The construction of meaning in alcohol addiction: A narrative study of socially excluded people's stories about alcohol.

Aim: The aim of this study is to illuminate the experience of living with alcohol addiction from the perspective of socially excluded people outside the healthcare system. It presents the results from a qualitative study of five personal narratives from socially excluded men living with alcohol addiction in Denmark. The group is rarely heard and often underprioritised in the Danish healthcare system, contributing to the social inequality in public health. Therefore, giving them a voice will contribute important insight into the individuals' own experiences and understandings of their situations. Design: Five semi-structured interviews were conducted with socially excluded people living with alcohol addiction. Positioned in a narrative methodology, the focus of the study was on the construction of meaning on a structural, performative and thematic level of the narratives of addiction, as told by the person with addiction.
Results: Social identities as "alcoholics" were constructed across the narratives; however, there was a distinct difference between the different informants' own positions. Some constructed meaning in their addiction by including an identity as a stereotypical "drunk" defined as a certain type of unhealthy, unkempt, low-income addict. Others distanced themselves from this identity. Furthermore, alcohol was presented with a double meaning, being associated with positive memories and relationships as well as negative consequences and bad experiences, complicating a potential wish for sobriety. Conclusions: The study illuminates the individual perspectives in the identity construction of socially excluded people with alcohol addiction. When relating to the characteristics of the stereotypical "drunk", the individuals' self-perspectives may differ from the common understanding. The constructed identities reflected the participants' lived experience with addiction, with alcohol as an unavoidable life companion, consequently creating individual meaning in one's addiction.

Alcohol addiction among people living in social exclusion is of great concern for the individual as well as being a major burden on the public health and economy. Therefore, people with an addiction along with multiple physical, psychological, and social issues have been of continuing interest in the health and social sciences. Gaining insight from a first-person perspective can provide valuable information and give voices to those rarely heard. However, this group is hard to reach in a research perspective, limiting related scientific knowledge. In previous addiction research, studying personal narratives has been a way of gaining knowledge about people’s experienced reality within their addiction. Through the process of constructing meaning in a narrative, people recreate past experiences and events in different social contexts. They will emphasise what they see as important, while positioning themselves within the story and constructing certain social identities (Larsson et al., 2013a, 2013b; Riessman, 1993, 2008). In the past, this approach has been used by researchers to study Alcoholic Anonymous (AA) stories (Christensen & Elmeland, 2015; Hall, 1994; Steffen, 1997; Strobbe & Kurtz, 2012), as well as other addiction and recovery narratives (Hänninen & Koski-Jännes, 1999; Järvinen, 2001; McIntosh & McKeganey, 2000). Although the experience of alcohol addiction obtained and analysed through personal narratives is well described in the health and social science research, studies positioned in a narrative methodology, focusing on addiction specifically among socially excluded people, is limited in the scientific literature.

Social exclusion is a multi-dimensional process characterised by unequal resources, capabilities, and rights, leading to health inequality (Popay et al., 2008). Despite a growing international interest in the subject, an inconsistency in the meaning and use of the term exists in the literature. In this study, social exclusion is to be understood as a broad term, closely related to both social marginalisation and vulnerability. It involves people with interrelated problems, including alcoholism, for whom social marginalisation has led to severe social problems, excluding them from parts of society. Thus, social exclusion is a social construction which can be viewed as both a cause and effect of the addiction. Within alcohol addiction research, qualitative studies have mainly been conducted on different subgroups of socially excluded addicts. Homelessness and mental illness often go hand in hand with addiction, and several studies have been conducted on people living with these challenges. On the issue of homeless people with addiction, researchers have, among other things, focused on the effect of different treatment strategies, such as the 12-step AA programme (Rayburn, 2015) and harm-reduction approaches as an alternative to alcohol abstinence (Collins et al., 2016; Kidd et al., 2011; Pauly et al., 2019). The need for shelter can be interrelated with alcoholism, influencing the path for homeless people living with addiction (Burlingham et al., 2010; Collins et al., 2016). For mentally ill persons with addiction, it has been found that Dual Diagnosis Anonymous (DDA) is a good alternative to AA, as DDA creates a space for acceptance and understanding for people struggling with similar issues, providing hope of overcoming both illnesses (Roush et al., 2015). Others have argued that the psychological state is influenced by whether the person stops drinking or reduce his or her intake (Green et al., 2015), and that self-help strategies have an important influence on obtaining sobriety (Luciano et al., 2014).

