Healing Alcoholism
BOOK THREE: Healing Alcoholism
In this section I aim to provide psychotherapists with a set of guidelines for the therapy of alcoholism. These guidelines will also be of interest to the spouses, relatives, and friends of alcoholics, since they can be used, with a few modifications, by anyone who wants to relate to an alcoholic in a helpful way. Let me summarize.
Alcoholism is not a disease; therefore, the best solutions to alcoholism are not medical.
Alcoholism is not incurable. It is an acquired condition different from person to person, based partly on innate, biochemical responses to alcohol, partly on social pressure to drink, and partly on the emotional, thinking, and nutritional habits of the alcoholic.
Alcoholism can be healed, and a few former alcoholics (about 10%) are evidently able to return to normal drinking though the majority either can't or choose not to.
The physical factor responsible for alcoholism is the addictive properties of alcohol. This is treated by maintaining sobriety for at least a year.
The social factors responsible for alcoholism are the intense social pressures to drink, and the participation of alcoholics and their circle in the Alcoholic game with its three roles: Victim, Rescuer, Persecutor. These roles must be avoided by anyone who wishes to help the alcoholic
The psychological factors responsible for alcoholism reside in the Enemy. The Enemy is a collection of harmful messages that have been adopted by the person and that interfere with thinking, feeling, getting strokes, and being aware of one's bodily states. This is treated by confronting and neutralizing the messages and emotional patterns which the Enemy promotes. One very effective method to achieve this goal is emotional literacy training.
AA should be enlisted whenever possible. The therapist’s job is to encourage the client to take action against the alcoholism and to provide protection as the alcoholic changes his or her life.
Chapter 12. Myths of Alcoholism.
There are many theories about what causes alcoholism but precious few specific approaches to the problem. Alcoholics Anonymous remains the best choice for people who find themselves in difficulties with alcohol. The professional literature, on the other hand, is filled shot through with big words like compulsion, regression, passivity, dependency, character disorder, psychosis and so on. These terms humiliate alcoholics and do not seem to answer the main question: what do we do to help the alcoholics?
As a result of this poverty of approaches, it is very difficult for an alcoholic to obtain reasonably competent treatment. Many therapists feel afraid and uncomfortable with alcoholics and are therefore reluctant to get into therapy with them. The more experienced therapists will happily refer alcoholics to other therapists while they keep the more pleasant clients for their own comfortable practices.
Let us briefly explore certain myths about alcohol and alcoholism. These myths have served to obscure the obvious in a field that has been riddled with contradictory opinions and points of view. Disposing of these myths can clear the way for a sensible and objective approach.
1. Alcoholism is just an illness
As we have seen, the notion of alcoholism as an illness (in the sense that the medical profession defines it) is an obstacle to its proper treatment. It is important not to confuse the illness, which is a consequence of excessive drinking with excessive drinking itself, which is not an illness at all. Saying that alcoholism is an illness (because of the different illnesses that are associated with it, like delirium tremens, heart disease, or liver or brain disease) is like saying that driving recklessly is an illness because it often leads to broken bones and concussions, which are treatable only by physicians.
On the other hand alcoholism is a health disturbance in a more general sense. Modern holistic medicine, regards disease in a completely different light from Western allopathic, (drug-and-surgery-centered) medicine. In the holistic view any disturbance of healthy bodily functioning is a health disturbance.
The approach outlined in this book, and even its title, are strongly influenced by holistic health ideas. Holistic medicine's specific treatment of alcoholism bears little resemblance to what has been the traditional medical approach. Above all, sedatives and tranquilizers are not used. Instead, diet and life-style changes are recommended, together with an expectation of the alcoholic's active participation in the healing process.
Attempts to treat alcoholism with drugs have failed even though at certain points of a drinking episode it appears that certain drugs can be of some help. However, at this moment, there are no drugs that specifically treat alcoholism, nor are there or have there ever been any drugs that show any promise. In my opinion drugs for alcoholics should be avoided altogether-except for medical emergencies. It is important that alcoholics and their therapists abandon the notion that alcoholism and medicine are necessarily related in any way except in the terminal stages of alcoholism when it has become intimately associated with bodily tissue damage.
The sense that the alcoholic is progressively, incurably ill and that therefore nothing can be done about the illness, except to keep the cork on the bottle, is as much a myth as the other extreme of thinking, which states that alcoholism is strictly a matter of choice.
2. Alcoholism is just a choice
This myth lies beneath the notion that the alcoholic chooses to be an alcoholic and that the remedy is simply a matter of choosing differently. According to this view, the alcoholic or any other addict doesn't need therapy, A.A., or any help at all. All she needs to do is make her mind to stop, "just say no" and "do it." This view is all the more prevalent since it is clear that some alcoholics do just that; they quit and even return to social drinking.
But for the majority of alcoholics who are not able to just stop, this approach overlooks the many pressures to drink that the alcoholic finds herself under and how those pressures are, at times, irresistible. It is an approach that leads to callousness on the part of the helper; nothing but the alcoholic's will to drink or not to drink is considered of any importance.
Only someone who has never been under the compulsion of drug or other substance abuse can understand how humiliating and persecutory such a point of view can be. Some alcoholics are so browbeaten by this view that they will accept and defend it themselves. "I am just a weak-willed person." "All I have to do is stop drinking-then I’ll stop being an alcoholic" or "I have to do it myself-that's all there is to it'" are the kinds of things alcoholics who have been thus indoctrinated will say about themselves.
These views are not very useful, they sound brave and responsible, but they don't help because they are unrealistically simple and almost never work. Most frequently they result in nothing more than guilt and further feelings of powerlessness because they ignore the powerful factors other than choice that are the causes of alcoholism (addictions habit, social pressures, the inner Enemy, etc.) They interfere with a realistic view of people's responsibility in their own life.
3. Alcoholism is just a symptom.
This point of view, though less and less prevalent, is that drinking is merely a symptom of a deeper psychological or social problem. As a consequence, these therapists will choose not to discuss the drinking (because it is merely a symptom) but will attempt to investigate its "dynamics" and origins (childhood traumas, social environments, script injunctions and attributions, early family constellations, emotional conflicts, or repressed primal screams) through a variety of techniques such as psychoanalysis, gestalt therapy or psychodrama-all of which ignore the everyday realities of the alcoholic's drug use.
Since these views consider drinking just a symptom of a deeper problem these therapists do not typically seek complete cessation of drinking and will have to deal with clients who are almost always under the influence of alcohol, (or between binges) and cannot realistically exercise enough common sense and Adult control to deal with whatever they must do from day to day to make their lives work.
From the Transactional Analysis point of view, the therapist who chooses to ignore the client's drinking in favor of dealing with his more "basic" conflicts is playing the role of Rescuer (Patsy variety) in the game of Alcoholic and is contributing to the continuation of the problem. Regardless of whether drinking is a symptom or not, it is necessary and desirable that the alcoholic take some realistic action. Regarding alcoholism as only a symptom can be a major mistake comparable to forgetting to bail out a sinking boat while looking for leaks.
To stop drinking is the very first step. Stopping the drinking may not be a cure, but it does stop the progression of the script and is thus an indispensable move. Only a reliably sober person can find the energy and clarity of mind necessary to deal with the "underlying" causes of alcoholism. Changing life styles, friendships and social circles follows.
Allied with the misconception that alcoholism is just a symptom of deep underlying emotional conflicts is the assumption that only "deep" one-to-one individual psychotherapy can be effective in dealing with it. In fact, group psychotherapy has proved to be every bit as effective as one-to-one therapy-especially in the treatment of alcoholics. In groups, alcoholics seem more capable of ridding themselves of the problem permanently than in deep" one-to-one analysis. In my experience alcoholism does not require "deep" or heroic methods of therapy. It does require a relaxed, patient, nurturing, well-informed, experienced, demanding, persistent and optimistic approach.
In summary: alcoholism isn't any one single problem. Instead, it is the result of a combination of physical, personal, and social factors which exist in different people at different times in their lives. When the 'right" combination occurs-and it occurs in about twenty million people in this country at this time-alcoholism results. Alcoholism can be healed and what can be done to heal it will be discussed in the rest of this book.
Chapter 13. Can Alcoholism Be Healed?
Some argue that alcoholism is incurable. Can Alcoholism really be healed? This is a good question that deserves a serious answer. The short answer is "Yes!" and that nature’s healing powers are on our side.
In Transactional Analysis we believe that children are born OK, with an innate potential for spontaneity, awareness, and intimacy-or, as Eric Berne put it: "People are born princes and princesses (and their parents turn them into frogs.)" Depending on what kind of a household or situations we are delivered into by fate, our development to full potential may be fully allowed, or we may be "turned into frogs" when our potential is nipped in the bud or barely permitted to muddle along.
Another way of saying this is that human beings are imbued with a life force for health and survival which, if give the opportunity, will heal the body and soul from most damage. This force, Nature’s helping hand named Vis Medicaterix Naturae by Hippocrates, is present in all the living and is the greatest ally of the client and therapist in the struggle against alcoholism.
The cynics are convinced that people don't change, not really. The optimists believe that everyone can, given the proper motivation and help. As usual the answer is somewhere in between; of course people can change. A donkey will never be a mule but change is the essence of life. The question is how much and how fast.
Change is inevitable but three things promote or stimulate it. The first is intense need. That is what alcoholics call "hitting bottom," the point at which the consequences of excess finally become unacceptable or unbearable. One day the alcoholic wakes up facing financial, personal, social or health disaster and he says to himself: "This has to change I have to do something about my drinking!"
The second major requirement is the capacity to manipulate one’s behavior through symbolic thinking or what we in TA call "Adult control" Neither of the two alone—desire or control--is sufficient but together they are capable of shaping behavior in a permanent way.
Thirdly, radical change requires action. The significant changes that healing alcoholism requires are unlikely to happen without concerted action on the part of the alcoholic.
Change, as I said, is an inevitable aspect of life. Healing change is generated from within and we can either help it along or interfere with it. As long as there is life, the struggle to change for the better usually continues and the therapist can help. Sometimes, for a while, a person may not want to improve his or her life but that too is liable to change.
