Today’s blog is brought to you in honour of Stoptober and my six month soberversary (happy coincidence). The drink in the picture is a juniper cordial mixed with tonic and lemon with a sprig of lavender. If you don’t feel like reading the whole blog but would like some useful resources – they’re at the bottom of the page; feel free to skip ahead to the good stuff but I will be hiding some helpful documents in hyperlinks in the text as well. As a general resource that’s readable and pretty consistent with the evidence www.drinkaware.co.uk is a good website to signpost people to, with the hesitation that they promote moderation rather than abstinence and that might be unhelpful for some. My top book recommendation is In the Realm of Hungry Ghosts by Gabor Mate.
Talking about an evidence base, and evidence-based practice in the area of alcohol feels ridiculous. This is not an area where any of us want to hear facts.
This blog will probably feel challenging for some of you. This is a very personal topic and this is just my take on it – I’d love to hear other perspectives (there’s space for guest blogs on here if you want to write one!). Please read it in the spirit that it’s intended – that of gentle and curious care. I have described significant parts of my own experience instead of using generic examples or examples from clinical practice because I want to be clear that I’m in absolutely no position to judge anyone for their alcohol use. You know that old guideline that most people will only report half of their alcohol use to a health professional? I’ve done that – lied flat out to my practice nurse when I went for a check-up. This blog is the expression of some hard-learned lessons that are intertwined with nine years in IAPT, and I want to draw on that to offer something that might be useful for anyone who has got depression and/or anxiety who also uses any amount of alcohol, and for the people working alongside them.
Gray areas?
Fun fact: the first time I walked up to a bar and ordered a bottle of wine with only one wineglass was while I was in my IAPT training year. Every week eight of us went from the Low intensity training course at the University to a bar that sold cocktails in fishbowls (I avoided the cocktails, my usual went from a big glass to a bottle of merlot over the year); we got hammered while we swapped horror stories about the week and the course. It genuinely felt like the only way to cope. On the last night of the course we did our usual trip to the bar and then carried on, three of us were still drunk and dancing to Lady GaGa’s The Edge of Glory (‘I’m on the edge’ really spoke to us as a lyric) at 3AM the next day. Even now, on a Monday there are always at least four hungover people in the office; there’s a running joke that is actually a shared understanding that everyone drinks to cope with the work that we do.
The relationship between IAPT and alcohol is fundamental and dysfunctional. Our patients are badly affected; It’s another one of those grey areas where we just don’t seem to be able to draw any clear lines. How much is too much? When do we have to say that IAPT can’t treat the depression because of the alcohol use? It’s been asked in my service recently and six managers and three clinical leads couldn’t come up with a firm answer. At the LI special event at the BABCP conference this year one of the presenters said, ‘stick to the evidence base or the wheels fall off.’ Which is blunt but correct; yet in this area we seem to really struggle to adopt evidence into practice, and that’s not surprising when you think about how pervasive and emotive alcohol is in British culture.
Talking about an evidence base, and evidence-based practice in the area of alcohol feels ridiculous. This is not an area where any of us want to hear facts. Alcohol is so deeply entrenched in our national identity, our adolescent experiences, what we observed as children and how we cope as adults that I haven’t met anyone who’s rational about it. But let’s have a crack at some facts anyway.
In 2016 the Chief Medical Officers in the UK released new guidelines on what constituted ‘lower risk’ drinking. The guidelines were clear that there is no ‘safe’ alcohol use; in any amount it does affect our health and increase the risk of several rather nasty health conditions. These guidelines were released after a thorough review of the research into alcohol use and its effects that took account of learning from all over the world. Most people know that ‘lower risk’ drinking was defined as 14 units a week (that’s about 6 pints of beer, a bottle and a half of wine or 14 single shots of spirits), with several alcohol free days every week, and no binges.
How much is too much? When do we have to say that IAPT can’t treat the depression because of the alcohol use? It’s been asked in my service recently and six managers and three clinical leads couldn’t come up with a firm answer.
There was a public consultation before the guidelines were released; people who participated were informed of the methodology that had informed the guidelines and that the science was as good as it’s possible for science to be (my paraphrase); they were instructed not to comment on the science or the evidence base that underpinned the recommendations, that wasn’t in doubt. Even then there were a significant number of comments that ‘objected to the guidelines overall’. That’s a head-desk moment guys.
