E-Book, Englisch, 102 Seiten
Maisto / Connors / Dearing Alcohol Use Disorders
1. Auflage 2007
ISBN: 978-1-61334-317-3
Verlag: Hogrefe Publishing
Format: EPUB
Kopierschutz: 6 - ePub Watermark
E-Book, Englisch, 102 Seiten
Reihe: Advances in Psychotherapy - Evidence-Based Practice
ISBN: 978-1-61334-317-3
Verlag: Hogrefe Publishing
Format: EPUB
Kopierschutz: 6 - ePub Watermark
Practice-oriented, evidence-based guidance on treating alcohol problems – one of the most widespread health problems in modern society.
This volume in the series Advances in Psychotherapy – Evidence-Based Practice provides therapists and students with practical and evidence-based guidance on the diagnosis and treatment of alcohol problems.
Alcohol abuse and alcohol dependence are widespread, and the individual and societal problems associated with these disorders have made the study and treatment of alcohol use disorders a clinical research priority. Research over the past several decades has led to the development of excellent empirically supported treatment methods. This book aims to increase clinicians’ access to empirically supported interventions for alcohol use disorders, with the hope that these methods will become the standard in clinical practice.
It is both a compact “how-to” reference, for use by professional clinicians in their daily work, and an ideal educational resource for students and for practice-oriented continuing education. The volume has a similar structure to others in the series, and is a “reader friendly” guide covering all aspects of clinical practice. It makes liberal use of tables, boxed clinical examples, and clinical vignettes, and the appendix includes numerous assessment instruments, tools, and homework assignments for use in daily practice.
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2 Theories and Models of Alcohol Use Disorders The definitions and descriptions of alcohol use disorders (AUDs) presented in Chapter 1 give the basis for our describing current ways that clinicians and researchers understand AUDs. By “understand,” we mean perception of factors that affect the development of a disorder, its maintenance, and its modification. Such information is critical for this book, because how clinicians think about and understand a problem may directly affect how they assess its manifestations and intervene to change it. 2.1 Traditional Theories of AUDs A number of theories have been proposed to explain AUDs Until recently, researchers and clinicians alike usually sought a single-factor explanation of what causes and maintains alcohol problems. Miller and Hester (2003) provided an excellent review of these models/theories. They summarized 12 single-factor models by describing each one, identifying its major emphasis about the cause and maintenance of AUDs, and citing an example of an intervention to modify AUD-related behavior that follows from the model. These 12 models span the biological, psychological, and social/environmental domains, and the etiological factors include individual characteristics (e.g., genetics, personality characteristics, lack of knowledge, motivation), environmental effects (e.g., cultural norms), and the interaction between the individual and their environment (e.g., family dynamics, social learning). Due to the wide variety of causal factors, AUD assessment and intervention differ considerably for each model. Treatment approaches vary widely also, and include interventions such as moral suasion, spiritual growth, restriction of alcohol supply, confrontation, coping skills training, and family therapy. It is here that we see why awareness of how the clinician understands AUDs is so important: If it guides what clinicians do with their patients, then the content, process, and outcomes could differ in major ways. Through about the first three-quarters of the twentieth century, AUD theories frequently outpaced the data necessary to evaluate them. More recently, the quality of research in each of these domains has improved considerably, and each of these “single-factor” theories has been found to have some merit. Nevertheless, each set of factors alone, biological, psychological, or social/ environmental, has been found lacking in its attempt to provide a satisfactory explanation of the AUDs. 2.2 Biopsychosocial Model of AUDs The biopsychosocial model is the approach most widely endorsed today Empirical evidence and a newer way of conceptualizing health and illness merged in the latter twentieth century to lead to the generation and broad influence of a “biopsychosocial” model of AUDs. Besides dissatisfaction with the account of AUDs that single factor theories provided, there were several other manifestations of alcohol problems that have been influential. In this regard, in the important report by the Institute of Medicine (IOM, 1990), three main features of alcohol problems were highlighted that led the authors of that report to the conclusion that there is no one “alcoholism” that is a unitary “disease.” Instead, alcohol problems are heterogeneous in their manifestation and etiology. Specifically, the IOM report argues that research conducted primarily since the early 1970s had shown that alcohol problems are, first, heterogeneous in their presentation, that is, they might be thought of as a syndrome with a variety of symptoms (Shaffer, LaPlante, LaBrie, Kidman, Donato, & Stanton, 2004; Vaillant, 1983). Second, alcohol problems are heterogeneous in their course. This conclusion is in contrast to more traditional ideas of alcoholism as a