Issues in Mental Health Nursing, 35:588–596, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2013.879357

Experiences of Everyday Life in Men with Alcohol Dependency—A Qualitative Study Anna Maria Thurang, PhD, RN Center for Dependency Disorder, Stockholm, Sweden

Tom Palmstierna, MD, PhD Karolinska Insitute, Social and Forensic Psychiatry Programme, Stockholm, Sweden

Anita Bengtsson Tops, RN, PhD Kristianstad University, Health & Social Sciences, Kristianstad, Sweden

The aim of the present study is to describe and understand the meaning of living with alcohol dependency (AD) as a man. Studies point out a high prevalence of AD in men and the reasons for, and consequences of, that are complex. However, today there is a lack of knowledge about men’s lived experiences of having AD. Indepth interviews were conducted with 15 alcohol dependent men and analyzed using a phenomenological-hermeneutic approach. In the comprehensive understanding, findings from the na¨ıve understanding and the structural analysis were interpreted with help from both gender and caring theoretical perspectives. “A Fallible Man” and “A Man with Powerfulness” were disclosed as two main gender formations influencing senses of well-being. A Fallible Man involved varying experiences of restrictions, being in control, and meaninglessness. Being in control promoted a sense of well-being. A Man with Powerfulness involved energetic activity, and the development and maintaining of interests as well as risk-taking. Being powerful diminished feelings of meaninglessness, cravings, and social alienation. The results show, among other things, that the men live an incompatible life and, because of that, need support and guidance to find a more meaningful life. This can be accomplished if caregivers allow men to be in focus and involved in planning their own care. To avoid limiting the men while they are in treatment, the health care professionals also need to focus on the men’s everyday life. This focus involves acknowledging the men’s individual experiences of what enriches and limits their everyday lives.

In many societies drinking alcohol is often a mark of leisure, pleasure, and reward, but the consumption of alcohol is increasing the world over (Ramstedt, 2010; Rehm, Mathers, & Popova, 2009) and, from that, alcohol dependency (AD) is also increasing. According to the Diagnostic and Statistical Manual for Mental Disorders (DSM; American Psychiatric Association [APA], 2000) a diagnosis of AD is given to individuals who have

Address correspondence to Anna Maria Thurang, Center for Dependency Disorder, Stockholm County Council, Box 179 14, Stockholm, SE-118 95 Sweden. E-mail: [email protected]

developed tolerance to alcohol, experience withdrawal symptoms, demonstrate a loss of control over alcohol intake, and show unsuccessful efforts to cut down intake. Previous research has singled out AD as a risk factor for both physical and psychiatric health problems, such as heart disease, diabetes, dementia, and aggressive behaviors (Brien, Ronksley, Turner, Mukamal, & Ghali, 2011; Roerecke & Rehm, 2010; Schomerus et al., 2011). In general population studies it has been found that men, compared to women, consume alcohol more frequently as well as consume more alcohol (Wilsnack, Wilsnack, Kristjanson, Vogeltanz-Holm, & Gmel, 2009). It also has been found that men with AD, compared to non-addictive men, more often lose work hours (Lemke, Schutte, Brennan, & Moos, 2008; Rahav, Wilsnack, Bloomfield, Gmel, & Kuntsche, 2006), take part in crime (Hagg˚ard-Grann, Hallqvist, Langstrom, & Moller, 2006), and become perpetrators of domestic violence (Cooper, 2000; Hirschel, Hutchison, & Shaw, 2010); these all cause an increased cost for society (Rehm et al., 2009). It may, therefore, be suggested that AD in men is both a health and societal problem. The reasons for high consumption rates of alcohol in men are probably complex and interwoven, involving interplays among physical, psychological, and social aspects of life (Andersson, ¨ Johansson, Berglund, & Ojehagen, 2007; Wilsnack et al., 2009). For example, it has been proclaimed that consuming alcohol in the Western world is associated with performing masculinity (Eriksen, 1999; Iwamoto, Cheng, Lee, Takamatsu, & Gordon, 2011) and, according to gender theorists, problematic drinking may be related to norms of performing masculinity (Lemle & Mishkind, 1989; Mahalik, Burns, & Syzdek, 2007). According to Connell (2007), performing masculinity takes place in a situation where individual, societal, cultural, and economical aspects of life meet and fall together. Additionally, performing masculinity is an ongoing process involving creation and recreation of positions and formations of masculinity both between and within individuals (Connell, 2007).

