Running Head: Behavioral Analysis: Alcoholism

Behavioral Analysis: Alcoholism

Harris Cacanindin
Saint Louis University

Behavioral Analysis: Alcoholism

I. THE PROBLEM
Substance abuse refers to the harmful or hazardous use of psychoactive substances,
including alcohol and illicit drugs. DSM-V defines the essential features of substance abuse as a
diagnostic category as a maladaptive pattern of substance use manifested by recurrent and
significant adverse consequences related to the repeated use of substances.
The purpose of this paper is to present a clients situation that currently faces the same
dilemma and how he copes thru all the whips and chains of ill fate. Also, this paper is presented
with the individuals behavioral analysis. Behavior analysis is a science based upon the
foundations and principles of behaviorism. The field of behavior analysis has a long-standing,
but confusing and conflicting treatment of motivation as a source of behavioral control. In many
behavioral textbooks motivation is not considered as an independent variable, nor given its own
chapter along with the other behavioral principles and major concepts (e.g., reinforcement,
extinction, stimulus control, generalization). However, in all of Skinners early books on
behavior analysis, and in the first generation of textbooks on behavior analysis (Millenson, 1967)
motivation was presented as a basic principle of behavior.
CLIENT DESCRIPTION
Patient DD is a 26 year old male of Cordilleran descent, who has been in suffering from alcohol
abuse for 7 years. He works as a contractors assistant dealing with paper works and
documentary completions. He is sociable, friendly and forthright in discussing his experience
with substance abuse. He made steady eye contact and seemed pleased to share his history. His
tone of voice was moderately fast, and at times he made jokes, it seemed, as a way to divert from
the sadness of his history.

Behavioral Analysis: Alcoholism

FAMILY BACKGROUND AND DRINKING HISTORY

Patient DD is an only child. He never knew his biological father. When he was three
years old his mother, got married again with a man whom he called papa, an alcoholic whom
he thought for several years was his father. Both parents are affectionate and warm toward him;
however, this affection soon took the form of physical abuse from his father. By the age of nine,
he realized something was wrong here, and he started trying to escape from him. Patient DD
would often do his choirs early and sleep early or sometimes stay overnight with his cousins. For
the next six years he was always trying to box me. When he was drunk, he would physically
abuse him as well, but not his stepbrother who was five years older and his biological son.
Finally when he was 15, his fathers alcoholism became so bad that he became abusive to my
mother, and his mother left him. Throughout this period some extended family members were
aware of the abuse of patient DD, but were afraid to bring it to his mother who was in denial
about it. Patient DD, who also felt it was useless to tell his mother, was left feeling unprotected,
that no one cared for him that lead him to be depressed, and with low self-esteem.
During his adolescent years, his mother was very strict, and drinking was not allowed. I
couldnt drink alcoholic beverages even in family gatherings. I could go out with friends, but I
but still no drinking of alcohol. He attributes this to what he believes is a cultural restriction of
drinking among children. When people do drink to excess, its not talked about, nor is depression
or other mental illness. In retrospect, he realizes that several of his relatives, uncles and cousins
were alcoholics and some died because of alcohol related illness or accident. But no one talked
about and its not necessary to talk about it.

Behavioral Analysis: Alcoholism

When he was in third year high school, his mother went abroad to work and he was left
being taken cared by his grandmother. During the next couple of years, he began drinking
alcohol when his friends call him especially during occasions. Since her mother is physically
distant, and her grandmother was lenient, supervision was loose and eventually causes patient
DD to do things unsupervised. Consequently, the drinking alcohol got more frequent. He said
that at some point I even had my drinks at the back of our school and so he claimed that the
drinking started to become his hobby and even to an extent where his allowance get spent
majorly on alcohol.
He began drinking seriously in his twenties, because I found that alcohol let me be more
sociable, to talk with people more easilyto go out, and to dance, which he loved. Without it I
couldnt because I feel a bit conscious and restricted. However, drinking also led to some bad
relationships. There was a point where he was emotionally depressed and needed his mom for
security. I was left by my girlfriend because she doesnt like it anymore that I was always out
with my friends and coming home drank. And so I called my mom a couple of times but she
wasnt answering, busy I guess. A lot of bad things happened to me back then and so I always try
to call my mom, sometimes she answers it and gives me advice and tries to console me, but
oftentimes shes not there. After some time Patient DD felt distant from his mom and felt that
theres a big gap between them. Her grandmother was of help but then DD relied more to his
friends and tend to voice out his feelings to them. At first he drank only on weekends, but
gradually increased to daily drinking and by the time he was 26 he realized he had a problem.
At many occasions when he was out of money, he would sell his staff- his laptop, his shoes and
even his fathers staff or anything around the house just to buy alcohol.

