ALCOHOL CASE STUDIES
Gerald Bowen and Thad R. Harshbarger

The following case histories are examples of using Treatment Maps in working with alcoholic patients. The three patients, Bill, Rich and Ed, had different backgrounds, attitudes, symptoms, strengths and weaknesses, and relationships with alcohol. The therapists job is to be ready for the full range of patients and their issues. The purpose of the maps is to help the therapist organize an appropriate treatment process for each patient.

For the most effective use of these examples, it may pay to print them out, then read the printed examples while you go through the maps on screen. For each patient, begin at the top of Alcohol Map 1, where it says “Preparation”, and follow the arrows from box to box and page to page.

The links at the beginnings of some paragraphs refer to points along the individual alcohol treatment map for the patient. These in turn correspond to points on the flow charts and corresponding sections of text. You can also link to a map by clicking on it in the right-hand navigation bar.

Whenever you leave the example to visit the map, you can return using the left arrow button on your computer screen. That way you return at the same place you left.

1. Preparation
The therapist for all three patients is a certified social worker [CSW] and a certified alcohol and substance abuse counselor [CASAC]. He also has postgraduate certificates in psychoanalytic psychotherapy and psychoanalysis. He is aware of local treatment resources and prepared to work with the patient as needed.

CASE 1: BILL

2. Intake
Bill made the initial phone call, at his wifes insistence, requesting marital counseling. The relationship was cold and getting worse.

An appointment was made to see the two of them together. They arrived at the same time and sat apart in the waiting room without talking.

Background
Bill is 45. The couple have a two boys ages 6 and 9. He is a vice-president in his father-in-laws business.

First Session
From the start, Bills wife was the one pressuring for treatment. She said that he was not only detached and distant from her, but also with the boys. There was no sense of being partners, no feelings of closeness, no sexual intimacy. He was often irritable, with occasional outbursts of temper that scared her without his ever hurting others or breaking things. Bill admitted this was true, and blamed work pressures and family conflicts.

Their history of marital intimacy problems started soon after their marriage and Bills beginning to work for his wifes father, which happened about the same time. In reflecting on their life together, it seemed to both of them that these issues had gotten worse over time.

The first two sessions focused on Marys complaints and Bills attempts to minimize blame. At the end of the second session, the therapist suggested that they have a couple of individual sessions each, and they both agreed.

In her sessions, Mary complained that, among other things, there had been no regular sex for over five years. At present, Bill couldn’t sustain an erection long enough to initiate sex.

Bill agreed with his wife but was discouraged about the possibility of change. He had previously been in twice-weekly psychotherapy for over three years, dealing with issues of intimacy, with no real success.

Bill thought that his erection problems were related to several things: work stress, which he brought home with him, his wife’s complaining, and his drinking.

He admitted that he drank every day, to relieve stress and because he liked the feeling of being a little drunk. He knew that he was drinking more than in the past. He had had a couple of blackouts, at parties, one of them fairly recently.

However, he didn’t think he was an alcoholic. He had never had a DWI or any other legal complication, and his work seemed fine.

Bill’s father had owned a restaurant and managed to never pay taxes in his life. He was seen as distant, there-but-not-there. Perhaps Bill was like him.

His mother was a chronic alcoholic, a daily drinker. She progressed to the point that Bill, as a child, was taking care of her. Bill was husband, confidant and caretaker to his mother. He would accompany his mother on her various affairs with other men. Mother behaved in sexually inappropriate and stimulating ways with Bill, although without direct contact. Mother died of alcohol-related diseases.

Bill was a controlled drinker, proud of how much he could hold. Whatever he did, he drank. Mainly, he drank vodka. He would pour 4-5 shots at a time. His rationalization was that no one knew he was drunk, so he could continue. He was determined never to be a loud, out-of-control drunk like his mother.

In his previous individual therapy, the issue of his drinking had never come up.

