The constitution of the alcoholic self,communicative processes and administrative practices: On the varied uses of four terms denoting problematic drinking

Abstract

Aims:

The aims of this article were to examine the various meanings ascribed by three stakeholder groups – social workers, journalists and individuals with previous experience of problematic drinking – to four widely used terms in the alcohol field – alcoholism, alcohol dependence, alcohol misuse and risky drinking – and to examine how variations in the definitions of these terms correspond to specific pragmatic needs arising within different practices.

Design:

We conducted focus-group interviews with 15 individuals from the above-mentioned stakeholder groups. We identified three practices, we identified three practices which shaped the meanings ascribed to the four terms denoting problematic drinking.

Results:

The results showed that the meanings ascribed to the four terms were both fixed and fluid. For the individuals with previous experience of problematic drinking, the four terms had fixed meanings, and their definition of the term “alcoholism” as denoting a disease, for example, was vital to the practice through which they sought to come to an understanding of themselves (“practice of self”). The social workers and the journalists on the other hand saw the four terms as being context dependent – as fluid and imprecise. This allowed them to establish trustful communicative relationships with informants and clients (“practice of trustful communication”), and to control the communicative process and successfully navigate between different administrative systems (“practice of administration”).

Conclusions:

Since the meanings ascribed to the examined terms denoting problematic drinking are shaped within varying practices, confusion regarding the actual meaning of a given term could be avoided by referring to the practical context in which it is used.

Keywords

concept analysis discourse groups practices problematic drinking stakeholder Sweden

In a paper written by Nils Christie and Kettil Bruun for the 28th International Congress on Alcohol and Alcoholism, the authors lamented what they label the “conceptual mess” that is inherent to our understanding of alcohol and drug problems. Concepts such as “drug dependence” are here famously described as “fat words”, which are so vague and all-embracing that they are more or less meaningless. The authors ask themselves how we got ourselves into this conceptual mess, how we might resolve it, and what would happen “if we were able to invent words that give clearly and precisely the same message to all the parties concerned?” (Christie & Bruun, 1969, p. 65). Christie and Bruun have not been alone in lamenting the lack of precision in the field of alcohol and drugs, as evidenced by the numerous attempts to provide “final” or “true” definitions of, e.g., alcohol dependence, alcoholism, problematic drinking etc. (see Blomqvist, 1998; Campbell, 2012; Fraser et al., 2014 for an overview). However, as several authors have noted, such attempts at establishing “final” definitions rest on a notion of concepts such as “addiction”, “dependence”, or even of the effects produced by various substances – such as alcohol – as being fixed, essential, and in a sense transcultural objects – as being pre-constituted entities that exist independently of our ways of understanding them (cf. Campbell, 2012; Dwyer & Moore, 2013; Edman, 2009; Fraser et al., 2014; Vrecko, 2010a, 2010b). In opposition to this more or less essentialist notion, it has been suggested that we analyse, for instance, “addiction” or “problematic drinking” not as objectively existing “facts”, but rather as phenomena that emerge within specific temporal and cultural contexts and which are dependent upon “a complex assemblage of personal, social, material and political factors” (Vrecko, 2010b, p. 55).

Previous research indicates that experiences and meanings of (problematic) drinking are indeed manifold and variable across time and space, and that it may therefore be difficult to capture them by means of a few distinct concepts. Studies that have devoted themselves to the conceptual, historical and empirical analysis of terms generally associated with drinking have inter alia concluded that the mere fact that there are numerous synonyms for “drunk” or “drunkenness” (no less than several hundred synonyms in American English; Levine, 1981; see also Cameron et al., 2000; Thickett et al., 2013), most of which have clearly identifiable positive or negative connotations, implies that the very experience of consuming large amounts of alcohol is complex – being both “feared and tabooed” and “sought, desired, and loved” (Levine, 1981, pp. 1050–1051). In addition, a couple of studies comparing the cultural meanings of drunkenness in selected European countries have identified substantial cross-national variation (Cameron et al., 2000; Thickett et al., 2013), leading the authors of one of these studies to suggest that the term “drunkenness” is unsuitable for use in cross-national research (Thickett et al., 2013). Similarly, Egerer (2014), studying conceptualisations of different addictions among general practitioners and social workers in Finland and France, has demonstrated how conceptualisations of such behavioural phenomena are institutionally embedded and vary across nations. Other studies have found that the meanings of these terms change over time. For example, Herring and colleagues (2008) showed that the general meaning of the term “binge drinking” – as employed in the UK – changed during the second half of the 20th century, and the authors concluded that binge drinking is “one of those slippery terms that to date has eluded precise definition” (Herring et al., 2008, p. 478). Furthermore, not only the terminology used but also images of the suggested causes and character of drinking and drug use have been found to be both manifold and variable. For example, a number of studies have shown that the dominant perceptions of the severity of addiction-related problems (for the individual and for society), the assumed nature of addiction, and the way options for recovery from addiction are rated all vary considerably across different substances linked to addiction, and also across different populations and countries (e.g., Blomqvist, 2009, 2012; Blomqvist et al., 2014; Hirschovits-Gerz et al., 2011; Holma et al., 2011). Several studies have also demonstrated that variations in how phenomena such as “dependence” or “addiction” are constituted actually develop in response to concrete practical needs that arise within specific contexts (cf. Campbell, 2012; Fraser et al., 2014; Vrecko, 2010b).

