Joel Erblich & Mitch Earleywine. The Health Psychology Handbook: Practical Issues for the Behavioral Medicine Specialist. Editor: Lee M Cohen. Sage Publications. 2003.
What causes alcoholism? Or, put another way, why is it that although so many people consume alcohol on a regular basis, only a small minority become dependent? This seemingly straightforward question has bewitched clinicians and researchers for centuries. Only recently, with generous help from the disciplines of molecular genetics and neuroscience, have behavioral scientists begun to piece together this age-old puzzle. Part of the problem lies in the way in which alcohol dependence is defined and conceptualized. Another concern is that we have yet to identify the proverbial “switch”—that functional entity (biological, psychological, or otherwise) that “transforms” a nondependent consumer of alcohol into one who is alcoholic. But perhaps most critically, the parallel paths of behavioral scientists, molecular geneticists, and neuroscientists have until recently severely limited the transdisciplinary idea sharing and collaborations that are essential to gaining a complete and balanced understanding of the etiology of this classic biobehavioral phenomenon. This chapter attempts to provide some unifying themes that appear to be common to all etiologic models of addiction and to review what is known about some of the more common genetic, constitutional, and learned/environmental factors that have been implicated in the pathogenesis of alcohol dependence. A rapprochement of these diverse factors may result in a clinically useful working model of understanding the risk for alcoholism.
Definitions and Description of Alcoholism
A nosologic consensus is the outcome of clarifying an etiologic disease pathway. Unfortunately, the classification of alcoholism, like many other multisymptomatic behavioral disorders, has been a matter of some debate. The classic medical approach employs the categorical disease model in which alcoholism is conceptualized as being qualitatively distinct relative to normal “social” drinking (Meyer, 2001). Theorists espousing a categorical point of view would consider abstinence/nonuse, use, abuse, and dependence as conceptually distinct states. Also consistent with this approach is Cloninger and colleagues’ (1988) classic description of “types” of alcoholics, an approach that has received only mixed empirical support (Sannibale & Hall, 1998). Concerns regarding the limited nature of such categorical approaches have led many to adopt a quantitative approach, which stresses that alcohol use lies on a continuum from nonuse to dependence (Meyer, 2001). Factors such as quantity of alcohol consumed, frequency of consumption, and variability (i.e., regularity with which drinking occurs) move people along this continuum, the extreme of which is alcohol dependence (Streissguth, Martin, & Buffington, 1976). Recent discussions about the existence of a “switch” that is responsible for transforming a “normal drinker” into an “alcoholic” (e.g., Tsuang, Bar, Harley, & Lyons, 2001), as well as data suggesting that there is great individual variability within the subset of alcoholics, have led to a blending of the two approaches. By the prevailing view, alcoholism is seen as a qualitatively distinct state, but there is a continuum of symptom severity within the subgroup of alcoholics (Meyer, 2001). In addition, quantitative drinking factors (e.g., quantity, frequency, variability) are necessary predictors of the development of alcoholism. That being said, it must also be acknowledged that the putative switch has not yet been identified, and as such, most researchers have relied on studying quantitative drinking factors as a reasonable surrogate. Therefore, the preponderance of theoretical grist has aimed at understanding why some would drink more than others rather than at directly addressing why some people become alcoholics. For now, the proverbial lamppost shines down on the quantitative approach.
The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) (American Psychiatric Association, 1994) defines drug dependence as a collection of any three of seven symptoms. All must create meaningful distress and occur within the same year. The diagnosis requires judgment on the clinician’s part, but the symptoms tend to be obvious. Each symptom reflects the idea that a person requires the drug to function and makes maladaptive sacrifices to use it. The current diagnosis focuses on consequences rather than on the amount or frequency of consumption. These consequences are (a) tolerance and (b) withdrawal, which were once considered the hallmarks of dependence. The additional symptoms are (c) use that exceeds initial intention, (d) persistent desire for the drug or failed attempts to decrease consumption, (e) loss of time related to use, (f) reduced activities because of consumption, and (g) continued use despite problems.
Tolerance serves as a hallmark of physiological dependence. It occurs when repeated use of the same dose no longer produces the same effect. This symptom often indicates extensive drinking and may motivate continued consumption. People do not grow tolerant to a drug; rather, they grow tolerant to its effects. After repeated use, some of the effects of a drug may decrease, whereas others may not. Tolerance to the desired effects of alcohol may encourage people to drink more, and increased use may coincide with a greater chance for problems.
The second symptom of dependence, withdrawal, refers to the discomfort associated with an absence of the drug. No two people experience withdrawal in the same way. Hallmark signs can range from mild irritability to full-blown hallucinations. Alcohol withdrawal frequently includes tremor, anxiety, craving, and troubled sleep. A severe, palsylike tremor with frequent perceptual aberrations, known as delirium tremens, often accompanies severe withdrawal.
The DSM-IV distinguishes between dependence with physiological aspects and dependence without physiological aspects. If tolerance or withdrawal appears among the three required symptoms, a diagnosis of physiological dependence is appropriate. Nevertheless, even without the presentation of tolerance or withdrawal, individuals may still receive a diagnosis of alcohol dependence without the specifier “with physiological dependence.” This change in procedure has made the diagnosis of alcohol dependence potentially more common.
The third symptom of dependence involves use that exceeds initial intention. This symptom suggests that individuals may plan to have only a couple of drinks but then drink markedly more once they become intoxicated. Use that exceeds intention was once known as “loss of control.” Many people misinterpreted the idea of loss of control, suggesting that it referred to an unstoppable compulsion to drink everything available. Based on this interpretation, people who drank to the point of blackout but still had liquor in the house the next morning might have claimed that they did not show loss of control. Today, use that exceeds intention does not imply this dramatic unconscious consumption. This symptom simply suggests that dependent users may have trouble drinking only a small amount if that is what they intend to do. Ironically, people who never intend to drink a small amount might not get the opportunity to qualify for this symptom.
Dependence also includes failed attempts to decrease use, or a constant desire for the drug, as the fourth symptom. An inability to reduce drinking despite a wish to do so certainly suggests that the drug has altered behavior meaningfully. Yet people with no motivation to quit would likely never qualify for failed attempts. Thus, people who have not attempted to quit may still qualify for this symptom if they show a persistent continuous craving. An inability to stop drinking or a constant desire to consume alcohol suggests dependence.