588

589

EVERYDAY LIFE IN MEN WITH ALCOHOL DEPENDENCY

With regard to professional nursing, the primary goals are to meet the patients’ general and specific needs, encourage their sense of well-being, and relieve suffering (Eriksson, 2006; Healey-Ogden & Austin, 2010; Morse, 2001). The understanding of the patients’ own experiences of everyday life is, therefore, of importance (Dahlberg, Dahlberg, & Nystr¨om, 2008; Morse, Bottorff, Anderson, O’Brien, & Solberg, 1992; Todres, Galvin, & Dahlberg, 2007). In the research area of alcohol and substance abuse, the importance of focusing on the patients’ lived experiences of suffering from a diagnosis of dependency disorder (Kearney, 1998; Jacobsson, Hensing, & Spak, 2008; Smith, 1998) as well as gender aspects of this experience (Hensing & Spak, 2009; Rolfe, Orford, & Dalton, 2009; Tuchman, 2010) have been stressed. There is an increasing interest in understanding factors that enhance the quality of life during recovery, although limited research has been conducted in the field (Best, Savic, Beckwith, Honor, Karpusheff, & Lubman, 2013). Therefore the aim of the present study was to describe and understand the meaning of living with AD as a man. METHODS The study is qualitative and exploratory in nature and founded in a reflective life world perspective. To grasp the phenomenon under investigation, a phenomenological-hermeneutic method was chosen. A phenomenological-hermeneutic approach aims to illuminate the meanings of the phenomenon (Lindseth & Norberg, 2004). The method was inspired by the French philosopher Ricoeur (1993) who assumed that lived experiences can never be fully understood by another. However, the meaning of the experience may be understood and become public by means of interpretation. Further, Ricoeur (1993) states that the utterance meaning of a phenomenon always has its roots in a concrete lived situation and only can be illuminated in relation to its context. Participants Fifteen men with AD participated in the study. The inclusion criteria for participating were being a male diagnosed with AD according to the DSM (APA, 2000) without any comorbidity with regard to severe mental illness or other substance use disorders. All participants were in treatment for AD and checked by their respective psychiatrist to ensure that the inclusion criteria were met. Participants were thus purposefully selected (Polit & Beck, 2008) but also strategically selected since they came from eight various outpatient units in a geographic metropolitan area of Sweden. Outpatient units located in suburbs and the inner city are represented. The background characteristics of the men are presented in Table 1. The men were middle aged, and most of them lived alone in independent housing. Nine of the men at the time of their interviews were employed in the private sector. Half of the men had suffered from AD for more than ten years and one of them only for one year.

TABLE 1 Background Characteristics of the 15 Participants Variable Age (mean) Marital status Married/cohabitant Divorced Children Living at home Living conditions Independent living Shelter Income source Working in private sector Disability pension Retirement Unemployment benefit Education University Vocational/senior high Elementary (9 years) Sick-leave due to AD Years with AD (median) Length in treatment for AD (median) Number of relapses during current period of treatment

Number 50 years (range from 37–70 years) 5 10 8 3 14 1 9 (out of which 2 had retirement pensions) 1 3 4 3 10 2 7 10 (1–20) 12 months (range 14 days– more than 10 years) 6 (2 participants were in relapse)

Note: AD = Alcohol dependence.

Data Collection Data were collected by the first author through open, indepth, interviews (Kvale, 1997). The first ten interviews covered two main phenomena (i.e., the experiences of living with AD and being professionally cared for). In order to ensure deepness and richness of meaning in relation to the phenomenon under investigation, five more men were strategically selected using the inclusion criteria. All men were initially asked in the interview to narrate about a regular day in their life, as sober or intoxicated with alcohol. The men’s narratives were followed up by means of questions such as: “How do you mean?” “What did you feel?” and “Please, can you tell me more about that?” The interviews lasted between 30 and 120 minutes, and took place according to the men’s wishes in a room at their respective outpatient facility. All interviews were digitally recorded and transcribed verbatim into a text.

590

A. M. THURANG ET AL.

Data Analysis Data were analyzed by means of a phenomenologicalhermeneutic analysis model (Lindseth & Norberg, 2004). Initially all the transcribed interviews were subject to a na¨ıve reading. Thus, each interview was read several times, in an attempt to gain an initial and overarching understanding of the phenomenon (i.e., living as a man with AD). A short summary for each interview, including key points, was then written down. These summaries were put together, abstracted, and written down as a na¨ıve understanding of the phenomenon. In the next phase of the analysis process, a structural analysis of the interviews was performed. The interview text was divided into meaning units, comprising one or more sentences, a part of a sentence, or words that captured key meanings in relation to the phenomenon under investigation. The meaning units were then concentrated into condensations including the main core of the meaning units. The condensations were reflected upon and compared across all interviews, looking for similarities and differences. The condensations were further abstracted into subthemes and themes (cf., Lindseth & Norberg, 2004) (see Table 2). The themes and subthemes were compared with the na¨ıve understanding to achieve validation. The steps of the structural analysis resulting in meaning units, condensations, subthemes and themes are presented in Table 3. During the structural analyses the meaning units become de-contextualized from the text as a whole and the condensed meaning unit was reflected upon independently of contextual aspects. In the final phase of data analysis, and in accordance to a phenomenological-hermeneutic analysis model, a comprehensive understanding of the findings in na¨ıve understanding and structural analysis was performed. In the comprehensive understanding, findings were interpreted using theories of nursing and gender as well as previous research. Through the interpretation process, the meanings of the phenomenon under investigation were deepened and broadened (Ricoeur, 1993). During all stages of the analyses, the authors regularly questioned and reflected on their pre-understanding and scrutinized tentative findings in relation to the raw data material, previous work, and other life experiences.

