Mental health and alcohol use – a chicken and egg problem

During counselling psychology training, I have had the opportunity to offer interventions in a range of contexts including bereavement, Improving Access to Psychological Therapies (IAPT), voluntary, secondary care and specialist alcohol/ drug use support services. For me, placement opportunities were enriching but also illuminating; a valuable vantage point to get a sense of how different services operate. In multiple IAPT and mental health charity services, I witnessed numerous clients being refused mental health service treatment due to their alcohol use. This was both alarming and intriguing. 

Perhaps I should not have been surprised. Just a cursory internet search of IAPT exclusion criteria highlights a host of reasons why alcohol use can contravene eligibility for mental health services. These refer to instances where alcohol use is the client's primary issue, note its inhibitory psychoactive property on affect, or consider 'alcohol misuse' a barrier to treatment. Furthermore, my experiences of mental health charities have highlighted that clients are frequently considered ineligible for treatment for being too chaotic, as judged by their alcohol use. 

In IAPT Services, triage supervision serves as gatekeeping to treatment, with prospective clients frequently directed away from services to work on their 'recovery from alcohol misuse'. Are we doing a disservice to an already stigmatised and under-represented group in society? As I have contemplated where my sense of unease originates, I have thought on some of my own experiences and the comments that seem to perennially pop-up in different service contexts. Do these commonly cited concerns and exclusion criteria really help to maintain boundaried and efficacious treatments?

The very stuff of psychodynamic work

One tenet I've encountered is that people who are actively using alcohol can't fully engage with therapy, as it numbs their emotions. That can be a problem if, for example from a CBT perspective, protocols around an issue such as anxiety disorder involve monitoring subjective units of distress scores in response to exposure work.  

Yet my own observations of clients that have accessed support for their alcohol use and comorbid anxiety disorders has been that they are receptive to their changing anxiety levels over the course of treatment. Furthermore, my experience of client transference has been characterised by a full complement of affect during more relational work. 

In fact, clients' drinking behaviour itself can be seen to represent a means of clients testing the integrity of the therapeutic relationship and can evoke powerful transference and counter-transference. I have noted on occasions that clients have displayed a sort of latent aggression, keenly observing my own reaction to their confessions about increased alcohol consumption over the preceding week; a sort of acid test, to gauge if I can be trusted to tolerate their drinking, perhaps to establish whether our therapeutic relationship is worth their investment. In such examples, the clients' use of alcohol and how this is conveyed in therapy, far from being an obstruction to understanding affect and inter-personal dynamics, is the very stuff of psychodynamic work.  

A discrepancy

Furthermore, there appears to be a discrepancy between how practitioners respond to client disclosures about their prescribed psychiatric drugs, and about their use of alcohol to cope with distress. Many clients that access mental health services are prescribed a range of psychiatric drugs, including benzodiazepines, antidepressants, mood stabilisers and antipsychotics, all of which can have sedative and or emotional dampening properties. Yet I cannot imagine many prospective clients being refused psychological interventions on the grounds that their affect might be dampened by psychiatric drugs. Rather, the process of ascertaining their prescribed drug regime and its psychoactive properties is clinically relevant information to be worked with during therapeutic work, for example, allowing clients to explore their relationship with their mental health problem and psychiatric drug use. 

The parallel between prescription drug use and alcohol consumption extends into the cognitive effects that their use can imbue. Rizq and colleagues' short guide to what every psychological therapist should know about working with psychiatric drugs highlights memory impairment, poor concentration, confusion, losing track of ideas and problems staying focused as just some of the adverse cognitive effects of psychiatric drugs, which a reader could easily confuse with some of the effects associated with unmoderated alcohol use.  

Despite these parallels, there is sometimes little forbearance for prospective clients who act with transparency and disclose their relationship with alcohol use. 

I have noted that prospective clients have been refused mental health service treatment and referred to specialist addiction services, or invited to reduce their intake before engaging further with the service, when their alcohol consumption marginally exceeds that recommended by the NHS – at the time of writing 14 units per week. Whilst I appreciate the wider imperative to model wellbeing as health services and professionals, I wonder how many of our colleagues might be rendered ineligible as service users on occasions, if such a precedent was followed routinely. Given the potential role of alcohol use as a coping strategy for mental distress, this seems at odds with many other presentations that mental health service staff encounter. Framed this way for some individuals, alcohol use could be seen as a form of, albeit complex, safety behaviour – one which relieves distress in the short-term but maintains it in the long-term. My guess would be that mental health services would look radically different if safety behaviours represented grounds for exclusion from treatment. 

