"I Don’t Remember Last Semester" - Examining the Normalcy of Blacking Out On College Campuses

A Truth of College Life

College life is often associated with memorable experiences and substance experimentation. However, an alarming phenomenon has taken root on college campuses: "blacking out." Miller et al. (2018) note that 49% of college students who drink experience alcohol-induced blackouts.[1] In a society where excessive alcohol consumption has become commonplace among college students, it is crucial to explore the associated underlying influences and mental health issues, in addition to spreading support to those affected.

Understanding Blacking Out

Blacking out refers to a state of temporary amnesia triggered by excessive alcohol consumption, in which memories from experiences of heavy alcohol consumption cannot be recovered. Binge drinking (i.e., excessive drinking in short periods of time) is as prevalent as alcohol-induced blackout experiences among college students.[2] This indicates the link between college cultures of normalized, excessive drinking and frequent blackout experiences. In her memoir, “Blackout: Remembering the Things I Drank to Forget,” University of Texas alumni Sarah Hepola shares that through her research and interactions with current college students, she discovered that blacking out is now considered more casual than it once was 40 years ago, when she was attending UT.[3] In many college cultures, blacking out is often perceived as an inevitable rite of passage, trivializing its potential dangers as it is employed through peer pressure or initiations, particularly in fraternities and sororities.[4]

The National Institute on Alcohol Abuse and Alcoholism (NIAA) notes that blackouts can be separated into two categories:[5]

1. Fragmentary Blackouts - Fragmented memories from events during alcohol consumption exist, but without the ability to connect them.

2. Complete Amnesia - Memories from events during alcohol consumption cannot be recovered.

It is crucial to differentiate between occasional alcohol-related memory lapses and chronic blackouts, which might indicate underlying alcohol use disorder (AUD). Identifying these distinctions early-on can significantly impact an individual's mental well-being and prevent future difficulties with alcohol addiction. It is also important to distinguish blacking out from passing out following alcohol consumption. While “passing out” is the loss of consciousness or falling asleep from excessive drinking, “blacking out” refers to the loss of memories and the inability to create new memories while in a state of excessive alcohol consumption.[6] While a person can blackout and subsequently pass out, it’s also possible to blackout while still remaining completely awake (but unaware).

Your Brain When You Blackout

The amount of alcohol that one's body can withstand depends on blood alcohol concentrations (BACs). The NIAA reports that BACs of about 0.16 percent (about twice the legal driving limit) and above can induce blackouts.[7] However, this value can vary and become lower among:[8]

• Those who consume anti-anxiety medications 

• Those who consume common anti-inflammatories (e.g., Advil/ibuprofen)

• Those who consume alcohol more frequently (indicative of a tolerance)

Many other substances like opioids and antidepressants, in combination with alcohol, can lessen the BAC threshold as well, increasing risks related to these drugs or medications (e.g., overdose or liver failure).[9]

This excessive amount of alcohol results in the temporary block of the transfer of memories, or memory consolidation, from short-term to long-term memory storage via brain structures including the hippocampus.[10,11] Specifically, blackouts lead to anterograde amnesia: the prevention of the formation or storage of new memories.[12] Banerjee (2014) notes that alcohol’s interaction with neurons in the brain leads to the enhancement of inhibitory neurotransmitters and pathways like GABA while lowering the function of excitatory neurotransmitters like glutamate.[13] Such processes lead to heavy intoxication symptoms of poor motor function, altered reward systems, slurred speech, impulsive behavior and poor memory.

From a long-term lens, Nunes et al. (2019) found that frequent blackouts and binge drinking can lead to degenerative and functional deficit trends in the brain through hippocampal and frontal brain damage.[14] Additionally, going to sleep intoxicated shortens the REM (Rapid Eye Movement) phase of sleep [15] which Peever & Fuller (2016) found is responsible for consolidating memories and information in the brain from that day.[16] Exacerbating the issue, this loss of REM sleep may contribute to both short-term and long-term memory/cognitive issues.[17]

