An Introduction to Alcoholism
Jim Leffel holds a B.A. in philosophy from The Ohio State University and an M.A. in Philosophy of Religion from Trinity Evangelical Divinity School. He is a teacher and leader at Dwell and has been studying alcoholism and its effects for over a year.
If alcoholism is a disease, then it is one of the greatest epidemics of modern times. While no real consensus exists among experts in the field concerning how alcoholism should be defined, recent statistics indicate that 10 million Americans are classified as alcoholics (i.e., those with chronic, problematic drinking patterns). According to a recent Gallup Poll, one out of three persons reported that alcohol abuse had caused trouble in their families. Heavy drinking is involved in 60% of violent crimes, 30% of suicides, and 80% of fire and drowning accidents. Every 22 minutes a drunk driver kills someone. Alcoholism is involved in a quarter of all admissions to general hospitals, and its abuse years estimated to cost our society 50 billion dollars per year.1
In light of these statistics and the personal experience of many people who struggle with this issue as a daily burden, addressing the problem of alcoholism cannot be regarded as optional. This paper will address three aspects of alcoholism: (1) etiology, that is, what is alcoholism?; (2) diagnosing the problem, intervention and treatment options; (3) alcohol abuse and the church: issues and options.
One of the most controversial issues in current discussions of alcoholism is the list of questions surrounding etiology: What is the cause of alcoholism? What does it mean to be an alcoholic? What is the difference between alcohol addicts and nonalcoholic abusers and users? These are not mere academic questions. The way in which one answers them will direct the diagnosis, treatment, and prognosis of the alcohol dependent person. For Christians struggling with alcohol addiction, understanding the causes will enable them to address serious personal, emotional, and spiritual obstacles to their recovery. For the believing community, it will enhance our ability to provide adequate support and effective prevention.
There are three approaches to the etiology of alcoholism. All three will be discussed in terms of the reasons for holding them, limitations of the models and positive contributions toward understanding the problem. This section will end with a working model of alcoholism based on the available research data and biblical teaching.
This is the traditional analysis of alcoholism in the Christian community. The Temperance Movement, the ultimate agenda of which was the Prohibition Act of 1919, popularized the moral model. According to this perspective, the problem with alcohol dependency is the moral weakness of the abuser. If a person was sincerely trying to follow Christ in his life, and was truly given over to his lordship, there would be no problem with alcohol abuse. Those struggling with alcohol dependency were encouraged to present their lives to Christ, and upon receiving a conversion or deliverance experience, were freed from the addiction. Any lapse back to the bottle signified moral laziness or lack of faith. Typically, total abstinence from alcohol was considered the ideal for society on the moral model. The proponents of this view optimistically assumed that if society was ridded of the substance, most of the pressing burdens of our culture would be lifted. In his funeral address for "John Barleycorn" on the eve of Prohibition, the famous evangelist Billy Sunday spoke for the Temperance Movement,
"The reign of tears is over. The slums will soon be only a memory. We will turn our prisons into factories and our jails into storehouses and corncribs. Men will walk upright now, women will smile, and the children will laugh. Hell will be forever for rent."
The analysis of alcoholism as an essentially moral problem is not without biblical support. Consider Paul's words in Eph. 5:18, "Do not get drunk on wine which leads to debauchery. Instead, be filled with the Spirit." This passage is of particular importance for two reasons. First, it clearly teaches that drunkenness is a sin (cf., Gal. 5:19). This does not, of course, teach that drinking per se is wrong. Rather, it teaches that being controlled by the substance is immoral. Consider also Paul's words in 1 Cor. 6:12, "Everything is permissible for me, but I will not be mastered by anything." Peter warns the church to be "sober and alert" (1 Pet. 5:8). Second, the abuse of alcohol is "volitional." In Eph. 5:18, Paul exhorts the church to make the choice to be filled with the Spirit, rather than wine. This clearly implies the ability to make such a decision. As Christians, committed to the authority of the Bible, any assessment of alcoholism must conform to scripture, regardless of what theoretical perspective is in vogue in our society.
It is the issue of volition in the biblical teaching on alcohol abuse that is of primary concern to the problem of alcoholism. This is because the experience of most alcoholics is, as the first step of Alcoholics Anonymous states, "we admitted we're powerless over alcohol that our lives had become unmanageable." From the perspective of the alcoholic, there is no choice involved in sobriety. As Anderson Spickard, a Christian physician and alcoholism researcher points out,
"While the alcohol abuser chooses to get drunk, the alcoholic drinks involuntarily. His will power is in the service to his addiction and he cannot resist his craving for alcohol. Telling an alcohol addict to shape up and stop drinking is like telling a man who jumps out of a nine story building to fall only three floors."2
So observations like Spickard's raise an important question: How are we to reconcile the alcoholic's experience of powerlessness with the biblical injunction to make a choice for sobriety?
The only way to reconcile this tension between experience and exegesis is to understand what choice the alcoholic is capable and, consequently, responsible for making. Contrary to the traditional moral model, sobriety is rarely achieved by a one time experience of conversion or deliverance. Rather, lasting sobriety involves a process of steps with many difficult decisions along the way. The path to victory over alcohol addiction is almost always marked by failures. We should no more expect the truly addicted alcoholic to instantly practice sobriety than we should expect the lifelong homosexual or worrier to instantly comply with the biblical injunction against their sin. For the alcoholic, the beginning of control over alcohol abuse begins with personal recognition of the gravity of the problem and the willingness to seek help. The point of choice is to submit to a treatment plan that will ultimately bring the individual's life in line with biblical teaching. Feelings of powerlessness over the bottle do not entail the inability to receive treatment and comply with the biblical mandate for sobriety.
