Mental Illness from a Counselor's Perspective: Key Disorders

Alcohol Dependency in Women

Alcohol dependency, or alcoholism, is suspected when a person appears preoccupied with the consumption of alcoholic beverages (Johnson, 2003). The three prototypical markers of alcohol dependency are: loss of control over alcohol consumption, preoccupation with drinking, and continued use despite adverse effects on quality of life. For example, one client was disturbed by her inability to have just a few drinks. According to her, when she went out with friends they would have two or three drinks, while she would invariably consume over a dozen until she was drunk.

The social consequences of alcoholism differ between men and women, with men typically incurring less social condemnation (Johnson, 2003). A drunk male is generally seen as out having a good time, while a drunk female is often characterized as morally suspect and sexually promiscuous. This may help explain why 75% of all sexual assaults involve alcohol. Furthermore, when men and women consume equivalent amounts of alcohol, the outcomes differ markedly: women become inebriated more quickly and symptoms persist longer.

The physiological consequences of long-term alcohol exposure also differ substantially by sex. Organ damage occurs in women who consume as few as two glasses of wine per day, compared to six for men. The liver is the primary organ affected, but the cardiovascular and nervous systems are also negatively impacted. Other problems may manifest, including vitamin deficiencies and cancer. The risk of death is twice as high for women compared to men. This gender difference in alcohol susceptibility is due in part to women having less body water to dilute alcohol and producing less alcohol dehydrogenase enzyme in their stomachs to metabolize ingested alcohol. Women suffering from alcohol dependence are therefore more susceptible to negative health and behavioral outcomes than men.

Alcoholic families can still appear socially successful, yet the negative consequences will affect all family members (Johnson, 2003). Women who become pregnant and continue to drink may give birth to children with significant birth defects. In one case discussed in the source video, a client gave birth to five children while continuing to drink; one infant died shortly after a premature birth and another died of Sudden Infant Death Syndrome (SIDS) a few months after birth. Her oldest child suffers from Fetal Alcohol Syndrome (FAS), though the client only became aware of this diagnosis after her child reached adulthood. Other disorders linked to prenatal alcohol exposure include autism spectrum disorders, attention deficit hyperactivity disorder, borderline personality disorder, depression, intellectual disability, oppositional defiant disorder, posttraumatic stress disorder, and receptive-expressive language disorder.

Counseling is an important component of recovery from substance abuse, including alcohol dependence (Marsh, Dale, & Willis, 2007). The three core symptoms of alcohol dependence — loss of control, preoccupation, and denial — are all amenable to counseling interventions. Of primary importance is the therapist's ability to quickly establish a therapeutic alliance with the client. Doing so requires the therapist to become a recovery advocate. Another critical role is that of educator, helping clients understand the nature of alcohol dependency and how to begin and sustain recovery.

The video source devotes considerable time to explaining how one client was never informed that alcohol was more damaging than the opiate drugs she had been taking, particularly to fetuses (Johnson, 2003). Although less relevant in the specific case discussed, therapists should also work to ensure that clients' basic needs — such as food, shelter, and safety — are being met, since alcoholism is not uncommon among those experiencing homelessness, poverty, or domestic abuse. When this situation arises, the therapist takes on the role of social worker, helping clients identify and access needed social services. Once basic needs are met, the work of recovery becomes far more achievable. The therapist may also need to evaluate clients' overall physical and mental health and provide referrals to address comorbid conditions.

Once one client accepted that her alcohol dependency was destroying rather than sustaining her life, she began attending Alcoholics Anonymous meetings (Johnson, 2003). This step helped her recognize that she was not alone in her struggles with addiction. She also learned that stress was a trigger for alcohol consumption and began practicing effective stress management techniques, including exercise. She gradually became comfortable spending time alone and with the person she was becoming in sobriety. She began her path to recovery by entering a residential recovery program for one year, away from her family, and then spent another year reengaging with her family while remaining in the program. A key element of recovery for both women featured in the video was becoming educated about the negative effects of alcohol dependency — not only for themselves, but for their children and families.

The CAGE test, discussed in the video, helps identify whether someone may be suffering from alcohol dependency (Johnson, 2003). If a person has ever felt they should cut back on their drinking, they have met the "C" diagnostic criterion. If they have been annoyed by criticism of their drinking, this meets the "A" criterion. Feelings of guilt about drinking, or needing a drink first thing in the morning, fulfill the final two criteria. The more criteria a person answers affirmatively, the more likely they are suffering from alcohol dependence.

The diagnostic criteria recommended by the American Psychiatric Association (APA, 2013) are similar: alcohol use disorder is diagnosed when an individual meets at least 2 of 11 criteria within the past 12 months. These criteria include loss of control over drinking, preoccupation with alcohol consumption, and denial of a drinking problem, as well as alcohol use interfering with the ability to meet work, school, or family obligations. Cravings, tolerance, and withdrawal are also diagnostic criteria.

