Is “Almost Alcoholic” a Useful Concept?
Lowering the threshold for alcoholism can make us mindful, or hobble us
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 Novinski. (See 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 twenties, 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 ten alcohol-related problem criteria—with which I generally agree—to consider the list’s inflationary diagnostic tendencies:
• You drink to relieve stress.
• You often drink alone.
• You look forward to drinking.
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).
• I sometimes have a shot in my coffee at tense moments (I’m involved in a law suit over my treatment program).
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.
• I live alone—so I do a good portion of my drinking alone.
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.
• At the end of a work day, I look forward to a shot or a beer (my father did too).
I’m done defending myself. You tell me if I should be worried.