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Alcohol abuse represents several ways in which alcohol has a negative impact on an individual’s life. Some alcohol problems are severe and involve substantial consumption of alcohol, which results in multiple physical and psychosocial problems. Other alcohol problems are less severe—an individual experiences some negative consequences as a result of his or her drinking, but these difficulties have not impacted the individual’s overall functioning.
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Alcoholism Research Paper Outline
I. What Is Alcohol Health?
II. Normal Development and Epidemiology of Alcohol Abuse
III. Etiology of Alcohol Problems
A. Biological Factors
B. Environmental Factors
C. Cognitive Factors
IV. The Changing Nature of Alcohol Abuse over Time
V. Risk and Protective Factors
VI. Continuum of Intervention for Alcohol Abuse
I. What is Alcohol Health?
In order to understand the problematic use of alcohol, it is helpful first to consider what constitutes a state of health with regard to its use. Alcohol has held a common, even honored, place in the daily life of many cultures for thousands of years. It has been an element central to religious observances in Judeo- Christian and other faiths, and has often been part of important social and cultural events as well. Wine has long been recommended to promote physical health, and indeed recent scientific evidence indicates a consistent association between moderate drinking and longevity, although the reasons for this link are still poorly understood.
At the same time, it is abundantly clear that heavier drinking is often associated with devastating consequences to the individual and to society. Alcohol is involved in about half of all traffic fatalities, and a substantial proportion of fatal falls, drownings, deaths by fire, homicides, and suicides. Excessive drinking is also closely linked to violence, crime, injuries, and a plethora of chronic diseases.
The relationship of alcohol to health can thus be understood as a continuum. At one end of the continuum are abstainers, those who do not drink alcohol at all, who constitute more than one-third of adults in the United States. Such people obviously have no negative consequences related to their own drinking. Next are moderate problem-free (“normal”) drinkers. The average consumption for this large group is about three or four drinks per week. They fall largely within the limits for safe drinking recommended by the National Institute on Alcohol Abuse and Alcoholism: not more than two drinks per day for men, and not more than one drink per day for women, with some alcohol- free days each week. Because alcoholic beverages differ in content, it is important here to define what constitutes “one drink.” A useful definition is that one standard drink contains one-half ounce of ethyl alcohol.
When moderation is exceeded, or when one drinks at all in dangerous situations, one enters the realm of risky drinking, which includes both acute and chronic risk. Acute risk has to do with the immediate effects of intoxication. Even low levels of alcohol in the bloodstream, for example, can significantly impair driving ability. The only safe blood alcohol level behind the wheel is zero. A small amount of impairment from intoxication can also be lethal when combined with activities such as water sports, skiing, hunting, climbing, or using power tools, where minor misjudgments can have major consequences. There is no known safe level of drinking during pregnancy. Perhaps one of the most dangerous aspects of intoxication is that above very moderate doses, perception and judgment are among the first abilities to be impaired. This can and does result in errors of perception regarding one’s ability or (lack of) impairment, and in decisions and judgments that themselves lead to risky consequences.
Chronic risk, on the other hand, has to do with the long-term effects of drinking. Heavy drinking is closely linked to a wide range of health problems, at least doubling the risk for heart disease, cancers of many types, and hypertension. Risks for liver disease and for cancers of the mouth and gastrointestinal system are greatly increased by drinking above moderate levels.
Harmful drinking is when negative consequences from drinking actually occur. In addition to adverse effects on physical health and appearance, common types include legal problems, social consequences, damage to relationships, financial problems, and emotional disturbance. Because alcohol is a depressant drug, depression is often caused or exacerbated by heavy drinking. In college students, drinking level has a strong and negative relationship to grade point average. Memory problems are common in heavy drinkers, and the occurrence of memory blackouts is associated with brain impairment from alcohol. A majority of crimes resulting in imprisonment are committed under the influence of alcohol, which is also associated with domestic violence.
