sharing of older members, of their progress and
the changes they have achieved, instil hope in the new sceptical ones.
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— Helps clients understand their own attitudes about chemical
dependency and their defences against giving up chemicals by
identifying similar attitudes and defences in others.
— Verbalisation of thoughts and feelings, open feed back from others
about positive and negative behaviour and being a witness to
successful conflict resolution, helps them develop socialisation skills.
II
— Teaches meihbers interdependence (in contrast to dependence on
chemicals) and thus build a better social net-work. This also helps
chemical dependents to work through social and emotional isolation.
— Provides a congenial atmosphere to powerfully confront denial, and
assess high-risk situations. Members utilise the group as a laboratory
for developing new responses and new skills.
— Provides an opportunity to formulate realistic goals and plans.
— Sharing insights, offering suggestions and support, gives an
individual the pleasant feeling of helping another. This altruism aids
in strengthening self-esteem.
That group therapy can be effective is beyond doubt. The task then for
the Counsellor is to maximise the gains within the available time frame.
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GROUP THERAPY
Following are a few basic guidelines that contribute to efiecl
therapy sessions.
*
Size of the group
5 — 10 members in a group is termed by Yalom as the ‘Acceptable
Range’. When there are less than 5 members, it fails to function as a
group; with more, it becomes unwieldy — both making it less !
c.
Duration of the group meeting
A minimum of one to one and a half hour is needed for the group ■ >
settle down and get to work on an issue. However, if a group streb-i •
beyond 90 minutes, fatigue sets in and diminishing gains are report
Frequency of meetings
f
Five group meetings a week works well at the Aller-care < ('ib:
On discharge/follow-up, meetings may be held once or twice v ' to strengthen changes made and offer support through the rccovei
process.
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Physical environment
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A pleasant quiet room, that ensures privacy is a pre-requisite tor group
therapy meetings. The seats should be similar and placed in a ciiclc
conveying that all are equal. Moreover, everybody is visible to the rest,
of the group; face to face interaction is made possible and non-verbal
behaviour can be easily observed.
-
>
Rules and limit setting
3
The Counsellor clearly spells out basic rules like punctuality, regular
attendance and staying for the entire session and not leaving J ■
not attending under the influence of drugs, at the beginning ■<’ Hh
session. The following norms are important and they help iiKnb?'-rs
function appropriately:
Confidentiality
Any information gained about another group member in
group therapy setting is to be treated in strict con: iJ mcc. hi .: ■ •
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“What happens in the group, stays within the group
repeatedly stressed.
should be
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Listening
Maintaining eye contact, willingness to listen to other person’s feelings
and words without interrupting, are important. Interruptions are not
to be made unless
- the other is repetitious.
- the other is rambling without focussing on issues relevant to the topic
of discussion.
- the listener has not understood and wishes to clarify his thoughts.
Using 4’ Statements
‘We’ and ‘They’ statements lead to superficial sharing on generalised
issues. ‘You’ statements usually turn into critical, judgemental ones.
‘I’ statements, on the other hand, help him speak only for himself and
own responsibility for his feelings, thoughts and behaviour. (Example:
“I feel ashamed. I have hurt my parents”).
Open, Honest, Spontaneous sharing
Group therapy offers an unique opportunity for handling issues.
It should be emphasised that to maximise gains, wholehearted
participation of the group is essential. Each member needs to remember
that “the more he puts into a group, the more he will benefit from the
experience”.
All participants are considered equal, irrespective of their drinking/drug
taking status, number of days they have stayed at the Centre, or nature
of the damages. The Counsellor, as a facilitator of the group, need not
share any details regarding himself.
Feedback
Guidelines for giving feedback
Feed back is an essential component of group therapy.
The following are a few guidelines to be discussed with the clients prior
to entry into the group:
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To talk about behaviour one can see.
It should be specific and relevant. “I notice that you arc late by
5-10 minutes everyday. So we are unable to start the group
meeting on time.”
★ Feed back should be given caringly and not by hurting or attacking
another member. No judgemental statements should be made.
‘T can see your problem. You are working in a bar, and you have
no access to A. A. meetings also.”
★ Members should avoid sarcasm and condescending remarks while
giving a feed back. No advice is to be given - only responses.
“You want to repay debts to the tune of One lakh in 6 months? You
must be joking.” - Sarcastic remark.
“Listen to me. You cannot handle this. You better ask your wile.”
- Advice.
“Let us plan out various methods and see how best it can be worked
out.” — Proper response.
★ Members should be encouraged to share positive feed back also,
“lam touched by your honest sharing.”
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Guidelines for receiving feedback
Members should spontaneously ask for feed back and openly
receive it.
★ Excuses should not be given. Members should avoid defensiveness.
★ Members should learn to acknowledge the value of feed back and
express appreciation.
‘T am glad you have helped me see the positive qualiiies of my
brother.”
★ Members should think and build upon the feed bad d -cm i b'•
should view feed back as a continuing exploration.
★
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The process of group therapy
Classically the group process can be divided into three phases i' e ■ ■
phase is the beginning of the group, particularly the first Ic jn-'ctirivs.
The middle phase is the substance of the group, with the cliciie minnh
ALCOHOLISM AND DRUG DEPENDENCY
184
together, interacting, sharing, growing and changing in the Counsellor’s
presence. The last phase is when the client completes the programme
and leaves the group.
The first meeting
Group members are usually very anxious over their first meeting. As in
any relationship, introductions are needed. The Counsellor initiates the
process by introducing himself, outlining the purpose of the group, and
soliciting introductions from the clients. This can be done in several
ways, of which the following is one example:
“I am glad that every one of you could make it. Let’s get started.
As you know my name is
I want to tell you why we are here
and what we will be doing in these meetings. Some of you know
each other and others do not. One thing that every one has in
common is being dependent on alcohol or drugs. This is going to
be a time to get to know each other, learn about problems each
one is facing, and find new ways to deal with them. At times we
will talk about issues which may be sensitive like feeling lonely,
depressed, problems at home etc. Here you will discover that you
are not alone with these feelings and when you start sharing you
will definitely feel less painful. Members here will help you minimise
your pain.”
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The introduction sets the tone for the group. In the above example we
find the following messages:
1) A statement of the purpose of the group
2) Identification of commonality. This aids in developing unity in the
group.
3) Disclosure that sensitive issues will be explored. It is vital that clients
know that such topics will be discussed.
4) Often they are overwhelmed by their problems and are disillusioned
that no alternatives exist. Group gives them the much needed hope.
Introduction of clients can be done in many ways. When the suggestion
is open ended that is: 4‘Let’s say our name. Talk something about
ourselves,” the response may be either anxiety -ridden silence, or names
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185
rattled off in a rapid fashion with no mention of personal data.
Introductions are the chemical dependent’s first step towards self
disclosure. They can be in a state of panic and can have a lot of anxiety.
To get over this initial barrier, the following methods may be followed.
First the group can be divided into pairs and each client asked to
introduce himself to his partner. After this initial contact, they could
come back, form a group and introduce the person each one met.
This exercise helps the client take off direct focus on self. The second
method of approach is to request senior members to introduce themselves
first, thereby setting a role model for the new comers. After the
introduction, the next step is to spell out group guidelines. These group
guidelines have been discussed in the earlier part of the chapter.
Extensive clinical observations show how the group evolves and moves
through three stages of growth. In general, a successful group will flow
through them. While at times, it may regress to the previous stage, it
will eventually move into the later stages.
Each stage is characterised by its own set of feelings and behaviour.
Being familiar with these, will help the Counsellor identify which stage
the group is in, so that he can aid its moving successfully through its
developmental stages.
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Stages in group therapy
First Stage: Formative Stage
Hesitant participation with random spurts of energy mark this stage.
The participants look at each other with caution, find similarities and
differences and attempt to establish Ihe universality of the problem of
addiction.
Not sure of how the group will progress, participants display dependency
on the Counsellor. Communication is limited to superficial issues,
stereotyped and directed more to the Counsellor than to other members.
They frequently look to the Counsellor for approval and appreciation.
Here the Counsellor should encourage members to relate to the group.
By repeatedly calling attention to the need for T messages and
descriptive rather than judgemental statements, the Counsellor sets the
stage for smooth progress.
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ALCOHOLISM AND Di<UG DEPENDENCY
The therapeutic benefits which the client experiences in the early
phase are —
★ Anxiety is reduced.
★ Clients establish relationships which remove loneliness and isolation.
In the early stage, sharing is more on structural details rather than
feelings. Members talk about their expectations, about what they want
to achieve during their stay at the After-care Centre, etc. After the initial
verbalisation, they start sharing about their addiction-related damages.
Middle Stage
As the group completes its initial tasks, it moves into relating — the
heart and soul of group therapy. Initially, the Counsellor will have to
actively facilitate sharing, with clear focus on specific issues. The most
important therapeutic, task in the middle phase is the handling of
defences. Defences will be high, and nurturing intervention in the form
of support from the Counsellor and the group is necessary in order to
break the patterns. The predominant form of defence used is denial.
There are atleast two levels of denial in a chemical dependent. First
is the denial of the magnitude of the drinking/drug taking problem.
Once the initial denial has been overcome, a second form of denial is
encountered — the denial of the need to change. This is seen more
commonly in the After-care Centre. Both these forms of denial can be
handled in the therapy group.
A general approach to handle denial is direct confrontation.
Confrontation will be successful only if the patient is well integrated
into the therapy group and has made a strong emotional investment
in the group process. Confrontation is most useful when spoken with
concern and accompanied by examples of the confronted behaviour.
Confrontation should be descriptive, focussing on what one has
observed in the person. It should be based on specific facts and not
a generalised comment, advice or discussions about something which
has not been witnessed by the confronter. Confrontation is best
accomplished by other members of the group.
The other therapeutic task of group therapy in the middle phase is
motivation. This should be an issue of concern throughout and must
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be built progressively. Initially motivation is built by focussing on
damages, thereby/giving insight to the client on the need to change.
