Getting the Treatment Right: Most Problem Drinkers Are Not Alcoholics

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Most problem drinkers are not alcoholics, according to a recent study — and that should be a worry for “one size fits all” treatment programs that prioritize the task of overcoming actual chemical dependence.

A substantial portion of my early professional training and subsequent work in clinical practice was devoted to the substance abusing population. And over the years, I’ve encountered my fair share of folks who were truly addicted, suffering from the “disease” known as alcoholism. But whether it was on the alcohol and drug units of hospitals or the floors of specially dedicated substance abuse treatment programs, I observed a troubling pattern: after completing some initial screening, patients were routinely conferred the diagnosis of chemical dependency, and routed into program components fashioned specifically to help addicts “recover,” and maintain sobriety. I had long ago seen the movie Days of Wine and Roses and had vivid memories of the scene where Jack Lemmon is going through delirium tremens or the “DTs” during his withdrawal. But I can remember only a handful of folks who went through the “detox” phase of the program who showed any signs at all of genuine withdrawal. It gradually became clear: while all of the patients were without a doubt highly problematic drinkers, most were not truly addicts. Yet, despite the fact that professionals are trained to match intervention strategies to each individual’s unique needs, everyone in the program received the same therapeutic services — services designed to treat the chemically dependent.

Recently, a substantial longitudinal study conducted by the Centers for Disease Control and Prevention found that the vast majority of problem drinkers are not truly dependent on alcohol and therefore cannot technically be considered alcoholics. Among the non-alcoholic substance abusers looked at in the study were some particularly problematic drinkers: the binge drinkers, who consume large amounts episodically, experience significant negative social and occupational consequences as a result (such as major family life disruptions or driving while impaired), and who persist in their drinking despite those consequences. Many of these folks end up pressured into treatment in some way and many of the programs to which they are referred are fashioned on the addiction model. This is potentially a problem, because if we’re to believe the research, most of these folks are, by definition, not alcoholic.

The diagnostic criteria for chemical dependency have been fairly clear for quite some time. True “dependence” on a substance is defined in terms of a person developing increased “tolerance” — i.e., more and more of the substance is required for the desired effect to kick in — and in such cases a person might ingest enough of the substance to severely intoxicate most folks yet continue to function in what appears to be a relatively unimpaired manner. It’s also marked by the distinctive physiological and mental manifestations of withdrawal, meaning that the person manifests unusual and debilitating behaviors upon cessation of using the substance. Relatively few individuals meet these criteria. More meet the criteria for substance abuse: problematic use that persists despite a wide variety of problems associated with that use and despite repeated attempts to exercise more responsible control over the use pattern. Among the more problematic substance abusers are the binge drinkers I mentioned above, who episodically drink to excess and in prolonged drunken states wreak significant havoc in the lives of those who work with and care for them. But according to the CDC study, even binge drinking doesn’t necessarily stem from chemical dependency.

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Getting the diagnosis right is fundamental to providing the right kind of intervention. And while there are many solid treatment programs that comprehensively assess folks on the front end and specifically tailor intervention methods to meet the person’s unique individual needs, there are too many programs that employ a “one size fits all” approach. Such an approach is likely to be not only cost-ineffective but also lacking in treatment efficacy. A variety of factors can contribute to problem drinking patterns that fall short of chemical dependency. Various clinical conditions, personality traits and disturbances, and situational factors can all lead someone down the path of problem drinking. And for treatment to be fully effective, such factors have to be taken into account. A person who, for example, has been laboring under a chronic depression and has been problematically using alcohol as a means of “self-medication” of their condition, might be expected to return to a more normal use pattern once their underlying illness is effectively treated. Such would not be the case, however, for a person who in the process of problematic self-medication has indeed become chemically dependent. Similarly, a person whose pattern of substance abuse mirrors other abusive behavior patterns that mostly stem from problematic personality predispositions could not be expected to make a full “recovery” unless treatment interventions specifically address the relevant character issues. I know from experience how important this is and provide illustrations in my books In Sheep’s Clothing In Sheep’s Clothing [Amazon-US | Amazon-UK](?) and Character Disturbance Character Disturbance [Amazon-US | Amazon-UK](?).

If the most recent CDC study confirms anything, it underscores the importance of having a much wider vision of the nature and scope of problematic use patterns and of providing interventions that attend to all the relevant aspects and reasons for a person’s maladaptive substance use. We are complex creatures, and most of our problems are multidimensional. If we’re to intervene in a mindful and effective way, we have to take into account each person’s individual makeup as well as their particular needs. And while there’s little doubt that problematic substance use is an all-too-common problem, we’re not likely to make a significant dent in it from a prevention or treatment perspective until we take into account all the crucial predisposing factors and provide sufficient access to intervention that incorporates components capable of adequately addressing them.

All clinical material on this site is peer reviewed by one or more clinical psychologists or other qualified mental health professionals. This specific article was originally published by on and was last reviewed or updated by Dr Greg Mulhauser, Managing Editor on .

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