Angela's parents were deeply discouraged, and more than a little angry. Their daughter had been a heavy drinker for the past 10 years, and they had spent a good portion of that time smoothing over her scrapes with school authorities, the law and various angry employers.
Although Angela often promised to get her drinking under control, and had even attended a few Alcoholics Anonymous meetings here and there, the drinking never really stopped for more than a few weeks at a time. The fresh hope her parents would feel when she seemed to regain control was always destroyed by the onset of a new crisis.
When she was finally arrested for driving while intoxicated, they borrowed heavily to pay for her care at a private hospital specializing in the treatment of alcoholism.
Angela was hospitalized for 30 days. During that time, her parents participated in several programs offered by the hospital to educate them about alcoholism and to help them cope more effectively with their daughter's problem. They also attended some meetings of Al-Anon, a self-help group for families and friends of alcoholics.
When Angela was released from the hospital, her parents were understandably apprehensive. They were very afraid that without the constant support of the hospital staff, Angela would drink again. She surprised and pleased them by remaining sober for 5 1/2 months after her release from the hospital.
She was able to get a job and to move out of their house and take an apartment with a friend. She even enrolled at the local university in an effort to complete the bachelor's degree she had abandoned years before. Everything seemed fine.
But just when her parents began to feel that the long struggle might be behind them, Angela fell off the wagon, and badly.
She left school the day before her mid-term exams were to begin, stole her roommate's car and some cash, and drove to a motel in West Virginia. At the motel, Angela drank steadily for three days before calling her roommate to apologize and beg for help.
The roommate called Angela's parents, who drove to West Virginia, collected their daughter, returned home and contacted a therapist.
Angela's recovery, which had been so costly in emotional as well as financial terms, appeared to be in a shambles. Her parents wanted to know what to do. More to the point, they wanted to know whether it was still worthwhile to try to do anything at all. "Every bit of that hard work has come to nothing," her father said with tears in his eyes. "I feel like giving up."
"Angela" is a pseudonym and some details have been changed to protect the privacy of the family. Every event actually occurred, however, and the anger and despair that this woman's father expressed are agonizingly real to the millions of people in this country who live with, and love, alcoholics.
They are also familiar feelings to medical and mental health professionals who treat alcoholics and to alcoholics themselves, whose own fragile hopes for a stable recovery are threatened by repeated periods of relapse.
The question that inevitably arises in the aftermath of a renewed bout of drinking is "Why?"
When everything was finally going so well and there has been so much misery on account of the drinking, why? The search for an answer leads directly to a complicated and heated controversy concerning the nature of alcoholism itself.
Though the great majority of people who use alcohol do so without substantial emotional or physical cost, approximately 10 percent of drinkers use liquor in ways that are harmful to themselves, their families and their communities.
Throughout the ages, philosophers, physicians, prophets -- and alcoholics and their families -- have wondered and fought about the causes of harmful drinking. Today we are still trying to discover what it is in the personality or physical makeup of alcoholics that make them so different from other drinkers.
The problem is seen by some as a moral failing, by others as a disease that may have genetic underpinnings, and by still others as a problem of learning or a defense against psychic pain. Few therapists believe it is a moral failing, but rather argue heatedly over the genetic versus learning viewpoints.
The disease concept of alcoholism is the basis for thousands of treatment programs across the country, including the recovery program advanced by Alcoholics Anonymous. It includes the ideas that the alcoholic is different from the nonalcoholic physiologically, psychologically or both; that the alcoholic suffers from an irreversible and progressive disease process characterized by a loss of control over drinking, and that while this disease cannot be cured, it may be arrested by total abstention from alcohol.
This view has been strengthened by the observation that alcoholism tends to run in families, as if inherited, and by recent research that seems to confirm the role of genetic factors in certain cases of alcoholism.
For example, two studies have shown that children whose biological parents are alcoholic, and who are adopted at birth, had a much higher incidence of diagnosed alcoholism than do children, also adopted at birth, whose biological parents are not alcoholic. And the development of alcoholism in the children was independent of the drinking practices of the adoptive parents.
