The patient, Fred, is a 61-year old American man who lives in Adelaide. He has a 91-year old mother, wife and 2 sons.
Presenting Information and Social Structure
Fred was admitted to the hospital with alcoholic dependence combined with episodes of chronic depression. Since he was retired 10 years ago, he is constantly depressed, additionally, he has long alcoholic experience, which he was treated from, but the treatment was not successful.
Fred is on his retirement since 50 years, when he decided to dedicate himself to his family life.
He lives in a house in Adelaide. However it is not clear whether he is living alone or with his family.
Previous psychiatric history
Fred was hospitalized in 2005 after a leg fracture into the detox unit due to the chronic alcoholism with the help of his brother.
In April 2006 Fred went to Kuipto for a five-month program which did not lead to a positive result.
Fred’s father died in the age of 55 after a long illness. His mother is still alive at the age of 91. His brother died because of oesophageal cancer, which probably developed due to abuse of alcohol.
Alcohol / Illicit Drugs
Patient suffers from alcohol dependence, habit which was developing from the age of 14.
Patient mentions that his family does not love him, which can be strong point to lean on. The family is still very important for him and this trigger should be carefully used during the therapy process. Patient has witnessed deaths of his brother and one of the friends, both of which were connected to the alcohol abuse. These facts did not stimulate Fred to stop drinking, however, could also be used during the treatment.
Fred’s father died at the age of 55 and Fred was ready to die at the same age, when this did not happen he was completely lost. Presumably this situation has played a significant role in his further condition.
Summary of Assessment
Summarizing all the issues, which were mentioned above, Fred is suffering from a combination of chronic depression and alcohol abuse. He was not able to quit drinking even after several courses of therapy, for what he blames others (family), which is typical for a person with alcohol dependence.
The elements of treatment appropriate for patients with alcohol problems are fairly straightforward.
Three general steps are involved in treating the alcoholic person—intervention, detoxification, and rehabilitation.
The main goal in this step is to break through feelings of denial and to help the patient understand the consequences likely to occur if the disorder is not treated. Intervention is aimed to create high level of motivation for treatment and long term abstinence.
Intervention involves convincing patients that they are responsible for their own actions while reminding them how alcohol has created significant impairments in their life. Psychiatrists often find it useful to take advantage of a person’s main complaint, which in Fred’s situation is an ability to cope with his life’s stresses and depression. (Blane&Leonard, 1999) Psychiatrist can then explain a patient how alcohol has either created or contributed to these problems and can reassure the patient that abstinence can be achieved with a minimum of discomfort.
A physician intervening with a patient can use the same tolerant but persistent approach each time an alcohol-related impairment is identified. It is the level of constancy rather than exceptional interpersonal skills that usually gets results. A single intervention is rarely enough.
Most alcoholics need a series of reminders about how alcohol contributed to each developing crisis before they seriously consider abstinence as a long-term option. (Kaplan&Saddock, 2000)
Usually family can be a good help in the intervention. In Fred’s case it is also true. Family members must learn not to protect Fred from the problems caused by alcohol otherwise he may not be able to gather the energy and the motivation necessary to stop drinking. During this phase family can meet with other people recovering from alcohol abuse and their families. They can cooperate, share coping strategies and help each other find community resources. Those groups meet many times a week and help family members and friends see that they are not alone in their fears, worry and feelings of guilt.
Most people with alcohol dependence have relatively mild symptoms when they stop drinking. The essential first step in detoxification is a thorough physical examination. In the absence of a serious medical disorder or combined drug abuse, severe alcohol withdrawal is unlikely. The second step is to offer a patient adequate nutrition and multiple vitamins, especially those containing thiamine. (Martin et al., 1993)
For most patients, rehabilitation includes three major components:
- Continued efforts to increase and maintain high levels of motivation for abstinence
- Work to help a patient readjust to a life-style free of alcohol
- Relapse prevention.
Because these steps are carried out in the context of acute and prolonged withdrawal syndromes and life crises, treatment requires repeated presentations of similar materials that remind the patient how important abstinence is and that help the patient develop new day-to-day support systems and coping styles.
