romance, realism and the future of alcohol intervention systems

We publish below a series of invited commentaries on theeditorial by Humphreys & Tucker, together with a reply by theauthors.

RESPONSIVE INTERVENTIONS NEEDRESPONSIBLE FUNDING

This insightful editorial (Humphreys & Tucker 2002) presents the current state of the art in alcohol treatment.It does so within a coherent guiding theoretical frame-work. The authors recognize client motivation and extra-therapeutic, environmental forces as crucial forrecovery. An integrated therapy focused on the individualand using as many types of interventions as possible has been shown to be the most effective approach when dealing with alcohol problems. The suggestedmodels of stepped care, outpatient counselling andextended case managing are certainly well worth trying.However, ‘responsive’ interventions need responsiblefunding in order to be realistic. Institutional downsizingand staff burn-out are unfortunately the realities in most places today.

Humphreys & Tucker are right that caring for diversepopulations and cultural groups is often missing in prac-tice. Working populations may be an especially importanttarget, because employment situations can provide someof the most potentially rewarding areas for intervention.A growing body of research indicates that as work prob-lems increase there may be a decline in health, family stability and community cohesiveness, while at the sametime there is an increase in alcohol and drug addiction,aggression and delinquency (Greenberg & Grunberg1995; Bourdieu et al. 1999). On the other hand, people inhigher socio-economic groups may escape the conse-quences of heavy drinking more easily. For example, theymay have access to better medical care or to more socialsupport, which may help them to quit drinking after thefirst symptoms of disease (Mäkelä 1999).

I agree with the authors that researchers shoulddevote more attention to natural recovery and to patternsof informal help-seeking. Long observation periods areneeded because alcohol effects and behavior change areoften slow (Dufour 1996). Evidence from the Lundbystudy, with a naturalistic, longitudinal design, supportsthis view. The main reasons for recovery were social stabi-

lization (84%), treatment (58%), family and peer pressure(58%) and medical complications (33%). The differentcauses were probably interactive over time—detoxifica-tion, motivation for change, therapeutic interventionsand an improved life situation (Öjesjö 2000; Öjesjö et al.2000). More studies of this kind would be welcome for validation and for international comparisons.

LEIF ÖJESJÖDepartment of Clinical NeuroscienceMagnus Huss ClinicKarolinska InstituteStockholm S-117 76SwedenE-mail: [email protected]

References

Bourdieu, P., Accardo, A., Balazs, G., Beaud, S., Bonvin, F.,Bourdieu, E., Bourgois, P., Broccolichi, S., Champagne, P.,Christin, R., Faguer, J.-P., Garcia, S., Lenoir, R., Aeuvrard, F.,Pialoux, M., Pinto, L., Podalydés, D., Sayad, A., Soulié, C. & Wacquant, L. (1999) The Weight of the World: Social Sufferingin Contemporary Society. Oxford: Polity Press.

Dufour, M. (1996) Risks and benefits of alcohol use over the lifespan. Alcohol World: Health and Research, 20, 145–151.

Greenberg, E. S. & Grunberg, L. (1995) Alienation and problemalcohol behavior. Journal of Health and Social Behaviour, 36,83–102.

Humphreys, K. & Tucker, J. A. (2002) Toward more responsiveand effective intervention systems for alcohol-related problems. Addiction, 97, 126–132.

Mäkelä, P. (1999) Views into studies of differences in drinkinghabits and alcohol problems between sociodemographicgroups. Contemporary Drug Problems, 26, 633–651.

Öjesjö, L. (2000) The recovery from alcohol problems over the life course. The Lundby Longitudinal Cohort, Sweden.Alcohol, 22, 1–5.

Öjesjö, L., Hagnell, O. & Otterbeck, L. (2000) The course ofalcoholism among men in the Lundby longitudinal study,Sweden. Journal of Studies on Alcohol, 61, 320–322.

TREATMENT SERVICES FOR DRINKINGPROBLEMS: HIDDEN QUESTIONS

The medicalization of alcohol problems that progressedover the latter half of the last century has broughtnumerous benefits both for those suffering from theseproblems and for those affected directly and indirectly.

© 2002 Society for the Study of Addiction to Alcohol and Other Drugs Addiction, 97, 133–140

Commentaries

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Prosecution was replaced by medical treatment, repres-sion by care, social exclusion by hopes of re-integration.

