A nasty truth we like to ignore or even hide, is that chaplains mostly pass by the rooms of patients who may be afflicted with the illness that is the cause of more family pain than anything else–alcoholism. Alcoholics Anonymous was created by miserable drunks desperately seeking a way to stop drinking alcohol in the mid-1930s. Their forebearers having gotten little or no help in past millennia from medicine, religion, government, and law, they stumbled upon some new understanding they fashioned into Twelve Steps by which they were staying sober through a unique quality interaction with one another. The following is a description of a few skills that spiritual caregivers can learn to reduce chaplain helplessness in this area, to engage situations in which there is reason to believe there may be a drinking problem afoot. They include a soft and tough approach, remaining personally confident with realistic expectations of outcomes. As a chaplain develops these skills, they will be helping problem drinkers even though the positive outcomes will almost never be seen.

After three units of clinical pastoral education, I was home in the church rectory in Rockwell IA when a CPE supervisor (now clinical educator) called to offer me a supervisory residency at Presbyterian St. Luke’s Medical Center in Chicago.

The next part of the conversation went like this.
Me: Where in the hospital is it? What specialty?
Bernie: It’s in a new alcoholism treatment program in Psychiatry.
Me: Oh Gees. I don’t want that!
Bernie: Why not.
Me: I want to be a general hospital chaplain. I don’t want to get that specialized.
Bernie: That only shows how little you know about alcoholism. It’s in every unit of your hospital. That illness causes all kinds of medical problems that get people hospitalized. You’ll never regret learning something real about it.

I took the residency and indeed have never regretted getting immersed in it. What is still true is that most chaplains avoid any serious engagement of patients who may have a drinking problem. We could write tomes about the illness without getting much practical skill in caring for it. But there are such skills. And they can be described briefly in this chapter. Described not incorporated into a practice. That will take repetitive effort, frequent feelings of failure, and being able to endure quite a lot of misunderstanding along the way. Especially the encounters that involve a deft, persistent line of gentle but courageous confrontation, a chaplains’ best chance of providing real help.

There is no such thing as a typical alcoholic. That idea that there is, frustrates most real help for people who suffer alone with a drinking problem. Such people are legion, and most of them probably look a lot like you. Research shows that they comprise somewhere between 10 and 35 percent of hospital patients. It also shows that if a physician doesn’t mention drinking as a problem, patients aren’t likely to listen much to anybody else about it. And that those with the illness of alcoholism will need to hear it many times before the realization occurs. So be prepared to be spurned repeatedly if you invest in caring for them.

Also learn to completely rid yourself of moralism before you embark on this care. They will smell it in the air almost before they see you. They likely became accustomed to any form of moralism decades ago if they are old enough. As a chaplain however, you likely have two things going for you in engaging them.

The first is that you have developed a very broad concept of spirituality from which you care for peoples’ spirits. The Twelve Step recovery process can be characterized as a deeply spiritual process – if you don’t insist on being religious. Religion in general and God in particular, evoke in seasoned drinkers mostly feelings of sadness, guilt, fear, inadequacy, and deep hurt, none of those very effective in promoting recovery. Many alcoholics, as a subset of people with drinking problems, reflexively defend themselves strongly against both religious and spiritual language. But even a few minutes of calm conversation with a healthily religious figure can be valuable to the life of these quietly suffering individuals.

Secondly, there is a window of vulnerability when a problem drinker is hospitalized. It’s not wide or lasting, but it does provide an opportunity for them to be serious and speak courageously about their own life. An open, accepting, calm, and savvy looking face may just get through the fog in which they are likely to be living. But it takes a unique set of skills and attitudes to midwife them into getting the help they both desperately need and impulsively avoid.
So, what are the skills? (Dialogue here represents the patient as a male, though now about 45% of alcoholics are women. All of the original AA members were probably male).

  1. 1. First, prepare yourself
  2. This conversation may not be easy. Remind yourself that this person you are about to converse with is one fine individual and will appreciate your slightly formal, open, serious manner, whatever transpires. If this person may have a drinking problem, be prepared to follow the conversation closely and say what you want to say without social banter or attempts at humor. The patient may be in a quite pensive mood, and that will be to your advantage. If the person is an experienced alcoholic they will be trying to defeat you and at the same time hope you “win.”

  3. Remind yourself of your agenda. The term “agenda” has a bad rap in early clinical spiritual education. What a neophyte student is needing to do first is to recognize their own goals for the conversation that have been hidden from themselves –their hidden agenda. As experience shapes chaplains, it makes much more sense to stop inventing the wheel with every patient when there are observable patterns that are common. At the same time, be suspicious of your own patterns. Repetition quickly steals your authenticity.

