Engs, Ruth C. [Ed.]. Controversies in the Addition's Field.. Reid K. Hester, Ph.D. and Nancy Sheeby, M.A. CHAPTER 1: The Grand Unification Theory of Alcohol Abuse: It's Time to Stop Fighting Each Other and Start Working Together
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CHAPTER 1: The Grand Unification Theory of Alcohol Abuse: It's Time to Stop Fighting Each Other and Start Working Together
Reid K. Hester, Ph.D. and Nancy Sheeby, M.A
The number of other chapters in this section demonstrate the wide diversity of current theories of alcohol abuse. While these chapters are representative of the current crop of perspectives, space limitation precludes an exhaustive discussion of all of the current and historical theories of alcohol abuse. Indeed, by 1960 Jellinek presented a summary of over 200 definitions, theories of etiology, and conceptualizations of the phenomena of alcoholism.
The purpose of this chapter is to review current and historical theories of alcoholism within a framework which allows us to examine each theory's causal factors, appropriate agents and mechanisms for change, and implied interventions. By presenting the theories in this fashion we will show how each theory can account for some aspect of what we know about alcohol abuse. With one exception however, each theory is shortsighted and limited in its ability to comprehensively explain all that we know about alcohol abuse on a macro level. After discussing current and historical theories of alcohol abuse, we will present a model which is integrative and comprehensive.
Moral Models. Moral models have historically emphasized deficits in personal responsibility or spiritual strength as the cause of excessive drinking or drunkenness. While many might consider that the moral model is something of a historical artifact, it is still alive and well. Consider that driving under the influence of alcohol is a crime regardless of whether the individual is diagnosed as alcoholic or not. Indeed, while the vast majority of criminal acts are committed under the influence of alcohol or drugs, intoxication has rarely been a justifiable defense in the United States. Clearly, the judicial system holds individuals personally accountable for their actions. The implied agents of change include the clergy, to act as spiritual motivators, and law enforcement to punish acts of "willful misconduct."
The Temperance Model. In the late 1800s the temperance model was developed and emphasized the moderate use of alcohol. While sometimes confused with the moral models, the temperance model viewed alcohol itself as a dangerous drug which was to be consumed cautiously. As the temperance movement became more popular and increased its political influence, its perspective of alcohol became more extreme. Alcohol came to be viewed as an extraordinarily dangerous drug which no one could use, even in moderation, without progressing down the road to ruination and death. Sustained moderate consumption in any form was not considered possible. This movement eventually resulted in Congress passing the 18th amendment to the Constitution which began the era of Prohibition. While the law proved to be unpopular and encouraged the expansion of organized crime, it did significantly reduce alcohol consumption and alcohol-related problems in the U.S. during this time. The repeal of Prohibition in 1933 by the 21st amendment rang the death knoll for the temperance movement.
Key assumptions of the temperance model have survived, however, and influence our thinking about alcohol and drugs to this day. The model emphasized the hazardous aspects of the drug alcohol. This, in turn, has influenced our investigation of many of the physically debilitating consequences of excessive drinking. Viewing alcohol as dangerous is also similar to how cocaine, marijuana, and heroin are viewed today.
The temperance model implies that prevention and intervention should be conducted by abstainers who can act as role models in exhorting others to abstain. Legislation to restrict the availability and promotion of alcohol is another appropriate intervention with this model.
The American Disease Model. Two years after the repeal of prohibition, Alcoholics Anonymous came into being and with it the American disease model. The central assumption of this model is that alcoholism is a progressive, irreversible condition characterized primarily by loss of control over drinking. It cannot be cured, only arrested by complete abstinence. Alcoholics are somehow different constitutionally form nonalcoholics and this individual difference makes it impossible for them to drink moderately or without problems for anything but short periods of time. Denial of alcoholism is another cardinal symptom of the disease. Until strongly confronted, alcoholics will deny their disease.
The disease model had an immediate advantage for alcoholics: Humane treatment rather than derision or prison. It also enabled society to accept moderate drinking for most but not all people. Eventually the disease model was accepted by the medical community. As a disease it required medical treatment. Finally, it was embraced by the liquor industry because of its implication that most people can drink with impunity without risk of becoming alcoholic.
The American disease model implies that the most appropriate agents for intervention are recovering alcoholics. Because of the unique aspect of denial, recovering alcoholics are best able to spot it and intervene with confrontation. Prevention is best accomplished by early identification of those at highest risk from a constitutional standpoint for becoming alcoholic.
Educational Models. A central assumption in educational models is that alcohol abuse stems from a deficit in knowledge about the harmful effects of alcohol and heavy drinking. Once armed with this knowledge, individuals will understand that alcohol abuse or alcoholism causes significant harm to themselves as well as to their families and society. Abstention from drinking is then a logical conclusion. The implied intervention then is educational lectures about the harmful effects of alcohol by educators.
