Counselling for Alcohol Problems

Richard Velleman

• Publisher: SAGE Publications Ltd
• Year: 2011
• ISBN:
  9781446241929
• Edition: 3
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Counselling for Alcohol Problems, third edition, is a practical and bestselling guide to working with people who have problems with their use of alcohol. It is the key book recommended by most alcohol counselling courses in the UK, including the Scottish national alcohol counsellors training scheme.

The author provides clear guidance for counsellors and demonstrates the need to treat every client as an individual, attempting to understand and therefore enable the client to understand, what they are doing and why. This new edition includes:

-New content on the current political, social and counselling context surrounding alcohol use

-A wider range of case-studies

-New ideas that help students and trainees develop the skills and strategies they need for working with their clients

-Further guidance for generic or non-alcohol counsellors who face alcohol problems with their clients.

This third edition is an invaluable resource for practitioners, both those specialising in work with alcohol misusers and those who encounter problem drinkers in the context of a more general counselling practice.

Part 1

Approaches

1	Understanding Alcohol Problems

Steve telephoned me, drunk and in tears. He had come to the end of his tether, and someone had advised him to phone me – I was his last resort. His wife, who he loved very much, had died a year ago, and he had been drinking heavily ever since. He had tried Alcoholics Anonymous (AA), and a spell in an expensive private treatment centre, from which he had discharged himself after three days. Nothing had worked. Would I help?

Sajid was depressed and drinking. His arranged marriage to Yasmin was in trouble and he was trying to hide his drinking from his wife, family, mosque and the local community. Yasmin contacted me, asking what she could do.

Sharon was worried that her third marriage might be on the rocks due to her drinking. Both she and her husband were heavy drinkers, but ‘he can hold it’, whereas Sharon was increasingly acting in ways which embarrassed her husband and others. She realised that unless she did something she might lose her marriage, but she did not know what to do, given the lifestyle which she, her husband, and their whole circle of friends had adopted. What could I do?

Mark appeared at the alcohol advisory centre one day, angry and shouting. He had been referred everywhere, it seemed to him, and no one was prepared to help because he had a drinking problem. Everyone seemed to think he could not be trusted, that he was lying to them, and that he did not really want to be helped; he knew he did want help, but did not know what to do.

Marilyn, a single parent with two young children, was lonely and isolated. Her family, her ex-partner and his family all lived at the other end of the country; social services had placed her children on the at-risk register, and she did not know how to cope. The drinking, she said, was her way of turning an unbearable situation into one she could live with.

Martin took early retirement, possibly due to his drinking, and at the same time his father, whom he had planned on looking after, died very suddenly. Martin was married, with three school-age children, and his wife worked full-time. He felt depressed, although he did not think his drinking had any relationship to any of his problems.

This chapter deals with two main questions: what difficulties do these and other clients with alcohol-related problems pose for us as counsellors? and how can we understand them? The first question will be examined quite briefly, with the rest of the chapter being concerned with terminology and with the range of theories about the causes of alcohol problems.

What difficulties do clients with alcohol-related problems pose?

Working with clients with alcohol-related problems poses exactly the same set of difficulties as working with any other client group. There are problems which all clients share, irrespective of the area with which any agency is concerned, or the issues any client initially presents.

However, in common with any other client group, there are difficulties which relate to the specific presenting problem, which could be bereavement, debt, marital crisis, and so on, but which in the case of this book is alcohol.

Let us look at these two statements in a bit more detail.

Similarities common to all counselling

Wherever we work, the types of emotional difficulties with which clients present are similar. Whether or not we work in an agency specialising in alcohol, drugs, relationships, bereavement, sexual orientation; whether we work in social services, hospitals, community teams, education; whether we work in the statutory or the voluntary/non-statutory sector – people living in today’s society have similar problems.

Clients may present with any combination from a wide range of emotional, cognitive, behavioural, and practical difficulties. They may be overcome with grief (as Steve was); depression (as Sajid was); anger (as Mark was); uncertainty (as Sharon was); bewilderment, anxiety, and so on. They may have problems with their social lives, their relationships, the law, their jobs, their health, their finances or housing.

People who have developed a problem with alcohol are still people – seeing a client with an alcohol problem does not mean that you as a counsellor will be faced with an entirely different set of issues than if you worked with any other sort of presenting problem.

The second similarity is that the counselling process is the same irrespective of the type of problem the client presents with. There are certain roles, functions, tasks and responsibilities that we as counsellors have to fulfil, which do not differ depending on the sort of difficulty a client brings (Chapter 3).

Specific difficulties with alcohol problems

There are, however, particular difficulties which relate specifically to clients’ alcohol consumption. These are usually concerned with two issues: that alcohol is an addictive drug which can give rise to problems of tolerance and withdrawal, dependency, craving, and a strong ambivalence about whether or not giving up or reducing use is either possible or desirable (see Chapter 4); and that public and professional attitudes to drinking problems are so negative that clients will often find it difficult to get help when they need it.

How can we understand alcohol-related difficulties?

This question relates to the issue of cause, and there are many theories which seek to explain the cause of alcohol problems. In particular, this field has been bedevilled for decades by the simple misconception that there is a single cause for alcohol problems. This immediately raises two further questions: what do I mean by an alcohol problem? and why am I so disparaging about there being a single cause?

What is an ‘alcohol problem’? The issue of terminology

My own definition of an alcohol problem is very simple: if someone’s drinking causes problems for him or her, or for someone else, in any area of their lives, then that drinking is problematic. If someone’s drinking causes problems with his or her health, finances, the law, work, friends or relationships, then that drinking is problematic; if it causes problems for husbands, wives, children, parents, bosses, or subordinates, then that drinking is problematic.