Alcohol dependence occurs as a person develops a pattern of alcohol use that results in substantial impairment in functioning. The person’s life becomes more and more entangled with drinking. Typically, alcohol dependent people are quite able to “hold their liquor,” showing less apparent intoxication from drinking than might be expected in the average person. Such tolerance is misleading, however, because while it appears that the person is unaffected, in fact he or she has a sufficiently high blood alcohol level to cause serious acute and chronic risk. Drinking occupies more of the person’s time, and becomes increasingly important so that it is unpleasant to be away from alcohol. Gradually, the body adjusts to the presence of alcohol, so that sobering up results in unpleasant experiences such as hangovers, insomnia, agitation, or nervousness, sweating, and trembling. In the extreme, alcohol can produce a withdrawal syndrome stronger and considerably more life-threatening than that associated with heroin addiction. Other features of alcohol dependence include drinking more or for a longer time than intended, failed attempts to reduce or stop drinking, and foregoing other important activities in favor of drinking.
II. Normal Development and Epidemiology of Alcoholism
What is the normal course of human development with regard to alcohol? The answer to this question is quite specific to culture. In some cultures, the normal course is lifelong abstention from alcohol. In France, on the other hand, heavy drinking is common among adults, resulting in one of the world’s highest levels of alcohol-related health problems. In Mexico, binge drinking is common among males, whereas women are usually abstainers.
Large general population surveys reveal that a majority of Americans drink alcohol. In 1992, researchers conducting the National Health Interview Survey interviewed more than 40,000 people about their alcohol consumption. At one end of the continuum, about one-third of men and one-half of women were classified as abstainers—individuals who drink less than once per year or not at all. Most individuals were classified as either light drinkers, consuming I to 13 drinks per month, or moderate drinkers, consuming 4 to 13 drinks per week. Fewer individuals were classified as heavier drinkers (14 or more drinks per week), although men were more likely to report heavier drinking than women (19% versus 7%, respectively).
Although most Americans drink without negative consequences, a significant minority of individuals are found at the harmful end of the use continuum. Recent surveys estimate that 15.3 million individuals meet criteria for alcohol abuse (“harmful drinking”), dependence, or both. Drinking at these levels becomes increasingly dominated by men, who drink more often, in greater quantities, and report more frequent episodes of intoxication than women. In fact, studies find that men are more than three times more likely to be diagnosed with alcohol abuse or dependence at any age than are women.
In addition to gender, drinking patterns are affected by age. After little or no drinking during childhood, alcohol use increases sharply during adolescence and peaks in young adulthood. Young adults drink in greater quantities, show the highest rates of binge drinking and problems related to alcohol use, and show the highest rates of alcohol abuse and dependence of any age group. With adulthood, drinking tends to decrease, with most young adults “maturing out” of problem drinking in their later twenties. The percentage of abstainers increases with age, although it is thought that heavier drinkers may be more likely to show stability of heavy drinking over time. This decrease in the number of people who use and abuse alcohol continues into older adulthood. Adults over age 65 have the lowest rates of alcohol abuse, dependence, and alcohol-related negative consequences of any age group. Some longitudinal research suggests that drinking patterns remain fairly stable over time, with the decreased rates of use and problems in older adulthood being attributable to increased mortality of heavy drinkers.
Along with gender and age, a growing literature documents differences in alcohol use and problems across racial/ethnic groups. Although studies of general population samples indicate that consumption and problems are greatest during the young adult years, studies have found that minority groups do not always follow this pattern. For example, Blacks have been found to show low rates of heavy drinking in young adulthood, followed by increased rates of heavy drinking and problems in their adult years. Importantly, rates of abstinence are higher among Blacks of all ages, especially among Black females. Research has also found variations by age from general population samples in patterns of drinking among Hispanics. In a way that is similar to non-Hispanic Whites, heavy drinking and associated problems increase during the young adult years among Hispanics. Hispanic men, however, show a smaller decrease in heavy drinking and problems from young adulthood to adulthood than that found among general population samples. For Hispanic men, heavy drinking and negative consequences remain high into middle adulthood, and Hispanic men show higher rates of alcohol abuse and dependence than other racial/ethnic groups over this time as well. In addition, Hispanic women show higher rates of abstention at all ages than non-Hispanic White women. Importantly, research with Hispanic samples is complicated by the practice of studying individuals of Mexican, Cuban, and Puerto Rican descent together, ignoring the substantial cultural and geographic differences among these groups as well as their different rates of drinking and attitudes toward alcohol use.
