Alcoholism: Disease or Behavior

Criterion A.2. of Alcohol Use Disorder, as presented in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), is the foundation for my conceptualization of alcoholism as either a disease or a behavior.  Obviously a person who meets the criteria for a mental disorder warrants a diagnosis of a mental disorder, right?  Isn’t the DSM gospel?  Okay, so cynicism aside, the criterion of which I am referring is as follows: “There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.”  In short, if a person is behaving in a manner that they do not wish to behave, and they have put forth significant honest efforts to stop that behavior (or emotion, etc.) then they need help.  If help is most effective by way of mental health intervention, then I believe that the mechanisms should be in place for that assistance to be received (thus a diagnosis be present within the DSM).

It is in the assessment of the criterion of reference where the distinction is made between people who are engaging in an irresponsible manner versus a person who is “ill”.  I would almost go as far as to say that the criterion should be listed separately from the others and be required in addition to “at least two of the others.”  The reality is that due to its subjectability, the criterion is not a foolproof method for determining “disease.”  What a person says they have done to stop, cut down or control alcohol is unfortunately not always factual in nature.  This in itself creates a conflict with therapeutic approaches that the clinician accepts the client’s reality (regardless of truth), similar to the process of dealing with victims of violence or abuse.

Gaining an understanding of the hopelessness a client feels is often a prerequisite for intervention (which sometimes proves therapeutic in itself); however, validation of the hopelessness should not be required of a clinician.  With this thought process in mind, which is often best, clinicians commit due diligence to understanding the problem as the client sees it, and make some efforts to validate the claims the client makes with regard to their unsuccessful efforts to control their alcohol use.

During this validation process it is useful to understand the means by which the client has presented themselves to therapy.  Was it court-ordered, were they pressured or did they come on their own accord?  The reason for a client sitting in your office is oftentimes a predictor of the level of expected success, though asking the client directly may be illuminating as well.

With the work of Michele Weiner-Davis in mind, a therapist should also search for evidence of pretreatment change.  These are all factors that are associated with determining the “classification” of alcoholism and more importantly the need for intervention.  Regardless of how it’s classified, as a clinician, with a client sitting in front of you, you have an obligation.

Consideration of the factors mentioned above may also serve as a guide to a therapist evaluating which approach to intervention may best suit a particular client.  Due to my affinity for Marriage and Family Therapy, I would be remiss if I didn’t mention an assessment of the effects of the alcohol use, regarding the family (if present), should also be a factor in determining the goals of therapy.

Jordache Williams

 

Jordache Williams is currently based in Rock Hill, SC and is the Program Manager for Atlas Concepts, LLC. He is a Certified Life Coach and holds a Master’s Degree in Human Services.

 

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Mental Health for the Impoverished and Unemployed

I can stare in the mirror and recite, “Every day, in every way, I’m getting better and better,” and I will still experience my life as awful unless I also have opportunities to succeed or I live in a community where, by comparison, I am no worse off than others. Wellbeing is a social phenomenon (Ungar, 2014).

It is no secret that poverty and unemployment are highly correlated; however, it is somewhat less widely known that these factors mediate, and are influenced by, mental health.  Recent research suggests that socio-economic hardship precedes inferior mental health (Heflin & Iceland, 2009).  Commonly, mental health is associated with emotions and feelings including stress, depression and loneliness.  On the other hand, mental illness is reserved by many for diseases and disorders such as schizophrenia, bipolar disorder, posttraumatic stress disorder, etc.  The reality is that many diagnosable mental disorders are based on criteria regarding the factors considered by many to be a part of everyday life (i.e. stress, anxiety, alcohol, drug and even tobacco use).  The Mayo Clinic estimates that one in five adults experience mental illness in a given year (2015).  Furthermore, Kessler states that forty-six percent of Americans experience at least one mental disorder in their lifetime (as cited in Anakwenze & Zuberi, 2013, p.147).  In either course, the mental state of an individual, and societies at large, have vast socioeconomic implications.  Scholarly contributions from the United Kingdom suggest that the lowest wage-earners are twice more likely to experience mental health issues than average wage-earners and are more likely to experience unemployment (Kronenberg, Jacobs & Zucchelli, 2015).  In 1997, William Julius Wilson found a relationship between poverty and mental health, of which, he concluded that unstable work and low income decrease self-efficacy (as cited in Anakwenze & Zuberi, 2013, p. 148).  However, despite a rather lengthy history of research concerning the topic (which continues to be empirically vetted), there has yet to emerge a viable socio-economic prescription for mental illness.  This review of literature focuses on determining the key socioeconomic factors associated with mental illness, and adds clarity to the relationship between poverty, unemployment and mental health.

