Healing Psychology, Part C - Alcoholism

In our culture, the enjoyment of alcoholic beverages is the norm – despite the many problems caused by drinking. Most adults use alcohol, at least occasionally. And yet, only a small percentage of drinkers – under 10 percent – develop an Alcohol Use Disorder. The conventional explanation for this disorder is that exposure to alcohol changes the brain in a way that leads to cravings. But … if most people use alcohol, most people’s brains are being exposed to alcohol. Why, then, don’t most people become alcoholics? Maybe we need a new understanding. 

Transcript

Part C – Alcoholism

This Episode of Healing Psychology is a reading of Chapter Two of my upcoming book, Reimaging Psychology.

Copyright © Thomas O. Whitehead, 2022   All rights reserved

[Introduction}

The enjoyment of alcoholic beverages is normal in our culture. Moderate drinking is associated with easing tension, lightening up, enjoying life, and having fun with our friends. But for some people, the recreational use of alcohol gets out of control, turning into something quite destructive. In other words, it becomes an addiction.

How does that happen? Today’s conventional wisdom is that exposure to alcohol “changes the brain.” But is this really a good enough explanation? It’s reasonable to think that understanding would lead to control. But this way of understanding certainly hasn’t reduced the incidence of alcoholism. In fact, Alcohol Use Disorder is on the upswing.

This podcast is Part C of the multi-part series “Healing Psychology.” In this part, we reinterpret the strange features of Alcohol Use Disorder by applying the foundational principles of biology. Many of the ideas presented here are mainstream thought about addiction. But understanding addiction as a parasitic habit is not mainstream at all. You’re invited to listen … anyway.

[Reading]

 Alcoholism is above all a disease of denial. [1]

 - David Stafford

How can a behavior be diseased? The best way to answer that question is with concrete examples. These examples reveal our current psychology’s failure to account for the characteristic details of such destructive activities. To understand behavioral disease, we need to examine these details from a disease perspective.

We’ll start with a close look at a destructive pattern everyone knows about—alcoholism. [2] Our very familiarity with alcoholism makes it a useful illustration. [3] Most of us aren’t alcoholics. But problem drinking has touched nearly everyone in some way. Somebody we know—a person in our family, or someone with whom we work, or a friend—has an issue with alcohol. 

Before going further, I should clarify that somebody can drink—even drink habitually and substantially—without being an alcoholic. Drinking doesn’t always reflect disease. Experimenting with alcohol, and even drinking regularly, are normative aspects of this culture. In the experience of drinkers, alcohol-containing beverages are as frequently associated with good times as they are with bad. [4] Alcohol use, even habitual use, is clearly pathological only when it escapes the drinker’s control, and begins to create serious life problems. [5]

George E. Vaillant, a researcher who studied drinkers intensively over many years, concluded that drinking is a distinctive problem for only a small minority of people. All the others fall somewhere along a smooth curve of what’s regarded as social drinking. [6]We shouldn’t take the term “smooth curve” to mean that levels of drinking follow a “normal curve” in the statistical sense. They most emphatically do not fall into a normal curve! The curve of alcohol consumption is extremely skewed. In fact, heavy drinkers, not average drinkers, consume the majority of the alcoholic beverages sold. Heavy drinkers are those whose level of consumption is large enough to place them at risk of harm—whether or not they are true alcoholics.

We’re about to make some points about alcoholism that don’t apply to normal social drinking—consumption that remains under the control of the drinker. Alcoholism is not normal social drinking; it is an addiction. Alcoholism is a pathological pattern of repetitive, stereotypical, patently destructive alcohol intake—a drinking habit that has somehow escaped the consumer’s control. It’s common to refer to it as a disease. [7] [8] That’s because alcoholism is recognizably disease-like. Foremost among its mysterious features is what clinicians call denial. 

A descending fog

Around 1990 a 23-member multidisciplinary committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine conducted a 2-year study of the definition of alcoholism. They identified one of the defining characteristics as “distortions in thinking, most notably denial.” [9]A person’s alcohol consumption would probably never reach the destructive proportions we see in full-blown alcoholism without the pervasive denial at the heart of this disorder. [10]

Denial is a kind of distorted perception that makes continued drinking more likely. In his book The Treatment of Alcoholism, Edgar Nace says denial “functions partly like armor, repelling the efforts of those who point out reality to the alcoholic, and partly like radar, detecting any movement that threatens the drinking position.” Denial differs from delusion, he says, because denial “wards off reality rather than finds a substitute for it.” [11] What we’re calling denial is the persistent and determined tendency to remain clueless about the unsavory consequences of one’s drinking habit. 

The late Vernon E. Johnson was a recovering alcoholic. He found a good use for his intimate, first-person knowledge of the process. Johnson became an alcoholism expert and wrote   practical books on the subject. He provided a detailed description of the gradual process in which a normal drinker changes into an alcoholic. [12] This transformation happens gradually through incubation, a gradual process of change that I will describe in more detail in a later chapter. 

Incubation is a course of self-selection that integrates behavioral patterns, beliefs, attitudes, and self-concept into the semi-autonomous habit of alcoholism. The change results from the natural selection of habit variants, a process that shapes a drinking problem into its most malignant form. Incubation is the progression that creates alcoholic zombification. [13]

According to Johnson, the pattern we call alcoholism begins as a normal habit, and gradually evolves into a malignancy. The evolution happens in three phases. Here they are:

• First, the individual discovers a benefit to the use of alcohol. 
• Second, he begins to drink regularly, putting together a habit that feels right to him. Repetition with variation allows the habit to evolve.
• Third, his flourishing habit escapes his control, as denial clouds his ability to manage it.  

We can make this clearer with a concrete example. We’ll create a fictional character named Barbara to illustrate each of the three phases.

Here’s a little background information on our soon-to-be-alcoholic Barbara. She is twenty-four years of age, and she’s married. She and her husband have a loving relationship. Barbara is employed, and has experienced success in a demanding job with a large firm. She’s proud of her work performance.

Even though Barbara’s native intelligence is good, her “emotional intelligence” is below average. That’s because she grew up in a family where feelings were mostly ignored, not discussed much. Because she’s not great at recognizing and dealing with feelings in herself and others, social situations are awkward for her. Her deficit also creates problems with her husband, because their arguments never seem to resolve anything. Limited emotional intelligence is one of the risk factors for addiction, for reasons we’ll discuss later.

And there’s something else Barbara’s family includes several alcoholics. Her maternal grandfather was alcoholic, as are two of her uncles. Her grandfather’s drinking caused enormous problems for her mother growing up. This is important, because we have evidence that genetic makeup is another risk factor, a major one. 

