Alcoholism and Other Drug Problems
By James E. Royce, S.J., Ph.D., David Scratchley, Ph.D.
Any of us could suffer the effects depicted so far of alcohol and other drug misuse on our health, driving, social relations, and pocketbook, whether addicted or not. This chapter will address the development of addiction, using alcoholism as a model. The approach will be descriptive rather than explanatory, leaving to Chapter 7 any considerations of causality. The focus here is on what addiction is, not why. The distinction is important, for much needless quibbling about types is really mistaking description for explanation.
Types of Alcoholics
Alcoholics differ over the whole range of human variation in physiological and psychological characteristics. No two people are exactly alike. Each alcoholic is a unique individual, so that there is a temptation to resign ourselves to the existence of 10 million alcoholisms in a population of 10 million alcoholics. Alcoholism itself is not a single disease entity any more than cancer is, but a multiple illness, which amply justifies a growing trend toward use of the term alcoholisms.
With those facts in mind, it is clearly a serious mistake to assume that a "true" or "typical" alcoholic must be much like the one you know-or the one you are. The result, of course, is that the patient may not be able to identify with the accepted archetype, so will feel either left out or confirmed in his or her denial of being an alcoholic at all. The mere fact that the counselor or older AA member can't imagine an alcoholism different from the one with which he or she is familiar does not disprove its existence.
The best-known classification is that presented by the late E. M. Jellinek in The Disease Concept of Alcoholism (1960, pp. 36-41). Jellinek deliberately identifies his various types of alcoholics by letters of the Greek alphabet, to avoid names that might imply theories as to cause or nature. Whether or not one accepts his scheme, it is so much a part of the literature that one must be familiar with it in order to read or converse intelligently in the field. Note that these are not stages of progression, that is, from Alpha to Beta and so on.
The Jellinek Types of Alcoholisms
Alpha. This is purely psychological dependence on alcohol. These people have poor frustration tolerance or inability to cope with tensions. They use alcohol to boost morale, block out reality, bolster self-confidence, or relieve emotional or bodily pains. They drink too much and at the wrong times, which may result in offense to others, family squabbles, absenteeism from work, and a drain on the family budget. They can be called problem drinkers, but Jellinek rejects the term here because it can include the physically dependent. There is little or no progression and no physical addiction or withdrawal symptoms (although there can be some of the nutritional deficiencies of alcoholism). Hence Jellinek was reluctant to call it an illness per se, although he definitely says it is alcoholism. Some call it a symptom of mental conflict, but it is a symptom that has become the disease in its own right. At least 10 to 15 percent of AA membership is of this type. Psychotherapy can help with the conflict, but medication would only lead to dependence on more alcohol or other drugs. Alpha alcoholism may develop into Gamma alcoholism, Jellinek says, but it can also continue for thirty or forty years with no progression. Addictions to compulsive gambling and marijuana seem to involve this psychological vulnerability.
Beta. This is characterized by social dependence on alcohol, without either psychological or physical dependence. The usual problems from excessive drinking arise, including nutritional deficiencies and organic damage such as cirrhosis and gastritis. These alcoholics are often seen in general hospitals, where their physical ailments are all too often treated without remedying the drinking habits that caused them. They seldom join AA. The cause of their drinking is largely sociocultural or situational and is common in occupations where "everybody" gets drunk every weekend. This "everybody does it" feeds denial. In any case, heavy social dependence should not be dismissed lightly; it is one of the main obstacles to long-term rehabilitation of chronic alcoholics. Jellinek says this Beta type is alcoholism (p. 41), and it meets the third element of our working definition, because there is interference with important life functions. Both Alpha and Beta may involve some loss of control, but this is not paramount in either type.
Gamma. This is the chronic, progressive type of alcoholism most commonly seen in American males. It usually begins with psychological dependence and progresses to physical dependence. There is progressive loss of control over how much one drinks; except in the later stages, one can usually still choose when to drink or not, but once started there is little or no control over when to stop: "One drink is too many and a thousand are not enough." There is usually an increase in tolerance, and in the middle stage it may reach a remarkable level. There may be shakes or tremors for days after withdrawal. In the late stages withdrawal symptoms are severe, and tolerance drops irreversibly to below one's initial level so that a single drink is quite toxic. This is the classic instance in which the habitual addiction is the disorder. Searching for reasons why these people drink is superfluous; they drink because they are addicted to alcohol. This type is most responsive to the AA approach, but anything that will break the habit pattern can be useful: Antabuse (disulfiram), aversion conditioning, a religious conversion, or intensive treatment with a strong emphasis on understanding the nature of the illness and good physical rebuilding-any approach that attacks the pathological drinking as the primary disorder, on which all of the foregoing approaches agree.
Because members of Alcoholics Anonymous were the most available and cooperative when Jellinek did his research, the majority of his two thousand subjects reported histories that conform to this type. He observed that Alcoholics Anonymous "naturally created the picture of alcoholism in their own image", and in spite of his great admiration for AA he warns sternly that we must not let this selective sampling deceive us into imagining that the Gamma is the only typical or true alcoholic.
Delta. This is often called the maintenance drinker: the alcoholic who has lost control over when he or she drinks rather than how much. Inability to abstain, rather then inability to stop once they start, is the characteristic. Unlike the Gamma type, Deltas cannot "go on the water wagon" for even a day or two; yet they seldom appear to be drunk. Are they alcoholics? Yes, they show increased tolerance and even go into severe withdrawal symptoms (DTs) if deprived by accident or other circumstances, though they may have never been drunk in their lives. Social attitudes that favor regular drinking seem to play a major role. This is the commonest type of alcoholism in France and such other wine-drinking countries as Chile and Peru, and perhaps among American women. Or one can be a member of the three-martini-lunch bunch, the executive who must have alcohol to get through the day. One patient, told to cut out salt and alcohol as a routine treatment for high blood pressure, promptly went into DTs, although alcoholism was not suspected. Deterioration is so gradual that the Deltas do not realize that they don't feel very good most of the time; changes in family relationships are likewise so subtle that nobody recognizes the problems. Because their drinking rarely precipitates a crisis that would bring them to AA, they are not highly visible in the fellowship. Another reason is that they cannot identify with the distressing and sometimes amusing experiences other alcoholics recount from their drinking escapades.