The NIAAA Website – A Critical Review

by Terence T. Gorski

720px-US-NIH-NIAAA-Logo.svgI have reprinted a section of the website of the National Institute of Alcohol Abuse and Alcoholism (NIAAA). In the past I have always been impressed by the up-to-date and in-depth information presented. I am sorry to report that my opinion has changed. As you read the information on the website below please note the following in mind:

1. There is no attempt to organize the information on alcoholism in a biopsychosocial framework, which is the current working standard for the field. (See: The Biopsychosocial Revolution http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495036/ )

2. The distinctions among alcohol use, abuse, and addiction (Alcoholism) is not clearly established. The operational definitions of these terms is implied but not made specific and related terms are not clear related to the current diagnostic language.

3. This summary is still based upon DSM-IV when the current standard is the DSM 5. (https://terrygorski.wordpress.com/2013/10/15/dsm-5-substance-use-disorders-a-concise-summary/ ) This is not a bad thing. I believe the DSM 5 is a step backward, at least in terms of understanding addiction and mirroring current research.

4. There is no reference made to the definition of addiction of the American Society of Addiction (ASAM), which is the most comprehensive integration of biopsychosocial research available. (http://www.asam.org/for-the-public/definition-of-addiction )

5. There is no reference made to the extension of the term “addiction” to include gambling in DSM 5 and its widespread applications in treatment to other compulsive problems know as Behavioral Addictions. (https://terrygorski.wordpress.com/2013/10/15/dsm-5-substance-use-disorders-a-concise-summary/ )

6. There is no reference made to the level of care system of ASAM. (See: http://www.samhsa.gov/co-occurring/topics/screening-and-assessment/ASAMPatientPlacementCriteriaOverview5-05.pdf and http://www.ncdhhs.gov/dma/lme/UMASAM.pdf )

7. There is no discussion of the treatment provisions of the Affordable Care Act (ACA) which will economically shape the next decade of treatment develop for Alcoholism (if that is the correct term to be used), chemical dependence, chemical addictions.(See: http://www.samhsa.gov/SAMHSANewsletter/Volume_18_Number_3/AffordableHealthCareAct.aspx and http://beta.samhsa.gov/health-reform )

8. There is no reference made to move toward evidence-based treatment. (http://www.nrepp.samhsa.gov) Again, this is not necessarily a bad thing. Some of the most effective treatment methods like active listening and helping characteristics are not evidence-based. One of the most important research-based finding is ignored. That is that the most important single factor in all psychotherapy is the relationship between the patient and the therapist. Manualized treatment, when based upon this foundation and allowing clinicians freedom to respond in the moment to emerging patient needs, is then an improvement.

For non-nonsense clarification of these issues you can read: Straight Talk about Addiction by Terence T. Gorski.

I am seriously concerned because without strong leadership from the NIAAA and its parent organizations, The National Institute Of Health (NIH) and The Substance Abuse and Mental Health Services Administration (SAMHSA), the entire framework if addiction as we know it today is at risk of being lost. The addiction field has already been absorbed behavioral health, a code word for mental health, and is now being pushed into general health care under the ACA.

If you are feeling confused you are not alone. I don’t feel confident that the guidance being given by the highest levels of our government is current or reliable in the area of addiction, recovery, relapse, or comprehensive treatment.

GORSKI BOOKS – GORSKI TRAINING/CONSULTATION
LIVE SOBER – BE RESPONSIBLE – LIVE FREE

Below is the information in the NIAAA website. Read it on the Internet at: http://www.niaaa.nih.gov/alcohol-health

Alcohol Use Disorders 

Alcohol use disorders are medical conditions that doctors can diagnose when a patient’s drinking causes distress or harm. In the United States, about 18 million people have an alcohol use disorder, classified as either alcohol dependence—perhaps better known as alcoholism—or alcohol abuse.

Alcoholism, the more serious of the disorders, is a disease that includes symptoms such as:

Craving—A strong need, or urge, to drink.

Loss of control—Not being able to stop drinking once drinking has begun.

Physical dependence—Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety after stopping drinking.

Tolerance—The need to drink greater amounts of alcohol to feel the same effect.

People who are alcoholic often will spend a great deal of their time drinking, making sure they can get alcohol, and recovering from alcohol’s effects, often at the expense of other activities and responsibilities.

