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TREATMENT NEEDS FOR YOUTH
ALCOHOL ABUSERS

presented by
Miliswa Nthabiseng Sobukwe

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TREATMENT NEEDS FOR YOUTH
ALCOHOL ABUSERS

By

Miliswa Nthabiseng Sobukwe

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS

Department of Sociology
1985

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Marilyn Aronoff

Theodore Chavis

Dennis Bryde

ABSTRACT

TREATMENT NEEDS FOR YOUTH
ALCOHOL ABUSERS

By

Miliswa Nthabiseng Sobukwe

Numerous research investigations indicate that adolescent drinking
is becoming an increasingly urgent problem. However, studies reporting
data on the treatment need for youth alcohol abusers have been sparse
and provide only treatment approaches suitable for adult alcoholics.
This extensive review of the literature on treatment needs for youth
alcohol abusers examines some of the more important variables such as:
Biological influences, psychological, peer pressures, family dynamics,
sociological influences and institutional influences. Past attempts to
develop effective programs to effect moderation in drinking and prevent
abusive alcoholic patterns in youth have been unsuccessful. Therefore,
further investigations which are specifically directed toward the

treatment of young alcohol abusers are needed.

 

DEDICATED TO MY PARENTS

 

Veronica Zodwa and Robert Mangaliso Sobukwe.
Who have always supported, encouraged and

inspired me to strive for greater accomplishments.

ACKNOWLEDGEMENT§_

 

I would like to express my sincere appreciation to my major
advisor, Dr. Donald Olmstead for his assistance and guidance throughout
the study and for accepting me as his graduate student. Sincere
appreciation is also given to Dr. Marilyn Aronoff, Dr. Theodore Chavis
and Dr. Dennis Bryde for their assistance. I would also like to thank
Dr. Robert Green for his support.’

Special thanks go to my brothers Dinilesizwe, Dedanizizwe and
Dalindyebo for their good wishes and words of encouragement.

Again, I thank my parents for their never-ending faith in me and
my abilities, particularly in the face of my self-doubts.

Finally, I would like to extend my love to my daughter,

Antwiwa Miselwa. I would also like to extend my love and warmest thanks
to my husband, James Whyte, for his love, understanding and encouragement.
For his patience and endurance through difficult times. His optimism
balanced my pessimism, enabling me to feel hopeful and excited during

difficult moments.

TABLE OF CONTENTS

CHAPTER

I

II

III

IV

VI

INTRODUCTION
Focus of Study
Definition

Positional Statement
SCOPE OF THE PROBLEM

WHY YOUNG PEOPLE DRINK
(A) Theories of Deviance
l. Biological
2. Psychological
3. Peer Group
4. Family
5. Socialization or Value Development

6. Institutional/Opportunity

OPERATING A YOUTH TREATMENT PROGRAM
(A) Staff Requirements

(B) Youth Assessment

CONCLUSION AND RECOMMENDATIONS

A LOOK AT A SYSTEM OF SERVICES
APPENDIX. TABLE AND FIGURE

PAGE

ll

l8

l9
20
20
22
23
24

26
26
28
38
34
Al

INTRODUCTION

 

Adolescent use and misuse of alcohol is becoming an urgent problem
in the United States (American Medical Association, 1973; Chafetz,
l983; Blane, l979; Moser, l980; Who, l980). At the beginning of the
adolescent period, the bulk of the population is abstinent. As one
passes through the years the likelihood steadily increases that the
person will no longer be abstinent. First, real exposure is likely to
come in mid-teens and the incidence of drinking grows as one moves
toward late adolescence. Many high school students are exposed to
alcohol before getting to college. Grade school children have been
reported going to school drunk in several states (Alibrandi, l978).

The child's age does not disqualify him from being an alcoholic. Current
studies suggest that between 20 and 40 percent of high school students
use alcohol excessively (Rachat et al, l982; Donovan and Jessor, l978).
By their senior year of high school, 90 to 95 percent of students will
have experimented with some type of alcohol (Braucht, 1980). Moreover,

a high proportion of young people who try illicit drugs remain users
(Kandel, 1982).

Every indicator and every statistics available shows that there
is a definite shift from narcotics and hard drugs to alcohol as a
preferred drug (Luks, 1983; Serban, l984). One must accept the fact
that alcohol is the most common drug man has historically taken to alter
his reality from time to time. We therefore, must be familiar with
what it does to one's system and mind. Alcohol seems to cause 30 times

more deaths than all other drugs combined (Fox, l973).

According to administrators, advisors, alcoholism experts and the
students themselves, campus drinking has grown harder, heavier, and
more frequent. Students are more and more having parties where organizers
stipulate "bring your own booze". This increase is being thought to
be coming about by the drop in the legal drinking age and peer pressure.
While alcohol is not the only chemical misused for "kicks", it
ranks high among the problems of youth and merits intensive study.
Over the past years there has been a gradual change in the general
attitudes of society toward the alcoholic and his alcoholism. Encouraging
signs indicate that society is ready to approach the alcoholic's complex

condition with less emotion and with greater objectivity than before.

The Focus of Study

 

It has been reported that there are very few alcohol treatment
programs for the young alcohol abusers (Addeo, 1978; Alibrandi, 1978;
Forrest, 1983; Isralowitz and Singer, 1983). The best described types
of treatment are designed for the adult alcoholics and are given to
young people merely because they happen to be part of the patient
population.

Suggesting some treatment modalities for young alcohol abusers is
the central objective of this study. This is accomplished by reviewing
the literature on alcohol abusers in the United States, and discussing
the issue with some professionals in the field of alcohol and substance
abuse. This author hopes that bringing together this kind of information

will provide sound data to implement programs for averting some of the

difficulties that sometimes accompany youth drinking.

As a starting point, therefore, it is useful to consider what types
of services young alcohol abusers need. My focus is on what does the
patient need rather than what services can a given program offer. With
young people, a system of care that is available in different settings,
which represents varying intensities, that has specific criteria for
determining what services in which settings are most appropriate, and
is coordinated in order to maximize the "system" nature of care are
fundamental principles to the organization and delivery of treatment

services for young people.

Definition

 

Alcohol abuse must be defined if problems encountered by its use
by youth groups are to be discussed. A major agency of the U.S.
government reported alcohol abuse as:

Repeated episodes of intoxication or heavy drinking

which impairs health, or consistent use of alcohol

as a coping mechanism in dealing with the problems

of life to a degree of serious interference with an

individual's effectiveness on the job, at home, in

the community, or behind the wheel of a car... and

may raise a strong interference of alcoholism.

(Department of Health, Education, and Welfare 1971:l)

The World Health Organization (WHO) defines an alcoholic in two
ways for two purposes: the first based on lack of selfécontrol of
alcoholic drinking and the second to make as large a group as possible
eligible for treatment. WHO set forth these two definitions

as follows:

Lack of self-control may be manifested either by the
inability to abstain from drinking for any significant
time period, or by the ability to remain sober between
drinking episodes but an inability to refrain from
drinking to intoxication whenever drinking an alcoholic
beverage...A1coholism can be defined as the use of
alcoholic beverages to the extent that health or economic
social functioning are substantially impaired.

(Department of Health, Education and Welfare, 1971:106)
HEW has established four categories for determining the amount of
alcohol consumption by individuals:

The moderate drinker is neither a teetotaler nor a
heavy drinker. An individual was a heavy drinker,

if for at least a year, he drank daily and had six

or more drinks on one occasion at least twice a month,
or had six or more drinks at least once a week, for
over a year, but reported emphasis added no problems.
A problem drinker was a heavy drinker with problems,
but not enough of them to be classified as an alcoholic
person, alcoholism was inferred if an individual met
the criteria of heavy drinker and had alcohol related
problems in at least three of the four areas:

1. Social disapproval of his drinking by friends
and parents marital problems.

2. Job trouble, traffic arrests, other police trouble.

3. Frequent blackouts, tremor, withdrawal,
hallucinations, and convulsions.

4. Loss of control over drinking, morning drinking.

(Department of Health, Education and Welfare, 1974:46)

Literally hundreds of definitions have been offered. While many
are definitive enough to be helpful, each of course, reflects the
viewpoint of its author, and none has become distinguished by universal

acceptance.

Because of the complexity of the illness, and because of the diver-
gent orientations among its investigators, it seems unlikely that any
one of them will ever be endorsed completely by everyone interested in
the subject. Nevertheless, enough agreement exists to support the
accuracy of the following broad definition (American Medical Association,
1973):

Alcoholism is an illness characterized by preoccupation

with alcohol and loss of control over its consumption

such as to lead usually to intoxication if drinking is

begun; by chronicity; by progression; and by tendency

toward relapse. It is typically associated with

physical disability and impaired emotional, occupational,

and/or social adjustments as a direct consequence of

persistent and excessive use of alcohol.