Behavioral Analysis: Alcoholism

According to World Health Organization, the harmful use of alcohol results in 3.3 million
deaths each year. On average, every person in the world aged 15 years or older drinks 6.2 litres
of pure alcohol per year. Less than half the population (38.3%) actually drinks alcohol, this
means that those who do drink consume on average 17 litres of pure alcohol annually. At least
15.3 million persons have drug use disorders. In 2012, about 3.3 million net deaths, or 5.9% of
all global deaths, were attributable to alcohol consumption. There are significant sex differences
in the proportion of global deaths attributable to alcohol, for example, in 2012 7.6% of deaths
among males and 4% of deaths among females were attributable to alcohol. In 2012, 139 million
net DALYs (disability-adjusted life years), or 5.1% of the global burden of disease and injury,
were attributable to alcohol consumption. There is also wide geographical variation in the
proportion of alcohol-attributable deaths and DALYs, with the highest alcohol-attributable
fractions reported in the WHO European Region.
ETIOLOGY
Psychodynamic theorists hypothesize that some people may use alcohol to help them deal
with self-punitive harsh superegos and to decrease unconscious stress levels. A self-punitive
harsh superegos result to guilt and according to Freud (1964), guilt is a weapon used by the
superego to influence the egos decision. In his view, the moral sense of guilt is the expression
of the tension between the ego and the super-ego. Freud speculates that the individual, once
forbidden from expressing this desire externally, subdues excess aggression by redirecting it
towards his own ego. The super-ego regulates the actions of the ego in the form of a
"conscience" and consequently imposes a sense of guilt and need for self-punishment on the
individual. Going back to Patient DDs case, he has a history of physical abuse as well as a strict
upbringing both of which had cause DD to feel a sense of fear and restriction and had driven and

Behavioral Analysis: Alcoholism

intimidated him to keep self from expressing. This is further proven when DD failed to tell his
mother about the abuse. Moreover, these conflicts lead to anger being directed inwards, further
lowering self-esteem (Freud, 1946). Poor self-esteem then gives rise to DDs guilt. Ultimately,
parental fear becomes the source of his guilt and for him to cope with the guilt is to suppress it
thru alcoholism.

Suppression temporarily shifts conscious attention away from negatively

charged intrapsychic states while maintaining some awareness (Bowins, 2004).

Self-esteem is a subjective appraisal of self and reflects how an individual perceives
themselves to be worthy or able (Anderson & Polmhausen,1999). Low self-esteem can lead to
negative consequences, including engaging in abusive relationships, alcohol and other drug
overuse and abuse and self-injurious behaviors. Low self-esteem can also lead to an increased
vulnerability to criticism and rejection, causing young people to inflate their feelings of
inadequacy and perceived incompetence, which can lead to depression and anxiety.
On the other hand, Freud (1946) also hypothesizes that at least some alcoholic people
may have become fixated at the oral stage of development and use alcohol to relieve their
frustrations by taking the substance by mouth. In the assumption that Patient DD is orally
fixated, it would subsume that this is a result of overly or underly gratified need given during
breastfeeding when he was an infant. When the prospect of taking the next step becomes too
anxiety provoking, the ego may resort to the strategy of remaining at the present, more
comfortable psychological stage. Such a defense is called fixation (Feist and Feist, 2008). People
who continually derive pleasure from eating, smoking, or talking may have an oral fixation.
Perhaps DD searches for immediate gratification of his needs, or ways to escape tension, turning
to alcohol to experience a state of euphoria.

Behavioral Analysis: Alcoholism

Other theorists believe that early childhood rejection, overprotection, or undue

responsibility can cause an individual to become dependent on alcohol or drugs to cope with
increased anxiety, depression, social or sexual inadequacy, increased social pressures, selfdestructive behavior, or due to a desire to lower one's inhibitions (Berman, 2001).
Based on Eriksons Psychosocial Theory, the transition into young adulthood from
adolescence requires completing a variety of developmental tasks that include becoming more
independent, developing new relationships, including intimate relationships, and beginning a
career. Adolescents and young adults experience fundamental changes in their self-regulation.
Ideally, personal identity formation occurs as individuals, through exploration and commitment;
develop a secure and enduring sense of self that encompasses an integrated set of personal
interests, values, goals, and commitments (Schulenberg, 2001). Arnet (2005) identifies features
specific to young adults that increase the risk of AOD overuse, abuse, and dependence. First,
young adulthood involves significant identity exploration. During this stage, young people are
discovering who they are and what they want from friendships, romantic relationships, and
careers. Part of this self-exploration involves use of alcohol and other drugs to expand their
awareness and experiences (i.e. sensation seeking), but some young adults may use substances to
relieve the tension related in this time of uncertainty. The transition into young adulthood is ripe
with change and instability, which is the second feature. As young people engage in identity
exploration, they go thru a variety of changes and in Patient DDs case it is in terms of where he
leaves when his mother went abroad to work and he was left to his grandmother, also it is in
terms of who he spend with, often without a clear guide or roadmap of where they are headed.
While many of these changes may be exciting, they can also create anxiety and discomfort, and
young people may turn to alcohol and other drug.