Following the insights provided by these studies, the aim of this article is twofold. First, we seek to examine various meanings ascribed to the four terms most frequently employed in Sweden to define problematic drinking: “alcoholism”, “alcohol dependence”, “alcohol misuse” and “risky drinking” (in Swedish: alkoholism, alkoholberoende, alkoholmissbruk, riskdrickande; for a discussion regarding the correspondence between the Swedish and English terms, see Wallander & Blomqvist, 2019). In Sweden, alcohol misuse has long been the most well-established term denoting problematic drinking; it is the term employed in the contemporary Swedish legislation and in the tradition of the Swedish social work profession, which bears the primary responsibility for dealing with problematic drinking at the individual level. At the same time, the term alcohol dependence constitutes an established part of the health professions’ vocabularies and also manifests itself in the term used to designate the part of the healthcare system that deals with problematic drinking and drug use (cf. “beroendevården”; in English “dependency care”). Further, while alcoholism is by far the oldest and most long-standing term associated with problematic drinking (stemming from the middle of the 19th century), the term risky drinking was first launched less than 20 years ago, in connection with a Swedish project aimed at developing competence among primary care staff in dealing with patients with presumed drinking problems (Wallander & Blomqvist, 2019). For a more detailed outline of the historical roots and contemporary usage of each of these four terms (with a focus on the Swedish context), see Blomqvist and Wallander (2017).¹ In this article, we are particularly interested in understanding how social workers, journalists and individuals who have experienced alcohol-related problems – three groups of people for whom these terms are important in various ways – make use of the terms.

Second, and most importantly, rather than lamenting the “conceptual mess” that exists in the alcohol field, we aim to examine how variations in the way the four terms are defined correspond to specific pragmatic needs that may arise in the context of different practices. The questions posed in the article are: (1) What meaning do the interviewees ascribe to the terms “alcoholism”, “alcohol dependence”, “alcohol misuse” and “risky drinking”? (2) What pragmatic needs do the specific definitions described by the interviewees correspond to? (3) How do the interviewees establish legitimacy for their definitions of the terms? By examining these questions, this article seeks to demonstrate how the four terms acquire their meaning from specific discourses that emerge within certain practices (cf. Foucault, 2002a, p. 195). Such an approach has been very useful in similar analyses since it enables the analyst to unearth the assumptions underlying specific terms, thus enabling novel ways in which to understand these terms and the practices within which they circulate (e.g., Bacchi, 2009; Roumeliotis, 2015, 2016). Following the two discourse theoreticians Michel Foucault and Carol Bacchi, we understand discourses to be constituted through articulatory practices by means of which reality and objects for thought (e.g., certain states of being such as “alcoholism” or person categories such as “alcoholic”) are constituted in specific ways (cf. Bacchi, 2009; Foucault, 2002a). Discourses are thus not simply passive masses of text or talk, nor are they just ideas or linguistic phenomena signifying “real” phenomena out in the world. Rather, they make up, and are connected to, wider configurations of practices through which reality is shaped. From this follows that our approach does not proceed from a notion that there are “true” definitions of the terms that correspond to phenomena that exist in reality, but rather that phenomena such as “alcoholism”, “alcohol dependence”, “alcohol misuse” and “risky drinking” are constituted through articulatory practices. In other words, phenomena such as “alcoholism” are not treated as transcendent phenomena with a fixed essence that we could somehow observe objectively, but rather as phenomena that are constituted through discursive practices (cf. Bacchi, 2012). However, this lack of “true” definitions and the fact that the meaning of terms might be contested does not mean that specific terms and the meanings ascribed to them are unimportant. On the contrary, there is much at stake since different attempts to ascribe specific meanings to terms take part in a struggle involving competing visions of reality and, perhaps more important, they have real effects on the lives of people (Bacchi, 2009). In the context of this article, we have attempted to delineate three different discursive practices that shape reality in different ways and through different logics.

In order to understand the meaning ascribed to terms such as “alcoholism” or “alcohol dependence” it is important to analyse what Bacchi (2009, p. 5) has called “conceptual logics”. The term “logic” refers here to the assumptions – including values, cultural, ontological and epistemological assumptions – that underpin specific ways of defining or using terms. So, by analysing how meaning is ascribed to specific terms it is possible to gain an understanding of the underlying assumptions that come with specific uses of terms and thereby also to enable a deeper understanding of the discursive practices in which these terms are used. In our analysis we have examined three different discursive practices. The first concerns a practice through which individuals seek to understand themselves. This involves several different practices such as self-monitoring, seeking guidance and narrating a history that explains the emergence of this self. The second practice concerns communicative processes. This involves the construction of different relations between those involved in communicative processes in order to gain each other’s trust. The final practice concerns administration and how individuals are categorised in order to be able to “fit” into different administrative systems which carry with them their own internal logics (for example legal or medical rules).

Method

Respondents and analysed material

This study analyses material generated by means of focus-group interviews with individuals belonging to three stakeholder groups. Focus-group interviews are a highly useful means of analysing how a collective understanding of various phenomena emerges by means of negotiations within the groups examined (Barbour, 2007; Morgan, 2018). When the participants in a focus group talk amongst themselves on a particular topic of interest, they draw on their own (and on each other’s) perspectives and experiences, as well as on broader discourses, thus generating patterns of consensus and diversity in the understandings of the examined phenomena (Morgan, 2018). The interaction within the group allows us to examine how certain understandings may gain influence and become established as “collective truths” in the group (Demant & Törrönen, 2011, p. 1247). In this study, we were interested in exploring collective understandings and practices associated with the terms alcoholism, alcohol dependence, alcohol misuse and risky drinking in three stakeholder groups: journalists, social workers and individuals with previous personal experiences of problematic drinking. These three groups represent different levels, positions and interests in relation to problematic drinking, and may be described both as stakeholders and as claims-makers involved in a struggle about how to understand and define problematic drinking (cf. Loseke, 2017). The journalists, who are active at the level of the larger society, are engaged with disseminating information about alcohol and problematic drinking via the media. By drawing on various discourses related to problematic drinking – for example through using and defining certain terms – they are likely to inform popular perceptions of this problem (e.g., Loseke, 2017). The social workers, who represent the clinical level, bear the primary responsibility for dealing with problematic drinking (in Sweden). As such, they aspire to a professional authority to define – by means of certain terms – the character of the problem in question (e.g., Abbott, 1988). Finally, in this study, the individual level is represented by individuals who have themselves experienced problematic drinking – individuals who make use of available discourses, perceptions and definitions in order to understand themselves (e.g., Hacking, 1991).