No single major life event, traumatic life period, or identifiable psychiatric disorder is known to be a unique cause of alcoholism. In addition, the effects of any causes of alcoholism are likely to have been diluted by the effects of alcohol on the brain and the years of an altered life-style, so that the alcoholism has developed a life of its own. This is true even though many alcoholic patients believe that the cause was depression, anxiety, life stress, or pain syndromes. Research, data from records, and resource persons usually reveal that the alcohol contributed to the mood disorder, accident, or life stress, not vice versa. (Schuckit&Hesselbrock, 1994)
The same general treatment approach is used in inpatient as well as outpatient settings. The selection of the more expensive and intensive inpatient mode often depends on evidence of additional severe medical or psychiatric syndromes, the absence of appropriate nearby outpatient groups and facilities, and the patient’s history of having tried but failed in outpatient care. The treatment process in either setting involves intervention, optimizing physical and psychological functioning, enhancing motivation, reaching out to family, and using the first 2 to 4 weeks of care as an intensive period of help. Those efforts must be followed by at least 3 to 6 months of less frequent outpatient care. Outpatient care uses a combination of individual and group counseling, the judicious avoidance of psychotropic medications unless needed for independent disorders, and involvement in such self-help groups as Anonymous Alcoholics.
Counselling efforts in the first several months should focus on everyday life issues to help Fred maintain a high level of motivation for keeping away from alcohol and to develop his levels of functioning.
Counselling can be carried out in an individual or group setting. The technique used is not likely to matter greatly, and usually boils down to simple day-to-day counselling or almost any behavioural or psychotherapeutic approach focusing on the here and now. To optimize motivation, treatment sessions should explore the consequences of drinking, the likely future course of alcohol-related life problems, and the marked improvement that can be expected with abstinence. Whether in an inpatient or an outpatient setting, individual or group counselling is usually offered for a minimum of three times a week for the first 2 to 4 weeks, followed by less intense efforts, perhaps once a week, for the subsequent 3 to 6 months.(Saddock, 2000)
A lot of time in counselling deals with how to build a life-style free of alcohol. Discussions cover the need for a sober peer group, a plan for social and recreational events without drinking, and approaches for re-establishing communication with family members and friends.
The third major component, relapse prevention, begins with identifying situations in which the risk for relapse is high. The counsellor must help the patient to develop modes of coping to be used when the craving for alcohol increases or when any event or emotional state makes a return to drinking likely. An important part of relapse prevention is reminding the patient about the appropriate attitude toward slips. Those short-term experiences with alcohol can never be used as an excuse for returning to regular drinking. The efforts to achieve and maintain a sober life-style are not a game in which all benefits are lost with that first sip. Rather, recovery is a process of trial and error; patients use slips when they occur to identify high-risk situations and to develop more appropriate coping techniques. (Schuckit, 1998)
Most treatment efforts recognize the effects that alcoholism has on the significant people in the patient’s life and an important aspect of recovery involves helping family members and close friends to understand alcoholism and how rehabilitation is an ongoing process that lasts for 6 to 12 or more months. Couples and family counselling and support groups for relatives and friends help the persons involved to rebuild relationships, to learn how to avoid protecting the patient from the consequences of any drinking in the future, and to be as supportive as possible of the alcoholic patient’s recovery program. (Schuckit al., 1997)
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Blane, H.T., & Leonard, K.E. (Eds.). (1999). Psychological theories of drinking and alcoholism. New York: Guilford.
Martin, P.R., McCool, B.A., & Singleton, C.K. (1993). Genetic sensitivity to thiamine deficiency and development of alcoholic organic brain disease. Alcoholism Clinical Experimental Research, 17(1), 31-7.
Sadock, B.J., & Sadock, V.A. (Eds.). Kaplan & Sadock’s Comprehensive textbook of psychiatry. (2000). Lippincott Williams & Wilkins Publishers.
Schuckit, M.A. (1998). Educating yourself about alcohol and drugs. New York: Plenum.
Schuckit, M.A. & Hesselbrock, V. (1994). Alcohol dependence and anxiety disorders: What is the relationship? American Journal of Psychiatry 151, 1723.
Schuckit, M.A., Tipp, J.E., Bucholz, K.K., Nurnberger, J.I. Jr, Hesselbrock, V.M., Crowe, R.R., & Kramer, J. (1997). The lifetime rates of three major mood disorders and four major anxiety disorders in alcoholics and controls. Journal of Affective Disorders, 79(3), 209-215.