However, medicalization also had its adverse conse-quences. It led to individualization of alcohol problems,to neglecting their environmental and societal determi-nants, to legitimize alcohol production and trade as eco-nomic activities that do not require particular control.Moreover, in many countries public spending on alcoholtreatment grew exponentially, contributing to the crisisof the welfare state. Alcohol control policies, which werepromoted since the mid-1970s as an efficient responsereducing the number of alcohol-related problems, arelosing ground in a climate of economic freedom and globalization (Moskalewicz 2001).

Attempts to invent new, more effective treatmentsshould be seen and discussed in this ideological con-text rather than be reduced to technical innovations ‘that are better supported empirically’ (Humphreys &Tucker 2002). Otherwise, traps and drawbacks that areinherent in virtually all new or old policies are camou-flaged and rational choices cannot be made, either byindividual clients or by policy-makers.

‘Extensity’ of service provision, which is postulated byHumphreys and Tucker (2002), has its advantages: itscost per one intervention is low, a number of clients pertime unit—higher, continuous care—provided. On theother hand, this approach is very likely to produce moreand more chronic clients heavily dependent on particu-lar services. Is it not a repetition of the revolving-doorconstruct? With a new ideology, which is less frustratingto the staff and in fact offers more job security to careproviders? In purely economic terms, ‘extensity’ mayimply higher efficacy per each budget year but increasingnumber of clients and higher overall costs in a course ofseveral years.

A plausible solution to overcome this economic barrierof the cost of prolonged services is to link treatment withself-help movements that can offer extensive and continu-ous care at very low cost or without any public funds beingabsorbed. Too strong a link, however, is very likely todeprive self-help activities of their advantage of being in-dependent. Moreover, participation in self-help groups isnot attractive for the majority of those who meet relevantcriteria, and it may lead to the marginalization of people inghettos of comrades with similar life histories.

My comments should not be seen as critical of thisparticular editorial. It is an excellent paper that offers avery tempting vision of a more responsive and effectiveintervention system. I was more than enthusiastic whilereading its section on implications for the interventionresearch agenda. However, I dare to use the opportunityof commenting on it to postulate that most of our policy-oriented choices and recommendations should not belegitimized by science and empirical evidence only. We

should be aware of the values and interests involved as well as the potential adverse consequences of any proposed solutions.

JACEK MOSKALEWICZInstitute of Psychiatry and NeurologySobieskiego 902–957 WarsawPoland E-mail: [email protected]

References

Humphreys, K. & Tucker, J. A. (2002) Toward more respon-sive and effective intervention systems for alcohol-related problems. Addiction, 97, 126–132.

Makela, K., Arminen, I., Bloomfield, K., Eisenbach-Stangl, I.,Helmersson Bergmark, K., Kurube, N., Mariolini, N.,Olafsdottir, H., Peterson, J. H., Phillips, M., Rehm, J., Room, R.,Rosenqvist, P., Rosovsky, H., Stenius, K., Swiatkiewicz, G.,Woronowicz, B. & Zielinski, A. (1996) Alcoholics Anonymousas a Self-help Movement. A study in Eight Societies. Madison:University of Wisconsin Press.

Moskalewicz, J. (2001) Alcohol policy as a public issue.Reconsidering an old concept and its relevance for mentalhealth. Epidemiologia e Psychiatria Sociale, 10, 71–76.

ASK THE RIGHT QUESTIONS ANDMAKE GOOD USE OF THE ANSWERS: ARESPONSE TO HUMPHREYS & TUCKER

Humphreys & Tucker (2002) raise provocative issues thatshould stimulate a long-overdue debate on the directionof future research. Quite correctly, they observe thatalcohol treatment systems have traditionally concen-trated more resources on a relatively small number ofalcohol-dependent people, giving less attention to themuch larger number of problem drinkers who actuallycontribute a bigger share of society’s alcohol-relatedharm (see Kreitman 1986 for a similar argument in theprevention field). Recently, however, the alcohol researchand treatment communities have begun to focus on this latter group, sometimes with notable success. Forexample, brief interventions have yielded significantreductions in alcohol use and related consequences withnon-dependent drinkers in primary care medical settings(e.g. Fleming et al. 1997, 1999) and in emergencymedical settings (e.g. Gentilello et al. 1999; Monti et al.1999). Nevertheless, for the most part such efforts havebeen unsystematic. In fact, although the alcohol treat-ment system has changed dramatically in the decadesince publication of Broadening the Base of Treatment forAlcohol Problems [Institute of Medicine (IOM) 1990],these shifts may have been more the result of economic,structural and organizational factors than of the IOM’scall for change.

