Practical Approaches to Alcoholism Psychotherapy

288 Pages·1978·23.57 MB·English

by  Sheldon Zimberg (auth.)

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; Direc
tor, 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 de
spair, which proclaims thatgaps in knowledge of the cause of alco
holism are so great and failures to treat alcoholics successfully so dra
matic that there is no assurance that efforts will lead to a positive
outcome. This denial is perhaps the most troublesome because it re
flects 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 hope
lessness, 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 in
terpersonal 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 phi
losophy, 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 indi
vidual, 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 op
erates is underlined and the usefulness of understanding psychody
namics in applying general prindples of psychotherapy to treatment of
alcoholism is pointed out.
Moreover, we recognize that sodal status, income, ethnic back
ground, 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" ex
isted 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 develop
ment, of the pressures of being poor in an affluent sodety, of sexism,
of discrimination against racial minorities, and of rejection of the el
derly. 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 hos
pital door. This orientation does not espouse a single rigid response to
FOREWORD ix
what could be incorrectly described as a unilaterally determined dis
order. 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 disadvan
tage reflect recognition of the interaction of the individual and sodety,
the approach is not restricted to the sodal-environmental view some
times espoused by those who deeply feel the effects of deprivation
that alcoholism would no longer exist if sodal and economic inequities
were to be removed. Instead, several possible rehabilitative and treat
ment 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 skill
ful, 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 psychothera
peutic 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 so
cioeconomically deprived, are presented to highlight the fact that al
coholism 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.
Sheldon Zimberg, M.D.
John Wallace, Ph.D.
Sheila B. Blume, M.D.
xi
Contents
THEORETICAL CONSIDERATIONS
Chapter 1
PRINCIPLES OF ALCOHOLISM PSYCHOTHERAPY
SHELDON ZIMBERG
Introduction 3
Psychodynamics of the Alcoholic 4
Treatment of Alcoholism . 7
Sociopsychological Factors Affecting Psychotherapy 8
The Treatment Process 9
Summary 17
References 17
Chapter 2
WORKING WITH THE PREFERRED DEFENSE STRUCTURE OF
THE RECOVERING ALCOHOLIC
JOHN WALLACE
Introduction 19
The Preferred Defense Structure (PDS) of the Recovering
Alcoholic . 20
xiii
xiv CONTENTS
Tactical and Strategie Use of the PDS 26
Summary and Conclusions . 29
Chapter 3
CRITICAL ISSUES IN ALCOHOLISM THERAPY
lOHN WALLACE
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
SHELDON ZIMBERG
Introduction 47
Methodology 49
Results 52
Case Histories 53
Discussion . 59