Understanding and Counseling the Alcoholic by Howard J. Clinebell, Jr.
Howard J. Clinebell, Jr. Is Professor of Pastoral Counseling at the School of Theology at Claremont, California (1977). He is a member of the American Association of Marriage and Family Counselors, and the American Association of Pastoral Counselors. He is a licensed marriage, child and family counselor in the State of California. His personal website is http://members.aol.com/clinebellh/index.htm, and his email address is clinebellH@aol.com. This book is the Revised and Enlarged Edition published by Abingdon Press, Nashville, 10th Printing, 1990. Used by permission. This material ws prepared for Religion Online by Richard V. Kendall.
Chapter 9 - The Process of Counseling with Alcoholics: Relationship and Motivation
Learn your theories as well as you can, but put them aside when you touch the miracle of the living soul. Not theories but your own creative individuality alone must decide. -- Carl C. Jung 1.
Before describing the principles and methods of counseling with alcoholics, it should be emphasized that the heart of any effective counseling process is a relationship characterized by warmth, genuineness, acceptance, caring, and trust. This quality of relatedness is described in psychological language as "therapeutic" and in religious language as "redemptive." Such a relationship is the basic channel of the helping process. If it does not exist, no amount of finesse in "counseling techniques" is of value. If a therapeutic quality of relationship does exist, constructive changes can occur in spite of weaknesses in a counselorís methodology. Within such a relationship, skill in counseling techniques is a potent factor in enhancing the healing-growth process.
Each counseling relationship is a new creation. Each is unique, developing as it does from the interaction of two unique individuals, a counselor and a counselee. Because of this, all counseling is, to some extent, "by ear." This is the meaning of Jungís words (quoted above), addressed originally to psychotherapists but applicable to all types of counseling relationships. The uniqueness of each relationship makes counseling both an art and a science. A counselorís effectiveness depends on his discovery of his own creative style which will allow him to connect with others and to use himself (in his uniqueness) as a growth facilitator in relationships.
One danger of any description of counseling approaches is that the artistic essence of the helping process may become obscured by a concern with technique. To reduce this danger, it should be made clear that what follows is a description of general guidelines, principles, and methods which have proved useful in counseling with many alcoholics. They should be seen as suggestive rather than definitive; rough guideposts rather than precise directions. To be most useful to the reader, they should be employed experimentally, evaluated critically, and adapted to his own particular mode of relating. It is salutary to remember that different counselors, using a variety of methods, obtain positive and roughly comparable results with alcoholics. It should be clear from this that there is no one "right" way of counseling with alcoholics. The point is not that counseling techniques are unimportant but that each counselor must develop his own approach which will release his unique personality resources in the counseling relationship.
Counseling is a disciplined art in that it is based on generic principles which transcend the infinite differences in both counselors and counselees. In learning to play the piano, there are principles of harmony, rhythm, and technique which must be mastered as a part of the discipline of the art. By mastering these, the person becomes free to use them as a foundation for developing his own unique musical expression. As he progresses in skill, the music he produces becomes more and more his own. It flows through and from him, expressing a musical individuality as much his own as his fingerprints. In an analogous way, the counselor aims at that mastery of the principles of his art which will free him to develop his own style of counseling -- a style which releases his unique personhood in the human encounter called counseling. If the process of learning and adapting the principles in the laboratory of actual counseling experience with alcoholics can be supervised by someone skilled in counseling, oneís growth will be greatly accelerated.
Establishing a Counseling Relationship
Counseling with an alcoholic is fundamentally the same as counseling with anyone else in that the general principles of sound counseling apply in both cases. To discuss these principles in detail is beyond the scope of this book. 2. . However, it is necessary to apply the general principles to the specific problem of counseling with alcoholics, and to do so with particular reference to some of the psychological characteristics which are typical of many alcoholics.
When the minister makes contact with an alcoholic, the first step in counseling is to begin to build a relationship-bridge with him. As in other counseling, this is done by listening in depth and relating with oneís full being. Karl Menninger has observed that "listening is the most important technical tool possessed by the psychiatrist." 3. It is also the pastoral counselorís most important tool. Listening requires suppressing oneís urge to interpret, reassure, or ask a series of informational questions. Listening in depth means listening with the "third ear" (as Theodor Reik put it), or being sensitive to the feelings that are behind the words and the subtle messages communicated in mood, posture, and facial expression. "Psychotherapeutic listening" 4. is different in basic ways from the superficial listening of most everyday relationships. It is a skill which the counselor must learn through disciplined practice.
Intensive listening allows the counselor to begin to sense how the alcoholic feels about himself, others, and his problem. Gradually the counselor begins to grasp precious fragments of understanding of his inner world of hopes, fears, and pain. He begins to see how life looks through his eyes. Listening and responding with warm understanding serves to establish the first strands of the interpersonal bridge called "rapport" over which the counseling process moves back and forth.
It is not easy for a nonalcoholic to understand the inner world of an alcoholic, but it is also not impossible. Heart-understanding can be acquired by really listening to recovering alcoholics and allowing them to become oneís teachers. If an alcoholic counselee senses that the pastor really desires to understand, even though his initial efforts to do so are fumbling, this may open the door. The alcoholicís awareness that the counselor cares and is trying to understand allows the counselor to establish a beachhead from which he may move into the dark terrain of the alcoholicís world. As one becomes familiar with the typical experiences and feelings of many alcoholics, it is easier to pick up the feelings of a particular alcoholic more accurately and respond to them more precisely. Often one can sense what the person is feeling before he actually verbalizes it fully. As the counselor is able to stay on the alcoholicís emotional wavelength, the relationship is strengthened by the alcoholicís awareness -- "This man really does understand and care!"
In Chapter 2 we noted that many alcoholics are plagued by low self-esteem and a sense of isolation (and differentness), as well as guilt and anxiety. These painful feelings make them defensive and increase the difficulty of establishing rapport with them. Because of this, the first interview may require more time than would be true in some other counseling. One must move slowly and work carefully in building the relationship. Because of his anxiety the alcoholic is hypersensitive to anxiety in others. If alcoholics make a minister anxious, this will be communicated to the alcoholic counselee, to the detriment of the relationship. Because the alcoholic feels so guilty (although he often hides it behind a façade), he often expects and even courts rejection. His emotional antennae are always up, and he is hypersensitive to condescension and rejection. The counselor should try to avoid saying anything that might be interpreted as criticism or passing judgment on him.
The emphasis on the importance of listening does not mean that the counselor should function passively or give the impression of detachment. Because of his low self-esteem, the alcoholic is easily threatened by feelings of being alone and under scrutiny. Not knowing what a silent counselor is thinking, he tends to project his own self-disparagement onto the counselor and thus feels judged by the latterís silence. To be effective, the counseling relationship must be a warm, human relationship. It should be more than this, but it must not be less. The "more" consists of the counselorís skills and understanding not present in non-counseling relationships. But the human quality is the indispensable foundation of whatever else is present.
