Clinical S o c i a l Work Journal

Vol. 23, No. 3, Fall 1995

ALCOHOLISM: THE QUEST FOR TRANSCENDENCE AND MEANING

Thomas K. Gregoire, Ph.D.

ABSTRACT: A vigorous and long standing argument continues in an effort to define the etiology of alcoholism and prescribe its treatment. Each side advances its cause by challenging the other's efficacy. However, none of the prevailing responses to alcoholism is very effective. Fighting on the ideological battlefield of western science results in a sterile understanding of alcoholism and provides social workers little information to help them understand the experience of alcoholism and the complexities of recovery. The experience of alcoholism is profound. More than a bad habit or a disease, alcoholism is an attempt to give life meaning, to assuage existential dilemmas. Effective recovery from alcoholism occurs when clients learn to disengage from their relationship with alcohol and give their lives a new sense of meaning. Sources of knowledge outside empirical science offer important principles to help workers facilitate recovery.

A fierce debate exists among professional helpers who ply their trade with alcoholics. Although there are m a n y sides in this fight, the lines are d r a w n roughly between those who explain alcoholism as a disease, a n d social learning theorists, who are certain t h a t it is not. The a r g u m e n t is vigorous and contentious. Workers j u s t beginning their practice are often indoctrinated in the dogma of their agency and t h e n acculturated to ignore, if not belittle alternative conceptions of alcoholism. One consequence of the struggle between the dominant disease concept a n d competing non-disease ideology has been the rejection by both camps of knowledge about alcoholism t h a t does not fit easily within their framework. As a result, u n d e r s t a n d i n g of alcoholism has been comp a r t m e n t a l i z e d and dichotomized among the factions. C a u g h t in the crack between the two camps are thoughtful practitioners a n d alcoholics seeking answers. Prevailing responses to alcoholism have h a d only minimal success, In an effort to stake out an exclusive foothold, the disease and social learning ideologies have perpetuated 339

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a sterile and barren understanding of alcoholism. Both sides have limited the ability of the social worker to help the alcoholic by avoiding important questions about the experience of being addicted to alcohol and the personal meaning of alcoholism. Far more t h a n the curse of a bad genetic code, or the result of unfortunate maladaptive learning, alcoholism is better understood as a problem of body, mind, and spirit, and an impediment to the resolution of existential dilemmas.

PAST AND PRESENT THOUGHT ON ALCOHOLISM Alcoholism and its consequences have placed great demands on social workers since the inception of the profession. The First Conference of Charities and Corrections listed intemperance among the principle vices contributing to poverty and the need for public support (Harris, 1874). J a n e Addams and the staff of Hull House conducted an investigation of local saloons in 1896, and succeeded in lobbying saloon keepers to prohibit the sale of alcohol to minors (Addams, 1910). Settlement workers involved with Northern European immigrants were frequently confronted with the consequences of excessive alcohol use. In spite of their efforts to create alcohol free social centers, saloons often served as central meeting places for immigrants (Davis, 1984). By 1915, American consumption of alcohol was at an all time high. The bulk of this increase was attributed to the drinking habits of Irish and G e r m a n immigrants, who saw saloons and drinking as important aspects of their cultures (Gusfield, 1963). C. M. Hubbard told the 1907 Conference that between fifteen and twenty-five percent of poverty could be traced directly to intemperance (1907). Albert Kennedy (1932) wrote " . . . case work with inebriates and their families consumed more of the energy of most settlement staffs t h a n any other single type of individual and family problem ~ (p. 203). The emergence of the concept of alcoholism as a disease attributed by some to the 1940's public relations efforts of Alcoholics Anonymous, (Alexander, 1990; Fingarette, 1988; Peele, 1984; 1986) has a notably longer history. BenjAmin Rush of Philadelphia, considered the father of American psychiatry, and the Scottish physician Thomas Trotter first described alcoholism as a disease in the late eighteenth and early ninet e e n t h centuries. Rush offered one of the earliest clinical descriptions of alcoholism as a disease, suggesting that the alcoholic suffered a gradual and progressive addiction leading to loss of control over the consumption of alcohol. This condition required abstinence from alcohol for effective t r e a t m e n t (Blume, 1983; Levine, 1978). The idea of alcoholism as a progressive disease culminating in loss of control and improved by abstinence has remained a cornerstone of the disease concept for 200 years.

