The theoretical explanations put forward to explain alcohol dependence

This assignment aims to evaluate current theoretical explanations that are relevant to the field of addiction and to explore the reasons and intentions behind various prevention programmes for hazardous drinkers. There are many different types of theoretical explanations and models relating to addiction, and most research has focussed on alcohol dependency. (Ogden, 2004)

However it is important to define what is meant by the term ” addiction”; Goodman (2005) puts forward the following as a definition for addiction:

A process whereby a behaviour, that can function both to produce pleasure and to provide escape from internal discomfort, is employed in a pattern characterized by recurrent failure to control the behaviour and continuation of the behaviour despite significant negative consequences.

Although the term ” addiction” is still widely used current theorists and scholars are tending to use the term ” dependence” in modern research and studies.

People can become dependant not only on external substances that are ingested but also to risky behaviours such as gambling, extreme sports etc.

In this respect anything that induces a pleasurable physiological change has the potential to lead to dependence or addiction.

Brain cells have a central core covered by a sheath, at one end of the cell are roots at the other end ” fronds”. A charge is passed through the fronds to the fronds of another brain cell and neurotransmitters are released, these neurotransmitters are responsible for feelings of euphoria and heightened pleasure. Some substances mimic neurotransmitters or may cause receptors to cut out; the use of some substances (such as alcohol or opiates) may cause the brain to stop producing neurotransmitters leading to dependence.

Orford and Heather (2003) have identified the puzzling aspect of addiction, the fact that although the addict wants to give up the addiction they often find themselves returning to the substance or action that they are dependant on. ” The core phenomenon of addiction and it’s most puzzling aspect is the fact that the addict returns repeatedly to a form of behaviour that he or she has vowed to give up” (Orford and Heather, 2003, online)

There are three main approaches that can be used to explain theories of addiction; these are the psychological approach, the biological approach and the environmental approach.

The psychological approach looks at addiction from a psychodynamic point of view, there are a variety of treatments i. e. cognitive therapy, psychoanalysis etc. (Ogden, 2004). Freud suggested that all individuals go through stages of psychosocial development and this development is connected to different erogenous zones. These zones represent different areas of the body and if these stages of development are not satisfied an individual may become fixated with this zone i. e. if a child is weaned too soon the individual may have an oral fixation and be more susceptible to developing an addiction such as smoking. (Ogden 2004)

Freud argued that an addiction may be the result of either latent homosexuality or a need for oral gratification. This perspective emphasis a psychological abnormality and predates the onset of addictive behaviour. (Ogden, 2004, p. 107)

Under the umbrella term of psychological approaches comes ” social learning theory”. This is an explanation of behaviour that puts forward the theory that individuals generally learn by association and mimicking the behaviour patterns of others, particularly role models. (Stuart-Hamilton, 1999).

Albert Bandurra illustrated this explanation by carrying out experiments with children and ” Bobo dolls”. This experiment showed two films of a female authority figure playing with toys, including an inflatable Bobo doll. One film illustrated the person playing sensibly and the same person was filmed playing aggressively towards the Bobo doll. The children were divided into two similar groups, one group was shown the positive film and the other was shown the negative film.

The children who had seen the positive behaviour mimicked this positive behaviour towards the Bobo doll and the children who had seen the aggressive behaviour carried out similar behaviour patterns to the one that they had observed. (Stuart-Hamilton, 1999)

The outcome of these experiments strengthened Bandurra’s theory that behaviour is learned through observation of others, especially role models. Early in life role models tend to be the child’s parents or primary carers. However, later on in the child’s development more importance is placed by young people onto peer group acceptance and being part of a group. (Guptal and Deverensky, 1997).

Guptal and Deverensky, however found that young people and adults often maintain familial behaviour patterns that they were exposed to as young children. Four hundred and seventy seven children between the ages of nine and fourteen took part in a questionnaire that aimed to analyse their gambling habits and their attitude to gambling behaviour. Those that gambled at an early age with members of their family were more likely to take up gambling with their friends or as an isolated activity during adolescence.

Also adolescents who came from a family that regularly gambled saw this as socially acceptable behaviour and were more likely to mimic this behaviour when with their peer group. (Guptal and Deverensky, 1997)

It is common with people, who have a reliance on a substance or an action to have other psychiatric diagnosis, all theories should take into account co-morbidity i. e. a number of reasons for behaviour, there is a high incidence of people who are alcohol dependant suffering from mental illness. There is often doubt as to what came first, the mental illness or the dependant behaviour for instance it is widely debated by scholars and psychiatrists whether drug use is a predeterminant for schizophrenia or whether schizophrenia leads to drug use. (Ogden, 2004)

The biological approach to addiction defines the individual as having a biological predisposition to substance dependency. This approach reflects the medical model of dependency in which the addicted person is seen as ” defective” in some way and needs a medical intervention to correct their deviant behaviour. These models are sometimes referred to as Disease Models of addiction. (Booze and Drugs. com, 2005)

The biological approach to addiction suggests that anyone can become dependant; early theorists put forward that continued use of substances was the addicts’ way of relieving withdrawal symptoms. However, most addicts after going through the detoxification process took substances again thereby discrediting some early theorists. (Crossley, 2000).

