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The myth of alcoholism prevention
PREVENTIVE
MEDICINE
4, 404-416 (1975)
The Myth of Alcoholism MELVYN Santa Clara County Mental
Health, Alcohol
Prevention’
KALB~ Services Division,
San Jose, California
Although practically every article about alcoholism contains at least one or two paragraphs that stress the importance and need for prevention programs, the “hows” and the “specifics” are rarely spelled out in any detail. The analysis of why this situation exists points to the existence of three central premises around which the present alcohol prevention model is constructed. Each of these premises has at its core the existence of some invalid statements, the perpetuation of which effectively blocks the establishment of more appropriate prevention models. Awareness of ‘Ifacts” about alcohol leads to a change in drinking. The paper cites evidence from experimental and empirical sources, illustrating that the presentation of facts, although in some cases altering attitudes, does not result in changes in certain behaviors. An explanation and model are provided stating the conditions under which “facts” do and do not result in behavioral change and where “alcohol facts” fit into this paradigm. Prevention programs centered around “consequences” are an effective way to produce changes in drinking. The common theme most alcohol prevention programs share today is
that their “message” deals with the consequences of drinking. This approach is highly unsuccessful in appealing to alcoholics whose characterological style ties them to the present and not the distant consequences of their behavior. Applicability
of a medical primary
and secondary prevention
model to alcohol education.
This section of the paper deals with the misapplication of the medical primary and secondary prevention models to alcoholism. It discusses why the etiology of alcoholism must be understood prior to the establishment of a primary prevention program. It also questions the methodological premises around which the early warning signs of alcoholism are buih and their validity in successfully predicting the later development of alcoholism. The need for more longitudinal studies is suggested.
Although articles about alcoholism and programs designed to treat alcoholism are diverse in their range and focus of interest, they share, in most cases, at least one common theme. Invariably one or two paragraphs appear that stress the importance and need for programs on prevention. What is puzzling about the paragraph(s) on the “need and importance of prevention programs” is that elaborations are usually absent. A certain quality about these prevention statements exists that seems to preclude further comment. The “bows” and the “specifics” are rarely elaborated on or spelled out in any detail. It is almost “as if” the statements themselves are in lieu of any concrete proposals. The frequency with which this format appears in the alcohol literature has led ’ Presented in part before the Section on Prevention of Alcohol Problems, North American Congress on Alcohol and Drug Problems, December 17, 1974. ’ The opinions expressed herein are those of the author and do not necessarily reflect the views of the Santa Clara County Alcoholism Program or the Santa Clara County Public Health Department. Present Address: Department of Psychiatry, Kaiser-Permanente Medical Center, 900 Kiely Boulevard, Santa Clara, California 9505 1. Reprint requests should be sent to this address. 404 Copyright @ 1975 by Academic Press. Inc. All rights of reproduction in any form reserved.
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this author to conclude that to talk about prevention belongs in the same category as “Mom and Apple Pie” -everybody is unquestionably for it, and no one dares speak out against it. This “sacred cow” philosophy has established a climate in the alcohol field whereby lip service is paid to the importance of prevention programs but such programs are not openly and extensively discussed and criticized nor evaluated for their effectiveness. The oft cited analogy about prevention - “talking about prevention is like talking about the weather: everybody talks about it, but nobody does much about it”-accurately reflects this basic posture. What is perhaps even more surprising is that after more than 25 yr of published research in the alcohol field, controlled studies that have attempted to evaluate the effectiveness of preventive approach A versus preventive approach B are sorely lacking. It is somewhat mystifying to imagine that prevention, a goal that Dr. Morris Chafetz, Director of the NIAAA, lists as the number two priority (2), second only to the treatment of alcoholism, is so devoid not only of extended and critical discussion but research as well. In 1959, McCarthy and Fain (36), writing about alcohol education programs, reached the general conclusion that no systematic evaluation of the effectiveness of educational or publicity programs had been published. In 1973, 14 yr later, Braucht, Follingstad, Brakarsh, and Berry (9, p. 1289) concluded after a comprehensive review of approaches to all drug education that “there is almost no empirical evidence as to these programs’ effectiveness.” Similar conclusions are reported in recent reviews of drug education programs by Blane (8) and Gusfield (26).
It is this author’s contention that this absence of empirical evidence, of more critical and extended discussion, is an outgrowth of the central premises around which the present alcoholism prevention program is based. These premises are: (a) awareness of “facts” about alcohol leads to a change in drinking, (b) prevention programs centered around “consequences” are an effective way to appeal to and produce changes in drinking behavior, and (c) applicability of a primary and secondary prevention model to alcohol education. Each of these premises has at its core the existence of some invalid statements, the perpetuation of which effectively blocks the establishment of more appropriate prevention models. It is the thesis of this paper that these invalid premises should be relegated to the status of a myth and that as long as we continue to base our present prevention programs around them, prevention in alcohol will forever be wedded to apple pie. A. AWARENESS OF “FACTS” TO A CHANGE
ABOUT ALCOHOL IN DRINKING
LEADS
The premise that the present prevention model advances is that if information about alcoholism is imparted to the alcoholic, the potential problem drinker or the general public, a cessation or reduction in the amount of alcohol consumed will result. The core of this thesis is that “the facts” about alcoholism would somehow modify or deter heavy future drinking behavior since it would be illogical for the individual to continue to drink immoderately or initiate a heavy
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drinking pattern when the facts are made known. Although an analysis of this statement appears convincing and although inherently the statement does make sense, the empirical evidence is less impressive. For example, each year millions of dollars are spent informing the public about the dangers of cigarette smoking and drug use. Testimony is presented in various formats (i.e., medical studies, newspapers, television, Madison Avenue advertising) on the “facts” about the dangers of the use and/or continued use of cigarettes and drugs. Despite these ominous facts, cigarette smoking has reached new highs, and drug use has continued to rise (16, 24, 30, 46). Consider too the repeated statements, publicity, and money spent attempting to inform the public on the importance of using seat belts in the automobile. Yet the presentation of facts showing how seat belts can save lives and reduce injury has not resulted in “buckling up” for three-quarters of the American drivers (2 1, 38, 42). Numerous other examples could be offered, but what becomes apparent is that there is obviously something much more (or higher) involved in governing peoples’ behaviors than the rational, logical facts of the situation. The psychotherapeutic system, a method established to change behavior, stands as a monument to the undermining of the principle that “facts” lead to behavioral change. Every textbook on the psychotherapeutic process underscores the notion that intellectual insight alone is clearly insufficient for behavioral change to occur. Some schools of psychological thought (e.g., behaviorism) even consider the discovery of facts epiphenomenal. In attempting to help people unlearn old behaviors and learn new ones, the presentation of facts alone is ineffective as a change modality. The underlying premise of the “facts” model of prevention is the assumption that increased knowledge about alcohol will lead to a change in drinking behavior. Although frequently the learning of facts does result in a change of attitude, its effect on behavior remains questionable. The results of the studies by Williams, DiCicco, and Unterberger (53) and Swisher and Crawford (50) highlight this point. Williams et al. evaluated the effect of an alcohol education program of which the aim was to promote responsible and discourage irresponsible drinking behavior among Catholic high school boys. The authors found that in comparison to a control group that experienced neither education nor discussion about alcohol, students who did undergo an alcohol education program held more favorable attitudes toward temperate alcohol use than prior to the alcohol education program and had increased their knowledge about alcoholism facts. The attitude change lasted a month after the termination of the alcohol program but less than 1 yr, although the increased knowledge of alcohol facts continued for at least 1 yr. The results, however, on whether these attitude changes and increased knowledge resulted in responsible drinking behavior were not as positive. A slightly higher percentage of the students who underwent the alcohol education program, as compared to the controls, became intoxicated during the year following the program. A similar outcome was noted in Swisher and Crawford’s study evaluating the effect of a very brief drug program conducted by psychiatrists and rehabilitated
