I. ALCOHOL AND OTHER DRUG ABUSERS WITHIN THE PROFESSION

II. BASIC CONCEPTS

• Definition of Terms
• Characteristics of Problematic Use
• General Warning Signs on the Job
• Common Physical Signs
• Common Behavioral Patterns
• Case Examples

III. INTERVENING WITH SOCIAL WORKERS

• Common Doubts about Intervening with Colleagues
• Models of Intervention
• Employee Assistance Program Model
• Supervisory Model
• Peer Assistance Model
• Intervening with a Supervisor or Administrator
• Guidelines for Intervention

IV. TREATMENT RESOURCES

• Information and Referral
• Intervention Services
• Detoxification
• Alcohol and Drug Rehabilitation Facilities
• Out-Patient Services
• Self-Help Groups

V. CONCLUSION

VI. INFORMATION REFERRAL AND RESOURCES

VII. REFERENCES

I. ALCOHOL AND OTHER DRUG ABUSERS WITHIN THE PROFESSION

Most people In this country grow up with inconsistent, ambivalent attitudes toward alcohol and other drugs and are confronted with many conflicting messages about their use. In the absence of cultural norms or clear societal prescription, the majority evolve a personal value system which includes the social use of a substance and suffer few if any bad consequences.

Some people, however, use alcohol and other drugs in a manner that creates problems for themselves, their family and friends, and even their colleagues in the workplace. Social workers are no exception. Moreover, when social workers' functioning is impaired by their use of alcohol or other drugs, the impairment influences the quality of their service to clients. Studies of social workers recovering from alcohol and drug abuse have indicated that these social workers were not confronted by colleagues about their abuse in spite of severe symptoms which were apparent on the job (Bissell, Fewell & Jones, 1980). Furthermore, social workers whose family members or close friends are substance abusers, also suffer consequences in their personal and professional lives (Fewell, King & Weinstein, 1993).

The NASW Code of Ethics states that a social worker who has direct knowledge of a social work colleague's impairment due to personal problems, psychosocial distress, substance abuse or mental health difficulties should consult with that colleague and assist the colleague in taking remedial action.

This publication, by the Peer Consultation Committee of the New York City Chapter of National Association of Social Workers, provides information to help social workers determine whether a colleague has a problem with alcohol or other drugs and suggests ways to intervene constructively.

II. BASIC CONCEPTS

Definition of Terms

Much confusion exists among professionals about how to identify alcohol and other drug abuse. The American Psychiatric Association (DSM lll-R, 1987) uses the diagnosis of "Substance Use Disorders" and differentiates between "abuse" and "dependence" of all psychoactive or mood altering substances.

The DSM lll-R (APA, 1987) defines "substance abuse" as the continued use of a psychoactive substance despite experiencing social, occupational, psychological, or physical problems, or the recurrent use in physically hazardous situations such as driving while intoxicated. Individuals are diagnosed as dependent on a substance if they show at least three of the following nine symptoms:

1. if they repeatedly take more of a substance, or for a longer period of time, than they Intend

2. if they know that they are using too much but are not able to stop

3. if they spend much of their time obtaining the substance, being intoxicated, or recovering from its effects

4. if they are unable to fulfill social, family and work obligations because of intoxication

5. if they give up most of their other activities in order to use the substance

6. if they continue to take the substance in spite of the knowledge that it is interfering with their psychological or physical health or social functioning

7. if they develop tolerance to the substance thus necessitating an increase in the dose in order to preserve the original effect

8. if they manifest withdrawal symptoms, or

9. if they use the substance to relieve or avoid withdrawal symptoms.

Characteristics of Problematic Use

It is evident that there is no single symptom that is absolutely definitive when deciding whether to be concerned about someone's drinking or drug use. There is, rather, a broad picture that shows either an increasingly destructive pattern over time, as is the case with alcohol use, or a more dramatic shift in behavior as seen with the use of cocaine or "crack."

The symptoms of alcoholism or other drug dependence can easily be mistaken for other problems. For example, the sedative effect of alcohol, sleeping pills, barbiturates or minor tranquilizers such as Valium ingested steadily over time can be mistaken for depression. Similarly, the intense low that follows the powerful cocaine/crack high, along with the anxiety, fatigue, irritability, fearfulness and insomnia that occur when the drug wears off, can also be mistaken for depression or anxiety. These effects will disappear only after weeks or even months of abstinence.