While the moral model rightly views alcoholism as a volitional, moral, and spiritual problem, it has been severely limited through its traditional adherent's narrow understanding of the dynamics of alcohol dependency. It does not serve the goal of recovery to simply label the alcoholic a moral degenerate. We must grasp the fact that the alcoholic's realm of "moral freedom" to make the decision not to drink or to moderate drinking is virtually absent. It is a gross mistake to consider all persons suffering under the burden of chronic alcohol dependence as "weak willed." With that kind of outlook, very little practical help can be extended. Because of the relative ineffectiveness of the moral model in helping the alcoholic, clinicians and researchers have looked in a different direction to explain the phenomenon of alcoholism and alcohol treatment.
The medical model has gained prominence over the moral model since the 1930's, and in 1957, the American Medical Association labeled alcoholism a disease.3 What precisely is meant when alcoholism is considered a disease? Three aspects of disease are attributed to alcoholism:
- Addiction is a primary disease. That is, it is not a secondary symptom of something else. Various influences may become a factor in a person's initial decision to drink. However, once addicted, the addiction becomes a disease in and of itself.
- Addiction is a progressive disease. By definition, once addicted, the disease will not go into spontaneous remission. Without external intervention, the disease continues to spiral downward, usually resulting in death.
- Addiction is a chronic disease. There is no known cure. Sometimes the disease can be maintained in a state of remission, but only through total abstinence. If the addicted person drinks (suffers relapse), the disease will pick up where it left off.
We will consider the research data in support of each of the three criteria for the disease model.
Alcoholism as a Primary Disease
The disease model holds that there is something physiologically different about the alcoholic than other non-addicted drinkers prior to the onset of symptoms.
The most important empirical support for the disease model is genetic study. There is some recent research data that draw a correlation between heredity and alcoholism.4 D.W. Goodwin's study of foster children is significant in this regard. He found that children with an alcoholic biological parent who were raised by nonalcoholic foster parents had a rate of alcohol abuse four times greater than children without alcoholic parents who were raised by an adoptive family.5 Cloninger's study in Sweden produced similar results. His study indicated that sons of alcoholic fathers placed at birth in nonalcoholic families were found to have an alcohol problem at the ratio of nearly four to one over male adoptees without alcoholic fathers.6
Specific mention should be made of a recent and much publicized study that ties alcoholism to genetics. In "Allelic Association of Human Dopamine D2 Receptor Gene in Alcoholism,"7 the presence of the A1 allele in the dopamine D2 receptor gene correctly classified 77% of alcoholics and was found to be absent in 72% of non-alcoholics in a blind test.8 This provides an experimental basis for the contention that ones' genetic makeup may play a role in some people for becoming symptomatic with alcoholism. It must be pointed out that there were 31% of alcoholics who were tested who did not possess the suspected genetic composition and 18% who did possess the D2 receptor were not diagnosed as alcoholics. In summarizing their study, the authors state,
"These observations indicate that one must proceed with caution in interpreting allelic association with behavioral disorders, including the findings obtained in the present study."
While these and other less conclusive studies have shown an impressive correlation between alcoholism and heredity, other research suggests a weaker relationship. Twin studies are of particular importance to the genetic argument. This is because if alcoholism is an inherited disease, then one should expect to find quite similar patterns between the twins of alcoholic parents. In a current study in London, an analysis of 78 twins who have presented themselves for treatment of alcoholism is underway. Fifty six co twins have been located to date. Of the monozygotic (identical) twins studied, 21% display similarity with respect to alcohol patterns of their hospitalized twins. In dizygotic twins, 25% evidenced an alcohol problem analogous to their hospitalized twin.9 This research data is quite significant, because if alcoholism is a genetically explained disease, then one would expect, ex hypothesi, a much higher correlation between drinking patterns, especially of the monozygotic twins. Further, it does not explain why dizygotic twins had a slightly higher correlation with respect to alcohol abuse than monozygotic twins.
Genetic studies raise an important question: Is the link (however strong) between genetic makeup and alcoholism or between genetics and other personality factors that may give rise to dispositions toward behaviors which are likely to lead to problematic drinking under certain environmental conditions? The distinction is crucial, because the former view supports the unitary diagnosis of alcoholism as an inherently genetically transmitted disease, whereas the latter does not. In relation to the first option, Spickard (himself a proponent of the disease model) concludes,
"Many people have tried to prove through scientific experiments that there are discernible physical differences between alcoholics and non-alcoholics prior to the addiction. So far, no one has succeeded. [N]one of the popular notions about the causes of addiction have proven to be true. "10
A more plausible (and biblical) way of explaining the link between genetics and alcoholism is the latter. But if this is the case, then it is merely the disposition toward compulsive behavior in general under certain circumstances and not alcoholism per se which is genetically based. In the JAMA article mentioned earlier, the researchers make a similar point with respect to the biological argument for alcoholism:
". . . follow up studies of children during adolescence reveal the sons of alcoholics to have enhanced consumptive behaviors relative to alcohol, tobacco, and marijuana compared with the sons of non-alcoholics."11
Another theory that seeks to define alcoholism as a primary disease is the "addictive personality" thesis. While this view enjoys increasing popularity, there are little experimental data to support it. Again, quoting Spickard,
"People who work with alcoholics know there are many personality traits which show up with uncommon frequency among addicted people."12
Alcoholism as a Progressive Disease
According to the disease model, once a person has become symptomatic for alcoholism, he is on a downward spiral, ending in probable death without external intervention. Among chronic alcoholics studied, there is a noted commonality in the progression of the disease. Below is a summary of the popular Johnson Institute analysis of the progression of the disease:
1. Learning mood swing
The person learns that alcohol can provide a temporary mood swing in the direction of euphoria. At this point, they trust the alcohol's effect, but regulate the intake. All social drinkers fall into this category.
2. Seeking mood swing
While seeking the benefits of what has been learned about alcohol consumption, they impose rules on their consumption. That is, they remain social drinkers, but a pattern of consumption has emerged.