American Indians tend to show higher rates of alcohol problems than the general population, with a death rate from alcohol dependence that is more than five times higher than the rate for other races. Patterns vary widely by tribal affiliation, however, with some tribes drinking more than the general population average and others drinking less. Alcohol use among American Indians is highest and is associated with the greatest number of negative consequences through young and middle adulthood, with a decline in consumption in the forties.
III. Etiology of Alcoholism
Whatever the population, it is clear that a significant minority of individuals drink in an excessive or harmful way. What causes alcohol problems? Historically, this question too often has been answered by pointing to a single cause. In the nineteenth century, drunkenness was the mark of a sinful person who lacked morals or will power. More recently, alcohol problems have been attributed to genetics, an alcoholic personality, or a “dysfunctional” family. It is clear, however, that there are many causes of alcohol problems, which develop out of interacting biological, environmental, and cognitive factors that begin early in life and continue over the course of development. At various points in development, different factors have more or less of an influence on drinking behavior.
A. Biological Factors
Much research has shown that genetics play a role in the development of alcohol problems. This research studies individuals with varying degrees of genetic relatedness to individuals with alcohol problems, and observes the rates at which these different relatives develop alcohol problems themselves. For example, family pedigree studies look at biological relatives of alcohol dependent adults; twin studies examine the rates at which identical and fraternal twins both develop alcohol problems; adoption studies follow children of alcohol dependent individuals who have been adopted by individuals without alcohol problems. The results of contemporary genetic studies strongly support a role for genetics in the development of alcohol problems, particularly among sons of alcohol dependent parents, who are three to four times more likely to develop alcohol problems than sons of nonalcohol dependent parents.
Knowing that genetics plays a part in the development of alcohol problems, researchers have now turned their attention to identifying those processes or deficits that might be genetically transmitted and contribute to alcohol problems. Alcohol problems are often conceptualized as stemming from biologically based difficulties in temperament and self-regulation, defined by Diaz and Fruhauf in 1991 as the ability to “plan, guide, and monitor one’s own behavior flexibly according to changing circumstances.” Self-regulation becomes more sophisticated over the course of development. As children are required to function more independently, they learn skills to help them evaluate situations and change behavior such as self-monitoring of functioning, evaluating functioning in comparison to a standard, and designing and implementing behavior change if needed. Some children make this transition readily, while others fail to become competent self-regulators. Temperamentally difficult children- those showing poor behavioral control, hyperactivity, and impulsivity–are thought to have poor self-regulation. Such children can be difficult to parent. Their heightened activity interferes in the development of self-control skills, as well as in the formation of strong relationships with others such as parents who would help them develop these skills. As individuals develop and are required to behave more autonomously, individuals who are poor self-regulators may be less able to change their behaviors to meet new challenges. As a result, they rely on external sources of regulation such as alcohol and drugs, which in turn tend to impair self-regulation still further. A large body of research has shown that temperamentally difficult children show a greater likelihood of developing alcohol problems as adults.
B. Environmental Factors
Although genetic and biological processes contribute to the development of alcohol problems, environmental factors are also strongly involved. Difficulties in temperament and self-regulation can be thought of as risk factors that interact with personal and environmental factors to lead to the development of alcohol problems. Social learning models of alcohol use and problems emphasize the importance of social reinforcers—reactions from others in the social world that either reward or punish particular behaviors. Positive reactions serve to reinforce drinking behavior, while negative reactions punish such behavior. Also important to such a model are personal, internal events that guide an individual’s perception of the external world, such as attitudes and expectations about drinking.
