What to do for a client with a history of addiction who is socially drinking? Twenty years of Tips and Topics. What’s next?

Welcome to the April edition, the start of year 21 for Tips and Topics.

In SAVVY, STUMP THE SHRINK and SKILLS,  two clinical vignettes about clients with a history of moderate to severe Alcohol Use Disorder and three DWIs (Driving While Intoxicated) raise assessment and engagement questions to be considered.

In SOUL, I started publishing Tips and Topics April 2003. On this 20th anniversary, I look back at what the initial goals were; whether I lived up to those; and what’s next for Tips and Topics.

SAVVY, STUMP THE SHRINK, AND SKILLS

This April edition of Tips and Topics marks the start of my twenty-first year of writing each month about whatever is on my mind. Much of the inspiration for what goes into each edition comes from readers and subscribers of Tips and Topics….and that is no different this month. A subscriber just sent me this message:

I have two issues that I would like to know your thoughts on. 

1. I am wondering how you think a history of a moderate to severe substance use disorder (SUD) should be treated for diagnosing and treatment? For example, a client reports a history of a moderate alcohol use disorder 3 years ago but the last 12 months he reports drinking socially.

2. Secondly, what are your thoughts on a client who reports 3 driving while intoxicated (DWI) charges 2016, 2017, and the last one 2018. Then reports that during the last 12 months drinking socially? In addition, collateral information indicates concerns about his alcohol use due to the DWIs.

Thank you for your time.

Tip 1

Resist the impulse to jump to conclusions before doing a more in-depth assessment and history-taking.

In these vignettes, it is natural to conclude that if someone is “drinking socially” after a previous diagnosis of moderate or severe SUD or multiple DWIs, that they must be relapsing and heading for trouble. But here are some Assessment and Engagement Questions to consider.

Assessment Questions:

• Have you been given a formal diagnosis of a substance use disorder or alcohol use disorder e.g., in a medical record; or has any healthcare professional said that you have addiction or are an “alcoholic”? – Just because there is a “history of a moderate to severe SUD”, it is easy to label someone as having addiction without having done a careful diagnostic criteria review. Similarly, while three DWIs would likely indicate a SUD, it is good to check that he met diagnostic criteria.
• If you were told you have an addiction illness, who gave you that diagnosis and were they trained in addiction diagnosis and treatment? – A physician or other healthcare professional may document that the person has an SUD but may not be skilled in understanding diagnostic criteria and erroneously label someone as having a SUD when it may have actually been a severe substance-induced or substance-related event e.g., a young person who overdosed on alcohol at a party.
• If the client indicates that he did have a diagnosis of “moderate alcohol use disorder 3 years ago”, it is worth checking on what diagnostic criteria were met back then by reviewing what alcohol related problems were showing up 3 years ago. – This serves to assess how clear the client is that he indeed had an addiction to alcohol and to check if the diagnosis was accurate; or whether it might have been a developmental phase of alcohol use as a young person; or a coping mechanism for other co-occurring issues like trauma, other mental health challenges or even physical health problems like chronic pain.
• If it becomes clear that the client does indeed have alcohol addiction illness and recognizes that, then review what addiction treatment and/or self/mutual help the client has participated in. – He may have been diagnosed but never engaged in treatment or recovery groups; and may not be knowledgeable about addiction.
• If the client did have formal addiction treatment, assess what worked and what didn’t work to initiate and maintain sobriety. – Did he get good education about addiction; did he attend regularly; was there continuing care and ongoing monitoring? Or was he simply “graduated” from a program with poor linkage to ongoing care?
• Whether the client had treatment or not, how long were any periods of abstinence and how did he achieve those? – It is always good to support self-efficacy (the optimism and confidence that a person can change) by complimenting the client on whatever length of abstinence was achieved and to evoke solutions and skills that worked for whatever the period of abstinence. “You didn’t use for 6 weeks? That’s great, how did you do that – who did you hang out with, what did you do with any cravings to use, where were you staying during that time?
• What does the client mean by “drinking socially”? Is that once a week; or beer or wine with a meal; or drinking just at times of celebrations like birthdays? Does he get drunk, blackouts or has he been told that he behaved inappropriately when drinking?
• What other drugs besides alcohol does he use; and remember to include tobacco? How much does he gamble?– You want to assess the breadth of his addiction in substance use and other addictive behaviors.

Engagement Questions:

• Regardless of what others have told you, do you yourself think you have alcohol addiction? If so, why and if not why not? – This indicates what stage of change the client is at and his level of interest in changing or not.
• Is there any help you need at this point with your alcohol use? If yes, what help do you want; if not, help me understand your thinking.
• Is social drinking something you want to continue? How will you monitor your drinking so that it doesn’t become a problem in your physical, emotional or social life? – Given his past history with alcohol, you want to engage the client in a “discovery, dropout prevention” plan to discover or not whether he indeed still has a problem with alcohol.

Tip 2

Involving family, friends and other collateral sources in the assessment and treatment of addiction is always important. 

The person suffering from addiction is often the last person to realize how out of control their addiction illness has become. The survival defense mechanism of “denial” serves to solve the cognitive dissonance a person in active addiction faces:

• How could I be causing all these physical, emotional and social problems and doing this to myself through my substance use or addictive behaviors? It must be my partner’s fault, or my boss, or the police who are harassing me. (Minimization, projection of blame, rationalization).

