Alcoholism in Theory

A woman yesterday shopping pleasantly in a supermarket for a loaf of bread and a carton of milk, today crosses the street to avoid her neighbors spotting her purchase two bottles of scotch in an adjacent liquor store. She is driven by a recurrent and excessive desire to drink alcohol. This desire defeats a variety of otherwise powerful and prudent countervailing considerations. Among them, her liver is diseased, and she knows it. She is an alcoholic. She knows that, too. She is embarrassed by her condition. She does not wish to be stigmatized as an alcoholic.

In his ambitious and complex paper, Gabriel Segal (2013) offers several central elements of a theory of alcoholism. In this commentary, I outline Segal’s aspirations or goals for his theory, comment on features of the aspirations, and offer some suggestions or emendations.

On my reading, Segal’s theory has three primary aspirations or goals. The first is to delineate characteristics of alcoholism and to distinguish between those that are essential to alcoholism and those that are not essential, even if often associated with alcoholic behavior patterns. One of the essential characteristics, for Segal, is that alcoholism is an impairment or disorder of prudent decision making or rational resolve and self-control. The impairment comes in degrees and is relative to context, but in its most severe form it means, says Segal, some alcoholics would rather waste away and die than refrain from consuming alcohol.

The second main aspiration is to account for the relationship between what an alcoholic may believe is harmful or dangerous about their behavior, on the one hand, and how they decide and act when faced with a perceived choice between consuming and refraining, on the other. Consumption in the face of potentially decisive contrarian knowledge is part of the evidence base for the attribution of impaired decision making or self-control in alcoholic behavior patterns.

Consumption requires a capacity on the part of the alcoholic for self-interpretation. Even if any particular alcoholic fails to classify themselves as an alcoholic, no alcoholic acts in a self-descriptive vacuum. Alcoholics offer accounts of their own behavior to themselves for themselves and others. So, a theory of alcoholism, for Segal, must treat consumption by an alcoholic as a self-interpreted consumption—harboring its own first-personal, multidimensional phenomenology.

What I take to be the third main aspiration of Segal’s theory is that it aims to make clear that alcoholism, properly so-called, is not a matter simply of bad decisions, for which persons are fully responsible. Alcoholism is not just drinking too much, too often, and too harmfully. Segal uses the potentially loaded term ‘disease’ to classify the affliction or disorder of alcoholism, although he intends to deploy it in a non-loaded way, without, he says, meaning “anything precise, deep, or very committal” (Segal 2013, 297). He adopts the term, in part, because, he wishes to deny that alcoholism is simply a pattern of foolish or ignorant choices. To call it a disease is to put his foot down against any conception of alcoholic behavior as something other than a form of pathological addictive behavior, aptly treated in a medical context, broadly understood. Alcoholics have therapeutic needs. They may require or be assisted by medical intervention.

There is, no doubt, something it feels like to be an alcoholic. Segal recognizes this. Interesting remarks appear throughout the paper about the complex and evolving emotional texture of the condition—part of its first-personal phenomenology. Alcoholics have feelings and emotional dispositions that unfold over time.

One such feeling was indirectly evident to me when, decades ago, working in a clinic in a Harvard teaching hospital, I cared for a number of alcoholics. Oftentimes they reported that the pre-admission, pretreatment image or hope that they had for themselves as, in the future, not drinking but being an inactive alcoholic, had felt, while in the throes of their alcohol consumption patterns, deeply and profoundly alien to them. Not really or truly them. They could not successfully comprehend how they themselves could be someone not tethered to consumption. “I...