What environmental factors might be important to drinking behavior? There are multiple levels of environmental influence–more immediate influences include family members and peers, while farther removed factors include aspects of society, culture, and religion. Family and peers strongly influence drinking behaviors by setting examples, altering availability of alcohol, and by encouraging or discouraging alcohol use. Much evidence suggests that adolescents and young adults tend to hold attitudes toward alcohol and show drinking behaviors that are like those of their parents and peers: young individuals who drink tend to have parents and peers who drink. Through these links with drinking others, young people observe the positive features of drinking, learn how to drink, and receive positive feedback for their drinking. Similarly, peer influence appears to have a particularly strong impact on drinking in adolescence and young adulthood. Heavy-drinking youth typically are involved with similarly heavy-drinking peers. Such drinking networks may serve to teach adolescents and young adults how to drink, model appropriate (or inappropriate) drinking behavior, and reward such behavior with attention, movement into a higher social status, and an identity as a drinker.
Along these lines, Jessor describes a problem-behavior theory in which proneness both to problem drinking and to other problem behaviors in youth results from an interaction of personality, environmental, and behavioral systems. Personality proneness to problem behavior includes a low value on academic achievement, a high value on independence, and greater tolerance for deviance coupled with lower expectations of attaining goals and lower self-esteem. Environmental stressors include low parental support and control along with high peer engagement in and approval for deviance. Together these factors have been described as a style of unconventionality. This unconventionality makes for problematic behaviors and stressful interactions with others.
Importantly, environment includes more than just an individual’s home and peer experiences. Characteristics of the person and the immediate environment occur within a larger social context. Cultural ideas about alcohol use, societal attitudes toward intoxication, and laws about the purchase and consumption of alcohol all interact with an individual’s biological, environmental, and cognitive makeup. For example, during Prohibition in the United States, when attitudes were distinctly anti-alcohol and purchasing liquor was illegal, people drank less and experienced fewer alcohol problems. Patterns of alcohol use and problems vary by religious group affiliation. Jews tend to report a high prevalence of drinking but very low rates of alcohol problems, while Catholics tend to report higher rates of both drinking and heavy drinking. An especially important societal influence in modern society is the media. Both visual and print media provide a variety of models of and reinforcers for alcohol consumption. Messages about the positive effects of alcohol (it’s fun and everyone is doing it) are delivered via television, movies, radio, billboards, and magazines. Drinkers are shown as attractive, socially adept, and healthy. In contrast, messages regarding the potentially harmful effects of alcohol on physical and psychological functioning are rarely shown.
C. Cognitive Factors
Recently, the alcohol field has become interested in a third set of factors that influence and are influenced by an individual’s biology and environment. Cognitive factors m beliefs about alcohol and its use, one’s ability to cope with stress, and ideas about what sorts of things might help a person with their problems become increasingly important in decisions to engage in risky or harmful drinking. The young adult who has difficulty with self-regulation, is engaging in multiple problem behaviors, and experiences poor interactions with others is then faced with the more adult task of coping, a skill that has been found to be lacking in adolescents and young adults who drink heavily. In explaining differences between normal and problem-drinking adolescents, some researchers describe a stress-coping perspective in which adolescents who drink the most are using alcohol to cope with high levels of stress and few external rewards. Studies in this area have shown that teens who drink heavily report more life stressors along with poorer coping skills than teens who drink moderately.
In making a decision about how to cope with a stressor or a problem, beliefs about the effects of alcohol appear to be another important cognitive factor. Alcohol expectancies are beliefs that alcohol use will have positive outcomes, such as increased feelings of relaxation, assertion, or general well-being. Alcohol expectancies have been found to be related to differences in drinking behavior in adolescents and adults—individuals who drink more report more positive expectations or beliefs about alcohol and its effects. Moreover, individuals who develop alcohol problems report stronger alcohol expectancies than normal drinking adults. Positive experiences have been found to exist before a child’s direct experience with alcohol, suggesting a role for expectancies in developmental models of alcohol problems. Importantly, alcohol expectancies may connect coping and stress: problem drinking develops from using alcohol to cope with stress by those individuals who lack other means of coping and who perceive alcohol as being able to help resolve bad feelings. Research has shown some support for this view, finding that poor coping is linked to problem drinking in individuals with strong, positive alcohol expectancies. Thus at highest risk for problem drinking is the individual who, when faced with stress, shows low coping self-efficacy (I can’t cope) and has strong positive expectancies about the effects of alcohol (Alcohol will help me cope).
