Honouring Strength: Overcoming Addiction Identities

My thesis explores how some people manage their relationship with / without alcohol in ways that do not seem to harmonize with status quo discussions of alcohol abuse and recovery. My question was: How do the experiences and needs of those overcoming addiction independently of 12-step / disease-model culture impact social work practice? This qualitative study explores experiences of seven "outsider" participants. Two quit drinking completely without the help of addiction therapy or self-help groups; the remaining five participants reclaimed a manageable relationship with alcohol after years of dedication to 12-step programs. The participants’ experiences are explored using a social constructionist cultural model. Issues regarding the political context of addiction counselling are explored, and implications including assessment and resource development for social work practitioners are discussed.

After 20 years as a social worker / alcohol and drug counsellor in northern British Columbia, my practice has been greatly impacted, strangely enough, by political rhetoric. After earning a degree in psychology, I found that strategies I learned were not acceptable to the support agencies in the town where I started my career, unless they were within the theoretical boundaries of the disease model and the 12-step approach to treatment for "alcoholics" (a self-proclaimed title). I understood the practical reasons for this policy; essentially, before alcohol and drug counsellors were available, the local community depended on Alcoholics Anonymous as the only support for people with alcohol problems. Later, as I earned my BSW and moved to a somewhat larger northern community, I found there was more room for a variety of approaches in a multi-staff alcohol and drug counselling office. I found that, as a result, I had a front-row seat to the political turf wars between multiple recovery cultures. Polemic disputes occur on several levels. One concern is over the ethical dilemma of client self-determination versus a prescriptive disease model that assumes that "insanity" and "denial" (terms often used in 12-step literature) preclude the client’s capacity to make healthy choices. Another level relates to policies and practice of harm reduction versus zero-tolerance and tough-love approaches. The conflict also highlights disputes about the context of expert knowledge (those with personal experience versus those without). The fundamental issue is the debate over alcohol addiction as individual experiences of one truth, one journey, and one solution informed by pathologizing practice, versus a perspective of addiction as individual experiences with multiple knowledges, journeys, and many uncharted territories where outsiders find themselves (Korzybski said that "the map is not the territory" (Truan, 1993). Consequently, the uncharted is beyond the conception of the rhetoric commonly used to understand the experience of addiction).

People have been coping with the negative consequences of drinking alcohol since the beginning of civilization. However, how these causes and consequences associated with drinking problems are defined varies according to culture. For example, modern western perspectives of alcohol addiction management are heavily influenced by medical positivist research (Peele, 1989). In contrast to positivist traditions, cultural studies theorists (Alasuutari, 1992; Bannerman, 2000; Denzin, 1993; Gusfield, 1996; Pinderhughes, 1989) have played an instrumental role in informing my research of alcohol problems and recovery. As Pinderhughes (1989) observes, "Culture determines how we see a problem and how we express it¼ " and culture can "determine what specific symptoms people experience, whom they seek out for help, and what they regard as helpful" (p.13). Key concepts that are useful from cultural studies include the valuing of discipline-jumping and genre-jumping; bricolage; polyvocality; and incompletion or non-closure of knowledge. These concepts embrace some postmodern assumptions: that reality is subjective in relation to our experience, and that experience is informed by more than one framework. Consequently, knowledge itself is as relative as our self-awareness in relation to people we observe (Furman & Ahola, 1992; O’Hanlon, 1993; White, 1993).

This study was developed based on a relatively regular phenomenon, which has fascinated me throughout my career as an addictions counsellor. I have witnessed individuals who were able to establish a more meaningful identity in relationship with alcohol after many years as an "alcoholic" or "alcohol-dependent" person. This has occurred in spite of a general belief among addiction treatment professionals that those with serious substance abuse problems warrant a "substance-dependent for life" label. Consequently, these persons achieved their success by methods outside the boundaries of traditional disease rhetoric and intervention.