3. Misuse?
Clearly, Bill was misusing alcohol. The evidence included:

• Family history of alcoholism
• Admitted: a daily drinker
• Blackouts
• Tolerance
• Progression
• Memory Loss
• Irritability
• Dysfunctional relationships
• Sexual difficulties

Additional Points

1. Bill didn’t come in because of alcohol misuse. It would be easy to work on the other issues he had, such as work stress and a precocious sense of responsibility, and not address his alcohol problem.
2. Many alcoholics won’t come in at all. His wife might have come in and worked on her relationship with him. He might have stayed away and thought of her as the one who needed help.
3. Resolving Bill’s other issues won’t treat his alcohol misuse. If you don’t dig, you won’t find. Bill’s previous therapist never addressed his alcohol problem, and also didn’t resolve some of Bills basic issues. His history of prior treatment seems to support the common notion that it is difficult to work therapeutically with an active alcoholic.
4. We are not determining here whether Bills drinking caused his marital problems or the reverse. In either case, alcohol misuse becomes a problem in itself that must be handled.

6. Dangers
Although the long-term physical consequences of dependence can be quite serious, his blood work suggests that they are not imminent. However, the immediate consequences on his relationship with Mary and the potential for car accidents make the situation serious.

47. Preliminary Issues
Bill seems to be in a contemplation stage relative to both sex and drinking.

30. Medical Work-up
He was referred to a urologist, had a medical work-up. The therapist contacted the urologist before his session, and asked for a full blood work-up, because of Bill’s alcohol misuse.

He was sexually normal, so his sexual problem was a functional one, and not physiological. Surprisingly, his liver functions came out O.K. Possibly, this was a result of his drinking pattern: he drank heavily on weekends – at sports events and other social occasions – and minimally during the week [commonly, he had two vodkas before dinner, then shared a bottle of wine during the meal]. Interestingly, he drunk-drove after these events – hundreds, maybe thousands of times – and was never arrested. [Scary for the rest of us!]

4. Physiological dependence?
At first, he may appear to be an abuser, because he only got really drunk on weekends. However, there were also soft signs of physiological dependency: during the week he would drink much less , but enough to keep his blood alcohol level elevated and avoiding possible withdrawal symptoms. Because of this, it was not clear whether he would need detoxification. A cautious approach, given that he is in contemplation with regard to alcohol misuse, is to Go on to Map 2.

When asked about misuse, he initially didnt think so, but he was willing to learn. What motivated him was his relationship with his wife, and his inability to have sex.

31. Alcohol Education Series
He was referred for an alcohol education series, that was held one evening a week for four weeks. He was mildly interested but still mostly in denial regarding the negative effects and consequences of drinking.

7. Willing to go for Detox?
He was clearly not interested.

13. Have an Intervention?
It seemed unlikely that a successful intervention could be arranged, because the behavioral consequences of his drinking were not obvious enough outside of his marriage for friends or family to be willing to participate.

There was also some evidence that he might be able to get sober without detox or rehab:

• He was able to go without drinking for short periods of time.
• He drank much less during the week than on weekends.
• He was motivated and willing to listen
• He functioned well with his family and on the job.
• He had a support network.

39. Continue to Treat.
He was already in psychotherapy and trying to deal with his emotional and interpersonal issues when the issue of his drinking became clear.

Go On to Map 5
20. Continue with Individual Psychotherapy
Bill and Mary had both defined their problems as mainly Bills, and there seemed no reason to change focus to couple work. Bill was in the contemplation stage relative to both alcohol and interpersonal issues, so it seemed that further exploration might be helpful.

19. Adjunctive Care Decision
He was totally against AA. He had a number of inhibitions, was shy and conflicted about being assertive. The therapist agreed to his not going to AA, and used his not-going as an additional motivator for continued individual therapy.

He had already had a check-up and was physically sound. He didn’t need any medications. Nutritional work did not seem urgent and wasn’t pursued.

27. Establish Abstinence as a Goal
In therapy it was possible to challenge him to try days of abstinence, and to examine the consequences. He did, and didn’t seem to have any significant withdrawal reactions.

He prided himself on not drinking before noon; and it was a long time before he would admit to having hangovers. Proof of non-hangovers was that he could still go to work. However, as he became more sensitive to his alcohol reactions, he became convinced of his dependency on alcohol and interested in overcoming it.