Because of her god-awful childhood experiences with her alcoholic father, Barbara’s mother shunned the use of alcohol. Her mom made sure Barbara was aware of the trouble drinking could cause. So, throughout her life Barbara has stayed away from alcohol. 

But one day that changes.                                                                                                                                                        

Phase One: Discovery. In this phase Barbara first experiences what alcohol can do for her. She discovers that alcohol makes her feel better. Then she finds out she can control how much better she feels by controlling the amount she drinks.

Here’s how the discovery phase might go. Barbara and her husband Mike visit the home of friends. They spend an evening together. As usual, Barbara is feeling a little uncomfortable in this social setting. Then, at the urging of her hosts, she accepts a drink. 

Barbara discovers that the drink actually makes her feel better. It’s as if she’s been trapped in a cage all her life, and she unexpectedly gets a taste of precious freedom. She finds this very rewarding. Barbara, her husband, and their friends have a great time. When the effects of the alcohol wear off, Barbara’s state returns to normal. There’s no obvious drawback to her initial encounter with booze. She wonders if her mother’s fear of alcohol was exaggerated.

Sometime later Barbara makes another delightful discovery: where one drink made her feel pretty good, two or three make her feel even better! It’s like some kind of magic! Drinking loosens her up. She finds it much easier to laugh and joke with her friends. Her mild social anxiety is no longer a barrier to living her life the way she wants! And when the effects wear off, she simply goes back to the way she was before. Barbara’s pretty happy with this.

Phase Two: Incubation. Incubation means about the same thing as gestation. In medicine, incubation is the time between infection with a pathogen, and the appearance of symptoms. In this incubation phase Barbara gradually molds the separate elements of her drinking pattern into a single habit. And as her pattern comes together, she moves it to a central place in her life, simply because her life feels more fulfilling with alcohol.

A habit evolves as it is repeated. Barbara repeats her drinking habit over and over—with variation and selection. Without intending to, she’s giving it the opportunity and the time to become ever more deeply entrenched in her life. She continues to experiment with alcohol, learning through trial and error exactly the change in mood she’s shooting for, and how much she must drink to create that change. She affirms again and again that she can control the process with precision. 

Barbara is developing a positive relationship with alcohol. Her genetic makeup, reflected in her family history of alcoholism, increases her vulnerability to addiction. And her limited emotional intelligence places other ways of handling her social anxiety out of her reach. So, her habit solidifies and deepens with each episode of use. It’s important to know that Barbara doesn’t have to make any special effort to refine her drinking habit. She builds it as automatically, as she would build any other habit, guided by her experience of satisfaction. 

Increasingly, Barbara anticipates her evening buzz with relish. She develops “rules” for drinking, a system. For example, she tells herself that she will not drink before six o’clock. Mike expresses his concern and frustration from time to time, but she just laughs it off. Drinking feels good to her. Her experience is that her life is better with alcohol.

Phase Three: Final Pattern. In this phase Barbara’s individually crafted alcoholic pattern takes on a fully “zombified” form. Up to this point her drinking has been a habit that arguably served her interests. Now denial and conceptual distortion come to dominate her pattern, reducing her ability to control her habit.

Barbara sticks to her drinking rules at first, but eventually finds them too constricting. Barbara’s body is adjusting. She has developed a physical tolerance for alcohol—she must consume more to re-create the same positive experience. Things other than drinking don’t seem as important to her as they once did. So, she gradually changes her behavior and her rules to accommodate heavier and more frequent use. She exercises her ingenuity to set up drinking opportunities in advance. She stashes bottles around the house, for example. 

As part of her adjustments, Barbara becomes secretive, protecting her habit—because it has become precious to her. She senses that others would not like the direction her alcohol consumption is taking her, so she hides her drinking from them. She even conceals the extent of her use from her husband. To disguise her morning nip, she often drinks her bourbon from a coffee cup. 

Though it might seem impossible, Barbara even hides her habit from herself. She starts telling herself things that aren’t exactly true, little internal thought-speeches that make it easier to drink regularly and substantially without feeling concerned. At some intuitive level, she knows there’s a problem. But she’s developing an ability to duck full awareness. Without intending it, she is dismantling her awareness-based “behavioral immunity,” her ability to protect herself from her own behavior. 

What’s behavioral immunity? During our development, each of us develops a sense of self. We put together a set of protective personal boundaries that stop us from doing things we know are “not who we are.” Our boundaries are rooted in an intuitive awareness of consequences. In addition, most of us have friends and loved ones willing to help steer us away from things they think “aren’t us.” But incubation is dismantling Barbara’s protective internal boundaries, one by one. And as for external protection, she now avoids the people who might help protect her. She makes new friends who drink, friends who approve of her drinking.

With both internal and external controls removed, Barbara drifts free from her moorings. The disabling of attention cripples her ability to see the trouble in her drinking pattern.

Mike, the person who knows her best, finds he has to run interference for Barbara, explaining her behavior to their acquaintances and making excuses for her. He’s resentful, but feels he must protect his wife. [14] One day at a party Barbara drinks way too much. She engages in some bizarre, inappropriate behavior. Mike is mortified. He gathers her up, makes an awkward apology, and hurries her home. Sobering up, Barbara finds that Mike is furious with her. 

The incident threatens to bring the problem into her full awareness. Jarringly, she’s confronted with the consequences of her drunken behavior. She feels embarrassed and guilty. She regrets what happened, and is thrown into a state of confusion. She wonders how such a thing could’ve happened. She earnestly apologizes to Mike, and assures him it won’t happen again. 

But then something quite strange happens. At this critical point, when she has finally glimpsed the problem, an unusual thought pops into her head: “Wait a minute! Last night I drank on an empty stomach. That was a mistake. I’ll never do that again!” 

Uh oh! Barbara has put together a rationalization that unravels her insight. She has decided the problem was not the drinking itself, but the way she drank. This distortion obscures cause and effect, making it hard to see the need for change. The fog of denial is rolling in, and it will only thicken over time.

The increasing prominence of denial is real trouble. Zombification is undoing her ability to govern her actions. From this point forward, Barbara’s capacity for attention will be progressively compromised. Crippled awareness is the last nail in the coffin. As she continues to drink, additional distortions spring up like weeds to support the addictive pattern’s continuation. These adjustments provide no benefit at all to Barbara or to the people in her life. But they do benefit the malignant habit.

With the third phase, Barbara’s drinking pattern has passed a critical threshold. Her capacity to evaluate what’s happening, the backbone of her supervisory control of her habits, has been broken. Freed from its leash, the drinking pattern itself is now calling the shots. 

Addictions expert Alan Leshner is a former director of the National Institute on Drug Abuse at the National Institutes of Health. He stresses that passing into true alcoholism is like going through a one-way turnstile. Once the passage is made, there isn’t any way to unmake it.

