Alcohol Use Disorders
Alcohol Use Disorders
2 Theories and Models of Alcohol Use Disorders (p. 10-11)
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
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
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 b