Subsequently motivation is strengthened by focussing on the positive
changes each individual has achieved. This leads to a hope among group
members that it is possible to lead a drug-free life.
Recognition and identification of feelings is another task here. Now the
clients will feel comfortable and will be able to identify their negative
and positive feelings. An understanding of the fact that addiction is
a disease helps them to be able to talk/share about their feelings of
guilt, shame and hurt. Also members learn to respond openly to others’
feedback, and spontaneously report their feelings without hiding.
Chemical dependents discover that it is more helpful to be open than
to be right.
The more common negative emotional states like guilt, resentment, Ipw
frustration tolerance, shame, fear and anxiety are also dealt with. During
the ‘group process’, healing also takes place.
The Counsellor’s main task here lies in being alert to changes in the
tempo of the group. The Counsellor should be adept in making
significant interventions in case they lose the focus. He should help them
focus on issues, bring conflicts to the fore-front and deal with them
appropriately.
Towards the latter part of the second stage, the group weaves its way
through conflicts with little help from the Counsellor. As the group
progresses, they slowly take responsibility for decision making.
The Counsellor makes conscious efforts to this end by refusing to
answer questions and encourages group participation in views expressed
and decisions made. The group thus learns to look for resources and
directions from within itself. The group’s attitude turns into one of
support and understanding for each other. This is eventually followed
by a stage of encouragement, appreciation, closeness and intimacy.
The therapeutic benefits of this stage are
★ Open sharing and ventilation of feelings are made possible.
★ Defences are handled in the group itself by the group members.
★ Dependence on the Counsellor is replaced by dependence on other
group members.
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ALCOHOLISM AND DRUG DEPENDENCY
Third Stage
The stage is now set for bringing in the most productive and satisfying
phase of the process. Members find it comfortable to express all feelings
and take responsibility for what they wish to achieve in the group.
Opposing view points are no longer threatening, and conflicts are
resolved constructively. Participation is at its best. Significant issues
are discussed, feedback received well and tasks get done at a rapid pace.
Sometimes groups fail to get here developmentally especially when
conflicts are seen as negative factors. The Counsellor’s task will be to
stay with the group in the second stage, work through conflicts and
help them reach this stage where members feel their dependence as well
as their independence. They are able to see their similarities and
differences, disagree at times and still feel comfortable.
The Counsellor’s intervention helps sharpen focus on emerging issues
and provides useful input to handle complex issues. The group may
have been revisiting the same problem areas as in the previous stage
but they are now viewed from a different perspective. The Counsellor
stays tuned to the tempo of the group guarding against stagnation on
one issue. During this stage the Counsellor consciously gets ready to
bring the group to the stage of completion. The major issues to be
focussed on are relapse prevention and recovery plans.
The therapeutic benefits of this stage are
★ Complicated issues are openly discussed and conflicts resolved.
★ Motivation to continue sobriety becomes their priority.
★ Members feel the significance of independence and interdependence.
Understand the importance of A.A./N.A. and After-care services
to maintain abstinence.
The Resolution Stage
When the group draws closer to completion or when a few members
prepare to leave the group, the situation may be anxiety — provoking
for all. To the members who are leaving, having to make do without
the group’s support and encouragement can be unsettling. The rest of
the group may also feel bad because they would miss the contribution
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189
of the older members. Now the Counsellor can give them reassurance
and encourage the members who are leaving, to make frequent visits
to the Centre.
Role of the Counsellor
*
The secret of making group therapy a powerful source for change is
an art and a skill. Here as in a counselling relationship, the basic
personality of the Counsellor, his professional training and experience
can make a world of difference. The Counsellor has to maintain a
relationship characterised by warmth, empathy, concern, acceptance
and genuineness. An effective Counsellor will be sensitive and flexible
to the needs of the group and flow with it, all the while making valuable
interventions.
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★ Helping members belong
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The group therapy situation may be stressful for the new comer.
The members are strangers to each other and look to the Counsellor
as the unifying force. By using this ‘special member’ status, the
Counsellor goes on to create one physical entity — “a group”, from
a collection of members with different experiences and problems.
Being supportive, accepting and sensitive to all members and
displaying this through appropriate verbal and non-verbal
behaviour, the Counsellor can create a sense of “oneness” or
“togetherness”.
Late coming, absenteeism, sub-grouping (two or three members
carrying on interactions while actively excluding others) and ‘scape
goating’ (majority of the group making one member the target of
their negative feelings) threaten cohesiveness. The Counsellor should
act early and decisively to counteract these forces.
★ Encouraging ‘Feeling Level’ Interactions
Feelings of shame, guilt, resentment and fear are the predominant
negative emotions. Being able to talk about them in a supportive,
caring environment to people who have actually experienced them,
is what makes group therapy effective. Handling anger and
resentment means getting to grips with the underlying true feelings.
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Members who are eloquent, may find it easy to share on a super
ficial level. By encouraging and emphasising ‘feeling level’ statements,
the Counsellor can help them get in touch with their negative feelings
which they try to run away from. Separating thoughts from feelings
and labelling feelings, helps them explore further and deal with them
better. This exercise stands them in good stead in their future
communication patterns and problem solving efforts.
★ Facilitating growth
The Counsellor should never forget that his involvement is of prime
importance in shaping the group norms. Too exacting behaviour
or being too passive can both inhibit members. He needs to play
his role with confidence and poise.
Basic rules that are set at the start of the group process may
sometimes need further strengthening. The Counsellor can draw
attention to the norms through statements, observations, questions
and display of appropriate non-verbal behaviour. For example, to
encourage member to member communication, the following
methods can be used:
- Asking for the other members’ reactions
- Refusing to answer questions directly
Nodding, smiling, good attending behaviour and verbal
reinforcements help shape positive behaviour. The Counsellor
choosing not to react to low tone conversations, late coming etc.
will be noticed by members of the group. Not attending to these
can even be seen as non-caring. Unhealthy practices like frequent
interruptions or excessive criticism can grow on quickly and it is
the Counsellor’s responsibility to guard against them.
The Counsellor should encourage feed back. When a member is
criticised or confronted, caring questions like, “How do you feel
about what was just said?”, helps that member respond. When
many suggestions or comments have been made in response to one
member’s sharing, asking him “What did you find most helpful?
How did you feel to receive so much?”, helps members give
appropriate feed back.
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The Counsellor is a ‘model setting participant’ in many ways.
Displaying good attending behaviour is quickly copied by the
members. By giving support and encouragement, the Counsellor
invites members to follow suit. The Counsellor’s handling of
conflicts by permitting expression of negative feelings and working
through them rather than suppressing them, helps members learn
to do the same even in real life situations.
★ Recognising the Group’s Power
The primary therapeutic agent in a group is always the interaction
between the members and not the Counsellor. An effective
Counsellor thus recognises that the group’s power is more than his
own and makes the group assume responsibility to make the
interactions. If the Counsellor takes the responsibility, the members
would sit back and wait for the Counsellor to make the interventions
as if watching a movie.
The Counsellor needs to resist the urge to quickly intervene with
the right answers, and should wait for a discussion to follow and
allow it to slowly steer to a conclusion. The group values the
decisions that they arrive at and does not look for quickfix answers
from the Counsellor even if the solutions are just as, if not more
effective.
Recording
The progress or lack of it among each member in the group and the
Counsellor’s impressions need to be recorded. This will help the
treatment professional to see clearly the level of progress and plan
further directions of progress. In case a different Counsellor takes over,
he will be able to
- assess the progress of each member
- set specific goals for each one
- identify and help him plan to deal with negative factors so that they
don’t grow stronger and interfere with the recovery process
- use these facts to give appropriate feedback to members.
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alcoholism and drug dependency
Recording is thus extremely useful and clearly necessary But for the
5ime o essed’ Counsellor, if recording needs a lot of time, it can become
SHS P00“ omplianoe .ill resull. To prevent this,
should be structured, and carefully structured recordtng wrll not take
more than 10 minutes.
If 5 sessions are held in a week, a weekly recording will suffice. If the
Session is " nee a week, recording can be done imrnedtately. Group
therapy initiated changes, may continue in-between these sessions a .
Recording helps the Counsellor keep tabs on the tssues dtscussed and
maintain continuity between sessions.
The ultimate goal of group therapy is to aid self understanding and
initiate changes to the maximum level possible in each and every mem er
of the group. Three factors contribute to this outcome.
1. The skill of the Counsellor.
2. The openness of the members who constitute the group.
3. The (genuine) interaction between the members.
Therefore the skill of the Counsellor needs to be sharpened periodically
through frequent self-assessment, clinical reviews with peers, oP^ne
to new techniques and readiness to explore in directions suggested y
group therapy research studies. The Counsellor has some control over
the second factor also in the sense that through a display of suPPor”
care and concern, he can facilitate the group to become open and hones
in their sharing. This will lead to genuine ‘feeling level’ interaction an
coX resolutions. To put it plainly, the Counsellor, even though
a catalyst, is the key player and his skill is o prime importan .
GROUP THERAPY
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Additional information
Problems in group therapy
While conducting group meetings, the Counsellor may encounter certain
problems with the patients. Some of the problems posed by patients
and methods to deal with them are listed below.
Monopolist
He talks incessantly, interrupts frequently and attempts to be the centre
of attention. Ordering him point blank to stay quiet can hurt him and
also frighten away other members. On the other hand, if left unchecked,
others will become bored, react negatively leading him to sulk and
withdraw.
His tendency to hold the stage is often an attempt to keep to the
superficial level and prevent others from getting to the real issues. He
thus fails to grow in the group.
The monopolist can be handled at both the group and individual levels.
The Counsellor can tactfully call for responses from other group
members while desisting from discounting the monopolist. By
highlighting the need for their participation, the other group members
can be made responsible for the manner in which the group is
progressing.