The late Otis Rice once suggested that the counselor must "stay close to the alcoholicís ego." 5. Somehow the pastor must let the alcoholic know that he is with him emotionally -- that he is reaching out to him as one human being to another. Conveying this is important because the alcoholic tends to see the clergyman as one who reaches down rather than out to him. Because the minister is perceived as a "superego figure" by many people -- as one who represents the "oughts" of society -- counselees may believe that he is sitting in judgment when he is not.
There are various ways of staying close to the alcoholicís ego. Not threatening him with a barrage of questions but rather responding to his painful feelings in an empathic, accepting way has an ego-supportive effect. Jellinek stressed the importance of not asking any save "tiny little questions" during the early phases of counseling, thus respecting the alcoholicís right to stay as hidden as he needs to stay. 6. In contrast, asking questions which seem impertinent or irrelevant may strike the alcoholic as prying into his private affairs.
The pastor should do whatever he can to let the alcoholic know he is "feeling with" him in his problem, as he sees it. The appropriate use of what Rice said one of his colleagues called "encouraging grunts" 7. lets the alcoholic feel that one hears. It may be helpful to paraphrase occasionally what he thinks the alcoholic is saying and feeling in order to communicate understanding or correct misunderstanding. How one responds or at what points are not crucial issues. ĎWhat is crucial is that oneís responses be an expression of a genuine fellow-feeling and growing understanding on the counselorís part.
Often an alcoholic comes to a minister because he wants desperately to unburden himself. The pastor is not only the most accessible professional person to many people, but he is also the one to whom many turn for help with guilt feelings. As the alcoholic pours out his painful feelings, three helpful things occur. First, emotional unburdening takes place. This has value in itself, lightening his guilt load enough to free some of his previously paralyzed energies for use in coping. Second, as the counselor listens and resonates, the bond of rapport grows stronger. Such a bond develops between any human beings who share an emotionally meaningful experience. Being listened to, in oneís agony, by an accepting authority figure is a profoundly meaningful experience. Third, by avoiding getting in the way of the verbal-emotional flow, the minister usually acquires much of the relevant information which he needs in order to understand the personís problem. What he does not obtain spontaneously, he can get by direct questions.
Here is an illustration of how one minister got in the way of the developing therapeutic relationship:
An alcoholic came to talk to his pastor and began to pour out all manner of self-condemnation and remorse. Feeling that the manís self-blame was exaggerated and distorted, the pastor sought to reassure him, pointing out that after all there were extenuating circumstances involved. Each time the alcoholic tried to express his deep feelings of guilt and despair, the pastor pointed out that things werenít as bad as he seemed to think. Finally the alcoholic left and did not return for another interview.
The two facts that this minister had overlooked were that reassurances of this kind do not reassure, and that the manís negative feelings must be expressed and accepted before they could be replaced by more positive ones. By attempting to reassure, the pastor unintentionally convinced the man that his feelings were not recognized or understood. Thus, instead of helping the alcoholic experience forgiveness, the minister had blocked the path of confession by which one moves from guilt to forgiveness.
The use of the "we" approach is a method of staying close to the alcoholicís ego by avoiding putting him in an exposed position. Otis Rice, who suggested this approach, gave these illustrations of how it might be put: "Now what can we find in the situation?" or "What can we do with the problem you have brought?" The use of "we" lets the alcoholic feel the counselorís collaboration and support in the difficulties he is facing. It puts the counselor on his side as an ally. Jellinek once told of discussing an alcoholicís relationship with his wife and of doing so, not in terms of "your wife," but in terms of his relation with his own wife. The interjection of the counselorís personal relationships may seem to some to be anathema so far as principles of good counseling are concerned. In practice, this approach seems to be a sound way of keeping the alcoholic from feeling on the spot and from raising his defenses. Since he is uneasy about his dependency needs, it is supportive to know that the counselor has needs and problems too. The example, par excellence, of the use of the "we" principle is the manner in which AAís operate in their Twelfth Step work.
The AA member stays close to the alcoholicís sensitive ego by talking about his own drinking problem and AA experiences. Thus he communicates forcefully that he is not talking down to the other person or judging him. This is what Paul Tillich once described as the "principle of mutuality," a principle that is basic in all pastoral counseling. Tillich pointed out that the counselor must communicate to the counselee the message that he understands well on the basis of his own experience. 8. Marty Mann has this useful idea concerning the pastorís approach to the alcoholic:
The pastor who feels it is his bounden duty to act as a spiritual mentor to an alcoholic who comes to him could perhaps succeed if he could recall out of his own experience some time of deep crisis or personal suffering in which he found comfort from his faith, and could tell that story simply and directly. In other words, if he could come down from his symbolic mountain above the battle and meet the tormented soul of the alcoholic on its own level of suffering; the soul could perhaps accept comfort from him and gain some of his faith. 9.
She recommends that if the minister canít draw on his own experiences in meeting personal crises, he should tell of someone he has known who has received help with the problem of alcoholism.
In the authorís experience, reference to oneís own problems or struggles is best made in a kind of "in passing" manner. This lets the alcoholic know that the minister has problems, is aware of his fallibility, and is speaking as one who shares the foibles and limitations of the rest of the human race. Alluding casually to oneís problems lessens the risk that the alcoholic will resent a comparison of what seem to him to be the clergymanís relatively minor problems with his all-consuming and devastating problem.
The fundamental way of staying close to the alcoholicís ego is by communicating acceptance in the relationship. In Modern Man in Search of a Soul, Carl Jung declared:
If the doctor wants to offer guidance to another, or even to accompany him a step on the way, he must be in touch with the other personís psychic life. He is never in touch when he passes judgment. Whether he puts his judgments into words, or keeps them to himself, makes not the slightest difference. 10.
A basic factor which influences the acceptance-climate of the relationship is whether or not the pastor really accepts the sickness conception of alcoholism. Unless he accepts it at a heart as well as at a head level, he will convey a judgmental attitude in spite of his conscious intentions. By accepting the sickness conception with all of its ramifications, the counselor divorces from his mind the feeling that he is dealing with what is basically a moral deviation or perverse habit; he accepts alcoholism as one symptom of the common sickness of our culture, in which all of us share.
Protecting the alcoholicís ego so that he will not become defensive is not the same as protecting him from the consequences of his immature behavior. The former is therapeutically constructive; the latter is unconstructive. Accepting the alcoholic does not mean approving his destructive behavior which is harmful to himself and others. It is important that the alcoholic know that the counselor, who accepts him as a person, does not approve of his irresponsible behavior. It is because the counselor accepts and cares about him and his family that he does not approve of behavior which hurts any of them. Only as the people around the alcoholic are able to be both accepting and firm will he be required to face the reality of the adult world and his irresponsible relation with it. Allowing him to avoid reality by protecting him is what John Ford calls "cruel kindness." A part of the counselorís firmness must be insistence that people who are sick have an obligation to society to obtain treatment.
