There is no greater agony than bearing an untold story inside you.
-Zora Neale Hurston
“There’s no problem that can’t be made worse with alcohol.”
When I use this line with clients, they look a bit startled and then laugh with recognition. Like any good interpretation, this pithy saying from Alcoholics Anonymous makes its point without being preachy or judgmental. It often leads us into further exploration and reflection about the patient’s relationship to alcohol.
January is the perfect month for therapists to follow up, “How were your holidays?” with some questions about the patient’s drinking. Many people see the old year out with a bang, or with a binge, or with a series of binges. They wake up in the New Year with a massive hangover, a crateful of regrets, and a boatload of resolutions. Some discover their closest relationships are in a shambles and that they’ve gotten themselves into a mess they can’t remember, let alone sort out. Remorse and resolutions are why gyms are so full the first weeks of January. It’s also why newcomers appear at AA meetings with their “day counts” in the single digits.
Therapists are uniquely positioned to help their alcohol-abusing patients recognize the problem before they actually “hit bottom”. But historically, psychoanalysts have been leery of wading into the troubled waters of substance abuse (Freimuth 2003). “I know they have a problem, but I’m not sure how to talk to them about it,” they often say. Sometimes a therapist’s reticence has to do with not wanting to depart from customary techniques, such as following the patient’s associations, careful listening, and avoiding ‘leading the patient’ at any cost. “I don’t want to impose my agenda on them,” is what I sometimes hear.
Interpersonalists have an edge in this regard. Because of our comfort in asking questions, we can easily adapt the detailed inquiry to an assessment of someone’s substance use or abuse. We know from experience that if we don’t ask, the patient often won’t volunteer the data. But when we do, all sorts of useful information come out that can further the treatment.
God (or the devil) is in the details
There are two other obstacles to our conducting a detailed assessment of a person’s drinking or drug use. “I don’t want to come across as critical or moralistic,” therapists will say. Naturally, we all want to maintain an empathic stance with our patients. But I’ve found it possible to do this while sensitively exploring a person’s important, and often hidden, relationship to alcohol. The approach I use is to ask people to talk about their own concerns about their drinking, focusing specifically on harmful consequences they’ve experienced (Damron 2003).
For the last obstacle, “What questions should I ask?” there are several assessment tools that have enabled therapists, doctors, and other helping professionals to quickly ascertain whether a patient’s alcohol use has crossed over into dependence. Two of the simplest ones are the four-question CAGE questionnaire, developed by Dr. John Ewing (1984) and the 10-question AUDIT, which targets quantities, harmful consequences, and loss of control. Psychotherapists who have an already-established relationship with a patient who drinks or drugs will probably want to adapt these questions to their own way of speaking.
For example, when someone mentions loss of control while drinking, I’ll ask if this happened recently. If the patient alludes to a three-day binge, I’ll say, “Can you walk me through it? (i.e., what time did it start, how much did you drink, at what point did you fall asleep, etc.). Following up with, “Did anything happen during the binge that wouldn’t have happened if alcohol hadn’t been involved?” may highlight for the patient the way alcohol abuse is making them betray their own values. Such a realization can act as a powerful motivator for cutting back or stopping altogether (Frankfeldt 2002). In this way, therapists can assist in raising a patient’s “bottom”. A detailed inquiry about a patient’s substance use or abuse can last several sessions, and might even become an important and ongoing theme in the treatment.
If someone does come in this month expressing concern about how much they partied over the holidays, this would be the perfect time to start exploring it with them.
CAGE & AUDIT Questionnaires: www.addictionsandrecovery.org/addiction-self-test.htm
Emily Damron, LCSW, is a graduate of Manhattan Institute for Psychoanalysis. She is a supervisor and is on the faculty at Psychoanalytic Psychotherapy Study Center, where she also founded the Committee on Psychoanalysis and Addictions Treatment. Ms. Damron is in private practice in Chelsea and Park Slope. She also provides individual and group consultations.
Damron, E. (2003). A Guideline for Understanding & Assessing Addiction. The Participant Observer: The Newsletter of The Manhattan Institute for Psychoanalysis, 2:2, Spring Issue. 4 pp.
Freimuth, M. (2003). The Unseen Diagnosis: Addiction Assessment, The Psychotherapy Bulletin, 37: 38-42.
Frankfeldt, V. (2002). Complex Problems Require Complex Solutions: Donnie: A Life Apart, Harm Reduction Psychotherapy: A New Treatment for Drug and Alcohol Problems. A. Tatarsky, Ed., NY: Jason Aronson, pp. 137-159.