There are, and have been, many theories about alcoholism. The most prevailing theory, and now most commonly accepted, is called the Disease Model. Its basic tenets are that alcoholism is a disease with recognizable symptoms, causes, and methods of treatment. In addition, there are several stages of the disease which are often described as early, middle, and late. While it is not essential for a supervisor to fully define these stages, it is useful to understand them in terms of how the disease presents itself in the workplace.
The Early or Adaptive Stage
The early or adaptive stage of alcoholism is marked by increasing tolerance to alcohol and physical adaptations in the body which are largely unseen. This increased tolerance is marked by the alcoholic’s ability to consume greater quantities of alcohol while appearing to suffer few effects and continuing to function. This tolerance is not created simply because the alcoholic drinks too much but rather because the alcoholic is able to drink great quantities because of physical changes going on inside his or her body.
The early stage is difficult to detect. By appearances, an individual may be able to drink a great deal without becoming intoxicated, having hangovers, or suffering other apparent ill-effects from alcohol. An early stage alcoholic is often indistinguishable from a non-alcoholic who happens to be a fairly heavy drinker. In the workplace, there is likely to be little or no obvious impact on the alcoholic’s performance or conduct at work. At this stage, the alcoholic is not likely to see any problem with his or her drinking and would scoff at any attempts to indicate that he or she might have a problem. The alcoholic is simply not aware of what is going on in his or her body.
The Middle Stage
There is no clear line between the early and middle stages of alcoholism, but there are several characteristics that mark a new stage of the disease. Many of the pleasures and benefits that the alcoholic obtained from drinking during the early stage are now being replaced by the destructive facets of alcohol abuse. The drinking that was done for the purpose of getting high is now being replaced by drinking to combat the pain and misery caused by prior drinking. One basic characteristic of the middle stage is physical dependence. In the early stage, the alcoholic’s tolerance to greater amounts of alcohol is increasing. Along with this, however, the body becomes used to these amounts of alcohol and now suffers from withdrawal when the alcohol is not present.
Another basic characteristic of the middle stage is craving. Alcoholics develop a very powerful urge to drink which they are eventually unable to control. As the alcoholic’s tolerance increases along with the physical dependence, the alcoholic loses his or her ability to control drinking and craves alcohol. The third characteristic of the middle stage is loss of control. The alcoholic simply loses his or her ability to limit his or her drinking to socially acceptable times, patterns, and places. This loss of control is due to a decrease in the alcoholic’s tolerance and an increase in the withdrawal symptoms. The alcoholic cannot handle as much alcohol as they once could without getting drunk, yet needs increasing amounts to avoid withdrawal.
Another feature of middle stage alcoholics is blackouts. Contrary to what you might assume, the alcoholic does not actually pass out during these episodes. Instead, the alcoholic continues to function but is unable to remember what he or she has done or has been. Basically, the alcoholic simply can’t remember these episodes because the brain has either stored these memories improperly or has not stored them at all. Blackouts may also occur in early stage alcoholics.
Impairment becomes evident in the workplace during the middle stage. The alcoholic battles with loss of control, withdrawal symptoms, and cravings. This will become apparent at work in terms of any or all of the following: increased and unpredictable absences, poorly performed work assignments, behavior problems with co-workers, inability to concentrate, accidents, increased use of sick leave, and possible deterioration in overall appearance and demeanor. This is the point where the employee may be facing disciplinary action.
The late, or deteriorative stage, is best identified as the point at which the damage to the body from the toxic effects of alcohol is evident, and the alcoholic is suffering from a host of ailments. An alcoholic in the final stages may be destitute, extremely ill, mentally confused, and drinking almost constantly. The alcoholic in this stage is suffering from many physical and psychological problems due to the damage to vital organs. His or her immunity to infections is lowered, and the employee’s mental condition is very unstable. Some of the very serious medical conditions the alcoholic faces at this point include heart failure, fatty liver, hepatitis, cirrhosis of the liver, malnutrition, pancreatitis, respiratory infections, and brain damage, some of which is reversible.
Why does an alcoholic continue to drink despite the known facts about the disease and the obvious adverse consequences of continued drinking? The answer to this question is quite simple. In the early stage, the alcoholic does not consider himself or herself sick because his or her tolerance is increasing. In the middle stage, the alcoholic is unknowingly physically dependent on alcohol. He or she simply finds that continuing to use alcohol will prevent the problems of withdrawal. By the time an alcoholic is in the late stage, he or she is often irrational, deluded, and unable to understand what has happened.
In addition to the effects of these changes, the alcoholic is faced with one of the most powerful facets of addiction: denial. An alcoholic will deny that he or she has a problem. This denial is a very strong force. If an alcoholic did not deny the existence of a problem, he or she would most likely seek help when faced with the overwhelming problems caused by drinking. While denial is not a diagnosable physical symptom or psychiatric disorder, it is an accurate description of the state of the alcoholic’s behavior and thinking and is very real.
An alcoholic will rarely stop drinking and stay sober without outside help. Also, he or she usually will not stop drinking without some kind of outside pressure. This pressure may come from family, friends, clergy, other health care professionals, law enforcement or judicial authorities, or the employer. For example, a spouse may threaten divorce, or the alcoholic may be arrested for driving under the influence. There was at one time a widespread belief that alcoholics would not get help until they had "hit bottom." This theory has generally been discredited as many early and middle stage alcoholics have quit drinking when faced with consequences such as the loss of a job, a divorce, or a convincing warning from a physician regarding the potentially fatal consequences of continued drinking.