The fifth symptom of dependence involves loss of time related to use. The time lost can be devoted to experiencing intoxication, recovering from it, or seeking the drug. Because alcohol is legal, users might not spend considerable time in search of it. Hence, the number of hours required to qualify for a meaningful loss of time remains unclear, making this symptom quite subjective. A clear-cut case would be anyone whose day is devoted to obtaining alcohol, drinking to the point of intoxication, and recovering from the effects of alcohol. An individual who spends even a portion of the day (e.g., a few hours) on these activities would also qualify. In contrast, an individual who consumes several drinks an hour before going to bed each night might argue that he or she has lost little time and should not qualify for this symptom. Thus, subjective assessment of a meaningful amount of time may contribute to problems with the diagnosis of dependence.
The sixth symptom of dependence is reduced activities because of drinking. This symptom focuses on work, relationships, and leisure. The presence of this symptom suggests that alcohol has taken over so much of one’s daily life that the user would qualify as dependent. Any impairment in job performance because of intoxication, hangover, or devoting work hours to obtaining alcohol would qualify for this symptom. Individuals missing work every Monday to recover from weekend binges might also qualify. Sufficient functioning at work, however, does not indicate that one is not dependent. Even with phenomenal job performance, impaired social functioning may be indicative of problems. If a drinker’s only friends are drinking buddies and they only socialize while intoxicated, the substance has obviously had a marked impact on friendships. Recreational functioning is also important to the diagnosis. A decrease in leisure activities suggests impaired recreation. A drinker who formerly enjoyed hiking, reading, and theater but who now spends all of his or her free time intoxicated in front of the television would qualify for this symptom. This approach to the diagnosis implies that drinkers who are not experiencing multifaceted lives can improve the way in which they function by drinking less.
The final symptom of dependence requires continued use despite problems. People who persist in using the drug despite obvious negative consequences would qualify for this symptom. Recurrent use regardless of continued occupational, social, interpersonal, psychological, and/or health problems obviously shows dependence. Many of these difficulties involve meaningful others in the drinker’s life. Continued consumption despite conflicts with loved ones, employers, and/or family members might qualify for this symptom. This situation supports the idea that anyone who continues to use despite negative consequences (e.g., stomach ulcers, feelings of guilt, loss of self-respect) must have a strong commitment to alcohol.
A subset of individuals may experience negative consequences from alcohol that do not qualify for a diagnosis of dependence but that meet criteria for a diagnosis of abuse. This diagnosis requires significant impairment or distress directly related to drinking. A diagnosis of alcohol abuse requires only one of the four symptoms that appear in the DSM-IV: (a) interference with major obligations, (b) intoxication in unsafe settings, (c) legal problems, and (d) continued use in the face of problems. Each of these signs requires some interpretation on the part of the individual making a diagnosis; however, most experienced diagnosticians agree on who meets criteria for substance abuse and who does not (Üstün et al., 1997). Abuse remains distinctly separate from dependence, which requires different symptoms and more of them. Although a diagnosis of abuse clearly serves as a sign of genuine troubles, many clinicians consider dependence to be more severe. Thus, those who qualify for dependence would not receive the diagnosis of abuse.
The first symptom of abuse, interference with major obligations, requires impaired performance at work, home, and/or school. Impairments may arise due to intoxication, recovery from intoxication, and/or time devoted to searching for liquor. The definition is necessarily broad so as to include people with a variety of responsibilities. Specifically, this symptom applies to employees who miss work because they have hangovers, students who fail tests because they attend classes intoxicated, and parents who neglect their children so that they can spend time in bars.
The second symptom requires intoxication in unsafe settings. The DSM-IV specifically lists driving a car and operating machinery as hazardous situations in which intoxication could create dangerous negative consequences. Many experienced drinkers claim that their intoxicated driving differs little from their sober driving. Such statements may reflect poorly on their driving abilities in general, but people who tremble as a result of withdrawal might actually drive better after a couple of drinks. Despite this fact, driving a car while drunk, even for only a few blocks, qualifies as alcohol abuse.
The intoxicated performance of any task can lead to a diagnosis of abuse if impairment may lead to negative consequences. This action need not be as elaborate as scaling a skyscraper or handling a firearm. Driving a forklift or using power tools might qualify. Note that no negative consequences actually need to occur; their increased likelihood alone can qualify for abuse. Thus, those who drive drunk but never receive tickets or have accidents would still qualify for abuse due to the fact that they increase their likelihood of experiencing negative consequences.
The third symptom included in the diagnosis of alcohol abuse concerns legal problems. This symptom may say as much about society’s values as it does about an individual’s behavior (Brecher, 1972; Grilly, 1998). Any legal troubles related to public intoxication, driving while intoxicated, drunk and disorderly behavior, alcohol-related aggression, or underage drinking would qualify.
Finally, the fourth symptom of alcohol abuse concerns consistent use despite problems. Note that recurrent use in the face of occupational, social, interpersonal, psychological, and/or health problems qualifies as abuse.
Describing alcohol-related difficulties as addiction, abuse, or dependence creates certain misunderstandings. All three words may sound deprecating (Eddy, Halbach, Isbell, & Seevers, 1965; Miller, Gold, & Smith, 1997), and each lacks clarity; however, addiction has no accepted definition. As noted previously, abuse and dependence have formal definitions, but the specific diagnosis does not reveal an individual’s actual problems. Anyone who qualifies for abuse may have one or more of the four symptoms required, meaning that an individual with such a diagnosis could be experiencing any one of more than a dozen combinations of symptoms. Likewise, dependence requires three of seven symptoms, providing more than 30 potential combinations of symptoms. These terms may also encourage the minimization of problems that do not qualify for a diagnosis, and this can interfere with treatment.
People experiencing negative consequences from alcohol may prove to be unwilling to limit consumption if they do not qualify for addiction, abuse, or dependence. This limitation has inspired an approach that emphasizes problems rather than diagnoses or diseases. Thus, instead of worrying about whether a specific user qualifies for a disorder, time might be better spent identifying individual problems related to drinking. For example, a client may report frequent stomach pains. A survey of this person’s drinking may reveal that the pain often follows a binge. Although this problem might not interfere enough to qualify for abuse, the client may benefit from drinking less or quitting. This emphasis on problems may allow the clinician to avoid pointless arguments about whether or not someone is an addict. Instead, the clinician and the client can focus on reducing the harm that alcohol may cause.
