Antabuse An Emerging Health Ca
“ANTABUSE: AN EMERGING HEALTH CARE ISSUE IN THE TREATMENT OF THE ALCOHOLIC”
written by Marc Martin
“A’ never broke any man’s head but his own, and that was against a post when he was drunk.”
. . . King Henry V., III. ii. [43]
William Shakespeare, (1564-1616)
“ANTABUSE: AN EMERGING HEALTH CARE ISSUE – – –
- – – IN THE TREATMENT OF THE ALCOHOLIC”
AN ATTEMPT TO DEFINE THE PROBLEM:
Just how many alcoholics there are is not easy to determine. No one can really be certain about the extent of this problem that seems to bring more attention to those alcoholics who are killed in an auto accident, taking the lives of other innocent victims; than those alcoholics who are killed by burning themselves up while falling asleep in a drunken stupor, or falling down stairs, or in front of a moving bus.
There have been many attempts to establish the extent of alcoholism in our country with very little success.(See also Jellinek’s article, “Estimating the prevalence of alcoholism.”, in which he modifies his formula and offers an alternative approach.)(FOOTNOTE:)[Jellinek, E. M. ( Estimating the prevalence of alcoholism), (Quarterly Journal of Alcohol Studies, 1959), vol. 20, pp. 261-9.] The method used to estimate the proportion of alcoholics within our communities in order to create a budget to be able to provide treatment for these individuals is nearly archaic. It is based on a system largely devised by E. M. Jellinek in his revolutionary book, “The Disease Concept of Alcoholism”, which simply utilizes all those who die of cirrhosis of the liver in order to make some estimate about the prevalence of alcoholism in our society. However, since no one can accurately state how many alcoholics there are in the United States, there are still some very ambitious investigations being undertaken in order to help determine the extent of this major health problem. This becomes vitally important when allotting federal, state and local funds among the various communities for their health needs. The slice of the monetary pie that is allocated for alcoholism treatment is based on just such estimates. At the present time, it is generally estimated that there are somewhere between four and six million alcoholics in this country.(FOOTNOTE:)[Anonymous, (Manual on Alcoholism), (American Medical Association, New York, 1967) p. 7.] Many think that this estimate is quite conservative and feel that the incidence of alcoholism is on the increase, which they correlate with the annual total alcohol consumption which is apparently reported to be increasing each year. (FOOTNOTE:)[(Ibid), p. 8.] Although there are no reliable statistics to substantiate the scope of alcoholism, the National safety Council provides figures that point to alcohol as a causative factor in over half of the automobile accidents in this country. There are all sorts of effects on our society which have been attributable to alcoholism, e.g. firms have estimated that the alcoholic losses about twenty-two more working days per year then their non-alcoholic counterpart. Even with all of these facts and statistics, it still remains difficult for anyone to envision how many alcoholics there may really be within your immediate social circle. If we were to accept only these very conservative estimates of the extent of alcoholism, it would mean that one out of every twelve persons in our midst are alcoholic. Perhaps if we imagine ourselves attending some regular social event such as the local P.T.A. meeting at our children’s school, and counted off each group of a dozen persons and realized that there was one person who was an alcoholic among every group; it might give us a more visual image of impact regarding the extent of this problem within our own social strata. It is important to realize that alcohol addiction disregards social class. It has been called by some, “an equal opportunity disease.”
DEFINITIONS OF ALCOHOLISM:
Jellinek in his book, “The Disease Concept of Alcoholism”,(FOOTNOTE:)[Jellinek, E. M.,(The Disease Concept of Alcoholism), (Hillhouse, New Haven) 1960.] makes some attempts to classify alcoholics into mutually exclusive classes, which he names with letters from the Greek alphabet, e.g. the “Gamma” alcoholic is that drinker who drinks periodically, rather than staying inebriated most of the time. Much of his attempt to classify alcoholics has been discarded because of the overwhelming number of exceptions and the difficulties of assigning certain drinkers to a “mutually exclusive category.” Naturally, in order provide services for alcoholics, there must be some accepted form of classification.
