There is increasing demand for specialized units for the treatment of alcoholism to be set up in Britain. The model for such centres was established by the Yale Plan Clinics, the first of which opened in Connecticut in 1944.1 The essential of treatment in these clinics was the provision of a team comprising a psychiatrist, a general physician, a psychologist, a social worker and a secretary. If they were to function effectively the clinics had to be situated in the community which they served.
The most valuable asset of a specialized unit is trained and experienced staff who regard alcoholism as an illness and approach alcoholics without hostility or contempt. Nurses soon learn to respond to alcoholics without moralizing or condescension but they still require training and supervision to develop the necessary special clinical skills. Treatment staff who are judgemental, or who are liable to react with censure or disapproval if a patient discloses disturbing material, forfeit the chance of continuing to be useful to that patient.
The specialist clinic provides alcoholics with a treatment facility to which they can go when in need. The staff work as a team and provide a coordinated handling of the medical, psychological and social problems of each patient. The psychiatrist integrates the contributions of each member of the treatment staff and formulates for each patient the treatment approach that will be adopted. The psychiatric social worker, customarily a woman, although men work very well with alcoholics and their wives, is a very necessary member of the therapeutic team. She will not find a job or a home for the alcoholic; nor will she settle his debts; but she can show him where to start, how to break up a seemingly overwhelming burden into smaller, manageable portions. Similarly she can assist the patient and his wife to a better understanding of each other’s point of view. Usually she will set about this by seeing the wife on many occasions. When the alcoholic first begins treatment his wife often feels that her difficulties are not appreciated and that the patient’s account of the marital relationship is being accepted uncritically, so much so that she is regarded by the doctor as more to blame than her husband. It is the job of the social worker to be concerned with her point of view, to support her in her difficulties and yet to show her dispassionately what is happening to her husband and how she can help him at the present juncture. The psychiatric social worker can act as a non-participant go-between, to point out to both parties how they act in opposition to each other.
The job of the social worker does not end there for, in the period after the abstinent patient leaves hospital, he and his wife will have to learn to readjust to a new situation. He will wish to take over the reins of management again and she perhaps be loath to relinquish them, being with reason unsure whether it is going to last. If for the last few years a wife has conducted the entire financial running of a failing business and the domestic economy, she may not be willing to see this authority depart from her, especially into the hands of a potential squanderer. Yet the patient will have been encouraged by his doctor to accept more responsibility and will feel himself fit to do so. Many remissions achieved in hospital flounder because of failure to reconcile the marriage partners and it is primarily the task of the psychiatric social worker in the therapeutic team to help overcome marital difficulties.
The psychologist helps in the assessment of the patient’s abilities and in providing vocational advice.
Patients in a special unit learn from witnessing how their own illness manifests in others.
The patients attending such a clinic, a specialized unit, may be of a different type from those generally met with in the wards of a psychiatric hospital. Most of them are employed; they are still living with their wives and taking an active part in the life of the community. This also was the finding of Straus and Bacon, who reported on 2,000 alcoholics treated in community clinics in the United States.1 They found that the type of men who came for treatment differed greatly from what had been expected and called for a revision in the medical stereotype of the alcoholic. These patients were by no means deteriorated socially but had a high degree of social and occupational integration in the community. They came spontaneously to clinics situated near their homes, which provided treatment facilities allowing them to keep up their work and family ties.
The Ministry of Health recommended in a memorandum issued to hospital authorities in 1962 that special units for alcoholics should be established. Hospital boards were urged to establish one unit in each of the twenty hospital regions in Great Britain and increase this provision if necessary. The need for such units to maintain out-patient clinics as well was stressed. To site such clinics far from patients’ homes is unrealistic on a number of counts. The alcoholic patient’s motivation is his greatest treatment asset; he should be able to find an immediate and convenient response when he makes his initial appeal for help. He should resume his community ties as swiftly as possible. His in-patient and out-patient stages of treatment should be provided by the same service, which cannot be done if the in-patient unit is far from his home. His wife needs to be seen repeatedly to help her gain the understanding of the illness needed if she is to help her husband during his recovery.
What are the forms of treatment which a patient can expect to receive in a special unit for the treatment of alcoholism? We shall first outline the methods which we advocate. Individual patients require individual treatment plans but on the whole this is the customary approach.
It involves: the use of drugs to make it easier for the patient to abstain, the commonest used being antabuse; individual or group therapy; and, where it is considered appropriate, the assistance of Alcoholics Anonymous.
Treatment generally begins with the patient in hospital and continues on an out-patient basis.
Although the most important element in the treatment programme is psychotherapy, we begin by discussing antabuse, because it is introduced at the onset of the treatment programme.