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We predict that enduring improvements to the alcoholtreatment system will come from two sources: an expan-sion of the types of research questions that are examinedand a systematic process of adopting research findingsinto clinical practice.

Expansion of services research

As Humphreys & Tucker (2002) point out, servicesresearch needs to expand its scope. For example, treat-ment research has often focused on how well patientsrespond to the requirements of the treatment protocol(i.e. compliance). However, services research must alsoassess how well the treatment system fits the needs of thepatients for whom it is intended (e.g. comprehensiveness,system integration, length). In a similar vein, treatmentretention often is attributed to patient characteristicsand, more specifically, lack of retention ascribed to per-sonal inadequacies. In spite of this, it is probable thatretention also reflects the appropriateness of the particu-lar set of treatment services offered to the prospectiveuser.

We will also need to think more creatively about ourresearch methods. Failure to replicate promising clinicaland laboratory research findings in field settings cansometimes be traced to misapplied research designs orother methodological shortcomings (Perl, Dennis &Huebner 2000). Designs that maximize external validityare especially important in studying treatment in appliedsettings. Similarly, conducting services research overlonger timeframes (i.e. treatment careers) and acrossdiverse populations, settings and systems should lead usto consider a broader pool of designs that are better ableto answer specific research questions (Dennis et al. 2000).

We pause here to note that Humphreys & Tucker(2002) recommend a number of specific changes intreatment practice. The most striking feature of this listis that it can scarcely be gainsaid; does anyone seriouslyargue that treatment should not be more accessible, moreappealing and more diverse? From this, however, arisesthe question, ‘Why haven’t these eminently reasonableimprovements been made?’ One answer is that they aretoo expensive—or they may seem to be. This in turn sug-gests that research on the costs and cost-effectiveness oftreatment services should stand high on any list of futurepriorities. Credible knowledge on the cost and value oftreatment is essential to inform health and social policy.

Adoption of research findings

The difficulty in translating scientific findings intoapplied practice settings is a critical barrier to reducingalcohol-related problems. Research results are not trans-mitted routinely to providers. By the same token,providers’ views on the research questions most useful to

their needs are seldom conveyed to investigators. The seri-ousness of this two-way communication gap has beenthe subject of a recent IOM report (Lamb, Greenlick &McCarty 1998) and at least one paper by an independentobserver (Brown 2000), as well as a notable element instrategic plans issued by the National Institute onAlcohol Abuse and Alcoholism (NIAAA 1997) and theCenter for Substance Abuse Treatment (CSAT 2000).Advances in the alcohol field will require major improve-ments in the flow of communication in both directions.From our vantage point, a substantial share of thisburden falls on the research community. Researchersmust seek out actively the sense of research prioritiesheld by providers. Similarly, they must learn how toconvey findings in formats that effectively reach serviceproviders and policymakers.

We therefore conclude with the hope that investiga-tors, practitioners, policy-makers and all others with aninterest in solving alcohol problems will begin to askmore of the right questions and then have the wisdom tomake better use of the answers that follow.

HAROLD I. PERL & MICHAEL E. HILTONHealth Services Research BranchNational Institute on Alcohol Abuse and Alcoholism6000 Executive BlvdSuite 505, MSC 7003Bethesda, MD 20892–7003USAE-mail: [email protected]

References

Brown, B. S. (2000) From research to practice: the bridge is outand the water’s rising. In: Levy JA, Stephens RC & McBride DC,eds. Advances in Medical Sociology 7, pp. 345–365. Greenwich,CT: JAI Press.

Center for Substance Abuse Treatment (CSAT) (2000) Im-proving Substance Abuse Treatment:: the National Treatment PlanInitiative. DHHS Publication no. (SMA) 00–3479. Rockville,MD: Center for Substance Abuse Treatment, Substance Abuseand Mental Health Services Administration.

Dennis, M. J., Perl, H. I., Huebner, R. B. & McLellan, A. T. (2000)Twenty-five strategies for improving the design, implementa-tion and analysis of health services research related to alcoholand other drug abuse treatment. Addiction, 95, S281–S308.