At least one study ranks alcohol as equally harmful as heroine and crack cocaine to the user and society, and more harmful than cannabis. None of us want to hear this; drinking is British, all of our very admirable (hem hem) politicians keep reminding us of that. We’re saturated from birth with pro-booze messages, talking about reducing or stopping it’s use feels transgressive, profoundly counter-cultural and, frankly, like I’m painting a target on my forehead.
IAPT was created as a vehicle to deliver NICE recommended treatment for depression and anxiety, for many people in England we are the only place where they can go when they want talking therapy for depression and anxiety and that’s a heavy responsibility. We can’t safely and ethically treat addiction of any kind in IAPT with our current set up (although I’m pretty sure I know a couple of ex-substance misuse people who have a go) but we have to keep it in mind as part of person centered, holistic working, it can’t be ignored.
In my experience of my OH’s depression, it was the opposite. Alcohol was totally brushed off as a possible cause/ exacerbator of the condition! And I’ve heard similar from many other people. Sorry that’s purely anecdotal but it would be great to mention this aspect too
New and Wild, a Soberista (with permission)
We know that a lot of people drink when they get depressed or are anxious; of course they do, alcohol is promoted as happy juice in billions of pounds worth of advertising that we can’t escape from. So, many of the people who come to us for help were depressed before their drinking exceeded the guideline amounts. Shouldn’t we treat the depression in order for the drinking to stop? That’s what we’re usually asked to do. Frustratingly you’ll get a different answer from every team, but NICE seems to be suggesting that we shouldn’t.
The NICE guide ‘Interventions for harmful drinking and alcohol dependence’ says that ‘For people who misuse alcohol and have comorbid depression or anxiety disorders, treat the alcohol misuse first as this may lead to significant improvement in the depression and anxiety. If depression or anxiety continues after 3 to 4 weeks of abstinence from alcohol, assess the depression or anxiety and consider referral and treatment in line with the relevant NICE guideline for the particular disorder.’ (p.6). What I can’t find anywhere is a firm definition of ‘misuse’ or even ‘dependence’. I find it helpful to think of alcohol dependence as a scale. If you drink regularly, if you drink enough to have a hangover, you’re probably on the scale somewhere, just because of the chemical nature of alcohol and how it interacts with the human body.
There is a positive practice guide for IAPT services working with people who use drugs and alcohol; unfortunately a lot of the recommendations it makes demand time that LITs just don’t have. The guide does stress ‘the value of timely and co-ordinated responses to enabling people to access the services they require’. Which means that we’re back to integration with other services. IAPT teams and local alcohol services have got to talk to each other and create seamless processes for people to move between them for any of this to work.
There are problems with integration. Most alcohol teams are stretched to their limits with people who are drinking at crisis levels, IAPT patients who are still working and maintaining relationships aren’t on their radar most of the time, and a lot of their group based interventions might feel alienating to someone who is functioning well.
The way that we do things at the moment is a terrible and frustrating trap for people who need help, and the people who are trying to provide a service to them. A lot of the time a decision comes down to the individuals in a room and their spidey senses, or intuition, and the power dynamics, histories and personal experience that are in the room with them.
Think about the 25 year old (or 35 year old, or 55, it doesn’t matter really, but statistically more likely to be 20 something) LIT who’s sitting in a clinical room, plagued by memories of what they might or might not have done while drunk over the weekend, waiting for the text that will reassure them that they didn’t do anything irreparable. It’s two days after their last binge, but they’ve had a couple of glasses in the evening on Saturday and Sunday. They’re not sleeping well, and the carb cravings are strong. They do an assessment of a well presented and highly educated middle-aged woman who works full time and co-ordinates her three teenaged children’s activities and has an active social life with her husband. The patient has got symptoms of GAD and depression. When the LIT asks how she copes she laughs and makes an offhand comment about her glass of wine in the evening. On further questioning the ‘glass’ turns out to be at least 500ml of sauvignon blanc a day.
