Intro to Addiction

Addiction - An Introduction to Understanding

By Peter O'Loughlin

(This article is by way of course notes from the authors workshops)

What is Addiction?

Addiction is a much misunderstood condition. Part of this misunderstanding is due in no small measure to the idea or theory, that some drugs and/or behaviours are physically addictive, whilst others are psychologically addictive.

Whilst both points of view are valid, I believe they are restricted. It may be that it is because so much time has been devoted to theories, and concepts about the potentially addictive characteristics of drugs and/or behaviours that we have so many definitions of what addiction is.

The most recent and politically ‘correct’ interpretation is to avoid using the word alcoholic or addict. Instead we are now hearing phrases such as “Alcohol/drug related difficulties.” Or, “Alcohol/drug dependence syndrome.” Such fashionable phrases have provided a further opportunity for theories to be posited about what one is as opposed to the other, together with even more theories as to the ‘cause’ of those conditions. So much time is now being spent on searching for either the cause(s) of addiction, or finding descriptions that avoid the harsh reality of the condition, that the needs of those who are suffering can be overlooked. In an effort to avoid the latter I have coined the phrase Addictive Behaviour Pattern which is defined as follows:

A condition having adverse affects a person’s life. It also impacts negatively on the lives of those with whom he/she comes into regular contact. The behaviour can be continuous, dormant, or intermittent. Periods of abstinence are followed by indeterminate periods of engagement, where the behaviour takes precedence over all other considerations. Although the immediate gratification of the desire or craving appears to offer the benefit of relief, it locks the person who is addicted into a progressively downward spiral. The paradoxical outcome of which is not only undesirable, but frequently disastrous, affecting the person’s mental, physical and/or emotional health, as well as their spiritual wellbeing. O’Loughlin Peter. (2000)

The underlying cause of an ABP may be traceable to an inner feeling of incompleteness, or isolation, combined with a yearning for a sense of harmony and fulfilment, between the person who is afflicted and their environment.

I suggest that without addressing the possibly, unpopular and unfashionable concept of how or why one’s inner feelings or spirituality influences addiction we are minimising the chances of successful recovery.

Spirituality and addiction have much in common, not the least of which is the misunderstanding that often accompanies both. The former has connotations of religion. The latter is often viewed as immorality and/or weakness. The truth is that spirituality has little, if anything in common with the dogma of religion. One of my patients, who whilst in the grip of addiction was nearer a sinner than a saint, described the difference between spirituality and religion in the following manner:

“Religion is for people who don’t want to go to hell. Spirituality is for people like me who have been there.”

Regardless of which category a drug falls into, focusing solely on whether the

outcome is physical or psychological can and does detract from resolving the issues and needs of the person who has become addicted. It also disregards the fact that many addictions have internal or spiritual influences, or desires. Although not apparent at first sight there is a stronger than superficial relationship between addiction and spirituality as observed by Dr. E. M. Jellinek, a renowned physician, who along with others pioneered the concept of alcoholism as a disease.

“Drunkenness can at first, seem a shortcut to the higher life, an attempt to achieve a higher state without emotional or intellectual effort.”

A somewhat different view was expressed by Susan Sontag in her book, Illness as a Metaphor.

“Spirituality is a lot like health. We all have health; we may have good health or poor health, but it’s something we can’t avoid having. The same is true of spirituality: every human being is a spiritual being. The question is not whether we have spirituality but whether the spirituality we have is a negative one that leads to isolation and self destruction or one that is more positive and life giving.”

In my experience all addictions are accompanied by prominent characteristics of self destruction.

To further clarify the essential differences between religion and spirituality, I offer the following: definitions:

“Religion is characterised by a set of particular beliefs about God or a higher power shared by a group of individuals, and the practices, rituals and forms of governance that define how those beliefs are expressed.” Miller (1998)

“Spirituality is a deeply personal and individual response to whatever the individual chooses to regard as A Power greater than himself, or an animating force in the world, or if he so chooses God as the individual understands him, her or it.” National Institute on Alcohol Abuse and Alcoholism & Fetzer Institute. (1999.)