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drug users in a private school. The results of their evaluation indicated that while there was an increase in drug knowledge, there was no change in attitude, and no significant reduction in drug use. Weaver and Tennant (52) also compared the effectiveness of an intensive and costly 3-week education course given to 452 eighth-grade students with a similar control group of eighth graders who received minimal drug education. The authors found that while the students in the experimental group demonstrated superior knowledge of drugs after taking the intensive drug course, there was no significant reduction in their drug-taking behavior. In fact, a follow-up survey of the experimental students done 9 months later revealed that their drug use increased despite their exposure to the intensive drug program. Braucht et al. (9) in their review of the research on drug education programs pointed to the discrepancy between cognition concerning drug use and actual drug-using behavior. They noted that “while a program may be effective to some extent in altering cognitive states such as knowledge and attitudes, it may have little or no effect on behavior” (p. 1289). Aubrey (5) offered an explanation for this result, maintaining that decisions concerning drug use involve a combination of cognitive and affective elements and that presentation of only factual or intellectual evidence is not enough. Ironically, the “factual” model approach to prevention has even been cited as arousing the curiosity of the listener and encouraging drug use (27, 32). It is important to note that the disregard of facts about alcoholism is not restricted to the nonalcoholic population, where it might be argued that the dangers of alcoholism seem remote. Within an alcoholic population itself-a group seemingly with much to lose were heavy drinking to continue- the same principle appears to operate. In a recent article, Ueckler and Solberg (51) reported a high degree of skepticism concerning the effectiveness of alcohol education in the treatment of individuals already addicted. They noted that in an inpatient alcoholic population, “it seems to be a case of locking the barn after the horse has been stolen” (p. 5 12). What Ueckler and Solberg found was that favorable attitudes toward alcoholism, alcohol education, and treatment of alcoholism were not markedly strengthened by an alcohol education program. They concluded that their data raised questions concerning the wisdom of spending many hours of staff time on making alcoholics familiar with current knowledge about alcoholism. Their findings were also in agreement with those reported in an earlier study by Levinson and Sereny (34). They reported that an inpatient program of resocialization and recreational training was more effective in achieving posthospital sobriety than a program of alcohol education, group psychotherapy, and individual psychotherapy. The authors concluded that their results tended to cast doubt upon the effectiveness of formal instruction about alcohol for an alcoholic population. While undoubtedly there are situations in which the individual does alter his behavior in the light of the “facts,” it is critically important to differentiate those conditions under which facts do and do not lead to change and, concomitantly, to locate where “alcohol facts” fit into this paradigm.
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Six main factors appear to be operative in determining whether “the facts” are heeded and the target behavior subsequently altered: (a) the degree of adversity of the “facts” involved (the severity of the negative consequences of continued “target” behavior) (48), (b) immediate or delayed adverse effects of the target behavior on the individual (the temporal factor) (48), (c) the believability of the espousing authority (3, 4, 37), (d) the degree to which the “facts” are amenable to personal empirical verification by the consumer, (e) the degree of immediate primary and secondary reward value that the target behavior provides (payoff factor) (48), and (f) the degree of availability of alternative behaviors that can equally produce the same rewards for the individual (the interchange factor) (33). The payoff or immediate reward factor of the target behavior and the degree to which alternative methods of achieving a similar payoff are available become the focal points through which the other pieces of information (what happens if I continue, when will it happen, who says it, and can I find out about this myself?) are viewed and evaluated. For example, a few years back, a situation existed concerning reports about the safety of the Corvair automobile (39, 40). The Corvair was reputed to be an unsafe car to drive, having been shown, under test conditions, to have serious “problem areas” considered by automotive engineers to be hazardous. Since for the general public, the reward value of driving the Corvair was not exceptionally high (relative to more prestigious automobiles) and since many other cars were available for the consumer to choose from (each of which would equally serve and gratify the needs that a Corvair provided), it was not at all difficult for the consumer to heed the warnings of the automotive experts and give up purchasing a Corvair for another model. In the case of the Corvair, the adversity of the facts, the believability of the espousing authority, and the degree to which such facts were amenable to empirical verification all became secondary to the question of its primary reward value (what does owning a Corvair “do” for me?) and the degree to which alternative methods of achieving satisfaction were available (can I buy another car that will “do” the same?). The continued use of alcohol strikes a different chord. In alcohol use, the primary and/or secondary reward values are very great, being the principal reasons for its continued use (41). Moreover, the availability of alternative behaviors that can equally produce the same desired end are quite remote unless the individual wants to move into the area of illegal drugs. It is against this background then that the user evaluates the degree of adversity of the “facts” about alcohol, when the adverse conditions will occur, and the status of the authority who advocates its dangers. Thus, the consumer’s willingness to accept on face value the facts presented to him (without personal, empirical validation) appears to be inversely related to the degree of primary and/or secondary reward value of target behavior (29) and directly related to the degree of its interchangeability. Resistance to accepting the facts and altering drinking behaviors lies, not only with the high degree of immediate primary and/or secondary reward value that
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alcohol provides, but also with the notion that the facts about the dangers of alcohol are not quite saleable. Since 68% of the population does drink (1, 13) and enjoy alcohol without any apparent negative consequences and only 12% are heavy drinkers (13), the presentation of logical facts concerning “the dangers” of alcohol seems somewhat labored. The campaign to publicize the dangers of alcoholism may have the effect of damaging the credibility of both the alcoholism authorities and the facts about alcohol abuse. If John Smith knows first-hand N people who drink X ounces Y times weekly who do not appear to him to have an “alcohol problem,” the effect will likely be to lower his belief in the alcoholism authority making the pronouncements and in the “facts” themselves (43). Globetti (23) similarily makes the point that a campaign for young people that warns of “the dire results and tragic consequences of alcohol use in ways which make them inevitable if a person drinks . . . runs counter to the experiences of a great many people and has the adverse consequence of substantially reducing the credibility and believability of the campaign” (p. 242). This situation is exactly what has happened in attempts to inform the public on the “dangers of marijuana.” The public feels that these statements are false on the basis of comparing what they are being told with what they have personally experienced or know through the experiences of friends. This approach has resulted in a wide credibility gap between the proselytizers and the users. What remains, therefore, is that not only do many people (including the alcoholic population) behave in a manner that seems to disregard available facts about the dangers of alcohol, but the “facts” themselves are frequently looked upon with suspicion. B. PREVENTION PROGRAMS CENTERED AROUND “CONSEQUENCES” ARE AN EFFECTIVE WAY TO APPEAL TO AND PRODUCE CHANGES IN DRINKING
A corollary to the thesis advanced above is the related proposition that the presentation of facts that deal specifically with the consequences of alcohol abuse is an effective way to produce changes in drinking. This approach posits that the deterrent quality to acting in a particular manner is a direct function of the consequences of such behavior. The common theme most alcohol prevention programs share today is that the “message” deals with the end result of drinking. An “if . . . then” relationship is sold, giving the listener fair notice, so to speak, that if the behavior in question continues, then some harmful outcome will inevitably result. This approach is highly successful in appealing to those individuals whose behavior is fashioned by carefully weighing the consequences of engaging in various alternative behaviors. These “consequence people” make decisions by temporarily suspending their impulses in the service of examining how the behavior in question will atfect their future. For these “consequence people,” the “if. . . then” approach of the present prevention model does an admirable job. The fit could not be better. Unfortunately, they are likely to be the last people who would become alcoholics.