3. Early dependency
The drinker begins to experience periodic loss of control over alcohol use. They can no longer predict behavioral outcome from consumption (drunk at parties, does embarrassing, illegal or immoral things). This is of great significance in the development of the pathology, because the drinker's value system is violated when drunk: guilt feelings are now associated with drinking. Strong negative feelings about themselves emerge. The abuser at this point experiences growing anticipation and preoccupation with drinking. He or she desires to continue drinking when others have stopped. Self imposed rules about drinking are regularly violated. Tolerance to alcohol increases and they begin to need more to obtain the same high. Finally, they drink to get drunk.
4. Using to feel normal
A pattern of drinking to cope, rather than to feel high occurs. The person's schedule and social contacts begin to revolve around drinking. Thus, they will not go to places where there is no alcohol, or they show up drunk. Alcohol is a regular habit that has destructive consequences in their lives. They lose the ability to maintain close relationships. When confronted with a drinking problem, excuses and rationalizations occur. Physical addiction may occur at this point. Blackouts and memory loss are common. If a person remains at this stage, they will undergo serious physiological problems that are likely to lead to death. Jellinek observed that it may take anywhere from two to twenty five years to arrive at this point.13
The problem with this analysis of alcoholism is that it can neither be universalized to include the drinking behavior of all alcoholics nor can it serve to identify which social drinkers will advance to the final stages. It is important to note the thesis that alcoholism is a progressive disease is based on commonalities that exist among alcoholics in treatment facilities in the most chronic stage of dependency. The almost universally used "Jellinek chart," which traces the progression of alcoholism, is based on his study of men who were in Alcoholics Anonymous, and clearly had long term, chronic dependency on alcohol. This retrospective generalization commits what is referred to as the "post hoc" fallacy in scientific methodology. In effect, the methodology used to prove that alcohol dependency is progressive is analogous to tracing the heroin addict's pattern of abuse from the time they first started smoking marijuana and ending with their problem prior to seeking treatment and then generalizing the data to hold that all persons who abuse marijuana will end up heroin addicts.
Retrospective studies do not tell us which users or abusers are going to progress into more dysfunctional patterns of abuse. In fact, there is strong evidence that many abusive drinkers never progress beyond the third stage. Valliant's study indicates that "the [second and third stage of the Johnson Institute analysis] is heavy social drinking, frequent ingestion of 2 or 3 ounces of alcohol (3 5 drinks per day) for several years. This stage can continue asymptornatically for a lifetime; or because of a change of circumstances or peer group it can reverse to a more moderate pattern of drinking; or it can "progress" into a pattern of alcohol abuse (multiple medical, legal, social, and occupational complications), usually associated with frequent ingestion of more than 4 ounces of ethanol (8 or more drinks) a day. At some point in their lives, perhaps 10 15% of American men reach [this more advanced stage]. Perhaps half of such alcohol abusers either return to asymptomatic or controlled drinking or achieve stable abstinence."14 The conclusion which current research on alcoholism strongly suggests is that there is no clearly predictable progression from alcohol abuse to alcohol addiction and that dependency itself is manifested in a variety of forms.
Alcoholism as a Chronic Incurable Disease
Without a cure, the disease can only be controlled through total abstinence. As AA teaches, "once a drunk always a drunk." While it is true that for the chronic alcoholic who has been involved in seriously dysfunctional drinking for a number of years that normal drinking patterns will never likely occur, it is clearly not true for many who are labeled as alcoholics.
For many, especially young abusers, total abstinence as a goal of treatment is neither necessary nor perhaps helpful. It is not necessary, because studies indicate that alcohol abuse can be moderated. We noted earlier Vaillant's findings that many abusive drinkers moderate their patterns of consumption through independent choice or changes in peer group. The notion of total abstinence may prove unhelpful, because for those in the early stages of alcohol dependency, they simply will not identify with the goal of abstinence. Thus, they are polarized by the disease view: either drink abusively (because that is the nature of the disease) or never drink again. Such a dichotomy is false in many cases. We must recognize that the term "alcoholic" is a powerful euphemism in our culture. Being labeled an alcoholic often unnecessarily stigmatizes a person and can make them feel alienated from normal social contexts.15
The fact is, we live in a drinking culture! The use of controlled drinking as a treatment ideal will be discussed later. The issue here is whether or not the disease model is correct in positing that alcohol dependence is a chronic disease requiring total abstinence. Where abstinence is unnecessarily stressed, it creates a crisis of conscience for the person who has even a single drink, because of the pre-understanding given him/her by the disease model that they are just one drink away from being a drunk. Violating ones' conscience is one of the most common causes of relapse. Marlatt calls this the "abstinence violation effect."16 In Romans 14:23, Paul cautions the church not to engage in amoral practices that violate ones' conscience. This biblical principle is critical to helping alcohol abusive and dependent people, as we will later see. It is also something which secular research clearly verifies, as Lewis comments, "[A drink] can be devastating if defined as a disaster and as a failure. "17
Identifying everyone employing new patterns of alcohol consumption from a previously abusive one as being in "denial" can be destructive and unnecessary. Having made that point, it must also be stressed that the phenomenon of denial is very real and must be taken seriously. Many though not all, formerly chemically dependent people are in a state of denial when they appear to be moderating alcohol use.