The agitation of beginning withdrawal from alcohol and other depressants can be mistaken for psychologically caused anxiety or insomnia. The person definitely feel' anxious, at times fearful, but for undefinable reasons. A such times use of minor tranquilizers may begin, thus perpetuating the sedative cycle and risk of dual addiction. These seemingly emotional problems will not be resolved until the substance abuser is treated and abstinence is established.

Addictive patterns of drug use are set up as a result of the user's developing increased tolerance to the substance over time, which means an increasingly greater amount is needed to achieve the same mood change as the body becomes accustomed to the substance. Addiction also results from the user's efforts to mitigate withdrawal effects. All mood changers produce withdrawal effects which are the opposite of what the person was trying to achieve. Thus withdrawal' from the calming, relaxing. effects of alcohol includes tremulousness, agitation, anxiety; and withdrawal from cocaine includes lethargy and depression. The situation becomes more complicated when abusers use varying combinations of substances such as alcohol, marijuana₁ cocaine, heroin, amphetamines, or prescribed minor tranquilizers and sleeping medications such as Valium; Xanax, Halcyon, Ativan, etc., to prolong or reach the-"high" or to ease the withdrawal effects as the drug wears off.

One key sign of addiction is the phenomenon of loss of control. During the development of addiction, the individual is usually able to control whether or not he or she will drink or use drugs on any given occasion and how intoxicated s/he will become. Over time, however,' the individual loses the ability to control the frequency and the amount of alcohol or drugs consumed. At times, the drinker or drug user may opt for periods of abstinence in order to demonstrate that s/he can "control the use of the substance." However, any problem, stress, or even an apparently pleasant occasion can trigger a return to uncontrolled drinking or drug use.

An almost universal aspect of drug and alcohol' abuse is the reliance on such defense mechanisms as denial, rationalization and projection (Fewell & Bissell, 1978). These defenses make it difficult for the abuser to correctly assess his/her behavior and its impact on others (Straussner, 1993). One other dramatically induced effect of taking drugs is the phenomenon of "euphoric recall" (Johnson, 1986): Once the users brain chemistry has returned to normal, only the pleasant effects of the "high" are vividly recalled. The sickness and unpleasantness of the withdrawal effects become minimized and discounted by the user. This is one compelling reason why others who have observed the consequences of the use need to be willing to represent reality-40 confront the substance abuser with what has really happened. This Information is not accessible to the person since his/her recall of the experience is distorted by the experience itself.

General Warning Signs On The Job

Some drugs have effects which are more easily observable on the lob, while others are difficult to detect except during withdrawal (e.g. heroin). The following are some of the physical and behavioral signs which may be observed on the job:

1. Drinking on the job or smell of alcohol on breath.

2. Red face, bloodshot eyes, puffy or bloated appearance.

3. Slurred speech.

4. Tremulous hands.

5. Time lag in verbal response.

6. Poor coordination.

7. Transient lethargy.

8. Frequent watery eyes and/or sniffling.

9. Rapid speech.

10. Hyperactivity.

1. Erratic work performance or loss of interest in the job developing in a colleague who has previously been steadily productive. This pattern may simply show a decline in performance or it may alternate between being under-productive (or absent) and over-productive.
2. Marked rapid changes in mood especially if they occur following a coffee or lunch break or a trip to the bathroom. A colleague may appear tense, irritable and depressed at times during the day, especially in the morning, and mellow and good humored or full of confidence at other times.
3. Absenteeism and tardiness. Many alcohol and other drug abusers arrive late, leave early, take long lunch breaks and are frequently absent particularly on Mondays, Fridays, before and after holidays, or for vague health reasons.
4. Increasing instances of poor judgment, forgetfulness or repetitiousness.
5. Difficulty in concentration.
6. Increasing suspiciousness.
7. Being seductive or demonstrating otherwise inappropriate behavior with clients or colleagues.
8. Inattention to dress or hygiene in a usually well-groomed person.
9. Frequently borrowing money from co-workers.

The following vignettes, which are based on disguised clinical material, illustrate some of the prototypical symptoms and behaviors which have been exhibited by substance abusing social workers.

This colleague is using a combination of alcohol and tranquilizers during the day and sleeping medications at night, thus keeping himself on one sedative or another around the clock in order to avoid the painful withdrawal effects. He avoids using alcohol during the day when the smell may be detected. He is trying his best to compensate for his loss of coping ability, let alone his previous creativity, by an over-productivity in some areas. He has begun experiencing blackouts (chemically induced amnesia) with their accompanying anger and disbelief when confronted by the facts of the situation.

