Labelling & language in mental health & alcohol with Dr Lucy Foulkes

In this episode we talk to Dr Lucy Foulkes about labelling and language in the context of mental health and alcohol issues.  We discuss how labels like alcoholic or schizophrenia may serve an important role for people to identify or respond to problems, but also carry important implications for stigma and recovery. We explore how there are many similarities between the pros and cons of labelling in mental health and for alcohol issues, but some important differences.

Dr Lucy Foulkes is a senior research fellow at the Anna Freud National Centre for Children and Families and an honorary lecturer in psychology at UCL. Her research focuses on mental health and social cognition, particularly in adolescence. She is the author of the book Losing Our Minds: What Mental Illness Really Is And What It Isn't (Penguin Random House, 2021), which explores how we talk about mental health and illness.

Transcript

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James Morris: 0:00

So thanks so much for agreeing to come on the podcast, Lucy. So you wrote an article in The Guardian about some of the issues around the conversation about mental health, particularly in terms of labelling and diagnosis and kind of the tricky territory between what we should perhaps recognise as normal in inverted commas, kind of periods of low mood or anxiety, etc. And when that might be then considered more kind of a clinical mental health issues. So I'm really interested in the same kind of questions in the context of alcohol use and problems, particularly in terms of how we describe and understand you some problems. So can you tell me a bit more about perhaps that article and what you think of the key issues in terms of labelling and language in the context of mental health to start with?

Lucy Foulkes: 0:46

Yes, so So I wrote the article, based on a book that I that was published around the same time losing our minds and in both are very interested in the idea that in our efforts to de stigmatise and raise awareness of mental health problems, particularly depression and anxiety, we've kind of pumped out that terminology into the public domain. So much so that it actually might be being used to readily so you know, depressive symptoms of depression symptoms of anxiety on a spectrum. And yet, the more we promote the idea of this language, the more it gets used for quite sort of mild, transient problems, you know, at the milder end of the spectrum. And I think that has some consequences that we can talk a lot about. So I think one issue is that kind of dilutes the language and dilutes the meaning of it for people who, who really do have severe difficulties. But at the same time, I think it's also sort of unnecessarily worrying and frightening for some other people to kind of take on these labels when perhaps they don't necessarily need them.

James Morris: 1:51

Obviously, you know, I'm kind of interested in in parallel to alcohol. Now, I guess, without in terms of alcohol problems, you know, we've got this quite dominant idea of alcoholism as a kind of severe form of alcohol problem, but a kind of lack of language to describe what we might describe in kind of clinical terms hazardous or harmful drinking, that those times don't really resonate with the public, or they don't really see those patterns of drinking as necessarily problematic, often because they contrast that against the kind of stereotypes of alcoholism, so to speak. So in a way is it is this partly about people trying to destigmatise or make sense of mental health is something that kind of everybody experiences. But inevitably, and perhaps, unfortunately, to some degree, drawing on ideas of kind of more severe characterizations of mental health or alcohol problems, because that's sort of the easiest way to try and make sense of them.

Lucy Foulkes: 2:49

Well, this is interesting. So as I think there are some parallels with what I'm interested in, in terms of anxiety and depression, and what you're interested in, in terms of alcohol abuse, but it's a slightly different problems. So I think all of its exists on spectra. But my concern about depression anxiety is that people at the milder end of things, or people who don't sort of fully meet clinical criteria have to readily and to perhaps do willingly using this language to describe themselves and others. And what seems to be happening in terms of alcohol use is that, again, it's on a spectrum, but sort of the opposite is happening. So you're saying actually, people at the milder end, or kind of in the middle of things should take on this terminology and consider themselves to possibly have a problem. It shouldn't just that concept shouldn't just be reserved for the people at the extreme end of things. So I think it's interesting that both on a spectrum, language matters deeply, but in slightly different ways for each, each phenomena.

James Morris: 3:47

But I certainly think the problem is that, you know, it's an absence of terminology or language to appropriately describe what people know are not severe alcohol problems, they know in a sense that they're not alcoholics in inverted commas, but therefore, the lack of language and wider framework to see things in, you know, what I would see as a continuum that is kind of there is a natural human tendency to categorise things, you know, health and illness versus alcoholics or nots. That's, you know, that kind of helps us in some ways to simplify and categorise the world we need to do that to get by and not see everything in all its complexity. But yeah, certainly my view is in the alcohol field that that explanatory vacuum or lack of language to describe, many people would say it's kind of non alcoholic, but heavy drinking doesn't exist. Whereas I guess you're saying that in mental health, the language of the more severe end is kind of almost being co opted, but inappropriately or with with kind of complicated consequences.

