Dr. Sadaqat Ali Tells you! What you must know about Alcoholism!

Dr. Sadaqat Ali, a graduate from Dow Medical College, Karachi is a recognized Addiction Psychiatrist with a background of training at HAZELDEN, Minnesota, USA. He is the Project Director of Easy Interventions & Willing Ways. He visited the United States under the auspices of the “International Visitor Program” of the United States Information Agency (USIA) in 1992 on the invitation of Mr. Nicholas Platt, American ambassador to Pakistan. His name was included in international “Who is who” professional’s directory. He appears frequently on national TV channels to express his views on drug addiction, alcoholism, compulsive gambling, suicide prevention and home runaway (Videos & Interviews). His website is www.easyinterventions.com and his personal email address is drsadaqatali@hotmail.com. To execute the plans and media related work, Dr Sadaqat would be contacted through his Executive PR Mr. Mohsin Nawaz (0300-8468522).

Q: So Dr. Sadaqat, what’s the difference between somebody who’s an alcoholic and someone who just likes a drink or two?
A: Well, an alcoholic is someone who has a problem with his drinking. Either he worries, or someone else is worried. There are some specific criterion that we use to determine alcoholism. We have a CAGE questionnaire. If you have unsuccessful attempts to Cut down, that means there’s an issue about your drinking. The second one is Annoyance. It’s a little bit more than annoyance after drinking when you should be actually pleased. You can see him changing in front of your eyes while he keeps on drinking. He becomes more and more irritable. He becomes louder and nothing seems right to him. The third one is Guilt, which is saying, I think, I shouldn’t be doing this. And the last, Eye-opener use of alcohol in the morning. But, there is a rule of thumb: if somebody points a finger at your drinking, its alcoholism.

Q: But someone who likes to take a drink at dinner, a glass of wine, that’s not a problem, is it?
A: It’s not a problem, if it’s not a problem. If it makes them more functional, then it is not a problem; rather it is a solution. If it doesn’t disturb their social and occupational functioning, if it doesn’t disturb their health, it’s not a problem. Everybody who drinks will not become an alcoholic. Only 10% will ultimately cross that invisible line into alcoholism. So to speak, if you decides to drink in order to make your nights beautiful, you can end up making your life a nightmare, actually.

Q: Is it a mind-set which is prone to alcoholism?
A: No! it is a mind-set which is prone to drinking; but it is a “body-set” which is vulnerable to alcoholism. Drinking requires a conducive environment; alcoholism requires an appropriate genetic make up. Drinking is a matter of mind; alcoholism is a matter of body. Seat of drinking is in the mind, the seat of alcoholism is in the body.

Q: What is the Disease Model of Alcoholism ?
A: The disease model basically says that alcoholism is a bio-psycho-social and spiritual disease. It starts in the biology and “metastasizes” in psychology, sociology and spirituality, in that order. It is a primary chronic, progressive illness; if untreated, it is fatal. A person is not responsible for his alcoholism just because he started drinking just as a person is not held responsible for diabetes and hypertention just because made unhealthy choices leading to this dangerous duo. However, like a diabetic and hypertensive he is responsible to recover from this deadly disease. Of course, he needs empowerment to seek help. His flesh is willing, but the spirit weak. It is the duty of the concerned other to motivate him towards recovery.

Q: Could you tell us more about the disease part? A: sure! Alcohol once taken produces tranquility and is normally broken down to carbon dioxide and water. Both are harmless end products and are eliminated from the body as such. In alcoholism, the metabolism becomes erratic and alcohol is broken down into a toxic substance, and hence the word “intoxicated”. The toxic substance produced is called acetaldehyde and it is quite similar to chloroform. This toxin makes the person numb knocks him down when produced in abundance. The alcoholic may pass out and his body has to do lot of restorative work. This cleansing process takes many hours and when he regains consciousness, he is hung over because of the residual toxin.

Q: Then why people “treat” hangover with drinking, when it was actually produced by alcohol?

