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# Alcoholism In The Workplace: A Handbook for Supervisors

## Table of Contents

### Introduction

                  - Alcoholism in the Workplace
                  - Supervisor's Role
                  - Signs to Look for
                  - Leave and Attendance
                  - Performance Problems
                  - Relationships at Work
                  - Behavior at Work

### Next Steps

                  - Employee Assistance Program
                  - Human Resources or Employee Relations
                  - Confronting the Employee
                  - Intervention

### Considerations During and After Treatment

                  - Leave Status
                  - Return to Duty
                  - Follow-up Care

### Other Topics

                  - Intoxication at Work
                  - Things to Avoid

### Conclusion

                  - Appendix - The Disease of Alcoholism

## Introduction

The National Council on Alcohol and Drug Dependence defines alcoholism this way:
> *"Alcoholism is a primary, chronic disease with genetic, psychological, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortion in thinking, most notably denial."*

Alcohol is the single most used and abused drug in America. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), nearly 14 million Americans (1 in every 13 adults) abuse alcohol or are alcoholics. Several million more adults engage in risky drinking patterns that could lead to alcohol problems. The costs to society in terms of lost productivity, health care costs, traffic accidents, and personal tragedies are staggering. Numerous studies and reports have been issued on the workplace costs of alcoholism and alcohol abuse, and they report costs that range from $33 billion to $68 billion per year. Alcohol is a major factor in injuries, both at home, at work, and on the road. Nearly half of all traffic fatalities involve alcohol. Please see the Appendix - The Disease of Alcoholism for a further discussion of alcoholism.

In the workplace, the costs of alcoholism and alcohol abuse manifest themselves in many different ways. Absenteeism is estimated to be 4 to 8 times greater among alcoholics and alcohol abusers. Other family members of alcoholics also have greater rates of absenteeism. Accidents and on-the-job injuries are far more prevalent among alcoholics and alcohol abusers.

The Federal workplace is no different than any other in respect to alcoholism and alcohol abuse. Though no studies have been done on the prevalence of alcoholism and alcohol abuse among Federal employees, it is safe to assume that a similar proportion of Federal employees are alcoholics or alcohol abusers as in the national workforce. The associated increased health care costs and lost productivity are passed along directly to the taxpayer, and to each and every one of us.

This booklet was developed in cooperation with the Department of Health and Human Services (DHHS) and is designed to foster a better awareness in supervisors, managers, and human resource personnel of the issues surrounding alcoholism and alcohol abuse, especially as it relates to the Federal workplace. The booklet is not intended to cover, in detail, all the various aspects of alcoholism and alcohol abuse but to give you enough information to understand and recognize the problems and know where to go to get assistance. See the Appendix for more detailed information regarding alcoholism.

## Alcoholism in the Workplace

As far as the Government as an employer is concerned, an employee’s decision to drink is that individual’s personal business. However, when the use or abuse of alcohol interferes with the employee’s ability to perform his or her duties, the employer does have legitimate concerns, including the proper performance of duties, health and safety issues, and employee conduct at the workplace.

### Supervisor’s Role

As a supervisor, you have an important role in dealing with alcohol problems in the workplace, along with other agency officials. You have the day-to-day responsibility to monitor the work and on-the-job conduct of your employees. You are not responsible for diagnosing alcoholism in employees. Basic supervisory responsibilities include:
              - assigning, monitoring, reviewing, and appraising work and performance;
              - setting work schedules, approving or disapproving leave requests;
              - taking necessary corrective and disciplinary actions when performance or conduct problems surface; and
              - referring employees to your agency’s Employee Assistance Program (EAP).

At some point, you will likely encounter employees with problems related to alcohol in dealing with performance, conduct, and leave problems. In some cases, you may not know that there is an alcohol problem. In other cases, you may know, either because the employee admits to being an alcoholic, or the problem is self-evident. For example, an employee may become intoxicated while on duty or be arrested for drunk driving. Your role is not to diagnose the alcohol problem but to exercise responsibility in dealing with the performance or conduct problem, hold the employee accountable, refer the employee to the EAP, and take any appropriate disciplinary action. Your role in dealing with alcoholism in the workplace is crucial. The most effective way to get an alcoholic to deal with the problem is to make the alcoholic aware that his or her job is on the line and that he or she must get help and improve performance and conduct, or face serious consequences, including the possibility of losing his or her job.