In Denmark, however, the national strategy for alcohol treatment differentiates to a lesser degree between the many subgroups of people living in social exclusion. Rather, it is aiming for a treatment that can accommodate the needs of the larger group (National Board of Health, 2015; The Danish Government, 2016). In 1998, Margareta Järvinen (1998) conducted comprehensive research on marginalised people with an addition in Copenhagen. She argued that due to the complexity of their problems, as well as stigmatisation, this group of people is often not, or is to a lesser extent, prioritised in the healthcare system, contributing to social inequality in public health. Recent research supports Järvinen’s results, arguing that the current public alcohol treatment programmes do not meet the needs of socially excluded people with an addiction, due to these people’s complex and individual physical, psychological and social issues (Andersen et al., 2016). Thus, the Danish Health Authority is struggling to find the right treatment strategy for this high-risk, low-income group, resulting in a still-growing group of excluded people living with alcohol addiction outside the healthcare system. In Denmark alone, it is estimated that 17% of all people who are either socially excluded or at risk of becoming so have an addiction to alcohol (The National Board of Social Services, 2013). Yet, since Järvinen’s study, no research has been conducted among the growing group of excluded people with addiction that are not receiving treatment regarding the experience of living with addiction. Without an insight into the complexity of the individuals’ problems, as well as insight into their own perspectives on the addiction, understanding and recognising the needs of these people will presumably continue to be a struggle to healthcare and welfare systems.

Aim

With this article, we intend to illuminate the experience of living with alcohol addiction outside the healthcare system from the perspective of socially excluded people with an alcohol addiction. Through the study of personal narratives about alcohol and alcohol addiction, the analytical focus of this study is how socially excluded people construct meaning in their alcohol addiction, and what that meaning is. This will contribute to a deeper understanding of socially excluded people’s own self-perception of their alcohol addiction, essentially giving a voice to a growing group of people rarely heard.

Design and methods

This study is positioned in a narrative methodology within a constructivist epistemology, and it is influenced by the thinking of Donald Polkinghorne (1988, 1995). The analytical focus is on the construction of meaning in the addiction. Narratives are viewed as a particular form of a meaning-making discourse, where the person draws together descriptions of states of affairs to create a higher order of meaning (Polkinghorne, 1988). Narratives are not necessarily true stories, but stories that are meaningful to the individual in their particular life circumstances. This creates an opportunity for researchers to gain an insight into a first-person perspective. The research question in this study is how the individual constructs meaning in their own addiction, and what that meaning is. In a healthcare perspective, this is valuable information which is otherwise hidden from the outside world. Thus, data in this study consist of narratives about alcohol and alcohol addiction obtained from in-depth, semi-structured narrative interviews with men living in social exclusion, with a self-claimed large consumption of alcohol.

Sampling

Due to both social isolation and a large alcohol intake, sampling people living with addiction in social exclusion for research purposes is generally challenging. Therefore, a convenience sampling strategy was used to recruit informants (Richards & Morse, 2013). Initial contact was established through emails to managers of shelters for homeless people, as it was assumed that users of these particular kinds of institutions were likely to meet the inclusion criteria of informants living in social exclusion. For ethical reasons, the majority of the managers were reluctant to establish contact to their users, but confirmed that they had users who met the criteria, and made arrangements for the first author to visit and thereby recruit informants. The author being present in the shelters provided an opportunity for the users to learn about the study and consider potential participation. As we aimed to reach people with alcohol addiction living outside the healthcare system, only informants with a self-claimed large consumption of alcohol, not currently enrolled in any alcohol treatment, were included in the study. Due to the focus on alcohol, people who reported a use of hard drugs, such as opioids, cocaine and LSD, were not included. The use of cannabis alongside a large alcohol intake was not considered an exclusion criterion. The number of informants was not decided in advance but depended on the depth of the interviews and construction of narratives within each interview. Four informants were recruited from the homeless shelters and one additional informant was found through snowball sampling. He was living on his own with very little contact with the outside world, besides monthly visits from a municipal social worker. Overall, five men, aged 49–64 years, participated in the study.

