Regina Christiansen und Jakob Emiliusen
[Journal für Philosophie & Psychiatrie, July 2019, Original paper]
In the present paper we will introduce the concept alcohol problems (Alcohol Use Disorder) and the corresponding diagnostic criteria. Our aim is to cast a light on how different conceptions of problematic behavior and diagnoses, makes defining alcohol problems a problematic endeavor. “The diagnosis” is the elementary concept in clinical medicine and is the concept on which further analysis rests within this field. The philosopher Ludwig Wittgenstein offers a way to understand different perspectives on the concept of diagnosis. Wittgenstein’s theory on language games reveal to us something deeply central to how human beings use words to create meaning in their lives. Through Wittgenstein we come to realize how the language game of alcohol problems is by nature conflicting. We found there to be two overall language games concerning the definition of alcohol problems. One game which is concerned with the scientific factual investigation of alcohol problems and the second concurrent game surrounding the family and the individual which concerns values on alcohol use and misuse. Utilizing the same proposition across various language games concerning alcohol Problems means that the proposition comes to mean different things in different circumstances.
Key words: Alcohol Use Disorder, Philosophy, Diagnosis, Psychiatry, Concepts, Wittgenstein
Discussions on psychiatric diagnoses and their implications may have been present ever since the first systems of diagnoses were presented. Psychiatric diagnosis has been debated extensively over the years and it has been suggested that, in spite of psychiatry being highly dependent on diagnoses, these are both arbitrary and constructed (Rosenberg, 2006). These critiques were further developed by Poland and Eckardt (2015) who concluded that the DSM-IV lacked empirical, conceptual, and foundational adequacy. A common answer to any critique of the diagnostic systems (the IDC and the DSM) has been that the diagnoses are just provisional maps of the psychiatric territory (Rose, 2015) and that they serve clinical and practical purposes (Poland & Eckardt, 2015; Sinnott-Armstrong & Pickard, 2015). They are rough guidelines that are rarely used in clinical work (Rose, 2015).
In spite of the suggested inadequacies of the diagnostic systems, it is evident that diagnoses have implications for many parts of human life as they are also used in everyday talk outside psychiatry (Petersen, 2015). Diagnoses do not merely function as a communicative tool and identification of pathologies. They also often serve as access points for social benefits and tools for prioritizing in treatment and research etc. (Rose, 2015). What is essential to the present paper is that diagnosis are social phenomena and anchored in contemporary understanding of treatment of diseases (Rose, 2015). For the patients; psychiatric diagnoses can be stigmatized, and can cause to interpret symptoms in terms of blame or empathy, depending on the nature of the diagnosis (Rose, 2015). These considerations underline how diagnoses and definitions of problems are perceived differently by different actors in different fields.
Utilizing alcohol problems (Alcohol Use Disorder) as an exemplary case, the aim of the present paper is to cast a light on how different conceptions (everyday, professional, patient etc. interpretations) of problematic behavior and diagnoses makes defining alcohol problems a problematic endeavor. Psychiatric diagnoses have suffered from a lack of objective and generally accepted categories (Rosenberg, 2006), which makes them good exemplars for discussion. Focusing on alcohol problems is crucial as alcohol has been estimated to be the most harmful drug among most other drugs (Nutt, King, & Phillips, 2010), and harmful alcohol use leads to 3.3 million deaths worldwide every year (WHO, 2015). Further, “… drug and alcohol use represents [a] tenaciously contested occasion for debating the applicability and legitimacy of disease concepts.” (Rosenberg, 2006, p. 409). However, where Rosenberg (2006) and others have discussed the problems of diagnoses in terms of their permanency, specificity and their correspondence to something in the world/the human being, we wish to dive into what problems different peoples’ different conceptions of alcohol problems create and try to understand how the different definitions interact. However, we intend to go beyond the face-value statement that objective and subjective evaluations of alcohol problems create difficulties in comparison and discovery of problems, and look deeper into how the notion of language games, as defined in Wittgensteinian theory, can help us understand failures in communication concerning alcohol problems,
Definitions of alcohol problems
In the present paper, we employ the term ‘alcohol problems’ as a generalised term to include all levels and severities of alcohol overuse, misuse and diagnostic definitions. However, to provide a basis for our discussion of the interactions between definitions, we will make short introductions of the different definitions we debate in this paper.
