Responding to Drinking Problems

In a seminal study of community agents, including doctors, the researchers identified three

factors influencing their intellectual and emotional preparedness to work with problem drinkers.18 This preparedness was termed Therapeutic Commitment, and its presence or absence was determined by:

Role Adequacy - the belief that the agents possessed sufficient knowledge to carry out the helping role when working with problem drinkers

Role Legitimacy - the belief that patients accepted their right to ask questions about drinking when necessary

Role Support - confidence that they could obtain expert advice and assistance when needed

Low therapeutic commitment was characterised by a clear pattern of avoidance of problem drinkers. This could take the form of denying their existence in the caseload, or of 'failing' to recognise' patients with alcohol problems, at least until the problems had reached such an advanced stage as to be unmistakable and undeniable. Other avoidance strategies included getting rid of drinkers, for example by referring them to another agency; regarding drinking problems as unalterable, and blaming drinkers for lacking the motivation to change their behaviour. The dominant feature of this negative response was a marked therapeutic pessimism and hopelessness - the belief that there was little point in trying to identify people with alcohol problems because they did not really want, and would not benefit from, the help offered.

In contrast, agents with a high degree of therapeutic commitment did not avoid encounters with problem drinkers or fail to recognise the signs and symptoms of alcohol problems. They did not regard problem drinkers as threatening to their professional competence or self-esteem. They were prepared to ask relevant questions and believed that their intervention was worthwhile, that beneficial change was possible.

Those with a high degree of therapeutic commitment shared a number of characteristics:

  • they were experienced in working with drinkers

  • they had role support available

  • they had received training in counselling- the more hours received, the less anxiety in regard to role adequacy and role legitimacy

  • they had clinical knowledge of alcohol and alcohol problems, the key parts of which were: the effects of alcohol on the individual drinker, for example how to recognise acute withdrawal symptoms, patterns of behaviour characteristic of high tolerance, the physical, social and psychological consequences of excessive drinking.

These factors were interrelated. In particular, one of the most important findings of this study was that in those with only limited experience of working with problem drinkers, the possession of even quite substantial knowledge of alcohol and alcohol problems did not reduce anxieties about their role adequacy.

This is consistent with later findings that, even in `rich' programmes in terms of number of curricular hours (36 hours/4 years in the USA), improved knowledge and attitudes in regard to role adequacy acquired during early undergraduate training can reduce significantly during senior years when the student enters his or her clinical rotations and is exposed to alcohol-related clinical situations with poor prognosis as well as pessimistic mentors. 19

The conclusion is unavoidable that education and training programmes on alcohol and alcohol problems are not sufficient in themselves to produce high degrees of therapeutic commitment. Attention also needs to be given to the working situation of doctors, the circumstances in which they acquire experience of alcohol problems and the amount and quality of support available to them in carrying out their role. What is at issue is the relationships between doctors and their colleagues with specialist expertise in this area.

References:

18 S. Shaw et al: Responding to Drinking Problems. Crome Helm 1978
19 Prof. N. el-Guebaly: Medical Education and alcohol-related problems in Canada. Paper presented at the Merck-Lipha Consensus Forum on Medical Education, Lisbon November 1998.



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