Rogers’ protection-motivation theory emphasizes a person’s perception of risk as crucial to the decision to engage in harmful behavior such as problem drinking. According to this view, health behaviors are guided by perceptions of threat and coping. First, a person must evaluate the likelihood of threat (Will drinking cause bad things to happen to me?) and the severity of the threat (If drinking causes bad things to happen to me, how bad will these things be?). Engaging in the maladaptive response, in this case harmful or risky drinking, is influenced by the interaction of rewards (feeling good, having fun, social approval) and consequences. Second, the individual makes a coping appraisal, a judgment about what alternatives are available and one’s ability to engage in alternative behavior (Are there things to do besides drinking and can I do them effectively?). Rogers stresses the importance of self-efficacy, an individual’s appraisal that he/she is capable of implementing and carrying out the behavior change. Problem-drinking individuals tend to evaluate the threat of problem drinking as low, the severity of potential consequences as low, the alternatives to drinking as unpleasant, and their ability to implement change as minimal.
Thus multiple influences over the course of development interact to produce threats to alcohol health. Alcohol problems can evolve out of inherited difficulties in temperament and self-regulation that lead an individual to engage in problem behaviors and poor interactions with others. With this foundation, a developing person is ill-equipped to cope with the stressors and problems that accompany the transition to adulthood. The balance of rewards that accompanies drinking and the perception of minimal threat contribute to an individual’s maintaining problem alcohol use.
Recently, researchers have become interested not only in the question of who is going to show alcohol problems at one point in time, but also in who is going to continue to have alcohol problems at many points in time. Remember that although young adults experience the highest rates of alcohol use and related problems, these rates decrease substantially in adulthood. These trends suggest that most young adults “mature out” of problem drinking upon entering adulthood. Different reasons for this “maturing out” have been suggested, most prominently that the assumption of adult roles such as work and marriage, along with a decrease in problem drinking among peers, leads young adults to moderate their use into patterns of typical social drinking. Individuals with alcohol problems, however, tend to report that they began drinking and experiencing negative consequences at a young age, so that rather than maturing out, some individuals will continue problem-drinking patterns from youth into adulthood. Some researchers have suggested that these patterns represent different problem- drinking typologies. According to this view, individuals who continue problem drinking over time are likely to be at the greatest risk for developing severe problems in adulthood; thus it is important to identify which young adults will be the ones to continue problem drinking into adulthood. Recent research suggests some qualities that may characterize individuals who will continue problem drinking from youth to adulthood, including having a higher degree of behavioral undercontrol, engaging in other problem behaviors in addition to problem drinking, and using alcohol to relieve negative feelings.
IV. The Changing Nature of Alcohol Abuse Over Time
The above discussion highlights some of the many factors that influence the development and continuation of alcohol problems over time. It is important to remember that alcohol problems vary widely: some individuals develop risky, harmful, or dependent patterns, and some cycle in and out of these various use patterns. Rather than being stable, alcohol problems change and develop over time and show a range of outcomes. Vaillant has provided the clearest illustration of this variability in his research on the natural history of alcohol problems. He has followed a large sample of men for more than 50 years, 110 of whom had experienced alcohol abuse at some point in their lives. These men drifted in and out of alcohol problems: some were abstinent for long periods of time, others relapsed to heavy or risky drinking, and others returned to dependent patterns of drinking. In his most recent follow-up of these men, now in their 70s, Vaillant stressed that alcohol abuse can have different paths for different people, sometimes progressing to more severe drinking, sometimes remitting, and most often varying in severity over time. Vaillant’s data illustrate that within an individual problem-drinking path there are many twists and turns, with periods of harmful and risky drinking interspersed with periods of moderate problem-free drinking or abstinence.
