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Psychosocial theories of alcohol abuse: an understanding and its relevance

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DOI: 10.25215/0802.096

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The International Journal of Indian Psychology
ISSN 2348-5396 (Online) | ISSN: 2349-3429 (Print)
Volume 8, Issue 2, April- June, 2020
DIP: 18.01.096/20200802, DOI: 10.25215/0802.096
http://www.ijip.in
Research Paper

Psychosocial theories of alcohol abuse: an understanding and its

relevance

Prem Prakash1*, Pradeep Kumar2, Amool Ranjan Singh3

ABSTRACT
Alcohol abuse is reflected as a major public health concern in worldwide. It impaired many
areas of life, including familial, vocational, psychological, legal, social, or physical aspects of
life. These people are widely considered to be a vulnerable population. The purpose of this
study is to explore the psychosocial theory related to alcohol abuse. Literature has been
searched the both electronic databases including PubMed and manual searches for this. This
article reviews the various theories related with alcoholism. Psychosocial theories of alcohol
abuse can be utilized to identify and contextualize trends in major treatment approaches for
the people of alcohol abuse and also provide possible future directions for research in that
specific area.

Keywords: Alcohol, Psychosocial, Behavioral, psychotherapy

Alcohol abuse is reflected as a major public health concern in worldwide. It impaired many
areas of life, including familial, vocational, psychological, legal, social, or physical aspects
of life. Approximately 2 billion persons worldwide consume alcohol and one-third (nearly
76.3 million) is likely to have one or more alcohol related disorders (WHO, 2002). Research
suggests that drinking alcohol is associated with nearly 1 out of 10 deaths in the ages15 to
49 years (Stockwell et al, 2016). Alcohol abuse leads to many social and personal problems
like; problems of health, disturbance in work life, poor family and social relationships,
separation and divorce and emotional hardship in the family. In India, it is estimated 3
million people who abused alcohol died in 2016 and consumption of alcohol has doubled
from 2005 (2.4 liters) to 2016 (5.7 liters) with 4.2 litres being consumed by men and 1.5 litre
by women. Alcoholism is attributed as a cause for 17 per cent of neuropsychiatric disorders
among men in India (Rehm et al, 2009). Alcohol use is typically initiated in adolescence
(Silveri et al, 2012), both for its positive and arousal effects and to conform with peers.
Religion (Mohanan et al., 2014) culture, family history of alcoholism (Warner et al

1
Consultant Psychiatric Social Work, District Mental Health Programe, Barabanki, (UP), India
2
Consultant Psychiatric Social Work, State Institute of Mental Health, PD BD Sharma University of Health
Sciences, Rohtak (Govt of Haryana), India
3
Professor, Department of Clinical Psychology, Ranchi Institute of Neuro-Psychiatry and Allied Sciences
(RINPAS), Kanke, Ranchi, (Govt of Jharkhand), India.
*Responding Author
Received: May 09, 2020; Revision Received: June 19, 2020; Accepted: June 25, 2020
© 2020, P. Prakash, P. Kumar & A. R. Singh; licensee IJIP. This is an Open Access Research distributed under the
terms of the Creative Commons Attribution License (www.creativecommons.org/licenses/by/2.0), which
permits unrestricted use, distribution, and reproduction in any Medium, provided the original work is properly
cited.
 Psychosocial theories of alcohol abuse: an understanding and its relevance

2007) and socio-economic factors (Pillai et al., 2014) all play an important role in initiation
and continuation of alcohol (Morean et al., 2014).

Recent literature has proposed many theories which combine different approaches in
themselves, therefore bio psychosocial theories gained importance. According to West
(2001) a classification of addiction theories could be made fewer than five headings. First
heading included broad theories on addiction conceptualization which includes biological,
social, psychological processes and combinations of these. West (2001) gave forty three
article references published till 1980 for this category. Second heading included theories
which examined the effects of certain stimulus that may be triggering addiction and this
cluster was more related with experimental psychology and neurobiology. Third heading
included theories focused on individual characteristics that made the person vulnerable to
addiction. Fourth set of theories focused on environmental and social conditions that
increase the risk for addiction for members of the society. Fifth group of theories involved
treatment and relapse issues which had links with the other four headings.