“One does not have to engage in religious rituals, belong to a church or even believe in God to be spiritual.” Newport. F. (1999)

More recently a two year research carried out by the Addiction and Substance Abuse faculty of Columbia University included the following comment:

“One only has to listen to the voices in recovery to hear how eloquently they speak of about the role of spirituality in their own healing process.”

It follows that any comprehensive understanding of addiction, or any programme of therapy that seeks to arrest, if not extinguish ABP cannot be restricted to either physical, and/or psychological strategies, but has to include our spiritual, or inner self.

ABP can be identified in substance abuse, eating disorders compulsive gambling, promiscuity, difficulty in forming committed relationships, and work related difficulties, together with stress, anxiety disorders, and depression resulting from the behaviour. It is also possible that those affected have, or appear to have indifferent physical health and may be ‘regulars’ at their doctor’s surgery. Addictions are not confined to any of the above. Nor are they confined to substance abuse. Gambling Bulimia, Anorexia, are addictive behaviours. The same applies to self injury. The difference is in the choice of semantics we use to describe them, such as ‘obsessive’ or ‘compulsive’ as in ‘compulsive gambler.’

For the purpose of clarity it should be understood that the following notes relate to drug and alcohol addiction. Other addictions will be examined in future study days.

Since twice as many people, (1/13)* become addicted to alcohol as compared to all other drugs combined, (1/26)* the former will be addressed more frequently. (Statistics supplied by Alcohol Concern and confirmed separately by The Royal College of Psychiatrists)

The first thing to remember about addiction is that whatever drug(s) of choice is being used, that drug has become the centre point of the addict’s life. It has taken priority over all other considerations, including family, work and social activities. That is the sum of addiction. The person who has become addicted will continue to indulge regardless of the consequences.

Addiction is when the need for the drug becomes compulsive, and where the addicted person has an uncontrollable craving to both acquire and use that drug. Whether that compulsion or craving is physical or psychological is irrelevant to the addicted. They are only aware of their needs.

It is the compulsion and need that blinds them to all other considerations, irrespective of whether those considerations are moral, physical, financial, social, or domestic. In most cases they are not only blind to the harm they are causing themselves and others, they would vehemently deny that they even have an addiction.

The second important consideration in addiction as defined above is to realise that once that stage has been reached, the idea of ‘social’ or ‘recreational’ usage is no

longer an option. Once addiction has set in the addicted person has crossed a line. There is no going back. The only safe option is abstinence. Whilst addictions can be arrested through abstinence, to date there is no known medical cure. The body of evidence and research point to the conclusion that attempts to moderate intake of the substance(s) fail in the vast majority of cases.

Notwithstanding any social learning theories to the contrary, there is no clear cut organic, behavioural, or environmental evidence as to why social or recreational use of drugs causes addiction in some and not others. Nor does the hypothesis of social deprivation, stand up to critical examination. One can find addicts who are in receipt of welfare benefits and those who command six figure incomes. Addiction is a complex condition that can contain physiological, psychological, environmental, behavioural, cognitive, emotional, spiritual, physical and genetic factors. It is from these component factors that various theories of dependency have evolved.

The principal theories of dependency, which include such hypotheses as Social Learning, Addictive Personalities, Chemical Imbalance, Hereditary & Genetic Influences. Will be examined during further training days.

A third important consideration is that based on all available data, the universal relapse, or failure to recover rate for drug and alcohol addictions is 90-95 per cent. The reasons advanced by the majority of people who work in this field for this exceptionally high figure is ‘poor compliance.’ It is suggested that because those who are addicted fail to comply with prescribed medical or therapeutic interventions they relapse. (It may be purely coincidental that the suggestion of ‘poor compliance’ is advanced most frequently by those who run recovery and/or rehabilitation programmes devoid of any spiritual content.)

