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Growing up alcoholic: a story of addiction Innes, Bonny Marie 1994

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GROWING UP ALCOHOLIC: A STORY OF ADDICTION BY BONNY MARIE INNES B.Ed., University of British Columbia, 1965 B.S.R., University of British Coumbia, 1984 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN THE FACULTY OF GRADUATE STUDIES DEPARTMENT OF COUNSELLING PSYCHOLOGY We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA April 1994 Bonny Marie Innes, 1994 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. (Signature) Department of ^~Ml/(Sl&^JCfs.As\ (¥ The University of British Columbia Vancouver, Canada 1/ DE-6 (2/88) ii ABSTRACT This study investigated the process one woman went through in becoming dependent on alcohol. The story of the process, and its context, was elicited from the main character and from her sister, brother, and husband. Each participant in the study was interviewed and transcripts were made. The story was developed by integrating information from all the interviews. The process revealed evolved from the interaction of biological, psychological, sociocultural and economic factors. It was grounded in attachment and learning processes. The addictive process was identified as a maladaptive stress-coping cycle that developed a "life of its own" due to the feedforward effect of circular causation. TABLE OF CONTENTS ABSTRACT ii TABLE OF CONTENTS iii LIST OF APPENDICES vi ACKNOWLEDGMENTS vii CHAPTER I INTRODUCTION 1 CHAPTER II BRIEF HISTORY OF ALCOHOLISM 3 ETIOLOGICAL THEORIES 17 CHAPTER III METHODOLOGY 27 Design 27 Participants 27 Interview Procedures 28 Research Procedures 30 Validity 35 Introduction to Results 36 CHAPTER IV RESULTS Story Part I 37 Story Part II 59 Epilogue 82 CHAPTER V ANALYSIS iv Introduction 88 Overview and Definition of Terms 88 Part I: Development of Vulnerability 90 Temperament Stress and Emotion 93 Fear and Separation Anxiety 95 Attachment Theory and the Need for Connection 97 Alienation 99 Association of Alcohol with Shame 100 Connection and attachment 103 Need for Attention 108 Coping Strategies Increased Stress 109 Recurrent Abdominal Pain and Other Manifestations of Stress 112 Alcohol Relieves Distress 119 Part II: Actualization of Potential for Addiction 125 Stance Towards Alcohol 125 Decisional Balance 126 Access 127 Relief of Stress by Alcohol 129 Private Drinking 130 Incentives Overbalance Disincentives 131 Alienation 133 Lack of Coping Skills 134 Self Focussing and Alienation 137 Alcohol Damages the Body 139 Attempts to Control Intake 140 Escalating Cycle of Dependence 141 Depression 141 Summary 143 CHAPTER VI DISCUSSION Results 146 Limitations 147 Implications for Theory 148 Implications for Practise 150 Implications for Further Research 151 Summary 152 REFERENCES 153 vi LIST OF APPENDICES APPENDIX A Consent form APPENDIX B Self Administered Alcohol Screening Test vii ACKNOWLEDGEMENTS I would like to extend my appreciation to all those whose cooperation helped me make the deadline for this thesis submission: my advisor and committee, my colleagues, and my mother. I also wish to acknowledge the participants of this study whose candid contributions made this thesis possible. CHAPTER I INTRODUCTION According to one publication, alcohol was a factor in the crimes of 70%-80% of males in B.C. prisons, in illnesses being treated in a third of all hospital beds, and in half of all divorce cases (TRY, 1988). Steel and Josephs (1990) report alcohol involvement in 70% of fatal motor vehicle accidents, 65% of spouse battering and 55% of violent child abuse. In the United States the Department of Health and Human Services estimated the costs of lost production, crime, and accidents due to alcohol to total over $117 billion in 1987 (Steel & Josephs, 1990). The Epidemiological Catchment Area Survey rates for DSM-III alcohol abuse/dependence were 24.3% for men and 4.4% for women. (Robbins et al. cited in Stabeneau, 1990). Jellinek (1960) estimated that 10% of alcohol users become addicted. The economic, medical, social and personal costs of alcohol abuse are powerful incentives to find a remedy. The logical first step is to clarify the problem. The purpose of this project is to understand the process and experience of one specific individual in the course of her becoming dependent on alcohol. The research question is "How does a person become addicted to alcohol?". Each person is uniquely human. As members of the same species, we share certain basic potentials with subtle variations and each of us express these potentials in unique ways. So this woman's story is unique just as she is unique; the exact combination of biological, psychological, social and cultural factors Page - 1 that interacted to create this individual's experience can never be exactly duplicated. But because this story is one expression of the human potential it has pertinence to the rest of us. Saleebey (1985, p. 19) says "the nature of human nature is that we can and do become addicted to anything." Orford (1985) also considers appetitive excess a human potential rather than a property of the substance or activity which is the focus of the behaviour. Therefore attempting to understand this one person's experience, unique as it is, may provide insight into not only the process by which others may become dependent on alcohol but human behaviour generally. Page - 2 CHAPTER II LITERATURE REVIEW A Brief History of Alcoholism To understand this story it is useful to place it in the historical context of social, cultural, and scientific attitudes and understandings. Alcohol is a product of the natural biological environment. It is present in some well ripened fruit to the extent that birds attracted to the largesse may eat themselves into a stupor. Human kind has probably enjoyed alcohol since the beginnings of society. In Tequila, Mexico the Sauza distillery has a mural depicting the origin of tequila. Lightning (the power of the Gods) strikes a maguey plant (Agave americanum). The sugary pulp of the thick squat stem of this dryland succulent ferments and is sampled by the natives. Impressed by the psychoactive properties of the alcohol, they give thanks to the gods for their gift and develop a drink called pulque from the fermented maguey. The Spaniards use distillation technology and native labor to transform the pulque into tequila. The end of the mural shows the God of Tequila, represented by a horned mask, presiding over the revelry and debauchery induced by the alcohol. This mural might be interpreted as illustrating changes in cultural use of and attitudes toward alcohol. The original naive appreciation of the wonderous psychoactive properties of alcohol lead to a reverent and ritual use by primitive societies. Its psychoactive properties were naturally associated with the spiritual or supernatural realm and so Page - 3 these 'spirits' became associated with religious ritual. Ritual drinking in large quantities was a part of religious rituals in ancient Greece and Rome (Jellinek, 1960) . The communal experience of psychoactive effects in a spiritual context - an act of communion with one another and with the divine - probably functioned as an integrating and cohesive factor in early society. The symbolic meaning of drinking anything as taking in the "stream of life" (Goodenough, cited in Jellinek, 1960) probably developed from an awareness of the significance of blood and water to the maintenance of life. Thus the experience of the psychoactive power of alcoholic beverages was overlaid on the existent symbolism of drinking as taking in the power of life, enlivening oneself, and becoming one with the universal. Drinking together was an experience of communion, bonding, and identification. It performed a powerful social function. These symbolic functions continue to influence alcohol use today (Jellinek, 1988) especially among men. The culture changed as small, intimate, rural communities developed into large, complex, sophisticated, urban and industrial societies. In the process, the use of alcohol and drinking patterns changed. Ritualistic and occasional functional tribal drinking patterns were replaced by predominantly personal utilitarian drinking (Jellinek, 1960). The utilitarian or functional use of alcohol for purposes of personal hedonism or tension reduction was learned from experience of these effects in the original ritual drinking with subsequent personal utilization on an Page - 4 increasing basis (Jellinek, 1960). The ritual use of alcohol in religion became reduced to a token symbolism. Perhaps a more significant remnant of ritual drinking is represented by the "pressure" to participate in social drinking (Jellinek, 1960) . Development of technology for production, preservation and distribution made large quantities of alcohol readily available to individuals (Jellinek, 1960). Political expansion and colonization in the 18th century combined with use of slave labor, made vast quantities of cheap rum readily available to the North American British colonies and prodigous quantities of all kinds of alcoholic beverages were consumed. In the colonies that became the United States, regular drinking was a way of life and alcohol was even used as a medicine (Jung, 1994). "Most people were not concerned with drunkenness; it was neither especially troublesome nor stigmatized behavior" (Levine, cited in Meyer, 1988). It just too much of a good thing (Fingarette, 1988). Even a clergyman spoke of rum as "the good creature of God" (Fingarette, 1988). Movement from a stable, independent, rural, agrarian based economy to a fluctuating, insecure, dependent, urban, industrial one changed the structure of society. The concept of "leisure" developed as distinct from "work" and the condition of "unemployment" was created. The culture developed in the North American colonies was highly individualistic and capitalistic. All these changes can be assumed to increase the physical, social, psychological and Page - 5 spiritual stressors that increased the anxieties, frustrations and tensions of individuals. Thus individual functional use of alcohol to relieve stress was motivated by personal and social conditions and supported by ready availability. This was a time of political, economic, social and scientific development and expansion. "The concept of disease became a touchstone in social thought . Moral and social ills were now perceived as pathologies of either the individual or the body politic" (Fingarette, 1988, p. 16). In 1785, the physician Benjamin Rush was among the first to attribute bizarre behaviour and emotional states to disease of the mind (Fingarette, 1988). It was a short leap then for both Rush in the U.S. and Trotter in Britain to extend the concept of disease to the condition of habitual intoxication or inebriety (Jellinek, 1960). Rush proposed abstinence as the only cure. In 1838 the French psychiatrist Esquirol also recognized a mental illness he called the "monomania of drunkenness" which was characterized by episodes of persistent irresistible drinking (Paredes, 1986). As the structure of the society and its economy changed, with its concommitant effects on drinking patterns, attitudes toward drinking began to change. The fine motor skills, judgement, and productivity desirable in mechanized, capitalistic industry were impaired by alcohol. Industry therefore had a vested interest in discouraging alcohol use (Fillmore, 1988). One might assume that in urban conditions of increased population density, the general public also Page - 6 became more aware of the condition and effects of inebriation. The clergy variously regarded it as a sin. Some regarded it as a "sin of excess" along with other types of gluttoney and some regarded it as a sin period and preached total abstinence. Alcohol became the scapegoat for all suffering, poverty and crime; "The good creature of God had become the demon rum" (Fingarette, 1988, p.16) By the 1830s the magnitude and specificity of the problem was deemed sufficient to prompt the establishment of inebriate asylums (Jellinek, 1960). Groups such as the American Temperance Society organized in 1833 lobbied against the use of alcohol (Jung, 1988). Between 1830 and 1850 U.S. percapita consumption of absolute alcohol was cut in half from 5 to 2.5 gallons per capita (Fingarette, 1988). In 1872 managers of inebriate asylums created a society to study the problem. It eventually became The American Medical Association for the Study of Inebriety and Narcotics which published the Journal of Inebriety. The function of the Journal was to promulgate the conception of inebriety as a neurosis and psychosis with alcohol being both an exciting and contributing cause as well as a symptom of pre-existent conditions (Crothers, cited in Jellinek, 1960). Two separate disorders were recognized in the nineteenth century: chronic alcohol use, which was associated with physical and psychological changes, and alcohol addiction, which was defined as an uncontrollable craving (Meyer, 1988). In Germany in 1901 Kurtz and Krepelin described an addictive disorder characterized by the inability to stop drinking even Page - 7 when faced with its destructive somatic, social and economic effects (Paredes, 1986). Alcohol and inebriety became a major political issue in the U.S. in the first half of the 20th century. Political stances were described as "wet", favoring freedom of consumption of alcohol, or "dry", favoring abstinence/prohibition/control of alcohol. An attempt to link the moralism of the social movement to government control as a method to manage all drinking by legislating abstinence was unworkable.(Fillmore, 1988). The Volstead Act of 1919 was repealed in 1932 (Jung, 1988). By this time, the expression "alcoholism", coined by Huss in Stockholm in 1852 (Paredes, 1986) and already widely used in Europe, had replaced "inebriety" as the preferred term (Jellinek, 1960). In the late 1930s the Yale Center of Alcohol Studies was established to be the intellectual and scientific center of work on alcohol problems. The disease conception was intentionally fostered in order to influence government policy and popular thinking away from the moral approach to people with drinking problems (Fillmore, 1988). It was believed that adoption of the medical approach would create a better climate for studying the problem and providing help. The 1930s also saw the beginning of the grassroots self help group Alcoholics Anonymous. It described alcoholism as an "allergy" to alcohol which results in craving and loss of control. This description has not been found to have any literal basis and was essentially a metaphor used to Page - 8 describe from a biological viewpoint the apparent selective vulnerability of some people to alcohol. From this perspective, abstinence was the only way to recover. In 1946 Jellinek analyzed responses to a survey published in the A.A. newsletter. His original description of the progression of alcoholism was based on information from 98 male respondents. The 60 responses that were discarded included those spoiled by pooling of information among members and those from women, whose responses did not fit into the male pattern (Fingarette, 1988). On the basis of this preliminary research, Jellinek designed a detailed questionnaire and administered it to over 2,000 "male alcohol addicts". He developed a description of the average trend in the sequence of symptoms of alcohol addiction, noting that all symptoms do not occur in every addict nor in the same sequence. (Later national surveys indicated that alcohol-related problems occur in a wide variety of patterns and that progression is not inevitable (Fingarette, 1988).) "For alcoholic women the "phases' are not as clear-cut as in men and the development is frequently more rapid" (Jellinek, 1952, p.676). Loss of control developed progressively and was not inevitable on a specific drinking occasion. In this sample of A.A. members, 13% never experienced loss of control (Jellinek, 1960). Jellinek concluded that "there is every reason why the student of alcoholism should emancipate himself from accepting the exclusiveness of the picture of alcoholism as propounded by Alcoholics Anonymous" (Jellinek, 1960, p. 38). Page - 9 When Jellinek analyzed the illness conception of Alcoholism he found "difficulties arising out of the fact that alcoholism has too many definitions and disease has practically none" (Jellinek, 1960, p. 11) A continuing problem in the evaluation and utilization of research results has been the variety of definitions and measures used. One cannot usefully compare measurements of apples to those of oranges. In 1952 Jellinek reports that only certain forms of excessive drinking are designated as alcoholism although other forms are recognized as presenting serious problems. He notes that "with the exception of specialists in alcoholism, the broader medical profession and representatives of the biological and social sciences and the lay public use the term ^alcoholism1 as a designation for any form of excessive drinking instead of as a label for a limited and well-defined area of excessive drinking behaviors" (p. 674). In 1960 Jellinek operationally defined alcoholism as "any use of alcoholic beverages that causes any damage to the individual or society or both" (p. 35). The Alcoholism Subcommittee of the World Health Organization distinguished two categories of alcoholics: alcohol addicts and habitual symptomatic excessive drinkers, or nonaddictive alcoholics. The distinguishing characteristic was "loss of control" over alcohol intake which occurred in those termed addicts after years of excessive drinking but not in others who may "drink as much or more than the addict for 30 or 40 years" (Jellinek, 1952, p. 674). Besides absence of loss of control, Page - 10 the course of the nonaddictive alcoholic lacked any clear-cut phases in its progression. The confusing array of characteristics, hypotheses and definitions of alcoholism led Jellinek (1960) to conclude that "there is not one alcoholism but a whole variety" (p. 10). Another source of confusion was "what the physician in the past has seen and regarded as the disorder of alcoholism was, in fact, its end result, complicated by the long-term effects both physical and mental of a heavy intake of alcohol over many years" (Hargreaves cited in Jellinek, 1960, p. 10) . The problem of distinguishing the effects of alcohol abuse from causes or antecedents that increase risk of abuse has continued to confound interpretation of research data, especially that from cross-sectional correlational designs. A study of international cultural differences in alcohol related problems contributed to Jellinek1s (1960) identification of 5 species of alcoholism. Although others may suffer damage as a result of their drinking, he limits the term alcoholism to these typologies. 1.ALPHA There is psychological dependence to relieve bodily or emotional pain but no physical dependence (no withdrawal). It is usually a symptom of some other underlying problem with no signs of progressivity but it may develop into gamma type. 2.BETA Excessive drinking produces organic damage without development of psychological or physical dependence (no Page - 11 withdrawal signs). It is less likely than alpha to progress to gamma or delta types. 3.GAMMA There is a progression from psychological to physical dependence with acquired increased tissue tolerance, adaptive cell metabolism, withdrawal symptoms, craving, loss of control, and behaviour changes. It may develop from alpha and beta types. This pattern is characteristic of 80-90% of the membership of A.A. 4.DELTA In this insidious form inability to abstain characterised by withdrawal symptoms develops from a pattern of regularly spaced intake resulting in a cumulative excess without obvious intoxication. Delta varies from gamma form in that there is no loss of control over the amount consumed on any particular occasion. This is the predominant species of alcoholism in France. 5.EPSILON This is a periodic form designated as dipsomania in Europe. Jellenik identifies a pseudoperiodic form of gamma alcoholism consisting of periods of sobriety interspersed with relapse and remorse. There seems to be an inherent human tendency to classify and categorize things in order to make sense of our world. Concepts are developed from perceptions that are shaped by concepts. Our experience is a continuous circular subjective interactive process. We cut off bits of this process, organize them into logical patterns and present them as Page - 12 reality. But reality is not static and these static representations can never truly capture the nature of the phenomenon. Jellinek recognized that alcoholism was not an entity and tried to expand and develop the concept to more accurately represent his perceptions. It seems most likely that "all the factors that cause alcoholism ...are mingled in DIFFERENT PROPORTIONS IN EVERY ALCOHOLIC. While the general pattern is repeated over and over again, the INDIVIDUAL VARIATIONS ARE INFINITE, as numerous as the actual number of alcoholics" (Lovell cited in Jellinek, 1960). An infinite variety of combinations of factors leads to an infinite variety of expressions of "alcoholism". Major reviews of alcoholism studies have identified multiple alcoholic subtypes (Brooner et al., 1987). There is obviously a continuum in the use of alcohol: some people never drink; some have an occasional drink, perhaps on special occasions; some drink regularly but moderately; some drink heavily regularly or on occasions; and some drink continuously. Three quarters of the percapita consumption of alcohol (2.5 gallons) is consumed by one fifth of the population (*). At some point on this continuum, drinking leads to problems. Most people who take a drink have probably experienced at least once some ill effect from having a little too much. It may be as simple as saying too much and feeling foolish afterward, or suffering from nausea and disorientation. Some people may do an intuitive cost-benefit analysis, decide the costs outweigh the benefits and successfully curtail their Page - 13 drinking. This group is of no concern to us. Even though they may make an occasional misjudgement, their drinking does not generally produce significant problems. We would certainly not call them "alcoholic". Yet just one misjudgment could lead to serious consequences, for example, a fatal motor vehicle accident. A second group of people fail to curtail their drinking despite the problems it brings. These may be called "problem drinkers". This is potentially a very mixed group with considerable variation in drinking patterns, severity and type of problems and cognitive processing of the situation. For example, some may find the costs tolerable for the perceived benefits and continue drinking; some may never think about it at all, may not even be aware of the problems until they become overwhelming or may not make a connection between the drinking and the problems; some may, at some point, unsuccessfully intend to curtail their drinking. How useful is it to carve out a section of this group and label these people alcoholics? How possible is it? What do we seek to accomplish? There are at least two reasons for making some distinctions within this continuum. First, if we are going to do any meaningful research it is necessary to clearly identify our subjects using valid and reliable measures. Any results reported must be clearly attached to the measures used. The variety of measures and different areas of the continuum of alcohol problems that have been sampled with these measures in the past has made meaningful review Page - 14 challenging. Second, we need some sort of screening device to assess the severity of the problem in order to allocate treatment. Resources are limited. The alcohol dependence syndrome (ADS) was developed by Edwards and Gross in 1976 and adopted by the World Health Organization to appear in their International Classification of Disease-9. It measures a continuum of pathologic alcohol use rather than assigning alcoholic/nonalcoholic categories. This model is significantly different from the traditional A.A. conception of alcoholism in that "impaired control of drinking, rather than a loss of control, is postulated by the ADS formulation to reflect that the phenomenon is not an all-or-none experience.... [and] all drinkers who develop alcohol dependence will not go through a progression of stages or phases with certain symptoms." (Jung, 1994, p. 113, 114). Development was based on the proposition that alcohol dependence should be defined along a continuum of severity and that dependence should be differentiated from alcohol-related disabilities and problems (Meyers, 1988). Severity of seven symptoms is assessed: narrowing of the drinking repertoire, salience of drink-seeking behavior, increased tolerance, repeated withdrawal symptoms, drinking for relief or avoidance of withdrawal symptoms, subjective awareness of a compulsion to drink, and reinstatement of drinking pattern after abstinence.(Jung, 1994).) The American Psychiatric Association published DSM-III diagnostic criteria for alcohol abuse (three criteria) and Page - 15 alcohol dependence (alcohol abuse criteria plus either physiological tolerance or withdrawal) in 1980 (Jung, 1994). DSM-III-R and DSM-IV revisions change the criteria somewhat. Abuse is identified by a maladaptive pattern of drinking or recurrent use dangerous situations and for the dependence diagnosis, at least three of nine criteria must be present. Criteria include measures of tolerance, withdrawal, preoccupation, control, interference with roles, exposure to danger, drinking despite ill effects. The function of the DSM criteria is to identify who needs to be treated. However, to design appropriate treatment, it would be useful to know what factors interacted in this particular individual to produce this outcome in order to know where to intervene. A description of behavioural and physiological outcomes doesn't tell us that. We do not yet have the information we need to develop such a tool. Individual case studies of the process of becoming dependent on alcohol will contribute to our understanding of these factors and their interactions. The International Classification of Disease provides a common reference for 140 countries.The proposed ICD-10 deals with all disease and related health problems. Proposed criteria for drug and alcohol dependence as follows: 1. Progressive neglect of alternative interests 2. Persisting with use despite clear evidence of overt harmful consequences. 3. Evidence of tolerance such that increased doses are required to achieve effects of initial use Page - 16 4. Physiological withdrawal 5. Substance use with intention of relieving withdrawal symptoms and awareness that strategy is effective. 6. Tendency to drink the same way, weekdays and weekends, despite social constraints. 7. Evidence of rapid reinstatement of syndrome on return to use after abstinence. 