Lucy Foulkes: 4:52

Exactly. So we need language to be able to describe our difficulties and our suffering and our distress and we do need to pay attention to the milder stuff, you know, partly because it's bad enough in itself, you know, even mild anxieties is horrible. But also because it can just be the start of something more serious, you know, especially in young people. So we shouldn't, I'm not saying let's dismiss everything that falls short of meeting clinical criteria, but it's it's more about being careful about the language. I think what's interesting with alcohol use that perhaps doesn't quite have the same parallel is this artificial binary, that people create thinking, you know, you either are an alcoholic with inverted commas, or you're not allows people to dismiss or deny the idea that they have a problem or that they're doing something that's causing them or other people harm. So I think that the value in the need to promote the idea of a continuum when it comes to alcohol use is the idea that, you know, you can still you can still have a problem that's causing harm that might need managing will help, even if you don't meet the criteria that people often have in their head about what counts as alcohol problem. Now, I can think of examples of people thinking, oh, you know, they can't, I'm going to use the word alcoholic. But I know that that's not generally used now. But you know, people say things that are they can't be an alcoholic, because they hold down a job or something, you know, and it's a kind of distancing yourself and protecting yourself and thinking I can't have a problem, or they can't have a problem because it doesn't meet these artificial criteria. So I think the language, the need that you're trying to change for my understand is that you don't need to meet the full criteria to get to have a problem and to need help. Be useful to promote that.

James Morris: 6:34

Yeah, I guess the problem is that there are no easy one to one replacement. So yeah, we'd certainly in clinical or policy guidance, we don't talk about alcoholism, instead, we have dependence, and that's on a spectrum. Cattle categories of hazardous or harmful or risky drinking, depending on what guidance you refer to. But yeah, absolutely. The there's no kind of single word replacements in the sense that Yeah, even the word alcohol problem is two words, but it's still a problem for one person may not be for another. And you know, problems is such a broad catch all that's, you know, and again, in the context of people's own lives, well, some using alcohol as a kind of coping mechanism is very understandable in many ways, even if knock on effects down the line. So I guess it comes down to trying to develop a more nuanced understanding, or understanding of alcohol use and problems, I kind of like the idea of that as a continuum. So you kind of have use on one end and problems on the other and every kind of type of problem or type of use, you could put on its own kind of dimension or scale in a way.

Lucy Foulkes: 7:43

Yeah, exactly. It's not even just a sort of single line. And have there been any campaigns that have attempt, you know, sort of public awareness raising campaigns that have attempted to promote this, this idea of a continuum.

James Morris: 7:56

I don't think so not, not explicitly or not, not with their intention of necessarily promoting a continuum model in alcohol use or addiction that I'm aware of, you know, in kind of my research experiments, we promote the idea of continuum by having someone talk about their alcohol use as something that could happen to anybody you know, that they went through, you know, it's kind of driven by their their kind of life experiences and their circumstances that anyone enacts, or alcohol, heavy environment with lots of peer influence, and then going through a period of stress might understandably start to use alcohol heavily or problematically over time. That's kind of how we promote in experimental studies. And that's obviously directly contrasted to the idea of a kind of disease model whereby you kind of have it or you don't, and if you have it, it's because of perhaps biological or neurological things that are kind of fixed within you. And, and obviously, that's heavily tied to stigma as well, where the idea of key kind of stage of stigma or part of the process is the separation of us and them. And I think, as you were saying earlier, that there is this kind of motivation amongst the general public or most drinkers to create that separation, because it serves them, subconsciously, at least to put themself in in the non stigmatised safe group.

Lucy Foulkes: 9:21

Yeah. And I think that does happen in mental health to a degree as well. Well, so thinking in advance of talking to you about whether that same phenomenon is happening, and I think it's interesting. So it really depends on what disorder you're talking about, for example, something like borderline personality disorder, which is very contested as a as a label and a concept. And schizophrenia. This certainly is happening that you know, there's people absolutely do not want that label, and there's this kind of us and then other ring happening, depression and anxiety. I think it's very much starting to shift and this is what I'm so interested in is that people not only seem less reluctant to take on these labels, but in some respects actually want them or, you know, sort of willingly have them. Say one example, I did a yoga class a couple of years ago, and the girl next to me had a tattoo on her arm that said, Warrior warrior. And I thought that was really fascinating because it's sort of like the extreme version of, of having a diagnosis kind of in your Twitter bio, which I think in itself is also an interesting phenomenon. It's as a not only an acceptance, but a sort of desire to promote having that label. I think you my sense of it is that that's fairly contained to anxiety and depression. I don't think you'd get the same thing with people who have, you know, problem with alcohol, or other mental disorders like schizophrenia?

