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The terms alcohol and drug abuse and dependence (addiction) are often used interchangeably, but they represent two quite different conditions. They also require two quite different remedies.
Alcohol/drug abuse is defined by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)1 as follows:
A maladaptive pattern of alcohol or drug use leading to impairment or distress, presenting as one or more of the following over a 12-month period and symptoms have never met the criteria for chemical dependence:
- Recurrent use leading to failure to fulfill obligations
- Recurrent use that is physically hazardous
- Recurrent alcohol- or drug-related legal problems
- Continued use despite social/interpersonal problems
As such, abuse means intentional overuse of alcohol and/or drugs. It is often described as people making bad choices about the use of alcohol or drugs.
People abuse alcohol and/or drugs for many reasons, including peer pressure, immaturity, insecurity, habit, mental illness, life problems, ignorance, and poor coping skills.
Alcohol/drug dependence, on the other hand, is defined in the DSM-IV as:
A maladaptive pattern of alcohol or drug use, leading to impairment or distress, presenting as three or more of the following over a 12-month period:
- Tolerance to the substance's actions
- Withdrawal symptoms or use to avoid withdrawal symptoms
- Substance is used more than intended
- There is an apparent inability to control use
- Effort is expended to obtain the substance
- Alcohol or drug use continues despite negative consequences
Dependence represents impaired control over the use of alcohol and/or drugs. Like abuse, it includes overuse, but overrides intention.
People become dependent on alcohol or drugs in response to a dysfunction in the brain's pleasure pathway that always involves neurobiology and often involves genetics.
The essential difference between abuse and dependence lies in control. Abusers can control their drinking and drug use whenever they choose. Dependents can control theirs on some occasions - perhaps even most - but not all. Their control is unpredictable.
The solution to avoiding the problems associated with abuse and dependence is different for each condition. Since abusers can control their use, their solution is consistent moderation. That may involve something as simple as setting limits and using will power to honor those limits. But it may involve more. For example, if someone is drinking excessively as a way to cope with grief and despair associated with the loss of a loved one, they may need to obtain counseling to learn more appropriate ways to cope with those feelings. Once the feelings are resolved, the "need" to self-medicate with alcohol fades away, and the alcohol abuse ends. Or if a person drinks a lot before and/or during social occasions to deal with low self-esteem and insecurity associated with being around people, they can get psychological help to feel better about themselves and become more confident in their ability to interact with others.
Alcoholics don't have the option of setting limits and sticking to them through will power. They may try many times to control their drinking, and will most likely succeed some of the time, but at least occasionally they will fail. They will drink more than they planned, and they will experience negative consequences associated with drinking. This is true even if they attend counseling to deal with problems and get help to develop positive self-esteem. Therefore, their only real solution is to abstain from alcohol and drugs and find recovery from dependence.
The following table provides a simplified use-abuse-dependence continuum that summarizes these differences:
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A section on this web site named Where to Get Help provides numerous resources at UT, in Austin, in Texas, and on the Web for getting help with alcohol and drug abuse and dependence.
Click here to access that page: Where to Get Help.
1Diagnostic and Statistical Manual of Mental Disorders. (4th ed., text revision). (2000). Washington, DC: American Psychiatric Association.
Abstinence vs. Recovery
By: Charles N. Roper and Brandy Whitten
A familiar story among 12-step program members and within the alcohol/drug abuse treatment community is of an Alcoholics Anonymous newcomer who approached an old timer and said, "You know, I'm starting to connect with these ideas and with you people, but there's one thing that I'm just not getting. What's this 'spiritual' part of the program that y'all keep talking about?"
The old timer scratched his head, thought for a moment, and then responded, "Well, I guess I could explain the spiritual part if you could tell me what the other part is."
The problem is that there is no other part. Recovery is a spiritual process. But understanding that concept is not always easy, even for people who have been around recovery for some time. It is often not understood by helping professionals outside of the alcohol/drug abuse field, and even occasionally by some within the field. People often mistake abstinence for recovery.
Abstinence begins when an alcoholic/addict quits consuming alcohol and drugs. It occurs at a particular point in time as an event. Recovery, on the other hand, begins when an abstinent alcoholic/addict starts growing and changing in positive ways. It occurs as a process over a period of time. Abstinence requires a decision; recovery requires time and effort.
It has been suggested that chemical dependency is a four-fold disorder - one that affects its victims physically, mentally, emotionally, and spiritually. If that's true, then to be real and lasting, recovery must occur on all of these levels - that is, in every area of your life.
Physical recovery is the least complex of the four, even though it is often the most immediate. Physical recovery happens primarily as the result of abstinence. The body has an amazing ability to repair itself, even when it has been badly neglected or abused.
Mental recovery is more complex because it includes not only issues associated with brain function and brain chemistry but also with attitudes, belief systems, and rational, abstract thought.