Not only is there great difficulty in establishing reliable figures for determining how many alcoholics we have in our society, but to compound the problem even further, we are given a number of different definitions for alcoholism. The Physicians Handbook classifies alcoholics into three general categories: viz.(Episodic excessive drinking), characterized by alcohol intoxication at least four times a year; including a middle category of (Habitual excessive drinking); to finally lump all of the persons who cannot go a single day without some alcohol consumption, and evidence some withdrawal symptoms, into the last category of (Alcohol dependence or addiction).(FOOTNOTE:)[Holvey, David N., (The Merck Manual of Diagnosis and Therapy) (Rahway, N.J., 1972), pp. 1417-22.] These classifications are derived from the commonly used Diagnostic Standard Manual which classifies mental and physical disorders.
There are also those who conceptualize “alcoholism” as a disease which can be drawn along a spectrum which begins with simple “problem drinking” and ends with “drinking like a ‘bum’.” Many individuals in the field of alcoholism are themselves, recovering alcoholics, and conceive of this linear picture of alcoholism as a useful tool for treatment since the progression is so clearly outlined.(FOOTNOTE:)[Doctor “Bob”, (Alcoholics Anonymous, “The Big Book”), (New York, 1976), pp. 571-2.] There are also those who consider alcoholism simply a life style and let it go at that. All of these different and sometimes conflicting ideas regarding alcoholism range from thinking of alcoholism as a disease which is espoused by Alcoholics Anonymous, as well as the American Medical Association. Others believe in a concept that alcoholism is purely a form of drug addiction which develops over a period of time depending on an individuals life style.
All of these “fuzzy” concepts foster a plethora of alcoholism treatment techniques that have ranged from L.S.D. and “controlled drinking”; to antabuse and total abstinence. In short, alcoholism is a condition about which there are many open questions. We are not really certain how many there are and we are not even agreed about when someone becomes an alcoholic; nor how to define the condition except for the obvious case where someone is physically addicted to alcohol. Since, there are no absolute answers to these questions, I will share the definition for alcoholism that appears to be the most universally accepted among treatment people. It is a definition supplied by (UNESCO), the World Health Organization of the United Nations. It states quite simply that any individual whose drinking of alcohol is interfering with their life in any one of three areas, (viz. Health, Work, or Interpersonal Relations) and that individual continues to drink; they are alcoholic. The reason that this is a useful definition is because it encompasses the whole spectrum of alcoholics from the “problem drinkers” to the “disaffiliated alcoholic.” It is because of this large range of addiction to alcohol that there is such a wide variance among alcoholics. Sometimes the only common thread binding alcoholics together is their lifestyle which centers on drinking behavior, whether at the corner bar and grill, or out in the bay on a boat.
DIFFICULTIES IN DIAGNOSIS:
There has been continuous efforts to discover some tool that could be used to diagnosis the alcoholic.(FOOTNOTE:)[Gitlow, Stanley E., (Alcoholism; a Practical Treatment Guide), (“Diagnosis and Recognition” by LeClair Bissell), pp. 23-45.] Recently in (Psychology Today), (May, 1983), there was an article which claims to ask individuals to tell all that they “. . . remember about your first drink.” Most non alcoholics could not even remember their first drink; while in contrast, most of the alcoholics could recall the experience which they felt was “significant” instantly and with great details. Researchers will grasp at anything that they think will lead them to some tool that can be used to diagnosis alcoholism. Because alcoholism is so difficult to diagnose and there have been several public acknowledgements regarding this difficulty by experts in the treatment field, it makes it very easy for the alcoholic to cling to a major defense mechanism, i.e. denial. Examples of this denial abound in the treatment literature and is even highlighted in the title of a book on alcoholism called, “I’ll Quit Tomorrow!” by Vernon E Johnson. It makes it easy for the alcoholic in the earlier stages to simply deny that there is any problem, especially since there is so much drinking in our culture as well as social rewards for being able to “hold your liquor.” This tends to spread the length of the addiction process out and contributes to the confusion regarding the symptoms and stages of alcoholism. Perhaps even more important, it contributes to preventing alcoholics from entering treatment.