Mental Health Consequences 

In addition to impacting cognitive functioning, blackouts inflict significant effects on one’s emotional well-being. Miller et al. (2020) found that in heavy-drinking college students, blackouts were related to increased symptoms of depression.[18] Further, students who experience blackouts may already struggle with anxiety and depression, and abuse alcohol as a coping tool. For example, alcohol can often be employed as a social anxiety “buffer”, as alcohol alleviates behavioral inhibitions.[19] In a survey of 772 college students by White et al. (2002), increased frequencies of blackouts were associated with lower grades, increased heavy drinking and increased frequencies of high-risk behaviors like vandalism.[20] College student blackouts can also impact many aspects of a young person's life including academics, physical health, depression and anxiety risk, memory and cognition, sexual assault risk, and even suicide.[21] 

Pertaining to the college cultures that promote the normalization of blackouts, Greek Life subpopulations are of particular interest. Turrisi et al. (2006) note that these organizations are linked to heavier alcohol consumption.[22] Further, Estaban et al. (2018) found that male fraternity engagement predicted high levels of binge drinking and other drug use in young adulthood as 45% of participants experienced alcohol use disorder (AUD) by age 35.[23] These rates were significantly higher when compared to non-fraternity-associated adults.[24] Additionally, as Cara Rosenbloom in The Washington Post (2019) remarks, eating disorder rates are increased for these college subgroups, and the term “drunkorexia” (purging before excessive alcohol consumption) has arisen on campuses.[25] This phenomenon has created tendencies of heavy and high-risk drinking to replace normal eating, particularly among women struggling with body image.[26] The lack of food in one’s system when consuming alcohol makes binge drinking even more dangerous, as it increases the rate of intoxication.

Shedding the Light on Blacking Out

Due to societal stigmas surrounding mental health, many students hesitate to seek help or support. Wombacher et al. (2019) add that most college students rationalize frequently blacking out while completely acknowledging that the habits are unhealthy.[27] It is crucial to normalize help-seeking behavior and offer accessible resources to those facing alcohol-related issues and potential mental health concerns. By promoting responsible drinking and educating students about the risks, universities can foster a safer environment conducive to positive mental health, both relevant to long and short-term life. Integrating mental health support into college curricula and readily available campus resources empowers students to address their concerns proactively.

Harm reduction approaches may target the engrained social norms on college campuses. In this way, resources may be provided to reduce high rates of negative consequences such as emergency room visits due to alcohol poisoning, anxiety and depression and dangerous behavior. Such educational approaches may spread information about:

• Substances to avoid combining with alcohol

• Ways to be mindful when partaking in alcohol consumption

• Safe sexual practices like consent

• Awareness to avoid situations of peer pressure

• Accessibility to counseling and medical care

• Bystander awareness training 

Additionally, student accessibility to forms of psychotherapy would lead to beneficial effects for students struggling with alcohol use. For example, Ehman & Gross (2019) found that Acceptance and Commitment Therapy (ACT), a modality used to focus on awareness of mental states and thoughts, in addition to Motivational Interviewing (MI), lead to reductions in alcohol consumption and less heavy drinking in college students.[28]

Blacking out might be perceived by many as an “ordinary part of college life”, but its implications on physical, mental and cognitive health require urgent attention. By raising awareness about the normalcy and consequences of blacking out, it is possible to dismantle the harmful aspects of social cultures that perpetuate this behavior. 

If one is experiencing excessive alcohol use, binge drinking, addiction, or blackouts that impair well-being and/or daily life, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Miller, M. B., Merrill, J. E., DiBello, A. M., & Carey, K. B. (2018). Distinctions in Alcohol-Induced Memory Impairment: A Mixed Methods Study of En Bloc Versus Fragmentary Blackouts. Alcoholism, clinical and experimental research, 42(10), 2000–2010. https://doi.org/10.1111/acer.13850 

2 Juergens, J. (2023, April 17). Binge Drinking. AddictionCenter. https://www.addictioncenter.com/alcohol/binge-drinking/ 

3 Walsh, K. (2015, November 25). UT Unspoken: Students Reflect on Blackout Drinking Culture. The Daily Texan. https://thedailytexan.com/2015/11/25/ut-unspoken-students-reflect-on-blackout-drinking-culture/

4 Ibid. 

5 National Institute on Alcohol Abuse and Alcoholism. (2023 February). Alcohol’s Effects on Health: Research-Based Information on Drinking and its Impact. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/interrupted-memories-alcohol-induced-blackouts

6 Ibid.

7 Ibid. 

8 Ibid.

9 National Institute on Alcohol Abuse and Alcoholism. (2022, May 6). The Healthcare Professional’s Core Resource on Alcohol: Alcohol-Medication Interactions. https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/alcohol-medication-interactions-potentially-dangerous-mixes#:~:text=Nonsteroidal%20anti%2Dinflammatory%20drugs%20(NSAIDs,alcohol%20significantly%20increases%20the%20risk. 