Fleming, M. F., Barry, K. L., Manwell, L. B., Johnson, K. &London, R. (1997) Brief physician advice for problem alcoholdrinkers: a randomized controlled trial in community-basedprimary care practices. Journal of the American MedicalAssociation, 277, 1039–1045.

Fleming, M. F., Manwell, L. B., Barry, K. L., Adams, W. &Stauffacher, E. A. (1999) Brief physician advice for alcoholproblems in older adults: a randomized community-basedtrial. Journal of Family Practice, 48, 378–384.

Gentilello, L. M., Rivara, F. P., Donovan, D. M., Jurkovich, G. J.,Daranciang, E., Dunn, C. W., Villaveces, A., Copass, M. & Ries,R. R. (1999) Alcohol interventions in a trauma center as a

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means of reducing the risk of injury recurrence. Annals ofSurgery, 230, 473–480.

Humphreys, K. & Tucker, J. A. (2002) Toward more responsiveand effective intervention systems for alcohol-related problems. Addiction, 97, 126–132.

Institute of Medicine (IOM) (1990) Broadening the Base ofTreatment for Alcohol Problems. Washington, DC: NationalAcademy Press.

Kreitman, N. (1986) Alcohol consumption and the preventiveparadox. British Journal of Addiction, 81, 353–363.

Lamb, S., Greenlick, M. R. & McCarty. D., eds (1998) Bridging theGap Between Practice and Research: Forging Partnerships withCommunity-Based Drug and Alcohol Treatment. Washington,DC: National Academy Press.

Monti, P. M., Colby, S. M., Barnett, N. P., Spirito, A., Rohsenow,D. J., Myers, M., Woolard, R. & Lewander, W. (1999) Briefintervention for harm reduction with alcohol-positive olderadolescents in a hospital emergency department. Journal ofConsulting and Clinical Psychology, 67, 989–994.

National Institute on Alcohol Abuse and Alcoholism (NIAAA)(1997) Improving the Delivery of Alcohol Treatment andPrevention Services: a National Plan for Alcohol Health ServicesResearch. NIH Publication no. 97–4223. Bethesda, MD:National Institute on Alcohol Abuse and Alcoholism,National Institutes of Health.

Perl, H. I., Dennis, M. J. & Huebner, R. B. (2000) State-of-the-artmethodologies in alcohol-related health services research.Addiction, 95, S275–S280.

STRIKING THE BALANCE BETWEENSCIENCE AND COMMON SENSE

About 20 years ago, Harold Mulford summoned thoseworking in the field of alcoholism treatment to liberatethemselves from the ideological convictions that at thattime fettered both professional and popular minds, and toconfide in their common sense (Mulford 1979, 1984,1988). By and large, his message was that people get intotrouble with alcohol in much the same way as they dowith many other activities and experiences, and thatsuch life-style problems can best be solved within thecontext of people’s own lives and with the help of preva-lent community resources (Blomqvist 1988).

Since then, much water has passed under the bridge.There has been a tremendous expansion of epidemi-ological and treatment outcome research and the traditional disease model has, in most contexts, beenreplaced by other paradigms. However, as demonstratedby Humphreys & Tucker (2000), this does not mean that the call for common sense in planning interven-tions for alcohol-related problems has become super-fluous. On the contrary, the oft-noted gap betweenresearch and practice prevails, even if today’s problemmay be less the uncritical adherence to a simplistic diseaseideology, than a widespread disregard of the many limita-tions in using conventional clinical trials and box-scorereviews as a basis for practice guidelines (Finney 2000).

I concur with most of what the authors have to say

about the need for professional helpers to take intoaccount the diversity of the help-seeking population, to‘meet clients where they are’, to adopt realistic goals, toconsider the time dimension of the change process, and topay attention to the role played by extra-therapeutic envi-ronmental forces. Indeed, at the present stage of knowl-edge in our field, delineating basic principles such as theseis a both safer and ethically sounder way of disseminatingresearch findings to those concerned, than are the ‘largeclaims’ scrutinized in an earlier volume of this journal(e.g. Winter 2000). Similarly, I could not agree more withthe appeal to researchers to expand their scope to include,e.g. the long-term dynamic of personal change processes,and problematic drinkers’ patterns of help seeking.

