Case Illustration

Although a brief case summary cannot capture the complexities, the ebb and flow, and the important session-by-session details of an actual course of treatment, the following vignette provides a sample of how a cognitive therapist might initiate a discussion about an alcohol problem with a reluctant, depressed patient.

Drake, a 38-year-old married man working as an insurance agent, sought CT for his chronic depression and intermittent suicidality. At the initial diagnostic interview, Drake was very open about his emotional misery, but he was tight-lipped about alcohol and other substance use, often answering assessment questions with the pat answer, "No more than most people." The therapist decided not to press Drake for further details at that time, because he noticed that Drake was becoming visibly perturbed, and might decide not to follow through with therapy. Instead, the therapist silently decided that he would "flag" the issue of chemical dependence in his notes and come back to it at a more favorable moment.

In the first therapy session, Drake's score on the Beck Depression Inventory (BDI; Beck, Steer, & Garbin, 1988) was 40, indicating a severe level of depression. He endorsed marked sleep disturbance, self-reproach, and suicidal ideation, among other symptoms. The first part of the session focused on Drake's thoughts about suicide. When the therapist was satisfied that the patient did not pose an imminent threat to himself or others, he asked about Drake's use of alcohol and other substances. The following is a condensed facsimile of the dialogue that ensued:

Therapist: I remember something you said last week about your drinking alcohol "no more than most people," but I'm wondering whether your alcohol use may be interfering with your sleep. Can we talk about this?

Drake: It's a nonissue. (Long pause, but does not continue.)

Therapist: Meaning?

Drake: I can't sleep because I can't shut off my thoughts about how much I hate my life, not because I choose to relax with a few beers when I get home from work, like anybody else.

Therapist: Well, one thing we definitely want to talk about is those thoughts that keep you up at night, and how you can manage them more favorably rather than letting them plague you. But I think we should cover all our bases, because your depression is severe, and we don't want to miss any factors that could be inadvertently making your depression worse, such as a few beers after work every day.

Drake: Hey, I'm not paying you to imitate my wife. I can hear all this at home for no charge. (Laughs loudly and nervously, then retreats into a long, awkward silence.)

Therapist: I hit a nerve, didn't I? Sorry about that. I didn't know that your wife was concerned about your alcohol consumption.

Drake: Doc, you're getting the wrong idea. Here's the deal. My wife doesn't like the fact that I tune her out when I get home, and she blames the beer for that. She's not worried about me being some kind of alcoholic or something. She just wants me to have stupid conversations with her about stuff I'm in no mood to hear.

Therapist: It sounds like you've got some resentment toward your wife, and I certainly don't want you to resent therapy as well. (Waits for Drake to respond, but Drake just looks away and remains silent.) I gather that drinking beer has been a means of escape for you—a way to drown out the stresses and strains of your everyday life. What I worry about is the inadvertent depressive effect of your drinking beer every day. I am concerned about how drinking could disturb your sleeping too, which you noted was a big concern of yours.

Drake: Tell you what. If it will make you happy, I'll give up the beer. I'll switch to wine and Jack Daniels. (Lets out a hearty laugh, but his face is turning red.)

Therapist: (Recognizing that Drake is angry, he just looks at Drake sympathetically for a while, and then weighs his words very carefully.) I know I'm not winning any popularity points with you right now, Drake. I'm trying to offer you my best professional judgment. I think I owe that to you. What are your thoughts right now?

Drake: This isn't going to work.

Therapist: You mean therapy isn't going to work?

Drake: Therapy, the medication, the whole nine yards. And you're trying to get me to stop doing the one thing that helps me.

Therapist: You mean the drinking?

Drake: (Shoots back a look that seems to say "What else?")

Therapist: I'm starting to "get it," Drake. You're deeply depressed, you're resentful about your home life and your job, you're trying to cope the best that you can, you're willing to try pharmacotherapy and cognitive therapy, but you're not very hopeful about the results, and the idea that you should give up drinking seems to miss the mark and really ticks you off. How close am I to being on target?

The therapist recognized that Drake was ambivalent about staying in treatment, and that if he insisted that the patient stop drinking, he might drop out of therapy altogether. At the same time, he realized that it would be potentially hazardous to ignore Drake's use of alcohol, and would send the wrong message about how therapy should proceed. Thus, the therapist opted to engage Drake in the collection of data, as the following dialogue illustrates.

