Chapter 10: Process of Counseling with Alcoholics Moving Toward Recovery
The four operational goals of alcoholic counseling were outlined in Chapter 8. In the chapter just concluded, the achievement of the first and most difficult of these goals was explored -- helping the alcoholic to accept the fact that his drinking per se is a problem with which he requires assistance. It was shown that the process is one of reaching and helping to mobilize his inner motivation to accept help. The heart of this approach is the establishment of a trustful relationship which then becomes the instrument by which the alcoholic is helped to face reality with reference to his drinking. One aspect of the process is the educative dimension of counseling aimed at increasing the person’s understanding of his addictive illness. Although the pastor may be the key person in working with a resistant alcoholic, the help of an AA member or understanding physician who can "talk turkey" in ways that reach the alcoholic may be needed to complement the minister’s efforts.
Recognizing Openness to Help
Here is a segment from a counseling session involving a minister and an alcoholic:
Mr. B.: I didn’t mean to get drunk last week. It was the first time in a month that I’d had anything to drink. I was worried about a few things at the office that weren’t going well. I decided I’d walk around a little, and I passed by this beer joint -- well, you know, the first thing I realized I was inside drinking. I didn’t want to, but I just couldn’t help it.
Pastor: You thought that getting drunk would solve all your problems. Did it help?
Mr. B.: No, it only made things worse. I broke my promise to you and God -- and I feel terrible. I’m sick, I tell you. I’ve got to have some help!
Pastor: You feel sick because you broke your promise and got drunk.
Mr. B.: I -- don’t know. Maybe that’s the reason. Maybe it goes beyond that. I I guess I’m all wrong inside. 1.
This interaction illustrates the difficulty which a counselor may have in hearing an alcoholic’s cry for help when he begins to utter it. In his first statement, Mr. B. apparently seemed to the pastor to be giving a rather lame excuse for beginning to drink again. (The pastor responded with a statement which may or may not be the way B. felt, and an obvious and finger-pointing question that must have felt rejecting to the alcoholic.) What the minister missed was the possibility that B. was really expressing his fear and desperation at finding himself drinking against his conscious intention. This should have been explored by the minister, beginning with a response such as: "How did you feel when you realized you were drinking in spite of your decision not to?" or "Somehow you felt as though things were beyond your control?" This might have opened B. to talk about his awful feelings of weakness and of being trapped by his compulsive drinking and distorted thinking. If he is beginning to experience the panicky fear of not being in control and of the destructive consequences of his drinking, he is probably becoming open to help. The last two sentences of B.’s second response and his third response support the view that he is feeling desperate and is crying out for help. In the pastor’s second response, he again misses the alcoholic’s-desperate plea for help, focusing instead on B.’s guilt feelings related to the broken promise. These feelings are certainly within the legitimate concern. of counseling, but focusing on them at this point distracts the process from the crucial issue -- B.’s reaching out for help. The pastor’s second response might well have been a recognition of his feeling, such as, "The situation feels desperate to you, and the need for help is very pressing." The pastor could then say, "You mentioned that you feel sick. Tell me more about how you see this and what kind of help you feel you need." This would give the minister some grasp of B.’s perception of his problem and the required treatment. By moving in this direction, the pastor could eventually introduce the idea of getting help from AA or such other resources as seem appropriate.
Obtaining Medical Help
The second goal of counseling is to get the alcoholic to a physician who I can, if necessary, facilitate detoxification and treat the physical consequences of prolonged inebriety, as well as decide whether brief hospitalization is needed; if the physician is oriented psychiatrically, he may be of assistance in identifying cases of severe underlying psychopathology. Medical treatment is often required long before the alcoholic hits bottom psychologically. Many alcoholics require repeated hospitalizations before their motivational teeter-totter tilts decisively and they determine to accept treatment for the addiction per se. In such cases, it is essential that the alcoholic and his family know that simply treating the physical effects of excessive drinking, as important as this can be, does not constitute treatment of the addiction. Some persons erroneously believe that "unsuccessful treatment" of alcoholism has occurred when actually only the preliminary stage of treatment -- "drying out" and physical rehabilitation -- has taken place.
Alcoholics who are obviously in need of medical attention, who have the "shakes" or other withdrawal symptoms, and those who say that they feel "sick" (Mr. B., for example) will usually not resist seeing a physician to get relief from their pain. It is wise for the minister to encourage even those who are feeling relatively well to have a physical checkup to ascertain if there are less obvious organic problems which need treatment. The minister’s role is to assist the alcoholic to "connect" with a doctor who accepts alcoholics as patients, knows the latest methods of treating the problems associated with alcoholism, and is appreciative of the contributions of AA and pastoral counseling. A physician who does not understand alcoholism and AA can, by his attitudes, unwittingly push the person deeper into his addiction and away from the help he desperately needs. To illustrate, the statement by a trusted family doctor to an alcoholic patient, that he "is not an alcoholic but simply drinks too much and should cut down," can petrify that man’s resistance to seeing his problem for what it is. The doctor’s statement usually reflects a Skid Row stereotype of "the alcoholic." On the other hand, because of the status of physicians in our society, an accurate explanation of the nature of alcohol addiction and a recommendation that the help of AA be sought can carry special weight with some alcoholics.
What is the minister’s role during the period when an alcoholic counselee is hospitalized? He should maintain a supportive pastoral relationship, showing his continuing interest by visits and phone calls to the alcoholic and to his family. In addition, he has an opportunity to encourage carefully selected AA members to establish a relationship by visiting the alcoholic in the hospital (with the permission of the person and his doctor). Al-Anon members can do the same for the spouse and other family members.
If the minister is contacted by an alcoholic or the family of one who has been on a prolonged bender, it is crucial to make sure that he gets medical attention. As indicated in Chapter 8, withdrawal symptoms such as delirium tremens and alcoholic convulsions can be very dangerous, even fatal. The danger is compounded if the person has been combining alcohol and barbiturates ("goof balls"), since each tends to enhance the depressive effects of the other. The alcoholic may have been taking barbiturates without the family’s knowledge. The only safe course is to make certain he gets medical help.
Interrupting the Addictive Cycle
The third goal of counseling is to help the person learn how to avoid reactivating his compulsive-addictive chain reaction of drinking. Early in the process of working with an alcoholic, it is helpful to discuss the fact that he has an uphill battle against an insidious illness, and then to spell out what is involved in winning the battle. Gordon Bell, a physician who directs an addiction treatment center in Ontario, Canada, has an effective way of describing to the alcoholic the task he faces. Bell explains to the person that his body has burned out its ability to handle the chemical (alcohol) which he has been using to cope with stress. He then points to that person’s symptoms of loss of this ability, such as, getting drunk on less, having blackouts, and so forth. Next, he stresses the fact that the person must, for health reasons, learn other ways of handling stress -- by "people methods" rather than chemical methods. Finally, he tells the person that he is caught in a self-perpetuating process in the interruption of which there are two phases. The first is "turning off the physical motor" by getting the alcohol out of his body (thus interrupting physical craving), and second, "turning off the mental motor," which means terminating obsessive thinking about alcohol (mental craving) and the response of automatically turning to alcohol to handle any stress. 2. This general outline is useful in pastoral counseling with the alcoholic.
