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Thursday, May 22, 2014

Blog Reader Book Review: Returning the Lost Sheep

Returning the Lost Sheep: Ministry to the Alcoholic and Addict: An Orthodox Perspective, Fr. Dimitrios Moraitis. Self-published, 2013.
A review by Michael Huber ThM, MA, CSAC, LPC, psychotherapist at BridgePoint Health, Sheboygan, Wisconsin.
Reading through the first two sections of this book I felt like I was in a time capsule of 30 years ago—the beginnings of Hazelden treatment center, the Johnson Institute, the modern renaissance of Alcoholics Anonymous, DePaul recovery hospitals, prominent Catholic priests publishing spiritual recovery materials, Health Communications, Inc. publishing house. Orthodoxy was late arriving in America so we could expect Orthodoxy arriving late into the recovery scene, but thank God it has with this now third Orthodox publication in the field.
Fr. Moraitis clearly attempts to accomplish what those Catholic priests and a number of Protestant ministers attempted to do 30 to 40 years ago—to bring awareness, information, compassion and inspiration to Orthodox clergy in the current era. The theological/pastoral thrust relies on the combination of Mt. 9:12 regarding Jesus’ common sense saying that it’s the sick who need a physician and the parable of the lost sheep from Lk. 15 to deliver the mission call which is depicted prominently on the front cover. Not to overly criticize Orthodox priests. It has been hard enough just establishing an extremely small minority of Orthodox in the States with a minimum of worship and community life let alone specialized ministry to those suffering  alcoholism and addiction. But perhaps it is time and this book is a welcome and much needed addition.
Having read a brief preview summary of the book I feared an over spiritualized approach by Fr. Moraitis. But nothing could be further from the truth. Clearly Fr. Moraitis follows in the path of those 30-40 years ago in the modern “tradition” of the recovery movement as defined by the Alcoholics Anonymous subculture, along with the AMA and US Department of Health and Human Services Substance Abuse and Mental Health Services Administration definitions. He has picked up on all the details well and communicates the “tradition” effectively. Thankfully he is up to date and supportive of the latest scientific research establishing with certainty the genetic/biological component of alcoholism and likely of some forms of addiction in the modern world. It’s possible that Fr. Moraitis might receive criticism from some for over relying on these “secular” sources.
Fr. Moraitis takes the best of the recovery “tradition,” promotes it, and at the same time adapts it to the ministry and theological approach of Orthodox clergy to whom this work is primarily directed. Therefore, this work is an effective synthesis that Orthodox priests can have full confidence in. As such its approach compliments the current other two Orthodox works in this field by Fr. Webber and Victor Mihailoff, whose book was earlier reviewed for the Orthodoxy and Recovery blog.
Fr. Moraitis neatly assembles this work into three appropriate and progressive sections. Part One deals with the above mentioned definition of alcoholism. He presents an abundance of nationwide polls and even his own poll within the GOA to deliver the call to clergy involvement. He unabashedly espouses the “disease” model as a part of the “tradition” supported by modern era genetic research and the sources cited above.
In Part Two Fr. Moraitis tackles the theological questions of alcoholism and addiction, necessitating the reintroduction of the scientific research and genetic/biological aspects to ward off the simplistic notion of sola sin. Using Clinebell’s research seven possible views of the tension between “disease” and sin are suggested. Though he clearly leans toward a view of a combination of these possibilities as representative of Orthodox thought, he seems to leave it somewhat open for the individual priest to wrestle with on his own. But it’s the heart matters that dominate for Fr. Moraitis. Alcoholism and addiction can legitimately be viewed as opportunities that bring the individual to a place of receptive humbleness for priests who see the possibilities of ministry. Much of the book emphasizes this ministering to the sick, rather than the healthy citing the wisdom of our Lord.
In this section Fr. Moraitis cautions readers with regard to realistic expectations. It is so true that when some people get a loved one into treatment the thought is that “now everything will be fine.” The average number of relapses cited in the author’s surveys is 15!! This often times includes multiple relapses following one or more 30 day residential treatments.
Part Three is a clever and well presented application of the 12 “Core Competencies for Clergy” from the 2003 government report of the Expert Consensus Panel Meeting. Fr. Moraitis takes each one and makes special application for Orthodox clergy. It clearly works very well. There is an excellent section in “Core Competency 2” where each Step of the 12 Steps is explained with an appropriate Scripture verse and complements nicely the work of Fr. Webber. It is in this section though that Fr. Moraitis’ tension between strongly supporting AA, which has been very strong up to this point in the book, and criticizing it (and the modern treatment program) regarding religious integration reaches its zenith. There is no doubt that, despite his support of AA, especially the 12 Steps within AA, some Orthodox clergy might have some reservations referring individuals to AA as a result. The issue, a distinct irony, is AA’s avoidance of promoting itself as a religious group actually turns out to be one for many individuals.
