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Part One
The social construction of womenâs alcohol use
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ONE
The context for a social model of alcohol use
Peter Beresford
Introduction
We know that dependence on, and inappropriate use of, alcohol is now widely seen as a global social problem. It is closely associated with crime and violence. It is a major contributory factor to road traffic and other accidents, resulting in countless deaths and serious injuries. It creates massive costs in terms of both personal and familial unhappiness and distress, it creates economic inefficiency and it imposes a massive burden on healthcare through reducing life expectancy and increasing morbidity (Heather et al, 2001). For some discussants, its costs far outweigh those associated with the use of illegal drugs, yet still it is essentially conceived of and treated in the same old individualised terms that would have been familiar in societies much more than a century ago. In the United Kingdom (UK), radical social policies in response to tobacco smoking have resulted in unprecedented reductions in the proportion of people smoking and the damage done. Yet over the same period, we have seen public policies that have increased access to alcohol and rising concerns about serious increases in alcohol-related problems.
At the same time, the dominant model of treatment for alcohol problems continues to be the â12-stepâ model with its talk of reliance on a âhigher powerâ. There can be few social or medical issues in the West in the 21st century that are still framed in such individualised, quasi theological or metaphysical terms. This is a wake-up call for a radical rethink of alcohol and alcohol dependence, building on more recent understandings. That is why this book is so important, because it offers a space to develop such a discussion, which determinedly seeks to move from medicalised, individual, to more social understandings, particularly in relation to a group who have historically received different and inferior treatment in relation to alcohol use â women.
In addition, if we are seeking new and different understandings that may be helpful in reconceiving alcohol problems and the responses made to them, then a particularly fertile field is likely to be the lived experience and experiential knowledge of service users themselves. For this reason, this chapter is concerned with ideas that have been developed by service user movements, particularly the movements of disabled people and mental health service users/survivors. What has conspicuously characterised these has been their social orientation.
A social approach
From 11 March until 6 July 2014, the MusĂ©e dâOrsay, a museum in Paris, held an exhibition entitled Van Gogh/Artaud: Suicide by Society. In 1947, the French actor and writer Antonin Artaud (1896-1948), himself a psychiatric system survivor, who had experienced electric shock treatment among other âtreatmentsâ, put forward a thesis that Van Goghâs work so disturbed society that it shunned his art and led to his despair and suicide. He concluded that van Gogh was a man âsuicided by societyâ.1 Artaud dismissed simplistic and pathologising psychiatric assessments of van Gogh that even now continue to obscure his life and work. Instead, what he offered was a pre-figurative âsocial model of madness and distressâ.
A social model approach is generally understood to have been developed first and most comprehensively in relation to disability. While its influence should not be overstated, there is no doubt that the social model of disability has had a major impact on disability policy and practice and also on the lives of countless disabled people. Since the emergence of the âsocial model of disabilityâ, there have been two additional and related developments. First, there have been far-reaching debates about the social model (Oliver, 2009). Such discussion has often been heated and polarised, with some highlighting what they see as the essential weaknesses of the model, others arguing that it was never intended to be an overarching theory and others still, seeing such discussion as part of its development as a helpful tool for explanation and understanding disability. I include myself in the last group.
The second development has been the efforts made to extend the application of the social model of disability beyond people with physical and sensory impairments â the groups that first developed it â to other groups. This particularly includes people with learning difficulties and mental health service users and raises issues that we will be drawn to later in this discussion (Thomas, 2007).
The distinguishing and innovative feature of the social model of disability is the distinction it draws between âimpairmentâ and âdisabilityâ. Impairment is taken to mean an actual or perceived impairment to the body, sense or intellect of the individual. Disability is regarded as the hostile social reaction that is accorded to people and groups seen as having such impairments. This negative reaction has been framed in different ways. Thus, it is sometimes presented in terms of the barriers or exclusions that operate against people with impairments. These may be attitudinal, communication or physical and environmental barriers, which restrict what disabled people are able to do and stigmatise and negatively stereotype them. It is also conceived in terms of the oppressions that disabled people may face in society; oppressions relating to discrimination and stigmatisation, as well as material, social and political oppression. Clearly, these two frameworks are inter-related. Both also highlight the human and civil rights of disabled people and their citizenship and ways in which these are breached and denied.
While as has been said, critically the social model draws a distinction between impairment and disability, to challenge traditional preoccupations with the individualâs body and perceived âpathologyâ, as discussion has developed around the social model, the relationship between the two has also been subjected to further examination. Some disabled feminists have argued that some impairments can exclude disabled people from some activities, even if disabling barriers are removed (Crow, 1992; French, 1993). Other commentators have challenged the idea of impairments as objective, highlighting that these are subject to different understandings, according to time, culture and ideology. Carol Thomas developed the idea of âimpairment effectsâ, where restrictions of activity are related to physical, sensory or intellectual impairments, making clear, however, that impairment and impairment effects should not be seen simply as ânaturalâ or biological. Instead, she has highlighted that how they are perceived by others and experienced by disabled people, is shaped by the interaction of biological and social factors (Thomas, 1999, 2007). As Cameron (2014, p 77) has suggested: âAt the level of everyday experience, disability and impairment effects interact, which is why it is important to be clear about the distinction between the two.â
These are issues we will return to when we come to explore issues of alcohol, alcohol dependence and âmisuseâ in relation to social understandings.