8. Subjective awareness of impaired control in terms of onset, termination or level of use. 9. Strong desire or compulsion to use (Jung, 1994). CHAPTER II Etiological Theories Current approaches to understanding the etiology of alcoholism favor a multifactorial person-environment interactional model (Braucht, 1982; Donovan, 1986; Levin, 1989; Zucker & Gomberg, 1989; Wallace, 1989; Nathan, 1990; Murrey, 1989). Donovan (1988, p.6) defines addiction as "a complex, progressive behavior pattern having biological, psychological, sociological and behavioral components." Lindsmith (cited in Donovan, 1988) says "addiction appears to be an interactive product of social learning in a situation involving physiological events as they are interpreted, labeled, and given meaning by the individual". The biopsychosocial model recognizes the primacy of physiological, psychological and social factors. The reductionistic approach of the logical positivism philosophy behind the "scientific" method accounts for the Page - 17 delay in recognizing the significance of an integrated model. The separation of mind and body may have originated as a compromise of science with religion in order to obtain approval for dissection and study of the body. However it has hampered an understanding of the true nature of human being as an integrated expression of mind, body and spirit. Of course this is just another construct. We tend to confuse our constructs for the things themselves which is understandable since all we have access to are our constructs. It is important to revise constructs so that although they may never truly represent reality at least they may provide a model which is more useful in guiding us toward desired outcomes. A person-environment model integrating biological, psychological, social, cultural and other contextual factors provides more scope for understanding the etiology of problem drinking and thence to treating it. While a number of differential physiological responses have been identified in alcoholics and sons of alcoholics understanding of etiological significance is lacking at this time. Twin, family, and adoption studies support a genetic component at least for some alcoholics. Searles (1988) notes that in the study of Goodwin et al. if the categories of problem drinker and alcoholic are combined, the genetic effect disappears. High rates of foster parent psychopathology (as high as 50%) may also have had differential effects on the development of alcoholism. Also, the mothers' drinking habits are not known and Searles presents the possibility of intrauterine effects on fetus. Page - 18 Daughters of mothers with any alcohol abuse were found to be three times more likely to be abusers themselves (Bohman et al, cited in Searles, 1988). Winokur, Reich, Rimmer, and Pitts (cited in Searles, 1988) found relatives of male but not female alcoholics showed the expected concordance of degree of alcoholism . We do not know what the mediators may be but multiple genes are believed to be tied to multiple biological risk factors (Wallace, 1989). Searles (1988) concludes there are multiple pathways to alcohol abuse with significant gene-environment interactions in at least some of them. The methodological problems associated with genetic studies are significant and signal caution in interpretation of results (Searles, 1988; Lester, 1988). Animal breeding programs have produced rats and mice which vary in their preference and response to alcohol. Neurochemical differences have been noted in these different strains, for example deficiencies of serotonin. In humans, serotonin deficiencies are associated with poor impulse control, suicide and obsessive -compulsive disorder (Wallace, 1989) . When enkephalins were lower, the animals drank more. Two major hypotheses involve the endogenous opioid system. They are based on the following assumptions: 1) effects of alcohol are mediated through neurotransmitter systems, 2) the opioid system is associated with motivation and 3) emotion and alcohol initiates processes altering motivation and emotions via the opioid system (Reid cited in Gianoulakis, 1993). These theories propose that alcohol increases the Page - 19 activity of the endogenous opioid system. A significant increase in opiodergic activity after alcohol intake may be the reinforcer for alcohol consumption (Gianoulakis). Increased opioid activity may provide the motivation to continue drinking once started. Alcohol preferring mice have a pronounced release of beta endorphins after alcohol intake (Reid cited in Gianoulakis, 1993). Another hypothesis proposes a basal deficiency condition which is normalized by the response to alcohol consumption. A pronounced increase in plasma beta endorphin levels after alcohol intake has been found in high risk subjects who had lower than expected pre-intake levels (Gianoulakis, 1993). It seems to be increases in opioid levels rather than circulating levels that affect alcohol consumption. Injections of small doses of morphine increased alcohol consumption, perhaps because they simulated the release of opioids in the way they are released by alcohol consumptions or by stress. In a similar fashion, acute ethanol increases opioid peptides and chronic ethanol reduces opioid peptides (Blum & Trachtenberg, 1988). Craving for alcohol correlates with a genetically based decrease in methionine-enkephalin and 50% of alcoholics may be suffering from this inherited deficiency (McClearn & Rogers and Martin, cited in Blum & Trachtenberg, 1988). As well, long continued stress can produce a chronic deficiency of enkephalins and endorphins (McGivern et al., cited in Blum & Trachtenberg, 1988). Stress leads to drinking leads to opioid deficiency leads to further drinking. In a study of 29 chronic alcoholics, B-endorphin levels were reduced over 65% Page - 20 (Genazzani et al. cited in Blum & Trachtenberg, 1988) and chronic alcoholics did not respond to acupuncture induced release of opioid peptides (Facchinette et al., cited in Blum & Trachtenberg, 1988) indicating inhibition of normal opioid production and deficiency of endorphins. Alcohol is metabolized to acetaldehyde by alcohol dehydrogenase. This metabolite is toxic if it accumulates. It is metabolized to acetate via aldehyde dehydrogenase. Acetate is metabolized in the Kreb's Cycle. There are individual and ethnic difference in alcohol metabolism which may be related to variations in isoenzymes. For instance, an atypical alcohol dehydrogenase is believed to be responsible for the typical alcohol sensitivity of the Japanese. The role of enzymes in alcoholism has get to be established (Agarwal & Goedde, 1990). Levin (1989) believes that the variability in acetaldehyde levels resulting from differential metabolizing of alcohol have something to do with drinking behaviour. Pihl, Finn and Peterson (1989) report that sons of alcoholics lack a certain degree of perceptual neuropsychological inhibition which renders them oversensitive to stimulation. They are stimulus augmenters, overreacting in skin conductance, cardiovascular reactivity, perception of pain, and psychological events in general. Alcohol reversed the overreactions significantly. The suggestion is that these subjects react as if many stimuli are threatening and this threat reaction is ameliorated by alcohol. Sher and Levenson (cited in Wilson, 1987) see the overall impact of intoxication as a dampening of stress Page - 21 arousal. They found a greater stress dampening effect of alcohol in people with prealcoholic personality traits. Neurobiological theory (Tabakoff & Hoffman, 1988) postulates alteration of CNS structure/function to resist the influence of alcohol thus producing tolerance. The theory suggests a genetic based differential capability to develop tolerance to both positive and negative effects of alcohol. Increased tolerance to negative effects (for example sedation) allows high dose levels which are postulated to activate positive reinforcement systems. Neurobehavioural theory (Tartar, Alterman, & Edwards, 1988) is specific to the early-onset antisocial alcoholic. A CNS dysfunction is postulated. There is evidence of dysfunction of the arousal mechanisms in high risk individuals. Hyperactivity in childhood is associated with disruption of arousal mechanisms (Douglas cited in Tartar, Alterman & Edwards, 1988). A hyperactive childhood appears to be a risk factor for alcoholism (Goodwin et al. cited in Tartar, Alterman & Edwards, 1988) and hyperactive adolescents are more likely to abuse alcohol (Blowin cited in Tartar, Alterman & Edwards, 1988). Off spring of alcoholics are more likely to be high in activity level, low in persistence, slow to soothe after stress, emotionally labile and disinhibited (Brooner, Templer, Svikis, Schmidt & Monopolis, 1990). The behavioural disinhibition, restlessnes, attentional disturbances and impulsividty reported in prealcoholics can result from anterior brain pathology. Drinking may be an attempt to normalize arousal instability. Hyperactivity is Page - 22 associated with attention deficit disorder and one third of alcoholics meet the criteria for attention deficit disorder, residual type. The risk for alcoholism may be related to the ability of the reticular activating system to control arousal level. Psychoanalytic theory (Barry,1988) suggests that anxiety and deprivation of satisfaction motivates craving for alcohol as a source of pleasure or relief. Anxiety and frustration may result from conflict between the instinctual striving for gratification and relief (Id) and social responsibility (Superego). Failure of the ego to mediate the conflict successfully results in psychopathology. Blum (cited in Barry, 1988) suggest three types of alcoholics depending on whether fixation is at oral, anal or genital states. In the anal stage, Id and Superego are in confrontation over bowel and bladder control. There is ambivalence between rebellion and control. Alcohol is adaptive in that it provides temporary release of inhibitions, relief from anxieties and escape from the pressures of reality. Alcoholics are more likely to be last born in large families (Blane & Barry, cited in Barry, 1988). The prevalent emotions are anger, misery, alienation and hostility directed toward self and others. The opponent-process theory (Jung, 1994) describes two opposing affective reactions to the receipt and termination of strong stimuli. The stimulus of alcohol produces an affective state A that is opposed by state B which follows and ends slightly later than state A. The result of the Page - 23 integration of the two processes is a short high followed by a plateau followed by a decrease below the original level before the alcohol when state B is unopposed by state A. As the opponent process more effectively anticipates and negates the effect of the alcohol, the positive state decreases and the negative state increases. Attempts to regain the positive state (which has been associated with alcohol intake through conditioning) continues to increase the opponent process and the negative state. Conditioning processes are central to several explanations of etiology (Sobell, 1987). Cues that are associated with alcohol consumption trigger reactions which anticipate the disruptions of normal function by the alcohol and attempt to compensate for them. These reactions are sensed as craving. This analysis of craving is supported by experimental, epidemiological and clinical evidence (Siegel cited in Wilson, 1987). Cues may trigger the compensatory reactions directly and thus trigger craving, or they may trigger the positive effects which then trigger the compensatory reaction. Social learning theory (Jung, 1994) is based on expectancies acquired through observation and experience. Social learning focuses on the expectations that alcohol will improve ability to cope with stressors, for example by reducing negative affect. Individuals with poor coping skills are more at risk for using alcohol to reduce tension, escape from problems and feel better. In college females drinking was found to be related to expectations of reduced tension or Page - 24 relaxation (Mooney, Frommme, Kivlahan & Marlatt cited in Jung, 1994). Past association of alcohol consumption with certain effects prompts the expectation that those effects will be repeated. The problem in researching and explaining the causes of alcoholism is that "all the factors that cause alcoholism ...are mingled in DIFFERENT PROPORTIONS IN EVERY ALCOHOLIC. While the general pattern is repeated over and over again, the INDIVIDUAL VARIATIONS ARE INFINITE, as numerous as the actual number of alcoholics" (Lovell cited in Jellinek, 1960). Research indicates multiple types of problem drinkers with distinct constellations of personal and environmental factors and probable multiple developmental pathways to alcohol abuse (Braucht, and Donovan & Jessor, cited in Braucht, 1983). Alcoholism is too complex and too heterogeneous a problem to be explained by a single etiological approach (Wallace, 1989). There may be many phenotypically similar but genotypically different forms of alcoholism in which the relative significance of genetic and environmental factors vary (Donovan, 1986). From the beginning, the significance of social, cutural, psychological and physiological factors in the development of alcoholism have been acknowledged, if only in a token way. However most etiolgical theories have focused on only one aspect (Jellinek, 1960). It is not surprising that theories would be developed from the perspective of the researcher's area of interest and expertise. The challenge is to understand how these theories fit together to explain the Page - 25 problem. Zucker and Gomberg (1986) consider the etiology of alcoholism best understood from a longitudinal developmental perspective that includes physiological, behavioral and sociocultural variables. As Braucht (1982, p. 88) says, the question is "how personal and environmental influences combine to influence the development of problem drinking". This study of one woman's process of becoming dependent on alcohol explores, from a longitudinal developmental perspective, the personal and environmental influences and interactions contributing to her alcoholism. The study was approached from a multifactorial perspective. The researcher was sensitive to the potential significance of biological, psychological, social, cultural, and economic factors. Page - 26 CHAPTER III METHODOLOGY Design In order to understand the individual one must study the individual; the study of single individuals provides insights into fundamental behavioural processes and must be the research unit when the dynamics of these processes is the issue (Denenberg, 1982). There is evidence in the literature that many factors may influence the development of alcohol dependence. Various typologies of alcoholism have been identified or postulated. Different types of outcomes would logically be the result of different patterns of influences. Statistical averaging of individuals is likely to obscure the process whereby specific factors interact to influence specific behaviour. The single case study method was chosen to explore the process of addiction within its developmental context in order to elucidate its nature. Convergent data was sought through interviewing witnesses to the process. These witnesses were the brother, sister and husband of the woman experiencing the process. The primary data was the experience of the main participant. The witnesses not only provided convergent and supplementary data, they provided examples of the social context in which the process developed. Participant The main participant of the study is a 54 year old woman with a 25 year history of alcohol abuse who has abstained from alcohol for 5 years. She is in the upper middle socioeconomic level, married with one child. She graduated Page - 27 from a country high school and went to business college for one year. When she was recovering from alcoholism she joined Alcoholics Anonymous and attended classes on alcoholism given by her doctor. She took three months of training at the Counsellor Training Institute in Vancouver, a one week course at the Betty Ford Center plus various seminars. She has done some private counselling. Her vocational titles include secretary, salesperson, retail manager, and cardiopulmonary technician. She volunteered for this study after hearing about it from an associate who supplied her with the contact phone number. She first made contact in 1992 and expressed her interest. The study was not initiated until 1993. When she was recontacted and the study was explained to her in detail she wanted to participate. Interview Procedures The participant was asked to describe the process she went through. It was suggested to her that she might imagine what episodes from her life would appear in a movie of the story of how she became alcoholic. The interviewing was generally very nondirective with no specific questions except to clarify what was being said. The Self Administered Alcohol Screening Test was done by the participant in order to validate her alcoholism and to provide a basis for comparison of this study to others using similar subjects. Including the screening interview there were four main interviews plus a couple follow up interviews and some telephone consultations to validate the story and clarify parts of it. In the later Page - 28 interviews the participant was asked to describe in detail some specific experiences or situations that she had mentioned in a general way. The main participant arranged for her brother and sister, who happened to be in town during the interviewing period, to be interviewed. The sister is eleven years older and the brother is seven years older. The brother was interviewed three times; the sister was interviewed twice before she returned home. The husband was interviewed once. These interviewees were asked to tell the story from their point of view. A conscious attempt was made to avoid leading questions at least until the interviewee had told their version of the story. Corroboratory information was sought by subtly directing attention to the general area of the information without identifying the issue of interest. Some more direct questions were put to the interviewees after they had presented their own general information. Directing attention toward a specific issue was particularly valuable in eliciting corroboratory evidence of parental quarrels and their significance. Each interviewee presented a specific point of view. As children, the brother and sister were not particularly aware of L. They were preoccupied with their own concerns. However there were some significant points of convergence, for example the quarrels of the parents. Each contributed significant information to the story. It was very difficult to arrange the interview with the husband. He was busy and only consented at his wife's request. He seemed uncomfortable Page - 29 and much of the information he gave consisted of things he had learned rather than what he had observed or experienced. There was a distinct difference between the attitude of the brother and the sister. Both were cooperative and helpful, but the sister's judgemental attitude was so strong that the interviewer was uncomfortable. The main character herself seldom showed any real emotion during the interviews. The interviews were given in a bright, chirpy voice interspersed with frequent ironic laughter that may have been a way of distancing herself from her former distress or an expression of her relief at having gotten past the pain. In latter consultations there was perhaps less of a "front" and more expression of emotion when she spoke disappointments and misunderstandings. Research Procedures This study was approached as a case study as described by Bromley (1986) because a case study provides an account of a process. Bromley defines the psychological case study as the account of a person in a situation as compared to a life history which is a series of episodes viewed in relation to one another. This study took on more of a life history approach because this was the natural form of the data. (Bromley notes that "behaviour disordered persons" are best studied by a detailed life history; psychologically significant episodes are usually associated with events earlier in a person's life.) The participant's experience of the process she went through in becoming addicted was reconstructed from interview data and interpreted. The result Page - 30 was a narrative account plus an analysis of relationships of elements of that account in an attempt to account for the plot structure. This could be construed as the "causal analysis" described by Bromley (1986). The result is a conceptual structure to account for her process, for how and why she behaved the way she did. Bromley (1986) says to find an explanation is to impose a pattern of meaning on the information. This pattern of meaning is the conceptual structure that is the outcome of this study. Triangulation, the systematic comparison of data from independent sources, was used to clarify the ecological context of the process and the significance of specific data. For example, the concordance of the distress experienced by the three siblings when their parents quarreled verified and leant significance to that element of the narrative. This process was also used to clarify the main participant's unique point of view and constructs so important to understanding behaviour. In accounting for elements in the narrative account, for example the amenorrhea, the relative likelihood of alternative explanations was examined. The interviews were taped and transcribed using a computer word processing program. The interviewer's word's were printed in italics and bracketed to distinguish them from the participants's words. Descriptions of nonverbal speech characteristics were included in the transcriptions. The tapes were listened to carefully to get a sense of the story and point of view of each of the participants. Meaning segments were highlighted in the transcripts. The Page - 31 interviews of the brother, sister and husband were condensed by picking out those meaning segments that applied to the story of the main participant, arranging them in chronological order and grouping them into themes. Material that related to the same theme and same chronological point was integrated. There was much repetition as well as much material that did not directly relate to the story so 50 pages of interview could be condensed to 10 pages of the interviewees own words. This method enabled condensing of data without losing any significant material. Meaning segments were identified in the main participant's interviews and arranged in chronological order. Again narrative repetitions were integrated. Meaning segments from the other interviewees were interspersed in chronological order with those from the main participant. These additions contributed to delineation of context and provided triangulation. Where accounts appeared discrepant, more information was elicited without confrontation. It is not surprising that accounts of events of 30-50 years ago should differ. As the brother said, "if I had know I would be ased about this I would have taken notes." Most discrepancies were not significant to the sense of the story, for example whether or not dresses were actually sleeveless. There did seem to be a pattern in the sister's comments; she was sensitive to amy implied criticism of their homelife ("My childhood was good.") There was one significant discrepancy in the memory of a pivotal point in the story. Even though the sister did Page - 32 not remember making the statement attributed to her, the significance was in what the child heard and concluded at the time, not in the actual statement. The main participant's report of avoiding drinking or becoming inebriated in her sisters presence as a result of the assumed statement was verified by the sister's interview. The attributed statement was also consistent with the sister's attitude and later behaviour. Her failure to remember the incident was seen to indicate that the incident was not significant to her at the time and therefore not remembered nearly 50 years later. It points up the child's sensitive temperament and her tendency to overrespond to implied criticism. Meaning segments from this general integrated chronology were examined for their role and significance in relation to one another and to the total story. The story was written by presenting the meaning segments in a way that reflected chronological events and themes and patterns both vertically and horizontally across time. The story was told mainly in the words of the interviewees. Some of the meaning segments were summarized for efficiency and a few interpretive and connecting comments were included. Because the final story is composed mainly of quotes from all the interviewees and confidentially had been promised during the interviews to ensure candidness, these quotes were specifically checked out with the sister and brother to make sure that the way they appeared in the story did not distort their intent and that they were comfortable Page - 33 with sharing these disclosures. Permission to use the quotes was established with the sister and brother before the story was passed to the main participant. The main participant and her husband had no concerns about sharing information they presented. One piece of disputed information was deleted when the contributor decided it was inaccurate. Other minor discrepancies which were not significant to meaning of the story were not changed. The main participant found the story to represent her experience except for some of the sister's quotes. These quotes were left in the story because they reflect an alternate viewpoint and the attitude of a significant influence in the main participant's life. The comments of the main participant were taken into account in the analysis. In the analysis of the story, a conceptual structure was built up from a "complex web of evidence and inference" (Bromley, 1986, p. 33) by integrating patterns perceived in the data with evidence and theory from the literature. The strength of such a conceptual structure lies in its connections to the data and in the logical consistency of its internal connections. The result of this synthesis is a "provisional hypothesis" (Turner, 1981, p. 237, cited in Tesch, 1990). Validity This story is essentially the experience of the main participant plus points of view and information from other participants. Validity is based on convergence of data and Page - 34 acceptance of the account by the participants. The brother read both his condensed account and the integrated story; the sister read the integrated story. The most important validation was from the main participant, since it was her story. Although she disagreed with some of the sister's evaluations the account was generally accepted. The story and interviews were submitted to a peer for reviewal of interviewing bias, distortions or neglect. The interviewing was judged to be unbiased. The reviewer noted a couple instances where a word is offered as a question and then used by the interviewee and she was not sure it was the right word for the interviewee. The reviewer noted that both brother and husband make references to religion that did not appear in the story. These references had been considered peripheral to the story because at no time was religion mentioned in the main participant's interviews. When asked to comment on this area of her life the main participant contributed more information which supported the analysis of her process. Similarities in sensitivity between the brother and the main participant were seen by the reviewer to be more strongly represented in the interviews than in the story. The reviewer wondered if the brother's comments on sensitivity referred to the whole family. No distortions were identified. The reviewer did note much repetition in the main character's interviews and interpreted it as a playing and replaying of a preformed agenda. The response style of the main participant in the interviews made the reviewer less sympathetic than she had felt after reading the story. Page - 35 The validity of the story may be affected by the main character's adoption of the explanatory concepts of Alcoholics Anonymous, for example the concept of being "allergic" to alcohol. However such concepts probably only contribute to the description of the end product of the process. Although the history given seemed to be somewhat rigid and well rehearsed, this may reflect her ongoing introspective process as well as her previous experience in telling her story. Stories become rehearsed over time. The participant's story was likely developed and rehearsed in the context of Alcoholics Anonymous. This is not believed to invalidate her story. In fact there are elements in her story which do not conform to AA concepts. introduction to Results The results consist of a story told using excerpts from the interviews using mainly the words of the main character. This story consists of two parts which can be described as positioning and positing. In Part I the main character develops the stance or orientation towards alcohol that carries the potential for addiction. In Part II this potential is actualized through the playing out of the stance in the context of her internal and external environment. This story then becomes the data for further analysis. Page - 36 CHAPTER IV RESULTS GROWING UP ALCOHOLIC: A STORY OF ADDICTION "I woke up in hospital with tubes all over. I was on all the life support systems, for my kidneys, for my heart, for everything. I had been unconscious 3-1/2 days. My heart had stopped beating. They didn't think I would ever pull through. It was an awful experience." "Two weeks later I was back to work. And back at it. I just had to have that drink. There was no stopping; it was an obsession. I didn't need a reason anymore, I just drank. I just drank the way I drank because I couldn't drink any other way, bottom line. Every cell in my body was craving it. It was sheer mental and physical anguish. I didn't know how I could live without drinking because the pain was so excruciating." "Through all the drinking, taking tranquilizers, sleeping pills, you name it, I developed liver problems, pancreatitis, bone marrow going dead. I would spend as long as three weeks in bed. Absolutely in bed trying to recover. Just shaking and cold. What I went through was just horrendous. Two detoxes. All the major hospitals in the city here. Crease Clinic. Psych wards at UBC, St. Paul's, VGH." "I was in constant pain. Every bone in my body ached. The cold sweats, the shakes, the heaves, the headaches, I could hardly walk. But I would still pick up a drink. It would kind of stop it. It got to the point I would have to be constantly drinking, every fifteen minutes, to keep the level Page - 37 up so that I would not shake so much. And that's when I used to take the pills I had." Eventually the alcohol did not make her feel better or even maintain the status quo. "It just intensified the pain. I would take one drink and the pain in my bones was so horrendous I didn't know how I was going to survive it. The doctor said, ' I don't know what to do for you besides pray for you. '" "It got to the point where if she drank too much longer, it would kill her. I am sure she came very close to dying once or twice. " (husband) * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Part I There were things in my family that made me very unhappy, but again it was the way I PERCEIVED them. But at that time it was very painful. To me." L. was born in 1939, seventh of eight children, youngest of 5 girls. Her family used horses to farm a quarter section of "not the best land". In her earliest years, she remembers the whole family eating and sleeping in one big room. They never went hungry; they always had plenty of the basics: potatoes, bread. But in her early years there was still an underlying current of concern about having enough. Basic survival needs were satisfied but not the "wants.' Everybody worked; it was a matter of survival. Like most small children, L. wanted to join in and be a part of whatever the family was doing. But her "help" was not Page - 38 appreciated by her older siblings. She just seemed to get in the way and was told she was too little, NWait until you're older'. L. felt lost in this large busy family where there was little time for individual attention. "I was second youngest. So I just felt with so many, I really wasn't needed and I really didn't know that I was loved, because there was so many of us." Even when they weren't working, it seemed that it was the older ones who got the attention. When the family got together or they had company she felt ignored and excluded. "I think and I feel that as a child you were supposed to be seen and not heard and you didn't really count. Children really didn't matter. You weren't important until you got to be big, grownup." "I just kind of felt I was not important. I didn't matter." She couldn't wait until she grew up so maybe someone would listen to her. Once she woke up after a nap to find herself alone in the house and thought "well they probably forgot about me." It seemed like with so many children and everybody so busy, they might just forget she even existed. And that was frightening. There were many frightening things in her life. L. was frightened of being left alone in the house when her mother was working outside and asked her to "board up the windows so the owl [can't] get me". The brother remembers the family chuckling over this and L. reports being teased about it. The farm surrounded by bush was frighteningly dark at night. Her brother teased her by promising her money to walk to the Page - 39 granary in the dark. She was torn between fear and desire. When her mother walked with her and she got the money, she still felt torn because she hadn't done it alone. "Bulls would chase us and it was really scary. And I mean they would chase to kill. And that was really awful. And we would be cutting through fields and all kinds of things. We used to detour to avoid the bulls and then we got hell for being late. Our parents were worried when we were late because they knew the bulls were vicious. I still have nightmares about it sometimes. Not like I used to, but it has never totally left me." Both parents were very particular. There was a right way and a wrong way to do things. Children were taught the right way and were expected to do things well, no sloughing off. The father picked the stones out of his fields and mowed the grass around the buildings. He expected the same attention to detail from his children. Perfectionistic expectations were fostered in the children and it bothered them when they failed to meet their standards. Her brother says "I try to do the best I can and if I fail, some things bother me, just kind of irks me and stay with me. I try to do the best I can and I believe L. is that way also." L. reports "I was a perfectionist to the hilt. I could walk into any place of my stuff and pick up any little piece of paper I had and I knew exactly where it was." "Religion was an important part