Alcoholism Class -E

Alcohol is found in medication, cleaning detergents, food, perfume and chemical materials.

Alcoholics are addicted to methanol and not to a specific type of alcohol. If they are desperate for alcohol they will drink anything with methanol in it.

Beer is the most popular type of alcohol. Beer has 4%-6% of alcohol. Black beer has 0.5%.

Wine – sweet, dry, semi. Prepared by boiling and fermentation. Sparkling wine with CO2. Alcohol with bubbles increases speed of becoming drunk. It gets absorbed faster into liver.

Stiff drink: 45% alcohol. Made from materials such anis, potatoes, rice etc. Wanted to reach the soul (SPIRIT) of the material. Preparation through: הבשלה, התססה ,זיקוק

Comparing drinks: 1 can of beer (100ml) = 1 glass of wine (30ml) = stiff drink (30ml).

Alcohol is dangerous but is a drug. It is a depressant of the nervous system. However, in the first stage, it often does the opposite to our behaviour. It has the same effect like Valium. Has effect of euphoria, decreasing anxiety etc. Alcohol enters the system and once it reaches the brain it depresses our inhibitions (everything that makes us normal- morals, logic, manners, embarrassment, humility, judgment). We loose our “breaks”. Alcohol gives one a sense of warmth when one drinks it. It broadens the blood vessels and actually decreases body heat. Beer makes one thirsty because it causes a person to urinate and loose bodily fluids. Does alcohol improve sexual activity? No, it decreases inhibitions but it is a depressant. Alcohol increases the drive but decreases the ability. When alcohol is normatively used it is fine, but when it is abused it becomes very dangerous.

Slowly and during meals because so that it is absorbed slowly. Add water or ice etc to dilute.

Using alcohol negatively: adding bubbles; cocktails; empty stomach; with medication.

After drinking…

Can be used to warm part of the body. It’s a disinfectant. French: Eat red meat but do not have cholesterol, because red wine decreases it. Kidney problems: A person should drink beer because it increases urination.

Longevity: Those who drink moderately; those who don’t drink at all; those who abuse alcohol.

Alcohol is very dangerous when taken with medication. Either it increases the intensity of the drug or cancels the effect or reverses it.

Alcohol has many calories 45% - 1760 calories per bottle. There are wasted calories (when they drink and eat, alcoholics put on weight, but in later stages then only drink and the calories are wasted).

Alcohol has a status in our society. People can sit over a drink and improve their conversation. The social use of alcohol is widespread. Alcohol has sexual connotations: names of drinks (orgasm, blowjob etc).

At the end of the 19^th century a protest group rose and went out against alcohol. They believed that alcohol destroys families and is a destructive force in society. Many states adopted this approach. In 1920’s there was a ban on alcohol (use and production). This did not last since there were mafia bootleggers who sold alcohol. In the 30’s alcoholism was referred to as a disease. In these same years self-help groups were first founded. These groups referred to it as a disease of addiction. Why is this behaviour a disease?

5) A person is sick, stabilizes, but is at risk of falling again. The more this spirals the more chance he has of falling. These are chronic diseases and a person will never be healthy. There is a gradual degeneration of the person.

In addiction a person becomes sick over a space of years. He gets treatment and becomes healthy again and can function but he is at a constant risk of falling again. It is like being allergic to something and a person remains allergic for life.

Chronic; procedural; progressive process; fatal life threatening disease; incurable disease where a person can only be rehabilitated and not cured; bio-psycho-social disease.

Definition (WHO): Alcoholism is a chronic disease, progressive, and potentially also fatal. Characterised by suffering סבילות and physical dependence; pathological changes in behaviour resulting from alcohol.

How does it happen that some abuse alcohol, others enjoy drinking it and others can’t even take a sip…?

שתיינים – Enjoy drinking, a culture of drinking but are able to control themselves.

Experiment: 10 monkeys were given alcohol. Two of them didn’t want to drink at all and 6 returned to drink more. Why do we see these differences?

Lets take 100 of the “drinkers”. In time 20% will develop a psychological need for alcohol. It will fulfil some kind of personal need. The will use alcohol more frequently and in larger dosages. 20% of these 20% (4 people) will develop a physical craving.

Psychoanalytical Theory: Speaks of a fixation in the oral phase. Those infants who did not complete the oral stage successfully will be attracted to alcohol during adolescence. This theory is not applied to treat alcoholism in the world.

