It is mind boggling how alcoholism impacts people from all cultures, races, socioeconomic class, gender, religion, profession, and academic background. Interestingly, all alcoholics are ultimately alike. The disease itself swallows up differences and creates a universal alcoholic profile. The personality changes that go with alcoholism are predictable and virtually inevitable.  Alcohol can precipitate the onset of a disease with a predictable, inexorable course. It can ultimately destroy the physical, emotional, spiritual, and mental life of the sufferer. Alcoholism is typified by a progressive mental “mismanagement” and an increasing emotional distress that can reach suicidal proportions.

Hidden costs of alcoholism are not small. Alcohol-related expenses cost federal, state and local governments $223.5 billion. Of that amount, tax payers are footing the bill for $92.4 billion.

Drinking Was Fun, Once Upon a Time

Early drinking is a mood-swinger, typically in a positive direction. It gives the drinker a warm, good feeling, that may lead to giddiness. When the effects wear off, the drinker feels normal. It does not take long to learn how to set the amount and select the mood. As the typical social drinker gets deeper into the booze, getting drunk begins to have a very different effect. Heavy drinking creates a sort of undertow that drags the drinker back beyond normal and into pain. This might be the point where euphoria is reached at a big cost—if it’s achieved at all. Now the booze is consumed in order to feel no pain. In other words, to get back to some degree of normal. This is the beginning of harmful alcohol dependence.

In addition to dependency, this phase also involves a rising emotional cost. We we see a significant and progressive deterioration of the personality of the alcoholic, and (eventually) a visible physical deterioration. Ultimately, the alcoholic’s whole emotional environment is torn to pieces and destroyed. Of course, most active alcoholics are in complete denial of the impending bottom.

There is now a progressive emotional cost for every single drink. The carefree days are gone, but the alcoholic is dimly aware of this fact at best. The rising cost is willingly paid. This is proof that dependency has become truly harmful. Of course, the drinker fails to comprehend the increasingly clear signs of destruction by alcohol. Frankly, at this point the alcoholic is learning to depend more and more on rationalization. Intellect begins to blindly defend against reason—indeed, against intervention. Eventually, the alcoholic will be completely out of touch with emotions. Internal dialog will become the soundtrack of an increasingly impenetrable defense system.

Denial is Not Just a River in Egypt

The tragedy is that rationalization actually works! This form of defense—which I employed constantly during my active addiction—continues to operate as the disease progresses. The alcoholic’s behavior will become increasingly bizarre, and the innate and unconscious ability to rationalize will be practiced to the point of perfection. The drinker finds it increasingly difficult to accept blame. Time passes, and the alcoholic condition worsens. Over a period of months and years the alcoholic’s self-image continues to wane. Ego strength ebbs. Feelings of self-worth sink low, and excessive drinking continues, producing painful and bizarre behavior. Eventually, emotional distress becomes a chronic condition. The drinker feels distress unconsciously even when not drinking.

Unfortunately, rationalization works. The tragedy is that this form of defense will continue to operate as the illness progresses.

Now, “mood swings” or personality changes are evidenced while drinking. The kind person becomes angry or hostile; the happy person becomes sad or morose; the gentle person becomes violent. Alcohol causes one’s guard to drop, and chronic unconscious negative feelings are laid bare. The drinker becomes truly self-destructive. All this drinking and emotional distress may lead to a vague but poignant feeling, I just might have a drinking problem. There is a general malaise so strong felt that desperate measures to escape are actually attempted. Geographical cure, a new job, divorce.

The Pathology of Alcohol Dependence

The final stages of alcoholism are close at hand. Continued excessive drinking and accompanying behavior bring on chronic suicidal feelings. I remember thinking many times, I should just go jump in the Susquehanna River! If the course of the disease is not interrupted, the end of all this is suicide—either slowly by continued drinking or in a direct manner. This is because as emotional distress mounts, and deterioration of the personality accelerates, these negative feelings are not clearly discernible. Quite the opposite is true: They are more effectively hidden.

A pathological use of alcohol can be measured by how the individual answers the following questions:

• Have you ever drank early or first thing in the morning?
• Have you ever drank alone?
• Have you ever drank an entire fifth of alcohol in a day?
• Have you ever felt remorse after drinking?
• Is there a growing anticipation of the welcome effects of alcohol?
• Has the anticipation moved into the realm of preoccupation?
• Do you hide your booze in unusual places?
• Are you unable to be honest about how much alcohol you consume?
• Do you suffer blackouts or experience an inability to remember chunks of time?
• Are you having difficulty with personal relationships, work, or the law due to drinking?