TABLE 2 Overview of the Themes and Subthemes Being Restricted Living an Incompatible Life Managing Life

Being encapsulated Having a shrunken life Being a stranger to oneself Being troublesome Doing activities Being in control

Ethical Considerations and Approval All participants were informed that participation was voluntary. Verbal and written informed consent was obtained from all participants before interviews took place. The study was approved by the regional ethics committee. RESULTS Na¨ıve Understanding The meaning of living with AD as a man was understood as involving limitations in everyday life that stopped the men from fulfilling life goals and dreams. It was understood that life was circumscribed. It made the men unable to live life to the fullest. Living with AD was further understood as a life in conflict with one’s own and other’s value systems. A life in conflict became evident when, for example, the men could not live up to what they considered social duties, such as caring for close ones. Living with AD was understood as being a disappointment to others. It also was understood as a life full of exposure to risks that challenged health; social relationships; and the borders of bodily capabilities, weakness, and strength. It was further understood as a life in activity. Being active kept the men occupied and released them from feelings of restlessness, boredom, and craving. Additionally, living with AD was understood as a life in control, involving control instilled by others or by themselves. Being in control, including following the advice and demands of others, logical planning of daily activities, and setting short-term goals, made life easier. Structural Analysis The structural analysis revealed three overall themes: (1) Being Restricted, (2) Living an Incompatible Life, and (3) Managing Life. Each theme had two subthemes and both the themes and subthemes are discussed below. Being Restricted Living with AD as a man meant Being Restricted, which was signified by the subthemes, Being Encapsulated and Having a Shrunken Life. Being Encapsulated meant being enclosed by walls of insatiable desire for alcohol or restricting the same desires. It included being fixed in a frame of contradictions involving the alcohol’s seductiveness in relation to feelings of relaxation and its physically demanding side effects, as well as the necessity of practicing self-discipline. The wife came home with two bottles of white wine and put them in the fridge. She drank half, and thought that this is the end when I come home from work. But it was not. I think it’s a hell of a victory [to abstain]. This was a personal victory. And it was then that I actually made the decision that this stuff can go to hell. . . . I saw it [that I drank too much], but not logically. I could not say to myself, “You’re an idiot if you go to buy beer.” I did it, but it was not me who did it. It was the alcohol dependency that did it. (Participant 4b)

591

EVERYDAY LIFE IN MEN WITH ALCOHOL DEPENDENCY

TABLE 3 Example of the Structural Analysis of Themes Occurring in the Alcohol Dependent Men’s Narratives Meaning Unit

Condensation

Subtheme

So that the days then are quite the same they are All days are alike and gray, do not Having a quite gray. I do nothing or something like that, do anything special. No social shrunken life huh, I like. I’m not particularly, I’m not life—everything has shrunk to particularly, I live, no real social life, eh, almost nothing everything there has shrunk to almost nothing. You are ashamed, they are an embarrassment [to Feel shame and embarrassment. Being a stranger be diagnosed with AD], again a little bit from The picture of how an alcoholic to oneself the picture we have of alcoholics, the addicts. is—do not want to be associated You think of yourself like the first team on the with it, or see myself as part of it park bench. No part of the population is eager to be associated with or see himself as part of them. My brother phoned me, the great and powerful in Help brother when he is sick. Being in control the family, and needed my blood, he had cancer. Forced to pull myself together. He, who has never drunk or smoked or Cut down to be sober when anything. His wife and children were helping him completely devastated. I was forced to shape up. It was no race or anything. I went down [scaled down drinking] a bit and a bit more. I was sober before I met him. I was sober for five, six, weeks each time we met at the hospital

In periods of drinking alcohol, the men experienced being absorbed by thoughts of how to get access to enough alcohol, where and when to drink it, and how to best avoid withdrawal symptoms, such as anxiety, tremors, and sweating. In periods of soberness, the men experienced being occupied by thoughts of how to handle their cravings, how to procrastinate until the time at which they would start drinking again, and how to maintain their abilities and skills that allowed them to perform in their ordinary life. Being Encapsulated was experienced as being drained of energy and having feelings of exhaustion appear.

Theme Being restricted

Living an incompatible life

Managing life

a little. So she said, “You can only handle two beers and stay with it, then it’s okay.” (Participant 4b)

Being restricted also meant Having a Shrunken Life. Having a Shrunken Life concerned losing opportunities for personal development and social status. For example, this was experienced when the men became unable to work or couldn’t pursue their life goals, plans, or dreams. Having a Shrunken Life was experienced as coming closer to a mediocre level of life.

Trying to cope, it’s partly about the psyche and then comes the physical side, you become so damn tired in the body that you have to fight to get up in the morning, you struggle to make breakfast, you struggle to move on, to be positive, you are completely without energy. (Participant 4a)

At the start, I was a star attorney and worked at the largest, finest, offices and worked around the clock . . . I’ve lowered my level of ambition from being the best in the world to being good enough, you can say. (Participant 4l)

Being Encapsulated also meant having experiences of being segregated, of not being a part of, or the same as, others and being deprived of positive reinforcement. For example, this feeling of being segregated was experienced when the opportunity to drink alcohol for pleasure and leisure was taken from them. Being Encapsulated also referred to a loss of freedom and spontaneity and was experienced when, for example, being told what to do by their wife, children, or friends.

