An existential view of alcohol dependence

Those of us who have contributed to the literature about models of drug dependence have indulged in irrelevancies. We have pushed an abstract scientific course rather than responding to existential needs. We have produced a psycho-bio-social model of drug dependence that excludes the essence of human existence – options, freedom to choose and the centrality of human values. 

Drew, 1990.

The "world’s favourite drug" (Edwards, 2000) has a relatively simple molecular structure of C2H5OH, but the physical, intrapersonal/interpersonal, and societal costs of alcohol use are far from simple – they are immense. The World Health Organisation (WHO, 2004) estimates that of the 2 billion people worldwide who consume alcoholic beverages, 76.3 million ‘suffer’ with diagnosable alcohol use disorders. Alcohol is estimated to cause about 20–30% of cases of oesophageal cancer, liver cancer, cirrhosis of the liver, homicide, epileptic seizures, and motor vehicle accidents worldwide (WHO, 2002). Closer to home, the burden of alcohol-related problems is estimated to cost the NHS up to £1.7 billion every year. Alcohol-related diseases account for around two million NHS bed days and 40,000 NHS day cases annually. When all social, workplace, health and criminal harm is taken into account, the estimated cost to society of alcohol-related harm is £20 billion (Strategy Unit, 2003). In England alone, 8.2 million people (aged 16-64) have an alcohol use disorder which equates to 26% of the population and the gap between the perceived need for alcohol treatment and access is surprisingly large with only 1 in 18 (5.6%) accessing specialist treatment nationally per annum (NHS, 2004). 

With counselling becoming more established in statutory and academic settings, and alcohol (directly or otherwise) already a common occurrence in private practice, the opportunity to offer something distinctive and useful to the field (and ‘addictions’ in general) is available. Counsellors with a working knowledge of existential thought are ideally placed to question the prevalent ‘disease’ model and such concepts as ‘diagnosable alcohol use disorders’ and ‘specialist treatment’, and consider not only the usefulness with regard to our understanding but importantly the effect upon the client. Such nomothetic approaches do little to encapsulate or give an understanding of the client’s experience, or importantly allow expression of the client’s own constructed meaning as a being-in-the-world facing the trials and tribulations of life. And perhaps it is with such socially constructed concepts as ‘dependence’ and ‘addiction’ that existentialism can remind society to continually question ‘established’ approaches, and prize the meaning attributed by the individual we are attempting to assist. 

There is a clear demand from existentialists to examine the concept of addiction (Wurm, 1997b: 2002: 2003; Du Plock & Fisher, 2005). They point out that much addiction research already highlights existential issues even though the author may use other terms to describe them (see Vaillant, 1995: 1996: 2003). However, these ‘givens’ (Yalom, 1980) are unlikely to be assessed during evaluation of treatment if the treatment modalities are based on narrow, reductionistic models of alcohol use and human behaviour (Black, 1991; Brady, 1993; Drew, 1986: 1987: 1990; Wurm, 1997a). 

In the current socio-political climate, the trend is to promote the evidence-based practice to support the premise that desirable outcomes will arise for all concerned (Wurm, 2002). Particular evidence-based interventions are ‘matched’ to respective typology (Project MATCH, 1998) and expectedly the feeling is that ‘cognitive behavioural approaches to specialist treatment offer the best chances of success’ (NTA, 2005, p.9). The attempts to ‘pathologise’ or ‘classify’ alcohol use has led to an over-emphasis upon the biological ‘disease’ model (Drew, 1986: 1987: 1990; Johnson 1999; Wurm 1997b: 2002: 2003), and the emphasis upon symptom reduction might not just be misplaced, but even counterproductive (Wurm, 2002). Just as pain is useful in warning of the danger of physical harm, emotional distress is also potentially valuable. Many therapists understand the fundamental value of anxiety, of pain, of sadness and guilt (Clearihan, 2000). They may reflect a healthy conscience, rather than an unhealthy or ‘sick’ mind (Wurm, 2002). Achieving insight and self-awareness may at least be as valid as reducing symptom scores. The individual client must decide which goal they prefer (Milkman & Frosch, 1973).

