ALCOHOLISM

Alcoholism, excessive and repetitive drinking of alcoholic beverages to the extent

that the drinker repeatedly is harmed or harms others, the harm may be physical or
mental; it may also be social, legal, or economic. Because such use is usually
considered to be compulsive and under markedly diminished voluntary control,
alcoholism is considered by a majority of, but not all, clinicians as an addiction and
a disease.

The concept of inveterate drunkenness as a disease appears to be rooted in

antiquity. The Roman philosopher Seneca classified it as a form of insanity. The
term alcoholism, however, appeared first in the classical essay “Alcoholismus
Chronicus” (1849) by the Swedish physician Magnus Huss. The phrase chronic
alcoholism rapidly became a medical term for the condition of habitual inebriety,
and the bearer of the “disease” was called an alcoholic or alcoholist (e.g., Italian
alcoolisto, French alcoolique, German Alkoholiker, Spanish alcohólico, Swedish
alkoholist).

DEFINING ALCOHOLISM

Alcoholism is a complex, many-sided phenomenon, and its many formal

definitions vary according to the point of view of the definer. A simplistic
definition calls alcoholism a disease caused by chronic, compulsive drinking. A
purely pharmacological-physiological definition of alcoholism classifies it as a
drug addiction that requires imbibing increasing doses to produce desired effects
and that causes a withdrawal syndrome when drinking is stopped. This definition is
inadequate, however, because alcoholics, unlike other drug addicts, do not always
need ever-increasing doses of alcohol. Opium addicts, on the other hand, become
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so adapted to the drug that they can survive more than a hundred times the normal
lethal dose, but the increased amounts to which alcoholics become adapted are
rarely above the normal single lethal dose. Moreover, the withdrawal syndromes in
alcoholism occur inconsistently, sometimes failing to appear in a person who has
experienced them before and never occurring in some drinkers whose destructive
behaviour is otherwise not distinguishable from that of someone who is
pharmacologically dependent on alcohol.

A third definition, behavioral in nature, defines alcoholism as a disorder in which

alcohol assumes marked salience in the individual’s life and in which the
individual experiences a loss of control over its desired use. In this definition,
alcoholism may or may not involve physiological dependence, but invariably it is
characterized by alcohol consumption that is sufficiently great to cause regret and
repeated physical, mental, social, economic, or legal difficulties. Clinicians call
such a behavioral disorder a disease because it persists for years, is strongly
hereditary, and is a major cause of death and disability. In addition, alcohol
permanently alters the brain’s plasticity with regard to free choice over beginning
or stopping drinking episodes. As with other medical diseases but unlike most bad
habits, prospective studies demonstrate that willpower per se is of little predictive
significance.

An informed minority opinion, especially among sociologists, believes that the

medicalization of alcoholism is an error. Unlike most disease symptoms, the loss
of control over drinking does not hold true at all times or in all situations. The
alcoholic is not always under internal pressure to drink and can sometimes resist
the impulse to drink or can drink in a controlled way. The early symptoms of
alcoholism vary from culture to culture, and recreational public drunkenness may
sometimes be mislabeled alcoholism by the prejudiced observer. In the general
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population, variation in daily alcohol consumption is distributed along a smooth
continuum. This characteristic is inconsistent with the medical model, which
implies that alcoholism is either present or absent—as is the case, for example,
with pregnancy or a brain tumour. For such reasons, the sociological definition
regards alcoholism as merely one symptom of social deviance and believes its
diagnosis often lies in the eyes and value system of the beholder. For example,
periodic intoxication can cause sickness necessitating days of absence from work.
In a modern industrial community, this makes alcoholism similar to a disease. In a
rural Andean society, however, the periodic drunkenness that occurs at appointed
communal fiestas and results in sickness and suspension of work for several days is
normal behaviour. It should be noted that this drunkenness at fiestas is a choice and
does not produce regret. If the sociological model were entirely correct, alcoholism
should often be expected to disappear with maturation as is the case with many
other symptoms of social deviance. This does not occur, however.

Finally, epidemiologists need a definition of alcoholism that enables them to

identify alcoholics within a population that may not be available for individual
examination. To define alcoholism they may rely on quantity and frequency
measurements of reported community drinking and alcohol-related
hospitalizations, on a formula based on the frequency of deaths from cirrhosis
within the population, or on arrests for alcohol-related misbehaviour.