James Morris: 10:47

What do you think? I think these are directly correlated to how stigmatised they are. I mean, I met someone the other day, who was talking about having an autism diagnosis. And I think, you know, and he said, that's sort of the best thing that's ever happened to him. And I think that's very common, isn't it? Because I think I think I'm not sure, but I think the stigma around autism is less. And I think that perhaps is partly related to the fact that probably most people recognise it as a spectrum disorder as such, rather than, you know, kind of a binary Autistics or not. But But yeah, he seemed very happy and proud to talk about having that diagnosis, like there was no kind of need to feel. Of course, he's right. But stigma is kind of the the shaming aspect of it, that people are trying to protect themselves against, that they know other people judge them for having kind of stigmatised condition and treat them differently. You but yeah, like alcohol problems are very heavily stigmatised once you're in that threshold of having a problem, and that's why the kind of gathering happens, where it's maybe you know, depression, anxiety, autism, it's just there's more public acceptance, that these are things that are on a continuum, and we all kind of experience or many of us experience to some degree.

Lucy Foulkes: 12:04

Definitely. I mean, I think it's partly about recognising that it's a spectrum. But I think it's also partly about how frightening does the disorder seem to other people, how threatening is it to their own understanding of the world and the way people should behave? You know, if you have alcohol use disorder, or schizophrenia, it might make you behave in ways that other people find unpredictable or don't understand, I think that probably plays into how stigmatised a disorder is.

James Morris: 12:37

And I think the reason why alcohol and addiction problems are so heavily stigmatised is definitely in part because of the way in which people see it as a choice involved, that the people are sort of have made choices, or, you know, just not exerting willpower. And that, of course, you know, part of the idea of the disease model was to try and move away from the kind of old moral model that when people were very much to blame for having an alcohol problem as such. But that's still a big part of the stigma is that people are still in some ways seen personally responsible for having addiction problems in the way that they might be less so for having mental health problems.

Lucy Foulkes: 13:19

I think it's so interesting that it's yeah, it's problem drinking so obviously, involves a behaviour. I mean, obviously, lots of mental health problems involve behaviours. But I think that there's sort of the impression that it's a sort of intentional action, there's definitely a kind of heavy moral dimension of a lack of understanding of, you know, if you're choosing to do it, and why don't you just not do it, especially when it's when it's causing all sorts of difficulties for the person and for everyone around them.

James Morris: 13:48

And that's obviously part of the attraction of, you know, identifying as having addiction or alcoholism, in a model that conveys it as a kind of disease or something that's beyond your control, because it obviously does alleviate that kind of sense of blame that is so heavily connotated definitely, which is one of the benefits, you know, idea of diagnosis is so interesting, because, you know, across the board, there are, you know, different disorders, there are some benefits and some costs. And I think one benefit is definitely that idea of removing, letting you know, it's not your fault that you feel, do the things you do. But the issue I have with it is that blame is just one component of stigma. And, you know, there's these kind of meta analyses where they look at these, what they call attribution effects, different kinds of beliefs about the causes of addiction or alcohol problems. And even though if you see it as a disease, you might, you know, people generally will say you're less to blame. They'll also see you as more different because it's a disease and therefore, the kind of almost more instinctive side of stigma comes out so people will even discriminate or judge you more as a kind of diseased other even though they may blame you less.

Lucy Foulkes: 15:03

So it's that really complex two sided rationally and the idea that you're more stuck with it right? Like it's so it might remove the blame in terms of it's not your fault that you have it or you are like this, but it but it's haven't stuck with it and it's permanent. Yeah. Which again feeds into this sort of fear, I suppose around how these people, etc.

James Morris: 15:28

And the other thing going back to just what we were saying about labels to make sense of a problem or to own it, and, you know, particularly of alcohol is the idea that an alcohol problem is characterised by loss of control or lack of control, which, again, is maybe partly derived from the need to remove the idea of blame from oneself. But, but, but you know, that that can be kind of self fulfilling in itself as well. And that people, you know, like maybe that, you know, the abstinence violation effects that, you know, I've done experiments going back a long time that people who believed in the idea of the sort of AA saying one drink one drunk, you know, the idea, if you have one sip, that's it, you're going to have a full blown relapse, those things can be self fulfilling, and obviously, a big part of alcohol treatment is actually building self efficacy.