Proponents of the disease model believe that since alcoholism is a chronic illness, relapse is a more or less inevitable feature of recovery. They point out that, as with some other chronic diseases, relapse in alcoholism tends to occur when an individual is exposed to unaccustomed stress. They believe that most instances of relapse can be handled, just as crises in diseases like diabetes or hypertension are dealt with, by adjusting the treatment regimen to accommodate the additional stress.
The disease hypothesis is challenged by those who say that there is little experimental evidence to support the idea that alcoholism is irreversible or that it involves an absolute loss of control.
Such critics favor psychological explanations of compulsive drinking. Some see it as a learned behavior that can be modified by "retraining" alcoholics -- teaching them, for example, to sip rather than gulp their drinks.
Others who favor a psychological model point to the feelings of low self-esteem and fear of failure that seem to torment many alcoholics. They argue that the use of alcohol and other drugs is actually an effort to drown these severe psychic pains.
In this view, compulsive drinking is a defense against other "deeper" psychological problems.
Psychological theories are bolstered by studies that claim to have helped heavy drinkers to establish control over their drinking. Such research is considered inconclusive because it is difficult to establish whether the subjects were truly alcoholic to begin with, and since authorities disagree as to what constitutes "controlled" drinking. (Some studies allowed their subjects to consume as much as six ounces of liquor a day.)
Because the evidence is so unclear, nearly all treatment programs encourage alcoholics to abstain from alcohol rather than try to establish control.
Psychological models of alcoholism usually relate relapse to either a failure of new learning or to a return of painful emotions and a regression to destructive ways of coping with psychic distress. It signals that treatment was ineffective, or that it is still incomplete.
Some authorities favor an integrated, "multivariate" explanation of alcoholic drinking. This approach incorporates the idea of genetic vulnerabilities without discarding the unshakeable impression of most clinicians that learning and environmental stress also play crucial roles in this problem.
It emphasizes that there are many patterns of alcohol abuse and dependency and suggests that relapse, like harmful drinking itself, means different things in different cases. This view holds that the relative importance of physical and psychological factors may vary from individual to individual, and that the same person may relapse for different reasons on different occasions.
Though relapse often triggers feelings of intense disappointment and even hopelessness in alcoholics and their friends and family members, it should be noted that none of the major theoretical perspectives on the problem regards relapse as a sign of hopelessness.
Rather, relapse is seen today as related to the complexity and chronic nature of alcoholism. Specialists in alcoholism treatment expect that it will frequently be a part of the process of recovery.
A treatment strategy will be viewed as successful if the number of relapses declines steadily over time, and if the periods of sobriety grow progessively longer.
Alcoholics and their families are told that relapse is a common occurence during recovery, and need not signal a return to active alcoholism as a way of life. They are warned that relapse is most likely to occur on holidays and occasions that disrupt the normal daily routine, and under conditions of special stress such as a job crisis or an illness or death in the family.
Though alcoholics usually feel ashamed when they "slip," they are encouraged to fight their shame and to talk about relapse and other problems with fellow AA members and sympathetic friends and family members. Many find that such sharing relieves the intense internal pressure that can trigger a resumption of drinking.
Family members who enter treatment learn that the possibility of relapse is only heightened if they create a punitive or fearful atmosphere in which feelings of stress and the temptation to drink cannot be shared.
Treatment programs now attempt to use relapse and near-relapse as an opportunity to uncover and remedy the flaws in a particular treatment plan. There is widespread agreement that relapse should be greeted by a redoubling of treatment efforts rather than a surrender to compulsive drinking.
Angela's parents had discussed the possibility of relapse with hospital staff and Al-Anon members, but they lost touch with these sources of help during the period that Angela was sober. Their perspective on her problem began to be shaped more by their hopes than by a realistic understanding of the nature of alcoholism.
After her relapse, they were encouraged to return to Al-Anon, and with the help of that program and counseling, they were ultimately able to take heart from the fact that their daughter had achieved several months' sobriety after ten long years of active alcoholism.
They discovered that, prior to her relapse, Angela had abandoned her AA meetings in order to study for exams, and they surmised that the loss of contact with supportive friends in the program, as well as heightened pressure at school, were probably responsible for triggering her binge.
Once Angela's parents overcame their feelings of despair and analyzed the relapse, they were able to help her regain her own hope for a stable recovery. Most important, they helped her to return to AA, where she is now in her second year of sobriety.