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Accountability for alcoholism in American families
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Pergamon
Sot'. Sci. Med. Vol. 40, No. I, pp. 15-25, 1995
0277-9536(94)00123-5
Copyright © 1994 ElsevierScienceLtd Printed in Great Britain. All rights reserved 0277-9536/95 $7.00 + 0.00
ACCOUNTABILITY FOR ALCOHOLISM IN AMERICAN FAMILIES LINDA A. BENNETT Department of Anthropology, The University of Memphis, Memphis, TN 38152, U.S.A. A~tract--Responsibility for alcoholism is examined within the context of families with an alcoholic parent. The perceptions of alcoholics and their spouses are discussed with respect to who or what is responsible for the etiology of alcoholism, the alcohol-related behaviors, and the consequences of the drinking in terms of the family's reaction to and the eventual resolution of the problem. In their attempt to understand the source of alcoholism and solutions to the problem, families draw upon different explanatory models of responsibility which frequently involve guilt, blame and shame. Brickman et al.'s theoretical framework for responsibility for helping and coping behaviors is applied to interview data from alcoholic families in the United States with respect to alcoholism. While these families typically do not hold the alcoholic responsible for the presence of the alcoholism in the first place, ultimately they do hold the alcoholic accountable for finding a solution to the alcoholism. Key words--alcoholism, family, responsibility, accountability, blame, shame, guilt
Alcoholism has surfaced as a major social and health problem at various times and places in modern history. American society is at such a juncture now [1]. Furthermore, alcohol and other drug addiction is perceived to be a destructive public health problem in most developed and developing countries [2, 3]. Amid widespread concern about alcoholism, two questions are inevitably raised: first, who or what carries the burden of responsibility for alcoholism? And second, what rationale is drawn upon to attribute responsibility for alcoholism? In this paper I propose some ideas for exploring the complex attribution of responsibility for alcoholism. In testing these ideas, I have applied them to a sub-set of in-depth interview data from a study of family cultural influences upon the well being of school aged children growing up in families with an alcoholic parent*. The multidisciplinary contributions from disciplines such as anthropology, psychiatry, psychology, sociology, epidemiology, economics and public health are particularly important for addressing individual, family, and wider cultural influences on prevailing beliefs about accountability for alcoholism. The emphasis of this analysis, however, is on a family-level cultural understanding of the roles of blame, shame, and guilt in attributing responsibility
for alcoholism in American society. Since the home environment is typically the initial context where children learn ideas and behaviors underlying concepts such as responsibility for alcoholism, this is a critical area to understand more clearly. In the paper, I combine a review of recent literature dealing with issues of accountability for alcoholism; the presentation of a theoretical framework for furthering our understanding of accountability and its component parts--blame, shame and guilt; and an examination of this framework in light of in-depth interview data collected from alcoholic families.¢
*A grant from the National Institute on Alcohol Abuse and Alcoholism, in part, supported the research upon which this paper is based. "tOut of concern for the anonymity of the families interviewed, no detailed profiles of the ten families are included in this paper.
With respect to macro-level fluctuations and transitions in drinking levels and alcoholism prevalence cross-culturally and over time, researchers from many disciplines have studied political, legal and economic trends. Some of these trends constitute
ss~ 40,t -B
STUDIES OF RESPONSIBILITY FOR ALCOHOLISM Three general approaches to questions of responsibility are represented in the burgeoning literature on alcoholism and alcohol-related problems: (1) in macro-level terms through examining international and national political and economic forces; (2) in mid-level terms through analyzing specific cultural contexts; and (3) in micro-level terms through considering individual, family and small group effects upon drinking patterns and problems.
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LINDAA. BENNETT
formal alcohol control policies [e.g. 4-7]. Anthropologists, however, have not taken a lead role in this research. Anthropologist Merrill Singer, in fact, argues that they have shied away from the hard questions regarding the impact of economic and political factors upon increased alcoholism rates, especially among the working classes during early periods of industrialization [8]. Thus, anthropologists, overall, have not tended to look to the wider political-economic structure for explanations of responsibility for high alcoholism rates. In contrast, considerable anthropological inquiry around drinking patterns and levels has been carried out within particular cultural settings [e.g. 9-13]. Anthropologists have focused mainly on intercultural and intracultural patterns and variation in drinking practices generally and, sometimes, specifically on drinking problems. Dwight Heath's review articles thoroughly document this genre of anthropological research [e.g. 14-16]. Thus, anthropologists have discerned responsibility for alcoholism within the incentives and constraints on drinking found within particular cultural contexts and in the value orientations of those societies regarding alcohol consumption and alcohol-related behavior [e.g. 17, 18]. These contexts provide informal alcohol controls on both consumption and drinking behavior. Micro-level influences on theories about responsibility for alcoholism only recently have garnered the sustained attention of certain anthropologists; most are from the field of medical anthropology and many conduct collaborative multidisciplinary research. Their work represents a link to a long scholarly tradition on studies of kinship and family within the discipline of anthropology [e.g. 19-23]. Responsibility for alcoholism at this level is investigated in terms of attributes--biological, personality, social, and experiential--of the individual and his/her family as well as groups that they come in contact with regularly. Such influences constitute a second sub-set of informal alcohol controls. While recognizing the critical importance of political-economic and sociocultural contextual pressures on drinking levels and alcohol-related problems, I consider microlevel informal controls on attitudes and behaviors toward drinking alcoholic beverages--and responsibility for its consequences--particularly powerful ones in the early development of children. It is also within this domain that husband and wife bring together two sets of ideas about alcoholism accountability from their families of origin at the time that they marry. Through the course of early marital development of a family identity and the socialization of their children, couples select certain societal norms about drinking alcoholic beverages and its consequences to become part of their family culture [22]. For these reasons, families warrant closer examination regarding responsibility for alcoholism, drinking-related behaviors and attendant consequences.
POST-WORLD WAR II CHANGES IN THE UNITED STATES
Since the Second World War, a notable shift has occurred in societal perceptions of alcoholism and the alcoholic [12, 13,24, 25]. At the national policy level since the passage of the Uniform Alcoholism and Intoxication Act in 1971, public intoxication has been decriminalized to a great extent [26]. Still, exceptions are obvious, especially among homeless people living in jurisdictions with no public detoxification centers. While we have witnessed a movement toward decriminalization of public drunkenness among non-drivers over the past two decades, since the early 1980s most states have passed stringent legal penalties for driving while under the influence of alcohol (DWIs or DUIs) [1]. A third post World War II trend is evident in the plethora of occupationally based efforts to intervene in alcohol-related problems, mainly through employment assistance programs (EAPs) [27, 28]. Finally, massive financial support has been allocated from federal sources and private insurance companies for alcoholism treatment [29, p. 336]. During the post-World War II era, American society has shifted from an emphasis on a moral model of alcoholism toward an affirmation of a medical or disease model [30-33]. Jellinek initiated this attitudinal change through his work and writings [30]. The American Medical Association reinforced this newly evolving view of alcoholism in 1956 when it labeled it a disease. Since then, the general public increasingly has come to view the behavior of someone addicted to alcohol--however undesirable---not so much as sinful, but instead as ill or sick behavior, "resulting from biological and social forces beyond an individual's control, rather than a display of personal immoral choice" [34, p. 34]. This transition is far from complete, however. American society still operates under the paradox that "The alcoholic is perceived by others to act with intention and choice, while he experiences within himself an explicit lack of intention and choice" [34, p. 34]. Furthermore, surveys indicate "that a substantial portion of the population perceives alcoholism as a moral weakness, with about half of these persons also agreeing with the notion that alcoholism is an illness" [32, p. 24]. Thus, many people are convinced that alcoholism is complex and is caused by both moral inadequacies and physical attributes of the individual. Howard Stein argues that while alcoholism is perceived to be a problem at a conscious level, it actually provides a solution to internal cultural ambivalence at the unconscious level [13, p. 203]. "Alcoholism reveals that such culturally ideological opposites as responsibility/ irresponsibility, control/out of control, order/ disorder, and the like are in fact dynamically two extremes of the same pole of ambivalence" [13, pp. 202-203].
