Treating Alcohol and Other Drug Abusers in Rural and Frontier Areas
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Jack Peterson
Director
Alcohol Recovery Center
Ontario, Oregon
The delivery of quality residential treatment requires three essential ingredients. Each is indispensable. These ingredients include:
These are what determine the success of a treatment program.
AbstractAlcoholism and chemical dependency are discussed in the context of of the Alcohol Recovery Center Intensive Residential Treatment Program. Three elements essential to the delivery of quality residential dynamics of the illness; formulating all treatment methods toward direct treatment of the disease; and maintaining a highly motivated treatment team. Alcoholism and chemial dependency are typical medical dependcy are typical medical diseases that contain components of mental and emotion compulsions that recur even when active drinking or drug use is arrested. Drawing on the teachings of Father Joseph Martin, the author states that alcoholism and drug additction teach its victims how to be afraid; one gets rid of fear by learning to love again. Treatment is a process in which clients are placed in a position of learning to love. Self-sacrifice, delayed gratification, and ego deflation are all key elements of success in intensive residential treatment. It is important for a counselor to act in a mature manner and not sacrifice honesty for the client's approval. The author advises that counselors should not compare themselves to, compete with, or criticize other counselors. |
Alcoholism and chemical dependency are typical medical diseases which contain components of mental and emotional compulsions that recur even when active drinking or drug use is arrested. Dr. Frederick A. Montgomery, addictionologist and author of Alcoholism and Chemical Dependence, states:
The abuse of prescription drugs results in more injuries and deaths to Americans than all illegal drugs combined. In 1983, there were 1.5 billion prescriptions dispensed and several hundred million pills were diverted to illicit use. Prescription drugs are involved in almost 60 percent of drug-related emergency room visits, and 70 percent of drug-related deaths are commonly associated with alcohol. In almost every case of prescription drug abuse, there is also a dependence on other drugs and/or alcohol.
People who are genetically prone to the development of alcoholism may inadvertently find themselves dependent on medications prescribed for legitimate reasons. Physicians view many of these drugs as being relatively harmless. But to those persons who are genetically predisposed, the medications become gateways to drug dependence and/or alcoholism. Abstinence from all psychoactive drugs is the only reasonable method to deal with chemical dependency.
Violations of conscience can be considered to be "invoking precedence." Once an invoking precedence has occurred, a psychological phenomenon takes place in the subconscious that conditions the alcoholic/chemically dependent person to learn to live with the fact that one's behaviors have fallen below one's own values. This type of situation makes it easier with each recurrence for the client to live with the behaviors that violate his or her personal values.
With inhibitions chemically altered, the alcoholic/addict does not have the same level of psychological defenses that would normally prohibit unacceptable behaviors. As the illness progresses, there tends to be a progressive diminishment in the effectiveness of the inhibitions. Each unchecked violation of values will promote the capacity for even greater violations.
The client becomes mentally ill as he or she begins to cope with the implications of the depth and seriousness of those violations. Rationalizing becomes a way of life as the client tries to block out the psychic pain. The client blames something or someone else . . . the same process he or she uses concerning denial of the drinking and drug problem.
Once the unacceptable behavior is established and "owned" through a process of "condoned" repetition, it becomes attitudinal and eventually hardens into a state of being. The client has developed rational defenses to protect himself or herself from the psychic pain corresponding with that self-knowledge. Rather than using the defenses as he or she once did—to stop the self from committing the act that was unacceptable—the client begins to use defenses to explain away personal responsibility. This is an important shift in emphasis. At this point, the defenses are no longer the tool; they are the master. The shift in emphasis is not noticed, because the behaviors are perceived by self to be condoned. What is not seen is that the behaviors are in direct conflict with the client's own values. It has been said that the alcoholic drinks because he—or she—can't not drink. The alcoholic acts the way he—or she—acts because he—or she—can't not act that way.
Whether the alcoholic/addict is using or not, whatever behaviors have been solidified into a state of being are now "acceptable" options, because the client has effectively hardened or shielded self from the truth that would make the person feel bad about it. With the passage of time, that same person will forget the fact that the violations of personal values had anything to do with chemical use. The greater the pain, and the higher the number of unacceptable incidents of values-violation, the greater the deception has to be. With time and distance placed between the chemically addicted person and that person's behavior comes a natural lack of comprehension of cause and effect.
