The pre-delirium syndrome in alcoholic patients in ambulatory care and its treatment

In an administrative district of roughly 70,000 inhabitants, two-thirds urban, one-third rural, 60 patients, 46 male, 14 female, received out-patient treatment for alcoholic predelirious syndromes during the period 1982-1986. The total number of predeliorious attacks was 91, age incidence lay between 18 and 65, peaking at 35 to 45. In 61.7% of the cases only one predelirious attack occurred, in 28.3% two, and in 10.0% three or more. Through the period there is a perceptible rising tendency. In eight cases there was an epileptic grand mal fit in the course of a predelirious attack. Out-patient treatment was successful in all but three cases, which definitely called for hospitalised treatment. Diazepam, Diazepam/Haloperiodol, and Distraneurin were administered orally as a regular part of the program of treatment. 30 times Diazepam and Haloperidol effected a cure, while in 61 attacks it appeared that treatment with Chlormethiazol was inevitable. Results are discussed and conclusions drawn.     

Issues in treatment efficacy research with alcoholics.

A variety of therapeutic strategies have been used in the treatment of alcoholic patients. Within this context, behavioral techniques have been widely employed with varying degree of effectiveness. This paper attempts to explore theoretically 2 widely used behavioral therapeutic methods, systematic desensitization and covert sensitization, along with traditional insight-oriented therapy. Possible merits and limitations of applying these treatment approaches to alcoholic patients are explored.     

Uncovering Strengths of Children of Alcoholic Parents

Being a child of an alcoholic (COA) is neither a diagnosis nor a psychosocial death sentence. Neither alcoholic families nor COAs are monolithic. A variety of factors converge in developmental trajectories resulting in diverse individual outcomes. Supportive relationships with non-substance using parents and siblings and appropriate levels of parentification all may enable a significant proportion of COAs to enjoy high self-esteem, lack of problematic substance use, and good adaptive capability. Therapists and clients should refrain from looking at COAs through a deficit framework and instead should look for evidence of relational resilience in alcoholic families of origin. Such strengths-based assessments will increase therapeutic leverage with COAs seeking treatment for a range of presenting problems.     

Simulated alcoholic delirium

Of 200 diagnosed cases of alcoholic delirium 5 (= 2.5%) involved, from the differential diagnostic viewpoint, simulation of alcoholic delirium with all the symptoms involved. The symptoms of the simulation case are compared with the acute symptoms, and points in common to all simulation cases are presented: Definite alcoholic anamnesis, wide experience of treatment for alcohol abuse, dynamics of a pronounced purposeful action when social complications are imminent and course of the symptoms when the interview turns to simulation. In connection with therapy, special attention is drawn to Distraneurin treatment, which is not indicated in such cases.     

Pastoral counseling with alcoholics and their families

The pastor is often in contact with the alcoholic and his or her family. Providing help to alcoholics and their families is a spiritual, humanistic, and therapeutic challenge. Recent developments have favored a family systems orientation to working with alcoholic families. This orientation acknowledges the family as contributor to maintaining alcoholic behavior and includes the family in treatment. Specific family systems concepts are discussed and how they relate to the dysfunctional unit which houses an alcoholic. Implications for pastors and specific role definitions are explored. Krebs' therapeutic model is expanded to: 1) evaluate, 2) support, 3) refer, and 4) support, as appropriate for the pastor working with alcoholics and their families.     

An Organizational Framework for Occupational Therapy in the Treatment of Alcoholism

Because occupational therapists are increasingly involved with alcoholism rehabilitation, an organizational treatment framework is presented that is based upon the psychodynamics of this diagnosis. Factors that contribute to the development of a unique defense structure characteristic of alcoholism are discussed as prerequisites for understanding the treatment needs of the adult. Treatment is organized into three hierarchical levels that correspond with progressive changes in the alcoholics' defense structure. Alcoholics at level one require directive treatment approaches that do not aggressively confront the preferred, but maladaptive defense mechanism in order to attain abstinence. Teaching coping strategies that provide alternatives to the preferred defense mechanisms are beneficial at level two. The third level involves stimulating the arrested emotional development of the alcoholic thus effectively challenging the continued utilization of these defense mechanisms. Specific occupational therapy methods and frames of reference are outlined that are appropriate for implementation at each treatment level.     

Alcohol abuse—an interactional approach

In this article, the author points out the usefulness of applying an interactional approach to the treatment of alcoholic abuse. First, the relational significance of the symptom is discussed and an analysis is made of the principal communication patterns existing between the partners of the couple.
The essential contents of the therapeutic strategy are then described, as well as the homeostatic reactions of the system: two types of intervention were applied, paradoxical and structural, which were aimed at eliminating the symptom and gradually changing the couple's relationship.     

Personality characteristics of substance abusers: an MCMI cluster typology of recreational drug users treated in a therapeutic community and its relationship to length of stay and outcome.

