Alcohol as Anti-Depressant: How to Break the Cycle
What actually takes place in addiction treatment? In the second of a three-part series, Dr. Tom Horvath shows cognitive therapy for a dual depression/drinking problem in action.
Heavy drinkers who use alcohol to “drown their sorrows” face a dilemma: Alcohol, a depressant, makes you feel worse in the long run, but it is often the most effective anti-depressant “in the moment.” It can be a quick fix, with its desired effects lasting several hours. Only later does the depressant effect kick in. And then the cycle starts over again if you keep on drinking to soothe your soul. In short, using alcohol as an anti-depressant is a process of “taking one step forward, then two steps back.”
Heavy drinkers often struggle with depression, and vice versa. Nearly one-third of people with major depression also have an alcohol problem, according to the National Institute on Alcohol Abuse and Alcoholism. A “heavy drinker” is, in my view, everything from alcohol dependence (alcoholism) and alcohol abuse to binge or at-risk drinking.
When you work with a client who is dealing with these dual problems, one of the trickiest challenges is figuring out how to address their "anti-depressant" drinking at the right time and in the right way.
If you push them to abstain or reduce their drinking before they are ready or in a way that is too confrontational, they may feel threatened and end treatment or they may comply temporarily in order to please you but not make lasting change. Both the severity of the drinking and the severity of the depression are major considerations. In severe cases of one or both, admission to a psychiatric hospital or rehab may be required.
Many therapists feel safest insisting on abstinence. If you don't insist, and the patient has a DUI or other problem, is the therapist responsible? I discuss this issue directly with clients, and so far no client has suggested that I am. But if you think someone loses control the moment a sip of alcohol crosses their lips, then you need to figure out if they are a "real alcoholic"; if so, advise them to abstain. In my experience, this instant loss of control rarely fits the facts.
The goal to control their drinking must be one they embrace fully—not because they “have to” but because they “want to” and “need to.” I have found that many people are capable of getting there only when they believe that there is another way to cope with their depression. Often, by beginning treatment by focusing on the depression, progress can be made.
In the following case example, “Evelyn” (a composite of several clients I have worked with) has mild clinical depression and alcohol dependence that is serious but not yet severe. A widow, Evelyn had been very depressed since her husband died five years earlier but had managed to hide the depression from everyone, including her daughter. She was not as effective at hiding the drinking. (In our first session she told me that she was not on anti-depressant medications: “I’ve tried them all—they don’t work for me.”)
Dr. Horvath: You’ve been depressed for a long time and feeling nearly hopeless. I’m pleased that you’re willing to give therapy a chance.
Evelyn: I felt a little better after my first session. It seemed like you understood me and how bad my life is. So I decided to come back. But I lied about one thing. Last week, I told you I only drink one or two glasses of wine every few nights. Actually I drink every night, a lot. Every time I see a shrink—and I’ve seen quite a few—they insist I quit drinking or they won’t see me anymore. Are you going to do that, too?
Dr. Horvath: You don’t want me to treat you like the others did.
Evelyn: No. I want you to understand that alcohol is the only way I have to feel better.
Dr. Horvath: You don’t have much hope in any other solution to your depression.
Evelyn: I want to think that the depression could get better. I’ve been reading about cognitive therapy for depression. Maybe it would work for me. But I don’t want to give up drinking before I get out of the depression. It would be too painful.
Dr. Horvath: You don’t want me to insist on your stopping the only thing that works for you.
Evelyn: Right. Are you willing to do that?
Dr. Horvath: How we work together is up to both of us. I’m not trying to control you. But I do have some concerns about your drinking. May I ask a few questions?
One of the trickiest challenges is figuring out how to address a depressed client's "anti-depressant" drinking at the right time and in the right way.
I gathered additional information. I concluded that Evelyn did not present urgent concerns such as drinking and driving, or drinking to the point of passing out. She visited her doctor regularly, who knew about her drinking, but not the full picture. I encouraged her to be more forthcoming with her doctor. Evelyn was not interested in any alcohol treatment outside of her individual sessions with me.
