Aginq. No: 361. 1990 I

The Heart of Treatment for 1

AtCffifrTGH,TCS *{aa {-

,t “”‘F’ I *S! .1 :. !a’ : .1;* ,ir .{- \ fi 3 i.i l\ .r-‘Fii’, .: ;’- \\ ‘{— {d\ ‘u i

>”*”r:.Yll , #rii”a! ” -.n4.-,,”F

f;t,.t’1′.” —‘r&{

+_l ”’,eP’ds’€’

W'””‘-‘,’.i

‘”9{ .$;r,/ c’ ;/

l*

iAlcoholism NOI{YMOT]S: , . “*.-.,,.,1:.:.t by James J. Hinrichsen, Ph.D. “:q-“If, r’.:kt*i ,-( en years ago I rvas principal inr t’sliIltt0t r)l] J lllll\sivL’. 1 \..r \ Federally-lLrnclcd stutly of alcoholisrr in the elclerly.* A varietv of research approaclies were usecl t, to acldress questions rvhich rangcd in lcvel and focus frorri government policv to indii’idual case-hanclling. While a tremendous allnoLult of useful ancl irtrpor- -‘”-l**”* tanl infornration rvas cieveloped in that studl’. none ol it is as ir.nportant or useful as u,hat vou are about to rcad in this art ic Ic. Health ancl social servicc providers r,”ho u’ork u,ith elderlv peoplc necd to realize that about l0% ol the elclcrly are likell’ to manifest varl,ing degrees o1′ health. psychological and social dysfunctions related to the excessive use of alcohol. The difficulty’ associatcd with detecting excessivc alcohol use is in- 1 I versely related to the chronicity and scverity of the problem. About trvo-tlrirds of elderly alcoholics are severe. chronic “-t alcoholics *,hose symptorns tcnd to be both obvious and prol’ound. These syilrptoms are like Iy to include physical signs of intorication (e .g. dysnrthria. ataxia. impaired motor skills. attention and nremorv deficits, inappropriate behavior) alcohol withdrarval (e.g. Ircntulott \nes\. ni.lU\ci] . rot’ttiIino. anriety. tachycardia, hypertension. sweating. insomnia. loss of appctite. nrild disorientation). medical problems (c.g. gastritis. cancers of thc ciigestive tract. especiallv csophagus nnd stotnach, pancreatitis. lattv liver. hepatitis. cir rhosis. organic brairr svndronle, peripheral Ileuropath\’. blackouts. atherosclerosis. h)’pertensive hcart diseasc. cardiornyopathy. muscle pliin and

No.361 1990 13

deterioration, weakness). atlnormal latroratory tests (e.g. clevated uric acid, low levels of platelets and clotting proteins. decreased production of red and white blood cells. SGPT and SGOT elevations, lorv magnesiunr and potassium), and ps.v-chiatric and emotional problems (e.g. anxiety and depression. suicidal ideation. sleep disturbances, confusion and disorientation. frequent life crises, disturbecl interpersonal relations, and marked change in personality when drinking). The rernaining one-third of cases are likely to be less obvious. These people generally started drinking excessively later in li1-e and their dependence on alcohol has not yet resulted in profound debilitation. Regardless of the obviousness or chronicity of the alcohol problem, “patients” are far more likely to present themselves as having medical problems than to walk in and announce that they have a drinking problem. Denial is the most basic and frequent psychological response to the suggestion that one has an alcohol problem. Thus, while you are well-advised to get some training in the recognition of alcohol problems, it is not likely to help you much unless you also have some idea about what to do with older people who drink exccssivclY oncc vou have founcj theni. This is where we get into the areas of intervention and ref’erral for treatment the most delicate aspects of handling alcoholic clients. A major difliculty in meLking referrals lbr illcoho]ism treatment is resistan(e on the part of the client. This may be augmented in elderly problem drinkers who were the youth and teens of the Prohibition era and who hold very negative and about alcohol and alcoholism. and their ship between drinking and symptom nroralistic attitudes about alcoholics. denial of alcohol problems is likely to be rnanif’estation; or educate the client as to This population is also poorly educated supported by their observations tlrat they future problems he or she can expect if do not drink or act as their stereotype of drinking is continued. The counselor an alcoholic woulcl. should avoid the label “alcoholic”as well Dr. James Hinrit’hsen, u tlinital Confiontation may thus be thc flrst ls jrrdgmenlrrl. blaming. or punitive psychologist procticing in Mianti, step in the ref’erral process. Icleally. the statements. Florrclct. specializes in treatment relating counselor will have established a col- When the client has accepted the need to alcohol or drug abuse and also doe.s laborative relationship rvith the client, for, or tlre reality of the referral, it will be pro g ram – I ev e I r: o nsull at io n. F rtrnte r ly 6n and a mutual rapport. Gene rally, the best necessary for the counselor to explore the Jaculty oJ’ the Depot’tntenl of Ps1,- approuch is for the con [‘runtirrg per\on lo with the client his or her perceptions cholog,- ot the Unirersity’ oJ’ Mionti, share his or her concerns, using the about h’eatment, and neecls and pref’eren- Dr. Llinric:hsen served as printipal inves client’s presenting complaints to bring up ces in regard to treatment. Fear is a comtigator J.or u 2-_,-ear study on alc’oholism the subject of excessive clrinking. The rnoll response to the idea of entering in the eLclerh’,funded by the Administra- counselor may wish to point out clcstruc- alcohol treatment, and the counselor tion on Aging. tive pattems of alcohol use; the relation- should allow the client to express f’ears of

