What is "normal" drinking? A podcast for therapists

Episode 84

What is normal drinking? This is a very common question. I was asked a couple of different versions of this question from colleagues. In today’s episode I’ll talk about what government entities say is “moderate” and talk about a few scenarios that I’ve seen. Alcohol that we see portrayed in media or on ads, is not showing at all what is normal drinking. In shows, the amount is there to make a point about the story. In ads, it’s completely to sell more alcohol. Showing bigger sizes, making it seem normal. The alcohol industry spends a TON of money each year on lobbying congress and public image to keep alcohol from getting taxed and more regulated. So we can’t rely on what we see in the media to tell us what’s normal. Listen to the episode below.

Transcript

You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use from a mental health perspective. I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice. So join me each week as we talk about All Things Substance.

Welcome back to the All Things Substance podcast. This is episode 84. Today we’re going to be talking about some scenarios of clients and how their use might impact them. I’ve asked a number of colleagues their questions on client substance use. Some of the questions I got were more broad and wanting to know about some limits and others were about really specific situations. So today we’re going to be covering situations regarding alcohol.

There is an alcohol episode that was pretty early on in the podcast, I believe it’s episode 19, that kind of gives an overview of alcohol, its origins, culture, and potential risks. If you haven’t heard it yet, you can head over to Betsybyler.com/podcast or over to your favorite platform for podcasts and find episode 19.

Today, it’s going to be a little more discussion about the questions that I received about alcohol. Alcohol’s an interesting substance. Most people don’t think about alcohol being a drug because we tend to talk about alcohol and drugs as though they’re different things.

In that sense, perhaps they are. But if we’re talking about a drug being a mind altering substance, then alcohol is a drug too. There’s something about alcohol that puts it in its own category in culture. Now I know that in other places in the world, alcohol culture is totally different.

In the United States our alcohol laws are that you can’t purchase or consume alcohol until age 21. This is something that was left up to the states to decide and so some states had laws about 19 and some had laws about 21. Well, the federal government can put pressure on states in different ways. One of those ways is highway funds and there are times over our history that the federal government has been able to incentivize is the word I’ll use states to conform to certain laws.

I happen to live on the border between two states. The state I’m in Wisconsin used to have a liquor law age of 19, the neighboring state. Minnesota had a liquor law age of 21. So all of the 19 and 20 year olds would head over the bridge to Wisconsin in order to drink because it was legal. That’s not just here, that’s all over. I remember kids who grew up near the Detroit Michigan area would just go over the bridge to Canada to drink since the drinking age was 19. Some critics have talked about the focus on keeping alcohol till 21 makes it taboo and increases its allure.

It’s possible, but I do think that the desire to check out of our mind to change the channel in our head or to feel differently is pertinent at any age. So I’m not really sure what impact the laws have on it. I think that surrounding social culture has a lot to do with people’s views on alcohol. Our families of origin also have a lot to do with that.

Even in families where drinking wasn’t really a big deal or wasn’t really common there are unspoken rules about drinking. About how much is too much about what’s acceptable and all of that varies. I think about my own growing up and the block we lived on. As I think about all the different families on our block, I can think of the alcohol rules, quote unquote, in those houses, even though that was never overtly discussed with me, I just know that of the people on our block, we had varying rules.

We had neighbors that never drank no alcohol in the house, no cooking wine, no nothing. We had neighbors who, when they would have family barbecues and get together, they would have beer and it was always cans of beer and it wasn’t unusual for one of the parents to have a beer or a couple after work. I don’t know that I ever saw anybody drunk and I think there were probably some relatives that drank more than they quote should. We had other folks who had cocktail hour and drank a lot. It just completely depended upon the family culture.

The town I grew up in was a dry town until the mid nineties, when finally. One of the restaurants got a liquor license. It was a really big deal. This was just because of the religious nature of the foundation of that town and that it just took a while.

So when we think about what’s impacting our clients’ use of alcohol, there is the surrounding culture, their family culture, and then their personal experience. Each of those things is going to impact how they view normal. That’s what people want to know: what is normal drinking? When you look at what people Google, and even in our recovery stories that we’ve heard, people will talk about having Googled, do I have a drinking problem?

They usually say something to the effect of, if you have to Google that you probably have a drinking problem. What people can drink and still be in the normal range is of great interest. So I thought I’d start there.

