The 4 L’s

There is a brief diagnostic tool that I use with many clients that are questioning if they have a problem with their use of substances.  The short answer for me has almost always been if it causes a problem when you do it, or when you don’t, then it’s a problem.  This model goes a bit deeper and can also help to shape a treatment plan and even establish some concrete goals to address early on, and later, in the therapeutic process.

Anyway, it is “The Four L’s” Liver, Lover, Livelihood and Legal.  These are four main areas that are usually affected by an individual’s use of a substance, combination of substances, behavior(s), etc.   When there are impacts in these areas related to a specific behavior, then that behavior is often the problem*.  That is not to say that there are not difficulties in these areas due to other factors such as the human condition, the economy, weather, acts of God…..

Liver, or any physical complication, is sometimes one of the easiest to diagnose.  When a man in his early 30’s who drinks heavily and frequently is diagnosed with cirrhosis, this is an obvious one.  There are more, and less, subtle symptoms to consider.  An assault, on either side of it, is frequently painful and damaging.  From personal excessive drinking experience, in the last several circumstances where I was part of an a## whipping, I provided at least 80% of the a## that got whipped.   This may also show up in more extreme cases as malnutrition, obesity and other health issues.  An intoxicated person is far more likely to be involved in a car crash, an assault, a domestic battery or any other form of violence than someone who is sober.  Think about the crazy, stupid things that people will eat just before going to sleep it off and it is no wonder that there are significant health problems.

This brings us to lover, or any interpersonal relationship, that has been negatively impacted by substance use.  Like the medical area, this may be overt such as divorce, loss of child custody, or lack of positive, pro-social connections.  Or, it may be more covert and even aggravating.  The client may not drink unless his wife nags him about his drinking, so he provokes her to nag him so that he can drink.  When a client tells me “Everybody drinks (smokes, gets high, etc.)” that tells me that his worldview is limited to those people that do what he does, effectively normalizing his level, frequency and intensity of drug or alcohol use.  If the only place where a person has fun with other people is at a bar, then not drinking is going to be a really hard sell.

Livelihood, or employment, the means of making a living are so important in our culture that in many cases it is one of the last bastions to fall to addiction.  There is so much ego and identity tied up in one’s profession that it is often held on to as a means of denial.  Just try asking someone in line at the grocery store, church, or gym “What do you do?”  Chances are that they will respond with their profession.  Most of us spend more than 25% of our week actually doing our jobs and countless hours commuting, preparing and recuperating.  Having a career is also a way of providing funding for substance abuse, while a mechanism for denial of the problems caused, or aggravated by, the use of a substance.  Losing a job is fairly easy to quantify; however, being passed over for a promotion, not being able to work in certain professions and poor performance are sometimes overlooked.  I had a client that could not pass a simple urine drug screen that would have given him a promotion along with a 75% increase in his salary, because he was unable, or unwilling, to stop smoking cannabis.  Drug problem?  You better believe it.

Legal problems are one of the areas where substance abuse problems become abundantly apparent.  Judges, as do police, probation and parole officers, have a way of bringing to someone’s attention the error of their ways.    A single, lifetime, DWI arrest could be a mistake; several probably are not.  Drug possession is almost always illegal, as is distributing medications without a prescription.  These are criminal charges; but, also consider the civil matters that are at stake with a substance use disorder.  Would the client be going through a divorce, child custody issue, dispute with a neighbor if they were not intoxicated?  This is not to imply that these circumstances are not always the result of drinking or drug use; however, if drinking or drug use is the cause, or impairs the amicable resolution of these issues, then the using is at least part, if not the only part, of the problem.

Finally, these issues intertwine and overlap, overshadowing one another.  For instance, if a person gets a DWI arrest, there is an obvious legal issue.  There will be a significant financial issue for fines, fees and lawyering.  Even a first DWI can run into the thousands of dollars.  Their job may be in peril, especially if they missed days from work due to jail or court.   Their status as an employee that represents their company may be compromised.  Some professions, such as truck drivers, physicians and pilots, have specific penalties for substance-related infractions.   The impact a night in jail has for someone’s status as a parent is incalculable.  As mature, responsible adults, we are rightfully expected to be someone who can be trusted, respected and accountable.   Not showing up for supper, a child’s ball game or other social commitment because of an arrest is inexcusable and injurious to a relationship.  Finally, jail is a bad place to be physically.  The client may find himself sleeping on the floor, either there or at home, neither of which is all that attractive or pleasant.


*Note:  I seldom like to use the work “problem.”  I prefer to use the terms situation, challenge or circumstance because I can turn one of them into a problem just by sprinkling a little dope or liquor on top of it.  Similarly, by staying sober, they can become accomplishments, trials and points of growth.


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