The monopolist often continues his unwelcome behaviour unaware of
the negative feelings of others towards him. Helping him become aware
of this is important. Saying, “Let us now check out on how the group
is feeling’’, can help him get feedback. Summing up the monopolist’s
sharing can lend focus to his utterances. This, followed by others’
feedback, can also help. Repeated, gentle interventions and feedback
will be useful in tackling this difficult member who intends to
monopolise the group.
Patient who has difficulty in expressing emotions or feelings
He seems isolated, emotionally blocked and acts as if nothing affects
him. He is in the group and yet far removed from it — he may go on
minimising others’ feelings or dismiss them as insignificant.
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Helping this patient get in touch with his feelings and verbalising them
needs to be done.
Frequently such a person’s non-verbal behaviour betrays his feelings.
The Counsellor has to call attention to this and ask for his feedback.
For example, “I saw you lean forward and show concern when he talked
about his loss of job. Would you like to share?”
Encouraging him to give feedback when a member shares something
significant, with emphasis on feelings can also help.
Silent Patient
He willingly stays a passive spectator to the group’s proceedings. His
silence may arise from
- his discomfort in talking about himself in a group.
- his anxiety that if he shares a little, others will force him to share
more — more than what he wants to.
- his fear that if he starts talking he may cry or breakdown letting
everyone see how shattered his life is.
Some information about the patient’s history can help the Counsellor
initiate him and make him open up. Even the ‘silent’; patient is never
‘silent’; his non-verbal behaviour speaks for him. The Counsellor needs
to be sensitive to this — note when and what topics interest him; which
ones make him tense, amused, and bring them to his notice and ask
for responses.
Some prodding and questioning of gradually increasing depth is useful.
When the patient does share a little, he needs to be encouraged and
appreciated. The Counsellor can get the silent patient to commit himself
by saying, ‘You shared when questioned today. Did you feel
pressurised?’ When the patient says ‘No’ as he usually will, the
Counsellor can settle the issue saying, T am happy about that. We can
then continue doing this in later sessions too. Isn’t it?’
An individual session can help in making him comfortable in the group.
He should be helped to understand the need for sharing and guided
to plan for sharing non-threatening areas.
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One who believes he is always right
He advises and gives solutions to all the members and sees his ideas
as being the most ideal. He feels an impelling need to be seen as being
‘right’ all the time. This behaviour is more enhanced if he is older, richer
or more educated than the rest of the group. His ‘air of superiority’
leads others to be hostile towards him as the group progresses.
The underlying message in his sharing, frequently is to stress ‘how well
I have succeeded in spite of problems’. He is unable to lower his facade
and get help.
With this patient, surprisingly, the key issue is shame, hurt and a low
self-esteem. The common theme in his sharing will be, T did so many
things right and yet received no recognition’.
The Counsellor needs to make special attempts to help him recognise
and verbalise the shame and hurt in his relationships. The other members
will take the cue and build on this. This focus moreover helps others
to be supportive rather than get irritated by this patient.
Boring Patient
His sharing is usually superficial and repetitious, delivered in a flat
monotone. He never ‘opens up’ his feelings for fear of being rejected.
When this patient launches off on his insipid oft heard statements, group
members usually betray boredom by yawning. They also display other
behaviour patterns that indicate restlessness.
At some point, members will tell the patient that he repeats the
same issues and that his contribution is not sufficient. When this
happens, the Counsellor should intervene and ask him to focus on other
relevant issues.
Help-rejecting complainer
He has a list of things going wrong (including the poor progress of the
group) and will present problems as if his is the biggest of all. He
frequently asks for suggestions but does not make use of them. Even
when he implements them and finds them useful, he will not
acknowledge it. This patient’s constant complaints may reduce the faith
and hope of the group and weaken cohesiveness.
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The Counsellor should guard against becoming resentful of this patient
because this is what the patient wishes to happen. He can then use this
to ‘revalidate’ his self-pity and prove to himself that nobody understands
or helps him.
The Counsellor should consciously refrain from offering solutions for
they will be rejected. The Counsellor should help members see the ‘yes
but approach of the patient to suggestions made. The members thus
take over and help him see his ‘self-defeating behaviour’.
The Questioner
He frequently asks questions and raises doubts often with a false air
of high motivation to get more attention. Questions when excessive can
draw the Counsellor off focus and also lead the members to
intellectualise on issues.
When not related to the topic of discussion, the Counsellor can say,
“I am afraid that by answering this question, we will side track from
the present issue. I will be happy to discuss this with you after the
group”.
The Counsellor needs to be sensitive to genuine requests for information
and clarification. When meeting this need, answers are to be kept short
followed by a return to topics of discussion.
Patients attending under the
influence of chemicals
Patients who have been discharged from the After-care Centre should
be encouraged to come for follow-up regularly. During these follow
up visits, clients may participate in group therapy sessions. Involving
clients who come on an out-patient basis may spark a few problems
in the group. These problems have to be handled.
Primarily these problems revolve around relapses. The four types of
behaviour discussed below reflect resistance to treatment and must be
dealt with assertively by the group.
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Behaviour
Methods to deal with it
Coming to the group
intoxicated.
Member should be asked to leave and to
return in a condition appropriate for
participation.
After the member leaves, other group members
should be encouraged to share their feelings.
When patient returns abstinent for next
session, other group members should be asked
to share their feelings and discuss what should
be done.
Drinking but refusing
to acknowledge it.
Technique of confrontation with specific
data can be used.
Remind the group contract of total abstinence
and sharing openly about, occurrence of
relapses.
If drinking/drug taking behaviour continues
and is not discussed, client may be asked to
leave.
The group members discuss their feelings
subsequently.
Drinking and talking
about it with no
intention of stopping
or
Continued drinking
while verbally
endorsing group norm.
Members to be asked to discuss their
feelings about violation of group norms.
Establish contingency contract for the relapsed
patient. Group discusses specific requirement
that client will have to adhere to (taking
antabuse daily under supervision, going to 3-5
A.A. meetings, calling on the staff at the
treatment centre everyday) to maintain his
group participation.
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Behaviour
Methods to deal with it
Repeatedly coming under
the influence of
chemicals and refusing
to leave the group.
The group should not allow this to
continue indefinitely.
The group should assume responsibility for
setting limits and if necessary remove him from
the group.
The group should be made to understand that
the decision is based on current behaviour and
that the door remains open for further
participation at a later time.
Bibliography
1. Social Group Work and Alcoholism — Social Work with Groups,
Altman Mayorie and Crocker Ruth (Editors) (Vol. 5, No.l). The
Haworth Press, New York, 1982.
2. Advances in the Psychological Treatment of Alcoholism, Galanter
Marc and Pattison Mansell E (Editors) American Psychiatric Press,
INC., Washington, 1984.
3. Group Psychotherapy with Alcoholics — Special Techniques,
Vamicelli Marsha, Journal of Studies on Alcohol, Vol. 43, No. 1,
1982.
4. Treatment Services for Adolescent Substance Abusers, Alfred
S Friedman and George M Beschner — National Institute on Drug
Abuse — USA 1985.
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THE ROLE OF THE COUNSELLOR
AND COUNSELLING TECHNIQUES
Individual Counselling aims at enabling the client to learn and pursue
realistic and satisfying solutions to his problems including those related
to his chemical abuse. In order to make individual counselling effective,
the therapist has to understand the client as an individual, the influences
which have affected him, his perception of self and others, so that he
can help the client realise how those forces have led to unhealthy ways
of coping. This understanding at the feeling level rather than at the
cognitive level, will enable him to cope with life more satisfactorily.
The purpose is to help the client in making decisions about his life and
enable him understand the need to take responsibility for the consequences.
Qualities necessary for a Counsellor
★ Ability to listen
★ Empathy
★ Non-judgemental
Absolutely essential. Listening is much more than
hearing. It involves intuitive perception, watching
for cues other than those conveyed through words
(tone of voice, gestures, posture) and under
standing the messages which the client is trying
to convey, over emphasise or avoid.
Ability to sense the client’s private world “as if”
it were the Counsellor’s own, but without losing
the “as if” quality. Empathy does not imply
agreeing to the client’s views of things; also it does
not allow for any judgement on the part of the
Counsellor. He neither agrees nor disagrees; just
understands and appreciates the view.
Being open to and aware of the other person’s
rights. Such an unbiased involvement is essential
to a constructive approach to the client’s problem.
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*
Genuineness
The Counsellor’s sincere interest in the care and
well-being of the client, which, in turn, results
in his expressions always truly reflecting his
thoughts and feelings.
★
Patience
To tolerate slow or no progress in the client.
★
Flexibility
The Counsellor should be able to adapt his role
and pace according to the client’s needs and
capacities. Rigidity in roles and approaches may
provide comfort for the Counsellor, but often does
little for the client. The Counsellor should be a
sympathetic friend, a leader, a negotiator or an
educator and able to move between these roles.
★
Emotional maturity
The Counsellor should be able to maintain a
balance and not get unduly swayed.
*
To be in command
Once assessment is made and counselling has
started, the client should be able to have a person
who guides him away from trivialities or
irrelevancies. The Counsellor who allows himself
to be manipulated without knowing it, will not
command respect from the client.
Therapeutic communication skills used in counselling
The outcome of the meeting between the Counsellor and the client will
depend a great deal on how free the client feels to entrust the Counsellor
with his genuine feelings including information which he may feel is
very private and personal and which he is reluctant to share. This can
be achieved by the use of certain communication skills which create
an atmosphere of support for the client and the process.
Attending
Attending is fundamental to the use of all other counselling skills.
It implies a concern by the Counsellor with all aspects of the client’s
communication. It includes listening to the verbal content and observing
the non-verbal cues and then communicating back to the client that
the Counsellor is paying attention.