What may warrant further consideration, however, isthe issue of what could and should be subsumed withinan intervention system. Akin to the broad definition of‘treatment’ in the Institute of Medicine (IOM)’s originalreport (IOM 1990), the authors seem eager not to leaveanything out of their systems approach. However, thisambition may be fraught with some complications. Forexample, I think that we must take into account that vol-untary initiatives, as well as many other ‘natural’ reha-bilitative forces, may actually lose their authenticity, andthereby much of their effectiveness, if we try to incorpo-rate them in a formal treatment setting (Blomqvist1996). Moreover, if we take seriously what factors, suchas people’s social capital, life opportunities and supportfrom significant others, have been shown to mean to the prevention and solution of alcohol problems(Klingemann et al. 2001), the foremost implication mightbe that we need stronger social policies rather than moretreatment (Blomqvist 1998). After all, there is no formalintervention as ‘extensive’ as a personally fulfilling livingcontext.

However, as much as I would welcome further discus-sion of these remarks, they should not conceal the impor-tance of the editorial’s core message: that we need to useour common sense, not as a substitute for scholarlyempirical facts about treatment effectiveness, but to beable to understand what these facts mean to those whostruggle to overcome their alcohol problems—and tothose who try to assist them in this struggle.

JAN BLOMQVISTResearch and Development Unit (FoU)Social Services AdministrationSE 106 64 StockholmSwedenE-mail: [email protected]

References

Blomqvist, J. (1996) Paths to recovery from substance misuse:change of lifestyle and the role of treatment. Substance Use andMisuse, 31, 1807–1852.

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Blomqvist, J. (1998) Beyond Treatment? Widening the Approach toAlcohol Problems and Solutions. Stockholm Studies in SocialWork, 13. Stockholm: Stockholm University Department ofSocial Work.

Finney, J. W. (2000) Limitations in using existing alcohol treatment trials to develop practice guidelines. Addiction, 95,1491–1500.

Humphreys, K. & Tucker, J. A. (2002) Toward more responsiveand effective intervention systems for alcohol-related prob-lems. Addiction, 97, 126–132.

Institute of Medicine (IOM) (1990) Broadening the Base ofTreatment for Alcohol Problems. Washington, DC: NationalAcademy Press.

Klingemann, H., Sobell, L., Barker, J. & Blomqvist, J. (2001)Promoting self-change from problem substance use: practicalimplications for prevention, policy and treatment. Dordrecht:Kluwer Academic Publishers.

Mulford, H. (1979) Treating alcoholism versus accelerating thenatural recovery process: a cost-benefit comparison. Journal ofStudies on Alcohol, 40, 505–513.

Mulford, H. (1984) Rethinking the alcohol problem: a naturalprocesses model. Journal of Drug Issues, 14, 31–43.

Mulford, H. (1988) Enhancing the natural control of drinkingbehavior: catching up with common sense. ContemporaryDrug Problems, 15, 321–334.

Winter, K. (2000) Warning label: this treatment approach maycause claims of a magic cure. Addiction, 95, 1770.

SCRIBBLING IN THE MARGINS:COMMENTS ON HUMPHREYS & TUCKER

As one of the original cast of ‘Broadening the Base’, I ampleased to see that the version, indeed the vision, of alco-holism treatment that emerged from the Institute of Medicine (IOM) Committee is still alive and well in the musings of Keith Humphreys and Jalie Tucker(Humphreys & Tucker 2002). This is one of those paperswhere I find myself desperately searching for a pencil toscribble notes in the margins, excited that two thought-ful authors could say something to pique my interest,reinforce old prejudices and even stimulate new thoughtsabout an issue that has preoccupied many of us whowork in the margins of the disease concept.

My first scribbled note was written illegibly next to theheading, ‘Alcohol problems are environmentally respon-sive behavioral health problems’. It reads, ‘good idea, bad marketing potential’. The limitations of the diseaseconcept of alcoholism have been known for some time,and we should be constantly reminded of them. Thealternative (or perhaps complementary) view, neatlyarticulated in this essay, has enormous implications forthe design of interventions for people with alcohol prob-lems, be they medical, moral, social or psychological.Nevertheless, there is something in the sound of ‘diseaseconcept’ that seems to have captured the imagination ofmany diverse constituency groups, all of whom findsomething useful to achieve through its promotion.Could it be that alcoholismus chronicus caught on years

ago within the medical profession simply because doctorscould write it down in Latin? This absurd thought pro-voked my second scribble, ‘What’s the Latin trans-lation of environmentally responsive behavioral healthproblem?’

