The Etiology of Addiction

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25

CHAPTER 2

The Etiology of Addiction

Almost everyone has an easy answer to the

question: Why do people use drugs? According

to Stewart (1987), heroin addicts

use “junk” the fi rst time because they are curious.

Heroin has a mystique. It is used by pop stars, writers,

and glamorous people, and they like its effect.

For those who fi nd daily life to be fairly humdrum,

heroin can be the ultimate filler of gaps—it can

substitute for career, religion, romance, or virtually

anything else. Weil and Rosen (1993) believe

that drug use (and addiction) results from humans’

longing for a sense of completeness and wholeness,

and searching for satisfaction outside of

themselves. As noted author (and addict) William

S. Burroughs (1977) indicated in Junky, “Junk

wins by default. I tried it as a matter of curiosity.

I drifted along taking shots when I could score. I

ended up hooked” (p. xv). This notion of drift is a

recurrent theme in theories of addiction.

People begin using cocaine for some of the

same reasons. According to Baum (1985), his clients

provided these excuses for using cocaine:

“The mystical reputation aroused my curiosity.” . . .

“It’s available and being offered all the time.” . . .

“It gave me a sense of well-being, like I was worth

something.” . . .

“It felt good to be a part of a group.” . . .

“It was a great way to escape.” (pp. 25–42)

The reasons why people continue to use drugs

to the point of becoming physically and/or psychologically

dependent on them are more complex.

Some have attempted to explain this phenomenon

as a defi cit in moral values, a disease, conditioning

or learned behavior, or as a genetic propensity.

Still others see it as a “rewiring” of the brain (see

Chapter 3 ). At this point, there is no one single

theory that adequately explains addiction.

Jacobs (1986) attempted to develop a general

theory of addiction, drawing on his experience

and research with gamblers. In his view, addiction

is a dependent state acquired over time to

relieve stress. Two interrelated sets of factors are

required to predispose persons to addiction: an abnormal

physiological resting state, and childhood

experiences producing a deep sense of inadequacy.

He argues that all addictions (drugs, sex,

alcohol, etc.) follow a similar three-stage course of

development.

Most models of addiction assume that an addiction

is an “addictive disease” (Washton, 1989,

p. 55). As such, it continues to exist whether or

not the addicted person continues to use the drug.

Even if a person who has the disease is abstinent for

a long period of time, the symptoms of addiction

will appear again from renewed contact with the

drug. The disease model of addiction rests on three

primary assumptions: predisposition to use a drug,

loss of control over use, and progression (Krivanek,

1988, p. 202). Johnson (1973) put it somewhat

differently in saying, “The most signifi cant characteristics

of the disease [ alcoholism ] are that it is primary,

progressive, chronic, and fatal” (p. 1). There

are others, such as Peele (1985), who question the

validity of this model. Speaking of the complex

nature of addiction, he rejects all strictly biological

explanations and says that addiction cannot

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26 PA R T O N E ● Theories, Models, and Definitions

be resolved biologically because “lived human

experience and its interpretation are central to

the incidence, course, treatment, and remission

of addiction (see Preface).” An adequate theory

would have to synthesize pharmacological, experiential,

cultural, situational, and personality

components.

Drummond (2001) provides an interesting

perspective on theories of drug craving, most

of which can be classified into three categories:

(1) phenomenological models, which are based on

clinical observation and description; (2) conditioning

or cue-reactivity models, which are useful in the

exploration of craving and relapse; and (3) cognitive

models, which are based on social learning theory.

He concludes that no one theory provides an

adequate explanation of the phenomenon of craving.

Addiction, drug dependence, and craving are all

terms used to identify the phenomenon of loss of

control over drug-taking behavior, although each

has a slightly different meaning.

Etiological Theories

Addiction is not easily defi ned. For some, it involves

the “continued, self-administered use of a substance

despite substance-related problems, and it results

in tolerance for the substance, withdrawal from

the substance, and compulsive drug-taking behavior

due to cravings” or drives to use the substance

(Schuckit, 1992, p. 182). However, the American

Psychiatric Association’s criteria for dependence do

not require that tolerance or withdrawal be present

(see Chapter 5 ).

There are at least as many explanatory theories

of addiction as there are defi nitions. We will

focus on three broad theoretical categories—

psychological theories, biological theories, and

sociocultural theories—as well as discuss some

alternative explanations. These theories are not

mutually exclusive, and divisions sometimes

seem quite arbitrary. None is presented as the

correct way of explaining this phenomenon. We

do have preferences, and we lean more toward

certain models than others, but no single theory

adequately describes the etiology of addiction or

dependence. (For a more comprehensive treatment

of etiology, see Ott, Tarter, and Ammerman

[1999].) As social workers, it seems fitting to

suggest that the “person-in-environment” model

may ultimately provide the best mechanism for an

understanding of addiction. We will return to this

perspective at the end of the chapter.

The Moral Model

One of the earliest theories offered to explain the

etiology of addiction is humankind’s sinful nature.