Behaviourist Learning Theory: An alcoholic is an addictive personality. It is an infantile personality. Infants are characterised by dependence, immediate gratification, extremity and instability. When the adult faces a problem and he feels that there is something that can solve his problem and helps them function. They are not able to delay gratification and they know that alcohol works for them. This is emotional psychological alcoholism. Physical craving for alcohol is definitely referred to as alcoholism. There is no reason by someone becomes physically addicted or psychologically addicted.

The process of addiction to alcohol is slow and can take up to 10-15 years. In children the process is much faster.

Alcoholism has detrimental affects on the body, both physically and mentally. Alcohol users are depressive have paranoia and unique cases of psychiatric hospitalisation with schizophrenia like affect (psychotic, hallucinations etc). Form a physiological point of view there is a destruction of brain cells, memory deterioration and liver injury.

The disease is not that they are drinking; rather it is that their body cannot take alcohol. We cannot blame anybody until he knows that he is forbidden to drink.

People who seek treatment are in a very poor state – they have reached the bottom.

Who is the most important person in my life, who would I do almost anything for? What is most precious property? What quality is my favorite and that I’ve very proud of? What is my personal secret?

These are the most important things to me. How would I feel if those who are most important to me would rather consider me dead? Or that one threw away his most precious possession or lost his best quality. This is reaching the lowest bottom, valueless. This is the situation that people come to treatment. They are at there lowest. They are also addictive infantile personalities. We can usually see that these people were warned but didn’t pay attention but when they decide they want treatment they want it immediately (immature; immediate gratification).

The goal of treatment of alcoholism is rehabilitation. This means the desire to live a normal life without alcohol. In rehabilitation there is no talk of cure or health, rather they remain sick people who are able to function. Social workers often deal with rehabilitation and most rehabilitation workers are social workers.

The first stage is stopping to drink and then the next is change. Withdrawal will not be maintained if it will not be followed by change (in perception, way of life, behaviour etc). It is difficult to make or keep a change if it was not preceded by withdrawal. The ideal situation is that a person comes to treatment, stops drinking and makes all the necessary changes and returns to function. Another person goes through all the stages but does not make a change (he doesn’t drink but doesn’t do anything else either). The first has failures but he picks himself up again and continues functioning. The medal thus goes to the first. Success is measured according to the goal that is to return to normative functioning. Therefore withdrawal alone is not the goal but only a means to the end. One can learn through mistakes. Almost all alcoholics after withdrawal try drinking again to see whether they can beat the method and not fall again. They learn through these mistakes.

Sometimes there are compromises – therapists accept semi-withdrawal for a certain time (e.g. providing syringes to junkies to limit disease transmission; institutionalize prostitution).

Change can be attained through psychosocial means. Treatment is psychological (individual and group intervention), social (rehabilitation; occupation, family etc), medical intervention (support in the rehabilitation process which helps the person to balance himself).

Antabus is a pill that interferes with the process of absorbing the alcohol in the liver resulting in liver poisoning. This pill cannot be taken if a person drinks. This pill is like a personal policeman that warns a person not to drink.

An activity is stopped. It can be total (alcohol and drugs) or partial (cutting down on eating). It is not easy to go through withdrawal. It is like stopping to do something that one does very frequently every day. Social workers are asked to refrain from a behaviour for a week so that they can feel what its like to withdraw.

Includes stopping to drink and preparing to see a psychological change. This change in behaviour is purely technical and there is no need for consciousness and there is no need for a therapeutic agent. The preparation needs to be conscious. Part of the preparation is in the content and the person needs to internalize the process of knowing what it is like to wake up in the morning and not to drink.

1) Need of a framework or context: The conditions in which the withdrawal will take place. In this context a person needs to take responsibility. In the stage of preparation he is just planning his withdrawal but still drinks and this can take up to 2 months. We provide the framework and the person decides.

2) Processing the separation from the alcohol: Similar to the stages of mourning. They ask themselves how they will cope without the alcohol which was always with them in good and bad times.

3) Recruiting support: A person needs to know which stages he will go through and this gives a sense of control. A person needs to recruit his friend who will be there to support and help.

4) Practice: They need to put there day into details and to practice mentally how they will cope minute-by-minute to avoid taking a drink. Sometimes alcoholics are asked to write a goodbye letter to alcohol.

A person decides on a day that he is going to stop drinking. Withdrawal needs to be absolute and total – refraining of all types of alcohol or types of cakes with alcohol.