In short, alcoholism is regarded as a type of drug dependence of
pathological extent and pattern, which ordinarily interferes seriously
with the total health of the patient and his adaptation to his
environment.

As the illness progresses, the alcoholic's preoccupation with
alcohol lead him to organize and orient his life around drinking. He
very often takes great pain to obtain, ensure and conceal his supply.
Consumption of very substantial amounts of alcohol, however, and
frequent intoxication per se are not necessarily equated with alcoholism,
even though these signs are usually prominent in the codrse of the
illness. It can happen that some alcoholics actually consume less
liquor over a given length of time than do some social drinkers, but
this fact in itself does not alter the basic condition nor make it less

serious. The key factor is in control (American Medical Association,

1973).

Drinking by oneself, drinking early in the morning, or drinking
only one kind or brand of alcohol cannot be used as absolute criteria
in defining the disorder (or in diagnosing it). It is conmon for the
alcoholic dependent person to use the absence of these features from
his drinking pattern as "proof" in his denial of his problem to himself
and to others.

Looking at these different definitions of alcoholism, it seems to
this author accurate to classify the majority of teenage drinkers as
"alcohol abusers" or "problem drinkers" rather than florid alcoholics.
This author uses the terms "alcohol abuse" and "problem drinker"
interchangeably, and they refer to the development of a life-style in
which an individual is involved in car accidents, violent behavior,
family conflicts, anti-social behavior and poor school performance, as
a result of alcohol. Since alcoholism is a progressive disease, alcohol
abusers have not progressed to the stage of physiological addiction but
rather their drinking causes social, legal, familiar or personal problems.

Just as there exists different forms of alcoholism, there are
different types of alcohol abusers. Forrest (1984) describes three
forms of alcohol abuse.

One form involves persistent, heavy weekend drinking. Teenagers
who follow this pattern begin to drink heavily on Friday night and
continue drinking throughout the weekend. They may become physically
sick, experience morning “hangovers" and suffer memory loss or "blackouts"
on a regular basis. Many of these youngsters, Foster (1984) reports,

harm themselves physically while intoxicated by tripping or falling,

getting into car accidents or fighting.

Another form of alcohol abuse involves episodes of acute intoxication
at parties or teenage social gatherings. A minority of teenage alcohol
abusers appear to limit their pathological drinking to these situations.
They are not weekend binge drinkers and may even go weeks or months at
a time without drinking. However, when they get together with peers for
special events where alcoholic beverages are present, they almost always
drink too much.

The last pattern of teenage problem drinking involves intoxication
in combination with dating and sexual intimacy. Many teenagers feel
threatened and anxious about their sexuality. Some turn to alcohol in
order to cope with this issue.

Forrest (1983) reminds us that over one-half of today's teenage
Americans are sexually active. Several hundreds of teenage females
utilize some form of contraception. Hundreds of abortions are performed
on teenagers each year. Thousands of adolescent females fail to graduate
from high school as a result of pregnancy. Others graduate pregnant,
unmarried and without jobs. This data is relevant because it makes us
realize that alcohol plays a role in the initial sexual experiences of
a huge number of teenagers. Teenage alcohol abuse is associated with
sexual promiscuity, unwanted pregnancy, rape, emotional trauma, venereal

disease and a number of other sexual problems.

Position Statement

 

The position which will be presented in this paper follows the

approach proposed by Blum and Singer (1983); that substance abuse

among young people should be viewed as a rule/norm violation

behavior occurring during a developmental period in which the individual
is undergoing physiological and psychological change and stress as

part of the more general problem of social deviancy. This position make
possible for the utilization of a number of theories and intervention
technologies which have been found useful in understanding and treating
other dysfunctional behavior. This position has implications as well,
for the organization and delivery of services.

Support for this position can be found in the reality that many
young substance abusers are also involved in other delinquent acts, or
have problems in school, or have run away, or are involved in family
conflicts or have other delinquent acts. It has been found by those
who specialize in deviance behavior that individuals usually reflect a
multitude of rule or norm violating behavior, especially if any of these
problems have gone for a long length of time.

My second positional statement explains the controversy surrounding
the issue of total abstinence vs. controlled or responsible drinking.
Much is written and disputed about the goals of treatment for alcoholism.
The emerging concepts of alcohol dependence suggest the use of a single
drinking treatment goal for all individuals with alcohol problems, a
reduction in drinking to a nonproblem level. For some (Alcoholics
Anonymous, 1976; National Council on Alcoholism, 1971; 1981) such a reduction
might be achieved only through total abstinence, while for others
(Chafetz, 1983; Sobell and Sobell, 1972) it might be accomplished

within the context of nonproblem drinking.

The thoery of exposing a child to alcohol early, thus satisfying
childhood curiosity has been shared by researchers such as Chafetz
(1983) former head of the National Institute of Alcohol Abuse and
Alcoholism (NIAAA). Chafetz (1983) suggests that teaching a youngster
to sip, rather than gulp alcohol, and allowing him or her to drink at
home would reduce his or her chances of becoming an alcoholic.

Ruth Fox's (1973) critique of Davies' 1962 study (see Davies, 1962)
states: "My own practice covers many hundreds of alcoholics, and though
I have never been in a position to do follow-up, I do not know of a
single patient of mine who have been able to resume normal drinking".

Upon surveying the literature therefore, and following my own
observations, I believe that very few people, if any, who establish an
extended alcohol dependence can safely return to drinking responsibly".
An alcohol abusing patient has proven that he/she has a weakness in
controlling his or her alcohol intake. Therefore, in my opinion, both
young people and adults who consume five or more alcoholic beverages
daily for several months to several years are not apprOpriate candidates
for a treatment which attempts to return the person to controlled
drinking.

Having now stated my two general statements and having examined
the scope of the problem - alcohol abuse and alcoholism - I would like
to examine the first positional statement more closely in relation to
dealing with the problem of alcohol abuse in young people. The aim is
to help the program planner and/or therapist to apply this knowledge

of deviance theories to the treatment of alcohol abuse in young

l0

people. The greater part of this paper therefore, will concentrate
on some considerations in the treatment of young people. Two general
topics that will be explored are: l) Theories of deviance and their
application to the treatment of problem drinking; 2) the types of
services adolescents need and clinical considerations in delivering
such services.

Blum and Singer (1983) categorize programs that are designed to
deal with deviance into three categories based on their desired outcome:

(First, there are programs whose major goals are prevention and/or
early identification of adolescents who are at risk or are showing
initial signs of behavioral problems. The focus of this program should
not be limited in either its underlying theories or in the program
design to substance abuse. Rather, Blum and Singer suggest that programs
should reflect an understanding and approach to the range rule/norm
violating behavior in adolescence since there is such great overlap
among behaviors.

The present author concur with Blum and Singer. Much too often
program planners and practitioners do not use other alternatives in
helping the young alcohol abuser but focus only on specific treatment
methods, for example, individual or group therapy.

Second, there are programs which are aimed at stopping the
problematic behaviors which Blum and Singer call acute treatment programs.
The design of programs for treatment of alcoholism, drug abuse, runaway,

stealing, etc., are different and should be based on knowledge which is

11

specific to the particular behavior. Specialized knowledge about the
particular behavior must be utilized to design treatment programs.
Third, programs and interventions focus on supporting and maintain-
ing the individual as he or she readjusts to a lifestyle free of deviant
behavior. Support and maintenance programs addressing the range of
adolescent behavior problems should have greater similarity than
difference. Again, the position of this author is in agreement with
that of Blum and Singer (1983) that there are common factors and
theoretical understandings which should dictate the design of such

programs within the broader category of social deviance.

The Scope of the Problem

 

In addition to the data and theory found in books and journals
reporting the results of research activity in youth alcohol abuse,
this author felt it would be desirable to get a better feel for the day
to day situation faced by people in treatment centers. Information in
books is too abstract and kind of lifeless. So that is why information
from interviews with several therapists at different substance abuse
treatment centers was included in this study. The idea was to utilize
this information to better understand and to get a clearer picture of
the alcohol abuse problem and to then convey this information to the
reader.

A counselor in the Lansing, Michigan Office of National Council
on Alcoholism told me that arrests of youngsters under the age of 18

for driving while drunk have more than doubled in ten years.

12

Recognizing that the drop in legal drinking age has spawned the
teenage alcoholism epidemic and she said that alcohol in the Lansing
area has surpassed other drugs as a chief juvenile problem today.

Ethel White, a counselor in the Lansing, Michigan Office of the
National Council on Alcoholism reported, "We no longer have a drug
trend but are now in the drinking trend," she mentioned that older
people seem to drink more because of loneliness. With young people,
it is restlessness and boredom.

Another counselor, "Mary" at the Alcoholics Anonymous Office in
Lansing, Michigan mentioned to me some of the popular reasons young
people offer as to why they drink. They drink because drugs are too
expensive and dangerous; they like it better than drugs. Besides, it's
something their parents do; and also because it is illegal and they
do it to look older.

