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Dependence is defined as a cluster of three or more existing criteria according to
the DSM-IV for alcohol dependency over a period of 12 months. According to Riley,
substance abuse is commonly referred to as an addiction. These terms are often used
interchangeably. Dependency occurs over time and is usually taken in excessive
quantities causing harm to the individual (Riley, 1998). There is no known cause for
alcohol dependency. However, there are contributing factors to the etiology of alcohol
dependence. These factors are age, gender, cultural differences, depression, and schizoid
personality traits. The DSM-IV states, “low educational level, unemployment, and lower
socioeconomic status are associated with dependency, although it is often difficult to
separate cause from effect” (DSM-IV, 1994, p. 201). Alcohol is more common in males
than females with a 5:1 ratio. The reason for the high ratio is because females have a
tendency to drink later on in life due to the increase of stressors. There is a link between
familial history increasing the risk for alcohol dependency, as well as, a genetic
predisposition (DSM-IV, 1994).
Symptoms of depression, anxiety, and insomnia accompany alcohol dependency
along with suicidal ideation. According to the DSM-IV the prognosis for individuals
with alcohol dependency is promising. “Follow up studies indicate that highly
functioning individuals show a higher than 65 percent 1 year abstinence rate following
rehabilitation. Twenty percent or greater of individuals with alcohol dependency achieve
sobriety without current treatment” (DSM-IV, 1994, p. 202-3). Most individuals
demonstrate self control and are able to actively participate regularly in daily activities.
Individuals with alcohol dependency slowly increase their social and vocational roles
with the aid of treatment (Reed, 1991).
The enzyme acetaldehyde accumulates in the blood with any consumption of
alcohol. Most treatments involve the use of Disulfiram, also known as Antabuse. It is an
inhibitor of the enzyme aldehyde dehydrogenase which with a single drink causes a toxic
reaction. This drug should not be administered until 24 hours after the individual’s last
drink. Several side affects could occur if one ingests alcohol while being treated with
Antabuse. Physicians should caution patients of affects. According to Kaplan and
Sadock, this drug can increase psychotic symptoms in some patients with schizophrenia
in the absence of alcohol. The drug Naltrexone aids in decreasing one’s craving for
alcohol. The recommended dosage for this drug is one dose daily. Its primary goal is to
promote abstinence by preventing relapses and decrease alcohol consumption in
individuals (Kaplan & Sadock, 1998). Anti-anxiety agents and antidepressants have
been used as treatments for those symptoms associated with alcohol. However, there is
rising attention to the use of psycho active drugs in order to control alcohol cravings
(Kaplan & Sadock, 1998). Alcohol related disorders, such as, alcohol dependency can be
accompanied by a number of other disorders: mood disorder, anxiety disorder, sexual
dysfunction and sleep disorder which are all alcohol induced. According to Kaplan and
Sadock, Lithium has shown to reduce mood cycles in manic-depression as well as an
individual’s desire to consume alcohol. Research is still underway to confirm the link
between the two. The reduction of alcohol cravings is also being researched and
validated with the use of serotonin specific re-uptake inhibitors or Tranzone (Desyrel)
(Kaplan & Sadock, 1998).
Precautions should be taken when working with an individual with alcohol
dependency. The foremost important precaution, however, is to observe drinking
behavior for relapses. Looking into the environment, whether it be at the individual’s
work or home should be considered while treating an alcohol dependent individual. This
is important in order to catch the possibilities of relapses or codependency. Another
concerning consideration in treating an individual with alcohol dependency is the
medication he/she is taking at the time of treatment. All medication the individual is
taking while consuming alcohol is also a critical issue to consider in treatment.
The alcoholic dependent person spends a great deal of their time in activities
necessary to acquire the substance, in consuming the substance, and in recovering from
its affects. At times when they are expected to fulfill major role obligations at work,
school, or at home they will be intoxicated or suffering from the symptoms of
withdrawal. Withdrawal symptoms can include tremors, hallucinations, sweating,
seizures, and diarrhea. Alcoholism can be physically hazardous causing injury to the
person while engaging in occupations under the influence of alcohol. Intoxication can
cause auto accidents leading to injury or death of persons involved. There is also
deterioration in overall function especially to the liver, heart, and brain. There is a high
incidence of social, occupational, or recreational activities given up or reduced due to
substance abuse. Alcoholism affects family life, vocational performance, self-care
abilities, physical and emotional health, social relationships, and financial well-being.