Having a Shrunken Life also meant shrinking back to one’s shell and living a socially isolated and humdrum life. The result of this was a life of emptiness and meaninglessness. Having a Shrunken Life was experienced as having the blues, being in sorrow, or having a gray, monotonous, and boring everyday life.

My wife drinks. She does not want to see me as a teetotaler, if you know what I mean. That would disturb relations with acquaintances

So that the days, then, are quite the same. They are quite gray. Huh, I do nothing, or something like that, huh. I, like, I’m not particularly, I’m not particularly, I live, no real social life. Eh, everything there has shrunk to almost nothing. (Participant 4e)

592

A. M. THURANG ET AL.

Living an Incompatible Life Living with AD as a man meant an Living an Incompatible Life and was signified by the themes Being a Stranger to Oneself and Being Troublesome. Being a Stranger to Oneself meant that the men were leading a life not in accordance with their own norms and values. This involved a feeling of inconsistency regarding their inner subjective wants and their actual concrete behaviors. Being a Stranger to Oneself was experienced as incomprehensible, especially in moments or situations when cravings for alcohol took over their daily scheduled practical plans. When you approach by car [the liquor store on the way home], then the exit is there and then the force [craving] becomes unbearable a hundred meters from the exit and it has won. Then, the brain has become empty, the alcohol has won. So you step into the liquor store and buy and it’s as if you are radar guided. . . . It’s like a cruise missile that is headed for a goal. (Participant 4a)

Being a Stranger to Oneself also meant that these men questioned the way their life was led when addicted to alcohol. It involved a cracked identity and was experienced when, among other things, the men were told they had a diagnosis of AD by a professional caregiver, but could not identify with this category using their own imaginations. You are ashamed, it is an embarrassment [to be diagnosed with AD], again a little bit from the picture we have of alcoholics, the addicts. You think of yourself like the first team on the park bench. No part of the population is eager to be associated with or see himself as part of them. (Participant 4g)

An incompatible life also meant Being Troublesome. It meant putting relationships at stake and taking the risk of being abandoned by close ones when being ruthless, egoistic, or scheming in their pursuit or intake of alcohol. For I have told her [the wife]: “You have filed for divorce, I will not sign.” . . . Yeah, I’ve been there before, then she has not had any financial responsibility for me. I was supposed to take care of myself entirely. I should have paid half the rent, half the loan, all half. And I only have my unemployment benefit, but she has her pay. So she could walk away and have a good time now and I just sit there. (Participant 4b)

Being Troublesome was especially experienced when the men’s craving for alcohol was put first, instead of listening to their close one’s wishes and demands. Being Troublesome meant being a disappointment to others. It was experienced as following impulses regardless of whether these impulses were in conflict with their own or others’ expectations, for example, when agreements or commitments were broken. We [me and the kids] were to go sailing in the archipelago and have a few nice days. Then my daughter called and said, “Dad the commuter train is a bit difficult so we can’t arrive until an hour after we had planned.” I was already finished with the boat, everything was packed. Then I thought, like lightning, for it was a sunny day this late in the summer, perfect for being out in the archipelago and the whole thing. Then I thought about open fires, guitar playing, swimming in the sea, and fishing, and all that shit and I got the

feeling for a few beers. So I went up and bought ten beers . . . then I called for a mate, we drove straight up to town, and we dropped the children off after they arrived by train. I told them it was wrong of me to drink beer but it does not work to go out sailing and drinking beer, and that we can sail another time. (Participant 4j)

For these men, Being Troublesome meant subjecting themselves and others to risk. It was manifested when, for example, driving while drunk, exposing themselves to physical injury, or ignoring self-care when recovering from severe physical illness. Then the hospital, I lie there for a week [with myocardial infarction], the same day I am sent home, I go out and get a drink. Direct and just bang it turns black. So it took well 20 hours until I managed to get as much in me so that it slapped in my heart again. (Participant 4n)

Being Troublesome also referred to a downshift in social status and was experienced as not being a valuable part of society when, for example, these men lost their job after mismanaging work. Managing Life Living with AD as a man meant Managing Life. Managing Life was signified by the themes Doing Activities and Being in Control. Doing Activities meant doing the rational work of suppressing strenuous emotions such as cravings, boredom, anxiety, and restlessness. Just now, I don’t have that planned or the urge to leave [and drink alcohol] [Interviewer: What do you do instead?]. I have so much to do. I’m renovating a house that I live in, a lot of auctions, and I’m fixing up old cars, and I have a dog. It was important to get a dog. It can, it can probably be recommended to people. Then there’s someone to look after. (Participant 4c)

Doing Activities led to a sense of freedom. Doing Activities in periods of soberness brought thoughts of self-degradations, blame, and regrets. But, Doing Activities in periods of drinking made life more enjoyable, aroused, and unrestricted. Time passes very quickly, you cannot believe it can go as fast as that and then you drink more than you had planned. . . . You do what you think is the most fun and nothing else. (Participant 4k)

Doing Activities could imply, among other things, skipping social responsibilities related to close ones or work and going for an unplanned vacation trip. Doing Activities involved enrichment and stimulation in everyday life as well as resuming old interests and exploring new pleasurable activities. Doing Activities by themselves or together with others was experienced as satisfying and made the men feel at peace. Being in Control meant mastering oneself. For the men, it involved deciding, on their own, when to have periods of drunkenness and soberness. It was experienced as being able to make their own determinations that would then have an impact on their own life or the lives of others. It meant being someone on which others could rely.