Therapeutic work on abstinence began with contemplation-stage interventions [ Section 25 ] with the goal of helping him to move into action to stop drinking.

• discussion of his reactions to the alcohol education series
• dealing with denial
• focusing on his motivations and triggers for drinking
• examining the negative consequences [including sexual] of drinking
• recalling his own reactions to his mothers drinking,
• noticing how much better he did when he didnt drink
• working on ways to cope with social situations without drinking
• noticing how others looked and behaved when they were drunk, etc.

As he reduced his drinking, he was amazed at the increase in the clarity of his thinking, his improved cognitive ability, his better memory, his perception of himself. His self esteem increased, along with improved interpersonal functioning and eventual vocational success.

Eventually he stopped drinking and became totally abstinent.

Additional Issues Not Covered Here:

• Effect of sobriety on his sex life, and where that went.
• Other therapeutic issues that were addressed [Section 37]
• Work to control relapse [Section 33]

CASE 2: RICH

2. Intake
Rich is a 42 year old single man who is self-referred after breaking up with a girlfriend he was involved with for about 7 months.

He appeared well dressed, handsome, neat, trim, with no obvious signs physically of substance abuse.

He presented initially with symptoms of a mild dysthymic disorder principally manifested by feelings of sadness, low energy level, mild loss of appetite, intermittent insomnia, low self-esteem and numerous thoughts of inadequacy regarding his manliness, appearance and potency.

During the first 5 consultative sessions his symptomatolgy diminished, with his appetite, sleep, and mood markedly improved. His health didnt seem threatened by these symptoms at any time.

It was decided that a psychiatric evaluation was not warranted, because Rich responded positively to the establishment of an open non-judgmental working alliance.

During early sessions, he reported that he drank only occasionally: 1-3 beers or glasses of wine, usually in social situations and never alone. He felt he did not have a problem with alcohol, and he had never tried any illicit drugs. So it seemed initially that substance misuse was not a clinically relevant issue.

The patient had worked for 20 years as a fireman in a large city, and was retired on ¾ disability after being injured on the job. He had regular checkups and except for his disability was in good health.

He was the older of two children, with a sister 5 years his junior He described himself as a child and adolescent as lonely, isolated and socially inept, despite promising athletic abilities and good looks.

He remembered his father as controlling, explosive and narcissistic, while his mother was only a shadow of a person in the early stage of his treatment. She later emerged as a pivotal source of the patients fears concerning intimacy and closeness.

Rich had been in therapy 7 times during the previously 15 years. Treatment usually lasted for no more than 6 months and seemed generally to have been at least temporary helpful. None of these previous treatments had addressed the role alcohol may have played in his life. He thought that now he was finally ready to learn about himself, so he could settle down, get married and have a family.

Rich began weekly individual psychotherapy with the goal of working through the loss of his girlfriend, and exploring his pattern of poor object choices, his inability to commit and his fears around intimacy and closeness.

Weekly sessions over the first four months revealed greater involvement with alcohol than initially presented. 1-2 times per week he met friends at a local bar and “sipped” beer, often not remembering that earlier in the day he had felt frustrated, lonely, or bored. Once, after an unfulfilling blind date, the patient felt “old and unattractive” and casually described sitting in front of the TV that night later on drinking 4-6 beers. Numerous other examples confirmed that Rich used alcohol mainly to reduce anxiety, although at times he became euphoric or felt powerful – or at least, adequately masculine.

Early exploration revealed many examples of self-doubt. The doubt was expressed by a sense that Rich was unable to cope without the use of alcohol. It was only the uplifting and sedative effects of alcohol that restored his confidence. His self-doubt was reinforced by the subsequent euphoria of alcohol use: it further proved to him that he needed to drink to feel good.

3. Misuse
During these early sessions, he was able to function for many days without the thought or urge to drink. This suggested that he was not physiologically dependent.

Yet at times, issues around socializing triggered a need to drink. Although his social skills were well established, he was certain he would be boring to women. A few drinks diminished his interpersonal anxiety, which further legitimized his use of alcohol and reinforced his sense of ineffectiveness without it.