A recent study by Timko et al published in the Journal of Alcohol Studies (July 2000) supports these views. 466 alcoholics who participated in a detoxification program, indicating that they had hit some sort of bottom were studied for eight years. Some received no treatment, others had some sort of psychotherapy some went to AA and some had both treatment and AA. After eight years it was shown that all improved. Those who had both forms of intervention did best, AA and psychotherapy separately had a lesser but roughly equivalent improvement and of those who had no treatment 25% improved anyway. It is a feature of living things that they have self-healing mechanisms independent of any healing administered by any intentional healer.
There are many recorded cases of extreme alcoholism that was healed without healing intervention of any sort. Still a good therapist can be very helpful. A competent, honest therapist works for a living and is mindful of her job. She is humble as to what, in the end, helps the client: a combination of nature's healing power, the clients efforts to take responsibility and bring about changes and the therapist's direction and skills. Every session she reviews what progress is being made, openly rejoices or regrets the client's changes and is ruthlessly analytic about the process using the most advanced knowledge to inform her work. She recognizes the unique individuality of each client and applies her creativity to the client's specific difficulty. She is tuned into and respectful of the client’s perceptions and opinions. She provides permission to change. She provides protection against the demons that beset the client in uncharted, healing waters and she devotes constant, potent attention to the whole process. Her love of truth keeps her honest about the effects of the therapy; positive, negative or neutral.
A jungle healer
Here I would like to tell a brief, apocryphal story: A physician was called to visit a village in the jungle because of epidemic of dysentery that affected 8 out of 10 of the people. After a brief tour of the town he called a meeting of the elders: "I noticed that your latrines are next to the river. Here is what you must do right away. Always take your drinking water upstream of the latrines and your problem will be solved.
The villagers followed this basic, generic, public health principle and the epidemic abated. Still 20% of the villagers continued to be ill. Later measures such as boiling the water, moving the latrines away from the river, antibiotics, etc reduced disease by another 15%
With alcoholism, stopping the drinking, like stopping the drinking of polluted water is an essential aspect of the process of healing. In addition most psychotherapies share a number of mental health principles which will be beneficial to the sober alcoholic. A good therapist will be nurturing and will endeavor to be attuned, thoughtful and soothing while the client is encouraged to talk about problems and vent feelings.
But every person’s problems are different and the basic methods described above are often not sufficient; a higher level of expertise is needed to combat the Critical Parent, deal with unruly emotions, handle emotional complications and nutritional and other health issues. The various factors that are important in the healing of alcoholism will be explored in the next chapters.
Chapter 14: Personal Responsibility
How does it happen that in spite of having the capacity for choosing any kind of life, we wind up with the particular enslaving scripts that we live?
Even North America where people have an unusual range of choices and reasonable freedom to choose between them, approximately 10 percent will become slaves to alcohol and suffer the devastating horrors of alcoholism. One-fourth will be addicted to cigarettes and (this is my guess) as many as one-third will let themselves be dominated by some form of addiction: caffeine, sugar, fattening foods, prescription or over-the-counter drugs or narcotics.
Does the alcoholic simply lack will power and insists in making bad choices? Or is the alcoholic a victim of his heredity childhood experiences and family? Heredity matters and childhood experiences matter but no one is willing to claim that they are the reason why alcoholics are alcoholics. We assume that the alcoholic has choices, yet he feels powerless.
Powerlessness
One experience is common to all addictions, and that is the feeling of powerlessness. If there is an innate healing positive force within all of us why is alcohol so powerful and alcoholism so difficult to overcome?
Being unable to control one's behavior is a devastating experience. Not having the power to stop the use of cigarettes, sleeping pills, coffee alcohol, amphetamines, heroin, marihuana or prescription drugs, gambling or sexual compulsion when we know they are harmful, is most damaging to self-esteem. When we experience the humiliation of powerlessness, it poisons our daily life, makes us feel worthless, contemptible, and ashamed. We look around and see other people who appear to be in control of their lives, doing what they must do, avoiding what they must not. Yet we see ourselves chained to our habits, powerless to control our own actions.
Many people manage to avoid confronting their powerlessness over substance abuse by telling themselves and others that the amount of harmful substances they consume is reasonable, that there is no problem, that they are in fact consuming these substances voluntarily, because they enjoy it and don't see anything wrong with it. Still many of those people secretly would like to stop.
The terror that comes with the realization of how helpless we really are is one of the greatest obstacles to people's success. Discovering that we are powerless to stop doing things we don't want to do is an experience we wish to avoid. Many who know and believe that it would be desirable to do something about their harmful habits simply do not attempt it because they believe they will fail, and, quite understandably, do not want to face the humiliation of their impotence. That is why acknowledging one’s helplessness vis-à-vis alcohol is the first step in AA recovery.
We are brought up to believe that anybody who is anybody can do whatever he needs to do by himself, without any help. To seek advice, to request nurturing, are taboo. This is especially true for men in our culture, who believe that doing it alone, without help, without discussion, is how it really should be done. It is true that some people manage by themselves. But addictions are very powerful; help is needed, and trying to do it alone is unnecessary, foolish, and prideful while seeking help is intelligent, human, and effective.
By ignoring the realities of addiction and blaming ourselves for lacking willpower we make ourselves more powerless than we really are. Addictions are difficult to overcome but with help it can be done.
According to some, people choose what they do and are completely responsible for what occurs in their lives. If their lives aren't working satisfactorily it is because they are choosing them to be so. People can choose to be poor, and people can choose to be rich. People who are not loved have a need not to be loved and could find a faithful lover merely by looking. People who are ill can choose health; people who are persecuted can choose to be free.
If we are to believe this view, we have no one but ourselves to blame for the quandaries in which we find ourselves, life is exactly as we want it to be and if we wanted it to be otherwise we could simply change it. There is no point in blaming our parents or teachers, advertising, our government or the media, the multinational corporations or globalization the quality of our lives; we are free to choose whether we want to be happy or unhappy, employed or unemployed, healthy or sick.
Those holding this view, remind me of the finger who, because it could move this way and that, every time it wanted to, developed the delusion that at was separate from the other fingers and in complete charge of its own destiny.
The Greek word idiotes means separate individual. Hence this finger’s delusion can be justly called idiotic. It is plain to the observer that the finger is attached to a hand and that its everyday life and destiny is intimately tied to factors beyond its control. The absurd notion of total personal responsibility was successfully sold to people through millions of copies of best-selling pop-psychology books in the late 20th century.
A further, equally mistaken, corollary of the idiotic view of total responsibility is that since we are completely responsible for what happens to us we can’t be made to do things or to feel emotions by others. We are not responsible for what happens to other people nor are they responsible for what happens to us. This especially true in the area of emotions where the notion is that "I can’t make you feel and you can’t make me feel." This latter fallacy is thoroughly explored in my book: Emotional Literacy; Intelligence with a Heart.
Let us, however, look further into this notion and ask ourselves why the myth of total personal responsibility is so appealing to people. The idea does have a substantial grain of truth. We do choose just how we are going to live our lives. However, the choices we have, especially as children, are usually very limited. If we looked realistically at the tens of thousands of children who are born every day, we would see that only a few lucky ones will be given true freedom to choose. Many face starvation from the first day on, many will never have the basic human right to speak freely or to express their emotions-let alone to choose for or against in matters of importance to their lives.
Many are not much freer in the "land of the free." We smoke, drink coffee and alcohol and sodas, eat Macburgers and French fries and then we get fat and develop back trouble, diabetes or cardiac disease. It could be said that we chose all that from our free will. But how many of us can work eight hours and commute two hours a day, cook a healthy meal, do the dishes, take care of the kids and the dog and then jog or exercise for an hour at the end of the day? Sure, we choose to drink, drink, drink from sun up to bedtime. But we are pressured to drink by friends, coworkers, employers and constant advertisements. We aren't allowed any other avenue for the expression of our needs, for fun, love or human contact. We are also addicted and don't know it.
Most script choices are made in the distant past, and they have consequences not so easily changed. It is as if life was a walk through a thick forest. If, early in the day we choose a certain fork on the path and decide by noontime that we made a mistake, the right path can be found again but not all that simply. So, yes, we choose, but we choose among the alternatives available to us at the time, and we choose before we know much about what our choice means or leads to. That can hardly be translated into the claim that we are fully responsible for the shape our lives have taken.
Another reason that people adopt the view of total responsibility may be because it gives them a feeling of power over their lives "If I didn't believe that I have power over my life, I could become completely discouraged, I'd want to give up and kill myself!" a patient once told me.
Psychotherapists who espouse the idiotic view seem to be convinced that anything short of taking complete responsibility would cause their patients to give up all efforts to change and settle into a mire of irresponsible blaming. My experience with this matter is different. I believe that people's lives are the result of a combination of external and internal factors; an alcoholic is an alcoholic because she has a genetic predisposition to it, because her father and grandmother were alcoholic and because she decided to sneak drinks when she was a teenager. She is surrounded by people and advertising which encourage her to drink. She is overworked and exhausted from an ill-paying and monotonous job and she doesn't eat or sleep properly. Her choices are combined with external influences to shape her life. It is a fifty-fifty proposition.
Some therapists think that this is yet another dangerous idea that encourages people to blame other people and bad conditions, rather than themselves, for their alcoholism. However, when I explain this to my patients, they don't respond by giving up and blaming the world for their problems. They simply come to see more clearly why their lives are what they are and why, at times, they feel powerless over them. So far as I can see, this realization only leads to renewed efforts and power rather than to giving up.
Chapter 15: How to Help Without Rescuing
People often ask me, "What is the secret of good psychotherapy?" My answer often is, "One-third not Rescuing, one-third transactional analysis, and one-third hasn't been figured out yet."
In a reasonable helping situation, we are able to make as much of a contribution as we want to make for as long as we want to. We remain free to withdraw and let the person help himself or find others to help him.