Historically, the alcoholic was considered to be an “immoral” person who should be scorned. It was actually Jellineck’s book, “The Disease Concept of Alcoholism” that first provided the “disease model” for alcoholism and began to slowly change society’s attitudes towards the alcoholic. Later there were several popular movies that were quite sympathetic to alcoholism, e.g. “Days of Wine and Roses”, “The Lost Weekend”, to name only a few.The basic tenant of Jellineck’s thesis in his book, “The Disease Concept of Alcoholism” was that alcoholism imitates any chronic disease in at least two distinct ways:
1- If treated in the earlier stages, the prognosis is better.
2- If treatment is discontinued, the disease progresses.
Although this appears to hold true for alcoholics, it cannot seem to convince everyone that alcoholism is indeed, a disease. It is clear though, that alcoholism as a process can progress from some rather mild withdrawal symptoms, e.g. “hangovers”; to the more extreme withdrawal symptoms, e.g. Alcoholic Hallucinosis or Delirium Tremens. This can take anywhere from fifteen to thirty-five years depending on the frequency and quantity of an individual’s alcohol ingestion. Since this process is so spread out in the case of alcohol addiction, there are many “alcoholics in the making”, who have not reached a particular stage where they are forced to recognize that they have a problem. This accounts for much of their denial. It is believed that the only important person who can say if a person is alcoholic is that same person himself. Yet most often because of denial, the alcoholic is usually the last person to find out that they are alcoholic. The alcoholic denial has been attributed to the extremely slow pace of the alcohol addiction process. The reason that the addictive process is so spread out is because of the fact that ethyl alcohol is one of the slowest addicting drugs in the history of pharmacology. This means that it takes a great deal of both, time and alcohol, in order to establish the alcohol addiction. Unfortunately this contributes towards delaying an individual who is becoming addicted to alcohol from becoming accessible to treatment.
THEORIES ABOUT ALCOHOLISM TREATMENT GOALS:
All theories regarding alcoholism treatment fall into two classes, i.e. those that follow a goal of “controlled drinking”, and those who believe that the only goal for alcoholism treatment must be total abstention. The first group encompasses behavior modification treatment which “educates” the alcoholic to “learn” how to drink “socially.” The leading proponents of this theory are a husband and wife team known in the field of alcoholism as “the Sobells.”(FOOTNOTE:)[Sobell, L. C., and Sobell, M. B., (Individualized Behavior Therapy for Alcoholics), State of California Dept. of Mental Hygiene, Sacramento, California, 1972.] The Sobells are currently working at the Toronto Addiction Center in Canada. They are still the strongest proponents of the idea that alcoholics can learn to drink “normally” again. Evidence for this has appeared in other studies by the Rand Corporation, among others, but which any further discussion would take us well beyond the scope of this paper.
The major accepted treatment goal for alcoholism in this country is total abstention. Most available treatment modalities encourage, if not demand that this be the alcoholic’s treatment goal and this has received wide acceptance. It is supported by religiously sponsored treatment facilities, and most federal, state and local alcoholism treatment agencies. And of course it is absolutely espoused by Alcoholics Anonymous whose dictum regarding how to remain sober for the rest of your life is to aim for only “twenty-four hours at a time.” There are other therapeutic modalities, e.g. hypnosis, psychodrama, etc., which also maintain treatment goals of absolute sobriety, although these modalities themselves are held in less esteem than some of the other more conservative forms. These include individual supportive psychotherapy and group therapy, both of which have been acclaimed to be successful in treating alcoholics at various stages of addiction. Since the major accepted goal for alcoholism treatment is total abstention, Antabuse has become an emerging health care issue in the treatment of the alcoholic.
