An Adjustment Demand: Resistance To Alcoholism Treatment With A DWI Population

James A. Garrett

Coordinator, Community Alcoholism Treatment Services Unit New York State Division of Alcoholism and Alcohol Abuse

The 1970's were witness to a highly technical and specialized emphasis which was placed on the detection, arrest, conviction and rehabilitation of individuals involved in a Driving While Intoxica (DWI) offense. This paper will deal with the early identification and intervention potential of the DWI arrest and the necessity for the treatment community to provide therapeutic services to those "mandated" clients who are referred for evaluation and treatment.

Alcohol Safety Action Projects (ASAP) have given the field a useful nomenclature for understanding the categories of drinkers arrested for a DWI offense. This categorization includes three levels of drinkers:

Level I - social drinkerLevel II _ potential problem or unidentified Level III - problem drinker or alcoholic

(National Highway Traffic Safety Administration, 1979) The ASAP screening experience with more than 200,000 DWI

offenders at 36 sites indicates that 44% of those arrested were classified at Level III or alcoholic drinkers, 20% were Level II with a potential problem and 36% were Level I social drinkers. (Nichols and Reis, 1974)

It is the alcoholic drinkers and problem drinkers who are screened and referred to a treatment agency which compose the "mandated" client population.

The ASAP levels integrate well with the conceptualized format proposed by Brown, et al. regarding the use of the National Counci

on Alcoholism Criteria in the diagnosis of alcoholism (Brown and Lyons, 1980). Chart I reflects the behavioral and physiological tracts proposed by Brown. A DWI offense is a certain indicator of behavioral impairment due to excessive drinking. The physiological impairment can be measured by such things as BAC at the time of arrest, tissue tolerance, elevated liver emzymes tests if available, and prior medical treatment for alcohol related problems, i.e., gastritis, high blood pressure or ulcers.

Behavioral| Impairment!(Track II |Diagnostic Symptoms |Level 4:

Relative Behavioral Severity Vector

Physiologi cal Impairment (Track I Symptoms

0 )

x:

Diagnostic Level 4:Not Related To AlcoholDiagnostic Level 3:Not Related To Alcohol

Diagnostic Level 3; Potentially Related ToAlcohol

Diagnostic1Diagnostic Level 2: 'Level 1: Probably I Definitely Related |Related To I ToAlcohol I Alcohol

Diagnostic Level 2: Probably Related To AlcoholDiagnostic Level 1s Definitely Related To Alcohol

<D

Verbal Equivalents A NonalcoholicB Early Problem DrinkerC Behaviorally Impaired DrinkerD Physiologically Impaired DrinkerE Alcoholic

Chart I

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When there is sufficient evidence to indicate a combination of behavioral and physiological impairment or a series of indicators in one of the Tracts the person can be diagnosed as alcoholic or a Level III drinker. The Level II drinker will exhibit symptoms of behavioral impairment and can be seen as having a drinking problem. The remaining arrested drinkers fall into a Level I drinking pattern and do not exhibit symptoms which are problematic.

Recent evaluations of the rehabilitative effect of the ASAP's indicate that a straight educational program from the Level III drinker is not effective and may in fact be counterindicated. "In addition to the highly probable outcome that such (education) programs will have no effect whatsoever on the majority of persons exposed to them, it is entirely possible that educational programs may have a detrimental effect on certain types of referrals (e.g., severe problem drinkers)" (National Highway Traffic Safety Administration, p.23, 1974). Such indications along with studies documenting the disproportionate representation of alcoholics and problem drinkers arrested for a DWI offense (Waller, 1967 and Selzer et al., 1963) lead to the conclusion "that programs designed to reduce the recidivism rate of DWI's need to intervene in the problem drinking behavior manifested by a large percentage of this population. Thus, the efforts of enforcement, judicial, and alcoholism rehabilitation systems are seen as complementary in attacking the social problem of the drunk driver (Sandler et al, 1974). This clearly underlines the important role the alcoholism treatment system has in the evaluation and treatment of "mandated" clients.

These "mandated" clients provide an opportunity and a challenge to clinicians in the alcoholism rehabilitation field. The opportunity lies in the fact that there is a ready mechanism to give more than lip service to the concepts of outreach and early identification. The challenge comes from the fact that these clients will be referred under a "mandate" from courts, probation departments or the drinking driving program and the clinicians must utilize the "constructive coercion" to motivate and engage the client in the process of change. This challenge to helping professionals is put in poetic style by R.D. Laing.

