How does a psychiatrist explore a patient's concern about unreported abuse of alcohol with a psychotherapy patient?

We clinicians often encounter this important and common problem. While it presents us with the power to intervene and help it also confronts us with the limits of our therapeutic capacities. One complicating factor may be a clinician's basic psychotherapeutic stance as a predominantly receptive listener who attends primarily to the distressing symptoms that the patient brings to our attention. This stance can be problematic with patients who abuse alcohol because they often may not report the extent of their drinking both from shame and avoidance and also because the defenses of denial and dissociation minimize the importance of the issue within their own awareness.

So, how can we become aware of an alcohol problem that may not be accurately reported by the patient? Several points are helpful to keep in mind:

Once we elicit the report of alcohol abuse, how can we intervene? It is crucially important to understand the patient's psychological history and psychodynamics as a whole with particular regard to the role that alcohol use has played within the patient's psyche. A few very typical examples include the use of alcohol a) to soothe chronic anxiety and/or low self-esteem that constrict interpersonal and social functioning, b) to ease crippling and inhibiting perfectionism, and c) to give relief with stringent restrictions and even frank prohibitions against sexuality. Some typical clinical examples and therapeutic strategies follow: