by Marion Rackard
Throughout recorded history, alcoholic beverages have been used in many societies for many purposes. As psychoactive substances, alcoholic beverages are used for their mood-changing properties. As intoxicants, they are used to escape reality. As liquids, they are used to quench thirst. As sources of calories, they are used as foodstuffs. Of course, whichever physical property of the beverage is sought by the user, to some degree it also necessarily carries the other properties. Apart from their physical properties, alcoholic beverages and their use also carry a wide variety of symbolic meanings, positive and negative. Depending on the culture, drinking alcoholic beverages may be a token of inclusion in or exclusion from a social group or a symbol of celebration. On the other hand, drinking or drunkenness may be socially disapproved of and stigmatized in some cultures.
Drinking alcohol is synonymous with being Irish. It is a substance of major cultural significance. Our ballads, poems, prose resound with alcohol references from Thin Lizzy to Patrick Kavanagh, Brendan Behan and John B Keane and many more. Our identity worldwide is inextricably linked with certain alcoholic beverages and our image is of one of the heaviest drinking nations in the world. Psychotherapists are familiar with the concept of “splitting” and this is most evident in the visible external world of drinking and it’s enjoyment in contrast to the many hidden manifestations of alcohol related harm within the mental, social and physical realm of individual lives whose effects appear and reappear within counselling rooms.
Some reflections on harm
Self-harm or suicide can take place after just one drinking session. A person doesn’t have to be a heavy drinker or even a regular drinker: just one occasion of heavy drinking can reduce inhibitions enough to self-harm or act on suicidal thoughts.
Alcohol initially produces feelings of happiness and well-being but can lead to a significant lowering in mood hours after use or in the following days, an experience which is sometimes accompanied by feelings of hopelessness. If someone is already experiencing a degree of depression, the fall in mood can lead to suicidal ideas..
A new study published in the latest edition of the Irish Medical Journal found that 6 per cent of students in two Dublin universities reported suicidal thoughts in the previous month. The study, which involved 338 medical and business students in UCD and Trinity, found that 14 per cent were depressed, while about a quarter had an alcohol disorder. Ongoing abuse of alcohol is itself a major contributory factor in depression and suicidal behaviour. (Irish Times 3/3/09)
A 2008 HSE report on alcohol-related harm tells us that “alcohol can facilitate suicide by increasing impulsivity, changing mood and deepening depression”
In 2006/2007 alcohol was a factor in 41% of all cases of deliberate self-harm. It was more common in cases involving men (44%) than women (38%)(National Suicide Research Foundation)
The Coombe Women’s Hospital study (2006) found that 63% of women reported alcohol use during pregnancy, of which 7% drank 6 or more drinks per week. Taking the number of births each year and those engaged in high risk drinking, these figures would suggest that at least 4,500 children each year are at increased risk of harm from maternal alcohol use.
In 2008, the average amount of alcohol consumed by every person in this country aged 15+ was 12.4 litres of pure alcohol. This amounted to 490 pints or 129 bottles of wine or 46 bottles of vodka (Alcohol Action Ireland website 2009). Ireland has a higher percentage of abstainers than other countries, which implies that those who do drink, consume alcohol in greater quantities than drinkers in other countries do (Mongan et al: 2007).
Attitudes to drinking
For an unknown number of people the extroversion of drinking for enjoyment can gradually and insidiously transform into the introversion of dealing with the consequences of heavy drinking which is so often neutralized by the declaration and sometimes glorification of the hangover, sick tummy, the row with the “husband/wife” all often joked away in the memory of a good night. As an addiction counsellor my ear is attuned to the many varied subtle signals in everyday conversations which permit, expect and rationalize heavy drinking and associated behaviours. We have all stood in line in an airport on return from holidays frequently overhearing conversations about how much alcohol was consumed and the “craic” that followed. There is no doubt of the pleasures of alcohol but the concern internationally about Ireland is our pattern of drinking which involves large quantities of alcohol with resulting intoxication. It is this repeated intoxication which increases the harm. This concern does not relate only to young people but within all age groups.
In a national population survey carried out independently on behalf of Alcohol Action Ireland in 2006, 82% of people believed that our alcohol consumption levels then were a problem and 85% felt that our cultural attitude to alcohol needed to change. 44% of people admitted to having been injured, harassed or intimidated as a result of someone’s use of alcohol. One can only hazard a guess at the derivations of our cultural attitudes to alcohol but what is clear is that if the above figures are to be reduced and reversed we are as a nation going to have to make significant shifts and changes in our relationship to alcohol. I have been reflecting on this issue for some time as to what can be done. There are many voices speaking out on the diverse range of alcohol topics but no major strategic plan of action is in place to begin to tackle this leviathan. I do believe that as a nation we need to look at our sense of who we are and the relationship we want and need to have with alcohol in order to reduce the transmission of harm and trauma to future generations.