10 Wetherill, R. R., & Fromme, K. (2016). Alcohol-Induced Blackouts: A Review of Recent Clinical Research with Practical Implications and Recommendations for Future Studies. Alcoholism, clinical and experimental research, 40(5), 922–935. https://doi.org/10.1111/acer.13051 

11 National Institute on Alcohol Abuse and Alcoholism

12 American Addiction Centers. (2023, July 12). Blackout Drunk: Signs, Causes, and Dangers of Blackout Drinking. https://americanaddictioncenters.org/alcoholism-treatment/blackout 

13 Banerjee N. (2014). Neurotransmitters in alcoholism: A review of neurobiological and genetic studies. Indian journal of human genetics, 20(1), 20–31. https://doi.org/10.4103/0971-6866.132750

14 Nunes, P. T., Kipp, B. T., Reitz, N. L., & Savage, L. M. (2019). Aging with alcohol-related brain damage: Critical brain circuits associated with cognitive dysfunction. International review of neurobiology, 148, 101–168. https://doi.org/10.1016/bs.irn.2019.09.002

15 Brower K. J. (2001). Alcohol's effects on sleep in alcoholics. Alcohol research & health : the journal of the National Institute on Alcohol Abuse and Alcoholism, 25(2), 110–125.

16 Peever, J., & Fuller, P. M. (2016). Neuroscience: A Distributed Neural Network Controls REM Sleep. Current biology : CB, 26(1), R34–R35. https://doi.org/10.1016/j.cub.2015.11.011

17 Brower (2001)

18 Miller, M. B., DiBello, A. M., Merrill, J. E., Neighbors, C., & Carey, K. B. (2020). The role of alcohol-induced blackouts in symptoms of depression among young adults. Drug and alcohol dependence, 211, 108027. https://doi.org/10.1016/j.drugalcdep.2020.108027 

19 Locco, A. (2021, March 15). Alcohol and Blacking Out. Resurgence Behavioral Health. https://resurgencebehavioralhealth.com/blog/alcohol-blacking-out/ 

20 White, A. M., Jamieson-Drake, D. W., & Swartzwelder, H. S. (2002). Prevalence and correlates of alcohol-induced blackouts among college students: results of an e-mail survey. Journal of American college health : J of ACH, 51(3), 117–131. https://doi.org/10.1080/07448480209596339 

21 Juergens (2023)

22 Turrisi, R., Mallett, K. A., Mastroleo, N. R., & Larimer, M. E. (2006). Heavy Drinking in College Students: Who Is at Risk and What Is Being Done About It? The Journal of general psychology, 133(4), 401. https://doi.org/10.3200/GENP.133.4.401-420 

23 Esteban, S., Veliz, P., & Schulenberg, J. E. (2018). How collegiate fraternity and sorority involvement relates to substance use during young adulthood and substance use disorders in early midlife: A national longitudinal study. The Journal of adolescent health : Official publication of the Society for Adolescent Medicine, 62(3 Suppl), S35. https://doi.org/10.1016/j.jadohealth.2017.09.029

24 Ibid. 

25 Rosenbloom, C. (2019, March 11). New Concern on College Campuses: ‘Drunkorexia,’ a Combination Drinking and Eating Disorder. The Washington Post. https://www.washingtonpost.com/lifestyle/wellness/new-concern-on-college-campuses-drunkorexia-a-combination-drinking-and-eating-disorder/2019/03/08/093cf47c-4028-11e9-9361-301ffb5bd5e6_story.html 

26 Ibid.

27 Wombacher, K., Matig, J. J., Sheff, S. E., & Scott, A. M. (2019). "It Just Kind of Happens": College Students' Rationalizations for Blackout Drinking. Health communication, 34(1), 1–10. https://doi.org/10.1080/10410236.2017.1384351 

28 Ehman, A. C., & Gross, A. M. (2019). Acceptance and Commitment Therapy and Motivational Interviewing in the Treatment of Alcohol Use Disorder in a College Woman: A Case Study. Clinical Case Studies, 18(1), 36–53. https://doi.org/10.1177/1534650118804886