The evidence from genetics, which is the primary justification for the disease model, must be taken seriously. Where alcoholism is present in a parent, it is much more probable to occur in their children than in the children of non-alcoholics. The drinking child of an alcoholic parent needs to exercise a high measure of caution and accountability in their drinking patterns. Yet, as is evident from the above discussion of the three principles of the disease model, we must challenge the notion that alcohol dependency is a unitary diagnosis. Reflecting on the scientific support for the disease theory, Lewis states,
"Although the disease concept has enjoyed wide acceptance, predominant support for their acceptance is based on anecdotal reports. In fact, the medical model is based primarily on unproven assumptions that are not synthesized from strict scientific study."18
Commenting on the ideological hegemony enjoyed by the disease model, Stanton Peele, (author of Diseasing of America: Addiction Treatment Out of Control) states,
"The modern 'scientific' view of alcoholism and addiction has actually caused addictive behaviors of all kinds to grow. It excuses uncontrolled behavior and predisposes people to interpret their lack of control as the expression of a disease which they can do nothing about. Treatment advocates attack those who don't accept the disease model of addiction as being `unscientific' and `moralistic', or as practicing `denial'. On the contrary, the refusal to accept the `loss of control (lability)' myth seems to inoculate people against addiction ....In the area of addiction, what is purveyed as fact is usually wrong and simply repackages popular myths as if they were the latest scientific deductions. To be ignorant of the received opinion about addiction is to have the best chance to say something sensible and to have an impact on the problem."19
Rosenberg expresses great concern over the lack of openness in the substance abuse profession to critically evaluate the research data. He states,
"Questioning established dogma (disease view) or entertaining alternative ideas is to be avoided. It has also been argued that the support for these beliefs as systematized in AA philosophy is so powerful as to inhibit the development of scientifically based alcoholism research and treatment methods.”20
More important, for the Christian, any view of alcoholism must emerge from the biblical record. As was shown earlier in the paper, the scripture clearly places alcohol abuse and chronic drunkenness in the moral, not medical, realm. Paul teaches us not to associate with the drunkard (1 Cor. 5:11). This would be cruel if the person was suffering from a disease!
Social Behavioral Model
Several leading researchers from a variety of academic disciplines are beginning to stress the role of social environment and social learning in the development of alcoholism. We consider first the correlation between cultural values and attitudes and alcoholism.
In an important study charted below, E. M. Pattison identifies four cultural groupings relative to their values concerning alcohol consumption and their corresponding rate of alcoholism.21
In these societies, strong negative norms against drinking and no positive norms are established. Those few who drink are likely to be considered socially deviant and show a high risk for drinking problems. Among these cultures are Mormons and Moslems. A related cultural grouping are those in which alcohol has been introduced by Western society in recent centuries. In these cultures, termed "disorganized cultures" for the purpose of alcohol consumption, such as the American Indians, there were no cultural norms for drinking prior to the influence of Europeans. Where alcohol has been introduced to a previously abstinent tribal society, fully 92% of all drinkers have developed what Pattison calls "normless alcoholism."22 It should be noted that oppression and radical cultural change accompanied the introduction of alcohol to these cultures. This lack of social stability is a likely factor in the creation of "normless drinking".
These are cultures that have conflictual norms. Abstinence is often taught and highly valued, yet drinking is common. This conflict produces high numbers of problem drinkers, called "deviant addicts". They deviate from the norm, yet there are many who fit this category. They are highly likely to be seriously encumbered with conflict, guilt, shame, and turmoil over drinking. This is the alcoholic from the Bible belt.
Integrated Structural Culture
Strong positive and negative social sanctions exist concerning alcohol consumption. When the norms are strong, the incidence of alcoholism is relatively rare. Of particular importance, as Pattison points out, when the norms become confused through generations of cultural assimilation, the rate of alcoholism increases significantly. Jews and Italians are good examples of this phenomenon. This factor points to a very important correlation between developing destructive drinking patterns and the extent to which cultural values are internalized.
This is the description of the modern, urbanized West. It is characterized by weak, vague and ambiguous norms about drinking. Here, the majority of the population drinks and drinks frequently. Pattison points out that, in the United States, the consumption of alcohol increases by an average of 10% per year. Incidents of problematic drinking are steadily on the rise in the West.
U.S. Subgroup Orientations Toward Alcohol Use
N-Somewhat Negative; MN- Moderately Negative; SN-Strongly Negative; C-Conflictual; V-Vague, Ambiguous, Pluralistic; P-Somewhat Positive; MP-Moderately Positive; SP-Strongly Positive
||Populations at Low Risk
||Populations at High Risk
Methodists, Fundamentalists, Cults, So. Baptists
||All Who Drink
||Legal - MN; Cultural - P/N
||Most of Culture
||Ascetic, Christian, English, Slavic, German, Irish
||Heavy Drinkers, Deviant, Addict
||All Who Drink
These data are of great value both for the treatment and prevention of abusive drinking patterns. It suggests that a proper and clearly articulated set of expectations regarding the consumption of alcohol should yield normal drinking patterns. If the abusive, though not yet compulsively dependent, drinker violates the internalized values of the identity group, the behavior can be corrected. I think that this has been the experience of many, perhaps hundreds of people in our fellowship. This will be discussed in the final section of the paper.
A second factor in the development of problem drinking, according to social learning theorists, is how a person comes to understand the use of the substance. That is, its purpose and the role that it plays in the life of the drinker are important. Consider the following factors that affect consumption patterns:
Anticipated Drug Experience
Drug experiences are, to a large measure, learned. That is, we learn how to get high and do so in groups. A state of anticipation is produced in the user as he is told what to expect. Lewis' comments on this phenomenon are instructive:
"A user's expectations about the drug's effects are derived from several sources, including experience with the substance, friends' accounts, the mass media, education and training, and professional descriptions. These expectations have a considerable impact on the effects one obtains from a drug."23
If the social setting defines alcohol consumption as an act of rebellion, deviant behavior can be anticipated. For example, drunk teenagers act much differently than drunk businessmen at a cocktail party. If, however, alcohol consumption is done in the social context of significant interpersonal relating, the role that drinking plays is geared toward enhancing social conviviality. A person will be more self-regulating, because too much booze will inhibit the intention for the use and cause embarrassment which is more costly than moderation. The clear implication is that where the individual learns to drink, and how the individual understands the purpose for drinking will guide the pattern of use. It is for this reason that drinkers from abstinent families are more likely to develop dysfunctional and abusive patterns of drinking than people from homes in which alcohol is consumed, but at a visibly moderate level.