One of the things about culture right now is the mom wine culture. I’m not sure a day goes by that I don’t see something pop up on my Facebook feed about wine and moms. I’m not totally certain where it started or how it started and I’m certain it’s not new, but man, is it big? You can find all sorts of things relating to it. Coasters, handbags. T-shirts, kids’ clothes, advertisements talking about moms and wine. When I was growing up, it used to be about bubble baths being for moms. Now it’s about wine.

A lot of women’s activities have started adding wine, like yoga and wine or book clubs and wine. Things that didn’t necessarily have an alcohol context to them, but now it’s being added. That has definitely had an impact on women’s consumption of alcohol.

I don’t know if they’ve been able to quantify that yet, but definitely the messages are really powerful and all around. We all, as adults, would like to think that we are immune from advertising and from peer pressure. As therapists we know that is not true. We are greatly impacted by what people around us are doing.

There are multi-billion dollar businesses that are designed to just figure out how to get us to engage and buy more of a product. It works. When it comes to alcohol it is the one drug that I can think of that people will actually give you shit about not using. Many, many people who have tried to cut back will go to family gatherings, or their a book club or a party or out with friends and someone asks them why they’re not drinking.

If there is a female of childbearing age, speculations that they might be pregnant pop up rather than maybe they don’t relate great to alcohol. Maybe they don’t like it, but regardless of the answer, you typically have to defend yourself. In recovery groups, women often talk about pressure from family and friends to drink. Like, oh, come on. Just let loose. It’s just for today. Or it’s been a while since that last incident you can handle it now, or you’re no fun. You’re not gonna have any fun, all sorts of things that really sound like peer pressure because they are.

So why is it that we, as a culture, find the need to badger people into drinking. There could be a lot of reasons for that. I think one of the main reasons is that we want others to join us in letting go and letting loose. We want people to also be on the same page so that we don’t stand out or do something that doesn’t fit into the norms of the group we’re in at the moment. For some people who are badgering, it’s a lot of times because they are drinking a little more than perhaps they quote unquote should, and they want people to join them there. That way they don’t feel bad about how much they’re drinking.

Beyond that we have some religious culture about drinking. Many religions have opinions about alcohol and have guidelines or outright bans on drinking alcohol. This sort of leads to this sense that alcohol might be bad. I think that plays a role in informing someone’s attitude about alcohol.

One of the things we know from research is that alcohol consumption has gone up statistically significantly over the pandemic. From what I can tell, this is across the adult lifespan. I know anecdotally it has increased in the adolescent group as well, being home alone, but we’re just going to talk about adults right now, since that’s something that has more research with it. During the pandemic alcohol became something that people turn to.

Quickly into the pandemic when lockdown happened, services popped up all over that expanded their delivery services to include alcohol. So now people could have alcohol delivered to their house and not have to leave. It became more readily accessible and because we were in “unprecedented times”, it seemed like a good time to have a drink.

I want to be really clear. I do not have judgment about that. I can understand the desire to have a drink. The reason I don’t is because I can’t. My body doesn’t understand moderation and personally, I don’t understand having a drink or two. That is not in my wheelhouse. It doesn’t make sense. Why would I do that? If I’m going to drink, I’m going to fucking get it done and let’s get hammered. That’s kind of how I knew that my thinking about that is not normal.

Professionally speaking and as a person who specializes in substance use, I have a different opinion about other people and their drinking. I think the majority of people can moderate. I think that a high percentage of people who drink alcohol all over the world drink normally. It’s this gray area drinking, which is actually a phrase that you can Google and find some information on. It’s becoming more well-known. Gray area drinking, being that place between what was normal and what’s clearly an alcoholism pattern.

So let’s talk about what is “normal”, according to government entities. So for us in the United States, that’s going to be the CDC and the National institute on Alcohol Abuse and Alcoholism. So the NIH. And let me clarify, this is the section specifically on alcohol. So it’s the NIAAA and I’m just not going to say that every time. So the NIH talks about different levels of drinking.

First it’s drinking in moderation. So the U S Department of Health and Human Services and the USDA, which is the Us Department of Agriculture put forth dietary guidelines for Americans and this comes from their guidelines from 2020 to 2025. They put forth that drinking and moderation is limiting intake to two drinks or less in a day for men and one drink or less in a day for women.

