Enough: Part 1

The following is an excerpt from Dr. Jon R. Weinberg's medical analysis on alcoholic pathology:


Why Do Alcoholics Deny Their Problem?


Introduction


The denial system of a person with alcoholism is notoriously well-known to anyone with even a passing acquaintance with the problem. The individual will not accurately report the quantity and frequency of alcohol consumption. The adverse behavioral consequences of drinking will be minimized, explained away, or denied completely. For example, violent fights with a spouse may be described as minor arguments, or explained as due to the mate's bad temper, or simply ignored altogether. From the standpoint of the helping professional or friend or relative, the alcoholic's denial is usually perceived as lying, a transparent dodge to escape responsibility for his harmful actions. The result more often is hostility, as people generally have an intense dislike for lying and clarify the factors which produce and maintain the denial system, so that others may react helpfully rather than rejecting the alcoholic.

Three components may be identified as critical in generating the denial system, all of which are interdependent and interact with one another to maximize their impact. For convenience, however, they will be discussed separately under the headings Cultural History, Social Environment, and Intrapsychic Consistency.


Cultural History


Alcoholic behavior has been described throughout recorded history. As with mental illness, the rationale used by people over the centuries to explain grossly inappropriate behavior involved possession by demons (including demon rum) or similar forces of evil. The problem was then dealt with by punishing the individual whose mind was possessed. The 19th century saw the beginning of a shift in attitude toward those called insane, but to this day a social stigma is clearly evident for this group. The problem with alcoholism is still more complex as a function of the enormous cultural ambivalence toward drinking. One of the dominant institutions of our society, organized religion, has influenced us so powerfully against alcohol as an evil this this century saw a successful attempt to legally proscribe its use on a national scale. The failure of Prohibition reflects the eternally continuing importance people attach to using mind-altering chemicals.

The great majority of people today do use alcoholic beverages and are culturally endorsed for doing so in their own peer group and by enormous mass media pressure exerted by the liquor industry. At the same time, however, our history is one of applying a powerful moral and social stigma to those whose drinking produces sufficiently undesirable behavior to lead to the label "alcoholic." In short, we reinforce drinking but vilify victims of alcoholism. In spite of a few decades of trying to shift social attitudes from a view of the alcoholic as "an evil person who should be punished" to "a sick person who should be treated," this transition has barely begun. The mentally ill have a century advantage over alcoholics in this respect and are by no means free of stigma. (Note that wealthy people who act crazy are usually sent to a "rest farm" in the country or a general hospital to recuperate from a "nervous breakdown" or from "overwork," while the poor end up in state hospitals labelled schizophrenic.)

In brief, alcoholics have historically been regarded as being evil, morally and/or mentally inferior, and thus subject to social punishments -- disapproval, rejection, ostracism. Who wants to be placed in the category "alcoholic"? Nobody! This is how cultural factors set the stage for denial.


Social Environment


The section above noted that drinking is a highly prevalent behavior in our society, with the combination of social custom and advertising glamour of alcohol use as an essential part of the "good life." For most people, drinking is a generally harmless activity secondary to various social occasions. For perhaps 8% to 10% of those who drink, however, alcohol use slowly shifts from a harmless to a harmful activity. The person's behavior gradually becomes increasingly inappropriate to the occasion. For example, a holiday gathering of a large family may be spoiled by his loud tirade directed at a sibling for some alleged old injustice. Perhaps an embarrassing scene occurs at a neighborhood party when she propositions her best friend's husband in front of everyone. Or again, he has the boss over to dinner hoping to win a promotion and ends up by telling him exactly where to go.

What will be the normal consequences of the undesirable behaviors sited? The answer is either nothing at all or at worst an admonishment the next day by the spouse. The latter may even suggest the desirability of drinking less, but the family or the friends and even the boss are very unlikely to say a single word to the individual (although they may be gossiping freely elsewhere.) The budding alcoholic who may remember the incident fuzzily or not at all (a "black out") is unlikely to accept the mate's version as accurate without other confirmation, and may impugn her motives or otherwise rationalize it away. Faced with hostility from the drinker and lack of support from relevant others, the spouse most often takes the path of least resistance and resentfully tolerates his behavior. Worse, she may buy the common idea that his drinking is somehow caused by her allegedly inadequate behavior as a wife. She is even likely to cover up for him by making excuses for his behavior to others, e.g. telling the boss he's home sick with the "flu" instead of a hangover. Thus reality is not being forcibly presented to the individual.

