DOCONEIT RESUME

ED 148 536 BC 010 271

AUTHOR Bock, George; And OthersTITLE Alcoholism - A High Priority Health Problem. A Report

of the Indian Health Service Task Force onAlcoholism.

INSTITUTION Health Services Administration (DHEW/PHS), Rockville,Md. Indian Health Service.

REPORT NO DHEW-HSA-77-1001Pui2 DATE 72MOTE 25p. ; Not available in hard copy due to use of

colored ink in original document. Reprinted 1976

EDRS PRICE MF-$0.83 Plus Postage. HC Not Available from MIS.DESCRIPTORS *Agencies; Agency Role; *Alcoholism; *American

Indians; Community Involvement; Definitions;Financial Support; *Guides; Health Education; HealthNeeds; *Health Services; Medical Treatment;Organizations (Groups); Planning; PreventiveMedicine; *Program Development; Program Evaluation;Research Needs; Socioeconomic Status

IDENTIFIERS *Indian Health Service

ABSTRACTThree separate reports are included in this document

on American Indian alcoholism. Section I of the document (December1969) outlines the history, nature, extent, and significance ofIndian alcoholism (reporting that the incidence of alcoholism amongIndians is twice that of the national average, low socioeconomicstatus, rather than a physiological propensity, is cited as a majorcause). Section II (February 1970) addresses the problems ofalcoholism prevention, control, and treatment (direct personalservices via both professionals outside the community andnonprofessionals within the community; thorough, coordinated trainingfor those providing services to alcoholics and/or their families;major health education principles and methods; communityrelationships which utilize the Indian Health Service as a catalystfor program development; the importance of data collection, research,and evaluation in any alcoholism program; and a suggested approach toprogram planning, including 12 specific recommendations) . Section III(April 1970) is a reference guide to alcoholism programs andresources (includes a glossary of common words used in literature onalcoholism, short descriptions of a few of the modern methods ofalcoholism treatment, and a list of organizations and agencies whichcan provide information, consultation, and, iu some cases, financialsupport for community alcoholism program development). (JC)

Documents acquired by ERIC include many informal unpublished materials not available from other sources ERIC makes everyeffort to obtain the best copy available. Nevertheless, items of marginal reproducibility are often encountered and this affects thequality of the microfiche and hardcopy reproductions ERIC makes available via the ERIC Document Reproduction Service (EDRS).EDRS is not responsible for the quality of the original document Reproductions supplied by EDRS are the best that can be made fromthe original.

-)

am =IN- MI SWSR INS M1111

MENEM MN .-M11.9111111raw um ammisImMil .11

MINI aims /111111.IMINE PM MI 1111. NMI

me SIM muumuus UM NS NMSi NIS MI NMI1111AINIF NISI OM

-quawr

ma III*. wow roamO / -II MIMI NIROINN rIMAM.MN -"NIEMEN UNE NM

abo-ang JEW INEIisliv MO ow els

a high priority health problem

U S OEPACTME NT OF HEALTHEDUCATION &WELFARENATIONAL INSTITUTE OF

EOUCATION

THIS DOCUMENT HAS BEEN REPRODUCED ExACTcr AS RECEIVED FROMTHE PERSON OR ORGANIZATION ORIGINATLNGL poNTS OF ,,EA, OR OPINIONSSTATED 00 NOT NECESSAR.LY RCPRESENT Dr-, ,clAt NATIONAL

INSTITUTE OFco,cAToN POSITION OR Pt-ft ICY

"PERMISSION TO REPRODUCE THISMATERIAL IN MICROFICHE ONLYHAS BEEN Gr ANTED BY

TO THE EDUCATIONALRESOURCES

INFORMATION CENTER (ERIC) ANCUSERS OF THE ERIC SYSTEM

a report of theIndian Health Service Task Force on Alcoholism

U S DEPARTMENT OF HEALTH, EDUCATION AND WELFAREPublic Health Service

Health Services AdministratiorIndlan Health Service

411111

- AIM

,

ma

am

AM

.

ow

imm

t

r MP

WI

IIIMIN

W

=I

i= NM

NM

ME

MM

II

MO

MS

=I

s

..-

110111,-110.1=1

1111

1/41

MN

II

NM

VW

mt

`NM

,

OM

OM

.'

AIN

E.

awn

isms

um Iwo-

-yr

Em

s

Aim

0111.101=

IIM IME

NI

INN

IMM

I

MN Mr

NM

a high

priority

health

problem

a PO

flOri

a the

Indian

Health

Service

Task

Force

on

Alcoholism

DH

EW

Publication

No

(HS

A)

77 1001

U S DE

PA

RT

ME

NT

OF

HE

ALT

H,

ED

UC

AT

ION

,

AN

D

WE

LFA

RE

Public

Health

Service

Health

Services

Adm

inistration

Indian

Health

Servre

it . ! I E 1,n ; [ f i ,) `,-;ti)

/9 7z.

Pepri

/lied

19 7 4,

FOREWORD

Alcohol is the most abused drug in the United States. As indicated in the First Special Reportto the U S Congress on Alcohol and Health from Secretaries of Health, Education and Welfare,1971, the extent of problems related to alcohol abuse and alcoholism has reached majorproportions, Among American Indians (including Alaska Natives), the ncidence of alcoholism isestimated to be at least two times the national average.

In October 196, the Indian Health Service Task Force was appointed to review the extent ohalcoholism on Indian reservations and c mmunities, evaluate existing programs and resources, andprovide guidelines and plans of action to assist in meeting the problem Task Force members were.

George Bo,:k, N1 D , D:rector, Navajo Area Indian Health Service Chairman,Robert Fortume. M.D Assistant to the Chief, Office of Program Services, HIS

Executive Secretarybert Bergman, M.D , Psychiatrist, Navajo Area

John Bopp, Social Worker, Ft Hall Service Unit.Joseph Exendine, Tribal Affairs Officer, Aberdeen AreaRobert LaFromboise, Health Educator, Flathead Service Unit.Eileen Maynard, Anthropologist, Pine Ridg, service Unit.Sheldon Miller, M D , Psychiatrist, Navttio Area.Ben Prins, M,D , Medical Officer in Charge. Indian Health Center, Da Ice, N:w MexicoSylvia P Rhodes, PHN Supervisor, Santa Fe Service Unit

Section I of the Task FoiLe Report (December 1969), outlines the history, nature, extent andsignificance of alcoholism in the Indian population

Section 2 (February 1970) is addressed to the problems of prevention, control and tieatrnentof alcoholism

Section 3 of the Report (April 1970) is a ieterence guide to alcoholism programs andresources

4dditional program information for the:prevention and control of alcohol abuse and alcoholismis available from the National Institute of Alcohol Abuse and Alcoholism (NIAAA), which wasestablished by Public Law 91-616, the "Comprehensive Alcohol Abuse and Alcoholism Prevention,Treatment and Rehabilitation Act of 1970."

Emery A, Johnson, M.D,Assistant Surgeon GeneralDirector, Indian Health Service

Table of ContentsPage

Section ISummary of background information for development of specific plans ofaction in dealing with alcoholism (December 1969).

Introduction and definition of the problem 1

Historical background[

Alcohol and the Indian todiy.General comments 3The patterns and extent of Indian drinking 3Alcoholism and its effects 4

Factors contributing to alcoholism in Indians:General comments 5Historical-cultural factors . . . 6Psychological-social factors 6

Summary

References

Section 11Problems of prevention, control and treatment of coholism (February1970).

7

7

.

Introduction . . ....... ..... 9

Direct personal services. 9

Training . .. . . - .......... . 12

Health Education 12

Community relat,onships . . 13

Data collection, research, and evaluation . . .. 15

Suggested approach to planning . 15

Section III- Reference guide for Indian tribes and communities wishing to undertakealcoholism projects (April 1970)

Introduction 17

Meaning of common terms related to alcOholism 17 X

Programs for the treatruent and prevention of alcoholism.Medical treatment .`. 18Facilities.. ..... 19Counseling programs. 20Other programs .. . 21

Resources .. 21

v

5

Section 1Sti/Mmary of Background Information forDevelopment of Specific Plans of Action

in Dealing With Alcoholism (December 1969)

INTRODUCTION AND DEFINITION OFTHE PROBLEM

The Indian Health Service considers alcoholism tobe one of the most significant and urgent healthproblems facing the Indian and Alaska Native peopletoday Probably no other condition adversely affectsso many aspects of Indian lite in the United States Itis the policy of the Indian Health Service that servicesand programs for the prevention and comprehensivetreatment of alcoholism be given the highest possiblepriority at all levels of administration.

Alcoholism is an e\ceedingly serious problemeverywhere in the Natiofi, but virtually nowhere is itgetting the attention that it deserves from healthworkers, not to mention other professionals andcommunity leaders Its roots are many and complexIt is called a disease by some, a symptom by others,and apparently is totally ignored by a substantialnumber. Parts of the problem are in the domain ofmany different protessional and non-professionalgroups, yet leadership and the full cooperation andparticipation of all are essential for its effectivecontrol Although health workers have a part to play,perhaps a leading part, alcoholism is no less theresponsibility of the :_rgy, teachers, law enforce-ment officers, courts, welfare agents, social workersand perhaps, most of all, the community itself.Alcoholism is harmful not only to the physical andmental health of individuals, but to family relation-ships, economic functioning and the whole fabric ofsociety It is a problem that demands attack on manyfronts

Alcoholism in the Indian population has certainfeatures which make it a particularly serious problem.This report will attempt to delineate some of theorigins, causes, and characteristics of the problem inthe hope that a clearer understanding of the uniqueaspects of Indian alcoholism will help health profes-sionals to give it the priority it needs and to deal withit more effectively on a local level Indian leadersmore and more are recognizing the gravity of thealcohol problem and usually are agreeable to assistingin every way,

fhe Indian Health Service has defined alcoholismas follows 20

"A disease, or disorder of behavior, characterizedby repeated drinking of alcoholic beverages, whichinterfers with the drinker's health, interpersonalrelations or economic functioning."This definition, modified and cosykiised from that

of the World Health Organizdtion,42 encompasses the

6

total range from alcohol dependence through what isgenerally called problem drinking to repeated mini)..,intoxication, provided that health, family, and othetsocial relations and/or economic functioning areimpaired as a consequence

It is important to recognize that alcoholism maybe considered a disease, in the strict sense, or abehavioral disorder, fhe term alcoholic is commonlyapplied to patients suffering from alcohol addiction,Laennec's cirrhosis, delirium tremens and certainother recognized disease syndromes associated withthe excessive use of alcohol However, the regfilarSaturday night drinker who drings to intoxication,then severely injures himself or others while drivinghome, is less definitely an "alcoholic" in mostpeople's minds, yet he is every hit as serious a healththreat to himself, and what is worse, a threat to thehealth of others. Both types of alcoholism must beaccommodated in the definition and both types mustultimately be dealt with by the Indian Health Serviceand the community.

Alcoholism by the above definition is a costlyproposition in every sense of the word Personalhealth may be impaired by cirrhosis and its compli-cations, neuropsychiat'tic disorders and nutritionaldeficiencies. The majority of accidents, especially thefatal ones, are associated with alcohol, as are nearlyall homicides, assaults, suicides and suicide attemptsamong Indians. The vast majority of all arrests, finesand prison sentences in the Indian population arerelated to alcohol. The loss of personal freedom andproductivity, the break-up of families, the hardshipand humiliation involved are considerable, althoughnot easily measured.

A substantial portion of medical care, welfare andlaw rcement agency costs must be attributeddirect or indirectly to the effects of excessivedrinking. In communities with few enough resourcesalready, such a diversion of funds is particularlyunfortunate.