## Signs to Look for

Even though you must not try to diagnose the problem, there are many signs that may indicate a problem with alcohol, and should trigger a referral to the EAP.

### Leave and Attendance

              - Unexplained or unauthorized absences from work
              - Frequent tardiness
              - Excessive use of sick leave
              - Patterns of absence such as the day after payday or frequent Monday or Friday absences
              - Frequent unplanned absences due to "emergencies" (e.g., household repairs, car trouble, family emergencies, legal problems)

The employee may also be absent from his or her duty station without explanation or permission for significant periods of time.

## Performance Problems

              - Missed deadlines
              - Careless or sloppy work or incomplete assignments
              - Production quotas not met
              - Many excuses for incomplete assignments or missed deadlines
              - Faulty analysis

In jobs requiring long-term projects or detailed analysis, an employee may be able to hide a performance problem for quite some time.

## Relationships at Work

              - Relationships with co-workers may become strained
              - The employee may be belligerent, argumentative, or short-tempered, especially in the mornings or after weekends or holidays
              - The employee may become a "loner"

The employee may also have noticeable financial problems evidenced by borrowing money from other employees or receiving phone calls at work from creditors or collection companies.

## Behavior at Work

The appearance of being inebriated or under the influence of alcohol might include:
              - The smell of alcohol
              - Staggering, or an unsteady gait
              - Bloodshot eyes
              - Smell of alcohol on the breath
              - Mood and behavior changes such as excessive laughter and inappropriate loud talk
              - Excessive use of mouthwash or breath mints
              - Avoidance of supervisory contact, especially after lunch
              - Tremors
              - Sleeping on duty

Not any one of these signs means that an employee is an alcoholic. However, when there are performance and conduct problems coupled with any number of these signs, it is time to make a referral to the EAP for an assessment so that the employee can get help if it is needed.

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## Next Steps

### Employee Assistance Program

Employee Assistance Programs deal with all kinds of problems and provide short-term counseling, assessment, and referral of employees with alcohol and drug abuse problems, emotional and mental health problems, marital and family problems, financial problems, dependent care concerns, and other personal problems that can affect the employee’s work. This service is confidential. These programs are usually staffed by professional counselors and may be operated in-house with agency personnel, under a contract with other agencies or EAP providers, or a combination of the two.

The EAP counselor will meet with the employee, assess or diagnose the problem, and, if necessary, refer the employee to a treatment program or resource. (Please see the material in the Appendix ) With permission of the client, the EAP counselor will keep you informed as to the nature of the problem, what type of treatment may be needed, and the progress of the employee in treatment. Before releasing this information to you, or anyone else, the counselor would need a signed written release of information from the client which would state what information may be released and to whom it may be released. The EAP counselor will also monitor the employee’s progress and will provide follow-up counseling if needed.

Sometimes, the employee will contact the EAP on his or her own. However, in some cases, the employee will be referred by you because you have noted a decline in the employee’s conduct, attendance, or performance and/or seen actual evidence of alcohol use or impairment at work.

### Human Resources, or Employee Relations Program

The role of the Human Resources, or Employee Relations office in dealing with cases of substance abuse is to advise management of appropriate adverse, disciplinary, or other administrative actions which may be taken. They also advise employees of their rights and the procedures in such cases. They do not obtain confidential information from the EAP nor do they independently approach the employee regarding the problem.

As a supervisor, you are responsible for confronting the employee. Employee relations staff will work with the EAP to the extent that confidentiality is not violated, will try to assist you in working with the EAP, and will work with you to try to make sure that any adverse or disciplinary actions are appropriate and defensible. In most agencies, it is the employee relations or human resources specialist who actually prepares or drafts adverse or disciplinary action letters, including those involving a firm choice. A firm choice is a clear warning to an employee who has raised alcohol or drug abuse in connection with a specific performance, conduct, or leave use incident or deficiency. He or she must make a choice between accepting treatment for the alcohol or drug problem and improving job performance or facing disciplinary action, up to and including removal.

