Michaele Dunlap, Psy. D.
Managed care privacy invasions.
The future of therapists on the Internet.
The side effects ...
Questions, Checklists and Treatment Reports: Privacy Invasion and Professional Discrediting
Michaele P. Dunlap, Psy.D.
Previous versions of this article appeared in the AMHA-OR Newsletter and the
Coalition Report of the National Coalition of Mental Health Professionals and Consumers
Several managed care (MC) companies send checklists to mental health professionals for clients to complete and return to the company at the beginning of psychotherapy. Some MC companies request checklists or questionnaires every few sessions. Some MC companies also require clinician reporting forms which expand the invasive information requests. The checklists and report forms are focused on symptoms of emotional distress, employment distress, family or marital distress. Sometimes they include questions about alcohol or drug use and family history of mental illness or chemical abuse. Often, before clients are allowed to go to therapy they are asked invasive questions about their lives, substance use and emotional distress by gatekeepers who must be contacted before permission is given to use psychotherapy benefits.
When the checklists are given to clients, the experience of many professionals is that clients tend to exaggerate the range of their concerns and distress; both to assure that they will get mental health services and because they are in emotional pain. When the forms are returned to the companies, clinicians sometimes get calls and letters from the company suggesting medications, or asserting that the client is suicidal. People can be distressed without being suicidal and without needing psychotropic drugs. The process of the questionnaires invades the relationship between the therapist and the client, it demonstrates to the client that the company asserts some "right" to their personal information and further, demonstrates that the company sees itself as needing to closely monitor the process of the relationship between the client and the professional. The managed care companies’ argument is that they need the information to improve services, or to monitor the process of therapy.
I ask you, do they have patients’ complete physical complaint symptom checklists to be sent in for “monitoring” every fifth time there is a physician visit? Of course not! The assumption is that physicians know what they’re doing and mental health professionals do not! No one at the MC company apparently reads the clients’ checklists. Instead, as I understand it, they are scanned by optical scanners and reviewed electronically for “warning signs.” By scanning the checklists with an optical scanner, the MC company makes the information "electronic" and easily subject to "down-stream release" to researchers, marketers, other insurers, and government entities -- under the regulatory permissions for access under the Health Insurance Portability and Accountability Act (HIPAA.) This process, of course, totally violates every principle of personal privacy.
When professionals contract with managed care companies they often must agree to complete the required checklists. That is one of the many reasons why my involvement with MC companies is extremely limited. The only MC companies I deal with that use such forms are those for whom I see clients as an “off-panel” professional. I advise clients not to use the "self reporting questionnaire forms" and they don't. And the client gets services. And I get paid. I advise my clients to refuse to allow me to disclose any information beyond a diagnosis code and the dates of service on clinician reporting forms. I write "disclosure refused" on those forms. And I get paid. When I know a prospective client will have to deal with a telephone "gatekeeper" who has a battery of invasive questions, I advise that they simply say they are experiencing emotional distress and respectfully refuse to answer further questions; that they assert they prefer to deal with their chosen mental health professional. And, those clients do get the referral they request. Why? Because the managed care companies know that their questionnaires and report forms and pre-authorization information requests exceed the bounds of necessary information and they know that if they tried to insist on receiving that information my clients and I would have grounds for legal action against them. The insurance companies don’t want the legal fight. However, they make their information demands in such an authoritative fashion that most clients and many professionals comply. The purposes of the insurance company or managed care carve-out are varied; to gather statistics, to limit the number of treatment contacts, to carry forward an agenda about "best practices" (as defined by the insurance industry) or "medication management" in lieu of psychotherapy. None of those purposes serve the interests of confidentiality or effective psychotherapy.
When I must create a report about psychotherapy, in order to extend treatment, or help a client with some legal or employment issue, I review the reporting requirements and the report with my client. I am as non-detailed as possible to protect the privacy of my client. I have the client review the report. I explain that they are losing control of information that leaves my office
Some professionals won't sign any contract that requires them to participate in unwarranted disclosure in order to be paid. Considering the "regulatory permissions" in HIPAA, even the disclosure of a diagnosis code can become problematic for some clients. My refusal to encourage or participate in MC companies' demand for personal information is based on our professions' ethical and legal requirements to protect the confidentiality of clients, even when they naively might allow such disclosure. It is also based on the “minimum necessary” disclosure rule under HIPAA which defines that (the professional) “who holds the information always retains discretion to make its own minimum necessary determination.” (Federal Register / Vol. 67, No. 157 / Wednesday, August 14, 2002 / Rules and Regulations, p. 53197)
Our responsibility as professionals is to protect the privacy of our clients, especially when they are naive about the consequences of allowing their personal disclosures to go beyond the privacy of our offices. Licensed mental heath professionals are deemed by their professional licensing boards to have capacity for independent professional judgment. Managed care began and continues as a means of limiting payments by insurers. Managed care often operates in ways that discredit professional judgment. As professionals, there are boundaries we must maintain. For me, not subjecting my clients to invasive managed care questionnaires is one of those boundaries.
Michaele P. Dunlap, Psy.D.
503-227-2027 x 10
Predicting the Future
It is, as they say, hard to predict, especially the future. But let's try.