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There must be something the matter with him because he would not be acting as he does

unless there was therefore he is acting as he is because there is something the matter with him

He does not think there is anything the matter with him because one of the things that is the matter with him

is that he does not think that there is anything the matter with him

thereforewe have to help him realize that,the fact he does not think there is anythingthe matter with himis one of the things that isthe matter with him

(Laing, 1972)

Contrary to recently published optimistic reports, (National Highway Traffic Safety Administration, p. 31, 1979) I have experienced a great deal of reluctance, skepticism and in some instances refusals by clinicians to work with these mandated clients. Clinicians report the hostility, resistance and anger which they are subjected to. Many counselors take the attitude that the individual will not change if forced into treatment. The idea that the person has not "hit bottom" is often used as a rationale to not treat the "mandated" client.

This gap in service was troublesome to me. On the one hand the research is saying that the problem drinker and alcoholic must be treated for "the" problem and not just schooled to provide information and insight. On the other hand, the treatment community was displaying as much resistance to treating the mandated client as the client was displaying. This dilemma lead me to investigate the literature for theory and models which build on the early

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identification potential of a DWI arrest and give clinicians a structural framework within which to view the hostility, resistance and anger exhibited under forced treatment (Ward, D., 1979; Panepinto, W. and Higgins, M., 1969; Bjeiver, K., 1972; Smart, R., 1970;Valiant, G., 1966; Gallant, D.M., 1971; Gallant, D., et al., 1968; Gallant, D., Faulkner, M., et al., 1968; Ditman, K. and Crawford, G., 1966; Rosenberg, M. and Liftik, J., 1976; Nichols, J., et al., 1978; American Automobile Association, 1976; Blinder, M. and Korblum, G., 1972; Maier R. and Fox, J., 1958; Mills, R., and Hetrick E., 1963).

I concluded that the two functions in this early identification system (screening/referral and treatment) were not theoretically linked. The alcohol and highway safety literature documented the need to identify and refer problem drinkers and alcoholics. The treatment literature centered mostly around an outcome comparison of mandated V.S. voluntary treatment. No wonder, there is confusion, resentment and objection to the mandated client. The following design is a structural model to view the experience an individual goes through as the result of a DWI arrest. The model is intended for use by clinicians to better understand the development of stress and the power of the hostility in mandated clients. It must be under­stood from the client's perspective.

But if for a moment we concerned ourselves with the "inner world of alcoholism" -with a view from the "inside out" rather than outside in -what might we discover?

When we adopt the frame of reference of the alcoholic himself and attempt to understand his experience of the disease, we are engaged in an analysis called "phenomenological".In this type of analysis we are concerned with the world not as it might be described "objectively", but

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with the world as experienced by the person himself. (Wallace, 1977)

The stress model does not replace alcoholism counselling, but enhances the applicability of alcoholism theory in the treatment of mandated clients by recognizing, designing and starting the treatment process where the client is (Drye, 1977). A delicate balance is needed by the therapist to recognize the strength in the resistance of the mandated client (dealt with first in the treatment process) and yet not to become an enabler by colluding in the alcoholic defense structure.

-- denial is a well-charted hazard in alcoholismtherapy. Therapists working with alcoholics are so familiar with their client's unwillingness (or inability) to see the facts of the drinking-- .

What is not appreciated however, is the corresponding Charybdis of premature self-disclosure. In working with alcoholics we must realize that the denial is there for a purpose. It is the glue that holds an already shattered self-esteem system together. And it is the tactic through which otherwise overwhelming anxiety can be contained. (Wallace, 1977)

The term stress is borrowed from the engineering field and means a force directed at an object. When an object is under stress, the consequent distortion or change is called strain. Thus, a light snowfall which cumulates on a roof causes stress with a minimum amount of strain. However, a heavy snowfall on the same roof increases the stress and depending on materials, construction, design and building condition the increased strain could result in the roof collapsing. I will utilize this engineering concept as it applies to the human organism.

Stress for humans is any physical, mental or emotional experience resulting in anxiety caused from factors which have altered an existent equilibrium.

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There are varying degrees of stress and idiosyncrotic stress reactions to the same event by different individuals. It is necessary to set two premises at this point:

(1) Humans strive for and need a homeostasis or equilibrium to maintain a functional integration. The homeostasis is foundationed by identity and self-esteem. "Equilibrium may be described as the permissible range of variations (i.e., behaviors) that may occur within a system without loss of its identity and organization (Leonard and Berstein, 1969).