Since it is diffi cult to show empirical evidence of

a sinful nature, the moral model of addiction has

been generally discredited by modern scholars.

However, the legacy of treating alcoholism and

drug addiction as sin or moral weakness continues

to infl uence public policies regarding alcohol and

drug abuse. Perhaps this is why needle/syringe

exchange programs have been so strongly opposed

in the United States.

Psychological Theories

Another explanation for the origins of craving alcohol

and mind-altering drugs lies in the psychological

literature—that is, the literature that deals with

one’s mind and emotions. Psychological models defi

ne addiction as an individual phenomenon but do

not necessarily exclude or minimize social factors

or other elements in the development of an addiction.

There are actually several different psychological

theories of alcoholism and drug addiction; they

include cognitive-behavioral, learning, psychodynamic,

and personality theories, among others.

Cognitive-Behavioral Theories. The cognitivebehavioral

theories offer a variety of motivations

for taking drugs. One such explanation states

that humans take drugs to experience variety

(Weil & Rosen, 1993). The need for variety is demonstrated

in cross-cultural expressions such as

singing, dancing, running, and joking. Drug use is

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C H A P T E R 2 ● The Etiology of Addiction 27

an individual can avoid the unpleasant symptoms

of withdrawal. Repetitive action motivated by the

avoidance of unpleasant stimuli is called negative

reinforcement. (In an alcoholic, the need to avoid

withdrawal symptoms generally occurs from 6 to

48 hours after the last drink.) Another source of

negative reinforcement may lie in the avoidance of

unpleasant things other than withdrawal. There

is a high correlation between traumatic events

and subsequent substance abuse (Janoff-Bulman,

1992). The traumatized individual may take drugs

to avoid unpleasant memories or heightened physiological

states such as startle responses.

Learning Theory. Closely related to cognitivebehavioral

theories is learning, or reinforcement, theory.

Learning theory assumes that alcohol or drug

use results in a decrease in psychological states such

as anxiety, stress, and tension, thus positively reinforcing

the user. This learned response continues until

physical dependence develops, at which time the

aversion of withdrawal symptoms becomes a prime

motivation for drug use (Tarter & Schneider, 1976).

There is a considerable amount of evidence

to support that part of learning theory related to

alcohol use and physiological aversion. Abrupt

cessation of drinking will lead to unpleasant symptoms

of withdrawal (A & DRCC, 1995). For the

alcoholic, withdrawal can lead to trembling, shaking,

hallucinations, and tonic-clonic seizures, formerly

known as grand mal seizures. Similarly, for

the heroin addict, abrupt withdrawal may lead to

symptoms much like a case of severe fl u. In each

case, the addict quickly learns that these symptoms

may be avoided by resuming use of the drug.

An interesting view of becoming a heroin addict

is provided by Krivanek (1989). Dependencies

that involve drug use follow the same basic principles

of learning theory, as all other dependencies.

Krivanek views drug dependence as a psychological

phenomenon that can vary in intensity from

a mild involvement to an addiction that seriously

restricts the user’s other behaviors. Pattison,

Sobell, and Sobell (1977) view alcoholism as

a continuum. That is, “An individual’s use of

associated with a variety of activities—for example,

religious services, self-exploration, altering moods,

escaping boredom or despair, enhancing social

interaction, enhancing sensory experience or

pleasure, and stimulating creativity and performance.

A study on inner-city youths revealed that

youths are motivated to take drugs out of a desire

for variety, citing curiosity, celebration, getting

high, and rebelling as reasons for drug use. (In the

study, the youths celebrate or explore drugs by using

alcohol at home, whereas they choose to use

illegal marijuana away from the home [Esbensen

& Huizinga, 1990].) Assuming that people enjoy

variety, it follows that they repeat actions that

bring pleasure (positive reinforcement).

The desire to experience pleasure is another

cognitive explanation for drug use and abuse.

Some animals seek alcohol and even work for it (by

pushing a lever) to repeat a pleasant experience.

Alcohol and other drugs are chemical surrogates of

natural reinforcers such as eating, drinking, and

reproductive behavior. Social drinkers and alcoholics

both report using alcohol to relax, even though

tests of actual tension-reducing effects of alcohol

have yielded quite different results; scientific observations

of persons using alcohol actually show

them to become more depressed, anxious, and

nervous (NIAAA, 1996). The dependent behavior

is maintained by the degree of reinforcement the

alcohol provides, and this, in turn, depends on the

actor’s perception of his or her need hierarchy and

“the likelihood that this course of action will meet

the most important needs better than other available

options” (Krivanek, 1989, p. 96). Since alcohol

and drugs are more powerful and persistent

than natural reinforcers to which the human brain

is accustomed, they set the stage for addiction.