CAUSES OF ALCOHOLISM

Many theories of the causes of alcoholism rest on the limited perspectives of

specialists in particular disciplines or professions. These theories range from
heredity, environmental contagion, bad character, and economic misery (or
affluence) to bleak childhoods, preexisting depressive disorder, ready and
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inexpensive availability of alcoholic beverages, or sociopathy. More discerning
theories take into account the complexity of the disorder and acknowledge that
alcoholism is usually caused by a combination of factors.

Prospective studies of lifetimes have often shown that some theories of alcoholism
were incorrect because they confused cause with association. For example, on the
basis of current evidence, alcoholism is seen to be associated with but not caused
by growing up in a household with alcoholic parents. Likewise, alcoholism is
associated with but not usually caused (in men, at least) by depression, and
alcoholism is associated with but not caused by self-indulgence, poverty, or neglect
in childhood. Rather, alcoholism in individuals often leads to depression and
anxiety; indeed, self-medication with alcohol makes depression worse, not better.
Again, alcoholism in parents often leads to childhood poverty and childhood
unhappiness; the same parental alcoholism also increases the risk of later
alcoholism in such children, but for genetic, not environmental, reasons.

Studies of twins and adoptees have confirmed the common belief that alcoholism
can be inherited. This genetic component is not inexorable, but reflects a
predisposition that renders some people significantly more vulnerable to
alcoholism than others. At present there is no evidence that this predisposition
depends upon a single gene. Rather, there are probably a large number of genes,
each with rather small individual effects, that affect the risk of developing
alcoholism. Recent evidence indeed suggests that much of the genetic risk is not
due to neurological vulnerability but to a heightened resistance to the unpleasant
side effects of heavy alcohol consumption. As a corollary to this evidence, a
genetic defect has been identified that interferes with the degradation of
acetaldehyde (a metabolic product of alcohol). Many people of Asian descent who
are homozygous (carry two identical copies of the gene) for this defect have a
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marked and often uncomfortable flushing response to even small quantities of
alcohol, which makes it unlikely that they will develop alcoholism. Another
hereditary factor causes young women (but not young men) to break down less
alcohol in the stomach prior to absorption through the digestive system. Young
women therefore experience higher blood-alcohol levels from a given dose of
alcohol.

Research in animals has linked the development of compulsive drinking behaviour

to a specific circuit in brain that runs between the prefrontal cortex and the
brainstem. Notably, distinct differences in the activity of this neural circuit were
identified among male mice with identical alcohol exposure experiences. The
findings of this work, and of related studies, further highlight the significance of
individual variance in compulsive alcohol consumption.

Besides heredity, there are at least five other major contributing causes to
alcoholism: peer influence, cultural influence, certain coexisting psychiatric
conditions, availability, and occupation. Peer social networks (friends, clubs, or
spouses) that include heavy drinkers and alcohol abusers increase the individual’s
risk of alcoholism. Cultural attitudes and informal rules for drinking are also
important. Cultures that permit the use of low-proof alcoholic beverages with food
or religious ritual, but have well-established taboos against drunkenness (as in
Israel and Italy), enjoy low alcoholism rates. Cultures that do not have traditions of
consuming alcohol with food or ritual, yet are tolerant of heavy drinking (as in the
United States and Ireland), experience high alcoholism rates. Cultures that have no
well-established rules at all for alcohol use (as among indigenous rural immigrants
to large cities in Australia and Africa) and cultures in which high-proof alcohol is
drunk in the absence of food or ritual (as among Native Americans and Russians)
are at increased risk for alcoholism. Certain psychiatric conditions also increase the
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risk of alcoholism: they include attention deficit disorder, panic disorder,
schizophrenia, and, especially, antisocial disorder. Easy availability also increases
risk. Communities or nations that have low alcohol taxes, cheap alcohol with
extensive advertising, and limited societal control over sales suffer high rates of
alcoholism. Finally, persons who are unemployed or who have occupations with
irregular working hours (e.g., writers) or close sustained contact with alcohol (e.g.,
diplomats and bartenders) may be prone to the development of alcoholism.

A return to normal drinking is often possible for individuals who have abused
alcohol for less than a year, but, if alcohol dependence has persisted for more than
five years, efforts to return to social drinking usually lead to relapse. Thus,
although the frequency of alcohol-related problems is highest among men aged 18–
30, the development of chronic alcohol dependence for both men and women is
most common from ages 25 to 50. Put differently, the process of becoming a
chronic alcoholic with loss of control over initiation and cessation of drinking
often takes several years. There are several million young persons whose heavy
drinking has the potential to lead to alcoholism, but in many cases the process is
not carried to completion, and by age 30 many such drinkers will have returned to
a pattern of social (volitional) drinking.

PREVALENCE OF ALCOHOLISM

Estimates of the prevalence of alcoholism vary depending on the definition used

and upon the methods of estimation. In the United States 10 to 20 percent of men
and 5 to 10 percent of women at some point in their lives will meet criteria for
alcoholism, depending on the stringency of the criteria employed. These rates are
similar to the rates for many countries in western Europe, and the rates are a little
higher in eastern European countries. Rates in countries around the eastern

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Mediterranean and in Southeast Asia are much lower. Overall, rates in Africa are
low, but they are very high in the new urban slums.

Variations in the definition of alcoholism, however, make it difficult to compare

rates in different countries. In England and Wales, estimates of the prevalence of
alcoholism have suggested rates that range from 1.1 to 11 percent, and in
Switzerland the suggested rates range from 2.2 to 13 percent. The prevalence of
alcoholism in France has been estimated at as high as 15 percent of the adult
population, but more conservative estimates suggest 9 percent.

National per capita consumption of alcohol is an important factor in the prevalence

of alcoholism, yet Portugal, with one of the highest per capita alcohol-consumption
rates in the world, did not even recognize alcoholism as a problem until the late
20th century. In the mid-20th century, the death of Soviet dictator Joseph Stalin
resulted in a shift from official denial that any significant alcohol problem existed
in the Soviet Union to an outcry that alcoholism involved 40 percent of adult
males. In both circumstances, however, statistics were inadequate. In short, there is
a strong subjective element in statistics of alcoholism. In addition, comparative
data invariably fail to take account of changes in diagnostic policies and whether
illicit, untaxed alcoholic beverages are included in estimates of national
consumption.

DISEASES ASSOCIATED WITH ALCOHOLISM

Know about the chemical elements in alcohol and their adverse effects on the
human body. Excessive users of alcohol have been shown to suffer in varying
degrees from both acute and chronic diseases. Worldwide, morbidity due to
alcohol abuse is on a par with malaria and unsafe sex, greater than that from
smoking, and far greater than morbidity from illegal drug use. These numbers
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place alcoholism in the front rank of public-health problems. Among alcoholics,
mortality is 2.5 times the expected. Heavy smoking shortens life by roughly 8
years—alcoholism shortens it by 15 years. In the United States, active alcoholics
account for as many as 25 percent of the patients in general hospitals.

Although the magnitude of social and psychological pathology associated with

alcoholism is more difficult to calculate—in part because of public denial—it is
enormous. The number of patients hospitalized for depression and personality
disorder resulting from alcoholism, often undiagnosed, is large if uncalculated.
Alcoholism in parents vastly increases the chances that their children will fail in
school, become delinquent, or misuse drugs.

Acute diseases

Alcohol intoxication produces a wide variety of disturbances of neuromuscular and

mental functions and of body chemistry. In addition, the intoxicated person is more
liable to accidents and injuries. Alcoholics—who chronically experience severe
intoxication—are said to be 30 times more liable to fatal poisoning, 16 times more
liable to death from a fall, and 4.5 times more liable to death in a motor-vehicle
accident. Risk of death by suicide, homicide, fire, and drowning are roughly
doubled. These liabilities reflect not only the effects of immediate intoxication but
also poor self-care by alcoholics.

Other acute conditions associated with alcoholism are those that occur in the
postintoxication state—the alcohol-withdrawal syndromes. The most common and
least debilitating of these syndromes is the hangover—a general malaise typically
accompanied by headache and nausea. After a prolonged bout of drunkenness,
however, severe withdrawal phenomena often supervene. These phenomena

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include tremulousness, loss of appetite, inability to retain food, sweating,
restlessness, sleep disturbances, seizures, and abnormal changes in body chemistry
(especially electrolyte balance).