In an interview with Sue Hoeineger, a counselor at Dimondale
Substance Treatment Center in Lansing, Michigan, mention was made that
rarely in an adolescent is alcohol the only chemical used. The same
problem applies to other drugs. Most drug addicts also use alcohol
and many mistakenly believe that even though they are addicted to drugs,
it is safer to use alcohol.

Despite the increased interest in youthful drinking problems,
little is known of which treatments are best for them. None of the
people that I talked to seemed to know which treatment modality is

effective to the treatment of young alcohol abusers. The treatment of

13

alcohol substance abuse is an ill defined topic. Filstead and Anderson
(1983), observe that in three very significant publications, Alcohol

and Youth: An analysis of the literature (Blane and Hewitt, 1977).
Alcohol and Health, Fourth Report to Congress (1981) and the Institute
of Medicine's Report on Alcohol (1980), the topic is not even mentioned.

After discussing with different alcohol experts the alcohol
abusing youth, I now realize that little is known of the youth who comes
in contact with alcoholism treatment facilities. Furthermore, the
treatment that has been developed for adolescents represents a modification
of adult treatment programs.

It is unfortunate that we must acknowledge that most members of the
medical profession have failed to accomplish a great deal in the
treatment of alcoholics. They have been slow in recognizing alcoholism
as an illness and, in practice have tended to dismiss alcoholic patients
as hopeless or, unpleasant and unrewarding (American Medical Association,
1973). In spite of voluminous literature published every year on the
subject, major advances in the field have seemed disappointingly slow.

But change is coming. The Comprehensive Alcohol Abuse and Alcoholism
Prevention, Treatment, and Rehabilitation Act of 1970 established the
National Institute of Alcohol Abuse and Alcoholism within the National
Institute of Mental Health. In 1971, the National Conference of
Commissioners on State Laws adopted a Uniform Alcoholism and Intoxication
Treatment Act. Funding for alcoholism research and treatment has risen

dramatically in the past few years (American Medical Association, 1973).

14

Within the medical profession, there is growing awareness that alcoholism
is indeed an illness, a serious one. Secretary of Health and Human
Services, Richard Schweiker planned to launch a national awareness
campaign about teenage problem drinking (Luks, 1983). The U.S. Senate
approved a resolution designating a "National Drunk and Drugged Driving
Awareness Week", every December (which President Reagon signed; Luks,
1983). As the 1980's begin the headlines show that the nation now
realizes that alcohol abuse is by far its greatest drug problem.

Luks (1983) points out that in recent years the public learned how
the nation's most powerful leaders were touched by alcoholism: former
President JimmyCarter's brother and former President Gerald Ford's wife;
the wives of Senators Ted Kennedy and Howard Baker; President Reagan's
father.

Phillips documents (1983) that the ever increasing numbers of young
people abusing alcohol has become so serious that the Secretary of HHS
has recently announced a new program costing $35 million to be spent
on Special Target Problems and Populations, the first priority of which
is youth. HHS has also allocated $12.5 million for education, prevention
treatment and research related to problem drinking among youth. In
addition, HHS has funded five comprehensive alcolism-prevention projects,
targeted at 75,000 young people with the help of Boy Scouts, Girl Scouts,
Catholic Youth Organizations and others. In cooperation with the
Department of Transportation, the national media, and the alcohol

beverage industry, HHS has launched an "information campaign" focusing

15

on auto safety and encouraging sensible attitudes toward drinking among
young people.

Alcohol related problems account for more than 10,000 deaths each
year in the age group 15 to 24 years and are the leading cause of death
for this age group in the United States (Phillips, 1983). Also, more
than 40,000 young people are injured every year in drinking accidents
-many of them crippled, paralyzed or otherwise disabled for life
(Phillips, 1983).

Some researchers have provided the following as tentative answers
to why so little literature exists describing youth in treatment or the
treatment programs for young people:

1. Smart (1972) reports that many clinicians believe that young
alcoholics are very difficult to treat, have more symptoms and have low
recovery rates than older alcoholics.

2. Gwinner (1977) examined young alcoholics being treated in
facilities for British Navy personnel, he found that they developed
symptoms earlier than older alcoholics. Smart (1979) examined the
propositions that young alcoholics had more problems at intake than
older alcoholics. The study examined drinking symptoms and demographic
characteristics at intake, the type and length of treatment and overall
recovery rates in terms of drinking symptoms evaluated according to the
Alcoholic Involvement Scale. The results showed that compared with
older alcoholics, the younger ones entered treatment with fewer resources

in terms of interests and people to help them, lower social stability,

16

poorer attitudes toward abstinence, and lower motivation for treatment.
Because younger alcoholics began their drinking careers earlier, they
had fewer social supports when they came into treatment.

As I look at the literature, I agree with Smart (1979). I do not
find any evidence that younger alcoholics are more difficult to treat
than older alcoholics. Apparently, there's a tradition that younger
alcohol abusers are difficult to treat. A number of questions remain.
Is it likely that young alcohol abusers retain a resistency because of
their age, which allows them to overcome their problems of low motivation
for treatment? Are young people less deteriorated physically than older
alcoholics. In any case, the present author does not find any evidence
that young alcohol abusers will not do as well as older alcohol abusers
in treatment. It seems that the pessimism about treating young alcohol
abusers may be unjustified, and efforts to get young alcoholics into
treatment are likely to be productive.

It seems to me that for younger patients, it's easier to change
habits than it is for older patients, that is, the same amount of energy
directed to a younger person may be expected to be more efficient than
that directed to older patients. Furthermore, the earlier the problem
is diagnosed, the better.

3. The topic of adolescence and alcohol contains an array of
conceptual and definitional problems. For example, the developmental
processes associated with adolescence itself are often ignored, but

more likely is not even identified as an issue to consider (Filstead

l7

and Anderson, 1983). The expectations and perceptions of alcohol and
other substances associated with the different age groups that are
included in adolescence presents other considerations. Filstead and
Anderson (1983) argue that in some states lB-year-olds can drink,
whereas in others, 21 years of age represents the point where the
purchase and consumption of alcohol is legal. The experimentation with
alcohol and/or other substances that is associated with growing up is
another consideration. Filstead and Anderson (1983) observe that
frequently, data gathered through surveys of nonclinical populations
attempts to define a given behavior as being an indication of abuse.
The assumption is that such interpretations are valid. Therefore, the
alcoholism field is supposed to develop treatment responses for these
identified problems. In effect, nip the bud early before it flowers
into full addiction.

4. Also information about youth use of alcohol comes primarily
from surveys of the general population of adolescents (Filstead and
Anderson, 1983). Little data are available on the nature of adolescents
who are in treatment. Filstead and Anderson (1983) observe that more
is known about the use/misuse and its consequences among non-clinic
populations of adolescents than adolescents who are receiving treatment.
The opposite is true for adults. More is known about treatment popula-
tions than the general population of users. Consequently, what the
field believes it understands about adolescent alcohol is based on

populations who are generally not in treatment. Extrapolations from

18

these survey data are made and then used to indicate the extent and
scope of "adolescent alcoholism and/or substance abuse", (Filstead and
Anderson, 1983).

5. Concern with adolescent alcohol and/or substance misuse
developed out of the increasing interest in education, prevention and
early intervention programs. According to Filstead and Anderson (1983)
researchers have argued that to focus just on treatment issues ignores
work that might prevent the development of alcoholism and/or substance
misuse in individuals, especially the young. For a number of reasons,
prevention is thought to be most effective among the youth. While the
emphasis has been on prevention, the question of “how" to prevent "what”

is a hotly debated topic (Filstead, 1976).

Why Young People Drink

 

Parents often worry about the drinking behavior of their children,
which is natural. They ask themselves, "Why?" "Why is my son or daughter
drinking so much? Why does he or she get drunk every Saturday?"

Parental guilt is frequently associated with this questioning. Personally,
I think society has put too much blame on the parents for their children's
bad behavior. It is important, however, to realize that there are a

number of reasons why young people drink, many of which have no

connection with parents. Every young person is an individual, with

his or her unique reasons for drinking. People react differently to
alcohol. Why is it that of two rather similar-appearing social drinkers,

one will continue his/her modest consumption indefinitely, while the

 

19

other will drink increasingly and end up being an alcohol abuser, or

an alcoholic? Since there is rarely a single cause for a person abusing
alcohol, the answer is complicated. It seems worthwhile to review the
various theories (Blum and Singer, 1983) that attempt to explain why

teenagers drink.

I Biological

 

Genetic

Evidence has emerged that suggests genetic factors may have an
important influence on susceptibility to alcoholism (Bohman, 1978;
Saunders, 1982). Studies have also indicated a possible relationship
. between dysfunctional behavior and minimal brain dysfunction (Woods,
1961; Assgel, Kohen-Ray and Alpern, 1967).

