ALCOHOLISM OR PROBLEM DRINKING

by Sarah Webb

Consumption of alcohol is an activity which can lead to problems. This fact is unlikely to be disputed. However, theories of why some people drink to a degree which is detrimental to their well-being - physical, social, mental or economic - abound.

When do we drink?

For most people in the western world, drinking is a recreational activity associated with relaxation or social and celebratory events. Much business is also conducted with the aid of alcohol. It is essentially an ice-breaker. In these circumstances the majority of people manage to drink without incurring any harmful consequences.

It is also used, more perilously, as a way of avoiding unpleasant feelings e.g. to relieve stress and anxiety or feelings of unhappiness. For some individuals, drinking reaches a level which begins to jeopardise their health and welfare. The quantity and pattern of consumption at this point will vary from person to person.

When is drinking harmful?

General guidelines state that for men, drinking more than 3 to 4 units of alcohol a day is more likely to cause harm, and for women, drinking more than 2 or 3 units a day. The risks of harm increase as consumption increases.

1 unit=

I small glass of wine or

1 measure of spirits or

1/2 pint of ordinary strength beer

Problem drinking

Problem drinking has been defined as: abnormal (usually excessive) drinking that leads to disturbance in social function and/or deterioration in health. Those affected include individuals, family members and society as a whole.(Wells, 1992) More specifically, alcohol causes problems of the following nature:

• physical brain damage, liver damage, gastritis, heart problems, impotence and accidents.
• psychological depression, anxiety, aggression, delirium tremens and withdrawal states.
• social problems at work, family disruption, financial difficulties, drunken driving.

Who drinks?

Current figures show that 27% of men and 13% of women in the UK exceed sensible drinking levels.

18 to 24 year-olds, both male and female, are the most likely to exceed the sensible limits.

Certain occupations have a greater incidence of alcohol misuse such as publicans, actors and doctors.

Population studies indicate that the more overall alcohol use that takes place within any culture, the more misuse there will be. Price and availability are important factors in total consumption.

Causes of problem drinking

The principle theories of alcohol misuse have varied both historically and geographically; the Atlantic being the greatest divide. Key concepts are disease models, favoured in the US and by Alcoholics Anonymous (AA) or social learning models, favoured in most UK treatment agencies.

Disease model

Dating back to the 17th century, the disease model experienced a revival after the repeal of prohibition in the US in 1933. As the term suggests, disease models uphold the view that a dependence on alcohol is an illness in which the drinker loses control once he starts drinking. The importance of this approach is that it removes the responsibility for alcohol misuse from both the drinker and the drink.

An early proponent of the disease model was E.M. Jellinek who published research in the 1940s and 1950s. His work, in conjunction with the growth of AA, the self help movement which embraces its own version of this model, led to formal acknowledgement of ‘alcoholism’ as a disease by the World Health Organisation in 1955.

Features of the disease model

All disease models have a number of basic assumptions in common. These are:

• that those suffering from the disease differ qualitatively from those who do not:
• that alcoholic drinking results from an involuntary impaired control over drinking and an abnormal craving for alcohol which can be precipitated by just one drink:
• that this lack of control and craving is irreversible and that only total abstinence will provide relief from the condition.

There are several variations on the basic theme:

One version suggests that ‘alcoholism’ is a pre-existing physical or chemical abnormality which gives the sufferer an enzymatic inability to metabolise alcohol.

Alternatively it is mooted that such people have a specific sensitivity of the brain to alcohol.

A third theory asserts that ‘alcoholism’ is a mental illness and that there are certain ‘alcoholic personalities’ who have a vulnerability to dependence.

Jellinek felt that heavy drinking was initially a result of learning and that the disease of ‘alcoholism’ developed at some point as drinking became increasingly excessive. He did not believe an ‘alcoholic’ lost control over his drinking every time he took alcohol. Jellinek identified five types of ‘alcoholic’ ranging from mildly to severely alcoholic. Within this continuum he distinguished between psychological and physical dependence, and continual and episodic drinking.

AA believe that there is some specific biological pre-disposing factor which is present whether drinking takes place or not. They regard ‘alcoholics’ who have been abstinent for many years as still having the disease and therefore as ‘recovering alcoholics’.

Criticisms of the disease model

The basic assumptions of the disease model shaped the treatment for ‘alcoholics’ for many years including the approach taken by the hugely popular (in the US) Alcoholics Anonymous. Indeed, the model is still reasonably widely used. But since the 1960s criticisms of this approach have increased, leading to the inception of a number of different models which heavily influence alcohol counselling services, certainly within the UK.

‘One drink, one drunk’?

A survey conducted in 1962 following up the long term progress of discharged ‘alcoholics’ found that a small number had been drinking normally for most of the time since discharge. This countered the notions that ‘once an alcoholic, always an alcoholic’ and that total abstinence was the only option. Subsequent research has confirmed these findings.

Craving disputed

A psychiatrist called Merry gave ‘alcoholics’ small amounts of alcohol either with or without their knowledge. If a patient was unaware that he had consumed alcohol there was little evidence of increased craving or loss of control. Another study showed that subjects who were told they were drinking alcohol, whether they were or not, reported craving. This undermines the physiological basis of craving and loss of control features in the disease model.

Other factors

The disease model fails to take account of social and environmental factors and generally overlooks the fact that drinking behaviour takes place along a continuum. By focusing on heavy, ‘alcoholic’ drinking patterns, it ignores the different kinds of damage, both medical and social, which more moderate drinkers can experience.

