George, aged 19, is a college freshman from a comfortable middle-class home in which his parents drink on occasion. He was forbidden to do so, and has continued to drink very little while in college. However, he recently pledged the local chapter of his father’s fraternity, where heavy weekend drinking is common. Wanting to “fit in,” he has learned to enjoy beer, although ordinarily he does not consume large amounts. But last weekend he became intoxicated and, while pursuing a dare, crashed his car and fractured his pelvis.
Sally has had a speech impediment from childhood. Despite considerable attention from speech therapists, her ability to speak clearly has been only intermittent. In her adolescence she developed the notion that she was able to speak much more clearly while under the influence of alcohol; she did not like its taste, however, and so used it only sparingly. Recently she accepted a position as an assistant receptionist. When her coworker is absent, she is called upon to be the interface between the office and the outside world, something she has found difficult because of her impediment. Accordingly, she has turned increasingly to the use of alcohol, taking vodka in the mornings before work and at lunchtime. As yet her drinking has gone undetected in the workplace, but she has recognized that what was initially self-medication has become a practice that she is beginning to find gratifying in itself.
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Patrick, a foundry worker, is one of a pair of fraternal twins. His father was a foundry worker as well, and had a small local reputation as “a man who could hold his liquor.” Peter, his twin, has reacted strongly to his father’s drinking (which was not as well controlled within the home as outside it) and has become an abstainer. Patrick, however, enjoys the conviviality of before-dinner drinks at the local bar with his workmates. A small group of them has taken to attending the races on weekends and skipping work on Monday if they make money on the horses, in part to recover from “being under the weather.” On two occasions in the past half-year, Patrick’s foreman has spoken sharply to him regarding his absenteeism.
David is the star salesman for a small company that specializes in corporate liability insurance. Because of the pressures of his clients’ work, and because of his own view that an important factor in his success is his personal relationship with them, much of his business is transacted at luncheons or dinners. In part because they are underwritten as legitimate business expenses, these occasions tend to be lavish both in terms of food and drink. On weekends, feeling “let down” from “the excitement of the working week,” David has taken to having two to four drinks per day, preferring to remain at home. Increasing tension has developed with his wife and children for this as well as other reasons. Both his wife and his private physician have cautioned him about the level of his alcohol consumption, his weight, and his gradually rising blood pressure. In dismissing their objections, he points out that they have never seen him in an intoxicated state.
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Ordinarily, William is a sober and well-mannered man. A loner, he lives in a rented room and rarely goes out except to work. However, from time to time, and increasingly in recent years, he will suddenly start drinking enormous quantities of alcohol in the form of cheap fortified wine. Except to purchase his gallon jugs he does not leave his room at these times, but he can be heard at all hours, pacing up and down and talking loudly to himself. After a week or two (or three, in recent months) his room becomes quiet, and some time later, looking much the worse for wear, William emerges to seek a new temporary job. When asked by his sympathetic landlady what causes him to behave in this way, he says, simply, “I don’t know.”
Elizabeth and her family have lived in the California wine country ever since their ancestor migrated to North America several generations ago. For as long as anyone can remember, both in the Old World and the New, most family members have been involved in the production of wine. Plentiful and inexpensive, it is always in evidence, and not only at mealtimes. For most of her adult life Elizabeth has accounted for between one and three bottles daily, depending in part on whether there was something to celebrate. Aside from a tendency toward stoutness, she has been in good general health and of a pleasant disposition. Last week, however, she suddenly began to vomit bright red blood and then passed out. Although she is now out of immediate danger, the doctors have told the family that her “condition” is “serious.”
Gregory does not drink. Yesterday, however, he took two drinks of whiskey; they proved to be two too many. He and his close circle of friends had been celebrating, and (primarily to deflect their insistent teasing) he participated in their good cheer. After doing so, he developed what his friends recall as a “glazed” appearance and briefly left the group. He returned with a shotgun that he promptly discharged at point blank range into the chest of his closest friend, killing him instantly. Returning home, he immediately fell into a deep sleep, from which he awakened with a professed amnesia for what had happened. Informed of the death of his friend, he reacted with an outpouring of grief. As he waits in his detention cell to be evaluated by a forensic psychiatrist, he maintains that he could not possibly have killed his friend deliberately but must have been temporarily insane at the time.
Jimmy did not drink a great deal until he entered the military, where a combination of boredom, the ready availability of alcohol, and boon companions led to excesses that occasionally resulted in disciplinary action. Nevertheless, he compiled an impressive service record and was considered a war hero in his neighborhood at the time of discharge. Initially successful as a junior executive, he soon found that coping with the adjustment to civilian life, a sharply competitive business environment, a joyless marriage, advancing age, and the sudden death of his father from cirrhosis of the liver was a burden that was bearable only with the daily consumption of alcohol and frequent extramarital affairs. He has had a long series of admissions to inpatient medical care for gastritis and pancreatitis; during the course of one of these hospitalizations he developed delirium tremens. On three separate occasions in the last five years he attended well-known 28-day residential treatment programs and briefly affiliated afterwards with Alcoholics Anonymous; subsequently he did reasonably well for several weeks to several months. On this occasion he is accompanied to the emergency room of the local hospital by a police officer; he was found wandering about the streets intoxicated and bleeding profusely from both wrists, which he had slashed with his army sheath knife after an especially bitter encounter with his estranged wife.
* * *
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The foregoing vignettes are based upon actual individuals encountered by clinicians in the course of providing services to persons seeking assistance for alcohol problems. In light of the limited number of instances that are portrayed, the vignettes cannot be considered fully representative of the great variety of individuals who develop alcohol problems, or of the problems themselves. Yet those who have worked in treatment settings will recognize all or most of these people and their problems—and many more besides. They are the focus of the treatment enterprise.
In the sense that they possess a number of common characteristics, these individuals form an identifiable group. For example, all are experiencing problems around their consumption of beverage alcohol. All may need to be dealt with effectively in some manner by someone with special knowledge of alcohol problems (“treated,” in the older sense of the term, which survives when one speaks of a literary or other artistic treatment of a person or subject).
Yet within even this small group there are marked differences. Some of the problems experienced by these individuals are relatively mild (e.g., George, Sally), others are quite severe (e.g., Gregory, Jimmy), and the remainder occupy intermediate positions. Some problems are relatively acute or intermittent (e.g., Patrick, William, Gregory) while others are relatively chronic (e.g., Sally, David, Elizabeth). Some problems have occurred in the context of heavy consumption and some in the context of comparatively light consumption. Some problems are clearly secondary to specific, preexisting conditions; others are not. Some individuals have developed various signs and symptoms or have experienced specific consequences associated with the use of alcohol; others have not. The individuals described here differ widely in terms of age, sex, cultural background, occupation, education, and other factors.
That both important commonalities and important diversities exist in such a group of persons presents a major challenge to those who deal with them. To what degree should each be emphasized, and for what purposes? Some frameworks which are currently employed in dealing with these phenomena, such as those for which the key terms are alcoholism and the alcohol dependence syndrome , tend to emphasize the diversity of the group as a whole, and at the same time the commonalities between individual members of the group, especially at the more serious end of the spectrum.
An alternative approach is to emphasize the commonalities of the group as a whole and at the same time the diversities between individual members of the group, even at the more serious end of the spectrum. This approach has been taken in the present study, as will be discussed in the balance of this chapter. These two approaches are alternative perspectives upon the same phenomena. Both represent attempts to cope with the combination of commonalities and diversities that are intertwined in this complex and perplexing human problem.
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