Alcohol & Anxiety: A Vicious Cycle

Comorbidity: Grounds for Investigation

Alcohol use and anxiety disorders are commonly comorbid, with alcoholics prone to experiencing symptoms of anxiety compared to the general population.[1] Schuckit & Hesselbrock (1994) report that 2 out of every 3 alcoholics possess the criteria to be diagnosed for another psychiatric disorder, such as anxiety.[2] There are explanations for both directions of the relationship, as people with anxiety may be using alcohol to feel better but alcohol could also lead to anxiety. In other words, anxiety disorders can cause alcohol abuse, and symptoms of anxiety are key aspects of alcohol dependence, particularly during withdrawal.[3] Although the etiology of the relationship between alcohol and anxiety is not clear, there is a link. Understanding the mechanisms behind the link between alcohol and the onset of anxiety can allow for the development of new solutions for stress and alcohol-related disorders. 

ADOLESCENTS AT RISK

Alcohol is the most commonly used drug among adolescents and this cohort is also more likely to experience alcohol abuse and dependence.[4] This is significant as adolescence is an important period in brain development during which critical regions of the brain (such as the prefrontal cortex (PFC), responsible for cognition and executive functioning) are still developing.[5] This process of brain development leaves adolescents vulnerable to psychological disorders such as anxiety, and drinking alcohol could exacerbate symptoms of anxiety and/or negatively affect brain development. 

UNDERSTANDING THE LINK

Several regions of the brain are implicated in the relationship between alcoholism and anxiety, particularly the PFC and the amygdala. The PFC relays information to the amygdala, which has important implications in pathologic behavior states.[6] The functional connectivity between the PFC and amygdala is crucial for several major psychological processes such as the regulation of emotions and stress. Hyperactivity and hyperreactivity of the amygdala are important measures of anxiety disorders. In particular, the central amygdala (CeA) is a primary component in the regulation of stress and anxiety. The CeA is the major output region in the amygdala and is part of the larger extended amygdala, a network of limbic forebrain structures, which is involved in the transition to alcohol dependence.[7] The CeA transforms emotional and sensory information into physiological and behavioral responses. Specifically, the signaling of the hormone corticotropin releasing factor (CRF) in the amygdala plays a significant role in anxiety as it is a prostress peptide, meaning it promotes anxiety-like behavior.[8,9] Injections of CRF into the amygdala lead to anxiety-like behaviors; therefore reducing levels of this hormone may alleviate anxiety.[10] Similarly, the CeA is a critical region involved in alcohol addiction and the negative reinforcement of alcohol abstinence.[11] Dysregulation of CRF signaling can therefore influence the development of alcoholism. 

Dysfunction in the amygdala is associated with both anxiety and substance abuse disorders. Acute and chronic exposure to alcohol have significant effects on synaptic transmission (signaling between neurons) in the amygdala, a key region of stress and anxiety circuitry.[12] This commonality of the involvement of the amygdala in both anxiety and alcoholism suggests a connection between the two disorders. Alcohol has been found to increase stress sensitivity from neurological changes in the amygdala.[13] For instance, CRF is a neuropeptide involved in the stress circuits that regulate anxiety associated with drug dependence. This hormone contributes to the regulation of anxiety and alcohol-related behaviors and thus plays an important role between anxiety and the neurological effects of alcohol consumption. A study by Silberman (2009) found that the release of CRF in the CeA increases in animals that are alcohol-dependent and contributes to anxiety resulting from alcohol-withdrawal.[14] This demonstrates that CRF is the mediating factor between dependence on alcohol and anxiety produced, as drinking alcohol increases the production of CRF in the amygdala, which consequently increases stress and anxiety. CRF plays a critical role in regulating negative affect and excessive alcohol drinking via the CeA.[15] Gilpen et al. (2012) found that binge drinking in dependent and non-dependent adolescent rats produces lasting neural and behavioral changes implicated in anxiety and alcohol use disorders.[16] 

IMPLICATIONS FOR SOLUTIONS

It would be beneficial for scientists to further examine the role of the amygdala in anxiety and alcohol consumption, especially in terms of seeking novel treatment options. Since anxiety is a key factor resulting from alcohol withdrawal that often leads to relapse, targeting this anxiety could prevent relapse. Pharmacologic approaches (e.g., developing drugs or medications that target CRF production) could alleviate the anxiety associated with alcohol consumption, which could help alcoholics recover rather than drinking more to alleviate anxiety; it could also prevent people from developing alcoholism by avoiding excessive drinking. Additionally, it could also prevent people from self-medicating their anxiety by consuming more alcohol. Targeting the prevention and reduction of withdrawal symptoms of alcohol consumption could be effective in treating alcoholism. 