The purpose of this investigation was to define homogeneous personality subtypes among substance abusers treated in a long-term, inpatient, drug-free therapeutic community and to determine how the resulting typology was related to length of stay and treatment outcome. A hierarchical agglomerative cluster analysis was performed on the Millon Clinical Multiaxial Inventory (MCMI) scale scores of 235 admissions to a therapeutic community. Five cluster types emerged, which were similar to typologies found in studies with alcoholic inpatients. A concordant solution evolved when a different clustering algorithm was used with the same sample and when clustering was done with a different group of substance abusers. As hypothesized, clusters of patients with average MCMI elevations that indicated avoidant, schizoid, and antisocial qualities tended to stay in treatment fewer days and relapsed earlier during the 1-year follow-up. The implications for substance abuse treatment are discussed.     

Personality Characteristics of Substance Abusers: An MCMI Cluster Typology of Recreational Drug Users Treated in a Therapeutic Community and Its Relationship to Length of Stay and Outcome

The purpose of this investigation was to define homogeneous personality subtypes among substance abusers treated in a long-term, inpatient, drug-free therapeutic community and to determine how the resulting typology was related to length of stay and treatment outcome, A hierarchical agglomerative cluster analysis was performed on the Millon Clinical Multiaxial Inventory (MCMI) scale scores of 235 admissions to a therapeutic community. Five cluster types emerged,, which were similar to typologies found in studies with alcoholic inpatients. A concordant solution evolved when a different clustering algorithm was used with the same sample and when clustering was done with a different group of substance abusers. As hypothesized, clusters of patients with average MCMI elevations that indicated avoidant, schizoid, and antisocial qualities tended to stay in treatment fewer days and relapsed earlier during the 1-year follow-up. The implications, for substance abuse treatment are discussed.     

Why are psychological treatments prolonged? Predictors of a longer duration of treatment and analysis of the differences between long- and short-term cases

The purpose of this study was to identify variables that may explain a longer psychological treatment and to analyze differences between short- and long-term cases. Data from 419 patients of the University Clinic of Psychology at the Complutense University of Madrid were analyzed. Number of intervention techniques, comorbidity, previous treatments, and a primary diagnosis of mood disorder or eating disorder were the factors that explained longer treatment duration. Significant differences were observed between short- and long-term cases in number of intervention techniques, number of therapeutic objectives, and also in some clinical variables (diagnostic group, comorbidity, previous treatment) and demographics (age and educational level). Results are discussed and some lines of intervention and/ or reflection are proposed.     

Approaches to chemical dependency: chemical dependency and interactive group therapy--a synthesis

Though the focus on interpersonal interaction is a powerful therapeutic factor in group therapy, traditional chemical dependency therapy groups generally fail to employ the interactional group orientation. An interactional approach can be effectively applied to alcoholics if the following guidelines are observed: (1) recovery is always accorded priority, (2) the patient accepts identification as an alcoholic, (3) anxiety is carefully modulated, (4) the proper distinction is made between what the alcoholic is and is not responsible for, (5) the therapist is thoroughly familiar with Alcoholics Anonymous language, steps, and traditions. It is important that therapists not permit misperceptions of A.A. to be used as therapy resistance and that they be able to harness the wisdom of A.A. for psychotherapeutic ends. Group therapists must also be prepared to deal with common themes arising in the treatment of the alcoholic patient: idealization, devaluation, externalization, defiance, grandiosity, conning, and avoidance.     

Some Relationships between Group Process and Mental Health Phenomena in Theory and Practice

Though the focus on interpersonal interaction is a powerful therapeutic factor in group therapy, traditional chemical dependency therapy groups generally fail to employ the interactional group orientation. An interactional approach can be effectively applied to alcoholics if the following guidelines are observed: (1) recovery is always accorded priority, (2) the patient accepts identification as an alcoholic, (3) anxiety is carefully modulated, (4) the proper distinction is made between what the alcoholic is and is not responsible for, (5) the therapist is thoroughly familiar with Alcoholics Anonymous language, steps, and traditions. It is important that therapists not permit misperceptions of A.A. to be used as therapy resistance and that they be able to harness the wisdom of A.A. for psychotherapeutic ends. Group therapists must also be prepared to deal with common themes arising in the treatment of the alcoholic patient: idealization, devaluation, externalization, defiance, grandiosity, conning, and avoidance.     

Current status of knowledge on the changes in the hypothalamo-hypophyseo-adrenal cortex system and their effects in chronic alcohol use and withdrawal

The results of investigations into the changes in the function of the hypothalamus-hypophysis-renal gland system in chronic alcoholics are collated. The review shows that the activity of the hypothalamus-hypophysis-renal gland system is below-normal in at least some alcoholics, but due to conflicting results, it is not possible to decide whether the hypofunction of the adrenal gland is a primary of a secondary effect. The interrelationship between glucocorticosteroids and catecholamines is described and its importance for the adaptability of the organism is stressed. On the basis of the review it may seem advisable to introduce corticosteroid treatment into the therapeutic schema for delerious alcoholic patients and also to apply it on patients with the alcohol withdrawal syndrome if tests show that the function of their hypothalamus-hypophysis-renal gland systems is impaired.     

Risky sexual behavior among married alcoholic men.

