Issues in managing an alcoholism caseload.

Alcholism is a disease that crosses all social, economic, ethnic, racial, and geographical lines. Estimates on its prevalence in the United States vary from 4% of those eighteen years and older to 10% of the males and 5% of the females eighteen years and older (Gallant, 1987). A 1978 Gallup Poll asked the question, "Has liquor ever been a cause of trouble in your family?" and 24% of those queried responded positively (Apthorp, 1985). There can be little doubt that rehabilitation counselors will encounter persons who have this disease. Whether counselors have a general caseload to manage, or a specialized caseload of clients whose disability is alcoholism, there are certain issues related to alcoholism that must be addressed for effective case management.

Such issues may be divided into four general areas, as illustrated by Figure One. First, there are issues concerning a counselor's personal experience with the disease and the subsequent perceptions and reactions to persons with the disease. Second, the disease of alcoholism affects all family members. The involvement of the client's family members in the disease process and in the rehabilitation process will be a source of issues to be evaluated. Third, alcoholism entails issues affecting the client's employment history (e.g., multiple positions, unfocused future, and lack of acceptable work habits). Finally, there are issues specifically relating to the client. These relate to the chronic, progressive and potentially fatal nature of the disease of alcoholism.

Counselor Issues

The first area of discussion focuses on issues arising from the counselor's personal experience with the disease. One of the realities about alcoholism is that it is characterized by highly charged emotional undercurrents--everyone has an opinion. These undercurrents may manifest themselves in both personal and social ways.

The counselor should begin by looking to his or her own experience with alcohol and alcoholism. This personal evaluation can begin with some basic questions. Did the counselor grow up in a home where one or both parents were alcoholic? Is the counselor married to an alcoholic? Does the counselor have reason to be concerned about her or his own use of alcohol? Is the counselor a recovering alcoholic? Is the counselor currently abusing alcohol? Affirmative answers to any of the above questions should be warning flags for the counselor. The counselor's effectiveness with clients with alcoholism may be determined by a personal experience with the disease. This same awareness also applies to counselors who grew up in a dysfunctional family of any description. The estimates are that one in three helping professionals are adult children of alcoholics, because helping others is an easy and natural role for adult children. These persons had family roles of care-takers from an early age, and it was an easy transition to teaching and helping professions (Anonymous, 1988).

It is possible to believe that a person should be knowledgeable about working with persons with alcoholism, because they grew up in a home where alcoholism was present. As with so many factors related to alcoholism, the obvious and logical cannot be taken for granted because of the dysfunctional thinking that grows out of the dysfunctional family system. In some ways the least effective counselor, whether an alcoholic or the adult child of an alcoholic, is the one who has not acknowledged and dealt with a personal history with alcoholism. Anonymous (1988) warned that "our early experiences in alcoholic homes may have caused us to develop attitudes and to exhibit behaviors that actually impede the work of the school [or rehabilitation agency] in substance abuse prevention and recovery (p. 22)." It is easy for the counselor to become a professional enabler, making it possible for clients and colleagues to avoid the consequences of their addictions (Anonymous, 1988). If a counselor is to work effectively with clients who are alcohol abusers, then that counselor must come to terms with personal and family history.

There are numerous community and learning resources available for persons with a personal or family history of alcoholism. The most well-known programs are Alcoholics Anonymous and its derivatives (e.g., Narcotics Anonymous, Al-Anon, Nar-Anon, ACOA/ACA (Adult Children of Alcoholics), CoDA (Codependents Anonymous)). Information about these Twelve Step programs and meeting times and locations are available through the local AA Hotline (the number can be found in the telephone directory).

There are a number of excellent books available about alcoholism, chemical dependency, and the many variables involved. The writings by Janet Woititz (Adult Children of Alcoholics, Home Away From Home), Claudia Black (It Will Never Happen To Me!), Sharon Wegscheider-Cruse (Choice-Making), Melody Beattie (Codependent No More), Earnie Larsen (Stage II Recovery: Life Beyond Addiction), Vernon Johnson (I'll Quit Tomorrow), George Vailant (The Natural History of Alcoholism), and Donald Gallant (Alcoholism: A Guide to Diagnosis, Intervention, and Treatment) are all excellent beginning points.

There are primary treatment programs (inpatient, outpatient, and residential) for alcohol and drugs, co-dependency, eating disorders, adult children of an alcoholic and dysfunctional family. Information about alcohol and drug treatment centers may be obtained by calling the different centers in one's area. These treatment centers, will be listed in the telephone book. Again, the local AA Hotline can be valuable resource for treatment center information.

