Criterion A.2. of Alcohol Use Disorder, as presented in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), is the foundation for my conceptualization of alcoholism as either a disease or a behavior. Obviously a person who meets the criteria for a mental disorder warrants a diagnosis of a mental disorder, right? Isn’t the DSM gospel? Okay, so cynicism aside, the criterion of which I am referring is as follows: “There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.” In short, if a person is behaving in a manner that they do not wish to behave, and they have put forth significant honest efforts to stop that behavior (or emotion, etc.) then they need help. If help is most effective by way of mental health intervention, then I believe that the mechanisms should be in place for that assistance to be received (thus a diagnosis be present within the DSM).
It is in the assessment of the criterion of reference where the distinction is made between people who are engaging in an irresponsible manner versus a person who is “ill”. I would almost go as far as to say that the criterion should be listed separately from the others and be required in addition to “at least two of the others.” The reality is that due to its subjectability, the criterion is not a foolproof method for determining “disease.” What a person says they have done to stop, cut down or control alcohol is unfortunately not always factual in nature. This in itself creates a conflict with therapeutic approaches that the clinician accepts the client’s reality (regardless of truth), similar to the process of dealing with victims of violence or abuse.
Gaining an understanding of the hopelessness a client feels is often a prerequisite for intervention (which sometimes proves therapeutic in itself); however, validation of the hopelessness should not be required of a clinician. With this thought process in mind, which is often best, clinicians commit due diligence to understanding the problem as the client sees it, and make some efforts to validate the claims the client makes with regard to their unsuccessful efforts to control their alcohol use.
During this validation process it is useful to understand the means by which the client has presented themselves to therapy. Was it court-ordered, were they pressured or did they come on their own accord? The reason for a client sitting in your office is oftentimes a predictor of the level of expected success, though asking the client directly may be illuminating as well.
With the work of Michele Weiner-Davis in mind, a therapist should also search for evidence of pretreatment change. These are all factors that are associated with determining the “classification” of alcoholism and more importantly the need for intervention. Regardless of how it’s classified, as a clinician, with a client sitting in front of you, you have an obligation.
Consideration of the factors mentioned above may also serve as a guide to a therapist evaluating which approach to intervention may best suit a particular client. Due to my affinity for Marriage and Family Therapy, I would be remiss if I didn’t mention an assessment of the effects of the alcohol use, regarding the family (if present), should also be a factor in determining the goals of therapy.