(2) A DWI arrest is traumatic and causes some degree of stress. The significance and degree to which the individual's identity, self-esteem and psycho-social organization are disrupted, will depend on the "appraisal" of the situation by the individual (Arnold, 1960).

Hamlet's soliloquy is reminescent of the stress which could be from a DWI arrest. Shakespeare seemed to have a degree of insight into working with the "mandated" client. Hamlet is talking about identity, self-esteem and the degree to which his life has become disorganized. His quest is one of personal integration.

To be, or not to be: that is the question:Whether 'this nobler in the mind to suffer The slings and arrows of outrageous fortune,Or to take arms against a sea of troubles,-- .For who would bear the whips and scorns of time The oppressor's wrong, the proud man's contumely,The pangs of despised love, the law's delay,-- .

Hamlet, Act III, Scene I

The resultant strain from the stress of a DWI arrest arises in connection with problems of choice, conflict, interference, frustration, overloading, social pressures and other related aspects of living (Sarbin, 1968). The arrested person is now faced with a series of enforcement, legal, judicial, educational and treatment experiences. These situations are stress producing. It is important for clinicians to realize when the mandated client reaches the treat­ment agency, he is not coming with a problem drinking history alone;

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but is presenting from a perspective of being threatened by various encounters in the health-legal-enforcement system. "To qualify as the source of threat in the process of threat appraisal, the stimulus need not be realistically capable of harm. It need only be apprehended as such. The correctness or incorrectness of the appraisal is unimportant as a defining characteristic, although it is important if we are interested in the adequacy of adaptation or in the defensive distortion of reality" (Arnold, p.55, 1960).

The major components of stress are frustration, conflict, pressures and overload. The following outline shows these areas as they relate to a DWI arrest.

(1) Frustration - is a sense of insecurity and dissatisfaction which comes from unresolved problems. There are four areas of frustration which relate to a DWI.

A. Loss - many DWI1s result from an accident and, therefore, mean the loss of a car for temporary repairs or permanently from a "total" wreck. The Court process usually results in sometype of action against the drivers license (see Alcohol Safety Program Progress, Vol. 2, State Program Progress for summary of how individual states handle driver license suspension/revocation). The complications caused by the loss of a car and/or drivers license are significant. Imagine the frustration you would experience by having to arrange on short notice for getting to work, buying the groceries and taking the children to school, Little League or music lessons for a two to six month period of time.

B. Failure/Guilt - the personalization of a DWI arrest results in feeling of failing as a motorist, a member of a community, a wife, a businessman, etc. Even for the alcoholic a DWI represents significant failures, for in spite of attempts to control drinking and remain problem free, a new problem has occurred.

C. Lack of Resources - many DWI offenders consider themselves to be law abiding citizens and have little experience with criminal offenses. Suddenly, the "careful" ride home is interrupted and the individual finds themself arrested, handcuffed, in most instances, read legal rights and given a chemical test. One must hire an attorney, face insurance complications and enter a system which will screen for a drinking problem. It is little wonder

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the individual feels hostile by the time he comes to a treatment agency. Not only does he not have any knowledge, desire or skill in forming a therapeutic relationship, but it is one more system which makes the individual feel "out of his league."

D. Delays - this relates to the organizational disruption which results from a DWI. The individual no longer is in control of setting a schedule, and making decisions for work, pleasure and personal activity. Time has to be taken off from work to go to Court. The loss of license means delays in personal activities and constraints of movement.

2. Conflict - is an inner disharmony resulting from incompatable inner needs. With a DWI arrest, this disharmony usually occurs from the reward or punishment value the alternatives have. The following two types of conflict serve as a classification system: (Coleman, 1969)

A. Approach - Avoidance Conflicts.- A DWI offense has "mixed blessings" for most people. Some negative and some positive features must be accepted regardless of the personal choices made after the arrest. For instance, the person is confronted with avoiding or facing the seriousness of driving after drinking because of the arrest. Most people are in the fortunate situation of saying "well it could have been worse" or "why wasn't I told this information earlier." For the alcoholic in treatment as a mandate involving the retention of a drivers license, the approach-avoidance is clear. "I need my license so I'll do what you say I have to do, even though I don't think I have a problem." This is a workable situation in a treatment setting (Bissell,1976) and should not be confused with unworkable denial. The individual is caught between two conflicting alternatives. By refusing the "mandated" treatment the person faces the risk of further Court action, probation action and/or loss of driver's license. By accepting the "mandated" treatment, the person agrees to examine a problem he does not believe exists or if he admits to a drinking problem "it isn't that bad to need treatment." This decision to enter treatment is made with the motivation to keep the driver s license and to avoid further legal problems.

