Broadening the Base of Treatment for Alcohol Problems (1990) / Chapter Skim
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Chapter 2--What is being treated?
Chapter 2--What is being treated?
Pages 23-41
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From page 23... ...
Increasing tension has developed with his wife and children for this as well as other reasons. Both his wife and his private physician have cautioned him about the level of his alcohol consumption, his weight, and his gradually rising blood pressure.
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From page 24... ...
He has had a long series of admissions to inpatient medical care for gastritis and pancreatitis; during the course of one of these hospitalizations he developed delirium tremens. On three separate occasions in the last five years he attended well-known 28-day residential treatment programs and briefly affiliated afterwards with Alcoholics Anonymous; subsequently he did reasonably well for several weeks to several months.
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From page 25... ...
The Alcohol Problems Perspective Alcohol problems are defined for the purposes of this report as those problems that may arise in individuals around their use of beverage alcohol and that may require an appropriate treatment response for their optimum management. Alcohol problems can be conveniently described in terms of their duration (acute, intermittent, chronic)
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From page 26... ...
A recent definition, derived through a Delphi process that surveyed persons felt to possess appropriate expertise nominated by 23 professional organizations, is "a chronic, progressive, and potentially fatal biogenetic and psychosocial disease characterized by tolerance and physical dependence manifested by a loss
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From page 27... ...
This applicability is attested to by the high levels of interrater agreement achieved for the similarly defined diagnosis "alcohol use disorder" in the field trials (Spitzer et al., 1979) of the third edition of the Du~gnostic arid Statistical Manual of the American Psychiatric Associati~or' (DSM-III)
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From page 28... ...
Bill W., for example, spoke in "The Big Book" of "moderate drinkers" and of "a certain type of hard drinker" who could experience serious consequences but who were not "real alcoholics" (Alcoholics Anonymous World Services, Inc., 1955:20-21)
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From page 29... ...
, and operationalized criteria are now being tested for inclusion in the forthcoming tenth edition. With respect to the D`agnostm and Statistical Manual of the American Psychiatric Assocu~t~on, the alcohol dependence syndrome has become the conceptual basis for the diagnosis of "psychoactive substance use disorders" in the revised version of the 3rd edition of the manual, or DSM-III-R, implemented in 1987 (American Psychiatric Association, 1987~.
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From page 30... ...
The scope of terms that are often used to refer to individuals and groups according to their consumption levels and the degree of their problems are illustrated; question marks indicate that the lower boundary for many of the terms is uncertain. The triangle in the figure represents the population of the United States, partitioned into drinking categories according to level of alcohol consumption, which is indicated along the upper arm of the triangle.
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From page 31... ...
In aggregate data, however, these individual differences tend to balance out, and a relatively direct relationship between consumption and alcohol problems emerges. By drawing dotted rather than solid lines, and by placing two-way arrows in the figure, the committee intends to indicate that both alcohol consumption and alcohol problems lie along a continuum and that categories, such as moderate or severe, are conveniences for communication rather than fixed entities.
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From page 32... ...
Yet Jellinek's concept of alcoholism, as discussed earlier, included at least two types that he considered diseases and that differed from each other, as well as other types that he did not consider diseases. This report will not deal extensively with the disease concept debate, which is well detailed elsewhere (cf.
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From page 33... ...
In an earlier era Sir William Osler remarked that "to know syphilis is to know medicine." Some medical educators feel that this is now true of alcohol problems precisely because of their seemingly infinite variety of clinical presentations. At Johns Hopkins Medical School, alcohol problems have become the central focus of teaching: "the purpose of the program is to get every medical student and every clinician at the institution acquainted with the early signs of alcoholism and competent to detect and recommend appropriate treatment for the disorder" (Holder, 1985~.
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From page 34... ...
Vaillant's longitudinal studies, for example, delineated a group of "atypical alcoholics," individuals "who spend a lifetime abusing alcohol but never progress." He commented that "the atypical alcohol abusers by no means were individuals who were not really alcoholics and illustrated this point by a statistical comparison with his clinic sample (Vaillant, 1983:144-45)
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From page 35... ...
A representative statement of this perspective for alcohol problems is the following: This way of thinking views every drinker as being at some stage of a dynamic, lifelong process influenced by a multitude of weak, interacting social, psychological, and physical forces with no single factor, except alcohol, being necessary, and none at all being sufficient to cause advancement in the process to the point of being labelled Alcoholic or Problem drinker. From this viewpoint, the alcohologist's task of identifying the forces influencing the alcoholic process and untangling their complex interrelationships is much like that of the meteorologist's attempts to understand the process called "the weather.
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From page 36... ...
It does not seem warranted at our present level of therapeutic knowledge to develop separate programs for different categories of alcoholics .... Within a single treatment approach it is possible to acknowledge and deal with individual differences thereby treating both the common problem of alcoholism-chemical dependency and the problems unique to individual patients.
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From page 37... ...
Summary and Conclusions To focus concretely on its response to the question, "What is being treated? ", the committee has presented a series of vignettes of individuals in whom problems have arisen around their use of beverage alcohol and who may require an appropriate treatment response for their optimum management.
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From page 38... ...
Nevertheless, considering the complexes of the problems themselves and of the individuals who manifest them, the committee believes that effective approaches to treatment for alcohol problems must be able to cope with these complexities. REFERENCES Alcoholics Anonymous World Services, Inc.
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From page 39... ...
Senate Governmental Affairs Committee hearing regarding the causes of and governmental responses to alcohol abuse and alcoholism, Washington, D.C., June 16. Jellinek, E
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From page 40... ...
1979. A critique of the concept of the alcohol dependence syndrome.
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From page 41... ...
1983. Fifth Special Report to the U.S.
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