A psychiatrist reflects on how we can educate patients about avoiding alcohol misuse without getting caught up in polemics on politics.
“And then they crawled out of the garbage can, dripping with blood and covered in goo. One after another, looking like little babies, except they were dead.”
Was she describing that cheesy 1970s-era horror film It’s Alive, a Times Square special about a major obstetrical mishap that self-propelled and devoured every bit of beef in the freezer? Or did this concern a later cult craze for “Garbage Pail Kids” cards, which were far more benign but nevertheless bizarre and popular enough to be known by the acronym, GPK? Or was this imagery more personal—something to discuss in a psychiatrist’s office, which is exactly where she was? The source of her concern would become obvious moments later.
Meg breathed in before she continued. She shuddered as she spoke, but she shed no tears.
She gripped the sides of her chair, her chipped nails leaving deep indentations in the well-worn leather. Her scraggly body sunk into the overstuffed armchair. She practically disappeared in the furniture.
Her disheveled appearance spoke for itself. Her half-bleached blonde hair was stringy and unkempt. Sweat beaded up on her forehead, making matters much worse.
She was scared, not sad, as she recounted the dreams that reoccurred almost every night since her last procedure. And she emphasized the word, “last,” implying that there were many more before the most recent termination of pregnancy.
It would have been easy to label her symptoms as posttraumatic stress disorder (PTSD), a result of uneasy feelings about ending a pregnancy that was never intended and never expected. She freely admitted that she was intoxicated the night that she conceived. She could remember next to nothing about the event—not even the name of the man she met that evening—but she remembered everything about the nights that followed.
Meg was only 22 years old, yet this was the third time that she terminated an unplanned pregnancy. There was 1 difference between this time and the previous abortion. Meg’s OB told her she could not in good conscience continue to treat her and perform another procedure unless Meg saw a psychiatrist and addressed her drinking. In my experience, it is unusual but admirable that this OB focused on something other than the immediate medical situation.
“And how did she know about the alcohol?” I asked. Meg did not hesitate to tell me that her liver enzymes were elevated. According to the OB, that was an ominous sign in anyone, but especially in someone so young.
Having read the paperwork that she filled out before her first appointment, I already knew that Meg (or “Margaret Mary,” as per her insurance card) was Catholic. As she disclosed during her first appointment, she was not a lapsed Catholic or an “ex-Catholic” but a practicing Catholic who sometimes attended Sunday mass and always made it to midnight mass at Christmas. So, I expected Meg to feel conflicted about a choice that contrasted with the tenets of her church, a church that she still valued. Yet I was not surprised by her choice, knowing that individuals from religions that oppose abortion are just as likely to have an abortion as those from religions that condone abortions or have no religious affiliation at all.
I also knew that Meg had recently left detox—but a little too soon. She said she signed out against medical advice when she felt well enough to walk out.
“And how did you decide upon detox?” I queried.
Again, Meg was forthcoming. She reminded me that she stopped her alcohol intake abruptly, a few days before her scheduled procedure, as she was worried that alcohol might affect the anesthesia. Someone in the recovery room at the women’s clinic saw that her hands were shaking and suspected that her tremor was more than simple anxiety. As Meg recalled, her blood pressure was high even after the anesthesia wore off. The nurse feared that Meg would enter withdrawal, so she summarily sent Meg to the hospital—not because of complications from a legal abortion performed in a safe and sterile setting, but because of the aftermath of long-standing and unchecked alcohol overuse.
It is uncommon for healthy young individuals to go into delirium tremens (DTs)—which can cause vivid and frightening hallucinosis—but it is also uncommon for a young woman to drink as much as Meg did with impunity. Meg did not know it at the time, but women develop neurotoxic symptoms from alcohol at one-third less alcohol than men. Downing a pint of vodka each night was more than her emaciated body could endure. To look at her, one would wonder if she had “alcoholorexia”-– an unofficial, non-DSM diagnosis for weight-conscious women who save their calories for alcohol and starve themselves of food.
Over the next few weeks, Meg shared more details about her life goals and lack of goals. Meg was an “on again, off again” student who worked for a local coffee chain, putting in just enough hours to get health insurance and college tuition reimbursement. Sometimes she signed up for writing classes; at other times, she filled her schedule with painting studios. She never took enough courses in a single subject to earn credit toward a college major that would make her eligible for a degree. In many ways, Meg was the opposite of her deceased father, who had been a hard-working, highly-motivated, small-town doctor—until his drinking got out of hand. In other ways, she was strikingly similar to her father, given that they each had drinking problems.
Even though Meg knew little about the man who died when she was young, she still knew details that her hometown paper published: that he was found dead, alone, lying face-down on the floor, next to an empty bottle of booze. The article wondered if his death was accidental or intentional, since he succumbed a few days before a scheduled hearing at the medical board, where he expected to lose his medical license because of a botched procedure, presumably performed while under the influence.