Michaele P. Dunlap, Psy.D. 1/14/03
The trends In June1993 there were 123 academic and government sites on the Internet, the Internet was a bright new idea. The electronic transmission of information on line was a fuzzy concept to nearly everyone. People said, "I'll never understand it. It has nothing to do with me." Now, a decade later, there are millions of web sites, most people understand how to use the language of Internet domains, and the pattern of people's daily use of the Internet includes e-mail, on-line news, fourth graders homework, play and chit-chat, the habit of buying movie tickets on line, getting a map to a new dentist, or the quick click into a favorite shopping site to purchase and send a gift, a book, a new cartridge for the printer.
Another trend Internet listings for mental health professionals are being promoted by professional organizations, for-profit companies and the publishers of mental health magazines, insurance companies and local professional groups post lists of members names and addresses on line. One organization, the American Mental Health Alliance - USA (AMHA-USA) has created and is developing a unique professional resource, available to all licensed professionals who value integrity, client privacy and professional collaboration. The development of Internet presence for AMHA-USA began in 1998 with the work of Dr. Michael Conner, an AMHA Oregon member who created the site http://www.OregonCounseling.org for Mentor Research Institute. That site lists Oregon AMHA members, each on their own page, and links their pages to articles they have written. Dr. Conner's research with creating interlocking sets of domain names and sites helped develop the design protocols for the more elaborate site created by Mike Davis and Warren Dexter for AMHA-USA which was launched in April, 2000 at http://www.AmericanMentalHealth.com
A unique resource On http://www.AmericanMentalHealth.com, AMHA-USA member professionals each have web listings that allow their skills, professional focus and location to be searched by more than two hundred terms pertaining to types of problems, theories, types of interventions, location, professional training and specialized skills. AMHA-USA members, uniquely have access to their own professional information data bases, the capability to administer, change, improve, revise and update their listings at will from their own home or office computers.
Does the process of managing a professional data page on www.AmericanMentalHealth.com require a bit of persistence to learn? Yes. Is it worthwhile? Yes. And, in the near future it will become an essential of professional practice development and maintenance to be "findable" on the Internet.
In some communities more than 70% of the households and 80% of the businesses use the Internet to find information and make purchasing choices every week. Mental health professionals who do not present their practices on the Internet will miss the opportunity to serve large numbers of clients, businesses and organizations. Well, you say, I can get a free listing, or a free web site. And, yes, you can. But ... how will you advertise it? The Internet is crowded to bursting with individual and small group web sites. Those sites however have little more drawing power for your practice in New York or Oregon than a billboard in Colorado . That is ... the process of promoting and pulling web searchers to web sites is now a vitally important a part of visibility on the Internet. By creating a national site, with every page and every article and every discrete page posting and enhanced page posting individually searchable on the web by its own search terms, by developing sub-sites for chapter activities and by advertising the sites and several different and attractive domain names nationally on Internet yellow pages and with Internet search engine placement marketing, AMHA-USA is creating dozens, soon hundreds, then thousands of layers of "searchablity" to pull client searches to members' practices.
And, then there are enhanced pages! AMHA chapter members and AMHA-USA national members have enhanced pages that take the capabilities for control over how much and what sorts of professional information one presents on line to deeper and more useful levels. With an enhanced page, and the time it takes to master the relatively simple steps of enhanced page management, the AMHA-USA member professional can add her own articles, her new groups and workshops, the marketing of her pamphlet or book, a demonstration of his skill as a public speaker, a sample of his new education tape on parenting skill, a copy of the electronic map to her office, a link to the best new article on the internet about improving a marriage .... to his/her very own personal page, all embedded within the network of interlocked sites and listings advertised nationally by AMHA-USA. And, the AMHA member can purchase and point a unique personal domain name to the enhanced page, allowing personalized local marketing in addition to the national, regional and chapter marketing efforts. For samples of what some members are beginning to do with their enhanced pages go to www.AmericanMentalHealth.com click on the Therapist Locator Features can be pre-set to turn themselves on and off at certain dates. Does it take a while to learn how to manage an enhanced web page on www.AmericanMentalHealth.com ? Yes. Is it worth it? Yes.
But, what about the future? Oh, yes, here's my prediction. Not many years from now, you'll find a great quotation, or you'll plan a new group, or you'll read or write a good book, or make a new relaxation tape, or write a thoughtful paper, or change your office furniture, and, as casually as today you might call a colleague and share the information, you will post the quotation, information about the group, an e-mail form to register for it, the link to buy your book, the link to buy the other author's book, a sample of the audio tape and a payment link to purchase copies, or the new interior picture of your office on your professional web page, which will be advertised on your business card, your office wall, at your professional listing on your professional association's page, in the local Internet yellow pages, and on the Intranet of seventeen local businesses. And, then, of course, you'll want your own web site within www.AmericanMentalHealth.com so you have the flexibility to create a practice presence as multi-layered as http://or.americanmentalhealth.com.
Michaele P. Dunlap, Psy.D.
503-227-2027 x 10
Biological Aspects of Beverage Alcohol
Ethyl alcohol or ethanol, known commonly as alcohol, is the same whether the beverage is wine, beer, or hard liquor. Beverage alcohol is a drug that depresses the central nervous system, like barbiturates, sedatives, and anesthetics. Alcohol is not a stimulant. There is no question that the person who drinks alcohol seems stimulated. Speech becomes free and animated, social inhibitions may be forgotten, and the drinker can begin to act and feel more emotional. But these effects are misleading; the "stimulation" occurs only because alcohol affects those portions of the brain that control judgment. "Being stimulated" by alcohol actually amounts to a depression of self-control. A principal effect of alcohol is to slow down brain activity, and depending on what, how much, and how fast a person drinks, the result is slurred speech, hazy thinking, slowed reaction time, dulled hearing, impaired vision, weakened muscles and fogged memory. Certainly not a stimulating experience!
