DAVID MARKS, MD: Thanks for joining us, I'm Doctor David Marks. For the millions of Americans who suffer from alcoholism, accepting their diagnosis is an important first step. But getting through treatment can be an even greater challenge. There are many treatment options out there. What are they like? And how do you know which treatment strategy is the right one?
Joining me to discuss treatment for alcoholism are two experts. Doctor Carol Weiss. She's an addiction psychiatrist, and Clinical Assistant Professor of Psychiatry and Public Health at Cornell University Medical College and New York Presbyterian Hospital, and Doctor Richard Rosenthal. He's Chief of the Division of Substance Abuse at Beth Israel Hospital in New York. Welcome.
Before we start talking about treatment, talk to me about pre-treatment. This is the new philosophy, correct?
RICHARD ROSENTHAL, MD: Well, it's a new idea that's developed the last several years, and it comes from people that have been looking at motivation and treatment. Very often when people are identified as having drinking problems, they may not really believe itbecause there's either denial on the person's part, or they don't really recognize the potential damage that their drinking behavior is doing to their families, their job, to their bodies. So, to just go right in and say, "You have to go have treatment now" may not be a very good match-up. It may drive the person away form treatment, in certain instances.
So, in order to get the person really to make the decision that they need treatment, it's useful to have that person usually, talking to a professional to discuss the issues in a much more discussion-oriented way. It's a conversation where the person will bring up with the problem drinker issues around drinking, get them to think about what the nature of their drinking behavior is about. Perhaps they can come to the conclusion that this is something that they might want to pursue in terms of getting treatment, as opposed to sort of being shoe-horned into something which they may be sort of carried kicking and screaming into, and then really not engage in in a helpful way.
DAVID MARKS, MD:Who's doing this pretreatment?
RICHARD ROSENTHAL, MD: Typically it's addiction professionals that would be doing that. But really, just to meet with the person to discuss it and have a conversation. There are other folks that have been trained to do these kinds of interventions, some of whom are primary care physicians, some of whom are substance abuse counselors. Usually, it's somebody with some kind of professional training. That does not mean that family members can't engage in a dialog, as long as it's not coercive and punitive, which is likely to raise somebody's hackles and get them to not think about it.
CAROL WEISS, MD: If I may add, a very important aspect of the pre-treatment is that there's no commitment involved. It's non-confrontational. It's non-judgmental. But also, there's no commitment. You're just there to talk. People who drink are afraid of giving up their drinking. It's not such an easy thing for them to agree to give up drinking. So, you need to have a part of the treatment -- what we call "pretreatment" now -- where you just talk about what drinking means to them, what their fears are about giving it up. You don't have to give it up, but what are you afraid of in terms of giving it up? What are you afraid of about treatment? To just explore their fears in a very open-ended way. They don't have to commit to stopping drinking to do it.
You know, there used to be a time when people thought that you can't be in treatment until you stop drinking. Well, that's quite challenging. Once you've stopped drinking, you've really accomplished a lot of what you're trying to do. So, the pretreatment is when they're still drinking. Hopefully not during the session, butwhen they're still drinking in their lives, but are willing to talk to you about what role it plays in their lives and what their fears are about giving it up. It's really extremely valuable.
DAVID MARKS, MD: Now, this sounds very different, in fact opposite, from something we've all seen, which is one of these interventions where the family members and friends ambush a person who they think is abusing a substance. That seems to be the opposite of this.
RICHARD ROSENTHAL, MD: Well, it is in a certain way. It's essentially trying to achieve the same effect, which is to get the person to buy in to the concept that they need treatment. But this way is a very different way of doing it, which is essentially a confrontational style where important figures from the person's life are marshaled. It's not necessarily just family. It can be work associates. It can be close friends. Anybody who's been affected by that person's drinking behavior. And this is usually done professionally, with somebody who really knows how to organize this type of intervention. The person essentially is given access to all of these people who then say, "This is how your drinking has affected my life. This is what I see. This is what it means to me. This is what's happened to me because of how you are behaving with respect to alcohol."