Accountability for alcoholism in American families With the advancement of the disease model of alcoholism, the usefulness of blame and punishment as concepts is seriously questioned and at the same time the idea of individual responsibility for being alcoholic is also challenged. "Alcohol consists of a widely accepted pretext for the abdication of personal responsibility" [12, p. 358]. It appears that we are left with a vacuum of responsibility for behavior which many people view as extremely objectionable--especially drinking and driving--and extremely difficult to control [35-39]. It remains a real paradox. This paradox was nicely expressed in an interview conducted during the early 1980s in the home of a couple living outside Washington, D. C. The husband was critically ill due to excessively heavy drinking over a 40 year period. His wife described her coming to terms with what alcoholism is in this way: With drinking, you get to the point of saturation where you can't do anything about it, and it's affecting your life so much you try to push it away. There is only so much you can take, and then you don't want any more part of it. I've known for a few years that alcoholism is a disease, but the thing is how long can you live with a disease and go along as if it's all right. There is a point you get to and then, the hell with it, I've had enough and want no part of it because the disease is getting to you then [40, p. 195]. At its most extreme, the disease concept of alcoholism treats the alcoholic as a victim, someone who is not responsible for his or her own actions. Herbert Fingarette notes that people who advocate the classic disease model of alcoholism see "alcohol as a dominating necessity for the alcohol-dependent p e r s o n . . . In this view, alcoholics are victims of physiological and neurological abnormalities that cause uncontrollable behavior" [39, p. 32]. Generally, the American public is not ready to buy this argument in its entirety. Instead, people often say that alcoholism is a disease, while berating the alcoholic for his/her behavior. I believe we are stuck in our understanding of alcoholism. Instead of understanding alcoholism in its complexities, we mainly think in polemics. Perhaps this is due, in part, to the fact that the majority of Americans are directly familiar with alcoholism. Such experience can mislead them to believe that they are experts on alcoholism in its totality and that they do not need to look beyond personal experience for a fuller and more accurate point-of-view about the etiology and course of alcoholism. In our tendency toward polemic about alcoholism, on the one hand some people think the alcoholic is totally responsible for his or her alcoholism while at the opposite end of the spectrum, others hold society responsible. We need a more sound conceptual basis to provide an alternative to these two extremes which will take into account shared responsibility. As alcoholism has become transformed "from a sin to a sickness model, traditional concepts of alcoholism eliminated blame and punishment for the alcoholic,
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but also deeply confused and distorted the concept of responsibility" [34, p. 35], LOOKING TO FAMILIES F O R RESPONSIBILITY
In exploring these ideas about attribution of responsibility for alcoholism in American families, I have examined in-depth interview data from a sub-set of alcoholic families who took part in a study of family cultural influences upon the relative well being of school aged children [41, 42]. The group consists of the first ten alcoholic families interviewed out of a sample of 37. Each family discussed here was intact and middle class, had at least one biological child between the ages of 6 and 18, and lived in the Washington, D.C. area. I conducted two semi-structured interviews dealing with family culture jointly with husband and wife, at least one of whom was a currently drinking or recently recovering alcoholic or problem drinker, according to Goodwin et al. criteria [43]. The term alcoholism, as used throughout the paper, encompasses Goodwin's problem drinker and alcoholic categories; both categories take amount, frequency and duration of consumption into account, as well as negative consequences of the drinking. In addition to in-depth ethnic, religious and historical backgrounds of each couple's families of origin and nuclear family, I elicited extensive information about drinking and other drug use patterns over four generations of the family. The focus of the second interview was on family rituals such as dinner time, holidays, vacations, family celebrations and the role of alcohol and alcoholism in each ritual. The methods and results of this research are reported elsewhere [41, 42]. In brief, we found that: (1) children in non-alcoholic families are functioning better behaviorally, cognitively, and emotionally than their counterparts in alcoholic families [41]; and (2) certain family culture characteristics--such as deliberately planning and carrying out family ritual observances--mediate between parental alcoholism and the children's relative well being [42]. I organize responsibility regarding alcoholism into three domains: first, the cause of the problem, or its etiology; second, the f o r m of the problem or the undesirable behavior exhibited by the alcoholic under the influence of alcohol; and third, the consequence of the drinking behavior in terms of its impact on other people and the action or recourse taken to respond to the problem. Several confounding conditions confuse any clear characterization of responsibility for familial alcoholism. Different members of the family may hold varying points of view. For example, one sibling may seem to be oblivious to any negative effects of his father's drinking while another sibling may be extremely angry that her father does not participate
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L1NDAA. BENNETT
fully in family activities. Yet another sibling may be relieved to have the father absent from most family events. Furthermore, any particular person may express different perspectives on the problem, depending on immediate circumstances and/or ambivalent thinking generally. After all, the precise border between 'normal' drinking and 'problem' or 'alcoholic' drinking is seldom clear, even in hindsight. Instead, a large grey area often exists through the course of alcoholism where it is difficult for someone outside looking in on the alcoholic's behavior and thoughts to know with certainty when a problem has definitely emerged. Finally, change is a natural part of family development and the life course of alcoholism. Depending on the time we enter the alcoholic family, we may hear very different accounts about responsibility by family members. For example, conversations with an alcoholic during the time he or she is still drinking and then during recovery are very likely to present discrepant points of view, in spite of the fact that he/she may genuinely attempt to be both lucid and honest. CONCEPTS OF RESPONSIBILITY,GUILT, BLAME A N D SHAME Just what is meant by responsibility for alcoholism? It implies accountability for the condition. Responsibility can refer to the state of being an alcoholic, the behavioral and/or health consequences of drinking, and efforts to take control of the problem. One of the criticisms leveled against the disease model is that it discourages an alcoholic from taking responsibility for becoming dependent upon alcohol and from doing anything about it [38, p. 331]. Fingarette offers a constructive analysis of this issue in his discussion of the heavy drinker's willpower and responsibility for coming to grips with the drinking: If our righteous condemnation is not in order, neither is our cooperation in excusing heavy drinkers or helping them evade responsibility for change. Compassion, constructive aid, and the respect manifest in expecting a person to act responsibly--these are usually the reasonable basic attitudes to take when confronting a particular heavy drinker who is in trouble... There is no more validity in putting the entire burden of successful change on the drinker's goodwill than in absolving him of all responsibility as though he were helpless [39, p. 112]. Responsibility for alcoholism can lie within the alcoholic, within wider sociocultural forces, among other family members, within personal experiences or through a combination of such influences. The notion that someone or something could have done something differently, thereby resulting in another outcome, is implied. The potential power of a predisposition to become alcoholic due to biological/genetic reasons carries much currency in the United States [e.g. 44--48]. The proposition that 'An alcoholic is born an alcoholic' represents a highly fatalistic expression of this view. Alcoholism researchers rarely take such a narrow perspective.
Although most researchers prefer to study either predisposing (biological, genetic) or precipitating (cultural, experiential, environmental) factors, most recognize the complex interplay between multi-factorial influences on the etiology of alcoholism [49].
The Brickman et al. responsibility model Philip Brickman and his colleagues offer a theoretical framework for understanding helping and coping behaviors which is useful for examining attribution of responsibility for alcoholism [35]. Within this framework, they distinguish between responsibility for the origin of a problem and its solution. They delineate four models of responsibility and the position of control within each, all of which can apply to alcoholism accountability. In the moral model the person is considered responsible for both the problem and its solution. According to this model "drinking is seen as a sign of weak character, requiring drinkers to exercise willpower and get control of themselves in order to return to sobriety and respectability" [35, p. 370371]. Of all four models, the moral model implies the ultimate accountability to the individual for his/her own drinking and recovery from addiction. In contrast, the compensatory model does not hold the person responsible for the problem, but does expect him/her to find a solution for it. Thus, an alcoholic would look to forces outside him/herself for understanding how dependence on alcohol developed, but would feel compelled to take control of the drinking. When successful, they are given considerable credit for resolving the problem while still not being blamed for its cause. According to the medical [disease] model, the person is accountable for neither the problem nor the solution. One advantage of this model for alcoholics is "that it allows people to claim and accept help without being blamed for the weakness" [35, p. 373]. On the other hand, it can also foster dependency. Much as with diseases like tuberculosis or cancer, blame for alcoholism is not attributed to anyone [13, p. 226]. A potential value of such a perspective is that it can help alcoholics free themselves from "excessive, irrational, and self-defeating guilt," thereby helping with problems such as "low self-esteem, shame, and self-disgust, all of which are likely to drive them back into drink if not resolved" [38, p. 331]. Finally, in the enlightenment model, the person is not responsible for the solution, but is responsible for the problem itself. Alcoholics Anonymous, according to Brickman et al. draws mainly upon this idea in its philosophy and method in that it "explicitly requires new recruits both to take responsibility for their past history of drinking (rather than blaming it on a spouse, a job, or other stressful circumstances) and to admit that it is beyond their power to control their drinking" [35, p. 374). Alcoholics Anonymous and a community of recovering alcoholics can provide the external resources necessary to attain and maintain sobriety.
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Accountability for alcoholism in American families
Shame, guilt and blame are common responses to irresponsibility. Table i shows the various conditions under which we can expect the alcoholic to experience shame, guilt and blame according to each of the Brickman et al.'s four responsibility models. They are most likely to emerge when the alcoholic, his/her family and friends, and the wider society subscribe to a moral model of alcoholism. At the other extreme, if they endorse the medical/disease model, the alcoholic is least likely to feel shame, guilt or blame. In the compensatory model, these emotional reactions are most likely to emerge if the alcoholic does not achieve a successful solution to the problem. In contrast, in the enlightenment model, we anticipate the appearance of blame, shame and guilt only for the presence of the problem. Later in the paper I examine these emotional reactions with respect to familial attribution of responsibility for etiology, behavior and consequences of the alcoholism. According to Webster, shame is "a painful feeling of having lost the respect of others because of the improper behavior, incompetence, etc. of oneself or another" [43, p. 1232]. In the case of a family with an alcoholic parent, the alcoholic may feel shame for being alcoholic, for behaving in certain ways under the influence of alcohol, or for not achieving and maintaining sobriety. Similarly, family members may feel shame on behalf of the alcoholic and/or due to shared membership in an alcoholic family. When the mother is an alcoholic, she may worry especially about the effect of her drinking upon homelife and the children [21]. Shame can take the form of embarrassment on the part of a spouse of an alcoholic with regard to what other family members or friends think: "His family became aware of his drinking, and they expected me to insist that he stop. When he
didn't, it got to be really embarrassing for me when we would see them." Guilt is inner-directed and, like shame, is highly distressing: "A painful feeling of self-reproach resulting from a belief that one has done something wrong or immoral" [43, p. 600]. One husband described his feelings of guilt while when attending a recovery program while he was still drinking: "I must have worked there seven straight days, all the time masquerading as a non-alcoholic. I felt so awful." While we might typically expect the alcoholic to be the one to experience guilt, children and a non-alcoholic spouse often feel guilty about the drinking because they see themselves as responsible in some way. Blame, also a common occurrence in alcoholic families, involves accusation or fault-finding. The object of accusation can be the self, someone else or something else. Very often a spouse or a child of an alcoholic heavily blames the alcoholic parent. One of the couples interviewed repeatedly noted that their older son was very angry about his father's drinking, in contrast to his brother who did not want to hear about it or discuss it. Parents in recovery frequently worry about the effect of their prior drinking upon their children's development and blame themselves for any possible ill effects. As one non-drinking alcoholic mother said, "I felt more and more useless . . . I am very proud of my kids; they are really neat people, and I hope I haven't screwed them up that much." In contrast, blame is sometimes directed toward a hypothesized genetic predisposition, rather than other attributes of the alcoholic. It arises when we try to determine whether the cause is internally or externally derived [35, p. 369]. In reviewing the interview data for these 10 families, I found that all of them evidenced at least some blame, shame and guilt in their attempts to
Table 1. Brickman et al. responsibility models: association with shame, blame and guilt Alcoholic responsible for:
Moral model
Problem?
or Solution?
yes
yes
Presence of problem Absence of problem Successful solution Unsuccessful solution
Compensatory model
no
no
Blame?
++
++
++
++
++
++
- -
+
- -
++
++
++
no
Presence of problem Absence of problem Successful solution Unsuccessful solution
Enlightenment model Presence of problem Absence of problem Successful solution Unsuccessful solution + + , Strong positive association. + , Positive association. - - . No strong association.
