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CONTENTS
PART - A
Pages
f |2 DRUGS - A CLOSER LOOK
-Narcotic Analgesics
^Stimulants
^depressants
/hallucinogens
1
2. CANNABIS
Pharmacology
Effects on the user
Tolerance and dependence
Withdrawal symptoms
15
3. HEROIN
Pharmacology
Effects on the user
Tolerance and dependence
Withdrawal symptoms
20
4. OPIUM
v
Effects on the user
Tolerance and dependence
®ALCOHOL
28
J
R
31
Factors influencing the effects of alcohol
Path of alcohol in the body
Effects on the user
Physical and Psychological dependence
Interaction of alcohol with other drugs_^
Types of alcoholic beverages
Methyl alcohol
Quiz
ix
91I
Pages
MEDICAL COMPLICATIONS RELATED
TO THE USE OF ALCOHOL
Gastrointestinal tract
Vascular system
Respiratory system
Nervous system
Muscles
Excretory system
Reproductive system
Skin
Endocrine system
Alcohol and Nutrition
Withdrawal symptoms
if
I
ST
46
‘
7. ADDICTION - A DISEASE
Addiction to Alcohol
Characteristics of Alcoholism
Symptoms of the Early, Middle and Chronic phase
Jellinek’s classification
Three distinct stages
Diagnostic criteria
Michigan Alcoholism Screening Test
56
Addiction to Drugs
Symptoms of the Early, Middle and Chronic stage
Elements of the syndrome
&
I
I
i
8} DENIAL
Different forms of denial
Enablers, Victims and Compensators
80
9. CAUSATIVE FACTORS
^Causes for alcoholism
Physiological theories
Psychological theories
Sociological theories )
89
Causes for drug dependency
Physiological theories
Socio-cultural theories
x
Pages
flJR PROBLEMS EXPERIENCED BY THE FAMILY
97
Emotional responses
Behavioural responses
Guidelines for the family members
Problems experienced by the family
11. CHILDREN OF ALCOHOLICS
Problems faced by the children
Roles taken
Three unwritten laws
Fetal alcohol, syndrome.
Case study'
Children of'Alcoholics Screening Test
12. ADDICTION - THE ROLE OF PARENTS
114
130
Building a positive relationship
Recognising a chemically dependent
Guidelines for parents
134
13. TREATMENT
Medical Management
Psycho-social Management
Other techniques
Comprehensive multi-disciplinary approach
A model treatment programme
149
14. RECOVERY
Distinct phases in recovery
^Factors that complicate recovery
' Guidelines for ‘living sober’
161
15. SELF-HELP GROUPS
Alcoholics Anonymous
Al-Anon
Narcotics Anonymous
Alateen
166
16. DRY DRUNK’ SYNDROME
Sobriety based qualities
‘Dry drunk’ based qualities
Life history of Solberg
xi
Pages
' 11. RELAPSE DYNAMIC
I Characteristics of a relapse
/ iS*1 p™b^ms associated with abstinence
1 rolonged abstinence syndrome
I Structured programme of recovery
178
PART - B
CJF BASIC COUNSELLING
TECHNIQUES
Fundamental principles
Communication skills
Personal qualities of a counsellor
Addiction counselling
Psychological tests
185
19. interviewing skills
Supportive communication techniques
Facilitative communication techniques
196
20. PROFILE OF CHEMICAL DEPENDENTS
204
■ ' > .. pr°^e
a Dru® Dependent
/ ^Profile of an Alcoholic
21. MOTIVATING THE CLIENT
Motivation skills
211
22. CASE-HISTORY TAKING
..V
Interviewing the chemically dependent
-^Components of case-history taking
Eliciting problem areas
214
23. DEALING WITH DENIAL
218
Confrontation
Types of discrepancies
I
xii
Pages
223
24. GROUP THERAPY
Goals
The process
'
‘
Therapeutic tasks \
Role of the counsellor
Yalom’s Curative Factor' '
229
25. RELAXATION THERAPY
The Jacobson Procedure
Guidelines for the therapist
234
26. ASSERTIVENESS TRAINING
Goals
Techniques
27. IMPROVING SELF-ESTEEM
Guidelines to improve self-esteem
239
MARITAL COUNSELLING
245
Guidelines
Communication skills
Sex problems
d
253
29. FINANCIAL MANAGEMENT
Guidelines
30. PROBLEMS PRESENTED BY THE
CHEMICALLY DEPENDENT CLIENTS
Refusal to take medication
Clients arriving intoxicated for counselling
Suicidal tendency
257
APPENDICES
261
263
276
279
281
288
MEDICAL HISTORY
IN-TAKE FORM
THERAPY CHECKLIST
GROUP THERAPY RECORD
ASSIGNMENTS
FOLLOW-UP RECORD
xiii
PART-A
I
1
DRUGS - A CLOSER LOOK
When a pharmaceutical preparation or naturally occurring substance is used primarily
to bring about a change in some existing process or state (physiological, psychological
or biochemical) it can be called a ‘drug’. In simpler terms, any chemical that alters
the physical or mental functioning'oF an individual is a drug.
Drugs may or may not have medical uses; their usage may or may not be legal. When
drugs are used to cure an illness, prevent a disease or improve the health condition,
it is termed ‘drug use’.
When drugs are taken for reasons other than medical, in an amount, strength,
frequency or manner that damages the physical or mental functioning of an individual,
it becomes ‘drug, abuse*. Any type of drug can be abused. Drugs with medical uses
can also be abused.
With medically prescribed drugs, drug use and drug abuse can be differentiated.
Drugs with medical uses can be abused in the following ways:
Too much: Taking an increased dosage without medical advice, e.g. Taking 10
mg of valium when only 2 mg has been prescribed.
Too often: Taking small doses frequently, e.g. Taking the drug during day-time
when a bed-time ddsage alone has been prescribed.
Too long: Taking the drug for an extended period of time — longer than the
prescribed period, e.g. Continued use of the drug for months when the physician
has advised usage only for a fortnight.
Wrong use: Taking a drug for reasons other than medical, for which it is intended,
or taking a drug without medical advice, e.g. Taking Cardinal (an anti-epileptic drug)
for the sedative side-effects it produces.
Wrong combination: Taking a drug in combination with certain other drugs,
e.g. Taking barbiturates (a depressant drug) with alcohol to enhance the effect.
>i
2
ALCOHOLISM AND DRUG DEPENDENCY
Illegal drugs like brown sugar and ganja have no medicaHisjiatall. With these drugs,
there is no ‘drug use’. To use them is to abusFthFmrFrom the very outset, it is
drug abuse.
Drug abuse leads to drug addiction with the development of tolerance and depen
dence. Tolerance refers to a condition where the user needs morejaninLorepf the
drugjo experigncejji^ same-effect. Smaller quantities, whicFwefe^ufficient earlier,
are no longer effective and the user is forced to increase the amount of drug intake.
Some drugs produce only psychological dependence while others produce both
physical and psychological dependence.
dependence is a state characterised by emotional and mental
preoccupation with the effects of the drug and by a persistent craving for it. When
psychological dependence develops, the user gets mentalgrhooked^nfto^he drug.
a Psychological
When physical dependence develops, the user’s body becomes totally dependent
on the drug. With prolonged use, the body becomes so used to functioning under
the influence of the drug, that it is able to function normally only if the drug is present.
After the user becomes dependent, if the intake of drugs is abruptly stopped,
withdrawal symptoms occur. In a sense, the body becomes ‘confused’ and ‘protests’
against the absence of the drug. The withdrawal symptoms may range from jnild
discomfort toxonvulsions, depending on the type of drug abused. The intensity of
withdrawal symptoms depends on the type of drug abused, the amount of drug intake
and the duration of abuse.
These withdrawal symptoms make it difficult to give up drugs. The user is seemingly
caught in a web of his own making. He wants to avoid the unpleasant withdrawal
symptoms; to avoid them he needs the drugs. The addict is thus forced to continue
drug use even when he knows that drugs are hurting him.
I
Classification of addictive drugs
Addictive drugs are classified in various ways based on their origin, chemical structure,
mechanism of action etc. When classified according to their effects on the user,
addictive drugs can be classified into FIVE major categories:
1. Narcotic analgesics
2. Stimulants 3. Depressants
> k I To < n
X‘
4. Hallucinogens
5. Cannabis*
The first four categories are dealt with individually in the following pages. Detailed
information about cannabis can be found in the chaptet on ‘Cannabis’.
For a long time Cannabis was classified as a hallucinogen. But since a few effects like flashbacks
do not occur with cannabis a separate category was created.
(
J
3
DRUGS - A CLOSER LOOK
Narcotic analgesics
In Greek the prefix ‘narco’ means to ‘deaden’ or ‘benumb’. Analgesic means pain
killing or pain-relieving. The term ‘narcotic’ medically refers to opium and opium
derivatives or synthetic substitutes, that produce opium-like effects?'’
All narcotic analgesics share the common property of benumbing and thus relieving
pain. As a class, they are painkillers with a high addictive potential.
Drugs belonging to this category can be studied under three broad categories —
narcotics of natural origin, semi-synthetic narcotics and synthetic narcotics. Drugs
belonging to the first two categories are referred to as opiates while the synthetic
drugs are known as opioids.
NARCOTIC ANALGESICS
r
Natural
Synthetic
Semi-Synthetic
Morphine
r^hppyl „
__JZZ
Meperidine
Plant’ |
P~Heroin [
Methadone
Pethidine
* I ^Ppium 'I
Brown Sugar
(Heroin + Adulterants)
Morphine
Codeine
Figure-One
Narcotics of natural origin
The poppy plant, ‘Papaver Somniferum’, is the source of naturally occurring narcotic
drugs. For thousands of years this plant has been widely cultivated for its pleasurable
effects. Today, its cultivation has been restricted by law.
Opium
Opium is made from the milky fluid that is collected from the unripe pod of the
poppy plant. Opium is a dark greyish or brownish tar like substance.
Opium is smoked, chewed and absorbed through the mucuous membranes of the
mouth. It is also boiled with water and drunk.
Detailed information can be found in the chapter on ‘Opium’.
I
4
ALCOHOLISM AND DRUG DEPENDENCY
Morphine
Morphine is the principal alkaloid that is extracted from opium. (An alkaloid is a
type of drug which can be extracted from a plant.) About 10 — 15% oFl^ o^ium
exudate contains morphine. Morphine is one of the most effective drugs for relief
of pain. It is still used medically.
Routes of administration
Injected — subcutaneously, intramuscularly or intravenously. Most morphine addicts
use the intravenous route.
Codeine
Codeine is another alkaloid found in opium though in a smaller percentage than in
morphine (one to two percent).
Codeine is used in cough-suppressant drugs and anti-diarrhoeal preparations.
Routes of administration
Injected — subcutaneously or intramuscularly.
., • - ' - *
'
Oral -- medical preparations of codeine are usually made in combination with other
chemicals and are available in the form of tablets and syrups. - '
Codeine is very rarely abused as its analgesic effects are niild and'severe side effects
convulsions) are often experienced.
-
Semi-synthetic narcotics
Heroin/Brown sugar
Heroin
di-acetyl morphine.')
«eroin ((dnacm
morphine) iis a semi-synthetic derivative of the drug morphine,
rown sugar is the adulterated form of heroin. Brown sugar is smoked or ‘chased’.
Detailed information can be found in the chapter on ‘Heroin’.
Synthetic narcotics
Synthetic narcotics are produced only in the laboratory. These drugs imitate the
enect or the opiates but are not prepared from opium. Pethidine and methadone
are the most widely available synthetic narcotic drugs.
Meperidine
Meperidine [Pethidine^] is probably the most widely used drug for the relief of
moderate to severe pain.
Routes of administration
Oral — Meperidine can be administered orally in the form of tablets.
Injected — subcutaneously, intramuscularly or intravenously.
Pethidine addicts almost always inject the drug intravenously.
DRUGS - A CLOSER LOOK
5
Methadone
From the 1960’s Methadone received wide recognition in the area of narcotic addiction
treatment in the United States. It later became a part of heroin addiction treatment.
Ironically, later on, many got addicted to methadone and it became the major cause
of overdose deaths. Since then, it’s use has declined.
Routes of administration
Methadone is almost as effective when administered orally as it is by injection. So
methadone is usually taken in the form of tablets.
Short-term effects of narcotic analgesics
When injected, the effects are immediate and pronounced. With other routes of
administration, the effects are felt only gradually.
The main effects include:
— a short-lived state of euphoria during which feelings of hunger and pain are not felt.
— mental clouding — impairment of intellectual processes
— drowsiness, apathy, decreased physical activity
— reduced heart rate and blood pressure
— constipation
— constriction of pupils (with the exception of synthetic narcotics)
_ —
.
-—
A few adverse reaction may also appear:
— nausea, vomiting
— dysphoria (a feeling of unpleasantness)
— increased sensitivity to pain after the initial effect wears off
— itchy skin
With large doses, pujhls consiriciXQ pm point ^size and respiratory depression^becomes
more pronounced. With an overdose, cyanosis develops in which skin becomes cold,
moist and bluish. Convulsions occur which may be followed by respiratory arrest
and death.
Long-term effects
Severe constipation, contracted pupils and moodmess are some of the long-term
effects. Chronic users may develop lung problems due to its effects on the respiratory
system. Infection can be caused by unsterile needles. Abscesses (pus formation),
cellulitis (inflammation of connective tissues), liver damage, tetanus and brain damage
are the other problems which may develop.
6
ALCOHOLISM AND' DRUG DEPENDENCY
Tolerance and dependence
Tolerance develops fairly rapidly making higher doses necessary to maintain the
intensity of its effects. The narcotic analgesic class of drugs is highly addictive, and
regular use results in severe physical and psychological dependence.
Withdrawal symptoms
The withdrawal symptoms of narcotic analgesics are more painful and severe,
compared to the withdrawal symptoms of other categories of drugs. The severity
of withdrawal symptoms will depend on the type of narcotic used* the amount, the
duration of use and the general health condition of the person.
C
With the deprivation of narcotics, the first withdrawal symptoms are usually experi
enced shortly beforejhe_timc^of the next scheduled dose. Although withdrawal can
cause considerable suffering, the initial symptoms resemble those of a moderately
severe bout of influenza. Throughout, complaints, pleas and demands of the addict
are prominent. Symptoms such as watery discharge from eyes and nose, yawning and
perspiration appear about 8 to 12 hours after the last dose. Restlessness, irritability,
Jos^ofappgtite, gopsejlesh, tremors, pupilarydilation? yawning and seyere_sneezing
also occur. Thereafter the addict may fall into a restless slgep. Withdrawal symptoms
intensify and reach their peak between 48^and_72 hours after the last dose. The patient
becomes weak and depressed. Nausea and vomiting occur. Stomach cramps and
diarrhoea are commonTTIeart rate and blood pressure are elevated. Chilis alternating
with flushing and excessive sweating are also characteristic symptoms. Excruciating
pain in the bones and muscles of the.back and extremities occur as do musclespasms
and kicking movements. At this time the individual may develop suicidal tendencies.
Without treatment, the syndrome eventually runs its course and most of the symptoms
will disappear within 7 to 10 days. The time taken to restore physiological and
psychological equflibfium7'hbwever, is unpredictable. For a few weeks following
withdrawal, the addict will continue to think and talk about his use of drugs and
be particularly susceptible to an urge to use them again.
Stimulants
Stimulants are drugs which excite or speedup the central nervous system. The two
most prevalent stimulants are nicotine, found in tobacco products, and caffeine, the
active ingredient in coffee andTeaTThese however will not be discussed here. The
more potent stimulant drugs will be the focus of attention. They include
amphetamines and cocaine.
Amphetamines
Amphetamines are synthetic drugs produced entirely within the laboratory.
Amphetamine, dextroamphetamine and meth-amphetamine collectively come under
I
DRUGS - A CLOSER LOOK
7
the term amphetamines. The effects produced by these three are the same and can
be differentiated only by clinical analysis.
* Amphetamines are still used medically to treat narcoplexy (an uncontrollable tendency
to sleep) and hyperkinetic behaviour in children (excessive activity and short attention
span).
Amphetamines are sometimes used in weight control programmes, in the treatment
of mild depression and to provide relief from fatigue. Amphetamines however are
now recognised as a poor choice for treating these disorders.
Amphetamines are,white, odourless, crystalline powders with a brtter taste. Illicit
varieties include fine or coarse powders and crystals that are off-white to yellow in
colour. They are supplied loose or in the form of capsules and tablets.
Amphetamines are usually abused by:
— students^ toward' off sleep, enabling them to study through the night prior to
the examination
— athletes, to mask feelings of fatigue and increase their endurance.
— Busy executives often abuse both stimulants (‘uppers’) and depressants
(‘downers’) — the stimulant to increase their activity during the day and the
depressant to calm down the sleep during the night.
Routes of administration
Oral: Amphetamines are absorbed orally and are taken in the form of tablets or
capsules.
Cocaine
Cocaine, a potent stimulant of natural origin, is extracted from the leaves of the coca
plant (Erythroxylon coca).
Cocaine was formerly used in eye, nose and throat surgery because of its ability to
anaesthetize tissues and simultaneously constrict blood vessels and limit bleeding.
It is no longer employed medically.
It is an odourless, white, crystalline powder, with a bitter numbing taste. Street
cocaine is^ften adulterated with other chemicals.
Routes of administration
Oral: The leaves of the coca plant are sometimes chewed and cocaine, the chief psycho
motor chemical present, is absorbed through the mucuous membranes of the mouth.
Snorted: Cocaine is usually ‘snorted’ or taken in through the nasal passages (like
snuff).
Very rarely, cocaine is injected for a heightened effect.
•Tfr^rar* ’■•• i®.:- kt-wf-v-
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<
8
ALCOHOLISM AND DRUG DEPENDENCY
Short-term effects of stimulants
Amphetamines and cocaine have different mechanisms of action but the overall impact
is the same and their effects parallel each other very closely.
The main effects include:
— a heightened feeling of well being, euphoria (elation)
— a sense of super-abundant energy, increased self-confidence
an increased motor and speech activity
— a suppression of appetite (which is why it is used in diet pills)
— an increased wakefulness that masks feelings of fatigue (the reason why
amphetamines are abused by students during examinations).
Pupilary dilation, dryness of mouth, increased respiration, heart rate and blood
pressure, reduced gastrointestinal activity and urinary retention are other effects.
Unpleasant effects such as temporary impotence, anxiety or even panic may be noticed.
With large doses, very rapid heart beat, hypertension, headache, profuse sweating,
severe agitation and tremors may occur. Very high doses cause rapid, irregular and
shallow respiration, convulsions and coma.
Long-term effects
Chronic sleep problems, poor appetite, high blood pressure, rapid and ifreguiar'heart
beat, impotence, mood swings, anxiety and tension states are the tong-term effects
of stimulant abuse.
Acts_oUyiolence, homicide and suicide_rate.s_among stimulant^ abuxsefs are high.
Chronic use may produce ‘amphetamine psychosis’. Paranpidideations,'hallucinations
and purposeless sterotype behaviour may develop. A full blown amphetamine
psychotic state closely resembles paranoid schizophrenia.
Snorting of cocaine may result in perforation of the nasal septum.
Tolerance and dependence
Tolerance does develop to a certain extent. For a long time, it was not clear as to
whether stimulants produced physical dependence. But now it is clearly known that
it does to an extent. As the intensity of the pleasurable effects are high, strong
psychological dependence also develops.
Withdrawal symptoms
When chronic use is abruptly discontinued, withdrawal symptoms occur. However,
the clinical picture does not include major grossly observable physiological disruptions.
Extreme fatigue, prolonged but disturbed sleep, voracious appetite, irritability and
moderate to severe depression are the commonly reported withdrawal symptoms.
•mw,
9
DRUGS - A CLOSER LOOK
Depressants
Depressants are drugs which depress or slow down the functions of the central nervous
system. The drugs which come under this category include:
1. Sedative-hypnotics
2. Alcohol*
Sedative-hypnotics
Sedative-hypnotics are non-narcotic depressant drugs whose primary effects are
calming, sedation or inducing pf sleep. Barbiturates and benzodiazipines are two
4main drugs that fall into this category.
Barbiturates
More than 2500 barbiturates have been synthesized and about 50 compounds
marketed. These compounds have been researched and developed for their
tranquilising and sleep inducing effects. Some of the more commonly used
barbiturates are listed in the table below:
Generic Name
Thiopental
Pentobarbital
Secobarbital
Phenobarbital
Secobarbital &
Amylobarbital
Trade Name
Sodium pentothal
Nembutal
Seconal
Luminal
Cardinal
Vesparax
Barbiturates are medically prescribed for sedation and to induce sleep. They are also
used for narcoanalysls^tnith-serum) and as anti-convulsants (anti-seizure, e.g.
phenobarbital^ ;
-
Salts of barbiturates are white bitter powders.
Routes of administration
Barbiturates are administered orally in the form of tablets or capsules. Barbiturates
can also be injected — subcutaneously, intravenously or intramuscularly.
* For details about alcohol refer to the chapter on ‘Alcohol’.
10
ALCOHOLISM AND DRUG DEPENDENCY
' I
Benzodiazepines
Over 2000 types of benzodiazepines have been synthesised but bnly twelve ofthem
are marketed. Benzodiazepines as a class are the most frequently prescribed drugs.
The following table lists some of the most commonly prescribed benzodiazepines.
Generic Name
Trade Name
Diazepam
Chlordiazepoxide
Flurazepam
Alprazolam <
lorazepam x
Valium, Calmpose
Librium
Dalmane
Alprax
Ativan
Benzodiazepines are clinically used to reduce^anxiety, induce^sleep and for muscle
relaxation. These are also used as pre-anaesthetic medications and to control seizures.
Of late, however, physicians have been discouraged from prescribing these drugs
for anxiety arising out of everyday living. The use of tranquilisers on a daily basis
for more than three months is becoming less acceptable.
Benzodiazepines are white or pale yellow crystalline powders.
Routes of administration
Benzodiazepines are taken in the form of tablets or capsules. Diazepam and
chlordiazepoxide are also injected intravenously.
Drugs like meprobamate (e.g. equanil), glutethimide (e.g. doriden), chloral hydrate
(e.g. mickefinn drops) do not fall into either of the two categories mentioned above.
But the overall depressant effects produced are similar. Methaqualone preparations
(e.g. Mandrax), are sedative hypnotics that have been banned and are no longer used
medically.
Short-term effects of depressants
Sedative hypnotics produce effects that are similar to that of alcohol. The main effects
include:
— relief from anxiety and tension
— euphoria (usually with barbiturates)
— mild release from inhibitions
— sedation, sleep with larger doses
— poor motor coordination (especially for fine motor tasks)
DRUGS - A CLOSER LOOK
11
— impaired concentration and judgement
— slurred speech and blurred -vision
Nausea, abdominal pain, excitation which may lead to hostile behaviour can also
occur.
x
With large doses, barbituratescan cause irregular breathing, weak pulse, coma and
death. Death due to overdosage rarely occurs with other sedative hypnotics. Death
due to overzdo^age usually occur with a combination of sedative hypnotics and alcohol.
Long-term effects
Long-term use can produce depression^ chronic fatigue, respiratory impairments,
impaired sexual function, decreased attention span, poor memory and judgement.
Chronic sleep problems may develop. Reduced REM sleep due to drug use makes
the quality of sleep so poor that the user does not feel rested on waking up.
Tolerance and dependence
Tolerance does not develop uniformly in all the drug-induced effects. With
barbiturates, tolerance to the sleep inducing effects develop very rapidly often within
a week or two of regular use. In the case of benzodiazepines, with chronic use,
tolerance develops to the anxiety and tension relieving effects.
The user increases the daily dose to maintain the sought after effects.
Cross tolerance to other drugs of the depressant class also develops (i.e. the desired
effect will not be felt, if the user who is tolerant to one of these drugs ingests another
at a dose level which would otherwise be sufficient to produce the same effect).
Tolerance diminishes following a short period of abstinence.
Physical dependence can develop with regular use.
However, the psychological dependence produced is significant.
Anxiety or even panic is evident if the user is temporarily unable to obtain supply
of the drug. The User experiences a persistent craving for the drug even when
significant psychoactive effects are not felt.
Withdrawal symptoms:
The withdrawal symptoms after abrupt abstinence are often not as severe as
withdrawal from other classes of drugs.
Mild withdrawal symptoms like anxiety, insomnia, weakness and nausea are usually
noticed.
With very high and chronic use of the drug, agitation, high body temperature,
delirium, hallucinations and convulsions develop.
12
ALCOHOLISM AND DRUG DEPENDENCY
Hallucinogens
Hallucinogens are drugs which dramatically affect perception, emotions and mental
jyrocesses. As they distort the perception of objective reality and produce
hallucinations, these are known as ‘hallucinogens’. Hallucinogens are also referred
to as ‘psychedelic’ (mind altering) drugs.
Hallucinogens include a wide variety of substances ranging from wholly synthetic
products to naturally occurring substances. Hallucinogenic drugs are very rarely
available in India, making it the leagtjibused class of drugs. The most common
hallucinogenic drugs are listed below:
LSD (Lysergic acid diethylamide)
LSD is a semi-synthetic drug and the most powerful hallucinogen.,.It is produced
rom lysergic acid, a substance derived from the ergot Jhrjgiis which grows on rye,
or from lysergic acid amide, a chemical found in morning glory seeds.
LSD was used only as a research tool to study the mechanism of mental illness. LSD
has no medigal. use.
LSD is a white odourless crystalline material which is soluble in water.
Routes of administration
It is easily absorbed orally and is usually taken in the form of tablets. LSD blotter
papers are also common. Here LSD is dissolved in water and is absorbed in blotting
paper. A piece of this paper is torn off, placed under the tongue and sucked.
PCP (Phencyclidine)
PCP was synthesised and tested as a human anaesthetic in the 1950’s. Its use was later
discontinued due to its side effects that included confusion and delirium. It'latfcr came
to be used in veterinary medicine. PCP is now produced only in clandestine laboratories.
PCP is commonly called ‘angel-dust’. PCP in its pure form is a white crystalline
powder that readily dissolves in water.
'
\ '
Routes of administration:
It is snorted, smoked, eaten and rarely taken intravenously.
Mescaline:
Mescaline is derived from the ‘Mexican peyote cactus’ and the ‘San Perdo cactus’
r or centuries consumption of mescaline was part of religious ceremonies in parts of
North America. It is still used in these areas. Mescaline can also be produced synthetically.
Mescaline appears as a white or coloured powder.
DRUGS - A CLOSER LOOK
13
Routes of administration
The oral route of administration is most common.
Psilocybin
Psilocybin is chiefly derived from the ‘psilocybe’ mushroom. The drug can be
synthetically produced only with great difficulty. Crude mushroom preparations
containing psilocybin are usually sold as dried brown mushrooms.
Routes of administration
This drug is well absorbed orally. The mushroom itself may be eaten or dried,
powdered and smoked.
DMT (dimethyl-triptamine), DOM (4 methyl-2, 5 dimethoxy-amphetamine), MDA
(methylenedioxyamphetamine) and belladona in alkaloids also come under the
hallucinogen category of drugs.
Short-term effects of hallucinogens
The physical effects produced and perceptual effects created differ from one drug
to another and wide chemical differences also exist. The main effects include:
— Alterations of mood — usually euphoric but sometimes severely depressive.
— Distortion of the sense of direction, distance and time (e.g. passage £f a few
minutes may seem like_haurs).
— Intensification of sense of vision. Colour and texture of items become more vivid
■* and perception of details is increased.
— ‘Psuedo’ hallucinations (‘pseudo’ because the user knows that the experience is_^
not true, e.g. seeing a myriad of colurs or bizarre images).
— Synesthesia (melding of two sensory modalities). [User may feel he can see music,
heancoloufs-etc.] '
— Feelings of dfcpersonalisation, loss of body image and a loss of sense of reality
(the user may feel that his body is shrinking or becoming weightless).
— Sense of past, present and future may be jumbled. Concentration becomes difficult
and attention fluctuates rapidly.
— Vague ideas and extreme preoccupation with philosophical issues is common.
The great truths and insights he believes that he discovers are unintelligible or
nonsensical to those not under the influence of LSD.
Hallucinogens are however unpredictable in their effects each time they are used.
Acute panic reactions can also be produced resulting in a ‘bad trip’. Acute anxiety,
restlessness and sleeplessness are common until the effect of the drug wears off.
Self destructive behaviour and rash decisions and accidents springing from impaired
judgement are common.
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ALCOHOLISM AND DRUG DEPENDENCY
Long-term effects
— ‘Flashbacks’ or spontaneous recurrences of an LSD experience can occur without
warning for upto a year after LSD use. The exact mechanism of this effect is
not known. The user may experience effects such as intensification of colour,
apparent movement of a fixed object or other hallucinogenic effects even after
abstinence for a few months.
k — Amotivational syndrome: The user becomes very apathetic, h very passive and
shows no interest in life.
/
— LSD precipitated psychosis: Acute panic reactions which can occur may lead
the user into a stage of drug-induced psychosis. It may resemble paranoid
schizophrenia in many respects with hallucination? (mainly yistial), delusional
thinking and bizarre behaviour. The psychotic episode-normally lasts for several
hours but in some cases it may last for years.
Tolerance and dependence
Tolerance develops very quickly and disappears rapidly after discontinuation. Due
to rapid development of tolerance, most of the users discontinue use of the drug
atleast for a while, to regain original sensitivity.
Psychological dependence develops though the user does not become physically
dependent. Particular withdrawal symptoms are not reported.
Bibliography
1. Anthony Radcliffe, Peter Rush, Carol Forrer Sites, Joe Cruse, The Pharmer’s
Almanac — Pharmacology of drugs, MAC Printing and Publication Division,
Colorado, 1985.
2. Ministry of National Health and Welfare, Straight facts about drugs and drug
abuse, Canada, 1983.
3. Terrence C Cox, Michael R Jacobs, Eugene Leblanc, Joan A Marshman, Drugs
and Drug Abuse — A reference text, Addiction Research Foundation, Toronto,
1983.
I
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2
CANNABIS
Cannabis drugs are made from the Indian hemp plant — Cannabis^Sativa. This plant
has been cultivated for centuries in many parts of the world for the tough fibre of
the stem and for its psycho-active properties. When its mind altering properties came
to light, the cultivation of cannabis was banned. Its therapeutic potential and possible
medicinal properties were and are being studied. As of now, cannabis drugs do not
have any medical use.
More than 60 constituents, known as cannabinoids, occur naturally in and only in
the cannabis plant. The chief psychoactive substance in them is delta-9-tetrahydrocannabinol — commonly referred to as THC. THC is responsible for the effects
that the cannabis drugs produce. THC can be produced synthetically but only at
a considerable cost and effort.
The main drugs under this category include:
Ganja/Marijuana
Ganja is prepared from the dried leaves and flowering tops of the plant. Ganja is
commonly referred to as grass, pot or stuff.
The concentration of THC in ganja varies widely depending on the source and
selectivity of plant materials used.
Ganja may range in colour from greyish green to greenish brown and in texture from
a dry leafy material to a finely divided tea like substance.
Ganja is usually smoked in the form of hand-rolled cigarettes (‘joints’ or ‘reefers’) or
pipes specially made for this purpose. Ganja is usually mixed with tobacco and smoked.
The proportion of ganja and tobacco is altered according to the need of the user.
Hashish/Charas
Both male and female forms of the cannabis plant exist. The female plant secretes
a sticky resin which has a high THC concentration. The resinous secretion of the
cannabis plant, which is collected and dried is known as Hashish/Charas.
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16
ALCOHOLISM AND DRUG DEPENDENCY
The THC content in hashish ranges from 5-15%.
:X“n£sk,he dr‘ed compressed■" »'■>“
Hashish can be smoked and is sometimes baked with food and eaten.
Hashish Oil
“aihr.\t^Por^u„cStty„^Pfrasc^
ant material
Hastash oil ,s a dark viscous liquid. I, is usually dripped on cigarettes and smoked.
Bhang
2msS-Si Siem.111 Ca”nab,S dr“eS'
orhmilkiSaa„db,M,erial “'b
•»= «“<
«f the
tWigS' BhanS is^d with tea
I
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Pharmacology of Cannabis Drugs
Absorption
I
' -z
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new lifh
SACRED HEART
HOSPIUI'
tuticorin 628002.
IAMB- NADU.
CANNABIS
17
When taken by the oral route, the effects are felt after 1 hour and the peak is reached
only after 4-5 hours. Users prefer to smoke the drug, as it is about three times more
potent when compared to the oral route of administration.
Distribution
After absorption, THC rapidly leaves the blood and enters the body organs. THC
is not distributed evenly throughout the body and concentrates especially in the fat
tissues. As it is highly fat soluble, it enters the brain also. The absorbed THC stays
in the brain, reproductive organs and fat tissues for long periods of time as it undergoes
no breakdown in these tissues.
Excretion
THC rapidly enters the fat tissues from the blood. From here they must pass back
to the blood and reach the liver to get metabolised.
THC is metabolised by the liver into more water soluble compounds so that it can
be excreted. Some of the metabolites (products of metabolism) which are produced
are also psychoactive.
Effects on the user
The exact effect that cannabis drugs produce cannot be accurately predicted. The
prior experiences and expectatidn of the user, the potency of the drug etc., are
important factors .that produce the psychoactive effect. The main effects include:
— mild euphoria followed by a dreamy state of relaxation
— increased auditory and visual acuity (e.g. sound seems louder and clearer, vision
seems brighter and sharper)
— sense of smell, touch and taste are often enhanced
— lowering of inhibitions, spontaneous laughter
— altered sense of time perception (e.g. time seems to pass more slowly)
— impaired short-term memory, reduced attention span, poor concentration and
disturbed thought patterns
— impairment of ability to perform complex motor tasks
— decreased muscle strength
— splitting of consciousness is evident. The user experiences the ‘high’, while at
the same time becomes an objective observer of his own intoxication. He may
have paranoid thoughts, and yet simultaneously laugh at them.
Some users experience a ‘bad trip’ which includes adverse reactions like mild paranoia,
fear, anxiety, or even panic. Nausea, vomiting and dizziness may occur.
I
18
ALCOHOLISM AND DRUG DEPENDENCY
In addition to the above effects on the central nervous system, the following effects
are also noticed:
Cardiovascular
— Tachycardia (increased heart beat) is very prominent
— Slight drop in body temperature and blood pressure causing dilation of blood
vessels. Due to the dilation of the conjunctiva, reddening of the eyes can be
noticed.
Respiratory
Irritation of the mucosal membranes lining the respiratory system; bronchodilation.
Gastro-intestinal
Increased appetite, especially for sweets; dryness of the mouth apd throat due to
decreased salivary flow.
'
Other effects
— Suppression of REM sleep
Higher doses intensify reactions. The individual may experience shifting sensory
images, mood swings, a flight of fragmentary thoughts, an altered sense of self
identity, impaired memory and lack of attention despite an illusion of heightened
insight. Confusion about the past, present and future and hallucinations may also
develop. Very high doses may result in toxic psychosis.
Tolerance and dependence
Frequent and regular users of high doses develop tolerance to the drug. To maintain
intensity of effects, users increase their daily dose. Original sensitivity can be restored
with abstinence for several days.
Physical dependence on cannabis develops only in high dose users. Strong
psychological dependence develops with the regular user. User acquires a persis
tent craving foi the drug which consequently takes on a central role in his
life. Even if cannabis is temporarily unavailable, anxiety or feelings of panic may
ensue.
Withdrawal symptoms
Abrupt cessation of cannabis use leads to withdrawal symptoms — sleep disturbances
(sometimes with recurrent nightmares), loss of appetite, irritabhity, nervousness, anxiety, sweating and an upset stomach. Sometimes chills, increased body
temperature and tremors develop. Withdrawal symptoms usually last for less than
a week.
19
CANNABIS
Complications
— Pronounced psychological dependence is particularly high among users with
emotional problems who turn to cannabis for relief from psychological stress.
They may come to depend inappropriately on cannabis instead of learning a drugfree means of coping with stress.
— Amotivational syndrome: The user may lose all interest in his work, family etc.
He may become so apathetic that he may not even respond when his name is
called out.
— Psychosis: A typical psychotic episode characterised by confusion, delusion,
hallucinations, disorientation and paranoid symptoms may develop.
— Frequent long-term cannabis use may produce bronchitis, asthma, sinusitis, or
chronic redness of the eyes because of its irritant effect.
— Sterility: There is evidence to indicate that prolonged use can cause reduced sperm
count and decreased sperm motility.
Ongoing studies have revealed some evidence to show that cannabis use reduces the
immunity by impairing a component of the white blood cell defense system. It is
also speculated that smoke from cannabis increases the risk of cancer.
Medical management
There is no specific medical treatment for cannabis abuse. If the person uses the
substance for anxiety reduction or for the alleviation of depression, an anti-anxiety
agent or anti-depressant should be considered as substitution therapy. For an acute
anxiety reaction, the drug diazepam is useful. For any psychotic problems detected,
major tranquilisers should be used.
Bibliography
1. Anthony Radcliffe, Peter Rush, Carol Forrer Sites, Joe Cruse, The Pharmer’s
Almanac — Pharmacology of drugs, MAC Printing and Publication Division,
Colorado, 1985.
2. Ghodse Hamid, A. Cannabis Psychosis, British Journal of Addiction, 81, 473-480,
1986.
'
3. Kaplan Harold and Sadock Benjamin, Modern Synopsis of Comprehensive
Textbook of Psychiatry, 4th Edition, Williams & Wilkins, London, 1985.
4. Terrence C CoX, MichaefR Jacobs, Eugene Leblanc, Joan A Marshman, Drugs
and Drug Abuse — A reference text. Addiction Research Foundation, Toronto,
1983.
U1
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3___
HEROIN
Heroin belongs to the category of narcotic analgesics and is a semi-synthetic derivative
ot the drug morphine. Brown sugar is an adulterated form of the drug heroin.
When heroin (diacetyl morphine) was first synthesized, medical men thought they
had an effective painkiller on their hands. Years later, when the negative side effects
use whatsoever6 Pr°PertieS Were ldentified> “ ^as banned. Heroin has no medical
Pure heroin is a white crystalline powder with a bitter taste and is a costly drug bv
SmXr^^
thC mar.ketabilky ^e drug, an adulterated variety
T* market. Cleaning powder, quinine, starch, maltose, agarbatti ash
datura and even soap nut powder are added to heroin to increase the bulk
dark brown' ?^t0 f adu,lteranta added’ the dru®’s colour varies
light to
dark brown. This is referred to as ‘brown sugar’ or ‘smack’. Purity of the brown
from 9 m Tr Streets.vane^wideIy- DUuents are mixed with heroin in ratios ranging
rrom y to I to as much as 99 to 1.
6 6
Routes of administration
Injected
^per^8‘ttdlSSOk^e/uin yater and iniected subcutaneously or intravenously. When
not dissolSTmnlet I18
ed
eXperienced is magnified. But heroin does
not dissolve completely in water and some of it is wasted.
Heroin is rarely snorted.
Inhalation
Smoked with tobacco in cigarettes or ‘chased’.
Chasing: The drug is sprinkled on a silver foil or placed-in a bent spoon and heated
mouth with a roltd "
fUmeS Which ariSC 3re taken in throuSh the
moutn with a rolled up piece of paper.
.
HEROIN
21
‘Chasing’ is the method-most commonly used to take brown sugar while users of
heroin generally'prefer to inject the drug.
In general, brown sugar is not taken orally. Narcotic analgesics, being alkaline in
nature, are not absorbed in the acidic medium of the stomach. In the intestine, the
heroin molecules quickly conjugate (attach) to other molecules, making absorption
difficult. The little that gets absorbed must pass through the liver before getting
into the bloodstream. The liver quickly destroys the drug thereby drastically reducing
its potency. It is estimated that about 90% of the effect is lost when taken orally.
Metabolism
Distribution
Brown sugar is not absorbed evenly by all the parts of the body. It concentrates
in the tissues especially in the kidneys, liver, skeletal muscle, lungs and spleen. Only
small amounts of narcotic analgesics cross the blood brain barrier* (BBB) but the
central nervous system is so sensitive that even minute amounts are sufficient to
cause a pharmacological effect.
Small quantities of the drug cross the placental barrier, and fetal dependency can
develop.
* The brain is surrounded by several membranes and blood vessels which supply blood to the brain.
These form a barrier around the brain which is selective as to what can cross over into the brain
tissue from the main blood circulation. This is called the blood brain barrier.
w
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22
ALCOHOLISM^ AND DRUG DEPENDENCY
Excretion
J
J.
Excretion of narcotic analgesics is largely through the urine after metabolism to water
soluble metabolites (products formed due to chemical reaction in the body) A little
amount passes through the lungs and bile.
Pharmacology
Thttre
Spfclflc r^cePtor sites on cell membranes in the brain and other places
in the body In our body we have endorphins and enkephalins which are involved
in the regulation of pain perception and the emotional response, to it.
ScTwheTh6^^111 e?kephalin recePtors in the body and produce the same
ettect When high doses of narcotics are taken, the normal body production of
enkephalin and endorphin is decreased. When narcotic administration is stopped,
e body goes through a period of re-adjustment until the body’s oym enkephalin
production returns to normal - this is the
withdrawal period'.
" ''
the withdrawal
period'. '
Short-term effects
Analgesia, drowsiness mood changes and mental clouding are'thetoain effects. Other
mouth Th°nSf arC h
°f ™th: heaviness of extremities, and dryness of the
h^rrav^
faCC beComes flushed due t0 the release of histamine. Among the
reported ThisT’f I?
. hlgh (rUSh)’ described as akin to an orgasm is
reported. 1 nis is followed by sedation.
b
Effects produced by brown sugar are similar to those of morphine. But its analeesic
brXouicke^reC timeS m°re P°tent
iS 3180 fGlt mUCh f3Ster as il reach^the
Other physical signs and symptoms include constipation, muscular impairment
constricted so6 thafthev
PS P°int PUpils (pUpiIs are “aximall^
constricted so that they cannot constrict any further in response to light).
As the dependence increases, a progressive deterioration in general health occurs
he victim becomes dull, apathetic, anaemic, haggard and cachetic (malnourished)
osing interest m himself and his environment. His intellectual faculties are impaired
and his sense of moral values warped.
»unpairea,
System effects
CNS (Central Nervous System) effects
— Euphoria
— Analgesia
— Drowsy, dreamy, mild dozing state. In some, excitation may be noticed
— Apathy, decreased physical activity, inability to concentrate
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HEROIN
23
— Pin-point pupils, droopy eye-lids, reduced visual acuity
— Vomiting in novice users due to stimulation of the chemotrigger receptor zone
in the brain (area in the brain which controls vomiting or the vomiting centre)
— Decrease in REM sleep (rapid eye movement - the rapid, jerky movements of
the eye which occur during certain stages of the sleep cycle when dreams occur).
The REM stage of the sleep cycle is most beneficial to the body as the body is
most relaxed at that time. Brown sugar causes drowsiness but decreases sleep
time and decreases REM sleep.
Respiratory system
_ Depression of respiration due to the effect on the respiratory centre in the brain stem.
Cardio-Vascular system
— Bradycardia or decrease in the heart rate
_ Dilation of peripheral blood vessels, which is the cause of flushing
— Hypotension or low blood pressure
Gastro Intestinal tract
— Constipation and poor appetite.
Kidneys
— Mild decrease in urine formation due to increased secretion of the ADH (anti
diuretic hormdne).
Other adverse reactions
When an individual takes brown sugar, his experiences are not always pleasurable.
The adverse reactions that occur usually are:
— Nausea, vomiting
— Mental clouding', dizziness
— Dysphoria or a feeling of unpleasantness
— Severe constipation
— Allergic reactions (manifested as hives which can appear at or near the injection
sites due to release of histamine in the body).
Long-term effects
Mood instability, reduced libido', constipation, pupilary constriction (which affects
night vision) and certain types of respiratory impairments can develop. In female
drug users, menstrual'irregularity usually occurs.
24
—AND drug dependency
In addition, the following complications can develop.
- Serum hepatitis which is caused by use of infected needles
Syndr°m')
“
°CCUr
“ ““ °!
- Complications due to the presence of adulterants like quinine, datura etc in brown
- Fe^d?", °f ““L SeP'™ if thC
°f
has been snorting
wkhd^XX’sSahce, batb!eS b°r KT add,C"d mWh“s dCTd°P
K SXXSs”2' C°"VUlsioX™oec7r’. S
dXseTbfood°pressure Xs“’7
SX irreg“lar brcathi"g-
arrest or other respirator^ or cardio-vaSl ^phSi”8”10
rapira'0^
Tolerance and dependence
euphoric effect! Toleranceso^velXsTo^ts6 satisfactory analSesic’ sedative and
inducing effects. However tolerance Hn
j respiratory"^ePressant and nausea
or constipating effect
nOt deVel°P t0 the puPUary constricting
TO achteve theddeJfSeffct Xe ohte a”d th' S'? 8[ad“-dly increases the dose
is sufficient to P»”.X±??"J"Cl,Sh'r'
°f <he drug
the use of theXmXwSXXoms.'
with bro™
ug use leads to withdrawal symptoms.
Withdrawal symptoms
in tthdrawa! symptoms appear between S and 12 hours after rhe las. dose. Symptoms
«X'^XXX0fX)^iwith
—),
1
25
HEROIN
Withdrawal symptoms peak between 36 and 72 hours. There are usually alternations
between bouts of chills and shivering and bouts of flushing and excessive sweating.
Goose flesh is highly prominent. Uncontrollable yawning, vomiting, nausea,
diarrhoea, abdominal cramps, pain in the bone and muscles, muscle spasms and
uncontrollable kicking movements (which gave rise to the term ‘kicking the habit’)
are also experienced.
Increased irritability, restlessness, severe agitation, insomnia, emotional depression
can be noticed. Generalised hyperaesthesia (increased sensitivity to touch 3f tactile
stimuli), paraesthesia (distorted perception of tactile stimuli), neuralgic pains
(excruciating pains in extremities), clouded consciousness and delirium can also occur.
Cardio-vascular instability giving rise to hypertension and tachycardia (increased heart
rate), increased blood pressure, -and general weakness are also noticed.
Long after the observable physical symptoms of withdrawal disappear, a psychological
craving for the drug persists. Chronic depression, and period of agitation may last
for extended intervals of time. (
The main withdrawal symptoms of heroin are presented below in the form of a table:
■\
-
1
Symptoms
Craving for drugs, anxiety
Yawning, perspiration, running nose, tears
Pupil dilation, goose pimples, muscle twitches, aching bones
and muscles, hot and cold flashes, loss of appetite
Increased intensity of the above, insomnia, raised blood
pressure, fever, faster pulse, nausea
Increased intensity of the above, curled-up position, vomiting,
diarrhoea, increased blood sugar, kicking movements
Time in hours
4
8
12
18 to 24
26 to 36
Medical management
Brown sugar dependents suffer from a complex combination of medical and psycho
social problems. Consequently, multiple treatment methodologies are often used for
these patients. Several treatment approaches are used simultaneously or sequentially.
Detoxification
This is the first step in a long term treatment programme. This simply means
withdrawing the drug upon which the person is dependent and making the withdrawal
period more comfortable with medication.
IHMB
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ALCOHOLISM AND DRUG DEPENDENCY
Withdrawal from brown sugar is quite painful and unpleasant and, without medical
help, the user may become prone to suicide. The user may become agitated and
violent during withdrawal. Sedatives, tranquilisers, analgesics, anti-diarrhoeals are
usually used during the withdrawal period to make the patient feel somewhat comfortable.
Narcotic withdrawal is usually not life threatening, although a marked electrolyte
imbalance caused by excessive vomiting and diarrhoea must be watched.
For those patients with psychiatric disorders in addition to substance abuse^ specific
treatment is required. Failure to attend to these psychiatric problems will result in
a relapse.
Clonidine is a drug often used to handle the withdrawal symptoms of brown sugar.
It is not a narcotic drug, but it relieves many of the symptoms of opiate withdrawal,
particularly those which involve physical symptoms of the autonomic nervous system
hyper-activity. It is an adrenergic agonist and inhibits the activity of neurons in the
locus ceruleus, which may explain its ability to block the withdrawal symptoms.
Clonidine does not produce euphoria and it is also not an addictive drug.
Narcotic antagonist drugs
Use of narcotic antagonists like Naltrexone is becoming a part of the treatment
programme for heroin dependency. Narcotic antagonists are drugs' which block or
reverse the effects of narcotics. The main effect of this antagonist is to occupy opiate
receptors and prevent opiate drugs from exerting any effect like euphoria. As they
compete for the same receptor site, if narcotics are already on the receptors, naltrexone
can displace
noreotib
displace them,
them, reversing
reversing the
the effect
effect anH
and raiiQino
causing narco
tit xTyitKrit-nYTmi
withdrawal.
L'’
Lc
n i®
■
■'
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Mechanism of action of naltrexone. Naltrexone occupies the opioid receptor sites in the brain, thereby antagonizing
the analgesic, euphoric, and other psychotropic effects produced by large doses of narcotics, such as heroin.
)
HEROIN
27
Naltrexone is being tried as part of the after-care therapy for heroin dependency.
This drug is not a treatment by itself but it has been found to be effective within
the context of a comprehensive rehabilitation programme for prevention of relapse.
After treatment, the addict is given naltrexone on a regular basis (sometimes as
infrequently as two to three times a week). If a person on naltrexone takes brown
sugar, he will not experience any of the ‘sought effects’. Thus this medication will
provide protection against re-addiction, should the person impulsively take a dose
of brown sugar.
Methadone
Methadone is a substitute drug used in the treatment of narcotic analgesic dependency.
Methadone is a synthetic narcotic with a long duration of action. Methadone is usually
administered orally in the form of tablets.
Methadone fully blocks withdrawal which would naturally occur on abrupt cessation
of narcotic use making ‘cold-turkey’ a less painful condition. Thus, methadone is
sometimes used to make withdrawal more comfortable.
Methadone maintenance programmes were initiated to reduce relapse rates with
narcotic dependents. Heroin addicts were put on regular doses of methadone. This
therapy was effective in reducing the ‘drug-hunger’ without producing the much
sought after effects of euphoria or sedation.
