The email from my former client arrived on a recent Wednesday morning.

I smiled as I read it, “Just thought you would like to know that I’m celebrating my first year of sobriety and with no slips! Thanks again for all your help.”

Pausing to reflect on our work together over a three-year period of regular and very challenging therapy sessions, I marveled at his present sobriety, given how severe his drinking had become. When he had arrived at my office in early 2016, he was consuming up to two bottles of wine a night and was often experiencing blackouts.

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As with all my clients who struggle with substance abuse and related issues, we had started our work by examining the criteria for a substance use disorder, and in his situation, an alcohol use disorder. He had met 6 of the 11 criteria, including some of the most common issues I look for including tolerance and experiencing regular cravings for alcohol. It had helped my client build his motivation to change when he realized that his drinking habit was actually a diagnosable disorder, and it had allowed him to puncture some of the denial he was experiencing about the severity and destructive nature of his alcohol use.

Once we had established that he did indeed have an alcohol use disorder, I had asked about his drinking goals. I have learned that it is important to not assume a client wants to get sober. In fact, most clients, even those with severe substance issues, generally want to strive for moderation rather than abstinence. If they sense I have an agenda for them to quit, they often withdraw from therapy prematurely. Thankfully, my client had recognized that he was unable to drink moderately and was committed to finally getting sober--complete abstinence.

We had started our work with the goal of gradually reducing his drinking, with the idea that if he was unable to significantly alter his intake through individual therapy, we would consider outpatient treatment centers to further support his recovery. We aimed to reduce his drinking by 25% each week, as this would be sufficiently challenging while not overwhelming. I had asked him about his daily drinking patterns, and we paid special attention to his triggers. For him, fights with his partner would leave him feeling frustrated, angry and alone, and would inevitably lead to heavy drinking that night. He would also associate arriving home from work with going directly to the fridge to pour a sizable glass of wine, often before he had even removed his coat. Another potent trigger was social functions associated with his job—he would often drink too much and not remember much from the previous night.

“The key to getting sober is to anticipate which evenings will be threatening to your sobriety and then develop a concrete plan to get through them,” I had told him.

Each week, we spent time talking about upcoming events that worried him because there would be alcohol present. We worked out how many drinks he could have based on our reduction goals. We also reduced the window of time where he would be out of the house, thereby giving him less time and opportunity to drink. He would arrive late to the various events and leave early. We also discussed some effective strategies he could use, such as having a big glass of water between each drink, eating a meal before going out to slow the absorption of the alcohol, and only bringing the necessary cash to buy our predetermined number of drinks—he would leave his cards at home to reduce temptation.

At the beginning of each session, we would review how the previous week had transpired and we would adjust our goals or strategies accordingly. I would often remind my client that getting sober is not a linear process, there will be inevitable slips and even potentially full relapses. I assured him that this was normal and reminded him to not be too critical of himself if he drank too much one night. He just needed to continue moving forward, learning from his slips and applying that knowledge to the next experience.

My client had struggled in those initial months to meet our goals for reducing his drinking, so we had agreed that he would also start attending Smart Recovery, a weekly support and psycho-education group. This additional support was what he needed, and we began to see a steady decline in his overall drinking.

Several months into our work, I recall him arriving at our session one morning and he was beaming. He sat down, stared at me and waited for me to ask, “How did it go this week?”

“I didn’t drink a thing,” he reported through a smile. “I can’t believe I actually did it.” My client was ready in every possible way to change his relationship with alcohol and worked diligently toward that goal.

I was brought back to the present moment with the sound of my kids demanding something from upstairs. I quickly reread his email, felt quietly proud for his recovery, and continued with my day, a bit lighter. 

File under: The Art of Psychotherapy