Models of Alcoholism
As with many other topics in psychology, there are nearly as many theories of the development of alcohol problems as there are theorists. By and large, however, there is agreement that people drink alcohol because it makes them feel good. Principles of operant conditioning suggest that either positive reinforcement, negative reinforcement, or a combination of the two play a role in drinking behavior. Some data support the role of positive reinforcement in alcohol consumption. For example, Newlin and Thomson (1990) argued that individuals with a positive family history for alcoholism may be more sensitive to the positive/stimulant effects of alcohol, and several studies support this supposition (e.g., Erblich, Earleywine, Erblich, & Bovbjerg, in press). Research in this area has also underscored the importance of negative reinforcement in understanding alcohol consumption. Nearly a half century ago, Conger (1956) advanced the now classic “tension reduction hypothesis,” which speaks broadly to alcohol’s negatively reinforcing properties. More recent modifications to the tension reduction hypothesis have focused on alcohol’s ability to dampen the human stress response (Levenson, Sher, Grossman, Newman, & Newlin, 1980), and further modifications have demonstrated that stress response dampening may be mediated by alcohol’s impairment of cognitive processes (Erblich & Earleywine, 1995; Josephs & Steele, 1990). Regardless of the mechanism, reinforcement appears to play a central role in the initiation and maintenance of drinking behavior.
Over the past two decades, Schuckit and colleagues (e.g., Schuckit, 1994; Schuckit, Tsuang, Anthenelli, Tipp, & Nurnberger, 1996) have presented considerable empirical evidence (both cross-sectional and longitudinal) indicating that drinkers who experience lower levels of response to alcohol consumption are more likely to experience problem drinking. They have suggested that such individuals may need to drink more than others to achieve a desirable level of reinforcement or that such individuals’ lower interoceptive responses to the substance make it more difficult for them to regulate intake appropriately. Conversely, others have suggested that those who experience higher levels of response to alcohol consumption are more likely to develop problem drinking (e.g., Nagoshi & Wilson, 1987). These theorists have proposed that the more reinforcing the effects of alcohol, the more likely one is to consume. Newlin and Thomson (1990) proposed that both may be the case; that is, lower levels of response to the aversive effects of alcohol, coupled with higher levels of response to its positive effects, create a “double whammy” risk factor for problem drinking. Subsequent empirical studies have provided some support for their model (e.g., Erblich et al., in press). The prevailing view remains that the reinforcement value of alcohol figures prominently in understanding problem drinking. A critical question, by extension, would be the following: What factors contribute to differential levels of alcohol’s reinforcement value?
Specific Genetic Factors
Quantitative genetic studies have demonstrated in a compelling fashion that alcoholism has a substantial, but not an exhaustive, heritable component. Cadoret, Troughton, O’Gorman, and Heywood (1986) estimated that up to 60% of the population’s variability in alcoholism is attributable to genetic factors. Other epidemiological studies have established that individuals who have an alcoholic parent are three to four times more likely to develop alcoholism themselves. Although exogenous (i.e., nongenetic) factors may account for some of the observed intergenerational transmissibility of alcoholism, the confluence of these epidemiological and quantitative genetic studies suggests a preeminent role of genetics in conferring vulnerability to problem drinking.
In 1990, Blum and colleagues became the first to discover a relationship between a specific genotype and alcoholism. A long tradition of research in neuroscience has implicated dopamine as the central nervous system (CNS) neurotransmitter of reward, and studies have demonstrated that drug use is associated with increased CNS dopamine release. Based on this research, Blum and colleagues (1990) tested the possibility that polymorphisms (i.e., geno-typic variants) in the dopamine D2 receptor gene (DRD2) would be related to alcoholism. Indeed, they found that severe alcoholics were significantly more likely to carry the DRD2 “A1” allele compared with controls. They suggested that this locus may be related to a lower number of D2 receptors, resulting in hypodopaminergic function that could be alleviated by, among other things, alcohol consumption. This suggestion may be consistent with the overall reinforcement model of risk for alcoholism, such that carriers of this polymorphism may find consuming alcohol more rewarding than do noncarriers. Whether or not this is the case remains to be seen. Strikingly, studies of genetics have typically not included assessments of perceived levels of reinforcement, so that intuitive relations between genotype and reinforcement remain largely speculative. Another concern is that molecular biology has, to date, procured only sketchy evidence that the DRD2 polymorphism is functional; that is, carrying the A1 allele does not necessarily translate to fewer D2 receptors. Therefore, the mechanism through which DRD2-A1 confers increased risk for alcoholism remains unclear.
Nevertheless, Blum and colleagues’ (1990) initial findings have spurred an intensive search for other candidate genotypes that may predict problem drinking. Blum and colleagues (2000) have since tested other dopamine-related genotypes, including polymorphic loci on DRD4 and SLC6A3, a gene that generates the protein responsible for regulating presynaptic dopamine reuptake. Other candidate genes (e.g., SLC6A4, 5HT-1B, GABA-A, muOR, PENK) include those related to serotonin function, GABA function, and opioid release (for a review, see Blum et al., 2000). Studies have provided mixed results, and even the positive studies account for only a small proportion of variance in alcoholism or drinking, with substantial heterogeneity. Findings underscore the importance of polygenic or gene-environment interactions in better understanding this complex behavioral disorder. Indeed, early biochemical research (Davis & Walsh, 1970) has suggested that by-products of alcohol’s metabolism (i.e., tetrahydroisoquinolines) may cause a cascade that directly impinges on opioid receptors but that also indirectly affects the breakdown and availability of synaptic dopamine. Although not yet tested, work by Berridge and Robinson (1998) raised the possibility that genes related to dopamine function may operate by increasing the motivational salience of the substance (e.g., craving or “wanting”), whereas relevant polymorphisms in opioid genes may operate by increasing the hedonic value of consumption (e.g., actual reward or “liking”). Although perhaps a way off, possession of these genotypes may suggest distinct loci of intervention (i.e., craving management therapy for carriers of dopamine-related high-risk genotypes vs. opiate antagonist therapy or counterconditioning for carriers of opioid-related high-risk genotypes).
Along similar lines, recent studies characterizing the dysregulation of CNS functional systems through chronic alcohol use have demonstrated striking down-regulation of both the D1 and D2 receptor systems (Self & Nestler, 1998). To the extent that genetics may play a role in receptor density, a potential gene-environment interaction may exist that renders some drinkers particularly susceptible to chronic hypodopaminergic states. This possibility is particularly intriguing as data emerge suggesting that, within the dopamine system, the D1 subsystem is associated with liking, whereas D2 is more associated with wanting (Berridge & Robinson, 1998; Self, 1998). The convergence of these data may suggest that psychopharmacological agents with differential affinities to D1 and D2 may prove to be selectively efficacious depending on the particular need of the drinker (e.g., a D2 genetically “vulnerable” person may need more craving management).