A great deal of misinformation is abroad con-cerning the subject of Indians and alcohol. Indeed,the "drunken Indian" is one of the most pere:Aentand pernicious stereotypes found in American folkculture today, The attitude that Indians somehowhave an inherent inability to cope with alcohol is

quite prevalent .mong a great many people, includinghealth professionals, clergy, teachers, social workersand police officers, as well as bartenders and, simplyprivate citizens. There are differences, indeed, in thepatterns of alcohol use by some Indians, just as thereare differences among Jews, Englishmen, Irishmen,

and Italians in the manner in which they drink. Suchdifferences include variations in attitudes towarddrinking and drunkenness, in responses to deviantdrinking behavior, in the ways in which young peopleare introduced to alcohol, and the way in which thesocial group acts towards excessive or harmful drink-ing These patterns of behavior for any cultural groupoften have a reasonable historical, social, or economicbasis, No valid evidence is available that Indians diff.rin any way from others in their physiological orconstitutional response t alcohol

HISTORICAL BACKGROUNDMost authorities agree that none of the Indians

north of Mexico knew distilled aicoholic drinks priorto the arrival of the Europeans in the 16th and 17thcentury although there is evidence that some tribesnude fermented beers or wine, which were usuallyemployed o n l y n ceremonies and religiousrituals 15,22,3-7,41

The Indians, Eskimos and, Aleuts of North Amer-ica were therefore quite unprepared to deal with thedistilled beverages the early explorers and tradersCommonly ofkred them as a sign of friendship 41 Itis not surprising that sonic declined to drink somespat It out in disgust and others accepted 't and drankto the point of intoxication Alcohol was creditedwith supernatural powers anion certain tribes in the16th, 17th and 18th centuries because it releasedinhibitions, dulled pain and at the extreme, induLedoblivion the same reasons many people find alcoholhelpful today

Alconolic beverages soon beLa'ine Common alongthe ..tntire frontier I he French I nglish, Dutch andSpanisq all used it as an enticement to alliance or asdp article of trade In the northern and easternforests, whiskey played a dominant part in the earlyactivities of the fur-traders, being used chiefly as areward on special occasions such as the end of .1

successful season of trappingMost of the 12spectable traders discouraged the use

of alcohol as regular pay ment for furs partly hecau ,c

drinking obvious, lowered productivity Hit partlyalso because the) timid see all too clearly howdisruptive it ,ould he in a society with po traditionalmeans of coping w Ifni it 41

Xs .0111petition tor furs increased, howocr someIndef.s were led to use All ()1101 as an e\111.1 111d11.0-111ent to the Indians Before long the wInsi,ev tradebecame something of in end in 'kelt since the moreunscrupulous traders found OW the desire f, r strongdrink led s Indt,ls to give up their nr st valualdepossession, I he plooal ion %villa inevitahh, result-ed irons such activity is clearly described by II r On %I

hill,1nderi"It (the liquor I Ais ref inicd will the most s!, stein-ati, fraud tten aiountmg to sheet esc flange ofnothing for Hit goo,ls of the Indians It was thepolio, of the slue w,l tr oter to-st to get his vii tonso intomcated that he no longer drive a god

irgalP I he Indl heoilltIrle more and 1110ree,lee,k 1,0 imuor would yleid up ill he possessedtor an .IddIn ri11,upor iv.,) 4"

The drink was usually a cheap form of brandy,ram or whiskey, not only diluted but often adulter-ated with drugs, _Lich as laudanum. Some justified theadded opiate on the "humane" grounds that it woulddiminish the likelihood of destructive aggressionwhile the Indians were drunk 18

Indeed, aggressive acts appeared to be commonoutcome of heip'y drinking bouts A number of earlywriters noted the terrible effects which stro g liquorhad on an Indian community. The general patternconsisted of rapid drinking by the men until utterdrunkenness ensued or until the supply of alcoholWas exhausted. Verbl abuse of one another thenoLenrred followed by fist fights and linally armedviolence.6' 17' 22 During such episodes, womenusually tried to stay clear of the men, often gatheringup all the weapons they could find and hiding themalong with their children in the woods until theeffects of the liquor had worn off and it was sate toreturn. They might Lome back to find the camp ashambles, with some ni'en dead, some maimed and therest asieep.22 Of course this behavior Has not charac-teristic of all Indian communities, nor of all indivi-duals, even in the eastern forests, but the generalpattern was apparently widespread

Most tribes had no traditional way of coping withsuch a problem There was no system tor punishingcrimes committed while a man was drunk, no matterhow terrible, since the drunken nun was not consid-ered in control of his actions 3,30 [his uncertaintyregarding how the community should react to drunk-enness is a key historical point which is relevant tocontemporary attitudes

Defeats in war, torced relocation of tribes tar fromtheir traditional homes. the extermination of thebuffalo and other game, the breakup of families, andconstant harassment from settlers and soldiers allcontributed to the demoralization of these proudindependent people In tome areas hunters wereforcibly turned into farmers, an activity which washumiliating and wholly distasteful to them In otherareas the poor reservation land permitted no usefulactivity at all and the Indians were forced to live onthe Indian Agent's dole Wherever there were Indianshowever there usually were unscrupulous bootleggerswho were willing to help them forget t Hut. troubles, itonly briefly, at Cie price of their It:W remainingpossession,

In the 1 dr North, where hunting still W OS a V.1,1, oflife and there were neither soldiers nor reservations,the %%haler, and others foand a ready market forliquor Hew too disaster in form of starvation wassometimes the result, since a whole fishing or huntingsea Ain might he dpsipated m drunkenness

As earl' a', the I 7th Century, thoughtful Indianleaders recognized the real and potential gravity ofthe al ohid prohlem Many requested the traders andothers not to permit liquor to he sold to their people,though usually their efforts were in vain 411 Becauseof the mounting seriousness the alcohol problemduring the ISO) and l'Ith centuries several Indianreligious prophets, notahly the Handsomelake and the Paiute Wevcoka advocated a return tothin' old ways including total ahctention troll alcohol

The eontempeary Native American Church advo-Late, some of the saint: principles

An Indian (hiet Little furtle, appealed directly toPresident fhomas Jefferson in January 1802 Amongother things, he pointed out that Indians were an,iidustrious people kept poor by liquor and that theyhad become less numerous and less happy since theintroduction Of this "fatal poison Partly in respcnseto Little Turtle's request for the pr( ht hit ion of liquorsales to Indians, President Jefferson less than a

montt later, called upor Congress to take steps tocontrol the liquor trat "rhese people,- he pointedout, "are be...oming scr} sensible of the banefuleffects produced on their morale, their health, andemsterwe, b} the abuse of ardent spirits and some ofthem earnestly desire a prohibition of that articletrom being earned among them ( ongress actedpromptly, authorizing the President "to present ofrestrain the sending or distributing of spirituousliquor among all or any (i1 the said Indian

rIbeS!linty y,irs later on July 9, 1 832, ( ongress

passed the first general statutory prohibition onliquor trait based on the constitutional authority01 Congress to regulate comment: with the Indian

ribes I he law, as expanded user the years, coveredsale gift, transportation and possession of liquor onresersations or sometimes adjoining Indian land,without reeard to State boundaries Later ale, beerand wine were added to the list of prohibi ed drinksOther. restilet ions on liquor Raffle were meorporatedinto individuai treaties and agreements with differenttribes

these laws were originally designed mainly toprotect the Indians from cruel exploitation by theunsavory whiskey trader; Both the (iovernment andthe tribal leaders recognised the need tot sue hcontrol though undoubtedly' from somewhat (M-icron points of slew I Moreement of these laws wasneset markedly su(cesstul however sine(' bootleggingand smuggling could hardly he ettectively controlledIII the vast thinly populated Indian country by thefew enforcement offieers asailable for sueli duty1 here is esen some es idence that certain tiosernmnt,dticials issue() spirits to the Indians as part of them-reg iations

13y ilk' 20th century the Indian liquor laws wereincheasingls re 'ignited especially by the Indiansthem-sc. a, being frankls Mscriminatois IthoughIndians had become full citizens under the law ill

they were not permuted to bus drinktrills atter Prohibition repe 'lied in t i:; I hehi,ntlegiieu a'. ',tor( (ontinticd to tl,it nsh Not,ibs did the India i hast to pas tat mot ° theirdrinks firm -rhos they tiso hid hi drunk ,,ter11\

beinJ, it ' onprJsond Hind the sees. 1, 1:6 'ne m Itt,tC,t,,,tti

;'t OW 101. ,C111 Ind kOlit1;4

1,1t01,.

It It r, t, ,, t Ulf, 11,1P1.'.1:,,,ti Hid it.1 'tit t t I In t \.11,1,11kttlt 1 ,n Ili,

t t , I h, t%. I uh.tllsI ihr I Her

1- e i asine ti;.11 to the

individual States for off-reservation communities andto Tribal Councils for reservation lands. A number ofreservations still retain local restrictive laws of theirown, some forbidding liquor entirely and otherscontrolling or monopolizing its sale and distribution.

ALCOHOL AND THE INDIAN TODAY

General Commentsthis section will attempt to describe some of the

general patterns of drinking in the Indian populationand then outline the extent to which excessivedrinking has adversely affected health, social andeconomic well-being

the sources of information on alcohol usage arenumerous but of unequal quality and ti set ulnessVital statistics, hospital records, court records, socialservice and welfare records, traffic accident reportsand liquor sales are examples of records which can beand have been used for the determination of theextent and patterns of alcohol use and abuse. Nosingle agency collects information on all aspots ofthe problem among Indians however nor does any-one agency have ,cress to all sources of informationwhich :nay be asailable.

Measurement of the patterns of drinking and theextent of alcoholism in any population is difficult,esen under the most favorable circumstances thedifficulties are greatly compounded when dealingwith the Indian population, however, be.ause of thesear.hty ut careful studies and the widespread mis-conceptions and bias which surround the sutnect ofIndians and alcohol

Most people will agree that alcoholism is a majorproblem among Indians but will disagree on its natureand size. I Mortunately those with the closesttontatt with Indians are often the least scientific inthen judgments, while those who set up a rigorousstudy design occasionally have instillment knowledgeot ;ndians and their ways Adding to the tintare (littering definitions of the problem, differentgoals in the (.0110(.1 on of data and perhaps mostimportantly, (littering patterns of drinking in thesarious Indian groups I he North Ameriean Indiansare a heterogeneous population with a great diseisityof eultures, attitude, and religious persuasions

It is necessary, theretore, to he cautious Iii theinto pietation of the data ss lit II li)11,,w In general,reasonably valid information is presented for a

spec die plat t and tot a specific time \ II the figureshave problems of rehabilds ,1 validity Ind noneshould be the basis for genemlifat ion to Ihr Indijuropulat Ion at large I hes are intended rather to givea general view ui i he evt(nt of the ploblcin And itnt ois manifestations

The Pattern's and LAtent of Indian Drinking

In p1,1111, u,sent it ittil II pcl,C111 tt; thep ,tvel 11,011., I hisnum Ito; insludt.d per,cnt Hit t, .11.1

pi I .'!it I 'he In r, 1 .1,1, 'Jo

tie "Il it I lit' in II in,i rt. I, , nil tet

1, 11111k, I . wtitIt t 1'11,111) I I1C

figures were 93 percent and 85 percent respectivelyAfter forty there was a marked decline in thepercentage of women drinking and a smaller declinefor the men

In the 15-17 age groups, 50 percent reporteddrinking, 60 percent of the boys and 40 percent ofthe girls Drinking began between the ages of 9 and17, with an average of 15'r.i Ot those under 17, 88percent reported that most of their friends drank Inthis study, 31 percent of the total sample wereabstainers, 45 percent drank less often than 3 times aweek and 24 percent drank three or more times aweek Effdence was presented to show that bothsexes, but especially the women, were drinking morein this generation than in the last

In' a small Great Lakes Indian community, onlysewn out of 74 persons over I8 1,111 classifiedc.assi.le... asnon -d' nkers or moderate drinkers Most youthsbegan drinking between the ages of 14-16 13

In a study ot high school students in a PlainsIrihe, 84 percent of the boys and 76 percent of the

girls claimed they drank. I lurty-seven percentclaimed they drank trequently.29

Among Southwestern Indians hospitallied for vari-ous reasons, 78 percent ot men and 48 percent otwomen described themselves as drinkers 'Iwo thirdsof these men and one half of the women consideredthemselves "heavy drinkers the percentage ofdrinkers carted in different tribes trom 73 percent to80 percent in the me% and from 20 percent to 08percent in the women

in a study ot an Indian village in the Southwestpoor to repeal of the liquor laws, 105 out 01 014adults were "aced to be regular drinkers and abouthalt were estimated to he at least occasional drinkersI he male to temalc ratio was 3 to I Atter repeal thepattern did nor change noticeably I s

11though tt a unsate to uneralite, what Sewstudies that have been done on drinking patterns inIndians trace a certain consistency Drinking is wide-spread reachr4 its peak trequei cy in the agegroups 25-44 %We, usually outnurnho kindlesratio ot at least to I 13,, t he age ot 15, most youth,ot both sines hive tried alcohol and time arcdrinking regularly Atter the age of 40, there isnoticeable &dm: in the number of drinkers and theextent 01 drinking Man\ Indians ot all ages are totalabstainers

I or the twist part drinking ,,.curs in peer groupsrit extended iamb groups 11,01101,,, heverdgcs, 'hostoften beer and wine, are treely shared within thegroup lirinking usually N associated with happy ortest lye ILL ash iris, stir h as weekend soc tat evert s,pay-day, pow-wows, ot the end of a work seaonIntoxication is a comfit in but be no Means int:citableoutcome of these epiydes

AlColitilisM and its Effectshe odw,,e curet, alcohol 1.1+.'

be approached thiotrah an examination ot generalmortality and hospitalaeation statistics, specialstudies, and welfare, court and police records

In calendar year 1'0,7, there were 183 Indiandeaths primarily attributed to alcoholism, alcohhc

psychosis, or cirrhosis with alcoholism tn the 24Federal reservation States, for an overall mortalityrate of 33.1/100,000. These deaths made up 3 8percent of all Indian and Alaska Native deaths thatyear. A substantial but unknown percentage of the1,000 other Indian deaths from accidents were duedirectly or indirectly to the problem of excessivedrinking.2I

In a Lower Plateau tribe, there were 50 deathsdirectly asso:lated with drinking and 5 others indi-rectly associated with drinking in a population of1,581 in an 11 year period Ot the 61 deaths, 47 weremales and 14 ,.re females The cause ot deathincluded 12 --ides, 12 "over-consumption otalcohol," I I auto accidents, 8 other accidents,murders and 12 miscellaneuas 3 5 On the same reser-vation, the Service Unit Director stater th-,1 38percent of all hospital days for 1967 were attributedto the use of alchol

In a northern plains community of 3,500 therehave been 42 deaths attributed to excessive drinkingin a 4 yea: period. Ten of these were homicides andanother six were suicides 9

A study ot adult Indian autopsies in the Southwestshowed an incidem e ot tatty, nutritional cirrhosis ot12 8 percent, about tour times the national averageThis condition may be related, though not neces-sarily to excessive drinking."