The issue of the inheritance of alcoholic traits becomes a practical
matter when counseling young children who have one or both alcoholic
parents. It seems to me that this well-known fact that alcohol abuse
runs in families has no grounds for attributing drinking behavior to
one's chromosomes. It would seem like environmental factors would also
play a significant role in such instances. Environmental factors could
be sorted out if the children of alcoholic parents would be adopted by
non-alcoholic parents soon after birth. This kind of study has been
done by Shuckit (1972) and Goodwin (1973). They believe that genetic
factors do play a role in the transmission of an alcoholism potential
to the children. Cohen (1983) reports a Danish twin study where 25

percent of non-identical twins and 65 percent of identical twins who

20

had at least one alcoholic parent became alcoholics whether they were

reared by alcoholic parents or by non-alcoholic foster parents.

11 Psychological

 

A great deal of emphasis has been placed on individually-oriented
personality and self image theories to explain alcohol drinking behavior
and other deviant behaviors. For example, identity development
(Erickson, 1950), learning theory (Ullman and Krasner, 1969), self-
image concepts (Reckless, Dinitz and Murray, 1956) and Psychoanalytic
Theory (Redl and Wineman, 1956).

The question posed is given that a youth may be responding to
environmental influences, at what point do these influences affect his
personality development to the point where the initial stimulus is no
longer needed and the behavior itself is self-generating or addictive?
Counselors must ask themselves too whether therapy can be effective if
the self-generating aspects of behavior are neutralized, but leaving
the initial environmental stimuli unchanged. It is often expected that
changes in an individual will prove powerful enough to equip him to
withstand the pressure of the environmental forces. However, for many
troubled youth, staying out of trouble requires that they have individual
strengths beyond those of the average person. It is important for

treatment programs to keep this in mind.

III Peer Group Theories

 

Studies (Thrasher 1936; Whyte, 1934) have found that peer groups

exert two types of influences that result in deviant behavior. First,

21

peer groups can effectively set normative standards for the behavior

of their members - they may demand conformity with group norms of deviant
behavior. Second, groups can create a stimulus and support for deviant
behaviors which are neither consistent with the values of individual
"embers of the group nor represent ongoing group norms.

The youngster peer group therefore, rejects individuals who do not
drink alcohlic beverages. Young people feel a deep need to belong to
a group, and may respond to that need. The sexual identity of some
young people is also enhanced by drinking alcoholic beverages. Male
drinkers often tend to view their nondrinking counterparts as lacking
in masculinity. Female young people drink in order to feel more feminine,
attractive and sensuous (Forrest, 1983).

This universal presence of peer-group conformity can be understood
from several perspectives. Developmentally, young people derive
progressively less protection and information from their parents, while
at the same time they are receiving increasing support from and choosing
more interaction with peers. Clark (1975) documents a shift toward
friends as an information source about drugs from seventh grade on.
Utech and Hoving (1969) and Curtis (1974) find that parents decrease
as reference sources as children grow older. The results of these
studies show that youth are not influenced equally by peers in all areas
of life. Teenagers most strongly influence each other regarding dress
and appearance, choice of leisure time activities, language and use of

alcohol and other drugs (Hedin and Simon, 1980). Parental influence

22

is strongest with regard to moral and social values, vocational plans
and educational plans (Cooper, 1977). Stone.(1979) further points

out that some youth are more parent-oriented while others are more
peer-oriented, and that choices with respect to drug use may differ
according to those orientations. These studies show that youth are
more at risk if people in their dominant reference group use substances
and less at risk if the group is comprised of nonusers. Peer-oriented
youth are more at risk if their friends use substances; parent-oriented

youth are more at risk if their parents are users.

IV Family Theories

 

The variables which have been studied from a number of perspectives
include broken homes, single parent families, deviant behaviors of
parents, role confusion in the family, family inconsistencies in
discipline, family violence, lack of family affection, and insufficient
communication among family members (for theories specific to substance
abuse, see Maddox and McCall, 1964; and Zucker, 1976)

The studies indicate that some families in which both parents are
alcoholics produce children who are potential alcohlics. To the
contrary, parents who are not alcoholics produce children who abstain.
Experts of alcoholism stulies seem to agree on this general) concept that
alcoholic parents may produce alcoholic children. The present author
disagrees with this general consensus. It is unfortunate that the
people who study alcohlism concentrate on alcoholics and ignore the

control cases. For example, there are children of alcoholics who don't

23

want to turn out to be alcohlics because they don't want to be like their
parents, but these people are never studied (at least I did not come
across such studies).

Also there are cases where complete parental abstinence from
alcohol actually encourages the teenager to drink. If drinking is a
taboo in the family, then the contrary-minded youngster may conclude
that drinking must be fun. Drinking, for some youngsters, may offer a
great way to upset and control parents who are nondrinkers.

While the above mentioned variables have been found to be associated
with some deviant behavior in particular studies, they offer no explana-
tion for the other percentage of youth who experience similar family
situations but do not become involved in substance abuse.

It is important here that interventions be designed to compensate
for the specific deficiency involved. In addition to both individual
and family treatment, consideration must be given to the use of Big
Brothers and Sisters, jobs for the youth and income provision programs
for independent living arrangements. In extreme cases, the youth should

be removed from the family.

V Socialization or Value Development Theories

The relationships between value development and deviant behavior
have been studied from a variety of perspectives: the differences in
value orientation in delinquency areas (Kobrin, 1951), the effects of
lower class culture (Kvaraceus and Miller, 1959), and neighborhood

values (Shaw and McKay, 1942). Blum and Singer (1983) categorize this

24

range of theoretical approaches into three subgroups of troubled
youth: 1) socialized youth whose deviant behavior must be explained
by other theories; 2) unsocialized youth whose behavior is the result
of the lack of internalization of values and who therefore are susceptible
to situational stimuli and stress; and 3) negatively socialized youth
who have a clear set of values but whose values are in conflict with
those of the larger society.

The critical point in the theoretical approaches cited above is
that one's social environment is the source of one's value orientation;
consequently, efforts to affect a youth's socialization process must
be directed at the environmental source as well as to the individual.
Each of these theories identifies a different environmental source,
which means that interventions shoUld relate to the particular environ-
mental source which is influencing the value formation of the specified

sub-group of troubled youth.

VI Institutional/Qpportunity Theory

This theory explains deviance on the basis of the blockage of
legitimate opportunities for success and the resulting use of illegiti-
mate means for achieving legitimate ends (Cloward and 0h1in, 1961;
Cressey, 1970); the failure of schools to provide adequate education
(Polk and Schafer, 1972), and the consistently high unemployment rates
of youth.

The above theories call attention to the importance of institutional

arrangements in the society. Newspaper articles report high drop-out

25

rates in the schools, the failure of schools to provide adequate vocational
programs, the failure of schools to provide basic educational preparation.
It seems important therefore, that parents and the community as a whole
engage in efforts to bring about institutional changes that will result

in more adequate educational preparation for young people, and broader
opportunities for them to prevent deviant behavior.

Parents, professionals and the community as a whole cannot wait for
these basic institutional changes to occur in planning treatment programs
for the youth who is in trouble. Ways to make optimal use of available
opportunities must be sought. They must act as advocates for their
children with existing institutions, and attempt to get school systems
to develop needed educational programs that meet the specific need of
the young people. Professionals and counselors in particular have
excess to such existing resources. The opportunity theory emphasizes
the need for programs to the educational and employment needs of youth.

I noticed that for the most part, the study samples from which
these theories are drawn include white males only - little attention
has been paid to the degree to which they are applicable to females,

and other races.

26

Operating A Youth Treatment Program

 

Staff Requirements

 

1. It is important to select staff who have a capacity to be
flexible in their approach to treatment issues. It is important with
adolescents to know when and how far to bend so that the treatment doesn't
break. Many clinical staff do not share the value of "bending" (Filstead
and Anderson, 1983). Furthermore, it is not necessary for the treatment
of a young person to take place in a traditional setting, i.e., the hour
appointment in the therapist's office. Rather the therapist has to
spread time with the kids playing cards, listening to records, talking
about anything, etc. Such encounters have a significant role in generat-
ing, a sense of trust and in gaining rapport with the adolescents.

2. As mentioned before, young people present different demands
and expectations than adults. Staff have to be conscious not to try and
fit the young people into their way of working with adults. To do so
will be clinically unproductive and frustrating.

3. Since young people represent a developmental process, which is
clinically challenging, these issues have to be addressed in treatment.
Filstead and Anderson (1983) point out that issues such as sexuality,
self-concept, identity crisis, establishing an identity apart from the
family, etc., represent issues that alcohol/substance abuse counselors
are not generally trained to consider.