of family life. The parents would read the Bible to the children at night. Strict religious principles formed the basis of their value system: Page - 40 no adultery, no fornicating, no drunkenness. L. learned God was all powerful and loving. He saw everything; you couldn't hide from God. "God didn't want me to do things that would displease him, like being disobedient to my parents. So I had to be a Good Girl or I would displease him." If she displeased God and her parents, "Probably I would die". "When I was a kid at home I didn't have toys like NORMAL people. I had a book and a pencil and an eraser. And later I didn't have an eraser because I wasn't supposed to make mistakes. Nobody told me that. But they just didn't buy me an eraser. And that was what my Dad would bring home for me from town. He'd go to town to get groceries and that was my present from town, a book and pencil and eraser, and then no eraser. So I probably figured that myself, that I'm not supposed to make mistakes. And I do believe one of my older brothers or sisters said "The reason you didn't get an eraser is you're a big girl now and you shouldn't make mistakes. You have to be more careful.' And when I look back at that now, of course at that time I just took it the way it was, but I know that was a lot of what I even feel now. Because even now when I'm into anything new or anything I still feel I'm not good enough. So, I know where it comes from. Up here I know it (in my head) but down here I don't feel it (in my heart). I know that I'm good enough and all of that but I don't really own it, you know. I needed, well I still need to be perfect! I still need to be perfect!" "L. always wanted to be best. That was very important to her. She was always good but she wanted to be best. It kind Page - 41 of bothered her if she wasn't better. Even today it is important for her to be top. I don't know why she wanted to be best. Maybe because Mom praised her so much all the time. It may be that was the way she got her attention is by being extra good. She never threw tantrums or any such thing to my knowledge. She just always was so good. She always got the praise." (sister) "As she grew up, she was a good child. She always was prompt in her work and whatever, just as she is today. She was quick and you could depend on her. She was always good about taking responsibility. She was a good kid." (sister) "I was the lost child, the goody goody girl who couldn't do anything wrong because if I did I was afraid that I would be really lost. I am the kind of person that gets things done. I'm not one of those procrastinators. If I have an appointment at 3:00 I'll be there by at least 2:30. That's my whole life style; just gotta be a step ahead of everything. Which is really wearing and tearing on me! I know that. I still do it." L.was a sensitive child who wanted to please her parents. And generally she was quite successful. "Mom always praised her for everything she did: VL. did this so good and L. did this so good.' More so than us older ones. L. didn't do anything wrong. I'm not saying that she didn't sometimes get chastised for something. But L. did everything that was great and L. was a good kid." (sister) L. was a bright, capable child who willingly took on responsibilities very early. Perhaps it was a way of creating Page - 42 security for herself by being needed and valued. Perhaps she was just fulfilling perceived expectations. "We were all hard workers in my family and very responsible. Mom and Dad would go to town and I was left to keep the home running, which was no big deal because I was very capable. This one time they went to town just right after lunch. And the table was full of dishes. And I remember it was really stormy. And I was really scared! So I crawled into bed and just covered up my head so I wouldn't see it! And Mom and Dad came home and the dishes were on the table, the floors weren't scrubbed, just things weren't done. It was just the way they left it. But when I heard them coming home I got out of bed so they wouldn't know that I was scared. I guess I was afraid of what they would think of me. I was afraid because in my thinking and feeling I was responsible -and I really was - and it was not responsible to do this." "And I remember the sheer hell I got from my mother because I didn't do anything. And yet I was just SICK inside because I was so terrified of this storm. And I didn't tell her! I didn't tell her! I don't know why I didn't tell her. I guess it was fear of something. I guess fear that I would displease her and she - I wouldn't be accepted. I don't know what it was at the time. But I just swallowed it and never said anything. Just felt really awful. I just remember as a child all the time in that agony." "They were counting on me to have the place all done up. They would go away and I would scrub the floor, paint the house. And so I was very responsible in getting things done. Page - 43 But I was a little girl inside. I was a little girl all around! I was just taking on, you know, adult responsibilities. I was never allowed to just be a child. It was a matter of survival at that time. I accepted it but I was not ready for it." L. was a "scrawny" little girl, covered with freckles. Others used to tease her that the freckles were "fly specks" and she felt like an "ugly duckling": different, dirty, undesirable. She remembers her mother telling her to "keep yourself covered up" and concluded there was something shameful about showing her arms. If she was wearing a sleeveless little dress she felt half naked and wanted to be covered up. Sometimes she would "pee" her pants and felt very embarrassed and ashamed. L. had a special bond with her Dad. She felt so proud and important when she was able to bring him a jug of water when he was working in the fields. She used to walk with him for hours behind the team of horses. When he was away she was always concerned that something would happen to him; she had heard about accidents where the horses would run away and somebody would be hurt. So she would listen for his characteristic cough and feel worried until she heard it and knew he was returning safely. When he had to go to Winnipeg to sell some pigs and do some business, she clung to his leg and said she was going to kill all the pigs so he couldn't go. The parents had strict standards. The mother used to caution her daughters about "what was right and proper". In Page - 44 the wintertime, L. and her father used to spend a lot of time together while her mother was cooking and sewing."Dad was playing with me and Mom said to me "Big girls don't play with boys'. I couldn't quite figure it out. But I remember I was really hurt. I was isolated. You see the bond between my father and me was a lot more than between my mother and me. It was very painful." Frequent arguments between the parents would explode, then blow over like storms. Her mother would threaten to pick up and leave but she never did. The children were distressed and fearful the parents would separate. When they argued "It seemed like the end of the world". As a very young child, L. did not really know what she was afraid of, only that she had an awful fear when they argued. "It was totally devastating." She would "go in the corner crying" or think "what can I do to fix it", "let's distract them". Any kind of a discussion she perceived as a fight and she often felt responsible. Her mother suffered at various times from bad headaches, menopausal symptoms and the "stressfulness" of hard times. One time "Mum was quite sick. And she always used to say to my oldest sister, "If I die will you look after L. and E.?' Because we were the two youngest ones. And my sister was tired of hearing my Mom talk like that and she said "No I won't look after them.' And I took that upon myself, that she didn't like me. She didn't want me. That nobody would be there to look after me. I just really really felt awful." L.'s parents had emigrated to Canada when they were children. L. was able to understand their native language but Page - 45 was the only child who never learned to speak it because she was afraid of saying things wrong and being laughed at. She remembers her mother saying to her "You're not my daughter because you don't speak our language" and she felt very hurt. From the time L. was a young child, before she ever went to school, she had abdominal pain, bad cramps and constipation. Sometimes the pains were so bad they would have to carry her home from school. She remembers a time when she was 4 or 5 when they made a special trip into town, ten miles with a horse and buggy, to get prunes, castor oil, milk of magnesia etc. for her. "And I'm sick and I throw up with all this but I say vNo I'm fine because I'm scared that I'm going to go to the hospital. So I would hide it as much as I could. But I would wake up crying at night and then they knew there was pain. Even though I never said it to anyone, I was in a lot of pain most of the time. I just wasn't saying it." She also had terrible headaches. "It got to the point that I could not hide it. I always wanted not to cause any waves, not to cause trouble for Mom and Dad". She remembers going to hospital with bad headaches and stomachaches and being diagnosed with pneumonitis. It seemed like she was there for months. She was around seven years old, having recently started school. "The hospital must have been about 35 miles away and they couldn't come and see me very often. And I thought the hospital was going to be my home. I really felt abandoned. That was very painful." "I started school when I was about seven because I lived Page - 46 very far from the school so I studied at home. And then there was once when I was about 8 years old I - like living out in the country it was a long distance to school, like 3.5 miles and big snowbanks and all this kind of thing - they took me into town where I was to stay with my sister and her husband. And I just felt totally abandoned, even though I was with my sister. I was so homesick and so lonesome. They had to come in the middle of the night and get me home. And I skied to school all winter. "I come from a family where my parents were poor. They wanted better for us. So it was, like, you know, study. Cause we gotta do good."l) "So I skipped grades all the way along the way. And most of the time I was 98 per cent, 99, 100. If I got 98% it was vIf you just studied a little harder you would have had a 100!' It was never quite good enough. So I still carry that with me, even now. I did not feel good about myself. And that's something I struggle with till this very day. Up here, cognitively, I KNOW that I'm doing well. But down here there is some kind of a blocker." "Skipping grades caused a lot of pressure for me as a youngster because I was a lot younger than all the other kids for the grade I was in. So there was a lot of animosity amongst the other children with me all the way through. They would be mean to me. It was my perception of the way I felt they felt about me. It was not them, though there was an element of jealousy. They would be mean to me because I would be, you know, a lot younger than them and a lot of them failed grades. Because coming from a country backgound, a lot Page - 47 of them would have to miss a lot of school, you know, to help with the harvest, look after kids, all that kind of thing. And bottom line, a lot of them didn't want to be there. And I DID. And I had to be perfect. And so there was always those kinds of things. And being the super sensitive person that I was, I picked all of these things up, whether they were there or not. I would NEVER recommend kids skip grades today. I would never recommend it." Her brother remembers that L. demanded a lot of herself and "We had some school problems, like kids picking on us. There were certain things we disagreed on with them. Like we were Jehovah's Witnesses ...and we were persecuted and prosecuted and tortured in different parts of the world. And we as kids also took that seriously. If it bothered her - and I'm sure it did - like it bothered me sometimes, to be picked on, then it was quite extensive, quite bothersome. It was just pressures of life that were hard because we took it seriously." When her sister came to visit with her kids they would get into L.'s things and mess them up or tear them. They were only paper dolls cut out of the Eaton's Catalogue but they were precious to L. And the adults didn't seem to care. "I was not important. My stuff was not important. Today I would say I felt violated. But I really felt hurt. And I carried that feeling with me always." When she was older, L. was expected to look after her sister's kids when they came to visit. L. would be in the house cooking and cleaning and looking after the kids while the others were outside working. Page - 48 She resented having to take care of the kids. "Well I just felt they're not my kids, why should I have to do it. I just felt I was taken advantage of by my sister." There was a very large extended family "maybe 30 aunts and uncles with big families" but they didn't have contact with most of them. One uncle and a cousin were believed to have died from alcoholism and there were others who were heavy drinkers. There were stories of past generations who were alcoholics but L.'s parents seldom drank when she was growing up. Alcohol was a rare treat in the household. Not only could they not afford it, but it was not readily available. An older brother remembers "in those days you used have to sign your name and sign your life away to buy a bottle.We had to mail all the way to (town X) from (town Y), which is about 75 miles, and it had to go by mail, or you had to drive by horses so you know how often we went. That maybe happened 3-4 times in our early life." (brother) "There was never any liquor around. You know, 26 ounces of wine between two adults and 8 hardworking kids, none of us were inebriated! And that was maybe once, twice in a year or so. That's all. It was a rare treat that we enjoyed fully. And, I heard many times, mother especially used to say, 'Sure, you know we enjoyed it. Too bad we couldn't afford to treat you more'. But my parents, because of lack of education, didn't warn too much of anything like this you know. Just too bad we can't have more fun! We would never, we didn't have the money even, to enjoy constant drinking. But Page - 49 whenever they could, they give us a drink." (brother) Alcohol was associated with special, happy times: after harvests, seeding, family weddings. Even five year olds were allowed a sip and it didn't take much to affect a young child. A brother describes his first drink at age seven or eight. "The wine just hit the spot. I hit the roof! I was stretching it, but yes I enjoyed it. It didn't take much to excite us 'cause we weren't used to it. You get a little dizzy, you get a sense of well being. And like I say, Yeah! I enjoyed it. And so did the other kids. That's my first memory. I think I enjoyed it, to the full, yes. I enjoyed alcohol all time. I do now. I enjoy the effect. Kinda get - doesn't take much when you aren't drinking an awful lot or frequently - but you kinda feel lightheaded, you feel like singing. You know you kind of feel like a million dollars, you're a little taller than the ceiling." L. also remembers her first drink vividly. "I was probably about 7 years old. And that was at one of these times, probably harvest time or some special occasion and my Dad came home with a bottle of wine for a whole bunch of people. And you know they drank like normal people. And I had that much, [a quarter or half an inch in a tiny glass], but you know, at that tender age? It's so vivid in my mind even till this very day. Oh it was fantastic! I was happy. I wasn't feeling all this inner turmoil within me. I could do things without you know the RESTRAINT I was feeling within me all the time to having to be GOOD and having to be all these things that I had in MY mind, what I perceived that others Page - 50 wanted of me. And so that was just kind of forgot, all those inhibitions. It blocked off all of those bad feelings, those hurt feelings, those angers, that I never expressed. Cause I probably would have liked to punched them out! But I wouldn't say it. But I was probably thinking it". "And I remember to this very day. It did for me what it didn't do for others. When I saw my sisters drink, especially K. and M., they would have a little dribble like this. And they would leave it and they didn't want it and everything. It was no big deal for them. But for me it was. And I wanted more! And I wanted more! Course I didn't get it. There was no more! Even at that young age I would have drank it all. I would have passed out. I never did. But I can also remember when Dad would be gone, and Mum, and the glass would be empty. Cause they would have lots, like this. And they'd be gone and I'd take their glass and get the drops together and I would have those drops. Normal people don't do those kind of things! So even back then I knew I was different! And I hid doing it so nobody would see me doing it. So I knew. And of course that made me feel even worse. Cause here now I was doing these things and nobody else is doing them." "At that point alcohol was associated with happiness. Harvest was over, our seeding was done. And I had this little drink too and it just knocked out all these inhibitions in me. So, you know. Yeah I could join right in. And I could be silly and it was OKAY." "I was not a big child. Very, kind of scrawny. And I remember I took this coat and put my feet in the sleeves and Page - 51 I was walking down the floor, stuff like that. And right then, when I was being silly, I remember my sister that is a nurse - she is eleven years older than me - I remember her saying to Mum even then, she said "L.'s an alcoholic." And I remember it very vividly even till this day. And even then, I didn't know anything about alcoholism, but I KNEW there was something about me that was different from the rest with alcohol. Even at that tender age I knew it. I don't know how I knew. I knew. I just knew. I couldn't give you a description of it or a definition, but I knew. And I knew she was right. I knew she was right." "And I associated alcoholism with shame and all that kind of stuff. And I was hurt. I was hurt when she said that. And I was really angry at her. Never ever told her. I carried that resentment with me. I felt guilty and shamed. I felt ashamed. So consequently I was very careful around her; when she was around, later even, I wouldn't drink when she was around or I'd have what I considered acceptable in her eyes." "I was very sensitive and very hurt. And I never ever said anything to her but I carried that resentment I guess with many many other resentments. All this pent up emotion. I would drink today if I was still carrying all that stuff. So I have no doubt in my mind now that I was an alcoholic LONG before I had my first drink. It just took time to develop and progress." She always felt things very strongly but hid her feelings because "If I tell you something, now you are really going to think I am awful. You might think it now, but if I Page - 52 tell you, then you will really know I really am awful. Not a nice person." "And I remember coming home from the hospital. A neighbor and my sister and my brother came to pick me up when I was in the hospital the three months that time. I remember they had beer in the truck. And can you imagine, they had a beer in the truck and they gave me one. And I drank the whole thing. A whole bottle of beer. They were not "drinker" people but this was you know kind of a big treat going into town and everything. And you drank it in the truck. And they gave me a bottle. And I drank the whole bottle myself. And I was a skinny little runt, smaller than other kids my age. And I really enjoyed it. And I would have had more. I remember it. I can remember like it was right now! I liked it because it made me feel happy. I didn't feel all those sad things that I was feeling. " As alcohol became more physically and financially accessible it was used more often as a treat or a welcome to visiting family members. "When the family would get together, the parents would see that we have a treat. The parents liked to treat us. Alcohol was a treat for the kids. What I'm trying to say, we all, there was 3 boys, 5 girls, we all enjoyed a drink." Sometimes her father had too much, got a headache, and slept it off. After he retired, and could afford to drink every day, he gave up drinking altogether without any difficulty. As she approached puberty, L. filled out from "a very skinny little runt" to being "on the plump side", about 125 Page - 53 pounds on a small frame, but "solid like a rock". Her older sister was very slim. Then "somebody said something about fat. I heard that word FAT and that was a real negative to me. It was a reflection of the way I felt about myself: insecure." So she stopped eating to lose weight. By the time she was 11-12 years old "I'm really skinny. I'm not eating well. All I got was hell. "Eat. Put this on your plate. Eat it.' And so I did. And pretty soon I learned to purge. So then it was binge and purge. Even if I was 8 9 pounds, in my mind I was still fat." At that time there was little awareness of eating disorders and again L. thought "I'm just different than everybody else. And I was ashamed to say or do anything. I just did it and nobody kind of knew." At one point L. remembers "Mom is really trying to encourage me to eat. She is saying "What's wrong with you, are you sick?' And I says "No I'm okay.' But I really am sick. And I'm into the laxatives, epsom salts, all kinds of things already. And I'm blown up like everything. And in my mind I'm thinking "Probably she's thinking maybe I'm pregnant or something.' And I'm worried because I don't even get my period. And this was scary, it was really scary. I never did get my periods - I think I had them once at 12, once at 15, at 26 and then not until 39 when I had acupuncture. But I wouldn't tell my Mom anything. Because she might give me hell yet, on top of it. I didn't KNOW what for. I don't know. But whatever it was, I would now feel GUILTIER even. So if I could even just HIDE all of the pain I'm in, then she won't, you know, ask me any questions. Ask me anything, make me feel Page - 54 worse. Because I really was a Good Girl. And I didn't want to cause any trouble. And I thought she might think these things of me, that maybe I'm not a clean person. And I was building all of this up in my mind. You didn't talk about these things. And I felt very uncomfortable with them. And so I didn't want to bring anything up or show any kind of emotion or anything. Because she might ask me things like that and it would be embarrassing and scary and all that kind of stuff." "And I remember I was in grade 12 and I thought well maybe I should go and see a doctor [about my periods]. It was a little country town. And I went into this doctor's office after school waiting to go in. You don't make appointments, you just walk in. You take your turn going in. And lo and behold who walks in but my mother. She came in from the country and I was living in town. So she was really concerned and all of this kind of stuff. And now I thought x0h, what have I done now, causing them all this worry', and now there is going to be all these questions and I didn't want to talk about it. It was a pretty awful feeling." L. stayed with her sister in town to go to school after the elementary grades. It was a sacrifice for her sister to take her in. "There were six children of my own, the two of us, and I took her in. And we lived in a 20x30 home. One level. Everybody pitched in. She had an obligation in my home the same as my daughter did. They worked. There were things to do. And she was good. She helped us do the dishes and weekends came and there was cleaning and that sort of thing. Page - 55 If necessary I would get after her but she was very sensitive that way. You didn't get after L. too much." [You didn't have to.] "But there was one incident. We went to the neighboring town where I live now and we took my nephew from my husband's side and we had like a cabin on the truck. And they just went out earlier and sat in the back. So I said to her you know that's not nice. You shouldn't do that. Because it wasn't nice for two people of the opposite sex to be by themselves. So she got quite offended. She got quite offended. So we dropped it at that." Her sister had six kids, including a stepdaughter nine months younger than L. "I would be left in charge of all these kids. It was hard work. We went home at lunchtime which meant I had to get food ready for all the kids, clean up the mess and go back to school. Because I was the responsible one. My sister was too busy doing other things. And it was just expected of me." L. readily took on what she perceived to be expected of her. The more responsible she was, the more seemed to be expected of her. After graduating from high school at 16 L. went to Saskatoon, the big city, for Business College. "L. is the only one of the eight children that got an education beyond high school. The folks sacrificed to send her to secretarial school. Well by this time there was more to give...but she was the only one who got more." When she was out working L. repaid her parents for her tuition. They found an apartment for L. in Saskatoon and she moved there alone at 16. "And I was so lonesome and so sick I Page - 56 was going to hitchhike to go home. Because I was so, you know, just sick over it. Kid in a BIG city you know, country kid. So they came and got me and then they got me in to stay with an aunt and uncle in the city and then it was better. Emotionally I was stunted. I really think I was because I was far too young to be where I was. And have gone through all the things that I had." "I was so LONELY and so insecure in myself, not feeling I was as good as all these other kids, you know, that grew up in the city and they were off roaming around and knew everything and I just didn't fit in. Of course the rest of them were older than me too. And they had their friends. So again I had to, you know, be the best in school and so [to compensate] yeah. In MY mind of course. Not in anybody else's. So it was- those were big things in my life. To someone else they would probably be a hill of beans. That's what it was to me." "Actually even in business college I had horrendous gastrointestinal problems where I had gone on laxatives, all that kind of stuff. I started either not eating or the eating and purging stuff, the laxatives and all of that." The family noticed that when she would come home she was "so very thin". "When I was in business college I was like a rake." "So that went on a long time. Actually it went on even through my drinking years. I would drink the booze and throw it up or drink the booze and eat only enough to just kill my appetite. Whatever I did I overdid. And then I got bulimic. So it was back and forth. All that kind of stuff. Every crazy Page - 57 diet that I ever heard of I would be on. I would drink lemon and drink vinegar- anything I would read that you would lose weight. And you see because I was so bloated, I associated bloating with weight. Whereas in fact it was really from the spasms and all this other stuff." The eating disorder continued for many years during her drinking career. She eventually confided in a doctor who was the first one to recognize and validate the bulimia/ anorexia. Dealing with the eating disorder allowed her to continue drinking. "It was a way of pushing that to the back burner." "In my sister's house there was no alcohol at all. To this very day she's not one who even has a glass of wine. All the years that I went to college I never really drank. I would maybe have a little glass of wine if somebody offered it to me. I would not have had more because I knew that this was really doing to me what it wasn't to others. For the fact that, like my Mom described it, it was like a magnet to me and it was shameful for me to want more. This was my interpretation of it. It would be shameful for me to have another glass. Even if it was offered. Other people would have more but I wouldn't because it was shameful. "But I sure liked what it did to me. But you see all those years I was too young to buy it. And I would be too embarrassed to ask somebody to buy it, so I never drank. I used to think it would be nice to have a glass of wine or something. But I was not old enough to buy it. And I would not ask anyone to buy it for me. I was too afraid. Well, you Page - 58 know, you don't do things like that. People will think I'm an alcoholic, or whatever. "I enjoyed it right from the first time when I was about seven years old. When harvest time, or whatever it was, yeah. If I would have had access to it I'm sure I would have been an alcoholic by eight! The stage was set. All I needed was the booze. I had the emotional pain, I had the genetics. Everything. It was all there. I just didn't have that elixir yet, the alcohol. I really believe I was an alcoholic BEFORE my first drink. Everything was there: all the feelings; all the genetics,the feelings were there. It was just that I didn't have the opportunity to get into it." Part II "Yeah. The stage was set. Just a matter of getting it, getting into it. And you see even, I was very embarrassed ever to walk into a liquor store, even when I was 23. And I was embarrassed for a long time until I was oh way up in years and had been into the liquor store and it got to be second nature." L. was married when she was around 21. "I remember my husband bought some wine and then it was something that I really took a liking to and I remember he said vBe careful, don't have too much because you'll get sick' And I knew then I'd have to hide it. He could see what it was doing to me. But inside of me I knew that I had a problem. I knew that all the time." She always felt guilty about her drinking. "And ashamed. And ashamed." Page - 59 They would have wine when they had company for dinner. "My husband poured it. If there were six or eight people for supper there was just one round poured in eight glasses and it was just gone. And I'd say "Well maybe we should buy another one and he'd say "No. That's enough.' "I basically didn't ask [my husband] to buy wine because inside of me I knew I was an alcoholic and if I would ask for the wine then he would know I was an alcoholic. But what happened is we would have company more frequently. And that would be so that I could have the wine more often in my house. And eventually it got progressively worse. And so then it would be TWO bottles of wine." When she had the opportunity to pour the wine, "Mine would be a little bigger. Or I would go in the kitchen and refill mine a little bit. All those tricks." But it wasn't until she started buying the wine herself that the drinking really took off. "From age seven there was, you know, basically nothing until 23 when I really started drinking. But even then it got much worse at 26, 27, and from there on it really progressed." Meanwhile, the abdominal pain