Finding a place in society

As a part of the Fair Labor Standards Act in the U.S., the Wage and Hour Division of the Department of Labor [DOL] authorizes employers to pay subminimum wages to individuals who possess disabilities that effect job performance (2008).  Mental illness is included among the list of impairments which qualify for a subminimum wage (DOL, 2008).  Regardless of the intent, these standards imply a degradation of value to those with mental illness.  The chasm between economical and humanistic thinking is evidenced by such government actions.  That is, economically, individuals lose their name and their very identity (i.e. self-efficacy) and are considered in conventional terms, “factors of production”, “government expenses”, “buyers and sellers”, to name a few.  Government intervention that provides a means for employers to pay individuals with mental illness less for jobs which they are less than qualified, does little to fix any economic or mental health dilemma.  Efforts may better be served by providing resources, such as research endeavors purposed with determining suitable employment options for those with specific mental illness.  Employing individuals in positions where their efforts and productivity are economically valuable to employers decreases the need for subminimum wage authorizations, and has potential to improve workers’ mental health and the business’ output.  One challenge to this effort may be that individuals with serious psychological distress are more likely to have less than a high school diploma (Heflin & Iceland, 2009).

Not only do mentally disabled individuals face difficulty fitting into the workforce, they also are more likely to face sub-quality living conditions.  In the United Kingdom, one in three households, housing a disabled person is considered to be substandard (Snell, Bevan & Thomson, 2015).  These substandard conditions not only create a sense of dissatisfaction for those residing in such dwellings but also increase their susceptibility to chronic illness (Snell et al., 2015).  These individuals’ increased susceptibility to illness is, in part, due to rising energy prices and the inability to afford heat and/or air conditioning (Snell et al., 2015).  Because many of these individuals lack employment, it is assessed that more time is spent in the home, thus exacerbating the amount of time they are exposed to substandard conditions (Snell et al., 2015).  Heflin & Iceland (2009) concluded that providing relief for energy costs and eviction prevention may have high social benefits, especially if provisions are extended to those within two hundred percent of the poverty line, as oppose to only those living in poverty.

The individual’s perception of their condition and the associated dissatisfaction both play a role in increasing the individual’s risk of experiencing depression (a degraded or impaired mental state) (Anakwenze & Zuberi, 2013).  Depression can aggravate an existing mental health condition or in itself become a mental illness.  The living conditions available to those with disabilities, including mental illness, is largely impacted by their ability to find and sustain employment providing the necessary income for suitable accommodations.  The condition they find themselves in (i.e. facing mental illness, unemployment and poverty) is a cyclically diminishing one.  It doesn’t take a John Maynard Keynes to understand that this cycle cannot recover itself efficiently.

Affording treatment

Well into the U.S.’s 2015 political debate season, a potential increase in minimum wage remains a pivotal topic.  Many Americans are in favor of increasing the minimum wage standards, suggesting a societal need for increased income.  To be clear, mentally healthy individuals making minimum wage claim to need more money.  How can poor, mentally ill individuals, earning a subminimum wage afford treatment?  The reality is that they likely cannot. But even if provided with income increases, mental health can only be improved by monetary gains if those gains are employed appropriately by the individual.

It has been suggested that an increase in minimum wage would improve mental health.  This is largely based on research which has found positive correlations between income and mental health.  Kronenberg et al. (2015) points out the expenses businesses can attribute to mental illness, such as absenteeism, and suggests that a minimum wage increase could improve mental health and productivity, thus becoming an affordable expense.  While this logic may hold some merit, it is not determined if individuals would invest additional income towards improving their mental health and, moreover, there is a lack of empirical evidence to support such assumptions.  It is determined, however, that disabled individuals, as compared to non-disabled individuals, face proportionally greater increasing living costs, are less likely to be employed, are less likely to be employed full-time (if employed), and receive lower wages (Snell et al., 2015).

In many instances, individual’s mental disorders go untreated.  While this in itself is tragic and sometimes fatal, in impoverished communities it is more likely that a mentally ill parent’s interactions with their children be harmful.  Not only do children in these situations grow up with the same economic insecurities, they are exposed to, and are affected by, the stress, anxiety, and depression present within the household.  These situations have a biological effect on the brain and require treatment (Anakwenze & Zuberi, 2013).  This needed treatment often doesn’t occur.  In many cases, mental illness coupled with poverty leads to criminal activity and imprisonment.  Harding suggests that a physiological mechanism exists by which the violence present within low income neighborhoods yields mental health concerns, such as chronic stress (as cited in Anakwenze & Zuberi, 2013, p. 150).  These mental health problems undermine individual’s self-efficacy and perpetuate further negative consequences.

The socioeconomic issues covered herein do little to scratch the surface of what seems to be a nearly silent epidemic.  Overshadowed by international threats, presidential debates and Hollywood shenanigans, the issue of mental illness has many socioeconomic implications.  I suggest further research is needed in many areas related to mental health reform, to include: the role of mental illness concerning violent and juvenile offenders, neighborhood disorder (i.e. perceived levels of social support and integration), and the relationships between depression, aggression, addiction and trauma.  The relationship between poverty, unemployment and mental health is complex, yet it can be reduced to a simple term, vicious circle.  I conclude that mental health care in the U.S. is a substantial component to economic stability.  Reformation of the economic strategy should include progressive government intervention in impoverished communities, to include crime prevention, education, job training and mental health rehabilitation and sustainment.  Such programs create a demand for jobs and supply qualified job seekers.  Long-term, such programs reduce crime rates and unemployment as well as have the potential to increase gross domestic product.