### Confronting the Employee

It is generally a good practice to notify any employee who is being counseled for a performance or conduct problem about the availability of the EAP. However, it is crucial to make a referral to the EAP in the case of an employee with a known alcohol problem. Although you are not diagnosing the problem, you are dealing with employee performance and conduct and, possibly, alcohol-related misconduct such as using, possessing, or being under the influence of alcohol at work.

As a supervisor, you need to develop a strategy for addressing the work-related problems, as well as for encouraging the employee to get help. A good starting point is to meet with the EAP counselor, if possible, to discuss the problems observed and any other behavior by the employee that needs attention. The EAP counselor can help devise a strategy for confronting the employee and advise on techniques of addressing the problems.

Before actually meeting with the employee, you should gather any documentation of performance or conduct problems and think about what items to discuss with the employee. It is important to be specific about the problems in the employee’s performance and conduct and the particular incidents of concern. It might be helpful to rehearse this or at least go over the documentation with the EAP counselor.

Once prepared, you should notify the employee of the time and place of the meeting. The meeting should be held in a private place away from distractions. It is important to calmly but firmly explain the problems with the employee’s performance, the specific acts of misconduct or troubling behavior, and the consequences of any misconduct or poor performance. Unless the employee reveals the existence of an alcohol problem or there is immediate evidence of on-duty impairment, you must be careful not to offer any opinion that the employee may have a problem with alcohol. You should refer the employee to the EAP and explain that failure to correct any deficiencies may result in disciplinary or other action. It would be preferable to have already made an appointment for the employee with the EAP. While the employee may not be forced to take advantage of the EAP services, you should make clear that it is in the employee’s best interest to use the services.

Sometimes the employee will not accept the referral to the EAP or will deny the existence of a problem. If this happens, it is important to continue to document any problems and to take any necessary disciplinary action. It is not unusual to have additional meetings with the employee and to make additional referrals. The employee is in "denial" at this point and does not see that he or she has a problem. This is the hardest part of dealing with an alcoholic. The disease is so strong that the individual is unable to see what is happening to himself or herself. In any case, the appropriate course of action is to continue to hold the employee accountable for his or her performance and/or conduct, regardless of whether or not the employee has admitted an alcohol problem.

If an employee chooses to use the EAP at your urging, he or she may enter some type of treatment program as described earlier in this booklet. If the employee does not choose to go into treatment, the next step will be to take any disciplinary or corrective actions that are necessary.

### Intervention

One technique which can be used to confront the employee is called intervention. It generally consists of scheduling a session with the employee where a number of people significant in his or her life are present, including you, the spouse, children, clergy, other family members, co-workers and other friends.

The session must be led by a trained professional, such as the EAP counselor. It involves having each of the individuals present directly tell the employee how his or her drinking has affected their lives and what the consequences of that employee’s drinking have been. If the

intervention is effective, this can be a very powerful tool to counter denial and may help the employee consider treatment. It is extremely important that such an intervention be led by a trained professional and not by a lay person, such as a supervisor, because it can be a very emotional and powerful event and, if not conducted properly, may very likely backfire. Supervisors should contact an agency EAP counselor for more information about the intervention technique.

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## Considerations During and After Treatment

### Leave Status

During the period of time that the employee is away from work receiving treatment, he or she will usually be carried in some type of approved leave status. In most cases, it would be appropriate for the employee to be carried on any available sick leave. Otherwise, annual leave or leave without pay would be appropriate. Normally, the employee would not be charged as absent without approved leave (AWOL) unless the employee’s absence had not been approved. Check with the Human Resources office about the rules and policies regarding approval and denial of leave.

### Return to Duty

When the employee has completed any treatment requiring extended absence and is ready to return to work, it is a good practice to have a back-to-work conference. The conference should be attended by you as the supervisor, the employee, the EAP counselor, a staff member from the treatment program, other appropriate personnel from human resources, and the employee’s representative if one has been elected. This back-to-work conference can help explain what has gone on in treatment, what the employee’s treatment schedule looks like, and any needed changes in work such as travel schedules or closer supervision.