Counselors gather a history of the behavior patterns by questioning those who spend meaningful or extended time around the alcoholic. Here, the basic goal is to discover whether there has been a changing lifestyle secondary to the use of alcohol, which would indicate a growing dependence.

Drug and alcohol counselors often explore this changing lifestyle by asking probing questions. Has there been a growing tolerance to alcohol? Does it take more booze for the drinker to get the desired effect? Does the alcoholic start drinking in the kitchen before bringing drinks for guests into the living room? (I often drank secretly before drinking in front of guests or family.) To what lengths is the alcoholic willing to go to get the amount of alcohol needed? The degree of ingenuity used to get more booze becomes the scale for determining how far dependency has progressed. All instances of harmful dependency that show up in alcoholic behavior patterns indicate a maladaptation of the lifestyle to (a) growing anticipation of the welcome effects of drinking, (b) an increasingly rigid expected time of use, and (c) a progressive cunning in obtaining larger amounts of alcohol.

Rational defenses and projection take hold. Why is it that the alcoholic cannot see what is happening? Simple. They have lost the ability to see it at all. The reason alcoholics are unable to perceive what is happening to them is actually understandable. As the condition develops, self-image continues to deteriorate. Ego strength grows increasingly weaker. For many reasons, they are progressively unable to keep track of their own behavior and begin to lose contact with their emotions. Their defense systems continue to grow, so that they can survive in the face of their mounting problems. The greater the pain, the higher and more rigid the defenses become—and this whole process is unconscious. Alcoholics do not comprehend what is happening. Quite literally, they are victims of their own stinkin’ thinkin’.

As the emotional turmoil grows in chemically-dependent people, rational defense activity turns into real mental mismanagement. The drinker erects a wall around him or her. The end result is that the alcoholic is cut off from increasingly negative feelings about themselves. They are unaware of the presence of such destructive emotions.

Not only is the drinker unaware of the powerful, highly developed defense systems, they are also unaware of the intense feelings of self-hate buried inside them. Moreover, the problem is being compounded by the fact that these defenses have now created a mass of free-floating anxiety, guilt, shame and remorse, which becomes chronic. In other words, the alcoholic no longer drinks from a “normal” point, experiencing an upswing in mood to feeling great or euphoric; rather, they must start from where they feel depressed or pained and drink to feel normal again.

Alcoholics drink because they drink. A Chinese proverb says, “First the man takes a drink, then the drink takes a drink, then the drink takes the man.” The drinking pattern becomes thoroughly unpredictable or compulsive. The alcoholic quits, then resumes, and does not know why he or she is drinking again. And whenever they do start again, the resumption is at the level of chronic emotional deterioration. Conditions worsen with each new episode, trapping the drinker in a deadly downward spiral.

Depression and low self-esteem become so great, the alcoholic begins to employ projection—a defense mechanism in which unwanted feelings are displaced onto another person, where they then appear as a threat from the external world rather than from within. The alcoholic does not know this is happening. The more hateful alcoholics see themselves, the more they will come to find themselves surrounded by hateful people. Depending on the personality of the drinker, such projection can present itself in ways ranging from gentle complaining to outright aggression. It is obvious the easier targets are those people typically spending time with the alcoholic, including the most meaningful. Although alcoholics tend to hate themselves, their projection works so well that they actually believe they are attacking hateful people.

People who live and exist around the active alcoholic have predictable experiences that are also psychologically damaging. As they meet failure after failure, their feelings of fear, shame, frustration, inadequacy, guilt, resentment, self-pity and anger mount. So also do their defense mechanisms. They too use rationalization as a defense against these feelings. The chemically-dependent—and those around them—all have impaired judgment; they differ only in the degree of impairment.

People who are chemically-dependent on alcohol have such a highly-developed defense system that they become seriously self-deluded. The rigid defenses that have risen spontaneously around their negative feelings about themselves, and therefore around their behaviors that caused these feelings, would be quite enough, were they the only deluding factors, to draw these people progressively and thoroughly out of touch with reality. Not only do these defense mechanisms become more rigid, but such individuals develop a growing rigidity in their very lifestyle. They are less able to adapt to unexpected change. They eventually reach a point where even schedules are burdensome. This is primarily because, paradoxically, they are less likely to plan ahead. Or, when they do plan something, they tend to feel trapped as the moment closes in.

