What is alcohol use disorder?

Caring for a loved one with a drinking problem is challenge. While voicing concerns might be difficult, it takes time and patience to help someone realize they might suffer from a problem with drinking. Baylor College of Medicine experts Drs. Coreen Domingo and Thomas Kosten explain alcohol use disorder and how to help others.  

Q: What is alcoholism?
A: “Alcoholism” is a commonly used term, but healthcare professionals now generally use the term alcohol use disorder (AUD) because it is less stigmatizing and more accurately reflects a chronic medical condition influenced by a combination of genetics, environment, social and psychological stressors.

A diagnosis of AUD is not a matter of lack of willpower and can affect anyone regardless of age, education, income or background. It exists on a spectrum ranging from mild to severe and is not based solely on the amount of alcohol a person consumes, but whether alcohol use is causing problems or impairing functioning in key areas of life, such as personal relationships, work, health status and everyday responsibilities. In simple terms, AUD is characterized by difficulty controlling alcohol use despite experiencing negative consequences.

Q: What are signs that someone you love might suffer from AUD?
A: The signs are not always obvious, especially in the early stages. Those with AUD tend to hide as well as minimize their drinking behaviors, which can make it challenging for loved ones to recognize not only that a problem exists, but also the extent of it. Some common warning signs include:

• Physical signs: Slurred speech, impaired physical coordination, memory lapses or blackouts, disrupted sleep patterns and frequent hangovers.
• Changes in mood and behavior: Becoming defensive about their alcohol use, increased withdrawal, irritability and mood swings, neglecting personal and work responsibilities, increased conflicts with family and friends, financial problems related to drinking and continuing to drink despite negative repercussions.
• Changes in drinking behavior: Drinking alone or in secret, drinking more often or more heavily than before, hiding stashes of alcohol and needing increasing amounts of alcohol to achieve the same effect.

Q: If you think a loved one is drinking too much, how should you approach the subject?
A: Assuming a nonjudgmental and supportive stance tends to be more effective than a confrontational demeanor. Choose a space that is neutral and non-triggering and a time when the individual is sober is essential. As tempting as it might be to criticize or shame, don’t. Instead of statements like, “You’re an alcoholic and you need to admit it,” or “If you really loved me, you’d stop drinking,” use “I” statements. “I” statements focus on specific observations and their impact:

“I’ve noticed that you seem really stressed lately, and I’m concerned about you.”

“I know you’ve wanted to cut back, and I can see that it’s been difficult. I’m concerned and want to support you.”

“I’m worried about how alcohol is affecting our relationship and our family. Maybe we can talk to someone about it?”

People are more receptive when they feel supported rather than judged.

Q: How and when should you suggest getting help?
A: Excessive drinking to the point of exerting a deleterious effect on an individual’s health and wellbeing, social and occupational relationships, finances and safety suggests the need to seek professional help. Focus on encouraging rather than pressuring engagement with care since treatment tends to be more successful when it is voluntarily sought. Assume a supportive rather than judgmental stance: “Would you be willing to talk with someone about this? You don’t have to do this alone.”

There are a myriad of outpatient, inpatient, as well as partial hospitalization programs, and services that are generally covered – although to varying degree – by insurance plans, including Medicare and Medicaid. There also are community-based resources like Alcoholics Anonymous (AA) and Al-Anon with meetings in multiple languages available across the country and internationally.

Q: What can you do to help as a loved one?
A: Remain supportive. But being supportive also means setting healthy boundaries so you don’t inadvertently become part of the problem by enabling and excusing drinking behaviors.

Do: Listen without judgement, encourage treatment, offer practical support, and acknowledge and celebrate positive steps.

Don’t: Lie or make excuses to protect them from natural consequences of their behavior (such as calling in sick for them to their employer). Don’t try to control their drinking by hiding alcohol as this breeds resentment and secrecy. Don’t give ultimatums (like threatening to leave if they don’t stop drinking) unless you plan to follow through. Don’t compromise your safety, emotional wellbeing or financial stability by rearranging your entire life around their behavior. Restructuring your life around another person is neither healthy nor sustainable.

Q: What if they are not receptive?
A: Being receptive implies an awareness of their drinking as problematic and a willingness and capacity to address it. For many individuals with AUD, that awareness is compromised. Wanting them to be in a different space because you want change does not make it so. Be realistic, stay calm and avoid arguing because you will be baited as they test limits. Be respectful of their autonomy while expressing concern and importantly, maintain healthy boundaries. Sometimes, it’s a matter of allowing them to experience the discomfort of their choices without trying to fix it. Navigating this discomfort can create a space where true healing and recovery can begin.

Q: When should you stop trying to help?
A: Understanding the difference between helping someone and trying to control their choices or behaviors is essential when caring for someone with an AUD diagnosis. It is time to step back and reassess if that support is exacting a toll on your own wellbeing and your safety is in jeopardy; the relationship has become abusive or you have become part of the problem by rescuing, covering up and enabling to the detriment of yourself and others. Taking care of yourself is not giving up on someone else. It is recognizing that you cannot control or dictate someone else’s behavior.

Important but often overlooked points when someone you care for is challenged with AUD:

• You didn’t cause the problem. You can’t control it. You can’t cure it, and you are not responsible for fixing it. Only they can do that, and it will only happen when they are ready.
• Treatment works, recovery is possible and relapses can occur but that does not negate progress made. With support, the relapse can be no more than a blip in the overall recovery cycle.
• Families and loved ones need support as well as part of the overall paradigm of care.

Coreen Domingo is an assistant professor in the Menninger Department of Psychiatry and Behavioral Sciences. Thomas Kosten is a professor and director of the division of Alcoholism and Addictive Disorders in the Menninger Department of Psychiatry and Behavioral Sciences.

By Homa Warren