Constructing narrative data

In this study, obtaining narratives from the informants was a condition for illuminating the construction of meaning in the addiction. Our theoretical definition of “narrative” is based on Polkinghorne’s (1995, p.7) interpretation of a narrative as referring to a particular type of discourse, the story, where “[…] events and actions are drawn together into an organized whole by means of a plot”. Though narratives are not limited to a certain form or context, not all empirical data can be viewed as narratives, as a narrative per definition demands a plot, where presented events are connected in a certain timeline (Polkinghorne, 1995). To generate narrative empirical data, a semi-structured interview guide was developed asking only open-ended questions which were narrative in origin, and thus setting the stage for narrative answers (Riessman, 2008). An example of these questions is: “Tell me about the time when you started drinking?”, followed up with “Then what happened?” and “How do you recall that time of your life?”. The purpose was to facilitate a construction of detailed accounts, with a focus on timeline, significant incidents, turning points and shifts in topic. Guided by the interviewer, the informants took the lead in the interviews, constructing personal narratives about alcohol that were meaningful to themselves and told in their own words. Yet, at times the interviewer had to direct the informant in the storytelling to maintain a focus on alcohol. An example of this is “Take me back to an incident where alcohol played a significant part” follow by “What role did alcohol play in your life from that point?”. The interviews resulted in complex, personal narratives and numerous sub-narratives, revealing various plots, characters, emotions and events. The overall narratives, the informants’ life stories about alcohol, as well as sub-narratives, constituted the empirical data of the study and the subject field of analysis. All the interviews were individual and conducted face to face in the place each informant was living at the time of the interview. The duration varied between 32 and 69 minutes (mean 54 minutes), depending on the informants’ ability to maintain focus. The interviews were audiotaped and transcribed in full. NVivo 11 software was used to organise data and analysis.

Ethics

All informants provided informed consent to participate in the study in accordance with The Danish Data Protection Agency (The Danish Data Protection Agency, 2015). Full anonymity was established through name-changing, as well as a change of other personal details. We consider socially excluded people to be a vulnerable group to research. Therefore, we have placed a focus on giving them a voice without prejudice as well as keeping their integrity throughout the study (Nordentoft & Kappel, 2011). To reduce the experience of stigmatisation, the words “social exclusion” and “addiction” were avoided when presenting the study to the informants in the initial meeting, letting them define their situation and relationship to alcohol. However, all informants articulated some degree of addiction to alcohol and both concepts were found fit to be used in this article. People who did not meet the inclusion criteria, or who seemed too influenced by alcohol at the time of the interview, were not included in the study (Aldridge & Charles, 2007). Only adults (> age 21 years) were sampled.

Analysis

The work of Cathrine Riessman (1993, 2008) was used as a frame for conducting the analysis. A threefold model was composed consisting of a structural, a performative, and a thematic analysis. The threefold analysis model is presented in Table 1. The structural analysis was used to gain insight into how each informant used structures to highlight certain points of events, and thereby construct certain meanings within the story. This was done by labelling all lines with codes of structural elements. When all lines were labelled, the overall structure of each narrative was evaluated. The performative analysis concentrated on how informants performed in the narratives as well as the dialogic aspect. The intention was to understand social discourses, as well as the informants’ own positioning in the narratives, in order to gain insight into their individual identity construction and social reality. This was done in several rounds, focusing on micro and macro contexts and the use of language and metaphors, respectively. Where the structural and performative analysis focused on form and function of the narratives, the third analysis, an inductive, narrative thematic analysis, was used to explore the content of meaning in each narrative. Keeping the narratives intact, the thematic tracks were explored by labelling sections of the narratives with emerging themes, eventually condensing the primary themes in each narrative. The first author performed the interviews. Both authors have discussed themes and analytical perspectives during the analysis process to maximise reliability.

Table 1.

