Stanton reviews the entire scope of psychological theorizing in the field of alcoholism. He finds that these theories are robust and disprove many assumptions about the pharmacological determinants of alcoholism and the disease nature of alcoholic behavior. But he also notes (along with the volume's editors!) how the theories ignore the major determinants of alcoholic behavior--e.g., alternative opportunities, values, and associations in people's lives. Moreover, he is stunned that the one larger theoretical model of addiction presented in the volume--opponent-process--consists entirely of stories from AA, omits any reference to data, and breezily espouses an abstinence only approach--contrary to the gist and substance of most of the rest of the volume! It is fascinating to see how this watershed volume, and the limitations it underlines, are exactly as true today as they were when the volume first appeared.
Psychology of Addictive Behaviors, 1:120-134, 1987
Book Review: Psychological Theories of Drinking and Alcoholism, Howard T. Blane and Kenneth E. Leonard (Editors), New York: Guilford Press, 1987
Reviewed by Stanton Peele
Howard T. Blane is director of the Research Institute on Alcoholism (RIA) and professor of psychology at State University of New York at Buffalo. Kenneth Leonard is a senior scientist at RIA. Stanton Peele has theorized about addiction and alcoholism in Love and Addiction and The Meaning of Addiction.
The appearance of Psychological Theories of Drinking and Alcoholism is an important event. Perhaps as recently as 10 years ago, there were not psychological theories of alcoholism so much as there was an idea that alcoholism was an outcropping of one or another personality type or psychological conflict. This volume presents different psychological elements in alcoholism and theories underlining a variety of sources of the motivation to drink. The volume is thus a sign of the maturing of psychology's view of alcoholism and of the creation of real bodies of data and a firm foundation for understanding alcoholism from a psychological perspective.
The editors, Blane and Leonard, arrange nine bodies of psychological theory and research about drinking and alcoholism into two sections: Traditional Approaches and Recent Theoretical Models. The chapters do not deal with equivalent kinds of theories; the theories differ not only in their scope but in their level of analysis. Nonetheless, given the differences in the material and the amount to be reviewed, the volume accomplishes very well what it sets out to do. The presentations are inclusive and generally well written. They organize largely distinct areas of psychological knowledge into accessible chapters. The contributors give attention not only to theory and data but also to clinical applications of the theories. In nearly all cases, the chapters serve as perhaps the best available surveys of the topics, making this an invaluable teaching tool and reference book.
Cappell and Greeley review the data on alcohol and tension reduction. As Cappell has indicated in earlier reviews, empirical support for the tension-reduction model of drinking is ambiguous and complicated. The complexities include the drinker's expectations about alcohol's efficacy in reducing tension and other individual variations in responses to alcohol. While tension reduction is more apparent in alcoholic and problem drinking than in normal drinking, overall the tension-reduction model does not explain much that we want to know about drinking in any form. Instead, this first chapter on a psychological theory discounts a very popular and widespread notion of the tension-reducing benefits of drinking and the role of tension reduction in alcoholism.
Cox updates the status of personality theory. Although the importance of personality constructs has diminished both in the alcoholism field and in psychology generally, Cox indicates that several dimensions of personality have repeatedly appeared to underlie problem drinking. For example, antisocial impulsivity has been strongly implicated in problem drinking and alcoholism among men. Palliation of negative emotional states is somewhat less clearly tied to alcoholism, although it is more important for women's drinking than men's. Overall, the concept of personality that emerges in this chapter is more indebted to social learning theory than to Freud: "people are motivated to drink alcohol in order to control their positive and negative affective states."
Sadava reviews interactional theory (meaning models that incorporate both personality and social setting) through the work of Jessor, Huba and Bentler, and Zucker. All these models "conceive of problem drinking within a larger context of functionally equivalent behavioral patterns and thus are not specific theories of drinking. All focus on adolescence, and on precursors, sequelae, and developmental stages." Sadava's accomplishment in summarizing this complex work is formidable. At the same time, he offers guidelines for evaluating statistical causal modeling techniques such as LISREL. Although developmental models have produced powerful predictive coefficients "accounting for up to 50% of the variance over time in adolescent problem behavior"these models sometimes contradict one another and are often so complex as to be unassimilable.
Much of the theorizing in this book is indebted to a broader psychological approach: social learning theory. Abrams and Niaura outline Bandura's social learning model and its expansion of traditional learning theory to include social and cognitive elements. Such a model fits well with the expectations and environmental and social effects shown conclusively to play a role in drinking and alcoholism. Reciprocal determinism describes how problematic drinking, despite its negative consequences, paradoxically exacerbates the motivation to drink. This dynamic explains loss-of-control drinking without positing an insupportable underlying biological process. Recovery involves "both general coping skills required for everyday life, and the specific self-control skills necessary to manage drinking." This chapter is full of rich material; unfortunately, it is not well written and does not synthesize its seminal material in a powerful way.