THE ROLE OF ANTABUSE IN ALCOHOLISM TREATMENT:
In 1947, Antabuse, (generically known as “disulfiram”) was discovered by Erik Jacobsen in Copenhagen, Denmark. It was brought to this country by Ruth Fox who was one of the individuals who pioneered its use in this country. Initially very large doses were given and there were many problems involving side effects. Antabuse is an alcohol deterrent which causes any individual with antabuse in his system to have a violent reaction if they ingest any alcohol.(FOOTNOTE:)[Fox, Ruth,(Alcoholism:), Chapter 22, (Disulfiram), pp. 242-55.] It operates in an ingenious manner by interfering with the body’s own oxidation of ethyl alcohol in the liver. The antabuse substitutes for an enzyme that helps precipitate the chemical change of the alcohol from an intermediate stage which is highly toxic. If there is antabuse present in a person’s system, the alcohol will be delayed in completing its metabolism, and its intermediate by-product called acetaldehyde will accumulate literally poisoning the person with the alcohol they themselves imbibed. Depending on how much antabuse is in a person’s system and how much alcohol they ingest, they could experience symptoms as mild as simple nausea to those as extreme as full blown shock; just as though they had been poisoned by a snake bite. Symptoms include loss of breath, vacillating blood pressure(tachycardia), etc. Since antabuse is excreted from the body very slowly, a person may be unable to drink alcohol without these symptoms for anywhere from five to fourteen days after taking the last dose.
Antabuse is widely accepted and used throughout the world for alcoholism treatment. If an individual takes antabuse, it prevents them from drinking for up to fourteen days, although it is prescribed on a daily basis (250-500 mg. O.D.) so that the antabuse level remains stable in the person’s system preventing possible side effects. Since its emergence in this country, there have been no reported remarkable side effects from therapy using antabuse. Fox reports that with an N. of 2,300, there was only an occasional skin rash in 1% of the cases which cleared up when the dosage was reduced to 125 mg. O.D.(FOOTNOTE:)[(op. cit.), p. 245.] Therefore it is accepted that antabuse is considered a safe drug which can certainly prevent drinking alcohol. The fact that it persists in the body for such a long time provides several benefits for an alcoholic.
1- Any decisions to drink must be planned.
2- Forgetting to take the antabuse can be interpreted as an
unconscious desire to drink which signals the presence of increasing inner conflicts or stress.
NEGATIVE ISSUES REGARDING THE USE OF ANTABUSE:
Many A. A. members are opposed to the use of antabuse as the sole form of alcoholism treatment. Some are opposed because A. A. follows a general principle of discouraging the ingestion of any substances which fall under the label of, “drugs.” Certainly antabuse is provided with the explicit recommendation that it should never be given to anyone without their full knowledge. In addition, there are several kinds of alcoholics with whom it is not recommended to give antabuse at all. These include:
1- Psychotic alcoholics, 2- Retarded alcoholics and 3- Alcoholics with cardiac problems.
The reason in the first two cases is simply that these individuals might not have the mental capacity to determine whether they were drinking alcohol or not. The reason in the third case is because, if that individual were to drink on antabuse, they could possibly have an extreme alcohol/antabuse reaction which might shock their already weak heart into stopping.
At this time there are several researchers who are investigating some possible health hazards that antabuse could impose over a long period of time. None of these have ever been substantiated except in very isolated cases, but it is enough to make anyone take a second look at proposing long term use of antabuse. Ruth Fox writes that she has several patients who have been on antabuse for six or seven years.(FOOTNOTE:)[(op. cit.), p. 247.] There is also the unfortunate possibility of some irate spouse putting it in their alcoholic help mate’s coffee without mentioning it. Antabuse has also been used by alcoholics to help them control their alcoholic binges. When under the gun of pressures that may cause the alcoholics to lose a job or family, and they may be willing to take antabuse just long enough to get most of the pressures off their back. But once things have calmed down, they begin drinking again.
