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Almost Alcoholic, subtitled “Is My (or My Loved One’s) Drinking a Problem?” is well worth reading. It is written by Robert Doyle, MD, and Joseph Nowinski, PhD, mental health professionals who received significant training in chemical dependency. Importantly, they are researchers and clinicians.

Thus the authors are able to draw on their own cases to illustrate various attributes that constitute people who fall on a scale they describe as being “almost alcoholic”. The authors suggest that the almost alcoholic lurks in the shadows rarely getting proper attention from the health care community.

The benefit the authors provide to those of us working in the field is a conceptual as well as practical guide for when therapists, substance abuse counselors, nurses, family doctors, as well as family members “smell smoke” regarding a client’s or loved one’s drinking.

The book also serves as a resource to educate our clients when they are drinking themselves into a precarious spot.

So who are the “almost alcoholics” and why should we care. The authors point to 5 primary criteria which differ from frank alcoholism only by degree.  They are:

  • Continued drinking despite some negative consequences
  • Looking forward to drinking
  • Drinking alone
  • Drinking to influence emotions or mood
  • Suffering as a result of drinking (suffering can either be to the the drinker or a family member or loved one)

In the case of alcoholism these factors exist in extreme fashion, while with the almost alcoholic typically they are present to a lesser degree.

As a therapist who works frequently with alcohol and substance problems, this book describes a phenomenon I often notice with my clients. Doyle and Nowinski point out that for the almost alcoholic, drinking is rarely what clients say is bringing them to treatment.

With a client in this situation I might say, “You know, the people on Market Street (in San Francisco where I work) pushing shopping carts and with stuff running down their nose, didn’t always look like that!” Or I will tell them the apocryphal story of  the frog in a slowly heating pot of water that cooks to death before realizing the severity of its situation. Even if television’s Mythbuster’s has torn this canard to shreds, my clients get the message.

The authors also write about the type of relationship a person can have to alcohol. Having blogged about this very same idea last year: http://psychologyofeverything.com/wp-admin/post.php?post=214&action=edit,          I find this a very useful idea.

The authors describe a casual relationship to alcohol where a person drinks occasionally, has 1 drink, (or 2 drinks at most), and only in social situations. Drinking is not used  to alter mood,  emotions,  deflect problems, or reduce stress.

A serious relationship characterizes the relationship of the almost alcoholic. The drinking level might include 3-4 drinks over a 2-3 hour period or probably enough alcohol to have  a blood alcohol level of between .02-.07.  Almost alcoholics can drink more or less but if they did so on a consistent bases then they would have a different relationship to alcohol.

Getting back to the frog, the line between a social and serious relationship can be subtle at first and be years in the making.

The committed relationship is for the true alcoholic.  I have dubbed this relationship as being at the “I can’t quit you” stage. A very serious problem.

Doyle and Nowinski do a very good job of highlighting almost alcoholic behaviors that the drinker either does not see as a problem or does not fully appreciate the role their alcohol use plays. Examples might be driving while slightly buzzed or having relationship problems that stem from being withdrawn or irritable after a few drinks.

While the first half of the book focuses on describing what is going on with the almost alcoholic, the second half is devoted to solutions. Unlike alcoholism where the solution must be sobriety because the very nature of the problem means that controlled drinking is not possible, the almost alcoholic can potentially moderate to the point where they can become social drinkers who then have a casual relationship to alcohol.

The authors correctly point out that many almost alcoholics, sobriety will be a preferred option. Many so-called “high bottom” alcoholics seen with greater frequency in recent years in AA may well be on the moderate to severe range of the almost alcoholic drinking scale.

In keeping with their idea that almost alcoholics differ from alcoholics only by degree, Doyle and Nowinski offer advice that is quite similar as to what many clinicains tell their alcoholic clients.

Chapters are devoted to helping people build a support system, change routines, learn how to refuse alcohol in social situations, cope with loneliness and boredom, deal with anger, guilt and resentment etc.

Almost Alcoholic provides a tremendous service by calling attention to an underserved, if not unrecognized population. I do not go along with the authors assertion that they are identifying a heretofore unrecognized population.

Where I believe the authors run into problems is in providing enough guidelines for dealing with the variance within the the almost alcoholic population. It is probably not for no reason the Doyle and Nowinski don’t come right out and just tell us how many almost alcoholics research suggests there are. If one reads carefully between the lines of Almost Alcoholic, there are over 30 million alcohol dependent people and 210 million almost alcoholics in the United States alone. This is fully 70%-80% of the United States population. There is a smell test problem here.

The authors state clinical judgement is needed in determining who qualifies as being almost alcoholic. However the sheer strength of the term “almost alcoholic,” which has powerful benefits when it helps someone to wake up to a drinking problem, can become a detriment. Without careful consideration, more guidance, and even nuance, the term “almost alcoholic” could describe the vast majority of the US population. If this conclusion is warranted, I’d like to see the evidence.

As helpers we need to be careful how we label. For example, might there be a group of people qualifying to be called  almost, “almost alcoholic?” And what is the opposite of being an almost alcoholic? Being almost not an alcoholic? Over-inclusion and over-attribution to a neglected problem is understandable, but is still not the best solution.

We need to identify situations where the “smoke” in the air will not cause undue harm if it is not treated. At the same time we should follow Doyle and Nowinski’s lead by realizing that early intervention often has the most benefit.

In the mean time I applaud the authors for their contribution and suggest to all of us, doing this work, to keep at it.

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