History of Alcoholism Treatment in the United States of America and Alcoholism Causal Models

History of Alcoholism Treatment in the United States of America and Alcoholism Causal Models

Author: Ekaterina V. Shkurkin, MSW, LSW, PhD

Associate Professor, St. Martin's University, Lacey, Washington

Abstract: The author sketches the history of alcoholism treatment in the United States. Alcoholism causal models are reviewed, as are the treatment used for each model. A brief overview of dual diagnosis (alcoholism and mental illness) is included.

Keywords: Alcoholism treatment; dual diagnosis; alcoholism causal models

History of Alcohol Treatment

Alcoholism treatment has developed along a similar path as mental health treatment in that there have been several rival schools of thought, all which claim superiority. Miller and Hester (1989) argue that there are three mistaken assertions: 1) Nothing works; 2) There is one particular approach, which is superior to all others; and 3) All treatment approaches work about equally well. Instead, their research finds that there are several different approaches that are significantly better than no intervention or alternative treatments. They say that no one approach "stands out from all the rest, but neither are all treatments equally effective (or ineffective)" (p.4). This gives promise, because there are several effective treatments, and some are more effective for certain types of people than others. For most individuals, this means that there is a good chance that there is an effective treatment choice among these alternatives.

Treatment choices follow lines of causal attributions for alcoholism. Schools of thought exist attributing alcoholism to biochemical imbalances, social learning theory, family dynamics, sociocultural influences, and personal choice. Moral models were the first models in the United States, which emphasized personal choice as the main cause of alcohol problems. An individual is seen as making choices to abuse alcohol, and as capable of making (and having made) other choices.

The temperance model, often confused with the moral model, predominated in the United States from the nineteenth century to the repeal of prohibition in 1933. The emphasis was on the extreme danger of alcohol as a drug, and that the core cause of alcoholism is the drug itself. Alcohol is seen as dangerous to the extent that there should be high caution in its use, if it is used at all. This is not unlike the way that heroin and cocaine are viewed today. (Miller and Hester, 1989, p.5)

The American Disease Model came into practice after the end of Prohibition, and was made popular by the start of Alcoholics Anonymous (June 10, 1935). Alcoholics were seen as substantially different from non-alcoholics, possessing a quality that made them incapable of drinking in moderation. Their disease was seen as a combination of physical, psychological and spiritual causes (Alcoholics Anonymous "The Big Book" 4th ed, 2001). The medical profession came to accept alcoholism as a disease requiring medical treatment.

Alcoholism causal models

The following models pair causal attribution of alcoholism to their treatments of choice.

Educational Models: One drinks because one either doesn't understand the risks, or doesn't have the information that would enable them to stop drinking too much. The treatment therefore would be to educate the alcoholic.

Characterological Models: The roots of alcoholism lay in abnormalities of the personality, and change would require a restructuring of the personality. Treatment would be in psychotherapy to "deal with the basic underlying conflicts and bring the person to more mature levels of functioning" (Miller & Hester, p.6).

Conditioning Models: Drinking is a learned habit, responding to ordinary principles of behavior. If the person gets a positive reward from drinking, he would continue or increase drinking. If this is a learned behavior, it can be unlearned, using classical conditioning or aversion therapy.

Biological models: Closely related to the American Disease Model, the biological models stress the influence of heredity, and physical processes as the causes of alcoholism.

Social Learning Models: Like the conditioning models, the social learning models emphasize the ecosystems approach, where an interaction of the person and their environment may encourage alcohol usage and discourage any alternatives. The individual is seen as using alcohol as a coping strategy.

General systems model: Alcoholism is seen as being a part of a larger family system, and emphasizes assessment of the larger systems that a person is in to intervene upon the problem. "What appears to be an individual's alcohol problem is, in fact, the malfunctioning or dysfunction of a larger system" (Miller & Hester, p.8). Family systems work to maintain the status quo, and will resist change.

Sociocultural models: A macro-systems view, these theories look at the attitudes, availability, convenient access, and legal regulation of alcohol. The more readily available they are, the more alcoholic beverages are consumed.

Public Health models: Using the three types of causal factors already existing in Public Health work (the agent, the host, and the environment) the Public Health model draws together several of the above-mentioned models. This model focuses on the interaction of the agent (alcohol), the host (the drinker), and their environment, which encourages the alcoholic to continue the behavior. In this way, alcohol is acknowledged as a dangerous drug, recognizes individual biological, psychological and social differences, and stresses the importance of environmental factors in encouraging and discouraging alcohol use. Interventions based on this model would necessarily be diverse. Miller and Hester see this model as being the most promising one, since it moves away from "only one theory is right and best", gives flexibility to using many methods, and is moving towards using an "informed eclecticism" (p.11) for treatment with the highly diverse alcoholic population.

Dual Diagnosis

The models listed above worked well for people with a primary problem of alcoholism. If alcoholics also had a concurrent diagnosis of mental illness, they were most often screened out of the treatment programs as not being appropriate for treatment,