14 Aging

t rnhe real test . . . does not occur until the patient ;

I ir back out in the world and independenily faces the challenges of abstaining from alcohol.

cohol program or to a detoxiflcation cen- network have only a superficial awarebeing “locked up,” socially ostracized, or ter may be appropriate. Does the client ness of A.A. Unless they are members of financially ruined as a result of entering an alcohol treatment program. When the have spccial health-care needs or dis- A.A. or have a close relationship with an client has overcome the initial shock and abilities rvhich would bear on his or her A.A. member. their knowledge of A.A. is its attendant anxieties. the counselor can eligibility ol trcatrlient? Before ref’e ning likely ro be deficient and their attitudes -fhe a client to any institution it is advisablc to toward A.A. may be distorted. notion explore those issues pertaining to the bc aware of thc organization’s require- that A.A. is a “re ligious program” which type of f acility which is acceptable to the rrre nls lrtttl llte seopc of its scrviecs. “has twelve steps” and “requires a lot of client. ‘Ihe third step in the referral process is meetings in smoke-filled rooms” fails to dojustice to a vilst, sophisticated and fiee assisting the client in contacting the The Most lmportant Things alcoholism recovcrY program. referal agency. This might include ar- You Need to Know about The majority of alcoholism treatment ranging transportation to the agency; contacting directly the person who will Alcoholism Treatment programs in the U.S.. including hospitalhased in-paticnt prosrams. out-palienl meet the client there; arranging a specific ‘[hc vrrrictl of apltroaches to thr trellt- prognlms. tnd lortg-tcrnt residerntial care tinie lor the appoirltr.ncnt: ()btaining ment of alcoholic patients is mincl-bog- prograrns use the A.A. philosophy and signed releases for the transf’er of infbrgling in its diversity and this diversity encourage patients to become actively mation; and arranging for follow-up report(s) from the referral agency. Refer- constitutes a testitnonial to the frustratiorl involved with A.A.. While a period of rals to agencies with long waiting lists and lack of success which caregivers hospitalization may be necessary for should be avoided. as research shows have experienced. Once you move many alcoholics to detoxify saf’ely and to that the longer an aicoholic waits before beyond standard medical remedies for stabilize medically, the real test of the entry into the treatment system, the less the physical maladies associated with efficacy of treatment does not occur likely he or she is to enter or succeed in alcohol dependence, you enter the realm until the patient is back out in the world treatment. of actually treating the disease of and independently faces the challenges There are a varietY of existing alcoholism. After 20 years of clinical and of abstaining from alcohol. Data from the programs for the treatment of al- research exprrience, I am convinced that AoA-funded study clearly indicated that coholism, ranging from in-patient, hospi- the prograrn provided by Alcoholics elderly alcoholics who became actively tal-based programs to out-patient clinics Anonymous (A.A.) has provided more involved with A.A. were far n”rore likely and half-way houses. In choosing a ref’er- help to rnore people than anY other to remain sober than those who did not. ral for an elderly alcoholic or problem approach. Furthermore, I see no evidence This research also clearly showed that drinker, a number of factors must be con- to suggest that this reality is likely to group therapy and social support, change in the foreseeable future. The whether related to A.A. or not, were the sidered. First is an assessment of the most important infonnatior.r in this article most important and effective elements of person’s physical condition. Does he or is what you are now going to read about treatment. she require detoxification or immediate medical attention’? lf this is judged to be A.A. and how it works. The A.A. approach lo recovery incor- Most caregivers in the elderly services porates a “medical” nlodei of alcoholism the case, then refenal to a hospital’s al- ^ *This 2-year sntdt,(ot.t, t979 – Der” l98l ),Juntlcct bt. rhe Atlministration otr Aging. sent research teunts to intervievr s;a.ff ond clients in l0 alt:oltolisnt ttc(ttnrn[ prt)gt’LlDts in 6 states und 7 progrdms speciuli:ing in treotmertt o.f’thc elderly.7’\r study

