In the introduction to the recent best seller ‘How the world thinks’, Julian Baggini states:
“Most people do not consciously articulate the philosophical assumptions they have absorbed and are often not even aware they have any, but assumptions about the nature of the self, ethics, sources of knowledge, the goals of life, are deeply embedded in our cultures and frame our thinking without our being aware of them.”
In simple terms, practically everything we believe – extending well beyond the more obviously culturally bound belief systems such as religion or politics – is steeped in a complex set of cultural and human processes. How we think about alcohol problems, whether as members of the public or professionals in the field, is no exception.
In a recent publication “(Mis)understanding alcohol use disorder: making the case for a public health first approach” we attempt to unpick some of the ways in which various socio-cultural processes have shaped the language, concepts and responses to alcohol problems. In doing so we argue that views about alcohol problems amongst the public are largely misconceived, particularly via stereotypes about ‘who’ and ‘what’ people with alcohol problems are, and in turn, what should be done.
As such, public language around alcohol problems is at odds with ‘scientific’ conceptualisations. Whilst alcohol use disorder (AUD) is the main contemporary concept for identifying and seeking to address alcohol problems from clinical and policy perspectives, few members of the public recognise or use the term AUD, or think of them in terms of AUD concepts (e.g., as per the DSM, or in the UK, as per NICE). Instead, ‘alcoholism’ is the dominant ‘belief system’, whereby most of the public will decide whether their own or someone else’s drinking is a ‘problem’ against common scripts and stereotypes about ‘alcoholics’.
Public vs scientific understandings of AUD
‘Alcoholism’ however fails to capture the very complex and varied nature of AUD. In particular, beliefs about alcoholism typically reflect ideas around the most ‘severe’ alcohol problems, particularly physical dependence. Alcoholism is also heavily tied to narratives such as ‘hitting rock bottom’, the need for lifelong abstinence, and the belief that it is a ‘chronically relapsing disease’ arising from biological factors such as genes.
Whilst there is still scientific debate about whether severe AUD (or ‘addiction’) represents a ‘disease’ in any form, there is a general consensus that AUD exists on a broad continuum with a very wide range of different symptoms and consequences. Thus, it is not controversial to say lower severity cases of AUD (which affect a much larger proportion of drinkers) have very little resemblance to common ‘alcoholism’ ideas. Indeed, public discourse around ‘binge drinking’, ‘borderline alcoholism’ (as recently described by the singer Adele), or ‘grey area drinkers’ may be seen as attempts to address limitations of the alcoholism concept.
How did the ‘alcoholism’ model come to dominate beliefs about AUD?
We therefore explore how the alcoholism model has evolved alongside a range of other forces that have led to beliefs about alcohol problems being heavily focused on the severe end of the spectrum, and crucially, over-emphasising AUD causes and responsibility to the individual. For example, over recent decades, the rise in genetic and neuroscientific technologies and research have placed significant emphasis on ‘biomedical’ explanations and treatments.
However, despite heavy biomedical investment, there has been no major advances in AUD treatment. Other powerful forces, including alcohol industry interests, have also focused on individually focused explanations, in turn diverting attention from the clear environmental drivers of alcohol problems including price, availability and marketing. Further, common cognitive biases, such as the need to simplify complex issues, or minimising personal susceptibility to risk by pointing to the more extreme ‘other’ (i.e., the most severe cases of AUD), have also aided the spread of an ‘alcoholism’ concept.
It is always important to acknowledge that an ‘alcoholism’ model is often a valuable concept for people with more severe AUD. The ongoing existence of Alcoholics Anonymous (AA) and evidence supporting its effectiveness for some groups is testament to this. However, whilst acknowledging the value of alcoholism models for some, particularly those who recover through AA, we outline how its continued dominance in the public mindset hinders many important public health objectives.
What should be done to improve AUD understanding?
Whilst AUD concepts themselves also have many notable limitations, we call for more proactive efforts to extend public understanding of the nature of AUD and its resolution. For instance, most people recover ‘naturally’ from AUD without formal treatment, and many ‘re-learn’ a non-problematic (or still importantly, a less harmful) relationship with alcohol. Using ‘alcoholism’ terminology outside of self-identification contexts overlooks these important opportunities. Adrian Chiles is one example of someone who did not contemplate his drinking as a ‘problem’ for many years because he did not consider himself an ‘alcoholic’, showing how the culturally embedded assumptions about alcohol problems can hold back change.
Broadening the public’s understanding of AUD beyond ‘alcoholism’ towards recognition of it as existing on a broad continuum, with many routes to recovery including moderation, will help facilitate a shift towards a stronger public health approach. This does not mean individually focused treatments or research are not important. But it is time to pay greater attention to the heavy costs of focusing on AUD as ‘within’ people, rather than as occurring through people existing in a complex and largely pro-alcohol environment.
The full article “(Mis)understanding alcohol use disorder: making the case for a public health first approach” is published as open access in the journal Drug and Alcohol Dependence.
Written by Dr James Morris, Research Fellow at the Centre for Addictive Behaviours Research, London South Bank University, Dr Cassandra L. Boness, Research Assistant Professor and Licensed Clinical Psychologist, University of New Mexico, and Dr Robyn Burton, Office for Health Improvement and Disparities and with the Institute of Psychiatry, Psychology & Neuroscience, King’s College London.
All IAS Blogposts are published with the permission of the author. The views expressed are solely the author’s own and do not necessarily represent the views of the Institute of Alcohol Studies.