Alcohol abuse and alcohol dependence are widespread, and the individual and societal problems associated with these disorders have made the study and treatment of alcohol use disorders a clinical research priority. Research over the past several decades has led to the development of excellent empirically supported treatment methods. This book aims to increase clinicians’ access to empirically supported interventions for alcohol use disorders, with the hope that these methods will become the standard in clinical practice.

The Authors

Stephen A. Maisto, PhD, ABPP (Clinical Psychology), is a Professor of Psychology at Syracuse University and is the Director of Research at the VA Center for Integrated Healthcare. He earned his PhD in experimental psychology in 1975 at the University of Wisconsin-Milwaukee and completed postdoctoral respecialization in clinical psychology in 1985 at George Peabody College of Vanderbilt University. Dr. Maisto’s research and clinical interests include the assessment and treatment of alcohol and other drug use disorders, HIV prevention, and the integration of behavioral health in the primary medical care setting. Dr. Maisto has authored or coauthored numerous journal articles, book chapters, and books.

Gerard J. Connors, PhD, ABPP, is Director of and a Senior Research Scientist at the Research Institute on Addictions at the University at Buffalo. He earned his doctoral degree in clinical psychology from Vanderbilt University in 1980. Dr. Connors’ research interests include treatment of alcohol use disorders, relapse prevention, self-help group involvement, early interventions with heavy drinkers, and treatment evaluation. He is a fellow of the American Psychological Association (Divisions of Clinical Psychology and Addictions). Dr. Connors has authored or coauthored numerous scientific articles, books, and book chapters.

Ronda L. Dearing, PhD, is a Research Scientist at the Research Institute on Addictions at the University at Buffalo. She earned her PhD in clinical psychology from George Mason University in 2001. Dr. Dearing’s research interests include help-seeking for alcohol and substance abuse, substance abuse treatment approaches, and the influences of shame and guilt on behavior and health. She is coauthor of the book Shame and Guilt (2002), and has authored or coauthored several scientific articles and chapters.

2 Theories and Models of Alcohol Use Disorders (p. 10-11)

The definitions and descriptions of alcohol use disorders (AUDs) presented in Chapter 1 give the basis for our describing current ways that clinicians and researchers understand AUDs. By"understand," we mean perception of factors that affect the development of a disorder, its maintenance, and its modification. Such information is critical for this book, because how clinicians think about and understand a problem may directly affect how they assess its manifestations and intervene to change it.

2.1 Traditional Theories of AUDs

Until recently, researchers and clinicians alike usually sought a single-factor explanation of what causes and maintains alcohol problems. Miller and Hester (2003) provided an excellent review of these models/theories. They summarized 12 single-factor models by describing each one, identifying its major emphasis about the cause and maintenance of AUDs, and citing an example of an intervention to modify AUD-related behavior that follows from the model. These 12 models span the biological, psychological, and social/environmental domains, and the etiological factors include individual characteristics (e.g., genetics, personality characteristics, lack of knowledge, motivation), environmental effects (e.g., cultural norms), and the interaction between the individual and their environment (e.g., family dynamics, social learning). Due to the wide variety of causal factors, AUD assessment and intervention differ considerably for each model. Treatment approaches vary widely also, and include interventions such as moral suasion, spiritual growth, restriction of alcohol supply, confrontation, coping skills training, and family therapy. It is here that we see why awareness of how the clinician understands AUDs is so important: If it guides what clinicians do with their patients, then the content, process, and outcomes could differ in major ways.

Through about the first three-quarters of the twentieth century, AUD theories frequently outpaced the data necessary to evaluate them. More recently, the quality of research in each of these domains has improved considerably, and each of these"single-factor" theories has been found to have some merit. Nevertheless, each set of factors alone, biological, psychological, or social/ environmental, has been found lacking in its attempt to provide a satisfactory explanation of the AUDs.

2.2 Biopsychosocial Model of AUDs

Empirical evidence and a newer way of conceptualizing health and illness merged in the latter twentieth century to lead to the generation and broad influence of a"biopsychosocial" model of AUDs. Besides dissatisfaction with the account of AUDs that single factor theories provided, there were several other manifestations of alcohol problems that have been influential. In this regard, in the important report by the Institute of Medicine (IOM, 1990), three main features of alcohol problems were highlighted that led the authors of that report to the conclusion that there is no one"alcoholism" that is a unitary"disease." Instead, alcohol problems are heterogeneous in their manifestation and etiology. Specifically, the IOM report argues that research conducted primarily since the early 1970s had shown that alcohol problems are, first, heterogeneous in their presentation, that is, they might be thought of as a syndrome with a variety of symptoms (Shaffer, LaPlante, LaBrie, Kidman, Donato,&, Stanton, 2004, Vaillant, 1983). Second, alcohol problems are heterogeneous in their course. This conclusion is in contrast to more traditional ideas of alcoholism as a unitary, progressive disease. In fact, the course of alcohol problems can vary significantly, as shown by many longitudinal studies, and may or may not be characterized by"progressivity." Third, alcohol problems are heterogeneous in etiology. This conclusion rests on the findings that no single cause or set of causes of alcohol problems has been identified. Rather, individuals who are identified as having alcohol problems present with diverse developmental trajectories of AUDs that are likely the result of the confluence of biological, psychological, and social factors. No single factor, set of factors, or factor domain has etiological priority of importance over another, none is necessary or sufficient in any case, and the influence of any factor or set of factors in AUD development varies across individuals.