Confronting Substance Abuse

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Confronting Substance Abuse

Use, Abuse & Dependence: How are They Different?

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What is the difference between someone using alcohol and drugs, abusing them and being dependent on them? People throughout recorded history have always found a way to chemically escape the routine of day-to-day life, or to seek an altered state of consciousness. To expect that we will ever completely wipe out this desire is foolish. However, there are customs, traditions and laws that attempt to govern the use of substances so that a minimum of harm is brought to individuals and society. As with most individual decisions about things that can potentially bring us harm, free will is an important component of one's decision to use alcohol and drugs.

Because of the anesthetic properties of alcohol and drugs, they often become an easy target for abuse by someone who may be experiencing emotional and psychological difficulties. This does not necessarily mean that the individual is dependent on them. It could be a time limited abuse pattern that may or may not disappear whenever the difficulties are behind him/her. Abuse can often occur developmentally, i.e. as a way of fitting in during adolescence, or a means of easing some of the difficult challenges that growing up often provides. An example of this is often seen on college campuses where a style of drinking alcohol may be considered "alcoholic drinking", yet once the students are out of that setting, they find that they can give up drinking altogether, or cut down on their drinking behavior considerably without any difficulty. This would be seen as a temporary pattern of abuse. Can abuse lead to dependence? I believe so. I have seen this happen many times, even when there does not appear to be a family history of alcoholism.

Substance dependence is defined in the American Psychiatric Association's diagnostic manual (DSM-IV) as a pattern of substance use, leading to clinically significant impairment or distress, as manifested by three or more of the following, occurring at any time in the same 12 month period:

  1. Tolerance, as defined by either of the following:

    1. a need for markedly increased amounts of the substance to achieve intoxication or the desired effect

    2. markedly diminished effect with continued use of the same amount of the substance

  2. Withdrawal, as manifested by either of the following:

    1. the characteristic withdrawal syndrome for that particular substance (e.g. with alcohol withdrawal: sweating or pulse rate greater than 100, increased hand tremor, nausea or vomiting, anxiety, seizures, hallucinations, etc.)

    2. the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms

  3. the substance is often taken in large amounts or over a longer period than was intended

  4. there is a persistent desire or unsuccessful efforts to cut down or control substance use

  5. a great deal of time is spent in activities necessary to obtain the substance (e.g. visiting multiple doctors or driving long distances) use the substance (e.g. chain smoking), or recover from its effects

  6. important social, occupational or recreational activities are given up or reduced because of substance use

  7. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g. continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

Because denial is always one of the largest symptoms of substance abuse, it is almost impossible for someone who is physically dependent to self-diagnose. Most substance abusers will only get help because they have to. And the three biggest reasons are pressure from family (threat of separation or divorce), employer (threat of job loss) and/or the courts (DWI).

How Can I Talk to Someone I Supervise about His/Her Substance Abuse Problem?

Without a doubt, this is always one of the most difficult aspects of being a supervisor, so much so, that most supervisors ignore the problem when it appears and hope that it will go away all by itself. Forget it, substance abuse problems only get worse and it is your responsibility to address them. How? First of all, don't try going it alone - it is usually too difficult. Always call the FSAP (x48170 or x48099) to get some support and input as to how to best address the problem with your employee/co-worker/family member. In the meantime, consider these points:

  • Always deal directly with the employee in a face-to-face meeting. Keep the meeting both private and confidential. This includes typing your own memos rather than allowing someone else to do it.
  • Treat the employee with respect. Most supervisors are very angry by the time they are ready to speak with the employee. Try to not allow your anger to cloud the issue or to treat the employee disrespectfully.
  • Stay relaxed and non-judgmental. Focus on job performance deterioration. Prepare ahead of time by documenting specifics. Do not talk in generalities. Be able to backup your concerns. DO NOT FOCUS ON YOUR SUSPICION OF SUBSTANCE ABUSE.
  • Avoid threats of discipline unless you are prepared to carry them out - substance abusers will always know when you are bluffing. They will not change unless they absolutely have to - and that is only when they know that you mean business.

It is rare that an employee will follow through with your recommendations to go to the FSAP the first time around.  Here are some tips for overcoming barriers that may arise when addressing an employee's performance problems:

Denial: The worker denies there's a problem, and insists that you or another employee are out to get him/her. Suggested response: Stay calm. Keep at hand documentation of the employee's job performance or conduct, remain focused on performance issues, even though they may want to talk about personal issues that are causing the performance issues.

Threats: The employee threatens to see a lawyer, make a scene at work, quit immediately. Suggested response: Remind the employee that he/she may do whatever they choose; however, your own responsibility as supervisor is to uphold the university's policy and find a solution to mutually benefit the organization and the employee. If you think you are losing objectivity or need help to resolve a conflict, ask another supervisor or manager for help.