The concluding Appendix is a summary “Clergy Handbook” for quick reference and organization. The book flows smoothly enough and is readable for any clergy. This reviewer strongly agrees with back cover endorsements by Fr. Joseph Allen and Dr. Philip Mamalakis, two prominent figures in the Orthodox pastoral counseling world.
What now follows is a more technical and detailed look at certain relatively minor concerns this reviewer has with some of the material presented in the book. Those clergy and laymen who are more actively involved and knowledgeable in the field may want to consider these things from this reviewer, a thirty year professional in both mental health and alcohol/drug counseling.
The terms “alcoholic” and “disease” are frequently used by the author in this volume. This reviewer tends to greatly limit, if not eliminate the use of these terms. As I am fond of saying, we don’t call people with cancer “cancerics.” The word “alcoholic” is a throw back to more ignorant times that reflect the very thing Fr. Moraitis and others are trying to eliminate--the moral stigma of the condition. Instead, individuals are referred to as having genetically inherited the condition of alcoholism. But those religious individuals who still regard alcoholism simply as a sin would find this completely unacceptable. Certainly the individual with alcoholism who continues to want to call him/herself an “alcoholic” for the purpose of sobriety is more than welcome to as, of course, is common in AA meetings.
 In addition there continue to be significant problems with the image of the word “disease” in modern culture despite Fr. Moraitis’ consistent use of the U.S. government’s and AMA definitions of alcoholism as a disease. Most people still associate “disease” with a virus or “bug” that one catches, completely irrespective of choice and decision making. Even though I completely agree with the “disease model” as Fr. Moraitis presents it, I refer to alcoholism as the Medical Model definition of alcoholism in which the genetic acquisition and biological components are prominent. Why cause people to stumble over words and images needlessly?
I can’t help but chuckle to myself when I read Fr. Moraitis’ “generally accepted definition of alcoholism.” There is no such thing despite, again, Fr. Moraitis heavily leaning upon the government information. If one were to interview 50 alcohol and drug professionals, one would come up with at least 10 different models or definitions of alcoholism. Furthermore, the Diagnostic and Statistical Manual (DSM), which all professionals in both alcohol/drug and mental health fields use for diagnoses, does not use the word “alcoholism” nor “addiction” for that matter. In fact, in the latest edition of the DSM (5) drunken driving convictions, as well as any other legal consequences, have been eliminated from the criteria for an “alcohol use disorder.”
None the less, what stands out is the approach of nonjudgmental compassion by Fr. Moraitis who clearly is authentic in this practice. This is about loving some of the most unlovable that there are—at least while they are in their state of “insanity.” Having said that, Fr. Moraitis is not about emotional mush. He is completely balanced with regard to insight and tough decision making regarding the aspects of enmeshment with dysfunctional family systems—at times making the difficult decisions to separate when appropriate and refusing to be cast in enabling situations. His advice throughout clearly represents the wisdom of experience.
In Part 2 regarding the theological considerations mention of “anger, frustration, agony, depression, and fear” is referred to as “spiritual maladies.” These are NOT “spiritual maladies” but psychological ones. This is an important point. Especially with regard to depression, religious individuals have sometimes not received treatment that could help because it was viewed as a “spiritual” problem for which the clergy were not equipped to effectively deal with. And in some cases has led to tragic deaths completely needlessly because of this misunderstanding. “Spiritual malady” strictly refers to that area of one’s relationship with God no matter what the physical or psychological condition—something that Fr. Moraitis generally does well in the rest of the book.
With regard to the issue cited above regarding individuals making AA their “church,” there can be no other way of saying it. At least in part, the church at large, including Orthodoxy, has failed in regard to this matter. If church individuals with alcoholism and/or addiction had been experiencing the genuine, authentic power of the Christian life there would be far fewer individuals making AA their “church.” From the perspective of this reviewer it is easy to understand why individuals make AA their “church.” They have experienced genuine, heartfelt spiritual awakenings and social camaraderie akin to war veterans that they never came close to experiencing in traditional church settings. Why would they then seek it out back in their old church? And, ironically again, it is because they experienced it through classic, Christian based spiritual practice in the 12 Steps, but is certainly not associated with the former church experience.
Fr. Moraitis calls it the “relativism” of AA and the modern treatment program. But, I believe, why should Fr. Moraitis have expected any thing different? Ever since the 12 Steps used “Higher Power” the die was cast. Throw in modern American sensitivity and there was no doubt there would be no overt, obvious Christian emphasis in AA or treatment programs except those operated under the auspices and financial support of specific church groups, and there are some around the country. AA’s appeal as a nonreligious group, casting off stereotypical “hell and brimstone” images of God attracted (and kept) people. I completely agree with Fr. Moraitis in his example/encounter with the homosexual in recovery regarding Orthodox sacrificial practice. But the rest of “Christendom” is very relative compared to Orthodoxy’s practice of progressive sacrifice let alone AA and secular treatment programs. All the more for Fr. Moraitis to strongly attempt to persuade Orthodox priests for active ministry to Orthodox individuals. This reviewer sees no Orthodox since there is only a very small and struggling Greek Church within a 50 mile radius of his clinic.