(I) Psychodynamic Perspective

In Classical Freudian Psychoanalysis, addiction was explained as an “oral fixation”. As per
this notion, individuals who have had the experience of a traumatic event in the oral stage of
development tend to develop pathological fixation at this stage (Ramos & Perkins,
2006).According to Hooper (1995), the main cause of the addiction syndrome is the
unconscious need to entertain and to enact various kinds of homosexual and perverse
fantasies and at the same time to avoid taking responsibility for this. It is hypothesized that
specific drugs facilitate specific fantasies and using drugs is considered to be a displacement
from, and a concomitant of, the compulsion to masturbate while entertaining homosexual
and perverse fantasies. The addiction syndrome is also hypothesized to be associated with
life trajectories that have occurred within the context of traumatogenic processes, the phases
of which include social, cultural and political factors, encapsulation, traumatophilia, and
masturbation as a form of self-soothing. Chafetz (1959) called it an “oral perversion”. Later
prospective studies showed that oral over activity in children did not precede alcoholism in
adulthood rather accompanied it (Ramos ,2004). When oral fixations occur, psychological
disorders related with the mouth area are expected. For example, smoking, alcohol
dependence or overeating can be because of oral fixation. On the other hand, Rado (1933)
stated that it is the person’s way of adaptation which is destructive to him. Addiction is a
way of aggressive acting-out behavior. Ego psychologists emerged in the 1970s. They
argued that addiction is a defect in the ego functions. This defect is thought to be rooted in
unresolved conflicts or failures to internalize parental functions in childhood
(Yalisove,1997). Freud was the first psychoanalyst who examined the roots of addiction in
his writings. In his paper “From Civilization and Its Discontents” (1929), he stated the
associations between happiness, pleasure, reality principle, and religion. Meanwhile, he also
mentioned addiction as a way which supplied happiness and helped in avoiding unhappiness
at the same time. As the person is liberated from the external world, immediate rush of
pleasure captures him/her. For Freud, while the person reaches an ultimate happy state far
from the external destructive mechanisms like society and human relations, this state
consumes too much of the person’s energy which could have been used for other purposes to
improve himself/herself (Yalisove,1997). On the other hand, Freud, himself, was an
antiquities collector and (Subkowski, 2006) thought that “collecting” was similar to
addiction in terms of finding and taking something for oneself to feel more complete in a
systematic way regularly and passionately. Additionally, the object of interest should be
something that has a depth or a culture behind it like alcohol culture.
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 Psychosocial theories of alcohol abuse: an understanding and its relevance

Collecting and addiction according to Abraham (1917) are symbolical gratifications of

repressed desires which occur because of transferring libido to an unlimited number of
objects (Subkowski, 2006). According to the psychoanalytical approach, addiction can also
be a result of “sublimation”. Sublimation is drawing the sexual energy, libido, from the id to
the ego, hence that the sexual energy is turned from inside onto an external, independent
object like alcohol. Gurol (2004) argued that addiction is a process of gaining and losing the
object of love. Hence, addiction occurs as a result of faulty object relations. The dependent
person seeks the drug or alcohol. He is relieved for a short period of time after consuming it.
Subsequently, the drug’s effect diminishes. The dependent person feels insecure and
ambivalent when the relief is lost. This kind of relation with the drug is experienced as a
result of severe infantile trauma according to the psychoanalysts. As a child, the dependent
person may have come face to face with an uncontrollable external object (probably an
inadequate care-taker). The child cannot internalize the mother’s love. Accordingly, the
child decides to externalize his mother’s love which is defined as an “externalization of
idealized object”. The child starts to fantasize that someone loves him/her but she/he is not
there at that moment. Since the inadequate mother takes care of the child from time to time,
the child tries to internalize his mother’s love. However, he cannot because the care of the
mother is not permanent. This type of relation with the mother is unsatisfying for the child’s
love. It is similar to the dependent’s relation with the drug in terms of the vicious circle
going around losing and gaining the object of love. Another characteristic observed in
dependent individuals is that their mothers are either extremely empathetic or lacking
empathy totally (Gurol ,2004). Winnicott calls it “good enough mother” for the woman who
is empathetic enough and not in an extreme way. While the mother satisfies the needs of her
child, the only tool in her hand is her empathy because the baby cannot express his feelings
or needs verbally. If she is overly empathetic, the child cannot learn how to satisfy his needs
by himself. If the mother is not empathetic at all, repetitive traumatic experiences may occur
for the child. Self-care capacity of a person is a determinant in addiction because if the
person did not learn how to do it in his/her childhood, she/he starts seeking external ways to
do it in adulthood. Ramos (2004) argued that the mother’s incapability to satisfy the baby to
an optimum degree leads to problems about narcissistic gratification in the baby which goes
on to the baby’s adulthood. However, studies about the mothers of alcoholics did not show
an extreme rate of problems between alcoholic patients in therapy and their mothers
retrospectively, rather a rate of problems similar to other patient populations was found. In
alcohol dependence, it was found in most of the studies on the etiology of addiction that a
father figure was missing which was thought to be causing a weak and fragile ego in
alcoholics (Ramos, 2004). As a result, many psychodynamic theories converge in some
points. These points are related with a dysfunctional ego and problems in gratification of
desires.