continued. "The pain was just absolutely awful. The doctors didn't know what to do. Anything they did didn't do me any good. Another lady, she was a little older than me, we used to visit back and forth. Usually her and I would be in the kitchen cooking supper and we'd have a glass of wine before the rest would come and I found that this eased the pain too." Page - 60 "I was afraid to go into a liquor store. Because nice girls don't do that. In my mind. No. That was shameful. Men smoked, men drank, women didn't. Women were supposed to be at home looking after the kids and the house. You know, all that. Like a lot of people to this day think beer is man's drink, not a woman's drink. Basically beer was MY drink. Wine and beer was mine, preferably beer. So. I was everything against the norm of society." So she had another reason to feel guilty, abnormal, isolated. "Well the first time I [went into a liquor store] was when I was in Ontario. My husband and I were there for 6 weeks when he was on a job there. It was just after my 23rd birthday, and I walked into a liquor store. Because nobody knew me, so it was okay. This was the first time I'm going into a liquor store. The first time. It actually started with the FEAR of going into a liquor store. [And then there was] THE REJECTION I was getting from the clerk! He was no way going to give me this wine and I'm fumbling there for my birth certificate, my marriage license, whatever. Because they did not believe I was 21 or whatever age I was supposed to be. I said %I'm not, I'm 23.' Finally when I gave them all my documentation, I had a lot of anger, I had, oh I can just remember, I was probably shaking. I was very angry. Today I would take it as a big joke, take it as a compliment. But I really, at that time, I guess it was my own fears and insecurities and everything that were REALLY surfacing. Because I had never done this before. It was stepping into the unknown. Whereas before if I Page - 61 wanted anything I always depended on my husband to bring it in. But it was safe for me to do this because I think the fact I was away from home. Nobody really knew me. Even at that time, where I came from, women didn't do those kind of things too much, and if they DID, they were what you would call not nice women. But you see I was away from home." "I started cooking. And I have a little glass of wine. And so I get my supper all on. And just having a little bit more wine. I know it didn't take much to inebriate me right now because I couldn't tolerate a lot. But my tolerance level grew and by the time my husband came home, I probably had a third of a bottle gone. Which does not sound a lot to me today. "Probably no big deal for the taste; I never drank alcohol for the taste ever. It was the effect. The CALMNESS. I drank for the effect it produced in me. A calmness. It kind of just made me feel better. How can I explain how my agitation was way up here and if I bring it down a bit I felt more comfortable. And obviously this is what was happening to me as I am drinking this wine. And pretty soon I am really liking it so I have a bit more. I am liking the feeling of calmness. I am not feeling all this agitation in my body." Her first foray into a liquor store was a stressful experience but "after having the wine I have now gained this feeling of comfort within my own body." "And so my husband comes home and he says 'You look like you have been drinking' And I says 'Yeah I picked up some wine for supper and I have a real nice supper ready'. So he Page - 62 had some wine and I had a bit more. And pretty soon he says 'I think you better not have anymore'. And I think that hurt me as well. That hurt me. I'm finding it very hurtful because I am now saying to myself ~I am not a nice person. I am not a good person' but I am associating it to the alcohol. And I think that too I was associating it to that because usually where I came from people were associated as alcoholics when they were drinking too much and all of that. And now my husband is telling me this and I am mentally going through all of this and I am finding it very hurtful. It was an awful experience. [I felt] anger welling up in me and hurt under the anger. In my stomach, all through [my abdomen]. Belittling. That's the way I was interpreting it. But I wanted more wine. By the time I went to bed, I finished that bottle of wine." "And I wake up in the morning with an awful headache, not waking up early and bright like I usually do. The second day, or the third day, I did go back to the liquor store and they did not give me a hassle. And I did get more wine. And I remember my husband said NL. I think this isn't good. Because you know you drank all that wine the other night and you are drinking again.' And I am already sensing in my body I have a major problem. But I am not wanting M. to know this. So I'm minimizing and all of this but the GUILT within me, and SHAME, HUMILIATION. It's awful. But I want that wine. Because now I want to KILL all these feelings. So it's a vicious circle that I have got myself into. And that was basically the start of all of this. And it got progressively worse. Page - 63 Worse and worse." "It affected her more than anything else because it created a lot of shame for her." It was when they were in Ontario and she started buying the wine herself that her husband noticed there was a problem with her drinking. "[In the beginning] there was not anything so dramatic, you know. I drank like other people did. Socially. What normal people would say was social drinking. But knowing what I know about alcoholism, to me it was not social. Because it did for me what it did not do for other people." So L. hid her drinking. "And sometimes I bought two bottles. But my husband didn't know about the second one. And he would say, vWell you better not have any more because I can see that glass of wine has really affected you already'. Well yeah, sure did. But I didn't have much, out of THAT bottle. But the other one was HIDDEN. I would wait and drink after [people] were gone. Or I would have one bottle for me and one bottle for company. I drank some with the company and then I drank mine behind the scenes." When she was out visiting "I would have just a little bit in a glass even though they offered me more. I didn't have more. But I would go home and [drink]." There were few witnesses to the progression of her drinking because she hid it as long as she was able. However her brother stayed with her from time to time and noticed that her drinking was increasing. "So it was just when I saw the increase at different times, always increasing, so eventually at some point you just see that it's going to come to no good. At exactly what time I saw this, I couldn't say Page - 64 exactly when I noticed it but it was when it was on the increase. I just saw that she had too much. She would go to sleep and have a hangover. Then she enjoyed more drink more frequently as time went on. And that's it. It got to be a gradual growing thing." He was concerned and brought it to her attention. "But I was there enough times to recognize that I felt that there was a problem developing. And you can see a pattern so I figured that now is the time to start to stop that pattern and she agreed. I just mentioned it casually, I said 'You keep doing this and you're gonna become addicted to it.' and she said well, maybe she should stop. She said she decided to stop. She didn't say it right away but then some time later, day or two or hours later, she said 'I'm gonna quit'. I spoke to her and she said she'd quit. And then she did, oh I would probably say three weeks or so." L. was still having a lot of gastro-intestinal problems. "And the pain was just horrendous." A doctor told her that her pains were due to "nerves" and a little wine would help to settle her nerves. "When you drink enough pretty soon you don't feel anything. So I drank until I didn't feel anything." When she told her doctor the wine was effective he told her 'If wine helps you, well have it!' The drinking really escalated after that. The intestinal problems produced a lot of bloating and one doctor said 'Oh you are retaining fluids' and put her on lasix. After 20 years, the diuretics and laxatives she was taking were depleting her potassium and affecting her heart. The medical and emotional problems interacted with the Page - 65 addiction; it was hard to tell where one left off and the other started. Her husband remembers "it all started because of the health problems. Well the health problems she had all her life but she never used to like to drink. It was probably-after noticing, the first time it made a difference on her insides, on her gastro-intestinal system. It relaxed it, or anaesthetized it or whatever. And as time went on, doctors would say, 'Have a brandy or wine or whatever for your stomach.' She would have some and then it would make her feel better, just kill the pain or relax her. She always had trouble with her gastro-intestinal system. So the pain got too bad she would just drink." The doctors didn't all advise her to drink but "you know if you have trouble with your stomach, and she says that wine relieves it, they say "Have it1" The doctors didn't ask how much she was drinking and she didn't tell them. On reflection, her brother remembers that even as a child "Subconsciously I would see that there could be something wrong. Then of course when she went to a doctor for stress, I saw that maybe I did have something, that there was a stress. You can see a stressful person, lines drawn, and you know, tension. That's how I noticed it. I felt stressed and I concluded that L. was the same. Why is a child born an idiot or tense or something else? The other kids can go ahead and have a fight and smile about it tomorrow, see. It didn't go that way with me. And I presume we are from the same family and we were often tarred with the same brush so to Page - 66 speak. You know, things run in the family. So it probably runs in the family: tension, probably the alcohol. That's just one of the makeups I guess." Her brother disagreed with the doctor's recommendation that L. use alcohol to cope with her abdominal pain. He also had problems with pains attributed to "nerves". "Over many years now, I've visited the doctor many times and it was nerves. He didn't tell me to drink. You know, different doctor. And so then she went back to drinking. Not excessively, but it kept building. And she had more confidence I believe that she can't get hooked on it. She threw caution to the wind. She enjoyed the drink before that, and when she went to the doctor he didn't approve going overboard, but he said 'no problem'. So she carried on. The availability was there. And the likeability was there; she enjoyed it. The recommendation was there. So everything was directed towards vthat's okay.' And in this way I saw it develop. And I am not blaming the doctor, he was probably trying to recommend the best. You know they ain't perfect also. But that's what I feel." So she became dependent on the alcohol to cope with the abdominal pain. "The pain was just horrendous. I doubled up in pain. The spasms are just UNreal. And as I was taking more wine I'd become, you know, anaesthetized so that I don't even feel the pain anymore. So now I NEED the wine. I already needed it emotionally and mentally, and now physically it's blocking the pain because I'm anaesthetized. It certainly didn't take the pain away. But I'm not feeling the pain." It Page - 67 wasn't a cure but it masked the problem. "I didn't care what it's doing. Just do SOMETHING. And so that was an ongoing problem. That's basically where all my drinking got started was because of my gut problem. I'd have a drink and it made my guts feel better. So I'd have another drink." "At times my husband would say VL. I'll get you some wine to ease the pain'. And of course I was all for it. That would now defuse some of the guilt and the shame for me." The physical pain legitemized the drinking in a way that the emotional pain could not. So she would have the wine and it did ease the pain and spasm in the colon. For a while, it numbed mind, body and spirit. The physical and emotional pain had both been present as far back as she could remember. It is hard to say which was more influential. One probably influenced the other. In the beginning, "I didn't KNOW that this was going to ease the physical pain. But the minute I had it I could feel the lifting of spirits and the emotional agony I was in. And it was from then that when I had physical pain I noticed that it eased that. So probably the emotional pain came first. Because I did not know that wine would do this for me." "Well she may, like I say, she has always had some health problems, no doubt. Because none of us have perfect health. But she inflicted a lot of the illnesses on herself. She used to always use illness as a coverup. Of course she was sick but when she got drunk she got sicker. But you see what I mean, she used to tell us these were her health problems. And at the time we didn't know. So you sort of Page - 68 believed her. You sympathize. But then pretty soon you quit when you realized that she was inflicting it on herself through drinking and anorexia. But we didn't know about it for the longest time that this is what the problem was. We just thought it was her health. But it seemed like then that's all she was, she was so sick so she would take to bed after she'd had enough. When she couldn't function anymore." "[When she first started drinking] there weren't the same quantities so it was manageable. But it didn't take long after, that you know you could see that sometimes there would be the tendency to drink what people call too much. When it affects your senses. When you can't manage it or you can't control it. At the start she was able to [have just -[one or two drinks] When [the addiction] was triggered, one drink was too much for her. One drink was too much." It seemed to her husband like the addiction was there all the time and the first drink just activated the process. Her brother noticed "It just kept getting worse and worse; more drink, more often. The pattern was that at one time she was just drinking lots. As time went on she was drinking more. How do you see the water rising. You know? It just all the way up slowly. At different times I wasn't sure that I saw correctly. I know when I look back sure I saw a pattern. She was increasing in drinking and suffered more after effects and so on. She'd sleep longer. Sleep through the day." "That's not a normal thing unless you are sick. [She] became restless. She was never totally negligent, but Page - 69 she became more negligent of the house." She hid her drinking as long as she could. "I was a closet drinker. But that didn't last too long that I could hide it. Because it would show on me." She couldn't hide what the alcohol did to her judgement and emotions. "It happened quickly in that you could see that alcohol had a negative impact. She was different than she is without alcohol. She was different. Like some people when they drink, they sort of cheer up or whatever. They still continue being positive. Seems like for her, it would have a very depressing effect on her. She might have been more angry. Cause you know how it is when one person drinks and another doesn't, you get into discussions that are strong and verbal disputes." She drank to feel better but she ended up feeling worse. It became a vicious cycle. "And of course then there was the guilt and the remorse that set in and I'd go on a shopping spree and I'd feel guilty about all of that stuff. So then I'd have another drink to drown THAT sorrow, because I spent money I didn't really have. And it just went on and on." L. was careful in her sister's presence. Her sister rarely saw her drink. "There was the odd time that we would stop at a bar and we would have a beer. But that's where it stopped. She never got drunk then. I never saw her drunk until she was so well established in it that there were a few times." But "She would quite often phone and make these stupid phone calls for an hour at a time. There was no use for her to be wasting her money because she wasn't really saying anything. You couldn't reason with her on anything.Her Page - 70 phone bills would go up to an exorbitant price. The more she drank the more she bought, the more she spent. Because she would buy, she would go on binge buyings. Like her reasoning was gone." (sister) "I shopped to make myself feel better, because I liked clothes. I still like good clothes, but [now] I'm not a compulsive shopper. Now I think things through. I shopped [then] because I didn't feel good about myself. It was a facade. I felt rotten on the inside so I was trying to make myself look better on the outside. I would always present myself as being confident and calm, and dress the part. The whole facade. Other people always thought that I was so confident. All through school my grades were good, I was good in sports, I was good in whatever I did. My mother used to say vDo it well or don't do it at all.' So I always did well. But never good enough." "Somehow she is not satisfied with herself. She needs more. She needs to be best. Why, I don't know. You might put a label of selfishness on it - I wouldn't say selfish, but in a sense. I don't know how to word it. I just thought she was thinking of number one, me. You know, that she was thinking of herself. That she had to be more important or something. But it seems like she still has to be in the limelight in a strange way. As soon as someone had any ailment, she had one to equal it. She had to be the thinnest, the best dressed, that sort of thing. I think she wants you to notice."In a group of people L. felt "Like a square peg in a round hole. I could be in a group of people, I could be contributing in whatever, but I am not Page - 71 feeling NORMAL, like other people are feeling. I am just not fitting in, not feeling good enough. Not measuring up in any way." She might be in a crowd laughing and talking "But that's a mask. That's not what it really is. Inside you are totally isolated. Because you feel like a square peg in a round hole. You feel different. And you don't tell other people about it because of the FEAR that's in you. And if I had to describe alcoholism in one word, it would be isolation." When she would drink, she would feel more comfortable. "So when you have that drink, and it gets the endorphins and all of that stuff moving and it kind of puts you up to a level where other people are. So that's why you start drinking because you recognize that then you have that panacea. It puts you over here where you kind of feel what other people are feeling. So then along with the drink and the sedation comes the agitation which brings me away back here. Now I have to drink a lot more to get me up to here. And so on and on it goes." Her insecurity was reflected in the way she interacted with others. Present situations would trigger the same reactions she had to painful childhood experiences. "I carried the insecurity about being loved and needed and wanted when I was a little child all the way through adulthood." When inlaws came to visit, in all the hullabaloo she felt left out, pushed into the background. Just as she had when she was a child, she felt as if she did not belong, that "others are more important. Don't make yourself important. Don't get in the way of things." She reacted to Page - 72 situations feeling used and abused but not being able to express her feelings assertively. "I never said anything to anyone until probably 5-6 years ago when I started recognizing this stuff. But [the anger and resentment] would be eating me inside". So she would drink. "Because you see I could drown all that stuff that was in here. Block everything off. I was a serious drinker. I really got into my drinks. To block out whatever I was feeling, all those insecurities. It just made me feel happy. Well it finally got to the point of anaesthetizing me." "My brother-in-law and his wife were down. And typical, you know, visit. Everybody was having some wine and whatever. Lots of food and all of that kind of thing. But it was kinda like, 'Don't give L. any because L. will get sick, L. will drink too much. L. will this that and the other thing.' Nobody actually said it but they would give me this much and half the glass to everybody else and leave me out. I really felt slighted. So again you see I was being treated differently. So that was very hurtful. Just out of kindness and consideration they could have treated me the same." And I was damn angry. I walked out. I would go home and tie on a GOOD one on! I really got into this blaming thing - people, places and things. Anything for an excuse to get bombed. Because that's just the way it was for me." "And I was in the psychiatrist's office and he said, 'Well I'd feel the same under the circumstances.' And this is really dumb on his part, he added more tranquilizers to my Page - 73 diet. I already had a cupboard full. But he added more to them." Over the years doctors gave her pills for "pain, bad nerves, depression". "Going to doctors, that would be the first thing they would give me: tranquilizers, sleeping pills, you know, all this nonsense. At that time, well you know, the doctor gave it to me so it's got to be okay! They continued prescribing medication that would ADD to the addiction. Cause there are a lot of medications that stimulate the desire of alcohol." Both her husband and brother became concerned about her drinking. Her brother "scolded her" and once "physically stopped" her from drinking, and L. remembers being very angry at him. When they went out socially "my husband would say vYou'd better not have anymore drinks or just don't drink any because you'll make a fool of yourself.' And I wouldn't. But I would be just waiting to go home. And I would walk out or we'd leave early. I'd either have a stash at home or get my husband to buy something for me on the way home. So my mind was not even on the wedding. It was on my drink that I was going to have." In the middle stages "I didn't drink all the time. I could go 6 months. I could go a year. Which I did, on a bet." "She stopped once for a year. Once for a month. And then she might drink for a week straight, or two weeks straight, every day. three weeks straight, every day. She quit several times. But it wasn't until she really started working with Dr. (X) that things started improving. Even while she was with him, it took a long time before she was able to make the change." Page - 74 (husband) When she started drinking again after a period of abstinence the problem seemed worse than before she stopped. "And I was cutting down. I was ALWAYS cutting down! ALWAYS CONTROLLING Controlled drinking? Hey if you gotta control, you gotta problem! So many of us have been through that type of thing and once you have to control, you've got a problem. But I was controlling. I would buy a mickey I wouldn't buy a big bottle. I'd only buy a six pack. I wouldn't buy 12." "As I progressively got sicker, in the hold of addiction, I would take lesser jobs so that I could still excell above everybody else. That was another thing that I did. I [would] always quit my job and get into another job before I would HAVE to quit. I was missing work. Blackouts were just phenomenal. One day my sister-in-law was staying with me and asked "are you going to work?" I said "No. What day is it?" She said "You have already missed a whole day of work." And I didn't go to work until probably three days after that." "Eventually I would be drinking every night. I would go home from work and I would be going to the liquor store before I went home to make supper. In the morning I would be pretty hung over. And I gotta go to work. So then in the morning you take valium to stop the shakes. Sometimes I could hardly write. Pretty bad when you can't write a check, sign your name on a check to get some money to buy some booze. Page - 75 "The family was really suffering. Because I was so into myself, even though I was feeling badly about it, I would then say [to my daughter] 'Well here's 20 bucks, go down town, take your friends with you, do whatever you want to do1. Like get off of my turf here so I can drink without any problems." She began wondering where her next drink was going to come from and having problems with her husband because he is saying she shouldn't be drinking. "I got to be what you would call a maintenance drinker, drinking every day just to keep the level up. My husband didn't want to buy it for me and I was too sick to go out to get it. So I used to have that fear as well, [not to have it when I needed it]. I was embarrassed and in no shape to go out and get it so I used to call a cab to bring it to my door. Dial a bottle would take too long!" "When my daughter was 12 or 13 I gashed my head really good, just hit my head and my nose was cracked, my ribs were cracked. She rushed my into Mt. St. Joseph's because she knew I didn't want to go to St. Paul's or VGH again. There was blood all over the rug in the living room. And I guess she rode in the ambulance with me. And you know, I don't remember any of that. I'd go to the doctor and ask him to do a liver test for me. Because I knew how much I was drinking but I wasn't going to tell. And he said 'Your liver is fine' so I kept on drinking." "And I remember this other time I passed out - well I was in a coma - in a restaurant with a friend of mine. She Page - 7 6 was also an alcoholic and we stopped for lunch because we wanted some booze. So I ended up in the hospital right from the restaurant. I had probably been drinking for days already and it builds up." "When a person has to drink and it has ill effects and makes you suffer and you still drink again it's a pretty good clue you are drinking for different kinds of reasons. I think very early you could see it had this very depressing effect on her. The effect was different than you would see from a normal person who would be drinking. And eventually, when it got bad, it would create suicidal tendencies." (husband) "My husband had a lot of fear. And I just felt like I was being watched. And I was. He would have his mother come over to watch me. And that only made it worse. I was very angry. It is an awful thing. You are already feeling so rotten about yourself and now it's being validated. Nothing positive was ever said. Nobody knew the pain I was going through. Nobody was interested in knowing the pain - the only comments I would get was "everybody has pain". There was absolutely no help for me. There was absolutely no help. No help from the medical profession and no help from anybody at that time. And as far as I was concerned there was no help from my family. My husband was at his wits end. He didn't know what to do. He meant well by having his mother there, but it was just degrading, belittling, dehumanizing." It was hard to know how to help her. "The big problem is, you don't know at what point you should stop helping someone, taking care of somebody. And you have to be careful, Page - 77 cause there are legal responsibilities and so on. And you can enable her because you don't want the person to get hurt or whatever." (husband) As an adult, when her sister continued to label her alcoholic "It was really hurtful, really hurtful to me, even though I knew it. But it was like, kind of sDammit! What do I do about it? Put a plug in the jug?' That would have been a start but that's not enough! When she needed it most, she felt she had no support. Instead it just felt like people were being judgemental. Alcoholism was perceived as a moral issue. It appeared to her sister that "She wanted someone to feel sorry for her. That's the feeling that I got. [she wanted] sympathy. I just felt like she wanted me to feel sorry for her because she was so sick. And I couldn't feel sorry for her because -only if I was sorry that she was in the state she was in. But I couldn't feel sorry because I knew it was in her control. She knew exactly what she had to do about it. We have to answer for our actions. That's the way I see it. She failed to take responsibility for her actions. We can choose what we want to do. But we also have to bear the consequences. And she sort of, she did it, but she didn't want to bear the consequences. Now she does." She lost her connections to people she had been closest to. "When she got on drugs-I shouldn't say drugs, alcohol, which is a drug. She just, like we drifted. Really drifted. [When people drink and lose their senses] it is repulsive to me, very repulsive. [She kept trying to make that connection Page - 78 but the alcohol got in the way.] Because like I mean there was no reasoning. And she wanted sympathy but I couldn't give her what she wanted. We got to where we couldn't associate. She was self centered. Everything was "me". "I am so sick' and then because nobody was feeling sorry for her she would feel that everybody was against her or something. She would always say to me, 'Well you're just like Dad and M.'" (sister) "Because I was feeling so guilty and shameful I would take a drink to try and ease that emotional pain. Initially my hope was [to feel good]. The mental anguish was so horrendous. Get that jolt in, it would ease it a bit. But at the same time that increased the other pain, the shame and the guilt, the remorse and the whole bit, because it was a vicious cycle. And of course it was affecting me physically as well." "The physical pain was there as well. Because every cell in my body was craving it, even when I wasn't detoxed but just a little lower level of alcohol in my blood, I would need to take another drink to kind of ease that pain, even the physical pain. And it did work [at] the start. The first drink would make me feel a little bit more comfortable within my own skin. It really did. Usually I would have a few drinks and then I would have something to eat. Because I was going to be careful. If I had drank without eating I would probably NOT have survived. From the start, it just made me feel a lot better. The second drink probably just kept me up to that level for a Page - 79 bit. But by the time I would be to the third or fourth, it wouldn't be doing that any more. But I would drink anyway. There was no stopping. I wanted to get even feeling better. Experience after experience and it doesn't work but I keep doing it. Even I would be so saturated there wasn't even the craving anymore, I could hardly even hold another drop. I drank it anyway. By that time, there would be all these promises starting. "If I get through this, I won't do it again'. But right now, I'm finishing off everything I have." "An alcoholic very quickly FORGETS what it was like. "This time it is going to be different I am going to drink differently. This time I'll be careful I'm gong to CONTROL this time'. After detox she would start drinking again. "And maybe for a week or so I could have a couple of drinks, three drinks or so, even though I wanted more. I was feeling so rotten, whether it was physical, mental or emotional, basically it was all of them. I had a tremendous amount of physical pain along with it that was compounded by the alcohol. I used to have crawling sensations from all the nerve damage, prickling feelings, cold aching bones. And the booze would initially help. So I would pick up that drink. And you are just back into the same situation." "I was very very depressed. So I had all these pills in the cupboard: Valiums, ativans, seraxes, you name it. Sleeping pills, wake up pills. And I said that's it. I am not tolerating this anymore. And I was really feeling hopeless and helpless. So I went to the liquor store and bought some wine and took all of these pills, every last one Page - 80 of them. And I drank the whole bottle of wine. And I lay on the bed and thought to hell with this. I just wanted out of everything." "I woke up in hospital with tubes all over. I was on all the life support systems, for my kidneys, for my heart, for everything. I had been unconscious 3-1/2 days. My heart had stopped beating. They didn't think I would ever pull through. It was an awful experience. "Two weeks later I was back to work. And back at it. I just had to have that drink. There was no stopping; it was an obsession. I didn't need a reason anymore, I just drank. I just drank the way I drank because I couldn't drink any other way, bottom line. Every cell in my body was craving it. It was sheer mental and physical anguish. I didn't know how I could live without drinking because the pain was so excruciating. The physical pain was devastating. It had affected my bones, everything in my body." "Through all the drinking, taking tranquilizers, sleeping pills, you name it, I developed liver problems, pancreatitis, bone marrow going dead. I would spend as long as three weeks in bed. Absolutely in bed trying to recover. Just shaking and cold. What I went through was just horrendous. Two detoxes. All the major hospitals in the city here. Crease Clinic. Psych wards at UBC, St. Paul's, VGH." "I was in constant pain. Every bone in my body ached. The cold sweats, the shakes, the heaves, the headaches, I could hardly walk. But I would still pick up a drink. It would kind of stop it. It got to the point I would have to be Page - 81 constantly drinking, every fifteen minutes, to keep the level up so that I would not shake so much. And that's when I used to take the pills I had." Eventually the alcohol did not make her feel better or even maintain the status quo. "It just intensified the pain. I would take one drink and the pain in my bones was so horrendous I didn't know how I was going to survive it. The doctor said, VI don't know what to do for you besides pray for you.'" "It got to the point where if she drank too much longer, it would kill her. I am sure she came very close to dying once or twice."