This is why involving collateral sources, relatives and friends in assessment and treatment is important:

• To get as accurate information as possible about the frequency, quantity, and effects of drinking on all significant others, including the identified client.
• To engage and educate significant others about addiction – how it has affected their lives and how they can help or not help to promote recovery for all people affected.
• To support and assist significant others as they live with either active addiction in their loved one; or learn how to recover with their loved one when and if addiction recovery begins – What boundaries and limits do the significant others have around their loved one’s drinking? How hopeful or discouraged are they? If recovery has begun, how is their loved one reintegrated into a family that adjusted to exclude him or her from family and parenting decisions or even from routine daily activities like family meals?

The Bottom Line:

• Can a person with moderate or severe Alcohol Use Disorder later socially drink? – Usually once a person has crossed the line into verified addiction illness, it is not likely that a person can return to social drinking free of negative effects on physical, emotional and social functioning.
• But before assuming that social drinking will inevitably not go well, it is important to verify that there was indeed an accurate diagnosis of a SUD. 
• Involve significant others in the assessment and treatment of their loved one’s addiction. This is to both assure as accurate information as possible and also to guide significant others on how to help their loved one and themselves.
• If a person does indeed have alcohol addiction but wants to try social drinking, motivational enhancement therapy and motivational interviewing is needed to engage the client with a “discovery, dropout prevention” plan. The focus is to keep the client involved in treatment and help them discover whether they can safely return to social drinking or not. You may be clear that they cannot, but our work is to have them see and experience that for themselves.

Soul

This edition of Tips and Topics marks the 20^th anniversary of publishing what I called back then an “e-zine” – “a magazine published only in electronic form on a computer network.” As I start this 21^st year, I reviewed the three original goals that launched Volume 1. No. 1 in April 2003 to see if they are still relevant in 2023.

The first reason I started Tips and Topics was that clinicians have ongoing clinical questions that need answers. I coined STUMP THE SHRINK to highlight the questions I still receive and that prompted even this very April edition. This is still a very relevant goal that underpins Tips and Topics.

The second goal, to help people apply new-found knowledge, drives the SKILLS section. It’s useful to be SAVVY about various topics, but if they can’t be implemented skillfully, the new knowledge soon fades and clinicians fall back to their familiar, and sometimes ineffective practices.

I remember speaking to my therapist soon after completing my psychiatric specialty training and starting a private practice. I was interested in getting referrals of patients wanting psychotherapy not just medication. My therapist said, just let the other psychiatrists know you want such referrals. My rookie, unconfident mentality said “But why would they refer me patients when they would want to keep them in their practice?”

My therapist said “Firstly, not everyone wants to do psychotherapy and are more interested in medication management; and secondly, just because someone has been doing psychotherapy for a long time doesn’t mean they are any good at it.” As I grew in professional confidence and also grew ‘longer in the tooth’, I observed the truth of that for some of my colleagues.

The third reason for publishing Tips and Topics was because I want to make a difference in our field. When I decided over 25 years ago to work for myself from home in full time training and consulting, it was a big risk with a family of three kids to support. In a freelance independent business, your next invitation to train or consult depends essentially on whether you are effective in making a difference in the practices and policies of your audience. There was no guaranteed direct deposit in my bank account every two weeks; no paid sick time or vacation; no health insurance benefits or retirement contributions.

I said that if I couldn’t make it, I could always get a “real” job like being a medical director for a treatment system or some other salaried position. Fortunately, by the ‘grace of God’ and the gratitude of my audiences, I never did have to take that salaried position. That tells me I succeeded in my third goal.

What’s Next?

While these three goals are still relevant and while it still is fun to pull together Tips and Topics each month, you will keep receiving it, if you wish. I don’t send this out unsolicited to random people on mailing lists – everyone in the over 7,300 people on the mailing list should have opted in. If someone else put them on the list unbeknownst to them, they can and should Unsubscribe if they want, just as anyone can do if and when Tips and Topics becomes irrelevant to you.

If you have been a subscriber over the years, you’ll know that the SOUL section is a hodge podge of whatever is on my mind that month. Some readers have told me they read the SOUL section first, not always interested in the SAVVY and SKILLS content. I suspect the SOUL section will become even more hodge podgey as I proceed more heavily into retirement mode…..there are so many interesting insights and ideas that percolate when freed from the daily grind of catching planes, Uber or Lyft, checking into hotels late at night; and all that goes with a busy training and consulting practice.

So stay tuned for some emerging thoughts on ponderings like:

• What is the balance between digging deep into past trauma and counterproductive coping patterns versus focusing on the Here & Now of living joyously and optimistically?
• If trauma (in the broadest sense) is baked in on a cellular level affecting people’s fight or flight triggering responses, what is the mix of psychotherapy, body work and corrective experiences needed to allow a person to live unshackled from the past?
• Is Law of Attraction a law of the universe as fundamental and real like we accept the Law of Gravity as real and fundamental?
• How can you be at peace when there are physical, emotional, social and spiritual challenges swamping you?

Tips on subscribing and using Tips and Topics

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Thanks for reading Tips and Topics and for the comments you send that help me know what speaks to you or not. 

Now on with the next 20 years…..or not.