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* Genuineness
★ Patience
* Flexibility
Emotional maturity
★ To be in command
The Counsellor’s sincere interest in the care and
well-being of the client, which, in turn, results
in his expressions always truly reflecting his
thoughts and feelings.
To tolerate slow or no progress in the client.
The Counsellor should be able to adapt his role
and pace according to the client’s needs and
capacities. Rigidity in roles and approaches may
provide comfort for the Counsellor, but often does
little for the client. The Counsellor should be a
sympathetic friend, a leader, a negotiator or an
educator and able to move between these roles.
The Counsellor should be able to maintain a
balance and not get unduly swayed.
Once assessment is made and counselling has
started, the client should be able to have a person
who guides him away from trivialities or
irrelevancies. The Counsellor who allows himself
to be manipulated without knowing it, will not
command respect from the client.
Therapeutic communication skills used in counselling
The outcome of the meeting between the Counsellor and the client will
depend a great deal on how free the client feels to entrust the Counsellor
with his genuine feelings including information which he may ee
very private and personal and which he is reluctant to. hare Thu ca
be achieved by the use of certain communication skills which
an atmosphere of support for the client and the process.
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Attending
. .n
Attending is fundamental to the use of all other counselling skil s
It implies8 a concern by the Counsellor with all aspects ot the client .
communication. It includes listening to the verbal
the non-verbal cues and then communicating back to the client
the Counsellor is paying attention.
THE COUNSELLOR AND COUNSELLING TECHNIQUES
201
Guidelines for effective attending are
- to communicate listening through eye contact and facial expression
- to physically relax and lean forward occasionally, using natural hand
and arm movements
- to verbally “follow” the client, using a variety of brief encourage
ments such as “um-hm”, “yes”, or repeating key words.
In attending, the Counsellor’s goal is to listen effectively, to observe
the client, and to communicate his interest and attentiveness. The skill
of attending is the foundation on which all other skills are built.
Processing
This includes the Counsellor’s ability in mentally cataloguing data,
including the client’s beliefs, knowledge, attitudes and expectations,
and thereafter categorising factors influencing the client’s judgement
and performance.
Probing
Probing is the Counsellor’s use of a question or statement to direct the
client’s attention inward to explore his situation in greater depth. A
probing question should be open-ended which requires more than a oneword answer (“yes or no”) from the client. Probing helps to focus the
client’s attention on a feeling or content area. It may encourage the
client to elaborate, clarify or illustrate what he has been saying. It
sometimes enhances the client’s awareness and understanding of his
situation and feelings. It directs the client’s attention to areas the
Counsellor thinks need attention.
Client — “I had always been a good worker. I even received
an award for excellence four years back. But the last two
years
My God! So much of problems! Lots of problems
for me in the office during the past two years. ”
Counsellor — “For the past two years you have been having
problems. What do you see as the reason behind these
problems?”
The Counsellor should use his judgement to identify the subject or
feelings touched by the client that need further exploration. It is
ALCOHOLISM AND DRUG DEPENDENCY
202
important that the Counsellor uses ‘probing’ only after ‘attending’ to
the client. By listening to and observing the client, the Counsellor may
identify areas that either seem unresolved or need furtner development.
Paraphrasing
Paraphrasing is a response that restates the content of the client’s
previous statement. It concentrates primarily on the words spoken, the
content which refers to events, people and things. In paraphrasing, the
Counsellor reflects to the client the verbal essence of his last comment
or last few comments. More often, paraphrasing is using words that
are similar to the client’s, but fewer in number.
‘Paraphrasing’ can be an indicator to the client, of the Counsellor’s
accurate verbal following. It sharpens the client’s meaning to have his
words rephrased more concisely and often leads him to expand his
discussion on the same subject. It can spotlight an issue, thus offering
a direction for the client’s subsequent remarks.
Client — ‘'My boss constantly irritates me. He 'picks on me’
for no reason at all. He is all powerful and he can even 'sack
me. I don’t know what I can do if he does that. ”
Counsellor — "You are having problems in getting along with
your boss. You seem to be worried that you may lose your
job. ”
Paraphrasing enables the Counsellor to verify his perceptions of the
verbal content of the client’s statements.
Reflection of Feelings
‘Reflection of feelings’ is the Counsellor expressing the essence of the
client’s feelings, either stated or implied. Unlike in ‘Paraphrasing’, the
focus is primarily on the emotional element of the client’s
communication. The Counsellor tries to perceive the emotional state
of the client and feedback a response that demonstrates his
understanding of the client’s state. ‘Reflection of feelings’ is an
empathetic response to the emotional state or condition of the client.
It conveys to the client that the Counsellor understands what he is
experiencing and feeling. This empathy reinforces the client’s willingness
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to express his feelings more openly. It gives the client an opportunity to
recognise and accept his feelings. It also verifies the Counsellor’s perception
of what the client is feeling. It allows the Counsellor to check with the
client whether he is accurately reflecting what the client is experiencing.
Client — ((I don ft feel like going home at all. When I come
home for the week-end from the After-care Centre, my house
is in a mess. The kids are dirty and my wife constantly nags
and complains. She doesn "t even prepare good food; doesn "t
do her duties. That makes me angry. ”
Counsellor — ftYou are not satisfied with the way she is
running the house. That irritates you.
Through reflection of feelings, problem areas can be identified without
the client feeling pushed. It also helps the client understand that feelings
cause certain types of behaviour.
Summarizing
Summarizing is the tying together by the Counsellor of the main points
discussed in a counselling session. Summarizing can focus on both
feelings and content and is appropriate after discussion of a particular
topic within the session or as a review at the end of the session of the
principal issues discussed. In either case, the summary should be brief,
to the point, and without new or added meanings.
Counsellor — tfWe have talked about two issues now. You
feel you have hurt your parents and given them lots of
problems. You want to do something about this. The other
issue is related to your work. You feel you have been blaming
your bosses all along for losing quite a few jobs. Now you
understand that drugs had been the cause.
Summarizing clarifies the client’s meaning by having his scattered
thoughts and feelings put together. It can terminate a session in a logical
way through review of the major issues discussed in the entire session.
Interpreting
Effective interpreting has three components — determining and restating
basic messages; adding Counsellor’s ideas for a new frame of reference;
and checking out these ideas with the client.
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It is very important that the Counsellor uses the skills of attending,
paraphrasing, reflection of feelings and summarizing prior to and in
conjunction with interpreting. The first step in interpreting is to
determine the basic messages the client has expressed or displayed, and
restate them. As the Counsellor is restating them, he will have some
idea about alternative ways of viewing the client’s situation, or may
begin to see connections, relationships or patterns in the events the client
describes. When these ideas are included in the material being restated
to the client, the Counsellor adds his ideas to offer the client a new
frame of reference from which to view his situation.
Counsellor — ((You say you had difficulty in getting along
with your parents. Once you mentioned that sometimes you
simply broke the rules for the sake of breaking them. You
have given up three jobs. Each time you said it was because
of the highhanded behaviour of the boss. You feel you are
unable to relate to the Warden here in the Aftei-care Centre.
Can it be a possibility, that you find it difficult to accept
authority?
Because the Counsellor is offering alternative view points, it is very
important to phrase them tentatively or to check out directly with the
client his reaction to the new point of view. Tentative phrases like ‘The
way I see it
’ or T wonder if....’ are appropriate ways to begin an
interpretation. Then there is a greater possibility that the client will see
the offered interpretation as a possibility rather than as a judgement.
He is thus likely to react to an interpretation openly if it is offered
tentatively.
Self-disclosure
Self-disclosure is the act of sharing and exposing the Counsellor’s own
feelings, attitudes and experiences with the client. The following
guidelines should be kept in mind during self-disclosure.
- The disclosure should relate directly to the client’s situation.
- The Counsellor should disclose only experiences that have actually
happened to him (personal pronouns such as T, ‘me’, ‘my’ or
‘myself’ can give a clear message that it is one’s own experience).
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- The Counsellor should guard against any self-disclosure that is likely
to shift the focus of the interaction away from the client to the
Counsellor.
- The premature use of an intimate past experience or a threatening
present feeling could make the client anxious and thereby damage
the relationship.
- The Counsellor should guard against disclosing anything about
himself that the client may ignore, deny or ridicule. If the client’s
perception of the Counsellor changes negatively because of an
inappropriate self-disclosure, the relationship will be disrupted.
If self-disclosure is done properly, it will build a sense of trust and
rapport between the Counsellor and the client. It helps to reduce the
client’s feelings that he is alone in the situation he is experiencing because
he comes to realise that his Counsellor also had problems and made
mistakes. It creates an atmosphere in which the client feels free to express
content that he had previously avoided. It also enables the relationship
to move to deeper levels by fostering a feeling of empathy.
Confronting*
Confrontation is the deliberate use of a question or statement by the
Counsellor to induce the client to face what the Counsellor thinks the
client is avoiding. The Counsellor may, for example, point out
discrepancies between the client’s verbal and non-verbal behaviours,
between two of the client’s statements, or between the client’s past
behaviour and his behaviour in the Counselling session.
In confrontation, the Counsellor identifies contradictions that are
outside the client’s frame of reference, whereas paraphrasing, reflection
of feelings and summarizing involve responding within the client’s frame
of reference. In using confrontation, the Counsellor gives honest
feedback about what he perceives is actually happening with the client.
Confrontation should not include accusations, evaluations or solutions
to problems.
* This technique is dealt with in great detail in the chapter on ‘Dealing with Denial’ in our earlier publication
‘Alcoholism and Drug Dependency — The Professional’s Master Guide’.
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Sometimes the Counsellor may hot know what to do after he attempts
a confrontive response. The following guidelines may be of help.
- If the client accepts the confrontation and agrees with the
discrepancy pointed out, the Counsellor can use the opportunity
to reinforce positive behaviour.
(<I am happy that you are able to see the problem from this
angle. Let us plan what we can do about it.”