The focus of counseling, in this stage, is on the drinking pattern itself and the need to learn how not to take the first drink. A part of this learning consists of identifying and interrupting the rationalization process which leads to the first drink. (For instance, "One glass of beer can’t possibly hurt me. After all, I’ve been stone sober for three weeks.") The alcoholic should be helped to see that although his heavy drinking may have begun as a symptom of other problems and may continue to be aggravated by them, the drinking itself has now become a problem which must be treated in its own right if the person is to recover. The late Harry M. Tiebout likened the "runaway symptom" of the alcoholic’s out-of-control drinking pattern to the dangerously high fever of pneumonia. The fever is a symptom of the underlying infection, but unless it can be lowered, the person may die of the "symptom." As Tiebout pointed out, the direct treatment of the alcoholic’s "runaway symptom" is essential, and it consists of methods by which the cycle of drinking to overcome the effects of previous drinking is blocked.
Counseling procedures, in this stage, should deal primarily with behavior and only secondarily with feelings. The counselor should not allow himself to be diverted into extensive discussion of why the person drinks excessively, whether this discussion is in terms of attempts to understand his inner conflicts, early life experiences, or current external pressures. Searching for causes, in whatever direction, is usually unproductive with respect to the alcoholic’s problem of highest priority -- how to keep the addictive cycle from being reactivated. The "causes" which are discovered may be used by the alcoholic to avoid responsibility for changing his present irresponsible (self- and other-damaging) behavior. Instead of searching for the why of his drinking, counseling should focus on the facts about his drinking and its consequences, and on how he can avoid taking the first drink and thus increase his ability to be more responsible in other areas of his life.
The alcoholic’s other problems can become accessible to handling and help only if he learns how to avoid the first drink. For example, a counselee makes a statement such as, "If I didn’t feel so depressed, it would be easier to stay off the bottle"; or "If my wife hadn’t left me . . ."; or "If I didn’t have to live in one room .. ."; at this point the counselor can point out that although there is certainly some truth in his statement, his first problem is to stay off alcohol. This is his first problem in that its solution is a prerequisite to getting at the others. Even though he feels depressed, misses his wife, and abhors living alone in one room, he doesn’t have to drink. The choice is still within his power to make. Furthermore, his wife’s leaving was a consequence of his drinking, and his chances of getting her back are contingent on interrupting the drinking. If a person continues to put other problems ahead of sobriety, it may be an indication that he is still fighting acceptance of the fact that he is an alcoholic. A frank discussion of this issue is in order in the counseling session.
The most widely available means of keeping the addictive cycle broken while new coping patterns are learned is AA. The minister should do whatever is required to help the person establish a strong relationship with a local AA group. When the pastoral counselor senses that an alcoholic is evidencing some receptivity to help, he should ask: "How would you feel about talking over your situation with someone who has been through the same problem and has found an answer that works for him?" If the person agrees, the minister can make a phone call while that person is present to arrange for a three-cornered talk involving the two of them and an AA member. (The AA member should be of the same sex, general age, and socio-educational group as the person, if possible.) After explaining that the person they will be talking with is an AA member, the pastor should inquire what the alcoholic knows about that fellowship. This may reveal blocks to Successful affiliation with .AA, which the person needs to work through in counseling. When asked what she knew about AA, a woman responded, "Am I that badly off?" Behind her question was the misconception that AA is designed to help only those in advanced alcoholism. Another alcoholic responded to the minister’s suggestion that he try AA with the information that his alcoholic uncle had stopped on his own by simply deciding to quit drinking. The message the person was communicating was two-pronged -- discomfort at the thought of identifying himself with a group of self-acknowledged alcoholics and the feeling that he should, like his uncle, be able to gain sobriety without outside help. 3.
In describing why the person should go to AA as well as participate in counseling, it is well to stress that making the grade to stable sobriety is a difficult accomplishment in which several forms of help are often needed. The AA fellowship will give group support that the person will need in addition to what he derives from counseling. Although the minister knows that the person will receive a multitude of benefits from AA beyond group support, it is better for him to restrain his enthusiasm and avoid seeming to oversell the AA program.
If the three-cornered meeting goes well, communication will be well-established between the AA member and the counselee before it is over. When this has happened, the pastor may decide to excuse himself, thus encouraging the two of them to develop their relationship without his presence. The typical outcome of such a meeting is that the AA member invites the alcoholic to come with him to an AA meeting.
The counselor should encourage the alcoholic to attend as many AA meetings as possible during the early phases of his recovery, whether or not his reactions are entirely positive. If the person continues to expose himself to the AA philosophy and group élan, he may begin to identify with AA, almost in spite of himself. The sense of belonging which exists in most AA groups is a powerful magnet. The counselor can help the person deal with any blocks to full identification which may arise during the early stages of AA attendance, by inquiring regularly about the person’s reactions to AA.
Many alcoholics are now encountered who have dabbled in AA, or tried it seriously but unsuccessfully. Some seem to be "vaccinated" against it by having attended a few meetings when they were in a highly defensive state. To help such persons, the counselor can first explore the nature of the resistance to AA. Does the resistance reflect the limitations of a particular AA group or the person’s reluctance to admit his need for help? Second, the counselor can recommend strongly that he try AA again, perhaps going to a different group or to several, if they are available in the vicinity. Third, the minister can arrange for him to get acquainted with an experienced and accepting AA member who may serve as a bridge to feeling at home in an AA group [In a study of factors which produce "readiness" for affiliation with AA, Harrison M. Trice discovered that alcoholics with the following characteristics tend to relate effectively to AA: Before contact with AA, they often shared troubles with others, had lost drinking friends, had heard positive things about AA, had no relative or friend who had quit through willpower. These and other findings of Trice’s research can be useful to the counselor in his efforts to reduce the resistance of an alcoholic to affiliation with AA. (See: A Study in the Process of Affiliation with Alcoholics Anonymous," QJSA, XVIII [March, 1957], No. 1, 39-54.)]
With those alcoholics who will not attend AA or do not respond to it, the minister’s role is to assist them in finding other help. Referral to an alcoholic clinic or to a physician for Antabuse may supply the help that is needed to break the addictive cycle and achieve stable sobriety. Such a referral is also appropriate in the case of alcoholics who are continuing to work at the AA program but seem to need additional help. If an alcoholic counselee suffers from a severe underlying personality disturbance, he will probably require psychiatric and other medical treatment, in addition to AA, in order to keep the addictive cycle broken. Disturbed persons sometimes use alcohol to deaden their overwhelming anxiety. Abstinence, without psychiatric help, may cause them to deteriorate psychologically. 4.
Many alcoholics have one or more "slips," particularly in the first year or two of their serious efforts to keep the addictive cycle broken. It is important for the counselor to handle these in such a way as to make them opportunities for insight -- concerning the rationalization process, the buildup of resentments, or the pattern of staying away from AA meetings, which tend to precede a return to drinking. The alcoholic may avoid the minister after a slip because of his guilt feelings. Under such circumstances, it may be wise for the minister to take the initiative in reestablishing contact. Otherwise, his opportunity to help the alcoholic may be terminated. It is particularly salutary for a person with alcoholism to discover that a clergyman is not judging him or angry at him because he had a slip.
The pastor’s tolerance of failure and his not becoming ego-involved in the outcome of counseling (as discussed in Chapter 9) are extremely important in counseling with alcoholics because of the practical fact that he will fail so often. The process of such counseling is often slow and characterized by many setbacks. The counselor must be content with "little successes" in many cases. For example, counseling is a relative success if a person who has had an average of five binges a year is able to cut the number to two or three. Counseling with alcoholics is difficult and often frustrating to the counselor. It can also be deeply satisfying when the counselor senses that he has been an instrument in helping a person who has been engaged in slow suicide to move into a new and constructive chapter in his life.
