by Melissa Raven
First published in New perspectives on ‘addiction’, special issue of Dulwich Centre Newsletter, 1997, nos 2 & 3, pp. 48–50.
When people think about drug problems, they tend to think about illicit drugs such as heroin, cocaine, and marijuana. However, by far the most problematic drugs in contemporary western society are alcohol and tobacco. Alcohol contributes to many cases of traumatic injury and death through car crashes, accidental injury at home and at work, violence, and suicide. It also contributes to foetal alcohol syndrome and many common diseases such as heart disease, cancer, and diabetes. It features prominently in relationship problems and many cases of crime. It has profound economic costs, such as those related to medical treatment, absenteeism and reduced productivity. Collins and Lapsley (1996) conservatively estimated the social costs of alcohol use in Australia in 1992 to be A$18.845 billion. The US National Institute on Alcohol Abuse and Alcoholism (1991) quoted estimates of the cost to society of alcohol abuse ranging from $70.3 to $116 billion per year between 1980 and 1988.
A problem only for ‘alcoholics’?
When the issue of alcohol-related problems is raised, most people think of ‘alcoholics’, people who are dependent on alcohol, who constantly drink to excess and are unable to control their drinking. However, non-traumatic medical problems such as heart disease are often associated with excessive regular use rather than dependence per se, and many alcohol-related injuries and deaths, both accidental and deliberate, are associated with intoxication, not dependence. A review by Hayward, Zubrick & Silburn (1992) of suicide research found reports of alcohol involvement in 20% to 50% of suicide cases. Although suicide is sometimes associated with alcohol dependence, more often it seems to be triggered by acute intoxication coupled with interpersonal conflict.
To many people, the idea that intoxication and excessive regular use may be more important than dependence is surprising and unsettling. Many of us drink frequently and occasionally drink too much. Many people believe that it is only people who are dependent whose drinking creates problems – and there is often a circular logic applied: if someone gets into strife, they must be dependent. This logic is comforting to many of us, and exceedingly useful to the alcohol industry, which argues that alcohol is not a problem, it’s just that there are a small number of unfortunate individuals who have this disease called ‘alcoholism’ which means they shouldn’t drink at all – but the rest of us can cheerfully drink to our health.
However, empirical evidence shows that there is a continuum of alcohol use, with no clear cut-off between non-alcoholic and alcoholic, and although people who drink very heavily have a much greater individual risk of experiencing problems, the rest of us are not immune. Alcohol problems are distributed throughout the entire drinking population: They occur at lower rates but among much greater numbers as one moves from the heaviest drinkers to more moderate drinkers (Moore & Gerstein 1981, p.44). Thus, most alcohol problems occur to, or are caused by, drinkers who are not dependent on, or addicted to, alcohol. Within the general population, alcohol problems occur more often among men and most often at younger ages – 18 to 24 years (Moskowitz 1989). This is not to say that there is no need for concern about people who suffer from ‘alcoholism’. However, the situation is not straightforward. Hilton (1989, p.459) asked the question, ‘How many alcoholics are there in the United States?’, then proceeded to give three different answers:
- I can’t answer your question because it is based on a false premise [that ‘alcoholism’ is something you either have or don’t have, there is a clear division between ‘alcoholics’ and ‘non- alcoholics’].
- Well, it all depends on how you measure it.
- There are an estimated 10.4 million ‘alcoholics’ in the country, an estimated 7.1 million men and 3.3 million women [an official estimate].
The concept of alcoholism is predicated on the disease model (or more accurately models – there are several variants) which is closely linked to the twelve-step model used by Alcoholics Anonymous (AA). Disease models have dominated the treatment field in the USA and have had significant influence elsewhere. However, the value of other models is increasingly being recognised. There is considerable evidence that problem drinking is a learned behaviour which can be unlearned and relearned in different ways, and that many people who drink excessively gradually moderate their drinking with little or no intervention. In other words, people can move along the continuum, in both directions. Treatment approaches based on these ideas are proving effective for some people. There is good evidence that no one form of treatment is appropriate for everybody, and that there needs to be a range of options available.
Within the drug field there is still a tendency to individualise problems and pay little attention to structural and social justice issues such as gender, class, ethnicity, poverty, and racism. One important issue is that problematic alcohol use is often a response to poverty and unemployment and racism and other forms of disadvantage and discrimination. However, the implications of such structural factors are complex. For example, a requirement of AA is to admit powerlessness and this can have very different implications for people disadvantaged by their race, gender and socioeconomic status than for people from affluent and successful backgrounds.
A good thing?
It is important to recognise that alcohol’s negative effects sit side by side with what many people see as its positive social effects. It is used for celebration and relaxation, and in many cultures it is an integral part of happy family life. It provides livelihoods for countless people and generates huge revenues for governments. This quote, from a Mississippi state senator in 1958 (cited in Goodwin 1988, p.8) illustrates the paradoxical effects of alcohol:
You have asked me how I feel about whisky. All right, here is just how I stand on this question: If, when you say whisky, you mean the devil’s brew, the poison scourge, the bloody monster that defiles innocence, yea, literally takes the bread from the mouths of little children; if you mean the evil drink that topples the Christian man and woman from the pinnacles of righteous, gracious living into the bottomless pit of degradation and despair, shame and helplessness and hopelessness, then certainly I am against it with all of my power. But, if when you say whisky, you mean the oil of conversation, the philosophic wine, the stuff that is consumed when good fellows get together, that puts a song in their hearts and laughter on their lips and the warm glow of contentment in their eyes; if you mean the drink that enables a man to magnify his joy, and his happiness, and to forget, if only for a little while, life’s great tragedies and heartbreaks and sorrows, if you mean that drink, the sale of which pours into our treasuries untold millions of dollars, which are used to provide tender care for our little crippled children, our blind, our deaf, our dumb, our pitiful aged and infirm, to build highways, hospitals, and schools, then certainly I am in favour of it. This is my stand. I will not retreat from it; I will not compromise.
Moderate alcohol use is purported to have significant health benefits, particularly in relation to the risk of heart disease. However, the issue is controversial and there is sound empirical evidence that there is no genuinely safe level of consumption. Alcohol has been used for millennia, by most known societies. It touches most lives, with both positive and negative effects. It has been the subject of much writing and many debates. It has been celebrated and vilified and cautiously accepted. It is likely that it will continue to be widely used. How we face the dilemma of dealing with the many dimensions of alcohol remains to be seen.
Collins, David J. & Lapsley, Helen M.1996: The social costs of drug abuse in Australia in 1988 and 1992. National Drug Strategy Monograph Series No.30. Canberra: Australian Government Publishing Service.
Goodwin, D.W. 1988: Is alcoholism hereditary? (2nd ed.). New York: Ballantine. Hayward, Linda, Zubrick, Stephen R. & Silburn, Sven, 1992: ‘Blood alcohol levels in suicide cases.’ Journal of Epidemiology and Community Health, 46, 256-260. Hilton, Michael E. 1989: ‘How many alcoholics are there in the United States?’ British Journal of Addiction, 84(5):459-460. Moore, M.H., & Gerstein, D.R. (eds) 1981: Alcohol and public policy: Beyond the shadow of prohibition. Washington, DC: National Academy Press. Moskowitz, Joel M. 1989: ‘The primary prevention of alcohol problems: A critical review of the literature.’ Journal of Studies on Alcohol, 50, 54-88. National Institute on Alcohol Abuse and Alcoholism, 1991, January: ‘Estimating the economic cost of alcohol abuse.’Alcohol Alert, No.l 1. Copyright © Dulwich Centre Publications 1997 See more articles and books at the Narrative Therapy Library and Bookshop