(II) Behavioral Perspective

Behavioural theories of psychology are based on the overt behavior which is observable and
measurable. One of the first theoreticians in behavioral psychology was Skinner who
considered addiction as the flaw of the society because the society cannot teach its members
appropriate ways of behaving and individuals do not learn alternative functional behaviors
because of lacking reinforcement (Thombs, 2006). There are two types of conditioning
which leads to learning. The first one is classical (Respondent/Pavlovian) conditioning. In
this type of conditioning, the reflexive respondent behavior is changed by pairing an
unconditional stimulus with a conditional stimulus. For example, the environment may be
the conditioned stimulus for the positive effects of alcohol like inhibition of introversion.
The dependent person thinks he/she can socialize or feel euphoric only in the place that
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 Psychosocial theories of alcohol abuse: an understanding and its relevance

she/he is used to drink. The person forgets how to socialize without alcohol, or during
occasions that no one drinks alcohol. Consequently, social skills are impaired. The second
type of conditioning is operant conditioning theory which was established by Skinner. In
operant conditioning, the behavior is not reflexive, rather it is voluntary. The behavior is
learnt by reinforcement or punishment occurring subsequently to it. Reinforcements are any
events that occur after the behavior so that the behavior’s occurrence increases in rate. In
opposition to reinforcement, punishment decreases the rate of the behavior (Thombs, 2006).
For example, the positive consequences of drinking alcohol like euphoria or increasing
sociability are positive reinforcements. There are also negative reinforcements which again
increase the rate of the behavior but by the disappearance of a negative event supplying
“relief”. For example, when the person quits alcohol, withdrawal symptoms occur. The
withdrawal symptoms are tremors, anxiety or craving for alcohol. Starting to drink again
supplies relief from the withdrawal symptoms, hence it is negatively reinforcing. If the
person quits drinking alcohol for a long period like one month, the body is detoxified. When
the person starts to drink again, the body cannot process large amounts of alcohol that it did
previously to quitting. Therefore, alcohol intoxication occurs. In terms of punishment, the
negative events occurring after alcohol intake like intoxication, getting sick in the stomach
or being bullied by friends decreases the probability of drinking one more time. Relapse
could be explained by operant conditioning too (Thombs, 2006). When the reinforcement is
removed from the environment, the behavior’s rate of occurrence declines. When the
behavior totally ceases, it is called extinction. Relapse is starting alcohol intake after the
behavior had ceased because of treatment and it could mean that the problem behavior did
not successfully and totally become extinct.