The controversy created by outsider experiences reflects, from a cultural studies perspective, the influences of more dominant cultures and how these ideas seep into the community in which this study was conducted. Dominant ideas are sold through a market-driven deluge of television shows, magazines, music, and newspapers. This subtle or overt propaganda is disseminated through many modes and role models. For example, a key character in the award- winning, long-running ABC network television series NYPD Blue(episode 65, "Closing Time," broadcast on May 14, 1996, written by David Mills and directed by David Rosenbloom), detective Sipowicz (played by Dennis Franz), suffers loss of control over his drinking. The character’s capacities deteriorate until he surrenders his will, asks for help, and rejoins AA. In this series, Sipowicz also tries to sponsor another department member. This plot depicts the classic American disease model view of anyone with a drinking problem. Many depictions of alcohol or drug problems as viewed from the disease / recovery culture are demonstrated in popular culture, from major motion pictures such as Leaving Las Vegas (Figgis, 1995), Clean and Sober (Howard, 1988), and 28 Days (Thomas, Topping, & Grant, 2000), to television episodes, to themes and images pervasive in most forms of media. Marketers for brewers or distillers construct dream sequences of bikini or Clydesdale teams on the air to remind the consumer that the good life happens with alcohol. The consumer’s boring lifestyle is shaken, not stirred. The capitalist prerogative to saturate markets for profit continues, neither acknowledging nor taking responsibility for the consequences. Whereas marketing discourse serves to popularize drinking, alcohol problems are marginalized, objectified, and relegated to the gaze of medical discourse. To have a problem with alcohol is to be abnormal. The message is that if you join a fellowship, abstain, and toe the line, perhaps you will be redeemed, or at least viewed more acceptably, like detective Sipowitz. How does this polarized perspective serve the needs of persons who seek help? What is the role of the social worker?

The field of addiction treatment has often been described as a multidisciplinary setting, with competing etiological assumptions and theoretical applications concerning addiction and therapy. Since the inception of the Alcoholics Anonymous fellowship in the 1930s, there has been significant progress in the development of therapeutic methods to assist individuals with alcohol- or drug-related dependencies (Baker, 1988; Berg & Reuss, 1998; Blum & Roman, 1987; Chang & Philips, 1993; Roberts, Ogborne, Leigh, & Adam, 1999a). Nevertheless, in North American culture the concepts of the disease model and 12-step program treatment dominate (Kaiser Foundation, 1997; Lender, 1979; Roberts et al., 1999b). The culture of the disease model and the 12 steps of Alcoholics Anonymous tend to predominate and marginalize alternative options in northern remote communities.

For many who overcome an addiction habit, personal identity relating to the process of recovery changes over time (Sommer, 1997). Others who face addiction and are adversely affected by the dominant practices of the "recovery industry" (Peele & Brodsky, 1991) find alternative ways of healing. Whereas society often marginalizes the addicted, 12-step discourse often further marginalizes those who do not conform to the accepted etiological assumptions and resulting implications of the program (Granfield & Cloud, 1996; Kearney, 1998a; Peele & Brodsky, 1991). In spite of pressure toward conformity in the culture of recovery, there are those who have success in overcoming addiction in their own lives outside of a 12-step program or formal treatment (Anderson, 1994; Granfield & Cloud, 1996; Kearney, 1998a).

These stories of outsiders who eschewed the alcoholic-in-recovery identity may reflect a self-perception based on strength and capacity, turning away from a deficit identity. Some of these people tell stories about learning to accept love, and about taking responsibility not only for their potential worst, but for their best as well. These persons seem to have developed a maturity and insight that comes from years of personal work and growth. One participant described a journey of discovery for the love within himself he knew wasn’t afforded him as a child. Others describe their families as their greatest strength, and that placing the family first affirmed all of the love, support, and incentive needed. Still others found that stepping out of the culture of recovery was necessary to reclaim their creativity and find love. Other qualities included demonstrations of strength, commitment, compassion and consideration for others, and a potent determination to never again give up their right to decide how to view the problem, or the solution. Outsider recommendations invite reflection on what it means to offer a no-harm practice; I believe we do no harm whatsoever to our clients by identifying, amplifying, and celebrating their strengths and capacities.

The information described from the experiences of these people may have some interesting implications for social work practice. These insights may also have meaning outside of the boundary of discourse on alcohol problems and recovery, in that some of the participants’ stories reflect a similar context of struggle experienced by others, such as people with drug problems or smoking and eating disorders.