A final set of candidate genotypes that has been examined include those genes responsible for generating alcohol metabolic enzymes (e.g., alcohol dehydrogenase, acetaldehyde dehydro-genase, P450 liver enzymes in the cytochrome system) (Higuchi, Muramatsu, Matsushita, Murayama, & Hayashida, 1996). Polymorphic loci on these genes (e.g., ALDH2, ADH2, ADH3, CYP2E1) are subjects of continued scrutiny and may also relate to the magnitude of the hedonic response to alcohol consumption. Because stress is a potent antecedent of alcohol consumption, examination of genetic factors that relate to the stress response (e.g., cortisol regulation) may be a promising avenue in the future. Clearly, the preliminary search for candidate genotypes has yielded only modest results. Genome-wide microarray technology may prove to be highly useful in elucidating the roles of multiple genes in animal models of alcoholism.
There is currently a large body of research demonstrating that individuals with a genetic predisposition to alcoholism display substantial cognitive and neuropsychological deficits. Giancola and Moss (1998) argued that cognitive and neuropsychological deficits, especially those related to executive functioning that predate drinking experiences (e.g., attention, planning, cognitive flexibility, appropriate inhibition), may somehow be related to the development of alcoholism. For example, Alterman, Gerstley, Goldstein, and Tarter (1987) reported that “children of alcoholics” perform more poorly on tasks that putatively assess frontal lobe functioning such as the Stroop task, the Trail Making task, and the Wisconsin Card Sort task. Studies of stimulus-evoked potentials, especially the P300 component (Rodriguez, Porjesz, Chorlian, Polich, & Begleiter, 1999), have provided converging biological support for the notion that children of alcoholics display poorer attentional capacities than do other children. In contrast to the predictors mentioned previously, these cognitive predictors do not necessarily directly operate through differential reinforcement. A likely explanation is that although drinkers with cognitive deficits experience comparable levels of reinforcement from alcohol to those of drinkers without such deficits, the former lack the cognitive resources to regulate their intake or to say “no” when offered a drink. This problem may become particularly pronounced when high-risk drinkers, who are already mildly cognitively deficient, become intoxicated, further undermining their ability to process information or to attend to internal or external intake regulation cues. The possibility also exists that cognitive deficits are epiphenomenal to a broader relation between chronic hypofrontality (which may, in fact, be related to the reinforcement value of alcohol) and future drinking behavior. Alternatively, Erblich and Earleywine (1999) suggested that such deficits may also stem from the more general effects of growing up with an alcoholic parent. Poorer nutrition, educational opportunities, and physical abuse have been reported among children of alcoholics (Rao, Begum, Venkataramana, & Gangadharappa, 2001). One could speculate that growing up in such an environment may lead to the observed cognitive deficits and, as indicated previously, may be an important mechanism through which problem drinking develops. Speculation aside, the precise mechanism through which cognitive and neuropsychological deficits lead to alcoholism remains unclear. In addition, whether these deficits are genetic or environmental in origin is also unclear. Nevertheless, these factors are important to consider when developing an etiologic model of alcoholism.
It is now well established that specific personality factors are strongly predictive of drinking behavior. Nearly four decades ago, MacAndrew (1967) identified clusters of items on the Minnesota Multiphasic Personality Inventory (MMPI), primarily related to deviance proneness, that significantly differentiated alcoholics from nonalcoholics. This early research was one of the first systematic investigations of the potential role of personality characteristics in problem drinking. Since then, the MacAndrew Alcoholism Scale and the Holmes Alcoholism Scale have become mainstays of risk assessment for alcoholism. Recent modifications have found that shorter versions of these scales (7 to 13 items) may be even more strongly related to alcoholism (Conley & Kammeier, 1980; Hoffman, Lumry, Harrison, & Lessard, 1984). Problem drinking has been related to other measures of deviance proneness as well. For example, several studies have found that problem drinkers, alcoholics, and children of alcoholics score significantly more pathologically on the Socialization scale of the California Personality Inventory (e.g., Finn, Sharkansky, Brandt, & Turcotte, 2000). In addition, symptoms of antisocial and borderline personality disorders are common among problem drinkers, alcoholics, and children of alcoholics. Indeed, Sher and Trull (2002) reviewed the literature on personality disorders and concluded that although substance abuse is related to many personality symptoms, including those of paranoid and avoidant personality disorder, the largest consistent set of findings is in antisocial and borderline symptoms.
Problem drinking appears to be related to other personality constructs as well. Studies have demonstrated repeatedly that high scores on Zuckerman’s Sensation Seeking Scale (and other similar scales) predict drinking behavior (e.g., Finn, Earleywine, & Pihl, 1992). Other studies of novelty seeking using similar instruments provide additional support for such a relation (Hesselbrock & Hesselbrock, 1992). A longitudinal study of children’s novelty seeking found that those who scored highly were more likely to become alcoholics as adults (Cloninger et al., 1988). Interestingly, one of the relatively few transdisciplinary studies performed (Laine, Ahonen, Rasanen, & Tiihonen, 2001) revealed that individuals high in novelty-seeking personality traits also have higher densities of CNS dopamine transporter (DAT). This finding is consistent with genetic hypotheses that high levels of DAT (which clears dopamine from the synapse) would relate to problem drinking.
Still other studies have examined the role of traits such as disinhibition, reward dependence, external locus of control, and negative self-concept and have found significant relations with drinking behavior (e.g., Hesselbrock & Hesselbrock, 1992). Interestingly, neurophysio-logical studies have linked many of these personality traits, especially sensation seeking, disinhibition, and deviance, to chronic hypo-perfusion of the orbitofrontal cortex (Friedman, Cycowicz, & Gaeta, 2001). Theorists have suggested that these personality traits may represent part of a broader syndrome related to cortical underarousal (Brennan & Raine, 1997). The localization of these traits in the CNS is particularly intriguing because the orbitofrontal cortex is precisely the area involved in the cognitive deficits mentioned previously. Furthermore, this region of the brain is highly dopaminergic. The physiological convergence of these biogenetic, cognitive, and personality factors speaks to the preeminent role of a “hungry” brain in dramatically increasing the incentive salience and reward value of alcohol consumption.
