Silence Hurts
Alcohol Abuse and Violence Against Women
Formal Specialized Treatment
For some adults, pretreatment approaches may prove quite effective. This is especially true for late-onset drinkers and prescription drug abusers with strong social support and no mental health comorbidities. Followup brief interventions and empathic support for positive change may be sufficient for continued recovery. There is, however, a subpopulation who will need more intensive treatment.
Despite the resistance that some problem drinkers or drug abusers exert, treatment is worth pursuing.In determining a formal course of treatment, some important considerations include:
•Whether adequate efforts have been made to help the client to reduce alcohol use to safe levels
•Whether abstention or harm reduction is the goal of treatment
•The attitudes of staff and philosophy of the program
•The availability of required modes of treatment (e.g., detoxification, inpatient, intensive outpatient, outpatient)
•The availability of aftercare or continued involvement
Types of treatment include:
•Cognitive-behavioral approaches
•Group-based approaches
•Individual counseling
•Case management, community-linked services, and outreach
Not every approach will be necessary for every client. Instead, the program leaders can individualize treatment by choosing from this menu to meet the needs of the particular client. Planning information comes from:
•Interviews
•Mental status examinations
•Physical examinations
•Laboratory, radiological, and psychometric tests
•Social network assessments
•Other sources (see Module 7 for more on assessments)
Cognitive-Behavioral Approaches
As a prelude to cognitive-behavioral therapy, a therapist might use motivational counseling. This is a more intense process than the motivational interviewing that may take place during a brief intervention. Motivational counseling acknowledges differences in readiness to change and offers an approach for "meeting people where they are."
Motivational counseling has proven effective with adults.1 An understanding and supportive counselor:
•Listens respectfully and accepts theadult's perspective on the situation as a starting point
•Helps the individual identify the negative consequences of drinking
•Helps the person shift perceptions about the impact of drinking or drug-taking habits
•Empowers the individual to generate insights about and solutions for his or her problem
•Expresses belief in and support for the adult's capacity for change
Motivational counseling is an intensive process that enlists patients in their own recovery by:
•Avoiding labels
•Avoiding confrontation (which usually results in greater defensiveness)
•Accepting ambivalence about the need to change as normal
•Inviting clients to consider alternative ways of solving problems
•Placing the responsibility for change on the client
This process also can help offset the denial, resentment, and shame invoked during an intervention.2 It falls somewhere between brief interventions and pretreatment interventions.
Types of Cognitive-Behavioral Approaches
There are three broad categories of cognitive-behavioral approaches: behavior modification/therapy, self-management techniques, and cognitive-behavioral therapies. Behavior modification applies learning and conditioning principles to modifying overt behaviors, which are those behaviors obvious to everyone around the client.3,4 Self-management refers to teaching the client to modify his or her overt behaviors as well as internal or covert patterns. Cognitive-behavioral therapy involves altering covert patterns or behaviors that only the client can observe.
Cognitive-behavioral techniques teach clients to identify and modify self-defeating thoughts and beliefs.5,6 This is intended to improve mood and reduce the probability of drinking as a method of coping, especially in the face of relapse pressures. These pressures include negative emotional states, such as depression, anger, and frustration; peer pressure; and interpersonal conflicts with spouse, family, a boss, and others.
The Drinking Behavior Chain
The cognitive-behavioral model offers an especially powerful method for targeting problems or treatment objectives that affect drinking behavior. Together, provider and client analyze the behavior itself, constructing a "drinking behavior chain." The chain is composed of:
•The antecedent situations, thoughts, feelings, drinking cues, and urges that precede and initiate alcohol or drug use
•The drinking or substance-abusing behavior (e.g., pattern, style)
•The positive and negative consequences of use for a given individual
When exploring the latter, it is particularly important to note the positive consequences of use: those that maintain abusive behavior. Cognitive-behavioral therapy is ideally suited to individuals who are slow to learn because of residual impairment of cognitive functioning. This is because this method breaks down information into small manageable units and repeats them until understanding is ensured.
Researchers have developed an instrument that can elicit by interview the individual's drinking or drug use behavior chain.7 Immediate antecedents to drinking include feelings such as anger, frustration, tension, anxiety, loneliness, boredom, sadness, and depression. Circumstances and high-risk situations triggering these feelings include marital or family conflict, physical distress, and unsafe housing arrangements, among others.Alcohol use is often a form of "self-medication, a means to soften the impact of unwanted change and feelings.