The interviews were carried out by two of the authors (Carlsson & Johansson Erkenfelt) between August and October 2018 at three locations in southern Sweden. The respondents were recruited by means of snowball sampling, which is a non-probability sampling technique in which existing respondents provide information that is used to recruit future respondents from among their acquaintances. The initial contact with the respondents was made via email, to which a short letter containing information about the study – including information about research ethics – was attached. The 15 respondents who participated in the study comprised four journalists (three women and one man), six social workers (all female) and five individuals with personal experience of problematic drinking (two women and three men). The journalists have been active in the profession for between 10 and 40 years, and they all have experience of writing newspaper articles and commentaries on the subject of problematic drinking. Likewise, the social workers, all of whom have a university social work education, are experienced in the subject of problematic drinking, having practiced in the area of substance use investigations, treatment, policy etc. for between 2 and 35 years. The individuals with personal experience of problematic drinking have been sober for many years (between 5 and 27 years), and all are engaged in self-help groups for alcoholics (Alcoholics Anonymous, and “Länkarna” (The Links)).² Being sober and engaged in a self-help group were not pre-requisites for participating in the study; the fact that all five of these individuals had these same characteristics was instead a result of the snowball sampling process. As will be seen below, the discourses that emerged in the discussion among the respondents with personal experience of problematic drinking drew to a large extent on the vocabulary and problem definitions associated with Alcoholics Anonymous and “The Links”. This is perhaps not so surprising given that these individuals are involved in these organisations and are therefore familiar with the knowledge produced within them. It is very likely that alternative discourses would have emerged if the focus group had included respondents with no connection to these self-help groups and with other experiences. The fact that the sample of respondents for this study makes up no more than three focus groups – one for each stakeholder group – naturally limits the generalisability of this study’s results. For example, since only one focus-group interview was carried out with each stakeholder group, the saturation criterion was not met (cf. Morgan, 2018). However, while this study aimed to examine how variations in the definitions/understandings of four terms might correspond to pragmatic needs in the context of different practices, we never aspired to identify all potential variations in the collective understandings shared by the members of a particular stakeholder group. Therefore, our results should be treated as examples of how variations in collective understandings correspond to pragmatic needs in the context of different practices. The study’s three focus-group interviews (one for each stakeholder group) lasted for about two hours and followed the same structure: the researchers began by stating that no responses – to the interviewers’ questions – would be regarded as correct or incorrect and that they would welcome the discussion of all types of experiences, beliefs and attitudes associated with the study object. After this introduction, the researchers presented the four terms that were to be discussed: alcoholism, alcohol misuse, alcohol dependence and risky drinking. As the four terms were simultaneously introduced at the beginning of the discussion, the respondents were able to compare the terms at all stages of the interview. The discussion was based on an interview guide, which included themes carefully formulated so as to be able to further explore the understanding and practical employment of the terms in each of the stakeholder groups. These themes included the use and usefulness of the terms, the terms’ separate connotations as well as the various ways that they related to each other, and their meanings as defined from one’s professional belonging and/or from the perspective of one’s own experiences of problematic drinking. Apart from making sure that all the terms were thoroughly discussed, the interviewers deliberately played a passive role in the discussions, so as to ensure that the respondents’ conversations stayed in focus. The recorded interviews were fully transcribed, so as to enable a detailed analysis of the material.

Analytical strategy

Our analytical strategy was based on our research questions. The material was read through the lens of our theoretical perspective, meaning that we sought to understand how the analysed terms were given meaning within specific contexts rather than carrying with them a stable meaning from the start. As a first step, we examined how the interviewees defined the terms (a question of signification). In part, we drew on the second step in Bacchi’s (2009) “what’s the problem represented to be?” approach as a methodological resource. This step means that the analyst seeks to answer the question of what ontological and epistemological assumptions, or value assumptions, underlie specific representations. We conducted thorough individual readings of the material and compared our findings in order to see whether our interpretations differed and to gain a wider variety of interpretations to work with. Our theoretical perspective guided us in our reading of the material. For instance, our knowledge of Foucault’s (1990, 2002b) analyses of the practices through which individuals form their selves was actualised when we identified several similar phenomena in the analysed material. Second, we sought to understand what was enabled by these specific definitions in terms of different practices (a question highlighting the “function” the terms acquire in relation to specific practices). In our aim to identify specific practices we took as our starting point the definitions provided by the interviewees. So, for instance, the social workers’ references to legal and medical definitions led us to think about the practical contexts within which the terms circulated. We delineated and specified these practices and constructed three labels to describe them: “practices of self-understanding”; “practices of trustful communication” and “practices of administration” (these will be presented in more detail in the analysis section). Finally, we sought to examine how legitimacy was established in the interviewees’ accounts (a question focused on who holds the right to establish authoritative interpretations of the terms). By means of this process we were able to highlight the connection between the analysed terms and the practices in which the interviewees were involved. It is important to note in this context that our aim has not been to provide an exhaustive account of the different ways in which the analysed terms have been – or could be – used in concrete situations, but rather to illuminate the variations found in the connection that exists between terms and practices. Nor do we claim that the practices described below are exclusive to certain groups or that the practices are mutually exclusive. Instead, we have sought to provide a somewhat rough outline of these practices, including some of the components that these are made up of.