Also under the umbrella term of ” biological approach” comes ” genetic theories; these put forward the argument that the dependant person has a genetic predisposition to addictive behaviours. These theories have been validated through studies that have been carried out on monozygotic twins.

An example of a study into genetic predeterminants of alcohol addiction is that described by Cadoret et al (1995). These studies were done on people that had been put up for adoption and the biological parents had an alcohol dependency. The results showed that there was a three to four fold increase in this group of developing a dependency on alcohol over the rest of the population. (Cadoret et al 1995)

Although these studies suggest that there is a genetic predisposition to dependency Cadoret et al do not indicate whether or not there is a heightened risk factor for dependency due to other factors that are related to their adoption.

There are certain races i. e. Eskimos, American Indians, and Asians who are genetically predisposed to lack the production of an enzyme called ” acetaldehyde” which is necessary for the breaking down of alcohol by the liver. These groups have a severe and immediate reaction when alcohol is consumed. Although the metabolic process is quite similar in all of these races the effect of addiction to alcohol is quite different.

American Indians and Eskimos are more likely to become addicted to alcohol than Asians, although studies have shown that American Indians and Eskimos are more predisposed to other addictive behaviours such as gambling or drug taking. This has raised the argument that one gene may be responsible for multiple addictive behaviour. (Sparknotes, 2005)

Another aspect of the biological approach to addiction is ” Exposure Theory” ” The exposure model is based on the assumption that the introduction of a substance into the body on a regular basis will inevitably lead to addiction” (Sparknotes, 2005. online). Explanations for this are that some substances, when introduced to the body, cause a change to the body’s natural endorphin producing capabilities. Endorphins are naturally occurring painkilling substances that bring about pleasurable feelings, the body can become reliant on the substance to release these endorphins either to avoid the withdrawal sensation or because the body has cut down on natural production.

The bio-medical model of disease seeks to overcome the problem of addiction through the application of scientific principles:

The patient becomes a problem to be solved, and the solution to that problem lies in adopting a scientific, mechanistic approach that precludes any consideration of social, psychological or behavioural influences. (Crossley, 2000, p. 18)

The ” Environmental Approach” to dependency looks at the social and cultural context of addiction. Society accepts some drugs and not others i. e. in the UK cigarettes and alcohol are legally available (dependent on age) whereas crack cocaine and heroin are not socially acceptable. Other cultures have different socially acceptable substances, for instance Khat is used in parts of North Africa as commonly as western cultures use tea and coffee. However Khat can have a damaging effect on individuals and society by causing poor health, lethargy, poverty, unemployment etc.

It is not unusual for society to have its own acceptable drugs; however what is considered an acceptable substance can vary from culture to culture. Also attitudes can change over time due to how much evidence is available about the substance; an example of this is cigarette smoking. In the early part of the 20th Century tobacco smoking was becoming popular throughout the population of the UK. It was promoted as a health giving substance and it was not until the 1950s and 1960s that evidence began to emerge from the USA that tobacco was detrimental to health. (Ogden, 2004).

Smoking tobacco has in recent years become less socially acceptable to the point where some pubs and eating places have got segregated smoking areas. In Southern Ireland smoking has been banned in all public meeting places, this has been enforced by fining any establishment where people are found to be smoking.

A number of theories suggest that people that come from socially deprived areas and have lower socio-economic status are more prone to addictive behaviours. (Ogden, 2004). However, people from lower socio-economic groups are more likely to have intervention from the state, such as contact with health or social service professionals. People from higher socio-economic groups are more likely to have private health care provision or their profession may be more likely to provide support. There may also be mechanisms in place to provide long term paid leave or a more flexible working environment that takes away some of the financial pressure of long term dependency.

Dependency may be a learned behaviour that is passed down through the generations; the main predictor for smoking amongst children is having a parent who smokes: In addition parents’ attitudes to smoking also influence their offsprings’ behaviour , for example if the child perceives the parent to be strongly against smoking he/she is seven time more likely not to smoke. (Ogden, 2004, p. 112)

Understanding the theoretical framework of addiction will help practitioners analyse how and why people become addicted to certain behaviours or substances. Once the practitioner feels that they have an understanding of the client’s addictive behaviour appropriate intervention strategies can be put in place. An intervention is a way of coming in between the person and their behaviour.