In cases of severe alcohol withdrawal, it is common for seizures, mental clouding,

disorientation, and hallucinations (both visual and auditory) to occur during the
first 48 hours. Depending on the amount and quality of care and treatment as well
as on the possible occurrence of additional disease, delirium tremens can develop,
usually after 36 hours. Delirium tremens involves a gross trembling of the whole
body, fever, and frank delirium. It can last from 3 to 10 days, with a reported
fatality rate, if untreated, ranging from 5 to 20 percent. Rarely, chronic alcoholic
hallucinosis develops, with or without preceding delirium tremens, and can persist
for weeks to years.

Prolonged drinking that interferes with an adequate diet may lead to Wernicke
disease, which results from an acute complete deficiency of thiamin (vitamin B1)
and is marked by a clouding of consciousness and abnormal eye movements. It
also can lead to Korsakoff syndrome, marked by irreversible loss of recent
memory, with a tendency to make up for the defect by confabulation, the ready
recounting of events without regard to the facts. Vitamin deficiency associated
with alcoholism can also lead to polyneuropathy, a degenerative disease of the
peripheral nerves with symptoms that include tenderness of calf muscles,
diminished tendon reflexes, and loss of vibratory sensation. Inflammation and fatty
infiltration of the liver are common, as are disorders of the gastrointestinal tract
(gastritis, duodenal ulcer, and, less often, severe pancreatitis).

Chronic diseases

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The chronic disorders associated with alcoholism are psychological, social, and
medical. Among the psychological disorders are depression, emotional instability,
anxiety, impaired cognitive function, and, of course, compulsive self-deleterious
use of alcohol. After some six months of abstinence, the mild cortical atrophy and
impaired cognition often associated with alcoholism disappear. After an extremely
variable period of abstinence, ranging from weeks to years, there is usually marked
improvement on tests assessing chronic depression and anxiety.

Among the social disorders associated with alcoholism are 2- to 10-fold increases
in driving and sexual offenses, petty crime, child and spousal abuse, and divorce.
Homicide, homelessness, and chronic unemployment are several times more
common among alcoholics than nonalcoholics.

Many of the chronic medical consequences of alcoholism are caused by dietary

deficiencies. Alcohol provides large numbers of calories, but, like those from
refined sugar, they are empty calories—that is, devoid of vitamins and other
essential nutrients, including minerals and amino acids. The small amounts of
vitamins and minerals present in beers and wines are insufficient for dietary needs.
During bouts of heavy drinking, alcoholics neglect normal eating or, because of
digestive difficulties, cannot absorb enough of the essential food elements. These
nutritional defects are the cause of many of the chronic diseases associated with
alcoholism.

In long-lasting alcoholism, one or more of the chronic nutritional-deficiency

diseases may develop. Probably most common are the more severe effects of long-
term thiamin deficiency—degeneration of the peripheral nerves (with permanent
damage in extreme cases) and beriberi heart disease. Another nutritional disease in
alcoholism is pellagra, caused by deficiency of niacin. Other diseases include

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scurvy, resulting from vitamin C deficiency; hypochromic macrocytic anemia,
caused by folate deficiency, vitamin B12 deficiency, or certain chemotherapeutic
agents; and pernicious anemia, resulting from vitamin B12 deficiency. Severe open
sores on the skin of alcoholic derelicts whose usual drink is the cheapest form of
alcohol—low-quality fortified wines—are sometimes miscalled “wine sores,” but
they result from a combination of multiple nutritional deficiencies and poor
hygiene.

The classic disease associated with alcoholism is cirrhosis of the liver (specifically,
Laënnec cirrhosis), which is commonly preceded by a fatty enlargement of the
organ. Genetic vulnerability, the strain of metabolizing excessive amounts of
alcohol, and defective nutrition influence the development of alcohol-related
cirrhosis. In its severest form, Laënnec cirrhosis can be fatal; the successful
treatment of cirrhosis or the retardation of its progress is impossible in an alcoholic
who cannot be stopped from drinking. Alcohol abuse also increases the risk of
other liver conditions, including fatty liver disease and alcoholic hepatitis, as well
as the risk of certain types of cancer, including head and neck cancer (e.g., oral
cancer, pharyngeal cancer), esophageal cancer, liver cancer, breast cancer, and
colorectal cancer.