Alcohol is also classified as a food because it contains calories. The average drink has about the same calorie count as a large potato but, unlike a potato or any other food, alcohol has no nutritional value. The calories are empty.
Basics of alcohol metabolism:
Alcohol is not digested like other foods. Instead of being converted and transported to cells and tissues, it avoids the normal digestive process and goes directly to the blood stream. About 20 percent of the alcohol is absorbed directly into the blood through the stomach walls and 80 percent is absorbed into the bloodstream through the small intestine.
Alcohol dilutes itself in the water volume of the body in order to travel through the system. Those vital organs, like the brain, that contain a lot of water and need an ample blood supply are particularly vulnerable to the effects of alcohol. Alcohol's dilution in the body does cut its effect somewhat. There one important biological difference between men and women comes into play: Muscle tissue contains more water than fat tissue, so men (who have more muscle and less fat on the average than women) can have about 10 percent more water in their bodies. If a lean man and a lean woman of equal weight consume the same amount of liquor, the woman is more adversely affected for this and other reasons.
The initial impact of alcohol:
The brain, liver, heart, pancreas, lungs, kidneys, and every other organ and tissue system are infiltrated by alcohol within minutes after it passes into the blood stream. The strength of the drink will have a significant effect on absorption rates, with higher concentrations of alcohol resulting in more rapid absorption. Pure alcohol is generally absorbed faster than diluted alcohols, which are, in turn, absorbed faster than wine or beer.
Alcohol taken in concentrated amounts can irritate the stomach lining to the extent that it produces a sticky mucous which delays absorption. The pylorus valve which connects the stomach and small intestine may go into spasm in the presence of concentrated alcohol, trapping the alcohol in the stomach instead of passing it on to the small intestine where it would be more rapidly absorbed into the blood stream. The drinker who downs several straight shots in an effort to get a quick high may actually experience a delayed effect. Finally, the temperature of the beverage affects its absorption, with warm alcohol being absorbed more rapidly than cold alcohol.
Measurement of effect by blood alcohol level (BAL):
The drinker's blood alcohol level rises as a factor of the relationship among the amount of alcohol consumed, body size and proportion of body fat, the amount of food in the stomach, and what is mixed with the alcohol. The BAL rises more rapidly in those who drink on an empty stomach. Water and fruit juices slow the absorption process, while carbon dioxide speeds it up. The carbon dioxide in champagne and carbonated mixers such as Cola, and soda water rushes through the stomach and intestinal walls into the blood stream, carrying alcohol with it and creating a rapid rise in BAL. A 0.08 BAL, for example, indicates approximately 8 parts alcohol to 10,000 parts other blood components. When a person drinks more alcohol than his or her body can eliminate, alcohol accumulates in the blood stream and the BAL rises.
Elimination of alcohol from a healthy adult body occurs at an average rate of approximately 2 to 3/4 ounce per hour, the equivalent of 1 ounce of 100-proof whiskey, one large beer, or about 3 to 4 ounces of wine. When blood alcohol concentrations reach very high levels, the brain's control over the respiratory system may be paralyzed. A .30 BAL is the minimum level at which death can occur; at .40 the drinker may lapse into a coma. At .50 BAL, respiratory functions and heartbeat slow drastically, and at .60 most drinkers are dead.
Body Systems and Effects:
The Liver: Located in the upper-right side of the abdomen, the liver is the body's largest glandular organ. Its complex functions are associated with dozens of processes of body chemistry and metabolism. It produces the bile that helps digest fatty foods; it manufactures heparin, an anticoagulant, it stores and releases sugar. The liver also produces antibodies that help ward off disease, and it cleanses the body of poisons, including alcohol. With small amounts of alcohol, this cleansing can happen effectively. When the amount of alcohol is high, imbalances are created which can lead to hypoglycemia (low blood‚ sugar), hyperuricemia (as in arthritis or gout), fatty liver (which may lead to hepatitis or cirrhosis), and hyperlipemia (build-up of fats sent to the bloodstream; which leads to heart problems).
The Central Nervous System: The central nervous system (CNS) includes the brain, the spinal cord, and the nerves originating from it. Sensory impulses are transmitted to the CNS and motor impulses pass from it. When alcohol acts on the CNS, intoxication occurs, affecting emotional and sensory function, judgement, memory and learning ability. Smell and taste are dulled. The ability to withstand pain increases as the BAL rises.
The central nervous system (CNS) includes the brain, the spinal cord, and the nerves originating from it. Sensory impulses are transmitted to the CNS and motor impulses pass from it. When alcohol acts on the CNS, intoxication occurs, affecting emotional and sensory function, judgement, memory and learning ability. Smell and taste are dulled. The ability to withstand pain increases as the BAL rises.
Different parts of the brain seem to be affected by alcohol at different rates, creating alternate periods of restlessness and stupor. Long‑term effects of alcohol on the central nervous system include tolerance, dependency, and irreversible damage. Changes in tolerance for alcohol, and the alcoholic drinker's dependency on alcohol, demonstrate that changes occur in the brain.
With each drinking episode, central nervous system functions deteriorate in a predictable sequence, beginning with intellectual functioning, followed by disturbances in sensory and motor control. Last affected are the automatic biological functions, such as breathing and heart action.