Threefold analysis model.a

Analysis	Purpose	Practice	Relevance to findings
Structural analysis	To examine how the informants use structures to construct a certain meaning in the narrative	Used primarily in the early stages of the analysis to identify the functions of clauses in each narrative – e.g., when informants carry action forward, evaluate events, provide details to the story, or resolve the narrativeCarried out by line-by-line labelling of structural elements combined with a comparison to the overall structure	Provides an overview of the narratives, revealing how the informants highlight specific points in their story, contributing to the understanding of the overall plots
Performative analysis	To examine how the informants perform in the narratives, with what purpose	Attention to the informant’s performance of the narrative – e.g., the interaction between informant and interviewer, and when and why statements are included in the narrativeCarried out by exploring the use of:- contexts- identity construction, including self-positioning and presentation of characters- language	Provides an insight into how the informants portray themselves and others in the narratives. It indicates how they create meaning in their situation by positioning themselves in a certain way in relation to the addiction, as well as how they want to be perceived and received by others
Thematic analysis	To examine the content of meaning in each narrative	Attention to what is said in the narrativeBased on the findings of the structural analysis, the main events of the plots are organised into a chronological timeline in order to identify meaningful passagesLabelling of themes and thematic tracks throughout the passages is carried out with a continuous awareness of the overall narratives	Provides an insight into what the informants present as meaningful in the narratives

a Developed with inspiration from Cathrine Riessman’s (1993, 2008) interpretation of narrative analysis.

Findings

Two main findings were associated with the constructed meaning in the overall narratives and the way the meaning was constructed, respectively (Table 2). First, alcohol was found to be a life companion with a double meaning. Here, six themes referred to the meaning in the narratives, where alcohol contributed with both positive and negative associations in one’s life complicating a potential wish for sobriety. Second, the way the informants positioned themselves in the narratives revealed two types of identity constructions. The informants either positioned themselves as stereotypical drunks or not, which reflected different ways of construction meaning in the addiction.

Table 2.

Main findings.

Alcohol – a life companion with a double meaning		Identity construction in the addiction
Negative associations: – Remorse – Blame – Fear	Positive associations: – Joyful memories – Pleasant experiences – Fellowship	– Stereotypical drunka	– Not stereotypical drunka

a In the context of the narratives, the use of the term “drunk” refers to a certain type of unhealthy, unkempt, low-income addict, who has difficulties “fitting in” to society.

Alcohol – a life companion with a double meaning

Across the narratives, the position of alcohol as a life companion was found to be a main issue when constructing meaning in one’s addiction. All informants led a rough lifestyle constructing plots characterised by heavy addiction, personal and financial chaos and, for most, homelessness and loss of contact to relatives. Their addiction seemed to play a main role in creating a life in social exclusion and was articulated as one of the roots of their problems. Yet, alcohol was still described as a close life companion linked to both negative and positive associations. As well as the themes remorse, blame and fear, themes like joyful memories, pleasant experiences and fellowship, emerged from the analysis. It hereby became evident that by allowing alcohol a double meaning in its role as a life companion, the informants constructed meaning in their narratives.

Remorse, blame and fear

For all informants, the addiction to alcohol had various negative consequences on a psychical, psychological, financial, social, and emotional level. Of the expressed negative consequences, the themes that emerged as the most meaningful in the informants’ narratives were remorse, blame and fear. Both remorse and blame were linked to the loss of contact with relatives or wrongdoing in general caused by the addiction. One informant, Jorgen, expressed remorse when talking about his lost relationship with his daughter. Her mother prohibited him from seeing her, as he had been too drunk or fallen asleep due to too much alcohol when he was supposed to be taking care of her on many occasions. He continuously returned to the topic of his daughter, when talking about his life with alcohol. The loss of contact with her had been a turning point in the plot, recognising himself as an addict, wanting and trying to get sober:Yet, despite multiple attempts he was unsuccessful in maintaining sobriety for more than short periods and he never regained a relationship with his daughter. Across the narratives, expressing remorse stood out as a way of moving on from previous problems, creating a new path in life. However, with the alcohol addiction still going on, this theme was closely linked to the theme blame. Though not all informants expressed a wish to obtain sobriety, three were unsuccessful despite willingness, resulting in an emerging blame towards themselves, their backgrounds or “the system”, expressed in the narratives.

