“Is it more on a bad day?” – Talking non-judgementally about alcohol use

“Is it more on a bad day?” – Talking non-judgementally about alcohol use

At medical school I learned that no-one ever tells the truth to their doctor about how much they drink. We were taught to multiply whatever the patient said by anything from four to ten depending on what we could see before our eyes. Even then I could see how disrespectful that was but perhaps it was also realistic.

Why do people lie about alcohol?

Recently a friend of mine had a very serious motor vehicle accident. He is a regular heavy drinker but he did not happen to be “over the limit” at the time of the accident. He told the treating doctors that he drank very little and only on the weekends. This was absolutely not true, but he admitted to me later that he was afraid he would be judged if he told the truth and perhaps not treated as well as a non-drinker. He was also concerned that his insurance company would not pay out on his treatment. He said that the last thing he wanted, as he lay in the ED in a lot of pain, was a lecture about the evils of alcohol.

So, I guess my friend is a good example of how a drinker behaves in a health care environment. He thinks he knows how health professionals think about alcohol and wants to avoid their judgement. He hates confrontation. He is ashamed of how much he drinks but feels helpless in the face of the need for behavioural change. He is afraid of the consequences if anyone (other than his mates) finds out how much he drinks. He is short of money and doesn’t want anyone to know how much he spends on alcohol.

These are all pretty powerful reasons to avoid the truth.

“My liver is OK”

In many situations it’s important that health practitioners know the truth about a person’s alcohol consumption. It’s not just because of the effects of acute inebriation but because of the damage done by chronic intake as well. Most people know that too much alcohol over too long a time (or big amounts over short periods) can damage the liver and eventually the brain, but it comes as a surprise to many to learn that alcohol use damages many other organs and bodily functions including the heart, the pancreas, the testes and more.

We’ve got a problem here

How can we as health practitioners understand someone’s  needs and help them appropriately if there is so much between us and the truth?

  • We could explain what we mean by a “standard drink” and ask them how many of those they have in a day/week/month. Many of us have been taught to do things this way. I wonder if we can all do that without appearing judgemental?
  • We could use an AUDIT questionnaire – but will that get to the truth? Maybe, maybe not. At least using it will let the person know that their alcohol intake is a subject that interests us and is important to us.
  • We could wait for alcohol to get into the conversation organically and then be sure to use the language they use to talk about it (eg winding down, having fun, fitting in).
  • We could ask if there were any times that the amount they drink is more or less than usual. (“What about the bad days?”)
  • We could make an effort to understand why they drink alcohol and what drinking means to them.
  • We could hold off on conversations about the damage they are doing to themselves and those around them until they are well engaged with us.
  • We could offer to help them change their relationship with alcohol when they decide they want to do so.

Are there online tools that can help with that?

There are a lot of online mental health tools that can help with the wellbeing issues that lead to drinking alcohol at a damaging level. There’s also plenty of psychoeducation about why a person should stop. What is often needed is a tool that will support people through the process of changing their relationship with alcohol.

There’s evidence to suggest that peer support can be very effective when it comes to alcohol but not everyone is happy about going to AA meetings or about the general philosophy of AA. Those people might like the Hello Sunday Morning website which supports behavioural change by offering information and advice about changing habits, drinking harms, what to expect if you stop drinking and what alternatives there are to alcohol (complete with recipes!!). There’s also a blog full of personal stories.

Hello Sunday Morning is linked to a smartphone app called Daybreak. The app is free, secure and anonymous and compatible with all types of smart phones. It provides users with access to a community where everyone is supportive and everyone is trying to change their relationship with alcohol.

How can we get people enthused about Daybreak?

I imagine there will need to be a fair bit of motivational conversation with most people before talking about the Daybreak app but some people do warm to the idea of a supportive online community quite quickly. It helps that the language used is about “changing your relationship with alcohol” rather than stopping drinking altogether.

If people are interested, show them the app on your own phone and explain that they will need to set it up by registering (with an email address) and choosing an alias. They will also need to do a couple of questionnaires when they first log on but if you explain that in advance then show them the on your own phone it will be less time consuming. A brief look at what’s already in the chat is usually enough to persuade people that it’s worth a try.

Why not give it a go?

There’s not a lot to lose and a whole lot to gain from these conversations and with a bit of luck we might be able to help some people to extend dry July into the rest of the year.