So here’s where we have to pause and we have to take a sidestep to what is a drink. This is something that I have to clarify with people often. When they say they had X number of drinks or beers or glasses of wine or whatever that varies wildly. It’s sort of like. If I say I had a quarter of a pizza, does that mean a quarter of a small pizza, a medium, large, extra large, those are very different things.

Well, the same goes true for alcohol. If you’ve ever had somebody make you a mixed drink, you can tell whether they are a heavy pour or whether they’re on the light side. There are times when somebody has handed me a mixed drink, that I was like, holy crap. Like, what the hell is that? Where it’s pretty much rum with a splash of Coke. Then there’s places where I’ve had rum and Coke, and it’s been mostly Coke with a bit of rum. That sounds like it might not be a big deal, but when we’re talking about hard liquor, the difference between a shot or two shots or whatever is a lot. And especially if you’ve had multiple drinks.

So when the government’s talking about two drinks in a day for a man and one drink in a day for a woman what the amount that is, is really important because it will change the definition of quote drinks, depending on the volume here.

So when it comes to beer, we’re talking about something that is about 5% alcohol. That’s pretty middle of the road. There are some beers that are less alcohol content and some that are more kind of depends and I’m not nearly as up on my beer lingo as I used to be. But one beer is 12 ounces. A pint glass that you would get in a restaurant is 16 ounces.

So already in a drink we’re getting a little more than 12 ounces. Now it’s not the full 16, maybe it’s 15 ounces, but those ounces add up, it wouldn’t take many drinks to add an extra drink onto a tally, according to this measure. The alcohol content if it’s higher, that’s going to lower the amount of ounces that count as a drink.

The next category the government calls out is malt liquor. That is not a phrase that I really hear a lot, but there are some things that are common that are considered malt liquor. And basically this is something that has on average 7% alcohol content.

And this one, a drink is only eight ounces. Some examples of malt liquors could be Old English, Colt 45, Mickey’s Labatt Blue, Dry, Molson, Dry, St. Ives and King Cobra to name a few. So a pint glass is double that.

Next up is wine. So for wine, we’re talking about five ounces equaling a drink. They expect that this is at about 12% alcohol content. So five ounces of wine is not very much. So think about taking a can of pop and pouring out less than half into a glass. That is a glass of wine. Most places I have been, most people’s houses I’ve been in, most things I’ve seen in the media, no one is drinking five ounces of wine. People who are drinking five ounces of wine are people who really don’t drink very much at all or they’re at a wine tasting. Our glass of wine seems to have become super-sized over the years.

So lastly, we talk about a shot. So a shot is 1.5 ounces of alcohol. And so here, we’re talking about 80 proof, which is 40% alcohol by volume, distilled spirits or liquor. So that could be vodka, rum, gin. whiskey, those sorts of things. When someone orders one of those alcohols, but on the rocks or needs or whatever, then it’s just the alcohol. Not a lot of fillers. There are drinks that have a lot of different alcohols in them.

So for instance, let’s take a Long Island Ice Tea. A Long Island. Ice Tea is made up of vodka, rum, gin, tequila, triple sec, and sour mix. There are five alcohols in that drink. Some recipes say that that’s four shots of alcohol. Some say it’s five, some say it’s three and a half, but it all depends on who’s pouring it. I’ve seen bartenders hold all four bottles of liquor upside down at the same time and pour it that way. Adding the triple sec and sour mix later. This is an alcohol heavy drink.

I recall when I used to drink, there was a place we went to when I went to Michigan State that had Long Island Ice Teas and they were in like root beer mugs. So think about a big, heavy root beer mug, but bigger. I remember having at least two of those and still functioning. That’s not normal. Because that is an incredible amount of alcohol. If I’m sitting in a restaurant and I have two of those bad boys, and somewhere between 20 and 30 ounces, I would bet.

I’d have two of those in like an hour and a half time slot or maybe two. So I would tell somebody I had two drinks. That is not two drinks. That’s like 10, not exaggerating. So the volume really, really matters when we’re talking about how much is too much.

So the NIH considers binge drinking to be a pattern of drinking that brings the alcohol concentration to .08, which is our legal limit in most states or higher for a typical adult. This is about five or more drinks for a man, remembering what drinks means, and four or more for a female in about two hours. It goes on to say that heavy alcohol use for men is consuming four or more drinks on any day or more than 14 drinks per week. For women consuming more than three drinks on any day or more than seven drinks per week.

