When problem drinkers are standing before them, clinicians can directly observe the problems that these patients might “carry with them”: neurological impairment, medical complications, psychopathology, and illegal drug dependence. These are all serious disorders worthy of clinical attention and are accordingly addressed in other chapters of this book. But this chapter is about what cannot typically be directly observed in the consulting room: the web of family interactions, social networks, and institutional responses that problem drinkers encounter in their daily lives. This surround can have a profound influence on the course of treatment and on the drinker’s life course as well. A drink-driving (drunk-driving) arrest can shock one patient into productive action but send another into drunken despair. A network of drinking mates can undermine treatment, whereas a supportive but firm family can be a major aid to therapeutic progress. And a single alcohol-fuelled act of violence can have life-long consequences, both for the perpetrator and the victim.
Before proceeding to specific social contexts in which drinking problems reverberate, we consider four important conceptual issues. Each shapes our understanding of how drinking problems unfold and therefore has implications for clinical intervention.
Chapter 3 discussed the causes of drinking problems, which logically must precede them in time. This chapter addresses the complications, which logically must follow drinking problems in time. Yet the discerning reader will note that some problems (e.g., marital conflict, difficult economic circumstances) are mentioned under both headings. Likewise, in the treatment of individual patients, clearly distinguishing putative causes from consequences can be quite challenging.
Marilyn is a 28-year-old estate agent who has been married to a carpenter for 3 years. The couple planned a traditional family arrangement in which Marilyn would keep her job only until she became a mother and then focus entirely on rearing children. After 2 years of marriage, the relationship began to sour when the couple discovered that Marilyn was infertile. Marilyn reacted to this news by feeling like “a failure as a woman” and suspected that her husband secretly held the same view. Until this point in her life, Marilyn had rarely consumed alcohol for fear that she would end up like her bullying, frequently drunk parents. Nonetheless, Marilyn began to drink regularly when she was alone, despairing: “What difference does it make?” She describes her husband as having steadily withdrawn attention and affection. During this period, her drinking increased, as did her depression and loneliness. She began missing appointments with clients and eventually lost her job. She is now typically severely intoxicated by 3 p.m. and has headaches and vomiting most mornings. Her sexual relationship with her husband has all but ceased in the past year, starting when he called her “repulsive” after finding her extremely intoxicated and naked on the bedroom floor. She has lately had the persistent anxiety that he is having an extramarital affair, and she states that alcohol is the only thing that stops this fear from racing through her mind.
One could argue that the lesson of this sad situation is that Marilyn’s drinking problems created complications for her marriage and her emotional well-being. Yet one could also hypothesize that it was actually health problems and personal tragedy – infertility in someone who desperately wanted a child – that caused Marilyn’s problem drinking. Alternatively, perhaps Marilyn’s depression and anxiety accelerated the course of her incipient drinking problem, which otherwise would have been transient. Or perhaps Marilyn acquired a genetic liability from her alcoholic parents and that is the true cause of her current misery. One could even argue that this married couple’s perceptions of a woman’s proper role (i.e., that her worth is tied ultimately to being a mother) is causing drinking problems, marital unhappiness, and depression. Even from this short case description, a number of other conjectures on the causes versus the complications of Marilyn’s drinking could be made, much as one could stand in a river and speculate endlessly about which particular rivulet, eddy, rock, and overturned tree stump is truly defining the water’s course.
The question of whether causes and complications can be clearly made out in a complex life seems less academic when one recognizes how commonly patients want to know the answer to the “big questions”; for example, “Did something make me drink?” “Is this suffering my fault?” “What else will change if I get my drinking under control?” For the clinician to say “there is no way to know for sure if all of your problems would have befallen you even if you had never had a drink” is philosophically correct, but clinically inept because it potentially destroys the patient’s incentive to change. At the other extreme, for the clinician to hang every bad event in the patient’s life on problem drinking could induce crushing guilt, inappropriate self-blame, and false hope that life will be a bed of roses as soon as the cork is in the bottle.
Clinicians needn’t pretend to have perfect understanding of what caused what in an individual’s past nor shield the patient from the fundamental uncertainties that are part and parcel of human existence. In general, focusing on what can be changed – the future – is more likely to motivate behaviour change than is trying to assign responsibility for the past. Speaking probabilistically to patients is often the best course (i.e., “Neither of us can know for sure if your marriage became unhappy because you started drinking heavily or the reverse, but I hope we can agree that it’s more likely to get better in the future if you get your drinking under control”). As authors, we adopt precisely the same probabilistic stance in this book. We highlight problems that we consider social “complications” because scientific evidence shows that they are prevalent in the drinking population and that they are usually made worse by drinking. These two facts make them worthy of the clinician’s attention. Yet in using the term “complication,” we unhesitatingly acknowledge that, in any individual life, the complication may actually have been a cause of problem drinking or, for that matter, both a complication and a cause.