(III) Cognitive Perspective

Cognitive models refer to the link between our emotional states and our thoughts which
includes “expectancies”, “beliefs”, “schemas”, “automatic thoughts” and “thinking errors”.
In terms of cognitive theories, Bandura’s (1986) “social learning theory”, which is also
called “social cognitive theory” or “self-efficacy theory”, or “alcohol-expectancy theory” is
one of the most influential theory in this field. Goldman, Brown and Christiansen (Goldman
,1987) also explained addiction in terms of cognitive perspective. Until the appearance of
social cognitive theory, in psychology it was believed that the human being cannot control
his/her own thoughts or desires because psychoanalysts argued that the personality is shaped
in childhood. It is very difficult to change after childhood; additionally, desires are
controlled by the unconscious. Behaviorists argued that learning occurred by external
stimulus and stimulus interactions. On the contrary, social cognitive theorists found that a
person can learn a behavior just by observation which is called vicarious learning
(Bandura,1961).According to the vicarious learning paradigm, the person does not need to
receive direct reinforcement to learn a behavior; observing someone being reinforced is
enough. According to Bandura (1986) vicarious learning which is also called “modeling”
can occur in three ways. Firstly, it can be a result of “observational learning effects” on
behaviors that does not exist in the individual’s repertoire. Secondly, it can be a result of
“inhibitory-disinhibitory effects” that the individual wants to increase or decrease the rate of
occurrence. Thirdly, it can be a result of facilitation effects” on behaviors which existed in
the individual’s repertoire but have not been used until the observation of others doing it
(Thombs, 2006).

Bandura (1986) defined self-efficacy as “the conviction that one can successfully execute
the behavior required to produce the outcomes”. In terms of self-efficacy, it was found that
the efficacy beliefs of a person determined whether a person evaluates a problem as a
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 Psychosocial theories of alcohol abuse: an understanding and its relevance

challenge that he/she can transcend or as an obstacle on the way to happiness. When
perceived self-efficacy is high, the person deals with the problem better and when the
problem is over, the person becomes even stronger. High perceived self-efficacy was found
to be more prevalent in successful quitters in alcohol or drug dependence and in eating
disorders as well (Bandura,1999). In terms of addiction, self-efficacy is especially important
when physical dependence has been overcome. It can be said that the craving that occurs
after the physical dependence has diminished is purely psychological. These psychological
urges that induce relapse can be dealt with cognitive and behavioral self-regulatory
strategies only if the person evaluates these urges as under his/her own control (Bandura,
1999). For example, 40 million people have quit smoking and did not relapse. It does not
mean that they are living lives free of unhappiness; rather they are living lives that they view
as manageable and under control which is a result of high self-efficacy. According to
Bandura (1986) there are four sources of self-efficacy in daily life. Firstly, performance
accomplishments which are direct experiences to gain personal mastery are effective on self-
efficacy. Successes increase self-efficacy as much as failures decrease it. It is the most
powerful way of changing self-efficacy and it can be established by participant modeling
technique in therapy. Secondly, vicarious experiences influence self-efficacy which is a
result of seeing another person perform an act and watch the results of his/her behavior. It
can be achieved by modeling technique in therapy. Thirdly, verbal persuasion is a source of
self-efficacy development because suggestion is the most prevalent and easily available
technique but its effect ends when the person behaves accordingly and sees the results; it
turns into performance accomplishment. Fourth source is emotional arousal which affects
the efficacy perceptions in anxiety provoking situations; hence some methods aim to
decrease emotional arousal to overcome problem situations. In a study, Bandura (1986)
investigated perceived self-efficacy of patients who had snake phobia. Three treatment
conditions were compared in terms of initiation and persistence for treatment. The three
conditions were participant modeling, modeling and control. Participant modeling subjects
firstly watched the therapist performing the feared behaviors with the snake and then they
performed the same acts in a gradual manner. In the modeling condition, subjects only
watched the therapist perform the same feared graduated activities with the snake. The
control subjects did not receive any treatment; they only waited till the same time period
with the treatment conditions elapsed. As a result, self-efficacy was found to be a predictor
of successful task accomplishment in specific phobia treatment. Participant modeling
subjects as expected had highest self-efficacy expectations among three conditions, and they
had the best treatment outcome in three conditions. In addition, modeling condition which
corresponds to “vicarious experience” in social cognitive theory was found to be highly
predictive of approach behavior in phobic situations as much as subjects in the condition of
participant modeling. Recently, self-efficacy has been studied in addiction studies as
Prochaska and Norcross (2003) embedded it into their model as a construct which was found
to be related with the stages of change.

A study on self-efficacy of socially anxious college students showed that those socially
anxious participants with low self-efficacy reported more alcohol consumption than the
socially anxious individuals with higher self-efficacies. A recent study concluded that after
one year of treatment, individuals with higher self-efficacies showed greater reduction in
frequency of heavy drinking and drinking problems; in treatment of depression, impulsivity,
avoidance coping; in receiving social support; and they attended Alcohol Anonymous (AA)
meetings for longer durations than those with low self-efficacies (McK J et al, 2008).