• It is ... important to correct the common misimpression that drug use, abuse, and addiction are points on a single continuum along which one slides back and forth over time, moving from user to addict, then back to occasional user, then back to addict. Clinical observation and more formal research studies support the view that, once addicted, the individual has moved into a different state of being. It is as if a threshold has been crossed. Very few people appear able to successfully return to occasional use after having been truly addicted... [15]

The transfer of control

It would be natural to expect, as Barbara’s impairment becomes destructive to her, and painfully obvious to others, that the truth would eventually dawn upon her. But that isn’t what happens at all. Incubation has reshaped her attentional processes so much that her habit has stopped protecting Barbara, and has begun to aggressively protect itself instead.

As the negative consequences of her drinking become clearer and clearer to those around Barbara, the scope of her denial simply expands to keep her in the fog. No matter how bad things get, the haze of illogic thickens to obscure the truth. It is always just dense enough to keep her bewildered.

To be clear, her confusion has nothing at all to do with her intelligence. Barbara is no dummy. She has proved her intelligence through her success in a complex and demanding job. But as the disease progresses, her rationalizations become more and more extreme, and less and less sensible. Despite her intelligence, they begin to sound stupid. Her logic isn’t logical anymore. The situation is indeed a sad one. Her drinking habit has already reshaped every other aspect of her life. And now her intellectual strength is being turned against her as well. All of her resources are at the service of the alcoholic pattern.

Here’s where we need to pay really close attention. There’s something terribly fishy about what’s happening to Barbara. And that fishy something is why professionals most familiar with alcoholism believe it to be a disease—not just stupidity, error, or moral failure. 

When we foolishly put our hand on a hot pan, we get burned. But we learn from the mistake. We are careful not to burn ourselves that way again. Not so with the alcoholic. The hand strays to the hot pan over and over. The injuries keep on happening, with no growth of insight. In fact, insight shrinks as time goes on. The alcoholic handles the hot pan more and more often. And the burns get worse and worse. This just isn’t the way normal habits work.

When Barbara started messing with alcohol, her actions were voluntary, sensible, under her conscious control. She could logically defend her choices. She was legitimately exploring something that she felt provided her a benefit. Post-zombification, though, her actions are no longer logically defensible. It’s obvious to everyone but her that the costs far exceed the benefit. The emerging addiction has somehow snatched the reins from her, and is now making her choices for her. 

At some point the needs of the alcoholic pattern started to take precedence over Barbara’s needs. Drinking gradually changed from “something Barbara does” into “something that does Barbara.” The essence of that mysterious change is the transfer of control. Control has shifted from the behaving person (Barbara) to the behavior itself (alcoholism). 

We might be tempted to say that Barbara has descended into uncontrolled drinking. We could say she lost control because alcohol changed her brain. That’s the way today’s psychology explains addiction. But the word “uncontrolled” doesn’t really fit the way she’s drinking. Her behavior has not become chaotic. Her drinking continues to be systematic and well organized. The scary truth is that her drinking isn’t so much “uncontrolled” as it is “out of Barbara’s control.” Something else is controlling it.

A life of its own

The strings are now being pulled by the drinking habit itself. Here’s the thing: It’s as if the pattern has acquired a life of its own. In this sense it resembles an illness rather than a series of deliberate acts. It is, in fact, behaving like a parasitic disease, with Barbara as its host. 

Remember how we differentiate the symptoms of disease from voluntary acts. The symptoms of a disease are not things we choose to do. It’s the disease that produces the symptoms. Parasitic disease organisms are real, and they act in service of their own needs, using their own evolved strategies. Their agendas are often in conflict with ours. When we experience the symptoms of a pathogenic illness, we know it is the pathogen that is causing them. We are not voluntarily choosing them. The parasite is taking care of itself, not us.

By the time the alcoholic reaches the third phase, the disease has seriously compromised her control over what she is doing. Her symptoms are god-awful, but involuntary. The addiction is arranging its own perpetuation. Full-blown alcoholism looks like a disease, because it is a disease. 

But what kind of disease? Alcoholism certainly isn’t caused by a parasite like a tapeworm. It’s not caused by a tiny bacterium, as with anthrax. Nor a biological virus, like the one that causes the flu. But as we will see, alcoholism behaves enough like a virus that calling it “virus-like” can help us understand what’s happening. Barbara’s drinking has somehow morphed from a normal human habit into what we can properly call a behavioral parasite, a self-recreating, virus-like pattern, a major focus of this book. 

Responsibility

But hold on! Isn’t Barbara the star of this show? Isn’t she the one actually doing all these things? Isn’t she the one making all the bad choices? She is the one hiding bottles all over the house, right? She is the one breaking her own rules. She’s the one avoiding concerned friends and telling herself and everyone else lie after lie about what she is up to. Who but Barbara could we possibly hold accountable? It’s her behavior; isn’t it? There’s nobody else to blame. Barbara definitely created this mess. Um … didn’t she?

Ah! We have arrived at the crux of the matter—the issue of responsibility. This is exactly the place where it all becomes so terribly confusing. And it’s exactly where a comparison with viral parasites can really help us resolve the confusion. Let’s take a close look at the way viruses operate. 

What’s a virus?

The cellular virus is one of the simplest of parasites. A virus is so simple that it can’t do anything at all on its own. To get anything accomplished, it must hijack the resources of a host cell—a lifeform far more complex. Before infection, that host cell is doing many sophisticated things, producing all sorts of complex chemical products. The host is much, much more capable than the tiny virus. The cell evolved each of the clever things it can do, to fill its own needs. 

When the virus invades, the complex activity within the host cell doesn’t stop. The cell continues to do the same amazing things it has always done. But after infection there is a big difference. The virus has transferred control of the cell’s activity to itself. With the virus pulling the strings, that activity is no longer focused on filling the cell’s own needs. The invader zombifies the cell, redirecting its behavior to address the needs of the virus. And those needs boil down to just one thing—reproducing the virus. 

The simple viral lifeform selfishly exploits the more complex cell to create the next virus generation. After it gets infected, the host cell’s energy gets channeled into reproducing the pesky virus. Under viral control, the cell does things that seem senseless, as they provide no benefit to the cell. But they make all the sense in the world from the invading virus’ point of view. The infected cell’s activities create more viruses.

When talking about the viral infection of cells, it would be silly to blame the cell for its destructive behavior. Yet, we have to admit that it’s the cell that’s doing all the behaving. Remember, the virus can’t do anything at all on its own. So here’s the thing: even though it’s the cell that’s actually doing things, it’s the virus that’s responsible. 