Whether of not someone will be given antabuse will always be decided by a physician, since antabuse is only available with a doctor’s prescription. Therefore, since the determination of whether an alcoholic will be given antabuse, if the alcoholic is willing to take it; is always a medical decision. This means that there will be some agencies where antabuse is dispensed almost “automatically”; while in other places, it may be very difficult for the alcoholic to procure antabuse simply because the physician may be unfamiliar with the substance, or perhaps feel fearful of a malpractice suit if approaching retirement. In either case, there are two questions that prevail.
1- Should an alcoholic be forced to take antabuse? And 2-Should alcoholics have the right to antabuse if they really want it?
In certain agencies, where antabuse is mandatory, the alcoholic cannot avail themselves of treatment unless they submit to the antabuse drug therapy. It is thought that this type of agency policy is structured in order to make things easier for the agency rather than the individual alcoholic who comes seeking help. By making a policy of mandatory antabuse, the agency limits the possibility of dealing with alcoholic slips and possible difficult patient management problems. In other words, this policy can be used against the patient as a form of social control by the treatment agency, if it is used routinely without regard for the individual patient’s needs.
The antitheses of this situation can also exist as a negative issue regarding the use of antabuse in the treatment of alcoholism. In a large urban areas, there are usually many different agencies that care for the alcoholic at different stages of recovery. There may be an agency that specializes in the detoxification of the alcoholic, at the first stage of treatment. These are usually associated with a hospital and generally dispense antabuse as part of their treatment regime. The next stage of treatment might possibly take the alcoholic to the Rehabilitation Treatment Center, an intermediate care facility, where antabuse is discouraged and feared, since there may no longer be the complete medical back-up found in the hospital setting. So an alcoholic moving through this system of services might be discharged from the medical detoxification center, having already been started on antabuse; and arrive at the second stage of treatment only to be told to surrender the antabuse while in treatment at the rehabilitation center.
POSITIVE ISSUES REGARDING THE USE OF ANTABUSE:
The longest an alcoholic was reported to take antabuse was for over seventeen years with no ill effects. Ruth Fox(FOOTNOTE:)[Fox, Ruth, (Medical Aspects of Alcoholism), 1966, p. 28.] recommends a period of at least two to three years of individual supportive psychotherapy in conjunction with antabuse. The antabuse can be used as a test of motivation for sobriety. If after education regarding antabuse, there is extreme reluctance towards taking antabuse on the part of the alcoholic, if only even in discussion; it can be surmised that this client is uncertain of their own desire to maintain sobriety. If the client does agree to take the antabuse willingly, the treatment agency can also be fairly certain that this client will remain accessible to the treatment program and therefore will be afforded a better opportunity for successful recovery. Antabuse should never be given to anyone without a complete education about how it works and the possible effects of an alcohol/antabuse reaction. Generally the client is given a card to carry which states that they are taking antabuse and should not be administered any alcohol. It also lists the name and address of the dispensing physician and agency. Often the onset of alcohol addiction has had a long time to create an addictive life style so that the rehabilitation of the alcoholic involves changing not only the drinking behavior, but other behaviors with their roots in the psychologic, social and biologic depths of the individual. This means that it is of utmost importance for the alcoholic to maintain sobriety, so that these therapeutic issues can be addressed and it is here that antabuse can often make the difference between failure and success. The more time an alcoholic spends sober, the greater is the accumulation of reasons that motivate the alcoholic to maintain sobriety in order not to lose those benefits that sobriety has brought. Rehabilitation of the alcoholic takes time, and it is exactly that, which antabuse can give to the alcoholic. When maneuvering within the chain of services for the alcoholic, it could be the antabuse which provides the glue that will prevent the alcoholic from falling through the “cracks of treatment.”