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 Psychosocial theories of alcohol abuse: an understanding and its relevance

Another study focusing on self-efficacy in alcohol dependence found that the participants
who had higher self-efficacy resisted drinking regardless of the extent of risk situation they
faced for six months (Vielva&Iraurgi2001). In a study conducted upon Turkish university
students, Sonmez (2008) found that self-efficacy of the participants that attended the
smoking-cessation program significantly increased. On the other hand, the control group that
did not attend the program had significantly lower self-efficacy in the second assessment
which was in line with literature as in the time period between the first assessment and
second assessment, the control group participants may have lived unsuccessful occasions in
resisting smoking which is known to decrease smoking related self-efficacy.

(V) The Trans-theoretical Model of Change (TTM)

Prochaska and Norcross (2003) argue that most of the theories of psychotherapy lack
empirical support although they are rational, and findings show consistency for the placebo
effect caused by the researchers attention. In addition, the theories have usually focused on
the content of problem behaviors or personalities rather than the processes of change. The
eclectic approaches lack empiricism too because psychologists take some parts that “they”
think that are useful but they do not have a model when choosing what to apply from
different models of treatment (Prochaska, 2003).

Prochaska and Norcross (2003) built up a model of psychotherapy and behavior change that
would go beyond “the relativism of eclecticism through a commitment to creating a higher
order theory of psychotherapy that, in Werner’s terms, appreciates the unity and the
complexity of the enterprise”. In that sense, their theory is called the “trans-theoretical
model of change”. This theory has three core dimensions: Processes, Stages and Levels of
change.

Psychological theories involve associations between psychological factors and alcoholism in

individuals. One major difficulty with studies in this area is that psychological differences
between alcoholics and controls could as easily reflect the consequences of years of abusive
drinking as be their case
.
(VI) The following are some of the specific theories.
(a). Tension reduction Hypothesis.
A large number of investigations have been centered on the ability of alcohol to decrease
tensions. The purported effect of alcohol on tension as it might be related to alcoholism can
be broken down into two parts: the first part consists of the hypothesis that alcoholics, when
compared to controls, may have different baseline levels of anxiety and the second part
relates the possible effects that alcohol might have in differentially decreasing levels of
tension for alcoholics (Roebuck & Kessler,1972).

The stressful life events are reported to cause alcohol-related problems in alcoholics
(Morriserry&Schuckit,1978).The theory also stresses that alcohol helps them to relax after a
stressful day though very little data support a direct cause- effect relationship between
specific stressor and the onset of alcoholism. Thus, tension reduction hypothesis is still a
variable theory in explaining cause of alcoholism (Cappel& Herman, 1972).

(b.) Reinforcement theories.

Reinforcement theories are based on the premise that people begin drinking, drink
excessively or remain alcoholic because alcohol serves some useful purpose; that is, the
drinking behavior is awarded or reinforced. The reward could be the induction of
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 Psychosocial theories of alcohol abuse: an understanding and its relevance

pleasurable psychological change, the removal of discomfort (Conger,1956) or having other

enjoyable experience. Alcohol intake has been said to be a learned behavior resulting from
the need of youth to model or copy adult practices. Among purported positive reinforcing
properties are approval of peers, enhanced or altered social interactions (Nathan &Lisman,
1976), decreasing the pressure of a hard day and offering the chance to feel independent or
powerful (Roebuck, 1972).

(C.) Transactional theories.

Transactional theories assume that disordered level of communication may have been
responsible for both the initial development of alcohol intake and for alcoholism and that
these levels of communication become more disordered and almost self-perpetuating as
alcohol intake increases (Steiner, 1971). Steiner also stated that the consequences of being
drunk become a game in itself and might become self-reinforcing. According to this theory,
alcoholism is a style of interaction in which the individual and his family use drunkenness
and helplessness as an excuse for behavior. As a consequence, one unexpected result can be
the disintegration of the family interaction when the alcoholic stops drinking; new rules have
to be established for the family to survive as a unit (Ward & Faillace, 1970).

