The Client Who "Only Drinks on Weekends"
Marcus, 41, is referred by his employer after a second DUI in 18 months (BACs 0.19 and 0.16). He tells you he "only drinks on weekends," which he defines as Thursday through Sunday: 8–10 beers plus several shots of whiskey each of those days. He has had morning tremors twice in the past year. His wife reports he was "a different person" - irritable, sweating, unable to sleep - on the two occasions he stopped for a few days. He takes lisinopril for hypertension and works the night shift. AUDIT score 24. He denies cravings and says, "I could quit tomorrow if I wanted to; I just don't want to yet." He is insured through Medicaid and has never been in treatment.
1. Marcus concedes he drinks heavily but insists he is not addicted. Using his specific data, explain what separates his pattern from heavy social drinking. Then describe how you would present that to him without reciting a diagnostic checklist at him.
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What the data show
- Quantity/frequency: roughly 30–40 standard drinks across four consecutive days weekly - well above heavy-drinking thresholds and, critically, clustered rather than spread.
- Withdrawal: the tremor/sweating/irritability episodes when he stopped are physiological withdrawal, not "stress." Withdrawal is a criterion he meets on his own report, and it is also a medical risk factor for his next cessation attempt.
- Impaired control and consequences: two DUIs at high BAC, marital conflict, and continued use despite a known hazard.
- Notably, tolerance is not required, and physiological dependence alone does not equal addiction.
How to present it Not as a scorecard ("you meet five of eleven criteria") - that invites debate about each item. Instead, use his own words and reflection: "You've told me Thursday to Sunday you're drinking eight to ten beers plus shots, and that twice when you stopped your hands shook and you couldn't sleep. And two DUIs in eighteen months. I'm not interested in labeling you - I'm interested in whether this is costing you things you care about." Summarize the discrepancy, let him respond, and avoid arguing. Document the criteria you observed so the record reflects clinical reasoning, not just his denial.
2. "I could quit tomorrow if I wanted to." How do you respond, and what are you specifically trying to avoid?
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This statement is a mixture of sustain talk and genuine ambivalence - and it may also be true, which is why arguing is a mistake.
Avoid:
- Direct confrontation ("If you could quit, why two DUIs?") - this reliably raises resistance and gives him something to push against.
- Quiet collusion ("Sounds like you've got it under control") - that abandons your clinical judgment.
Do:
- Reflect both sides: "So part of you believes you could stop whenever, and part of you is here because your employer and your wife don't see it that way."
- Explore the two times he did stop: how long, what it felt like, what made him start again. That converts an abstract claim into specific data he generates himself.
- Test confidence, not importance: "On a 0–10, how confident are you that you could stop for thirty days starting tonight?" If low, ask what would move it up one point.
- Reframe abstinence as an experiment rather than a verdict: a 30-day trial gives him information and costs him relatively little.
Denial is not a clinical diagnosis and not something to be broken through; ambivalence is the expected starting point. Document what he said verbatim and your response.
3. What medical and contextual factors must shape your assessment, and what findings would change your initial clinical impression or your sense of urgency?
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Medical
- Hypertension + lisinopril: heavy alcohol use raises blood pressure and withdrawal spikes it further; his BP needs monitoring and his prescriber should know about the drinking pattern with his written consent.
- Withdrawal history is the key urgency variable. Two prior symptomatic episodes put him at elevated risk of seizures or complicated withdrawal on cessation. Ask directly about prior seizures, hallucinations, and delirium - none are reported, but the two episodes suggest he cannot simply stop at home unmonitored.
- Rule out alternatives before attributing everything to alcohol: tremor from hypoglycemia, anxiety disorders, or thyroid disease; sleep complaints may be primary insomnia.
Contextual
- Night-shift work shapes both his access and his social world; "weekends" on nights may mean something different than you assume. Ask what his drinking day actually looks like hour by hour.
- Screen for depression and suicidal ideation - irritability and sleep disruption overlap heavily with mood disorders and change the treatment plan.
What would change my impression: any seizure, hallucination, or delirium history (refer for medically supervised withdrawal), a positive screen for stimulants or opioids, or a comorbid untreated mood disorder requiring integrated care.