September 2006. Gerry Hickey MBACP.
TACKLING THE CHRONIC ALCOHOL PROBLEM.
Despite the expenditure of tens of millions in trying to tackle our chronic alcohol problem the message appears to have little effect. Why? Alcohol fuelled public order offences and attendance at Accident and Emergency departments, excessive drinking and driving are frequently the symptoms of a deeper alcohol problem. So too is alcohol fuelled domestic violence. Many, if not most problem drinkers, will drink and cause harm no matter how heavy the penalties are. They will continue to kill and mane people on our roads as well as terrorise and agonise those they live with. Their primary concern is in feeding their obsession with alcohol and I have seen homes, jobs, marriages and any shred of personal dignity scarified for this. By not constantly challenging and naming this behaviour as serious problem drinking we are effectively enabling it to continue. Frequently we only address the consequential nuisances and in doing so we fail to treat the core issue of problem drinking. This is the reason why things have gotten progressively worse and many appear unable to understand this! Acknowledging the reality mean accepting that people who repeatedly offend and / or are harmed while under the influence of alcohol are problem drinkers, alcohol dependent or addicts, whichever you prefer to use. Being caught drunk driving or having to attend Accident and Emergency appears to be just another possible negative side effect of the problem drinker’s list of risks. It is no longer good enough for mainstream society to be expected to tolerate the consequences of such actions. It is a sad fact that I have to make clear that I am not “anti-alcohol”, “anti-social” or “anti-fun”. Too frequently those drawing attention to our chronic alcohol problem are dismissed with such inappropriate labels. I see nothing wrong with the inclusion of alcohol in social occasions where it is treated with the vigilance such a powerful drug demands. However, the drug has horrendous negative side effects for our society and frequently those left in its trail of destruction go unheard and unaided. Therefore, it is correct to say that I am against the human devastation alcohol can cause. For over 20 years I worked with problem drinkers, their families and others in their lives. Frequently, Clients present with signs of serious stress, anxiety or depression. In over 68% of cases, over a 12 month period, the Client either grew up in a home seriously affected by alcohol, was involved in a relationship with someone damaged by alcohol or were themselves using alcohol in an unhealthy manner. For many years I have found it necessary to constantly challenge the spin and untruths perpetrated by those minimising the negative effects of alcohol. I have had some success including a number of radio and TV interviews, newspaper letters, the placing of a parliamentary question in 2004 and an oral submission to the Dail Select Sub-Committee for Health and Children in 2005. However, success in this mission will never be gained by solo runs or egos. It demands consistent team based approaches to tackling the core issues. Thankfully organisations like the NGO, Alcohol Action Ireland are making a start in gathering interested groups and concerned individuals together giving structure and formation to the process of challenging us to look critically at the problem. Unhappily, it seems the message of concern frequently falls on deaf ears or at best gets a nodding, patronising acknowledgement. This leads me to speculate that there are real fears of tackling the problem itself and of the producers, promoters and providers of alcohol. It is vital that we move beyond this fear. Confronting our denial and enabling regarding the country’s chronic alcohol problem would be an important first step. Our health services could benefit greatly from this action. Reports and studies usually contain practical suggestions but most appear to miss the following vital ingredient in accessing this problem. Many people drink alcohol for the effect of the drug. Some use it as a relaxant, an escape. Others use it as a means of self-medicating for issues, mostly psychological, best dealt with by proper medical attention. Many cannot or are unwilling to control the intake of this drug. They are OUT OF CONTROL. Therefore, for them, requests for “responsible and sensible” intake raise serious questions as to the sincerity of the alcohol industry in tackling the negative side effects of its product. Soft warnings to problem drinkers are quiet frankly the equivalent of telling a dog not to bark. Our society has a relaxed and tolerant attitude towards alcohol. Frequently we are selective in our condemnation of its negative side effects. Perhaps this revolves around our own personal consumption of the product. Many fear to challenge others drinking as it may mean they have to examine their own. It is therefore safer to adopt the preverbal “head in the sand” approach. Random breath testing and curbs on advertising are welcome actions towards altering attitudes. Thankfully, there is substantial notional evidence that it is no longer “cool” to admit to drink driving. I suggest that concentrated Education and Opportunistic Intervention are of paramount importance now. The time for flirting with remedial actions is over. As the country’s chronic alcohol problem is everybody’s problem it is imperative that all are included in the solution. The following 6 key proposals would enhance our efforts in a radical manner and involve the active participation of all willing to help.