Addiction needs to be understood both from the above perspectives and, wherever it has occurred, as an ever-present condition with periods of remission. The periods of remission may be short, or long term; they are dependent entirely upon the physical, mental and spiritual development of the addict during withdrawal or abstinence. In the words of Carl Jung, “psychotherapy alone is useless in dealing with this condition. Science has no answer. What is needed is a spiritual experience.” (1). It is in recognising, and accepting, that addiction is a disease that affects mind, body and spirit, that solutions leading to rehabilitation of those who become addicted can be found.

It is only comparatively recently that alcohol addiction has been recognised in this country as a disease. Until the 1950’s successive governments refused to recognise alcoholism as a disease that like any other disease needed treatment. Alcoholics were stigmatised as social pariahs and moral defectives. Our medical authorities of the day made their own contribution to this stigma by forming a policy making committee for dealing with sufferers and labelling it A “Committee for Alcoholics and Vagrants.” Medical practitioners had no idea how to treat this addiction. It may be a reflection of how the stigma has clung, when we consider that in a recent survey conducted by Alcohol Concern some 65 per cent of GPs felt they had insufficient knowledge or resources to either recognise symptoms of alcoholism, or to treat it

A further point of interest is that it was not until the early 1960’s that the World Health Organisation (WHO) was persuaded by eminent addictions psychiatrist Max Glatt (deceased) to regard drug and alcohol addictions as similar problems. The wisdom of that decision is borne out by the fact that many of those who become addicted to alcohol also become addicted to drugs, including tranquillisers and anti depressants.

The Cycle of Addiction.

Some people obtain greater pleasure, or more of a ‘glow’ than others when using alcohol or other drugs. This pleasure is mostly of a short duration and is invariably followed by feelings of discomfort including remorse.

Alcoholics quickly learn that such feelings can be “easily taken care of” by having more to drink. In doing so he obtains a certain, but frequently diminishing, amount of pleasure. More importantly for him by ‘depressing’ his feelings, the alcohol relieves his discomfort, which normally includes physical and emotional pain. Increasing quantities of alcohol are required in order to get the desired ‘benefits.’ In time most alcoholics drink to ease their craving which contrary to popular opinion is not merely physical, but includes the feelings of remorse and self loathing that they ‘crave’to be free of. At this stage our alcoholic is unable, or unwilling to believe that anything else but alcohol is the answer. The highs and lows of the cycle apply equally to those alcoholics who drink daily and to those who alcoholics who have periods of abstinence between binges. In the latter case they are frequently unable to stop drinking, until the ‘high/low cycle has burned out. Death through ‘misadventure’ is quite common.

Drug addicts have similar experiences. In the beginning they find that the drug has a pleasant affect. There is the initial ‘rush,’ and euphoria. But as time passes and increased amounts, or stronger substances are need to get that effect, the ‘rush’ becomes more elusive, whilst the pain of withdrawal is more frequent and intense.

The Physical Symptoms of Addiction.

Physical symptoms and damage of drug and alcohol addiction include, but are not limited to: Aspiration Pneumonia: (Excess lung fluid and inflammation.) Oesophagitis: (Inflammation of the oesophagus due to hiatus hernia when stomach acid regurgitates into the lower part of the oesophagus causing damage and inflammation of the wall.) Pancreatitis: Liver damage including fatty change, hepatitis and cirrhosis: Cerebrovascular Accidents: (A general term referring to cerebral blood clots, thrombosis, or haemorrhage.) Cardiac arrhythmias: (Irregular heart rhythms.) Neurapraxia: (A temporary block to the conduction of nerves, similar to what is experienced after a local anaesthetic.) Myopathy: (A primary muscle disease.) Hypoglycaemia: (Sugar deficiency in blood.) Osteoporosis: (Fragile bones as the result of calcium deficiency.)