ICD-10 and DSM-5: The ICD-10 differentiates between harmful use and dependence syndrome. Harmful use is defined as a pattern of use “… that is causing damage to health...” that can be both mental and physical (World Health Organization, 1992). Diagnosing harmful use “… requires that actual damage should have been caused to the mental or physical health of the user.” (Ibid). The dependence syndrome is characterized as a “… cluster of behavioural, cognitive, and physiological phenomena that develop after repeated substance use…” Ibid. The dependence syndrome is also described as including a strong desire to take the drug and disparate behaviours related to lack of control of drug intake and preoccupation with acquiring and taking the drug. To be diagnosed with alcohol dependence you must fulfil three or more of six criteria and the required criteria have to be fulfilled within one year.
The DSM-5 is different from the ICD-10 as it describes only Alcohol Use Disorder (AUD) as a general term and specifies severity ranging from Mild to Severe. Severity is scored on an eleven-point scale. Fulfilling two-three symptoms leads to a diagnosis of Mild AUD, whereas fulfilling six or more leads to a Severe diagnosis (NIAAA, 2016). As in the ICD-10, the 11 criteria reflect repeated use, continued drinking in spite of harm and craving symptoms.
Hence, the diagnostic systems define alcohol problems based on a set of behavioural and emotional, observable symptoms. It is important to realize that the diagnostic systems do not include an amount of alcohol consumed in their criteria. This is important as other conceptions of alcohol problems do use amount consumed as a measure for whether alcohol is a problem (see recommendations paragraph below).
Danish Health Authority Recommendations: In Denmark, and other countries such as the UK (National Health Services, 2017), there are guidelines on the recommended alcohol intake for adults. In Denmark the Danish Health Authority (DHA) states that no alcohol use is without risk and that the low-risk limits for alcohol intake is 7 standard drinks a week for women and 14 for men, but only five on one occasion. The high-risk limits are 14/21 (Sundhedsstyrelsen, 2016). The low-risk/high-risk definitions refer to the risk of adverse sequela health problems. In these terms, alcohol problems can be defined as an amount of alcohol drunk relative to the health-risk. However, it is important to realize that the recommendations from the DHA are not diagnostic criteria. The DHA defines an alcohol problem in relation to the increased risk of sequela. Hence, the recommendations from the DHA are not diagnostic criteria but they are still criteria to assess an alcohol intake by in terms of physical health.
Pragmatic definitions: In relation to what has been called the alcohol problem perspective – an integration of different models for understanding alcohol problems, Nielsen (2016) has attempted a pragmatic definition of alcohol problems stating that alcohol is a problem if someone is upset by its use. This definition is echoed by Becker (2016), who also states that the best “… definition of alcohol problems might be that you have an alcohol problem, if someone is upset by [your alcohol use]…” (our translation Becker, 2016, p. 33). In this definition, alcohol problems are defined in relation to social interaction and consequence.
The individual experience: As was pointed out by Nielsen (2003) problem drinking and alcohol abuse is not objective conditions, when you turn to the experiences of the individuals. In a recent study (Emiliussen, Andersen, & Nielsen, 2017a) it was found that the way older adults rarely define their alcohol use in relation to objective standards (like the criteria for diagnosis or the recommendations from the health authority) but seem to rely on subjective evaluations of the alcohol use and its influence on work and ability to take care of family, perceptions of getting drunk, comparisons to stereotypical drunkards, physical symptoms of alcohol overuse and how their social network reacts to the use of alcohol. Further, it seems that there can be certain discrepancies between the individual’s experience of alcohol use and the way in which family perceives the same alcohol use (Emiliussen, Andersen, & Nielsen, 2017b). Hence, there seem to be two subjective evaluations of when alcohol is a problem – one for the individual and one for the family.
We have identified four different ways to talk about alcohol problems in the above. One is in terms of diagnostic criteria, one is in terms of risks to physical health, and one is a pragmatic definition and the last is based on the individual experiences. It should be apparent here that the ways to talk about and define alcohol problems are multiple and have very different purposes and starting points. This invariably leads to interactions between the different ways in which the same term “alcohol problem” is used.
Wittgenstein’s approach to language
The discussion above involves the basic nature of diagnosis. “The diagnosis” is the elementary concept in clinical medicine and is the concept on which further analysis rests within this field. To offer a way to understand different perspectives on the concept of diagnosis, we take our departure in one of the most influential philosophers in the 20th century: Ludwig Wittgenstein. The approach in the present paper is based on Wittgenstein’s concept of form of life. With this concept he suggests that there is one fundamental form of life for all humans to participate in, however variation in human living give rise to differences in how this fundamental form of life is realized, resulting in various actual forms of life. According to Wittgenstein: when humans engage in life they interact with other humans through language as a speaking part of a form of life (O'Connor, 2016). Human being’s participation in language games are based in their form of life and their alcohol problems will be conceptualized in relation to this. Further, the objective of philosophy is to facilitate that human beings work with themselves in how they see things, interpret them and their expectations related to life. Philosophy is meant to help people find the right balance, simplicity, proportion and functionality, to ensure agreement in life and the interaction with other people (Wittgenstein, 1984).