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When the alcoholic thinks of taking a drink, one of the factors least considered is the distant effects of his behavior on himself and others (7, 3 1, 35). His choice of drinking is dictated by his felt need for the drink at that moment and the rewards it provides rather than its delayed negative effect (short or long term) on him and/or his family (20). His cognitive style places his focus on the stimulus, not the outcome, and sets his time frame in the present, not the future (49). Indeed, the psychological characteristics most frequently used to describe the alcoholic personality are his impulsiveness, “poor ego controls,” and difficulty in “delaying gratification” (10, 14, 18, 22). Given this state of affairs, prevention programs fail in matching their consequence-deterrent approach with the cognitive style of the audience that they are trying most to reach. Moreover, the rationale underlying this consequence-deterrent model lies in its view of man as a rational, pleasure-seeking, pain-avoiding creature (25). Buikhuisen (1 l), for example, argues that general deterrence implicitly assumes a rational approach to deviance. The excessive use of alcohol as a problemsolving device by the alcoholic or problem drinker does not have rational underpinnings, and as such, the alcoholic is unlikely to be responsive to deterrence messages with the hidden agenda of “be rational.” The inadequacy of this consequence-deterrent approach has been recently underscored by the National Safety Council in discussing the drinking driver (19). It noted that: while threats and rules may influence social drinkers, they may be useless in dealing with problem drinkers who, so long as they remain practicing alcoholic persons, will likely continue to drink abusively regardless of the possible penalties. (p. 7)
In a similar light, Gusfield (26) noted that The laws prohibiting public drunkenness and alcohol-impaired driving have had as a justification their supposed influence on potential offenders. The fear of an arrest or fine and/or jail, and the public shame of police arrest booking, and court appearance have been viewed as strong deterrents to the commission of the offenses and thus to the behavior whose eradication is sought. In general, the results of such legislation in preventing problem drinking has been disappointing. . There is little evidence (for example) that laws against drinking driving have been very effective in reducing recidivism, automobile fatalities or fatalities due to drinking. (P. 10)
The necessity for a change in focus has already been recognized by other organizations whose aim is to alter consumers’ behaviors. One such change has been in the approach to have drivers use their seat belts. The approach for many years had been tied to messages that dealt with the outcome of not using versus using seat belts (i.e., “seat belts save lives”). As previously noted, their efforts had been largely unsuccessful. Recently, however, a new approach has been developed that has shifted the concern to the personality of the driver and away from the outcome of not using seat belts. Billboards and magazine ads now appear that simply state: “There is a name for people who don’t use seat belts-STUPID.” Ironically, it is this approach that for many years has appeared in advertisements promoting the sale of alcoholic beverages. The al-
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coholism advertising industry has always associated drinking with virility, sociability, success, and sexuality. Alcohol prevention programs, instead of stressing facts about the consequences of drinking, could easily follow the lead of the alcohol advertising industry and stress the negative aspects of the “image” of the drinker. Prevention programs might associate heavy drinking with insecurity, social awkwardness, failure, and sexual ineptitude. This approach has many precedents, the most notable of which is the Volkswagen campaign that has successfully fought the popular “success” image of the big car driver. By picturing the VW driver as a secure, wise “saver” who exhibits his security in his lack of need to sport a huge gas-eating “success symbol,” the company has successfully undermined the image that the media had established. C. APPLICABILITY OF A PRIMARY AND SECONDARY PREVENTION MODEL IN ALCOHOL EDUCATION
In their zeal to do something to offset the rising incidence of alcoholism, alcohol personnel borrowed from the analogy of “alcoholism is a disease” to establish a medically oriented, primary prevention model. Without entering into the argument of whether alcoholism is or is not a disease, the application of the medical primary prevention model to alcoholism serves as an excellent example of the Procrustean fit. Before examining this confusion in detail, it is necessary to make a distinction between primary and secondary prevention models. Primary prevention is the application of a procedure (or procedures) to prevent the occurrence of problems. Secondary prevention is the application of a procedure (or procedures) to stop, retard, or reverse processes that if continued would lead to a more serious stage of the disorder. Primary prevention models of medical diseases are built around the concept of both isolation, i.e., isolating both the individual and the community from the known etiological agent (or agents), and immunization. Given an outbreak of typhoid fever, the prevention program drawn up will be designed in accordance with the knowledge of the etiology of typhoid, namely the microorganism Salmonella. Knowledge of this microorganism (how and where it thrives, its toxicity, its reproduction cycle, etc.) directly shapes the structure of the primary prevention programs established to combat this disease. The establishment of a primary prevention program for a medical disease of which the cause is not known is a case of putting the cart before the horse. The incongruity of this approach is highlighted when medical diseases of which causes are presently unknown become subject to a primary prevention model. A primary prevention program for cervical cancer does not exist because the cause is unknown. Prevention efforts in this area have been limited to secondary prevention (i.e., see your doctor regularly for a pap smear, and have a cancer checkup). In this case, the “go-ahead” for a particular treatment to be enacted is dependent on the presence of certain signs or positive indicators on a test. In short, because we do not know the etiology of cervical cancer, we have to wait until it occurs at some level before treatment can begin.
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Workers in the field of cervical cancer do not address public groups informing them of the dangers of cancer and “how to avoid getting it.” Their approach rather concentrates on having the individuals go for frequent checkups so that if it is discovered that cervical cancer is present, treatment can begin at an early stage of development. One reputedly possible exception to this doctrine of “knowledge of the etiology precedes the application of primary prevention programs” is said to be found in the use of legal measures established by governments to control alcoholism. For example, the Chinese Communist government has reported great progress in eradicating alcoholism (44). Thus, while the etiology of alcoholism is reputedly no better known in China than in the United States, primary prevention programs have been established and are reported to be successful. A careful analysis of the preceding paragraph indicates that rather than being an exception to the rule, it provides another illustration of its application. In this case, the “cause” of alcoholism is seen as alcohol; thus, without alcohol there can be no alcoholism. The steps taken to implement this epidemiological “environment-agent (alcohol)-host” primary prevention model, e.g., the restraining of both overall production and consumption, are predicated on the assumed “cause” of alcoholism, namely, alcohol. While this primary prevention model is tautological with the use of the term “cause” being based on the concept of material cause (necessary and essential conditions) rather than efficient cause (conditions that result in a behavior), nonetheless it does not alter the concept that the preventive actions taken stem directly from the assumed etiological premises of the nature of alcoholism. Thus, until the (efficient) cause (or causes) of alcoholism are determined, the application of alcohol prevention programs can be at best of a secondary type, namely, once the early signs and symptoms of alcoholism appear, “get help as soon as possible.” Primary prevention programs, such as educating the young and the general public about the dangers of alcoholism, will have to wait. Failure to do this will only result in the public’s being even more dubious and distrustful about the dangers of alcoholism. Efforts should be concentrated on motivating people who do manifest some “signs” of alcoholism to come for treatment. To compound the difficulties in this area, the question arises as to whether we possess at present the knowledge of the “signs” or symptoms, the presence of which indicate (with a high degree of probability) the development of alcoholism. Put more simply, what preliminary signs exist that, if not heeded, herald the development of alcoholism? What signs should we look for to base our secondary prevention program upon? Numerous prognostic indicators have been proposed and purportedly identified, but to date, as Chafe@ Blane, and Hill (15) noted, “the presumed relationship has no sound empirical basis.” Being the child of an alcoholic, drinking heavily as a teenager, experiencing occasional blackouts, drinking heavily in social situations, etc., have all been cited as examples of prognostic indicators of alcoholism. All of these signs are present in some degree in those who eventually become alcoholics, but the more important question is how many individuals become alcoholics who have these signs. Recent evidence cited by Cahalan (12) in-
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dicated that the figures may be less than originally thought or suggested by Jellinek’s “progressive deterioration curve.” Cahalan, on the basis of his extensive 1967 National Survey, reported that his findings “raise doubts that heavy drinking almost inevitably grows worse in a progressive irreversible snowball effect” (p. 4). Cahalan speaks about the process of “maturing out” to refer to his finding that the problem drinking status of many individuals changes over time. He found, for example, a general tendency by individuals in their early twenties to move out of the drinking and problem-drinking categories as they approach their thirties. The concept of early warning signs of alcoholism is derived from retrospective analyses utilizing clinical thought and experience of clinical alcoholic populations. The applicability of the assumptions derived from these clinic populations to the general population-at-large, however, has been questioned recently. Room (45) cautions strongly against such generalizations, maintaining that: a prevention program is built on illusion if it assumes. . that the problems of alcohol in the general population are simply the problems of alcohol in the clinical population writ large (p. 16).