Psychological and emotional deterioration for the alcoholic may include low self esteem,
anxiety, depression, paranoia, emotional numbness, and poor handling of frustration.
Failure to move through the normal emotional developmental milestones is an outcome
of early onset addictions. They remain emotionally immature and may act very similar to
adolescents. Their behavior may be rebellious, temperamental, demanding, and
dishonest. The process of learning to be responsible, accountable, mature, and
independent adults may take up to 3-10 years. Alcohol dependency is accompanied by a
life of denial and defense systems that serve to maintain the addictive process. Denial is
seen in the early stages of addictions. Defense mechanisms include minimizing the
negative impact of the behavior, rationalizing the drug use, and blaming others for their
choices and actions. The lives of those close to the alcohol dependent person can also be
affected. Being in a long term relationship with a substance abuser often results in low
self-esteem, depression, chronic anger, and stress related illnesses. They may attempt to
control the addict’s behavior or compensate for the addict by taking on some of their
responsibilities enabling the addict to continue use. These dysfunctional ways of relating
to the alcoholic is referred to as codependency. Many negative consequences associated
with difficulty in expressions of emotion are job loss, marital separation, loss of child
custody, and alienation of prior support network, such as friends and family. Chemical
dependency treatment programs attempt to assist the dysfunctional family by altering the
family members’ way of dealing with conflict, interpersonal needs, communication
patterns, and domestic responsibilities. Social attitudes and solutions for alcohol
dependent persons include rehabilitation programs, decriminalization to imprisonment,
and mandatory sentencing of drug users and sellers (Riley, 1998).
Lifestyle adjustments for the recovering alcohol dependent person could include
restructuring their environment. This process would entail removing alcohol from the
home, office, and other areas where the person may keep alcohol. Social environments
need to be changed to exclude bars and friends who are not empathetic to the needs of the
recovering alcoholic. Transportation routes can be altered to exclude areas of temptation
for the alcoholic. The alcohol dependent person needs to realize that he has a problem
and take the initiative to live a life without substance dependency. The alcoholic will
need to gain better control over negative emotions and learn better stress coping skills.
He/she will have to take back responsibilities that were avoided while dependent on
alcohol. He/she will also need to take responsibility for the behavior and consequences
of the past. Overall, he/she will have to learn to be an independent adult (Riley, 1998).
In considering the expected level of independence for the person with alcohol
dependency the occupational therapist will concentrate on OT domains of concern which
include performance areas, performance components, and performance contexts.
Primarily, functional impairment are seen in leisure and work performance areas. The
alcoholic usually gives up leisure activities in order to spend more time acquiring and
using alcohol (Riley, 1998). They will need to explore and develop a variety of leisure
activities and skills (Reed, 1991). Work may be interrupted or jobs lost due to the
physiological and psychological effects of short and long term dependency. These effects
include decreased concentration, poor judgment, poor problem solving skills, increased
absenteeism, and poor time management (Riley, 1998). Other performance areas where
deficits appear are in activities of daily living and home management. They may neglect
self-care and lack skills in money management (Reed, 1991). Performance components
affected include sensory and perceptual motor deficits, cognition, psychosocial, and
psychological issues. Sensory and perceptual motor impairments include a loss in tactile
perception, figure ground perception, visual-spatial (greatest impairment), and fine motor
coordination (Riley, 1998). Motor deficits may include decreased physical tolerance,
endurance, and peripheral neuropathy (Reed, 1991). Cognitive impairment include
memory, attention span, concept formation, problem solving, and learning. Abstract
reasoning, nonverbal problem solving, short term memory, and perceptual motor
integration may become permanent losses (Riley, 1998). The person may have cognitive
disorders associated with brain damage (Reed, 1991). Of the alcoholics entering
treatment, 75% have neurocognitive deficits. Psychosocial and Psychological
performance components which are affected by alcohol dependence includes values,
self-image, self-esteem, self-expression, interpersonal and role related skills, time
management, coping skills, and social conduct (Riley, 1998). Other problem areas can be
the inability to define goals, lacking goal oriented behavior, and depression (Reed, 1991).