In addition to the mental symptoms that may accompany pellagra, other mental
disorders more specifically related to the consumption of alcohol include mild
dementia, which may persist for up to six months after cessation of alcohol
ingestion, and a relatively uncommon chronic brain disorder called Marchiafava-
Bignami disease, which involves the degeneration of the corpus callosum, the
tissue that connects the two hemispheres of the brain. Other brain damage
occasionally reported in alcoholics includes cortical laminar sclerosis, cerebellar
degeneration, and central pontine myelinolysis. Alcoholics, especially older ones,
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frequently experience enlargement of the ventricles as a result of atrophy of brain
substance caused in part by the direct effects of alcohol on the central nervous
system. In some cases, however, brain atrophy is the result of damage caused by
accidents and blows. Many of those who survive long years of alcoholism show a
generalized deterioration of the brain, muscles, endocrine system, and vital organs,
giving an impression of premature old age.

Finally, chronic alcohol abuse heightens the risk of stroke and heart disease
through cardiomyopathy, high blood pressure, and failed smoking cessation. It also
greatly increases the risk of diabetes (by placing stress on the pancreas), of
unwanted pregnancy and sexually transmitted diseases (through unsafe sex
practices), and of infection (by alcohol-induced suppression of the immune
system).

TREATMENT OF ALCOHOLISM

The various treatments of alcoholism can be classified as physiological,

psychological, and social. Many physiological treatments are given as adjuncts to
psychological methods, but sometimes they are applied in “pure” form, without
conscious psychotherapeutic intent.

Physiological therapies

The most important physiological medical treatment is detoxification—the safe

withdrawal of the patient from alcohol, usually in a hospital setting. This process
prevents life-threatening delirium tremens and also provides attention to neglected
medical conditions. In addition, sophisticated hospital detoxification programs also
provide patients and their families hope for recovery and begin the alcoholic’s

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education in relapse prevention. As is the case with smoking cessation, relapse
prevention is critical.

One of the popular modern drug treatments of alcoholism, initiated in 1948 by Erik
Jacobsen of Denmark, uses disulfiram (tetraethylthiuram disulfide, known by the
trade name Antabuse). Normally, as alcohol is converted to acetaldehyde, the latter
is rapidly converted, in turn, to harmless metabolites. However, in the presence of
disulfiram—itself harmless—the metabolism of acetaldehyde is blocked. The
resulting accumulation of the highly toxic acetaldehyde results in such symptoms
as flushing, nausea, vomiting, a sudden sharp drop of blood pressure, pounding of
the heart, and even a feeling of impending death. The usual technique is to
administer one-half gram of disulfiram in tablet form daily for a few days; then,
under carefully controlled conditions and with medical supervision, the patient is
given a small test drink of an alcoholic beverage. The patient then experiences
symptoms that dramatically show the danger of attempting to drink while under
disulfiram medication. A smaller daily dose of disulfiram is prescribed, and the
dread of the consequences of drinking acts as a “chemical fence” to prevent the
patient from drinking as long as he or she continues taking the drug. Other, less
scientific physical and drug therapies that have been tried in the treatment of
alcoholics include apomorphine, niacin, LSD (lysergic acid diethylamide),
antihistaminic agents, and many tranquilizing and energizing drugs. More recently,
antidepressants and mood stabilizers (e.g., lithium) have been tried. In controlled
studies of more than a year, however, none of these treatments, including
disulfiram, has been shown more effective than a placebo in preventing relapse to
alcohol abuse.

Most recently, naltrexone (an opiate antagonist) and acamprosate, or calcium

acetylhomotaurinate (a modulator of gamma-aminobutyric acid [GABA] and N-
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methyl-D-aspartate [NMDA] receptors), have, like disulfiram, been effective in
reducing relapse over periods up to a year. But there is no evidence that either of
these agents reduces the risk of relapse over the long-term.