Current thinking in the field of addiction is that ” Brief Intervention Strategies” have a more beneficial and cost effective outcome than periods of hospitalisation. (Bien et al 1993) Hospitalisation can lead to a breakdown of social networks, feelings of isolation and a non realistic environment away from many of the triggers for dependant behaviour. (Ogden, 2004).

There is evidence showing that effective interventions for the treatment of dependency are techniques such as motivational interviewing, community reinforcement programmes and social skills training. (Finney and Monahan, 1996) It could be argued that a possible reason for their success is that they all require the individual to realise that they have a role to play in their treatment. There is also evidence that suggests that these types of interventions are cost effective.

Finney and Monahan’s research has indicated that interventions such as electrical aversion therapy, video tape self confrontation therapy, group therapy and individual therapy are less effective than those previously discussed. (Finney and Monahan, 1996). Electrical aversion therapy may only deliver a positive outcome for a short period of time this therapy reflects Pavlov’s theory of operant conditioning where electric shocks are administered when a certain act is undertaken. Pavlov used dogs to test his theory that behaviour could be altered by using external shock tactics. He placed dogs inside a cage that had two doors, entry through one of these doors would trigger a small shock to be administered to the dog and after a short time the dogs learned not to use that particular door.

Some theorists thought that a similar treatment could be effective for people with a substance dependency. Research has shown that long term success rates are poor when using this method of intervention. (Brady and Sonne 1999)

Even though some treatments have higher success rates than others all avenues should be explored when treating someone with a dependency as each case is different with its own individual merits and history. However brief intervention programmes undertaken within the community seem to have the most effective outcomes. (Brady and Sonne, 1999).

Brief intervention strategies often involve motivational interviewing techniques. Motivational interviewing techniques use open ended questions allowing the individual to come to conclusions, enhancing self-awareness and promoting responsibility for the self. Directive interviewing takes on a medical viewpoint by telling the interviewee that they have a problem and what they should do to solve that problem. Current thinking in brief intervention strategies does not advocate the use of directive interviewing techniques as a more holistic approach is seen to have more effective outcomes. (Brady and Sonne, 1999)

Motivational interviewing encourages the treatment participant to go through a process of change. Prochaska and Diclemente (1986) identified a ” stages of change model”; the first step on this change process involves pre-contemplation. This identifies the situation before any change process occurs. The next stage ” contemplation” needs the individual to comprehend the current situation and realise the need to, and method of, change. This stage may have an element of urgency and may be precipitated by a crisis situation. (Ogden, 2004)

Following contemplation comes ” preparation to change” this may be seen to be a positive step in the right direction and involves deciding which path to take and when to implement changes. ” Action” another positive step in the right direction and this stage puts an emphasis on carrying out the actions that have been decided in the previous stage.

The ” maintenance” of positive behaviour change may include periods of relapse and earlier stages of the process may be revisited. Also stages of the process may inter-change. (Ogden, 2004)

In recent research and development of treatment interventions ” the transtheoretical model of behaviour change” has been widely used. Identification of what stage the individual is at is important when ascertaining which type of treatment will be effective: For example, a smoker who has been identified as being at the preparation stage would receive a different intervention to one who was at the contemplation stage. (Ogden, 2004, p. 23.)

John et al (2002) cited evidence of brief opportunistic interventions as being effective in the prevention of alcohol misuse. Young men attending accident and emergency units to have stitches removed from facial injuries were given ten to twenty minutes of brief intervention. This intervention consisted of making the individual aware of what consisted of a unit of alcohol and educational information about risks associated with over the limit alcohol consumption.

After three months and twelve months this group was re-visited and contrasted with a similar group who had not had a brief intervention. It was found that the intervention group was drinking significantly less than the control group.

This assignment has aimed to analyse current theories and methodology in the field of addiction and also take a brief look at intervention strategies and preventative measures that can be used with people who have a dependency on a substance or action. There is no one method of analysing and treating a dependency that is the most effective method, however it is important to remember that addictive behaviour differs with each individual.

The American Government expect research and treatment into alcohol dependency to have as its main goal total abstinence, therefore treatment normally starts with a period of de-toxification. However, in the UK research and treatment have recently focussed on controlled drinking rather than complete abstinence and treatment is often used to intervene before total dependency occurs.

Intervention programmes for people with a dependency can take many different forms. These can range from medical interventions such as narcotic antagonists which block the desire for substances to cognitive behavioural approaches which seek to adjust a person’s behaviour by analysing their thought processes however, treatments that engage the individual seem to have more effective outcomes than directional treatment measures.