In the analysis, we have italicised key passages in the quotations in order to highlight passages and words that are central for the analysis. We have labelled the interviewees in the following way:

Social workers: SIP no.

Journalists: JIP no.

Individuals with previous personal experience of problematic drinking: PDIP no.

Analysis

The analysis has been divided into three parts, each reflecting a specific practice in which the four analysed terms are used in different ways. In the first analytical section, we have sought to demonstrate how meaning is ascribed to the terms within a practice that aims to build up a specific kind of self-understanding and to establish an identity for oneself. In the second section we examine how meaning is ascribed to the terms within certain communicative practices when professionals seek to establish a communicative relationship between themselves and others. The final section demonstrates how the terms acquire their meaning within different administrative practices that require specific definitions of terms in order to function. This analytical section is followed by a discussion summing up our main conclusions.

Practices of self-understanding

In this section we illustrate how the interviewees who have experienced problems related to their own alcohol consumption discussed the terms alcoholism, alcohol misuse, alcohol dependence and risky drinking and how these terms are centred around the practice of establishing a relationship to a self. This includes practices by means of which individuals seek to come to an understanding of themselves by establishing a specific kind of identity, confessing to this identity, constructing a “history” for the identity, and above all, base their understanding of themselves upon the “truth” of this self. The philosopher Michel Foucault (1990, p. 28) has discussed this practice of establishing a relation to one’s self in terms of,

a process in which the individual delimits that part of himself [sic] that will form the object of his moral practice, defines his position relative to the precept he will follow, and decides on a certain mode of being that will serve as his moral goal. And this requires him to act upon himself, to monitor, test, improve, and transform himself.

The practice examined here involves the practical means through which the interviewees try to understand and shape an identity for themselves, including how they define and “categorise” themselves, how they explain the emergence of this self and the different bodies of knowledge they make use of in constructing this self. It also involves the constitution of a whole epistemology that defines the rules for what constitutes “true” knowledge. In short, it is about how they constitute themselves as persons with specific identities through specific discursive practices.

In their discussion of the terms, the interviewees understood the terms “alcohol misuse”, “alcohol dependency” and above all “alcoholism” as all signifying a disease comparable to allergies. In doing so, they gave expression to one of the most common understandings of drinking problems in the Western world, which can be traced back to the late 18th century and which constitutes a central tenet within the AA movement and the Swedish Links movement (cf. Blomqvist & Wallander, 2017; Kurube, 1997). What in this context could roughly be called an “AA discourse” constitutes a kind of hybrid discourse, consisting of a mixture of other discourses such as those of medicine and psychology.

In the interviewees’ accounts, this disease is located at the very core of the individual, and forms the very essence of the self. It thereby enables the interviewees to establish a specific kind of identity for themselves. Accordingly, one of the interviewees defined herself as a “dependent person” (in Swedish, “beroendeperson”).³ As she expressed it:

And I am of course a dependent person even when I’m sober. And I see this in other things. And they need not be harmful. But I usually refer to this really banal thing, that if I am having sandwiches for breakfast, then I can’t have ham on one, cheese on another, and liver pâté on a third. It messes with my brain. If I’m having cheese, then I have cheese. And I can eat it for three weeks on the go. That’s also part of being a dependent person. That we like patterns, we are consciously and unconsciously looking for patterns the whole time. (PDIP 1)

In their attempts to define this disease, the interviewees argued that the physical/biological dimension only constitutes one third of the disease while what they referred to as an “emotional disease” or “emotional disturbance” and a “spiritual” problem constituted two thirds of the disease. The latter dimensions are more deeply seated than the physical/biological dimension, which was expressed by one of the interviewees in the following way:

And at bottom it’s an emotional disease. I can of course drink myself into a chemical dependence. That I become like all shaky and have to have [a drink]. Or a drug, I have to have it, you know. But when I look behind this, then you have an emotional disease or an emotional disturbance, you could say. (PDIP 2)

Central to this emotional dimension is the notion of emotional trauma, often based on childhood experiences, that in a sense constitutes the self. Through the notion of emotional trauma, the interviewees are thus able to construct a history that explains how this “dependent person” has come to be.

According to the interviewees, the diseased person seeks to escape him/herself and the trauma that haunts him/her by consuming alcohol. However, this need to escape oneself is not necessarily restricted to people with alcohol problems; it could also be expressed through other behaviours or activities such as “gambling, sex, lying, shopping, sugar…pick whichever, it is only about not being with oneself” (PDIP 2). Thus, the disease is understood as being more complex than – and as expanding the boundaries of – a mere physical dependency on alcohol. As the theme of escaping oneself implies, this includes a problematic relation to oneself in which we find a split within the individual; a self which seeks to escape its “other”, with the latter being a product of emotional trauma.

Apart from this tripartite division along physical/emotional/spiritual dimensions that is found within the disease, the disease is also characterised by the fact that the diseased person is unaware of it and unable to confess to it:

What is most difficult is to confess that one is an alcoholic and that takes time. When you eventually join an association or something similar. You need help, you know. Simply confessing that you’re an alcoholic, no, that takes time. (PDIP 4)

During the interview, it became clear that the moment of confession is central to the establishment of a true relation to one’s self (cf. Foucault, 2002b). Confession enables the individual to take on a specific identity and it is through the act of confessing that individuals are able to overcome the split located within themselves. Hence, establishing a relation to the disease through confession in a sense means establishing a relation to oneself. What is interesting in this context is how the interviewees discussed the term “risky drinking” as constituting an obstacle to coming to a true understanding of the disease. For instance, in discussing “risky drinking”, one of the interviewees mentioned a treatment facility that provided treatment for “risky drinkers” in order to get them to moderate their drinking habits and to learn how to drink “socially”. The interviewees were highly sceptical of this:

PDIP 2: But they are today trying to treat him so that he moves away from [the risky drinking]. That they are leading a risky drinker to believe that they can teach risky drinkers to drink socially.