S,.r\,€_v- on aLr:oholisnr. For.furrher ir(‘ornrutiort on tht: AoA-.fLutded stutll’,.see “Srr,ggesred Reading” on puge l7′

trto. 961 1990 15

I :

and a “moral-spiritual” model of The second step of A.A. further preclude an examination of each of them , recovery. The rncciical rrotlcl of al- ret-lects the genius ol the program ii’r that coholism asserts that alcoholism is a dis- it provides hope and strcngth to replace they cover. In A.A. it is accepted that the i

ease lvhich, i1’not treated. is protressive despair and weakness. In this step rhc r’csslllion trl’ rlrinkins tloes not tonstitutc and may leail to preniature illness atxl alcoholic ackrrowled-ecs the existence of recovery-it merely makes recovery ileath. The furrdiirnental ntcdical problent a prower grcater than self which can possiblc. J’he neecl for protbund lil-e-style is that sonre people restr.rond phr sicalll, tcr restore “sanity.” Thc acceptance of a change is retlccted by the individual’s alcohol rn an abnonral *rrv uhich leads “Highcr Powcr” is both a source of conscious decision to lead a less selfto excessive use. depenclence. ‘craving” strength and inspiration to some people centered life and to accept one’s place in ancl an inabilitv to control alcohol intakc. and an obstacle to be dealt with ior the broacle r scheme of life. The alcoholic The mcdrcal nrodel ol alcrrholisrn has others. The cclncept of a Higher Power in is askecl to make “a searching and f-earreceived some persuasive research sup- A.A. ref-ers to “God as we understood less moral inventory of self” and to share polt in recent years as evidence has been llim” and it is thc comerstone of the this with another person. Sound psycholgenerated in support of the assertion that spiritual foundation of A.A. Unlbrtunate- ogy is represented here in that exposure there rnay exist, in sonre people. a seneti- ly, the “religious” nature of the A.A. pro- of the truth is consistent with a heatthy cally inherited prcdispositron to becorne _eram has been used by many alcoholics orientation to reality and the emotional alcoholic. Whiie it is truc that there is a to justify their avoidance of the program. catharsis associated with relief from guilt continuing scientilic clebate over the T’hey complain or argue that this is a and shame represenis an unburdening of charactcrizalion of alcoholisnt as a dis- “turn-ofl’ or that they can’t relate to it. the self from negative, depressive emo- t