- If the client denies the confrontation, the Counsellor should return
to an empathetic response.
tfYou are finding it difficult to see the problem the way your
family members and I perceive. It seems to be bothering you.
Think about it. Let us talk about it later. ”
The client may not be ready at that point of time to deal with the
discrepancy and it would not be helpful to persist in the confrontation.
It can however, be dealt with at the appropriate point in time.
- The client may simply act confused or ambivalent after a confrontive
statement. In that case, the Counsellor could focus on the current
feeling.
t(Ypu seem to feel confused by my statement. Let me make
myself clearer. ”
An effective confrontation breaks down the defences of the client which
he has consciously or unconsciously put up. It will enrich the condition
of empathy in the Counselling relationship if the client perceives the
confrontation as being done due to the care and concern of the
Counsellor.
Silence
Silence can be very powerful. It can be a time when things really ‘sink
in’, and feelings are really felt. When combined with ‘attending cues,
it can serve to encourage the client to continue sharing. It can allow
the client to experience the power of his own words.
The above mentioned qualities, skills and technical know-how in
themselves are not sufficient to make a competent Counsellor.
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The following attributes also contribute to the effectiveness of the
Counsellor:
The Counsellor in after-care should
- Have all necessary information regarding chemical dependency
including relapses and recovery.
- Be aware of his status as a role model for clients in the therapeutic
community with regard to personal behaviour and attitude towards
alcohol and other drugs.
- Be able to obtain complete and accurate information on client’s
problems and history.
- Be able to apply knowledge of addiction in counselling situations
and help the client learn to apply this knowledge to his own
problems.
- Be willing to show respect for the client and assist him in developing
self-respect.
- Be able to assist the client in expressing feelings about his problems.
- Have the ability to assist the client in recognising and assuming
responsibility for his behaviour.
- Be able to lead group counselling sessions; assist group members
to express their feelings and draw insight from interactions within
the group.
- Have the ability to handle crisis situations (client coming drunk,
threat of suicide, medical emergencies) in a calm and effective manner.
- Be able to assist family members to develop productive behaviours
and attitudes that will support the client’s efforts towards recovery.
- Be able to identify the problem pertaining to the client’s situation
and develop a treatment plan to deal with that problem.
- Have the ability to recognise problem situations that are beyond
the Counsellor’s capacity to handle and refer such individuals to
appropriate experts.
- Be able to maintain all records of the client upto date and complete.
- Take the trouble to keep in touch with former clients to follow-up
on their progress and provide support.
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Processes of counselling
★ Enhancing Motivation and Building Rapport
If the chemical dependent has come under pressure from somebody
else (for example, his wife), the Counsellor’s first task is to meet him
alone. Even if the ‘motivating party’ is absent physically, she will be
present psychologically; so his preoccupation should be removed before
the counselling relationship with the chemical dependent can be
established.
Counsellor — <(I realise that your wife thinks you need
extended help. But what I am mainly interested in at this point,
is knowing how the situation looks from your point of view.
What seems to be the trouble, as you see it?”
Hopefully, as this approach is followed, the client will sense that the
Counsellor is not taking sides with his wife in the struggle between them.
He may begin to realise that the Counsellor is genuinely interested in
understanding the situation including his perception of it and is prepared
to help him. When this happens, the client will begin to lower his
defences and risk some openness with the Counsellor.
It is important during the first interview to help the person verbalise
his feelings. Whether the person comes under pressure or threat, or is
merely fighting his inner resistances to admitting that he needs help,
the Counsellor should assist him in getting his negative or conflicting
feelings out into the open. Following are some of the factors which
may make him avoid facing his need for help — his fear of the pain
of withdrawal, of abstinence, his fear of not belonging to the ‘peer
group’, his feeling that the drug is all that ‘works’ for him, the blow
to his self-esteem of admitting loss of control, the fear of his socially
unacceptable condition, etc. What is he worried, afraid, angry or
frustrated about? What would he like to see changed? It is important
that these inner barriers to admitting his need for help, be discussed
with understanding and empathy by the Counsellor. If the person can
bring his fear into the open, the help of the Counselling process becomes
available for coping with them. As these feelings are being discussed,
the Counsellor should let the person know, by his attitude, that he
respects his right to whatever feelings he may have.
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In working with any client, particularly the one who is resistant, it is
important to discover his areas of hurt. It is at this point that the offer
of help is most likely to be accepted. Often the ‘hurt points’ can be
found by encouraging the chemical dependent to talk about his problems
as he sees them.
The person’s “Achilles’ heel”— the place where he is motivable — is
the place where he is hurt, worried, or is aware of some need for help.
“During those days, I didn even bother to pay my daughter's
school fees. So she had to discontinue her studies. Now Ifeel
very upset
very hurt!"
“My boss had been so very understanding. I don 7 know how
I used such language while talking to him. ”
Such motivable areas have to be first identified, so that the Counsellor
can work on those to enhance motivation.
★ Assessment and Problem Identification
Assessment is an on-going process in the therapeutic relationship, the
first step in the formulation of a treatment plan. It is the process of
data collection, clinical interpretation of that data, and development
of a plan based on the strengths and weaknesses which emerge from
the data. An assessment of a client includes his abilities, strengths,
problems, needs and resources as well as his weaknesses, stresses or
danger areas.
The purpose of this phase is to secure as much information as the
Counsellor needs to understand the client as a whole. Therefore, one
needs to view this process through four lenses — physical, psychological,
social and the environmental context.
When carrying out an assessment, the Counsellor should first encourage
the client to talk about what he wants. While being sensitive to his
wishes, it is also necessary to look at the client’s awareness of the
damages caused and the extent of the problems. An inventory of these
can then be compiled and the client may be asked to rank all the
problems noted in terms of severity and urgency. When all the problems
have been looked at in this way, the Counsellor should go on to consider
them in the context of the person who is experiencing them.
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What are the client’s strengths and weaknesses?
What personal and social stresses are being experienced?
What is the goal preferred by him?
How is he going to achieve it?
In considering these aspects, the Counsellor will be considering the
capacity of the person to achieve the various treatment goals which may
be envisaged.
It is not possible to gather all the necessary information in one or two
interviews. The Counsellor begins where the client perceives discomfort
and proceeds from there. It is important for the client and the Counsellor
to know at the end of each session where they stand in the process of
assessment; what kinds of additional information will be necessary and
what is expected before the next interview.
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Goal-setting and problem Solving
Treatment goal spells out a desired result or destination for the client
in the process of recovery and, in short, it is the reverse of the stated
problem. For a client to agree that a goal is meaningful and worth
working toward, it must be clearly related to his problem and realistically
defined. The goal, therefore, describes what the Counsellor and the
client would expect to see when a problem is resolved.
Problem: George does not have any formal training and feels
low and frustrated that he couldn't get a job.
(<(I can't get any job. So what is the point?")
Goal: George will accept his need to get trained in a Vocational
Guidance Centre.
- He will visit the Guidance Centre.
- He will identify the skill in which he wants to get trained.
- Make plans with the authorities to undergo training.
In treatment planning towards problem solving, the Counsellor should
- work with the client to formulate goals, objectives and acceptable
alternatives for treatmem that will increase the likelihood of a
positive treatment outcome.
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— consider a range of options in developing an individualised
treatment plan, including the components of the continuum of care,
the various treatment modalities, and formal and informal support
groups.
— develop a complete, individualised treatment plan appropriate to
the client’s needs and resources as identified in the assessment process
and acceptable to the client.
— assess progress towards treatment goals periodically with the client
and modify treatment plans as indicated.
★ Resolution and Follow-up
Optimally, the completion of treatment should be jointly planned over
a few weeks so that the client can get in touch with, adjust to and express
his feelings related to discharge. It is very important to let the client
know that although treatment is ending, progress has to continue.
The need for regular medication, follow-up visits to the treatment
centre, attendance at AA meetings should be emphasised The client
must continue the same self-exploratory attitude developed in the
treatment.
The issues to be discussed should focus on enhancing and consolidating
the gains achieved till then.
Counsellor — ftIn your three months’ stay at the After-care
Centre, you have got used to a structured and disciplined way
of living. You are able to take others’ criticism. You are taking
up responsibilities and carrying them out. You have also learnt
a new skill. ”
Short-term goals and long-term goals should be clearly spelt out. Follow
up sessions should be planned so that the therapeutic relationship does
not end abruptly. Regular follow-up for a period of one year should
be emphasised. If the client has a relapse or if he doesn’t turn up for
a long period of time, it is essential that the Counsellor takes the initiative
to contact the client.
Sometimes, 'drop out’ or unplanned termination can occur.
The Counsellor should learn to accept such terminations without feelings
of guilt and anger over the “failure”.
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The new way of life of the recovering chemical dependent is a path
along which he moves, and not a static goal which he achieves. * David
Stewart describes 5 stages in sobriety
1. Initial sobriety: Physical health regained, preoccupation with
sobriety, reduction of guilt and anxiety, increased self honesty.
2. Learning sobriety: Loss of freedom to become a social drinker
accepted; give and take of real personal relations replace grandiose
behaviour; regains acceptance of family and friends; sense of humour
replaces self-pity; learning to cope with anxious or depressed states.
3. Accepting sobriety: L.oss of desire to drink becomes lasting; thinking,
feeling and ethical perception improves.
4. Creative sobriety: Freedom from alcohol oeeply appreciated;
religious desires centred on new way of life; appreciates need for
help from others; uses new freedom in other activities.
5. Pleasurable sobriety: At peace with oneself and the world; anxiety
and shyness diminish in genuine interpersonal relations; enjoys
rewards of sobriety.
Sobriety is a new way of life, and it is a process. The role of the
Counsellor is to help the client in this process so that he moves forward
in stages towards a productive and meaningful future.
* This description of the 5 stages is abbreviated from Stewart’s “Thirst for Freedom".
