Alcoholism in psychological thought: from ancient Greece to modern interventions

Chemical Dependency, Particularly Alcoholism, Within the History Of Psychology

Since the dawn of humankind, people have been experimenting with various chemicals for recreation, to alter their conscious state for religious purposes, or for medicinal applications. Indeed, a vast cornucopia of pharmaceutical preparations has been identified over the millennia that provide modern healthcare consumers with remedies for many human ailments, and more are being developed and identified every day. Used properly and under the supervision of healthcare providers, these chemical substances can deliver analgesic relief, reduce fevers and inflammations, cure diseases and much more. Used improperly, though, the abuse of many chemicals, particularly alcohol, has been a plague on humankind since fermented berries were first discovered, creating the need for timely and effective psychological interventions today. To gain some additional insights into the history of psychology as it relates to chemical dependency in general and alcoholism in particular, this paper provides a critical review of the relevant peer-reviewed and scholarly literature, followed by a summary of the research and important findings in the conclusion.

Review and Discussion

Context in which the topic was born and developed

The roots of modern psychotherapy are attributed to the ancient Greeks, and the context in which the practice emerged remains largely unchanged today. For example, McGillicuddy-De Lisi and De Lisi (2002) report that, "The ancient Greeks counseled people to seek moderation in all things. But the history of psychology shows that not many people heeded this advice. The literature is filled with either/or debates" (p. 183). Given its subsequent influence on shaping psychological thought, it is not surprising that a majority of modern psychology textbooks include specific references to this period. In this regard, Henley and Thorne (2005) report that:

Most history of psychology textbooks cover the Ancient World in some detail. For example, such books often discuss the importance of rational medicine, the contributions of Plato to all subsequent conceptions of mind, and Aristotle's thoughts on many topics covered in an introductory psychology course (associative learning, the causes of behavior, dreams, emotions, free will, language, memory, motivation, perception, reasoning, etc.). (p. 104)

The so-called "modern period" of psychology began in the 16th and 17th centuries based on the work of principal figures such as Descartes, Leibniz, and Locke) (Henley & Thorne, 2005). In addition, Henley and Thorne suggest that, "Understanding Wundt requires at least a cursory consideration of the various empirical, associative, faculty, and rational traditions that preceded him" (p. 104).

By the fin de siecle and heavily influenced by Freud, Jung and other human developmental theorists, psychologists increasingly turned their attention to the deep-seated motivations that drove behavior (McGillicuddy-De Lisi & De Lisi, 2002). Although the context in which psychology has developed over the years continues to be defined by the frailty of the human condition, the fact that people have been unwilling or unable to practice moderation in their lives throughout history suggests that when people find a substance that makes them feel good, some will abuse this substance to the point where it interferes with their lives.

Today, the need for psychological interventions for chemical dependency is based on the multifaceted manner in which the problems associated with the condition are manifested. For instance, people with chemical dependencies tend to experience a wide range of adverse outcomes, including problems with their personal and social relationships, employment, financial difficulties, involvement with the criminal justice system, as well as a host of health-related conditions (Esterly & Neely, 1999). Moreover, psychological interventions for chemical dependency are frequently necessary because of the numerous ways that individual problems are experienced. For instance, Esterly and Neely add that, "The problems may be extremely severe or relatively mild, and they may or may not be recognized by the person involved. The problems may have existed over a long period of time or they may be of a more recent vintage. Whatever the case, without proper help or treatment, the problems are sure to worsen" (1999, p. 1). Moreover, the costs that are associated with chemical dependencies are truly alarming. In this regard, McKay and Hiller-Sturmhofel (2011) report that, "Alcohol and other drug (AOD) use disorders (i.e., AOD abuse and AOD dependence) are substantial public health problems, affecting approximately 10% of the population and resulting in economic costs to the Nation of around $360 billion annually, with roughly half of this amount attributable to alcohol use disorder" (p. 356). Given the enormous human and economic impact that chemical dependencies have, it is therefore important to determine the manner in which psychological treatment regimens have been developed and administered over the years to identify trends and current best practices and these issues are discussed further below.

How changing times have influenced topic area

As a helping profession, psychology would not exist unless there was a need for such services and the demand that exists at a given point in time will likely be a driving force in shaping the specialty areas pursued by psychology students. This has certainly been the case with the evolution of psychology in response to the increasing use and abuse of various substances that can have mind-altering and life-changing implications. For instance, Pacione and Jaskula (1999) report that, "The drug epidemic and the resulting 'war on drugs' markedly increased the demand for drug and alcohol treatment" (p. 55). The long-term psychological interventions that are required for chemical dependencies, though, are expensive and there has been a push to identify efficacious treatment interventions. In this regard, Pacione and Jaskula add that, "This demand, coupled with heightened concern over the escalating cost of mental health and chemical dependency care, creates a challenge for clinical and administrative social workers to provide quality chemical dependency treatment that is cost-effective" (p. 55). This combination of growing demand and the need for more cost-effective treatment modalities has continued to fuel the search for optimal clinical interventions, and these issues are discussed further below.

