Models of Alcoholism: Belief Structure / Individual Choice

glass-alcoholThe National Council on Alcoholism and Drug Dependence (NCADD), in cooperation with the Research Society on Alcoholism (RSA), is proud to provide Research in Alcoholism: Models and Science as the first article in the new NCADD Research Update. The 5 Part series provides background information on the different ways of thinking about alcoholism that contribute to our understanding today. Following Part 1, The Introduction, Parts 2, 3, and 4 will review, different models of alcoholism, and the final Part 5 will respond to reader questions and comments. Because science, like prevention, treatment, and recovery, depends on the health of the community, we invite questions and comments from readers (click on Add New Comment at the end of the article).

Individual Moral Failure Models:

Over the most recent centuries, and some would argue for many centuries before, alcoholism has been regarded as a personal moral failing that required a courageous moral choice to overcome it. While the processes of choice remain crucial to improvement, the model of an immoral person casts the alcoholic as "a bad person trying to become good," in the words of a recovering alcoholic person in our clinic. This effectively removes all or part of a sense of hope, that crucial ingredient needed to come to terms with uncontrolled behavior—in this case uncontrolled drinking.

The proscription of any alcohol use by formal religious sects, such as the Methodism of the 19th Century, or the Mormonism or some of the Islamic groups of our day can be regarded as applying a "good-versus-bad" model towards all alcohol use. In that model, to be among the chosen people, drinking is not allowed1. This model often works well for those who remain "in the faith," so to speak, but often fails among those who leave the faith community. So it is, for example, that the Mormon community offers highly respected programs that train alcoholism counselors to address this problem, even among those who no longer follow their Church's beliefs2.

Cultural and Religious Models:

At the same time, the approach of many formal religions exemplifies the model of cultural sanctions with respect to alcohol use: when, when not, and how such sanctions may be useful. For example, different observers over time have noticed the relatively low rates of alcoholism among the Mediterranean cultures in southern Europe and the Near East. Some scholars believe this is due to the cultural values that define drinking alcohol as a social good and drunkenness as disapproved socially. In this line of thinking, proper use of alcohol brings people together in socially constructive ways whereas drunkenness serves only to separate them. As a result, sanctioned drinking occurs only at set times and in places of social gathering in which alcohol use is not the goal of the participants. Rather, social contact is the goal, such as when meeting friends, family, or neighbors. Multiple generations and both genders are present and food is served, as in a family gathering or a social gathering of the village or the neighborhood members gathering, as may be seen in the ideal British Pub system.

Character or Personality Pathology Models:

The idea of underlying "badness" driving drinking and "goodness" as a state reached with abstinence appears again in some models of human psychology. The term "character disorder" conveys one or more sets of chronically repeated behaviors, often very slow to change, in which the drinker characteristically "blames" their own problems on other persons. A very small percentage of the alcoholic population in the US suffers from the kinds of long standing character disorders that begin in the setting of childhood behavioral disorders and may indicate harm reduction, rather than abstinence treatment models. But the great majority do not3. Alcoholics were often thought to suffer from "passive dependent character" pathologies. But careful study established that, for the great majority of alcoholic persons, pre-existing character problems rarely occurred before the advent of heavy or uncontrolled drinking, and the apparent passive dependent character attributes disappeared with abstinence in most cases. Both the harm reduction and abstinence models offer hope--whether through preserving life and health in limiting harm, or through return to proper function when alcohol recovery/abstinence takes place in the alcohol dependent person4.

1The Book of Discipline of the United Methodist Church, United Methodist Publishing House, 2004
2Church of Jesus Christ of Latter-Day Saints, Doctrine and Covenants 89, 2012
3Vaillant, G.E., The Natural History of Alcoholism, Revisited, Harvard University Press, 1995
4Chafetz, M.E., Blaine, H.T., Hill, M.J., Frontiers of Alcoholism, Science House, 1970

Models of Alcoholism: Belief Structure and Individual Choice

Etiology of Alcohol Abuse or Dependence

Approach

Clinical Intervention

Response/Effect

Clinical Outcome(s)

Belief Structure / Individual Choice

Individual Moral Failingi

Exercise a personal moral choice

"A 'bad' person trying to become good"

Subjective definitions of "good" and "bad;" lessening hope for improvement

Religious Beliefsii

Proclaim a moral doctrine

Personal alcohol use ban

Dependent on adherence to specific belief system(s)

Character Pathologyiii

Provide psychotherapy

Innate character pathology versus alcohol induced personality changes

Hope may assist abstinence; psychotherapy at underlying causes may provide hope (placebo) or may worsen drinking

 

iChurch of Jesus Christ of Latter-Day Saints, Doctrine and Covenants 89:1-21; The Book of Discipline of the United Methodist Church, United Methodist Publishing House, 2004

iiClinebell, H.J., Understanding and Counseling the Alcoholic, Abingdon Press, 1956; Burns, K., (2009) Prohibition [DVD], United States: Florentine Films

iiiChafetz, M.E., Blaine, H.T., Hill, M.J., Frontiers of Alcoholism, Science House, 1970

The NCADD Research Update welcomes constructive comments on current installments and suggestions for further topics.

Acknowledgements:

Benjamin Temple, Francisco Maravilla, Chelsea Dize, Ph.D., and Chad Emrick, Ph. D., deserve credit and many thanks for their assistance in developing this Table.

Dr. Beresford would like to thank Ben Temple, Francisco Maravilla and Dr. Chad Emrick for their invaluable review and comment on this series, along with Robert Lindsey, Leah Brock and Greg Muth of NCADD as well as David Lewis, MD and Sara Jo Nixon, PhD, my most esteemed colleagues.

 

Acknowledgements:  Benjamin Temple, Francisco Maravilla, Chelsea Dize, Ph.D., and Chad Emrick, Ph. D., deserve credit and many thanks for their assistance in developing this Table.

 

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Sunday, 17 December 2017