Therapist: I'm interested in what you said about the alcohol being "the only thing" that makes your mood less depressed. I wonder if we can make a more objective study of this hypothesis. (Looks at Drake to gauge his body language before taking the risk of proceeding further.) If you're willing to be a social scientist, with yourself as the subject, I think we can take a closer look at this phenomenon.

Drake: What, that beer is my best medicine?

Therapist: Exactly.

Drake: So what am I supposed to do?

Therapist: You collect data on yourself, every day.

Drake: How?

Therapist: There are a few ways, but here's one idea, for starters. First, you'll have to keep a logbook of your moods, your alcohol intake, and your associated thoughts. (Explains the nuts and bolts of how this would look in practice.) I would suggest that you use a scale of 0 to 100 to chart your mood when you get home from work, then after you've had your final beer or any other alcoholic beverage for the evening.

Drake: Assuming I'm still conscious. (Laughs out loud.)

Therapist: (Thinks that Drake is giving away more hints that his alcohol use is in fact excessive, and that it is important to make the reduction of alcohol consumption a high-priority goal for therapy.) Well, I guess we'll find out, won't we? But that's not all. I wonder if you can log your mood rating the next morning, right before you leave for work. That will give you three mood ratings per 24 hours—one before you drink, another after you drink, and the final rating the morning after. Oh, and one more thing—could you jot down how many drinks you have each day, just so we can see how this goes together with your mood ratings?

Drake: Didn't you say something about writing down my thoughts too?

Therapist: That's pretty ambitious for now, but if you want to start doing that, I'm all for it. (Goes on to explain the concept of self-monitoring one's automatic thoughts.)

The upshot of this dialogue is that the issue of alcohol was now firmly placed on the therapeutic agenda and would be brought up routinely each session. Drake was willing to come back for further sessions, and he and the therapist began to develop rapport.

As one might predict, Drake had difficulty completing the assignments on a regular basis, but the data he managed to collect were sufficient to advance the cause of understanding the relationship between his moods, his alcohol intake, his thought patterns, and how he felt "the morning after." This set the stage for further interventions, such as experimenting with "an evening of sobriety," so that Drake could collect data on his moods, his thoughts, his quality of sleep, and his feelings the next morning on those days he chose not to drink when he arrived home from work. Such an assignment was a "win-win" proposition. If Drake succeeded in not drinking, the therapist lauded it as a triumph. Furthermore, he took the opportunity to focus Drake's attention on the positive effects of sobriety, such as more pleasant interactions with his wife, a lesser caloric intake (Drake had stated that he wanted to lose 10-20 pounds), saving money, and the chance to focus on productive activities he had abandoned. If, on the other hand, Drake had difficulty in enacting the sobriety experiment, the therapist would note how this was evidence that the drinking had become "habit-forming," thus warranting more attention in treatment. Either way, something productive would come out of the assignment.

Drake's course of therapy was typified by discrete "bunches" of sessions separated by absences of various lengths, some planned and others based on Drake's avoidance of treatment. The patient's condition was at its best when both his drinking and his depressive symptoms decreased significantly, at which time Drake usually wanted to terminate therapy. The therapist often agreed with this plan, provided that Drake continue to take his ADM and to meet as scheduled with his psychiatrist. Almost without exception, Drake's worst times were typified by the following scenario—he would call the therapist "out of the blue," after an unscheduled absence from CT, asking to be seen again following a significant recurrence of binge drinking and related dysphoria.

Drake reluctantly acknowledged that he tended to blame his depressive relapse on his ADM "no longer working" rather than to examine his increase in alcohol use. Drake would then seek CT to improve his mood, but was more ambivalent about addressing the alcohol issue. By the time Drake had reentered CT for the third time following a relapse, the therapist advised Drake also to attend AA as a way to address his alcohol use continuously, irrespective of his current and future involvement in CT. Thus, AA became the "bridge" between Drake's successive trials of CT.

Alcohol No More

Alcohol No More

Do you love a drink from time to time? A lot of us do, often when socializing with acquaintances and loved ones. Drinking may be beneficial or harmful, depending upon your age and health status, and, naturally, how much you drink.

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