Critically analysis of shortcomings in the area chosen

One of the more perplexing aspects of chemical dependency is the difficulty in treating it effectively and preventing relapses that will destroy all treatment efforts to date. Despite decades' of research, including dozens of randomized clinical studies, the results to date have been mixed with respect to the efficacy of various psychotherapeutic interventions for chemical dependency in general and alcoholism in particular. As Thombs and Osborn point out, though, "The fault for the gap between practice and research does not rest entirely with chemical dependency counselors. The research community has been slow to collaborate with practitioners and to make research findings more accessible. This predicament is not unique to the addictions field. Similar problems have been noted in other professions and organizations" (2001, p. 450). Indeed, the treatment of chemical dependencies in general and alcoholism in particular has been a challenging enterprise from the outset.

According to Mckay and Hiller-Sturmhofel (2011), the current approach to treating alcohol dependency typically involves an initial intensive stage that is addressed on an inpatient basis; once individuals are stabilized and their withdrawal symptoms are resolved, they are provided with a less intensive stage that is usually provided on an outpatient setting basis, frequently at a different facility from the inpatient setting. These authors advise that, "In most cases, the approach used by these programs is the 'Minnesota Model,' a 28-day inpatient/residential rehabilitation program that was developed at the Hazelden Foundation and other residential programs" (Mckay & Sturmhofel, 2011, p. 356). The Minnesota Model is based on the 12-step Alcoholics Anonymous guidelines; however, the Minnesota Model provides a more holistic approach to treating the whole person with respect to mind, body, and spirit (Mckay & Sturmhofel, 2011).

Following completion of the inpatient and outpatient phases of treatment, people are typically referred to various 12-step programs for continuing care purposes (McKay & Sturmhofel, 2011). Besides the foregoing modalities, patients may also be encourage to take part in outpatient aftercare group therapy sessions to smooth the transition from the protected inpatient environment into the "real world." While this treatment approach has been found to be effective for a number of people, it has two major constraints as follows:

1. The approach typically has been relatively inflexible, with little room for adapting to a given patient's characteristics or needs. In recent years, however, treatment programs based on the Minnesota Model have become more flexible, particularly during the continuing-care phase.

2. The Minnesota Model's exclusive focus on the AA/NA principles and philosophy, which are embraced by many AOD abusers but rejected by others. As a result, for patients who are not willing to follow the AA/NA rules and recommendations, the Minnesota Model is not a viable treatment option (Mckay & Hiller-Sturmhofel, 2011, p. 357).

While this traditional approach continues to be widely used for the treatment of chemical dependencies in general and alcoholism in particular, the search for treatment modalities that draw on the best attributes of the Minnesota Model while addressing the foregoing shortcomings continues, and these issues are discussed further below.

How changing times have led to this area rising or falling in prominence

There have been a number of treatment models developed in recent decades for chemical dependency, varying in content, duration and ideological approach. Over time, one treatment regimen may gain prominence by virtue of its efficacy in high-profile celebrity cases, while others diminish in prominence. Likewise, ideological perceptions regarding different treatment regimens may shift as evidence-based results become available and further research is conducted. As a result, it has become increasingly important to identify what treatment approaches are preferred by chemical dependency counselors because as Thombs and Osborn point out, "Ideology influences clinical decision making, and treatment strategies are derived from differing assumptions about the nature of addiction problems" (p. 451).

Just as paradigm shifts have taken place in other fields, the treatment of chemical dependencies remains dynamic rather than static, and new research and empirical observations from the field continue to reshape current thinking about what treatment interventions are optimal for a given individual. For example, O'Farrell and Fals-Stewart (2003) report that, "Nearly 30 years ago the U.S. National Institute on Alcohol Abuse and Alcoholism (NIAAA) hailed marital and family therapy as 'one of the most outstanding current advances in the area of psychotherapy of alcoholism.' This NIAAA report also called for controlled studies to test these promising methods" (p. 121). An analysis of family treatment studies conducted during the period 1950 to 1975, though, showed that there was a dearth of studies that demonstrated the efficacy of the family treatment approach (O'Farrell & Fals-Stewart, 2003).