EVERYDAY LIFE IN MEN WITH ALCOHOL DEPENDENCY My brother phoned me, the great and powerful in the family, and needed my blood, he had cancer. He, who has never drunk or smoked or anything. His wife and children were completely devastated. I was forced to shape up. It was no race or anything, I went down a bit [scaled down drinking] and a bit more. I was sober before I met him. I was sober for five–six weeks each time we met at the hospital. (Participant 4j)

Being in Control also meant balancing life. It concerned weighing capacity and incapacity, and strength and weakness against each other, and searching for moderate levels of how to live a life. I have not changed my habits, it is clearly about going down to the pub and sitting down with mates who sit and drink beer whenever you get tempted all the time, so to speak. I mean, like on Wednesday last week, when I thought all right, let’s see, I’ll go down and see if I can do this and I did. Then on Thursday, I managed it better [to be with friends]. (Participant 4b)

Regardless of whether the men were sober or drunk, Being in Control was experienced as being in tune with daily life. It meant taking part and following others’ directives, advice, and demands. Being in Control meant trusting others—relatives or drinking fellows—to stay with them at times when the men’s own capacity of control had diminished. When this kind of direction came from family members, it was experienced as supportive. My sister told me she didn’t want me to drink. I had to choose whether I would meet him [my nephew]. He is everything to me since I have no children of my own. So I’m looking for help then instead, trying to get away from this. (Participant 4i)

Comprehensive Understanding In order to deepen our understanding what it means to live with AD as a man, findings from the na¨ıve and structural analysis are interpreted primarily in relation to a gender perspective (Connell, 2007). However, the gender perspective focuses on the human being as an unstable entity and proclaims that gender formations or positions are continuously performed in the interplay among situational, environmental, and individual factors (Connell, 2007). In the present study, the gender perspective is a support to deepen the interpretation by illuminating the context in which the men with AD live. Two main gender formations related to aspects of the men’s well-being and suffering come to light in the comprehensive understanding of the phenomenon Living with AD as a Man. The gender formations were labelled, A Fallible Man and A Man with Powerfulness. These influenced the men’s sense of well-being or suffering in positive or negative ways. In the following text each gender formation is illuminated under separate headings. A Fallible Man The gender formation of A Fallible Man assigns to the men’s narrations of being imperfect and living a life that is defective. According to the na¨ıve understanding and the structural analysis, life was full of limitations, restrictions, and feelings of

593

being encapsulated and segregated. Their lives were shrunken. Ricoeur (1986) noted that being limited in life is synonymous with fallibility, thus man’s degree of being is his experienced quantity of being. In the present study, the men experienced being limited in everyday life by their AD, but they also described having a free and spontaneous social life, which decreased the men’s ability to fulfill life goals and important projects. The gender formation of A Fallible Man also came out when the men narrated about living an incompatible life. Their life is unreliable, fraudulent and, to some extent, fictive since it is a life not in line with their own norms and value systems. The gender formation of A Fallible Man also assigns feelings of social degradation to the men when they are not able to live up to demands in their social relationships and achieve increased social status. Being A Fallible Man implied making adaptations in order to live a mediocre life instead of finding ways to live life to the fullest and being the best. This is not in conjunction with what Connell and Messerschmidt (2005) label as hegemonic masculinity, meaning the ideal masculinity, indicating successfulness related to life goals, powerfulness, being self-decisive, and being alert to challenging and extending emotional and physical limitations. Hegemonic masculinity represent a traditional pattern of masculinity in the Western world (Meuser, 2003) and not being able to fulfill common norms of masculinity may lessen men’s sense of being (Connell, 2007). Not being able to fulfill social commitments due to an illness or disorder is thought to negatively one’s sense of well-being and may hinder processes of health promotion (Eriksson, 2006). In the present study, the gender formation of A Fallible Man indicated loss of freedom, melancholy, and social isolation. These findings are supported by Ricoeur’s (1986) analysis of existential negation, which states that fallibility first appears as an inequality between the man and the other, and then the man experiences an inequality from himself within himself. This feeling interiorizes and occupies the man with sadness (Ricoeur, 1986). The gender formation of A Fallible Man may be understood as the interplay among the physical sensations of being AD (e.g., cravings and symptoms of withdrawal), existential dilemmas, and a sense of being deviant. A Fallible Man also can be understood as a gender formation of subordinate masculinity in relation to the hegemonic ideal of masculinity. According to Coles (2008), being aware of needing to adhere to subordinated masculinities may result in a sense of social alienation or, on the other hand, in developing male features that reduce feelings of subordination. In the present study, the men, for example, executed self-control and did activities that resumed old interests, which reduced their feelings of being deviant. A Man with Powerfulness The gender formation of A Man with Powerfulness considers the men’s narrations of their proneness to be energetic and forceful in doing activities. According to the findings, in na¨ıve understanding and in all the themes in the structural analyses, it was shown that the men were energetic and active in finding