Further, since adolescents are more vulnerable to developmental neurodegeneration (both in general but also from alcohol consumption) understanding the effects of alcohol on the brain in relation to anxiety could prevent impairments in functional brain activity and cognitive dysregulation.[17] This could benefit adolescents for the rest of their lives, as neurological changes from alcohol consumption that occur during adolescence have the potential to permanently impair their psychological abilities, thus hindering the ability to achieve their goals. 

If you or a friend/family member suspect you may have alcohol addiction, please reach out to a licensed mental health provider to discuss treatment options. 

Contributed by: Preeti Kota

Editor: Jennifer (Ghahari) Smith, Ph.D.

REFERENCES

1 Schuckit, M. & Hesselbrock, V. (1994). Alcohol dependence and Anxiety Disorders: What is the Relationship? The American Journal of Psychiatry, 151(12), 1723-1734. 

2 Ibid.

3 Gilpin, N., Herman, M., & Roberto, M. (2015). The Central Amygdala as an Integrative Hub for Anxiety and Alcohol Use Disorders. Biological Psychiatry, 77(10): 859-869. https://doi.org/10.1016/j.biopsych.2014.09.008

4 Witt, E. (2010). Research on alcohol and adolescent brain development: opportunities and future directions. Alcohol, 44(1): 119-124. https://doi.org/10.1016/j.alcohol.2009.08.011

5 Ibid.

6 Gilpin et al. (2015)

7 Ibid.

8 Ibid.

9 Silberman, Y. (2009). Neurobiological mechanisms contributing to alcohol-stress-anxiety interactions. Alcohol, 43, 509-519. doi: 10.1016/j.alcohol.2009.01.002

10 Gray, T., & Bingaman, E. (1996). The amygdala: corticotropin-releasing factor, steroids, and stress. Critical Reviews in Neurobiology, 10(2):155-68. DOI: 10.1615/critrevneurobiol.v10.i2.10

11 Silberman (2009)

12 Ibid.

13 Gilpin et al. (2015)

14 Silberman (2009)

15 Gilpin et al. (2015)

16 Gilpin, N., Karanikas, C., & Richardson, H. (2012). Adolescent Binge Drinking Leads to Changes in Alcohol Drinking, Anxiety, and Amygdalar Corticotropin Releasing Factor Cells in Adulthood in Male Rats. PLoS ONE, 7(2): e31466. doi:10.1371/journal.pone.0031466

17 Zeigler, D., Wang, C., Yoast, R., Dickinson, B., McCaffree, M., Robinowitz, C., & Sterling, M. (2005). The neurocognitive effects of alcohol on adolescents and college students. Preventive Medicine, 40(1), 23-32. https://doi.org/10.1016/j.ypmed.2004.04.044 

Examining Substance Use & Addictive Disorders: A Q&A with SAS Therapists

An Uncontrollable Use

Substance use disorder (SUD) is a mental disorder affecting one’s brain and behavior, leading to an uncontrollable use of substances such as drugs, alcohol or medications. Symptoms can range from moderate to severe, with the most severe form of SUD referred to as an addiction.[1]

The National Institutes of Health (NIH) note the prevalence of SUD among adults in the U.S.:[2]

• Nearly one-third of adults have alcohol use disorder at some time in their lives, but only about 20 percent receive treatment.

• 10 percent of adults have drug use disorder at some point in their lives, but only 25% receive treatment.

Further, nearly 6% of those aged 12+ experienced prescription psychotherapeutic drug misuse in 2020.[3]

Comorbid conditions tend to present more in those with SUD, although research has not yet found concrete causal relationships among them. Co-occurring disorders may include: anxiety disorders, depression, attention-deficit hyperactivity disorder (ADHD), bipolar disorder, personality disorders, and schizophrenia. In the event of comorbid conditions, treatment for one disorder may be compounded and more difficult, though is still achievable.[4]

Compared to those without drug use disorder, individuals experiencing drug use disorder are:[5]

• 1.3 times as likely to experience clinical depression

• 1.6 times as likely to have post-traumatic stress disorder (PTSD)

• 1.8 times as likely to have borderline personality disorder (BPD).