Initially, methadone was shown to decrease relapse rates and methadone clinics were
opened in many parts of United States.
Later methadone was also found to be abused. Moreover, methadone maintenance
also resulted in physical dependence and exacerbated hypophobia when methadone
treatment was discontinued (Martin et al 1973). The resultant negative mood state
sometimes persisted for many months after detoxification. In view of these
developments, most methadone clinics were closed down.
Bibliography,
1. Anthony Radcliffe, Peter Rush, Carol Forrer Sites, Joe Cruse, The Pharmer’s
Almangc — Pharmacology of drugs, MAC Printing and Publication Division,
Colorado, 1985^ '
'
2. Jones Patricia and Wihens Weldon, Drug and Society — a biological perspective,
Wadsworth Health Sciences, Monterey, California, 1983.
3. Kaplan Harold, and Sadock Benjamin, Modern Synopsis of Comprehensive
Textbopkdof Psychiatry, Fourth Edition, Williams & Wilkins, London, 1985.
4. Terrence C Cox, Michael R Jacobs, Eugene Leblanc, Joan A Marshman, Drugs
and Drug Abuse — A reference text, Addiction Research Foundation, Toronto, 1983.
4
OPIUM
1
3BI®
...........
i
Opium is obSd fromTheVjppy‘PapTe^Som0! mean“g/poppy Mce’.
- -V P- Of the woridZitsXS^
syntheticlarcotic SXgs^017 °f narCOtic analgesics and is the main source of non-
Jhe poppy plant grows to about one metre in
u i
flowers are white, purple or red in colour Sav 1
e3VeS are oblong and its
a greenish pod, two mohes !o„g and° boutM,
IS still unripe, incisions are made on the nod Th
'
r’ 1S f°rmed- While ir
that requires skill to ensure that the nod i™ I f J' aJdel1,Cate J}and operation,
exudes from the out, coagulates on fxposum wah‘tm,' The
iui“ which
hand and dried m the shade for seve^ days. ^h^Xc^X^
OPIUM
29
Cheap labour is one of the important prerequisites for successful opium cultivation.
(It is estimated that the collection of 1 kg of opium requires approximately 280 hours
of labour.)
Countries of Asia Minor, Turkey, and the Far East remain the primary source of
both illegal and legal opium cultivation and trade. In India, opium is largely cultivated
in Madhya Pradesh, Rajasthan and Uttar Pradesh. Many control measures have been
enforced in the area of poppy cultivation. The poppy plant can now be cultivated
only with a licence ftorri the Narcotics Wing of the Excise Department and the
produce can be solc| onlyuo the Government. Unfortunately, certain quantities are
diverted from the legally cultivated plants. Poppy plants are also grown illegally.
Opium was traditjopdlly used in mid and far eastern areas such as Iran, Thailand,
Hongkong, Phillipines, China and India for hundreds of years. In India, opium is
still commonly Used in western Rajasthan, parts of Punjab and Haryana. Opium
use is culturally sanctioned and is a socially acceptable practice. In many rural
communities, opium is often served to visitors as a mark of their hospitality.
Opium is a dark brownish or a dark greyish tar-like substance with a musty odour.
Opium is usually sold in the form of small balls, lumps or bricks.
Routes of administration
Opium is primarily taken in orally. The dried opium is usually boiled in water and
the solution is drunk. Ingestion is a relatively inefficient route of administration and
the effects felt are only mild.
Opium is sometimes mixed with tobacco, chewed and then kept in the mouth. The
absorption of the drug takes place through the mucous membranes of the oral cavity.
Opium can also be smoked. Opium smokers increase the purity of the crude
susbstance, by boiling it in water and filtering it several times till it becomes a sticky
paste. This paste is then dried and smoked.
The infamous ‘opium dens’ of the yesteryears are non-existent today. Opium is now
smoked alone or in groups in their own houses. Opium smoking has declined
considerably because it has to be done entirely surreptitiously due to the noticeable
odour of opium. A special piece of equipment, (sometimes simple but generally
elaborate) is used by opium smokers. Opium is smoked in the lying down posture
to reduce the feelings of nausea.
Short-term effects
Opium contains a number of naturally occurring alkaloids. Morphine is the principal
alkaloid present in opium and ranges in concentration from 4 — 21%. The bulk
of the remaining quantity consists of a variety of substances which have little or no
pharmacologial effect.
30
ALCOHOLISM AND DRUG DEPENDENCY
The main'effects of opium include:
— A feeling of euphoria
— Drowsiness, lethargy, a feeling of relaxation
— Decreased physical activity in some and increased physical activity in others
— Difficulty in concentration
Nausea, vomiting, constipation, loss of appetite and pupilary constriction are some
of the unpleasant side-effects.
Long-term effects
Among long-term users, mood instability, impaired night vision, constipation and
reduced libido usually develop.
Tolerance and Dependence
With prptracted heavy use, tolerance develops necessitating increased quantity of
drug intake.
Physical and psychological dependence develop in the regular high dose user.
Withdrawal symptoms are virtually identical to those of brown sugar. Watery eyes,
nasal discharge, uncontrollable yawning, sweating, agitated sleep, nausea, vomiting,
excessive weakness, severe aches and pains in the muscles and joints, and stomach
cramps appear. Depression, irritability, periods of agitation, loss of appetite and
continued craving which point to the psychological dependenc on-the drug ate also
reported.
x>
Bibliography
X
/
\
1. Anthony Radcliffe, Peter Rush, Corol Forrer Sites, Joe Cruse, The Pharmer’s
Almanac — Pharmacology of drugs, MAC Printing'and Publication Division,
Colorado, 1985.
2. Terrence C Cox Michael R Jacobs, Eugene leblanc, Joan A Marshman, Drugs
and Drug Abuse — A reference text, Addiction Research Foundation, Toronto,
1983.
i
5________
ALCOHOL
What is Alcohol?
The word ‘Alcohol’ is derived from the Arabian term, ‘abkuhul’ which means ‘finelydivided spirit’. There are many types of alcohol — aniyl, butyl, isopropyl, isobutyl,
methyl, ethyl alcohol, etc. Different types of alcohol have various industrial and
chemical uses.
Ethyl alcohol (Ethanol} is what is commonly consumed. In this chapter, we are going
to talk only about Ethanol therefore when ‘alcohol’ is mentioned hereafter, it will
refer to Ethanol.
Alcohol is a clear, thin, highly volatile liquid, with a harsh burning .taste.
There are various processes by which alcohol is obtained. They are:
Fermentation
Alcohol is the product of a natural process called fermentation. If the juice of certain
fruits or vegetables is left in the open air, this process will begin. A microscopic
plant called yeast floats freely and reacts with the sugar in the juice. This reaction
produces alcohol and releases carbon dioxide in the air.
Distillation
,
'
To make beverages with higher alcohoLcontent, a process called distillation is used.
Distillation is the heating of a liquid until it turns into a vapour and then condensing
it into a liquid again. When wine or beer is heated in a ‘still (vessel used for
distillation) tO'179°F', the alcohol boils off as a vapour and the water and most of
the other ingredients of the wine or beer remain in the still. The vapour is then cooled.
It becomes a liquid which is almost pure alcohol. The distillation process is used
to make alcoholic beverages that contain 40 jSQSkakohpl. They are called distillsd.
spirit (e.g. Whisky, Gin, Rum etc).
Colouring, flavouring and other constituents called congeners are added during its
commercial preparation.
32
ALCOHOLISM AND DRUG DEPENDENCY
The alcohol content and the source of some alcoholic beverages are given /below:
Name of the beverage
BrandyWhisky
Rum
Wines
(Port, sherry,
Champagne, etc)
Beer
Toddy
Arrack
1
Source
Approximate Percentage
of
alcohol
X
, \
Distilled Wine
Cereals
Sugar Cane
(Molasses)
Grapes
40 - 50%
40 - 55%
40 - 55%
10 -22%
Cereals (Barley)
Palm juice
Molasses
6 - 8%
5 - 10%
50 - 60%
Before proceeding further, let us understand what ONE DRINK implies:
1 Drink or 10 grams of alcohol
H—
Whisky, Brandy, Rum
30 ml
H oz)
Wine
60 ml
(2 oz)
Toddy, Beer
285 ml
(10 oz)
i
I
Factors influencing the effects of alcohol
The effects of alcohol are directly related to its concentration in the blood (Blood E>AC
Alcohol Level). Alcohol acts directly on the brain and changes its working ability.
The effects depend on the speed at which the person drinks, his weight, presence
of food in the stomach, and the type of beverage taken. The effects of alcohol on
an individual also depend on a variety of other factors like the situation, one’s attitude
to drinking and one’s drinking experience.
i
Here are a few factors
I
Speed of drinking
I
The more rapidly an alcoholic beverage is taken, the higher will be the blood alcohol
concentration (BAC).
I
ALCOHOL
Body weight of the drinker
33
|
J—
The greater the weight of a person, the lower will be his BAG. Because of the way
alcohol circulates in the body fluid, the weight of the drinker is also a factor related
to the effect of alcohol. For instance, a person weighing 80 kilos will not feel the
effects of one glass of whisky as much as a person weighing 50 kilos.
Presence of food in the stomach
Food in the stomach slows down the rate of absorption. A drink after eating a meal
will have less effect than if it is taken on an empty stomach.
Type of alcoholic beverage
The basic ingredient in all major alcoholic beverages is Ethyl Alcohol. Some beverages
have more alcohol content in them than others. For example beer has
alcohol
whereas distilled spirits have 40jn_60%. A person consuming a beverage with a higher
alcohol content will experience its effects much more than a person taking a drink
with a lower alcohol content.
, Situation
Behaviour gets regulated when one is drinking, depending on where he is and whom
he is with. A young person having dinner with a friend may feel slightly ‘high’ after
one drink. If he has dinner with his boss the next night, one drink may not have
any effect at all. Here we find the individual regulating or closely monitoring his
behaviour.
Drinking experience
Those who are used to alcohol, recognise when it is beginning to interfere with their
judgment and coordination. Certain reactions warn them as to when to stop drinking
and when to control their behaviour.
Inexperienced drinkers do not have a clear picture of how they will react to
alcohol; nor have they learnt to control their reactions. In fact, since they are expecting
something to happen, they may purposely behave with less control. They may
also be unsure of when to stop, and may drink much more than what they can
handle.
Path of alcohol in the body
What happens in reality when we drink alcohol?
How does the body deal with it?
34
ALCOHOLISM AND DRUG DEPENDENCY
. rcwcH
_KIDNEY
mEsriNr5;
The statement numbers are key to the diagram.
1. Alcohol is taken into the body through the mouth and travels to the stomach via the esophagus.
Alcohol, in its initial state, is in a form which can be immediately used by the body.
2. In the stomach, chemicals are added to the alcohol. These chemicals have little effect on the alcohol.
Much of the alcohol is absorbed into the bloodstream directly from the stomach.
3. The remaining alcohol travels to the small intestine where it is absorbed into the blood.
4. Once in the bloodstream, the alcohol travels to all parts of the body. It affects heart rate, blood
pressure, appetite, gastric secretion, urine output, etc.
5. Alcohol also affects the brain, causing a variety of reactions ranging from relaxation to
unconsciousness and death.
6. In the liver, the chemical alcohol undergoes the process of oxidation, where it is eventually changed
to carbon dioxide, water and a release of energy. These chemicals re-enter the bloodstream and
move on to the kidneys.
7. The kidneys filter out the end products of the oxidation process, which are finally excreted out
of the body.
8. About 95-98% of the alcohol undergoes steps 1-7; however, the remaining 2-5% escapes unchanged
via sweat, the breath and the urine.
ALCOHOL
35
Alcohol is one of the few things that is absorbed as soon, as it enters the stomach.
Its molecules are small and its chemical pattern simple enough to be used for fuel
almost immediately after swallowing.
Unlike other food, alcohol does not need digestion. After ingestion, it is carried to
the stomach and sm61| jjnt^stines and immediately gets across through the wall of
the stomach into the-blood stream, from where it is carried to almost all the organs.
I)
As already stated, the rate of absorption is not constant, but depends on various
factors like the'speed'of drinking, concentration of alcohol taken, the amount of
foodstuffin the^stomacKTetc» In the liver, alcohol undergoes a process of oxidation
whereby it is changed into carbon dioxide and water and finally energy is released.
Metabolism
Alcohol is used and disposed of by the body, in four phases. They are: absorption,
distribution, oxidation and elimination.
Absorption
This takes place in the stomach and small intestines. It is a process whereby the
thinnest of blood vessels called capillaries found inxhe walls of the stomach and small
intestines, pick up alcohol as soon as it enters and transport it to all parts of the body.
Distribution
This is the process by which alcohol travels in the blood to each organ, tissue and
cell. By simple diffusion, alcohol leaves the bloodstream and enters the cells. Alcohol
then begins to affect the various organs including the brain.
Oxidation
Once alcohol is absorbed into the bloodstream and distributed throughout the body,
the process of oxidation begins. The liver plays a major role in the break down or
oxidation of alcohol. Alcohol is oxidised by the liver at the rate of 8 — 15 ml per
hour. The oxidation process is brought about by the enzymes produced by the liver.
Alcohol is first changed into Acetaldehyde, which in turn is converted to Acetate
by the enzyme Aldehydrogenase. As a result of the process of oxidation, alcohol
is changed into carbon dioxide, water and energy.
The energy yield of alcohol-oxidation is about seven kilo calories per gram of alcohol.
There is a mistaken notion that exercise, fresh air, cold shower, hot bath or black
coffee will help in making a person sober. This is not true at all. The fact remains
that these methods have no effect on the oxidation rate.
All that one can do is to wait, and let the liver do its work.
I
I
36
ALCOHOLISM AND DRUG DEPENDENCY
Elimination
After cxidauon, these chemicals re-enter the bloodstream and move on to the kidneys,
lhe kidneys filter out the end product of the oxidation process. They are finally
excreted from the body. 95-98% of alcohol consumed undergoes the above stated
changes, while the remaining 2-5% escapes unchanged through sweat, breath and
urine.
I
Ethyl alcohol (C2H2OH), the intoxicating substance in alcoholic beverages, is
considered a food that supplies empty calories — calories without any nutritive value
whatsoever.
Je medica! and psychological point of view, it is a depressant, an anti-septic,
anaesthetic, and a hypnotic agent.
F
Alcohol is a dependency-producing, habit forming, highly addictive drug.
Alcohol is a DRUG
Even though many people are not aware it, it is an undisputed fact that alcohol is
po ent drug. Ethyl alcohol (C2H2OH) the intoxicating substance in alcoholic
beverages produces physical and psychological changes. Therefore, alcohol is
ofweh bJnv0?6 3
thC C3Se °f alCOh°1’ theSe effects range froni a feeling
S A g experienced ^5 °,ne or ^o drinks, to drunkenness, which is the acute
effect of having too many drinks.
Alcohol is a DEPRESSANT
Alcohol is often misunderstood as a stimulant because it appears to make people
more lively and less “hibited. It is actually a depressant. If taken in small quantities,
relaxTd^Wh blPard °f
^ain WhiCh ^^hibitions, and so the person feels
relaxed. When blood alcohol concentration (BAG) is low, the drinker experiences
eelmg of relaxation, tranquility and a sense of well being. It slightly increases the
nrt ra ’vSateSRArOd Vuessels’ stimulates appetite, and moderately lowers blood
pressure. When BAG is high, it depresses the other areas of the central nervous
system, and this results in severe problems.
Short-term effects:
These effects appear rapidly even after small or large doses and disappear within
behrvihomrSThiChh°
brain.and nerve cells’ which in turn affect human
behavmur. The brain is highly sensitive even to very low alcohol concentrations.
1 he disturbances which result are shown in the activities of the organs controlled
by the brain.
A pceuliar characteristic of alcohol is that all the nerve cells in the brain are not
affected by the same BAG. Some nerve centres are more resistant than others,
r V
37
alcohol ~
and are net affected by low BAG. Forexample the.tot m be
controlling the higher functions that have ten earnl ThesemcMe m
judgement. It is always
differently to
£tol ‘themisZXS "d behaviour fs to how much of alcohol
a person has consumed. It can only be approximately generalised.
EFFECTS of ALCOHOL ON AREAS OF THE BRAIN
brain
^XEREBRUM
ConAclouA on
UoLaniany Contnol
Contnol
Heaton
A* VA\vi
I'JjS* xx**,*’1*.
MEDULLA
■ ■ i
xg
** CEREBELLUM
CocMLinating Skeletal Mu2>clet>;
Maintaining balance.
btealhlng, Uow °(>
SPINAL CORD
Centw of,
bci<M 5he
Key For Brain Diagrarti.
Qne to two drinks.
IM
Three to four drinks.
ykXxJtxx
Five to seven drinks.
xXKXXAX
Eight to twelve drinks.
u——
38
ALCOHOLISM AND DRUG DEPENDENCY
The most predominant short-term effect of alcohol is that it temporarily removes
normal inhibitions.
It also acts as a psychic anaesthetiser, temporarily erasing painful feelings of anxiety,
worry, tension, hopelessness and anger.
If larger doses are ingested in a short span of time, 3 state of so,cial and physical
incompetence, known as drunkenness or intoxication ensues.
The following table illustrates the approximate effects produced by alcohol when
a person consumes it over a period of one hour.
x
No. of drinks
Approximate effects
1
2
Feeling of relaxation and an enhanced sense of well being.
Feeling of well being and garrulousness.
Impairment of judgement and foresight.
4
5
7
22-25
-Decision making capabilities get affected.
Lack of motor coordination.
Drunkenness becomes obvious.
Evident deterioration in physical and social control and
competence.
Staggering and double vision. If this level is rapidly reached,
vomiting can occur.
Loss of consciousness; but still the drinker can be aroused.
Breathing stops and death ensues.
Long-term effects
When alcohol is repeatedly taken in large doses over; '
a long period of time, it proves
disastrous, impairing both the length and quality of life.
' ‘
are affected6
imp°rtant °rgans of the bodylike the heart> Hver and brain
As a person continues to drink excessively, his tolerance for alcohol increases. That
is, he is required to take more and more of it, to experience the same effect.
■
ALCOHOL
39
Prolonged and regular intake of alcohol in large doses can create tissue resistance.
The body’s nerve centres in try to compensate for the depressant effect of the drug
in an attempt to help’the body function in a balanced manner. The more they
compensate, the'more alcohol is required to obtain the same degree of effect. However,
such tissue tolerance is developed only after prolonged and regular drinking in more
than normal amounts. The moderate drinker doses not develop this tolerance to any
significant degree.
Over a long period of time, the consistently heavy drinker becomes physically and
psychologically dependent on alcohol.
Physical dependence occurs when body tissues have adapted themselves to
alcohol and require its presence in the system in order to function normally. The
body becomes so accustomed to the presence of alcohol, that as soon as its intake
is abruptly stopped, withdrawal symptoms appear. These symptoms range from sleep
disturbances, mild tremors, hallucinations, and convulsions, to delirium tremens
and death.
An excessive use of alcohol over a lengthy period of time leads to psychological
dependence.
Psychological dependence is present when alcohol becomes so central to a
person’s thought^ feelings and actions (morbid preoccupation) that it is almost
impossible for him to stop using it.
This form of dependence refers to a craving for the psychological effects. For those
who have developed psychological dependence, even a temporary non-availability
of alcohol tends to produce anxiety and feelings of panic.
To sum up,
★ Ethyl alcohol is a product of fermentation and distillation.
★ It is a drfig and has no nqtritiye value.
It is a depressant of the central nervous system.
★ It is a dependency-producing, highly addictive" drug.
★
W
40
ALCOHOLISM AND DRUG DEPENDENCY
Value additions place
— Additional information
Interaction of alcohol with other drugs
In the past several decades, hundreds of new drugs have been produced and intro
duced to the public. Many of these drugs are obtained only through medical pres
cription. Others are freely available in drug stores, super markets, etc. Some of these
drugs, when combined deliberately or accidentally with alcohol, produce harmful effects.
The following table gives an idea of the possible effects:
Drugs
1. Antihistamines
(for cold/fever)
2. Anticoagulants
(for problems associated
with blood clotting)
3. Anti Diabetics
(for high blood sugar)
4. Anti Anginal Agents
+ (for heart problems)/Anti
Hypertensive Agents
' (for high blood pressure)
5. Antidepressants
/ \
(mood elevating drugs)
'
6. Analgesics
/^\
(Painkillers)
(
'
7. Sedatives
(for sleep problems)
8. Muscle Relaxants and
Mild Tranquilizers
9. Antipsychotic Tranquilizers
(for mentally ill patients)
10. Amphetamines
(so called ‘uppers’)
Possible effects with alcohol
Increased sedation and drowsiness.
Complication of blood clotting factors.
Facial flushing, headache, weakness, nausea,
dizziness.
Sudden drop in blood pressure when a
person stands up — dizziness, fainting, loss
of consciousness.
Increased sedation.
Increased central nervous system depression,
respiratory arrest. - -xl
>
Increased central. nervous-System depression,
respiratory arrest, death.
Increased central nervous^system depression,
respiratory arrest, deaths
Increased central nervous system depression.
A false sense of sobriety when the person is
actually drunk.
v-
ALCOHOL
41
— Additional information
Types of alcoholic beverages
Wines are ipade from a variety of fruits such as peaches, plums and apricots, but
the most common wines are produced from grapes. The soil in which the grapes
are grown and the weather conditions in the growing season determine the quality
and taste of the grapes. When ripe, the grapes are crushed and fermented in large vats.
Beer is also made by the process of fermentation. A liquid mix, called wort, is pre
pared by combining yeast and malted cereal, such as corn, rye, wheat or barley.
Fermentation of this liquid mix produces alcohol and carbon dioxide. The process
offermentation is stopped before the yeast completes its work. This is to limit the alcohol
content of the beverage. The beverage, now called beer contains 6 — 8% of alcohol.
Toddy is obtained from the flowers of the coconut or palm tree. A white liquid with
a sweetish taste oozes out of these flowers. This liquid is collected and allowed to
ferment. At times, yeast is added to hasten the process. The fermented juice has
an alcohol content of approximately 5 — 10%. When consumed fresh, this juice has
no intoxicating effect.
Whisky is made by distilling the fermented juice of cereal grains such as corn, rye
and barley. Scotch whisky is made in Scotland, mainly from fermented barley and
it is coloured with caramel.
Gin, also a distilled beverage, is a combination of alcohol, water, and various flavours.
Gin does not improve with age; so it is not stored in wooden casks.
Rum is a distilled beverage made from fermented molasses or sugarcane juice and
is aged for atleast three years. Caramel is sometimes used for colouring.
Brandy is distilled from fermented fruit juices. Brandy is usually aged in oak casks.
The colour of brandy comes either from the casks or from caramel that is added.
Arrack is a distilled beverage, obtained from paddy or wheat. Jaggery or sugar is
added to either of these two cereals and boiled with water. At times sugarcane is
added. This is allowed to ferment, after which it is distilled. This alcoholic beverage
contains about 50 — 60% of alcohol.
Liqueurs are made by adding sugar and flavouring such as fruits, herbs, or flowers
to brandy or to a combination of alcohol and water. Most liqueurs contain 20
65% of alcohol. They are usually drunk in small quantities after dinner.
42
ALCOHOLISM AND DRUG DEPENDENCY
— Additional information
Methyl alcohol
Methanol, otherwise called methyl alcohol or wood alcohol is,produced through a
process of chemical synthesis. It is used in paint removers, cleanifag solvents, anti
freeze solutions, and liquid fuels. It is used chiefly as^an industrial solvent.
Its absorption and distribution are similar to that of Ethyl Alcohol, but the rate of
metabolism is very slow. The pharmacological actions initiily resemble those of Ethyl
Alcohol due to central nervous system depression. Then it is oxidized to formaldehyde
and subsequently to formic acid and hence is more toxic. Poisoning can occur with
ingestion of small quantities (15 ml).
Initial complications of toxicity include headache, vertigo, nausea, severe abdominal
pain, and motor restlessness. Coma and blindness occur rapidly, and they are followed
by shallow respiration (gasping) and death.
Many cases of sudden blindness and death reported after consumption of illicit liquor
are due to the presence of methyl alcohol in the beverage consumed.
IP
43
ALCOHOL
— Quiz
Tick the correct answer
(Answers can be checked on page
1. Alcohol is a drug
)
2. Alcohol is digested like any other food.
True/False
True/False
, because it is a stimulant.
True/False
4. Everyone’s body reacts the same way to the same amount
of alcohol.
5. Alcoholic beverages are fattening.
True/False
6. All alcoholic beverages are equally strong in alcohol content.
True/False
3. Alcohol tends to pep up a person
7. Alcohol taken ‘neat’, will affect a person faster than
if it is mixed with water.
8. A person can sober up quickly by drinking black coffee,
or having a cold shower.
9. Drunkenness and alcoholism are one and the same.
True/False
True/False
True/False
True/False
44
ALCOHOLISM AND DRUG DEPENDENCY
— Answers
1. Alcohol is a drug.
True
Alcohol is a drug. It affects the nervous system when it reaches the brain.
2. Alcohol is digested like any other food.
False Alcohol does not need any digestion. As soon as it is consumed, it is
immediately absorbed into the bloodstream through the walls of the
stomach and small intestines. The blood carries it to all organs of the
i
3. Alcohol tends to pep up a person, because it is a stimulant.
False Alcohol is only a depressant. Alcohol’s first action is to depress that part
•
b™11 which controls inhibitions. Since the person becomes less
inhibited, he immediately feels more relaxed. But his nervous system
is being depressed, not stimulated. Consumption of large quantities results
in impairment of thought, judgement, coordination etc.
4. Everyone’s body reacts the same way to the same amount of alcohol.
False
Reactions to alcohol vary tremendously. The same amount of alcohol
produces different reactions in different people. This is because reactions
depend on many complex physical and psychological factors.
i
i
5. Alcoholic beverages are fattening.
True
Alcohol is higher in calories than sugars and starch. The ‘empty calories’
in alcohol contribute to overweight. However, if alcohol'is used as a
substitute for a balanced diet, the person may suffer from
malnounshment.
6. All alcoholic beverages are equally strong in alcohol content.
False
Alcoholic beverages are prepared by two different processes fermentauon and distillation. Distillation produces beverages containinghigher concentration of alcohol.
7. Alcohol taken ‘neat’, will affect a person faster than if it is mix^d with water.
True
Liquor taken ‘neat’, reaches the brain faster because it is absorbed into
the bloodstream faster than when it is diluted.
8. A person can sober up quickly by drinking black coffee, or having A cold shower.
False
Nothing can speed up the sobering process -because the liver oxidises
alcohol only at- a steady rate. One has to wait for his liver to burn up
the alcohol.
i
L-
45
ALCOHOL
9. Drunkenness and alcoholism are one and the same.
False Drunkenness is a temporary loss of control over one’s reactions and
behaviour. Even a social drinker may get drunk. Alcoholism is a serious
illness which requires treatment.
Bibliography
1. Comprehensive Health Education Foundation, Here’s Looking at You Two A teacher’s guide to alcohol/drug abuse, Seattle, USA, 1982.
2. Glatt MM, Alcoholism: A social disease, Hodder and Stoughton, London, 1976.
> _
6
MEDICAL COMPLICATIONS RELATED
TO THE USE OF ALCOHOL
Alcoholism perse is a disease that leads to physical, emotional, psychological and
social problems. It is a progressive and permanent disease. 'Apart from this an
excessive use of alcohol affects the functioning of various systems in the body and
SeVeraI C0mpl^atl0ns- Thls chapter focusses on the impact of alcohol on
the different systems of the body and the consequent damages
Alcohol and the gastro-intestinal tract
Esophagus
It is clear that alcohol damages the esophagus by direct chemical irritation to its
mucosa (interior lining) It interferes with normal motor functions, thereby causing
ThePm aid move™entof the stomach acid into the esophagus which erodes the tissue
The major complication in this process is haemorrhage, which is either preceded
or accompanied by local pain and difficulty in swallowing. Massive and fa£ upper
6 Ceding I5 alS° CaUSed by the sPontaneous rupture of dilated veins
along the esophagus - (the dilation is a result of cirrhosis of the liver)
Stomach
Alcohol also causes acute gastric damage accompanied by bleeding Alcohol has been
°f ,n”am^a“>ry a"d “eed»gleslg„„Xes^ehn
ne degree of the damage it causes to the lining of the stomach is related to tho
concentration of alcohol. Damage to the cells rapidly occurs after alcohol ingestion
celies.mUC0S 311161 getS damaged and leads to the gastric juice damaging the epithelial
gaSs WhiTtUhT^and iS belieV£d t0 cause both acute and chronic
Lfh □ •
r
ffe5_ts of 31001101 °n the stomach tissue are well known the actual
echamsm of damage has not been clearly established. However excessive use of
alcohol ,s known to be one of the causative factors of peptic deer SmSoms th
as nausea, vom.fng, bleeding and epigastric pain may occur
;,ymp,°ms such
A
x
47
MEDICAL COMPLICATIONS RELATED TO THEUSE OF ALCOHOL
Small intestine
J-
u
c in th? small intestine are common in alcoholics. Excessive
intestine. This eontribates to the durthoea^^fX^tS hSanon of the mucous
intestinal molabsorptton can also tesulmfrom aleojoi^estion,
°f u°
mmbolism oHipS^^. BtU.es involved in eholes.emi synthesis ate also
affected.
Pancreas
Alcoholism is associated with a
SeOehses
of the organ.
nanrreatic secretion of digestive enzymes that
S^um Stsotr^of the abnormalities in intestinal absorption associated wtth
alcoholism.
AC"KPh^™s^“^
back^s^it'progresses^Vomiting occurs
Laboratory tests show amylase berng
of patients die despite treatment.
scan shows an eriarged
a
48
ALCOHOLISM AND DRUG DEPENDENCY
With chronic pancreatitis, there are recurrent attacks of pain and malabsorption of
food. Even with treatment, the course cannot be modified; only predisposing causes
can be eliminated.
I
Alcohol and the liver
The liver is the largest and metabolically the most complex organ in the body. It
is functionally involved in circulation, excretion, immunology, metabolism and
detoxification, all of which are affected due to the presence of alcohol in the body.
This organ is the first to receive digested products and other substances absorbed
from the gastro-intestinal tract. It also receives substances from general circulation
through the hepatic artery. Although it is the primary site for the detoxification of
alcohol, the liver can be damaged by alcohol and its metabolic products.
Alcohol has a number of metabolic effects on the liver. It inhibits the conversion of
amino acids to glucose, a major energy producing fuel in the body. When the liver’s
store of glucose is low (as it often happens in the case of poorly nourished alcoholics),
it results in hypoglycemia. This is similar to the condition of reduced blood sugar
seen in diabetics, who have taken too much insulin. Alcohol causes three major
pathological problems in the liver — fatty liver, alcoholic hepatitis and cirrhosis.
Alcohol stimulates hepatic synthesis of certain other proteins, including lipoproteins,
which transport fat in the blood. This results in elevated blood triglyceride (fat) levels
(frequently seen after alcohol ingestion). The alteration in fat metabolism results
in a gradual accumulation of fat in the liver, and this in turn causes a fatty liver.
This condition leads to liver failure and death particularly in younger people. The
patient with a fatty liver may be asymptomatic or may have vague gastro-intestinal
symptoms. The liver is enlarged and non-tender. Treatment is possible and the patient
recovers within six weeks.
Alcoholic Hepatitis is a very serious condition which may lead to hepatic failure
or cirrhosis. This often follows severe or prolonged bouts of drinking. This problem
may persist even when patients give up alcohol. The most important problem
experienced is jaundice. Other symptoms of alcoholic hepatitis include weakness,
fatigue, loss of appetite, nausea and vomiting, low grade fever and loss of weight.
Some of the changes associated with alcoholic hepatitis are reversible, if only the
person totally stops drinking.
On the other hand, if he continues to drink excessively, it will result in Alcoholic
Cirrhosis. Cirrhosis can also occur without prior occurrence of alcoholic hepatitis.
The word, ‘cirrhosis’ means ‘scarring’. In a cirrhotic liver, there is a widespread
destruction of the liver cells. These cells are replaced by fibrous tissue scars. This
condition is irreversible and is associated with metabolic and physiological
abnormalities. The liver is unable to perform its function. Hepatic coma can occur
as a result of this.
'
I
49
MEDICAL COMPLICATIONS RELATED TO THE USE OF ALCOHOL
*
Although alcoholic hepatitis may be a precursor of cirrhosis, it also has been shown
that alcohol by itself can produce fibrosis, and perhaps even cirrhosis without any
antecedent stage. Individual susceptibility to the disease may be related to genetic
and other factors in addition to heavy chronic alcohol consumption. Not all alcoholic
individuals develop this disease.
r
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*
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it
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s-zyv‘z.- ■
: 1«W
....
4'^*'
-•
v;.
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Alcohol and the vascular system
Alcohol in moderate amounts causes dilation of blood vessels — especially blood
vessels in the skin. This causes a sensation of warmth and flushing. Due to the dilation
of blood vessels, a lot of body heat is lost and internal temperature also drops. If
larger amounts of alcohol are consumed, the mechanisms which regulate body
temperature get suppressed and the resultant temperature drop can be severe.
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ALCOHOLISM AND DRUG DEPENDENCY
The most common disorder found in alcoholics is an increase in MCV (mean
corpuscular volume). The red blood cells are larger than normal in size. This blood
test is frequently done to diagnose alcoholism. Alcohol dependent persons become
deficient in folic acid, since alcohol decreases the absorption of folic acid from the
small intestine. This leads to folic acid deficiency anaemia.
Chronic alcohol ingestion decreases white blood cell production, and this leads to
a number of infections since the white blood corpuscles are an important part of
our body defense system. Chronic alcohol intake also decreases platelet function in
the body by interfering with the ability of platelets to stick together. Platelets control
the blood clotting mechanism, and the adverse effect of alcohol makes the person
bleed profusely.
Alcohol and the heart
Alcohol and its metabolic product acetaldehyde, have specific effects, on the heart
muscle which can lead to problems. Alcohol consumption coupled with pobt nutrition
can lead to other conditions such as alcoholic berLberi."
—
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Alcoholic cardiomyopathy
- J
Alcoholic cardiomyopathy is believed to be caused by the toxicf effects of alcohol
or its metabolic products on the myocardium. Its symptoms are chronic shortness
of breath and signs of congestive heart failure. It causes enlargement of the "heart,
abnormal heart signs, oedema, enlargement of the spleen or the liver and disturbances
in the cardiac rhythm.
The disease, which does not occur suddenly, often exists in a subclinical form. Its
severity is related to the duration of drinking by the patient, and the prospect of
recovery is good in individuals who give up alcohol totally.
Alcohol and the respiratory system
Alcohol affects the rate of respiration. Low to moderate doses of alcohol increases
the respiratory rate. In larger doses, the rate of respiration is decreased. The lungs
are not directly damaged by alcohol. However, they are susceptible to its toxic effects
in an indirect fashion.
Alcohol and the nervous system
Brain nerve cells generate and conduct electricity, transmitting information to the
adjacent nerve cell by the release of specific chemicals called neurotransmitters. The
receiving cell provides feedback to the transmitting cell regarding the message sent.
Each cell can receive and integrate information from many others. This is a function
which alcohol can, and does alter.
9
MEDICAL COMPLICATIONS RELATED TO THE USE OF ALCOHOL
51
Peripheral nerve damage
Nutritional neuropathy is a most common of all the nutritional disorders of the nervous
system. It is characterised by progressive weakness and muscle wasting of different
degrees — more in the legs, arms and the distal muscles than in the proximal ones.
Patients complain of coldness, ache, numbness, tenderness in the calf muscles and prickly
sensation in the feet and fingers. Muscles become flabby, and the skin, dry, red and
shiny. There is excessive perspiration on hands and feet. A shooting pain is also felt.
Wernicke-Korsakoff syndrome
This particular type of brain disease, its name and associated impairments are
determined by the portion of the brain that is affected. Wernicke s syndrome and
Korsakoff s psychosis are two such syndromes closely associated with alcoholism.
Both are associated with the nutritional depletion of thiamine.
Clinically, a person with Wernicke’s syndrome is apt to be confused, apprehensive
and delirious. There is a characteristic dysfunction of the eyes (Nystagmus) —
paralysis of the eye muscles that control eye movements. Nystagmus is rapid
involuntary movement of the eye balls either in a horizontal or vertical direction
Nystagmus is often one of the first symptoms to occur. The patients complain of
double vision and their gait becomes unsteady. Difficulty in walking is due to the
peripheral and/oncerebellar nerve damage. When first seen, the patient may display
signs and symptoms of alcohol withdrawal - delirium, tremulousness, confusion,
hallucinosis, altered sense of perception etc. He is apathetic, listless, and disoriented.
Korsakoff’s psychosis is characterised by distorted memory function. Because of
the severe brain damage, the patient cannot process or store information. In order
to fill these memory gaps, he makes up stories. The ability to learn is severely
impaired. He will require long-term medical attention.
Alcoholic cerebellar degeneration is a complication of chronic alcohol abuse. In
such cases, the patient gradually develops a slow, broad based gait as if he were about
to fall down. There may not be any cognitive or mental dysfunction.
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alcoholism’and drug dependency
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Alcoholic dementia
This occurs when a person is going through withdrawal and it is characterised by
disturbances of memory and thought content. There is impairment of social and
occupational functioning. Evidence of brain disorders remains due to the actual loss
of cells from the cortex
the thinking portion of the brain. It is not yet known
whether dementia associated with alcoholism is a primary effect of alcohol, or its
metabolites on the brain, or the indirect consequences of malnutrition. Frequent
head injury and liver diseases that occur with chronic alcoholism may also be a
causative factor of dementia.
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Neuropsychological impairment
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Mental deterioration is not seen until very late in the course of alcoholism. The IQ
of most alcoholics remains relatively intact and normal. Nevertheless, there are other
defects like decreased ability to solve problems or to perform complex motor functions.
Most of these functional impairments are not readily apparent.
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Alcohol and the muscles
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Alcohol is known to cause damage to muscle tissue. In binge drinkers, acute muscle
damages occur as a result of which they experience pain and weakness especially
in the limbs. The affected muscles may later become swollen and bruised. This
indicates a certain degree of muscle tissue death. The dead muscle tissue floating
m the bloodstream can clog up the kidney’s filtration system. If this problem is severe,
it may result in death due to kidney failure.
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Chronic alcohol use can also cause peripheral muscle weakness and wasting. This
is due to the direct damage caused by alcohol to the muscle itself or to the nerves
that control the muscles.
Alcohol and the excretory system
Diuresis
5
Alcohol inhibits the release of an anti-diuretic hormone, which leads to excessive
urination (diuresis). This results in increased fluid loss and it occurs only when the
level of blood alcohol is rising. It does not occur when the blood alcohol level is
either stationary or falling. With chronic use, alcohol itself may have an anti-diuretic
effect, and an alcoholic may retain water in his body.
The initial loss of water caused by alcohol leads to the loss of some important body
chemicals such as potassium, magnesium and phosphorus. This can lead to serious
muscle, nerve and other damages.
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MEDICAL COMPLICATIONS, RELATED TO THE>USE OF ALCOHOL
53
Gout
The metabolism of alcohol causes an increase in the amount of NADH. With excessive
NADH production, the body releases lactic acid as a by-product of converting NADH
back to NAD. If too much lactic acid is formed, it can cause problems by creating
an acid environment in the body cells and blood. By itself, iactic acid is not toxi .
However higher quantities of lactic acid act as an environmental pollutan .
Another problem with increased lactic acid in the body is that it prevents the secretion
of uric acid. When there is too .much of uric acid in the blood, it causes swelling
and pain in the joints^ '
Alcohol and the reproductive system
There is a popular misconceptionThat alcohol improves sexual functioning. There
is a common misunderstanding that alcohol acts as an aphrodisiac, and apparently
increases sexU“ functioning. This is totally wrong. Alcohol depresses that part of
the brain that controls inhibitions, and therefore the person becomes less inhibited.
The problem lies, however, with the fact that although the desire exists, sexual
performance and capability are diminished. Not much clinical research has been don
in this area; but there does seem to be a direct correlation between increasing alcohol
blood levels and decreasing sexual performance. It is proved however, that male
alcohol dependents suffer from sexual dysfunction.
Alcohol affects the sexual functioning of women also This mechanism is only poorly
understood; however in alcoholic women there is failure to ovulate. Fetal alcohol
syndrome is a disorder found in children born of mothers who used alcohol excessively
during pregnancy.
Alcohol and the skin
The skin disorders in alcoholics are a result of vitamin deficiencies inability to fight infections;
or the person may neglect to take care of cuts and bruises when they become mfected.
If an excessive alcohol user has a liver disease, spider angiomas can be seen especially
in the upper chest area. Acne rosacea, the red nose of alcoholics, may result from
chronic dfiation of blood vessels. Rhinophyma or ‘Brandy nose is a result of increase
in nasal sweat glands which causes an increase in the size of the lower part of the nose.
Alcohol and endocrine system
Alcohol affects the endocrine system in three major ways. It alters the function of the
pituitary glands - the master gland which regulates the functions of many other glands.
Alcohol directly affects other glands also and interferes with their ability to respond.
Interference with the endocrine system can also develop as a result of liver damage.
54
ALCOHOLISM AND DRUG DEPENDENCY
Alcohol and nutrition
Prolonged use of alcohol leads to a deficiency of several nutrients. Alcohol’s oxidation
provides heat and energy. Because alcoholics receive so many calories from their
alcohol intake, they tend to neglect other food sources and ignore nutritional needs.
Therefore they develop protein malnutrition and diseases caused by vitamin
deficiencies (pellegra, alcoholic beri beri, xerophthalmia or night blindness,
nystagmus, dermatitis, dementia, diarrhoea and ultimately death).
The levels of magnesium, calcium and zinc are greatly reduced in alcoholics due
to poor dietary intake and increased urination. Magnesium deficiency syndrome
results in tremors, involuntary movements of extremity, mental aberrations and
convulsions. Clinical features of zinc deficiency include dermatitis, usually generalised,
loss of taste and slowness in the healing of wounds.
Alcohol and cancer
Indisputably, alcohol is one cause of cancer. Drinking alcoholic beverages exposes
the drinker to an increase in the risk of cancer at various sites in the body. Heavy
drinking increases the risk of developing cancer of the tongue, mouth, pharynx,
esophagus, larynx and liver. Alcohol has a synergistic effect with tobacco that increases
the risk of cancer.
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Alcohol withdrawal
- 'm
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Sudden stoppage of alcohol consumption produces withdrawal symptoms like tremors,
convulsions, seizures, deliriumtremens etc. Delirium tremen^ occurs only in 5% of
alcoholics. The severest form of alcohol withdrawal is delirium^eine^ It occurs
within one week of the cessation of alcohol intake; •'There is severe autonomic
hyperactivity such as tachycardia, sweating and elevated blood pressurelind
^wre^sturbance manifested by disorientation and clouding__oLconsciousness.
There are perceptual distortions, most frequently visual or tactile hallucinations and
fluctuating levels of psychomotor activities ranging from hyper excitability to lethargy.
Delusions and agitated behaviour are common. Fever is also present Grand
malseizures are a common occurrence in withdrawal, although they precede the onset
of delirium.
The delirious patient is a danger to himself and others because of the unpredictability
of behaviour. The patient may be aggressive or suicidal or may be acting on the
hallucination or delusions, thinking that they are genuine dangers. Untreated delirium
tremens has a mortality rate of 20%, death usually occurring as a result of intercurrent
medica1 illness like pneumonia, rehal disorders, hepatic insufficiency or heart failure.
hysical illness predisposes this syndrome — a person in good health rarely develops
delirium tremens during alcohol withdrawal.
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MEDICAL COMPLICATIONS RELATED TO THE USE OF ALCOHOL
55
Another severe condition of alcohol withdrawal is hallucinosis. The essential feature
of alcoholic hallucinosis is that it is either visual or auditory, usually beginning within
48 hours after cessation of drinking and persisting even after the patient has recovered
from the symptoms of alcohol withdrawal. For most people, they are unpleasant,
perhaps taking the form of voices pr unformed sounds. In some cases, the
hallucinations last for several weeks. Alcoholic hallucinosis is differentiated from
delirium tremens by the absence of a clear sensorium in delirium tremens. 7
Bibliography
1. Anthony Radcliffe, Peter Rush, Carol Forrer Sites, Joe Cruse, The Pharmer’s
Almanac — Pharmacology of drugs, MAC Printing and Publications, Colorado,
1985.
2. Ernest P Noble, Alcohol and Health, U S Department of Health, Education and
Welfare, Maryland, 1978.
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ADDICTION - A DISEASE
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addiction !?1 h -15!3^ incr!asing tendency to study both alcoholism and drug
addiction as chemical dependency’. In this manual also, the term ‘addiction’ haf
whi??8? t0 rCfer tO,both addlctl0n to alcohol and to other drugs. Nevertheless
whde elaborating, we have chosen to make a differentiation between the two Several
sepSmly
°
drUg 3ddiCti0n 3nd th6ir manifestations have been discussed
Addiction to alcohol (Alcoholism)
The common man sees ‘alcoholism’ as a weakness of character. The moralist looks
elerXXi” i?”a Sin,he
’ -tae. The
Medicd Ass““‘”
“
®?°re elfb°™“S on the disease concept of alcoholism, let us clearly understand
who an aleohohc ts, and in what respects he is different from the siw drX
Who is a ‘social drinker’?
A social drinker is one who drinks the way his social group permits He never
oversteps their unwritten, unspoken, but clearly understood boundaries He either
doe^noS^ y’
moderate quamities. His intake of alcohol
does not cause any problem whatsoever in his life.
Who is an ‘alcoholic’?
An alcoholic is one, whose drinking causes condmiingnrpblems in one or more
MAVV tS
^y-^anonship, financial positionT^ation, etc)” - MAR??
MANN,. Inspite of these problems, he will keep on drinking. Here, ‘continuing^
is the key word. This is what differentiates him from a social drinker.
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ADDICTION - A DISEASE
An ‘alcoholic’ will not be able to take note of his problems and stop drinking totally.
He tries but never succeeds on a long-term basis. He develops a physica^ and
psychological dependence on alcohol. He will have no control over his drinking, and even
tf he stopTdrmkmg for a short duration, he will definitely go back to obsessive drinkmg.
Out of the ten people who start drinking for the pleasure associated with it, twoJ^Z
become alcoholics. Unfortunately,’ the cause is still not known.
----- --------
\z '
\
Why is alcoholism classified as a disease?
Clinically, a disease is.cpnfirmednf the following are present:
a) The aetiological agbnt (that which causes the disease)
b) i) How the agent comes in contact with the patient (Epidemiology)
ii) What happens when the contact is made (Pathogenesis)
c) The lesion - the focus of damage and its consequences - (structural, biochemical,
physiological and behavioural)
4 .
,
d) The syndrome. (A collection of symptoms complained by the patient and ‘signs
observable to others that regularly occur together)
In ‘Alcoholism’, the
a) Aetiological agent is Ethyl Alcohol or Ethanol.
b) i) Epidemiology - a clearly seen, but complex process.
ii) Pathogenesis - numerous effects in the body (dealt with in chapter 6 m detail)
c) The lesion — quite clear cut in the liver.
well defined and stereotyped reaction (as we are going to see in this
d) Syndrome —
chapter).
Now we realise that the alcoholic is a sick person - a person with a disease.
What is alcoholism?
The most widely accepted definition of alcoholism, is the one offered by Keller and
EffronZ*‘Alcoholism is a chronic illness, psychic, somatic or psychosomatic, which
manifests itself as a disorder of behaviour. It is characterised by the repeated drinking
of alcoholic beverages, to an extent that exceeds cu§toi^ry, dietap/ use or comphance
with the social customs of the community and that interferes with the drinker s health
or the social or economic functioning. //
Alcohol dependence can be both physical and psychological.
Physical dependence is a state wherein the body has adapted itself to the presence
of alcohol If its use is suddenly stopped, withdrawal symptoms occur. These
symptoms range from sleep disturbances, nervousness, and tremors to convulsions,
hallucinations, disorientation, delirium tremens (DTs) and possibly death.
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ALCOHOLISM AND DRUG DEPENDENCY
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The characteristics of alcoholism are as follows:
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It is a primary disease
I
Irutially, alcoholism was considered a symptom of some psychological disorder. Now
it has been understood that alcoholism per se is a disease which causes mental
Zt Z and|PhySO1M0blemS' These associated problems cannot be effectively
dealt with, unless alcoholism is treated first.
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It is a progressive disease
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If it is not treated, the disease progresses from bad to worse. Sometimes there may
intermittent periods where one feels there is improvement; but over a period of
time, the course of the disease will only be towards deterioration.
P
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It will be a terminal disease, if not treated
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A person drinking excessively, may die due to some medical complication like cirrhosis
or pancreatitis. But on close scrutiny, it will be found that the complication itself
was induced by alcohol. Thus alcohol is the real agent behind the person’s death.
It is a treatable disease
The disease cannot be cured; but it can be successfully arrested, with the help of
fromyalcohdP[nate
C0,mprehensive treatment. Treatment aims at total abstinence
from alcohol. Ingestion of even a very small amount of alcohol will lead the person
to obsessive drinking within a few days and he will lose control. In other words
an akohohc^caip never go back to social drinking, even if he has remained sober
* numbe^of yeafsOHence alcoholism is con«aFred"a permanent-disease.
There are three distinctly noticeable phases in the disease of alcohblism.'
{Early phase}
Increased tolerance
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7XZ XTeV^eXdX^coholism',s a "«d fOT hl8hcr
fOr lnst“c^ initially he may have taken a peg or two of whisky to experience a
»izsxsisz"sum g*ng us
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ADDICTION - A DISEASE
59
Black-out
This is a period of temporary amnesia which occurs during the drinking days. Black
out’ should not be confused with ‘passing out’ which means unconsciousness. .During
a ‘black-out’, the person may go through many activities, without being able to recall
even a trace of them later on. The person walks, talks, even drives ‘ apparently
normally”; but has no recollection of it afterwards.