So even when I thought I was drinking moderately, because alcohol was not my gig. I would go drink because I had friends who were bartenders and I would have four pint glasses of an amber beer that they made in house. The reason that matters is because microbrewed beers are going to have a higher alcohol content.

So I would sit and have my four pint glasses and I would stop when I felt my teeth starting to go numb. That is what I considered taking it easy and moderate drinking. And I don’t think that seems excessive to a lot of people. However, as a woman, more than seven drinks in a week, I would absolutely have that on a weekend easily. And that’s not even if I was trying to get hammered. I liked the line of the four drinks, because I would get a little buzz, but wasn’t drunk and could function the next day.

Just a side note. There are people who will say, but isn’t a glass of wine good for you? Well, there have been some studies, but generally the consensus is that less alcohol is better. Some of those studies, they feel like weren’t necessarily saying the things that mainstream media wanted it to. There are some things that might be good in red wine, but they aren’t necessarily outweighing the other risks.

So what the NIH is calling moderate drinking is two drinks or less for men on a day and one drink or less for women on a day. So that’s 14 drinks a week for men, seven drinks a week for when. That seems low compared with what I see people doing and not just up here in Northwest Wisconsin, where drinking is sort of a sport, so to speak, but more because the definition of what we think is a drink is much smaller than what we tend to drink here in the United States.

So if it’s low, does that mean we throw it out? Totally. I think of it a little bit, like the weight charts, the ones that tell you that if you’re six foot that you should weigh between this and that weight, those always seem a little on the low end, but they’re not super far off.

We do know that BMI or body mass index isn’t the best way to calculate health, but it’s something that the medical community came up with and it’s a shorthand, so to speak. So we don’t throw out totally where a healthy weight would be. But we do recognize that perhaps it might be a little too low.

I wanted to share with you what the NIH and the CDC are saying is normal and moderate. For people who are moderate drinkers, who don’t really drink very often there’s really not a problem. According to them, a five ounce glass of wine, once a day, the classic wine with dinner that people point to, they’re not really concerned about that causing a problem.

So let’s talk about our clients and what we end up seeing. This question was posed by a couple of different people online and also in other groups that I’m involved in: what is normal? When should we be concerned about our clients? So we’re going to talk about a few scenarios here and I’ll let you know my opinion about it as a substance use counselor and someone who specialized in this work for the last 19 years and has studied about the effects of alcohol on the body. There are a ton of links on episode 19 for alcohol and its effects if you want some more information.

So to me, there are a few things I hear when I ask people why they drink. They drank to help them sleep, helping them relax after work, dealing with stress, dealing with anxiety, social anxiety in social situations or to have fun. So let’s break that down into sleep, stress, fun, and social anxiety.

I recall a number of years ago when I used to play World of Warcraft, it’s a massive multiplayer online role-playing game and I would play numerous nights a week. One of the guys in my group who was a friend in the computer, we call it, I would hear on our voice chat each time he opened a can of something. Could have been cans, a pop, but I knew him well enough to know this was cans of beer.

I didn’t really start counting at first because whatever, but the more I played with him and the more I got to know him and I knew he had a pretty stressful job and felt like life in general was stressful.

So he drank for two reasons. One was stress and the other was sleep. One night. I decided to count the number of beers that I heard and I heard nine. Nine aluminum cans popping. Assuming that those are 12 ounce cans. That’s nine drinks in one night at my best. So for us, I am not sure about you, but I know even when I was drinking that nine cans of beer would have been a lot.

Now he was a big dude. He’d been drinking a long time, but he drank this every night and possibly more, a few shots here and there he said, because he had trouble sleeping. He never felt rested. He would wake up in the morning, groggy headache kind of hangover. He had not started drinking in the morning. He did not have morning shakes.

I don’t know how much physical withdrawal he was having in the mornings, but he would go to work. And then when he would get home, that’s when he would start drinking it wasn’t to get hammered. It was just dealing with stress and trying to relax from the day.

The problem with using alcohol to sleep is that it messes with your quality of sleep and so therefore your body isn’t repairing. I’ve talked about this in a few episodes, but I’ll go over it here. We go through stages of sleep and we travel through them numerous times. We need to go through each of those stages in order for our body to do the things they’re supposed to do. REM sleep, which is where we’re dreaming is where we’re getting our most repairative sleep.