Generally, it is better to treat the SUD and co-occurring mental disorder together, not separately. Thus, health care providers need to conduct full evaluations and provide a treatment plan based on one’s specific situation, in regards to their: age, misused substance and comorbid mental health disorder(s).  Both Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) have been found to be effective in treating substance use disorder.[6]

Q&A

SAS THERAPISTS DISCUSS SUBSTANCE USE DISORDER AND EFFECTIVE TREATMENT MODALITIES

1. How does someone even become aware that they have a problematic substance/alcohol use disorder/addictive disorder versus simply enjoying ____ to relax/unwind on a frequent basis? How does someone know when it’s time to seek assistance?

“Awareness of alcohol or substance use disorder or an addictive disorder (e.g. gambling, shopping, etc.) often comes as a result of some unwanted consequence related to the behavior - for many people this looks like a DUI, concern expressed from a loved one, physician, employer, etc., a negative test result from the doctor, or just feeling so crappy the next day that you start to wonder if the substance is worth the pain. It could be an incredible amount of debt, being kicked out of a casino, or having your credit cards maxed out and shut off/things going to collection. People also become more aware of the behavior as problematic when they try to stop and can't seem to stick to that goal. It freaks them out. Generally speaking, if you're worried you might have a problem, there's a good chance you do!

It's also important to note that using a substance to ‘unwind on a frequent basis’ in and of itself is problematic - what happens if you don't use this substance? What do you feel? If you can't tolerate your thoughts or emotions or physical sensations without using a substance to ‘unwind,’ it might be a good time to check in with a therapist.” (Jennie Ketcham Crooks, LICSW, MSW)

“This is a question frequently asked, both by those who use substances themselves and concerned loved ones. There are some aphorisms from the recovery world I often quote when helping to answer the question, including: ‘If you have to control it, it is already out of control.’ While of course this isn’t absolute, it can be a helpful realization that even minor things like counting drinks or scheduling use (‘I only use on weekends’, etc.) are not common in actual recreational users. It can be a cue for us and friends/family that the ‘control’ is gone if we are talking about controlling, so that cue can lead to seeking assistance. It is a helpful reminder that merely seeking assistance is not admitting addiction or signing-on for lifetime abstinence. Many folks today are trying on a trend – with regard to alcohol – called ‘sober curious’ for instance, which highlights a period of sober time with an attention to what is lost and gained without the presence of a drug (including alcohol) in their lives. In all, seeking assistance or merely asking questions (Google can be our friend!) is unlikely to be harmful. The more you know, right?!” (Kate Willman, MA, LMHCA, HCA)

2. In your experience, what are the biggest obstacles that someone has to overcoming a substance/alcohol use disorder/addictive disorder? How can they best overcome those obstacles?

“A major obstacle is the way in which society normalizes the use of alcohol and marijuana in particular - we think as if we ‘should’ be able to ‘drink normally,’ and when we fail to do so, it is pretty crushing. So we try and try again, and fail and fail again. Yet, the biggest obstacle to overcome is the tolerance of uncertainty; we don't know if you'll ever use again (That is, not until you use! Then we know!). Intolerance of uncertainty may be one contributing factor to why the relapse rates are so high. If one cannot tolerate the uncertainty about when they will use again, the only way to gain certainty is to use.” (Jennie Ketcham Crooks, LICSW, MSW)  

“The first ‘big obstacle’ that comes to mind is that drugs work. That may sound a bit odd, but: it’s true! The substances themselves will always be potent, will always have a desired effect on neurotransmitters at various levels, and are likely to always be made available in one way or another. In fact, some addictive substances are even legal to obtain. Therefore – in part to account for the assurance that drugs work – the next biggest obstacle most folks must overcome is their own desires to keep using. Again, this might sound odd to an outsider, but many addicts even in long-term recovery readily admit that if they could still use successfully, they would! So a person might have every desire in the world to stop using, and they can still retain some desire to keep using. Behavioral addictions like gambling or pornography use are similar in that the process or ‘chase’ of the behavior stimulates neurotransmitters in much the same way as a substance would.