Dr. Horvath: You understand that by continuing to drink you may slow down recovery from depression and possibly prevent that recovery?
Evelyn: I don’t see how I could do it any other way.
Dr. Horvath: How about we move forward with cognitive therapy. Would you be willing to keep a daily record of drinking, as well as work on the daily projects we’ll be doing for depression?
In about six weeks, Evelyn was feeling slightly better. As is the goal in cognitive therapy, she could identify her negative thinking patterns and challenge them with some success. Her life involved more activities that brought her pleasure or a sense of accomplishment. For instance, she was taking daily walks and socializing more.
I was able to persuade her to delay her drinking until later in the evening so that she could renew some friendships with phone calls made in the early evening. Nevertheless, the amount of her drinking, as revealed by her drinking logs, was unchanged.
Dr. Horvath: I’m proud of the progress you’ve made. You started this therapy as an act of faith. You didn’t really know what to expect. But you’ve worked at it, and it’s starting to pay off.
Evelyn: I actually have times I feel OK. Not great, but OK.
Dr. Horvath: I have a suggestion: Would you consider cutting back by one drink each day?
Evelyn: I knew you were going to do this!
Dr. Horvath: I’m glad you understand me so well!
Evelyn: OK, OK. I’ll do it.
Dr. Horvath: How about if I call you tonight to help make the first night a success? What time would be good?
In order to make the drinking reduction work, a significant amount of session time was spent teaching Evelyn the three crucial facts about craving: It is time limited, does not harm you and does not force you to drink. Once she had tested and understood these ideas, she was ready to wait out cravings until they went away.
One month later, Evelyn’s mood was nearly normal, but her drinking was still well above "moderate" guidelines (no more than three drinks a day for a woman). At six months, there was further improvement in both her mood and her drinking. At one year, her depression was resolved and her drinking was moderate. We cut back to meeting once every three months.
Evelyn now understood how the untimely death of her husband had revived her old belief that she couldn’t be successful in the world without a man to lean on. After many sessions and much between-session activity on her part, she came to realize that she was a competent woman who could take of herself, without a man and without alcohol.
Dr. Horvath: Thanks for catching me up on the exciting things that are happening in your life. Do you realize it has been one year and three months since we started? And everything is going well!
Evelyn: Thanks. I never really believed a good life, on my own, was possible for me. Now I see that it is.
Dr. Horvath: What were the turning points for you in our work together?
Evelyn: At first it was your willingness not to insist that I quit drinking right away. You accepted my belief that alcohol worked for me. Then you gradually taught me how to cope with depression, and finally to see that without a man I couldn’t make it in the world. I think that was the hardest part—all the experiments we did to provide evidence that I could do things on my own.
Remember that time I didn’t want to call the dryer repairman, and kept hanging the clothes out all around the house to dry? Then I finally did call, and it worked out OK. I will never forget our role-plays, where you played one type of obnoxious repairman after another, until I felt confident I could handle any of them. After that, cutting down on drinking wasn’t that hard. I had a meaningful life to live, and alcohol was getting in the way.
Dr. Horvath: I’m proud of you! I look forward to seeing you again in three months. When we get together again, how about we talk about your smoking?
A case like Evelyn's could have gone on almost indefinitely if the client had not been able to move forward at key points, such as postponing drinking in the evening, cutting out one drink per day, or working through her thought records about depression. But she kept making progress. By empowering her to make her own decisions about her treatment, we took a major step toward empowering her about her entire recovery. Along the way she learned a number of specific skills that she can employ for the rest of her life, including recognizing and responding rationally to irrational thoughts, being assertive and coping with cravings to drink.
A. Tom Horvath, PhD, ABPP, is the founder and president of Practical Recovery in San Diego, CA, a self-empowering addiction treatment system including sober living, outpatient services and two residential treatment facilities for alcohol and drug abuse. He is also the president of SMART Recovery, an international nonprofit offering free, self-empowering, science-based, mutual-help groups for addiction recovery. A past president of the Society of Addiction Psychology (Division 50 of the American Psychological Association), he is the author of Sex, Drugs, Gambling & Chocolate: A Workbook for Overcoming Addictions.