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Although the social work literature initially referred to alcoholism as a vice, by the turn of the century, journals were replete with explanations of alcoholism as a disease (Richmond, 1917; Brooks, 1911; Neff, 1911; ShiUady, 1911; Woods, 1911; Hubbard, 1907). The profession was prepared for a transition at this time to understanding alcoholism as a disease r a t h e r than a moral problem. In the late nineteenth and early twentieth centuries social workers made a conscious effort to decrease associations with religious movements in response to increasing criticism of religious charity (Leiby, 1985). A view of alcoholism as a disease rather t h a n a sin was consistent with this endeavor. The social work response to alcoholism was twofold, involving the treatment of the alcoholics and their families, and active lobbying for the prohibition of alcohol. Social workers saw their role as both motivating the alcoholic to seek treatment and providing aftercare (Richmond, 1917; Woods, 1911). Mary Richmond's Social Diagnosis included a screening questionnaire to guide social workers' assessments of persons with alcohol problems. Proper diagnosis of the inebriate required investigation of the person's medical and physical history, the pattern of drinking, heredity, and family and social environment (1917, p. 430-432). Good treatment was judged to be individualized, based on the person's unique needs (Richmond, 1917; Neff, 1911). John Shillady (1912) told social workers that the physician could not be effective in treating the alcoholic without the social worker's support in responding to the alcoholic's financial, social, and family problems. Consistent with the dominant view held today, effective alcoholism treatment early in this century required life-long abstinence from alcohol (Richmond, 1917; Neff, 1911; Hubbard, 1907). A disease explanation of alcoholism fit nicely with social work's other agenda for responding to alcoholism, prohibition. Many among social work ranks thought that only through prohibition could alcoholism and its "evils" be alleviated (Kennedy, 1932; Richmond, 1917; Addams, 1910; Hubbard, 1907). The National Conference of Charities and Corrections officially endorsed national prohibition in 1917 (Davis, 1984). Support for the idea of alcoholism as a disease caused by the ingestion of alcohol gave prohibitionists a scientific, rather than moralistic, justification for their efforts in a time when the influence of science was rising. Embraced by the temperance movement, alcoholism as a disease became less a scientific hypothesis than a powerful political and social construct of the late nineteenth and early twentieth centuries. Schnieder (1978) asserted that the diminished interest in the scientific validity of the disease concept represented a critical milestone of the disease debate. "An important consequence of the use, politically, of the disease concept was that the idea was not examined as an intellectual or scientific claim during most of the nineteenth century" (p. 363).

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Having achieved prohibition, social workers seemed to lose interest in alcoholism. Social work journals paid scant attention to problems of alcoholism once prohibition was initiated (Baker, 1940). With the failure of prohibition came the renewal of the disease concept and the rekindling of the debate on the cause and treatment of alcoholism. This debate continues today. Although arguments about alcoholism are made on moral and philosophical grounds, the argument to which practitioners are most frequently exposed emanate from science. The three pillars of the disease theory assert that alcoholism is progressive, transmitted through heredity, and characterized by loss of control over consumption once drinking begins. Opponents have challenged the validity of the disease concept on all three grounds. Elvin Jellinek (1960) proposed a model of alcoholism which included the most prevalent type, g a m m a alcoholism, said to be a chronic and progressive disorder with predictable symptoms including loss of control over one's drinking. A number of empirical demonstrations that alcoholism does adhere to some type of progressive process have been provided in the literature (Piazza & Wise, 1988; Park, 1973; Trice & Wahl, 1958; Jackson, 1957). However, disease antagonists challenge the idea that alcoholism progresses for the majority who experience severe problems with alcohol. They cite longitudinal studies which find that individuals who demonstrate a steady irrevocable downward progression compose a small minority. Instead they suggest that the majority of those exhibiting severe symptoms of alcoholism correct them, often without professional intervention (Faulkner, Sandage, & Maquire, 1988; Peele, 1987). Disease theorists argue that alcoholism has a physiological and genetic etiology. Studies with monozygotic twins of alcoholics, removed from their parents at birth and reared by non-alcoholics, found a statistically significant difference in the incidence of alcoholism among the offspring of alcoholics (Cloninger, 1983; Goodwin, 1976). Blum et al (1990) correctly classified seventy-seven percent of alcoholics studied and seventy-two percent of non-alcoholics by identification of a " . . . gene t h a t confers susceptibility to at least one form of alcoholism . . ." (p. 2055). Further laboratory research led to identification of differences between alcoholics and non-alcoholics with respect to the presence or absence of particular neurotransmitters such as Serotonin and Dopamine, or metabolites of alcohol such as Tetrahydroisoquinolines (THIQ) (Wallace, 1989). Social learning theorists have greeted support for a genetic link with skepticism, instead advancing the greater role played by psychosocial and environmental factors (Fingarette, 1988; Peele, 1986; Marlatt, 1985). Fingarette (1988) questioned the substantive meaning of Goodwin's (1976) twin studies in which eighteen percent of the children of alcoholics versus five percent of the children of non-alcoholics became alcoholic:

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to see the full picture.., turn the numbers around: 82 percent of the sons who had an alcoholic p a r e n t . . , did not become alcoholics. So if we generalize from Goodwin's results, we must say that about 80 percent of persons with an alcoholic parent will not become alcoholics (p. 53). 9

