Anugraha Institute of Social Sciences

Nochi-odai-patti, Dindigul, Tamil Nadu, India – 624 003

P.G. Diploma
in
Counselling and Psychotherapy

Non-Semester System

Paper 4: DRUG ABUSE COUNSELLING

Name : ………………………………………………………………………………

Stream : 1

Roll No. : ………………………………………

Year : 2017-18

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 PAPER IV -- DRUG ABUSE COUNSELLING

Syllabus

1 Drugs – Difference types of drugs – their composition -- Drug Abuse -- its effect on
physical and mental health of the individual.

2 Addiction – symptomatology of addiction, stages of addition- Michigan Alcoholism

3 Denials - Concept and meaning –Different forms of denials.

4 Management of addicts – Medical Model--Disease Model -- Social Learning --

Deaddiction –withdrawal symptoms –Re-educative therapy-Psychosocial
management.

5 Recovery –phases in Recovery –factors that complicate recovery -- Role of parents

and the community in the recovery process.

6 Relapse Dynamics – Relapse Mechanism, Factors leading to relapse -- relapse

prevention.

7 Social support system – Self-help groups like AA, Al-Anon, and Ala-Teen-
Mobilizing the community support.

8 Rehabilitation –Scope of rehabilitation --physical and social rehabilitation – the

short-stay homes –involvement of the family and the community in the rehabilitation
process.

9 Prevention –primary, secondary and tertiary prevention. Role of different agencies –

the laws related to drugs.

*********

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 PAPER 4 -- DRUG ABUSE COUNSELLING

TABLE OF CONTENTS

(This table of contents will be of help to you in revising and reviewing this
paper – especially before the examinations.)
____________________________________________

UNIT 1…………………………………………………page 11
1 Drugs – Difference types of drugs – their composition -- Drug Abuse -- its
effect on physical and mental health of the individual.

1.1 DRUGS
1.2 THE DIFFERENCE TYPES OF DRUGS
1) Narcotics
(1) Of Natural Origin
1) Opium:
2) Morphine
3) Codeine
(2) Semi-synthetic Narcotics
(3) Synthetic Narcotics
1) Meperidine (pethidine)
2) Methadone.
2) Depressants
(1) Barbiturates ( ‘downers.’)
(2) Methaqualone
(3) Meprobamate
(4)Benzodiazepines
3) Stimulants
(1) Cocaine (Coke, Flake, Snow)
(2) Amphetamines : e.g., ‘Speed’
(3) Hallucinogens
(1) Mescaline
(2) Psilocybin and Psilocyn
(3) LSD
(4) Phencyclidine (PCP)
5) Cannabis
(1) Ganja (Marijuana)
(2) Charas (Hash or Hashish)
6) Unconventional Abuses
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1.3 THE COMPOSITION OF DRUGS
Please re-read the above Section on the types or kinds of drugs.
1.4 DRUG ABUSE

1.5 THE EFFECTS OF DRUGS ON THE PHYSICAL AND MENTAL HEALTH OF THE
INDIVIDUAL
Neurological Effects
Death : Drugs can be deadly, even when taken for the first time.

Fetal Effects

Other Effects: The risks of illegal drug use can cause long-term damage.
________________________________________________________
UNIT 2…………………………………………………page 18

2 ADDICTION – SYMPTOMATOLOGY OF ADDICTION, STAGES OF ADDICTION-

THE MICHIGAN ALCOHOLISM SCREENING TEST (MAST)

2 ADDICTION
2.1 ADDICTION : Definition of Addiction:
2.2 SYMPTOMATOLOGY OF ADDICTION

 Tolerance
 Withdrawal
 Difficulty cutting down or controlling the addictive behavior
 Social, occupational or recreational activities becoming jeopardized
 The person becoming preoccupied with the addiction

A Caution
Effects of Alcohol:
The Pet Theories of the Alcoholics:
Stages in Alcohol Dependence:
1) Early Stage Symptoms:
(1) Frequent Desire
(2) Increased Tolerance
(3) Black Out
(4)Sneaking Drinks
(5)Preoccupation
(6)Avoiding any Reference of Alcohol:

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 2) Middle Stage Symptoms:
(1) Loss of control
(2) Morning Drinking
(3) Rationalization
(4) Grandiose Behaviour
(5) Unsuccessful Attempts
(6) Binge Drinking
3) Chronic Stage Symptoms:
(1) Decreased Tolerance:
(2) Physical Deterioration.
(3) Ethical Breakdown:
(4) Paranoid Condition:
(5) Suicidal Tendency
Characteristics of Alcoholism:
Alcoholic Games:
1) Drunk and Proud:
2) Lush:
3) Wino:
Alcoholic Women & Homosexuals:

2.3 STAGES OF ADDICTION

2.3.1 STAGES OF ALCOHOL ADDICTION (Tellinek’s classification of alcoholism)

1. Alpha Alcoholism
2. Beta Alcoholism
3. Gamma Alcoholism
4. Delta Alcoholism:
5. Epsilon Alcoholism:
Tellinik’s four different phases of alcoholic addiction
(1) Pre-Alcoholic
(2) Prodromal Phase
(a) "Blackout"
(b) Pre-occupation with drinking
(c) Avoids talking about alcohol.
(3) The Crucial Phase
(a) Loss of Control.
(b) Rationalizing:
(c) Grandiose Behaviour:
(d) Aggression:
(e) Guilt and Remorse:

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 (f) Abstaining from Alcohol:
(g) Changing the Drinking Pattern:
(h) Social Relations begin to Decay:
(i) As the problem with family and job mounts up he may seek help,
not really to get rid of his alcoholism, but to put his life back in
order.
4. Chronic Phase
(a) Binge Drinking:
(b) Decreased Tolerance:
(c) Ethical Breakdown:
(d) Paranoia, fears, and hallucinations:
(e) Lack of Motor Co-ordination:
(f) Turning to God:

2.3.2 STAGES OF DRUG ADDICTION

i. First Stage: Preoccupation/Anticipation

ii. Second Stage: Binge/Intoxication

iii. Third Stage: Withdrawal/Negative Affect

2.4 THE MICHIGAN ALCOHOLISM SCREENING TEST (MAST)

UNIT 3…………………………………………………page 32

3 DENIALS - CONCEPT AND MEANING – DIFFERENT FORMS OF DENIALS.

3.1 DENIALS - CONCEPT AND MEANING

Denial: Why Alcoholics and Drug Addicts Think it is OK to Drink and Use Drugs
i. Physical Components of Denial
ii. Thought Patterns of Denial
iii. Emotions and Denial
iv. Behavior Patterns of Denial
3.2 DIFFERENT FORMS (TYPES) OF DENIALS
Denial of fact
Denial of responsibility:
Denial of impact:
Denial of awareness
Denial of cycle
Denial of denial

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 _____________________________________________________
UNIT 4…………………………………………………page 36

4 MANAGEMENT OF ADDICTS – MEDICAL MODEL -- DISEASE MODEL -- SOCIAL

LEARNING -- DEADDICTION –WITHDRAWAL SYMPTOMS – RE-EDUCATIVE
THERAPY - PSYCHOSOCIAL MANAGEMENT.

4 MANAGEMENT OF ADDICTS

Treatment of Alcoholism:
1) Biological Measures:
(1) Detoxification:
(2) Aversion Therapy:
Counselling the Alcoholics:
1) Hurdles to Counselling:
(1) Unwillingness:
(2) Psychiatric Disorders:
(3) People with psychopathic trends:
2) Overall Approach:
3) Stage-wise Approach:
(1) Early Stage:
i) Physical Recovery:
ii) Psychological Recovery:
(i) Intrapersonal Determinants :
(ii) Interpersonal Determinants:.
(2) Middle stage:
(3) The Later Stage & Beyond:
4.1 THE MEDICAL MODEL -- THE DISEASE MODEL OF ADDICTION
4.2 SOCIAL LEARNING

4.3 DEADDICTION
Phase I
Phase II
Phase III
Phase IV
INTERVENTION
Direct Intervention
Family Intervention
De-toxification
Rehabilitation

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 Helping the Dependent
Helping the Family
After Care
Half Way Homes
4.4 WITHDRAWAL SYMPTOMS

1. Alcohol withdrawal syndrome

2. Withdrawal symptoms of drugs
1. Depressants
2. Stimulants
A. Mild stimulants
B. Severe stimulants
Treatment
4.5 RE-EDUCATIVE THERAPY
Psychological Measures
Psychosocial Measures
(1) Group Therapy
(2) Sociotherapy
(3) Alcoholics Anonymous (AA)
(4) Taking Care of Environmental Cues
(5) Follow-up
Counselling the Alcoholics
Excuses Made by Alcoholics
Overall Approach
Stage-wise Approach
(1) Early Stage
i) Physical Recovery
ii) Psychological Recovery
(i) Intrapersonal Determinants:.
(ii) Interpersonal Determinants:.
(2) Middle stage
(3) Later Stage & Beyond

4.5 PSYCHO-SOCIAL MANAGEMENT

Direct Intervention
Family Intervention
Rehabilitation
Helping the dependent
Helping the family
After care

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 UNIT 5…………………………………………………page 59

5 RECOVERY – PHASES IN RECOVERY – FACTORS THAT COMPLICATE RECOVERY --

ROLE OF PARENTS AND THE COMMUNITY IN THE RECOVERY PROCESS.

5.1 RECOVERY

5.1 PHASES IN RECOVERY

The 5 Phases of Addiction Recovery

1. Admission of a problem
2. Compliance
3. Defiance
4. Acceptance
5. Surrender
5.2 FACTORS THAT COMPLICATE RECOVERY

5.3 ROLE OF PARENTS AND THE COMMUNITY IN THE RECOVERY PROCESS.

___________________________
UNIT 6…………………………………………………page 61

6 RELAPSE DYNAMICS
RELAPSE MECHANISM
FACTORS LEADING TO RELAPSE
RELAPSE PREVENTION.
_______________________
UNIT 7…………………………………………………page 63
7 SOCIAL SUPPORT SYSTEM – SELF-HELP GROUPS LIKE AA, AL-ANON, AND
ALATEEN - MOBILIZING THE COMMUNITY SUPPORT.

7.1 SOCIAL SUPPORT SYSTEM

Half Way Homes
.

7.2 SELF-HELP GROUPS LIKE AA, AL-ANON, AND ALA-TEEN

ALCOHOLIC ANONYMOUS (AA)

The Twelve Steps of Recovery
The Twelve Traditions of AA

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 Organization
Meetings
Slogans
Sponsors
Narcotic Anonymous (NA)
Al-Anon
Ala-teen
New Life through AA
Serenity Prayer:

7.3 MOBILIZING THE COMMUNITY SUPPORT.

Please re-read the entire Section 4.7.

UNIT 8…………………………………………………page 69
8 REHABILITATION –SCOPE OF REHABILITATION -- PHYSICAL AND SOCIAL
REHABILITATION – THE SHORT-STAY HOMES –INVOLVEMENT OF THE FAMILY
AND THE COMMUNITY IN THE REHABILITATION PROCESS.

Please re-read the entire Section 7.

__________________________________________________________________
9 PREVENTION – PRIMARY, SECONDARY AND TERTIARY PREVENTION. ROLE
OF DIFFERENT AGENCIES – THE LAWS RELATED TO DRUGS.

UNIT 9…………………………………………………page 69
9 PREVENTION
9.1 PRIMARY, SECONDARY AND TERTIARY PREVENTION
Primary prevention
Secondary prevention
Tertiary prevention

9.2 ROLE OF DIFFERENT AGENCIES

Please re-read the entire Section 7, 8 and 9. Also, read the entire Chapter 14 in the book
Types of Counselling by D. John Antony.

9.3 THE LAWS RELATED TO DRUGS

********

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 Paper IV -- Drug Abuse Counselling

1 DRUGS – DIFFERENCE TYPES OF DRUGS – THEIR COMPOSITION -- DRUG

ABUSE -- ITS EFFECT ON PHYSICAL AND MENTAL HEALTH OF THE
INDIVIDUAL
******

1.1 DRUGS

A drug is a substance which may have medicinal, intoxicating, performance enhancing or

other effects when taken or put into a human body or the body of another animal and is not
considered a food or exclusively a food.

In pharmacology, a drug or medication is "a chemical substance used in the treatment, cure,
prevention, or diagnosis of disease or used to otherwise enhance physical or mental well-
being."Drugs may be prescribed for a limited duration, or on a regular basis for chronic
disorders.

Drugs are usually distinguished from endogenous biochemicals by being introduced from
outside the organism. For example, insulin is a hormone that is synthesized in the body; it is
called a hormone when it is synthesized by the pancreas inside the body, but if it is
introduced into the body from outside, it is called a drug / medicine.

1.2 THE DIFFERENCE TYPES OF DRUGS

An excerpt from Chapter 14, Section 7: Kinds of drugs (pages 272 to 277) in the book Types
of Counselling, [2nd edition, 2011, by D. John Antony, Guru Publications, Dindigul; also
available free of cost in www.anugraha.info] is given below:

The drugs that are used or abused can be grouped into five categories as narcotics,
depressants, stimulants, hallucinogens, and cannabis. Unconventional abuses of snake bite venom and
scorpion bite venom can be added as the sixth category.i

1) Narcotics

Narcotics are opium, its derivatives and synthetic substitutes. Narcotics are most effective
pain-relieving agents and are also used as cough suppressants and in the treatment of diarrhoea. For
medical purposes they are administered either orally or by intramuscular injection. But as drug they
are usually introduced by 1) smoking through a cigarette, 2) snorting – inhaling through the nasal
passage, 3) fixing/mainlining – by injection the liquefied drug intravenously so as to reach the blood

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stream directly, 4) skin-popping – by injection the liquefied drug just beneath the skin; usually it is
done in the loose skin at the back of the palm. Narcotics are of three kinds: natural origin, semi-
synthetic and synthetic.

(1) Of Natural Origin

The poppy plant, Papaver somniferum is the main source of natural narcotics. Opium gum is
produced from the milky fluid that oozes from incisions in the unripe seedpod and is air dried.
Recently the method of harvesting is by the industrial poppy straw process extracting alkaloids from
mature dried plants. The extract may be either liquid or solid or powder. Its various forms are:

1) Opium: Opium is gummy substance of chestnut-brown colour and when it is old, it is

hard, brittle, dark brownish or blackish in colour. It may be got as rounded or irregularly formed or
flattened with bitter taste. 2) Morphine: It is an odourless, bitter-tasting white crystal or injectable
preparation, taken in by skin popping, intramuscularly or intravenously. 3) Codeine: It is used in
relief of moderate pain and cough in the form of syrups.

(2) Semi-synthetic Narcotics

Its various forms are: 1) Heroin: It is a bitter tasting while powder in its pure form though
what we get in the market may be brown because of impurities. It may be adulterated with diluents
like sugar, starch, powdered milk and other powders. It is taken in by smoking, snorting, injecting
(fixing/mainlining) and skin-popping. 2) Brown Sugar: It is a light brownish bitterish substance taken
in usually by smoking (From a cigarette a little tobacco is removed and the rest is made loose and the
desired quantity of brown sugar is poured into the cigarette and made to sink to the level of filter and
the joined portion of the cigarette paper is usually made wet with spittle to ensure a longer smoking),
or chasing (Brown sugar is placed on a strip of aluminium foil like the silver wrapper in a cigarette
packet and the foil is heated from underneath by a candle or a matchstick. The heated brown sugar
liquefies and rolls along the foil emanating blackish fumes. The fumes are inhaled by using a hollow
tube, which is called ‘Chaser’ about 3 inches in length. Since the fumes are chased by the user it is
called chasing). Or injecting (Brown sugar is mixed with sour lime (limbo) and ordinary tap water in
a spoon and the solution is heated and drawn into a syringe and injected intravenously which is called
fixing or mainlining). It is not taken orally.

