One of the terms I use, alcohol abuse or alcohol abuser, is used generically and is meant to include both problem drinkers and alcohol addicts – persons commonly termed as ‘alcoholics’. You may attach moral implications to the term alcohol abuse and alcohol abuser, but the author intends none. We are dealing with issues of health, not morality and the goal is to help people achieve and maintain it.
Definition of a ‘Drink’
A note of caution here about use of the term ‘single drink’ – a problem drinker/alcoholic rarely measures the size of their drink or keep track of the number consumed. What a heavy drinker means when they say they have had a ‘couple of drinks’ often turns out to be a couple of double or triple drinks, but it can also refer to nightlong drinking sessions, when vast quantities are consumed. Counselors need to be specific and clear when collecting data about the person’s drinking.
I learned this some time ago when an alcoholic assured me he had never taken more than a single drink a day. It took some careful probing to discover that his single drink was a ten-ounce tumbler containing eight ounces of vodka topped with a splash of orange juice. Since then I have always been careful to clarify what both the client and I, as the counsellor, mean when we refer to a ‘drink’. Indicating the size of a drink with fingers in the air is a graphic and helpful way to do it.
Three items from the list below are required to determine whether or not a person is abusing alcohol on some level.
1. Substance often taken in larger amounts or over a longer period than the person intended.
2. Persistent desire or one or more unsuccessful efforts to cut down or control substance use.
3. A great deal of time spent in activities necessary to get the substance, taking the substance or recovering from its effects.
4. Frequent intoxication or withdrawal symptoms when expected to fulfil major role obligations at work, school, or home.
5. Important social, occupational or recreational activities given up or reduced because of substance use.
6. Continued substance use despite knowledge of having a persistent or recurrent social, psychological or physical problem that is caused or exacerbated by use of the substance.
7. Marked tolerance.
8. Characteristic withdrawal symptoms.
Jellinek noted the delta drinker does not live through the social and psychological experiences of the gamma and will not identify with, or desire to enter, the world of Alcoholics Anonymous. His/her drinking is often socially approved because few people are aware of the importance of the daily drinking required by the delta alcoholic, which can be maintained slowly throughout the afternoon and evening. The absence of loss of control and of drunkenness veils the extent of the alcoholism.
5. Epsilon alcoholism refers to binge, episodic or periodic drinking in which the individual abstains for weeks, even months, at a time, but then is drawn to a binge that continues with uncontrolled drinking that is carefully scheduled by some drinkers in order to hold onto a job. The epsilon is often unaware that he/she is moving toward a binge, although a perceptive partner may recognise its incipience in the alcoholic’s increased agitation. This type of drinker has zero ability to stop drinking after ingesting a few drinks.
Jellinek delineated only the five types of drinking patterns above, but said he could have continued using the rest of the Greek alphabet to describe many other types of alcoholism. The importance of that diversity is the rationale for including Jellinek’s five types in this course. Although the counsellor should be acquainted with them, their use is not encouraged, since, as the preceding discussion makes evident, it is believed they are flawed.
Definitions in DSM-111-R
Another classification system that merits attention is found in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, third revised edition, released May 1987 (DSM-111-R). This revised edition does not present lists of criteria specific to alcohol abuse and alcohol dependence as did the earlier DSM-111 (American Psychiatric Association 1980), instead DSM-111R provides one super-ordinate diagnosis, Psychoactive Substance Dependence, which lists a single set of criteria for classifying any of the following psychoactive substances:
Alcohol: Amphetamine or similar acting Sympathomimetic; Cannabis; Cocaine; Hallucinogens; Inhalants; Opiates; PCP-Phencyclidine or similarly acting Arylcyclohexylamines; and Sedatives, Hypnotics, or Anxiolytics.
In my opinion, there are both gains and losses in the diagnostic categorisation of substance abuse and dependence in DSM- 111R. The gain is that one inclusive category provides a cluster of cognitive, behavioural and physiological symptoms broad enough to include all psychoactive substances – this can be helpful when a client is using more than one substance. The limitation is in the lack of specificity of each drug in terms of its unique nature, usage and effect, especially over time the most relevant factor to be considered in most alcoholic drinking.
This discussion has attempted to note some of the definitional problems in this speciality. As mentioned earlier, there have been hundreds of definitions presented by specialists in the field and there is no agreement about them. The terminology continues to evolve.
are prone to drink frequently to drunkenness. Others drink much in their teens and less afterwards. Some seem to begin at one end of the spectrum, drinking little at twenty, more at thirty, a great deal at forty and then they give it up completely, or drink themselves to death or discover they get drunk on very little.
There is no unitary path for all.
Jellinek’s Five Levels of Alcoholism
Jellinek, EM, considered to be the father of scientific research in the field of alcoholism, categorised five types of drinking patterns to which he applied the Greek letters in an attempt to delimit particular types of drinking behaviour. They are reviewed below to promote awareness of the variety of drinking patterns the counsellor is likely to encounter and to consider whether the specific patterns are valid or not.