Language as a tool
The work of the philosopher is, according to Wittgenstein, to free the human being from what he called the bewitched pictures, distorted conceptual conditions and absurd or unfounded expectations (Wittgenstein, 1961). According to Wittgenstein, we reach clarity of this by investigating our use of words. He did not believe that language represents a reality “out there”, but rather that language is a sort of tool embedded in all inter-human practices and for that reason language is ambiguous in its structure. Therefore, it defies simplicity and has a complexity that can make language difficult to survey (Wittgenstein, 1961). Human beings live in a world of language where they use words to do things. In addition, language has an influence on how people live and who they are. Wittgenstein believed that, if human beings want to change the way they interact with the world they must change the way in which they use words.
Wittgenstein introduces the theory of language games to be able to say something about how human beings use words to create meaning (Wittgenstein, 1963). Human beings use words in accordance with the expectations contained in the language game that they play with their surroundings in a certain context. Hence, words get their meaning by being used within the social practice that it is a part of. Further, Wittgenstein introduces the private language argument. Wittgenstein emphasize it is essential to concepts that they can be utilized right and wrong. Concepts which refer to some private objects are true to the person but not to others because there are no criteria for correct use, hence no right and wrong. (Wittgenstein, 1969).
Form of life
Wittgenstein’s intention is to show that speaking a language is part of an activity, a form of life that plays out. A human being can be involved in multiple ways of living (forms of life) that establishes different worldviews and these are not something humans construct themselves. In some respects, we do not equally share the same forms of life and this in turn leads to differences in the way we perceive the world and its meaning.
The way in which we communicate shows that human beings share some of the same understandings in everyday life – the concept of colors for instance. To know words is part of language and not something prior to language, as a logical necessity of language. Wittgenstein made a distinction between surface grammar and a depth grammar in human language, where surface grammar Wittgenstein refers to traditional grammar. In surface grammar focus is on the grammatical elements which guides correct and clear sentences. However, the main interest of Wittgenstein is with depth grammar which refers to the use of words in our everyday language, e.g. the circumstances in which we use words or expressions and how they are involved in certain activities. He argued that some language games might have a depth grammar that is distinct from its surface grammar (Wittgenstein, 1963). A language game can seem to involve empirical matters but beneath the surface the discussion is not empirical but conceptual. Mácha (2015) offers a way to interpret this concern of Wittgenstein.
Internal and external relations
Mácha argues that the distinction between surface and depth grammar concerns a distinction between internal and external relations contained in the use of language. In Wittgenstein’s early writings; internal relations only exist among tautologies. However, Mácha states how Wittgenstein argues that internal relations also can be exhibited in grammatical propositions in general in his later writings (Mácha, 2015). Grammatical propositions are to be understood as explicit statements of the grammar involved in a language game and in this way as descriptions of the human form of life. This distinction can help us realize where the troubles occur when human beings use concepts. Internal relations are an expression of the relationship between concepts, and are “timeless”, whereas external relations describe the relationship between objects and are “temporal”.
For Wittgenstein internal relations only exist between concepts. If internal relations exist between objects we must understand this as a description of objects through concepts (Mácha, 2015). Sometimes a circumstance or a situation is described by the same verbal presentation but uses both internal and external expressions about the same thing. Mácha gives the following example: You can say that two faces are alike. In the instance where you refer to two peoples’ faces being alike, it is an external sentence. The sentence is external because it describes two people, who can change their appearance and not be alike at later time. Contrary, if you are talking about the shape of the face, it is an internal sentence. When a sentence is internal, it is because you are referring to the shape of the faces, characterized by having the same descriptive elements: round or curvy; we can understand internal sentences without further descriptive elements (Mácha, 2015).
Furthermore, Wittgenstein pointed to the fact that uses of a word may vary and may not share a core meaning. Because of this, we cannot assume that one language game is more original or foundational than the other. To grasp this aspect, Wittgenstein introduces the concept of family resemblance to define what characterizes the relation between the meaning of words in different language games (Wittgenstein, 1963). He uses the example of a family, where all the children share some features, but where none look completely alike – there are different similarities between the children in different ways. In the same way, there is not one similarity that is the same for all language games: human beings can play many language games with all kinds of different similarities. This means that the use of a word often falls into several language games but serves different purposes within each language game. A word gets its meaning when used in language. Hence, it is necessary to put the word in the right context for to be able to understand the specific word. This presupposes insight into what language game is being used in a specific context and means that there is a risk of not using the right language game when communicating because of our different forms of life. The language may be at risk of distorting reality through use of concepts. In the words of Wittgenstein, human nature and interaction can be bewitched by our uses of words. Wittgenstein wants to aid in lifting the spell, for human beings to be able to see the world in another way (Wittgenstein, 1969).