(3) Synthetic Narcotics

Synthetic narcotics are prepared in the laboratory. 1) Meperidine (Pethidine) – It is used

orally or intravenously. 2) Methadone – It can be taken either orally or by injection.

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2) Depressants

Depressants are sedatives or tranquillisers and are prescribed by physicians or psychiatrists

for relief from anxiety, tension, irritability and insomnia. When used excessively it produces a state of
intoxication similar to that of alcohol. Its various forms are:

(1) Barbiturates are called ‘downers.’

(2) Methaqualone is administered orally whose larger doses may cause coma accompanied by
convulsions.

(3) Meprobamate is a muscle relaxant and does not produce sleep and is less toxic but its excessive
use can result in psychological and physiological dependence.

(4) Benzodiazepines – Its family contains Librium and Valium meant to relieve anxiety, tension, and
muscle spasms, produce sedation and prevent convulsions. But regular high doses will result in
psychological and physiological dependence.

3) Stimulants

While depressants slow down the activities of the central nervous system, the stimulants
speed up the activities of the central nervous system. This is taken to feel more active, stronger, more
decisive and self-possessed. It gives a temporary sense of exhilaration, abundant energy hyperactivity,
extended wakefulness and a loss of appetite. To intensify these effects, users might inject this
intravenously. If withdrawn, users exhibit profound depression, apathy, fatigue and disturbed sleep.
Its various forms are:

(1) Cocaine (Coke, Flake, Snow)

It is extracted from the leaves of the coca plant (Erythroxyln coca). In the illicit market it is
sold in white crystalline powder often adulterated with sugar. It could be either snorted or taken
intravenously.

(2) Amphetamines : e.g., ‘Speed’

It will stir up activity and help the users to function temporarily above their normal capacity.

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(3) Hallucinogens

This drug which can be found both in natural and synthetic forms is believed to induce
hallucinogens, which is the distortion of the perception of objective reality. Of course it excites the
central nervous system with the alterations of mood, mostly euphoric and at times depressive. There
is the impaired judgment which might lead one to rash decisions and accidents. There will be
disorientation with regard to direction, distance and time. Its various forms are:

(1) Mescaline

It is derived from the fleshy parts or buttons of the plant called peyote cactus or prepared
synthetically.

(2) Psilocybin and Psilocyn

These are mushrooms which when eaten have effect on mood and perception similar to
Mescaline and LSD. Now it can also be prepared synthetically.

(3) LSD

It is the product of lysergic acid. LSD is the abbreviated form in German language of lysergic
acid diethylamide. It enables the users to discover and put to use their latent talents and potentials with
the objects becoming clearer, sharper and brighter. The LSD ‘trip’ could either be pleasurable or
horrifying.

(4) Phencyclidine (PCP)

It is called PCP and is being referred to, by terms such as Angel Dust, Super-grass, Crystal
and Rocket Fuel. In its pure form it is a white crystalline powder which dissolves in water easily and
when contaminated it becomes brown and gummy. It is marketed in tablets, capsules, powder and
liquid form. It is also applied to leafy materials like Ganja (Marijuana) and is smoked. Its users
usually feel a sense of detachment, estrangement and distance from their surroundings. They feel
numb, strong and invulnerable and their speech is slurred with a blank stare, rapid and involuntary
eye movements and an exaggerated gait. There may be auditory hallucinations, image distortion and
severe mood disorder.

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5) Cannabis

Cannabis sativa is the hemp plant which has a mood-altering (psychoactive) ingredient
which is known as THC (delta-9-tetra-hydro-cannabinol). This THC ingredient can also be
synthetically prepared in laboratory. It is normally smoked in the form of loosely rolled cigarettes
(‘joints’ or ‘reefers’) or in a pipe/chillum. It can also be administered orally. Low doses include an
increasing sense of well-being, then a dreamy state of relaxation with hunger especially a craving for
sweets. Changes in sensory perception of vivid sense of the five sense organs are experienced.
Prolonged use usually impairs memory and reduces the ability to concentrate and to make swift
decisions.

(1) Ganja (Marijuana)

Ganja known as Marijuana, grass, pot, weed, reefer comes from the leaves and flowering
tops of the cannabis plant; it is smoked by filling it into a cigarette, pipe or chillum. The tobacco is
removed from the cigarette and is mixed with ganja, refilled into the cigarette and then smoked. The
leaves can be immersed in hot water and the water can be drunk and ganja can be baked in pastries,
biscuits and other food items according to one’s taste. The effect of Ganja makes the experience of
the world very pleasant with richer sensations. There will be disorientation with regard to time.
Pleasurable experiences like sex play and intercourse will be enhanced.

(2) Charas (Hash or Hashish)

It is the resinous secretion of the cannabis plant, collected, dried and compressed into a
variety of forms like balls and cakes. It is smoked in a cigarette or chillum. The tobacco of the
cigarette is removed. The charas roasted over a flame, mixed with tobacco, is refilled into the
cigarette/chillum and then smoked. The user experiences an enhanced, cheerful, laughing and
talkative mood.

6) Unconventional Abuses

People who can no longer afford the usual drug from the market on account of poverty or
non-availability of the drugs and are chronic in their dependence on drug, take to snake bites and
scorpion bites. Snake bites are given between the fingers or toes and some even take a bite on the tip
of the tongue. A tourniquet may be used to regulate the flow of poison into the bloodstream.

1.3 THE COMPOSITION OF DRUGS

Please re-read the above Section on the types or kinds of drugs.

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1.4 DRUG ABUSE

Drug abuse is an increasing problem in our affluent societies and carries great social and
economic costs through its impacts on crime and health.

From the neuroscientist's point of view addiction is increasingly seen as an organic disorder
of brain function; if this could be better understood we might be able to offer more effective
treatments to addicts.

The definition of addiction has changed in recent years. The term was previously applied
only to such ‘hard’ drugs as heroin, where there are obvious signs of tolerance and physical
dependence in regular users, and a painful or even life-threatening physical withdrawal
syndrome when drug use is stopped. Psychiatrists now use the term ‘substance dependence’
to include both psychological dependence (where there may be no obvious withdrawal
syndrome or tolerance) and physical dependence. The cigarette smoker who cannot stop
smoking or the cannabis smoker whose drug habit has come to dominate their life is no less
addicted than the chronic heroin user, even though they may suffer only mild withdrawal
signs when drug use is stopped.

An alcoholic is one who has developed physical and psychological dependence on alcohol,
whose drinking causes continuing problems in one or more areas of his life. Chemical
dependence or drug addiction and alcoholism is acknowledged as a primary, progressive yet
treatable disease. Drug addiction and alcoholism progress through the same distinctly defined
stages and the treatment for both are basically the same. Hence in this work drug addiction and
alcoholism are used synonymously. Alcohol is a drug. Therefore what is said about alcoholism
applies to drug addiction and vice versa, and what is said of drug addict applies to alcoholic
and vice versa.

Now, we do not use the term “alcoholic.” Instead, we use the term “alcohol-dependent
person.”

1.5 THE EFFECTSOF DRUGS ON THE PHYSICAL AND MENTAL HEALTH OF

THE INDIVIDUAL

Chemicals found within many illegal substances can impair your process of thinking, damage
your body and lead to dangerous situations. Despite potential risks, many will take drugs
either because of addiction or because of environmental exposure, such as peer pressure. The
use of illegal drugs contributes to 53,000 deaths annually, the American College of
Emergency Physicians states.

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Neurological Effects

Illegal drugs will alter the composition of your brain, especially if you take them frequently.
Methamphetamine not only causes psychosis, it can lead to brain damage similar to
Alzheimer's disease, the ACEP notes. Club drugs, including Ecstasy or MDMA, can cause
depression, anxiety and paranoia, Kids Health indicates. Cannabis in users can lead to
heightened paranoia, especially in those suffering from mental illnesses such as
schizophrenia. Perpetual cannabis users may develop a dependency on the drug. The use of
cocaine can cause bizarre and erratic behavior when taken in large amounts.

Death : Drugs can be deadly, even when taken for the first time.

Cocaine use can cause cardiovascular disturbances such as heart palpitations and increased
heart rate. In rare occurrences, cocaine has caused sudden death after first time use, the
National Institute on Drug Abuse notes. Cardiac arrest and respiratory arrest can also result
from cocaine abuse. Overdosing from heroin can cause convulsions, coma and death.
Ketamine, or Special K, which is used for human anesthesia and veterinary medicine, can
cause fatal respiratory failure when taken in high doses. Tolerance to a drug can occur,
leading to taking more and more of a drug in order to produce a high. Developing a tolerance
for a drug can lead to accidental overdose.

Fetal Effects

Illegal drug use can put your fetus at risk for developing dependency, as well as serious
health risks. The Lucile Packard Children's Hospital at Stanford asserts that nearly every type
of drug can transfer to the fetus via the placenta. Marijuana use during pregnancy can result
in behavioral issues for the child. If you use cocaine during your pregnancy, your infant has a
higher risk of dying from sudden infant death syndrome, the Packard Children's Hospital
reports. Babies born from mothers addicted to opiates, such as heroin, can develop
withdrawal symptoms and also have a risk for SIDS and apnea.

Other Effects: The risks of illegal drug use can cause long-term damage.

Long-term use of opiates can damage your veins, heart and lungs. Sharing needles to inject
drugs can put you at risk for developing diseases like HIV/AIDS and hepatitis C. Illegal drug
use can impair your judgment, leading to injury or death if you drive. The mixing of drugs
can cause undesirable effects on your body. For example, the combination of alcohol with
drugs such as cocaine can cause confusion, respiratory failure and coma.*********

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 UNIT 2
ADDICTION – SYMPTOMATOLOGY OF ADDICTION, STAGES OF ADDICTION-
THE MICHIGAN ALCOHOLISM SCREENING TEST (MAST)

2.1 ADDICTION : Definition of Addiction:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related
circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social
and spiritual manifestations. This is reflected in an individual pathologically pursuing reward
and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral

control, craving, diminished recognition of significant problems with one’s behaviors and
interpersonal relationships, and a dysfunctional emotional response. Like other chronic
diseases, addiction often involves cycles of relapse and remission. Without treatment or
engagement in recovery activities, addiction is progressive and can result in disability or
premature death.

2.2 SYMPTOMATOLOGY OF ADDICTION

All addictions, whether to substances or to behaviors, involve both physical and

psychological processes. Each person’s experience of addiction is slightly different, but
usually involves a cluster of some of the following symptoms of addiction. You can still be
addicted even if you do not have all of the symptoms.

There are many different addictions, but similar symptoms span them all.

Some of the common symptoms of addiction are:

 Tolerance - the need to engage in the addictive behavior more and more to get the
desired effect
 Withdrawal happens when the person does not take the substance or engage in the
activity, and they experience unpleasant symptoms, which are often the opposite of
the effects of the addictive behavior
 Difficulty cutting down or controlling the addictive behavior
 Social, occupational or recreational activities becoming more focused around the
addiction, and important social and occupational roles being jeopardized
 The person becoming preoccupied with the addiction, spending a lot of time on
planning, engaging in, and recovering from the addictive behavior

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 Signs of Addiction

Symptoms can only be experienced by the person with the addiction, whereas signs can be
observed by other people. You can never know what someone else is experiencing unless
they tell you, so if you are concerned that someone else may have an addiction, look for signs
as well as for symptoms.

You might see some signs in an addicted person but not others. These are signs which occur
across many -- but not necessarily all -- addictions:

o Extreme mood changes – happy, sad, excited, anxious, etc

o Sleeping a lot more or less than usual, or at different times of day or night
o Changes in energy – unexpectedly and extremely tired or energetic
o Weight loss or weight gain
o Unexpected and persistent coughs or sniffles
o Seeming unwell at certain times, and better at other times
o Pupils of the eyes seeming smaller or larger than usual

o Secretiveness
o Lying
o Stealing
o Financially unpredictable, perhaps having large amounts of cash at times but
no money at all at other times
o Changes in social groups, new and unusual friends, odd cell-phone
conversations
o Repeated unexplained outings, often with a sense of urgency
o Drug paraphernalia such as unusual pipes, cigarette papers, small weighing
scales, etc
o “Stashes” of drugs, often in small plastic, paper or foil packages

Caution

Most of the signs of addiction are similar to normal teenage behavior. Unfortunately,
teenagers are one of the groups most vulnerable to addiction. Parents who are concerned
about their teenage child should be very careful when discussing addiction with a teenager.

The most important factor in finding out whether someone has an addiction (or not) is trust.
Trust needs to be earned, so try to be supportive. A confrontation with someone with an
addiction is likely to just lead to denial and rejection from the addicted person.

An excerpt from the book “Types of Counselling” (2nd edition, 2011) by D. John
Antony (pages 280 to 287) is given below.

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Effects of Alcohol:

Alcohol is a depressant which affects and numbs the higher brain centres thus
impairing judgement and other rational process and finally lowering self-control. There will
be motor in-co-ordination and lack of discrimination and perception of cold, pain, and other
discomforts are dulled. There is the general sense of warmth, well-being, expansiveness, self-
esteem and adequacy. What affects an individual is not the amount that is consumed but
rather the amount that enters into the bloodstream that intoxicates. The effect of alcohol will
depend upon the personality, the physical condition, the amount of food in the stomach and
the duration of drinking. A person will be considered intoxicated when 0.1% of alcohol
enters the bloodstream at which level muscular co-ordination, speech, and vision are usually
impaired and the thought process are in a way confused. If alcohol reaches 0.5% in the
bloodstream, the entire neural balance is upset and the person becomes unconscious which
perhaps acts as a safety measure since concentration above 0.55% of alcohol in the
bloodstream is lethal. Since alcohol is a high-calorie drug, it reduces the drinker’s appetite
for food. But it has no nutritional value and the person who drinks excessively usually suffers
from malnutrition. If the prolonged alcoholic debauch is followed by abstinence, the
individual will experience delirium tremens; this means that the person suffers from the
withdrawal symptoms such as disorientation of place, person and time, vivid hallucinations
especially of small and fast-moving animals like snakes and rats (which is rare), acute fear,
extreme suggestibility, marked coarse tremors of the hands, tongue and lips, and perspiration,
fever, rapid and weak heartbeat. The symptoms last from three to six days:

10. The Pet Theories of the Alcoholics:

Alcoholics have pet theories about ways and means of sobering up such as drinking a
strong black coffee, eating a big meal, taking vitamins, taking a cold shower and taking
aspirin. All these theories are not scientific to tell the least.

11. Stages in Alcohol Dependence:

We can roughly divide the whole process of dependence into three stages as early,
middle and chronic.

1) Early Stage Symptoms:

(1) Frequent Desire: There is an increasing desire to drink quite frequently and the
person will meticulously see to the maintenance of the steady supply of alcohol.

20
 (2) Increased Tolerance: There is a phenomenon called ‘increased tolerance’ which
denotes the need for higher amounts of alcohol to experience the same degree of pleasurable
feelings experienced at the previous drink.

(3) Black Out: There is usually a ‘black out’ relating to the time of intoxication. It is
an inability to recollect incidents or parts of them while one was in intoxication. One may fill
in such gaps of black out with fanciful tales. In his drunkenness one might have promised
many things but on becoming sober may not remember any of them. People around him
mistake him for telling lies or withholding the truth but in fact he genuinely does not have
any memory of the events that took place when he was intoxicated.