The Alcoholicís Motivation
During the first contact with an alcoholic, it is essential to find out to what extent he is open to help and what kind of help, if any, he desires. If the alcoholicís initial motivation is inadequate and this is overlooked by the counselor, the usual result is that nothing productive occurs even though there may be an extensive exercise of "going through the motions" of counseling. It is an axiom in counseling that people can be helped only with those problems which they regard as problems and with which they want the counselorís help, to some extent.
In order to discover the nature of the alcoholicís motivation, questions such as these should be in the counselorís mind as he listens and talks with the alcoholic during the first interview:
What does he see as his problem?
From his point of view, is his drinking a problem or a solution?
Does he see it as a cause of his other problems or simply a way of gaining relief from them?
Does he feel that he needs help from others? From me?
If so, what kind of help does he want? (Does he want someone to pacify his wife, intervene with his boss, help him learn to drink in moderation, or help him lick his drinking problem in whatever way is required?)
Why did he come for help now? (He has had the problem for several years.)
Was he threatened or dragged into coming by his spouse?
Is there some special crisis that puts him under acute pressure at the moment, but which will pass?
Is his primary motivation for coming external pressure or internal pressure?
Why did he come to a clergyman?
Does this throw light on the kind of help he expects?
If, as the first interview progresses, the counselor finds that he is not getting clear answers to questions of motivation such as these, it is appropriate to ask enough of them to gain a picture of the alcoholicís reason for coming and the help he expects.
Generally speaking, an alcoholicís motivation is inadequate, so far as successful treatment is concerned, if he mainly sees alcohol as a solution, wants help in changing those around him or avoiding the consequences of his immature behavior, and/or comes because he was pressured (either by a person or by crisis circumstances of which he feels himself the victim). Conversely, motivation adequate to successful treatment is usually present if he sees alcohol as one factor which contributes to his many troubles, has some desire to change himself or his way of behaving, and comes primarily because of inner pain which he sees as resulting from his use of alcohol, directly or indirectly.
In sizing up the alcoholicís motivation, the key question is this: Is he able to admit that alcohol is giving him serious trouble and that he needs help in handling it? In attempting to answer this, it is important to bear in mind that the alcoholicís motivation, like all human motivation, is mixed. Few, if any, alcoholics desire unambivalently and wholeheartedly to stop drinking. That is to say, they seldom completely want to stop drinking, nor do they want to stop drinking completely. They are pulled in opposite directions by inner forces. A part of their psyche wants to stop; another part drives them to continue drinking. Put another way, many alcoholics want to stop because they are afraid of the disastrous consequences of continuing, and yet they are also afraid to stop because alcohol has become the center of their psychological universe. To some extent, this conflict is present in most alcoholics.
Thus, to ask: Is this alcoholic ready to stop drinking? is not a precise or satisfactory way of ascertaining the adequacy of his motivation for recovery. The useful question is whether his desire to stop is stronger than his desire to continue. Put differently, one can ask whether the pain resulting from drinking outweighs the satisfactions derived therefrom. Often this is not easy to determine. It is helpful to think of the alcoholicís motivation as something like a teeter-totter which tips back and forth. At times the pain of drinking and the fear of the probable consequences of continuing outweigh the craving for alcoholís anesthetic effects and the fear of life without it. When this happens, the alcoholic "hits bottom" -- becomes open to help. At other times his motivational teeter-totter tilts away from being receptive to help. A hangover period following a binge may present a "little bottom" -- i.e., a state of emotional receptivity during which the alcoholicís defenses against recognizing his need for help are temporarily cracked by the physical and emotional pain of the experience. The counselor should encourage the alcoholic to get help immediately and not "to wait until he feels better." There is quaint wisdom (which is relevant to the "fall" which is alcoholism) in the old Christian hymn:
Come, ye weary, heavy-laden,
Lost and ruined by the fall;
If you tarry till youíre better,
You will never come at all. 11.
In the light of the complexity of human motivation, the familiar statement, "You canít help an alcoholic until he is ready!" is, at best, a dangerous half-truth. The danger is that the counselor will use it to avoid his responsibility which is to discover, stimulate, and mobilize the alcoholicís latent motivation toward accepting help. Since few, if any, alcoholics are ever completely "ready," it is more productive for the counselor to ask: Does this person show a possible willingness to consider sobriety, providing he can be shown that there is a better way than the one which he has been following? This question recognizes that the person may not be able to admit his need for help (even to himself) until he has some ray of hope that help for him is a possibility. Beyond this question, it is crucial to ask: What can I as a counselor do to help this person become more open to help?
I recall a Twelfth Step call upon which I accompanied an experienced member of AA. The person upon whom we were calling mentioned that he wasnít sure whether he was an alcoholic or just a heavy drinker because he had never taken a morning drink. (Later he admitted that this was usually because he hadnít made sure the night before that he had a supply for the next day.) The response of the AA member suggests both a useful test of a personís motivation to stop and an excellent general approach to an alcoholic:
To discuss whether one is a heavy drinker or an alcoholic can easily become a matter of semantics. The important question is this: Are you satisfied with your life as itís been going for the past year, two years, five years? Take any period you want. If you are, thereís no problem. If you arenít satisfied and feel that alcohol is the cause or at least part of the cause of the way your life has been going, then the thing to do is to make a decision that youíre going to stop. Then the problem is to make the decision stick -- thatís where AA comes in.
The discussion turned in the direction of the individualís painful experience during the recent binge and his resolve not to let it happen again. The AA member said, in effect:
The problem is to make your present feeling stick -- to keep it alive. Youíre very sincere now, weíre assuming that, but how about in three months or six? AA is the way you keep the desire alive -- keep on remembering that you have a problem with alcohol. After youíve been away from alcohol for a while, you begin to question whether itís really a problem or not. AA helps keep your present desire from dying.
Toward the end of the visit, the AA member said: "You have to remember, John, that nobody really cares if you have a few drinks. Itís up to you. If you want to stop drinking, then AA can help you. But itís your decision." The purpose of such a statement was apparently to make sure that the initiative was left with John and that he did not feel that he had been persuaded to stop drinking. Here is a demonstration of the recognition that the alcoholic himself must make the initial decision to accept help (however mixed his feelings about it), before any real counseling or therapy can begin.