ANTABUSE AS AN ADJUNCT TO ALCOHOLISM TREATMENT:
(FOUR CASE HISTORIES)
CASE NUMBER ONE: “JUAN”
Juan was an alcoholic who entered the rehabilitation center directly from the sobering up station where he had been started on antabuse because their policy was to make it a mandatory requirement for treatment. Upon arriving at the rehabilitation center, he was asked to surrender all medications which only consisted of his antabuse. He offered no resistance to giving up his antabuse. At the time he was assigned to me, he expressed a profound sense of hopelessness and no real desire to remain sober. It developed that through the individual supportive psychotherapy sessions, Juan rediscovered one of his childhood dreams; to become an artist. Once he regained contact with that part of himself that could be creative and begin to believe it, he was asked to set up an interview with the counselor at the Office of Vocational Rehabilitation. His purpose was to find out some more facts about planning a realistic career for himself at age twenty-nine. He had received psychological tests which showed him to be of average intelligence, but quite depressed emotionally. His interview with O.V.R. stimulated him even more and he returned very excited about the fact that the person who interviewed him at O.V.R. explained that they would provide the money and education for him to attend a school. “But not to study art,” he explained to me, “but to become a cake decorator!”
He said that he felt this was also a form of art and told me how excited and enthusiastic he felt. He reported that the counselor told him the only stipulation in order to receive his education was to remain sober for at least six months before he began his training. At this time, he had already had almost two months of sobriety, and since the rehabilitation program was limited to only six weeks, he was about to be discharged to an alcoholism half-way house which had a mandatory policy regarding antabuse. He had gone for an interview and they had accepted him. Juan had come a long way from that point when we had just met. Even the treatment team made comments acknowledging Juan’s improvement. Before leaving, he had made several attempts to procure his antabuse while still in treatment at the rehabilitation center, but was always refused by the doctor who chose to be extremely cautious about prescribing antabuse. On the day he left, he was ready to continue his treatment for alcoholism at the half-way house. He even had a contingency plan which we concocted together, in case he should have a “slip”, that would bring him right back into treatment to help prevent any further alcoholic deterioration. Juan never made it to the half-way house and has subsequently been seen drunk on the Bowery by one of our staff members. There is no question that Juan would have made it to the next link in the chain of services for alcoholics, if Juan had been allowed to take his antabuse. How long would his sobriety have lasted is anybodies guess, but the training and support of the half-way house treatment would have been a great help in promoting the personality changes so necessary in Juan’s recovery.
CASE NUMBER TWO: “MARY”
Mary was a personal friend and an atomic physicist. She was also an alcoholic. She decided that the only form of therapy she wanted was antabuse. She procured the antabuse and satisfied her husband’s plea to stop drinking. She was also told that they would have to let her go at the university where she taught if she didn’t “cut down” on her drinking. The antabuse seemed to be a dream come true for Mary. She no longer had to deal with her hangovers, nor other peoples criticism about her drinking behavior, as long as she took the antabuse. Mary told me that she never thought of herself as an “alcoholic.” For everyone knew that “alcoholics” were “bums in the street” and certainly Mary was far from a “bum.” And for a while, it really seemed to be the answer to her problem. She would never even consider going to A. A. since that would identify her with alcoholics and she was certain that she was not “one of those.” Within two months, Mary stopped taking the antabuse and got drunk. She has subsequently lost her job, her family, and disappeared. Her husband has not heard from her for over two years. In Mary’s case, we begin to see why so many A. A. members are opposed to antabuse on the ground that it does nothing to promote the personality changes necessary for recovery from alcoholism. Instead the antabuse was used as part of the denial system, actually prolonging any direct encounter with the alcohol problem. It is often argued that antabuse can only be an accessory to alcoholism treatment, which this case illustrates. Yet even if it remains “only” an adjunct to treating alcoholism;
it needs to be evaluated in order to make a determination about how antabuse can be helpful for the recovery of each individual case.
