| About the
Author
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 in Xenos 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.
Etiology
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.
Moral Model
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.
Medical
Model
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:
1. 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.
2. 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.
3. 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.
5. 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 bung proven 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
Abstinent
Culture
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".
Ambivalent
Culture
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.
Over-permissive
Culture
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
| Orientation |
Subgroup
Examples |
Drinking
Norms |
Populations
at
Low Risk |
Populations
at High Risk |
| Abstinent
Religious |
Mormans, Methodists,
Fundamentalists, Cults, So. Baptists |
MN |
Most |
All
Who Drink |
| Legal |
Amerindians |
Legal
- MN;
Cultural - P/N |
Few |
Most
of Culture |
| Ambivalent |
Ascetic, Christian,
English, Slavic, German, Irish |
P/N |
Light
Drinkers |
Heavy
Drinkers, Deviant, Addict |
Integrated-
structured |
Italian, Jewish |
SN,
SP |
Most |
Few |
| Disorganized |
Blacks, Hispanics |
P/N |
Abstinent-moderate |
Most
Drinkers |
| Over-Permissive |
Urban Cosmopolitans |
V |
Few |
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
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.
Interpersonal
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.
Intrapersonal
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.
Biological
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.
Environmental
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:
a. How many days of the week do you
drink?
b. Are there regular days in which
you do not drink?
c. How much do you drink in one day?
d. Do you drink more, less, or the
same as your closest friends?
e. Do you drink to relieve stress,
depression, or anger?
f. In what way does your mood or
personality change when you drink?
g. How long have you had your current
drinking pattern?
h. Do you orient your social life
or work schedule around drinking?
i. What times of the day do you drink?
j. How often do you drink alone?
i. How do you feel before
deciding to drink alone? E.g.: depressed, lonely, stressed out,
etc.
ii. Would you rather
drink alone or with other people?
iii. What happens when
you drink alone? Do you tend toward depression, etc.?
iv. How much do you
drink when you are alone?
k. Why do you drink?
l. Do you take any other drugs with
alcohol? What kinds? How often?
m. With whom do you regularly drink?
n. Have you ever been troubled with
the extent of your drinking? If so, what did you do about it?
o. When was the last time you drank
too much? Describe.
p. How often do you drink too much?
q. Are there alcoholics in your family?
i. Who is it (they)?
ii. How were you
affected by their problem?
r. What is the attitude toward your
drinking by those closest to you?
i. Do they oppose
the fact that you drink or the extent to which you drink?
ii. Have you ever
been confronted about your drinking? When, by whom, how often?
s. Do you have a history of alcohol
abuse or drug abuse? Explain.
t. 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?
Persona! Problems Associated With
Drinking:
a. Have you ever had legal problems
associated with drinking? Explain.
b. Have you ever had problems with
work related to drinking? Explain.
c. Have you ever had problems with
school associated with drinking? Explain.
d. Have you ever had financial problems
involving drinking? Explain.
e. Have you ever had family problems
over drinking? Explain.
f. Have you ever had serious conflict
with others or embarrassing situations occur when drinking? Explain.
g. Do you have physical
problems that are affected or caused by drinking? Explain.
General Life Issues:
a. I would rate my spiritual life:
excellent, good, struggling, troubled.
b. I would rate my family life: excellent,
good, struggling, troubled.
c. I would rate the
quality of my best relationships: excellent, good, struggling,
troubled.
d. 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:
1. People with any
kind of physical problem that would likely be exacerbated by continued
drinking Beg: liver dysfunction, gastrointestional problems, cardiac
problems, etc.).
2. People who are
committed to abstinence and who are well adjusted to that life
style.
3. People who have
strong external pressure to be abstinent.
4. People who lose
control of their behavior when they drink.
5. People who have
been physically addicted to alcohol.
6. Those who are
in the following circumstances: over 40, divorced and not in a
supportive relationship, unemployed, or 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
a. Failure to make
progress in less intense levels of care
b. High risk
chemical withdrawal (seizures, delirium tremens)
c. High tolerance
to one or multiple substances
d. Acute exacerbation of medical
or psychiatric problems related to chemical dependence (cardiomyopathy,
hepatitis, depression)
e. Concomitant medical
or psychiatric problem that could complicate treatment (diabetes,
bipolar disorder, hypertension)
f. Severely impaired
social, familial, or occupational functioning.
Criteria for Non-hospital
Residential Care
a. Failure to make
progress in less intensive levels of care
b. Ability to undergo
chemical withdrawal without close medical supervision
c. Stable medical
or psychiatric problems that require monitoring
d. Impairment of
social, familial, or occupational functioning requiring separation
from environment
e. Sufficiently developed
interpersonal and daily living skills to permit a satisfactory
level of functioning
Criteria
for Partial Hospital Care
a. No need for 24 hour medically
supervised chemical withdrawal
b. Stable psychiatric or medical
problems
c. Sufficiently developed interpersonal
and daily living skills to permit a satisfactory level of functioning
in this setting
d. No need for intensive psychiatric
care.
e. Need for daily support rather
than weekly or biweekly sessions.
f. Social system that is, family,
friends, or employment capable of providing support.
Criteria
for Outpatient Care
a. Ability to function autonomously
in present social environment
b. Stable psychiatric or medical
problems
c. Sufficient capacity to function
in individual, group, or family therapy sessions
d. No need for 24 hour medically
supervised chemical withdrawal
e. Willingness to work toward goal
of abstinence from harmful drug use28
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 Xenos 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.
Footnotes
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.
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