That’s how viruses do what they do. A virus acts through the capabilities of its host. This truth is the source of untold confusion, because it sounds so paradoxical. So I will re-emphasize this critical point several times in the coming chapters.

Even when we’re only talking about biological viruses, the issue of control is confusing. But when we turn our attention to alcoholism, the confusion becomes overwhelming. A very simple, viral-like pattern  of behavior takes control of the complex abilities of the alcoholic, its sophisticated host. The alcoholic habit, like a cellular virus, is far too simple to reproduce itself without the capabilities of its complex host.  

Before alcohol came into Barbara’s life, she had many constructive habits. Each of her habits helped meet her needs. Later, under the control of the alcoholic pattern, she continued to do the same kinds of sophisticated things she had always done. But now there was a difference. Barbara’s doings were no longer geared to meet her own needs. Instead, the alcoholic pattern was exploiting Barbara’s capabilities simply to perpetuate itself—to keep itself going. It is in this sense that she became the involuntary host to a parasitic, self-reproducing habit. 

Being hijacked by a parasite sounds like something from a B-grade horror movie. “Invasion of the Habit Snatchers,” perhaps? But no. This parasite isn’t an alien. It’s just a rogue habit, one that began its existence as one of Barbara’s ordinary habits. Despite its humble origins, that habit morphed into something that wasn’t Barbara anymore. It no longer operated within the limits of Barbara’s self. It no longer “had her interests at heart.” [16] 

A full-blown alcoholic pattern acts in its own interest. And in line with the principle of natural selection, the elements of Barbara’s drinking habit evolved to satisfy the viral pattern’s interests, not Barbara’s. All other considerations fell by the wayside. In this sense, we can consider the malignant habit to be a true parasite.

Isn’t such a thing rather far-fetched? Not at all! Among living things, exactly this kind of takeover is the rule, not the exception. It happens regularly in the animal world. In fact, most of the creatures on the face of the earth are parasites. Each of these entities perpetuates itself at the expense of a host. Each hijacks the resources of its host—both bodily and behaviorally—in order to complete its own life cycle. 

All parasites drain host resources, and many exert control in ways that harm their hosts. So perhaps it is not unreasonable to expect that something similar happens within the arena of human behavior. If the idea seems far-fetched, it’s only because our psychology hasn’t historically made use of biological concepts. And that neglect is no accident—something that will become clear in the coming chapters.

Lying and denying

Denial lies at the heart of alcoholism. Denial plays a critical role in converting an ordinary habit into something that acts like a disease. A similar perceptual-conceptual distortion exists at the core of all addictions, no matter what type. Using alcoholism to illustrate this distortion is handy, because treatment professionals have for decades recognized this function of alcoholic denial. 

In his 1995 book The Natural History of Alcoholism Revisited author George Vaillant comments on the close connection between denial and severity of symptoms. As the devastation produced by the illness becomes more obvious, denial manifests in progressively more fixed and less realistic forms, so that “the individuals who are most symptomatic and thus most frequently seen in medical clinics may also manifest the most flagrant denial.” [17]

In this context, denial means remaining unaware that something bad is happening, when it really is happening. Denial plays a central role in the maintenance of any addiction simply because it masks the ongoing damage—full awareness of which would halt the process. 

Philosopher and addiction theorist Hanna Pickard views denial as a grossly neglected factor in the destructive use of substances. It is the fog of denial that disables our control. She says,

• We can only be guided in our decision-making by the outcome of actions of which we are aware. If addicts do not know that their drug use has negative consequences, there is no puzzle as to why they continue to use in the face of them… Denial blocks straightforward attributions of knowledge.[18]

Author Albert LaChance goes even further, stressing in his book Cultural Addiction that denial is the defining characteristic of all addictive processes. The addiction’s specific form—whether it be alcoholism, drug addiction, addiction to pornography, or some other form of spiritual infirmity—is not as important as the fact that it is a retreat from truth, the awareness of which would bring the process to an end. With repetition, that retreat becomes second nature—involuntary, automatic.

• Alcoholism, and the other names for addictions, might be misnomers for this illness of spirit, mind, and body. Denialism might be a better word for the real problem. Addictions of all kinds, alcoholism included, are symptoms of denial. Then, too, denial becomes a symptom of addiction. Denialism is an illness that is involuntary. People do not choose to die horrible, alcoholic deaths. Denialism and the addictions that result from it are not a refusal to admit to what is real; Denialism is the inability to do so. [19]

The perceptual/conceptual distortion that accompanies addiction is distinctly malignant. Denial makes it difficult for the alcoholic to identify the true source of his problems, and so derails motivation for change. It is for this reason that most drug/alcohol treatment programs regard denial as the most troublesome barrier to recovery.

The process of incubation, which is just a form of natural selection, shapes denial’s specific form. Though she doesn’t use the word incubation, addictions professional Krista Smith highlights denial’s central role in the gradual emergence of a recognizable addiction.

• … Where denial becomes harmful is when we ignore warning signs that are detrimental to our physical and mental health, which is incredibly common for those struggling with alcohol or drug addiction. Few people start out with a full-blownaddiction to alcohol or drugs. It creeps up slowly, building as it goes, which is why it can be easy to ignore the signs that your use is getting out of hand. When well-meaning friends and family give gentle nudges, we tend to blow it off and make excuses. [20]

If we think of alcoholism as a parasitic, self-reproducing system, denial’s function in that system is clear. It fogs awareness of the need for change. So change never comes. The only real controversy is whether denial means actual lack of awareness. Is the alcoholic genuinely in the dark about the consequences of her drinking? Or does she know what she’s doing, and is simply spouting a pack of lies to herself and everyone else. Could she be doing both? These questions underline the deep confusion about responsibility—the confusion we can resolve with the virus metaphor.

In the back of every alcoholic’s mind, somewhere below the surface, there simply must be an intuitive sense that his or her drinking has taken an unacceptable turn. During the progression of the disease, as illustrated with the fictional Barbara, it’s common for alcoholics to become secretive about their intake. 

Author Caroline Knapp’s 1996 book Drinking: A love story is a fascinating and deeply moving account of her own twenty-year entanglement with alcohol. Knapp provides a lucid description of this advance toward stealthy consumption.  

• As my drinking progressed, I’d learn to be more discreet. So would most alcoholics I know: we hid what we drank, and where we drank it and how much and under what circumstances. We hid it from our friends and families; often, we took pains to hide it from total strangers… Lots of us would shop at different stores every day, sometimes going miles out of our way to get to a new liquor store in order to hide the exact levels of our consumption from the salespeople. Two bottles here, two bottles there, a case somewhere else… Alcoholic drinking is by nature solitary drinking, drinking whose true nature is concealed from the outside world and, in some respects, from the drinker as well. [21]

Now, how does this secretiveness line up with denial? If alcoholics genuinely don’t know their drinking is a problem, why would they be hiding it? Can someone know something with life-or-death consequences and not know it at the same time? 