Perhaps the issue which most clearly differentiates the combatants is the stand each takes on the issue of loss of control9 Loss of control over the ability to abstain from alcohol once consumption begins has been identified as the most frequent symptom of gamma alcoholism and a prelude to progressive symptoms of alcoholism (Piazza & Wise, 1988; Keller, 1972; Jellinek 1960). Belief in the phenomenon of loss of control as a physiological symptom becomes the basis for the insistence that abstinence from alcohol is the only appropriate goal for alcoholics (Keller, 1972; Jellinek, 1960). Davies (1962) ignited the modern debate over the validity of loss of control and the singularity of the abstinence goal when he reported a group of gamma alcoholics participating in a long term follow up study had returned to sustained normal drinking. Other studies with treated alcoholics found similar results (Heather & Robertson, 1981; Ward, 1978). Two studies in the 1970's dealt further blows to the concept of loss of control9 Each raised the volume of the debate to new levels. In 1972 Mark and Linda Sobell reported that subjects participating in a treatment group with a goal of controlled drinking experienced better outcomes than those receiving traditional abstinence oriented treatment. A 1976 report from the Rand Corporation (Armour, Polich & Stambul, 1976) reported that some of the subjects in National Institute on Alcohol Abuse and Alcoholism (NIAAA) funded treatment programs returned to normal drinking. This study concluded that a return to drinking was an attainable goal for some alcoholics. These findings sparked an unparalleled furor9 Both the Rand Report and the Sobell study were challenged on methodological grounds. A plethora of press conferences resulted in commissions convened by both sides to further the critique or support of this research (Weiner, 1981). Research findings supporting the feasibility of controlled drinking have alternately been branded as flawed and dangerous (Wallace, 1985; Pendary, Maltzman, & West, 1982) or heralded as the emergence of a new scientific paradigm for alcoholism (Faulkner, Sandage, & Maguire, 1988; Marlatt, 1985; Sobell & Sobell, 1984). The vehement attacks against the challengers of the disease concept may be representative of the struggle that Thomas Kuhn (1962) suggested would accompany a scientific revolution. Consistent with Kuhn's argument that increasing anomalous findings presage scientific revolutions, many enigmas emerge in the understanding of alcoholism that advocates of the disease concept are hard pressed to explain. The predicted efforts at suppression of new ideas which threaten the dominant

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paradigm (Kuhn, 1962) may be at the root of the fury with which the Rand report (Armour, Polich & Stambul, 1976) and the Sobells' (Sobell & Sobell, 1972) study were rebuked. The vigor with which biological and genetic research is occurring of late (Wallace, 1989) may be an example of the puzzle solving Kuhn (1962, p. 35-42) said pervades the research of normal science (Faulkner, Sandage, & Magaire, 1988). Enough of the Kuhn's criteria explaining shifts in scientific paradigms have been met to conclude the current paradigm for alcoholism is losing influence. However, the social learning explanation for alcoholism has not fulfilled an important last requirement of a paradigm shift; the new theory must more aptly explain a phenomena t h a n the theory it would replace. Kuhn asserted that "To be accepted as a paradigm, a theory m u s t seem better than its c o m p e t i t o r s . . . " (Kuhn, 1962, p. 17). Neither explanation for alcoholism offers a more efficacious response to the problem, simply a different one.

LIMITATIONS OF POPULAR RESPONSES TO ALCOHOLISM The disease model has not been very effective in helping people rem a i n abstinent for protracted periods. Ample research supports the contention t h a t the majority of participants in disease oriented treatment do not achieve long term abstinence (Pettinati, Sugarman, DiDonato & Maguire, 1982). George Valliant (1983), a disease proponent, concluded t r e a t m e n t for alcoholism has no more effective an outcome t h a n natural remission. The Sobells (1972), while demonstrating r a t h e r poor outcomes with social drinkers, found clients with abstinence goals did even worse. The social learning school has fared no better. Only slightly better t h a n 7.5 percent of the subjects in Davies' (1962) study exhibited prolonged problem-free drinking. Pettinati et al. (1982) found only three percent of controlled-drinking subjects doing well at four year follow-up. The SobeUs' controlled drinkers exhibited a higher degree of well functioning days not because of successful controlled drinking, but because they were abstinent more days than the comparison group. Such dismal performance is the rule rather t h a n the exception. The concept of controlled drinking remains poorly defined in any event. McCrady (1985) noted that subjects in the Sobells' (1972) experiment could consume up to fifty-seven mixed drinks per week and still meet the criteria of "social drinkers." Weiner (1981) noted that the standards for social drinking in the Rand study were so liberal that twenty-five percent of the subjects studied met the criteria for acceptable social drinking prior to enrolling in the t r e a t m e n t program. Looking past the straw persons erected by each side and the hyper-

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bole of the debate, one finds more similarities than differences between these two conflicting ideologies. Virtually all of the disease proponents allow for the influence of psychological, social, and cultural variables in describing the onset and course of alcoholism (Blum et al, 1990; Miller & Gold, 1990; Wallace, 1984; Valliant, 1983; Blume, 1983). The ardent disease concept advocate John Wallace (1989) wrote " . . . that neither a simple behavioral model nor a simple disease concept can adequately explain alcoholism. The illness is too complex and alcoholics too heterogeneous for any single set of explanations to account for the data" (p. 325). Staunch opponents of a disease concept acknowledge the possibility of at least some genetic role in the transmission of alcoholism (Fingarette, 1988; Peels, 1986; Marlatt, 1985). Beneath the social drinking bedlam one identifies disease theorists who concede that some alcoholics may take up controlled drinking (Piazza & Wise, 1988; Valliant, 1983; Keller, 1972). Controlled drinking proponents have written that abstinence is still the preferred goal for severe and tong standing cases of alcoholism (Marlatt, Demming, & Reid, 1973). On closer inspection the two camps begin to look more similar than different. Contrary to arguments t h a t either side represents a different paradigm for alcoholism, these are two peas of the same pod, both products of the prevailing scientific paradigm. If the struggle between disease and non-disease does not represent the conflict attendant with the emergence of a new paradigm, it can still be explained, albeit with a less noble purpose. A more accurate assessm e n t might conclude that this debate represents a struggle for market share. McCready (1985) suggested to her fellow psychologists that their effort to advance the controlled drinking goal is motivated primarily because psychology has equated itself with the controlled drinking outcome. Peele (1984) complained " . . . the markets for psychological services in alcoholism appear to be eroding and beleaguered" (p. 1339). These comments suggest a greater concern with turf than with truth. This is not a new argument. J. E. Todd suggested in 1882 that the idea of alcoholism as a disease was being advanced largely by physicians reaping financial profit from its treatment (Todd, 1882). Jellinek's model of disease has been expanded to include drinking behaviors he had never intended to label as "disease" (Blume, 1983). He expressed concern t h a t " . . . even at the present time the propagandization of the illness conception of 'alcoholism' is encumbered with too much sentimentalism ~ (1960, p. 5). Regardless of the good and genuine intentions of practitioners on both sides of the disease concept argument, one may conclude that a struggle for market share often eclipses the concern for the alcoholic who still suffers. Notwithstanding each side's claims to victory, there has been little real progress in reaching consensus on the etiology of alcoholism. Mani-