The Resynthesis of Life
The fourth goal of counseling is to help the person develop a new way of life to replace his alcohol-centered way of life. To reintegrate his life without alcohol, he must find new, satisfying values and new, effective ways of coping. The recovering alcoholic must find nonalcoholic means of satisfying the needs he formerly satisfied or attempted to satisfy through drinking -- reduction of anxiety, closeness to others, psychological "vacations" from painful reality, a sense of adequacy, experiences of transcendence, and euphoria. Permanent sobriety and productive living are contingent on finding such satisfactions in relationships -- with fellow AA members, family, and, in many cases, a "higher Power."
The rebuilding of one’s values and relationships is obviously a long-range objective. Its achievement involves clearing up the debris in one’s inner life, striving for constructive relationships, surrendering one’s self-centeredness, finding a place to make one’s life count for something, discovering a sense of meaning in existence, learning to draw on the help of other people and also to be of help to them, and finding some transcendent resource for coping with the burdens and anxieties of existence.
For many, AA’s Twelve Step recovery program is an invaluable means of stimulating precisely these types of personal growth. As was evident in Chapter 5, the AA group and program are designed as a means of facilitating the particular kinds of continuing growth which are necessary to under-gird productive sobriety.
The clergyman-counselor can contribute significantly to helping the alcoholic move toward the goal of reconstructing his life without alcohol. During the early stages of recovery in AA or in an alcoholic treatment facility, the minister’s role is mainly a supportive one. The primary responsibility for learning to avoid the first drink is the alcoholic’s, and his major resource for accomplishing this is AA (or other treatment approaches). His main source of emotional support (often hour-by-hour) during the first difficult days and weeks are his fellows in AA.
The minister’s role is to give pastoral care, to maintain a warm, caring relationship with as much support as the person needs and to be easily available for counseling if the alcoholic desires it. Without being possessive or prying, the pastor should show interest in the person’s experiences in AA or in treatment. Dropping by for a cup of coffee, phoning to express interest in "how things are going," occasionally attending the open meeting of his AA group -- these are some of the ways the minister can keep in touch with the early-stage recovering alcoholic. He should express his pastoral interest and support without "hovering" over the person or seeming to check up on him. As the alcoholic identifies more closely with AA, he may need to withdraw some of his emotional ties with the pastor. This is a part of his growth. In many cases, the alcoholic eventually moves beyond this and chooses to relate to his minister on a new and close basis.
There are at least three points at which the minister’s counseling skills can be particularly helpful to the recovering alcoholic, after he achieves a reasonably stable interruption of his drinking cycle and begins to strive for a re-synthesis of his life. The first is in assisting the alcoholic who requests it with the "moral inventory" steps in AA (4 through 10).
AA member: Pastor, I’ve talked these things over with my sponsor, and it helped, but it seems like it would be a good idea to discuss them with you, too. There are a couple of points in my inventory where I really felt hung up-and still do. The guilt and resentments just won’t seem to go.
A minister who is trained in counseling is equipped to help the alcoholic take his moral inventory in depth, to look below the surface behavior to some of the sources of resentment, self-pity, guilt feelings, and self-rejection which feed the behavior and push the person toward drinking.
In his discussion of the minister’s role in assisting the alcoholic with the moral inventory, John E. Keller states:
The inventory procedure needs to be talked about in a positive way, pointing up the value of taking such an inventory. Hopefully he will benefit by being able to: (1) Get to know himself better; (2) Become more keenly aware of how he needs to change; (3) Recognize danger signals to his sobriety before he takes the first drink; (4) Live more comfortably with himself and others; (5) Have the door opened for a more personal and meaningful relationship with God. 5.
Helping AA members with their moral inventories can be a means of engaging them in an ongoing counseling process through which the hard, cold lumps of guilt which immobilize growth and block relationships can be melted. An indispensable part of the inventory process is making amends to the persons one has harmed (steps 8 and 9). The counselor should encourage this follow-through, in spite of the pain involved. Otherwise the recovery process is short-circuited. By taking action to assume some responsibility for past irresponsibilities, guilt is reduced, self-acceptance enhanced, and relationships improved. As the alcoholic makes a list of those he has harmed, one person in particular should not be forgotten. As Keller put it: "Essential also is to put himself on the list and make amends with himself. He may have hurt a lot of people, but no one quite as much as he has hurt himself." 6. During fourth step counseling, the minister can help the person see that self-forgiveness and forgiveness of others are always linked and that the way one makes amends to himself is to live in those ways that fulfill one’s person-hood and potentialities.
A second area in which the clergyman can help the alcoholic reconstruct his life is by being easily available to counsel with him regarding his problems of coping constructively with responsibilities and relationships. Such counseling, usually at the alcoholic’s request, can complement the help the person receives as he continues to work at the AA program. By the time the alcoholic achieves sobriety, his marital, parental, vocational, and social relationships frequently are in shambles. Interrupting the drinking cycle is a prerequisite to rebuilding these vital relationships, but it does not automatically accomplish it. The permanency of his sobriety may be dependent, to some degree, on the revitalization of these shattered relationships or their replacement if they are beyond repair. The counseling process here is relationship-centered, helping the person change those attitudes and behavior patterns by which he gets in his own way as he attempts to relate to others. Marriage and family counseling is the most important form of such counseling help.
The minister who is well trained in counseling and psychotherapy may help the alcoholic whose inner conflicts and residual feelings from early relationships make his hold on sobriety tenuous. Earthquakes from the cellar of the person’s psyche shake the house of his present relationships so continuously and violently that some form of psychotherapy is essential. The minister who is trained in pastoral psychotherapy and has the time and inclination to do so can render a significant service to such alcoholics. However, these considerations should be kept in mind. First, exploration of depth feelings and early-life relationships can be very disturbing and should be attempted only after other forms of help have proved inadequate and only after sobriety has been reasonably stable for several months or longer. Second, looking at the past can become a substitute for responsible coping with the demands of the present, and over-focusing on feelings can become a way of evading responsible action. To minimize this second danger, it is well to keep a four-pronged focus in psychotherapy with alcoholics -- on the past and the present; on feelings and actions in relationships.
The Spiritual Dimension of Recovery
A third way in which the minister’s counseling skills can be useful to the recovering alcoholic’s re-synthesis of his life is in helping to further his spiritual growth. The discussion of philosophical and religious factors in the etiology of alcoholism (Chapter 2) and of the psychodynamics of a religious approach to alcoholism (Chapter 6) emphasized the following points:
Alcoholism is a spiritual illness (as well as an emotional, physiological, and cultural illness). It is a spiritual illness in two senses: There are spiritual factors among its causes, and full recovery depends on the discovery of a philosophy of life and/or a religious experience that can satisfy the alcoholic’s fundamental religious needs.
As one who is professionally trained to be a spiritual growth enabler, the clergyman can fulfill a unique role in helping alcoholics. When a recovering alcoholic comes to him for help with his religious problems or with the "spiritual angle" in AA, he has an opportunity to contribute to the creativity of that person’s new way of life. The goal of counseling in this area is to help the alcoholic develop a meaningful relatedness to the vertical dimension of life -- the dimension of values including the ultimate value which is called God. In counseling with alcoholics, one discovers that problems in the vertical dimension are always intertwined with problems in the horizontal (person-to-person) dimension. Spiritual and interpersonal difficulties, and growth are actually two sides of the same reality -- the reality of one’s relationships. Anything that enhances the quality of one’s relations with one’s fellows will tend to improve one’s relationship with God, and vice versa. Conversely, blocks in relationships with one’s spouse, children, and friends have .their counterparts in blocked relatedness with God. The skilled counseling pastor should be able to move in both dimensions with equal facility and to help the alcoholic see the connections between them. It is noteworthy that again and again in AA, as an alcoholic reconstructs his relationships, his spiritual life gradually becomes more meaningful to him.