Opinions about alcoholism are also expressed in a social setting also. It is only within the last generation that the American Medical Association has recognized alcoholism as a disease. In the collective understanding of American culture, alcoholism previously was seen as a moral weakness. This perception lingers today in more subtle ways. It is not unusual to hear statements like, "I really don't like those alcoholic people. They should do something about their drinking."

One of the perceptions of alcoholism that is common in society is that the person who is alcohol dependent is morally weak. Alcoholism is seen also as willful misconduct by some persons, institutions, and organisations. "Alcoholism, [is] a medically accepted definition that carries no moral judgements. To that end, we can be most effective if we understand alcoholism to be a primary, progressive, chronic, and fatal disease...alcoholism is not a symptom of a more serious problem (Apthorp, 1985, p. 57)."

The consequences of such a perception of alcoholism result in marginal treatment opportunities, limited support of the client who is in recovery, and denial of the magnitude of the disease's power over the client's life--past, present and future. It is also a pessimistic view for ultimate recovery through treatment and rehabilitation. To hold such a position is not unlike saying that the person with diabetes or cancer has developed their disease because they chose to do so. The surest cure for such a perception of the disease is continuing and continual education on alcoholism and drug addiction, both for counselor and the community.

Family Issues

The second area of discussion includes issues related to families. Alcoholism does not exist within a vacuum, for it is a disease shared by the whole family. It is often described as a family disease. The type and extent of family members' involvement in the rehabilitation process will have definite effects on the way the counselor manages the case. Good family involvement is essential for successful rehabilitation. As with persons with other types of disabilities, the person who is an alcoholic will have family involvement across the full spectrum ranging from total rejection to overprotection and enabling manipulation.

One extreme of familial presence is alienation, rejection, or being disowned by one's family. The resulting sense of isolation and disconnectedness feeds the poor self-esteem that is often part of the client's psyche. Another expression is the family member or members who encourage alcohol abuse out of their own sickness. This arises when family members are alcohol abusers themselves, from a pathological need to maintain control, or from the multiple dynamics of codependency. Gallant (1987) maintains that:

Although there is no consistent family system or psychologic pattern that develops within families of alcoholics, the therapist working with alcoholics should be aware of a number of maladaptive behavioral patterns common to such families. The alcoholic has a profound effect on family members and other individuals closely associated with the family. Psychologic reactions to the alcoholic can vary considerably among family members, depending partially on the alcoholic's behavior while sober as well as drinking and partially on the family member's psychological state. (p.199).

The client's rehabilitation can easily be sabotaged by a family member determined to maintain a familiar family system. It even may be a wildly dysfunctional family system but it is one that is known. The operative principle is that known unhealthy behavior is better than unknown health. A family system naturally seeks the homeostasis, the balance, regardless of dysfunctional expression in order to reestablish a sense of peace in the family. This sense of familial peace is often false, unhealthy, and temporary, but in the dysfunctional perception of the family it is seen as normal.

The counselor's awareness of such actions by the client or client's family is essential. Awareness and action by the counselor may avert a situation that jeopardizes the rehabilitation plan and goals, and may lead to a loss of sobriety. In many ways, this is the most difficult area for the counselor because it is the one over which the counselor has little or no control. There are families who clearly are the greatest threat to the client's sobriety, recovery, and rehabilitation.

How does the counselor deal with such a situation? There is no easy or standard answer for this problem. The counselor may find that the client can best be served by leaving the home environment, and entering a half-way house. Referral to community mental health agencies, child and family services, private social service agencies, or private mental health providers may be the most effective path to follow. Here the counselor's developed network of community resources can come into play for the client's benefit.

Employment Issues

The third general area of discussion concerns issues revolving around the client's employment history, such as multiple positions, unfocused vocational future, and lack of acceptable work habits. Issues in this area relate to past, present and future employment obstacles. Employment and alcohol have a symbiotic relationship. Employment is often necessary to obtain the money to purchase alcohol, and alcohol significantly affects productivity in the economy.

Employee Assistant Programs (EAPS) came about in the 1940s in response to the needs of recovering alcoholics, who "returned to past employers and said, 'If you hadn't been so nice to us, we might not have lost our jobs and families. We know there are many other alcoholics in the workplace--will you let us start a program?''' (Watts, 1988, p. 11). EAP consultant Dale Masi found that, on average, public agency supervisors covered up for twelve years and private-sector supervisors for up to eight years for problem drinker employees. "It's much easier to close your eyes to problem employees, demote them, promote them, or put them on detail work." (Watts, 1988, p. 11). In the job development and placement portion of rehabilitation, the potential exists for finding employers who will be enablers of the client's disease by avoiding the tough love decisions that become part of recovery. Employers may be alcohol abusers themselves, and do not consider alcoholism a disease. This places the client in an environment that jeopardizes sobriety.