Existential approaches to addiction stress the importance of choice in the way that people use alcohol, despite the social, psychological and physiological aspects such as withdrawal symptoms that may make it hard to for the individual to choose differently (Wurm, 2003). Of course, sometimes the behaviour pattern becomes so entrenched that it is hard for the individual to see that there are conscious decisions involved, but describing the problem as an ‘addiction’ or ‘dependence’ may make it even harder to see the role of decision making (Wurm, 1997b). The usefulness of the term ‘addiction’ has been questioned (Drew, 1986: 1987: 1990; Wurm, 2002: 2003) principally due to this notion that choice is irrelevant or impossible (Wurm, 1997). Counselling, more so than say Clinical Psychology (with its predominately medical lineage, Reber and Reber, 2001, p.124) is in a position to incorporate the philosophical thoughts of existentialism and offer a distinctly ‘human’ perspective of dependence, one which stresses the importance of an idiographic view – and in contrast to the prevalent ‘disease’ model, also stresses the responsibility of choice. 

Of all the existential therapies Logotherapy (or Existential Analysis) has been applied to the field of addictions more than any other (Wurm, 2002). For its founder, Viktor Frankl, a human being’s most basic motivation is to find meaning in life: ‘A cause, a reason, “a certain why,” an aim, an ideal, or a purpose in the sense of an orientation towards a goal for which one devotes one’s energies and time’ (Tengan, 1999, p.142). Other motivations are secondary to this, thus an individual may aim to be content in life, but this is because she has set contentment as her life’s goal. A lack of such direction or purpose leads to a sense of frustration, emptiness and depression and in extreme cases neurosis. This idea has the intrinsic sense to many of us and has been echoed by Yalom (1980): ‘The human being seems to require meaning. To live without meaning, goals, values or ideals seems to provoke considerable distress.’(p.422), Nietzsche: ‘He who has a why to live can bear with almost any how’ (in Frankl, 1984, p.97), and McWhinney: ‘The majority of so-called mental illnesses encountered by family physicians, however, are existential crises, and these are problems of the human spirit rather than illnesses’. (1989).

Together with the desire for meaning, Frankl stresses the responsibility of the individual to find his/her meaning in life. Paradoxically human freedom is the ‘freedom to accept responsibility to fulfilling meaning within the confines of death and destiny’ (Nelson-Jones, 1995, p.134). This seems to agree with the Sartrean view that we ‘are condemned to be free’; but rather, Satre’s ‘no-thing-ness’ is a worldview devoid of meaning. Frankl’s is one where meaning is waiting to be discovered through the choices of the individual, and like the Heideggerian view of ‘care’, this is not seen as the ‘random ability to do as we please’ but the freedom to respond to the demands of a particular situation – to listen to the call of our conscience – as opposed to turning away from it (Cooper, 2003). These two interlinked poles of freedom and responsibility are found throughout existential thought, and it is this explicit emphasis upon choice and explicit mention of ‘addiction’ by Frankl that the approach has influenced many researchers who try to offer an alternative to the ‘disease’ model of addiction.  

The idea that addiction problems, including excessive drinking and drug use, are based in the pursuit of pleasure as a way of dulling the existential pain – or the ‘existential vacuum’ (Frankl, 1972, 1997) has found support not only with philosophers and therapists. Empirical studies support an association between poor meaning in life and mental health problems (Kinnier et al, 1994) in addition to high meaning in life and psychological well being (Zika & Chamberlain, 1992). In particular to this proposal, research has highlighted the relationship between poor purpose and meaning in life and heavy alcohol use (Harlowe, Newcomb & Bentler, 1986; Hutzell & Peterson, 1986; Jacobson, Ritter, & Mueller, 1977; Orcutt, 1984; Waisberg & Porter, 1994). Newcomb and Harlow (1986) found that perceived meaninglessness in life mediated the relation between uncontrollable stress and substance use. Individuals abusing drugs or alcohol reported significantly lower levels of purpose in life than those without substance abuse problems. Furthermore, reported levels of purpose in life increased after individuals received treatment for their substance abuse problems (Noblejas de la Flor, 1997; Waisberg & Porter, 1994). Waisberg and Porter also found that individuals who experienced an increase of purpose in life were less likely to have abused substances at a three-month follow-up. 

