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A novice clinician can get a false impression of how the treatment of drinking problems typically proceeds. Clinical case conferences, published case studies, and therapeutic gurus on television chat shows all tend to focus on remarkable successes rather than abject failures. This can be intimidating to inexperienced clinicians: the performance standard may seem to be a therapeutic record of unending triumphs as each patient responds beautifully to wise and well-delivered interventions.
This chapter is designed to explode such unrealistic and potentially damaging expectations. Specifically, it describes common reasons why setbacks are encountered as well as particular types of patients who pose unusual challenges in treatment (see Table 17.1). Throughout, the focus will be on how things can be put right when treatment goes wrong.
Losing the balance:
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Challenging patient types:
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One cannot treat drinking problems without occasionally experiencing setbacks. The essence of treatment is very commonly a series of trials and errors rather than a straight-line advance. To acknowledge frankly that the best-laid treatment plans can fall apart is not a licence for complacency. Rather, it challenges clinicians to be alert to such situations and make immediate efforts to put them right.
When an effort to treat a patient with a drinking problems goes awry, clinicians must manage both the objective demands of the situation and their own subjective emotional reactions to it. This includes having the humility to seek consultation from colleagues and to accept that not everything that goes wrong in treatment can be blamed on patients: even highly skilled, highly experienced clinicians sometimes make a hash of things. A key professional development task for clinicians is to not be discouraged or defeated by clinical reversals. Instead, treatment setbacks should be turned so far as possible to good therapeutic advantage and, just as importantly, should be understood as learning opportunities.
This chapter does not attempt a consideration of all possible eventualities. Anyone who has experience of this field will see ways in which the list might be extended, and a personal listing of cases where treatment was unproductive (a list kept, as it were, on mental file) is a valuable working tool.
Three common ways of losing the balance
Much of treatment is a matter of finding balances among clinical approaches, goals, and directions. Treatment can go off course when it veers toward either end of the following dimensions.
Emphasizing the drinking/emphasizing all else
In the life of a human being who has a drinking problem, alcohol is neither everything nor nothing. Accordingly, treatment should not become so exclusively focused on a patient’s drinking that the complex human being doing that drinking in a multifaceted environment is overlooked, nor should sensitive awareness of a patient’s total life situation result in a destructively pervasive drinking problem being minimized. Finding this balance can be difficult.
At a certain stage of learning and experience, many soft-hearted, open-minded clinicians fall into the trap of underestimating the seriousness of the drinking problem. But the admirable desire to see the whole person and to respect the complexities of that individual’s life should not be put in opposition to awareness of the true threat of the drinking:
A 44-year old man had experienced a deprived and troubled childhood. However, he reported that his adult life had been much happier, mainly due to what he described as a loving, stable marriage of 16 years. Then his wife had an affair, and his world fell to pieces. All his fearful beliefs as to the inevitability of rejection were proved to be well founded. His feelings towards his wife were unforgiving. He determined that an unhappy episode should be the occasion for catastrophe and he divorced, threw in his job, sold his house, gave up his friends, and moved to a new city. A couple of years later, he went through an emergency detoxification during a drinking bout and consequently came under the care of a psychotherapist who treated him for a year, exploring his problems relating to his mother. He frequently turned up drunk at therapy sessions, which was duly interpreted as understandable self-medication of his underlying psychodynamic conflicts. He was then admitted to a hospital after a nearly successful serious suicidal attempt. The psychiatrist who saw him on the medical ward the following morning diagnosed a severe and untreated depressive illness and started him on an antidepressant. He noted that the patient had “recently engaged in some secondary relief drinking.” The evening following the first dose of the antidepressant, the patient developed an acute confusional state. One of the night nurses made the correct diagnosis of delirium tremens.