Lucy Foulkes: 16:19

And do you mean that as in like, it's become self fulfilling? Because if you promote that idea, then someone who has a problem with alcohol, if they do have one set, but one drink, they think, Oh, well, I'm screwed now. So I'm just gonna pick exactly when actually, they could perhaps pull themselves back.

James Morris: 16:34

Yeah, absolutely. That's, you know, and certainly in terms of what's called relapse prevention, although the term relapse itself is obviously questions because in in a sense, it implies something, you know, is associated with a full blown relapse, whereas a lapse or a hiccup, or even a kind of learning opportunity might be better ways of looking at it. Yeah, we're gonna love it.

Lucy Foulkes: 16:54

Isn't it so interesting that every element of this, it's about what words you use and the implications that they have?

James Morris: 17:00

Exactly, yeah. And what kind of stereotypes or thought processes or frameworks they kind of intrinsically trigger? Yeah, but but but yeah, this idea of controllability as a kind of key characteristic of having an alcohol problem, I think is, you know, needs a lot more attention as well, because even studying, like aspects of compulsion, or cravings, or whatever, those things are highly subjective and also amenable to changing the way you frame or what language you use to describe the problems or the experiences etc.

Lucy Foulkes: 17:32

As in you could potentially make things more malleable, genuinely more malleable, by the way you talk about them? And

James Morris: 17:39

Exactly. Yeah, I mean, there was a really good study that just promoting the idea that addictions are malleable rather than fixed, they found that the people were more likely to seek help. There's other studies that show that people that believe it is a more fixed thing do have higher chances of relapse.

Lucy Foulkes: 17:59

And yet, I feel like these ideas just aren't really out there in the public domain. And they should be you know, this, this is not well known information about alcohol use, I don't think

James Morris: 18:09

No, I totally agree. And, and that's the challenge. And I guess why I'm so interested in you know, why I think it's so important that the alcohol and addiction fields learn from what's going on in mental health where, you know, obviously, it's not perfect, and there's a long way to go. But I think in in a lot of ways, there's a lot more attention or a lot more discussion about the different framings, the different models, how these conversations may impact, more investment in trying to address stigma, even if much of it falls short of the mark. Absolutely. And I think, you know, there's interesting examples in terms of free Since dry January, which is probably you know, over the last few years really kind of increased in popularity, and I think that's undoubtably a good thing on the whole. It's, you know, there's obviously important questions about who takes part in it. And you know, it's always being sort of caveated by it's not intended for dependent drinkers, particularly those who, you know, might be physically dependent,

Lucy Foulkes: 20:22

Oh definitely, it's funny that you bring it up, because I'm doing dry January for the first time ever. I've normally dismissed it as an idea. But yeah, some of the stuff I've read about it, you know, the first thing is, you know, actually, for some people, it can actually be fatal. So I think that's the tricky thing is with alcohol use, and with all mental disorders, is that they are on a spectrum, and we need to promote that. But just because someone's on a spectrum doesn't mean that the two extremes are, you know, much of a muchness something can be on a spectrum, you can still be up at the extreme end, and have something not just quantitatively, but qualitatively, quite different. So all these efforts to promote the continuum idea, which are important and true, need to also be balanced with the idea that that doesn't mean everyone's all the same, that you know, there are still it sets the bad to be at the extreme end of things.

James Morris: 21:14

I was reading something about diagnosis in mental health, because obviously, there's much more debate about pluralism and the different kinds of models taking place, but kind of psychiatrist describing diagnosis or categories, I think it was somewhat useful oversimplifications. You know, they're useful in the sense that we need to Yeah, we just need to as humans categorise things, and particularly if we, you know, we're going to have treatment systems, which I think we need to for both alcohol and mental health issues.

Lucy Foulkes: 21:47

I talk about this a lot in the book, actually, to say that, you know, lay out but it is all a spectrum. But in spite of that, we do still need to create these somewhat artificial boundaries, because they serve some purposes, you know, we need to, even though it's artificial, we do need to sort of draw a line in the sand and say, this is where we're gonna be, we're gonna call something depression, rather than struggling with your mood for all sorts of reasons in terms of running trials to test treatments in terms of making sure we don't give, for example, medication to everyone, you know, you need to draw the line somewhere, even if it's an artificial one. I think it's it's trying to promote that understanding that these these cut offs are artificial.