References 

Ashworth, P.D. (1993). Participant agreement in the justification of qualitative findings. Journal of Phenomenological Psychology, 24:3-16.

Black, W.A.M. (1991) An Existential approach to self-control in the addictive behaviours. In Heather, N., Miller, W.M., and Greeley, J. (Eds) Self-control and the addictive behaviours. Sydney: Pergamon Press. 

BPS (2006) Code of Ethics and Conduct. Leicester: BPS. 

BPS (n.d.) Ethical Principles for Condution Research with Human Participants – revised content. Retrieved March 04, 2008, from BPS website: http://www.bps.org.uk/the-society/code-of-conduct/ethical-principles-for-conducting-research-with-human-participants.cfm#introduction 

Brady, M. (1993) Giving up the grog: an ethnography of Aboriginal drinkers who quit without help. Drug and Alcohol Review, 12(4):401-411. 

Brewer, J., & Hunter, A. (1989) Multimethod research: A synthesis of styles. Newbury Park, NJ: Sage.

Cherryholmes, C. C. (1992). Notes on pragmatism and scientific realism. Educational Researcher, 21:13-17. 

Clearihan, L. (2000) Is suffering part of being human? Australian Family Physician, 29(2):97.

Cooper, M. (2003). Existential Therapies. London: Sage Publications.

Crumbaugh, J. (1968). Cross validation of Purpose in Life test based on Frankl’s concepts. Journal of Individual Psychology, 24:74-81. 

Crumbaugh, J., & Maholick, L. (1964) An experimental study of existentialism: The psychometric approach to Frankl’s concept of neogenic neurosis. Journal of Clinical Psychology, 20:200-207.

Davidson, R.,& Raistrick, D. (1986). The validity of the Short Alcohol Dependence Data (SADD) questionnaire. British Journal of Addiction, 81, 217-222.

Drew, L.R.H (1986). Beyond the disease concept of addiction. Drug use as a way of life leading to predicaments. Journal of Drug Issues, 16:263-274. 

Drew, L.R.H. (1987) The emperor has no clothes: the limits of science in dealing with drug problems. Australian Drug and Alcohol Review, 6(4): 265-269. 

Drew, L.R.H. (1990) Facts we don’t want to face. Drug and Alcohol Review, 9: 207-210. 

Drummond, D. (1990).The relationship between alcohol dependence and alcohol-related problems in a clinical population. British Journal of Addiction, 85, 357-366.

Du Plock, S. and Fisher, J. (2005) An Existential perspective on addiction. In Van Deurzen, E. and Arnold-Baker, C. (Eds) Existential perspectives on human issues. London: Palgrave Macmillan. 

Duttweiler, P.C. (1984). The Internal Control Index: A Newly Developed Measure of Locus of Control. Educational and Psychological Measurement, 44:209-221.

Evans, R.G., Barer M.L., and Marmor, T.R. (eds.). (1994). Why Are Some People Healthy And Others Not? The determinants of health of populations. New York, Aldine de Gruyter.

Furnham, A. & Steele, H. (1993). Measures of Locus of Control: A critique of children's, health and work-related locus of control questionnaires, British Journal of Psychology 84: 443-79.

Frankl, V. (1967). Psychotherapy and Existentialism. New York: Simon and Schuster, Touchstone. 

Frankl, V. (1972). The Doctor and the soul, (2nd ed.) New York: Alfred Knopf.

Frankl, V. (1997). Man’s search for ultimate meaning. New York: Plenum. 

Gergen, K. J. (2001). Psychological science in a postmodern context. American Psychologist, 56:803-813.