The extent to which the alcoholic considers drinking a cause, as contrasted with an effect, of other circumstances and problems is often a significant indicator of his degree of motivation. I remember one alcoholic who was in wretched condition, but who could not admit that his drinking was a real problem. Again and again he would attribute his drinking to his poor sexual relationship with his wife. Undoubtedly his poor sexual relationship (and the inadequate interpersonal relationship which underlay it) was a contributing cause of his drinking. But the fact that he could not recognize that alcohol was a problem per se and one cause of his poor sexual adjustment showed that his motivational teeter-totter had not yet tipped toward openness to help with his alcoholism.
The Resistant Alcoholic
Many alcoholics who come to ministers and other counselors are still resisting facing the truth about their addiction. They, therefore, resist any real commitment to help. About one third of the persons seeking treatment at outpatient alcohol clinics in one state did not return after the first interview. 12. Deficient motivation was undoubtedly a cause of many of these failures to continue treatment. Recall that Jellinekís chart (Chapter 1) showed that the mean age for "felt religious need" was 35.7; where as the mean age for "hit bottom" was 40.7. This helps explain why many alcoholics come to ministers before they are "ripe" -- open to help. I would suspect that the majority of alcoholics, at the point of their first contact with clergymen, are still resisting to a considerable degree. It is very important, therefore, to learn the skills which frequently are effective in helping to motivate the resisting alcoholic.
A pastor was completely baffled by the behavior of a man in his early thirties who in the period after his binges would come to see him full of remorse and good resolutions. Each time the minister would attempt to help him relate to AA without avail. In spite of repeated defeats in his "battle with the bottle," he was still sure that he could "lick the thing" himself. To the minister it was apparent that the man was not yet "at bottom," and he pointed this fact out to the family. To this the family posed the obvious question in its most disturbing form: "Do you mean that we must sit and watch him go down and down and down, and do absolutely nothing?"
Few things in life are more heartrending or frustrating to a counselor or to the family than to watch helplessly while the alcoholic engages in what amounts to protracted suicide. But, as a matter of fact, it is not necessary simply to wait and do absolutely nothing. The discussion which follows delineates what the counselor can do to discover and stimulate the alcoholicís motivation to accept help. The familyís role in this process will be explored in Chapter 11.
There are two general principles for work with recalcitrant alcoholics. First, avoid if possible doing anything which may destroy the possibility of developing a helpful relationship at some later time. Private sermons and pleadings should be avoided for this reason, as well as for the fact that they are utterly ineffectual. Second, attempt to sow seeds of understanding -- of the person and of alcoholism -- which may take root and eventually flower in openness to help. Implicit in this suggestion is the concept that motivation of a resisting alcoholic is a process which may extend over a considerable period of time.
In some cases, the need to help motivate an alcoholic is indicated by the circumstances under which the pastor is contacted.
A pastor received a phone call from a parishioner, Mrs. P., in which she asked in a tearful voice, "Will you please come over and talk to Henry? Heís having his problem again." Because of his strong desire to be helpful, the pastorís automatic response was to accept her plea as a challenge to his ability to help. When he arrived at their home, he discovered that Henry was quite drunk and in no mood to talk to the pastor about anything, particularly not about his drinking. In fact, he was intoxicated enough to be unrestrained in his expression of resentment toward his wife for calling the minister and toward the minister for "sticking his nose in other peopleís business!"
By responding as he did, this pastor had allowed himself to be drawn into the power struggle between P. and his wife, on the side of the wife. This naturally incurred P.ís resentment which practically eliminated the possibility that the minister might have been of real help at some later time, when P. had become more receptive. Nevertheless, having gotten himself in this situation, the minister might have salvaged something for the future by saying to Mr. P. that he had come thinking he needed him, but since he was mistaken, he apologized. If he had done this and accepted the manís resentment, the door might have been left ajar for future help.
A more constructive approach would have been this. When Mrs. P. called, he might have first determined whether she and the children were in danger of physical harm from P. If so, he would have suggested some direct action to the wife such as going to stay with relatives for a few days or calling the police if P. became violent. Further, he should have found out more about P.ís condition and attitudes during his phone conversation with Mrs. P. An important question would have been: "How does your husband feel about talking with me, at this point?"; another would have been: "Does he feel that his drinking is a problem with which he wants help?" In view of the situation which these questions would have brought to light, the minister could then have said, "It would probably do more harm than good for me to try to talk with your husband if he does not want to talk with me. It would only antagonize him and perhaps give him added reason to go on drinking. However, as soon as he is sober, I suggest that you consider telling him that I will be glad to talk with him anytime, about whatever he wants to discuss with me. If he can come to my study, fine; or, if he wants to talk but doesnít feel up to coming here, Iíll come to your home. In the meantime, why donít you keep in touch with me and let me know how things are going?" If P. does respond to the ministerís invitation -- either by coming to his study or indicating his willingness to talk with him at the P.sí home -- he will have exercised some initiative in the matter, thus improving the possibility of a constructive outcome. Coming to the pastorís study may indicate stronger motivation on P.ís part, and it will give the minister an opportunity to talk with him without having Mrs. P. complicate the interview. If P. does not respond, it would be appropriate for the minister to make a pastoral call in a few days, to make himself available to be of assistance either to Mr. or Mrs. P., or both.
It should be emphasized that Mrs. P.ís phone call provides an opening for the minister to give pastoral care to her and the children, and perhaps to counsel with her, even if P. does not become accessible to help. In many cases, a person who calls requesting help for someone else is, in this indirect way, asking for help himself.
When a minister goes to see an alcoholic at his request, it is often advisable to obtain his permission to bring a member of AA along. If possible he should find a person in approximately the same age bracket and general socio-educational background in order to increase the chances of his establishing rapport with the alcoholic. In calling on a woman alcoholic, it is crucial for the minister to take a woman member of AA with him. In general, it is wise for a male minister not to call on female alcoholics who are drinking and alone, unless a stable female AA member is available to accompany him. Taking an AA member along is particularly helpful if the pastorís visit to an alcoholic is made during the period following a binge. The AA member may be able to utilize the alcoholicís openness to help during this time in a way that the nonalcoholic minister cannot.
When the minister talks with a resistant alcoholic, in whatever setting, it is important to find out if he has been nagged or dragged to come to the minister (or let the minister come to him). If the alcoholic has come under third-party pressure, the counselorís first job is to get rid of the third party. Unless this occurs, there will usually be no real counseling relationship. If the spouse or relative is physically present, it may be advantageous to get a "feel" for the quality of the interaction between that person and the alcoholic. After this, however, it is imperative that the pastor talk with the alcoholic alone. A polite but firm request such as this usually suffices:
Pastor: I appreciate having your perspective on the situation. Now I believe it would be helpful for me to have a chance to talk privately with your husband about the situation. Youíll find a magazine in the next room.