It should be noted that although the above are common symptoms and results of drug and alcohol addiction they are not exclusive to addiction and may have other primary causal sources. Closer study of the of these together with more

serious physical illnesses that result from addiction will be presented in future study days, workshops and seminars.

Mental and/or Psychological Aspects of Addiction.

When an addict is deprived of the drug of choice, or perceives that he/she is about to be deprived of it, the craving will also manifest as emotional mental and psychological turbulence. These will include, anger resentment, despair, loneliness, anxiety and depression. They will in many cases also experience desperation, that will lead them to lie, cheat, rob or steal, in order to ease their mental and spiritual discomfort.

Alcohol and Depression.

“Sometimes we drink to relieve a depressed mood; ‘to drown our sorrows.’ Occasionally drinking excessively is a symptom of severe clinical depression. More often it is the other way around and depression is a consequence of excessive drinking.” The Royal College of Psychiatrists. (2001)

Depression which is a common feature of alcohol abuse is not unlike that which is seen in manic-depressives. The latter’s condition leaves the sufferer with prolonged and not infrequently disabling episodes of depression, sometimes accompanied by mania. Another link between both conditions is the high rate of suicide. It is generally recognised that in Western countries that alcoholism and manic depression are the principal causes of suicide.

We need to clearly understand that alcohol is a brain depressant that helps those who abuse it to avoid the reality of facing their problems. Simultaneously it releases inhibitions. Almost paradoxically it engenders strong, sometimes overwhelming feelings of self hatred and disgust which manifest themselves as anger and aggression. This negative spiritual condition sooner or later leads the alcoholic to increasing isolation from his family, his friends and his work colleagues. The inevitable despair can make suicide an attractive option.

Another well established association is that of drug abuse, addiction and anxiety disorders. Unfortunately despite various studies there is no conclusive evidence that suggests whether severe anxiety disorders precede or are the result of addiction. What has been clearly established is that heavy drinking produces anxiety, more so when accompanied by a hangover.

Other forms of anxiety disorder or phobias such as public speaking, or performance may lead the person who is so afflicted to form a belief or concern that others will judge them as inadequate. Such a conclusion may lead them to use alcohol or drugs, or in some cases both, in order to alleviate their feelings. As time goes on they require more of their drug of choice to produce the same result and eventually become substance dependent.

Other psychiatric and social problems.

A common phrase of today is “Antisocial Behaviour.” There appears to be a direct connection between alcohol and drug abuse and the increasing occurrence of anti social behaviour, as can be witnessed most weekends in our towns, and cities. In addition assaults on elderly people, the principle motive of which appears to be robbery, is increasing as addicts desperate for their ‘fix, appear to be willing to go to any lengths to obtain the wherewithal to satisfy their craving.

Breaking the Cycle of Addiction.

Despite the gloomy prognosis for those who become addicted, recovery is possible. The first step towards a successful recovery is for the person who has become addicted to have a desire to recover. However there is a caveat to that. If the desire to recover is primarily due to fear in the form of fear of loss either of friends, family, physical health or material considerations, or to avoid retribution of some sort, lasting recovery is unlikely. The evidence for that seemingly uncompromising claim may be found among those who are in the process of long term recovery.

A survey of almost 7000 members of Alcoholics Anonymous (AA) carried out in 1998 “indicates that no less than 47% had been sober for a minimum of 5 years.”

Alcoholics Anonymous (2001a.)

Since attendance at AA is purely voluntary, as opposed to state funded recovery agencies, I suggest it is reasonable to assume that those attending are seeking recovery purely for themselves. A further consideration in arriving at this conclusion is that state funded agencies as may be found within many communities fail to publish any figures in respect of recovery, other than those of short term experimental initiatives. The latter are normally confined to small numbers of participants.