Stress is the most consistently reported antecedent to drinking behavior. Naturalistic studies of stress have found strong relations between a number of stressors (e.g., social, medical, trauma) and drinking behaviors. As one example, Seeman and Seeman (1992) found that chronic stress associated with work predicted later alcoholism. Indeed, anecdotal clinical reports consistently support the contention that acute stress is a powerful proximal determinant of drinking episodes. To ascertain a causal relation between stress and drinking, investigators have employed laboratory-based studies of experimental stressors (Stewart, 2000). Findings have demonstrated that social, cognitive, and physical stressors can induce alcohol craving, potentiate the hedonic impact of consumption, and increase the amount of alcohol consumed post-stressor (Stewart, 2000). Interestingly, the magnitudes of stress reactions also predict drinking behavior, such that the previously mentioned drinking parameters are more severe for those who have stronger stress reactions (Sinha & O’Malley, 1999). This finding is important because it suggests not only that stress is a predictor of drinking but also that some who are predisposed to more powerful stress reactions (through some genetic factor or otherwise) are at a particularly high risk for problem drinking. The classic stress vulnerability model may be particularly appropriate for understanding alcoholism. Specifically, constitutional factors, such as genetics, personality characteristics, neuropsychological dysfunction, and stress reactivity, may render some individuals particularly vulnerable to the effects of stress and place them at high risk for dependence.
If stress predicts drinking behavior, coping skills should moderate the degree to which stress has an impact. Indeed, studies have demonstrated that coping skills can buffer the effects of stress on drinking behavior (Wills, Sandy, & Yaeger, 2002). Darwin, Freud, and (most recently) Bandura have underscored the importance of coping in adapting to stressful situations. The Darwinian model of homeostatic maintenance would predict that an organism would consume alcohol to return to a baseline “pre-stress state” (Darwin, 1859/1998). Indeed, ethologists have speculated that animals may take laborious detours from traditional migratory paths to find psychoactive substances. It is thought that this may serve to maintain homeostasis during the stressful process of migration. Freud (1901) formulated the role of coping in terms of “defense mechanisms.” He argued that those who are “orally fixated” (i.e., those who experienced some sort of developmental arrest in early life when oral pleasure dominated) might use alcohol to cope with stressors in favor of other healthier coping mechanisms. Finally, Bandura (1969) argued in his social learning theory that use of alcohol as a coping mechanism may stem from imitative learning processes. Drinkers may have observed their parents use alcohol as a method of “unwinding” after a long day, or they may have observed similar media representations of alcohol (e.g., “Miller time”). All of these theorists share the notion that management of stress is a critical moderator of drinking behavior and must be considered when trying to understand the effects of stress on the development of alcoholism.
Another major predictor of drinking behavior is one’s expectations of the consequences of drinking (e.g., Keane, Lisman, & Kreutzer, 1980). The more one expects alcohol consumption to lead to positive outcomes (e.g., better social performance, better sexual performance, more tension reduction, euphoria), the more one will drink. Similarly, the less one expects alcohol consumption to lead to negative consequences (e.g., hangover; excessive sedation; sluggishness; trouble with family, friends, work, and the law), the more one will drink. Studies have shown repeatedly that the Alcohol Expectancy Questionnaire, a classic instrument used to assess positive expectancies, predicts drinking behavior (e.g., Williams & Ricciardelli, 1996). Similarly, the more recently developed Negative Alcohol Expectancy Questionnaire has been found to negatively correlate with drinking variables (McMahon & Jones, 1994). Recent innovations have identified powerful ingrained cognitive schemata that underlie these expectations (Rather, Goldman, Roehrich, & Brannick, 1992), and these are especially strong among those at risk for alcoholism (Erblich, Earleywine, & Erblich, 2001). In an intriguing study, Smith (1994) found that expectations of favorable drinking consequences predated drinking experiences, suggesting that such expectancies may be learned relatively early in life and are not simply a readout of people’s actual experiences with alcohol.
Modeling is another critical component in the development of drinking behavior, according to Bandura’s social learning theory. Children and teens often rely on role models when developing behavioral repertoires, especially regarding health behaviors (Yancey, Siegel, & McDaniel, 2002). Observing parents, siblings, and other peers consume alcohol may play a powerful role in shaping future behavior (Roski et al., 1997). Other role models, including those seen in advertisements, television programs, and movies, can have a profound influence as well. Thompson and Yokota (2001) found that although the trend has been decreasing, a substantial number of G-rated movies depict alcohol and/or drug use.
Social support is yet another factor found to be involved in the development of problem drinking. Individuals who report low levels of social support are more likely to report problem drinking than are others (Green, Freeborn, & Polen, 2001). In a longitudinal study, Schuckit and Smith (2001) found that even among individuals at high risk for alcoholism, high levels of social support protected against developing alcoholism 15 years later. Marlatt (1996) discussed numerous “proximal determinants” or factors that contribute to the decision to consume alcohol “in the moment.” He suggested that those individuals with poor social skills, especially those who are uncomfortable with saying “no,” are more likely to consume alcohol (see also Smith & McCrady, 1991). In addition, those who have lower levels of self-efficacy, especially regarding the willpower to abstain or moderate drinking behavior, are more likely to consume alcohol. Taken together, stress, coping, expectancies, modeling, social support, social skills, and self-efficacy can be conceptualized as necessary, but not sufficient, moderators of risk for developing alcoholism, such that the presence of these factors may determine whether or not someone who is vulnerable (by virtue of genetics, personality, or cognitive functioning) will develop alcoholism. It should be noted that although these concepts are being presented independently, there is a sizable literature suggesting complex interrelationships between factors that is beyond the scope of this chapter. An illustration of this point is that coping, social skills, and self-efficacy all may be related and may be affected by expectancies (Marlatt & Gordon, 1985). Nevertheless, we believe that the current body of literature on predictors of drinking behavior points to a classic stress vulnerability model, whereby constitutional factors such as genetics, personality, and cognitive capacities can render an individual vulnerable to the effects of numerous exogenous factors. In sum, the available data suggest that the stress vulnerability approach provides a clinically useful working model of the pathogenesis of alcoholism.
Psychological Treatments for Alcohol Problems
At least three different approaches have shown considerable promise in minimizing the negative consequences of alcohol: cognitive-behavioral therapy (CBT), motivational interviewing, and 12-step facilitation. CBT focuses on changing the thoughts and situations that previously led to the use of alcohol. Motivational interviewing uses assessments and interpersonal interactions to enhance decisions to alter problem behaviors. Finally, 12-step facilitation employs specific techniques to help people make good use of 12-step treatment.