In one shot – this process needs to be done in one shot and not gradually, unless the person has extreme heart problems or only in extreme cases.

There may not be any and there are no substitutes for the alcohol. There is no synthetic alcohol. There are however pharmaceutical medications such as Valium which can be a substitute because it is a depressant.

Belief – a person needs to believe in himself that he can succeed to stop drinking. They are able to stop in one day because they understand that they have to stop. Belief helps one realize that he has the strength to do it. Often success is connected to belief that one can succeed. This factor is much stronger that the others.

Rituals – there needs to be some kind of ritual. The day that they stop smoking they may connect to their birthday. (Symbolically I wrote the date of Rosh Hashana and Yom Kippur on cigarettes when I stopped smoking).

But then there are crises. These are called withdrawal symptoms. The body is used to alcohol and now needs to cope without. The first reaction is shaking, trembling, dry mouth, excreting body fluids (sweating and defecating), nervousness, restless.

DT – Delirium Tremens/ Tremble. The only treatment is hospitalization. They hallucinate and have delusions and can imagine all sorts of things with life threatening consequences.

In addition to the physiological symptoms there are psychological symptoms. There is insomnia because the alcohol would put the person to sleep. The alcohol weakened their mechanism that allows them to go to sleep. There are also interferences in thought association and concentration.

These symptoms are frightening to alcoholics and those who experienced withdrawal want to avoid it. Today an injection can be given so that the person does not feel that process. The physical symptoms of withdrawal disappear within a few days. The psychological symptoms can take up to two weeks or three.

90% of those who come to treatment are able to withdraw… the problem is maintaining the change.

Increased awareness: This is a process of internalising the knowledge. Knowledge is often an obstacle because it is difficult to teach someone who thinks he knows. Those who have knowledge can help others but not themselves.

1) To admit that they are sick. They need to say that alcohol has taken control over their lives and that they are alcoholics. They need to realize that they are disabled – they will never be able to drink again.

2) This is a chronic disease – a disease for life and a person will never be able to drink again. This is an essential change that needs to be made. They often say “just for today” – they live day by day and do not plan ahead. This is a way to live with not ever being able to drink.

3) Responsibility: Alcoholics tend to blame everybody and everything for their alcoholism. As long as the person makes excuses for his behaviour the responsibility is shifted. They usually say that something happened and consequently they began drinking. This is also shifting the responsibility. We know that this is not true. Events do happen and they lead to feelings of hopelessness and sometimes one does not know what to do. Sometimes we get advice and help with the problem. Usually we use productive means to solve the problem. The alcoholic uses alcohol to deal with hopelessness! Usually people turn to other agents (help, treatment, friends of in extreme cases suicide). The event is only the trigger.

Therefore we don’t need to ask “Why do you drink?” but “For what do you drink?”. The responsibility is then shifted onto the alcoholic. If doesn’t matter why he started drinking what matters is that he made the choice to drink. Once he has this awareness he can chose from a number of options to solve him problems.

5% off the events – to refrain from events, and people associated with feelings. Places and people who irritate us and those who make us happy. Therefore the alcoholic needs to avoid those who make him nervous, which results in drinking alcohol.

Most of the treatment should be invested in how a person reacts when he is hopeless. When he is hopeless there are a number of options – drinking is just one of them.

4) Injuring others: This is difficult for an alcoholic to accept that he hurt others. They deny that they hurt others. They were not there for their loved ones when the latter needed them.

Denial is on the opposite polar to awareness. Denial is not a lie. A person who is in denial says something and believes that what he says is true. A lie, on the contrary, is conscious. Denial is not a negative thing – maybe in comes in extreme dosages and then they seem negative. People who are coping with mourning usually use denial as a defense mechanism. When a person in not able to contain the painful truth they protect themselves by wrapping themselves in denial. Denial helps alcoholics to survive and to continue as if nothing has changed.

The largest circle includes statements like: I’m not an alcoholic; I just drink every now and again. No, others are exaggerating. When a person doesn’t admit to having a problem it is very difficult to help him.

An internal circle is … OK, I have a problem and when I want I will stop. He wants the responsibility to decide when he will stop. We can work with these people – because they know that they need to stop but do not have the courage to do so or do not know how to do it. They do not understand that they need to stop – they are not 100% sure about stopping.