Method

The research question I developed for this study was, how do the experiences and needs of those overcoming addiction without the 12-step / disease model culture impact social work practice? I conducted an interview study with seven participants, using a flexibly structured interview process in order to ensure participant experiences would be documented in their richest detail, in relation to the objectives of this research. The social constructionist (where meaning is negotiated in discourse) design was intended to invite participants into a "co-authorship" relationship, sharing power and insights. This "co-authorship" function was supported through a member-checking follow-up discussing and negotiating the results of a retrospective analysis of problem severity and a thematic analysis. The "co-authorship" intention of this research is demonstrated through the use of participant quotation as much as possible to ensure that experiences, theoretical developments, arguments, and other insights could be credited to each of the participants. The use of quotation would also serve to distinguish my voice in the research from theirs - enhancing reflexivity, as well as the credibility and transferability of the participants’ experiences.

Due to the politically controversial nature of this research, I chose to conduct a retrospective analysis of problem severity, in order to address the argument that participants did not suffer from serious alcohol problems. I documented, through personal review of interview transcripts, the extent of alcohol-related problems apparent in each participant’s narrative. I developed the units of measure for this analysis by adapting criteria from the DSM-IV-TR, which is widely accepted in addiction assessment discourse. I did not use the specific substance dependence criteria from the DSM-IV-TR, to dispel any assumption that the participants in this study could be diagnosed as substance dependent. This analysis was limited to the presence of evidence within each participant’s narrative that satisfied each of the adapted criteria.

I also conducted a thematic analysis; however it was not my intention to attempt an exhaustive, complete description of participant narratives. According to the social constructionist view that meaning is a dynamic, ongoing negotiation within discourse, the notion of completion is an unobtainable goal. I ended the analysis development when the information from each participant had been thoroughly reviewed according to the objectives I developed reflecting the research question. Furthermore, I chose not to overly interpret participant experiences through the thematic analysis, preferring instead to use quotation from the participants to allow their direct input to discourse with the reader. I believe that this decision supports the integrity of the social constructionist process, the wisdom of the participants, and the imagination and critical judgement of the audience.

There were, in the end, seven participants. In retrospect, I believe I could have found many more outsider interviewees who would have shared their divergent success stories. Five interviews were conducted face-to-face, one by telephone, and one via email. Interviews (other than the email process) were audiotaped with participant permission, and transcribed.

I managed to contact six of the seven participants for the purpose of member-checking, after providing each of them a copy of their transcribed interview and a draft of the thematic framework I had developed. Each indicated they believed the model I used accurately reflected her or his personal experience and perspectives. One participant did not respond to my package nor to several phone messages. Since this person had been provided several means to contact me, had been briefed prior to signing the consent to participate, and had been informed of my timeline, I assumed that her silence did not constitute her withdrawal as a participant. She received a copy of the finished thesis as mutually agreed.

The participants in this study have all experienced serious alcohol problems, ranging from tolerance and avoiding important events because of drinking, to withdrawal seizures. However, the retrospective analysis was controversial for the participants. Beth, (all participants have been given pseudonyms), provided some feedback regarding this analysis which I believed reflected a common concern participants had, over a process which involved potentially pathologizing practices:

I think it is important to understand that I am not a certified diagnostician, nor did I approach this analysis from a completely neutral and objective position. Moreover, there are obvious weaknesses in retrospective self-reports, particularly concerning descriptions of character blemishes, and especially regarding recollection of events over a decade old. It was my intention that this exercise would provide evidence to caution any assumptions trivializing the impact of participant histories with alcohol.

I attempted to create a framework to describe participant experiences, and came up with a map (Figure 1) of the model I developed for the purpose of organizing information from participants’ narratives:

The model I developed is somewhat simplistic; I began with the social construction concept, mapping the process of negotiating meaning through discourse. Within the social construction process, each interview had moments when the participant was her or his own narrator. Consequently, each story was grounded by descriptions of self, the "I," a dynamic focal point that I referred to as personal identity. The participants’ conversations reflect their present sense of identity, situated in the present, in context to their story and their visions for the future. Their narratives include stories of their experience with different alcohol-related environments, which I have argued can be considered as cultures. Different rhetorical frameworks such as the disease model and the philosophy of the Alcoholics Anonymous fellowship also inform discourse according to each view of people attempting to overcome alcohol problems. I chose to describe these different perspectives as cultures as well. For example, all participants spoke about living in modern society, which I refer to as the dominant culture (Fillingham, 1993; Rabinow, 1984), and about their "old relationship with alcohol," which involved other people, rituals, practices, and meaningful experiences. Whereas some participants speak of a new life without alcohol (which I termed "Abstainer Pioneers"), others speak about entering the fellowship of Alcoholics Anonymous or other 12-step programs and later reclaiming their ability to drink responsibly (which I termed "New Relationship With Alcohol"). Each of these situations involves other people, specific rituals, practices, and meaningful experiences. Viewing these different milieus as cultures has been accepted practice (Alasuutari, 1996).

