CNSforum The Lundbeck Institute

When a Man Loves a Woman - The true story about the Green family

(See also what the International Movie Database says about When a Man Loves a Woman)

Please note: This article may spoil your spontaneous enjoyment of the film. A number of significant events are revealed, so if you want to watch the film without preconceptions, we advise you to read the article after watching the film.

"When a Man Loves a Woman" is about an airline pilot, Andy Garcia, and his wife, Meg Ryan and how they are forced to face the consequences of her alcoholism when her addiction threatens her life and their daughter's safety. While the wife enters detox, her husband must face the truth of his enabling behaviour.

By Dr Göran Nordström, Senior Physician

When a man loves a woman

The true story about the Green family

There are scenes in Luis Mandoki’s film "When a Man Loves a Woman" which, to put it mildly, are not that convincing. Yet, it would be a pity if some of the scenes made some people switch off because the film is better than that. As it turns out, this is not so much a sickly-sweet film, but one based on an essentially tragic theme. But watch the film first and then read this article afterwards. The film is not full of thrill, but gives us material for us to research its various underlying themes.

So why a Hollywood film about alcoholism? If you look through the list of films made by director Mandoki prior to and after "When a Man Loves a Woman", there is nothing to suggest an interest in alcoholism or social problems in general. The fact that the film company signed up Meg Ryan (who had previously starred in the blockbuster "Sleepless in Seattle"), Andy Garcia ("The Godfather") as well as Ellen Burstyn in an important supporting role suggests this was a major venture with a large budget.

This usually means that the film company is expecting a box-office hit which usually tantamount to a film with a message that is neither too complicated, nor too controversial. With a dutifully charming Meg Ryan and a stylish Andy Garcia, it should of course be reasonable to produce a film with a sufficiently shocking and yet sufficiently sweet story. In line with the standard Hollywood genre an uplifting end has to be added, even if the subject matter is alcoholism.

So you should go and see the film. It is about Alice Green (Meg Ryan), who is married to the handsome and reliable pilot, Michael (Andy Garcia). She has two sweet children who together with Michael live in a beautiful house in San Francisco. Nevertheless, she drinks too much. Why? The emptiness behind the idyllic facade? Far too many lonely evenings when her pilot husband is away working? Problems she has been dealing with dating back to her past?

Her mother's attitude towards her has never been good for her self-esteem. Her father drank and there are other problems. Furthermore Alice’s oldest daughter is from a previous relationship, and the girl’s father only gets in touch with her now and again.

The film deals with a young woman who, deeply unsure of her worth, ends up using alcohol as a means of escape. This is how alcoholics manage to keep a grip, however, there is a big risk that the alcohol will take over like it does with Alice in the film. Her husband, Michael, is possibly part of the problem because he fixes everything and, more often than not, smoothes everything out with his pleasant behaviour. It is possible that he somehow condones her reckless behaviour when she is intoxicated. Gradually, the problem becomes impossible to manage even with the occasional extra help from the nanny. Alice is admitted to a rehab centre where she confronts her relationship with alcohol on the basis of the twelve-step model.

She and Michael attend counselling as a couple and things do not go well at all. Michael has difficulty finding his role when Alice abandons her alcoholic behaviour. With the help of AA and the support of other alcoholics, Alice manages to regain her self-respect.

"The film, about Alice's path out of abuse, deals with a young woman who, deeply unsure of her worth, ends up using alcohol as a means of escape"

Central to the change in Alice is the fact that she becomes more serious and more competent. She stops using jokes or her attractive smile in order to deal with difficult situations. The final scene shows how Alice, in a humble and balanced way, talks about herself and her alcoholism in front of other AA members and their relatives. Furthermore, Michael, who as a result of problems in the marriage temporarily moves out of the home, attends and listens as well. The film ends more or less as it starts, with a tender kiss between Alice and Michael, right in the midst of the people around them.

It has a classic comedy-drama ending where our heroes have been tested, they have changed, and are now able to embark on their future life stronger, thanks to the insights they have gained.