PDIP 3: Yeah, but that just isn’t possible.

PDIP 5: I don’t know how that would work.

The idea of risky drinking in many ways goes against the view held by the AA and Links movements, that alcoholism is a disease that requires total abstinence in order to overcome it (Kurube, 1997). In the interviewees’ accounts, therefore, “risky drinking” becomes part of the denial of the underlying problem and in a sense threatens the process of coming to a true understanding of the disease. This was stressed more emphatically in the interviewees’ discussion of the term “alcohol dependence” (with this discussion signalling an ambivalent relation to the term dependency, given that it has earlier been said to signify a disease):

PDIP 1: No, and I know many who, if I say dependency, then I am still running away from myself. I don’t really want to confess to what the problem is that I have. That’s roughly how I understand that word.

Interviewer: It’s like a little outside myself in some way.

PDIP 1: Yes, I can hear that sometimes when I’m at the treatment home and I’m supposed to tell my life story. Then some people are “yes, Kalle alcoholic” and “Bella alcoholic” and then someone sits there and squirms and says “yes, my name is Nisse and I’m dependent” (laughs). Well I’m also dependent on food, sleep and so on, but I’m an alcoholic. I have this disease.

Since the relationship between the individual and the disease is initially marked by denial, the act of confession becomes a difficult task. However, it is possible to gain true knowledge of the disease with the help of guidance, two types of which can be identified in the interviewees’ accounts.

The first involves various authoritative texts that provide the guidance needed to come to an understanding of one’s disease. Several of the interviewees had attempted to gain an understanding of their situation by reading books, and they sometimes even referred explicitly to various texts during the interview. For instance, PDIP 3 based her understanding of emotional trauma on having reading about it in a book on female alcoholism, while PDIP 2 had even brought a book published by AA to the interview situation. Although books offer authoritative explanations of the disease, they do not by themselves provide a true understanding of the phenomenon. What is needed is also a certain experience, partly provided by others who have managed to come to an understanding of the disease. This means engaging with a community that can offer guidance by sharing its experiences:

…the other thing was going to AA of course. […] It has given me the strength to move on. And that it is treatable, so when I came to AA, I listened to those who’d been sober for a while, the old ones who had experience, and like absorbed it. And that’s what we do at the Links too, of course. Also have meetings like that. So it’s like the treatment, that you’re with like-minded people…share experiences and, yeah. (PDIP 3)

In order to acquire the truth about this disease one has to experience it first-hand but one also needs guidance in order to be able to interpret it and come to a true understanding of this experience. This notion of experience simultaneously sets the limit for the possibility of “outsiders” being able to understand the underlying phenomenon. In this way, first-hand experience, coupled with the guidance of books and seniors, constitute a whole epistemology that provides the rules which one has to follow in order to come to a true understanding of the phenomenon. This provides the interviewees with a certain authority when they define it. Accordingly, they could claim that “if you have no experience of this thing we’re talking about, then I can read about it in a book, but I’m still not in contact with it” (PDIP 2). This reflects an understanding of the “problem” that has a long history. According to Kurube (1997), the Links movement was established in the 1930s and the 1940s as a reaction against the ideology of social engineering that sought to overcome social problems through the use of experts and scientists. Instead, the starting point for the Links movement was that the alcoholic person is the one who is in the best position to understand and remedy his or her problems.

Accordingly, in their accounts of the general population and of doctors, social workers and other professionals working within the field of substance use treatment, the interviewees were critical of how these groups understood the phenomenon. As one of the interviewees expressed it:

Yes, because if I think that a social worker with no experience of their own who hears alcoholism, yes, the individual needs to stop drinking. Check. I as an alcoholic think, yes that’s what’s primary. The first thing you need isn’t to put the top on the bottle, it’s to refrain from unscrewing it again. And then you need help with your emotional problems. Because if the person doesn’t get help to deal with that, then it’s soon back. (PDIP 1)

To sum up, the term “alcoholism”, and to some extent also the terms “alcohol misuse” and “alcohol dependency” served in this context as tools, with the help of which the interviewees, in Foucault’s (1990, p. 28) words, were able to “delimit” the part of themselves (the “disease”) that formed the object of their moral practices. The terms derived their meaning in relation to the underlying concept of “disease”, which was in turn related to an essential part of the self.

Practices of trustful communication

In the previous section we demonstrated how the terms derived their meaning in relation to a solid, underlying concept of disease. When the terms are located within practices of communication, however, their meaning is derived from somewhere else. In their accounts, the journalists and social workers construct a grid of different communicative positions within which meaning is negotiated. This practice thus aims to construct specific relationships between different parties that make possible certain forms of communication based on trust. This, in many ways, reflects the ethical frameworks within which these professionals act. As we will see, this entails an awareness of the possible connotations that certain words have and of certain considerations that have to be taken into account in order to establish the communicative relationship. In the journalists’ accounts, the establishment of a trustful communicative relationship also involves an interesting controlling “function” within the communicative process, whereby the interviewed journalists attempt to manage how meaning is created.

