Professional Voices—'Twas the Night Before Detox

By Dr. Neta Tal 12/17/14

A clinician spends the holidays wondering: How much do we really know about what our patients are doing?


'Twas the night before Christmas for a helpful clinician,

Who was looking forward to vacation without a suspicion;

The patient had been nurtured with the utmost of care, 

In the hopes that his stable recovery soon would be there;

But the case took a turn and there arose such a clatter,

For the patient never mentioned what was really the matter.

It’s late one Christmas Eve when I receive an email from my patient “Matt.” The tone of the email, while ostensibly apologetic on account of its unfortunate timing, is also loaded with a sense of urgency imploring me to respond quickly.

Matt, who I’ve been working with for almost a year in weekly, outpatient psychotherapy for his alcohol use disorder, writes that he is en route to check himself into a local hospital for detox from alcohol, and that he would like to speak soon about a plan for the next steps in his treatment.  Later that evening, we have a very brief conversation, during which he reveals to me he had begun moderating alcohol about six weeks ago, and that for the last couple of weeks things had started to “spiral out of control.” Matt reported that he had been drinking nearly a liter of vodka daily when he checked himself into the hospital, mainly out of fear that he would have a seizure were he to try to stop drinking on his own. We are two minutes in when he tells me a nurse is making him shut down his phone. I tell him I will be in touch soon with suggestions regarding next steps.  

As far as I had known at that point, Matt hadn’t picked up a drink in almost a year, so I was pretty disoriented—confused, questioning of myself, and even maybe a little annoyed. Part of me was trying to think quickly about next steps—perhaps rehab for a few weeks, which would likely be followed by a couple of months in an intensive outpatient program.  But then I started to play the last few sessions back in my mind; he had canceled the last two on account of supposed scheduling conflicts, but what about the ones before that? What had I missed? Had I asked him about cravings and triggers for alcohol, or, more importantly, if he had been drinking? Or had I assumed, based on my perceived sense of the honest exchange that I thought existed between us, that if Matt was thinking about picking up, or certainly if he had resumed drinking, that he would simply tell me about it?

Matt, a very successful businessman in his early 40s, had initially come into treatment with me following a stay in a 28-day rehab. At the time we met, he also began attending a well-regarded, abstinence-based intensive outpatient program (IOP) for substance use, in which he maintained rather consistent attendance for the first 6 months of our work together. When the time came for him to graduate from that program, we discussed the plan for several weeks, plus all the steps he could take to ensure a smooth transition back into his “normal” life, one that he hoped would involve getting back to work and finally getting engaged to his long-time girlfriend. Over the course of our work, it had become clear to me that Matt’s status in the world, his successful career and the image of the self-assured, athletic, “man of the world,” he exuded were central to his self-esteem.

From time to time, in the months after the IOP ended, Matt would first bring up and then almost immediately relinquish the idea of trying to drink alcohol in moderation. That he would want to consider it hardly came as a surprise, given that Matt had been a social drinker for most of his life. Drinking had only become a problem for him in the year before he went into treatment, on account of a chain of events that began with a series of sports-related injuries, subsequent surgeries, severe pain and a prescription for a strong cocktail of prescribed painkillers. When the painkillers were no longer available, however, Matt found himself drinking copious amounts of hard liquor in the service of self-medicating his opiate withdrawal symptoms. Drinking at that level of intensity lasted for about six months before he went into rehab.

Based on his history, personality, and other factors, the idea that Matt could, one day, go back to drinking moderately did not seem completely out of reach to me (as it does for some other patients). At the same time, whenever he brought it up and we began the usual discussion of the pros and cons, or how he would know the timing was right for trying to moderate, Matt would ultimately end up recounting how well things in his life had been going during his year of abstinence from alcohol and would voluntarily and consistently reaffirm his commitment to sobriety. I walked away from these sessions feeling confident that I had created a safe space for my patient to openly talk about his options and genuinely wrestle with the potential consequences of them—without judgment or an agenda being imposed by me. In retrospect, I believe these conversations also gave me (what I can now see clearly) a false sense of assurance regarding our therapeutic alliance. I believed that Matt, should he ever decide to drink again, would surely tell me about it, if not consult with me in advance of doing so. Indeed, these interactions left me feeling quite certain that my patient would have little to no incentive to hide much at all from me.

I had always liked Matt very much. I have appreciated his well-related presentation and psychological-mindedness, not to mention his intelligence and humor. Moreover, he had consistently treated me in a highly respectful and appropriate manner, one that has communicated to me that he values both my time and insights, and our work together. Indeed, I had routinely looked forward to and enjoyed my sessions with Matt more than with many of my other patients, whose treatments I often experienced to be more frustrating and less rewarding. Matt seemed liked an ideal patient in many respects—making progress with sobriety, forthcoming about his cravings, non-aggressive in his demeanor and appreciative of my efforts. Above all, he didn’t give me that sinking feeling, well known in addiction counseling, that I was not going to be able to help.

