A Clinical Perspective of the Cause-Consequence Controversy in Alcoholic and Addictive Suffering

All of us depend on concepts to understand and respond to complex problems. Alcoholism and addiction certainly are no exception, and, in fact, concepts and theories have abounded to explain this maddeningly elusive and tragic problem in our society. But we have not achieved a consensus on what the various concepts and the approaches that grow out of the concepts teach us. Despite all of our disclaimers that alcoholism/addiction is no one thing and that it has multiple determinants, we almost invariably, if not necessarily, fall prey to considering our own formulations, concepts, and data to the exclusion of other perspectives. Nowhere is this more evident than in the controversy over whether psychological or psychiatric dysfunction is a cause or consequence of substance abuse.

Unfortunately the cause-consequence debate mirrors and recapitulates old controversies in the philosophy of science in which polemics over nature-nurture, psyche-soma, and environment-heredity dominate, which are counterproductive and reflect linear and reductionistic reasoning. Findings from genetic, neuropsychological, longitudinal, and diagnostic studies are cited to suggest that the effects of chronic and heavy drug/alcohol use produce the psychopathology associated with substance dependence. These arguments are bolstered by observations of alcoholics and addicts who respond favorably to Alcoholics Anonymous/Narcotics Anonymous and experience marked amelioration of their psychological suffering when they abstain from alcohol and drugs.