The field of Clinical Psychology has advanced considerably in the last several decades.

From a field dominated in the early part of the century by nebulous and unsubstantiated theories of human behavior and psychotherapeutic techniques of questionable efficacy, clinical psychology has evolved into a discipline dominated by sound, empirically driven interventions.

At last psychology can join the table of other sciences, having demonstrated that its constructs can be operationalized, investigated and validated and that there are some therapy treatments that actually work!

To mention but a few recent advances; intricate scientifically based models of emotion which explain maladaptive mood disorders, treatments for depression and anxiety that focus primarily on peoples distorted thinking, behavioral parent training methods for impulsive children and extremely precise near-psychological assessment tools that can map out specific areas of brain damage.

One area which has experienced a great deal of research attention recently is substance abuse.

Over the last two decades our understanding of addiction has advanced tremendously. Some recent advancements include: assessment instruments which can help measure severity of substance abuse, individual antecedents for relapse and even level of motivation for change.

Other advances include new models of addictive behavior which take into consideration social learning, beliefs and memory as contributing to the vulnerability to addiction problems.

Further, research has provided evidence as to which treatments appear to be most effective for various levels of substance abuse severity.

Unfortunately (and quite curiously) most of the advancements in this area have not made it out of the Ivory tower.

There are volumes of research in this area, most of which are not applied in clinical settings.

This inequity has always ailed the field of psychology and in many ways appears to be singular to it. Research and clinical practice are often on opposite sides of the fence.

A medical analogy should drive home the significance of my point. Imagine a proven advancement in the treatment of Rheumatoid arthritis being published in the December issue of The Journal of the American Medical Association (JAMA).

Suppose that this article suggested that, based on a number of clinical trials, the new pharmacological treatment is considerably more effective than an existing treatment.

How long do you think that this new treatment would take to become a standard in care? My guess would be, if not the month of the issue, several months before!

It would be quite unacceptable for a physician to continue using a method that has been proven to be less effective than another, given the symptom picture.

In fact many would deem the behavior unethical and perhaps evidence of malpractice.

In the field of psychology things are much different. There has always been a vast separation of research and practical application.

If the practice of psychotherapy mirrored its own scientific knowledge base, things would be much different.

For example, therapists would no longer administer silly inkblot tests (given that there is no conclusive proof of their ability to detect anything), non-directive "play" as a model of therapy for children would not predominate and large hospitals would not be reimbursed by insurance companies for placing individuals with non-severe alcohol problems in intensive and expensive inpatient and "partial hospitalization" programs.

Thankfully, things are changing in some realms of psychology. For example, to not administer cognitive therapy to a depressed person, in lieu of another technique like long term non-directive psychodynamic therapy, would raise many eyebrows in the mental health field.

Without a doubt this technique has been supported by research to be the most effective psychotherapeutic intervention for unipolar non-psychotic depression.

However, the field of substance abuse treatment is lagging significantly.

The field of addiction has been dominated by a model that has not changed much since its beginning.

I am referring to the disease model and the 12-step model of recovery.

It has withstood the test of time, and for some unsettling reasons.

First a brief history of American Drinking:

Alcohol has been a part of American culture since its beginning. The meaning of drinking, however has undergone changes in the course of American history.

As Stanton Peele points out (Peele, 1989) in his sobering book, The Diseasing of America, Americans were not particularly concerned about alcohol problems in colonial times.

Rather, drinking alcohol was very much woven into people’s lifestyles. It was considered a part of normal life and was therefore considered healthy.

Most social gatherings included alcohol, even when children were present. This is not to say that drunkenness, with all of it's inappropriate behavioral referents did not occur., but it was conceptualized differently:

"Drunkenness was not so much seen as the cause of deviant social behavior--in particular crime and violence-as it was looked at as a sign that someone was willing to engage in such behavior." (p.36).

From the turn of the 18th century and into the third decade of the 19th century, there was a tremendous increase in the population and in industry.

The tight knit community and the tight knit family virtually disappeared. Taverns were no longer a place for family gathering; rather, the saloon was the place where the overworked American male went to get drunk and to gamble.

Violence was not uncommon. It was under these conditions that Americans became acutely aware of the effects of alcohol abuse. But rather than focusing on the social problems and inequities of the time, drink was blamed.

From the turn of the 18th and into the first half of the 19th century America’s population increased tremendously as did industry and lifestyle.

The tavern lost its place as the family gathering place, and the saloon replaced it. It became a place where primarily men went to get drunk after a tremendously dissatisfying day.

The American Temperance Movement was established around this time. This movement Promulgated the idea that alcohol was the root of all evils and pushed abstinence as the only cure. The movement was quite effective, about 1 million drinkers quit.

Benjamin Rush, a physician (who incidentally signed the Declaration of Independence), advocated the temperance movement and was the first to take a stance on the idea that chronic drinking was a disease. It should be added that his stance was based on a personal conviction as opposed to scientific evidence.

The temperance ideology was not the same as today's disease model. Temperance mentality suggested that everyone should abstain from alcohol because the substance is inherently poisonous. Everyone, according to this doctrine, could develop the disease of alcoholism.

As Peele points out, the key element was the same as current ideology however, "loss of control", that the alcoholic, in the throes of the disease is helpless and incapable of making rational decisions. The only cure was a religious conversion that led the drinker to swear that he would never drink again.

Following the Civil war, the temperance movement became tremendously invested in the prohibition of alcoholic beverages. Prohibition went into effect in 1920. During these thirteen years, cirrhosis deaths and all alcohol-related fatalities dropped for the nation.

The negative effects of prohibition, in addition to all of the opportunistic crime it created, were that distilled spirits replaced beer and wine as most popular drinks because they were more concentrated and easier to smuggle.

Families didn't drink together, and food was not served with alcohol. The whole point of going out to drink was to get drunk. (See J.P. Morgan, M.D for a chilling account of the ill effects of prohibition, past and present).

Needless to say, Prohibition failed to clean up America and was repealed in 1933.

Two years later, AA was created by Bill Wilson, a stockbroker and Robert Smith, a physician. The proposition was that the alcoholic is unable to control his or her drinking and that only through the support and help of other alcoholics could he keep from spiraling into the insidious disease which would inevitably lead to death if allowed to continue "untreated".

What made AA philosophy different from Temperance philosophy is that it claimed that alcoholics were a special group who had an inherited allergy and that alcoholism was a lifetime condition (this explains why those in AA consider themselves "recovering" even with 10 or 25 years of sobriety!

Elvin Jellinek M.D., using pseudo-scientific methodology, endorsed the disease model, and by the 1940's alcohol as a sickness was the law of the land.

From longer article at http://www.habitsmart.com/stifle.html