The brain is the organ that is most affected by alcohol, and proves that it is being damaged through the drinker's behavior changes and emotional distress. Three noticeable effects of alcohol injury to the brain: memory loss, confusion, and augmentation. (Augmentation is a physiological response to alcohol which results in hyper-alertness to normal situations, perceiving light as brighter or sounds as louder than usual, or the drinker=s becoming extremely sad or angry for no apparent reason.) The drinker's rapid mood swings and emotional and behavioral instability can be brought under control by stopping drinking.
Blackouts, or loss of memory for a period during drinking, are a physical effect of alcohol on the brain. They occur as alcohol cuts off the supply of oxygen to the brain. Lack of oxygen supply to the brain can kill tens of thousands of brain cells every time a person becomes intoxicated.
Another effect of alcohol on the brain is the "learned behavior syndrome"; when a behavior is learned under the influence of alcohol, the drinker sometimes must re-learn that behavior after stopping drinking.
The Blood: One effect of drinking alcohol is "blood-sludging" where the red blood cells clump together causing the small blood vessels to plug up, starve the tissues of oxygen, and cause cell death. This cell death is most serious, and often unrecognized, in the brain. With this increased pressure, capillaries break, create red eyes in the morning, or the red, blotchy skin seen on the heavy drinker's face. Blood vessels can also break in the stomach and esophagus leading to hemorrhage, even death.
One effect of drinking alcohol is "blood-sludging" where the red blood cells clump together causing the small blood vessels to plug up, starve the tissues of oxygen, and cause cell death. This cell death is most serious, and often unrecognized, in the brain. With this increased pressure, capillaries break, create red eyes in the morning, or the red, blotchy skin seen on the heavy drinker's face. Blood vessels can also break in the stomach and esophagus leading to hemorrhage, even death.
Other effects of alcohol on the blood include: anemia; sedation of the bone marrow (which reduces the red and white blood count, and weakens the bone structure); lowered resistance to infection; and a decrease in the ability to fight off infections.
The Gastrointestinal Tract: The stomach, the small and large intestines, and the pancreas are each affected by alcohol. Alcohol increases acid in the stomach. That can result in gastritis or stomach or intestinal ulcers. The pancreas produces insulin which is necessary to regulate the amount of sugar in the blood. Drinking causes a steep rise in the blood sugar; the pancreas responds by producing insulin which causes a fast drop in blood sugar and the symptom of low blood sugar or hypoglycemia. 70-90% of alcoholics suffer to some degree from the disorder of hypoglycemia, chronic low blood sugar, as a long term effect of their drinking. Symptoms of hypoglycemia can include dizziness, headaches, lack of ability to concentrate, depression, anxiety, light-headedness, tremors, cold sweats, heart palpitations, loss of coordination, and upset stomach. In time, the drinker's overworked pancreas may stop producing insulin and diabetes can result. Conversely, a person with a family history of diabetes may be more vulnerable to problems with alcohol.
The Muscles: Alcohol reduces blood flow to the muscles, including the heart, causing muscle weakness and deterioration. One outcome is cardiomyopathy (sluggish heart) which is common in alcoholics. Another outcome, arrhythmia (irregular heartbeat), or "holiday heart," is often treated in emergency wards after several days of party drinking. Muscle aches are a common symptom of excessive-drinking "hangovers."
Alcohol reduces blood flow to the muscles, including the heart, causing muscle weakness and deterioration. One outcome is cardiomyopathy (sluggish heart) which is common in alcoholics. Another outcome, arrhythmia (irregular heartbeat), or "holiday heart," is often treated in emergency wards after several days of party drinking. Muscle aches are a common symptom of excessive-drinking "hangovers."
The Endocrine System: This system controls the body's hormones and includes the pineal, pituitary, thyroid, and adrenal glands, and the ovaries or testes. Alcohol sedates these glands, resulting in under-production of hormones; effects include increased susceptibility to allergies. Alcohol can effect sexual functioning in various ways. In low doses, it lowers inhibitions and may make a person feel sexier; but in higher doses, it can decrease sexual functioning: in men, by decreasing the frequency of erections, decreasing the maintenance of erections, decreasing penile size during erection, and increasing the amount of time between erections, in women by interfering with normal processes of sexual stimulation, and blocking orgasmic response. With chronic and prolonged use of alcohol in men, there is a shrinkage of sex glands and an increase of the "female hormone" estrogen. This produces secondary sexual characteristics, such as enlarged breasts and a decrease in body hair. Prolonged use of alcohol can cause infertility in both men and women.
This system controls the body's hormones and includes the pineal, pituitary, thyroid, and adrenal glands, and the ovaries or testes. Alcohol sedates these glands, resulting in under-production of hormones; effects include increased susceptibility to allergies. Alcohol can effect sexual functioning in various ways. In low doses, it lowers inhibitions and may make a person feel sexier; but in higher doses, it can decrease sexual functioning: in men, by decreasing the frequency of erections, decreasing the maintenance of erections, decreasing penile size during erection, and increasing the amount of time between erections, in women by interfering with normal processes of sexual stimulation, and blocking orgasmic response. With chronic and prolonged use of alcohol in men, there is a shrinkage of sex glands and an increase of the "female hormone" estrogen. This produces secondary sexual characteristics, such as enlarged breasts and a decrease in body hair. Prolonged use of alcohol can cause infertility in both men and women.
TERMS TO UNDERSTAND
tolerance: As people drink, their tolerance for alcohol may increase. They might seem to be able to "handle" alcohol better and need more to achieve the same effect as before. The liver does not become more tolerant, and is damaged over the course of time, leading to poor liver function and a noticeable decrease in tolerance, or "reverse-tolerance". A heavy drinker's reverse-tolerance is a sign of late‑stage alcoholism.
withdrawal: The effects of alcohol on the body account for the sick, uncomfortable, shaky feelings following a period of drinking. Withdrawal symptoms vary in intensity according to the amount and prolonged frequency of drinking.