Mood has a significant effect on the experience given by a substance. A depressed drinker is likely to develop dysfunctional drinking patterns. Alcohol produces a lift to the depressed, which provides brief respite from one's emotional state. As the association of depression relief and alcohol is habitually engrained in the thought processes and behavior patterns of the drinker, addiction is far more likely. "Relief drinking" is a consistent factor in the presence of alcohol dependence. As the consumption of alcohol replaces normal, healthy ways of dealing with life's pressures, a pattern of abuse and dependency will often follow. The reasons for drinking, as well as the context of drinking, will be viewed in the next section as two of the four most important diagnostic criteria for alcohol abuse and potential dependency.
On the basis of the models considered in this section, we now turn to a working etiology for alcoholism.
The weight of biblical data clearly defines problem drinking as sin and falls within the behaviors subject to church discipline. It should be observed in this regard that the biblical term "drunkard" applies to the lack of control in alcohol consumption. No distinction is made between the chronic abuser and an addicted person. It must be pointed out that the disease diagnosis is foreign to the biblical world. Indeed the view that alcohol is anything other than habitual lack of self control is the product of 20th century secular theorizing. The research data in no way excludes a central role for choice in the life of the alcoholic. It should be noted, however, as was mentioned earlier, that the place of moral accountability is on seeking help (in the advanced stages of dependency), not on the drinking pattern, itself. Profound psychological and physical dependence is a fact for many alcohol abusers.
Problem drinking should be viewed as the product of a complex of factors that include genetic disposition (in some cases), social and environmental factors, a person's life situation, morally significant choices in dealing with problems in life, etc. If we think too reductionistically, treatment will be superficial and will tend to overlook some of the crucial personal antecedents that will give rise to other forms of compulsive behaviors. It is useful to think of alcoholism in terms of a continuum of dysfunction surrounding the abuser, rather than an all-embracing term applied with equal weight to all abusers or dependent persons. Pattison argues that:
"The theoretical assumption (of the disease model) has little utility, and the search for an unequivocal method of accurate binary diagnosis has failed because the term "alcoholism" does not refer to a concrete entity, but rather to a diverse set of behaviors and problems. The unitary concept assumes that there is a distinct class of persons who have the specific disease of alcoholism, who are substantively different from problem drinkers, heavy drinkers, etc ....Most scientific authorities in the field of alcoholism now concur that the construct of alcoholism is most accurately construed as a multivariate syndrome. That is, there are multiple patterns of dysfunctional alcohol use that occur in multiple types of personalities, with multiple combinations of adverse consequences, with multiple prognoses. . . "24 Concludes Lewis, "Use of a simple diagnosis of alcoholism or drug addiction actually interferes with treatment planning by masking individual differences."
"A simplistic approach to assessment also lessens the potential effectiveness of treatment by discouraging early intervention in cases of problem drinking or drug use. An either/or diagnosis leads inexorably to a generalized, diffuse treatment package that at worst brings results no better than the natural progression of the disorder and at best meets the needs only of individuals with serious, chronic, long lasting substance abuse disorders. Insistence on a clear diagnosis of "alcoholism" for instance, drives away from treatment many people who are not necessarily alcohol dependent but who could benefit from assistance in dealing with life problems associated with incipient alcohol abuse.”25
Lewis' analysis is of particular importance in understanding and dealing with young abusers of alcohol. Filstead points out that the criteria used to diagnose adult alcoholics should not be applied to adolescents. He further indicates that public perceptions regarding a significant increase in adolescent alcohol use and abuse do not correspond to available research data.
"A survey of the youth and alcohol literature suggests that societal perceptions as to the nature and seriousness of adolescent use and increase in the frequency of alcohol has undergone a radical shift. Available data does not support a significant increase in the frequency of alcohol use, the magnitude or scope of the problem, nor the consequences that result from such use. It is the perception of these realities at this time that makes them real. If people define a situation as real, it is real in its consequences.”26
Diagnosis and Treatment
Not only should alcohol abuse be considered a continuum but it also should be diagnosed by a variety of criteria. Diagnosis must take into consideration the physical health of the abuser, as well as the number and severity of dysfunctions associated with alcohol use. Four areas of analysis for gauging drinking dysfunctionality need to be considered. Here we outline in brief form the kind of issues to be taken into consideration in assessing dependency.
The most important criterion for ascertaining alcohol dependency is the inner life of the abuser. How do they view the role of alcohol in their life? That is, what is its purpose, how do they feel about their use, what beliefs do they hold about alcohol abuse and dependency? When one observes signs of emotional or psychological dysfunction accompanied with an unhealthy view of the role of alcohol in the abuser's life, there is reason for great concern.
Two areas must be evaluated in this category. The social context of the alcohol abuser must be taken into consideration. Does the abuser drink more than other individuals in typical social situations? What kind of behavioral changes occur with the consumption of alcohol? Does the abuser have a hard time feeling a part of the identity group? Are the patterns of consumption in the identity group healthy? Are there regular times in which drinking in the identity group does not occur? Is the abuser's interaction with the group different in these non-drinking contexts? Second, how does the abuser relate to his/her immediate family and close friends? Are there significant conflicts, growing discontent or distance? Often, this is the first sign that an abuser is moving in the direction of dependency.
The physiological concern is twofold. First, is there a history of alcoholism in the abuser's biological family? Aspects of learned behavior from the family and possible genetic predisposition toward compulsive behaviors must be taken seriously. Second, has the alcohol abuse caused physical consequences such as frequent hangovers which have prevented normal functioning at work, etc., blackouts, or withdrawal symptoms when abstinent? The second set of issues suggests an advanced state of alcohol dependency and must be professionally treated.
Often, alcohol abuse is a coping strategy for dealing with oppressive conditions. It is likely that this is the reason why alcohol and drug dependency results in a greater level of dysfunctionality in poorer communities. One must consider what pressures bear on the alcohol abuser. Some examples are, job pressures and satisfaction, financial issues, and life situation issues such as being dissatisfied with marital status, family conditions, etc.