In an Indian community ot 2,300 persons in thenorthwest, a register ot accidents and their relation todrinking was kept in fiscal year 1908 Forty-five outof 50 auto accident injuries, 56 out of 181 otheraccidental injuries, 30 out ot 32 tights involvinginjury and all 3i suicide attempts were related todrinking I hese figures were telt by the WS stall tobe conservatives In a study of suicide in a south-western Indian tribe, 47 percent ot cases invokedintoxication at the time ot or Just bet ore the act

Since deaths must 11111111.1tel he assigned to asmgle cans. only many .1 victim ot chronic alcoholismor acute intoxication is listed as a death tromaccident suicide homicide, bronchopneumonia or ahost ot other causes Ilospitahration data 11.1e many01 the same limitations especially it only the primaryor immediate cause ot hospttaltiation is consideredMany hospitals in tact, will not admit a patientsintering from the Oleos ot alcohol unless there isanother Justification tor admission s well Diagnosticfashions are another source ot contusion in this areallospitdkedtion rates will he dtfected by the bedscleanable, local hospital policy, recognition ot therelat lye importance (if alcohol', in as a healt 0 problemand the attitudes of the local people toward theirhospital

For the period July I. 1907 through June 30,1Q68, there were 1,415 discharges from all IndianI !edit h Service and contract hospitals with theprimary diagnosis of simple alcohol mtoxication andanother 1372 discharges for the various other formsot alcoholism I hese totals account tot I 7 percentand 16 percent, respectively, ot the total dischargesfrom these hospitals For the Indian Ilealth ServiceHospitals in the Window Rock, Phoenix, Aberdeenand Billings Areas in the period July I, 1968 through

December 31, 1968, when more detailed informationwas available, simple intoxication was listed as oned,agnosis on 3 2 percent of all discharges and otherforms of alcoholism on another I 3 percent Formales aged 20-44, where the problem of alcoholism isprimarily concentrated, these figures become 12 4percent and 5 0 percent respectively The overall sexrat o 114'1.1 for discharges for which simple intoxi

ition was listed .vas 2.51/1 00 For cirrhosis withalcoholism the sex ratio was 0,87 I ,00 and forocitnum treiliens it was 5.61' I 00

An overall view of the age and sex distributionpatterns for simple intoxi, ation and cirrhosis n hestshown by a table of discharge rates which .ire dcrisedtrom primary discharges from all WS and contracthosp,tals for trswl Scar I 968

I Alit I I IhsLharge Rates per thousand population) tc SimpleInt )xication & Cirrhosis. with Alt.ohohsth, all IIIS and ContractHospitals, tub, 1, 1967 through June 10, 1968

Xge Intosit dhoti ( irrhosis with AlcoholismM I Total M Tr Tot

0-14 2 0(f* 0I1c 1,i 2 4 0 1620-'4 8 ; 28 65 OW OW 0 1125 14 1 6 5 95 14 2h 2015 -44 I' 2 12 1

29 16 3245_54 10 0 1 et 71 24 v6 i5:5_64 ; 1 7 41 1 X 17 1865 2 1 0 2 0 0 5 02 04

\ S I 2 0 1 5 0 7 0 9 0 ft

1 hp. table clea,h, shows for tx0h sews the gradual Increase inrotes Null age. a peaking in the age g up 15-44 and a gradualdecline thereat ter. the sex rano for situ* intoxication remainsLurk _onstont with age at an average of 2.55/1 00, whereas for,urho is with alcoholism the overall sex rieto is reversed at0 78'1 00 -1

*numbers too small for tat, of a relia6te rate

I he records of the local pont e, courts and prisonsprovide one of the most useful and graphic sources ofinformation on the extent and impact of altholproblems in a population In many Indian com-munities, it is often the only source which has beenexplored In interpreting such information, however,a word of caution is necessary Police and courts,whet"' r 1rihal, municyal, county, State or Federal,air inclined to deal more harshly with Indians whoare found intoxicated than they would with non-Indians. An Indian usually runs a tar greater risk ofbeing arrested and locked up for drunkenness than anon- Indian would under similar circumstances Arrestand conviction figures for Indians, therefore, aresom,what inflated when compared with those of thegent ral population. I ven when these allowances aremade, however, the figures are still an impressivetestimony not only to the extent 01 drinking but tothe social and family disruption, the loss of pro-ductiveness, the loss of self-respect, and the accidentsand ill health caused by the excessive use of alcohol.

I he figures that follow are chosen to he fairly

representative of a considerable mass of availableinformat

In l'460, Indians were arrester 12,2 times asfrequently for alcohol-related offenses as the U.S.population generally. Whereas 43 percent of allarrests in the U S were related to drinking, thecomparable figure for Indians was 76 percent. Drunk-enness triune accounted for 71 percent of all Indianarrests. I he arrest rate for non-alcohol related of-fenses was found to he only dightly above the U Sav erage. 16

In a central plains reservation, there were in oneyear 2585 arrests for ''disorderly conduit withdrunkenness'' in a population of 4600 adults Overthree year period, 44 percent of males and 21 percentof temales had been arreskd at least once for adrinking-connected ottense Of these, 2/3 had beenarrested more th..n once and /10 more than 10

times. Of all juvenile offender, (tinder 18) one-quarter had been booked at least once for disorderlyconduct or a drunken driving charge Thirteen per-cent of the entire population aged 15-17 had beenhooked at least once on a charge relates' to drink-

In the Southwest, i reservation lept rted that 70percent of crones on the reservation were alcohol-related in an ot t-reservation town nearby there were750 arrests per month for drunkenness, 90 percent ofwhich were Ildians.1

In one State Penitentiary, Indians made up 34percent of the inmates \chi re.). in the State theycomprised only' S percent of the population. A largemajority of the crones were committed while underthe influence of alcohol, 6 In 1959, all 36 Indianprisoner .t a Federal prison had been convicted ofmurder or manslaughter which had occurred whilethe individual was intoxicated 2

On a northern plains reservation with a totalpopulation of 3500, there were in fiscal year 1068,1769 arrests resulting front excessive drinking, 10percent of them in juveniles IQ Further in thenorthwest, there were 445 disorderly conduct arrestsand 72 liquor possession arrests in one year inpopulation of 2300 Male addlts outnumbered bothfemale adults and juveniles by a 1.010 of about 5 I

The excessive use of alcohol clearly has a tre-mendous impact not only tin the lives of individualIndians and their families, but on the tangible andintangible resources of their communities Nearlyevery person, whether a drinker or not, is touched inome way by alcoholism A poignant example comes

front a reservation where a recent survey of highschool students showed that no 1-ss than 339 out of350 persons disliked living in their own communitybecause of excessive drinkingli

FACI ORS CONTRIBUTING TOALCOHOLISM IN INDIANS

General CommentsTo devise effective measures for the prevention

and control of alcoholism requires some under-standing of the roots and causes of the Various

manifestations of harmful drinking in the Indianpopulation. It is inevitable that any discussion ofcontributing factors will he an oversimplification ofwhat is an exceedingly complex problem with manyramifications in different tribes, communities andindividuals Recognizing these limitations however, itmay still be useful to make "some comments whichhive sonic general acceptance among many qualifiedpersons, including Indian leaders themselves.

These comment will he set forth. under two broadheadings historical-cultural tactor; and socialpsychological factors

Historical-cultural factorsAs pointed out above, alcoholic beverages arc

fairly recent addition to the experience ot theAmerican Indian people Until the coming ot theEuropeans. Indians had very little or no contact withalcoholic beverages, and therefore had no culturalmeans of dealing with them in their everyday hte Incontrast, western culture has for thousands of years,used alcohol for s rt. bus and therapeuticpurposes. There has in shor, been more time inwestern culture-to establish the Olace and regulate theuse of this substance more tully

With this lack of cultural norms in the use ofalcohol, sorpe dangerous patterns of drinking havedeveloped to Indian groups 1 wo patterns haledeveloped which particularly increase the difficultiesof those who are potential problem drinkers oralcohotics first is the use of alcohol as a focus forgroups to develop. this in itselt would not he harmfulexcept that such drinking in the group often leads tothe pattern of drinking until the supply of alcohol isexhausted or 'until the members of the group havebecome intoxicated A great deal of sharing ofalcohol exists within these groups, with strong pres-sures on tb! members both to he generous and toaccept the generosity of others Many problemdrinkers question whether they wi I have any friendsat all it they do not join in the drinking group It isnot unusual to hear a persor attempting to give upalcohol ask the treating physician where he will findfriends when he no longer drinks, since those withwhom he regulirly associates and shares other inter-ests are usually drinkers

Besides the function of alcohol to form groups.there is a second common and potentially dangeroususe. Behavior which occurs under the influence ofalcohol, especially aggressive behavior. is somehowless daniagtng to the individual in the eyes of theothers The same type of behavior while the indi-i,idual is sober would result in discipline and dis-approval on the part of other people. but is urn-monly tolerated with drinking

Psychological-social factors

Uncertainties in social relationships may result inpersonality problems in later life, of which onemanifestation may be excessive drinking 1 he causesof any person's drinking problem are highly indi-vidual and vary as much as do the personalities of theproblem drinkers Certain common Indian psycho-

0

logtcal problems, however, seem to contribute par-ticularly to alcoholism For many Indian problemdrinkers, the use of alcohol seems to tic their meansof dealing with anger and frustration. Drunkennessreleases and sometimes redirects pent-up anger. Insonic cases the anger origtnates in the feelings offrustration, worthlessness ane helplessness derivedfrom a real or imagined lack of autonomy. Many ofthese attitudes are related to problems of employ-ment, unemployment and de ndence on welfareassistance. The person who has no job at all has verylittle oppoitunity to prove him elf. his problem maybe compounded, however, if his wife is either thebreadwinner in the family or occupies a lob which ticsa lugher status and a higher income than tne ones towhich he can aspire. The entharr..ssment and angerwhich many such men feel may tnen be expressed iitexcessive drinking.

In general, the average employed Indian male findshimself working in low status, relatively menial Jas.in which it is impossible to assert himself in anymeaningful way. fie often gets the fCeling that peopledo not expect him to be able to give high qualityperformance, that they expect him to be unreliableand irresponsible An individual with this type ofpressure upon him may have very hal: open to himin most Indian communities except the solace andfellowship of the drinking group

What is true for the average non-alcoholic becomeshoubly so for the individual who has already had aproblem with a'cohol For him the available jobs areeven fewer, and the income lower. his job security isoften extremely uncertain since such people are hiredonly in temporary and menial jobs. In sonic casesthere seems to he little advantage in working asopposed to accenting welfare assistanee, in tact, thewelfare check might even he a more reliable source ofincome.

Many new industries coming onto the reservationemploy only women leaving the man at home withlittle responsibility and little opportunity to he theleader of the family. When men are employed theyoften work at the same jobs as women, creating stillanother unhealthy situation for the adult male. Theresult is the lowering of the man's teelings abouthimself as well as a mounting angry feelirg about hiswife and his general position in the world Suchleehings can certainly contribute to the onset ofdrinking, which in turn may lead to the breakup offamily relationships and a resulting damage to thedevelopment of the children within the family.Women of course are also subjected to many stresses,not the least of which are the tensions which mayresult from an alcoholic husband. In general, how-ever, the woman, because of her useful and tradi-tional role in rearing the family, is usually less at riskfor the development of alcoholism than the man inmost Indiin communities.

Sonic individual Indians and their families. oftenassisted by Government agencies, leave the reser-vation to find work in urban areas. Many arecompletely successful in making the adjustment andlead normal productive lives For others, however, theeliaage of environment brings riw stresses in addition

to the old. Cut off from their (annual surroundingsand their circle of friends and relatives, a few Indiansdo not successfully adapt to urban living Manyreturn home even more discouraged, while' othersdrift into the slum, sections of the city whereincreasingly h.rmful drinking may he the outcome "3

A final point is the lack of autonomy manyIndians fe,e1 in dealing with the resources theyconsider to be then right, such as land holdings orfunds held in trust, Restrictions on the Inialan': use otthese resources may also be a factor leading to angerand trustr..ition ind may contribute further to theIndian's teeling of powerlessness.