594

A. M. THURANG ET AL.

behaviors and strategies for best sustaining or giving in to their cravings. Also, when trying to manage life, the men worked at re-starting old activities of interest or finding new ones. Being energetic and forceful in doing activities and having a “can do” attitude have been proposed as positive and resourceful representations of masculinity (Levant, 2008). A Man with Powerfulness also may be understood as a gender position attributed to the men’s trait of being grandiose when, for example, the men were being troublesome to others by doing what they wanted, breaking promises, suppressing the needs of close ones, and executing power in social relationships. These behaviors may, according to a stereotype of masculinity, be interpreted as dominating behaviors (Mankowski & Maton, 2010). They also may be understood as the men’s inability or unwillingness to see others as vulnerable. Courtenay (2000) states that demonstrating powerfulness in terms of domination has its pros and cons: It involves a risk of being abandoned and, at the same time, offers the opportunity to be considered a man by those in the social environment. In contrast to gender formation, A Man with Powerfulness also accepts letting others control him or give him directions in situations when he could not master his own behavior. By doing this, he may jeopardize his ability to live up to a hegemonic masculinity. DISCUSSION Men living with AD were found, in the present study, to have a complex life that involved varying degrees of restriction, control, and activation as well as conflict related to their own and others’ value systems and demands. This lif involved feelings of meaninglessness, breaking boundaries, sparking feelings of freedom, and wielding power. In the comprehensive understanding, men living with AD were understood A Fallible Man and A Man with Powerfulness. These two gender formations are not necessarily contradictions of each other; instead, they are expressions for interlacing processes when constructing the everyday life. According to Connell (2007), construction of masculinity is a dynamic, situational act that mirrors the interplay of individual, social, and cultural aspects of life and gives room for different formations of masculinity to occur within the same individual, sometimes at the same time. The findings in the current study illuminate that the men felt circumscribed to a gray everyday life, involving struggles with emotional and existential aspects of life, and leading to experiences of being restricted and having life become meaningless. According to a salutogenetic perspective (Antonovsky, 2005), meaninglessness is related to having a worse sense of well-being and health. Previous studies have pointed out that people suffering from AD report a great deal of negative mood in their life, involving social and emotional stressors (Lemke et al., 2008; Mueller, Degen, Petitjean, Wiesbeck, & Walter, 2009). The findings in the present study indicate that by doing activities, the men promoted feelings of well-being and alleviated suffering in their everyday life. According to Ricoeur (1986),

men project meanings of life outside of the self in different activities to bring sense and meaningfulness to their life. Being active, whether sober or drunk, gave the men meaning in life. A recent study found that a sense of meaning in life is a central part of the recovery process in individuals suffering from substance dependency disorders (Wiklund, 2008). Furthermore, it has been pointed out that men suffering from AD felt they were being cared for when professionals gave them room to actively combat temptations of alcohol and to expand the life sphere themselves (Thurang, Rydstr¨om, Bengtsson-Tops, 2011). However, the findings in the present study also show that the men’s activities sometimes led to trouble and jeopardized both their social relationships and physical health. These findings support results in previous studies that showed that men with AD take risks and neglect health-related problems (Bloomfield, Gmel, & Wilsnack, 2006; Schomerus et al., 2011). These findings also are supported by Ricoeur (1986), who reports that in the occasion of being fallible, man can become evil when he questions his own capacity of what it means to be a man in the eyes of others and in the eyes of himself. These findings can be compared to earlier studies on women with AD who, instead of being outward looking, became introverted in a way that was both self-destructive and nurturing for the women (Kearney, 1998; Thurang & Bengtsson-Tops, 2013). Another finding in the present study was that executing power in terms of controlling oneself or others made the men’s life manageable. Wiklund (2008) pointed out that in order to make the life comprehensible and manageable, individuals suffering from substance dependency need to have their life under control in the recovery process. Exercising self-control is connected to power and is a part of the hegemonic masculinity (Connell, 2007). However, in the present study, it also was found that the men needed to be controlled by others in order to experience the life as manageable, a finding that breaks with the ideal of hegemonic masculinity.

Conclusion and Clinical Implications Living with AD constitutes a sense of vulnerability and strength as well as a need to be in control and have power. Doing activities and being in control gave meaning to life and made it more manageable. The result of the present study may give caregivers and policymakers more understanding and knowledge about what it means to live as a man with AD. The results show, among other things, that these men live an incompatible life and, because of that, need support and guidance to find a more meaningful life. This can be accomplished if the caregiver allows the men to be the focus of care and involves them in planning their own care. To avoid limiting the men while they are in treatment, health care professionals also need to focus on the men’s everyday life. This focus involves acknowledging the men’s individual experiences of what enriches and limits their everyday lives.