Inexperienced clinicians sometimes assume that problem drinkers invariably define an adverse consequence of drinking as would those around them. A patient losing a job from problem drinking may distress the clinician, as well as the patient’s partner and children, but the patient may enjoy the newfound free time and lack of responsibility. Another spouse, to the clinician’s surprise, may be perfectly satisfied that her otherwise demanding and tiresome husband slowly passes out from heavy drinking each evening, granting her peace, quiet, and the run of the house. For these reasons, the experienced clinician will always assess the drinking surround neutrally, rather than subtly cuing the patient as to which drinking-related consequences should be considered problematic. After all, therapeutic leverage often comes more from what the drinker considers the complications of drinking than from what others view as its downsides.
Problem drinkers do not choose the liver with which they were born, nor can their liver seek greener pastures when heavy alcohol consumption imposes added strain. In contrast, problem drinkers can often choose the social environments in which they will and will not participate. In like fashion, the people who compose the drinker’s social environment can chose whether or not they wish to associate with the drinker. For example, one of the interesting observations of social epidemiology is that people who drink heavily tend to have social networks in which heavy drinking is common. This comes about in part through selection by the drinker (e.g., choosing to hang around in pubs or to drink at hours of the day that most people consider “too early for a drink”). It also comes about through the choices made by other people; for example, the light-drinking relatives who slowly reduce contact so as to avoid exposure to a couple’s drunken rows. This phenomenon helps explain why many heavy drinkers do not see themselves as above average in their alcohol consumption: they drink about as much as those around them.
Clinicians are therefore well-advised to conduct a “higher level” review of social complications beyond that needed for medical or psychiatric consequences. Specifically, one must consider not only the consequences of problem drinking in the drinker’s social environment, but also how drinking got that person into that specific environment in the first place. This awareness can help patients see new possibilities in life that are not apparent because they have drifted into their current range of social environments in order to support their drinking. For example, a problem drinker may be pleased to hear that, rather than worry about how to get along with a demeaning boss and cope more effectively with menial pay as a warehouse worker (a job chosen because it allows drinking), bringing drinking under control may open better job opportunities in which such concerns are irrelevant. The same principle often applies in romantic relationships (e.g., rather than attempt to divine which of the habitués at a dive bar might be asked out on a date, a problem drinker can start seeking dates in locations not centred on heavy drinking).
In addition, this “higher level review” can guard against any tendency in the clinician to regard the patient as a passive victim of social environments, which is a ”story” that some patients like to tell and may even believe themselves. For example, the man who says he drinks heavily because he has no wife or friends, or because his children never visit, isn’t acknowledging that his drinking may be causing others to drop him from their social networks in the first place.
A person’s resources moderate the strength of the link between drinking problems and social complications
Consider two women with identical drinking problems. Each drives her car home from a late-night party while intoxicated and encounters a roadside sobriety checkpoint. The police officers’ breathalyzer test indicates that each woman’s blood alcohol level is just barely over the legal limit. In theory, the fates of these two women – their “complications of drinking” – should also be identical, but, in practice, they may not be. If one of the women is a well-known author and the other is a short-order cook, or if one drives a Mercedes and the other a shambling jalopy, or if one is toothsome and charming and the other rudely stamped and verbally clumsy, the policeman may use his discretion differently. In the case of the more successful, wealthier, or more appealing woman, a warning may suffice in his mind, “Just this once,” but for the less successful, poorer, less-appealing woman no such mercy may be forthcoming.
Some people, whether through social standing, money, guile, good looks, charm, or connections are unusually good at evading what would otherwise be the consequences of their drinking problems. The high-profile parade of spectacular drinking disasters among rich and famous people is often attributed to the media’s obsession with celebrity. But an alternative explanation is equally plausible: because such people are often insulated from the more minor complications of their drinking when their problem is less severe, they (ironically enough) may be more likely to progress to the point at which they experience a complication that no amount of influence, money, or fame can make disappear.
Clinicians, like anyone else, can have their judgement affected by a patient’s affluence, wit, and the like and must guard against the tendency to buy into the patient’s narrative that drinking cannot really be that serious because consequences have been largely eluded thus far. At the other end of the continuum, the therapeutic relationship can suffer if a clinician ignores the fact that social complications can come down unusually harshly on certain individuals (e.g., the higher odds that a patient from a racial minority group will be pulled over in “random” traffic stops by police).
