Addiction professionals have always encountered clients who have certain negative feeling states intimately tied to their drinking and drug abuse. As we speak, The National Institute on Alcohol Abuse and Alcoholism is launching a $2 million dollar project to examine techniques that can assist clients through certain negative emotions associated with drinking (particularly onset and relapse potential).

Over the years, negative feeling states and the connection to addiction have generated a mountain of research — notably, the findings of stress on drinking (Alcohol Alert, 1996). Stress is often described as a pressure or tension state. It is provoked in a number of ways (in no particular order):

• Coping with economic stress (e.g., can’t pay the bills)
• Job stress (too much of it, boss is a jerk)
• Marital problems (arguments galore)
• Little or no social support (no sober friends)
• A different genetic make-up (more prone to it)
• A sense of control over the stressor (inner confidence to handle the stress)
• Accessibility of alcohol in times of stress (bottle or bar nearby)
• Availability of social support (friends close or far)

If the stress happens to be chronic and severe, so often is the drinking. Research has even found increased drinking in animals exposed to stress.

Similar research
A close cousin of stress is anxiety. And, again, addiction professionals constantly encounter the interconnection between anxiety and substance abuse. Past research indicates the rate of anxiety disorders is two to four times greater with alcohol-dependent individuals than is found in normal populations.

Recent research has specified that particular anxiety disorders appear to be more associated with alcoholics. Kushner et al (2005) surveyed 82 individuals just after they entered treatment and three months post treatment as to clinical significance of this co-morbidity to treatment. The key finding was that having an anxiety disorder before starting treatment marked such individuals at a significantly greater risk for relapse within four months. One other interesting finding was that different anxiety disorders predicted different aspects of relapse. For example, patients with a social phobia (significant fears and avoidance of social situations) at the outset, turned out to be a strong predictor of returning to any drinking. Panic disorder (periods of intense anxiety and arousal) was a strong predictor of relapse to dependence levels at follow-up. In other words, social phobias were risk factors for minor relapses, while panic disorders were a major relapse potential.

More research on feeling states and addiction
Dearing et al (2005) recently completed research on negative feeling states that addiction professionals also see daily — shame and guilt. They surveyed 235 individuals (college undergrads and jail inmates) concerning shame and guilt, and the association to substance abuse. Their research pointed to something not delineated before — essentially, shame-
oriented clients were associated more with substance abuse than a guilt-oriented sample. Thus, shame, described as problems with life and feeling bad about self, is linked more with substance abuse than guilt, which is described as feeling bad about a specific behavior.

For the sake of clarification, perhaps a little more differentiation of shame and guilt might be helpful in terms of distinguishing these allied feeling states. Shame can be seen as a painful emotion that entails dishonor, disgrace, or condemnation of one’s reputation. It can be said that shame is difficult to experience without an external frame of reference (other people knowing about it or, somehow, and in some way, contributing to shame type feelings).

On the contrary, guilt is an internal remorse for having done something wrong. It is self-reproach and regret, all of which is more of a personal or private oriented feeling. This clarification may assist you in terms of assessment and eventually for treatment direction and emphasis.

Try it
The Kushner et al research indicates that a traditional alcoholism treatment will not be particularly effective for the anxiety drinking mix. Yet, it would be a mistake to infer that treating the anxiety would partially or wholly eliminate the abuse risk. So, the general treatment suggestion centers on an integrated treatment program for anxiety disorders and addiction. Since the anxiety alcohol interaction is rather complex, an integrated dual disordered treatment is warranted.

For instance, you could immediately upgrade your assessment practices to account for anxiety issues. Use DSM-IV criteria or any number of standardized instruments to ascertain clients who potentially have these anxiety disorders (social/panic). Once established, special attention to the period following treatment in terms of anxiety reduction might entail greater use of support and anxiety reduction skills.

Based on the Dearing et al research, a good research to practice exercise would be to attempt to identify clients who are shame-oriented (the more at risk group) in your assessments. To help differentiate between shame and guilt, you might want to include the following questions: “Do you generally feel more badly about yourself or specific things you have done?” and, “Do you often feel more badly about your overall life or some of your past behaviors?”

Once you have established whether the client is more shame-or guilt-oriented, you can adjust your therapy by addressing the differentiated issues. For example, shame loaded clients may benefit from completing a simple line plot — an exercise that has the client rate the intensity of the shame each day on some graph paper (intensity on the vertical line; time on the horizontal). Then, have the client connect the dots for each day. This will enable you (the counselor) to get a picture of the client’s shame intensity.

From the graph, identify what set off the higher levels of shame, and for the low shame days, find out what the client was doing not to elicit intense shame. For the high shame days, a series of thought-stopping or distraction skills could be utilized to assuage that feeling. The goal of such a skill is to diminish the shame so it does not overwhelm clients. For the low shame days, ask clients what they were doing to keep the intensity so low, and encourage them to repeat whatever they did. In addition, it might benefit the client to utilize traditional approaches of making amends, or to simply talk about the shame, its causes, and the constant pain.

The following proposed research projects involve two surveys that would focus on shame/guilt. One survey would assess how many of your clients are anxiety or shame/guilt oriented. To measure shame, use the Harder Personal Feelings Question-naire. This instrument can be found in Corcoran and Fischer (2000), and would basically be applied to a random sample of clients (n > 75) from your program. The survey results would give you an estimate of how many such clients exist in your program. If the number is significant, the data could then be used to support appropriate staff training.

After you determine the number of shame-oriented clients, you could follow and survey those clients, post-treatment, to ascertain if they were indeed relapsing more than a non-shame based sample. Again, this would be very useful information and could indicate a need for treatment program modification.

Should you need assistance with one of these projects feel free to email me at the address below. I remain interested in your findings.

Michael J. Taleff, PhD, CSAC, MAC, is an instructor at the University of Hawai’i at Manoa and West Oahu campuses, and an instructor at National University (Hawaii branch). He can be contacted at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
Alcohol Alert. (1996). Alcohol and Stress. Washington, DC. National Institute of Alcohol abuse and alcoholism.
Corcoran, K. & Fischer, J. (2000). Measures for clinical practice: A sourcebook (3rd Ed., Vol. 2). New York: The Free Press.
Dearing, R.L., Stuewig, J., Tangney, T.P. (2005). On the importance of distinguishing shame from guilt: Relations to problematic alcohol and drug use. Addictive Behavior, 30. 7, 1392-1404.
Kushner, M.G., Abrams, K., Thuras, P., Hanson, K.L., Brekke, M. & Sletten, S. (2005). A follow-up study of anxiety disorder and alcohol dependence in comorbid alcoholism treatment patients. Alcoholism: Clinical & Experimental Research 29, 8, 1432-1443.

This article is published in Counselor,The Magazine for Addiction Professionals, February 2006, v.7, n.1, pp.54-55.

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