Navigating the Intersection of Work and Mental Health

Working Better and Stressing Less

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Posts tagged alcoholism
Reducing suffering without reducing anxiety - WHAT!?

I specialize in treating anxiety and so it might be disconcerting for you to read that reducing my clients' anxiety is one of my least important treatment goals. Hear me out though please... 

The American Psychological Association defines anxiety as, " emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure. People with anxiety disorders usually have recurring intrusive thoughts or concerns. They may avoid certain situations out of worry. They may also have physical symptoms such as sweating, trembling, dizziness or a rapid heartbeat."

The problem with "treating anxiety" is that it doesn't respond well to us going straight after it. This is why so many extremely competent, smart, functional people end up in therapy offices after failing to fix their own anxiety. Anxiety is a monster fed by many factors, one of them being attention, and so the more direct attention we put on getting rid of it, the biggest and stronger it becomes. So rather than focusing on anxiety reduction, I focus on reducing the total suffering of the client at hand. Most clients have the following types of suffering:

1. Primary symptoms - In the case of anxiety, this may be physiological arousal, worrisome thoughts, and irritability. 

2. Coping mechanisms - It takes energy to cope with anxiety and anything that takes energy away from other things in our lives is stealing from us or making us suffer. Coping mechanisms become their own type of suffering. 

3. Fear of it getting worse - In all psychological disorders and especially in anxiety, sufferers fear symptoms getting worse or feeling forced to use maladaptive coping mechanisms (alcohol, drugs, self-harm, etc.)

4. Shame around the coping mechanisms, symptoms, and fear of worsening. Almost everyone with psychological suffering feels bad that they feel bad. They feel bad about what their symptoms have done to their relationships, jobs, or hobbies. They feel shame that they have turned to harmful coping strategies when the pain gets to be too much. 

The problems with targeting only the first of these four factors are that first, anxiety itself is slippery. And second, the anxiety itself often comprises a minority of total suffering patients experience. So, I go backwards. 

Let me explain using a couple of hypothetical patients that I created to represent typical courses I've observed in my practice. In the graph below, this hypothetical patient started with a total suffering level of 100. In this course of treatment, we targeted their shame around anxiety symptoms and coping mechanisms and did a bit of work on their fear of symptoms returning or having to use maladaptive coping mechanisms. We never targeted their anxiety or coping mechanisms themselves. The result was still a huge reduction in suffering - from 100 to 50. 

More typically, a course of treatment does eventually influence actual anxiety or depression symptoms and not just the ancillary shame and fear. In the graph below, this hypothetical patient and I worked on shame and fear around anxiety symptoms and coping mechanisms. Because those were a big source of their worry and anxiety, they experienced actual reduction in worry and physical anxiety symptoms.

Does this mean we don't ever work with anxiety directly? Of course not! I teach relaxation techniques, meditation and mindfulness, some simple yoga practices, and other skills to help clients work more skillfully with their anxiety. The problem is that none of the four factors above will EVER get to zero. No one walking on this earth has zero anxiety, zero coping stress, zero concern about getting "sicker," or zero shame. So if I don't teach my clients how to manage the cycle of anxiety, coping, concern, and shame and only treat their anxiety symptoms, they will eventually get worse again.  

Once clients let go of shame and begin practicing the cultivation of compassion for themselves, they feel less bad about their coping strategies, release worry about getting worse, stop needing as many coping strategies to get through the day, and have less anxiety overall. More importantly, they have a system to continue practicing throughout their lives so that after therapy is over and over time, they keep working to increase compassion and reduce shame and suffering. 

Therapists don't take you to the end - we just help you get started on the journey. 

A few of our favorite books on shame, self-compassion, and anxiety

Drinking too much: When is it really a problem?

Today at the grocery store, I found myself staring at a shelf of rosé, wondering what chilled wine goes with broccoli beef. The sommelier suggested a couple that were very interesting to him and another that, "is perfect for drinking out of mason jars at the beach when you are there finishing a bottle by yourself..." I chuckled but realized that he was serious. He had a wine recommendation for binge drinking. 