Participant narratives provided information that suggested some similar experiences. I have categorized experiences relating to personal development and self-concept, such as "strong conviction", "focus on strengths / abilities", "resist limiting rhetoric" and "adapt to change". Other experiences that related to environment and lifestyle I depicted as other cultures. Consequently, personal experiences outside of the aforementioned cultures, such as the 12-step fellowship, could be recognized as contributing factors in the mediation of identity.

Although the participants’ narratives resemble a generally linear storyline, each person’s current identity has been cumulatively impacted by their experience within each of these cultures. Each of these cultures’ perspectives relating to a person’s current relationship with alcohol, whether abstinence or responsible use, is a mediating factor in the person’s self-concept and their identity as they adapted to a new lifestyle. Consequently, there is an ongoing relationship between personal self-concept and different cultures, proportional to the person’s experience, where meaning and consequent identity integration are constantly negotiated.

For the purpose of this model and the analysis, I considered the tools used in the mediation and expression of culture and concepts of personal identity. Common methods I noted included story, metaphor, good or bad appraisals, description of everyday life, theoretical view and development, and the integrating statements.

Each participant’s narrative is a story in itself, and within each narrative are many stories that help to situate the person in his or her context, relating to the surrounding culture that he or she was immersed in. These stories are the allegories that inform the listener about the significance and the meaning attached by the teller. They are the building blocks of these people’s messages—their most vital tool in communicating their experience. Consequently, participant stories have been constructed in a manner specific to this research, and would have been constructed differently in another situation.

The use of metaphor, a figure of speech where one word or phrase is used to imaginatively but not literally replace another, has been a significant and long-standing tool of qualitative research (Gubrium & Holstein, 1999). In recovery culture, one can expect to find a rich and seemingly endless number of metaphors (or codes and ways of decoding cultural insiders’ constellations of meanings). Each one is essentially a story unto itself; perhaps it is an allegory with a moral or an in-your-face political message. These metaphors are the shorthand of the political rhetoric of recovery, which involves major transformations, such as the emergence of a new identity, or profound shifts in the perceptions and practices of everyday life. These metaphors can describe experience across cultures, such as Joe’s:

Like my AA buddy, who is hard-ass, hard-core AA, has no concept of his motives, although he’s learning. I can’t help but love the guy. But we have another connection. We met in school, when I was making a career change. We have a bond that is from being in another trench. From being in the school trench¼ (Joe)

Or the recovery metaphors can be cloistered within a culture, closed and cryptic, such as "A friend of Bill’s (in reference to Bill Wilson, one of the founders of Alcoholics Anonymous,)", "I took the pledge," "disease," "cunning, baffling, and powerful¼ " "the word of recovery." Such metaphors mark insiders to each other, and exclude those who are outside of the culture of AA. Other metaphors can also provide a powerful indicator about how the teller views his relationship with the problem, the culture, or another relationship, such as, "I was firmly captured and imprisoned by the alcohol"(John).

Appraisals are a significant part of the process of moving from one culture to the next. They can provide a method of preparation for migration similar to Smith and Winslade’s work (1997), grounded in a number of practical models assessing change, such as motivational enhancement (Miller & Rollnick, 1991) and the transtheoretical model (Prochaska et al., 1994). Participant stories tend to indicate the level of commitment a person has in a culture by the preponderance of positive appraisals about the culture, relating to her or his identity. Judy spoke about AA, and stated:

There’s no doubt it helped me, there’s no doubt about that. It gave me people to be with that were trying to stay sober too, which is what I needed and they supported me. And I think that’s AA’s absolute biggest asset: people caring. And it put me on some paths that I wouldn’t have explored if I hadn’t been there, like spirituality. (Judy)

Stories reflecting outsiders’ ambivalence tend to include more of a balance of good and bad appraisals for different cultures. John gave a poignant example during a moment of reflection:

It makes me think back to that old story about AA, "once an alcoholic, always an alcoholic," right? And I dismissed that, at one point. But I need to know under new evidence, re-evaluate¼ Because I certainly don’t want to be going back to where I came from. But saying that, that little voice of alcohol pops up and says "maybe." (John)

Exit stories tend to reflect a shift of appraisals, with the bad ones describing the culture being left behind, and the more positive stories describing the culture they are moving to. These positive appraisals often incorporate powerful reflections of personal strengths and identity. Joe provides another excellent example:

I stepped off into the world. I couldn’t stand the hypocrisy. And you know what? At some point someone came along and said to me, "Well, you know, these [meetings] are great, but you get healthy here, and then you move on." And it was a seed that they planted in my head. It was just a thought, just an idea. It sat there, and suddenly I realized that I can’t stay here forever. (Joe)

Participants who have settled into a new, possibly outsider identity over time may begin to use positive appraisals about former cultures, in proportion to the number of ideas from the culture they have been able to incorporate into their new identity. These appraisals are indicators reflecting the negotiation of meaning between cultures and personal identity. Judy reflected:

And you know, to give AA their due I learned some good things there, too. Like ways to deal with fear, and just all the things life brings at you¼ the "one day at a time," that’s good advice for anyone. (Judy)

Everyday life experience is the common ground between personal experience, social and cultural context, and theoretical perspectives (Alasuutari, 1992). John provided a poignant picture of living in a world of hopelessness:

I tried suicide¼ because to me at the end I termed it being between the proverbial rock and a hard place. I took the gun out, I loaded it, I stuck it in my mouth¼ and I couldn’t pull the Goddamn trigger. I was scared of living and I was scared of dying and I had nowhere to go¼ For me, even when I wasn’t drinking, I could be out on a beautiful sunny day like this walking down the road and it would actually look grey. It was just dull. And that was my whole affect, right? I know, my first sponsor, he said he used to watch me walk by and I never looked up. I was watching my feet, walking down the road¼ (John)

These are the parts of a person’s narrative that provide the witness with a window to life at that time, and provide an illustration of how different cultures and political views look and feel as normal, everyday experience.

As a person migrates from one culture to another, explanations become a natural part of integrating the process. It is noteworthy to consider the migrating person’s explanations from the perspective of the different cultures she or he is negotiating. These explanations are the core of the social construction process. This is where political rhetoric crashes into personal reality and anecdotal truth. For example, George described his personal model of addiction as, "I believe it’s a mental thing, not a physical thing, in that sense. I figure that if it’s mental then you have control over that, as a person." George’s theory is his practical explanation of his success in abstaining without help. If the reader reflects on his perspective in contrast with the deficit-identity messages of the AA fellowship, the implications of rhetoric on the person’s identity and attributions of success become more apparent. Other statements that exemplify participants’ outsider theoretical views include "The pain and anxiety of growing up in that household, that’s why I drank," (Joe); "Alcohol, it isn’t the substance that’s the problem, it’s the user" (Joe); "It’s about a number of things. It’s about running, it’s about not facing reality. It’s about fear. It’s about pain" (Claire).

Integration statements are affirmations regarding self-concept in relation to cultural influence. These are the statements that reflect upon what a person’s story is telling her or him about who she or he is as a person. Many stories end with integration statements, whether these stories are allegorical or about the living journey itself. Integration statements are often reflective potent descriptions, with a focus on what is and leaving behind what isn’t. These statements can also reflect fundamental understandings about need, hope, and acceptance, and can be spiritual affirmations: "Let’s say I was an alcoholic" (George); "I’m one of the strongest people I know" (Joe); "The choice I made I feel great with," and "I didn’t make this decision thinking everybody was going to accept it. I didn’t make it for them, I made it for me" (Claire).

I have identified and described these different processes of negotiating and expressing meaning as if they were mutually exclusive; obviously this is not the case. These processes are more than the sum of their parts, and they are interconnected; it would be unlikely to have integrating statements without inferring some theoretical view, good or bad appraisals locating self-concept in relation to political rhetoric, or without the use of metaphor. Wrapping the entire context of a person’s identity and journey into the label "story" seems to trivialize the person’s experience and meaning. A story is just one description of the complexity of one’s experience. It is the profound nature of the experience that makes these stories so rich and provocative.