(4)Sneaking Drinks: Since the person still appears to be a social-drinker and not yet
dependent on alcohol, he wants to maintain that image and at the same time wants to have the
required quota every now and then and so he hides alcohol and drinks secretly.

(5) Preoccupation:

The one preoccupation for an alcoholic is the next drink and how to get if for which he
needs money to ensure a steady supply. There is a fear that he may run out of supply and so
extra care is taken to hoard stock. When he goes to social gathering where alcohol is being
served, he takes a few drinks ahead of time lest there should be shortage of alcohol.

(6) Avoiding any Reference of Alcohol:

People at this level do not want to hear of alcohol dependence since they feel terribly
guilty about it. Even people who are not normally seen angry get charge of an institution in
which there was a man who used to clean the toilets of the institutions. He used to spend all
his money on drinking. I proposed to him that if, instead of spending a large amount in
drinking, he saves some money from his salary I would add the equal amount as an incentive
and put that amount in the bank for him. The person who used to be extremely submissive to
me at the people in that institution began to flare up and started abusing meat the very
mention of drinking. Definitely his guilt – feelings was stirred by my mention of drinking I
have seen persons even in later stages of dependence; avoid drinking socially with others
when invited, since they feel a tremendous guilt-feeling. People at this level do not even want
to hear of the mention of alcohol. With all these a person passes to the middle stage.

2) Middle Stage Symptoms:

(1) Loss of control: There is a marked loss of control over the amount, time, and
occasion. Their social sensibility is lost with regard to their surroundings. All that matters is

21
the drink and nothing more. Now he stops sipping and drinking but just he gulps down the
quantity.

(2) Morning Drinking: when a person wants to drink as soon as he gets up from the
bed it is a clear sign that the condition of alcoholism is going beyond control. Morning
drinking may be to get rid of the hangover of the drinking of the previous day or to steady
himself to face the realities of the new day.

(3) Rationalization: Every drinking person at this level has a strong network of
rationalization or justification. They find out a number of reasons why they should drink. I
saw a bank manager repeatedly three times in a psychiatric clinic for de-toxification and at
every time he was complaining to me that he takes to drinks to forget his worry about not
having a child.

(4) Grandiose Behaviour: With all the rationalization, the self-esteem of the alcoholic
is very low and so to boost up his image he exhibits extravagant and grandiose behaviours by
spending lavishly, presenting gifts to friends, talking too loud, and monopolizing
conversation.

(5) Unsuccessful Attempts: In an attempt to give up drinking he change companions,

places, the type of beverages but fails in all his attempts. He keeps himself away from
alcohol for some time and obsessively starts drinking. On abstinence, he develops withdrawal
symptoms like nervousness, tremors, anxiety, convulsions and hallucinations. The bodily
dimension of the addict’s personality is affected by his satiation. Our bodies are in tune with
the type of work we do. The type of work we engage, effects a specific tuning in our nervous
system and of our biochemical and physiological dynamism’s. The more one remains in one
mode, the more it is difficult for that person to turn to any other mode, for, the body strongly
resists such a change. For example, the one who is doing office work most of the time
suddenly cannot take to manual labour without a considerable physical strain and likewise a
person who had been doing manual work cannot take to office work without a considerable
physical strain, because our bodies get tuned in, to the type of work we do. For an addict
whose body is tuned in to the presence of alcohol in his system, the abstinence will be
protested by the body by way of withdrawal symptoms. 12

(6) Binge Drinking: He drinks for several days and stops for a while only to return to
drinking obsessively. This binge drinking symptom in itself does not indicate addiction
because as psychiatrists believe, it is sign of mental illness mostly depression. It is to cover
one’s mental illness of depression one takes to drinks. Therefore binge drinking is a mental
problem rather than an alcoholic problem. So binge drinking is practiced by people having
manic depressive disorders. Binge drinking is only a cover-up.

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3) Chronic Stage Symptoms:
(1) Decreased Tolerance: Just as the increased tolerance marked the early stage, the
decreased tolerance marks the chronic stage. At this level the alcoholic gets drunk even with
a small amount of alcohol.

(2) Physical Deterioration: The physical condition of the person is completely broken
down with the result that he becomes so feeble in health. Repeated and excessive drinking
usually affects various vital organs of the body; Heart – Unstable blood pressure, irregular
pulse, enlarged heart; pancreas – painful inflammation of the pancreas; Liver – Severe
swelling of the liver, Hepatitis and cirrhosis; Muscles – Weakness of the muscles and the
loss of muscle tissue; stomach – Intestine lining becomes inflamed, Ulcers; Nervous system –
Tingling and loss of sensation in hands and feet; Brain – Cell damage resulting in loss of
memory, confusion, hallucinations; Lungs – Greater chance of infections including T B;
Genitals- Temporary impotence; Skin – Flushing, sweating and bruising; and Blood –
Changes in red blood cells.

(3) Ethical Breakdown: Whatever be his status he now is willing to beg, borrow, steal
and even kill to maintain his steady supply of alcohol.

(4) Paranoid Condition: At this level the alcoholic is likely to have paranoid of
persecution and jealously. He may think that others are against him and are plotting against
him. Since alcohol is a depressant, his sexual powers though appear to have been aroused
will not easily consummate. His desire for sex increases but his capacity to perform sexual
acts is decreased. Consequently he becomes impotent on account of which he usually
suspects his wife of infidelity and ill-treats her. I met a case in a clinic where a man was
admitted for the treatment of alcoholism. He was suspecting his ten-year-old son having sex
with his wife.

(5) Suicidal Tendency: It will not be uncommon for counsellors to meet alcoholics at
this last stage with suicidal tendency. The physical and mental conditions are completely
broken down with the result there is a general inability coupled with the delusion of
persecution and jealousy which drive the alcoholic to suicide.

12. Characteristics of Alcoholism:

(1) It is a primary disease in the sense that it is a disease per se. (2) It is a progressive
disease in the sense that when one after a period of abstinence relapses, he starts off from
where he left and not from the very scratch. (3) It is a terminal disease in the sense that the
person dies a premature death. (4) It is a permanent disease in the sense that it cannot be

23
treated; it can only be arrested. An alcoholic can never become a social drinker. It is like a
one-way traffic.

13. Alcoholic Games:

An alcoholic’s situation can be analysed from his psychological game position. He
seems to be playing three major games in his life to perpetuate his basic life position.

1) Drunk and Proud:

This is one of the games played by an alcoholic. His existential position seems to be
one of ‘I’ m no good and you’re O.K. (ha, ha). Apparently he seems to be putting himself in
a disadvantageous position of being disapproved of, but in fact he is taking the upper hand
and persecutes the one whom he apparently proclaims to be O.K. The very ‘ha, ha’ is an
indication that he is unconsciously sure of the not O.K.ness of the other. In this position
anybody trying to help an addict will end up feeling foolish and angry and definitely not O.K.
This is precisely what the alcoholic wanted.

2) Lush:

The player of this game is a stroke-starved person mostly sexual in nature. The person
does not get enough strokes from his or her partner and so plays the game of lush to get the
needed stroke. Getting drunk does not necessarily obtain for him or her the needed stroke
since his or her partner is not in a position to give the stroke. The person goes out seeking a
partner (mostly sexual) who can give the stroke since with the drinking parental prohibitions
and adult objections are eliminated from oneself. The player, as it were says, ‘I’ m crazy
(depressed), you can make me feel better (cure me) (ha, ha).’ This is played to the partner
who is unable or for whom it is difficult to give strokes. The cynical ‘ha, ha’ is an indication
that the partner will not be able to give the stroke. And so he or she is justified in going to
another partner for strokes (may be for sex). By playing this game one feels justified in
seeking sexual partner (for strokes) outside the marital bond.

3) Wino:

It is a game from the self-destructive life script. He says, ‘I’ m sick, you’re well (ha,
ha). Here the alcoholic becomes ill to get the strokes he wants. His bodily integrity is
sacrificed for the sake of strokes. In all the three games it is not to be taken that the player
really considers the others as O.K. Deep down in his unconscious he is convinced that the
others are O.K. and that is why the cynical ‘ha, ha .’ I would interpret these games as those of
a persecutor to put the others down by playing apparently the victim’s role. No doubt these

24
are unhealthy and manipulative ways of getting strokes. Training the alcoholic to become
aware of what he needs and ask and get it in a healthy way is the task of the counsellor.

14. Alcoholic Women & Homosexuals:

There are special alcoholic populations such as women and homosexuals. Women
drinkers seem to suffer greater physical damage more because of the disapproval and
negative attitude of the society in which they live; in fact, they are more vulnerable due to
their deficient parenting practices and sexual misconduct. Because of the lowering of sense
of decency, inhibition is absent; practically all the addicts have sexual promiscuity; on
recovery overcome by guilt and shame. There are clandestine homosexuals and open
homosexuals. In some societies homosexuals are openly acknowledge whereas in some, they
are ignored. Depending upon the social climate the alcoholic homosexuals feel estranged
mainly due to the lack of support group unless they join Gay AA. Counsellors working with
women alcoholics and homosexual alcoholics need to free the former the guilt feeling and the
latter from loneliness.

2.3 STAGES OF ADDICTION

2.3.1 STAGES OF ALCOHOL ADDICTION
The author Tellinek classified alcoholism, into five categories:

Alpha Alcoholism: A purely psychological dependence on alcohol. There is neither

loss of control nor an inability to abstain.

Beta Alcoholism: The drinker is not psychologically or physically dependant but

develops various physical problems resulting from alcohol, such as cirrhosis or gastritis.

Gamma Alcoholism: Marked by a change in tolerance, physical changes leading to

withdrawal symptoms and a loss of control. There is a progression from psychological to
physical dependence. It has got four phases: pre alcoholic, prodromal, crucial and chronic.

Delta Alcoholism: Similar to Gamma alcoholism. There is psychological and physical

dependence but there is no loss of control.

Epsilon Alcoholism: Periodic alcoholism marked by binge drinking. It is different

from the others. Most of the alcoholics treated in clinics and in treatment centres are gamma
type alcoholics. They have characteristic behaviour alterations that in a reasonably predictable
sequence. In our present study alcoholism refers to gamma alcoholism.

****

25
Tellinik in his masterwork, "The Disease Concept of Alcoholism" develops the idea of four
different phases of alcoholic addiction. They are: pre alcoholic, prodromal, crucial and chronic.

(1) Pre-Alcoholic

Drinking started off as socialisation soon turns out, for a prospective alcoholic, to be an
experience of psychological relief. He seeks out occasions when drinking will occur. Drinking
becomes his standard means of handling stress. His drinking behaviour at this stage will not
look different to the others. Tolerance for alcohol increases, that is, an increased dosage is
needed to experience the same effect as before. At this stage the individual starts gulping his
first few drinks so that the desired effect is felt immediately.

(2) Prodromal Phase

(a) "Black out" indicates the beginning of this stage. During a black out the person
may go through many activities -- walking, talking, drinking, etc., without being
able to recall them later on

(b) Pre-occupation with drinking increases how, when and where he could get the
next drink.

(c) Avoids talking about alcohol: Earlier he would boast about how much he could
drink. But as a result of feeling guilt he does not want to talk about drink at all.

(3) The Crucial Phase

(a) Loss of Control: First there is a loss of control over the quantity of alcohol
consumed and eventually the patient loses control over time and place of
drinking. Drinking becomes compulsive. He becomes totally powerless over
alcohol; Loss of control is the clear sign that alcoholism has developed.

(b) Rationalizing: The patient begins to rationalize, finds reasons and excuses to
reduce his guilt feelings.

(c) Grandiose Behaviour: To avoid the truth about his drinking he starts exhibiting
grandiose behaviour, buying things which he does not need or giving lavish
gifts which are beyond his means.

(d) Aggression: The self-hatred he feels within himself is directed towards others in
verbal or physical abuse.

(e) Guilt and Remorse: These feelings become part of drinking. These feelings
often lead him back to the bottle.

26
(f) Abstaining from Alcohol: He attempts to give up alcohol on his own. He may
succeed for a while but he will inevitably go back to obsessive drinking.

(g) Changing the Drinking Pattern: In his effort to give up drinking he may change
the drinks from whisky to beer or shift places and times of drinking but to no
effect.

(h) Social Relations begin to Decay: His job will be affected; he may even lose his
job. He is unable to keep the family together in place. There is a hangover,
jitters, guilt, remorse and depression due to morning drinking.

(i) As the problem with family and job mounts up he may seek help, not really to
get rid of his alcoholism, but to put his life back in order.

4. Chronic Phase

(a) Binge Drinking: The patient goes on drinking continuously for several days
having lost all controls. This is called Binge. He feels utterly helpless. Other
alcoholic complications like gastritis, liver dysfunction and polyneuritis occur.
There is total disregard for the family, job, everything.

(b) Decreased Tolerance: Due to severe physical deterioration he now gets "drunk"
even with small quantities of alcohol. This results in higher degree of
alcoholism in the blood.

(c) Ethical Breakdown: Compulsion for alcohol forces him to say lies, borrow or
steal in order to maintain the supply of alcohol.

(d) Paranoia, fears, hallucinations: The patient becomes suspicious of people

around him as plotting against him. The male alcoholic having lost his sexual
desires functioning at this stage becomes suspicious of his wife having affairs
with other men. He is frightened of nameless fears. He is afraid even to cross
the road, enter a dark room, etc. He sees things that do not exist, hear
imaginary voices, feels as though something is moving on the skin

(e) Lack of Motor Co-ordination: He experiences shakes and tremors. Formerly he could
control them by taking more alcohol but now alcohol does not help in quietening them.
He is unable to do his ordinary work.

(f) Turning to God: The patient at this stage becomes desperate. His entire being is nearly
destroyed by addiction. He now turns to God only to ask him to maintain a supply so
that he can manage his drinking.

So what was once sought to release tensions and to provide means to cope with a
difficult life situation has become the killer disease, destroying the whole person.

27
2.3.2 STAGES OF DRUG ADDICTION

First Stage: Preoccupation/Anticipation

Constant cravings for a drug are the very first sign that addiction is taking hold.

An overwhelming urge to use the drug of choice preoccupies the user despite other events,
responsibilities or relationships in his or her life. Irritability, agitation, fatigue, depression and
difficulty concentrating are the warning signs that something is out of balance.

Second Stage: Binge/Intoxication

As the drug is introduced into the body more frequently, larger amounts are necessary to
continue experiencing the same high. To increase that feeling, excessive indulgence of the
drug (binging) pushes the effects of intoxication to dangerous levels.

Prolonged exposure results in desensitization, which can result in an overdose as the user
attempts to regain the initial euphoria experienced when using the drug for the first time.

The warning signs of the second stage include missing days or showing up late at work or
school because you are using or recovering from a drug or alcohol binge; continued use in
spite of threats of getting fired or expelled; scheduling your day around obtaining, using or
recovering from drug use and choosing to attend events or spend time with friends only if
drugs or alcohol will be available. Unexplained personality changes, sudden need for
money, excessive need for privacy or possession of drug paraphernalia are all indicators
of a full-blown addiction.

Third Stage: Withdrawal/Negative Affect

The withdrawal symptoms experienced anytime the drug is not present cause tremendous
suffering if not managed by a caring medical professional.

Symptoms differ according to the specific drug, but can include:

 Agitation, anxiety, panic

 Insomnia, depression, paranoid thinking
 Fatigue, muscle pain, feeling shaky
 Headaches, dizziness, seizures
 Nausea, vomiting, chills, cramps
 Shakes, sweats, tremors
 Psychotic reactions

28
At this stage, the only motivation in an addict’s life is to avoid the agonizing symptoms of
withdrawal. All other conventional activities cease to have meaning beyond finding and
continuing to use the drug.

