Practical Approaches to

Alcoholism Psychotherapy

Practical Approaches to

Alcoholism Psychotherapy

Edited by

Sheldon Zimberg, M.D. Director of Psychiatry

Hospital for Joint Diseases and Medical Center New York, New York

John Wallace, Ph.D. Director, Talbot House

Putnam County Alcoholism Services Mahopac, New Y ork

and

Sheila B. Blume, M.D. Unit Chief

Charles K. Post Alcoholism Rehabilitation Unit Central !slip, New Y ork

Plenum Press· New York and London

Library of Congress Cataloging in Publication Data

Main entry under tide:

Practical approaches to alcoholism psychotherapy.

Includes bibliographies and index. 1. AIcoholism - Treatment - Addresses, essays, lectures. 1. Zimberg, Sheldon. 11.

Wallace,john,1931· III. Blume, Sheila B. RC565.P715 616.8'61'06 78-15811 ISBN 978-1-4615-7654-9 ISBN 978-1-4615-7652-5 (eBook) DOI 10.1007/978-1-4615-7652-5

© 1978 Plenum Press, New Y ork Softcover reprint ofthe hardcover 1st edition 1978

A Division of Plenum Publishing Corporation 227 West 17th Street, New York, N.Y. 10011

All righ ts reserved

No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming,

recording, or otherwise, without written permission from the Publisher

Contributors

1. A. ALlBRANDI, PH.D. • Assistant Professor of Addiction Studies, School of Health Related Professions, University of Arizona, Tueson, Arizona

SHEILA B. BLUME, M.D. • Unit Chief, Charles K. Post Alcoholism Rehabilitation Unit, Central Islip Psychiatrie Center, Central Islip, New York; Co-Director Caribbean Institute on Alcoholism, College of the Virgin Islands, St. Thomas, U.S. Virgin Islands; Assistant Clinical Professor of Psychiatry, School of Medicine, State University of New York at Stony Brook, Stony Brook, New York

DOUGLAS K. CHALMERS, PH.D. • Associate Professor of Psychology, School of Social Sciences, University of California, Irvine, California; Direc­tor, PATHS Foundation, Laguna Beach, California

}UNE }ACKSON CHRISTMAS, M.D. • Commissioner of Mental Health, Mental Retardation and Alcoholism Services, City of New York

CEllA DULFANO, M.S. W. • Consultant in Family Therapy and Alcoholism, Clinical Assistant Professor, Department of Psychiatry, State University of New York, Downstate Medical Center, Brooklyn, New York

}AY FISCHER, PH.D. • Executive Director, Veritas Therapeutic Community; Consultant, New York City Affiliate, National Council on Alcoholism; Private Practice

DONALO P. HOWARO, M.Eo. • The Howard Institute Family Counseling Center, Columbia, Missouri

NANCY T. HOWARO, B.S. • The Howard Institute Family Counseling Center, Columbia, Missouri

}OHN S. TAMERIN, M.D. • Clinical Associate Professor of Psychiatry, Cornell University College of Medicine, New York, New York

}OHN WALLACE, PH.D. • Director, Talbot House, Putnam County Alcoholism Services, Mahopac, New York; Psychological Consultant, Hospital for Joint Diseases and Medical Center; Guest Investigator, The Rockefeller University, New York, New York

SHELDON ZIMBERG, M.D. • Director of Psychiatry, Hospital for Joint Diseases and Medical Center, New York, New York; Associate Professor of Psychiatry, Mount Sinai School of Medicine, New York, New York

v

Foreword

Sodetal attitudes toward alcoholism are characterized by several types of denial, with disastrous personal and sodal consequences. Refusal to admit the extent of alcoholism as a major national health problem leads to a public policy which allocates relatively few resources to research, prevention, treatment, or rehabilitation. On an individual basis, the combination of sodally approved drinking and the stigma assigned to the chronic alcoholic results in individuals blinding themselves to the existence of the problem in family, friend, and self until it has reached such an advanced or obvious degree that denial is no longer possible.