To Make Matters Worse

Chemically-dependent people have two factors progressively working together to draw them out of touch with reality: Their defense mechanisms and distortions of memory. Consider euphoric recall, which is the tendency for an alcoholic to remember their drinking escapades euphorically or happily—in only the best light—with gross distortion of the truth. They believe they remember everything in vivid and accurate detail, thinking that all was “just fine.” Of course, this will only serve to bury the drinker’s antisocial or destructive behavior. There is a destructive distortion of perception itself. There is a lack of ability to see and appreciate reality. No recognition or acceptance that they are on a downward spiral, fast approaching rock bottom.

Either of these defense mechanisms seriously impair judgment. The time inevitably comes when it is plain that alcoholics cannot see they are sick. Yet they are acutely ill with a condition that will ultimately lead to death and destruction, and which will seriously impair their constitution emotionally, mentally, and spiritually during the final months of year of their active addiction. Accordingly, treatment for acute alcoholism cannot concern itself merely with putting the drink down. It also has to do with restoration of adequate ego strength to enable the alcoholic once again to cope with life.

The Best Approach

Therapy for acute alcoholics must address the whole person. The alcoholic suffers emotionally, mentally, physically, and spiritually. Treatment often involves physicians, psychiatrists, sociologists, psychologists, pathologists, and clergy. If the whole person is not treated simultaneously, relapse is simply… inevitable. If, for example, the emotional disorder alone is addressed, the alcoholic may believe he or she feels “so good” now that they can handle the drink. When treatment is short-sighted or limited, friends and family of the alcoholic may be heard commenting, “He was easier to live with when he was drinking!” This is akin to being a dry drunk. As this “dry” condition worsens, mental gains erode away and the alcoholic inevitably reverts to drinking to feel normal.

A description of despair by Søren Kierkegaard found in his book The Sickness Unto Death. Human despair is found at three distinct levels. First is the despair that expresses itself in sentences such as, “Oh what a miserable wretch I am! Oh, how unbearable it is to be me!” Second is the despair  that expresses itself by crying out, “Oh, if only I were not what I am. If only I could be like that person!” This is deeper despair because it considers self to be so worthless as to want to abandon it completely. But the third, deepest, despair of all is despair that does not believe one is a self at all. In other words, “I used to be… but not I am not.”

Physical complications, mental mismanagement, and emotional disorder are accompanied by a similarly progressive spiritual deterioration. Guilt, shame, and remorse exact their inevitable and immobilizing toll as time goes on. Feelings of self-worth begin to decline. As meaningful relationships wither on the vine, the growing estrangements lead to spiritual collapse. At the end, these feelings produce suicidal moods, ideation, and, unfortunately, suicidal attempt and/or death. If asked, “Can’t you see you’re drinking yourself to death?” the alcoholic replies, “So what? Who cares?”

Concluding Remarks

When asked how alcoholism is treated, people commonly think of either the 12-step program of Alcoholics Anonymous (AA) or inpatient drug and alcohol rehabilitation. There are, however, a variety of treatment modalities currently available. Today’s treatment for alcoholism naturally rests upon decades of research. AA was founded by Bill Wilson (“Bill W.”) and Bob Smith (“Dr. Bob”) in Akron, Ohio in 1935. AA’s program of spiritual and character development is based on the premise that turning one’s life and will over to a “personally meaningful higher power” is the key to recovery. It is, in fact, referred to as the key of willingness. Another central idea is that sobriety or recovery depends on the admission of powerlessness with respect to alcohol or other substances.

Treatment for alcoholism has made significant advances in the last 20 years. Researchers are constantly seeking novel approaches for improving the effectiveness, accessibility, quality, and cost-effectiveness of treatment. Alcoholism is a treatable disease. Regardless of how someone is diagnosed as alcohol-dependent, or how they came to realize they have a drinking problem, the first step to treatment is a sincere desire to get help. Overcoming an alcohol problem is an ongoing process that sadly might involve relapse. Granted, relapse is not a “requirement” for recovery—you don’t have to change your sobriety anniversary!—but it is merely a setback and not an indication that you will fail in your attempt to get sober.