In addition, in the “Core Competency 2” section Fr. Moraitis gives a good and succinct review of the drugs of abuse, including opiates, which are now the rage across the country. This reviewer is the lead therapist in the most prominent Suboxone program in East Central Wisconsin. Fr. Moraitis’ statement that Suboxone should be used no longer than a few months is inaccurate. The length of Suboxone treatment will vary considerably from one individual to the next based upon a number of complex factors. I have had individuals with milder symptoms and histories with good motivation take only several months with good results. The majority are far more severe and require lengthier and often multiple treatments.
From the perspective of this therapist opiate addiction in many cases resembles alcoholism to a large degree. In these cases there is likely a genetic component as well, though, unlike alcoholism, we have yet to have the scientific evidence. Suffice it to say that in our program we are proactive with patients to move them off of Suboxone as quickly as is reasonably possible—something that is generally not true with Methadone programs, though the philosophy of treatment is the same. On average opiate dependence is capable of destroying an individual and family far more quickly and effectively than alcoholism is. Therefore, Suboxone has been incredibly effective for quickly saving individuals from destroying themselves in almost every area of their lives. The advantage of Suboxone over methadone is the inclusion of naloxone, an opiate blocker, sometimes referred to as the life saving, emergency rendered Narcan in heroin overdoses, which has received nationwide publicity as of late. The Orthodox priest ought to always consider the option of referring an opiate addicted individual to a Suboxone prescribing physician in the area. If the prescribing physician is not a part of other outpatient treatment resources the individual should be referred to such and/or local NA groups.
I should also state that there is medical treatment for alcoholism as well—something that Fr. Moraitis fails to mention in the book. Antabuse has been an historic, effective treatment for some with alcoholism where all other interventions have failed. There is also some new evidence that antabuse can cut craving for cocaine addicts, though the phenomenon of “craving” in cocaine addicts is yet to be fully understood. In addition, in some cases, the opiate blocker, naltrexone, and the newer Campral, have also worked well in a minority of cases. There is also new evidence of the effectiveness of gabapentin with some. The reader should understand that these are not stand-alone treatments. The individual with alcoholism/addiction should always be treated on multiple levels.
Also in this section Fr. Moraitis succinctly describes and outlines the three stages of the progression of alcoholism. This can be helpful for the uninitiated but as Fr. Moraitis correctly states later in the book, these stages should not be calcified into a rigid system. In most cases it doesn’t flow into a neat and predictable progression. In addition, drug addiction will not progress the same way alcoholism does in many cases.
But there are other problems as well. The “Early Stages of Alcoholism” are described by symptoms of “use to calm nerves,” “increase in tolerance,” “driving under the influence,” “relief use” (this is no different than “calm nerves”), “secret irritation when confronted by a spouse.” The fact of the matter is that the vast majority of clients I see with these “symptoms” unequivocally do not have alcoholism. Some of them even have no diagnosable alcohol problem whatsoever. In addition, I’ve had a number of cases in which the spouse is complaining of the “alcoholic’s” use to find out that the spouse is greatly exaggerating the use and objectively there is no alcohol problem for the supposed “alcoholic.” In fact, collateral reporting of a number of family members verifies that the spouse has had a chronic habit of grossly over exaggerating many other things as well. In some cases the “irritation” by the supposed “alcoholic” is the result of the spouse chronically and falsely accusing the individual of a problem that doesn’t exist.
Even the symptom of “blackouts” is often not a solid indicator of what kind of alcohol difficulty is present. I’ve had clients with blackouts who clearly do not have alcoholism. I’ve had many cases of absolute certainty of alcoholism and those individuals have never experienced a blackout.
In the “Middle Stage” “alcoholics” are described as “egomaniacs with inferiority complexes.” This is a gross stereotyping of the “original” “alcoholic” himself, Bill W., one of the cofounders of AA who clearly had this character quality. From then on this gross over generalization has taken place, another one of the many faults of the “tradition” of AA. The truth of the matter is there are many individuals with alcoholism who do not exhibit this character quality. The danger in this should be obvious. I’ve had many individuals with alcoholism who have the “inferiority complex” entirely without the “egomania.” These individuals should not have alcoholism then, right?