James Morris: 22:26

And that goes against our kind of innate cognitive need for for categorization and reductionism. Definitely. And, you know, I guess, I guess the DSM is is an example of it was originally developed for for research purposes of kind of collecting symptoms that such was the kind of almost desire for creating categories and labels about mental health conditions that that became the way of categorising and labelling.

Lucy Foulkes: 22:52

Yeah, sort of got totally carried away. But I think, yeah, that just because of flaws, lots of flaws with the DSM and with the idea of categorising, I don't think the solution is to, you know, eradicate the attempt to categorise all together. It's more about promoting the idea that is messy, you know, it's really it's not straightforward. And people can't agree about where the lines, you know, the lines are made up, and they keep moving. I mean, this is a big thing I talked about, I think it's useful to look back historically, and see how much there's the boundaries that people draw around these conditions. And the names that they give the conditions keep changing, right? I mean, that's a really useful demonstration that it is essentially, humans trying to draw lines around things that don't don't clearly exist in that way. In the real world.

James Morris: 23:37

Yes, a sense making process, I think, which both clinicians and people with who experience problems and engage in treatment, and I guess, you know, this kind of movement around formulation, which I think, you know, most most clinicians or good clinicians who would use categorical diagnoses, as you know, in a functional way would be be actively trying not to use them in the context of conversations or labelling with the person with with problem.

Lucy Foulkes: 24:08

I think it also really depends on the person doesn't I think there's a lot of enthusiasm to sort of dismiss diagnosis diagnostic categories altogether. But I think what often gets lost is that there are big individual differences in terms of whether people want these labels and these terms or not, some people absolutely don't. But some people just like the person you mentioned with autism find it extremely valuable, either because it helps them understand themselves, or because it leads to treatment, or it's because it's a term that they can use with their family or their work or whatever. I think that the argument about whether diagnostic categories should exist or not tends to forget that actually, maybe they can exist for some people and not for others, you know, that there should be flexibility from the person's perspective and from the clinicians perspective about when you use that language, who it's useful for.

James Morris: 24:58

I agree although the big caveat for me, though is also that, you know, certainly if we look at Alcoholics Anonymous, and you know, the massive role that's played out, undoubtedly, in helping many millions of people in saving, you know, a number of lives that you couldn't put a number on. And obviously AA is, is kind of characterised by identification of the self as an alcoholic. That's a such a big part of the process. And I think there are undoubtedly many people who are very willing to do that and that is very helpful sense making process for them. However, I would say, you know, like, one of my favourite kind of studies by Hill & Leeming talks about how some people really wrestle with taking on that identity in that context. So they kind of know they have a problem, they know that they want to do something about it, and that's why they're engaged in AA. But they know that the label is very heavily stigmatised. So they might draw on people in the in the group and, you know, find solidarity with people in that group. But they still wrestle with taking on that label and knowing all the stigma entails and all the consequences, I guess, you know, like, people obviously have the right to self label, but they also do so in a context where, where certain narratives and ideas are kind of norms or representations of alcohol, and they don't necessarily have alternative ideas. And I guess that's why we're seeing things like smart recovery or other alternatives to AA.

Lucy Foulkes: 26:29

Are they less dependent on the idea of yourself?

James Morris: 26:32

Yeah, exactly. So smart recovery is more of a CBT based peer support network. But but the mechanisms are mainly the same, the research tends to show that here support is, is the support, and the social network of a group does not drinking rather than your pre existing networks, which are focused on drinking, those are the main active mechanisms. But of course, there is the big aspect of social identity. And for many people, recovery is about changing your view of yourself and who you are with, from one that alcohol was a defining feature to one where not drinking is a defining feature.

Lucy Foulkes: 27:06

Yes, I one thing I was just thinking, then is how interesting it is. Because with other disorders, you know, if you have a treatment for depression, there wouldn't be this requirement in you know, session, one of CBT that you sort of admit that you're depressed..?

James Morris: 27:23

Yeah, I mean, even in Yeah, and a lot of AA groups, they're not step focused. So you don't have to work through the steps. You know, the first one of admitting powerlessness, you know, yeah, I forgot what they call the thing that's sort of where they just non step groups where people just go, and they draw on each other's experiences in solidarity. And it's, you know, I attended AA for a bit when I, a couple of years after Actually, I'd stopped drinking at 21. And I found that the peer support aspect of it's so powerful, it was so refreshing to have people that actually supported me and not drinking when I've been generally kind of butting up against a peer network who were sort of saying, oh, you know, you don't have a problem is fine. You know, why don't you just drink a bit less?

