“So just sit down and be quiet. The reason is your are drunk and this is the edge of the roof.” Rumi
This is a story of how I advanced in knowledge about the pathology of addiction and ways to treat it. My internship for the MA degree was at a clinic for heroin addicts, people at the top of the addiction list and about whom I hardly had any awareness. The clients were medicated with methadone, and I was assigned to some of them as a therapist. They were travelers through one of the darker landscapes of the psyche. Therapy and counseling were beneficial to those who were seeking to at last be free of both the power of the drug and the methadone.
As a kid I saw Frank Sinatra in The Man With the Golden Arm directed by Otto Preminger. I was in over my head, but even a grade school kid could sympathize with how much suffering had to be endured to “kick.” Sinatra’s character complained, “I gotta forty pound monkey on my back.”
During my matriculation in the MA counseling program at Southwestern College, I too traveled through some dark corners of my own psyche, but this did not include addictions. One of the requirements was that students commit to a cycle of therapy under our own warrant, and our progress was covered by the standard rubric of confidentiality, unless there were revelations of danger to self and others. I did not present in therapy with issues regarding abuse or dependence. Though I was a drinker of alcohol, nothing surfaced that produced questions of suitability to progress toward graduation. It is not that I never overindulged, but I was not being therapized as a habitual abuser. If anything, in hindsight, I have to consider myself at most a social drinker, without too many second thoughts about it.
Regarding the run of the mill substances, such as cannabis and a few uppers and some psychedelics, I considered myself an experimenter, and overall the most needed for me was to drink alcohol moderately, and going forward in this profession, of course, to not use illegal substances.
Along with its general observations of our overall presentation, the faculty did not leave matters of our possible addictions and mental problems to our imaginations. The directive of the faculty was to be introspective, to look deeply into our habits, heal ourselves, and practice sobriety. Sobriety is not equivalent with abstinence from alcohol. If one drinks moderately, sobriety can be maintained.
Surprisingly, official agencies publish a range of definitions of moderation.
Look at this: “Moderate drinking is defined as up to four alcoholic drinks for men and three for women in any single day, according to The National Institute on Alcohol Abuse & Alcoholism (NIAAA), and a maximum of 14 drinks for men and 7 drinks for women per week.” (Dec 4, 2015)
And: “Drinking Levels Defined. Moderate alcohol consumption: According to the Dietary Guidelines for Americans 2015-2020, US Department of Health and Human Services and US Department of Agriculture, moderate drinking is up to 1 drink per day for women and up to 2 drinks per day for men.”
Though there is some latitude regarding moderation, regarding pathological substance use, there is one most definite assessment—the simple and objective question: “Am I having problems due to my drinking and using habits?”
If my problems are severe and presage “dependency,” either I progress toward catastrophe or face reality and commit to abstinence—difficult though this may be.
If the diagnosis is “abuse,” either I learn healthy “moderation management,”* or continue abuse habits and risk stumbling into dangerous situations—good intentioned though I be.
*Moderation Management was founded in 1994 to create an alternative to Alcoholics Anonymous and similar addiction recovery groups for non-dependent problem drinkers who do not necessarily want to stop drinking, but moderate their amount of alcohol consumed to reduce its detrimental consequences. “Moderation Management.” (2017, February 17). In Wikipedia, The Free Encyclopedia. Retrieved 21:05, June 16, 2017
My First Postgraduate Lesson
After graduation, I was hired by a clinic to treat court ordered DWI offenders. Shortly, a new clinical director (call him “W”) was hired. His therapy model was the AA** Twelve Steps built upon practice of abstinence from alcohol. One does not go to AA to learn to drink moderately.
**“The place to go if you have ever: pissed your pants; wrecked your car; been arrested for multiple DUI’s; passed out outdoors; urinated in an interior corner or plant; hid beer for ‘later’; drank alcohol you think is foul because there is nothing else; thought hair of the dog is a good idea; lost a weekend; called up your friends to piece together why you are home without your pants; missed Thanksgiving or Christmas dinner by accident; been fired ‘cause you are too drunk/hungover to get to work; woke up wondering who is sleeping next to you; intend to drink a cocktail and ended up drunk, and; you sincerely cannot stop drinking but don’t want to live a miserable life.” (http://www.urbandictionary.com/define.php?term=AA)
Compared to my director, my preparation to treat addiction was a general awareness of AA, Adult Children of Alcoholics, and Al-Anon. Nevertheless, I was a trained clinician, though new in the field, and could always depend on close clinical supervision by W to guide me.