A major block in the spiritual life of the drinking alcoholic, which often continues as a barrier during his sober life, is a magical understanding and use of religion. Until this changes, the channels of a more vital relationship with the spiritual universe seem to remain blocked. Typically, if the drinking alcoholic has any religious life, it reflects his narcissism and his unresolved inner conflict between autonomy and dependence.
He often expects God to take care of him in infantile, magical ways. He tries to use God as an overprotective grandmother whose main function is to extricate him from alcoholic scrapes scot free. He makes impossible demands, expects a special set of rules-of-the-game, and then feels rejected when God does not "come through" according to his demands. His religion both reflects and enhances his narcissistic self-worship and his dependency conflict. Rather than allaying anxiety it increases it because it operates in the same manner as his neurosis. The underlying meaning of much alcoholic atheism seems to be, "All right, if you won’t take care of me like a child, I’ll show you! I’ll destroy you by the magic of thought -- by not believing in you!" 7.
Thus, during active alcoholism, as the person is cut off from nurturing relationships including his relationship with God, he is forced into a kind of idolatrous position in which he is his own god. His grandiosity and feelings of being above needing others are a part of his defense against deeper feelings of isolation, vulnerability, and fear of closeness.
Some drinking alcoholics come to ministers seeking easy, magical solutions to their complex problems. The pastor must not comply and seem to sanction their expectations. Many recovered alcoholics tell of praying "until they had calluses on their knees" during their drinking days, to no avail. Generally their prayers are of the magical, manipulation-of-reality type described above. The minister should work with persons who have such orientations to help them see that problems of their relationships with God are directly related to problems in their human relationships, and to guilt-producing living. The counseling process should first aim at interrupting the addictive cycle and straightening up human relationships; then it is appropriate to turn to overtly spiritual problems, which are interrelated with all of the alcoholic’s other problems.
The counselor can help the recovering alcoholic gain the inner strength to let go of his tendency to defeat his own spiritual quest by his manipulative style of relating to God and the universe. The AA approach provides a sound model for the counselor in helping the alcoholic move toward a reality-respecting religious life. Step eleven of that program says, "Praying only for knowledge of His will for us and the power to carry it out." If the "will of God" is understood as a symbolic way of saying "the way things are" (the nature of reality in an orderly, cause-and-effect universe), the profound significance of this step becomes clear. The alcoholic is asking for the knowledge and ability to line up his life with reality rather than expecting (as in his drinking days) that reality should adapt itself to him. The recovering alcoholic thus is striving to develop a relationship with God which is almost the exact opposite of that of his pre-sobriety days. In doing spiritual counseling with a person having a magical, immature faith, the aim is not to deprive him of that faith (which he may need to hold his world together), but to help him outgrow it and replace it gradually with a more mature faith.
Surrender and Recovery
To understand the psychodynamics of recovery and particularly the role of spiritual growth in this process, the concept of surrender, as explored by the late Harry M. Tiebout, 8. is illuminating. The phenomenon which he described has been observed by various workers with alcoholics, including the author. Surrender occurs on different levels at progressive stages of recovery. The first and most decisive surrender is the alcoholic’s illusion that he can handle alcohol. To take step one of the AA recovery program -- "We admitted we were powerless over alcohol, that our lives had become unmanageable" -- the alcoholic must let go of that factor in his self-image which makes him need to feel equal to whatever comes. Another surrender is required by step three: "Made a decision to turn our will and our lives over to the care of God as we understood him."
Tiebout observed that when an alcoholic really surrenders, there is a dramatic shift in his inner life. His self-deceiving "alcoholic thinking" is replaced by openness and honesty. He stops fighting life and begins to cooperate with it. Feelings of inner peace, acceptance, and genuine humility replace his guilt, tension, isolation, defiant-grandiosity, and self-idolatry. Surrendering seems to be letting go of a terrible burden -- the unsuccessful attempt to play god. It is significant that step eleven states that a "spiritual awakening" occurs as a result of the previous steps -- the surrender and moral inventory (and restitution) steps. This sequence can serve as a guideline in the counselor’s work with alcoholics on their spiritual blocks. Tiebout stated the matter this way:
A religious or spiritual awakening is the act of giving up one’s reliance on one’s omnipotence. The defiant individual no longer defies but accepts help, guidance and control from the outside. And as the individual relinquishes his negative, aggressive feelings toward himself and toward life, he finds himself overwhelmed by strong positive ones such as love, friendliness, peacefulness. 9.
Surrender, as used here, is not a negative giving-up. It is a turning away from a futile, self-defeating orientation and toward a reality-accepting way of feeling and coping. By accepting his weakness and finitude, the alcoholic finds relatedness and strength for coping constructively with his problems.
Mark M., age 40, came to his minister because his marriage was on the verge of disintegration because of his alcoholism. He made it plain to the counselor that he wanted no part of AA. He had tried that approach, he said, and felt that he was too intelligent to need that kind of help. He expressed the view that he could handle his drinking himself and that he just wanted a few tips on "how to keep the little woman off my back." During the first three weeks of counseling, he maintained this mask of defiant self-sufficiency, tinged with superiority feelings. He kept the minister at a distance. His view of his problem was that all would be fine if his wife would nag less and be more appreciative of his good points. Nothing significant was accomplished in counseling, and he continued to come only because he was afraid his wife would leave him if he stopped. His drinking was undiminished.
After a two-weeks break in the counseling, Mr. M. appeared at the minister’s study door for a counseling session with a strikingly different look on his face, which caused the minister to exclaim, "What happened?" Mr. M. replied, "I don’t know, but I guess I’ve given up my 1-ism." He described a family crisis, during the past two weeks, involving the tragic death of a child. Instead of joining with other family members in giving the mutual support that everyone desperately needed, he had gone on a binge to end all binges. Following this, his guilt and remorse were intense. It was in the midst of this painful self-confrontation that Mr. M. "hit bottom." His smug mask of self-sufficiency, denying his problem and blaming others, was jarred loose by the awareness that he had been living a self-centered lie. His alibis and his compulsion to "run the show," as he put it, collapsed. His defensive pride crumbled, and he experienced the self-disgust that was behind it. After a while, this began to pass, and he felt more relaxed, self-accepting, and grateful for life than he could have imagined before this happened.
Mr. M. reported that he had gone back to AA after letting go of his I-ism; he said that that it was a new experience, as though he had not been to AA before. He said that he felt closer to his wife and children than ever before. Even the colors in nature seemed more vivid to him.
In counseling, Mr. M. showed a new openness. He began searching for ways of making his marriage more constructive. The focus of counseling was on this and on how he could keep his 1-ism from returning, which was one of his major concerns. Reflecting on his drinking, he said, "When my 1-ism increased, I drank more, and the more I drank, the stronger my 1-ism became." Gradually he learned to recognize the danger signs of regression into 1-ism- -- the ego-centric, self-pitying, demanding superiority feeling that always seemed, in retrospect, to precede a drinking bout.
Flow can we understand the surrender experience? The 1-ism which Mark described seems to be derived from infantile narcissism. Alcohol facilitates psychological regression to this position of magical power and grandiose self-sufficiency. Narcissism is a defense against deeper feelings of powerlessness and fear of death. 10. But the regression to the psychological position of the infant exposes the person to the giant anxieties of that period of development. As alcoholism progresses, these produce "nameless fears"; the illusion of special power becomes more and more difficult to maintain in the face of increasing failure in the various areas of one’s life.