Though it doesn’t seem possible, the answer is apparently yes. One can be aware enough to feel an intuitive discomfort, but unaware enough to consciously disregard that discomfort. Quirky and mind-boggling, this “knowing-but-not-knowing” drives friends, spouses, and relatives crazy. 

Despite this subliminal awareness, most experts who deal with unrecovered alcoholics see them as authentically befuddled. Many sophisticated treatment professionals carefully distinguish between ordinary lying and this kind of denial. Robert Lefever, director of Promis Treatment Centers, says 

• We need to differentiate lying from denial. Denial is the basic psychopathology of addiction, where we genuinely don’t see what we’re doing… I’m telling the truth, but you can see that my truth is wrong. That is denial. And it’s very difficult for other people to tell the difference between denial and lying. The chap who says (in a noticeably slurred voice) “I haven’t had a drink” is telling the truth. He’s telling absolute God’s truth. You know that it’s not true. His truth is wrong. But he doesn’t know that, or she doesn’t know that. “I haven’t had a drink.” He believes it. She believes it. But it’s just not true. That is denial. And that is the basic psychopathology of all addictive behavior. [22]

Vernon Johnson likewise stressed that the drinker remains ignorant of the cause of his increasingly painful situation. Ignorance persists because the fog of denial expands on demand to hide the truth. And it expands in precisely the ways it needs to expand in order to keep the drinking going. Said Johnson,

• It is worth emphasizing, over and over, that the chemically dependent person remains utterly unaware of the progress of the disease. As the behaviors become more bizarre, the rationalizations simply grow stronger to compensate for the increasing numbers of instances that exact an emotional cost. Rationalizations are no longer trotted out on occasion; they are part of the fabric of everyday life. They are invisible, they are insidious, and they are a necessary – and potentially disastrous – response to the feeling of pain. The more the individual believes in his or her own rationalizations, the further into delusion he or she goes. [23]

Addiction expert and author Abraham Twerski notes that if we can’t accept that addicts are victims of their own distorted thinking, we can’t deal with them productively. We will simply remain frustrated and angry with them, an attitude that derails any benefit to them or to us. [24] Even though awareness may live within the alcoholic at some subliminal level, the fog of denial effectively camouflages it, and so robs it of its power. [25]

And yet, far beneath each alcoholic’s conscious evasion, nonsensical beliefs, and insane behavior, there persists a tiny sliver of reason. That sliver is a piece of surviving wisdom. Some would say he can find this wisdom at the level of his spirituality. It is a smoldering ember of intuitive awareness that can’t be touched by the disease, because it’s built right into his genes. The alcoholic can rekindle that intuitive sense into a fire of recovery, should he ever sincerely decide to do so.

An alcoholic epiphany

A concrete example may cast light upon the bizarre knowing-yet-not-knowing of denial. Author Sarah Hafner’s fascinating 1992 book Nice Girls Don’t Drink is a collection of first-person accounts that provide an intimate look into the experience of alcoholic women in America. One of the self-reported accounts is that of “Jane” (not her real name), who had her first alcoholic blackout at age 6. Early on Jane developed a fascination with alcohol, but vowed that she would never be an alcoholic like her mother.

Jane got her first taste of hard liquor at age 17. She liked it very much indeed. The only reason her drinking didn’t immediately fly totally out of control was that she didn’t have much money. Even so, she drank all she could. 

Jane developed serious symptoms—both physical and psychiatric. She had few friends, partly because she ditched those who expressed concern about her drinking. Her problems escalated to the point that she suffered from DTs, and was suicidal. Jane knew she was miserable—in fact, she knew she was near death. But she couldn’t put her finger on the source of her troubles. 

Jane ended up at the office of a psychiatrist who immediately diagnosed her alcoholism. The doctor referred her to AA. Jane did not agree that she had a drinking problem, despite having the alcoholic shakes every morning. She had to drink an “eye-opener” just to calm her twitching body. She was often so sick that she threw the liquor up.

Jane somehow began attending AA regularly. She liked the sense of warmth and acceptance she experienced in the meetings. But she didn’t quite grasp what the members were talking about. And she remained clueless about why she was there herself. 

It may seem strange that someone could attend Alcoholics Anonymous regularly without snapping to the fact that they have an alcohol problem. But Jane’s denial was intense at this late stage of her disease.  She was in a state of inattentional blindness. She had fixed her attention on her own pain, her anger about her miserable situation, and her pressing need to dull her tortured feelings with drink. 

Jane’s epiphany came at an evening AA meeting. Because the room was full, she had to sit in the front row. The speaker was a woman she had never seen before.

• I sat there looking at that woman, she looked so nice… Her nails were almond-shaped and perfect. She had on very understated but nice gold jewelry. Her hair was lovely, and I thought, “You have never been where I’ve been. You have never felt what I’ve felt or known what I’ve known.” The rage was unbelievable. Then I noticed as she went to light a cigarette that her hand was trembling. I think this was when the real miracle happened for me. I thought, “My God, she’s nervous.” And in that moment I became interested in another human being. I think that’s when my recovery began. [26]

The well-dressed speaker recounted a personal story even more horrific than Jane’s. It was through her identification with this attractive stranger, a woman she recognized as someone like herself, but modeling the courage to face the truth, that Jane finally saw the root cause of her own personal suffering. An alcohol professional would say that on that fateful evening her denial began to crumble.

Many faces

It’s important to realize that denial is not always a simple “I’m not an alcoholic.” It’s a state of skewed perceptual, cognitive, and behavioral functioning that has many faces. The term “denial”  is a generic label for that state, which can take several very different forms. Here are a few of them:  

• Simple Denial – Taking the position that excessive alcohol use isn’t an issue.(e.g. “An alcoholic? That’s ridiculous, John. I’m nothing like an alcoholic. I can stop drinking anytime I want.”) 
• Rationalization – Employing excuses or justifications to explain the problem away.(“Whew! Things got a little out of control last night. That’s the last time I mix beer and hard liquor.”)   
• Minimization – Admitting alcohol use, but downplaying its significance.(“Sure, I drink. But just a couple of beers—not hard liquor. It’s no big deal.”)
• Projection – Assigning responsibility for alcohol use to someone or something else.(“If you weren’t always bitching at me, Elaine, I wouldn’t have to drink.”)
• Avoidance – Removing oneself from situations that might make the reality of alcoholism apparent.(“I don’t need to see any damn doctor, Todd! I’m not sick!”)
• Intellectualization – Diminishing awareness through intellectual posturing or theorizing.(“Life is pain. Each of us must choose an anesthetic. I have chosen alcohol.”) 
• Diversion – Changing the subject to avoid dealing with the excessive drinking. (“Lighten up, baby! This is no time to argue. We need to get the kids off to school.”)  
• Hostility – Derailing discussion through expression of anger or counter-attacks. (“Get off my back, Kenny! You’ve got some nerve criticizing me! Clean up your own act, you jerk!”)