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fest in the disease a r g u m e n t has been an assumption t h a t agreement exists on w h a t constitutes "a disease. ~ It would be difficult to argue alcoholism into or out of disease status without consensus on the definition of disease. Yet little attention has been focused on the explication of disease in this debate. Upon f u r t h e r inspection, this definition proves to be elusive and less subject to science t h a n might be assumed. Samuel Guze (1977) wrote: 9 . . disease can be defined only very generally . . . the definition evolves and changes with new knowledge . . . it's boundaries are fuzzy a n d . . , it is a metaphorical concept.., any attempt to define disease so as to exclude more psychiatric disorders also excludes many conditions about which there is no debate as to their medical significance (p. 225). Campbell, Scadding, and Roberts (1979) found a wide diversity among medical academicians and practicing physicians on acceptance as "disease" of such dissimilar and presumably non-controversial disorders as epilepsy, hypertension, and muscular dystrophy. Scadding (1963) suggested t h a t the concept of disease remains r a t h e r poorly defined. "Att e m p t s a t defining disease a r e . . , mostly tautologous, equating a disease with some other poorly defined concept such as a condition or a process" (p. 1425). Efforts at defining disease in the alcoholism literature have been largely endeavors to build a stage for one's pet theory, or a cage for one's adversary. Of greater importance t h a n new knowledge to the definition of disease m a y be who does the defining. Schneider (1978) suggested t h a t the concept of disease is less a scientific issue t h a n a social and political construction: Because physicians represent the dominant healing profession . . . they have control over the use of the labels 'sickness', 'illness' and 'disease'... as such, these designations become political rather than scientific a c h i e v e m e n t s . . . The question of whether or not a given condition constitutes a disease involves issues of politics and ideology questions of definition, not fact (p. 361, 370). Weiner (1981) traced the social and political roots of the reemergence of the disease concept of alcoholism in the 1940s and concluded t h a t t h e formulation represented a social construction. "Less t h a n a scientific proposition, the s t a t e m e n t 'alcoholism is a disease' represents a response, a social imperative t h a t is expressed in different social institutions, and in bureaucratic actions" (p. 90). A social construction perspective rejects the a r g u m e n t t h a t alcoholism can ever be proved or disproved a disease. Definitions of alcoholism are not authenticated by a scientific notion of disease but r a t h e r a value stance. If t r u t h as it per-

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tains to the etiology of alcoholism is a social construction, then a more salient question becomes not %Vhat is the proper explanation of alcoholism?" but rather, %Vhat are the consequences of how we define alcoholism for the people with the alcohol problems?"

CONSEQUENCES OF THE PREVAILING RESPONSES TO ALCOHOLISM While it may not be possible to conclude that one side prescribes a more effective response to alcoholism, both sides have made positive contributions to the way we respond to people with alcohol problems. The disease model reduces guilt, making it easier to seek help and to access the health care system for treatment (Valliant, 1983). A large alcoholism treatment industry has evolved to try to meet the needs of alcoholics. Blume (1983) suggested that the disease model protects the civil rights of alcoholics and encourages treatment rather than imprisonment as the societal response of choice. Although the disease model's singular goal is abstinence, the behavioral model has increased the available outcome options. Abstinence, while an appropriate goal, can be among a range of choices. The social learning model of alcoholism may also have increased sensitivity to the psychological and social experiences of persons with alcohol problems (Marlatt, 1985). These and perhaps other contributions emanate from both the disease and social learning schools of alcoholism. However, many more of commonalities of the current responses to alcoholism represent limitations of the two viewpoints. Problems created by rigid adherence to either the disease or the social learning arguments far outweigh their contributions. In the battle for ideological supremacy (or market share), each side has engaged in vigorous science to prove its theory. One consequence of conducting the fight in the scientific ring has been a tendency to diminish the experience of alcoholism to that which can be operationalized and measured. Ernest Becker (1969) used the term ~fetishization" to describe the inclination to reduce complex phenomena to measurable variables. Becker writes: ~... when we phrase our theories in narrow terms involving few factors we phrase them so many people understand them" (p. 166). A consequence of alcoholism as fetish is that ~... it destroys the total picture by narrowing it d o w n . . . " ( p . 169). Behaviorists have conducted studies in laboratory settings in which alcoholics engaged in button pushing or other behaviors equally devoid of social context and used research results to argue that alcoholics can control their drinking (Bigelow and Liebson, 1972; Cohen, Liebson, Fallace and Allen, 1971). The disease advocate James Milam (1970) pro-