Each treatment has its strengths. An enormous project that contrasted the outcomes of these three treatments for alcohol-dependent individuals found that all three were comparably effective (Project MATCH Research Group, 1998). The treatments share several factors, and this may help to explain their similar outcomes. Each emphasizes the client’s responsibility for change, each treats alcohol use as a phenomenon independent of the individual’s value as a person, and each stresses regular attendance and active participation in treatment.
Descriptions of these therapies do not reveal all of their nuances, and even the best attempt to reduce a treatment to a few pages of text invariably fails. Academic descriptions of psychotherapy often miss its potential for intimate and curative interactions, whereas stereotypical depictions of the process often emphasize education, empathy, encouragement, and occasional insights. Ideally, these descriptions combine to alter actions, diminish problems, and increase happiness. The techniques and rationales of each of the treatments discussed in what follows provide only a limited picture of the ways in which they actually proceed.
Although treatments differ in their methods and strategies, most require a meaningful relationship with a therapist. Therapists often believe that techniques create change, but the relationship may serve as an equally important contributor (Strupp, 1989). The idea that the relationship is more important than specific strategies may help to explain some of the similar outcomes created by different therapies (Wampold et al., 1997). Manualized treatments, which clearly delineate specific material for each session, can lead to different outcomes with different therapists. Although the therapeutic relationship may account for these differences, it does not mimic the friendship and coaching common outside of therapy. Data clearly support psychotherapy’s efficacy, but the mechanisms that lead to success remain unclear (Dawes, 1994).
Space limitations preclude a lengthy description of all available treatments for alcohol-related problems. Given the widespread familiarity and availability of 12-step programs, this chapter focuses on CBT and motivational interviewing. The reader who is interested in facilitating participation in 12-step programs is encouraged to read the work of Nowinski and Baker (1992).
CBT for alcohol problems focuses on altering environments, thoughts, and actions associated with drinking. Different environments may trigger undesired problematic consumption. These triggers involve both external and internal factors. External factors include any person, location, or object associated with alcohol. A beer mug, a rock song, or a swizzle stick may easily trigger a desire to drink. Internal factors include thoughts and feelings linked to alcohol. Some triggers are direct and some are indirect. Direct factors, such as craving and urges, are close to drinking. Indirect factors also increase the chance of drinking, but their import is less obvious. These include frustration, anger, and even delight. CBT suggests that problem drinkers learn to use alcohol in reaction to these triggers in much the same way as people learn any behavior. Therefore, they can learn to engage in new behaviors instead of problematic drinking by altering environments, thoughts, and actions (Beck, Wright, Newman, & Liese, 1993).
The situations that precede drinking often appear to be diverse. For example, an assessment might reveal dramatic drinking at a sporting event, after conflict at home, and every Friday night. The commonalities among these situations are obscure. The cognitive-behavioral model suggests that thoughts about the situations may contribute more to drinking than do the circumstances themselves. Thus, each environment may elicit specific thoughts. A common thought in all of these situations might be that “alcohol is the only way in which to enhance this experience.” These types of thoughts are probably easier to alter than are the situations, so the thought rather than the environment becomes the focus of CBT.
The cognitive-behavioral model suggests that people carry a set of underlying beliefs into each situation. Certain situations activate these beliefs, eliciting specific thoughts that subsequently lead to action. For example, a problem drinker might believe that alcohol provides the only way in which to relax. The drinker may interpret a situation as stressful, leading to the activation of the belief that he or she needs alcohol to relax. This belief would likely lead to thoughts of drinking, which might inspire all of the actions required to get a drink. In CBT, the client would learn to challenge his or her beliefs in an effort to minimize or eliminate drinking. Thus, the client may develop skills enabling him or her to see the situation as less stressful, thereby altering the belief that drinking is the only effective way in which to relax (Beck et al., 1993). Instead of drinking, the client might listen to music, meditate, or exercise.
Therapists have developed many techniques for altering these beliefs. Most require identifying the underlying belief and then looking for evidence to support or dispute it. A common strategy that cognitive-behavioral therapists employ includes Socratic questioning, a method by which therapists guide clients through a series of questions so that they might arrive at their own answers. Instead of providing information, this strategy teaches a process for discovery. Eventually, clients can learn to ask these sorts of questions of themselves so that they can maintain sobriety without therapists.
This process also elicits the thoughts and feelings most important to clients. For example, those who believe that alcohol provides the only way in which to relax might respond particularly well to questions about alternative ways in which to unwind. Questions about restful recreation in general may prove helpful. Queries about favorite activities before clients began drinking may also work. As clients generate their own list of preferred ways in which to soothe themselves without alcohol, the belief that alcohol is the sole source of relaxation weakens. It is important to note that clients find their own examples more compelling than any list of relaxation techniques that therapists might generate. This approach also respects clients’ ability to present evidence to alter their beliefs (Overholser, 1987). In sum, changing the thoughts about situations that previously led to drinking can help to decrease problematic consumption.
CBT relies on other techniques that are too numerous to list here, but one key set of strategies concerns relapse prevention. Many people can quit drinking briefly but cannot maintain abstinence. Thus, many cognitive-behavioral techniques focus not only on quitting but also on avoiding relapse to alcohol. Thoughts and beliefs remain important in preventing relapse given their relevance to a phenomenon known as the abstinence violation effect. The abstinence violation effect concerns the way in which people cope with backsliding once they have committed to altering their alcohol consumption.
Most people who decide to eliminate or decrease their use of alcohol subsequently make mistakes. They use alcohol when they intended to quit, or they use more than their established limits. The abstinence violation effect may occur when a small thoughtless sip of beer turns into a full weekend binge. It is as if people say, “Well, I wrecked my abstinence, so I might as well drink the whole bottle.” Minimizing the impact of small slips is essential to relapse prevention. Although many believe that the pharmacology of alcohol makes a single dose inevitably turn into a relapse, changes in thinking can actually prevent these slips from creating further problems. In fact, it has been shown that the interpretation of the slip appears to contribute more to relapse than does the actual occurrence of the slip itself (Marlatt & Gordon, 1985).
There is no doubt that intoxicated individuals can make poor decisions about continued drinking and that the pharmacological effects of alcohol contribute to these decisions. Nevertheless, many individuals who relapse report abstinence violation effects that occurred at extremely low doses. A single sip of liquor or smell of wine often lead to the decision to binge. Pharmacology might not play a particularly strong role in these relapses. Marlatt, Demming, and Reid (1973) revealed that alcoholics who drank alcohol but were not aware of doing so did not show the abstinence violation effect and did not continue drinking after the initial dose. In contrast, alcoholics given a placebo believed to be alcohol did show the abstinence violation effect and did consume considerably more alcohol after the placebo. These findings indicate that thoughts also play an important role in relapse prevention.