Studies carried out by Emrick (1999) Winzelburg & Humphries (1999) Tonnigan, Montgomery & Little (1993) show that regular attendance of AA or Narcotics Anonymous (NA) meetings in conjunction with other treatment is a significant part of getting well.

Apart from the important fact that both AA & NA offer a process of recovery

that embraces the concept that addiction is a mental, physical and spiritual disease, seemingly unconnected research may go some way to explaining why the simplicity of their similar programmes work so well.

During the early part of the 1980’s two experimental clinical psychologists, James Prochaska, and Carlo DiClemente, who concerned by the apparent inability of people who although wanting to stop smoking had difficulty in staying stopped, decided to carry out research into the reasons why. They carried out their research across a total of some 2000 smokers, ex smokers and smokers who were endeavouring to quit. Among other facts to emerge was the realisation that many of those who had actually succeeded in stopping had not actually done so until their fourth or fifth attempt.

It was the latter that helped them to understand the cycle, or process that people actually go through when change occurs, as opposed to theoretical assumptions, that led them to develop what is became universally known as ‘The Process of Change.” It is now used extensively, some say exclusively, by those working in the field of addiction recovery. When used in conjunction with therapies such as Hypnosis, Cognitive Behaviour Therapy, Motivation Interviewing, and last but by no means least, a relevant 12 step programme, it is highly effective. I believe that in understanding and employing the model, together with acquiring relevant knowledge and skills of the other therapies, the effectiveness of therapists is considerably enhanced, with increased beneficial outcomes for their clients.

The simple but inescapable, key principle of the model is that people only change when they are ready to change. It is interesting to note that this blindingly simple truth was expressed by the early members of AA some 50 years earlier within the following phrase:

“We don’t know anyone who stopped drinking until they reached their own rock bottom.”

In other words, “people only change when they are ready to change.”

Based on the facts that emerged from their research, Prochaska and DiClemente were able to break down the process of change down into the following six stages.

(1) The Pre-Contemplation Stage.

This first stage is where our alcoholic, or drug addict is unwilling, or unable to contemplate changing their lifestyle. They may present with ‘other problems’ such as described earlier. It is possible that they have never even considered change, or been made aware of the risks their present habits involve. Obviously the health professional’s aim is to assist patients to achieve a safer or healthier lifestyle.

If, at this stage the health professional/therapist has no basic awareness of alcohol or drug abuse may be influencing the presenting condition, and simply treats the presenting condition, a number of things could happen, none of which are going to help the patient.

A GP might prescribe tranquillisers or anti depressants. In many case the first actually enhances the effect of alcohol. A further consideration is that along with anti depressants, some of these drugs are contra indicated with alcohol and other drugs. Since our patient is not even considering that it his lifestyle is the cause of his problems, he is unlikely to volunteer that he might be drinking, or drugging.

If our GP is enlightened he may refer the patient for counselling, and/or psychotherapy. If the therapist has not received any alcohol/drug awareness training he/she will also be treating the symptoms, without being aware of the cause. It follows that in either event, our patient is unlikely to make much progress.

On the other hand if either the doctor or the therapist had received some instruction and understanding of how alcohol/drug abuse can cause depression, anxiety, or stress, and providing he/she had been trained in the use of diagnostic tools for screening of those possibilities, their awareness of our patient’s habits, could have influenced the treatment.

(2) Contemplation Stage.

If the patient is aware, or has been made aware that his habit(s), or behaviour are having a negative influence on his problems he may be ready to enter this stage, At this point it is important to note that until the patient is ready to acknowledge that it his lifestyle that is at the root of his difficulties, he is simply not ready to enter this stage. However, with skilful handling he can be helped to recognise, that unless he is willing to start thinking about changes in his lifestyle, his life is unlikely to improve. Compared with the first stage, that in itself is change. It is not unusual for people to stay at this stage for extended periods of time.

(3) Preparing to Change.