Even if the "motivating party" is absent physically, he is present psychologically; he must be removed psychologically before a counseling relationship with the alcoholic can be established. This may be accomplished by an approach which begins like this:
Pastor: I realize that your wife thinks that you have a problem with alcohol, or she wouldnít have pushed you to come to see me. But what Iím mainly interested in at this point is knowing how the situation looks from your point of view. I can imagine that things must look somewhat different from where you stand. What seems to be the trouble, as you see it?
Hopefully, as this approach is followed, the alcoholic will sense that the counselor is not siding with the wife in the struggle between them by accepting her view as the complete and accurate picture. Equally important, the alcoholic may begin to realize that the counselor is genuinely interested in understanding the situation, including his perception of it, and he is interested in being of whatever help he can be to them. When this happens, the alcoholic begins to lower his defenses and to risk some openness with and trust of the counselor.
In removing the pushing person from the alcoholic-counselor relationship, it is important not to criticize or side against that person. The pastorís responsibility is usually to be of all the help that he can both to the alcoholic and his spouse (or other relative). The spouse may need help as desperately as does the alcoholic. If the counselorís criticisms are quoted (or misquoted) to the spouse in a moment of angry attack, the possibility of being of help to that person is virtually destroyed. Further, by being critical of the spouse, the counselor may have contributed to the worsening of an already deteriorated relationship between the alcoholic and a "significant other" who has a concern for the alcoholic, however misguided it may seem.
The wife-motivated alcoholic is familiar to most pastors. Like many other things in counseling, shifting the initiative from the wife to the alcoholic is usually easier said than done. However, its importance cannot be overemphasized. In a workshop on counseling alcoholics, at the Yale Summer School, 13. E. M. Jellinek told how he proceeded when an alcoholic had been "brought" or "sent" by a spouse. He described inviting the alcoholic into the counseling room, whereupon he would direct the conversation to some irrelevant subject. During the course of this light discussion, he might drop a few seed thoughts about the nature of alcoholism. For example, he might ask, "Have you heard about the experiment they tried at Yale?" He would then tell about the rat experiment (see Chapter 2) which he found useful in conveying to the person the reality of the physical component in alcoholism. After a while he would say, "Well, I guess youíve been in here long enough to satisfy your wife. You may go now if you wish." This approach has a kind of shock value, and it tends to put the counselor on the "same side of the table" as the alcoholic. It prevents the alcoholic from keeping his hostile feelings toward his wife attached to the counselor by perceiving him as her ally. Further, it forces the person to make a choice -- to leave or to stay on his own initiative. Respecting his ability and right to make this choice enhances his self-esteem and strengthens his relationship with the counselor. I would recommend the use of this technique in those situations in which the alcoholic remains resistant (actively or passively) during the interview in spite of the use of the other strategies described in this chapter.
It is important during the first interview to help the person verbalize his feelings toward being there. Whether the person comes under pressure or threat, on the one hand, or merely fighting his inner resistances to admitting he needs help, on the other, the counselor should assist him in getting his negative or conflicting feelings out into the open. As these feelings are being discussed, the counselor should let the person know, by his attitudes, that he respects his right to whatever feelings he may have.
Pastor: I can imagine that it must annoy you to feel pushed into seeing me.
If the alcoholicís hidden resentment is overlooked by the counselor, he may stay as tightly defended as a clam for no apparent reason. Not recognizing and helping the person ventilate such feelings accounts for the failure of many potential counseling relationships to "get off the ground." The hidden feelings about being coerced or of weakness for having to ask for help may function like a logjam blocking the flow of interaction in counseling. The log-jam tends to be dispersed as the alcoholic senses the counselorís acceptance of his feelings, including his reluctance to admit that he needs help.
In dealing with the resistant alcoholic, it is essential for the counselor to accept the personís right not to accept help. This is a right which he can exercise regardless of the counselorís preference in the matter. In some cases, the pastorís acceptance of the alcoholicís right and freedom not to accept help actually is a dynamic factor in enabling the alcoholic to accept help. Speaking symbolically, it is as though the counselor must respect a personís right to go to hell before he can be an instrument in helping him move toward heaven. Implicit in this is the principle of not attempting to push help toward a person who has no openness to his need for it. A personís "right to fail" should be respected.
In working with any counselee, but particularly the one who is resistant, it is important to discover the point or points at which he is hurting. It is at this point that the offer of help is most likely to be accepted. Often the hurt-points can be found by encouraging the alcoholic to talk about his problems as he sees them. About what is he worried, afraid, angered, frustrated, hopeless? ĎWhat would he like to see changed? Which of his wants or needs are not being met, as he sees matters? The late Harry M. Tiebout once pointed out that even the most adamantly resisting alcoholic usually has an Achilles heel and that it is the counselorís job to find it in order to reach the person with help. A personís Achilles heel -- the place where he is "motivatable" -- is the place where he is hurting, worried, or aware of some need for help.
I am not suggesting that the alcoholic necessarily be given the kind of help for which he is asking the counselor. Frequently, what he wants would in the long run work against his recovery, for instance, a loan or gift of money, intervention with an authority to protect him from the consequences of his behavior, or bringing pressure to bear to change someone else in the alcoholicís interpersonal world. What I am recommending is that the counselor begin by understanding what the alcoholic wants and then, if necessary, attempt to modify gradually his expectations of what the counselor can do.
The counselor should encourage the resistant alcoholic to talk about his drinking -- when he drinks, with whom, how he feels, what happens when he drinks? Does he see any relationship between his "hurt-points" and his drinking? Early in counseling, the alcoholic is usually defensive. He will therefore give an inaccurate or incomplete picture of both his drinking pattern and his feelings about drinking. He may be much more concerned about his drinking than he admits to the counselor at this point. But, if the counselor resists the temptation to put too much pressure on him, he may gradually reveal more of the truth as the relationship grows stronger.
Whether or not tile alcoholic gives an accurate picture of his drinking, his discussion of it gives the counselor an opportunity to plant seeds of understanding (educative counseling) and seeds of creative anxiety. Several of the following questions can be asked as they fit into the flow of the conversation:
Have you ever pulled a blank (had a memory loss) while you were drinking?
Do you ever have a desire to drink alone, just to get loaded?
Do you sometimes find yourself drinking more than you intend?
Are your "must" times coming earlier in the day?
When youíre at a party, do you ever find yourself sneaking a quick one on the side when no one is looking?
Do you ever take a drink in the morning to ease a painful hangover?
Have you ever found yourself taking a drink to get you through tough social situations?
Do you ever get a bit defensive when your wife questions you about whether youíre drinking too much?
Does food lose its appeal when youíre drinking?
Is your efficiency at work ever cut down by a hangover or by drinking at lunchtime?
Have you lost time from work because of drinking?
Do you feel that the problems in your marriage may be increased by your drinking?
Do you sometimes spend money you canít really afford on liquor?