When a person comes to treatment he acknowledges that he has a problem and says that he cannot help himself. Many tried helping themselves and after failing sought treatment. In treatment there is also denial. The person does not want to sit with the other alcoholics because “he is not like them”. He also believes that after he receives treatment he will be able to control his alcohol intake. He also denies hurting others.

He rejects the therapist, who is his worst enemy because he wants to help him. They reject anyone who tries to help them. They feel that everyone is against them.

1) We must not turn the denial into an issue. With time it will be easier for them to talk about it. With group work a person becomes less inhibited and engages in self-exposure. He also has an opportunity to hear others. Alcoholics often consider suicide in order to save the family and friends. In the group there are others who speak of these suicidal thoughts. A person in a group feels safe that he can express himself in the group.

2) We can deal with denial paradoxically: If a person is in denial we can tell him that he can leave if he does not need treatment. The person then needs to persuade the therapist that he has problems.

3) Empathy or acceptance from others: Even the therapist can say that if he was in his situation he would not know if he would have the strength to cope. It’s normal that it is difficult.

4) Confrontation: We ask the alcoholic to focus on the facts. There are instruments to test whether someone drank. Or there is a smell of alcohol in their breath. Also we need to confront the alcoholic with things from his past (relationships with family).

He needs to be confronted with pain he caused his family. The entire family needs to be present during the confrontation. Facts need to be presented. The things must be said with love and care. When the painful facts are wrapped in love it is better heard.

Alcoholism is a family illness because it affects the entire family to one extent or another. Here we are not referring to heredity. We are talking about the process and how the alcoholic interact with each family member. Each person plays a part in the process and therefore each family member plays a role in helping him. The family needs to go through a change if the alcoholic is to make a change and to maintain it.

All those who gradually become addicted to the alcoholic and to living with him. They loose their ability to control themselves and dedicate their lives to the other and to helping him. Consciously we can admire them and their willingness to help, but in actual fact the co-dependent is worse. Addiction, even to something positive is a negative thing. The family never takes care of themselves and their needs because they always have the “alcoholic” in their mind. When the alcoholic knows that there is someone who will always take care of him or save him when he falls he can continue drinking. They serve the alcoholics needs. The co-dependents are therefore maintaining the behaviour of the alcoholic. Family members also need to be referred to in treatment.

Is it by chance that a woman marries an alcoholic? No. People find the most appropriate partner even though the relationship is unhealthy. Some marry people who are similar to them and there is harmony, while others marry those who complete or complement them.

A research on alcoholics’ wives: Hundreds of alcoholics’ wives were questioned. One out of every 4 women had alcoholic fathers. The girl may identify with the mother and her role and helps the mother cope with these issues. She adopts the role of one who knows how to cope and treat alcoholic men and consequently marry them. May of these women married men, knowing that the man was already an alcoholic. There is an intergenerational connection.

1) The dominant woman: Maybe she was dominant from the beginning and the alcoholic man marry her knowing this and is dependent on her. Some women become dominant with time and their husbands become weaker and more dependent. Sometimes the wife get secondary gains from her husband’s problem – she feels strong and powerful. These women are like internal terrorist who prevent their husbands from being rehabilitated. האישה החבלנית

2) The caretaker: A women who always needs someone to take care of. They dedicate their lives to taking care of others. They need to have a weak, dependent husband. Once he is rehabilitated she has no meaning in her life and does not know what to do.

3) The suffering battered wife/ the victim: She always lives in the shade of a strong and aggressive husband. She runs away to a hostel but always comes back. She feels that she is to blame and maybe she said something that hurt him. They return either because they feel things will change or because they feel that this is their place or that they know how to function only in a situation like this. They have secondary gains from their husband’s alcoholism. She is very powerful in her passivity. The husband projects strength and power but this is just a façade. Using strength is an expression of weakness. A person who hits has exhausted all other resources.

They are the true victims because they did not choose to be born to alcoholic parents and they have a genetic predisposition. In a family study, 45% of alcoholics are children of alcoholics. The fathers of male alcoholics and mothers of female alcoholics were alcoholics. In Russian populations there is even the second and third generation of alcoholics. Among the Arab population alcoholism is a new phenomenon.

Children adopt behavioural patterns of a significantly parent through socialization. One of the children chooses to drink as a way of coping because this is the behaviour that he modeled at home.

