Based on a post in The Atlantic -- "Are You Almost Alcoholic? Taking a New Look at an Old Problem" -- Gizmodo has helpfully(?) declared: "Is Everyone You Know an Alcoholic?" These posts are based on the widely publicized release of the book, Almost Alcoholic: Is My (or My Loved One's) Drinking a Problem? by Robert Doyle, M.D., clinical instructor in psychiatry at Harvard Medical School and Joseph Nowinski. See, for example, Brian Lehrer's interview with Dr. Doyle on NPR/WNYC.
At first, I thought the Gizmodo title was sarcastic, reflecting on the inherent ridiculousness of the idea it expressed. But it wasn't. Both The Atlantic and Gizmodo pieces point out that, prior to becoming alcoholics, people display drinking problems, that alcohol abuse occurs along a spectrum of which alcoholism is only an end state.
There are two ways of considering this perspective. Alcoholics Anonymous -- coming from the temperance model -- sees all such problems as progressing to alcoholism. The data supporting the spectrum model, however, come from an entirely different perspective -- epidemiological research. The recent embodiment of this perspective is the National Institute on Alcohol Abuse and Alcoholism's NESARC (National Epidemiologic Survey of Alcohol and Related Conditions) study of 43,000 Americans' drinking over their life spans.
NESARC reveals startling information -- albeit information that every large-scale epidemiological survey has repeatedly found. About a third of Americans encounter a drinking problem in their lives. Not to worry, most outgrow them. Indeed, NESARC finds, of the 10 percent of people who sometime in their lives achieve the more serious diagnostic status of "alcohol dependence" (read as "alcoholism"), three-quarters fully recover, and three-quarters of those who fully recover do so without any form of treatment. Moreover, a majority of these fully recovered alcoholics don't abstain.
Shocking, I know. This violates the American perception of alcoholism as a binary disease, which derives from AA and temperance notions. Instead, it turns out that alcohol problems occur along a spectrum with people moving back and forth on that spectrum -- most often back, especially when they leave their 20s, get married, and have children -- only occasionally forward.
How do we regard this information? Comments on the Atlantic piece fall into two categories: that recognizing alcohol abuse early is helpful, and that this is more Puritanical bullshit. Ideally, the awareness behind the Atlantic piece would lead people to more mindful drinking, where they were aware when they use alcohol in ways that aren't helpful, and that can hurt them, just as we seek to be mindful of our eating.
On the downside, identifying many people who have drinking problems -- say a third of Americans -- could inflate our health care system beyond any reasonable boundaries. And, per NESARC, it wouldn't be a helpful step for the individuals involved, who would tend to be regarded -- and regard themselves -- as alcoholics.
There is a tradition in America of expanding a problem further down the spectrum, a name for which is "problem inflation." One way this is done is to link any signs that people have an incipient problem with the cases of people who suffer the worst forms of that problem.
I fear that the Atlantic article follows the inflation methodology by opening with the Whitney Houston case. We don't have to expand existing diagnostic categories and alarms to encompass Houston -- she was sufficiently dependent on, taken individually and together, medications, illicit drugs (cocaine), and alcohol to have warranted attention due to existing criteria. And, in fact, she had repeatedly received such attention, including intensive treatment.
I also fear that the American habit -- which has grown exponentially in the last decades -- of regarding every type of problem people encounter as suitable for medical care has not made us a happier nation, one that is less depressed, mentally ill, substance abusing, or subject to any one of a number of emotional-behavioral problems that we face.
Let's take the first three criteria from the Atlantic/Gizmodo list of 10 alcohol-related problem criteria -- with which I generally agree -- to consider the list's inflationary diagnostic tendencies:
Take me. I am 66 years old, and have not yet been diagnosed as a substance abuser or been treated for it, although I did develop an addiction treatment program called the Life Process Program(c).
Reasons for not enrolling me at Betty Ford or in the Life Process Program (aside from not being able to afford them): I am a highly productive person, and continue to be into my senior years. I don't take any psychiatric medications for tension or depression -- thank you, that occasional shot and some beer or wine are good enough for me.
Off-setting criteria. I never get drunk. I drink moderately when I'm both alone or with others -- I can barely count the number of times I have had more than two drinks on one occasion, alone or socially. It's just not my habit.
I'm done defending myself. You tell me if I should be worried.
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Susan Shapiro: How To Tell If It's A Habit Or An Addiction
Susan Blumenthal, M.D.: How Healthy Are Today's Young Adults?
Joseph Nowinski, Ph.D.: Over 50 and 'Almost Alcoholic'
Theresa Albert: The Benefits of Booze
It sounds like the author has no inclination to stop drinking, in which case, he is not an alcoholic. The only caveat would be if a loved one suggested to him that he stop drinking, in which case he might want to take a closer look.
AA is not a temperance movement, and takes no position on alcohol regulation whatsover. In fact, a crucial step in recovery is realizing that alcohol is not the problem, rather, it is my abnormal reaction to alcohol.
Also, AA literature supports the assertion that someone can be a hard drinker without being an alcoholic. From the "Big Book" (pp. 20-21): "Then we have a certain type of hard drinker. He may have the habit badly enouth to gradually impair him physically and mentally. It may cause him to die a few years before his time. If a sufficiently strong reason...becomes operative, this man can also stop or moderate, although he may find it difficult and troublesome and may even need medical attention. But what of the real alcoholic? He may start off as a moderate tdrinker; he may or may not become a continuous hard drinker; but at some stage of his drinking career he begins to lose all control of his liquor consumption, once he starts to drink."
Why Dr. Peele feels it it necessary to distort and misrepresent what AA believes in furtherance of his own ideas should perhaps inform his readers as to the soundness of those ideas.
To begin with, the temperance movement was founded primarily by religious types in the late 19th century. It's ascendancy ironically was also aided by the Woman's suffrage movement. It was in fact the primary driving political force behind the passing of the laws that brought about prohibition.
AA wasn't formed till the 1930's and has absolutely no position on the claims or goals of the Temperance movement or any other social or political movement then or now! AA has steadfastly maintained it's neutrality on all such "outside issues". So for Dr. Peele to attempt to interpret what AA believes is more invention than research.
When Dr. Peele suggests the AA believes that all alcohol problems "progress to alcoholism" he is simply confabulating evidence in place of facts.
AA is a voluntary self-help program that has no admission criteria other than a desire to stop drinking. It also has no capacity for assessment or on-going evaluation. It is just a group of men and Woman who meet together regularly to help each other stay sober.
Many in the fellowship have left, as is their right and returned to drinking. If they can pull it off, more power to them, is usually the general consensus. If they can't they're welcomed back!
cont.
Yes, substance abuse is on a spectrum and people move along the spectrum. I do believe that there are some people for whom abstinence is the only workable solution, but there are more who have shown substance abuse behaviors who can find a place of moderation that works for them. If the abuser-industry ever decides to rationalize its approach and use an evidence-based approach to treatment, it will be a giant step forward for abusers and for society.