People who are not alcoholics, may also occasionally have black-outs. However, in
people progressing towards alcoholism, repeated episodes of black-out occur.
35 year old Rakesh hails from an orthodox, religious family. He had been
drinking for over ten years. His drinking, however, gradually became excessive.
He always arrived home late, totally drunk.
One day, as usual, Rakesh came home in an intoxicated state. He complained
that the food was not to his liking; he shouted at his wife; aggressively got up
and smashed all the pictures in the pooja room, and then fell asleep.
Next morning, when Rakesh got up, he was surprised to see his mother and
wife sulking in a comer. Nobody spoke to him.
Rakesh asked his mother,
“What happened? How is it that you are not busy with the usual pooja?
His wife got angry and went away without speaking a single word. His mother
narrated what he had done the previous night.
Rakesh was taken aback.
He was totally shaken; for he did not remember anything — not even a trace of it.
Preoccupation withjirinking
Even when the alcoholic is not drinking, he is always preoccupied with thoughts
of how, when and where he could get the next drink. While at work, he may be
thinking about, and waiting to get his drinks at noon, during lunch break When
going to a party, he,'somehow finds out if there will be alcohol. Drinking is
synonymous witli having a good time. If drinking is not going to be part of any
activity, his response will be, “Count me out .
Avoiding any talk about alcohol
This is a result of his feelings of guilt. Formerly he had been formerly boasting about
how much he could drink; but now he does not want to talk about it at al . If someone
else brings up the subject, he totally diverts the topic, for fear that they will talk
about his drinking. He does not want to talk about, listen to, or even read anything
which has reference to drinking.
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ALCOHOLISM AND DRUG DEPENDENCY
Middle phase
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Loss of control
Initially, there is a loss of control over the quantity of alcohol consumed. That is,
the person is not able to predict what will happen after thexfirs,! drink. Intending
to have one or two pegs on his way back home from the.offide, Ije'enters a bar; but
he is still drinking till the bar closes.
.
'
As alcoholism progresses, the patient will lose control over the time and place of
drinking (comes drunk early in the morning to the office).
He now reaches a point when he literally cannot keep away from drinking, or control
the amount consumed. Drinking becomes compulsive. Now he is totally powerless
over alcohol. Loss of control is a clear-cut sign that alcoholism has now developed.
The warning signs are gone. It may get worse; but he is not likely to get better
without help.
Satish had been drinking alcohol for quite a number ofyears. His family wanted
to go to Tirupati and he had agreed to take them. In all earnestness, he stopped
drinking 2/3 days prior to the trip. On the appointed day of travel, Satish and
his family boarded the train as planned.
At one of the stations, Satish got down to fill his water bottle. As he was filling
the bottle, he spotted an arrack shop just outside the platform. He was tempted.
He knew that the train would stop there for a few minutes, and there would
be time for him to have one drink. He thought, “Let me have only one drink
.. nothing more!”.
He started with only one drink... wanted to have one more quick one. He had
another... one more... one more... etc.
When he came out, it was too late; the train had left the station long ago.
Justifying his drinking
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He feels guilty and depressed. He begins to rationalise. He develops an elaborate
defence system of reasons and excuses to reduce his guilt feelings. He will keep on
explaining as to why he drinks a little too much, and gets a little too drunk.
Grandiose behaviour
Another way by which an alcoholic avoids the truth about himself and his condition,
is by exhibiting grandiose behaviour which is inconsistent with his financial and
professional capabilities. For example, he buys things he does not need, gives lavish
gifts and pays others’ bills at the bar.
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ADDICTION - A DISEASE
61
Mohan had been drinking excessively for three years. He had borrowed money
from various people and his debts had mounted up.
One day, a shop-keeper came, stood outside his house and shouted:
“You have not-yet, paid-niy dues which you promised to pay last month itself.
I want the money right away! J will return in the evening to collect it from you.
If you fail to repay, I will, drag you to the police station!
Mohan ’s wife felt extremely-ashamed, and was terribly annoyed. Mohan told
her, “Dmfworry! Today I will take a loan from my salary. We can pay him
back this evening itself. ”
Mohan went to the office. On his way back home, he bought five packets of
‘Gold Flake’ cigarettes and happily distributed them to his friends. They smoked
and drank together. Mohan called for a taxi, and when he came back home,
he had no money left to pay the taxi driver.
Aggression
Since he believes that others are the cause for his problems, he strikes out against
them with verbal abuse, sometimes even with physical abuse. Such abuses are only
an expression of self-hatred directed towards someone else.
Guilt and remorse
Now he slowly becomes aware of what he had been doing to himself and to others.
He is unable to throw it off as easily as before. He feels a deep sense of personal
guilt and this guilt and remorse often lead him back to the bottle. But when the
alcohol is gone, his guilt remains. These feelings now become as much a part of
his alcoholism as drinking and getting drunk.
Abstaining from alcohol
He attempts to quit on his own — to give up alcohol — not for ever, but for a definite
period of time. He feels this will ‘prove’ that he can give up drinking whenever he
wants to. He may stay away from alcohol for a period of time he has set — a week, a
month, or whatever — but then his compulsion for alcohol may make him either shorten
the period of time he has set for himself, or he may be able to abstain for the set period;
in either case, after this stretch, he will inevitably go back to obsessive drinking.
Changing the drinking pattern
After trying to abstain, he now takes another precaution. He changes his drinking
pattern to show that he can start drinking again without experiencing the same old
problems. He changes drinks — from whisky to beer, or shifts the place and time
of drinking. But no matter how many changes he makes, if it is alcohol he is drinking,
he will soon be immersed in the same problems which haunted him before.
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ALCOHOLISM AND DRUG DEPENDENCY
Decaying of social relationships
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As he continues to drink, he becomes aggressive. This is the time his friends start
moving away He may start establishing new friendships, where people are in tune
Wlth bis drinking pattern. When he comes out of his problem of addiction, it is a
tJ°,realise that his ‘so called friends’ were nothing more
than mere drinking friends .
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Problems on the job
Until now, his job may not have been affected. But he can no longer hide his hangover
his absenteeism and low quality of work. Everyone becomes aware that he is drinking
oo much He is now being watched. He receives memos, suspension orders. He
may even lose his job.
Family problems
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rn3hh ? UnfbIe kee? the family together bl peace. The major problems begin
to weigh heavily on his wife and children. They suffer due to unmanageable problems.
Morning drink
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Physica1 dependence is very apparent. The morning drink takes care of the hangover,
the jitters, the guilt, the remorse and the depression.
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He needs it to start the day This initiates the cycle of continuous drinking and speeds
up the progression of alcoholism.
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Seeks help
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Problems with the family and on the job mount up. These motivate him to seek
m nmBthpeVe?
hrrWL T* Seek help f°r his ^^bolism. He wants help only
to put the rest of his life back in order.
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Chronic phase
Now he is getting close to the bottom. Other alcoholic complications like gastritis,
liver dysfunction and polyneuritis occur.
-- •
He has a total breakdown in his relationship with the family. There is considerable
confusion and mental deterioration.
consiaeraoie
Binge drinking
Now the alcoholic has absolutely lost control and goes on drinking continuously for
several days and this is referred to as a binge. He is utterly helpless. There is a
oral disregard for the family, job, everything. At the end of such a ‘binge’, he is
aeain1 Rm k t?8’ rightened’ guiJt-ridden condition. He promises never to drink
again, but it happens over and over and again.
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ADDICTION - A DISEASE
Decreased tolerance
Initially, the alcoholic needed more and more alcohol to experience the 'desired
effects’; or in other words he had ‘increased tolerance’. Due to severe physical
deterioration, the alcoholic now gets ‘drunk’ even with very small quantities of
alcohol. Drinking smaller amounts results in higher degree of blood alcohol
concentration than in the past.
Takes a drink
Decreased tolerance —
small quantities; greater frequency
Effect wears
off soon
Gets quickly
intoxicated
Stops
Ethical breakdown
The alcoholic is so dependent on alcohol that he will lie, borrow or even steal in
order to maintain his supply of alcohol.
John, 42 years — married with two children. He had been drinking excessively
for a few years, as a result of which he was facing a financial crisis.
He was totally broke.
He had no money to pay his children's school fees.
Many of his bills remained unpaid.
In spite of his financial problems, he could not stop drinking. He desperately
needed money to buy 'alcohol.
He went to the church o^ieday. The plate for collecting mass-offenng came round.
Without any hesitation, he put a fifty paise coin in the plate, and took away
a five rupee note. He immediately went to the arrack shop and spent this money on alcohol.
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Paranoia
At this stage, the alcoholic is suspicious that everyone is watching him, talking about
him or even plotting against him. He is a victim of circumstances over which he
has no control.
He becomes jealous of everyone - of friends, of neighbours, even of his own family.
With a male alcoholic, there is a loss of sexual desire/functioning at this stage. This
results in him becoming suspicious of his wife having affairs with other men. This
is an extension of his inability to perform as a marital partner.
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ALCOHOLISM AND DRUG DEPENDENCY
Indefinable fear
He is frightened by nameless fears. Now he is afraid even to cross a road, enter a dark
room, etc frightened of all kinds of things which are in no w^y reldteckto reality.
Hallucinosis
“
Auditory (imagining voices speaking), visual (seeing non-existent things) and tactile
(feeling as though something is moving on. the skin) hallucinations are experienced.
Bhajan Singh had been drinking for nearly 30 years. His family and friends
had been requesting him to either stop or reduce hiir alcohol consumption. He
did neither.
One night, Bhajan Singh was behaving in a very strange manner.
He said that he saw Rajiv and Sonia Gandhi entering his house. He ran, woke
up his wife and asked her to prepare tea for the eminent visitors.
He could hear several people shouting, “Long live Sonia Gandhi! Long Live
Rajiv Gandhi!" To him, these voices were clear and distinct. He started repeating
the slogans and asked his wife also to join in.
His wife got terribly scared. She felt he was mad. She did not know that he
was experiencing visual and auditory hallucinations.
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Lack of motor co-ordination
At this point, he loses most of his motor co-ordination. He is unable to tie his shoes,
or button his shirt, until he ‘steadies’ himself with a few drinks. His legs and arms
do not respond automatically. He experiences shakes and tremors. This is not the
first time he is experiencing tremors. But formerly he could control them by taking
more alcohol’. Now the ‘shakes’ are more pronounced, and alcohol does not help
in quietening them’.
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Turning to God
I
He becomes desperate. He is unable to face the reality of his situation and turns
to God for help. Even now, he does not ask God to remove his desire for alcohol.
He pleads with God to help him to maintain a supply so that he can manage his
drinking. His entire being is nearly destroyed by addiction at this stage.
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Finally, the inevitable vicious circle begins. He gets sick, drinks to feel better and
becomes ill again. This continues endlessly. He drinks just for the sake of drinking;
he drinks only to stay alive.
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When he reaches this stage, two things may happen to him. He continues to take
alcohol and becomes mentally ill.
or
He continues drinking and dies a premature, painful death.
The only solution to this problem iis to stop drinking totally for life.
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ADDICTION - A DISEASE
65
Addiction to drugs (Drug addiction)
Just like ‘Alcoholism’, dependency on any other drug is also a disease — a primary,
progressive, yet treatable disease. Here also abstinence is the one and only solution
to the problem. ‘
.
X
The disease is progressive and goes through distinctly defined stages as in the case
of alcoholism.
Early stage
— Quantity of drug intake increases and doses are taken more frequently.
Increasingly, more time is spent using the drugs and in being in the intoxicated
state.
— Alters situations to facilitate increased use of drugs — reduces time and money
spent on other non-drug behaviour, e.g., Cuts down money spent in the cafeteria
to ensure sufficient money for the drug.
— Thoughts and conversation centre often around drugs. Thinks about when he
can use the drug, from whom he can get or how he is going to pay a lower price.
— Rationalises his use of drug. May tell himself that drugs are not dangerous to
use and “drug warnings” are not based on facts.
Middle stage
— Tolerance for the drug increases dramatically.
— Addiction develops — he needs the drug to ensure a sense of well being and later
on, to avoid withdrawal symptoms.
— Is unable to limit drug use. Frequently, loses control over the occasions when
he uses drugs.
e.g. Previously he might have desisted from using the drug during his monthly
tests but is now unable to do so.
— Resolves often to stop drug use; but his repeated efforts only fail. Substitute drugs
are tried.
e.g. Heroin addicts may try alcohol or other barbiturates.
— Maintains hidden supply of the drugs because the very thought about its absence
is threatening.
e.g. The nurse addicted to pethidine may start buying them, in addition to pilfering
from the hospital supply.
— Begins to have problems at school, college, and place of work.
e.g. Decline in performance, poor attendance etc.
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ALCOHOLISM AND DRUG DEPENDENCY
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— Uses drugs to handle unpleasant emotional states and sometimes uses them even
when he anticipates problems.
e.g. Feeling of embarrassment about test results; anger and irritation when parents
question about his frequent absence from home.
— Family relationship becomes strained — neglects responsibilities; is not
dependable.
— Personality shifts are observable — person is more irritable and withdrawn.
— Alienation from friends who were close to him prior to drug use. Interest in extra
curricular/leisure activities decline considerably.
— Neglect of personal hygiene — poor grooming and poor eating habits.
— Feelings of anxiety, guilt or shame may strengthen.
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Advanced stage
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— Drug use turns continuous.
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— Loss of control over the drug is complete. Experiences less and less pleasure from
the drug; but continues using it to avoid withdrawal symptoms.
e.g. Heroin addicts often complain that the intensity of euphoria is not the same
as before.
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— Cheaper drugs are used when the drug of choice cannot be obtained,
e.g. Heroin addicts may use other depressant drugs.
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— The individual becomes increasingly dependent on other people to carry on the
pretense of living. He often eats only because he is pressurised to.
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— Social relationships are almost non-existent and companionship is limited almost
exclusively to drug addicts.
— Person may leave home and start living alone.
!
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— Many face premature death due to poor health condition. -
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Elements of the syndrome
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The drug dependent’s life-style is altered in many ways.^The shifts can be studied
from different angles.
.
Behavioural changes
As the disease develops, behaviour becomes more and more drug related. Life seems
to revolve around drugs.
— Drug usage becomes more heavy and more frequent. From weekend use of ganja,
he proceeds to everyday use, and finally to a state of continuous intoxication.
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ADDICTION - A DISEASE
67
— Initially attempts to reduce drug usage but succeeds only for a very short while.
Slowly loss of control becomes more and more evident.
— Seeks occasions to use drugs and “friends” who use them regularly. The individual
becomes more skilled at obtaining, using and covering up his use of drugs. When
compulsive usage develops, daily activities revolve only around drugs. He seems
to live only for the sake of drugs.
— Poor grooming, total unconcern for personal appearance and utter disregard for
the opinions of others become pronounced.
Psychological changes
— Initially, uses drugs to feel better — more confident, get relief from anxiety, etc.
Slowly reaches a stage where he feels normal only with drugs. In the chronic
stage, he does not enjoy usage but is unable to stop.
— Emotional reactions — Mood swings related to drug use are evident. Gradually
personality changes, increased emotional liability can be noted. User feels
increasingly resentful, guilty, inadequate, and inferior. In the advanced stage,
behaviour is erratic, becomes increasingly apathetic and feels deserted and lonely.
— Cognitive process — In the initial phase, user is mentally obsessed with thoughts
about drug taking. With continued use, increased deterioration of self image,
self deception about drug use and its effects develop. Confusion, lack of objective
perception of himself and the world around him become more prominent.
— Judgement and insight —• Initially, when off drugs he is able to express concern
about drug use and is'able to get but of problems created by it. Problem solving
becomes increasingly difficult; Very poor insight and extremely poor judgement
are evident in the late- phase.
Social changes:
— Interpersonal relationships — As the disease progresses his choice of friends shifts
from abstainers to heavy users. His interpersonal relationships weaken
considerably in the second stage, as he repeatedly breaks promises, utters lies,
takes advantage of others’ sympathy and uses them to buy drugs. In the late phase,
he becomes increasingly manipulative.
— Family relationships — Even in the initial stage user is argumentative, withdrawn,
and spends very little time at home. As the disease develops, lying, stealing
and violence weaken his relationship with family members. Most drug depen
dents, in the chronic stage, are fully alienated from their family and often start
living alone.
— Social activities — Loses interest in non-drug activities even in the initial stage.
As the disease grows, he becomes more involved in the world of drugs and even
his ‘short lived friendships’ are made only with drug dependents.
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ALCOHOLISM AND DRUG DEPENDENCY
— Educational/occupational performance — Decreasing grades, poor attendance can
be noted in the initial stage. As the disease progresses, more problems crop up
and he may be suspended or may drop out voluntarily.
— Management of finances — Initially, spends money intended for other activities
on drugs by curtailing his interests. As the need for the drug increases, he spends
all the money that he gets on drugs. In the later phase, he becomes involved in
illegal activities and may also be in debt.
(
K > -z'
The drug dependent person may exhibit many or most of the-signs'and symptoms
listed above in a variety of combinations. The problems or damages which may follow
also occur in diverse combinations. The degree to which the dependency is developed
also varies widely. It is the responsibility of the consellor hot'to, simply label the
patient as an addict but rather to specify what signs arid symptoms support such
a diagnosis.
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ADDICTION
69
A DISEASE
Value additions place
— Additional information
Jellinek’s classification
The Question, ‘Is Alcoholism a Disease?’ has been analysed in detail by E M.
SIX a foimer eonsulun. o„ alooh»llSm ro the World Health Organ,aation.
He concludes that there are several types of ‘alcoholism’. Common to all types are
mo features - drinking and the damages it causes He names five common sub
species of the ‘genus’ alcoholism. They are listed in the table below:
Jellinek’s classification
Characteristics
Type
Alpha
Purely psychological dependence; the individual
drinks only to free himself from pain.
a
No physical/psychological dependence; heavy
drinking combined with poor nutritional habits
lead to severe physical damages.
Beta
Gama
y
Delta
d
Epsilon
£
“Loss of control” — inability to abstain from
alcohol for long periods of time.
No loss of control, but inability to abstain.
Drinks intermittently everyday but does not
necessarily get drunk.
Periodic uncontrollable drinking (BINGE).
70
ALCOHOLISM AND DRUG DEPENDENCY
— Perceptive findings
Three distinct stages of alcoholism
Warning signs
As felt by the patient
As perceived by others
Increased
Tolerance
Increased amounts of
alcohol are required to
experience ‘the same kick’.
Remains ‘steady’ even after
many drinks.
Blackout
People say “I did this; said Has become a liar. Refuses
that! Can it be true? Am I to believe others when they
forgetting totally?”
tell him how he behaved.
“I want to drink;... Yes,
Gives lame excuses for going
right away!”
out; always returns drunk.
“They have again started
Even at the mention of
talking about alcohol. They alcohol, he flares up, gets
are sure to pounce on me
angry, walks away, or
finally. I have to stop this
changes the topic.
conversation!”
Early stage
Preoccupation
Avoiding
references
to alcohol
Relief drinking
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“Drinking helps me to
Drinks at the slightest
overcome negative emotions provocation (criticism,
like stress, anger or
conflict or stress).
anxiety.”
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Middle stage
Loss of control
Denial
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I m not able to stop with Drinks continuously —
one or two drinks; I am
anywhere;' anytime of the
unable to exercise control
day.
over the time or occasion of
drinking”.
I do drink; but it does not .Finds reasons, excuses for his
cause any problems. ’
behaviour.
Everybody is exaggerating”.
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71
ADDICTION - A DISEASE
Grandiosity
Aggression
I have a lot to give others. Talks ‘big’ about himself;
’ for
' beyond
’
’ 1his
’; means.
Let me give away something spends
to others also.”
Physical, verbal abuse;
“Others are too unreason
able. They make me angry.” breaks articles.
Abstaining for
short periods
Tf I want to stop, I can do He can give up drinking if
it; I have proved it before.” only he wants to. He did it
when he went on a
pilgrimage. He only has to
make up his mind.
Solitary drinking
“I prefer to drink alone.”
Drinks at home all alone.
Is not able to avoid
continuous drinking.
Drinks day in and day out —
from morning to evening.
Chronic stage
Binge drinking
Decreased
tolerance
Ethical
breakdown
Unable to drink as much as Even with a very small
quantity he gets intoxicated.
. before.
“I must have alcohol right Steals money; tells lies about
money matters; has lots of
v now., I do not care how I
debts.
get it.” .
Feeling of fear
Indefinable fear.
Refuses to open the door
when someone rings the bell;
hides himself when people
come to his house.
Paranoia
“Everybody is after me.
They are going to harm or
kill me! My wife is also
having affairs with other
men.”
Suspects his wife; believes
she is having an affair with
someone else.
Hallucinosis
Hears voices, sees visions,
feels something is crawling
on his skin.
Afraid he is getting crazy.
Lack of motor
coordination
Unable to control body
movements.
Is not able to button his
shirt, tie his shoe laces, or
hold a glass.
Note:
These perceptive findings, can also be effectively used as a diagnostic tool to gather valuable
information about the patient.
72
ALCOHOLISM AND DRUG DEPENDENCY
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— Diagnostic tool
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Diagnostic criteria
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All over the world, two main systems are followed for diagnosis in psychiatry One
iw hf;ITtTeri?a,tlTal Classification of Diseases 9th Revision (ICD-9) puBlisfed by the
World Health Organisation (WHO). The second is the Diagnostic and Statistical
Manual, 3rd edition Revised (DSM-IIIR) published by the American Psychiatric
Association, USA. The diagnostic criteria as stated bv these twdManuals are given
below:
x
b
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ICD - 9
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Alcohol dependence syndrome
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A state, psychic and usually also physical resulting from taking alcohol, characterised
by behavioural and other responses that always include a compulsion to take alcohol
on a continuous or periodic basis in order to experience its psychic effects, and
sometimes to avoid the discomfort of its absence; tolerance may or may not be present
A person may be dependent on alcohol and other drugs; if so also make the appropriate
coding. If dependence is associated with alcoholic psychosis or with physical
complications, both should be coded.
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Drug dependence
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A state, psychic and sometimes also physical, resulting from taking a drug,
characterised by behavioural and other responses that always include a compulsion
to take a drug on a continuous or periodic basis in order to experience its psychic
effects, and sometimes to avoid the discomfort of its absence. Tolerance may or may
not be present. A person may be dependent on one or more than one drug.
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The various sub-categories listed are:
— Morphine type
— Barbiturate type
— Cocaine
— Cannabis
— Amphetamine type and other psychostimulants
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ADDICTION'- A DISEASE
73
— Hallucinogens
— Others
— Combinations of morphine type drug with any other
— Combinations excluding morphine type drug
— Unspecified
DSM III - R
This classificatory system prefers to call this group as psychoactive substance use
disorders.
Diagnostic criteria for psychoactive substance dependence
A. At least three of the following:
1. Substance often taken in larger amounts or over a longer period than the person intended.
2. Persistent desire or one or more unsuccessful efforts to cut down or control
substance use.
3. A great deal of time spent on activities necessary to get the substance (e.g. theft),
taking the substance (e.g. chain smoking), or recovering from its effects.
4. Frequent intoxication or withdrawal symptoms when expected to fulfil major role
obligations at work, school, or home (e.g. does not go to work because of a hang
over, goes to school or work ‘high’, intoxicated while taking care of his or her children)
or when substance use is physically hazardous (e.g. drives when intoxicated).
*
I
5. Important social, occupational or recreational activities given up or reduced because
of substance use.
6. Continued substance use despite knowledge of having a persistent oi recurrent
social, psychological or physical problem that is caused or exacerbated by the
use of the substance (e.g. keeps using heroin despite family arguments about it,
cocaine-induced depression, or having an ulcer made worse by drinking).
7. Marked tolerance: need for markedly increased amounts of the substance (i.e.
at least 50% increase) in order to achieve intoxication or desired effect, or the
markedly diminished effect with continued use of the same amount.
Note
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The following items may not apply to cannabis, hallucinogens or phencyclidine (PCP).
8. Characteristic withdrawal symptoms.
9. Substance often taken to relieve or avoid withdrawal symptoms.
B. Some of the disturbance have persisted for at least one month, or have occurred
repeatedly over a longer period of time.
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ALCOHOLISM AND DRUG DEPENDENCY
Diagnostic criteria for severity of psychoactive substance dependence
Mild: Few, if any, symptoms in excess of those required to make the diagnosis, and
the symptoms result in no more than mild impairment in occupational functioning
or in usual social activities or relationships with others.
Moderate: Symptoms or functional impairment between ‘mild’ and ‘severe’.
Severe: Many symptoms in excess of those required to make the diagnosis and the
symptoms markedly interfere with occupational functioning with usual social activities
or relationship with others.
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In partial remission: During the past 6 months, some use of the substance and some
symptoms of dependence.
In full remission: During the past 6 months, either no use of the substance, or use
of the substance and no symptoms of dependence.
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Diagnostic criteria for poly substance dependence
This category should be used when for a period of at least 6 months, the person
has repeatedly used at least 3 categories of psychoactive substances (not including
nicotine and caffeine), but no single psychoactive substance has predominated. During
this period the criteria have been met for dependence on psychoactive substances
as a group, but not for any specific substance.
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75
ADDICTION - A DISEASE
— Implementation tool
Screening test
Standard psychological tests are being extensively used for evaluation of alcoholism.
Many scales have been developed. Of these, the Michigan Alcoholism Screening Test
(MAST) is used more often. The MAST is a relatively short screening test that asks
direct questions about alcohol consumption. Validation efforts have been impressiv ,
and objective confirmation of MAST diagnosis have been obtained from a vane y
of institutional and public records. A copy of the screening test, along with the scoring
and interpretation key has been given here for your use.
Michigan Alcoholism Screening Test (MAST)
Instructions: Here there are 25 questions. For each question,
No’-. This
by ticking ‘Yes’ or ‘
-------is not an ability test. Please read carefully
and indicate your choice as directed above.
Yes
No
□
□
2. Have you ever awakened in the morning after
some drinking the night before and found that
you could not remember a part of the evening
before?
□
□
3. Does your spouse (or parents) ever worry or
complain about your drinking?
□
□
5. Do you' ever feel bad about your drinking?
□
□
□
□
6. Do friends or relatives think you are a normal
drinker?
□
□
1. Do you feel you are a normal drinker?
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4. Can you stop drinking without a struggle after
one or two drinks?
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76
ALCOHOLISM AND DRUG DEPENDENCY
7. Do you ever try to limit your drinking to certain
times of the day or to certain places?
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8. Are you always able to stop drinking when you '
want to?
'
9. Have you ever attended a meeting of Alcoholics
Anonymous (AA) ?
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10. Have you gotten into fights when drinking?
l
11. Has drinking ever created problems with you and
your spouse?
4
12. Has your spouse (or other family member) ever
gone to anyone for help about your drinking?
I
13. Have you ever lost friends or girl friends/boy
friends because of drinking?
14. Have you ever gotten into trouble at work
because of drinking?
15. Have you ever lost a job because of drinking?
16. Have you ever neglected your obligations, your
family or your work for two or more days in a
row because you were drinking?
17. Do you ever drink before noon?
18. Have you ever been told you have liver trouble?
Cirrhosis?
19. Have you ever had delirium tremens (DT’s),
severe shaking, heard voices, had seizures or seen
things that were not there after heavy drinking?
20. Have you ever been in a hospital because of
drinking?
21. Have you ever gone to anyone for help about
your drinking?
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77
ADDICTION - A DISEASE
22. Have you ever been a patient in a psychiatric
hospital or in a psychiatric ward of a general
hospital where drinking was a part of the
problem?
□
□
23. Have you ever been seen at a psychiatric or
mental health clinic or gone to a doctor, social
worker, or clergyman for help with an emotional
problem in which drinking had played a part?
□
□
24. Have you ever been arrested, even for a few
hours, because of drunk behaviour?
□
□
25. Have you ever been arrested for drunk driving
or driving after drinking?
□
□
8
DENIAL*
(DENIAL’ is a psychological process that takes place at the unconscious level in
the alcoholic. During this process, the alcoholic’s mind recreates an illusion so
convincingly that he believes it to be a ‘reality’. He is not consciously aware that
this change in thinking is taking place. People who are close to him, will definitely
be able to identify the methods of denial adopted by the alcoholic.
What exactly is ‘Denial’?
The individual will not report accurately the quantity, frequency or the problems
associated with his excessive alcohol consumption. The adverse behavioural
consequences and the problems associated with his drinking will either be minimised,
explained away, rationalised or denied completely. In short, there will be a denial
of reality.
For example, violent fights with the wife may be described as a minor argument,
or rationalised as due to the arrogant behaviour of the wife, or simply ignored.
The wife, friend, relative, or even a counsellor may perceive this ‘denial’ of the
alcoholic, as lying, - a method deliberately adopted by the alcoholic to escape taking
responsibility for his harmful actions. As a result of this, people close to him become
hostile and develop an intense hatred and dislike towards him for his dishonesty
and irresponsibility.
This chapter is intended to help in clarifying the factors which produce and maintain
the ‘denial mechanism’ of the alcoholic, so that everybody including the counsellor
may respond helpfully rather than reject the alcoholic.
* Over the years, it has been established that ‘Denial’ is part of the disease bf^addiction — be it
addiction to alcohol or any other drug. The name of the particular chemical abusqd is not important
in recognising the illness, and consequently the words ‘alcohol’ or ‘alcoholic’ used in this chapter
can very well be applied to any other chemical or chemical dependency, It does not make any
difference as to which chemical is being talked about.
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denial
81
Why do alcoholics deny their problems?
KS'“W Wof'good'lS'^o™os't^op“e dSn M<i s'01101
proiKIed “ “
associated with social occasions. Unfortunately in
3 harmJfess actiW normally
people who drink, alcohol use slowly deviates from a h T °f tW° °Ut of the ^n
he is branded a ‘dS^and^S
stigma
is looked upon a<Qn. eyif pfrs^n who deseX"p
7 d'™ °f alcohoJism-
person who needs understanding, support and nbf
rather than as a si^
Normally, nobody wants to be categorised a^d sf
' h ’ P
S1°na] help'
and mentally anfelior to others, and subiect hhZr
“’t'"1 PerMn> morally
re,ectton and social boycott. This is one ofS K »hS“T"’ di!apP"™‘.
Tw0 diametrically opposite beliefs can never eoeret for a
I
f°r den,al'
i . i . i
Xlst tor a verY long period in one individual
As a person’s flrmtag
L
beg,ns to iead to problems, a conflict is created 0^7
to problems, a conflict i
hand, alcohol has'b7come
:
’
,
V
"P.
mp
?
rta”'
»fhis life. Stem d7“
because it produces
tamte
|£?X»F
°f
”
d
help,
him
trying to rei„for«'X±s^7“mf"hee'
On
created by alcohol in his ramdy,'XZok7"2
‘lifet”n him about fhe probJems
awareness
etc.
t this point, he has only two options before him - > ’
rejectthe
drinking
or reject
reality.
ha'rdSX^'" reality bea“S' hd »
» exercise
other opt,on
ho^r
■I
•i ''til
becomes increasingly
o“f hfe'appe'’ W°'S'’ SiV'n8 “p dr“tag
ennseqnently the mechanism of dental “St^SrcT
“d
: The6 X:8o7fX“ls7hd°fsm ridB ,he 8tou"d f” ■d'““’-
.JSour proS
0?u„^XX2“a' Knde”Cy K a™d
them ‘loosen up’.
g
encourages denis!
ln a social Atting with friends, to help
feel better. To him it is a
thm'hrirXXsoiJe^^^
f
82
ALCOHOLISM AND DRUG DEPENDENCY
Gradually, there appears a difference in the emotional effect of using alcohol for
the person who begins to become dependent on it.
In the initial stages of alcoholism, the alcoholic drinks much more than others; he
doesn’t sip drinks; he gulps fast; and conceals the amount he drinks. He drinks more
than others; more often than others; and above all, it means far more to him than
to others.
For him, drinking is no longer a matter of choice; it is no more a display of his
strength. This is the first sign of his alcoholism. Repeated ‘denial’ by hiding the
bottle and drinking alone shows how necessary alcohol has become for him to lead
his life. He starts with one drink and goes on and on; he is unable to stop.
Everyone and everything which were hitherto important in his life become secondary
and the alcoholic begins to reject everything which he feels may threaten his continued
use of alcohol.
The reason why the alcoholic is unable to perceive what is happening to him is
understandable. As this condition develops, his self-image starts deteriorating.zFor
many reasons, he is unable to keep track of his own behaviour and he islosing contact
with his emotional self. His defence systems continue to grow; so that he can survive
in the face of his problems. The greater the pain he suffers, the higher and more
rigid the defences become; and this whole process takes place without his conscious
knowledge. Finally, he becomes a victim of his own defence mechaiiism.
His rational activity turns into real mental mismanagement. This serves to erect a
secure wall around the increasingly negative feelings he has about himself. The end
result is that he is separated from those feelings and becomes largely unaware that
such destructive emotions exist within him. Not only is he unaware of his highly
developed defence system, he is also unaware of the powerful feelings of self-hatred
buried behind it, sealed off from conscious knowledge, but explosively active. Because
of this, his judgement is progressively impaired.
In short, instead of returning to ‘feeling normal’ after the ‘high’ wears off, the
person experiences negative consequences due to an excessive use of alcohol
(e.g. embarrassment arising out of actions done under intoxication such as aggres
sion, drunken driving, blackouts etc). The problem gets compunded by the fact that
these defences, by locking in the negative feelings, have now created a mass of freefloating anxiety, guilt, shame, and remorse which become chronic in the course
of time.
The person is no longer able to start any given drinking episode from the ‘normal
point’, whereas before his illness he could always do so, and then proceed to ‘feel
good’. Now he starts from a depressed or painful emotional state and drinks to feel
normal. In the final stage of alcoholism he has no option but to drink in an attempt
to feel normal.
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DENIAL
83
Because there is an absolute dependence on alcohol, it is impossible for him to fully
realise that there is a tie between his negative feelings or behaviour and alcohol.
‘Denial’ or an addictive thinking pattern begins to develop to protect the alcoholic
from the reality of his alcoholism. As already stated, it is a defence mechanism used
to protect himself from the guilt, shame and blame which usually accompany the
consequences of his continued excessive use of alcohol. As he becomes more and
more dependent on alcohol, the ‘denial mechanism’ takes various shapes.
Let us discuss some of the most common forms of denial.
Simple denial
Initially, the alcoholic totally denies the existence of any problem associated with
his use of alcohol, even though these problems are quite obvious to others.
For example, the alcoholic may admit that he takes alcohol, but denies the fact that
his alcohol intake has produced any adverse consequences.
f 'Drinking produces no problems whatsoever. As a matter offact, I feel 'good'
and I am able to solve my problems better after drinking. "
Minimising
He accepts that his drinking leads to some problems; but keeps on repeating that
these problems are not as much or as many as the others make it out to be. He tries
to convince himself that it is much less serious than what it actually is.
"I drink, alright;... but it is not all that bad ...I drink only on weekends.
I give enough money to my wife to run the family. I am not spending excessively
on my drinks, as she complains. It certainly does not cause any financial problem
as it is made to appear."
Blaming or projecting
The alcoholic blames others fordiis own shortcomings. In this case, he denies
responsibility for many bf his alcohol-related problems and shifts the responsibility
to someone else.
\
It is only the cause of the behaviour which is denied and not the behaviour itself.
"My wife does'nov respect me. I slog only for her and for my children. But
she does not understand of my problems. She is constantly on my back. She does
not bother about my feelings at all. I drink only to forget my misfortune. ”
Rationalising or giving excuses
The alcoholic gives innumerable excuses, justifications, and alibis for his behaviour; but
never admits that the real cause for his adverse behaviour is his excessive use of alcohol.
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ALCOHOLISM AND bRUG DEPENDENCY
b°ss keeps. on sayinS that 1 have not completed my assignment on time
The alcoholic never accepts that alcohol is the real reason for his bad performance.
Intellectualisation or explaining away feelings
»“> <-“■»»•
1 am a doct°r and 1 know what » means to be an alcoholic. How can you
ever come to the conclusion that I drink excessively, thus damaging my liver
or brain? Do you really think that I am as stupid as all that?
Anyway, I will not get angiy with you, because it does not do any good anyway!”
Diverting
tSeS'e"hm"any referen“,0 alC°M
The alcoholic 3s friend says,
“ f?
i
dlvelopin8se™re problems due to excessive drinking It is high time
that you take care of your health, see a doctor and go for treatment. ”
“evenfimsh ,he
I heard you have not yet booked your ticket to Bombay. Nowadays booking
are ecommg ifficult You have to book sufficiently in advance The booking
clerk is my fnend and I will certainly help you m booking your twkeH ’
Hostility
MuX0™ °f denial WhiCh ,he alCOhO1K may UK “ his
is anger and
aE8reSS'0Ve' '"
h“
the
the other person avoid that to^ta^p^'"
haI
h,sever
a"^
Silence
soasin,fS x1”wha,ever be ,h' provoca'ion-He ““
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DENIAL
85
It seldom continues in isolation frpm others. Therefore, to understand alcoholism
and ‘denial’, we mustdopk not merely at the alcoholic but also at others closely related
to him. For the alcoholic to maintain his ‘denial’, others contribute unknowingly.
If excessive drinking continues for a long time, it inevitably leads to a crisis, where
the alcoholic gets into-trouble and will end up in a mess, if only others are not there
to support him. Tl^is cah happen to each individual in a different way. But the pattern
always remains the same.
Alcohol, which at first gave him a sense of success and independence, has now exposed
him and made him a helpless, totally dependent child. Now, everything is taken
care of by others.
He behaves as if he is independent when all the while he is totally dependent on others;
and drinking makes it very easy for him to convince himself that this is true. The adverse
consequences of his drinking always make him more and more dependent on others.
When he gets into a crisis, he waits for somebody to take up the responsibility and
cover up the consequences; thereafter he ignores the crisis and walks away from it.
The people who protect are referred to as the Enablers, the Victims, and the
Compensators. Their behaviour is called ‘Enabling Behaviour’.
“Enabling” is a therapeutic term which denotes a destructive form of helping. Any
act that helps the alcoholic to continue drinking without suffering the consequences
of his inappropriate use of alcohol is considered ‘Enabling Behaviour’.
The Enabler
The Enabler is a person who may be impelled by his own anxiety and guilt to rescue
the alcoholic from his problems. He wants to save the alcoholic from the immediate
crisis, and relieve him of the tension created by the situation. To the enabler, it is
like saving a drowning man. This rescue mission conveys to the alcoholic what the
person really thinks, “You cannot face your problems without me.”
In reality, the ‘Enabler’ is meeting a need of his own, rather than that of the alcoholic,
although he does not realise it himself. The enabler actually reveals a lack of faith in
the alcoholic’s ability to take care of himself, -which is a form of judgemental
condemnation.
This role is normally played by the ‘doctors’, or ‘social workers’ who lack scientific
information about alcohol or alcoholism which is essential in helping alcoholics out
of their problems.
The behaviour of these people conditions the alcoholic to believe that there will always
be a protector, who will come to his rescue, even though these enablers insist they
will never again rescue him. They have always rescued him and the alcoholic knows
that they always will. Such rescue operations are as compulsive to them as drinking
is to the alcoholic.
86
ALCOHOLISM AND DRUG DEPENDENCY
Victim
The victim is usually the boss, the employer, the supervisor or a co-worker. When
the alcoholic fails to perform his job, the ‘victim’ normally completes the work. If
the alcoholic is absent due to his drinking or due to a hangover, the ‘victim’ gets
the work done for him.
Statistics in industries show that by the time drinking interferes with a man’s job,
he may have been working for the same company for quite a number of years, and
his supervisor or boss, by now would have become his real friend. Protection of a
friend is a perfectly normal response.
The victim always hopes that this will be the last time that he will be rendering this
sort of a help. But he continues to protect the alcoholic again and again.
The alcoholic becomes completely dependent on this repeated protection and cover-up
by the victim. Otherwise he will not be able to continue drinking in this manner.
In short, it is this ‘victim’ who unknowingly helps the alcoholic to continue with
irresponsible drinking without losing his job.
The compensator
The key person is normally the wife or parents of the alcoholic, or the person with
whom the alcoholic lives. This person has played the role of ‘compensator’ much
longer than anybody else.
The wife is hurt and terribly upset by his repeated drinking episodes. She has to
take up the responsibility to hold the family together in spite of all the problems
created by drinking. She becomes bitter, resentful, afraid, and deepjy hufb She
controls, sacrifices, adjusts, but never gives up. The alcoholic blames,.her for
everything that goes wrong in the house, or outside.
. .
In helping the alcoholic, she also unconsciously meets a need of her own. ,She enjoys
her inevitability arising out of the alcoholic’s total dependence, oh he'r.x
She is also forced to play the role of a responsible and accommodating housewife,
who can function efficiently in spite of the problems surrounding the entire family.
She is afraid that society will otherwise brand her as ‘non-cooperative,
unaccommodating and inefficient'.
She tries whatever is possible to make her marriage work and to prove that she is
able to manage her problems efficiently. She plays all the roles — the role of a wife,
the role of a father, the role of an earning member and so on.
When an alcoholic gets into trouble, her typical response is to try and minimise it.
{<Let us hush this up!”
“Let me inform his office that he is taking leave because there is a function
at home!”
DENIAL
87
These are moments when he is drunk. These are the ways the compensator minimises
the force and the pain of each crisis as it develops. While they are trying to be helpful
they are actually aiding and abetting the development of the disease. Everytime they
try to rescue an alcoholic, they are only postponing the necessary treatment.
Living with a man with the disease of alcoholism, she tries to learn, and counsel
him as well.
As a result of this, she hurts herself, adds more guilt, bitterness or hostility to the
situation which in the course of time becomes unbearable.
If the alcoholic is rescued from every crisis either by the Enabler, the Victim or the
Compensator, there is no chance for the alcoholic to recover at all. Long term recovery
is possible only if the major block, namely denial, is broken.
In reality, the alcoholic is helpless; by himself he cannot break the lock. He will
recover only if the above mentioned people learn to break his dependency on them
by refusing to help him get out of the crisis created by his alcoholism.
The alcoholic will feel helpless and desperate because some crisis or the other will
inevitably occur due to his excessive use of alcohol. He will find no one ready to
take up responsibility for his actions. He will find it impossible to deny the problems
associated with his use of alcohol and it is the crisis that will force him to come for
help in despair.
The Enablers, the Victims and the Compensators, too, must seek information, insight
and understandingjf they plan to change their roles, so that the alcoholic’s denial
is broken and he realises the need for help.
They should realise1 that: — ‘Denialis the result of the social stigma attached to alcoholism; the alcoholic’s
defense mechanism and the ‘enabling behavior’ of the people significant to him.
— A Crisis is an opportunity — it need not be terrifying.
— The problem is to get people knowledgeable enough to use it creatively, i.e.,
out of crises, develop opportunities for intervention.
— The resulting confrontation following a crisis can break through denial and this
will be the first step towards recovery; — perhaps even the beginning of treatment.
— The task of treatment is to make the alcoholic well. But, it is the task of
intervention to bring him to treatment.
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ALCOHOLISM AND DRUG DEPENDENCY
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Value additions place
Kt
— Diagnostic tool
IIMW
Different methods of denial adopted
Simple denial
Denying the existence of any problem
whatsoever associated with the use of
drugs/drinks.
Minimising
Underplaying the extent of the problem,
Blaming or projecting
Holding others responsible for one’s own
shortcomings.
Rationalising
Finding excuses and justifications for one’s
inappropriate use of alcohol.
Intellectualising
Attempting to avoid facing any alcoholrelated problem by looking at it
theoretically.
Diverting
Totally changing the subject of
conversation whenever it focuses on the use
of drugs or drug-related problems.
Hostility
Displaying anger and irritability.
Silence
Not responding verbally to any provoca
tion.
Bibliography
1'
tkaR' XbCrg! Why do alcoholics deny their problems? Hazelden Publications,
U on, 1 70O.
2. Alcoholism - A Merry Go Round named Denial, Mid Town Station, New York.
<<:■
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CAUSATIVE FACTORS*
Causes of Alcoholism
The search for a unitary cause of alcoholism has shifted to inter-disciplinary
exploration of factors that might, individually or collectively, account for the
development of problem drinking in various types of individuals. Although there
is no generally agreed-upon model of how alcoholism starts, research into the
physiological, psychological, and sociological factors has resulted in a far greater
understanding of the conditions that may precede, underlie, and maintain problem
drinking. The state of knowledge is still quite crude. There have, however, been
several promising leads which may ultimately contribute to better prediction an
protection of individuals likely to develop alcohol problems, and to improved
treatment techniques for those already ill.
Physiological theories
Despite considerable research efforts to find physical factors, either in alcohol itself,
or in the biological makeup of those who drink, which could account for alcoholic
drinking and addiction, to date, many of the questions remain unsolved. Some of
the proposed theories are presented here for consideration, including the genetic,
endocrine, and genetotrophic theories.
Genetic theory
Some workers in the field theorise that alcoholism may be inherited. Alcoholism
appears to run in families; it is therefore, suggested that an alcoholism prone individual
may have inherited a susceptibility to be influenced adversely by ingested alcohol.
Research has provided some evidence to support this theory. The possibility that
humans may inherit a predisposition for alcoholism or an immunity to it does not
rule out other factors also contributing to its occurrence in a positive or negative
manner. Thus, the development of alcoholism may be the result of a collection of
factors rather than just one.
• This chapter has been reproduced from: Comprehensive Health Education Foundation, Here’s Looking at you Two A teacher guide for Drug + Alcohol Education, CHEF, Seattle, USA, 1982.
-A H
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CAUSATIVE FACTORS
90
Endocrine theory
Another major physiological theory of the cause of alcoholism indicates a dysfunction
he endocrine system Similarities between the symptoms seen in alcoholic patients
and m patients wnh endocrine disorders suggest that some failure of the endocrines
might be causally related to the onset of alcoholism. If alcohol ingestion stresses the
rganism, chronic heavy drinking could cause a hyperactivity of the pituitary gland
eventual exhaustion of the adrenal cortex, and consequently, a breakdown in the
functions regulated by the adrenal hormones.
As with other theories, the experimental clinical evidence to date is not concluve. he available information suggests that the endocrine characteristics associated
with alcoholism may be a result of chronic heavy drinking rather than its cause.
Genetotrophic theory
The genetotrophic theory of alcoholism combines the concept of a genetic trait and
nutritional deficiency. It is postulated that, due to an inherited defect or ‘error’ of
metabo ism some people require unusual amounts of some of the essential vitamins.
Since, they do not get these unusual amounts in their normal diet, they have a
genetically caused nutritional deficiency. Those who drink alcohol develop an
abnormal craving for the substance, and the consequence is alcoholism.
Other physiological theories
Physiol^lcal theories about alcoholism include factors such as allergies
i ering metabolic rates, and non alcoholic components of alcoholic beverages
(congeners). Although there is a theoretical basis for each, the scientific evidence
does not yet exist to support them.
In summaiy, it is generally held that physiological factors probably contribute to the develop
ment of alcoholism, but none has yet been conclusively proven to be the single cause.
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Psychological theories
Some researchers believe that individuals with alcohol problems possess a number
of distinctive traits which together make up the ‘alcoholic personality’. However
there is no agreement on the identity of these traits, nor on whether'they may be
the cause or the result of excessive drinking. Three approaches to th'e psychological
cause of alcoholism are explained in this section. The psychoanalytic theory, the
learning theory and the personality trait theory.
Psychoanalytic theory
Psychoanalytic explanations of the causes of alcoholism rest on three major theoretical
positions.
a) The Freudian view
b) The Adlerian view
c) The view that alcoholism develops.as a response to an inner conflict between
dependency drives and aggressive impulses.
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CAUSATIVE FACTORS
91
The Freudian view as expressed by a number of people relates alcoholism to such
factors as repressed urges, oral dependency, need for security, self-punishment and
parental hatred.
The Adlerian view is that alcoholism represents a striving for power, which
compensates for a pervasive feeling of inferiority. It is assumed that alcoholics derive
their feelings of inferiority from a childhood in which overindulgent parents did not
permit them to learn how to cope with the problems of adult life. The alcoholic turns
to alcohol to enhance his feelings of self-esteem and prowess.
Other studies suggest that frustrated ambitions may play a role in the development
of an alcohol problem. It is suggested that alcoholics may have an enhanced need
for power, but find themselves inadequate to achieve their goals. They resort to alcohol
because it provides a sense of release, a sense of power and feelings of achievement.
Since overindulgence in alcohol precludes effectively coping with the existing problems
and leads to additional problems, this vicious cycle results in confirmed alcoholism.
Evidence to support the psychoanalytic views is inconclusive, since it is difficult to
devise experimental tests of these theories. Nevertheless, in some cases, the application
of psychoanalytic ideas in the treatment of alcoholism has been successful.
Learning theory
The learning and reinforcement theory explains alcoholism by considering alcohol
ingestion as a reflex response to some stimulus and as a way to reduce an inner drive
such as fear or anxiety. This theory holds that persons tend to be drawn to pleasant
situations or repelled by unpleasant or tension-producing ones. In the latter case,
alcohol ingestion is said to reduce the tension or feelings of unpleasantness and to
replace them with a feeling of wellbeing or euphoria.
The obvious troubles experienced by alcoholics might appear to contradict the learning
theory in the explanation of alcoholism. The discomfort, pain, and punishment they
experience should presumably serve as a deterrent to drinking. The fact that alcoholics
continue to drink in the face of family discord, loss of employment, illness and other
sequels of repeated bouts is explained by the fact that alcohol has the immediate
effect of reducing tensibn while the unpleasant consequences of drunken behaviour
come only later.
, v- v
The role of punishment is becorping increasingly important in formulating the cause
of alcoholism based on the principles of the learning theory. While punishment may
serve to suppress a resppiise, experiments have shown that under some circumstances
it can serve as'a reward and reinforce the behaviour. Thus if the alcoholic has learned
to drink under conditions of both reward and punishment, either type of condition
may precipitate renewed drinking.