In a 2006 study on “What it means to be Irish – Children’s Construction of National Identity” by Fionnuala Waldron and Susan Pike at St Patrick’s College, Dublin, ideas relating to identity and belonging as a citizen in Ireland were explored. The authors stated that understanding children’s ideas about national identity was vital if educators are to engage children in the construction of an hospitable, critical and reflective citizenry. Research was undertaken in two phases during 2003 and 2004. Participating in the study were 119 children, drawn from a range of social contexts. Premised on a social constructivist view of children and childhood, the research drew on participative and democratic methodologies. While the study suggested the existence of an essentialist conception of Irish identity, it also demonstrated the capacity and willingness of children to engage in critical reflection on their constructions of Irishness. Among the reflections named by children were the following:
“Irish people are really fond of their culture, especially when it comes to Guinness, Irish dancing and Irish music. We Irish are different. We go mad and do stupid things but we laugh and have fun. Great craic, as they say.” “I’m glad I’m Irish cause the Irish made Guinness.” “They say Irish are always good for a pint and it goes to show we like to live life to the max.” “Despite our reputation as drunks and Paddys, Ireland is actually a nice place.” The authors concluded: “Once again, it appears that there is a dynamic interplay between children’s experience, the internalisation of stereotypes (both positive and negative), and a market-driven mythology around Irishness, drink and that essential element of the Irish experience, ‘craic’. Occupying a place in the national psyche, as portrayed by the children’s writings and drawings, at least as significant in its symbolic power as the national flag, Guinness has indeed achieved an emblematic status”.
As one child commented: “It’s not that they’re alcoholics or anything, it’s just Guinness is just what makes Ireland Ireland. Not actually what makes Ireland Ireland but it’s kind of like part of it. It’s kind of like a mark, like you had a birthmark, that’s kind of Ireland’s birthmark. It’s just like a something you’d add to, if you got a map of Ireland, you know, you’d put a Guinness beside it.”
The power of cultural cliches and national stereotypes:
Child’s Image from 2006 study: “What I think an Irish person looks like” (Waldron and Pike, 2006)
Collectively and culturally Irish drinking attitudes and patterns are continually reinforced with significant support from the alcohol industry which spent 69 million euros in 2007 on alcohol marketing in Ireland which was a 31% increase from 2006. Guinness spent more than €1.4m on rugby and €1.6m on hurling sponsorship. Heineken spent €2m on its Irish rugby sponsorship, €239,000 on its Heineken Cup sponsorship and €217,000 on the Heineken Champions League (HSE 2009). This expenditure contrasts with the recent opinion of the scientific committee of the European Alcohol and Health Forum, which states, “Commercial communications increase the likelihood that adolescents will start to use alcohol and to drink more if they are already using alcohol. When reading this scientific opinion, it should be remembered that only a small part of the marketing mix has been analysed and reported”. (EU Commission 2009). A 2006 report by the Office of Tobacco Control revealed that Irish 16 and 17 year-olds spend an average of €20.09 a week on drink. Early involvement with alcohol by young people can shape their recreational interests, coping strategies, social relationships and attitudes to other forms of substance use. Damage from alcohol use during adolescence can be long term and irreversible. Therefore, it is critically important to delay the age of onset of drinking by young people, as recommended by the World Heath Organisation.
“Alcohol consumption has the potential to trigger long-term biological changes that may have detrimental effects on the developing adolescent brain, including neuro-cognitive impairment”, US Surgeon General, 2007
It should be no surprise therefore that the level of alcohol related harm is so significant in this country as each generation is reinforcing the cultural attitudes passed on from one generation to the next and there is no statutory regulation of alcohol marketing preventing this continual reinforcement. Efforts by the alcohol industry to demonstrate “social responsibility” through their 20million funded organization MEAS, elicted the following response from my colleague Rolande Anderson in an article entitled “Bottled messages” in IAAAC magazine Vol.36 (2006):
“On the one hand they want to sell their products, maximise profits, sponsor sport and music and TV programmes etc while on the other hand they want to be seen to be behaving responsibly. They worry about retribution and state control. In particular they fear health taxes, bans on advertising and law-suits by individuals and families harmed by their products. They are concerned about future profits and the tide turning,as it did with tobacco. So they solve this dilemma by trite, meaningless, sound bite advertisements. They call it social responsibility.”