4. Thorough evaluation assessment process through which a
determination is made as to the extent of the problem and the appropriate

action to take is important. Far too often young people can be

27

misdiagnosed (Filstead and Anderson, 1983). It is better to know exactly
what is there. A solid foundation is necessary for treatment to be
successful.

5. A counselor must establish an effective relationship with the
young person, so that he or she will accept the reality of his illness,
seek treatment and continue as an active participant in the therapeutic
situation. To be an effective counselor, one must have a basic under-
standing of the alcoholic and enough knowledge of the natural history of
the alcoholic's illness so as to be able to interpret it to the patient
and his family against their resistance to see it as an illness. The
therapist should also be able to understand and cope with the difficulties
of interpersonal relationships, something that presupposes an understanding
and reasonable control of one's own emotional difficulties.

6. A characteristic problem which often arises in the treatment
of alcoholics is the parasitic attachments they develop toward anyone
who can offer them support and indulgence. These traditionally involve
members of their own family but also and often involve the counselor-
therapist who should try and avoid or correct the problem before too
long.

7. The staff should include young recovered alcoholics who can
pass along their own joy of sobriety, by sharing their own experiences
of recovery and life improving behavior. The young problem drinker then
can hear, first hand, the benefits of making it to school, following
parents'guidance, holding a job, and generally staying out of trouble.

These advantages are lauded, not from an adult point of view but from

28

a contemporary who has been there. Conversely, anyone who is an alcoholic
or other drug abuser ought not to be a counselor for youth until his or
her own problem is solved. Otherwise, the counselor's advise becomes
another replay of that old adult-to-child theme: "Do as I say, not as

I do" (Alibrandi, 1978).

Youth Assessment

 

It is important for the practitioner or therapist to look for signs
and symptoms in an alcohol abusing individual. Ritson (1983) outlined
a list of items which are clues or risk factors in developing alcohol
problems. These include:

Risk factors:

1. Family history of alcohol problems: there is some evidence
that the more malignant forms of alcoholism in the young may possess an
inherent component (Goodwin, 1976).

2. Parental drinking habits deviant for their culture, either
excessive drinking or extreme teetotal views (Davies, 1972).

3. Insecure personality when the maintenance of a masculine
aggressive facade cloaks extreme dependency needs.

4. History of behavior disorders in childhood and adolescence
(Robins, Bates and O'Neal, 1962)°
Clues:

1. Growing preoccupation with alcohol to the exclusion of friends

and neglect of work.

29

2. Delinquency, particularly alcohol-related offences - drunk
driving, violence when drunk.

3. Recurrent accidents when under the influence of alcohol.

4. Parents concerned by change in behavior - drunkenness,
irritability, demands for money, change in friends concentrating on
those who are heavy drinkers.

5. Consulting doctor: complaining of headaches, stomach troubles,
diarrhea, sleeplessness, depression, nervousness (the doctor may find
the patient has a tender enlarged liver and, on testing the blood, a
raised gamma-glutamyl transpeptidase and mean corpuscular volume).

6. Recurrent inexplicable absences from school or work with
deteriorating performance.

7. Breath frequently smelling of alcohol during the day.

Ritson (1983) points out that the above list of predisposing
influences and clues to identification is not exhaustive but that it
indicates factors which can be sought when counseling young people. It
also illustrates the range of crises which the young problem drinker
encounters and the agencies which may encounter them. The crises
themselves suggest the people who are most likely to be able to offer
help. In the front line are family and friends.

Survey evidence suggest that these 'spontaneous remissions' represent
the influence of the curative capacity of the drinker himself and his
immediate associates (Saunders, Kershaw, 1979). Next come those primary

level agencies who do not possess specialist training in alcohol problems

30

but are ideally placed to recognize and respond to the adolescent at
the time when the crisis occurs, such as: schoolteacher, youth-club
leader, police, casualty staff, doctor, employer, employment agency.

In assessing the needs of the young problem drinker Ritson (1983)
differentiates those who suffer from alcohol related problems as a
consequence of injudicious drinking and those who have developed depend-
ence on alcohol. Table 1 lists a range of alcohol problems noted by
Ritson (1983). Those who consistently drink more than 80 g of alcohol
daily increase their risk of developing alcohol problems of various kinds,
Ritson (1983) points out. Edwards and Gross (1976) have delineated the
alcohol dependence syndrome and outlined the following characteristics:

1. Narrowing of drinking repertoire - in which the drinker loses
flexibility about the quantity he consumes on any given occasion.

2. Salience of drink-seeking behavior - with the patient becoming
increasingly preoccupied with finding his or her next drink.

3. Increased tolerance - the patient can sustain high levels of
blood alcohol without evident impairment.

4. Repeated withdrawal symptoms - the patient begins to experience
symptoms of tremor, sweating, nausea and anxiety when deprived of alcohol.
These symptoms may be variable and mild at first, complaints of being
nervous or on edge without a drink are common.

5. Relief drinking - the patient finds that a drink of alcohol
relieves withdrawal symptoms. Essentially he only feels 'normal' when

he has had a drink.

31

6. Subjective awareness of compulsion to drink - the patient feels
an insistent desire for alcohol and although he may fight against this,
he eventually surrenders to the compulsion.

7. Reinstatement after abstinence - the pattern of abnormal drink-
ing quickly returns after a period of abstinence.

Ritson (1983) notes an important caveat about reifying the syndrome
made by Edwards and Gross (1976), "We take the term syndrome to mean no
more than the concurrence of phenomena. Not all the elements need always
be present, nor always present with the same intensity". It is possible
to have both: problems due to drinking and the alcohol dependence
syndrome but either may occur in isolation. Figure 1 illustrates the
point (Ritson, 1983). Both of these groups require counseling and advice
about their drinking but those who have developed symptoms of alcohol
dependence or have evidence of physical harm will be advised to abstain
totally from alcohol. Alcoholics Anonymous (AA) and some counseling
agencies would advocate total abstinence for life while others would
simply require abstinence until the patient's physical health had
returned to normal. Most authors agree that abstinence is particularly
difficult as a long-term goal for younger alcohol addicts and would
prefer to teach the adolescent ways of restricting his or her drinking
to harm-free levels. (Heather and Robertson, 1981).

One reason for the relatively poor success of substance abuse
programs has been a tendency to try to force all clients into a single

conceptual category and to utilize a single explanation of their behavior

32

and a single treatment approach. Blum and Singer (1983) comment that
therapists tend to do what they know how to do - individual counseling
or group counseling, etc., even if it is not the most appropriate
treatment approach for the particular case.

I now think it is appropriate to translate the six mentioned deviance
theories into focal points of treatment. The assessment framework used
in this paper is that proposed by Blum and Singer (1983). Their framework
uses a matrix which can be used to assess individuals or sub-groups and
to plan specific interventions. Blum and Singer (1983) propose that
during the assessment process, the client or client group should be
assessed in each of the six categories on the basis of the various
theories within each category, to determine whether and in what ways
factors related to each of the categories contribute to the problematic
behavior. The assessment would provide a "problem profile" for each
client or client group. Blum and Singer's report from experience
that these profiles could differ greatly among the client populations.
For some youth, family or self-image factors may be the most critical
contributing factors, while for others, peer group, value development.
and institutional provision factors may be more important. There should
be a specific intervention in the treatment plan aimed at relieving,
changing, or compensating for its influence. For example, family
conflicts in one case may be the influential cause in stimulating the
deviant behavior. The treatment plan should specify whether the good
is to try to change the interaction through family counseling, place the

youth in a peer support group, thus compensating for the lack of family

33

support. If the same youth is having a school problem (such as a
learning problem, lack of concentration, etc.) the plan should indicate
a particular intervention aimed at the specific school problem and whether
the goal is changing the school situation (i.e.. transferring from an
academic to a vocational program, or enrolling in a training program).

Blum and Singer are aware that sometimes there will be multiple
factors and these cannot all be addressed at the same time. In these
instances, Blum and Singer suggest that the plan should outline a
progression of steps and a projected time sequence that may require that
an alternative living arrangement be found, then involve the youth in
a peer support group and at the same time design a tutoring program.

The assessment framework should provide a checklist which both identifies
the contributing factors and indicates how the treatment plan and
procedures address each of them.

What is so impressive about Blum and Singer's assessment framework
is that it recognizes the interrelatedness of deviant behaviors, the
complexity of multifactor assessment;and the requirement for differential
program and individual approaches. It is especially good for programs
that are aimed at treatment, prevention and early identification, and
support and maintenance of troubled youth. The framework is clearly
not an undimensional one. Thus the practitioner is faced with utilizing
knowledge across different social disciplines and organizing it for use
in program design and treatment.

Blum and Singer's framework represents a beginning to try to put

current thinking in a systematic way and to make linkages between theories

34

and treatment. More research is needed however. It is still not clear
what the differential effects are when treatments such as individual
counseling, peer group counseling are applied to different types of

cases, for example poor self-image and lack of opportunity.