The chemically addicted person has a free-floating mass of negative emotions long detached from the incidents that caused them. Once this has followed the course to its end, the person is left with several potential target objects for blame. Some blame self and undergo all types of self-destructive changes, usually manic or depressive in nature. Many are often diagnosed as having unipolar or bipolar disorders. Some blame others and become antisocial or psychopathic. Still others are not quite sure who or what is to blame and begin to manifest behaviors similar to a paranoid schizophrenic. Others may blame the system or the government, become very antiauthoritarian, and join various hate groups and organizations that are antiestablishment. Some blame God and develop all manner of spiritual troubles. Their guilt, shame, and remorse for past misdeeds prohibit them from approaching the truth they fear. The question might well be asked, "What kind of punishment can a person warrant whose guilt is greater than the misdeeds?"
People coming into contact with a person suffering from any one of the mentioned delusions will often unwittingly support that negative assumption, because many aspects of the person's belief system seem plausible. In fact, if the beliefs had not been plausible, they would not have been adopted.
Some youth begin drinking or taking drugs when their personalities are still in the developmental stage. This is the other destructive situation where the psychological phenomenon develops of invoking precedence through a violation of the client's values. Society makes a definite distinction between a juvenile record and an adult record for good reason. A child needs to learn the limitations in which he or she must abide, and that takes some testing of limits. Driving fast, fighting, stealing, cursing, lying, and pretending are natural in adolescence . . . but are quite inappropriate at age 25 or 30. Sometimes we see cases of arrested adolescence, where the client has not yet established his personality. This same person may well have violated his or her own values before starting to drink "in search of self," and that created the invoking precedence that carried over into adult life, making the person feel and act inappropriately as weighed against his or her own values.
I do believe that if the client becomes more aware of himself or herself as a worthwhile productive person, that client will less obsessively focus on past unacceptable acts and will pay more attention to present behaviors and values. Rather than closely examining causes and motivations for behaviors that occurred before, during, and after drinking and drug-taking episodes, it is better to require a client to begin to examine "Who am I?" Then, the answer to the dilemma will lie in the process of learning once again to function within the confines of his or her personal values. Though the client may well be legally responsible for his or her actions, the person is in no way morally responsible for doing things he or she did not "want" to do, for those actions were obviously against the client's will. Proof of that statement is observed easily through identification of conflicts. The proof of conflict shows the value violations, and that is much easier to establish than the true cause of the unacceptable behaviors.
The person who, once started, cannot control use of chemicals, is the one who creates the most problems for our society. Such an individual may show periods of control but, once he or she returns to chemical use, problems inevitably occur. It is just a matter of time. Such persons are the most resistant toward accepting treatment and the most apt to be misdiagnosed unless there is a thorough chemical addiction history. That dilemma is through no fault of the consulting physician, since the chemically dependent (addicted) person is unable or unwilling to level with the doctor. The chemically addicted person is grossly deluded by his or her psychological defense system. Typically, these individuals are in their early twenties and feel that other people are picking on them. Any attempt to help the individual is viewed as interference, unless it is monetary in nature with "no questions asked."
The chemically addicted person will have developed a support system of people willing to "enable" that person to continue using drugs or alcohol. He or she will continue to have crisis after crisis that requires financial support. The crises will appear real, but in actuality are stories made up for the purpose of obtaining money to support the addiction.
Interestingly, the person who becomes the chief enabler becomes just as deluded as the chemically addicted person. That often complicates the possibility of the addicted person getting the help that he or she needs. Ironically, the chief enabler is a highly responsible person in other areas of life and can become a rather formidable "opponent" when one is trying to help the chemically addicted person. Treatment for both is available and appropriate. If the chemically addicted person is not to blame, how much more not to blame is the person or persons who have been adversely affected by the client's illness?
Father Joseph Martin said that alcoholism and addiction teaches its victims one thing: how to be afraid. It is not surprising to learn that at the base of all anger is some unconscious fear. People with alcohol and drug problems are fearful, angry people.
By the time a client arrives at treatment, there has been an enormous amount of pain associated with out-of-control behaviors. Loss of control produces enormous fear. Clients fear losing loved ones, losing freedom, losing financial security, health, reputation, and, at times, even sanity. When people do things they deem to be bad, they feel that they are losing their personal moral integrity.