Not so in a Rescue. A Rescue is like a fishhook; once we take the bait, it is very hard to let go. We cannot stop the Rescue because we develop the impression that our Victim will drown, fall apart, die, or kill himself if we do. We are stuck because we do not want to be responsible for the tragic end of another. Somehow, in the process, our victim has shifted the responsibility for his condition entirely onto our shoulders and because we are reasonable, humane, human beings, we cannot simply dump him-so we unwilling carry the load sometimes through extraordinarily long and arduous periods of time.
In this connection it is helpful to distinguish between a small "r" rescuer and a capital "R" Rescuer. The rescuer is someone who as part of his vocation or avocation helps people in distress. Among such are lifeguards, firefighters police, physicians, nurses, social workers, alcohol psychotherapists and so on. It is quite possible to be effective as a rescuer and truly benefit other people in need. On the other hand, rescuers can also be Rescuers, people who get caught in the Rescue triangle game with a victim.
When a rescuer becomes a Rescuer, he steps into the merry-go-round of the Drama Triangle. He becomes an actor in a play and loses his potency as a healer. Specifically with alcoholism his behavior will cease to be therapeutic; his words will become lines read from the alcoholic's script which serve only to promote the alcoholic's tragedy through to the final curtain.
The basic difference between a genuine "rescuer" and a game "Rescuer" is relatively easy to detect. If you are doing more than 50 percent of the work or investing more than half the effort in a situation in which you are helping someone you are Rescuing. Even God in his infinite mercy won't help those who don't help themselves-or so the saying goes. It doesn't make any sense to try to help those who don't participate in the effort; it is important to only go halfway in any situation in which we are trying to be helpful. That means, first and foremost, that we do not help someone who is not asking for help. Diving head first into situations where the victim hasn't even asked to be saved is the most blatant example of a Rescue. Alcoholics are expert at presenting us with a situation which is in need of repair. They may not want to commit themselves to working on it, but they're quite willing to let us try if we want to.
Characteristically, the alcoholic's Rescuer does most of the talking, cooking, traveling, staying awake, planning, or thinking while the alcoholic simply does most of the drinking. A good contract, faithfully followed, is the best insurance against that sort of outcome. (As discussed in Chapter 16)
This may come as a shock to you, but if you are helping an alcoholic and really don't want to do it anymore, and don't stop soon, you will be Rescuing. If you are Rescuing, you are not only not helping the alcoholic, you are actually harming her. This is true for anyone-whether she works in an agency dealing with alcoholics or is in a relationship with an alcoholic-as a child, spouse, or parent. If you are helping without the desire to help, or if you are doing more than your share of the work you are not only not big helpful, you are making the problem worse.
This is difficult for people who may be totally immersed in Rescuing an alcoholic to believe, but it is true. I have witnessed scores of situations in which, after forcefully pointing this out to a Rescuer and encouraging that he stop the Rescue, the alcoholic did not go under, die, or commit suicide, but in fact pulled himself together and made some improvement in his life. Alanon the self help organization was designed to help the persons close to alcoholics to avoid just such a situation.
Everyone, sooner or later has had the experience of being sucked deeper and deeper into doing more and more with and for a deeply troubled person who seems to be getting nowhere fast. Each renewed effort starts with hope and ends in disappointment. Or we may have experienced the anger and dismay of seeing months of support and involvement in seeming success dissolve into a binge or a similar breakdown. Yet it seems that turning away from someone else's need would be heartless and selfish.
These are traumatic experiences for the Rescuer; but, as I have said repeatedly, they are also harmful to the Victim and they must be avoided for the sake of everyone involved.
Again, Rescuing is simply a matter of:
(1) Doing more than your share of the work in a relationship, and/or
(2) doing something you don't want to do.
But what about compassion? The Good Samaritan? The duty to help? Can we let these intellectualizations guide our behavior when we come across a life and death situation and the Rescuing guidelines recommend that we stay aloof and refuse to help?
Please don’t confuse these words with hard heartedness or cruelty. Of course we stop and help a person who is injured or dying. Of course we extend a helping hand to the sick or needy. I am speaking here of helping a person over time when that person is not matching our efforts with theirs.
How do we know when we are doing more than our share in helping another person? This is not always clear. In an attempt to develop Rescue-free relationships, some people have carried this concept to extremes. Rescue avoidance has been misunderstood by some to mean being distant and noncommittal, avoiding a warm, nurturing attitude with anyone who needs help, being suspicious of any situation, which seems to pull at our sympathies. This is not what I mean; when not Rescuing is carried to that extreme, it is a subtle (or not so subtle) form of Persecution.
Doing your share in a relationship is a much more subtle process than merely staying aloof. Consider the following telephone conversation I once had with a man who eventually joined one of my groups:
CS: "Hello."
Mr A: (Surprised at hearing a male voice rather than an answering-service operator) "Hello, may I speak with Dr. Steiner?"
CS: "This in Dr. Steiner."
Mr A: (Seems disappointed). "Oh, I didn't expect to get you on the phone. "
CS: "Well, here I am, how can I help you?"
Mr A: "(Somewhat hesitant) I'm calling because my sister thought I should speak to you."
CS: "About what?"
Mr. A: "Well, she says I'm an alcoholic."
CS: (Cheerfully) Well, good, thanks for calling. What do you say?"
Mr. A: (Startled) "About what?"
CS: "About being an alcoholic."
Mr. A: Well, to be perfectly honest, I'm not sure I know. I guess I am an alcoholic.
CS: Okay. What can I do for you?
Mr. A: Well, I really don't know.
CS: (Nicely): I'm sure I don't know if you don't know. Why don't you call me back when you know what you want from me? I'm usually easy to reach, and you can...
Mr. A: (Anxious) "She said that you have classes for alcoholics."
CS: "That's right. Actually, they're not classes, they are therapy sessions."
Mr. A: "I guess I should come to one of the sessions."
CS: "What for?"
Mr A: "Well, to try 'em."
CS: "That would be okay, but I don't think you really want to come. (Silence-no reaction from Mr A.) Why don't you tell your sister that you spoke to me and tell her that we agreed that it probably wouldn't work. That way she will be satisfied, and I will be able to go back to what I was doing before you called."
Mr. A: (Relieved) "You don't think it would work? Why not?"
CS: "Well, because you really don't want to do it, and therapy never works for people who don't want it."
Mr. A: "I can see that, and I really don't want to do it right now."
CS: "Well, if you don't want to do it, I don't want to do it either. Thank you for calling. You didn't tell me your name."
Mr. A: "The name is Amble. Karl Amble."
CS: "Okay, Mr. Amble, nice talking to you."
Mr. A: "Well, maybe I should try it."
CS: "You should think about it. I'm always here-you don't have to decide right now I have group therapy once a week, and if you want to know more about me you can read my book Healing Alcoholism, or you can call me again. Okay?"
Mr. A: "Okay, Good-bye."
With Mr. A's example, I have tried to illustrate the process of starting therapy with one who needs help, without Rescuing.
In order to avoid Rescuing in a group setting it helps to visualize the situation between the people involved in terms of a space in which negotiation take place. Two or more people are sitting around an initially empty space. As the conversation proceeds, everyone puts something into the common central space. The people in the helping role, whether they be therapist, friends, or group members, ask questions, put in suggestion, or offer nurturing. The person who has taken the role of being helped (let's call him Karl) examines the offerings and chooses what he wants. If he likes a suggestion or accepts a criticism, he picks it up and acts on it. If he doesn't, he leaves it alone.
If Karl wants the nurturing he is offered, he accepts it. The helpers are keenly aware of Karl and what he takes and what he rejects. If he is eager, then the helpers become eager as well. If he is reluctant, the helpers sit back; the helpers and Karl maintains a balance of activity. If Karl rejects a number of ideas, then the helpers stop making suggestions.
I have a personal rule that I call "three strikes and you're out" as in baseball. I keep track of the suggestions I make. And when three of them are rejected, I stop. I may even say, out loud, "strike three" I might explain that I've made three suggestions that must not have been very good and have therefore struck out. This may sound disingenuous but it really isn't, because I truly believe that any suggestion that is rejected probably was not a good one. It was either not put in the proper words, so the person could understand it, or it was poorly timed, or perhaps-wonder of wonders-it was really a poor suggesting.
I am of the opinion that a valid, properly worded and timed suggestion will be accepted, and that when a suggestion is rejected, there was probably something wrong with it
Not Rescuing helps because it rejects the Victim role. To the alcoholic's plea, "Help me! I can't do it!" the response of the effective helper is, "I am interested in helping you if I can see what you are doing on your own behalf. What are you doing for yourself? What else can you do? What will you do if I help you? What would you like me to do? Let's make a deal: I'll do X if you do Y."
It is also necessary to be able to say, "I understand that you would like me to help you, but I don't have the desire (or time) (or energy)."
Not Rescuing additionally avoids Persecution. Persecution is the inevitable result of Rescues, and for every minute that a person spends rescuing another, it is inevitable that another minute will be spent Persecuting. Yet, since no one is perfect and no one can really avoid Rescues every once in a while (as I keep noticing myself), it is important to know how to deal with one's Persecution tendencies as well as one's Rescue tendencies.
First, it is important to recognize that Persecution is a harmful transaction and that when we feel angry at others because they're not working hard, or because they're rejecting all of our moves, or because they are not getting better, that this anger is our responsibility and should not be foisted on them. When, for one reason or another, after having Rescued an angry feeling of persecution emerges, it is important to say so and to take the responsibility for it.
"Karl, I am getting angry at you because you are not accepting my suggestions (or because what I do doesn't seem to help). I realize that I shouldn't be angry and that my anger has to do with trying too hard. I apologize for having Rescued you and I will try not to be angry. I hope you will understand if I pull back a bit and stop trying so hard."
Having spoken so strongly against Rescues, I feel I need to say a few words to prevent too strong a reaction in the opposite direction. I call this reaction an anti-Rescue and believe it to be a subtle form of Persecution in which our present fear of helping is a reaction to mistakes of the past. An effective therapist is willing to stick her neck out a little to start the ball rolling. Being initially eager, helpful, friendly, and active does not mean that one is Rescuing.