Rationalization: The employee makes excuses in order to avoid the real issue: "If this job wasn't so stressful, I wouldn't be making so many mistakes..." Suggested response: Avoid letting the excuses distract you; stay focused on work performance, let the person know help is available by calling the FSAP.

Angry Outburst: The employee gets angry, cries, yells or screams-to scare you off and make you drop the issue. Suggested response: Don't react. Give the employee time to cool down, then continue where you left off. If necessary, reschedule the meeting.

Allow this thought to motivate you: over 85% of alcoholics get better when they are confronted by their supervisor at work and are sent to the FSAP. You will not only have a more productive employee but you may have saved a life.

What Do I Do When An Employee is Under the Influence at Work?

When a supervisor suspects that an employee is currently unfit for duty, immediate referral for medical evaluation according to the guidelines below is the appropriate action. It is always better to refer the employee when you detect the problem, rather than after he/she has returned the following day.

When an employee does not appear to be fit for duty, the supervisor should immediately inquire about his/her physical condition but should be aware that physical symptoms usually related to alcohol/drug use may apply to other health problems as well. If, in the opinion of the supervisor the employee is currently unfit-for-duty, he/she should take the following steps:

  1. If the employee appears unfit-for-duty, first call Staff Relations at (301) 405-0001.  They can advise you as to whether or not the employee should be driven to the Health Center (or to the hospital or Campus Police when the Health Center is closed) for a fitness-for-duty evaluation. If the employee refuses to go to the Health Center or the hospital, contact a family member to make arrangements for the employee to be picked up from work. DO NOT ALLOW THE EMPLOYEE TO DRIVE. Depending on the circumstances, it may be necessary to call an ambulance or the police (x53333).

  2. It is helpful if you alert the Health Center before bringing the employee. You may contact either Mr. Tom Ruggieri (x48170) or the Appointments Desk at 301-314-8184.

  3. After conducting a physical examination, the Health Center physician will inform the supervisor of whether the employee is:

    1. able to return to work

    2. is being detained in the Health Center for bed-rest or some other time-consuming treatment

    3. has been referred directly from the Health Center to an outside medical facility or

    4. has been advised to go home.

  4. If the employee is being required to go home, it becomes the responsibility of the supervisor, not the Health Center, to make sure that arrangements are made for the employee to make it home. He/she should not be allowed to drive or take a bus home. Ideally, if a family member can pick him/her up, that would be preferable. If no other means of transporting him/her home is available, call the campus police. Supervisors transporting an intoxicated employee home would be the absolute last choice.

  5. When the employee has been advised to go home, the Health Center physician cannot divulge the reason why, but can only tell you that the employee is unfit for duty. When that occurs and the immediate problem of getting him/her home safely and away from others is solved, it is important to then address whatever disciplinary action and counseling needs are necessary.

  6. Whether and how an employee is disciplined for being unfit-for-duty varies from one department to another. The Staff Relations Department (x55651) will be able to advise on this matter.

  7. It is extremely important that the supervisor follow-up with the employee by talking with him/her directly about reporting to work unfit-for-duty and referring him/her to the Faculty Staff Assistance Program (FSAP) at x48170 or x48099.

  8. If the employee is sent home, a follow-up visit will be scheduled with the FSAP Counselor and a return-to-duty evaluation must be conducted at the Health Center before the employee is allowed to return to work.

Addressing Faculty Alcoholism

It is important to provide a working definition of alcoholism in order to understand the complex problem of what to do about it in the faculty ranks. Alcoholism can be seen as drinking that contributes to a continuing problem in any area of an individual's life and that the drinker seems unable to control through the normal exercise of will (Donovan, 1990). Employee assistance programs (EAP's) are ideally suited to address problems of alcoholism in universities with a majority of the workforce, i.e. the non-academic employees. In fact, over 500 Faculty Staff Assistance Program (FSAP) clients have been evaluated and referred for treatment for alcoholism and drug abuse since 1988. A very small minority have been faculty.

This is a rather common phenomenon on most campuses throughout the country. The problems of identifying and treating alcoholic professors has been well documented (Donovan,1990; Thoreson, 1983; Roman, 1980). The rate of alcoholism amongst professors appears to be no greater or no less than other populations. The difference, however, is that most alcoholic faculty are able to drink in a dependent fashion with fewer adverse social and occupational consequences. In " The Professor at Risk: Alcohol Abuse in Academe" Thoreson explains that professors "... work in an environment of low supervision, low visibility of performance, freedom from time demands, and vaguely defined and non-enforced standards of performance, a veritable Mecca for both scholarship and alcohol abuse." What makes referring an impaired faculty member for counseling different from referring anyone else is the lesser amount of leverage that most department chairs feel they have.