First of all, the LIT compares what the woman is describing with what they and their friends drink and doesn’t really think the lady has got a problem. But the LIT is aware of guidelines so has the conversation anyway. Is that LIT seriously going to tell that woman to come back after a month without the one thing that she’s relying on to keep her going? Probably not.
If the LIT does some brief education about the effect of alcohol on depression and anxiety and suggests talking to the alcohol team for support if she can’t reduce her drinking, that lady gets very angry; she isn’t an alcoholic but thinks that is what the LIT is implying. She isn’t going to come back for a second appointment after that, she feels threatened and rejected. She wont get help with her drinking either, unless she gets caught with a morning-after blood alcohol level over the limit while she’s doing the school run.
The problem is – well, you remember that precious alliance I wrote about? The rapport and trust between a LIT and their patient that makes it possible to carry on with treatment; that goes away as soon as you start to talk to someone about drinking less.
Them and us
I think back over my years as a low intensity therapist and cringe for many reasons. I’ve made loads of mistakes. One of the big ones was refusing to accept that my personal journey with alcohol was impacting on the care and advice that I provided to my patients. I convinced myself that when I was in the room with a patient I was a professional, I was ‘us’ and I worked within my competencies and the patient was ‘them’ and their experience did not relate to mine. For many years I drank a lot but within “social norms”. I have had a lot of conversations with people who described alcohol use well over the recommended limits but I would compare that to my own and my friend’s and colleagues use and think ‘I had more than that last week and I’m fine…’ so it wouldn’t properly inform my decision making.
We know that a lot of people drink when they get depressed or are anxious; alcohol is promoted as happy juice in billions of pounds worth of advertising
The other thing for us to keep in mind is that it is hard for someone who is functioning but who wants to change their drinking behaviour to get support. Drawing on my own experience now – I went to an alcohol team when I couldn’t manage more than a couple of weeks without a drink, just like I had advised many of my patients to do over the years. I described alcohol use that was well over the lower risk limits and expressed distress at my lack of control over how much I was using. The nurse looked at me and said ‘lots of people drink more than that and don’t feel like they’ve got a problem, what makes you think you’ve got a problem?’
Can you imagine being the person who goes to IAPT for help with depression. IAPT tell you that you need to stop drinking for three to four weeks before they can do anything. You try to stop drinking but find it harder than you expected so you do what the IAPT worker told you and call the alcohol team. Their reaction is to tell you that you haven’t got a problem. Where do you go then?
Shame and the alcoholic …
Why does everyone react in horror when they hear a suggestion that they might have to reduce how much they drink? It’s because 1) they like a drink, they believe strongly that it adds pleasure and relaxation and social connection into their life and 2) because the suggestion that you are drinking too much sounds like an accusation that you’re an alcoholic.
Alcoholic is a loaded word isn’t it? It feels very labelling, very blaming, deeply shaming? It speaks to character, inner strength and resources, willpower, morality. If someone called me an alcoholic I would feel shame, and shame is one of the big reasons why people drink in the first place, so there’s another self-perpetuating nightmare. The label of alcoholic implies that you are different (in a bad way), you are broken, unable to drink “normally”. Who and what you are is spoiling the fun for everyone else.
Honestly, I think the concept of the alcoholic is unhelpful. The science tells us that alcohol is an addictive substance. Once you’ve had some you will want more. Once you’ve drunk some you will need more to get the same effect. Having a predictable chemical reaction to a socially celebrated substance is not a personality flaw and we have to be so careful with the language we use and the unconscious beliefs that it implies.
Because we don’t widely acknowledge the addictive nature of the substance that we consume we tell ourselves that we ‘should’ be able to control it easily – but that isn’t a realistic expectation and we’re setting ourselves up to fail. Most people don’t realise how hard it will be to control their drinking behaviour until they try to reduce and find that they can’t. When our drinking creeps up for whatever reason we blame ourselves for being weak, for failing. It feels isolating and like something that should be kept secret – which increases the isolation and shame.
