Focus and Terminology

Excerpted from Chapter One: Theories of Addiction and Implications for Counselling in Alcohol & Drug Problems: A Practical Guide For Counsellors

This book is about ways to help people with alcohol and other drug problems. It is not especially about helping “alcoholics” or “drug addicts,” although many people who use substances may be given these labels by those who know them and by some clinicians and researchers. This book has a broader focus: it concerns people whose problems with substances vary in kind and severity.

This chapter also has a broad focus: it summarizes theories of substance use, including use that is often labelled “addictive.” However, the terms “addictive” and “addiction,” and the related term “alcoholism,” will generally be avoided, because they have no agreed definitions and have limited value in many counselling settings. These labels are used in this chapter only in a historical context or if they appear in a cited study.

Most experts do agree that the concept of dependence is useful. Dependence refers to a cluster of cognitive, behavioural and physiological symptoms of varying severity, consistent with the use of the term by the World Health Organization (1992) and the American Psychiatric Association (2000).

The American Psychiatric Association’s (APA) criteria for a diagnosis of substance dependence are met when any three of the following occur at the same time during a 12-month period:

• tolerance as indicated by the need to increase dosage to obtain the desired effect, or reduced effects with continued use of the same dose
• withdrawal symptoms characteristic of a particular substance
• use in larger amounts or over a longer period than the user intended
• persistent desire for the substance, or unsuccessful efforts to cut down
• a great deal of time spent in obtaining or using a substance
• social and other activities given up or reduced due to substance use
• use despite persistent or recurrent problems (e.g., health or social problems).

Although the moralistic implications of the term “substance abuse” concern many experts, the APA uses this term to refer to a condition that is met when one or more of the following symptoms occur within a 12-month period, provided the criteria for substance dependence have not been met during the same period:

• recurrent substance use resulting in a failure to fulfill obligations at work, school or home
• recurrent substance use in physically hazardous situations
• recurrent substance-related legal problems
• continued substance use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

We will use the phrase “alcohol or other drug problem” with the understanding that such problems are social constructions. In some cases, such use may be essentially benign, but may be seen as a problem because it contravenes social norms (e.g., occasional use of alcohol by people whose religion forbids it, or the occasional use of cannabis). More serious problems may also be defined differently by each of those involved. Weekend drunkenness may be intolerable to a spouse but just fine to the drinker’s companions. An important task for counsellors is to negotiate a common understanding of the problems to be addressed. Relevant issues are discussed in the chapters in this book on assessment and motivational interviewing.

This chapter does not deal with the so-called “disease” concept of alcoholism, which is less a testable theory than an analogy. Nonetheless, it has important implications for the ways in which “alcoholism” is regarded and treated. When viewed as a disease, alcoholism becomes a legitimate condition for treatment by medical and allied professionals, rather than simply a bad habit or a sign of moral weakness. The disease analogy is appropriate if the term is understood to include complex conditions, such as high blood pressure, that are influenced by genetic and lifestyle factors. However, the analogy breaks down when alcoholism is compared with diseases with clear causes, such as tuberculosis or syphilis.

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