It is very important to consider performance contexts especially in the areas of
development, cultural, and social environments. For many of these deficits
improvements have been noticed with prolonged recovery, although some losses may be
irreversible. Treatment programs can help these people over time or compensate for
deficits from alcohol dependency (Riley, 1998).
Individual therapy is part of many treatment programs, however, most of these
programs employ various forms of some type of group treatment (Neistadt & Crepeau,
1998). Substance abusers in general have a tendency to isolate themselves, feel they are
alone, or are unable to cope with their problems. Here is where group therapy helps those
who have had similar experiences.
Group treatment settings in particular are appropriate for alcohol dependent
individuals since many people with alcoholic disorders tend to be emotionally and
socially isolated, drink alone, and have difficulty tolerating conflict or relating socially
(Riley, 1998). Group settings can help foster acceptance and a sense of belonging which
strives to put the newly recovering individual at ease (Riley, 1998). During a session, the
individual would be encouraged to share feelings and experience group discussion, and
participate in role playing or psychodrama (Reed, 1991). These opportunities are
provided to the individual as a means to decrease social isolation, learn new interpersonal
skills, and practice reintegration into social settings such as family or work environments
Treatment settings offer a wide range of services which include hospitals,
residential programs, halfway houses, and organizations including Alcoholics
Anonymous, Al-Anon and Alateen.
Programs that involve chemical dependency usually take place in a special unit of
psychiatric or general hospitals, are run by professionals including ex-addicts, where
length of stay vary from a number of days to a month. After discharge from the
hospital, the client is encouraged to join some type of follow-up program such as
Alcoholics Anonymous (Neistadt & Crepeau, 1998).
Residential programs are run by former addicts whose lives have been consumed by
addiction in one form or another. This type of community requires a lot of structure
where all members of the household are given responsibilities to maintain the
environment. The community is closely monitored and residents usually have little or
no contact with outsiders for certain lengths of time. During their stay, residents
confront their addictions on a continuous basis (Neistadt & Crepeau, 1998).
When a patient with an alcohol-related disorder is discharged from the hospital, it
becomes important to find somewhere to stay other than home. Previous familiar
places have often proved themselves counterproductive to the patient. The halfway
house provides emotional support and counseling to help reintroduce the patient back
into society (Kaplan & Sadock, 1998).
Alcoholics Anonymous is a voluntary program that helps the individual through
social support. The ideas behind AA is to stay focused on the value of being
abstinent (Riley, 1998). This program uses a twelve-step method as well as others,
and many provide the individual with a more secular approach to treatment because
they emphasize seeking help from a higher power (Neistadt & Crepeau, 1998).
Al-Anon is an organization primarily for the spouses of people with alcohol-related
problems (Kaplan & Sadock, 1998). This group is structured similar to AA, which
aims to provide group support, assist the efforts of spouses to regain self-esteem, to
refrain from feeling responsible, and to develop a rewarding life for themselves and
their families (Kaplan & Sadock, 1998).
Alateen is an organization that focuses on children of people with alcohol
dependence. The organization helps children understand their parents’ alcohol
dependence (Kaplan & Sadock, 1998).
There are several models of therapy to use when treating people with
alcohol-related disorders. Behavior therapy focuses on relaxation training, assertiveness
training, self-control skills and new strategies to help them master their own environment
(Kaplan & Sadock, 1998). Operant conditioning programs are often used with people
who have alcohol-related disorders to either modify or stop drinking behavior (Kaplan &
Sadock, 1998). Types of reinforcements range from monetary reward, to opportunities
where one can live in an enriched inpatient environment, or have access to pleasurable
social interactions (Kaplan & Sadock, 1998).
Cognitive-behavioral therapy believes that addiction is primarily a learned
behavior, and therefore can be unlearned (Riley, 1998). In order to eliminate behavioral
habits, the client must also change their cognitive patterns which distort thinking and
perpetuate alcohol use (Riley, 1998). When identifying consequences as a result of
behavior, therapist help the person by examining the following (Riley, 1998).
