General Theory Of Alcoholism There are many theories of alcoholism, and some approaches explain and treat certain alcoholics better than others. One of the common themes throughout the readings is that addicts display a range of personal and situational problems. There is no “typical” addicted personality or emotional problem (Allen, 1996).
Because of these facts, it comes as no surprise that there are also no typical assessment or treatment for these individuals. For instance, a medical/disease model of alcoholism may be more useful to some alcoholics than others. The point is that instead of rigidly applying one model, a counselor’s goal is to use the models that are most effective to the particular alcoholic in question. A primary thesis is that the way we construe alcoholism highly determines the way we diagnose, treat, and feel about alcoholism. Therefore, it is important for us to clearly and consciously know our own personal views (theories, beliefs, assumptions, expectations) toward drinking and addiction. I believe that each one of us hold theories about alcoholism which may be more or less helpful and/or harmful.
For example, if we view an alcoholic only as one who is on skid row, frequently drunk, out of control, and blatantly disruptive and embarrassing, then our theory of alcoholism must be modified for successful assessment and treatment. Although such a view does include some alcoholics, it excludes most of them and therefore precludes helping them. Instead of one “alcoholism,” I have come to believe that there are many “alcoholisms.” And as reflected in the referenced readings, instead of one theory, there are many theories and treatments. This is rather frightening to the new MSW! How will I know? Through the years, I have pieced together a general theory of alcoholism. First, alcoholics are more or less obsessed with the thoughts of drinking (manifested in idle thinking, dreams, fantasies, intrusive thoughts, and concrete plans).
Alcoholics look forward to drinking, think about and give reasons for not drinking, justify their drinking, lie about and hide their drinking, or think about the comfort of drinking. Simply put: A lot of thought is given to drinking. Furthermore, the promise of drinking in the near future helps alcoholics to relax in the present, and conversely the thought of not being able to drink for an indefinite time evokes anxiety and subtle sadness. Non-alcoholics simple do not think this way. Alcoholics feel compelled to use alcohol as a means of effecting changes in mood, thinking, or over-all well-being.
They feel a desire that drives them to use alcohol – to achieve contentment, to affect a buzz, to reduce tension, to numb feeling, to forget, to relax, to reward, and to feel better. And, their pleasant feelings reinforce the compulsion to use again. Why are some people compelled to drink alcoholically, while others are not? No one knows for sure. There are many ways to explain alcoholism. Some approaches accent organic/genetic/biochemical factors, others emphasize non-organic/psychogenic/environmental factors, and others try to integrate both nature and nurture.
Depending on the person, there can be many reasons (and combinations thereof) to feel compelled to drink – such as genetics, biochemistry, habit, stress mismanagement, expectations, environmental pressure, cultural and societal sanctions, etc. One drink can compel some alcoholics to drink until they pass out or get sick. For them, one drink is too many. Other alcoholics feel compelled to drink daily while managing to function without blatant disruption. Others feel compelled to drink only on weekends, during holidays, or at festive occasions.
Others seldom drink, but when they do, they drink alcoholically. Many alcoholics feel that they are entitled to drink and that life without alcohol is somehow not right, incomplete, or difficult. Although many alcoholics can abstain, they miss it. Their efforts to abstain, which include intense willpower (white knuckle approach), making great sacrifices, irritability, constant complaints, or dry drunks give evidence of their compulsion. Another of alcoholism’s powerful dynamics, which reinforces its obsessive ness and compulsiveness, is the relative certainty and immediacy of its rewards.
Unlike the risk and uncertainty of interpersonal fulfillment, alcoholics can safely count on the effects of drinking. Drinking seldom lets them down; it usually gives them what they ask for. Alcoholic effects are easy to come by and occur quickly. There is little waiting; the rewards are immediate. Compounding the certainty and immediacy of gratification is the easy availability of alcohol. Alcohol is legal and easily acquired.
One of the biggest problems in improving treatment for alcoholics in mental health care is that of assessment and diagnosis. More than half of the veterans admitted to the acute psychiatric care ward (2P) of the Boise VA Medical Center (VAMC) are substance abusers, yet they are not dually diagnosed. These patients most often exhibit symptoms of an apparent mood disorder that can range from dysthymia to a major depressive episode. Symptoms of anxiety are also a common feature, often mixed with symptoms of depression.