Next to the second section (‘Alcohol interventionsystems are often unresponsive to the full range of prob-lems, etc.’) my note reads: ‘The Cook’s Tour dilemma’. Bythis I mean that early identification, brief interventionand outpatient treatment do not attract professional andpolitical tourists the way that inpatient programs do. Asa career alcohologist, when I visit a foreign country I amoften given a Cook’s Tour of the local inpatient programby hosts and colleagues. Whether it was Hospital 17 inMoscow (6000 beds, 6-month minimum length of stay),the Nairobi psychiatric hospital alcohol unit, or HôpitalLouis Sevestre in France, I have been constantlyimpressed, like Humphreys & Tucker, with the concen-tration of scarce resources on the most difficult andintractable cases, to the virtual exclusion of other popu-lations and programs. But perhaps you need to create atourist attraction to generate interest before society andthe allied health professions will support less glamorousapproaches. It may be that the United States provides agood example of the evolution of treatment systems inmodern industrial societies, with resources first placedinto the management of the most severe cases, followedby a diversification of services and programs that even-tually reach larger and larger proportions of the affectedpopulation. Contrary to the characterization of thisapproach as dysfunctional, it may be a necessary part of a Hegelian dialectic that allows us to identify theextremes and work toward a more functional synthesiswithin a broad historical timeframe. One must alsorealize that the observations we make about our own fieldoften apply equally well to other areas of public health,and that the anomalies we see in conceptualization andservice provision are not unique to alcohology.

My next comment begins with the marginal question:‘Where is the environment?’ Even environmentalistssuch as Humphreys & Tucker can be guilty of ignoringthe environment. What I mean by this is that the social,cultural, economic and physical environment are not astatic given that exerts a constant effect on drinking prob-lems and alcohol consumption, but a set of causal influ-ences as complex and important as the treatment systemdesigned to deal with the human suffering inflicted byalcohol. Because the drinking environment is all aroundus, we tend to ignore it, but only at our peril. Downstreaminterventions such as alcoholism treatment programshave a compelling immediacy for practitioners and policymakers, even at the system level, compared to theupstream forces such as alcohol advertising and bingedrinking customs. They keep the focus on the disease and

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its treatment rather than the context and its lessons forprevention. What good are screening, early identifica-tion, telehealth and a complete array of intensive andextensive services if every incremental gain in populationhealth is countered by public policies and industry activ-ities that make alcohol more available, more appealingand more rewarding, especially to the young and the vul-nerable? One clause in GATT, liberalizing alcohol tradeand repositioning alcohol as an ordinary commodity, ismore influential than the feeble attempts at systems-building made by well-meaning and forward-lookingentities such as the IOM and WHO.

Would it not be wonderful if treatment on demand,access to a full spectrum of services and life-time casemanagement were all that are needed to drive down population rates of alcohol-related accidents, injuries,cirrhosis and fetal effects. The systems level approachdescribed by Humphreys & Tucker is certainly what isneeded as the next step in the historical evolution oforganized services. But we must ask ourselves whether itis also time for the scientists and practitioners who focusso much on the individual problems and the problems ofindividuals to adopt the mantra: alcohol problems areenvironmentally induced behavioral health problems. Assuggested by the authors, the extra-treatment environ-ment would be a good place to begin, not only throughassessment and research, but also through advocacy andappeals to equity. Once binge drinking and alcohol depen-dence become endemic in a society, it is legitimate to asknot only how can the treatment system be improved, butalso how can the drinking environment be changed, firstto shorten the problem drinking careers of those affectedby alcohol, next by preventing the onset of alcohol prob-lems in adolescents and young adults?

As for the authors’ admonition to shift the emphasisfrom ‘therapy-tinkering’ research to more population-oriented studies, I could not agree more. My notes herewere to confess a fear that the message in these words isa truth many of us would find difficult to face: academicshave too often been looking for the wrong things in thewrong place, in part because of the convenience of ourscientific tools and the methodological bias of our scien-tific training.

Unless we can find better ways to expand, replace, sup-plant or abolish the disease concept, which has provenremarkably immune to the relatively weak antidotes ofthe social and behavioral sciences, I am afraid that crea-tive musings such as those provided by Humphreys &Tucker will prove to be no more than scribbling in themargins of the disease concept. As our understanding ofalcohol problems matures, what we need is a shift inpublic awareness and policy orientation from the indi-vidual to the population, from disease states to problemrates, and from etiology to ecology.