Both the psychotherapist and the psychiatrist had focused only on those aspects of this man’s condition that fit comfortably within their own clinical predilections. Neither had bothered to take a drinking history. The patient never actively covered up the seriousness of his drinking because he never had to: both clinicians turned a deaf ear whenever he mentioned his alcohol use. A careful reconstruction of the history later identified a drinking problem going back to the early days of marriage. The marriage had been much affected by the husband’s heavy alcohol consumption, and his wife had finally moved out because she could no longer tolerate the drinking and attendant violence. Had the drinking problem been taken more seriously by the genuinely compassionate clinicians who treated him, the patient may well have avoided significant suffering.
Clinicians can also commit the reverse error: seeing the patient as just “an alcoholic” whose every problem can be understood and treated within that definition alone. A short extract from another case history illustrates how this can occur:
A 33-year-old construction worker had been admitted to an alcohol treatment unit, where a diagnosis of alcoholic hallucinosis was made. It was noted that he had previously been admitted to another hospital, but the other hospital’s case notes were not requested because the correct diagnosis seemed obvious. The patient was put into the ward therapeutic group but seemed to spend more time listening to imaginary voices than participating. After 3 weeks, he was discharged to a hostel for people with drinking problems, which was run on intensive therapeutic community lines. He was put into a challenging group therapy session on the evening of his arrival and shortly thereafter again developed florid psychotic symptoms. This occasioned readmission to the first hospital rather than to the alcohol unit. Their case notes recorded the onset of a schizophrenic illness at the age of 17 years and many emergency readmissions since. He has since done fairly well provided he was not too stressed and could find a supportive environment. On an opportunistic basis, he engaged in binge drinking a few times a year, but otherwise rarely consumed alcohol.
The staff of the alcohol treatment unit had so specialized a perspective that when a case of schizophrenia presented to them they reacted in terms of a predetermined cognitive set. The consequent diagnosis led to a package of group therapy and confrontation for a man whose needs were quite otherwise.
These two rather extreme cases illustrate the poles of imbalance that can occur. The errors are usually on a smaller scale and more subtle. Perhaps the mass of general practitioners tend to underrate the importance of the drinking, whereas alcohol specialists sometimes overcompensate by being too alcohol-focused.
Too ambitious/too unambitious goals
Sometimes patients (or the clinician) become frustrated because they have unrealistic expectations of what changes may be achieved and at what pace. This dilemma can occur at any stage of treatment. The mistake may be that too great a therapeutic pace is being set, which can readily force the patient into breaking contact, but, equally, the problem may be in the direction of inertia:
A 60-year-old man stopped drinking but continued to treat his wife in a curmudgeonly fashion, was at cross purposes with his grown-up children, and had no leisure activities other than watching television and grumbling about the quality of the entertainment provided. At the end of a further year, he was still sober and still regarding the world with unrelenting enmity.
What is the community psychiatric nurse to do the next time she or he calls round on this family and the man purposely turns up the volume on the television while otherwise angrily staring ahead and not acknowledging the caller’s presence? The wife offers a cup of tea in the kitchen and says: “He’s always been that way and I suppose he won’t change – a real old misery I call him.” What is the right balance of treatment ambition?
The reality may indeed be that a man of 60 who has for most of his existence defined the world as antagonistic and who has built up his self-image largely in terms of afflicted righteousness is unlikely to change his ways radically. His wife’s assessment of the situation may be just about right, and she does not seem too put out by his ill-grace. Her father was much like that anyhow, and her husband’s behaviour is in accord with what she expects of men. She is happy enough that he is no longer running her short of money.
Yet it seems sad to leave it at that. There is the lingering feeling that the goal is being set too low, that more happiness for two people should be possible than is seen here. The answer is perhaps to try setting a moderately more ambitious goal on a trial basis. The goal had better be expressed concretely, and the starting point must be the identification of something that patient and wife themselves at least half hint at being wanted. In this particular instance, the wife let drop, “and he never takes me on holiday of course.” The ”of course” was an important part of the statement; it was clear that the wife’s communication with her husband often carried the implication that she expected his response to be negative. A modestly realistic goal in these circumstances was to see if this couple could go away for a week’s holiday together and come home with the feeling that they had enjoyed themselves. Working at first through the wife and suggesting that she might for once expect the answer “yes” from her husband, the holiday was booked. The couple went for a week to the coast, and although the holiday provided much cause for grumbling, in sum, the week provided a real sense of shared reward. Beyond the immediate happening, a small shake-up had occurred in negative patterns of interaction, and the basis was established for the possibility of further small changes.