One other assumption is that to simply nurture someone who is hurt or feels powerless or in distress is to Rescue. I think it is very important to distinguish between Rescue and nurturing. When someone is upset and is showing his feelings freely, I see it as a very substantial contribution toward improvement. I feel no qualms about responding with some feelings of my own. Most of the times when a person cries, the tears are a genuine expression of feelings of despair and powerlessness. People's anger reflects their frustration. I will assume that these are honest feelings and will respond in kind, with my own honest feelings. Only if this becomes a pattern, where the person gets angry or cries or engages in emotional outbursts repeatedly, without any visible progress or change, will I then consider the possibility that I should not respond lovingly and that perhaps, as some T.A. therapists say, "I am stroking a ‘racket’ or game."
Nurturing someone is not automatically a Rescue, it is a legitimate aspect of helping people. Not nurturing someone who is genuinely upset is, once again, a subtle form of Persecution. Some people who become therapists and who have problems being loving and nurturing will use the concept of not Rescuing or Tough Love to justify their lack of warmth, but this use of the concept is nothing more than an easy copout.
Ten Rules to Avoid Rescues:
Although there are many ways of Rescuing an alcoholic, some ways are typical. Here are ten of them:
1. When three or more suggestions to an alcoholic have been rejects you are Rescuing. Instead, offer one or two, and wait to see whether they are acceptable. If they are not, stop making suggestions. Don't play "Why don't you… Yes, but…"
2. It's O.K. to investigate possible therapists for an alcoholic, but never make an appointment for him or her. Any therapist who is willing to make an appointment with an alcoholic through a third arson is probably a potential Rescuer and eventual Persecutor.
3. Do not remove liquor, pour liquor down the drain, or look for hidden stashes of liquor in an alcoholic's house, unless you're asked to do so by the alcoholic. Conversely, do not ever buy, serve, mix for, or offer alcohol to an alcoholic.
4. Do not engage in lengthy conversations about alcoholism or a person's alcoholic problem while the person is drunk or drinking; that will be a waste of time and energy, and will be completely forgotten by him in most cases when he sobers up.
5. Never lend money to a drinking alcoholic. Do not allow a drunk alcoholic to come to your house, or, worse, drink in your house. Instead, in as loving and nurturing a way as possible, ask to see her again when she is sober.
6. Do not get involved in errands repair jobs, cleanups, long drives, pickups, or deliveries for an alcoholic who is not actively participating in fighting his alcoholism.
7. When you are relating to an alcoholic, do not commit the common error of seeing only the good and justifying the bad. "He's so wonderful when he's sober" is a common mistake people make with respect to alcoholics. The alcoholic is a whole person, and his personality includes both his good and bad parts. They cannot be separated from each other. Either take the whole person or none at all. If the balance comes out consistently in the red, it is foolish to look only on the credit side.
8. Do not remain silent on the subject of another's alcoholism. Don't hesitate to express yourself freely on the subject, what you don't like, what you won't stand for, what you think about it, what you want or how it makes you feel. But don't do it with the expectation of being thanked or creating a change; it’s not likely to happen. Do it just to be on the record. Often your outspoken attitude will be taken seriously and appreciated, though it may not bring about any immediate changes. Just as often it will unleash a barrage of defensiveness and even anger which you should staunchly absorb without weakening.
9. Be aware of not doing anything that you don't want to do for the alcoholic. It is bad enough if you commit any of the above mistakes willingly. But when you add to them the complications of doing them when you would prefer not to, you are compounding your mistake and fostering an eventual Persecution.
10. Never believe that an alcoholic is hopeless. Keep your willingness to help ready, offer it often, and make it available whenever you detect a genuine interest and effort on the alcoholics part. When that happens, don't overreact, but help cautiously and without Rescuing; doing only what you want to do, and no more than your share.
Remembering these guidelines about Rescuing will be helpful regardless of what else is done.
Let us now look at the first important thing to do to help the alcoholic; making a contract.
Chapter 16. The First Step: Contract
Most of us have a healthy desire to nurture and take care of people who need us. Many of us have also had the experience of starting out as helpers and rescuers-and winding up the victims of the very person we are trying to help. The classic example is the innocent bystander who is walking on the beach and sees someone drowning. He jumps in, swims up to the victim, and in the process of rescuing him, drowns right along with him-though at times, ironically, survives.
Many of the techniques lifeguards learn are designed precisely to prevent their being drowned by a drowning swimmer. Similarly, a person who is interested in helping others needs to develop effective techniques for helping. These techniques which need to include safeguards against being dragged down and destroyed by the very ones she aims to help.
Alcoholics, especially, seem to have the knack of attracting the good graces of people who start out feeling that they can help and wind up totally swamped. Very often we began a helping relationship with love in our hearts and a true desire to help. In certain situations, this desire remains part of our motivation and we continue to want to help. Very often, however, our desire to help diminishes and eventually disappears while it suddenly appears that we are now compelled to go on helping whether we like it or not.
Drawing up a contract is the indispensable first step in avoiding the game of alcoholism and its roles; Rescuer Persecutor and Victim. Transactional Analysis is a contractual form of group treatment which must be distinguished from other activities that may be of therapeutic value. A person may do all sorts of things alone or in groups which could presumably be helpful. Going to a football game or a dance, joining an encounter group, spending a weekend in the wood meditating or beginning psychoanalysis are all activities that might be helpful. The basic difference between these activities and a Transactional Analysis group is the contract.
Therapeutic contracts-contracts between a person who holds herself out to be a competent therapist and a client-should be regarded with as much respect as legal contracts in a court of law. Two aspects of legal contracts are fully applicable to therapeutic contracts (1) informed mutual consent, (2) consideration. These requirements were developed over hundreds of years, so it is reasonable to accept them as pragmatically effective as well as socially desirable in the establishment of a therapeutic contract.
Informed Mutual Consent
Mutual consent implies that both of the parties in a contract are consciously and sincerely agreeing to the terms of the contract. Therapeutic consent implies the request, offer and acceptance of therapy. Presumably the client has come to the therapist to get help for her condition. Presumably also, the therapist understands the situation and is willing to make a contribution to the improvement of that condition.
In order to make an informed, intelligent offer, the therapist should clearly understand the client's specific situation and what the client wants to accomplish. In order for the acceptance to be informed consent the client needs to understand what the therapist requires as conditions for the therapy. Consequently, the therapeutic offer should contain a clear description of what the therapist considers essential for the process to be successful and how success will be defined.
Establishing mutual consent as part of the contract is particularly relevant to the therapy of alcoholics, since alcoholics are accustomed to enter into a therapeutic relationship without any contract at all.
For example: It is common for alcoholics to get into therapy as a result of pressures applied by family or by the courts. A therapist may mistakenly assume that there is mutual consent in the ensuing relationship when, in fact the client is not willingly involved but instead feels coerced and even victimized in the situation, a situation which places the therapist inauspiciously in the Persecutor role. On the other hand it is also typical in the therapy of alcoholics that a willing client blindly agrees to entering the situation without any understanding of what its requirements are-only to find out later that the requirements are far different and more complicated than expected.
My experience is that the minimum requirements for successful therapy with alcoholics are as follows.
1. Complete sobriety for a minimum of a year during which
2. The client attends group therapy regularly every week for two hours and
3. Involves himself in specific homework including diet and other life-style changes addressed to his specific problems including, perhaps, attendance in AA and
4. Attends my monthly body-work sessions.
The establishment of a mutual informed-consent relationship involves three transactions.
1. The request for treatment from the client,
2. An offer of treatment by the therapist and
3. An acceptance of treatment by the client.
It is not unusual in the relationships between therapist and client for them to enter into therapy without these three elements having been fulfilled.
Consider the following conversation between Jonas. an alcoholic, and Jill, a therapist
Jill: "What can I do for you, Jonas?
Jonas: "I'm here to get therapy. "
Jill: "Fine I have an opening available for you on Tuesday at six o'clock. Can you make it? "
Jonas: "Yes, I can. I guess I’ll see you on Tuesday. "
Jill: "Good."
This conversation may seem to achieve mutual informed consent. If examined closely, however, it may turn out that the client's request was really only as follows.
Jil1: What can I do for you, Jonas?
Jonas: (My wife is leaving me and I was arrested for drunk driving and my mother, the judge, and my wife say that I need to get into therapy, so) "I am here to get therapy."
This is not really a request for therapy, and it is definitely the opening move in a Rescue game. It would be a great mistake for a therapist to agree to work with a person under the above circumstances.
Let's try again.
Jill: "What can I do for you?"
Jonas: "I'm here to get therapy."
Jill: "Why do you want therapy? "
Jonas: "Well, I guess I need it."
Jill: "Maybe you don't need it. What makes you think you do? "
Jonas: "Well. I'm drinking too much, and I'm getting sick. My wife is going to leave me, and l may have to go to jail for drunk driving. I want to stop drinking because it is ruining my life. Do you think you can help me? "
Jill: "Yes, I think I can. I have an opening available on Tuesday at six o'clock. Can you make it? "
Jonas: "Yes, I can. I’ll see you on Tuesday."
This example involves a request for therapy, but it doesn't involve a proper offer because the therapist has not stated what she intends to do or what she hopes to accomplish. She hasn't really got the information to understand whether she can actually help and she has not stated her conditions for help.
In fact they are both still considerably in the dark with respect to informed mutual consent. The therapeutic offer by the therapist implies that she understands the problem, that she is willing to deal with it, and that she has reasonable expectations to be successful in the process.
In order for informed mutual consent to occur, the therapist needs to have certain information. In my experience, the following facts must be investigated before a therapist can enter into a therapeutic contract with a client.
Does the person recognize himself to be an alcoholic? Does the person feel that has drinking is out of control and/or that it is harming him?
Jonas has indicated that he recognizes both: he feels that his drinking is out of control and that it is harming him. If a person with a drinking problem asks for therapy but does not see his drinking as being out of control or harmful, it is important to examine the extent of the drinking. The following questions are useful.