Although people who abuse alcohol are not physically dependent, they still have a serious disorder. They may not fulfill responsibilities at home, work, or school because of their drinking. They may also put themselves in dangerous situations (like driving under the influence) or have legal or social problems (such as arrests or arguments with family members) due to their drinking.*

Like many other diseases, alcoholism is typically considered chronic, meaning that it lasts a person’s lifetime. However, we continue to learn more and more about alcohol abuse and alcoholism; and what we’re learning is changing our perceptions of the disease. For instance, data from NIAAA’s National Epidemiological Study on Alcohol and Related Conditions has shown that more than 70 percent of people who develop alcohol dependence have a single episode that lasts on average 3 or 4 years. Data from the same survey also show that many people who seek formal treatment are able to remain alcohol free, and many others recover without formal treatment.

However severe the problem may seem, many people with an alcohol use disorder can benefit from treatment. Talk with your doctor to determine the best course of action for you.

Addendum: December 4, 2013

The following comment was submitted by linda.lakecalm@gmail.com and I wanted to share it in the body of the blog. Thank you Linda.

Thanks Terry for the review. The links were useful. In the spirit of pointing out some of the inconsistencies between agencies and definitions, I was a little surprised to see the definition of addiction on the ASAM site:

“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations.”

It didn’t seem like the ASAM definition was entirely consistent with the biopsychosocial framework. I looked further for how ASAM defined spiritual as an additional component to the biopsychosocial framework. ASAM says:

“Other factors that can contribute to the appearance of addiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include: [below are the two manifestations that seem to relate to spiritual]

f. Distortion in meaning, purpose and values that guide attitudes, thinking and behavior;
g. Distortions in a person’s connection with self, with others and with the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others)”

ASAM goes on to say:

“The diagnosis of addiction requires a comprehensive biological, psychological, social and spiritual assessment by a trained and certified professional.”

Perhaps a disconnection from God may be part of the addiction manifestation, but in light of the recent court rulings on separation of church and state, is this the proper role for an addiction counsellor who may be acting in the role of “agent” of the government with criminal or family court ordered patients? I don’t know quite what the answer is, but if disconnection from God is part of the disease, then perhaps there’s some other way to do the religious assessment than having the counsellor ask questions or probe into and document the patient’s relationship with God. If the counsellor is in the “agent” role this could create issues of mixing in a religious assessment, Or, a waiver from the patient for the religious part of the assessment that involves a relationship with God might be a good protection for the counsellor,

And perhaps I misunderstood how assessments are done, but I felt it was worth mentioning in the effort to align with how government or “agents” of the government shouldn’t be involved in religion.

GORSKI BOOKSGORSKI TRAINING/CONSULTATION

LIVE SOBER – BE RESPONSIBLE – LIVE FREE

8 Responses to The NIAAA Website – A Critical Review

  1. Linda R says:

    Thanks Terry for the review. The links were useful. In the spirit of pointing out some of the inconsistencies between agencies and definitions, I was a little surprised to see the definition of addiction on the ASAM site:

    “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations.”

    It didn’t seem like the ASAM definition was entirely consistent with the biopsychosocial framework. I looked further for how ASAM defined spiritual as an additional component to the biopsychosocial framework. ASAM says:

    “Other factors that can contribute to the appearance of addiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include: [below are the two manifestations that seem to relate to spiritual]

    f. Distortion in meaning, purpose and values that guide attitudes, thinking and behavior;
    g. Distortions in a person’s connection with self, with others and with the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others)”

    ASAM goes on to say:

    “The diagnosis of addiction requires a comprehensive biological, psychological, social and spiritual assessment by a trained and certified professional.”

    Perhaps a disconnection from God may be part of the addiction manifestation, but in light of the recent court rulings on separation of church and state, is this the proper role for an addiction counsellor who may be acting in the role of “agent” of the government with criminal or family court ordered patients? I don’t know quite what the answer is, but if disconnection from God is part of the disease, then perhaps there’s some other way to do the religious assessment than having the counsellor ask questions or probe into and document the patient’s relationship with God. If the counsellor is in the “agent” role this could create issues of mixing in a religious assessment, Or, a waiver from the patient for the religious part of the assessment that involves relationship with God might be a good protection for the counsellor,

    And perhaps I misunderstood how assessments are done, but I felt it was worth mentioning in the effort to align with how government or “agents” of the government shouldn’t be involved in religion.

