Intoxicating habits: some alcoholism researchers say they are studying a learned behavior, not a disease.

Intoxicating Habits

Most alcoholism treatment programs in the United States operate on the assumption that people seeking their help have a disease characterized by physical dependency and a strong genetic predisposition. The goal of treatment, therefore, is total abstinence.

Herbert Fingarette, a philosophy professor at the University of California, Santa Barbara, pored over alcoholism and addition research and came up with a suggestion for the many proponents of this approach: Forget it.

In a controversial new book (Heavy Drinking: The Myth of Alcoholism as a Disease, University of California Press, 1988), Fingarette says alcoholism has no single cause and no medical cure, and is the result of a range of physical, personal and social characteristics that predispose a person to drink excessively.

"Let's view the persistent heavy drinking of the alcoholic not as a sin or disease but as a central activity of the individual's way of life," he contends. Seen in this context, alcoholism treatment must focus not just on the drinking problem, but on developing a satisfying way of life that does not revolve around heavy drinking. Total abstinence -- the goal of medical treatment centers as well as Alcoholics Anonymous -- is unrealistic for many heavy drinkers, holds Fingarette.

Disputes over the nature of alcoholism have a long and vitriolic history. But Fingarette's arguments reflect a growing field of research, populated mainly by psychologists, in which alcoholism and other addictions -- including those that do not involve drugs, such as compulsive gambling -- are viewed more as habits than as diseases. Addictive behavior, in this scheme, typically revolves around an immediate gratification followed by delayed, harmful effects. The habitual behavior nevertheless continues and is often experienced by the addict as uncontrollable.

"Addiction occurs in the environment, not in the liver, genes or synapses," says psychologist Timothy B. Baker of the University of Wisconsin in Madison. Biology may, in some cases, increase a person's risk of developing a dependency, but "an individual chooses to take drugs in the world. The likelihood of a person trying a drug or eventually becoming addicted is influenced by his or her friends, marital happiness, the variety and richness of alternative to drug use and so on," Baker contends.

Expectations and beliefs about alcohol's power to make one feel better shape the choices leading to alcohol addiction, according to one line of investigation. The most notable of these beliefs, says psychologist G. Alan Marlatt of the University of Washington in Seattle, is that alcohol acts as a magical elixir that enhances social and physical pleasure, increases sexual responsiveness and assertiveness, and reduces tension (SN: 10/3/87, p.218).

The initial physical arousal stimulated by low doses of alcohol pumps up positive expectations, explains Marlatt. But higher alcohol doses dampen arousal, sap energy and result in hangovers that, in turn, lead to a craving for alcohol's stimulating effects. As tolerance to the drug develops, a person requires more and more alcohol to get a short-term "lift" and a vicious cycle of abuse picks up speed.

Despite falling into this addictive trap, Marlatt says, some people drastically cut back their drinking or stop imbibing altogether without the help of formal treatment. In these cases, he maintains, external events often conspire to change an individual's attitude toward alcohol. Examples include an alcohol-related injury, the departure of a spouse, financial and legal problems stemming from drinking or the alcohol-related death of another person.

When treatment is sought out, Marlatt advises, the focus should be on teaching ways to handle stress without drinking and developing realistic expectations about alcohol's effects. Marlatt and his co-workers are now developing an "alcohol skills-training program" for college students, described more fully in Issues in Alcohol Use and Misuse by Young Adults (G. Howard, editor, Notre Dame University Press, 1988). Preliminary results indicate many students who consume large amounts of alcohol every week cut down considerably after completing the eight-session course. In fact, says Marlatt, children of alcoholics show some of the best responses to the program and are highly motivated to learn how to drink in moderation.

Psychologists teach the students how to set drinking limits and cope with peer pressure at parties and social events. Realistic expectations about alcohol's mood-enhancing powers are developed, and participants learn alternative methods of stress reduction, such as meditation and aerobic exercise.

The program does not promote drinking, says Marlatt, and students showing signs of hard-core alcohol dependency are referred for treatment that stresses abstinence. "But it's inappropriate to insist that all students abusing alcohol are in the early stages of a progressive disease," he contends. "Our approach acknowledges that drinking occurs regularly and gives students more options and choices for safer drinking."

A similar approach to helping adult alcoholics has been developed by psychologists W. Miles Cox of the Veterans Administration Medical Center in Indianapolis and Eric Klinger of the University of Minnesota in Morris. Their model, described in the May JOURNAL OF ABNORMAL PSYCHOLOGY, holds that although a number of biological and social factors influence alcohol abuse, the final decision to drink is motivated by conscious or unconscious expectations that alcohol will brighten one's emotional state and wipe away stress. An alcoholic's expected pleasure or relief from a drinking binge, for example, may outweigh fears that it eventually will lead to getting fired or divorced.

Cox and Klinger's technique aims at providing alternative sources of emotional satisfaction. They have developed a questionnaire to assess an alcoholic's major life goals and concerns. A counselor then helps the alcoholic formulate weekly goals based on his or her responses. Counseling also attempts to reduce the tendency to use alcohol as a crutch when faced with frustration. "Alcoholics often have unrealistically high standards and lack the capacity to forgive themselves for not meeting these standards," Cox says.

