When Alcohol Becomes A Problem
The word ‘alcoholism’ is a contentious and emotive one. It tends to attract somewhat negative and derogatory associations, which can serve to reinforce the stereotyping and stigma that people with alcohol problems may experience and, which may be obstacles to them seeking or being offered help. Furthermore, there is a lack of consensus as to how and to whom the word should be applied. More commonly used are the terms ‘alcohol dependence’ and most recently ‘alcohol-use disorder’, which recognises that alcohol problems exist on a continuum from mild to the most severe.
However, the word alcoholism does describe a situation that some people will find themselves in and, as such, it may be a useful one in reflecting the seriousness of their situation. For that reason, it will be used throughout this document.
There are various definitions of alcoholism, but the common defining features are: the excessive or compulsive use of alcohol, a lack of control over alcohol use, the continued use of alcohol despite negative consequences, and the development of both physical and psychological dependence over time.
It is the case that many people will meet those criteria at some point in their lives but will manage to regain control over their drinking or successfully stop drinking altogether by themselves or with some well-designed help. However, there will also be those who try repeatedly to regain control over their drinking and/or try to stop drinking and fail repeatedly on both counts. The future for these individuals may be grave.
Is alcoholism an illness?
By the time that the World Health Organisation declared alcoholism a disease in the 1950s, Alcoholics Anonymous (AA), which formed in 1935, had already adopted the disease model in response to the prevailing attitude that alcoholism was the result of moral turpitude, poor choices, weakness, and a lack of will power. In classifying alcoholism as a disease, it recognised a set of discrete and diagnosable symptoms: loss of control, craving, progression leading to tolerance and withdrawal, and the need for sufferers to access medical help.
The disease model remains controversial – some see this attitude as letting people off the hook. It is important to stress that to regard alcoholism as an illness and afford it the compassion and treatment pathways that apply to other illnesses, is not to detract from the need for the person to face up to the problem – and the consequences of their alcoholism – and to do all in their power to seek help and to prioritise their recovery.
What are the causes of alcoholism?
There is no single cause of alcoholism. Crucially, it is not a matter of poor choices, weakness, or a lack of will-power but a combination of factors that make one person more than another vulnerable to becoming alcoholic. These factors include a family history of alcoholism or addiction, childhood trauma (for example: abuse, loss of a parent, family breakdown, neglect, bullying), poor mental health, post-traumatic stress, bereavement, and drinking from a young age. For such individuals, alcohol may serve an important purpose in promoting feelings of confidence, providing solace and comfort, numbing emotional distress, or suppressing painful memories and difficult feelings by which they might otherwise feel overwhelmed.
Alcohol delivers a reward; for most people it makes them feel good! In truth, many of the things that we do deliver this reward: taking exercise, enjoying a slice of cake or a favourite meal, listening to music, having sex, planning a holiday, meeting up with a loved-one. It is important for our well-being that we find pleasure in the many and varied aspects of our lives. However, for most people, these pleasurable activities (including drinking alcohol) do not become compulsive. They are activities to be enjoyed and looked forward to, they make life feel worthwhile but generally they do not have negative consequences. Indeed, if they did, we would probably stop doing them!
However, for some, and particularly those who are vulnerable in some way, the ‘feel good reward’ they get from alcohol is pleasurable in a particular way; it hits the spot and the temptation therefore is to do it again and again and again. As this behaviour is repeated, the drinker becomes more tolerant – that is, they need to drink more and more to achieve the same effect. It is as though they are always chasing that initial reward and trying to hold on to it. But, of course, the ‘good’ feeling wears off, and thus the person drinks more and more and often without regard to any negative consequences. An added complication is that both mind and body become accustomed to alcohol – this is called dependence – and without it the person will experience withdrawal symptoms, which can be unpleasant, but which are instantly alleviated when alcohol is ingested. Thus, the person becomes trapped in a vicious circle that is hard to break.
Whether we are comfortable with the classification of alcoholism as an illness and whether we see the underlying cause as bad genes, bad experiences or bad luck, alcoholism is a very serious problem and is responsible for untold misery to sufferers, their friends and family and, sadly, for thousands of deaths every year.
Can an alcoholic regain control over their drinking?