A. Hangover is not produced by alcohol; it is produced by chloroform like toxin, acetaldehyde as I said before. This toxin accumulates in alcoholics only and not in healthy people. And they are aware that alcohol will works best on hangover. Alcohol overshadows the ill effect of the toxin for the time being and in turn is broken down to produces more toxin. Sips of alcohol continue all day. While alcohol keeps on treating the ill effects of toxin, alcoholism keeps on generating more toxin and the liver keeps on cleansing the toxin all the day long. And in the evening he is back with a bang! Now he likes to drink like a fish and passes out. Only he does not know that fish do not drink alcohol.

Q: So, drunkenness is the sin-qua-non of Alcoholism?
A: Drunkenness is only one side of alcoholism; the other side of this coin is unusual consumption. These two ingredient together produce a variety of alcoholisms; that is why we say, “Alcoholism includes alcoholisms.” Large quantities of alcohol ultimately exhaust the liver and large quantities of toxin produced directly affect the functioning of all the body organs especially the brain.

Q: If there is no hang-over, then we can safely assume that alcoholism does not exist?
A: No! We can never safely assume that alcoholism does not exist. When a person is visibly drunk after drinking, passes out later to regain conciousness in the morning and faces hangover, he is suffering from macro-alcoholism; but if he looks tipsy after drinking and is kind of okay in the morning too, he may still harbor a little toxin, he may be suffering from what we call micro-alcoholism. Now, if he happens to be an air-force pilot, or a neurosurgeon or a foreign office negotiator, he may jeopardize a plane or a brain or a claim. Whereas a person with macro-alcoholism may mess things up quite visibly, a person with micro-alcoholism may quietly play havoc with delicate matters of great significance. However, a person who just consumes large quantities of alcohol and does not look drunk suffers because of other reasons. He is preoccupied with drinking all the time, neglects his responsibilities and burdens his liver day in and day out. Drinking is never absolutely safe and when we choose to drink, we are taking 10% risk on our life. And it is a great risk especially if we in a sensitive profession.

Q: Dr. Sadaqat, some people are suffering from alcoholism, whole world knows it, but they don’t seek help?
A: Well, another hallmark of alcoholism is denial. The alcoholic really is not aware of what’s going on. Fish discovers water last. His life starts to develop itself around drinking. It becomes a friend to people. It becomes a way to cope. It becomes a way to have fun. And people aren’t so keen on giving that up so quickly. And until you can accept and discuss the problem at an appropriate forum you can’t solve it. Three things prevent an alcoholic to see the light: euphoric recall drinking, memory losses and a bundle of enablers around. Concerned other need to work at it very seriously; just stepping in is not enough.

Q: But, people are also worried about withdrawal, the shakes, delirium tremens.
A: It happens to people who have been drinking a lot, and then usually stop cold turkey. These people develope a profound withdrawal syndrome. What will most people do in that state is go back and drink more alcohol. So they end up in a vicious cycle. They learn helplessness and continue to drink. However, people in treatment go through withdrawal quite comfortably.

Q: Are there any physical signs with progressive drinking?
A: Oh, absolutely. There are physical changes that occur with sometimes heavy drinking. Liver function tests, however, remains normal for quite a long time. Liver is stubborn for a long time but one day it succumbs to this ongoing assault. However, they are actually affected, in terms of physical ailments like gastritis, pacreatitis and whole lot of other 324 diseases during this downhill path. They also suffer from diabetes, hepatitis and high blood pressure secondary to alcoholism. Mentally they are irritable, paranoid and sick and tired. Memory is pretty bad. Relationships are sour.

Q: Tell me what kind of impact alcoholism really has on families. How bad is it?
A: Alcohol works from the top down. After working in the identified patient, it works in concerned others too who do not drink but provide short term solutions when the life of the drinking person tends to be messed up. Alcoholism like all other chronic diseases has a shadow which encroaches on the family. You see a lot of symptoms in family members too. It affects practically every aspect of family life. It affects the family life in a variety of ways. Family members go through paradigm shifting experiences with emotional repercussions. Family members start seeing them in a new light. There are widows with living husbands. There are children who can’t look to their father in times of difficulty. Rather he is creating difficult times. There is verbal abuse. There is domestic violence. So you name it, that’s how it affects the family.