I believe and think that this [the mother of his daughter prohibiting him from seeing her] was the reason I said to myself “now this [extensive alcohol use] has to stop” (deep exhalation). (Jorgen)

Fear was often associated with the direct and indirect consequences of a large alcohol intake, and was found as a theme in several of the narratives. For example, in the context of explaining his current alcohol intake, one informant, Peter, refers to previous experience of how bad his addiction may become:By associating a relapse with death, Peter constructs meaning in his current alcohol intake. Thus, fear becomes a factor in his addiction, scaring him, yet preventing him from escalating his addiction. However, Peter also expressed a current fear of who he would be without drinking, as he did not like himself sober. In the following example, Peter is reflecting on himself in a sober period of his life:According to Peter, this resulted in him resuming drinking. In his narrative, Peter expressed a fear of escalating the drinking as well as a fear of getting sober. Hence, fear as a theme in the narratives can be seen as a multiple cause and effect of alcohol addiction among the informants.

I am really scared of relapsing […] because then I’ll die […] Even though I think that it [his alcohol intake] is bad now, I know that it can become much worse. (Peter)

I tried to make myself as invisible as possible, but I could feel that I just got worse and worse […] I couldn’t stand myself and I didn’t really have anybody to talk to. (Peter)

Joyful memories, pleasant experiences and a feeling of fellowship

Living in social exclusion with alcohol addiction is generally not perceived as “a good life”. However, all informants nevertheless associated alcohol with memories and experiences of joy and good times. One informant, Per, describes his feelings towards drinking as follows:When the informants associate alcohol with something positive, they create a meaning in their addiction, which otherwise might not exist for themselves or others. Most of the situations where alcohol was associated with joyful memories and pleasant experiences were found to be related to memories that included a feeling of fellowship. Being drunk with friends meant having fun and escaping problems. In the following quotation the informant John, reflects on the double meaning of alcohol in his life:The pleasant experiences that alcohol is associated with prevent John from making a change in his addictive behaviour. The expressed feeling of fellowship whilst drinking with others, was consistent in John’s as well as the other narratives. One informant, Bo, describes the feeling as follows:Bo’s statement substantiates how the feeling of fellowship adds to the double meaning of alcohol, where having a good time drinking with friends meant an escalation in intake as well as a loss of control.

Well, it is kind of…I won’t say disclaiming, but it really is very pleasant to be intoxicated – it really is […] and you sit on a bench in the sunshine and chat and – well, you can call it escapism, in a way that is what it really is. (Per)

Sometimes I’ve done something about it [his large alcohol intake], you know? And kept away for a while. But then you run into Frans [his friend] again, and we did so much together, you know? The gallop season is long, right? And every Saturday. And then I wasn’t home there either. And, hell, we liked to play pool, you know? And we also liked to drink beer, you know? I still do, I think it is damn fine to drink beer. I just love to go out, I really do. (John)

When I had time off, it was with the guys at the pub. And then, you know, then I think you started drinking more and more – and then you no longer had control – it was not because of group pressure, you just did it – with the co-workers, meeting up in the weekends, together, right? And playing pool and just letting go and all of that, you know? (Bo)

The interaction between the positive and the negative is described by the informant John in the following quotation:Hereby, he summarises the finding of the main constructed meaning across the narratives: the alcohol had unavoidable negative consequences, yet it was associated with pleasure. Thus, it accompanied the informants as a companion with a double meaning, making it difficult to fulfil a potential wish for sobriety or change.

It [the alcohol] has had so many consequences. It really has – and it has had that for everybody. No matter who says the opposite. It has consequences and they sneak up on you along the way and you feel them ‘why the hell did you do that?’ you think, ‘could you just not have done that, dammit’ – But you can’t, when you’re in the middle of it all. You don’t have a true grip on your life. You try to keep straight – because it is fucking fun. And you’re just so unaware that you don’t have that ability to break through to yourself. (John)

Identity construction in the addiction

Constructing an identity in relation to the alcohol addiction was found to be a main issue in each of the informant’s narratives. All informants articulated an addiction to alcohol to some degree, where “being an addict” was found across all narratives. Yet two main positions divided the stories. Common understandings of the social characteristics of a certain type of addict were included in the construction of identity. The difference lay in whether the informant positioned themselves as a stereotypical “drunk” or not. Here, the use of the term “drunk” refers to a certain type of unhealthy, unkempt, low-income addict, who has difficulties “fitting in” to society. This social construction of a stereotypical drunk shares the characteristics of the group we have initially defined as the socially excluded addicts.