Guilt?
yes
Presence of problem Absence of problem Successful solution Unsuccessful solution
Medical/disease model
Model associated with: Shame?
m m yes
no ++
++
++
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LINDAA. BENNETT
resolve the question of who or what was responsible for the alcoholism. Beyond this general observation, however, there was great variation in which particular members mainly felt these emotions. While in some families the alcoholic felt both shame and guilt, in others the non-alcoholic spouse felt these emotions strongly and the alcoholic did not. Furthermore, the relative emphasis on these emotional responses often depends on the drinking status of the alcoholic parent. For example, there was a strong tendency for the alcoholic to feel guilt while drinking, but those feelings would gradually dissipate upon cessation from drinking. In contrast, a non-alcoholic spouse might lay blame on the alcoholic spouse only during the drinking period. And children--once they became aware of the parent's drinking--often would be ashamed of the parent's behavior while drinking, but lose this sense of shame during abstinence. While it was more often the case that the alcoholic parent would feel both guilt and shame while drinking, some seemed to think that their families overreacted: "My wife has a tendency to be an alarmist . . . As unreasonable as I was about my drinking, you could make a fair case that she was equally unreasonable in overreacting." In short, the specific patterns of shame, blame and guilt with regard to attribution of responsibility for alcoholism in these families are tremendously variable. FAMILY ACCOUNTABILITY FOR ETIOLOGY
To explore the role of shame, guilt, and blame in attributing responsibility for alcoholism with respect to the three dimensions mentioned earlier----etiology, behavior and consequences--I have reviewed the transcripts for the 10 couples interviewed in their entirety. To begin with, I looked for thoughts expressed by either spouse regarding why the alcoholism developed in the first place. N o one suggested that etiology was due directly to biological makeup. Instead, five types of precipitating influences were described as being coterminous with an increase in drinking: (I) (2) (3) (4) (5)
family pressure to drink or not to drink; a traumatic life experience; occupational situation; emotional problems within the family; and 'loving alcohol'.
With respect to this last influence--which might be indirectly attributed to some biological influences-one recovering alcoholic wife stated: "I used to love to drink." A recovering alcoholic husband similarly explained: "I loved the stuff from the start." Although most family pressure regarding alcohol consumption discouraged drinking, occasionally alcoholic parents described pressures from family members to drink. In one family where both the husband and wife were recovering alcoholics, the couple "aided and abetted each other" in their continuing
alcohol consumption. In a second where both spouses had been drinkers and where abstinence came earlier for the husband, the wife felt personally rejected and renounced by her husband when he stopped drinking. She had encouraged him to drink and never expressed disapproval. In addition to his wife's pressure to drink, the husband was urged to drink by his father-also an alcoholic---during his recovery. Thus, in some families other family members--alcoholic or n o t - can actually make it difficult to stop drinking. I have found this to be very much the case in former Yugoslavia also where wider cultural patterns so firmly support a positive value toward heavy drinking---especially among men--such that the pressures to drink within and without the family can be extremely compelling [50]. More typically, though, the non-alcoholic spouse pressures the alcoholic to stop drinking, often with little success. For one husband in this study, to have his wife tell him before a social event that he should moderate his drinking was enough to precipitate him to drink even more since he "didn't like to be told what to do." In most families in this and two earlier studies we have conducted on familial alcoholism [51, 52], the non-alcoholic spouse used a wide assemblage of strategies to cajole the husband (most often) into curtailing his drinking. Couples did note one particular impetus to drink from the wider political-social context: the Vietnam War. The war experience repeatedly came to the fore in discussions with one couple; they identified this as the time when the husband began drinking with a vengeance. He began describing his experience well over a decade earlier in the present tense: "Vietnam changes the life of everyone who goes through it. I don't suppose I am the same person I was before I went over. It made indelible changes in my psyche. A lot of drunks came back from Vietnam." Several interviewees in our three studies pointed to military experience, in general, and Vietnam, in particular, as the time when they began to drink particularly heavily. Other couples reported similar, though less traumatic, life events which led to substantially increased drinking. One husband described the joint impact of moving from one state to another where the drinking laws were more liberal, taking a job in which his work peers regularly drank together, and playing music with a heavy drinking group as factors coming together to provide the added incentive to drink to the point of becoming an alcoholic. Another husband also connected a change in position and permissive open drinking on the job as one--though not the only--reason for the decisive increase in his drinking. Emotional problems in the family--other than having to do directly with the alcoholism--were seen as tied closely to accelerated drinking leading to alcoholism, especially among the women. One mother lamented, "We started having trouble with our son, and it was exceedingly painful to me
Accountability for alcoholism in American families emotionally. So the drinking progressed to the point of putting myself on ice so I wouldn't feel anything." The alcoholics and their spouses in this study are impressive in their willingness and ability to depict internal and interpersonal struggles with drinking in order to come to grips with the problem. Listening to their accounts of the natural history of alcoholism in their families, we might view them with skepticism, as though they are trying to find excuses, rather than to offer solid explanations. Given our imperfect knowledge and understanding of what makes an alcoholic an alcoholic beyond having to drink to become addicted, much can be learned by listening carefully to the language used by the still drinking and recovering alcoholics and their spouses and children to better understand the attribution of responsibility for alcoholism and its consequences. Contrary to the opinion that alcoholics and their families spend much of their lives in denial [13], I believe it is more accurate to see them as employing varying cognitive and behavioral strategies to grapple with the problem and try to do something about it. Alcoholism, as I noted earlier, is insidious in part because we live in a place and age where drinking 'moderately' is considered the norm for most adults. Only when we behave in unacceptable ways while drinking---such as driving with a blood alcohol level above tile legal limit, when we drink at inappropriate times or places, or when we develop serious health problems--are we taken to task for our drinking. In short, at that point we become irresponsible drinkers. In trying to find explanations for the etiology of alcoholism, these families fit the Brickman et al. compensatory model of responsibility best. Rather than focusing upon attributes of the alcoholic as causing the problem, both spouses tend to look to the situations in which the alcoholic finds him/herself as providing the extra incentives needed to transform heavy drinking to problem drinking or alcoholism. Since the direction of their attention is away from the alcoholic, little shame and guilt are felt by the alcoholic with regard to the etiology itself. This suggests that from the point of view of the couple, the absence of informal alcohol controls in the alcoholic's environment are particularly instrumental in the development of the alcoholism. They can, in fact, be blamed for the problem, at least to a moderate degree (see Table 1). Financial or legal considerations--typically within the province of formal alcohol controls--are barely mentioned in these interviews. FAMILY A C C O U N T A B I L I T Y FOR T H E A L C O H O L I C ' S O B J E C T I O N A B L E BEHAVIOR
Families focus more on the negative behavior of the alcoholic under the influence of drink than they do on concerns about how the problem
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evolved in the first place. Anyone who either has lived with an alcoholic, has studied familial alcoholism in depth, or has worked clinically with alcoholic families is very familiar with objectionable drinking behaviors. These behaviors, however, typically vary from alcoholic to alcoholic and for a given alcoholic over time. Couples identified three types of alcohol-related behaviors as being particularly troublesome for the family: (1) not doing something he/she was expected to do; (2) doing something intrusive or unpleasant; and (3) 'becoming' someone different temperamentally. For the first category--failure to carry out expected responsibilities--couples frequently cited instances such as coming home late, forgetting obligations, avoiding family activities, neglecting housework and generally shirking regular duties to the family. One wife expressed her continuing distress with her husband's tardiness, especially at dinner times: "As his drinking progressed, the time he got home for dinner got later and later." Even at the time of the interview, the husband did not view this as a major fault, suggesting that, "It's much more preferable for them to go ahead instead of arguing about having to delay dinner for me." In another family, the wife was extremely alarmed about her husband's lateness in coming home at all. She explained, "I would never know what time of the day or night he was going to come home. A couple of times he stayed out all night. And he would always come home totally polluted." Her husband offered no excuses for his behavior, and rather, described himself while drinking as "totally irresponsible. It was a vicious circle. When I sobered up, I had guilt feelings about neglecting my wife and the kids, and then I drank some more." While wives of alcoholic husbands were typically distraught about their husband's lateness for or absence from normal family activities, husbands of alcoholic wives often focused their remarks on the deterioration of the home and the wife's neglect of 'her duties.' One husband remarked that he "was taking on more and more of the household chores" as her drinking progressed, and he was not at all pleased by that. Although sins of omission--as described above seriously troubled families, and sometimes very deeply, intrusive or offensive behaviors of the alcoholic parent drew particularly strong criticism, especially when they involved the children. While verbal misbehavior was often reported, couples only occasionally described physical violence under the influence of alcohol; and this was usually expressed in veiled terms. In one family, the husband acknowledged that "I was physically violent and abusive. I consistently overreacted to problems . . . When I was
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under the influence of alcohol, I was more likely to r e a c t . . , in a much stronger way than I do when I'm not drinking." His wife concurred. More commonly, though, the alcoholic parent was verbally abusive. One wife reported that when her husband was drinking, he became "very belligerent (but not physically so), sarcastic, cynical, sometimes downright nasty." Another husband acknowledged that he tended to be hard on his children under the influence of alcohol: "If I haven't been drinking, I'm not as likely to be as critical." In contrast, he was more congenial when he was not drinking. 'Becoming' a different sort of person often goes hand-in-hand with such offensive behavior in that in becoming transformed into a new persona under the influence of drink, the alcoholic frequently perpetrates major transgressions. However, the change in demeanor itself--aside from, untoward behaviors--would often alarm the rest of the family. One husband could always tell when his wife had "a little buzz on" since drinking made her quite hostile. This, in turn, made him and the children very uneasy. In contrast, another husband described himself as becoming "quiet and withdrawn" when drinking. Sometimes families did not make a clear connection between drinking and modifications of behavioral style. In fact, when chronic emotional problems-such as depression---coincide with alcoholic drinking, families have a difficult time distinguishing the two. Referring to his wife's drinking, one husband explained, "I thought what I was seeing was due to pathological anger and depression. I didn't associate it with drinking." This is not particularly surprising since alcoholism and depression, in particular, are often closely intertwined [53]. When it comes to the family's perspective on the offensive behavior of the alcoholic, they conform more to Brickman et al.'s moral model of responsibility for alcoholism. The family wants the alcoholic to take control of his/her behavior first and foremost, and it tends to lay blame on his/her inability to behave in acceptable ways. Even the alcoholic tends to stress his/her negative actions more than the source of the problem. They often point to their feelings of guilt for either not doing the right thing and for doing the wrong thing: "I felt so awful for being such a fraud . . . I was abandoning her and the kids" and "I had guilt feelings about neglecting her and the kids" (two different husbands). While the alcoholic spouse typically feels guilty about his/her actions, the non-alcoholic spouse was more likely be ashamed of the alcohol-related behavior. One wife reported, "I feel so embarrassed by his behavior when he is drunk that I won't go to parties with him anymore." In short, the alcoholic is most likely to experience guilt for drinking-related behaviors, while other family members are the ones to lay blame on and to feel shame about the actions of the alcoholic.