The surrender experience seems to have at least two components. First there is the unconscious renunciation of the path of regression to infantile narcissism, which no longer gives satisfactions to offset its disadvantages. David A. Stewart, in Thirst for Freedom, describes the operation of the alcoholic’s narcissism as "the little dictator," an unconscious complex of magical thinking, false pride, fear, anger, lack of insight, and resistance to facing one’s need for outside help. When surrender occurs, the little dictator is deposed, 11. and the self-damaging defense of narcissism is given up.
The second component in surrender is a desperate leap toward trustful relationships to fill the void left by the now-empty pattern of distance from people and self-centeredness. One alcoholic gave this description of the experience: "It’s a leap of fear. You leap from the chasm blindly, not knowing what’s on the other side. Fear is pushing you, and hope is pulling you." During his drinking days, the alcoholic often saw the world as peopled with depriving mother figures. Having taken the leap toward trust, he discovers (in AA, for example) that trustworthy relationships are possible for him and that he can participate in the give as well as the take of life. For many alcoholics, this is a strikingly new experience. By his leap toward trust, the alcoholic breaks the vicious cycle in which he has been trapped, the cycle of spiraling anxiety, isolation, anger, and grandiosity. Thus, as one alcoholic put it, "he rejoins the human race."
As a direct result of this positive surrender to life, the person begins to develop feelings of genuine self-esteem (the opposite of narcissism), rooted in trustful and mutually nurturing relationships. New and effective ways of coping with anxiety are discovered within these relationships. The alcoholic has let go of his narcissistic need to play god. Because of this and because of his involvement within a group (AA) which incarnates and communicates the accepting love of a higher Power, the alcoholic begins to develop a relationship with God as he understands him. As this relationship grows, it reinforces his ability to trust people and to become a giving person himself. By remaining in a dependent relationship with the higher Power, he is helped to retain his humility and to resist the temptation to regress to narcissistic self-idolatry and to drinking. Equally important, a trustful relatedness to God gives him an effective way of facing and handling his existential anxiety, depriving it of its terror and making it a stimulus to creative living. As Tillich holds, it is only when existential anxiety is confronted and taken into the person’s self-affirmation that it enriches rather than diminishes life. The alcoholic who has developed trustful relationships -- with himself, others, and God -- is able to "die living rather than live dying," as one put it:
Yet the surrendered alcoholic must continue to exercise vigilance to avoid losing his humility. The underlying problem of infantile narcissism is not resolved but instead is walled off in the experience of surrender. When deep-seated anxieties are aroused by threats to his self-esteem or by failure to grow spiritually, the old temptation to regress to his primitive defense and curse still remains. This accounts for the necessity which most AA members feel to "work the program" continually, even though their sobriety has been stabilized for years. 12.
Counseling and Surrender
Surrender represents a profound reorientation at a depth level of the psyche. It seems to occur when an alcoholic "hits bottom," i.e., is faced by the bankruptcy of his old way of life. It usually follows a long and painful struggle within the person. Although it involves a person’s consciously letting go of old self-damaging patterns of living, it is not a simple matter of deciding to surrender. Since it occurs at least in part at an unconscious level, it involves a more than conscious intention to change.
The counselor can help to create the conditions under which surrender is most likely to occur by utilizing the methods of "elevating the alcoholic’s bottom," described in the last chapter. In particular, these conditions can be created by: (a) Avoiding and helping others avoid protecting the alcoholic from the consequences of his self-centered behavior. Mr. M. was not shielded from the reality of his wife’s intention to leave unless he changed, nor from facing the fact that he responded inappropriately to the death in the family. (b) Providing an accepting relationship which will stimulate the alcoholic’s hope and encourage him to take the leap toward trust. (c) Helping the person see that his I-ism is the cause of his inability to accept help and the source of his agonizing loneliness. (In some cases, discussion of the "little dictator" or an opportunity to read Harry Tiebout’s or David Stewart’s discussions of surrender may help develop awareness of the nature of their trapped condition.) (d) Helping the person see that his denial of reality is depriving him of the very things he wants out of life. (e) Avoiding strengthening his defensive grandiosity by not becoming engaged in a futile power struggle with him. The alcoholic may feel that he must outwit the counselor or in other ways prove that he is smarter than the counselor. If he can lure the counselor into a position of taking responsibility for his sobriety, giving him advice, or making decisions for him, he can "defeat" the counselor by getting drunk, or proving that the advice or decisions were not sound. (f) Exposing him to a group such as AA in which the contagion of genuine self-acceptance is present because many of the members have experienced surrender. Spiritual growth occurs most readily in a group committed to spiritual values. In such a group a stimulus to growth is caught from others who are growing spiritually.
The Alcoholic’s Basic Religious Needs
Every human being has certain fundamental needs which can be satisfied adequately only within some religious (philosophical, existential, or spiritual) context. These include: (a) The need for an experience of the transcendent and the numinous. Anthropologist Ruth Benedict referred to the belief in "wonderful power" which was found to be ubiquitous among the cultures she studied. Abraham Maslow describes the "peak-experiences" which are the raw material of religions.13. (b) The need for a sense of meaning, purpose, and value in one’s existence. Viktor Frankl calls this the "will-to-meaning" 14. and sees it as more basic in man than Freud’s will-to-pleasure or Adler’s will to-power. (c) The need for a feeling of basic trust and relatedness to life. Maslow uses the phrase "oceanic feeling" in his discussion of the self-actualizing person to describe the experience of being a part of the whole universe. (d) The need for an "object of devotion," to use Erich Fromm’s phrase. Each person needs something that transcends himself to which he may give devotion and in which he may invest oneself. (e) The need to share a common philosophy of life and object of devotion with a group of one’s fellows.
The minister’s distinctive contribution to helping alcoholics is in the spiritual dimension of recovery. It consists of assisting them in discovering effective ways of satisfying the fundamental religious needs listed above. This is particularly crucial since many alcoholics suffer from spiritual longing and emptiness, which they have been attempting to fill by a pseudoreligious means: alcohol. Only as they are successful in developing spiritually vital lives can their religious needs be met in a satisfying way. The renewal of "basic trust" (Erikson) and the filling of the "value vacuum" (Frankl) are indispensable to full recovery from alcoholism.
The minister has several resources for use in this work, in addition to his counseling skills. One is the church fellowship. Many recovering and recovered alcoholics find help in the supportive relationships of a person-centered church. The spiritually feeding experiences -- worship, religious festivals, communion, fellowship groups, service opportunities -- help gratify dependency needs, renew basic trust, and strengthen the alcoholic’s sense of meaning and purpose in life. The clergyman-counselor can help the person discover which small groups within the church help to satisfy his particular spiritual needs and stimulate his spiritual growth. The counselor must avoid pushing the alcoholic toward involvement in the church before that person is ready for this experience. Often considerable spiritual growth in AA must precede such readiness to participate in the more heterogeneous church group.
Increasing numbers of churches are establishing personal growth and counseling groups under a variety of labels. 15. Their aim is to stimulate growth in relationships, including one’s relationship with God. As increasing numbers of alcoholics are sober for extended periods, the desire for study and growth experiences beyond AA becomes more prevalent. In some cases, this desire is the result of a flare-up of underlying personality problems, often after a decade or more of sobriety. In other cases, it is simply the result of an inner push to move ahead in one’s spiritual growth, building on what has occurred in AA. Whatever its source, this desire represents a growing opportunity for the churches. In small (usually twelve or less) spiritual growth groups, people with a variety of problems can assist each other in moving toward more authenticity in relationships and a richer, more meaningful faith.