Symptoms of alcohol withdrawal include:
hangovers -- fairly common result of overindulging-- headache, fatigue, thirst, and nervousness. There may be nausea and abdominal cramping. Diagnosed alcoholics report fewer hangovers than drinkers who are non-alcoholic, this may be because they have learned to ignore the symptoms.
sleep disturbance -- waking up earlier than usual after expecting to "sleep it off," being unable to fall asleep, disturbed dreaming.
irritability, anxiety, and restlessness -- all caused by the irritant effects of alcohol.
tremors, or "morning shakes"-- Tremors will clear after several days of abstinence, if there is no permanent damage to the nervous system
physical weakness, rapid heart rate,
difficulty thinking clearly or flexibly
all are lingering evidence of alcohol's impact on muscles, heart and brain.
For the drinker with only a mild degree of physical dependence, withdrawal effects may not extend beyond the symptoms listed above.
Some drinkers experience second stage withdrawal, marked by:
convulsions -- seizures usually occur between 12 and 48 hours of the last drink. There may be a loss of consciousness and body control.
Third stage withdrawal symptoms involve:
alcoholic hallucinosis and delirium tremens -- auditory, visual and tactile hallucinations occur. This period may last for three to four days, during which the de-toxifying person is in a severe state of agitation, is often completely disoriented and sleeps little, if at all. The delusions are almost always terrifying and may produce violent behavior. There is a 10%‑20% mortality rate associated with this stage of withdrawal. Detoxification of the acutely ill alcoholic requires medical supervision.
SPECIAL CONCERNS OF WOMEN
Female drinkers reach higher blood alcohol levels (BAL's) faster because of less water and more fat in the body and because of differences in digestive enzymes. Women develop alcohol-related disorders such as brain damage, cirrhosis and cancers at lower levels of drinking than men. It is also known that the menstrual cycle affects alcohol metabolism in women. Women have been shown to develop their highest BAL's immediately before menstruating, and their lowest on the first day of menstruation. This can be related to hormone level shifts. There is evidence which shows that premenstrual syndrome with its emotional and physical discomfort and de-stabilized blood-sugar levels can trigger excessive drinking by some women.
FETAL ALCOHOL SYNDROME (FAS) and FETAL ALCOHOL EFFECT (FAE)
Women who drink during pregnancy risk the development of both mental and physical defects in their children. Effects on the child can include: growth deficiencies; poorly formed bones and organs, heart abnormalities, cleft palate, retarded intellect, delayed motor development, poor coordination, behavior problems, and learning disabilities. Smoking cigarettes, combined with alcohol use, will increase the chance of birth defects. Use of alcohol increases the chance of miscarriage. It is best that a woman avoid alcohol, cigarettes, caffeine, and other drugs entirely during pregnancy. Antabuse is not a suitable treatment for the pregnant or potentially pregnant alcoholic woman; it interferes with maternal liver function and may cause harm to the developing fetus.
Since harm to the infant may result even before a woman realizes that she is pregnant, women who might become pregnant need to be particularly cautious about what they consume.
Secondary Diabetes: Diabetes can result from prolonged, excessive use of alcohol. Because it is caused by drinking and not from a genetic disorder, it is called "secondary" diabetes. The symptoms are identical to genetic or "primary" diabetes. Abstinence from alcohol is a vital part of treatment for this disorder.
Vitamins and Proteins: Those who use alcohol excessively deprive their bodies of essential nutrients. The drinker and the recovering alcoholic must pay special attention to diet. A diet high in protein not only provides many of the nutrients vital to recovery, but also keeps the blood sugar from too rapid change. It is better for those who drank excessively to get protein from eggs, milk, or vegetables, than from meats or cheeses. Because of an already fatty liver, excessive drinkers cannot process the extra fat. When they eat meat, fruit should be eaten; it aids in breaking down fats. Vitamin supplements are helpful for people with drinking problems: these include, vitamins A, B, C and E. Protein supplementation may be important to reducing alcohol craving and maintaining emotional balance for alcoholics wanting to recover from their past heavy drinking. Similarly, a diet high in complex carbohydrates stabilizes blood glucose and reduces the low blood sugar state that can lead to craving alcohol. Understanding one's own special nutritional needs is an important aspect of recovery from excessive alcohol use.
OTHER DRUGS AND ALCOHOL
Drugs such as marijuana and cocaine which are used, like alcohol, for "recreational" purposes have different, but similarly harmful, physical effects.
Research on marijuana use has shown several severe emotional and physical effects:
Frequent use can lead to the "amotivational syndrome", in which the person becomes apathetic, loses the ability to set realistic goals, lacks drive and ambition.
An active ingredient of marijuana (THC) settles in the fatty tissues of the body, especially in the reproductive organs. Male hormone levels drop and there is an increased level of impotence. Drop in hormone levels for women will affect the menstrual cycle and may result in a higher incidence of miscarriages.
Marijuana has from 7 to 10 times as much tar as one cigarette, increasing the chances of lung damage and emphysema. The chemistry of marijuana is extremely complex, dried marijuana contains over 420 chemical compounds. Delta 9 THC is generally cited as the psychoactive ingredient of marijuana, but research suggests that other compounds acting independently or interacting with Delta 9 THC also contribute to the intoxicating potency of the drug. While stored in body fats, THC and its metabolites are slowly released back into the bloodstream. Complete elimination of a single dose can take 30 days.
