-IBIS-1.5.0-
rx
issues and approaches
stages of treatment
psychospiritual approaches

definition

Stages of recovery in alcohol treatment (or any addiction):

•"Repeated studies of alcoholics have confirmed that it is almost invariably fear which drives an alcoholic to seek help; fear for his safety, health, or sanity; fear of loss of love, family, home, or job. An event ferocious enough, frightening enough, appalling enough, or humiliating enough happens to breech his denial system. The dam of excuses, rationalizations, and evasions surrounding the drinking gives way. Chagrined, shamed, remorseful, the alcoholic takes the first step: he contacts AA, consents to hospitalization, makes an appointment at a treatment clinic or with a therapist. But the defenses of the mind are like those of the body; they rush to wall off, to localize and repair damage. NO sooner has the alcoholic faced the magnitude and malignancy of his drinking problem than the denial begins to build again and he begins to temporize. He registers how different he is from other patients, how obviously out of place, and therefore how irrelevant the treatment offered is.

The alcoholic is particularly vulnerable to this forgetfulness and minimizing, for after he stops drinking, his life tends to become much more manageable and rewarding. The people around him, in their relief, ease up pressure on him; his sobriety is so welcome that they gloss over other problems stemming from his immaturity. He himself grows optimistic, buoyant, confident. As paradoxical as it seems, therefore, the first phase in any treatment approach to the alcoholic, even the alcoholic who has specifically presented himself to obtain help with his drinking problem, must center on his being continually confronted with the inescapable fact of his alcoholism. He must be repeatedly reminded he is an alcoholic, that he is no different from other alcoholics in his vulnerability to alcohol, and that his feelings of imperviousness to relapse are not justified. Even with persistent confrontations, it may take 3-6 months before the alcoholic's efforts to rebuild his denial system taper off, and this will be the time of greatest danger that he will drop out of AA, or back out of treatment.

The traditional treatment approach of neutrality and inactivity must be tempered with the alcoholic in the direction of expressed warmth and an active effort to persuade him of the sympathetic concern felt for him. His own disputatious nature will tend to garble the incoming message; the superficiality of his own emotional life will make him cynical about its truthfulness; and his passive-aggressive stance will render him standoffish and prickly. The therapist and/or other people dealing with him must be prepared for this and cope with it straightforwardly - by both understanding it, and prompting him to understand it as his own rather than situationally justified. Playing a waiting game with the alcoholic, waiting for him to see the roadblocks he is putting in the way of getting help and involving himself in treatment, is playing a losing game. Unless he receives immediate gratifications in the treatment situation, the long range goal of finding that life can be better lived without alcohol will be too remote to hold him in treatment.

The alcoholic will not suddenly relinquish his denial system and achieve a commitment to therapy. Instead, if he is in AA, there will be a slow erosion as he becomes increasingly aware of his similarity to other alcoholics. As he becomes conscious that their struggles are his, their problems are his, he will begin to see himself in them. This identification will lend him the ego strength to begin to confront his own attitudes and rationalizations.

When this second phase of acceptance has gradually superseded and driven out the first phase of denial, the alcoholic often waxes exceedingly enthusiastic about AA, the hospital program, or his individual or group therapy. He feels that the approach is special and invaluable. He views it as the answer, not only for himself, but for all alcoholics or even all troubled souls. He proselytizes and basks in the warmth of tolerance, understanding, and acceptance. So positive does he feel, nestled in the cocoon of belongingness and 'we-ness,' that he cannot conceive of a return to his old self. The tense, frustrated, volatile, vulnerable, and infantile self seems to be another person in another time, who will never reappear.

But as he becomes freer, less defensive, and further from alcohol, old angers arise, old disappointments come back to plague him, and old behaviors reinstate themselves. Although he feels he has changed, he finds angrily that life and the world have not. Having made what seems to him an heroic effort to stop drinking, he feels he has qualified for a magical dispensation from the vicissitudes of life, and is startled to find that sobriety is only an initial step toward a different life. The phase of acceptance and enthusiasm is over. In its wake come irritation and disenchantment, and the treatment that was overvalued becomes undervalued because of keen disappointment that it has not solved all problems.

The possibility of flight is again strongly present; a return to alcoholism or if not a literal drunk, a prolonged 'dry drunk' of almost unrelieved fits of irritability, depression, isolation, and dysfunctional relationships. This is a turning point, a time of harsh choice for the alcoholic. He can turn away from exploration of his problems and pursue satisfaction of his needs, or turn inward and try to understand. That is, he can choose to abdicate responsibility or to shoulder it. He can come to accept that he must also shape his existence and behave well - it is not enough just to be sober.

Unfortunately, his choice is not influenced by any objective curiosity about his own functioning. He does not consider it interesting to find himself. He is impatient with the task, bored with its tedium, and dubious about its value. He cannot conceive of taking a delight in self-exploration for its own sake. If he goes on, assaying the middle phase of therapy in which his confrontation is no longer with his alcoholism but with himself, he will be satisfied with just that amount of self-understanding which will allow a simple truce, not peace. Because of this, a recovered alcoholic almost never pursues self-exploration to levels of deep insight and pervasive personality reorganization.

Treatment is necessarily incomplete without this reorganization. Further, in the long run it is ineffective if the alcoholic does not learn to adopt the technique of self-examination on a daily basis. It is not enough to understand what happened in the past; the present moment or any moment in which tension threatens to build must be a signal to stop and evaluate, not run or react. Therapy can acquaint the alcoholic with his vulnerable areas, those masses of buried affectivity which are likely to be triggered into an explosion, but psychological treatment does not produce a cure. He must, in effect, become his own therapist; that is, he must keep his finger on his own psychological pulse. With 'preconscious vigilance,' at the first hint of tension building, he must replay the preceding thoughts, sensations, words, and emotions so that he can identify and face the feelings aroused and track the significance of the events.

If the alcoholic, despite the nostalgia for that old self who did not have to be aware, who could blot out reality instead of having to puzzle it out, can make his own acquaintance and knows how to renew it when threatened, he is well on his way through the fourth stage of therapy, synthesis of what has been under analysis. He begins to separate, to trust himself, to trust his ability to stand on his own, to trust his own powers of choice and discretion. When the alcoholic has come this far - through the mourning and the fearfulness, with acceptance of his inherent aloneness, into the openness and confidence to experience whatever befalls him - he can be said to be a recovered alcoholic. He cannot drink again, and there will be times when he will long to drink again; but the drinker he once was is a figure of the past. An internal shift has been made from chronic flirtation with avoidance and oblivion to an affirmation and acceptance of life as it is."
(Coudert, p. 225-244)

see:
addiction: psychosocial approach
hologram of an alcoholic
meditation: forgiveness
process paradigm
recovery: precautions with AA programs
recovery: twelve step programs
search for god
state-dependent learning
subjective inquiry approach
the shadow and physical symptoms


footnotes