More specifically, Room (44) states in discussing the differences in patterns of drinking between the two populations that: our recent studies of drinking practices and problems in the general population suggest that, among the substantial proportion of the population who at one time or another get into problems with their drinking, having a particular problem at a particular time is only a modest predictor of having other particular drinking problems at the same time or having the same problem at another time (p. 12).
On the basis of their extensive surveys and analyses of alcoholism in the nonclinic population, Clark (17), Cahalan and Room (14), and Clark and Cahalan (18) argue strongly for a reevaluation of the validity of the early warning signs of alcoholism as a valid predictor of alcoholism. Their general population data suggest that most people with the traditional warning signs of alcoholism do not end up with serious consequences. Similar findings have been noted by Bailey, Haberman, and Sheinberg (6). They reinterviewed 90 respondents from a large community mental health survey who 3 yr prior identified themselves as having drinking problems. Ten percent of these individuals reported an increase in drinking since the first interview, 23% claimed abstinence, and 3 1% claimed a decrease in drinking. Schmidt (47), in reporting on a repeat survey in Ontario County after a 20-yr interval, found that remission had occurred in 3 1% of the original milder-problem-drinker category. In general, longitudinal research programs that attempt to identify those individuals who possess the purported early clinical signs of alcoholism and discover what proportion of that group later becomes alcoholics are lacking. Chafetz, Blane, and Hill (15) underscore the importance of such research programs, stating that we do not know how accurately assessments of problem drinking predict alcoholism. This defect is common to all research dealing with early identification and points to the need for longitudinal studies. (p. 263)
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Until such research is carried out and the results clearly indicate a stronger relationship between certain drinking behaviors and the later development of alcoholism, the notion of secondary prevention in alcoholism will remain somewhat cloudy. CONCLUSION
What this article has attempted to show is that the present prevention programs in the field of alcoholism, an area of critical importance, have started off on the wrong path. We can continue to perpetuate and compound these myths or we can acknowledge our errors. Our efforts in alcoholism prevention programs, if they are to be at all successful must be responsive to the recommendations set forth by Room (45): In the recent past . . . the topic of prevention was primarily the occasion for rhetorical gestures rather than practical efforts. But the situation is now different; for a number of reasons, prevention ranks high on the agenda of the future. It is a time not for sloganeering and selling but for debate about priorities, for settling on modest and realistic goals, for comprehensive planning, for pilot programs and evaluations, for thinking ahead, and for research which tests the thinking against the realities. (p. 21)
ACKNOWLEDGMENTS The author acknowledges the contribution of Morton S. Propper, Psychiatric Social Worker, Santa Clara County Alcoholism Treatment Center, whose suggestions and comments were invaluable in the writing of this paper.
REFERENCES 1. American Institute of Public Opinion. ‘Gallup Political Index, Political, Social and Economic Trends Report.” Princeton, N.J., 1974. 2. An interview with Dr. Morris Chafetz, Alcohol Health and Research World 1, 2-4 (1973). 3. Aronson, E., Turner, J., and Carlsmith, M. Communicator credibility and communicator discrepancy as determinants of opinion change. J. Abnorm. Sot. Psychol. 67, 3 l-36 (1963). 4. Asch, S. “Social Psychology,” Prentice-Hall, New York, 19.52. 5. Aubrey, R. F. Drug education: can teachers do the job? Teachers College Record 72,417-422 (1971). 6. Bailey, M. B., Haberman, P. W., and Sheinberg, J. Identifying alcoholics in populations surveys: a report on reliability. Quart. J. Stud. Alcohol 27, 300-3 15 (1966). 7. Blane, H. T. The personality of the alcoholic, in “Frontiers of Alcoholism” (M. E. Chafetz, H. T. Blane, and M. J. Hill, Eds.), pp. 16-28. Science House, New York, 1970. 8. Blane, H. T. Education and the prevention of alcoholism, in “The Biology of Alcoholism” (B. Kissin and H. Begleiter, Eds.), Vol. 4. Plenum Press, New York, forthcoming. 9. Braucht, G. N., Follingstad, D., Brakarsh, D., and Berry, K. L. Drug education: a review of goals, approaches and effectiveness, and a paradigm for evaluation. Quart. J. Stud. Alcohol 34, 1279-1292 (1973). 10. Buhler, C., and Lefever, D. W. A Rorschach study on the psychological characteristics of alcoholics. Quart. J. Stud. Afcohol8, 197-260 (1947). 11. Buikhuisen, W. General deterrence: research and theory. Absfracts on Criminology and Penology 14, 285-297 (1974). 12. Cahalan, D. Drinking practices and problems: research perspectives on remedial measures. Public Aflairs Report 14 (2), 1-6 (1973). 13. Cahalan, D., Cisin, I. H., and Crossley, H. M. “American Drinking Practices: A National Survey of Drinking Behavior and Attitudes.” Rutgers Center of Alcohol Studies, New Brunswick, N.J., 1969. 14. Cahalan, D., and Room, R. “Problem Drinking Among American Men.” Rutgers Center of Alcohol Studies, New Brunswick, N.J., 1973.