It manifested sometime later in the treatment that most of his sexual experiences involved the use of small quantities (1-3 drinks) of alcohol and he was fearful and uncertain as to whether he could respond without drinking first.

6. Danger
Dangers seemed not to be very serious. He never drank to excess, thus avoiding both short-term acute risks and the danger of long term physiological dysfunction.

30. Medical Work-up
Because of his regular positive checkups and his not being either abusive of, or physiologically dependent on alcohol, he was not sent for a medical work-up.

47. Preliminary Issues
Rich appeared to be in an action stage relative to self-esteem and interpersonal issues and a contemplation stage regarding his dependency on alcohol. This suggested that it might be possible to engage him initially regarding social relationships and lead into work on his drinking, possibly leading to a “virtuous spiral”.

4,5 Diagnosis
Because he needed alcohol to believe that he could function and used alcohol to control his anxiety, he was psychologically dependent. But he never went so far that he did damage to himself, others, or property, so he was not abusive.

Go on to Map 4

At the time that his psychological dependence on alcohol became clear, Rich was already in treatment, dealing with interpersonal and intrapsychic issues that were related to his alcohol use.

23. Treatment Disrupted?
Treatment was not disrupted by his drinking; in fact, his drinking may have stimulated his seeking therapy, if only indirectly.

8. Comorbid Disorders
Although he suffered from mild anxiety and depression and used alcohol as a mood management tool, he did not appear to be suffering from another serious disorder that needed to be addressed separately.

12. Rehab Decision
Therefore, it was decided to continue outpatient therapy without rehabilitation.

Go on to Map 5

20, 14. Psychotherapy Continued
He had already begun individual treatment and appeared to be doing well. Therefore, it was decided to continue that form of treatment, with at least one focus on abstinence.

19. Adjunctive Treatment
AA attendance was made a condition of treatment. He agreed and began attending meetings on a twice-weekly basis. No other adjunctive treatment seemed essential.

27, 25. Ongoing Psychotherapy
The antidotes to his self-doubts were first, his gradual and successful re-experiencing of threatening situations in an alcohol free state; and second, an opportunity to identify with confidence –building role models found among AA members.

The emphasis of AA on living one day at a time was essential in order for him to avoid feeling overwhelmed by a future without alcohol. Fear of being unable to cope without drinking was very real to Rich. It seriously eroded self-confidence, and it was vital that the therapist not support his self-doubt. It was explained to Rich that these concerns are in fact an effect of the alcohol and reflect the destructive impact of alcohol on self-confidence. Such an interpretation established a therapeutic priority-first to avoid alcohol use, then to deal with other problems. It also avoided attempting to address character pathology at a point in treatment when it couldnt be distinguished from long-term effects of alcohol dependence.

37. Psychodynamic Exploration. Rich is currently in his third year of treatment with over two years of not drinking. Frequency was increased to twice weekly and he continues to struggle with various conflicts that are associated with his mother, early childhood and narcissistic injury.

33. Relapse. At present there is no evidence for risk of relapse, but the possibility must be kept in mind. We continue to examine his issues and occasionally notice whether he has been tempted to drink to relieve anxiety or to feel more powerful. As he learns to cope effectively without drinking, the risk diminishes.

CASE 3: ED

2. Intake
Ed’s wife Harriet was individual therapy that revolved around her relationship with Ed. Her therapist suggested that couples work with a new therapist might be of value. She made the initial call, after getting Ed’s reluctant agreement to come along.

Background

Ed is C.E.O. of a large corporation, age 53. He is an attorney with an MBA. He is seen as brilliant and extremely good at problem solving. He is a workaholic, driven. At the same time, he is scornful of other people with more education whom he manages and controls.

The couple have been married 11 years. His stepson George – from Harriet’s previous marriage – is 14. Ed is so busy with work that he has no time for his wife and stepson. He dismisses this as not being an issue of significance.