Out-of-control behaviors cause disruption in society. Police often intervene to protect the rights of others. If we have children, social service agencies intervene to protect those children. If we use illegal drugs, we often are stopped by drug enforcement officers. Many of us have had to go to jail, and pay fines, and have been placed on probation because of our drug- and alcohol-related behaviors. All these interventions have one thing in common—authority. It seems logical that we develop a resentment toward people in authority. We often feel picked on, singled out, or set up. We often begin to believe that our main problem is with the system. We often feel that if they would just leave us alone, things would be all right.
Most of us did not come to treatment because we wanted to. We often came because we felt we had to. Our first response to treatment is often similar to our response to policemen, jailers, or narcs. It was us against them. We rebelled against the possibility of "them" finding out things about us because we didn't trust them. It has been our experience that anything we said could be used against us in a court of law.
Father Joseph Martin said, "We are meant to love." A person caught up in chemical addiction is not able to love in a mature way, because addiction demands that we take. Love is giving. The primary ingredient in love is self-sacrifice. It is doing something for someone else at sacrifice of self. How can we reach out to others and share with them something we haven't got? Chemical addiction robs us of our openness. It robs us of our trust. It makes us doubt other people's motives. It makes us accuse those we love of things we know deep down are not true. It often makes us avoid being around those we love. We hide from them. We are afraid to let them know us as we really are, because we don't like ourselves and know that if they really knew us, they wouldn't like us either.
How does one get rid of fear? By learning to love again. All of us seem to have one of two choices, to love others or to fear others.
Some people have the idea, "You've got to learn to love yourself before you can learn to love others." Self-love is the alcoholic's main problem. The alcoholic's selfishness and self-centeredness (caused by overdeveloped defenses) block him or her off from loving others. I think alcoholism and drug addiction are extreme examples that prove selfishness and self-centeredness stem from vain attempts to experience love through the process of loving one's self.
Treatment is a process whereby clients are placed in a position of learning to love. Clients are constantly asked to share with others their experiences, strength, and hopes. They are asked to speak when they would rather not. When a client does something he does not "want" to do, isn't that client sacrificing of self? This is an expression of love. Self-sacrifice, delayed gratification, and ego deflation are all key elements of success in intensive residential treatment.
It sounds too simplistic. It is simple, but it is not easy. A lifetime of selfishness is not easy to break. It requires a change in attitude, a change in focus, and mostly a change of heart.
Work in the field of alcoholism and drug addiction brings with it certain difficulties. One dilemma I have noted is that the very factor which motivates many people to want to work in this field often proves to be the major factor leading a sincere person to leave the career of his or her choice. We are all changing (for the better or worse) as we adapt to new situations. For persons who are starting careers in the alcoholism or drug addiction field, there actually needs to be change in the basis of their motivation. We all want to get to know our clients, get involved in their lives, and help them along the road to recovery. One of the major causes of stress and burnout is getting too close to the client. Getting involved in too much small talk, too much personal disclosure (on the counselor's part), or too much inappropriate joking and laughter erodes the professional ethics of counseling.
A client whose life has been selfish, self-centered, and out of control suffers from many problems, maybe the most obvious being emotional immaturity. I believe there needs to be an imaginary gulf (not a wall) between the client and counselor, especially in the beginning of the treatment process. I believe it to be necessary that there is a contrast between maturity and immaturity. When a counselor engages in conversation (even nonverbal) that is basically immature, two major things occur:
A client whose life has been a series of superficial relationships soon gets the feeling that you are no different than they, and therefore may have little to offer. This creates a situation Dr. Steven Glen describes by the term "naive clarity," wherein no positive changes occur—you just reflect what they are.
A mature counselor familiar with traps of co-dependency in the treatment setting will not sacrifice honesty for the client's approval. A mature counselor is not in the business to find and make new friends, even though that is often the long-term result. A mature counselor insists on sharing with the client at a level of maturity and expects the client to rise to the occasion. When this occurs, counseling is in the mode conducive to change in the client. Neither the client nor the counselor is diminished in a therapeutic setting in which information is exchanged at a level of maturity.
Once the client becomes aware of who you are, the client will respond accordingly. A counselor needs to create an imaginary gulf between himself or herself and the client who is talking nonsense, if for no other reason than that it simply doesn't work. Personal integrity is the counselor's hallmark. With it, when you speak the client will listen. The client will listen seriously. The client will listen intently. Without establishing a personal integrity of maturity between counselor and client, no matter what is said, it is taken with a grain of salt. The client cannot trust himself or herself and feels that, if you are not somehow different, he or she won't trust you, either.