During their journey, we have been able to witness a lot of what the everyday reality of alcohol dependence looks like. Heavy drinking. The highs. Shame. Emotional outbursts. Relations that break down. One deception after another. At the same time, the alcohol abuser may come across as someone who is normal, well presented and nice. It you look through the list of symptoms of dependence in ICD or DSM you will se that most symptoms are neatly and realistically personified in "When a Man Loves a Woman”.

The shame is even greater if you are an alcoholic and a woman since it can often be the case that specially formulated approaches are required to help women suffering from alcohol problems. Read Agneta Österling’s highly informative contribution further down! If treatment for alcohol abuse is initiated in time, there are grounds for optimism because there are good, validated methods out there - both pharmacological and psychosocial which you can read more about this in Lars Schultz and Bengt Sternebring’s articles!

But let’s get back to the film. The similarity between the closing scene, after Alice's speech at the meeting, and the opening scene, where they are having lunch in a café, opens up another perspective, different to the one I gave at the beginning. In the opening scene, Alice and Michael are engaged in some kind of role play in front of a public audience. They appear as if they do not know one another. Michael strikes up a conversation with Alice and manages (so it seems to the amazed clientele in the café) to enchant Alice with his words, so much so that she instantly flings herself into his arms. Again, in the closing scene, Michael does exactly the same thing! He has listened to Alice. He goes up to her. And then he starts to talk about his wife who is an alcoholic, but who has 600 ways of smiling which make him melt …

"The shame is even greater if you are an alcoholic and a woman"

So he talks to Alice about his wife – as if is was not one and the same person. This is the same trick used at the café where they have lunch similar to a teenage game, a secret that just the two of them share.

As the film progresses, Michael goes through various phases. As enabler, as failed family father, as potentially supplanted spouse (Alice has close contact with a man from the treatment centre, played by a young Philip Seymor Hoffman), as separated father of his children. But does he learn anything? Or is his verbal magic in the closing scene a sign that he is back where the film started?

He draws a veritable smokescreen over reality and we are led to believe that everything is well again. If you see the film from this perspective it is less clear whether Alice's and Michael's tender kiss in the closing scene is a happy ending. Does Michael actually want to have a wife who has left all her delusory antics behind her? Or is it the case that the enabler is laying the ground for a relapse?

I think that there are many of you who will recognise aspects of Michael's behaviour in relatives or in one or more patients suffering from lifestyle problems. It is easy to feel sympathetic and to have understanding, but nevertheless you sometimes wonder whether there is anything attractive about being the stronger party.

The film about Michael shows, among other things, that the desire for change – so clearly expressed, so visibly obvious – does not always manifest itself in the way people really act. His is a more disturbing tale than the one about Alice, and a story which highlights why it is sometimes the case that the whole "family unit" – patterns of communication, the balance of power – must be included in the treatment if you really want to get anywhere.

Yet the really dark dimension to the film revolves around the daughter, Jessica. Jessica knows what to do when bottles of alcohol are thrown into the dustbin. She has seen her mother do it many a time. She has been given clips round the ear and has seen her drunken mother collapse in a mess at home.

She has had deal with emotional outbursts out of all proportion. She has been involved in all attempts to keep the family together, with overtime for the nanny. When the family does split, she receives some acid comments about her biological father from Michael. Her attempt to talk earnest with her mother, Alice, is met virtually every time with jokes or evasion.

At an "AlAnon" meeting (an offshoot of AA, for relatives) Michael hears a woman talk about her situation as someone who is emotionally abused by her alcoholic husband. If there is someone in this film who is emotionally abused, it is Jessica. Her story is a story of a long series of deceptions and abandonment of various kinds.

Alcohol dependence and alcohol abuse are common and many children grow up with similar experiences to Jessica's. We may not all agree on theories about the significance of past traumas on later life, however, if and when we see children whose life is like Jessica's, then there is actually no room for theoretical niceties. Children in a situation like this are not doing well. There are no fixed answers, no simple ways to help but those who see what happens must, morally, try to do something. As physicians, it may even be the case that we have a duty.