Paul Roman further identifies four barriers to identifying alcoholic faculty members:

  1. a paucity of success in the measurement of academic performance;

  2. guild-like protection of faculty;

  3. a limited distance between faculty and their "supervisors";

  4. minimal agreement on what constitutes good performance.

Without good performance indicators available to department chairs, the idea of confronting a colleague about a problem that most people see as "personal and none of your business" becomes unthinkable.

The irony in all of this is that more alcoholics have recovered as a result of pressure from the workplace than any other way. It has been demonstrated that most alcoholics will leave their homes and families five years before they leave their jobs.

When alcoholism has reached a point where all activities are scheduled around drinking, families often become an inconvenience. A separation or divorce also fits into an alcoholic's defensive way of perceiving all of his/her problems as attributable to his/her spouse. Losing a job, on the other hand, is a harder reality to brush away. Most alcoholics are willing to do anything to prevent that from happening. Sometimes, even getting sober.

The one rule of thumb that is most important when confronting faculty members about their drinking is to not mention your suspicions about whether or not you think they are alcoholic. You are not in a position to evaluate that. Simply put, your job is to evaluate their performance and to do whatever you can to urge them to get help. Once they have taken that step, an evaluation of their drinking can be done in a confidential setting through the FSAP, without the department chair knowing the results of that evaluation. Most people will feel more comfortable with that arrangement than having to be honest about their drinking with someone that could make life difficult for them. The referred professor is almost always encouraged by the FSAP staff to sign a consent form allowing discussion between him or her and the referring chair. In most cases, faculty will agree to do this, especially when they are aware that the chair is supportive of their recovery.

Understanding that the role of the department chair is not one of a diagnostician, there are still some performance indicators that one can look out for. Richard Thoreson, the Employee Assistance Program Director at the University of Missouri, has identified the following characteristics:

  1. A narrowing of job performance. The academic alcoholic performs as well as he or she did in previous years, only in a much narrower domain.

  2. Work task simplification. The quality of work is still relatively high, but the tasks completed are pedestrian in nature.

  3. Dependence on past learning. Remote memory for the academic alcoholic is intact, but short-term memory for current events is impaired. Thus, lectures tend to focus on problems and theories that were popular during the "early days" of the academic's career.

  4. Student Complaints. Complaints by students about teachers are legion. In the instance of alcoholism, however, student complaints will focus on the professors' arrogance, confusion and outdated lectures.

  5. Irregular or non-existent office hours. Regrettably, the tendency toward outdated lectures and irregular office hours is sometimes all too common and consequently, cannot always be seen in isolation as an indicator of alcoholism.

  6. A surprising gaffe or departure from high performance. An example of this would be a professor who blacks out and forgets to give his final examination.

  7. Increased obsession (and reduced efficiency) with work to the exclusion of all other activities. Though it is difficult to distinguish this work obsession from normal obsessive behavior of executive professional types, an accompanying lack of efficiency may help to differentiate it.

  8. Chronic, free-floating anxiety and low self-esteem seem common to virtually all such alcoholics. The external appearance of normalcy and competence is maintained at a price of internal squalor.picture of some flowers in a greenhouse

  9. A greater emphasis on telephone contact to the neglect of face-to-face conversation.

  10. Meticulous attention to dress (in the middle stages) and neglect of appearance and dress (in the later stages).

  11. Physical signs, serious accidents, injury and health problems. In the more advanced stages there will be cigarette burns on clothing, bruises, facial varices, cuts, gross tremors, serious accidents, injury and health problems.

These signs and symptoms are a general indicator of what you may see in an alcoholic faculty member. Be careful not to see any one of these in isolation as "proof." Confronting an academic alcoholic is never easy and something you should not go into alone. While there are some similarities, it is important to look at every situation differently. Calling the FSAP counselor to help you to prepare for a confrontation is advised.

Legal Considerations

There are two legal considerations that I am aware of that affect substance abusing faculty members. The Rehabilitation Act of 1973 (later amended as the Americans with Disabilities Act of 1990) has always viewed alcoholism as a handicap and, as such, is entitled to a “reasonable accommodation.” In the past, a reasonable accommodation was always seen as a referral to an employee assistance program. There is some confusion over the new Americans with Disabilities Act and we may not know the status of this until a test case emerges. It would appear to be safe, however, to always err in the direction of providing help rather than ignoring the problem. Our legal department would certainly be in a better position to advise in this area.

The second legal consideration involves the Drug-Free Workplace Act of 1988, an executive order initiated by then Governor Schaefer. Among other things, this Act requires specific actions to be taken for all employees convicted of any on or off-the-workplace alcohol driving offense:

  1. On the first conviction, the employee is to be referred to the FSAP, and in addition, is subject to any other appropriate disciplinary actions;

  2. On the second conviction, at a minimum, be suspended for at least 5 days, be referred to the FSAP, be required to participate successfully in a treatment program, and in addition, be subject to any other appropriate disciplinary actions, up to and including termination;

  3. On the third conviction, be terminated.

The number of alcohol-related convictions is counted from when the Drug-Free Workplace Act was actually implemented, i.e. 1989.

