One clinician’s perspective on how to get past denial in identifying alcohol abuse and dependence

Throughout my forty years as a practicing psychologist, I witnessed many shifts in opinion around assessing alcoholism, both in the therapy setting and in medicine in general. Back in the earliest days of my career in the 1970s, issues around alcoholism were rarely if ever brought up on the “couch” or in the examining room. Therapists were neither trained not encouraged to address such issues. We regarded problems which were the direct fallout from alcoholism as merely a matter of a twisted egos or neurotic neediness. Only end stage alcoholism with its DTs was on the health care radar. Korsakoff’s syndrome was rarely fodder for the outpatient therapy session or routine medical appointment. I suppose we all assumed those affected were “friends of Bill” or hallucinating on some gurney in a back ward.

Then things shifted. As we moved into the 1980s, 28-day residential alcohol rehabilitation programs spawned like salmon swimming upstream, urged on by the profit motive and rarely efficacious. Private therapists, like myself, were courted and actively encouraged to refer. The group “intervention” session was created for the more reluctant—where the afflicted sat on the hot seat amidst a gaggle of friends and family who “guilted” them into thinking that all would be well if they would just enter a program. AA was thrown in for good measure. DUI programs were also on the ascent. If not effective for the perpetrator, they were at least perceived as advancing the common good.

Toward the end of that period, large health organizations got in on the action, developing multi-level recovery programs based on a medical model and including residential, day-treatment, and intensive out-patient services. Many, like Kaiser Permanente’s Chemical Dependency Recovery Program, were very well thought out and executed. Equally effective long-term social model recovery programs popped up in bucolic vineyards and on the mean inner-city streets. Recidivism rates were discouraging regardless of the approach, but at least alcoholism was being addressed.

The need has only mushroomed since. Aside from the obvious health risks to the alcoholic (remember that more alcoholics die from their disease than recover from it!), the most devastating impact of alcoholism is on families. I once evaluated the seven to eight thousand patients I had personally seen in my counseling career and estimated that, regardless of the presenting problem, an alcohol-related issue was present in nearly 80%, coming in the form of living with, growing up with, or giving birth to someone who developed an alcohol problem.

And since those suffering from alcoholism rarely waltz in and ask for care—because denial is and always has been a major hallmark of the disease—the quandary remains as to how to connect those in the deepest throes of alcoholism with the help they so sorely need.

Any approach to identifying the alcoholic and referring them to treatment is best begun by remembering what Dr. Harry M. Tiebout (AA’s most supportive psychiatrist back in the 1950s and 1960s) said—that the alcoholic is in a life and death struggle to prove that the truth isn’t so. His words are still, in my opinion, the best working definition of alcoholism that exists, regardless of what national drug institutes may suggest are “too many drinks” for males and females.

The next most important thing to understand is that an intervention at any level that goes wrong isn’t just unsuccessful in getting the patient into recovery, it can also be incredibly successful in driving the afflicted person deeper into denial, making them even less likely to respond to interventions in the future. So getting it right means not necessarily leading a patient to a recovery program but opening a door for successful future interventions.

It generally falls upon the primary care physician, who has been tasked with inquiring about various unhealthy lifestyles from smoking to depression to unsafe sex, to screen for alcohol abuse and dependence. Tools have been developed from the one shot question about number of drinks consumed to more formal questionnaires, but none are the silver bullet able to put a hole in denial.

Questions can be asked about how much alcohol is consumed, but to avoid hitting that brick wall of denial, they must be asked in an off-handed, innocent manner with answers quietly recorded and not commented upon. Comments or questions that are welcomed with interest by a non-alcoholic person immediately increase defensiveness in the alcoholic. And they need to be asked in the following order.

  1. What type of beverages do you usually consume when you use alcohol? Chatting about favorite brands is helpful here!
  2. What is the least amount you drink on any particular day?
  3. What is the most amount you drink on any particular day?
  4. About how many days per week do you drink that least (most) amount?

Two additional questions can be added which I found to be the best predictors of alcohol or drug problems, again asked in a neutral manner.

  1. Did you ever drink more than even you intended to?
  2. Has anyone who says they care about you ever nagged you about your drinking?

Note that using the word “nagged” is essential. The question is often worded as, “Is anyone who cares about you concerned or annoyed about your drinking?”  Face it, alcoholics don’t care if someone else is “concerned” or “annoyed.” But they don’t like to be “nagged.” “Says they care” is also essential—alcoholics don’t feel “cared” about when someone confronts them about their drinking. That includes their physician.

Then, if any of their responses indicate there might be a problem, the next queries are the most important for increasing motivation to seek treatment in the future. And, not to worry: if someone wants help NOW, he or she will tell you!

  1. Are there any changes you’ve been thinking about making regarding your alcohol use?
  2. If YES: Is there any way I can be of assistance in making those changes?
  3. If NO: I do have referral information available if you need it in the future.

Please note that this approach leaves it entirely up to the member to determine whether or not they need to make changes. Keep your own opinions to yourself unless asked. Nudging and judging are not useful. You will be the first person in their life who brought up their drinking without telling them what to do about it! In terms of your very busy schedules, I found that with practice I could go through all these inquiries in a minute or two.

When referral information is requested, remember that Substance Abuse services are provided through the 14 counties that Partnership serves. The list of phone numbers for these County managed Alcohol and Drug Services is on the PHC Website. In addition, if members have co-occurring mental health issues or you have a question about the appropriateness of a substance abuse referral, you or the member can contact Beacon Health Options, PHC’s mental health provider, at (855) 765-9703.

Karen Stephen, PhD                                                                                                         PHC Mental Health Clinical Director

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