Psychological therapies

Psychotherapy employs an entire range of strategies, including individual and

group techniques, to treat the psychoneuroses and character disorders associated
with alcoholism. The aim varies from eliminating underlying putative
psychological causes to effecting just enough shift in the patient’s emotional and
volitional state so that he or she can abstain from drink entirely or only drink in
moderation. Psychoanalysis is rarely tried, having shown little success in treating
alcoholism. Analytically oriented and cognitive-behavioral therapies are more
common, often in conjunction with supportive aims. Unfortunately, as with
pharmacotherapy, the effects of most psychotherapies upon alcoholism are
impressive mainly over the short term.

In the 1990s a promising psychological technique sometimes called “motivational

interviewing” was developed specifically for alcoholism and consists of identifying
a patient’s motivation for change. The patient first learns to recognize his or her
loss of control over alcohol and the deleteriousness of the situation in order to
develop a wish and a hope for change. Only then is the patient likely to become
actively engaged in the process of change.

With alcoholics, group therapies are often regarded as more effective than
individual treatment. Such group therapies range from instructional lectures and
superficial discussions to deep analytic explorations, psychodrama, hypnosis,
psychodynamic confrontation, and marathon sessions. Mechanical aids include

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didactic motion pictures, movies of the patients while intoxicated, and recordings
of previous sessions. Many institutional programs rely on a “total-push approach,”
in which the patient is bombarded with multiple methods of treatment with the
hope that one or more methods will affect the patient favourably. Other
institutional programs rely on merely removing the patient from a stressful outside
environment, with a period of enforced abstinence. The therapists may be
psychoanalysts, psychiatrists, clinical psychologists, pastoral counselors, social
workers, nurses, police or parole officers, or lay counselors—the latter often being
former alcoholics with special training. Careful, controlled, long-term studies of
institutional programs have not shown intensive inpatient therapies to be superior
to much briefer outpatient interventions. However, brief outpatient interventions
are most successful when the process of addiction is still in very early stages.
Treatments have been developed for spouses and occasionally for whole families,
either separately or jointly, in recognition of the fact that in alcoholism the
“patient” is not just the alcoholic but also the family.

Over the past few decades, psychologists have repeatedly tried to develop
cognitive-behavioral techniques for teaching a problem drinker how to return to
controlled drinking. In early stages of problem drinking, before plasticity regarding
choice has been lost and physiological dependence initiated, brief interventions
that help pre-alcoholics to become conscious of how much they drink, of the risks
involved, and of the regret they experience after heavy drinking have been helpful
in reducing consumption to safe amounts. These techniques have been repeatedly
proved effective and inexpensive. However, once sustained loss of control is
established and once plasticity of choice has been lost—a characteristic of most
individuals who receive a diagnosis of alcoholism—efforts to teach ways to return
to moderate drinking have proved difficult. Long-term studies have consistently

15
demonstrated that once the patient’s own voluntary efforts to cut down on drinking
have repeatedly failed, sustained abstinence is the practical answer.

The treatment of diabetes provides a helpful analogy to why most professional

treatment of alcoholism has enjoyed only limited success. In diabetes, as in
alcoholism, medical intervention is often life-saving, but successful long-term
treatment of diabetes depends not upon elaborate medical intervention but upon
strict self-care (diet and self-administration of insulin) to prevent relapse. The same
principles apply to alcoholism.