With time, the brain adapts to the presence of

the drug or alcohol. The removal of the substance

from the host reveals certain abnormalities experienced

by the brain. The host experiences unpleasant

withdrawal symptoms, such as anxiety,

agitation, tremors, increased blood pressure, and in

severe cases, seizures. Naturally, one wants to avoid

painful stimuli; by consuming the substance anew,

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28 PA R T O N E ● Theories, Models, and Definitions

deprivation are not specific to alcoholism or addiction

to other drugs. In fact, they are commonly

reported by non-addicted adults with a variety of

other psychological problems. Perhaps the most

serious shortcoming is in the psychodynamic theories’

implications for the treatment of alcoholism

or drug addiction. Many counselors warn that a

nondirective approach that focuses solely on the

patients’ development of insight into their problems

neglects the addictive power of alcohol or

other drugs (Cunynghame, 1983).

Nevertheless, there is a feeling among some

scholars (Collins, Blaine, & Leonard, 1999) that

psychodynamic approaches should not be dismissed

because they serve “to guide a substantial

portion of clinical practice” (p. 162). Even though

the empirical support of psychodynamic theory is

scanty, it has shown a remarkable resiliency and the

ability to capture the imagination of practitioners.

Personality Theories. Personality theories,

which frequently overlap the psychodynamic

theories, assume that certain personality traits

predispose an individual to drug use. An individual

with a so-called alcoholic personality is often

described as dependent, immature, and impulsive

(Schuckit, 1986). Other personality theorists

have described alcoholics as highly emotional,

immature in interpersonal relationships, having

low frustration tolerance, being unable to express

anger adequately, and confused in their sex-role

orientation (Catanzaro, 1967). After reviewing

these personality theories, Keller (1972) summarized

them in Keller’s law: The investigation of any

trait in alcoholics will show that they have either

more or less of it. However, the many scales that

have been developed in an attempt to identify alcoholic

personalities have failed to distinguish consistently

the personality traits of alcoholics from

those of non-alcoholics. One of the subscales of

the Minnesota Multiphasic Personality Inventory

(MMPI) does differentiate alcoholics from the general

population, but it may actually detect only the

results of years of alcohol abuse, not underlying

personality problems (MacAndrew, 1979).

alcohol can be considered as a point on a continuum

from nonuse, to nonproblem drinking, to

various degrees of deleterious drinking” (p. 191).

Learning theory is helpful in treatment

planning because it addresses the adaptive consequences

of drinking. (For a more extensive discussion

of adaptation and addiction, see Peele

[1998].) Also, behavioral treatments have incorporated

learning theory into a treatment framework

based on the premise that what has been

learned can be unlearned (Bandura, 1969). It

follows that intervening early is important, since

there will be fewer behaviors to unlearn. Learning

theory is also quite adaptable to the systems view,

which is followed throughout this book.

Psychodynamic Theories. Psychodynamic theories

are more difficult to substantiate than most

other psychological theories because they deal with

hard to operationalize concepts and with events that

may have occurred many years before the onset of

addiction. Although Dr. Sigmund Freud never devoted

a single paper to the subject of alcoholism, his

disciples were not the least bit reluctant to apply psychoanalytic

theories to alcohol addiction. The earliest

explanations linked alcoholism with the “primal

addiction” of masturbation (Bonaparte, Freud, &

Kris, 1954). Later, most explanations linked alcoholism

to ego defi ciencies, suggesting that alcohol

is used to attain a sense of security. This theory assumes

that during childhood, inadequate parenting,

along with the child’s individual constitution,

caused the child to form weak attachments to significant

others, resulting in a need to compensate

for or dull the insecurity. This is accomplished in the

consumption of alcoholic beverages (Chordokoff,

1964). Alcohol abuse has also been explained by

psychoanalytic theorists as an expression of hostility

and of homosexuality. Still others view alcoholics

as self-destructive, narcissistic, or orally fi xated

(Schuckit, 1986). Psychoanalytic theory has even

blamed the development of alcoholism on the failure

of mothers to provide milk (Menninger, 1963).

A major problem with psychoanalytic theories

is that experiences such as early childhood

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C H A P T E R 2 ● The Etiology of Addiction 29

3. A sense of social alienation and a general tolerance

for deviance.

4. A sense of heightened stress. (This may help

explain why adolescence and other stressful

transition periods are often associated with severe

drug and alcohol problems.) (pp. 11, 15).

Research on personality theories of addiction

seems to have waned during the 1990s, and there

are few recent empirical studies that focus on this

explanation for addiction.

Biological Theories

Biophysiological and genetic theories assume

that addicts are constitutionally predisposed to

develop a dependence on alcohol or drugs. These

theories support a medical model of addiction.

Their advocates apply disease terminology and

generally place responsibility for the treatment

of addicts in the hands of physicians, nurses, and

other medical personnel. In reality, the medical

model is generally practiced only during the detoxifi

cation phase.

Generally speaking, biological theories branch

into one of two explanations: neurobiological

and genetic. There has been such an explosion

of knowledge in recent years in the neurobiology

of addiction that we have devoted a separate chapter

to it (see Chapter 3 ). But at this point, we will

briefl y review the research on genetics.