FAMILY ACCOUNTABILITY FOR THE CONSEQUENCES OF THE DRINKING
When we examine the consequences of these behaviors, we get glimpses into the use of guilt, shame and blame in the family's attempt to make sense of irresponsibility of the alcoholic parent. A wide range of outcomes was reported, including: worry, embarrassment, tension, being upset, confusion, apprehension, alarm, concern, anger, nagging, disgust and hysteria. Overwhelmingly, the most common response by the family--especially the spouse--was anger. This was clear in the following statement: "There was a lot of anger in the house. We were all angry at one another. It was just a terrible time." In one family, the husband became depressed and often forgot his obligations to the family. He felt guilty about being irresponsible. In contrast, his wife was "mad as hell." She would wake him up in the middle of the night and confront him about his drinking. He sought treatment for his alcoholism on his own and was taking his recovery extremely seriously. In planning an upcoming work-related trip, he thought a lot about how he could maintain his sobriety even under pressures to drink from coworkers: "I'm going to have to use every reinforcement I know to make sure I don't drink. If I have antabuse, that's an absolute guarantee. It is a tempting situation." Another couple presents a very different sort of picture. The husband, who was still drinking at the time of the interview, was described as being antagonistic and superior acting to his wife and children. As a consequence, his wife was embarrassed, upset and disappointed in him. She expressed both shame and blame. One son was also very angry, blaming his father for the unpleasant family environment. The father himself recognized that "alcoholism is the big problem, but not the most fundamental one" and did not appear to feel particularly guilty about his drinking. In one family where the wife was alcoholic--in recovery at the time of the interview--she felt useless as she was less able to take care of the housework on a regular basis. Her husband blamed her for drinking and for not taking care of the home; he nagged at her, but did not directly confront her. When she stopped drinking, he was relieved. When we think of guilt as a response to alcohol-related behavior, we might logically think that the alcoholic would be the one to experience guilt. This is not always the case, as indicated in the following contrast between two couples. In the first, the alcoholic husband used to stay out all night, much to his wife's consternation. This would upset and concern her, but she did not directly confront him over his drinking. He felt guilty about being totally irresponsible and neglecting his family even though he continued to work. Eventually he stopped drinking on his own. While these alcoholics and their families may look to external influences to help explain the origins
Accountability for alcoholism in American families of alcoholism, they tend to look first within themselves for finding solutions to the problem. In another family, the husband became quiet and withdrawn, passive, and a non-participant in family activities. This put his wife in a bad mood, and she would fight with him about it. However, she began to wonder if there was something wrong with her interpretation of what was happening. And then she began to feel guilty for her husband's drinking and the consequences of his drinking. At the time, he was in recovery, and the family was in family therapy and, in retrospect, had a pretty firm grasp of their experience with the father's alcoholism. Not surprisingly, the family where the father became both verbally abusive--not unusual in these families--and physically violent--which is unusual in these particular families--the mother became angry, disgusted and self-righteous. She left him at one point and repeatedly confronted him. The husband viewed alcoholism as the basic problem in the home and was struggling to abstain from alcohol, but with little Success.
Spouses of alcoholics are often haunted by the question of what response on their part might make a difference in the drinking behavior and its consequences upon the family. In particular, does confrontation of the drinking work? Direct confrontation by other family members of the alcoholic parent occurred in four of the ten families. In two of these cases, the drinking was still going on at the time of the interview; in the other two, the drinking had stopped. As far as these particular families are concerned, confrontation in and of itself does not seem to provide the necessary stimulus for the alcoholic to stop drinking. Instead, reportedly, the alcoholic had to come to terms with the drinking him/herself, decide that it had gotten way out of hand, and that there were good reasons to stop drinking before a solution could be reached. The two main eventual consequence of the alcoholrelated behavior in these families are: (1) solution of the problem through taking control of the drinking (usually, but not always abstinence); or (2) e x t r u s i o n of the alcoholic member. In this regard, the compensatory model best applies. If the alcoholic does not take charge him/herself, the family itself may feel responsible for doing something about the problem. Extended family members may take a stand on what the non-alcoholic spouse should do: "His parents knew about his drinking. They were after me to do something about it. They told me to put my foot down." She did, and the couple separated for a year, then reconciliated after he stopped drinking and began to get clinical help. In most of these families, though, the alcoholic parent was the one to find a solution to the drinking. One alcoholic wife recalled, "I guess it was about a SSM 40 I--C
23
year ago when I realized I was totally out of control. Booze was not the answer any longer. So I just quit." Sometimes they make these decisions because they know the family will no longer accept their drinking behavior: "My husband realized that he would either have to stop that behavior or there would be no marriage." CONCLUSION
Where does this leave us in our understanding of the attribution of responsibility for alcoholism? Returning to the initial question raised as to who or what is responsible for alcoholism, I suggest that these families arrive at different answers depending on whether they are considering the cause of alcoholism in the first place, the drinking-related behaviors, or the consequences in terms of a final solution to the problem. Accountability for the origins of alcoholism--its etiology--is diffuse in these families' perspectives. Responsibility lies primarily outside the family and certainly is not lodged totally within the alcoholic's biological makeup or personality. However, the alcoholic is held responsible for his/her behavior under the influence of alcohol. And finally, the family shares responsibility with the alcoholic in terms of the consequences of the drinking and efforts to resolve the problem. When we examine these families' perspectives within the context of Brickman et al.'s four models (moral, compensatory, medical/disease and enlightenment), the moral and compensatory models are most congruent with the reports of these ten families with regard to alcoholism accountability. Although the alcoholic is n o t held accountable for the origins of the alcoholism (thereby conforming to the compensatory model), he/she is held responsible for alcohol-related behavior (moral model) and for finding a solution to the problem (compensatory model). As a result, considerable blame, shame and guilt are associated with unsuccessfully finding a solution, while the etiology of the problem in the first place is associated with almost no shame and guilt and only a moderate amount of blame (mostly toward events and situations external to the alcoholic). The medical/disease and enlightenment models do not readily apply to these families because they see finding a solution to the problem as being within the alcoholic's area of responsibility (contrary to both of these models) and because families do not attribute responsibility for the presence of the problem in the first place to the alcoholic (contrary to the enlightenment model). The fact that we remain in a quandary as to who or what is responsible for alcoholism should not come as a big surprise. This is probably a much more responsible position to take than to become locked into either a moral model whereby blame, shame and guilt are laid solely at the feet of the alcoholic or a disease/medical model in which the alcoholic is not
LINDA A. BENNETT
24
held responsible. Becoming a n a l c o h o l i c - - i n m o s t i n s t a n c e s - - o c c u r s t h r o u g h a long gradual process during which m a n y forces come together in the alcoholic's m o v e m e n t t h r o u g h the grey area of ambiguous heavy drinking a n d across the threshold into alcoholic drinking. Guilt, blame, a n d s h a m e are u n d e r s t a n d a b l e - - i f not usually 'successful' responses to the uncertain course o f alcoholism.
21.
22. 23.
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24. 1. National Institute on Alcohol Abuse and Alcoholism. Seventh Special Report to the U.S. Congress on Alcohol and Health. U.S. Department of Health and Human Services, Rockville, MD, 1990. 2. World Health Organization. Program on Substance Abuse: Strategy Document. WHO, Geneva, 1990. 3. Maula J., Lindblad M. and Tigerstedt C. Alcohol in Developing Countries. Nordic Council for Alcohol and Drug Research, Helsinki, Finland, 1990. 4. Rumbarger J. J. Profits, Power, and Prohibition. State University of New York, Albany 1989. 5. Marshall M. and Marshall L. B. Silent Voices Speak: Women and Prohibition in Truk. Belmont, California, Wadsworth, 1990. 6. Moore M. H. and Gerstein D. R. (Eds) Alcohol and Public Policy: Beyond the Shadow o f Prohibition. National Academy Press, Washington, D.C. 1981. 7. Single E., Morgan P. and de Lint J. Alcohol, Society, and the State 2: The Social History o f Control Policy in Seven Countries. Addiction Research Foundation, Toronto, Canada, 1981. 8. Singer M. Toward a political-economy of alcoholism: The missing link in the anthropology of drinking. Soc. Sei. Med. 22, 113, 1986. 9. Bennett L. A. and Ames G. M. (Eds) The American Experience with Alcohol: Contrasting Cultural Perspectives. Plenum, New York, 1985. 10. Douglas M. (Ed.) Constructive Drinking: Perspectives on Drink from Anthropology. Cambridge University Press, Cambridge, 1987. 11. Marshall M. Weekend Warriors: Alcohol in a Micronesian Culture. Mayfield, Pain Alto, 1979. 12. Stein H. F. Ethanol and its discontents: Paradoxes of inebriation and sobriety in American culture. J. Psychoanalyt. Anthrop. 5, 355, 1982. 13. Stein H. F. Alcoholism as metaphor in American culture: Ritual desecration as social integration. Ethos 13, 195, 1985. 14. Heath D. B. Anthropological perspectives on alcohol: an historical review. In Cross-cultural Approaches to the Study o f Alcohol: An Interdisciplinary Approach (Edited by Everett M. et al.). Mouton, The Hague, 1976. 15. Heath D. B. Cross-cultural studies of alcoholism. In Recent Developments of Alcoholism (Edited by Galanter M.). Plenum, New York, 1984. 16. Heath D. B. A decade of development in the anthropological study of alcohol use, 1970-1980. In Constructive Drinking (Edited by Douglas M.). Cambridge University Press, Cambridge, 1987. 17. MacAndrew C. and Edgerton R. B. Drunken Comportment: A Social Explanation. Aldine, Chicago, 1969. 18. Peele S. A moral vision of addiction: How people's values determine whether they become and remain addicts. J. Drug Issues 17, 187, 1987. 19. Ablon J. The significance of cultural patterning for the alcoholic family. Family Process 19, 127, 1980. 20. Ablon J. Irish-American Catholics in a West Coast Metropolitan Area. In The American Experience with
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Alcohol (Edited by Bennett L. A. and Ames, G. M.). Plenum, New York, 1985. Ames G. M. Middle class Protestants: Alcohol and the family. In The American Experience with Alcohol (Edited by Bennett L. A. and Ames G. M.). Plenum, New York, 1985. Bennett L. A. Family, alcohol, and culture. In Recent Developments in Alcoholism (Edited by Galanter M.). Plenum, New York, 1989. Holmila M. Wives, Husbands, and Alcohol: A Study of Informal Drinking Control within the Family. The Finnish Foundation for Alcohol Studies, Helsinki, 1988. Tropman J. E. Conflict in Culture: permissions versus Controls and Alcohol Use in American Society. University Press of America, Lanham, MD, 1986. Anthony J. S. Drug abuse as a forensic issue. Am. J. Forensic Psychol. VI, 29, 1988. Garrett G. R. Alcohol problems and homelessness: history and research. Contemporary Drug Problems Fall 301, 1989. Roman P. M. Growth and transformation in workplace alcoholism programming. In Recent Developments in Alcoholism, Vol. 6 (Edited by Galanter M.). Plenum, New York, 1988. Trice H. and Roman P. Spirits and Demons at Work: Alcohol and Other Drugs on the Job, 2nd edn. Publications Division of the New York State School of Industrial and Labor Relations at Cornell University, Ithica, New York, 1978. Segal B. Drugs and Behavior: Causes, Effects, and Treatment. Gardner, New York, 1988. Jellinek E. M. The Disease Concept of Alcoholism. Hillhouse, Highland Park, New Jersey, 1960. Ames G. M. American beliefs about alcoholism: historical perspectives on the medical-moral controversy. In The American Experience with Alcohol (Edited by Bennett L. A. and Ames G. M.). Plenum, New York, 1985. Roman P. M. The disease concept of alcoholism: sociocultural and organizational bases of support. Drugs and Society 2(3/4), 5, 1988. Room R. Sociology and the disease concept of alcoholism. In Recent Advances in Alcohol and Drug Problems, Vol. 7(Edited by Smart R. G., Glaser F. B., Israel Y., Kalant H., Popham R. and Schmidt W.). Plenum, New York, 1983. Pattison E. M., Sobell M. B. and Sobell L. C. Emerging Concepts of Alcohol Dependence. Springer, New York, 1977. Brickman P., Rabinowitz V. C., Karuza J. Jr, Coates D., Cohn E. and Kidder L. Models of helping and coping. Am. Psychol. 37, 368, 1982. Hill S. Y. The disease concept of alcoholism: a review. Drug and Alcohol Dependence 16, 193, 1985. Miller N. S. and Gold M. S. The disease and adaptive models of addiction: a re-evaluation. J. Drug Issues 20, 29, 1990. Wallace J. A biopsychosocial model of alcoholism. Soc. Casework 6, 325, 1989. Fingarette H. Heavy Drinking: The Myth of Alcoholism as a Disease. University of California Press, Berkeley, 1988. Bennett L. A. and Wolin S. J. Family culture and alcoholism transmission. In Alcohol and the Family: Research and Clinical Perspectives (Edited by Collins R. L., Leonard K. E. and Searles J. S.). Guilford Press, New York. Bennett L. A., Wolin S. J. and Reiss D. Cognitive, behavioral, and emotional problems among schoolage children of alcoholics. Am. J. Psychiat. 145, 185, 1988.