Ample experimental evidence supports the hypothesis that excessive alcohol consump
tion can be learnt. However since conflicting studies exist, the learning theory requires
further research.
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ALCOHOLISM AND DRUG DEPENDENCY
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Personality trait theory
Psychological research has also attempted to define the causes of alcoholism in terms
of an alcoholic personality’. Though it is conceded that all alcoholics need not have
the same characteristics, it is postulated that in the pre-alcoholic stage, a personality
pattern or constellation of characteristics should be discernible and should correlate
with the pre-disposition towards alcoholism. One of the main difficulties in this
approach is that the population ordinarily available for study is already in trouble
’ The q^es1tl°" ^ whether the personality traits observed in these people
p edate the onset of alcoholism, or are a consequence of alcoholism.
Using objective and projective tests, researchers have attempted to identify an
ym8 perso^aJlty disorder. As yet, these approaches have failed to identify a
ofZ
Struc:ure Of the aIcoholic Patient which would be predictive
of alcoholism. There is evidence that alcoholic patients exhibit some personality traits
ommoX
h3rS been eStabllShed’ these Pati^s ^ow'some
behaV10ural and trait manifestations which appear to be more relevant to
alcoholism than to other psychological disorders.
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Sociological theories
Alcohol serves vastly different functions within and among societies, cultures
subcultures, and ethnic and religious groups. Attitudes concerning its use range from
xtmme permissiveness to absolute abstinence. But abstainers can always be found
when permissiveness is the watchword, and, conversely, drinking does not disappear
when abstinence reigns. The purposes for which alcohol is used include religkLs
Sta H a PlychlC’ ^mmomal, hedonistic, traditional, social and medicinalSones’
to" hrS °f aCCeptablJlty aPPlied t0 the manner or pattern of drinking vary according
XcumXcer^011’ S£X’ CUltUral back^tmd, social class and* the'particular
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Cultural theory
The cultural theory of alcoholism suggests that within a given society, there are three
ways in which the culture may influence the rate of alcoholism. '
3'
WhiCh the CUltUr£ °Perates t0 bring ab°ut inner tensions or acute
needs for adjustment in its members.
b. The attitudes towards drinking the culture produces in its members.
=. The degree to which the culture provides suitable substitute means of satisfaction.
Societies may provide alternatives to or substitutes for alcohol use. Some societies
^lenhnrSS
mg“tsanctlons a8amst narcotic drugs and therefore have a lower
therebv mo'v d
?
emOti°naI °UtletS thr0Ugh ceremonies and rituals and
thereby provide a culturally accepted means of anxiety reduction.
<5
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CAUSATIVE FACTORS
93
Deviant behaviour theory
Depending on the context, the use of alcohol can be illegal or only illegitimate...
acceptable or even sanctified... forbidden or abominated. Thus, the concept of alcohol
abuse as deviant behaviour is receiving increasing attention by researchers. The
deviant behaviour theory represents the alcoholic as someone who, through a set
of circumstances, becomes publicly labelled a deviant and is forced by society’s
reaction into playing a deviant role.
A Summary of the Causes of Alcoholism
The search for a single cause of alcoholism may be an unrealistic goal. Nevertheless,
researchers with specialised interests and with needs to define alcoholism from their
own perspectives will probably continue to look for a unitary answer to solve the
problem of how alcohol addiction occurs and to identify the crucial factors associated
with its onset and progression.
Many theorists, however, suggest a multifaceted approach which incorporates
elements from two or more hypotheses. Generally, such an approach selects from
each of the broad areas discussed — physiology, psychology and sociology.
An individual who (i) responds to beverage alcohol in a certain way, perhaps
physiologically determined, by experiencing intense relief and relaxation; and who
(2) has certain personality characteristics, such as difficulty in dealing with and
overcoming depression, frustration, and anxiety; and who (3) is a member of a culture
that induces guilt and confusion regarding what kinds of drinking behaviour are
appropriate, is more likely to develop trouble than most other persons.
More research will have to be done to gain a deeper insight into the causes of
alcoholism. Work is needed to identify better the association between alcohol use
and all aspects of physiological responses, predispositions and attitudes, and the social
context and consequences of drinking.
Causes of Drug Dependence
In any general discussion of drug dependence, the use of substances which produce
several different and even contradictory effects are included together. Researchers
in the field have abstracted three main areas within which to explore the causes of
dependence: the physiological, the psychological and the sociocultural.
Physiological theories
Physiological explanations for the causes of drug dependence have attempted to relate
the pharmacology of particular drugs to some physical effect or change in the
individual using the drug. This approach has led to two types of hypotheses: 1) that
dependence may be the result of an inherited predisposition or genetic factors), and
2) that dependence may result from ir drug-induced alteration in the boc y’s
physiological functioning.
94
ALCOHOUiiM AND DRUG DEPENDENCY
or relatives of drug dependent individuals, leading to the suggestion that there may
be some tnnented inability to control psychoactive substances. The genetic factors
have received some more support from the recent discovery of naturally occurrina
opiate Id e compounds endorphins - in the brain. This discovery has led to the
eultmg mhough uhdiv undemonstrated hypothesis that lower than normal 1-vels
oi these ompiiunds stimulates a need for self-medication, and facilitates the
^PlttC
Unfortunately, no similar natural compounds
have been isolated which correspond io other psychoactive substances. Also, it is uot
known what the impact of environment is upon genetics as it relates to the drug field.
Physiological adaptation to a particular drug which is not reversible by detoxification
cr withdrawal has been a primary focus of research which attempts to understand
why drug dependent individuals relapse and show continued craving for the depend
ency producing substance. One possibility proposed for the opiates, and leading to
tie establishment of methadone maintenance programmes, is the theory that physical
use of an opiate results in a biochemical change in the
individual s system, not reversed by detoxification, and only relieved by continued
ingestion o» opiates. No physical evidence for this theory has been found, although
tie success < . the methadone maintenance programmes lends it some support.’
Oilier types of drugs, such as the amphetamines and different hallucinogens havbeen implicated in theoretical approaches which propose that continued use stimulates
' ?’V',ard centresbrain in such a way that a craving for ongoing administration
of the drug is established physiologically. We still know too little about the normal
aS Tit11' ftUncUOns’ a?d t0°,itde about * ways in which different drugs
affect these functions, for any of these adaptational theories to be more than
provocative hypotheses at this time.
Psychological theories
A search for the common factors in the drug dependent personality has long been
deXd01 resea^h for the/tld °f Psychol°gy- This psychoanalytic approach to drug
dependence is dominated by the idea that persons with drug dependence do share
ProX.dSyCh0
cJaracteristics which comprise the “addictive personality”,
reposed persoruility characteristics linked to drug dependence include unresolved
needS’ e.scapifsm’low self-esteem, compulsiveness, and a lack of internal
i™ ' Changes in tiaese factors ^ve had some correlation with success in treatment.
•.'
uri^rtam however, whether these personality characteristics are not mere
ad J
15 and resuIts,of 1116 drug-dependent lifestyle and orientation, psychological
adaptations as it were, than representatives of any pre-disposing pattern. It is reasotSble
o suppose that some personality characteristics may make a person more susceptible
s:m h 8 dependence than other!’ but h°w these characteristics interrelate, and why
simdar persons do not become drug dependent have not been satisfactorily explored^
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CAUSATIVE FACTORS
95
An alternative psychological approach is one which does not seek to identify distinct
personality characteristics, but rather attempts to consider the responses of the
individual to certain drug or drag-related stimuli, and the way these responses become
habitual or produce dependency.
Behaviorist theories, applied to drug dependency, attempt to cluracterize how users
who learn to enjoy the effects of a particular substance may continue to use that
substa nee both because of the learned positive effects, such as euphoria, and to avoid
the learned negative effects, or withdrawal. Similarly, many drugs are thought to
have an instrumental or reinforcing effect which leads to continuation of use and
dependency. The reinforcement for use is thought to be the reduction in fear, stress,
anxiety, or conflict which drugs may provide, and thus the drug dependency may
be a functional adaptation for the individual in a personal sense despite adverse
consequences in other areas. This stimulus-response approach to the causes of drug
dependence leads to powerful explanations, although some professionals view that
as an over-simplification of the dependency process.
Sociocultural theories
As with the previous theories, there are two aspects of dependence examined through
the sociological approach. Researchers are both examining the social and cultural
bases for the onset of dependence, and describing those social and cultural factors
which contribute to the perpetuation of dependence.
In the theories of social deprivation, relative deprivation, and anomie, individual s were
thought to turn to drug use and eventual dependence as a result oi the conoitions in
their social environment which denied them opportunity for achievement. While fitting
fairlv closely some conditions of minority ding dependence, these approa< es ave
little’ explanatory power for the present generation of middle-class, Caucasian abusers
except in the broader sense that these individuals may also experience social frustrations.
Other explanations for the causes of drug dependence rest on the observed examples
of drug use as a statement of pretest and separation from mainstream values, and
the support of this separateness by some peer groups. The concept or peer Pressure
has attained major importance in our understanding of why individuals engage in
deviant behaviour such as drug use.
The second aspect of the sociocultural approach explores the manner in which the
larger environment may support the continuation of substance use and foster depend
ency? American society, by generally viewing as desirable and necessary the use of
drugs for relief of life’s pain and enhancement of life’s pleasures, tends to provide
a singular climate for all forms of drug dependency. Countering this climate of support
is the stigma associated with illicit drug use and drug dependence. The concept of
deviance labelling, in which the individual through his/her use of non-permitted
substances in non-permitted ways becomes labelled as deviant, ^^“P110 exp 3111
drug dependence as an outcome of this labelling. Through the labelling process,
96
ALCOHOLISM AND DRUG DKPBNDENCY
and society’s responses to the labels, the drug use becomes the most important aspect
of the individual’s life due to the exclusion by society of other alternatives.
Researchers have also examined the ways in which the immediate environment of
the substance user, referred to as a subculture, supports and reinforces drug
dependency through provision of a structure and a sense of community. The drug
subculture both attracts new users and retains more experienced users through its
own attractiveness, and through the reduction of other life styles due to their drug
dependence. The subcultural perspective may further explain the return to use after
treatment or detoxification, since for many persons, it is the only life style in which
they can find a sense of belonging, and in which they can succeed.
Summary
,
E.
;
All of the above theories overlap frequently in several ways, with terminology being
the major difference among them. Since no single theory proposed thus fiir can account
for the physical, the psychological, and the sociocultural aspects of becoming and
being drug dependent, some professionals are now examining the interaction of their
theories as an explanation of dependence.
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ADDICTION - THE ROLE OF PARENTS
Research has shown that one of the causative factors of chemical dependency is a
strained relationship’ in the family, — especially between parents and children.
Any programme which aims at prevention of chemical dependency should therefore
include parents as their target group. Educating and creating awareness about effective
parenting would help develop a healthy and positive parent-child relationship. This
would pave the way for their child’s untroubled, addiction-free adult life.
Building a relationship
A healthy family relationship includes sharing, open communication, honest expression
of feelings, warmth, understanding and active participation in each other’s interests.
The following are some of the guidelines towards ‘positive parenting’.
★ Parents should make the child feel that his participation in the family activities
is valuable. For example, when the child helps in cleaning the house, watering
the plants or buying provisions/vegetables, parents should express their satisfaction
and appreciate the contribution made.
★ Parents should learn to recognise the child’s strengths and encourage him to work
to the best of his ability.
★ Parents should regularly allot time, to spend with their children. Parents should
express sincere interest in their child’s activities — studies, games, other
interests, etc.
★ Parents should get interested in their child’s friends and establish a warm and
cordial relationship with them.
★ Effective communication begins with the parent’s commitment to listening.
Listening involves attending to whatever the child has to share regarding his
experiences at school, problems with other children, joyful moments, ambitions
etc. Parents should make eye contact with the child while listening. By listening,
parents make the child realise that they do appreciate the child’s point of view.
129
CHILDREN OF ALCOHOLICS
Yes
No
28. Did you ever stay away from home to avoid the drinking
parent or your other parent’s reaction to the drinking?
29. Have you ever felt sick, cried, or had a ‘knot’ in your
stomach after worrying about a parent’s drinking?
30. Did you ever take on any chores and duties at home that
were usually done by a parent before he or she developed
a drinking problem?
Interpretation
If the child has given 6 or more ‘yes’ answers, it means that this child is likely to
have an alcoholic parent.
Bibliography
1. Cathlene Brooks, The secret everyone knows, Kroc Foundation, San Deigo, 1981.
2. Janet Geringer Woititz, Adult Children of Alcoholics, Published by Health
Communication, USA, 1983.
3. Claudia Black, Repeat after me, MAC Printing and Publications, Colorado, 1985.
4. Jael Green Leaf, Co-Afcoholic/Para Alcoholic, New Orleans, 1987.
X
I
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128
ALCOHOLISM AND DRUG DEPENDENCY
Yes
No
10. Did you ever feel like hiding or emptying a parent’s
bottle or liquor?
11. Do many of your thoughts revolve around a problem
drinking parent or difficulties that arise because of his
or her drinking.
12. Did you ever wish that a parent would stop drinking?
13. Did you ever feel responsible for and guilty about your
parents drinking?
14. Did you ever fear that your parents would get divorced
due to alcohol misuse?
15. Have you ever withdrawn from and avoided outside
activities and friends because of embarrassment and
shame over a parent’s drinking problem?
16. Did you ever feel caught in the middle of an argument
or fight between a problem drinking parent and your
other parent?
.
17. Did you ever feel that you made a parent drink alcohol?
18. Have you ever felt that a problem drinking parent did
not really love you?
19. Did you ever resent a parent drinking?
20. Have you ever worried about a parent’s health because
of his or her alcohol use?
' - 1
21. Have you ever been blamed for a parent’s drinking?
22. Did you ever think your father was an alcoholic?
23. Did you ever wish your home could be more like- the
home of your friends who did not have a parent with
a drinking problem?
24. Did a parent ever make promises to you that he or she
did not keep because of drinking?
25. Did you ever think your.mother was an alcoholic?
26. Did you ever wish that you could talk to someone who
could understand and help you solve the alcohol related
problem in your family?
27. Did you ever fight with your brothers and sisters about
a parent drinking?
x
CHILDREN OF ALCOHOLICS
127
KC
— Diagnostic tool
itaM
s-
Children of Alcoholics Screening Test
The CAST developed by John W Jones, Ph.D., is a valid and reliable screening
test that can be used as an aid to identifying children of alcoholics. The questionnaire
consists of 30 questions that describe the feelings, behaviour and experiences related
to a parent s alcohol abuse. The child is asked to answer all 30 questions by marking
either ‘yes’ or ’no’ in a way that best describes his/her feelings, behaviour and
experiences related to his or her parents’ drinking.
Please check the answer below that best describes your feelings, behaviour, and
experiences related to a parent’s alcohol use. Take your time and be as accurate as
possible. Answer all 30 questions by ticking ‘yes’ or ‘no’.
Sex: Male
Female
Age:
........................
Yes
1. Have you ever thought that one of your parents had a
drinking problem?
0
iI
p
!
2. Have you ever lost sleep because of a parent’s drinking.
3. Did you ever encourage one of your parents to quit
drinking?
4. Did you ever feel alone, scared, nervous, angry or
frustrated because a parent was unable to stop drinking?
5. Did you ever argue or fight with a parent when he or
she was drinking?
6. Did you ever threaten to run away from home because
of a parent’s drinking?
7. Has a parent ever yelled at or hit you or an other family
member when drinking?
8. Have you ever heard your parents fight when one of
them was drunk?
9. Did you ever protect another family member from a
parent who was drinking?
No
IrI
126
ALCOHOLISM ANDx DRt(G dependency
Sometimes I also cry. I cry when I see daddy vomit or fall;! cry-when he scolds
or beats me for no fault of mine.
Suddenly mummy shouted, “Go to your room!
“It is not bedtime! Why is she asking me to go to bed? This happens every day
why a™
~~ eSf)ecially when 1 ask her anything about daddy. . . But
Little Ram had a terrible time with my father the other day. He said that his
friend called my father a ‘drunkard’. My father slapped him and said, “Don’t
you ever use that word in this house!” We agreed with him silently After all
it is a dirty word.
’
Mummy shouts when daddy doesn’t go to work. She gets angry and they start
fighting. What can we do? we also cry. When she is worried, she yells at me
at Kam, at Mohan — at everyone around.
I love my father; I love my mother; but I hate the smell that comes from daddy.
I wish mummy did not cry all the time; did not blame my father for everything.
She cnes and shouts; never answers any of our questions; she does not have any
time to talk to us or even sit with us.
Last week, daddy promised to take us to a movie. We waited till late in the evening.
He never came back from the office. When he came home, he was not walking
straight. It was too late and he went back to sleep. He never spoke to any of us.
This is not the first time that he has broken his promise.
Mummy also never keeps her promises.
She says daddy forgets because he drinks. She does not drink at all. How is
f at s^e^ls0 for£ets everything? One fine day, she bought me a toy and a
ball. I had never asked for it.
We do not want a ball. We do not want any toys. We want to sit with themplay with them; talk and eat with them; go out with them...! We want lovewe want affection. Will we ever get it at all?!
We want hugs; we want love — we do not want toys! We want our daddy to
get well soon. Only then can we all go together to movies, to the beach, to the
zoo. .. to our grandparents' house. . .
Will he get well? Can we talk, laugh and enjoy?
wiUhurtus SCared' 1 am a^raid daddy wil1 hurt mummy, and mummy in turn
Iu>ant to shout, “We hate all ofyou!” and run away as far as possible from
this house .. ..BUT. .. WHERE?!!
■
125
CHILDREN OF ALCOHOLICS
— A Case Study
Ss* i*'^
The secret cry of a child
Mummy looked very sad. She did not answer.
“Is something wrong with my house?. . . It appears to be a very nice house!. ..
Daddy has a good job!.. . But why is it that there is always yelling at nights
in my parent’s bedroom?
Again I asked mummy, “What is ‘drunk’, ma?”
Mummy turned — “Why do you want to know?”
Karthik said, “Your daddy is a ‘drunk’...” what does that mean, ma?
She did not speak. Suddenly she said, “Your daddy drinks a lot. He seems
to like the way it makes him feel, and he does not stop drinking even though
it makes him sick. ”
“When I start eating cone ice-cream, I eat right down to the end. Even after
that, I feel like having some more. Does daddy feel the same way when he
drinks?”
Mummy kept quiet. She was crying.
‘Mama, why don't you ask daddy not to drink so much? Fhen he won’t get
sick. You make him stop drinking. ”
Mummy continued to cry — did not talk to me.
Nowadays, mummy is always in bed with some illness. It never seems to go
away. Ddb dot even invite my friends to come and play in my house.
I think daddy is really sick. He is sick because he drinks a lot. . . But what
is wrong-' with mummy? Why is she always sick?
' ^I§^something wrong with my mummy also?. . . But I don’t see her drink!! She
always either cries or shouts. I am unable to understand anything. I am confused.
I don’t tell even my dearest friends as to what is happening in my house. I feel
so alone; no one understands me. Mummy says that I should not speak about
my daddy’s drinking to anybody — not even to my grandpa. Even we brothers
do not talk about it between ourselves. .. But why?!
124
ALCOHOLISM AND DRUG DEPENDENCY
he most significant characteristics of the fetal alcohol syndrome include mental
retardation, poor movement coordination (especially fine motor movement), and
growth deficiency (such children tend to have low birth weights and continue to
remain small throughout childhood despite adequate caloric intake). These children
also tend to show a characteristic facial appearance (such as small head circumference,
short eyeslits, low nasal bridge, short upturned nose, thin upper lip etc).
Obviously, many of these facial features are not unique to the fetal alcohol syndrome,
but occur commonly in other children. It is the clustering of these facial features
(along with mental retardation, poor motor coordination, and growth deficiency)
in children of alcoholic mothers that makes the features part of the fetal 'alcohol
syndrome.
Originally we doubted that fetal exposure to alcohol itself was the cause of the fetal
alcohol syndrome. Some investigators thought the syndrome might- be due to
nutritional deficiencies in the mother that are often associated with klcohojism. Others
thought the syndrome might be related to cigarette smoking,5 a practice that is also
common among alcoholics. Still others thought it might be related to other medication
that physicians sometimes prescribed for pregnant women. While all of these practices
in their own right may have detrimental effects on the fetus, it is now clear that
alcohol itself is capable of producing the effects that are seen. This conclusion has
come primarily from animal research, where exposure to smoking, diet, and other
drugs in the developing fetus can be experimentally controlled. A number of animal
studies have shown that alcohol itself is capable of producing symptoms that closely
resemble those seen in the fetal alcohol syndrome in humans.
Since its original description in 1973, the existence of the fetal alcohol syndrome
has been verified by a large number of medical studies. While the disorder seems
to be limited to children of chronic alcoholic women, not all chronic alcoholic women
have children with fetal alcohol syndrome. In fact, only a minority do. Several recent
studies have found that 26-33% of the children born to chronic alcoholic women
show evidence of the fetal alcohol syndrome. In no case has the syndrome been found
in children of non alcoholic women or in children of women who used alcohol
moderately. The disorder apparently does not develop in children of alcoholic men
(unless their wives also happen to be alcoholic), since it involves the direct action
of alcohol on the fetus of the pregnant woman.”
123
CHILDREN OF ALCOHOLICS
Value additions place
— Additional information
Fetal alcohol syndrome*
The fetal alcohol syndrome is a disorder that affects the infant whose mother had
been taking alcohol excessively during pregnancy.
■Tn pregnancy, the de.leopr.g
receives from its; mother s bloo^str^h^efs \mnortant for proper growth and
number of substances from tie
however a placental barrier prevents
development of the fetus. At the same t
’
crossingPmto the fetal bloodstream
“7aS\"htd\»ei:pme„t of the fetus. Unfortunately, the barrier
hnot successful in keeping all such chemicals away.
Chemicals crossing the placental barner can^have
the same effect that the chemical has on th mother
sedation and calming m the mother, it wi p
-
pXin'A—b'
behavioural functioning of the child.
effects^o
bMh lh'
duces
in the fetus
chemical is in the
8trUC“re and
. armft,i effects
Originally researchers thought the de^el^
not the case,
of alcohol by the placental barner. No
k^
circulatory system
Alcohol readily crosses the placental b
alcohol has an
shortly after the mother begins drinkl^0 her^body'In addition, we have recently
intoxicating effect, just as it does in the immh
b d* has the ^ability of altering
“X ferns. If Is one of rhe mosr clesHy
recognised.
----------- ------------------V^Cc^^TaSScsT Hs'zdden Public.^.
.
122
AND DRUG DEPENDENCY
— They feel responsible for so much because the people around them feel responsible
for so little.
- The children of alcoholics are pathetic victims of alcoholism. They do not drink
80
th'
~ ™d“otfusion “kt?"8 S,r"8gli”® d'W«ly to Set away from .heir hurt
“mfOr'’Cat'- “>““^‘1 "b»e X
psyXologie^
'to?
CHILDREN OF ALCOHOLICS
121
But none qf thesQ>things ever happend - They were ail only Lies. The declaration
next morning would always be ‘I will do it later, not now!’.
The ‘later’ never came, therefore, the message to this child is, ‘forget it — do not
believe anyone — do not trust anybody!’.
Don’t Feel
These children do not have a model to identify feelings. Parents suppress their
feelings, and cease to discuss them and the children have no opportunity to develop
an adequate vocabulary of ‘feeling words’ to describe their emotions.
There is no model whatsoever for appropriate emotional expression, and there is
an implied negative judgement on the feelings themselves. Often, as the tension
increases at home, the implied judgement becomes overt. Children are instructed
not to talk about their fathers’ drinking and not to talk about its problems and
consequences. Direct reprimands for expression of feelings are also common.
These reproofs are always preceded by an emotional eruption and they serve not
only to restrict the expression of the child’s feelings, but also to label the feelings
wrong, inappropriate and destructive. Initially, the child learns that expressing feeling
is wrong. The child eventually ends up believing that feelings itself are wrong.
John joyfully said,
I have got the highest marks in English. My teacher was very happy!’.
The already upset, confused, grief-stricken mother showed no sign of happiness.
She did not acknowledge his efforts or performance. Instead, she shouted,
You are unaware of the struggle I am going through because of your
'blessed' father. Do I have any time at all to think about you, your school or
your exams?"
The child instinctively learns that he cannot share his feelings with either his alcoholic
lather or his tired mother.
The child also learns that an expression of feelings will be met with disapproval,
ostility, or rejection. In order to avoid'what can only be viewed as punishment
the child learns to suppress his feelings.
We must remember that the alcoholism syndrome produces only particular kinds
of behaviours, and not particular kinds of people.
The childien of alcoholics get so absorbed in other people’s problems, that they
do not have the time to identify or solve their own.
— They care so deeply, and often so destructively, about the problems of people
surrounding them, that they always forget how to care about themselves.
..u..
120
I
ALCOHOLISM AND DRUG'DEPENDENCY
Meena’s Eng/ish Exams were the following day. When she was' about to go
to sleep, her father entered the house thoroughly intoxicated.'He had been run
over by a cycle and was injured.
Meena s mother was upset and started shouting at her drunken husband.
Meena was panic-stricken. She immediately cleaned her father’s wound, fed
him and put him to sleep. She sat up the whole night attending to her father’s
ne next day her eyes were red, swollen and droopy. When she entered school,
her best friend, Renu asked her,
'Meena! Are you not well? You look very dull and sickly today. What is wrong
with you?
b
Meena automatically replied, 'I am quite alright. I studied till midnight My
eyes are puffy because I didn’t sleep well. ’
She walked away desperately, even though in her heart of hearts she wanted
to cling to Renu, wanted to open out and say, ‘Oh! It is so terrible at home.
1 am not really sure what is wrong, but I know that something is drastically
wrong. Please . . . Please help me!’.
She wanted someone to understand without her having to tell them; but she knew
no one would.
Meena alone with her pain. She does not share her problems with anyone,
hough her memory is painful, she feels that sharing the real problem will be
worse. It will amount to letting her family down.
“I will not talk or disclose anything. Let me suffer my pain all alone. ”
Don’t Trust
Children of alcoholics never develop trust because the behaviour of their parents
is inconsistent and unpredictable. They always hear only lies and broken promises.
here is absolutely no visible model of trust. There is no comprehension of trust
as a value. On the other hand, trust is always seen as a trick or a trap.
The parents never provide physical, emotional or psychological support to their
cnildren. They never do what they promise to do.
All along, Rekha's father had made many promises.
(I will take you for a movie on Saturday!"
(I will buy you a new dress!"
‘Today I will come home early for dinner. We will all eat together!"
I will clear all your doubts in Physics today!"
3
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CHILDREN OF ALCOHOLICS
119
They learn that the expression of any feeling is wrong, and will be met with dis
approval, hostility, or rejection. In order to avoid this sort of punishment, they learn
to suppress their feelings.
They are often confused with being ‘well-adjusted’ in the real sense of the term or
being unaffected by the family chaos. The adoption of artificial behaviour is not
conducive to full emotional development, no matter how good it looks.
Such children when they grow up, become the victims of manipulation of people
around them. They cannot assert themselves even when aware of being manipulated.
They, therefore, get victimised in many ways at home, in their place of work and
in other social interactions.
The placating child
The ‘placator’ goes one step beyond the ‘adjuster’. He anticipates the problems of
others around him and tries to help them out, unmindful of getting hurt in the process.
This child is always busy taking care of everyone else’s emotional needs. The child
assists his brother in not feeling hurt or disappointed. This child intervenes and
ensures that none of the children are too frightened after a ‘screaming scene at home.
This is a warm, sensitive, listening, caring child who shows a tremendous capacity
to help others. For the placator, the essence of survival lies in taking away the fears, •
sadness and guilt of others.
Acting out child
Some children in alcoholic homes become very angry at a very early age. They are
confused and sacred, and they act out their confusion in ways that get them a lot
of negative attention. They normally get into trouble at home, school, and even wit
their neighbours. These kids keep shouting ‘there is something wrong everywhere .
These children ,ehd up as rebels, — show delinquent behaviour, throw temper
tantrums, and 4^P
from school.
Three unwritten laws in the home of alcoholics
The childrep of alcoholics are governed by three unwritten laws
—
—
—
Don’t Talk
Don’t Trust
Don’t Feel
Don’t Talk
These children never share or talk freely about anything which happens at home.
Any chaotic situation at home like shouting, crying, or even physical abuse will never
be discussed with friends, teachers, or relatives.
' rtn-n*
1 -
-
r
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ALCOHOLISM AND DRUG DEPENDENCY
118
I
I
Responsible child
the other siblings.
of achievements and accomplishments. But because these
not out of choice, but out of a necessity to survive, there is usually a pnce pa.d
r
this ‘early maturity’.
family and even looks after the father, when he comes back home dru
.
To an outsider, this child will seem to be
SJX fX“ wasHn8”s vomit, changing his soiled clothing, or carrying
h
XXX the nurturmg, help
legitimately deserve, they are tota y
.
f
d with being desperately needed,
is OT*“'d with
ty’“d
r
|
intimacy is confused with being smothere
Adjusting child
Sem^aS^.
The adjusting child finds it easier “““^^"“’^“atOTpt’to change, prevent
detatch themselves emotionally, physically and socially as muc
p
For example, .he child would have been
birthday. Later on, when the father m ■
situation. The child has learnt
'tta'thXXZmXeaee m the f.nuly is by responding to the instructions
of others without any questions.
3
•IWWS'-
0
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117
CHILDREN OF ALCOHOLICS
This feedback is normally negative and he internalises these messages. Sometimes
the child gets dual messages, one contradicting the other. He does not know which
part is true; so sometimes he picks up one part and sometimes the other.
No matter what the child does, it is not good enough. There is always .somebody to
find fault with him.. The child does not believe he is capable of doing anything right,
no matter how hard he tries. In short, he feels totally incapable, unworthy, and low.
'.Z/
\
Depression
A
'
It is a depression .arising out'of ‘deprivation’. Parental attention is never focussed
on the chili. It is always focussed elsewhere. There is actually nobody with whom
the child can share his problems. Even the non-alcoholic mother is often not available
or too exhausted and depressed to interact with him. The child suffers alone. He
learns that when he has a need, there will be nobody for him.
Not only is there the absence of someone to share his problems which is very vital
to a healthy childhood development, but also there is extreme anxiety caused when
he undertakes a task which requires skill, knowledge and experience much beyond
his ability. These children develop pseudo-maturity that covers the unmet but
undiminished needs of childhood.
The enormity of both the task and its results, the inability to change things, and an
unavoidably situation are the causes for chronic depression. This depression inevitably
leads to feelings of helplessness, self-pity, self-hatred, isolation and incompetence.
Fear
The children of alcoholics are often treated with the same cool formality and distance
with which adults treat each other. There are no cuddles and hugs and the child learns
to regard physical warmth with suspicion while simultaneously craving for it. Beneath
the mask of self-control, is a’lonely, frightened child, hungry for care, warmth and love.
Unable to cope with the enormous problems surrounding them and their family,
they are forced to take up certain roles which are either thrust on them, or voluntarily
assumed by them.
^Children raised in dysfunctional homes typically play one or more roles within the
family structure. These roles may be identified as The Responsible Child, The
Adjuster, The Placator and The Acting Out Child. With the adoption of each role,
there are invariably negative consequences. Most people easily recognise the strengths
of the first three roles, but fail to look at the deficits of each role.
Let us analyse how these children are thrust into adult roles.
* This classification of roles has been macle by Claudia Black who has been responsible for family
programming in 25 alcoholism-treatment centres in the U.S.A. She has done extensive research
on the children raised in dysfunctional families, and is a world-wide lecturer and trainer on the
subject of ‘Children of Alcoholics”.
!
116
ALCOHOLISM AND DRUG DEPENDENCY
he is unable to find anything to replace it with. He has not learnt any other method
of handling anger and he has rejected the only means he has learnt. So there is a gap
in the child’s behaviour. This gap inevitably gets filled by passivity and helplessness.
Lying
Children of alcoholics lie when it would be just as easy to tell the truth.
Lying is basic to the family system affected by alcoholism. It starts as a denial of
unpleasant realities, cover-ups, broken promises and inconsistencies.
Spouses of alcoholics live with lies and ultimately start telling them. They lie to cover
up alcoholism and protect the dignity of the family. Their lying is goal-oriented and
begins with a good intention. Lying becomes an adaptive response. The child hears
lots of promises from his alcoholic father. All these turn out to be lies. Therefore
the child learns that it is alright to tell lies. It will make his life much more comfortable
The value of truth totally loses all meaning.
If they are confronted with the truth, they become genuinely confused, both by the
disapproval and by the concept of truth. Their lying does not lead to any guilt because
they really see nothing wrong with lies. In fact, they are more likely to feel guilty
telling the truth it that truth affects someone important to them. The paradoxical
message creates only a contusion and not a desire for honesty.
Denial
Denial takes various forms — denial of problems leads to denial of the feelings
produced by those problems.
Honesty, when applied in traumatic situations, will often cause discomfort. Therefore
these children learn to minimise, discount, and rationalise for fear of the consequences
which are likely to follow if they tell the truth. Often when the child, tells the truth,
he is told that what he sees and reports is not accurate.
Your father is not drunk. Your father is only depressed. He is sick due to viral
fever.' ’
The parental rationalising and discounting serve as a perfect role model for the child
to begin his own rationalising, discounting and denial process.
The suppression of anger is used to avoid a fight; the suppression of hopes to avoid
disappointment; the suppression of affection to avoid rejection.
Loss of self-esteem
This child does not feel worthy. He has a very low self-esteem. In order to measure
se f-esteem, one needs the sense of ‘self. This child, unfortunately does not even
have one. He determines what he is by the inputs of the significant people around him.
I
4
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CHILDREN OF ALCOHOLICS
115
These children lose their identity — as a matter of fact, they never had an opportunity
to form one. They are subject to situational reinforcement and are always trying
to please people.
Children of alcoholics as a group, have a higher incidence of emotional problems
like anxiety, stress and depression. They also have lots of school problems — difficulty
in concentration, conduct problems, and truancy. They experience all sorts of
adjustment problems.
In addition to emotional and adjustment problems, severe medical disorders have
also been associated with the children of alcoholics — Fetal Alcohol Syndrome, Hyper
active Child Syndrome and a Predisposition to Alcoholism.
‘The Fetal AlcohobSyndrome’ is a disorder that sometimes occurs in babies born
to alcoholic mothers. It results in physical malformation and intellectual impairment
of the baby.
’ ‘
‘The Hyperactive Child Syndrome’ becomes noticeable when the child is about three
years old. It is-characterised by inattentiveness, lack of concentration, impulsiveness
and hyperactive behaviour. These children can easily be distracted and as a result
they experience problems at school.
Children of alcoholics show an increased predisposition to abuse of alcohol or other
drugs when they enter adulthood.
Problems faced by the children of alcoholics
Lack of Role-Model
No child is born with standards for evaluating behaviour, social skills or moral values.
They learn from what they see. In an alcoholic family, they see nothing but guilt,
justification, denial, aggression and repetitive negative behaviour. The child has no
other experience except possibly being scolded or getting beaten. There is no yard
stick to define any situation.
The alcoholic father is sometimes very loving and warm. He is everything one expects
a father to be — caring, interested, promising all the things that the child wants.
The child feels that he is being loved.
But at other times, the same father is entirely different. Those are the moments when
he is drunk. He does not come home at all; the child waits and is worried. When
he comes home, he picks up a quarrel and the child is scared. The child does not
know what to do. He is uncertain of what is going to happen next, and he feels
desperate. The father has forgotten all the promises he made. The child feels strange.
The behaviour of the father teaches the child that anger means violence and that
violence and love go together; the child has no opportunity to learn that only
tenderness and love go together. If the child rejects violence as a coping mechanism,
■
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11
CHILDREN OF ALCOHOLICS
Alcoholism is a family disease which affects not only the alcoholic, but also each
and every member of the family living with him. It affects the children with the
same intensity with which it affects the spouse, infact even more. Adults can choose
their spouses; so they have the option of leaving them. Children have neither the
choice nor the mobility to enter into or exit from the parent-child relationship While
the spouse feels trapped, the child is really trapped. The spouse is emotionally
helpless, whereas the child is emotionally and situationally helpless.
When does a child lose his childhood? — when he.lives with an alcoholic parent
lo others, he looks like any other child, dresses like any other child, and walks about
like any other child until they get close enough to notice that edge of sadness in
his eyes, or the worried look on his brow.
He behaves like a child - but he is not really enjoying; he just carries on. He does
not have the same spontaneity that other kids have. But nobody really notices it.
bven if they do, they probably do not understand it.
The fact remains that he never feels like a child. He has never known what a child
reels like. Any normal child is an innocent, beautiful, delicate being - bubbling
with energy, offering and receiving love easily; mischievous, playful, doing work
or approval or for reward, but always doing as little as necessary. The most important
tact is that he is always carefree.
In contrast, the child of an alcoholic is not a carefree little one — he is often a
withdrawn child who never gives trouble to anybody. He hides himself in a corner.
1 hough he does not really want to be hiding, he always instinctively hides in a shell,
hoping to be noticed sometime or the other. But he is powerless to do anvthinu
about it.
• / •
6
Children in families with alcoholism syndrome are generally ignored because all the
attention is directed either towards the alcoholic parent or towards his alcoholism .
1 he self-centred, uncooperative, destructive behaviour of the alcoholic collects in
totality all that the child longs for — attention. At the same tirhe,,the child learns
not to rock the boat, not to develop any desires or needs,- not to make demands.
hr?
PROBLEMS EXPERIENCED BY THE FAMILY
Behaviour/Feelings
Of the patient
113
Of the family member
15. Acute depression
Caused by excessive/ Due to loss, frustration and
inappropriate use of chemi- helplessness,
cals. (Consequence of the
toxic effects of the drug on
the central nervous system.)
16. Is a victim
Of chemical dependency.
Victimised
“by
the
chemical” even though she
is not using it.
SOMETHING WORTH PONDERING OVER
The chemically dependent person resorts to drugs to ‘numb’ his feelings and thereby
escape from problems and pains.
What about his family member?
She gets victimised by the chemical - but is left to suffer “all alone” because for
her there is no anaesthetising agent or “escape route!”
Who suffers more?
Who gets more deeply hurt?
Difficult to answer.... but
Worth pondering over.
Bibliography
1. James E Burgin, Guidebook for the family with Alcohol Problems, Hazelden
Publications, 1982.
2. Chemical dependency and recovery are a family affair, Johnson Institute,
Minnesota, USA, 1979.
3. Melody Beattie, Co-dependent no more, 1987.
4. Sharon Wegscheider, The family trap, 1976.
5. Mary M, Family Denial, Hazelden Publications, 1985.
6. Donald E Meeks, DSW - Alcoholism and the family, 1985.
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112
ALCOHOLISM AND DRUG DEPENDENCY
Behaviour/Feelings
7. Denial
Of the patient
Of the family member
Denies the
problem’
totally, or justifies his
misbehaviour by holding,
others responsible.
Totally denies -the ‘problem’
or denies the fact that some
problems in the family are
a result of her own irrespon
sible behaviour. Blames him
for every problem.
8. Guilt
At times, feels guilty about Wonders whether her
his <own behaviour and inadequacy is the reason
makes promises to change.. behind his abuse. ' / ?
9. Attempts to change Attempts to t out
Attempts to change her
dependency. (Though un behaviour; tries to display a
successful, he makes several caring, warm and affec
attempts)
tionate personality; but
does not succeed in main
taining it.
10. Avoiding social Abuses chemicals all alone; Stops meeting neighbours,
relationships
becomes totally withdrawn, relatives and even her own
and avoids society at large. parents.
Takes away money from his
pocket, so that he will not
be able to buy chemicals,
(Viewed by her own
children as stealing.)
11. Ethical breakdown
Begs, borrows or
or steals
(goes to any ' extent) to
maintain his supply of
chemicals.
12. Indefinable fear
Afraid that everyone around Afraid of even minor events;
is going to harm him experiences constant lur
(paranoia).
king fear, due to her inter
nalised emotional stress.
13. Low Self-worth
Feels unworthy and low.
14. Dishonesty
Utters all sorts of lies to Tells lies to cover up the
‘hide’ his chemical depen consequences of chemical
dency.
abuse. Utters lies even when
it is not at all necessary.
Lying becomes an adaptive
response.
Always feels inadequate —
very low self-esteem.
5'
■wt-sa.f.
FW
a
111
PROBLEMS EXPERIENCED BY THE FAMILY
Value additions place
—- Perceptive Findings
Chemical dependency is a disease which affects the family member with the same
intensity with which it affects the dependent person. How?
Behaviour/Feelings
Of the family member
Of the patient
1, Preoccupation
waits for the earliest oppor with the behaviour of the
dependent
tunity to use the chemical. chemically
“How can I slip away to person.
“My God! What is this
have a ‘quick one’?”
person going to do next?”
2. Loss of control
over the quantity, time and
place of chemical abuse.
3. Avoiding any talk
about the chemical
over her own responses and
behaviour.
diverts any talk pertaining gives> instructions even to
her children to keep che
to chemicals.
mical abuse a family secret.
‘use’
4. Justifying
Justifies his
chemicals.
5. Aggression
Verbal/physical abuse
6. Grandiosity
of Justifies her own irrespon
sible attitude towards the
family — holds the chemi
cally dependent person res
ponsible for each and every
problem in the family.
Throws tantrums — some
times anger becomes mis
placed. (Beats the children
for trivial mistakes com
mitted by them).
Talks ‘big’ about himself; Tries to maintain a permuch more sonality ‘too good to be
gives others
<------- ------true’, which is incompatible
than what he can afford.
with her abilities. Aims at
an ‘illusory perfection’.
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110
ALCOHOLISM AND DRUG DEPENDENCY
To conclude,
The chemically dependent person and his family are both hurt, and are facing a crisis.
Within the family, there is severe stress, negative feelings and growing problems.
The patient needs primary treatment for the disease of addiction and the family
members need treatment for their dysfunctional behavioural patterns. Treatment
methods may vary but the need for recognition, acceptance and understanding of
each member’s role in the family disease is absolutely necessary for full family
recovery.
Whatever time it takes, recovery is worth the effort. One point is worth repeating
— chemical dependency is a family problem and recovery, a family responsibility.’
i
ram
juum;-"
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PROBLEMS EXPERIENCED BY THE FAMILY
109
* Family members normally feel reluctant to give up all responsibilities. When the
chemically 'dependent {verson was abusing drugs, the entire household responsibility
centered round the wife or parent. She had all the power in hand. She would have
enjoyed'the appreciation of relatives and neighbours around regarding her ability
to manage . the hou§e^ in spite of the enormity of the problems.
★ Once the , patient starts recovering, he may start taking up many of the
responsibilities previously carried out by the family member, as a result of which
her importance is likely to come down. The wife or parent should anticipate this
sort of a change and learn to accept it. Apart from this, she should also take extra
efforts to involve the dependent person in all family activities.
II
* During the problematic period, there would have been a lack of proper
communication in the family system. There would have been only telegraphic
communications like “come and eat”, “go to sleep” etc. Also, during the period
of chemical abuse, the person would have been continuously talking to his wife
in the night, whereas in morning the wife would be continuously talking. In either
case, there would have been no listener. Two-way communication would never
have been there. Real issues like financial management, problems related to children
etc, which had previously been ignored should now be discussed. Two-way
communication is a must in the process of recovery. Addicts are likely to have
feelings of guilt even during their recovery period. Therefore, in the beginning
they may find it difficult to talk or communicate anything openly. It will help
a lot if the family member takes the initiative and initially makes an effort to
accept him and communicate with him. This will necessarily strengthen family
relationships.
* When the addict abstains from drugs, there will be an increase in his appetite.
He will like to have a variety of dishes. Formerly the wife would not have cooked
properly. She should change this attitude and concentrate on his physical needs.
She must take up the responsibility of making special dishes on occasions like
festivals, birthdays, etc.
* So far, no importance would have been given to household cleanliness. The wife
would have neglected her children, her house, and even herself. But now, she
has got to change her old ways of thinking and behaving and take up her
responsibilities and make her house a pleasant place to live.
* During recovery, the family may find it difficult to socialise. The family
member would have been so isolated, that she would have even forgotten as
to how to relate to others. It will help her if during the recovering period, she
learns to get back into society, attend family functions and get togethers
and communicate with friends and relatives. It will also help her if she attempts
to pursue old hobbies which she would have enjoyed before the problem of
addiction arose.
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108
ALCOHOLISM AND DRUG DEPENDENCY
The following are a few guidelines which may help the family members to avoid
facing problems during the recovery of the chemically dependent person:
* It is the responsibility of the chemically dependent person to stay away from drugs.
The family member who had all along been protecting him, should make conscious
efforts to refrain from taking responsibility for the consequences of his chemical
abuse. Staying away from drugs and keeping sobriety intact is his own responsibility.
To give an example, she should refrain from calling people and asking them not
to serve liquor; she need not threaten ‘old friends’ saying, “He has taken treatment.
If you force him to take drugs again, you will face dire consequences.”
* All along the addict would have been treated only as a child and never as an adult.
This is because he had never taken responsibility for anything, and would on many
occasions have really behaved like a child. Now the family members should make
conscious efforts to accept him as a responsible adult. Maturity automatically comes
with taking up responsibilities. If he is gradually allowed to manage small problems,
he will find himself competent enough to manage them. This will lead to his feeling
of self-worth. They should stop providing help wherever he can manage all by
himself. They should not protect him from facing minor problems.
!
I
* All along the family members would never have trusted the chemically dependent
person. Now during his recovery, they should take extra efforts and learn to trust
him gradually. They should build up and maintain a faith that he will be able
to carry out his responsibilities.
* Normally the family members expect that after treatment the addict will totally change
for the better. If this expectation is there, they will be disappointed. During the period
of chemical dependency, he might have developed many personality defects like
irresponsibility, dishonesty, and selfishness. Many of these defects are likely to con
tinue during the initial stages of abstinence also. An awareness of this will make it
easy for the family member to avoid impossible expectations. These defects will
gradually change with professional counselling, with sharing and with exposure to AA.
* Even though the patient has undergone treatment, the family should not expect
miracles to happen overnight. During the initial stages of recovery, he may have
difficulty in concentration, thought process impairment and skill impairments.
The family members should be aware of the problems he will be undergoing, and
should be prepared to accept these and give him a helping hand. If this is done,
he is likely to have a speedy recovery.
* The family members may experience a lingering fear all the time that the recovering
person may have a relapse. They may find it very difficult to ‘let go’ their fear.
As a result of this, they “take care” of the addict and try extra hard to retain
peace and avoid conflict. This attitude of the family members should necessarily
change. They should expect ups and downs during the recovery period, because
real sobriety or full recovery may take years.
I
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PROBLEMS EXPERIENCED BY THE FAMILY
107
— Not attempt to punish, threaten, bribe, preach or use emotional appeal.
Punishment: “I will stop cooking if you continue drinking.”
Bribe: “I will definitely clear all your debts if you stop smoking Ganja.”
Threat: “If you don’t stop taking brown sugar, I will commit suicide.”
Preach: “Your liver will be damaged and you will end up in a hospital if you
drink excessively like this.”
Emotional appeal: “If you love me and your father, you will not smoke ganja
again.”
— Not feel guilty if the behaviour of the chemically dependent person is
inappropriate.
Problems experienced by the family members during recovery
As chemical dependency develops into a family disease, virtually all the members
of the family need some kind of help to recover. If chemical dependency has existed
in the family over a long time, it is most likelv that all the members of the family
will be in need of some outside help in restoring themselves to a state of health and
happiness.
As already stated, in their efforts to protect themselves from the pain of the disease,
they would have developed their own emotionally insufficient ways of coping with
the problem. They would have already lost the battle.
If one member of the family makes efforts towards fundamental changes, it
automatically creates a tendency in the other member to also change considerably.
Addiction is a disease that has taken years to develop and therefore cannot be resolved
overnight, even with treatment. The family should be prepared for a long and
conscious process of recovery. Rather than reacting with despair or defeat, the family
members can help the addict to return to sobriety. Abstinence is the first step. During
subsequent recovery., the family members must adjust to each other on a new basis
in the course of which new problems may emerge. Roles and functions undertaken
by the wife all along, would have probably provided some satisfaction. But some
of these have to be necessarily given up.
Some problems experienced during chemical dependency may linger during the
recovery period also. Lack of communication, unsatisfactory sexual relation
ship, mismanagement of finances, or difficulty in maintaining discipline can no
longer be attributed to the stress caused by addiction or by the addicted indivi
dual. She should start “owning up” and accepting responsibility for some of
•the problems at home. Actually adjustment is initially difficult, but definitely
possible.
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106
ALCOHOLISM AND DRUG DEPENDENCY
— Try to accept the addict’s relapses with calmness and understanding, because
relapses are also a part of the disease.
— Accept the patient as a normal person and involve him in all the family activities.
— Share problems and feelings with someone you trust. This will help in ventilating
negative emotions.
— Understand that addiction is a progressive disease which requires professional
treatment. To do nothing about it, is the worst choice one can ever make.
I
In respect of some specific actions, you, as a family member SHOULD
— Not hide drugs or liquor. These methods will not work because the person will
definitely know several ways of getting his supply of chemicals. As a result of
this, you will only get frustrated.
— Not argue or quarrel with the person while he is under the influence df chemicals;
asking him reasons as to why he drank or took chemicals-doesmot help; he will
only be justifying his action by giving excuses. These are not likely to be true at all.
— Not justify his use of chemicals. If you try to justify his use of chemicals, he
will only continue taking drugs and not stop as you think. '
— Not allow the addict to take advantage of your vulnerability.
Given below is an example of the alcoholic’s manipulative behaviour.
Mithun was in need of money to buy alcohol; he chose the moment when there
were visitors at home and demanded money from his wife. He did this, knowing
that his wife would definitely give him money just to avoid an awkward situation.
He was right. She did give him the money and he walked away to the bar.
If you give in, it will only lead to the perpetuation of the disease.
— Not take up the responsibility of covering up the consequences arising out of
his inappropriate use of chemicals.