Genetic Theories. Recent studies supported by the

National Institute on Drug Abuse (NIDA, 2008)

found that a variant in the gene for a nicotinic

receptor subunit doubled the risk for nicotine addiction

among smokers. This is the first evidence

of a genetic variation influencing both the likelihood

of nicotine addiction and an individual’s risk

for the severe health consequences of tobacco use.

National Institute on Alcohol Abuse and Alcoholism

(NIAAA) has funded the Collaborative Studies

on Genetics of Alcoholism (COGA) since 1989, but

specifi c genetic factors have never been established

as a definite cause of alcoholism, although the

There is some evidence that individuals with

an antisocial personality (as defi ned in the DSM-IV ,

APA, 1994) have a higher incidence of alcoholism

than the general population. There is no evidence

that this personality disorder caused the alcoholism,

but these individuals were more disposed to

develop alcohol problems because of their antisocial

personality. Apart from this relatively rare occurrence

of the antisocial personality, alcoholics

have not been found to exhibit a specifi c cluster of

personality traits (Sherfey, 1955). Vaillant (1994)

argues persuasively that personality (as well as psychological)

factors are, at most, of minimal consequence

as a cause of alcoholism. There have been

similar attempts to link a constellation of certain

personality traits to drug addiction as well as alcoholism

(Gossop & Eysenck, 1980). A consensus

seems to have evolved that personality traits are

not of much importance in explaining drug dependence.

In fact, most of those who work in this fi eld

agree that an individual can become dependent

irrespective of personality attributes (Raistrick &

Davidson, 1985). One book lists 94 personality

characteristics that have been attributed to drug

addicts by various theorists (Einstein, 1983).

These include many characteristics that are polar

opposites of one another—for example: poor selfimage

and grandiose self-image, ego infl ation and

ego contraction, self-centered and externalization,

pleasure-seekers and pleasure-avoiders, and several

dozen other contradictory pairs.

A report to the National Academy of Sciences

(“Addictive Personality,” 1983) concludes that

there is no single set of psychological characteristics

that embraces all addictions. However, there

are, according to the report, “signifi cant personality

factors that can contribute to addiction.” These

factors number 4 (not 94) and are as follows:

1. Impulsive behavior, difficulty in delaying

gratifi cation, an antisocial personality, and a

disposition toward sensation seeking.

2. A high value on nonconformity combined

with a weak commitment to the goals for

achievement valued by the society.

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30 PA R T O N E ● Theories, Models, and Definitions

polymorphisms (Nichols, 1986). A more recent

study reports that the so-called dopamine D2 receptor

gene, which affects the capacity of cells to

absorb dopamine, was present in 77 percent of the

brains of alcoholics and only 28 percent of nonalcoholics

(Blum et al., 1990).

In 1990, the front page of an edition of The

New York Times hailed the discovery of a gene

claimed to be directly linked to alcoholism. Two

years later, this so-called alcoholism gene, formally

known as the dopamine D2 receptor gene, had become

the focus of a bitter controversy. Blum and

Noble insisted that their finding had been amply

documented by subsequent research, and they took

steps to market a test for genetic susceptibility to alcoholism.

Blum suggested that job applicants, children,

and perhaps even fetuses could be tested.

In Blum and Noble’s experiments, the D2

gene was shown to have at least two variants, or

alleles, called A1 and A2. They found the A1 allele

in the genetic material of 69 percent of the alcoholics

studied, compared to only 20 percent of the

controls. Blum and Noble theorized that A1 carriers

may use alcohol or other drugs excessively to

compensate for a reduced ability to absorb pleasureinducing

dopamine.

A study of 862 men and 913 women who

had been adopted early in life by nonrelatives identifi

ed two types of alcoholism (Boham, Cloninger,

von Knorring, & Sigvardsson, 1984). Type I, or

milieu-limited, alcoholism is found in both sexes

and is associated with alcoholism in either biological

parent, but an environmental factor—low

occupational status of the adoptive father—also

had to be present as a condition for alcoholism

to occur in the offspring. Type II, known as malelimited

alcoholism, is more severe but accounts for

fewer cases. It is found only in men, and it does not

appear to be affected by environmental factors.

Vaillant (1983), however, points out the potential

biases in the preceding study. He says that

the study failed to control for the environmental

effect of parental alcoholism. He continues by

pointing out that antisocial personality disorder

must be distinguished from alcohol dependence

statistical associations between genetic factors and

alcohol abuse are very strong (NIAAA, 2009). A

great volume of research has been amassed in this

area over the last several decades, and much of the

evidence points toward alcoholism as an inherited

trait. It has been observed that (1) adopted children

more closely resemble their biological parents

than their adoptive parents in their use of alcohol

(Goodwin, Hill, Powell, & Viamontes, 1973), (2) alcoholism

occurs more frequently in some families

than in others (Cotton, 1979), and (3) concurrent

alcoholism rates are higher in monozygotic twin

pairs (53.5 percent) than in dizygotic pairs (28.3

percent) (Kaij, 1960). Children of alcoholics are

three to seven times more likely to be at risk of alcoholism

(Koopmans & Boomsina, 1995). Having an

alcoholic parent (but not necessarily both parents)

can increase the risk of becoming an alcoholic. Yet

even in the presence of elevated risks, only 33 percent

sons and 15 percent daughters of alcoholics

demonstrate evidence of the disorder.

