Why Our Understanding of Alcohol Use Needs Turning on Its Head

Alcohol withdrawal can, in certain circumstances, be life threatening. Heroin withdrawal – despite numerous depictions in films suggesting the opposite – is not. One is a legally available, culturally-sanctioned substance of choice. The other is a Class A drug. Discuss…
 
I’ve worked with drug and alcohol users for 16 years, and in 2002 I formed Just Say Know, to try to shift our understanding of addiction and dependency behaviours from stigma to understanding. To work effectively with people who use alcohol, I believe it is vital that therapists should appreciate the many reasons why people drink, and understand how and why alcohol affects us. That means confronting our own cultural, medical and moral preconceptions about alcohol.
 
I think we are posing the wrong question when we ask, “How does alcohol affect this person?”
 
A better one would be, “How does this person affect alcohol?”
 
Because, while the basic physiological effects of a substance can be predicted (a depressant drug will depress the central nervous system, a stimulant drug will stimulate it), there are numerous possible variables that affect the actual experience of that drug.
 
In addition to dose, and how the drug is taken, evidence conclusively demonstrates that ‘set’ and ‘setting’ are powerful influences on a person’s actual experience of any substance.
 
SET refers to the personality, mood, past experiences, motivation, awareness, expectations, attitudes, beliefs, (drug) knowledge and imagination of the person.
 
SETTING refers to the conditions in with the drug is taken, including the physical, social and emotional environment, and the ‘set’ of the other people present.
 
The use of alcohol in western culture demonstrates the huge influence set and setting has on the drug experience. So does the fact that alcohol, which is a depressant drug, should play such a vital role in stimulating us during our celebrations and festivals. Numerous experiments conducted under strictly controlled conditions (double-blind, with placebos) have demonstrated that mood and actions are affected far more by what people think they have drunk than by what they have actually drunk.
 
Meanwhile, the relentless celebratory and glamorous images of alcohol in advertising contribute to widespread public misunderstanding of its ‘true’ nature. Alcohol is a diuretic drug, not a thirst-quenching drink, as all these images of rivers, waterfalls, and droplets of water sliding enticingly down the side of a glistening glass would have us believe.
 
I think we need a shift in emphasis. To allow for the development of a healthier relationship to alcohol use, we should be thinking about psychological integration, not separation. The substance using part of the self needs to be understood, not condemned. All behaviour has a pay off – no one does something for nothing. So an individual’s relationship to a substance serves a function. It meets a need, or needs. 
 
These may include: to belong or be part of a group, for the buzz, as a reward, to relax, to allow intimacy, to facilitate or enhance sex, for space, to quieten a busy head or stop thinking, to deal with boredom or change their relationship to time, to manage depression, and for confidence. While anyone can choose not to pick up a drink, no one can choose not to be human: needs need meeting. Therapists should also be particularly aware of 
alcohol’s role, for some people, as a permission giver for forbidden behaviours, feelings or parts of the self. Think about the person who never becomes angry, or never risks intimacy, or won’t allow themselves to be happy, or sad, or scared, or to take (other) drugs, or engage in certain sexual behaviours, unless they are drunk.
 
So the focus is misplaced on what is being given up or abstained from. The more alcohol use is framed as a ‘vice’ or ‘sin’, the more we encourage parts of the self to operate outside of conscious awareness – and the more dysfunctional drinking becomes. Instead, we should be focussing on what is to be added or introduced. Once we have identified and accepted the human needs behind the drinking, we can work with clients to find different and sustainable ways of meeting them.