Lucy Foulkes: 28:07

So, which I think is partly why I've seen recently some movements as a movement I'm sure you're familiar with called the sober girl society.

James Morris: 28:17

Yeah. And there's Soberistas, and Club Soda and so many now.

Lucy Foulkes: 28:21

Yeah, yeah, exactly. And I think my sense from those is that this huge part of it is being part of a community of other people who are experiencing and yet trying to change something, and it's in a similar way to you there must be incredibly kind of comforting and powerful.

James Morris: 28:38

And there's been some research that some people are using these kind of alternative groups and networks or movements, because, you know, they don't want to adopt the label of alcoholic that doesn't feel right for them. So yeah, they're kind of drawing on on different ways. You know, maybe because, you know, they feel more comfortable talking to other women who have experienced the same stresses and pressures around I don't know, family and childhood or whatever. Well, interesting. You see this and so the girls society was set up by Milly Gooch, and yeah, talks a lot about her alcohol use in university, that kind of age and that being a deciding factor to stop. But yeah, I mean, that the that stuff just didn't exist, not so publicly. I'd say until fairly recently. But yeah, all of this has got me thinking about it's what a shame that all this these ideas are quite kind of behind closed doors. You know, I just I haven't considering the enormous onslaught of mental health awareness campaigns. I've not really seen anything about, yeah, alcohol use. Well, I think the exception is probably Adrian Charles, who I did the first episode with because he did this documentary called 'drinkers like me' a couple of years ago now where he spoke to, I don't know half a dozen or so people with alcohol problems but they represented very different experiences. You know, one person was you know, self identified alcoholic who'd been in AA for a long time that had worked for him and other people were people who'd cut down and he himself, you know, came to the conclusion, I think I'm just gonna cut down a lot. And obviously, you know, Adrian Charles is a very high functioning TV personality or journalist and, you know, for him to have modelled that I if I can have a sort of alcohol problem then kind of anyone can.

Lucy Foulkes: 30:18

Which I guess is what happened started happening 10-15 years ago with people like Stephen Fry and Ruby Wax, yes, maybe the same thing is happening with drinking. It's just a little bit delayed.

James Morris: 30:29

I think you're right there is you know, I was told by someone once, oh, if you go to an AA meeting in the Kings Road, you see all the celebrities in Hollywood actors. And obviously, you know, Alcoholics Anonymous is anonymous by its nature. So in the episode I did with Wendy Dossett, I kind of learned that actually, anonymity is is actually more about kind of humility, and not yes, it's partly about not kind of going out there and telling everyone or making a big deal of it about kind of getting on with it and keeping it to the groups rather than just kind of protecting people from from the stigma, which is obviously important, too. But yeah, I do. So I remember being in a meeting years ago, and someone's saying, well, we need the kind of Jamie Oliver for alcohol doing doing what Jamie Oliver is doing for food or kind of obesity.

Lucy Foulkes: 31:14

And you know, as we talk, I'm thinking there are countless celebrities and public figures who have now said they have problems with depression or an anxiety disorder. I can't think of, you know, there might be celebrities who are known to be teetotal, but not but not people who stand up and say, This is what happened.

James Morris: 31:32

And this was the problem that well, yeah, well, that's certainly something that I face because I want those kinds of people to come on to the podcast. And obviously, Adrian Charles, was brilliant in I'm very grateful for him. Having done that. I've got an agreement from Jonathan Ashworth, who was talking about his kind of experience of having of his father who died from alcohol problems and how that affected him in a very powerful way. And Dan Cardon spoke in Parliament several times as have other MPs, I think there's some MPs that are doing really good stuff. I guess what I would say again, though, is that the similarly with kind of Dry January, and most of these movements, they're all focused on sobriety. And I think obviously, abstinence is such a huge is an important, if not the most important route to recovery once you've had an alcohol problem, but you know, as Adrian Charles demonstrates, and I sometimes talk about myself, moderate drinking is possible, what used to be called controlled drinking is possible for some people and I think there are lots of people out there who are on the continuum, they don't have severe alcohol dependence, and they do have quite a lot of social capital, and a bit of realignment and cutting down their alcohol use would do them would still help from a health point of view, or at least, a huge benefit. But they're put off by doing that, because they think it's abstinence, or enough or carry on sort of thing.

