The EAP Referral Who Says the AUDIT Was a Joke
Marcus T., 41, is referred by his employer's EAP after he fell asleep at a machine console and was suspended pending evaluation. He tells you he 'drinks a couple of beers on weekends' and that his wife 'has it out for him.' His AUDIT score is 14, but he says he answered 'for effect' because he assumed the EAP would require treatment regardless. His wife, whom he asks you to call, reports three blackout episodes in the past year, an ED visit after a fall, and drinking 'most evenings.' Labs: AST 71, ALT 68, GGT 112, MCV 101. He has no prior treatment and no legal charges, and he wants to keep his job. Midway through he asks you to 'write whatever keeps this off my record.'
1. Self-report, screening score, collateral, and biomarkers point in different directions and the employer is paying. How do you decide what to believe, and what methods do you use?
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Reframe the problem: this is not a question of who is lying, it is a question of which data sources are reliable for which purpose.
- The AUDIT is a screen, not a diagnosis. A score of 14 indicates a positive screen and warrants further assessment; it cannot establish a diagnosis on its own, and his claim that he answered 'for effect' is testable rather than dismissible.
- Use a structured diagnostic interview anchored to DSM-5 criteria and a Timeline Followback with calendar anchors (holidays, paydays, the fall, the blackouts). Ask for standard drinks per week and specific dated events, not global self-ratings.
- Biomarkers are supportive, not diagnostic. GGT 112 and MCV 101 are consistent with sustained heavy drinking but have other causes; treat them as convergence, not proof.
- Collateral with written consent - ask the wife for dated, observable events rather than judgments.
- Treat minimization as a finding. Note in behavioral terms that he deflects and externalizes; do not confront early, but do not accept the denial as the baseline either.
- Count criteria by source. If 4-5 criteria are met, that is moderate severity even if he endorses only two.
The decision rule: diagnose on the preponderance of evidence across sources and document which criteria rest on which source.
2. He asks you to 'write whatever keeps this off my record.' What do you actually write, and what do you tell the EAP?
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- You never falsify or omit. The record must be contemporaneous, objective, and defensible; a note that reads 'no evidence of a problem' when the collateral and labs say otherwise is both clinically wrong and professionally hazardous.
- What goes in the note: the diagnosis with the specific criteria met and their sources, the discrepancy between self-report and collateral, and how it was resolved (or that it remains unresolved and why). Phrase it behaviorally: 'Client reports weekend-only use; spouse reports three blackouts in 12 months; client declined to discuss the ED visit.'
- What you tell him: in plain language, what the note will say, what the EAP will receive, and that his signed consent governs the release. SUD records carry heightened federal confidentiality protections; consent must be specific as to recipient and purpose and can be revoked in writing.
- If he refuses consent, nothing goes to the EAP. Tell him what happens then - the EAP may draw its own conclusions from non-participation.
- Offer transparency - read the note with him before finalizing. It reduces the adversarial frame and models honesty.
- Do not promise a favorable diagnosis. You can honestly say that an accurate diagnosis plus documented engagement is usually more protective than a falsely clean record that collapses at the next incident.
3. The wife calls before he has signed any release. What do you say, and what do you do with what she tells you?
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- You may listen; you may not confirm or deny that he is a client, and you may not disclose anything about his evaluation. Federal SUD confidentiality rules do not permit implied or verbal consent.
- Ask for her number and request consent from him at the next session. If he refuses, document the refusal and the reason, and do not contact her.
- If she describes an imminent safety situation - he is driving with a child now, there is a weapon, he is unresponsive - that shifts the analysis entirely and you act on the risk, documenting your reasoning.
- Guard against triangulation. Her frustration is clinically meaningful and belongs in the treatment conversation with him, not in a parallel channel with her.
- Do not use her call as a substitute for consent. Record that she called, that you declined to confirm or discuss, and what you advised.