There are many implications of such a simple definition. It means that whether or not someone has a drinking problem is not determined by fixed quantities of alcohol, or fixed timings, but instead is a matter of negotiation by the individual with him or herself, family, friends, workplace, and society as a whole.

The idea of negotiation within context may be illustrated with a few examples:

• Within a marital context, it might be the case of a person who drinks one pint of beer a week but is married to a confirmed teetotaller: the one pint may cause problems, and will need to be negotiated within the marital context.
• Within an employment context, someone might drink half a bottle of wine during a business lunch, or might visit the pub at lunch-time with colleagues. In some contexts, such drinking has been negotiated as acceptable behaviour; yet the same drinking may cause severe problems within an industry which has introduced an alcohol-at-work policy which forbids drinking during the working day.
• Within the social context, fifty years ago someone’s ability to drive after drinking was determined by their ability to walk a straight line; now, someone’s ability to drive after drinking has been re-negotiated by society such that it is determined by their blood-alcohol level, and if it exceeds a certain amount (and they are detected by the police!) they are automatically deemed unfit to drive, and will have their licence revoked.

Someone has an alcohol problem if their drinking causes them or anyone else a problem. This idea is gradually gaining acceptance, but there are still many phrases that are in common use, such as ‘alcoholism’, ‘alcohol-dependence syndrome’ (ADS), ‘alcohol-related problems’, ‘social drinking’, ‘normal drinking’, ‘controlled drinking’, and so on.

Problematic drinking

Various ways of understanding alcohol problems have been put forward. These include the following.

As a moral issue, with people who misuse alcohol being seen as morally degenerate. They are lacking in self-control, and should become social outcasts. This view is held by many people.

As a disease issue, where the misuse of alcohol is seen as the corollary of the chronic illness of alcoholism. Alcoholics are ill, and hence need care and concern, not moral outrage. Another form of this states that alcoholism is an allergic reaction to alcohol. This view is held by Alcoholics Anonymous, and by many health and other care practitioners.

Although this disease view has been with us for a long time, it was helped along by the formation of AA in the 1930s, and especially by the publication of a book entitled The Disease Concept of Alcoholism (Jellinek, 1960), in which the author suggested there were five types of alcoholism:

• alpha – psychological dependence on alcohol, no physical dependence;
• beta – heavy drinking resulting in physical damage, but no dependence;
• gamma – physical dependence with loss of control when drinking;
• delta – inability to abstain for even short periods;
• epsilon – long periods of abstinence plus bouts or binges.

There are, of course, huge problems inherent within these distinctions. Can one distinguish between psychological and physical dependence? Or between loss of control and inability to abstain? Nevertheless, the categories underline an already apparent point: there exists great variety in the way an individual can misuse alcohol.

There are both advantages and disadvantages to using the term ‘alcoholism’. Many people find the disease concept useful, and conceptualising it as an illness has allowed a far more helpful approach to be developed within the workplace, where people with alcohol-related problems can be helped to overcome their difficulties as opposed to being sent immediately down the disciplinary route. Disadvantages include the fact that ‘alcoholism’ is often used as a generic label, implying a single entity; this in turn has led to expensive and fruitless searches for both a single cause and an all-embracing cure. Furthermore, the idea of the ‘disease’ of alcoholism suggests a medical problem, where people are physically addicted and are subject to powerful cravings for alcohol. This medicalisation links it with a whole range of beliefs concerning diseases and illnesses held in our society: treatment is the job of the medical profession; there is nothing I can do about my drinking – the solution is not my responsibility, it is the doctors’; and so on. The term also dissuades many people from seeking help either because they do not want to be labelled an ‘alcoholic’, or because they are sure their drinking, even though it may be causing some ‘slight’ problems, is nothing like the stereotype of what an alcoholic is like.

Because of some of these reasons, the World Health Organization (WHO) in 1977 suggested replacing the term ‘alcoholism’ with ‘alcohol-dependence syndrome’ (ADS). In many ways, this is an improvement. It suggests that a drinking problem can be described in terms of three factors: the degree to which a person’s drinking behaviour is abnormal; they feel there is something wrong with their drinking; or they have an altered physiological response to alcohol (tolerance/withdrawal symptoms).

Hence the definition accepts that there are three indices which need to be measured – behavioural, subjective, and physiological; these are all continua running from normal to highly abnormal; and it is possible for a person to be high on one or two dimensions without necessarily being high on all. However, although officially ADS has replaced ‘alcoholism’, it is the latter term which is commonly used by both the general and the counselling public.

Many people argue that, although the development of the ADS is an improvement, it is still a medical, disease notion of what is fundamentally a non-medical problem; although others argue that because people do develop problems with their consumption of an addictive drug, it is reasonable to use such a medical notion.

It is clear that there are both positives and negatives associated with the notions of alcoholism and alcohol-dependence syndrome.

A final way of viewing problem drinking is as an issue relating to the problems caused by alcohol, for example, problems with health, the law, work, family, social life, violence, and so on. This is the position taken by this book, as outlined earlier.

Having discussed what problematic drinking might mean, some of the other terms need explanation.

Social drinking

Social drinking is often juxtaposed with problem drinking, as in ‘I don’t have a problem with my drinking; it is purely social’. However, a person’s drinking can be both problematic, in that it has caused or is causing them problems with, for example, their health or finances and social, in that they drink in ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• List of Case Examples
• About the Author
• Preface to the Third Edition
• Preface to the Second Edition
• Preface to the First Edition
• Acknowledgements
• PART 1 APPROACHES
• PART 2 HELPING PEOPLE WITH ALCOHOL PROBLEMS
• PART 3 OTHER IMPORTANT TOPICS
• Appendix: Useful Addresses and Websites
• Index