  4. Potential drinking problems are an agenda example. While there may be several issues to address in a heavy drinker, there is a general tack that can be taken that is likely to serve people who have problems probably caused by drinking. Briefly, it is to: 1) Have a calm conversation about their own concerns about their drinking. 2) Keep focusing on THEIR concerns, deftly. 3) Take advantage of the mention of the key word— alcoholic. It is never your job to diagnose or even assess a person for alcoholism. But use of the word provides an opportunity to offer some solid, simple and clear instruction on this illness that is still so widely misunderstood. 3) Your overall aim is to see the patient accept an assessment by a qualified addiction counselor. Have one in your mind, and a phone number.

  5. The following is a description of an effort to peek beneath the massive denial of some people’s alcoholism. They are a subset of drinking problems. Don’t rule out the possibility that they are alcoholics too soon.
  6. 2. Recognition: Clarify the indicator
  7. Whatever there was that got you thinking there might be a drinking problem in this person is the indicator. And it is ONLY an indicator, not a diagnostic certainty or even a solid impression. Resist at all costs the temptation to see more than an indicator there. You do need one indicator of a drinking problem. You cannot confront without that. Without identifying what suggested a drinking problem in this person, you literally don’t know what you are talking about. You will be no match for the kind of self-deceptive interaction this person may have spent years developing in the service of maintaining a shred of self-esteem amidst horrible events attacking it.

  8. Was the indicator a comment from the patient’s spouse, partner, or friend voicing their frustration about essentially, trying to love this patient? Was it a staff shared comment, charted or verbalized by a treatment team member? Was it a wondering by a savvy physician or nurse based on common presenting problems in a hospital setting, such as pneumonia, liver disease, pancreatitis, or failure to thrive” FTT). Was it a series of comments by the patient suggesting a preoccupation with alcohol, such as requesting you get them a beer? Get it clear in your mind, especially if there have been several such indicators. You may need them in the conversation, though one clear one is enough.
  9. 3. Raise the issue
  10. Shortly after introductory comments, mention the issue of drinking. If you don’t, and proceed too far down the congenial charade of superficial social chatting, it will become crystal clear to this person why you are really visiting them, to get them to do whatever you want them to do. Then their well-established manipulator will have bested yours, sealing off the window of vulnerability that hospitalization creates for finding the narrow path towards real help.
    How to raise the issue? That depends on the indicator. Use it. For example, a few days after a vehicle crash, (definitely not while he is drunk) soon after greeting the patient, “I noticed that the ER report says you were apparently drinking before this accident.”

  11. Pt. – O s___! I had a drink or two at the party. What’s wrong with that? And who the hell are you?”
    C. – Well, I’m a chaplain here and I’m wondering if you ever have concerns about your drinking.
    Pt. – What do you mean?
    C. – Just, do you sometimes feel a little negative about some of your drinking?
    Pt. – I like to drink. It makes me feel good.
    C. – I’m sure you feel good most of the time when you drink. But are there times when you wonder – or regret some things?
    Pt. – Well I ain’t no angel you know.
    C. – What kinda stuff are you thinking about?
    Pt. – Well s___. My wife gets scared when she drives with me sometimes. I aint proud of that. Hate it when she cries.
    C. – Yeah. Feels bad when she feels scared and cries. Her hurt kind of gets to you.
    Pt. – Well she knew I drank when she married me!
    C. I suppose. But now she cries when she drives with you drinking.
    Pt. – Sometimes.
    C. – What does she say to you about your drinking.
    Pt. – She don’t like it. But what ya gonna do?
    C. Puts you in kind of a bind huh. She’s concerned about your drinking and so you sometimes are too.
    Pt. Yeah. But I don’t like everything she does either.
    C. Right. But you do love each other. Does she say why she gets scared and cries?
    Pt. Not really. But I ‘spose she doesn’t want us to get hurt, or ….die.
    C. How long has this been going on – you driving while drinking, she crying scared, and you not liking it either?
    Pt. Oh maybe a year or so.
    C. That must be getting old for her.

  12. The patient is getting a little AA Step One counseling in which, in the window of vulnerability of hospitalization, he is getting close to his feelings of regret that occasionally surface in his day. Continuing in this vein later in a counseling or AA group/sponsor situation, will expand that awareness until he lets the flood of emotions about the consequences of his drinking settle in his soul. He is a long way from that here. The goal for a chaplain is always to see a patient agree to an assessment by a counselor. That rarely happens. But when it does, that patient will remember that chaplain for a very long time.

  13. The immediate tack of the chaplain is to continue a calm conversation with the patient until there are tears of the patient or their anger insists you leave the room. That takes patience. The persistent, calm, soft confrontation can be difficult for the patient to resist. It may be only 1 percent of what will be required to break through to the ability to give an AA “testimony” of how bad things got, what happened to change that, and how is it now. But it may be the first one percent.