What kind of alcohol and in what quantities does the person drink? This question needs to be answered in detail. No ambiguity should be allowed. If the amount the person drinks varies, an average for a typical week should be obtained. A person who drinks more than two ounces a day regularly or who drinks more than five ounces within a period of two hours more than once every three months can be considered a problem drinker.
When does the drinking occur? Anyone who drinks before lunch and everyone who drinks regularly in the evening can be considered a problem drinker. On the other hand, a person may drink what seem imprudent amounts at times and not really have an alcoholic problem though he may be in danger of developing one.
For instance, a person may regularly drink before going to sleep. She may be using alcohol as a sleeping medication. It is a reasonable substitute for some other form of drug. While this is definitely a problem, it isn't necessarily a problem of alcoholism, but it may be a problem of insomnia. When a drug is taken just for its purely physical biochemical effects, it lacks the social and psychological aspects of alcoholism. It will be easier to deal with and will require a different approach than the usual alcoholic problem.
If the therapist has adequate information about the client's drinking she can now involve herself in mutual, informed consent. If the client shows signs of alcoholism and sees himself as having an alcoholic problem, she is now in a position to make an offer. Consider the following:
Jill: "What can I do for you, Jonas? "
Jonas: "I am drinking too much and I am getting sick. My wife is going to leave me, and I may have to go to jail for drunk driving. I want to stop drinking because it is ruling my life. Do you think you can help me? "
Jill: Okay, Jonas, I think I can help you. Let me tell you what is involved if you get into therapy with me, I have certain expectations of you. In order for it to work, you need to come to group meetings every week for a two-hour session and to body-work meetings once a month. You need to attend regularly and on time and not have had a drink for 24 hours previously. This kind of therapy doesn't work while you are drinking so it is necessary that you stop drinking altogether as soon as possible and that you don't drink at all for at least one year. During that year, in addition to attending group regularly, I expect you to be actively involved in working to solve your problem and that will include doing homework on diet and life-style changes between meetings, and perhaps attending AA. So if you come to group regularly, don't drink for a year and we work together on your problem, I expect that you will be cured of your alcoholism. If you are willing to agree to this we can proceed. I have an opening available for you on Tuesdays at six o'clock."
Jonas: "I understand, I will see you on Tuesday."
This highly condensed example contains three requirements for mutual informed consent: a request, an offer, and an acceptance. It is a model for a successful beginning contract, which is likely to result in satisfactory work to both of the parties (client and therapist) as well as the other members of the group.
On occasion, an individual seeking therapy is clearly an alcoholic, but wants to work on some other difficulty.
For example, Jonas may want to work on his relationship with his wife but may wish to leave his drinking alone. Making an offer to treat a disturbance such as marital troubles without dealing with his alcoholism, is a mistake that will surely lead to difficulties. It can be compared to being willing to perform plastic surgery on a terminal patient and should be declined on the ground that the alcoholism is so disruptive in itself that it will defeat any efforts to deal with some other lesser problem. Unless the therapist wants to face unending frustration and difficulties, such a request should be politely denied with a frank explanation.
On occasion a person may come to therapy with a drinking problem that is not severe enough to be called alcoholism. Under those circumstances, it is best to take a "wait-and-see" attitude. It is possible to make a temporary, short-term contract to deal with some minor difficulty and pursue the alcohol situation to see whether the drinking is serious enough to require a primary contract dealing with alcoholism.
On occasion drinking troubles are really minor and fade away as other problems are dealt with. I am always willing to give clients the benefit of the doubt and take some time to see how severe their alcoholism really is.
The Consideration
The consideration is the second (after informed consent) requirement of the contract.
A helper gives of himself. To avoid a Rescue, the person helped needs to give sometime in return. In legal terms, this is called the consideration.
Every contract must be based upon a valid consideration. Valid consideration refers to benefits that pass between the therapist and the client. These benefits may be bargained for and eventually agreed upon. The benefit conferred by the therapist should always be a competent attempt to remedy the problem. In exchange, the client will usually pay the therapist money. But money is not the only kind of benefit a client can confer upon the therapist. Let us look at the consideration in some detail.
As stated above, the benefit conferred by the therapist should be a remedy of the problem. That is why it is important that the client clearly states the way her life is unsatisfactory and what would be required for satisfaction. The client needs to state specifically what is making her unhappy. Is she drinking too much? Is she unable to sleep? Does she cry all the time? Does she fail to have good relationships? Is she shunned by her friends? Is she unable to keep a job? and so on. She should also be able to state what would make her life satisfactory. Getting a job and keeping it, being in a reasonably happy love relationship, being able to sleep and wake up refreshed and happy, making friends, getting rid of headaches or stopping drinking. The therapist has delivered his consideration in the contract when the person, the therapist, and the majority of the members in the group agree that the problem described in the beginning of therapy is no longer present. That is why, at the beginning of therapy, problems need to be stated in clear, behavioral, simple, observable terms, understandable to an ten-year-old. Without this initial statement it is impossible to determine whether the problem has been solved.
On the other hand the consideration given by the client can vary. The most common consideration in the therapeutic contract is money, but in the absence of a full fee it is also possible to accept a partial fee temporarily with the understanding that the full fee will be expected when the client is able to pay it.
People who wish to help an alcoholic as friends rather than as therapists need to be equally scrupulous about mutual consent and consideration involved in the relationship. In addition to making it clear that the alcoholic wants our help and is willing to work at least as hard as we are on his problem, it is also important that we get something in return (not necessarily of a material sort) for our effort. If you are my friend, and if I am willing to speak to you on the phone for an hour about your problem then I expect you will be willing to listen to me for an hour at some future date should I need it.
If I come to your house and help you clean up a mess you made, then I expect you to do a similar favor for me should the need arise. I will make an effort to ask you for your help so that we keep the balance of energy devoted to each other more or less even. If I lend you money, I expect you not only to return it but to lend me money or something that I need when I need it. If I give my help to you freely I expect you to give help equally elsewhere. The equation of energy-in/energy-out has to maintain some semblance of balance between us or we will slip into a Rescue game and I will inevitably become angry with you, cease to have an interests in helping you, and may eventually Persecute you.
People who "selflessly" help others while expecting nothing in return are weakening the effectiveness of their help. At the very least, a helper can expect an energetic effort to change, a willingness to work hard, and an eagerness to learn. To many helpers, this type of positive attitude is sufficient consideration for their work. If so, well and good-it is the very least that should be expected. To expect more is reasonable. In any case the consideration must be made fully clear and should be negotiated for maximum success
The Alcoholism Treatment Contract
As I have mentioned earlier, every alcoholic's first task is to stop drinking. Therefore this is also the first contract. However, it does not need to be the only contract. As long as the is drinking it is foremost in importance; but obviously, when the drinking ceases, other matters will have to be attended to in his personal life, his work, recreation, health habits, nutrition. Consequently, an alcoholic in therapy will have additional contracts, such as:
Finding a better job
Getting strokes
Stop eating sugar (or drinking coffee) (or smoking) (or all three)
Make friends
Improve sex life
Fight the Enemy
Stop Rescuing
Develop an Ally
Give more strokes
Be truthful
Show feelings
And so on.
For some people, completing a contract such as "showing my feelings" can represent a couple of years' work which results in a change of life-style that includes giving up alcoholism. Other contracts, such as "Find a better job" can be one of a series of contracts which the client chooses during her therapy.
For effective therapy, a client needs to have a contract throughout. As each contract gets worked through, the question becomes: "Is therapy complete, or should we start on another contract?" The answer to this question is up to the client rather than the therapist. Any new contract should be made with the same scrupulous attention to mutual involvement as the last. Therapists need to look out for that common tendency in our profession which compels us to tell our clients what they should (or shouldn't) do. This is essential to ensure that any contracts arrived at are based on the needs and desires of the client rather than the therapists. This is not to say that the therapist should not freely express his opinions on this or any other matter-only that these opinions should take a back seat to the client's needs and opinions.
In addition to the specific personal contract that each client works on there is another universal contract in my groups which involves all the group members, including the therapist: the Cooperative Contract.
This contract specifies that there shall be no power plays among the participants, specifically "No Rescues and no lies."
Rescues have been amply covered so far; let me briefly explain what is meant by no lies and no power plays.
No power plays; A power play is a transaction designed to manipulate another person into doing something she or he would not otherwise do. Accordingly, people cannot intimidate, bully, threaten, or yell at each other to get desired results. Nor can they try to get the same result by sulking, guilt-tripping, or withdrawing from the group. Especially important is the application of this rule to the therapist's behavior; many of the "motivating'' tricks that therapists feel free to use are not allowed in a cooperative problem solving group. For example, according to the cooperative contract, it is not permissible to pretend to be angry and to insult someone in order to help him get angry and express his feelings. That would be both a lie and a power play to boot.
No lies : Alcohol loves lies. Everyone in the group agrees to complete truthfulness. This means no deliberate untruths or lies of commission are told, and that includes secrets or lies of omission as well. If a group member who has been drinking is asked about it and denies it, this is a lie of commission. But if she is not asked and fails to mention it, she is lying as well. According to the definition, a lie is the deliberate act of hiding what someone else wants to know. Clearly, in a group therapy situation, everyone at the very least wants to know whether an alcoholic member is drinking. The same is true in the social circle of the alcoholic; therefore the same commitment to truthfulness should be extended to friends and family.
This rule applies also to the hiding of feelings, desires, or opinions. If a person has angry or loving feelings for someone else in the group, not expressing these feelings is keeping a secret. Similarly, not expressing desires or critical opinions is a form of lying as well. Truthfulness involves asking for 100 percent of what one wants 100 percent of the time.
This contract is especially useful to stimulate the full expression of feelings. It encourages the honest expression of opinions and feedback. It is an ideal testing ground for asking for what one wants and for not Rescuing. It provides the necessary trust and feelings of safety that are essential for the open and honest discussion of all the facets of one's life right down to the most embarrassing.
Cooperative contracts, together with each member's individual contract, are a powerful social structure within which people can radically improve their lives.