V. Risk and Protective Factors
What factors put individuals at increased risk for alcohol problems? A public health model offers a useful framework for describing different types of risk factors and illustrating how they interact to influence outcomes. As with other complex disease processes, this approach highlights three kinds of risk factors– agent, host, and environment–to be considered in understanding the development of alcohol problems. The agent in infectious diseases is a bacterium or virus, but in this case the agent is alcohol. Alcohol has its own destructive properties, much like a particular virus can cause specific symptoms and damage. Yet in most diseases, only some individuals who are exposed to the agent actually come down with the disease. Similarly, only some individuals who are exposed to alcohol develop problems, highlighting the importance of host factors–individual characteristics that increase or decrease risk of alcohol problems. There are many such factors that are involved, including biological and psychological influences. One of the most important is gender. Men are more often drinkers and show a greater likelihood of drinking at a risky or harmful level at all ages. A family history of alcohol problems also is a significant risk factor. Evidence from family, twin, and adoption studies suggests that a genetic vulnerability contributes to alcohol problems in some individuals, especially in sons of alcoholic fathers. Yet even identical twins may differ in whether or not they develop alcohol problems, indicating the role of environmental factors in addition to agent and host factors. Age also constitutes a significant risk factor for problem drinking young adults show the greatest use and greatest number of alcohol-related problems of any age group. In his study of the natural history of alcohol problems, Vaillant found that more than half of the individuals who would meet diagnostic criteria for alcohol abuse did so by age 31.
Other host characteristics include temperament, coping skills, expectancies, and other psychopathology. As described earlier, temperamentally difficult children show a greater likelihood of developing alcohol problems as adults. Relatedly, individuals with alcohol problems tend to show poorer coping skills and to use alcohol to cope with the pressures and stresses that face them. As discussed earlier, individuals with strong, positive expectancies for alcohol (expecting alcohol will help relieve bad feelings) are more likely to drink and to develop alcohol problems. Finally, research shows that experiencing a psychological problem such as depression or anxiety, greatly increases risk for developing an alcohol problem.
A third relevant domain is the environment. As discussed earlier, environment can be defined in a number of ways. Immediate environmental risk factors for alcohol problems include heavy or other problem-drinking family members who not only contribute possible genetic influences but also serve as role models for alcohol use and create a stressful home environment that may contribute to alcohol use. For adolescents and young adults, peer influences are among the most important– being part of an alcohol-using peer group increases risk for alcohol problems in these populations. Aspects of the larger environment are also relevant. Heavy-drinking communities show greater rates of alcohol- related problems. Cultures that sanction liberal use of alcohol likewise show higher rates of risky and harmful drinking. Stress may also be an important environmental risk factor: research suggests that severe and prolonged stress appears to be an important factor in problem drinkers returning to drinking after a period of abstinence.
While there are characteristics that put people at increased risk for alcohol problems, there are also factors that protect individuals in the face of these risks. Protective factors are not merely the opposite or lack of risk factors. Rather, they are influences that moderate the links between risk factors and alcohol outcomes such that an individual may be exposed to risk but show resiliency and avoid problem alcohol use. Several protective factors have been identified in adolescents and young adults, including close and positive relationships with parents, adolescent conventionality, parental adjustment, and success in school. Religious affiliation and involvement appears to be a strong protective factor. Individuals who report strong religious beliefs or high levels of religious commitment consistently show lower levels of alcohol use and fewer alcohol- related problems. In contrast, individuals with alcohol problems are less likely to report firm religious beliefs or involvement. In addition, social support has been found to play an important protective role: individuals engaged in supportive relationships with others appear less likely to develop alcohol problems, and social resources are thought to offset other potentially harmful stressors and risks. It also makes a difference whether one’s social group supports abstinence, moderation, or risky and heavy drinking.