Below is a set of questions taken from a variety of diagnostic sources that will help assess the extent of abusive drinking. The issues raised in the survey isolate factors to be considered when assessing whether or not a person has an abnormal drinking pattern.
Personal Drinking Habits
- How many days of the week do you drink?
- Are there regular days in which you do not drink?
- How much do you drink in one day?
- Do you drink more, less, or the same as your closest friends?
- Do you drink to relieve stress, depression, or anger?
- In what way does your mood or personality change when you drink?
- How long have you had your current drinking pattern?
- Do you orient your social life or work schedule around drinking?
- What times of the day do you drink?
- How often do you drink alone?
- How do you feel before deciding to drink alone? E.g.: depressed, lonely, stressed out, etc.
- Would you rather drink alone or with other people?
- What happens when you drink alone? Do you tend toward depression, etc.?
- How much do you drink when you are alone?
- Why do you drink?
- Do you take any other drugs with alcohol? What kinds? How often?
- With whom do you regularly drink?
- Have you ever been troubled with the extent of your drinking? If so, what did you do about it?
- When was the last time you drank too much? Describe.
- How often do you drink too much?
- Are there alcoholics in your family?
- Who is it (they)?
- How were you affected by their problem?
- What is the attitude toward your drinking by those closest to you?
- Do they oppose the fact that you drink or the extent to which you drink?
- Have you ever been confronted about your drinking? When, by whom, how often?
- Do you have a history of alcohol abuse or drug abuse? Explain.
- How many times in the past two months have you gotten up in the morning wishing you'd not had so much to drink the night before?
Personal Problems Associated With Drinking
- Have you ever had legal problems associated with drinking? Explain.
- Have you ever had problems with work related to drinking? Explain.
- Have you ever had problems with school associated with drinking? Explain.
- Have you ever had financial problems involving drinking? Explain.
- Have you ever had family problems over drinking? Explain.
- Have you ever had serious conflict with others or embarrassing situations occur when drinking? Explain.
- Do you have physical problems that are affected or caused by drinking? Explain.
General Life Issues
- I would rate my spiritual life: excellent, good, struggling, troubled.
- I would rate my family life: excellent, good, struggling, troubled.
- I would rate the quality of my best relationships: excellent, good, struggling, troubled.
- I would rate my job satisfaction: fulfilling, satisfactory, unsatisfying, troubled.
In assessing the problem of alcohol abuse, it is necessary to consult not only the perceived abuser but also those closest to them. When a person is progressing from a state of abuse to dependence, they will minimize the problem and, often, will not be honest. Sharing observations with family members and close friends is also crucial, because problem drinkers have the ability to deceive those involved in their lives. If there is a generally shared opinion that an abuse problem exists, it is necessary to do two things.
Assessing the Extent of the Problem
First, consider the above factors from the perspective of both number and severity of problems. If there is no health threatening issue, or obvious dysfunction in the person's life, it is best for person closest to the abuser to simply raise personal concern for him/her. Share your observation (facts) and feelings. Ask them for their view. Talk together about what one another considers "normal" drinking. This will help establish common ground. Be sure to give them time to consider the issue: even the suggestion of a drinking problem is very threatening, and it takes a while to mull over. If there is noted resistance to talking about the issue and settling on parameters for drinking, then others should be brought in. Other family members or people in positions of spiritual authority over the abuser may need to express their concerns too. Where inappropriate drinking occurs, those involved should wait until the next sober opportunity and directly confront the abuser with the facts. At this point, specific alternatives need to be given to the person: abusive drinking must have consequences. Consequences may range from attending alcoholism awareness seminars (Riverside, etc) to marital counseling, various levels of church discipline, etc. Imposing consequences is a judgement call: The goal is to help a person come to terms with the fact that an unacceptable pattern of use exists and that it will not be tolerated.
This level of alcohol abuse may be dealt with on a home church level, though input from a counselor who is knowledgeable on the issues should be considered. However, careful monitoring of the situation is vital. If there is no sign that the abuser is clearly moving toward normal, non-problematic drinking patterns, professional help will be necessary. If the decision is made to push for treatment and the abuser is willing, it is important that those involved with the abuser stand behind the treatment suggested as much as possible. The alcohol-dependent person needs to have a unified support team. If they perceive significant differences in outlook regarding the severity of the problem or the measures necessary to maintain sobriety or control, they will tend to rationalize away their problem.
A note on controlled drinking at this level of abuse is relevant. To overreact to abusive drinking may be harmful to the goal of controlled drinking or abstinence, if that is called for. We need to think of alcohol abuse in the life of a person in their teenage years or early twenties much differently than a person who has had an abusive drinking pattern for 10 or more years. Teenage alcohol abuse usually is centered on teenage rebellion or peer pressure. Almost all teens who drink are abusive drinkers. These are the issues to be addressed, not simply the alcohol issue. For others, we must consider what things are going on in their lives: Work problems, death in the family, bad marriage, etc. If we are too heavy and press for rigorous treatment or total abstinence, the real issues do not get addressed adequately: alcohol becomes the issue. It is much better if a person can self regulate his drinking, based on the resolution of life conflicts. Individual or family counseling, along with accountability in drinking, is the best solution at this point.
While controlled drinking may be an option for many of our young alcohol abusers, it is not a program designed for many, and perhaps most, chronic alcohol abusers. Those who should not attempt a program of controlled drinking include the following:
- People with any kind of physical problem that would likely be exacerbated by continued drinking (liver dysfunction, gastrointestional problems, cardiac problems, etc.).
- People who are committed to abstinence and who are well adjusted to that life style.
- People who have strong external pressure to be abstinent.
- People who lose control of their behavior when they drink.
- People who have been physically addicted to alcohol.
- Those who are in the following circumstances:
- over 40
- divorced and not in a supportive relationship
- those with a significant family history of alcoholism.