(d.) Personality theories

The general consensus of personality studies is that there is no one personality type that can
be measured as being necessary and sufficient for the development of alcoholism and the
range of personality types of alcoholics is not different from that found in the general. [46]

(e.) Excuse Theory

When people drink, they attribute some of their behavior to the effect of drinking, especially
if they might otherwise be blamed or criticized for misconduct while drinking. Being under
the influence of some drugs such as alcohol is widely accepted by others as social excuse
(MacAndrew & Edgorton, 1969).

(f.) Socio-Cultural Theories

Alcoholism has been found to be associated with socio-cultural factors. It is believed that on
a super /supra cultural level, alcoholism occurs in any society combining a lack of
indulgence of children with demanding attitudes toward achievement and a restrictive
posture toward dependent behavior in adults (Becon et al., 1974). Other culture specific and
sub cultural theories regard alcoholism as a result of downward social mobility, possibly
beginning before the problem drinking (Jones &Borland, 1975). This can result from an
inability of individual to participate in opportunities of the community, which might
generate frustrations and result in alcoholic patterns. Once alcoholism has begun, it is
possible that cultural factors help to determine the most prevalent type of problem drinking
(Ward & Faillace, 1970). It was also found that alcoholism often correlates with the degree
of cultural stress (Jones &Borland, 1975).

The concordance between alcoholism and crime on, between alcohol abuse and forms of
psychiatric illness has led the primary-versus-secondary alcoholism dichotomy and theories
on the importance of personality in alcoholism. Family history and twin data from
population have resulted in genetic hypothesis. No one cause for alcoholism is known. This
is at least in part, a result of the length of time between onset of drinking and the
development of alcoholism as well as that a number of different factors may be involved at
the same time. The theories are not mutually exclusive and are somewhat arbitrarily divided
into psychological theories, socio- cultural theories, constitutional theories (Roebuck &
© The International Journal of Indian Psychology, ISSN 2348-5396 (e)| ISSN: 2349-3429 (p) | 807
 Psychosocial theories of alcohol abuse: an understanding and its relevance

Kessler, 1972). There is no single, simple explanation for why some people abuse alcohol.
One of the central findings of the large body of research that has examined the psychosocial
causes of alcohol use is that there are multiple pathways to behavior that involves alcohol
consumption (Sher et al., 1997). Multiple biological and psychosocial factors mutually
influence each other in causing alcohol abuse; it would be incorrect to view psychosocial
causes as either independent from, or competing with, biological causes. Rather, alcohol use
and alcoholism are best viewed as end products of a combination of biopsychosocial
influences. Researchers face the challenge of explaining

CONCLUSION
Alcohol abuse alcoholism are fundamentally a behavior and most human behavior is a
learned behavior. This theoretical approach has helped us to understand how people learn to
engage in an unhealthy behavior and enables us to understand how people can unlearn a
behavior. This is also true that much of addictive behavior originates from thoughts and
beliefs. Another psychological reason of addiction is a person's developmental maturity.
Psychotherapy can be considered a form of accelerated development. Therefore, it can be
very helpful for people who are attempting to recover from alcoholism or other addictions.
The theoretical aspects have also helped professionals/academician to understand why
people find it so difficult to discontinue an unhealthy behavior like alcoholism. People may
find recovery difficult because they lack good problem-solving skills and sufficient
motivation. Alcoholism can also occur as a means of coping with uncomfortable feelings or
stress. Psychotherapy can help to strengthen people's motivation and to improve their
problem-solving skills, stress reduction skills, and coping skills. Lastly these psychosocial
theories of alcohol abuse can be utilized to identify and contextualize trends in major
treatment approaches for the people of alcohol abuse and also provide possible future
directions for research in that specific area.

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Acknowledgements
The author appreciates all those who participated in the study and helped to facilitate the
research process.

Conflict of Interest
The author declared no conflict of interest.

How to cite this article: P. Prakash, P. Kumar & A. R. Singh (2020). Psychosocial theories
of alcohol abuse: an understanding and its relevance. International Journal of Indian
Psychology, 8(2), 801-810. DIP:18.01.096/20200802, DOI:10.25215/0802.096

© The International Journal of Indian Psychology, ISSN 2348-5396 (e)| ISSN: 2349-3429 (p) | 810

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