Not Drinking Tonight

Chapter 1

Would Your Life Be Better Without Alcohol?

I’d say the most common thing to do in the year before quitting booze is to hunch over a laptop and miserably type Am I an alcoholic? into Google at 1am.

—Catherine Gray

“It’s not like I can’t go a day without drinking,” Andrea says earnestly. She looks put together as always, wearing a button-down shirt tucked neatly into a high waisted skirt. A self-described perfectionist, Andrea and I have been working together for two months. In the past few sessions, we have been talking more about her drinking habits and how it impacts her anxiety, her relationship with her new fiancé, and her low self-worth, which she says she has struggled with since she immigrated to America from Peru at age nine.

“I understand,” I say, and I do, more than she knows. I myself sat on a similar looking couch and said the same exact thing to my therapist almost a decade ago.

“Sometimes I can go months without drinking. It isn’t even that difficult,” Andrea says, matter-of-factly. Her face searches mine for validation. I can tell she wants me to agree with her and move on to another topic, but she also knows me well enough to know I’m not going to let that happen.

“I believe you,” I say. And I do. She smiles.

Here’s the thing—I’m sure Andrea doesn’t drink every day and she probably has had periods of time when she didn’t drink. It’s just that the frequency of her drinking isn’t her issue. The issue is the impact that drinking has on her life. The truth is that Andrea, like many other women who come through my door, do not come to see me for “alcohol addiction” or their inability to stop drinking. They end up on my couch because they are depressed, anxious, have eating disorders, low self-esteem, don’t get along with their families, keep dating the wrong people, want more meaningful friendships, are unfulfilled with their careers, or any number of other things that seem to have nothing to do with alcohol consumption or any other addictive pattern of behavior… except they actually do. Of course, this is not to say that every one of these issues is caused by alcohol consumption or that every one of my clients needs to stop drinking to work through their issues. Quite the contrary. However, the way we, as a society, discuss alcohol consumption and alcohol use disorder is unhelpful at best and harmful at worst. In order to fully understand this, I think it’s important to dive into the history of alcoholism so we can understand how the stigma evolved and is perpetuated and how our current models of treating it are unsatisfactory in dealing with the current reality of the drinking landscape.

Despite the fact that recent studies show that individuals in the United States are drinking more in the past few years than ever before, and women especially are experiencing increasing health complications due to alcohol consumption, it is more stigmatizing to not consume alcohol than to consume it. Most women are more afraid of consuming sugar and artificially flavored foods than alcohol. Never mind the fact that alcohol, also known as ethanol, is the same substance we use to fuel cars. (Seriously, look it up if you don’t believe me.)

Alcohol is tightly woven into the fabric of our lives. Every major holiday in the United States incorporates alcohol. We use it to bond, connect, and commemorate weddings, funerals, dates, social events, good news, bad news, and almost everything in between. If someone says they don’t drink, we often assume the person is either religious, pregnant, or an alcoholic. In our society, those are the only reasonable reasons to abstain. Most doctors still tout the heart-healthy benefits of a glass of red wine without inquiring into the patient’s relationship with alcohol or how it may be causing or exacerbating their problems.

Andrea stares out the window and a childlike smile appears on her face as she sees a squirrel hopping across the window ledge. She appears to forget where she is for a moment. She then quickly turns back to me and re-furrows her eyebrows seriously.

“It’s just—I’m not an alcoholic. I know I’m not. I looked it up.” I take a deep breath as Andrea unfolds a piece of paper that she tells me she printed out from a website. Of course, Andrea printed out the criteria for alcohol use disorder. Our work is just beginning.

So often the question that clinicians (or in this case, concerned individuals searching the internet) focus on answering is “Is this person an alcoholic?”

Here’s the backstory—the term “alcoholism” was coined by a Swedish physician in 1849 and it became largely adopted throughout the world. This term referred mostly to the physiological damage of long-term drinking, not to any of the mental impacts of the disease. In 1918, when the American Medico-Psychological Association (which later became the American Psychiatric Association) created the first handbook of mental disorders, alcoholism was characterized by symptoms like hallucinations, tremors, delirium, amnesia, and paranoia. Safe to say, you had to have a pretty severe case to be diagnosed with alcoholism at this time. However, it is unclear what an acceptable level of alcohol ingestion looked like at the time considering this manual’s publication coincided with the temperance movement and prohibition.