Although all of the fa, tors just mentioned aredamaging to adults, their effect on the adolescent andthe child growing op in such a tanull may he evenworse The normal development of any adolescentboy or girl depends to a large degree of the modelthat the parent piesent, to the child, When adoles-cents and children see the powerlessness, and the lackof self-determination and autonomy in their pare-itsand neighbors, which have developed as a result of

crcumstances. they tind it difficult tol'findan adult with whom they can ident,ty. The resultingrustration and anger which a child must ex pertein

often seem to find thir relief in thc use of alcoholicbee crages. lie begins to teel the same frustration andsense ot inadequacy tukit tie sees in many of theadults surrounding him

Although the extent to which adverse psychologi-cal and socio-economic conditions in Indian com-munities toster excessive drinking should not heunderestimated, it would be wrong to close thissection without reference to the tarot that there aremany features of Indian life and culture which arereal strengths. Solid tamely life, religion, and a

sometimes extraordinary ability tp bear physical andpsychological hardship are qualities which help mostIndians io hear successfully the very real stresses toulna they are subjected in their daily lives.

Without these strengths'it Is quite possible thatalcoholism might he an even greater threat to healthant well -being ot the Indian people

SUMMARY

Alcoholism is one of the most serious healthproblems facing the Indian people today This fact isnow clearly recognized both by Indian leaders and bythe Indian Health Service

Historically, alcohol was introduced into mostIndian cultures from the outside, among a peoplewho had no traditional way of coping with it. 1 heeffects on health, family relationships and traditionalsociety were profound and in some cases disastrousPartly due to the efforts ot the Indians themselves,the Fed (,overnment banned the sale ot alcoholicdrinks to Indians trom I M02 to 1953, although liquoralways found its way, with the help ot bootleggers, tothose who wanted it Since 1953, the sale ot liquor toIndians has been a State or local tribal matter.

The adverse eftects of alcoholism in the Indianpopulation today are generally telt to be considerable

but valid intormation is scarce Special surveys havedocumented that the prevalence of drinking is high inmany communities, that drinking is primarily a socialactivity and that intoxication is the common but byno means inevitable, outcome Probably a majority ofsuicides, murders, accidental deaths and injuries areassociated with excessive drinking, as are many casesof infection, cirrhosis and malnutrition, By tar themajority of arrests, fines id imprisonments inIndians are for drinking or are the results ot drinkingThe associated loss of productivity and the resultingabnormal social adjustments are by-products of con-siderable importance

Like most Americans, Indians usually have mixedfeelings about their relationship to alcohol. Drinkingto excess is not condoned but neither is it criticisedby, many Indians, so long as no harm is done toothers. Mans others feel that alcohol should heentirely banned from sale or distribution in Indiancommunities,

Alcoholism in Indians has in general many under-lying causes, It is a means ot coping with feelings otanger, frustration or boredom, all of which are relatedto the position in which man5i Indians find them-selves today, Interiority feelings about their lack ofeducation, meaningful employment, status and eco-nomic autonomy which are characteristic of manyIndian groups, are expressed in excessive drinking,These features oi modern Indian lite particularlyafte..t the adult men and adolescei, i both sexesThe latter group are further faced with uniqueproblems in both the home and school environment,such as the breakup of family relationships (often due

'to drinking) and the disparagement in the schools oftheir parents' way ' lite.

Alcoholism, tneic.ore. is a problem which deservesthe best efforts of the Indian Health Service staffworking not alone, but to conjunction with otheragencies or groups who are concerned, and especiallywith the Indian people themselves, who more andmore recogn.ze the urgency of the situation

REFERENCES

In addition to the references cited in the text, thisbibliography contains a number of other selectedarticles of interest for further study on Indianalcoholism. A copy of each ot these items is availableon loan to Indian Health Service staff by contactingthe Lxecutive Secretary Indian Health Service laForce on Alcoholism Indian Health Service Head-quarters.

1 Armentrout, I) t' Personal Communication, 19682. Baker, J. L Indians, Alcohol and Homicide, J Social

Therapy 5 )70.275, 19593 Bales, R ! Cultural Differences in Rates of Alcoholism.

in Drinking and Into' reaturn, Rutgers ('enter for AlcoholStudies, New Brunswick, N J., 1959

4, Berreman, G Drinking Patterns of the Aleuts, QuartJ Stud, Alcohol 17 503-514, 1956,

5 Bopp, J Personal Comniunication, Dec 16,19686 Carpenter, 1 S Alcohol in the Iroquois Dream Quest,

liner J Psvcluat, 116 148-151,1959

12

7 Cohen, I S. Handbook of Federal Indian Law, Depart-ment of the Interior, Office of the Solicitor, Washington. D.( 1944, pp. 352-3578 Curley. R T Drinking Patterns of the Mescalero

Apache, Quart J Stud Alcohol 28 116-131, 19679 Devereu , G I unction of Alcohol in Mohave Society,

Quart J Stud Alcohol 9 207-251. 1948.10 Dozier, I P. Problem Drinking Among Amc...canIndians. The Role of Sociocultural Depnvation, Quart. J.Stud /M oho, 27 72-87, 196611.1 erguson. 1 N. Navaho Drinking Some TentativeHy potheses. Human Orgammtron 27 159-167, 196812 Graves, I' D Acculturation. Access and Alcohol in afn-F thmc Community, liner -Ihthrop 69 306-321. 1967.I 1 Hamer. 1 II Acculturation Stress an 1 the I unctions ofAl,ohol Among the Forest Potawatomi, 0,..11,,,hol 26 285-302. 196514 Hawthorne. II 1) . Belshays, ( . S , Jan I fieIndians of British Columbia and Alcohol, Mcohousrn Review2 10-14,1957.15. Heath. I) 13 Prohibition and Post-Repeal DrinkingPatterns Among the Navajo, Qua; t. J Stud Alcohol25 119-135,196416 llonigmann, J J llonigmann. I Drinking in an Indian-\ bite Community, Quart 1 Stud 11,ohol S 575-619, 194517 Dorton, I) the i unction of Alcohol in PrimitiveSocieties A Criss - Cultural Study. Quart. J Si. l Alcohol4 199-220, 194318 Hyde, 0 1 Red (loiid.r 1.olk ,.1 Ihstort of the OglalaSioux. Indians, University of Oklahoma Press, Norman. 193719. Indian Health Seance, Billings Area Indian Vital Statis-tics for 'sears 1%4-1%7, Unpublished Report.20 Indian Health Service Prelimman Report 01 the IndianHealth Service lask I (m..: on Alcoholism, 1)111 W, IISMIIA,II1S, Jan i96921 Indian Health SrviLe Program Analysis Branch, Speciallabulations 196922 Jenness. I) /7/, Indian% o/ Canada. Nat Museum ofl anada hull 65, Antlu,,pologu al Series No 15, Queen'sPrinter, Ottawa I °6323 l tattier R I Lorinci A II Alcoholism Ind Addictionin I fbamred Sioux Indians, iitnt.:1 Thelon'. pp 530-541,()A 196724 1 emelt I M AI( 01101 and the Not' huest Coasi Indians,I on, rsit tali! NMI rnons (ulture S, 2 303-406, 195425 Lemert, I .1 the Use of Alcohol .1 three Salfsh Indiantribes, Quart J Stud 16011ol 19 90-107. 1958

26. Levy. 1. E.. Navajo Suicide, Human Organization24 308-318, 1965.27. Loeb. E. M.. Primitive Intoxicants, Quart. J StudAlcohol 4 387-398, 1943.28. Mackay, D.. The Honorable Compant, A History of theHudson's Ray Company, McClelland ,and Stewart, Ltd..Toronto. 1966.29. Maynard, E. Relationship of Drinking to SocioeconomicFactors among Indians in the Pine Ridge Reservation, aPreliminary Report. Part I. Background. (Unpublished Study.1968)30. Peckham, H. H.. Pontiac and the Indian Uprising. Univer.of Chicago Press, Chicago, 1147.31. Reichenbach, D. D Autopsy Incidence of DiseaseAmong Southwestern American Indians, AM,I Archives ofPathology 84 81-86, 1967.32. Rhodes. S.. Personal Commuiucation. Dec. 14, 1968.33. &ward. R. 1 Effects of Disulfiram Therapy on Relation-ships within the Navajo Drinking Group. Quart. J Stud..4lchol 29 909-916. 196834. Sievers, M L Cigarette and Alcohol Usage by South-western American Indians, Amer J. Publ. Health 58 71-82,1968.35. Slater. 4. D . A Stily of the Extent and Costs ofExcessive Drinking on the- Enttah-Ouray Indian Reservation(Unpubl. study, 1967).36. Stewart, 0 Questions Regarding American Indian Crimi-nality, Human Organization 23 61-66. 196437. Underhill, R Red Man's Religion, Frover. of ChicagoPress. Chicago. III.. 1965.38. Whittaker. 1 0. Alcohol and the Standing Rock SiouxTribe. I. The Pa n of Drinking, Quart. ! Stud /v.ohol23 468-479, 1962.39. Whittaker. 1 0 Alcohol and The Standing Rock 5.,iixTribe, II. Psychodynamic and Cultural Factors in Drinking,Quart J. Stud Alcohol 24 80-90, 1963.40. Winkler. A M Drinking on the American I rontier.Quart J. Stud Alcohol 29 413-445. 1968.41 Vi'issler (' Indians of the United States, Four Centuriesof Their history and Culture, Doubleday & Co Inc. GardenCity. N Y , 194042. World Health Organization. Report of the First Session ofthe Alcoholism Subcommittee, Expert Committec on MentalHealth, W110 Tech, Rep. Ser No 42. Sept . 1951

8 13

Section IIProblems of Prevention, Control andTreatment of Alcoholism (February 1970)

INTRODUCTION

The Indian Health Service Task Force on Alcohol-ISM has prepared the present work as a guide to thedevelopment of more meaningful programs to dealwith alcoholism at the local or Service Unit level, It ismeant to assist health professionals to provide moreeffective services both to individuals and to com-munities with alcohol problems.

Most Service Unit leaders have had relatively littleexperience in dealing with alcoholism I'ven the besttrained physicians usually have not seen more than afew cases of Ors or acute intoxication, generallyassociated with injury in hospital emergency rooms.where the prevailing staff attitude is generally unsym-pathetic Social workers, although familiar with thechronic alcoholic, often have an equally limitedopportunity to see the ill patient. Neither has muchchance to deal with the broad community aspects ofalcoholism or has tried to devise a program to combatit In addition, no matter how experienced inalcoholism Service Unit staff might be. they areusually unprepared for some of the patterns ofdrinking seen in Indian communities.

This guide, therefore, presents a brief outline ofhow a Service Unit might approach the problem ofalcoholism in an Indian community.

It attempts to provide a balanced view betweenthe comprehensive treatment of the individual andthe broader community aspects of the problem, suchas education,, training, planning and program develop-ment. A truly successful program must contain all ofthese components in some measure

The Task Force is well aware of the limitations ofsuch a guide. Despite superficial similarities, everyIndian community, like every other community, isunique and requires a careful assessment of localattitudes, resources, and many other favors before aprogram can be successfully developed Service Unitsalso, have vastly differing resources and hence capa-bilities for action On the other hand, certain basicpm, tples underlie what the Task Force believes is anadequate alcoholism program in any area. The detailsmust in every case be worked out conjointly by theService Unit, the Tribe, and the community.

DIRECT PERSONAL SERVICES

Alcoholism is very much a community affair andthe resources of many agencies, groups, and individ-uals must be mobilized for its effective control. Inmost Indian communities, however, the IHS is theonly resource which is equipped to provide directpersonal services, particularly medical services, to the

individual alcoholic. A community-wide progiam haslittle chance for success without the humane ap-proach to the individual alcoholic which a goodtreatment program demonstrates Open hostility, orridicule and rejection are all too often apparent whenbusy health professionals are confronted with analcoholic. Such attitudes must be replaced with asympathetic appreciation of the patient as a person introuble and with the realization that alcohol abuse ismore likely a symptom of a deeper problem than acause of the apparent one.

Health professionals must be careful about thetendency to moralize or make value judgments aboutalcoholism and its causes On the basis of mortalityand morbidity statistics alone, alcoholism is on ofthe inc,:-. serious health problems facing the Indianpeople today and most Indian leaders have recognizedthis fact. Whether considered from the point of viewof mental illness, cirrhosis, accidents, nutritionaldisorders. Dr infectious disease, alcohol is one of themost important determining factors of ill health. TheIndian Health Service in attempting to raise thehealth of the Indians, can hardly afford to neglectalcohol and its impact on human health.

In the section that follows, brief attention will begiven to each of the main types of direct personalservices and to some guiding principles of comprehen-sive care of the alcoholic.