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Additional Information
Confidentiality
What exactly does the Counsellor mean when he promises
confidentiality? ‘Confidentiality’ is safeguarding information about an
individual that has been obtained by the Counsellor in the course of
counselling. Sometimes, for the sole purpose of helping the patient,
the Counsellor uses his discretion to disclose some information to
significant people. When the Counsellor says he will maintain
confidentiality, he assures the client that whatever he tells him, will be
used responsibly and will be guarded against misuse.
There are two types of confidentiality — absolute and relative.
Absolute confidentiality
The security of information is absolute when data learned or observed
by a Counsellor stay with him and are never passed on to any one else.
Relative confidentiality
Some of the information given by the client is shared with others in
the system in a responsible manner as part of the treatment process.
In an inter-disciplinary setting, such as the After-care Centre, exchange
of information will occur. Case histories will be discussed with other
therapists in order to help clients.
For example, a case may be discussed with the Vocational Counsellor
for rehabilitation.
As part of case discussion, information may be given to other
Counsellors. This sharing is done with the intention of giving the client
better help by seeking clarification from colleagues. A newly appointed
Counsellor may find it necessary to consult a senior therapist regularly
to discuss and get guidance regarding treatment strategies.
Some guidelines for maintaining confidentiality
Following are some of the most common instances in which violation
of confidentiality is likely to take place. Inappropriate disclosures like
these have to be guarded against.
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★ The Counsellor sharing details with his own family and friends
This is one of the most frequent violations. The Counsellor may
rationalise, “It’s okay, as long as I don’t use names. Besides, they don’t
know the people I am talking about. So what is wrong with discussing
clients or work situations with my family members?”
The Counsellor who is tempted to share information, must first ask
himself a basic question: “Is my friend or relative bound by the same
rules of confidentiality as I am?” If the answer is ‘no’, then that person
cannot be prevented from passing on the information to a third person.
It is acceptable for Counsellors to share feelings experienced as a result
of daily activities, but here too names and specific details regarding
clients and others should not be disclosed. Emotional reactions to
confidential material rather than the confidential information itself can
be shared. It certainly is permissible to state, “Oh! I had a frustrating
day today — nothing went right”, or
“A patient of mine had a relapse and it took everything I had to deal
with it”, or
“A client I have been working with for months, died today and I am
really upset”. Indeed, such release of feelings is essential, as friends
and family provide the emotional support and empathy needed from
time to time.
★ Disclosure to the client’s family members
The Counsellor should be aware that certain information revealed by
the patient need not be conveyed to his family members (e.g. pre
marital/extra marital relationships). If the family is not staying with
the client or is not involved in the treatment (for example, wife separated
from client, not attending treatment programme), and they want to
know some details about the client, the Counsellor should assertively
say ‘Sorry’, and the information should not be given.
★ Informal discussions with colleagues
A Counsellor may be grappling with a client’s problem when his
colleagues join him during lunch or coffee break. There will be a
tendency to ventilate feelings and discuss unresolved problems during
that break. Sometimes, these indiscreet conversations can be overheard
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215
and may lead to problems. Therefore, information should be shared
only in privacy and in a professional manner with the purpose of helping
the client.
★ Inappropriate remarks to co-workers and other patients
Every patient should be treated with dignity and any inappropriate
remark about him to other patients or co-workers should be avoided.
For example
“Hello Mr. Prakash — lam sorry I had to keep you waiting
for so long — the other client just went on and onff.
Another example is,
Counsellor — 1
Counsellor — 2
“Hello VSG., what is wrong with
Mrs. Ravi? Has she fought with her
husband again?”
Had a big
“Yes. She has started again
fight with her husband.”
Such discussions should be avoided.
★ Recognising the client outside
The Counsellor may see the client at social functions, in cinema
halls, hotels etc. Unless the client acknowledges and talks to the
Counsellor, the Counsellor should not take the initiative and recognise
the client.
★ Release of information to others
Someone other than the client may seek access to information contained
in the records. The principle is that the client’s consent should be
obtained before any confidential information about him is disclosed.
First the client must be told that there is a request for certain data.
He must be made aware of the following details:
- who has asked for the information
— what information they have asked for
the purpose of their request
He should also be fully informed of any repercussions that might occur.
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Common sources of request for information
A few sources that may ask for or need confidential information from
records are listed below.
★ Family and friends of the client: It is natural to assume that family
and friends always have the client’s best interests in mind and should
therefore be given whatever information they want. This is not
always true. Therefore, the client has to be consulted before any
information is passed on. A standard response may be ‘Tm sorry;
1 am unable to give you that information. I’ll contact the client,
and if he gives permission, I will get in touch with you. Or, I will
ask him to contact you directly.”
The caller may insist that he has already obtained the client’s
permission. Still this statement should not be taken for granted.
A formal written consent from the client should be obtained.
Usually, families of chemical dependents would ask for certificates
of treatment taken at the centre for the purpose of divorce, claiming
of child, property, job etc. These certificates should not be issued
without the client’s consent.
Legal authorities: No information should be passed on to legal
authorities (court, police etc.) unless they come with a formal
request, or send the orders through the proper channel. Even then,
the information should be addressed to the source of
request/appropriate authority only.
★ Employer: If the client has been referred by the employer, limited,
relevant information can be passed on to the employer. If the
employer has not referred, then no information need be given.
★ Non-clinical staff: They should not gain access to patients’ records.
★ News media: No information pertaining to clients should be given
to the news media and no photographs taken without prior
permission.
★ Others: Information with regard to treatment facilities, charges,
duration, availability of beds etc., can be given to the public. On the
other hand, the Centre may get telephone calls asking if a particular
person has been admitted, taken treatment earlier etc., for which
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217
no information should be given, as the caller could contact the
respective family for such information.
Thus, maintaining confidentiality is an integral part of the treatment
process, since it lays the foundation for mutual trust and confidence,
which is very vital to a positive client-counsellor relationship.
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Counsellors’ Burnout
Professionals working in the field of addiction treatment are prone to
stress. When this stress is not managed properly, it becomes an overload
and leads to ‘burnout’, making the job tedious, draining and frustrating.
It results in the Counsellor feeling exhausted and worn out. He feels
physically and emotionally drained. From a position of helpfulness,
care and concern for his patients, his condition turns to one of
frustration and apathy.
Why does burnout happen?
Repeated unresolved problems in work situations lead to stress. Totally
uncooperative, highly demanding and manipulative clients, patients
repeatedly violating rules and frequency of relapse; are some of the
contributing factors for a Counsellor’s burnout. Family problems, stress
at home, lowered stamina of the Counsellor due to physical illness, also
have a bearing on his ability to cope. Interpersonal conflicts and
problems in relationships among members of staff activate stress. Lack
of clarity of roles, leading to overload of work on one Counsellor and
a non-supportive working environment can result in a Counsellor’s
burnout.
The resultant burnout manifests itself physically as fatigue, headache,
insomnia and backache. The body literally breaks down and is no longer
able to manage. The mind also switches off.
The Counsellor experiences depression, anxiety, feelings of frustration
and anger. The syndrome also includes apathy, weariness, lack of
personal involvement and a lack of enthusiasm for the patient’s
rehabilitation.
Burnout is an inevitable consequence of ineffective identification and
management of stress. Since burnout is not an uncommon condition
in treating chemical dependents, Counsellors should be forewarned and
prepared to take a variety of coping actions, all of which will lessen
stress on themselves, their work, their relationship with clients and their
communication with their fellow workers. By identifying stress
contributors and developing strategies to deal with them, a Counsellor
may be able to avoid ‘burnout’ before it becomes a problem. If this
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219
problem is not handled properly, it will not only make the individual
ineffective, but also bring down the staff morale.
Dealing with burnout
★ Good interpersonal relationship among staff is a must for any
treatment centre. Honest and open communication among staff,
leads to a healthy, supportive environment which will lower the
incidence of stress.
Senior Counsellors can teach newcomers on what to expect from
★
troublesome clients and how to handle their own emotions.
If one Counsellor is not able to stand the stress and tackle a particular
patient, sharing of the burden with other Counsellors will definitely
lighten his strain. When he is pent-up at times, it is therapeutically
good to share the problem with someone and arrive at a reasonable
solution together.
★ When a Counsellor is under stress, he can reduce the number of
hours given for counselling for the time being. He can relax by taking
up other activities like writing letters to treated patients, filling up
case files and reading professional journals.
★ The Counsellor should understand that relapse is an integral part
of the recovery process. He need not feel guilty or frustrated if a
patient relapses in spite of his honest efforts. 1 he professional can,
at best, only help the patient to deal with his relapse, if it does occui.
However, if repeated relapses happen, the Counsellor can discuss
the cases with senior Counsellors and ensure that his plan of action
and anticipatory guidance are proceeding in the right direction.
★ Apart from the daily therapeutic programme, they can periodically
organise self development programmes which will enhance their
creativity and also help them in strengthening their self-esteem.
Recovered persons may be encouraged to celebrate their birthdays
★
(drug-free abstinent years) at the After-care Centre. This will bring
about a sense of gratification to the Counsellor, while at t le
same time, it will provide incentive and hope to the recovering
patients.
★
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★ Some provision can be made in the After-care Centre for the
Counsellors to have a break from the routine — a' i occasional outing
or a picnic with other staff members.
★ Small things like not taking one’s work home, getting sufficient rest,
talking about problems at work while at work, developing variety
in one’s work and reducing the repetitive routine aspects of it
wherever possible, will definitely help in reducing or preventing
“Counsellors’ burnout.”
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THE COUNSELLOR AND COUNSELLING TECHNIQUES
221
Individual treatment plan*
Counsellors have increasingly felt the need to provide help specifically
tailored to the individual need of each client. Since chemical dependency
is a complex, multifaceted problem, it becomes essential to develop
treatment plans specific to each client who comes to After-care Centre
for treatment.
