Challenging the language of alcohol problems

For many people, alcohol use is an integral part of UK culture, deeply embedded in rituals of socialisation and relaxation. Even the UK 'Government's Alcohol Strategy' from 2013 states that alcohol can have a positive impact on wellbeing in terms of sociability and that community pubs are 'a key part of the fabric of neighbourhoods'. Yet alcohol misuse has a significant cost to the nation, when accounting for the wide-reaching social, economic and individual impacts.

Whilst there have been well-reported declines in young people's drinking over recent years, middle and older aged adults are yet to follow suit. In fact, hospital admissions for alcohol-related liver disease have continued to climb and alcohol consumption is still shifting from bars and pubs to the home. Public Health England (PHE) estimated, in their 2016 evidence review on 'the public health burden of alcohol', that there are some 10.6 million adults who drink at levels that could place their health at risk, but that 1.6 million of these adults are classed as 'harmful' drinkers and have some level of alcohol dependence.

An ongoing challenge has been how to engage and support change within this group. Even amongst the estimated 600,000 people with more established alcohol dependency, PHE figures suggest only one in five access treatment for alcohol problems. A number of key barriers for seeking formal help include stigma and a common desire for people to recover on their own. Many people with addictions do indeed recover on their own. For some, this involves simply 'outgrowing' problems as they go through life and acquire more responsibilities that drug or alcohol use becomes incompatible with.

Others, however, may never recognise their own drinking as problematic and worthy of change. When harmful drinkers are asked about their relationship with alcohol, they are often quick to point out who the 'real' problem drinkers are… and it's certainly not them. This 'othering' of problem drinkers is a recognised and common sociological phenomenon which often includes describing 'alcoholics' as a distinctly different group from the person seeking to normalise their own drinking. 'Othering' tends to rely on a range of readily available public stereotypes about 'alcoholism' such as 'hitting rock-bottom', drinking in the morning, or a total loss of control of one's drinking or behaviour. In truth, most alcohol-problems – and even many cases of serious conditions such as liver disease – are not confined to those with severe alcohol dependency.

This common practice of pointing to the 'other' type of drinker relies on binary thinking; people are either problem drinkers or not. We seek out simplified explanations of the world around us for a range of reasons, with the complex nature of alcohol and other such problems often overlooked. Whilst the disease model of addiction has been credited with a move away from the 'moral model' of the past, many prominent addiction scientists argue that whilst brain change is a feature of addiction, such a pathogenic brain-centric interpretation is scientifically insufficient. Crucially, the shift towards seeing addiction as a disease has failed to halt the global rise of addictive behaviours and associated stigma.

The simplified public narrative around drinking was explored last year in a BBC documentary featuring Adrian Chiles, Drinkers like me. The programme was applauded by The Telegraph for its 'sobering, fascinating and disarmingly honest look at social drinking' in which Chiles explored whether his relationship with alcohol was indeed a 'problem'. The show was predicated on disentangling the false binary of alcoholism. It starts with Chiles stating 'My name's Adrian Chiles, and I'm not an alcoholic… at least, I don't think I am'. He continues, 'I do drink most days, but compared to a lot of people, I don't put loads away'. And here lies the classic escape clause – the ever-available option of pointing to other drinkers as the 'real' problem drinkers.

By coincidence, last year also saw the publication of a meta-analysis of qualitative explorations tasked with 'understanding drinking among midlife men' in the UK, led by research officer Hannah Parke. It identified a number of common ways in which drinkers justify and explain their drinking as 'normal'. These themes emerge throughout Drinkers like me, with the use of justifications and the importance of social identity particularly apparent. 'I'm not someone who fights, or gets involved with the wrong people when I'm drinking', Chiles reassures the viewer. However, he continues to say that the programme is not about people 'who drink sherry in the morning or wake up in shop doorways… this is about nice, regular drinking, and the damage quietly being done to ourselves and society, by drinkers like me.'