VI. Continuum of Intervention for Alcohol Abuse
From the previous discussion, it is clear that alcohol problems encompass a range of risk factors and difficulties that vary along a continuum of severity. All individuals are exposed to some risk factors; many individuals experience multiple risk factors that make them increasingly vulnerable. Some individuals are just beginning to develop problems with alcohol; others already have well-developed dependence. Such diversity necessitates a variety of intervention strategies. Any single type of prevention program is not likely to reach all who are at-risk, and one brand of treatment will not be effective for all problem drinkers.
At one end of the continuum are universal prevention strategies, designed to target a large population with the goal of reducing the incidence of alcohol problems; for example, by increasing awareness of risks and promoting alternatives to alcohol use. A target population might be all individuals in a particular city, school district, or university campus. An example of a universal prevention strategy is instituting an excise tax on alcoholic beverages that makes alcohol more expensive, with the result that people purchase less. Print and electronic media campaigns are also designed to reach large groups of people with their alcohol- related messages. Universal prevention strategies target everyone in a population, regardless of their level of risk for developing problems.
Other interventions focus on individuals who are at high risk for developing problems. Termed targeted prevention strategies, such interventions are aimed at particular groups who have not yet developed a problem but are at increased risk due to their exposure to particular or multiple risk factors. Examples of such high-risk groups are children of parents with alcohol problems, adolescent boys with behavior problems, and college students with poor grades. The goal of targeted prevention is to stop a problem before it starts, or at least early in its development, by intervening with those at highest risk. For example, programs in college dormitories, fraternities, and sororities are aimed at providing information to individuals at high risk for drinking and related problems.
Prevention is aimed at individuals who have not yet developed problems. Once an individual is identified as having an alcohol problem, the focus of intervention shifts toward treatment. Individuals identified as already having an alcohol problem may be referred for some sort of intervention or treatment. However, only a small percentage of individuals with alcohol problems ever receive formal treatment. A critical bridge between developing problems and receiving treatment is the person’s motivation for change. Strengthening the commitment to change constitutes an important first step, and may need to be addressed before treatment takes place. Effective methods are available for enhancing motivation for change. Among the important elements of such interventions are providing personal feedback about drinking, empathic listening, acknowledging a range of alternatives for working toward behavior change, and emphasizing personal responsibility and ability to make change happen. Such motivational interventions are designed to help an individual become more aware of the impact of his/her drinking and to instill a commitment to change.
This discussion has emphasized the diversity of alcohol problems along a continuum of severity. The implication of this diversity is that what is helpful or appropriate for a drinker just beginning to develop an alcohol problem will differ from the most effective treatments for more severe, dependent drinkers. Individuals who are just beginning to show signs of problem alcohol use might fit the description of “risky’ or “harmful” drinkers who are drinking heavily or in potentially dangerous situations. Intervention with these individuals is aimed at recognizing a problem early and preventing it from reaching diagnostic levels. For example, businesses have employee assistance programs where personnel are trained to recognize the early signs of alcohol problems in their employees. Other early identification strategies include urine drug-screening programs, justice system referrals, screening during routine health care, and programs for impaired drivers. Individuals at the beginning stages of problem development are often helped by brief interventions– motivational strategies that help individuals see their increasing involvement with alcohol and the negative consequences they may experience as a result. These interventions are usually one or two sessions of alcohol-related counseling and advice to reduce drinking. Some brief interventions involve providing clients with reading and other educational materials that review drinking patterns and ways to reduce drinking. Studies have consistently found that such brief interventions help problem drinkers reduce their alcohol use.
What about individuals who are far enough along the continuum to have developed more severe alcohol problems? There now exist a range of promising and effective approaches for use with different types of drinkers. As individuals with alcohol problems frequently have difficulties in many areas of functioning, several interventions are often combined. For drinkers with more severe problems, detoxification may be necessary to overcome the acute effects of alcohol withdrawal. With proper supervision, an addicted drinker is through the worst withdrawal within a week, and modern medical care can prevent the more uncomfortable and dangerous symptoms of alcohol withdrawal. Detoxification, however, is not treatment. Simply detoxifying a dependent drinker is unlikely to have any long-term effect on drinking.