### Follow-up Care

After the employee’s return to duty, there will be some type of follow-up care such as a 12-Step program or other group meetings, therapy, EAP sessions, or any combination of the foregoing (please see the Appendix ). These sessions should cause only minimal disruption to the work schedule. The EAP counselor can explain the importance of the follow-up program to the employee’s continued sobriety.

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## Other Topics

### Alcohol Testing

Generally, agencies do not have the authority to conduct mandatory alcohol testing. Although some agencies may have the equipment and trained personnel to administer an alcohol test, such a test would be voluntary. Most alcohol testing would probably be conducted with an evidentiary breath testing device (EBT), commonly referred to as a breathalyzer. While there are other methods of testing for alcohol, including blood or saliva tests, an EBT is the predominant method because it is less invasive and is already in use by law enforcement personnel. Law enforcement personnel on Federal property may administer alcohol tests to drivers when there is an accident or reasonable cause to do such testing. However, cause for such testing must be based on a violation of motor vehicle and traffic rules and not mandatory testing by the agency.

The Department of Transportation (DOT) has issued rules regarding alcohol testing for certain groups of employees such as those who are required to possess a Commercial Driver’s License, and certain employees in aviation-related positions. These rules call for mandatory alcohol testing, using EBTs, of applicants for identified positions and in cases of reasonable suspicion of alcohol use, and for random testing of employees in these positions. Any agencies conducting this type of testing will have a specific program spelled out in agency policy.

An agency may conduct voluntary alcohol testing. An example of this might be an instance where you think that an employee is intoxicated but the employee denies it. In this instance, an alcohol test may be given at the employee’s request or with the employee’s permission. If intoxication is indicated by the test, the agency may use it as a basis for some type of administrative action, such as sending the employee home, or taking disciplinary action. An agency may not take disciplinary action solely because an employee declines to undergo a voluntary alcohol test.

### Intoxication at Work

An area that is often troublesome for supervisors is what to do when an employee is apparently under the influence or intoxicated at work. Agencies have a fair amount of latitude about what to do in these situations. The following is a list of steps you should take in dealing with such a situation. Though not all steps would be appropriate in all situations, most would be applicable.

If the employee is performing, or required to perform, safety-sensitive duties such as driving vehicles, using heavy equipment, working around explosives or weaponry, or performing patient care activities, he or she must be restricted from performing these duties.

If the employee is willing, he or she may be sent to the health unit for observation or a possible assessment. Health unit personnel may be able to offer a medical judgment that, in their opinion, the employee is intoxicated. They may also be able to conduct a voluntary alcohol test, most likely an EBT. Unless the employee is in a job with specific medical or physical requirements, you cannot order the employee to undergo any type of medical examination, including an EBT. Examples of the types of jobs that may have specific medical requirements include police officers, certain vehicle operators, air traffic controllers, and various direct patient-care personnel.

The EAP should be contacted. The counselor may be able to assist in any immediate assessment or may be at least able to talk to the client immediately. Even if the EAP counselor is unable to see the employee immediately, EAP personnel should be informed of the situation. You should refer the employee to the EAP after the employee returns to duty.

If the employee is disruptive to the workplace, you should remove him or her from the immediate worksite. This may involve taking the employee home or at least taking him or her to the health unit, the EAP office, or some other safe location. An employee who is physically resisting should be dealt with by agency security or local police. The employee should not be sent home alone or allowed to drive. It would be appropriate to consider having a family member take the employee home. A taxi is also an option. There could be some serious liability issues involved here so it is important to consult with Human Resources, Employee Relations, and the legal counsel’s office.

It is important to immediately and accurately document in writing what has transpired. Record all the events that led to sending the employee home, especially if any disciplinary action is necessary. It is important to work with the EAP and employee relations staff and keep them informed of such events because the quality of the information they receive from you impacts on the quality of their advice and service.

