Background to the current notions of alcoholism

Two very different schools of thought attract the largest following at the moment—the social learning and the disease models of alcoholism. The former is a relatively recent development, mainly since the 1970s.(9) It contends that alcohol misuse is an acquired behaviour which the individual is capable of correcting with adequate cognitive-behavioural training; even to the point of relearning to drink in a 'controlled' manner. (10) Thus, the learning model tends to play down the importance of predisposing factors, and to ignore the variance in individual biological responses to alcohol, or the brain changes caused by chronic intoxication. Indeed, it assumes that all alcoholics are basically the same and that they are not different from any other drinker in their capacity to exert control over alcohol use.

In marked conceptual contrast, the inability to restrict the quantity or frequency of drinking is a key notion in the disease or 'medical' model of alcoholism. ^D This anomaly is thought to result from heavy alcohol exposure, or else to pre-exist in constitutionally vulnerable individuals. This model further suggests that, once in place, such loss of control over drinking is irreversible.

Learning theorists currently object to the disease concept on scientific grounds, but this modern argument is very much the continuation of old ideological debates on the nature of alcoholism. Pioneer medical authors such as T. Trotter in the early 1800s, Magnus Huss, who coined the term alcoholism in 1849, and the founders of the American and British Societies for the Study of Inebriety towards the end of the nineteenth century had already maintained that the disorder involves the loss of voluntary control over drinking,(12) and this is still the opinion of an important sector of the scientific community today. (13) Moralists of the turn of the century opposed that notion because it exempts the drinker from personal blame. Of course, they viewed any form of drinking as intrinsically wrong, and alcohol itself as an evil which should be eliminated through prohibition.

The leaders of the 1960s 'antipsychiatry' movement thought this disease entity to be nothing but a self-serving concoction of the medical profession. (1J) According to these ideologists, alcoholics are always capable of choosing whether or not to drink, and must assume full responsibility for their behaviour. Thus, by denying the existence of a pathological process, today's supporters of the social learning model find themselves defending the same ideas as the old temperance preachers and the detractors of psychiatry.

This chapter is an eclectic summary of the aetiological theories on alcoholism, most of which view alcohol dependence as ill health. Sociocultural factors

It is an undisputed fact that the prevalence of alcohol problems varies markedly across different cultural and social settings; that certain environmental conditions appear to facilitate their occurrence while others seem to prevent them. (1i) Macrocultural influences such as values, beliefs, and mores; social role functions; local economy; customs and dietary habits; rapid social change; and cultural stress do shape and dictate the way alcohol is used in human societies. But even within a single society, there is variance in the alcohol problems profile of different subgroups. For instance, drinking, heavy drinking, alcohol use disorders, and treatment for alcoholism are more frequently recorded in men than women,^ the risk of hospital admission for alcoholic psychosis, acute intoxication, and liver cirrhosis is elevated in unskilled and blue collar workers when compared with higher occupational categories, fy5 alcoholics are over-represented in occupations with flexible work schedules, in those less supervised, and in the ones which facilitate access to alcohol, (16) and although there are a larger proportion of regular alcohol users among the older, the wealthier, and the better educated, frequency of heavy drinking (i.e. episodes of intoxication, 5+ drinks at a time) is inversely correlated with age, income, and level of education. (31Z)

Cultural beliefs about drinking and related social norms largely determine the manner in which alcohol is used. Disorderly conduct and drunken violence are more likely to occur in societies which, while allowing drinking, do view alcohol as an evil substance. (1®) Similar consequences can be expected if drunkenness is culturally considered as a 'time out,' when socially unacceptable behaviours are tolerated or excused. (!9> In fact, the social condoning of drunkenness is considered as an epidemiological risk factor. (1.4)

The very availability of alcohol and the social promotion of frequent or heavy drinking are examples of social risk. But environmental facilitation per se does not explain the genesis of an alcohol dependence in specific individuals. This disorder is best understood as the result of social prompting and individual vulnerabilities. However, an individual predisposition is likely to play a lesser role in high availability societies with strong drinking traditions. Conversely, in 'dry' cultures, where drunkenness or even drinking itself are viewed as deviant behaviours, alcohol abusers would tend to be more 'abnormal' individuals capable of disregarding the stronger social barriers against drinking.(1.2)

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