As adverse consequences of drinking gradually multiply, more people are introduced into the picture. A physician, marriage counselor, or clergyman may be consulted at the mate's insistence, after years of increasing family turmoil. What are the chances that alcoholism will be diagnosed and made a central focus? Minimal, as a function of inadequate training in alcoholism plus, often, systematic cultural biases against considering a person alcoholic until the late stages. Physicians may quietly suggest "cutting down" on drinking while writing a prescription for some other sedative drug which potentiates alcohol. Counselors may discuss "improving marital communication" and ignore the drinking as a "mere symptom." Clergymen may press for more regular church attendance and family togetherness. Here, "experts" are saying in effect that the problem is not alcoholism. Furthermore our social system is so structured that the higher the income level the less probably alcoholism will be diagnosed.

In summary, what are all the important people in his life, possibly excepting his mate, most often saying to the person with early-stage alcohol-related problems? Nothing whatever about the harmfulness of his drinking. They may be just plain ignorant about the early stage of alcoholism, believing alcoholics are winos in the gutter, never well-dressed businessmen and housewives; they may be too polite or too fearful of hostile reaction to discuss this socially embarrassing topic with the individual; or they may feel it's none of their business. The result of this innocent but deadly conspiracy of silence in the individual's social environment is to provide extremely fertile soil for denial of reality.


Intrapsychic Consistency


It appears to be a law of human behavior that two directly conflicting beliefs cannot co-exist for very long in one individual. As a person's drinking begins to produce adverse results, such a conflict is created. On the one hand, alcohol has become an important and rewarding component to his life. He likes to drink because it produces unusually good feelings and/or helps shut off bad feelings. On the other hand, reality is relentlessly trying to impose awareness of impaired mate and family relations, work efficiency, etc. At this point, there are only two possible resolutions of the conflict: reject drinking or reject reality. Some in fact do select the former, especially is he is one of the lucky few who has important people, such as family members or helping professionals, confronting him with the connection between drinking and undesirable reality. Many more, unfortunately, begin to reject reality, which is obviously the more likely alternative given the remarkable propensity of humans to rationalize whatever behavior they find highly rewarding.

Is the alibi system of the alcoholic really so different from that of the compulsive smoker who rejects the medical evidence for lung damage, the compulsive eater who says people like her better fat, the compulsive executive with heart disease who insists the corporation would collapse if he didn't put in 16-hour days? All of these people have a specific delusion, a denial of reality, which serves the vital purpose of allowing the desired behavior to continue without overwhelming mental conflict. The primary reason people are sometimes more disturbed by the alcoholic's denial is that his behavior is relatively more harmful to other people, as opposed to being harmful only to himself (which probably also explains their higher recovery rate.)

For the alcoholic, accepting reality is tantamount to working to maintain sobriety, and it is simply unreasonable to expect someone with a profound dependence on a substance to give it up without a struggle. The longer the history of dependence, the worse reality becomes, the more complete the denial must be, and the greater the struggle to modify the process. In the terminal stage, near death from cirrhosis, the alcoholic may deny any history of drinking whatsoever. Such pathetic outcomes can only be prevented by a widespread knowledge of the early symptoms of alcoholism combined with a forceful confrontation with reality by all those deeply concerned with the developing alcoholic. In the early stages, such intervention will lead to a high proportion of successful outcomes.


Summary


The history of moral stigma associated with alcoholism provides the cultural context for denial. The tendency of family, friends and helping professionals to avoid or overlook the issue in dealing with the alcoholic in the earlier stages provides the social environment which permits and encourages denial. The individual's normal tendency to avoid internal conflict fosters denial of unpleasant reality in order to permit the rewards of continued drinking. If the cultural attitudes toward alcoholism are successfully shifted to an illness-without-stigma model; and more importantly, if concerned persons are knowledgeable enough to see alcoholism developing and persistently confront the individual with reality, then far fewer problems will occur with the third, or individual, component. In other words, if the environmental reinforcements for denial are absent, the individual will have little opportunity to successfully generate a denial system. Until those changes occur, we will continue to be frustrated by the stubborn resistance to change of the advanced stage of denial most people associate with the illness of alcoholism.

Whew. That's a mouthful and a work out for the old fingers.

But, all the same, I hope that you can find some new insights into the condition of alcoholism from this article.

I know that I have--and that's why I will be using many elements from within Dr. Weinberg's analysis as a touching point for the next part of this entry.