1. Alpha alcoholism is a purely psychological dependence on the effect of alcohol to relieve bodily or emotional pain. Damage from drinking is restricted to relationships or job performance. There are no signs of a progressive process, nor does the drinking lead to loss of control or inability to abstain. Jellinek noted that others might label this type of drinker a problem drinker, but he avoided using the term. He hedged his opinion about alpha alcoholism by noting it may sometimes be a developmental stage preceding gamma alcoholism, but many alphas remain at the same level of drinking and its problems for thirty or forty years. On the basis of his own data collection, which involved 2,000 AA members in the 1940’s, he estimated that 10/15% of AA membership consisted of alphas.
It is unfortunate that Jellinek muddied definitional waters by applying the label ‘alcoholic1 to this category of drinkers. The alpha is a situational, reactive and non-addicted drinker, whose body may totally lack the predisposition often assumed in middle and late stage loss of control. Alphas are often included in research studies aimed at proving alcoholics can be taught to drink in a controlled manner. Since they experience minimal loss of control, such training is likely to be superfluous.
2. Beta alcoholism has a primary characteristic adherence to socio-cultural norms of heavy drinking that, in the end, leads to nutritional deficiencies and such physical diseases as polyneuropathy, gastritis and cirrhosis of the liver. However, there is no physical or psychological dependence on alcohol and no withdrawal symptoms. Jellinek states that beta might develop into gamma or delta alcoholism, but is less likely to be a developmental step than alpha alcoholism. It is difficult to comprehend how someone can develop a lethal malady such as cirrhosis and not be dependent on alcohol both physically and psychologically.
3. Gamma alcoholism includes acquired increase tissue tolerance to alcohol, adaptive cell metabolism, withdrawal symptoms and craving (physical dependence), and loss of control. There is definite progression from psychological to physical dependence and marked behavioural changes. Jellinek believed that gamma was the predominating species of alcoholism in America and Canada, as well as in other Anglo-Saxon countries and was most representative of alcoholics in AA.
4. Delta alcoholism includes the first three characteristics of gamma alcoholism, but instead of loss of control delta is able to control the amount ingested, the delta drinker is unable to abstain from drinking for even a day or two and, thus, has measurable alcohol (albeit often a small amount) in the bloodstream at all times. Although this type of drinker may show intoxication rarely, withdrawal symptoms are likely if he or she stops drinking for even one day. The delta pattern is the predominant type of alcoholism in France and
late stages of alcoholism. Once the counsellor has diagnosed the severity of the problem, they can create a treatment plan. Before presenting the model, it is necessary to examine some of the best-known systems in the field.
Alcoholism is referred to as a ‘disease’ by Jellinek, EM (1960), whose research is the cornerstone on which many in the area of alcohol studies build.
Defining alcohol and its use and abuse, and correlating various treatments mirror its many facets; alcohol is a beverage, a drug and a food. Its use can be considered culturally, psychologically, physically or spiritually. Because of its complexity, it attracts specialists, who study it in a wide variety of ways. Epidemiologists measure the extent of the alcohol problem, whilst anthropologists note differences in ethnic customs. Behaviourists seek antecedents and explore consequences of drinking, whilst psychoanalysts probe for underlying causes. Those concerned with genetics examine biochemical markers in children of alcoholics who do not yet drink, whilst pathologists study slices of tissue of those who drank too much alcohol. As inheritors of the intellectual methods of Descartes, answers are sought in reductionist polarities; it must be this or that, never both and more.
In the America, the history of alcohol use was one of ardent promotion until the middle of the 19th Century. Although it was assumed the majority of citizens would drink alcohol, no one was supposed to suffer negative consequences as a result. If someone was repeatedly drunk or developing physical ailments, it indicated a failure of will that made it clear he or she was a weak and bad person. That belief was part of the heritage of the moral model against abuse of all kinds espoused by the Church and conservative elements of the community. It intertwined with issues of sin and pleasure, self-reliance and necessary independence. Good people drank moderately or not at all, and those who made a mess were sinners.
It was not until Alcoholics Anonymous (AA) defined alcoholism as a ‘disease1 in the 1930’s and got the medical community to accept the concept that a change of attitude began to develop.
In 1967 the American Medical Association (AMA) defined this human problem in a new way:
“Alcoholism is an illness characterised by preoccupation with alcohol and loss of control over its consumption such as to lead usually to intoxication of drinking is begun; by chronicity; by progression; and by tendency to relapse. It is typically associated with physical disability, impaired emotional, occupational, and /or social adjustments as a direct consequence of persistent and excessive use.”
Certain phrases in the AMA definition are key terms that have been adapted by other organisations, being:
Illness, preoccupation with alcohol, loss of control over consumption, chronicity, progression, tendency toward relapse, physical disability, impaired emotional/occupational and/or social adjustments, persistent and excessive use.