Some genetic theorists speculate that an

inherited metabolic defect may interact with

environmental elements and eventually lead to

alcoholism. This genetotrophic theory posits an

impaired production of enzymes within the body

(Williams, 1959). Others hypothesize that inherited

genetic traits result in a deficiency of vitamins

(usually of the vitamin B complex), which

leads to a craving for alcohol as well as cellular or

metabolic changes (Tarter & Schneider, 1976).

It is important to remember that, despite the

impressive statistical relationships in these studies

implying a genetic link, no specifi c genetic marker

that predisposes a person toward alcoholism has

ever been isolated. The fi rst biological marker established

for alcoholism was thought to be color

blindness, but a few years later, it was demonstrated

that color blindness was actually a result of

severe alcohol abuse (Valera, Rivera, Mardones, &

Cruz-Coke, 1969). Several other genetic discoveries

have met a similar fate. A workshop on genetic

and biological markers in drug and alcohol abuse

suggests promising areas for genetic research,

such as polymorphisms in gene products and DNA

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C H A P T E R 2 ● The Etiology of Addiction 31

Genome Project (HGP), supported by the National

Institutes of Health and the U.S. Department

of Energy, has been an important impetus in

the search for genes related to alcohol behavior

(NIAAA, 2000). The research was completed in

2003, but analysis of the data may take several

additional years (HGP, 2008).

Sociocultural Theories

There is little high-quality research regarding the

macrovariables that seek to explain addiction

(Esbensen & Huizinga, 1990). Yet, as we mentioned

earlier, almost every known culture has discovered

the use of beverage alcohol. “All societies establish

a quota of deviance necessary for boundary setting”;

rules around alcohol and drug use are a part

of boundary setting. The ways in which different

societies encourage, permit, or regulate the use of

alcohol varies considerably, however.

For the most part, sociocultural theories have

been generated by observations of differences or

similarities between cultural groups or subgroups.

Sociocultural theorists are prone to attribute differences

in drinking practices, problem drinking, and

alcoholism to environmental factors. For example,

socially disorganized communities often fail to realize

the common values of their residents and to

maintain effective social controls. Therefore, innercity

drug use is more rampant than in the suburbs.

We know that differential rates of alcohol use

between genders vary greatly between nations

(Bloomfi eld, Gmel, & Wilsnack, 2006). Unless greater

biological differences occur between women, from

country to country, or between men, from country

to country (a remote possibility), it seems logical that

culture is a strong infl uence on alcohol use.

According to Goode (1972), the social context

of drug use strongly infl uences, perhaps even

determines, “four central aspects of drug reality”

(p. 3): drug defi nitions, drug effects, drug-related

behavior, and the drug experience. The sociocultural

perspective stands in direct opposition to

what is called the chemicalistic fallacy —the view

that drug A causes behavior X.

and that developmental effects of abusing individuals

must be controlled. Furthermore, for his studies,

Vaillant excludes individuals with other major

psychiatric disorders that could, by themselves,

directly contribute to alcohol dependence. Such

cases (direct and uncomplicated cases) are estimated

to represent 60 to 70 percent of the alcoholdependent

population (Schuckit, 1986).

The notion of Type I and Type II alcoholics

hangs, in part, on the age of the onset of alcoholism.

Vaillant (1983) found in a study of alcohol-abusing

men in inner cities and in college that age of onset

and degree of antisocial symptomatology correlated

with disturbed family environments but was independent

of positive or negative heredity for alcoholism.

In other words, this negated the hypothesis that

heredity predicts the age of onset. “Alcoholic abuse

began 11 years earlier for the socially disadvantaged

men with a heredity negative for alcoholism than for

the college men with two or more alcoholic relatives.”

In other words, early-onset alcohol abusers in inner

cities had no more alcoholic relatives than did lateonset

alcohol abusers in college. Furthermore, innercity

men were 10 times as likely as the college men to

come from multi-problem families, to exhibit traits of

sociopathy, to have delinquent parents, and to have

spent time in jail.

These findings lead one to ask: “How do

biological factors interact with environment to

contribute to heavy enough drinking over long

enough periods of time to produce physical and

psychological dependence?” (Schuckit, 1986).

Vaillant (1983) suggests that rather than there

being two kinds of alcoholism, there may be

(1) genetic loading (predicting whether one develops

alcoholism) and (2) an unstable childhood environment

(predicting when one loses control of

alcohol). (Late onset is less associated with dependence,

substance-related problems, hyperactivity,

and dysfunctional families in one’s youth.)