Each participant story of experience reflects more than one culture, and some reflect the influences of more cultures than are within the scope of this study, including cultures of ancestry, career (for example, families of railroaders), or gender. The process of describing the different cultures in the participant stories resembles a general map of the journeys the participants took, implying an archetypal story worthy of Ulysses’ narration. However, "the map is not the territory." Although the description of the different cultures is offered sequentially as a general narrative roughly similar to these participants’ experiences, this framework should not be considered as a grand story but rather as a reflection of each participant’s identity development in relation to the impact of different cultures over time. Each participant took her or his own journey toward a better identity.

Participants offered their own ideas about what they felt professional practitioners need to know in order to help others struggling with addiction problems. Here’s what they had to say.

Joe’s response addressed his own experiences with counsellors:

If you choose to be in social work, or a counsellor or something, you’re choosing to help people. Then you better have helped yourself.

Joe implied the need for professional helpers to understand his theoretical framework: that addiction is merely a destructive solution for underlying issues. While Judy provided some hints at her own etiological assumptions about addiction, her advice is simple:

I’ve got a bit of a biologist, science kind of slant with my work, and I don’t believe it’s a disease until I have the proof.

Judy’s last statement implies the need for client-centred practice; giving people the room to do whatever works requires providing therapeutic space to respect the client’s perceptions of problems, solutions, goals, and outcomes.

George’s response to the question, "What do you think that professional people (social workers, therapists, and the like) need to know from your experience about overcoming addiction?" was powerful:

I think [pause] as witnessing the Ministry’s [of Children and Family Development] problems that they have—they’re understaffed, they’re underpaid, and they have one social worker for two handfuls of kids. They cannot protect them all, they cannot be eyewitnesses to everything that goes on in the houses were they are.

Yup that was the gist of it. I feel that [pause] that kids today, they’re probably in worse than I ever was because before when I was going to school, you know everybody partied on the weekends and stuff, but drugs wasn’t the problem that it is today. Kids, you know [pause] you got to get to them early in my eyes. (George)

George’s response reflects his values about nurturing children, which he believes needs to be the principal focus for preventing or reducing the harm of substance abuse.

Gina’s answer, in response to why she decided to participate in this research, reflected a holistic worldview, addressing everything from the desire to live to self-care:

You’re going to pass it along, and maybe somebody will benefit from it, they’ll be open about themselves, and, just spewing your guts out about what your problem is. Don’t be afraid, don’t try and hide it. You want to do something. Everyone wants to help themselves, nobody wants to die. Nobody wants to.

Gina’s response reflects the need to recognize and develop goals with people in a holistic manner, addressing issues from physical health to a healthy environment, parenting, and hope that provides motivational and spiritual grounding for a person to reclaim a life worth living.

John’s insights underscore the need for patience, persistence, and empowering people who are overcoming alcohol problems:

I think the most important thing I think for people working with people with alcohol and drug problems is it’s a process. Relapse is normal. I’m trying to think if I know of even one person who never had a relapse. Including myself up till the time I actually got it, like I tried to quit a hundred times. You know? It didn’t work. ’Course I wasn’t trying to get any support or figure out a way to do it, I was just going to stop drinking.

John’s advice reflects Gina’s ideas about working from a holistic framework, and Joe’s theoretical view that addiction masks underlying issues. I infer that his thoughts about patience and perseverance, about the non-linear process of recovery, and the need for empowerment suggest client-centred approaches. "Give them power" implies the concept of therapy as a political act, a perspective amenable to feminist and narrative therapeutic frameworks.

Claire, responding to the question, "Imagine that you have been given a magic wand, which will help you create the ideal circumstances for people like yourself to resolve their addiction problems. What would you like to do?" demonstrated her insight as a practitioner:

What would I do? Oh wow, that would be so much fun! I would have everything in one centre. And what I mean by that is after they were all detoxed and stabilized and all that kind of stuff, instead of just preaching the 12-step programs, going through the little alcohol and drug system during recovering planning, I would have them meet people in the programs that were¼ . Say the 16-step empowerment program because it’s a lot different than a 12-step program. And yet they would meet the 12-step program people. They would meet people who are doing what I’m doing today. Like harm reduction I guess would be the word cause I can’t really find a word for it. Yeah, so they would have all the choices, all the time in the world right? You can learn about them all, and they all have their own little workers of course, [laughter] cause we got lots of money. One-to-one here, who had no opinions except to totally inform them and completely empower them to make their own choices. Then I think people would get recovery, but it costs a lot of money. Because I think that when we’re making choices for other people we’re not empowering them so we see them over and over and over again. But I also think they don’t have the money to do that, right?