The new way of life of the recovering alcoholic is a path along which he moves rather than a static goal which he achieves. David Stewart describes five stages of sobriety:
Initial sobriety: Physical health regained; preoccupation with sobriety, reduction of guilt and anxiety; increased self honesty.
Learning sobriety: Loss of freedom (to drink in moderation) accepted; gi~ve and take of real personal relations replaces grandiose behavior; regains acceptance of family and friends; sense of humor replaces self-pity; learning to cope with anxious or depressed states.
Accepting sobriety: Loss of desire to drink becomes lasting; thinking, feeling, and ethical perception improves.
Creative sobriety: Freedom from alcohol deeply appreciated; religious desires centered on new way of life; appreciates need for help from others; uses new freedom in other activities.
Pleasurable sobriety: At peace with oneself and the world; anxiety and shyness diminish in genuine interpersonal relations; enjoys sobriety; rewards of sobriety clearly exceed tough times. 16.
However one conceptualizes the stages of sobriety as a new way of life, it is clear that it is a process. The role of the clergyman and the church in stimulating spiritual growth varies from person to person and from stage to stage. In general, the spiritual growth factor becomes more crucial as one moves ahead in the process. The aim of the counseling minister should be to contribute to each person’s spiritual growth by helping him meet his spiritual hungers at his particular stage of growth.
The Use of Religious Resources
A natural question which arises in the mind of a pastor is this: Shall I use prayer, sacraments, or scripture in counseling with the alcoholic? There are no fixed answers to this question. The general principle is to use such religious resources only after rapport has been established and the minister has an understanding of what they will probably mean to the particular counselee. Even then, they should be employed with extreme care and in moderation. One reason why some alcoholics are reticent about going to talk with a clergyman is the fear that they will be "prayed over." Even those who come to clergymen may feel some hostility toward religion and God. So the minister whose tendency is to pray at the drop of a hat should restrain himself where alcoholics are concerned. It is well to remember that it is sometimes necessary to avoid the outward symbols of religion in order to preserve the relationship with the alcoholic which can become religious in the deeper sense of being a channel for the healing power of cod. As AA’s are fond of saying, the spiritual angle often has to slip up on an alcoholic.
Marty Mann has a valuable suggestion concerning work with an alcoholic about whose religious attitudes the pastor is not certain. "If he is not sure of the alcoholic’s attitude, he would be wise to understate the spiritual aspects, not only of AA but of his own interest in the case?’ 17. This is important because, if the pastor presents AA as a spiritual approach, he may prevent the alcoholic from going to it for help.
The establishing of a strong counseling relationship should always precede the use of religious tools. Only within such an interpersonal context can they be used meaningfully. One of the Yale ministers put it well: "In some cases I have had prayer. The patient must be well chosen and must understand that the minister understands him before prayer can have the right psychological results. A lot of pious phrases from a minister can leave a sense of guilt that may send him out to get drunk again." If one does pray, it is well to reflect the feelings of the alcoholic in the prayer (showing him that one regards his feelings, however negative, as acceptable to God). It is also well to avoid any phrase which might be construed to mean asking for a magical solution, to emphasize the idea that God stands ready to help us when we actively participate in using his help, and to point to the fact that help comes through a revitalization of our own inner resources. The "faith without works is dead" philosophy is a healthy emphasis in counseling with alcoholics.
It is true that an alcoholic who comes to a minister may want something different from what he wants when he goes to a psychiatrist. He may want the strength and help of religion. Satisfying this need may or may not involve the use of overtly religious tools or resources. The clergyman should remember that whatever he does will register as religious in the sense that he represents the spiritual dimension of life and the religious community to the alcoholic. It is well for the pastor to adopt the Emmanuel philosophy that healing by any means involves the action of God. On the other hand, if prayer and scripture reading are familiar and natural, and they seem to have value for the particular person, they should be used. Ernest A. Shepherd expresses an important caution in this matter when he writes: "Every clergyman should be warned against using these means as ways to make himself feel more useful, regardless of the effect on the parishioner." 18.
In deciding whether or not to use religious resources in a counseling relationship, the minister may ask himself the question of whether such use will contribute to the person’s sobriety and to his development of a more mature faith. Will such use increase or lessen the possibility that the person will move toward the experiences of surrender and spiritual awakening? Will it stimulate spiritual growth or contribute to the neurotic misuse of religion that contributes to spiritual cripplings. Only when the pastor is reasonably sure that such use will not block growth and may stimulate it should he employ traditional religious symbols and practices. In counseling with the drinking alcoholic, such resources are apt to be experienced in a distorted fashion by the alcoholic. In contrast, the person who has achieved stable sobriety and is searching for a deepening of trust may find the use of such resources, by the minister and in his own personal devotions, exceedingly helpful.
Counseling Homeless Alcoholics
Most ministers, especially those with downtown churches, are frequently confronted with the perplexing problem of how to deal constructively with the homeless alcoholic who comes to the door. He may be one of the "town drunks" or a part of the great mass of homeless men who live on an itinerant basis.
The homeless alcoholic usually comes to the minister for an "easy touch," since he regards a minister as a "live one." Of course hitting a minister for a "loan" is not confined to derelict alcoholics. Many alcoholics, particularly those who have not yet reached the lower levels of the disease, are extremely ingenious in concocting stories as to why they need money. Most ministers acquire a protective skepticism concerning hard-luck stories from strangers -- a skepticism based on disappointing experiences when they were more naïve.
What about giving money to alcoholics or to persons one suspects are alcoholics? The best rule is almost never do it. No matter how convincing the story, the minister should follow the procedure of all social agencies and investigate. For example, if the person says that he is down on his luck because of a prolonged illness, ask for the name of the physician and check with him before giving any monetary help. If the person is an alcoholic, he will usually develop his story in such a way as to make it seem imperative that he have some money at once. This is the bait which the clergyman sometimes takes, to his subsequent regret. A wise procedure is to say, "I’m sorry but it is my policy never to give financial help without investigating first. If you will come back this afternoon, I’ll be able to tell you whether or not I can loan you the money you need." After the person leaves, the pastor can check the address given and any other facts in his story. If the person is not on the level, he will usually not return. If his story is factual and his need legitimate, he will return.
But does not this procedure mean missing many opportunities to give real help to sick persons? No, because an opportunity usually does not exist. If an alcoholic’s only motive in coming is to get money for drinking, the odds are great that he is not open to real help at that point. I recall once giving a "town drunk" type alcoholic some money on the theory that he might return when he became open to help. The hope proved illusory. In spite of the fact that I gave him no more money, I was plagued for several years by return visits motivated only by his desire for a "loan." Each time he came he looked more like the shadow of death, but he showed no desire for basic help. It is probable that, by giving him money, I had blocked rather than opened the way to real counseling.
The type of alcoholic who makes his living by panhandling has an inner contempt for those he exploits. Underneath his surface show of gratitude he is sneering at the sucker he has duped and reveling in his own superior cleverness in having accomplished the duping. By giving him money one is contributing to his neurotic, exploitative orientation, as well as helping to push him a little further into the morass of alcoholism.
Even if an alcoholic shows what appears to be a genuine desire for recovery, it is not wise to give him more than a little money. AA experience has shown that it is better for a newcomer to work his way up from the bottom. This forces him to rely on his own resources and if he succeeds, it is his victory. Second, it helps to keep him from becoming overly dependent on the helper. This is particularly true because of the fact that money is a symbol of power and independence in our culture. The alcoholic cannot tolerate the dependence of being too indebted. Third, it tends to help him face the fact that his problem is not the lack of money, which has been one of his favorite rationalizations, but staying sober.