The current study explored whether the wives of men entering alcoholism treatment are at risk for sexually transmitted infections (STIs) exposure as a result of their husbands' sexual risk behaviors. The extramarital relationships of married alcoholic men entering outpatient treatment (n = 125) were compared with those of a demographically matched community sample of nonalcoholic married men (n = 125). The proportion of alcoholic men who reported 1 or more extramarital affairs in the previous year (14%) was significantly higher than that of the community sample (4%). Additionally, only 2 alcoholic husbands and 1 nonalcoholic husband reported that his wife was aware of the extramarital relationship. For both groups, none of the men who engaged in extramarital relationships reported consistent use of condoms when having sexual intercourse with their wives or with their extramarital partners. These results suggest that wives of alcoholic men are unknowingly placed at risk for indirect exposure to STIs as a result of their husbands' sexual risk behaviors. Thus, infidelity in treatment-seeking alcohol-abusing men represents a significant public health issue.     

Alcoholism: etiologies proposed and therapeutic approaches tried

Alcohol, probably the most popular mood-altering drug, has frightening consequences when abused. Genetic factors and sociocultural influences contribute to alcoholic behavior. Study of endocrines, neurotransmitters, and neuropeptides may reveal biological markers to help identify those at risk for alcoholism. Drinking patterns are often based on the expectation of alcohol's mood-altering quality. The focus of treatment has expanded to include not only drinking behavior but also emotional, social, and vocational adjustment. Controlled drinking has proved effective for some, so that complete abstinence is no longer the sole goal of therapy. Behavioral, martial, group and individual, outpatient and inpatient therapy, and drugs as adjuncts, all help some alcoholics, but none is a cure for all. Answers still lag behind questions but researchers have registered some advances that challenge therapists to enlarge therapeutic approaches to fit the multifaceted picture of alcoholism.     

Family participation in the treatment of alcoholism

The effect of family involvement on the efficacy of alcoholic treatment was investigated. Degree of family involvement, as measured by the participation of the wives of 60 alcoholics in a hospital family lecture series, was compared to recidivism rates and to completion of the in-patient treatment program. The wives' participation was closely related to whether or not their husbands completed in-patient treatment. Participation also appeared to be related to recidivism although additional services in the area of counseling for discharged alcoholic patients and their families are obviously needed.     

Barriers to treatment participation and therapeutic change among children referred for conduct disorder.

Examined predictors of therapeutic change among children seen in outpatient therapy. Children (N = 200) referred for oppositional, aggressive, and antisocial behavior and their families participated. The major findings were that (a) socioeconomic disadvantage, parent psychopathology and stress, and child dysfunction predicted therapeutic change from pretreatment to posttreatment; (b) barriers to participation in treatment also were significantly associated with therapeutic change and this effect was not explained by the other family, parent, and child predictors; (c) as the level of perceived barriers to participation in treatment increased among families, the amount of therapeutic change decreased; and (d) among children at risk for relatively little therapeutic change, the perception of few barriers to treatment increased the degree of child improvement. The implications for further work on predictors of therapeutic change and the role of barriers in the treatment process are discussed.     

Building therapeutic relationship in schizophrenic and alcohol-related disorder cases

Current literature on the dual diagnosis in cases of schizophrenia and alcohol dependence has reported how pharmacological treatment has positive effects on the reduction of both disorders. Nevertheless, patients have considerable difficulties in following the prescribed medication. This work aims to build an engagement stage and therapeutic relationship in seven patients with schizophrenic and alcohol-related disorder cases. This result was achieved through the use of the vignette technique and narrative psychodynamic approach during group counselling sessions. Positive and Negative Symptoms Scale (PANSS) and Munich Alcoholism Test (MALT) were applied before and after treatment. A follow-up session was organized. The PANSS and MALT scores indicated there was no reduction of the psychiatric symptoms after treatment. The follow-up session showed positive outcomes in terms of increasing the level of socialisation as well as awareness of their own condition; at the same, an adherence to pharmacological treatment and psychotherapy for all the subjects.     

Experiences with directed dynamic group psychotherapy in psychotherapeutic ambulatory care

The psychotherapeutic situation of public assistance at a district without stationary institution for psychotherapy calls for the ambulant effort of methods personally centered group psychotherapy. The Intended Dynamic Group Psychotherapie was developed on stationary conditions of a therapeutic sommunity. In a practical report about eight therapy groups are discussed possibilities and limits of this method on ambulant conditions.     

Implementation and Utilization Characteristics of a Rural,School-linked Mental Health Program

We examined variables associated with treatment engagement in a real-world therapeutic setting. The model of care examined involved school-linked mental health care for children and their families in a rural county. Service utilization characteristics, as well as child- and treatment-specific variables were examined in relation to their impact on therapy length, missed appointments, and treatment outcome. A total of 168 students and their families participated in therapeutic services over a period of approximately 4.5 years. Overall, children who had less psychopathology and a higher level of clinician-rated functioning (GAF) at the start of therapy were more likely to successfully complete treatment. Parental involvement in therapy was associated with a longer course of therapy, as well as more missed appointments. Barriers to treatment and treatment engagement, as well as future directions of study, are discussed.