Genetic research on addiction shows promise,

but it is an incredibly complex activity. Even

the most sanguine recent studies still use phrases

such as “the gene that may infl uence alcoholism

and addiction” (Science Daily, 2007). The Human

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32 PA R T O N E ● Theories, Models, and Definitions

condones the use of alcohol to relieve those tensions

is likely to have a high rate of alcoholism.

Bales also believed that collective attitudes toward

alcohol use dramatically infl uence rates of alcoholism.

He classified these attitudes as favoring

(1) abstinence, (2) ritual use connected with religious

practices, (3) convivial drinking in a social

setting, and (4) utilitarian drinking (drinking for

personal, self-interested reasons). The utilitarian

attitude, especially in a culture that induces much

inner tension, is the most likely to lead to problem

drinking, whereas the other three mitigate against

alcohol problems.

Also important in Bales’s (1946) theory is the

degree to which a society offers alternatives to alcohol

use for the release of tension and for providing

a substitute means of satisfaction. A social system

with a strong emphasis on upward economic or social

mobility will excessively frustrate an individual

who has no available means of achieving success.

In such a system, high rates of alcohol use would

be expected (Tarter & Schneider, 1976).

Unfortunately, few alternatives to alcohol

or drugs seem to exist in most modern societies.

In traditional societies, such as the hill tribes

of Malaysia, a shaman may assist tribesmen in

achieving a trancelike state in which endorphin

levels are altered (Laderman, 1987). Also at the

supracultural level, Bacon (1974) theorizes that

alcoholism is likely to be a problem in a society that

combines a lack of indulgence of children with

demanding attitudes toward achievement and

negative attitudes regarding dependent behavior in

adults. Another important factor in sociocultural

theories is the degree of societal consensus regarding

alcohol use. In cultures in which there is little

agreement regarding drinking limits and customs,

a higher rate of alcoholism is expected (Trice,

1966). Cultural ambivalence regarding alcohol

use results in weak social controls and allows the

drinker to avoid being labeled as a deviant.

Culture-Specifi c Theories. According to Room,

in “wet” drinking cultures, alcohol is used almost

daily, with few restrictions on availability. Conversely,

Because no object or event has meaning in

the abstract, all these central aspects must be interpreted

in light of social phenomena surrounding

drug use. For example, morphine and heroin

are not very different pharmacologically and biochemically.

Yet heroin is regarded as a dangerous

drug with no therapeutic value, whereas morphine

is defined primarily as a medicine. Definitions

are shaped by the social milieu surrounding

the use of each substance.

People using morphine as an illegal street

drug experience a “rush” or a “high” generally

unknown to patients using the same drug in a

hospital setting. Psychedelic drugs, such as peyote,

which are taken for religious purposes (as in

some Native American churches), do not typically

result in religious or mystical experiences when

taken simply to get high. Drugs, according to

Goode (1972), only potentiate certain kinds of

experiences; they do not produce them. It is important

to distinguish between drug effects and the

drug experience . Many changes may take place in

the body when a chemical is ingested, not all of

which are noted and classifi ed by the user. A drug

may have a more or less automatic effect of dilating

the pupils, causing ataxia or amblyopia, and

so on, but the experience is subject to the cognitive

system of the user’s mind. A person must be

attuned to certain drug effects to interpret them,

categorize them, and place them within appropriate

experiential and conceptual realms (Goode,

1972). One’s propensity to use drugs, the way one

behaves when one uses drugs, and one’s definitions

of abuse and addiction are all influenced by

one’s sociocultural system. Why else would someone

defi ne heroin and LSD as dangerous drugs, yet

almost never perceive social drinkers and smokers

as drug users?

Supracultural Theories. The pioneering work

of Bales (1946) provides some general hypotheses

regarding the relationships among culture, social

organization, and the use of alcohol. He

proposed that a culture that produces guilt, suppressed

aggression, and sexual tension and that

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C H A P T E R 2 ● The Etiology of Addiction 33

rate is one of the highest in the world, and the Jewish

rate is one of the lowest (Bales, 1946).

Subcultural Theories. There have been many

investigations of sociological and environmental

causes of alcoholism at the subcultural level.

Within the same culture, a great diversity in alcoholism

rates has been related to age, sex, ethnicity,

socioeconomic class, religion, and family background

(Bloomfield, Gmel & Wilsnack, 2006;

Tarter & Schneider, 1976). One of the landmark

studies of social variables at this level was conducted

more than three decades ago by Calahan

(1970). He specifi ed that social environment determines

to a large extent whether an individual

will drink and that sociopsychological variables

also determine the level of drinking. In becoming

a problem drinker, variables such as age, sex, ethnicity,

and social position infl uence the probability

that a person will learn to drink as a dominant

response. Labeling the person as a heavy drinker

then reinforces the probability of that response.

Of course, these processes do not occur in isolation

from other factors, such as the process of

physical addiction. Goode (1984), Laurie (1971),

Imlah (1971), and many others have examined

the sociocultural context of drug addiction and

found there to be many similarities to alcoholism.

A major difference is in the outcast nature of

certain illicit drug users such as heroin addicts.