Accountability for alcoholism in American families 42. Bennett L. A., Wolin S. J. and Reiss D. Deliberate family process: a strategy for protecting children of alcoholics. Br. J. Addiction 82, 821, 1988. 43. Goodwin D. W., Schulsinger F., Hermansen L. et al. Adoptees raised apart from alcoholic biological parents. Arch. Gen. Psychiat. 28, 238, 1973. 44. Fillmore K. M. The 1980's dominant theory of alcohol problems--genetic predisposition to alcoholism: where is it leading us? Drugs and Society 2(3/4), 69, 1988. 45. Goodwin D. W. Is Alcoholism Hereditary? Oxford University Press, New York, 1976. 46. Goodwin D. W. Alcoholism and genetics. The sins of the fathers. Arch. Gen. Psychiat. 42, 171, 1985. 47. Begleiter H., Porjesz B., Bihari B. and Kissin B. Eventrelated brain potential in boys at risk for alcoholism. Science 225, 493, 1984.
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48. Cloninger C. R., Bohman M. and Sigvardsson S. Inheritance of alcohol abuse. Arch. Gen. Psychiat. 38, 861, 1981. 49. Straus R. Interdisciplinary biobehavioral research on alcohol problems: a concept whose times has come. Drugs Society 2(3/4), 33, 1988. 50. Bennett L. A. Treating alcoholism in a Yugoslav fashion. East Eur. Q. XVlli, 495, 1985. 51. Wolin S. J., Bennett L. A., Noonan D. L. and Teitelbaum M. A. Disrupted family rituals: a factor in the intergenerational transmission of alcoholism. J. Stud. Alcohol 41, 199, 1980. 52. Bennett L. A., Wolin S. J., Reiss D. and Teitelbaum M. A. Couples at risk for transmission of alcoholism: protective influences. Family Process 26, l l l, 1987. 53. Woodruff R., Guze C. P. and Carr D. Alcoholism and depression. Arch. Gen. Psychiat. 28, 97, 1973.
Pergamon
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ACCOUNTABILITY FOR ALCOHOLISM IN AMERICAN FAMILIES LINDA A. BENNETT Department of Anthropology, The University of Memphis, Memphis, TN 38152, U.S.A. A~tract--Responsibility for alcoholism is examined within the context of families with an alcoholic parent. The perceptions of alcoholics and their spouses are discussed with respect to who or what is responsible for the etiology of alcoholism, the alcohol-related behaviors, and the consequences of the drinking in terms of the family's reaction to and the eventual resolution of the problem. In their attempt to understand the source of alcoholism and solutions to the problem, families draw upon different explanatory models of responsibility which frequently involve guilt, blame and shame. Brickman et al.'s theoretical framework for responsibility for helping and coping behaviors is applied to interview data from alcoholic families in the United States with respect to alcoholism. While these families typically do not hold the alcoholic responsible for the presence of the alcoholism in the first place, ultimately they do hold the alcoholic accountable for finding a solution to the alcoholism. Key words--alcoholism, family, responsibility, accountability, blame, shame, guilt
Alcoholism has surfaced as a major social and health problem at various times and places in modern history. American society is at such a juncture now [1]. Furthermore, alcohol and other drug addiction is perceived to be a destructive public health problem in most developed and developing countries [2, 3]. Amid widespread concern about alcoholism, two questions are inevitably raised: first, who or what carries the burden of responsibility for alcoholism? And second, what rationale is drawn upon to attribute responsibility for alcoholism? In this paper I propose some ideas for exploring the complex attribution of responsibility for alcoholism. In testing these ideas, I have applied them to a sub-set of in-depth interview data from a study of family cultural influences upon the well being of school aged children growing up in families with an alcoholic parent*. The multidisciplinary contributions from disciplines such as anthropology, psychiatry, psychology, sociology, epidemiology, economics and public health are particularly important for addressing individual, family, and wider cultural influences on prevailing beliefs about accountability for alcoholism. The emphasis of this analysis, however, is on a family-level cultural understanding of the roles of blame, shame, and guilt in attributing responsibility
for alcoholism in American society. Since the home environment is typically the initial context where children learn ideas and behaviors underlying concepts such as responsibility for alcoholism, this is a critical area to understand more clearly. In the paper, I combine a review of recent literature dealing with issues of accountability for alcoholism; the presentation of a theoretical framework for furthering our understanding of accountability and its component parts--blame, shame and guilt; and an examination of this framework in light of in-depth interview data collected from alcoholic families.¢
*A grant from the National Institute on Alcohol Abuse and Alcoholism, in part, supported the research upon which this paper is based. "tOut of concern for the anonymity of the families interviewed, no detailed profiles of the ten families are included in this paper.
With respect to macro-level fluctuations and transitions in drinking levels and alcoholism prevalence cross-culturally and over time, researchers from many disciplines have studied political, legal and economic trends. Some of these trends constitute
ss~ 40,t -B
STUDIES OF RESPONSIBILITY FOR ALCOHOLISM Three general approaches to questions of responsibility are represented in the burgeoning literature on alcoholism and alcohol-related problems: (1) in macro-level terms through examining international and national political and economic forces; (2) in mid-level terms through analyzing specific cultural contexts; and (3) in micro-level terms through considering individual, family and small group effects upon drinking patterns and problems.
15
16
LINDAA. BENNETT
formal alcohol control policies [e.g. 4-7]. Anthropologists, however, have not taken a lead role in this research. Anthropologist Merrill Singer, in fact, argues that they have shied away from the hard questions regarding the impact of economic and political factors upon increased alcoholism rates, especially among the working classes during early periods of industrialization [8]. Thus, anthropologists, overall, have not tended to look to the wider political-economic structure for explanations of responsibility for high alcoholism rates. In contrast, considerable anthropological inquiry around drinking patterns and levels has been carried out within particular cultural settings [e.g. 9-13]. Anthropologists have focused mainly on intercultural and intracultural patterns and variation in drinking practices generally and, sometimes, specifically on drinking problems. Dwight Heath's review articles thoroughly document this genre of anthropological research [e.g. 14-16]. Thus, anthropologists have discerned responsibility for alcoholism within the incentives and constraints on drinking found within particular cultural contexts and in the value orientations of those societies regarding alcohol consumption and alcohol-related behavior [e.g. 17, 18]. These contexts provide informal alcohol controls on both consumption and drinking behavior. Micro-level influences on theories about responsibility for alcoholism only recently have garnered the sustained attention of certain anthropologists; most are from the field of medical anthropology and many conduct collaborative multidisciplinary research. Their work represents a link to a long scholarly tradition on studies of kinship and family within the discipline of anthropology [e.g. 19-23]. Responsibility for alcoholism at this level is investigated in terms of attributes--biological, personality, social, and experiential--of the individual and his/her family as well as groups that they come in contact with regularly. Such influences constitute a second sub-set of informal alcohol controls. While recognizing the critical importance of political-economic and sociocultural contextual pressures on drinking levels and alcohol-related problems, I consider microlevel informal controls on attitudes and behaviors toward drinking alcoholic beverages--and responsibility for its consequences--particularly powerful ones in the early development of children. It is also within this domain that husband and wife bring together two sets of ideas about alcoholism accountability from their families of origin at the time that they marry. Through the course of early marital development of a family identity and the socialization of their children, couples select certain societal norms about drinking alcoholic beverages and its consequences to become part of their family culture [22]. For these reasons, families warrant closer examination regarding responsibility for alcoholism, drinking-related behaviors and attendant consequences.
