A man With a Problem

foreign since my last spell in hospital in June I'm to a drinking stage where my health has failed me once more I'm not sleeping at nights even with the help of alcohol or drugs I have been drinking since I was 18. I started on beer but in years to come it became too gassy for me so I I transferred to Whiskey and and then Brandy because it was cheaper and about the Locking for Brandy and and soon was drinking good quantities of it and then consequently my heart failed on me and then my liver it might ingestive system and and on my nerves and legs and arms my wife was stuck to me and looked after me when I was Ill but it affected the children they realized something was wrong and my little son had a nervous breakdown at the age of five he was in hospital and is still a very nervous child when he sees me drinking you know something is wrong and he's seen me fall over which kind of affects him when I was in my last full-time job a job which I was in for 14 years my wage was 28 pounds a week and I was spending up to eight or nine pounds a week and by the time I bought cigarettes and petrol for the car it did not leave my wife very much she had to skimp and save and make do and now I have a part-time job which brings in a total of 30 pounds a week and out of that I'm spending eight to ten pounds a week it's now January and I'm more in debt and the worries of being a failure to myself and my family have persuaded me to seek further medical attention to try to give away drinking and to to help get myself back to a normal life [Music] in 1959 I could not walk properly and I I went to the doctor and was told that I had dropsy I was immediately put into hospital and the cardiograph revealed what they called a berry berry heart which is caused by excessive alcohol then I was in the Queen Elizabeth Hospital with heart trouble where they diagnosed cirrhosis of the liver in the four-year period between April 1962 and February 1966 Doug has had four admissions to the medical Wards of the hospital the diagnoses on these occasions have been acute gastritis leonex cirrhosis cardiomyopathy megaloblastic anemia and peripheral neuritis in other words he has or has had most of the possible somatic complications of chronic alcoholism in addition during this four-year period he had a number of admissions to Mental Hospitals attended Alcoholics Anonymous meetings and had a number of clergymen social workers and Friends combining in efforts to help him he never stayed off alcohol after leaving hospital but at no time has he been certified he was referred for psychiatric consultation to the university Department of Mental Health towards the end of his fourth admission at this stage he suffered from a chronic anxiety state with secondary alcoholism an important factor contributing to this latter development was a job he had held a number of years previously which encouraged a high alcohol intake the ready accessibility of alcohol greatly accelerated the development of the habit and of both psychological and physical dependency the relative importance of this Habit Factor in the etiology and psychopathology was considered to be an indication for the use of a behavior therapy procedure rather than one of the better known and more Orthodox forms of management such as supportive or group Psychotherapy or the use of the drug and abuse the further reason for not using this drug was that the pattern of his drinking consisted of a rapid intake of alcohol over a short period of time if he had done this while taking antabuse the effects could have been serious if not dangerous particularly in view of his impaired liver and heart function a modern deconditioning procedure involves the use of a mild electric shock much of the experimental research with such therapy is being done by clinical psychologists when I had my first illness in 1959 I tried a mental hospital but it didn't make any impression there was no drugs no therapy to help you make a start and I found it didn't help me at all how can we offer help to a man like this such a complex problem has no simple answer many treatment methods are in use but no single one provides the complete answer we shall examine the approach which was used with Doug to see how a team of people may converge to offer help in a number of complementary ways the psychiatrist whom we have seen physically examining the patient who remains all the time in charge of Doug's case asks for help from his psychological colleague and working together in a therapeutic atmosphere will be seen trying to change the habit of drinking and putting something better in its place [Music] surgical examination is carried out this includes personality measurements and an assessment of what effect alcohol has had on thinking ability such testing provides further information enabling the psychologist to plan treatment appropriately as well as providing results which can be compared with those to be obtained later when treatment is over to understand the treatment procedure which will be based on conditioning techniques it is necessary to leave Doug for the moment and see something of what psychologists know of childhood experience in recent years psychologists and others have taken a closer look at the behavior of men and other living creatures to find out why we behave the way we do it is now clear that a great deal more behavior is learned than we once thought only a few very simple responses are unlearned among simpler creatures there are many examples of unlearned patterns of behavior like that of the moth which instinctively flies towards the light this Tropic behavior is something carried out by the whole creature the opposite Tropic response is seen in the Cockroach which always flees as quickly as possible except when being filmed away from light the Cockroach does not have to learn this response any more than a bird has to learn how to build its own type of nest as we grow older we retain a few reflex protective mechanisms perhaps the best known of these is the knee-jerk reflex [Music] but at the human level very few responses are unlearned those we do have involve one or other part of the body rather than the whole person the young baby does not have to be taught how to suck quite naturally he derives satisfaction both from the feeding experience and from the relationship with his mother he clings tenaciously and grasps strongly even when an attempt is made to pull away Beyond this very simple level however it can be shown that practically all our behavior is learned as the young child explores the things around him he finds that some bring pleasure that is they provide their own rewards and he is happy to repeat them some of the things he does bring approval from parents such external rewards reinforce the behavior to he will approach adults with a sense of trust and learn to repeat this as long as he is not disappointed he also finds the attitudes of his brothers and sisters are important other responses prove less rewarding so he learns that they are not worth repeating when the pattern of rewards and punishments proves consistent in a child's life he develops a sense of security learns to discriminate between approved and disapproved responses and so builds up predictable patterns of behavior