W conducted interviews with each of the staff. I reported my understanding of recovery and my personal stance regarding drinking. This did not satisfy the director. He felt that I had not sufficiently examined my drinking habits, even if I had gone through a lot of soul searching at Southwestern College. He also noted that I should get to know the Twelve Steps first hand. Many of my clients would have been attending AA meetings and needed to have the Steps reinforced.
He then did direct me to attend AA meetings regularly for the next 30 days, but also to abstain from drinking alcohol, and then we would confer again. But he augured what that conference would entail: if I would not commit to abstinence and continuing in AA, he would not retain me on the staff. Did this imply that I was viewed as addicted and in denial—an old saw heard around the AA rooms. In actuality, no, but can you imagine how this sounded having just been hired, having just achieved an MA?
If nothing else I was again set on a road of serious soul searching like I had gone through at Southwestern.
This directive was “black and white” clinical intervention—abstinence in all cases. I would later expand beyond only abstinence as a treatment modality, and find my way to “moderation management”*** as an appropriate recommendation in cases of abuse.
***How to Cut Back Your Drinking | Moderation Management https://www.practicalrecovery.com/prblog/diy-moderate-drinking/
Feb 26, 2015
I took the challenge. Being a therapist meant that I had put my hand to the plough and would not look back (But Jesus told him, “Anyone who puts a hand to the plow and then looks back is not fit for the Kingdom of God.” Luke 9:62 (NLT)) because I owed this to myself and to my future patients to continue my healing and clinical skills. Is not there the great maxim: Cura te ipsum?
I attended AA meetings, eventually connected with a wise sponsor, and stopped drinking alcohol for some four years. The AA meetings and self-disclosure there were no big deal for me. For two years at Southwestern, that is what I and my fellow students had been doing in spades.
At a 6:50 a.m. meeting, my sponsor would check in with: “I’m George, a grateful recovering alcoholic, and I haven’t had a drink today.” This was a seasoned veteran of AA, and when I questioned whether he might have had a drink so early, he said that back in the day, yes, often he’d have already had a drink.
AA is the hallowed recovery program, but there is no lack of pros and cons. Personally, I approve wholeheartedly. The steps can take their place among the classical treatment paradigms. Yes, AA is faith based, and in addition, in my opinion, it utilizes objective cognitive-behavioral methodology.
My Next Lesson
I referred, above, to learning of ‘moderation management.’ This occurred when I was hired by another clinic where I was told, “We are not AA here. Yes, abstinence is recommended for alcohol addicted patients.” However, they supported moderation management as a legitimate, evidence based treatment in cases where abusive patterns, not addiction, have been empirically judged by the clinician.
An alcohol-abusing patient can get into as much trouble as an alcohol addict, in that his incidents of abusing can be as dangerous as a dependent drinker. Excessive alcohol in any case can endanger or lead to a deadly accident. The difference between abuse and dependence is that abuse is sporadic, excessive use of mind/mood altering substances, whereas dependence is habitual, stubborn abuse. If a patient’s symptoms indicate abuse, then the therapy is to train the abuser to pull back from incidents of excess intake and practice moderation. If abusive drinking starts to progress to the danger zone of dependency, then the pass the abuser got to drink needs to be reexamined, and it is recommended that this patient bite the bullet of abstinence.
As for me, having kept my word to W, and now in another agency, with new clinical options, I looked at myself and returned to moderate drinking and declared that I was not a AA “lifer.” Integrity, in this case, would be for me to examine that this choice is a healthy choice and in keeping with a therapist’s commitment to live himself the truths toward which he is leading his patients.
Commentary beyond an original article by Arthur Panaro, “Recovery: Meeting Myself,” appearing in El Dorado Sun, August 2000, p. 30-35.