This article belongs to Addictions Anonymous column.
In the days when I was working as a clinical psychologist in hospital programs where we treated addictive behavior, it was common to have members of Twelve Step groups bringing people in for help. They would turn up at the hospital at any time of the day or night, often with no warning. Some self-help group members, of course, discourage professional mental health treatment thinking that the group should be all things to all members, but severe withdrawal, serious physical illness, and suicidal behavior were problems beyond the scope of self-help groups, and most members recognized that.
They knew we could hospitalize eligible patients and give them the full range of medical and psychological support services, usually in a two to four week inpatient program. If, for some reason, we could not admit a patient in crisis, we were able to make a referral to some other facility or to an outpatient program.
Members of self-help groups brought us alcoholics who'd run out of tolerant family, money and friends. We got jobless gamblers with huge debts and legal problems. One day we even got a man with lung cancer who wanted to die a non-smoker; he just wanted help quitting tobacco. For him it was a matter of self-respect. Most of the members of his alcoholics' self-help group were smokers and could offer no suggestions, but they honored his desire to stop and knew that we supported the American Lung Association's program to end smoking.
Every time we got a call for help from a self-help group, I wondered why they didn't have a better method of making referrals, something better that waiting until matters had come to a crisis.
Certain specific questions can help you decide whether you should recommend professional mental health treatment to other members who seem to be having special problems. All a group can do, of course, is offer its best recommendation. Except for extreme cases, the decision to get professional help must be left to the individual. First, keep in mind that not all addicts need psychotherapy or medications for emotional problems. Nor is a self-help group by itself always the only answer for everyone. Mental health professionals and self-help groups can and do work together; frequently group members will know of therapists who work well with self-help groups.
The following questions are not for the troubled individual to answer, and that person need not even be present when these questions are discussed in a closed session. The member is not on trial and would probably be defensive and possibly even disruptive. It is probably best to let the person know you are going to meet to discuss the situation lest you be accused of sneaking around behind that person's back. By all means, have the person present if he or she is cooperative.
Such a meeting should never be confused with what is called an intervention or confrontation. These are techniques used by some professionals to force someone into a program. Your job is to suggest getting additional help, not to force it on someone. This is just an executive session in which the group officers or senior members discuss someone who, in crude language, might be called a pain in the butt or, perhaps, a bit odd.
The person in question can, of course, provide important information. So can family members and members of the fellowship who know the individual. It would be best to assemble a small committee of experienced members to evaluate each question below and then present any recommendation in writing to the individual along with assurance that obtaining help is not a requirement for membership. Changing certain dangerous or disruptive behavior may be a condition of continued admittance to group sessions, but the refusal of professional treatment in itself should not be held against a member. The over-riding principle is that the common welfare of the group comes first.
These questions should not be discussed in the usual open meeting, and the recommendation, if any, should be presented in a private, non-combative, and compassionate way with no further debate, coercion, or discussion.
Your only source of information will probably be what the person tells you and your observations of how that person behaves in group meetings. You probably cannot get information from outside without violating the individual's right to privacy, so don't try to be amateur detectives. However, in preparation, try to find out (1) if the individual is currently in treatment for mental health problems, (2) is taking medications for emotional problems and/or (3) has a history of mental health treatment. Learn what you can about the person, but you do not necessarily need his or her permission just to consider mental heath needs. Any recommendation should represent a single group opinion. Try to come out of your meeting with a unified voice.
The critical questions
1. Is the individual a serious problem for the group? Examples: demanding too much attention, persistently interrupting others, using excessive foul language, and refusing to conform to minimal social standards, etc.
2. Has he or she reported recent violent behavior and/or domestic violence?
Violence is sign of significant problems. The individual may not have good anger management skills. Intoxicants can also cause lost of control and violence. Violence in the home cannot be tolerated and may require legal or police intervention before treatment can be offered.
3. Does the person report having had serious traumatic experiences? Examples: combat in war, childhood abuse, violent rape, serious injury or accident, etc.
4. Does the person have serious and extreme character defects upon which he or she refuses to work or which persist in spite of efforts to change? Use the list of character defects most Twelve Step groups use as a reference, or see the list in Chapter Eight of this book.
5. Does the individual report seeing visions, hearing voices or having persistent bizarre ideas? In a case like this there is likely to be some history of mental health treatment. A general psychiatric ward or outpatient psychiatric care may be needed more than addictions treatment program in order to get the psychological symptoms under control.
6. Does the person voice any intention to hurt or harm self or others? Not all threats of violence are carried out, of course, but prediction is risky. Be especially concerned if the person names a specific individual to be harmed, if weapons are available and if there is a detailed plan of attack.
7. Is he/she asking for a treatment referral to addictions treatment? What better place to ask than in a group where others may have had experience and may know reliable professionals who work well with self-help groups, therapists who support long term membership in those groups?
8. Has the individual been trying sincerely to abstain in self-help groups with no success for six months or longer? It takes time for a program to sink in, so don't be in a hurry to suggest treatment just because a person has been around for a few months and still has not got the hang of abstinence. Repeated slips, procrastination, and stalling will eventually get the attention of the group and they will want some better, more intensive intervention.
A "Yes" answer to any one of these questions would suggest a referral for professional mental health treatment. If you recommend treatment outside your group, be prepared to assist the person in finding appropriate help. If you have a certain therapist to suggest, be specific about his/her name, address, and phone number.
Although legal problems can evoke an emotional storm in the person who caused the trouble, legal problems are not, in themselves, sufficient reason to consider referring someone to a mental health professional. The so-called insanity defense seldom works when addiction itself caused the misbehavior.
The common welfare of the group comes first. The right of the group to a peaceful and efficient meeting is above the right of any individual to violate and ignore the accepted format and agenda. If a member cannot or will not stop disruptive behavior, refuses to work on personal problems, and refuses to find needed professional help, then the group has the right and the obligation to remove the person from the group, an action that most members of self-help groups are very reluctant to take. After all, the old rule is that the only requirement for membership (in Alcoholics Anonymous and similar groups) is a desire to stop using.
The job of group leader or session chairperson can be very difficult because it is the chairperson's obligation to manage the meeting by taking whatever steps may be required to insure group tranquility and effectiveness. A group leader must be much more than a master of ceremonies. A disruptive member, regardless of mental status, should be asked to leave and may be barred from future meetings until a sponsor or other group representative approves re-entry. If a disruptive person refuses to leave—and here comes the really hard part—civil authorities must be called in to provide immediate help. The group must avoid physical intervention except to prevent immediate harm to others. Everyone should know the location of the nearest telephone, and it is far better to dial 911 just in case than to allow a situation to get out of hand.
Practice tough love. It's difficult, but it works. Do not hesitate to call on appropriate civil authority to assist in crisis situations. This is the right of any citizen.