If a person says he is hungry, give him food, not money. If he needs clothing, give him some that has little pawn value. If he needs shelter, it would be better to make direct arrangements for it rather than give him money for a room. If he has a legitimate and pressing need for a little money (for example, for carfare to get to work), let him work for it. This will keep him from feeling weak and dependent as well as test the legitimacy of his need.
In assaying the available resources a pastor will need to visit the local Salvation Army center and/or mission. By discussing the work of the institution with the leaders, one can determine the basic philosophy and procedure, and discover whether constructive handling is likely. If the Salvation Army men’s service center has an AA group connected with it, the pastor is fortunate insofar as referral of homeless alcoholics is concerned. It means that the alcoholics will have an opportunity to get help through either the evangelistic or the A A approaches; it also indicates a broader philosophy on the part of the leadership.
However hard or well he tries, the minister should not expect to succeed in a very large percentage of cases of homeless alcoholics. For, as we said in Chapter 3, one is dealing, not with just one problem but with two. To the problem of alcoholism is added the psychosocial problem of homelessness. For this type of alcoholic, homelessness often is a way of life that fits his psychological eccentricities with the least pain.
Detroit attempted to do something constructive about the problem by establishing a "counseling center" in a storefront adjacent to the main Skid Row area. In addition to the counseling proper, the center was also equipped to arrange for food, lodging, and employment. Out of the original group of 770 men who were counseled, only 70 were judged successful. 19. Even with optimum resources, success is not high in this type counseling.
It might be helpful to a minister in sizing up a counseling situation to know about certain factors which were found to be linked with success in counseling homeless alcoholics in the Detroit project. It was found that the chances of success were greater if (a) a homeless man had been married, (b) his occupation was clerical, skilled, or professional rather than unskilled, (c) he recognized that he was an alcoholic, (d) he did not ask for money, and (e) he attended church during and after the counseling.
There are several rays of hope on the horizon in the treatment of homeless alcoholics. One is the enlightened approach of the Men’s Service Center of Rochester. 20. The director is Thomas B. Richards, a clinically trained minister with broad experience as an institutional chaplain. He has transformed the center from a conventional evangelistic mission to an institution which is pioneering in a combined religious and scientific approach. An AA group meets there, and a new philosophy of social service for homeless alcoholics has been developed. There is also a halfway house to which those who are motivated to stop drinking can go. Pilot experiments such as this may, it is hoped, provide both the pattern and the inspiration for other cities to take constructive action in relation to their Skid Row problems. The cost of such rehabilitative work is undoubtedly less than a city spends for the police-jail-public shelter approach to alcoholism which is essentially futile.
Another ray of hope (mentioned in Chapter 3) is the work that AA has done and is doing with low-bottom alcoholics. In the early days of AA a high percentage of members had spent time on Skid Row. This fact shows that AA is often effective in helping such alcoholics. In some areas, AA groups have made special facilities available for contacting and helping homeless alcoholics, by providing physical help as well as the basic AA program. One reason why AA is able to help many who have lived on Skid Row is the fact that a considerable portion of these men have not accepted the homeless life as a permanent state. They are there only temporarily while they are on a binge. These who are not resigned to permanent homelessness still have the psychological resources to identify with an AA group.
This leads to the suggestion that in cases in which a homeless alcoholic seems to have even an embryonic desire for help, it may be wise to discuss the matter with an AA member who has himself lived on Skid Row, rather than referring the person directly to the Salvation Army. The AA member will be able to size up the situation rather accurately. Having lived on Skid Row, he will be better able to establish rapport with the homeless man.
One of the few helpful discussions of an effective pastoral approach to homeless alcoholics is in an article by Thomas B. Richards, who was mentioned earlier; it is entitled "The Minister and the Bum." His discussion reminds me of the all too accurate definition of a city as "the place where people are lonely together." Richards writes:
The city minister, busily engaged in church activities and active in all manner of worthy civic causes, may forget the fact that for many, many people a city is a cold, lonely place. In his preoccupation with the obligations of a clergyman in a big city he may overlook the growing multitude of those who are friendless and alone on the city streets, in the hospitals, and in the institutions that are within a stone’s throw of his church.
On the basis of this, Richards suggests an area of special opportunity for the city pastor:
If his basic interests are with people . . . he will discipline himself to the point where he will be able to find the time to follow through on those whom he refers to the expert for professional care.
There is need, heart-breaking need, for his intelligent interest and friendly concern. He can supply the personal touch, the time to listen, and the patience to understand, which the institutional officials are too busy to give. They are inundated by sheer weight of numbers, tired out and pressed down by the masses of those in any institution who await their professional care.
Herein lies the minister’s greatest opportunity. The harassed institutional official will welcome his help. This does not mean that he is to "meddle" in the diagnosis or attempt his own particular "cure." It does mean, however, that his intelligent interest and friendly concern for the individual involved will be of tremendous importance in the entire healing process.
This is the "team" approach discussed earlier. Richards puts it well when he writes: "The minister who readily assumes that the doctor, the psychiatrist, or the social worker have no need for him, or that they resent his presence, is too easily dissuaded from his ‘high calling,’ or else he is allowing himself to rationalize an unpleasant responsibility." 21.
The development of "halfway houses" for homeless alcoholics, in various parts of the country, is another bright spot in a generally dark picture. Such facilities provide a temporary residence, halfway between life on Skid Row and the demands of living as a part of a family in a normal community. Having a bridge of this sort helps some men make it across a gigantic social chasm. Halfway houses are sponsored by a variety of agencies including Councils on Alcoholism, churches, municipalities, and groups of AA members. The most effective houses are small (not more than twenty-five clients), have simple rules, maintain an atmosphere of homelike informality, and employ staff counselors who are recovered alcoholics, often former Skid Row-ers. 22. In June, 1966, the Association of Halfway House Alcoholism Programs of North America 23. sponsored a significant conference involving the directors of such programs.
A number of hopeful programs are underway using a combination of medical, psychiatric, and vocational therapies. Most workers in this field agree that some form of institutional care is an essential ingredient in the treatment of Skid Row alcoholics. The program at Boston’s Long Island Hospital has been in operation for over ten years. Only volunteers are accepted for treatment. After a careful social, psychiatric, and physical evaluation, the man is put on Antabuse, given psychiatric help and "religious counseling" to deal with some of his emotional problems as he begins to work and attempt to reestablish relationships in the community. AA is an integral part of the program. A three-year follow-up study of one hundred men who had attempted the program showed that twelve had achieved complete sobriety and had reestablished themselves with their families; forty-two showed improvement in their drinking patterns but remained dependent on the structured hospital community; and the remaining forty-six had changed little if any in their drinking or social patterns, in spite of all the help offered them. 24.
New York’s "Operation Bowery" is a multifaceted program of action, research, and community planning. With an interdisciplinary staff of fourteen full- or part-time persons, the project maintains a diagnostic and treatment center where homeless men receive medical and psychiatric examinations, psychological testing, group or individual psychotherapy, vocational counseling, and Antabuse. A "Fellowship Center" at the Men’s Shelter provides lay counseling services. A pilot detoxification center for drying-out, treatment, and referral is planned. Operation Bowery helps to interrupt the futile "revolving door" practice of the police and courts, with its repetitive arrests of homeless alcoholics -- "life imprisonment on the installment plan." 25. When attorneys of the Legal Aid Society began to represent homeless men arrested on "disorderly conduct" charges, convictions dropped from 98 to 2 percent. A second blow to the revolving door system came in 1966 when the Federal Court of Appeals ruled, in effect, in the Driver and Easter cases, that public intoxication per se is not a crime. Columbia University’s Bureau of Applied Social Research carries on sociological studies of homelessness under a contract with Operation Bowery.