There are those people who do regain control over their alcohol use. An example might be a university student who drinks heavily and suffers serious consequences as a result; they might fail their course, be convicted of a drink/driving offence, lose friends, accumulate debts, or get into a fight. Without doubt, they would meet the criteria for alcohol dependence However, let us say that subsequently, they get a job, meet a partner, set up home and start a family and in the face of these adult responsibilities, they cut right back on their drinking. Over the long-term and with no return to the problematic dinking of their student days, we would probably say that that person is not an alcoholic.
Other examples might be an older individual whose long-term partner or spouse dies, someone who develops a life-limiting physical condition, is attacked, involved in a road traffic accident, made redundant from their job, or other instances where individuals face situations by which they feel temporarily overwhelmed and for whom alcohol provides relief from intense and unbearable emotional distress. However, with no previous history of alcohol dependence and where the appropriate support is available, it is by no means inevitable that those individuals will become alcoholic over the longer-term
But there are those people who have lost the capacity to exercise control over their alcohol intake; even in the face of growing negative consequences they try time and time again to regain control without sustained success – for them, a diagnosis of alcoholism would be appropriate. It is safe to assume therefore that an alcoholic has probably tried (many times) to regain control over their drinking, or to stop drinking altogether, and has failed; thus, controlled drinking is not likely to be a way forward for them.
Why would someone continue to drink in the face of negative consequences?
This is a very good question and one that defines the alcoholic situation. As has been said earlier, if a behaviour has a negative impact on us, we are inclined not to continue it. To persist, suggests an investment in that behaviour that goes beyond what is rational and points to a behaviour that is serving a vital purpose for that individual. If the prosect of life without alcohol is worse that a life centred around alcohol use then the decision to continue to drink, despite consequences that seem to others to be adverse and contrary to that person’s well-being, makes some sense.
The idea of abstinence can feel like a huge challenge. Questions such as, how to celebrate a birthday, Christmas, go on holiday or to a wedding, etc are common. And it is true that when alcohol has been the usual accompaniment to such occasions, the prospect of being sober might not be a happy one. However, if the person can be honest with themselves, they will remember that many of those occasions were spoiled by them having drunk too much. Remember that we are talking about an alcoholic as someone who continues to drink despite negative consequences and who is likely to have tried many times to drink’ normally’ without success and thus, for those individuals, abstinence is likely to be a last resort. This failure is not a lack of will-power or a moral weakness, but it is the case that that person – for reasons that may not be obvious – has developed a dependence on alcohol to a point where they are unable to drink alcohol safely.
What makes a person decide to stop drinking?
Any single adverse consequence, at a particular moment in time, may provide the impetus for someone to address their drinking problem -to make the decision to seek help and/or stop drinking all together. For someone else, it may be the gradual wearing down of their ability to manage their life in the face of their dependence on alcohol that leads to a desire for change.
This is also the question that is most often asked by family members or friends who are desperate for their loved-one to stop drinking. These are those people who are affected greatly by their loved-one’s drinking and understandably want to know what they can do to effect change. But the truth is that there is probably little that can be done other than to try not to enable the person to go on drinking. It seems natural to offer reassurance to a loved-one about their behaviour, or to phone-in to work to say that they are ill and unable to come to work, or to believe (yet again) – even in the face of evidence to the contrary- that this time their loved-one has got their drinking under control once and for all! However well-intentioned, these actions only serve to protect the person from the consequences of their drinking and to make it more likely that they will continue to drink. It is when these actions are resisted whilst, at the same time supporting and encouraging efforts to seek help or stop drinking, that change may happen.
Living sober: cues, triggers, cravings
For someone who has become dependent on alcohol, living sober may pose a challenge, particularly in the early days. To the extent that they have used alcohol to change the way they feel, to feel better, they have now to manage their relationship with themselves and with others, and to manage the ordinary ups and downs of life, without recourse to alcohol.
Added to this there are all the many occasions when alcohol was – and will still be for others – a normal part of life: family get-togethers, meeting friends, birthdays, holidays, weddings, funerals, and many others. A cue is a reminder or an association with alcohol. As well as occasions, cues can also be times of day – for example, the end of the working day or week or sitting to relax and watch television in the evening. Watching sport, seeing an advertisement for alcohol or a scene in a film picturing people drinking, or the sight of tables outside a pub on a sunny day may similarly provoke such associations.