This list certainly isn’t exhaustive. Drinkers can use any combination of these forms, and are always inventing new variations. The incubation process shapes the specific form, and that form depends upon the individual’s thought process and personality. But whatever form it takes, its function is the same: what’s clear to outsiders (the negative consequences of drinking, the pressing need to halt the process) remains unclear to the alcoholic. 

As important as it is, denial is just the most visible part of a much larger distortion of perception. By the time the addictive pattern is fully incubated, the alcoholic is living in a different world. I do not mean that he has stepped through an inter-dimensional portal into a parallel universe. Yet his perception and his thinking have been transformed in ways that might make it seem that way. And like a lobster in a slowly heating pot, he probably hasn’t noticed the transition. 

The trickster

The intensity of the perceptual and conceptual distortion can fluctuate. A person can be relatively rational at one time—admitting that his drinking has gotten out of control, acknowledging problems, and seeing that things have to change. He may say he has to stop drinking—and may actually stop. Later, frustratingly and inexplicably, the blinders have slipped back on. 

This back-and-forth in denial is a major factor in relapse. An alcoholic can clean up, and go for years without drinking, without even the temptation to drink. Things seem perfectly fine. He breathes a sigh of relief, concluding that his problem is a thing of the past. 

Then, for no apparent reason, some strange notion pops into his head. It may occur to him that his long abstinence is “proof he is cured,” so he is at long last able to drink normally. Or perhaps that unusual levels of stress justify drinking “temporarily” in order to cope. Or that a new book on “controlled drinking” offers promising techniques he should in good conscience evaluate. Or whatever. 

It’s like a herpes infection that flares up unexpectedly, with no apparent cause. As with the herpes virus, the distortion and clouded thinking so typical of this disorder can remain dormant for long periods. But the absence of symptoms doesn’t mean it has gone away.

One way of talking about this is to say that the incubation process permanently installs a strange new perspective within the alcoholic. It’s as if a trickster friend has come to live with him. His new trickster buddy is likely to give him terrible advice at the worst possible moments. What the alcoholic doesn’t realize is that the entire purpose of the trickster’s advice is to undermine his sobriety, and start him drinking again. The trickster is part of the parasitic pattern, playing an important role in its ability to perpetuate itself.

The trickster’s terrible advice is well illustrated by the personal account of actress Claudia Christian. She knew that she had a serious drinking problem, but found it nearly impossible to stop. 

• I was swept up in a nearly decade-long battle with something I referred to as “the monster.” Addiction is a monster... You can be the most disciplined person in the world. When it gets you, it has you. It is in control... I relapsed close to 20 times, and each relapse became more difficult to recover from... I had 6 months of sobriety under my belt, and that’s when the addict started to talk to me in my head. That’s the insidious thing about addiction. Once you have a little bit of sobriety under your belt you say “Hey! I’m not an addict!” It whispers to you: “Go ahead. Have a drink. You’ll be able to control it. Just one drink.” So I listened to that idiot in my head. And I went out to dinner that night, and I had a glass of wine. And I came home and I was so chuffed. “Wow! Look! The idiot’s right. I’m not an addict. I only had one glass.” Right. Day two I had two glasses. Day three I had three glasses, plus I picked up a bottle to drink on the way home. Day five I was in a full-blown binge... [27]

At the time, the trickster’s advice seemed to make sense. But in retrospect it wasn’t sensible at all. The alcoholic later asks, “How could I have been so dumb?” How can someone with any intelligence fail to recognize such obvious distortion? The answer lies in incubation, the process that assembles the elements of “the monster.” Among those elements are sweeping changes in logic and perception that make up the trickster.

Book 1 of this series [28] emphasizes that each of us operates within a special sort of waking dream. Our actions are guided by our perception of the world around us. But the reality we perceive is never objective reality. It is a “constructed” reality. It is a personal model of the world built to the specifications of our individual needs. One way of speaking about the world of personal experience is that it is simply a useful map, a “user interface”  that helps us navigate toward our own fulfillment. 

But because it isn’t real, our perceived world can be manipulated. It can be modified to the point that we are no longer heading toward our own fulfillment. As an element of the overall zombification, the world of our personal experience can be rebuilt to the specifications of an addictive pattern. It can change so much that we end up living our lives in the service of a parasitic monster.

As the needs of the apprentice alcoholic converge upon the regular use of alcohol, incubation progressively reshapes the world as he perceives it to support the continuation of his drinking. A false reality is not what he wants. A false reality will not serve him. But a false reality is what suits the needs of the monster inside him.

In the end, the alcoholic’s perception of his environment, his perception of his own acts, his behavior, and his interpretation of the consequences of his acts are all quite different from those of others. Things that are obvious to the outsider are not at all obvious to the alcoholic. Behavior that seems normal and necessary to the alcoholic appears nonsensical and destructive to outsiders. 

As I have noted, the alcoholic’s logic may seem solid at times—only to turn squishy at some critical moment. I will illustrate this inconsistency with another example, this one from the Big Book of Alcoholics Anonymous.  

Jim (not his real name) was a good man of fine character. In his thirties, he had several encounters with heavy drinking, with disastrous consequences. He had lost his business and was at the point of losing his family as well. Jim finally conceded that he was an alcoholic, and in serious trouble. He accepted that he could no longer drink. He vowed to drop the habit, and to his credit did manage to stop. 

While on a sales trip, he stopped by a roadside restaurant. He knew they served liquor there, but he had no intention of drinking. He ordered a sandwich and a glass of milk. Then he ordered another sandwich and “decided to have another glass of milk.”

• Suddenly the thought crossed my mind that if I were to put an ounce of whiskey in my milk it couldn’t hurt me on a full stomach. I ordered a whiskey and poured it into the milk. I vaguely sensed I was not being any too smart, but felt reassured as I was taking the whiskey on a full stomach. The experiment went so well that I ordered another whiskey and poured it into more milk. That didn’t seem to bother me so I tried another. [29]

Shortly thereafter Jim became the guest of an asylum—and not for the first time. 