Characterological Models. These models focus on psychopathology or deficits in personality functioning as the cause of alcohol abuse. Rooted initially in psychoanalysis and evolving after World War II, alcoholics were thought to be fixated at some stage in their personality development, usually the oral stage. Other psychoanalytic theories have considered alcoholism to be a manifestation of sex-role conflicts, latent homosexuality, or low self-esteem. Given these causes, the natural agent for intervention is the psychoanalytically-oriented psychotherapist.
Conditioning Models. The premise of conditioning models, as they are applied to alcoholism, is that excessive drinking is a pattern of learned behavior which has been reinforced. As a reamed behavior it is subject to the same laws of reinforcement as other behaviors. It is also subject to change through relearning and different patterns of reinforcement. Treatment then, is a matter of counterconditioning (e.g., aversion therapies), altering contingencies for drinking and sobriety (e.g., community reinforcement approach or "disenabling"), and/or relearning new ways to reduce tension or deal with conflicts which have precipitated heavy drinking. Prevention efforts might focus on factors which create positive expectations about drinking (e.g., advertising) and incentives which encourage heavy drinking (e.g., 2 for 1 happy hours). The implied agents of intervention are behavior therapists.
Biological Models. Biological models have emphasized genetic and physiological factors resulting in alcoholism. The genetic models are supported by evidence of higher levels of alcoholism among the offspring of alcoholics, even if not raised by their biological parents. The implied intervention here is risk identification by diagnosticians and the urging of caution about the use of alcohol in individuals at high risk. The concept of pharmacological addiction represents another biological model. The assumed causal factor here is alcohol itself. The implied agents of intervention are physicians and the intervention is medically-oriented treatment.
Social Learning Models. These models go beyond the conditioning models by emphasizing the social context in which heavy drinking occurs. Causal factors include deficits in coping skills, peer pressures and modeling of heavy drinking, positive expectancies about drinking, and psychological dependence. In the latter, heavy drinking is seen as a strategy for altering psychological states or coping with problems. In these models the appropriate agents of intervention include cognitive-behavior therapists and role models.
General Systems Models. These models focus on the larger social system in which the alcohol abuser is but one part of a whole. Most often the social system is the family. The implied causal factor is a dysfunctional family an individual is a part of while he or she grows up. Because the family system is seen as having an inherent drive to maintain the status quo, changing the individual with treatment without addressing the family dynamics has a low chance of succeeding. Consequently the agents of intervention are family therapists and the intervention is systems-oriented family therapy.
Sociocultural Models. These models emphasize the roles of societal norms about drinking, the cost and availability of alcohol, and the nature of the drinking environment itself. For example, per capita consumption of alcohol is strongly influenced by its cost and availability. An important assumption here is that the more alcohol consumed in a society, the more alcohol-related problems it has. Recent moves to increase the liability of those who serve alcoholic beverages is another recognition that the environment in which a person drinks is, in itself, an important influence on how much a person consumes. In the view of the sociocultural models, the agents of intervention include legislators and makers of social policy. The implied interventions include legislation to restrict access and to increase the price of alcohol and training of servers of alcohol.
Summary. Table 1.1 summarizes the models we have described thus far. Until recently proponents of each of these models have squared off against each other in futile attempts to defend their model as the most important. This is unfortunate, as it has led to more conflict and strife than there needs to be. It is beyond the scope and space limitations of this chapter to even summarize the evidence supporting each model. Suffice it to say that each has evidence to support its validity. At the same time, each model is limited in its ability to account for all that we know about alcohol abuse.
Fortunately, in recent years the Publc Health Model has been promoted by public health professionals as an approach which integrates all of the models we have described thus far.
Public Health Model
Public health professionals conceptualize health problems in tempts of an interaction among three factors: the agent, the host, and the environment. Most often the agent is an organism (e.g., a virus) but, in this case, it is ethanol. This involves such issues as the chemical action of alcohol at a celluar level, its impact on organ functions, and its interaction with disease processes. The second factor in the model is the host. As a causal factor, the host involves intraindividual consideration of the many biological, sociological, and psychological variables which influence drinking behavior and mediate its effects. Subjects for investigation within this category include genetic predispositions to the effects of alcohol, personality disorders, and an individual's positive expectancies about drinking. The environment includes the social, cultural, political, and economic variables which affect alcohol use and its consequences. Issues of concern here include sociocultural norm for drinking and availability of alcohol. The public health approach to the etiology, course, and outcome of a health problem, therefore, involves the examination of the complex interaction of the multitude of variables affecting the agent, the host, and the environment.