It is not unusual for a client, whose disability is alcohol abuse, to have a voluminous work history. The recovering alcoholic who has a career or a profession to return to after treatment is not often a client for public rehabilitation services. The type of client that the counselor normally encounters is an individual who has had multiple jobs in varied fields, but rarely for an extended period of time. They often have been terminated because of drinking. The typical client has a limited sense of their vocational future because little or nothing has happened to encourage forward thinking on these issues.

One of the clear strengths of rehabilitation counseling is its routine use of vocational assessment. A client with a spotty work history can well be served by vocational evaluation. This could include not only such factors as interest inventories, intelligent tests, and achievement tests, but also the person-to-person interview This evaluation process should not begin until the client is well into treatment, and is drug-free.

Counselors also must face the need for adjustment in client work habits. Interwoven within the client's poor work habits are recurring events of conflict with the boss and other persons in positions of authority. Absenteeism or laying out are undesirable traits, that are often a typical part of a client's work history because of the physiological effects of alcohol abuse. The client's referral to a work adjustment program may be an essential ingredient of a total rehabilitation plan. The counselor will have to determine the timing of training and adjustment according to local resources. Specialists in job placement and development can be an invaluable resource at this portion of the rehabilitation process.

Client Issues

The fourth area of discussion concerns issues that specifically revolve around the client. Once it was thought that someone was an ex-alcoholic or a recovered alcoholic as if there was a cure for the disease. However, the counselor needs to always remember that there is no known cure for the disease, and that a client will never become an ex but will always be recovering. The single most important goal for the client is to maintain sobriety by not doing things that would jeopardize recovery.

One of the important ways that the counselor may benefit the client is to understand the patterns of alcohol abuse that the client followed. Knowledge of this may provide necessary warning flags of possible relapse. The disease process and symptoms were defined by E.M.Jellinek (1942,1960) as having three stages. Stage I is the Early Stage in which alcohol is consumed socially (use). Stage II is the Middle Stage when a person becomes a problem drinker(misuse). Stage 111 is the Late Stage in which a person is dependent on alcohol (abuse). Another descriptive pattern maintains that there is a five-stage process leading to chemical dependency: (1)experimental use; (2)social use; (3) habitual use; (4) abuse; and (5) addiction.

Those reaching the final stage, the alcohol abuse client, are often children of an alcoholic home. They left a dysfunctional. home and moved into or created one that was equally dysfunctional. This familial unhealthy environment has provided clients with skills to survive in craziness but not in health. Such clients often will have great difficulty appropriately expressing emotions and feelings. Such clients may have their feelings so tightly under control that they truly do believe that they feel okay. They have a poor self-image, and their self-esteem will need constant attention. Further, clients will often prefer to be in the safety of the known past or self-structured fantasy of the future. It is often less painful to avoid the realities of the present. This is particularly characterized by denial of a problem. The significance of denial in the disease process of alcoholism is such that it is seen as one of the definitive symptoms. The counselor may be one who will assist the client in staying in the present, confronting client denial, and dealing with the realities of rehabilitation.

The physical deterioration that comes from chronic alcohol abuse could present additional complications for the counselor, particularly if the client enters rehabilitation in later stages of the disease. Counselor knowledge of the significance of relapse on the physical condition of the client is essential. The client who starts to drink again will not return to a pre-drinking stage, but will begin at the point where he or she was before the period of abstinence. There may be accelerated physical and mental deterioration with death an ever-increasing possibility. The physiological processes are unrelenting in their potential for deterioration.

This, if for no other reason, should merit the counselor's attention to the dangers of relapse. Relapse is an ever-present danger for a client, particularly during the first months of sobriety, but there are community programs available to support the client.

Considering the emphasis that is placed on the Twelve Steps of Alcoholics Anonymous in alcohol and drug treatment units, and the success of the program of Alcoholics Anonymous, it is appropriate for the counselor to be familiar with the Twelve Steps. The two books that contain essential information on Alcoholics Anonymous (A.A) and on the Twelve Steps are Alcoholics Anonymous (1976) and Twelve Steps and Twelve Traditions (1981). As stated above, additional information on AA and access to its many resources are available through the AA Hotline (see the local telephone directory). Though a person cannot be forced to be involved in AA, the client would well be served by participation. The AA Twelve Step program is the one that succeeds where others have failed.