This figure illustrates how a language game concerning ‘alcohol problem” are entangled with each other. It further illustrates how forms of life overlap one another and thus obscures the use of the term ‘alcohol problem’.
If we look at the different definitions of the term “alcohol problems”, clarified in the beginning of the present paper, in the light of Wittgenstein’s theory on language games, we come to realize that the central term “alcohol problems” are embedded in different language games played by different parties. Even, if language serves as to bridge in interpersonal relations, various language games may make this interaction a field of conflict. The family resemblance between the different uses of the term “alcohol problem” can be analysed through the concept of form of life and grammar of language. When different parties communicate about “alcohol problems” they enter the language game as a part of an activity; where some parts of various forms of life are shared by all parties. However, because of diversity and variation among humans depending on socio-cultural matters or e.g. educational background we come to realize various forms of life. When the parties experience variations in forms of life when communicating about “alcohol problems” conflict may appear. Hence the person experiencing AUD might frame some aspects of treatment differently than the caretaker because they don’t fully share the same form of life but manage to bridge their communication in language game. Moreover, the grammar of the language can be from the perspective of science surface grammar. However, for the individual and her family the depth grammar of their language game will be involved. Even distinct grammar might be involved between an individual with alcohol problems and an individual without alcohol problems because their difference in form of life.
It is important to realize that there seem to be several forms of life involved in defining alcohol problems (see figure 1). One is concerned with the scientific factual investigation of alcohol problems and is partly concerned with uncovering and categorising the alcohol problem, to be able to react descriptively, preventively or with treatment measures. The second (the personal relations) is the form of life of the family and the individual and concerns their interaction regarding values on alcohol use and misuse. The form of life of the family deals with suffering in the form of the concerns brought on by the individuals’ use of alcohol. The third form of life is that of the individual is concerned with a dichotomy between the individuals’ need or craving for drinking and the responsibility towards their loved ones. This means, that even if there are family resemblances between peoples uses of ‘alcohol problems’ and their interaction in the language game concerning AUD, they still frame aspects of AUD differently based on the certainties which are most in accordance with their form of life. This is so, even while believing they take part in the same activity; speaking of alcohol problem.
In the recommendations concerning alcohol use, the term alcohol problem can be used to describe a situation where somebody drinks too much (too many litres/units of alcohol). Oppositely, diagnosis is concerned with categorising alcohol problems based on a given behaviour. In the DSM and ICD there is no mention of the number of drinks, but only references to behaviour and consequences. This underlines that, even though both language games are concerned with alcohol problems, they employ different frameworks for dealing with the same term. The DSM is concerned with the discovery of an alcohol problem, whereas the recommendations are concerned with the maintenance of good health. The pragmatic definition is purely based on a form of life concerning the social-cultural impact, whereas the DSM is also concerned with other consequences of alcohol use.
Science describes different ways in which alcohol problems can be defined. This may seem unproblematic as the main concern for treatment is to identify if there is a perceived problem. However, looking at the relations among different players on the science part we come to realize that a scientific approach e in general involves a risk of detaching the individual because of a lack of understanding of the individual’s way to conceptualize the term alcohol problem.
There are, naturally, other forms of life that could have been relevant for the present investigation such as how alcohol problems are framed and conceptualized in policies, religion and the wider society (and different societies). However, we are not trying to find out how many different conceptualizations there is of alcohol problems, we are merely trying to point out that there are different conceptualizations. The point is to make clear that different conceptualizations of the “same” term leads to incompatibilities within the “activity” of trying to relief the suffering of the individual experiencing AUD.
There is another question that can be posed when looking at variations within forms of life: when is alcohol a problem and for whom? The Wittgensteinian breakdown of the definitions of alcohol problems illuminates the problems inherent in the definitions. The definitions employ different cut-off criteria. And these criteria can and will be interpreted differently.
The problem is that each party assume they have a shared understanding about the meaning of the concept of alcohol problems on a conceptual level. However, when we use the concept in practice, where the shared understanding must lead to an action, the differences comes apparent. We talk differently about a situation or a series of circumstances. When relating this to the definitions of alcohol problems, it becomes apparent that there are many overlapping circumstances between the individual definitions. However, the concept of alcohol problem is used differently within every definition, because the context in which the language is used is different even though it is the same thing that is talked about.