This encounter reminded me of a challenge that counselors often face in working with our clients. We know that many of our perfectly functional, quite healthy, generally low-risk clients drink more alcohol than medical guidelines consider moderate. In fact, success and affluence, things we often associate with lower psychological and medical risk, are associated with increased drinking.  Counselors know that we should discuss excessive drinking and its causes in therapy. However, we often feel afraid our client is going to hear, "I think you are a serious alcoholic," and consider us alarmist or worse, shame themselves for being irresponsible drinkers. At best, a client confronted with more than moderate drinking could think, "how can it be a problem when the wine guy has a recommendation for drinking in quantity?" At worst, they may think, "I have a serious problem and am at serious risk. I'm an awful and irresponsible person." So how do we ride that fine line of educating clients about medical risks without shaming them or without disrespecting their lifestyle choices? 

The first hurdle is bringing up alcohol use as a topic of conversation in therapy. Sometimes this is easier to do on paper for both the client and therapist. Intake forms provide a nice impersonal way of sharing this information. The truth is that I get anxious about asking this question in session because of the alarmist/shame responses referenced above. I often approach it like, "Sometimes I can learn more about someone's anxiety or depression by learning more about how they react to alcohol and caffeine. Could we talk about your alcohol and caffeine intake for a bit?" I also think it's fun to hear about clients' favorite coffee drinks and alcoholic drinks to learn more about their social lives. Both substances are foundational for many social relationships in our society. 

Once I know more about the client in front of me, I like to orient myself and the client to any relevant facts. The CDC defines moderate drinking as one drink a day for a woman or two for a man. The National Institute on Alcohol Abuse and Alcoholism uses the CDC guideline for moderate drinking but also notes that women who drink no more than three drinks on a single day and no more than seven in a week or men who drink no more than four drinks on a single day and no more than 14 drinks per week are low risk for having an Alcohol Use Disorder (AUD).  Internationally, there isn't complete agreement on these guidelines but based on a comparison of various countries' recommendations, no government seems to recommend more than two drinks per day, per person on average or more than four drinks in any given day. Since I practice in the US, I'm expected to use US guidelines in my practice. Here's the problem: By US standards, a majority of my clients over the course of my career have qualified as drinking too much, at least during phases of their lives. I share this fact with my clients. More people than not in my office drink more than is recommended. Not all of them have a drinking problem. 

We know that occasional and moderate drinkers seem to take on minimal extra health risk through their drinking patterns. We know that heavy drinkers seem to take on substantial extra health risks through their patterns. There is a large gray area between the guidelines for moderate drinking and the threshold at which there is clear medical and psychological harm caused by drinking more. As licensed healthcare professionals, we have to give clients a conservative definition of moderate drinking that is generally agreed upon by health authorities in our country and I tell my clients "Hey - according to the CDC, you may be taking on extra health risks by drinking more than they recommend.."

As a mental health professional, I'm most concerned about how drinking impacts mental health. I know less about medical risks and pay less attention to them than I do to the psychological risks of Alcohol Use Disorder (AUD).  If a client meets the DSM-V criteria for AUD, I will probably suggest that we discuss alcohol use, impacts on loved ones, and how to reduce harm. If I know a client is physically dependent on alcohol, I will strongly encourage them to allow me to build a team of professionals to help because of clear medical risks that I do understand (and am a little scared by). 

If a client presents to my practice drinking more than moderately but not meeting the criteria for AUD, I will generally do nothing more than remind them of the CDC guidelines and ask them to acknowledge that they understand the risks. If you and the wine guy think it's a good idea to finish a bottle of medium-priced rosé on the beach, you understand the risks, you don't meet the criteria for AUD, and you're otherwise doing fine, it's not my place to intervene. 

Good reads on a harm-reduction approach to alcohol use