### Things to Avoid

Avoid being an "enabler." An enabler is someone who allows the alcoholic to continue the addiction without being held responsible for his or her actions. Supervisors often think that they are being kind, when actually they are hurting the alcoholic employee by letting him or her continue to engage in self-destructive behaviors. In addition, failing to hold the alcoholic employee accountable can have a negative effect on co-workers’ morale. Examples of supervisory behavior that might be considered enabling include:
              - Covering up for the employee;
              - Lending the employee money;
              - Allowing the employee’s spouse, rather than the employee, to call about the employee’s absence;
              - Failing to refer the employee to the EAP;
              - Shifting the employee’s work to other employees;
              - Trying to counsel the employee on your own;
              - Making excuses to others about the employee’s behavior or performance; and
              - Adjusting the employee’s work schedule, for example, allowing the employee to continually come in late and make up
              the hours later. ul>

## Conclusion

Alcoholism is a disease. Employees who suffer from it need the agency’s compassion. However, sometimes that compassion has to be firm in order to communicate that, while the agency is willing to help the employee get assistance, the employee is ultimately responsible for his or her own rehabilitation, recovery, and performance.

The best help that you as a supervisor can offer is to learn something about the disease, refer the employee to the EAP, and hold him or her accountable for his or her conduct or performance.

This is just a brief road map for dealing with alcohol problems in the workplace. For further information on alcohol abuse and alcoholism, contact your agency’s Employee Assistance Program (EAP), your Human Resources or Employee Relations office, local mental health or substance abuse programs, or by email at worklife@opm.gov. Additionally, a great deal of information can be obtained from the National Clearinghouse for Alcohol and Drug Information (NCADI) at:

National Clearinghouse for Alcohol and Drug InformationP.O. Box 2345Rockville, MD 20847-23451-800-729-6686TDD 1-800-487-4889

## Appendix - The Disease of Alcoholism

There are, and have been, many theories about alcoholism. The most prevailing theory, and now most commonly accepted, is called the Disease Model. Its basic tenets are that alcoholism is a disease with recognizable symptoms, causes, and methods of treatment. In addition, there are several stages of the disease which are often described as early, middle, and late. While it is not essential for a supervisor to fully define these stages, it is useful to understand them in terms of how the disease presents itself in the workplace.

### The Early or Adaptive Stage

The early or adaptive stage of alcoholism is marked by increasing tolerance to alcohol and physical adaptations in the body which are largely unseen. This increased tolerance is marked by the alcoholic’s ability to consume greater quantities of alcohol while appearing to suffer few effects and continuing to function. This tolerance is not created simply because the alcoholic drinks too much but rather because the alcoholic is able to drink great quantities because of physical changes going on inside his or her body.

The early stage is difficult to detect. By appearances, an individual may be able to drink a great deal without becoming intoxicated, having hangovers, or suffering other apparent ill-effects from alcohol. An early stage alcoholic is often indistinguishable from a non-alcoholic who happens to be a fairly heavy drinker.

In the workplace, there is likely to be little or no obvious impact on the alcoholic’s performance or conduct at work. At this stage, the alcoholic is not likely to see any problem with his or her drinking and would scoff at any attempts to indicate that he or she might have a problem. The alcoholic is simply not aware of what is going on in his or her body.

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### The Middle Stage

There is no clear line between the early and middle stages of alcoholism, but there are several characteristics that mark a new stage of the disease. Many of the pleasures and benefits that the alcoholic obtained from drinking during the early stage are now being replaced by the destructive facets of alcohol abuse. The drinking that was done for the purpose of getting high is now being replaced by drinking to combat the pain and misery caused by prior drinking.

One basic characteristic of the middle stage is physical dependence. In the early stage, the alcoholic’s tolerance to greater amounts of alcohol is increasing. Along with this, however, the body becomes used to these amounts of alcohol and now suffers from withdrawal when the alcohol is not present.

Another basic characteristic of the middle stage is craving. Alcoholics develop a very powerful urge to drink which they are eventually unable to control. As the alcoholic’s tolerance increases along with the physical dependence, the alcoholic loses his or her ability to control drinking and craves alcohol.

The third characteristic of the middle stage is loss of control. The alcoholic simply loses his or her ability to limit his or her drinking to socially acceptable times, patterns, and places. This loss of control is due to a decrease in the alcoholic’s tolerance and an increase in the withdrawal symptoms. The alcoholic cannot handle as much alcohol as they once could without getting drunk, yet needs increasing amounts to avoid withdrawal.