A Look at a System of Services

 

What components are the basic elements of a treatment system? A
system of care reported by Filstead and Anderson (1983) which is available
at the Lutheran Center for Substance Abuse and Parkside Medical Services
in Illinois, forms the basis for the remarks that follow:

1. Evaluation-Assessment Services: The adolescent and/or family

 

member can be present for treatment under varying conditions. The
decision as to the most appropriate treatment setting is made during

the initial evaluation-assessment process. The length of time available
for evaluation-assessment (E/A) depends upon the presenting clinical
condition of the patient. The more acutely distressed the patient
(because of either medical and/or psychiatric complications) the shorter
the initial E/A time. Should the patient enter treatment the E/A will
occupy the first few days of residential care and/or the first few
outpatient visits until a thorough picture of the alcohol/substance abuse
are reviewed.

2. Residential services: many adolescents who reach the point of

 

presenting themselves for help generally have encountered a variety of
serious problems in a relatively short span of time. School and/or job

performance often is affected. In many cases the adolescent has

35

experienced serious problems in school and may be suspended or expelled.
Family relationships are markedly impaired. The legal system often is

in volved. The presence of other behavior problems and/or psychiatric
conditions (e.g., hyperactivity, learning disabilities, mental retardation,
violent behavior, suicidal thoughts or gestures, etc.) is common.

The focus of treatment in a residential setting is to address the
misuse of alcohol and/or other substances through educational sessions,
group, individual and family sessions, and the reinforcement of positive
behavior and the regulations of negative behavior through peer oriented
treatment milieau. It is important for treatment strategies to address
these patients as both adolescents and substance misusers.

3. Outpatient Services: The key clinical criteria that would

 

indicate a patient may be a candidate for outpatient services are:
l) absence of acute medical and/or psychiatric problems; 2) ruling out
the existence of chronic medical problems that would preclude outpatient
treatment; 3) willingness to abstain from all mood altering chemicals;
4) if the person hasn't failed in outpatient treatment in the past;
5) the extent to which the family is interested in becoming involved in
the patient's treatment; and 6) the source(s) of motivation. What is
behind the person's desire for treatment. If the source of motivation
is strong (to stay in school, to avoid the jail term, etc.), there is
reason to believe outpatient treatment could be considered.

In order to be involved in outpatient treatment, the following rules
have to be followed: 1) no use of alcohol or other substances for any

reason; 2) no violent behavior; 3) regular attendance at therapy

36

sessions; and 4) Alcoholics Anonymous (AA) meetings. If the counselor
suspects use of substances, a urine screen is requested. Failure to

comply results in termination from the program.

 

4. Extended Care: Many adolescents who complete the 4- to 6-weeks
of residential care or the 4 to 20 weeks of outpatient treatment still
require additional time to continue the rehabilitation process. A return
to home or remaining at home may not be the best option for the patient
or the family. The change from the structure of residential care to the
relative freedom of the home environment is oftentimes too abrupt and
dramatic a shift for the adolescent to make. He or she needs to have
time to work at the changes in attitude and behavior that have been
suggested so that they can become more established. Extended care provides
a transition period of treatment and relearning which stimulates the
responsibilities of daily living but within a structured environment.
Residential care focuses intensively on unlearning old patterns and
learning new patterns of behavior in order to accept the need for, and
the ability to maintain chemical abstinence. Extended care places an
emphasis on putting these skills into practice in everyday living
situations. Extended care can be as short as three months and as long
as six months. Patients in this phase live in a dorm-like setting.
Patients are expected to be attending school or to be working.

In summary, a system of care according to Filstead and Anderson
(1983) would include: 1) evaluation-assessment capabilities; 2) out-

patient services; 3) residential treatment of varying intensity; and

37

4) extended care services. Not all adolescents need each type of
service, but all services are necessary to provide adequate care for
adolescents. Furthermore, in each of these settings, there are educational
programs so that the academic programs of the patients can be maintained
during the course of the treatment.

What is impressive about this system of care is that it provides
a variety of settings for the treatment of the young person. It is not
unidirectional. Also, criteria are identified which distinguish which
level of care is most appropriate for the presenting clinical condition
of the young person. Total abstinance and acquiring a skill after
treatment seem to be the goal of this system. However, this author sees
some shortcomings to this treatment approach. First, the philosophy of
treatment stresses individual responsibility; emphasis is made that the
individual has to be willing to abstain from alcohol and other drugs,
otherwise, he or she will be terminated from the program. However, m9§t_
addicts enter treatment unwillingly. They agree to treatment because
maybe they don't want to be kicked out of school, to be forced to
leave home, or don't want to be sick. Few enter treatment with a positive
attitude. If they had in their lifes been able to be "willing" to
abstain from alcohol, they probably would not have become chemically
dependent. The better treatment program therefore, should recognize
that helping the addict to want to be well is the primary task of
treatment. Secondly, it is this author's view that this system would

be more productive and more effective if it considers the theories of

38

deviance in young people and apply these theories to the treatment of the
young person rather than terminate treatment if the individual does not
"comply" with the system's philosophy. Young people are in a period of
transition from childhood to adulthood, young alcohol abusers deserve

special attention.

Conclusion and Recommendations

 

This paper has analyzed a broad spectrum of factors related to
youth problem drinking and has proposed a theoretical approach to the
treatment of alcohol abuse in young people. A number of studies have
been identified which recur consistently in relation to patterns of
problem behavior. The role of the peer influence is only one of the
many factors. Although parental influence is more important for some
young people than others, peer influence seems to be the dominant factor
for many youngster's entrance into alcohol abuse. Since peer influence
is so clearly part of the problem, it must also be part of the treatment
solution. Peers may not always influence each other negatively by
manipulation, but may also influence each other positively by offering
advice, support and discuss conflicting view points. This author is not
denying the reality that for treatment to be even more effective the
family as a whole should be part of it. Too much emphasis is on the
parents than on the peer group or both.

By providing as many opportunities as possible to healthy develop-
ment, and by minimizing risks, young people's vulnerability to alcohol

abuse could be reduced. In agreement and in accordance with the concept

39

of alcoholism as a disease (Jellinek, 1960), an etiological approach
could be ideal to the treatment of alcohol abuse. We had best accept

the hypothesis that no single cause leads to alcoholism but rather a
combination of biological, psychological, physiological and environmental
factors.

Programmers, particularly governmental health, protective, Welfare,
and rehabilitation officials, must be fully conscious of the diversity
of problems arising from the excessive use of alcoholic beverages. These
problem drinking situations embrace a variety of related alcohol use:
interference with recovery from other ailments, rehabilitation, parental
conflicts, drinking and driving, juvenile care, deviant behavior and
other similar problems of public concern.

The services which alcohol treatment programs undertake in relation
to these problem areas should be expressed in terms of prevention: first,
the prevention of the progress of existing alcoholism, alcohol abuse and
other excessive drinking problems; and second, the prevention of new
growth. These goals represent a treatment as a remedial approach to the
long range plan of effective control and eventual total prevention.

To prevent new growth of alcoholism/alcohol abuse and other drinking
problems, consideration must be given to achieving more positive controls
over the misuse of beverage alcohol. Governmental liquor control boards
have a responsibility to use the authority vested in them to curb misuse.
Greater effectiveness in curbing abuse could be achieved through closer

consultation between alcoholism agencies and liquor control boards.

40

Preventive education must do more than acknowledge the magnitude
and incidence of alcoholism. It must achieve more than an acknowledgement
of alcoholism as a treatable illness.

There are instances of alcoholics requiring vocational guidance for
training. This entails cooperation between the alcoholism program,
schools and vocational guidance agencies. Consultation and cooperation
are also indicated between treatment centers and child guidance, welfare,
family, social services, law enforcement and other agencies. The
responsibility of such coordination develops upon the alocholism agency.

For alcoholics who are repetitively arrested and jailed for offenses
against intoxication laws, rehabilitation centers are better suited to
treatment of their problem drinking than penal institutions which rarely
offer therapeutic care.

Separate agencies are needed to deal with chemically dependent young
people. Programs for young alcohol abusers are few. When funds are
short, programs to help youthful alcohol abusers frequently are cut, and
the schools are left to pick up the slack. General educational facilities
simply are not able to answer the need because of budget problems of
their own.

Alcoholism programs should be offered within all juvenile detention
facilities, and long-range monitoring of the recidivism rate of these
offenders who receive treatment, as opposed to those who don't is
necessary. Any alcohol abusing youths who are able to overcome their
problem and stay out of jail save taxpayers enormous amounts of money in

court costs and detention facility overhead.

41

The media must be used to counteract the 'better living through
chemistry' brainwashing which has taught the youth that there is a pill
for every ill, that you can control your feelings, relationships, status
and who-knows-what-else chemically. Public personalities - music idols,
movie and television and sports heroes - should do their part in present-
ing responsible images and information.