1. Clarity of definition.
In general most people appear very vague in their understanding as to what constitutes a drinking problem. This is reasonable as part of the confusion with clarity is the myriad of sub-definitions of problem drinking presented to us. Labels such as “hazardous,” “harmful,” “dependent” and “binge” drinking are examples of these sub-definitions of problem drinking. There is a place for these sub-definitions once problem drinking has been established to exist but not before. I feel uneasy with these labels as their broad range frequently leads to confusion and gives the problem drinker, wriggling to protect their drinking, excuses and opt-out options and in effect minimises serious problem drinking needing drastic action to resolve. “I only go on a binge from time to time”, “I’ve never had an accident while drunk”, “My drinking doesn’t harm anyone” are frequent replies to my questions regarding a problem drinkers drinking. Another one is “I only drink at weekends so I don’t have a problem”. This statement is frequently selective in its honesty as the large amount consumed and resultant negative consequences at the weekend are conveniently omitted. Problem drinkers appear to be totally unaware of the high state of anxiety they cause those they live with as they stagger from drunken episode to drunken episode. A major contributory factor to the confusion and unwitting enablement is that there is no real, widespread understood definition of what constitutes problem drinking. Until such time as this is established and commonly understood we will remain in an obscure space regarding identification. Therefore enabling excuses and justifications to flourish and allow the problem drinker delude themselves that they are not harming others, particularly those close to them. In fact, I am convinced that the existence of a problem can only be truly established through honest and accurate individual assessment involving both the drinker and those close to him or her.
“SO YOU THINK YOU DON’T HAVE A DRINK PROBLEM? ASK YOUR PARTNER, ASK YOUR CHILDREN, ASK YOUR PARENTS, ASK YOUR FRIENDS IN A SOBER, NON-CONFROTIONAL MANNER HOW THEY REALLY FEEL ABOUT YOUR TAKING OF ALCOHOL. BE LED BY THEIR REPLY AND NOT YOUR OWN INSTINT”.
I suggest the need for a precise, weighted, simple definition of what constitutes problematic and possible addictive drinking. A clear definition would also allow people identify the problem at an early stage particularly in those close to them. Having this definition would thereby inform the unwitting enabler, helping them to freedom in the process. The following could be an example of such a definition:-
“Problem drinking is a pattern of drinking in which a person has lost control over their drinking so that it is interfering with some vital area of their life such as family, friends, job, school, health or other such area important for them.”
This definition would need to be keenly understood by all those in the health, justice and educational sectors. Our educational system would play a pivotal part in this matter. From an early age our children could be informed of the dangers of alcohol consumption and the indicators of problem drinking. Every responsible member of our society could play am important role in insuring the widespread understanding of the definition. There is far too much subtle association between alcohol and “fun times” Balance as to the negative side effects of this drug needs to be highlighted in equal measure so that “fearful, anxious people” are given the same airtime as the “shinny happy people” currently paraded as the sole beneficiaries of the effect of alcohol. Once-off campaigns would be of little benefit here. The promotion of the definition would need to be every bit as consistent and vigorous as the promotion of alcohol itself currently is.
2. Accurate assessment as to the seriousness of the problem.
Alcohol imbeds itself in our culture in an insidious manner, subtly endorsed at celebrations, on public occasions and at major sporting events. Labelling major sporting and music events with names of alcohol producers and prioritising “a drink” at national events are examples of this. There is no issue here for the drinker who does not have a problem but as problem drinkers are notorious for their intransient denial, then who is to determine whether there is a problem or not? In most cases this unenviable task falls to those close to the problem drinker. They are the people who live in anxiety as they await the return of the problem drinker fearing the mood that may be presented. Most of these people continue to suffer in silence enabling shame, embarrassment, secrets and lies, 4 of the major constituents of dysfunctional living, to flourish. It is estimated that each problem drinker affects in the region of 8 to 12 people. Parents, siblings, partners and children are particularly vulnerable in this immediate group. Here we have the breeding ground for depression and suicidal tendencies not only in the user but also in those close to them.
As there are an estimated 200,000 problem drinkers in this country, this would mean that around 2 MILLION people are negatively affected by problem drinking.
What a staggering figure! Surely we need to closely and honestly examine why we tolerate such internalised family and societal abuse. For children the ripple effects of this chronic situation can last a lifetime. I frequently see people in their 30’s and 40’s paralysed by emotional insecurity and uncertainty, unable to maintain healthy relationships whose origins are firmly rooted in the subtle state of high anxiety experienced in an alcoholic household. Chronic insecurity is rampant in the alcoholic household and can have lifelong ramifications for those affected by it. Once clarity of definition is established, I am suggesting a structured, nationwide survey to establish the true extent of the problem. We ought not to fear the result of honest assessment as once accurately established, we will have a great opportunity to confront any denial and adopt a structured, multifaceted, intolerant approach to deal with it. Perhaps this would finally draw attention to our need for urgent pro-active endeavours.