Without seeming to "grill" the person, which would make him defensive, a few of these questions can be sprinkled into the discussion, followed by the observation that these are some of the typical early symptoms of problem drinking or alcoholism. It is well to make it clear that a person need not have all or any of these experiences to be headed for trouble with alcohol, but that they are frequently present in the early stages of what becomes a serious drinking problem.
The defensive alcoholic often will deny that he has had any of the experiences mentioned by the counselor. This does not mean that the effort has been wasted. If the person is in the process of losing control over alcohol, the odds are that he will have had several of the experiences mentioned. What the counselor may have done was to help him begin to recognize the symptoms of alcoholism in his drinking behavior. After he leaves tile minister, he may ruminate: "I certainly pulled the wool over that stupid ministerís eyes . .but I wonder if thereís anything to what he said about blackouts." Hopefully, the seeds of creative anxiety which the minister has sown will eventually flower in willingness to face the reality of his drinking problem and his need for help.
Two instruments which are "useful tools in diagnosing alcoholism" (and can be so described to the alcoholic counselee) are Seligerís list of twenty questions (see Chapter 1) and the "valley chart," (see end of chapter).. Here is an illustration of how the chart can be used with the mildly resistant alcoholic.
Pastor: It might be helpful for us to use a kind of diagnostic approach to see if you might, by chance, be on the road to the illness. Here, as you go down the left-hand side of the chart, youíll find the typical symptoms which identify the various stages of this progressive illness. Letís take a look at these to see if any of them fit.
The medical model of diagnosis is useful at this point in helping the alcoholic take an objective look at his drinking pattern. By tracing the road down into advanced-stage alcoholism, the counselor gives the person a preview of where he may be headed if he continues drinking. The road up toward recovery, on the right-hand side of the valley chart, shows the typical stages of the recovery process after one hits bottom. There is value for the alcoholic in seeing these alongside the road down, since it tends to kindle hope that recovery is possible. The chart in larger form is available from the National Council on Alcoholism (2 East 103rd Street, New York, New York 10029). The counselor who does not have a printed chart can draw his own, during the counseling interview, discussing the alcoholicís reactions as they proceed. The essential thing in all this is for the counselor to be familiar with the warning signs of alcoholism so that he can help the person recognize them in himself, if they are present.
In attempting to motivate the resistant alcoholic and in the early phases of working with an alcoholic who is gradually becoming more open to help, it is advisable to emphasize the physical component in alcoholism. Drawing an analogy between this problem and allergic reactions or diabetes is an effective way of communicating to the alcoholic that his illness is a reality -- that itís not "all in his mind" -- and that obtaining treatment is therefore essential to recovery. Psychological explanations still carry overtones of moralism and free-will-ism in our culture, whereas medical analogies seem to escape these overtones to a large degree. Most people have an allergy of some kind or know someone who has; most are acquainted with someone who has diabetes. This serves as a bridge to accepting the physiological component in the illness of alcoholism. The parallelism between alcoholism and diabetes makes the latter a particularly useful communication device. Both the alcoholic and the diabetic have conditions which are incurable but treatable. Both must learn to live within the limitations imposed by the condition and, if they accomplish this, both can live productive lives. Both conditions involve some malfunction of the organism and, if untreated, become progressively more severe and inimical to healthy living.
Helping the counselee understand the basic facts about alcohol addiction is an essential part of all alcoholic counseling. This is true even in those cases in which the person appears to be quite open to recognizing his illness and accepting help with it. As indicated earlier, all motivation is mixed. In every alcoholic, the counselor should assume the presence of some degree of resistance. Relative openness to help may lessen as the pain and the memory of the suffering resulting from excessive drinking subside. The person may begin to question whether he is really an alcoholic, since he feels so well and is obviously in competent control of his life. It is at this point that the personís knowledge of the nature of his illness, including the tendency to rationalize, can help him resist taking a course that will probably eventuate in a drinking bout. In the case of the alcoholic who has not achieved sobriety as yet, the appearance of openness to help may hide an underlying resistance; it may be a passive-aggressive way of defeating the counselor by seeming to agree and comply.
In counseling aimed at motivating a resistant alcoholic, it is sometimes helpful to point out that loss of control is gradual in most alcoholism and is, therefore, a matter of degree. The process is often so gradual as to be imperceptible to the person, particularly because of the universal human tendency to see oneís own behavior as "normal" even when it is grossly abnormal. It is also important to discover and attempt to change the personís inner picture of an "alcoholic" if he is holding to a Skid-Row stereotype which naturally excludes him. Furthermore, it is helpful to point out that one need not be a psychiatric cripple in order to lose control of alcohol. All of these procedures are aimed at removing the misconceptions which make it difficult for the individual to see his own alcohol problem.
After some degree of trust exists between the alcoholic and the pastor, the use of constructive confrontation may be in order. If the alcoholic continues to avoid the truth by rationalizing his abnormal drinking, confrontation in one of its various forms may help. The counselor may describe for him how his alibi system functions 14 and why he feels he must defend his need to drink. By showing understanding of how difficult it is for the alcoholic to let go of his alibis, the counselor may help him to do so. He may begin to become aware of the fact that it is his alibi system which blinds him to the danger signals which are present in his drinking pattern. If the alcoholic is nearly "ripe" for treatment, this direct attempt to reduce the operation of his rationalization system may be effective. If not, he may become more defensive for the time being; but, the seeds of recovery may have been planted.
Here are some of the factors which cause the alcoholic to avoid facing his need for help: 15. his fear of the pain of abstinence (life without his pain-killer); his fear of not belonging to a drinking group which he enjoys; his feeling that alcohol is all that "works" for him; the blow to his self-esteem of admitting loss of control and, in the case of a male, of his inability to "drink like a man"; his fear of recognizing that he has a socially unacceptable condition; his fear of unsympathetic and punitive professional helping persons; his fear of what it might do to his job, family, church, or social relations to be identified as an "alcoholic." It is important that these inner barriers to admitting his need for help be discussed with understanding and empathy by the counselor. If the person can bring his fears into the open, the help of the counseling process becomes available for coping with them.
Constructive confrontation may include saying to the resisting alcoholic that he appears to have some of the warning signs of addiction. If the person is obviously defensive, it is wise to understate the case and thus avoid a head-on collision with his defenses which would only make them more rigid. The late Harry M. Tiebout once told of an alcoholic who came to see him in a defiant mood. He described his drinking pattern and then demanded of Tiebout, "Tell me, does that make me an alcoholic?" Rather than giving a direct answer that the man could easily have rejected, Tiebout responded, "I suppose that what really matters is your answer to that question. But frankly, Iím glad Iím not in your shoes." Several years later, the man introduced himself after an AA meeting at which Tiebout had been guest speaker. He reported that he had been sober for some time in AA and that Tieboutís words had been a key factor in his decision to seek help.