Essentially, what it does is it tries to challenge denial. It tries to challenge the rationalizations.–Look, we all have rationalizations.We all get through life with little neurotic defenses that we use to sort of disavow little painful realities. But in the case of someone with alcoholism, it's something that's gonna blow up. It's something that's gonna get worse, typically worse and worse over time, and not only ruin the person's life, but maybe ruin the family members' lives as well, and blow up a career, and all the rest of it.
That's part of what's being marshaled, in terms of the intervention. It's trying to get that denial lifted, and really give a very clear and comprehensive view from the people in the person's life what the problem is. Then hopefully, that person says, "Okay, I get it. I have to do something now."
CAROL WEISS, MD: What I think is worth adding to that though, is that intervention should generally be a later-stage intervention. That is, it's helpful to first try to took the person, coerce them.
RICHARD ROSENTHAL, MD: I agree with that.
CAROL WEISS, MD: Right. Because it does happen on occasion that this big, massive intervention is arranged, and family members are flown in from all over the country, and the boss has to change his schedule so he can be there, and you all sit down and tell the person, "Okay, you have a problem and we want you to get help."The person will say, "How come nobody told me before this that you were interested in me getting help?" That does happen at times. So it is important to try other things first because if it is a big intervention, a lot of people, time, and money is involved.
DAVID MARKS, MD: Well, let's say you pass the pretreatment stage, and you get the person to recognize they have a problem. One of the things we hear about are 12-step programs. What is that all about?
CAROL WEISS, MD:12-step programs are sort of a core of many kinds of treatment available. But in particular, because we're talking about alcoholism, Alcoholics Anonymous is a self-supporting, self-run, peer-run group of people around the world who get together in meetings to share their experience, strength and hope about the disease of alcoholism and its treatment. It's an extremely powerful mode of treatment where peers have the greatest power, they believe, to help other peers, other co-alcoholics get better. There's so much to be said about this, but the main point is that it is this peer-run organization that's available 24 hours a day. There are meetings all over the world, all over the city, all hours of the day. There's also a support network that you can call anytime you want.
DAVID MARKS, MD: And it works?
CAROL WEISS, MD: And it is, to my mind --and probably to other scholars' minds -- the most reliably effective treatment for people with alcohol problems. For those people who go and are able to connect to the program, it's a very powerful, important element of treatment.
DAVID MARKS, MD: What's the rate of relapse for people who are just using a 12-step program?
CAROL WEISS, MD: Those figures are hard to come by because it's hard to do followup work with people in an anonymous organization, to study them. I don't know.
RICHARD ROSENTHAL, MD: It's in process now, and people have been able to work out certain inroads to try to protect anonymity, but still get some of the data. But I'm not familiar with those outcome data as yet.
CAROL WEISS, MD: But you know, if I may, not to hedge on that question, but what's important to know about the concept of relapse rate is that alcoholism is a chronic, relapsing condition. And many times people feel "Oh, if they returned to drinking, well then they failed." But it's important to realize that you have to look over a lifetime. There are people who stop drinking and then may have slips or then may have a relapse, but then can still get better.That's also a very difficult aspect of assessing relapse rate because you have to really look at the person over a lifetime.
DAVID MARKS, MD: Is a 12-step program enough?
RICHARD ROSENTHAL, MD: That's really a great question. For some people, yes. For some people, they get into the 12-step program, they get a sponsor, which is somebody who has sort of "been there, done that," gotten into good recovery, gotten good sobriety, and knows how to give counsel purely with respect to drinking behavior and how not to drink, and how to sustain sobriety, and works through these steps, which are really kind of a step-wise procedure for changing how you relate to the world, not only how you relate to alcohol, which really kind of solidifies one's character in sobriety. Lots and lots of people are out there who have changed their lives, and been able to make use of 12-step programs, and have gone on to have very very fine recovery and very good sobriety.
However, there's another group of people, often folks , as Carol said, who for one reason or other can't make use of 12-step or self-help programming or for whom that is not enough because they have other problems. Specifically, these problems can be what we would call "co-morbid disorders," other disorders, like other psychiatric disorders, for example. Profound disorders. –Perhaps people have manic-depressive disease, or what we call "bipolar disorder" today, or major depression.