It may be helpful at this stage to draw a distinction between the social model of disability and social approaches to issues such as disability and mental health more generally. There has long been an interest in more social approaches to such issues. In the context of mental health, for example, more recently this has been associated with the production of a growing number of publications (for example, Sayce, 2000; Ramon and Williams, 2005; Tew, 2005, 2011; Tew et al, 2012). However, such sources, while interested in and exploring social factors relating to mental health, tend nonetheless generally to accept essentially medicalised understandings of âmental healthâ and the diagnostic system associated with them. These tend to be taken as given, while there has been a concern to extend the search for causation beyond the individual, to their social circumstances. This is in some contrast to the social model of disability, which rejects the traditional dominant Western medicalised individual or âtragedyâ model of disability, which conceives of it in terms of personal abnormality, pathology and âtragedyâ.
So far there seems to have been little consideration of a social model approach in relation to problems of alcohol. A key exception is the contribution by the editor of this book, Patsy Staddon, in her writings (for example, Staddon, 2012). She developed this in âTheorising a social model of âalcoholismâ: service users who misbehaveâ, in an earlier edited text on service users in mental health research (Staddon, 2013a). It is not being suggested in the present discussion that alcohol âmisuseâ is necessarily the same as disability. Rather, the aim is to see what, if any, helpful insights the social model may have to offer in any consideration of women, alcohol and alcohol misuse.
Women: âa special caseâ
Before we turn to this, however, it is important to highlight that there is a critical history to the exploration of women and alcohol, which takes account of social, cultural and gender issues. A key pioneer in this was the research psychologist Shirley Otto. Otto was writing about the particular barriers and oppressions faced by women users of alcohol more than 40 years ago (Otto, 1974). She highlighted the historic âscandalising of societyâ of women neglecting their children for the sake of alcohol â âmothersâ ruinâ â and their Victorian association with the âdangerous classesâ. She also highlighted that little was done to help the âwoman alcoholicâ although she faced particular stigma and opprobrium, âparticularly the woman who is drunk and, worst of all, disorderlyâ (Otto, 1974, p 28).
In many parts of our society it is quite acceptable for a man to get âpissed out of his mindâ while even in sophisticated London many women are reluctant to go into a pub alone for a quiet drink, not because they fear assault but for the fear of being misunderstood; women and drink are still associated with sexual promiscuity. (Otto, 1974, p 28)
If the traditional way of understanding disability has been what Oliver (2009) called the âtragedyâ model, then one longstanding approach to representing dependence on alcohol has been the âfarceâ model, with the âdrunkâ as a figure of fun and ridicule. However, this has tended only to be applied to men. Since Otto was first writing, of course the coupling of women with inappropriate behavior, sexual laxness and disrepute has increased, with modern moral panics about a âladetteâ culture of half-dressed young women partying, getting drunk and vomiting in public (Coslett and Baxter, 2014). Ottoâs concern was to develop understanding about the issues involved in the âspecial caseâ of women and alcohol in order to increase awareness and improve support. Sadly, all the signs are that progress on both fronts has been hesitant to say the least and been tied to the same old, often stigmatising and punitive thinking. âBinge drinkingâ by women is such an issue (Plant and Plant, 2006; van Wersch and Walker, 2009). As Staddon (2013a, p 108) states: âfury is expressed where women are seen as âbinge drinkersâ and are seen to be out of controlâ. She goes on:
Whatever âfree choicesâ women may make, they lay themselves open to criticism in a way that men do not âsince most discourses construct femininity in negative terms relative to masculinityâ. Concern is frequently expressed about their health, with particular anxiety about their function as future or current mothers. However what seems principally at issue is their right to intoxication, indiscretion and inappropriate behavior. (Staddon, 2013a, p 109)
The conventional conceptualisation of âalcoholismâ
Staddon (2013a), in this earlier discussion of a social model in relation to alcohol use/abuse, offers food for thought, which is helpful for the present discussion. She suggests that alcohol service users tend to accept prevailing treatment views of themselves. This is perhaps hardly surprising; these are all they are likely to be familiar with and know. Such medicalised understandings have gained enormous authority and common currency â like traditional medicalised understandings of mental illness and disability. The individual who, for example, rejects the 12-step programme approach, runs great risk of losing both self-and external esteem â if they are unable to maintain âsobrietyâ. It is a very difficult but ever-present yardstick to be judged by, in challenging orthodox thinking.
This is particularly true given the complex mixture of moralising and medicalisation upon which prevailing conceptualisations of âalcoholismâ are based. Thus, what is regarded as an inappropriate reliance on alcohol tends to be understood in medical terms variously as alcohol psychosis, as a disease and as a diagnostic category of mental illness. At the same time, such categorisation seems to be inseparable from moral and value judgements. Thus, dependence on alcohol is also seen as immoral, a âcharacter flawâ and a âdisease of the willâ, where the individual is inadequate. Women dependent on alcohol are to be blamed and shamed (Munt, 2007; Morgan, 2008; Staddon, 2012, 2013a, p 110).
What has it got to do with disability?
At first glance, this seems some distance away from ordinary understandings of disability, perhaps limiting the likelihood of a social model having relevance or being appropriate to apply. Even in its most medicalised incarnations, we might imagine that disability is about defect and pathology rather than inadequacy and immorality. But more careful consideration of disabled peopleâs own discourse about disability offers a rapid reminder that over the ages right up to the present, attitudes and imagery associated with disabled people have frequently been negative and judgemental and that, in some cultures, there is a continuing association of impairment with wrongdoing (in the person or their parents) either in this or a previous life (Campbell and Oliver, 1996; Fazil et al, 2002; Bywaters et al, 2003).
It is also important to remember the complex issues emerging in developing discussions about the social model of d...