Given the slow clearance of marijuana's chemicals from the body, researchers predict that repeated use of marijuana at intervals of less than 8 to 10 days results in accumulation of THC and other psychoactive substances in the tissues of body and brain.
If marijuana is used with alcohol, the effect is greater than if the two effect patterns were added together.
Driving after using either alcohol or marijuana is unsafe, after using both, driving is more than twice as dangerous. Judgment, reaction time, and coordination are worse than with either drug taken alone.
Cocaine,"Crack" and amphetamines are fast-acting stimulants. People who use alcohol and stimulant drugs together will drink more tofeel the effects of alcohol because of the stimulant effects. When stimulant effects wear off, the alcohol effects "catch up"quickly, and that can be extremely dangerous, both in terms of physical effectsand distortions of perception and judgment.
Stimulantsare also quickly-addicting drugs which cause their users to need more and moreto get the same "high". Chronicstimulant use leads to dysphoria--a depressed, low-energy state; flattenedemotions, a lack of interest in sex, and physical immobility.
Thephysical and psychological consequences of heavy stimulant use include:hallucinations and delusions, a mental state that appears "really crazy." Many stimulant users experience formication, the sensation thattheir skin is crawling with bugs. Impairedjudgment and feelings of persecution are common. Users may overstimulate their heart muscles and cause sudden death from asingle heavy dose.
Drugsprescribed for medical conditions are frequently harmful if combined withalcohol. Addiction to alcohol isaddiction to all sedatives. Drugswhich are prescribed to combat anxiety include various sedatives,"tranquilizers" and barbiturates; most frequently prescribed isValium. Tranquilizers areaddictive, and, if taken with alcohol will multiply the effects of both tosedate the user. This interactiveeffect can lead to a coma or death. Sometimes antidepressants, or amphetamines,are prescribed to treat depression or for weight control. These drugs speed up the nervous system and are addicting. Because they are stimulants, the effects of drinking whileusing them is like the effect of cocaine with alcohol -- they "cancel eachother out" until the stimulant wears off, then intoxication occurs quickly.
Medicationof any kind should not be mixed with alcohol. None should be taken by therecovering person, unless the physician who prescribes is fully aware of thealcohol use history.
Over-the-counteror "ordinary" medicine such as cold tablets or cough medicine arefrequently used without caution. Drugstoremedicines can have dangerous effects when mixed with each other, with alcohol,or when taken by the recovering alcoholic. Read the label. Ask the druggist.
Michaele P. Dunlap, Psy.D.
American Mental Health
preserving client privacy and professional integrity:
National Coalition of Mental Health Professionals & Consumers;
Fighting to protect quality care and patient choice, privacy and decision-making power.
SOCIAL HISTORY OF ALCOHOL USE AND ABUSE
BEFORE 6000 BC
Early legends described the origins of wine as a god-given gift or affliction. The power of the gods to give joy and inflict pain seemed synonymous with the power of wine to create a cycle of ecstasy, sorrow and silent sleep. Since alcohol's power over the mind and body came magically from the fermentation of fruits and grains, it was a mysterious force to pre-historic peoples.
6000 B.C. - 3000 BC
In Mesopotamia, the Sumerians worshipped Gestin, a goddess, protector of the vine.
3000 B.C. - 500 BC
The Egyptian god, Osiris, was worshipped as god of wine and lord of the dead.
The Chinese Emperor Yu discovered rice wine, and subsequently prohibited its use.
The Persian King Dshemshid was convinced wine was poison. A suicidal woman at court took wine to die, but instead was cured of her chronic headaches; wine became "Royal Medicine".
In Greece, Dionysus was worshipped as god of wine; he was honored each year with a four-day feast -- by the preparation and distribution of wine, intoxication and revelry, sobering up and atonement, -- then celebration of Dionysus' return. This pattern of celebration continues in the Judeo-Christian traditions of Yom Kippur (atonement), Rosh Hashanah (the New Year celebration), and Easter (resurrection).
1000 B.C. - 300 A.D.
Roman god Bacchus (bacca is the Latin word for grape) was both a saint and a satyr. Bacchanalian feasts, orgies of intoxication, were celebrated at the grape harvest. As Judeo-Christian theology became dominant, the ancient festival became identified with the sins of intoxication.
Exceptional groups included the Moslems, who abstained in obedience to the Koran; the Brahmin in India, and the followers of Buddha. In each of these, intoxication was abhorred as a sin against Spirit and Self.
WHAT THEY DRANK
From pre-history through the Sixteenth Century alcoholic beverages were derived from fermentation. They were wines and beers containing, at most, 14% alcohol. Their use was common both in ceremony and as replacements for other beverages which might be unsafe to drink, such as water from public wells.
15TH - 16TH CENTURY
Alcohol began to be used as a pain killer and anesthetic during and after surgery. Distillation processes were developed in Europe and beverages containing 50%, or more, alcohol were drunk.
During the period 1710 - 1750, England experienced the "gin epidemic." Low cereal prices and an unfavorable balance of trade prompted a surge in the production of cheap gin. By the 1740's, when the cumulative effects of this overindulgence were acutely felt in declining birth rates and enormous incidence of malformed and retarded children, there was a social protest. Parliament was prevailed upon, in 1751, to increase taxes on distilled spirits and to limit the numbers of places it could be sold.