A trigger generates the urge to have a drink. The cue has stimulated a memory stored in the brain, which triggers the thought of alcohol. This thought can then quickly become a craving, which may be hard to resist even though the individual is aware that having a drink is not a good idea. This is where the need for help and support is so important as the newly sober person learns to avoid or safely navigate those situations and become more confident in their ability to say ‘no!’.
Gradually though, the brain stores new memories that are not alcohol associated and thus, as time goes by, cues become less triggering and the urge to have a drink diminishes. But that person will need to remain careful around alcohol; it is easy to get complacent and assume that the cravings have gone away for good, or after a few months of sobriety when things are getting back to normal to think that they can have the odd glass of wine with friends. As has already been said, a return to controlled drinking is not likely to be an option for the alcoholic.
A return to drinking is called a relapse. This is disheartening for all concerned but it is not uncommon and for some it provides a learning experience that may reinforce the need for abstinence. However, having been without alcohol for a time, the body’s tolerance that was previously built up will have diminished and thus the situation will quickly escalate and become serious once again. It is vital that the person re-engage with their sources of help and support and commit themselves once again to their recovery.
Treatment and support
The decision to ask for help, whether this is of the person’s own volition or at the insistence of others, is a huge step. This help may take various forms.
Residential treatment provides the opportunity for the alcoholic to be in a supportive environment, where alcohol is not available and where they can be helped to understand and accept their situation. Meeting with others in similar circumstances, they find that they are not alone and some of the guilt and shame that they feel about their drinking is replaced by the motivation to be honest about and face up to the extent of the problem. Often, the person will be given medication to ease the symptoms of withdrawal (this is called a de-tox); without which they may experience fits and other serious symptoms. Importantly, they will start to learn the tools of remaining sober and how best to support their recovery once they return home.
However, residential treatment is expensive and beyond the means of many. Out-patient options are available. A GP can supervise a detox at home and refer the person to their local drug-and-alcohol service where they will be allocated a key worker and access to counselling and other support. There are also counsellors and psychotherapists who specialise in working with addiction and alcoholism. Additionally, the support of family and friends will be hugely helpful as will membership of mutual aid groups such as AA where peers offer one another support, encouragement and guidance to reinforce the importance and benefits of recovery.
Underlying mental-health problems
For some people alcohol has become a way of medicating underlying mental-health problems. Some examples of these may be to do with unresolved childhood trauma, social anxiety, or symptoms of depression and/or anxiety, and alcohol with its ‘feel-good reward’ is experienced as a solution to the problem. Unfortunately, in certain vulnerable people, the use of alcohol then becomes compulsive and problematic. Drinking serves to mask the underling difficulty and it is also less likely that they will get the help that they need to treat their mental-health problems and here we see the emergence of the vicious circle from which the person cannot break free. It is only when the person stops drinking that the underlying problem can be seen and treated. We call this situation, dual diagnosis – they are diagnosed with both their mental-health disorder and alcoholism – both will require treatment.
What about other addictions?
Alcohol is not, of course, the only thing on which people can become dependent. Illicit, prescribed, and over the counter, drugs as well as sexual behaviour, exercise, restricting food/bingeing, gambling, and gaming, to name but a few, may for certain vulnerable people become problematic and may require treatment and support to overcome. There are similar pathways to dependence between these various problems, both neurologically and behaviourally, although there are also differences that pertain to the drug or behaviour of choice and the underlying and predisposing factors. And then there are those individuals who may swop one dependence for another; take for example, the person who may stop drinking only to turn to abusing prescription drugs. In such a case, the need to identify, understand and treat the purpose that is being served becomes a crucial way forward.
A few words of encouragement!
Understanding and acceptance are the keys to change. Like any other chronic illness or condition, adjustments must be made, and the appropriate treatment and support sought and continued. The good news is that very many people do accept their situation and get well and go on to live a full and meaningful life in recovery.
If you have any questions and would like to discuss the subject of alcoholism further, please feel free to contact me by email: firstname.lastname@example.org
Jill Fowler MSc MA UKCP Registered Jungian Analytic Psychotherapist