THOMAS F. BABOR

Department of Community MedicineUniversity of ConnecticutFarmingtonCT 06030–632USA

Reference

Humphreys, K. & Tucker, J. A. (2002) Toward more respon-sive and effective intervention systems for alcohol-relatedproblems. Addiction, 97, 126–132.

ROMANCE, REALISM AND THE FUTUREOF ALCOHOL INTERVENTION SYSTEMS

The astute commentaries of our colleagues share twothemes. The first is that scientific knowledge is never the only force affecting alcohol intervention systems and may, on occasion, be a trivial one. Öjesjö (2002)notes that responsive systems need responsible fund-ing, Perl & Hilton (2002) argue that fiscal forces usually move systems more than do research findings,Blomqvist (2002) and Babor (2002) point out thatbroader social policy factors may affect societies’ alco-hol problems more than do treatment systems, andMoskalewicz (2002) describes the political and ideo-logical constraints on what intervention systems canaccomplish.

These concerns are undeniably realistic, and we have made similar points ourselves elsewhere(Humphreys & Rappaport 1993; Tucker 1999). However,as we indicated at the outset of our editorial, we deliber-ately presented an idealized vision based on what the scientific labor of our field would support. One might sayit was rather romantic of us to act as if scientific resultsshould have a place in social policy formation compara-ble to that of politics, ideology, and money. However,articulating such a vision unencumbered by politicalconcerns has inherent value because it gives all stake-holding groups a clearly stated, scientifically supportedagenda which they may embrace, reject or modify inintervention development, policy formulation and fund-ing decisions. We have no doubt that our colleagueswould agree that articulating in an unvarnished fashionwhat the scientific community knows is better than articulating only those scientific findings that would notrun counter to powerful cultural, political and economicforces.

The absence of significant disagreement with the substantive points of the editorial concerning inter-vention development and applied research directions is the second theme apparent in our colleagues’ com-

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ments. It is a considerable achievement for addictionresearch to have matured to a point that it supports acoherent perspective about alcohol problems and yields a set of consensus recommendations for interventionssystems in our often divided field. To the extent that principles and conclusions are widely shared, they offera practical map for infusing some scientific content andinfluence into decisions about alcohol interventionsystems.

That broad-level agreement noted, our colleaguesmake clear that certain specific points in our editorialmerit refinement, clarification, and further debate. Forexample, all of the commentators make useful caveatsabout our proposal for more extensity in intervention,including greater promotion of self-help group involve-ment. Blomqvist (2002) and Moskalewicz (2002)warned sagely of the potentially damaging effects of pro-fessional systems on self-help organizations and othervoluntary sector initiatives. Unfortunately, many helpingprofessionals think of non-professionals engaged insimilar activities not as potential collaborators, but assecond-rate helpers in need of consultation and control.This threatens the authenticity of voluntary initiatives(Blomqvist 2002) and risks turning them into sub-sidiaries of professional systems (Moskalewicz 2002). Ifour proposal is to succeed, the education and socializa-tion of addiction treatment professionals will have toincorporate more lessons from the growing literature onrespectful, productive collaboration between professionaland voluntary sector organizations (see, e.g. Powell1987).

In his witty commentary, Babor (2002) raises anotherconcern about extensive services, namely their lack ofglamor and marketability relative to the intensive inter-ventions which are currently showcased on ‘Cooks’Tours’. This observation applies to extensive interven-tions across a variety of public health problems (e.g.work-site wellness programs, safe highway design,chronic disease support groups). Such interventions lackthe visibility and drama of intensive interventionsaddressing more salient morbidity and mortality, eventhough the latter affect only a small segment of the population. As a result, intensive interventions maycommand more political and economic support andattract greater professional interest. The US health-caresystem illustrates repeatedly this well-known conun-drum, with its over-allocation of resources to high technology clinical medicine for the gravely ill and itsunder-allocation of resources for preventive care. Thus,the challenge of generating more interest in extensiveinterventions is not unique to the alcohol field, and wewould be wise to learn from the broader field of publichealth about how to address it better. We have some opti-mism about this possibility, because even though we

concede Babor’s chicken, we also know there is an egg:professional and public interest can be a product ofwhere a society invests intervention resources, as well asa cause of it. If societies invested more money in exten-sive interventions, the Cooks’ Tour might well includesome new stops.