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15. Chafetz, M. E., Blane, H. T., and Hill, M. J. “Frontiers of Alcoholism.” Science House, New York, 1970. 16. Chambers, C.. D. An assessment of drug use in the general population, in “Treatment and Rehabilitation of Narcotic Addicts,” pp. 473-638. U.S. Government Printing Office, Washington, D.C., 1971. 17. Clark, W. B. Operational definitions of drinking problems and associated prevalence rates. Quart. J. Stud. Alcohol 27, 648-668 (1966). 18. Clark, W. B., and Cahalan, D. Changes in problem drinking over a four-year span. Paper presented at American Public Health Association meeting, San Francisco, 1973. 19. Favorable effect seen from countermeasures instituted by ASAP. Alcohol and Health Notes 1 (Dee), 5 (1973). 20. Ferster, C. B., Numberger, J. I., and Leviat, E. B. The control of eating. J. Consult. Clin. Psychol. 32, 2-12 (1968). 2 1. Fleischer, G. A. A study of the effectiveness of a radio/T.V. campaign on safety belt use. J. Sa$ Res. 5, 3-l 1 (1973). 22. Force, R. C. Development of a covert test for the detection of alcoholism by a keying of the Kuder Preference Record. Quart. J. Stud. Alcohol 19, 72-78 (1958). 23. Globetti, G. Alcohol education in the school. J. Drug Educ. 1, 241-248 (1971). 24. Gosset, J. T., Lewis, J. M., and Phillips, V. A. Extent and prevalence of illicit drug use as reported by 56,745 students. J. Amer. Med. Assoc. 216, 1464-1470 (1971). 25. Grupp, S. “Theories of Punishment.” Indiana University Press, Bloomington, Indiana, 1971. 26. Gusfield, J. The prevention of drinking problems, in “Alcohol, New Thinking and New Directions” (W. J. Filstead, J. J. Rossi and M. Keller, Eds.). Ballinger Publishing, Cambridge, Mass., forthcoming. 27. Halleck, S. The great drug education hoax, reprint 72-5. Alberta Alcoholism and Drug Abuse Commission, Edmonton (1973). 28. Halpern, F. Studies of compulsive drinkers: psychological test results. Quart. J. Stud. Alcohol 6, 468-479 (1946). 29. Johnson, H., and Steiner, I. The effects of source on responses to negative information about one’s self. J. Sot. Psychol. 74, 215-224 (1968). 30. Johnson, K. G., Donnelly, J. H., and Scheble, R. Survey of adolescent drug use: sex and grade distribution. Amer. J. Public Health 61, 2417-2432 (1971). 3 1. Jones, M. C. Personality correlates and antecedents of drinking patterns in adult males. J. Consult. Clin. Psychoi. 32, 2-12 (1968). 32. Kitzinger, A., and Hill, P. “Drug Abuse: A Source Book and Guide for Teachers.” Sacramento, California, State Department of Education, 1967. 33. Leventhal, H. Findings and theory in the study of fear communications, in “Advances in Experimental Social Psychology” (L. Berkowitz, Ed.), Vol. 5, pp. 119-186. Academic Press, New York, 1970. 34. Levinson, T., and Sereny, G. An experimental evaluation of insight therapy for the chronic alcoholic. Can. Psychiatr. Assoc. J. 14, 143-146 (1969). 35. Lisansky, E. S. The etiology of alcoholism: the role of psychological predisposition. Quart. J. Stud. Alcohol 21, 341-343 (1960). 36. McCarthy, R. G., and Fain, T. G. Measuring knowledge of alcoholism in the community. Quart. J. Stud. Alcohol 20, 645-654 (1959). 37. Middlebrook, P. N. “Social Psychology and Modern Life.” Alfred Knopf, New York, 1974. 38. Moves to make you use your seat belt. U.S. News and World Report 73, 64-66 (1972). 39. Nader, R. “Unsafe at any speed: The Designed in Dangers of the American Automobile.” Grossman Publishers, New York, 1965. 40. Nader, R. Profits vs. engineering: the Corvair story. Nation 201, 295-301 (1965). 41. Pittel, S. Where the current drug scene is heading. Paper presented at the University of Utah School on Alcoholism and other Drug Dependencies, Salt Lake City, 1973. 42. Robertson, I,., and Kelley, A. B. “A Controlled Study of the Effect of Television Messages on Safety Belt Use.” Insurance Institute for Highway Safety, 1972. 43. Robinson, R. The prospect of adequate education about alcohol and alcoholism. Journal of Alcohol Education 14, l-4 (1969).
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44. Room, R. Minimizing alcohol problems. Alcohol Healfh and Research World 12-17 Fall, (1974). 45. Room, R. Governing images and the prevention of alcohol problems. Prev. Med. 3, 1l-23 (I 974). 46. San Mateo County Department of Public Health and Welfare. “Surveillance of Study of Drug Use.” San Mateo County, California, 1973. 47. Schmidt, W. The prevalence of alcoholism and drug addiction in Canada. Addictions 15, 1-13 (1968). 48. Skinner, B. F. “Science and Human Behavior.” Macmillan, New York, 1953. 49. Smart, R. G. Future time perspective in alcoholic and social drinkers. J. Abnorm. Psychol. 73, 81-83 (1968). 50. Swisher, J. D., and Crawford, J. L. Evaluation of a short-term drug education program. School Counseling 18, 265-272 (197 1). 51. Ueckler, A., and Solberg, K. Alcoholics knowledge about alcohol problems: its relationship to significant attitudes. Quart. J. Stud. Alcohol 34, 509-5 13 (197 1). 52. Weaver, S. C., and Tennant, F. S. Effectiveness of drug education programs for secondary school students. Amer. J. Psychiatry 130, 812-814 (1973). 53. Williams, A. F., DiCicco, L. M., and Unterberger, H. Philosophy and evaluation of an alcohol education program. Quart. J. Stud. Afcohot 29, 685-702 (1968).
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The Myth of Alcoholism MELVYN Santa Clara County Mental
Health, Alcohol
Prevention’
KALB~ Services Division,
San Jose, California
Although practically every article about alcoholism contains at least one or two paragraphs that stress the importance and need for prevention programs, the “hows” and the “specifics” are rarely spelled out in any detail. The analysis of why this situation exists points to the existence of three central premises around which the present alcohol prevention model is constructed. Each of these premises has at its core the existence of some invalid statements, the perpetuation of which effectively blocks the establishment of more appropriate prevention models. Awareness of ‘Ifacts” about alcohol leads to a change in drinking. The paper cites evidence from experimental and empirical sources, illustrating that the presentation of facts, although in some cases altering attitudes, does not result in changes in certain behaviors. An explanation and model are provided stating the conditions under which “facts” do and do not result in behavioral change and where “alcohol facts” fit into this paradigm. Prevention programs centered around “consequences” are an effective way to produce changes in drinking. The common theme most alcohol prevention programs share today is
that their “message” deals with the consequences of drinking. This approach is highly unsuccessful in appealing to alcoholics whose characterological style ties them to the present and not the distant consequences of their behavior. Applicability
of a medical primary
and secondary prevention
model to alcohol education.
This section of the paper deals with the misapplication of the medical primary and secondary prevention models to alcoholism. It discusses why the etiology of alcoholism must be understood prior to the establishment of a primary prevention program. It also questions the methodological premises around which the early warning signs of alcoholism are buih and their validity in successfully predicting the later development of alcoholism. The need for more longitudinal studies is suggested.
Although articles about alcoholism and programs designed to treat alcoholism are diverse in their range and focus of interest, they share, in most cases, at least one common theme. Invariably one or two paragraphs appear that stress the importance and need for programs on prevention. What is puzzling about the paragraph(s) on the “need and importance of prevention programs” is that elaborations are usually absent. A certain quality about these prevention statements exists that seems to preclude further comment. The “bows” and the “specifics” are rarely elaborated on or spelled out in any detail. It is almost “as if” the statements themselves are in lieu of any concrete proposals. The frequency with which this format appears in the alcohol literature has led ’ Presented in part before the Section on Prevention of Alcohol Problems, North American Congress on Alcohol and Drug Problems, December 17, 1974. ’ The opinions expressed herein are those of the author and do not necessarily reflect the views of the Santa Clara County Alcoholism Program or the Santa Clara County Public Health Department. Present Address: Department of Psychiatry, Kaiser-Permanente Medical Center, 900 Kiely Boulevard, Santa Clara, California 9505 1. Reprint requests should be sent to this address. 404 Copyright @ 1975 by Academic Press. Inc. All rights of reproduction in any form reserved.
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this author to conclude that to talk about prevention belongs in the same category as “Mom and Apple Pie” -everybody is unquestionably for it, and no one dares speak out against it. This “sacred cow” philosophy has established a climate in the alcohol field whereby lip service is paid to the importance of prevention programs but such programs are not openly and extensively discussed and criticized nor evaluated for their effectiveness. The oft cited analogy about prevention - “talking about prevention is like talking about the weather: everybody talks about it, but nobody does much about it”-accurately reflects this basic posture. What is perhaps even more surprising is that after more than 25 yr of published research in the alcohol field, controlled studies that have attempted to evaluate the effectiveness of preventive approach A versus preventive approach B are sorely lacking. It is somewhat mystifying to imagine that prevention, a goal that Dr. Morris Chafetz, Director of the NIAAA, lists as the number two priority (2), second only to the treatment of alcoholism, is so devoid not only of extended and critical discussion but research as well. In 1959, McCarthy and Fain (36), writing about alcohol education programs, reached the general conclusion that no systematic evaluation of the effectiveness of educational or publicity programs had been published. In 1973, 14 yr later, Braucht, Follingstad, Brakarsh, and Berry (9, p. 1289) concluded after a comprehensive review of approaches to all drug education that “there is almost no empirical evidence as to these programs’ effectiveness.” Similar conclusions are reported in recent reviews of drug education programs by Blane (8) and Gusfield (26).