Social learning theory has by now been classified as a "traditional approach," and ends the first section of the book. Beginning the next section is Goldman, Brown, and Christiansen's chapter on expectancy theory. Just as social learning theory has become a universal background for the models in this book, expectancy theory has become the central psychological mechanism to explain alcoholic behavior: Cognitive variables "play an integral role in determining drug effects and in an individual's choice to use or not use a drug." Happily, given the centrality of this chapter's topic, it is a model of strong writing, explication of theory and research, and application. It also melds survey and epidemiological data with laboratory experimentation.
The accomplishments of expectancy research to date are impressive; according to the authors:
The predictive power of these expectancies is at least as good, and perhaps better than, the best demographic and drinking history variables used in earlier work.(p. 210)
The repeated observation of a relationship between the strength of positive alcohol expectancies and the degree of drinking among diverse types of adult drinkers indicates the robustness of the alcohol expectancy approach. (p. 209)
One-year follow-up of treatment outcome showed that the strength of the alcoholic's expectation for relaxation and tension reduction better predicted treatment outcome than traditional variables such as participation in aftercare programs.... (p. 210)
The task now is for clinical researchers to develop treatment strategies designed to modify those expectancies. (p. 219)
Reinforcing the value of Goldman et al.'s work is the frequent reference to it by other contributors.
The four other "recent theoretical models" are associated with single individuals, three of whom are authors of chapters. Sher presents the stress response dampening (SRD) model, which "is fundamentally a modest, pared-down tension reducing hypothesis." The model is based on "findings that physiologic stress response, especially cardiovascular responding, is dampened by alcohol." It emphasizes "that persons who show prealcoholic personality characteristics are particularly susceptible to SRD effects." While this chapter relies on pharmacological and physiological concepts, its claims about why people drink are based on human performance research that rarely measures the supposedly operative physiological mechanisms.
Hull describes his self-awareness model, which maintains that alcohol interferes with the "higher-order cognitive processes related to the encoding of information" about the self. "Given that self-awareness is sometimes painful (for example, following personal failures)," Hull proposes the importance of drinking motivated by a desire to avoid self-awareness. This chapter presents a series of innovative studies which indicate that alcohol reduces self-reference, that highly self-conscious people have distinct response patterns in tasks involving self-reference, and that such reactions are diminished by drinking. Most important, Hull and his colleagues have demonstrated that these social-psychological principles predict relapse rates for certain alcoholics who experience failure following treatment.
Hull and Sher each discusses his theory in relation to the other, and in relation to the tension reduction hypothesis. Berglas also compares his self-handicapping model to tension reduction and other theories. Self-handicapping is a strategy for protecting drinkers' self-images by using alcohol to justify failure or to emphasize success in challenging situations. Based on attribution theory, self-handicapping is the most psychodynamic model in the collection; it also claims the least distinct area of information and theory. Self-handicapping fits somewhere between models of drinking as an excuse for aggression (as investigated by expectancy researchers) and drinking to reduce tension. In addition, the chapter would benefit from discussions of Critchlow's work on blaming alcohol for misbehavior and, from this volume, Hull's model of drinking to relax negative self-attributions, as well as such basic psychological models as fear of failure and test anxiety.
Such comparative analyses and research are worthwhile. How are the different theories in this volume related? Are they distinct and separable mechanisms in alcoholic behavior? Do they apply to different populations? Are they overlapping explanations? Are they different labels for similar or identical processes? The models generally lay claim to very limited domains and describe those domains as representing one among many potential mechanisms in drinking behavior. Sher is typical in indicating "stress-related drinking may only represent a very minor category of drinking behavior." As the editors note in their conclusion, "there is ample evidence in this volume of an emphasis upon the part rather than the whole and upon the microscopic rather than the macroscopic." It seems that in rejecting global theories that proved to have many holes in them, psychology has gone in the opposite direction and refuses to speculate about the larger issues in alcoholism.