There is the third kind of denial, exemplified by therapeutic de­spair, which proclaims thatgaps in knowledge of the cause of alco­holism are so great and failures to treat alcoholics successfully so dra­matic that there is no assurance that efforts will lead to a positive outcome. This denial is perhaps the most troublesome because it re­flects an attitude of therapeutic helplessness. It discourages families from seeking help, and it reinfOlces the tendency of physidans and other human-services workers to overlook the presence of alcoholism as they treat its physical, sodal, and economic consequences. Denial frequently surrounds those who treat alcoholics with an aura of hope­lessness, which itself is a negative therapeutic force.

Indeed, even within programs that provide alcoholism services, a limited conception of the possibility of therapeutic effectiveness is sometimes based on the underlying assumption that there are no in­terpersonal skills essential to treating alcoholism which can be clearly defined, written about, or taught to others. This assertion frequently goes hand in hand with the belief that only those who have themselves experienced the pain and anguish of alcoholism can be helpers of others and that even this experiential knowledge is something intuitive over which there can be no intellectual mastery.

This book puts the lie to these views. Written by practitioners

vii

viii FOREWORD

from various fields, each with years of experience in the provision of alcoholism services, this book is based on the assumption that there is knowledge of what works, and that this knowledge can be delineated with justice to both theoretical underpinnings and practical guidance. At the same time, this volume recognizes the need for alcoholism services to stand the test of evaluation as weIl as of conviction and of time.

Therapeutic techniques discussed, based on a psychosodal phi­losophy, are considered from a wide perspective. Yet the book does not attempt to deal with all types of alcoholism services. Instead, it focuses on a range of psychotherapeutic approaches, including indi­vidual, group, and family therapies, along with the folk psychotherapy intrinsic to the most successful approach, Alcoholics Anonymous. As we look at these techniques, the basic theoretical knowledge that op­erates is underlined and the usefulness of understanding psychody­namics in applying general prindples of psychotherapy to treatment of alcoholism is pointed out.

Moreover, we recognize that sodal status, income, ethnic back­ground, sex, and age are not merely entries on an intake record, as they are too often considered to be. They are, instead, significant factors that have to be addressed in the provision of services to those who abuse alcohol and to their families. The need for sodoculturaIly syntonic services is sometimes underemphasized as if "the case" ex­isted outside of the sodal environment or "the disease," outside of the human being.

While the holistic sodopsychological approach does not accept singular causality and recognizes that much more information is needed about determinants, it nevertheless addresses the significant factors of adolescent task accomplishments and emotional develop­ment, of the pressures of being poor in an affluent sodety, of sexism, of discrimination against racial minorities, and of rejection of the el­derly. These critical forces have to be reckoned with as part of the therapeutic plan if alcoholism services are to relate to the individual in a sodal context as, indeed, they should.

To plan and implement services that may be effective in treating alcoholism requires an orientation that relates to these factors as they contribute to human personality, growth, and sodal behavior. This is far different from the traditional psychiatric approach, which focused (when psychiatrists were willing to accept alcoholics as patients) on individual psychopathology, or the medical approach, which resulted only in repeated detoxifications and trips through the revolving hos­pital door. This orientation does not espouse a single rigid response to

FOREWORD ix

what could be incorrectly described as a unilaterally determined dis­order. Although the focus is on psychotherapeutic approaches, it does not reflect the view that alcoholism can be helped solely through the resolution of intrapsychic conflicts, nor the moralistic approach which speaks to defects of will. Even though the sections on sodal disadvan­tage reflect recognition of the interaction of the individual and sodety, the approach is not restricted to the sodal-environmental view some­times espoused by those who deeply feel the effects of deprivation­that alcoholism would no longer exist if sodal and economic inequities were to be removed. Instead, several possible rehabilitative and treat­ment approaches are addressed and clearly defined, and significant questions are raised about the need to evaluate the effectiveness of each.