One of the informants, John, verbalised a positioning in what he called “a low-class society”. He described how he grew up in an environment where alcohol played a central part of everyday life. Long days of drinking at the pub were common in his upbringing as well as in his own adult life. According to John, his social heritage was the root of his addiction, and it was meaningful for him to position himself as a drunk accordingly to this. Therefore, the identity he constructed in the narrative was linked to his upbringing as well as his current situation. In his narrative John repeatedly referred to a former co-worker, Henning, with whom he became very close and at one point moved into a shared flat with. He described Henning as “high class” with “good financial status”. Unlike John, the lifestyle of public drinking was unfamiliar to Henning, yet they shared an addiction to alcohol. In the following quotation from John’s narrative, he reflected upon the difference between them:Though they drink every day “from morning to evening”, Henning would not go out to the pub drinking with John. With John’s constructed identity in the narrative, going out and drinking in public was normal, making Henning snobbish for not wanting to go out.

We drank a lot. Actually, we drank every day from morning to evening. I went to bars, but Henning, he couldn’t go anywhere, you know? He could walk with a crutch, right? But he was…He was a little too snobbish, right? He really was – he came from a family where…Well, he cooled off with that snobbish-thing. Because of the carpenter and me. We were more down to earth than the people he used to be around. We peeled that off him, but still…(John)

Another informant, Peter, presented a different upbringing, yet he constructed a current identity as a drunk comparable to the one John presents. In the following quotation, he described the transition he had gone through in his addiction:According to Peter, being groomed and well-dressed was “a façade to be cracked”, as his addiction created a social downturn. Peter constructed an identity as one of them, a “bum”, as the alcohol forced him to “snob down”. Simultaneously, he presented a morale in his narrative, where no one is better that anybody else – what differentiates a drunk from any other person addicted to alcohol, are the prejudices that exists within ourselves. Consequently, Peter hereby constructed an explanation for his own position as a drunk which was meaningful to himself in his narrative.

Sometimes I went to a pub, but it was this kind of crap. Here, I learned something about snobbing down. I sat there, and I looked fairly groomed, maybe with nicer clothes than the bum, I thought. That turned out to be your own prejudice, that could somehow make me better in some way. I lived on that for a while, but hell, that was a façade to be cracked completely. (Peter)

Contrary to John’s and Peter’s constructed identities, other informants dissociated themselves from the type of drunk previously presented. For example, Bo explained the relationship between himself and the other people living in the shelter:Bo positioned himself as different than the others, whom he referred to as “them” and “the tough ones”. Though he spoke openly about his addiction to alcohol, he was explicit in not wanting to interfere with them and preferred “more reasonable company”. This indicated that his perception of “them” is unlike the perception of himself, which contributed to the construction of an identity as an addict unlike the stereotypical drunk.

When you arrive here [at the homeless shelter] and you have an addiction – then you need to be strong to live here, dammit. You meet so many people – if not on drugs, then alcohol or other things, you know? So if you have an idea that you want to stop, then you really need to be strong to live here, right? […] I don’t let myself lure in, but we can go together to get a beer – but I don’t interfere with them – the tough ones, as we call them. Those ones – I don’t want to. I prefer more reasonable company where you can talk and enjoy a beer in nice company, you know. (Bo)

Discussion

This study aimed to illuminate the experience of living with alcohol addiction outside the healthcare system from the perspective of the socially excluded people with an alcohol addiction. From an outside perspective, all informants had their lives negatively affected by the addiction. Most lived in homeless shelters and all were defined as socially excluded from society. Yet, when confronted with a request to tell their life stories, alcohol had both positive and negative associations. Furthermore, a difference between a constructed identity as a stereotypical “drunk”, or distancing themselves from this, was evident. This was found to be a way of constructing meaning in one’s addiction. Previous researchers have argued that alcohol can contribute to the quality of life for people living with addiction or for whom alcohol has compromised other quality gaining factors in life (Collins et al., 2016; Kidd et al., 2011). In contrast, Hänninen and Koski-Jännes (1999) found, in their study of narratives of recovery from addictive behaviour, that life with addiction was generally seen as problematic, whereas life without addiction was valuable. Thus, our findings have both similarities and differences with findings from previous narrative addiction studies. In our study, informants expressed how alcohol provided joyful memories, pleasant experiences and a feeling of fellowship, along with the problematic side to addiction, including remorse, blame and fear. This suggests that having an ongoing addiction affects how people construct meaning in their life stories as compared to people with former addiction. Hence more research is needed to explore this difference.