In terms of meaning, the terms were not fixed but rather (quite explicitly) treated as empty vessels, ready to be filled with meaning. This means that the terms acquire the meaning that, for example, an informant ascribes them, and the journalist’s task is to communicate this in an undistorted way. In this way, the journalists ascribe their informants (and as we will see below, the reader) the authority to define the terms. As one of the interviewees explained it:

It can be different for different people, I think. I mean, I think – that’s not the way you work as a journalist, I think…that you think like “this is what it is”; our job is rather to find out “what is it for the person you’re talking to at the time?” or the person who has done the research or whatever it is that it’s about. Our job is not to inform, it’s like, on the basis of our opinions, it’s like to communicate, report what someone else says, so what I think it is doesn’t matter…(JIP 4)

As the above quotation demonstrates, the journalists rarely start out with their own definitions of the terms but rather take on the definitions of their informants. This is partly linked to their work as journalists, where their role is to communicate the information provided by their informants without adding any of their own understandings to this process.

A similar way of relating to the meaning of the terms can be observed in the way social workers described relations between themselves and their clients:

SIP 1: when I meet the client, it’s not so important to me, if it’s a voluntary application, to define what it is and what it is not. In those cases, I instead listen to how the client defines it.

[…]

SIP 3: I agree with that. I think, it’s also…exactly, I mean, that you let the individuals themselves actually decide which words they use…

SIP 1: Exactly, yes.

SIP 3:…what they call it. And if they call it a dependency or alcohol misuse and so on, then I use that word when I need to name it, so to speak.

SIP 2: Responding to it, how does someone talk about their problem.

SIP 3: Hmm, or it might be called the craving. That they get to like choose the word.

The use of certain terms is linked to the ethical relationship established between the journalist/social worker and the informant/client. This means that the journalist/social worker does not wish to use loaded terms to categorise the informant/client but rather prefers to use the term that the informant/client uses to describe him/herself. For instance, one of the interviewed journalists discussed the problem of using the term “alcoholic” to “diagnose” an informant:

No, but it’s like…these things are also sensitive, you would never write that unless…I mean, you wouldn’t ascribe that to a person unless the person themselves – you would never as a reporter ascribe a diagnosis to someone if they like don’t say it themselves. That would be a major transgression. […]…and then if someone wants to include it in the story of their lives then – sure. But then it’s also important that you use the right term, so that the person feels ok with it. (JIP 4)

The social workers also see “labelling” their clients as a sensitive issue. They are aware of the differences in meaning that reside in everyday language and in the language used in scientific or medical practice. As SIP 6 described it:

SIP 6: The word misuse is more, in my mind, associated with a higher level of problems. And the word dependency is a scientific…I mean, so it’s more a, a diagnosis. But I don’t think that’s the way those who have this problem think, or other people. But on the basis of DSM-54 which nonetheless constitutes the basis for a lot, and you can think what you want about that, but anyway…breaking it down into different levels. For us who work with it professionally, I think it’s good. For the individual, I think it makes no difference, at least to begin with, because putting that kind of label on it is sensitive…But I have never heard [the term] risky drinking. That’s a new word, I have never heard it, that comb-, that combination.

The journalists’ accounts are grounded in an understanding of both the indeterminacy of words but also the potentially negative or positive connotations that words have. They are also aware that “people are so aware of the image of themselves and want to govern what is communicated” (JIP 2), and this is something they have to take into account in their ethically infused relationships with their informants. This entails an awareness of the mental “images” (JIP 2) or “associations” that are invoked by certain terms, and the contexts in which these terms are located.

Apart from the informant, the journalists often mention an implied reader to whom they ascribe such mental images. The conjuring up of an implied reader constitutes part of the journalists’ attempts to control the communicative process by anticipating the various images that might be associated with the terms. For JIP 2, for instance, the term “alcohol dependency” has less-negative connotations than “alcoholism”:

But it designates something that awakens a mass of images in people of course. I mean, that are, no, but, yes, I could talk more about that, but I think that…yes, so I also think that alcohol dependency is a way of being a bit milder there in some way…(JIP 2)

It seems, however, that determining which mental images or connotations certain words carry with them is dependent on the associations made by the journalists themselves. For instance, for JIP 3, the term “alcohol misuse” conveys a sense of social misery. By applying this term in a text “it maybe awakens, as was said, images in the reader, and then that’s, then you have to look at this so…so misuse, it’s a bit more like social misery”. JIP 1 and JIP 2 on the other hand, seemed to prefer this term since it connotes something less determining than the term alcoholism. In this case, the term seems to signify a form of drinking that situates the drinker in a “danger zone” from which it is possible to back away:

JIP 2:…I think I’ve written articles that, where it’s more been about, I mean articles that give a warning, I mean somewhere, there’s an undertone where I nonetheless try to use misuse more [than alcoholism], that word, so as not to turn readers off. So that people will understand that we have like, what is it, 10–20 percent who have, are in the danger zone. I mean, to try to involve the readers in the text and [get them] to decide to “do this”. So that there’s a pedagogic…

JIP 1: I agree with that.

As the above quotations demonstrate, the journalists are aware that certain words that carry negative associations might dissuade certain readers from reading the text. This leads the journalists to reflect on the various connotations that the terms might invoke as well as on the most strategic way to communicate their message.

A similar “tactic” is employed by the social workers. For instance, when interacting with the employers of their clients, the social workers refrained from using words such as “problems” and instead sought to formulate the issue in terms of people’s “relation to” alcohol:

Because relation, because it’s ok to use alcohol, so what does your relation to alcohol look like? I mean, it can also be an open question. On the basis, I mean, more that we talk like that. At least when we are talking with employers. And there of course it’s a lot on the basis of work environment problems or costs or, and I can hear how boring this sounds. But it’s a way in, to how you bring the employer on board (laughs). In some way. So it’s very much about different contexts. With the social services or the probation service, there you can communicate more directly and clearly. But in the other contexts, because of course there are enormous problems at our workplaces. (SIP 6)

To sum up, the journalists and the social workers considered the terms to be dependent on the various contexts in which they were used, ready to be filled with meaning and not attached to a single ontological ground. The terms rather acquired their meaning through fleeting associations and the “mental images” of the informants/clients and readers. The ethically informed relationship that is established between the informant/client and the interviewees, and the journalists’ need to control the communicative process, were central to how the different terms were or were not used.

