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A Comparison of Two Types of Treatment for Alcoholism

Melissa A. Bromwell

One of the largest debates in the study of alcoholism is the etiology of the disorder. The prevailing theory today seems to be that alcoholism is a disease, a biological affliction that can only be ameliorated by abstinence or medication. However, there are those who believe alcoholism has its roots in environmental influences and that the disorder is a maladaptive pattern of behavior. The two main methods currently employed for treating alcoholism reflect the foundations of the two main theories.

Perhaps the most widely known method is the "Twelve Step" program created by the founders of Alcoholics Anonymous (AA) (1). Underlying this process is the belief that alcoholism is a biological disease that can never be cured, nor can it even be hindered without the use of external forces(2).. Members of AA are required to admit that they are powerless to fight alcoholism and need to relinquish control to a "power greater than ourselves." (3).This power can take any form for the adherents to the program, yet there is repeated mention of God and other aspects of Christian spirituality(4). More relevant to the topic at hand is the belief that alcoholism is a biological disease, which can be inferred from the acknowledgement that help with alcoholism can only come from God. This implies that alcoholism is out of one's own hands and thus should not be considered a "character flaw" or an aspect of personality; it also implies that alcoholism is something more intrinsic to the individual. In fact, the Big Book, the handbook of AA, states that alcoholism is a medical disease. (5)..

Indeed, there is a substantial amount of evidence to support this assertion; this is based on treatment types and the comorbidity of alcoholism with specific forms of mental illness. Two of the most frequently used medications for alcoholism are disulfiram (Antabuse) and naltrexone. (6).The mechanism of disulfiram's effectiveness is not related to any underlying biological process which may be responsible for the development of alcoholism; rather, it functions more in the manner of sensitization, (7).a therapeutic behavioral process that will be discussed later. It has been suggested that alcohol serves to increase the activity of the endogenous opioid system, a system which purportedly mediates euphoria. Naltrexone operates at this neuronal level, serving as an antagonist to endogenous opioid receptors and blocking the enhanced feelings of well-being that can occur with the consumption of alcohol. (6).

Other medications currently in use for the treatment of alcohol include several antidepressants; the tricyclic type (which affects both the norepinephrine system and the serotonin systems) and the selective serotonin reuptake inhibitors (SSRIs) have both proven to be helpful. This would indicate that alcohol affects the operations of both neurotransmitter systems.

However, research suggests that the SSRIs are more effectual in decreasing an alcoholic's desire to drink and this evidence has incited a theory that malfunctioning serotonin systems are responsible for alcoholism. Serotonin has a putative role in the regulation of mood and reinforcement and it has been reported that low serotonin activity may be responsible for depression and anxiety. This dual action of decreased serotonin activity, producing both alcoholism and depression, may explain why there is such a high correlation between the two disorders. One study examined this possibility using animal models and showed that animals that have chronically low serotonin activity are more likely to drink alcohol than those animals with normal serotonin activity. When the animals with low serotonin activity were given fluoxetine (Prozac), there was a decrease in the amount of alcohol they voluntarily drink. (8).

A large number of studies focusing on genetics have also supported a biological etiology of alcoholism. Children of alcoholics have a higher risk for developing alcoholism than do children of non-alcoholics. (9).This has been supported by adoption studies, looking at the outcome of children of alcoholics who were raised by adults who were not alcoholic; it was shown that children of alcoholics are more likely to develop the disorder than are children of non-alcoholics, even when raised in a non-alcoholic environment. In addition, it has been documented that there is a greater concordance of alcoholism in monozygotic twins than in dizygotic twins. (10).

Despite the reputed evidence of a biological etiology of alcoholism, there are some schools of thought that believe alcoholism has its roots in the environment. These theories claim that alcoholism is a behavior built on the learned contingency between drinking and relief from unpleasant affect. Some treatments in cognitive-behavioral therapy are aimed at breaking that contingency. One frequently employed method is exposing the alcoholic to the cues which they have previously associated with drinking, such as a specific place, a thought, or a feeling. The alcoholic is then prevented from drinking, thus destroying the association they have made between the stimulus and the need to drink. Another procedure used is sensitization, in which drinking is repeatedly paired with something aversive until the alcoholic loses all desire to drink. A medical correlate for this procedure is the use of disulfiram. Disulfiram inhibits the metabolism of alcohol and thus creates an excessive amount of acetaldehyde, a toxic by-product of alcohol; this results in severe nausea and vomiting. (11).

Cognitive-behavioral therapy also tries to restructure cognitions that perpetuate drinking, such as feelings of low self-worth. An alcoholic who begins to have feelings of guilt, shame, or sadness concerning their drinking may not know how to handle such affects and will turn to drinking in order to cope, thus continuing the cycle. If they are taught how to eliminate such self-defeating thoughts and behaviors, their self-confidence will increase. This sense of self-efficacy will enable them to cope with stress-inducing (and relapse-inducing) situations without using alcohol. Other cognitive-behavioral methods aim to replace the drinking with another activity, such as relaxation techniques which can be implemented anytime the desire to drink arises. (7).

Although both medical treatments and cognitive-behavioral therapy have been shown to be equally effective(11)., I personally believe that more long-term benefits can be reaped through cognitive-behavioral therapy. According to AA, alcoholism can never be cured; I believe this is true and that abstinence is necessary to remain healthy. If medications are the only deterrent to drinking, once an individual ceases to take such medications, the desire to drink will return. In addition, by merely taking pills, an individual does not gain any insight into their disorder and its specific causes for them as an individual. However, with therapy, an alcoholic can learn what exactly impels them to drink, thereby providing them with insight. This can be useful to them even after therapy has ended and stressors continue to occur. In addition, they will have learned various methods to combat their desire to drink and if a relapse should occur in the future, they will hopefully be able to maintain the positive cognitions acquired during their therapy and be able to halt their drinking before it escalates into a severe situation.

WWW Sources

1)Historical Data: The Birth of A.A. and its Growth in U.S./Canada

2)The Twelve Steps of Alcoholics Anonymous

3)A Newcomer Asks

4)The 12 Step Café

5)The Doctor's Opinion

6)Neuroscience Research and Medications Development


8)Animal Models in Alcohol Research

9)Children of Alcoholics: Are They Different?

10)The Genetics of Alcoholism

11)Treatment of Alcoholism