1) The Parental Child (usually the firstborn): This child is very successful but because of the parents weakness the child adopts the parental role. He takes care of the siblings and often replaces the mother, aids her and listens to her. He is also encouraged thought the positive feedback that he receives by helping his mother. He substitutes the weak father. He is the internal terrorist because he wants to maintain his role.

2) The Scapegoat: He adopts this role and volunteers to be the one who gets the blows in order to protect his siblings. He often is provocative to declare that there is a problem and to have someone pay attention. They are troublemakers not by nature but because they play the role.

3) The Lost Child: He is a quiet child who copes by avoiding the situation -מתעלם. He creates a fantasy world and denies the reality. He creates internal friends and drowns himself in a world of books. They have mental problems and the boundaries between reality and fantasy are blurred and they often life according to the fantasy.

4) The Cameo Child: He is often the last-born. He is a clown, the special nice child. It is forbidden to shout in his presence and a lot of hope is put into him and often he cannot fulfill the role. When he enters the room everyone becomes silent and therefore he clams the family atmosphere.

Lack of security: One never knows what will be tomorrow – it depends on how the alcoholic will behave.

Embarrassment/ Humiliation – בושה: Children are often embarrassed of the alcoholic father who makes a fool of himself at school or at a wedding. These families often avoid humiliation by alienating themselves.

Violence associated by fear: There is a constant fear that a father will beat them when he is drunk.

Lies and faithlessness – חוסר אמון: In order to survive the drunk lies to his wife; and the wife lies to her son and the son lies to his friend. Everyone knows that everyone else is lying.

Guilty feelings/ consciousness: Children often place all responsibility on the mother and hate the father. They are angry with the mother because they say she could have done something but didn’t.

Family sculpture/structure – creating a family by means real people. The more a person “falls down to the floor” the more each person knows his place and knows how to behave.

The group leader then asks the fallen alcoholic to go to treatment (i.e. to rise and stand). How does this affect the entire family? Change shakes the system even though it is a positive thing.

There is a struggle over roles. There is no longer anyone to blame – alcoholism is just an excuse. It is then revealed that the family has other problems and that they cannot blame everything on the alcoholic.

Security/ Faith – אמון: The family often doesn’t have faith in the alcoholic who stopped drinking.

The problems do not stop after withdrawal; sometimes they intensify, other times they change.

Today we will discuss the sociological aspects of alcoholism. No single social factor causes a person to be an addict. A person becomes an addict because of psychological factors but the social factors provide the environment in with addiction can develop. There are direct and indirect factors.

1) The Formal Level: To what extent can the law encourage or decrease alcohol drinking. To what extent should there be complete freedom and people are responsible for their own lives. Or should we return to the dry period. Or is there something in between (limited to % of alcohol; age; time-limited; personal state etc). The influence of law and its ability to be enforced is shaky. Law is only affective if the law is passed before the norm has been determined and not if it is passed after the norm exists.

2) Semi-Formal Level: This is determined according to religion. For example Islam forbids alcohol. Judaism encourages drinking in limitations – in is a mitzvah to sanctify holy days with alcohol. In South America certain ethnic groups use alcohol and drugs as part of the religious ritual. Alcohol is a part of India’s mourning processes.

3) Informal Level: This level has the strongest influence. The society is tolerant to drinking alcohol. A conservative moral society adheres to certain social norms and all those who belong to the community live according to these norms. The social norms and value system determine the behaviour.

1) Social Insecurity (economic, occupational etc): A society like this has citizens who will chose the easy way out to cope with their problems. Youth who were witnesses of terror reported using more drugs and alcohol than their counterparts.

2) Well-Based Affluent Society: They have everything and are well based and therefore they search for excitement. In the UK the greatest problem is alcoholism. Scandinavia countries are well off and also search for excitement. Also in the north they drink high-class alcohols while in the south they drink hard chore Arak.

3) Immigration: An immigration society is characterized by insecurity and consequently substance abuse. Immigrants use substances to help them cope. Also homeless use alcohol - almost 80% of them are new immigrants and 60% have alcohol problems. When a society with ambivalent attitudes towards alcohol absorbs a society with clear attitudes towards alcohol the society’s attitude will shift towards the stronger attitude.

There are two myths: Jews don’t drink; alcoholism cannot develop in such a hot climate.

1) The dry period: Before the establishment of the state few Jews drank and they were mainly the bohemians. Also the English drank and Israelis didn’t want to identify with them.

2) Despair associated drinking: These people were not helped. Only in the 60’s was the first time that the influences of alcohol were addressed.