Emotional recovery is more complex yet. It involves not only attitudes, belief systems, and rational thought, but also thought's first cousin: feelings. Emotional recovery involves learning to deal with feelings openly, honestly, and responsibly. It includes learning to express and resolve feelings in appropriate and effective ways. For most people, emotional recovery takes years.
Abstinence alone seldom, if ever, encourages recovery on mental and emotional levels. Indeed, some individuals find abstinence alone to be a hindrance to mental and emotional recovery. Have you ever met someone who is more restless, irritable, and discontented sober than they were when they were drinking or using drugs?
For some people, drinking or using drugs helps them to change the way they are feeling or thinking. It is an external means to internal change. The process of recovery empowers abstaining addicts and alcoholics with the means to learn healthy, internal ways to handle their thoughts and feelings without relying on chemicals.
Spiritual recovery is the most complex of all because:
- It incorporates aspects of the other three life areas.
- It occurs on a deeper human level.
- It takes a lifetime and is never finished.
- It is rather abstract and illusive in nature.
If a dozen spiritual "professionals" were asked to define spirituality, they would surely produce a dozen different definitions. Therefore, it may be useful to discuss spirituality and spiritual recovery as generically as possible, incorporating several components.
In its broadest sense, spiritually is a way of life - an attitude toward life that manifests through your values, beliefs, and personal characteristics. If asked to list positive spiritual qualities, most people would include at least some of the following: serenity, conscience, goodness, honesty, genuineness, integrity, humility, kindness, generosity, courage, faith, tolerance, acceptance... you get the picture.
Of course, each of these positive spiritual qualities has a negative counterpart. Hence, the not-so-obvious fact that spirituality has a dark side as well as a bright one. Negative, or anti-spiritual qualities include deceit, laziness, self-hatred, cowardice, selfishness, bigotry, nihilism, etc. If spirituality is a way of life and an attitude toward life, then, negative spirituality might be exemplified by the attitude "Life's a bitch and then you die."
These personal qualities - both positive and negative - all have something in common: they run very deep, to the essence or core of your being. Personal spirituality resides, and therefore spiritual recovery occurs, at that very deep levelÑat the coreÑtapping, transforming, and strengthening positive spiritual qualities that had become hidden behind negative ones.
Deep and profound internal transformations might include: from fear to faith, from pride to humility, self-pity to gratitude, resentment to acceptance, dishonesty to honesty, cynicism to trust, isolation to connectedness, and reliance on self-will to reliance on God (or a power greater than oneself).
Profound internal changes such as these typically occur quite subtly over extended periods of time. That's the way recovery works. Fortunately, they don't stay hidden internally. They manifest in behavior, or the outward expression of internal qualities. The alcoholic or addict's friends and family will begin to notice the change. The recovering individual will begin to notice it as well, especially in the experience of his or her relationships, including all of the following:
- The relationship with him or herself, in terms of self-esteem, self-acceptance, and sense of meaning & purpose in life
- Relationships with other people, in terms of openness, genuineness, and depth
- The one with his or her Higher Power, in terms of faith, trust, and connectedness
Despite the focus on personal spiritual growth, it is important to understand that recovery is not religion. Rather, it is a process by which alcoholics and addicts get what it takes to stay sober. Even though we mention God and Higher Power, adherence to any particular religion or even a belief in God is not required. From the "big book" of Alcoholics Anonymous1 (one guide to recovery):
Most emphatically we wish to say that any alcoholic capable of honestly facing his problems Écan recover, provided he does not close his mind to all spiritual concepts. He can only be defeated by an attitude of intolerance or belligerent denial. We find that no one need have difficulty with the spirituality of the program. Willingness, honesty, and open mindedness are the essentials of recovery. But these are indispensable.
Fortunately, help with the process of spiritual growth and change - with recovery - is very readily available. In fact, help is an essential ingredient in the process. Spiritually weak or spiritually bankrupt individuals don't recover using will power alone. In fact, strong will power often impedes spiritual growth more than it helps.
Structured treatment programs, substance abuse counseling, and 12-Step programs do help. While they are not the only sources of help, they are the most consistently effective, especially when combined in some systematic fashion. Treatment and counseling provide structure, support, and intervention. They facilitate trust by creating a supportive and accepting environment. They encourage insight and movement through denial, which blocks recognition of the need for both abstinence and recovery.
Twelve-Step programs, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous (CA), Al-Anon, and Alateen, provide powerful blueprints for spiritual growth and change, which when followed, lead to personal transformation and a spiritual way of life. Furthermore, support groups offer fellowship and opportunities for service to others with similar problems.
Recovery is said to be simple but not easy. It is simple because spiritual concepts are simple - truth is truth. But work is work. Recovery requires effort and patience, and then more effort and patience, and then more... It is certainly worth the effort, though.
Recovery is a dynamic process. Growth and change open doors for more growth and change. Finally, as recovery deepens, abstinence simply becomes another of its many wonderful by-products.
1 Alcoholics Anonymous (4th ed.). (2001). New York, NY: Alcoholics Anonymous World Services, Inc.
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