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posed to explain the varying rates of alcoholism in differing cultures as a function of heredity and the length of time alcohol has been present in the particular culture. It seems wrong to construe research conducted in the sterile behavioral laboratory as being at all informative about the experience of being alcoholic out in the world. To imagine that the incidence of alcoholism is largely the function of some form of Darwinism seems equally limiting. The reductionism in which both the behaviorist and the disease proponents engage to fit their explanation of alcoholism within limited frameworks strips the experience of being alcoholic of its social, emotional, cultural, and spiritual context, and provides little guidance to the professional endeavoring to understanding the alcoholic sitting in the office. Thoughtful practitioners who work with alcoholics often struggle to resolve the contradictions of the model to which they have been indoctrinated. Few individuals behave in their alcoholism as predictably as science suggests they should. Another unfortunate similarity of both the disease and social learning school is the relationship of the professional to the client. Alcoholism is a very disempowering condition, there is little free will. The consequences of drinking and efforts to protect and control the relationship with alcohol drive most of the alcoholic's decision making. The dominant schools do little to enhance the personal command of those seeking help with alcohol problems. The client is in a "one down" relationship with the helper, dependent on the prescriptions of the learned experts who m u s t marshal empirically validated techniques to alleviate the client's problem. They are admonished not to try to do it alone; television commercials urge family members to get professional help before it is too late. The client's voice is diminished. Treatment is prescriptive, the client's role is to listen and follow advice. When the client talks, it is for the purpose of providing the professional information to facilitate more accurate advice-giving. When information provided does not fit the professional's understanding of addiction, it is often ignored or challenged as denial and delusion. The giving over of one's personal power to experts is representative of a scientific culture that promotes looking outside of ourselves to provide our lives power and meaning (Fox, 1980). Matthew Fox argued that a culture such as ours, which denies mysticism and diminishes personal power, increases the likelihood of addiction: "It encourages seeking outside stimulants to provide meaning for life and defense from enemies because it is so woefully out of touch with the power inside ~ (p. 43). The prevailing paradigms for alcoholism have little to offer people in re-discovering personal power. The experience of alcoholism encompasses the totality of the person. Alcohol is used to meet many social, emotional, and psychological needs.

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As alcohol use increases, reliance on alcohol to function in the world also increases. The alcoholic forms a primary relationship with the alcohol (McAullife & McAuliffe, 1975). Most importantly, the alcoholic's all consuming relationship with alcohol serves as a vehicle to give life meaning (Saleebey, 1985). Addiction to alcohol provides a way to obtain wholeness, meaning, and fulfillment (Van Kaam, 1987), and to meet our human need for transcendence (White, 1979). Addiction to alcohol has been described as " . . . a specious way of transcending the self without really doing so" (Darmer, 1987, p. 52). Carl Jung, in written correspondence with AA co-founder Bill Wilson, likened the alcoholic's craving for alcohol to the " . . . equivalent on a low level of the spiritual thirst of our being for wholeness..." (1974, p. 64). In the scientific paradigm where both the disease and social learning schools reside, knowledge is restricted to that which can be measured. Under this paradigm the experience of being addicted risks being reduced to little more than a cycle of tolerance and withdrawal or stimulus-response. Scientists seeking to advance understanding of the alcoholic conduct studies of genetic material or of performance in the behavioral laboratory setting. Both sides trivialize the addicted experience and deny the importance of the meaning of addiction in the person's life. The dominant paradigm tends to ignore spiritual questions being more comfortable with the language of science than that of belief (Johnson, Griffin-Shelly, & Sandler; 1987). The important role alcohol has played in the alcoholic's life is diminished. "Reformed" alcoholics are left to reconstruct a sense of personal meaning on their own, to come to grips with existential questions which were previously delegated to the alcoholic relationship.

BEYOND THE DOMINANT PARADIGM But people do get better. We often learn of persons who have recovered from their alcoholism to lead full and satisfying lives. By considering what has worked, some precepts which may help our efforts with alcoholics will begin to emerge. The worker seeking to understand the alcoholic experience would do well to understand the existential dilemmas with which we all struggle. At an early age we realize our lives are finite, and we must die. Our lives have no intrinsic meaning; any sense of meaning we acquire, we alone must provide. We are free, and the responsibility for ourselves that free will entails cannot be evaded. No matter how close we may become with another, we are ultimately alone (Johnson, Griffin-Shelly, & Sandler; 1987). Fearing both the responsibility of life and the finality of death, we seek out objects or persons in t h e form of heroes which