POST-WORLD WAR II CHANGES IN THE UNITED STATES
Since the Second World War, a notable shift has occurred in societal perceptions of alcoholism and the alcoholic [12, 13,24, 25]. At the national policy level since the passage of the Uniform Alcoholism and Intoxication Act in 1971, public intoxication has been decriminalized to a great extent [26]. Still, exceptions are obvious, especially among homeless people living in jurisdictions with no public detoxification centers. While we have witnessed a movement toward decriminalization of public drunkenness among non-drivers over the past two decades, since the early 1980s most states have passed stringent legal penalties for driving while under the influence of alcohol (DWIs or DUIs) [1]. A third post World War II trend is evident in the plethora of occupationally based efforts to intervene in alcohol-related problems, mainly through employment assistance programs (EAPs) [27, 28]. Finally, massive financial support has been allocated from federal sources and private insurance companies for alcoholism treatment [29, p. 336]. During the post-World War II era, American society has shifted from an emphasis on a moral model of alcoholism toward an affirmation of a medical or disease model [30-33]. Jellinek initiated this attitudinal change through his work and writings [30]. The American Medical Association reinforced this newly evolving view of alcoholism in 1956 when it labeled it a disease. Since then, the general public increasingly has come to view the behavior of someone addicted to alcohol--however undesirable---not so much as sinful, but instead as ill or sick behavior, "resulting from biological and social forces beyond an individual's control, rather than a display of personal immoral choice" [34, p. 34]. This transition is far from complete, however. American society still operates under the paradox that "The alcoholic is perceived by others to act with intention and choice, while he experiences within himself an explicit lack of intention and choice" [34, p. 34]. Furthermore, surveys indicate "that a substantial portion of the population perceives alcoholism as a moral weakness, with about half of these persons also agreeing with the notion that alcoholism is an illness" [32, p. 24]. Thus, many people are convinced that alcoholism is complex and is caused by both moral inadequacies and physical attributes of the individual. Howard Stein argues that while alcoholism is perceived to be a problem at a conscious level, it actually provides a solution to internal cultural ambivalence at the unconscious level [13, p. 203]. "Alcoholism reveals that such culturally ideological opposites as responsibility/ irresponsibility, control/out of control, order/ disorder, and the like are in fact dynamically two extremes of the same pole of ambivalence" [13, pp. 202-203].
Accountability for alcoholism in American families With the advancement of the disease model of alcoholism, the usefulness of blame and punishment as concepts is seriously questioned and at the same time the idea of individual responsibility for being alcoholic is also challenged. "Alcohol consists of a widely accepted pretext for the abdication of personal responsibility" [12, p. 358]. It appears that we are left with a vacuum of responsibility for behavior which many people view as extremely objectionable--especially drinking and driving--and extremely difficult to control [35-39]. It remains a real paradox. This paradox was nicely expressed in an interview conducted during the early 1980s in the home of a couple living outside Washington, D. C. The husband was critically ill due to excessively heavy drinking over a 40 year period. His wife described her coming to terms with what alcoholism is in this way: With drinking, you get to the point of saturation where you can't do anything about it, and it's affecting your life so much you try to push it away. There is only so much you can take, and then you don't want any more part of it. I've known for a few years that alcoholism is a disease, but the thing is how long can you live with a disease and go along as if it's all right. There is a point you get to and then, the hell with it, I've had enough and want no part of it because the disease is getting to you then [40, p. 195]. At its most extreme, the disease concept of alcoholism treats the alcoholic as a victim, someone who is not responsible for his or her own actions. Herbert Fingarette notes that people who advocate the classic disease model of alcoholism see "alcohol as a dominating necessity for the alcohol-dependent p e r s o n . . . In this view, alcoholics are victims of physiological and neurological abnormalities that cause uncontrollable behavior" [39, p. 32]. Generally, the American public is not ready to buy this argument in its entirety. Instead, people often say that alcoholism is a disease, while berating the alcoholic for his/her behavior. I believe we are stuck in our understanding of alcoholism. Instead of understanding alcoholism in its complexities, we mainly think in polemics. Perhaps this is due, in part, to the fact that the majority of Americans are directly familiar with alcoholism. Such experience can mislead them to believe that they are experts on alcoholism in its totality and that they do not need to look beyond personal experience for a fuller and more accurate point-of-view about the etiology and course of alcoholism. In our tendency toward polemic about alcoholism, on the one hand some people think the alcoholic is totally responsible for his or her alcoholism while at the opposite end of the spectrum, others hold society responsible. We need a more sound conceptual basis to provide an alternative to these two extremes which will take into account shared responsibility. As alcoholism has become transformed "from a sin to a sickness model, traditional concepts of alcoholism eliminated blame and punishment for the alcoholic,
17
but also deeply confused and distorted the concept of responsibility" [34, p. 35], LOOKING TO FAMILIES F O R RESPONSIBILITY
In exploring these ideas about attribution of responsibility for alcoholism in American families, I have examined in-depth interview data from a sub-set of alcoholic families who took part in a study of family cultural influences upon the relative well being of school aged children [41, 42]. The group consists of the first ten alcoholic families interviewed out of a sample of 37. Each family discussed here was intact and middle class, had at least one biological child between the ages of 6 and 18, and lived in the Washington, D.C. area. I conducted two semi-structured interviews dealing with family culture jointly with husband and wife, at least one of whom was a currently drinking or recently recovering alcoholic or problem drinker, according to Goodwin et al. criteria [43]. The term alcoholism, as used throughout the paper, encompasses Goodwin's problem drinker and alcoholic categories; both categories take amount, frequency and duration of consumption into account, as well as negative consequences of the drinking. In addition to in-depth ethnic, religious and historical backgrounds of each couple's families of origin and nuclear family, I elicited extensive information about drinking and other drug use patterns over four generations of the family. The focus of the second interview was on family rituals such as dinner time, holidays, vacations, family celebrations and the role of alcohol and alcoholism in each ritual. The methods and results of this research are reported elsewhere [41, 42]. In brief, we found that: (1) children in non-alcoholic families are functioning better behaviorally, cognitively, and emotionally than their counterparts in alcoholic families [41]; and (2) certain family culture characteristics--such as deliberately planning and carrying out family ritual observances--mediate between parental alcoholism and the children's relative well being [42]. I organize responsibility regarding alcoholism into three domains: first, the cause of the problem, or its etiology; second, the f o r m of the problem or the undesirable behavior exhibited by the alcoholic under the influence of alcohol; and third, the consequence of the drinking behavior in terms of its impact on other people and the action or recourse taken to respond to the problem. Several confounding conditions confuse any clear characterization of responsibility for familial alcoholism. Different members of the family may hold varying points of view. For example, one sibling may seem to be oblivious to any negative effects of his father's drinking while another sibling may be extremely angry that her father does not participate
18
L1NDAA. BENNETT
fully in family activities. Yet another sibling may be relieved to have the father absent from most family events. Furthermore, any particular person may express different perspectives on the problem, depending on immediate circumstances and/or ambivalent thinking generally. After all, the precise border between 'normal' drinking and 'problem' or 'alcoholic' drinking is seldom clear, even in hindsight. Instead, a large grey area often exists through the course of alcoholism where it is difficult for someone outside looking in on the alcoholic's behavior and thoughts to know with certainty when a problem has definitely emerged. Finally, change is a natural part of family development and the life course of alcoholism. Depending on the time we enter the alcoholic family, we may hear very different accounts about responsibility by family members. For example, conversations with an alcoholic during the time he or she is still drinking and then during recovery are very likely to present discrepant points of view, in spite of the fact that he/she may genuinely attempt to be both lucid and honest. CONCEPTS OF RESPONSIBILITY,GUILT, BLAME A N D SHAME Just what is meant by responsibility for alcoholism? It implies accountability for the condition. Responsibility can refer to the state of being an alcoholic, the behavioral and/or health consequences of drinking, and efforts to take control of the problem. One of the criticisms leveled against the disease model is that it discourages an alcoholic from taking responsibility for becoming dependent upon alcohol and from doing anything about it [38, p. 331]. Fingarette offers a constructive analysis of this issue in his discussion of the heavy drinker's willpower and responsibility for coming to grips with the drinking: If our righteous condemnation is not in order, neither is our cooperation in excusing heavy drinkers or helping them evade responsibility for change. Compassion, constructive aid, and the respect manifest in expecting a person to act responsibly--these are usually the reasonable basic attitudes to take when confronting a particular heavy drinker who is in trouble... There is no more validity in putting the entire burden of successful change on the drinker's goodwill than in absolving him of all responsibility as though he were helpless [39, p. 112]. Responsibility for alcoholism can lie within the alcoholic, within wider sociocultural forces, among other family members, within personal experiences or through a combination of such influences. The notion that someone or something could have done something differently, thereby resulting in another outcome, is implied. The potential power of a predisposition to become alcoholic due to biological/genetic reasons carries much currency in the United States [e.g. 44--48]. The proposition that 'An alcoholic is born an alcoholic' represents a highly fatalistic expression of this view. Alcoholism researchers rarely take such a narrow perspective.
Although most researchers prefer to study either predisposing (biological, genetic) or precipitating (cultural, experiential, environmental) factors, most recognize the complex interplay between multi-factorial influences on the etiology of alcoholism [49].
The Brickman et al. responsibility model Philip Brickman and his colleagues offer a theoretical framework for understanding helping and coping behaviors which is useful for examining attribution of responsibility for alcoholism [35]. Within this framework, they distinguish between responsibility for the origin of a problem and its solution. They delineate four models of responsibility and the position of control within each, all of which can apply to alcoholism accountability. In the moral model the person is considered responsible for both the problem and its solution. According to this model "drinking is seen as a sign of weak character, requiring drinkers to exercise willpower and get control of themselves in order to return to sobriety and respectability" [35, p. 370371]. Of all four models, the moral model implies the ultimate accountability to the individual for his/her own drinking and recovery from addiction. In contrast, the compensatory model does not hold the person responsible for the problem, but does expect him/her to find a solution for it. Thus, an alcoholic would look to forces outside him/herself for understanding how dependence on alcohol developed, but would feel compelled to take control of the drinking. When successful, they are given considerable credit for resolving the problem while still not being blamed for its cause. According to the medical [disease] model, the person is accountable for neither the problem nor the solution. One advantage of this model for alcoholics is "that it allows people to claim and accept help without being blamed for the weakness" [35, p. 373]. On the other hand, it can also foster dependency. Much as with diseases like tuberculosis or cancer, blame for alcoholism is not attributed to anyone [13, p. 226]. A potential value of such a perspective is that it can help alcoholics free themselves from "excessive, irrational, and self-defeating guilt," thereby helping with problems such as "low self-esteem, shame, and self-disgust, all of which are likely to drive them back into drink if not resolved" [38, p. 331]. Finally, in the enlightenment model, the person is not responsible for the solution, but is responsible for the problem itself. Alcoholics Anonymous, according to Brickman et al. draws mainly upon this idea in its philosophy and method in that it "explicitly requires new recruits both to take responsibility for their past history of drinking (rather than blaming it on a spouse, a job, or other stressful circumstances) and to admit that it is beyond their power to control their drinking" [35, p. 374). Alcoholics Anonymous and a community of recovering alcoholics can provide the external resources necessary to attain and maintain sobriety.