REM sleep, doesn’t count for a lot of our sleep in a night, maybe 20 or 30%. On average, we go through three to five REM cycles a night. If we get between seven and eight hours of sleep, about 90 minutes of that will be REM sleep. I know it feels like we’re dreaming much longer than that during the night, but dreamland time doesn’t really match up with awake time.

t’s not that deep sleep or other stages of sleep don’t help our bodies. They absolutely do and are totally necessary. The problem here is that when someone is using a depressant, such as alcohol marijuana, opiates, or any other kinds of depressants, it’s going to push them down further into deep sleep, and they’re not going to be popping back up and going through the four stages of sleep. And so they wake up either still drunk, still high or groggy and feeling unrested.

Certainly alcohol helps with onset of sleep and that’s usually why people are drinking it because they can’t fall asleep and a few drinks or many drinks helps them. The issue here is the quality of sleep is not good. The longer-term issue here is that tolerance is a real thing. So if one drink will help you, over time one drink doesn’t do it anymore and it needs to be more. And so eventually we’re ramping up needing to drink more, to get to sleep. And again, that’s pushing them down through the cycles of sleep and they’re not popping back up very much until their alarm goes off.

It is a short term once in a while coping mechanism that I’m not recommending, but that some people use on a long-term basis, though. It is going to have diminishing returns and it’s going to cause a lot of other issues.

My friend was also drinking for stress relief. Being a supervisor in a high stress position is difficult. It was a lot of people, a lot of complaints about things that he could do nothing about because as a middle manager, he didn’t have a lot of power over the things that he was asked to do. He was required to make the staff do certain amounts of things or volume of tasks or whatever and he couldn’t change those things. He often felt really stuck in between. His only release from stress then. I was drinking.

He did have hobbies hunting, fishing, outdoor sports, and gaming, but all of those involved drinking. In his mind, whenever he was going to relax, alcohol was involved. Part of that is cultural, where he lived and in the family he grew up in drinking was just part of things. A lot of the men that he was around drank and drank to access and so it didn’t seem like a big deal. The fact that he was still going to work every day and had an important job, made him feel like his drinking was totally normal. He wasn’t an asshole. He wasn’t hurting anybody. He wasn’t driving drunk. It really didn’t seem like that big a deal.

The problem is that when someone is using a substance, in this case, we’re talking about alcohol to manage stress, it is effective. It does slow down the central nervous system. It does help you stop thinking about stressful things and it does make you feel good. And so it works, which reinforces it. And so next time you feel stressed out and a drink sounds really nice. The problem with this long-term is that people don’t develop other coping skills.

They have alcohol to cope and that’s about it and nothing else is going to compete with that. No breathing skills, no visualization, no exercise is going to compete with the speed and effectiveness of alcohol. It is a difficult habit to break. And oftentimes when people go to break it, they are surprised and in some cases shocked by the level of cravings they get.

There may be no physical withdrawal. However, the withdrawal they feel is the agitation from feeling stress that is unmitigated by alcohol. It is the habit that is difficult to break changing patterns and having to find something to do that isn’t going to cause more problems like overeating or other things that can get really compulsive.

The question of when our clients are using alcohol to sleep is how often, how many times a week are they doing that? I would say if it’s every week, that feels like they need a different coping mechanism. If it’s once a month, I don’t really have an issue with that. Once a week feels like that’s going to increase and that drinking to get to sleep is going to create more and more problems.

If someone that you’re seeing is drinking to get to sleep, that would be one of the very first things I tackle trying to see if they can cut that back and if we can figure out how to help them get some sleep. whether it’s medication or a specific therapy, like cognitive behavioral therapy for insomnia. Which by the way is available free on the internet. It’s not done for free. Like there isn’t a therapist doing it for free, but the VA put out a whole sheet on CBTI for everybody to access and it’s actually pretty cool. I’ll put a link in the show notes.

So getting to sleep is one of their very first things I tackled regardless of substance use, because I feel like if sleep is off, it’s going to affect other parts of the body and I want to be able to rule that out.