Friends and loved ones may notice lost interest in family or social activities, hobbies, or even
personal appearance. Risky behavior (stealing, sharing needles, unsafe sex), changes in
eating habits, unexplained weight change, difficulty paying attention, violent or bizarre
outbursts, even paranoia are all indications of the destructive cycle being playing out.

*********

2.4 THE MICHIGAN ALCOHOLISM SCREENING TEST (MAST)

Developed in 1971, the Michigan Alcohol Screening Test (MAST) is one of the oldest and
most accurate alcohol screening tests available, effective in identifying dependent drinkers
with up to 98 percent accuracy.

Questions on the MAST test relate to the patient's self-appraisal of social, vocational, and
family problems frequently associated with heavy drinking. The test was developed to screen
for alcohol problems in the general population.

Drawbacks of the MAST

There are two drawbacks to the MAST test, compared with other alcohol screening tests
available today. The length of the test makes it less convenient to administer in a busy
primary care office or emergency room setting, compared to the shorter four- or five-question
tests available. The questions on the MAST test also focus on problems over the patient's
lifetime, rather than on current problems. This means the test is less likely to detect alcohol
problems in the early stages.

Over the years, there have been several variations of the MAST developed, including the
brief MAST, the short MAST, as well as the self-administered MAST. The following is the
22-question, self-administered MAST.

The MAST Test

The MAST Test is a simple, self-scoring test that helps assess if you have a drinking
problem. Answer yes or no to the following questions:

1. Do you feel you are a normal drinker? ("Normal" is defined as drinking as much or less
than most other people)
___ Yes ___ No
29
2. Have you ever awakened the morning after drinking the night before and found that you
could not remember a part of the evening?
___ Yes ___ No

3. Does any near relative or close friend ever worry or complain about your drinking?
___ Yes ___ No

4. Can you stop drinking without difficulty after one or two drinks?
___ Yes ___ No

5. Do you ever feel guilty about your drinking?

___ Yes ___ No

6. Have you ever attended a meeting of Alcoholics Anonymous (AA)?

___ Yes ___ No

7. Have you ever gotten into physical fights when drinking?

___ Yes ___ No

8. Has drinking ever created problems between you and a near relative or close friend?
___ Yes ___ No

9. Has any family member or close friend gone to anyone for help about your drinking?
___ Yes ___ No

10. Have you ever lost friends because of your drinking?

___ Yes ___ No

11. Have you ever gotten into trouble at work because of drinking?
___ Yes ___ No

12. Have you ever lost a job because of drinking?

___ Yes ___ No

13. Have you ever neglected your obligations, family, or work for two or more days in a row
because you were drinking?
___ Yes ___ No

14. Do you drink before noon fairly often?

___ Yes ___ No

30
15. Have you ever been told you have liver trouble, such as cirrhosis?
___ Yes ___ No

16. After heavy drinking, have you ever had delirium tremens (DTs), severe shaking, visual
or auditory (hearing) hallucinations?
___ Yes ___ No

17. Have you ever gone to anyone for help about your drinking?
___ Yes ___ No

18. Have you ever been hospitalized because of drinking?

___ Yes ___ No

19. Has your drinking ever resulted in your being hospitalized in a psychiatric ward?
___ Yes ___ No

20. Have you ever gone to any doctor, social worker, clergyman, or mental health clinic for
help with any emotional problem in which drinking was part of the problem?
___ Yes ___ No

21. Have you been arrested more than once for driving under the influence of alcohol?
___ Yes ___ No

22. Have you ever been arrested, or detained by an official for a few hours, because of other
behavior while drinking?
___ Yes ___ No

Scoring the MAST Test

Score one point if you answered "no" to the following questions: 1 or 4. Score one point if
you answered "yes" to the following questions: 2, 3, and 5 through 22.

A total score of six or more indicates hazardous drinking or alcohol dependence and further
evaluation by a healthcare professional is recommended.

(Source: The National Council on Alcoholism and Drug Dependence of the San Fernando Valley.)

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 UNIT 3
3 DENIALS - CONCEPT AND MEANING – DIFFERENT FORMS OF DENIALS.
Substance addiction follows a pattern. We can identify the pattern as follows:-

1. When a person gets used to having an addictive substance he needs more of it to produce the
desired result (Tolerance)

2. When the intake of addictive substance is stopped abruptly, the body and mind reacts with
stress and backlash actions. As a result one feels uneasiness, irritability, panic and
experiences symptoms that are the exact opposite of those caused by the addiction
(withdrawal symptoms)

3. The mind of addict creates its own tricks to perpetuate the addiction. These are DENIALS,
rationalisation and every form of defence mechanism (self deception).

4. The person becomes totally powerless over the addictive substance. All resolution to stop
addiction fails, further reinforcing addiction (lose of will power).

5. The mind gets so fixated with the addictive substance that the person is not able to pay
attention to anything else in life. The person deteriorates in every aspect of his life (the
lost person).

3.1 DENIALS - CONCEPT AND MEANING

Denial: Why Alcoholics and Drug Addicts Think it is OK to Drink and Use Drugs

Denial is a defense mechanism that allows a person – despite overwhelming evidence to the
contrary – to deny that something is true, when in fact, it is true. It is one of the most
powerful and difficult problems that Alcoholics and Drug Addicts face before, during, and
after treatment, because it is always the thinking that precedes the act of picking up a drink or
a drug.

Physical Components of Denial

Over the course of time, drinking and using drugs can cause changes in the brain that affect
thought processes and emotions. For example, when the hippocampus, which controls
memory and judgment, is damaged, the Alcoholic or Addict has great difficulty remembering
the bad things that happen when they drink or use. This coupled with impaired judgment
allows them to actually believe that drinking or using drugs is ok.

Poor judgment is further compounded by the over stimulation or inhibition of two important
neurotransmitters: Serotonin and Dopamine. Serotonin affects thinking and emotions, while
Dopamine affects the pleasure and reward center of the brain. When a person drinks or uses

32
drugs excessively, these neurotransmitters are over stimulated, and the body develops a
tolerance to them. This causes the individual to need more and more of the substance while
they get less and less of an effect.

Non-addicted people find it very difficult to understand the thinking and actions of the addict
or alcoholic. They just don’t “get it” because their brains have not been damaged so their
thinking is not organically impaired and they have the capacity to differentiate between truth
and falsehood.

Thought Patterns of Denial

The essential and most basic of all Denial thinking is this: “I don’t have a problem with
alcohol or drugs, and the things that are wrong in my life don’t have anything to do with my
drinking or using.” This erroneous belief gives rise to all sorts of strange twists and turns of
thought that are common in Addicts and Alcoholics.

Substance Abusers blame others for the negative things that happen in their lives and lie
about where they have been and what they have been doing. They live in a fantasy world
where they have convinced themselves that their lives are “not so bad” despite the loss of
jobs, marriages, family and friends. They say that if only they had more money or if the
people in their lives would understand them, that everything would be ok.

They do not acknowledge, nor do they connect the fact that drinking and using drugs have
become the root cause of their current problems; this is Denial.

Emotions and Denial

Alcoholics and Addicts vacillate between feelings of superiority and inferiority, mania and
depression, and typically suffer from tremendous anxiety and fear. They use drugs and
alcohol to cope with these strong and painful emotions, but this only provides temporary
relief and is counterproductive because when the effect wears off the feelings are still there,
and are compounded by shame, guilt, and remorse. For the alcoholic/addict, the usual
response to these new emotions is to drink or use again. The fact that it did not solve
anything does not register with them.

In addition, substance abusers almost always have low self-esteem and deep seated emotional
issues that are rooted in childhood. They often say things like “I never felt like I fit in” or “I
never felt good enough.” They do not know how to deal with negative emotions. When they
had their first drink or drug that changed. Instantly, they had relief from the painful feelings;
they felt like they fit in, and didn’t feel bad about themselves anymore. This is where
emotional denial begins. While under the influence, problems and painful emotions don’t

33
exist; it seemed to be a real solution, because it worked. What they did not know, is that
instead of being the solution, it was the road to self-destruction via the highway of Denial.

Behavior Patterns of Denial

Family, friends and employers notice changes in the behavior of an alcoholic or addict long
before the person with the disease does. This is the first indicator that someone is in denial
about their disease. Tragically, as it progresses, the individual barely notices the changes and
deterioration because they happen gradually, day after day and seem normal to the sufferer.

Typical behaviors include, but are not limited to: being late to work, inability to hold a job,
getting arrested, ending relationships when people criticize their drinking or using, spending
rent money on drugs or alcohol, not keeping commitments, driving under the influence, poor
personal hygiene, frequenting dangerous neighborhoods, and living on the street.

Again, the alcoholic or addict does not notice or pretends not to notice that these behaviors
are related to their substance abuse, when clearly they are.

Summary

Denial is one of the biggest roadblocks to recovery. It is an elusive and dangerous pattern of
thinking that is extremely difficult to break because it has so many different causes and
manifestations. The first clue that someone is in denial is that their behavior and dialog
changes dramatically and they develop a litany of excuses for this that do not include
drinking or using drugs.

This is further compounded by physical damage to the brain and its chemistry, which
exacerbates poor judgment, increases tolerance, and enhances denial. The fundamental
problem of denial is that the alcoholic/addict actually sees substance abuse as the cure not the
cause.

It is only when a person has a moment of clarity; where they see through the fog of denial
and connect their problems to their drinking or using drugs that they will seek help. When
this happens, recovery is possible.

3.2 DIFFERENT FORMS (TYPES) OF DENIALS

Denial of fact: This form of denial is where someone avoids a fact by lying. This lying can
take the form of an outright falsehood (commission), leaving out certain details in order to
tailor a story (omission), or by falsely agreeing to something (assent, also referred to as
"yesing" behavior). Someone who is in denial of fact is typically using lies in order to avoid
facts that they think may be potentially painful to themselves or others.
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Denial of responsibility: This form of denial involves avoiding personal responsibility by
blaming, minimizing or justifying. Blaming is a direct statement shifting culpability and may
overlap with denial of fact. Minimizing is an attempt to make the effects or results of an
action appear to be less harmful than they may actually be. Justifying is when someone takes
a choice and attempts to make that choice look okay due to their perception of what is "right"
in a situation. Someone using denial of responsibility is usually attempting to avoid potential
harm or pain by shifting attention away from themselves.

Denial of impact: Denial of impact involves a person avoiding thinking about or

understanding the harms their behavior have caused to themselves or others. By doing this,
that person is able to avoid feeling a sense of guilt and it can prevent that person from
developing remorse or empathy for others. Denial of impact reduces or eliminates a sense of
pain or harm from poor decisions.

Denial of awareness: This type of denial is best discussed by looking at the concept of state
dependent learning[2]. People using this type of denial will avoid pain and harm by stating
they were in a different state of awareness (such as alcohol or drug intoxication or on
occasion mental health related). This type of denial often overlaps with denial of
responsibility.

Denial of cycle: Many who use this type of denial will say things such as, "it just happened."
Denial of cycle is where a person avoids looking at their decisions leading up to an event or
does not consider their pattern of decision making and how harmful behavior is repeated. The
pain and harm being avoided by this type of denial is more of the effort needed to change the
focus from a singular event to looking at preceding events. It can also serve as a way to
blame or justify behavior (see above).

Denial of denial: This can be a difficult concept for many people to identify in themselves,
but is a major barrier to changing hurtful behaviors. Denial of denial involves thoughts,
actions and behaviors which bolster confidence that nothing needs to be changed in one's
personal behavior. This form of denial typically overlaps with all of the other forms of
denial, but involves more self-delusion.

*********

35
 UNIT 4

4 MANAGEMENT OF ADDICTS – MEDICAL MODEL -- DISEASE MODEL --

SOCIAL LEARNING -- DEADDICTION –WITHDRAWAL SYMPTOMS – RE-
EDUCATIVE THERAPY - PSYCHOSOCIAL MANAGEMENT.

4 MANAGEMENT OF ADDICTS
An excerpt from the book “Types of Counselling” (2nd edition, 2011, Guru
Publications, Dindigul; also available free of cost in www.anugraha.info) by D. John Antony
(pages 287 to 295) is given below.

Treatment of Alcoholism:

2) Biological Measures:

(1) Detoxification:

In acute intoxification when individuals are brought to the hospital the process of
detoxification which is the elimination of the harmful alcoholic substance from the
individual’s body starts. A hospital setting is helpful to handle withdrawal symptoms and to
ensure detoxification.

(2) Aversion Therapy:

Whatever aversion therapy was used formerly is now abandoned by the medical
practitioners on account of the risk it involved to life. The one currently practiced is the
method of using disulpherim ('Antabuse') which is a drug that creates horrifying
uncomfortable effects when followed by alcohol. This method may act as a deterrent to
further drinking. 2) Psychological Measures:

Individual Therapy: Apart from individual problems, alcoholic have personal

problems like anybody else and they need to be handled by the counsellor for which
counselling and psychotherapies are employed. Here, whether the patient is psychologically
dependent on drugs or physiologically and psychologically dependent on drugs is assessed
and the therapies are given depending upon the nature of the patient and the extent of damage
he suffers; the therapies could be from any discipline like psychoanalysis, rational emotive
therapy, reality therapy, transactional analysis and the like.
3) Psychosocial Measures:
(1) Group Therapy:

36
 Once the de-toxification process is over the person will profit if he is introduced into
a group therapy. In group therapy the alcoholic is made to realize that he has a drinking
problem and there are evil consequences of drinking.

(2) Sociotherapy:

] Family therapy assumes great importance in the treatment of the alcoholic. In

treatment, rehabilitation into the family with the roles he formerly held is emphasized. When
a person returns home, the other family members who have already started to take his
position will not be willing to let him have his role and status at home and many even do not
believe his conversion and so being frustrated he is likely to relapse into alcoholism. It has
been noted that the older children especially boys are so angry with the recovering alcoholic
that they will not at times admit him into their homes. Some children do not forgive their
father because of the misery to which the family was brought on account of the drinking. If
the drunken father had sexually abused the female children, it is unlikely that they forgive
him so easily. Therefore family counselling is necessary for rehabilitating the alcoholic. He is
helped to learn more effective coping skills an attempt is made to see that his environment
does not react to sobriety with hospital .If the family members are not adequately counselled,
their negative attitudes and their degrading treatment will induce the recovering alcoholic to
relapse.

(3) Alcoholics Anonymous (AA):

Joining an Alcoholic Anonymous serves as a support group of people who had

similar problem with regard to drinking. They are not only supportive but also model for his
coping skills. Treatment also must take into account the relapses it is worth helping the
alcoholic to remain sober.

(4) Follow –up:

Apart from the motivation of the alcoholic what stands out as the unique factor for
success is the follow-up programme for the alcoholic. We take for granted that relapses are
normal among the alcoholics and therefore to strengthen them in their resolve to remain dry
and sober, follow-up programmes are absolutely essential. Where follow-up programmes are
wanting, recovering alcoholics are known to have relapsed into their former condition.

16. Counselling the Alcoholics:

2) Hurdles to Counselling:

37
(2) Unwillingness:

What stands as one of the biggest hurdles for recovery is the unwillingness of the
addict \ alcoholic himself. Recovery does not mean mere abstinence with growth. Most
alcoholics do not want to give up drinking. Perhaps they have no alternative forms of
behaving, spending time, dealing with problems and meeting their needs and so they cling on
to their drinking habits.