Clinicians can also set the bar too high for patients. Even when driven by compassion and optimism, this can have destructive effects on the therapeutic relationship:
A 26-year old war veteran with chronic lower back pain, symptoms of post-traumatic stress disorder, and low self-esteem was treated at a veterans’ medical facility for misuse of alcohol and prescribed medications (e.g., opioids and benzodiazepines). She had recently escaped homelessness but was unhappy with her shared accommodations because both of her flat mates were heavy users of alcohol and other drugs. Her counsellor, a fellow veteran and a successful Alcoholics Anonymous (AA) affiliate, urged her to commit to attending 90 AA meetings in 90 days and to giving up alcohol forever. Not wanting to disappoint her counsellor, whom she liked and respected, the patient threw herself into the endeavor, managing to stay sober for 10 days before joining in on late night drinking session with her flat mates. She woke up the next day with her confidence in her ability to recover shattered. Because she felt humiliated at the thought of having to acknowledge her drinking to her counsellor, she skipped her remaining scheduled appointments and broke off all contact with the treatment programme.
The counsellor was correct in thinking that the patient’s life would have been improved by lifetime abstinence, but he established with little consultation that this would be the first goal of treatment. He was well-intended, yet set his patient up for failure. A smaller initial goal, for example, finding a place to live that would not result in constant temptations to drink or ceasing to use the potentially lethal combination of alcohol, opioids, and benzodiazepines on the same days would have been more attainable. Furthermore, such a smaller success would likely have strengthened the patient’s battered self-confidence and the therapeutic alliance, both of which could become the foundation from which to pursue more ambitious goals as treatment progressed.
Too indulgent/too demanding
In the therapeutic relationship, clinicians must find a balance between being, on the one hand, supportive and nonjudgmental and, on the other, being tough-minded and confronting the patient with manifestly unpleasant realities. To put the matter in terms of absolutes and contradictions is an oversimplification, but consider two contrasting examples. First, imbalance in the direction of indulgence:
A social worker of rather little professional experience became highly committed to helping a struggling family. The 30-year-old man was not alcohol dependent, but seemed to use drink to enhance his passivity and incompetence. He seldom worked. He borrowed, pawned, and stole. The wife, who was faced with this chronically difficult situation, tried to prop up the family as best she could. When the social worker arrived on the scene, she soon became no more than a provider of gifts, and she protected the man from the consequence of his having cheated on welfare payments. She found him good second-hand clothes so that he could go for a job interview, and when he sold the clothes and did not go to the interview she treated him as an amusingly naughty child.
The social worker was operating on the hypothesis that this patient was deprived and was testing out her “goodness”; she believed that she “must not reject him.” Where she may have gone wrong is in her assumption that the opposite to rejection is indulgence.
The following case of an “unmotivated” patient illustrates the other extreme of the indulgent versus demanding continuum:
A man with a serious drinking problem was to be discharged from prison and it had been agreed in principle that he should then be admitted to an alcohol rehabilitation unit. In the event, the Consultant in charge of the treatment unit decided that, “as a test of sincerity,” the man would first be required to find himself lodgings and gainful employment. Coming out of prison after 4 years, the man was anxious, disoriented, and lacking any meaningful familial attachments. He made his way to old friends and resumed drinking within hours of his release. A few days later, he was arrested for drunk and disorderly conduct. The Consultant expressed to her staff the hope that they, too, would someday acquire her talent for being able to sense when a potential patient “just wasn’t ready to change.”
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