CASE NUMBER THREE: “JOE”
Joe was alcoholic who had established his life style around his drinking. He would pan handle for small change and sometimes combine what he had with other alcoholics so that they could purchase a bottle of “Night Train” wine which they would share. He had been detoxified at least forty times and was well known at all of the alcoholism facilities in his area. He had established himself as a “career alcoholic”, which the alcoholism literature phrases more politely as, “the disaffiliated alcoholic.” He was in treatment at an out-patient clinic associated with a major hospital, and their antabuse policy was simply that antabuse would be mandatory for all their clients. It was a system that worked well since most of the time it prevented the problem of having to deal with clients coming to the clinic under the influence of alcohol. Joe, however, was a decent sort of man who would never cause any trouble, and certainly if he was under the influence of alcohol; the clinic would be the very last place that he would want to visit. So what Joe would do is to “cheek” the antabuse whenever it was dispensed at 1:00 P.M every day at the clinic. He would simply place the antabuse between his cheek and his gums and swallow the small cup of water that the nurse gave him, pretending to have taken the antabuse; while waiting for his first opportunity to spit it out. Joe knew his way around these agencies and only once had a problem when one of the staff members, a nurse, suspected that some of the alcoholic patients were not swallowing their antabuse. The nurse went to a great deal of trouble pulverizing each antabuse tablet in order to insure that it was being taken in earnest. (Antabuse is not water soluble.) In a recent study to determine the degree of compliance with antabuse therapy, they reported results which showed that reliability cannot be determined through self reports, or therapists impressions. The issue raised here is once again how the antabuse is being used, rather than the antabuse itself. In this case, the clinic has assumed the responsibility to keep the clients sober. Well it is certainly clear that there is no human being that can keep any other person sober, if they don’t really want to remain sober. In order to insure a person’s sobriety, you would have to be on duty twenty-four hours a day (no napping allowed). Then follow the person where ever they go, even into the toilet just in case they should they decide to bend their elbow.(FOOTNOTE:)[Fuller, Richard K.,( Evaluation and Application of a Urinary Diethylamine Method to Measure Compliance with Disulfiram Therapy), Journal of Alcohol Studies, (March, 1981) pp. 202-7.] So when the treatment agencies, or representative staff members begin to assume the responsibility for keeping their clients sober, it becomes like a game of cops and robbers. In order for anyone to recover from an addiction, they must be willing to take care of themselves. Perhaps we should ask ourselves who would be encouraged to assume autonomy, if they already have a “caretaker” in the form of an agency, or a counselor to nurture their dependent behavior. Joe’s case illustrates how he, as an individual, can assert himself even within a system of dependency by covertly resisting the mandatory antabuse. He is the exception; the others at this agency are forced into their sobriety without any consideration about their individual feelings about antabuse.
CASE NUMBER FOUR: “JIM”
Jim appeared across the desk from me trying to conceal the anger he was feeling about being forced to come to the “alcoholism” clinic by the court judge. The court ordered client is almost always angry, if not openly belligerent. No one likes to be forced by an authority to do anything, no less to grapple with a problem that you pretend you don’t really have. Well apparently, this judge wasn’t convinced that Jim didn’t have a drinking problem because he offered him thirty days in jail or a probationary sentence of one year at the alcoholism clinic. Jim wisely choose the clinic as the lesser between the two “evils.” His drinking had caused him to get into trouble with the law and now he was sitting before me, defying me to “prove that I’m an alcoholic!” Jim told me that he could stop drinking whenever he wanted to and that he believed this was indisputable proof that he was not an alcoholic. When it was pointed out to him that many of the members of A. A. had also chosen to stop drinking ( I didn’t mention “forever”), that any alcoholic could stop drinking if they choose to and that this really proved nothing; the confrontation began. He also informed me of the fact that he was gainfully employed and supported his wife and family in a grand style. I was impressed and continued to listen to Jim until he was engaged in the therapy. Needless to report, after a great deal of discussion and some persuasive alcohol education, Jim finally decided that although he was definitely “not one of them alcoholics”; he would like to take antabuse in order to help him to “stabilize his life.” Jim was not coerced into taking antabuse. He was not mandated to take it and it was strictly his own personal choice. Once he had decided and made the commitment to remain sober, he appeared much happier and relieved. It was as though a large burden had been lifted from his back. He remained at the alcoholism clinic for over two years, staying sober with his antabuse and attending individual supportive psychotherapy sessions on a regular basis every week. He refused to become involved with A. A., but was willing to attend a few meetings to see, “what those alcoholics were really like.”