Behavioral Analysis: Alcoholism

Although identity exploration is normative and considered part of healthy development, it

may also represent a risk factor for experimentation with potentially risky behaviors such as
alcohol or other drug use (Maggs et al., 1997). The role played by drinking alcohol in
adolescents lives is paradoxical, just as it is for other risk behaviors, such as illicit drug use and
sexual behavior (Maggs et al., 1995; Maggs & Hurrelmann, 1998). Consistent with the
Transition Catalyst Model, despite the possibility of serious harm from alcohol misuse, drinking
also may serve important constructive functions for adolescents, such as helping them to make
friends or explore personal identities, and indicating a transition to a more mature status (Chassin
et al., 1989). Accordingly, Patient DDs case did include peers in which he began drinking with.
Young adults begin to individuate from their parents in adolescence and continue to be
influenced by their peer group more than by older adults. Patient DDs adolescent life has been
perhaps greatly influenced by his friends since it is where he finds the sense of being a part of a
group and since his mother is away and cannot provide the emotional support that DD needs.
Friends are diversion for Patient DD- being with them, drinking and jamming. To Harry Stack
Sullivan, like countless other psychologists, he considered friends to be crucial to developing
into a healthy adult. Friends are a source of social support, and it is comforting to lean on them
when times are tough or when youre having a bad day (Feist & Feist, 2008). Also, peer
relationships provide opportunities to compare values, beliefs, and mental and physical abilities.
This social comparison helps them feel validated and gives them a sense of belonging, but it can
add pressure to engage in behaviors such as alcohol or other drug use that they may not be
comfortable with to gain acceptance from their friends and acquaintances (Feldman, 2006).
As Cooper (1994) noted, there are four motivations for young people to use alcohol and
presumably other drugs. First, alcohol can help people obtain or maintain a positive mood and

Behavioral Analysis: Alcoholism

outlook. This is true to patient DD since he perceive that drinking alcohol makes him more
sociable. Second, drinking can make social activities more fun. As DD perceive drinking
alcohol makes him sociable, he is then able to talk with people more easilyto go out and to
dance. Third, people drink to conform to the desires of others (e.g peer pressure). And fourth,
people drink as a way to cope with or reduce negative feelings such as anxiety or sadness. To put
in sequence, patient DD perhaps felt sadness since it was this time that her mother went abroad
and left him with his grandmother and with the eventualities, he started drinking alcohol.
Since the migration of his mother made a great impact as to how Patient DD became
alcoholic, the causality of migration necessitates further explanation. It is now well accepted that
international migration of a parent or family member can have both positive and negative effects
on non-migrant children in the home country. First, there is the possibility that remittances sent
from abroad will relax the household budget constraint and result in an increase in child
schooling, child health, and a corresponding decrease in child labor. Several studies find
evidence supporting this hypothesis (Alcaraz et al., 2012). Yet researchers have also recognized
that parental migration inherently involves parental absence from the home that can have a
negative impact on child outcomes which may outweigh the positive effect of remittances.
Findings are consistent with anecdotal reports regarding families of migrants and with
studies of clinical samples that have suggested that substance use and risk for substance use
disorders change because of migration (Borges, 2007).
Consistent with this, Giannelli and Mangiavacchi (2010) find that parental migration has
a negative impact on school attendance for children left behind in Albania. Since men are the
ones to migrate in most contexts, much of the literature has focused on the fathers contributions