DAVID MARKS, MD: They may need medication, right?
RICHARD ROSENTHAL, MD: They may need medications, and psychiatric treatment in order to both keep their mental illness under control, and be able to make use of addiction treatment. So, there's a wide range of folks out there who have drinking problems.
DAVID MARKS, MD: Well, one of the other options is an outpatient program, correct?
CAROL WEISS, MD: Right.
DAVID MARKS, MD: How does that differ from the hospital program for the very severe abusers?
CAROL WEISS, MD: Well, there is such a thing called "outpatient rehab". And this is a rehabilitation program that occurs in a clinic setting that varies in intensity. There are some programs that have early phases of the outpatient rehab where you may need to go five days a week, say from 9 to 12 in the morning, or for a few hours a day. Or, there are outpatient rehabs where you need to go two or three times a week in the initial phases. Then that eventually tapers off to once or twice a week, and then once a week.
The outpatient rehabs provide a structure that isn't available in the 12-step programs, in that you are held accountable to a counselor who is a professional, as opposed to a laypersonor a peer. There is a schedule that you're expected to attend. The 12-step program is anonymous. If you go or don't go there's not really anybody following up on your attendance. So you're expected to go. You have to pay for going. Either insurance pays or you pay, but it does cost something, as opposed to 12-step, which is free.
There are many different things that occur in the outpatient rehab. There are group meetings. Now, those meetings can be either educational, or they can be therapy groups. There's also individual meetings sometimes in outpatient rehab. There's also family meetings occurring in outpatient rehab. So there are many different modalities of treatment, many different types of treatment in the outpatient rehab.
DAVID MARKS, MD: Now, you had mentioned that alcoholism is a chronic disease.
CAROL WEISS, MD: Yes.
DAVID MARKS, MD: Do these people need treatment for the rest of their lives?
RICHARD ROSENTHAL, MD: That's a really good question. I would ask a parallel question: do people with diabetes need treatment for the rest of their lives? Do people with chronic heart disease need treatment for the rest of their lives? There's a lot of stigmatization of addiction in this country, and really worldwide. It's time people recognized that these are bona fide illnesses. And because they're bona fide chronic illnesses, they need chronic treatment. That is not to say that you necessarily need the same intensity of treatment, lifelong. But, I have a patient who was sober for 40 years, and relapsed. It was as if he had not stopped drinking. He went back into fullblown alcoholism after 40 years of sobriety.
DAVID MARKS, MD: So it's really like any other chronic disease.
RICHARD ROSENTHAL, MD: That's correct.
DAVID MARKS, MD: In that you have to be vigilant,.and you may require treatment on a long-term basis.
RICHARD ROSENTHAL, MD: That's right.
DAVID MARKS, MD: Okay. Is thereany advice you can give a person that would help them stick with the treatment, very briefly?
CAROL WEISS, MD: To help them stick with it. Well, it depends on what treatment they're in. When it comes to how long do you need treatment,different treatments have different expectations of the patient. If you go to 12-step programs, they believe that you have this disease for life -- well, we do too because we think it's chronic -- but that you should be going to meetings your whole life.
If you go to an outpatient rehab, they may have a very set period of time that they expect you to attend. Six months, let's say. Then after that, you're on your own, hopefully, to attend 12-step meetings on your own or to come back when you feel you have a problem. So in terms of "Can you stick with it," you need to look at "Have you completed the program as it's been prescribed?" If you haven't, and if you think you're ready, and the other people don't think you're ready either, your therapist or your sponsor, you have to talk with them about why you think you're ready to quit and they don't.
DAVID MARKS, MD:Good. Carol Weiss, Rick Rosenthal, thank you for joining us.
RICHARD ROSENTHAL, MD: Thank you.
DAVID MARKS, MD: We hope this webcast has been very helpful. Thank you for joining us. I'm Dr. David Marks.
©2007 Healthology, Inc.