Second, we consider the more advanced case of alcohol abuse, where different measures will need to be entertained. If there are serious and numerous dysfunctions associated with alcohol abuse, intervention will need to be more forceful. Successful interventions (outlined by the Johnson Institute, etc) include the following:
Concerned parties meet with a counselor to discuss their perceptions of the problem. An assessment is made, based on the collective observations of the extent of the problem. Often, the counselor is able to direct the discussion. It is important in assessment to be as concrete as possible: Name specific things which are occurring in the person's life related to alcohol abuse, the affect these things have had on those involved, and the concern for the abuser's future. After discussing the data and an assessment is made, each member prepares what they want to say to the abuser.
A confrontation time is scheduled where all parties involved gather and, with the guidance of a counselor, confront the abuser. Johnson Institute suggests that the intervention should take place as soon after a drunken episode as possible. During the intervention, the counselor explains why each person is gathered and asks the abuser to listen to their concerns. After the confrontation, the abuser is given opportunity to respond. The session ends with a concrete plan of action, ranging from immediate hospitalization to a commitment to begin counseling that day or the day after. Some form of discipline must be agreed upon by the confronters should the abuser refuse treatment. This may mean firing from a job, temporary marriage separation, etc. The consequences of not acting must be painful, more painful than proceeding with some form of treatment. Immediacy is the issue here.
Knowing the range of treatment options is crucial. In our society, hospitalization is usually pushed for all diagnoses of alcoholism, regardless of the extent of dysfunction or duration of abuse. This is often excessive and can be counterproductive. Lewis states,
"Clients can be harmed if they are coerced into treatment that is more life disrupting than necessary. Beyond this, there is little evidence that long term hospital care brings the results that its high cost would warrant, at least where alcoholism is concerned. The absolutely consistent testimony of controlled studies is that heroic interventions-those in longer, more intensive residential settings-produce no more favorable outcomes overall than treatment in much simpler, shorter, and less expensive settings."27
Admission Criteria for Substance Abusers
Criteria for Acute Hospital Care
- Failure to make progress in less intense levels of care
- High risk chemical withdrawal (seizures, delirium tremens)
- High tolerance to one or multiple substances
- Acute exacerbation of medical or psychiatric problems related to chemical dependence (cardiomyopathy, hepatitis, depression)
- Concomitant medical or psychiatric problem that could complicate treatment (diabetes, bipolar disorder, hypertension)
- Severely impaired social, familial, or occupational functioning.
Criteria for Non-hospital Residential Care
- Failure to make progress in less intensive levels of care
- Ability to undergo chemical withdrawal without close medical supervision
- Stable medical or psychiatric problems that require monitoring
- Impairment of social, familial, or occupational functioning requiring separation from environment
- Sufficiently developed interpersonal and daily living skills to permit a satisfactory level of functioning
Criteria for Partial Hospital Care
- No need for 24 hour medically supervised chemical withdrawal
- Stable psychiatric or medical problems
- Sufficiently developed interpersonal and daily living skills to permit a satisfactory level of functioning in this setting
- No need for intensive psychiatric care.
- Need for daily support rather than weekly or biweekly sessions.
- Social system that is, family, friends, or employment capable of providing support.
Criteria for Outpatient Care
- Ability to function autonomously in present social environment
- Stable psychiatric or medical problems
- Sufficient capacity to function in individual, group, or family therapy sessions
- No need for 24 hour medically supervised chemical withdrawal
- Willingness to work toward goal of abstinence from harmful drug use.28
Alcohol Abuse and the Church
In this final section, two issues will be addressed: (1) providing proper support for recovering alcohol dependent or abusive people; (2) principles to prevent alcohol dependency from developing in the home church community.
Supporting Recovering Alcohol Dependent or Abusive Persons
This particular aspect is difficult to address in any comprehensive sense, because the dynamics of abuse and dependency are so complex and unique to the individual. Thus, we will consider some basic principles based on commonalities among people struggling with alcohol abuse.
If the person is involved in some form of counseling or treatment, people in the home church need to be informed of the goals and methods of treatment. The alcohol dependent or abusive person needs to have the support of a united group of natural helpers behind him/her. Thus, if an agreed upon treatment goal is to sustain total abstinence from alcohol, it is vital that those involved with the person under treatment support it. It is destructive to the goal of recovery when members of the Christian community determine, based on their theology or personal experience what an alcohol dependent person can or cannot handle. As a general principle, never encourage a person committed to total abstinence to have a drink for any reason.
Become familiar with what external pressures tend to give rise to the temptation to abuse alcohol. Be available to discuss them on a regular basis. If the alcohol abuser begins to withdraw from supportive, informed relationships, this is a sign that they may be contemplating abuse. It is important to be long on empathy and listening and short on solutions if the person is involved in counseling. If the abuser is not in counseling, then natural helpers become ad hoc counselors and play a crucial role. Help the abuser think through a plan of action for dealing with the things in his/her life that are likely to produce failure. Success in problem areas will give the abuser a sense of freedom from the need to escape in alcohol abuse.
Promote "normal living." It is the tendency of alcohol dependent or abusive people, especially if they have gone through most treatment programs, to be focused on the problem of abstinence. While this is an important focus, it is not the only focus needed for long term victory over their problem. They will need assistance in developing relationships and a role in the home church. If the abusers or dependent persons begin to feel that they have a place in the Body that is personally rewarding, they have a much stronger incentive to maintain sobriety.
Many alcohol dependent people suffer from a variety of emotional and social problems, due largely to the fact that emotional and personal development typically stops when abusive patterns of alcohol consumption begin. Thus, supportive friends need to exercise patience and grace. Most recovering alcoholics "relapse" at least once and often more times than that. These experiences must be interpreted for the dependent person in such a way that they do not despair of ultimate success. Concerning this issue, it must be pointed out that the AA dogma that the alcoholic is just one drink away from being a drunk is often false and potentially destructive. With the proper input, the alcoholic, like the homosexual or any other person suffering from a compulsive habit, can climb back on the wagon and move forward.