Genetic influence

Biological theories pre-suppose some genetic influence. However, genetic (principally twin) studies of ‘alcoholics’ have not demonstrated any significant links and have generally failed to distinguish between the genetic and environmental influences of having, for example, a problem drinker for a parent.

While the disease model has become much less dominant and indeed has been strongly criticised, it was important in softening the view of drinkers as morally weak and reprehensible characters and opened up avenues for further investigating causes and, therefore, possible treatments.

Social learning models

The principle alternative to the disease model is the social learning model. This asserts that (problem) drinking is, like all human behaviour, learned. Drinking alcohol is a functional activity which either produces a pleasant consequence or avoids an unpleasant one such as anxiety. Acting upon this basic psychophysiological effect are social and psychosocial factors such as cultural, peer group and family influences together with occupation, personality, subculture, price and availability.

All these features operate together to shape how different people will respond differently to life events and circumstances. Only some people, for example, will drink more heavily in response to divorce, bereavement, redundancy, loneliness etc. Some may drink more for a short while and some on a long term basis. Most people’s drinking varies over time. Formation of a steady relationship and parenthood, as well as increasing age, are factors which moderate young adults’ heavy drinking.

Furthermore, supporters argue, continued drinking does not inevitably result in progressive deterioration but rather is subject to the effects of the various contingencies. The term ‘alcoholic’ is unpopular amongst proponents of this model, who prefer the term "problem drinking."

Treatment, therefore, is not based on a need for total abstinence as it is possible to alter or manipulate the influencing factors. For example, a change of social circle or occupation may be enough to remove the triggers for heavy drinking but enable someone to continue to drinking moderately. This is often referred to as controlled drinking. The Rand Report in 1980, a large scale follow-up of treated problem drinkers, demonstrated that abstainers and ‘normal drinkers’ had equal chances of avoiding relapse. More severely dependent drinkers did better by abstaining but equally important factors were social ones such as age, marital status and employment.

This model is sometimes criticised for not adequately explaining the apparently illogical self-destructiveness of some levels of alcohol consumption.

Cognitive-social learning model

Arising from social learning theory, this model (also known as cognitive-behavioural) attempts to explain a drinker’s motivation to drink persistently, despite increasingly negative consequences.

The emphasis is placed on the thinking of the drinker, which with alcohol is powerfully linked to the anticipated short term (positive) effects taking precedence over more negative medium and long term effects. Rationalisation on a subjective basis gives the drinker permission to continue drinking even though this may be based on considerably negative thinking. For example, a previously abstinent drinker who has a couple of drinks may continue on the basis that he has already let himself down and confirmed his inability to control his intake.

Learning theorists refute the notions of craving and loss of control. Rather, they argue that a strong wish for the anticipated pleasure from consuming alcohol is not the same as an internal need for the substance. The cognitive-social learning model does take into account situational factors and the accompanying cognitive and emotional features which result in pressure to drink. Understanding these and devising alternative responses to these high risk situations forms the basis of treatment e.g. by teaching drink-refusal skills.

Other theories
Analytical model

Analysts would explain drinking as a response to childhood experiences.

Genetic model

Linked in many ways to the disease model, proponents of this model assert that a tendency to drink excessively is the result of a genetic predisposition, largely based on the extent to which drinking runs in families. It has been claimed that 50% of fathers and 20% of mothers of problem drinkers have histories of similar alcohol abuse. (Paton, 1992) Evidence of an exclusively genetic influence is scant and most experts in the alcohol field accept genetics as a contributory rather than causative factor.

Alcohol Dependence Syndrome

Alcohol Dependence Syndrome is an important move in the understanding of alcohol related problems in that it attempts to identify the features of problem drinking rather than the causes. It can be used in conjunction with any model and reconciles many of the contradictions between different schools of thought by avoiding them.

Advocates of ADS emphasise that these are only guidelines, but they are important for identifying the heavy end of the drinking spectrum so that treatment can be appropriately matched.

Key features of Alcohol Dependence Syndrome

• Withdrawal symptoms sweats, nausea, ‘shakes’ and less commonly delirium tremens (DTs).
• Increased tolerance to alcohol needing to drink more to get the same effect.
• Narrowing of drinking habits drinking the same drink in the same environment.
• Importance of drinking drinking takes precedence over family, work and other factors.
• Relief drinking drinking to avoid withdrawal symptoms.
• Thinking about alcohol even against conscious wishes, for a majority of the time.
• Return to original drinking pattern after abstinence at a rapid rate.

Conclusion

There is, therefore, still a degree of controversy about the causes of problem drinking with research only resolving some of the issues. Causes relate importantly to treatment approaches and therefore the greater the understanding the more effective the treatment.

Evidence to date shows that whatever the underlying theoretical cause, different individuals respond positively to different interventions. There is as yet every merit in keeping support and treatment options broad.

Sources

• Avis, T (1993) Theoretical approaches to alcohol misuse,Executive Summary no.23, Centre for Research on Drugs and Health Behaviour
• Davies,I and Davies, D (1981) Dealing with drink, BBC
• Paton, A (1992) The determined quest for genes, Alcohol Concern magazine, vol.7, no.3, May-June
• Robinson, J (1988) On the demon drink, Mitchell Beazely
• Wells, B (1992) What is an alcoholic? I, Executive Summary no.12, CRDHB