Ask the Expert: Exploring the Clinician's Concern About Unreported Abuse of Alcohol

A careful initial history that includes all medical problems, medications, and history of alcohol and drug use provides invaluable information. Although it may not immediately lead to the diagnosis of alcohol abuse, it may be helpful in retrospect if the issue subsequently becomes a question. For example, a history of tremor, an unexplained dulling of consciousness, or a vaguely explained history of hospitalizations may assume increased salience with events that raise the question of alcohol abuse during the course of treatment.

The clinician should always be alert to symptoms and complaints that may refer to an unreported abuse of alcohol. Here is a recent example: a relatively new psychiatric patient telephoned the covering physician while her doctor was away and complained that the newly prescribed antidepressant medication might be making her sleepy and feeling overly medicated in the morning. A careful review of medications led to an inquiry about all drugs and substances and rather rapidly led to the admission that the patient had been drinking one to two bottles of wine per day for at least the previous month. The patient had withheld this information not only from her psychiatrist but also from her internist whom she had also recently consulted. The omitted history was probably due to both shame and minimization by the patient. She was able to accept a firm and matter of fact confrontation about the damaging effects of the alcohol, including its effect on the treatment for her depression. Of course, the information was passed by the covering physician to the treating psychiatrist and addressed immediately in the treatment. In this case, the complaint to the on-call physician and the ease with which the previously withheld relevant information was elicited may attest to the patient's search for an indirect way to alert her psychiatrist to behavior she could not bring herself to confide more directly.

When the patient begins to acknowledge symptoms or behavior suggestive of alcohol abuse, psychiatrists have a unique advantage in their medical background and experience with differential diagnosis to explore and intervene. It is helpful to maintain an accepting and matter-of-fact tone to draw out the relevant previously unreported or understated alcohol use pattern. On occasion, a calm but firmly confronting tone may be helpful for patients with certain avoidant or aggressive personality styles.

A sophisticated male patient was usually very pleasant, self-revealing, respectful, and receptive to the ideas and suggestions of his psychiatrist. Although he reported past episodes of youthful overindulgence in alcohol, which he seemed to deplore, it gradually emerged that the episodes continued into his current life. His characteristic defenses of minimization and denial played a role in the delay of this revelation. As his psychotherapy progressed, both a family history of alcoholism and his parents' unempathic demands for compliance and perfection emerged. As the treatment and transference deepened, the patient's hidden rage became conscious, and his continued heavy drinking was exposed as a vehicle for the expression of his defiance as well as the only relief from his anxious perfectionism, low self-esteem, and sexual inhibition. After several stormy years of intensive treatment, the patient was gradually increasingly able both to want and to be able to control his drinking.

A 50-year-old chronic alcoholic, whose alcoholism was controlled with disulfiram, was asked at the beginning of each psychotherapy appointment if he had been taking his medication. He reported that he appreciated the question, feeling that it kept him on track in his constant struggle with his wish to resume drinking. However, when stress at work became overwhelming, he ceased taking his disulfiram for several weeks in order to plan a weekend of binge drinking. During this period he lied to his psychiatrist about skipping the disulfiram, confessing all only after the weekend had been spent drinking. Subsequently, the patient was filled with remorse and self-disgust, and the episode was not repeated, although temptations to do so were reported and explored in his psychotherapy. As his treatment progressed, several helpful elements included exploration and understanding of his lifelong intense anxieties and severe depression as stimuli to his self-medication with alcohol, a careful fine tuning of his medications for anxiety and depression, and assistance in arranging a part-time work schedule to minimize his intense ongoing work-related stress.

An 80-year-old highly intelligent and active retired professional was a respected leader of the local Alcoholics Anonymous meeting but was also, secretly, a serious chronic daily drinker at home. On several prior occasions he had stopped drinking for up to 1 year after intense pressure from previous psychotherapists and physicians. Refusing individual therapy but willing to engage in couples therapy with his supportive but exasperated wife, the patient was helped to examine in an atmosphere of respect the function of alcohol in soothing his lifelong severe anxiety and perfectionism, never previously investigated in his many prior treatments. The patient was also helped to engage in a gradual exploration of his deep investment in his continuing health, intellectual capacities, tennis game, still active sexual life, and especially his family's positive feelings and esteem for him—all of which his drinking was eroding. This elderly alcoholic then made, on his own, the decision for abstinence. This radical change in discarding a cherished lifelong addiction was therapeutically based on finding and allying with those motivations for abstinence already present (without an externally based coercion) within the patient as a part of his desire to protect valued personal goals. A similar approach to working with patients, especially substance abusers, has been described in a growing body of literature on “Motivational Interviewing” (1).

Finally, we need to be aware of the many alcoholic patients with whom we experience a certain degree of failure. One such patient was a pleasant, well-educated, highly functional mother of two in a failing marriage with an irresponsible husband. She was also a very severe alcoholic. With her, there was no issue of minimization, denial, or dishonesty with her psychiatrist. She did not disagree that her habit presented grave risks for her health and future. She explored willingly the function of alcohol as a soothing presence in her life. Even as she pursued a divorce, stabilized her life, and subsequently established a far more satisfying marriage, the patient was simply unable to diminish her alcohol abuse. With such patients, the psychiatrist must reach a decision about continuing to provide a treatment which fails in the important goal of curtailing a health-endangering addiction. No definitive rule can be made about arriving at such a decision; clinicians may decide that some actively alcoholic patients may benefit in other important ways from continuing the treatment, whereas with others, psychiatrists may feel they cannot continue to be a part of a pattern of destructiveness that endangers the patient and others in his or her life. Certainly our alcoholic patients confront us with the limits of our effectiveness and remind us of our need for humility in combination with our confidence in our expanding therapeutic skills.