The strength of "When a man loves a woman" lies in the fact that it binds together the various different strands in such a convoluted way that, just as in reality in our clinics, we can end up seeing just one of the many films that are being played out at the same time.

By Agneta Österling, Specialist in General Psychiatry

From a woman’s point of view

Consumption
Total alcohol consumption has increased by a good 30% since the end of the 1990s. Among younger people, alcohol consumption in boys has fallen in the past five years, whilst consumption among girls has increased successively since the end of the 1980s. The gap between boys and girls is less than it was in the past, and the trend towards binge-drinking has been noted.

The latter is a risk factor in the development of alcohol dependence. Young women drink less than young men and a consumption peak is observed in the 20-25 year age group, when consumption among men is twice that of women. Thereafter, consumption gradually tails off with age in men, but the drop for women is significantly less pronounced and does not become clear until the 50s age bracket.

In parallel with the increased alcohol consumption, an increased rate of alcohol-related traffic accidents and mortality in both men and women is observed. However, the number of incidents of people being found drunk in charge, suspected breaches of drink-driving laws and the level of hospitalisation/ medical care for alcohol abuse in institutions/ as inpatients has, along with alcohol-related deaths, increased by a relatively higher rate among women in the 2000s, meaning that the gap between the sexes has narrowed.

Alcohol abuse/dependence
In a study of all 42-year olds in Malmö who took part in a health survey in
1981, alcohol problems were observed in 4.6% of women and 15.5% of men at some time in their life (men: women; 3.3). Roughly half had suffered alcohol abuse/ dependence. In an American population study in 2001- 2002, a 12-month prevalence of alcohol abuse/ dependence was observed in 12.25% of men and 4.87% of women (men: women 2.5). Serious alcohol problems are thus still more common in men, but the gap has narrowed.

Mental comorbidity
Women with alcohol dependence have a lifetime prevalence of other mental disorders, in particular depression and anxiety syndrome. Mental comorbidity (lifetime prevalence) occurs in 66% of women and 45% of men with alcohol dependence. It is more common among women for other mental disorders to begin prior to alcohol dependence. Anxiety and symptoms of depression can be seen as risk factors and warrant an in-depth "alcohol case history" in patients suffering such complaints.

In both international and Swedish studies, a link between sexual violations (in children or in later life) and the subsequent development of alcohol abuse, depression and anxiety syndromes in women has been successfully substantiated.

”It is more common among women for other mental disorders to begin prior to alcohol dependence.”

Somatic complications of high-level alcohol consumption are different in men and in women in terms of certain organ damage. The reasons behind this are not entirely clear. The distribution of fat/muscle mass in women leads to relatively less water in the body (in which alcohol is released) compared with men.

Women, therefore, will have a higher alcohol content in their blood if they consume the same volume of alcohol as men. A lower content of alcohol dehydrogenase in the stomach (especially in female abusers), differences in the rate of elimination of alcohol in the liver and fluctuations in female sex hormones have been studied and judged to be significant.

However, even if you take account of physiological differences between the sexes (different levels of high consumption between the sexes, where that of women is 33% lower than that of men) it is thought that women are more prone to alcohol-related liver and cardiovascular disease and to CNS influences compared with men. Women suffering alcohol abuse are more likely to develop chronic alcohol-related liver disease and myopathy (both of skeletal muscles and heart muscle) than male alcohol abusers.

This even happens after a shorter consumption period where smaller quantities than those consumed by men are drunk. This is known as the "telescope effect". It is also thought that women with alcohol abuse are more easily affected by structural and functional defects in the heart (measured by CT, MR and neuropsychological test methods) compared with male alcohol abusers presenting a similar telescope effect.

Alcohol and health

Extensive longitudinal studies from the USA have shown that alcohol in moderate quantities has a cardioprotective effect compared with people who are teetotal. It should, however, be pointed out that the reduced risk of cardio-vascular incidents applied above all to post menopausal (55+) women. In the same studies, however, it was also observed that this same alcohol consumption is associated with an increased risk of breast cancer.

It is important that the level of alcohol consumption designed to promote health is worked out on the basis of careful medical assessment, where any positive effects have to be weighed against risks.