We now turn to domains in which social complications of drinking are commonly experienced: family, work/education, crime, and financial stability/housing.
Drinking problems can reverberate throughout a person’s social network, including to friends and to distant in-laws who may be in contact only a few times a year. But in almost all cases, the most profoundly affected people are the drinker’s partner and children, upon whom we focus here.
A “partner” could be the problem drinker’s legally recognized spouse (of a different or the same sex) or a significant nonmarital romantic relationship. Because clinical writings in prior eras often took as read that “partners” were female and problem drinkers male, we emphasize here that we use “partner” to refer to men as well as women, consistent with the rise of heavy drinking among women in recent decades (Grucza, Bucholz, Rice, & Bierut, 2008).
Some clinicians take a history from the partner solely to obtain independent information on the problem drinker. This approach ignores an important reality: partners of problem drinkers are people in their own right. When this is not recognized in the assessment process, weeks can go by before it is suddenly realized that treatment is proceeding on the basis of much being known about the patient while the partner remains a cipher, and their interaction is hence inexplicable. Treatment of the patient is handicapped, and the fact that the partner may also need help is overlooked.
Interviewing a person about their personal life when they have come to the clinic in support of someone else can feel overly forward to clinicians, a traducing of reasonable social constraints. For their part, partners may sometimes feel defensive about any clinical enquiries and raise an objection (e.g., “I’m not the one with the problem!”). Clinicians must persist gently but firmly through their own hesitations and any partner resistance for the mutual benefit of the patient and partner. How to take an initial history from the partner in respectful, comfortable terms is fully discussed in Chapter 10.
As mentioned, social networks to some extent select their members. In the case of couples in which one member has a drinking problem, this can result in social isolation as outsiders withdraw out of embarrassment, discomfort, or fear. The nondrinking partner may encourage this isolation, either out of shame or from a desire to protect the drinking partner from criticism.
A frequent additional stressor is the unpredictability of the drinker’s behaviour. A wife may not know whether, when her husband gets back from the pub, he will be docile and drowsy or in a raging temper. A man readying himself for an evening on the town might worry that this will be one of the occasions when his partner gets drunk and humiliates them both in a social situation by being loud, crude, or sexually inappropriate. The exhaustion that can be engendered by the experience of dealing with continuing distress and peaks of crisis over a period of years may be the partner’s dominant complaint.
Historically, clinical writings with a sexist cast attributed much of the behaviour of wives of problem drinking husbands to psychopathology (e.g., a secret joy or sense of superiority that their husband was alcohol dependent). Yet a more direct explanation of the behaviour of many wives – and husbands as well – is that they continue to love the problem drinker despite it all. Cross-culturally, the allowing of second and third chances, the tolerance of abuse and disappointment, and the efforts to control drinking are very commonly motivated by the fact that the partner worries about, cares for, and wishes to help the problem drinker (Orford et al., 2005). In this stressful situation, the partner suffers from having to watch a loved one harm him- or herself and agonizes over where love ends and damaging overindulgence begins.
In addition to emotional strain, partners of problem drinkers often face concrete realities that can be tangibly threatening; there is the risk of eviction if the rent is not paid, or violence may result in serious physical injury. Divorce, which often has significant adverse economic and psychological effects, can also result from problem drinking. More commonly, problem drinking creates a host of minor tangible problems that have to be coped with: electricity shut off for a day until the bill is belatedly paid, the neighbours complaining about doors being slammed when the drinker got home last night, frequently rowing, the smell of vomit in the toilet, or the drinker being unkempt or wetting the bed.
It would, however, be a mistake always to picture such relationships only in extreme terms. Intense suffering certainly occurs with sad frequency, but infinite gradations exist. Sometimes the problem drinker’s deportment when inebriated causes little distress. Perhaps the drinker becomes a bit silly and argumentative or simply nods off and is difficult to drag up to bed.
On a more positive note, partners can benefit substantially from the problem drinker’s successful treatment. Spouses of remitted alcohol dependent patients score similarly or somewhat better on mental health measures as do controls and substantially better than spouses of actively drinking alcoholics (Moos, Finney, & Cronkite, 1990). Much of what is sometimes put down to enduring psychopathology in partners of problem drinkers is therefore actually a reaction to a difficult situation that dissipates when the drinking problem is resolved.
The types of hardship that the partner may encounter are discussed in more detail in relation to taking the “independent history” from the partner (see Chapter 10).