Gorman D., Duffy, S., Raine, S., & Taylor, C.(1989). Level of agreement between questionnaire measures of alcohol dependence, alcoholism and problem drinking in a sample presenting at a specialist alcohol treatment service. Drug and Alcohol Dependence, 24, 227-232. 

Greenberg, J., Koole, S. L., & Pyszczynski, T. (Eds.) (2004) Handbook of Experimental Existential Psychology. New York, N.Y.: The Guilford Press.

Hair, J., Anderson, R., Tatham, R.,& Black, W. (1998). Multivariate data analysis (5th ed.).

Hanson, W.E., Creswell, J.W., Plano Clark, V.C., and Creswell, J.D. (2005) Mixed method research designs in counselling psychology. Journal of Counselling Psychology, 52(2):224-235. 

Hanson, W.E., Creswell, J.W., Plano Clark, V.C., and Morales, A. (2007) Qualitative research designs: selection and implementation. The Counselling Psychologist. 35(2):236-264.

Harlowe, L., Newcomb, M., & Bentler, P. (1986). Depression, self-derogation, substance misuse and suicide ideation: Lack of purpose in life as a mediational factor. Journal of Clinical Psychology, 42:5-21. 

Heather, N., Tebbutt, J., Mattick, R., & Zamir, R. (1993). Development of a scale for measuring impaired control over alcohol consumption: A preliminary report. Journal of Studies on Alcohol, 54, 700-709.

Henwood, K.L. and Pidgeon, N.F. (1992) Qualitative research and psychological theorizing, British Journal of Psychology, 83: pp97-111.  

Hutzell, R., & Peterson, T. (1986). Use of the Life Purpose Questionnaire with an alcoholic population. International Journal of the Addictions, 21(1):51-57. 

Jacobson, G., Ritter, D., & Mueller, L. (1977). Purpose in life and personal values among adult alcoholics. Journal of Clinical Psychology, 33(1):314-316. 

Johnson, B. (1999) Three perspectives on addiction. Journal of the American Psychoanalytic Association. 47:791-815. 

Jorge, M., & Masur, J. (1985). The use of the short-form Alcohol Dependence Data Questionnaire (SADD) in Brazilian alcoholic patients. British Journal of Addiction, 80, 301-305.

Kinnier, R., Metha, A., Keim, J., Okey, J., Adler-Tapia, R., Berry, M. & Mulvenon, S. (1994). Depression, meaninglessness, and substance abuse in “normal” and hospitalised adolescents. Journal of Alcohol and Drug Education, 39(2):101-111. 

McWhinney, I.R. (1989). A Textbook of Family Medicine. New York: Oxford University Press. 

Marsh, A., Smith, L., Piek, J., and Saunders, B. (2003). The Purpose in life scale: Psychometric properties for social drinkers and drinkers in alcohol treatment. Educational and Psychological Measurement, 63:859-871. 

Milkman, H. & Frosch, W.A. (1973) On the preferential abuse of heroin and amphetamine, Journal of Nervous Mental Disorders, 156:242-248. 

Newcomb, M. D., & Harlow, L. L. (1986). Life events and substance use among adolescents: 

Mediating effects of perceived loss of control and meaninglessness in life.  Journal of 

Personality and Social Psychology, 51:564-577.

NHS (2004). Alcohol Needs Assessment Research Project (ANARP). Department of Health; University of London. St George's. Division of Mental Health. Section of Addictive Behaviour; Kable Limited; MORI Social Research Institute

NTA (2002) Model’s of Care: full reference report. London: National Treatment Agency, NHS 

NTA (2005) The Effectiveness of Psychological Therapies on Drug Misusing Clients. London: National Treatment Agency, NHS.  

Orcutt, J. (1984). Contrasting effects of two kinds of boredom on alcohol use. Journal of Drug Issues, 14:161-173.

Polkinghorne, D. (1983). Methodology for the Human Sciences. Albany: Suny Press.

