TREATMENT AND REHABILITATION OF THE CHRONIC ALCOHOLIC THE BIOLOGY OF ALCOHOLISM Volume 1: Biochemistry Volume 2: Physiology and Behavior Volume 3: Clinical Pathology Volume 4: Social Aspects of Alcoholism Volume 5: Treatment and Rehabilitation of the Chronic Alcoholic TREATMENT AND REHABILITATION OF THE CHRONIC ALCOHOLIC Edited by Benjamin Kissin and Henri Begleiter Division oj Alcoholism and Drug Dependence Department of Psychiatry State University of New York Downstate Medical Center Brooklyn, New York PLENUM PRESS • NEW YORK· LONDON Library of Congress Cataloging in Publication Data Kissin, Benjamin, 1917- The biology of alcoholism. Includes bibliographies and index. CONTENTS: v.I. Biochemistry.-v. 2. Physiology and behavior.-v. 3. Clinical pathology.-v. 4. Social aspects of alcoholism-v. 5. Treatment and rehabilita tion of the chronic alcoholic. 1. Alcoholism. 2. Alcoholism-Physiological effect. I. Begleiter, Henri, joint author. II. Title. [DNLM: 1. Alcoholism WM274 K61b] RC565.K52· 616.8'6'1 74-131883 ISBN-13:978-1-4613-4201-4 e-ISBN-13:978-1-4613-4199-4 DOl: 10.1007/978-1-4613-4199-4 First Printing - January 1977 Second Printing - April 1978 Third Printing - March 1979 © 1977 Plenum Press, New York Softcover reprint of the hardcover 1st edition 1977 A Division of Plenum Publishing Corporation 227 West 17th Street, New York, N.Y. 10011 All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher Contributors Frederick Baekeland, Department of Psychiatry, Division of Alcoholism and Drug Dependence, State University of New York, Downstate Medical Center, Brooklyn, New York Allan Beigel, University of Arizona College of Medicine; and Southern Arizona Mental Health Center, Tucson, Arizona Edward Blacker, Division of Alcoholism, Massachusetts Department of Public Health, Boston, Massachusetts Howard T. Blane, Division of Specialized Professional Development, University of Pittsburgh, Pittsburgh, Pennsylvania Sheila B. Blume, Alcoholism Unit, Central Islip Psychiatric Center, Central Islip, New York; School of Medicine, fjtate University of New York at Stony Brook, New York; Caribbean Institute on Alcoholism Dan W. Briddell, Rutgers University, New Brunswick, New Jersey; now at Munson Medical Center, Traverse City, Michigan Morris E. Chafetz, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Mental Health, Department of Health, Education and Welfare, Rockville, Maryland; now at Johns Hopkins University, Baltimore, Maryland David R. Doroff, Alcoholism Treatment Program, St. Luke's Hospital Center, New York Stuart Ghertner, Southern Arizona Mental Health Center, Tucson, Arizona Benjamin Kissin, Alcoholism Division, State University of New York, Downstate Medical Cmter, Brooklyn, New York v VI Contributors Barry Leach, Research Psychologist, New York; formerly Departments of Medicine and Psychiatry, The Roosevelt Hospital, New York Lawrence K. Lundwall, Department of Psychiatry, State University of New York, Downstate Medical Center, Brooklyn, New York Peter E. Nathan, Rutgers University, New Brunswick, New Jersey John L. Norris, General Service Board of Alcoholics Anonymous; Associate Medical Director (retired), Eastman Kodak Company, Rochester, New York Earl Rubington, Department of Sociology and Anthropology, Northeastern University, Boston, Massachusetts Peter Steinglass, Center for Family Research, Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine, Washington, D.G. Robert Yoerg, National Institute on Alcohol Abuse and Alcoholism, Depart ment of Health, Education, and Welfare, National Institutes of Mental Health, Rockville, Maryland Preface The present volume contains a large variety of treatment approaches to the long-term rehabilitation of the alcoholic, ranging from the biological to the physiological to the psychological to the social. The multiplicity of proposed therapies, each of which has its strong proponents, suggests that alcoholism is either a complex medical-social disease syndrome requiring a multipronged treatment approach or a very simple illness for which we have not yet dis covered the remedy. The latter may, indeed, be true, but we cannot use what we do not know and must use what we do know. We do, however, have the obligation to be responsible in our treatment, to provide the best that is known at this time, and to be discriminating in our prescription of appropriate treat ment for individual patients. If there is one conclusion we would like to offer in our preface, it is that alcoholics constitute a markedly heterogeneous popula tion with widely disparate needs, for whom, at least at our present level of knowledge, a broad spectrum of treatment modalities is necessary. If this is true, then probably most of this book has validity. With this volume on the treatment and rehabilitation of the chronic alco holic, we bring to completion our five-volume series, The Biology of Alcoholism. As the title of the present volume indicates, we have departed from our original intention to deal solely with biological aspects of the syndrome and have attempted rather to produce a more comprehensive work. In