17TH CENTURY - COLONIAL TIMES
The Governor of Massachusetts in 1629, was advised by English superior: "... if any shall exceed in that inordinate kind of drinking as to become drunk, wee hope you will take care his punishment be made exemplary for all others."
In Plymouth Colony, 1633, John Holmes was censured for drunkenness: his penalty - to "sitt in the stocks, and was amerced forty shillings." First time offenders were put in the stocks. Repeat offenders were sentenced to hard labor or corporal punishment.
Cider, beer, and wine were the drinks of choice. The Puritans believed alcohol was God's gift to man, and a test of his soul. "The wine is from God, but the drunkard is from the Devil". (Puritan aphorism)
Tithingmen, tax-collectors who oversaw ten-families each, monitored excessive drunkenness and reported it to the minister, who reported it to the Governor's representative. Ministers could punish first time offenders, but repeat offenders were sent to the governor's representative for punishment.
The rum trade with Barbados was opened, and domestic rum distilling became common by 1750. Rum was the drink of choice. As America became an urban society, public drunkenness became more commonplace and less controlled by local moral-prohibitions.
During the decade before the American Revolution, the average annual alcohol intake per person was 3.7 gallons of alcohol, mostly high-alcohol content rum.
The language to describe drunks was recorded by Benjamin Franklin in his Drinkers Dictionary.
Description of drunkard:
He's drunk as a Wheelbarrow, As drunk as a Beggar, Got Corns in his Head, Loaded his Cart, Cock Ey'd, God'd, Frozen, Been at an Indian Feast, As Dizzy as a Goose, Got the Glanders, Juicy, Merry, Mooney's, mellow, Oil'e, Got the Night Mare, Like a Rat in Trouble, In the Sudds, As stiff as a Ring-bolt, Soak'd, He carried too much sail, Topsy Turvey, Tipsey, He's wet."
By 1790, the estimated alcohol consumption of each adult was six gallons of absolute alcohol per year (2.5 oz. alcohol/adult/day) - twice the estimated level of alcohol consumption in America in 1985.
The American Temperance Movement began with a pamphlet by Benjamin Rush, first Surgeon-General of the U.S., which labeled intemperance as a disease and listed the symptoms of tolerance and alcohol withdrawal that form the basis of syndrome of alcohol dependence.
The first temperance movement opposed hard liquor, but condoned beer and wine. People found that: "houses could be built, barns could be raised, grain could be harvested, christenings could be enjoyed and the dead could be mourned without the constant accompaniment of distilled spirits."
The temperance movement waned in the 1820's. A rebirth followed Lyman Beecher's message proposing: "the banishment of ardent spirits from the list of lawful articles of commerce, by correct and efficient public sentiment, such as has turned slavery out of half our land; the dissemination of information on intemperance; the formation of an organization to carry on this work; the support of churches and of physicians; renunciation of spirits as a medicinal drug."
Temperance workers sought to control the sale and use of alcohol but tended to ignore the problem of drunkenness and consider it hopeless.
Serving alcohol to workers on the job was abolished during the 1870's but that did not end the problems of drinking on the job.
In Philadelphia and Boston, the category of "insanity caused by intemperance" accounted for over 50% of hospital psychiatric admissions. Drunkenness was prevalent among leaders of the community.
As the medical profession joined the temperance movement, the disease concept of drunkenness was further defined. Samuel Woodward, a physician, characterized alcoholism by tolerance, psychological dependence ("a tormenting thirst, and insatiable craving"), and physical withdrawal symptoms ("a sense of vacuity, faintness, and depression, which calls imperiously for a repetition of the stimulant upon which it depends.")
Immoderate drinking became a crime and drunkenness became a disease. Woodward and others called for prohibition of all intoxicating beverages, arguing that the legal system supports and encourages excessive alcohol consumption.
The temperance movement waned during the Civil War as its proponents turned their energies to abolition of slavery.
The post-Civil-War Era brought new problems with alcohol abuse. and opiate addiction. Federal taxes were imposed on alcohol. Organized opposition to Temperance began. The Prohibition Party was founded.
What Americans drank changed with the immigration of Germans and other Middle European people. Between 1850 and 1970, beer consumption increased from 1.6 to 3.8 gallons per person per year. However, increasing numbers of lower-alcohol-content beers were brewed.
OPIUM became a major substance of abuse after the Civil War.
There were no restrictions on importation or use of opium until the 1920's. Most opiate addicts were women between the ages of twenty-five and forty-five including domestics, teachers, prostitutes, nurses, and society ladies.
It was easy to become addicted to opium and cocaine: until 1903, cocaine was an active ingredient in Coca-Cola, was an additive to teas, tonics, wines, cordials, cheroots, cigarettes and inhalants.
COCAINE was recommended for gastric indigestion, asthma, as an aphrodisiac, a local anesthetic, a stimulant and to combat the effects of alcohol and morphine. Cocaine was advocated in the treatment of opium addiction and vice-versa. Opiates were a "therapy for alcoholism" and heroin was a "cure for morphinism." Most "female complaints" were treated with opiates. Opiates and cocaine were a socially acceptable substitute for alcohol; several "pillars" of the anti-alcohol movement were addicted.
WHY THE WEST WAS WILD
As the Western United States opened up after the Civil War, the saloon became a primary meeting place. Newspaper accounts suggest that one or both parties were drinking heavily in at least half the fourteen murder incidents in Leadville, Colorado, between March and October, 1880.