Lucy Foulkes: 32:55

Yeah, exactly. And I think that's definitely this sort of colloquial understanding of problem drinking, is that yeah, you either have a problem or you don't. And if you do have a problem, then you need to have to give up entirely or just plough on as you are. And yeah, I think it would be doing a great service. If that was better clarified, I think,

James Morris: 33:15

Do you have any particular thoughts in terms of how, you know, alcohol problems and mental health issues overlap?

Lucy Foulkes: 33:22

You know, I think it's, again, it's this is a false separation in so many ways, so many people would not want to see themselves as, you know, having an alcohol problem, or separate to the sort of, you know, the things that they're, they're kind of, you know, life is difficult and stressful. And, you know, same my, I'm definitely not an expert on this, but my understanding of it is that alcohol is often used to cope with the symptoms of, you know, what we might separately call mental health problems. So, I'm sure you're aware, you know, as a kind of emotion regulation, strategy, a coping technique. So I think partly that's the relationship. So if you have very difficult feelings, you might be more inclined to use it to manage those feelings. But then also, I think part of the relationship is that once you start drinking in a problematic way, that then causes or exacerbates problems that then Well, firstly, directly in terms of cognitively, you know, making more anxious and depressed but also affecting things in the outside world in terms of your you know, your job and your relationships that might then themselves increase the mental health problems. So my understanding of it is that debts they're intimately linked and in a kind of vicious cycle.

James Morris: 34:34

Yeah, I think that effect or mood regulation, particularly for anxiety, there's you know, that's there's some very strong evidence that that's a key association with with problematic drinking. And I think that's, that's a key reason for needing to we still have on the whole very separate services and difficulty in kind of joining them up and getting them to work together. So yeah, again, That's a kind of another challenge in terms of how we both categorise, but also recognise the nuance of both issues.

Lucy Foulkes: 35:07

Yeah. And if you have both, you probably can't solve one without tackling the other.

James Morris: 35:12

Yeah, there's some evidence that when you do treat or work with one issue, the other is obviously more likely to improve. But yeah, still, yeah, I guess if you become less depressed or less anxious, you might be less inclined to drink to mask or manage those things. Exactly. Yeah. And certainly, in my case, when you know, my drinking was kind of peaking, I experienced, what what would probably be described as quite severe anxiety attacks, where I would suddenly feel very paranoid, as if something terrible was going to happen, even though I was perhaps in a perfectly safe environment, and would kind of have these weird sweating fits. But yeah, after I'd stopped drinking for a couple of weeks, they disappeared completely. So yeah, it's kind of kind of physiological effects of disruption to the homeostatic system caused by the messy drug that alcohol is or when used?

Lucy Foulkes: 36:06

Yeah, definitely. I'm sorry. Because those Yeah, those things are awful and terrifying. And I think, yeah, people might have little bit more sympathy for. I mean, I know you're saying that it's the alcohol that set that off, but I'm thinking about it in the other direction in terms of people having incredibly difficult feelings. And it you know, it's not surprising that people want to reach for something to dampen down or to cope with those feelings. And yeah, I'm not just talking about, you know, thoughts. I'm talking about, you know, your whole body, isn't it?

James Morris: 36:34

Yeah, absolutely. And again, just exactly as you're saying, you know, I think the reason that I was drinking very heavily in the first place is that I had sort of some internalised issues that I hadn't kind of yet dealt with. And I strongly believe the reason that I can now drink moderately is, you know, having done a load of psychotherapy, and resolved, I think, you know, a lot of the issues that I think drove me to quite heavy drinking as an undergrad. So I just don't have that desire to change the way I feel in the way that I did used to.

Lucy Foulkes: 37:05

Which is really interesting, because yeah, I remember someone saying to me, you can't you can't take alcohol away from someone who has a problem with drinking, unless you replace it with something else, you know, if you take it away, it's without replacing it with an alternative coping mechanism, you know, then that's kind of actively cruel, and it won't work. So it's interesting, what you're saying that you could take it away to an extent because you replaced it with another means of, yeah, managing what was happening?

James Morris: 37:32

Yeah, certainly in AA, they'll call it white knuckling where someone stopped drinking, but they've still got all the all the stuff to deal with that was driving the drinking. So you know, obviously, for everybody, that's, that's different. But I you know, I'm certainly, you know, strong advocate of there's, there's all the social and behavioural aspects to it. But life is difficult and stressful, and we all have ups and downs. And it's kind of a normal coping response, if you look at it in a kind of functional way to try and regulate our mood.