EVERYDAY LIFE IN MEN WITH ALCOHOL DEPENDENCY

Methodological Considerations The study used a qualitative design, including a small sample of men with AD. Claims of generalizability ought to, therefore, be made with caution. All participants were purposefully and strategically selected and came from various outpatient settings that provide care to individuals with AD. The data analysis was made independently by the authors. These procedures strengthen the trustworthiness of the results (Polit & Beck 2008). Patients admitted to hospital settings or individuals who selfheal from AD were not included, which might, to some extent, create limitations related to the issue of representativeness. Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. ¨ Andersson, C., Johansson, K., Berglund, M., & Ojehagen A. (2007). Alcohol involvement in Swedish university freshmen related to gender, age, serious relationship, and family history of alcohol problems. Alcohol & Alcoholism, 42(5), 448–455. doi: 10.1093/alcalc/agm008 Antonovsky, A. (2005) H¨alsans mysterium. [The mystery of the health.] Stockholm, Sweden: Natur och Kultur. Best, D., Savic, M., Beckwith, M., Honor, S., Karpusheff, J., Lubman, D. I. (2013). The role of abstinence and activity in the quality of life of drug users engaged in treatment. Journal of Substance Abuse Treatment, 45(3) 273–279. doi: 10.1016/j.jsat.2013.02.010 Bloomfield, K., Gmel, G., & Wilsnack, S. (2006). Introduction to special issue: Gender, culture and alcohol problems: A multi-national study. Alcohol & Alcoholism, 41(1), i3–i7. Brien, S. E., Ronksley, P. E., Turner, B. J., Mukamal, K. J., & Ghali, W. A. (2011). Effect of alcohol consumption on biological markers associated with risk of coronary heart disease: Systematic review and meta-analysis of interventional studies. British Medical Journal, 342(7795), 480–494. doi: 10.1136/bmj.d636 Coles, T. (2008). Finding space in the field of masculinity: Lived experiences of men’s masculinities. Journal of Sociology, 44, 233–248. Connell, R. W. (2007). Masculinities. Cambridge, UK: Polity. Connell, R. W., & Messerschmidt, J. (2005). Hegemonic masculinity: Rethinking the concept. Gender Society, 19, 829–859. doi: 10.1177/0891243205278639 Cooper, D. (2000). Alcohol use. Abingdon, England: Radcliffe Medical Press. Courtenay, W. H. (2000). Constructions of masculinity and their influence on men’s well-being. A theory of gender and health. Social Science & Medicine, 50, 1385–1401. doi: 10.1016/S0277-9536(99)00390-1 Dahlberg, K., Dahlberg, H., & Nystr¨om, M. (2008). Reflective lifeworld research. Lund, Switzerland: Studentlitteratur. Eriksen, S. (1999). Alcohol as a gender symbol. Scandinavian Journal of History, 24, 45–73. Eriksson, K. (2006). The suffering human being. Chicago, IL: Nordic Studies Press. Hagg˚ard-Grann, U., Hallqvist, J., Langstrom, N., & Moller, J. (2006). The role of alcohol and drugs in triggering criminal violence: A case-crossover study. Addiction, 101, 100–108. doi: 10.1111/j.1360-0443.2005.01293.x Healey-Ogden, M. J., & Austin, W. J. (2010). Uncovering the lived experience of well-being. Qualitative Health Research, 21(1), 85–96. doi: 10.1177/1049732310379113