How could such a thing happen? Jim had been fully aware that he couldn’t drink, and he had actually stopped! Jim wasn’t stupid. Even so, a stupid idea waltzed into his head. In some distant corner of his mind there was a sense of danger. But for some mysterious reason he could not bring that alarm to his full awareness. [30]

The scary part of this story is the reason why he could not bring his concern to full awareness. Though he’d recently been avoiding drink, Jim had previously descended into full alcoholism. Incubation had installed a trickster in his life. Now and into the future, the trickster will give him crappy advice at crucial junctures. He will get stupid ideas that—in the moment—inexplicably seem to make sense. Once installed, the trickster cannot be uninstalled. But with recovery it will probably fall silent for long periods. That silence can be deceptive.

In the restaurant, the trickster nudged Jim. It briefly threw his thinking off-center and into a different place. His unfathomable willingness to indulge his idiotic notion returned him to a dark path, one he had sincerely promised never to travel again. For the few seconds it took him to take that first drink, his logic differed not only from the way other people reason, but from the way he himself was reasoning just a short time before. 

A cart-load of misery

Theorists have quite naturally wondered whether some personality types—those who tend toward depression, for example—are more likely to become problem drinkers. Reporting his unusually comprehensive study of alcoholism, George Vaillant commented that the question is understandable, because heavy drinkers do share dysfunctional traits. Further, alcoholics themselves may tell you they drink to control depression or anxiety, or to cope with unusual stress. 

But Vaillant cautions us not to put the cart in front of the horse. His data show that many of these commonalities are not premorbid traits. Rather, they are symptoms of the disease. Comparing it to a biological virus, it’s not that runny noses cause people to catch the cold. The runny noses are evidence of infection.

• Work by many investigators suggests that despite what alcoholics tell us, objective observation in the laboratory reveals that chronic use of alcohol makes alcoholic subjects more withdrawn, less self-confident, often more anxious, and commonly more depressed with increased suicidal ideation… [31]

Says Vaillant, alcoholism creates the very misery that the alcoholic escapes through drink. He cites a 1991 study [32] that looked at the relationship between anxiety and drinking over several months. Hospitalized alcoholics viewed themselves as chronically prone to anxiety and worry. Psychological testing confirmed they were indeed anxious. These patients rationalized their drinking as self-medication for their anxiety problem. 

But after two weeks of abstinence, their measured anxiety levels had returned to normal. The real kicker came after discharge from the hospital. Some patients began drinking again; others did not. The patients who relapsed over the next few months became anxious again. Tellingly, levels of anxiety in those that stayed sober continued to decline.

The same appears to be true for the depression that is so common among alcoholics. Drinkers often see themselves as “drowning their sorrows.” They believe they must drink to ease the pain of their depressing circumstances. Yet Vaillant cites “compelling prospective evidence that the prolonged abuse of alcohol causes rather than alleviates depression.” [33]

Louise Roper and colleagues reached a similar conclusion in a study reported in 2010. The alcoholics were patients admitted to a brief residential abstinence program. At the time of admission, all the patients reported high levels of depression and anxiety. Following a 3-week period of “drying out” and education, the same patients showed significant improvement in depression and anxiety. [34]

Taken together, these studies suggest that it isn’t premorbid depression and anxiety that cause the drinking. It’s the other way around. Drinking causes depression and anxiety. The alcoholic horse drags behind it a cart full of painful feelings. 

Is there anything else in that cart? Definitely. It’s packed with personal chaos. Remember that the general course of alcoholism is a downward spiral. That means things are progressively getting worse. Over time, an alcoholic’s life becomes a pattern of drinking, and dealing with the consequences of drinking. The alcoholic increasingly neglects and mismanages the important details of life, creating a muddle of disorder and dysfunction. If these facts are confusing for us, they are doubly so for the drinker.

The beneficiary

The desire to escape misery motivates drinking, but the drinking produces misery. The alcoholic pattern creates unpleasantness, which fuels continuation of the pattern. The downward spiral is a feedback loop. Like a whirlpool in a moving river, alcoholism is a self-replicating corkscrew of behavior that feeds upon itself. The misery in this spiral supports the pattern, not the drinker. It keeps the whirlpool going, endlessly recreating itself. The pattern itself is the one and only beneficiary of the misery and confusion it engenders.

For some, the downward course persists until the drinker “hits bottom.” Often the misery caused by drinking intensifies until he reaches a point of collapse. Some people think of persistent habits like alcoholism as simple pleasure-seeking—hedonism. While it’s true that the pattern often begins as pleasure-seeking, it’s the resulting misery that sustains it. 

One can choose to accept or reject the notion of behavioral disease. One can apply or decline the labels “behavioral parasite,” “parasitic habit,” “behavioral virus,” or “zombification.” But whatever we call these things, repetitive, stereotypical, pathological behaviors are something other than typical human habits, because in the end they have nothing to do with fulfilling human needs. They are not “something we do,” but “something that does us.” The patterns maintain themselves at our expense. They are not ultimately explainable in terms of ordinary human motivation.

Summary

• Alcoholism is a malignant pattern involving repetitive, excessive, compulsive consumption of alcoholic beverages. 
• At the heart of the disorder is denial, a characteristic perceptual-conceptual distortion. Typically, alcoholics have a hard time recognizing what is obvious to outsiders—that their drinking has become a serious problem. 
• The alcoholic pattern is a rogue habit that repeats itself for reasons mostly outside the control of the alcoholic. 
• The pattern persists through mutually supporting elements of several types—for example, learned habits and skills, denial, hereditary factors, and the experience of misery. 
• Each of the specific elements contributes to a feedback loop that replicates itself within the behavior of that individual. 

Next

Is alcoholism the only disorder we can interpret as a behavioral parasite? Unfortunately, no. Such things are quite common. In the next chapter we will look closely at a disorder we might assume to be completely unrelated—anorexia nervosa.