Looking back, it is clear that his penchant for always presenting a certain image to others came to include me as well. Instead of using our work as a means of ensuring that his addictive behavior was kept at bay, our work, at least in part, was part of Matt’s “impression management strategy.” It allowed him to present himself as in control and “on top of everything” to potential employers, his fiancé and others while actually gradually losing control and sliding backwards. Even here, in the work I was doing with Matt, where I believed that I had created a safe space for him to discuss a return to social drinking, the pressure he felt to keep his urges to drink, and then his return to drinking, to himself, was obviously intense. Not talking about them served to shield him from dealing with any reactions or questions I may have had about his decisions that may have challenged his notion that it was safe for him to try moderate drinking again.

What is or isn’t revealed by patients in therapy is hardly a new topic for consideration; after all, we only know what our patients choose to tell us. I imagine that any thoughtful clinician is keenly aware of how circumscribed their view is of their patients’ inner lives as well as the myriad of details that comprise their daily existences. Indeed, one could argue that only the most naïve clinicians would lose sight of the inherent limitations of the accuracy and scope of what they know of their patients’ lives. After all the therapeutic relationship is often restricted to one or two hours per week of contact in the largely controlled setting of our office.  

But what are the additional challenges that we face, those of us who work in the treatment of substance use disorders, with respect to our ability to fully know what is truly happening in our patients’ lives? 

Undoubtedly, there are a slew of obstacles that might cause our patients to decide to conceal their substance use from us: shame, fear of judgment, actual negative consequences and embarrassment representing just the tip of the iceberg. Does that mean that we, as clinicians, should expect or even assume that patients are underreporting use, if not flat out being untruthful in response to our probing about use? And if so, what are the risks that taking this stance may pose to the integrity of the treatment alliance and the trajectory of clinical work?

When Matt and I speak the day after Christmas, he is still in a state of awful disrepair. Medical complications from his excessive alcohol use have him confined to the ICU, and I can tell from the tremor in his voice how painful it is for him to be in this predicament over the holiday, following so many months of making successive positive changes in his life. We talk about a plan; I have contacted a trusted rehab facility that will call him to coordinate an admission date. Our conversation is longer this time, but still I try to keep my questions straightforward and simple. When did the drinking start? When did it escalate to the point of physical dependence? Did his girlfriend know? Did his parents know? Will they help him with the logistics and finances of checking into rehab next week? All the while, I'm doing my best to conceal what I really want to know, which is: “How come you didn’t tell me sooner…and I thought you trusted me…and how the hell did I miss this?"

I spend the holiday mulling over this question—did my overly positive countertransference towards this patient lead me to develop a blind spot to what was actually going on with him? I find myself wondering whether my need to feel like a successful and useful therapist, an experience that can be elusive in my line of work, may have caused me to overlook the genuine struggle he was facing with regards to his relationship with alcohol. At the same time, however, I feel that my impression of Matt was simply consistent with the state of affairs that he was invested in conveying to me.

Ultimately, I realized that I had an opportunity, and a responsibility, to examine the situation from two vantage points. Of course, my own countertransference needed to be explored and understood so that similar situations would set off therapeutic alarm bells the next time around. But I also realized that analyzing the conditions and impact of my countertransference was just part of the process. Mainly, I needed to focus my clinical lens on what may have motivated my patient to downplay his ambivalence around his abstinence from alcohol and conceal from me the fact that his drinking had resumed. 

Clearly, any and all of the above were meaningful and relevant lines of thinking to pursue in the continuation of my work with Matt. Moreover, as with so many aspects of the frequently intangible nature of the craft of psychotherapy, it can be extremely difficult to pinpoint the factor, or multitude of factors, that leads to certain material either emerging or remaining unsaid at any given juncture in a treatment. However, in the treatment of substance use disorders, what is revealed or kept hidden in sessions seems to take on greater significance, given the inherent risk and consequences associated with the very behaviors for which one has come into therapy. What is interesting to consider is how this increased emphasis on the importance of reporting can actually fuel the illusion of certainty of what we think we know about a patient’s experience. Because the stakes are so high, and the temptation for our patients to be less than forthcoming is increased as well, our own stance towards the therapeutic alliance we form with our patients may require even more constant and careful examination. 

*All identifying information has been changed to protect patients’ confidentiality.

Dr. Neta Tal is a clinical psychologist at the Center for Motivation and Change, and in private practice, in NYC; she specializes in the treatment of substance use disorders. 

Please read our comment policy. - The Fix
neta tal.jpeg

Dr. Neta Tal is a clinical psychologist at the Center for Motivation and Change, and in private practice, in NYC; she specializes in the treatment of substance use disorders. You can find Dr. Tal on Linkedin.