Hi Ralph. I'm sorry you are still struggling.

I think all of us are different and some may need more structure than others. It's intriguing that you feel you need it, but you don't like it. What do you think it is about structure that you are resisting? Could it be about maintaining a healthy balance between different aspects of yourself?

You know yourself best. Have you assertively shared with your therapist your concerns about your depression despite the fact that you are still able to function?

What need does drinking meet?

I hope today is peaceful for you.

Maybe you're just labeling the things you still need as "depression" because they used to be part of your depression, which leaves your therapist wondering what you mean. Can you be as clear with them as you were with us, that you're having trouble with setting a direction and so on?

Too, it occurs to me to be honest with the people you haven't heard (maybe "I have difficulty focusing on what you said; could you run it by me again?") After all, that's the reality, though I know it can be hard admitting to a deficit in a work environment. And maybe there's an alternative you can use for next time, like taking notes? I guess I don't know what works for attention deficit, when your mind starts to wander ... but I bet something can work.

Beth, I think that I resist structure because I associate it with punishment. I've never had structure that involved any positive reinforcement. I haven't shared my concerns with my therapist because I am still figuring out how to say it. I don't want it to come out in the wrong way and I have a great talent for making things sound wrong. Drinking stops my constant self critical thoughts and makes it so I don't care that I'm isolated. It meets the need to belong by anesthetizing it. It also impairs my judgment, causes hangovers, and makes my anxiety worse the next day. So I think my body is telling me to cut it out already.

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Mark, I can try being clearer with my therapist. I have mentioned that I am having trouble with direction but she didn't seem to want to get into it at that time. I can use all sorts of compensation strategies to deal with my concentration problems, and I do. None of these are free, though - they cost time, energy, and political/social capital. The latter two are the resources I am quickly running out of, while I need to draw on them more the more complex my work assignments get.

Structure could be considered a limit or boundary as well. Sometimes limits can feel punitive, which could bring up feelings of resistance, but limits can be positive because they help us respect and care for ourselves. I don't know if any of that rings true for you or not, but possibly this is a place to challenge your thoughts? My verbal abilities aren't always the best so it always helped me to write my feelings out for my therapist. I don't know if that might help for you, but I can relate to the feeling of verbal expressions coming out wrong. I know that can be frustrating.

Drinking stops my constant self critical thoughts and makes it so I don't care that I'm isolated. It meets the need to belong by anesthetizing it. It also impairs my judgment, causes hangovers, and makes my anxiety worse the next day. So I think my body is telling me to cut it out already.

You're very self-aware and this is great. Maybe it helps to work with self-care and your inner voice. When you feel the urge to drink, maybe you could try reaching out to someone instead? Do you work with your therapist on learning new methods of coping? Maybe there are ways to confront your feelings of isolation and need to belong. I understand that isn't easy for you.

I hope your weekend is serene.

How are things for you, Ralph?

Thanks for asking. I had a therapy appointment yesterday. We talked about what has been going on, and it made her more convinced I need to be on ADHD meds. I am worried about this because ADHD meds are controlled substances, which makes it more of a pain for my pdoc to prescribe and I am worried he will be uncomfortable writing a prescription for the meds that could help me. But my therapist said that I could find an MD and she would talk to that person if I need to go somewhere else, which took away a lot of the despair and frustration I was feeling over having a diagnosis of ADHD but not really able to get the first line of treatment for this condition. So overall I am feeling better but I will have to struggle with ADHD for a while before I can get appropriate help.

Is there anything you can think of to do, to reassure your pdoc that you won't misuse the meds you get? If necessary, is there anything you need to do to reassure yourself that you won't?

Personally, I think you want to feel better, but you may need safeguards to keep yourself safe. Small refill quantities, especially at first? Some other form of monitoring? It makes sense to work something out with the doc so that both of you feel okay with the decision.

Mark I don't know what I could say to my reassure my pdoc. I feel like if he is suspicious I will abuse my meds based on my alcohol history, then anything I have to say in my defense is already discounted. My therapist did speak with him briefly though, and I am hopeful that he will take her professional opinion into account.

Now reassuring myself is a different question. I recognize there is a risk, but when weighed against the potential benefit I think it's a risk worth taking. Knowing my personality, the best safeguard is for me to be trusted with the meds. I tend to conform to others' expectations, so if I am trusted to use meds as prescribed, then I will strive to be worthy of that trust. I don't mind being monitored if that's what my pdoc needs to feel comfortable, but I will feel insulted if my pdoc thinks that any risk of misuse is unbearable. Such black and white thinking would discount entirely the risk of not medicating, which is that I continue to get worse and possibly experience major life consequences such as job loss and more failed relationships.

I've explored non-medical interventions for ADHD, and the common theme I keep encountering is that behavioral techniques work much better with medication. This is also what my therapist tells me. I certainly don't prefer to approach medication as a primary treatment for a mental health issue, but it seems like for this condition, meds are virtually indispensable. I did try coaching before, and I did better, but I could have gotten more out of it if the ADHD symptoms weren't themselves preventing me from learning the very techniques that I could use to manage it.

I wasn't really talking about verbal reassurance, or self-defense. But there might be some practical measure you could work out, like small refill quantities, that would help him safer. After all, at least partly, he is just trying to keep you safe from addiction.

And practical means of that sort might also help reassure you.

Could you take that last two paragraphs to him, just as you wrote them? I think they're a fairly eloquent statement of your awareness of the risks and your need for someone to trust you on this.