Lucy Foulkes: 38:00

Definitely, I mean, we will do it all the time. I mean, everything. So much of what we do is about emotion regulation, isn't it in all different kinds of ways, and just some of them are healthier than others?

James Morris: 38:11

So how are you finding dry January? And has has, do you have any thoughts about whether you might do anything differently? I guess it's still early, early days,

Lucy Foulkes: 38:19

It's very early days, day seven. But it's been a very interesting exercise. But I certainly wouldn't describe myself as having a problem with alcohol. But I like drinking, I really enjoy it. It's deeply social for me, and has been for a long, long, long time, right from when I was about 13, which I don't think is particularly unusual. I think there's, you know, as a British teenager at that time, but yeah, it's always something I've enjoyed. So it's, it's just a very interesting exercise to do dry down the way to, it makes you question when you do it, and why you do it. And, yeah, to what extent is it just a ritual, you know, on a Friday, on a Friday evening with your partner or whatever? And to what extent are you relying on it to, you know, overcome awkwardness, you know, social awkwardness or whatever. So I'm glad I'm doing I think it's an interesting exercise, but I don't know right now, if anything would change long term. Yes. To be kind of continued. Yeah.

James Morris: 39:18

I definitely think it's a really good thing for anyone to do just as a, you know, I kind of like the idea of mindful drinking, even though it's understood differently in different contexts. But for me, it means just really being aware that in a sense, when you drink alcohol you are drug taking. And that's don't mean that in any kind of judgmental way, because as I said, it's it's a normal part of human behaviour and most people drink without problems and experience far more benefits than they do negatives. Even though you can argue there's no safe level of alcohol use from a physiological point of view. I do think, you know, the relax and social benefits are obviously significant. It's not used problematically. But I think because of the degree of normalisation and cultural expectations around drinking, it's for many people just do not consider it as an act of you know, taking a drug, which it is. So just being a bit more mindful of it in that context,

Lucy Foulkes: 40:16

I think dry January is a good exercise in in in supporting that shift. Definitely just like anything, you know, there's read a book about a by Carl Newport about social media and phone use and going on digital detox. And his suggestion is to start with delete everything for a month. Because only by stopping using these apps, can you reflect that month? You know, why use them whether you really need to keep using them? And I think yeah, there's an interesting parallel there.

James Morris: 40:46

Yeah, definitely. Like, I think kids growing up today were being glued to smartphone is perfectly normal that, you know, we perhaps old older generations have the benefit of remembering a time when that wasn't normal to kind of compare that or kind of anchor a bit more towards. so yeah, realise that there you could exist without it.

Lucy Foulkes: 41:06

Although, although we did it when no one else had phones, I think it's incredibly difficult for teenagers now because it's so integrated in so your social life tricky, but that's another conversation.

James Morris: 41:19

Yeah, exactly. Well, thanks so much, Lucy. That's been a really brilliant conversation. And I think there are no easy answers or easy solutions, I think, to the question of labelling and language, but I think the main thing that we can do is keep talking about it and recognise that for almost any term or concept or way of thinking about something, there are pros and cons, and they're context dependent. They may work for some people and not others.

Lucy Foulkes: 41:45

But definitely, and also, one thing I want to say earlier was that not only are the labels in different language useful for some people, and not others, but within the same individual labels can have pros and cons. You know, in some respects, you might find a diagnosis, you know, like you were saying earlier about this sort of conflict. In some respects, it's useful in some, in some respects citizen and I think, yeah, I'm just all about trying to promote me once and complexity, but it's difficult because you know, campaigns and social media and limited word count, and everything doesn't really allow for it.

James Morris: 42:19

I think the stories just sharing a diverse range of experiences and stories is really important. And in the, in the context of alcohol, I think that it's not about silencing, you know, more widely known narratives and recovery stories, because they're important still, but it is about broadening out much more widely, so that we do have more Adrian Charles's and other people that have different experiences of kind of, you know, recovery. I don't even think it's the right word, but you know, changing their alcohol.

Lucy Foulkes: 42:49

Yes. So, yeah, definitely. Because I mean, we're all different, right? So we need to, yeah, promote different narratives

James Morris: 42:58

Horses for courses.

Lucy Foulkes: 42:59

Yes, exactly. But yeah, thank you. It's been really fascinating to hear about the parallels and the differences. Yeah. So thank you for inviting me.

James Morris: 43:08

Thanks so much for coming on.