It is this author’s contention that this absence of empirical evidence, of more critical and extended discussion, is an outgrowth of the central premises around which the present alcoholism prevention program is based. These premises are: (a) awareness of “facts” about alcohol leads to a change in drinking, (b) prevention programs centered around “consequences” are an effective way to appeal to and produce changes in drinking behavior, and (c) applicability of a primary and secondary prevention model to alcohol education. Each of these premises has at its core the existence of some invalid statements, the perpetuation of which effectively blocks the establishment of more appropriate prevention models. It is the thesis of this paper that these invalid premises should be relegated to the status of a myth and that as long as we continue to base our present prevention programs around them, prevention in alcohol will forever be wedded to apple pie. A. AWARENESS OF “FACTS” TO A CHANGE
ABOUT ALCOHOL IN DRINKING
LEADS
The premise that the present prevention model advances is that if information about alcoholism is imparted to the alcoholic, the potential problem drinker or the general public, a cessation or reduction in the amount of alcohol consumed will result. The core of this thesis is that “the facts” about alcoholism would somehow modify or deter heavy future drinking behavior since it would be illogical for the individual to continue to drink immoderately or initiate a heavy
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drinking pattern when the facts are made known. Although an analysis of this statement appears convincing and although inherently the statement does make sense, the empirical evidence is less impressive. For example, each year millions of dollars are spent informing the public about the dangers of cigarette smoking and drug use. Testimony is presented in various formats (i.e., medical studies, newspapers, television, Madison Avenue advertising) on the “facts” about the dangers of the use and/or continued use of cigarettes and drugs. Despite these ominous facts, cigarette smoking has reached new highs, and drug use has continued to rise (16, 24, 30, 46). Consider too the repeated statements, publicity, and money spent attempting to inform the public on the importance of using seat belts in the automobile. Yet the presentation of facts showing how seat belts can save lives and reduce injury has not resulted in “buckling up” for three-quarters of the American drivers (2 1, 38, 42). Numerous other examples could be offered, but what becomes apparent is that there is obviously something much more (or higher) involved in governing peoples’ behaviors than the rational, logical facts of the situation. The psychotherapeutic system, a method established to change behavior, stands as a monument to the undermining of the principle that “facts” lead to behavioral change. Every textbook on the psychotherapeutic process underscores the notion that intellectual insight alone is clearly insufficient for behavioral change to occur. Some schools of psychological thought (e.g., behaviorism) even consider the discovery of facts epiphenomenal. In attempting to help people unlearn old behaviors and learn new ones, the presentation of facts alone is ineffective as a change modality. The underlying premise of the “facts” model of prevention is the assumption that increased knowledge about alcohol will lead to a change in drinking behavior. Although frequently the learning of facts does result in a change of attitude, its effect on behavior remains questionable. The results of the studies by Williams, DiCicco, and Unterberger (53) and Swisher and Crawford (50) highlight this point. Williams et al. evaluated the effect of an alcohol education program of which the aim was to promote responsible and discourage irresponsible drinking behavior among Catholic high school boys. The authors found that in comparison to a control group that experienced neither education nor discussion about alcohol, students who did undergo an alcohol education program held more favorable attitudes toward temperate alcohol use than prior to the alcohol education program and had increased their knowledge about alcoholism facts. The attitude change lasted a month after the termination of the alcohol program but less than 1 yr, although the increased knowledge of alcohol facts continued for at least 1 yr. The results, however, on whether these attitude changes and increased knowledge resulted in responsible drinking behavior were not as positive. A slightly higher percentage of the students who underwent the alcohol education program, as compared to the controls, became intoxicated during the year following the program. A similar outcome was noted in Swisher and Crawford’s study evaluating the effect of a very brief drug program conducted by psychiatrists and rehabilitated
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drug users in a private school. The results of their evaluation indicated that while there was an increase in drug knowledge, there was no change in attitude, and no significant reduction in drug use. Weaver and Tennant (52) also compared the effectiveness of an intensive and costly 3-week education course given to 452 eighth-grade students with a similar control group of eighth graders who received minimal drug education. The authors found that while the students in the experimental group demonstrated superior knowledge of drugs after taking the intensive drug course, there was no significant reduction in their drug-taking behavior. In fact, a follow-up survey of the experimental students done 9 months later revealed that their drug use increased despite their exposure to the intensive drug program. Braucht et al. (9) in their review of the research on drug education programs pointed to the discrepancy between cognition concerning drug use and actual drug-using behavior. They noted that “while a program may be effective to some extent in altering cognitive states such as knowledge and attitudes, it may have little or no effect on behavior” (p. 1289). Aubrey (5) offered an explanation for this result, maintaining that decisions concerning drug use involve a combination of cognitive and affective elements and that presentation of only factual or intellectual evidence is not enough. Ironically, the “factual” model approach to prevention has even been cited as arousing the curiosity of the listener and encouraging drug use (27, 32). It is important to note that the disregard of facts about alcoholism is not restricted to the nonalcoholic population, where it might be argued that the dangers of alcoholism seem remote. Within an alcoholic population itself-a group seemingly with much to lose were heavy drinking to continue- the same principle appears to operate. In a recent article, Ueckler and Solberg (51) reported a high degree of skepticism concerning the effectiveness of alcohol education in the treatment of individuals already addicted. They noted that in an inpatient alcoholic population, “it seems to be a case of locking the barn after the horse has been stolen” (p. 5 12). What Ueckler and Solberg found was that favorable attitudes toward alcoholism, alcohol education, and treatment of alcoholism were not markedly strengthened by an alcohol education program. They concluded that their data raised questions concerning the wisdom of spending many hours of staff time on making alcoholics familiar with current knowledge about alcoholism. Their findings were also in agreement with those reported in an earlier study by Levinson and Sereny (34). They reported that an inpatient program of resocialization and recreational training was more effective in achieving posthospital sobriety than a program of alcohol education, group psychotherapy, and individual psychotherapy. The authors concluded that their results tended to cast doubt upon the effectiveness of formal instruction about alcohol for an alcoholic population. While undoubtedly there are situations in which the individual does alter his behavior in the light of the “facts,” it is critically important to differentiate those conditions under which facts do and do not lead to change and, concomitantly, to locate where “alcohol facts” fit into this paradigm.