40% of fatal car accidents involve alcohol as a factor.
51% of Domestic violence cases involve alcohol consumption.
87% % of public order offences are alcohol related.
50% of work absentees admit to an alcohol input in their absence.
3. INTERVENTION.
(A) The Problem Drinker.
I see a major inconsistency in the way we deal with alcohol related crime and health issues. Currently, over 25% of A & E attendants are alcohol fuelled. Garda figures quote figures as high as 87% of public order offences relate to alcohol. Surely those attending Accident and Emergency departments with alcohol fuelled problems could be challenged about their alcohol problem? This would have particular relevance if there were more than one such attendance. My suggestion is that prior to their discharge they would be offered an hour’s consultation by a suitably trained on-call facilitator. This would be a choice rather than a requirement. However, a strong suggestion would be made that it be taken up. It should not be too difficult to devise a manner of making it appealing for the patient to partake in the process. Similarly, those arrested for alcohol related offences be held in Garda custody until such time as they sober up. Prior to release then they could be offered an hour’s consultation by a suitably trained facilitator. Again this would be a choice rather than a requirement. However, a strong suggestion would be made that it be taken up. Both of these proposals would mean, in effect, intervention at a core, opportunistic level. At the very least this challenges people about what could be a serious problem in relation to their alcohol consumption and at best it could mean people accepting help for their problem. Should the patient / arrestee refuse the option of a meeting with the facilitator, this fact would be noted and could form part of any case being presented in any future court case or hospital admission. If this causes legal difficulties, then let’s deal with them. My suggestions regarding brief intervention at Garda stations or A & E wards will go someway towards at least naming the problem directly with the abuser and giving the opportunity to them to take positive action. The person carrying out the intervention need not be a formally qualified therapist, as we currently understand it, but rather a member of the Gardai, a part-time consultant or other person trained in basic educational and intervention skills concerning problem drinking. They would be skilled in helping to evaluate a person’s drinking habits in a thought provoking and pro-active manner. They would be subject to supervision in this role. There is an untapped army, countrywide, available on the sidelines to help this process. An example of this is the vast numbers of people active in long term recovery from problem drinking and solid members of the PTTA. Many could easily be trained to be an "On-call, Focused, Assessment Facilitation Team" for hospital, Garda station and, if need be, Home assessments. Is this radical, challenging and perhaps not too welcome thinking? Maybe, but changing the focus on dealing with this chronic problem to where it is really needed. Of course this approach could expect to be met with considerable resistance from the patient, the arrestee and indeed other interest groups. However, I suggest that it is time for band-aiding the bullet wound, with the bullet still in it, to stop. There is limited research available to measure the effectiveness of intervention but a recent London Underground 5 year study on staff showed success rates of 55%. This is very encouraging. Short-term, focused therapy, even just one constructive session, can have a life changing effect on a person when available at an appropriate time. There are studies which confirm this and my own professional experience would concur. One to one gentle confrontation in a non-judgemental, confidential environment proves most effective in getting the problem drinker to at least question their drinking and this makes it all worth while. I suggest however that every educational intervention is successful. Recently I’ve become aware of a number of hospitals introducing forms of intervention procedures and it is very encouraging to hear this. Once a problem drinker has become informed through this type of intervention, I suggest that they have no further excuses for their behaviour and ought to, then, face the consequences However, if people wish to receive further help for their drink problem a process could be developed to facilitate this. A countrywide network of vetted, more qualified, therapists could be easily complied so as to refer people. This would apply to both the public and private sectors.
(B) Those they live with or who are concerned for the Problem Drinker.
One of the largest contributors to continued overindulgence in alcohol is the unwitting enabling partaken in by family, friends and partners of a problem drinker. Frequently, those close are unaware that they are indeed enabling. Some just seem to deny the problem and hope it will go away. It will not. Some fear the conflict resulting from challenging the problem drinker. This is very understandable as the challenge frequently leads to rows, violence, financial loss and more intense drinking. Others, still, are aware but if they question other’s drinking they may be leaving themselves vulnerable to be questioned on their own personal consumption. I regret to say that I have come across this factor even in helping professionals who tend to minimise patient’s drinking measured on the basis of their own. I have evidence of professionals saying to problem drinkers “sure I drink more than that myself, you’ve no problem, just keep an eye on it”. They seem totally unaware that it is unprofessional to compare quantities consumed as ultimately it is the negative effect of the drug and not the quantity consumed that determines whether a person has a problem with alcohol or not. Victims of the problem drinker live in fear and anxiety. They have to tolerate denial, mood swings, irrational behaviour, financial insecurity, outbursts of anger and other emotional methods used by problem drinkers to protect their drug usage. They question their own actions and frequently doubt themselves leading to self esteem issues and depressive thoughts. Many of us, though very well intentioned, do have a relaxed view about this drug. It is an intricate part of our lives and has assumed a status far beyond its value to the Nation’s health. Therefore, I am suggesting that a method be investigated whereby the concerned persons relating to the person arrested or treated in hospitals could be given basic information on drug abuse, addiction and the enabling participation of those to the problem. Experience has shown that informed concerned persons are better equipped to help themselves and the problem drinker. They begin to withdraw the enabling and no longer tolerate the bad behaviour of the problem drinker. Frequently, this is the turning point for the problem drinker and left to confront themselves they begin to see the real effect their alcohol consumption is having on themselves and others. Educational intervention, through handouts, would assist people living with the problem drinker in evaluating their positions and review any enabling, entrapment and silence.