Constructive confrontation means confronting the person with reality and helping him look at it squarely. In biblical terms, it is "speaking the truth in love" (Eph. 4:15). If the alcoholic feels the ministerís concern, he may listen, and the words may have an impact even though the person has to deny verbally that they describe the way things really are. The alcoholic may resent the ministerís picture of the truth about his drinking and its consequences; yet, in spite of this, constructive wheels may be set in motion in the alcoholicís thinking. It is important to offer help and hope at the same time one holds up reality, firmly and acceptingly. It is less difficult for the alcoholic to face the grim fact that his life is in shambles because of his drinking if he knows that there are effective ways of stopping and of rejoining the human race.
The various methods of attempting to motivate the resistant alcoholic, described in this section, are all ways of "elevating the alcoholicís bottom." This apt phrase was suggested by internist Daniel J. Feldman -- formerly with the Consultation Clinic for Alcoholism, Bellevue Medical Center, New York University. 16. He pointed out that it is possible to save some alcoholics from years of suffering by hastening the point at which they become open to help -- "hit bottom" psychologically. Feldman emphasized two factors in this process: "acceptance" and "bringing reality through." By acceptance he meant accepting the alcoholic as a sick person. If a counselor cannot do this, he should refer the alcoholic to someone who can. Obviously the alcoholic cannot be receptive to the help that is appropriate to a sickness until he accepts the fact that he has a sickness; a counselorís lack of acceptance of this fact will reinforce the alcoholicís resistance to accepting it. "Bringing reality through" is the same as constructive confrontation. Feldman advises counselors: "Keep holding the reality situation before him in a factual, non judgmental way. For example, ĎIím not saying that itís good or bad -- thatís for you to decide -- but itís a fact that your employer is just about through with you.í" It is usually better to mention the ways in which the person is hurting himself and blocking himself from goals he desires, rather than to call his attention to the harm he is doing to his family. As long as he is drinking, he will be highly ambivalent toward them. On one level he feels overwhelming guilt feelings about his harming of them; on another level (often unconscious) his drinking may be a way of expressing hostility and resentment toward them. If the counselor is able to keep the reality situation before the alcoholic without the therapeutic bond of acceptance being broken, he may move him toward openness to help.
A key factor in elevating the "bottom" of the resisting alcoholic consists of working with the spouse to "release" him emotionally. This working concept, drawn from Al-Anon, will be explored in more depth in Chapter 11. Briefly, it consists of three actions: (a) letting go of the obsessive and futile efforts to "get my husband sober"; (b) letting go of her overprotective behavior by which she has unwittingly kept him from experiencing the painful consequences of his behavior which may have been precisely what he needed to become open to help; (c) letting go of the assumption that any improvement in the family situation is totally dependent on her husbandís achieving sobriety. This third release enables the wife and children to develop their own lives and relationships, whether or not the alcoholic decides to accept help. When a spouse succeeds in releasing her husband in these three ways, a crisis is created in his psychic economy which may result in his becoming accessible to help sooner than he otherwise would.
The first two elements in release also apply to the counselorís attitudes and behavior in relationship to the alcoholic. The counselor must let go of any illusion that he can "get the alcoholic sober." Ultimately, motivation to recover can come from only one place -- within the alcoholic. Second, the counselor can be alert to the danger of unwittingly becoming an overprotector of the alcoholic.
Almost without exception, alcoholics attach themselves to those upon whom they can lean and upon whom they can depend for protection from the consequences of their drinking. It is possible for a counselor to allow himself to be used in this way. One of the Yale ministers told of working closely with an alcoholic, saying, "He recovered, but only after I too had withdrawn my support, and he was forced to return to a hospital for treatment."
An alcoholicís strong dependency needs, coupled with the role of parent-image into which the minister is cast by the emotionally immature, make it easy for unconstructive dependency relationships to develop. One minister tells of the hours and hours he spent trying to get and keep an alcoholic parishioner sober. The experience ended in failure and convinced the minister that he had made the mistake of "babying" the alcoholic -- doing things for him which he should have been doing for himself. This conclusion fits with the recognition in AA that it is not helpful to pamper or "hold the hands" of a still-drinking alcoholic.
It is essential to keep the responsibility for recovering with the alcoholic. In his efforts to "get and keep" the alcoholic sober, the minister had taken over this responsibility. This is bound to fail since no one can get or keep another person sober. The alcoholicís dependent side tends to draw the counselor into the trap of assuming responsibility for his sobriety. Some alcoholics will expect the minister to be a wonder-worker who can, by some magic religious formula, cure him of his alcoholism. This is where it is wise to let the alcoholic know, gently but firmly, that no one, including God, can cause him to recover from his alcoholism unless he takes the initiative and is willing to work at recovery. He must use his own God-given resources, with the help of the counselor, AA, and other resources, to work out his own sobriety. No one can do it for him or to him.
The alcoholicís ambivalence toward authority is a psychological characteristic which must be taken into account in counseling. The alcoholic may be relatively mature in many ways, but he is often like an adolescent in his relationship to authority, alternately craving and resenting dependence. He tries to make the counselor into an authority figure, upon whom he can be dependent and against whom he can then rebel. If the counselor falls into this trap, the counseling relationship will be seriously distorted.
In order to avoid becoming ensnared in assuming responsibility for the alcoholicís sobriety or lack of it, the counselor should strive not to become ego-involved in the outcome of the counseling process. If there is any kind of counseling in which a success drive on the part of the counselor is detrimental, it is in work with alcoholics. If the alcoholic senses that the counselor has too great a stake in his getting sober, he has acquired a weapon to use against the counselor in periods of hostility and anti-dependency. The alcoholic unconsciously senses that he can frustrate him by not moving toward sobriety. The counselor who tries too hard and thus reveals that he must prove himself by succeeding as a counselor conveys a lack of concern and respect for the person in and of himself. The alcoholic with his low self-esteem catches this feeling of being manipulated and reacts to the counselor in the same way that he would to a mission worker who gives the alcoholic the impression that he is interested in him as an opportunity to save a soul. Otis Rice once warned against the attitude of those clergymen who enjoy "collecting spiritual scalps"; this warning has its relevance for counselors of alcoholics.
The counselor should not give the impression that the alcoholicís lack of sobriety is the counselorís defeat, nor that the alcoholicís success is a victory for the counselor. Thus, he respects the alcoholicís right to drink or not to drink, and he keeps the initiative where it must be if he is to stop. How does a counselor achieve this attitude? It is not easy, for it requires a high degree of self-esteem not to need to prove oneís self or to be threatened by the alcoholicís lack of success. Most of us achieve this attitude only to a limited degree. It helps some to recognize that if an alcoholic becomes happily sober, it is because he, the alcoholic, has achieved sobriety with the help of God. The counselor, at best, is only a catalytic agent. As one seasoned worker with alcoholics observed, "If an alcoholic with whom Iíve been working gets sober, I try to remember that it may be that it occurred in spite of what I did." The same can be said, of course, about the alcoholic who does not make the grade to sobriety. Any counselor who is worth his salt has a genuine concern for his counselees and their welfare. The point that has been emphasized in this section is that the concern should be for them and not mainly for the gratification of his own need for success. A discussion of this whole matter, which could be read with profit by the minister, is found in an article by Giorgio Lolli entitled "On ĎTherapeuticí Success in Alcoholism." 17.