When relating the distinction between internal and external relations to the concept of alcohol problems, we can highlight problems inherited within the different definitions. For example, in the proposition “harmful use and dependence syndrome” (parts of the recommendations and diagnostic language games) the two parts “harmful use” and “dependence syndrome” have an internal relation even though the proposition is external. The concepts have an internal relation because “harmful use” is a concept that is a symptom of having an alcohol problem and “dependence syndrome” is a description of the behavior of the alcohol problem; both here belong to the definition of an alcohol problem. The proposition is externally defined because the meaning of the concepts is not written within the concepts themselves but needs further criteria to be explained. The external criteria that can be used to explain the two concepts are: amount of alcohol consumed, health related consequences, craving etc. However, there can be multiple other criteria through which ‘harmful use’ comes to mean something different in the future than today. This means that further research probably will lead to other distinct criteria different from the ones we use today to define “harmful use” and “dependence syndrome”. Additionally, this shows that the language game is always changing in relation to research, which can change our concepts and bring external relations into question.
Generally, propositions regarding mental illnesses have external relations and not internal relations. There are no symptoms of mental illnesses that can be described in the same timeless fashion as in Máchas’ example with the two round faces. Sometimes the propositions concerning mental illnesses contain relations between concepts as the example above regarding harmful use and dependence syndrome. In other instances, there are relations between objects and concepts as e.g. 7/14 recommendations of the Danish Health Authorities. When the proposition contains an object rather than just concepts, it is easier for human beings to relate. When communicating on physical illnesses we can more easily follow the line of reasoning because of external criteria however they are not based on relations between concepts only. This underlines that mental illnesses cannot be described or talked about in the same way as physical illnesses.
When actors are initiated into a language game, they sometimes use the same concepts and they believe they are talking about the same meaning of a concept. But Wittgenstein shows us, that external relations cannot stand alone, but must be explained through further concepts as for human beings to arrive at the same meaning of a concept. This type of sentence is temporal because the language game it is a part of may change over time. The individual and their relatives risk coming into conflict with the alcohol treatment department because the concepts the clinicians use are inherited from science. In some cases, the concepts of alcohol problems stated in one language game can be far from the concept that is employed by the individual using alcohol (to a problematic degree). Hence, the verbal or written expression of the concept might be similar, but there are significant problems in relating the concept from one language game to another. As mentioned earlier, it seems that the use of language in the science language games mainly uses factual terms – external relations. Oppositely, the individual and their families’ language is based on concepts concerning values and experiences which is defined in terms of internal sentences. Hence, this shows that one sentence can be used to describe the same situation but in two different ways. Mácha (2015) further argue that the reason for this confusion is that on one hand one may be interested in the specific objects in a situation and the relation among them (external relations). On the other hand, one may be interested i the properties of the objects and their relation to describe the situation (internal relations) One situation concerning alcohol problems can be stated in various ways. However, we often assume that we mean the same. Consequently, we think we agree upon a concept as “alcohol problems”. However, inherited in this specific “activity” are various forms of life where facts or sentences used fall between different frameworks. This may imply the interaction between patient, relatives and caretakers is conflicting in nature and hence they will meet difficulties in moving towards profound solutions for getting patients into treatment or succeed in Treatment.
The present paper has been an exploration of different definitions of alcohol problems. We have attempted to move beyond the surface objective-subjective evaluation of alcohol problems and have looked at how the term appears in number of different language games and that this seem to give rise to some difficulties in defining alcohol problems between different parties. Wittgenstein helps us realize that the language game concerning alcohol problems is not limited to one fundamental form of life for all humans but also inherited in forms of life which is conflicting in nature because of socio-cultural issues. Thus, utilizing the same term across different practices and backgrounds gives the term different meanings to the participants in the language game. Further, different frameworks for facts also risk obscuring the clarity of the scientific approach to alcohol problems. We believe, that the discussion concerning alcohol problems serves as an exemplary of how language games concerning mental illnesses lead to vastly different evaluation of the same proposition. Clinically, this may lead to pronounced difficulties in both problem self-discovery and professional elucidation of alcohol problems.
The writers have received unconditional funding from the Lundbeck Foundation, the Region of Southern Denmark and the University of Southern Denmark, while writing this paper.
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Information about the authors:
Regina Christiansen and Jakob Emiliussen
The Unit for Clinical Alcohol Research,
University of Southern Denmark
J.B. Winsløws Vej 18, Entrance 220B,