Kishore fs father got a letter from his son "s school stating that his academic
performance was going down and that he was absenting himselffor quite a number
of days. The father who knew about his son's abuse of ganja, immediately went
to the school and convinced the school authorities that his son was unwell and
that was the reason behind his absenteeism and poor performance.
This did not help at all because Kishore never realised his mistake. He knew that
there was always somebody to take responsibility for the consequences of his action.
He continued to take drugs.
— Not accept the promises given by the addict. Promises cannot be kept because
he has a disease which requires treatment.
I
1
PROBLEMS EXPERIENCED BY THE FAMILY
105
Even if there is a major crisis, her outward response will be minimal. Rewards for
being apathetic are manifested in the feelings of self-pity and safety which she
experiences. Actually she also seems to have developed an ‘I don’t care’ attitude.
While the apathetic person may appear to be calm, her behaviour does not quieten
the anxiety she experiences within herself.
This behaviour is often indicated in ways such as:
— separating oneself from others
— passive rejection of the family
— wishful thinking and day dreaming
The family member who is'apathetic allows the disease to progress. By refusing to
recognise the problems1 associated with addiction, she helps to maintain the illusion
that nothing is wrong with the family.
So far, we have dealt with in detail, the various behavioural responses and the different
roles adopted^by thefamily members. All these situations are a result of the family
not being able^ to recognise the fact that addiction is a disease. The counsellor should
appreciate the enormity of the probl em experienced by the family and educate them
towards implementing the desired behavioural changes.
Given below are some practical steps which will benefit the family immensely. The
treatment professional could effectively use them in educating the family. To make
it easy and convenient to use, the presentation is in direct narrative — as though
the counsellor is actually talking to the family.
You, as a family member should
— Realise that addiction is a disease — not a moral weakness, not a lack of willpower,
not a deliberate attempt at creating unpleasantness, not done intentionally or
wantonly.
— Accept it. This will, to a large extent, help in changing your attitude and approach
towards the person. Efforts can be initiated to show care, love and compassion.
This in turn, is likely to speed up his recovery.
— This acceptance will have to get ‘internalised’ steadily. Understanding or accepting
merely at the logical level will not be adequate. It must take place at the level
of feelings and actions. It may appear to be difficult initially, but it is achievable
through continued efforts.
— Try to remain calm and patient. This tip may appear rather unrealistic. But this
is not so. It can be achieved by adopting the following:
a) plan for one day at a time
b) never exaggerate or minimise the real consequences of any problem
— Realise that the disease of addiction has developed over a period of time. Recovery,
therefore, cannot “happen” overnight.
104
ALCOHOLISM AND DRUG DEPENDENCY
To protect herself from further emotional pain and to hide her feelings, she tahes
on a protective defensive behaviour. At the ‘JOHNSON INSTITUTE in
Minnesota, they list out three generalised categories of defensive behaviour which
an individual adopts in a stressful family situation:
— Being too good to be true
— Being rebellious and
— Being apathetic”
Being too good to be true is a defensive behaviour that is used to disguise the pain
of the individual. It gives an illusion that the family does not have any problems.
When she attempts to be too good, it is very apparent that she is looking tor
recognition in the family.
She keeps stretching her abilities to cope with the problems created by his abuse.
She manages the house, looks after the children, makes all the decisions, counsels
the addict and also earns for the family. She treats her husband like a child.
As she continues to do this, he starts thrusting more and more responsibilities on
her. A period comes when the chemically dependent person starts finding fault with
her if she does not properly manage any problem arising out of his inappropriate
use of chemicals. She is expected to take up responsibility for everything, whereas
he becomes less and less accountable for anything happening at home or outside.
;;
I
As a result, this family member shows behavioural patterns such as.
— Struggling for an illusory perfection; denying any mistakes committed
— Acknowledging family stress only at the thinking level; denying feelings associated
with stress
— Meeting everyone’s expectations; trying to keep everyone happy.
While this behaviour pattern looks admirable, it insulates the chemically dependent
person from having to experience harmful consequences arising out of his dependency.
Performing all the duties which the chemically dependent person actually ought to
be doing, only enables the addict to continue with his use of chemicals.
’
Being rebellious is another behaviour by which the family member diverts attention
from the primary family problem of dependency. Most often this rebellious person
draws negative attention — for example, when the addict shouts, she suddenly walks
out of the house without any proper plans, and never bothers to inform anybody.
She even calls the police and gets her son who is a ganja addict arrested. She hardly ever
bothers to think about the consequences of these actions. “Being rebellious is effec
tive in disguising pain, because such behaviour brings the focus of family attention
towards the rebellious person. Even though this is only negative attention, they adopt it.
Being apathetic is a defensive behaviour, which is very difficult to explain because
the individual happens to be a passive person who shows no emotions whatsoever.
The person quietly withdraws from stressful situations.
J
J
4
S‘
PROBLEMS EXPERIENCED BY THE FAMILY
103
For example, the spouse may find the dependent person having lots of debts. Instead
of making him realise and face the problems arising out of his irresponsibility, she
clears all his debts and makes all his payments just to avoid an awkward situation.
In this process, she takes on the role of an ideal wife who is able to manage everything
without any support. This, in turn, makes life easy for the chemically dependent
person. He continues with his abuse. She continues to protect him, support him,
apologise for his mistakes and find excuses for his drug abuse. She is not even aware
that it is this role adopted by her that enables him to continue with his irresponsible
behaviour and inappropriate use of chemicals.
Controller
The spouse makes all sorts of attempts to control the chemically dependent person’s
abuse. Some of the methods adopted by her are:
— asking him to drink at home
— pouring out liquor or hiding drugs
— accompanying him everywhere to control his accessibility to drugs
The more the spouse tries to control her husband, the less fruitful her efforts become.
With a vengeance, he starts abusing chemicals more and more and the situation
becomes worse.
Blamer
She desperately attempts to handle her increasing feelings of low self-esteem.
Unknowingly her feelings of failure get projected onto others in the form of fear
and anger. She instinctively feels that her husband is the reason behind all the family
problems. She coilceals her negative feelings about herself in typical ways.
Justification
: ‘ ‘I unnecessarily beat the children, because I am unable to ‘fix you’! ’ ’
I \
Direct Attack' : “If you are a man with a little bit of willpower, you would have
' stopped drinking long ago.”
Sarcasm
: “You are coming home at 10 O’clock at night. I am sure, your
boss would have retained you at the office as usual.”
Threat
: “I will throw you out of the house if you don’t stop taking brown
sugar”.
Loner
As chemical dependency progresses, the spouse/parent experiences inappropriate
mood swings. She goes into deep depression and indulges in hours of lonely crying
or violent outbursts of anger. These had been there earlier also, but now they are
triggered by even minor provocations. Her uncontrollable mood swings make her
feel that she is becoming insane.
ALCOHOLISM AND DRUG DEPENDENCY
102
Behavioural responses
The emotions described above lead to a set of behavioural responses to addiction.
The following are some of the instinctive but destructive behavioural patterns and
roles adopted by the family members with the honest intention of helping the addict
to get over his problem.
As fear increases, they experience a denial that is similar to the denial of the addict.
Family denial normally takes two shapes.
Family denial*
1. The family denies the existence of any problem whatsoever and gives excuses
such as “going through a stage” or “too much pressure”, etc.
2. The family acknowledges the problem, but emphatically declares that the problem
is limited to the dependent person. They believe that the chemically dependent
person has been responsible for each and every problem in the family.
They not only deny that their actions, behaviour and attitudes have been affected,
but also fail to see that the result is an environment that has lost its balance.
Denial is different from lying. It is an unconscious defence mechanism used without
conscious knowledge or thought, to control fear and anxiety.
x ~
The family members are often as reluctant to give up familiar attitudes and behaviour,
as the dependent person is to give up drugs. They share their fear of the unknown
and that is the principal component of family denial. Fear accompanied by defence,
serves as their survival technique.
\
'
Each family member becomes locked in a set of rigid survival defences and needs
help to become aware of these compulsive behavioural patterns.
At this point in time, reality intrudes. As the disease of addiction progresses and
becomes worse, the people who are significant to him realise that the problem can
no longer be denied or hidden, and that they must do something about it. So they
instinctively take on the following roles.
Protector
The spouse of the chemically dependent person is the primary ‘enabler’* who starts
with good intentions. She wants to show care and concern for the chemically
dependent person and wants to get him out of his problems; apart from the above
reasons, she wants to protect her own dignity. She takes on this role to bring down
her feelings of guilt and low self-esteem. She covers up the consequences arising
out of his inappropriate use of chemicals.
* Explained in detail in the chapter on “Denial”.
s
i
101
PROBLEMS EXPERIENCED BJ THE FAMILY
Shame
Mos. of .he painful experiences resul.mg
shame to the family members.
e.mapp P
tom
embarrassed As the situation in
X^Xlehande„ymembe.
of the family., <
. ■' -
thought leads to shame and hatred.
Fear
fear that nothing is going to become normal.
“What will happen to the family if things get worse?
In fact, she is deeply afraid °^ve^g ’^mfrutes hmfromTchool/she becomes
each individual family member experiences.
Loneliness
The stressful stauion in d.e chemxully dependem's
“t'h'
The ■soia,,°”crea,ed by “
of communication always leads to bitter loneliness.
behavioural patterns.
u
mHz
with a purpose;
The family members
talk qa lotlot, but
but thev
they never communicateThey
dQ not
sXS*—“ >—d“p,v
alone.
07127
O<ro
A'
100
if
AND DRUG dependency
Problems do not get resolved. Anger therefore does not subside. It continues to
bubble.
Their anger gets misplaced; they shout at their children. Suppression of anger leads
o physical problems like migraine headache, digestive disorder?, .etc.;
XcS ZndberS’ Hnger iS Often uhe result Of a meMal confllct •' Fam> members
forced to unde dePehnde,nt person’ but hate the painful experiences that they are
orced to undergo. They become caretakers’ with the-only purpose of keeping their
dignity intact and saving their own face. This caretaking attltS h norSXted
with any feeling of deep love at all. The painful experiences lead to anger towaJdl
the addict, and it is not at all easy to separate the dependency from the person The
fe feeds the alcoholic when he comes home totally drunk (caretaking) PMore often
the same wife feels that he should die so that her life can be peacefulZte)
Hurt
JeseZment and^urtt
icdciiuHcni ano nurt icelings.
" PerS°n’ 11 automatically ^sults in frustration,
5
Emotiona! pain can be very deep and destructive. As the harmful dependency
progresses, his inappropriate behaviour can no more be hidden. At every point the
family members eel humiliated. They are ashamed of the person ofZ shZefu
behaviour, and they cannot do anything about it. It hurts to become invoZ in
f07h“KZ,ZmpK °r"gry “Cto,geS- Noma“y ,he adtfa blam« tn™
“I am not asking you to stay with me. I don t need you at all! You can go
out of this house and get lost. I don’t care!”
Her immediate reaction will be
am not staying here for your sake. I am tolerating all these things only because
I realise I have a duty towards my family and my children. If I had been as
irresponsible as you, I would have left you long ago1”
SSSSSSSS'SE
“ sz±ep:x„The addict con,i"”s ™h his
PROBLEMS EXPERIENCED BY THE FAMILY
99
Such self blame produces more guilt and shame. Guilt of this proportion cannot
be sustained or tolerated. Therefore in the course of time, each starts blaming the
other, and this illusion prevents both the partners from developing self-awareness
which might lead to a positive change. Each is trapped in his or her own net — the
chemically deperidetit.person in dependency, the spouse in the equally familiar and
repetitive pattern of behaviour and attitude.
Grief
Grief is another emotional response of the family to addiction. The family has lost
the pleasures of life. It is not a total loss that can be confirmed by death and mourning
and a consequential healing. It is a chronic extended period of loss and anxiety with
no visible end. There is the mere physical presence which neither helps nor supports.
On the other hand, the presence itself creates unmanageable problems.
For the family members, grief is the result of all sorts of losses
loss of prestige,
loss of family and personal dignity, loss of feelings of love, loss of care and understanding, loss of security, loss of friends, loss of finances
loss in each and every
area of their life.
The most pathetic truth is that they do not share their feelings of grief with anyone.
They suffer each and every problem all alone.
Just like any bereaved person, they need someone to listen to them as they pour
out their grief; someone to understand that they are also victims of the disease;
someone to help them to shift their feelings from the dependent person towards their
own self. This is the only way which can help them overcome grief.
Anger
When they are not even heard, they experience anger and deep sadness. Initially
this anger is focussed towards the addict and his inappropriate behaviour.
“Everyone is laughing at us. We are not able to go out at all — it is all because
of you. Aren’t you ashamed of yourself? I wish you were dead!”
As the disease worsens, the wife or parents are unable to manage the enormous
problems any more. They do not know what to do. Their utter helplessness
makes them get more angry. Now their anger does not have any focus at all. 1 hey
are angry with themselves, with their husband even when he is not drinking, with
their children, friends, society — in short, their anger is directed towards the entire
world at large.
Even though the family members are extremely angry, they never let off steam.
Hostility lurks just below the surface, waiting for an opportunity to come out in
the open. Anger sometimes explodes, but the family member is not able to achieve
anything positive.
ALCOHOLISM AND DRUG DEPENDENCY
98
Codependency means being a partner in dependency. “Cpdeperidency is an
emotional, psychological, and behavioural condition that develops as a result of an
individual’s prolonged exposure to, and practice of, a set of oppressive rules -- rules
which prevent the open expression of feelings as well as the direct discussion of
personal and interpersonal problems.” (Robert Subby). “Codependency” is the term
used fo describe a person whose life is affected, as a result of her involvement with
the chemically dependent person. This codependent normally develops an unhealthy
pattern of coping with life. Even though she wants the addict to give up drugs totally,
she unconsciously takes up defective and destructive roles which strengthen his
chemical dependency.
Codependents are people who keep on reacting. They react to the problems, pains,
and behaviour of others. They react to their own problems and pains. They will
have to be guided to act rather than to react. They need a great deal of help to learn
to act.
As the problems around mount up, codependency leads to isolation, depression,
emotional/physical illness and suicidal attempts. Like any other repetitive behaviour,
it becomes habitual. Codependents keep repeating habits without thinking; and these
habits automatically take on a life of their own.
Let us now analyse the various responses and behavioural patterns of codependents.
Emotional responses
When a chemically dependent person gets into trouble and develops problems due
to the abuse of chemicals, his family is deeply concerned and gets upset.
Guilt
The emotional response to addictive illness in a family member frequently has its
roots in guilt feelings. Our culture often implies that if a person drinks too much,
or takes to addictive drugs, someone else is to be blamed.
Normally, the outside world blames the wife or parents.
e<Ram's wife is from a very nch family. She is arrogant and always tries to
boss over him. She does not care for him at all. No wonder Ram drinks a lot. "
e(I have never seen parents like these. They are very indulgent. They never cared
for their son. They put him in a hostel. Poor boy! That is why he is on drugs!"
Society’s attitude and outlook automatically lead to self-blame.
“Am I responsible for his drinking?"
“Am I inadequate?"
“Does he deserve a better wife?"
10
PROBLEMS EXPERIENCED BY THE FAMILY
Chemical dependency is not an isolated effect that affects only one individual. For
every case, there are multiple victims. Apart from the chemically dependent person,
the prime victims are his wife, parents and children.
Each family seems unique. Yet all of them have certain common traits and
characteristics. All families tend to react in patterned and predictable ways when
one member of the family becomes the victim of chemical dependency.
The working of the family is directly related to and influenced by the sickness of
the chemically dependent person. The members of any family operate in a system,
wherein they are interdependent and work together for survival and enjoyment. When
there is stress, the whole family readjusts and realigns itself in order to bring about
balance and stability.
The family of the chemically dependent person is a set of hurt, confused people.
They are victims of addiction who do not use chemicals, but are nevertheless
victimised by the drug. They are victims struggling desperately to solve their
problems.
“The chemically dependent partner numbs his feelings, and the non-abuser is doubled
over in pain — relieved only by anger and occasional fantasies , wrote Janet Geringer
Woititz.
T
The family members of the chemically dependent person suffer in the background
of the sick person. These people are rarely treated as individuals who need help.
They are rarely given a personalised recovery programme for their problems and
pain. The pathetic truth is that they are also desperately in need of proper help,
support and understanding.
These people who do not drink or take drugs but are victimised by chemical abuse,
are called codependents. Codependency is a normal reaction to the abnormal
behaviour of people around.
Chemical dependency means being physically and psychologically dependent on
alcohol or other drugs.
ADDICTION - THE ROLE OF PARENTS
131
+ Parents should learn to respect the feelings of their children. Often feelings
are expressed less directly but with enough cues so that a sensitive receiver
can pick them,up. The child should be given a feedback that he is being
listened to.
★ Since children tcn$ to adopt the behaviour and values of the parents it is very
important that parents always do what they expect their children to do. The
chances of children taking to drugs are more, if the parents themselves drink
alcohol or . smoke heavily.
Parents may ask the counsellors as to how they can find out if their children arc
addicted to chemical!;. Counsellors should educate parents regarding the changes
(physical and others) that indicate the use of chemicals. The following are the
indicators:
Recognising a chemically dependent child
Physical changes
— Reddening of eyes due to smoking cannabis
— Vacant look at times
— Puffiness under the eyes
— Slurred and unclear speech
— Unready movement
■j
— Poor eating habits
— Poor hygiene
— A number of injected t sites on the body
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Other changes
— Pool attendance tit schoul/college
— Sharp decline in academic performance
— Highly irritable
_ Hapny for sometime and angry’ the very next moment.
— Peculiar smell on breath and clothing
— Presence of candles, bent blackened spoon, silver foil, strange packets etc. at home
— Speeding long hours in the toilet
— Disappearance of articles from home
A point to be emphasised is that these changes should be seen repeatedly and over
a period of time. Parent:; should avoid coming to hasty conclusions based on wrong
judgement.
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ALCOHOLISM AND DRUG DEPENDENCY
c-
What should the parents do?
■
When a parent identifies that his child is an addict what are the immediate steps
to be taken.*'
H
The first step a parent should take is to ensure that his son is definitely taking drugs
ITus can be done by checking with the teacher about his attendance and performance.
It can also be done by talking to his friends and sharing a sense of concern about
possible unusual behaviour, apparent mood swings, money borrowed, etc.
If the fact is established, the parents would normally get terribly shocked, angry
and would immediately feel like punishing the child. The counsellor should tell the
parents that they would have to control these emotions and try to be:
r
★ Understanding
‘T am not blaming or comdemning you. I understand you have-a problem and
that you need help.”
★ Firm and supportive
t
This has affected your studies and health drastically. This cannot be continued.
You have to take treatment. All of us are here to help you in every possible way. ”
What should the parents not do?
— DO NOT talk harshly
‘‘You have always been giving me trouble. You never allow me to live in peace.”
— DO NOT tell the child that he is cheating
‘ All the while, we believed that you were studying. Your mother and I have
teen working hard only to provide you with good education. But you have
cheated us thoroughly.”
— DO NOT indulge in self-pity
” Why should this happen only to me? Why should I alone suffer so much, at
this age, when everyone else is relaxed and contented?’’
— DO NOT blarne yourself
“Aly sister warned me not to allow you to stay in the hostel. But I did not listen
to her advice. It is my fault.... only my fault.”
P1^TtS1S,h°Uld be made aware that if
do not adhere strictly to the above, th-ir
child will not accept help from them. This will make the problem more complex.
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F
£
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£
ADDICTION - THE ROLE OF PARENTS
133
With the drug problem assumirg such magnitude, prevention is largely in the hands
of the parents. A good parent — child relationship goes a long way in the prevention
of drug abuse.
■fc
Bibliography
r
r
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*
*
*
f
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1. Fine J Marvin, Parents Vs Children — Making the relationship work, Prentice
Hall, Inc, Eagiewood Cliffs, New Jersey, USA, 1978.
2. Lerman Saf, Parent Awareness Training — Positive Parenting for the 1980’s.
A & W Publishers Inc, New York, USA, 1980.
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13
TREATMENT
’The disease of addiction affects the * whole’ person - physically, mentally and
psychologically. Therefore, therapy for the addict should also address man in his
totalitv.
Addieuon-treaunent is not the responsibility of a single profession. People from
various disciplines work together in the common task of treating and rehabilitating
the acciict. Doctors, nurses, psychologists, social workers and recovered addicts are
the members of the therapeutic team, who have to work together in co-operation,
to achieve the best possible results.
Goals of treatment
In most of the treatment centres, the goal is, complete abstinence from drugs, in
any form and under any condition, for the rest of the patient’s life. This is coupled
with the goal of a change in life style, which will help in arresting the disease.
Currently, research is being conducted to determine if a return to social drinking
might be possible for some individuals. However, this is a highly debated and
controversial issue and no definite conclusions have been drawn so far.
Methods
Various methods, in different fields, have been implemented by various professionals.
These arc discussed below:
I
Treatment Methods
__.4—
Medical
managemeof
Psycho-social
management
Other
techniques
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135
TREATMENT
Medical management
Medical management becomes necessary to handle problems associated with drug
abuse. Medical help is given in the following ways:
— handling problems associated with overdose of drugs
— dealing with withdrawal symptoms
— administering medicines like antabuse or narcotic antagonists
Overdosage
Overdosage is the intake of chemicals in a quantity larger than that normally or safely
taken at one time. This usually leads to some adverse or toxic reactions, which can even
be fatal Frequently, overdosage or excessive consumption occurs in drugs like opiates
hvnnotic-sedatives or alcohol. These depress the central nervous system, and resu t
in pneumonia or heart failure^ Prompt and careful medical attenuon becomes essential.
WithdrawalDetoxification
Withdrawal results from physical dependence. The problems
ESSSSSSSk:
injury, poor nutrition, or fluid and electrolyte imbalance.
problems associated with addiction, are also given.
10 days, but may vary in individual cases.
This process normally takes about 3 -
Administering medicines
Disulfiram (Antabuse)
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136
1
alcoholism and drug dependency
Prolonged use of disulfiram produces side effects like metallic taste in the mouth
fat^ue^an^impote^ce36/3^0^5111 °f
drUgS’insomnia’ generalised weakness,’
atigue, and impotence. In rare cases, it induces psychosis. Most recently, there have
PrOd“CinS diSUlfiram ‘"’P1’"'-”"
W be
Narcotic Antagonists
Psychosocial management
\
.
Of d‘fferen'
.reaunen.
— individual counselling
— group therapy
— family therapy
— behavioural therapy
Individual counselling
T,ves ,ns,8ht-
«"■
peobtans nacre reabstMy and develop the ES
sSElSSSStxr
formoftreannentmerhodsfc^ptapy,' fanady djpyXSE
Individual counselling skills are discussed in detail in Chapter 18.
Group therapy
by
other patients rather than by the couSlor
Group therapy skills are discussed in detail in Chapter 24.
P eonfrontatron
i
treatment
137
Family therapy
simuitLeously T thVsfsX35 ThVueXTn^X^b11311
°f 3 famiJy
interpretive. The problem experienced hv n
V i?e SUpportJve’ directive or
disturbances in the other family members and I'"?°f 3 family may lead t0
and functioning.
V members and may affect interpersonal relationships
en?r',fami,y is brou^
■«
with past resentment, etc. Helping the farndv memb
deVel°pmg trust’ dealing
not only serves to improve family funcdoX bu a - h 7 “TT their intera^ons
person in maintaining abstinence.
S
he PS the chemically dependent
family situation.
g
the^specific treatment for chemical
abstlnence and a marked improvement
improvement in
in the
the
Behavioural therapy
attacking the symptoms rather rhnn
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-aT
g PV focusses”ond
t^era
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akernadve
<
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s
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op“™
seen as a behaviou? S funfc Se comXr’a^T' ““ °f, ChOTWs is
quent e,eMS (reinforcers). For exampk an indi S TT’ S'“nU'i and
his wife, feels tense, and 'the^foT^^ll^
with
after consuming alcohol. This acts as a reinfn
•
feels relaxed and light
This acts as a reinforcer for him m
f cer for him to consume alcohol,
tense, or faces a stressThus
r
whenever he ^els
various environmental events to engender absdnence8
" manage
functioning.
g
stinence, and to improve social
This section reviews some of the i.vtm deveiopmei
recent developments
of chemical dependency. .Three groups
of techniq in the behavioural treatment
[ues are differentiated:
1. techniques for abstinence
2. techniqu'es-for prevention of relapse
3. other techniques to help the patient improve overall fonetioning.
138
alcoholism and drug dependency
behavioural therapy
I
abstinence
A.™,.
conditioning
1
PREVENTION
OF RELAPSE
Coming^
Management
[Hospital]
Contingency
Management
[Family and
community]
Assertiveness
training
OTHERS
Relaxation
therapy
Bio-feed
back
Electro
sleep
Techniques for abstinence
Aversive conditioning
Punishment for drinkina
•
castes
are painful and are
" t0 the patient when he sips alcoh 1
method- Usually,
spitting
the alroSI0C'a“d Wi,h *• of al'ohol. The shock can be^Xd
naSt'
« adverse
e or adverse
"P“bs/b.rsonasteofchenrica.Xe™
• Here physically painful
Educing disulfiram reaction i- This is known
.
“another type of avcrsi„c... .
1 as the ‘challenge
test’
on iantabuse, ■ -so
that he
’
medical
—I supervision.
atauB are no.
Contingency management in a 1
hospital setting
s, f
. cutie interventions are based on n
appointments etc desirable beZXtr^ViX p510™’ tanedPa]tsXdu?arS Z
use the telephone or get food from the canteetf.
tQ'
dut for walks,
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TREATMENT
139
Techniques for prevention of relapse
t
Contingency management in the community and family
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This technique is based on social learning theory, and contains some separate
components designed to provide satisfaction that will continue to prevent/postpone
drug taking:
I
1. Placement in a steady and remunerative employment.
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2. Marital and/amily counselling to increase participation and derive pleasure from
family activities. K
3. Social clubs to provide support for abstinence during free time, and
1
4. Enhanceriieiit of activities such as hobbies and formal recreation to provide
alternatives- to chemical abuse.
Assertiveness training
Assertiveness training helps people overcome anxieties and inhibitions. It aids in
the development of greater interpersonal skills and more effective and spontaneous
social behaviour.
Assertiveness is an essential trait to be developed by the recovering patient, and this
plays a crucial role in both recovery and relapse prevention. This has been discussed
in detail in Chapter 26.
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Other behavioural therapy techniques
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Relaxation therapy
Relaxation therapy is a form of behavioural therapy wherein the patient is taught
to relax by demonstration of the opposing feelings of tension and relaxation. Many
chemically dependent individuals have difficulty relaxing during the early phase of
abstinence. They experience muscle tension, feelings of dysphoria and anxiety.
Relaxation helps them alleviate insomnia and other psychophysiological disorders.
This has been discussed at length in chapter 25.
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Biofeedback
Biofeedback focusses primarily on the direct modification of physiological responses
as opposed to cognitive or motoric responses. The eventual goal of these techniques
is to prevent or reduce the occursence of the unpleasant/negative physiological
responses. Biofeedback in treatment of chemical dependency is used to teach the
patient to bring about a relaxation response. In this method some means — such as
alpha waves from the electro encephalograph (EEG) or Galvanic Skin Response (GSR)
indicating perspiration — are used to provide the individual with some perceptible
“feedback” regarding the state of their body or brain waves. Since alpha waves or
a low GSR are associated with a state of relaxation, the individual is asked to relax.
ALCOHOLISM AND DRUG DEPENDENCY
140
Once a low GSR or alpha waves are produced, a perceptible ‘feed back’ stimulus
(such as a sound with specific tone) is produced. As the individual becomes less
relaxed, the sound or tone changes. Thus the patient ‘learns’ to get into a state of
relaxation.
*
Electrosleep
In this method low voltage electrical current is passed through the head (not high
voltage as used in ECT’s). It produces a state of relaxation, accompanied by a sense of
wellbeing or euphoria. It has been used to treat mild to moderate withdrawal symptoms.
Other techniques
Acupuncture
In recent years, patients have received this treatment. This method is more popular
in Asia. It has been applied for the acute phases of narcotic withdrawal. A wide variety
of acupuncture methods have been applied. Some of them consist only of placement
of needles without electrical current. Other approaches include placement of needless
in the ear or earlobes, followed by the passage of a low voltagje curtenV across the
head. Acupuncture technique can alleviate the agitation and paip.of withdrawal and
produce rapid sedative and even euphoric effects on .the patient.
However, tachycardia (increased heart rate), hyperventilation, and perspiration
continue despite the other clinical changes evident in the patient.
I
Comprehensive multi-disciplinary approach
A comprehensive treatment programme, implemented by a multi-disciplinary team
has been found to be most beneficial. We have discussed below in detail, the various
treatment facilities available in other parts of the world.
There are four broadly described phases in the treatment of addiction:
— Identification/Intervention
— Detoxification
— Rehabilitation
— After-care
Identification/Intervention
Identifying a chemically dependent person and motivating him to take treatment
are often carried out by a relative, a friend, a fellow employee, a supervisor, a doctor
or by school authorities. When the chemically dependent’s wife or parent brings
the person for treatment, it is called family intervention. Similarly, there may be
medical intervention, where the physician intervenes, discovers certain physical
damages in the individual indicative of drug abuse and refers him for treatment.
!>
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141
TREATMENT
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may be going through.
Information, assessment and referral services
After identification, they are brought
“ ag"TS^
located in industries providing EAP P ogramme wei
these centres relevant information inclu g h h
y
information? chemical
S other rZ^p^ems are diagnosed and referrals suggested.
Detoxification
Detoxification is a process wherein the toxicity of the drug in the body is removed.
This calls for an inpatient setting, with close medical supervision.
Detoxification Centres
The primary function of these institutions is to provide treatment servtces or
Jetoxificafion of patients who are experiencing withdrawal.
Detoxification centres are located in hospitals, emergency care services, etc
detoxification'for ^“f
. This period varies depending
treatment. Referral to appropriate
also made.
\ '
Rehabilitation
.
This phase aims ^t helping the: addict
friend! and
".hft S htpsle^n^ai:’posit.ve changes in his fife .y^
During this phase, the family of the addict “n’1»JX*“raVediLe, become
programme helps the family andTnen smn
need for making improvet£"s provided in different settings. These inchrde:
— Residential treatment facility
— Therapeutic community
— Out-patient programme
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ALCOHOLISM AND DRUG DEPENDENCY
Residential treatment facility
•
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*
These treauncnt centres provide an intensive structured programme of treatment
and rehabilitation wherein patients are given individual attention. These are done
in in-patient settings. The goals of this treatment are:
— to help the addict give up drugs totally for life
— to bring about positive changes in the patient’s behaviour and attitude, and thereby
enable him to lead a qualitative life.
X
tleranv3meth°ds adopted are indivldual counselling, group therapy, recreation
of AAP?1’ h peu ic commumty meetings, and relaxation techniques. The philosophy
of AA (i e„ powerlessness over alcohol and belief in a Higher Power) plays a significant
role in the treatment programme.
a^iuucdni
between ““uals and the group is utilised to reinforce and strengthen
Balanced diet and supplementary nutrition are providfd as
part of this Jerapy Patients are involved in therapeutic activities like cleaning the room
a€^”?"F^:’or,”ro,,eh“
personal
Therapeutic Community
swsssssss
J
individual psychotherapy or marital iherapyU“
rf
pharmoC0,0S“>l "^ents,
n’aiorbbehav,i0“tal a"d Psychological reorientation
in«dX^P« onhet/reSilira^n‘nTO,VK
fortong periods^' f™" 'herap"nic common,nes, pauerns may be required to stay
Out-patient programme
Sm a SXJ” SmTTh18'0'5' "“T “ reCeiV' "^cal/rehabilitation care
treatment
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NEW LIFE HOME
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SACRED HEART HOSPITAL
I
WTICORIN 628002.
Tamil nadu.
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TREATMENT
143
but need specialised treatment to come out of their chemical dependency and to make
adjustments to the problems they are likely to face during abstinence. Counsellors
prepare a social/psychological assessment of each patient and assign him to group
counselling^ses^i'ons that meet regularly — evening or night sessions for those who
are employed and day sessions for those unemployed. Individual counselling is also
included as part of the out-patient therapy programme. If a patient is found to be
drinking or taking drugs while attending the programme, he is transferred to the
in-patient programme, or if he is found to be difficult (uncooperative, irregular,
arriving intoxicated), he is discharged.
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After-care
I
This includes the package of services provided to the patient after successful discharge
from the programme. After-care activities can be viewed as the first line of defense
against return to drug use. The activities include attending self-help programmes
like NA/AA, regular follow-up at the treatment centre, staying at the half-way home, etc.
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Self-help groups
I
Self-help groups are voluntary, small group structures formed for mutual aid and
for the accomplishment of a special purpose. They are usually formed by peers who
have come together for mutual assistance in satisfying a common need — which may
be overcoming a common handicap or a life-disrupting problem or bringing about
a desired social and/or personal change, — through emotional support.
The most well known self-help groups associated with chemical dependency are:
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1. Alcoholics Anonymous for alcohol dependent patients (AA)
2. Narcotics Anonymous for drug dependent patients (NA)
3. Al-Anon for spouses or relatives of addicts
4. Al-Ateen for teenage children of addicts
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These are discussed in detail in Chapter 15.
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Half-way homes
This is a programme that attempts to combine the advantages of the residential
treatment with those of the ambulatory treatment. Patients live in a group, but are
permitted to leave the premises during the day and on week-ends. Problems are solved
through group interactions and community involvement. Members of this programme
would have already gone through a primary treatment.
The primary function of the institution is to provide, on a residential basis, support
and guidance to the patient to proceed towards the goal of independent living. These
patients require limited medical supervision but are in need of continued help to
tackle their alcohol/drug related problems. These centres provide supportive help
in the form of occupational, social and recreational activities.
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ALCOHOLISM AND DRUG DEPENDENCY
Patients who do not have a family or who are unmarried or divorced, or those prone
for relapse are recommended for this programme.
The treatment of chemical dependency involves considerable skill, patience,
understanding and experience. There is no known cure for chemical dependency.
The disease can only be arrested, and the chemical dependents are given guidelines
to lead a healthy and productive life without chemicals.
II
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145
TREATMENT
Value additions place
— Additional information
Phase
Goals
Methods
Settings
Phase I
Identiflcation/Intervention
* Problem definition
* Patients entering
treatment
★ Breaking of denial
Referral agency,
Employee Assistance
Programme, School
Welfare Agency,
Physician’s Office,
Criminal Justice
System, In-patient or
out-patient medical
and psychiatric
services
I
through empathetic,
non-judgemental,
supportive,
confrontation
* Individual therapy
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Phase II
* Helping the patient ★ Ingestion of medi
cines
td become drug free
Detoxifica- x
★ Nursing care
* Motivation coun
tion
A Counselling
selling towards
treatment and
rehabilitation
Phase III
Rehabili
tation
* Individual coun
□ For the patient
selling
and his family
* Re-educative
* Change in self
lectures
concept
★ Change in per
* Group therapy
★ Relaxation therapy
sonality traits
* Change in life style ★ Spiritual coun
selling
* Restoration of
physical health with
proper nutrition
Phase IV
After-care
* Prevention of
relapses
★ Reinforcement of
new patterns of
sober living
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* Same as Phase III
* Self-help groups
* After-care sessions
* Vocational rehabi
litation
Out-patient emer
gency care services,
in-patient hospital or
detox services.
In-patient, Out
patient, Day
programme
Out-patient clinics
Half-way homes
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146
ALCOHOLISM AND DRUG DEPENDENCY
— Implementation tool
A ‘model’ treatment programme
TTK Hospital/T T Ranganathan Clinical Research Foundation is a secular, non
profit, voluntary, welfare organisation, dedicated to the treatment and rehabilitation
of persons addicted to alcohol and drugs.
.
1
A comprehensive treatment facility covering both medical and psychological help
is provided by the hospital in the treatment of alcoholism and drug addiction.
Treatment at the TTK Hospital aims at:
★ total abstinence from alcohol and drugs for life
★ effecting positive changes in the behaviour and attitude of the individual to enhance
the quality of his life.
The treatment programme has been drawn up to offer the patient medical help and
psychological support that will enable him to recover from the disease of addiction.
Family members are also educated about the disease and are provided guidelines
to improve the quality of their life.
AK
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f", lla
WMg fl
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11(’
TREATMENT
147
The in-patient treatment programme at the TTK Hospital is a resrdential muludhciplinary therapeutic programme, conducted by a professional team of psychiatrists,
physK psychologists, social workers, resident counsellors and nursing staff. The
duration of the treatment programme is 4 to 6 weeks.
usage" of acute intoxication and chronic health problems associated with
addiction are dealt with during detoxification.
When the physical condition of the patient stabilises, he is. transferred to the
►
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psychological therapy wing.
The nsvchological therapy is also run as an in-patient programme. The patients have
a three week programme, each day structured with activities which include communi y
meetings, lecture classes, group therapy sessions, individual counselling sessions,
relaxation therapy, recreation and AA/NA meetings.
Since chemical dependency is a disease rha. affects the patient as well as his family
members, they are also given psychological support and treatmen .
Thp familv nroeramme is for two weeks and they also have a structured daily schedule
mduX cnXXmeeSgs, lecture classes, group therapy, counselhng, relaxatron
therap'y^XZeetmgs .Bre children of addicts are also green support durrng
I
this phase.
The topics included for the re-educative lecture sessions for patients are:
4
1. Drugs and their effects
2. Addiction — A disease
3. Denial
4. Emotional cost of dependency
5. Dry drunk behaviour
6. Problems in recovery
7. Sober living
8. Values
9. Self-esteem
10. Anger
11. Effective communication
12. Sex education
13. Coping with stress
Some of the topics discussed in group therapy are:
1. Damages - physical, sbcial, family, financial and educational
2. The worst ,dhig Taking episode
3. Blackouts and accidents
4. Grandiose behaviour' ;
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ALCOHOLISM AND DRUG DEPENDENCY
5. Loss of control
6. Insane and destructive behaviour
7. Preoccupation with drug taking
8. Powerlessness
9. Unsuccessful attempts to give up drugs
10. Denial
11. Violation of values
12. Problems in sobriety
13. Methods to remain sober
•i
The re-educative lectures for the family include:
1. Addiction — a disease
2. Roles taken up by family of addicts
3. Self-esteem
4. Understanding values
5. Effective communication
6. Problems in recovery
7. Children of addicts
8. Coping with anger
After the completion of this programme the patient is discharged and is encouraged
to attend after-care programmes.
After-care
After care programmes at the TTK Hospital offer a package of services for a period
of 5 years following discharge. They include follow-up counselling sessions, meeting
the doctor, and attending AA meetings. After-care is usually done on an out-patient
basis, since the focus is on personal re-entry into the community and coping with
the immediate problems associated with abstinence and recovery.
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Bibliography
1. Follmann Joseph F (Jr), Alcoholics and Business, American Management
Association, New York, 1976.
2. Pattison Mansell and Kaufman Edward(Eds), Encyclopedic - Handbook of
Alcoholism, Gardner Press, New York, 1982.
- .
3. Poley Wayne, Lea Gary, Vibe Gail, Alcoholism, — A treatment Manual, Gardner
Press, New York, 1980.
x
;
4. Mendelson Jack H and Mello Nancy K (Eds), The diaghosis and treatment of
Alcoholism. McGraw Hill Book Company,,USA, 198$.'
5. Westermeyer Joseph, Primer on Chemical Dependency — A clinical guide to
alcohol and drug problems, Williams and Wilkins Company, Batlimore, USA,
1976.
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14
RECOVERY
*
For a chemically, dependent person, recovery starts with abstaining from drinks,
or drugs. This abstinence should be total and for life. In addition, it should be
combined with a healthy adjustment of thoughts and feelings towards achieving
balance and harmony with'the living environment. Recovery denotes an orderly
arrangement-of tHer significant aspects of life.
'' ' '
' '' '
Recovery
-Physical recovery
-Psychological recovery
-Behavioural recovery
'■Social recovery
Recovery means learning to manage life better; it means learning to cope effectively
with financial problems; it means leading a ‘qualitative’ life.
It is therefore important that the recovering addict works out a daily structured
programme and executes it. He should have an effective programme which provides
guidelines for “effective thinking, reasoning, problem solving, regulating emotional
reactions, and structuring time and daily activities .
As part of a structured plan the chemically dependent person goes through clearly
defined, distinct phases of recovery. Each phase of recovery demands a specific plan
of action. Incompleteness of treatment in any phase — early, middle or late
will
automatically lead to a relapse.
Pre-treatment problems
i
In the period prior to the patient reporting for professional help, the chemically
to face any crisis
arising out of his improper
dependent person was not required
.
.r
use of chemicals all by himself. His employer, wife, parents; or somebody close to
him, was always there to cover iup
x the consequences and assume responsibility for
the problems created by his addiction.
---■-TTfr*!~!=
150
ALCOHOLISM AND DRUG DEPENDENCY
This enabled him to continue taking drugs or drinks. Once the employer, family
members or friends stopped covering up the consequences of his abuse of chemicals,
he was forced to face his chemical-related problems squarely — all by himself. He
could not manage the crisis. He k‘hit the bottom”. Following such a ‘motivational
crisis’ he sought help.
At this stage, people significant to him encouraged him to take treatment. They
intervened, and motivated him to seek help. Normally the people who intervene
are his employer (Occupational intervention), the family (Family intervention), or
the physican (Medical intervention).
Stabilisation (starting point of recovery)
This period starts with detoxification. It is followed by motivational counn?veh8nlnDUri?S thlS, pei;iod’ the Patient Sets gradually Stabilised-physically and
psychologically, so that he recognises the crisis and its prigin - namely his abuse
callvheS1Ca S'|HeiMS t° get completely stabilised neurologicahy and'psychologihe f norSd and h
8 eXperie?Ce1d due t0 deification may makeliim feel that
drug use
’
may Start
nklnS that h£ C3n attemPl c^trolled drinking/
diiaPattent altHiS Stage’ W°Uld nOt have
luired sufficient
have acc
acquired
sufficient knowledge
knowledge about
about the
the
disease to make decisions all by himself. He needs direction.
He may be confused and will be looking for answers. If he does not receive information
and guidance immediately, he will begin to create his own answers. In mos^ases
these answers are likely to be part of his original denial system. He may re-establish
and fixate upon his own rationalisation.
estaonsn
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7 >,mere'y Wi? 7 PnKeSS °fglV‘"g ade‘J“a" formation to
the patient. It actually begins with the attitude of the therapist.
The counsellor should provide positive support, reassurance, and encouragement
The patient should not feel that he is being judged or condemned As he comes to
revise that there are non-judgemental people, who are prepared to accept and believe
him, he will automatically start believing himself.
confused he will beo’* " to express his feelings. Even if he looks panicky and
mused, he will begin to take steps to stabilise himself. He will graduallv come
icalise that his thinking all along, has not been consistent wit/reality/
Apart from the patient, the family and the concerned people will also be unset
tightened, hurt and angry. So his family should also be part of the treatment and
recovery process. They should also be stabilised along with the patient
’1
151
RECOVERY
Early recovery
As soon as the initial stabilisation is achieved, an intensive diagnostic presentation
should be made, and the patient should be given all information about the disease
of chemical dependency and he should also be informed about the related problems
that are likely to persist even during recovery. If the family or employer intervention
had taken place earlier following a crisis, those events should be narrated to him,
repeatedly if required, during this period. This is because the chemically dependent
person is likely to have memory impairments and would by now have forgotten what
happened earlier. So, narrating these incidents again would help him to recall them
and become aware of the entire background with a certain degree of clarity.
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Middle recovery
The powerful impact of the diagnostic presentation made during the early rec°ve^
period should motivate him to decide without any hesitation to recover fully. It shodd
give him the conviction that his abnormal use of chemicals is the loot cause of a
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his problems.
Bv now, the patient should feel convinced that treatment is absolutely necessary
and that it isalso possible to recover fully. He can foresee and emotionally accept
the problems he is likely to face during recovery. The conflict between his mind
and emotions might have been resolved. He wd be convinced that recovery is worth
the price. At this stage, he should be able to formulate a structured life plan all by
himself.
Unfortunatelv, many patients enter this phase of treatment without completing the
task of stabilisation and pre-treatment periods. As a resuk they are
with the demands of the middle recovery period. Even if they try haid, thej wil
definitely fail. They fail, not so much because they do not want to recover, but more
due to the fact that they have not been prepared to enter this phase of recovery.
*
At this juncture, most of the counsellors blame the patient for his failure and confront
him in a non-supportive manner. As a result, in spite of the best of intentions,
Latment becomes unproductive. This sort of confrontation will either strengthen
the patient’s denial mechanism or make him merely comply without undergoing any
to
change in perception^of attitude.
s
Late recovery
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During this peripch the problems related to chemical abuse are identified, as distinct
from other life problems which are not related to chemical dependency. He would
also have developed a functionally independent personality which would enable him
to manage his problems better. He should also re-establish his spiritual values. His
attention should be drawn strongly towards a qualitative i e.
p/s-z Bo
07127 pOG
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152
I
alcoholism and drug dependency
Maintenance period
is that it creates a tendency tn'the'^chemi Jhy de°St i?POrtant aspect of tWs disease
old way of life, and the desire to use cheSs to radn
t0 g° back t0 his
Some of the aspects of this disease continue during he
frOm Problems.
can be maintained only if the natienr rem ■
u8 th recovery period also. Sobriety
for life and make a structured daily programme a
t0
aWay frOm chemicals
meet these needs will definitely lead to a Xpse
Failure t0
= ’Tucn.red pla„ based
should be informed abour he absomrn
counsellor.
absoll"c
'd “ S“k AA/NA f“
and he
of constant M„„ upPwi“
resources designed tome« tfelUd”tf £^10 a' d i''
j" s
“ "“J' °f
“'“na
of tre»tmenr
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X:
SXSo^
t
Factors that complicate recovery
° the,r
to recover. ’
-
'
complication
d
“"’Pbcate the normal recovery process
8'Ven
“ftment. appropriS
fo“”- comphc^X'xbhxM,,-v
°f the
Severe problems
- experienced during abstinence
Acute withdrawal
syndrome (AWS)
Recovery begins
AWS can manifesThsel™0™® '(k''""’1"1 fr°m the bodS'- D""'"K this period,
1- It is (
the form of trem
’,ws it!dfin
2. There is j
stress, elevation in blood
, - .ear of
to
Repioduced from Terence T c
i ■
-------- ■------------
H"1,d ** “ependenr P„“ tl.slX”
Pr=ve.,i„;
I
RECOVERY
153
The patient should be observed very carefully when he experiences either type of
AWS. In most cases, both medical and behavioural management become necessary.
The medication given should be addressed to the need to prevent the body from
over-reacting to the stress of being without the chemical.
Behavioural management consists of individual attention, talking about his pain and
anxiety, stress management exercises and reassurance.
Post acute withdrawal syndrome (PAW)
The major symptoms* of a.post acute withdrawal syndrome are thought process
impairments, emotional process impairment, short term memory impairment, stress
sensitivity and over-reaction to stress.
Normally the symptoms of ‘post acute withdrawal’ subside over a period of six months
to two years during which period the neurological healing takes place. Patients who
do not recover during this period require special individual, intensive treatment,
and extreme care should be taken to reduce the severity of their problems. Patients
should be made to understand that they should be prepared to spend time and make
an effort. They must be made to realise that their recovery demands a carefully
structured practical plan and its daily implementation.
Denial is a typical and common part of the disease; it subsides as the patient becomes
actively involved in treatment and a structured recovery programme. Severe denial
that does not respond to traditional treatment methods is not very common.
Denial, if extremely rigid and strong, may come in the way of recovery. Extremely
severe denial does not respond to common treatment methods. If such a rigid denial
is present, there is a possibility of the existence of other complications. So, special
efforts should be taken to diagnose and treat these complications. Otherwise the
patient will not recover and there is an increased risk of relapse.
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Strong craving may be triggered by accidental alcohol or drug ingestion. At times,
a patient may accidentally use a medication with an alcohol-based solvent for a
medication that contains a sedative or a narcotic. Such accidental ingestions lead
to a strong physical or psychological craving. Therefore every chemically dependent
person who comes for treatment should be educated to read the literature which
lists the ingredients before consuming anything; he should be structured to come
for help in case such an intake occurs.
Multiple drug dependency
Some patients use mood altering drugs along with alcohol. In such cases, specific
symptoms of alcoholism may not be present. When such patients abstain, strange
addiction-reactions occur. Withdrawal symptoms also become complex. Such multiple
addiction complicates the recovery process.
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* These are dealt with in detail in the chapter on ‘Relapse’.
154
Eb
__ ALCOHOLISM and drug dependency
^dJso^rbg re-educative treatmentd
■■
approPriately- During detoxification
concentrate^ ^oclls s'10u'd be ke^ o^Ph^c^emic^depeiidcnTs^'use'oTmuyd^e drugs^
In these cases, normal alcoholism treatment alone will not be effective.
Coexisting physical illnesses
high kveTof'stress.^f ^heml^l^detend^T0
che“ical^ePendency, produces,
like heart problems or diabetes he will
perSOn a s° su^ers from other diseases
the „o™.l treatme„? „r±“me I„ ,fl"b “ “'T' y diffiCult “ P’™iP«e ■»
recovery programme that can be im M
cases> the counsellor should design a
the coexisting .1”™
™Plemented along with the treatment needs of
■W--headache, etc,
extreme stress. If the coun^ lloZmesZ
W“hdrawal and ultimately lead to
guidelines about methods of pain redmrin
.^case’ he should be able to give
where specialised treatment along with tlie'^n ireCt the patient t0 sku?h clinics
dependency is given.