(husband) ************************************************************ EPILOGUE "I knew all the time I had to do something about it. But it wasn't that easy and it was like you know excuses and like not looking at what the REAL problem was. The drinking was only the top of the iceberg. So I'd just cut down and all this kind of nonsense which doesn't work. I had to start feeling better about myself, that I had a spot on this earh and was as good as anyone else." "So basically when I REALLY surrendered was just about 5-6 years ago. And I was on my death bed. And it was - my daughter was going to university and my husband was going to Toronto on business. And my husband and I were in the doctor's office and [my doctor] says "X.(husband), you go to Toronto, Y.(daughter), you go to [university]. L. knows what she has to do." Because I had been bouncing around long enough. I knew about AA and I had been in and out of Page - 82 meetings. And I knew up here what I have to do but I just hadn't surrendered to accepting that this is the way it was and I could not drink anymore or take pills. Recovery did not start until my total surrender [to the fact that] I could not pick up one drink." She was desperate."I knew that was the only way because I was going down fast. Really fast. Everything else I had tried did not work. I had been through two treatment centers. All of that kind of stuff. To get people off my back! This was the only last thing otherwise it was death. Because I had pancreatitis, liver disease, bone marrow disease. It seemed that I had tried suicide so many times; that didn't work. What was I going to do? And by this time I knew that I had to go to AA meetings. I had been to enough to know that this is what you do." "So I started going to meetings. I was still at home. And my sister-in-law stayed with me because I was so sick. She used to come and stay with me when my husband would go away. I had phenobarbitol and he said SI won't give it to L. If I give it to L. she will take it all.' so, but anyway, M. was leaving and I had the phenobarbitol and I did not take it all. " "I figured I got to smarten up. I'll call B., I'll go to a meeting. And it was after that horrible storm. And I could hardly walk. I couldn't hold a cup of coffee, I would be like this. And my sister-in-law had a beer and I still had a beer with the phenobarbitol. But I gradually started to get a Page - 83 little bit better. Went to meetings. Went to three meetings a day. Because at least when I was at a meeting I wasn't committing suicide, I wasn't drinking. But I had a suicide bag packed with me when I went to the meetings. [I went] to a downtown lunch meeting and there were a few people who heard me and they came and talked to me and they gave me their phone numbers and they knew where I was coming from because they had been through that low an experience." "Within the first two weeks of going to meetings I gradually started getting better. I was in touch with others in the group who had been through a horrible time themselves. And they could sense that I was really suffering. And they were just kind of there for me. And within the first two weeks, the obsession to drink had left me. It was the surrender. I KNEW I could no longer take another drink. If I were to drink it would kill me. And I just gradually kept getting better and better. And there was no stopping. I just got better all the way." "And so, well I still suffer with gastrointestinal problems. Except that now I know that I can't have lactose and I know that yeast doesn't agree with me. I'm currently being treated for a stomach infection from an ulcer I had, a duodenal ulcer where there is scar tissue left. And this is a result of leaving the office where I was rushed into the hospital by a cardiologist who insisted that I have an angiogram and the stress test, the works. And that was all negative. There is nothing wrong with the heart. So he said it could be that there is something gastrointestinal. So I said 'Could be'. Because that was Page - 84 where my problems had always been. So I went and had the gastroscopy and he told me this is what I had." "But doctors just marvel, because basically I'm in really good health. Doctors marvel that I'm in the shape I'm in today. Well they just can't believe the abuse I have put myself through, for the shape I'm in. All this stuff that I've gone through. And everything, from the ultrasound I had very recently, everything's in excellent shape. Except for this inflammation and scar tissue." "I really feel that [the intestinal problem] was caused by the emotional [problems]. I believe a lot of that was the garbage I was carrying around with me. Kinda like [being] out of ecological balance and it's got to come out someplace. And so no doubt that had gone into the spastic bowel and all the other stuff I had. I'm still up there dealing with those kinds of things. [Even after quitting drinking the stress] started coming out in physical [symptoms]. I was having ST depressions and myocardial ischemia and migraine headaches and all of this." "All these pent up emotions, these angers, these fears, these resentments, this having to be perfect stuff, internalizing, people pleasing - everything that I was carrying - I have no doubt in my mind now that I was an alcoholic LONG before I had my first drink. It just took time to develop and progress. It is a physical, mental, emotional and spiritual disease. I would drink today if I was still carrying all that stuff. But I now know, those are luxury things and those are luxuries an alcoholic does not carry. At Page - 85 one time I would be resentful and then I would drink. Whereas today I don't have to use the alcohol to push it down. I deal with it. In whatever way is appropriate for ME at the time. At one time I couldn't say no. I would just do it anyway, then feel angry in here. Today I don't do that." "That's why I go to all the meetings. That's why I share with people. I talk to a counsellor. If I'm at work, feeling a little down today, exhausted tired, all those other things, hungry, I pick up the phone and call one of the ladies who is my co-counsellor. And I'll talk to her half a dozen times. And I'll say, NP., I need a counsellor. Got a couple of minutes? I got to talk.' Whatever it is I get it out. Soon as I get it out I'm feeling better." "But you see at that time I bottled it in because if I tell you aren't going to like me. Now I don't give a damn. I got to do it. And nobody thinks any less of me. I can face up to whatever is happening without feeling guilty or shame or remorse that I used to bury and drown with pills and booze." Today instead of having to continually invest energy in maintaining a facade, she is able to feel real confidence and to admit and accept having fears at times as part of being human. "So it's a totally different ballgame today. Today the important thing for me today is do I react or do I respond. It's what's happening within me. So it's not what's happening out there, it's what's happening in me. That's because I've been through all this stuff. I've grown up. And I guess a lot of that is not just what I've gone through but maturity. Page - 86 Cause even if I didn't go through a lot of this stuff, seeing things at 53 and 5,6,7 is totally a different ballgame." Page - 87 CHAPTER V ANALYSIS AND THEORY BUILDING Introduction The participant in this research told a story of physical, emotional and spiritual pain which was initially relieved by alcohol. The story begins in childhood experiences and perceptions which shape her attitudes and behaviour toward alcohol. This chapter examines the story to discover a theoretical structure which could explain this woman's process of becoming dependent on alcohol. Using references to the literature and evidence from the research data, a theory of how this woman became dependent on alcohol is presented. Overview and Definition of Terms The story is divisible into two parts. Part I consists of the development of the psychological framework/stance/constructs that constitute her vulnerability to becoming dependent on alcohol. "To me now, I have NO doubt that I was an alcoholic long before I had my first drink. I just hadn't recognized or hadn't had the OPPORTUNITY to GET at this panacea that I found along the way." (interview 2, p.8) Part II is the actualizing of this potential when she has access to alcohol. Development of dependence is influenced by biological, psychological, cultural, economic and social factors. Tartar and Edwards (1988) conclude that alcohol abuse is the result of the interaction between environmental stressors and organismic vulnerability. A MALADAPTIVE STRESS-COPING Page - 88 MODEL is proposed for this woman's process of becoming dependent on alcohol. Stress is defined here as the physiological state of arousal induced by a stressor which may be: 1) the perception that a value is at risk; 2) physical trauma to the body; 3) any change or upset in homeostasis that calls for adaptive action; 4. anything you wish were different. Distress is used here to indicate both an unpleasant affective state and impaired health and function resulting from persistent nonoptimal levels of stress. For simplicity, when the term stress is used, it will refer to nonoptimal levels of arousal associated with distress. One may construe biological, psychological, social and cultural factors in this woman's life as initiating or supporting a stress-coping cycle gone wrong. Instead of decreasing stress, attempts to cope with stressors actually increased stress. Without the realization that these coping strategies were actually contributing to the stress state, the resulting increased distress prompted increased dependence on the exacerbating behaviours. Thus she was caught in an escalating spiral of stress, distress, and dependence on destructive coping strategies. Using data from this study and references from the literature, this analysis proposes to show how a maladaptive stress-coping model might explain the development of alcohol dependence in this woman. Page - 89 Part I: Development of Stance Vu.1 n^r^ble to Alcoholism Temperament The story starts with the birth of a child having an inherited constitution and temperament potentially vulnerable to stress. Buss and Plomin define temperament as the inherited component of personality; Thomas and Chess define temperament as behavioural style; and Rothbard sees temperament as the integrated behavioural expression of biological processes such as arousal level or perceptual speed (Seifer, 1988). The psychobiological approach sees temperament as individual differences in neurological, physiological and behavioural arousability or responsibility plus differences in neural and behavioural processes which modulate this reactivity (Goldsmith & Campos, 1982). These modulating processes include approach-avoidance behaviour and channeling of attention. Individual differences in temperament may contribute to vulnerability to stressful situations (Rutter, cited in Seifer, 1988). Goldsmith and Campos (1982) suggest that individual differences in susceptibility to stress may underly differential reactions to the "strange situation". Both sons and daughters of alcoholic fathers have significantly higher amplitudes of event related potentials. This means that they experience stimuli with particular intensity or are stimulus augmenters (Porjesz & Begleiter cited in Levin, 1989). Alcohol decreased such augmentation or actually produced stimulus reduction in Cloninger type 2 alcoholics (Levin, 1989). Page - 90 The significance of temperament lies in the relationship between the child's temperament and the context in which it is expressed, most notably the family. Thomas and Chess emphasized the "goodness of fit" between child and parents as a major determinant of the child's developmental outcome (Seifer, 1988). Thus biological, psychological social and cultural factors interact from the very beginning to influence psychosocial development. We shall see how this child's particular temperament interacted with her particular familial, cultural and economic circumstances to produce her vulnerability to alcohol dependence. One of the response systems for reactivity is the emotion system (Goldsmith & Campos, 1982). Emotionality is one of the dimensions of temperament. Low threshold and high intensity of arousal of the central nervous system constitute a sensitivity which may heighten the child's experience of associated feeling states such as irritability or tearfulness. L. was a "sensitive" child with intense reactions and a low threshold for arousal. She reports that whatever she felt, she felt strongly. She was the type of child you didn't have to speak to twice; any criticism upset her. "If necessary I would get after her but she was very sensitive that way. You didn't get after L. too much." [You didn't have to.] "But there was one incident So I said to her sYou know that's not nice. You shouldn't do that'. Because it wasn't nice for two people of the opposite sex to be by themselves. So she got quite offended. She got quite offended. So we dropped it at that."(p. 11) Page - 91 She took things to heart and tended to read into situations more than may actually have been intended. Her child mind drew conclusions that heightened her distress. "And being the super sensitive person that I was, I picked all of these things up, whether they were there or not."(p. 7) She remembers her mother telling her to "keep yourself covered up" and concluded there was something shameful about showing her arms.(4) "If I got 98% it was "If you just studied a little harder you would have had a 100!' It was never quite good enough." (p. 6) "I had a book and a pencil and an eraser. And later I didn't have an eraser because I wasn't supposed to make mistakes. Nobody told me that. But they just didn't buy me an eraser. I probably figured that myself, that I'm not supposed to make mistakes." (p. 3) "I was very sensitive and very hurt."(p.9) And her behavioural reponses tended to be excessive as well, that is, she was overresponsive both emotionally and behaviourally. "Everything I did, I overdid." (Interview 2, p.5) Her brother remembers her as a child screaming at the top of her voice when she was frustrated. It would appear that she had a low frustration tolerance, also a reflection of the hyperresponsive temperament. Her brother perceived that she as well as he had an inborn vulnerability to stress due to their sensitivity and reactivity. "If it bothered her - and I'm sure it did - like it bothered me sometimes... then it was quite extensive, quite bothersome. It was just pressures of life that were hard because we took it seriously." (p. 7) I felt stressed and I concluded that L. was the same. Why is a Page - 92 child born an idiot or tense or something else? the other kids can go ahead and have a fight and smile about it tomorrow, see. It didn't go that way with me. And I presume we are from the same family and we were often tarred with the same brush so to speak. You know, things run in the family." Stress and Emotion The structure of emotion has been described as 1) a judgement regarding availability of a value; 2) an affect state; 3) a physiological state; 4) a disposition to action to retain or enhance the value (Solomon, 1982; de Rivera, 1989). The judgement that a value is at risk activates a stress response and is associated with an affect state such as fear or anger. The stress response is initiated in the hypothalamus and limbic system (Milsum, 1984). The limbic system controls emotional responsiveness and affective behaviour via the hypothalamus (Farber, 1982). Thus affect and the stress response are intimately related. The stress response includes physiological changes such as increased muscle tone, increased heart rate and stroke volume, increased blood vessel tone, increased rectal and bladder tone, transformation of glycogen stores into glucose (Lask, B. & Fosson, A.,1989) The stress response varies with individuals; there is evidence that levels of cardiovascular reactivity are linked to neuroendocrine reactivity in response to a psychological stressor (Pohorecky, 1991). Intense emotional arousal will logically be associated with a more intense physiological reaction. The physiological reaction not only constitutes a drain on the adaptive energy but also produces distressing physical sensations which, Page - 93 especially in the supersensitive person, create distress which becomes a secondary stressor itself. Emotions, in particular those associated with loss of a value, are a call to action. If no action is forthcoming and the emotion is unresolved a chronic stress state of readiness for action may be maintained. As well as prolonging physical and emotional distress this state has serious implications for health (Milsum, 1984). There are several indications that L. was unable to resolve her emotions and therefore suffered from chronic stress. She had strong emotional reactions which she was unable to express or act on. Instead, she just held everything inside bound up with fear on top of fear and producing a generalized distress that was a motivating force in her life. "I was so terrified of this storm. And I didn't tell her! I didn't tell her! I don't know why I didn't tell her. I guess it was fear of something. I guess fear that I would displease her and she - I wouldn't be accepted . I don't know what it was at the time. But I just swallowed it and never said anything. Just felt really awful. I just remember as a child all the time in that agony." (p. 4) "It blocked off all of those bad feelings, those hurt feelings, those angers, that I never expressed. Cause I probably would have liked to punched them out! But I wouldn't say it. But I was probably thinking it" (p. 8) "And I never ever said anything to her but I carried that resentment I guess with many other resentments. All this pent up emotion." (p. 9) "And I was ashamed to say or do anything." (p. 10) Emotionally I was stifling all my feelings." (follow up interview) Page - 94 "I was isolated. I was really hurt. I carried all that kind of stuff for years." (interview 2 p.3) Association of Alcohol with Well-being L. reports intensity of both positive and negative feelings. However, her story seldom mentions positive feelings; other than her early relationship with her father, the most positive moments are when she obtains relief from distress. And significantly, these times are associated with alcohol from her first experience at age seven. The strength of the association of alcohol with well being is a function of her general distress level at the time. "Oh it was fantastic! I was happy. I wasn't feeling all this inner turmoil within me." (p. 8) "I remember it. I can remember like it was right now! I liked it because it made me feel happy. I didn't feel all those sad things that I was feeling."(p. 8) Fear and Separation Anxiety The emotions of fear, hurt, anger, guilt and shame are significant elements in the story. Mathes (1981) describes an evolution of values from preoccupation with personal survival to appreciation of abstract transcendent altruistic principles. The primary concern of the child is survival. L.'s values incorporated the rigid black and white moral standards of her parents' religion. She saw God as a loving, all powerful, all-knowing being whom she must not displease. "I had to be a Good Girl or I would displease him and my parents." If she did displease God and her parents "Probably I would die". If she was not good she might not be cared for; Page - 95 if she wasn't cared for she would die. L.'s many experiences of fear reflect the saliency of her concern for survival. "Bulls would chase us and it was really scary. And I mean they would chase to kill. And that was really awful." (P. 2) "And I remember it was really stormy. And I was really scared! So I crawled into bed and just covered up my head so I wouldn't see it!" (p. 4) "she said vNo I won't look after them.' And I took that upon myself, that she didn't like me. She didn't want me. That nobody would be there to look after me. I just really felt awful." (p. 5) One of her earliest memories is the feeling of fear when she woke up in the house alone. This incident appears in her story (p. 3). It was elicited again in a follow up interview when she was asked first to access her feelings during the height of her alcoholic career and then to find her earliest childhood memory. "Mom would put me to sleep and go out. And sometimes I would wake up. And I remember feeling so frightened this particular time. And I was scared that owls were going to come into the house. It was really affecting me. I guess it was a feeling of abandonment." (follow up interview) Separation can produce intense fear in a child ."The great source of terror in infancy is solitude" (James, cited in Bloom-Feshbach & Bloom-Feshbach, 1987, p. 45 ). A young child may assume separation signifies abandonment which is tantamount to death. Freud (cited in Kastenbaum & Aisenberg, 1972) suggested that birth produces a psychophysiologic state of primal anxiety which is the source of death fears and separation anxiety. The fear of abandonment is so potent that we will suffer any pain to avoid it (Mundy, 1990). Attachment Theory and the Need for Connection Page - 96 Bowlby (cited in Bloom-Feschback & Bloom-Feschbach, 1987) proposed the concept of an attachment behavioural system which motivates a person to stay close to a specific individual who is better able to cope with the world. He postulated that such behaviour would have survival benefit for young who maintained close connections with their mother and therefore would have evolutionary significance. In other words, the need for connection is an inherited psychological structure. Connection is motivated not only by the fear and anxiety of separation but also the comfort of psychological union (Bloom-Feshbach & Bloom-Feshbach, 1987). It may be conceived as a push-pull towards association. L. craved closeness and and connection with her family. "I felt better, even when my legs got scratched in the stubble, tagging along with her than being left in the house. I felt va part of when I was with her and my older sisters and with my Dad. I kind of felt va part of." ( follow up interview) "I really felt best when I was home with Mom and Dad" (follow up interview) "I helped Dad shingle a few times, when I was a little older. And that was really important to me. To be kind of 'with1 somebody, feeling va part of. Where I never really had that as a child at home." (follow up interview) "And I had this little drink too and it just knocked out all these inhibitions in me. So, you know. Yeah I could join right in. And I could be silly and it was OKAY."(p. 64) Her first experience with alcohol satisfied her need to feel connected, to join in and be a part of things! The meaning and significance of the alcohol, and its power, is rooted in the intensity of her unsatisfied need for Page - 97 connection which follows from the inadequate formation of early attachments. Most of the time L. didn't feel "a part of". She felt lost. "I wasn't good enough, I wasn't important, I could get lost in the shuffle. Nobody cared. If I died, nobody would miss me." (follow up interview) "I was the lost child, the goody girl who couldn't do anything wrong because if I did I was afraid that I would be really lost. So it was really traumatic." (follow up interview) Not only the size of the family but also L.'s position in the family constellation likely contributed to her feeling lost. She was three when her younger brother was born. Her older siblings made up two groups.They were ages 7,10,12, and 14,16,18. The three year old didn't fit into these groups of older children. When her brother was born she lost her status as the baby and was even more "lost". She would have liked to put her baby brother in the garbage. Birth order research indicates that the second youngest child is seen as less happy (Frank, Reinhart & Fitzgerald, 1987). "When K. was home she was with her older sister. They were off in the corner somewhere or out in the garden. Then F. and J. would be together. I would just be on my own. I was the lost child. Ed, the youngest, was with the boys. He would come play ball with me for a while. He was with Dad." (follow up ) "I was second youngest. So I just felt with so many, I really wasn't needed and I really didn't know that I was loved, because there was so many of us." (p. 2) "Bottom line, I came from a big family, there was eight kids, bottom line I felt like I wasn't needed. I felt like hell." (interview 1 p.11) Alienation Page - 98 L. suffered from a sense of alienation all her life; she always felt different, unconnected with other people. Jung (cited in Levin, 1989) construed craving for alcohol as a low level expression of the thirst of the soul for connection with the universal, a desire for wholeness or union with God. L. was vulnerable in this sense because of her feelings of alienation and poor self-esteem. She didn't feel part of her family and she didn't feel she had a place on this earth. "I was teased about [freckles] that they used to say was fly specks. And so I was very shy of that. And I thought I was the ugly duckling in the neighborhood and in the country. I felt different because I had these fly specks." (interview 3, p. 1,2) "They would be mean to me because I would be, you know, a lot younger than them and a lot of them failed grades." (p.6) "I was being treated differently. So that was very hurtful." (p.84) "I'd take their glass and get the drops together and I would have those drops. Normal people don't do those kinds of things!" (p. 8) "I knew there was something about me that was different with alcohol, than there was with the rest. Even at that tender age I knew it" (Interview 2, p.14) "Like a lot of people to this day think beer is a man's drink, not a woman's drink. Basically beer was MY drink. Wine and beer was mine, preferably beer. So I was everything against the norm of society." (p.72) At that time there was little awareness of eating disorders and again L. thought "I'm just different than everybody else. And I was ashamed to say or do anything, (p.65) In a group of people L. felt "Like a square peg in a round hole. I could be in a group of people, I could be contributing in whatever, but I am not feeling NORMAL, like other people are feeling. I am just not fitting in, Page - 99 not feeling good enough. Not measuring up in any way." (p.84) Feeling different was again a function of L.'s sensitive temperament. Feeling different meant being inferior to other people and disconnected from them. It meant being rejected if they knew she was different. Emotions grow out of the vicarious and empathetic experience of the other's feelings within the attachment system; the response of the significant other to the child's behaviour and expression of affect teaches her how she should feel (Goldsmith and Campos, 1982). Association of Alcohol and Shame When her sister labelled her an alcoholic L. learned that she was different in a way that was shameful. The shame she associated with alcohol she also associated with herself. Her sister does not remember this incident. Of course it happened nearly 50 years ago! Likely it was an off hand comment of no importance to the sister who therefore did not remember the incident. I suspect she may have disappoved of L.'s silly behaviour. L. seems characteristically to have picked up any negative toned reactions directed her way and exaggerated their significance. In any event, this experience was very vivid and significant to L. because of the meaning she put to it. The opponent process theory (Solomon cited in Jung, 1994) describes a state of intoxication A produced by the alcohol which is opposed by a homeostatic process which returns physiology to the normal state. As the effects of intoxication wear off, the effect of the opponent process produces an opposing state before return to baseline levels. Page - 100 This unpleasant B state resulting from the unopposed opponent process would have been paired with the shaming, since both would have occurred in the same time span. Thus shame would be a conditioned stimulus for the dysphoria of the opponent state and vice versa on future occasions. Because alcohol has been associated with relief of the dysphoria of the opponent state, a craving for alcohol may be induced by withdrawal symptoms characterizing the unopposed opponent state. By a conditioning process, shame would also elicit symptoms of withdrawal and stimulate craving. "I was happy. I wasn't feeling all this inner turmoil within me. I could do things without you know the restraint I was feeling within me all the time having to be good and having to be all these things that I had in my mind, what I perceived that others wanted of me And right then, when I was being silly, I remember my sister... saying to Mum even then, vL.s an alcoholic'. And I knew she was right. And I associated alcoholism with shame and all that kind of stuff. And I was hurt. I was hurt when she said that. And I was really angry at her. I felt guilty and ashamed." (p. 9) L. had heard all kinds of bad things about people who were labelled alcoholics. She had heard her parents talk about the neighbor. Goldsmith and Campos (1982) define shame as the acceptance of a lost or inferior position in the eyes of the other and also a protest of such loss. L. accepted the label without question. She was aware that she was doing things that her older siblings were not, but instead of attributing it to the response of a much younger child, she saw it as another indication of her innate differentness that alienated her from other people. And her sister put a label on that differentness that was consistent with social Page - 101 alienation. L. felt intense shame - a vicarious experience of the disapproval of not only her sister but all society if they knew. Schell (1982) says shame is the response to the threat of loss of connection with another person whose evaluation of us matters. Her sister's labelling made L. feel alienated from the sister with the potential for alienation from anyone else who knew. Shame is also a way of maintaining connection, even at the expense of the self (Goldsmith and Campos, 1982). Goldsmith and Campos (1982) relate the development of emotions of shame and guilt to the attachment system of the child. The caregiver's response to the child communicates whether the child's behaviour is appropriate and fosters development of guilt and shame. "If I had a sleeveless little dress on I felt like I was half naked and I wanted to be covered up. But then I remember my Mom always saying "Keep covered up'. So I believe that had a lot to do with that. I thought it wasn't nice to be showing my arms. But I would never have thought that if the idea had not been implanted in me."