Although alcohol related problems often don't occur in isolation, it is appropriate to deal with it as the main problem when it causes clinically significant impairment or distress to the individual.
There are a lot of organisations available worldwide that help people with their addictions. With alcohol, there are well known organisations like the AA (Alcoholics Anonymous). A first step for anyone who is suffering from alcohol related problems is to contact their general practitioner or doctor. They can give help and advice and also recommend specialist addiction services.
The treatment for alcohol will depend on how much the person is drinking, whether their drinking is harmful, hazardous or dependent and whether the person wants to give up drinking altogether or cut down. Treatment of established alcohol related disorders is more difficult than if someone has only recently developed a problem. Dependence makes treatment more complex. Sometimes just offering some psychoeducation and presenting a person with some leaflets on the hazards of drinking can be enough to dissuade someone from developing dependence from a habit of drinking excessively.
Assessing the Drinker
In order to determine whether someone potentially has a problem with alcohol health professionals need to ask the right questions. The following four questions known by the acronym 'CAGE' (cut, annoyed, guilty, eye opener) can be of use as a quick screening test:
- Have you ever felt that you should cut down on your drinking?
- Have people ever annoyed you by criticising your drinking?
- Have you ever felt guilty about your drinking?
- Have you ever had a drink in the morning to steady your nerves or overcome a hangover? (An eye opener).
If a person replies yes to two or more of these questions then this indicates a problem. Although some may not answer truthfully others will consider these questions as a less intrusive way to reveal their drinking problem.
Other indicators of alcohol related problems may be discovered through asking about family, work, criminal behaviour, and finances. Typically someone with an alcohol use disorder will report increased days off work, lack of money, difficulties with relationships and possibly breaches of the law. A woman who is with a drinker may report aggressive behaviour by her partner toward herself and her children or a lack of consideration. Sexual problems may also be present.
Those who present in hospital or at accident and emergency wards may display physical and behavioural withdrawal symptoms.
If someone does have a drink problem then gathering a full drinking history provides valuable material to work with. This needs to be done sensitively. It may be possible to ask the person about their drinking e.g. how much they drink, what they drink, when they drink, etc. Through careful questioning it should be possible to find out:
- When they have their first drink each day.
- When they first started to drink each day.
- Whether they experience withdrawal symptoms and when these occur.
- Whether they have attempted to stop drinking.
- If they have any associated medical or mental health problems.
- How they feel about their drinking.
The last point is important because it can help to determine what approaches to treatment are going to be most beneficial.
Motivational interviewing (Miller and Rollnick, 1991) has evolved from social learning theory. It holds that people's behaviour is motivated rather than merely in response to stimuli and therefore it is a method of encouraging people to take control of their decisions.
It is particularly useful for those who are ambivalent about stopping drinking or who are struggling to see the benefits. It can also reinforce the motivation of those determined to give up. Clients are encouraged to weigh up the costs and benefits of drinking so that they are able to see the problem more clearly. It is not done in a confrontational way but is less directive. The counsellor should never peddle their own opinions or openly judge the client on what they say. When conducting motivational interviewing the counsellor should:
- Demonstrate empathy.
- Not argue or disagree.
- Not challenge resistance directly.
- Point out discrepancies.
- Raise awareness between substance use and behaviour.
In order to help the client explore the costs and benefits of their drinking the counsellor should begin by focusing on what the client sees as the good things about drinking, e.g. "Tell me about what are the good things about drinking" or "What are the things you like about drinking?" Check with the client if there are any other good things before leaving this.
Next the counsellor should ask about what is not good about drinking. It's important not to use words like "bad", "problem" or "terrible". Instead ask about "What would you say are the not so good things about drinking?" or "Tell me about some of the things you don't like about drinking."
The less good things should be explored in more detail and may need further prompting like "What in particular don't you like about that?" or "How does that make you feel?"
Once the less good things have been identified it is necessary to determine whether they are of concern to the client. Sometimes they may acknowledge their behaviour or a consequence of it as being not good, but it is of no real concern to them. For example, they may acknowledge that drinking can cause cirrhosis, but they haven't been drinking for long enough for this to be a high risk for them. They therefore acknowledge it may be a problem it is not something that will motivate them to change their behaviour.
Having encouraged the client to explore all the good and not so good things about their drinking the counsellor should summarise these. A good way to do this is by highlighting the discrepancies i.e. "On the one hand you said....but on the other hand you said...." This should be done impartially. In this way the client can usually see how there is a mismatch between the costs and benefits. Check with the client that they agree with your summary.
Next the counsellor needs to help to raise the client's cognitive dissonance with regards to drinking, i.e. their discomfort with continuing to drink. This can be done in several ways but at all times be wary of causing the client distress. This is not the goal so once again the counsellor needs to remain empathic and acknowledge the difficulties the client is facing. The following techniques are helpful:
Ask the client about how past expectations are different to their current reality e.g. "When you were a child where did you think your life would be right now?" "How is that different to where you are at?" "How has your drinking affected that?" "How does that make you feel?"
Likewise you can ask the client bout their aspirations .g. "Where would you like to be in three years from now/" "Five years from now?" "What do you think will happen if you continue to drink?" "How would that make you feel?"
Self as drinker versus self as person
You can also encourage the client to observe the differences between how they view themselves as an individual compared to themselves as a drinker, e.g. "How would your partner describe the good things about you?" Having explored this, you can move on to questions about the self as a drinker, e.g. "How would you describe yourself as a drinker?" Following some further exploration you can ask how these perceptions go together, e.g. "How do your partner's and your own views work together?"
Given that this can be quite upsetting for the client as they begin to recognise the disparity between these two perceptions, once again this should be done with empathy and tact.
The final stage is to summarise what came to light in the interview. The summary is used to present all the reasons for change to the client. Many clients will by now want to make changes. Some will still resist. For the latter group it is helpful to emphasise the costs of continuing to drink as stated by the client. If they have made it known that they would like to reduce or stop their drinking then this can also be reflected back to the client. The purpose is to encourage the client to make a commitment to change their drinking habit. Questions may be used to do this, e.g. "What do you think you'll do about your drinking now?" or "How do you think you will go forward from here?"
Once a client has shown some desire to make changes then the counsellor can work with them to help them set realistic and achievable goals - even if the goal is to just cut down slightly. For those unwilling to make any commitment to change other strategies might work. It may help to ask them to keep a drinking diary for a few weeks so that you have other data with which to work.
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