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exceed our lives and transcend death and therefore allow us to deny both. Many spend their adult lives subjecting themselves to mentors, gurus, heroes, and other leaders seeking the experience of safety and passivity they knew as children. We struggle with the conflict between the need to surpass mere mortals and be special, and the wish to shut out the world, hiding from its realities in the manner of children pulling blankets over their heads (Becker, 1973). When we become addicted to alcohol, we make a commitment to alcohol as the foundation of our personal meaning (Saleebey, 1985). The authority we convey alcohol serves both sides of our existential struggle. We use alcohol to transcend our own bodies and to rise above (however fleetingly) the masses. Subject to the influence of alcohol, we experience greatness and power, attaining peak transcendent experiences. Alcohol also allows us to hide from and deny reality. The numbing glow serves to insulate us not only from the reality of alcohol's impact on our lives, but also from our existential crises. Ask recovering alcoholics, they will tell you that much of their later drinking revolved around efforts to recapture those initial peak experiences. Changing what they drank, how they drank it, the drugs they took with it, or how they used those drugs can all be understood as efforts to again experience the transcendence and power they once were granted in their relationship with alcohol. As the peaks became increasingly elusive, the ability to use alcohol to hide from personal experience served as some consolation. From this broader understanding of alcoholism comes a first principle which may aid the worker in understanding the person with an alcohol problem: Denial of alcoholism must be understood as a method of protecting a source of personal meaning. Workers intervening with the alcoholic must realize they pose a threat to the person's most important relationship, a relationship which has served to define the person. Recognition of the importance of the spiritual in overcoming alcoholism is behind the success of two of the more effective responses to alcoholism, the now defunct Emmanuel Movement, and the self help group Alcoholics Anonymous (AA). From the work of both groups we may extract a second principle: Alcoholism is best understood as a problem which affects body, mind, and spirit. Elwood Worchester founded the Emmanuel Movement at the turn of this century and believed that " . . . all diseases had physical, mental, and spiritual c o m p o n e n t s . . . [ a n d ] . . . the realm of the body, mind, and spirit interacted in a delicate b a l a n c e . . . " (McCarthy, 1984, p. 62). Although AA has been associated with the disease school, the adoption of this concept has served a vastly different function for AA members than for its professional supporters. By clo~kiug itself in the mantle of science AA avoided the polarization that accompanies identification with a reli-

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gious or spiritual organization. A reading of the Twelve Suggested Steps of Alcoholics Anonymous (Anonymous, 1937) reveals little adherence to a medical model of recovery. Rather one may find in the Twelve Steps a guide to spiritual transcendence (White, 1979). The literature of AA is replete with reference to spiritual awakening and meaning making that must transform the alcoholic if recovery is to be assured. In rejecting the traditional patient/physician relationship the Emmanuel Movement embraced another valuable principle for working with alcoholics: Treatment is most effective when the client has responsibility and control over its course. Worchester's patients did not surrender their power, or give over to experts in order to be helped. Patients were told they were responsible for the course of treatment ~... you are to be physician and patient at the same time" (p. 66). The recovery process was then transformed from a struggle between the omniscient professional and resistant client to a collaborative journey of peers. The Movement eschewed the practice of emphasizing the deficit and debility of clients, choosing instead to inventory their strengths. Worchester believed that each person had within a positive force which served as a source of enormous strength, creativity, and communication with the spiritual realm. The Movement believed that change was best attained by building a person's strengths rather than focusing exclusively on problems (McCarthy, 1984). This principle of building upon a person's strengths is as valuable today as it was at the beginning of this century. Many of the practices of both the Emmanuel Movement and AA enable alcoholics to come to terms with the existential struggle to give their lives meaning. The AA culture is oral, communicated through slogans and the stories of its members. Even the written material available through AA relies largely on the stories of its members to communicate important precepts. The stories are tales of quests because the alcoholic career is most easily understood as a quest (Elpenor, 1986). AA understands the alcoholic experience as a journey in search of oneself. The AA narrative is a powerful form of communication. Unlike the methodologies of the dominant paradigm, which so often strip experiences of their context and meaning in the name of measurement, narrative allows an understanding of people within their culture (Bruner, 1990). In the narrative of alcoholic quest, the story teller can find a sense of meaning. By listening to the stories of addiction and recovery one can find personal meaning in one's own quest story. Such meaning making is not possible in a paradigm that endeavors to isolate variables to understand them. Bruner (1990) argued that human nature cannot be understood independent of the culture in which it occurs. To know people and their cultures, one must hear their stories. This principle then emerges: Workers who value story telling and the meanings that

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reside therein will be more effective than those who excel at using clients' words to reduce understanding of their alcoholism to numerical diagnostic categories. Both AA and the E m m a n u e l Movement recognized the importance of engaging alcoholics in group work and mutual support. AA's founders believed that only through involvement with other alcoholics could a person expect to recover (Anonymous, 1937). When people connect with each other they transcend the self-centered relationship with alcohol. Two additional principles for alcoholism work are found here: Group involvement, essential to recovery, allows the client to engage with other h u m a n beings and disengage from alcohol. Helping people find healthy ways of making contact with others may help them develop meaning in their own lives. Little is more frustrating and enigmatic than listening to people with alcohol problems express insight into the problem, describe clearly w h a t is needed to change, and then proceed to fall flat on their faces. Alcoholics struggle with the existential dilemmas of freedom and responsibility and are often unsuccessful because they develop insight and understanding, yet fail to change their behavior. This is the downfall of insight oriented psycho-dynamic therapies. Alcoholics Anonymous has overcome this problem through the use of Twelve Steps which emphasize engaging in new behavior and progressive activity rather t h a n just awareness of the problem (Johnson, Griffin-Shelly, & Sandier, 1987). AA members learn early slogans like "Faith without works is dead" and "Fake it until you make it," which communicate the importance of taking action and doing new behavior. This is an important principle of successful work with alcoholism: Behavior change must accompany if not precede new insight for permanent change to occur. While AA attends to spiritual and existential needs, it is guilty, as are the disease and behavioral schools, of ignoring the body. If alcoholism is truly understood as impacting body, mind and spirit, then the role of nutrition in treatment of alcoholism cannot be overlooked. Nutritional explanations of alcoholism such as allergy, hypoglycemia, and inherited nutritional defects gained some prominence during the late 1970's and early 1980's (Leiber, 1984). Research has demonstrated that a higher percentage of alcoholics on special diets and dietary supplements were able to maintain sobriety (Guenther, 1983). Information on the role of nutrition, because it does not fit either dominant school of thought, has been largely ignored. Despite lip service by m a n y treatment centers, one need only inspect the menus of most programs to confirm that little attention is given to the role nutrition might play in properly supporting recovery. The body as regards nutrition is ignored by both the learning theorists and the disease advocates. The extensive availability of caffeine and nicotine at AA meetings also