Q: It almost sounds like it’s worse for the families.
A: Absolutely. That’s a good way of putting it. At least, he can numb his feel even if he is unable to enjoy drinking because of alcoholism. The problem is so big, the family can’t run away from it in any way. For them it is an endless suffering.

Q: Families break up, I assume, because of this problem?
A: Oh, it’s a relationship killer. Even if the family does not breakup, it disintegrates but strings are still attached. Concerned others are trying to keep their loved one alive with home remedies; this is counter productive. This is what we call enabling. They are providing short term solutions for a long term problem. He goes on progressing with the disease, and drags the whole family down with him.

Q: What it is like to live with an alcoholic?
A: Its terrible and horrible.

Q: What about acting like the police? Checking to make sure he does not keep big quantities.
A: Alcoholics are usually much smarter than concerned others. They’re going to hide the bottles in places that you won’t think of. It is an exercise in futility and a recipe for frustration. You see, it does not work. You are asking him to control his drinking which he can’t. He can call it a quit or drink the same way. So you need to motivate him. You need to promote treatment seeking behaviors in your loved one. If you are asking him to cut down, you addressing the wrong end of drinking problem. He is a magician; literally. He distort the reality, he will distract your attraction. He will make sure that the drinking continues.

Q: How the destructive drinking behaviors affect the children?
Imagine a house in which a child feels that the walls and floors are constantly moving and shaking. Would anyone be at peace in such a setting? Children are caged silenced songbirds, in a household with alcoholism. They blame themselves for not doing enough. Anger is often directed at the parent who is not alcoholic, for the child blames the sober parent for not solving a family problem. Healing occurs in counseling when the children learn that they are not responsible for the alcoholic’s behavior, but they are responsible for creating their own inner peace and harmony.

Q: What are the options family is left with?
A: The family is really caught in a trap. On the one hand, they’re upset, angry, furious and hurt by the behaviors of the alcoholic, on the other hand, they love that person. Either it’s a husband, or an other loved one. They can’t just throw him out of the window, especially if they have sensitivity to the notion that, that person was their darling all their life. The families often want him to get help. That becomes a whole big issue. They need professional help so as to learn how to enhance the treatment seeking behaviors in the identified patient.

Q: And they shouldn’t give up on him.
A: Exactly. The truth is that they cannot give up on him for long, but, there is a very delicate balance in helping and getting in the way. They use commonsense tactics and confrontations at the spur of the moment. These don’t work. They try to be nice; they try to be nasty. They are doing the same things again and again and each time expect different results. This is insanity. So they become codependent; sick and tired of being sick and tired. Codependence is shadow-alcoholism.

Q: What are the do’s and don’ts? How do they go about finding that balance?
A: Well, seeking professional help is the key. Sooner the better. To begin with you can do a few things; never talk to him when he is drinking and intoxicated. Prepare well before you talk. Never talk to him alone. Always take meaningful actions. Never be judgmental and attacking. Talk with care and concern. Don’t vent your anger. Tell your observation and express your feelings about his drinking behavior. And you should direct them toward getting help. You don’t want to extract a promise. Its often very helpful to point out, and to suggest to the variety of help, that is available.

Q: Some families threaten to end the relationship? What role does that play?
A: Threats don’t work especially if the alcoholic knows that you are not going to follow through. You know, all ways of intervening work best when they are specific to the problem, when they are tailored to the real problem. There are no easy knee jerk responses. Structured Intervention, Tough love and Assertiveness are the kind of subjects, you need to learn precisely before you attempt to step in. I suggest different strokes for different folks and different strokes for the same folks at different stages.

Q: Having a more reasonable talk with somebody about his drinking behavior in a non-harsh, non-punitive way is probably the best route.
A: I agree with you completely, but on the other hand, there are times when producing consequences and what we call “leverage” is helpful. It can help motivate him a little bit further. Sometimes all the nice discussions and gentle pep-talk doesn’t work.

Q: So, you want to say, treatment against patient’s will, does work?
A: Treatment against will is not necessarily bad or wrong. It’s not optimal, but there are plenty of people who get sent to treatment by loved ones, the courts, etc., who do get something out of it and do begin the road to recovery. So that’s worth throwing in there too.