(2) Psychiatric Disorders:

People with a psychiatric problem of depression taking to drinks will not respond to
treatment unless their psychiatric problem of depression is treated. Therefore diagnosing the
cause of drinking is essential for treatment and if psychiatric disorders are the cause of
drinking, the person needs to be treated psychiatrically which itself enhances the chance of
getting out of the clutches of alcoholism.

(3) People with psychopathic trends:

There is another category of people who according to the psychiatrist will not respond
positively to treatment. They are the persons with psychopathic trends of personality. They
take drinks for ‘kicks’ and gratification without any social sensibility. They may appear to be
repentant; since they are above normal in intelligence they cleverly manipulate the situation
to their advantage. There is a lot of pretence to show that one is truly changed whereas
clandestinely one will carry on drinking. There was a man with psychopathic trends who was
treated for alcoholism. On his return home after the discharge his wife found him drunk on
the way. This is a clear sign of psychopathic trend in personality. Otherwise he would not
have drunk on the very day of his discharge. If it were only addiction without psychopathic
trend, the person would have found it difficult to remain dry for a week or so and then.
Would have taken to drinks because of the addictive tendency. Since that individual had
personality disorder of psychopathic trends he wanted the ‘kick’ at the earliest after the
discharge.

Therefore in treatment and counselling it is good to know what causes a person to

drink. Unwillingness, psychiatric disorders and psychopathic trends are all major hurdles to
recovery which a counsellor faces in his counselling situation.

2) Overall Approach:

Let us now concentrate our attention on the counselling of the recovering alcoholic.
The fact that he has been given treatment is not enough to ensure that the problem of

38
alcoholism is over. Counsellors are rather reluctant to help an alcoholic because of the low
rate of recovery among them. It is true that relapses are as common as alcoholism. Rarely do
we find anyone just recovering from alcoholism once and for all. Most of the alcoholics have
relapse which might provoke anger in the persons who are helping them rehabilitate.
A developmental overview of the recovery process will be useful in helping the
alcoholic. In the developmental overview we have three separate but not always
distinguishable stages. The first stage is the ‘de-compulsifying’ stage which in a way takes
away the compulsion to drink and focuses primarily on physical recovery. The second stage
deals with the psychological aspects which make the effects of alcohol so seductive. The
third stage is focused on integrating the person’s identity as an alcoholic with an acceptable
vision of the meaning of life. Research has been done to evaluate death among alcoholics
who die in a year after becoming sober. Among them 20% die of suicide which means that
the recovery is not over just because a person has reached sobriety. If a counsellor responds
even in the slightest way judgmental to the alcoholic, he is likely to behave negatively. In the
beginning stage of recovery it is advisable not to deal with issues of ethical responsibility. 15

3) Stage-wise Approach:

Recovery can also be understood in terms of three stages each having tasks such as
physical recovery and psychological recovery. Thus we may find the following: 16

(1) Early Stage:

The two main issues here are ‘de-compulsifying’ drinking behaviour and the physical
restoration of the body.

i) Physical Recovery:

Alcoholic is known to harm virtually every major organ system in the body. Hence
referral to a physician is a must especially to deal with the emergency of the withdrawal
symptoms. The process of natural body restoration may last even two years. The alcoholic is
easily fatigued and his sleep patterns are disturbed at least for a year since brain restoration is
slow process. Excessive use of alcohol would impair cognitive functioning altering the
structure of the brain resulting in measurable intellectual deficit. It could be a chronic brain
damage not restricted to the period of intoxication alone. Recovery of cognitive functioning
continues for several years and may not be total. Short –term memory is rather poor and the
ability to deal with abstractions is impaired resulting in difficulties in learning new
programmes.

39
ii) Psychological Recovery:
Here the counsellor along with the alcoholic discovers the antecedents of drinking to
prevent lapses. Two major categories are identified as responsible for relapses and they are
intrapersonal and interpersonal determinants.

(i) Intrapersonal Determinants : 1) Negative emotional stages such as anger, anxiety,

depression and the like 2) Urges and temptations 3) Testing personal control in the sense of
whether one can again be a social drinker.

(ii) Interpersonal Determinants: 1) Interpersonal conflict, negative confrontation 2)

social and peer group pressure to take a drink. Therefore we can summarize the antecedents
to relapse as negative emotional stages, interpersonal conflicts and social pressure, negative
emotional stages, interpersonal conflict and social pressure.

(2) Middle stage:

Here the major concern is psychological recovery. The alcoholic faces the naked
primary life struggles without alcohol. Here physical recovery continues and psychologically
the alcoholic sees clearly the fundamental realities such as marriage, family relationships,
career and friends. There could be a sense of isolation as separated from his drinking
partners. There could be feelings of guilt over unresolved sexual issues since during the
drinking period the alcoholic usually messes this aspects of his life. With regard to sexual
behaviour two patterns are noted; one of them is that sexual behaviour starts with alcohol
ends with alcohol and therefore after sobriety there is no misconduct. The other is having
problem independently of drinking though drinking may accompany such sexual activities.

(3) The Later Stage & Beyond:

The major task is to integrate and accept one’s identity as an alcoholic. Now the
physical and the psychological recovery tend to stabilize.

1 THE MEDICAL MODEL -- THE DISEASE MODEL OF ADDICTION

The medical model views addiction, particularly substance addiction, as a complex illness,
involving the combination of several biological mechanisms. Dr. William B. Silkworth was
one of the first members of the medical community to recognize that alcoholism was more
than simply a moral weakness, and likened the physical component of alcoholism to an
allergy of the body (1955). Although he and the alcoholics who wrote the Big Book of
Alcoholics Anonymous (AA) lacked the scientific means in the 1930's to support their
beliefs, research within the last few decades has shown that alcoholics are physiologically
different than non-alcoholics.

40
Studies of adopted children in the 70's and 80's showed that there was a genetic component
of addiction within families, in that they found a significant correlation between the presence
of alcoholism in at least one biological parent, and the development of alcoholism in the
child, whether they were raised in an alcoholic environment or not. It was estimated that
“genetic influence is identifiable in at least 35 to 40 percent of alcoholics and alcohol
abusers, and it affects both men and women” (1985).

Other studies focusing on physiological characteristics of alcoholics and addicts found that
brain chemistry was different in addicts verses non-addicts, and that even without any
drinking problems being present, descendants of alcoholics metabolized alcohol differently
than relatives of non-alcoholics.

In the medical model, the physician is the primary person delivering treatment and abstinence
from the chemical is seen as the ultimate goal, and although the doctor might refer the patient
to a psychologist, not as much attention is paid to other potential aspects of the disease, e.g.,
psychological and social problems. The treatment of choice for this model involves dealing
with the physical consequences of the addiction through nutrition, etc., and the use of
medications such as disulfiram (Antabuse) and naltrexone (Revia) to ensure abstinence.

Critics of the medical model believe that the portrayal of addiction as a progressive,
incurable, and fatal illness, is both self-defeating for the addict seeking help, and is simply
not true in many cases.

To sum up, the disease model of addiction describes an addiction as a disease with
biological, neurological, genetic, and environmental sources of origin. According to the
disease model, the onset and development of addiction are influenced though genetic
predisposition and environmental factors.

2 SOCIAL LEARNING

Social Learning Theory and Addiction

Classical conditioning and operant conditioning describe how we learn from direct
experience. However, humans usually learn by observing others. This is called social
learning. Social learning is the most common way that people learn. Therefore, it has
important implications for recovery efforts. In this section, we discuss how learning occurs
within social groups. These groups may include the family, peers groups, and the larger
community.

The social interactions that have the greatest influence are with the people who mattered to
us as we grew up. This includes parents and other family members. It might also include a

41
neighbor or teacher. Maybe we noticed our parents only ever relaxed and had fun when they
gambled (perhaps playing cards with friends). Maybe they coped with stress by smoking pot.
Maybe we observed they never socialized unless they were drinking. If we observed these
sorts of things, then we will be more likely to try out these behaviors as well. This is because
we have learned through observation that gambling, smoking pot, and drinking achieved a
positive result. In the absence of other healthier examples, it would seem those activities
were good ways to relax, have fun, and reduce stress. We can attribute this to social learning.

People have a powerful need for social interaction. Therefore, it becomes important to
consider the compelling social nature of many addictions. Many types of addiction require at
least the cooperation of other people. Some types of addictions afford opportunities for
pleasing social discourse and interaction as well. For example, heroin addicts often help one
another obtain and use the drug. Alcohol is a frequent and often central feature of many
social venues. Gambling casinos strive to provide an exciting social atmosphere.

As addiction progresses, there are fewer opportunities for the addicted person to interact with
healthy, non-addicted persons. This is because friends and family eventually disengage from
the addict. Simultaneously, the addiction occupies more and more of the addict's time.
Gradually, the addict's entire social circle becomes other people who are associated with the
addiction. It is nearly impossible to free yourself from an addiction without forming new
relationships with healthier people, while disengaging from people who are not.

This is one of the reasons that support groups are helpful in addiction recovery. These groups
(such as AA) immediately provide a source of social support. Support groups (promoting
moderation or abstinence) date back at least to the 1500s. Time spent with others in recovery
reduces the amount of peer pressure to engage in addiction. From a social learning
perspective, support groups offer opportunities to observe and interact with healthier people.

When we apply the social learning theory to addictions treatment, the usual treatment goals
include:

1) Develop a new, healthier network of peers.

2) Observe and adopt the positive coping skills of these new peers.
3) Learn refusal skills to respond to peer pressure. These refusal skills are very important
because recovering people cannot altogether eliminate contact with their former addicted
friends. This is particularly true during the early stages of recovery

42
4.3 DEADDICTION

The disease of addiction affects the whole person -- physically, mentally and spiritually. While
the family and society make their contribution towards addiction, they in turn are badly affected
by addiction. Therefore, therapy for the addict should address man in his totality. Treatment for
addiction requires help from different fields of expertise. Doctors, psychologists, social workers,
spiritual guides and counsellors and recovering addicts all work together in cooperation with
one another to achieve the best possible result. This comprehensive multi-disciplinary approach
is done in four phases. They are:

Phase I

Identification/intervention in which the patient is taken for treatment by his wife,

friend, social worker, employer, a doctor or school authorities, and is brought to the breaking of
his denial through supportive confrontation and individual therapy.

Phase II

Detoxification through ingestion of medicines, nursing care and counselling the patient
to become drug-free.

Phase III

Rehabilitation through in-patient or outpatient programme where the patient and the
family is helped to change self-concept, personality traits and the life style.

Phase IV

After Care for prevention of relapses and reinforcement of new patterns of sober living.

We shall consider each of these four phases briefly below.

INTERVENTION

Alcoholism is a disease and as such can be arrested short of total tragedy, provided its
victim gets suitable help soon enough. The chances an alcoholic will ask for help on his own is
very little. It was generally agreed that the alcoholic had to "hit bottom" and voluntarily seek
help before it could be effective, but that usually happened too late to salvage much of his life.
Yet for some just the realization that they were risking their job or their marriage was incentive
enough to seek help (they were sometimes said to have hit a "high bottom").

"Hitting the bottom" means that the alcoholic has found himself in a crisis so painful and
so frightening that he will do anything to escape from it -- even stop drinking. Such a crisis often
can be created by those who care about him. This process is called intervention.

43
Direct Intervention

Sharon spells out the main points of intervention.ii It starts with one of the family
members approaching a counsellor for help. Sometimes it could be a family friend or the
employer or doctor. The counsellor reviewing the critical issues facing the Dependent forms an
intervention team that includes people who have personally witnessed the alcoholic behaviour
of the Dependent. It could also include the employer, pastor or close friends. The counsellor
explains the nature of the intervention process and prepares the team. It may take a few months
for this preparation. Before they start intervention they must be convinced that,

1. Alcoholism is not one of the problems but THE problem.

2. Given the nature of alcoholism the Dependent will not ask for help on his own.

3. All that they do to help the Dependent -- trying to control his drinking, assuming his
responsibilities, etc., are worse than useless. They are actually making it possible for him to go
on drinking without facing the consequences. The only thing they can do that is truly helpful to
him is to use their combined influence to get him accept treatment.

4. If each one of the family members is playing a role then they should be willing to lay aside
their role before they could ask the Dependent to give up his role. They should break out of their
defensive behaviour patterns into which they are each locked and to let their long buried
feelings emerge.

Now each member of the team prepares a list of specific instances when the Dependent's
behaviour caused someone pain, danger or other problems specifying the exact time, setting and
other details. There should be no hint of blame or hostility in their statements. They practice
making their statements so that they do calmly and courageously on the day of intervention. It is
better that each one reads from his list than speak extemporaneously. Then they decide on what
action they are going to demand from the Dependent.

Now chose a time when the Dependent is most likely to be sober with his defences at
low ebb. Somehow he should sense a crisis. A suitable place has to be selected where it is easy
to get the Dependent. With the presence of the counsellor the intervention begins. The piling up
of episode upon episode of his alcoholic behaviour, described in all detail by those who
witnessed it is usually defence shattering for the Dependent. The effect is heightened by having
those he loves confess the anguish his actions have caused them. The Dependent is usually
shocked into facing the painful truth about his condition. At this point a programme of treatment
and after care is presented to him. Any promises from his side to stop drinking on his own
should not be accepted. He should accept help, either rehabilitation, hospitalisation, joining
AA etc. Sometimes the intervention may fail but certainly matters are not worse than before.
Much has been learned by everyone. The family can continue its own recovery process and wait
for another more suitable occasion to intervene. Whatever the outcome of the intervention

44
attempt, the family's continued pursuit of their own individual recoveries is vital to their
personal well-being and to the Dependent's chances for eventually achieving sobriety.

FAMILY INTERVENTION

Alcoholism is a family disease. A crisis in the life of any member of the family can
become the "bottom" that brings everyone including the Dependent, to treatment. Reaching the
Dependent in this indirect way is called family intervention.

When a good employee begins to miss work, makes frequent mistakes, turns out less
work and have more accidents, to be touchy and irritable, the employer if he knows sufficiently
about alcoholism can detect the presence of alcohol in the family and intervene.

Physicians can detect alcoholism in the family and intervene when they see their patient
with stress symptoms -- digestive disorder, high B.P., heart problems, back ache, depression,
nervousness, unexplained weight gain or loss.

Lawyers and pastors realise that marital discord, financial problems, juvenile
delinquency or unwanted pregnancy all occur more often in alcoholic families and can reach out
to intervene.

The school children who require greatest amount of attention from their teachers --
trouble makers, the under achievers, the absentees, the shy loners, the hyperactive youngster
with learning problems -- are all exhibiting problems known to be characteristic of alcoholic's
children. The schoolteacher and administrator could reach out to the family of the child and
intervene.

DE-TOXIFICATION

When a Dependent has accepted to undergo treatment as a result of intervention, he is

taken for de-toxification. Sudden cessation of drugs leads to withdrawal symptoms. Acute
withdrawal syndrome is evident by the agitation of the central nervous system and shows itself
in the form of tremors, hallucinosis and convulsive seizers. There is internal anguish and
internal agitation. There is an increase in physical stress, elevation in blood pressure, pulse and
respiration. Progressive discomforts and fear of behavioural loss contents will begin to manifest
themselves.

De-toxification is the medical management process used to remove the toxicity of the
drug/alcohol from the body and ensure that the patient undergoes safe withdrawal from
chemicals. This calls for an impatient setting and close medical supervision. It lasts for a period

45
of three to ten days depending on the condition of the patient. The de-toxification centres also
provide formal counselling units that motivate the patient to take further treatment.