For the patient, new knowledge of his or her drinking chain often clarifies for the first time the relationship between thoughts and feelings and drinking behavior. This method provides insight into individual problems, demonstrates the links between psychosocial and health problems and drinking, and provides the data for a rational treatment plan and an explicit individualized prevention strategy.
Breaking drinking behavior into the links of a drinking chain serves treatment in other ways, too. It suggests elements of the community service network that may be helpful in establishing an integrated case management plan to resolve antecedent conditions (e.g., housing, financial, medical problems). Involvement from the community may be needed beyond the treatment program (see Case Management section).
Behavioral Treatment in Group Settings
Behavioral treatment can be used withadults individually or in groups, with the group process particularly suited towomen with abuse and addiction issues(see Group-Based Approaches). Equipped with the knowledge of the individual's drinking or drug abuse behavior chain, the group leader:
•Begins to teach the client the skills necessary to cope with high-risk thoughts or feelings
•Teaches theperson to initiate alternative behaviors to drinking, then reinforces such attempts
•Demonstrates through role-playing alternative ways to manage high-risk situations, permitting the client to select coping behaviors thatshe feels willing and able to acquire
•Asks for feedback from the group and uses that feedback to work gradually toward a workable behavioral response specific to the individual
The behaviors are rehearsed within the treatment program until a level of skill is acquired. The patient is then asked to try out the behaviors in the real world as "homework." For example, a client who has been practicing ways to overcome loneliness or social isolation may receive a community-based assignment in which to carry out the suggested behaviors.
After practicing, the individual reports to the group. Then the therapist and group members provide feedback and reinforce the individual's attempt at self-management (whether or not the outcome was a success). This process continues until the individual develops coping skills and brings the antecedents for abuse under self-control or self-management. Typically, as patients learn to manage the conditions (thoughts, feelings, situations, cues, urges) that prompt alcohol abuse, abstinence can be maintained.
Posttreatment Issues
Defining drinking behavior antecedents is also useful for determining when a client is ready for discharge. When the individual can successfully use coping behaviors specific to his or her drinking antecedents, the treatment team might assist the person in gradually phasing out of the program. Discharge that takes place before the client has acquired specific coping behaviors is almost certain to result in relapse, probably very soon after discharge.
Studies comparing early- and late-onsetproblem drinkers showed great similarity between these two groups' antecedents to drinking and treatment outcomes.8 Another study described a behavioral regimen that included psychoeducation, self-management skills training, and marital therapy. Studies recommend that treatment focus on:
•Teaching skills necessary for rebuilding the social support network
•Self-management approaches for overcoming depression, grief, or loneliness
•General problem solving9
Group-Based Approaches
Group experiences are particularly helpful to women in treatment. They provide the arena for:
•Giving and sharing information
•Practicing skills, both new and long-unused
•Testing the clients' perceptions against reality
Perhaps the most beneficial aspect of groups for older adults is the opportunity to learn self-acceptance through accepting others and in return being accepted. Guilt and forgiveness are often best dealt with in groups, where people realize that others have gone through the same struggles.
Special groups may also deal with the particular problems of aging. The group format can help patients learn skills for coping with many of the life changes that can put one at risk for substance abuse, including:
•Bereavement and sadness
•Loss of friends, family members, social status, occupation and sense of professional identity, hopes for the future, ability to function
•Social isolation and loneliness
•Reduced self-regard or self-esteem
•Family conflict and estrangement
•Problems in managing leisure time/boredom
•Loss of physical attractiveness (especially important for women)
•Physical distress
•Insomnia
•Sensory deficits
•Reduced mobility
•Cognitive impairment and change
•Impaired self-care
•Reduced coping skills
•Decreased economic security or new poverty status
•Dislocation
Therapy Groups
Therapy groups can be effective ways to provide peer support, particularly if AA meetings are not accessible. They focus on building new social and coping skills. They also encourage connections with peers or others, adding to the social network. Social contacts outside of formal meetings are usually encouraged.
Some therapy groups engage in behavioral interaction, others in more psychodynamic therapy. Both types of groups allow clients to test the accuracy of their interpretations of social interactions, measure the appropriateness of their responses to others, and learn and practice more appropriate responses. Groups provide each client with feedback, suggestions for alternative responses, and support as the individual tries out and practices different actions and responses.