Project MATCH Research Group. (1998). Matching alcoholism treatments to client heterogeneity: Treatment main effects and matching effects on drinking during treatment. Journal of Studies on Alcohol, 59:31–639.

Raistrick, D., Dunbar, G., & Davidson, R. (1983). Development of a questionnaire to measure alcohol dependence. British Journal of Addiction, 78(1):89-96. 

Reber, A.S. and Reber, E. 2001, The Penguin Dictionary of Psychology, 3rd edn, Penguin Books, London.

Reichardt, C. S, & Rallis, S. F. (Eds.). (1994). The qualitative-quantitative debate: New perspectives. San Francisco: Jossey-Bass. 

Sandelowski, M. (1986). The problem of rigour in qualitative research. Advances in Nursing Science, 8(3):27–37.

Sechrest, L., & Sidana, S. (1995). Quantitative and qualitative methods: Is there an alternative? Evaluation and Program Planning, 18:77–87.

Smith, J.A. (1996) Beyond the divide between cognition and discourse: Using interpretative phenomenological analysis in health psychology, in Psychology and Health, 11:261-271.

Smith, J.A., Flowers, P. and Osborn, M. (1997) Interpretative phenomenological analysis and the psychology of health and illness, in L. Yardley (Ed.) Material Discourses of Health and Illness. London: Routledge.

Smith, J.A., Jarman, M. and Osborn, M. (1999) Doing interpretative phenomenological analysis, in M. Murray and K. Chamberlain (Eds) Qualitative Health Psychology: Theories & Methods. London: Sage.

Tashakkori, A., & Teddlie, C. (Eds.). (2003) Handbook of mixed methods in social and behavioural research. Thousand Oaks, CA: Sage. 

Tengan, A. (1999). Search for meaning as the basic human motivation: A Critical examination of Viktor Frankl’s logotherapeutic concept of man. Frankfurt am Main: Lang.

Vaillant, G. (1995) The Natural History of Alcoholism Revisited. Cambridge, Mass: Harvard University Press. 

Vaillant, G. and Hiller-Sturmhofel, S. (1996). The natural history of alcoholism. Alcohol Health & Research World 20 (3): 152-161.

Vaillant, G. (2003). A 60-year follow-up of alcoholic men. Addiction, 98, 1043–1051.

Waisburg, J., & Porter, J. (1994). Purpose in life and outcomes of treatment for alcohol dependence. British Journal of Clinical Psychology, 33:49-63. 

Waszak, C., & Sines, M. C. (2003). Mixed methods in psychological research. In A. Tashakkori & C. Teddlie (Eds.). Handbook of mixed methods in social and behavioural research (pp. 557-576). Thousand Oaks, CA: Sage. 

Wertz, F.J. (2005). Phenomenological research methods for counselling psychology, Journal of Counseling Psychology, 52(2):167-177.

World Health Organisation (2004) Global Status Report on Alcohol. Geneva: World Health Publications.

Wurm, C. (1997a) Logotherapy and Existential Analysis: ‘Man’s Search for Meaning’ 51 years on. NZAP Forum, 3(June 1997), 162-169. 

Wurm, C. (1997b). Deciding about Drinking: An Existential Approach to Alcohol Dependence. In S. Du Plock (Ed.), Case Studies in Existential Psychotherapy and Counselling. London: Whiley. (141-156). 

Wurm CSE, 2002. Evidence and Existentialism in Addiction. In NCETA Workforce Development Symposium 'Catching Clouds: Exploring Diversity in Workforce Development for the Alcohol and Other Drugs Field', AM Roche & McDonald J [eds], pp211-216, Adelaide: NCETA, Adelaide.

Wurm, C. (2003). Is ‘Addiction’ a helpful concept? An existential view. European Psychotherapy, 4(1): 175-182. 

Yalom, I. (1980) Existential psychotherapy. New York: Basic Books. 

Zika, S., & Chamberlain, K. (1992). On the relation between meaning in life and psychological well-being, British Journal of Psychology, 83:133-145.