  14. The substance of Step One to recovery is a thorough sharing of that load of horrible feelings of guilt, shame, defiance, and utter failure resultant from hiding it all since adolescence. If it is shared enough, all that mass of emotion will return when a situation begins to compel the patient to drink again. The chaplain can facilitate a beginning of that recovery process, though they will likely never get to know it.
  15. 4. Focus persistently on the patient’s own concerns about their drinking
  16. That is the primary point of this chapter. In a very real sense, there are two people in that patient – one that maintains a solid “I’m OK” external impression and another that is inwardly alarmed with concerns about the consequences of their drinking. Your job is to ignore the first and address the second. On some hidden level, that patient has had concerns about their drinking behavior for a long time. But nobody has questioned that impression in any optimally uncomfortable way in that window of vulnerability. This chaplain is now doing that. Keep pressing ahead. And do your best to stay connected personally.
  17. 5. Respond to the term “alcoholic”
  18. When it is used or use it yourself eventually if the patient doesn’t. The charged word “alcoholic” offers an opportunity to do a bit of education about addiction. The patient will frequently use the term to assert that they are not as bad as somebody else, as in, “You wanna see some drinking, my cousin he does some real drinking. He’s a alcoholic.”
    C. Mr. Pt., how much do you know about alcoholism?
    Pt. I know some people drink a whole lot and can’t stop when they ought to. Alcohol ruins their life.
    C. Well alcohol does affect some people differently than other people. It is actually an illness. About one in ten people have it. Nobody knows for sure why some people get it and some don’t. It shows up as being able to drink more than other people, changes their attitudes, behavior, and memory – gets them into trouble. It’s not really how much you drink but how it affects you. You may notice that you can drink more than other people, you sometimes can’t remember what happened the night before, and tend to get in trouble when you drink. You tend not to stop drinking when other people do, and sneak a drink alone sometimes. And you may get bothered by some things that happen when you drink.
    Pt. Yeah?
    C. Yeah. It eventually causes you trouble in some major area of your life. You ever (been fired from a job?) (Been in jail?) (Been told you did stuff the night before that you don’t remember?)

  19. The pace of your questions matters. If it’s too fast there is no power in the confrontations. A calm, even leisurely attitude lends seriousness to the questions. The patient may be very familiar with fast talkers as wanting to manipulate them. You don’t want to resemble those people. If the patient shows any feeling in their voice or face, consider reflecting it, as a way to promote more specifics of disclosure. But more importantly, to further evoke emotion. Logic is only a small part of the conversation. It is the massive hurt hidden in that mind and body that needs to come to awareness, at its own pace.

  20. And remember, there is little truth in generalities. Specifics evoke feelings, the key to beginning the First Step phase of recovery.
  21. 6. Fashion a referral
  22. Making a referral is an art all its own. Only facilitate a referral after you have seen some significant feelings about the patient’s drinking behavior. If you’ve noticed sadness for example, consider reflecting it, simply, as in “You look a little sad all of a sudden.” In the rare hospitalization vulnerability, they may amplify feelings and let loose considerable disclosures they never have talked about before. Keep calm. Success in this kind of key conversation is like the proverbial pigeon in the park. If you chase it, it will flit away. If you sit quietly, it just may come and sit beside you. Don’t be surprised if the patient cries. Nor if they stop the session and ask you to leave. Remember, this approach only works rarely all the way to the patient accepting an assessment by a counselor. But it is often burned into the patient’s memory in a way you will never know about, and become a significant point in the difficult and complex process of early recovery.
    At some point if this process seems to be progressing, you may ask, “Mr. Pt., how does it feel talking like this?”
    Pt. – Kinda good actually.
    C. I know a guy (lady, person, fellow?) who talks to people about this stuff every day, for a job. Would you be willing to talk with Terry? I could get them to come over tomorrow, I think.
    Part of your preparation is to have a name and a number of somebody who assesses addictions, or in this case, preferably alcoholism, professionally. If the patient asks if you think he is an alcoholic, it may be best to not answer directly. It is somebody else’s job to diagnose and treat. It is yours to tease out the concerns at a time and in a way that the patient’s emotions may be connected to their words.
  23. 7. One step at a time
  24. Do not get ahead of yourself. It is so easy to launch into excessive teaching, too long, too soon, or too enthusiastically. It is called intellectualizing. It is quickly banned and suppressed in patients in AA meetings and in AA based counseling. Squelch the noise in your communication too. Focus on just the words you want to say. Doff any buddy talk, attempts to join the person. You’re not what he needs to recover. But you can be crucial in helping him find what he does need. Picture him sitting in a small group of similarly defeated people being listened to in a brand-new way. You are helping them to take the first or next steps to find that group, in AA or addiction treatment. Also, don’t generalize to “addictions” from alcohol. It likely only feeds the intellectualization. It may be seen as somehow cooler to talk about addictions, drugs, cocaine, etc., but alcoholism still causes more family pain than anything else. And finally, remember, bringing any general hospital patient to assessment of a drinking problem rarely works. Or rather it may take several times to work. If you had a few minutes of calm conversation about a person’s drinking, you have given them a gift, a taste of Step One, the narrow path to recovery. Most people with alcoholism still die from it. If you help a few in your career, allow yourself to feel some satisfaction.