One of the best ways I’ve seen others face and overcome this obstacle is through mutual support. Whether friends, family, professionals (like a therapist), or simply peer support from other people who have struggled with substance use or behavioral addictions… most people simply cannot do it alone. Many people today have also been able to find help online, through anonymous forums, meetings and/or social media. In the end, however, only the individual will be able to decide for themselves when ‘enough is enough’.” (Kate Willman, MA, LMHCA, HCA)

3. In what ways has the pandemic affected substance/alcohol use disorder/addictive disorder (rates, types, recovery) that you personally have witnessed in practice?

“Many people use substances or alcohol to ‘feel better’ - socially, it's been a way to connect (‘let’s grab a beer!’), physiologically it depresses your system (Anxious AF? Let’s grab a beer!), and the pandemic has been a context in which many people have needed social connection and experienced increases in anxiety (germs everywhere folks).” (Jennie Ketcham Crooks, LICSW, MSW)

“The pandemic seemed to exacerbate existing problems and / or introduce new anxieties for people. Many of our best, most natural coping mechanisms were unavailable to us, including – for instance – the live support of family and friends, the release, productivity + enjoyment of the workplace, and various hobbies enjoyed both socially or alone. And all of this at a time when we needed to cope more than ever. The already easy access to legalized substances like alcohol and cannabis became even easier via delivery programs in many areas, and so some people came to rely on use as a coping mechanism in the absence of others.

The two-or-so years of pandemic saw a decrease in coping outlets coupled with an overall increase in anxiety and depression (amidst other social, economic and political stressors). To boot, many people found themselves isolated. In other words, a prime opportunity for addiction issues to flourish, and since addiction already breeds isolation, a lack of social accountability encouraged isolation in the pandemic even further.” (Kate Willman, MA, LMHCA, HCA)

4. Would any specific psychotherapeutic modality be better-suited for someone battling these disorders than others?  If yes, which would you recommend and why?

“I think that any therapy that supports a client to identify their values and take committed action in alignment with those values will help them tolerate the distress of overcoming an substance or addictive disorder. I often talk about substances/alcohol or addictive behaviors as a solution to some problem, so knowing what's important to you in this life can help increase your motivation and your distress tolerance; chances are if you've quit a substance or alcohol (or gambling or shopping), whatever problem substances or alcohol solved will still be there. Ultimately, behavioral therapy will be an important component of treating substance and addictive disorders because your behavior will be required to change.” (Jennie Ketcham Crooks, LICSW, MSW)

“There is clinical research to support all types of different modalities for treating addiction.

The first that comes to mind specifically is Dialectical Behavioral Therapy (DBT) for its focus on skills to promote and practice emotional regulation, mindfulness, and tolerance for distress.

Acceptance and Commitment Therapy (ACT) combined with harm-reduction practices also comes to mind as a frequently used treatment as it does not focus on symptom reduction as an outcome. This can aid in recovery from or re-evaluation of a person’s relationship with drugs in that it removes focus on the substances and/or behaviors themselves and instead brings focus back to the person themselves.

Several variations on psychodynamic therapy have also been seen in addiction treatment, including existential and narrative therapeutic approaches.

Finally, people struggling with addiction – both behavioral and with substances – are still people, right? And their use is just a symptom of what are much larger problems. The person-centered approach can assist in a practitioner’s ability to use the best modality when treating those with use issues while also taking into account the presence of comorbid conditions.” (Kate Willman, MA, LMHCA, HCA)

5. Do certain comorbid mental health conditions appear more prevalent than others in those with these substance/alcohol use disorders?  Do some conditions make treatment more difficult?

“We see a high comorbidity between social anxiety and alcohol use disorder, largely related to what I noted in question 3 - when we feel nervous about social engagement, it can be easy to ‘grab a beer.’ While beer makes that anxiety go away temporarily, it ends up reinforcing an unhelpful learning pattern wherein the person ‘learns’ that beer is what kept them safe in the social engagement (versus learning that social engagement - and the experience of anxiety! - is a safe activity). That learning then says, ‘I must drink beer EVERY time I engage socially.’” (Jennie Ketcham Crooks, LICSW, MSW)

“The observable correlations between mental health issues and substance abuse are many.

First, the most common mental health issues such as depression, anxiety, etc. can lead to use or abuse of substances as a form of neutralizing discomfort (sometimes colloquially known as ‘self-medicating’). We see similar patterns in those experiencing behavioral addictions. Second, substance use itself can contribute to the experience of one or more symptoms of mental health issues – including depression, anxiety, suicidal ideation, psychosis, obsessive thoughts, etc.