Claire’s professional advice to colleagues strongly promotes client-centred practice: to eschew assumptions that clump clients into one category, to understand a person’s individuality, to absolutely listen, completely inform, and completely empower. Claire recognizes the authority of her professional status, but argues that decisions need to be made based only on the person’s needs, which I believe would take priority over the dominant discourse of institutional privilege. Claire’s belief in referral implies a professional duty to help situate clients back in their lives with resources that fit their needs.

Beth clearly provides an invitation for practitioners to accept and support clients who need to find their own path to a better life:

The ideal circumstances for people like me to resolve addiction problems would be to work with someone and /or a group that is not going to try and peg me into an already set pattern of use and that has the attitude of exploring who I am, what I need, what and how to be happy, healthy and fulfilled in ways that are not going to hurt me or others. A program of some sort that teaches ways of living in the world. This scenario would be expanding, empowering, and full of experiments. It would be far removed from disease and a continual alcoholic identity.

Beth’s advice also promotes self-determination reflecting client-centred practice, but with a distinctly postmodern flavour. She suggests a focus involving a counsellor’s intimate self-awareness, genuineness, and listening without judgement; and a process that eschews deficit rhetoric and promotes experimentation and exploration of needs, identity, and fulfillment in the context of the world.

When I reflect on these persons’ narratives and their suggestions intended for the professional practitioner reading this work, I believe they are asking to be listened to and respected as individuals, and to not be judged. I believe they meant that they’d like their issues to be treated in a manner that respects their individuality, and not as problems that fundamentally limit how they should see themselves. I believe they respect practical solutions for alcohol problems, including abstinence, especially in the beginning of the process of reclaiming their lives.

Participant experiences challenge a number of "one size fits all" theoretical tenets grounded in the etiology of alcoholism as a disease. Specifically, in spite of personal histories of serious alcohol problems prompting professional assessment and referral to AA, some participants’ current relationship with alcohol is not characterized by compulsive use, loss of control, nor progression. Four out of the five participants who chose to experiment with controlled drinking have managed to do so successfully for a period of time ranging from two years to more than a decade. These four participants indicated that they control their alcohol consumption and have not experienced compulsive urges or negative consequences attributed to their drinking. Consequently, there is no evidence of the phenomenon of progression. The fifth participant, John, who was ambivalent about his alcohol use, has made some significant changes, is now abstaining (without using disease / 12 step rhetoric), and enjoying a range of recreational and social activities.

Consequently, participant narratives challenge the primary tenet of the medical model of alcoholism: that it is an incurable disease. Disease concept proponents would argue that these four persons have demonstrated merely that they are not alcoholics. Although this is a possibility, this argument does not acknowledge the serious nature of each participant’s past troubled relationship with alcohol. Nor does this argument address the fact that professionals, and / or fellowship members themselves supported these participants’ inclusion into 12-step culture at one point, thereby accepting them as "recovering alcoholics." In fact, this argument tends to reflect the political nature of the disease concept, emphasizing that disease-focused theory has been constructed in a manner that prioritizes safest outcomes and risk reduction over self-determination, strengths, and capacities.

Applications of disease-focused theory (AA, 1976; American Society of Addiction Medicine, 2000; Canadian Association of Addiction Medicine, 2002; Diamond, 2000; Gorski & Miller, 1986; Jellinek, 1960) can have a totalizing feel (Le, Ingvarson, & Page, 1995). Alcohol misuse is often seen as symptomatic of the progressive illness of alcoholism, requiring abstinence and AA. Mandating a rigid prescription for least-risky behaviour does not necessarily honour individual capacities, as attested by the participants in this research. In respect to the disease model, these participants demonstrate that not all persons with serious drinking problems are alcoholics, and that 12-step programs may not suit the needs and preferences of all persons with a history of serious drinking problems.