Some people may need help in entering the group, particularly if they are used to isolation. This help could include individual counseling sessions in which the counselor explains how a group works. The counselor could also answer the client's questions about confidentiality.
The client's entry into the group may be eased by joining in stages, at first observing, then over time moving into the circle. The counselor may formally introduce the new person to the members of the group so that upon entering the group, he or she is at least somewhat familiar with them.
Older adults grew up before psychological terms had been integrated into everyday language. Therefore, therapy groups for older adults should avoid the use of jargon, acronyms, and "psychspeak." If leaders do use such terms, they should begin by teaching the group their meanings. If a participant uses an unfamiliar term, the leader should explain it. It may be helpful to develop a vocabulary list on a chart and for any individual notebooks.
Similarly, manyindividuals were raised not to "air their dirty laundry." Therefore, they should never be pressured to reveal personal information in a group setting before they are ready. Nor shouldpatients be pressured into role-playing before they are ready.
Educational Groups
Educational groups are an integral part of addiction and domestic violence treatment. Patients need information about addiction, the substances, their use, and their impact. Women also benefit from shared information about:
•The developmental tasks of each stage of life
•Support systems
•Medical aspects of aging and addiction
•The concepts and processes of cognitive-behavioral techniques
Educational units can be designed to teach practical skills for coping with any aspect of daily life, such as safety, nutrition, household management, and exercise.
Some basic principles for designing educational groups follow:
•Traumatized women can receive, integrate, and recall information better if they are given a clear statement of the goal and purpose of the session and an outline of the content. The leader can post this outline and refer to it during the session. The outline may also be distributed for use in personal note taking and as an aid in review and recall. Courses and individual sessions should be conceived as building blocks that are added to the base of theadult's life experience and needs. Each session should begin with a review of previously presented materials.
•Members of the group may range in educational level from functionally illiterate to postgraduate degrees. Manywomen are adept at hiding a lack of literacy skills. These individuals need to be helped in a way that maintains their self-respect. Group leaders should choose vocabulary carefully based on clients' communication skills.
Alcoholics Anonymous and Other Self-Help Groups
Many treatment programs refer patients to Alcoholics Anonymous (AA) and other self-help groups as part of aftercare. AA is a grassroots peer-assistance approach that has had the greatest impact on the treatment of chemical dependency. It addresses living without alcohol through working a Twelve Step program.
AA requires attending regularly scheduled meetings. This may be a problem for women who have transportation needs, although a sponsor in the chapter may be able to assist.
Providers should warnpatients that these groups might seem confrontational and alienating. The referring program should tell patients exactly what to expect. Group discussions may include profanity and younger members' accounts of their antisocial behavior.
To orient clients to these groups, the treatment program may ask that local AA groups provide an institutional meeting as a regular part of the treatment program. Other options are to help clients develop their own self-help groups or to facilitate the development of independent AA groups for older adults in the area.
Avoiding future problem drinking may depend on continuing affiliation with a recovering peer group. Some model programs have created volunteer alumni groups to allow continued affiliation after requirements for treatment, such as court supervision, end.
MFT Continuing Education http://www.aspirace.com
Individual Counseling
Because of current interpersonal conflicts and the underlying feelings of shame, denial, guilt, or anger, psychotherapy may be appropriate. It can occur in conjunction with other treatment methods such as AA or hospital-based treatment programs. Grief counseling can support the process of healing losses.
Individual counseling is especially helpful to the older substance abuser in treatment's beginning stages, but the counselor often must overcome clients' worries about privacy. Subjects that many older adults are loath to discuss include their relationships with their spouses, family matters and interactions, sexual function, and economic worries.
It is essential to assure the client that the sessions are confidential. In addition, the therapist should conduct the sessions in a comfortable, self-contained room where the client can be certain the conversation will not be overheard.
Older clients often respond best to counselors who behave in a nonthreatening, supportive manner and whose demeanor indicates that they will honor the confidentiality of the sessions. Clients frequently describe the successful relationship in familial terms: "It is like talking to my son, or, "It is as though she were my sister." Older clients value spontaneity in relationships with the counselor and other staff members. A counselor's appropriate self-disclosure often enhances or facilitates a beneficial relationship with the patient.