In various combinations these items appear regularly in screening tools and assessment documents.
Another element that feeds into the definitional problem is the endless variety of drinking practices. Some problem drinkers consume little alcohol most of their lives and then at a late age
• A subjective awareness of compulsion to use a drug or drugs, usually during attempts to stop or moderate drug use.
• A desire to stop drug use in the face of continued use.
• A relatively stereotyped drug-taking habit, e.g. a narrowing in the repertoire of drug taking behaviour.
• Evidence of neuron-adaption (tolerance and withdrawal symptoms).
• Use of the drug to relieve or avoid withdrawal symptoms.
• The salience of drug-seeking behavior relative to other important priorities.
• A rapid reinstatement of the syndrome after a period of abstinence.
‘Problem Drinker’ or ‘Alcoholic’
The business of classifying a person’s drinking habit and creating a treatment plan is complex and sometimes troubling. There have been hundreds of definitions of alcoholism, problem drinking and alcohol abuse, but no universal acceptance of any one of them. Moreover, once a diagnosis has been made, new questions arise about appropriate treatment. Often those counselors who have lived through alcoholism insist the only answer to anyone’s drinking problem is total abstinence. Many specialists in alcohol-related problems can teach the client to change their drinking behavior.
The question of what to do about the drinking habit is usually the main issue in creating a treatment plan for alcoholics and problem drinkers, in practical terms. However, the plan often becomes limited to a focus on assisting the recovering person to achieve and maintain sobriety, whilst many other important issues are neglected.
Meanwhile, what someone is experiencing when giving up a substance after years of ingesting it heavily is the loss of a way of life, a way of dealing with time, a fulcrum about which behavioral are created and the sound of a cognitive squawk box that messages about the importance of getting the next drink or fix. To separate the abuser from his/her drug of choice means opening a door on the emptiness within, on the existential vacuum formerly occupied by alcohol/drug(s) and the life it created. Without it one loses a compass and a clock, a predetermined plan about where one is going and how life works. Remove it and there is a void, one quickly filled with anxiety.
If the counselor/therapist fails to address the many issues that confront the client, it is likely the newly recovering person will slide back to drinking or using. Recovery is a major life transition and a plan must be created (substance free) and it often takes years to do that. The process can only happen one day at a time.
This course presents a model of diagnosis, which provides specific categories that help in separating problem drinkers, those in the early stage of difficulty, from people in the middle and
Although most seizures occur within a day or two of the last drink, their timing can be unpredictable. Some individuals have reported having seizures months after the last drink and also after a period of abstinence followed by a few drinks.
For some alcoholics, the experience of the first seizure is so frightening it serves as a motivator for seeking treatment.
Delirium tremens, or ‘DTs’, which few alcoholics’ experience, is the most severe alcohol withdrawal reaction. It may occur three or four days after the last drink and is often preceded by a seizure.
The person in ‘DTs’ experiences profound tremors, disorientation and anxiety, hallucinates, suffers marked sleep disturbance and shows such autonomic signs as tachycardia, sweating, hypertension, fever and arrhythmias. Since this syndrome occurs only in chronic alcoholics, after many years of drinking, the potential for death during ‘DTs’ is most evident in those over forty-five years of age with other severe medical problems.
It is, however, worth committing the above to memory for future use when confronting a client with the possible consequences of his or her drinking behaviour. It can be used as what is known as a ‘motivational hook’.
Psychological Withdrawal Symptoms
All chemically dependent persons embarking on the programme of recovery will experience psychology withdrawal symptoms. These are painful, though not dangerous.
Cravings for the Drug
Cravings may be constant throughout the day or they may hit the client at odd moments. They may feel overwhelming or may not. The counsellor needs to advise the client to think of the cravings as a kind of trick the drug is playing on him – the drug wants them back as a user. Rule number one to pass on to the client is to NOT ACT ON THE CRAVINGS.
Mood swings are common in the first few days of withdrawal. The client may swing from elation to suicidal depression, or from happiness to fury. All types of unpleasant feelings emerge as the drug leaves the system. Fear and anxiety are common. These emotions are painful, but in themself and under the counsellor’s guidance, they cannot harm the client. Here is the therapist’s opportunity to introduce the client to Relaxation Therapy, reminding him or her these symptoms will not last forever.
The same therapy can be applied to the following:
Agitation, Restlessness and Extreme Fatigue
The mind seems unable to concentrate and the body unable to relax. Yet, paradoxically, the client may feel absolutely exhausted. Thinking is unclear and he or she may be unable to settle to anything.
Many a client in withdrawal will have feelings of fear that almost overwhelm them. He or she is terrified they will not be able to stay off the drug. They are frantic at the thought they may not be able to resist it and, on the other hand, they fear a life without drug(s).