Introduction to Alcohol Counseling with Jerome David Levin

WebMD Live Events Transcript

Substance Abuse: Making a diffference through Alcoholism Counseling

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Event_Moderator  Welcome to the WebMD Live Special Events Auditorium. Our guest this evening is the Author of "Introduction to Alcoholism Counseling", Dr. Jerome David Levine. Welcome Dr. Levin thanks for joining us tonight. Can you begin our discussion this evening by telling everyone a little bit about your area of expertise?

Speaker_Levin  My work is on addictions, sexual and alcohol. I direct a program to train addiction counselors at the New School University in New York.  I also do writing. I have published nine books on addiction.  I have a couple more books in the works.

Special_Moderator  What do you mean when you say a Bio-Psycho-Social Approach to Alcoholism Counseling?

Speaker_Levin  Addictions are among the most baffling because they are a slow suicide We're trying to figure out why someone would engage in that behavior.  There's a predisposition for addiction, but not a gene.  There is definitely a biological factor.  Psychological factors are also important. For example, we know that childhood trauma predisposes to addiction.  So do certain personality styles.  Then the third factor is environmental, or social.  Both in the family and in a larger culture.  Social factors are very potent.  For example, smoking. 20 years ago, if you were a smoker it said nothing about your personality because that was culturally approved.  Today it's different. There is a lot of social disapproval. To be a heavy smoker today is driven by psychological factors.  It's true for all addictions.  The biological, the psychological, and the social surroundings.

Special_Moderator What are the different personality styles?

Speaker_Levin  The research evidence is that in externalizing, you act everything out, antisocial, angry temperament and behavior; it is highly correlated with chemical addictions.  Another style that accounts for a smaller population is kind of the opposite.  People who are depressed and withdrawn who take drugs for self-medication.

Special_Moderator  How do you know if you or a loved one  is an alcoholic?

Speaker_Levin   The 12 step programs, not how much you drink but what it does to you.  Someone is addicted, for example an alcoholic, if there's a disregard for consequences, the self and others. There is a compulsiveness to it, you'll do it if you want, there's a loss of control... Lastly, the drug use is serving some unconscious purpose.  The drinker thinks they're doing it for fun, but they're self-medicating, or warding off guilt.  There are subconscious elements affecting the person.  When it's driven, it's compulsive and driven by the subconscious factors. 

Addictive drugs do 2 things: they build tolerance so you need more and more to get the same effect and you get withdrawals if you stop.  True for alcohol, and a drugs like heroin Withdrawal from alcohol can be dangerous, because of the nervous system, but drugs like heroin and opiates are more addictive.  I would say it's physiological addiction; how long they've been drinking;

Special_Moderator   Is it true that true that all alcoholics have withdrawal systems?

Speaker_Levin  You might not go into withdrawals, but if you do, they come in a form of cravings.  It happens to smokers. They think they want a cigarette and it's actually a conditioned response to falling nicotine levels in the bloodstream.

Special_Moderator With all of the twelve step programs, is it a necessity to abstain completely and why can't people be taught to moderate their drinking?

Speaker_Levin   Two steps: The philosophy of the 12 steps is an abstinence philosophy.  If you participate, the expectation is that you will not use at all.   That comes out the experience of their members that use the AA slogan "One drink is too many and 1,000 is not enough".  Some people with alcohol problems can become moderate drinkers, but the 12 step program would not help.  Some doctors can teach people how to drink well.  You have to look at the consequences of the drinking in making a decision which way to go.  If you've lost three jobs, been divorced and have cirrhosis, there is no questions abstinence is the answer.

  If difficulties are milder, you can modify your drinking. If you succeed, great.  However, if you try this as an experiment and you find your drinking is sneaking up on you, then that approach does not work and you should try the abstinence model.   Judge it in terms of severity and an attempt to moderate. If it works, it works, if it doesn't, you have to try something else.

Special_Moderator   Is alcoholism still defined as a disease?

Speaker_Levin  The American Psychiatric Association publishes a manual called the Statistical Diagnostic Manual which lists all of the mental and emotional illnesses.  There is a section in there on substance abuse disorders.  One disorder is in the use of alcohol and the DNS4 has two categories; alcohol abuse and alcohol dependence.   What they call alcohol dependence is what most people would call alcoholism, so the answer is yes, at least according to the APA.   It is also described by the American Medical Association, National Association of Social Workers, and the American Psychological Association.  The mental health professions certainly believe that alcoholism is a disease. 