Initiating ways to combat youth alcohol abuse need not be left to
elected or appointed officials. Armed with a perspective on current
drinking problems among youth, parents can demand that programs be
instituted in schools or in other community facilities. Parents should
find out what, if any, detection or interception models are being used
in their school districts. Afterall, their children's lives are at
stake.

Programs should include young recovered alcoholics as counselors
who can pass along their own joy in sobriety, by sharing their own
experiences of recovery and life-improving behavior. The young problem
drinker then can hear, first hand, the benefits of making it to school,
following parent's guidance, holding a job, staying out of trouble.
These advantages are lauded, not from an adult reference point, but from
a contemporary who has been there. Conversely, anyone who is an alcohol
or other drug abuser, ought not to try to be a counselor for youth until
his or her own problem is solved. Otherwise, the counsellor's advise
becomes just another replay of that old adult-to-child theme: "00 as I
say, not as I do" (Alibrandi, 1978).

42

The evaluation of alcoholism treatment programs demands greater
emphasis on measurement of program effectiveness, programs need to
clarify their measurable objectives and develop their skills in gathering
measurable outcome data. Follow-up of discharged patients must become
more thorough, and more money and manpower are needed for follow-up.
Funding sources should request concrete and precise data related to
program effectiveness, and the regional coordinating agencies should
help individual programs increase their ability to gather and report
such information. General systems theory may be useful in enabling
programs to evaluate their performance in a meaningful way.

It should be apparent therefore, that the need for research is vital.
Research should be a major goal of an alcoholism program assessing its
effectiveness and impact, revealing and correcting deficiencies in
treatment services and assessing the efficacy of educational efforts.

It is necessary to learn more about what people know, feel and expect of
an alcoholic agency; how much influence it wields; how well respected
its services are among other agencies; what cooperation it receives from
other community facilities and resources. Through careful study and
investigation, alcholism agency directors can discover what the average
person - the mailman, teacher, taxi driver, doctor or clergyman - knows

about alcoholism and the work of the agency.

Introduction to the Appendix

Since this author was born and raised in South Africa, special
interest in looking at the alcoholism/alcohol abuse condition in
South Africa is considered. One of the underlying motives in
looking at the available alcoholism/alcohol abuse research in the
United States has been with reference to its possible usefulness in
the South African setting. In view of this, this appendix will take
a look at South Africa.

In future work, I will be asking myself to what extent will
research findings in the United States be applicable to South Africa

or to Africa as a whole.

APPENDIX
A VIEW OF ALCOHOLISM AND BLACKS IN SOUTH AFRICA

 

The alcoholic has been discriminated against in a number of ways.
This discrimination has reduced his life chances and opportunities.

Yet, in South Africa, there are other bases for discrimination besides
the stigma of alcoholism, namely, racial status.

Harper, (1980) points out that to hypothesize that there are no
significant differences among alcoholics of different sexes, ages, races,
cultures and social classes is illogical and emperically unfounded; yet,
he adds that, it is still often maintained that, “an alcoholic is an
alcohlic," and thus should be subject to the same alcoholism policies,
services, and treatment approaches. All of us as human beings are
similar in terms of our basic needs for physiological maintenance, safety,
love, esteem, and self-development (Maslow, 1970), we tend to differ
across cultures and social groups in regard to our lifestyles, perceptions,
values, attitudes, and social habits. Although there are similarities
common to all alcoholics, there are also qualitative and quantitative
differences among various social groups of alcoholics - differences that
should bear consideration in decisions concerning alcoholism treatment
and research in South Africa. Differences between Black Americans and
White American alcoholics have been documented in the literature and
include findings such as the following:

-Blacks, particularly in urban areas, have significantly higher
incidence of alcohol related homicides than Whites (Lunde, 1975; Harper,

1976).

Al

A2

-Black alcoholics tend to be younger than white alcoholics (Rimmer,
1971; Harper, 1979).

Although the above studies were made on Black Americans, generaliza-
tions will be made on the basis that Black Americans and Black South
Africans share similar characteristics, the major one is that both have
been discriminated against because they are Black.

Black South Africans often differ in their drinking behavior because
their history, culture, behaviors and economic status all differ from
that of the white South African.

If one is to develop a theoretical framework that would explain
Black drinking patterns and implementation of effective treatment programs,
then one must consider sociological, economic and historical factors that
influence their drinking behavior. Following are several hypotheses that
establish a theory to explain drinking behavior among Black South Africans.

First of all, the historical patterns of alcohol use and nonuse by
Blacks significantly influence their current drinking practices and
attitudes. It is not uncommon for Blacks to drink heavily on weekends
and holidays. This drinking is encouraged by many Whites as a means of
pacifying the Blacks to keep them from progressing mentally and education-
ally. For example, some blacks especially those who work in the farms,
or as maids, are paid with wine as part of their wages. Azziza (1984)
notes that under the so-called 'dop' (tot) system, farm workers are given
a tin filled with locally brewed wine, some farmers giving 10 'dops'

daily plus two bottles to take home. Workers thus become addicted and

A3

dependent on their employers (Louw, 1978). For Blacks, this heavy
drinking is a means of mental escape from the long days of heavy work -
working for the white man - under unpleasant conditions (constantly

being pushed around, insulted and sometimes slapped). Blacks tend to
start their drinking on Friday afternoon and continue through the

weekend (Daily News, 1982). Drinking of methylated spirits by alcoholics
is increasing because of its cheapness and availability (Cape Times,
1978).

Secondly, some Blacks choose to drink because liquor stores are
readily accessible. Unlike their distribution in the white community,
liquor stores are often located in black residential communities, which
contribute to high accessibility, visibility and frequent use. It is
very common to find liquor stores in the residential neighborhoods of
Black South Africans, especially in large cities such as Soweto (a
residential area for Blacks, a few miles from the city of Johannesburg).
These liquor stores are usually near homes, school, hospitals and churches.
In other words, the liquor industry is a business institution that has
become interwoven into the fabric of Black South African life. This is
directly opposed to the situation in white communities where liquor
stores are located in commercially zoned business areas.

Next, for many youngsters, drinking is a source of recreation and
social activity. Drinking among Blacks is also influenced by racial
segregation since Blacks are excluded from social and professional
opportunities and activities. This leads to drinking as a means of

recreation.

A4

Many Black parents drink heavily because of the economic frustrations
of not being able to get a job or not being able to meet financial
obligations. In most cities, many unskilled Blacks (men and women) work
for "The Boss", the white man, at a minimal wage. There are few jobs,
and if after looking for a job the whole day one is not successful,
frequently he or she is ashamed to go home to their families, so they go
to drink. Unemployment, underemployment and unstable employment creates
frustration for the parent. This lack of money and job pride creates a
sense of powerlessness that lends itself easily to drinking as a means
of escape. Alcoholism/alcohol abuse amongst better educated black people
is the result of frustrations as many cannot progress professionally
owing to the laws and customs of apartheid. Azziza (1984) notes that
amongst the migrant workers in the hostels in the urban townships, liquor
is a means of obliterating or at least softening, the harsh reality of
everyday life in which there is no home or family to return to after the
day's work. The West Rand Administration Board (WRAB) in 1978, reported
that the municipal beer halls were attacked by students in Soweto in
1976 in protest against liquor sales. The WRAB official was quoted as
saying, 'We build as the need arises'. Soweto is largely run on the
liquor profits made by WRAB. As mentioned before, a parent is the most
significant person in any child's life, an authority to whom a youngster
looks for reference points and boundaries. Therefore, some children
drink because they see their parents drink.

The youth of today in South Africa has seen it all - has observed

murders, rapes, robberies and has participated in booze parties in the

A5

"Shebeen Houses" (an individual's house in the neighborhood where liquor
is sold and people go there to drink, talk and dance). In addition,

the social consequences of problem drinking behavior often perpetuate its
continuance in higher rates of poverty, promiscuity, illegitimate
pregnancies, and physical and mental abuse.

Theorists who adopted the drug therapy defined problem drinking and
its results primarily by its psychological characteristics and followed
a disease model (Jellinek, 1960). According to Pattison (1966), this
"heuristic-cultural" need to define alcoholism as a disease has sprung
from a medical-pathophysiologica1 model which views disease as resulting
from an alteration of a pathophysiological process such as an allergenic
or endocrine disorder. To qualify alcoholism as a disease, it is also
necessary to demonstrate a physiological addiction, a habituation or a
compulsion to drink.

This approach, however, fails to take into account the importance
of individual differences or social roles. It presupposes that the
problem drinker is only "physically sick" and set forth to “cure him
without paying attention to his interaction with his external (sociological)
or internal (psychological) environment" (Enelow, 1974).

Like the drug approach, the psychotherapeutic approach also focuses
on the individual by attempting to understand and treat the developmental
personality disorder with which the drinking problem is associated.
Usually through a one-to-one encounter between therapist and patient,
treatment is designed to alleviate the personality disorder of individual

problem drinker.