In relation to the size of the problem and the response required, there is a dearth of alcohol counselling services. If our politicians were to be creative with solutions they might consider a certain percentage of alcohol industry revenue for marketing that could be diverted to setting up community based alcohol counselling services. In some countries there is a tax on alcohol marketing which is by way of diverting a fund for the victims of alcohol related harm.
Alcohol Manifestations in Psychotherapy practice
It is highly likely that most psychotherapists have encountered clients with some alcohol rubric presentation woven into other presenting problems within their practice. Likely presentations are:
- Client who frequently uses alcohol to self medicate
- Recovering alcohol dependent person
- Spouse/partner living with active/inactive addiction
- Co-dependency issues
- Adult child of alcohol dependent
Due to the fact that 80% of our population consumes alcohol, it is also highly likely that clients presenting with any issue will be a drinker. Most psychotherapy trainings provide a module on addiction where the signs and symptoms are identified and it is seen as a “specialty” area and therefore largely outside the confidence and competence of many psychotherapists. Hence clients with marked signs of psychological/physical dependency may be referred on for assessment. But what about the vast majority of drinkers whose drinking results in the greatest levels of harm to themselves and others? These are the hazardous and harmful drinkers and they need attention as their drinking might be likely to progress to the dependent phase without intervention. When I started out my training there were two groups of drinkers: social and alcoholic, the latter who were identified as having a “disease”. This term is now known as the alcohol dependence syndrome. The former were considered capable of consuming large volumes without undue harm. A continuum of drinking and associated problems which is the current Public Health model was not used and instead clients were identified as “alcoholic” or not by the use of the Michigan Alcohol Screening Test (MAST) which was a matter of ticking boxes resulting in a positive or negative result.
Due to some discomfort with this method, I soon left that questionnaire to one side as I was much more interested in working with a motivational interviewing style in order to understand the clients’ relationship with alcohol and the meaning of their drinking as a coping mechanism. Invariably alcohol played a powerful support in their lives to numb many unspoken fears and anxieties with unhealed trauma resulting in additional shame and low self esteem from the alcohol use. Because substance abuse and mental health problems are so often linked,a substance use history is an essential part of every mental health assessment no matter what the client’s presentation. Clients whose alcohol use is especially likely to be overlooked or minimized by therapists lacking specific substance misuse training are that group whose use of alcohol and/or other drugs appears to be a form of “self medication” aimed at enhancing functioning. Especially if the client is educated, articulate and insightful, the therapist may feel inclined to focus on the psychological factors that drive the client’s felt need for self-medication while the alcohol use itself is ignored.
Other therapists feel reluctant to raise the issue of alcohol use with clients who have not mentioned the issue themselves. There is concern that asking pointed questions about alcohol amount and frequency might offend clients or the therapist might be uncomfortable treading too deeply into areas that are beyond the scope of their clinical training. Whatever the reason, failure to identify clients who have problems with alcohol and or other drugs has serious consequences. Early stage alcohol problems tend to escalate into more serious problems when left unaddressed. Engaging in a non confrontational conversation with a client about their alcohol use is aimed at supporting the client to think about or plan a behavior change.
The Alcohol Use Disorders Identification Test comprises 10 questions which assist the client to identify if they are a hazardous,harmful or dependent drinker.
The client can self administer if willing to be honest in replies. AUDIT is available on http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf
You will find a range of screening questions on the very useful website www.alcohollearningcentre.org.uk. This site offers detailed information on Brief Interventions with video examples of how to do a BI. Using a motivational interviewing style to guide clients to explore and resolve their mixed feelings about a behavioural change is a way that enhances their motivation and ability to make positive choices. For further information see www.motivationalinterviewing.org. Brief interventions are not suitable for alcohol dependent clients whereas the AUDIT is. Brief Interventions can be delivered by all health and social care staff, however it is recommended that in order to feel competent to deliver brief interventions to clients professionals are advised to undertake a minimum of approximately 3 hours of BI training with 2 days being the ideal.