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s u g g e s t a lack of u n d e r s t a n d i n g of a last principle of effective helping: P r o p e r n u t r i t i o n plays a n i m p o r t a n t role in m a i n t a i n i n g r e c o v e r y f r o m alcoholism.

CASE H I S T O R Y A composite case study illustrates how workers employ these principles in their practice: Joe had experienced two stays in alcoholism treatment hospitals as a result of his drinking. In each case Joe reported that his good feelings in early recovery gave way to a sense of emptiness. Feeling that recovery did not work for him, Joe returned to destructive drinking. He entered psychotherapy on two occasions to explore his feelings and discover %vhy he drank." In both cases Joe was diagnosed as depressed and was prescribed an anti-depressant medication. However, he continued to drink excessively while in therapy and terminated both sessions reporting that the therapist meant well but Joe did not feel much was accomplished. After a third brief hospitalization in which Joe was detoxified he made contact with a new worker, explaining that he wanted to fred out what was wrong with him and why he drank. The worker told Joe she did not know what if anything was wrong with him and that it would be up to him to decide why he drank. When Joe countered that he needed an expert to help with his alcoholism the worker told Joe that if they were to work together he must recognize that he was the expert on Joe, and would therefore be responsible for directing treatment. In this step the worker disengaged from the power struggle so many therapists enter with clients with alcohol problems; she refused to take responsibility for treatment, or to force her will upon Joe. Joe's decision to lose his relationship with alcohol would not be imposed upon Joe by an outsider, but directed by himself. Joe and the worker agreed to two ground rules: mutual honesty and a willingness to not drink as long as they worked together. As their relationship progressed the worker would confront inconsistencies in Joe's interpretations, but left it to Joe to decide what was right for him. The worker asked Joe to tell her ~nis story." To Joe's surprise she wanted to hear first about what things were like for Joe when his drinking was rewarding and relatively problem free. She asked how he felt and what he thought about himself when drinking was good for him. The worker wanted Joe to describe how he has tried to recapture those initial experiences. They spoke at length about the longing Joe felt for the good drinking days. For the first time Joe had permission to acknowledge the importance of his relationship with alcohol and the magnitude of his loss. Joe began to recognize that his relationship with alcohol met important needs. He began to think of his failure to change as a function of the importance of the needs alcohol met rather than being indicative of some personal dysfunction. He came to realize the necessity of seeking less destructive means to experience the personal power and self satisfaction that drinking had provided in his early days. As Joe had done so many other times, he also told this worker the negative aspects of his drinking. He described the problems he encountered and the embarrassment and other consequences associated with his loss of control over alcohol. Joe talked of problems from his childhood and wondered if they were to blame for his difficulty. The worker surprised Joe again, for she dwelt little on

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the problems, only affirming Joe's assessment that drinking did not seem to work for him anymore. She seemed more concerned with Joe's descriptions of how he had managed to get out of the messes he made with drinking and survived despite his childhood problems. This was a new approach for Joe. All the prior workers had inventoried his strengths and weaknesses but ultimately they attended primarily to deficits and the influence of past difficulties. This worker gave most of her attention to an assessment of Joe's strengths. She marveled at Joe's ability to enlist the help of others when he was in trouble and how well he "thought on his feet ~ when he got in a jam. She thought his reported tendency to withdraw from others and read a lot might be an asset. She wondered with Joe how he might employ the skills he used to survive his drinking days to help his recovery effort. She encouraged Joe to use his knowledge of himself and his problem solving skills to identify what triggered his relapses and create plans for responding to these triggers. Like many other persons with alcohol problems Joe believed "I know what to do, I just don't seem to get it done." Throughout their relationship the worker helped Joe identify new behaviors to try in his recovery effort. She rewarded his efforts and celebrated both his successes and failures when he tried new behaviors. The worker often voiced less concern with the outcome of his new behaviors t h a n with his willingness to try something new. Joe reported a sense of social isolation, a common experience for persons with alcohol problems. He often thought that only he had experienced these types of problems. Joe yearned for social contact and understanding. He had been to a few AA meetings but found it hard to fit in. The worker supported Joe's desire for connection and explored options for meeting persons with similar interests. Together they decided that Joe would attend a number of different AA meetings to find a group with whom he identified. The worker suggested Joe identify some behavior that might help him feel a part of the group. He decided to volunteer to help drive members in need of transportation to and from the meeting. Helping others allowed Joe to develop a sense of meaning and belonging. In an effort to expand his world, Joe also decided to enroll in a gardening class at a local community college. Joe and the worker discussed how his relationship with alcohol had affected his spiritual beliefs. Although Joe had experienced what he described as a "traditional religious upbringing, ~ he had long ago left his church. She pointed out to Joe that, to the extent to which his relationship with alcohol had given his life meaning and the sense of a power greater than himself, this relationship had had a spiritual quality. The worker wondered if this did not reflect Joe's need for transcendence. The worker suggested that traditional churches may be only one path to spirituality. Since Joe liked to read, she gave him books on meditation and philosophy. When he requested further information, she referred him to a local minister who had helped many recovering persons work their AA Steps. The worker asked Joe to think about how his alcohol affected his diet and physical condition. She gave Joe a pamphlet to read on nutrition and alcoholism and at his request referred Joe to a physician who helped Joe identify a dietary and exercise regime that alleviated his cravings for alcohol and improved his moods. This worker addressed Joe's whole person--body, mind, and spirit--as she helped him facilitate his recovery. This style of helping gave permission for Joe to acknowledge the importance of alcohol in his life and established the need to fill the void created by the termination of the alcohol relationship. In contrast to his response to previous treatment, Joe took responsibility for his change. Help-