Another feature of middle stage alcoholics is blackouts. Contrary to what you might assume, the alcoholic does not actually pass out during these episodes. Instead, the alcoholic continues to function but is unable to remember what he or she has done or has been. Basically, the alcoholic simply can’t remember these episodes because the brain has either stored these memories improperly or has not stored them at all. Blackouts may also occur in early stage alcoholics.

Impairment becomes evident in the workplace during the middle stage. The alcoholic battles with loss of control, withdrawal symptoms, and cravings. This will become apparent at work in terms of any or all of the following: increased and unpredictable absences, poorly performed work assignments, behavior problems with co-workers, inability to concentrate, accidents, increased use of sick leave, and possible deterioration in overall appearance and demeanor. This is the point where the employee may be facing disciplinary action.

### Late Stage

The late, or deteriorative stage, is best identified as the point at which the damage to the body from the toxic effects of alcohol is evident, and the alcoholic is suffering from a host of ailments. An alcoholic in the final stages may be destitute, extremely ill, mentally confused, and drinking almost constantly. The alcoholic in this stage is suffering from many physical and psychological problems due to the damage to vital organs. His or her immunity to infections is lowered, and the employee’s mental condition is very unstable. Some of the very serious medical conditions the alcoholic faces at this point include heart failure, fatty liver, hepatitis, cirrhosis of the liver, malnutrition, pancreatitis, respiratory infections, and brain damage, some of which is reversible.

Why does an alcoholic continue to drink despite the known facts about the disease and the obvious adverse consequences of continued drinking? The answer to this question is quite simple. In the early stage, the alcoholic does not consider himself or herself sick because his or her tolerance is increasing. In the middle stage, the alcoholic is unknowingly physically dependent on alcohol. He or she simply finds that continuing to use alcohol will prevent the problems of withdrawal. By the time an alcoholic is in the late stage, he or she is often irrational, deluded, and unable to understand what has happened.

In addition to the effects of these changes, the alcoholic is faced with one of the most powerful facets of addiction: denial. An alcoholic will deny that he or she has a problem. This denial is a very strong force. If an alcoholic did not deny the existence of a problem, he or she would most likely seek help when faced with the overwhelming problems caused by drinking. While denial is not a diagnosable physical symptom or psychiatric disorder, it is an accurate description of the state of the alcoholic’s behavior and thinking and is very real.

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### Treating Alcoholism

An alcoholic will rarely stop drinking and stay sober without outside help. Also, he or she usually will not stop drinking without some kind of outside pressure. This pressure may come from family, friends, clergy, other health care professionals, law enforcement or judicial authorities, or the employer. For example, a spouse may threaten divorce, or the alcoholic may be arrested for driving under the influence. There was at one time a widespread belief that alcoholics would not get help until they had "hit bottom." This theory has generally been discredited as many early and middle stage alcoholics have quit drinking when faced with consequences such as the loss of a job, a divorce, or a convincing warning from a physician regarding the potentially fatal consequences of continued drinking.

There are obvious advantages to getting the alcoholic into treatment earlier rather than later. One advantage is that, the earlier treatment is begun, the probability of having less expensive treatment, such as outpatient care, is increased. There is also a greater likelihood of success in treatment with an individual who has not yet lost everything and still has a supportive environment to return to, including an intact family, good health, and a job. In addition, the employer has a stake in the early treatment of alcoholism, since the employee will have a greater chance of returning sooner to full functioning on the job if the disease is arrested at an earlier point. Early treatment is simply less disruptive to the workplace and can help the employee avoid further misconduct and poor performance. If an alcoholic employee doesn't’t get help until very late in the disease, there may have been irreparable harm done to the employee-employer relationship.

The alcoholic does not initially have to want to get help to go into treatment. Many people go into treatment because of some kind of threat such as loss of a job or possible incarceration. However, even the individual that is forced will eventually have to personally accept the need for treatment for it to be effective. The employer is a very potent force in getting the alcoholic into treatment. The threat of the loss of a job is often the push the alcoholic needs to enter treatment. This threat is usually communicated to the employee through some type of an adverse or disciplinary action and is accompanied by a referral to the Employee Assistance Program (EAP) which will refer the employee to an appropriate treatment program.