8
th th necessary treatment 'for chemical
Coexisting psychological and psychiatric disorders
develop along with chelTaf dtn^nVenl^
Sometimes'the disorders
after abstinence.
aePendency, and sometimes they develop immediately
Psychological disorders
Gambling, or belting on horses ar rhp
deviations which need attention
pr”“ 0“^“'“mpu,!ive Pathological
Adjustment disorders
disorder. Thi^wX exhXhbn^Senfs 'V676'?’ ” becomes an adjustment
or social dependence on the chemical is so
behavioural,
that area or unable to complete certain tasks withoumal^6 h Unable t0 function in
no matter how hard he tries otlieXeaSkS WIthout taklng that articular chemical,
able to do his job ^thThe^amrskillwiSh wdtich'h
drinking alcohol.
th
h
°f .recovery’ may n°t be
he used t0 do 11 before he started
area., of imp™ and they shoukl be hdped “ g^X
Fm “h -*■»
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S'
RECOVERY
155
If the counsellor is alert, he can identify the patient’s adjustment disorders that create
functional impairments and interfere with his ability to respond to treatment,
programme of retraining to overcome the specific dysfunction can be formulated
so that these impairments are rectified.
Sex problems
These include inability to perform, lack of interest in sex or total impotence. 1 hese
also require proper psychological treatment and reassurance.
Psychiatric disorders
If there is any severe psychiatric disorder, the patient will not respond typically dui ing
the stabilisation period. These responses should be noticed and carefully evaluate .
Depression (both endogenous and reactive) is the most commonly found ^sorder
that co-exists with chemical dependency. Anti-depressants may be included in the
treatment procedure.
Other problems like acute anxiety, indefinable fear, paranoia and suspicion are commonly
present. If they are unusually acute, attention should be focussed on these disorders ai
necessary medication should be given along with the treatment for chemical dependency.
Psychiatric treatment should go hand in hand with the multi-disciplinary treatment
for chemical dependency. The counsellor’s job is to consult the psychiatrist and
counsel the patient according to his particular needs.
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Crises situations
The death of a significant person, divorce, occupational problems, getting into a
new job marriage, or a family crisis can create a stress which will lead to a patient s
relapse.’it is difficulffor the patient to face these problems because he has all along
been using chemicals to cope with emotional problems. When a patient faces a major
crisis he may nee'd'sp&cial counselling - grief counselling, marital counselling, j
counXg, family counselling - and he should be supported and provided
stabilisation to maintain his. recovery without an unnecessary relapse.
To sum up,' - ’
Recovery from chemical dependency is a very active process which demands a daily,
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structured, implementable programme.
*
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Recovery is
* Totally refraining from mood-altering chemicals
* Getting out of neurological impairments, and organ system damages
better.
* Effecting positive changes in life style and learning to manage
i
„ problems
.
In short, it means,
LEARNING TO LIVE A QUALITATIVE LIFE AGAIN
hm im 111 iii 11
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156
Value additions place
I
— Implementation tool
Sober living
quX'a” TlVin8 aWay
'add,'“''e drUSS' '' 3150 m'anS ‘“■’“'“S lh'
rtddlC^°in njUSt,have aI1 a]onS been connected with many habits
some at the
thought-level and some others at the action-level. Now during sobriety, the chemicalk
dependent person has to develop new ways of thinking and acting.
JhemiXwill noT'rthe C0UnSe!1(,r ,t0 assure the P^ient that keeping away from
them cals will not turn out to be that uncomfortable, frightening or imnossiblen «.ll really be something he mU begot to eoioy and fmd eomfoit anZS !m
The following are few tips which can be given as guidelines to the chemicallv
dependent person towards leading a sober life. He can be reassured that these tins
be reassured
that these
tips
avt helped many recovering patients and he can also be certainly
benefited
by them.
Immediate plans to be implemented
- Staying away from the first drink/drug
qnanthy fi'wdl'tfi °r' i T
the dama«e’ One
^"P with a small
^bS'xd
chemical intake' '
nnpOrtant stcp 111 st;’vlI1S sober is to avoid the first
— 24 hour plan
o 1 x ro /"I
1
♦ 1
| i
sworn
of hts beloved
ones t ih
at
he would
never~ use rhe chemtcal again.C In
spireinothe
hisname
bS
mrenuons, he had never been abie io keep his promises. Ho would have in vhabl
gone back to obsessive chemical abuse.
mevitaoiy
("if Pl 1C*
ThrXrip?edee?willbhyen0W
t3Ught h? that lonS-term Pr°mises do not work.
successful and
implementable
if he
he says,
NOT
«"u™r|
“^P
‘-»«ble if
am
RECOVERY
157
No matter whahthe provocation or temptation, he can still be determined not to
take the chemical — ONLY FOR THAT DAY.
If the desire to use the chemical is very strong, the 24 hours can further be broken
down to smaller durations. For instance, he can decide not to use it for one hour
one more hour
and so on.
Recovery from chemical dependency always starts with one sober hour.
— Postponing the use of chemicals
An uncontrollable craving may occur all of a sudden. At that time, the decision to
postpone the use of chemicals may help. Once the idea becomes a part of the chemically
dependent person’s thinking, he will find this an effective way to achieve sobriety.
— Remembering the last episode of his chemical dependency
When the idea of using the chemical comes to mind, or if somebody offers a drug,
the addict should at once visualise the series of consequences that happened after
starting with a small quantity of the chemical. He should think down to the last
repulsive episode connected with his chemical dependency.
Miseries associated with chemical dependency — losing one’s job, torn family
relationship, financial damages — every detail should be recalled.
If he remembers the last repulsive stage — not the first pleasurable experience, there
is a good chance that the thought of using the chemical will automatically disappear.
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Avoiding all mood changing chemicals
The recovering person is likely to experience sleep problems during abstinence.
Sleeping pills are no solution for a chemically dependent person. This is actually
a real threat to his sobriety. The dependent person is prone to addiction — whether
it is alcohol or any other mood altering drug. There is a great possibility that he
will get addicted to sleeping pills also.
A glass of hot milk, a warm shower, or deep breathing exercises are some of the
methods that can be tried to get over sleeplessness.
— Changing old routines
Certain places, people and time closely associated with chemical abuse should be
avoided. These are dangerous traps to sobriety. Many old routines have got to be
changed.
For example,
— a different route may be taken while going home from the office, if a drinking
place is on the way.
— avoiding parties or meeting friends where liquor or chemicals is likely to be served.
r
158
ALCOHOLISM AND DRUG DEPENDENCY
eating early in the evening and never being on an empty stomach.
— avoiding old friends who abuse chemicals.
— learning to say ‘no’ whenever chemicals of any type are served. One can definitely
be polite and assertive at the same time.
y
rL
— Eating habits
It has been found that any nourishing food or i
snack reduces the desire to drink or
take drugs. The most important thing is one should
never get too hungry. As
chemically dependent people are always undernourished
any nourishing food in their
stomach makes them feel physiologically better.
— Taking plenty of rest
.■xsr*"bKause ,he
GradUaUy
problems
b°dy WlU *et readiusted ^d all these
— Always staying with people
Chemical dependency is often referred u v
to as a lonely disease”. Therefore, during
recovery
if
an
addict
starts
feeling
lonely,
are likely to follow.
°
the °ld r0Utines and episodes of abuse
help M £iv' offm|oa„eun°essali1f'h,
or relatives will
Long term plans to be made
— Live and let live
for them
realise
he'has'r
make h™ feel frustrated, or induce him io 6„ back to chemical abuse
chS2d°ab"«<d”crlled hlm 10
ChBnica,!’ “ "° one
not
drl™ him back to
All along, the chemically depenoent ]
person had been blaming others for his
diug abuse. In sobriety, he should realise that
-- —: no one else shapes his life.
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159
RECOVERY
He should be made to feel that it is in his interest to plan out and enjoy his own
life fully and let others live any way they desire.
Staying sober leads to a bright new life. It is worth sacrificing any grudge or
resentment to LIVE.
— Getting active
Staying away from chemicals leaves a person with a lot of leisure time Simply
deciding not to take chemicals (without making any concrete activity plan) wil
not help. He needs new activity plans to fill these blank spaces and utilise his energy
which had been previously spent in preoccupation or obsession with his chemica
abuse.
While planning, one should make it implementable so that in the end he does not
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feel tired or exhausted.
The following are a few suggestions:
— taking a leisurely walk or going out with one’s wife, children or parents
— visiting AA/NA members and having long chats with them
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— visiting friends and relatives
— doing physipd exercise
— helping other'chemically dependent people by sharing personal experiences as
to how to stay sober, this is another way of strengthening one s own sobriety.
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— Anger ajid resentment
I
Hostility, anger, resentment —
a threat to sobriety.
I
all these are powerful negative emotions which pose
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solvent for these emotions.
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be tried.
tfXcaSnttfy tTeZsTo'f^ge-nd theZe whether anger"i'ju'tififd or not
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Modern life is filled with stress. Relaxation, reading and listening to soft music may
I
be tried.
) understand that it is afterall
The chemically dependent person should be made to
in to the first drink/drug.
his life that is at stake if he gets angry and gives i-
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160
A!^S2H0LISM AND drug dependency
f
Availing of a sponsor
i-' ■.
'ta ,|h' ChemKa"y dCpenden' p"»" has a
yK
Can caJJ on him whenever he is in need of support - even at night,
to XTSber.U^TiieV0?6?^^1’
C3n help S°lve one ProbIe™ ~ how
be willing to reach out and°help.PerSOni exPerience in recovery. He will always
I
S “upefc“”°£d tta oT “ CO?fOraMy’ ^PPiJy.
arid sleephedthily
to be sober wday K
SOb" yes,erda>’ and ^tdefinirely decide
I
fectlXeheSSmetdMcWs”’T'?5 °< re“vliry' T“ undisputed
of relapses, recover
f rT “I"’1’"1’ re,apSeS are “>“■^ite
determines to get back to life wit^ I ' & udemically dependent person strongly
put in efforts m makeX ve o X anyA. the same ttme he should
able to lead a quXtiXd ba^S it”e
““
“ ““ »' “
Bibliography
1.
— A.A.
2. Hou””)^IdXetX^uTiS"5''11"8
Pre™“-
f
*
1
15
SELF-HELP GROUPS*
Self-help groups are voluntary, small group structures formed by peers who come
together for mutual assistance in handling a life-disrupting problem. Thus in chemical
dependency, self-help groups have been organised by those having problems
associated with chemicals. Through mutual aid, members help one another to
maintain abstinence and also to bring about desired social/personal change, lhe
various self-help groups founded in the field of addiction are discussed in this chapter.
Alcoholics Anonymous
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In this group, members come together to assist each other to help themselves with
their drinking problems. This process is more personal and less directive, lhe
individual seeks support from the group, and is also encouraged to seek spiritual
help in the form of a personal conceptualization of a Higher Power or God, of one s
own understanding.
Preamble
Alcoholics Anonymous is a fellowship of men and women who share their experiences,
strength and hope with each other, so that they may solve their common problem
and help others to recover from alcoholism.
The only requirement for membership is a desire to stop drinking. There are no dues
or fees for AA membership. They are self-supporting through their own contributions.
AA is not allied with any sect, denomination, political organisation or institution, it
does not wish to engage in any controversy; neither does it endorse nor oppose any cause.
The primary purpose is to stay sober and to help other alcoholics to achieve sobriety.
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How did AA get started ?
Alcoholics Anonymous had its beginning in Akron, in 1935, when Bill. W., a New Yorker
who was successfully sober.for the first time in years, sought out another alcoholic.
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* This chapter has hepn reproduced from various books and pamphlets published by the respective
World Service Offices.
•aJiUtgTUr^ci
162
ALCOHOLISM AND DRUG DEPENDENCY
During his few months of sobriety, Bill. W had noticed that his desire to drink
lessened when he tried to help other ‘drunks’ to get sober. In Akron, he was directed
to a local doctor with a drinking problem. Working together, Bill. W and the doctor
found that their ability to stay sober seemed closely related to the amount of help
and encouragement they were able to give other alcoholics.
For four years, the new movement, nameless and without any organisation or
descriptive literature, grew slowly. Groups were establishing in Akron, New York,
Cleveland, and in a few other cities.
In 1939, with the publication of the book ‘Alssholics Anonymous’, from which the
dQnVed 1 uname’ and as a result of the helP of a number of non-alcoholic
friends, the Society began to attract national and international attention.
°riCre T °Pened ln NeW Y°rk City t0 handle the thousands of inquiries
and requests for literature that poured in each year.
The twelve traditions of AA
1. unityCOInmOn Welfare Sh°Uld COme first; PersonaI recovery depends upon AA
2. For our group purpose there is but one ultimate authority - a loving God as
™ntseTS?imSeIf " °Ur Sr°Up C°nScience- Our leaders
buf trusted
servants; they do not govern.
3. The only requirement for AA membership is a desire to stop drinking.
4. AA^?lSUld b£ autonomous excePf in matters affecting other groups or
Txzi do d wnoie.
5. Each group has but one primary purpose — to carry its message to the alcoholic
who still suffers.
6. AA groups ought never endorse, finance
us from our primary purpose.
7. Every AA group ought to be fully self-supporting, declining outside contribution,
8. Alcoholics Anonymous should remain for
ever non-professional, but the service
centre may employ special workers.
9. AA as such ought never be organised, but we may create service boards or
committees directly responsible to those they serve.
10. AA has ino opinion on outside issues, hence the AA name ought never' be drawn
into public controversy.
11. As our public relations policy is based
12. Anonymity is the spiritual foundation of all our traditions ever reminding us
to place principles before personalities.
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163
SELF-HELP GROUPS
The twelve steps of recovery
■
1^
1. We admit we are powerless over alcohol — that our lives have become
unmanageable.
2 Come to believe that a power greater than ourselves can restore us to sanity.
3. Make a decision to turn our will and our lives over to the care of God as we
understand Him.
4. Make a searching and fearless moral inventory of ourselves.
human being the exact nature of
5. Admit to God/to ourselves, and to another
<—
our wrongs/ .' v
6. Are entirely ready to have God remove all the defects of character.
7. Humbly ask Him to remove our shortcomings.
8. Make.adist of all persons we have harmed, and become willing to make amends
to them all.
9. Make direct amends to such people wherever possible, except when to do so
will injure them or others.
10. Continue to take personal inventory and when we are wrong promptly admit it.
11 Seek through prayer and meditation to improve our conscious contactWlth
a^eSrsund Hta, prayer only for knowledge of hrs wrll for us and the
power to carry it out.
12 Have a spiritual awakening as a result of these steps, we try to carry this message
to alcoholics, and to practice these principles in all our affaris.
Within this framework of human support and spirituality, the above mentioned
12 steps guide the individual to:
- Work towards knowledge and acceptance
of self and powerlessness over
- Examine and attempt to correct personal defects that might contribute to alcoholic
- RriX'rce the recovery process by carrying the message to other acutely ill alcoholic
persons seeking help.
The AA sponsor
simply a sober alcoholic who helps the newcomer solve one probl
stay sober’.
176
ALCOHOLISM AND DRUG DEPENDENCY
and leads from there into a change of behaviour and a change in life structure that
interferes with the maintenance of the ongoing recovery- programme. The initial
change can also be an external event that forces a patient to alter his daily structure
and thus increases stress and triggers an internal change of attitude.
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Elevated Stress
Change produces stress to which alcoholics are apt to overreact and lor which they
may have low tolerance.
Denial Reactivation
As stress levels are elevated and become critical, there is a normal tendency to deny
the presence of the excessive stress and to reinitiate the denial mechanisms that
accompany the disease. When the alcoholic begins using denial patterns to deal with
stress, similar to the denial used to deal with the acceptance of alcoholism, other
associated thought processes are triggered.
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Post Acute Withdrawal (PAW)
Elevated stress intensifies the symptoms of PAW. As these symptoms — thought
processes, emotional processes, and memory problems intensify, stress levels are
elevated even further (which increases the severity of PAW).
Behaviour Change
As a result of the developing symptoms of PAW, reactivation of denial and chronic
elevated stress, the patient begins to act differently. He still goes to the same places
and engages in the same activities, but his behaviour invites unnecessary stress and
sets the stage for a future crisis.
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Social Breakdown
With a change in behaviour, there is a change in relationships. The alcoholic begins
to interact in a different way and there is a breakdown in the social structure.
Loss of Structure
Life structure begins to break down. Recovery plans are abandoned, routine and
daily habits are altered.
G
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Loss of Judgement
Lack of structure, lack of support systems and increasingly severe PAW lead to
confusion, disorder and the inability to solve problems or make decisions. The
alcoholic may be emotionally numb or may overreact emotionally.
Loss of Control
The next step is loss of control of thought processes and of behaviour. The person
does not make rational choices and is unable to interrupt or modify his actions.
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DRY DRUNK SYNDROME
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Option Reduction
He comes to believe that he is no longer in control of his life and believes that the
only alternatives available to him are insanity, physical or emotional collapse, suicide
or drinking.
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Acute Degeneration
He returns to drinking or drug use; he may develop stress-related illnesses, psychiatric
problems, emotional collapse or physical exhaustion; or he may attempt suicide or
become accident-prone.
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Bibliography
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1. R J Solberg, The Dry Drunk Syndrome, Hazelden Foundation, 1980.
2. Charles W Crewe, A Look at relapse, Hazelden Foundation, 1980.
3. R J Solberj,' Dry Drunk Revisited, Hazelden Foundation, 1980.
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.^SPHOy^ AND DRUG DEPENDENCY
Skills/techniques of counselling
be^CaSZeCd"'
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C°U”SellinB Pr0“S" 1WrfOre>
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The mam vehicle through which counselling takes place is communication. Therefore
developing communication skills is very important for the counsellor.
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The three elements that comprise communication between two individuals are:
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1. listening
2. processing
3. feedback
COMMUNICATION SKILLS
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Processing
Listening
Feedback
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Attending
Attitudes,
Beliefs,
Knowledge
Categorisation
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Paraphrasing
Reflection of
feelings
Summarising
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Listening is defined as jreceiving messages from a client by focussing attention on
what the client is expressing both verbally and non
-verbally. Attending is a
demonstration of concern and interest in the client.
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Processmg is the complex series of events that takes place within the counsellor
data Telirfs I1.Steni?g.and resP°nding to the client. It may include mentally cataloguing
judgement aS^rformalce
Categorization
^tor that influences
;hh:
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ved from listening to the client.
PROCESSING
COUNSELLOR
Listening, Attending
CLIENT
FEEDBACK
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BASIC COUNSELLING TECHNIQUES
Feedback skills can be broken down into the following:
Paraphrasing: A counsellor’s statement that mirrors the client’s statement in exact
or similar wording.
Client:
My boss doesn't understand me at all. He doesn't realise. I
am always shaky in the morning.
Counsellor:
Mornings are a tough time for you.
Reflection of feelings: The essence of the client’s feelings, either stated or implied,
as expressed by the counsellors.
Client:
I didn't want to come here. There is nothing wrong with me.
I only came to see you because my wife insisted.
Counsellor:
You do not seem too happy about coming here.
OR
I get the impression you are annoyed.
Summarising
This is a brief review of the main points discussed in the session to ensure continuity
in a focusseckdirection. This should be done at the beginning and at the end of each
session. In the beginning, .the client is asked to summarise the previous session and
at the end, the counsellor summarises the main points of the current session.
Researchers in this field have broadly outlined skills specific to the different processes
in counselling',’ but these may overlap and can be used in other processes also.
Skills for data collection
Skills for identification and
understanding of a problem
Skills for problem-solving
— All interviewing skills, psychological tests.
— Probing, interpreting, confrontation.
— Processing skills, interpreting, counsellor’s
self disclosure.
Some of the communication skills have already been discussed. The others mentioned
above will be briefly discussed below.
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Psychological tests: Psychological
tests; are standardised tools to obtain a more
scientific "assessment of an individual’s psychological characteristics such as
intelligence, aptitude, interests, personality etc.
The counsellor should be familiar with the diagnostic and personality tests, used
in the field of chemical dependency. The interpretation of the test scores should
be carefully explained to the client.
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ALCOHOLISM AND DRUG DEPENDENCY
Probing
A counsellor’s response that directs the client’s attention inward to help both parties
examine the client’s situation in greater depth.
Client:
I have been doing this job for years now and nobody ev^r complained
before. Now they are saying my job performance has not been as
good.
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Counsellor: In what ways do they specifically say your work has not been good?
Interpreting
Presenting the client with alternative ways of looking at his situation. Used effectively,
interpreting should assist the client to realise that there is more than one way of
viewing most situations thereby helping him to apply this kind of unrestricted thinking
to all aspects of his life.
Counsellor’s self-disclosure
The counsellor’s sharing of his personal feelings, attitudes, opinions and experiences
for the client’s benefit.
Client:
You know, I feel so ashamed. All my friends are going to find
out that I have a problem with drinking and I really don’t
know how I am going, to face them.
Counsellor:
I understand how you feel, because I can remember how
ashamed I felt, at first, when I had to admit to my friends
that my father was an alcoholic.
Confrontation
This refers to the counsellor’s statement or question intended to point out
contradictions in the client’s behaviour and statements — also used to induce the
client to face an issue the counsellor feels the client is avoiding.
Other skills
Contracting: Here, the responsibilities and goals of both the client and the counsellor
should be clarified either orally or in writing. It is necessary for all clients to
acknowledge what is expected of them and to articulate their own goals. A contract
should also include penalties for not fulfilling one’s part of the bargain. Penalties
must be issues that are valued by clients. Contracting helps prevent a situation in
which counselling ‘drifts aimlessly’.
Referral: Timely, prompt and appropriate referral to other professionals, community
resources, is essential in counselling. The counsellor should be aware of other services
available to help the client.
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BASIC COUNSELLING TECHNIQUES '
191
Record keeping: This aspect is usually forgotten or taken for granted, but it is a
skill of essential value which every counsellor has to develop. Prompt recording of
sessions, follow-up notes etc., are essential.
This helps the counsellor in quick reference, and it would help in situations when
there is a change of counsellor.
Planning individualised treatment: Here, the counsellor should learn to differentiate,
analyse, evaluate and synthesise a multitude of stimuli, communication and pieces
of information that emanate from the client, and then tailor intervention strategies.
To summarise, the following are the therapeutic responsibilities of a counsellor:
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□ Establishing and maintaining a healthy climate for counselling.
□ Taking note of the case history.
□ Preparing the necessary client reports.
□ Seeking consultation with other professionals whenever necessary.
□ Tailoring individual treatment plans.
□ Handling crises situations.
□ Explaining the nature of problems.
□ Helping clients establish contact with community services.
□ Involving/co-ordinating other resource persons in treatment.
□ Preparing after care activities for the client.
□ Evaluating the client’s progress, redefining goals if necessary.
Personal qualities of a counsellor
The expert, apart from having a thorough knowledge and perfect proficiency in skills,
should also possess the other specific qualities discussed below.
— A good listener: A counsellor needs to possess an inherent trait for being a good
listener. A counsellor should give up a fondness or ‘love for his own voice’.
— Empathy: Rogers defined empathy as ‘an ability to sense the client’s private world
as if it were your own, but without losing the ‘as if’ quality’.
— Patience: Patience implies the ability to maintain ,an equanimity during delays,
to remain undisturbed in the midst of obstacles, and to keep a non-complaining
calmness during the development of failures.
— Emotional Maturity calls for a well-balanced counsellor who does not get unduly
swayed.
— Genuineness: The ability to experience and share with the client, the feelings
which a counselling encounter arouses in the counsellor.
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ALCOHOLISM AND DRUG DEPENDENCY
- Flexibility: Effective counsellors should be able to adapt both their role and pace
according to the client’s needs and capacities.
P
“ wlXc'S.: AM,,V ”d ""'l,”8”ss “ *« a"y rel‘™ p™-
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Principles to follow in addiction counselling
depended is .
“i” :™“'y d'Pende”, Pe™" i!’ *■
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dependency
.s^x“‘ch affaK thp
- Never refer to the chemically dependent person as a ‘drunk’ or a ‘dope’
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“mpaSS1°” “d
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’ SEEShEEF-Help the client establish short term goals for recovery?'
Specific processes for addiction
These can be summarised as follows:
counselling
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BASIC COUNSELLING TECHNIQUES’
193
2. Explaining to the client and to his immediate relatives the role of chemicals and
the relevance of ‘dependency practices’ and their relation to the present and the
past difficulties. Assessment should be shared with the client and his family.
3. Explaining the concept of chemical dependency as a disease to the client, handling
denial, making realistic plans, and motivating him to maintain sobriety.
4. Helping clients resolve interpersonal and intrapersonal problems, in accordance
with the assessment initially made.
5. Helping the client make sobriety plans — both short-term and long-term. Short
term goals will be to handle the immediate environment that will influence his
maintenance of sobriety, and to formulate steps for relapse prevention. Long
term goals will be to help the client make efforts to attain a change in his life
style, personality characteristics and values, and plan aftercare measures and long
term follow up.
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ALCOHOLISM AND DRUG DEPENDENCY
Value additions place
— Diagnostic tools
WftM
Psychological tests
Multi-phasic questionnaire (MPQ)
^ventory^MMPI) * T'his^iTrdia"3'^/'j'”" ,he Mi"nes«a ““‘■i’Phasic
ir pr^4"“he,f0n0dZE°e gb“X “
diMrd“S'
paranoia, achiaophrenia, psyehopaIh8y (LsoerS),’hysS
“V trait, wiil be e0n!ited t0
haZ
Beck s scale for depression
L^aeiS d presZ0’““a'"1 ‘nberweenendogt™
signs and
dissatisfaction, guilt, self-dislike self harnn
Roscharch ink blot test
Wh“
i’
th'
sense of failure,
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RELAPSE DYNAMIC
195
Bibliography
&
1. Counselling alcoholic clients — a micro counselling approach to basic
communication skills, participant handbook, NIAAA, U S Department of Health
and Human Services, 1982.
2. Counsellor’s guide on problem drinking — report of the working party on
treatment, goals, National Council on Alcoholism, London, 1982.
3. Dave Indu, Basic Essentials of Counselling, Sterling Publishers Private Ltd, India
1983.
4. Jacobs R, Michael, Problems presented by Alcoholic clients — A handbook of
counselling strategies, Addiction Research Foundation, Toronto, 1981.
5. Prashantham B J5 Indian case studies in Therapeutic Counselling, Christian
Counselling Centre, Vellore, Tamil Nadu, India, 1978.
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INTERVIEWING SKILLS
An interview is a ‘conversation with
a purpose’. It is a counsellor’s fundamental
technique for both assessment and psychosocial
management.
ZwSZ"'Of
is communication. ~
—jn. The underlying philosophy
can ‘refrain from comnwricatiSh “ alWayS Occurrin& “ other word’s; no person
Communication can be:
Conscious: Communicate with one's ftdi knowledge, intention and understanding
s
greater impact.
Communicate without one's full awareness and understanding.
’
y 1116 non“Verbal part that ‘gets across’ with
In a counselling process, the
meretore r
it cantaLw SpeX tomm^tiom”8'’1'01 *IS
therapeutic ana
and therefore
f
About therapeutic communication
1. It should be a conscious, goal-oriented, planned process of interaction
' Saccording to the needs,
3. Purposes: Assist the client to
a) identify his needs
b) identify his strengths and resources
c; formulate a plan of action
d) focus on behaviour for problem resolution
e) recogmse progress, growth, effective coping skills.
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INTERVIEWING SKILLS
4. Pre-requisites:
a) purpose — an aim with which therapeutic communication should take place,
b) safety (confidentiality) — to maintain anonymity
c) belief in potential — belief that the client is capable of change.
d) agreement — between counsellor and client regarding their expectations
i.e.5 establishing a contract.
conducive
environment — includes the physical setting and the counsellor’s
e)
ability to convey Empathy, genuineness and respect.
Types of therapeutic communication
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Non-Verbal
(Attending)
* Eye contact
* Body posture
* Gestures
* Tone of voice
Verbal
* Paraphrasing
* Reflection of
feelings
★ Summarising
★ Questioning techniques
★ Imcomplete sentences
* Restatement
* Focusing
* Use of silence
* Interpreting
Supportive communication techniques
These are a collection of skills which form the foundation for all other skills, and
which create an atmosphere of support for the client and the process.
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Definition of attending
Attending implies a counsellor’s concern with all aspects of the client’s com
munication. It includes listening to the verbal content; hearing and observing the
verbal and non-verbal cues and the feelings that accompany the communication; and
then communicating to the client the fact that the counsellor is paying attention.
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Purposes of attending
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It encourages the client to continue expressing his feelings and ideas freely.
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It allows the client to explore ideas and feelings in his own way and thus provides
the client with an opportunity to direct the session.
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It can give the client a sense of responsibility for what happens in the session by
enabling him to direct the session.
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ALCOHOLISM AND DRUG DEPENDENCY
It helps the client relax and be comfortable in the counselling session.
It contributes to the client’s trust in the counsellor and sense of security.
It enables the counsellor to draw more accurate inferences about the client.
Components of attending
Effective attending has two components:
1. listening and observing
2. communicating to the client that listening and observing are going on
a'.
Guidelines for effective attending
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to communicate listening through frequent and varied eye contact and through
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 encouragements such as
‘um-hm-, ‘yes’ or repeating key words.
— to avoid talking very loudly
Verbal supportive techniques
Paraphrasing
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Paraphrasing is a ‘counsellor response’ that restates the content of the client’s previous
statement. Paraphrasing concentrates primarily on cognitive verbal cdptent, that is,
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.
Sometimes paraphrasing may involve simple repeating of the client’s own words,
perhaps emphasising one word in particular. More often, paraphrasing is, using words
that are similar to the client’s but fewer in number.
Purpose of paraphrasing
It communicates to the client that the counsellor understands or is trying to understand
what he is saying. It can thus be a good indicator of accurate verbal following.
It sharpens the client s meaning to have his words rephrased more concisely and
often leads the client to expand his discussion on the same subject.
It often clarifies the confusing content for both the counsellor and the client. Even
when paraphrasing is not accurate, it is useful because it encourages the client to
clarify his remarks.
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It can spotlight an issue by statng it more clearly in a few words, thus offering a
direction for the client’s subsequent remarks.
It enables the counsellor to verify his perceptions of the verbal content of the client’s
statements.
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INTERVIEWING SKILLS
199
The basic components of paraphrasing are:
1. To determine the basic message that is being expresed in the verbal content of
the client’s communciation and,
2. To rephrase the verbal content in similar but fewer words.
Reflection of feelings
Reflection of feelings is the counsellor’s expression of the essence of the client’s
feelings, either stated or implied. Here the focus is primarily on the emotional element
of the client’s communication, whether it is verbal or nonverbal. The counsellor
tries to perceive the emotional state or condition of the client and feed back a response
that demonstrates his understanding of this state. Reflection of feelmgs is an
empathetic response to the client’s emotional state or condition.
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The purpose of reflection of feelings
It conveys to the client that the counsellor understands or is trying to understand
what the client is experiencing and feeling. This empathy for the client usual y
reinforces the client’s willingness to express feelings to the counsellor.
It clarifies the client’s feelings and attitudes by mirroring them in a non-judgemental way.
It brings to the surface feelings of the client that may have been expressed only vaguely.
It gives the client the opportunity to recognise and accept his feelings as part of
himself. Sometimes the client may refer to ‘it’ or ‘them’ as the source of a problem,
when he means T was feeling angry’.
It verifies the counsellor’s perceptions of what the client is feeling. That is, it allows
the counsellor to check out with the client whether or not he is accurately reflecting
what the client is experiencing.
It can bring otft problem areas without the client feeling pushed.
Components of reflection of feelings
1. Identification — The counsellor must first identify the basic feeling(s) being
expressed verbally or non-verbally by the client.
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2. Formulation - The second component is to formulate a response that captures
the essence of the feeling expressed by the client.
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Summarising
‘Summarising’ is the tying together by the counsellor of the main points discussed
in a counselling session. Summarising can focus on both feelings and content. It
is appropriate after a discussion of a particualr topic within the session or as a review
at the end of the session of principal issues discussed. In either case, a summary
should be brief, to the point, and without new or added meanings.
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ALCOHOLISM AND DRUG DEPENDENCY
Purposes of summarising
It can ensure continuity in the direction of the session by providing a focus.
It can clarify a client’s meaning by having his scattered thoughts ^nd feelings pulled
together.
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It often encourages the client to explore an issue futher, once a central theme has
been identified.
It communicates to the client that the counsellor understands or is trying to understand
what the client is saying and feeling.
It enables the counsellor to verify his perceptions of the content and feelings discussed
or displayed by the client during the session. The cousellor can check out whether
he accurately attended and responded without changing the meanings expressed.
It can close discussions on a given topic, thus clearing the way for a new topic.
It provides a sense of movement and progress to the client by drawing several of
his thoughts and feelings into a common theme.
It can terminate a session in a logical way through a review of the major issues
discussed in the entire session.
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Components of summarising
1. Selection — the counsellor uses his judgment to select the key points discussed.
2. Tying together — the counsellor attempts to tie together these points and to feed
them back to the client in a more concise way.
Facilitative communication techniques
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Facilitative communication skills are used in conjunction with earlier skills and aim
to promote awareness, to help in problem solving and to enable growth.
Questioning
Questioning is a skill wherein the counsellor asks the client more details or points
to an issue to be discussed.
Questioning Technique
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Closed-Ended
Open-Ended
Probing
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INTERVIEWING SKILLS
201
Closed-ended questions
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Closed-ended questions are those which request specific information. They elicit
minimal client response characterised by short answers, usually of yes/no type. Closedended questions are effective in getting specific answers quickly. However, they are
‘counsellor centred’ and are not useful in building a rapport. So, if closed-ended
questions are used in succession and in large measure, the client can experience the
discomfort of being ‘interrogated’.
S
Open-ended questions
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Open-ended quetions, on the other hand outline the topic areas generally, without
dictating specific responses. These quetions cannot be answered with a ‘yes’, ‘no’
or ‘may be’. Open-ended questions are ‘client centered’ and encourage the client
to continue communication of thoughts and feelings. Open-ended questions cannot,
however, be effective without the client’s cooperation. If used beyond an optimal
level, it can result in rambling conversations and a lack of focus.
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Probing
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Probing is a counsellor’s use of question or statement to direct the client’s attention
inward to explore his situation in more depth. A probing question, sometimes called an
‘open-ended question’ requires more than a one-word (yes/no) answer from the client.
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Purposes of probing
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It can help focus the client’s attention on a feeling or content area.
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It may help the counsellor to understand better what the client is describing, by
giving him more information about the client’s situation. 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 or
feelings.
It directs the client’s attention to areas the counsellor thinks need attention.
The basic components of probing are:
1. To identify areas that the client has raised which need further exploration and
2. To phrase open-ended questions beginning with words such as what, where, when
or how.
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Cautions to be taken
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While employing the technique of questioning, the counsellor should be cautious
to avoid certain questions which raise doubts, create any uncertainty and are difficult
to answer. These are:
Rhetorical questions — questions that include the answer. Rhetorical questions can
effectively silence the client by communicating that they had better agree with you.
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ALCOHOLISM AND DRUG DEPENDENCY
Why questions - questions that begin with ‘why’ and call on the client to
immediately defend himself.
Either/or questions - those which offer (allow) two choices based on an assumption.
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Double questions - those questions which limit the client to two choices.
Bombarding (overloading) - the counsellor asks so many questions so quickly that
the client doesn’t have the opportunity to sort out thoughts and is not given a chance
to express himself.
When to use questions
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The counsellor can use questions when he doesn’t understand, can’t hear or wants
ended with a question.
When not to use questions
A counsellor should not use questions to establish authority. Moreover when the
counsellor does not intend to listen, a question should not be asked.
Additional brief facilitative techniques
Incomplete sentences: This is a skill wherein the beginning of a sentence is used
to encourage the client to continue after a pause (eJ. “And you feek ”)
’
Restatement: This is literally repeating the last word or few words the client has
said, to encourage continuance (e.g. “Feeling pretty angry
’’)
Focusing or refocusing: Pointing out or giving careful attention to the main theme
r|1 ee ing th^ the clieilt had been sharing before the diversion, (e.g. “You were
telling me about your first NA experience”).
Silence: Silence can be very powerful. It can be a time when things really have a
c^^10
’ °r f°r feeHngS t0 be really felL When combined with ‘attendipg’
cues, it can serve to encourage someone to continue sharing. It can allow the chent
to expedience the power of his own words.
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Interpreting
Interpreting is a technique used by the counsellor to present the client witH alternative
ways of looking at his situation.
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Purposes of interpreting
It helps the client realise that there is more than
one way of looking at most situations,
problems and solutions.
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INTERVIEWING SKILLS
203
It offers the client a role-model counsellor seeking alternative ways of viewing events
in life.
It can teach the client how to use self-interpretation to explore new points of view.
It can help the client understand his problems more clearly.
It often generates new and distinctive solutions to problems.
It may prompt the client to act more effectively when he offers solutions to problems.
It often enables the client to gain a better understanding of his underlying feeling
and how these might relate to verbal messages he has expressed.
Basic components of interpreting
— Determining and restating basic messages
•— Adding cohnSellor ideas for a new frame of reference
— ‘Checking out’ these ideas with the client
Whether the counsellor is-exactly on the target or not, the client is more likely to
reactyto.ah
interpretation openly if it is offered tentatively.
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Bibliography
1. Alcoholism Counselling, Core Curriculam, Trainers Manual, New York State
Division of Alcoholism and Alcohol Abuse, 1988.
2. Gary and Kathy Miller, Effective Communication, The effective communication
programme, Madras, India.
3. Counselling Alcoholic Clients — a microcounselling approach to basic
communication skills, Participant Handbook, US Department of Health and
Human Services, 1982.
4. Prashantham B J, Some aspects of the psychology of human relationships,
Christian Counselling Centre, Vellore, Tamil Nadu, India.
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PROFILE OF CHEMICAL DEPENDENTS
Drug dependents
While it is widely accepted that drug dependents can come from any walk of life,
mcidence seems higher in certain groups rather than in others. It is possible to-discern
just a few similarities among drug users. These are at their best only generalisations
and not the rule. Being aware of this, will make us more alert in identifying addiction
when dealing with groups with a high incidence of drug dependence.
Sex: The majority of drug dependents are males and the percentage-of females is
very low, though not negligible. While alcohol is more likely to be abused by men
a casual misuse of other depressants (e.g. valium) is more common among women’
Age: In contrast to alcoholics, most of the ganja and brown sugar dependents are
very^young — in their late teens or early twenties. The greatest risk of initiation
into illicit drug use is usually over by the mid 20’s. In a study of college students
in Bombay, the age of most drug users was found to be between 19 and 24 years.
Sedative hypnotic drugs are mostly abused by people in their 30’s and 40’s.
Education/occupation: Youngsters who try illicit drugs, usually have a prior history
of poor school performance and lack of motivation and initiative. Prevalence studies
conducted in India, showed that drug abuse was higher in students who lived away
from their families — in hostels etc.
^°feSS10nal: addict1ed
drugs (°ther than alcohol) physicians and other
health care professionals show higher rates of addiction. The easy accessibility of
narcotics and other potent drugs and the stress of the medical profession are probably
reasons behind such a high rate.
y
Economic status: Contrary to the common misconception that addiction is limited
o the elite class, drug addicts can come from any socio-economic background.
However, brown sugar addicts come mainly from the middle and higher socio
economic level. The prohibitive cost seems to be the factor behind such a
representation.
1.1..
PROFILE OF CHEMICAL DEPENDENTS
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205
Ganja being cheaper and more readily available, ganja dependents come from any
socio-economic level.
Abusers of medically prescribed drugs are mostly from the middle or high income
groups.
Types of drugs abused: Illegal drugs are more commonly abused by the younger
population. The use of legal drugs like alcohol almost always precedes the use of
illicit drugs.
Exposure, availability and price seem to be important factors in determining the
type of drug abused.
Prevalence studies conducted around a decade earlier, reported that alcohol and pain
killers were the most commonly used categories of drugs. Brown sugar did not even
find a mention in the study. Around 1% oi the students used cannabis. The drug
scene has changed considerably over the past five to six years, with brown sugar
and ganja being the commonly abused illicit diugs.
Teenage drug use: An adolescent’s choice of whether to try alcohol/drugs or not,
results from a complicated mix of feelings and values arising out of certain personal
and social factors. Curiosity and peer-pressure are the most common reasons behind
illicit drug use.
Recent research findings in the West point to the fact that a particular social structure
and behavioural patterns are predominant in those who try drugs It has been
concluded by experts, that no one personality trait is responsible for making a person
a drug dependent. A combination, however, may make him more prone to addiction.
1 The age when drugs are first used is a major pointer to serious drug abuse. The
younger the person when drugs are first used, the more serious will be his
involvement with drugs.
2. Immaturity and maladjustment seem to precede rather than follow drug use.
3. They often skip classes, have a low self-esteem and seem to suffer from a feeling
of alienation.
4. Greater susceptibility to peer influence, a certain amount of rebelliousness and
a need to display their non-conformity are usually noticed.
5. Drug-abusers seem tq go through a period of anticipatory socialisation —• that
is, they Stapr developing'attitudes favourable to use of drugs.
6. FarU’Uialdj; [Attitudes towards drug use and actual drug-taking behaviour among
his peers lead to his subsequent involvement with drugs.
7. Y mu users of legal or illegal drugs often lack a sense of positive involvement
..i,d uttachment to their family relationships. In one study of the family pattern
of male narcotic addicts, the presence of a dominant, over protective mother and
an indifferent, uninvolved father were identified.
— WJU
------ — ----------- ------ . -.
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ALCOHOLISM
AND DRUG DEPENDENCY
—i-------- -—---------- z---------------------------------------------------- —
--------- ----
Thus we see that it is possible to group some people based on a common history
and environment and predict whether they will use drugs or not.
ft
When drug use turns obsessive and chronic, changes in various facets of the person’s
life can be noticed.
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Physical appearance
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— Poor appetite and loss of weight
— Haggard look, dull and apathetic
— Poor personal hygiene and poor grooming
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— Wears ear rings, bracelets or chains with unusual pendents in an attempt to prove
his oneness with other drug users.
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Psychological state
— Interest in other leisure activities declines. Playing tennis, chess, or other hobbies
do not seem to interest him any longer.
— Becomes interested in rock music and other types of music that extol drug use.
Expresses and believes in myths connected with drugs. He may feel that drugs
increase creativity or that he is ‘real cool’ with drugs.
Value systems
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— Spiritual pursuits decline. Involvement in spiritual activities diminish.
— Tells lies frequently and may even cheat people to get money to buy drugs.
— May steal articles to pawn or sell. Initially these are things that will not be noticed
easily. Slowly even obvious pieces start disappearing.
— Some resort to ‘pushing’ or ‘peddling’ drugs to earn money to maintain their
supply of chemicals.
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Family relationships
— Dull, withdrawn. Prefers to spend time all alone.
— Communication with others is reduced and is secretive.
— Inexplicable mood shifts are noticed.
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Very irritable when questioned about his behaviour. Rebels against any kind of
discipline.
— Tells lies when asked about his whereabouts.
Excuses himself from family gatherings, outings etc.
— Makes increased demands for money (very noticeable, if ‘on brown sugar’)
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PROFILE OF CHEMICAL DEPENDENTS
207
Education
— Poor attendance at school/college
— Poor academic performance
— Spends little or no time with his books
Friendships
— Initially drug taking starts as a group behaviour. So the user looks for and finds
friends who take drugs regularly.
— Spends a lot of time with his new found ‘friends’. They may be school dropouts,
rebellious and generally not the kind of people one would like to have around.
Alcohol dependents
What is a typical alcoholic like?
Sex
The majority of alcoholics seen in the treatment centres and AA meetings are middle
aged men (35 — 45 years old). They seem to start their “social drinking” at the
age of twenty five, and continue drinking excessively for at least a period of ten years.
However, they come for treatment only after they get into the middle or chronic
stage of alcoholism. The incidence of female alcoholics is low, though not negligible.
Education/Occupation
Educational background does not seem to have any significance. From the illiterate
slum dweller tp a highly specialised professional, anyone can and does develop
alcoholism.
Alcoholics are found in all strata of society. Factory workers and people who are
subject to, physical labour (masons, other daily wage earners etc) are found to abuse
alcohol.' Senior1 executives and people on the sales job who are subject to tension
and stress also resort to the use of alcohol, in the course of time some of these
individuals end up as alcoholics.
Types of liquor abused
Most of the alcoholics seem to start their drinking experience with taking beverages
like beer; then proceed towards brandy, whisky, etc., and finally end up drinking
cheaper and more potent beverages like arrack. In short, they proceed from lighter
beverages to ‘hard liquor’.
When alcohol use turns inappropriate and excessive, changes in various facets of
his life can be noticed.
208
ALCOHOLISM AND DRUG DEPENDENCY
There are certain personality traits distinctly found in alcoholics. Nevertheless no
single characteristic or cluster of traits is common to all alcoholics.
The personality traits include:
— low frustration tolerance
— weak ego strength
— emotional immaturity
— impulsive
— inability to accept failures
— highly sensitive
These personality traits seem to precede and also follow alcoholism.
So far as the alcoholics are concerned, some generalisations can be made.
Physical appearance
— Haggard, week and sickly look
— Bloodshot eyes; bags under eyes
— Red nose
— Puffed face
— Pot belly
— Tremors
' '
-
. ’
> ’
..'
— Poor personal hygiene (Unshaven face; unclean dress).
Psychological state
— Totally denies that he has a problem with alcohol or gives excuses.
— Blames others for mistakes committed by him.
— Justifies his inappropriate behaviour.
Exhibits gradiosity — talks ‘big’ about himself or gives others much more than
what he can afford.
— Over sensitive even to minor criticism.
— Feels depressed.
Family relationships
— The majority of alcoholics stay with their family, even though their relationship
is absolutely strained.
— Some of them get separated off and on.
— Alienation from relatives.
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profile'o'f chemical dependents
209
— The alcoholic and his wife constantly fight with each other.
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— Has extramarital relationships.
— The alcoholic is apathetic and passive especially when he is required to take up
responsibilities.
— The wife plays the role of the husband.
— Verbal abuse and physical violence ensue.
Friendship
_ Stays away from ‘old’ non-drinking friends.
- Normally withdrawn and prefers to drink alone outside his house.
Value systems
— There is a total breakdown in ethical standards.
- In the chronic stage of alcoholism, he goes to any extent (begs, borrows or steals)
to maintain his supply of alcohol.
Society
— Becomes aggressive.
— Causes serious problems to others when he drives in a drunken state.
— Gets involved in legal fights.
— Displays anti-social behaviour.
Work place
— Frequent absenteeism.
— Marked deterioration in work performance.
— Has problems with inter-personal relationships.
_ Gets memos, suspension orders or is fired.
— Changes jobs frequently.
Financial
- Is a master at giving excuses and taking all sorts of loans from the office.
- Pawns wife’s jewellery to obtain his supply of alcohol.
_ Borrows money from friends and relatives.
— Sells off jewels, household articles and property if any.
— Is always in debt.
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ALCOHOLISM AND DRUG DEPENDENCY
These changes by themselves do not indicate chemical dependency,'However, if a
combination of these is repeatedly seen over a period of time, addiction to alcohol
or drugs can be identified as the cause.
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Bibliography
1. D Mohan, H S Sethi, E Tongue, Current Research in Drug Abuse in India,
Gemini Printers, Delhi, 1980.
2. Patricia Jones-Witters, Weldon Witters Drugs and Society — a biological
perspective, Wadsworth Health Sciences, California 1983.
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PROFILE OF CHEMICAL DEPENDENTS
209
!
— The alcoholic and his wife constantly fight with each other.
4
— Has extramarital relationships.
— The alcoholic is apathetic and passive especially when he is required to take up
responsibilities.
— The wife.plays the role-bf the husband.
— Verbal abuse-and physical violence ensue.
Friendship
— Stays away from ‘old1 non-drinking friends.
_ Normally withdrawn and prefers to drink alone outside his house.
Value systems
— There is a total breakdown in ethical standards.
— In the chronic stage of alcoholism, he goes to any extent (begs, borrows or steals)
to maintain his supply of alcohol.
Society
— Becomes aggressive.
— Causes serious problems to others when he drives in a drunken state.
— Gets involved in legal fights.
— Displays anti-social behaviour.
Work place
— Frequent absenteeism.
— Marked deterioration in work performance.
— Has problems with inter-personal relationships.
— Gets memos, suspension orders or is fired.
— Changes jobs frequently.
Financial
— Is a master at giving excuses and taking all sorts of loans from the office.
— Pawns wife’s jewellery to obtain his supply of alcohol.
— Borrows money from friends and relatives.
— Sells off jewels, household articles and property if any.
— Is always in debt.
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ALCOHOLISM AND DRUG DEPENDENCY
These changes by themselves do not indicate chemical dependency. However, if a
combination of these is repeatedly seen over a period of time, addiction to alcohol
or drugs can be identified as the cause.
h
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Bibliography
1. D Mohan, H S Sethi, E Tongue, Current Research in Drug Abuse in India,
Gemini Printers, Delhi, 1980.
2. Patricia Jones-Witters, Weldon Witters Drugs and Society — a biological
perspective, Wadsworth Health Sciences, California 1983.
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21
MOTIVATING THE CLIENT
Motivation is one of the key issues in the treatment of chemically dependent people
and it is the first phase of therapeutic treatment. ‘Motivation can be defined as the
desire to change one’s own dysfunctional behaviour. In this context, it may be said
to include the following:
— giving up drugs
— desire to make changes in one’s life style
— realisation that it is essential to take an active part in the treatment programme
— willingness to make adjustments in order to recover.
The motivation of a client can be assessed, based on the following factors:
— Accepting that there is, a-problem with chemicals
— Asking for help for the' same
— Reporting for treatment without coercion
— Compliance with the terms laid down by the treatment centre
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— A past histdry'of abstinence
— Interhal'-locus of control (i.e.) a desire to get better for one’s own sake.
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Chemical dependents generally come for treatment only when they are left to face
some crisis all by themselves - loss of job, marital dissolution or legal threat. When
the client meets the counsellor for the first time, he will have a very low motivation.
He will not admit, under any circumstances, that he has a prob em with chemic s
Initially, the client will focus attention on his immediate problems like his loss of
job, separation from his wife, etc. The most important thing is that ihe counsellor
should show understanding and reassure the client that his problems will be looked
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into.
It is not advisable to try and make him understand that chemical dependency is his
real problem because the client, at this juncture, will be experiencing severe stress,
arising out of acute fear - fear of withdrawal, fear about the kind of treatment he
is going to be given, fear about others coming to know about his problem, etc.