Soon after the end of prohibition, in 1935, Alcoholics Anonymous (AA) was formed. The organization believed alcoholics had a physical allergy to alcohol which prevented them from drinking like normal people. And while they could never safely consume any amount of alcohol, they could recover and become functioning members of society if they admitted their powerlessness over alcohol, confessed their mistakes, and made amends for their wrongs. This was a huge breakthrough because up until then, alcoholics were widely considered to be morally bankrupt and disgraceful members of society with no hope of changing or recovering. For the first time, alcoholics had a safe place to get support and help rather than be sent away to rot in an asylum. (However, it’s important to note that AA originated as a puritanical religious group, which makes a lot of the program steeped in morality. The program’s rigidity can breed shame as people are taught that there are right and wrong ways to act, think, and recover. While AA was a revolution at the time and still continues to help millions of people, the program has been largely unchanged since its creation, which originally did not allow women or people of color to participate.1)

The stigma against alcoholics persisted throughout the twentieth century. It wasn’t until the third edition of the Diagnostic Statistical Manual of Mental Disorders (DSM) was published in 1980 that alcoholism was classified as a primary disorder (rather than a personality disorder, which contributed to the stigma). Psychiatrists expanded the definition to include individuals who may not have developed a physical dependence or physiological damage. Of course, this led to a continuous debate among experts about how to separate “problem drinkers” from “alcoholics.” Fast forward to the current edition, DSM-5, released in 2013, which effectively created a spectrum of Alcohol Use Disorder (AUD) with three subtypes: mild, moderate, and severe.

Replacing the word “abuse,” which conjures negative connotations of destruction and harm, with “use” has made a difference in destigmatizing the disorder. Additionally, making it a spectrum allows healthcare providers to focus less on trying to decipher which disorder an individual has and instead recognize a range of symptoms that point to an individual having an issue with alcohol consumption. Adding in the “mild” subtype also makes it easier for individuals who don’t meet the criteria for alcohol disorder to get professional help. Unfortunately, a lot of stigma remains. I see it all the time in my practice. Due to AA’s popularity, most people still believe that they must label themselves as an “alcoholic” if they want to stop drinking. And given this fraught history with the label, it’s no surprise why the average individual resists calling herself an alcoholic.

I don’t blame Andrea for trying to convince me. The impulse makes perfect sense considering the enduring stigma. If you ask someone what they think an alcoholic looks like, most say an old man, who lost his family, home, and job, sitting on a stoop swigging from a bottle wrapped in a brown paper bag. Of course, Andrea, the twenty-four-year-old engaged, marathon-running med student does not see herself as an alcoholic.

“Andrea, let me ask,” I say, “what exactly makes someone an ‘alcoholic’?”

She thinks for a moment. “Well, I typically think of someone who drinks every day, or can’t stop drinking. The image I have in my head is typically an older man with drinking problems, like mi bisabuelo. He was probably an alcoholic. Or there were definitely girls I went to high school with who were getting in tons of trouble for underage drinking and then later DUIs. It wouldn’t surprise me if one of them was an alcoholic.”

“Ah, so someone either is an alcoholic or they’re not. They can’t become one?” I ask, trying to understand her point of view.

“I mean, I’m in medical school. I’ve studied alcoholism. It’s a disease and I know genetics play a large role. So according to the bio-psycho-social disease model, people are probably born with it, but then the problems aren’t revealed until later. Nobody in my immediate family is an alcoholic, so I don’t see how that could be me.”

Despite the APA’s attempts to destigmatize alcoholism by creating a spectrum and renaming it “alcohol use disorder,” the term “alcoholism” is still widely used. Part of this is because Alcoholics Anonymous has long been considered the dominant and only effective treatment for alcohol use disorders. Unfortunately, we don’t have much language for individuals to use to examine their relationship with alcohol without admitting they are an alcoholic.

This means that if someone thinks they may have a problem with alcohol, they google “Am I an alcoholic?” They check out some lists and typically find comfort in discovering that they don’t meet all the criteria. There are lots of tests online; Andrea has found the official eleven-point criteria from the current DSM for diagnosing alcohol use disorder. Keep in mind, the DSM is not intended for self-diagnosis. However, websites often list the criteria and say you can easily diagnose yourself, which of course leads to situations like the current one I am in with Andrea.

“Can I read it to you?” Andrea asks. I know the criteria by heart, but something tells me it’s important for Andrea to go through with her presentation so she can feel fully heard. “Go ahead,” I say. Andrea flattens her piece of paper and clears her throat.

1. Drinking more, or for a longer period of time than you intended.

Andrea says, “Yes, I’ve done that this year, but this just seems like a pretty ridiculous criterion. But yes, I’ll count it. That’s one.”

2. Having a desire to cut down or stop drinking but being unsuccessful.

“No, I haven’t been trying to quit and failing at it,” Andrea responds.

3. Spending a lot of time obtaining alcohol, drinking or recovering from it.

“No.”

4. Having a strong desire to use alcohol.

“No, I think I like it a regular amount,” Andrea says flatly.

5. Being unable to fulfill major role responsibilities at work, home or school due to drinking.

“No,” she quips.