Even further, there is substantial evidence that neurological changes can occur as a result of substance use, depending on frequency, duration + severity of use, as well as what substances are used and at what age(s) use begins. There are often correlations between substance use and mental health symptomology that are etiologically indistinguishable, i.e.: there is often a reciprocity between mental health issues and substance use issues that can make it difficult to discern the specific dynamics between them, let alone causation or source of either or both.

This is all to say that there are many possible comorbid conditions – especially those in the mental health realm – that make treating addiction more difficult. Additionally, a holistic perspective shows us that this generally means the life of the client is more difficult, and we should do our best to help mitigate confusion or shame in these cases. There are certainly some conditions we see more often than others – anxiety, depression, chronic pain, and various forms of trauma – however, this might be less correlated to addiction and more because these are prevalent conditions anyway.” (Kate Willman, MA, LMHCA, HCA)

6. Can you give an example of how you may guide someone in therapy who wants to overcome a substance/alcohol use disorder/addictive disorder? 

“If someone is seeing me specifically for addiction, we will begin with a practice of noting - with gentle curiosity - the behaviors they'd like to question. We gather data, do some values mining, and a functional assessment: Is this behavior moving you closer to or further away from a meaningful life. Then, depending on that result, we make some changes and commit to action. After a period of treatment, and after you see the changes happening in your life, we will do a course of mindfulness-based relapse prevention.” (Jennie Ketcham Crooks, LICSW, MSW)

“I would start by assessing for co-occurring disorders and then – if they are present – do my best assess which has a higher acuity and therefore probably requires attention first (this may or may not be the use itself). I’d also assess a client via the Stages of Change model to attempt to decipher ‘how ready’ they are to stop using. For instance, if a person is in ‘precontemplation’, we wouldn’t want to start jumping into recovery strategies. Once I’ve assessed where someone is in the process, we can collaborate on options to move forward. Sometimes a client needs support, needs to experience trust and empathy before they are willing to face the big world ahead of them without their drug or behavior of choice. Therapy, thankfully, is a great place to receive these, and even if a strong desire to change isn’t first apparent, it can develop over time through an informed and cooperative relationship.” (Kate Willman, MA, LMHCA, HCA)

7. Is there anything else you’d like to share with those interested in learning more about treatment and/or may be battling substance/alcohol use disorder/addictive disorder, themselves?

“Now, more than ever, there is more information about [and less stigma surrounding] the prevalence of substance use issues and the insidious nature of the disease of addiction. For those readers who don’t, themselves, identify as struggling with either of these issues, I urge you to become informed anyway, because the likelihood that you or someone you know will at some point face one or more of these issues is essentially guaranteed.

Support, accountability, empathy, and inclusion are paramount in treating the very real (and, too often, fatal) diseases of substance abuse + mental illness. We can all help by informing ourselves and others about the perils of addiction, the resources available for recovery, the universality of mental health issues, and the reality that love and understanding are key in facing these successfully.” (Kate Willman, MA, LMHCA, HCA)

Contributed by: Jennifer (Ghahari) Smith, Ph.D.

Jennie Ketcham Crooks, LICSW, MSW & Kate Willman, MA, LMHCA, HCA

Editor: Jennifer (Ghahari) Smith, Ph.D.

For more information, click here to access an interview with Psychiatrist Lantie Jorandby on Addiction Recovery.

Additionally, you may click here to access an interview with Psychologist Robyn Walser on Trauma & Addiction.

REFERENCES

1 National Institutes of Mental Health (NIH). (n.d.) Substance use and co-occurring mental disorders. (accessed 9-20-2022) https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health#:~:text=A%20substance%20use%20disorder%20(SUD,most%20severe%20form%20of%20SUDs 

2 National Institutes of Mental Health (NIH). (n.d.) 10 percent of US adults have drug use disorder at some point in their lives. (accessed 9-21-2022) https://www.nih.gov/news-events/news-releases/10-percent-us-adults-have-drug-use-disorder-some-point-their-lives

3 NIH: National Institute on Drug Abuse. (n.d.) What is the scope of prescription drug misuse in the United States? (accessed 9-21-2022) https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/what-scope-prescription-drug-misuse 

4 NIH. Substance use and co-occurring mental disorders.

5 NIH. 10 percent of US adults have drug use disorder at some point in their lives.

6 NIH. Substance use and co-occurring mental disorders.