Harriet made the initial call and appointment. Ed appeared to be there under duress. He seemed annoyed that he couldnt manage Harriet as effectively as his employees and competitors. They had been seen together a few times in the past, around Ed’s drinking and other issues, without effect.

Harriet led the session, with complaints about Ed’s drinking and the lack of sex or any other intimacy. She openly stated that she wanted to leave but feared being alone. Ed remained disgruntled and relatively unresponsive to her complaints.

Evidence of alcohol misuse from Harriet

• She knows that he drinks every day, but she doesnt know how much
• Ed shows some evidence of personality regression, loss of ego functions: grandiosity, impatience, loss of frustration tolerance, passivity, and disregard for future consequences.
• He has been drinking for 30 years or more.
• Ed has a history of numerous physical issues related to drinking, including a liver transplant 4 years ago.
• He goes to business meetings with alcohol on his breath, clearly drunk.
• Everyone at work knows he is an alcoholic but all fear to confront him.
• He drinks daily and continuously, starting when he wakes up.
• He is now drinking Gatorade and vodka, with the idea that there are some health benefits to the Gatorade.
• He takes a variety of medications, including some for liver, and washes them down with booze.
• He has been near death several times due to alcohol-related physiological reactions.
• He has never had a driving accident. He was once arrested for driving a boat under the influence, but because of his political connections, was able to have the charge dropped.
• He stopped drinking several times, after near-death experiences, including 6 months of sobriety after his liver transplant. He also detoxed himself numerous times, at great risk, vomiting blood, etc. Harriet, who is an R.N., always assists.

Ed’s Version:

• Denial: although he admits the truth of all that Harriet says, he claims that he is not affected by his drinking and doesnt need psychotherapy or detox. Instead, it is Harriet who needs to learn more effective ways of coping with reality.
• Ed is not interested in treatment for himself and thinks that their prior attempts at couple work were a total waste of time. In fact, he doesn’t believe in psychotherapy and is scornful of the process.
• The therapist’s attempts to confront him are met with annoyance and scorn.

3. Misuse?
Ed Misuses. He admits that he drinks too much, but believes that he can handle it.

6. Danger?
The danger is urgent. He has nearly died from alcohol on several occasions. He needs detox. Without it, he is likely to kill himself in the near future.

47. Stage of Change
Ed is clearly in precontemplation relative to drinking, medicine, psychotherapy, and anyone who disagrees with him.

30. Medical Work-Up
He refuses a medical workup. Has no respect for physicians, until he is physically debilitated and has no choice about going. The therapist judged it futile to ask for information about him from other sources, as Ed would surely have refused.

4. Dependence on Alcohol?
Ed is both psychologically and physiologically dependent. Because of this, the treatment path could now continue on either Map 2 or Map 4. Either path ultimately leads to the same treatment choice at Section 44.

You Could Go on to Map 2

7. Admits Dependence?
No

6. Urgent Danger?
Yes

7. Willing to Detox?
No

13. Have an Intervention?
It won’t happen. The problem is one of finding people to participate in an intervention. Everyone in his company is afraid of him and of losing their jobs if they stand up to him. He has no friends. Maybe his Chief Financial Officer and his wife would participate, but his mind wouldn’t be changed.

Without detox, he will probably not continue treatment for any substantial period of time, and if his drinking is raised as an issue or when he simply tires of treatment, he will terminate. He knows that the reason he is in treatment is his drinking, and to protect his drinking, he will stop coming. In addition, he refuses to engage interpersonally with anyone, including his wife or a therapist: he is pedantic, and thinks he has all the answers.

39. Continue to Treat?
No. Even if the therapist is willing, Ed isn’t.

Which takes us to Section 44 [see below].

Or you Could Go on to Map 4

Is He In Therapy? No. he is there under duress and has no respect for therapy.

46. Will He Go for Therapy?
No

16. Will He Consider a Self-Help Group?
No

Which also takes us to –

44. Treatment Without the Patient.
This is the only viable path at this point. Harriet can continue with the present therapist or go back to her previous therapist. She could also try a self-help group, such as Al-Anon, and her son George could be sent to his own therapy and/or Al-a-Teen.