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212
-------------- ALCOHOLISM AND_DRUG dependency
■ Ww ™ / so.ng u face lhe physml prMems aaKtaKd
s
wiMrmai>,,
k.„d Of„eatmm m ,hey emg K sm mt> __ Opcmjm?
“How am I going t0 face my <oldfriends and nezgflb()urs,?„-
for'S*Sb" XSS5"S SZpaTby””“dmi"ingh‘S
should start talking to hiiTabout h^obvatte?U°n ,On cheftlical dependency, he
of appetite, and noticeable weakness He'shod^81
pr°blemsIllke ^mors, loss
damages which are obviously seen. ’
concentrate onJy on the physical
recover^^^
in various centres, and failed to
have tried (though unsuccessfully) to sr^ ™
o minimal. He would already
have expe„e„eed8probleXS, ed S.hHe
patients at the treatment centre and mi
Meeting other recovering
help him overcome his anxie^v The r
ln? a out ^ls internalised fear will also
fear they had during ad ™
and XT"8 Pa,‘e",S Wi" ,alk ab<>m th'
IS possible.
mission, and give him reassurance that a safe withdrawal
area’’ which is a sensitive
area that has^Tbe^denS
to his verbal and non-verbal communication. ” ,UdgementaJ llstentng - listening
fe“““ "y
“ W «/>»
mmei
-y ^me upsas my dmehttr
S ta,k about
hls
fore™. t0 estabbah a ^irive
acceptance of the addicted cliem’ will in turn hT’ ^^^dgemental attitude, his
fos prob,etna free,, the tnere
hBi=
-nt His modvaho„
tned and found to be usefoi to enhane^at^.stoS™ ,1’<’dS b*™ b“”
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MOTIVATING THE'CLIENT
213
Verbalisation
feedback of the damages caused by chemical dependency in the
different afeas oChis life can now be addressed. This can be done in individual
counselling' sessions.
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Participation in group therapy and interaction with other chemically dependent
clients who have abstained for quite sometime, will give him the reassurance that
he is not ‘alone’. He will come to realise that others had the same or similar problems
and that they are able to lead a better life without the chemical. He will be reassured
that abstinence is possible.
Video presentations have been tried abroad and found to be very effective. This
involves a video recording of the patient’s behaviour under intoxication and replaying
it to him when he is sober. This method is a little expensive, and therefore not being
tried in India.
The client should be encouraged to read materials which give comprehensive
information about the disease of chemical dependency. An open discussion of the
successful recovery of other patients may foster additional optimism in the client
who has had a history of prior treatment failures, or who is doubtful about the
successful outcome of treatment.
Another method which is used for motivating the client, is involving individuals
whom the client holds in high esteem. Their involvement in the treatment process
will increase the motivation of the individual. Friends or employers who are genuinely
interested in his wellbeing may prove to be strong sources of support.
The technique of inducing fear and coercion has also been used. Diagnostic tools
like blood reports, CT scans, and X-rays with a proper explanation from a medical
professional will make him realise the physical damages caused by his chemical
dependency. However, this technique has to be adopted with extreme caution.
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There may be chemically dependent people who do not respond to any of the above
stated motivational procedures. For them, the emotional acceptance of the fact will
take a very long time. The counsellor may be challenged by them again and again.
The strength of his ‘acceptance’ will be tested on numerous occasions. Instead of
rejecting the clients or confronting them with logic and argument, the counsellor
should reassure them that they are always there to help and support them and that
they are welcome at any point, if only they decide to take treatment.
To conclude, acceptance of treatment by itself does not mean that motivation is strong.
Constant follow up and contact with the professional is necessary to sustain motivation
which in turn will lead to a commitment to recover.
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Bibliography
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Jacobs, R Michael, Problems presented by Alcoholic Clients — A handbook of
counselling strategies, Addiction Research Foundation, Toronto, 1981.
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22
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CASE-HISTORY TAKING
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needs and resources as well as his weaknesses, stresses, problems or danger areas
of a
pla”'and is an o"g‘“n^°“ss
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Interviewing the chemically dependent
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As assessment interview of a dependent can be conducted in the treatment centre
home, school, college, workspot etc. The counsellor should take this interview as
an opportunity to plan what kind of intervention or treatment might be most
appropriate and effective.
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How to conduct the interview will vary depending on whether or not the person
eing interviewed admits he has a chemical dependency problem. In either case
the chemical dependent will often play down his problems and may try to get rejected
by the counsellor, the very person to whom he has come for help. L the other haTd
hi. abuse exploits may occasionally be exaggerated out of bravado' 'Given an
and”6"'
Y 3nd understanding> ^emical dependents t^nd to be honest
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dependentTrharbeen
fo^d
reaS thJir difficX
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threatening
ProsPect for' the chemically
COnVey t0 the cllent that counsellors do
!
ahse their difficulty in talking freely about dependence. Here, the counsellor
can emphasise that talking about the problem is the Way to get help Beainnine
„he„ the chent perceive, diecemfen and proceeding8^'?hereTS
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Zhqenmhnt u CedS
that 111 am prOviding information not to a computer but
o another human being who is sensitive to my needs, respectful of my concern for
Siodd7be to^hones?my
f°r Change” Assurances given by the counsellor
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215
CASE-HISTORY TAKING
Chemical dependents are often quite fragile from the psychological point of view,
and ftrus^have set up so many defences that it is easy to underest,mate ho» troubled
they really are. The counsellor should be aware of these.
Rejections
Chemical dependents may want to be rejected by the counsellor, or may find reasons
2hvXv Should re ect the counsellor so that they have ample justification to leave
the interview and carry on their substance abuse. The defences used in rejection
fall into several categories.
You are no good, you don’t know anything. At the interview, chemical dependents
often test out their counsellor. Thus, to establish a good rapport with clients it has
been found that the discussion of the following issues evokes empat y
p ysic
effects (withdrawal), physical damages, life style, etc.
■V
c nncrl vnn are as bad as me. Counsellors should be prepared to face
X’S ”»•■S.Vu“’S'“L iheft cliems. A„ hones, reply is probably rhebesr.
v... .re no eood vou can’t cure me! In many instances, the chemical dependents
can be positive, reassuring and give direct advice here.
Denial
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7
A defence mechanism which occurs at the unconscious level, wherein the client
attempts to play down his troubles and problems.
This has been extensively discussed in Chapter 8.
Components of case -history taking
Before beginning the assessment
be elicited. These include:
interview, it is worth deciding what exactly is to
also make records complete.
2. Details about drinking, first drink, drinking status,
°f “mpU1'
Sion and a brief note on central nervous system sequelae of drinking.
3. Details about drug taking including type of drugs and pattern of use.
4. Psycho social damages of drinking/drug taking covering psychiatric problems,
drunken driving, arrests, accidents.
5. A detailed history of family origin including family history of mental illness,
alcoholism, drug dependence.
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216
ALC.OHOLISM and drug dependency
6.
With employers.
’
’
f,ob satisfaction, problems if any
Y’
8. Details regarding financial status.
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9. Marital history, details
nature-.of marital relationship,
^lationship wilh
10. A detailed sexual hmory of the cUent including history of. masturbation,
premarital, extra-marital relationship'
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1PS’ Problems in performance.
H. Complete medical history, coupled with
neurological examinationW'1'1 '
physical ^nation including
12. Laboratory investigation, psychological test reports.
13. A summary highlighting relevant and important details.
Eliciting problem areas
to understand0^3!^^'0^ prZms anTst'rengths^11 inf°rination as you need
psychological and ToSrthrne^pLt^s^o"1
threehbroad areas ~ Physical,
<the' problem
P— areas and needs of the client. Thi^^^ZS^ =
the following;
a) What are the client
b) What are the client’
?■
s strengths and weaknesses?
s patterns of coping?
c) Is the identified problem the real problem?
0 What are the individual/family dynamics?
n; What are the needs?
d> Is the problem acute or chronic and to determine
- the urgency of the problem
- dangerousness of the situation
- the client’s perception of what bothers him the most.
may be coping poorly^The technique of probilg woidd b
counsellor should note that each client’s nrnhi g
WherC the client
be extremeJy useful here. The
rote, time shouid be spent with each
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CASE-HISTORY TAKING
VT:riss==:—::s::as=~=
X—s X?the cottir observes (tone ofvo.ee, affect, faca! express™
etc) is also of prime importance.
his drinking/drug taking behaviour and his way of life.
It is important to remember that if a full assessment is made right at the beginning,
E‘Te best chance of making the right dee.s.on about what to do.
Bibliography
1. Davis Jan and Raistrick Duncan, Dealing with Drink - A handbook, British
Broadcasting Corporation, London, 1981.
2. Howard J, Cline Bell Jr, Understanding and Counselling the Alcoholic, Abingd ,
Pantheon Press, Nashville, Tennessee, USA, 19/8.
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DEALING ViTTH DENIAL
The concept of denial has been discussed in detail in one of the previous chapters,
he types of denial discussed are blaming, justifying, minimising, intellectualising
and silence. Here we will discuss how these forms of denial can be handled.
The handling of Denial’ goes through specifically distinct phases.
In the initial phase (i.e. at intake), when the client comes for help, it is important
for the counsellor to accept the client’s denial. The individual may have a very poor
motivation and may give reasons other than chemical dependency for seeking help
Blaming, justifying and minimising should be considered as part of the disease. Wlien
the client uses these defenses, the counsellor should be aware of these and at the
same time, not fall mto his trap. Acceptance of denial for the time being and emphasis
on the beginning of treatment, are of importance here. During this phase, the
counsellor should avoid referring to the client as an alcoholic or an addict. Instead,
he can use phrases like ‘problem drinker/drinking’, etc.
The next step would be to establish a contract with the client that he is always welcome
and that he can come back for help whenever he feels the need. It is important to
maintain a non-threatening and supportive counselling climate.
The next phase would be the warming up phase. The goal here is to establish a
therapeutic relationship. Many a time, the client may provoke the counsehor. Qualities
like patience and tolerance expected of a counsellor, should predominate here.
After entering the treatment programme, the client attends re-educative lectures on
topics like The Disease concept of chemical dependency’, ‘Denial’, ‘Personality
traits , Damages , etc. He also attends group therapy sessions. In approximately
en days time, the client’s denial would have been broken down to a large extent
Lectures, group therapy and counselling sessions would have facilitated this.
The next crucial phase is confrontation, and this must be carried out after proper
the Xrnh’ If after attendlnf lectures and group therapy sessions, the defenses of
the client have already started breaking down, confrontation in individual-counselling
sessions may not be necessary.
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Confrontation is the crucial technique through which demal is handled at later stages.
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DEALING WITH DENIAL
219
w
Confrontation
Confrontation is the deliberate use of a question or a statement by the counsellor
to induce the client to face what the counsellor thinks the client is avoiding. The
client’s avoidance is usually revealed by a discrepancy or contradiction in his
statements and behaviour. Thus confrontive responses point out discrepancies either
within the client or in the client’s interaction with the environment. In confrontation,
the counsellor frequently identifies contradictions that are outside the client’s frame
of reference. On the other hand, paraphrasing, reflection of feelings and summarising
involve responding within the client’s frame of reference. In using confrontation,
the counsellor gives an honest feedback of what he perceives is actually happening
in the client. Confrontation should not include accusations, evaluations or solutions
to problems.
Types of discrepancies
A discrepancy in the client is often a clue that confrontation is necessary.
1. A discrepancy between how the client sees himself and how he is seen by others.
Thirty-six years old Ranjit was running a small business firm. He got into
excessive drinking and gradually started neglecting his business. ‘He stopped
going to the shop as a result of which, his business suffered a great loss.
He was brought to the Treatment Centre by his brother, Vijay.
In one of the individual counselling sessions, Ranjit repeatedly complained,
“Nobody allows me to continue my business. I am never allowed to meet my
suppliers. I am scared that my business will come to a halt. ”
In another interview, his brother Vijay said, “During the last 6 months, Ranjit
went to the shop only on two occasions. He did not meet a single key customer
or supplier during this period. In fact, on one occasion, when a customer well
known to Ranjit dropped in at home, Ranjit never came out of his room even
to say hello to him. It put a strain on my old father who had to be a standby
for Ranjit. In spite of our daddy’s persuasion, Ranjit refused to go to the shop. ”
2. A contradiction between what the client says and what his behaviour indicates.
Sanjay told the"counsellor, “I am desperately on the look out for a job for the
last three months. I want to be able to support my wife and children. I must
get a job as early as possible. ”
Subsequentjftteriictions revealed that he had not sent even a single application
to any company during the last three months. He had not approached anyone
to discuss or talk about his job. He was doing nothing but watching video
programmes. Still he kept on saying he was hopeful of getting a job.
*5fAU..
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x^.-.daiOdJCEWfcfa Ju-i
s*.
220
ALCOHOLISM AND DRUG DEPENDENCY
3. A discrepancy between two statements made by the client.
“Z'fe'A T’KW‘'\
bun
‘•dmU
h°"
person if likdy Zed
°ther ”°nnal
fe
^ith ^eat
diffwulty^slZr^t
a small house for rent. She st>oke m h'
become responsible. His wife joined hint”^’
a S° helped
Setting him
that he WOuld
At the end of the month, Kadhir got his salary; went mstantly to the. arrack
shop and drank. Within
Th^^’
gn
t0 SXCesswe ^king, and
consequently lost his job. This incident really shook Kadhir’s wife.
Kadhir was again
<
brought to the treatment centre. When asked about his
occupational problems, he casually replied, ‘
only a mauer „) a
1
5' tXT” X: W1,at th' d,ent ”W
he Mi'- - and how he has
I
Suresh often slated that;
staying away from the bottle was no problem, but he
had three slips last month.
Areas to assess before
employing ‘confrontation’
L<
— Ftanly establish enrpathy and m„tuaJ trust as part of the
punX'Z" ShOl"d b' 3 P“-1™
dve act, and not a negative and
— The counsellor should address sn^m.
_ behavtour, so that the d.en.Zn tX™f sX““
benefits J the
C°UnSelJor must weigh the possible
— Prepare other family members, if they are
also to be involved in the confrontation
of the client.
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DEALING WITH DENIAL
221
Types of outcome
- The client may accept the confrontation, in which case, the counsellor should
reinforce the client’s acceptance positively.
_ If the client defies confrontation, it is probably wise for the counsellor to return
to an empathatic response. But it is essential to convey to the client that We
maintainwhat we say”. Confrontation may be tried again in later stages.
- The client may simply act confused or ambivalent after a confrontive statement,
in which case the counsellor could focus on current feelings.
- The client may decide to break the relationship. It is essential that the counsellor
is in touch with his feelings and emotions, especially when the client retaliates
or tries to break the relationship. The counsellor must take solace ^knowing
that he has done everything that could be reasonably expected of him.
Where to confront
Confrontation can take,plate in three settings.
- Individual counselling sessions
- Group counselling, ^ssions
_ Individual sessions .with the medical practitioner.
In the individual session, the counsellor can handle the client’s psychological defenses
personal
problems like
like marital
marital relationship,
relationship, personality
traits, etc, and help him
nal problems
personality traits
making changes in his life style.
In the group, other group> members may confront the individual. Here denial
pertaining to acceptance of chemical dependency, signs
d’amages incurred are best handled.
dependency, pattern of
c_ drinking and
.
physical damages caused.
How to confront
Confrontation is a technique which has to be employed with tremendous caution.
A counsellor should go through the process given below before confronting a clien .
- Establishment of an empathetic relationship is essential. Good rapport is a
prerequisite and the counsellor should convey to the client that he is cared or.
Mutual trust should be built.
- The counsellor should collect exhaustive information about the client. This is
done by talking to the client himself, to his family members and to other sigmfi
people (e.g. employers).
rtf<MWMiU.n.»»T?n»ar/y avi^r .1^.2
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<
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u ‘ ALCOHOLISM AND DRUG DEPENDENCY
— Discrepancies in the above information between the details given by the client
and the details given by others should be identified.
— At this point, the counsellor can cross-check with the client about the
discrepancies, but this should take place in a casual, non-threatening manner.
— If the previous step has not been successful, the counsellor should weigh the
possible benefits and losses in case the client is confronted.
— Timing is the most important factor in confrontation. A client who has just entered
the treatment programme or a patient who is just preparing for discharge should
not be confronted.
v
— If other people are to be involved in confrontation, (e.g. family) they should also
be informed and prepared for the same.
.
x
— Actual confrontation should always have its einphasis on the need for change.
The whole process should be carried out in an empathetic, caring and supportive
climate.
— Assessment of outcome and appropriate reinforcement should be made.
— The counsellor who is inexperienced or not confident of his professional
competence, would also be anxious before and after confrontation. These feelings
have to be recognised and appropriately handled, by discussing with senior staff
of the centre.
Bibliography
1. Hazelden Educational Materials, Dealing with Denial, Hazelden, USA, 1975.
2. National Council on Alcoholism, Counsellor’s Guide on Problem Drinking,
London, 1980.
fe
.
NEW life home
Mt red HEART HOSPITAL
EullCORiN 628002,
Tamil nadu.
24______________
GROUP THERAPY
The health field has used homogenous groups to enable clients to share common
concerns and gain therapeutic benefits through the concept of universality . It has
been contended that homogenous groups help members assume responsibility for
themselves and handle emotional responses to problems such as depression, guilt,
aggression and dependency. Groups provide an opportunity for people to discover
that they are not so odd, different or so alone with their problems as they think.
In the treatment of chemically dependent people, group therapy is one of the techniques
most recommended, since it dea' ’rith the multiple aspects of chemical dependency.
What is group therapy?
‘A group’ is a collection of individuals with similar problems. Group therapy helps them
to discuss/share their experiences with one another, and through this process, learn skills
of coping, decision making and problem solving. In the treatment of cnemical depend
ency the group participants consist of persons who are dependent on any chemical
— alcohol, ganja, pethidine, etc. Participants’ age, occupation or social class may vary.
Goals of group therapy
The general goals of group therapy for chemically dependent clients include.
— Accepting the fact that chemical dependency is a problem.
— Recognising the existence of other problems related to chemical dependency.
— Attempting to break denial.
— Becoming aware of and identifying feelings.
— Enhancing motivation.
_ Accepting personality defects and making attempts to change.
— Helping him change his life style.
— Improving interpersonal relationships.
— Learning new ways to respond to problems.
— Assisting him maintain-abstinence.
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ALCOHOLISM AND DRUG DEPENDENCY
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The process of group therapy
The optimal number in a group is 10 — 12 members with one or two counsellors.
The group can meet for one hour five days a week. The group can either be closed
or open. In a closed group, no new member is allowed, and the same members
continue throughout the programme. In an open group, new members can join in.
Members are seated in a circle and this has a significance which clients should
understand. Sitting in a circle symbolises that all clients in the group are equal. It
also facilitates ‘face to face’ interaction. The session can begin with the counsellor
explaining the group rules and purpose in brief and enabling group members to get
acquainted with each other. The general rules are
— to maintain strict confidentiality
— to be as honest as possible
to focus sharing on the topics which are being discussed
— to talk to the whole group
— not to interrupt when somebody is sharing
to be regular and punctual and to inform if unable to attend
— not to leave the group in between a session.
Ah participants are considered equal, irrespective of their drinking/drug taking status
or nature of the damages. The counsellor, as a facilitator of thevgroup, need not
share any details regarding himself.
7
Therapeutic tasks
Backing the earlier mentioned goals are the therapeutic tasks. These tasks include:
★ Helping clients verbalise their drug taking episodes and their consequential adverse
behavioural experiences. To enable the same, a structure can be provided in each
session in the form of a topic being decided for the group. The topics can be
flexible — depending on the stage of the group and can include problems like
damages, feelings, worst drug taking episode, past adverse life style, symptoms
o chemical dependency, denial, powerlessness and unmanageablity, commitment
to change and problems in sobriety.
★ Helping the client begin working through the mechanism of denial, thereby
making the gradual emergence of reality possible. To protect himself from painful
feelings, unpleasant insights and personal accountability for problems, the
chemically dependent person develops a rigid defense system, and denial is the
hallmark. The group medium has proved to be an exclusively effective tool in
breaking this system.
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GROUP THERAPY
225
★ Using interpretation to enable the client connect his past and present actions and
recognise the inappropriate aspects of his behaviour.
The clients who are in the first phase of group therapy can be allowed to focus on
damages, and on similar concrete, identifiable issues in the midst of a supportive
and accepting group, which acknowledges concerns and physical effects. Members
are enabled to share and identify themselves with others who are going through similar
problems.
In the second phase, the feedback from other members will be of help to them to
work through denial. In other words, the group process helps its members to clearly
understand their own attitudes about chemical dependency and the defenses used
by them to protect themselves from giving up chemicals. This is achieved by
confronting others with similar attitudes and defenses. All through, care has to be
taken to avoid creating any intense anxiety. Necessary precautions should be taken
to make the whole group experience, non-threatening to the members.
By the time they enter the third phase, the group experience would have enabled
the members to reach a stage wherein they are geared to concentrate on recox ery
plans. It has been observed that the process of the earlier interactions would by now
have led to a spontaneous outcome, whereby more important psychological and social
issues like loneliness, depression, problems in sobriety, interpersonal problems, and
future plans in recovery are discussed.
Group membership has to be contingent on maintaining abstinence, clients
willingness to struggle honestly with conflicts about continued use of chemicals (or
wish to take drugs).
Drug taking and other vagaries of behaviour like discontinuation of antabuse, misuse
of medication, irregularity, and tardiness are addressed and explored to the fullest
extent possible in the group, if and when they manifest themselves.
In between group sessions, the members also would require support through
individual sessions in order to counter shame, guilt, anger and ensure continued
participation. Extremely personal and intimate issues can be handled in the ‘one-toone’ individual sessions with the counsellor.
Therapeutic benefits
Most chemical dependents seem to possess certain patternised characteristics
like low frustration tolerance, inability to endure anxiety, feelings of isolation,
low self-esteem, problems in dealing with anger, and memory/cognition deficits.
The major defence mechanism used is denial. These characteristics can be effec
tively handled in the group. Group members provide the warmth and support
necessary to .help the 'individual develop trust in others, kindle hope in him
that recovery,is possible, and build a sense of self-acceptance and self-worth.
1**
226
ALCOHOLISM AND DRUG DEPENDENCY
The group is able to provide this help through the members sharing their personal
experiences of illness and recovery. The problem of isolation is also handled. The
members of the group help each other to overcome problems, feel more comfortable
with themselves and others.
The above mentioned benefits are achieved through the processes of
— peer identification
— mutual support
idealisation of those who maintain sobriety.
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Role of the counsellor
i
What are the roles of the counsellor in a group situation?
t
To function as a change agent.
— To help other group members provide acceptance, support and hope.
— To provide an opportunity for feedback, testing and learning.
To maintain a congenial and cohesive climate.
— To handle failure, rejection and other disruptive behaviour.
— To accept certain types of behaviours and attitudes, and to disallow those
considered non-productive.
— To keep the group focused on the topic.
i
Recording
I
Recording of an individual client’s performance has been found to be indispensable.
Kecordmg aids m the evaluation of the client’s performance and progress. The format
tor recording that can be followed is given in the appendix. The columns/items in
the format are self-explanatory.
To conclude:
★ Group therapy is one oi the most
various aspects of addiction.
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i ecommended techniques in dealing with the
★ The group helps the individual not only to abstain but also
comfortable with himself and others.
I
to learn to feel
★ The three important processes are peer identification,’mutual
idealisation of those who maintain sobriety.
<
support and
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GROUP THERAPY
Value additions place
— Additional information
Yalom’s curative factors*
Curative factors in group therapy have been widely discussed in literature, with the
rationale that the isolation of this group of factors would help in formulating systematic
guidelines for the tactics and strategy of the therapist.
Yalom (1975) has identified the following as having ‘curative value’ from the patients’
point of view.
1. Group acceptance implies ‘belongingness’ or a warm, friendly, comfortable
feeling in the group.
2. Altruism involves wanting to do something for others.
3. Universalization is realization that the individual is not unique and that there
are others with problems either identical or very similar to one’s own.
4. Interpefspnal learning — Input (i.e.) the group teaching the individual, showing
how he-relates to others, personality defects etc.
5. Interpersonal learning — Output using the ability to get along with other people,
learning about-the way to relate to other group members, etc.
6. Guidance: The therapist or other group members suggesting a course of action,
advice on how to behave with someone important in one’s life, etc.
7. Catharsis: Getting things off one’s chest; expressing positive and negative feelings
towards other group members, the leader etc.
8. Identification: Imitating others in the group, both members and the leader;
imitating others who are better adjusted in the group.
9. Family re-enactment: Resembling, understanding or reexperiencing the
individual family.
10. Insight: Discovering positive and negative aspects of one’s own behaviour which
were previously unknown or unacceptable.
* Reprinted from Bain Donna et al “Counselling skills, For Alcoholism Treatment Services, A
literature review and experience survey, Addiction Research Foundation, Toronto, 1979.
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ALCOHOLISM AND DRUG DEPENDENCY
11. Instilling hope: Inspiration and encouragement received from seeing and knowing
that others with problems similar to one’s own, have improved.
I
12. Existential factors: Learning that one must take ultimate respbnsibility for the
.way one lives regardless of the guidance received, recognising that life is
sometimes unfair and unjust etc.
.
Bibliography
■
1. Altman Marjorie and Crocker Ruth (Ed) Social Group Work and Alcoholism,
The Haworth Press, New York, 1982.
2. Bain Donna et al, Counselling skills for Alcoholism treatment services, A literature
review and experience survey, Addiction Research Foundation, Toronto, Canada,
1979.
3. Chakradhar Kala, Group Therapy: An effective treatment modality with
Drug/Alcohol addicts, Addiction Research Centre, T T Ranganathan Clinical
Research Foundation, Madras, India, 1987.
4. Kurtz E, Why AA works, the intellectual significance of Alcoholics Anonymous,
Journal of studies on Alcohol, Vol. 43, No. 1, 1982 (pp. 38 — 80).
5. National Institute for Alcohol and Alcohol Abuse, Group skills for alcoholism
counsellors (Readings) U S Department of Health and Human Services, 1982.
6. Vannicelli M, Group psychotherapy with alcoholics - special technique, Journal
of studies on Alcohol, Vol. 43, No. 1, 1982 (pp. 17 - 37).
7. World Service Office, Inc, Narcotics Anonymous, Van Nuys, CA, USA 1987
I
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(4th edition).
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25
RELAXATION THERAPY
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Chemically dependent people often resort to the use of drugs as a means of coping
with stress. Therefore, when they come for treattnent, it is essential that the counsellor
teaches them other methods of handling their stress and tension.
Relaxation is a behaviour therapy technique wherein clients are taught to keep their
body and mind calm, as a result of which they will be able to handle situations more
effectively?
A relaxation programme aims at teaching the client methods to produce the basic
relaxation response so that he can eliminate tension from his body and fee a deep
sense of relaxation. Later on, these relaxation skills can be used by the clients
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any situation, anywhere.
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The prerequisites for bringing on the relaxation response are the following:
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1) A quiet environment
2) A comfortable position
3) A mental device (some thought or object on which to focus one’s attention),
4) An ‘unruffled’ attitude whereby distractions are ignored and attention remains
focused on the mental device.
The basic principle in this programme, and its first goal is to teach the client what
the opposing feelings of tension and relaxation are really like.
I
The criteria for relaxation
l
1. The person should concentrate fully on what he is doing without allowing any
other thought to interrupt.
2. He should not fall asleep.
3. Tight clothes should not be worn during relaxation.
4. He should breathe normally without taking a deep breath. Neither should he
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hold his breath.
5. Concentration should be only on that part of the body which is engaged in tensing
and relaxing.
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230
ALCOHOLISM AND DRUG DEPENDENCY
6. 1 here are various steps which involve tensing and relaxing of muscles. The order
of steps should not be changed.
7. He should do it as slowly as possible and avoid sudden jerks when he executes
the steps.
The Jacobson procedure
Given below are instructions, in verbatim, which the counsellor would give to the
clients in person, in individual, or in group sessions. Jacobson was a renowned
behaviour therapist who evolved this procedure. His technique has been followed
here.
■
Lie down on your back with palms facing upwards, as comfortably as possible. Close
your ejes gently. Now chase away all thoughts coming into your mind. Try to
concentrate completely on what you are going to do, so that you can feel the difference
between tension and relaxation and thus enjoy the comfort of being relaxed.
RELAX
1) Tightly clench your right fist. Feel the tension. Feel how uncomfortable it is
when you are tensed. Now slowly relax your fingers. Relax them completely
and feel the difference. Feel how comfortable it is when you are relaxed. Enjoy
the feeling of being relaxed.
2) Repeat the same procedure with the left fist.
3) Do the same with both fists.
4) Clench both fists. 1 ouch your shoulders with your fist without raising your arms
from the floor , relax...
5) Press the sides of your body with your open palms (fingers open).
I
6) 1 ouch the sides of your body with your open palms and push your shoulders
downwards. . .
/ / I ouch the sides of your body with your open palms and push your shoulders
upwards (towards your ears). . .
8) Raise your eyebrows with your eyes closed gently.. .
9) Knit your eyebrows. . .
10) Press your eyelids harder (do not shrink them).. .
11) Press the upper part (roof) of the mouth with your tongue (the whole tongue
and not just the tip of the tongue). . .
12) Clench your teeth as hard as possible (press your upper teeth to' your lower
teeth).. .
13) Press your upper lip to your lower lip. .
n
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RELAXATION THERAPY
231
14) Raise your head off the ground and touch your chest with your chin. In the
same raised posture, slowly turn your head to the right (as much as possible)
then to the left, then slowly to the centre and then slowly relax..
I
15) Raise your chin upwards as much as possible. In the raised posture slowly turn
to your right, then slowly to the left and then bring it to the centre and then
slowly relax...
16) Trj' to bring your shoulders as close as possible, bv keeping your arms on the
ground (you can feel the tension at the nape of your neck). ..
>
17) Press your shoulders to the ground, so that your chest expands.
18) Push your stomach as far inward as possible.. .
19) Push your stomach as far outward as possible...
20) Keep your head, arms, waist, legs and feet on the ground and raise just your
back off the ground.
21) Tighten your thigh muscles...
22) Bring your feet closer and push them as far inward as possible (towards your
face without raising your legs)...
23) Bring your feet closer and push them as far outward as possible, . .
A
24) Now slowly take a deep breath and hold it (for few seconds) then slowly breathe
out...
Start breathing normally.
Now right from head to toe, each part of your body is relaxed and is as light as
a feather. Likewise your mind is also calm and comfortable. Enjoy the comfort of
being relaxed.
RELAX.... RELAX....
Be in that relaxed state for about five minutes, each minute enjoying the feeling of
being relaxed.
■
Then slowly count 5, 4, 3, 2, 1 and slowly open your eyes. Slowly turn to your right
and lie down and then slowly get up and sit down feeling light and relaxed, both
in mmd and body.
Guidelines for the therapist
1. Haye at least two regular appointments with the client per week for seven weeks.
Initially relaxation is taught muscle group-wise. Supervision continues even when
muscle groups are completed.
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ALCOHOLISM AND DRUG DEPENDENCE
2. Always start with the following order for relaxing of groups of muscles:
Major Group I
a. Dominant hand and forearm
b. Dominant biceps
c. Non-dominant hand and forearm
d. Non-dominant biceps
Major Group II
a. Forehand
b. Checks and nose
c. Jaws
d. Lips and tongue
e. Neck and throat
Major Group III
a. Shoulders and upper back
b. Chest
c. Stomach
Major Group IV
a. Thighs and buttocks
b. Calves
c. Feet.
3. You can suggest that your client relax at home for 20 or 25 minutes daily, to
get the full benefit of relaxation therapy.
4. To help in scheduling sessions and to keep track of progress, maintenance of
Log Sheets would be useful. A sample format is given below:
Name:
Sex:
Age:
Ciimcai diagnosis
Date
File number:
Session Number
What was practised
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RELAXATION THERAPY
2^3
5. Simultaneous individual counselling is an essential adjunct to rciaxation.
6. Family members may also be taught this technique since they arc also anxious.
This can be done at the discretion of the therapist.
I
We are aware that many people look upon diugs as a means by which an individual
can cope with stress. It is necessary that the counsellor teaches the client other ways
of handling stress and anxiety. Relaxation is one such technique that can be taught.
Bibliography
1. Franks M Cyril and Wilson Terence (Editors), Behaviour Therapy ~ Theory
and Practice — Annual Review, Vol. 5, Brunna/Mazel Publishers, New York,
1977.
2. Kovel Joel, A Complete Guide to Therapy from Psychoanalysis to Behaviour
Modification, Pantheon Books, New York, 1976.
3. NIDA Research Issues, Behavioural analysis and treatment of substance abuse,
Research Monograph series (25), US Department of Health, Education and
Welfare, 1979.
4. NIDA Research Issues, Behavioural Intervention Techniques in drug abuse
treatment. Research Monograph series (46), US Department of Health and Human
Services, 1984.
5. Rosen M Gerald, The Relaxation Book, An illustrated self-help programme,
Prentice-Hall Inc, USA, 1977.
6. T T Ranganathan Clinical Research Foundation Treatment Manual for Adolescent
and Young Adult Drug Addicts, TTK Hospital, Madras, India.
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ASSERTIVENESS TRAINING
Assertiveness is one’s ability to act in harmony with one's values and self-esteem.
without hurling others.
and at the s”’e
avoidin81’un,ne mimb
thc
When a person conduct himself in an ‘assertive’ manner, the feelings and welfare
of Othe. s as veil as his own feelings are taken into account. The verb ‘assert’ means
to state or aihrm positively, assuredly, plainly and strongly.
’
Each one of us can think and act in three different ways:
1 ofothe’T^1
■
Stand UP f°r °Ur rig,US ln WayS Wh'ch d° nOt vioiate the ri8ht’s
2' ^rThTTely:
Tand Up
0Ur rightS and t0 express our ^‘Oughts, feelings
and beliefs in such a way that others’ rights are violated.
3 Passively: to fail to stand up for our rights.
- to express our thoughts, feelings
and1 ''beliefs,
’ " or to express them so apologetically that they are ignored.
I he characteristic traits which dominate each personality
type are given in the
toHowing table.
Passive
Behaviour Doesn’t stand up for
one's rights.
Put oneself down
and always
apologetic about
feelings, needs and
opinions.
Aggressive
Stand up for one’s
rights but violate
others’ rights.
Put down others,
ignore or dismisses
feelings, needs and
opinions of others.
Express oneself in rude
ways.
Assertive
Stand up for one’s
own rights in such a
way as not to violate
others’ rights.
Express needs,
opinions and feelings
in direct, honest and
appropriate ways.
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ASSERTIVENESS TRAINING
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Attitude
1
Passive
Aggressive
Assertive
You’re okay, I am
not okay.
Think that others’
needs are more
important than one’s
own.
I’m okay, you’re not
okay.
Think that one’s
needs are more
important than
others’.
Think that others
don’t have rights.
Think that others
don’t have anything
to contribute.
I’m okay, you’re
okay.
Think that one has
one’s own rights,
others also have theirs.
Think that only
others’ have rights.
Think that only
others have
something to
contribute.
Feelings
Feel helpless,
frustrated and angry
with oneself and
resentful towards
others.
Aim
To avoid conflict
pleases others at any
expense
Think that everyone
has something to
contribute.
Feel good about
May feel good
because one has won , oneself and the way
one treats others.’
but feels remorse,
guilt and self-hatred
because of hurting
others.
Maintain selfrespect.
To win at any
expense to others.
People lack assertiveness because of one or more of the following reasons:
— low self-esteem- >■
— fear of'rejection
— inadequacy
— guilt - _
have evolved a therapeutic programme called
Therefore, behaviour therapists
Advene,.;
X- ^ve feei.ngs (anger, lean, gufl.) and posruve
feelings (joy. love, praise) appropriately.
ZSStJ^M aZCateXmg° oTwdlTemg m iZciZ
llllilllllH .
236
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alcoHOLISM AND.DgUG DEPENDENCY
rewards
satisfaction
from
life,
understand whatTwrongmTcking in his Th’'"' th| ““
of helping the client
and how to change or mfprove u^n them
communication styles
Assertiveness training stresses two factors:
I
1. Identification of the target behaviour that needs changing
• Plannmg a systematic programme with the patient
achleve ,hls resull.
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Goals of assertiveness training
Assertiveness training should a,m „ ,eachlng t„e
- Everyone has basic rights.
- h^of,”' “ reSP°”sible for h“”sdf “d his behaviour.
g'
-
......
Technique of assertiveness training
r^hirsah ?his tZ™^ USed technique of assertiver
;ness training is behavioural
interpersonal interact Pan of the^imTJhe
C°[lnSellor t0
> act out relevant
the counsellor assuming the role of sisniPr
C
? ays the role h™self, with
parent, employer, or spouse.
“ the clie^
suck as a
the other person’s role with some degref of redism Th^f ]?UnSeIIor must portray
of the main points associated with the techniane of h n The fo.llowin&ls the summary
to a specific area of mterpersojf dJfficS?^behaV10uraJ rehe^al as if is applied
as ix is applied
2. nee™”' r0'8 'he beha''i°Ur “ h' ™u,d “
real life.
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assuming the
4. The client then
5.
attempts the response again.
improvement. Steps three
,he eKenleaeeo^XX^SlS::^^
(>■ The interaction, if it i
dealt with sequentially. Then the client anT brokeJ! up lnt0 smaiI segments and
------------.:.e purpose" !nSe"OrCa"n'nlhro^th'“-interaction
for the
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I
ASSERTIVENESS TRAINn4G_LJ______1----------------------- ------ ------------
1
7. The counsellor and blienc should m^e^decisionsioi^ntly^regardingexpjes^ton^of
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assertive tactics.
changes in behavioural pattern may bring about
SZEZ2. Therefore teaming is earned out in a hierarchical manner.
Inrhef^level.adeficitinthefoUowingareasctmbehandled-eyecomact.pos
,
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The second^evel i™"
•1
X—ou’ghts’ in an open direct way, to handle criticism.
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of close personal relationships.
4
Types of assertive responses
1
Assertive responses which are to be developed by the client are briefly described here.
Non-verbal
.
_ Making adequate eye contact is most important. The dient should learn to look
people in the eye.
_ Talking in a loud, dear voice, so as to be heard by others.
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with different emotions.
— Using appropriate natural gestures.
_ Use ‘feeling talk’, which involves practice in expressing any feeling literally,
responsibility.
— Practise accepting compliments.
— Practise giving compliments.
238
ALCOHOLISM AND DRUG DEPENDENCY
Chemical dependency and assertiveness
Feelings of social inadequacy or an inability to express emotions can both contribute
to frustration and thus serve as potent cues for drug taking behaviour. Research has
shown that the social pressures exerted on chemical dependents, to get them to take
chemicals often led to a relapse. This finding has stimulated a number of behaviour
therapists to advocate that the chemically dependent should be taught how to say ‘no’
effectively. A study by Miller and Eisler 4(1977) indicated that alcoholics (when sober)
scored low in the ability to express negative feelings such as anger or irritation. They
further found that alcoholics who were unable to express their negative feelings subse
quently consumed more alcohol than alcoholics who did express their feelings. Thus
a correlation was noted between lack of assertiveness and excessive alcohol consumption.
Typically assertiveness training with a chemically dependent can take the following
forms. 1) Actual incidents wherein clients had been under tremendous social pressure
to consume drugs. 2) Situations where the client needs to convince a party otherwise.
These are then used in role playing sessions.
Examples
Client is attending a party where alcohol is sewed.
Wife suspecting that the client has consumed drugs.
— Wife insisting that she invest in a commodity that the client feels is not of
immediate priority.
Boss requesting the client to stay after office hours (overtime) but the client
having another important commitment.
The chemically dependent practises looking straight (eye to eye), varying his voice (tone)
and racial expressions where appropriate and confidently articulates appropriate replies.
The evidence pertaining to the efficacy of this therapeutic intervention indicates'that
c emical dependents are able to modify their habitual way of responciirig to social
pressure and have reported increased feelings of confidence and self-esteem after
successfully refusing drugs, using their newly learned skills.
,
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Bibliography
1. Bain Donna and Taylor Lisa, Counselling Skills for Alcoholism Treatment Services
A literature review and experience survey, Addiction Research Foundation,
Working paper series, Toronto, Canada, 1961.
2. London
AspCCtS of Alcoholisrn> Alcohol Education Centre, Maudsley Hospital,
3. Fensterheim Herbert and Baer Jean, Don’t Say Yes when you want to say no,
rutura Publications Limited, Great Britain, 1976.
4. Miller Peter and Richard M Eisler: Assertive Behaviour for Alcoholics,
A descriptive analysis, Behaviour Therapy, Vol. 8, No. 2, 1977, pp. 146-149.
27
IMPROVING SELF-ESTEEM
Self-esteem can be defined as a positive feeling and respect for oneself. It is essentially
a measure of self-worth and importance.
Self-esteem is an important part of the personality that has been shaped from very
early years. During childhood, if an individual’s feelings are respected thoughts valued,
and abilities recognised, the child’s self-esteem gets strengthened. When feelings
are trampled upon (“I don’t care about what you think/want ), thoughts belittled
(“What a lousy idea”), and abilities criticised (“You can never do anything correctly ),
the child’s self-esteem remains at a low point of development and is therefore weak.
During the course of time,-an individual faces many life situations. Depending upon
the success or Mure and one’s reaction to every significant situation in lite, seltesteem either grows stronger or gets considerably weakened.
An individual with a strong self-esteem is able to act towards others in non-threaten
ing ways, build healthy relationships and finds himself successful. He is confident,
dynamic, -appreciative, achievement oriented, contented and open to change.
An individual with a weak self-esteem has a negative self-image and poor self-concept.
These come in the way of his ability to build relationships, and to be successful.
He is critical, self-centred, cynical and diffident.
Some individuals who have a low self-esteem, may try to project themselves as persons
with adequate self-esteem. These individuals usually talk in superlatives, are ove confident and make unrealistic statements.
Self-esteem and addiction
One of the “pre-disposition theories” of drug addiction points out that an addict
has a low self-esteem, whichs manifests itself in the following ways:
Self-centred
The individual gives importance only to his own feelings, likes and dislikes He is
not willing to consider the feelings and needs of others. This self-centredness alienates
him from others.
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ALCOHOLISM AND DRUG DEPENDENCY
Critical
The person makes critical judgements about others’ behaviour in order to cover un
- WS
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Cynical
If odim He iJS"e”r>’One “ U"™S'; he‘is
io believe rhe wore,
™s. tie carries a huge load of past resentments based on real or imagined injustices
He mrsrnterprers erher,’ thooghrs and actions and makes himself InSSZX
Diffident
The individual starts thinking that nobody cares about him. He suffers from feelings
Fven
inseCi‘Ii,y- He sees even small failures as proof X inadequacv
Even if he has abilities, he fails to utilize them because he is convinced that he will fail.'
Guidelines to improve the self-esteem
of the chemically dependent
X—J bU“"g “P Self-e5t“m “ ‘sl™
Give positive strokes generously
SB
HsS^^
merits in rhe actions of peopie around and express appSiatta^^8'
comPetl^n. Muthu took great pride
s"o?e“exp'rSe’xXdyand
and build self-esteem.
Y
°P“ly“A
V he pS t0 strenSthen the relationship
>
IMPROVING SELF-ESTEEM
241
Avoid plastic strokes
Compliments which are excessive or not genuine, can be referred to as “plastic
strokes”. Like counterfeit money, which has no market value, fabricated compli
ments do nothing to improve the self-esteem of the giver or the receiver. This
dishonest ‘underhand exercise’ harms the giver as he loses the ability to pay honest
compliments.
Receive positive strokes gracefully
The client should be taught to receive positive strokes with grace. Many people feel
uncomfortable while receiving positive strokes. Refusal to accept them, is a serious
drawback in character that discounts feelings of self-worth.
Positive strokes are necessary for us to maintain a strong self-esteem. They are as
necessary as water is for plants. Positive strokes are extremely vital for emotional
wellbeing. Positive strokes are invaluable gifts given to us in recognition of our worth.
They need to be treated as such and accepted gracefully. Refusal to accept them,
is as ludicrous as throwing away a priceless gift.
Kumar’s manager said, “You have done an excellent job of the brochure.
Kumar responded saying, “Well! frankly speaking, I am not totally satisfied
with the outcome. I feel I could have improved upon the cover page. I hope
that the Chairman will like it.
Kumar could have been more gracious in receiving the compliment by saying
“Thank you for your encouragement, sir. I am happy that the extra efforts I
had put in have proved valuable.
In the above example, positive strokes have been examined with suspicion and found
to be wanting. Such an approach prevents an individual from utilising these positive
strokes towards the development of a healthy personality.
Even a person with a strong self-esteem may experience periods of uncertainty. During
such moments, sharing one’s feelings with someone who is empathetic and
compassionate will help in strengthening self-esteem.
Reject unconditional negative strokes
Unconditional negative strokes are those generalised, all encompassing, negatively
toned statements. Though these statements lack any factual basis, they are capable
of causing havoc to the self-esteem of the recipient.
The recipient is soften aware that the statement is not fully true. But he ponders
over it and asks himself “How can they say that about me?”, and wallows in
self-pity.
r ”
242
ALCOHOLISM and drug dependency
Praveen’s father told him, “You pretend as though you are
not taking brown
sugar. You have undergone treatment, and therefore, are making
i
a big show
discipJined- Even now’ 1 am afraid you must betaking
drugs at night without our knowledge! ”
Unconciit^na1 negative strokes mess up an individual’s self-esteem. They make one
to exerciVrightToX
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The following four steps may be practised.
- Compliment people directly and explicitly and experience a warm feeling
- Shun flattery.
- Receive genuine compliments with confidence and grace.
- Ignore unconditional negative strokes, and stay balanced, secure and comfortable.
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IMPROVING SELF-ESTEEM
243
Value additions place
— Implementation tool
Games are an effective modality through which the self-esteem of the client can
be improved.
Game I
The participants are a group of clients or a client with his family members. One
member sits in front of the group and all the other members express the positive
qualities of that person. Eye contact is maintained while giving the positive stroke.
Members should compulsorily use the terms, “I feel” and “You are” while talking.
Some people may say that they do not see any positive qualities in the other person.
In such instances, the group may be given an exercise. They may be asked to see
the figure drawn below:
This figure will be seen as a half-full tumbler by some and a half-empty tumbler
by others. Just like the fact that some people see only the empty half, there are some
people who choose to see nothing worth complementing in others. In other words,
what one sees in others, depends on what he chooses to see or not to see in himself.
At least with efforts, one can definitely see some good in each individual. This is
the message the counsellor should convey to the group.
244
ALCOHOLISM AND DRUG DEPENDENCY
Game II
This is an assignment. A group of clients are asked to write down whatever they
feel about the following:
1. Five positive qualities of your personality.
2. Three things you are really good at.
3. Some words you would like people to use when they talk about you.
4. Three special things you have learnt from people in your family.
5. Three things about yourself which you would like to change so that you become
a better person.
After the group has answered, they can be divided into smaller groups of 4 or 5
and can share whatever they have written. Sharing of positive thoughts and good
feelings will contribute towards strengthening the self-esteem of each participant.
Bibliography
1. Guendelsberger Sherri, Randale Paula, Project Pride — Elementary Attitudes
and Skills for Substance Abuse Prevention, A COD AC behavioural health services
publication, Arizona, 1986.
2. Rees D Constance Raye, Comparison of families of drug abusers with families
of non-drug abusers on measures of self-esteem, parental attitudes and perceived
parental behaviour. Thesis submitted to North Texas State University, 1979.
3. T T Ranganathan Clinical Research Foundation, Self-Esteem — A better you
Series I, TTK Hospital, Madras, India.
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MARITAL COUNSELLING
Much attention has been focussed in recent years on understanding chemical
dependency, the chemically dependent and his family. This is vitally important as
it calls for recovery of the family along with the chemically dependent. Apart from
paying attention to family relationships at large, counsellors need to handle the various
issues which are at conflict in the marital relationship.
Understanding chemical dependency per se is the issue which should be first
addressed. The wife might have never known that her husband used alcohol/drugs
or might be alarmed at the excessiveness of its use. In our culture, where the use of
chemicals is still largely unacceptable, this may also induce fear and mistrust in the
wife. The progressive dependency brings about a number of negative personality
traits in the chemically dependent person which further erode the foundation of the
marital relationship. Some of these traits are immaturity, intolerance, increased
sensitiveness, or irritability at times even leading to verbal or physical abuse
disturbed interpersonal relationships, low self-esteem, grandiosity (extravagance) and
irresponsibility.
The wife in turn develops her own set of patterned responses. Initially, she is confused
scared and unable to comprehend the negative consequences that will follow. But
as the dependency progresses, she tends to get over protective. Embarrassment and
s ame drive her to hide his lapses, or tell lies. She also experiences hurt and guilt
when she tries to explore whether she could be the cause. As the damages increase
anger and hate become predominant. Eventually, there is a feeling of hopelessness
which leads to a total indifference, or a resentful rebellion which leads her to think
of separation. In order to cope with problems, the wife makes several attempts to
control or put an end to the dependency; but seldom succeeds.
This leads to a progressive deterioration in the marital relationship. Communication
between partners becomes minimal and this leads to further misunderstanding and
baseless assumptions about each other.
The non-dependent wife often takes over the responsibility of running the family
making decisions, and at times, taking the role of a bread-winner too. This
unhealthy state of the marital relationship requires a lot of attention, so that the
damages in the relationship are rectified and changes brought about for the better.
246
ALCOHOLISM AND DRUG DEPENDENCY
And hence, the need for marital counselling. A trained unbiassed counsellor could
help the couple reflect on their past and present disturbances and work out changes
for the better. Marital counselling is actually the handling of marital conflicts by
a qualified person.
The use of therapeutic relationship in helping the partners develop an understanding
of themselves and their problems, is of prime importance.
Guidelines for marital counselling
★
The counsellor needs to first develop a mutual trusting relationship with the
couple.