595

Hensing, G., & Spak, F. (2009). Psycho-social aspects supplement. Introduction: Gendering sociocultural alcohol and drug research. Alcohol & Alcoholism, 44(6), 602–606. doi: 10.1093/alcalc/agp073 Hirschel, D., Hutchison, I., & Shaw, M. (2010). The interrelationship between substance abuse and the likelihood of arrest, conviction, and re-offending in cases of intimate partner violence. Journal of Family Violence. 25(1), 81–90, 94. doi: 10.1007/s10896-009-9272-1 Iwamoto, D. K., Cheng, A., Lee, C. S, Takamatsu, S., & Gordon, D. (2011). “Man-ing up and getting drunk: The role of masculine norms, alcohol intoxication and alcohol-related problems among college men. Addictive Behaviors, 36, 906–911. doi: 10.1016/j.addbeh.2011.04.005 Jakobsson, A., Hensing, G., & Spak, F. (2008). The role of gendered conceptions in treatment seeking for alcohol problems. Scandinavian Journal of Caring Sciences, 22(2), 196–202. doi: 10.1111/j.1471-6712.2007.00513 Kearney, M. H. (1998). Truthful self-nurturing: A grounded formal theory of women’s addiction recovery. Qualitative Health Research, 8, 495–512. doi: 10.1177/104973239800800405 Kvale, S. (1997). Den kvalitativa forskningsintervjun. [The qualitative research interview.] Lund, Switzerland: Studentlitteratur. Lemke, S., Schutte K. K., Brennan, P. L., & Moos, R. H. (2008). Gender differences in social influences and stressors linked to increased drinking. Journal of Studies on Alcohol and Drugs, 69, 659–702. Lemle, R., & Mishkin, M. E. (1989). Alcohol and masculinity. Journal of Substance Abuse Treatment, 6(4), 213–222. Levant, R. F. (2008). How do we understand masculinity? An editorial. Psychology of Men & Masculinity, 9(1), 1–4. Lindseth, A., & Norberg, A. (2004). A phenomenological hermeneutical method for nursing researching lived experience. Scandinavian Journal of Caring Sciences, 18, 145–153. Mahalik, J. R., Burns, S. M., & Syzdek, M. (2007). Masculinity and perceived normative health behaviours as predictors of men‘s health behaviours. Social Science and Medicine, 64, 2201–2209. doi: 10.1016/j.socscimed.2007.02.035 Mankowski, E., & Maton, K. (2010). A community psychology of men and masculinity: Historical and conceptual review. American Journal of Community Psychology, 45(1–2), 73–86. Meuser, M. (2003). Modernized masculinities? Continuities, challenges and changes in men’s lives. In S. Ervø & T. Johansson (Eds.), Among men: Moulding masculinities (vol. 1, pp. 127–148). Burlington, VT: Ashgate. Morse J. (2001) Toward a praxis theory of suffering. Advanced Nursing Science, 24(1), 47–59. Morse, J., Bottorff, J., Anderson, G., O’Brien, B., & Solberg, S. (1992). Beyond empathy: Expanding expressions of caring. Journal of Advanced Nursing, 17, 809–821. Mueller, S. E., Degen, B., Petitjean, S., Wiesbeck, G. A., & Walter, M. (2009). Gender differences in interpersonal problems of alcohol-dependent patients and healthy controls. International Journal of Environmental Research and Public Health, 6(12), 3010–3022. Polit, D., & Beck, C. T. (2008). Nursing research. Philadelphia, PA: Lippincott Williams & Wilkins. Rahav, G., Wilsnack, R., Bloomfield, K., Gmel, G., & Kuntsche, S. (2006). The influence of societal level factors on men’s and women’s alcohol consumption and alcohol problems. Alcohol and Alcoholism, 41(1), 47–45. Ramstedt, M. (2010). Change and stability? Trends in alcohol consumption, harms and policy: Sweden 1990–2010. Nordic Studies on Alcohol and Drugs, 27, 409–423. Rehm, J., Mathers, C., & Popova, S. (2009). Global burden of disease and injury and economic cost attribute to alcohol use and alcohol-use disorders. Lancet, 373, 2223–2233. doi: 10.1016/S0140-6736(09)60746-7 Ricoeur, P. (1986). Fallible man. New York, NY: Fordham University Press. Ricoeur, P. (1993). Fr˚an text till handling. [From text to action.] Stock¨ holm/Stehag, Sweden: Brutus Ostlings Bokf¨orlag. Roerecke, M., & Rehm, J. (2010). Irregular heavy drinking occasions and risk of ischemic heart disease: A systematic review and meta-analysis. American Journal of Epidemiology, 171, 633–644. doi: 10.1093/aje/kwp451.

596

A. M. THURANG ET AL.

Rolfe, A., Orford, J., & Dalton, S. (2009). Women, alcohol and femininity: A discourse analysis of women heavy drinkers’ accounts. Journal of Health Psychology, 14, 326–335. doi: 10.1177/1359105308100217 Schomerus, G., Lucht, M., Holzinger, A., Matschinger, H., Carta, M. G., & Angermeyer M. C. (2011). The stigma of alcohol dependency compared with other mental disorders: A review of population studies. Alcohol & Alcoholism, 46(2), 105–112. doi: 10.1093/alcalc/agq089 Smith, B. (1998). The problem drinker’s lived experience of suffering: An exploration using hermeneutic phenomenology. Journal of Advanced Nursing, 27, 213–222. Thurang, A., & Bengtsson-Tops, A. (2013). Living an unstable everyday life while attempting to perform normality—the meaning of living as an alcoholdependent woman. Journal of Clinical Nursing, 22(3–4), 423–433. doi: 10.1111/j.1365-2702.2012.04293.x Thurang, A., Rydstr¨om, J., & Bengtsson-Tops, A. (2011). Being in a safe haven and struggling against alcohol dependency. The meaning of caring for male

patients in advanced addiction nursing. Issues in Mental Health Nursing, 32(7), 401–407. doi: 10.3109/01612840.2011.553345 Todres, L., Galvin, K., & Dahlberg, K. (2007). Lifeworld-led healthcare: Revisiting a humanising philosophy that integrates emerging trends. Medicine, Health Care and Philosophy, 10, 53–63. Tuchman, E. (2010). Women and addiction: The importance of gender issues in substance abuse research. Journal of Addictive Diseases, 29, 127–138. doi: 10.1080/10550881003684582 Wiklund, L. (2008). Existential aspects of living with addiction—Part II. Caring needs. A hermeneutic expansion of qualitative findings. Journal of Clinical Nursing, 17, 2435–2443. doi: 10.1111/j.1365-2702.2008.02357. x Wilsnack, R., Wilsnack, S., Kristjanson, A., Vogeltanz-Holm, N., & Gmel, G. (2009). Gender and alcohol consumption: Patterns from the multinational GENACIS project. Addiction, 104, 1487–1500. doi: 10.1111/j.13600443.2009.02696.x

Copyright of Issues in Mental Health Nursing is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.