(interview 3, p.2) "All the years that I went to college I never really drank. I would maybe have a little glass of wine if somebody offered it to me. I would not have had more because I knew that this was really doing to me what it wasn't to others. For the fact that, like my Mom described it, it was like a magnet to me and it was shameful for me to want more. This was my interpretation of it. It would be shameful for me to have another glass. Even if it was offered. Other people would have more but I wouldn't because it was shameful." Everyone's opinion mattered to L., but her sister was particularly important. She was a model of adulthood, having recently been married. She acted as a surrogate mother for L. when L. stayed with her later while attending school in Page - 102 town. She was always a model for L. who tried to emulate her or compete with her by dieting to match her slimness or taking courses she had taken. The massive relief L. had felt and her ability to be a things was replaced by an intense sense of shame and alienation. The contrast between the two feeling states intensified the distress. The loss of the these values of well-being and connection prompted intense anger which had to be stifled so as not to entirely break her connection with her family. But the physiological arousal and emotional distress contributed to her chronic stress level. From her very first experience alcohol was associated with relief from chronic stress and paradoxically with increase in her stress level. The high of initial relief was replaced by an even lower low as the burden of shame, anger and guilt associated with the alcohol is added to the original experience of stress. The close association of shame with alcohol eventually fueled an inevitable escalating cycle of dysphoria which increased her dependence on alcohol for relief. Connection and Attachment L. was sensitive to any potential loss of connection. She makes a point of mentioning instances where she perceived her connections to be at risk. When [her father] was away she was always worried that something would happen to him; she had heard about accidents where the horses would run away and somebody would be hurt. So she would listen for his characteristic cough and feel worried until she heard it and knew he was returning safely, (p. 5) Page - 103 The children were distressed and fearful the parents would separate. When they quarreled "It seemed like the end of the world". As a very young child, L. did not really know what she was afraid of, only that she had an awful fear when they quarreled. "It was totally devastating." (p. 5) "Mum was quite sick. And she always used to say to my oldest sister, vIf I die will you look after L. and E.?' Because we were the two youngest ones. And my sister was tired of hearing my Mom talk like that and she said vNo I won't look after them.' And I took that upon myself, that she didn't like me. She didn't want me. That nobody would be there to look after me. I just really felt awful." (p. 5) "I guess it was fear of something. I guess fear that I would displease her and she - I wouldn't be accepted."(p. 4) Many of the emotions L. reports can be related to loss or lack of connection through separation, rejection or isolation. Separation responses may progress through anxiety, anger, rage, conflict, sadness, defensive detachment and depression (Bloom-Feshbach & Bloom-Feshbach, 1987). These experiences of painful isolation or separation are a major theme throughout her story from her earliest memories of fear of abandonment to her continuing sense of being different to her grieving even in the present the absence of a close emotional bond with her sister. "I know I am not going to get it and that is okay- but to me it is a grieving of what I would have really liked and I know I will never have, so it is a kind of double grieving. Loss and grief, that we never really had that really closeness."(follow up interview.) The separation response is a function of the quality of attachment. It depends on the quality of the child's relationships with her caregivers (Bloom-Feschbach & Bloom-Feschbach, 1987). Her father was an important attachment Page - 104 figure for L. The relationship with the parent depends in part on the "goodness of fit" between the temperament of the child and the personality of the parent. L. reports that "the bond between my father and I was a lot more than between my mother and me because I was too much like my mother." She enjoyed a very comforting relationship with her father until the following incident. "Dad was playing with me and Mom said to me "Big girls don't play with boys'. I couldn't quite figure it out. But I remember I was really hurt. I was isolated. You see the bond between my father and me was a lot more than between my mother and me. It was very painful." (interview 2, p.3) The alienation from her father, who had been her most satisfying connection, left her even more vulnerable to distress and thus potentiated her positive response to alcohol. "The knowledge that an attachment figure is available and responsive provides a strong and pervasive feeling of security" (Bowlby, p. 668, cited in Bloom-Feshbach & Bloom-Feshbach, 1987). In a secure and loving relationship the child is able to create for herself internal representations of her experience with caregiver that she can use to comfort and soothe herself. Such representations form the foundations of psychological organization and are the basis of interpersonal relating, self-esteem and inner well-being, and adult character (Bloom-Feschbach & Bloom-Feschbach, 1987). She recreates her primary relationship with her caregiver in her relationships with herself and others. She sees herself as she sees significant others seeing her. Page - 105 From L.'s story one may conclude than she did not have that "strong and pervasive feeling of security". Her parents arguments "made me feel insecure". Her mother's threats to leave endangered her attachments. Longitudinal studies following children from childhood or adolescence consistently report greater frequency of marital conflict in homes of children who become alcoholic (Zucker & Gomberg, 1986) The loss of her connection with her father left her feeling isolated. She never felt good enough. These feelings followed her all her life. Fenichel (cited in Vetter, 1985) believed addicts use drugs to satisfy security and self-esteem needs. "The bottom line was my self worth and self esteem. I did not feel good about myself. And that's something I struggle with till this very day." (interview 1, p.l) Anxious attachment may be promoted by experiences of separation, threats of parental abandonment or unsatisfactory patterns of interaction where the child's signals are misinterpreted or ignored (Lieberman, 1987). A major source of L.'s anxiety was likely the frequent parental quarrels in which her mother periodically threatened to leave, (p. 5) All three of the siblings interviewed were extremely upset by these quarrels and the fear that their parents would separate. "We suffered emotionally because of it. I remember crying my eyes out. Nobody's comfortable in a situation like that. It wasn't nice." Page - 106 This is one of the few negative family experiences that one of the interviewees would admit to and for that reason it is deemed to be a particularly potent stressor. Separation need not be physical; psychological availability and attention are important. The children in this family didn't receive much individual attention. One might assume that the mother was somewhat preoccupied not only with the physical effort of caring for family and farm, but also with the unsatisfactory relationship with her husband. She threatened to leave, but was obviously unable to do so. How would she care for her children? How could she leave them? She would have no money; theirs was a subsistance level existence in those early years. So the mother was under a great deal of stress which expressed itself in anxiety which L. was aware of. L.'s sensitivity to external cues makes it likely that she would pick up her mother's emotions but her child mind would not be able to logically account for them. The child's ego-centered mind generally explains the world around her in terms of herself, holding herself responsible for others feelings. According to Toman (1976) being in the position of youngest sister is associated with seeking to excell, being competitive, valuing recognition and praise, seeking the limelight, wanting to feel listened to and respected. While birth order research has been criticized for inadequate methodology (Frank, Reinhart & Fitzgerald, 1987) these characteristics do seem to have a certain logic assuming a need to compete for attention with more capable siblings and Page - 107 a sense of comparative inadequacy. Attention seeking also reflects a more primary survival mechanism in the infant. Attachment behaviours, for example crying, clinging, are designed to get the attention of the caregiver in order to keep her/him in protective proximity. Secure attachment requires psychological availability of the caregiver; inadequate attention is a type of separation (Bloom-Feshbach & Bloom-Feshbach, 1987). In this family "We didn't get attention like children do now. There wasn't time for all this." (sister p.4) Page - 108 Need for Attention L. craved attention; she never got enough. She did not feel secure in the attentions or affections of her family. This may be a facet of her anxiety due to insecure attachment. In fact her need for attention may have continued into her adult life. It is as if because those childhood needs for secure attachment were not satisfied, the need for attention and sensitivity to being ignored continued into adulthood and continued to contribute to her stress level and dysphoria. "I think and I feel that as a child you were supposed to be seen and not heard and you didn't really count. Children really didn't matter. You weren't important until you got to be big, grownup. I just kind of felt I was not important. I didn't matter." She couldn't wait until she grew up so maybe someone would listen to her. (p. 2) "L. always wanted to be best. That was very important to her. She was always good but she wanted to be best. It kind of bothered her if she wasn't better. Even today it is important for her to be top. I don't know why she wanted to be best. Maybe because Mom praised her so much all the time. It may be that was the way she got her attention is by being extra good." "At those times it seems as if she always had to be the best: the thinnest, the best dressed. That's the way I way I saw it. I think she wants you to notice." "I just kind of felt I was not important. It was very real to me. And I can even see that at my tender age NOW how it can affect me. I can really feel it even now. There would be all this hullabaloo when my brother-in-law and his wife came in from Toronto. I felt [pushed into the background like I didn't belong]. That others are more important. Don't make yourself important; don't get in the way of things." (interview 3, p.11) L. needed attention. She needed connection. She needed to feel secure. She needed to see a positive reflection of Page - 109 herself in other people's eyes. The most fundamental psychological needs of the child can only be met by others (De Rivera, 1989). Her emotions reflect her relationship with her caregivers which also becomes her relationship with herself (self-esteem). Coping Strategies Increased Stress In order to be valued by others so she could value herself she willingly took on responsibilities at an early age and learned to excell. And that was stressful. "I just felt with so many I really wasn't needed and I really didn't know that I was loved. So you see this is why I had to be this perfect child. To be needed. I wanted to be liked and all those kind of things. Because I needed everybody else's validation for what I wasn't feeling myself." (interview 2, p.17) "The bottom line was my self-worth and self-esteem. I did not feel good about myself."(interview 1, p.l) "All those insecurities in myself" (interview 1, p.12) "As she grew up, she was a good child. She always was prompt in her work and whatever, just as she is today. She was quick and you could depend on her. She was always good about taking responsibility. She was a good kid." "I was very responsible in getting things done. But I was a little girl inside. I was a little girl all around! I was just taking on adult responsibilities. I was really carrying more than I should have been. I was never really allowed to be a child. A lot of it was put on me. I accepted it but I was not ready for it." (interview 4, p.17) Accomplishment produces self-esteem only as a function of the value of that accomplishment to someone else. The sense of self worth obtained is relative to evaluation by someone else (De Rivera, 1989). It is therefore always at risk. One must continually work at being "good enough" and Page - 110 try to meet external standards whose lack of clarity contributes to stress. The more she tried to feel good by taking on responsibilty the more stressed she was both by the responsibilities themselves and by the precariousness of depending on external evaluation for feeling good about herself. True self-esteem has its foundation not in accomplishment (doing) but in the state of grace that comes from feeling unconditionally loved (being). L. was caught in a cycle of dependence on coping strategies which increased her stress. Her parents were perfectionists. To earn their conditional love she took on their perfectionism and did her best to meet their standards. "At home we always had to do things well. That was always stressed. There was no sloughing off. There was only two ways, the right way and the wrong way." (sister, p.2) "I needed, well I still need to be perfect! I still need to be perfect!" "a lot of them didn't want to be there. And I DID. And I had to be perfect." (p. 6) L. needed to please her parents. Fear, grounded in her insecure attachments and basic survival concerns, was a dominant motivating factor. Experiences associated with abandonment and loss lead to a dominance of fear for the self; one way of coping with this fear is to be good in order to please others so they will take care of you. (De Rivera, 1989) L. was motivated by fear to be the perfect child. In order to get her relationship and security needs met, she tried to be what she perceived would please her parents. No matter how hard she tried she was doomed to fail. Page - 111 Nobody is perfect. She tried to cope with the stress of her insecure attachments and low self-esteem by being what she thought they wanted her to be - perfect. It is pretty stressful trying to be perfect. Each failure to be perfect would increase her insecurity, increase her poor opinion of herself. So she would try harder and increase her stress level again. Her coping strategies became stressors which increased the need to use the coping strategies. "I was playing with their trucks and I remember Mom saying 'Girls don't play with trucks'. So I was put in a notch where I was supposed to be this proper kind of kid. And I was trying to fill this bill and I didn't feel I was doing it, no matter what I did. Comments like this validated that I wasn't good enough."(follow up interview) "If I got 98% it was vIf you just studied a little harder you would have had a 100!' It was never quite good enough. So I still carry that with me, even now. I did not feel good about myself. And that's something I struggle with till this very day." (p.6) She developed a competitive orientation. Perhaps the only way she could be sure she was good enough was to be the best. "So again I had to be the best in school. In my mind of course. Not in anybody else's" (interview 1, p.10) "She competes. Like she competes with me. Whatever I would do, she would take those courses so she could do and then she would drop it when she was finished with it. [It's as if she has to keep proving herself.] (sister, interview 1, p. 35,2) "As I progressively got sicker, in the hold of addiction, I would take lesser jobs so that I could still excell above everybody else." (interview 2, p.l) The internal psychological schema developed from the interaction between this child and her family continued to be Page - 112 a source of stress even into adulthood. "That's something I struggle with to this very day" The less the child perceives that she is loved the fewer internalized loving and soothing caregiver representations can be created. Anger, which is a positive force for protecting a value (De Rivera, 1989), escalates to rage when unchecked by adequate soothing representations. The idea of feeling rage toward a caregiver may be too threatening and it may be turned inward to create depression, and from depression to anxiety or psychosomatic complaints (Bloom-Feshbach & Bloom-Feshbach, 1987). We know that she was often angry, "all of those bad feelings, those hurt feelings, those angers, that I never expressed. Cause I probably would have liked to punched them out!" (p. 8) And we have one report of separation resulting in depression. "I spent a lot of time crying. I was really sad, I didn't want to do anything. I isolated. I was depressed." (follow up interview) We also have evidence of psychosomatic illness. From the time she was a small child L. had abdominal pain and problems with her gastrointestinal tract. Recurrent Abdominal Pain and Other Manifestations of Stress "As a very young child, before I ever went to school, I remember having bad cramps and everything." (interview 2, p.10) "I used to get horrible pains so bad they would have to carry me home from school." (interview 3, p.8) "They were going to send me to the hospital so I would hide it as much as I could. But I would wake up crying at night and then they knew that there was pain. It was pretty awful." (interview 4, p.15) All illness is multifactorial; it is the result of the interaction of developmental, biological, psychological and sociocultural factors (Kirmayer cited in Lask & Fosson, 1989). All distress may be expressed in the body Page - 113 (somatization). The best model for causality is circular; one cannot separate cause from effect because effects can become causes which escalate the problem or reinitiate it at a later date (Lask & Fosson, 1989) . Stress can precipitate a psychophysiological process which acts on a vulnerable part of the body as well as influencing behaviour and self-care (Lask & Fosson, 1989 ) L.'s gastrointestinal system was her vulnerable somatic substrate. "If you don't work things out it is going to come out in another way. Mine happened to come out in a gut ache. Emotionally I was stifling all my feelings so it had to come out some place." (follow up interview) Recurrent abdominal pain (RAP) occurs in 10-20% of school children; only 5% can be traced to any specific organic cause (Lask & Fosson, 1989). It may be accompanied by nausea, vomiting, perspiration and dizziness (Gaffney & Gaffney, 1987). IBS (irritable bowel syndrome) is one term used to describe RAP. About 1/3 of children continue to have abdominal pain into adulthood and another 1/3 develop recurrent headaches. The pain is believed to originate in variations in the child's gastrointestinal tract, for example a combination of excessive distension and spasm in proximal and distal colon respectively (Page-Goertz, 1988). Spasms increase with stress. Lactose intolerance also increases distension. Temperament, lifestyle and contextual factors contribute to the condition according to a multifactorial model (Levine & Rappaport cited in Page-Goertz 1988). The emotion of fear is particularly associated with Page - 114 the colon (Mundy, 1990). Christensen and Mortensen (cited in Wasserman, Whitington & Rivara, 1988) state that RAP occurs in "sensitive" children exposed to emotional tension. The sensitivity is construed as a combination of genetic predisposition, a tendency to internalize and an environment conducive to modelling. The emotional tension may in fact not be unusually high but in sensitive children results in abdominal pain. Gaffney and Gaffney (1987) hypothesize that RAP may be produced by gastrointestinal sensitivity to normal homeostatic responses to stress, one of which is the secretion of endorphins. Exogenous opiates can produce symptoms similar to RAP. When a child is unable to express emotions in words, a condition termed alexithymia, there is a tendency for increased somatization of distress which may be seen as a means of communication (Lask & Fosson, 1989). Emotions that are not resolved may cause psychosomatic disease (Mundy, 1990). Children who cried easily, readily became angry and worried excessively while outwardly appearing cheerful (anomic extraverts) formed one of the two personality configurations associated with later development of problem drinking ( Block cited in Tartar & Edwards, 1988). This appears to reflect a hyperresponsive temperament combined with difficulty in appropriately expressing emotion as is postulate for L. Lammert and Ratner (1986) report that clinical experience suggests that patients with irritable bowel syndrome (IBS) have difficulty being aware of feelings Page - 115 (affect) and expressing those feelings in words. Joan Borysenko (1990) believes that when fear is our predominant emotion and is coped with by denial there is a higher prevalence of stress-related illness, anxiety, depression and addiction. Symptoms of IBS include alternating constipation and diarrhea, abdominal pain, bloating and increased flatus. "I couldn't put it into words, what I felt then. Everything was, well I wasn't good enough, I wasn't important, I could get lost in the shuffle. I couldn't put it into words like I can as an adult."(follow up interview) In psychoanalytic terms, irritable bowel syndrome (IBS) "may be depicted as a psychophysiological symptom which substitutes for a missing psychic structure, thereby compensating for an ego deficit and operating as a defense against archaic separation and annihilation anxiety" (Lammert & Ratner, 1987) . This missing psychic structure is the aforementioned internal representation of positive interaction with a nurturing caregiver that allows a child to soothe herself during separation from the caregiver. Lammert and Ratner (1987) suggest that failure to develop an adequate positive internal representation impairs psychic regulation and feelings of anger and anxiety are experienced somatically rather than affectively and cognitively. Or, perhaps illness may be an unconscious way of manipulating the environment to provide the attention, care and closeness that satisfies needs for connection and safety. Leon Hammer (1990) suggests that the expression of emotional distress in the body may be a kind of Page - 116 choice of physical disease and discomfort over disorganization of the psyche in a mental breakdown which is much more damaging to the self. Because of its close connection with the autonomic nervous system, the gastrointestinal system is particularly vulnerable to stress; damage may be direct to the system, indirect through malfunction of the system or the reactivity of the system may be increased. (Lachman cited in Lammert and Ratner, 1986) Reviews of the literature indicate unanimous characterization of IBS patients as psychologically distressed (Schwarz et al., 1993). Universal stressors cited by Lask and Fosson (1989) include disruption of attachment relationships and parental discord. Langeluddecke (1985) reports evidence that childhood stress is significant in the etiology of IBS and it is well documented that acute emotion affects gastrointestinal function. Most IBS patients could recall an acute episode of stress preceding symptoms and half reported their symptoms were made worse by stress. Personality studies have described IBS patients as compulsive, over conscientious, dependent, sensitive, guilty, and unassertive (Langeluddecke, 1985) which is a good description of L. as a child. L. believes she was always sensitive to dairy products and did better when she drank coffee rather than milk as a child. It seemed to act as a laxative for her. As an adult she was diagnosed with lactose intolerance. However lactose intolerance may result from reduction of lactase by the alcohol. Page - 117 L.'s postulated sensitive temperament with its overresponsive physiology would predispose L. to above average levels of both stress (physiological arousal or general adaptation syndrome) and distress (discomfort and dysfunction). For L. the presence of IBS or RAP may be considered a marker for stress as well as an indicator of arrested development of psychic structure. Recurrent abdominal pain was not only an indicator of stress but a major contributor. In the circle of causation, the effect becomes the cause in a feed forward escalating cycle. L. has suffered from the recurrent abdominal pain virtually all her life. There is no cure and no effective relief for pain. There are two other indicators of abnormal stress in L.'s life: amenorrhea and anorexia/bulimia. "And I'm worried because I don't even get my period. And this was, it was scary, it was really scary." (interview 4, p.12) "I think I had them once at 12, once at 15 and then at 2 6 when I got pregnant. And then not until I was 39 when I had acupuncture." (interview 4, p.17) The hypothalamus is the seat of the emotions, the initiator of the stress response and the regulator of the the menstrual cycle (Tepperman, 1980). Stress, worry, disappointment and depression can cause amenorrhea (Walter, 1977; Ganong, 1979). The amenorrhea is also another way she is "different". It is not only a signifier for stress but, in another example of circular causation, a source of stress. The eating disorder could also have contributed to the amenorrhea (Tepperman, 1980). Many of the symptoms associated with anorexia are also controlled by the hypothalamus. Page - 118 However, it is judged more likely that both the amenorrhea and the eating disorder were related to L.'s emotional system and stress level. The eating disorder continued at least until L. was 40 and menses were reinstated at 39. "My older sister, next one to me was on a diet. K. or her husband said something about me being pretty fat. I would go days without eating. I knew that fat wasn't acceptable"(follow up interview)It was a reflection of how I felt about myself, insecure.(interview 3, p. 15) "When I was probably 11-12 years old, I remember by this time I'm really skinny, I'm not eating well. And pretty soon I learned the purge stuff. Then it was binge and purge" (interview 2, p.21) "And I'm into laxatives and I'm drinking epsom salts, all kinds of things."