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B. Double Avoidance Conflicts - this conflict occurs when all alternatives are undesirable or present such a threatening situation the individual chooses to face neither. The mandated treatment may be so undersirable or threatening that the individual becomes willing to risk the negative consequences of the alternatives by refusing treatment.

3. Pressures and Overload - develop from the burden of mental distress resulting from strain or a sense of urgency with events or matters demanding attention. A DWI results in fiscal, legal, family and social pressures.

A. Legal Pressures - result from the apprehension, arrest, prosecution and conviction of a criminal offense. Such acts as handcuffing, being placed in jail, having to post bail and appearing in Court with a possible jail sentence all result in legal pressures.

B. Fiscal Pressures - are realized soon after the arrest. Attorney's fees, increased insurance premiums, accident costs, property damage costs, lost wages, Court fines, rehabilitation and treatment payments are among the costs involved with a DWI arrest.It has been estimated that the average DWI arrest in New York State will cost the individual over $2,000 in a three year period of time.

C. Family Concern - over a DWI arrest is usually substantial. If the individual has promised family members that no more problems would result from drinking, a DWI arrest may resultin separation, self referral for counselling or attendance at Al-Anon. Most individuals arrested for a DWI have a sense of guilt which is compounded by the questions of the children and other relatives.

D. Social Pressures - usually begin with the individual's name being published in the local paper for having been arrested for a DWI. This results in feelings of embarrassment and guilt over the alcohol incident. When employers see the name in the newspapers they begin to question work performance, attitude and attendance as possibly being impaired due to an alcohol problem. The loss of the drivers license means making arrangements for transportation by depending on others when one is usually more independent.

This cumulation of stress results in a threat to the self-esteem, identity and equilibrium referred to earlier. Threat is no more than

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a personalization of anticipated harm. Once the arrested individual anticipates harm to the self-esteem, identity or homeostasis of the social/psychological/familial systems the sequence of stress aroused emotions occur (Chart II). It is important to see the development of these stress aroused emotions as being attempts by the individual to reduce the strain on his identity and equilibrium. "Greater stresses or prolonged stress excite the ego to increasingly energetic and expensive activity in the interests of homeostatis maintenance" (Menninger, p. 280, 1954). This mobilization of energy to protect the individual from the threatening experience is the result of the adjustment to the demand placed on the individual (Coleman, 1969). When the person reaches the treatment agency for an evaluation, he is not coming with the problem drinking history alone, but is presenting with a cumulative series of adaptive decisions forced by the adjustment demands the individual encountered at each of the points in the health-legal-enforcement system. What I am saying is that the hositility and resentment of the "mandated" client are defending mechanisms which have the powerful function of maintaining an equilibrium (regardless of how pathological the individual's drinking system might be). It is important to understand and appreciate this structural sequence in the formation of an adjustment demand as it relates to a DWI arrest.

E

E

N

PROCESS

Threat arouses anxiety

Anxiety results in an Q | Adjustment Demand

1. task oriented U I 2. defense oriented

Anxiety arouses fear

C | Fear arouses anger/hostilityor passivity

E

CHART I I

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Chart II shows the sequence and process which occurs internally as the result of a DWI arrest. The stress outlined earlier is internalized after appraisal as a threat to individual functioning. The threat becomes manifest emotionally as anxiety. The anxiety can best be seen as an uneasiness of mind or worry about some impending matter. Operating from the first premise stated earlier, humans strive for and need homeostasis to maintain functional integration^ the anxiety signals the disruption of the homeostasis and the individual's behavior derives from the choice of adjustment demands (Lazarus, 1966).