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References

Anakwenze, U., & Zuberi, D. d. (2013). Mental Health and Poverty in the Inner City. Health & Social Work, 38(3), 147-157.

Heflin, C. M., & Iceland, J. (2009). Poverty, Material Hardship, and Depression. Social Science Quarterly, 1051.

Kronenberg, C., Jacobs, R., & Zucchelli, E. (2015, Aug). The impact of a wage increase on mental health: Evidence from the UK minimum wage. Retrieved from http://www.york.ac.uk/media/economics/documents/hedg/workingpapers/1508.pdf

Mayo Clinic (2015, Oct 13). Mental Illness: Risk Factors. Retrieved from http://www.mayoclinic.org/diseases-conditions/mental-illness/basics/risk-factors/con-20033813

Snell, C., Bevan, M., & Thomson, H. (2015). Welfare reform, disabled people and fuel poverty. Journal Of Poverty & Social Justice, 23(3), 229-244. doi:10.1332/175982715X14349632097764

Ungar, M. (2014, Jan 12). Will a Higher Minimum Wage Make People Happier? [Web log comment]. Psychology Today.  Retrieved from https://www.psychologytoday.com/blog/nurturing-resilience/201401/will-higher-minimum-wage-make-people-happier

U.S. Department of Labor (2008, Jul). Fact Sheet #39: The Employment of Workers with Disabilities at Subminimum Wages. Retrieved from http://www.dol.gov/whd/regs/compliance/whdfs39.pdf

Atlas Concepts, LLC_Jordache WilliamsJordache Williams is currently based in Rock Hill, SC and is the Program Manager for Atlas Concepts, LLC. He is a Certified Life Coach and holds a Master’s Degree in Human Services.

Well…are they?

I love new information, and it’s especially helpful when that information includes numbers and graphics.  For instance, the American Psychological Association (APA) recently published results from the Center for Workforce Studies via www.apa.org entitled “Are psychologists in the states that have the most mental illness?”  This article included the graphic below.

Fields of Knowledge Blog_APA Mental Illness graphic

APA, November 2014, Vol 45, No. 10

Granted there are over 200 words that accompanied this graphic, but for me this information raised more questions than answers.  I invite you to take a look at the article yourself as it may speak to you differently.  Having personally conducted research, I can attest to the often arduous nature and inevitable error of that process and understand the power of research that prompts questions.  In that light, I am sharing the inquisitions which rose to mind as I perused the information presented.  I do so in part, with the hopes that others, with interests, resources and ability, can take hold of the lit torch.

The easy questions are often “Why?”  If, when you look at the graphic above, you feel that psychologists are not employed where they are needed, or if you are wondering why people are more mentally ill in a distribution, which appears to be a serpent traveling West across the United States, then you may ask, why?  Some of the more powerful questions however often begin with “How.”  How would this graphic look based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5)?  How do the state boards of psychology collect and record data?  A few other questions that came to mind are: Who reports mental illness to the state boards of psychology?  Psychologists are not the only collective who diagnose these illnesses.  What are the data collection efficiency ratings for each state?  Do state reporting criteria vary from state to state?  Keep in mind also that this study concerns ADULTS with REPORTED mental illness.

The point of all this questioning being an effort to avoid making false generalizations.  For instance, does South Carolina (my state of residence) need more psychologists or better psychologists?  Are we assuming that the presence of psychologists is correlated with a decrease in mental illness?  I would almost guarantee that the numbers reported for licensed psychologists is much more accurate than the percentages shown for adults with mental illness.  This may be the limit of my “admitted” assumptions concerning this study.  I assume this, because reporting and record keeping concerning licensed practitioners strikes me as more manageable information.

Lastly, it is not my desire to poke holes in this valuable information.  This is not David and Goliath.  I was prompted on this particularly day, by this particular article, simply because it provides a great example.  The fact is that social media and the internet at large make information assessable.  Assessable (in most cases) to every internet user. This means that those sharing information have a responsibility but moreoverly those who consume and utilize such information must do so responsibly as well. It is not responsible to accept everything at face value, and it is likewise not responsible to over scrutinize information merely for the sake of doing so.  It is my hope that recipients of quality information strive or maintain a level of responsibility conducive to interpretations that are of the most value to themselves and those they influence.  The mere fact that this study’s title is presented in the form of a question speaks volumes.  From my perspective, there is nothing misleading about the work; however, you must, as an individual, guard your “storage bin” of information and challenge yourself towards greater levels of understanding.  This often means knowing what questions to ask!

 

Jordache WilliamsAtlas Concepts, LLC_Jordache Williams is currently based in Rock Hill, SC and is the Program Manager for Atlas Concepts, LLC.  He is a Certified Life Coach and holds a Master’s Degree in Human Services.