Alcohol and pregnancy
when a women in her fertile years plans to have a family and become pregnant, her normal level of alcohol consumption can possibly no longer be seen as risk-free. Many women are now giving birth at the age of 28-30, by which time they have already established alcohol habits over many years, with many finding it difficult to change their ways.

In a study of maternity healthcare in Stockholm it was found that 30% of women continued to consume alcohol regularly during pregnancy. In the event of extensive alcohol consumption during the bulk of the pregnancy there is a high risk of the child developing foetal alcohol syndrome (FAS). This includes facial deformities, mental retardation and growth inhibition (pre- and post-natal) and is the most common cause of non-hereditary heart damage in children in the western world, but which is also entirely preventable.

Exposure to alcohol in the womb can also give rise to other physical deformities or neurodevelopment damage without the characteristic facial deformities. There are also studies which show that even regular, low-level consumption of approx. 10 g alcohol per day during pregnancy can mean an increased incidence of miscarriage, growth inhibition and damage to the growing brain, with cognitive and behavioural disorders.

Intensive consumption, where five or more drinks are consumed at every drinking session and a high ppm content is reached in a short period of time, have demonstrated damage to development of the brain in animal experiments.

"Alcohol and pregnancy"
So it is essential to map out not just consumption levels, but also drinking rates and drinking patterns. There is no good evidence to suggest that consumption during pregnancy is risk-free, which is why the message from the maternity care professionals in Sweden (as in the USA) is that pregnancy should be entirely alcohol-free. The same goes for drugs.

If alcohol is consumed during pregnancy, brief counselling or other preventive approaches (secondary intervention) can be applied in the first instance, with the aim of bringing about total abstinence for the remainder of the pregnancy. There is evidence of such measures, especially within primary care. Certain training in screening and Intervention methods is necessary, however.

If brief intervention is not successful or the pregnant women is suffering severe alcohol abuse/dependence then multidisciplinary treatment approaches should be selected to ensure adequate maternity healthcare, gynaecological/obstetrics follow-up, abuse treatment and social-services support. Inpatient or institutional care may be relevant as a continued form of support after childbirth.

Intervention and treatment
In the SBU report "Behandling av alkohol- och narkotikaproblem" from 2001 ("Treatment of drug and alcohol problems"), sex-related effects were discussed. It was noted in purely general terms in long-term follow-ups that women who undergo treatment have a better prognosis than men. In surveys into the natural course of alcohol dependence, there were no differences between the sexes, however.

Secondary intervention is effective for women with alcohol problems and, in certain studies, sometimes to a higher degree than for men. In a Swedish study into treatment for women with past alcohol problems, a specialist women’s unit was compared with a traditional mixed-sex treatment approach. The women's unit produced better results.

For women with complex mental disorders and experience of violations against them, complementary treatment /support beyond the actual treatment of the abuse per se is an issue which should ideally be dealt with within a single-sex treatment environment.

Useful reading

  • Drogutvecklingen i Sverige Rapport 2005, Centralförbundet för alkohol- and narkotikaupplysning
  • Behandling av alkohol- and narkotikaproblem. En evidensbaserad kunskapssammanställning. SBU 2001
  • Gunzerath L et al . National Institute on Alcohol Abuse and Alcoholism Report on Moderate Drinking. Alcoholism Clin Exp Res 2004:28:829-847
  • Österling, A. Gravid och missbrukare ss 95-107 i Antologi Könsperspektiv på missbruk. Leissner T, Hedin U-C (red) Bokförlaget Bjurner och Bruno AB 2001
  • Heilig, M. Den värnlösa patienten: Alkohol som fosterskadande medel ss 53-57 i Beroendetillstånd (Studentlitteratur) 2004
  • Göransson, M. Alcohol consumption during pregnancy: How do we separate myth from reality? Akademisk avhandling, Stockholm 2004. Karolinska University Press.

Web
www.niaaa.nih.gov/publications; Women and Alcohol: An Update Volume 26, Number 4, 2002
10th Special Report to the US Congress on Alcohol and Health