And so the journey begins. Chiles is filmed in the pub on a match day with his 'cronies'. It's still not midday, and so Chiles asks the group whether the ease with which the pints are going down begs the question '...is this a slippery slope? Am I going to be one of those people in Wetherspoons at ten in the morning?'. Fellow football fan Kev quickly offers justifications for the group's drinking, stating 'I do know lads who will start drinking Sambucas especially, as soon as they jump on the train. So, there's drinking and there's drinking.' Chiles, however, is not coming along for the ride this time. 'Kev, I know some genuine alcoholics, they all say words to that effect – "there's drinking, and there's drinking – and guess what, I'm on the right side of the line… they're drinking sambuca, they're drinking more than me and they stay up later than me, their kind of drinking is bad… mine's fine, 'cos I've made my own little rules".'

Kev's retort displays the rationale of 'control' – a theme also identified in the systematic review. 'Well I know my limit. Right? Some people don't.' Next Chiles ponders to the camera whether the classic alcoholic stereotypes are really representative of problem drinkers. 'Just because you're not any of those things, doesn't mean you're not alcohol dependent, or have got some kind of dependency issue with alcohol.'

Later Chiles meets Professor David Nutt, to ask how much more than the 14 units a week guideline one needs to be drinking 'to be considered an alcoholic'. Nutt offers a reality check. 'People say "well I'm not drinking very cheap cider, and I'm not sleeping in the gutter, so I'm alright". And that's not true. We know a third of people coming into the liver unit with alcohol-related liver damage, do not meet the criteria for alcoholism.'

Others attempt to offer familiar narratives. Sarah admits to 'not really having a stopping point' when binging, but says she it would never lead her to having a problem – she has no interest in morning drinking and is 'not a vommer'. Chiles also meets Mark, who he identifies as just like himself. Mark wants to highlight why his drinking isn't a cause for concern: 'I don't wake up in the morning thinking right…', but again Chiles is not here to be complicit. He challenges him; 'that's the fallacy I tell myself, I don't want to drink anything in the morning… but that doesn't mean that I'm not addicted to alcohol in some sense, which I am. I'm sure I am, and you are!?'. Mark pauses briefly, then half concedes, 'to a degree, we're addicted to it, without being alcoholics'.

Later on Chiles meets people who have actively changed their drinking. Charlie describes a 'rock bottom' where she was drinking three bottles of wine a night. The anxiety and other problems led her to seek help, and now she only drinks a bottle of wine a week. Chiles asks comedian and friend Frank Skinner, a self-identified 'recovering alcoholic', whether he needs to quit. Skinner admits his social life has 'never been the same' since giving up alcohol, but challenges Chiles to give up for three months. However Skinner reassures Chiles that if he's one of those people who can 'just keep this side of the dark side' he shouldn't stop indefinitely because drinking 'can be so brilliant'.

Whilst just a snapshot of the estimated 1.6 million harmful drinkers, Chiles engages with a variety of perspectives; whether they are unabashed drinkers, reconsidering, or have already made changes to their consumption. Through these encounters, themes reliably found in qualitative drinking accounts are repeatedly described, particularly what may be commonly described as 'denial'. Those not yet wishing to change heavy drinking habits justify them by defining problem drinkers as 'others' – those who drink more than them, can't control their behaviour, or need to drink in the mornings. As such, they place themselves on the 'safe side' of an invented dividing line.

The show's success may be best judged by its apparent stimulation of discussions and reflections about what alcohol problems really are, particularly given there is no 'one size fits all'. Chiles' conversations show us that issues around alcohol use are messy, complex and individual, and to really unpick this requires more nuance than common binary 'alcoholic' narratives. Not all viewers may agree, and some may even feel Chiles' may be irresponsibly promoting 'moderation' to drinkers who they feel just need to stop. Research, though, has shown that both addiction and recovery comes in many forms, even if public perceptions are more singular (see the 2017 study led by Kiran Pienaar – tinyurl.com/y82q34yl).

More nuance and honesty
The concept of alcoholism can be important for some drinkers seeking recovery from problems. But from a public health perspective, challenging this binary thinking should be seen as a potentially valuable change. Notably, shifting understandings towards a more continuum approach can help to break down the stigma of alcohol problems that stops many drinkers from contemplating change. We could all consider our own drinking with a little more nuance and honesty. There would be advantages to resisting easy but problematic simplifications such as 'alcoholics' or 'addicts' in our conversations, and instead recognising that people and the problems they experience are more complex.

- Claire Melia is a postgraduate student at Keele University
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- James Morris is Director of the Alcohol Academy
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