    • Terry Gorski says:

      This is an excellent comment.I am proud to have it associated with this bog. As to your questions about the supreme court decisions and the definition of the 12-Steps as being religious in nature I refer you to an extensive blog I have written about this. https://terrygorski.wordpress.com/2013/10/21/is-a-a-legally-a-religion/
      My understanding is that there is freedom of speech that applies to professionals as well as anyone else. The issue of discussing spirituality with a client is protected by free speech. If the program the counselor works for is funded by the USA government, which most are going to be directly or directly, the only restriction is to be sure patients are advised of secular support group opportunities and secular approaches to treatment. There is no prohibition from discussing or referring or exploring the benefits or disadvantages of any spiritual or religious program as long as patients are not told this is the only approach. This is especially true of noncompliance with a recommendation will have adverse legal consequences.
      The way ASAM describes spiritually, in my opinion, is very ethical and legal.
      I am more concerned about consolers who do not have adequate education in comparative religions and the psychology of religion playing minister and discussing their personal opinions of God and religion as if it were “spiritual truth.” This applies to all traditional and new age / new thought religions like The Secret. This, however, is just my personal opinion and would be an issue of professional ethics and not of law. My understanding is the statements of professional ethics do not cover this issue specifically and it is probably a good thing. There are too many people regulating too much about the way people should think or believe. It is beginning to make free and open debate difficult.

  2. Linda R says:

    Terry, I agree that a counsellor playing minister is a concern. Especially without adequate training. I think that you’re right too about discussions of faith being covered by free speech and would be entirely appropriate when a client feels this is a concern related to their treatment and wants to discuss it. This would be no different than any therapy session for any other DSM type of malady, where the discussion of faith might be relevant.

    The thing that bothered me somewhat about the ASAM diagnosis of addiction was that evaluating the faith and connection to God of the person being assessed seems like it is a required part of the assessment. This is likely not a problem if the person being assessed is willing to be asked questions about faith, but perhaps not in the situation where they are court ordered for an assessment, and don’t want to discuss their religious beliefs. Again, I’m perhaps missing the mark on how this “spiritual assessment” is actually done during the diagnosis of addiction. And yes, informing the patient of the different options for a treatment program should include all options, as you point out.

    I too thought the ASAM definition of spirituality was ethical and legal. My main reason for pointing it out was that in adding spirituality to its framework, ASAM’s definition of addiction seemed inconsistent with the biopsychosocial framework. Apart from providing a category to allow assessing the patient’s faith, there doesn’t appear to me to be a rationale for having this extra category. To me, the other aspects of ASAM’s definition (meaning, purpose and values that guide attitudes, thinking and behavior; and distortions in a person’s connection with self and with others) seem like they are a part of the psychosocial, rather than part of a special, separate spiritual category. This, however, is just my personal opinion, and perhaps there are sound medical reasons for ASAM to define addiction with a special spiritual category and differentiate it from all other biopsychosocial diseases.

    • Terry Gorski says:

      Linda, I personally and professionally understand spirituality in the sense of Ancient Greek Philosophy: “Man is composed of both the physical and the nonphysical. The nonphysical is know as spiritual.”
      I personally believe human being consist of more than the physical brain and also pissed a nonphysical mind that inhabits and, within limits can shape the direction of brain growth and change.
      It is the mind that allow us to transcend or rise above or move through situations that should make us run, fight or freeze.
      Meaning and purpose feed and direct the mind and manifest in free will.
      Deism is difficult for me.
      I see many fundamentalist athiests as

  3. Linda R says:

    Hi Terry, this is a good discussion and I appreciate your taking the time to try to sort through some of the confusing aspects of these issues. The way I see faith is very similar to the 2007 Pew Report:

    Conception of God – Total U.S. Population
    ——————————————————-
    60% personal God
    25% impersonal force
    7% other conception of God
    8% no conception of God
    —–
    100% total

    These percentages seem to correspond to how I hear people talk about God. The majority of people (60%) talk about a personal God who responds to prayer. A significant percentage (25%) have a conception of God as an impersonal force and they do not engage in prayer. I characterize these as the folk who generally believe creation was set in motion by God and God’s continuous creation is through natural laws and mechanisms such as evolution (Theistic Evolution.) The beliefs of this group can cover a wide range of beliefs about the extent of any intervention by God, with some approaching deism in rejecting continued intervention, whereas others see intervention at critical intervals in history.