If it is possible, someone close to the alcohol abuser should be with them in their counseling. This is rarely possible in most secular therapies (except family members), but it is stressed in our fellowship. Take advantage of this opportunity, assuming that the alcoholic extends the invitation. Supportive friends need to be aware of the fact that the early stages of alcoholism treatment are time intensive. Often, this involves several group counseling or support groups per week. This situation should be monitored. It should be affirmed for the role that it plays, even when it takes the person out of the "normal" range of fellowship activities. Remember that the dependent person is dealing with a potentially life-threatening problem in some cases. However, it must also be clear that the Christian community is the best long-term context for real healing to occur. Thus, if the alcohol abuser remains distant for a period of more than a couple of months from necessary contexts of body life to attend support group meetings, it would be helpful to discuss the issue with them. Clearly, support groups are no substitute for Christian fellowship. The process of transferring support from an alcohol focused group to the church can be difficult and requires discernment to work through the process.
Preventing Future Alcohol Dependency
The best way to protect potential alcohol abuse and dependency is to establish standards for proper use of alcohol. Home church leaders will need to set the example of responsible drinking and be open with members of the home church about healthy and unhealthy drinking patterns. Leadership in this area is crucial because, in our culture, there is no generally accepted set of norms for the proper use of alcohol. Leaders need to be open about how much they drink, how often they drink, and under what circumstances they drink. The example set by the home church leaders tends to become the norm for the church.
Home church leaders must be willing to address unhealthy patterns of consumption. When there are people who drink more than an acceptable level, the issue must be discussed with them. It is important not to lay down the law, but to express the importance of moderation and sobriety from the biblical perspective. Many new believers will simply carry into Christian fellowship the patterns of drinking they had in the world. If a home church leader is concerned about the level of drinking in someone's life, they should also find out what kind of past the person has with alcohol. Have they had abuse problems in the past; is there reason to believe that they are using alcohol to avoid dealing with issues in their lives; is alcohol causing a problem in their marriage or work, etc?
Drunkenness under any circumstances is not to be "sanctioned." If a person is drinking more than the equivalent of one beer per hour, they are legally unfit to drive. In social contexts where drinking occurs, make sure to provide food and coffee. If a person has "had enough," it is worth the potential embarrassment to offer them something nonalcoholic to drink. If excessive drinking occurs, it should be brought to the attention of the abuser. Usually, mentioning the offense is sufficient. In cases where a person is regularly drinking more than the rest of the group, this fact should be pointed out as a cause of concern and the situation should be monitored and assessed for potential dependency. When concern for a person's drinking pattern exists, it is helpful to be direct with the person about your concerns, citing specific facts about their pattern of consumption.
In the state of Ohio, it is illegal to offer a person under 21 alcohol. Sending a minor home after a home church function with alcohol on their breath (even if they are not drunk) can cause serious legal problems for home church leaders. Allowing alcohol consumption among minors can lead to a public confrontation with our ministry. It is a fallacy to think that we cannot effectively reach teenagers unless we offer them alcohol.
A body of Christians committed to spiritual growth and ministry is the best context in which to learn the proper use of alcohol and to respond to problematic drinking. We should recognize the fact that hundreds of members came to this fellowship with serious patterns of substance abuse of all kinds and have found their way to healthy patterns of use or abstinence. This paper is not intended to promote paranoia, but to engender a sense of vision and hopefulness that we have the opportunity to be an example to the world of the transforming power of Christ in this area.
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1. See George Vaillant, Natural History of Alcoholism (Cambridge: Harvard University Press, 1983) p. 316.
2. Anderson Spickard, Dying for A Drink (Waco: Word Books, 1985) p. 41
3. See DSM III; DSM IIIR, et. al
4. Vaillant, op. cit. pp. 64 71 for a survey of the literature
5. D.W. Goodwin, "Alcohol Problems in Adoptees Raised Apart from Biological Parents.", Archives of General Psychiatry, 28:238 243
6. C.R. Cloning, "Inheritance of Alcohol Abuse: Cross Fostering Analysis of Adopted Men", Archives of General Psychiatry, 38:1981, 861 8
7. JAMA, Apr. 18,1990 vol 263, No. 15
8. Ibid., p.2059 See editorial in JAMA for further criticisms of this study.
9. H.M.D. Gurling, "Investigations into the Genetics of Alcohol Dependence," Advances in Twin Research, v.2, Parisi, P (ed). (New York: Alan Liss, 1981)
10. Spickard, op. cit., p.23
11. JAMA, op. cit., p. 2058
12. Spickard, op, cit., p. 23
13. See Jellinek, "The Disease Concept of Alcoholism," 1960 (reprinted in numerous publications detailing the disease model).
14. Vaillant, op, cit., p.309
15. Judith Lewis, Substance Abuse Counseling (Pacific Grove: Brooks/Cole Publishing Company, 1988) p.152; Heather and Robertson, Controlled Drinking, (N.Y., Mathuea Press, 1983).
16. G.A. Marlatt, Relapse Prevention (New York: Guilford Press).
17. Lewis, op. cit., p.194
18. Lewis, op. cit., p.197
19. "Control Yourself", Reason, Feb., 1990.
20. Chaim Rosenberg, "The Paraprofessionals in Alcoholism Treatment", Encyclopedic Handbook of Alcoholism (New York: Gardner Press, 1982) p. 806.
21. E.M. Pattison, "Whither Goals in the Treatment of Alcoholism?", Drugs and Society, 1: 153 171.
22. Pattison, ibid., p.156
23. Lewis, op. cit., p.62
24. Pattison, op. cit, p.13.
25. Lewis, op. cit., p.5
26. William Filstead, "Adolescents and Alcohol", Encyclopedic Handbook of Alcoholism, p. 771.
27. Lewis, op. cit., p.23
28. Adapted from "Clinical Making in Chemical Dependence Treatment: A Programmatic Model" by D. Giuliani and S.H. Schnoll, Journal of Substance Abuse Treatment, 2, 203 208.