A6

This approach encourages the development of insight by promoting
increased awareness of those unconscious motivations which have led to
excessive drinking.

The origins of this approach may be traced back to the late 1800's,
when Freud and Brewer proposed this psychodynamic formulation of hysteria.
They hypothesized that psychologically traumatic events were associated
with the onset of observed hysterical symptoms. If these forgotten
events could be brought into consciousness, along with their accompanying
feelings, Freud and Brewer observed that patients lost their symptoms
and improved.

This concept has been expanded and modified by many theorists since
Freud. Enelow (1974) points out that all intrapsychic models share in
common the assumption that symptoms and disordered behaviors are produced
by unconscious conflicts between opposing tendencies or interests of the
individual or as a result of opposing forces generated when personal
wishes come in conflict with demands imposed by society and internalized
at an early age.

For the South African Black youth, in order for treatment to be
effective, rather than emphasizing drug, psychotherapy and behavior
approaches, it is necessary to view problem drinking as resulting from
phenomena derived from aspects of an individual's life pattern. Rather
than de-emphasizing the social dimensions of behavior and considering
them as essential to the origin and course of problem drinking, drinking
behavior as the primary source of the problem must be addressed if

rehabilitation is to occur.

A7

The early concept of alienation expressed by Durkheim (1956) was a
forerunner of later approaches to the formulation of a social model.

By suggesting that an individual's social and economic environment
defines and shapes his goals and the roles which he assumes in attempting
to attain them, Durkheim placed individual behavior in an appropriate
social context. He believed that if a person is successful in pursuing
goal-directed behavior or if he perceives that success is possible, he
will behave in a socially acceptable manner. However, when an individual
no longer views the goals or aspirations as potentially attainable, the
rules and values of society lose their regulatory value. This leads to

a feeling of alienation and subsequent deviant behavior.

Cahalan (1969) concluded that drinking behavior is primarily a result
of sociological and anthropological rather than psychological variables.
Referring to South Africa, support from this conclusion can be drawn from
drinking patterns and the manner in which these patterns are influenced
by age, family history, marital relationships and extent of urbanization.

It is recognized that the problem drinker faces conflicts and
problems which are not necessarily a result of social forces. However,
the social model maintains the theoretical position that problem drinking
is a phenomenon affecting all aspects of an individual's life inter-
dependently, and that psychological or biological aspects cannot be viewed
independent of the sociological.

Social systems theory provides a different and more realistic
orientation to understanding problem drinking and developing therapeutic

approaches for the Black South African youth. In a systems analysis,

A8

the problem drinker is considered neither a victim nor a victimizer,
but a product of system disruption. The total system is viewed as the
troubled unit, whether it is a marriage, a family, a society or a
culture, and effective treatment can only be provided at a system level.
Smoyak (1973) suggests that a social systems analysis entails the
viewing of persons within a single unit as well as the examination of
their roles in the multiple subsystems of the larger system. When a
social system is in equilibrium, all subsystems are working and the
negotiation and social-making processes proceed smoothly - when a
disruption of the operating order occurs, outside help may be needed to
restore some parts to a workable condition. Bowen (1974) suggests,
systems theory attempts to focus on the functional facts of these
relationships: what happened and how it happened, as well as where and
when. An essential difference between traditional, biological and
psychological models and social systems theory is the lack of emphasis
by the latter on the ”why” of human behavior.

For those in the lower end of the socioeconomic scale, lifestyle
and behavior are largely determined by a series of prohibitions and
constraints either formerly imposed or informally developed through
economic deprivations. There are few options open and considerably
reduced opportunity for individual volition in determining behavior
patterns. The extreme example of this is "apartheid", but some black
people remain so used to the external influences controlling their lives
that they have said little stimulus to develop controlled internalized

constraints, particularly in areas such as alcohol consumption where

A9

outside control has been the historical pattern. As a result, there is
little culturally systematized or religiously sanctioned pattern of
moderate drinking in black communities.

The churches in black communities traditionally follow white
fundamentalist beliefs and condemn outright the use of alcohol. In part,
this may be seen as a legitimate effort to encourage black people to
adapt to an oppressive society in which the use of alcohol, and particu-
larly drunkenness, is inevitably going to lead to conflict with the white
man's establishment. Moral condemnation for the use of alcohol has led
to an all-or-none atmosphere in black communities where the use of any
alcohol is regarded as sinful, and there is no middle ground where
moderate drinking pattern can be learned and accepted. In most black
settings it would remain hard to involve ministers in any attempt to
treat alcoholics because they continue to adhere to a moralistic Position
condemning the alcoholic as a sinner.

The traditional explanation for heavy drinking among minority groups
or the underprivileged has held that it is a response to effects of
deprivation and oppression and that the suffering could be more easily
borne by developing a frequent state of psychological anesthesia through
the use of alcohol (Fox, 1973). While with specific individuals such
factors can clearly be identified as important, there is a need for a
research study to be done with South African Blacks to see if there is
a consistent correlation cross - culturally between poverty, political

oppression, and physical deprivation and the use of alcohol. Perhaps a

AlO

more valid reason, for now, which seems more pertinent to the plight of
the Black South African, is that alcohol offers an accessible and
immediate pleasure which there is almost no valid reason to defer.
Prospects for the future appear so bleak in terms of increased income,
job promotion, higher education, or a more pleasurable or meaningful
existence that there is no motivation to defer immediate, if only brief,
pleasure anywhere and anyway it can be obtained.

Treatment programs for Blacks are needed, centered around needs for
funding, technical assistance and staff training. Their philosophy will
have to differ from those directed to a more white clientele and focus
less on the individualistic disease model. Specifically: (l) A substantial
recognition that social factors and especially poverty and its by-products,
including lack of upward mobility, are major contributing features in the
development of alcoholism. Changing the social environment is seen as
critical to long-term preventive factors in dealing with Black South
Africans. (2) Innovative and experimental approaches to dealing with
individual alcoholics should be emphasized with the belief, which is
correct, that as yet there is no single satisfactory model for dealing
with the black alcoholic.

To summarize, factors contributing to excessive drinking therefore,
are poverty, job reservations, poor living conditions, lack of recreation
facilities, and the group areas regulations. The apartheid system,
involving the removal of over three million people, the splitting of
families and the pervasive climate of police harrassment, is not a good

climate for the development of psychiatric and mental health. Aziza

All

(1984) reports that psychiatric facilities provided for Blacks are
inadequate and poor in quality. Patients have been laid open to abuse
in private institutions which, instead of providing therapy and support,
have been used as cheap labor camps (Aziza, 1984). Clearly then, the
South African government is fearful that treatment programs will infringe
in an area where they have previously enjoyed a monopoly.

The World Health Organization (1977), in their report on mental
health in South Africa concluded, '...such policies are however, part
and parcel of the overall doctrine of apartheid and radical improvements
in the present situation in mental health services are inconceivable as

long as apartheid remains in force'.

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Treatment of Alcohol-Dependent Adolescents

Table 1. Problems which are commonly alcohol-related with the agency
most often involved in their identification.

 

Problem Agency

 

Accidents at work, home or on the road

Alcoholic coma

Gastritis

Haematemesis following acute gastric erosion

Acute pancreatis

Recurrent diarrhoea

Recurrent headache, nervousness - hangover Medical/Surgical
symptoms

Hepatomegaly

Hepatitis

Epilepsy

Peripheral neuropathy

Thiamine deficiency

Obesity

Impotence
Oligospermia Obstetric/Paediatric
Foetal alcohol syndrome

Domestic arguments, violence
Financial crises, debts, pawning possessions

Homelessness Social work/Welfare
Inability to sustain relationships agency

Depression, bad nerves

Unemployment

Poor work performance

Increased level of absences due to sickness Employer
(Monday mornings particularly)

Frequent loss and change of job

Violence

Public drunkenness Police and courts
Drunk driving

Theft

Suicide attempts
Depression Psychiatrist and
Nervousness when abstinent counseling agency

 

The table lists some of the problems and crises which may reflect an
underlying drinking problem in a young person. The family doctor or
other primary level agent is often best placed to identify such problems
at an early stage and should ensure that adequate investigation of
possible drinking problem is undertaken when such problems arise.
Permission granted by the publishers, S. Karger. A.G. Basel.

Ritson

   

    
 

Population of
heavy drinkers

Alcohol dependence
syndrome

 

 

x
a?

‘11
xx xxx
L“‘.“
l 1111 ‘1‘
A1 xxxxxlx

 

problems

 

 

. h Alcohol-related

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fig. 1. Overlapping population of heavy drinkers, alcohol
dependents and those with alcohol-related problems.

Permission granted by the ublishers S
A.G. Basel. p ’ . Karger.

"llllllllllllllllls