If your clients are using alcohol for stress release. The first thing I would do is talk with them about why they’re doing it and at least help them do it in a way that is conscious. Where they are realizing that they’re not drinking because they deserve it or because it’s normal, they’re doing it because they feel stress and they want to alleviate the stress.

And then I want them to notice what that does to the evening. Are they able to get things done? Are they able to spend it in a way that they like and help them start to see what the impact is of that alcohol? Besides the issues that alcohol can cause, part of our job is to help people cope with their stress and anxiety in healthy ways.

Our coping skills, the ones that we teach can be really effective and helpful, and they’re not going to compete with alcohol. And so if alcohol has become the go-to, that’s a really big issue to address. I would want to know how often in a week they’re using alcohol to de-stress and when they drink, how much? What’s the average amount?

I find that people often say two drinks, two sips, two hits two whatever it is. I don’t know why it’s two one sounds like nothing and that’s not accurate, but more than two sounds like a lot. I don’t know. So I would just clarify, what are we talking about? Two what’s two 40 ounces of malt liquor, two mixed drinks, two five ounce glasses of wine, depending on what it is.

So I’d like to know how many times a week and how many times a month. If it’s a couple times a month, I don’t know that I have an issue with that. If it’s more than that, where it’s every week, that feels like that’s a slippery slope and that it’s going to continue because stress increases. It just does if we’re not learning how to cope with it and lower the stress, then it just sort of piles up. Additionally, if someone is not getting great sleep the next day, then they’re also going to be more irritable and have less distress tolerance, which is going to increase their perceived stress.

Let’s move to talking about social anxiety. Years ago, I met a client who had significant social anxiety. Although, that wasn’t immediately apparent to him. And he came in because he had gotten some consequences while drinking. He had gotten in a fight with his partner through something and punched a door. What he told me was that he and his partner fought a lot and that when he was drinking, he had trouble controlling his anger. So I started talking with him about his history, just like we normally do about growing up, about going to college, about his job, about his family and about his drinking habits.

And what it turned out to be was that this person had extreme social anxiety, like plus two standard deviations from the mean kind of anxiety. And I was thinking about him and like, wow, that must’ve been really hard growing up and having that level of anxiety and managing it.

He wasn’t drinking at the time he was seeing me because he had legal issues and wasn’t allowed to, and would get in a lot of trouble. Which sometimes stops people and sometimes doesn’t, but for him, his anxiety was absolutely keeping him from drinking. But his energy when he was with me was like he was going to explode at any moment and not necessarily in an angry rage, but panic.

And it was bubbling at the surface the whole time. Really sweet guy, not someone who’s normally violent and angry, just literally at the edge of a panic attack all day, every day. So as I explored this drinking, what happened was when he went away to school, he found out that drinking was really helpful.

He found out that drinking made it so he could be social with people and hang out and be at parties and have fun and be funny. He found out it was easier to talk to women. Then he figured out that if he had a drink or two, before he went to class, that he was able to do that with less stress. Alcohol was like a godsend for him. He recalled drinking a few times in high school, but not a ton. But when he went to college, he found out that the anxiety of being away from a comfort zone, away from people he knew, away from all the support he had was just too much for his social anxiety.

He talked to me about when he would drink this feeling of peace and of calm and of relief. And I felt for him. It was so palpable how much anxiety this man lived under and yeah, alcohol was effective. Until it wasn’t.

He ended up flunking out in the second semester because he was drinking all the time. Because the alcohol stopped working and so he had to drink more and then he was drinking so much. He wasn’t going to class and couldn’t concentrate and wasn’t turning in homework and all sorts of other things that come along with that. And then the shame of flunking out. And having to return home was also a lot.

What followed were a few years of drinking to deal with shame and stress, drinking to deal with social anxiety outside of work and drinking, to deal with the stress of his relationship. In addition, drinking to go to sleep.

Social anxiety is incredibly powerful as we know. I find that lots of people will say, oh, I have social anxiety. When I hear that, I’m thinking, do you, do you have the same level of social anxiety that I’m talking about here? Because yeah, we have social anxiety about different things. The fear of speaking in front of people or being around people is pretty common. What we’re talking about here though, is some very distinct things that are part of social anxiety. They are debilitating and often brushed off as, oh, you’ll get over it. I used to feel anxious like that too. It’s no big deal.