Various medications have been tested in treating alcohol problems. One of the most popular of these is disulfiram (Antabuse)–a medication that produces a negative physical reaction (nausea, vomiting) when alcohol is ingested. Naltrexone (ReVia) also appears to be a promising agent in reducing relapse and craving. Medications, however, are only an aid in treatment, and are unlikely to be effective when given without other treatment.
Some view alcohol problems as a lack of coping skills. Skills-training approaches view alcohol use as a maladaptive coping strategy, and teach appropriate coping skills as an alternative to drinking. Social skills training is used to help individuals with alcohol problems to interact effectively with other people, to cope with positive and negative feelings, and to handle stressful situations in the environment. The community reinforcement approach similarly emphasizes the need for the drinker to be prepared to cope with stress, and to establish a rewarding, alcohol-free life-style. Efforts are made to get individuals connected to community resources, social supports, employment, and other activities that would contribute to a rewarding life-style without alcohol. From this perspective, the focus is not only on stopping alcohol use but also on helping people to acquire skills and make changes that will support an alcohol-free life-style.
Alcohol problems often affect family functioning. Behavioral marital therapy (BMT) regards the marital relationship as crucial in the maintenance and change of an individual’s drinking behavior. BMT is designed to improve communication skills, teaching spouses how to reinforce changes in drinking behavior, and ways to cope with drinking-related situations and feelings. There are also effective approaches to help concerned family members and friends of individuals with alcohol problems, even if the drinker is unwilling to accept help. These concerned others often wish to help their loved one but lack the knowledge and skills to do so. Concerned family members can be helped to engage the problem drinker in treatment. Such treatments also attend to the needs of the family members themselves– to distance themselves from the drinker and to learn skills for coping with stress and other negative feelings.
Recovery from alcohol problems typically involves relapse. Effective treatment often includes attention to the people, places, and things that are likely to trigger alcohol use in the future. Marlatt’s relapse-prevention (RP) incorporates cognitive-behavioral strategies aimed at anticipating slips and considering how to handle high-risk situations. Specifically, RP stresses anticipating and working to prevent relapses and realistically considering how to recover and learn from relapses if they occur. To this end, clients identify specific high-risk situations and outline a plan for making it through without drinking.
For individuals with less severe drinking problems, strategies to teach skills for moderate drinking are sometimes used. Moderation training programs are designed for risky or heavy drinkers who might not participate in treatment aimed at total abstinence, but who could benefit from reducing their alcohol use. For example, behavioral self-control training (BSCT) teaches clients skills for moderating their drinking. BSCT makes use of behavioral principles of self-control and teaches ways to self-monitor drinking, to set goals for decreasing consumption, and to implement alternative coping skills. BSCT and programs like it may be used with either abstinence or moderation goals.
The above interventions all involve the individual with alcohol problems seeking assistance from a trained professional. Although outcome studies strongly support the efficacy of these treatment strategies, the fact remains that most individuals with alcohol problems never receive professional help and yet “recover” without formal intervention. Many of these drinkers will seek help not from professionals but from others with similar problems. Particularly in North America, mutual-help groups serve as a major source of help and support for many individuals with alcohol problems. The largest and best-known of these groups is Alcoholics Anonymous (AA), serving over two million members in 150 countries around the world. AA emphasizes commitment to abstinence and renewed spirituality recognizing the strength of a “higher power” as necessary to the change process. Other self-help groups, such as Women for Sobriety, SMART Recovery, Rational Recovery, and Moderation Management, emphasize personal control and responsibility in overcoming alcohol problems.
Alcohol problems encompass a range of difficulties. Some individuals with alcohol problems experience minor difficulties in a one area of functioning. Other individuals experience substantial impairment in multiple life areas due to their alcohol use. In this research paper, we have reviewed factors that put people at risk for alcohol problems, as well as theories that seek to explain how alcohol problems develop. There now exists a range of interventions for individuals at all levels of the alcohol problems spectrum. Future research will add to our knowledge of alcohol problems and yield important new information about how such problems develop and how they can be most effectively treated.
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