Chapter 17; Sobriety
After making a contract, a person who has decided to deal with her alcoholism must concentrate on stopping the use of alcohol altogether. Most people who are alcoholic realize that they have become powerless over alcohol and that the best approach to their problem is to stop drinking entirely. This realization is arrived at through an honest evaluation of the lack of success of previous attempts to deal with their drinking. Many people with drinking problems have also had contact with Alcoholics Anonymous and have come to see the one universally accepted truth in alcoholism work: You can't fight alcoholism while you are drinking.
People who have come to accept this commonsense fact are at a distinct advantage over those who still hope that they can deal with their alcoholism without giving up alcohol. Nevertheless, there will be people who will want to cut down their drinking instead of stopping altogether. They may have not seriously tried to stop drinking and imagine themselves still in control.
When a person insists that he wants to try to deal with his alcoholism without abstaining entirely, it is very important for the therapist to respond effectively to this understandable desire. The most effective response is one which succeeds in communicating the very important facts of "cutting back" while drinking and at the same time avoid the parental, persecutory, uptight authoritarianism which alcohol workers usually fall into in that situation.
This is a good place to discuss the concept of "loving confrontation" the ideal combination of therapeutic transactions which are most effective in working with alcoholics and, indeed, in any interpersonal working situation.
Loving confrontation
A client who seeks therapeutic help chooses a certain therapist presumably became he thanks that the therapist knows what he is doing. Thus it makes sense that the client wants to be presented with the facts as the therapist sees them.
Loving confrontation, is an attitude that shares some components with "tough love" a more recent concept that has become popular in the "helping professions." Tough love is associated with "Just do it!" another attitude applied to people who people who "need help." Both are attempts to avoid co-dependency; to help without Rescuing. Their effectiveness depends on the level of sympathy and empathy that is included in the help given.
If the therapist thinks that it is very difficult-if not impossible-to stop alcoholism by just cutting down then presumably the client would like to hear that, along with whatever other useful information the therapist has
However, alcoholic clients are often reluctant to accept that they must stop drinking completely in order to succeed. That reluctance may have more to do with the way the information is transmitted than with the information itself.
Granted, alcoholics usually secretly hope to hear that it is possible to have one's drink and beat alcoholism at the same time, but they don't mind being confronted with the facts as long as the information is presented in an acceptable manner. Nobody likes to have facts-no matter how correct-shoved down one's throat, unfortunately, therapists often give clients their opinions in a supercilious, parental, and generally obnoxious manner. It is possible to present information from a strictly Adult, scientific perspective, backed up by a Nurturing Parent emotional attitude. Accordingly the therapist might say:
"As you probably know the largest majority of the people who have attempted to deal with their alcoholism without stopping entirely have failed. It would seem that your chances are not much better."
This is a "Confrontation'' statement coming from the Adult of the therapist. It is certainly an improvement over the following statement, which comes from the Critical Parent.
"It is ridiculous for you to think that you can stop being alcoholic without stopping drinking entirely. I have never seen it done, and I don't expect you to be the first do it. You'd better do it the way everybody else does it. You can't afford to be special at this point in your life. Stop feeling sorry for yourself and just do it!"
This approach is liable to antagonize the client-and rightfully so, since it comes from the therapist's Critical Parent. Its wording and tone are going to stimulate the client's anger, guilt, shame, rebelliousness, or some other negative emotion, which can only lead to confusion and lack of success.
However, the proper mixture of factual confrontation with a nurturing emphasis and tone is the most effective in this situation:
"Look I can understand that you would like to continue to drink on occasion while you are trying to overcome your problem. Unfortunately, I don't believe it can be done. (Nurturing) My experience shows that only a very small percentage of people have been able to do it (Confrontation) and while I am not necessarily sure that you can't, I just think it would be a lot easier if you stopped drinking altogether. (Nurturing) What do you think? Do you think you can cut down? I don't" (Confrontational.)
Another approach might be:
"Listen, you may not realize this, but you are powerfully addicted to alcohol (Factual Confrontation) You probably wish that this wasn't so, and that you could feel more powerful in the situation and cut down gradually. I can understand that very well, (Nurturing) but the fact is that it is virtually impossible to do that. (Confrontation) Why don't you make it easy on yourself and just stop altogether? I'd hate to see you spend the next three months in all that useless agony. (Nurturing) And frankly it will make my life a lot easier too" (Confrontation)
For anyone who is addicted, the notion of having to stop completely is usually quite frightening. After all, the drug offers some pleasure or relief, and life is hard enough without giving up what seems to be its major pleasures. More important, though, someone who is addicted fears that stopping completely and abruptly might be extremely difficult and could become a horrifying struggle, ending ultimately, in failure. The need for complete sobriety reminds alcoholics of their helplessness, their fear of failure, the dread of being powerless and being shown up to other group members, friends, family and the therapist as lacking in will and self-control.
In addition, alcoholics don't often comprehend the magnitude of their addiction. Hence they blame themselves for their incapacity to stop, and they feel weak and gutless. Instead, they should realize that they are in the jaws of a veritable steel trap. That is why a nurturing, understanding approach is essential.
Therapists should not sit in judgment. They need to be sympathetic to the plight of the addicted person, and that sympathy is shown by avoiding a supercilious parental attitude as well as a cold and unemotional Adult attitude which simply serves up the facts without any feeling. Information is important, but information alone does not constitute the most elective form of therapy. On the other hand, love is not enough either. Information and love (Adult and Nurturing Parent) are both powerful aspects of therapy, but they are most powerful when they are offered to the person together in loving confrontation.
After mentioning the unlikelihood of success unless complete sobriety is achieved for at least one year, it is important to negotiate the agreement between the therapist and the client. If the client insists that she wants to "cut back" then I am usually willing to give it a try with the understanding that her effort will be evaluated after a few weeks. If it is not successful, I warn her, I will insist that she stop completely.
"Mary, I have not seen this approach work with someone as addicted as you, even though a lot of people want to try it to begin with. But I'm not going to stand here and tell you that you can't do it because you may be one of the few people who can. If some people have stopped being alcoholics by just cutting back, I have never experienced it. I'd rather you didn't but, if you insist, let's give it a try."
"Work at it for the next month. Let's say that you will restrict yourself to a total of seven ounces of alcohol per week for the next week, one a day maximum. We will talk about how you are doing at the next meeting, and I hope you succeed. Let's try it, but I want you to agree that if your drinking gets out of control you will let me know and proceed to try to stop drinking completely."
The client may want to drink a different quantity over a different period of time, that can be negotiated as long as the amount that is consumed clearly qualifies as social drinking. What is important: an attempt is being made to cooperatively negotiate on the basis of the therapist's and the client's points of view. This mutually respectful, cooperative approach may seem inefficient but, in the end, because it avoids power plays, it is the one that builds the kind of trust and mutual respect that is essential for good results.
Loving confrontation avoids Persecution on one hand and Rescues on the other. It is loving without being mindless, and it is and confronting (or tough, if you will) without persecuting. It cultivates mutual love and respect. And it works.
Antabuse
Clients who recognize the importance of stopping drinking entirely and who expect difficulty can be helped with disulfiram (Antabuse). Many people accept this offer without hesitation. Antabuse is a drug which in combination with even small quantities of alcohol, produces extremely uncomfortable symptoms with a susceptible person; if a lot of alcohol is taken, the alcohol/Antabuse combination can even lead to death.
Antabuse should be taken every day. Because it remains in the body for as long as seven days, it is an effective deterrent against the impulse to drink since drinkers have to plan days in advance if they wish to start drinking again.
Antabuse can be used in a number of ways, some of which are completely ineffective-if not harmful-in helping people overcome alcoholism. Most ineffective is forcing the alcoholic to take Antabuse eider by putting it in his food or through a more subtle form of power play. This approach may work as long as the therapist or his agents are capable of forcing the drug into the client's body, but inevitably it will create antagonism and resentment. As soon as an opportunity presents itself, the client will be compelled, due to justifiable pride-if for no other reason-to go on a bender with all possible speed.
To illustrate the total ineffectiveness of this type of coercive approach to drug abuse, let's look at Nick a borderline alcoholic who got into serious alcohol-related trouble with the law. To his great shock, he ended in jail with a nine-month suspended sentence. Nick is a reasonable man who understands that he has a drinking problem. He feels he needs to do something about it. During the nine months of his sentence which was seen by the authorities as a period of "rehabilitation'' he was forced to attend AA meetings and to take Antabuse. He took his Antabuse and attended AA meetings without protest. Nick is a D&P player, and I expect him to eventually deal with the problem and stop drinking excessively. But throughout the nine months he said that the very first thing he would do once the sentence was completed, was stop taking Antabuse and get drunk. When I asked him why he would plan such a thing, since alcohol was a problem for him and that this might be a very bad way of using his reprieve, he pointed out to me that it was a matter of simple red-blooded American pride. He would deal with his alcoholism later-but the first thing he would do as soon as he could was to get drunk, and there was no two ways about it.
Nick spent the nine months that were supposed to serve as rehabilitation designed to launch him on a drug-free way of life, planning day by day and hour by hour how drunk he would get, what he would drink, and whom he would drink it with.
Forcing Antabuse (or any therapy) on people does not help, but Antabuse can be extremely helpful to a habitual drinker who wants to be rid of the constant, nagging temptation to drink which is so characteristic of the beginning stages of sobriety. Antabuse has no direct effect on the desire to drink, but because the possibility of drinking is completely excluded, it basically frees the alcoholic's consciousness from the ongoing struggle between his desire to drink, and his decision to stop drinking. For some people, the elimination of this constant internal struggle can be a blessing; their minds can be occupied with other matters, and drinking becomes a much less dominant thought, which has to be dealt with only on occasion and which gradually recedes in its power to flood consciousness without warning or control.
