Chemical Dependency, Particularly Alcoholism, Within the History

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.

Topic's role in contemporary psychology

While a growing number of psychologists currently recognize the need to treat the whole person, the complexities of chemical dependencies and the difficulties that have been associated with treating them have influenced contemporary psychology in various ways. For instance, according to Moon (2002), "In the field of psychology, the past several decades have witnessed a jockeying for preeminence by various psychologies, each devoted to a different dimensions of the person (e.g., behavior, cognition, relationship, etc.) each attempting to explain changes in emotion" (p. 265). As Moon points out, though:

The history of psychology mirrors the difficulty a person may find in being able to raise the microscope high enough to get the big picture -- which is necessary if we are to gain a vantage point that will allow us to view the person in its interactive entirety. Authentic transformation, it follows, must involve the whole person or it will be something other than authentic and less than transforming. (p. 265)

This expansion of psychological approaches to the whole person has largely mirrored the need to treat the comorbid conditions that are frequently associated with chemical dependencies. For example, chemical dependency has been highly correlated with a number of compulsive behaviors, including eating disorders, compulsive sex and relationship problems, gambling, workaholism, stealing, overexercising, overspending and excessive shopping (Esterly & Neely, 1997).

The impact the area had on psychology, the impact today, and the prospects for future impact

The need for efficacious treatments for chemical dependencies in general and alcoholism in particular has been a driving force in shaping psychology in recent years. For example, Neimeyer (1998) reports that, "Only the most cynical observer of psychotherapeutic trends could fail to be impressed by the remarkable recent proliferation of cognitive treatments for various disorders, a trend that has been matched in the history of psychology only by innovative extensions of psychodynamic treatments in the 1940s and '50s, and the explosion of behavior therapies in the 1960s and '70s" (p. 58). These various treatment modalities have enjoyed mixed results for substance abusers, with some clinicians preferring one approach over another for personal or professional reasons, but with a common goal of developing something that works and sticks for this difficult-to-treat population.

Based on the need for evidence-based best practices and cost-effective treatment interventions for chemical dependencies, one of the more controversial solutions that has been introduced in recent years has been treatment manuals. For instance, Schumate (2002) reports that, "The prevalence and use of treatment manuals for specific mental disorders has become a prominent trend in recent years. Typically, these manuals are rooted in cognitive-behavior theory and they provide a coherent foundation and structure for counseling" (p. 69). Some critics charge that these treatment manuals are just "cookbooks containing recipes for treatment" for clinicians that fail to address the whole person while proponents emphasize the need for some level of standardization to help ensure that quality of the psychological services that are provided. In this regard, Shumate emphasizes that, "Advocates for their use assert that treatment manuals help establish a standard of care, apply current research to treatment, assist practitioners in their negotiations with managed care, and generally help counselors organize and evaluate their treatment approach using commonly accepted protocols" (2002, p. 69).

By contrast, critics of this growing trend maintain that treatment manuals "ignore a rich heritage of psychological theory, reduce treatment to simple recipes dictated largely by the pressures of the insurance marketplace, and subtly restrict responsive and creative adaptation of treatment to the diverse needs of a heterogeneous client population" (Shumate, 2002, p. 69). Armed with their DSM, PDR and appropriate treatment manuals, then, some clinicians may erroneously believe they have all of the tools they need to treat the most complex chemical dependencies cases they encounter. As Shumate concludes, "Most importantly -- some opponents contend-treatment manuals delude practitioners into the belief that the mysterious process of change and recovery has now been identified, quantified, and reduced to an easy-to-use, step-by-step format; a non-medical version of the prescription pad" (2002, p. 69).

Psychologists also have a growing number of pharmacological tools available that can be used in conjunction with a psychological treatment regimens that have been introduced in response to chemical dependency problems. According to Pacione and Jaskula, several chemical dependency-specific medications are also available that are either capable of blocking the euphoric effects of abused substances or are capable of generating undesirable or unpleasant side effects if substances are used or abused. Two common medications are disulfiram (Antabuse) and naltrexone hydrochloride (Trexan) that continue to be the focus of clinical studies (Pacione & Jaskula, 1999). Likewise, other nonspecific medications including antidepressants have been introduced in recent years to treat chemical dependencies and their symptoms (Pacione & Jaskula, 1999).

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.