When and if our addict is willing and able to acknowledge that it his habits that are causing him problems, rather than problems causing him to drink or drug, he is ready to enter this highly critical stage.

There are two connecting issues that have to be dealt with at this point: (1) our client will need continuous encouragement that he is capable of change. (2) There is a need to create, and/or reinforce his sense of self worth.

The client will have considerable anxiety and fear, both are generated by thoughts of letting go of his habit and how he will cope without the artificial stimulus that his drug of choice has been providing. He is only too well aware of the ‘benefits’ he obtains from his habit, and in the absence of being convinced that the benefits of sobriety will outweigh the former, there is every likelihood of him reverting back to the second stage. We need to be prepared to for our client to be moving back and forth, between the second and this stage. Our willingness to encourage and re-assure our client in their embryonic belief that change is not only worthwhile, but is possible, cannot be overemphasised. Combined with that, we also need to be aware that the client, in a bid to please us, or someone else may attempt to rush through this stage without adequate planning, or preparation for the next stage.

(4) Making the change.

Once our client has declared his readiness and willingness to enter this stage, we need to test that he his ready. This is the stage where action, rather than words is the keynote.

A simple, but highly effective way of testing the client’s willingness and readiness to change is to encourage him to start attending a twelve step programme related to his habit. More often than not we can expect to meet some resistance here. It is more than likely that our client has heard of AA, GA, or NA. The chances are that what he has heard will at best be negative, and at worst distorted. Unless the therapist is familiar with the programme, and the misinformed hearsay that is frequently dispersed, he will be unable to combat this resistance.

The need for support, and encouragement in devising strategies, that will assist our client to avoid people, places and situations, where the drug of choice is freely available, is paramount.

We also need to remember that our clients are likely to still be experiencing high levels of anxiety. More so as by this time he has (hopefully) stopped using the drug that he relied upon to mask his fears and emotions. It is also possible that any depression that was induced by the drug of choice, especially alcohol, will be more apparent. However this normally alleviates within two to three weeks of withdrawal. If it should persist the client should be encouraged to consult his GP in addition to any therapy being administered.

(5) Maintaining Change.

Once the use of the drug has been ceased, it is essential that a new pattern of behaviour starts to emerge. Having abandoned his old haunts, and fellow users, and the substance(s) used to help him cope; our client will be experiencing feelings of discomfort and also inadequacy. There is a distinct possibility that feeling unable to manage he will start to isolate, which could in turn lead him back to drinking or drugging.

At this stage his need for support is greater than ever, more so if as is common his relationships with his family are strained. It is for these reasons that he should be encourage to regularly attend relevant 12 step meetings. Within the rooms of the meetings he will meet those who have not only abandoned their old life style, but are actively enjoying new or rediscovered interests. He will be with people who having been where he is at, will share their experiences strength and hope. He will gain a sense of identification with people who understand the difficulties he is experiencing. If he agrees to implement the steps of recovery (which despite any hearsay are not compulsory) he will gain a better understanding of himself and come to realise he is no longer alone.

Providing the therapist has done his/her homework and gained an understanding of the 12 steps of recovery, and the principles involved, he/she has at this time a golden opportunity to help our client discover within themselves the power and the courage for new undertakings that are within the clients capabilities. Both Motivational Interviewing and ego strengthening with hypnosis can be usefully employed at this time.

It needs to be remembered that although our client is abstinent, the debris of his old lifestyle has to be faced. Chaos is evident in every area of our client’s life, not the least of which is his day to day living conditions and finances. Agreed plans and goals should be made, and where appropriate outside agencies such as debt counselling and social services need to be involved. The caring therapist will ensure that his/her client will have all the necessary contact numbers, and be ready to assist his/her client in approaching the relevant agencies.

The progression through this stage can be very painful for the client. They are having to face themselves and the consequence of their old life style with the raw emotions that they are used to suppressing. Sometimes the pain is such that they quit and revert back to their old habit. Those who do persist become very strong. Once they have put their own life in order, they are usually more than willing to help others who are still struggling. At this time the true fellowship of 12 step meetings is at it’s best.