So thankfully I was able to convince this young man to try some medication and it was a miracle, honestly. It took a little while, but he started having maybe one panic attack a week and then down to none and then able to go socialize and then speaking up and treatment groups that he was in. It was a huge transformation and I saw him be happy, truly happy.

What happened to him was that his alcohol use was started by social anxiety and then did turn into a straight up addiction over time. Physical withdrawal and the whole deal, whether your clients have reached that point or not. I don’t know.

All this time when we’ve been talking about assessment, the last, I don’t know, 5, 6, 7 episodes where I’ve been talking about how to set up a conversation, how to talk to people, how to get a substance use history is all about trying to figure out how it started, what the purpose was, what the purpose is and whether or not they’ve crossed into the place where addiction has taken over, how we treat. It depends on where they’re at in that spectrum.

One of the quickest ways to find out what’s going on is to ask them how they feel about an experiment. Could they try cutting back and having only X drinks that night, or could they cut back and not drink at all for the next three days or whatever it is that sounds like a little bit of a push.

We’re not asking them to quit drinking. We’re not asking them to do anything permanent. All we’re asking them to do is an experiment to see how it feels. If it turns out good and they feel good, then we can build on that. If they struggled, then we talk about that as well.

Finally, let’s talk about having fun or partying. Drinking can be fun. Can be really fun. There were plenty of times that I drank that were fun, and I didn’t do anything stupid and ended up having a good time and was safe. Because I’m an addict that didn’t last and even though I would only drink six, seven times a year. Uh, it started getting bad, which is why I don’t drink. That is pretty typical for people who have addictions is that we can cross addict very, very easily. Which is obnoxious and is just how it is.

It is normal for people to want to go out and have fun and have drinks be part of that. People look forward to going to the bars, to go into clubs and being able to have a few drinks and cut loose. It’s totally normal and perfectly fine in my opinion. How often is sort of how I judge that and whether or not it’s fine or whether or not it needs a discussion and perhaps a plan. It also depends on how much we’re talking about and what the consequences are that they experience.

If there are blackouts ever, that’s not normal, it is not normal to black out when you drink. I would want to know how often they blacked out and did anything happen during those times? For normal drinkers. If they have gotten a DWI, they usually stop drinking, and driving. It is enough to scare them and they’re like, fuck this. I’m not doing it.

People who get more than one DWI, there’s an issue there. That is just my experience. It is entirely possible that someone could literally have lightning strike twice. And that they are a normally responsible drinker and they thought they were fine. That has not been my experience with people.

If there are other consequences, like they’ve made a fool of themselves, they got injured, their friends were frustrated with them and how they were acting. Those are things I would pay attention to if those things are present and it’s not an isolated incident then I would definitely talk about it. If somebody is always getting sick every time they go out and party or making a fool of themselves somehow, or having an accident of some kind or driving drunk and it’s happening more than just an isolated incident, to me, that’s worth a discussion.

We’re not judging them. We’re just wondering where this is at. If they’re going out and getting absolutely hammered in places that are unsafe, whether it be situations where they have to drive or a lot of vulnerable people, whether it’s women or other folks that are vulnerable, getting really drunk and to the point that they can’t function and can’t protect themselves, I think that’s worth a discussion.

So when it comes to partying, we’re talking about frequency, quantity and consequences. So frequency, meaning are they going out Friday and Saturday night? Are they going out once a weekend? If they’re going out once a weekend, every weekend, I don’t know if that’s a problem. It depends kind of on how much they’re drinking at the time, but I don’t know, that feels fine.

If they’re going out both nights on a weekend every weekend, I don’t know that that’s immediately a red flag, but it does bear conversation. That means that they’re spending both days on the weekends, recovering from going out and from lack of sleep. That’s going to build up over time.

I mean, when you’re really young, you can do that. I dunno, something happens in your late twenties and early thirties that like, that’s not happening anymore. Your body doesn’t bounce back from that. I think that bears some conversation about how they feel during the week. Do they feel ready to go on Monday mornings or whatever their weekend is? That’s something I’d be checking into.

For some reason. Thursday night it’s a really big bar night. So I’d want to know, are they going out Thursdays or they’re going out three nights a week, three nights a week. Feels like a problem. If it was three nights a week, once every couple months, like that sounds fine to me. And here, I’m just giving you my opinion based on my experience with people and what I have seen lead to issues.