19
Accountability for alcoholism in American families
Shame, guilt and blame are common responses to irresponsibility. Table i shows the various conditions under which we can expect the alcoholic to experience shame, guilt and blame according to each of the Brickman et al.'s four responsibility models. They are most likely to emerge when the alcoholic, his/her family and friends, and the wider society subscribe to a moral model of alcoholism. At the other extreme, if they endorse the medical/disease model, the alcoholic is least likely to feel shame, guilt or blame. In the compensatory model, these emotional reactions are most likely to emerge if the alcoholic does not achieve a successful solution to the problem. In contrast, in the enlightenment model, we anticipate the appearance of blame, shame and guilt only for the presence of the problem. Later in the paper I examine these emotional reactions with respect to familial attribution of responsibility for etiology, behavior and consequences of the alcoholism. According to Webster, shame is "a painful feeling of having lost the respect of others because of the improper behavior, incompetence, etc. of oneself or another" [43, p. 1232]. In the case of a family with an alcoholic parent, the alcoholic may feel shame for being alcoholic, for behaving in certain ways under the influence of alcohol, or for not achieving and maintaining sobriety. Similarly, family members may feel shame on behalf of the alcoholic and/or due to shared membership in an alcoholic family. When the mother is an alcoholic, she may worry especially about the effect of her drinking upon homelife and the children [21]. Shame can take the form of embarrassment on the part of a spouse of an alcoholic with regard to what other family members or friends think: "His family became aware of his drinking, and they expected me to insist that he stop. When he
didn't, it got to be really embarrassing for me when we would see them." Guilt is inner-directed and, like shame, is highly distressing: "A painful feeling of self-reproach resulting from a belief that one has done something wrong or immoral" [43, p. 600]. One husband described his feelings of guilt while when attending a recovery program while he was still drinking: "I must have worked there seven straight days, all the time masquerading as a non-alcoholic. I felt so awful." While we might typically expect the alcoholic to be the one to experience guilt, children and a non-alcoholic spouse often feel guilty about the drinking because they see themselves as responsible in some way. Blame, also a common occurrence in alcoholic families, involves accusation or fault-finding. The object of accusation can be the self, someone else or something else. Very often a spouse or a child of an alcoholic heavily blames the alcoholic parent. One of the couples interviewed repeatedly noted that their older son was very angry about his father's drinking, in contrast to his brother who did not want to hear about it or discuss it. Parents in recovery frequently worry about the effect of their prior drinking upon their children's development and blame themselves for any possible ill effects. As one non-drinking alcoholic mother said, "I felt more and more useless . . . I am very proud of my kids; they are really neat people, and I hope I haven't screwed them up that much." In contrast, blame is sometimes directed toward a hypothesized genetic predisposition, rather than other attributes of the alcoholic. It arises when we try to determine whether the cause is internally or externally derived [35, p. 369]. In reviewing the interview data for these 10 families, I found that all of them evidenced at least some blame, shame and guilt in their attempts to
Table 1. Brickman et al. responsibility models: association with shame, blame and guilt Alcoholic responsible for:
Moral model
Problem?
or Solution?
yes
yes
Presence of problem Absence of problem Successful solution Unsuccessful solution
Compensatory model
no
no
Blame?
++
++
++
++
++
++
- -
+
- -
++
++
++
no
Presence of problem Absence of problem Successful solution Unsuccessful solution
Enlightenment model Presence of problem Absence of problem Successful solution Unsuccessful solution + + , Strong positive association. + , Positive association. - - . No strong association.
Guilt?
yes
Presence of problem Absence of problem Successful solution Unsuccessful solution
Medical/disease model
Model associated with: Shame?
m m yes
no ++
++
++
20
LINDAA. BENNETT
resolve the question of who or what was responsible for the alcoholism. Beyond this general observation, however, there was great variation in which particular members mainly felt these emotions. While in some families the alcoholic felt both shame and guilt, in others the non-alcoholic spouse felt these emotions strongly and the alcoholic did not. Furthermore, the relative emphasis on these emotional responses often depends on the drinking status of the alcoholic parent. For example, there was a strong tendency for the alcoholic to feel guilt while drinking, but those feelings would gradually dissipate upon cessation from drinking. In contrast, a non-alcoholic spouse might lay blame on the alcoholic spouse only during the drinking period. And children--once they became aware of the parent's drinking--often would be ashamed of the parent's behavior while drinking, but lose this sense of shame during abstinence. While it was more often the case that the alcoholic parent would feel both guilt and shame while drinking, some seemed to think that their families overreacted: "My wife has a tendency to be an alarmist . . . As unreasonable as I was about my drinking, you could make a fair case that she was equally unreasonable in overreacting." In short, the specific patterns of shame, blame and guilt with regard to attribution of responsibility for alcoholism in these families are tremendously variable. FAMILY ACCOUNTABILITY FOR ETIOLOGY
To explore the role of shame, guilt, and blame in attributing responsibility for alcoholism with respect to the three dimensions mentioned earlier----etiology, behavior and consequences--I have reviewed the transcripts for the 10 couples interviewed in their entirety. To begin with, I looked for thoughts expressed by either spouse regarding why the alcoholism developed in the first place. N o one suggested that etiology was due directly to biological makeup. Instead, five types of precipitating influences were described as being coterminous with an increase in drinking: (I) (2) (3) (4) (5)
family pressure to drink or not to drink; a traumatic life experience; occupational situation; emotional problems within the family; and 'loving alcohol'.
With respect to this last influence--which might be indirectly attributed to some biological influences-one recovering alcoholic wife stated: "I used to love to drink." A recovering alcoholic husband similarly explained: "I loved the stuff from the start." Although most family pressure regarding alcohol consumption discouraged drinking, occasionally alcoholic parents described pressures from family members to drink. In one family where both the husband and wife were recovering alcoholics, the couple "aided and abetted each other" in their continuing
alcohol consumption. In a second where both spouses had been drinkers and where abstinence came earlier for the husband, the wife felt personally rejected and renounced by her husband when he stopped drinking. She had encouraged him to drink and never expressed disapproval. In addition to his wife's pressure to drink, the husband was urged to drink by his father-also an alcoholic---during his recovery. Thus, in some families other family members--alcoholic or n o t - can actually make it difficult to stop drinking. I have found this to be very much the case in former Yugoslavia also where wider cultural patterns so firmly support a positive value toward heavy drinking---especially among men--such that the pressures to drink within and without the family can be extremely compelling [50]. More typically, though, the non-alcoholic spouse pressures the alcoholic to stop drinking, often with little success. For one husband in this study, to have his wife tell him before a social event that he should moderate his drinking was enough to precipitate him to drink even more since he "didn't like to be told what to do." In most families in this and two earlier studies we have conducted on familial alcoholism [51, 52], the non-alcoholic spouse used a wide assemblage of strategies to cajole the husband (most often) into curtailing his drinking. Couples did note one particular impetus to drink from the wider political-social context: the Vietnam War. The war experience repeatedly came to the fore in discussions with one couple; they identified this as the time when the husband began drinking with a vengeance. He began describing his experience well over a decade earlier in the present tense: "Vietnam changes the life of everyone who goes through it. I don't suppose I am the same person I was before I went over. It made indelible changes in my psyche. A lot of drunks came back from Vietnam." Several interviewees in our three studies pointed to military experience, in general, and Vietnam, in particular, as the time when they began to drink particularly heavily. Other couples reported similar, though less traumatic, life events which led to substantially increased drinking. One husband described the joint impact of moving from one state to another where the drinking laws were more liberal, taking a job in which his work peers regularly drank together, and playing music with a heavy drinking group as factors coming together to provide the added incentive to drink to the point of becoming an alcoholic. Another husband also connected a change in position and permissive open drinking on the job as one--though not the only--reason for the decisive increase in his drinking. Emotional problems in the family--other than having to do directly with the alcoholism--were seen as tied closely to accelerated drinking leading to alcoholism, especially among the women. One mother lamented, "We started having trouble with our son, and it was exceedingly painful to me
Accountability for alcoholism in American families emotionally. So the drinking progressed to the point of putting myself on ice so I wouldn't feel anything." The alcoholics and their spouses in this study are impressive in their willingness and ability to depict internal and interpersonal struggles with drinking in order to come to grips with the problem. Listening to their accounts of the natural history of alcoholism in their families, we might view them with skepticism, as though they are trying to find excuses, rather than to offer solid explanations. Given our imperfect knowledge and understanding of what makes an alcoholic an alcoholic beyond having to drink to become addicted, much can be learned by listening carefully to the language used by the still drinking and recovering alcoholics and their spouses and children to better understand the attribution of responsibility for alcoholism and its consequences. Contrary to the opinion that alcoholics and their families spend much of their lives in denial [13], I believe it is more accurate to see them as employing varying cognitive and behavioral strategies to grapple with the problem and try to do something about it. Alcoholism, as I noted earlier, is insidious in part because we live in a place and age where drinking 'moderately' is considered the norm for most adults. Only when we behave in unacceptable ways while drinking---such as driving with a blood alcohol level above tile legal limit, when we drink at inappropriate times or places, or when we develop serious health problems--are we taken to task for our drinking. In short, at that point we become irresponsible drinkers. In trying to find explanations for the etiology of alcoholism, these families fit the Brickman et al. compensatory model of responsibility best. Rather than focusing upon attributes of the alcoholic as causing the problem, both spouses tend to look to the situations in which the alcoholic finds him/herself as providing the extra incentives needed to transform heavy drinking to problem drinking or alcoholism. Since the direction of their attention is away from the alcoholic, little shame and guilt are felt by the alcoholic with regard to the etiology itself. This suggests that from the point of view of the couple, the absence of informal alcohol controls in the alcoholic's environment are particularly instrumental in the development of the alcoholism. They can, in fact, be blamed for the problem, at least to a moderate degree (see Table 1). Financial or legal considerations--typically within the province of formal alcohol controls--are barely mentioned in these interviews. FAMILY A C C O U N T A B I L I T Y FOR T H E A L C O H O L I C ' S O B J E C T I O N A B L E BEHAVIOR
Families focus more on the negative behavior of the alcoholic under the influence of drink than they do on concerns about how the problem
21