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Six main factors appear to be operative in determining whether “the facts” are heeded and the target behavior subsequently altered: (a) the degree of adversity of the “facts” involved (the severity of the negative consequences of continued “target” behavior) (48), (b) immediate or delayed adverse effects of the target behavior on the individual (the temporal factor) (48), (c) the believability of the espousing authority (3, 4, 37), (d) the degree to which the “facts” are amenable to personal empirical verification by the consumer, (e) the degree of immediate primary and secondary reward value that the target behavior provides (payoff factor) (48), and (f) the degree of availability of alternative behaviors that can equally produce the same rewards for the individual (the interchange factor) (33). The payoff or immediate reward factor of the target behavior and the degree to which alternative methods of achieving a similar payoff are available become the focal points through which the other pieces of information (what happens if I continue, when will it happen, who says it, and can I find out about this myself?) are viewed and evaluated. For example, a few years back, a situation existed concerning reports about the safety of the Corvair automobile (39, 40). The Corvair was reputed to be an unsafe car to drive, having been shown, under test conditions, to have serious “problem areas” considered by automotive engineers to be hazardous. Since for the general public, the reward value of driving the Corvair was not exceptionally high (relative to more prestigious automobiles) and since many other cars were available for the consumer to choose from (each of which would equally serve and gratify the needs that a Corvair provided), it was not at all difficult for the consumer to heed the warnings of the automotive experts and give up purchasing a Corvair for another model. In the case of the Corvair, the adversity of the facts, the believability of the espousing authority, and the degree to which such facts were amenable to empirical verification all became secondary to the question of its primary reward value (what does owning a Corvair “do” for me?) and the degree to which alternative methods of achieving satisfaction were available (can I buy another car that will “do” the same?). The continued use of alcohol strikes a different chord. In alcohol use, the primary and/or secondary reward values are very great, being the principal reasons for its continued use (41). Moreover, the availability of alternative behaviors that can equally produce the same desired end are quite remote unless the individual wants to move into the area of illegal drugs. It is against this background then that the user evaluates the degree of adversity of the “facts” about alcohol, when the adverse conditions will occur, and the status of the authority who advocates its dangers. Thus, the consumer’s willingness to accept on face value the facts presented to him (without personal, empirical validation) appears to be inversely related to the degree of primary and/or secondary reward value of target behavior (29) and directly related to the degree of its interchangeability. Resistance to accepting the facts and altering drinking behaviors lies, not only with the high degree of immediate primary and/or secondary reward value that
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alcohol provides, but also with the notion that the facts about the dangers of alcohol are not quite saleable. Since 68% of the population does drink (1, 13) and enjoy alcohol without any apparent negative consequences and only 12% are heavy drinkers (13), the presentation of logical facts concerning “the dangers” of alcohol seems somewhat labored. The campaign to publicize the dangers of alcoholism may have the effect of damaging the credibility of both the alcoholism authorities and the facts about alcohol abuse. If John Smith knows first-hand N people who drink X ounces Y times weekly who do not appear to him to have an “alcohol problem,” the effect will likely be to lower his belief in the alcoholism authority making the pronouncements and in the “facts” themselves (43). Globetti (23) similarily makes the point that a campaign for young people that warns of “the dire results and tragic consequences of alcohol use in ways which make them inevitable if a person drinks . . . runs counter to the experiences of a great many people and has the adverse consequence of substantially reducing the credibility and believability of the campaign” (p. 242). This situation is exactly what has happened in attempts to inform the public on the “dangers of marijuana.” The public feels that these statements are false on the basis of comparing what they are being told with what they have personally experienced or know through the experiences of friends. This approach has resulted in a wide credibility gap between the proselytizers and the users. What remains, therefore, is that not only do many people (including the alcoholic population) behave in a manner that seems to disregard available facts about the dangers of alcohol, but the “facts” themselves are frequently looked upon with suspicion. B. PREVENTION PROGRAMS CENTERED AROUND “CONSEQUENCES” ARE AN EFFECTIVE WAY TO APPEAL TO AND PRODUCE CHANGES IN DRINKING
A corollary to the thesis advanced above is the related proposition that the presentation of facts that deal specifically with the consequences of alcohol abuse is an effective way to produce changes in drinking. This approach posits that the deterrent quality to acting in a particular manner is a direct function of the consequences of such behavior. The common theme most alcohol prevention programs share today is that the “message” deals with the end result of drinking. An “if . . . then” relationship is sold, giving the listener fair notice, so to speak, that if the behavior in question continues, then some harmful outcome will inevitably result. This approach is highly successful in appealing to those individuals whose behavior is fashioned by carefully weighing the consequences of engaging in various alternative behaviors. These “consequence people” make decisions by temporarily suspending their impulses in the service of examining how the behavior in question will atfect their future. For these “consequence people,” the “if. . . then” approach of the present prevention model does an admirable job. The fit could not be better. Unfortunately, they are likely to be the last people who would become alcoholics.
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When the alcoholic thinks of taking a drink, one of the factors least considered is the distant effects of his behavior on himself and others (7, 3 1, 35). His choice of drinking is dictated by his felt need for the drink at that moment and the rewards it provides rather than its delayed negative effect (short or long term) on him and/or his family (20). His cognitive style places his focus on the stimulus, not the outcome, and sets his time frame in the present, not the future (49). Indeed, the psychological characteristics most frequently used to describe the alcoholic personality are his impulsiveness, “poor ego controls,” and difficulty in “delaying gratification” (10, 14, 18, 22). Given this state of affairs, prevention programs fail in matching their consequence-deterrent approach with the cognitive style of the audience that they are trying most to reach. Moreover, the rationale underlying this consequence-deterrent model lies in its view of man as a rational, pleasure-seeking, pain-avoiding creature (25). Buikhuisen (1 l), for example, argues that general deterrence implicitly assumes a rational approach to deviance. The excessive use of alcohol as a problemsolving device by the alcoholic or problem drinker does not have rational underpinnings, and as such, the alcoholic is unlikely to be responsive to deterrence messages with the hidden agenda of “be rational.” The inadequacy of this consequence-deterrent approach has been recently underscored by the National Safety Council in discussing the drinking driver (19). It noted that: while threats and rules may influence social drinkers, they may be useless in dealing with problem drinkers who, so long as they remain practicing alcoholic persons, will likely continue to drink abusively regardless of the possible penalties. (p. 7)
In a similar light, Gusfield (26) noted that The laws prohibiting public drunkenness and alcohol-impaired driving have had as a justification their supposed influence on potential offenders. The fear of an arrest or fine and/or jail, and the public shame of police arrest booking, and court appearance have been viewed as strong deterrents to the commission of the offenses and thus to the behavior whose eradication is sought. In general, the results of such legislation in preventing problem drinking has been disappointing. . There is little evidence (for example) that laws against drinking driving have been very effective in reducing recidivism, automobile fatalities or fatalities due to drinking. (P. 10)
The necessity for a change in focus has already been recognized by other organizations whose aim is to alter consumers’ behaviors. One such change has been in the approach to have drivers use their seat belts. The approach for many years had been tied to messages that dealt with the outcome of not using versus using seat belts (i.e., “seat belts save lives”). As previously noted, their efforts had been largely unsuccessful. Recently, however, a new approach has been developed that has shifted the concern to the personality of the driver and away from the outcome of not using seat belts. Billboards and magazine ads now appear that simply state: “There is a name for people who don’t use seat belts-STUPID.” Ironically, it is this approach that for many years has appeared in advertisements promoting the sale of alcoholic beverages. The al-
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coholism advertising industry has always associated drinking with virility, sociability, success, and sexuality. Alcohol prevention programs, instead of stressing facts about the consequences of drinking, could easily follow the lead of the alcohol advertising industry and stress the negative aspects of the “image” of the drinker. Prevention programs might associate heavy drinking with insecurity, social awkwardness, failure, and sexual ineptitude. This approach has many precedents, the most notable of which is the Volkswagen campaign that has successfully fought the popular “success” image of the big car driver. By picturing the VW driver as a secure, wise “saver” who exhibits his security in his lack of need to sport a huge gas-eating “success symbol,” the company has successfully undermined the image that the media had established. C. APPLICABILITY OF A PRIMARY AND SECONDARY PREVENTION MODEL IN ALCOHOL EDUCATION
In their zeal to do something to offset the rising incidence of alcoholism, alcohol personnel borrowed from the analogy of “alcoholism is a disease” to establish a medically oriented, primary prevention model. Without entering into the argument of whether alcoholism is or is not a disease, the application of the medical primary prevention model to alcoholism serves as an excellent example of the Procrustean fit. Before examining this confusion in detail, it is necessary to make a distinction between primary and secondary prevention models. Primary prevention is the application of a procedure (or procedures) to prevent the occurrence of problems. Secondary prevention is the application of a procedure (or procedures) to stop, retard, or reverse processes that if continued would lead to a more serious stage of the disorder. Primary prevention models of medical diseases are built around the concept of both isolation, i.e., isolating both the individual and the community from the known etiological agent (or agents), and immunization. Given an outbreak of typhoid fever, the prevention program drawn up will be designed in accordance with the knowledge of the etiology of typhoid, namely the microorganism Salmonella. Knowledge of this microorganism (how and where it thrives, its toxicity, its reproduction cycle, etc.) directly shapes the structure of the primary prevention programs established to combat this disease. The establishment of a primary prevention program for a medical disease of which the cause is not known is a case of putting the cart before the horse. The incongruity of this approach is highlighted when medical diseases of which causes are presently unknown become subject to a primary prevention model. A primary prevention program for cervical cancer does not exist because the cause is unknown. Prevention efforts in this area have been limited to secondary prevention (i.e., see your doctor regularly for a pap smear, and have a cancer checkup). In this case, the “go-ahead” for a particular treatment to be enacted is dependent on the presence of certain signs or positive indicators on a test. In short, because we do not know the etiology of cervical cancer, we have to wait until it occurs at some level before treatment can begin.