The counselor should use great caution in deciding to do anything that might have the effect of protecting the drinking alcoholic from the normal consequences of his irresponsible behavior. Seldom is it constructive to intervene with an employer, a spouse, or the law, to ask for special concessions on the alcoholicís behalf. Such interventions may prevent immediate consequences such as loss of a job, but the long-range results are usually negative in that they deprive the alcoholic of his right to experience the pain which might bring him to the point of openness to help. Such overprotection, as we have mentioned, has been called "cruel kindness." It appears to be kind, but its effects are usually cruel in the long run.
A psychiatrist who was connected with a sanitarium treating alcoholics described an alcoholic who had been going on periodic binges for a number of years, using the sanitarium as a drying-out place. It was only when, through a prearranged plan, the manís wife told him she was leaving if he didnít follow through on getting help, his employer announced that he was through unless he got help and stopped drinking, and the psychiatrist informed him that he would not be accepted as a patient unless he agreed to stay long enough to allow for effective therapy, that the man admitted he was licked and needed help. Before this, he had been shielded from the consequences of his behavior by the sizable allowances that significant people in his life had been making. It was when they stopped making these allowances, and meant what they said, that he was forced to face reality.
In most cases, it is not necessary to use such a calculated approach to "withdrawing the props" which have been supporting the alcoholicís denial of reality about his drinking. If the over-protectors in his life can get out of the way and stop blocking the normal consequences of his immature behavior, a tipping of his inner motivational teeter-totter toward accepting help will often occur. In effect, the over-protector sits on the wrong end of the teeter-totter, delaying the personís "hitting bottom." By withdrawing the dependency shields and allowing the alcoholic to experience the pain of being "clobbered by reality," the relative or counselor allows the teeter-totter to tilt toward getting help.
Non-addictive Excessive Drinking
The counselor should be alert to the possibility that an excessive-drinking counselee is not an alcoholic in the sense of being addicted to alcohol (Jellinekís Gamma, Delta, and Epsilon types). Many problem drinkers (Alpha alcoholics) do not respond to AA or other alcoholism treatment methods because they are actually not addicted. Instead, their heavy drinking is a direct response to the pain of a disintegrating marriage, a severe loss, frustration of a cherished dream, or a temporary depression. The drinking may, of course, worsen the marriage relationship, thus producing a vicious cycle. But, if the person has not yet moved into the zone of progressive "loss of control," the appropriate therapy is that which is aimed at lessening the pain for which the alcohol is being used as a self-prescribed anesthetic. For example, the minister may recommend marriage counseling (or offer it himself, if he is so trained), help the person work through his grief, or refer him for medical assistance with his depression, as the personís needs may indicate. If the person is not addicted, his drinking will diminish as the pain is alleviated. However, if he is addicted, the attempts to reduce the pain will usually fail. The person will not respond to marriage counseling. If the person is addicted, the heavy drinking will tend to continue, even if the pain is reduced, since the drinking is the result of a self-perpetuating inner process and not just a response to the pain.
On the subject of diagnosis, it is well for the counselor to have in mind the possibility that a person who appears to be addicted actually may be suffering from quasi-alcoholism. Ernest A. Shepherd, head of the Connecticut State Alcoholism Program, has pointed out that some persons who are psychotic, mentally deficient, pre-psychotic, or psychopathic personalities drink excessively but are not addicted. 18. The drinking pattern appears to be that of an alcoholic but when confined where alcohol is unobtainable, they do not experience the withdrawal symptoms and craving characteristic of an alcohol addict. Actually, their excessive drinking is almost entirely a symptom of the major pathology from which they suffer and which needs treatment. There are, of course, persons in all the above mentioned categories of pathology who are also addicted to alcohol. If a minister suspects that he may be dealing with a person suffering from a major mental disturbance or mental deficiency, whether or not he is addicted, the appropriate action is to refer him as soon as possible for a psychiatric evaluation.
(Above) CHART OF ALCOHOL ADDICTION AND RECOVERY:
Reprinted from M. M. Glatt, "Group Therapy in Alcoholism," The British Journal of Addiction, Vol. LIX, No. 2 (January, 1958). Used by permission of the author.
1. Psychological Reflections (New York: Pantheon Books, 1953), p. 73.
2. See H. J. Clinebell, Jr., Basic Types of Pastoral Counseling (Nashville: Abingdon Press, 1966), chapters 1-4.
3. The Vital Balance (New York: The Viking Press, 1963), p. 352.
4. This is Ernst Tichoís phrase; quoted by Menninger in The Vital Balance, p. 350.
5. "Pastoral Counseling of Inebriates," Alcohol, Science and Society, p. 454.
6. Workshop on "Therapy with Alcoholics," Yale Summer School, 1949.
7. "Pastoral Counseling of Inebriates," p. 451.
8. Paul Tillich, "The Theology of Pastoral Care" in Clinical Education for the Pastoral Ministry, Proceedings of the Fifth National Conference on Clinical Pastoral Education, Ernest E. Bruder and Marian L. Barb, eds. (Published by the Advisory Committee on C.P.E., 1958), p. 5.
9. "The Pastorís Resources in Dealing with Alcoholics," Pastoral Psychology, April,1951, p. 18.
10. (New York: Harcourt, Brace and World, 1933, Harvest Book edition, p. 234.)
11. Quoted by Wayne E. Oates in Religious Factors in Mental Illness (New York: Association Press, 1955).
12. Edith S. Lisansky, "Alcoholism in Women: Social and Psychological Concomitants," QJSA, XVIII (December, 1957), No. 4.
13. Held at Fort Worth, Texas, 1949.
14. From a paper "Criteria for Assessment and Motivation of the Alcoholic in Early Contacts," presented by Sam E. Wilson at the Utah School of Alcohol Studies, June 21, 1962.
15. Several of these are from a lecture by Gordon Bell at the Utah School of Alcohol Studies, June 18, 1963.
16. Presented at the Annual Meeting of the National Council on Alcoholism, March 18, 1955. Dr. Feldman is now with the Department of Physical Rehabilitation, Stanford University.
17. QJSA, XIV (June, 1953), No. 2.
18. Pastoral Care, J. R. Spann, ed. (Nashville: Abingdon Press, 1951); see the chapter entitled "Alcoholics," by Shepherd, p. 175.