Meg was unfazed by her father’s fate—or by the possibility that she inherited a genetic predisposition to alcoholism that could contribute to her own downfall as well. Data suggests that 40% to 60% of alcohol problems are inheritable, so many individuals with family histories of alcohol overuse exert extra caution. Meg was not one of those prudent people. Instead, she frequented the so-called art bars in the Village when she was not working the late shift at the coffee shop. She chose that shift because she was too hungover for the early morning shift that attracted bigger tippers on their way to work.
At the bars, Meg cavorted with itinerant artists, writers, and musicians who also devoted more time to upping their drinking than to perfecting their crafts. She envisioned herself as the next Mary Gaitskill, an author she admired who wrote short stories about the down-and-out crowd that she hung with.
Sadly, psychoeducation about the medical hazards of alcohol overuse did not dent Meg’s denial. For sure, these visions of dead babies had scared some sense into her, but then she countered with a quote from an art instructor, who said that Jackson Pollock gained fame from dripping paint on a canvas because he was too drunk to hold a brush. “So why would I expect my work to suffer?” she retorted.
When asked about alcohol’s impact on her writing style, Meg referenced Jack Kerouac, a drinker who cavorted with the Beat Generation before he died at 47 years old. Kerouac chronicled his road travels but otherwise lived with his mother. He popped Bennies to boot.
“Sure, he died young, and, yes, because of alcohol, but the world remembers him, and that’s a lot more than I could say for most sober people,” Meg said.
It was sad to see that someone who was so quick with counterpoints was also so blind to her own self-destruction. The telling moment came when Meg asked about me to comment on her abortion. She wondered if it was the abortion that made her suffer from so many nightmares. Then she asked my opinion about when life began. I suspect that she was hoping to hear medical data that countered her church’s stance, but I swiftly sidestepped that unsolvable argument.
“I’m not an expert in theology, but I do know something about embryology and the impact of alcohol on unformed fetuses.” There was no need to mention FAS or FASD or the many other manifestations of antenatal alcohol exposure1 to Meg—not at this point. Although it was impossible for me to forget.
“I also know about the medical consequences of alcohol overuse, and in women in particular.”
“Oh, you mean breast cancer?”
I was impressed because I encountered few individuals who knew that breast cancer—among many other cancers—is promoted by alcohol.
“Does that topic interest you? You seem quite knowledgeable already.” I tossed in those motivational interviewing techniques, with the hopes of making some inroads. That topic hit home for me because I lost about 1 patient a year to breast cancer that had been promoted by past alcohol use. Saddest of all was witnessing this in individuals who had stopped drinking and become sober years before, but not until after the damage was done.
Sensing Meg’s disinterest in pursuing this discussion, I took another course. “So, Meg,” I continued. “I realize that there are endless debates about when life begins, especially when it comes to making arguments for or against abortion.”
“What’s not open to debate, in my opinion, is that life ends earlier than it should when people continue to overuse alcohol,” I added. “Sadly, women bear the brunt of this uneven distribution of medical consequences, even though alcohol overuse is typically associated with men.” I have pamphlets from NIDA [the National Institute on Drug Abuse] about women and alcohol. Would you like one? Or you can look online. I can send you a link.”
I tried another sales pitch, hoping to appeal to Meg’s artistic inclinations. “Our government really did a good job with the graphics on the NIDA website. I think you would like them.” And that was the truth.
Having said my piece, I stepped off my soapbox, waiting to hear Meg’s response. Meg responded with a blank stare, neither agreeing nor disagreeing. The fear that was in her eyes at the first visit had been replaced by a dissolute look of indifference. Still, I hoped that something I said made sense.
In my mind, it would have been tragic to turn this discussion into a political or religious debate when the most important matter at hand was protecting Meg from premature loss of her own life because of her longstanding alcohol use. Her OB had already broken barriers by convincing her to see a psychiatrist and examine the causes and consequences of her behavior. Even though Meg refused Alcoholics Anonymous, there are still ways to acquire habits that lessen the likelihood of alcohol overuse.
I felt confident that offering treatments that could decrease Meg’s alcohol cravings, rather than rebuking her for choices she made in the past, was the best way to prolong Meg’s life. If that is not a topic that everyone can agree on, then what is? Still, I wonder how many opportunities to educate patients about avoiding alcohol misuse are missed simply because people get caught up in polemics on politics.
Dr Packer is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai in New York, New York.
1. Packer S. Jessica Jones, women, and alcohol use disorders. In Eds. Rayborn T, Keyes A. Jessica Jones, Scarred Superhero: Essays on Gender, Trauma, and Addiction in the Netflix Series. McFarland & Company, Inc., Publishers; 2018.