While convincing a faculty member that their drinking is problematic can be extremely difficult, knowing exactly where to send that individual for help can sometimes be just as complicated. The network of referrals that the FSAP utilizes is, in many ways, the core of the program. Utilizing the referral network encompasses the “managed health” portion of the FSAP in that employees are referred to a facility or practitioner based on their clinical needs; their “readiness” to begin addressing their problem; confidentiality; and cost considerations.

When an alcoholic client decides to meet with an FSAP counselor, there are a variety of levels of denial that he/she has about his or her own drinking. If we are lucky, he or she is able to accept it as a problem and is willing to do whatever it takes to address it. This makes our range of referrals that much more varied. On the other hand, an alcoholic academic may still need to be convinced that his or her drinking is problematic, and may only be willing to participate in treatment on a very limited basis, if at all.

Second, confidentiality plays a major role in where and how an individual will accept treatment. Being able to utilize facilities outside of the immediate geographical area insures confidentiality to someone who sees that as paramount. Being away from work for a month or so is oftentimes not an option, even though the clinical need for such a treatment may be indicated. An alternative for this individual might be a treatment program that allows him or her to stay at work every day and receive treatment in the evenings, after work. The range of treatment options used by the FSAP includes: inpatient treatment; short-term intensive treatment (meet every day after work for 5 or 6 weeks); less intensive outpatient treatment (2 to 3 nights per week); participation in Alcoholics Anonymous; meeting with an individual counselor who is knowledgeable in addictions (especially for those who are not ready to participate in groups); and ongoing follow-up with the FSAP counselor. There are a variety of treatment programs for each one of the above options. Choosing the right program for each individual is dependent on many variables. The FSAP is in a position to evaluate these programs and make recommendations based on the needs of the client.

The final consideration in making referrals is cost. In most cases, we work with the health insurance program to which the client belongs.. For a complete list of mental health and substance abuse coverage for individual plans, contact the FSAP or the Human Resources Benefits Office (301-405-5654).

Once treatment has ended and the client returns to work, the FSAP counselor is available to meet with the recovering faculty member on an as-needed basis to address any on-going concerns in relation to his or her recovery. Ongoing communication with the referring department chair in reference to the professor's performance at work is always helpful.

How Do I Know if My Child is Using Alcohol and Drugs?

This is a common question that we hear at the FSAP. Every situation is different and we are glad to meet with you and your child to help provide an accurate assessment of the situation.

“Most teenagers will have some experience with alcohol and other drugs. Most will experiment and stop, or continue to use casually without significant problems. Some will use regularly, with varying degrees of physical, emotional and social problems. Some will develop a dependency and be destructive to themselves and others for many years. Some will die, and some will cause others to die.”

Some people grow out of their use of alcohol and other drugs. But since there is no certain way to predict which teenagers will develop serious problems, all use should be considered dangerous. Saying no is often part of the solution, but "just saying no” is seldom enough.

Some teenagers are more at risk than others to develop alcohol and other drug-related problems. Highest on the list are those teenagers with a family history of Substance Abuse problems. Legally available products include alcohol (over 21) and tobacco (over a certain age),prescribed medications, inhalants and over-the-counter cough, cold, sleep and diet medications. Illegal drugs include marijuana, cocaine/crack, LSD, PCP, opioids, heroin and “designer drugs.”

Those who begin to smoke or drink during their early teens are at particularly high risk. These substances (nicotine and alcohol) are the typical "gateway drugs" which lead first to marijuana, and then to other illegal drugs. Most adolescents continue using the earlier drugs as they begin using still others. Warning signs of teenage drug abuse may include:

Physical: lasting fatigue, repeated health complaints, red and dull eyes, and a steady cough.

Emotional: personality change, sudden mood changes, irresponsible behavior, low self-esteem, depression, and a general lack of interest.

School: drop in grades, many absences, discipline problems.

Social problems: new friends who are less interested in standard home and school activities, scrapes with the law, and changes to less conventional styles in dress and music.

Some of the warning signs listed above can also be signs of other problems. Parents may recognize signs of trouble but should not be expected to make the diagnosis. An effective way for parents to show care and concern for their teenager is to honestly discuss the use and abuse of alcohol and other drugs with them.

Consulting a physician to rule out physical causes of the warning signs is a good first step. This should often be followed or accompanied by a comprehensive evaluation by a child and adolescent psychiatrist or licensed substance abuse counselor, psychologist or social worker.