unitary, progressive disease. In fact, the course of alcohol problems can vary significantly, as shown by many longitudinal studies, and may or may not be characterized by “progressivity.” Third, alcohol problems are heterogeneous in etiology. This conclusion rests on the findings that no single cause or set of causes of alcohol problems has been identified. Rather, individuals who are identified as having alcohol problems present with diverse developmental trajectories of AUDs that are likely the result of the confluence of biological, psychological, and social factors. No single factor, set of factors, or factor domain has etiological priority of importance over another, none is necessary or sufficient in any case, and the influence of any factor or set of factors in AUD development varies across individuals. The strength of the research and clinical evidence behind these conclusions along with newer conceptions of illness and health that rose to prominence in the 1970s have led to the current wide-spread influence of the “biopsychosocial” (BPS) model of AUDs. Engel (1977, 1980) presented the BPS model first to psychiatry and the rest of medicine and argued its superiority to the prevailing “biomedical” model in the treatment of patients presenting with medical or psychiatric disorders. Similar to conclusions that the IOM (1990) articulated about alcohol problems, Engel (1977) argued that to view a patient presenting to physicians with some medical or psychiatric disorder in one dimension (whether it be purely biological, psychological, or social) results in the likely result of missing significant aspects of the patient’s problem and thus its amelioration. Engel argued that health, and thus illness, is best viewed as the outcome of nonrecursive (bidirectional causality, such that change in “A” causes change in “B,” which in turn causes change in “A”) interactions among the hierarchical components of biological, individual, family, and community systems, and of components within those systems. Moreover, “lower order” components (biological) are subsumed by “higher order” (e.g., community) systems. Engel argued that this level of complexity is essential to understanding illness and its manifestations.Figure 1, from Engel (1980), illustrates this thinking. Figure 1
Continuum of Natural Systems (Engel, 1980)
Reprinted with permission from the American Journal of Psychiatry (© 1980), American Psychiatric Association. In 1988, Donovan discussed the “emerging” acceptance of a BPS model among alcohol clinical practitioners and researchers. In 2005, Donovan expressed the tenor of the field by noting that the BPS model of alcohol problems is no longer emerging but has emerged. This raises the question of what variables must actually be considered in understanding any instance of presentation of AUDs. O’Brien (2001) provided a summary in response to this question in his listing of important BPS factors in the “onset” and continuation of not only AUDs, but of other substance use disorders as well. O’Brien’s list of variables is divided into three classes: agent (drugs), host (user), and environment. The variables included in the agent category include substance availability (especially important in illicit substances), cost of the substance, substance purity or potency, and mode of substance administration, such as oral, nasal, or intravenous. The host variables include factors such as innate tolerance to a substance, i.e., the tolerance that an individual shows to a substance the first time that he or she uses it. Other tolerance-related factors include speed of acquiring tolerance to a substance and the likelihood of experiencing pleasure when using a substance. Another host factor is the speed and efficiency with which an individual metabolizes a substance. An individual’s psychiatric symptoms also may affect the onset and continuation of substance use, as might prior experiences with a substance and expectations about the consequences of using it. Finally, the tendency for an individual to engage in risky behaviors also may affect substance use. Environmental factors may range from the immediate setting of substance use to macro-environmental factors. Therefore, for example, the social setting may affect substance use, as might community attitudes. Included in the latter are peer influences and role models. Another environmental factor that O’Brien (2001) identified is availability of sources of pleasure or recreation (more generally, sources of positive reinforcement) besides substance use. Opportunities for employment or education also might be associated with substance use. Finally, after repeated use of a substance, cues in the environment may become strongly conditioned to substance use so that they become stimuli that elicit or trigger the desire to use that substance(s). It is notable in scanning O’Brien’s list of variables that each of them has empirical support for its importance. Nevertheless, none of these variables alone can explain the development and maintenance of the AUDs. In summary, the empirical evidence points clearly to the AUDs as complex and multiply determined, so that the BPS model seems to have the best chance to productively guide clinical practice and research on the AUDs. However, if we take the next steps in better specifying what this conclusion may mean for the everyday clinical practice of clinicians, the directions that the BPS model takes us may not be apparent. In this regard, the BPS model may seem so broad that deriving specific ideas for assessment and...