Special_Moderator   Is alcoholism curable or can it be?

Speaker_Levin  The way that question is answered is it can be arrested.  But is you're truly alcoholic as opposed to a problem drinker, having episodes of drinking too much,  you probably almost certainly cannot use alcohol safely, so you have to not drink one day at a time, as they say in AA.  You are considered having alcoholism problems, with no symptoms.  It's like diabetes; as long as you don't take in too much sugar, you're still a diabetic but you have it in control. These two run parallel.  It's possible it can happen in the future; there is no such treatment now. My experience with problem drinkers who are in recovery is in the beginning they miss it, but over time it becomes unimportant to them.  Even if they could drink, they do not chose to. They have found satisfaction in life.

Special_Moderator  Physically we hear a lot about liver disease related to severe drinking what other physical tolls does the body take from abusive drinking?

Speaker_Levin  Good question. Alcohol is a wonderful drug because of it's euphoric properties, but it is a wonderful drug with horrendous side effects, especially in high doses over a long period of time.  It is a small molecule so it can get everywhere in the body and goes through cell membranes easily.  There is no single receptor site for alcohol, that is a lock and key kind of arrangement.  So it doesn't get tied up in the way opiates do so it goes all over the place and can damage any organ in the body.  The main damage is to the nervous system, the brain.  Sometimes the peripheral nervous system as well, the liver, the blood, pancreas, and sometimes the heart I could go on, but those are the most common complications of alcoholism.  Alcoholism is probably the 3rd ranking killer after heart disease and cancer If you're going to drink, don't do it everyday and don't have large quantities.

It can have some positive affects.  Studies show one or two drinks a day can correlate with longevity and health, possibly because social drinking is normative in our society and a lot of people who don't drink may have had problems before or a pharmacological effect.  Low doses can be positive, but high doses are bad.

Special_Moderator  What are the different treatment approaches?

Speaker_Levin  The first thing you have to do is to safely detoxify.  It can be comfortable, but you should seek a professional to help you.  It is a prelude, a medical procedure, but not a treatment of the underlying disorder.  The psychosocial treatment is 3 phased: The first one deals with denial. The psychological factors are denial and projection, also rationalization and intellectualization.  If you don't deal with denial, the person will almost certainly relent.  The beginning of the treatment is confrontational, trying to break through and having that person deal with consequences.  The 12 step programs speak of hitting bottom, having a problem with alcohol, someone has to hit bottom and I agree with that.  The second phase is a kind of cognitive therapy and behavioral therapy which concentrates on helping people stay sober by dealing two things:  identifying triggers which might be a feeling, person, a situation. It might be 5:00, first and Main where your favorite bar is.  When triggers are conscious, it is less likely you will act on them automatically, you think about it first.  In helping people identify triggers, you need to teach them coping mechanisms.  For example, if 5:00 is the trigger, at the end of the workday, you need to help the person have another tension reducing factor, go to the gym, play cards, etc.  The third stage is the psychodynamic phase. You begin to look for the underlying causes to deal with the emotions of rage, depression Making an unconscious conflict conscious.  The best chance people have to do these three things successfully is to both go to the 12 step program, to AA, and to go into counseling or psychotherapy It's better to do one of the two than to do none, but it's best to do both.

There are people who are not comfortable in the 12 step programs. They find their ideology semi-religious and aren't comfortable.  You shouldn't go it alone, get into therapy with a specialized therapist.  When selecting a therapist, pick someone who works with addictions.  It's not very hard to find people who specialize in addiction therapy.  Ask doctors if they are trained in addictions and how they can help you, an ethical therapist who is honest with you.

Special_Moderator  Please define a recovering alcoholic?

Speaker_Levin   That's someone whose no longer actively an alcoholic, they're not drinking but define themselves as recovering rather than recovered.  Recovery to remind themselves they are still at risk to relapse.  The idea of identifying yourself as recovering is wise, but it doesn't mean that you have to walk around fearful all the time of a relapse.  People become comfortable with sobriety more and more.  You don't want to get cocky because that's dangerous. Think of yourself as recovering instead of recovered keeps you in check so you do not relapse.

Special_Moderator  Can you talk about the ingestion and absorption of alcohol, why it varies from person to person, etc?