REHABILITATION

Helping the Dependent

"Rehabilitation is a process aimed at bringing about a lasting and wholesome recovery

through an overhauling/reshaping of the addict's personality." iii As a process no fixed time can
be set aside for rehabilitation. Chronic addicts and dependents with a greater share of
personality disorders, usually require a longer time. In the rehabilitation centres patients are
given individual attention. The aim of these centres are to help the dependent give up drugs
totally for life and to bring about positive changes in the patient's behaviour and attitude, and
thereby enable him to lead a qualitative life. The treatment methods adopted are individual
counselling, group therapy, recreation therapy, work therapy, therapeutic community meetings,
and meditation and relaxation techniques. The twelve steps of AA programme plays a
significant role with treatment programme. During this period the family of the addict is also
given intensive therapy. It helps the family members and friends to understand that addiction is
a family disease and that they need to make improvement in their lives.

Usually it is the recovering dependents who play a major role in helping the patients
recover. They share their personal experience. Their presence gives hope to the patients that
they too can recover. Counsellors, social workers and pastors too help out in the programme.

The interaction between individuals and the group is utilised to reinforce and strengthen
continued abstinence. Balanced diet and supplementary nutrition are provided as part of this
therapy. Patients are involved in therapeutic activities like cleaning, helping in the kitchen,
gardening and marketing. On completion of the programme the patient is presented with a
medal.

There are other programmes that aim at a major behavioural and psychological re-
orientation of the individual just as the rehabilitation. There is the residential treatment
programme based on therapeutic community principle. In this programme peer pressure is
used to bring about change in patients and also to confront individuals whenever necessary.
Behaviour modification techniques are also employed to modify undesirable behaviour. There is
also the outpatient programme. This provides treatment in a non-residential setting. Counsellors
prepare a social/psychological assessment of each patient and assign him to group counselling
sessions that meet regularly. Individual counselling is also included as part of the outpatient
therapy programme.

46
Helping the Family

Sharon from her long experience of counselling Dependent's family puts down five
treatment goals for each member in the family in this phase. iv They are:

1. To let down the wall of defensiveness. The level of pain in the family is so high that
each person has sealed his feelings off from himself and others behind a stout wall of
defences. Sympathetic listening and caring helps to break through this defence.

2. To let the pain emerge. It is important to allow them to feel their pain fully. As the family
begins to feel the pain and allow it to emerge in words, tears or other appropriate
channels, they will require help from the counsellor to identify and name the feelings, as
most people in Dependent’s families are very vague about feelings. The counsellor helps
them to accept these feelings without judgement.

3. To begin to experience some positive feelings.

4. To accept the family illness and one's own part in it.

5. To make a personal commitment to our ongoing recovery programme for the family and
for themselves.

Each member in the Dependent's family is playing a particular role. The counsellor
should help them to identify their roles and to come out of it.

AFTER CARE

The services provided to the patient after he completes rehabilitation programme can be
called after care that is basically to defend the patient against returning to drug.

Half Way Homes

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. Patients live in a
group, but are permitted to leave the premises during the day and on weekends. The institution
provides supportive help in the form of occupational, social and recreational activities.

4.4 WITHDRAWAL SYMPTOMS

Signs and symptoms

Signs and symptoms of alcohol withdrawal occur primarily in the central nervous system.
The severity of withdrawal can vary from mild symptoms such as sleep disturbances and

47
anxiety to severe and life-threatening symptoms such as delirium, hallucinations, and
autonomic instability.

Withdrawal usually begins 6 to 24 hours after the last drink. It can last for up to one week.
To be classified as alcohol withdrawal syndrome, patients must exhibit at least two of the
following symptoms: increased hand tremor, insomnia, nausea or vomiting, transient
hallucinations (auditory, visual or tactile), psychomotor agitation, anxiety, tonic-clonic
seizures, and autonomic instability.

The severity of symptoms is dictated by a number of factors, the most important of which is
degree of alcohol intake, length of time the individual has been using alcohol, and previous
history of alcohol withdrawal. Symptoms are also grouped together and classified:

 Alcohol hallucinosis: patients have transient visual, auditory, or tactile hallucinations,

but are otherwise clear.
 Withdrawal seizures: seizures occur within 48 hours of alcohol cessations and occur
either as a single generalized tonic-clonic seizure or as a brief episode of multiple
seizures.
 Delirium tremens: hyper-adrenergic state, disorientation, tremors, diaphoresis,
impaired attention/consciousness, and visual and auditory hallucinations. This usually
occurs 24 to 72 hours after alcohol cessation. Delirium tremens is the most severe
form of withdrawal and occurs in 5 to 20% of patients experiencing detoxification
and 1/3 of patients experiencing withdrawal seizures.

WITHDRAWAL SYMPTOMS OF DRUGS

A person with a dependency on drugs may be hooked physically, psychologically or

emotionally. Addicts experience intense cravings for the drug, and those who stop can suffer
withdrawal symptoms. Some drugs will produce more severe withdrawal symptoms than
other drugs. A person trying to quit drugs will often need the help and support from her
physician, family and friends.

Depressants

 Withdrawal symptoms from central nervous system depressants may include anxiety,
restlessness, sweating, and sleep disorders. In more serious cases, the person can
experience tremors, hallucinations, seizures, increased heart rate, body temperatures,
and blood pressure. In severe cases, there can be life-threatening delirium.

48
Stimulants

 Withdrawal symptoms from central nervous system stimulants include anxiety,

depression, fatigue, and extreme cravings. There can also be thoughts of suicide,
paranoia and acute psychosis.

Mild

 Opioids include heroine, oxycodone, codeine, and morphine. Withdrawal symptoms

for opioids can range from minor to severe. The minor withdrawal symptoms can
include sweating, runny nose, anxiety, and cravings for the drug.

Severe

 Severe withdrawal symptoms from opioids include depression, rapid pulse, heavy
breathing, high blood pressure, stomach cramping, muscle and bone pain, diarrhea,
vomiting, and dilated pupils. There will also be an extreme craving for the drug.
Synthetic opiate is often used to help wean addicts off the drug.

Treatment

 After detoxification and suffering through the withdrawal symptoms, there are self-
help and addiction treatment programs to help the addict. This includes counseling,
treatment programs and self-help groups.

4.5 RE-EDUCATIVE THERAPY

An excerpt from the Chapter 14: Counselling the Substance Abusers (pages 277, 288, 290,
291 to 297) in the book Types of Counselling, 2nd edition, 2011, by D. John Antony, Guru
Publications, Dindigul, is given below:

Psychological Measures

Individual Therapy: Alcoholics have personal problems like anybody else and they need to
be handled by the counsellor for which counselling and psychotherapies are employed. Here, whether
the patient is psychologically dependent on drugs or physiologically and psychologically dependent
on drugs is assessed and the therapies are given depending upon the nature of the patient and the
extent of damage he suffers; the therapies could be from any discipline like psychoanalysis, rational
emotive behaviour therapy, reality therapy, transactional analysis and the like.

49
3) Psychosocial Measures

(1) Group Therapy

Once the de-toxification process is over the person will profit if he is introduced into a group
therapy. In group therapy the alcoholic is made to realize that he has a drinking problem and there are
evil consequences of drinking.

(2) Sociotherapy

Family therapy assumes great importance in the treatment of the alcoholic. In treatment,
rehabilitation into the family with the roles he formerly held is emphasized. When a person returns
home, the other family members who have already started to take his position will not be willing to
let him have his role and status at home and many even do not believe his conversion and so being
frustrated he is likely to relapse into alcoholism. It has been noted that the older children especially
boys are so angry with the recovering alcoholic that they will not at times admit him into their homes.
Some children do not forgive their father because of the misery to which the family was brought on
account of the drinking. If the drunken father had sexually abused the female children, it is unlikely
that they forgive him so easily. Therefore, family counselling is necessary for rehabilitating the
alcoholic. He is helped to learn more effective coping skills and an attempt is made to see that his
environment does not react to sobriety with hostility. If the family members are not adequately
counselled, their negative attitudes and their degrading treatment will induce the recovering alcoholic
to relapse.

(3) Alcoholics Anonymous (AA)

Joining an Alcoholic Anonymous serves as a support group of people who had similar
problem with regard to drinking. They are not only supportive but also models for his coping skills.
Treatment also must take into account the relapses which is part of the process of recovery. In spite
of the relapses it is worth helping the alcoholic to remain sober.

The wife and children of an alcoholic are called co-dependents, and they also need therapy
and support groups. Al-Anon is for the wives, and ACOA is for the adult children of alcoholics.

(4) Taking Care of Environmental Cues

All the environmental cues that surround initial drug use and development of the addiction
actually become conditioned to that drug use. When those cues are present at a later time, they elicit
anticipation of a drug experience and thus generate tremendous drug craving. Cue-induced craving is

50
one of the most frequent causes of drug use relapses, even after long periods of abstinence,
independently of whether drugs are available. An addict who became addicted in the home
environment is constantly exposed to the cues conditioned to his initial use, such as the
neighbourhood where he hung out, drug-using buddies, or the places where he bought drugs. Simple
exposure to those cues automatically triggers craving and can lead rapidly to relapses. Therefore, one
of the major goals of drug addiction treatment is to teach addicts how to deal with the cravings caused
by inevitable exposure to the conditioned cues

(5) Follow-up

Apart from the motivation of the alcoholic what stands out as the unique factor for success is
the follow-up programme for the alcoholic. We take for granted that relapses are normal among the
alcoholics and therefore to strengthen them in their resolve to remain dry and sober, follow-up
programmes are absolutely essential. Where follow-up programmes are lacking, recovering
alcoholics are known to have relapsed into their former condition very early.

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 Counselling the Alcoholics

Excuses Made by Alcoholics

Before an alcoholic admits frankly that he has a problem and wants treatment, he would have
had a set of psychological defence mechanisms aimed at protecting his image. Here below there are
some stereotyped addictive defences. 1) Psychotic Defence Mechanism: The addict asks the
question ‘Problem? What Problem?’ Since it denies or distorts reality itself it is called psychotic
defence mechanism. The addict denies that he has a serious problem with alcohol/drug. 2)
Downplaying the Problem: Of course, the addict admits that he has a problem with alcohol but he
thinks that the problem is not as bad as others make it out to be. He will say ‘I am not that bad!’ 3)
Rationalization: The addict construes alternative explanations and stoutly defends himself. If for
example an addict is arrested he would say that the officer is a corrupt individual. He will say ‘It was
not my fault or It is not the way it looks!’ 4) Justification: The addict believes that he has been
victimized and seeks consolation from his addiction. He thinks that alcohol is the only source of
comfort he has in a cruel world. He says ‘All I want is a little relief!’ 5) In Control: The addict
believes that he can stop drinking any time he wants to. His stopping will not easily come through
even though he says he can. 6) Procrastination: The addict thinks that today is not the right time to
stop drinking or taking treatment. Perhaps tomorrow he can do that. 7) Freedom to be Oneself: The
addict says that he has every right to be himself and nobody has the right to tell how he has to be.
After all he is not hurting anybody but only himself, he says. 8) Attacking the Attacker: The addict
believes in the adage: The best defence is a good offence. The addict has a keen eye and a sharp
tongue for the shortcomings of others and thus he attacks those who point out his alcoholism. 9)
Obliged to Drink: The addict says that he has to drink in order to earn his living or to drown his
trouble and sorrow. 10) You are the Cause: The addict thinks that it is because of the other that he
takes to drinking. He will really be all right if it were not for the other. These are only some of the
excuses and you might have encountered a number of other excuses.v

Therefore, in treatment and counselling it is good to know what causes a person to drink.
Unwillingness, psychiatric disorders and psychopathic trends are all major hurdles to recovery which
a counsellor faces in his counselling situation.

Overall Approach

Let us now concentrate our attention on the counselling of the recovering alcoholic. The fact
that he has been given treatment is not enough to ensure that the problem of alcoholism is over.
Counsellors are rather reluctant to help an alcoholic because of the low rate of recovery among them.
It is true that relapses are as common as alcoholism. Rarely do we find anyone just recovering from
alcoholism once and for all. Most of the alcoholics have relapses which might provoke anger in the
persons who are helping them rehabilitate.

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 A developmental overview of the recovery process will be useful in helping the alcoholic. In
the developmental overview we have three separate but not always distinguishable stages. The first
stage is the ‘de-compulsifying’ stage which in a way takes away the compulsion to drink and focuses
primarily on physical recovery. The second stage deals with the psychological aspects which make
the effects of alcohol so seductive. The third stage is focused on integrating the person’s identity as an
alcoholic with an acceptable vision of the meaning of life. Research has been done to evaluate death
among alcoholics who die in a year after becoming sober. Among them 20% die of suicide which
means that the recovery is not over just because a person has reached sobriety. If a counsellor
responds even in the slightest way judgmental to the alcoholic, he is likely to behave negatively. In
the beginning stage of recovery it is advisable not to deal with issues of ethical responsibility.vi
Otherwise it will jeopardize the recovery process.

Stage-wise Approach

Recovery can also be understood in terms of three stages each having tasks such as physical
recovery and psychological recovery. Thus we may find the following:vii

(1) Early Stage

The two main issues here are ‘de-compulsifying’ drinking behaviour and the physical
restoration of the body.

i) Physical Recovery

Alcohol is known to harm virtually every major organ system in the body. Hence referral to a
physician is a must especially to deal with the emergency of the withdrawal symptoms. The process
of natural body restoration may last even two years. The alcoholic is easily fatigued and his sleep
patterns are disturbed at least for a year since brain restoration is a slow process. Excessive use of
alcohol would impair cognitive functioning altering the structure of the brain resulting in measurable
intellectual deficit. It could be a chronic brain damage not restricted to the period of intoxication
alone. Recovery of cognitive functioning continues for several years and may not be total. Short-term
memory is rather poor and the ability to deal with abstractions is impaired resulting in difficulties in
learning new programmes.

ii) Psychological Recovery

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 Here the counsellor along with the alcoholic discovers the antecedents of drinking to prevent
lapses. Two major categories are identified as responsible for relapses and they are intrapersonal and
interpersonal determinants.

(i) Intrapersonal Determinants: 1) Negative emotional states such as anger, anxiety,

depression and the like 2) Urges and temptations 3) Testing personal control in the sense of whether
one can again be a social drinker.

(ii) Interpersonal Determinants: 1) Interpersonal conflict, negative confrontation 2) Social and

peer group pressure to take a drink. Therefore, we can summarize the antecedents of relapse as
negative emotional states, interpersonal conflicts and social pressure.

(2) Middle stage

Here the major concern is psychological recovery. The alcoholic faces the naked primary life
struggles without alcohol. Here physical recovery continues and psychologically the alcoholic sees
clearly the fundamental realities such as marriage, family relationships, career and friends. There
could be a sense of isolation as separated from his drinking partners. There could be feelings of guilt
over unresolved sexual issues since during the drinking period the alcoholic usually messes this
aspect of his life. With regard to sexual behaviour two patterns are noted: one of them is that sexual
behaviour starts with alcohol and ends with alcohol and therefore after sobriety there is no
misconduct. The other is having problem independently of drinking though drinking may accompany
such sexual activities.

(3) Later Stage & Beyond

The major task is to integrate and accept one’s identity as an alcoholic. Now the physical and
the psychological recoveries tend to stabilize.

Once one becomes an alcoholic, he is always an alcoholic in the future. For him no social
drinking is safe.