Summary

To be effective in the management of a specialized alcohol abuse caseload, or to be effective with alcohol abuse clients in a generalized caseload, the counselor can benefit from viewing the issues in four areas.

Counselor issues-how the disease may have affected the counselor in the past or is affecting the counselor in the present.

Family issues-- alcoholism is a family disease so the counselor needs to be attentive to familial interplay and its effect on the client.

Employment issues-- often the client will not have a good work history, will have poor work habits, and the counselor will have to work diligently in the development of the rehabiliation program.

Client issues-- the alcohol abuse client will come with a variety of inappropriate, immature, or unhealthy emotional patterns or responses, and the counselor will be part of the client's learning new and healthy ways to cope with daily living and in gainful employment.

Suggestions for Successful Rehabilitation

1. Require the client to make a commitment to abstain from all non-prescribed mood-altering drugs.

2. Have the client participate in an on-going treatment and recovery program (e.g., impatient or outpatient treatment at an alcohol and drug treatment center, AA meetings, Continuing Care/Aftercare after primary treatment).

3. Involve the client's family at all levels of the rehabilitation process.

4. Have the client develop a social system supportive of recovery (e.g., family, friends, other persons in recovery, employer, shop steward).

5. Have the client make a commitment to a daily structure that supports recovery.

6. Encourage the client to continue learning about the disease.

7. Encourage the client to look beyond self for the means and strength to continue in recovery-- in the tradition of Alcoholics Anonymous, this is one's self-defined Higher Power.

8. Develop clear expectations and consequences with the client regarding renewed use. Follow through on the consequences.

9. Develop clear expectations and consequences with the client's employer regarding renewed use. Follow through on the consequences.

Working with persons with alcoholism can be exciting, rewarding, and frustrating all at the same time. There will rarely be a dull moment in dealing with the myriad of issues arising from an alcoholism caseload.

References

[Alcoholics Anonymous World Services (1976). Alcoholics anonymous (3rd ed.). New York: Author. Alcoholics Anonymous World Services (1981). Twelve steps and twelve traditions. New York: Author. Anonymous. (1988). To help substance abusers, we must first help ourslves. Educational Leadership, 45(3), 20-26. Apthorp, S.P. (1985). Alcohol and substance abuse. Wilton, CT: Morehouse-Barlow. Baker, T.B. (1988). Models of addiction: Introduction to the special issue. Journal of Abnormal Psychology, 97, 115,-117. Cooper, M. L., Russell, M., & George, W.H. (1988). Coping, expectancies, and alcohol abuse: A test of social learning formulations. Journal of Abnormal Psychology, 97, 218-230. Feit,M.D. (1979). Management and administration of drug and alcohol programs. Springfield, IL: Charles C. Thomas. Forrest, J.L., Frances, R.J., Mooney III, A.J., Reilly, R.L., Ganz, S.B.,& Borders, C.R.,(1986). Identifying and motivating the alcoholic. Patient Care, 20,59-87. Gallant, D.M. (1987). Alcoholism: A guide to diagnosis, intervention, and treatment. New York: W.W.Norton. Jellinek, E.M. (1942). Alcoholic addiction and chronic alcoholism. New Haven Yale. Jellinek, E.M. (1960). The disease concept of alcoholism. New Haven: College & University. Nathan, P.E. & Skinstad, A.H.(1987). Outcomes of treatment or alcohol problems: Current methods, problems, and results. Journal of Consulting and Clinical Psychology, 55, 332-340. Niaura, R.S., Rohsenow, D.J., Binkoff, J.A., Monti, P.M., Pedraza, M., & Abrams, D.B.(1988). Relevance of cue reactivity to understanding alcohol and smoking relapse. Journal of Abnormal Psychology, 97, 133-152. Peyrot, M. (1982). Caseload management: Choosing suitable clients in a community health clinic agency. Social Problems, 30, 157-167. Schwartz, S.R., Goldman, H.H.,& Churgin, S.(1982). Case management for the chronic mentally ill: Models and dimensions. Hospital & Community Psychiatry, 33, 1006-1009. Vuchinich, R.E., & Tucker, J.A. (1988). Contributions from behavioral theories of choice to an analysis of alcohol abuse. Journal of Abnormal Psychology, 97, 181-195. Watts, P. (1988). Effective employee assistance hinges on trained managhers. Management Review, 77(1), 11-12.]