The very practical approach that is taken by Sheldon Zimberg, John Wall ace , Sheila Blume, and their collaborators is a significant addition to the armamentarium of writings on akoholism. More than a "how toff book, this volume raises questions about the course of recovery and the factors that are in operation at every stage of health and disease.

For those who are already involved in the provision of alcoholism services, these writings should provide a stimulating and provocative addition to the literature that has erred in the past by being too general and impressionistic. To those who have recognized the need for skill­ful, well-trained professional and paraprofessional practitioners, this book should be an encouraging beacon.

June Jackson Christmas, M.D. Commissioner of Mental Health

Mental Retardation and Alcoholism Services

City of New York

Preface

This book is designed to provide theoretical and practical guidelines for practitioners and students in alcoholism psychotherapy. It is based on the knowledge of clinicians who have had considerable experience and success in the treatment of alcoholism. A variety of psychothera­peutic methods wh ich have been applied effectively are described.

Modified approaches for the treatment of various subpopulations of alcoholics, including adolescents, women, the elderly, and the so­cioeconomically deprived, are presented to highlight the fact that al­coholism is a complex illness that manifests itself in differing patterns among particular populations.

The volume generally can be viewed as a text on applications of verbally oriented therapies in the treatment of alcoholism. The final chapter discusses the evaluation of patient progress and can serve as a guide to assessing clinical effectiveness.

The editors would like to acknowledge the assistance of Doris Borakove in the preparation and editing of this book.

xi

Sheldon Zimberg, M.D. John Wallace, Ph.D. Sheila B. Blume, M.D.

Contents

THEORETICAL CONSIDERATIONS

Chapter 1

PRINCIPLES OF ALCOHOLISM PSYCHOTHERAPY

SHELDON ZIMBERG

Introduction Psychodynamics of the Alcoholic Treatment of Alcoholism . Sociopsychological Factors Affecting Psychotherapy The Treatment Process Summary References

Chapter 2

3 4 7 8 9

17 17

WORKING WITH THE PREFERRED DEFENSE STRUCTURE OF THE RECOVERING ALCOHOLIC

JOHN WALLACE

Introduction The Preferred Defense Structure (PDS) of the Recovering

Alcoholic .

xiii

19

20

xiv

Tactical and Strategie Use of the PDS Summary and Conclusions .

Chapter 3

CRITICAL ISSUES IN ALCOHOLISM THERAPY

lOHN WALLACE

CONTENTS

26 29

Introduction 31 Denial versus Premature Self-Disclosure 31 Guilt versus Sociopathy . 32 Self-Blame versus Blaming Others 33 Rebellion versus Compliance . 34 Acting-Out versus Repression . 35 Obsession with the Past versus Refusal to Consider It 36 Indiscriminate Dependency versus Stubborn Independence 38 Compulsive Socializing versus Alienation . 39 Perfectionism versus Inferiority . 40 Self-Obsession versus Obsession with Others 41 Pessimist versus Pollyanna 42 Summary 43

TECHNIQUES OF TREATMENT

Chapter 4

PSYCHIATRIC OFFICE TREATMENT OF ALCOHOLISM

Introduction Methodology Results Case Histories Discussion .

SHELDON ZIMBERG

47 49 52 53 59

CONTENTS

Summary References

Chapter 5

GROUP PSYCHOTHERAPY IN THE TREATMENT OF ALCOHOLISM

SHEILA B. BLUME

xv

61 61

Introduction 63 Why Group Therapy? 64 Types of Groups in Alcoholism Treatment 65 Setting Up the Group . 67 Goals and Techniques of Group Psychotherapy in Alcoholism

Treatment 68 Problems in Group Treatment of Alcoholism Summary Reference Suggested Readings

Chapter 6

PSYCHODRAMA AND THE TREATMENT OF ALCOHOLISM

SHEILA B. BLUME

Introduction Why Psychodrama in Alcoholism Treatment? The Formal Psychodrama . Techniques Used in Psychodrama . Application of Psychodrama Techniques in Alcoholism

Education and Treatment Settings Case Histories .