While each of the models discussed earlier contributes to our understanding of the nature of alcohol-related problems, the public health model is more comprehensive (Miller and Hester, 1989). Other models emphasize one aspect, either the host, the agent, or the environment, to the exclusion of the others. For example, the temperance model emphasizes the agent—alcohol—as the cause of alcohol problems and excludes the role of the environment and the host. Moral, disease, educational, characterological, and biological models emphasize aspects of the host that lead to the susceptibility for alcohol abuse while excluding effects of the environment and the agent. Conditioning, general systems, and sociocultural models consider the environment as the crucial element in the etiology of alcoholism and minimize or exclude its interaction with the agent and the host and their separate contributions.
Although the public health perspective acknowledges the interactive effects of the host and the environment, the agent—ethanol—is recognized as a hazardous drug and its use at any level of consumption low or high, can lead to problems. Consequently, one form of primary prevention efforts focuses on decreasing access to, and the availability of alcohol. Legitimate criticisms have been directed at these control-of-supply recommendations (Peele, 1987). Proponents of the public health perspective recognize that the acceptance of this form of prevention depends upon the public's understanding of the rationale, need, and benefits to be received from such controls (Ashley and Rankin, 1988). This model also recognizes that the social context of drinking is important and that some individuals may be at greater risk for developing alcohol-related problems. Consequently, the primary prevention efforts implied by this model are multidimensional and broad spectrum.
In addition to primary prevention, the public health model emphasizes secondary prevention; the early detection of heavy drinking and reduction of alcohol consumption before chronic use leads to extensive and irreversible health problems. Its emphasis on public health makes primary health care (PHC) settings (e.g., emergency rooms, ambulatory care clinics, obstetrics units) appropriate sites for screening and prevention efforts. Evidence of the effectiveness of brief interventions in these settings is increasing (Chafetz, Blane, Abram, Clark, Golner, Hastie, and McCourt, 1964; Kristenson, Ohlin, Hulten-Nosslin, Trell, and Hood7 1983; Chick, Iloyd, and Crombie, 1985).
Unlike the other models previously mentioned, the public health model does not support one mode of intervention over others. Through its inclusion of the agent, the host, and the environment as causal factors, the public health model implies that different treatments are appropriate for different individuals. This approach to treatment is consistent with the evidence of the effectiveness of different treatment approaches (Millerand Hester, 1986). There is no single treatment approach which is most effective for everyone. Rather, the evidence suggests that there are a number of alternatives which are effective. The public health model, then, holds the promise of bringing together many professionals who have fought each other for so long. This field could benefit substantially from more cooperation and less confrontation.
Ashley, M.J., and Rankin, J.G. (1988). A public health approach to the prevention of alcohol-related health problems. Annual Review of Public Health, 9 233-271.
Babor, T.E., Ritson, E.B., and Hodgson, R.J. (1986). Alcohol-related problems in the primary health care setting: Areview of early intervention strategies. British Journal of Addiction, 81 23-46.
Chafetz, M.E., Blane, H.T., Abram, H.S., Clark, E., Golner, J.H., Hastie, E.L, and McCourt, W.F. (1964). Establishing treatment relations with alcoholics: A supplementary report. Journal of Nervous and Mental Disease, 138 390-393.
Chick, J., Lloyd, G., and Crombie, E. (1985). Counselling problem drinkers in medical wards: A controlled study. British Medical Journal, 290 965-967.
Jellinek, E.M. (1960) The Disease Concept of Alcoholism. Hillhouse Press: New Haven.
Kristenson, H., Ohlin, H., Hulten-Nosslin, M., Trell, E., and Hood, B. (1983). Identification and intervention of heavy drinkers in middleaged men: Results and follow-up of 24-60 months of long-term study with randomized controls. Journal of Alcoholism, Clinical and Experimental Research, 7 203-209.
Miller, W.R., and Hester, R.K. (1986). The effectiveness of alcoholism treatment: What research reveals. In W. R. Miller,, and N. Heather (Eds.), Treating addictive behaviors: Processes of change (pp. 121-174). Plenum: New York, NY.
Miller,W.R., end Hester, R.K. (1989). Treating alcohol problems: Toward an informed eclecticism. In W.R. Miller, and R.K. Hester (Eds.), Handbook of Alcoholism Treatment Approaches: Effective Alternatives. Pergammon Press: New York.
Peele, S. (1987). The limitations of control-of-supply models for explaining and preventing alcoholism and drug addictions. Journal of Studies on Alcohol, 48 61-89.
Skinner, H.A., and Holt, S. (1983). Early intervention for alcohol problems. Journal of the Royal College of General Practitioners, 33 787-791.
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