Users of illegal drugs such as heroin may be more

socially isolated than alcoholics because of their

addiction. Also, certain types of drug addiction

seem to thrive within specifi c subcultures. Heroin

addiction is a persistent problem among jazz musicians.

Inner-city youths frequently “huff ” spray

paint or sniff glue. With three feet of hose and an

empty can, Native American youths on certain

reservations can easily get high on gasoline fumes.

The impact of gender on drug use presents an

interesting perspective on sociocultural theories.

Either a culture-specifi c or subcultural model can

be used in explaining the differences between male

and female drug-related behaviors in the United

States. Historically, female drinking has been less

although legal and social restrictions govern

drinking in “dry” cultures, binge drinking and

even violent drunken behavior may be seen as

acceptable (2001). Levin (1989) describes two

examples of cultural contrast in attitudes toward

drinking: the contrast between French and Italian

drinking practices and the contrast between Irish

and Jewish drinking practices.

There are many similarities between the

French and Italian cultures; both are heavily Catholic

and both produce and consume large quantities

of alcohol. The French, however, drink wine and

spirits, both with meals and without, and both

with and away from the family. The French do

not strongly disapprove of drunkenness, and they

consider it bad manners to refuse a drink. On the

other hand, the Italians drink mostly with meals

and mostly with family, and they usually drink

wine. They strongly disapprove of drunkenness,

and they do not pressure people into drinking. As

one might expect, France has one of the highest

rates of alcoholism in the world, whereas Italy’s

rate is only one-fi fth as great. (In 1952, Italy had

the second-highest rate of wine consumption

in the world, consuming only half of the amount

of wine consumed in France [Kinney & Leaton,

1987].) The strong sanctions against drunkenness

and social control imposed by learning to

drink low-proof alcoholic beverages in moderation

seems to have something to do with the lower

rate of Italian alcoholism.

In a fashion, studies of Irish and Jewish drinking

practices draw some sharp contrasts. The Irish

have high proportions of both abstainers and

problem drinkers, whereas Jews have low proportions

of both (Levin, 1989). The Irish drink largely

outside the home in pubs; Jews drink largely in the

home with the family and on ceremonial occasions.

The Irish excuse drunkenness as “a good man’s

fault”; Jews condemn it as something culturally

alien. Bales found Irish drinking to be largely convivial

on the surface, but purely utilitarian drinking

was a frequent and tolerated pattern. Jewish drinking,

on the other hand, was mostly ceremonial.

Again, it is no surprise that the Irish alcoholism

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34 PA R T O N E ● Theories, Models, and Definitions

there is no general answer but that the explanation

lies not only in motives but also in a person’s

cultural background, life circumstances, special

life crises, and physical abnormalities. No single

item will be the reason.

Fingarette (1985) believes that it is no harder

for the alcoholic to choose to stop drinking than it is

for others to abandon activities central to their ways

of life. “We should see the alcoholic, not as a sick

and defective human being, but as a human being

whose way of life is self-destructive. The diffi culty we

face is stubborn human nature, not disease” (p. 63).

In a similar fashion, Peele (1988) has examined

the evidence on addiction and concluded

that “we have disarmed ourselves in combating

the precipitous growth of addictions by discounting

the role of values in creating and preventing

addiction and by systematically overlooking the

immorality of addictive misbehavior” (p. 224).

This is not a revival of the addiction as sin model

but an argument that addicts and alcoholics do

differ from other people in the ways in which

they prioritize their values.

As noted at the outset of this chapter, William

S. Burroughs (1977) attempted to answer the

question, “why does a person become a drug

addict?” in his book Junky. “The answer is that

he usually does not intend to become an addict.

You don’t wake up one morning and decide

to be a drug addict . . . You become a narcotics

addict because you do not have strong motivations

in any other direction” (p. xv). Schaler

(2000) has a similar view of addiction. He denies

that there is any such thing as addiction, in

the sense of a “deliberate and conscious course

of action which the person literally cannot stop

doing” (p. xv). He views addiction as a metaphorical

disease, not a physical disease.

Stages of Alcoholism

One of the fi rst attempts to describe the development

of alcoholism is found in Jellinek’s (1952) study of

2,000 male members of Alcoholics Anonymous. He

accepted than male drinking in the United States,

and being intoxicated is clearly more disapproved

of for women than for men (Gomberg, 1986).

Similar gender differences exist throughout the

world (Bloomfi eld, Gmel, & Wilsnack, 2006). These

double standards may account for the much lower

rate of problem drinking noted among women.

Social pressure and social stigma may result in

less problem drinking by women as a subgroup of

the larger U.S. culture.

Some aspects of this phenomenon may be

culture specifi c, however. The fact that men seem

to drink more and have more problems because of

alcohol in some cultures and not in others fi ts into

a supracultural model of drug use. The degree

of female problem drinking appears to be related

to cultural norms regarding the overall status of

women within different societies. Bear in mind

that the vast majority of the research on alcohol

and drug abuse has been conducted on men only.

Only recently have gender-related issues in this

area begun to be systematically examined.