Teen Anxiety Disorder

Based on the video from Alexander Street Press (2008), teen anxiety disorder manifests when a pre-teen or teenager experiences constant fear, doubts, and insecurities to the degree that it interferes with their ability to function at school or socially, and may elicit other serious health problems such as major depression. From a clinical perspective, these symptoms fall within social anxiety disorder and generalized anxiety disorder. Clinically relevant social anxiety involves an extreme fear or anxiety about being judged negatively by others or making a social mistake that leads to embarrassment. Generalized anxiety disorder, by comparison, consists of chronic worrying about a range of issues — family, health, academic performance — or may involve a more general concern, such as the threat of terrorism. In contrast to the fears, doubts, and insecurities that are a normal part of adolescent life, teen anxiety disorder is not transient and requires treatment by mental health professionals.

The main symptoms parents may notice include their child avoiding social and school activities (Alexander Street Press, 2008). Over time, parents may observe that the child is gradually eliminating social activities from their life, alienating friends, and placing the burden of social engagement on others. Another telling sign of teen anxiety disorder is that the child's hesitancy to engage socially is resistant to reassurance. More generally, parents should be concerned if their child experiences changes in eating, sleeping, schoolwork, activity levels, mood, relationships, or aggressive behavior — particularly when these changes appear to be more than transient.

One adolescent client described in the Alexander Street Press video (2008) reported feeling as though she did not fit in socially, and these feelings worsened in larger gatherings, leaving her unable to relax. As she approached puberty, physical symptoms began to emerge, including stomach aches, sweating, throat constriction, and ringing in the ears. Spending time at a friend's house would often result in a phone call asking to come home, and upon returning she appeared traumatized. While in classrooms, she would occasionally experience mental detachment (derealization), and upon waking in the morning she would sometimes begin crying, sweating, or experiencing chest pains, shortness of breath, or stomach pains.

These symptoms naturally elicited parental concern, but lacking an understanding of the source of the anxiety, frustration would result (Alexander Street Press, 2008). Some parents react by becoming overprotective and attempting to shield their child from any negative experience. This fosters the impression, in the child's mind, that they are incapable of navigating the world as it is, which in turn reinforces their anxiety. Eventually, healthy family functioning is compromised as family members begin to behave in ways that minimize any chance the anxious child will experience something negative — in essence, the family begins to walk on eggshells.

The recommended treatment approach for anxiety disorders is cognitive behavioral therapy (CBT), with adults benefiting most from individual therapy and children benefiting from either individual or group sessions (Armstrong, 2014). Social anxiety disorder is best treated by mental health professionals specifically trained in this area. When children and adolescents are the clients, involving parents in treatment is strongly recommended. Because seeking treatment is itself a social event, anxieties surrounding initial contact and sessions can be moderated by minimizing exposure to crowded waiting rooms or conducting initial sessions by phone. For clients who cannot or will not attend sessions, self-help materials may provide some benefit, and clients can also be referred to a physician if they are interested in antidepressant medications.

Treatment recommendations for children and young people also include psychoeducation, exposure therapy, and social skills training and rehearsal (NICE, 2013, p. 30). Parents should be offered psychoeducation and skills training to help them teach coping and social skills to their child, as well as to support the child's safe exposure to anxiety-triggering situations.

When one adolescent client decided to try therapy, she chose to proceed without medications (Alexander Street Press, 2008). The course of therapy was 12 weeks, comprising 14 sessions, two of which included her parents. The first half of treatment focused on teaching and building the skills needed to manage anxiety, including relaxation exercises. Her mother learned to detach from her daughter's anxiety and simply ask whether it would be acceptable to discuss whatever was upsetting her later — thereby giving the client the space she needed to manage her anxiety independently. Another important component was exposure therapy. In one example, the client was asked to make a phone call to confront her fear that nobody would answer; she would place the call from one room while the person on the other end allowed it to ring. This approach was used to reduce the anxiety triggered by such situations. The treatment was successful: the client obtained a part-time job working in a supermarket where she is required to interact with the public. From her perspective, getting the job was "… one of the best things that ever happened to me" (Alexander Street Press, 2008, 00:10:50).

As discussed in the video, social anxieties, doubts, and fears are common among adolescents (Alexander Street Press, 2008). It is therefore important to recognize when these experiences cross the line and become a threat to the health and well-being of teenagers and those who care for them. Based on the diagnostic criteria for social anxiety disorder (APA, 2013, p. 202), fear of social situations becomes clinically relevant when the magnitude of fear or anxiety experienced exceeds the actual threat posed by the prospect of judgment, ridicule, or embarrassment. When fears, anxiety, and social avoidance persist for six months, this is also clinically significant. A mental health professional should intervene when these symptoms begin to interfere with the adolescent's ability to navigate life as a student, friend, and family member.