Practices of administration

As the two previous sections have demonstrated, the definitions of the examined terms are highly dependent on the specific needs and considerations that arise within certain practices. In this final section of the analysis we will examine what we will call administrative practices. Such practices are centred around the practical administration of individuals, in this case within the context of substance use treatment and coercive care. These administrative practices consist in the categorising and sorting of individuals in order to be able to act upon them or to assign them to the appropriate location (cf. Foucault, 1977).

As Björk (2013) has demonstrated, practitioners working within the field of substance use treatment always need to handle and co-ordinate different “logics” (such as the “logic of care” and a “laboratory logic”) that are embedded in treatment practice. In the analysis below, we have sought to describe how this management of “logics” takes shape within the multiple relations between the social worker, the client, official treatment systems and juridical institutions.

In their discussions of their day-to-day activities, the social workers made a distinction between the relationship between themselves and their clients and the relationship between themselves and other official units within, e.g., the field of substance use treatment. As was demonstrated in the previous section, the relationship between the social worker and the client was established within practices of communication in which the clients were accorded the authority to define the terms used to describe their life situations. The social workers were highly aware of the possible negative connotations of certain terms. At the same time, they need to use some of these terms in their work, which gave rise to some reflection on the relationship between the role of the social worker, the client and the systems into which the client had to be integrated. SIP 5 was therefore anxious to emphasise that “[t]his is not about what I say to the clients, but it’s rather about misuse and so on, that is with regard to we who are working with it…”

As this quotation demonstrates, the social workers made a clear distinction between which terms should be used in their communication with their clients and which terms should be used in their communication with other official units. The social workers described the existence of this distinction as being a result of different “systems” that require certain terms in order to function as they do. Furthermore, another distinction is made between different systems at the official level. As SIP 2 explains:

…I mean, you need dependency in healthcare, because it’s a diagnosis and you have to make a diagnosis, you put it into the system. The LVM [coercive substance-misuse care] legislation talks about misuse. So we have systems that require those words, but in contrast so maybe we…if you work in healthcare or in the social services, I say “misuse”, you say “dependency”, and we may be talking about exactly the same situation and problem…(SIP 2)

As there is a need to assign the client to specific interventions (e.g., within treatment services or coercive care), this gives rise to a need to ground the terms in the language used within these “systems”. For instance, in their discussions of coercive care, the social workers drew on the definitions given in legal texts when seeking legitimacy for the decisions they made. As SIP 1 put it:

SIP 1: But specifically in, like I said before, in the LVM legislation, in the preparatory texts, it is stated fairly clearly and that is, of course, on a daily or almost daily basis, where it leads to major social, physical, psychological consequences. So there it’s a little better defined than in the SoL [social services] legislation.

[…]

SIP 1: But then I usually, I mean in the assessments, I motivate it with a reference to, I mean I have the preparatory text or summary of it, and like motivate why I assess it as ongoing misuse.

The substance use treatment services provided by the healthcare system, on the other hand, are grounded in a medical discourse and practice. For instance, the definition of the term alcohol dependency can be grounded in physiological processes which are possible to detect and monitor by means of laboratory tests:

While it is my experience that in healthcare, more that you have an alcohol dependency, because now we have given you tests for two months and there are high PEth (phosphatidylethanol)test values and for that reason it is this. And for the same reason, you belong here with us, I mean the dependency centre, otherwise they would not have been there. Because of course they should only have those with serious alcohol dependency, which they themselves…(SIP 1)

These medical definitions of the terms are also found in various diagnostic manuals. SIP 6, in a discussion of how social work has evolved over time, described how the practice of social work has changed from being based on the “social aspect” of various issues and was now moving “further and further into some other world, as a diagnosis” based on an understanding of the issue being located in the brain (see also the reference made by SIP 6 to the DSM in the previous section; American Psychiatric Association, 2013).

A problem emerges since the clients are given the authority to define the terms used to describe their life situations, whereas authoritative definitions of the terms used in substance use treatment are grounded in medical discourse and practice, and those of coercive care are grounded in legal discourse. This problem gives rise to a need for some translation. As SIP 2 explained:

SIP 2: But I think it’s also about, how do we use these words? I mean, do they have a meaning? And I can agree with you; in relation to the individual, when we can actually talk, they can define, but dependency is of course a diagnostic criterion, misuse is not a diagnostic criterion, so…there’s also that; what context am I in? How should I use it? And in healthcare, there you will probably always use the concept dependency because you have to apply a diagnosis because you take a person in…And misuse is used in LVM, but we could just as easily say…I mean someone can have an enormous dependency and social problems, and still say “it gets a bit out of hand sometimes”.

The social workers discussed the contingency of the examined terms and displayed a somewhat sceptical view of the need for exact definitions, instead arguing for a kind of contextual understanding of the phenomena they had to deal with. In their arguments they highlighted the impossibility of making hard distinctions between the various terms used to describe human behaviour, and instead promoted the use of broad descriptions that were better suited to capture the messy reality that they had to deal with:

SIP 1: So it’s there that I think that, that it’s not really possible. I think rather that, because maybe after a while that person may also be dependent, but also has a misuse, because it has such major consequences. But that it maybe isn’t primarily that; these words are constructed by people after all, the lines between them aren’t so definitive. And they maybe are not so important for us to [define], either.