Social treatment

Long-term naturalistic studies of addicts have revealed four types of nonmedical

community interventions that facilitate self-care and relapse prevention. The first is
external unavoidable community supervision, such as an employee-assistance
program that is connected with the alcoholic’s place of work and requires the
alcoholic to participate in order to stay employed. The second consists of
substitutes for the addiction that behaviorally compete with it, such as compulsive
hobbies, weight gain, or increased smoking. The third is what Carl Jung called the
“protective wall of human community,” which is found, for example, in
therapeutic and religious communities or in new love relationships. Obviously,
such interactions can also create substitute dependences. Unfortunately, because of
the alcoholic’s past behaviour toward his or her family, old relationships often are
less valuable for relapse prevention than new ones. The fourth community
intervention is a deepening spiritual commitment that often facilitates successful
abstinence. In this vein it is useful to reflect that faith communities (e.g., Islam and
Mormonism) have been successful in promoting lifelong abstinence, in contrast to
governmental interventions such as the American experiment with prohibition.
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A notable example that combines these last two types of community intervention is
Alcoholics Anonymous (AA). A voluntary fellowship of men and women, AA
enables its members to share their common experiences in a spiritual setting and to
help each other become and stay sober. AA was founded in the United States in
1935 by two alcoholics, Robert Holbrook Smith and William Griffith Wilson, both
of whom had been strongly influenced by a spiritual revival movement called the
Oxford Group. The members of AA strive to follow the “12 Steps,” a nonsectarian
spiritual program that includes reliance on God—or any “higher power” as
understood by each individual—to help prevent a relapse into drinking. It also
includes self-examination; personal acknowledgment of, confession of, and taking
responsibility for the harm caused by the member’s alcohol-related behaviour; and
assistance to other alcoholics in trying to abstain. At meetings members narrate the
stories of their alcoholic experiences and their recovery in AA. Today AA is a
worldwide community of more than two million. The fellowship is organized in
local groups of indeterminate size, has no dues, and accepts contributions for its
expenses only from those who attend meetings. Affiliation of the fellowship or of
its groups with churches, politics, fund-raising, or powerful leaders is strongly
discouraged by AA’s “12 Traditions.” Existing research suggests that finding a
sponsor, joining a home group, asking others for help when fearing relapse,
providing service to others, and striving for a more spiritual life all appear to help
sustain abstinence.

Paradoxically, severity of alcoholism often facilitates both abstinence and AA

involvement. Just as many individuals do not adopt an effective program of weight
reduction and exercise until after their first heart attack or accept a hip replacement
until severely disabled, so the more symptomatic alcoholics are more prone than
other alcoholics to join AA.

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AA apparently meets deep-seated needs among its members. It enables them to
associate with kindred sufferers who understand them, and it helps them to accept
the disease concept of alcoholism, to admit their powerlessness over alcohol and
their need for help, and to depend—without shame or stigma—on others. The 12
Steps provide a regimented, concrete training program that supports responsibility
for self-care and relapse prevention. The fellowship of AA also provides
community supervision and substitute gratifying behaviours (e.g., around-the-clock
meetings on holidays) that compete with relapse to alcohol dependence.

Professionals in the field of alcoholism now regard AA as, at worst, an inexpensive

addition to any therapeutic regimen and, at best, the relapse-prevention technique
of choice. AA has spawned allied but independent organizations, including Al-
Anon, for spouses and other close relatives and friends of alcoholics, and Alateen,
for their adolescent children. The aim of such related groups is to help the
members learn how to be helpful and to forgive alcoholic relatives.

AA groups, found in more than 150 countries, resemble each other and generally
use the same “approved” literature (including translations) published by its central
office in New York City. AA members include felons and physicians, young and
old, minorities and atheists, and Catholics, Buddhists, and Hindus as well as
Protestants. There are always some variations in style and conduct among AA
groups, each of which is autonomous. In some countries, AA groups are sponsored
by or affiliated with national temperance societies or accept financial support from
government health agencies, but this is not encouraged by AA’s central office.

RESULTS OF TREATMENT

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The success of treatment in any behavioral or personality disorder is always
difficult to appraise, and this also is true of alcoholism. Some clinicians believe
that one or another of the therapies discussed in this section works better for
certain patients, but such beliefs have not been demonstrated by experiment. It is
possible that the most effective therapy is the one in which the therapist or the
patient most believes. This factor of subjectivity may account for the inferior
results achieved in controlled experiments contrasting different treatments
compared with uncontrolled reports of alcohol treatment. The effects of new
treatments tend to be reported enthusiastically; later, critical examination of the
results and controlled studies usually diminish the claims. Follow-up studies of
treated alcoholics have often been too brief to determine whether or not lasting
results have been achieved, or the investigators have failed to locate a substantial
portion of the former patients. Moreover, the measures of “success” are
inconsistent. Some investigators regard only total abstinence as a successful
outcome; others are satisfied if the frequency of drinking bouts is lessened or if the
patient’s self-destructive behaviour or harm to others is reduced.

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