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to the family and connects the resulting loss when he becomes a migrant to the literature on
father absence more broadly (Antman, 2011). Zoller Booth (1995) stresses the importance of a
fathers role as disciplinarian and figurehead when interpreting the detrimental effects of paternal
labor migration on the school readiness of children in Swaziland. Lahaie et al. (2009) find that
the migration of a caregiver-spouse is significantly associated with academic, behavioral and
emotional problems for children left behind in Mexico.
Existing literature points out the impact of migration on the families and on the wellbeing, academic performance, and school behaviours, family and peer relationships of the
children left behind, and the need for interventions to address these concerns (Tarroja 2013). One
relatively new feature of research on the impact on sending areas is a focus on the separation of
families that migration so often implies. This may take many forms, whether it is an entire
nuclear family separating from extended family in the source country or a parent or child
migrating alone with dependents left behind. In many parts of the world, this type of migration is
circular and recurrent, raising questions about the impact of migration on family members left
behind and their reliance on the migrant for support (Antman, 2013). Migration is experienced
not only by individuals who migrate, but also by their family members that remain at home.
While previous research on origin communities has focused primarily on the economic impacts
of remittances, this study emphasizes the emotional repercussions of family member migration. I
use the Mexican Family Life Survey, a nationally representative data set, to empirically assess
the effects of migration on the emotional well-being of migrants family members in Mexican
communities of origin. Results indicate that migration of close family members to the United
States, especially spouses and children, significantly increases depressive symptoms and feelings
of loneliness reported by family members remaining in Mexico. Women, particularly mothers

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and wives, are more adversely affected by family member migration than men. On a practical
level, findings from this study illustrate a need for support programmes in origin communities to
help families cope with the migration of their family members (Silver, 2011).
It would be of emphasis that Patient DD grew with an abusive and alcoholic step-father.
This may be contributed to his alcoholism. As Banduras social learning theory (Feist and Feist,
2008) states that people can and do learn through direct experience, that is, learning by observing
others. People use drug because drug use is modeled by others. Simply put, DD drinks alcohol
because he saw his stepdad drinking alcohol.
Also, Patient DDs alcoholism maybe a product of conditioning. At first Patient DD only
took alcohol on occasions where he was called by friends. Eventually, with the occasional
alcohol drinking, the alcohol became a form of reinforcement that lead to its frequent recurrence.
According to Skinner (1987a), reinforcement has two effects: It strengthens the behavior and it
rewards the person. Patient DD thus perceives that taking alcohol gives him pleasure and
consequently strengthens the drinking behavior. This conditioning is termed by Skinner (Feist
and Feist, 2008), as operant conditioning. With operant conditioning (also called Skinnerian
conditioning), a behavior is made more likely to recur when it is immediately reinforced. He
developed the theory of operant conditioning on the idea that behavior is determined by its
consequences, be they reinforcements or punishments, which make it more or less likely that the
behavior will occur again. Using Pavlovian Principle, addiction occurs because of both the
pleasurable physiological effects (e.g of nicotine and alcohol), unconditioned stimuli, and the
taste of the substance, conditioned stimuli (Schwartz and Lacy, 1982).

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On a neurobiological perspective, neurotransmitters play a role on how DD developed

alcoholism. Neurotransmitters such as dopamine, GABA, glutamate, and serotonin are the major
neurotransmitters affected by substance abuse and these biochemical agents are involved in the
reward system of the brain. Rewards are defined as those objects, which we will work to acquire
through allocation of time, energy, or effort; that is, any object or goal that we seek. Rewards are
crucial for individual and support elementary processes such as drinking, eating and
reproduction. It has been demonstrated that dopamine is involved in the hedonic component of
reward. With addiction, the repetitive substance abuse corrupts the normal circuitry of rewarding
and adaptive behaviors causing drug-induced neuroplastic changes. Consumption of rewards
(e.g. alcohol and other drug) produces hedonic consequences which initiate learning processes
that consolidate liking the rewarding goal. Motivational state such as craving increases the
incentive salience of reward-related cues and the reward itself. The greater the craving, the
greater the likelihood that behavioral sequences aimed at obtaining alcohol and other drug will
be initiated and carried to conclusion despite distractions and obstacles that may arise (AriasCarrin et al., 2010).
It was also mention that Patient DD has been alcoholic for 7 years. In these years he had
gone to fights and was put to jail twice under the influence of alcohol. Though he was detain in
jail, the alcoholism still persisted. The continues use of the substance despite significant
substance-related problems is further explained by Eysenck`s Resource model of addiction.
Eyesenck theorized that habit of alcohol or drug-taking is developed because the substance used
fulfils a certain purpose that is related to the individual's personality profile. For such people,
drug taking behavior- or more specifically, addiction holds benefits even though there are
negative consequences that occur after some time. With personality profile, Cloninger (Fruyta,