4. Synchronicity of recovery options
Many problem drinkers may look for further help following intervention. A truly successful programme will have to be able to guide those seeking help to the appropriate assistance. There is a dire need for the establishment of a central guiding agency to devise and monitor best practice in regard to treatment and recovery in all agencies from the public, private and voluntary sectors. All medical services both public and private need to be required to be aware of the basics of problem drinking and recovery options as part of their everyday practice. I fear we have Trojan work to do in this regard. Complementing this is the need for the establishment of clear interaction channels between healthcare and security professionals. As I feel a sense of urgency about these actions I would strongly advise extending the the National Treatment Purchase Fund to include those seeking help for alcohol dependency.
5. CONSISTENT POSITIVE AFFIRMATION OF NON-DRINKERS.
We need positive affirmation of those choosing not to take alcohol. The reasons vary but they appear to be under enormous societal and peer pressure to partake. Some are made to feel less of a person and socialite for their choice. I am suggesting a major, active promotion campaign for positive, inclusive social attitudes to those in our society not taking alcohol through choice or for health reasons. Perhaps it would be appropriate at this point to mention that in all the advertising campaigns I have never once heard it said that SOME PEOPLE OUGHT NOT TO TAKE ALCOHOL AT ALL. OTHERS CHOOSE NOT TO - AND THAT NEEDS TO BE RESPECTED! Now, for many, that would be the most sensible and responsible advice alcohol providers could offer. There is a need to challenge the Mrs Doyle’s of the bar-fly circuit. You say you don’t want an alcoholic drink and then it starts. “Ah, go on! Go on! Go on”. This shows massive disrespect for your choice as the commodity being discussed is not as harmless as tea. Of course part of this is the unease of problem drinkers around non-drinkers and the need for positive affirmation of their personal alcohol usage. Being bullied into taking alcohol and the butt of derogatory terms, if refusing to do so, is wholly unacceptable. The inclusion of an affirmation of non-drinkers in all alcohol adverts may be a far better way of promoting healthy usage that telling people to be “responsible” and “sensible”. How about affirming respect and admiration for those choosing not to take alcohol?
6. Funding.
There are contrasting opinions on the participation of alcohol providers in providing financial assistance to help deal with the negative effects of their product. I see two issues here needing attention:
(A). Alcohol plays a very intricate part in our society and will not be leaving it. Many people profit from its existence and it plays a vital part of our government’s fund raising activities. These are facts and whether we like it or not, that’s it.
(B). Those of us dealing with the drug alcohol’s negative side effects witness the physical and emotional wreckage its use can cause.
We also see a lack of effective support and faculties for the victims and for those close to them suffering from the negative ripple effects of problem drinking. Financial issues play a major part in preventing concerned persons taking action. So there is a crying need for more funding. Hence a quandary exists. Perhaps we need an Independent Authority to be pro-active in the aforementioned educational and intervention activities. Its remit could be charged with implementing and monitoring the appropriate actions. It would be crucial that such an authority would be populated by innovative and radical thinkers rather than being just another recycling opportunity for those clinging to “board” status and doing the circuits of “authorities” This Authority would be sufficiently protected from commercial interference so that we could seriously consider discussing substantial, unconditional financial input by those who profit from alcohol. Not before time, the industry has to be seen as responsible and acting sensibly in contract to paying lip-service to the concept.
Conclusion.
We are a race know for innovation and applying ourselves in a focused manner.
I am suggesting that we now become leaders in tackling this problem, establishing our own programme progressing it to become a world leader, evidence based and incorporating best practice. We must be open to new ideas and challenge our own base beliefs no matter which side we stand on.
Most people who drink do so reasonably responsibly. But what of the others, far too many, whose drinking gets out of hand and endangers others and themselves?