Q: What is contingency management in intervention?
A: There definitely is a place for it. But again, it’s somebody who should be in treatment, so it’s a carefully planned set of contingencies about what the negative consequences will be for him if he does not get help and chooses to live with active alcoholism. When it’s done properly, it can be very useful. But, remember, you don’t have to win a battle with him, you need to succeed together.

Q: The bottom line is that families should talk to a professional before they take any actions, correct?
A: I agree with that 100%. That’s right.

Q: Now, are doctors failing to pick the diagnosis up on routine exams?
A: Absolutely. There’s not a question about that. Not just problem drinking,but even in advance cases, most physicians are not asking right questions. Doctors especially gastro- enterologists casually advise to cut down alcohol. No body cuts alcohol down. Even if you try to do so, alcohol strikes back like a rattle snake. There is all or none low. You call it a quits. Doctors can do wonders. By just being assertive and matter of fact, they can make miracles.

Q: What if somebody drinks because of stress and depression?
A: People think that the amount drank is indirect proportion to the level of stress. Alcohol like all drugs has a very limited range of dosage; rest is all alcoholism. Depression is the result and not the cause of alcoholism. So the tranquillizers and anti- depressants don’t work in alcoholism. You need to quit alcohol first.

Q: What is the Intervention when it comes to alcoholism?
A: Intervention is many things; however, there is no such thing as one-size-fits-all. It can be as an absolute intellectual exercise when the sanity of the patient is intact. The family goes into elaborate training and talks patient into treatment. This will be therapeutic structured family intervention. But, if the patient is paranoid, aggressive, there is verbal abuse and domestic violence, then intervention may comprise of a trained team moving into the “lion’s den”, when he is drunk and passed out and taken to hospital to open his eyes and say “Where am I?” This is crises intervention. And, there is a whole lot spectrum of interventions in between. I mean you need to choose the path for your loved one. You need to develop a plan most suited to your loved one. There three keys to success, however. You need to show the person that his drinking has turned into alcoholism because he cant see it. You need to be brutally honest while expressing love and maintaining high level of respect. And the third key is compassion, because without a sincere desire to help, intervention may not work. You don’t have to play doctor. You just have to look into problems generated by his alcoholism and use them creatively to construct a road map to prosperity.

Q: So they should take some action?
A: Yes! Life rewards actions. Professionals can empower you and you in turn can empower the patient.

Q: What about process intervention. This is the new philosophy, correct?
A: Well, it’s a new idea, and it comes from people who have been looking at motivation and treatment. Alcoholics don’t really recognize the potential damage their drinking behavior is causing. So, they don’t come running over each other for treatment. In order to enhance the treatment seeking behavior, it’s useful to, talk to a professional before talking to him. You sharpen your intervention skills and convince the patient as opposed to sort of carrying him kicking and screaming, and fearing he will not engage in treatment. It takes a little more time, like three to six months. This works best when the liver function tests are still well with in normal range and your loved one is still functional. Beyond that you need to do the structured family intervention or crises intervention.

Q: Who teaches the process intervention?
A: The doctors who do the treatment, Family members learn interaction and engage in a dialogue and it’s not coercive and punitive. It’s non-confrontational. It’s non-judgmental. You are not hell bent to take the patient into treatment “here and now”. You’re just there to talk. You stop enabling and provoking. You learn the rocs program. So, you need to understand what drinking means to him and what his fears are about giving it up? You also explore his fears about treatment. Family also needs to do something about their own fears and phobias before assuming a therapeutic role.

Q: So, the process intervention is when they’re still drinking, hopefully not during the discussion, but are willing to talk about their drinking problem.
A: Yes, and its extremely valuable.

Q: Now, this sounds very different, from family intervention where the family members and friends ambush a person into treatment?
A: Well, it is different. This is what we call the process intervention. However, its essentially trying to achieve the same effect, which is to get the person to buy in to the concept that he needs treatment. Family intervention is essentially a style where important figures from the person’s life are marshaled, out of love and concern to say, “This is what your drinking is doing to you and to us.” It tries to challenge the denial and rationalizations. All of them present reality to him in a receivable way and tell him to get help “NOW” or face the MUSIC. The person will say, “How come nobody told me before this that you were interested in me getting help. I am ready”.