Constructs of Alcoholism: Uses and Limitations

By: Sheila Roche

A Nasty Ring

“Alcoholic”. The word itself has a nasty ring to it. It carries with it a net­work of meanings and assumptions that may vary somewhat from person to person, but generally evoke a negative response. To describe oneself as an alcoholic is to accept oneself as weak, immature, irresponsible, selfish, sick and endless other impoverishing descriptions. To describe oneself as the partner or family member, of an alcoholic is to accept a similar list of impov­erishing descriptions. To be the therapist of an alcoholic is to work with a client who is seen as difficult, unmotivated, conniving, and frequently more trouble than he or she is worth.

Deficiency

Apparently everybody has opinions about problem drinking. I have yet to meet anyone who, when asked, could not come up with something on the subject, and invariably those opinions are voiced through language that focuses on deficiency.

It is, of course, easy to understand how these negative descriptions come into being. Problem drinking brings with it consequences, often horrendous consequences, for both the drinker and those who are close to the drinker. Anyone who has been affected by problem drinking is only too aware of its power of devastation in the lives of individuals and of families. However, what I wish to consider in this short article is the rigidity with which concepts of “alcoholism”, such as denial, delusion, acceptance, progression, total abstinence, etc., have been adhered to, and the impact of these rigid concepts on those of us in the mainstream of alcohol treatment, who hold them.

Self-Help Groups

The domain of problem drinking has, broadly speaking, been divided between two main systems, firstly, the self help groups, like: AA and AlAnon, Alateen and ACOA, and secondly, treatment centres specially set up to deal with issues of problem drinking and/or other addictions. A concept of “specialisation” has therefore come into being. The result is many people believe that one either has to be an “alcoholic” or an alcohol counsellor to work in this area. An idea that only the “experts” should deal with problem drinking appears to be widely held. It is my belief that this idea is neither entirely accurate nor helpful.

The self help groups’ stated aim is “to share their experience, strength and hope.” Members of the fellowships pass their own experiences on to new­comers in need of help. These groups have had widespread success, to the extent that it is mainly the concepts of AA that have informed public opinion about “alcoholism”. They understand alcoholism as a disease or an allergy. They believe that “once an alcoholic, always an alcoholic”. This implies a lifetime need for active membership of the group. Their goal is abstinence. These constructs of alcoholism are accepted without question and rigidly adhered to, the members having had experiential knowledge that AA works.

Social Network

When AA and associated self help groups work, they work extraor­dinarily well. They provide support, encouragement and a social network for their members. It might be argued that it is precisely the certainty of their beliefs that provides the most help and direction for their members. How­ever, it might also be argued that it is precisely their rigidity that alienates many others who have problems with their drinking.

How often have those of us who work in the field heard clients say: “I know I have a drink problem, but I’m not an alcoholic.” (Alcoholic usually refers to the AA stereotype.). They find themselves unable to buy the whole package – hook, line and sinker.

Recovering

In earlier days, when treatment centres were coming into being, a high percentage of alcohol counsellors were themselves recovering. Treatment centres associated themselves closely with AA, and adopted many of their principles. Their goal was also abstinence. Some did not espouse the disease concept of addiction. Most centres, however, did display the same rigidity about their preferred beliefs as was found in AA. Problem drinking was defined in a particular way, was believed to progress in a particular way, and was believed to require a particular method of treatment. Hence the pro­liferation of treatment programmes. Alcohol counsellors acted as if they had all the answers, and were in possession of some “objective truth” about problem drinking. It was as if alcohol counsellors had a blueprint for recov­ery, if clients would only cooperate.

Far More Questions

To my mind, the reality speaks otherwise. While we have undoubtedly helped many clients towards a sober and more fulfilling life, we have also undoubtedly failed to help many others. It is my belief that therapists have very very little ground for their claims to knowledge. There are still far more questions than there are answers about problem drinking. Looking at chang­ing constructs over time (Heather & Robertson, 1985), we find that alcohol has been esteemed and then despised. Problems have been blamed on the alcohol itself, then on the drinker. The drinker has been called immoral or criminal.

Mental Illness

When psychiatry emerged as a separate discipline, the “mental illness” concept was brought forth. There appears to be a psychological dimension. Systems theory has introduced a systemic perspective. Strategic therapists sometimes define the problem without reference to the alcohol. The explana­tions and descriptions seem endless, the perspectives unlimited.

Yet, as alcohol counsellors, we have been so enchanted by our beliefs, that when we have failed to help our clients, we have usually attributed this to some deficit in the client, such as poor motivation. We have seldom thought it necessary to question our own part in the therapist/client system. I believe the time has come to change this.

Political Nature

As alcohol counsellors, we do not simply share our experiences as they do in AA. We have other responsibilities towards our clients. Karl Tomm says, “The politics of drawing certain distinctions and not drawing others (that is, in making some observations and not others) is important in any field, but it deserves deliberate and careful attention by therapists because of their responsibility to be therapeutic.” (1992) In the world of alcoholism, we have not recognised the political nature of our descriptions. We have paid little attention to our language and conversation. We use many pathologising definitions. We have not acknowledged that the drawing of pathological distinctions often orients us, as clinicians, in pathologising directions, that is, they often orient us towards oppositional thought and behaviour.

Denial

To illustrate the above point, let me take the concept of denial. We have pathologised the concept of “alcoholic denial”. This has given us implicit permission for what I believe could be fairly called therapeutic violence. Clients were browbeaten and bullied, certainly in the past.