retrospect, we find gaps and weaknesses which might have been filled or treated more ade quately but, on the whole, we are satisfied that these volumes have, to a large extent, fulfilled that purpose. Our major thrust has been to present alcoholism Vll viii Preface all of its complexities, which appear to encompass every level of human In phenomenology from the biochemical to the social. This point of view, which initially generated the organization of the entire work, permeates our philosophy of treatment as well and at least has the virtue of consistency. Reading the galley proofs and writing the preface for the last of a five volume series is like putting the final touch of paint on a newly built house. One has a great sense of completion but also a sense of loss of a vital element of intellectual and emotional stimulation in one's life. Above all, one has a sense of obligation to those who helped plan the edifice, to those who actually built it, and to those who provided the emotional support necessary to complete a six year project. For the first, we wish to thank Bob Ubell of Plenum Press for his constant interest in and support of this project. Among the workers, we count all of our authors, many of whom we came to know as friends as a result of this collaboration. Still among the workers, we especially thank Mildred Cohen, who nursed all of the manuscripts-many literally handwritten-from the typewriter to the publisher. Finally, among the providers of emotional support, we thank our wives, Eve and Esther, for their patience and never-ending for bearance. Benjamin Kissin Henri Begleiter New York Contents of Volume 5 Contents of Earlier Volumes Volume 1 ............................................. XIX Volume 2 XXI Volume 3 XXII Volume 4 XXIV Chapter 7 Theory and Practice in the Treatment of Alcoholism Benjamin Kissin The Development of Alcoholism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Predisposing Factors .................................... 2 The Development of Primary Psychological Dependence ....... 5 The Addictive Cycle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Alcoholism as "Symptom" or "Disease" .................... 8 A Pathogenetic Classification of Alcoholics . . . . . . . . . . . . . . . . . . . . . . . . . 9 Biological Mechanisms .................................. 9 Psychological Mechanisms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Social Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Implications for Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Breaking the Addictive Cycle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Special Problems in the Rehabilitation Process ............... 26 The Core Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 ix ][ Contents Treatment Models in Alcoholism ................................ 32 The Medical Model of Alcoholic Rehabilitation .............. 32 The Behavior Modification Model ......................... 34 The Psychological Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 The Social Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 The Alcoholics Anonymous Model ......................... 40 The Multivariant Model ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 The Multimodal, Multidisciplinary Approach to the Treatment of . Alcoholism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 The Multimodal Approach to the Treatment of Alcoholism .. . . . 44 The Multidisciplinary Approach to the Treatment of Alcoholism. 45 Continuity of Care in the Treatment of Alcoholics. . . . . . . . . . . . . 45 Public Health Treatment Systems in Alcoholism . . . . . . . . . . . . . . 46 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Chapter 2 Medical Management of the Alcoholic Patient Benjamin Kissin Introduction ................................................. 53 The Role of the Physician in the Treatment of Alcoholism ............ 54 The Role of the Physician in Private Practice. . . . . . . . . . . . . . . . . 55 The Role of the Physician in General Hospitals. . . . . . . . . . . . . . . 59 The Role of the Physician in Special Alcoholism Programs . . . . . . 60 Criteria for Diagnosis ......................................... 62 Criteria for Referral and/or Treatment ........................... 63 The Therapist of Choice ................................. 68 The Treatment Model of Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Designing a Specific Treatment Plan ............................. 75 Special Problems and their Treatments ..................... 76 The Core Problem and its Treatment . . . . . . . . . . . . . . . . . . . . . . . 93 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 100 Chapter 3 Psychotherapeutic Approach Howard T. Blane Introduction ................................................. 105 General Considerations ........................................ 106 Initial Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 113 Relationship and Relationship Building . . . . . . . . . . . . . . . . . . . .. 113 Pretherapy Factors Affecting Treatment. . . . . . . . . . . . . . . . . . . .. 115