When the counselor requires that the client be addressed with maturity, inevitably the client responds similarly and is counseled. The majority of counseling is not in the group setting, in one-to-ones, or in lectures, but is in impressions gathered prior to the actual counseling session. How we present ourselves, how we interact with other staff members, and the manner in which our client sees us handling ourselves—all combine to create an impression of integrity or an impression of immaturity.
Father Joseph Martin's "Chalk Talk" shows the personality of the alcoholic represented by the formula E/I (emotions predominating over the intellect). As long as the client's emotions are in primary control, there will be immaturity. That does not mean we are to treat clients like children. That is their problem; others have treated them like children for too long. Clients need to be approached as adults, treated as adults, and expected to act and react like mature responsible adults. A part of treatment's responsibility is to diminish immature out-of-control behaviors and to foster a degree of self-control and self-discipline representative of adult behavior.
Initially, counselors doing their job will not be liked by the clients. However, they will be respected. It is more important to win their respect than to win their friendship. With the passage of time, clients who act responsibly begin to reap the positive benefits of their actions. Their view of the counselor will change as their views of themselves change. They will ultimately appreciate the counselor's work, respect the counselor's judgment, and learn to love the counselor, as the counselor has taught them how to love others.
We all have a hidden desire to be the one to get someone well. To realize we each have played a part in that process is inspiring. But, to feel responsible for independently bringing about that change can be disastrous. The counselor who finds himself or herself taking credit for someone's achieving or maintaining sobriety will soon find himself or herself taking responsibility for the client who doesn't. When a counselor takes credit for positive changes, that same counselor suffers with/for the client who chooses to drink or use drugs again. To allow a client to credit a counselor with his or her sobriety is a setup. A successful counselor is a person who is well trained, a team player, cooperative, inspirational, a positive example, and willing to work consistently within the parameters of her or his limitations. The primary limitation that must be faced early on in the career of a counselor is: "I am powerless over the alcoholic/addict" and "I cannot manage the alcoholic/addict."
Before a client reaches A.R.C., he or she has been through about 90 percent of what is required to get well. We know that, because we understand the characteristics of the illness. Clients have done exhaustive "research" into their drinking/drug taking. They have had loved ones go the extra mile for them. They have had crises. They have lost loved ones. They have been given hundreds of "second chances." They have tried everything—with the exception of what it really takes to get well. They have not accepted the truth about themselves nor have they accepted the truth about their condition. Our job is to see that they receive the unadulterated truth. We know the truth will hurt. They sense the truth will hurt. We know the truth will not be immediately accepted, but we have the responsibility to present the truth as often as we see error.
We teach clients how to love others, so that their experience of having love will be manifested in every area of their lives. As they begin to embrace reality with all the fervor they did the bottle or drug, the desire to drink or use drugs will be removed.
I must focus on my area of expertise. I am primarily a drug and alcoholism counselor. I understand alcoholism and drug addiction to be primary to the solving of other problems caused by the disease.
A counselor must not waste precious treatment time trying to control people, situations, and conditions of the client's external life. The futility of this is apparent in the sense that, if those problems were eliminated, the client would not feel the need for change. Every client's psychosocial history represents the futility of his or her attempts to change life to allow for continued drinking and using drugs. Every newly sober alcoholic honestly believes conditions drove him or her to drink. To the extent that we buy into this lie, we reinforce the client's obsession to "somehow, someday, control and enjoy my drinking." It has not worked over the past many years and it will not work for us!
We must continually work to increase the client's conscious awareness of blaming people, situations, and conditions for what was caused by the disease of alcoholism and drug addiction. The counselor who remains within his or her field of expertise and displays maturity and empathy in the conveyance of truth is always impressive. The old adage: "To thine own self be true" illustrates where the primary focus must be.
The simple formula that has helped considerably throughout my 15 years of counseling is the "three Cs" as explained to me by Gordon Lucky. Applied to other counselors, it simply teaches, don't compare (yourself to)—don't compete (with)—and don't criticize other counselors. We must each develop the method of teaching clients the truths we know based on our own personalities. We see a vast diversity of personalities in treatment. We have a vast diversity of personalities among staff.
Cooperation and forgiveness will help the team function in a cohesive manner. That is what we all want, and that is what we all must do.
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