There are obvious advantages to getting the alcoholic into treatment earlier rather than later. One advantage is that, the earlier treatment is begun, the probability of having less expensive treatment, such as outpatient care, is increased. There is also a greater likelihood of success in treatment with an individual who has not yet lost everything and still has a supportive environment to return to, including an intact family, good health, and a job. In addition, the employer has a stake in the early treatment of alcoholism, since the employee will have a greater chance of returning sooner to full functioning on the job if the disease is arrested at an earlier point. Early treatment is simply less disruptive to the workplace and can help the employee avoid further misconduct and poor performance. If an alcoholic employee doesn´t’t get help until very late in the disease, there may have been irreparable harm done to the employee-employer relationship.
The alcoholic does not initially have to want to get help to go into treatment. Many people go into treatment because of some kind of threat such as loss of a job or possible incarceration. However, even the individual that is forced will eventually have to personally accept the need for treatment for it to be effective. The employer is a very potent force in getting the alcoholic into treatment. The threat of the loss of a job is often the push the alcoholic needs to enter treatment. This threat is usually communicated to the employee through some type of an adverse or disciplinary action and is accompanied by a referral to the Employee Assistance Program (EAP) which will refer the employee to an appropriate treatment program.
There are various kinds of treatment and programs for alcoholism. Though some alcoholics do stop drinking on their own, this is rare. Most alcoholics require some type of treatment or help. The following are some common types of programs and approaches to treatment:
Alcoholics Anonymous (AA) – AA is what is called a 12-Step program and involves a spiritual component (not affiliated with any particular religion) and a supportive group of fellow alcoholics to provide a network for total abstinence from alcohol. There are AA meetings where alcoholics can gather to learn about the disease, hear talks from recovering alcoholics, and enjoy the support of fellow alcoholics who are learning, or have learned, how to stay sober. AA is not really a formal organization as it has no leaders. It is a loose confederation of groups formed by recovering alcoholics operating on common principles spelled out in the book Alcoholics Anonymous (it is also known as the "Big Book") which spells out the Twelve Steps and the principles of AA.
There are other support groups such as Rational Recovery which have a different focus than AA. Some individuals find approaches other than AA to be more useful in their treatment.
Detoxification – Detoxification, also known as "detox," is a process whereby the alcoholic undergoes a supervised withdrawal. The body can begin to recover from the toxic effects of alcohol and the patient can become sober. This is something that is best done in a medical setting where the patient can be closely monitored and have his or her medical condition evaluated. Detoxification can last anywhere from two to seven days.
Inpatient treatment – This consists of a formal, residential program which may include detox at the beginning. Typically an inpatient program would include education about the disease; medical treatment for related medical conditions and nutritional stabilization; counseling, including individual and group therapy sessions; an introduction to a 12-Step program; and monitoring of the patient including drug and/or alcohol testing to ensure compliance with the program. Inpatient programs last anywhere from one to six weeks, typically 3-4 weeks. Some are connected with hospitals while others are not. There are some programs called "day treatment" in which patients spend the entire day at the treatment center but go home at night or on weekends. Inpatient treatment is very expensive and can easily cost $5,000 to $10,000.
Outpatient treatment – This consists of counseling and treatment on a daily or weekly basis in an office or clinic setting. Outpatient treatment is often a follow-up to an inpatient or detox program. In some cases, the severity of the addiction is such that inpatient care is not needed, and the client undergoes only outpatient treatment. It may include education about the disease, individual or group therapy, or follow-up counseling. Outpatient treatment is not as expensive as inpatient treatment and may last anywhere from one month to a year.
Quite often, treatment will consist of a combination of all of the above, depending on such factors as the severity of the problem, the individual’s insurance coverage, whether detox is needed, and the availability of programs. The cost of treatment is the employee’s responsibility. All Federal Employee Health Benefit Plans have some kind of coverage; however, that coverage is limited. The EAP counselor and the employee benefits representative will have information on health benefits coverage. Employees should direct any questions to one of these resources.
After the initial treatment program, the employee may be in follow-up counseling and treatment for an extended period of time, possibly up to a year. This will most likely consist of outpatient counseling, AA meetings, and follow-up sessions with the EAP counselor. It can be very beneficial for the EAP counselor to schedule a back-to-work conference with the employee, the supervisor, and other interested parties such as an employee relations specialist or a counselor from the treatment program. The purpose of this meeting is to discuss the employee’s treatment, the expectations in terms of the employee’s performance and conduct, scheduling concerns in terms of follow-up counseling and AA meetings, and to help get the employee back into the regular work routine.
An important and frustrating facet of treating alcoholism is relapse or a return to drinking. An alcoholic often relapses due to a variety of factors including: inadequate treatment or follow-up, cravings for alcohol that are difficult to control, failure by the alcoholic to follow treatment instructions, failure to change lifestyle, use of other mood altering drugs, and other untreated mental or physical illnesses. Relapses are not always a return to constant drinking and may only be a one time occurrence. However, relapses must be dealt with and seen as a sign to the alcoholic that there are areas of his or her treatment and recovery that need work. Relapse prevention is an area in the treatment field that is receiving increased attention and research. A basic part of any effective treatment program will include relapse prevention activities. Good coordination between the EAP counselor and the treatment program can help the employee deal with and prevent relapse.