Speaker_Levin  You can get high by inhaling high proof stuff but  the route of entry into the body is by drinking it.  20% is absorbed in the stomach, and about 80% in the first part of the small intestine, called the duodenum.  The rate of absorption is determined by how much food is in the stomach.  If you drink on an empty stomach, it's going to hit hard.   Alcohol requires no digestion. It is absorbed into he body without chemical change.  There is an enzyme in the stomach which metabolizes about 1/3 of the alcohol before it is absorbed. This is for men, not women.  I don't believe there are other individual differences in absorption.  The difference is what alcohol does to the nervous system once it's in the body. Some people act irrationally for reasons we don't understand. That's called pathological intoxication. That's probably genetically determined.  Another difference is tolerance... For reasons which aren't clear, some people can drink a lot with very little effect and others can't.  If you can drink a lot, you're more likely to get hooked on it.  So high capacity is a risk factor.

Another difference is how reinforcing it is, how good it feels. That's probably a combined genetic experience variable.  We all know people who take a drink and says; it makes me sleepy or gives me a headache. They probably will never be hooked on alcohol.  Some people claim it is wonderful, I'm not shy, I can dance, etc.  They will go back and this will cause trouble.  There's differences that are largely neuro-chemical and genetically determined, but learning experience also plays a role.

Special_Moderator   What kind of program can one with a severe drinking problem check himself into if he can't quit alone?

Speaker_Levin  Good question.  There are many rehabilitation inpatient places in all parts of the country.  Some facilities provide medical services, including detoxification, some not, so you need to detoxify before you go.   In the rehab program, you are exposed to the 12 step program, attend lectures, have a primary counselor, participate in groups, participate in communal activities. A good rehab works you hard. You have a schedule you follow daily.  The patients treated successfully uniformly report it was one of the best experiences of their lives.   It wasn't easy, but it really paid off. If you're severely involved with alcohol, inpatient treatment is highly recommended.  AA usually knows the programs in a particular area but you can also ask your physician.  These programs used to run 28 days because of insurance. They are much shorter now, 10 days to 2 weeks, but it depends on your needs and resources.  They can really change your life.

Special_Moderator  What type of research is being done to find out more about alcoholism, treatments and possible cures?

Speaker_Levin  The vast majority of money is going into biological research. I'm not happy about that. I'm not against it, but they need to look at psychosocial treatments.  We do no know we get the best treatment with multi-model approaches, involves 12 step, family therapy, vocational counseling, individual therapy, etc.  The more severe the addiction, the more forces you want to bring.  There is a lot of research at the molecular level. I wish there was more money set aside for those studies. Our cure rates are not bad. Many people recover, some tragically don't.  Poet William Blake wrote, the road of excess leads to the palace of wisdom; unfortunately it also leads to a cemetery.

Special_Moderator   Is alcoholism counseling a popular line of work?

Speaker_Levin   Yes. It's fascinating, it's complexity because it involves so many areas; history, economics, psychology, medicine, genetics, etc.  it's very intellectually stimulating.  Addiction is a common human experience, so we learn more about human nature. On the clinical side, the actual work, it's very challenging emotionally.  Alcoholism counseling has been compared to taking a bone away from a hungry doberman, you have to learn to handle great anger and not take it personally.  You witness a lot of tragedy, child abuse, suicide, disrupted families. You can't take it personally.  You also see people recovering and see their lives change for the better so it can be satisfying.  On the economic side, there are jobs in hospitals, in rehab units, in outpatient units, in the schools, employee assistance programs, and you can make a pretty decent living at it. If you want to get rich I recommend Wall Street.  I worked with a  kid who abused a lot of drugs  a few years ago. Now he's cleaned up and making over $300,000 a year legally.  It's a very interesting field, you can teach, write, educate publicly, as well as do clinical work, administration.  You can also do research.

Special_Moderator  We are almost out of time is there anything else you would like to cover before we say good-bye?

Speaker_Levin  I would like to urge people who have addictive problems to try to peek around their denial and realize that it's driven by fear, very deep seeded fear that you're  not going to be all right without your thing, and that's not true.  You need to walk through it and don't do it alone. Get professional or peer help. Recovery is a very rewarding experience.  For those who want to enter the field professionally, I think it's a great field.

Special_Moderator  Well that is all the time we have. Thanks for joining us tonight for WebMD Live and a big thanks to Dr. Levin for being our guest speaker. Please check the program schedule to see what other live programs we have coming up. Thank you and goodnight!

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Last Editorial Review: 10/23/2003