Elsewhere, 60% of the misdemeanor arrests were for public intoxication. Frontier physicians noted alcohol-related deaths compounded by pneumonia and exposure. As farmers with families moved west, the temperance movement came with them.
The American Indians' quick addiction to alcohol led to a shame of America's past. With no history of exposure to alcohol, Indians easily became dependent, sickened and died. In spite of attempts to legislate against the sale of liquor to these naive people, many took advantage of their addiction to steal land, food, livestock, and furs.
EARLY 20TH CENTURY
The industrial revolution brought workers into factories. Drinking became a way to be accepted by peers at work. "Drink fines" were collected on becoming an apprentice, at the time of marriage, on the birth of a child, one "treated the gang." Hard drinking was an important way to achieve status at work, since frequent drinking was part of loyalty to the shop.
The temperance movement returned. Middle and upper class Protestants saw total abstinence as a symbol of respectability.
Temperance was identified with the Women's Suffrage Movement. Women would meet at the church, march to the saloon, protest by prayer and song, and demand that the saloon keeper give up his business and that drinkers stop drinking. This protest became the background for women to organize against sex-inequality in the work place and the voting booth.
Some saloon keepers protested against the protestors. In Portland, Oregon, women were hosed with cold water by one saloon proprietor. Then the women were arrested.
In Portland, OR, about 1910, Simon Benson gave the city a gift of twenty, ornate bronze drinking-fountains; his intent was to end workingmen's consumption of beer-by-the-bucket to quench their thirst. The bubbling fountains did cut tavern business.
The tactic designed by the Women's Christian Temperance Union (WCTU) was to dry up the country piecemeal through local option laws and statewide prohibition.
Georgia and Oklahoma adopted prohibition in 1907. In 1913, the Anti-Saloon League declared itself in favor of national prohibition by amendment to the federal constitution. It was opposed by the U.S. Brewers Association, and the National Wholesale Liquor Dealers.
On January 16, 1919, the 18th amendment became law.
The sale, manufacture, transportation, importation, and exportation of intoxicating liquors for beverage purposes in the United States and all territory subject to the jurisdiction thereof are forever prohibited...
The Volstead Act was passed to enforce the Amendment. 170,000 saloons were destroyed. The Volstead Act had loopholes which were quickly filled as illegal smuggling, home brewers and commercial distillers established themselves.
Repeal of the 18th Amendment was accomplished by the work of the Association Against the Prohibition Amendment; supported by several wealthy investors who were convinced that repeal would reduce their tax burden and hasten economic recovery from the Great Depression.
The 21st Amendment repealed the 18th Amendment and delegated authority to the states for regulation. Thirty states decided to allow legal availability of alcohol while eighteen states continued prohibition. In 1933, 38% of the population still lived in areas where alcohol was illegal.
Alcoholics Anonymous began in the 1930's.
The role of this alcoholics-helping-alcoholics organization has been enormously powerful in beginning to overcome old stereotypes. Alcohol misuse and abuse profoundly affect the lives of many who do not have the full biological syndrome of alcoholism. Directly and indirectly, alcohol abuse leads to tens of thousands of deaths each year. By providing a safe place to reveal alcohol concerns and share the problems of the disease, AA continues to help, and to reduce the social stigma of alcoholism and alcohol misuse.
SINCE WORLD WAR II
In 1966, the last state went wet. Presently, thirty-four states regulate alcohol sales by license systems; the state grants the privilege of conducting business. Sixteen states have control systems where ownership and operation of wholesale and retail alcohol sales operations are directly managed by the state.
The role of alcohol abuse in highway accidents and fatalities, as a contributing factor to crimes, to violent family disputes, to illness, brain damage and death is recognized. In the interest of public safety, states and the federal government continue pass laws that lower tolerance for alcohol use by those who operate vehicles or provide public services. Alcohol and substance-abuse education and treatment have become part of the "punishment" for many crimes. The US has the strictest youth drinking laws in the Western world, including the highest minimum drinking age in the entire world.
Heavy alcohol use among people in the US 17 years of age or younger dropped by two-thirds (65.9 %) between 1985 and 1997.
Americans continue to struggle with the misconception that drunkenness and alcoholism are the same thing. Many non-alcoholics on occasion become intoxicated or drunk. However, if they are not addicted to alcohol, they are not alcoholic. Of course, intoxication is never completely safe or risk-free and should be avoided. It is better either to abstain or to drink in moderation.
As a governmental alcohol agency has explained, "Alcohol no more causes alcoholism than sugar causes diabetes."
In 1973, fetal alcohol syndrome was first documented by extensive and careful research.
Fetal alcohol effects, which include dozens of pre-natal injuries, damage thousands of infants each year. The danger to the unborn is still not well enough understood by women. In the US no public warnings were issued until 1977. Women were then warned against consuming more than six drinks a day. At the same time, moves to display compulsory public health warnings about the dangers of alcohol to the unborn child were rejected. In 1980 a national workshop was held and the following year the American Surgeon General issued a warning to pregnant women against consuming alcohol, even in food. In spite of protests, this warning was widely publicized and increased research funding for nationally coordinated projects on the topic provided. Since 1989, every container of alcoholic beverage sold in the US has had to carry a label which gives a warning that women should not drink alcohol during pregnancy because of the risks of birth defects. Extensive medical research fails to find scientific evidence that light drinking by an expectant mother can cause fetal alcohol syndrome. Of course, the safest choice is to abstain during pregnancy.
social history of alcohol Use & Abuse ï¿½ 2006 Michaele P. Dunlap, Psy.D
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