'Alcohol misuse' is misused

It also seems pertinent to highlight the choice of language that is so readily available when searching for exclusion criteria. The term 'alcohol misuse' is misused. Mental health services would do well to learn from the research and practices of the services they make forward referrals to. Within social care services that support people with their alcohol use, there is arguably a greater sensitivity to language use and the values and messages that this perpetuates. Trauma Informed Care is widely adopted in such services and encourages the use of language that avoids deficit-based terms (such as misuse) in favour of that which reframes alcohol use as a strength-based adaptation, a normal response to abnormal circumstances in some cases, a view that is more compatible with Compassion Focused Therapy.

Then there's the notion of what the primary issue is – a 'chicken or egg' problem, a causality dilemma. Do people drink alcohol to cope with their mental health problems, or has prolonged drinking been instrumental in the development of mental health issues? Khantzian's Self-Medication Hypothesis suggests that addictive behaviour represents an attempt to manage perceived intolerable affect. This conceptualisation of addictive behaviour in the 1980s and 1990s was a noticeable departure from pre-existing ideas that addictive behaviour was the result of peer pressure, self-destruction or the pursuit of euphoria. Khantzian argued that individuals' unique affective states were instrumental in their choice of drug use, with alcohol's psychotropic properties being highly compatible with depression, as it is effective at assuaging the defences associated with people's sense of isolation and emptiness. 

This position would imply that alcohol is secondary to the difficult emotions that people experience. There is of course a third possibility, which suggests that alcohol consumption and mental health problems have a reciprocal and compounding relationship. Drinking alcohol might represent a form of coping, which subsequently results in a form of self-stigma according to Luoma and colleagues' Reducing self-stigma in substance abuse through acceptance and commitment therapy, along with psycho-social problems, ultimately resulting in further self-medicating alcohol use. 

Undoubtedly, the relationship between alcohol use and mental health problems is complex, which makes me all the more uneasy about individuals being given a cursory refusal of mental health treatment, in favour of diverting their efforts to working on their 'primary issue', whatever that is. It seems to reflect a lack of regard for holistic care and joined up thinking. This belief is echoed by the addiction psychiatrist Michael Kelleher who (in a July 2019 special collection in The Psychologist) highlights the unnecessary and arbitrary post-detox wait times required before they are considered eligible for treatment. Kelleher recommends a transition from detox completion into treatments for anxiety and depression. Based on my own clinical experiences, I would endorse this; clients can and do make tremendous progress, when the proverbial 'chicken' and the 'egg' are used in the same sentence and programme of treatment.

Collaborative power

According to the Centre for Mental Health and Institute of Alcohol Studies (2018), people with co-occurring alcohol problems and poor mental health are prone to being turned away from support as a result of complexity. They speculate that this might be due to discriminatory entry thresholds for services, or a lack of confidence among practitioners. The Centre for Mental Health Commission for Equality published a briefingAccess to mental health support in July this year, calling for the government to create 'a new alcohol strategy which would include clear expectations about the provision of integrated help and support'.  

According to the National Institute for Clinical Excellence (NICE) Clinical Guideline 51, there is no evidence that substance misuse renders conventional psychological therapies ineffective. More recently, Buckman and colleagues, writing on the impact of alcohol use on drop-out and psychological treatment outcomes in IAPT services, demonstrated that primary mental health care services can successfully treat depression and anxiety disorders in people with comorbid alcohol problems, with higher risk drinkers having comparable treatment outcomes to non-drinkers. The study did highlight that more extreme scores on The Alcohol Use Disorders Identification Test-Consumption were associated with higher attrition from treatment, but refreshingly, the authors invite further guidance to promote client engagement rather than onward referrals. 

Surprisingly, IAPT guidance for working with people who use drugs and alcohol highlights that 'only a small proportion of drug and alcohol users will require specialist treatment services' and that people with a history of alcohol problems, 'do not pose any special challenges for IAPT services but there are often substantial clinical gains to be made in working with them'. 

So, it would seem that the pattern of treatment refusal and forward referrals that I have noted is recognised; that it is not the result of policy; nor is it the result of the evidence-base that IAPT Services embrace so tightly. This begs the question, why do some services seem to sidestep those clients whose alcohol use exceeds recommended levels, rather than offer interventions? Perhaps the offer is considered too risky, too unpredictable and too unhealthy for recovery rates.

Public Health England's 2017 guidance for commissioners and service providers sets out a comprehensive vision for the collaborative power that drug/alcohol and mental health services could yield. It unequivocally states that the 'services have a joint responsibility to work collaboratively to meet the needs of people with co-occurring conditions'. Furthermore, it recommends a 'no wrong door' approach promoting an open-door policy for individuals with co-occurring conditions among alcohol/drug and mental health services. My sense is that the alcohol/drug service door is always open whether clients have mental health issues or not, but this sentiment is not always reciprocated.