    There seem to be a certain number of people (7%) who have various beliefs that seem to defy any type of singleness of grouping or categorization, but don’t characterize themselves as believing in a personal God or a single impersonal force. Many of these folks could fall into the categories of Wiccans, Pagans, New Age, etc. Finally, there’s the group (8%) who don’t have a conception of God. Typically, these folks are called atheists.

    I guess my concern with the Twelve Step Program is that it’s doctrines (Big Book and 12 & 12) per the objective and through examination by the judicial system “unmistakably urges that the path to staying sober and to becoming “happily and usefully whole,” is by wholeheartedly embracing traditional theistic belief” The Big Book and 12 & 12 spells out in detail a particular version of traditional theistic belief that entails the need for followers.to pray and expect direct personal intervention by God. In order to follow Big Book and 12 & 12 expressions and practices, 40% of the addicted population would need to change their conception of God (assuming the addicted population is similar to the general population.)

    The Big Book and 12 & 12 constitute the Twelve Step Program. I recognize that there are many fine books that offer up alternatives to how these texts in teach about the Program. But these alternate books are not what are used by the groups. The Big Book and 12 & 12 are the texts used (or the derivatives of these texts in non-AA fellowships) and are the only texts most groups allow their members to read or study during meetings. I was surprised to learn that TSF also followed a similar practice and focused on teaching from these texts. They are religious texts. It is evident to most people who read them, but the long-term usage of the phrase “spiritual, not religious” has confused this issue, as was pointed out by the judiciary:

    “Alcoholics Anonymous materials and the testimony of the witness established beyond a doubt that religious activities, as defined in constitutional law, were a part of the treatment program. The distinction between religion and spirituality is meaningless, and serves merely to confuse the issue.” — Wisconsin’s Federal 7th Circuit Court , Grandberg v. Ashland County, 1984.

    I think that the term spiritual can be defined in a meaningful way that would distinguish it from what the courts designated as religious expressions and practices. I tend to agree with the Rev. Ward Ewing, in distinguishing between religion and spirituality in this way:

    Region is taught at the head level, ‘Here’s the book and here’s what it means and this is what we do here.’ Spirituality is shared, not intellectually but at the level of the heart. Spirituality is something everyone has. We wake up with it in the morning. It is love and hate, anger and joy; we are spiritual beings because we are affected if people love us or hate us or ignore us”

    Teaching from the Big Book and 12 & 12 is the religion part. The spirituality part can be defined in additional way than what the Rev. Ward briefly provided. There are a whole host of definitions of spirituality which include “esprit de corps”; or events and experiences of great beauty or significance; or efforts people make to overcome their feeling of separateness. These definitions involve human thought and emotion or interaction with other human beings. What we can’t touch or taste or see. And there is ASAM’s definition of spiritual as “Distortion in meaning, purpose and values that guide attitudes, thinking and behavior”

    I think that the supernatural and metaphysical (connection between supernatural and natural) could be included with these other definitions of spirituality. Indeed, for the 92% of the population who do have a conception of God, they might even expect to see a relationship with the transcendent included as part of the definition of spirituality. ASAM does include this as: “connection with the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others).” The issue is that ASAM includes the relationship with the transcendent as part of its diagnostic criteria. How should this relationship be measured? Does 60% of the population have a “better” relationship than the rest the population who don’t have a personal God responding to prayers, since that doesn’t correspond with the Twelve Step Program?

    What does any of this mean and what’s the point? Well, it seems to me that the Twelve Step Program (Big Book and 12 & 12) defines 40% of the population as spiritually sick because they don’t have a personal God who responds to prayers. And the cure for this malady is conversion I think it’s very appropriate for private nonsectarian, nondenominational religious groups (AA, NA, CA, OA, ect.) to have the religious freedom to teach this theory of recovery, wherein they convert others to their religious viewpoint, as long as attendees are voluntary. My observation is that these groups have changed a lot from what they were 20-25 years ago. They focus much more on fundamental study of the expressions and practices of the first 100 AA members, rather than anything that’s been learned about addiction in the last 75 years. I think it is foolish to base modern addiction treatment on these two religious texts, and for the health care system to rely on these private, independent non-professional groups to provide addiction “treatment” in lieu of some type of professional treatment. These groups are not accountable to anyone nor do they have any type of organizational oversight.

    Me personally? I’m aligned with Father Joseph Martin: “God acts in accordance with the natural. If you ask God “Make me a Doctor, God answers by saying “Go To medical school!” This perspective is not taught in the Big Book or 12 & 12.

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