(6) Relapse Stage.

When a client for any reason, real or imagined, is unable to maintain change, old habits return. It is unlikely that a recovering addict’s unconscious mind is ever entirely free from thoughts of alcohol or drugs. Because of this, there is always the possibility that a conscious thought connected with alcohol or drugs emerges. Should our client continue to harbour that thought, it can lead to what is sometimes referred to as a ‘slip.’ Should that occur, much of the old way of thinking returns. His self esteem takes a battering. He is inclined to tell himself that he is hopeless, that he is no good. His loved ones confused and angry may reinforce those thoughts with verbal abuse. Depending on the strength, and/or duration of the ‘slip’ our client’s negative state of mind, may be worse than it was originally.

At this stage, once our client has ‘sobered up’ we need to remind him of the progress that he made prior to his slip. We need to point out the changes that have occurred, and that despite the slip there is no reason to assume that all his hard work has been wasted. That having quit once, he can quit again, this time much wiser. That he can return to his 12 step meetings and share his experience. That in doing so he will encounter many others who have done the same. He can share in depth his feelings of anger, guilt and shame. It should be pointed out to him what at first sight is a problem, can be turned into an opportunity to not only rebuild his own strength, but to help his fellow addicts others realise that when it comes to maintaining sobriety, complacency is to be avoided. Encouragement with realism is the key to getting our client back into the process of change cycle.

Progression through the stages.

It is unrealistic to expect clients to progress in an orderly manner from one stage to the next. In reality they move backwards and forwards around the cycle of change, spending varying amounts of time in each stage. However the majority do pass through all the stages. The authors of the model have said:

“Individuals who successfully leap over stages, such as pre-contemplation to maintenance may exist, but we have not found any. We have been able to successfully predict that individuals who leap into action without adequate contemplation or preparation are a high risk for relapse.’’

My work with addicts of all types confirms for me both the truth and wisdom of that statement.

References.

O’Loughlin Peter. The Eden Lodge Practice. (2000)

Jellnek. E.M. Posthumously published article, The Symbolism of Drinking. Journal of studies on Alcohol. 1977.

Sontag Susan. Illness as Metaphor. Farrar, Straus & Giroux. New York. (1978)

Miller. W. R. Researching the spiritual dimensions of alcohol and other drug problems. Addiction, 93(7) pages 979-990

National Institute on Alcohol Abuse & Alcoholism, & Fetzer Institute. Conference summary: Studying spirituality and alcohol. Fetzer Institute, Kalamazoo. (1999)

Newport. F. Americans remain religious, but not necessarily in conventional ways. (1999) Retrieved October 2001 from the World Wide Web; http:// www.gallup.com/poll/releases/pr991224.asp.

The National Centre on Addiction and Substance Abuse (CASA) Columbia University, New York. (2001)

Jung Carl. In an exchange of letters with Bill ‘W’ Co-founder of Alcoholics Anonymous. 1935. Retrieved from Alcoholics Anonymous Comes of Age. Alcoholics World Services Inc. New York. (1957)

Depression and Alcoholism. Public information sheet, published by The Royal College of Psychiatrists 2001.

Alcoholics Anonymous. (2001a). Alcoholics Anonymous 1998 membership survey.

Prochaska. J. O. & DiClemente. C. C. Towards a Comprehensive Model of Change. In Miller W. R. & Heather N. Treating Addictive Behaviours. Processes of Change. Plenum New York (1986)

Alcoholics Anonymous. “The Big Book” 5^th edition. AA World Services, New York 1962.

Prochaska. J.O. DiClemente. C. C. Velicer. W. F. Rossi. J. S. In answering criticisms and concerns of the transtheoretical model in the light of recent research.

British Journal of Addiction 87. pages 825 -835. (1992.

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