74 75 75 75

77 79 82 87

93 95

xvi

Summary References

Chapter 7

CONTENTS

96 96

BEHAVIORAL-MODIFICATION METHODS AS ADJUNCTS TO PSYCHOTHERAPY

JOHN WALLACE

Introduction Generalized Habit-Pattern-Disruption Techniques Discriminating Sober versus Alcoholic Behaviors Resolving the Alcoholic Identity Crisis Methods for Achieving Relaxation Fear-Reduction Procedures . Altering Attitudes toward Self Summary References

Chapter 8

FAMILY THERAPY OF ALCOHOLISM

Introduction Family Therapy Family Structure

CEllA DULFANO

The Influence of Alcoholism on Family Structure Family Therapy in Cases of Alcoholism Case Histories Discussion Conclusion References

99 100 102 105 107 111 113 115 116

119 121 122 123 124 126 133 134 135

CONTENTS xvii

Chapter 9

TREATMENT OF THE SIGNIFICANT OTHER

DONALD P. HOWARD AND NANCY T. HOWARD

Introduction 137 Getting Inside the Four Walls 139 The People Living Inside the Four Walls 140 The Treatment Plan: a Change in the Dance Steps, or Stop the

Clock . 142 Touch System 159 Summary 160 References 162

Chapter 10

THE FOLK PSYCHOTHERAPY OF ALCOHOLICS ANONYMOUS

L. A. AUBRANDI

Introduction The Sponsor in AA An Empirical Investigation References

TREATMENT OF SPECIFIC POPULATIONS OF ALCOHOLICS

Chapter 11

THE PSYCHOTHERAPY OF ALCOHOLIC WOMEN

]OHN S. TAMERIN

Introduction Characteristics of Women Alcoholics

163 166 168 180

183 183

xviii CONTENTS

Evaluation of Alcoholic Women . Psychotherapy of Alcoholic Women Case Histories Conclusion References

Chapter 12

TREATMENT OF SOCIOECONOMICALLY DEPRIVED ALCOHOLICS

SHELDON ZIMBERG

Introduction Treatment Approaches: Black Alcoholics; Puerto Rican

Alcoholics Evaluation of Treatment Outcome in Socioeconomically

Deprived Alcoholics Discussion Summary References

Chapter 13

PSYCHOTHERAPY OF ADOLESCENT ALCOHOL ABUSERS

JAY FISCHER

187 190 193 201 202

205

208

213 215 217 218

Introduction 219 Characteristics of Teenage Alcohol Abusers: Some Implications

for Treatment 220 Problems Encountered in the Treatment of Adolescent Alcohol

Abuse. 223 Persons to be Excluded from Treatment 225 Treatment of Choice . 226 Group Treatment Techniques . 228 Problems Arising within the Group 233

CONTENTS

Summary Referenees

Chapter 14

PSYCHOSOCIAL TREATMENT OF ELDERLY ALCOHOLICS

SHELDON ZIMBERG

xix

234 235

Introduction 237 Classifieation of Elderly Alcoholies 239 Psyehosocial Faetors in Geriatrie Alcoholism 240 Psyehosocial Treatment Teehniques . 242 Loeation of Treatment Programs . 245 Applying the Coneepts of the Therapeutie Community to the ~~ W

Use of Alcohol in Institutions 248 Summary 250 Referenees 250

CLINICAL EVALUATION OF PATIENT PROGRESS

Chapter 15

EVALUATION OF PATIENT PROGRESS

DOUGLAS K. CHALMERS AND JOHN WALLACE

In trod uction Inpatient Evaluation Outpatient and Follow-Up Evaluation Referenees Suggested Readings .

INDEX

255 256 265 278 278

279