An adjustment demand is the internal sequence of events which takes place in the individual's decision to cope or defend with the stress of a DWI arrest (Bruner, 1966). Whatever the decision, the goal of an adjustment demand is to reduce stress and enable the individual to return to homeostatic functioning. Those individuals who chose a task orientation to the anxiety, do not continue to escalate fear over anxiety and hostility over fear (see Chart II). The task oriented adjustment is a decision to cope with the alcohol related arrest. The task orientation builds in "the belief and associated feeling of comfort that no matter what happens to me, no matter how bad the situation, I will learn and grow from the experience" (Erskine, 1980). Task oriented adjustment has the following characteristics:

1. Necessitates a degree of self-confidence;2. Utilizes an objective analysis of the situation;3. Makes a decision which proceeds with a rational,

constructive course of action;4. Results in a positive outcome.These characteristics have observable behaviors associated

with them which include displaying increased problem solving competencies, new approaches to the problem, realistic goal setting and a new self understanding.

I believe the alcoholic must stop drinking and achieve a therapeutic sobriety in order to display the characteristics of a task oriented adjustment demand. The ideal situation exists when a DWI arrest motivates an individual to take a task oriented approach to one's alcoholism. Unfortunately, this happens only infrequently.

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Other individuals choose a defense oriented adjustment demand as their way of reducing the stress of a DWI arrest. These individuals will predictively escalate fear over anxiety and escalate anger or hostility over fear as they move through differing points in the system and eventually are referred for alcoholism treatment. From a clinical perspective, the passive or totally compliant individual has escalated the passivity over the fear. In this sense, the passivity serves the same purpose as the hostility. Often times referrals to treatment will try combinations of both behaviors trying to find the most successful way of defending against the psychological disorganization. The defense oriented adjustment is marked by the characteristic use of one or more defense mechanism. The defense mechanism is designed to protect the individual from the perceived threat and to alleviate the anxiety.The use of a defense mechanism leads to some degree of self- deception and reality distortion. But, it has the powerful use of allowing the individual to maintain a sense of adequacy and self worth.

By the time the individual with a DWI arrest gets to a treatment agency for an evaluation, he has encountered stresses outlined under frustration, conflict and pressures. The defense oriented adjustment demand - hallmarked by hostile, angry behavior— has been forming at earlier points to defend against a number of stresses. The resistance was not formed solely by probes into problem drinking behavior done at the treatment agency. I believe alcoholism clinicians working with this mandated population must recognize both the formation of a defense oriented adjustment as it relates to the stress from a DWI arrest, as well as, the alcoholism dynamics which may underlie the DWI arrest.

I believe this adjustment demand model has the following clinical implications:

1. The presenting hostile behavior which alcoholism treatment agencies often face with the mandated client must be viewed within a stress model and not solely within an alcoholism model.

2. There is power in the hostility and unless that is appropriately recognized and worked through the individual will not move toward looking at problem drinking behavior.

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3. Alcoholism treatment agencies should have the mechanisms and supports for clinicians to keep them refreshed and objective in working with the mandated client. This population is not easy to work with and requires additional skills to alcoholism counselling.I do not believe all alcoholism counsellors are qualified or prepared to work with the mandated client.

4. Intake interviews should be structured with the maximum amount of written information coming from the Courts, probation departments or the alcohol safety school outlining such material as arrest history, BAC, screening tests taken (MAST, Mortimer- Filkens) and a narrative rationale for the referral. This information will allow the clinician to assess the strength and choice of adaptive behavior. This clinical observation has direct treatment planning and assessment value.

5. The initial treatment exposure for the mandated client should be a time limited, structured group experience. This is necessary because the mandated client will be looking for "reasons" to not continue in the process. An open ended, unlimited treatment approach will cause more fear and escalate the hostility thereby making it more difficult to ever get to alcoholism issues."-- ambiguity intensifies threat because it limits the individual'ssense of control over the danger, thus increasing his sense of helpnessness" (Lazarus, p. 119, 1966).

6. Clinicians working with the mandated client need to be sensitive to and experience the value of their own resistance to "being made" to do things. This sensitivity will enable the clinician to create a psychologically safe environment by recognizing the power in the resistance and allow the clinician to then work on appropriate alcohol related issues.

7. Reluctance to treat the "mandated" client will be easily perceived. If a clinician does not believe change can occur from mandated treatment then this treatment is best done by others. Mandated treatment must have clinical elements which "demonstrate consideration for the patient's lowered self-esteem, reduce his frustration, establish and maintain a pattern of continuity of care,and communicate interest through action. -- an absence of controlsby the therapist is poorly tolerated by and quite threatening to a

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patient who is leaning toward a loss of ego control. (Panepintoand Higgins, p. 417, 1969).

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