For some informants, positioning oneself as a stereotypical “drunk” was linked to a turbulent upbringing and a sense of belonging to a group, which became an explanation for their current position. For others, distancing themselves from the group became a way of making their own narratives more bearable to tell. Thus, being socially excluded with an addiction to alcohol was associated with being a “drunk” suggesting that this socially constructed categorisation was recognised by our informants. Consistent with the work of Richard Jenkins (2004) on social identities, we found that an identification of the categorisation was a condition for constructing a group identity, since some informants created meaning by actively distancing themselves from this group in their identity construction. This identity construction is an ongoing process of assertion, imposition and negotiation between actors. It exists within the individual as well as between individuals across institutions (Hammersley et al., 2001; Jenkins, 2004). In a way, the individuals who construct an identity as a “drunk” legitimise their own actions, as they are simply doing what is expected from a person bearing this label. However, for the other group distancing themselves from the group identity, there is a discrepancy between the identity that they construct, and the identity constructed by society. This may cause challenges when encountering institutions that portray them differently than they do themselves. Even though identity construction is fundamental for all existence, there is not always consistency between how we see ourselves and how others see us, Jenkins (2004) argues. Similarly, Howard S. Becker (1963, pp. 1–2) states:Being a “drunk” means breaking the (social) rules of society, resulting in being what Becker defines as an outsider. Society defines what is regarded as deviant behaviour, making the rules for judgement of outsiders (Becker, 1963). Living in social exclusion is often linked to a certain unkept appearance, also articulated by our informants. This appearance itself can be perceived as deviant; however, drinking fairly large amounts of alcohol is common behaviour in Danish culture (Järvinen, 2003), and therefore not considered deviant on its own. In this perspective, one could be a heavy drinker without being judged as an outsider. This could be a co-determining factor in the diversity of identity construction found across the narratives.

…the person who is thus labeled an outsider may have a different view of the matter. He may not accept the rule by which he is being judged and may not regard those who judge him as either competent or legitimately entitled to do so.

Järvinen (1998, 2001) found that a small number of her informants did not identify themselves as alcoholics despite living in an institution for heavily addicted alcoholics. Although the setting was different, similarities were found in the way informants in our study position themselves as unlike “other drunks”, despite living with an ongoing alcohol addiction in a homeless shelter. Our findings add to the knowledge of alcohol addiction among people living in social exclusion and can contribute to the way we understand and approach this group. Receiving treatment in Denmark generally implies attendance and stability. However, keeping appointments can be challenging for people living in social exclusion and they often feel that their needs are not met (Andersen et al., 2016). In the light of the discussion on diversity of meaning and identity construction, gaining a deeper insight into the individuals’ own understandings of themselves and their situations may prevent some of the challenges that can appear in accommodating this group, and help ensure that their individual needs are being met.

Social exclusion is a process linked to the interaction of social, cultural, political, and economic dimensions (Popay et al., 2008). As people have unequal resources as well as different access to healthcare, the degree of inclusion/exclusion will vary. Thus, the sampling strategy in our study was expected to play a part in our findings. Since informants were either sampled from homeless shelters, or through a municipal social worker, informants were expected to be socially excluded in most dimensions. This left out people who have more, or other, resources than the informants included in the study, limiting the transferability. Furthermore, only people with a self-claimed large consumption of alcohol were included. Being socially excluded in fewer dimensions, or understanding one’s own addiction differently, would be expected to influence people’s narrative construction.

Conclusions

When presenting their narratives about alcohol and addiction, socially excluded individuals position themselves within a socially constructed reality, effecting the way they create meaning in their situation. Their diverse identities relate to the common characteristic of the type of “drunk”, thus using this perception in their individual stories. Gaining a deeper insight into the individuals’ own understandings of themselves and their situations may prevent some of the challenges that can appear in accommodating this group and help ensure that their individual needs are being met. The double meaning of alcohol in the individual’s narrative must be considered and may contribute with a deeper understanding of the individual’s self-perception and constructed identity when living in social exclusion with alcohol addiction.