4.5 PSYCHO-SOCIAL MANAGEMENT

Please re-read the above Section. Further points to be remembered are given below:

Alcoholism is a disease and as such can be arrested short of total tragedy, provided its
victim gets suitable help soon enough. The chances an alcoholic will ask for help on his own is
very little. It was generally agreed that the alcoholic had to "hit bottom" and voluntarily seek

54
help before it could be effective, but that usually happened too late to salvage much of his life.
Yet for some just the realization that they were risking their job or their marriage was incentive
enough to seek help (they were sometimes said to have hit a "high bottom").

"Hitting the bottom" means that the alcoholic has found himself in a crisis so painful and
so frightening that he will do anything to escape from it -- even stop drinking. Such a crisis often
can be created by those who care about him. This process is called intervention.

Direct Intervention

Sharon spells out the main points of intervention.viii It starts with one of the family
members approaching a counsellor for help. Sometimes it could be a family friend or the
employer or doctor. The counsellor reviewing the critical issues facing the Dependent forms an
intervention team that includes people who have personally witnessed the alcoholic behaviour
of the Dependent. It could also include the employer, pastor or close friends. The counsellor
explains the nature of the intervention process and prepares the team. It may take a few months
for this preparation. Before they start intervention they must be convinced that,

1. Alcoholism is not one of the problems but THE problem.

2. Given the nature of alcoholism the Dependent will not ask for help on his own.

3. All that they do to help the Dependent -- trying to control his drinking, assuming his
responsibilities, etc., are worse than useless. They are actually making it possible for him to go
on drinking without facing the consequences. The only thing they can do that is truly helpful to
him is to use their combined influence to get him accept treatment.

4. If each one of the family members is playing a role then they should be willing to lay aside
their role before they could ask the Dependent to give up his role. They should break out of their
defensive behaviour patterns into which they are each locked and to let their long buried
feelings emerge.

Now each member of the team prepares a list of specific instances when the Dependent's
behaviour caused someone pain, danger or other problems specifying the exact time, setting and
other details. There should be no hint of blame or hostility in their statements. They practice
making their statements so that they do calmly and courageously on the day of intervention. It is
better that each one reads from his list than speak extemporaneously. Then they decide on what
action they are going to demand from the Dependent.

Now chose a time when the Dependent is most likely to be sober with his defences at
low ebb. Somehow he should sense a crisis. A suitable place has to be selected where it is easy
to get the Dependent. With the presence of the counsellor the intervention begins. The piling up
of episode upon episode of his alcoholic behaviour, described in all detail by those who
witnessed it is usually defence shattering for the Dependent. The effect is heightened by having

55
those he loves confess the anguish his actions have caused them. The Dependent is usually
shocked into facing the painful truth about his condition. At this point a programme of treatment
and after care is presented to him. Any promises from his side to stop drinking on his own
should not be accepted. He should accept help, either rehabilitation, hospitalisation, joining
AA etc. Sometimes the intervention may fail but certainly matters are not worse than before.
Much has been learned by everyone. The family can continue its own recovery process and wait
for another more suitable occasion to intervene. Whatever the outcome of the intervention
attempt, the family's continued pursuit of their own individual recoveries is vital to their
personal well-being and to the Dependent's chances for eventually achieving sobriety.

Family Intervention

Alcoholism is a family disease. A crisis in the life of any member of the family can
become the "bottom" that brings everyone including the Dependent, to treatment. Reaching the
Dependent in this indirect way is called family intervention.

When a good employee begins to miss work, makes frequent mistakes, turns out less
work and have more accidents, to be touchy and irritable, the employer if he knows sufficiently
about alcoholism can detect the presence of alcohol in the family and intervene.

Physicians can detect alcoholism in the family and intervene when they see their patient
with stress symptoms -- digestive disorder, high B.P., heart problems, back ache, depression,
nervousness, unexplained weight gain or loss.

Lawyers and pastors realise that marital discord, financial problems, juvenile
delinquency or unwanted pregnancy all occur more often in alcoholic families and can reach out
to intervene.

The school children who require greatest amount of attention from their teachers --
trouble makers, the under achievers, the absentees, the shy loners, the hyperactive youngster
with learning problems -- are all exhibiting problems known to be characteristic of alcoholic's
children. The schoolteacher and administrator could reach out to the family of the child and
intervene.

REHABILITATION

Helping the Dependent

"Rehabilitation is a process aimed at bringing about a lasting and wholesome recovery

through an overhauling/reshaping of the addict's personality." ix As a process no fixed time can
be set aside for rehabilitation. Chronic addicts and Dependents with a greater share of
personality disorders, usually require a longer time. In the rehabilitation centres patients are
given individual attention. The aim of these centres are to help the Dependent give up drugs
totally for life and to bring about positive changes in the patient's behaviour and attitude, and

56
thereby enable him to lead a qualitative life. The treatment methods adopted are individual
counselling, group therapy, recreation therapy, work therapy, therapeutic community meetings,
and meditation and relaxation techniques. The twelve steps of AA programme plays a
significant role with treatment programme. During this period the family of the addict is also
given intensive therapy. It helps the family members and friends to understand that addiction is
a family disease and that they need to make improvement in their lives.

Usually it is the recovering Dependents who play a major role in helping the patients
recover. They share their personal experience. Their presence gives hope to the patients that
they too can recover. Counsellors, social workers and pastors too help out in the programme.

The interaction between individuals and the group is utilised to reinforce and strengthen
continued abstinence. Balanced diet and supplementary nutrition are provided as part of this
therapy. Patients are involved in therapeutic activities like cleaning, helping in the kitchen,
gardening and marketing. On completion of the programme the patient is presented with a
medal.

There are other programmes that aim at a major behavioural and psychological re-
orientation of the individual just as the rehabilitation. There is the residential treatment
programme based on therapeutic community principle. In this programme peer pressure is
used to bring about change in patients and also to confront individuals whenever necessary.
Behaviour modification techniques are also employed to modify undesirable behaviour. There is
also the outpatient programme. This provides treatment in a non-residential setting. Counsellors
prepare a social/psychological assessment of each patient and assign him to group counselling
sessions that meet regularly. Individual counselling is also included as part of the outpatient
therapy programme.

Helping the Family

Sharon from her long experience of counselling Dependent's family puts down five
treatment goals for each member in the family in this phase. They are:

1. To let down the wall of defensiveness. The level of pain in the family is so high that
each person has sealed his feelings off from himself and others behind a stout wall of
defences. Sympathetic listening and caring helps to break through this defence.

2. To let the pain emerge. It is important to allow them to feel their pain fully. As the family
begins to feel the pain and allow it to emerge in words, tears or other appropriate
channels, they will require help from the counsellor to identify and name the feelings, as
most people in Dependent’s families are very vague about feelings. The counsellor helps
them to accept these feelings without judgement.

3. To begin to experience some positive feelings.

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4. To accept the family illness and one's own part in it.

5. To make a personal commitment to our ongoing recovery programme for the family and for
themselves.

As we have seen in chapter II each member in the Dependent's family is playing a

particular role. The counsellor should help them to identify their roles and to come out of it.

AFTER CARE : The services provided to the patient after he completes rehabilitation
programme can be called after care that is basically to defend the patient against returning to
drug.

Half Way Homes

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. Patients live in a
group, but are permitted to leave the premises during the day and on weekends. The institution
provides supportive help in the form of occupational, social and recreational activities.

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 UNIT 5
RECOVERY – PHASES IN RECOVERY – FACTORS THAT COMPLICATE
RECOVERY -- ROLE OF PARENTS AND THE COMMUNITY IN THE
RECOVERY PROCESS.

5.1 RECOVERY

5.1 PHASES IN RECOVERY

The 5 Phases of Addiction Recovery

Addiction recovery can be thought of as moving through these five phases:

1. Admission of a problem

This is the key starting point. If there is no problem then there certainly is no need for a
solution. There is a certain logic to that. What would prevent someone from admitting they
have an addiction problem? Well, how about memory distortion caused by their chemical
dependency. There is a jazzy phrase called ‘euphoric recall’ which is the tendency to only
remember the good times and positive experiences of using. That is half of the equation, at
the same time we are suppressing or refusing to remember the far more numerous times
where indulging in the addiction has caused pain and embarrassment. Another block to
admitting the problem is our distorted defense mechanisms, such as minimizing, rationalizing
and good old fashioned denial. If we get to the point that we acknowledge there is a problem
and want to do something about it now, we can move on to the next phase of recovery which
is compliance.

2. Compliance

What is meant by compliance here is going along with the most important seeing and
agreeing to the concept of abstinence. This early phase of recovery usually involves little
emotional insight into the whys of the addiction; the concentration is simply on ‘don’t do it’
on a daily basis. Once we accept compliance as a necessary part of Addiction Recovery, we
can move toward the whys and wherefores. But it is not unusual to pass through the next
phase of recovery which is defiance.

3. Defiance

Defiance can rear its head in several ways the most damaging is in the form of believing that
the terms of addiction don’t apply to me. Picking and choosing what is to be done and not.
done An example might be rejection of continuing care believing that is for others not me, or

59
I have been ‘good’ for awhile I deserve to use again now that I proved I can quit. Another
example of defiance can be becoming engaged in anger toward others who do not have your
affliction or getting on the pity pot with the ‘poor me’s’. Defiance and anger can also be a
block toward connecting and resolving with your emotions and feelings that underlie the
blanketing emotion of anger.

4. Acceptance

Popeye, the Sailor Man, used to say “I am what I am.” However you come to accept your
addiction whether you believe it is a no fault illness, or you simple got dealt a bad hand in
life, accepting your addiction allows you to move out of the problem and into the solution.
People who are accepting are generally less defensive and have a greater sense of emotional
and personal identity. Acceptance is the first step toward beginning to trust yourself and
others, and open the possibilities of self-evaluation.

5. Surrender

We are not talking about submission but rather surrender they are very different. Submission
is a temporary yielding; it tends to leave the escape hatch of returning to the addiction open.
There is an implication of force being used or submitting against your will. Surrender can be
thought of as wholehearted acceptance and compliance. It is a voluntary action and does not
mean being defeated as does submission, but rather a conscious decision not to participate. A
boxer who has been knocked out has submitted to the power of his opponent. A boxer who
has retired and does not climb in the ring any more has surrendered to the idea that he no
longer chooses to fight.

In summing up the points made above we can say that progress in addiction recovery can be
made by admitting there is a problem and seeing the need for change. We move through
negativity and emotional blocks to our recovery to arrive at a point of acceptance. Our
acceptance of the need to change eventually moves through an attitude of being defeated to
voluntarily seeking a better life. Stringing these concepts together can be viewed as
movement through the phases of recovery.

5.2 FACTORS THAT COMPLICATE RECOVERY

Please re-read the Section above, on the: “Hurdles to counseling.”

Also, you may discuss with your friends and list out the other factors that complicate
recovery in India and Tamil Nadu in particular: For example: the free availability of liquor,
lack of recreational facilities, illiteracy, unemployment and under-employment, the
crumbling values, loneliness, emptiness, depression, peer pressure, the rather high cost of
good rehab centres, etc.

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5.3 ROLE OF PARENTS AND THE COMMUNITY IN THE RECOVERY PROCESS.
Please re-read the notes given above – the Section on “Rehabilitation.”
******
UNIT 6

6 RELAPSE DYNAMICS – RELAPSE MECHANISM, FACTORS LEADING TO

RELAPSE -- RELAPSE PREVENTION.

People in recovery learn to identify the warning signs that may lead to a lapse in their
abstinence and take positive steps to stay clean and sober. At the same time, they follow a
practical plan that addresses their illness in a positive and constructive way. The quicker they
learn to spot these signs and signals the sooner they can take positive action for their own
well-being and recovery.

Many factors can lead to a relapse or flare-up to one or both of our no-fault illnesses. A flare-
up of psychiatric symptoms can leave us more vulnerable to relapsing on drugs or alcohol.
Drinking and drugging can lead to a flare-up of our psychiatric illness. Maintaining
abstinence allows us the freedom to grow as individuals and manage our no-fault illnesses in
the healthiest possible way.

In chemical dependency, relapse is the act of taking that first drink or drug after being
deliberately clean and sober for a time. It helps though to view relapse as a process that
begins well in advance of that act. People who have relapsed can usually point back to
certain things that they thought and did long before they actually drank or used that
eventually caused the relapse. They may have become complacent in their program of
recovery in some way or refused to ask for help when they needed it. Each person’s relapse
factors are unique to them, their diagnosis, and personal plan of recovery.

Relapse is usually caused by a combinations of factors. Some possible factors and warning
signs might be:

 Stopping medications on one’s own or against the advice of medical professionals

 Hanging around old drinking haunts and drug using friends – slippery places
 Isolating – not attending meetings – not using the telephone for support
 Keeping alcohol, drugs, and paraphernalia around the house for any reason
 Obsessive thinking about using drugs or drinking
 Failing to follow ones treatment plan – quitting therapy – skipping doctor’s
appointments
 Feeling overconfident – that you no longer need support
 Relationship difficulties – ongoing serious conflicts – a spouse who still uses
 Setting unrealistic goals – perfectionism – being too hard on ourselves

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  Changes in eating and sleeping patterns, personal hygiene, or energy levels
 Feeling overwhelmed – confused – useless – stressed out
 Constant boredom – irritability – lack of routine and structure in life
 Sudden changes in psychiatric symptoms
 Dwelling on resentments and past hurts – anger – unresolved conflicts
 Avoidance – refusing to deal with personal issues and other problems of daily living
 Engaging in obsessive behaviors – workaholism – gambling – sexual excess and
acting out
 Major life changes – loss – grief – trauma – painful emotions – winning the lottery
 Ignoring relapse warning signs and triggers

Almost everyone in recovery has times when compelling thoughts of drinking or using drugs
resurface. In early recovery, drinking or drugging dreams are not uncommon. It helps to
remind ourselves that the reality of drinking and using has caused many problems in our
lives. That no matter how bad things get, the benefits of staying abstinent will far outweigh
any short term relief that might be found in drugs or alcohol. Recovery takes time.
Eventually the cravings, relapse dreams, and uncertainties of early recovery fade. When we
are committed to dual recovery we slowly but surely develop a new confidence in our new
way of life without drugs and alcohol.

Staying clean and sober and managing ones psychiatric symptoms constructively is an
ongoing process. Abstinence and dealing positively with a dual disorder go hand in hand.
DRA members build a personal inventory of recovery tools that help them meet these goals
by staying involved in the process of dual recovery. An individual is in dual recovery when
they are actively following a program that focuses on the recovery needs for both their
chemical dependency and their psychiatric illness. People in dual recovery make sure to use
some of their recovery tools each and every day. Their personal recovery tool kit serves as
the best protection against a relapse.

By identifying things that put us at risk for relapse and using the various recovery tools on an
ongoing basis, we try to prevent a relapse before it happens. We can periodically review our
relapse prevention plans with our doctors, treatment professionals and sponsors and modify
them as needed.

By becoming familiar with our triggers and warning signs, utilizing the various recovery
tools, and having a practical plan of action, we greatly minimize the tendency to lapse back
into our addictions. If and when lapses do happen, we do not judge or blame--we are not bad
people. We seek progress not perfection. We simply learn what we can from the situation and
move on with our program of dual recovery. Sharing our relapse experience with our
sponsor, group, and helping professionals is an important way to figure out what went wrong.
Our experience may also help others in recovery.************

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 UNIT 7

7 SOCIAL SUPPORT SYSTEM – SELF-HELP GROUPS LIKE AA, AL-ANON, AND

ALATEEN - MOBILIZING THE COMMUNITY SUPPORT.