Taking another tack, Blomqvist (2002) points outthat there is no more extensive intervention than a personally fulfilling life context; for example, a positiveemployment situation (cf. Öjesjö 2002) and satisfy-ing interpersonal relationships. Again, we are in agreement. Our proposal that intervention systems link patients to enduring, sobriety-supporting social contexts is obviously more workable to the extent that broader social policy makes such life contexts available.

The only comment with which we would differ signifi-cantly is Moskalewicz’s (2002) suggestion that extensiveinterventions may simply be a return to the revolving-door concept and that they may raise costs over time bycreating or adding to chronic patient populations.Regarding the former point, the ‘revolving-door’ conceptemanates from an intensive intervention approach (e.g.public psychiatric hospitals), in which patients receiveintensive services for short periods and are then dis-charged with little or no support in place, only to returnat a later point for more short-term intensive treatment.In extensive interventions, these extremes are softened,with treatment being less intense at its crest, moreintense at its trough and more persistent over time. Onthe second point, although only a few studies are avail-able, empirical work indicates that alcohol-related exten-sive interventions actually reduce health-care costs, inpart because they break the revolving-door cycle associ-ated with intensive service systems (Hilton et al. 2001;Humphreys & Moos 2001).

Moving beyond the comments about extensive inter-ventions to more general issues addressed in our edi-torial, we concur with Babor’s (2002) analysis of thecomplexity of understanding how drinking problems andtheir resolution are influenced by the environment,which we ‘tend to ignore, but only at our peril’ (p. ••).Addiction research (particularly in the US, seeHumphreys & Rappaport 1993) often ignores, mini-mizes, or oversimplifies environmental influences onalcohol problems. As Babor observes, environments arenot static influences on drinking practices and problems,but rather entail a complex, dynamic set of micro- andmacro- variables that range, for example, from personalsocial networks to treatment availability to alcohol adver-tising to international treaties concerning alcoholic beverage markets. Research aimed at understandinglocal environmental influences on drinking is growing,but we know little about macro-level environmental

140 Commentaries


influences, much less how they may interact withmicrolevel variables. The field of economics has wrestled with parallel distinctions between micro- andmacro-economic influences and therefore may offeraddiction researchers some useful guiding theory andresearch on these issues (see, e.g. Bickel & Vuchinich2000).

We close with an enthusiastic endorsement of Perl &Hilton’s proposals to make science matter more inshaping systems. They seem to share our romantic opti-mism of how science can be more than ‘scribblings in themargin’ (Babor 2002), and implementing their perfectlyrealistic suggestions for developing reciprocal learningrelationship between scientists, clinicians and policy-makers is an essential step for creating more responsiveand effective alcohol intervention systems.

Some academics would argue that Perl & Hilton’s(2002) proposal would take researchers outside theappropriate borders of their enterprise, and that scienceshould keep an arm’s length from applied concerns suchas technology transfer, policy-making and budget deci-sions. Our position, especially in light of the thoughtfulcomments of our colleagues, is that we can ill afford tosit on the sidelines in research areas that involve signifi-cant public health concerns such as alcohol-related prob-lems. To be effective, we must try to remain mindful aboutwhere policy formulation and political processes gainascendancy over scientific processes (which, of course,may contain a measure of political activity as well). It isin service of keeping these margins clear that our edi-torial is offered. We end by acknowledging the need forbehavioral scientists to extend our borders into theseother realms, but we urge them to do so with a vision ofthe landscape as articulated by the applied science firmlyin mind.

Acknowledgements

Manuscript preparation was supported by grantsAA11700 and AA00209 from the US National Instituteof Alcohol Abuse and Alcoholism, by the US Departmentof Veterans Affairs Mental Health Strategic HealthcareGroup and Health Services Research and DevelopmentService and by the Canadian Social Science andHumanities Research Council.

KEITH HUMPHREYS

Stanford University School of MedicineVAPAHCS (152-MPD)795 Willow RoadMenlo ParkCA 94025 USAE-mail: [email protected]

JALIE A. TUCKER

University of AlabamaBirmingham, AlabamaUSA

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romance, realism and the future of alcohol intervention systems

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