General Medical Care

No matter how elementary it may Seem, it is a factthat proper treatment depends on proper diagnosis.And diagnosis, in the medical sense, means more thana passive acknowledgment that the patient smells ofalcohol, rather, it is a recognition and subsequentconfirmation that an individual is intoxicated, or hascirrhosis, or delirium tremens, or whatever the mani-festations may be. Once a diagnosis of alcoholism ismade, the physician has assumed a commitment todeal with the condition as he would with any othercondition which threatens health or well-being.

Episodic treatment of the alcoholic has no place inproper medical management. Simple detoxification ofa drunk is no more valuable than treating a child forpinworms, knowing that all his siblings also have theparasite. Treatment once undertaken, must be com-prehensive and continuing. A plan should be devisedfor the alcoholic, assuring that he is properly fol-lowed, up after he leaves the hospital and that he isreferred to whatever community resources may beavailable and appropriate.

General medical care is usually provided first inthe emergency room, where the patient may be

9 14

---- '

brought in with an injury, spell of iiinconsciousness,strange behavior, or any number presenting fea-tures. Here it is of cruCial i rtance for thephysician to be alert for the eff sof alcohol, whichmay be masked by other sy i. . oms and signs. What isperhaps more common and more dangerous, theobvious signs of alcoholism may mask an underlyingdisease or injury of greater immediate threat.

Every physician has had the unpleasant experienceof sending a drunk home to "sleep it off", only tolearn later that the patient had a concussion, perfo-rated ulcer, active tuberculosis, or any number ofother dangerous conditions. Diagnostic evaluation ofany person suspected of drinking must be unusuallythorough and the phystclan's objective finding shouldbe recorded.

The decision to admit a patient with acute orchronic alcoholism may be a, crucial one for allconcerned An alcoholic with no other apparentdisease should be admitted if there are suspected orapparent physical complications or when it is clearthat intervention is needed to interrupt the drinkingpattern. An intoxicated person s seriously at risk ofinjury or illness as a result of his drunken condition.It is therefore r -portant that the emergency roomphysician be unusually- cautious about sending adrunken patient home, especially a long distance or inInclement weather. even if his injury or illness isotherwise relatively minor.

Certain serious manifestations of alcoholism re-quire hospitalization except in very unusual circumstances Among these are alcoholic stupor, alcoholiccoma, alcoholic hallucinations convulsive seizures,and delirium tremens Any of tnese conditions maybe in themselves fatal or may lead to a fatal outcomeas a result of complications. The full resources of thehospital are needed to treat them adequately. Certainorganic complications of chrome alcoholism alsorequire hospitalization. among which might be in-cluded acute hemorrhagic pamreatitis, hemorrhagefrom esophagael vances, and impending liver failure

Once a patient is hospitalized, a few generalprinciples of management apply Physical restraintshould be avoided unless it is absolutely necessaryThe greater the force needed to subdue the patient.the greater is resistance and fright When adequatenursing staff is unavailable. a member of the patient'sfamily should stay with him If possible. Professionalcare. of course. must he provided by a nurse, d tt isneeded. Confused or delirious patients should. ifpossible, be kept out of large noisy wards lhe roomshould be 'ly lighted, to avoid sharp shadowsSedation must be minimal and should he for thebenefit of the patient. not the staff. All members ofthe staff must be ,oittinuously alert foi signs ofcomplicating injury or illness. or an underlyingdepression Finally. overtreatment, either with drugs.fluids. or other means. should he avoided.

For the most part, treatment of the manifestationsof acute and chronic alcoholism is symptomatic Mildsedation may be used in simple intoxication, tremors,hallucinations, or DT's. but must he strictly avoidedin stupor, coma, or where a serious head injury maybe suspected Intravenous fluids are sometimes useful

10

if the patient is dehydrated, but IV "cocktail"mixtures should be avoided.

Once the acute phase is over, the physician incharge of the alcoholic patient must consider a planfor long-term management. taking into account theresources available in the Service Unit staff, in thelocal community, or in the State. A patient admittedwith any serious manifestations of alcoholism shouldgenerally be kept in the hospital for up to five days,during which time appropriate diagnostic studies canbe carried out and the cycle of heavy drinkingInterrupted It is usually a serious mistake to send apatient home as soon as his intoxicated state Im-proves.

Long-term management may involve many things,such as follow-up in the out-patient clinic forcounseling by the physician himself, referral to apsychiatrist or a social worker, or if available, acommunity alcoholism worker. If appropriate hospi-tal resources are not at hand, suitable cases might bereferred to the local Alcoholics Anonymous group orto a recovered alcoholic in the community who mightbe willing to help Some clergymen are also eager tohelp in this type of situation.

The important principle, of course. is that thealcoholic badly needs attention beyond his immediateintoxication episode If he does not get this kind ofcontinuing help and interest, the hospital becomesjust as bad as the jail with its "revolving door"

Psychiatric Care

Although psychiatry has an important part to playin the rehabilitation of many alcoholics, It is not arealistic view to depend on getting continuing psychi-atric help for most alcoholks, except under unusualcircumstances The few psychiatrists available to theIndian Health Service can be best employed in aconsultative or training role. Service Unit staff shouldrequest the area psychiatrist on his periodic heldvisits. to set up a professional training session for thedoctors, nurses, social workers, and others concernedwith the direct care of alcoholics. Hew difficult casesmight be presented for discussior

Serious cases of chronic brain syndrome due toalcoholism or alcoholic psychosis shoe id be referredto a mental hospital, if possible. for long-term care.hash Service Unit Director should become familiarwith the procedures and qualifications for admissionto the appropriate facility, with the help of the Veapsychiatric consultant, if needed. In choosing afacility, the wmrest Veteran's Administration Hospi-tal should be considered if the patient can qualify foradmiss' Jn

Social Services

In many Service Units, the medical social worker,if one is avallabIL, can be of invaluable help inproviding direct care to the alcoholic patient Thesocial worker frequently is better trained in counsel-ing techniques than the physician and in any case isoften in a better position to provide for the care ofthe patient's needs once the acute medical

cations are undo control. The social worker should ifpossible see the patient while the latter is stillhospitalized, then follow him regularly in the outpatient clinic either by himself or in conjunction withthe physician An occasional home visit is importantnot only to get a clearer picture of the patient'sneeds, but also-to demonstrate the hospital staff'scontinuing interest in the patient's well-being

The social worker would frequently be the mostlogical person to coordinate an overall plar for thealcoholic patient in conjunction with the physician..nd PUN, to see that he obtains whatever services heneeds.

In Service Units without social workers, many ofthe necessary functions can he carried out, at leastpartially, by a cooperative arrangement with a BIA,County or State Welfare Worker, or with a localclergyman

Nursipg

Clinical nursing of the alcoholic, of course, r, notessentially different from the care given to anyactutely ill patient and the general principle outlinedunder "Medical ('arc" should apply to nurses Thefask I orce clearly recognized that alcoholic patientsmay he not only unpleasant and-surly, but in factdangerous at times Although there is no easysolution to this problem, some of the larger hospitalsmight consider employment of a male "medicalattendant" to work evening and night shifts, in lieu ofa nursing aide or even LPN Such an individual couldbe of considerable assistance not only in the case ofacute alcoholics but as a security guard, an emergencyroom aide, or someone who could help with theheavy lifting.

fhe Public health nurse has a somewhat differentpart in the comprehensive treatment of the alcoholicShe of course, is in the best position to evaluate thehome situation and to report her findings to thephysician and )cial worker Since bad family rela-tionships may cause, or aggravate, or result from theexcessive drinking problem, it is essential to evaluatethem at first hand As with the infectious diseasesmoreover, it is not uncommon to find in the home ofone drinker a second alcoholic who also needs helpProbably the most useful function of the publichealth nurse however, is her health evaluation of thedependents of the alcoholic, such as small children orperhaps the elderly, since these dependents are all too

-often neglected or even actively abused Finally, theare those s :uations in which the public health nurse,by her regular visits and sympathetic interet may bea vital force in maintaining sobriety in an alcoholic onactive treatment

Personal Services by Non-ProfessionaLs

In addition to the medical attendants alreadymentioned, sonic of the larger Service Units maywant to consider employing alcoholism counselors foruse not only in the hospital but in the clinic or the(immunity. Such workers are usually local recovered

alcoholics themselves and there is no question that inmany cases they are able to establish a meaningfulrelationship with an alcoholic better than a healthprofessional.

An alcoholism counselor, atter a suitable period oftraining, may provide the patient with that cruciallink between his own seemingly overwhelming prob-lem and the professional help which- is available if hecould bring himself to use it The counselor isprobably also the most effective follow-up workerperhaps the only member of the Service Unit staffwho would have free access to sonic homes Suchworkers of course, are not necessarily employees ofthe hospital or health center In at least one area. aCommunity Health Representative serves as an alco-holism counselor Flsewhere such people may hemembers of the local Alcoholic Anonymous group orsimply volunteers Several of the programs of theOffice of Economic Opportunity have trained andpaid such counselors as well

Personal Services Outside the Community

A sew States now provide special rehabilitativecenters for alcoholics using the most modern com-prehensive treatment approach In some situations apatient may quality and be suitable for such aprogram

All States have sonic program of vocational reha-bilitation for its citizens and although frequentlyalcoholics are excluded, this is not necessarily thecase. The State psychiatric hospital may also ottersuch a program

Certain urban centers may provide cooperativegroup living services for alcoholics, or else "half-wayhouses" as a transition between the more sophisti-cated treatment center and the patient's home envi-ronment.

In considering all of these off-reservation-facilities,it is important to balance the advantages of groupliving and 'therapeutic environment" with the"cultural shrak" which most Indians will experience:n an urban setting among a group of alcoholics withattitudes, patterns and problems somewhat differentfrom his.

It should he clear from the foregoing that thetreatment of an alcoholic must go considerablybeyond the stage of detoxification Although thephsyician has the major for the care ofthe individual patient, he has not adequately fulfilledthis task unless he has devised a total plan for thepatient, using all the available resources of the ServiceUnit and the community. Perhaps the two greatestflaws in the management of the alcoholic today arethe failure to appretiiate alcoholism as a threat tohealth, and the failure to provide comprehensive careto the alcoholics who are diagnosed, Both of theseflaws can be 'argely remedial by a change of attitudetoward the t.roblem drinker on the-part of the entireIndian Health Service staff Positive leadership in thisrespect must begin with the Service Unit Director andhe fostered a' all levels and through all professionalcategories.,

16

TRAINING

The term "training", as used in this Guide, refersto educational programs or activities which aredevised for those who provide services to alcoholicsand/or their families. The importance of a coordi-nated training program m alcoholism for physicians.nurses, social workers, and other health workers atthe Service Unit cannot be overestimated Any suchtraining program should also include, if possible or ifappropriate, local teachers, ministers, BIA officials,Tribal Councilmen, and other community leaders. Inan area where contract medical services are widelyused, contract physicians and nurses should he urgedto participate as well.

The content of a training program should includeas a minimum II How alcoholism affects individualmen and women and how it affects the localcommunity, 2) What are the local, actual andpotential, community resources for the preventionand treatment of alcoholism, and how they can beutilized most effectivelyr and 3) What are theavailable clinical techniques for the treatment ofalcoholism and which would he most suitable for thelocal situation.

Framing may take a variety of external formsdepending on the needs and resources of the ServiceUnit Workshops, courses, and other longer sessionswill usually he held at the area offices, the IHStraining Center or on a university campus The areaoffice should keep the Service Units informed on theavailability of such courses, and the necessary ar-rangements for attending them Smaller study groupsor individual lectures and seminars are best held atthe Service Unit where a greater attendance can heexnected and where local problems and applicationscan be explored in greater depth On a still less formalscale med_ical or nursing stall meetings at the hospitalor clinic can he devoted to alcohol problems fromtime to time In CCf1, case it is best to have a wellplanned presentation caw report or a WM as a basisfor the discussion

Costs of a training program of course, will dependlargely on the scale in which it is undertaken Staftmeetings take time only I ()cal lectures and seminarscan usually he handled by the Service Unit since theonly direct ,osts are likely to be no more than a smalltravel expense or honorarium Speakers interested inalcoholism are osually only too happy to be invitedThe larger meetings, such as symposia, conferencesand workshops are best handled with the help of thearea office I unds are sometimes available, either forthe sponsorship of one of these meetings, oil° defraythe costs of those attending, if it is held away fromthe Service Unit

A partial list of possible sponsors of alcoholismtraining programs would include, in addition to theIndian Health Service, the State Ilealth Department,Association of American Indian Affairs, Arrow Inc ,

the Office of lb«mornic Opportunity, NationalCouncil on Alcoholism the National Institute ofMental Health and the. Bureau of Indian AffairsSeveral universities, notably the University of Utah,have been particularly interested in Indian alcoholism

and have sponsored special summer training pro-grams.