★
The couple’s motivation for change needs to be assessed.
★
The couple need to be assisted in identifying problem behaviours/areas.
★ Factors that initiate and maintain these behaviours need to be identified.
★ The counsellor also needs to be as specific as possible in his identification of
problem behaviour and planning of remedial strategies. This is to avoid any
confusion or use of manipulation on the part of either partners.
★ Appropriate behaviours to substitute problem behaviours need to be selected by
■O
the mutual consent of the couple.
The primary objective prior to specific marital counselling is the need for assessment
by the counsellor of the wife’s understanding of the problems created by chemical
dependency.
This means assessing the acceptance level of wife, — whether she is able to accept
the chemically dependent from the disease angle — and giving her proper education
wherever necessary. This is essential because inadequate understanding can prove
a continuous block to counselling while specific marital problems are addressed.
Some spouses take on a sympathetic attitude, — are understanding and open to change
— in their husband’s recovery. Some others become hostile and vehemently resentful
and blame each other for their disturbed marriage. A few are indifferent and even
unwilling to continue their relationship. With education and clarification, most of
the problems can often be sorted out. In some cases, temporary or permanent
separation might be found a better alternative, during which time individual
counselling for each partner needs to be pursued.
With regard to the issue of meeting the couple individually or together, (conjoint)
it is often found advantageous to meet them separately in the beginning, so as to
avoid open disagreement at the very outset. Often the partner’s themselves make
a request to be seen separately. Once information has been gathered and problem
areas sorted out, conjoint sessions can be held. With experience, a counsellor can
use his discretion in planning individual/joint sessions.
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247
MARITAL COUNSELLING'
In addition to the above, two important skills have to
mastered by the couple:
— communication skills
— problem solving .skills
By and large, these are the aspects which have been considerably damaged in the
marital relationship.
Communication skills
Marital satisfaction can be greatly enhanced by altering their style of interaction.
Here the counsellor monitors the way of communication while the husband and wife
attempt problem solving. The counsellor intervenes when there are destructive
interactions, and guides them through ways to improve their communication. A
specific and direct approach is often necessary to stop problematic communications.
Given below are the disruptive (Don’ts) and facilitative (Do’s) communications.
Couples could be briefed regarding these before the session.
Disruptive communications (Don’ts)
1. Interrupting: Interruptions may occur when a partner is actively talking and when
he or she has paused for a moment. This behaviour should be brought to their notice.
Husband: “Well, I have understood the harmful effect of chemicals. I will
definitely... ”
Wife: “You will not, you have promised this several times before. ”
Counsellor: “Keep away from interruptions because they frustrate your partner
and make him feel that you are not listening well. Listen and wait for him to
finish. ”
2. Blaming each other: Often partners blame each other and try to decide who is
at fault. The counsellor should teach the couple other ways of handling the situation.
Husband: “You shouldn’t have yelled at me when I was late. ”
Wife: “Well, I wouldn’t have if you had been on time. ”
Counsellor: “You are trying to decide who is at fault. People become angry
when they are blamed, and it will prevent you from working together. Don’t
argue about whose fault it is. Look for ways to handle the emotions/situations
that will satisfy both of you.
3. Trying to establish the truth: Often couples have different views regarding how
an event happened, and would try to convince the other partner that they are right.
The counsellor would have to intervene in such a situation.
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ALCOHOLISM AND DRUG DEPENDENCY
Wife: “You did not take your antabuse today.”
x
x-
Husband: “I did take it. You were busy....”
Counsellor: ‘ 'Both of you seem to have different views of how it happened.
Arguing over the truth of specific details won’t help you solve the problem, instead
it may make you both angry. ’ ’
4. Getting sidetracked: While discussing a particular problem, one spouse may divert
the conversation from the problem. Couples should learn to tackle only the issue
being discussed.
L
Wife: “You are very irritable. You are not taking antabuse regularly.”
I
Husband: “Nobody is listening to me when I talk about your mother's property.
She is also refusing to come and stay with us. "
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Counsellor: “You are getting sidetracked. Remember to stay on one issue at a
time. Other issues may seem related, but they get you off the track. ”
5. Dealing with multifaceted problems: Couple should learn to tackle one issue
at a time.
Wife: ‘ 'He is angry with my father for meeting his boss and refuses to go back to the
office. He did not have lunch today. He also wants to start business right away. ”
Counsellor: “You are talking about too many problems. It is often confusing
to deal with many aspects of a large problem — all at one time. It is best to
choose one part to work on. ”
6. Making the other person feel guilty: One spouse may often try to make the other
partner feel guilty.
Wife: “You just don't care about my feelings. You insult me all the time; you
are not bothered as to whether I live or die. ”
Counsellor: “When you say that, — whether you mean it or not, — it implies
that the other person is horrible and insensitive. This may make the person feel
guilty and angry and he may shout back at you. Avoid using guilt producing
statements. ”
7. Making improper moves and giving ultimatums: Spouses often tend to give
ultimatums to each other.
Wife: “If you drink again, III leave you, or commit suicide.”
Counsellor: ‘ ‘ You just gave your husband an ultimatum. Ultimatums push people
into a comer because they either have to lose face by giving in, or act tough
and tell you to go ahead. Either way they become more resentful, and the problem
will not gel solved. ”
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MARITAL COUNSELLING
249
8. Using the words ‘always’ and ‘never’: Couples would tend to use words like
“always” and “never” that have a sweeping impact.
Wife: “You are always late.”
Husband: “Not at all. Last Friday I reached home at 5 p.m. I have definitely
been more punctual than before. ”
Counsellor: “Avoid using the words “always” and “never”. They only lead
to useless arguments. It also conveys that you do not believe he would change
and you are not willing to notice any change for the better!”
9. Accusing the partner by labeUing him: Spouses at times tend to ‘label’ their
partners.
Wife: “You are an arrogant fellow. ”
Counsellor: “You have just called your husband a ‘name’, and that may make
him angry. When you label your husband, you imply that he cannot change.
Instead, you can tell him the specific behaviour you dislike in him.
10. Mind reading: Spouses tend to assume what their partner is thinking and express
their assumptions emphatically.
WT/e.- “I know that you think I have taken money from your purse.
Counsellor: “You just told your husband as to what he is thinking, as if you
could read his mind. Your judgement can be wrong, and even ifyou are right,
it can make him angry. If you want to know what your partner thinks, just
ask him.
11. Discrepant verbal and non-verbal communications: Quite often there may be
discrepancies between one’s verbal and non-verbal communications.
Husband: “Okay, if that is what you want..." (sighs and rolls eyes)
Counsellor: “Verbally you have agreed, but your gestures clearly show that you
are not agreeing. " .;
Supportive communications (Do’s)
i
A list of common skills which are useful for a couple to learn is presented below:
1. Talking td each other
“their side” against their mate.
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ALCOHOLISM AND DRUG DEPENDENCY
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2. Making eye contact
¥
Eye contact is encouraged because it can form a psychological bond which helps
the partners to work together as a team. Averted eyes may indicate a distracted or
disinterested partner, and this may lead to resentful feelings.
3. Making personal statements
I
These statements usually take the form of “I feel...” or “I think...” and take the place
of statements which speak about or for the partner, starting with “you feel...” or “you
think...” These statements provide direct information about the person’s own feelings
and encourage the partners to take responsibility for their behaviour and feelings.
I
4. Practising reflective listening
Reflective listening shows that the partner is listening to and understanding what
the speaker says, rather than implying that he is daydreaming or planning a confron
tation. 1 his skill is especially helpful for couples who frequently interrupt each other
because it slows their pace of interaction and teaches them to listen to each other.
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5. Giving encouragement
In order to change the couple’s negative reinforcement schedule to'a positive one,
couples should be encouraged to give positive reinforcement directly. They should
be encouraged to tell each other what they like about the partner,'where the partner
has been doing well and suggestions of the partner that have proved helpful.
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6. Attending behaviour
I
Nodding the head is an indication of good listening because it is a non-verbal way
of communicating to the speaker that his message is being received.
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7. Stating what one likes or needs
I
During the course of problem-solving the counsellor provides a safe situation in which
partners may honestly state what they like and need. Thus, they can be encouraged
to be open about their needs.
I
Problem solving skills
Another major characteristic of many troubled marriages is an inability to solve
problem. Counsellors could teach the couple specific problem solving steps. This
would consist of the following steps:
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Selecting and stating a problem
During the initial stages of therapy, most couples use vague, emotional words while
stating their problems. This is because they often see the partner with a different
understanding of the problem and always with feelings of blame, resentment and
guilt. Counsellors need to teach them to use specific, descriptive terms about the
partner’s behaviour when stating problems.
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MARITAL COUNSELLING
251
Another common difficulty is that couples often want to work on large, emotionally
laden problems early in therapy. However, the initial sessions of therapy should focus on
relatively small, non-threatening problems for two reasons. First, the focus of the early
sessions is teaching problem solving techniques and communication skills. When couples
deal with major problems they are likely to concentrate on the content of the problem
instead of on the development of skills. Secondly, until they become proficient with
their new skills, couples will not be able to resolve their large emotionally laden issues.
Listing possible alternatives
t
Once a couple has selected an appropriate problem and stated it specifically, the
second step — stating alternative solutions — begins. Couples have a “brainstorming”
session and a list of unevaluated alternatives are obtained. Next, they pick up one
alternative at a time, evaluate it and discard, if it is unacceptable. The preferable
choice is then consciously made.
Agreeing on a final solution
This involves the couple choosing the best alternative (as the solution) which they
agree to implement.
This alternative
must be acceptable to both the partners.
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Evaluation ,
It is essential that the couple review their choice of the best alternative and evaluate
if it has helped them in tackling the problem. This should be done honestly and
openly. If they find that the chosen solution has not been helpful, they should go
back to the first step.
E.g. A couple who has been separated due to “drinking problems” comes together
during treatment. The husband feels confident about his abstinence and wants to
bring his family over to live with him again. But he does not have a house to stay
in, has lots of debts and is not in a position to ensure security for his family. His
wife expresses these difficulties, and suggests that they get together after a year,
by which time things would have settled down. They ‘discuss’ problems which may
crop up if he continues to stay alone immediately after discharge — problems like
loneliness, food and isolation. They also discuss problems that may arise if they live
together immediately — adjustment problems, finance, house, children’s.school, etc.,
and decide on the better alternative. They also arrive at possible solutions to problems
anticipated in the alternative selected. Finally, they evaluate the decision taken.
No marital counselling would be complete without handling of sexual problems. Often
addiction to chemicals leads to disharmony in sexual relations also.
The major sexual problems in the male are:
1. Decreased sexual urge or desire or lack of inclination.
2. Premature ejaculation : Dysfunction where ejaculation takes place even before
full penetration.
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ALCOHOLISM AND DRUG DEPENDENCY
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3. Secondary impotency : Sustained inability to maintain an erection due to
(Erective dysfunction) psychological causes which will allow normal
heterosexual penetration and ejaculation to take place.
I
4. Desire to continue a long-standing pre-marital/extramarital relationship.
These need to be looked for in all clients and discussed. Appropriate referral to a
sex counsellor can be made. In the case of a desire to continue a long standing premarital/extramarital relationship it needs to be emphasised that such a relationship
and sobriety would not go together and the client would need to get his priorities clear.
I
The spouse (female) may also manifest problems in the form of:
1. Disinterest, decreased desire or lack of inclination.
2. Frigidity
: Dislike of or aversion to sexual intercourse of
psychological origin of sufficient intensity to lead, if not
to active avoidance, to marked anxiety, discomfort or
pain when normal sexual intercourse takes place.
The counsellor needs to explore this as a factor in sexual maladjustment.
Often with recovery in other spheres namely, physical, occupational, interpersonal,
financial and mental the sexual problems also return to normal.
I
Bibliography
1. Barbara McFarland, Sexuality and Recovery, Hazelden Foundation, USA, 1984.
2. Barker Philip, Basic Family Therapy, Granada Publishing Limited, Britain, 1981.
3. Lester W Gregory, Backlean Ernest, Baucom H Donald, Implementation of
Behavioural Marital Therapy, Journal of Marital and Family Therapy, April 1980.
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29
FINANCIAL MANAGEMENT
After an addict is treated, several problems which were earlier secondary to the
problem of addiction, come to his notice. Financial mismanagement, particularly
non-repayment of debts is one such problem which the treated chemically dependent
encounters. Repayment of debts creates an enormous amount of stress on the addict
and therefore it is a condition that warrants attention from the counsellor. In the
past, the client would have used the problem of debts as an excuse, to continue drug
taking. Possibly on several occasions the wife or other family members would have
cleared the debts, with the belief that once the debts are repayed, the client would
stop taking chemicals. This behaviour of the family is known as Enabling. While
counselling, the counsellor should not enable the client, but help him to make realistic
plans, and guide the client to take the necessary initiative and carry out his own
responsibilities.
Financial problems come under two broad heads*.
1. Repayment of debts
2. Living within the available income
Repayment of debts
Dimensions of the problem
— Individuals tend to borrow from several sources like friends, relatives, Pawn
Brokers, Loan Sharks etc. For a small sum of money, say Rs. 1,000, the client
may have to face many (5 or 6) money-lenders. No matter what the due amount
is, answering a lender poses a problem to the borrower.
— Loans from Pawn Brokers and Loan Sharks, who advance money without security,
carry exorbitant rates of interest. Because of the high rates of interest, whatever
the borrower manages to pay will cover, at best, only the interest, and the principal
liability would continue to remain forever. Sooner or later, the borrower gives
up the hope of ever getting out of his problem of debts.
256
ALCOHOLISM AND DRUG DEPENDENCY
— Acquiring objects: There may be a tendency to buy costly articles like T.V., fridge,
grinder, mixie, etc which they consider essential for the house. But this would
involve a sudden burden on the family budget. Therefore the family members
should be told to postpone it.
— Pilgrimages: After discharge, the whole family plan elaborate pilgrimages. This
is a sensitive, sentimental issue, but at the same time it will bring pressure on
the existing financial status.
— Impulsive buying: This involves buying unnecessary things — for example, buying
fruits everyday, buying expensive clothes or buying whatever one sees.
A
The family will justify their position. So these problems have to be handled with
great care. They will feel that they are all changing, and therefore celebrating it by
spending a little money is not wrong. The counsellor should intervene cautiously
so that the family does not feel uncomfortable.
x \ /
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Bibliography
1. Nickell Paulena and Dorsey Jean Muir, Management in Family Living, Wiley
Eastern Limited, New Delhi, 4th Edition, 1976. ,
' x
2. T T Ranganathan Clinical Research Foundation, Road to Recovery, T T K
Hospital, Madras, India.
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30
PROBLEMS PRESENTED BY THE
CHEMICALLY DEPENDENT CLIENTS
Apart from the problems already discussed in other chapters, there are three important
issues which the Counsellor will be required to tackle in the treatment of chemically
dependent people:
1. Refusal to accept medication
2. Clients corning for counselling in an intoxicated state
3. Acute depression experienced by clients leading to suicidal thoughts and
tendencies.
I
Refusal to accept medication
In the initial phase of recovery, chemically dependent people would have been asked
to take antabuse or other anti-depressant drugs. Some of the alcoholics will refuse
to take antabuse mainly because they harbour wrong ideas about the possible damages
likely to be caused by the medicine. They will also be deeply afraid about the
possibility of their having an acute craving for alcohol, in which case they cannot
resist drinking. As they know that alcohol and antabuse taken together will lead
to severe problems, they will find it easier to refuse to take antabuse. So they will
start giving all sorts of excuses.
((I have the willpower to stop drinking; I do not need any medication for that. "
I
((I do not want to depend on pills and evade my personal responsibility.
At this juncture, the counsellor should not force the client to take antabuse. Instead
he should investigate and find out the reasons for his refusal through supportive
non-threatening ways. He should aim at removing his fear. At the same time, the
counsellor should not forget to provide information to the client regarding the effects
of antabuse if taken along with alcohol. The counsellor should evaluate and establish
a contract instead (i.e.) if the client has a relapse, then he would definitely take
antabuse.
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ALCOHOLISM AND DRUG DEPENDENCY
258
The clients may refuse to not only take antabuse, but also the antidepressants pres
cribed by the doctor. They may be afraid that anti-depressants will have a sedative
effect and this will come in the way of their occupational performance. The duty
of the counsellor is to educate them about their need to take the prescribed medicine
and should concentrate on removing their ill founded fears.
Clients arriving for counselling in an intoxicated state
The arrival of clients for their appointment in an intoxicated state is infrequent; never
theless it does happen and the counsellor should know how to handle the situation.
Under no circumstance should the counsellor threaten him or drive him away. He
should accept him but at the same time be firm. He should give him another date
of appointment and ask him to come for counselling on that day without using any
chemicals. If the client is non-aggressive, he could be told that no counselling can
be done when he is intoxicated. If the client is aggressive, the counsellor should be
cautious. He should have the door of his room open. The client is likely to blame
the counsellor for his relapse. He will try to provoke him in every possible manner.
At this point in time, the counsellor should be extremely calm and allow the client
to ‘blow off steam’. He should be careful not to disagree or argue with the client.
The client should be told in a firm and understanding manner that counselling is
not possible in such a state. He should be sent away as early as possible. The client
can be reassured that when he returns sober, he will be taken up for therapy.
Suicidal thoughts and tendencies
On mental status examination, chemically dependent clients have been found to be
depressed. Depression is characterised by a pervasive mood of sadness, decreased appetite,
decreased sleep, crying spells, suicidal ideation and lack of interest in activities. It
is essential to differentiate between neurotic depression (a type of neuroses) and
endogenous depression (a type of psychoses) as this has major implications for treatment.
Neurotic behaviour
Psychotic behaviour
Precipitated by a life event, (loss of a
loved one, loss in business)
Depression is worse in the evening.*
Psycho-motor activity (PMA) minimally
decreased.
Personal hygiene not neglected to a
significant extent.
No distinctive qualitative change of mood.
Usually not precipitated by a life event.
Occurs even when there is no crisis/
Depression is worse in the'morning.
Psycho-motor activity (PM*A) markedly
decreased to the extent of stupor.
Personal hygiene neglected'.^
Initial isomnia
(difficulty in falling asleep).
Distinctive qualitative change of mood.
(I have never felt so sad in my life before.)
Terminal insomnia
(early morning awakening).
These clients should be sent to the psychiatrists; they may be given anti-depressants
along with supportive counselling.
<
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PROBLEMS PRESENTED BY'THE CHEMICALLY DEPENDENT CLIENTS
259
Assessing suicidal risk
Forany client who is found to be depressed, an assessment of suicidal risk is essential.
Approximately 30% of all those who attempt suicide are chemical dependents.
Certain behaviours suggest the possibility of increased risk.
1. A history of previous suicidal behaviour, especially while under the influence of
chemicals.
2. Any family history of suicide.
3. References to feelings of futility such as T don’t care whether I live or die’, or
‘life isn’t worth living’.
4. Preoccupation with dying and direct references to suicide such as T have thought
about death a lot lately’, or ‘sometimes I feel that I would like to kill myself.
5. Reports of increased depression while taking chemicals or during abstinence.
6. Recent crisis or loss.
7. Severely depressed clients will not have energy even to get up. When they take
anti-depressants, the psycho-motor activity will improve, but immediately
depression will not be lifted completely. The physical energy coupled with acute
depression may give them the strength to attempt suicide.
If two or more of the above indicators are present, intervention will be necessary.
What should the counsellor do?
1. If the client appears to have suicidal tendencies, he should be directed to psychiatric
units.
2. After necessary medical intervention, the counsellor should adopt a calm,
empathetic and reassuring approach.
3. The counsellor should also involve the family members in the treatment
programme. They have to be counselled to keep a close watch on the client; not
to leave him alone; not to leave sharp objects around. They should be instructed
not to store lethal chemicals.
4. The client, after attempting suicide, would be emotionally unstable. He would
feel guilty, ashamed, angry and would often blame himself. This emotional turmoil
could drive him to attempt suicide again. Thus preventive counselling, using
supportive and reassuring techniques is important. The counsellor should initiate
a discussion of the client’s behaviour and feelings, in an empathetic manner.
5. The counsellor should not feel guilty and preoccupied with the question “Where
did I go wrong?”. He must set aside self-condemnation and should not take on
the role of the ‘saviour’ or ‘rescuer’.
260
ALCOHOLISM AND DRUG DEPENDENCY
To conclude,
'
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Treatment of chemical dependency is a rather complex proposition. The outcome
or result of this treatment cannot be measured through the traditional criteria like
— ‘So many were treated, so many became okay and so many did not’. We have
to be fully aware of the fact that chemical dependency sets in over a period of time.
So, recovery is also essentially a ‘process’.
The real challenge lies in understanding the full dimension of this complex problem.
It is here that the therapist finds enormous scope to apply his superior knowledge
and his ‘fine tuned’ skill as a counsellor.
As this awareness gets internalised, the counsellor finds the whole process challenging
and gratifying.
Patients who recover express their deep felt gratitude, because for them, it is the
counsellor who has brought them ‘out of the rut’. He has given them a ‘rebirth’.
Even problem patients, instead of becoming objects of frustration, turn out to be
individuals who deserve more empathy and understanding.
From then onwards, it becomes
Professionally satisfying; Personally gratifying.
Bibliography
Jacobs, R Michael, Problems presented by Alcoholic Clients — A handbook of
counselling strategies, Addiction Research Foundation, Toronto, 1981.
i
I
Appendix I
MEDICAL HISTORY
I
Name:
Address:
Drugs Abused
1) Depressants
— Minor Tranquillisers
— Hypnotics
2) Narcotic Analgesics — Opiates
3) Cannabis — Ganja
4) Stimulants
5) Hallucinogens
Brief History
Physical Examination:
I. General Appearance
— Temperature, Pulse, Respiration
— Skin colour or Eruptions
—• Oedema
— Body Hair.
h .
— Deformities
— Pupils ,'
— Needle marks
II. Respiratory system
III. Cardiovascular system
IV. Abdomen
V. Central Nervous System
Laboratory Investigations:
— Blood
— Urine
— Stool
Age:
Prescribed
Sex:
Non-Prescribed
262
ALCOHOLISM AND DRUG DEPENDENCY
WITHDRAWAL SYMPTOMS
I. Depressants
1) Tremors
2) Insomnia
3) Anxiety
4) Depression
5) Restlessness
6) Loss of appetite
7) Loss of memory
8) Withdrawal fits
9) Delirium
II. Narcotic Analgesics
1) Tremors
2) Nausea, vomiting, diarrhoea, abdominal pain ' - 'z
3) Excessive lacrimation, rhinorrhoea; ' \
' *
yawning, sweating
4) Goose flesh (cold turkey), muscle jerks:
5) Headaches, bodyaches, etc.
'
6) Blurred vision
. ,
x
7) Hallucinations
~ ’
8) Delirious state
III. Stimulants
1) Tremors
2) Loss of appetite
3) Disturbed sleep and lethargy
4) Fatigue
5) Irritability
6) Depression
IV. Cannabis
1) Anxiety and nervousness
2) Sleep disturbances
3) Loss of appetite
4) Burning sensation in the chest
IV. Hallucinogens
1) Hallucinations
2) Tremors
3) Anxiety
4) Depression and restlessness
Appendix II
IN TAKE FORM
Full Name in BLOCK LETTERS
Date of Registration:
At the Detox Centre:
Registration No.
At the Therapy Centre:
» v
Reasons for discharge:
,1 Date of Discharge from the centre
Sex
Age
Date of Birth
1) Completed treatment
2) Left with advice of centre
3) Left against advice of centre
4) Referred
5) Hospitalised
6) Dropped out
Nationality
Religion/
community
Education
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Permanent Address:
Phone:
Temporary Residential Address:
Phone:
Address of a Responsible Person:
Phone:
. I
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264
Urban/Rural
ALCOHOLISM AND DRUG DEPENDENCY
Other Languages Known
Mother Tongue
4
t
{
Marital Status
4) Divorced
5) Separated
1) Single
2) Married
3) Widow/er
I
Occupational Status
1) Employed Full-time
2) Employed Part-time
3) Not employed
4) Retired
5) Student
Occupation
1) Unskilled/Semi-skilled
2) Skilled
3) Clerical
4) Executive
5) Business
6) Professional
7) Agricultural
8) Defence Service
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Specify
Place of Employment and address
I
Income per month
Phone:
Date:
Place of prior Alcoholism/Addiction Treatment
<
Whether detoxified (Currently)
Place
Date/Duration
i
Source of Referral
1) Self
2) Spouse/Family
3) Friend
4) Physician
5) Psychiatrist
6) Specialist
7) Employer
8) Hospital
9) Recovering addict
APPENDIX II 4- IN-TAKE FORM
265
Background information
1. Details of Parents:
Father’s age:
Mother’s age:
Alive/Dead
Alive/Dead
Occupation:
Occupation:
2. In case of death of parents:
1
a) Not applicable
b) Your age at father’s death
c) Your age at mother’s death
3. Details of siblings (in the order of birth)
Relationship
Age
Education
Occupation
Marital Status
4. Order of birth
5. Current Living arrangements:
a) Resides in family units (parents/spouse/siblings/children)
b) Living with friends or distant relatives
c) Living alone (own place, apartment, lodge)
d) Institutional arrangements
e) Transient
Details of drug-taking
6. Circle appropriate number that reflects your use. Specify the drug.
1) Never used
2) Have used in the past
3) Have used in the past and it caused problems
4) Now using
5) Now using and is causing problems
Heroin
Opium
Morphine/Pethidine etc
Stimulants, dexadrine, Vitalin
Ganja, hashish
Hallucinogens
Alcohol
Tranquillisers, sleeping pills
Tobacco
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
5
»
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266
ALCOHOLISM AND DRltG DEPENDENCY
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7. Pattern of Use:
J
Type of Drug
How taken?
How often?
How much?
For how long?
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8. How old were you when you first took drugs?
I
9. In what context?...,
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10. Do you particularly use one type of drug or do you use two or more types? Do you use them
in combination?....
11. Usual intensity of drug-taking:
I
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a) Take drugs beyond intoxication into a day or more of binge type drug-taking
b) Usually stops drug-taking when intoxicated
c) Usually stops short of intoxication
12. Usual compulsivity for drug-taking:
a) Have compulsive episodes of binge type drug-taking lasting more than a day
b) Have compulsive episodes of drug-taking to intoxication although not binges
c) Feel a compulsion to continue although you can still limit your drug-taking
d) Limit drug-taking at will: no compulsivity experienced.
13. Do you need more or less quantity of drugs to achieve the same effect as you
experienced when you started using?
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14. The morning after an <evening
’
ncuuc
of using drugs, have you ever had the CA
experience
of not being able to remember everything that happened the night before? Please gi've anXinple?
15. Has anyone ever told you about things you did or things that happened while
you were under the influence of drugs that you could not remember? Explain.
16. Have you ever experienced shakiness or hand tremors, sweating, hallucinations,
running nose, cramps, watering of eyes? Explain.
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17. Has a doctor ever told you to cut down, or stop your drug use for any reason?
Explain.
I
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APPENDIX II - IN-TAKE FORM
18. Have you ever been hospitalised or $sought help
or for complications arising from drug use? Explain.
267
because
of drug-taking
19. Have you ever sought any prior help for drug addiction? List when and where.
20. Have you ever been to a meeting of AA/NA?
21. Have you ever made attempts on your own to cut down, or stop your use of drugs?
Explain.
22. Do you make sure drugs are readily available? Do you stock up? Explain.
23. Does the thought of using drugs sometimes enter your mind when perhaps you
should be thinking of something else?
24. Do you ever look forward to the end of a day or the end of a week so that you can
use some drugs? Explain.
25. Do you ever use drugs to reduce tension/or relieve negative fellings? Explain.
26. Do you find it difficult to enjoy social events if there are no drugs or drinks?
27. Do you ever use, drugs to relieve physical discomfort or treat any illness? Explain.
28. What is your' behaviour’ like when you are using alcohol or other drugs? Are
you more.funny, talkative, angry, verbally or physically abusive, prone to being abused? Explain.
29. Have you ever got into physical or verbal fights when you are on drugs?
Give example.
ALCOHOLISM AND DRUG DEPENDENCY
268
30. Have you ever compromised or broken your values when under the influence of drugs?
31. Have your family members ever complained or commented about your use of drugs? Explain.
32. While on drugs do you ever get the thought of killing yourself? Have you ever attempted to
kill yourself while using drugs? Explain.
33. Have you had any motor vehicle accidents while on drugs?
34. Have you ever sustained physical injury as a result of drug-taking?
Health scale
35. Present health status (before detox)
x ,zx '
a) Health is poor, life is hampered by what are or what is regarded as illness.
b) Health is fair, manages to get along despite illness or what is regarded as illnesses.
c) Health is good, with certain conditional comments.
d) Describes health as unconditionally good.
36. Status of medical treatment
a) Had either in-patient or out-patient treatment for what, where?
b) Felt treatment was required, but did not obtain needed treatment. Why?
c) Has not required any in or out-patient medical treatment for any illness in the past, year
(including minor bruises, colds, cuts)
37. Non specific complaints
a) None reported
b) Present
— Changes in physical appearance
— Loss of weight
— Anxiety, tension, nervousness
— Loss of energy, fatigue, tiredness
— Digestive difficulties
— Sleeping difficulties
— Disorders of appetite
— Headache
— Others
38. Have you ever had help from Counsellors, psychiatrists, psychologists etc., regarding personal
problems? Give details.
APPENDIX II - IN-TAKE FORM
Financial status
I
I
39. Describe your sources of income
I
d) By shares/investment
e) By rents
i
f) By agriculture
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I
a) None
b) By employment
c) By business
40. Do you (or your family) have any assets?
a) No
b) Yes, agricultural plots
c) Yes, houses/buildings
d) Yes, jewels
41. Does anyone inake financial contributions to you or to your family? Mention here if you are
a dependant^
1
a) No
I
I
b) Yes
42. In the past one year, what percentage of your family’s expenses was met by you?
a) 'bione
b) About 25%
c) About 50%
d) About 75%
e) 100%
43. Have you incurred any debts in the past one year? Give details.
a) No
b) Yes, about
N
44. Have you sold any property, article, jewels, etc? Give details.
a) No
b) Yes, worth
45. Have you resorted to drug peddling in order to generate funds (earn an income)? Explain.
46. Have you ever been involved in gambling anytime and lost large sums of money? Explain.
270
ALCOHOLISM AND DRUG DEPENDENCY
Vocational functioning/employment/school
47. How far did you go with your schooling?
(if illiterate, skip items 48 to 54)
Any specialised training?
What degrees?
48. Did you use drugs during the years of schooling?
a) No (skip to item .. 54 ...)
b) Yes
49. Has there been a change in your school performance since you started using drugs? Explain.
50. Have you ever missed classes due to drug-taking?
51. Have you ever been to class after taking drugs?
52. Have you ever been detained in any class?
53. Have you had any difficulties with teachers or school authorities? Explain.
54. Describe your accomplishments at school — (academic performance, extra curricular activities,
prizes etc)
If you are a student, skip items 55 — 65.
55. Are you currently employed or unemployed?
56. If currently unemployed, give reasons
57. List your current or most recent occupation — describe business, naihe of'your employer/
company, how long you have been working there.
58. List all jobs held, length of time, starting with the most recent. Include periods of unemployement.
59. Do you plan to return to your job/business when you leave here? Explain.
APPENDIX II - IN-TAKE FORM
60. Are you in danger of losing your job or business at this time? Explain.
I
61. Have your co-workers bf employer ever said anything to you about your drug use?
•'•••v.
.......s..:......................
....................
62. How often have you missed work or been late because of drug use. Explain.
I
63. Has drug use ever caused you to be less efficient in your work?
I
64. Have you ever received any of the following. Give reasons.
a. Verbal warnings
b. Memos
c. Suspension order
d. Increment not granted
e. Transfer
f. Resigned on request or as a protest
g. None of the above
1
65. Explain any other way in which your drug use has affected your work.
I
Family history
66. Has there been anyone in your family who has had any of the following:
Relationship
Duration
a. Epilepsy
b. Mental Retardation
c. Attempted Suicide
d. Suicide
e. Depression
f. Others
67. Did either of your parents use alcohol/drugs heavily?
a. No
b. Yes, who?
I
Treatment
Recovered/Partial recovery/
No recovery
272
ALCOHOLISM AND DRUG DEPENDENCY
68. For how long?
years
How often
69. Were there any problems in your family associated with their use of alcohol/drugs?
a. No
b. Yes. What kind
70. Were there any deaths in your family apparently due to heavy use of alcohol/drugs?
a. No
b. Yes. Indicate relationship
71. Did anyone in your family (besides parents) use alcohol/drugs heavily?
a. No
b. Yes. Indicate relationship
I
72. What is (or was) your parent’s attitude regarding alcohol/other drugs?
73. In your own words, describe your father’s characteristics.
74. In your own words, describe your mother’s characteristics.
75. How has your drug use affected your relationship with your parents? Explain.
76. Are your parents involved in your treatment for addiction? How?
i
If unmarried skip items 77 — 80.
77. Details regarding spouse:
a. Name
b. Age/Date of birth
c. Religion/Community
d. Education
e. Occupation
78. In your own words, describe your spouse:
273
APPENDIX II - IN-TAKE FORM
79. DetaiTs regarding children:
Age
Sex
Occupation
Education
Marital Status
80. Relationship with spouse
a. Complete alienation, divorce, desertion
details
b. Usually poor relationship, blaming, hostility.
c. Mixed, uncertain vacillating relationship
d. Usually friendly, minor conflicts
e. Friendly, warm, affectionate, mutual acceptance, good integration
f. Not applicable
81. Relationship with children, parents, siblings
Children
Parents
a. Family has disowned you or vice
versa, mutual rejection
b. By and large alienated from family
c. Mixed and indifferent feelings
d. Usually friendly, minor conflicts
e. Completely friendly, generally
accepted by all or most
f. Not applicable (dead or living distant)
Sexual history
82. Record current sexual practices (Frequency, status of partner)
83. After you have started using drugs, what was the first noticed sexual problem?
a. Premature ejaculation
b. Delayed ejaculation
c. Impotency
d. Anorgasmia
e. Extramarital relationship
f. Complete abstinence
g. Promiscuity
h. Others
i. None
84. Record any previous significant sexual experiences
Siblings
274
ALCOHOLISM AND DRUG DEPEN
Social life and leisure activities
85. What are your interests/hobbies?
86. Do you pursue your interests and hobbies?
Regularly
Irregularly
87. Has drug use become so important or time-consuming to the extent that other interests are to
some extent neglected? Explain.
88. What do you normally do with leisure time?
89. Do you socialise with people who use drugs as you do?
90. How has your social life changed as a result of drug use?
91. Have any, of your friends commented on your drug use? Explain.
92. Have you ever lost friends because of your using drugs?
Legal status
93. Have you been arrested anytime? Dates and explanation of each.
94. Have you ever been charged? Give details.
95. Do you have any legal problems pending? Explain.
275
APPENDIX II - IN-TAKE FORM
I
Summary of assessment
Name of patient:
History of
Loss of Memory
Medicinal use
Protecting supply
Taking drugs to get
relief from negative emotions
Behaviour change
Injury/Accidents
Unsuccessful attempt to limit use
Withdrawal
Daily use
Binge use
Increased Tolerance
Decreased Tolerance
Preoccupation
Others
Areas affected
Health
Social
Financial
Legal ...
Vocational
Family
Sexual
Others: (psychiatric problems, previous treatment)
Impression
Signature of Counsellor
Date:
)
4
Appendix III
THERAPY CHECKLIST
Name:
A.
Date of Registration:
\ I
a. Current Physical problems:
1. Liver Disease
2. Hypertension
3. Diabetes
4. Any other
b. Medication:
1. Disulfiram
2. Antidepressants,
3. Antipsychotics
4. Other
c. Family Participation
d. Support persons:
1. Whom? If none, reasons
1. Present
2. Absent
e. Initial Motivation for Therapy: 1. Poor 2. Indifferent 3. Good
f. Identified personality problems:
1. Low frustration tolerance
2. Dependence
3. Lack of confidence
7. Wishful thinking
8. Lack of assertion
9. Arrogance/defiance
4. Irresponsibility
5. Loneliness, Isolation
6. Gradiosity
10. Selfishness
11. Impulsiveness
12. Perfectionism
g. Noticed pecularities if any:
1. Restlessness
2. Withdrawn
3. Lack of concentration
4 Intoxicated during sessions
5. Coming late for therapy sessions
6. Missing therapy sessions
7. Lying
8. Highly critical of others
9. Argumentative
10. Drinking/drug-taking outside
sessions
11. Planning for future
drinking/drug-taking
I
f
277
APPENDIX III - THERAPY CHECKLIST *
Week I
Normal food habits restored/maintained
Normal sleep pattern restored/maintained
General level of involvement in the
Recovery Programme
Poor/Neutral/Good/Very Good
Group therapy participation
Poor/Neutral/Good/Very Good
Denial Mild/Moderate/Severe
Is able to identify addiction
Acceptance of addiction
Understands importance .of total abstinence
Denial handled:
Not applicable/Yes/Nb'
Guilt feelings dealt with
Not Applicable/X'es/^o
'
k
, x
Probed into re^entme'nts/grievances
Not applicable/Yes/No
Sexual problems, if any and whether handled
Not applicable/Yes/No
Suggested ways to overcome sudden craving
Yes/No
Discussed future drug-taking situation
and relapse
Introduction to AA/AA member
NA/AA member
Reoriented to job
Reconciliation with spouse/family
Life history completed
Assignment completed
Any other specific problems encountered
Recovery programme completed.
If not, give reasons
Motivation at the time of discharge
Poor/Indifferent/Good/Very Good
Week II
Week III
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278
ALCOHOLISM AND DRUG DEPENDENCY
After-care plans
(Follow-up pattern after-care group, AA/NA, medications, specific problems relating to job, family
etc).
1.
2.
3.
4.
Signagure of Counsellor:
Date:
_ i
1
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Appendix IV
GROUP THERAPY RECORD
Name
Date of Registration:
Attendance
Week I
Week II
Week III
Behaviour observations: (Eye contact, posture, sly smiles, expressions, mannerisms etc).
Interaction in Group
High/low participation
Shifts from high to low
Talks more to whom
Keeps the ball rolling
Silence
Positive/negative influence on group
Leader/rival/neutral
Suggests
Summarises
Gives or asks for facts
Keeps group on target
Helps others
Begins/cuts off
Preoccupied
Congenial
Always disagrees
Indifferent
Member of sub-groups
1
Week I
Week II
Week III
280
ALCOHOLISM AND DRUG DEPENDENCY
Extent/Content of Sharing
Week I
Week II
Week III
Impressions
Week I
Week II
Week III
I
Week I
Week II
Week HI
Signatures:
Date:
1W4.. •' - t
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Appendix V
ASSIGNMENTS
f
i
— Here is an assignment that will help you to
— think
—- understand
— identify and
— assess
the extent of your addiction.
— Think deeply and write down whether the following things/events happened in your life. If so,
when, where, and how, and what your behaviour was during these situations.
— It will help you to recover better if you are open and sincere about what you write.
Part I — Symptoms
1. Preoccupation with drugs
i
e.g. 1. Always thinking about when you can take the drug next (waiting for closing time of office/shop
so that you can start using drugs).
2. Planning, getting and using (making schemes or plans to get money so that you can buy drugs).
3. Unable to concentrate on work because your drug-taking is delayed — postponing urgent
or important work in order to take drugs.
2. Loss of memory
e.g. 1. Forgetting how you reached home the previous night
2. Totally unable to recollect promises you made while on drugs
3. Losing money and not able to remember how and when you spent it
4. Acts of aggrpssioii or anger which you were unable to recall the next day.
3. Increased tolerance
e.g. 1. Needing more and more of the drug in order to experience the same effect
2. Hiding the supply
3. Ensuring supply by stocking -if
4. Trying out a combination of drugs to achive the same effect.
282
ALCOHOLISM AND DRUG DEPENDENCY
4. Taking drugs to relieve negative emotions
(1 aking drugs to forget unpleasant events or feelings)
e.g. 1. Tension due to loss of job/death of family member
2. Anger due to a quarrel within the family
3.. Criticism from the wife/boss who keeps on finding fault with whatever you do
5. Dishonesty (Lying)
e.g. 1. Coming home late and saying that there was work in the office/school
2. Saying that the salary was cut by mistake/salary was lost or stolen/given as a loan to a friens etc.
3. Saying you have a special programme/work in order to get away from home and take drugs
4. Obtaining money by saying that you have extra expenses at school/workspot
with money given to pay fees.
'
buying drugs
6. Grandiose behaviour
e.g. 1. Pretending to be an important person, whereas deep down you feel very,insignificant and
unsure
2. Giving large amounts as tips/travelling in taxis (when you cannot afford it)
3. Buying expensive clothes, shoes, making unnecessary purchases for home
7. Loss of control
e.g. 1. Amount
starting with the intention of having a small quantity of drugs but ending up
stoned/intoxicated
2. Tune, place and company — any time becomes drug-taking time; drug-taking is associated
wit persons far below your social status, taking drugs with strangers; in inferior environments;
being intoxicated in places where one is expected to remain sober (at religious functions;
when there are guests at home)
8. Loss of other interests
)
e.g. 1. In family welfare (neglect of responsibilities)
2. In recreational activities (reading, films, sports, hobbies etc)
3. In personal appearance (cleanliness, clothing)
4. In all social functions except in those which involve addict friends
9. Accidents
e.g. 1. otaggering or falling on the ground, perhaps injuring oneself
2. While driving a vehicle/or getting hit by a vehicle
3. While at work
5
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APPENDIX V - ASSIGNMENTS
283
10. Aggressive behaviour
i
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e.g. 1. Violence — beating wife/children/parents/siblings
2. Damaging/breaking household articles
3. Abusive behaviour — using foul language
11. Insane behaviour
e.g. 1. Talking/laughing/crying to oneself
2. Wandering about naked
3. Trying to commit suicide while on drugs
12. Secret guilt feelings
e.g. 1. Inability to face significant persons when sober
2. Inability to tolerate.any discussion about drugs
3. Realising vthat drug-taking has become abnormal but not accepting it
4. Feeling bad about the consequences of previous drug-related episodes
A
i
A
I
\
13. Attempts to_control, but fails
e.g. L'Making vows/promising yourself and others
2. Controlling the amount/frequency of drug intake
3. Changing the drug/changing the environment, moving to a new place
Part II — Damages
1. Physical problems experienced
J
I
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e.g. 1. Physical deterioration
2. Changes in appearance
3. Loss of weight
4. Inability to sleep, sleep difficulties
5. Digestive problems
6. Specific illnesses
7. Injury
8. Loss of energy, fatigue
2. Vocational
I
e.g. 1. Reporting for work only to save the job and doing the minimum work mechanically without
interest
2. Being absent frequently
3. Employer’s loss of trust (resulting in warnings, memos, suspension, finally dismissal)
284
ALCOHOLISM AND DRUG DEPENDENCY
4. Using capital for drugs without realising how much is being spent
5. Inability to work (both physically and mentally)
6. Attending work under the influence of drugs
7. Not accepting responsibilities, delegating all responsibilities to juniors/subordinates
8. Postponing work, missing deadlines
3. At School
e.g. 1. Attending class only to fulfilling attendance record and not taking any interest in studies.
2. Skipping classes
3. Caught taking drugs on campus — warnings, suspensions, dismissal
4. Unable to concentrate
5. Not completing assignments — postponing study
6. Skipping tests
7. Failing in tests/exams
8. Drop in grades/ranks
9. Avoiding extra-curricular activities
4. Financial
e.g. 1. Amount of money spent on drugs
2. Mounting debts
3. Loss of savings
4. Loss of pay/income due to absence from work
5. Taking advances from salary’
6. Selling jewellery, property, articles, clothes, books
7. Peddling drugs to earn an income
8. Buying drugs with money given for fees and special classes
5. Social
e.g. L Loss of interest in social get togethers, family functions. Avoiding the same.
2. Loss of good friends and associating only with those who use drugs
3. Becoming a loner
4. Loss of reputation/respect in the community
5. Loss of trust in/from.friends
6. Loss of interest in hobbies
WWWiK...
APPENDIX
V<- ASSIGNMENTS
----------------------------------------- X—i------- \:--------------------
285
6. Family ,
e.g. 1. Frequent; quarrels, conflicts at home
2. Loss of communication, isolation from family members
3. Rejection by wife/parents/children/siblings
4. Not providing adequately for the family
5. Not taking family responsibilities
6. Breaching rules at home
7. Loss of love/respect/trust
7. Emotional
e.g. 1. Guilt (about money wasted, people antagonised, wife and children neglected)
2. Shame (inability to face neighbours, close relatives and significant people in one’s life)
3. Self-hate (feeling worthless, loss of self-respect)
4. Fear (uncertainty about future)
8. Legal
e.g. 1. Getting arrested/flned for drunk driving
2. Arrested for being unruly while intoxicated
3. Arrested for possession of drugs
4. Arrested for peddling drugs
5. Pending legal problems
9. Values
e.g. 1. Stealing articles from home and selling them
2. Selling objects that have a sentimental value to self or to family members
3. Making wild promises in order to manipulate others
4. Peddling drugs in order to generate funds
5. Not keeping time, making people wait, arriving late for fucntions
Part III — Recovery
1. Denial
Which of the following methods did you use while taking drugs?
1. Justifying
— (I took drugs because of stress at work)
2. Minimising — (I took drugs but I always did everything they wanted at home)
3. Blaming
— (I took drugs because my wife keeps nagging, my parents are always controlling
me)
.11
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ALCOHOLISM AND DRUXLDEPENDENCY
286
4. Threatening — (I will go to another woman
house if you object)
5. Silence
6. Diverting
7. Bribing
if you object to my taking drugs; I will leave the
— (I am not harming anybody. I never open my mouth)
— (Why are the children not getting good marks/why is the house untidy/why is
my brother always treated better)
— (You can go for a film tonight. Here is the money/I will do the repair you wanted
me to do)
2. Drug-taking situations
Imagine four situations when you may be tempted to take drugs. How do yo propose to handle them?
e.g. 1) New Year or a festival when people drink or get intoxicated
2) When you have really not taken drugs, your wife or parents suspect you have taken drugs
3) Suddenly you get extra money (profit/bonus)
4) When you are frustrated/depressed/angry resentful/excited
I'
I;
3. Values
Think and write down which of the values you have violated, and resorted to the following:
e.g.
1) Dishonesty
— (lying, cheating, stealing etc)
2) Selfishness
— (wanting everything for yourself — money, food, comforts)
3) Irresponsibility
(Not going to work regularly — not providing the basic necessities
to wife and children disregarding rules at home)
4) Intolerance/
Impatience
— Inability to accept situations which are not to your liking
e) Pride/arrogance
— Inability to admit mistakes — refusal to accept advice or suggestions
from others — insulting others
f) Resentment/hate
— Hanging on to the displeasure aroused by real or imagined wrongs
and injustice done to you.
I
I
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!is
n
I
4. Negative emotions
Examine your exaggerated negative emotions. Give examples from your life.
e.g.
1. Anger/resentment — (Sulking, refusing to accept help, shouting, beating)
2. Self-pity
— (Complaining/feeling sorry for one self)
3. Anxiety/Fear
— (What is going to happen to my life)
4. Inadequacy/
Inferiority
— (Everybody is doing better than I am doing)
5. Envy
— (All my relatives/friends are well off)
I
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i
■ l
APPENDIX V - ASSIGNMENTS
ft
287
5. Goals
Short-term goals:
1. Managing finance — debts and savings
2. Immediate necessities you would like to spend on — buying clothes and other necessities
3. Changes in relation to your work routine/attendance at school
4. Social commitment/contacts
5. Taking care of your health
6. Treatment related plans, after-care
7. Completing exams — clearing papers
■
fp
-
8. Gaining employment
Life History
Write in detail, openly and honestly what you remember of your life so far.
1. Start from your childhood, stating any significant event from your childhood to your adolescence.
2. Say when and how you started using alcohol or drugs, and the pattern of use.
3. Write about the damages caused by drugs to your physical, emotional, social and family life.
4. Write how you came to this centre, the initial feelings when you entered the centre and your
present feelings.
5. Write about your plan of action and the steps you will take to stay sober.
■a'
i ■
Appendix VI
FOLLOW-UP RECORD
■ i1
Name of patient:
Address & Phone No.:
Date of Registration
’
x1
Status on discharge;
- ‘
(Completed treatment, drop-out);
Name of Counsellor:
\ , \ '
At 3 months
At 6 months
At 12 months
Date
Date
Date
Drug-use
Quantity, frequency, pattern
Date
Date
Date
Health Status
Financial Status
Vocational Functioning
Family Relations
Social/recreational activities
Date
Date
Date
Medication
Date
Date
Date
Attends AA/NA
Date
Date
Date
Counselling
Date
Date
Date
Source of follow up:
Patient visited
Others visited
Letter received from
patient/others
Letter sent by Counsellor
Home-visits etc
ADDENDA:
SCORING KEY
Selzer Weight
Yes
No
Q. No.
2.
3.
5.
✓
1
1
/
1
✓
1
✓
1
✓
1
/
2
✓
1
/
2
/
1
0
/
1
2
/
8.
9.
/
5
•c
✓
1
✓
1
10.
✓
2
✓
1
11.
K 2
/
1
2
/
1
2
✓
1
12.
13.
14.
✓
—
a
1
—y-
16.
✓
2
17.
✓
1
19.
1
1
1
y
2
1
5
✓_
1
5
21.
/
22.
✓
2
23.
✓
2
✓
24.
1
J
7
J
2
18.
20.
1
2
15.
*
1
2
2
6.
7.
Points
✓
4.
*
Points
✓
1.
Unit Weight
Yes
No
1
/
/
1
/
2
1
2
25.
1
Interpretation
Master Score
(Selzer Weight)
0
1-4
5-6
7-25
25-39
40-53
Mast Score
(Unit Weight)
0
1-2
3-5
6-13
14-20
21-24
Level of
Evidence
No Evidence
Low
Some Evidence
Clear Evidence
Substantial
Severe
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