3) In the 80’s we have despair associated drinking and affluence associated drinking. Along with the prosperity, pubs were opened and people began to drink. Once a social phenomenon exists in a society (despair associated drinking) the society doesn’t react but once it permeates the middle and high-class society it becomes a social problem. This began in the middle of the 70’s.

4) In the 90’s the culture of drinking began with immigration (both Russians and Ethiopians have drinking cultures).

During the despair associated drinking stage some form of treatment became available but it was intended to save the children. When drinking permeated into the “good society” they used the family to help the alcoholic. Today treatment involves treating the alcoholic and his family – systems theory. There is clinical/ ambulatory treatment today. In some cases there is hospitalization. All the treatment is given by social workers.

There is social alienation of the alcoholic himself. But there are also social injuries:

1) Violence, deviance, criminality: Alcoholics are involved in these behaviors because they are drunk. They may be involved in familial and social violence while under the influence of alcohol. There are no dealers, no law that forbids drinking or drunkenness. What does the law have to say: A person commits a crime and claims to have been drunk. Can he use this claim? The Israeli law can use this excuse but the person must prove that he was temporarily unconscious אי שפיעות and that someone made him drunk. Till today not one has succeeded in proving these two things. But there is lenience because the act was not intentional.

2) Driving under the influence of alcohol: 10% of all accidents are caused by alcohol abuse. One cannot drive with more than 5ml of alcohol in his blood.

3) Youth drinking: Today drinking among youth is widespread. There is no law against youth drinking. The law forbids the perpetrator from selling but does not forbid the child from buying. Also it is allowed to sell alcohol to a youth in a place where the alcohol cannot be drunk (supermarket).

The only thing that the members have in common is their addiction to alcohol and their will to get treatment. Otherwise they are a very heterogeneous group in all other aspects.

1) Sense of belonging: We are social beings that desire to belong to a group. When alcoholics come to treatment they loose many of their groups of belonging because they are often rejected. In the framework of the center and group they have a sense of belonging. Each AA member knows that it doesn’t matter where he is and what time he is never alone because almost in every western country there are AA groups. They have a sense of belonging almost everywhere.

2) Common experience: When one talks everyone feels that he knows exactly what he is talking about. They feel that they have been there. There is complete identification and this is strongly put across. There is also the ability to raise contents that are difficult to talk about on an individual level. It is easier to talk about it or to face the pain as a group because one does not feel alone. May alcoholics are victims of incest and they themselves have committed these deeds. If there are others it the same boat it facilitates understanding and working together without judgment.

3) Common coping: It is easier to cope in a group. There are many questions that alcoholics have (should they keep alcohol at home or not; should they say they are alcoholics at a job interview). They have an opportunity to share their own experiences and others can learn from their experience and how to cope. They do not give advice but talk about their coping from their own experiences.

4) Social pressure: There is always social pressure and therefore what is important is ones ability to stand firmly against the social pressure. If people think contrary to the social norm what is important is there ability to stand by their word. In a group situation there needs to be a majority who have withdrawn and function. Group members want new members to come in the following work and to report on how many days they are dry. Sometimes the majority drinks and they can cause the rest of the group to relapse.

1) Changing behaviour: We can provide acceptable norms for alcoholics. A therapist can be honest with his client (he can say – you stink etc). This can lead to change in behaviour. The client must dress properly when he comes to treatment (clean clothes). They need to come on time because if they are late they are not allowed into the group because they are disrespectful to others who arrived on time. Some don’t speak in groups because they are shy while others are monopolisers. A group is a suitable place to reflect these patterns of behaviour.

2) Changing values: They need to learn to listen to others and what they are really saying and not just to hear. People who only see themselves and their difficulties find it very difficult to listen to others and their difficulties. They also learn responsibility and how to make decisions and have integrity to stand behind their decisions.

3) Enjoying a non-drinking social meeting: They come to spend an entire evening (watch TV, chitchat, talk etc) without one drop of alcohol and this is a rectifying experience because it proves that they have the ability and don’t need the alcohol.

4) Economical - חיסכון: The group is economical because one doctor can come to lecture an entire group.

Bill Wilson in the 1920’s was a war veteran and a successful stockbroker. He began drinking although he was successful businessman. In 1929, during the economical depression he increased drinking and became an alcoholic. Was hospitalised and withdrew for short periods. He once spoke to a friend and it helped him. After his second withdrawal he would talk to alcoholics in the street. Bill felt that he needed to talk to another alcoholic. It worked. They went in search for alcoholics who wanted to withdraw. They invited them to meetings.