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Workers in the field of cervical cancer do not address public groups informing them of the dangers of cancer and “how to avoid getting it.” Their approach rather concentrates on having the individuals go for frequent checkups so that if it is discovered that cervical cancer is present, treatment can begin at an early stage of development. One reputedly possible exception to this doctrine of “knowledge of the etiology precedes the application of primary prevention programs” is said to be found in the use of legal measures established by governments to control alcoholism. For example, the Chinese Communist government has reported great progress in eradicating alcoholism (44). Thus, while the etiology of alcoholism is reputedly no better known in China than in the United States, primary prevention programs have been established and are reported to be successful. A careful analysis of the preceding paragraph indicates that rather than being an exception to the rule, it provides another illustration of its application. In this case, the “cause” of alcoholism is seen as alcohol; thus, without alcohol there can be no alcoholism. The steps taken to implement this epidemiological “environment-agent (alcohol)-host” primary prevention model, e.g., the restraining of both overall production and consumption, are predicated on the assumed “cause” of alcoholism, namely, alcohol. While this primary prevention model is tautological with the use of the term “cause” being based on the concept of material cause (necessary and essential conditions) rather than efficient cause (conditions that result in a behavior), nonetheless it does not alter the concept that the preventive actions taken stem directly from the assumed etiological premises of the nature of alcoholism. Thus, until the (efficient) cause (or causes) of alcoholism are determined, the application of alcohol prevention programs can be at best of a secondary type, namely, once the early signs and symptoms of alcoholism appear, “get help as soon as possible.” Primary prevention programs, such as educating the young and the general public about the dangers of alcoholism, will have to wait. Failure to do this will only result in the public’s being even more dubious and distrustful about the dangers of alcoholism. Efforts should be concentrated on motivating people who do manifest some “signs” of alcoholism to come for treatment. To compound the difficulties in this area, the question arises as to whether we possess at present the knowledge of the “signs” or symptoms, the presence of which indicate (with a high degree of probability) the development of alcoholism. Put more simply, what preliminary signs exist that, if not heeded, herald the development of alcoholism? What signs should we look for to base our secondary prevention program upon? Numerous prognostic indicators have been proposed and purportedly identified, but to date, as Chafe@ Blane, and Hill (15) noted, “the presumed relationship has no sound empirical basis.” Being the child of an alcoholic, drinking heavily as a teenager, experiencing occasional blackouts, drinking heavily in social situations, etc., have all been cited as examples of prognostic indicators of alcoholism. All of these signs are present in some degree in those who eventually become alcoholics, but the more important question is how many individuals become alcoholics who have these signs. Recent evidence cited by Cahalan (12) in-
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dicated that the figures may be less than originally thought or suggested by Jellinek’s “progressive deterioration curve.” Cahalan, on the basis of his extensive 1967 National Survey, reported that his findings “raise doubts that heavy drinking almost inevitably grows worse in a progressive irreversible snowball effect” (p. 4). Cahalan speaks about the process of “maturing out” to refer to his finding that the problem drinking status of many individuals changes over time. He found, for example, a general tendency by individuals in their early twenties to move out of the drinking and problem-drinking categories as they approach their thirties. The concept of early warning signs of alcoholism is derived from retrospective analyses utilizing clinical thought and experience of clinical alcoholic populations. The applicability of the assumptions derived from these clinic populations to the general population-at-large, however, has been questioned recently. Room (45) cautions strongly against such generalizations, maintaining that: a prevention program is built on illusion if it assumes. . that the problems of alcohol in the general population are simply the problems of alcohol in the clinical population writ large (p. 16).
More specifically, Room (44) states in discussing the differences in patterns of drinking between the two populations that: our recent studies of drinking practices and problems in the general population suggest that, among the substantial proportion of the population who at one time or another get into problems with their drinking, having a particular problem at a particular time is only a modest predictor of having other particular drinking problems at the same time or having the same problem at another time (p. 12).
On the basis of their extensive surveys and analyses of alcoholism in the nonclinic population, Clark (17), Cahalan and Room (14), and Clark and Cahalan (18) argue strongly for a reevaluation of the validity of the early warning signs of alcoholism as a valid predictor of alcoholism. Their general population data suggest that most people with the traditional warning signs of alcoholism do not end up with serious consequences. Similar findings have been noted by Bailey, Haberman, and Sheinberg (6). They reinterviewed 90 respondents from a large community mental health survey who 3 yr prior identified themselves as having drinking problems. Ten percent of these individuals reported an increase in drinking since the first interview, 23% claimed abstinence, and 3 1% claimed a decrease in drinking. Schmidt (47), in reporting on a repeat survey in Ontario County after a 20-yr interval, found that remission had occurred in 3 1% of the original milder-problem-drinker category. In general, longitudinal research programs that attempt to identify those individuals who possess the purported early clinical signs of alcoholism and discover what proportion of that group later becomes alcoholics are lacking. Chafetz, Blane, and Hill (15) underscore the importance of such research programs, stating that we do not know how accurately assessments of problem drinking predict alcoholism. This defect is common to all research dealing with early identification and points to the need for longitudinal studies. (p. 263)
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Until such research is carried out and the results clearly indicate a stronger relationship between certain drinking behaviors and the later development of alcoholism, the notion of secondary prevention in alcoholism will remain somewhat cloudy. CONCLUSION
What this article has attempted to show is that the present prevention programs in the field of alcoholism, an area of critical importance, have started off on the wrong path. We can continue to perpetuate and compound these myths or we can acknowledge our errors. Our efforts in alcoholism prevention programs, if they are to be at all successful must be responsive to the recommendations set forth by Room (45): In the recent past . . . the topic of prevention was primarily the occasion for rhetorical gestures rather than practical efforts. But the situation is now different; for a number of reasons, prevention ranks high on the agenda of the future. It is a time not for sloganeering and selling but for debate about priorities, for settling on modest and realistic goals, for comprehensive planning, for pilot programs and evaluations, for thinking ahead, and for research which tests the thinking against the realities. (p. 21)
ACKNOWLEDGMENTS The author acknowledges the contribution of Morton S. Propper, Psychiatric Social Worker, Santa Clara County Alcoholism Treatment Center, whose suggestions and comments were invaluable in the writing of this paper.
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