Disorders that involve disturbances in thinking, such as mania and schizophrenia also occur. The traditional view that psychiatric disorders are unrelated to alcohol and other drug use problems has hampered effective treatment of patients who exhibit both types of disorders (Woody, 1996). Psychiatric and substance abuse disorders can produce many similar symptoms and often coexist in the same patient, where one disorder can influence the course and treatment outcome of the other. This makes me question which may have come first – substance abuse disorder or the psychiatric disorder. And did one cause the other? Or is it possible that there is not a psychiatric disorder at all? Gersabeck (2001) suggests that mental health professionals embrace a new diagnosis, substance (chemical) dependency-induced psychosis (SDIP).
He states that the “majority of persons with a SDIP quite probably wouldn’t have become psychotic had they not first become chemically dependent” (2001, p. 2). According to Gersabeck’s recent research, a good clue to the SDIP diagnosis often is the chronic mentally ill person who stops his/her medication and starts to use alcohol or another addictive-type drug. The person may also combine the drug and his/her medication. Often, the result of the former action is rehospitalization and a psychotic episode. As I reflect on the past few months that I have interned on 2P at the VAMC, there have been numerous patients admitted with a diagnosis of depression, bipolar, schizoaffective, or schizotypal disorder with or without suicide ideation, and no reference to substance abuse.
When I complete the social history on these patients, they also have extensive substance abuse issues that were not addressed by the admitting physician. For example, John, a tall gaunt and very pasty 38-year-old veteran was admitted and diagnosed with a mood disorder – severe bipolar I, in the manic stage (having an abnormally and persistently elevated expansive or irritable mood lasting at least one week). The veteran had a long history of depression and suicide ideation. John was drugged and slept for two days before I met with him. During the course of our two-hour interview, I ascertained that he had been on an 8-month methamphetamine run and just prior to being hospitalized, John had not slept for nearly four days.
He had been using “uppers” since early adolescence, four years before his first diagnosis of depression. Did his substance abuse cause his mental illness? Did his mental illness cause his substance abuse? Which should be treated first? My thought is that substance abuse must be addressed first. I also believe that due to my personal history, I am predisposed to assuming substance abuse issues; believing that I will more often than not find it. This awareness will help me in taking great care not to attribute symptoms when there aren’t any.
On the other hand, I should be more alert to the symptoms when they are there. Bibliography Annotated Bibliography Allen, J. P. (1996).
Subtypes of alcoholics based on psychometric measures. Alcohol Health & Research World, 20, pp. 24-30. One approach to sub-typing alcoholics is the use of psychometric tests that quantify a person’s personality characteristics, psychological characteristics, and intelligence.
Drake, R. E., & Mueser, K. T. (1996).
Alcohol-use disorder and severe mental illness. Alcohol Health & Research World, 20, pp. 86-94. This article explores some problems in diagnosing and treating alcoholics with dual diagnoses. Gersabeck, N.
J. (2001). Chemical dependency and chemical dependency-induced psychosis. Available online (02/13/01): http://www.rust.net/~norman/. The diagnosis of substance (chemical) dependency-induced psychosis is a common type of functional psychosis and should be added to the DSM.
McCrady, B. S. (1985). Alcoholism. In D. H.
Barlow (Ed.) Clinical handbook of psychological disorders, pp. 245-298. New York: Guilford Press. Treatment of alcoholics is a difficult undertaking. Alcoholics are often uncooperative and in a state of denial.
Raskin, M. S., & Daley, D. C. (1991).
Assessment of addiction problems. In. D. C.
Daley & M. S. Raskin (Eds.), Treating the chemically dependent and their families, pp. 22-56. Newbury Park, CA: Sage.
Assessment can be one of the most difficult steps in the helping process, especially when addiction is the “hidden” problem. Vaillant, G. E., & Hiller-Sturmhofel, S. (1996). The natural history of alcoholism. Alcohol Health & Research, 20, pp.
152-162. There is strong evidence to support psychiatric disorders developed as consequences of alcoholism and that alcoholism in most patients is not secondary to other psychiatric disorders. Woody, G. (1996). The challenge of dual diagnosis.
Alcohol Health & Research World, 20, pp. 76-81. Patients with dual disorders may be misdiagnosed and improperly treated, often falling through the cracks in the health care system. Social Issues.