ease, this debate has proven to be of rnore So profbund is this phenomenon that in tions. Confession really does seem to be scientilic interest than therapeuiic value. Alcoholics Anony-ntoLrs. the A.A. “Big good lor the soul. In my opinion. the medical rrodel clf ad- Book” which describes how the program Additional steps in the A.A. program cliction has been valuable in therapeutic works, there is an entire chapter entitled instruct and encourage the individual to practice largely because it is nrore ac- “We Agnostics” which deals with this take actions, both practical and spiritual, ceptable to the “patient” iind to society to issue. For some, A.A. becomes the higher view addictions as illnesses rather than as power. For now, suffice it to say that it is sion of personal awareness, acceptance ret-lections of a personal l-ailure of will- a gross distortion of the A.A. program to of personal responsibility, and sharing i power or some other equalli’ humiliating assert that one must be a highly religious characteri zation. person to benefit from the program. tbrce and integrate the progress which The A.A. I l-stt’p f rosnrm (,f rcco\ cry ‘fhe remaining 10 steps of the A.A. the recovering person has made. begins with the practical observalion program also reflect the wisdom of those Recovery is seen as being a life-long that, fbr whatever reason. the indiviciual who have strugglecl to recover from al- process which must be protected at all has lost tl.tc 1rou.r’r ol’choicr- u ith rc:pect e oholisnr ancl ll hile space limitatiorrs trrncs. Thcre is no “curc” for addiction to to alcohol consunlption.’l he alcoholic’s capacity to drink moderatel\ is so inrpaired as to render the nolion of “freervill” a liction. Along with thc inabrlity to Suggested Reading control alcohol consumption is a Hinrichsen, J.J. Toward Improving Treatment The A.A. Member-Medications and diminished capacitv to nranage one ‘s Services for Alcoholics of Advanced Age. Other Drugs health and life in general. fhe rccogni- Al c o hol, H ea lt h a nd Re se arch Wo r I d,Yol. 8, No. 3, Spring, 1984. Clearinghouse for Al- Is There an Alcoholic in Yuur Life? tion and acceptance of this rc:rlitv concohol and Drug Information, P.O. Box Inside A.A. stitutes an enormousll inrportant 2345, Rockville, Md. 208-52. The A.A. Group psychological change lronr denial tcr How A.A. Members Cooperate awareness. It’s Iike walking lionr dark- Selected A.A. Publications: A.A. in Treatment Facilities ness into light and it constitutcs thc foulr- Al coho I ics Anonymous (book) A Member’s-Eye View o[ Alcoholics dation orr whit lr u pro.urirnr ol rccovcr) 44 Questions Anonymous can be built. It is part ol the * isdorn ol A Clergyman Asks About A.A. Problems bther Than Alcohol A.A. to know that this “arvakening” is Three Talks to Medical Societies by Understanding Anonymity vcry much an individual matter which Billw. A Newcomer Asks will not happen until the indir idual is “ready.” Getting to the point of readiness Alcoholics Anonymous as a Resource ls A.A. for You? for the Medical Profession A Brief Guide to A.A. nray require that the indiviclual -‘hit bot- A.A. in Your Community torn” through considerable suffering. (Complete order forms available liom A.A. for the Woman Sadly, some alcoholics never do reach a Time to Start Living (a pamphlet for General Service Office of Alcoholics , state o1- readiness and, other than interthe older alcoholic) Anonymous, Box 459, Grand Central vcntion through some form of confronta- Letter to a Woman Alcoholic Station, New York, NY 10163) tion, there scems to be little that outside agcnts can ckr to assist the proccss.

16 Aging

alcolrol, only an ongoing program of recovery. A number of features of A.A. rnake it cspecially appropriatc for eldcrly people. First, it’s free. Given limited funds and weak Medicare or other insurance i coverage for out-patient treatment, A.A. represents an appcaling alternativc. Moreover, all the gold in F-t. Knox cannot buy the suppofl and contntitment which is given ficely by A.A. merrbers. In A.A. you “work your program” with the help of a sponsor-a person who has “good sobriety” and who understands how the A.A. program works. Usually, these sponsors agree to be available 24 hours a day to assist you in case of crisis. Also, rnany A.A. meeting rooms are always open and this saf’e haven can be used by those who need it. The support provided by A.A. goes beyond sponsorship in “working the program.” It includes the provision of a sense of belonging, of being part of a group. This sense of connectedness can serve as a powerful antidote to the loneliness and isolation which is common among the elderly. If you need a ride to a n-reetirlg. someone uill provitlc it l’reely. Also, you can travel to just about any part of the country and many parts of the globe and you can find an A.A. rneeting, a safe haven, a place where You know you will be welcome. You can’t buy this. In closing, it should be noted that A.A. is not the “answer” for all people-nor does it claim to be. Some alcoholics stttp drinking with no assistance whatsoever but they are the minority 4nd it is questionable whetl.rer their psychological and spiritual growth continues rnerely because they are abstinent. Some alcoholics find that they rvant or need psychotherapy or medical treatl’nent for other psychological problents. Sonletimes A.A. is only the beginning of the recovery process but it is the best program I know of ancl no one can argue about its cost eff’ectiveness. lf you really want to be helpful to elderly alcoholics. learn about A.A. Get a coPY of A/coholits Anonyntous, .eet a copy of a “Where and When” booklet so you knou’ the location and tirres of local rneclings. go to some meeiin-gs. Find out if thcre ure ally rneetilt.g\ itt r ottt ittea c:PCcially lor older aclults. Share rvhat 1’ou leam.

No. 361 1990 17