Verify what rewards a person may experience by using alcohol.
What motivates them to drink even though they know the consequences will be
Examine whatever false beliefs the user may have concerning benefits obtained by
In addition to consequences, the individual will be asked to identify “warning signs” that
may lead to relapse. Other strategies include restructuring the environment in an effort to
reduce factors that may provide temptations which lead to usage (Riley, 1998).
When beginning treatment it is almost impossible to start with a specific
prescription of activities, and there is no need to (Doniger, 1953). Usually, the patient
will provide a spontaneous starting point with reactions, favorable or destructive,
observed with a practiced eye and open mind, which provides clues for purposeful
activities (Doniger, 1953). Often, patients are full of ideas but are slow to organize
anything along realistic lines. It is also important for the occupational therapist to be
specific when prescribing an activity because different things have different meanings to
individuals. The occupational therapist must be able to differentiate between constructive
expression, release, and the use of the activity to reinforce the pathological pattern
(Doniger, 1953). A patient who works his/her hostility out towards the therapist instead
of working it through at the scheduled time are ultimately working at their own
disadvantage. An example is a patient who uses creative painting to withdrawal into a
fantasy world, when really the patient should be drawn out and expressing his/her
emotions within the group. The occupational therapy group provides support,
opportunities for growth, and to assess one’s limitations. Occupational therapy, in some
circumstances, can help patients through vocational exploration even though some may
avoid contacts with working situations because of emotional difficulties (Doniger, 1953).
The following activities facilitate the individual in many ways. Classical treatment
Evaluation where a self-image collage, combined with an interview and goal-setting
session, serves as the foundation of the occupational therapy program.
Therapeutic use of crafts is used to indicate underlying resistance to the entire
program, and can surface when patients are asked to perform specific tasks. During
the task, the patient is asked to focus on dealing with behaviors and attitudes which
are related reasons for why they are in treatment.
Recreational programs provide extra opportunity for socialization, development of
interpersonal skills, group interaction, and to decrease social isolation.
Group process involves task-oriented groups where patients meet with the occupational
therapist to discuss issues or problems related to alcoholism. The emphasis is on learning
alternative ways of dealing with problems and issues relating to the recovery process.
Some innovative ideas for treatment concerning this particular patient population
Having the individual video taped during the behavior, then later have them watch to
see how it makes them feel, what it makes them look like, and how they think others
Viewing movie clips that make a point on how destructive their drinking behavior is
and has become. This part of the treatment plan would focus on extinguishing the idea
of “that would never happen to me.”
Having a party for the treatment group that simulates a bar-type atmosphere, however,
only non-alcoholic beverages would be served and they would be aware of the fact.
The purpose of this exercise is to facilitate social interaction, and to learn suitable
behaviors so they can realize alcohol does not need to be at hand in the presence of
In conclusion, occupational therapists are always learning and trying news ways
to approach therapy. If one activity does not work, then we know of one way not to
approach the problem. Every evening that a patient spends at a therapy social event is one
less night spent in a bar. These are the experiences that can provide opportunities to
rediscover interests and rebuild values.
Doniger, J., (1953). An activity program with alcoholics. American journal of
occupational therapy, VII, #3. (May-June) (pp. 110-112, 135).
Kaplan, H., & Sadock, B., (1998). Synopsis of psychiatry (8th ed.) (pp. 404-406).
Baltimore, MA: Williams & Wilkins publishers.
Neistadt, M., & Crepeau, E., (1998). Willard & spackman’s occupational therapy
(9th ed.) (pp. 724-728). Philadelphia, PA: Lippincott.
Reed, K., (1991). Quick reference to occupational therapy (pp. 497-501).
Gaithersburg, MA: Aspen publishers.
Riley, K., Ramsey, R., & Cara, E., (1998). Substance abuse and occupational
therapy. In E. Cara, & A. MacRae (eds.), Psychosocial occupational therapy: a clinical
practice (pp. 227-260). Albany, NY: Delmar publishers
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