The Biology of Alcoholism: Volume 5: Treatment and Rehabilitation of the Chronic Alcoholic

646 Pages·1977·32.44 MB·English

by  Benjamin Kissin (auth.)

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