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ing focused on the resources Joe had marshaled to survive past troubles and inventoried strengths rather than labeled pathologies. Although the worker confronted denial and inconsistencies she never presumed to know the %ruth, ~ leaving that for Joe to devine. This orientation enabled Joe to discover his personal power rather than see himself as a victim. For the first time Joe took charge of his life, no longer dependent on alcohol or professional helpers to derive a sense of personal meaning.

CONCLUSION While the supporters of the Emmanuel Movement believed their method was superior, the emphasis on spirit and the positive power of the unconscious ran counter to the science of the times and the influence of Freud. The allure of modern science was too great for Worchester's followers. Important philosophical changes were made in the program in an effort to imitate the prestigious intellectual ideas of the 1930's. Spirit, strength, and personal power were replaced by psychiatric jargon and expert healers. Predictably, the success of the organization declined and the movement faded in the late 1940s (McCarthy, 1984). The benefits of Alcoholics Anonymous have also been overlooked, presumably because the group is non-professional. Yet one irony of the controversial Rand report (Armour, Polich, & Stambul, 1976) was its most significant finding that the most effective recovery method was not via any of the competing professional therapies but from attending Alcoholics Anonymous (Fry, 1985; Valliant, 1983). Fry (1985) reported that combatants called little attention to this fact, and noted that The National Council on Alcoholism chose instead to advance its own agenda rather than emphasize the accomplishments of a non-professional organization such as AA. No case is made here to suggest that Alcoholics Anonymous represents a new paradigm for alcoholism. AA reflects the middle class Christian values of its founders and the majority of its participants. That fact alone precludes the participation of many and overly limits the paths available for personal understanding of spirituality. No less a disease advocate than Jellinek argued: "Alcoholics Anonymous h a v e . . , created the picture of alcoholism in their own i m a g e . . , there is every reason why the student of alcoholism should emancipate himself from accepting the exclusiveness of the picture of alcoholism as propounded by Alcoholics Anonymous" (p. 38). Nevertheless, many find help in AA, and lessons can be drawn from its success. In the rush to attain scientific dominance and capture the rewards of market share, mainstream knowledge of alcoholism has been overly narrowed. The experience of being alcoholic, and the meaning of the relationship with alcohol, is lost in a scientific shuffle. None of the mod-

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ern experts' approaches to alcoholism are very effective in helping people modify their destructive drinking. This paper has suggested an explanation of alcoholism and recovery broader than that offered by the dominant paradigm. More t h a n just learning a new way to drink, or not to drink, recovery is a holistic and transpersonal experience (White, 1979). The alcoholic's relationship with alcohol lies at the core of his or her being. Although largely ignored by western science, the importance of the spirit in recovery from alcoholism has long been acknowledged. Mary Richmond (1920) instructed social workers that conversion experiences as might be found in religion were the most effective form of treatm e n t for the alcoholic. Carl J u n g (1974) wrote that recovery from alcoholism required an experience beyond mere rationalism. While the E m m a n u e l Movement is long gone, and more fail than succeed in Alcoholics Anonymous, both attained success because they understood the experience of being alcoholic, the importance of connecting with other h u m a n beings, and the power of individuals to heal themselves. The leading competing approaches to alcoholism have been shown to be more the same t h a n they are different. A paradigm which restricts itself to the study of what can be measured leaves little room for the comprehension of spiritual and existential aspects of the alcoholic experience. The understanding of alcoholism requires much more t h a n knowledge of faulty genetics, maladaptive learning, weak moral standards, or healthy family dynamics. If we are to improve our ability to help persons with alcohol problems we must look beyond the current scientific paradigm. Greater understanding of alcoholism recovery will be revealed by expanding sources of knowledge rather t h a n through further reductionism. Modern social work practice is saturated with slogans like %lient empowerment," ~strengths approach," and "self determination." A frequent response to the argument made in this paper takes the form of "Oh yes, we already do that." Less common are legitimate examples of t r e a t m e n t of clients with alcohol problems that truly strive to marshal people's strengths, to seek answers within clients, and t h a t consider equally the importance of body, mind and soul. We m u s t pay more t h a n lip service to the principles described here. Until we do, clients with alcohol problems will not experience the struggle and t r i u m p h of making meaning for their lives.

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T h o m a s K. Gregoire, Ph.D. University o f K a n s a s School o f Social Welfare Lawrence, K a n s a s 66045