Regarding the “Late Stage” Fr. Moraitis’ discussion is thoroughly confusing besides being inaccurate. He states many “alcoholics” die before reaching this stage. What sense does that make? If the individual dies as the result of physiological complications as the direct impact of alcoholism this automatically qualifies the individual as having been in the late stage, perhaps for a lengthy period of time prior to death. Several of the “symptoms” of the late stage are described as “indefinable fears” and “unable to initiate action.” These “symptoms” are typical of many clients I see with the character structure most common with individuals with alcoholism but have no symptoms of alcoholism whatsoever. The problem is that the majority of individuals with this character structure (the Fear structure as Fr. George has frequently and accurately pointed out in his blog) not only do not have alcoholism (or any drug addiction) they don’t have any diagnosable alcohol problem at all.
The same exact thing is applicable when Fr. Moraitis takes up “Spiritual Stages.” The described symptom of “blaming God for their problems and consequences” is far more observed in individuals with this character structure who have no symptoms of an alcohol or drug difficulty. I have seen it happen way too many times when well meaning but ignorant people read descriptions like these and falsely accuse a loved one of a problem that they don’t have.
Ditto with the so-called “dry drunk.” What are individuals called who exhibit the same exact symptoms that “dry drunks” do but have never had an alcohol problem? The recovery “tradition” again has erred in its assessment of this. They have wrongly concluded that “dry drunk” symptoms are the direct manifestation of a part of alcoholism when, in fact, they come from the character structure dynamics of the individual.
I remember clearly 30 years ago reviewing a newly released video showing exemplars describing their “discovery” of ACOA (Adult Child of an Alcoholic). Even though there were absolutely no symptoms of alcoholism the exemplars attributed their difficulty to alcohol “somewhere back in the family history.” This is just one more error of the AA “tradition” attributing every thing that is wrong with the person to alcohol. This is a terrible injustice and disservice to the individual and completely misses the source of the difficulty.
The same exact thing is true again when Fr. Moraitis, on pp. 136-7 in Core Competency 9 lists the traits of “ACOA” individuals. All the traits listed for these individuals are true in one degree or another of the vast majority of individuals with the character structure referred to above but with no symptoms of alcoholism and there is no history of alcoholism in the family.
This leads me to my main criticism of the “traditional” recovery model, even though, like Fr. Moraitis, I also support AA and refer appropriate individuals to it. Unlike the Orthodox Tradition which was delivered by Divine authority, the recovery “tradition”, as helpful as it oftentimes has been, is entirely fallible and human. As with any human tradition the main downfall is the tradition’s calcification which doesn’t allow for any new, creative depth and search for truth. Time and again I have observed in alcohol/drug seminars and conventions and AA and other meetings the “mythologizing” of Bill W. and the Big Book to the degree that Bill W. takes on the aura of the religious prophet and the Big Book is its Scriptures. This dynamic is completely consistent with the above described character dynamics which exaggerates something beyond reality and partially answers why some individuals make AA their “church.”
There has also been the chronic difficulty of “who can help whom.” This is raised by Fr. Moraitis when he quotes the AA tradition’s insistence that “drunks” best help other “drunks.” (I’m sure you know how this reviewer feels about that term!) No doubt the success that AA has had in this area has naturally contributed to this idea. And, while it is true, it is far more often true that “drunks” “helping” other “drunks” leads to far more and severe drinking in the end! It is not the fact that the person is a “drunk.” It has everything to do with the quality, maturity and advanced spiritual progression (the desire/willingness to become sober and recover) of the individual than whether he/she is a “drunk” or not. This is sometimes made into a big deal. Some individuals in AA do not trust anyone outside AA who is not a “drunk.” The Orthodox priest will surely encounter this and should unequivocally reject this notion. Is it absolutely required that the Oncologist have cancer in order to treat cancer patients? The ridiculous comparisons could go on and on.
This reviewer heartily endorses the perspective of Fr. Moraitis who has seen the benefit of incarceration for some individuals. The reviewer completely rejects the so-called “California model” which would send all chemical offenders (outside of perhaps episodes of violence and dealing) to treatment facilities. Like Fr. Moraitis this reviewer has had too many clients directly state that incarceration was an extremely important part of their recovery. The “California model” is extremely naïve regarding the willingness, participation and potential successful outcomes of these individuals. As it turns out it would only serve as an enabling device for many.
Finally, I’d like to congratulate Fr. Moraitis and his seeming outstanding success with the “traditional” intervention. Though he states that the intervention usually fails on the first attempt success is generally accomplished with succeeding tries. In the practice of this reviewer in alcohol soaked Wisconsin no traditional interventions take place because there is generally no one inside or outside of the enmeshed family substance dysfunction to recruit for such an intervention. Those few who are or could be available are either too afraid or angry and/or disengaged to put forth such an enormous effort. In Wisconsin dysfunctional alcohol behaviors are generally accepted as a part of the culture.

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