Alternative Explanations

Fingarette (1985) sees alcoholism as “neither sin nor

disease.” Instead, he views it as a lifestyle. According

to Fingarette, proponents of the disease model describe

alcoholism as a disease characterized by loss of

control over drinking. Recovery is possible only if one

voluntarily seeks and enters treatment and voluntarily

abstains from drinking. Only then can one be

cured. Cured from what? From a disease that makes

voluntary abstention impossible and makes drinking

uncontrollable! This, says Fingarette (1985), is an

amazing contradiction.

His alternative explanation views the “persistent

heavy drinking of the alcoholic as a central

activity” of the individual’s way of life. Each person

develops his or her unique way of life, which consists

of a number of central activities. Some will

adopt parenting as a central activity, while others

will place sex, physical thrills, or their careers at

the center. Why do some people choose drinking

as a central feature? Fingarette (1985) says that

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C H A P T E R 2 ● The Etiology of Addiction 35

(1) all AA members, (2) all in the latter stages of

alcoholism, and (3) all males.

This traditional view of alcohol addiction

was supported by many other prominent scholars,

however. Mann (1968) described alcoholism as a

“progressive disease, which, if left untreated, grows

more virulent year by year” (p. 3). Others seem to

have conveniently ignored available scientifi c evidence

in making assertions such as “the true alcoholic

is no more able to metabolize ethanol than a

diabetic can handle sugar” (Madsen, 1974, p. 94).

Others conclude that alcoholism is the result of an

allergy and that “one does not become an alcoholic:

One is born an alcoholic” (Kessel, 1962, p. 128).

Vaillant (1995) was involved in one of the

most comprehensive studies of alcoholism. Two

samples were observed over a 45-year period, and

a third group was observed for 8 years. Among

the sample of 110 core-city alcohol abusers,

Vaillant identified four patterns: (1) progressive

alcoholism; (2) return to asymptomatic drinking;

(3) stable abstinence; and (4) atypical, nonprogressive

alcoholism. Although this study generally

supports the developmental or progressive

nature of Jellinek’s (1960) model, it is important

to note that Vaillant’s study observed both reversibility

and non-progressive alcoholism among a

substantial proportion of subjects. Over the period

of the study, 18 of the 110 subjects returned to

social or asymptomatic drinking. (Jellinek himself

identifi ed several patterns of problematic drinking

as not fi tting into a disease model.)

The traditional concept of the nature and

progress of addiction to alcohol was also challenged

by Pattison, Sobell, and Sobell (1977). Perhaps the

major difference in their view of alcohol dependence

(a more precise, less value-laden term than addiction

), is found in the following two assertions:

• The development of alcohol problems follows

variable patterns over time and does not necessarily

proceed inexorably to severe fi nal stages.

• Recovery from alcohol dependence bears no necessary

relation to abstinence, although such a

concurrence is frequently the case. (pp. 4–5)

characterized alcoholism as an insidious disease that

progresses through well-defined phases, each with

symptoms that develop in the majority of persons

in an additive, orderly fashion. In Jellinek’s (1960)

model, the drinker progresses through four distinct

stages: (1) prealcoholic symptomatic phase; (2) prodromal

phase; (3) crucial phase; and (4) chronic

phase (see Figure 2.1 ).

In the prealcoholic symptomatic phase, drinking

is associated with rewarding relief from tension

or stress, something almost all drinkers engage

in occasionally. The person who is more predisposed

toward alcoholism (due to chromosomes,

culture, or other factors) will tend to increase the

frequency of relief drinking over a period of time.

At the same time, the drinker develops a physical

tolerance to alcohol, so that increasingly larger

amounts are needed to bring the same degree of

relief from stress or tension.

The onset of blackouts marks the beginning

of the prodromal phase. These are periods of amnesia

not associated with the loss of consciousness.

The drinker may seem to be acting normally, but

later have no recall of those events that occurred

while in a blackout. This phase is also characterized

by an increase in the need for alcohol (and attempts

to hide the need for alcohol), surreptitious

drinking, and increasing guilt.

The primary hallmark of the crucial phase is

loss of control over drinking, as evidenced by the

inability to abstain from drinking or the inability

to stop once started. During this stage, the drinker

often will begin the day’s drinking in the morning,

will experience behavior problems in relation

to employment and social life, and will frequently

seek to avoid family and friends.

The final stage, or chronic phase, finds the

drinker intoxicated for several days at a time.

Drinking becomes obsessive, and both serious

physical and emotional problems are evident.

According to Jellinek’s (1960) original

model, this is where the alcoholic hits bottom.

Although this work was a pioneering effort

in the field of alcoholism research, we

must remember that Jellinek’s samples were

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FIGURE 2.1 The Natural History of Alcoholism According to Jellinek’s Model Based on Male Members of AA.

Source: From Alcoholism: Development, Consequences, and Interventions, 3/e by N.J. Estes and M.E. Heinemann. Copyright © 1986 Elsevier Ltd.

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