A colleague who is well-respected by other social workers in her department has begun to show an erratic work performance and unexplained mood swings. The degree of her anger over her job frustrations seems out of proportion. Lately she has begun to disappear for several hours at a time and has been found in her office sleeping. At other times she appears hyperactive. At a recent staff meeting she appeared to have difficulty sitting still and was shifting constantly In her chair. She complains frequently about her allergies and often is reaching for tissues to wipe her nose. She has been absent on several Mondays with vague physical complaints. Her co-workers have noticed a marked weight loss. When some of her colleagues shared their concerns about her with each other they realized that she has been borrowing money from all of them during the last few months.

This colleague is showing signs of cocaine abuse. The physical signs of cocaine use can be seen in the constantly runny nose and difficulty sitting still. When she disappears into her office she is "crashing" or sleeping after many hours of staying awake at night due to the stimulant effect of the cocaine. At other times she is using cocaine on the job to counteract the sleepiness and lethargy which are part of the rebound effect accompanying cocaine withdrawal. Her inappropriate anger is indicative of the moodiness caused by the hyper-alertness resulting from the stimulant effects of cocaine. The serious nature of the addiction is indicated by her physical deterioration, her erratic work performance and loss of control over her finances.

III. INTERVENING WITH SOCIAL WORKERS

Even if a social worker identifies a substance abuse problem in a colleague, there is a tendency to avoid confronting the person. Frequently the worker deals with the situation by filling In for the impaired colleague. However this may lead to the paradoxical consequence of perpetuating an alcohol or drug abusers dysfunctional behavior and create stress for those involved. This is called "enabling" (Levinson & Straussner, 1978).

Signs of abuse or dependence evident to professional colleagues are frequently rationalized or ignored, since there is a natural reluctance to intervene In what seems to be a colleague's private life. Telling a colleague that one thinks he or she may have a problem with alcohol or drugs may seem like making an accusation or unwarranted diagnosis. In contrast, we do not usually find it difficult to suggest to a colleague who is showing signs of depression that therapy could be helpful. In addition, people can often be counted on to get help for themselves when they are feeling depressed since the feeling of depression is experienced as painful and is a signal that something Is wrong. Alcohol and' drug abusers, however, tend to deny their problems. The abuser must therefore have the effects of his or her behavior presented from the outside either by a crisis resulting from the abuse, or hopefully, before that occurs, by caring people who can present the Information in a non-judgmental way. This external' feedback by others is known as "intervention" (Johnson, 1987; King, 1986).

Common Doubts About Intervening with Colleagues

The following views frequently deter people from intervening with a substance abusing colleague:

The following models can be used to help a substance abusing colleague. Which option is selected depends on a variety of factors such as agency structure and atmosphere, the nature of the work relationship and whether personal contact and friendship exist outside of the workplace.

Employee Assistance Program Model

Many social workers employed in large voluntary settings, such as hospitals, and all those working for the federal government and many state and local municipalities have access to formal Employee Assistance Programs (EAP) which provide free assessment, information and referral services to the employees and their families (Straussner, 1990). These services are strictly confidential and will not provide any identifying data to employers.

The EAP model is based on either a self, colleague or supervisory referral of the impaired worker. A concerned colleague may consult with the EAP to discuss various options regarding the situation or suggest that the social worker contact the EAP directly. A supervisory referral can be effective provided the agency policies adequately protect the workers job while treatment is obtained. The EAP model is based on documentation of diminishing job performance and referral to either an in-house or external EAP (Straussner, 1988; Scanlon, 1991). Failure to follow through might result in job jeopardy and/or job loss. This model has not been used much in social work employment where diminishing job performance is often difficult to document since much of the workers interaction takes place in private and clients themselves are seldom in a position to complain.

Supervisorv Model

If an agency does not have access to an EAP, the supervisor is in a unique position to intervene by using job performance as the focus. The supervisor can present to the worker, with concern, the impact of the worker's behavior or performance on clients, other staff and the supervisor. Acknowledging that the worker seems to be having a problem beyond the work situation, the supervisor can strongly recommend that the worker seek consultation and/or treatment and inform the worker that job performance will continue to be monitored.