The research concerning the efficacy of treatment modalities such as marital and family therapy (MFT) and behavioral couples therapy (BCF) for alcoholism has produced several salient findings as follows:

1. Evidence supporting behavioral couples therapy (BCF) has grown; studies show better drinking and relationship outcomes for BCT than for individual treatment, and recent studies show BCT has additional beneficial outcomes (e.g., reduced domestic violence, cost-benefit ratio of 5:1; improved functioning of the couples' children).

2. The disulfiram contract procedure, the type of BCT alcohol-focused behavioral contract with the greatest research support, should be disseminated to the treatment community as part of a BCT treatment package.

3. The Counseling for Alcoholics' Marriages (CALM) Project's "sobriety contract" also should be considered for dissemination.

4. Family systems therapy (a) had less drinking than individual treatment or a waitlist control in two studies, (b) retained couples with more troubled relationships in treatment better than BCT, and (c) had the first studies to treat the entire family and examine children's ratings of outcome.

5. The first controlled study of a family disease approach did not find an advantage for adding an emphasis on AA and Al-Anon to BCT (O'Farrell & Fals-Stewart, 2003, p. 123).

Despite the shortcomings that are associated with various treatment modalities, some clinicians may become tied to a certain psychological model because of their familiarity and comfort with it, a human predisposition that may place chemically dependent clientele at a disadvantage. For instance, Thombs and Osborn note that, "Disease model practitioners may not be receptive to, nor adequately prepared to adopt, new practices that deviate from their personal experience. Thus, there is a need for training programs that prepare practitioners for change" (2001, p. 452). Nowhere is this need more pronounced than in developing cultural-sensitive treatment approaches for chemical dependencies in an increasingly multicultural society, and these issues are discussed further below.

Examination of the topic within the framework of diversity

There is a growing recognition within the psychological community that there is no "one-size-fits-all" treatment modality available that works equally well in all situations with all types of people. For instance, in their text, The Handbook of International Psychology, Stevens and Wedding (2004) cite the "continued growth of the discipline and profession of psychology, the proliferation of scientific and applied specializations, regional revitalization, the expansion of psychology in developing countries, the feminization of psychology, and the emergence of new paradigms that accentuate contextual realities and challenges (e.g., multiculturalism and indigenization)" (p. 481). Significant cross-cultural differences between clinicians and patients can adversely affect the therapeutic alliance in ways that confound even the most thoughtful and careful psychotherapeutic approach, a constraint that is especially pronounced in chemical dependency treatment settings. For example, according to Campbell, Essex and Held, "Since the 1970s increased attention has been paid to the chemical dependency treatment needs of population subgroups by social work and other human services professions" (1999, p. 63).

Diversity is not limited to cross-cultural issues, though. In fact, among the various groups identified by the National Institute on Alcohol Abuse and Alcoholism is the so-called "multidisabled" group, comprised of people with mental or physical disabilities as well as chemical dependency problems (Campbell et al., 1999). Although there has been some research concerning psychological interventions for patients who suffer from chemical dependencies and physical disabilities, there remains a paucity of timely and relevant research for people with learning disabilities (Campbell et al., 1999). Generally speaking, the types of learning differences that are comorbid with chemical dependencies include limitations related to mental retardation, borderline intelligence, learning disabilities, hyperactivity, or brain injury; chemical dependent individuals suffering from these comorbid conditions remain inadequately served by the current mental healthcare system (Campbell et al., 1999).

The growing need for culturally sensitive and appropriate treatment modalities in an increasingly multicultural society means that clinicians will likely need some specific training for this purpose. This assertion is supported by the observation from Thombs and Osborn that, "This will require that the characteristics of practitioners be factored into the planning of professional development activities. Such planning may result in matching training to the needs and specific characteristics (e.g., attitudes) of practitioner subgroups" (2001, p. 452).

Conclusion

The research showed that the history of psychology has been shaped in large part by the increasing demand for efficacious treatments for chemical dependencies in general and alcoholism in particular. The research also showed that chemically dependent individuals typically experience a wide range of comorbid conditions that require a holistic and multidisciplinary treatment approach that includes, but is not limited to, psychotherapy. Although the research was consistent in attributing the history of modern psychology to the ancient Greeks, it is reasonable to conclude that more broadly defined, the practice of psychology can said to have began when humans first sought pragmatic explanations for various behaviors, including the effect of intoxicants on their fellows. The complex nature of chemical dependencies, though, and the difficulties that are associated with its treatment, have continued to drive research in the psychological community. At present, there is growing support for clinical interventions for alcoholism that use behavioral couples therapy in treating the whole person, but other treatment modalities may also hold significant promise depending on the circumstances. In the final analysis, chemical dependencies remain a major focus of psychological research and practice today, and the search for optimal clinical interventions continues.