In sum, CBT relies on the principles of learning theory to treat alcohol-related problems. The treatment may work by altering beliefs about alcohol use and its consequences. It also focuses on the prevention of relapse by identifying situations that may increase the risk of drinking and then teaching alternative ways in which to act under those conditions.
Motivational interviewing involves brief interactions with a therapist to help the client decrease alcohol-related problems. The treatment enhances motivation before attempting any changes in behavior because in the absence of motivation, any efforts to teach techniques for limiting alcohol consumption are typically an inefficient use of time for both the client and the therapist. Motivational interviewing focuses on identifying clients’ own reasons to quit. Once these reasons help to increase desire, clients often develop their own strategies for eliminating alcohol from their lives. Many people stop drinking on their own, and motivational interviewing essentially enhances the chances that a client will join this group.
Motivational interviewing relies on principles designed to help the client decrease alcohol problems. First, the therapist behaves in a manner that will increase the likelihood of change such as listening attentively without judgment or blame. Second, the therapist employs the “stages of change” model, which views change as a fluid process that requires a different intervention for each stage of the client’s willingness to act. In motivational interviewing, the behaviors employed by the therapist that are most likely to induce behavior change on the part of the client (e.g., empathy, nonpossessive warmth, genuineness) were originally emphasized in client-centered therapy (Rogers, 1950).
The Stages of Change Model
As mentioned in the previous section, empathy, warmth, and genuineness lay the foundation for any productive therapeutic interaction. Many therapies rely on these aspects of the therapeutic relationship to help support growth. Motivational interviewing combines these qualities with the stages of change model to decrease problem drinking. The stages of change model describes specific steps that individuals appear to take when they alter problem behaviors (Prochaska & DiClemente, 1983). The researchers proposed six stages: (a) precontemplation, (b) contemplation, (c) determination, (d) action, (e) maintenance, and (f) relapse (Prochaska, Norcross, & DiClemente, 1994).
Precontemplation describes the period before individuals consider altering behavior. Drinkers in precontemplation have never considered cutting down or quitting. An adept therapist would not waste time attempting to teach these individuals how to quit because they currently lack the motivation to do so. Instead, the therapist assesses clients’ quantity and frequency of drinking in an effort to get them to contemplate change. The best approach for this assessment is the time line “followback” (Sobell & Sobell, 1995), a calendar technique that asks drinkers to go through each day for the previous 3 months and list the number of drinks consumed. The therapist would also ask about any associated consequences such as negative emotions, fatigue, hangovers, accidents, and liver troubles. This assessment often leads clients to make the connection between their drinking and the consequences of their drinking. If these connections are made and they lead clients to consider change in any way, clients have entered the contemplation stage.
Contemplation includes the weighing of the pros and cons of altering actions or continuing the same behavior. The motivational interviewer encourages drinkers in this stage to candidly report all of the positive and negative experiences they attribute to their use of alcohol. Initial assessments of pros and cons often reveal ambivalence, that is, strong desires to continue drinking as well as equally strong desires to stop. Ambivalence serves as a common important component of contemplation. Other approaches to treatment may see ambivalence as denial. The stages of change model emphasizes ambivalence as an inherent part of change. During further discussion, the therapist respectfully reflects drinkers’ concerns back to them, emphasizing the negative consequences that they generated earlier. This process often leads problem drinkers to a decision to change. A firm decision to change qualifies as a step toward determination.
Determination begins with a clearly stated desire to alter actions. This stage serves as the appropriate time for drinkers to formulate a plan for limiting alcohol consumption. The plan often stems from brainstorming between the interviewer and the drinkers and may include any options that look promising. For example, the strategy for change may rely on techniques from CBT such as altering beliefs and preventing relapse. In addition, drinkers may decide that membership in a 12-step program sounds appropriate.
Once clients regularly limit their drinking or abstain, they have entered the action stage. They no longer merely consider change; they actually make the desired change. This stage proves to be particularly informative as the genuine experience of new habits and actions reveal valuable information unanticipated during the contemplation and determination stages. Clients may find some situations to be easier or more difficult than they expected. The motivational interviewer will offer reassurance about the process becoming less difficult with the passing of time and more practice. The interviewer helps clients to solve problems related to their alcohol use and listens attentively to clients’ detailed descriptions of their difficulties and successes.
After a steady period of action, clients may report increased confidence in their skills. This sense of efficacy, an optimism in their own ability to continue the new behaviors, serves as a hallmark of the maintenance stage. Self-efficacy and sustained change are the keys to maintenance. The therapist and the clients will now work together to prevent relapse. They identify situations that put the drinkers at high risk for relapse, and they plan ways in which to avoid problematic alcohol use in these circumstances. For example, clients may decide to avoid parties where alcohol is present. They may role-play refusing drinks if they are offered them. They may practice relaxation techniques if tension often precedes their drinking. They may call a hotline or a friend during times of temptation. It is important to note that these techniques for preventing relapse are consistent with 12-step and CBT approaches.
Occasional backsliding occurs in many efforts to alter maladaptive drinking behavior. The stages of change model considers lapses and relapses as another category of change. Discussing this fact with clients may help to normalize the occasional slip. Considering lapses as a part of the change process may decrease the chances of an abstinence violation effect transforming a slip into a full-blown relapse. The key to the lapse stage parallels the key to the maintenance stage—preventing relapse. Lapses require immediate action. Lapsing drinkers can prevent relapse by rapidly exiting the situation and removing the chance of continued drinking. Many who lapse berate themselves, but their time and energy may be better spent in identifying the precursors to the slips. A frank examination may reveal a new high-risk situation, providing the opportunity to formulate a plan for how to handle this predicament in the future. For example, a former drinker may find himself or herself lapsing after a fight with a family member. This situation might not be one that the drinker had identified as high risk before. Now the drinker knows that he or she needs to plan new ways in which to deal with conflict. The drinker can turn this lapse into a learning experience to prevent future drinking. Thus, lapses remain a part of the change process, and planning for them may minimize problems.