This leaves us with the matter of creating basic models of alcoholism and addiction. This book cries out for an integrative chapter that draws together the individual theories into an overall model. The one model in this book that purports to explain the fundamental nature of alcoholism is the opponent process theory, here described by Shipley. Indeed, opponent process may be the most popular psychological theory of addictive motivation since Richard Solomon presented the theory in the 1970s. The opponent process model has been applied to phenomena as diverse as test taking and compulsive love relationships. Actually, the model is applied to alcoholism here as only one illustration of its general utility: No studies are reported to test opponent process hypotheses in drinking human beings, alcoholic or otherwise. Oddly, for a model based on laboratory experimentation, this chapter relies the most on long, subjective narratives (primarily accounts by Alcoholics Anonymous members) for evidence of opponent process as a motivation in drinking.
Alcoholism is explained in the opponent process model as the result of repetitive drinking episodes in which alcohol's rewarding properties are gradually replaced by its opponent process, withdrawal, as the primary motivation for continued drinking. However, this inescapable reward-withdrawal model of alcoholism does not fit the phenomenology of alcoholism. As George Vaillant reported, alcoholics abstain more often than other drinkers. Alcoholic behavior does not seem to be prompted by withdrawal avoidance but rather by particular life circumstances. Nor do epidemiological data indicate problem drinking leads through any kind of invariant process to the full development of alcoholism. Thus, the only chapter that confronts alcohol addiction is stuck in a single neurological process and is the least connected to actual drinking behavior.
The placement of the opponent process model as the final chapter in this book reflects the general trend in psychological theorizing about alcoholism toward limited psychological and neurological mechanisms. The theorists in the book consistently call for rapprochement with other levels of explanationbut primarily the biological level. Less attention is paid throughout this book to social and situational determinants of alcoholism. For example, no psychological theory is included based primarily on environmentally induced drinking effects. Falk's laboratory model of schedule-induced polydipsia (which is actually based on research with alcohol) would seem more readily to fit into a book on alcoholism than would opponent process theory. In addition, a chapter by Moos and his colleagues on the effects of extratherapeutic experiencessuch as marriage and jobon alcoholic remission would be valuable.
The only research in this bookindeed in the alcoholism field at largethat substantially predicts actual human drinking are the interactional models that rely heavily on the social level; that is, ethnic, family, and peer group behavior. However, as Sadava indicates, this research reveals that "problem drinking tends to be self-correcting and reverses well short of clinical syndromes of alcoholism." This is because aberrant, excessive behavior lessens with the growth in real-world options people experience for the most part as they mature. Unfortunately, research and theory at this level is noticeably absent from this book. Although several chapteron personality, social learning, self-awareness, self-handicappingindicate the need for problem drinkers to develop alternate means of coping, they say little about how people move in this direction.
The editors note the "reemergence of individual differences [such as impulsiveness, self-consciousness, susceptibility to stress dampening] as critical factors in the study of alcoholism." Yet theories in this collection consistently shy away from examining the characteristics of people who reject real-world rewards in favor of alcoholic rewards. Not one theory in this book attempts to explain realistically why some people choose, and then continue or cease, to seek intoxication. Instead, the theories announce how indeterminate they are: "Even if alcohol is efficacious [for tension reduction] for some, other adaptations are nonetheless available" (Cappell and Greeley). In other words, very tense people who find that alcohol relaxes them still often drink moderately. According to Goldman et al., "Of course, a perfect linkage between expectancy patterns and alcohol consumption should not be anticipated. Individuals may hold similar outcome expectancies but find the value of the outcome differentially important."
The editors emphasize in their conclusion, "The pursuit of certain ... reinforcers, such as job satisfaction ... and positive family experiences" seems to inhibit excessive drinking. As a result "research that addresses ... the relationship among motivations to drink and motivations for other reinforcers strikes us as particularly important." At the same time, they urge consideration of simultaneous excessive behaviors that often accompany alcohol abuse: "Alcoholics are known for their prodigious use of coffee and cigarettes. Among adolescent problem drinkers, the use of other drugs is quite common." The editors and many of the contributors seem to be calling for a consideration of individual and social values in excessive drinking and related behavior. Yet, reflecting a deficiency in modern psychology, the book says little about the values that determine such life choices.
Nonetheless, the editors' work throughout in gathering and presenting these theories is exemplary. Their writing in the introduction and conclusion is modest and to the pointlike that of most of the contributors. Psychology has progressed in important directions in studying alcoholism and has made invaluable contributions that cannot be ignored by an alcohologistparticularly, as the editors note, in challenging such disease conceptions as "the primacy of physiologic dependency, alcoholism as a unitary phenomenon, and alcoholism as a progressive disease." The editors also indicate the most promising approach to prevention and treatment is to find "alternative methods of satisfying these motives" that are shown to underlie problem drinking. However, they do not substantiate their final optimistic statement: "We have little doubt that such research is being done, will be done, and will eventually accomplish this."