if Doug has learned his habit by reward and Punishment why shouldn't he be taught to unlearn it by attaching electrodes to the arm a harmless shock can be given when he thinks about alcohol while he is rewarded for more acceptable responses a psycho galvanometer to measure emotional changes is used with an electrical stimulator so that the effect of giving shocks can be carefully measured since much of the alcoholic's problem is that his thinking revolves around alcohol it is worth starting an aversion to drink by giving shots when he thinks about it the second week was a series of slides shown on the screen and my arm was connected to a small voltage machine and the slides were various Family scene a motor car or words like calm an unpleasant and the others were dealing with alcohol such as a bottle of whiskey or a drink of spirit or or words like brandy and port and when those were shown on the screen I received an electric shock it was unpleasant but but not harmful I was controlling the slides with a press button switch and the ones that I didn't get a shock on I could Linger on and get myself relaxed again and the ones where I did get a shock I could switch over immediately and and thereby stopping the shock in the arm this procedure carries on several times a day for a week by which time conditioning against alcoholic ideas has begun during this time it is also necessary to provide other ways of handling anxiety than by taking alcohol to take away the drinking habit by conditioning without providing an alternative habit would be self-defeating so throughout the weeks of treatment Doug is introduced to techniques of relaxation before each aversive session he spends a few minutes learning progressively how to counter anxiety with relaxation at first there are many indicators of restlessness which show the therapist where relaxation can be applied effectively [Music] foreign [Music] gradually he changes from being tense and Restless all the signs of being on edge are marked on arrival he learns to take control of various muscle groups to the point that he can voluntarily achieve a state of extreme relaxation he learns to make better use of his lungs by breathing more evenly and deeply as time passes he not only comes to feel better but he looks more relaxed too the relaxing therapy consists of learning how to relax the body when you get tense and I find towards the late afternoon I I get very tense and I'll go looking for a brandy the relaxing therapy is such that you learn the various movements of the arm and stomach muscles and leg muscles how to relax them from a tense position coupled with regular breathing tests and the whole idea is is to be able to get you to relax when you feel tense or when you feel tension coming on [Music] it then remains to begin a version of alcohol itself Doug is again linked up to the galvanometer and electrical stimulator so that his response to treatment can be carried out precisely and measured accurately alcohol is provided in a series of five glasses together with orange juice in another five glasses sometimes beer is used sometimes other forms of alcohol so here's in a situation where he chooses between alcohol or orange juice [Music] normally when faced with such a choice the alcoholic would choose alcohol every time but now he receives a shock most times he takes a glass with alcohol in it he is instructed to drink the orange juice but to spit out the alcohol as he takes a drink of alcohol he receives a shock at the moment of drinking this is shortened by spitting out quickly in this way he is able to reward himself for rejecting alcohol and at the same time discriminate between alcoholic and other drinks this discrimination is built up in an operant conditioning situation using avoidance that is Doug's own avoidance of alcohol enables him to reduce or avoid the shocks he receives the sequence of drinking and receiving shots is repeated several times at each session and through several sessions a day in order to build up effective conditioning which will not quickly extinguish some sips of alcohol are not shocked but he spits out nonetheless this is known as intermittent reinforcements the conditioning procedure consists of linking alcohol with an unpleasant stimulus the shock so that the alcohol itself becomes distasteful while at the same time offering a reward for rejecting alcohol the unpleasant shock immediately stops foreign [Music] [Music] [Applause] ometer meantime measures his level of anxiety through electrodes placed on the palm a rise in the tracing reflects increased autonomic activity with Associated reduction in skin resistance a look at the record he traces after a week of this procedure shows that he reacts strongly when he receives a shock but his response is almost as strong when no shock is given this shows that conditioning against alcohol is beginning to prove effective so for three weeks the aversion is carried out regularly every day before each session and between sessions he continues to learn his new adjustment through relaxation a lot of other important things are happening too he has not been isolated and ostracized by Society but finds himself among a group of people who accept him while receiving treatment for other problems the easy friendly atmosphere where people eat and play together where one helps another makes not only for an increased feeling of ease but also a developing sense of self-respect relationships can be formed and problems discussed against a background of acceptance and understanding Doug became part of a family group of patients sharing the daily life of the ward taking part in various activities and receiving help from this environment as from a good home and again giving such help to other members of the family and patients as he was able to with this would first come a sense of being wanted then a sense of being needed the ward environment seemed a necessary part of the total scheme leading to Doug's recovery not only do others help Doug but most important Doug is learning to help himself eventually the psychologist decides that this therapy has continued long enough and refers dug back to the psychiatrist who decides that a return home is possible success or failure must in the long run hinge on what happens after leaving hospital treatment must include support and follow-up including reinforcement of the aversion it is not suggested that the aversive approach is the whole answer but it does offer a Fresh Approach to a difficult problem results with this type of treatment have shown that with an upper socio-economic group more than 50 percent of patients achieve abstention for at least a year as Doug goes home we need to ask what the future will hold for him Having learned new habits will he maintain them in the past Doug has always gone straight back to the bottle so how should we measure success aversive conditioning with relaxation seems to help many people who would not benefit from other methods of treatment is it worth asking why it is clear that many things and many people together have helped Doug this far now Doug is helping himself it remains to be seen whether others will rally round or reject him the community too has its responsibilities towards this man with a problem [Music] foreign foreign