There are various kinds of treatment and programs for alcoholism. Though some alcoholics do stop drinking on their own, this is rare. Most alcoholics require some type of treatment or help. The following are some common types of programs and approaches to treatment:
              -  *Alcoholics Anonymous (AA)* – AA is what is called a 12-Step program and involves a spiritual component (not affiliated with any particular religion) and a supportive group of fellow alcoholics to provide a network for total abstinence from alcohol. There are AA meetings where alcoholics can gather to learn about the disease, hear talks from recovering alcoholics, and enjoy the support of fellow alcoholics who are learning, or have learned, how to stay sober. AA is not really a formal organization as it has no leaders. It is a loose confederation of groups formed by recovering alcoholics operating on common principles spelled out in the book Alcoholics Anonymous (it is also known as the "Big Book") which spells out the Twelve Steps and the principles of AA.  There are other support groups such as Rational Recovery which have a different focus than AA. Some individuals find approaches other than AA to be more useful in their treatment. 
              -  *Detoxification* – Detoxification, also known as "detox," is a process whereby the alcoholic undergoes a supervised withdrawal. The body can begin to recover from the toxic effects of alcohol and the patient can become sober. This is something that is best done in a medical setting where the patient can be closely monitored and have his or her medical condition evaluated. Detoxification can last anywhere from two to seven days. 
              -  *Inpatient treatment* – This consists of a formal, residential program which may include detox at the beginning. Typically an inpatient program would include education about the disease; medical treatment for related medical conditions and nutritional stabilization; counseling, including individual and group therapy sessions; an introduction to a 12-Step program; and monitoring of the patient including drug and/or alcohol testing to ensure compliance with the program. Inpatient programs last anywhere from one to six weeks, typically 3-4 weeks. Some are connected with hospitals while others are not. There are some programs called "day treatment" in which patients spend the entire day at the treatment center but go home at night or on weekends. Inpatient treatment is very expensive and can easily cost $5,000 to $10,000. 
              -  *Outpatient treatment* – This consists of counseling and treatment on a daily or weekly basis in an office or clinic setting. Outpatient treatment is often a follow-up to an inpatient or detox program. In some cases, the severity of the addiction is such that inpatient care is not needed, and the client undergoes only outpatient treatment. It may include education about the disease, individual or group therapy, or follow-up counseling. Outpatient treatment is not as expensive as inpatient treatment and may last anywhere from one month to a year. 

Quite often, treatment will consist of a combination of all of the above, depending on such factors as the severity of the problem, the individual’s insurance coverage, whether detox is needed, and the availability of programs. The cost of treatment is the employee’s responsibility. All Federal Employee Health Benefit Plans have some kind of coverage; however, that coverage is limited. The EAP counselor and the employee benefits representative will have information on health benefits coverage. Employees should direct any questions to one of these resources.

### Post Treatment

After the initial treatment program, the employee may be in follow-up counseling and treatment for an extended period of time, possibly up to a year. This will most likely consist of outpatient counseling, AA meetings, and follow-up sessions with the EAP counselor. It can be very beneficial for the EAP counselor to schedule a back-to-work conference with the employee, the supervisor, and other interested parties such as an employee relations specialist or a counselor from the treatment program. The purpose of this meeting is to discuss the employee’s treatment, the expectations in terms of the employee’s performance and conduct, scheduling concerns in terms of follow-up counseling and AA meetings, and to help get the employee back into the regular work routine.

### Relapse

An important and frustrating facet of treating alcoholism is relapse or a return to drinking. An alcoholic often relapses due to a variety of factors including: inadequate treatment or follow-up, cravings for alcohol that are difficult to control, failure by the alcoholic to follow treatment instructions, failure to change lifestyle, use of other mood altering drugs, and other untreated mental or physical illnesses. Relapses are not always a return to constant drinking and may only be a one time occurrence. However, relapses must be dealt with and seen as a sign to the alcoholic that there are areas of his or her treatment and recovery that need work. Relapse prevention is an area in the treatment field that is receiving increased attention and research. A basic part of any effective treatment program will include relapse prevention activities. Good coordination between the EAP counselor and the treatment program can help the employee deal with and prevent relapse.

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