The resources of a Service Unit for the care andprevention of alcoholism can often be considerablyaugmented, and at very little extra cost, by thetraining of existing staff, volunteers or other personsalready working in related fields in the community.Both initiative and ingenuity are required to devise asuitable program, but frequently the resulting Im-provement of attitudes and 'rvices will be well worththe effort.

HEALTH EDUCATION

Health education is another basic component ofany alcoholism program In this guide, health edu-cation means the dissemination of reliable informa-tion on alcohol, alcohol use and alcoholism toindividuals, groups, organizations and agencies withinthe community. It may he the Job of all members ofthe Indian Health Service staff at various times, invarious places, or under various circumstances It isalso the job of others in the community such asteachers, social workers, law enforcement officers,Judges and clergymen, to name a few

Health education has in the past been the hope,and often the only hope, of many individuals andorganizations for the control of alcoholism. Thetheory is that it a person knows the truth aboutalcohol and its dangers he will not drink. or at leasthe will not drink excess,vely, Every State in thecountry has a law on the boons requiring "alcoholeducation in the schools, but no one seriouslybelieves that these laws have been elk( tive inpreventing the abuse of alcohol either in school or inlater life

1 he reasons for the failures are complex In part,of course, they are related to the ambivalent feelingswhich many persons have about drinking in their ownlives. A teacher with a strong religiows upbringing andwho looks upon drinking as morally wrong is likely tobe Just as ineffective in teaching ahou' Icoholisin asone who has a drinking problem in his , .vin life and istrying to hide it Too often "scare techniques" havebeen used to encourage total absti' :ice arcnaicrestrictive laws, especially on Indian reservations,have complicated matters further, especially ,n com-munities where these laws are frequently violated[-malty, there is all too much emphasis on "alco-holism" rather than on "drinking" in conventionalhealth education programs

In short, perhaps too much has been expected ofhealth education as the main or even sole support ofan alcoholism program. It is an essential component,...-

' to he sure, but it must be carried out with the propercontact, by the right people, and under the rightcircumstances if it is to do more good than harm.Alcohol education cannot be legislated or forced.

Health education presentations must be appropri-ate to the goal to be accomplished and the mosteffective speaker may vary with the circumstances.For example, there arc many times when a recoveredalcoholic can make a far greater impact than a

12

1 'i

physician with a patient seeking to overcome hisproblem with alcohol.

In general, alcohol education can profitably bedirected toward nearly every individual or group inthe community, provided it is done in a rationalmanner Hospital employees, particularly nurses'aides, food service workers, housekeeping and laun-dry workers, and maintenance men all usually conicin contact with alcohol abuse at some time, either intheir own lives or at work, and they should beprepared to deal with it, Employees of other agencies,notably the Bureau of Indian Affairs, should also beincluded whenever possible in a teaching program.School officials, both teachers and administrators, arean extremely inidortant group to reach with a soundand up-to-date knowledge of alcohol and its effectsIt a local industry employs Indians, supervisors at alllevels need to he equipped with a deeper knowledge01 alcoholism than most already possess. Finally, ofcourse. eduLation must he directed toward individualsand groups (within the community Alcoholics Anony-mous. NI-Teen and Al-Anon are three worthy organi-zations which are devoted largely in one form oranoth,gr, to alcohol education, particularly for alco-holic, themselves, or for their familks Such groupsshould he actively encouraged or supported by theIndian Health Service staff since they Lan. adddimension to alLohol education which the healthprofessionals Lan rarely provide. Other groups, suchas youth clubs, men's and women's organizationsshould also he helped to sponsor an occasionalprogram on alcohol

It has been said that the transmission of alcoholinformation in the past has been outstanding it is justthat no one has been tuned in on the right frequencyto receive it I his comm 'niLation problem must bekept Lonstantly in mind when a health eduLationprogram is being devised "M8ralumg", "spare teLhm-ques 'ind "threats are hardly ever effective .nmaking a lasting impression Instead, it is reLom-mended that some of the following prinLiples he keptin mindI It is not e,ential to drink A person who abstains

from alcohol should not be excluded from a socialgroup

2 I icLessive drinking does not indivatc maturity ormasculinity, any more than eating an excess offood

3 Uncontrolled drinking or alLoholism, is an illnessand requires the proper medical treatment It isnot the result of perversity, charavter defect orimmorality.

4 Safe drinking depends on a number of factors suchas

a) the early development of health attitudes to-ward drinking,

hi the prevention of dangerous blood alcohollevels by the spacmg and dilution of drinks andthe Loneomitant use of food, and

it the recognition that drinking is dangerous whenused to solve emotionat problems

Intoxication is not neL.ssirily the outcome ofdrinking In every way dossible, the attitude thatintwoLation is an undesirable effect of drinking

'

and is not socially sanctioned by the group, shouldbe engendered

6. Alcohol, even in small quantities, has certainadverse physiological effects on the body and mayinterfere with important tasks such as driving orworking.In most Service Units, the Health Educator if one

is available, would be the logical coordinator of analcohol education program, but it could just as wellbe a medical social worker, public health nurse orphysician, depending on his or her skills and depth ofinterest. Among the methods Which should be con-sidered by this individual might heI. Arranging for speakers either from the local

community or from outside2. Ordering films, slides or tapes for use in staff or

public meetings3. Organizing andjor supporting local study groups

among youth or adults, including AlcoholicsAnonymous, Al-Anon and Al-Teen.

4 Arranging for group tours to certain institut,ons,such as jails, prisons, mental hospitals and specialtreatment centers.

S. Providing local news media with artiLles, spotannouncements and other materials on alcoholism.

6 Discussing with sLilool administrators the signifi-cance of the alcohol problem and helping them todevise meaningful alcohol eduLation programs inthe school and Lommunity.

7 Working closely with the managers of local indus-tries.

8 Developing appropriate materials (displays,exhibits, workshops) for use at Lonterences ofteachers, law enforcement officers or tribal groups.

COMMUNITY RELATIONSHIPS

This chapter deals with the Indian Health Service'srole as a catalyst for new'Lornmunity programs and amodifier of existing programs In this role we areconsultants, teLlmiLal advisors and enablers for a-chieving things in a Lommunity alcoholism programplanning

Each Service Unit should designate one person ascoordinator for all alcoholism activities This individ-ual will be responsible for interagency coordinationand for overseeing all alcoholism planning to helpassure that program objectives are met. He will alsobe the Servile Unit staff member with the primaryresponsibility for initiating and sustaining Loinmunityinterest and action in alcoholism programs. Theposition is one of liaison between the community andthe HIS staff, as well as the main Service Unit linkwith the Areal Alcoholism Program Officer or hisequivalent

The role of the Indian Health Service in alcoholismtreatment and community action must be developedin conjunction with .ind approved by the tribalgoverning bodies. To have any suLLess, it must havetheir constant input and special knowledge.

They should also take an active part in imple-menting these plans. To achieve this essential tribalparticipation each Service Unit should work with tnetribal governing bodies to appoint an Alcohol Pro-

gram Advisory Committee This committee will act man advisory capacity to the program, and should notbe confused with any existing Community Council onAlcoholism or with such a council that might beform in the future, although some of the membersmight :rye on each body. The advisory committeewould serve as the voice and hand of the tribe indirection and implementailon of their own prcgram.Although the advisory committee and total staff willwork closely tcgether, an especially close workingrelationstup should be maintained between the Serv-ice Unit Coordinator anu the Indian Advisory Com-mittee

Before we can assist the community with develop-ing alcoholism treatment and prevention programs, orin gams), effective professional consultation and sup-port to existing programs, we need to ta,:kle feelingsabout the alct,nollc .11111,elf and Its treatment Theprririties and treatment methods outlined in otherseLtions of this docurront should be carefully fol-lowed. The attitude and concern if the entire stafftoward this problem and toward the people afflictedwith it influence very directly the feeling of the restof the people of the community Service Unitpersonnel should promote preventive pro ms andshow th ir concern about the proper are andtreatment ot problem drinkers in the witole com-munity, not just in our own medical facilities Factistatt membt; should have an "open door poocy- forthose reople suftering from alcohchsm or whose livesarc touthLd by it

Tht at tive involvement and participation of theService. Unit statt in community affairs. f. rticularlthose conterned with alcoholism, can help determinthealthy Lommunit attitudes toward the patient whohas achieved sobriety and is making a new situationaladjustment The attituues ot health professionalstoward alLohylKs and alLo'Iolism can go a long wa,totLard tawrahls molding publiL opinion

\Aural triendship wnith and ready aLceptant ear ot p unary important, to the alcoholic undertreatment Both frequent contact and ,int ere concernfor the new demands piated on him in his new lifewill help him througn a Liitticult rriod lie should heunwed to ,octal hinthotis and he made to fedomit ortable . atte^nding them One ot the mostet fet tRi. means of thdping tae aiLoholie maintainsobriety I. to nvolve him i activities which arerelated to the treatment .1111.1 prevention of alcoholismIII the 0,It111111110. !le tan he ot assistance in planningineaningfin programs as well as in counseling thoseindividaals who are seelong help for ail alcoholismproblem themselves

I he altonolit under treatment ot Louise needslit 11 1.ry nt1 OIL hospti sl .111(1 ,i1111 101 platementit.11111tig 14.clt,ito transportation are all areas whichneed AtChtl()11 111 111, I he altolioln. needs the,111r.IM.... that are interested in him and are4.1111hg to -.unroll toll% his snorts to help tiinnell

I at 11 `setvite t nit should inform tommunityNer,,L religions ertmps legal nd governing bodiesand ,t her ,,f,.!1111,'111(11,, ,)t all their at tivities relatedro ,i1Loholi,in treatment and tontrot Its willingne,,,to tool-ter-AL with them in their oneoing prog,,inis

14

should be explicitly clear; as should its intention toassist them in program improvement or the initiationof new programs. The Service Unit should also workwith other resources as consultants, in planning formeetings and conferences, in staff education pro-grams and individual case management.

The staff should also participate in other com-munity planning not directly related to alcoholism,such as industrial development and school problems.An example might be a new reservation industry withmanagement that is fearful of drinking problems inthe existing labor pool. The Indian Health Servicestaff can offer advice and consultation on the extentof the problem, how the problems can be dealt with,availability of certain treatment services, and insetting up an industrial alcoholism program if desiredSimilar services can be offered to schools regardingtheir program and methods in relation to behal oraland learning problems of children.

An integral and necessary part of -my work withother agencies and resources is an adequate, work-abte, well defined method of accepting and referringcases, To do this it is essential that all organizationssuch as those suggested above know the Indian HealthService policies and procedures for accepting patientsfor treatment services. It must not be assumed thatthey know those policies, but each agency shouldhave a written outline of the procedure to befollowed In addition, the Service Unit should alsokeep an up-to-date resource file, which can bedeveloped by personal contacts with communityagencies and by making written notes of their intakeand referral policies foi alcoholics, The Indian Ad-visory Committee will be Involved in giving assistanceand impetus in setting up the methods and pro-cedures for planning and evaluating ,he alcoholismprogra m

Each Service Unit must he responsible for provid-ing needed consultation and technical assistance ontreatment of alcoholics, community program im-provements and program development to communityorganizations and ,genctes, Including informationregarding possible funding for new pro'ams. The aimshould be to supplement and support existing alco-holism programs which have real or potential value inthe 4.ommunity.

The preceding section has attempted to set themood and direction ot the Service Unit's program,feelings, intentions and actions regarding alcoholismand to (1.Mine its relationship with other agencies TheScr ice Ur r Coordinator and the Indian AdvisoryCommittee have a Walter essential and active role toorg,,inie the community to action about alcoholismas a major health prohiem

To do this etteLtively, it is necessary to identitythe -Indian people in the Lommunity who are mostinterested and can provide leadership I() find thesepop may he dittiLult, but perhaps the first stepwould he to discuss the matter with the IndianAdvisory Committee and other tribal leaders, explain-ing th' problem and asking their help It these ideasare acceptable to the community the leadership forthe program should identify thernselv::, before long,I he 'seivite Unit statt must rtspeLt their advice and

19

leadership in how to proceed, One of the first thingsto come may be a Community Alcoholism Councilmade up of these people

The Indian Health Service Task Force on Alco-holism is preparing a reference guide for communityleaders listing all types of alcoholism programs, andcontaining a brut summary about the assets andliabilities of each program It also contains infor-mation on resources available to develop these pro-grams, The Service Unit statt should be prepared tointerpret this guide for the lobe when necessary.

DATA COLLECTION, RESEARCH, ANDEVALUATION

In the first section of the Alcoholism Task ForceReport, the ditticulty in tending meaningful statisticsabout Indian alcohol' problems was pointed out. Thesituation is even worse with respect to information onthe eftectiveness ot treatment. It is therefore ex-tremely important in establishing any program to setup first the means of data gathering, as well as tobuild into the treatment program a means of con-tinuous evaluation ot that program.

