Looking for the Last Drink

Mar 08, 2017

“Certain experiences may be transmitted by language,
others — more profound — by silence;
and then there are those that
cannot be transmitted, not even by silence.”

Elie Wiesel

Looking for the Last Drink

TISA Description of the Problem: It is news to no one that it is sometimes difficult to get the truth about alcohol and substance use from clients suffering from addiction. But there are many interviewing techniques that can help with this problem. And it is always pleasant news to see creative solutions. The following technique recommended by Dina Solomon, a social worker from Philadelphia, is one such solution.

The choice of when to utilize a specific technique sometimes depends upon contextual elements unique to a particular interviewing dyad. In this case, this technique works best when the clinician senses that he or she has been able to develop a fairly solid alliance with the client as the initial interview has proceeded, perhaps reflected by the effective use of humor earlier. With such an alliance, the clinician may be in a particularly good position to play the following card.

Tip: I find that the following question, or one of its variants, is surprisingly good at getting clients to open up about their last use of alcohol or a street drug. The last phrase after the pause is always said with a bit of a knowing twinkle to the eye:

“When was the last time you used any drugs or alcohol (pause) . . . honestly?”

or

“When was the last time you used any drugs or alcohol (pause) . . . for real?”

or

“When was the last time you used any drugs or alcohol (pause) . . . the real rap?”

TISA Follow-up: These interviewing techniques have a playfulness to them that I think can be very effective when timed correctly and with the right client. The first part of the question also is an example of a well-established validity technique called “gentle assumption” that was first delineated by Pomeroy, Flax, and Wheeler (1). Gentle assumption can be used any time the clinician feels that there is sensitive material that the patient may be hesitant to share.

In this style of question, the clinician assumes that the suspected behavior is occurring and frames a question based on this assumption. The technique was developed as a tool for doing research on sexual activity, where it was noted that questions such as, “How frequently do you find yourself masturbating?” were much more likely to yield valid answers than, “Do you masturbate?” If the clinician is concerned that the patient may be “put off” by the assumption, it can be softened by adding the phrase “if at all” as with, “How often do you find yourself masturbating, if at all?” Examples of gentle assumption would include questions such as, “What other ways have you thought of killing yourself?” and “What types of arguments have you and your wife found yourself having?”

In any case, the technique shared by Dina combines a gentle assumption with a playful challenge from the interviewer. I believe it to be an effective combination and yet another nice tool to pass on as we teach the art of clinical interviewing.

(1) Pomeroy, W. B., Flax, C. C., and Wheeler, C. C.: Taking a Sex History. New York, The Free Press, 1982.

Tip provided by:

Dina Solomon, LSW
Residential Crisis Shelter for Homeless Youth
Philadelphia, PA