Peer Assistance Model

When there are growing suspicions that a colleague's job performance difficulties are related to substance abuse, the first thing that might be done is to seek out several other colleagues to see whether they have been aware of similar problems. Frequently this is the case.

The goal in approaching a colleague with a drinking or drug problems is to communicate in a clear, specific, non-judgmental way the concern you have for him/her, the direct experiences you have observed and the effect that these experiences have had on you. Your message should contain three parts: 1) the facts, 2) how you felt, and 3) the consequences for you. While we cannot act as therapists for colleagues, we can make them aware of the impact of their behavior on us. For example, rather than saying. "You came to the staff meeting drunk after lunch the other day," giving only the facts would be much more effective: "You came to the staff meeting with the smell of alcohol on your breath, slurred your words and laughed Inappropriately at times." Adding how you felt and the consequences you experienced further penetrates denial. "I felt embarrassed because I had invited a guest speaker whom I had told about your good work and he was eager to talk with you."

While each situation needs to be evaluated individually, often a presentation of facts by more than one person is more convincing to a colleague. It may also be Important to the people making the presentation to have reinforcement and validation of their view of the reality of the situation. if you are personally affected by your colleague's drinking or drug use by doing extra work or covering up for him or her, then you may be in an especially good position to present facts useful In confronting denial. Although it is more difficult to speak for yourself and give your own reactions, this approach Is more helpful and is experienced by the receiver as less critical and accusing. If the colleague Is a personal friend, you may have information from contacts outside working hours which you may wish to bring in to reinforce your concern.

It is important that you choose people who you feel can be sympathetic to the colleague and who you trust to be discreet. Meeting together to share your observations is an important first step because it gives you a chance to evaluate your concerns more objectively. It may be necessary to get more information about alcohol or drug abuse in order to understand the colleague's situation. You may also wish at this point to bring in a consultant from the alcohol and drug field who can give you practical information and a viewpoint outside your own system. Many private substance abuse agencies are willing to provide such a free consultation.

If you decide to confront the colleague with your observations and concern, you must be prepared for a variety of responses. The denial may cause the substance abuser to react with rationalizations about the many personal problems he or she is having and to engage you in a conversation about the underlying reasons for the abuse. Denial may also cause the colleague to react to your observations with anger. The drinking or drug taking may now be such an important part of that person's life that he/she cannot imagine doing without it. It is important not to expect to have your colleague give you a positive response or validate your observations. You cannot control the outcome of your contact. Speaking once or several times to substance abusers may not have visible impact. But we know that what tends to help is an accumulation of interventions over time. Taking some action is crucial, since without it the colleague's continued substance abuse may have tragic consequences.

Intervening With A Supervisor Or Administrator

Sometimes workers find themselves in the difficult position of having a supervisor or administrator who has an alcohol or other substance abuse problem which is affecting his/her work. An outside consultant may be helpful in weighing alternative ways to deal with the situation. It may be that some of the supervisor's own peers, friends or family known to the work group are also concerned about him/her and that several workers might make an appeal to them to join the effort to confront the supervisor. However, there may be realistic concerns about the loss of job or retaliation if action Is taken to report the supervisor and these must be considered carefully.

Guidelines for Intervention

Below are summarized guidelines to assist with intervention with a colleague or a supervisor:

DO

1. Be clear, factual and specific. Generalizations often sound judgmental.
2. Use incidents where you personally have been affected, burdened or harmed in some way. Speak for yourself in the first person.
3. Let your colleague know of your concern for him or her.
4. Express your knowledge that help is available.
5. Know the kinds of resources which are available and some specific telephone numbers your colleague can call.
6. Offer hope.
7. Be prepared for a reaction of denial, even anger.
8. Be prepared to make your observation without expecting agreement. ("That is what I observed. I wanted you to know I was concerned.")

1. Do not get involved in a discussion about why the person is using alcohol or drugs.
2. Do not argue with denial or rationalization.
3. Do not be reproachful or induce guilt.
4. Do not try to monitor your colleague's drinking or check on him/her in any way.
5. Do not predict disaster or add to your colleague's fear.
6. Do not expect or invite a confession.

Alcohol and drug treatment resources range on a continuum from pre-treatment to after-care facilities. They include in-patient and out-patient settings and espouse a variety of approaches and treatment philosophies ranging from total abstinence from all chemicals to methadone maintenance.