The recent trend toward the use of problem-oriented health records in the Indian Health Servicewell n the future provide a method of data collectionwine will he helpful in defining the extent ofalcoholism as well as many other disease entities, Atpresent, however, there are a number of other meanswhich can be used to collect data. A rough incidencefigure on inpatient cases of alcoholism could heobtained if upon discharge of the patient the phy-sician diagnosed any existing alcohol problem withinthe first four discharge diagnoses. Similarly, onpediatric cases it would he well to mention italcoholism in the family wisa contributory tacter tothe primary illness. Since alcoholism is rated as highpriority health problem, it seems reasonable toinclude it in the first four diagnoses these casescould then he tabulated by age, sex and residence onService Unit, area and headquarters levels, thus givingus a more accurate picture of the total problem.Alcohol related problems should also he more tre-quently diagnosed and tabulated from the outpatientclinics

Another use that could ;le nude of such datacoming from both inpatient and outpatient sourceswould he the creation it each Service Unit of analcoholism registry. I his could be constructed verysimilarly to the tuberculosis, cancer or venerealdisease registries now in existence. From this, on

addition to the statistical information it wouldprovide, various prevention and treatment 'programscould be constructed aimed directly at the involvedpatient and his family

In addition to the necessity of gathering pre-i,alence and incidence data, there is a need to evaluatethe demand made on professional time by patientswith problem drinking and alcoholism. I his is par-

. ticularly important in the outpatient departmentach 'service Unit could establish a simple recording

sheet which would be used eatli time a patient is seenfor J problem directly related to alcoholism Hu,

IS

record should he compiled by anyone having contactwith a problem drinker, such as doctors, nurses orsOcial workers

The outpatient department is also an importantsource in determining the involvement of alcoholw.th accidents. In the tabulation of the previouslydescribed contacts, it would be important to notespecifically the association of an occident withalcohol, A final source of information could be deathcertificates It is recommended that alcoholism hespecifically included as an associated cause of deathwhenever appropriate

The above recommendations pertain primarily toinformation gathering within the structure of theIndian Health Service There is a great deal however,to be learned trom other agencies. These organi-zations include fribal governments, BIA, State andmunicipal groups, as well a., those facilities used bythe Indian Health Service for contract medical care.Cooperation should he enlisted at all levels with thevarious organizations. It is hoped that a brief re-porting form can he used by all the agencies andorganizations mentioned, to serve a dual function,namely assistance in data gathering as well as meansof patient referral.

The coordination of information troin-these tormswould probably hest occur at the area level by analcoholism program officer. This person should re-ceive a copy of the form made out on any patientwhose home residence is in that area. The copiescould come from all the sources mentioned

It is important to stress again that any alcoholismprogram which is developed will depend on valid datafor the intelligent evaluation of effectiveness. Bothaccurate baseline data and the continuing impartialassessment of treatment outcomes are essential.

Further improvements over and above. what hasbeen suggested will be dependent on a total up-grading of the Public Health Service record system. Inthe Indian Health Service at least, this process hasalready begun, In the not too distant future. we -willhe able to have easy access to statistics on, alcohofilsmas well as other illnesses The increasing use ofcomputers in reco-d keeping will make this Inc as-ingly possible Until then however, a great deal can beaccomplished by a full use and correlation of theinformation already available t1'0111 many localsources,

A SUGGESTED APPROACH TO PLANNING

Implicit throughout this guide is the concept thatalcoholism progiams do not just happen, but ratherare planned, tunded, implemented and evaluatedthrough a conscious and rational piocess By way ofsummary, this section will outline briefly the neces-sary steps to the development of an alcoholismprcgram in the community !hese steps of course, arenot arranged in a rigid order of application.I Recognue the problem of alLoloilhm for what it

is, that is, a significant cause of mortality, mor-bidity and general community disintegration, I Insstep, obvious as it seems, is rarely en in noirethan a half-hearted manner I eader:hip if not

already assumed by others, should be taken by theIndian Health Service

2 Collect data on the extent and effects of alco-holism locally it is essential that the data beavailable as a basis for rational planning andevaluation Although trequently, accurate figuresdo not exist, a reasoned and informed judgmentfrom the sources as outlined in part VI is a goodstarting point. More sophisticated methods of datacollection must be developed as the program itselfdevelops.

3 Involve the leadership of the community early andbsten well to their advice and counsel No matterhow. elaborate and theoretically sound a programmay be, it will fail spectacularly it it is atcross-purposes with the local needs and attitudesof the people Not only Indian leaders should beconsulted, but also representatives ot othei or-ganizations and agencies concerned with the pro-blems of alcoholism.

4. Determine the magnitude and characteristics otthe total alcohol problem, in cooperation withcommunity leaders and resources The specificoature ot the local problem needs areful defi-nition, such as the epidemiological patterns otdrinking and harriers to progress

5 Take a careful inventory of locally existing re-sources for the recognition treatment and pre-vention ot alcoholism and identify the gaps inservices available tur alcoholics and their familiesStrengths ot the community are as important Isthe weaknesses in this regard

6 In conjunction with the local Indian leadership. setgoals and objectives for the type of new programthe sommunity wants and needs Such goals andobjective, must he realistic and rettett what thecommunity is prepared to support

7 Work out, with consultation troth the area statt, acommunity ak °holism council or alternative plansot as tionsw lush would he needed to a,comphshthe goal, and ()hies fives which are establishedSuch plans should include a realistic estimate otcost. taking into account existing space, statt, andtime as well as outside resources which might het'tiliied Plans should he comprehensive, withattention to training, health education, data col-lection and community action, as outlined in theguide

8 Choose, with the advice and approval of the TribalCouncil, the best alternatives for action andsubmit the entire plan to the area office, includingcost estfinate, goals and objectives The plan.thosen for adoption should incorporate a meansby which the programs can be evaluated.Implement the approved plan immediately to theextent possible. Any comprehensive plans fcralcoholism will include aspects which do notInvolve the expenditure of money or acquisition ofother new resources. These parts of the programshould be initiated as soon as possible, not onlylay the groundwork for future efforts, but to showgood faith to the Indian community and to thearea office.

10 Implement the whole plan as soon as extraresources become available It is important to keepthe tribe informed of progress in implementation.They have a right to know about the progressmade as well as the delays and frustrationsencountered 'It is quite possible that pressureto hear by the Indian people will be a most etfectIveway ot expediting outside funding

1 I F valuate the program objectively by comparingresults with baseline information and measuringthe extent to which original goals and objectiveshave been met. Evaluation should be done in Josecooperation with the Tribal Advisory Group

12 Revise goals, objectives, and plans in light of thenew experience gained from the evaluation and thecontinued operation of the programThroughout these steps it may be inferred that

planning and p:ograni development for alcoholism isthe sole or even primary responsibility ot the IndianHealth Service staff Nis inference is not necessarilycorrect. The planning process ideally should originateand develop within the community itself, with theIndian Health Service providing technical support andc(,nsultation only. The steps outlined here in essencedescribe a process which any planning group mustundergo to accomplish: any type of program ThetSSIIndian Health Service however, with its health protes-sionals and its physical tacilities, is in a uniqueposition to provide the kind of direct or indirectleadership or stimulus necessary, not only to recog-nise the need for an alcoholism program, but also toassist in a significant way in its development andoperation

9

(2 1

Section IIIReference Guide for Indian Tribes andCommunities W)shing to Undertake Alcoholism

Projects (April 1970)

INTRODUCTION

This guide was written to help Tribal Councilmen,Health Board Members, Community Health Repre-sentatives, and othei members of Indian communitiesbecome better informed on alcoholism as a healthproblem and to take action needed to prevent orcontrol it. This booklet will provide information onwhat alcoholism is, what can be done about it bymodern treatment methods, and how Indian peoplemight find out more or gain support for a communityalcoholism program.

The Indian Health Service is greatly concernedabout alcoholism as a health and social problem andits staff stands ready to assist Indian communities inany way possible to develop a suitable program tocombat it. Alcoholism has been given a high priorityby the Service just as it has by many Indian leadersacross the country. It is a problem which can besolved only by sincere interest, hard work andcooperation.

This guide has three parts. The first is a list ofdefinitions of common words used in books andpapers on alcoholism. A great deal of reading materialon alcoholism is available This glossary may helpwith some of the medical and technical words. Thesecond part is made up of short descriptions of a fewof the modern methods of treatment for alcoholismMany people either feel that alcoholism is incurable,or else they expect more of drugs, hospital care orother treatment than is possible. This section mayhelp clarify these matters The third part is II list oforganizations and agencies which can provide infor-mation or consultation on alcoholism and in somesituations, financial support for community alco-holism programs Addresses have been supplied wher-ever possible so that the organizations may hecontacted directly

MEANING OF ( .IMON TERMSRELATED 10 ALCOHOLISM

The list of words below contains many termswhich are commonly used in writings on alcoholism.The definitions given here are short and refer only 'tothe meaning of the word which applies to alcoholism.A bshnence Not using alcohol.,4ddiction Not being able to stay away from alcohol or some

other substance. such as drugs. An addict, by himself cannot give up his habit without bad effects such as

"shakes," Abdominal pains or nervousness..4ddic is can behelped by medical treatment, but they have a seriousproblem and must r,,ognia it as such.

2'2

Alcohol. A type of chemical which can be made by severalprocesses from fruits, vegetables, and other substances. Itis a colorless liquid and burns freely. Alcohol is present inall intoxicating drinks, although some kinds have morealcohol than others.

Alcohol, ethyl Ethyl alcohol, sometimes called "ethanol" or"grain alcohol" is the kind found in all intoxicatingdrinks. Distilled liquors, such as whiskey, rum, and odka,have the greatest amount of alcohol, while wine a'id beerhave much less, but enough to be harmful in largeamounts.

Alcohol, isopropyl Isopropyl alcohol, or "rubbing alcohol"is the kind used in hospitals for cleaning and sterilizingthe skin. It is made as a by-product of the e industry. Itis not safe to drink.

Alcohol, methyl. Methyl alcohol, also called "methanol" and"wood alcohol" is used in industry to dissolve othermaterials, for cleaning and other purposes. It is extremelydangerous to drink aid may cause death, blindness andbrain damage, even in small amounts. "Denatured"alcohol contains methyl alcohol and must not be drunk.

Alcoholism Alcoholism has been defined in many ways bymany people. The IHS Task Force on Alcoholism suggeststhis deflmtion"A disease, or disorder of behavior. charactenzed by therepeated drinking of alcoholic beverages, which interfereswith the drinker's health, interpersonal relations oreconomic functioning."

Antabuse. Also known as disulfiram. A drug which serves todiscourage the patient from impulse drinking. When thisdrug is taken regularly, the ingestion of alcohol causes ahighly unpleasant reaction, characterized by transienthypertension, (high blood pressure), then a quick fall inblood pressure, flushing, rapid heartbeat, nausea, vomit-ing, shortness of breath, and sometimes, collapse. Thesesymptoms are followed by drowsiness and recovery aftersleep.

Ascites A condition in which fluid builds up in theabdomen. It is caused by liver damage or cirrhosis,due to alcoholism. (ee cirrhosis)

Black-outs A bnef loss of memory during and after a periodof heavy drinking. These losses are often not noticed byother people, but the drinker may become aware laterthat he does not remember where he was or what he wasdoing during the period of dunking. Black-outs are aserious sign of alcoholism.

Blood alcohol-level Amount of alcohol in the blood. Thismay be found by a chemical test on a blood sample. Alevel of 0.05% is not generally harmful, whereas a personwith a level of 0.15% is considered in most States to betoo intoxicated to drive a car. Levels of 0.30% to 0.50%may,cause unconsciousness or death.

Cirrhosis A disease of the liver which is usually caused byheavy drinking over a long time. Pttor eating habits inalcoholics may also be a partial aline., In cirrhosis(sometimes called "Laennec's cirrhosit") there is often ascarred, shrunken liver, fluid in the abdomen, Jaundiceand bleeding from the esophagus, the passage way,from

J

the mouth to the stomach. (see varices, esophageal) It isusually fatal.

Coma Deep loss of consciousness. Normally a person in acoma cannot be awakened by calling, shaking, etc. Comamay be caused by heavy drinking and other conditions.Alcoholic coma is a serious sign and may lead to deathwithout proper treatment.

Delirium IYemens: Usually called "DT's" or "shakes" is aserious sign of alcoholism. It consists of trembling,sweating, fear, restlessness and confusion of the mind.Usually the victim sees insects, small animals, snakes orother frightening things. DT's is a very serious conditionwhich requires treatment at once in a hospital. Even withthe best treatment many people die from this condition.

Dependence: A need or craving for alcohol or a certain drugto which the mind and body have become accw tomedand without which proper function is almost impossible.

Detoxication The medical treatment for serious drunken-ness. This usually takes place in a hospital or specialfacility and may consist of injecting flwds in the vein,giving drugs to calm the patient, and rest.

