Chapter 4 Case Study

The Case of Robert Jones: Part 1

Robert (or Bob as he prefers to be called) is a 48-year-old African American male who has been married for 30 years to Paula. He has two children, aged 16 and 5. When Bob came to us, he was well dressed, presented pleasantly and appropriately, and had a friendly demeanor. He was not entirely sure why he was sent to the clinic, but he was sure that it was a mistake.

"I’ve got no idea what’s going on here. The cops stopped me one night after work. Both were African Americans, and they knew me. They’ve seen me in town, at church. They told me I was weaving all over the road, and they wanted to make sure I was okay. Of course I was okay! I’ve been driving for over 30 years and never had an accident, never had a ticket! They asked me twice if I’d been drinking. I don’t drink, well, not that much anyway. They thought I was drunk! Would I drive drunk? I’ve got two kids, one a teenager who’ll be driving soon herself. I told them no, and then they asked me to step out of the car as they wanted me to do some things for them. . . . "

Bob continued his story for us during his initial intake interview. "This was so insane! I’ve got a graduate degree. I’m an upstanding citizen. The cops asked me to walk a straight line, to touch the tip of my nose with the index finger of each of my hands. That wasn’t good enough! Then they asked me if I’d been drinking—again—and then they asked me to blow into a tube in this little machine. I wasn’t sure I needed to do this, but I’d heard if you refuse to do this you’re immediately arrested. Where’s the "innocent until guilty" here?" Bob decided that he’d better go along with the officers’ request and he did, but he complained the whole time. The end result was shocking to him, to say the least, "They said I was drunk! My…BAR…or something like that [we corrected him and explained that this was his Blood Alcohol Concentration (BAC)] was .20."

BAC refers to the percentage of alcohol that is in the body as compared to the total blood supply. A BAC of 0.08 is equivalent to about four drinks consumed per hour for an average-sized individual.

"That meant zip to me, so they told me it seemed like I’d had about 10 drinks. 10 drinks! That’d make me a rummy, a lush! I only drink beer anyway. Ten beers in one hour! That’d kill me much less anyone else!"

We confirmed the BAC results on Bob’s paperwork, sent to us by his probation officer. She sent him to us as part of his plea bargain in order to avoid jail time. Bob believed that he had no reason to be in our office. "Why don’t you concentrate on the real problems out there—the murderers, lying politicians, and the drunks that kill people while driving—huh? I’m a hardworking family man; I don’t belong in here with the winos and the loony tunes." We pointed out the conditions of his probation and gave him the option to leave. Bob thought about this for awhile and then finally stood up to leave.

The Case of Robert Jones: Part 2

"Okay, I tell you what. If I leave I go to jail. That kills my family, my job, and probably me as well. I’ll stay, but I won’t talk to you. Doc, you’re doing all of the talking. If I talk, you’ll get me on something, twist what I have to say." We explained—again—to Bob that our job was to help him in any way possible and to do that he had to talk. We also told him that a condition of his probation was mandatory AA attendance. "What? You want me to go to those? Geez, everyone thinks I’m a *&^% drunk here!" We explained how AA works and told him that, if he desired, he could remain silent in the meetings but that he had to attend.

After a number of sessions using cognitive behavioral methods and Relapse Prevention Training (along with AA), Bob’s defenses began to weaken somewhat, and he became less volatile. We worked on teaching him how to handle stressful situations at work and at home, and how to recognize cues that might spur him to drink again.

"I tell you what, I miss my beer. Not being allowed to have any—and yes, I haven’t had but a one—is not easy. My friends think I’m sick. It’s hard, especially in the summer with cook-outs and baseball." Bob actually began to look at his own drinking behavior as the sessions progressed and he realized that a problem might exist. "I really think that something might be happening with me. I’ve been drinking—I never told you this—for almost 30 years, having quite a few on many occasions. I’ve probably driven when I’ve had too much to drink but never got stopped. My wife—when she comes in, you can ask her—wanted me to stop for a long time. She gave herself a rash worrying that I’d kill someone or be killed. Maybe it’s time I looked at myself and at my behavior . . . my drinking behavior."

The Case of Robert Jones: Part 3

The Last Word on Robert

We discussed what Bob’s BAC meant and discussed how many people could not drive, especially not drive and avoid an accident, with that high of a BAC. We also discussed alcohol abuse and alcohol dependence and asked Bob directly about his drinking behavior. "Well, I can stop when I want to; it became a habit you see, a social aid. It hasn’t been easy to give up beer but I’ve been okay. I don’t see any elephants. I’ve done some reading on alcoholism. I can live without it, but it’s not easy. I always stopped when I needed to…well, most of the time." Bob did tell us that he adjusted to having more and more beer in his system but when he wasn’t drinking, he "just went to work or did other stuff; no problems there." Thus, Bob demonstrates tolerance but no apparent withdrawal symptoms and no loss of control. We then asked his wife for clarification.

"Well, he’s being somewhat truthful here. He’s been able to stop his drinking now, but in the past it was really a problem. He never got physically sick, but there were so many times when he told me he’d be home soon and when he snuck into bed it was 3 a.m., past closing time. I’ve threatened to leave him in the past if he didn’t get help. He’s also told me that he’s forgotten parts of evenings when he was out

drinking, and then he ended up with these massive credit cards bills with no explanation. I thought he was fooling around on me, but I never had any proof of that. He has tried at times to stop on his own, but he just couldn’t. I usually blamed myself; I was a lousy wife. Now it makes more sense after coming in here and going to Al-Anon meetings . In some ways I’m glad he got caught before he hurt someone."

Based on Robert’s reports, the probations officer’s case notes, and on his wife’s statements, we arrived at the following diagnosis for Robert:

Alcohol Dependence, with Physiological Dependence

We arrived at this initial diagnostic impression because Robert demonstrated tolerance (based on his statements that it takes more beer to get the same effect), loss of control, and denial. In addition, Robert often tried to cut down or control his alcohol use but to no avail.

Robert and his wife engaged in couple’s therapy, and Robert was placed into a Drinking Driver’s Group, an introductory psychotherapy group that also included educational components. Robert continued to attend his AA meetings and eventually his wife noticed quite a bit of progress, so she stopped attending the sessions. Because she still didn’t trust Robert driving, she drove him to all of his appointments.

Robert continued in the clinic for approximately nine months, making nice progress. He had two slips during that time; the first time, he became extremely upset but we worked with him using Relapse Prevention Training. The second time occurred when his wife was hospitalized for a mild heart attack and he "couldn’t hold it together." He understood that he’d probably drink and called us right after he did. He then called his AA sponsor and attended a meeting that afternoon while his wife was sedated.

Eventually Robert was discharged from the clinic and from probation with a prognosis of guarded. We gave him this prognosis because of his very lengthy drinking history; we wanted to be cautious. He thanked us and kept in touch for the next few months, calling to update us on his progress. He and his wife were going to take a cruise in the summer ("With no drinking! Water is good enough, and it’s free!"), and he promised he’d tell us how this went. This was the last we heard from him.