If this is not your experience, then go with your experience. Trust the data you see. What I was asked though, in these questions was how much is too much? What needs a conversation and a plan and what is not concerning.

The quantity of what they’re drinking, the volume of it on each of those nights is important. Knowing what they’re drinking, how much they’re drinking and if they can’t tell you how much they’re drinking, that’s also something that is worth a conversation. In my experience, people who go out to bars and clubs a lot, have bad experiences, or have witnessed them at least a few times.

I don’t know necessarily whether it’s them being involved, but things have happened around them to people they know and potentially to them. I would want to know what those experiences are because perhaps most of their experiences are good and then probably that’s okay. However, I feel like people want to minimize what’s happening so that it’s fine and they don’t have to look at it.

I want to go back to setting up the conversation so that we don’t have to face a lot of defensiveness about it. We’re just curious. We’re just asking how they do things. If there isn’t a problem, then it’s fine and we can let it go and move on. If there is a problem, the chance that it will progress is extremely high. Tolerance is very, very real. When somebody develops a tolerance to alcohol, they have to increase the amount that they use in order to get the same effect. It’s just biology. With that increased alcohol use comes higher risk for adverse outcomes.

I’m going to address two more things really quickly, because I know this episode’s getting kind of long. One is about “I drink because I like the taste”. This can be absolutely true. I personally know people who really do love the taste of alcohol, certain alcohols usually not all of them. And they will be really specific about what they do like. If people say they like the taste and they’re just drinking random stuff whatever’s around. I don’t really see that as being accurate when I’ve seen it happen.

When people really like the taste, they can talk about it in terms of ingredients, the way it was made, how it was distilled, et cetera. They might even be making their own and they don’t drink things they don’t like. That is normal. Still. We want to check on quantity and frequency just because we want to be sure, but it seems perfectly fine. People say that though, as a defense and to keep people off their back.

When I’m given that reason for why someone drinks the majority of the time, that’s not the reason they’re drinking. As we go through it. We find other reasons that they might like the taste of alcohol, but that’s not the primary reason and if you drink enough, you can’t taste it anymore. So the taste starts to become irrelevant.

The last part I’ll say it’s just a caution. When people drink, sometimes they will drink and mix substances. Sometimes accidentally. There have been people who have died from accidental overdoses because they mixed something with alcohol and depressants, stack.

So if you’re taking pain pills or some kind of downer and drinking alcohol, that depressant effect are on top of each other and therefore increasing the effect on the nervous system. I know on pill bottles, it says don’t mix with alcohol, don’t drive or operate heavy machinery. And a lot of times we kind of just ignore that because a lot of labels that we get from medical stuff feels sort of alarmist. A lot of things mixed with alcohol are really dangerous.

For us specifically benzodiazepines, opiates, those sorts of things are really dangerous. So that’s something that we want to make sure that when we’re talking with people, we’re just like, so you’re also taking this med talk to me about when you’re going to go out drinking what do you do about that? Maybe it’s Trazadone or Ambien. We just want to see what they’re mixing, because that’s a potential problem.

To sum up someone drinking once a week, even a little more than would be “moderate”. I don’t see a problem there. That’s not something I would get all worked up about. Someone who’s drinking once a week and having consequences, like getting injured or blacking out or driving drunk. I’m going to look into that and just poke around the edges to see if there’s an issue.

Someone who’s using alcohol to deal with stress on a weekly basis. Even one time a week. That’s something I would want to look into as well. It’s not necessarily that I’m saying that these people are going to turn into alcoholics. The question is, is their use of alcohol okay and no big deal, or is it in need of a conversation and perhaps a plan.

I hope that the information about alcohol and a discussion about these scenarios has been helpful. If you have specific things that you’d like me to address in terms of clients or even cases, I encourage you to reach out. I would love to be able to give you feedback on the situation and be able to share it with listeners.

I would, of course, make sure that we don’t have client information or identifying information. Anytime I talk about a client that I have had, I have changed details to protect their anonymity.

If you want to send me a question or a suggestion, send it to betsy@betsybyler.com. I will respond to you and perhaps it’ll be a topic for the podcast.

Next week. I’m going to be addressing another one of the questions and this one’s going to be about marijuana. The other substance that we hear the most about in outpatient, mental health therapy. I hope you’ll join me for that podcast and until then have a great week.

Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast. And until then have a great week.

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