Participants in this study seem to be more effectively supported using harm reduction perspectives, which also promote safety, but in the context of individual needs and preferences. While harm reduction rhetoric does not generally recommend experimenting with high-risk substances, this perspective accepts the fact that risky behaviour does occur. Harm reduction principles support ideas such as using personal guidelines and limits to manage alcohol use, as well as establishing criteria to assess and, if necessary, abandon the experiment with controlled.

Practice Implications of this Study

This research presents several implications for social work practitioners in the addiction field. Participant narratives illustrated a dilemma regarding assessment: most of the "new relationship with alcohol" participants were referred to 12-step fellowships by professionals. How do we effectively distinguish alcoholics, for whom 12-step referrals are appropriate, from other problem drinkers? Perhaps there are more effective methods of assessing client needs and preferences.

Participant narratives also illustrated a potential dilemma regarding resources. Claire provided an example of an alternative support community through her participation in a 16 step empowerment program (Kasl, 1992). In small, northern, and remote communities, professionals may refer clients to 12-step or other resources out of immediate necessity, lacking other resources that might provide a more fitting or effective service. In other words, ethical practice would indicate referral to the only resources available, a better-than-nothing scenario. Although all of the participants who attended a 12-step program in this research indicated gratitude for the program’s support in gaining a period free from abusive drinking, there was also significant interest in the development of accessible alternative resources and support systems.

Advice offered to social workers by participants suggests a preference for client-centred practice. Client-centred approaches are supported by the codes of ethics for social workers and addiction counsellors (British Columbia Association of Social Workers, 1999; Canadian Association of Social Workers, 1994)

Major Contributions of this Study

This study has provided evidence of possibility. Participants with serious alcohol problems in their past quit drinking without using deficit rhetoric associated with the disease model, or they abandoned the rhetoric and have successfully managed their drinking. These experiences have happened; this proves that they are a real possibility. Since my decision to end the information-gathering phase, I have heard from more people about friends or family members who have experiences similar to those of the participants in this study.

This study has made several contributions to the field of addiction research and social work practice. First, it has documented the experiences of people who have been marginalized by the rhetorical assumptions of dominant theoretical frameworks. Second, it has exposed dominant rhetorical deficit-focused perspectives as only one way of viewing people’s experiences. Participants’ narratives in this study reflect multiple knowledges, journeys, roads, and uncharted territories. Third, this research provides a social constructionist model depicting the negotiation of meaning between cultures of knowledge, which contribute to the transformation of identity. This model may have some utility for understanding experiences of people who choose to live in theoretically uncharted territories. Finally, this study has drawn several implications for social work practice, regarding assessment procedures, therapeutic approach, and resource development.

Conclusion

This study has described the experiences, needs, and preferences of people who have chosen to address alcohol problems beyond the rhetoric of the disease model and 12-step framework. In the process, some of these people have faced marginalization as a consequence of blazing their own trails through theoretically uncharted territories. Their narratives helped to explore issues surrounding deficit-focused paradigms of addiction treatment. They participated in the development of a social constructionist model to help understand discourse relating to their experiences. Their narratives demonstrated how overcoming serious alcohol problems can involve multiple knowledges, journeys, roads, and uncharted territories in the quest for a more fulfilling, more meaningful life. Several implications for social work practice were discussed regarding assessment, therapeutic approach, and resource development.

One of the most significant concepts of the discipline known as cultural studies is the idea that knowledge is relative; there can be no end point. Consequently, there is no conclusion for this research into alternative experiences and journeys relating to alcohol problems. I hope that this information will serve to invite the possibility of openness regarding how we in the helping profession see and serve the people we are asked to assist.

In summary, the experiences of the participants in this study contradict rhetorical assumptions that are often the foundation for strategic practice in the addiction field. Perhaps the best way to address this point is through the commonly used pickle metaphor. Essentially, cucumbers can become pickles, but never vice versa. Yet this research provides evidence of pickles "reclaiming cucumberhood." This research also clearly documents participants who were able to stop the pickling process on their own without professional or conventional help. Finally, this research supports the social constructionist view of pickles and cucumbers as linguistic conveniences that serve the viewer more than the person under gaze.

The persons in this study said they were willing to volunteer their experiences, providing that their stories might offer hope and assistance for one other person out there. I respect and reflect on their sentiment as a personal challenge, and respectfully invite you, the reader, to consider their ideas when reflecting on your own practice.

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