1) Way of life: AA groups are not therapeutic – it is not a type of treatment, rather it is a way of life. Treatment is a situation in which there are at least two people, on different levels (one is a practitioner, the other the client) and time-limited. In AA group everyone is equal and it is not limited by duration of session and length of treatment. AA becomes a way of life. People choose how many times a day or per week to come. Some are dry 30 something years while others are clean one day.

2) A spiritual aspect: These groups insert a deity into the group and each one can define his own god. There is something stronger than I that can help me. There are many Christian motives, but spirituality is universal.

3) The 12 steps: This is the process that each AA member goes through till he reaches a level of purity.

4 – 8: Working stages: A person does hashbon nefesh and confesses to others and asks for forgiveness. Few normal people go through this process.

AA groups assemble like a club. When a group of a few people organizes themselves they meet. They lead their own group. They make their own rules (e.g. if someone is dry for X months they can lead the group). The group leader changes every week.

The group leader presents himself first and then each one presents himself. (My name is Asha and I am an alcoholic…. We love you Asha) hee hee. They speak about their day and whether they drank of not and then add something else if they want. Then the group leader decides the topic that will be discussed. Each one speaks about his own experience. The group ends with a peace prayer. This prayer is used by all AA groups.

They don’t get donations from anyone. They buy their food and coffee. Each one pays according to their needs and with this money they pay electricity and beverages and whatever they need.

Sponsor חונך: A person who has experience and becomes a guide to others. A new person chooses his own sponsor from the veterans and the veteran must be at the new alcoholics call 24 hour per day. This is also beneficial for the sponsor because he remembers where he came from.

Rituals are very common in AA groups. They give medals to those who a dry for long periods of time. There are statements and slogans on the wall.

This process begins from the first day of drinking till the end of his life. This comes before increasing awareness etc. Since this is a chronic disease in which there is no cure, only withdrawal and rehabilitation and therefore coping is an ongoing process that becomes a habit (like dialysis treatment that becomes a weekly experience). People can live with these situations and treatments. “Once an alcoholic; always an alcoholic”.

The climax of treatment usually takes place in the beginning of treatment and then they try to maintain what they achieved in first days when they stopped drinking.

The event created a situation in which there was hopelessness and when an alcoholic feels hopelessness he drinks. One of the changes in the awareness is that there is something mediating between the event (which is not connected to them) and how they react to it.

The only axis in which there is no intervention is that event à drinking, because it does not exist in reality, unless someone points a gun to persons head and forces him to drink.

Drinking (5% intervention): Accessibility to alcohol – try to avoid places where there is alcohol, so as not to drink through others. If an alcoholic is in a place where there is alcohol it is a matter of time until he starts drinking.

Event (5% intervention): Events are a part of life and cannot be controlled. But we can identify certain people, places or situations that we are more sensitive to. An alcoholic can avoid these.

Between Hopelessness and Drinking (70% intervention): Controlling our feelings for various situations. Not ever tiny thing needs to throw you off the track. They can learn how to react differently. Alcoholics can learn how an alcoholic acts on a day-to-day basis. They need to be taught how to live a normal life without changing themselves. But how do you function and choose alternative ways to dealing with the feeling of hopelessness besides for drinking.

Once a person falls into a habit of drinking he limits his options and forgets what other options exist. When he comes to treatment he cannot remember the alternative options.

They live with a fantasy that once they will withdraw everything will be fine. Life without alcohol is normal – with the same problems and events that need to be resolved and coped with.

Individual Level: A person in his own struggle with or without alcohol. They wake with a prayer that they thank God for not drinking yesterday and pray that just for today they will not drink.

Social Level: The alcoholic needs to cope with his image in society. They often have a bad image in society and it is difficult to wipe out the bad memories. It is difficult to live with the idea that the society doesn’t forget and doesn’t trust them. This is associated with a lot of frustration. Our society is not tolerant of alcoholics, nor do they understand what alcoholism is. Society therefore pressures them into drinking and they need to explain that they are alcoholics of take antibiotics with them and say they are on medication so that others wont bother them.

Stressful Situations: How do they cope with chronic continuous stressful situations? These situations increase the frustrations.