(FOOTNOTE:)[Block, Marvin A., (Alcoholism), (The Court Case), p. 142.] Some of the basic changes this client worked on in therapy related to how he could focus on his own needs and go after satisfying them through his own efforts. After learning and practicing some of these new skills, he reported that he felt more self assurance or as he stated it, “I’m simply feeling more powerful.” The reason this made such an impression on me was because he had said that one of the reasons he felt a need to drink was to “feel more powerful.” If anything can be said to have contributed to Jim’s successful recovery, it would have to be his decision to take the antabuse. In the middle of his treatment, he came into the clinic and volunteered the information that he had legitimately “forgotten” to take his antabuse twice since he saw me last. With this as a clue to the fact that there were some strong unconscious “drink signals”, we worked on uncovering what pressures were impinging on his life. It turned out that the pressure was emanating from his job, but that he had been denying the increased anxiety to himself by not “feeling” it. Jim is just another illustration of how antabuse can be used in alcoholism treatment and how the results depend so much on how the antabuse is presented to the client. I feel convinced that if antabuse had been forced on Jim, it might not have become the valuable adjunct to treatment that it was.
CONCLUSIONS: ANTABUSE, A RISK WORTH TAKING?
Antabuse is somehow in a strange way, like alcohol. It is often said that alcohol is neither good nor bad. It only responds to how it is used. I feel that this concept could contribute to our understanding of antabuse as an issue that relates to alcoholism treatment. On the other hand I feel that antabuse depends so much on how it is presented to the client, and perhaps this is also true for alcohol as well. The facts about antabuse should always be fully explained to a client if antabuse is used as an adjunct to some other forms of alcoholism treatment. Bearing in mind the individual alcoholic’s needs, it can become a strong force along the road to recovery. In all fairness to the alcoholic, we must at least consider, the use of antabuse. Obviously there are many different types of alcoholics. Studies aimed at trying to discover the “alcoholic personality” always seem to end in dismal failure. For all we know, there is no “alcoholic personality, only individual personalities who succumb to alcohol addiction.”(FOOTNOTE:)[Jacobson, George R. (The Alcoholisms: Detection, Diagnosis and Assessment), pp. 13-23.] We are confronted with many different individuals who suffer from alcoholism, all at different stages in the addiction process. Any alcoholic who asks for help can be considered to be asking for antabuse in one way or another, because when an individual chooses to take antabuse, they are assuming the responsibility for their own sobriety. When treating alcoholics, there is no way to work on any of the other problems that the individual may have unless the drinking has abated first. I am always haunted by the first time I tried to help a client who wanted nothing more than to find employment. I ended up helping him to find out how he could get a job, which he then proceeded to lose within one week by going out for lunch and coming back drunk. It appears that the major difference in treating the alcoholic is that you need to deal with the drinking problem (first), and then continue to work with them as you would with any other client. As an emerging health care issue in the treatment of the alcoholic, antabuse can be that wonderful tool for accessing the motivation for alcoholism treatment in a client, and then later on, to continue to allow the client to remain accessible for treatment. For some alcoholics it can make a positive difference in their treatment and recovery; while for others it can be have an even more positive influence by providing those individuals with a tool that lets them choose between life and death. Until someone discovers the “one” way to successfully treat alcoholism; in all fairness to the struggling alcoholic, antabuse must be considered as a component of alcoholism treatment.
B I B L I O G R A P H Y
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