What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (34 page)

Are You an Alcoholic?

First the man takes a drink, then the drink takes a drink, then the drink takes the man.

Japanese proverb

Do you have a problem with alcohol? Is it “abuse,” or, worse, do you “depend” on drinking to get through the day? It will not surprise you to find out that the lines between handling liquor well, abusing alcohol, and being dependent on it are far from clear. As a rule of thumb, the more symptoms you have, the worse your problem. Take the following quiz:

MICHIGAN ALCOHOLISM SCREENING TEST
(adapted from Melvin Selzer, M.D.)

Scoring
. The scoring is simple. Total your points. There is no sharp cutoff, but a total of 5 points or more places you in the alcoholic—dependent on alcohol—category. Four points suggests that you abuse alcohol. Three points or less suggests no major alcohol problem. This test is conservative, a screening test, so it tends to call more people alcoholic than you would expect. If you score more than 3 points, you should attend very carefully to the sections that follow on recovery from alcoholism.

Is Alcoholism a Disease?

Is alcoholism a disease? There is no question about substance abuse that has produced more passionate controversy than this one. Alcoholics Anonymous insists that alcoholism is a disease and that the alcoholic is “powerless” before it. But for more than a hundred years, others have insisted that “drunkenness is a vice, not a disease,” and that “alcoholism is no more a disease than thieving or lynching.”
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For the scholar, this debate is a matter of truth and the sanctity of language. For the helper, this is a matter of helping tactics. Whatever, this is a subject that inevitably lends itself to give-and-take exchange:

Attack:
Alcoholism, unlike a real disease, is not physical. If someone tells you there is a known metabolic deficiency, a known gene, or a known biochemical weakness that alcoholics have, hold on to your wallet. There is no such thing. Alcoholism is a social, economic, and interpersonal problem, not a physical pathology.

Rejoinder:
Alcoholism is not a disease like malaria, with a specific germ or chemical abnormality as its cause; it is more like high blood pressure. Hypertension is bound up with social, interpersonal, and economic factors, and most hypertension is
essential
—it has no known physical cause. But it does have known physical consequences—heart attack and stroke—just as alcoholism brings cirrhosis of the liver and brain damage in its wake. Alcoholism, like many diseases, has strong heritability. Identical twins are more concordant than fraternal twins, and the offspring of biological parents who are alcoholic are several times more likely to become alcoholic, even if they are raised by teetotalers.
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Attack:
Heritability does not cut much ice: Stupidity, ugliness, and criminality are inherited, but that does not make them diseases. You either have a real disease, like syphilis or schizophrenia, or you don’t. But with alcoholism there is merely a continuum of alcohol consumed, with heavy drinkers at one extreme. So calling this extreme a disease is like calling very short people (midgets as opposed to dwarfs) diseased.

Rejoinder:
Just as there is no clear dividing line with hypertension, there is none with alcoholism. All we can say is the more of it, the worse the problems tend to be.

Attack:
This is an egregious instance of
victimology
, the art of transforming failures into victims. We are a society that does not take kindly to failure. Failures are felt to be vaguely immoral—lazy, stupid, mean, or obnoxious. But we have also become a gentler society in recent years—no longer are our classrooms appointed with dunce caps or our children’s report cards replete with Fs (we now have “Unsatisfactory” and “Incomplete” instead). No longer can our kids go unpunished for taunting a retarded child as the “village idiot.” We now deal with failures in a manner that tries to save them from the humiliations of the past. We relabel them victims, and of victims no ill can be said. Alcoholics are, in truth, failures, and their failure is a simple failure of will. They have made bad choices, and they continue to do so every day. By calling them victims of a disease, we magically shift the burden of the problem from choice and personal control, where it belongs, to an impersonal force—disease. This move erodes individual responsibility and even lends an aura of moral legitimacy to drunkenness. It magnifies the problem, making change less likely.