Experience: With time an alcoholic acquires more experience and with time an alcoholic learns to adapt. Each and every success gets a different meaning and intensity. But how can a social worker help. We need to examine how his week was and to take note of all the situations in which he didn’t drink and how he coped. We need to provide meaning and content for the previous week and to associate it with success. We need to transfer the feeling to him that he didn’t drink all week and that it is very significant. We need to show him how it changed his life. What was it like waking up without a hangover? It’s more than just OK.

Skill: We need to improve the alcoholic’s coping skills. We need to know how to see things in proportion and to know what we can change and what not. We need to have the courage to change what we can and to believe in our ability to do so. If I make a decision I can stand behind it and to act. It is all a matter of will. But there are things that cannot be changed and therefore there is no point in trying to invest energy into changing them. There should be no struggle to change what cannot be changed. A person must accept what cannot be changed. Things can be seen differently and what we see is not because it is objective it is because of our subjective interpretation. Alcoholics need to learn to interpret the reality differently. If they get frustrated by someone it is not because the other person irritated them, rather it is because they are nervous. It is their own responsibility. (e.g. the illusion of the young woman and the witch). When an alcoholic tells me about an event it is not what happened but his subjective perspective of the event. What they see it their interpretation.

Practice: Things need to be practical and not only theoretical. They need a first aid bag – it they are in need they need to have the phone numbers of people who will help them and to know what will help them when they are nervous. They need to know what they can do to make themselves fell better. Alcoholics don’t often know themselves and don’t often know what is good for them when they are breaking down. The better a person knows himself the easier it will be for him to cope.

External means: These can help a person with his ability to cope (e.g. biofeedback helps people identify there reactions). There are also meditation tapes that help people and alcoholics to relax. There are certain pieces of music that help people to relax.

Alcoholics who relapse commit “suicide” because they know exactly what will happen to them. They test whether they will succeed to drink in proportion. Alcoholics who think that they are strong enough try and within a few days or week fall. It is expected and natural for alcoholics to relapse and drink. Therefore there is a special program for alcohol relapse prevention.

How to help the alcoholics to prevent relapse. They speak to alcoholics about the risks because it may be just around the corner. We each have our good and bad areas in live.

Rosh Hashana and Pessah are the most difficult holidays because alcoholics feel that they don’t have families or are embarrassed. They need to prepare themselves before hand to prevent relapse. If they learn to identify their weak and sensitive spots they can control them.

Drinking begins in the mind and not when the bottle is in the hand. Relapse begins in the head and he opened the window to alcohol (making it accessible; visiting in bars; having alcohol at home).

One of the problems among addicts is that only a small percent that turn to treatment reach the final line. 30% reach the final line, while 70% fall out along the way.

Dropouts:		Patient’s responsibility	Therapist’s responsibility
5 sessions	25%	Lack of maturity for treatment. Secondary gains (bituah leumi).	There is not enough manpower to cope with alcoholics immediate gratification needs for treatment. Unsuitable treatment. Client-therapist chemistry. סחבת
Till 10 sessions	50%	Sense of omnipotence - שאננות Disappointment due to failure and embarrassment to tell others.	Not working according to contract of withdrawal and change. Client-therapist chemistry.
10 + sessions	25%	Stagnation. A client must express his feeling that nothing is changing. This is not the therapist role. Decrease in priorities. Some found alternatives (AA)	Lack of awareness of what is happening.

There is no direct connection between dropping out and treatment success. Many people persistently come to treatment but continue drinking or are in a cycle of withdrawal and falling.

3) Resources – there needs to be turnover of patients because there are not enough resources just to recruit new patients.

4) There are alternatives on 3 levels: self-help groups AA; treatment centers are always open to patients if they feel than need encouragement; other groups

To determine the success of treatment we need to go back to goals to see whether they have been fulfilled.

To life a normative life without alcohol. People need to withdraw for at least a year. Having life events and not turning to alcohol. They need a reason to wake up in the morning and have interest in life. That they are happy with their families.

2) Blaming and attacking therapists. Inducing guilty feelings in therapist who may feel they are abandoning them.

8) They do not leave treatment and continue meeting with other patients. They want continuity.

35% of all the patient (including all those who dropped out in initial stages of treatment) qualify the standard of success according to the 3 criteria and goals listed above (over one year withdrawal; satisfied with family). Drug addicts, in comparison to alcoholics, are less accepted by the society, have less education, no profession, no family etc.

Why is there such an intense investment in something that has such low percentages of success?

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After drinking…