The treatment plan gives both the Counsellor and the client a structure
in which they can function. Expectations become clear, and
misunderstandings are relatively easy to resolve. Treatment plan allows
Counsellors to clearly specify goals, monitor and evaluate progress. With
such a plan, counselling can proceed in a straightforward, outcomeoriented fashion. Without it, the client-counsellor relationship will be
poorly defined, unstable and unlikely to succeed.
The treatment plan can be simple or elaborate, provided it addresses
all the problems to be dealt with in treatment. The client’s chemical
dependency must be viewed in the context of other life problems,
although not necessarly in terms of causality. Chemical dependency
tends to be associated with a variety of social, psychological, family
and financial problems.
Each of the client’s major concerns should be addressed as part of the
counselling process under the assumption that a favourable outcome
involves rehabilitation across several life domains.
An individualised treatment plan is developed for each patient on or
about the seventh to tenth day of treatment. This is then made a part
of the patient’s record. Weekly notes are made in the patient’s
record indicating progress in implementing the methods outlined in
the treatment plan as also any revisions or alterations. At least one
treatment plan update is made within the next two weeks to
formally reflect progress or lack of progress or alterations to the
treatment plan.
* We acknowledge the valuable contribution of Mr. S. Mohan of Delhi, who has completed a course
in Counselling skills in USA, towards writing this chapter.
222
ALCOHOLISM AND DRUG DEPENDENCY
The treatment plan must include
★ The patient’s acceptance of his addiction, and the need to have total
abstinence as his recovery goal.
★ The Counsellor’s identification of the motivable areas and plans
to enhance motivation.
★ An assessment of all problem areas — physical, psychological, social,
occupational and environmental.
Identification of character defects which ma^ interfere in the
recovery process.
★ Identification of vocational skills to be learnt and developed.
★ The patient’s support system to be strengthened.
★ The patient’s relapse triggers to be identified, and coping methods
to deal with them, to be developed.
★ Identification of some positive ways of having fun.
In order to achieve treatment goals, specific methods should be stated.
These should be realistic and practical. After implementation, they
should be evaluated and then documented in the patient’s progress notes,
case consultation notes and group notes. Each goal in the treatment
plan should have a specific time frame for completion.
Certain other issues are also to be kepi in mind before making a
treatment plan.
★ Assessment of the extent and intensity of denial in the client is
important. A client with severe denial may require more therapy
hours to handle this, before other issues are raised.
★ The extent and seriousness of a particular problem in a patient may
sometimes call for priority. The patient may have one problem as a
top priority item to be dealt with, whereas the Counsellor may feel
that some other problem needs immediate attention. In such cases
the Counsellor and patient must jointly articulate their respective prefer
ences and then, through mutual agreement, determine treatment goals.
★ The involvement of significant others is quite important. As the
entire family has become dysfunctional, the family or other people
close to the patient should invariably be included. Counsellors should
set the stage to strengthen family relationships, so that the patient
gets their support during recovery.
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THE COUNSELLOR AND COUNSELLING TECHNIQUES
223
Treatment plan update
A treatment plan update must be completed for each patient and entered
into the patient’s record every two weeks. This can be done after two
weeks of therapy or when there is a major shift or change in the
treatment direction or patient status.
The treatment plan update can be written in a progress note form, and
must relate specifically to the treatment plan objectives, goals achieved
and dates of completion. If the target date has not been achieved, there
should be a statement as to why this is so, and new target dates should
be specified. The Counsellor may need to abandon one particular goal
from the treatment plan, when it is no longer applicable in the light
of new information. In such cases, the therapist should mention this
in the treatment plan update.
Treatment Plan
Name: Mr. S
Goal
Methods to achieve
the goal
1. To understand 1. Talk to 4 patients who have
been in the programme for
the need to stay
more than two months and
at the After
understand the benefits derived
care Centre.
by them.
2. Write down what you expect to
gain from this programme.
2. To realise in- 1. To prepare notes on your ‘life
history’.
depth, the
various
2. Share this in the group and get
damages caused
their feedback as to whether
by addiction.
the sharing was ‘honest and
in-depth’.
Actual
Target
Date for Date of
completion completion
25-08-92
27-08-92
28-08-92
28-08-92
03-09-92
04-09-92
ALCOHOLISM AND DRUG DEPENDENCY
224
Goal
Methods to achieve
the goal
Actual
Target
Date of
Date for
completion completion
3. To get totally 1. Meticulously attend the
programme schedules —
involved with
classes, group therapy, A.A.,
the programme
etc.
of the Centre.
2. Get involved in morning
exercise sessions/recreational
activities in the evening.
06-09-92
to
25-09-92
25-09-92
1. Attend re-educative class on
‘Anger Management’.
2. Write assignment on that topic.
3. Discuss this with the
Counsellor.
4. Play ‘Feelings Game’
(‘Ungame’) with the other
group members.
5. Practise relaxation techniques.
17-09-92
29-09-92
1. Parents to attend ‘family
5. To improve
sessions’ and meet the
relationship
Counsellor.
with parents.
To establish
2. Help mother in cleaning the
stable recovery
house prior to Deepavali
festival.
3. After every weekend ‘outing’,
give feedback to the Counsellor
of efforts taken to improve the
relationship with parents.
On-going
4. To deal with
anger
appropriately.
(Patient fell sick;
hence could not
complete it on time)
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THE COUNSELLOR AND COUNSELLING TECHNIQUES
Goal
6. To improve
self image.
Methods to achieve
the goal
1. Share five of your positive
qualities with the group.
2. Talk about five qualities you
want to have or develop.
225
Actual
Target
Date for Date of
completion completion
01-10-92
02-10-92
12-10-92
14-10-92
30-11-92
30-11-92
3. Identify one quality among
them and communicate to the
group as to how you are going
to develop it.
1. Make efforts to help new
7. To get over
comers at the centre.
the qualities of
procrastination 2. Take up specific tasks at
and selfishness.
home during week ends
- Buying vegetables/provisions
for the family.
- Watering plants.
3. Complete therapeutic duties
of each day at the alloted
time; give permission for
Mr. LN to point out when
ever you have not completed
on time.
8. To develop a
skill.
1. Learn ‘Tamil Typewriting’ and
prepare for ‘Lower’ Exam.
2. Spend half an hour every day
on practice.
3. Periodically communicate your
progress to the Counsellor.
ALCOHOLISM AND DRUG DEPENDENCY
226
Goal
Methods to achieve
the goal
Target
Actual
Date of
Date for
completion completion
9. To enjoy
recreational
activities.
1. Play carrom with other
patients twice a week.
2. Try and find out which games
you are interested in and spend
one day every week in playing
that game.
On-going
10. To develop a
recovery
support
system.
1. Identify a sponsor in A.A.
2. Ask him to meet your
Counsellor.
3. Give him full permission to
assess and communicate your
strengths and weaknesses.
10-11-92
12-11-92
j
Bibliography
1. Counsellor’s Guide on Problem Drinking — National Council on
Alcoholism, No. 3 Grosvenor Crescent, London SWIX 7 EE.
2. Planning Alcoholism Counseling Education (Pace) — U.S. Department
of Health and Human Services, Public Health Service, Alcohol, Drug
Abuse, and Mental Health Administration, National Institute on
Alcohol Abuse and Alcoholism, 5600 Fishers Lane, Rockville,
Maryland 20857.
3. Alcoholism Counseling Gore Curriculum — State of New York, Mario
M. Cuoma Governor, Division of Alcoholism and Alcohol Abuse,
Robert V. Shier, Director.
4. Counseling skills for Alcoholism treatment services — a Literature
review and experience survey by Donnabain, MSW and Lisa Taylor,
MSW, Addiction Research Foundation, Toronto, USA.
5. Confidentiality in Social Work — Issues and Principles — Wilson
J. Shanna, The Free Press, London 1978.
41
4
21________ ___________________
VOCATIONAL REHABILITATION
Research studies repeatedly demonstrate a strong link between ‘staying
clean’ and having a job. This vital relationship is usually well known
to treatment professionals and is also acknowledged by recovering
people. Most notably, employment means legitimate income and a
constructive activity, which help in increasing self-esteem and developing
healthy coping skills. Employment helps in the overall growth of the
patient.
Addiction would have led to damages in the area of employment.
The chemical dependent might not have completed his academic caieer,
and therefore, may not be able to get back to any vocation. Many of
them, even if they are employed, may not have a consistent track record.
They might have been shifting from one occupation to anothei. They
would not have bothered to update their knowledge or skills. Therefore,
during recovery, there is a specific need for their vocational
rehabilitation.
In dealing with this issue, what is crucial is the initial assessment.
The Counsellor should at the start, distinguish between two types of
problems clients may face
- difficulty in reintegration into place of work.
- currently unemployed, and hence requiring guidance to look lor a
suitable job.
If the chemical dependent is employed, he may be facing the con
sequences of previous disciplinary problems like absenteeism,
interpersonal conflicts etc. at work spot. This may cause stress to the
client.
The first step in handling this would be to collect a detailed history
with regard to the following.
228
ALCOHOLISM AND DRUG DEPHNDI-NCY
- how many years of service he has put in
what are the problems caused by addiction in his job
- what are the disciplinary actions he has to face. Any urgent issue
which needs to be looked into immediately (eg. under suspension)
- what is the nature of work. Assess if the nature of work is conducive
to sobriety, (eg. Does it give him an opportunity to attend A.A.
meetings, to come for regular follow-up.)
After collecting the data, the Counsellor should look for the blocks
within the client which may be making him uncomfortable to go back
to work. More often, these blocks will be at the feeling level. Clients
may feel ashamed to face their colleagues, may be anxious to relate
to their authorities, may be afraid of disciplinary action, may be
apprehensive of curious questions, teasing etc. The Counsellor should
help him share his feelings in depth with the group. If necessary, the
Counsellor could discuss relevant issues like the nature of treatment
given, the need for follow-up etc. with the personnel department.