The focuson an alcoholic's concerns and motivation is intended to complement other treatments, say the researchers. It is consistent, they note, with the efforts of Alcoholics Anonymous to drive home the negative side of drinking and the benefits of not drinking.

The context in which people consume alcohol is another part of the addictive process under study. Any combination of drinking and mildly pleasant activity, such as television viewing, conversation or card games, appears to provide the best protection against anxiety and stress, report psychologists Claude M. Steele and Robert A. Josephs of the University of Michigan's Institute of Social Research in Ann Arbor. Alcohol's ability to draw attention away from stressful thoughts and onto immediate activity may play a key role in its addictive power, they suggest.

Steele and Joseph tested this theory in their laboratory. They gave enough vodka and tonic to adult subjects to induce mild intoxication. Another group expected to receive vodka and tonic, but was given tonic in glasses rubbed with alcoholo to create the odor or a real drink. Everyone was told that in 15 minutes they would have to give a speech on "What I dislike about my body and physical appearance." Researchers asked some from each group to sit quietly before making the speech, while others were asked to rate a series of art slides before speaking.

Those subjects who drank alcohol and rated slides reported significantly less anxiety over the speech than the other participants. Viewing the slides when sober had no anxiety-reducing effects. According to the researchers, this supports the notion that alcohol's reduction of psychological stress has less to do with its direct pharmacological effects than with its knack for shifting attention with the aid of distractions.

On the other hand, being intoxicated and doing nothing before the speech significantly increased subjects' anxiety, note the investigators in the May JOURNAL OF ABNORMAL PSYCHOLOGY. Without any distraction, alcohol appears to narrow attention to the upcoming situation.

Recent investigations also suggest alcohol users are motivated by alcohol's ability to reduce psychological stress among people who are highly self-conscious and constantly evaluating themselves. Steele and Josephs did not, however, evaluate the "self-awareness" of their subjects.

A different approach to unraveling drinking behavior involves the search for cues that set off an alcoholic's craving or irresistible urge to drink. Just as Pavlov's dogs were conditioned to salivate after hearing a bell that previously had preceded the appearance of food, there are internal and external "bells" that provoke craving in many alcoholics, explains psychiatrist Arnold M. Ludwig of the University of Kentucky Medical Center in Lexington.

These cues are often quite specific, he says. For instance, recovered alcoholic and major league baseball pitcher Bob Welch has reported experiencing a craving to drink during airplane flights, after a game of golf and after pitching.

In a survey of 150 abstinent alcoholics reported in the fall 1986 ALCOHOL HEALTH & RESEARCH WORLD, Ludwig finds nearly all of them can identify one or more "bells" that trigger craving. With the exception of "internal tension," mentioned as a cue by more than half the subjects, there was considerable individual difference in reported drinking "bells." These included going to a dance, feeling lonely, having a barbecue, seeing a drink in an advertisement and driving past former drinking hangouts.

Alcoholics Anonymous, notes Ludwig, teaches that four general conditions -- hunger, anger, loneliness and tiredness -- make recovered alcoholics more vulnerable to drinking urges, an observation supported by research on craving.

Other evidence, Ludwig says, suggests that the more times uncomfortable withdrawal symptoms -- shakiness, agitation, hallucinations or confusion -- have been relieved by drinking in the past, the greater the likelihood that familiar drinking cues will elicit craving in alcoholics.

Many alcoholics feel helpless and bweildred when craving strikes, seemingly out of the blue. "But craving is not the elusive, mysterious force many believe it to be," says Ludwig. To successfully recover, he contends, alcoholics must become aware of the emotional and situational cues that trigger drinking urges.

The first drink in the right setting, he adds, often whets the appetite for more. Alcoholics should seek out "safe havens" where drinking is discouraged, he suggests, such as workplaces, Alcoholics Anonymous and outdoor activities.

Whereas Ludwig sees drinking cuses as stoking the internal embers of craving, other researchers focus solely on external "reinforcers" that affect an alcoholic's drinking behavior. When inportant reinforces outside the realm of drinking, such as a job or marriage, are lost, say psychologists Rudy E. Vuchinich and Jalie A. Tucker of Wayne State University in Detroit, a recovered alcoholic becomes more likely to resume drinking.

"The growing consensus from clinical studies [points to] the important role of environmental variables and changes in life circumstances in influencing the drinking behavior of alcoholics," they write in the May JOURNAL OF ABNORMAL PSYCHOLOGY. But the development of appropriate environmental measures to study drinking is still in the early stages, the investigators add.

While research into the psychology of alcohol addiction is beginning to mature, it remains largely ignored by the biologically oriented advocates of alcoholism-as-disease, says Marlatt. The research and clinical communities are especially polarized over suggestions from addiction studies that some alcoholics -- about 15 to 20 percent, according to Marlatt -- can safely engage in moderate or social drinking.

The characteristics of alcohol abusers who can handle controlled drinking are not clear, but Marlatt and other researchers see milder alcoholics as prime candidates for this treatment approach.

Given that most current alcoholism treatment is based on the disease model of total abstinence, which has been endorsed by the American Medical Association and the American Psychiatric Association for many years, reconciliation between opposing theoretical camps is not imminent.

"But biological and genetic approaches to alcoholism need to be integrated with psychological and social approaches," Marlatt says. "This really hasn't been done yet."