To sum up, the social workers use different communicative strategies in their discussions with their clients as opposed to the official systems into which the clients are to be integrated. This is due to the need to establish a trustful relationship between the social worker and the client, while simultaneously meeting the administrative requirements of the official systems – such as treatment provision – which are based on a medical or a legal discourse.

Conclusion

In this article we have sought to examine how social workers, journalists and individuals who have experienced alcohol problems ascribe meaning to four terms denoting problematic drinking. In addition, and most importantly, we have aimed to examine how variations in the way the four terms are defined correspond to specific pragmatic needs that may arise in the context of different practices. To this end, we have conducted focus-group interviews with 15 individuals from the above-mentioned stakeholder groups. Our analysis of the interviews was guided by the following questions: (1) What meaning do the interviewees ascribe to the terms “alcoholism”, “alcohol dependence”, “alcohol misuse” and “risky drinking”? (2) What pragmatic needs do the specific definitions described by the interviewees correspond to? (3) How do the interviewees establish legitimacy in their definitions of these terms? In the section below, we will summarise and comment on some of the most important findings relating to these three questions.

When it comes to the meanings ascribed to the four terms, these proved to be both fixed and fluid. For the individuals with experience of alcohol problems, the four terms had more or less clear and fixed meanings and were related to the various practices through which these individuals sought to come to an understanding of themselves and their lives. The social workers and the journalists on the other hand saw the terms as being dependent upon context – as being fluid and imprecise. Rather than lamenting this lack of precision in the meaning of the terms, however, they developed various strategies in order to handle this fluidity.

Further, our analysis shows that the four terms fulfil very concrete and pragmatic needs arising within various practices. Thus, for instance, insisting on a specific definition of the term “alcoholism” as a disease is vital in practices in which individuals who have experienced alcohol problems seek to come to an understanding of themselves and their situation in life. Similarly, the ability to remain flexible in their usage of the terms makes it possible for journalists and social workers to establish trustful communicative relationships with others – it is a sign of professional commitment and of respect for the right of others to define themselves and their lives (cf. The Press Ombudsman, 2019; The Union for Professionals, 2019).

The flexible usage of the terms in communicative and administrative practices is in part indicative of the various positive and negative connotations that nevertheless seem to be attached to these terms – irrespective of whether or not these connotations are imagined. The journalists’ and social workers’ choices of one term over another within a specific context might therefore, for instance, be guided by the wish to avoid stigmatisation rather than by which term most faithfully adheres to a “true” definition. What is especially interesting in the context of our analysis, is that not only the descriptive, but also the normative content of the terms appears to be more or less fluid. For the interviewed individuals involved in “practices of self”, for instance, the terms “alcoholism” and “alcoholic” simply signify an underlying (neutral) disease. Accordingly, they use the terms as interpretative frames that allow them to come to an understanding of themselves without attaching any clear negative connotations or stigma to them. At the same time, the social workers and the journalists tread carefully around the terms “alcoholism” and “alcoholic” in order to avoid the negative connotations that they understand to be attached to them.

When it comes to the question of establishing legitimacy in the definitions of the terms, the informants referred to various different authorities. Thus, our analysis shows that while the interviewed individuals with experience of alcohol problems turned to a number of authoritative texts for guidance, and highlighted the importance of connecting to an interpretative framework shared by a community of individuals with first-hand experience of this disease, the journalists instead focused on what they understood to be the “sender” and the “receiver” of their message, and on their narrated and/or imagined definitions, understandings and interpretations of the contents of this message. While neither of these two groups of informants described any major clashes between different authorities with regard to the establishment of legitimacy in the definition of the four terms, this was certainly the case among the interviewed social workers. They recounted several difficulties that emerged when the mandate to define the terms employed in a particular practice-related situation was alternately given to different parties (the client, the healthcare substance use treatment system and the legal texts regulating coercive care). Here they identified collisions between the use of terminology in the communication with their clients (where definitions are generally fluid), and the terminology required for the functioning of official “systems” (in which the terms employed are characterised by more or less fixed definitions). In their professional work with clients, social workers seem to navigate by using a kind of knowledge whose aim is to facilitate communicating and interacting with individuals face to face (e.g., taking over and making use of the other individual’s understanding of the situation), whereas judicial and medical knowledge is required to control and explain social phenomena at the general level (e.g., by employing established scientific or legal terms with fixed definitions). In addition, our analysis shows that in the administrative practices associated with their work, the social workers also navigate between competing authorities linked to different forms of knowledge (cf. Abbott, 1988) by relating to one or other of the terms dependency (grounded in a medical discourse) and misuse (grounded in a legal discourse that regulates social work).

It seems, therefore, that the fluidity of the terms may in fact be rather beneficial in many instances, since the varying uses of the terms examined here enable different practices which are seen as important by the interviewees. Furthermore, for those worried about the problems that such fluidity might cause for the possibility of communicating on issues related to problematic drinking, it might be useful to clarify the practical context within which the terms are used in order to avoid confusion.

Footnotes

Acknowledgments

The authors wish to thank Eva Samuelsson, Jessica Storbjörk and Torkel Richert, as well as the journal editors and two anonymous reviewers for their valuable comments on an earlier draft of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is part of a larger project (funded by the Swedish Research Council, project number 2014-14224-111923-43) that explores historical and contemporary conceptions and definitions of problematic drinking. The project has been reviewed by the Ethical Review Board in Stockholm, Sweden (number 2016/256-31).

ORCID iD

Filip Roumeliotis

Notes

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