Rejoinder:
Recall the Japanese proverb cited earlier. As alcoholism worsens, voluntary control gets weaker. Calling alcoholism a disease highlights how little control its victims come to have. Choice mattered at first, but in its later stages, alcoholics have almost no choice. A driver who chooses to speed down a freeway in a car with defective brakes and winds up spending years in casts made some bad early choices that had long-term disastrous consequences. But his broken neck and useless arm are now illnesses.
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A
ND
so the dispute continues through another half dozen attacks and rejoinders. There is a decent argument on each side: There are good reasons to call alcoholism a disease, but there are almost equally good reasons not to. The dispute is roughly a draw.

But a disease, unlike a triangle or a benzene ring, is not an object of science.
Disease
is not well defined; rather, it is a label that lies outside science itself and is used to introduce specific topics. It is a term like
cognition
as opposed to
short-term memory
in psychology, or
life
as opposed to
gene
in biology, or
cure
as opposed to
spinal-cord damage
in medicine. There is some latitude about whether or not to attach the label
disease
to alcoholism, and therefore I believe that other considerations come into play. Primarily, we should ask if people who label themselves
diseased
with alcoholism are better off. Are helpers of alcoholics more effective if they think they are treating a disease? Is change more likely?

Tactics
. The way we explain our failures to ourselves, unlike the truth of the disease concept of alcoholism, is not merely academic. In fact, how we label our troubles has sweeping consequences. When we believe an explanation that is permanent, pervasive, and personal, we do much worse than when we explain our problems in temporary, local, and impersonal terms. For example, if we explain our unemployment as “I have no talent” (permanent, pervasive, and personal), we get depressed, we feel helpless, we don’t look for a job, and our failure bleeds into the rest of our lives. If, on the other hand, we believe that the cause is the recession (temporary, local, and impersonal), we soon try to find another job, we fight off depression, we don’t feel worthless or helpless, and we go on in the other domains of living. This is the main concern of my book
Learned Optimism
, and it applies directly to the disease concept of alcoholism.

When someone finds himself dependent on alcohol, and it finally dawns on him that his life, his family, his career, and everything else he values is in danger, how should that man explain this to himself? As it turns out, he doesn’t have many choices. He can explain it as a disease. The other possibilities are to explain it as a vice, a result of bad choices and bad character, or as sin. Compare disease to vice. Disease is more temporary (it is often curable), whereas vice is more permanent (it stems from bad character, and character changes little if at all). A disease is more specific (it comes from an accidental biology and environment), whereas vice is global (it comes from being a bad person). A disease is impersonal, whereas a vice indicts you because
you
chose it.

The upshot is that a disease is a more optimistic explanation than vice, and optimism is about changeability. Pessimistic labels lead to passivity, whereas optimistic ones lead to attempts to change. It follows that alcoholics who label themselves as ill will be less depressed, less helpless, have higher self-esteem, and, most important, will try harder to change or be changed than alcoholics who label themselves bad people. There is another benefit of the disease label: It is a ticket into the medical care system.

I come down on the side of the disease concept of alcoholism. Not because it is unimpeachably true (I doubt that), but because it is more hopeful than the alternative explanations available until recently. Alcoholics who see themselves as ill, and professionals who see their alcoholic clients as ill, are more likely to try to change this state of affairs than if they see immorality. The “disease” of alcoholism is one of the therapeutic illusions that can help make life bearable for alcoholics.

Alcoholics Anonymous, in my view, only gets it half right. By calling alcoholism a disease, AA makes change more likely than if it let its members believe they were vice-ridden or sinful—the main alternative explanations when AA was founded. But the modern era has invented some gentler alternatives: A “habit disorder,” a “behavioral problem,” even a “human frailty” are ways a sophisticated alcoholic could explain his failures now. Each of these is a markedly more optimistic label than “vice” or “sin,” and probably more optimistic than “disease.” Habits can change, behavioral problems are specific, and frailties come and go. These ways of looking at alcoholism promote more change than either the vice and sin views or the disease model.
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