-------------------------------

[1] David Stafford is an author from Birmingham, England. Beginning his career in fringe and community theater in the 1970s, he has worked extensively in broadcasting. The quotation is from his author page on Amazon.com: https://www.amazon.com/David-Stafford/e/B000APE060/ref=dp_byline_cont_book_1. Accessed 12/19/2016.
[2] The DSM-5, the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (published in 2013 by the American Psychiatric Association) abandoned both “addiction” and “alcoholism” as diagnostic terms. It uses the term “Alcohol Use Disorder” to encompass what was formerly called alcoholism, for the stated reason that it is a “more neutral term.” We are using the older term alcoholism here because it more clearly implies an addiction to the use of alcohol.
[3] Much of the material in this chapter is recycled from another book in the series: [Whitehead T. Alcoholism: The Big Picture. A Kindle book, Published 2017, available from Amazon.com].
[4] Park CL. Positive and negative consequences of alcohol consumption in college students. Addictive Behaviors, 2004, 29, 311-321. Page 311. Of course, in drawing a distinction between social drinking and alcoholism we do not mean to imply that one can freely indulge in heavy social drinking without risking situational or health consequences. The available evidence makes it clear that there are serious consequences to all heavy drinking.
[5] The DSM-5 defines Alcohol Use Disorder (AUD) as “a problematic pattern of alcohol use leading to clinically significant impairment or distress…” It specifically points to (among others) the following as signs of AUD: use in larger amounts or over a longer period than intended; failure to fulfill major role obligations at work, school, or home; important social, occupational, or recreational activities are given up or reduced; recurrent alcohol use in situations where it is physically hazardous. [American Psychiatric Association. Desk Reference to the Diagnostic Criteria from DSM-5. 2013, American Psychiatric Association, Arlington VA. Page 233.]
[6] Vaillant G, 1995. Page 35.
[7] Leshner, AI. Addiction is a brain disease. Issues in Science and Technology, 2001, 17, 3. Available at http://issues.org/17-3/leshner/. Accessed 10/22/16.
[8] Nace EP. The Treatment of Alcoholism. Brunner/Mazel, New York, 1987. Pages 62-95.
[9] Morse, R and Flavin, D. The definition of alcoholism. Journal of the American Medical Association, 1992, 268, 8, 1012-1014. Page 1012.
[10] Interestingly, the DSM 5 does not include denial as one of the defining characteristics of addictions such as alcoholism. This omission places a roadblock in front of those seeking to more deeply understand its dynamics. In the absence of denial, it is difficult to grasp why an addict would not voluntarily end the pattern soon as it becomes obvious that it is destroying his health, his family, and his career. If we assume he knows perfectly well what he is doing, we are left with no choice but to condemn him for his shocking betrayal of himself and those he claims to care about. As we will see, most addiction treatment professionals do see denial as central to the psychopathology of alcoholism.
[11] Nace EP, 1987. Pages 89-91.
[12] Johnson VE. Intervention: How to help someone who doesn't want help. Johnson Institute books, 1986.
[13] In medicine, the term “incubation” refers to the development of an infection from the time the pathogen enters the body until it causes overt signs or symptoms to appear. Here I use the word incubation to refer to the time period between first use of alcohol and the appearance of alcoholic zombification. Although Johnson described the incubation process clearly enough, he did not himself use that term. Nor did he use the term zombification.
[14] Mike is incubating an addictive habit too. He becomes addicted to keeping his attention on Barbara’s issues rather than dealing with his own. This pattern is called codependence. It enables continuation of his wife’s drinking. But that’s a story for another time.
[15] Leshner, AI. Addiction is a brain disease. Issues in Science and Technology, 2001, 17, 3. Available at http://issues.org/17-3/leshner/. Accessed 10/22/16.
[16] Viral parasites do not of course have hearts. Nor do they have feelings. They don't have brains, or any awareness. There’s doubt they are even alive. They’re too simple to qualify as complete lifeforms. Nevertheless (and this is the confusing part) viruses do have interests (defined as a stake in an outcome favorable to them), a goal (an outcome that addresses their interests), and strategies (specific techniques for achieving their goal). How is that possible? Our own goals and strategies arise from our awareness. But viral patterns evolve theirs. Or in the case of addiction, they develop them through incubation. We will discuss the incubation process in more detail later.
[17] Vaillant G, 1995. Page 33.
[18] Pickard H. Denial in addiction. Mind & Language, 2016, 31, 3, 277-299. Pages 277-278. Available online at http://www.hannapickard.com/uploads/3/1/5/5/31550141/denialaddictionhpickard.pdf. Accessed 9/27/16.
[19] LaChance AJ. Cultural Addiction: The Greenspirit guide to recovery. North Atlantic Books, Berkeley, California, 1991. Page 3.
[20] Smith K. Breaking through denial in addiction. August, 2015. Online article available at http://www.addictionhope.com/recovery/self-help-tools-skills-tips/breaking-through-denial-in-addiction/ Accessed 8/27/2016.
[21] Knapp C. Drinking: A love story. 1996, Delta Books (a division of Bantam Doubleday Dell Publishing Group, Inc.), New York. Pages 102-103.
[22] Lefever R. Addiction – Denial or Lying. Video presentation detailing the philosophy of Promis Treatment Centers. Presented July 3, 2012. Available online at https://www.youtube.com/watch?v=O3dO0A06icg. Accessed 9/5/2016.
[23] Johnson VE, 1986. Page 26.
[24] Twerski AJ. Addictive Thinking: Understanding Self-Deception. 1997, Hazelden Foundation, Center City Minnesota. Page 13.
[25] Not every clinician agrees that denial is the centerpiece of addictions. Addictions expert Judith A. Lewis, for example, prefers to frame the addict's irrational rejection of evidence in terms of his ambivalence about whether to stop the abuse pattern. She writes, “This ambivalence about the possibility of change is often interpreted as 'denial' or 'resistance.'  Yet there is no evidence that denial is an inherent characteristic of addicts.” [Lewis JA. The addictive process. Chapter in Addictions: Concepts and Strategies for Treatment (Judith A. Lewis, ed). Aspen Publishers, Gaithersburg Maryland, 1994. Page 6.]
[26] Hafner S. Nice Girls Don’t Drink: Stories of Recovery. 1992, Bergin and Garvey, New York. Pages 3-25.
[27] Christian C. How I drank more to overcome alcoholism. TEDx Talks. TEDxLondonBusinessSchool, May 31, 2016. Available online at https://www.youtube.com/watch?v=6EghiY_s2ts. Accessed 9/25/16.
[28] Whitehead T, 2016(b).
[29] Alcoholics Anonymous, 1976. Page 36.
[30] It is interesting from a psychotherapist’s perspective that the trickster initially let Jim experience his craving as thirst for a harmless glass of milk. The trickster then slipped a shot of whiskey into the milk, all the while sustaining the impression that it was “just milk,” and therefore could not hurt him. The trickster also disguised the central issue. Jim knew full well that his problem was alcoholism. But in the moment his focus was inexplicably switched to the issue of whether the whiskey would “bother” him. Insidious!
[31] Vaillant G, 1995. Page 77.
[32] Brown SA, Irwin M, Shuckit MA. Changes in anxiety among abstinent male alcoholics. Journal of Studies on Alcohol, 1991, 52, 55-61. As reported by Vaillant G, 1995. Pages 79-80.
[33] Vaillant G, 1995. Page 81.
[34] Roper L, Dickson JM, Tinwell C, Booth PG, McGuire J. Maladaptive cognitive schemas in alcohol dependence: Changes associated with a brief residential abstinence program. Cognitive Therapy Research, 2010, 34, 207-215.