(interview 4, p.11) Again, L. is responding to the threat of disconnection. Being fat is not acceptable. Again she overreacts in both her interpretation of the situation and her application of a solution. She learned to diet from her sisters but she goes overboard. She heard about someone else who used laxatives to lose weight so she learns to do that. Again, she over reacts to a situation both in her assessment of it and in her response. "Whatever I did, I overdid." (interview 2, p.5) Gibson (1993) cites several sources characterizing bulimics as having difficulty with interpersonal relationships (Swisky); perceiving they are not living up to the expectations of their parents (Printz); trying to be the perfect child, feeling rejected and angry (Jones); fearing abandonment, recalling a loss or separation event and eating to alleviate fear of abandonment (Patton). Reynolds (cited in Gibson, 1993) suggests a relationship between the onset of Page - 119 eating disorders and shame. Perfectionism and the struggle for control may be defenses against shame. Mitchell, Pyle, Eckert and Hatsukami (1990) report an association between bulimia and substance abuse; one study reported a 50% rate of alcohol abuse by age 35 in bulimics. Taylor, Peveler, Hibbert & Fairburn (1992) report that eating disorders are more prevalent in women receiving treatment for alcohol problems. Such co-occurence may imply shared etiological factors.lt appears L.'s eating disorder is more than coincidence. Both may be reflections of an insecure attachment system. In any event, both the eating disorder and the amenorrhea functioned as stressors. Rosen, Compas and Tacy (1993) found that stress predicted increased eating disorder symptoms and eating disorder symptoms predicted increased stress in a bidirectional relationship. L. was stressed and distressed. "All these pent up emotions, these angers, these fears, these resentments, this having to be perfect stuff, internalizing, people pleasing - everything that I was carrying "Thinking and feeling like I was about myself anybody would be sick." (interview 3, p.10) "Subconsciously I would see that there could be something wrong. Then of course when she went to a doctor for stress, I saw that maybe I did have something, that there was a stress. You can see a stressful person, lines draw, and you know, tension. That's how I noticed it." (p. 17) Alcohol Relieves Distress In the midst of all her distress, she had her first drink at age seven. "It was fantastic! I was happy. I wasn't feeling all this inner turmoil within me." (interview 2, p.8) Alcohol is postulated to reduce the level of Page - 120 psychological and physiological responses to stressors. It reduces stress-induced emotional arousal. Ingestion of alcohol has been found to relieve subjective anxiety, decrease hand tremor associated with stress and reduce skeletal muscle tension. (Pohorecky, 1991). MacAndrew (cited in Gomberg, 1986) reports women claimed they felt less fearful, nervous and tense when drinking. Sher and Levenson's research indicates individual differences in response to alcohol and they hypothesize that consumption of alcohol is particularly reinforcing to individuals who obtain more of its stress-response dampening effects (cited in Pohorecky, 1991). Individuals with the type A behaviour pattern are more physiologically reactive to laboratory stressors and experience significantly greater stress reduction when intoxicated (Sher and Levanson cited in Wilson, 1987). L. shows evidence of type A behaviour. "I am the kind of person that gets things done. I'm not one of those procrastinators. Even if I have a doctor's appointment and it's at 3:00 I'll be there be at least 2:30. And that's my whole life style. Just gotta be a step ahead of everything. Which is really wearing and tearing on me! I know That. I still do it!" (interview 1, p. 17) . One may also conclude that alcohol's reduction of anxiety and the stress response will be particularly reinforcing to individuals who are more distressed compared to others who have the same capacity to respond to alcohol but have a lower level of distress. Whether or not L. is particularly responsive to alcohol, she obviously had a high level of distress. Her efforts to be the perfect child and Page - 121 her inability to express her feelings significantly contributed to her distress and therefore to her susceptibility to reinforcement by the stress reduction effects of alcohol. "...all those bad feelings, those hurt feelings, those angers, that I never expressed.... the restraint I was feeling within me all the time all the time having to be good and having to be all these things that ... I perceived that others wanted of me." (interview 2, p. 8; L. perceived that there was something different about her and alcohol. She was right. Her distress made her selectively sensitive to the relief produced by the alcohol. "It did for me what it didn't do for others." (interview 2. p. 8) "When I saw my sisters drink, they would have a little dribble like this. And they would leave it and they didn't want it and everything." (interview 3, p.17) Other people would have that little bit of wine and it was no big deal for them. But for me it was. And I wanted more. I wanted more." (interview 2, p.16) The context in which she experienced alcohol is important. Alcohol was used on special occasions, family celebrations and reunions. It was initially associated with family connections and, good times. Significantly, it appeared to facilitate her feelings of connection and her ability to enjoy these occasions. "Alcohol was a treat for the kids. When the family would get together the parents would see than we have a treat." (interview 2, p.13)"It was a rare treat that we enjoyed fully." (brother, interview 1, p.10) "I figured that one of the greatest [reasons not to drink] was that you don't have the money." (p.6) "At that point alcohol was associated with happiness. Harvest was over, our seeding was done. And I had this little drink too and it just knocked out all these Page - 122 inhibitions in me. So, you know, I could join right in." (P- 9) The relief from internal stressors plus the convivial atmosphere and enjoyment of childish play without inhibition were associated with the alcohol in an immediate learning experience. And L. learned fast! Alcohol was associated with relief from stress and being a part of the group. Steele & Josephs (1990) explain the effect of alcohol on the emotional state as the result of an impairment of information processing that restricts perception to the most salient cues in the immediate environment. They term this, "alcohol myopia". Thus restriction of her awareness to the happy social gathering and the play she was enjoying replaced her usual preoccupations with being good enough and she obtained relief from stress. "I could do things without the restraint I was feeling within me all the time to having to be good and having to be all those things that I had in my mind, what I perceived that others wanted of me. And so that was just kind of forgot, all those inhibitions. It blocked off all of those bad feelings." (P. 8) Steele and Josephs (1990) postulate three ways this mechanism may powerfully reinforce the use of alcohol: by releasing social inhibitions; by ego inflation; by relieving psychological stressors such as depression and anxiety. The principle reinforcing effect of alcohol is presumed to be relief from psychological stress. All of these would be reinforcing for L. She experienced inadequate social connection; she had low self-esteem; and she had a high level of emotional stress. Chronic psychological stress is an important risk factor for development of alcohol dependence Page - 123 because it provides conditions under which alcohol can be chronically reinforcing, as long as it is paired with distraction (Steele & Josephs, 1990) The dynamic that eventually intensifies the process of dependence on alcohol is the pairing of the positive experience of tension reduction by alcohol with the negative social and personal connotations of alcoholism. The sense of well-being produced by "alcohol myopia" is contaminated by shame when she is labelled an "alcoholic" at age seven while indulging in childish play after the reduction of inhibition by alcohol. Immediately, this sensitive child took on a sense of shame. "And my sister said vL.'s an alcoholic' and I associated that with shame and all that kind of stuff, (interview 3, p.16)."And I felt ashamed, I felt angry, I felt everything." (interview 2, p.16) L. accepted this label because she already had a sense of being different as explained above. "And I knew she was right. I knew she was right."(interview 2, p.15) This association of shame with alcohol use supports an escalating feed forward cycle of stress -> alcohol use -> initial relief of stress -> shame -> increased stress -> alcohol use ad infinitum. This has the potential to rapidly escalate into addiction. Freud (cited in Levin, 1989) presented a similar model of addiction based on a masturbation cycle of prohibition, gratification, guilt, decreased self-esteem, anxiety and relief through gratification. However, L. was only seven years old and she did not have access to alcohol. But the cycle was set. Page - 124 "And I wanted more. I wanted more. Course I didn't get more. There was no more. I would have drank it all." (interview 2, p.16) "If I had access to it I would have been an alcoholic by eight!" She didn't have free access to alcohol until she could buy it herself. "All those years I was too young to buy it. And I would be too embarrassed to ask somebody to buy it, so I never drank." (interview 3, p. 15) But as she grew up she was occasionally offered alcohol at social gatherings. She always controlled her intake. "I might have a glass of wine here and there but no big deal. But again, I wanted more all the time. I would not have had more because I knew in me that this was really doing to me what it wasn't to others. For the fact that, like my Mom described it, it was like a magnet to me. And it was shameful to want more. This was my interpretation of it. It would be shameful for me to have another glass even if it was offered. Other people would have more but I wouldn't because it was shameful." (interview 3, p. 16) The well-being associated with alcohol was a powerful incentive, pulling her toward alcohol like a magnet. But at this point, shame was an even more powerful disincentive. In part I of the story we have seen how a "gap" in the child's sense of security and well-being and her supersensitivity interact synergistically to produce a state of stress and distress. The child's attempts to provide herself with security and self-esteem increase her stress. Coping mechanisms become stressors in a circular process of causation. The distress potentiates the reinforcing power of alcohol but immediately after the initial reinforcement, L.'s use of alcohol is associated with alcoholism and shame. The Page - 125 associated shame controls her use of alcohol in part I. But the stage is set. "I enjoyed it right from the first time when I was about seven years old. If I would have had access to it I"m sure I would have been an alcoholic by eight! The stage was set. All I needed was the booze. I had the emotional pain, I had the genetics, everything. It was all there I just didn't have that elixir yet, the alcohol" (p. 13) "The addiction was there right from the start." (interview 4, p.l) "To me now, I have NO doubt that I was an alcoholic long before I had my first drink. I just hadn't recognized or hadn't had the OPPORTUNITY to GET at this panacea that I found along the way." (interview 2, p.8) The gap in her personal well-being interacts with her ambiguous stance toward alcohol as magic elixir for distress and bringer of shame in part II of the story. What is it that overbalances her toward indulgence? Part II: Actualization of the Potential for Addiction Stance Toward Alcohol Part I of the story represents the development of the potential for alcohol abuse and dependence. That potential develops from the interaction of biological, psychological, social, cultural and economic factors. The biological factors include her postulated temperament, an inherited bias of the nervous system towards hyperresponsibility. This interacts with her environment, most significantly the social factors. Social factors include her place in the family constellation, the relationships between the parents and between parents and children, number of siblings, personalities of siblings and Page - 126 parents. Cultural factors include morality concepts and gender stereotypes. Economic factors include the challenge and uncertainty of near subsistance farming and the limited resources for transportation and education. The family's agricultural based economy carries with it a rural context of relative isolation and lack of sophistication. Psychological factors include attachment needs and the development of internal representations of self and self-other interactions that form the foundation for a system of connections with self, others, and the universal whole. Biological, psychological, social, cultural, and economic factors contributed to an expanding spiral of stress in which stressors produced stress which activated coping mechanisms which acted as stressors themselves to increase stress. Caught in a circular pattern of causation and an escalating spiral of physical and emotional distress, the child was extremely susceptible to the power of alcohol to relieve her dysphoria. The experience of relief was a powerful reinforcement for ingestion of alcohol and a behavioural orientation was instantly acquired. "And I wanted more! And I wanted more! ... I would take their glasses and get the drops together and I would have those drops " (interview 2, p. 16) "Even at the young age I would have drank it all. I would have passed out." (interview 3, p.17) The stance toward alcohol was complicated by the association of alcohol not only with relief, but also with shame. Thus the stance is ambiguous, reflecting an approach-avoidance conflict toward alcohol. Now in Part II we see how Page - 127 this stance interacted with internal and external factors to produce her dependence on alcohol. The decision to drink or not drink may be considered to be the outcome of the balance of perceived incentives and disincentives. It is presumed that this decisional balance is mediated subconsciously in the pre-alcoholic and therefore is out of reach of rational processing. Decisional Balance Motivating factors in her ambiguous stance toward alcohol were: 1.relief from dysphoria; 2.avoidance of shame. At first, the motivation to avoid shame was a more powerful disincentive for drinking than relief from dysphoria was an incentive and she controlled her drinking. However, it is more complicated than that. Her sense of shame was based on other people's perception of her. She tried to avoid feeling shamed by controlling her behaviour in the presence of others. "I kept it supressed. It was there but I kept it supressed. Like I would maybe pour everybody a glass and mine would be a little bit bigger. Or I'd go in the kitchen and I'd refill mine a little bit." (interview 3, p.21) Access Availability was a subset of shame. In Part I, L. was too young to buy alcohol (cultural rules) and too afraid of being shamed to ask anyone to buy it for her. Thus she didn't have access. As an adult, access was still limited by shame. As long as her husband was buying the alcohol access was limited to social situations where she kept her drinking ! Page - 128 I suppressed. "I basically didn't ask him to buy any because inside of me I knew I was alcoholic and if I would ask for the wine then he would know I was an alcoholic." (interview" 2, p.18) Again, access is a function of her fear of being shamed. It was not until L. had private access to alcohol that the incentive to drink could be freely expressed. Because then she could avoid shaming by drinking in private. To do this she had to overcome the fear of entering a liquor store. She was sensitive to cultural attitudes towards women drinking. Heavy drinking may be a part of the accepted masculine image in many cultures/subcultures, but it is not a part of the feminine image. Alcoholism in women has always been more disapproved than in men (Fillmore, 1984). Fillmore suggests that society tends to consider any drinking by women as being deviant. Perhaps this has been protective for women who remained abstinent; the estimated abstinence rate for women is much higher than for men and the estimated alcoholism rate is much lower (Fillmore, 1984) . For L., it likely added to the burden of dysphoria that fueled her dysfunctional stress-coping cycle. Cultural attitudes threatened her connections through the shaming of women who drank. "Because I was afraid. I was afraid to go into a liquor store. Because nice girls don't do that. When I grew up, mostly men did those kind of things. Men smoked and drank, women didn't. Women were supposed to be at home looking after the kids and the house." (interview 3, p.22) She was first able to enter a liquor store because she was away from home in a strange city where she could be Page - 129 anonymous. Cultural attitudes were also likely different in a large city compared to a small rural community where everyone knows everyone. "Because nobody knew me so it was okay." (interview 2, p.19) Still, her first foray into a liquor was a stressful experience. She still carried the enculturation of her childhood. "It started with the fear of going into a liquor store. This was the first time I am going into a liquor store. The fear and the rejection I am getting from the clerk! He was no way going to give me this wine because they did not believe I was 21...Finally when I gave them all my documentation, I had a lot of anger. I was probably shaking. I guess it was my own fears and insecurities and everything that were really surfacing. I had never done this before. It was stepping into the unknown." (interview 4, p.2) Relief of Stress by Alcohol So she was well primed with stress when she poured herself a glass of wine and started making a special supper for herself and her husband. "Probably no big deal for the taste. It was the effect. I never drank alcohol for the taste ever. I drank for the effect it produced in me. A calmness. It kind of just made me feel better. And pretty soon I am really liking it -the feeling of calmness- so I have a bit more. I am not feeling all this agitation in my body. I gained this feeling of comfort in my body" (interview 4, p. 4) Alcohol has been shown to normalize certain characteristics of brain wave activity in alcoholics. The abnormal pattern found in Cloninger type 1 alcoholics is associated with dysphoria. Normalization produces a calm alertness and relief of tension (Levin, 1989). The greater her distress, the more reinforcing was the effect of the alcohol. The alcohol helped her to forget the stressful Page - 130 experience in the liquor store by limiting her perception to her immediate activity of cooking, (something she really enjoyed) associated with the anticipation of sharing a nice meal with her husband. This is another example of reinforcement for using alcohol as a coping strategy for stress management. Dysphoria returned when her husband commented on her drinking. It motivated her to return to the alcohol for more relief. At this point, accessibility to relief outweighs the risk of future shame. In fact, she probably could not process the possibility of future shame. She had enough to drink that the impairment of cognition by the alcohol (Steele and Josephs, 1990) would have limited her perceptions to immediate cues, these being the experience of dysporia and of alcohol as an effective remedy. This relief is lost when her husband comments on her intoxication. She needs more relief and turns to the alcohol even though it is the cause of her shameful state. "And pretty soon he says 'I think you better not have any more1. I'm finding it very hurtful because I am now saying to myself 'I am not a nice person.' Where I came from people were associated as alcoholics when they were drinking too much and now my husband is telling me this and I am finding it very hurtful. It was an awful experience.... The guilt within me, and the shame, the humiliation. It's awful. But I want that wine. Because now I want to kill all these feelings. By the time I went to bed, I finished that wine." (interview 4, p. 4-5) "So it's a vicious circle that I have got myself into. And that was basically the start of all this." (interview 4, p. 5-6) Drinking caused shame caused drinking. Private Prinking Page - 131 Once she got over the hurdle of entering the liquor store, she was no longer dependent on her husband to buy alcohol. Now she could hide her drinking and avoid being labelled with the shame of being alcoholic. However she could never entirely avoid shame; God always knew and she knew she was not behaving in accordance with her value system. "My husband didn't know about the second [bottle]. And he would say, 'Well you better not have any more because I can see that glass of wine has really affected you already1. Well yeah, sure did. But I didn't have much out of THAT bottle. But the other one was HIDDEN." (interview 1, p.13) "I would wait and drink after people were gone. Or I would have one bottle for me and one bottle for company. I drank some with the company and then I drank mine behind the scenes." (interview 2, p.l) "And they offered me a glass of wine. But you see when I was with them I would have just a little bit in a glass even though they offered me more I didn't have more. But I would go home and [drink]" Incentive Overbalance Disincentives Restraint was further weakened when she found alcohol effective in relieving her gastrointestinal pain. "And I was having a lot of gastrointestinal problems. And the pain was just horrendous. And as I was taking more wine I'd become, you know, anaesthetized so that I don't even feel the pain anymore. So I now NEED the wine. I already needed it emotionally and mentally, and physically its blocking the pain. Because I'm anaesthetized. It certainly didn't take the pain away. But I'm now not feeling the pain." (interview 4, p.6) Using alcohol to cope with the physical pain was perhaps the factor that overbalanced the restraint mechanism. "But how it started is I'd have a drink and it made my guts feel better. So I'd have another drink." (interview 1, p.8) Page - 132 "I would have the wine. And it does ease the pain. The descending colon would go into total spasm. It is AWFUL. And the wine of course did ease up the pain. I didn't care what it's doing, just do something!" (interview 4, p.6) The anticipated relief from both emotional and physical pain became an irresistible incentive to drink. The final caution was lost when a doctor validated her use of alcohol for stress and pain management. "And she had bad nerves, pressure, severe pains. And the doctor said she had nerves and "take a little wine. 'That will cool you down a bit.' (brother, interview 2, p.6) "Actually it really escalated after doctors told me "If the wine helps you, well have it.' That's when it really started to escalate. Because I had this spastic bowel. And when you drink enough pretty soon you don't feel anything. So I just drank until I didn't feel anything." (interview 2, p.6) "She enjoyed the drink before that, and when she went to the doctor he didn't approve going overboard, but he said "It's fine, it won't hurt you.' So everything was directed towards "That's okay." (brother interview 1, p.17) "She threw caution to the wind." (interview 2, p. 21) The doctor's blessing for using alcohol for pain and stress management removed another barrier: her husband's disapproval. It bothered him to see her in pain. "At times my husband would say "L. I'll get you some wine to ease the pain'. And of course I was all for it. That would now defuse some of the guilt and the shame for me." ( p. 18) "Doctors would say "Have some wine or brandy for your stomach. She would have some and then it would make her feel better, just kill the pain or relax her. So the pain got too bad she would just drink." (husband interview, p.1) When she began using alcohol as a coping strategy for pain management, the incentive/disincentive balance changed; Page - 133 incentives were increased and disincentives were decreased. The doctors' validation of this use of alcohol as a coping mechanism diminished her guilt and shame and removed more of her motivation to restrain her drinking. The ineffectiveness of other methods to cope with her pain added to the incentive to use alcohol. The literature on stress and drinking finds that the degree to which a stressor elicits drinking is partly a function of the availability of alternative coping responses (Jung, 1994). The gastrointestinal problems reflected her stress level. Coping strategies such as anorexia/bulimia and drinking, even though initially they may have seemed to fulfill their purpose, eventually intensified her pain by damaging the gastrointestinal tract. Alcohol decreases lactase, (producing intolerance to dairy products), increases then decreases gastric acid, causes gastritis, duodenal ulcers, diarrhea and malnutrition (Walgren & Barry, 1970). She drank to decrease the pain, the alcohol exacerbated the condition producing more pain so she drank more to relieve the increased pain. Again a circular pattern of causation. Alienation L. always had difficulty expressing her emotions. As a child, and even as an adult they were expressed in her body, in abdominal pain. She couldn't talk about her feelings unless she had a few drinks. Without the alcohol to dull her perceptions she was always concerned about what other people would think of her, always afraid of endangering her Page - 134 connections with other people and receiving feedback that would threaten her self structure. Her expectations of how others would react if she revealed herself grew out of her own poor self-esteem. Like the reflections when standing between two mirrors, the experience of self and the experience of others reflect one another until we cannot tell where it all begins. "If I don't tell you how I feel you aren't really going to know how I feel. And If I tell you something, now you are really going to think I am awful. You might think it now, but if I tell you then you will really know I really AM awful. Not a nice person." (interview 4, p.15) Perhaps as a child the intensity of her rage at not getting her needs for attachment met frightened her and made her feel she was not a good person for having those feelings. And no doubt when as an infant she expressed her distress and frustration in screams of fury her family let her know that behaviour was unacceptable. Her conclusion may have been that SHE was unacceptable. In adulthood she was unable to assertively stand up for her interests. The anger she felt may have been directed at herself as well as others. She used alcohol to suppress those feelings and the stress they produced. "I was damn angry. I would go home and tie a good one on!" (interview 3, p.18) "I would quit [the job] and be resentful. And then I would drink because I'm feeling awful and I'm angry because I quit and all that kind of thing." (interview 1, p.4) Page - 135 Lack of Coping Skills She lacked coping strategies such as assertive behaviour and she lacked the self-esteem needed to make such strategies operational. In contrast, in recovery, she has learned to express her feelings assertively. "Today I could make an expression about it." (interview 3, p.18) "But I didn't just walk away from it. I confronted him on the whole issue. At one time I wouldn't do that." (interview 1, p.4) "At one time I couldn't say no. I would just do it anyway. And then feel angry in here. Today I don't do that. " (interview 1, p.5) "I didn't assert myself and say ,Hey, this is they way it is. This is what I need. This is what I expect.' Whereas today, I can do that." (interview 3, p.12) Without the coping skills to handle situations or the emotions they produced she supressed her emotions like the insecure child she still was. She was trying to operate as an adult with a child's underdeveloped psychological framework. "I carried the insecurity about being loved and needed and wanted when I was a little child all the way through adulthood." p.21 "As things would happen in my life, I would be reacting to things that were happening now, but really they were painful situations from away back when. And it was only being triggered by whatever might be happening how." (interview 2, p. 4) "I didn't know what else to do with it, with all those things." (interview 2, p.4) "Emotionally I was stunted." (interview 3, p.6) Pohorecky (1991, p.443) reports that "the extent of alcohol consumption engendered by a stressor was related to the availability of other coping responses". Gomberg (1986) says that alcoholism in women is associated with Page - 136 dysfunctional coping mechanisms which appear early in life; Even ordinary life stressors produce distress and heavy drinking becomes a way of coping. L's story is a good example of the development of dysfunctional coping. Using alcohol was her most destructive dysfunctional coping strategy but there were others that contributed to her development of dependence by exacerbating her distress. Shopping was another way of trying to manipulate her feelings. "Well the more she drank the more she bought the more she spent. Because she would go on binge buyings." (sister interview 1, p.5) "And of course then there was the guilt and remorse that set in [after drinking] and I'd go on a shopping spree and I'd feel guilty about all of that stuff. So then I'd have another drink to drown THAT sorrow, because I spent money I didn't really have. And it just went on and on." (interview 1, p.8) "I shopped to make myself feel better, because I liked clothes. I still like good clothes, but I'm not a compulsive shopper." (p. 19) L. used expensive clothes as a facade. It was another way of overcompensating for her feeling of not being good enough. This reflects the patriarchal cultural bias of valuing women for their appearance. It is also a time honored coping strategy for a woman to "buy a new hat" to beat the blues. "I shopped because I didn't feel good about myself. It was a facade." p. (19-20) "Somehow she is not satisfied with herself (sister, interview 1, p.28) She has to be tops....I'll look shabby beside her. But there is no way I am going to spend $1400 for a suit. I am satisfied with me. I don't need other people's approval. I don't need things to make me happy." (p.34, sister)) Page - 137 "It was my insecurities. Just feeling so rotten about myself I put on all this facade to look good. I had to. Otherwise I would never have survived. Because that is the way life is. Put on a mask to fool people. But inside the pain was just killing." (follow up interview) "I just thought she was thinking of number one, me. You know, that she was thinking of herself. That she has to be more important or something." (sister, 1, p.5) "I had to [look good] so you wouldn't know how awful I really am." (follow up interview) Self Focussing and Alienation De Rivera (1989) says that the dominant sense of fear which may arise out of an experience of abandonment can lead to a self-concern and self-focussing that splits self and other apart. When asked first to focus on her feelings at the height of her alcoholic career and then to report the earliest memory that came to mind, L. remembered the fear of abandonment she felt on waking up alone in the house. Because we exist in relationship, the splitting off of self from other in the process of self-focussing diminishes the self. Just as self-esteem develops out of the primary relationship with the caregiver, so the quality of interpersonal relationships and sense of connection depend on the quality of the relationship with the self. Like the reflections when standing between two mirrors the experience of self and the experience of others reflect one another until we cannot tell where it all begins. L.'s lack of self-worth interfered with the connections she tried to make with others. "Being so negative about myself, I was self-centered. And I think that was part of the isolation as well. Because I didn't feel I was as good as, I wasn't as Page - 138 smart as, I wasn't as pretty as, whatever." (follow up interview) "I was self centered but in a negative sense. Not thinking [I'm] the best. Always thinking how horrible I am, how sick I am, how screwed up I am. Everything negative." Follow up interview) "She is kind and she is good but she is also self-centered. She will always be telling me what SHE is doing. " (sister, 1, p.13) "It seems like she has to be in the limelight in some strange way." (1, p.19) "I could be in a group of people I could be contributin in whatever it is, but I am not feeling normal, like other people are feeling. Not feeling good enough, not measuring up in any way. Just not fitting in. You can be in a big crowd and you might be laughing