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Article Excerpt
UNDERSTANDING THE NATURAL HISTORY of alcohol dependence informs diagnosis, early detection, prevention, and treatment (Schuckit et al., 1995; Valliant, 1995). Cross-cultural examination of addictions may help distinguish both common elements and those differentially shaped by culture. Within and outside of Native cultures, focusing on drinking problems has led to negative stereotypes (e.g., Westermeyer, 1974) and pessimism about the likelihood of remission. More recently, research on change processes has suggested routes for the resolution of alcohol dependence (Bezdek et al., 2004; Fletcher, 2001; Prochaska et al., 1992; Quintero, 2000; Sobell et al., 1993; Valliant, 1995). Including change efforts highlights the resiliency of cultures and individuals (Hazel and Mohatt, 2001). Constructing a combined sequence of problem emergence and change efforts may offer a more complete picture of the course of alcohol dependence.
Development of alcohol dependence
Jellinek (1946, 1952) conducted the first empirical evaluation of the development of alcohol dependence, yielding a sequence of alcohol-related events ("symptoms"). Researchers have found partial support for Jellinek's progression (Orford and Hawker, 1974; Park, 1973; Park and Whitehead, 1973; Trice and Wahl, 1958). However, idiographic support is missing; individuals neither experience all alcohol-related events, nor experience them in the same order (Jellinek, 1952).
Schuckit and colleagues (2002) have argued for a unitary course of alcoholism across genders, severity of dependence, care, and comorbidity (Schuckit et al., 1995, 1998, 2002). In contrast, others have found evidence for dependence subtypes, characterized by varied courses (Babor et al., 1992; Cloninger et al., 1996; Jellinek, 1960).
Cultural and gender differences
Examining the robustness of addiction models across cultures provides evidence for the utility of current conceptualizations. Addiction models have historically been developed based on predominantly white American male samples. Replicability across cultures would inspire confidence in unitary models and concepts of addiction. Cultural differences in the development of alcohol dependence could clarify the impact of well-documented socio-cultural differences in drinking practices (MacAndrew and Edgerton, 1969; Room and Makela, 2000). Although a recent study reported very high correspondence in the course of alcoholism between a predominantly white American sample (Schuckit et al., 2002) and a Mission Indian sample (Ehlers et al., 2004), Venner and Miller (2001) found that the reliability of Jellinek's model was reduced as the culture and gender of the samples diverged from Jellinek's original sample of U.S. men. For example, Navajo who were highly acculturated (identified with mainstream culture) evidenced a higher correlation with Jellinek's model than those with lower acculturation (identified with traditional culture). These discrepant cultural findings merit further investigation.
Believing women's phases of alcoholism were more erratic than those of men, Jellinek (1952) excluded women from his models. However, researchers who have assessed Jellinek's model with women have reported significant gender differences in both mainstream (Piazza et al., 1986) and Native (Venner and Miller, 2001) cultures.
Pathways to resolving alcohol dependence
Although many researchers have examined the development of alcohol problems, much less is known about the sequential development of efforts to resolve those problems. In 1958, Glatt described a U-shaped curve depicting the descent into alcohol dependence as well as the ascent toward remission. Unfortunately, no data were provided for Glatt's remission progression.
Recently, Forcehimes (2004) used items from Glatt's (1958) recovery curve among Alcoholics Anonymous (AA) members and found support for Glatt's hypothetical sequence.
Combining development of alcohol problems and recovery
This article examined the interplay of the onset of alcohol-related behaviors and change efforts among Native Americans with alcohol dependence in sustained, full remission (according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [DSM-IV-TR]; American Psychiatric Association, 2000). We specifically examined developmental sequencing of alcohol problem/dependence symptoms and efforts to resolve them. We also examined within-sample differences in sequencing related to gender and cultural identification and those found by other researchers.
Method
The authors conducted the 75 phone screens and 47 interviews. Recruitment efforts included strategies found to be useful with hard-to-reach populations (i.e., Heckathorn, 1997; Patrick et al., 1998), such as mailed letters and fliers, newspaper advertisements, and word of mouth. Before participation, all participants underwent a half-hour phone screening for substance dependence and abuse using the Structured Clinical Interview for the DSM-IV-TR (First et al., 2002). Of those participating in the 75 phone screens, 17 people (22.7%) were ineligible for being in early, full remission (less than 1 year; n = 13), not meeting lifetime alcohol dependence (n = 3), or current drug dependence (n = 1). Nine participants (12%) were eligible but not scheduled because of time conflicts and inaccurate contact information. Three people (4%) began the interview but did not complete it because of cognitive limitations (n = 2) or nonattendance (n = 1) for the second appointment.
Participants who demonstrated alcohol dependence in sustained, full remission (according to the DSM-IV-TR; American Psychiatric Association, 2000); fluency in English; and no evident psychosis or dementia were encouraged to set up an appointment for the 3-5 hour interview at the University of New Mexico Center on Alcoholism, Substance Abuse, and Addictions. Participants were compensated $50. Participants who traveled 25-50 miles and more than 50 miles were provided an additional $20 and $40, respectively, for travel expenses. This study was completed in compliance with the University of New Mexico's Institutional Review Board and with a certificate of confidentiality from the Department of Health and Human Services. All interviews were conducted during the period of March 2003 through February 2005.
Measures
Participants completed the following measures as part of a larger battery of questionnaires and interviews. First, participants completed a demographic questionnaire that gathered information about gender, current marital status, tribal identification, age, living situation, highest level of education achieved, employment, annual income, and first language.
Second, participants received a brief assessment of what their drinking patterns were during their self-reported heaviest 60-day drinking period (QFV-60, revised from Form 90 QFV-30 [Quantity, Frequency and Volume of drinking]; Miller, 1996; http://casaa.unm.edu/inst/Form%2090%20 QFV%2030%20days.pdf). The four items of interest were quantity, frequency of drinking, frequency of heavy drinking (number of days during which they had five or more drinks), and social drinking (tendency to drink alone, sometimes with others, or generally with others). Supporting its concurrent validity, Grant et al. (1995) found that the quantity-frequency measure positively correlated with dependence and alcohol-related consequence measures, including a calendar timeline follow-back (TLFB) measure and Skinner and Horn's (1984) Alcohol Dependence Scale (ADS).
Third, participants completed the 25-item ADS reporting on their heaviest year of drinking. This measure has been found to have high internal consistency ([alpha] = .92), high 1-week test-retest reliability (r = .92), and moderate convergent validity (r = .69) (Skinner and Horn, 1984). Moreover, the ADS is relied on in clinical and research settings...
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