Because receiving counseling may be a new experience for the client, the provider should explain the basics of counseling and clearly present the responsibilities of the counselor and the client. Summarizing at the beginning of each session helps to keep the session moving in the appropriate direction. Summarizing at the end of a session and providing tasks to be thought about or completed before the next session help reinforce any knowledge or insights gained. They also contribute to the older client's feeling that he or she is making progress.
In individual sessions, counselors can help clients prepare to participate in a therapy group, building their understanding of how the group works and what they are expected to do. Private sessions can also be used to clarify issues when the individual is confused or is too embarrassed to raise a question in the group. As the client becomes more comfortable in the group setting, the counselor may decide to taper the number of individual counseling sessions. Likewise, the client may prepare for discharge by reducing the frequency or length of sessions, secure in the knowledge that more time is available if needed.
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Case Management, Community-Linked Services, and Outreach
Case management is the coordination and monitoring of the varied social, health, and welfare services needed to support anadult's treatment and recovery. Case management starts at the beginning of treatment planning and continues through aftercare. One person, preferably a social worker or nurse, should link all staff who play a role in the client's treatment. This person should also coordinate with other important individuals in the client's social network.
The case/care manager develops the treatment plan, reviews progress, and revises the treatment plan as needed. There is a process for monitoring success in achieving the goals of treatment. The case manager serves as an advocate, representative, and facilitator of links to other agencies to procure services for the client.
The multiple causes of abused and addicted women's problems require multiple linkages to community services and agencies. The treatment program that seeks to be the sole source of all services for itsclients is likely to fail. Even in very isolated areas, programs can strengthen their services for women through linkages to local resources such as the faith community.
The case manager will likely refer the client to a combination of several community resources in response to the issues associated with the substance abuse problem. Case managers must have strong linkages through both formal and informal arrangements with community agencies and services such as:
•Medical practitioners, particularly mental health providers
•Medical facilities for detoxification and other services
•Home health agencies
•Housing services for specialized housing
•Public and private social services providing in-home support
•Faith community (e.g., churches, synagogues, mosques, temples)
•Transportation services
•Social activities
•Vocational training andemployment programs
•Community organizations that place clients in volunteer work
•Legal and financial services
If a program includes outreach services, case management may offer the best means of providing them.10,11 Case managers may, for example, initiate outreach services for homebound clients, although it is important to maintain continuity and assign only one case manager to an older client. If clients in a treatment program become seriously ill or dysfunctional and temporarily require services at home, a case manager may be the ideal staff person to broker services on their behalf. (Comprehensive case management for substance abuse treatment is described in detail in TIP 27.)
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References
1.Miller, W.R., and Rollnick, S. Motivational Interviewing. New York: Guilford Press, 1991.
2.Ibid.
3.Powers, R.B., and Osborne, J.G. Fundamentals of Behavior. New York: West Publishing Co., 1976.
4.Spiegler, M.D., and Guevremont, D.C. Contemporary Behavior Therapy. Pacific Grove, CA: Brooks/Cole, 1993.
5.Dobson, K.S., ed. Handbook of Cognitive-Behavioral Therapies. New York: Guilford Press, 1988.
6.Scott, J.; Williams, J.M.G.; and Beck, A. Cognitive Therapy in Clinical Practice: An Illustrative Casebook. London, UK: Routledge, 1989.
7.Dupree, L., and Schonfeld, L. Assessment and Treatment Planning for Alcohol Abusers: A Curriculum Manual. FMHI Publication Series, Number 109. Tampa: Florida Mental Health Institute, University of South Florida, 1986.
8.Schonfeld, L., and Dupree, L.W. Antecedents of drinking for early- and late-onset elderly alcohol abusers. Journal of Studies on Alcohol 1991, 52:587-592.
9.Schonfeld, L., and Dupree, L. Older problem drinkers: Long-term and late-life onset abusers: What triggers their drinking? Aging 1990, 361:5-9.
10.Graham, K.; Saunders, S.J.; Flower, M.C.; et al. Addictions Treatment for Older Adults: Evaluation of an Innovative Client-Centered Approach. New York: Haworth Press, 1995.
11.Fredriksen, K.I. North of Market: Older women's alcohol outreach program. Gerontologist 1992, 32:270-272.