A Philadelphia project has as its goal the relocation and rehabilitation of Skid Row inhabitants so that the Row could be terminated (as a part of Urban Renewal) without creating new ones elsewhere. Phase one consisted of organizing the cooperation of the City Council and social welfare agencies, and of publicizing a casework-oriented program. Phase two was a careful census and sociological study of Skid Row, involving 2,278 interviews.
In the third phase a diagnostic and relocation center was established, located near Skid Row, staffed by professionals and a research team as well as former Skid Row residents, and offering to a systematic sample of the men diagnostic, recreational, therapeutic, vocational-counseling and housing-relocation services, including training in social as well as occupational skills. 26.
A Model for Counseling with Alcoholics
To maximize his counseling effectiveness with alcoholics, the minister should have a clear picture of the style of counseling which has proved to be most functional with alcoholics. The author has described such a "revised model" of pastoral counseling elsewhere, 27. contrasting it with the client-centered or Rogerian model. In brief, the revised model has these characteristics:
(1) It emphasizes short-term, crisis counseling methods aimed at helping the person cope constructively with his current situation rather than exploring the past extensively. It uses supportive rather than uncovering methods. It focuses directly on assisting the person in increasing the constructiveness of his behavior. (2) It emphasizes helping the person face reality and function more responsibly. (3) It seeks to help the person enhance the constructiveness and mutual satisfaction of his relationships, rather than to aim at intrapsychic changes. Increase in self-esteem and the reduction of guilt are seen as the results of improved relationships.
In the early stages of an alcoholic’s recovery, counseling with him is essentially crisis counseling. The insights and methods of psychiatrist Gerald Caplan and his associates are highly useful in this phase. 28. Several key insights emerge from experience in crisis counseling. First, one does not need to know how a fire started in order to put it out, in most cases. 29. To illustrate, it is usually unnecessary to discover why an alcoholic became an alcoholic in order to help him to recover. In fact, the search for "causes," while the crisis is whirling, often produces a worsening of the drinking problem. Second, the personality is like a muscle -- it atrophies with disuse and is strengthened with exercise. While an alcoholic is drinking, his personality resources are increasingly immobilized. Interrupting the addictive cycle and beginning to cope with responsibilities such as holding a job, lead to the strengthening of the coping "muscles." Third, facing and handling a crisis constructively give the person new resources for coping with future crises. Each crisis that is handled in a reality-oriented way makes the alcoholic stronger and better able to handle the next crisis.
As mentioned in Chapter 5, the drinking alcoholic becomes increasingly like a car with the engine racing but the clutch disengaged. His personality is "out of gear"; he is not going anywhere. Breaking the drinking cycle puts his personality back in gear; he can now use his personality resources for handling adult responsibilities and rebuilding fractured relationships. The more he uses his "engine" to move in these directions, the stronger it becomes. In this way, many alcoholics can recover and live constructive lives without any pressing need to rebuild the engine (through psychotherapy). This is not true of the alcoholic who is deeply disturbed.
The orientation of ‘William Glasser’s "reality therapy" 30. is close to the revised model for counseling alcoholics. A central emphasis of this approach is on responsible living in the here and now. By "responsible," Glasser means satisfying one’s needs for love, self-esteem, and identity, within the realities of one’s relationships, and doing so without depriving another of the satisfaction of his needs. Glasser’s therapy consists of establishing a relationship with the troubled person, diminishing self-defeating (reality-denying) behavior, and then helping the person "learn to fulfill his needs in the real world" of human relationships. 31. Glasser’s approach is similar to what AA has been doing to help alcoholics for some thirty-plus years. Along with the other "action therapies," it can help balance the emphasis on feelings in pastoral counseling.
1. N. S. Cryer, Jr., and J. M. Vayhinger, eds., Casebook of Pastoral Counseling (Nashville: Abingdon Press, 1962), p. 221
2. Lecture at the University of Utah Summer School of Alcohol Studies, June 18, 1963.
3. If a person feels strongly that he can do it without help, the counselor should wish him success but then add that, should things not work out well, he should bear in mind that help will still be available.
4. See E. M. Pattison, "A Critique of Alcoholism Treatment Concepts," QJSA, XX’II (1966), 61-62.
5. Ministering to Alcoholics (Minneapolis: Augsburg Publishing House, 1966), p. 119.
6. Ibid., p. 57.
7. H. J. Clinebell, Jr., "Philosophical-Religious Factors in the Etiology and Treatment of Alcoholism," QJSA XXIV (September, 1963), 484.
8. Tiebout’s writings on surrender include: "Surrender Versus Compliance in Therapy, with Special Reference to Alcoholism," QJSA, XIV (1953), 58-68; "The Ego Factors in Surrender in Alcoholism," QJSA, XV (1954), 610-21; "Alcoholics Anonymous -- an Experiment of Nature," QJSA, XXII (1961), 52-68
9. "AA and the Medical Profession" (AA Publishing Company, 1955), p. 24.
10. For a more comprehensive discussion of how this operates see: Clinebell, "Plulosophical-Religious Factors in the Etiology and Treatment of Alcoholism."
11. (Toronto, Canada: The Musson Book Co., 1960), Chapters 3 and 6.
12. Clinebell, "Philosophical-Religious Factors in the Etiology and Treatment of Alcoholism," p. 486.
13. Religions, Values, and Peak-Experiences (Columbus: Ohio State University Press,
14. The Doctor and the Soul (New York: Alfred A. Knopf, 1955’).264
15. See H. J. Clinebell, Jr., "Group Pastoral Counseling" in Basic Types of Pastoral Counseling, pp. 206-21.
16. This description of the five stages is abbreviated from Stewart’s Thirst for Freedom, pp. 273.75.
17. "The Pastor’s Resources in Dealing with Alcoholics," Pastoral Psychology, II (April,1951), 18.
18. Pastoral Care, p. 178.
19. For a report on this project, see W. W. Wattenberg and J. B. Moir, "Factors Linked to Success in Counseling Homeless Alcoholics," QJSA, XV (December, 1954), 587-94.
20. Pastoral Psychology, VI (May, 1955), 6, 65, 66.
21. This series of quotes is from Thomas B. Richards, "The Minister and the Bum," Pastoral Psychology, VI (May, 1955).
22. Earl Rubington, "Halfway Houses," a lecture presented at the Alumni Institute, Summer School of Alcohol Studies, Rutgers University, July 18, 1966.
23. 334 Mounds Boulevard, Saint Paul, Minnesota 55106.
24. For a description of this project, see David J. Myerson, "Rehabilitation for Skid Row: The Boston Long Island Hospital Rehabilitation Program for the Homeless Alcoholic," Fifth and Sixth Annual Institutes on the Homeless and Institutional Alcoholic (New York: National Council on Alcoholism, 1960-1961), pp. 1-5.
25. "Dedication to Human Restoration, Operation Bowery" (Annual Report, September 3, 1965 -- September 2, 1966), p. 1.
26. Leonard Blumberg et al., "The Development, Major Goals and Strategies of a Skid Row Program: Philadelphia," QJSA, XXVII (June, 1966), 257.
27. Basic Types of Pastoral Counseling, Chapters 2 and 9.
28. Gerald Caplan, Principles of Preventive Psychiatry (New York: Basic Books, 1964), pp. 26-5 5. For a discussion of pastoral crisis counseling see Clinebell, Basic Types, Chapter 6.
29. This apt figure of speech is from William Menninger.
30. Reality Therapy (New York: Harper & Row, 1965).
31. Ibid., p. 60.