Having a predictable chemical reaction to a socially celebrated substance is not a personality flaw
The AA philosophy and programme has produced a lot of change and has been very helpful for a lot of people. But there are others for whom the idea that there is something fundamentally alcoholic about who we are is deeply shaming and unhelpful. If the only option was AA I would probably still be drinking. I started working the steps once, the first few were very helpful but then I got to the moral inventory and wrote to my counsellor – ‘I’m already constantly self-critical, I’ve felt ashamed since I was a child. It doesn’t feel safe to examine myself and look for flaws, I need to do less of that, not more.’ It isn’t the right approach for everyone, please educate yourself about the content before you signpost someone to any recovery programme.
…Or the sober revolution
We have got an alternative to AA now, or something that you can engage with alongside the 12 step programme, it doesn’t have to be either/or. The amazing sober revolution has been booming recently. This movement is based on the idea that alcohol dependence is not the result of a fundamental flaw in who you are, and that in living an alcohol free (AF) life you don’t lose anything that was worth having. It’s the idea that when alcohol stops occupying space in your life other things can grow. This blog is a by-product of my AF journey and support from the amazing community at www.soberistas.com; I wouldn’t have written any of this while I was drinking, let alone set up a website to host it.
You just never know
As astonishing and life affirming as the AF journey has been, it comes with cautions for the LIT. Just like our drinking can sway clinical decision making, so can engagement with the sober revolution. To get to the point of not picking up a bottle of wine with your M&S meal deal on the way home from work (I’m a middle aged divorcee single parent, don’t judge my dinner choices!) you have to re-educate yourself out of the pro-booze brain washing. You basically have to brainwash yourself the other way, and that spills over.
A few months ago I worked with a patient who drank to manage chronic pain. They were severely depressed but motivated to engage with behavioural activation. We had the chat about the effect of 6 cans of beer every night on depression and they agreed to reduce while we were working together. At the time I was deep in the throes of my re-education and really emphasised that it was important to cut alcohol out altogether for a few weeks at least. I got a way with it without scaring them off because they had independently decided that they wanted to reduce their alcohol use before they saw me. After four sessions I stepped them to a CBT therapist. I caught up with the CBT therapist for an update last week.
The CBT therapist reported that the patient had done very well and had moved to recovery on the measures for depression and anxiety. Our chat went something like this:
Me: Amazing, I’m so glad. What worked in the end?
CBT: Going shopping for beer.
Me: Jaw dropped
Me: I thought they were trying to stop drinking?
CBT: Well, when I said they didn’t have to stop just reduce they were a lot happier. They walked to the shop every day for two cans and just drank that. The walking did a lot of good.
So that’s my take on alcohol in IAPT. It’s a big subject and another one where we could do with getting our act together. I hope there’s something useful in there, do let me know what you think in the comments on here, on Twitter @notapwpguru or Facebook. I’ll include a list of resources that the users on www.soberistas.com recommend below.
Podcasts
- LoveSober
- Soberful
- The Bubble Hour
Books
- This Naked Mind Annie Grace
- Alcohol Explained William Porter
- The Sober Diaries by Claire Pooley
- Mrs D is Going Without by Lotta Dan
- Glass Half Full: a positive journey to living alcohol free by Lucy Rocca (founder of Soberistas)
- The Unexpected Joy of being Sober by Catherine Gray
- In the Realm of Hungry Ghosts by Gabor Mate
Websites
Thanks to Sonic for these
UK based healthcare professionals they can sign up to the Royal College of General Practice ( RCGP) and complete RCGP Certificate in the Management of Alcohol Problems in Primary Care. https://elearning.rcgp.org.uk/course/info.php?id=119The programme addresses co-occurring conditions which is mostly addressing mental health and substances correctly
https://alcoholchange.org.uk/. Think this is really good for people in the Uk. It helps professionals and the general public. The charity lead the campaign for Alcohol Awareness week and lists events etc.
Thetemper.com Is a spin off from hip sobriety but on the site lists a huge range of online communities and has its own sobriety school.
Smartrecovery.org.uk. A fab mutual aid group which doesn’t follow the 12 steps but is focused around key tools and based on cognitive behavioural theories
Not a Low Intensity Guru 
It’s such a tricky problem with a legal drug such as alcohol. I think you do a great outline of the issues and challenges, many if which are predicated on our own biases. I would really hope to see better guidelines and awareness around this topic for all health professionals in the future. Thanks for this!
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