Where do we go from here?

I am keen to emphasise that I am not a policymaker, nor do I have designs to be one. But the very thing that drew me towards studying psychology two decades ago is at the heart of the issue – people. A willingness to understand people, and with a bit of luck (and or evidence), an opportunity to support people indiscriminately, much like the 'no wrong door policy' advocated by PHE.  

Where to start? Well, as a non-policymaker, I would have to defer to my professional identity for some inspiration. The problem is complex and requires a holistic approach, which could extend into a review of cultural, systemic, clinical practises.

Surely, if mental health and alcohol use support services are offering a co-ordinated response to support clients, a shared non-deficit-based language needs to be developed. Clients' alcohol use to self-medicate distress should be framed as an understandable adaptational response, not misuse that needs to be eradicated before 'they'll unlock the door'. Another suggestion would be to include alcohol unit consumption data in IAPT Executive Summaries. IAPT Services are meticulous with data and advise staff to assess client alcohol and drug use. How is this data being used? It is of course possible to record and publish how many prospective clients with above recommended alcohol consumption are treated or referred; that is, for me, a notable omission at the moment. It would, after all, be nice to see how often the door is left ajar. 

Then there is the clinical aspect of the work itself. Applied psychologists are trained to assess and formulate clinical presentations. Alcohol use should be used as important clinical information within psychological formulations. Questions of interest could include: 

How and when is alcohol being used? 

What phenomenological significance does it have to the client?

How can clients adjust their relationship with distress in the absence of alcohol?  

It is time to give people that use alcohol to cope with distress a firmer clinical grounding which utilises transparent exclusion criteria and adheres to existing recommendations. At a time in which much of society is feeling the pinch of isolation, it highlights the value of togetherness. After all, two heads (and doors) are better than one.

-       Daren Lee is in the write-up phase of a Professional Doctorate in Counselling Psychology.

Originally posted online 26 November 2020.

References 

Rizq, R., Guy, A. & Stainsby, K. (2020). A short guide to what every psychological therapist should know about working with psychiatric drugs. London: APPG for Prescribed Drug Dependence.

Khantzian, E.J. (1985). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. The American Journal of Psychiatry.

Khantzian, E.J. (2003). The self-medication hypothesis revisited: The dually diagnosed patient. Primary Psychiatry, 10(9), 47-54.

Luoma, J.B., Kohlenberg, B.S., Hayes, S.C., Bunting, K. & Rye, A.K. (2008). Reducing self-stigma in substance abuse through acceptance and commitment therapy: Model, manual development, and pilot outcomes. Addiction Research & Theory, 16(2), 149-165.

Kelleher, M. (2019, July 21). Your number one problem substance is alcohol. The Psychologist. https://thepsychologist.bps.org.uk/volume-32/july-2019/your-number-one-problem-substance-alcohol

NHS (2018) Alcohol Units – Alcohol Support. https://www.nhs.uk/live-well/alcohol-support/calculating-alcohol-units/.

Arthur E, Seymour A, Dartnall M, Beltgens P, Poole N, Smylie D, North N, Schmidt R, Urquhart C, Jasiura F. (2013). Trauma-informed practice guide. Victoria: BC Provincial Mental Health and Substance Use Planning Council. 

NICE (2007). NICE clinical guideline 51. Drug Misuse: Psychosocial Interventions. London: National Institute for Health and Clinical Excellence.

Buckman, J. E. J., Naismith, I., Saunders, R., Morrison, T., Linke, S., Leibowitz, J., & Pilling, S. (2018). The impact of alcohol use on drop-out and psychological treatment outcomes in improving access to psychological therapies services: an audit. Behavioural and cognitive psychotherapy, 46(5), 513-527.

NHS (2012). IAPT positive practice guide for working with people who use drugs and alcohol.https://www.drugwise.org.uk/wp-content/uploads/iapt-drug-and-alcohol-positive-practice-guide.pdf.

PHE. (2017). Better Care for People with Co-occurring Mental Health and Alcohol/Drug Use Conditions: A Guide for Commissioners and Service Providers.

Centre for Mental Health and Institute of Alcohol Studies (2018) Alcohol and mental health: policy and practice in England. www.centreformentalhealth.org.uk/publications/ alcohol-and-mental-health.

Centre for Mental Health Commission for Equality (July, 2020). BRIEFING 2: Access to mental health support. https://www.centreformentalhealth.org.uk/sites/default/files/2020-07/CentreforMH_CommissionBriefingTwo.pdf