evolved in the first place. Anyone who either has lived with an alcoholic, has studied familial alcoholism in depth, or has worked clinically with alcoholic families is very familiar with objectionable drinking behaviors. These behaviors, however, typically vary from alcoholic to alcoholic and for a given alcoholic over time. Couples identified three types of alcohol-related behaviors as being particularly troublesome for the family: (1) not doing something he/she was expected to do; (2) doing something intrusive or unpleasant; and (3) 'becoming' someone different temperamentally. For the first category--failure to carry out expected responsibilities--couples frequently cited instances such as coming home late, forgetting obligations, avoiding family activities, neglecting housework and generally shirking regular duties to the family. One wife expressed her continuing distress with her husband's tardiness, especially at dinner times: "As his drinking progressed, the time he got home for dinner got later and later." Even at the time of the interview, the husband did not view this as a major fault, suggesting that, "It's much more preferable for them to go ahead instead of arguing about having to delay dinner for me." In another family, the wife was extremely alarmed about her husband's lateness in coming home at all. She explained, "I would never know what time of the day or night he was going to come home. A couple of times he stayed out all night. And he would always come home totally polluted." Her husband offered no excuses for his behavior, and rather, described himself while drinking as "totally irresponsible. It was a vicious circle. When I sobered up, I had guilt feelings about neglecting my wife and the kids, and then I drank some more." While wives of alcoholic husbands were typically distraught about their husband's lateness for or absence from normal family activities, husbands of alcoholic wives often focused their remarks on the deterioration of the home and the wife's neglect of 'her duties.' One husband remarked that he "was taking on more and more of the household chores" as her drinking progressed, and he was not at all pleased by that. Although sins of omission--as described above seriously troubled families, and sometimes very deeply, intrusive or offensive behaviors of the alcoholic parent drew particularly strong criticism, especially when they involved the children. While verbal misbehavior was often reported, couples only occasionally described physical violence under the influence of alcohol; and this was usually expressed in veiled terms. In one family, the husband acknowledged that "I was physically violent and abusive. I consistently overreacted to problems . . . When I was
22
LINDAA. BENNETT
under the influence of alcohol, I was more likely to r e a c t . . , in a much stronger way than I do when I'm not drinking." His wife concurred. More commonly, though, the alcoholic parent was verbally abusive. One wife reported that when her husband was drinking, he became "very belligerent (but not physically so), sarcastic, cynical, sometimes downright nasty." Another husband acknowledged that he tended to be hard on his children under the influence of alcohol: "If I haven't been drinking, I'm not as likely to be as critical." In contrast, he was more congenial when he was not drinking. 'Becoming' a different sort of person often goes hand-in-hand with such offensive behavior in that in becoming transformed into a new persona under the influence of drink, the alcoholic frequently perpetrates major transgressions. However, the change in demeanor itself--aside from, untoward behaviors--would often alarm the rest of the family. One husband could always tell when his wife had "a little buzz on" since drinking made her quite hostile. This, in turn, made him and the children very uneasy. In contrast, another husband described himself as becoming "quiet and withdrawn" when drinking. Sometimes families did not make a clear connection between drinking and modifications of behavioral style. In fact, when chronic emotional problems-such as depression---coincide with alcoholic drinking, families have a difficult time distinguishing the two. Referring to his wife's drinking, one husband explained, "I thought what I was seeing was due to pathological anger and depression. I didn't associate it with drinking." This is not particularly surprising since alcoholism and depression, in particular, are often closely intertwined [53]. When it comes to the family's perspective on the offensive behavior of the alcoholic, they conform more to Brickman et al.'s moral model of responsibility for alcoholism. The family wants the alcoholic to take control of his/her behavior first and foremost, and it tends to lay blame on his/her inability to behave in acceptable ways. Even the alcoholic tends to stress his/her negative actions more than the source of the problem. They often point to their feelings of guilt for either not doing the right thing and for doing the wrong thing: "I felt so awful for being such a fraud . . . I was abandoning her and the kids" and "I had guilt feelings about neglecting her and the kids" (two different husbands). While the alcoholic spouse typically feels guilty about his/her actions, the non-alcoholic spouse was more likely be ashamed of the alcohol-related behavior. One wife reported, "I feel so embarrassed by his behavior when he is drunk that I won't go to parties with him anymore." In short, the alcoholic is most likely to experience guilt for drinking-related behaviors, while other family members are the ones to lay blame on and to feel shame about the actions of the alcoholic.
FAMILY ACCOUNTABILITY FOR THE CONSEQUENCES OF THE DRINKING
When we examine the consequences of these behaviors, we get glimpses into the use of guilt, shame and blame in the family's attempt to make sense of irresponsibility of the alcoholic parent. A wide range of outcomes was reported, including: worry, embarrassment, tension, being upset, confusion, apprehension, alarm, concern, anger, nagging, disgust and hysteria. Overwhelmingly, the most common response by the family--especially the spouse--was anger. This was clear in the following statement: "There was a lot of anger in the house. We were all angry at one another. It was just a terrible time." In one family, the husband became depressed and often forgot his obligations to the family. He felt guilty about being irresponsible. In contrast, his wife was "mad as hell." She would wake him up in the middle of the night and confront him about his drinking. He sought treatment for his alcoholism on his own and was taking his recovery extremely seriously. In planning an upcoming work-related trip, he thought a lot about how he could maintain his sobriety even under pressures to drink from coworkers: "I'm going to have to use every reinforcement I know to make sure I don't drink. If I have antabuse, that's an absolute guarantee. It is a tempting situation." Another couple presents a very different sort of picture. The husband, who was still drinking at the time of the interview, was described as being antagonistic and superior acting to his wife and children. As a consequence, his wife was embarrassed, upset and disappointed in him. She expressed both shame and blame. One son was also very angry, blaming his father for the unpleasant family environment. The father himself recognized that "alcoholism is the big problem, but not the most fundamental one" and did not appear to feel particularly guilty about his drinking. In one family where the wife was alcoholic--in recovery at the time of the interview--she felt useless as she was less able to take care of the housework on a regular basis. Her husband blamed her for drinking and for not taking care of the home; he nagged at her, but did not directly confront her. When she stopped drinking, he was relieved. When we think of guilt as a response to alcohol-related behavior, we might logically think that the alcoholic would be the one to experience guilt. This is not always the case, as indicated in the following contrast between two couples. In the first, the alcoholic husband used to stay out all night, much to his wife's consternation. This would upset and concern her, but she did not directly confront him over his drinking. He felt guilty about being totally irresponsible and neglecting his family even though he continued to work. Eventually he stopped drinking on his own. While these alcoholics and their families may look to external influences to help explain the origins
Accountability for alcoholism in American families of alcoholism, they tend to look first within themselves for finding solutions to the problem. In another family, the husband became quiet and withdrawn, passive, and a non-participant in family activities. This put his wife in a bad mood, and she would fight with him about it. However, she began to wonder if there was something wrong with her interpretation of what was happening. And then she began to feel guilty for her husband's drinking and the consequences of his drinking. At the time, he was in recovery, and the family was in family therapy and, in retrospect, had a pretty firm grasp of their experience with the father's alcoholism. Not surprisingly, the family where the father became both verbally abusive--not unusual in these families--and physically violent--which is unusual in these particular families--the mother became angry, disgusted and self-righteous. She left him at one point and repeatedly confronted him. The husband viewed alcoholism as the basic problem in the home and was struggling to abstain from alcohol, but with little Success.
Spouses of alcoholics are often haunted by the question of what response on their part might make a difference in the drinking behavior and its consequences upon the family. In particular, does confrontation of the drinking work? Direct confrontation by other family members of the alcoholic parent occurred in four of the ten families. In two of these cases, the drinking was still going on at the time of the interview; in the other two, the drinking had stopped. As far as these particular families are concerned, confrontation in and of itself does not seem to provide the necessary stimulus for the alcoholic to stop drinking. Instead, reportedly, the alcoholic had to come to terms with the drinking him/herself, decide that it had gotten way out of hand, and that there were good reasons to stop drinking before a solution could be reached. The two main eventual consequence of the alcoholrelated behavior in these families are: (1) solution of the problem through taking control of the drinking (usually, but not always abstinence); or (2) e x t r u s i o n of the alcoholic member. In this regard, the compensatory model best applies. If the alcoholic does not take charge him/herself, the family itself may feel responsible for doing something about the problem. Extended family members may take a stand on what the non-alcoholic spouse should do: "His parents knew about his drinking. They were after me to do something about it. They told me to put my foot down." She did, and the couple separated for a year, then reconciliated after he stopped drinking and began to get clinical help. In most of these families, though, the alcoholic parent was the one to find a solution to the drinking. One alcoholic wife recalled, "I guess it was about a SSM 40 I--C
23
year ago when I realized I was totally out of control. Booze was not the answer any longer. So I just quit." Sometimes they make these decisions because they know the family will no longer accept their drinking behavior: "My husband realized that he would either have to stop that behavior or there would be no marriage." CONCLUSION
Where does this leave us in our understanding of the attribution of responsibility for alcoholism? Returning to the initial question raised as to who or what is responsible for alcoholism, I suggest that these families arrive at different answers depending on whether they are considering the cause of alcoholism in the first place, the drinking-related behaviors, or the consequences in terms of a final solution to the problem. Accountability for the origins of alcoholism--its etiology--is diffuse in these families' perspectives. Responsibility lies primarily outside the family and certainly is not lodged totally within the alcoholic's biological makeup or personality. However, the alcoholic is held responsible for his/her behavior under the influence of alcohol. And finally, the family shares responsibility with the alcoholic in terms of the consequences of the drinking and efforts to resolve the problem. When we examine these families' perspectives within the context of Brickman et al.'s four models (moral, compensatory, medical/disease and enlightenment), the moral and compensatory models are most congruent with the reports of these ten families with regard to alcoholism accountability. Although the alcoholic is n o t held accountable for the origins of the alcoholism (thereby conforming to the compensatory model), he/she is held responsible for alcohol-related behavior (moral model) and for finding a solution to the problem (compensatory model). As a result, considerable blame, shame and guilt are associated with unsuccessfully finding a solution, while the etiology of the problem in the first place is associated with almost no shame and guilt and only a moderate amount of blame (mostly toward events and situations external to the alcoholic). The medical/disease and enlightenment models do not readily apply to these families because they see finding a solution to the problem as being within the alcoholic's area of responsibility (contrary to both of these models) and because families do not attribute responsibility for the presence of the problem in the first place to the alcoholic (contrary to the enlightenment model). The fact that we remain in a quandary as to who or what is responsible for alcoholism should not come as a big surprise. This is probably a much more responsible position to take than to become locked into either a moral model whereby blame, shame and guilt are laid solely at the feet of the alcoholic or a disease/medical model in which the alcoholic is not
LINDA A. BENNETT
24
held responsible. Becoming a n a l c o h o l i c - - i n m o s t i n s t a n c e s - - o c c u r s t h r o u g h a long gradual process during which m a n y forces come together in the alcoholic's m o v e m e n t t h r o u g h the grey area of ambiguous heavy drinking a n d across the threshold into alcoholic drinking. Guilt, blame, a n d s h a m e are u n d e r s t a n d a b l e - - i f not usually 'successful' responses to the uncertain course o f alcoholism.
21.
22. 23.
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