If over the first few months of sobriety whenever the alcoholic thinks, "I want to have a drink" there is another, automatic thought that says, "Forget it-you'll get sick" the frequency and intensity of the desire to drink will be dramatically reduced. That does not mean that there will not be periods of time in which the alcoholic will have intense conflicts dealing with drinking and at which time he may consider stopping Antabuse so he can have a drink a few days later. But it can be clearly seen how this is a large improvement over the situation in which relief is only a swallow away.
This is how Antabuse was administered at the Center for Special Problems, a public health clinic in San Francisco where I worked as a psychologist in the 1970’s. With very few exceptions, any person who wanted Antabuse was prescribed the drug. People were refused if they had a recent history of its misuse or a medical condition that makes an Antabuse reaction threatening-more threatening than alcoholism itself. After appropriate warnings, the drug was dispensed. No attempt was made to produce the Antabuse reaction in the clinic. The initial dosage was 5|mg. (1 tablet) per day for seven days, which was then cut down to 2 mg. per day. With this approach there were no known deaths or severe reactions
A few patients on Antabuse will experiment by drinking a small quantity of alcohol just to see if the can. Most of them are quickly convinced of the drug's effectiveness and stop experimenting. On occasion, a patient reports such a small effect that he was able to continue drinking on top of Antabuse. In such cases, Antabuse therapy should be discontinued. Antabuse has a few unpleasant side effects, such as a strong garlicky breath, and this is another reason why people resist its use. These side effects can usually be eliminated by taking the daily dose just before going to sleep, at night, and by reducing the dosage to 1 mg (1/4 tablet) Usually the people who have strong reactions to the side effects also have strong reactions to the drug itself and do not need the larger dosage.
Men more often resist taking Antabuse than women. Men-more than women-feel that it is embarrassing and shameful to be out of control. I will always respond in an understanding manner to these feelings. But I will also explain that a person need not be ashamed of needing help, and that the best way to work on problems of this sort is by using as much help from as many sources as possible.
I also explain how sex-role scripting forces men to go it alone, without help, and how it is important to reject those expectations to profit from group therapy. But if an alcoholic insists that he wants to try to stop drinking without Antabuse, I would avoid arguing and would steer clear of the persecutory stance implied. I try to come up with a cooperative, negotiated agreement.
If sobriety cannot be achieved without the Antabuse within a reasonable period of time, however, I will insist that Antabuse be taken. This discussion could seem puzzling or even nebulous to some therapists who may say to themselves, "This approach is based on having an alcoholic who is willing to stop drinking. But the very nature of alcoholism is that the person cannot or does not want to stop drinking. It wouldn't work with somebody who is a real alcoholic. This approach is of limited value and doesn't deal with the real problem of alcoholism."
Of course. Only those who want to stop being an alcoholic will stop being an alcoholic. But there are many alcoholics who would like to and simply do not believe that they can. They have tried and failed. They have had violent withdrawal symptoms, they have given up over and over, and they have gone back to Devil Alcohol. They know that alcohol is destroying them, but they have developed a fatalistic, defeated attitude. This attitude may include arguments defending their right to drink on occasion or arguments minimizing the severity of their problem. But these are rationalizations which easily give way under the pressure of loving therapeutic confrontation. This approach brings to the surface the alcoholic's desire to stop drinking if it exists, and it exists in the great majority of alcoholics.
Most people who come for help will stop drinking completely within a month or two of attending therapy sessions. There is always a smaller group who agree to the contract but do not stop drinking, and they fall into two categories. One group continues to drink more or less continuously and attends meetings under the influence of alcohol. The other group reduces its drinking input and confined it to weekends or between sessions, they are sober during group meetings but drink in between.
The client who continues to drink steadily and attends therapy session under the influence of alcohol should be told that it is impossible to do psychotherapy under those conditions. Still, I always insist that he attend whether drunk or sober, and when he does, I make it a point to be friendly and nurturing, to ask how he feels, what his week has been like, and the extent and quantity of his drinking during the week. I will encourage him to speak about how he feels, since a person who is drunk is often in touch with emotions that are hidden when he is sober. This material can become important information for future therapy. However, I will not give advice or engage in discussions dealing with the reasons for drinking or any of the debates that alcoholics are fond of getting into-especially when they are drunk. I make sure that the inebriated client does not monopolize the session or take more than his fair share of time, and limit myself to being friendly, nurturing, concerned, and clearly insistent that the client come to group sober next time. I refuse to do Adult, "rational" work with a drunk alcoholic because it won't have any lasting effect; his Adult is out of commission. I do, however, try to convey a message of empathy and support which will penetrate that alcoholic fog and make an impression on his Child
The alcoholic who drinks between meetings presents a different problem, since he drinks and keeps the therapist in the dark about it. This type of alcoholic usually plays D&P and puts the therapist in the role of the Victim/Patsy. By concealing the facts of his drinking, he finds out whether the therapist is experienced enough to pursue the matter and confront him; the therapist who doesn't will probably be completely ineffective.
While working with an alcoholic who is still drinking, the therapist should make sure that she remains aware of the quantity and extent of the drinking. This is accomplished by uninhibited questioning and by being open to whatever information may be volunteered by employers friends and relatives. Because awareness is the best defense against becoming a Victim/Patsy, employers, friends and family are encouraged to communicate with the therapist. This is done openly, with the understanding that information will, not be divulged without the alcoholic's permission.
In this manner, confidence is preserved while awareness is maximized. Many therapists treat their client's relatives with aloofness verging on contempt. This attitude is usually rationalized as necessary to preserve confidentiality and trust, but it is really persecutory and wholly unnecessary. Instead, it is best to accept information as offered with the proviso that it mast be evaluated and used with caution.
When the therapist refuses to play Victim/Patsy and continues to focus on the client's drinking he plays the antithesis to the Alcoholic game and thereby makes it possible for the alcoholic to choose an alterative to game playing. Eventually the alcoholic will either cease drinking entirely within three months or will frankly admit that she is not interested in changing her drinking behavior and will discontinue treatment. To date, a very small portion approximately 10 percent) of alcoholics who have joined one of my groups realize that they don't want to quit drinking, openly say so and discontinue treatment.
Chapter 18 The Newly Abstaining Alcoholic
Once an alcoholic has stopped drinking, treatment takes a dramatic turn since, until then all efforts are addressed primarily to the problem of helping him to stop. The first consequence of completely stopping drinking is the physical withdrawal period. The withdrawal can take the form of severe withdrawal sickness or mild discomfort depending on a number of factors that affect how toxic the alcoholic body has become.
The end of the withdrawal detoxification period is normally followed by a lull lasting about two weeks-sometimes less-during which the alcoholic feels very strong and confident. He is sure he will never drink again is in good spirits; this is the well-known period when the alcoholic is "on the wagon" and feeling "on top of the world." From the point of view of script theory this period could be the beginning of a true script change or merely the "counterscript" within the script. The distinction is explained later in this chapter.
If sobriety continues a profound change in the quality of the person's consciousness will occur which can cause what I call "withdrawal panic." This withdrawal panic is particularly pronounced in people who have had a long history of uninterrupted drinking. Withdrawal panic should be distinguished from withdrawal sickness.
Both of these crises result from alcohol withdrawal, but the withdrawal sickness is mostly physiological: a bona-fide medical condition (especially in the extreme case of delirium tremens or D.T.'s, which is potentially fatal and may require hospitalization). The withdrawal panic comes two or three weeks later; and while it may have a subtle physical basis, it is primarily a psychological phenomenon.
Withdrawal panic may occur with or without withdrawal sickness and not all persons who stop drinking undergo a severe withdrawal panic. People who do-and who are not on Antabuse-are likely to drink at this time. If they do not drink, they may become obsessed by thoughts of drinking and constantly struggle against these thoughts. This struggle can completely flood consciousness and obscure the subtle mental changes that result from an alcohol-free nervous system.
Interestingly, people who take Antabuse and are therefore usually free of the desire to drink are more likely to become aware of the change caused by the absence of alcohol in their bodies. As an example of these subtle changes, one patient reported waking up in the middle of the night with uncontrolled thoughts racing through his mind, which somehow threatened to cause a mental explosion or breakdown similar to a short circuit in a computer. He felt extremely aware of minute bits of his wife's behavior, or of having special insights into motives and conversations, or of seeing things such as trees and flowers in an alarmingly sharp and vivid way. Because of their newness and unfamiliarity all of these symptoms created great anxiety he interpreted them in malignant terms; he felt as if he were about to lose his mind.
Some therapists analyze these reactions as evidence that alcoholism is a defense against the breakthrough of an "underlying psychosis." The theory that alcoholism often serves to protect the alcoholic from a preexisting psychoses is based on the observation that some alcoholics exhibit alarming psychotic-like symptoms such as auditory hallucinations or paranoid states even after the withdrawal sickness is over. A finding that further supports this theory is that it seems that some alcoholics are helped to maintain sobriety with the help of phenothiazine, "antipsychotic" drugs.
These alcoholics are thus thought to be basically psychotic and only incidentally alcoholic. This determination may have several outcomes, the patient may be henceforth ignored as incurable, maintained on drugs, but otherwise ignored, or he may even be "allowed" to go back to drinking, since, it is argued, alcoholism is the lesser of the two evils.
I believe that any diagnoses of an underlying psychoses is not to be made lightly. I always assume that such symptoms are temporary and will subside, usually within six weeks.
This was the case with the person described earlier and for many others who have gone through similar symptoms under my care. The vast majority of patients who go through symptoms of this sort are in the grip of a withdrawal panic and are not psychotic at all. They are experiencing an alcohol-free state which is so unfamiliar that it is frightening and difficult to comprehend. If the symptoms persist after three months of sobriety, considerations of underlying psychosis become reasonable.