Distillation A chemical process by which certain alcoholicdrinks are made. Distilled drinks have alcohol contents ashigh as 60%. Examples of distilled drinks are whiskey, gin,brandy, vodka, and rum. These are the most potent typesof alcoholic beverages.

Disulfiram Also known as Antahuse. A -bug which dis-courages a patient from impulse drinking (See Antabuse)

Fermentation A chemical and biological process m whichcertain fruit and grain extracts are changed into alcoholBeer, wine, ale and "home brew," are examples offermented drinks. They usually contain between 5 and10<;,, alcohol.

Gastritis A condition in which the stomach lining becomesred and swollen, causing pain in th., upper abdomenGastritis may be caused by heavy drinking

Hallucinosis A disorder of the mind in 1k hiLh the patientsees, hears, smells or tastes something which does notexist. There are several causes, one of them beingalcoholistn, It is a serious sign in an alcoholic and requiresimmediate medical treatment

Intoxication. Drunkenness, or the state of being drunk Thisword is sometimes used for other kinds of poisoning aswell as too much alcohol

Metabolism The process by which alcohol or other sub-stances are broken down by the body into simplersubstances so that they can be used or rejected by thebody.

Pancreatitis A disease state of the pancreas, a large digestivegland in the abdomen The organ is swollen, inflamed andat a later stage scarred The state causes severe abdominalpain and vomiting, and may be fatal The excessive use ofalcohol frequently leads to pancreatitis.

Proof A measure of the alcohol strength in a drink One halfof the "proof number" is the percentage of alcohol I or,:xample, "90 proof whiskey" contains 45'7 alcohol

Sedative A drug used to quiet or calm an existed oroveractive patient Sleeping pills are examples of se-datives

Spree or binge drinker Mix term is applied to the personwho occasionally becomes drunk for short periods butcan stop drinking anytime he wants Sui.h people areoften injured when they are drunk. Lqually often,unfortunately. they may injure other persons who havenot been drinking.

Stupor Severe drunkenness, at a stage when the person isunable to continue drinking In this condition a person.nay come to harm by exposure, injury or choking

ft/int/uric:a A type of drug which helps some kinds ofnervousness It is sometimes used for alcoholic patientswho are frightened or unable to relax

18

IYemor. Uncontrolled shaking of the fingers, hands or otherpart of the body. A tremor is often seen in chronicalcoholism and is a serious sign

Varices, esophageal: These are widened or "varicose" veins ofthe lower end of the esophagus, the tube connecting themouth and stomach. They are usually caused by cirrhosis(see "cirrhosis") of the liver, one of the complications ofsevere alcoholism. If these veins bleed, they may causedeath.

Wine Test. Used to test a patient's reaction to alcohol afterhe has taken Antabuse. It is usually given in a hospitalusing wine, or beer or any other suitable alcoholic drink.The test enables the alcoholic and the doctor to see howsevere the reaction could be if alcohol is taken.

Wino- A slang word for a chronic alcoholic, especially onewho drinks large amounts of wine.

Withdrawal The drying-out stage of chronic alcoholism.Withdrawal is sometimes accompanied by the DT's,tremors or extreme restlessness.

PROGRAMS FOR THE TREATMENT ANDPREVENTION OF ALCOHOLISM

The following pages describe emus methods,programs and facilities which are used for thetreatment and prevention of alcoholism Not all ofthese are available in all parts of the country at thepresent time and it is best to ask at your localhospital or clinic, if you are interested in learningmore about such programs in your area

Medici Treatment

Drugs

Drugs of various kinds are sometimes prescribedby doctors to help in the treatment of alcoholism,but there is no medicine which will cure alcoholismCertain drugs, properly used, can relieve some of itseffects for a short time. Some drugs themselves cancause dependence, just as alcohol does, if they areused in hIgh doses for a long time. It is of greatImportance that the alcoholic patient folloiis thedoctor's directions carefully in taking the drugsprescribed and that he never tries to use someoneelse's medicines, which may be harmful to him

Antabuse Antabuse, sometimes called "dis-ulfiram," is a drug which is sometimes used to helpan alcoholic give op drinking When taken reg-ularly, it causes a person to become violently sickwith headache, nausea, and vomiting whenever heor she drinks alcohol in any fodn Antabuse canonly be obtained through a hospital or clinic andonly while the patient is under the regular care ofa doctor

When a doctor prescribes Antabuse, he mustfirst be sure that the patient is seriously interestedin giving up drinking and that he will followdirections carefully. The doctor then must deter-mine by a careful examination and by somelaboratory tests whether the patient has any otherserious illnesses which might be made worry by theeffects of the drug Usually this examination isperformed in a hospital over a period of five daysor more If the patient is found suitable for

Antabuse treatment, he is usually given what iscalled the "wine test.' - first the drug and thensome wine, beer or other alcoholic drink This isdone in the hospital because it is important bothfoi the doctor and the patient to know what kindof reaction the patient will have when he or shetakes alcohol following the drug After dischargethe patient must attend the out-patient clinicregularly for a check up and to get a new supply ofmedicine as needed

Antabuse may help a few persons to give updrinking but is not a "wonder drug" by anymeans It can be dangerous and must be used withgreat care by both the doctor and the patient

Sedatives This is the type of drug most peopleknow as a "sleeping pill Other drugs of this kindare used to help quiet down a very restless oroveractive patient, or simply to relieve ome of the"nervousness" otten seen in persons with analcohol problem

Tranquilizers Tranquilizers have many of thesame effects as the sedative except that they arenot so likely to cause drowsiness Tranquilizersmay be used to calm down an excited or fright-ened alcoholic while the effects of alcohol arewearing off. Usually they are not used over a longperiod of time in cases of alcoholism.

Other drugs Frequently a doctor will prescribeother kinds of drugs for an alcoholic, but usuallythese drugs are for treatment of a complication ofthe condition rather than for alcoholism itselfExamples might be the use of antibiotics such 'Ispenicillin, for an infection or vitamin B shots .ornutritional deficiencies that many alcoholics have.

Psychotherapy

This is a form of medical treatment for analcoholic usually given by a psychiatrist Basically.psychotherapy involves the doctor and the patienttalking together privately on a regular basis Thepurpose of the treatment sessions is to help thepatient understand his feelings and the reasons whyhe behavec in the way he does The doctor exploreswith the patient, ways other than drinking that hecan learn to live with his underlying problems

Psychotherapy can help many patients but un-fortunately, it takes a lot of time both for thepsychiatrist and the patient Psychiatrists are in shortsupply, all over the country and it is not likely thatmany Indian communities will have the regularservices of one for many years to come

FacilitiesThere are many kinds of facilities used in the

treatment of alcoholism, some of them highly special-ized One thing that all facilities have in commonhowever, is their expense Treatment of an alcoholicin any hospital or special treatment center is ex-tremely expensive What is even more frustrating isthat most of these facilities, particularly the special-ized hospitals, have a long waiting list of patients.

Because of the expense and the .difficulty ofgetting treatment in these special centers, the doctorsmust choose very carefully, from the many eligiblepatients, the ones who are most likely to he helpedby the treatment which is offered The patient in 'urnmust be willing to cooperate in every way to helphimself overcome his alcohol problem

Detoxication Center

This is a facility used only for the treatment ofintoxication, or drunkenness The people who staffsuch a center are trained to help the intoxicatedpatient get over his dangerous state of alcoholpoisoning as quickly and as safely as possible Themetnods which are used include fluida in the vein,certain types of drugs and restraints if necessaryDetoxication centers are fairly new ol this countryand are found mostly in large cities For the mostpart, thy do not provide preventive services or anytreatment for the long-time alcoholic who wants helpin giving up his habit

Half-way House

A half -way house is a facility which provides food,shelter and care for the alcoholic after he has beendischarged from a mental or special hospital foralcoholics and before he returns to his home. Sonictimes an alcoholic may go directly to the half-wayhouse from his home commi',,Ity without going tothe hospital Most half-way nouses are in cities, butthere is no reason why one could not be establishedin a reservation community if the need were greatenough

A half-way house usually has 15.20 residents whoare all former alcoholics or alcoholics under treat-ment for their condition Everyone works together toobey the rules of the house, to maintain and clean itand do the cooking. Drinking is of course strictlyforbidden In addition to social events, most half-wayhouses have an educational program ,and otfen havevisiting speakers Group meetings such as AlcoholicsAnonymous may he held at the house regularly

19

24

General Hospital

A general hospital is one which deals with illnessesof all kinds. All the Indian Health Service hospitals,except for two tuberculosis sanatoriums, are of thegeneral hospital type. Most small hospitals do nothave specialized facilities for alcoholics Instead, suchpatients mt.st he tileated along with many other typesof patients, usually in the medical ward It is easy tounderstand how a noisy, intoxicated patient candisturb other sick patients and how difficult it is for anurse to try to control him No matter how much thealcoholic may need help and treatment, it may not bepossible to admit him to the hospital withoutendangering tile other patients or the nursing staff.

Several of the large Indian hospitals are nowdeveloping special wards for the treatment of alco-holics At least one of these is under the direction of

a psychiatrist In the future, more and more suchfacilities will probably be established.

The main advantages of the treatment of alco-holics in a general hospital are

(1) The alcoholic usually has other medical prob-lems which can be given more complete treat-ment

(2) The alcoholic can be treated closer to homewhere he can be visited by his family andfricnas

(3) The alcoholic is more likely to know the doctorand his staff personally, and therefore can moreeasily establish a good relationship with them

(4) The general hospital, with its outpatient clinicand field staff, can follow up on the treatmentof the alcoholic after he leaves the hospital

Mental HospitalAdmission to a mental hospital may he through

direct an.! volunary request by a patient. by referralfrom a doctor or by legal Lommitment by a court orJudge.

Many of the mental hospital., in this country aretoo crowded to accept patients who have an alcoholproblem only On the other hand, there are somemental hospitals which have a special program for thetreat men of alcoholism and many persons have beenhelped by them

he most common methods used to treat alco-holism in mental hospitals are

(I) group counseling or "group therapy"(2) drugs, such as sedatives and tranquilizers(3) occupational therapy and training(4) health education(5) AntabuseThe greatest advantages of menial hospitals in the

treatment of alcoholism are(I) The staff has a long experience with alcoholic

patients and greater knowledge of alcoholismproblems than staffs of most general hos-pitals.

(2) The mental hospital may provide a better"atmosphere" for treatment, since the patientis removed from his friends and many of thehome problems which may have helped causehis drinking problems

(3) Through psychotheraphy the alcoholic canlearn more about himself in rekition to hisalcohol problem

Specialized Hospitals

In recent years specialized hospitals for the treat-ment of ali..oholism have been established in a fewStates FOr the most part. such hospitals are

privately owned and operated; with a well-qualifiedstall and a well-organized program for alcoholics Themethods of treatment used are basically the same asthose listed under "mental hospitals" but patientsusually are given more personal attention. Onedisadvantage is that some Indian patients might findIt difficult. to, fit into such a program, since thesehospitals are usually established for alcoholics from avery different background or way of lire

Counseling Programs

Group Counseling

This is a method of treatment in which a psychi-atrist or other trained person meets regularly with agroup of alcoholics or problem drinkers The leaderencourages discussion among the group concerningalcohol and its effects on the individual, family andcommunity. The alcoholics talk out their problemswith each other Those who have L-en successful ingiving up the habit describe their experiences for thebenefit of the others, while those who still needsupport are given encouragement by the other mem-bers of the group Often group counseling is suc-cessful in giving a patient with an alcohol problem anew outlook and new courage. Regular meetings withfull participation are nec...ssary for this method to hesuccessful.

Individual CounselingA personal discussion between a patient and a

trained worker such as a doctor, nurse, social workeror minister may be called individual counseling. Inthis type of treatment the patient knows he candiscuss his alcohol problem freely with someone whocares and who wants to help and that the counselorwill never laugh at him, or use this informationagainst him in any way ,

Counseling often helps the alcoholic to understandhimself and his problem better than he could byhimself He has the chance to describe his feelingsabout alcohol, about himself, his family, and his job.Individual counseling, like group counseling, usuallyrequires regular meetings, since it depends on thecounselor and the patient getting to know each otherfairly well

Community Alcoholism Councils

A community alcoholism council is a group ofpeople in a community who are interested in Joiningtogether to deal with the problems of alcoholism. Thecoun.ill may be independent or it may he set up bythe Tribal Council It often consists of ordinaryresponsible citzens, especially recovered alcoholics, aswell as some of the trained workers in the com-munity

An alcoholism council may have many functions,dependiMg on the interests of its members and thetype of -problem in the community. They maycoordinate existing services, hold educational meet-ings or cone& information on alcoholism from thehospital, clinic, police, welfare office and othersources, plan what is needed to improve services foralcholics and even seek grants for an alcoholismprogram from Federal or State agencies. Perhaps themost important Job for alcoholism councils, however,is to bring together people who understand thecommunity and who want to do something aboutalcoholism. Such a council, by its hard work, may beeffective in changing the attitude of the wholecommunity toward this problem

20

25