However, this has to be done only with the consent and participation
of the client. After the client resumes duty, he should be encouraged
to share his feelings with the Counsellor and the group. An on-going,
parallel emotional support will positively assure his smooth re-entry
into the workspot.
There may be some clients who would be unemployed at the time of
admission. These clients may need help in looking for a suitable vocation.
In such cases, assessment should include the following.
- any job held so far. Details about jobs held, nature of work, reasons
for quitting etc.
- current skills and abilities.
Depending on the assessment, the Counsellor should help the client to
identify job opportunities. A few guidelines, to be kept in mind while
discussing this issue are given below.
- If client has a track record with short stints at various jobs, an indepth analysis into the difficulty in retaining a job would be useful.
(It may not be chemical dependency alone. For example, it may be
difficulty with interpersonal relationships).
VOCATIONAL REHABILITATION
229
- If any updating of skills by attending a short refresher course could
increase the employability of the client, he should be encouraged
to do so. When referrals are made, the focus should always be on
the patient’s need and the market need. It is improper to refei the
patient to a particular agency simply because it has connections with
the After-care Centre.
- Some jobs may not be safe for recovering people. It is wise to
consider carefully any employment opportunity in terms of how it
may help or hinder recovery and, if one accepts it, be prepared to
manage problems. For example, jobs involving travelling, especially,
sales job, starting a new business venture etc.
- During the initial stages of recovery, the environment can also be
stressful, especially because the person is adjusting to a drug-tree
life style. For example, long hours of work, night shifts, etc. Client
should learn to combat this stress through healthy ways.
Thus employment would help the client have
- a structure and purpose for his time and energy.
- a positive social environment.
- a sense of accomplishment.
- a continued experience of personal growth and development.
22
SOME MORE IMPLEMENTATION TOOLS
'Staying sober’ implies that the client starts thinking clearly and plans
his life appropriately in order to sustain his drug-free life. Assignments
have been found extremely useful to help recovering patients understand
their thoughts and feelings and realise how much these have a bearing
on their lives. In this chapter, various assignments that can be given
to patients, have been discussed. Each assignment can be given to
patients after they have attended the re-educative lecture on that
particular topic. Submission and discussion of assignments are found
very useful in the process of helping patients towards sobriety.
Assignment - 1
Damages in the area of education
As chemical use progresses, school and college often become less
important to the chemical dependent. What was once of high priority,
now gets pushed down the list to make way for drugs and a drug-centred
life style. To understand this, please complete the following chart.
i) Demarcate three or more stages of drug use and abuse in
chronological order, starting with the recent past.
Percentage of
Marks Obtained
In School/College
Rank
Rank Received
Received InIn
Classes
Classes
Degree of
Involvement In
Drug Use
SOME MORE IMPLEMENTATION TOOLS
231
Assignment - 2
How chemicals affect the ability to have fun
People usually begin using drugs in a social situation as an addition
to whatever activities they are involved in. Activities include hobbies,
sports, viewing movies etc. During this stage, fun and pleasure are
centred on people/that particular activity, and not on the chemical.
As drug abuse progresses, the centre of fun slowly shifts from the
activity to the drug. Eventually, very little pleasure is derived from an
activity unless the person is 'high’.
In your case,
i) What kind of activities did you enjoy before using drugs? How often
did you participate in those activities?
ii) Of late, how often have you enjoyed each of those activities?
During those moments, were you sober or ‘high’?
iii) Has using chemicals affected your ability to have fun? If so, how?
Give specific examples.
Assignment - 3
How chemicals weaken self-esteem
Self-esteem is essentially a measure of self-worth and importance. When
a person has positive qualities, his assessment of himself will be level
headed and reasonable. He will develop a strong self-esteem and will
be contented. When a person has too many negative qualities, his
assessment of himself will be low and poor. He will feel inadequate
and will develop a weak self-esteem.
Drug abuse affects every area of a person’s life. In this process, it
weakens a person’s self-esteem.
Given below is a list of some qualities a person may possess.
Intelligent
© Good in sports
Dishonest
© Spiritual
e Lazy
Friendly
Sensitive
Self centred
232
e
•
e
e
e
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ALCOHOLISM AND DRUG DEPENDENCY
e Clumsy
Impatient
e Honest
Artistic
Cowardly
Courageous
e Kind
Unfriendly
• Creative
)pen minded
e Energetic
lopeless
@ Takes things for granted
Rebellious
& Gets along well with people
Stubborn
felpful
/rite down five positive qualities you had, before you started using
Tugs.
ow did significant people refer to you while you were using drugs
{responsible, selfish, lazy etc.)?
/rite down five positive qualities you would like to get back now.
sdgnment - 4
How chemicals affect feelings
. oii.e examples of feelings — happy, sad, angry etc. Drugs have the
>•'. !ity to block or alter one’s feelings. Drug dependent people rely on
chemicals to take care of their feelings — “If you feel sad, get ‘high’
aii-.i feel good. If you feel lonely, get ‘high’ and feel better.”
T problem with this is when the person is not ‘high , these negative
Rxlihgs will come back. After a while, it will almost be impossible to
ge* through these feelings without resorting to drugs. It is very important
io be able to deal with feelings without resorting to drugs. It is for this
reason that the ways in which you had handled feelings in the past must
be examined.
The following example will help you understand the process.
Ram's son got the first rank in his class. He had shared his
happiness vdth his grand parents and even with neighbours.
He did not inform Ram. When Ram came to know about this
from his in-laws, he was deeply hurt. “Look! he has not
bothered to tell me!” Instead of discussing the issue with his
son, he went out and got drunk to escape from his hurt.
SOME MORE IMPLEMENTATION TOOLS
Y'1 '"
233
i) Specify how you had dealt with the following feelings while you were
on drugs — clearly describe the situation, your thought and behaviour.
- Resentment
- Over sensitivity to criticism
- Fear/Anxiety
- Inferiority
- Self Pity
- Rejection
- Happiness
- Boredom
ii) In what ways have you blamed others or circumstances for your
problems? Be specific with examples.
Assignment - 5
How chemicals interfere with friendship
As a person starts abusing drugs, his circle of friends changes. He is
no more interested in friends who do not use drugs. He makes new
‘friends’ who are in tune with his drug-taking behaviour. During
recovery, one realises that his ‘so called friends’ are not real friends
but only ‘drug-using companions.’
i) What are the qualities you notice in your ‘drug-taking friends’?
ii) What kind of qualities do you now look for in your friends?
iii) What are the activities you are planning to carry out with your new
friends?
Assignment - 6
Giving reasons for chemical use
As drug abuse progresses, drug users depend on drugs to escape from
problems, and keep on justifying their use. (For example, they
rationalise that they use drugs during tense moments like arguments,
during a particular activity, in a social situation etc.) During recovery,
these situations may occur again. Therefore, it would be helpful if you
remember how you had handled them before, so that you can plan
methods to handle them from now on.
i
234
ALCOHOLISM AND DRUG DEPENDENCY
Given below is a list of situations you may face now. State the plans
you have made to handle these ‘high-risk’ situations.
- You happen to meet others who are using drugs
- When you are alone
- During arguments at home
- At school/college when there is a ‘cultural’
- When someone suspects you
- If your family members ignore what you say
- While involved in an activity which you had been doing formerly
while you were abusing chemicals
- When in social situations
I
Assignment - 7
How chemicals destroy values
A man is normally known and acknowledged only by his values.
Sometimes, using chemicals becomes more important than certain
values. One may have to go against these values to use drugs. When
this happens, he experiences guilt. Using drugs may mask these feelings
of guilt, but they are still there. Feeling guilty often causes people to
want to get ‘high’ again. To get these drugs, he may again have to go
against his values causing more guilt and more pain. This is a self
defeating pattern.
Given below are some values. While this is not a complete list, it will
give you a good idea of what values are. Read the list slowly and
carefully and then answer the questions.
Honesty
Open mindedness
Loving
Hard work
Responsibility
Respect for elders
Discipline
Giving importance to education
Punctuality
Good health
Following family traditions
Alcohol/drug-free life
Spending money wisely
Gratitude
Helpful
Cleanliness
Trust in God
Patience
Orderliness
Listening
!
SOME MORE IMPLEMENTATION TOOLS
i) List five values you had,before you started using drugs.
ii) Did you ‘break’ any value during your ‘drug-taking days ?
Be specific about the situation and your behaviour,
iii) What are the values you would like to get back now?
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235
Printed by TT. Maps & Publications Limited,
328 G.S.T. Road, Chromepet, Madras-600 044.
Published by Mrs. Shanthi Ranganathan,
T T Ranganathan Clinical Research Foundation,
17, IV Main Road, Indira Nagar, Madras-600 020.
Distributed by Mr. J. Srinivasan
T T R Education Foundation,
17, IV Main Road, Indira Nagar, Madras-600 020.
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■ -
-:A;-; ■
OTHER VOLUMES IN THE SERIES
ALCOHOL ISM t\f if': ■. L X' S ? ■
THE
JD aMCY
5 KWFR 3UK)6
c
In this Professional’s Master Guide, you
have a full-time consultant on-site to
provide you with
0 In-depth analysis and coverage of
the major issues and complicated
problems you face in the field of
addiction management
® Concise, practical techniques
specific to ’addiction counselling’,
group therapy methods etc
• Useful diagnostic tools and step by
step method of approach in the
process of patient’s recovery
A must for every professional dealing
with alcoholism and drug dependency.
.'i
1.
This is an easy to use illustrated guide.
In simple language this book helps in
understanding
• Addiction as a disease
• The impact of addiction on family
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• The role of parents in the
prevention of addiction
• The methods to be adopted in
approaching an addict and
motivating him to accept help
(this requires specific knowledge
and skill).
A permanent reference guide for any
person playing a key role in society
including clergymen, health workers,
union leaders, teachers in small towns
& villages and volunteers working for
social service organisations.
J
&
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