The following treatment resources are the most likely to be utilized by social workers:

Information and Referral Services

Most communities today have alcohol and drug information and referral services. These include state and local governmental facilities, as well as voluntary agencies such as the local affiliates of the National Council on Alcoholism and Other Drug Dependencies.

There are a number of worthwhile books and pamphlets about alcoholism and drug addictions, many obtainable from local self-help or 12-step programs, the National Council on Alcoholism, local alcoholism councils₁ and even the public libraries and book stores.

Some NASW chapters have specialized committees which can provide alcohol and drug information services.

Intervention Services

Based on the model of Vernon Johnson (1986), "Intervention" facilities and practitioners train family members and concerned others how to confront and motivate an alcohol or drug abuser to enter appropriate treatment (Casolaro & Smith, 1993).

Detoxification

The purpose of detoxification is to avoid the untoward consequences of acute withdrawal from oploids, alcohol, barbiturates, other sedative hypnotics and amphetamines, i.e., tremors, nausea and vomiting₁ acute anxiety and, in more severe cases, alcoholic; hallucinations and/or convulsions. Detoxification from-alcohol takes approximately 3-5 days and is usually accomplished in a hospital in order to allow careful monitoring of physical status and to prevent potentially lethal withdrawal reactions. Detoxification from other substances varies and may take several weeks or longer. While cocaine abusers may not need a formal detoxification, the initial phase of cocaine withdrawal can produce intense depression. Whether or not detoxification is needed is best determined by an addiction expert.

Alcohol and Drug Rehabilitation Facilities

Alcohol and drug, or chemical dependency rehabilitation facilities are an intensive and highly structured form of residential treatment with the specific goal of helping the alcohol or drug abuser begin the process of learning how to live without chemicals.

The length of stay for traditional alcohol rehabilitation varies between 14 and 28 days, while in-patient treatment for other drugs may last 3 months or longer. Although the achievement of any degree of physical and psychological comfort takes much longer, the initial in-patient stay can give a person crucial protection from alcohol and drugs and allows the individual to learn or re-learn some of the tools for coping with life and people in a sober and drug-free state.

Intensive out-patient rehab programs provide the focus and many of the elements of in-patient treatment while allowing people to maintain their jobs and live in the community.

Not everyone needs "rehab," but it can be a particularly important phase for some professionals who face unusual social pressures to use alcohol or drugs, or have been unable to stay off these substances in their previous attempts at recovery.

Out-Patient Services

Out-patient services range from intensive daily treatment to weekly individual and/or group therapy, educational lectures and/or discussions. In general, individual psychodynamic-oriented psychotherapy is not recommended until an individual is quite secure in his/her abstinence from alcohol or drugs since the anxiety aroused during treatment may lead to the resumption of drug usage. However, if a social worker Is making serious efforts to abstain from drug and alcohol use, ego-supportive therapy with a cilnician who is knowledgeable about drug and alcohol treatment can be helpful (Straussner, 1993).

Self-Help Groups

Self-Help Groups or "12 Step Programs" such as Alcoholics Anonymous (M), Narcotics Anonymous, Pills Anonymous, Cocaine Anonymous, etc., have proven to be particularly helpful to social workers and are available in every community throughout the United States (Spiegel, 1993). Since groups tend to differ widely, it is wise to get some advice about which groups might be suitable for a particular person. Twelve Step Intergroup offices (available in all large cities) are a source of information on convenient meetings and offer immediate consultations for active alcohol or drug users as well as information on local treatment facilities.

In some communities, the self-help group Social Workers Helping Social Workers is an important resource for social workers who have had experience with drugs or alcohol abuse themselves or in their families.

Self-help groups for friends and families of substance abusers such as Al-Anon, Co-Anon and NarAnon, help those concerned about an alcohol or drug abuser understand the nature of the problem and learn a more effective way of dealing with the abuser and with oneself.

V. CONCLUSION

Being faced with a colleague's alcohol or drug abuse presents the social worker with the painful conflict about whether to intervene or not. This pamphlet addresses the facts and feelings behind this difficult choice. One social worker who answered a questionnaire about personal experiences with substance abusing colleagues summarized the essence of this dilemma: " the question I have most often had to ask myself in dealing with problems among my colleagues, be it alcoholism or anything else, is why I should do less for a colleague, let alone a friend than I would for one of my clients?" Your decision to intervene may save your colleague's life and protect clients.