Adversarial Stance

So, far from orientating us in a therapeutic direction, this concept of denial brought forth an adversarial stance between therapist and client, increased the distance and lack of understanding between them, introduced suspicion and blame in both, and therefore, no doubt prolonged, through this interpersonal dynamic, whatever resistance may or may not have preceded it. As alcohol counsellors, we need to take responsibility for our part in this.

Wrong Conclusions

The concept of denial also allowed us to dismiss what our clients had to say. We saw our clients as “in denial”, deluded, perhaps lying – all this goes with the role “alcoholic”- and so, we frequently did not bother to listen to them. We did not sufficiently acknowledge the fact that when we pathologise and label a person, we lose sight of that person. We cease to see them as individuals, and we see only what we expect to find. I suspect that we have frequently drawn the wrong conclusions.

For example, recently a middle aged man came to see me about his drinking. He appeared uneasy and evasive, and there were times when I thought he was lying. Some years ago, when we were less questioning, I might simply have interpreted this as a classic example of “alcoholic denial”. But now, using what Anderson & Goolishian call a “not-knowing”(1992) stance as therapist, and putting preconceptions to one side, I simply asked him to explain to me why he seemed so uneasy and why I got the impres­sion he was covering up?

He told me his wife had a drinking problem, she had been barred from the home, he had been given custody of their children, his wife was furious about this and was making trouble for him. She had rung neighbours, made complaints to social workers about him. As a result, a number of agencies had been in contact with him, and the man felt persecuted. He was afraid that if he even admitted he was concerned about his own drinking, his children would be taken away from him. Now, I am unsure yet whether this man’s drinking is a problem or not. But, that aside, if you or I felt anything like the pressure this man feels, would we not cover up too? What this con­versation has done so far, is to help my client and me to understand and respect one another. It has left us in a better position to have a more useful session next time round. Without this understanding, had I held on unquestioningly to the “alcoholic denial” concept, I might have had difficulty in relating to this man, been very frustrated by him and seen him as just another deluded drinker trying to buck the system.

So Confusing

It is my belief that rigidly held concepts of addiction have had the effect of impoverishing and limiting us. Both clients and therapists have lost out in the process. It is an interesting exercise to speculate about how and why all these certainties came into being. Could it be that the whole area of addiction is so confusing that we have found it necessary to grasp what looks like solid ground and hold on for dear life, without question?

Could it be that a large number of addiction counsellors have, certainly in the past, been in recovery themselves, and in some way have been unwilling to question what has obviously worked for them? Could it be that what people really want when confronted with addiction are social control agents, not therapists? Alcohol counsellors certainly feel pressured to act as social control agents. The legal system sends us resentful, unwilling clients and expects us to work with them. Employers do likewise. So do family mem­bers. Everybody wants the alcohol counsellor to get the problem under control. It is hardly surprising that alcohol counsellors may put this pressure on themselves.

And if one does feel under pressure from all sides, then it is reassuring to have certainties to fall back on. One is easily enchanted into taking a strong, firm line, if only it worked all the time!

Flexibility

My difficulty is not with the concepts of addiction themselves. These have been constructed from observations that have been noted time after time. My difficulty is that we have taken what has been frequently observed, and reified it, turned it into an absolute. We need more flexibility. We need to recognise that every description that we use both reveals something and simultaneously conceals other things. In a paper called “Alcoholism as an Opinion” (1987) Efran et al write ” … a pattern of behaviour, such as prob­lem drinking, can never be fully described in one set of language terms. Additional descriptive domains can always be created and either substituted for, or appended to, the original set.”

We do not have to struggle to impose our language and our concepts on clients, and we do not have to get them to agree with us. We need to listen more to our clients, use their own descriptions and meet them on their own ground. We need to have conversations that resonate with their experience and have meaning for them. We need to avail ourselves of differing perspec­tives and enrich our options.

Risk

Abstinence may still be the only option for a great number of people, but perhaps not for all. If clients want to try to control their drinking, why not work with them towards what they want while clarifying with them the degree of risk they may be undertaking?

Many clients fit happily into treatment programmes, find firmly held concepts reassuring, and benefit greatly from the same. But other clients require a different kind of conversation, we must respect that. We are after all, dealing with individuals experiencing a relatively common human problem. My belief is that when we free ourselves from unnecessary limits and restraints, our wider conversations will broaden the scope of options and interventions, for both our clients and ourselves.

I have a friend who has a parrot, an African Grey. In common with the rest of his breed, he is an especially good talker. Every night, when my friend is going to bed, she puts a cover over the parrot’s cage. And every night, when this happens, the parrot squaks – “Who put the f———– g lights out!!!?” On the face of it this seems like an intelligent response! Now, I know very little about parrots, but I really do not believe the bird fully grasps the meaning of this interaction. Isn’t it something to do with programming, rather than understanding? And, there are times when I cannot help but wonder if our responses to addiction might not be seen as similar to this? … I think we need to think it out again.

References:

Anderson, H.& Goolishian, H.(1992) The Client is the Expert: A Not-Knowing Approach to Therapy, in S. McNamee & K. Gergen (eds) Therapy as Social Construction, Sage: London.

Efran, J.S., Hefner, K.P., Lukens, R.J. (1987) Alcoholism as an Opinion, in family Therapy Networker, July/August.

Heather, N. & Robertson, I. (1985) Problem Drinking: The New Approach. Penguin: London.

Tomm, K. (1992) Therapeutic Distinctions in an Ongoing Therapy, in S. McNamee & K. Gergen (eds), Therapy as Social Construction, Sage: London.

Sheila trained as a Family Therapist at the Mater Hospital Dublin. She works from a systemic, constructivist perspective with individuals and groups. She is a member of the Family Therapy team at the Stanhope Centre in Dublin.