From the point of view of his script, a man who stops drinking is going against the parental injunction that he not use his Adult, and that he not think. While he is drinking, he is in a Child ego state, which is going along with the injunctions of his Parent. The withdrawal sickness and consequent feeling of well-being are a period in which the Parent ego state runs the show and during which the Child willingly stays out of the picture. Withdrawal panic represents a gradual return of the fully functioning Adult ego state; this clear-thinking state of mind is unfamiliar and is a frightening development. It is a mode of functioning which was strongly enjoined against and disapproved of by the alcoholic's parents. He may never have experienced it until now. At this point the patient needs protection and strong reassurances that he is OK and not going crazy and that he is experiencing an Adult ego state free of alcohol, Within a month or two, he will become accustomed to it and will be able to assimilate this new view of his world. Such reassurances are usually quite effective in countering the panic. Accordingly, the use of medication is strongly discouraged unless it is absolutely necessary. Instead, in addition to reassurance, soothing teas, hot baths, massages, and other relaxing activities are recommended.
Other symptoms observed during the withdrawal panic are dizziness, loss of balance, insomnia, mental anguish, nightmares, extreme colds extreme hunger, pain, blurred vision, and feelings of being clairvoyant or telepathic. Whether these symptoms are low-level remains of withdrawal sickness or whether they are purely psychological in nature is unclear. In any case they are reasonable sequels to withdrawal from long-term alcohol abuse. Similar combinations of physical and psychological symptoms characterize withdrawal from psychiatric drugs like SSRI antidepressants and especially benzodiazapines (Librium, Valium, Xanax, Halcion, etc ) which can last as long as one year and involve pain and severely disorienting neurological symptoms. These withdrawal symptoms need to be patiently endured; the good news is that nature’s helping hand will eventually bring the body into healthy drug free equilibrium.
Alcohol alone has a relatively short period (weeks rather than months) of withdrawal symptoms. Following the period of withdrawal panic (if the patient does not escape from it into renewed drinking) there is usually a "honeymoon" in which the patient becomes accustomed to the drug-free Adult ego state and during which he feels genuine relief and well-being. The honeymoon tends to include freedom from games and intense script behavior, and may last as long as three months. However, it can be expected to subside, and even though the patient may remain sober, the games which are linked to his specific game of Alcoholic and script-whatever it is-will begin to manifest themselves.
Many alcoholics find that when they stop drinking and choose to remove themselves from their alcoholic circle they become isolated and lose the important sources of strokes that they had when they were drinking. The depression resulting from this loss of strokes is a very common problem at this point and action needs to be taken to generate new stroke sources. Everyone who has been an alcoholic and has stopped drinking will be faced (as is anyone who gives up a major game) with an existential vacuum relating to the many hours each day that need to be structured and which cannot be structured as they were when they were drinking. Alcoholics who stop drinking often attempt to continue structuring time in familiar ways by going to a bar after work and drinking soda water. Others who are aware of the problems associated with structuring time in old alcoholic ways, may find themselves completely at a loss and unable to find satisfactory new methods.
A therapist who proposes to help must aid in finding ways to structure time as part of the sober alcoholic’s homework. For one patient, a schedule of activities was constructed to cover every waking hour, a week at a time. Another patient whose drinking started as a way of overcoming painful shyness was afraid and reluctant to contact friends and was encouraged to make several phone calls during the group meeting to arrange various activities and dates.
For married people with children, there is usually an increased positive interaction corresponding with the "honeymoon" period after withdrawal. This eventually yields to a period in which it seems that the members of the family not only expect-but almost seem to wish-that the alcoholic would resume dinking. This phenomenon is easily understood when we remember that alcoholism is a game that requires several players; the wife and children of the alcoholic are usually full participants in the game and feel a vacuum in their own lives when the alcoholic stops drinking similar to what is felt by the alcoholic himself. Thus, the alcoholic in a family might feel an even stronger urge to drink than a person who can leave his "game" social circle behind. In addition to his own internal compulsion to drink, he will feel the pressures applied by his family.
Because the healing of a married alcoholic requires simultaneous changes in two or more people in his or her circle, it almost seems at times that the single alcoholic has a better prognosis. However, the very real difficulty which is added for the alcoholic by the presence of a family is usually overshadowed by the positive support that families are able to provide. I have sometimes thought that a certain alcoholic might profit by a separation or divorce from her spouse because of the difficulties mentioned above, only to find, if the problems are worked through with the family, that the family is a great adjunct to the person's health as a source of strokes and as a basis for existential meaning. Sometimes, however, the family really pushes the alcoholic to return to drinking and a cure may require a separation between the two partners.
People who achieve sobriety by taking Antabuse generally want to stop taking it within six months. After six months of sobriety without a desire to drink most feel that it should no longer be necessary to take Antabuse. They yearn for the feelings of autonomy and self-determination that are implicit in not having to rely on the drug.
This desire should be regarded with caution and even suspicion. As soon as Antabuse is discontinued, alcoholics will almost always return to think about drinking, which may start them drinking again. I will weigh in on the side of caution and suggest that they extend the Antabuse use for another six months to insure the indispensable year of sobriety.
However it has been my experience that every alcoholic drinks again after some months of sobriety, regardless of my opinion. In the context of ongoing group therapy, this episode need not be disastrous, but may actually refresh the patient's memory about the realities of drinking. Except for the alcoholic who goes on an extremely self-destructive binge, one or perhaps two such relapses can have some positive educational aspects. The nature and extent of the drinking episode is usually a good indication of whether the therapy is having any effect. Generally, these episodes are shorter and less severe than the previous episodes, and this represents improvement In Adult control. A binge which is as bad or worse than previous ones indicates that therapy has not been effective and that the patient is only making superficial "progress" with no real changes in Adult control. People who are improving will emerge from the episode considerably wiser; they will have had a chance to review the different aspect of their drinking in a situation of improved Adult awareness and control; an experience that invariably proves to be sobering. However, for effective healing a full year of sobriety needs to follow after the alcoholic has anything to drink.
Two important events in the sober alcoholic’s life; deciding to discontinue Antabuse and/or having the first "social" drink after a long period of sobriety,(even against the therapist’s advice) are regarded as a public declaration by the alcoholic that he is no longer an alcoholic and is now O.K. Because it flies in the face of his Enemy (who says he is not-O.K.) as well as the beliefs of many recovered alcoholics and of AA (who say it isn't possible), these events are always potential trouble spots.
The therapist has to treat such landmarks with finesse, since he is neither a Patsy who blandly accepts renewing drinking as a harmless act, nor a Persecutor who predicts certain doom. The best attitude is the Adult wait-and-see, backed up by a promise of Protection no matter what happens. In any case I much prefer to be informed by the alcoholic about his intentions to have a drink or to stop Antabuse than to find out that he did when he gets drunk and calls me in the early morning hours to tell me.
The counterscript
As we know, people operate under the compulsion of scripts. Alcoholism as a script compels the alcoholic to uncontrollable drinking and self-damaging behavior. But there always are periods in the life of the alcoholic when she is not drinking or being self-destructive.
These periods are interesting because they bring up the question of cure. Between alcoholic bouts no one really knows whether the person has really changed into a nonalcoholic. Only time can tell whether the script is just dormant, waiting to re-emerge in full bloom, or whether it has been abandoned.
The counterscript is that period within a script during which the person is temporarily not following the most obviously damaging requirements of the script. During this period, the alcoholic is sober, content, and productive, but has not given up the script, which will return inevitably unless it has been truly been given up.
AA's point of view would argue that the alcoholic can never give up the script and that any periods of sobriety are merely a temporary counterscript. But my observations of alcoholics indicate that people who were once excessive drinkers who are no longer drinking come in two categories; some people give up the script; some are merely in a counterscript phase of the alcoholic script.
Berne pointed out that the most convincing evidence of script change for an alcoholic is a protracted period of moderate, social drinking. However, since many cured alcoholics lose interest in alcohol, this criterion is not always available. In general, the loss of preoccupation with alcohol--the alcoholic pastimes, or the game in any of its roles--is a good criterion as well. A radical change in time structuring and the development of avenues of stroke procurement and enjoyment without alcohol are crucial indicators of a script change. In addition, an often subtle change in the physical appearance of the alcoholic is a reliable index though difficult to assess. The alcoholic in a counterscript is tense, anxious, "up-tight" even when smiling and enjoying himself, as if constantly on the brink of relaxing and letting go, which he feels he can't do for fear that the script will take over. The cured alcoholic lacks this "on the brink" quality and therefore looks and feels quite different (relaxed, comfortable around alcohol) from the alcoholic in a counterscript.
However, I must warn the reader not to take this section too seriously--especially if it means that he or she is going to use the information to try to diagnose any one person's sobriety as being a real script change or merely a temporary counterscript. That type of analysts of other people's lives is presumptuous and meddlesome. Aside from the fact that it can lead to the wrong answer, it is also of very little use. This is why I mention it only as an afterthought. Sobriety is the first step for an alcoholic and it is clear that it is hardly ever enough. Many changes have to follow sobriety for alcoholism to be completely cured. These change are what we are interests in; whether a person is really cured is nobody's business but his own. Only he can answer the question, and then only to himself.
Chapter 19. Fighting The Enemy
* In a lively class discussion, Marge is asked a question by the professor. She is convinced that everyone is smarter and better read than she. She fears that her teacher will find out that she is a fraud and her mind becomes a blank as her whole body is frozen with panic.
* Doug hears voices in his head every time that he has an interaction at work: "Can't you see how weird and awkward you are? Every one else does!"
* Whenever Charlotte makes phone calls to sell customers her company's services, her heart beats wildly and she is filled with dread. Yet she has developed a system with which she manages to appear calm and self-assured. She suffers of constant stress-related headaches.
* When he approaches a woman he likes, Jacob has overwhelming emotional responses and expectations of ridicule. On the other hand he is unable to be affectionate and ask for the affection he wants when he is in a relationship.
* Hillary is in constant fear of danger; danger of bad food, bad air, dangerous people and risk of being stalked and raped. She performs complicated, extremely time consuming steps to keep her safe and has to limit her activities radically.
* Almost every night Daniel wakes up and spends long periods of sleepless time tossing in his bed while plagued by fantasies of bad things that could happen next day. He is unable to control his doom-ridden thoughts even though his fears fail to materialize. He is often tired and sleepy in the middle of the day at his high-tech, high achievement job.
* Sally lives under a cloud of sadness. Every so often she cries uncontrollably and for no reason and is convinced that she is doomed