and talking and all that kind of stuff outwardly, but that's a mask Inside you are totally isolated. You feel like a square peg in a round hole. You feel different. And you don't tell other people about it because of the fear that's in you.. So that's why you start drinking." (interview 2, p.24, 25) The isolation and alienation she felt motivated her to drink to feel comfortable. Alcohol produces a blurring of boundaries and feelings of closeness and integration that L. desired (Levin, 1989). But the alcohol interfered with making real connections. Psychoanalytic theory suggests that the alcohol becomes a sort of love object, an extension of the self or an omnipotent substance with which the addict merges (Levin, 1989). So the alcohol destroys real connections and provides a substitute. Merging with the powerful substance, becoming one with it gives the illusion of power and connectedness. "I was so blocked off from my own feelings, from reality, from people. I was just so self-centered into my own sickness, into my feeling so unworthy, so incapable." (follow up interview). "She was self-centered. Everything was 'me'. "I am so sick', and then because nobody was feeling sorry for Page - 139 her, she would feel that everybody was against her or something." (sister 1, p.8) "She just got to where she was unreasonable. She would just talk stupid. She just wasn't herself at all." (sister, 1, p.7) "We got to where we couldn't associate." (Sister, 2, p.2) Because like I mean there was no reasoning. And she wanted sympathy but I couldn't give her what she wanted. She was always so "sick'." (1, p.13) "I was so into myself.... Like get off of my turf here so I can drink without any problems." (interview 1, p.8) Alcohol Damages the Body Besides increasing her alienation, shame and gastrointestinal pain, her drinking caused other damage. Alcohol increases excretion of calcium and phosphorus. Deficiencies in these minerals plus other effects of alcohol result in osteomalacia, myopathy, paraesthesia, muscle weakness, cardiomyopathy and bone pain (Walgren & Barry, 1970). "Because I was feeling so guilty and shameful I would take a drink to try and ease that emotional pain. It would ease it a bit, but at the same time it increased the shame and guilt. And of course it was affecting me physically as well." (p.25) "I had a tremendous amount of physical pain along with it that was compounded by the alcohol. I used to have crawling sensations from all the nerve damage, prickling feelings, cold, aching bones." (P. 25) Besides reinforcing the use of alcohol initially, doctors supplied her with other drugs which she learned to abuse, especially Valium. "He added more tranquilizers to my diet. I already had a cupboard full. But he added more. Going to doctors, that would be the first thing they would give me: tranquilizers, sleeping pills, all this nonsense. They continued prescribing medication that would add to Page - 140 the addictions. Cause there are a lot of medications that stimulate the desire of alcohol." (p.22) Any drug that produces an experience similar to intoxication is like having a drink. Pharmacological intervention to decrease stress may add another dependence and/or maintain alcohol dependence. The cause and the effect of drinking became so intertwined it was impossible to tell where one stopped and the other began. L. simply knew that she experienced pain: mental, emotional, physical, spiritual. She felt sick. She drank to feel better. Alcoholism in women is strongly associated with subjective distress (Brooner, Templer, Svikis, Schmidt, Monopolis, 1990). "I was feeling so rotten, whether it was physical, mental or emotional, basically it was all of them. I had a tremendous amount of physical pain along with it that was compounded by the alcohol. I used to have crawling sensations from all the nerve damage, prickling feelings, cold aching bones. And the booze would initially help. So I would pick up that drink." (p.25) It is the immediate consequences that are most important in shaping behaviour. Even though alcohol exacerbated her condition, the immediate reward of relief was enough to keep her 'hooked'. Inconsistent reward produces behaviour most resistent to extinction. The restriction of attention to the most salient cues may produce inconsistent relief from stress depending on the nature of the salient cues. "But she inflicted a lot of the illnesses on herself. She used to always use illness as a coverup. Of course she was sick but when she got drunk she got sicker. But you see what I mean, she used to tell us these were her health problems." (p. 19, sister) "Nobody knew the pain I was going through. Nobody was interested in knowing the pain - the only comments I Page - 141 would get was 'everybody has pain1. There was absolutely no help for me. There was absolutely no help." (p.24) Attempts to Control Intake L. was always aware of her escalating problem and took steps to control it. She tried cutting down and periods of abstinence. She limited her public drinking. But as the spiral of stress and distress progressed, her whole life became focussed on the relief, the total oblivion, provided by the alcohol. Like the response of an abused child to her tormentor, she became more and more dependent on the alcohol. "And I was cutting down. I was always cutting down! Always controlling. I would buy a mickey, I wouldn't by a bog bottle; I'd only buy a six pack, I wouldn't buy twelve, (interview 3. p.22) "She stopped once for a year, once for a month. And then she might drink for a week straight, or two weeks straight, three weeks straight, every day. She quit several times." (p.20, husband) "My husband said 'You better not have anymore drinks or just don't drink any because you'll make a fool of yourself.' And I wouldn't. But I would be just waiting to go home. And I would walk out or we'd leave early. So my mind was not even on the wedding. It was on my drink that I was going to have. Escalating Cycle of Dependence Under the influence of her dysfunctional stress-coping cycle L.'s drinking spiralled out of control."It just kept getting worse and worse; more drink, more often." (p.19) As tolerance to alcohol develops it has been found to be less effective in reducing the subjective effects of stress (Pohorecky, 1991). Therefore she had to drink more to get the same effect. However, the window of optimal effectiveness for decreasing stress may be small. Some research has indicated that low doses of alcohol decrease anxiety while higher doses Page - 142 increase it (Pohorecky, 1991). Other findings indicate that tension reduction by alcohol is temporary; over the course of a drinking episode subjective distress may increase even though skeletal muscle tension declines (Pohorecky, 1991). Thus alcohol may bring relief in the short term and increased distress in the long term. This would seem to be how it was for L. Stress became both cause and outcome of drinking. Depression In the beginning, drinking under pleasantly distracting conditions distanced her from her dysphoria. But without the pleasant distractions, and in unpleasant conditions, like arguments over her drinking, one would expect her dysphoria to increase (Steel & Josephs, 1990). De Rivera (1989) suggests that depression may occur when a person acts in a way that is incompatible with the person's values. Depression prevents the person from being responsible for not doing what he or she ought by diminishing the capability to act. The dysphoria of depression allows the person to retain the value without acting on it. So L. could retain the value of cultural drinking norms while being unable to maintain them. However, De Rivera notes, although the value system has been kept intact, the self is still experienced as innately bad. The experience of shame is intensified. Goldsmith & Campos (1982, p.47) consider shame to be "a vehicle for the chronically throttled humiliated fury" described by Freud as the basis for depression. Even without the alcohol, L.'s supressed emotions and unassertive behaviour could have been Page - 143 a foundation for depression. By limiting awareness to current negative mood, alcohol could have accentuated depression. "She was different than she is without alcohol. It would have a very depressing effect on her." (p. 19) Her lack of success in controlling her drinking left her feeling helpless and hopeless. Depression deepened. First she drank to feel good. When that didn't work she drank to feel nothing at all. Eventually alcohol was not enough and she sought the total oblivion of suicide. "I was very depressed. And I said ^That's it. I am not tolerating this anymore. And I was really feeling hopeless and helpless. So I had all these pills in the cupboard: Valiums, ativans, seraxes, you name it. And I drank the whole bottle of wine and took all of these pills, every last one of them. And I lay on the bed and thought to hell with this. I just wanted out of everything." (p.26) Even suicide didn't work. Finally the alcohol no longer stopped the pain even temporarily. "It just intensified the pain. I would take one drink and the pain in my bones was so horrendous I didn't know how I was going to survive it. Summary The process L. went through in recovering from alcoholism points up the process she went through developing it. As long as alcohol was effective in decreasing the pain she used it. Even when she knew it was increasing her pain she still sought relief in inebriation. She had learned her lesson well, starting from her first experience at seven. Alcohol relieved her pain and made her feel good. She was conditioned to respond to any distress - mental, emotional, social, physical, spiritual perhaps any sort of physiological Page - 144 arousal by using alcohol. Craving was a conditioned response that was not easily extinguished. Alcohol was no longer a protection against pain. It wasn't working. It was only intensifying the pain. So she began to give it up. What she found in A.A. was unconditional acceptance. This unconditional acceptance fostered self acceptance and provided a safe place to express her feelings. Being able to accept herself and to express her feelings decreased her stress/distress. Being accepted as she was allowed her to change. In a nurturing atmosphere she let go of constructs and conclusions developed at age seven and began to grow up. In psychoanalytic theory alcohol addiction is seen as narcissistic regression, self-absorption and self-centeredness; the hallmark of the disease of alcoholism is immaturity (Levin, 1989) . "Seeing things at 53 and 5,6,7 is totally a different ballgame.... I've grown up." (p.29) A pivotal factor in the development of vulnerability to alcohol dependence was L.'s arrested psychic development. Inadequate psychological foundations are reflected in her feelings of alienation from self and others as an adult and her anxious attachment and separation difficulties as a child. Her psychic development was influenced by the interaction of her hyperresponsive temperament with her caregivers in the context of her socio-economic environment. The fear resulting from insecure attachment may have delayed psychological maturation by inhibiting the willingness to try out new behaviours and to learn from mistakes. Page - 145 An escalating cycle of stress developed from the interaction of hyperarousability, insecure attachment, inaccurate perceptions and maladaptive coping strategies. Into the seething turmoil of the child's stress/distress fell the soothing balm of alcohol which was instantly associated with relief, well-being, and the comfort of connection with self and others. This powerful association was overcome only with great pain over an extended period. Fragments of hope and desire for a repetition of that reinforcement probably still lurk in recesses of consciousness. The stance toward alcohol learned by this early experience was ambiguous; the experience of well-being was followed by shame and both well-being and shame became associated with the alcohol. The playing out of the stance was influenced by the balance of perceived incentives/disincentives. At first shame held the drinking in check. Medical authorization to use alcohol for stress and pain management tipped the balance by diminishing the shame associated with drinking. The destructive effects of the alcohol fed back into the maladaptive stress-coping cycle and fueled an ever-expanding spiral of stress and drinking. Page - 146 CHAPTER VI DISCUSSION Results This woman's process of becoming dependent on alcohol may be construed as the workings of a maladaptive stress-coping cycle. The process is rooted in her temperament (heritable physiological responsiveness) and the quality of her attachment system. Lack of secure attachment impaired her psychological development leading to her sense of alienation which is manifested in poor self-esteem, self-focus, and social discomfort. The development of dependence had two stages: 1) the development of an ambiguous stance toward alcohol that carried the potential for addiction and 2) the actualization of that potential through the playing out of the stance. The stance developed in Part I is the product of a learning experience potentiated by a pervasive perception of distress. This distress is the product of the dysfunctional stress-coping cycle fueled by her hyperresponsive temperament and insecure attachments. The stance cannot be played out until Part II when alcohol becomes accessible. The actualization process in Part II hinges on the balance of incentives/disincentives. The balance swings toward drinking when incentives are augmented and disincentives are diminished. Alcohol's ability to soothe her abdominal pain becomes an added incentive to drink and the doctor's sanctioning of its use for this purpose reduces the disincentive of shame. Once the balance has been tipped in Page - 147 the direction of drinking the development of dependence proceeds inexorably due to the circular process of cause and effect within the dysfunctional stress-coping cycle. The circularity of cause and effect characteristic of the maladaptive stress-coping cycle endows it with a "life of its own" through its built in process of escalation. Limitations This is the story of one woman's experience. It is unlikely to be duplicated exactly. However the principles which are seen to form the basis of the process are common to human development and experience. These principles include the interaction of temperament and environment, the attachment-separation process, the foundations of psychological development, the circularity of cause and effect and the stress-coping process. The specifics of inheritance and environment vary from person to person and the interactions produce an infinite variety of personalities and behaviours. The results of the interactions are infinitely variable but the types of interactions, for example between temperament and environment, or between stress and coping strategies, are common principles in human experience and development. The significance of this study is in directing attention to developmental and behavioural processes which influence the process of addiction and in demonstrating how they may do so. This study is also limited by the experience, awareness, constructs, and unconscious bias of the researcher. Only Page - 148 those principles within the scope of the researcher's experience and understanding could be recognized and incorporated. This story is only one possible version but it is a possible version. Researcher constructs which were instrumental in the analysis include concepts of stress, coping, and reciprocal interactions, for example mind-body and person-environment. Implications for Theory This study supports a stress-reduction theory of alcohol use. Depletion of endorphins by stress may have increased her susceptibility to the endorphin-like effects of alcohol. She would appear to be a stimulus augmenter who would suffer from threat reactions which would be soothed by the alcohol. The study illustrates the interaction of biological, psychological, social, cultural and economic factors in the development of dependence on alcohol. The biological factor is expressed in the inherited physiological reactivity of the nervous system or temperament; psychological factors include the quality of the relationships to self, others and the universe which develop in the context of early attachments; social factors include the family and other relationships; cultural factors include religious attitudes, gender bias, behavioural norms, and routes of access to alcohol; economic factors include allocation of resources and attention. The physiological and the psychological can be seen to merge in Steele and Joseph's (1990) theory of the effect of alcohol on Page - 149 the allocation of attention. The results of the study are consistent with this theory. The self preoccupation noted in this study is compatible with the psychoanalytic perspective of alcohol addiction as a narcissistic regression, self-absorption and self-centeredness (Levin, 1989). The suggested symbolic merging with the omnipotent substance as an extension of self or "love object" makes sense in the context of L.'s feelings of alienation. A "fixation" at the anal stage of ambivalence between rebellion and control seems appropriate, perhaps reflected in the intestinal problems. The conflict between instinctual gratification and social responsibility also seems appropriate. From reports, L. had difficulty tolerating frustration as a child. Fears for survival placed her focus on herself. She learned to supress personal gratification and gratify others so they would take care of her. Her sensitivity and need for approval made her particularly vulnerable to the judgemental attitudes of others. Her need for connection made her double vulnerable to her sister's judgemental attitude. She was sensitive particularly to those whose connections were most important to her, like her husband. When the doctor validated alcohol use for stress, the husband also validated it, thus decreasing her disincentives to drink. But eventually, as her drinking escalated out of control, the husband's disapproval fed into the self perpetuating cycle of distresss. Distress from emotional conflict made her vulnerable to the relief provided by alcohol. Page - 150 "From a social-learning point of view, alcoholics are people who have acquired, through differential reinforcement and modeling experiences, alcohol consumption as a widely generalized dominant response to aversive stimulation" (Bandura cited in Wilson, 1988, p.245). This study illustrates the acquisition of positive expectations for alcohol use through a powerful experience of reinforcement. Implications for Practise In this version of the story of the process of addiction a key role is played by the attachment relationship. Evidence was demonstrated for insecure attachment. For individuals for whom this story is valid, the therapeutic relationship will be particularly significant. An attitude of unconditional positive regard would best foster the self-acceptance necessary to reduce stress and allow therapeutic change. It is postulated that it was the empathic understanding and acceptance that this woman found in AA which facilitated her recovery. An atmosphere of unconditional positive regard facilitates the trust necessary for the client to express and explore feelings. Facing feelings rather than repressing and suppressing them allows resolution which decreases stress. If alcohol is being used to manage stress, then more healthy and effective coping mechanisms must be taught. If it is being used to distract the self from problems, these problems need to be addressed. Whatever function the alcohol is serving must be addressed. Page - 151 Implications for Further Research This study supports addiction as a process. More longitudinal research is needed to clarify this process. A developmental perspective is suggested for further research. The foundations of adult behaviour are in childhood psychic development. Understanding ways in which this development may go wrong and what impact it has on adult behaviour may suggests ways we can intervene to 1) prevent arrested development (difficult) or 2) stimulate healthy maturation in the adult. Prospective research is underway in childhood development. A team approach to the study of addiction would be profitable. The team might include specialists in child development, anthropology, sociology, and physiology. The process of becoming alcoholic should be charted both across developmental time and across levels of data according to Zucker & Gomberg (1986). Another interesting project would be to study a particular family where at least one child becomes addicted and one child does not. "It is as important to understand the multiple pathways to adaptations that avoid the development of problems as it is to understand how those problems are produced" (Zucker & Gomberg, 1986). A comparison of alcoholic and nonalcoholic siblings would clarify the developmental process of alcoholism and suggest how it may be prevented. In any event, this study should be repeated to identify other plots leading to addiction. It should be repeated with other women, and then with men to identify which elements may be universal, which may be limited to men and which may be limited to women. Page - 152 l I Summary This study investigated the process one woman went through in becoming dependent on alcohol. The story of the process was elicited from the main character and from her sister, brother, and husband in so far as they were witness to it. Each participant in the study was interviewed and transcripts were made. The story was developed by integrating information from all the interviews. 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Page - 159 CONSENT FORM PROJECT TITLE: The Process of Becoming Alcoholic: A Story of Addiction INVESTIGATORS: Bonny Innes 733-8009; Larry Cochran 822-6139 PURPOSE OF PROJECT: To develop as full an account as possible of the process of development of problem drinking using narratives of the experience from different perspectives and background information in such areas as work, family, and health. PROCEDURES: As a principal participant, you will tell your personal story of your experience in becoming addicted to alcohol in the context of your lifestory. To establish a detailed background for understanding that experience, you may be asked to provide information in areas such as health, family, education and work, as well as permission to interview others who may be able to contribute more information. Others will be interviewed only with permission. Two contacts you have provided, who have observed the process being studied, will be asked to tell the story from their perspectives. A family member will be asked to describe your growing up and to give family history information regarding problem drinking. Three or four interviews may be required with a total time of five to ten hours. Interviews will take place in privacy at a mutually acceptable location. Interviews will be transcribed and identifying information removed. Information will be treated confidentially. Tapes will be erased on completion of the project. RISKS/BENEFITS: Although the reflection and narration of this experience may result in reliving some painful times it also provides the opportunity to put them in perspective and make sense of them in the greater context of life. It will be an opportunity to participate in a process of discovery and to contribute to the understanding of a significant social problem. Bonny Innes may be contacted at 733-8009 for any concerns you may have during the study. You have the right to withdraw from this project at any time without jeopardy of any kind. I the undersigned agree to participate in this project under these conditions. I have received a copy of this document. CONSENT FORM, COLLATERAL RESEARCHERS PROJECT TITLE: The Process of Becoming Alcoholic: A Story of Addiction INVESTIGATORS': Bonny Innes 733-8009; Larry Cochran 822-6139 PURPOSE OF PROJECT: To develop as full an account as possible of the process of development of problem drinking using narratives of the experience from different-perspectives and background information in such areas as work, family, and health. PROCEDURES: As a participant of this study you will be asked to tell from your perspective the story of the process in which problem drinking developed in the principal participant. To establish a detailed description of the context for that development, you may be asked to provide background Information pertinent to the principal participant's experience in areas such as health, family. education and work. Two to four interviews may be required with a total time of four' to ten hours. Interviews will take place in privacy at a mutually acceptable location. Interviews will be transcribed and identifying information removed. Information v/i 11 be treated confidentially. Tapes will be erased on completion of the project. RISKS/BENEFITS: Although the reflection and narration of this experience may result in reliving some painful times it also provides the opportunity to put them in perspective and make sense of them in the greater context of life. It will be an opportunity to participate in a process of discovery and to contribute to the understanding of a significant social problem. Bonny Innes may be contacted at 733-8009 for any concerns you may have during the study. You have the right to withdraw from this project at any time without jeopardy of any kind. I the undersigned agree to participate in this project under these conditions. I have received a copy of this document. NAME: SIGNATURE: DATE: in SELF ADMINISTERED ALCOHOLISM SCREENING TEST ^_YyN 1. Have you enjoyed a drink now and then? Y \UJ2. Do you feel that you have been a normal drinker (that is, drink no more than average)? (y N 3. Have you ever awakened in the morning a-fter some drinking the night before and -round that you could not remember a part of the evening? /{Y/N 4. Have close relatives ever worried or cornp lained about your drinking? Y nd 5. Have you always been able to stop drinking without a struggle a-fter one or two drinks? \Q{J N 6. Have you ever felt guilty about your drinking? Y ny7. Have friends or relatives always considered you a nor fn a 1 drinks r ? Y(NjB. Have you always been able wanted to? stop drinking when you \YJ N 9. Have you ever attendind attesting of Alcoholics Anonymous <AA> because of your drinking? Y/N 10. Have you ever gotten into physical fights when drink ing? (V/N 11. Has your drinking ever created problems between you and your wife, husband, parent or near relative? Y/N 12. Has your wife, husband, or other family member ever-gone to anyone for help about your drinking? (Y) N 13, Have you ever lost friendships because of your drinking? /(YjN 14. Have you ever gotten into trouble at; work because of your drinking? /an ever lost a job because of your drinking? y^p^-v6)is-Have y ^ U (Y) N 16. Have y Qn N 16. Have you ever neglected your oblications, your family, or your work for 2 or more days in a row because of drinking? (\V)N i7. Did you ever drink in the morning7' (Y) N 18. Have you ever felt the need to cut down on your drinking? I I a Y/ N 19. Have there been times in your adult lite when you found it necessary to completely avoid alcohol? Qf/N 20. Have you ever been told you have liver trouble? Y niJZl. Have you ever had delirium tremens (DTs)? \Y)N 22. After heavy drinking, have you ever had Rpyprp -^h.-ik i nn- heard voices, or seen things tha;t weren't there? CyyN 23. Have you ever gone to anyone -For help about your dri nking? (Y/N 24. Have you ever been in a hospital because of your drinking? fY/H 25. Have you ever been told by a doctor to stop drinking? (Y)N 26. a) Have you ever been a patient in a psychiatric hospital or on a psychiatric ward of a general hospital? \Y/N 27. b) Was drinking part of the problem that resulted i your hospitalization? (y H 28. a) Have you ever been a patient at a psychiatric a mental health clinic or gone to anyu doctor, social workier or clergyman for help with any emotional problem)-YjH 29. b) was your drinking part of the problem? n& 30. a) Have you ever been arrested, even for a few hours, because of Y (hj/ a) drunken behaviour? How many times? '31. b) Driving while intoxicated? How many times' YJ|5> 32. Have any of the following relatives ever had problems with alcohol? Y (u) a) Parents \Y/H 33. b) Brothers or sisters? Y ^ N ) 3 4 . c) Husband or wife? m) 35. d) Children? ESCALATING SPIRAL OF DEPENDENCE BIOLOGICAL - hyperarousalibility - stimulus augmentation PSYCHOLOGICAL - ambivalence approach-avoidence conflict CULTURAL - uttitude to wenien drinking - religious values PSYCHOSOCIAL - alienation Ui-PART II DEVELOPMENT OF DEPENDENCE INCENTIVES BALANCED I*Y DISINCENTIVE^ AnikSpaiilm <$ Relief Arstidpas&n of S^m« I Limits Access Controlled Social Drinking Increased Access Private Dri Temperament Abdominal Pain Shame Feelings of Alienation, 'WortMessness !?<?reas€^ lacenlbes <- STRESS Drinking Dinn'ni^d •Doctor's Sanction i>islr*cei»iive$ LHusband's Approval -•Drinking R< ief Shame Shame -•Relief DISCINCEMTVES OVERB ALANCED BY INCENTIVES ' € ESCALATION 0* UR1XKIN0 , C DEVELOPMENT OF STANCE STRESS. PISTKESS Suppression of Feelings Accepts label of alcoholic Fear ! Anger *+-r Shame ** First experience of alcohol, age 7 •* Context of family celebration Meltef Ambiguous Stance Approach-Avoidance Conflict J Stress / Distress I CYCLE OF DEPENDENCE (U B, MALADAPTIVE STRESSUCOFING CYCLE Fear of Abandonment/Separation Anxiety I Fear->Anger->GuiIt->ShameFear I Abdominal Pain STRESS DISTRESS Desire for Connection _k. GQPING STRATEGJQSS r — Being "Good" — Taking Responsibility — Perfectionism — Competing (Needing to be Best) — Anorexia/Bulimia It? Temperament Attachment Process A. P&YCMC D&WtOPMENT Family Context" i— Economic Stressors -7th of 8 children '— Rigid Religious Values -marital conflict -mother's anxiety, depression-illness -perfectionistic standards Internal Representation of Relationship with Caregiver Self-concept -«*-Worthlessness -•Relationships Alienation Anxious Attachment/Separation Anxietv / \ " Fear of Abandonment Fear->Anger->GuiIt->Shame Desire for Connection B. MALADAPTIVE STRESS-COPING CYCLE Fear of Abandonment/Separation Anxiety Fear->Anger->Guilt->Shame U PARTI DEVELOPMENT OF VULNERABILITY A. PSYCHIC DEVELOPMENT Biological Economic ^Psychological 'STRESS J MALADAPTIVE STRESS-COPING CYCLE > Recurrent -«-Abdominal Pain • — Stress -*- Coping Strategies — Increased Stress a DEVELOPMENT OF A VULNERABLE STANCE Approach-Avoidance Conflict 1 Ambiguous Stance DEPENDENCE PART II -*- Stress -Distress Relief •*-Shame -+-•+ Alcohol 4 Socio-cultural Attitudes PARTI DEVELOPMENT OF VULNERABILITY A. PSYCHIC DEVELOPMENT I B. STRESS-COPING CYCLE OF CIRCULAR CAUSATION 1 C.AMBIGUOUS STANCE TOWARD ALCOHOL PART O 'NKING AND THE DEVELOPMENT OF DEPENDENCE A. INCENTIVES BALANCED BY DISINCENTIVES i DISINCENTIVES DECREE I C. ESCALATING CYCLE OF DISTRESS AM) DRINK l . i ^ t j f no 

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