Normally an article for Inside Out generally deals with the dynamics of therapy from the personal view point of the therapist. I would have liked to explore the deeper meanings of alcohol in relation to the human psyche as explored so well by my colleague Jack Houlihan in his book “A Ghost in Daylight-Making Sense of Substance Misuse” (Veritas 2006). However, I am interested more in trying to create a wider network of response to the management of clients with alcohol issues through the AUDIT and Brief Intervention tools, as I believe so many people are travelling uninterrupted on their journey towards addiction. It is a very similar scenario to cancer and the plethora of screening that now exists in an attempt to identify early signs. Any health or social care professional can undertake a brief intervention. Training is advised.
Alcohol problems are so pervasive in Irish society that it behoves all counselling training centres to develop and enhance their modules on substance misuse training so that all psychotherapists are equipped to take an active role in assisting clients to explore and identify a possible harmful relationship with alcohol and relevant consequences in their lives.
The human toll of alcohol related harm in Ireland is enormous. Despite the pleasures of alcohol, it is my belief that we live with a high tolerance for the trauma and loss of soul and life caused by alcohol which is continuing to erode and damage family and personal relationships throughout our country.Two recent RTE documentaries “A Song for Dad” (4/08/09) and “The House” were both moving depictions of the curtain of darkness and pain that alcohol and other unresolved issues can pull down on family relationships. The Family Support Agency identifies the use and abuse of alcohol and drugs as a cross-cutting theme in a number of research reports on the family.
In this article I am advocating for a deeper surveillance of the role played by alcohol in the psychological world of our clients and their families. I claim that this may be difficult for us due to the ingrained attitudes and relationship we have towards alcohol and even perhaps to our own drinking patterns. Obviously, working with an alcohol issue, it calls for our own self-reflection on how we use alcohol and why. This may be very uncomfortable for us.
The Ryan report recently shocked us all at the blind eye that was turned to the harm experienced by children in institutions. Children living in families who are similarly suffering will never have a collective grand scale opportunity to articulate the damage caused to them by parental drinking as they can never “squeal” on their parents. We have a duty and an obligation to try to prevent harm to any human being. We can best do this by upskilling ourselves in the area of harmful and dependent drinking/substance misuse, thereby facilitating clients to reflect on the meanings and role of alcohol in their lives.
Our President Mary McAleese recently said (Irish Times 14/7/’09):
“The Ryan report has helped us to understand, through the courageous people who revealed the fragments and tatters of their lives to the Ryan Commission, what happens to little children at adulthood when you raise them in an abusive environment. Over the next couple of years we’re faced with the downstream consequences of these things, and I hope that we’ll have the kind of good, probing, deep and wide debate that allows us to throw into the mix all sorts of new ideas, all sorts of new distilled wisdom that will help us to come out of this much stronger, much more intuitive and in many ways, a much better society beyond this, knowing there will be – and are – casualties.I think our role is to try to minimise those casualties, to be community to each other and to use it as a really important opportunity to learn about human nature and how to counter the downside of human nature as best we can.” She continued ‘‘what we now know about what happened in those institutions is still happening in homes in Ireland and we have an obligation to those little children who were the victims of abuse in State homes as we have to women who are victims of domestic abuse, as we have with men who are victims of domestic abuse and to older people who are victims of domestic abuse.”
The President is attuned to what is the most pressing problem in Irish society but we all need to do more to highlight the links between harmful use of alcohol, and the impact on our humanity. Psychotherapists can have an enormous influence on preventing and alleviating harm caused by alcohol if eyes remain wide open to the often isidious, “cunning, baffling and powerful” (Big Book, Alcoholics Anonymous) nature of alcohol by making timely and appropriate interventions.
Marion Rackard IAAAC, IAHIP has worked within the HSE in the treatment of alcohol dependents and their families and within a trauma service and is currently working to develop and manage projects aimed at harm reduction and prevention and can be contacted at: firstname.lastname@example.org
Alcohol Action Ireland (2006). ‘Alcohol in Ireland Time for action: a survey of Irish attitudes’. Alcohol Action Ireland website
Adworld. Alcohol advertising in Ireland http://www.adworld.ie/features/read/?id=3891ccf9-2a70-42b8-8b15-f2c9fe14f13c, 2009.
Hope A (2007). Alcohol-related harm in Ireland. Health Service Executive – Alcohol Implementation Group
HSE (2009) Alcohol and Sports Sponsorship in Ireland
Mongan D, Reynolds S, Fanagan S and Long J (2007) Health-related consequences of problem alcohol use. Overview 6. Dublin: Health Research Board.
Science Group of the European Alcohol and Health Forum 2009
Waldron, Fionnuala and Pike, Susan (2006) ‘What does it mean to be Irish? Children’s construction of national identity’. Irish Educational Studies 25:2, 231 – 251.