“Bob,” a 54-year-old Caucasian male truck driver, came to a Veterans Administration hospital after falling in his driveway. He had seriously injured his face and hands. A breath alcohol monitor suggested that his blood alcohol level was approximately .20. Surgeons removed small rocks from his face and hands and referred him to the chemical dependency treatment program. Assessment revealed that Bob had been drinking alcohol regularly for 41 years, since the age of 13 years, and had his first drink at age 10 years. A time line followback assessment suggested that Bob had consumed between 20 and 24 beers per day over the past 90 days, a pattern he said went back for at least 7 years. He had been in treatment twice previously, once in his late 20s and once approximately 8 years ago. He had maintained complete abstinence for approximately a year each time. Both treatments focused on 12-step interventions, but Bob was unwilling to return to meetings or inpatient treatment. He did, however, agree to attend a 1-hour outpatient appointment the following week.
Bob missed the first outpatient meeting, rescheduled after a telephone call, and missed the second meeting as well. A phone call after his second missed appointment revealed that he was willing to discuss the pros and cons of attending an outpatient appointment. Bob confessed that he thought that the hospital only offered 12-step interventions and that he thought he would be “strong-armed” into going back to “God meetings.” With the promise that there would be no discussion of steps or deities, he agreed to attend an outpatient interview the following week. The fact that he was willing to reschedule illustrates the importance of follow-up calls after missed appointments. Bob would have undoubtedly never returned to treatment if he had not been phoned after missing appointments.
Bob arrived promptly at an afternoon appointment with a breath alcohol concentration of .06. He stated that he had consumed 4 beers at lunch but that he was doing much better than he had been doing when he came to the hospital after his fall. He claimed to drink 12 beers per day over the previous 3 weeks and again declined inpatient treatment. On reflection, he admitted that he had cut down to 12 beers per day in the past but had eventually increased back to his usual case of 24 per day. He was unwilling to discuss abstinence but agreed to list the pros and cons of decreasing his drinking to 6 beers per day. This approach is consistent with motivational interviewing interventions for people in the contemplation stage.
Bob was surprised when the therapist asked him to first list the disadvantages of drinking only 6 beers per day. The most salient disadvantage to him was that he would be forced to drink them all at once on an empty stomach to notice any subjective effects. He also mentioned that he might receive ribbing from cronies for not “keeping up” when they watched sporting events or went fishing. The only advantages to decreasing to 6 beers per day that Bob could generate were financial. With some prompting, he decided that he might also have fewer conflicts with his adult children if he decreased his drinking. The therapist pointed out several other potential advantages. Specifically, Bob’s liver enzymes suggested the potential for medical problems, and these would eventually improve with a decrease (although they would not improve as much as they would with abstinence). In addition, Bob would be less likely to run into problems while driving his truck for work. Mentioning this potential advantage prompted several tales of bravado about his tolerance. With reflection, these eventually turned to a revealing disclosure about a blackout experience. Bob had arrived in a location more than 300 miles from his home and could not recall any aspect of the trip. He feared that he could have had an accident and killed another driver or himself. He expressed considerable shame, guilt, and fear. Reflection of these emotions appeared to inspire a willingness to limit consumption to 6 beers per day and to drink these only during the evening when it was unlikely that he would drive. Bob also agreed to three more outpatient visits during the next 3 weeks.
The therapist called Bob after 4 days to confirm his next appointment. When asked how he was doing, Bob replied, “If I can’t have a 12-pack, I really don’t see the point of drinking at all.” When asked to elaborate, Bob explained that 6 beers provided little change in his state of mind. He agreed to stick to the limit but implied that he might experiment with an occasional day of abstinence. When he arrived for his next appointment, his breath alcohol was .00. He had consumed 6 beers per day on each day, but he drank only 1 during the evening that the therapist had called. When asked why, Bob said that he felt “silly” drinking at all after what he had said about requiring 12 beers to feel any subjective effects. When asked what subjective effects of alcohol he preferred, Bob focused on tension reduction. The session then turned to standard progressive muscle relaxation training. Bob found relaxing in session to be a bit cumbersome but agreed to listen to a relaxation tape at home.
The following week, Bob decreased his drinking to an average of 4 beers per day, with 1 day of abstinence. When asked how he felt about it, he claimed little change in his own experience but some tentative changes in those around him. His adult children had commented that it was nice to see him drinking less. He said that this did not matter to him much, but his affect certainly seemed improved. He had been listening to the relaxation tape daily and agreed to discuss complete abstinence. The therapist reviewed some relapse prevention strategies and sent Bob home with a list of responses he had generated himself for handling difficult situations. He had focused on drink refusal with friends and stressful situations as his target high-risk situations. Bob generated the expression “I’ve already had my share” as a response for refusing drinks when offered. He also agreed to listen to the relaxation tape daily in an effort to reduce stress. He discussed looking at things differently in an effort to cope, and he agreed to attend a stress management seminar conducted in another area of the hospital.
At 1 month follow-up, Bob had lapsed one time. He attended a barbecue where an acquaintance handed him an open 40-ounce bottle of beer. Bob stated that he took a drink from the bottle automatically. He then reported that he excused himself to go to the bathroom and poured most of the beer into the sink. He reported that he then carried the partially empty bottle around the party for a while for reasons he could not explain. Bob exhibited signs of disappointment regarding this event. The therapist emphasized that it was a single slip, that Bob had not turned it into an excuse to start a binge, and that Bob did not drink again. Bob seemed happy with the interpretation. He agreed to go back to his favorite “I’ve already had my share” response if a similar experience arose in the future. The therapist called once the following week to confirm abstinence. At 3 months, Bob reported no new lapses and was happy to report that his liver enzymes had improved. At 9 months, he had continued his abstinence and reported even more improvement on his liver enzymes. Although 9 months of follow-up is not a long time, these initial results were encouraging for this combined approach of motivational interviewing and CBT.
Alcohol can create numerous problems in the lives of drinkers. Different genetic and environmental factors interact in the creation of alcohol abuse, dependence, and problems. A family history of alcoholism, a combination of personality traits, and a set of cognitive factors all can combine with various life stressors to lead people to turn to alcohol for relief of stress. Consistent use of large quantities may lead to alcohol abuse. It can further lead to alcohol dependence or to other life problems. Three imperfect but useful treatments have proved to be effective in alleviating alcohol problems for many individuals: CBT, motivational interviewing, and 12-step facilitation. These therapies have many overlapping characteristics but also employ techniques specific to each approach that are designed to decrease alcohol-related problems. Although the road to sobriety is fraught with difficulties, many people have changed their lives by eliminating the problems related to their continued alcohol use. Putting an end to problem drinking can have a dramatic impact on health and happiness.