7.1 SOCIAL SUPPORT SYSTEM

Please discuss with your classmates what social supports you can garner for your client.
Examples: church activities, church attendance, sport clubs, gyms, play facilities, self help
groups, youth clubs, family support, financial help through bank loans, etc, learning new
skills/ occupation, help in getting employment, government aids and programmes, AA, Al-
Anon, Ala-teen groups, short stay homes (halfway homes), etc.
Half Way Homes

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. Patients live in a
group, but are permitted to leave the premises during the day and on weekends. The institution
provides supportive help in the form of occupational, social and recreational activities.

7.2 SELF-HELP GROUPS LIKE AA, AL-ANON, AND ALA-TEEN

ALCOHOLIC ANONYMOUS (AA)

Alcoholic anonymous has been described as the single most effective treatment for
Alcoholism. Alcoholic Anonymous had its beginnings in 1935 in Akron, Ohio, USA, when Bill
Wilson was able to give up drinking after he had a spiritual experience. After a year he was
overtaken by a strong desire to drink. He began to seek out another suffering alcoholic as an
alternative. He noticed that his desire to drink lessened when he tried to help other "drunks" to
get sober. He was directed to Dr. Bob, a local doctor with a drinking problem and the idea of
alcoholics helping each other began with their first meeting. For four years, the new movement,
nameless and without any organization or descriptive literature grew slowly. In 1939 a group of
about a hundred sober members realized they had something to offer the thus far 'hopeless
alcoholics'. They wrote the first book Alcoholics Anonymous generally known as the Big
Book. Today the AA embraces thousands of local groups in thousands of communities. Its
members come from all social, economic and cultural backgrounds and from all over the world.

AA is an informal fellowship of men and women who have discovered that they cannot
control their use of alcohol. Having admitted it they have joined together to share their
experience, strength and hope in order to help one another and anyone else who may turn to AA
to achieve sobriety. The twelve steps and twelve traditions provide a framework for achieving
their goal.

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The Twelve Steps of Recovery

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.

5. Admit to God, to ourselves and to another human being the exact nature of our
wrongs.

6. Are entirely ready to have God remove all the defects of character.

7. Humbly ask Him to remove our shortcomings.

8. Make a list of all persons we have harmed, and become willing to make amends to
them all.

9. Make direct amends to such people wherever possible.

10. Continue to take personal inventory and when we are wrong promptly admit it.

11. Seek through prayer and meditation to improve our conscious contact with God, as
we understand Him; pray only for knowledge of His will for us, and the power to
carry it out.

12. Having had 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 affairs.

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The Twelve Traditions of AA

1. Our common welfare should come first; personal recovery depends upon AA unity.

2. For our group purpose there is but one ultimate authority- a loving God as He may
express Himself in our group conscience. Our leaders are but trusted servants;
they do not govern.

3. The only requirement for AA membership is a desire to stop drinking.

4. Each group should be autonomous except in matters affecting other groups or AA as a

whole.

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 or lend the AA name to any related facility
or outside enterprise, lest problems of money, property and prestige divert us
from our primary purpose.

7. Every AA group ought to be fully self-supporting, declining outside contribution.

8. AA should remain forever non-professional, but the service centre may employ
special workers.

9. AA as such, ought never to be organized, but we may create service boards or

committees directly responsible to those they serve.

10. AA has no opinion on outside issues; hence the AA name ought never to be drawn
into public controversy.

11. As our public relations policy is based on attraction rather than promotion, we need
always to maintain personal anonymity at the level of press, radio and films.

12. Anonymity is the spiritual foundation of all our traditions ever reminding us to place
principles before personalities.

Organization

AA functions around the Twelve Steps and the Twelve Traditions. The Tradition sets
forth the purpose and defines the principles of conduct. AA does not affiliate with other groups,
nor lend its name; it should not be organized and should remain non-professional. Individual
groups are autonomous and decline outside contributions. Their focus is on sobriety, anonymity

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and individual application of "the programme" which includes meetings, attempting to work the
Twelve Steps and service of the alcoholics.

Meetings

There are two types of meetings. The open meetings can be attended by anybody and
the closed meetings are attended only by professed alcoholics. A meeting may be a speaker
meeting or a discussion meeting. In the speaker meeting one to three speakers share their
experience of drinking and how they came to sobriety and in the discussion meeting a particular
step, topic or problem with alcohol is discussed, with the leader taking the role of facilitator.

Slogans

"One day at a time", "easy does it", "keep it simple", "live and let live", "let go and let
God", and other similar slogans are extensively used by AA members. This helps them to keep
the priorities before their eyes always to help the behaviour modification.

Sponsors

Sponsorship is the continuing interest and responsibility a member takes to support and
guide the alcoholic in his decision to quit drinking. The sponsor is not a counsellor. He is
usually a recovering alcoholic. He helps the new comer to stay sober. The new comer feel
secure to know that there is at least one person who cares, to whom he can turn to, when doubts
arise and confidence fails.

Narcotic Anonymous (NA)

Narcotic anonymous was founded in July 1953 in Southern California. It is a fellowship

of men and women who are learning to live without drugs. They are a group of recovering
addicts who meet regularly to help each other stay clear. Like the AA the NA programme
emphasises complete abstinence from all drugs. Identification of the problem includes addiction
to any mood changing, mind-altering substance. NA follows the 12-step programme from AA.

Al-Anon

The wives, family members and relatives of the alcoholic, experience disturbances in
their own behaviour. They encounter problem living with their alcoholics whether sober or
drinking. Seeing how a structured programme like AA has helped alcoholics to recover, Lous,
the wife of Bill Wilson, the founder of AA, started Al-Anon for the benefit of spouses, relatives
and friends of alcoholics. The purpose of Al-Anon is to help families and friends of alcoholics
by offering comfort, hope and friendship.

Al-Anon recognizes that the patterns of scapegoating the alcoholic and trying to
manipulate the drinking are non productive. The only person you can change or control is

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yourself. Family members in Al-Anon are encouraged to find an acceptable life style for
themselves regardless of the actions of the alcoholic.

Al-Anon uses the same 12 steps of AA and it incorporates AA slogans and meeting
formats. The alcoholic professes his powerlessness over alcohol whereas the Al-Anon members
profess their powerlessness over other's use of alcohol. They try to gain an understanding of
their own inappropriate responses to the alcoholic, and substitute a behaviour that will lead them
to health. They are not encouraged to dodge responsibility for themselves by continuing to focus
on the alcoholic as "the problem". Instead they see by shared example the effectiveness of
changing themselves, of "detaching with love" from the drinker. When the family members stop
behaviours that tent to perpetuate the alcoholic drinking, not only with their lives become better,
but also odds are increased for a breakthrough in the alcoholic's denial system.

Through the Al-Anon programme the sharing of experience with others who have lived
with the shame and grief caused by alcoholism and the attached stigma, has given support and
hope to many spouses and helped them for personal change and growth.

The email ID of Al-Anon India office is : gso.alanon.india@gmail.com

Ala-teen

Ala-teen is part of Al-Anon for the benefit of the children. The children of alcoholic
parents face many difficulties. Their problems are different from those of the spouses of the
alcoholic. Under the sponsorship of an adult Al-Anon or AA member, they are taught to deal
with their problems in Ala-teen. In Ala-teen children of alcoholic parents come together to share
experiences, strength and hope with each other, to discuss their difficulties, to learn effective
ways to cope with their problems and to help each other understand the principle of Al-Anon
programme.

In Ala-teen the children learn that:

- Compulsive drinking is a disease

- They can detach themselves emotionally from the drinker's problem while continuing to love
the person

- They are not the cause of anyone's drinking or behaviourism

- They cannot change or control anyone but themselves

- They have enough spiritual and intellectual resources to develop their own potentialities in
spite of what happens at home

- They can build satisfying and rewarding life experiences for themselves.

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Ala-teen was started in 1957 by a teenager in California whose father was in AA and whose
mother was in Al-Anon.

Ala-teen is not for teenage alcoholics, unless their lives have been affected by someone else’s
drinking.

Each Ala-teen meeting is sponsored by two experienced Al-Anon members who are screened
and cleared to work with young people by the Criminal Records Bureau in England and
Wales. There are a limited number of Ala-teen groups in the UK and the Republic of Ireland
and none in Scotland.

New Life through AA

AA has given new life to many alcoholics and their families, relatives and friends. It has
completely changed the personalities of alcoholics. Here is a woman who got a new life through
AA. She says,

I am no longer the scared, frightened, non-communicative woman that I was- not the `little girl'
that I was - when I came to AA. I have self-confidence, and I am no longer afraid to
help people and to put out my hand and seek to understand them instead of constantly
seeking their understanding of me. It is all so different. My attitude is certainly
positive. It is a joy to get up in the morning. The world is no longer a shambles, and it
is good to be alive. People are more important to me now, material things less so. It is
good to have friends - sure feels good and is wonderful. I still have problems in life, but
I don't say I have trouble. Trouble has gone out of my life and that is great. Trouble no
longer rides with me; problems, we all have.x

The Serenity Prayer: The serenity prayer commonly used by AA members:

God grant me:

Serenity to accept the things I cannot change

Courage to change the things I can, and
Wisdom to know the difference.

7.3 MOBILIZING THE COMMUNITY SUPPORT.

Please re-read the entire Section 7.

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 UNIT 8
8 REHABILITATION –SCOPE OF REHABILITATION -- PHYSICAL AND SOCIAL
REHABILITATION – THE SHORT-STAY HOMES –INVOLVEMENT OF THE
FAMILY AND THE COMMUNITY IN THE REHABILITATION PROCESS.

Please re-read the entire Section 7.

_____________________

9 PREVENTION – PRIMARY, SECONDARY AND TERTIARY PREVENTION.

ROLE OF DIFFERENT AGENCIES – THE LAWS RELATED TO DRUGS.

9 PREVENTION

9.1 PRIMARY, SECONDARY AND TERTIARY PREVENTION

Scientists are always looking for new and better ways to prevent disease and injury — both
to avert human suffering and to control the tremendous economic costs of ill health. But
when researchers and health experts talk about “prevention,” what do they mean?

Going upstream: Imagine you're standing beside a river and see someone drowning as he
floats by. You jump in and pull him ashore. A moment later, another person floats past you
going downstream, and then another and another. Soon you're so exhausted, you know you
won't be able to save even one more victim. So you decide to travel upstream to see what the
problem is. You find that people are falling into the river because they are stepping through a
hole in a bridge. Once this is fixed, people stop falling into the water. When it comes to
health, prevention means “going upstream” and fixing a problem at the source instead of
saving victims one by one.

In general, prevention includes a wide range of activities — known as “interventions” —

aimed at reducing risks or threats to health. These are usually grouped into three categories.

Primary prevention

Here the goal is to protect healthy people from developing a disease or experiencing an
injury in the first place. For example:

 education about good nutrition, the importance of regular exercise, and the dangers of
tobacco, alcohol and other drugs
 education and legislation about proper seatbelt and helmet use
 regular exams and screening tests to monitor risk factors for illness
 immunization against infectious disease
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  controlling potential hazards at home and in the workplace

Secondary prevention

These interventions happen after an illness or serious risk factors have already been
diagnosed. The goal is to halt or slow the progress of disease (if possible) in its earliest
stages; in the case of injury, goals include limiting long-term disability and preventing re-
injury. For example:

 telling people to take daily, low-dose aspirin to prevent a first or second heart attack
or stroke
 recommending regular exams and screening tests in people with known risk factors
for illness
 providing suitably modified work for injured workers

Tertiary prevention

This focuses on helping people manage complicated, long-term health problems such as
diabetes, heart disease, cancer and chronic musculoskeletal pain. The goals include
preventing further physical deterioration and maximizing quality of life. For example:

 cardiac or stroke rehabilitation programs

 chronic pain management programs
 patient support groups

What works best?

For many health problems, a combination of primary, secondary and tertiary interventions
are needed to achieve a meaningful degree of prevention and protection. However,
prevention experts say that the further upstream one is from a negative health outcome, the
likelier it is that any intervention will be effective — think about fixing the hole in the bridge
so people stop falling through and drowning downstream.

Unfortunately, this isn't always possible, especially when there's limited knowledge about
what causes a particular illness or injury. For example, when it comes to low-back pain, there
are few proven primary prevention measures. But researchers are learning more about
secondary prevention — i.e. how to reduce disability and promote recovery in workers who
have already experienced problems.

While primary and secondary prevention interventions are clear in areas like cancer or heart
disease, such distinctions may be less useful in talking about musculoskeletal disorders.
That's because episodes of back pain and other symptoms tend to come and go, blurring the

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lines between primary, secondary and tertiary prevention. So when it comes to
musculoskeletal disorders, some researchers prefer to talk about “prevention, period

9.2 ROLE OF DIFFERENT AGENCIES

Please re-read the entire Section 7,.8 and 9. Also, read the entire Chapter 14 in the book
Types of Counselling by D. John Antony.

9.3 THE LAWS RELATED TO DRUGS

Obviously, it is an offence to possess, sell, deal with or traffic drugs. It is punishable by
imprisonment.

India is located between two major illicit opium producing centres in Asia – the Golden
Crescent comprising Pakistan, Afghanistan and Iran and the Golden Triangle comprising
Burma, Thailand and Laos. Because of such geographical location, India experiences large
amount of drug trafficking through the borders. India is the world's largest producer of licit
opium for the pharmaceutical trade. But an undetermined quantity of opium is diverted to
illicit international drug markets.

India is a transshipment point for heroin from Southwest Asian countries like Afghanistan
and Pakistan and from Southeast Asian countries like Burma, Laos, and Thailand. Heroin is
smuggled from Pakistan and Burma, with some quantities transshipped through Nepal. Most
heroin shipped from India is destined for Europe. There have been reports of heroin
smuggled from Mumbai to Nigeria for further export.

In Maharashtra, Mumbai is an important centre for distribution of drug. The most commonly
used drug in Mumbai is Indian heroin (called desi mal by the local population). Both public
transportation (road and rail transportation) and private transportation are used for this drug
trade.

Drug trafficking affects the country in many ways.

 Drug abuse: Cultivation of illicit narcotic substances and drug trafficking affects the
health of the individuals and destroy the economic structure of the family and society.
 Organized crime: Drug trafficking results in growth of organised crime which affects
social security. Organised crime connects drug trafficking with corruption and money
laundering.
 Political instability: Drug trafficking also aggravates the political instability in North-
West and North-East India.

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A survey conducted in 2003–2004 by Narcotics Control Bureau found that India has at least
four million drug addicts. The most common drugs used in India are cannabis, hashish,
opium and heroin. In 2006 alone, India's law enforcing agencies recovered 230 kg heroin and
203 kg of cocaine. In an annual government report in 2007, the United States named India
among 20 major hubs for trafficking of illegal drugs along with Pakistan, Afghanistan and
Burma. However, studies reveal that most of the criminals caught in this crime are either
Nigerian or US nationals.

Several measures have been taken by the Government of India to combat drug trafficking in
the country. India is a party of the Single Convention on Narcotic Drugs (1961), the
Convention on Psychotropic Substances (1971), the Protocol Amending the Single
Convention on Narcotic Drugs (1972) and the United Nations Convention Against Illicit
Traffic in Narcotic Drugs and Psychotropic Substances (1988). An Indo-Pakistani committee
was set up in 1986 to prevent trafficking in narcotic drugs. India signed a convention with the
United Arab Emirates in 1994 to control drug trafficking. In 1995, India signed an agreement
with Egypt for investigation of drug cases and exchange of information and a Memorandum
of Understanding of the Prevention of Illicit Trafficking in Drugs with Iran.

********

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