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2000) stresses novelty seeking personality that accounts for the substance abuse of an individual.
According to Cloningers tridimensional theory, the important differences between all of our
personalities may be accounted for by three key qualities, or dimensions: harm avoidance,
novelty seeking, and reward dependence. Novelty seeking" describes a capacity to be exhilarated
by new experiences. It is viewed as a heritable bias in the activation or initiation of behavior
such as frequent exploratory activity in response to novelty which belongs to automatic, preconceptual responses to perceptual stimuli presumably reflecting heritable biases in information
processing (Cloninger, 1993). This would imply that Patient DD is with a high novelty seeking
personality and drinks alcohol for the thrill he experience from it. Some studies suggest that
people who seek out high-sensation experiences even at great personal riskso-called highsensation seekersare more vulnerable to drug and alcohol abuse (Patoine, 2009).
The interplay of biological and environmental factors would also explain how Patient DD
developed alcoholism. Hsu and colleagues (2003) conducted a research and were interested in
how repeated early life stress would influence the expression of different GABA receptor
subunits later on down the road. The GABA system is important in the discussion of addiction
because it influences the efficacy of ones stress response and plays a dominating role in the
pharmacology of many extremely addictive substances such as alcohol, heroine, morphine, and
most other forms of painkillers (Paulsen and Moser, 1998). The study suggests both strongly
implicate the GABAergic system DNA strands in the biological etiology of addictionthe study
both show that genes can predict the onset of pathology; however, environmental effects such as
repeated stress can act as an intermediary modulator between genes and behavior. This provides
support for what is known as the diathesis-stress model of psychology (Grant and Potenza,
2010), which asserts that in the interaction between diathesis (biological vulnerability) and stress

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(life stressors, traumatic events) serves as the best predictor of pathologys eventual onset. DDs
genetic vulnerability coupled by his lifes stresses- history of abuse, physically distant mother,
peer pressure, bad relationship, school concerns, predisposed DD to resort in alcoholism.
According to Festingers (1957) Cognitive Dissonance Theory, people are exposed to
new information in the context of their pre-existing knowledge. Festinger continues that if the
new events or information support the previously held beliefs, then the individual feels supported
as the new stimuli are in harmony with the individuals prior knowledge. This creates what
Festinger referred to as a state of consonance. However, Festinger also discussed a state of
dissonance, or discomfort, which would occur when new information or events stood in
opposition to previously held beliefs. When the new information creates a sense of dissonance,
there are four reactions we could expect, based on Festingers (1957) theory. First, the individual
may choose to attack the messenger as a way of discrediting the new information. Second, she or
he may choose to rationalize the information, or essentially modify the new stimuli in a fashion
that it is no longer in opposition to previously held beliefs. Third, the individual may accept the
new information as accurate, yet refuse to change her or his original beliefs, which would create
a continuing, or unresolved state of dissonance. Lastly, the individual may accept the new
information as accurate, and alter her or his original beliefs accordingly.
Those who are involved in alcoholism such as Patient DD will usually have to deal with
cognitive dissonance. This is because there is so much compelling evidence for why this
behavior is dangerous. The Patient DD is likely to be aware of this but he will overcome the
conflict by either: giving up alcohol, changing his opinion of substance abuse so that the
behavior appears less dangerous, he can also adapt a new idea that will help him escape the

Behavioral Analysis: Alcoholism

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dissonance. For example, he might accept that substance abuse causes damage to other people,
but he can handle it and so are not in danger.
II. THE SOLUTIONS
The global economic and health burden of alcohol use disorders is widely recognized, as
is the need for effective public health interventions to substantially reduce this burden (Riper,
2011). ). Therefore, visual explanation or a "map" of the behavior change and the expected
outcomes is presented below depicting an effective intervention for Patient DD.
ACTIVITIES:
Educational Videos
Relationship
Counseling
Instruction in
nutrition and exercise
Job Search
Internet Sites
INFLUENTIAL
FACTORS:
INPUT:

Friendssocietal
Money
pressure
Time

Self-esteem
Materials- books,
Stress of work
videos
Loneliness
Counselling

Unstable emotions
Support
Addiction
Backgroundalcoholic step father
INTERMEDIATE OUTCOMES Self-perception
Improved coping skills
Learned relationship skills
Gain tools to improve selfesteem
Ability to combat desire to
drink
Begins to make healthy
choices

OUTPUTS:
Learn New Skills
Attends counselling
Watch videos
Gathers information
Works on
relationship
Exercise more
Eats better

INITIAL OUTCOME
Reduced drinking
frequency
Gain support group
Begin contemplation of
maintaining new lifestyle
Motivated to quit
drinking

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Furthermore, the health belief model was used. The model is an intrapersonal theory that
"addresses a person's perception of the threat of a health problem and the accompanying
appraisal of a recommended behavior for preventing or managing the problem" (Cottrell, Girvan,
& McKenzie, 2006). And as such a diagram is presented below on how Patient DD's behavior
change lead to taking preventive actions for his alcoholism.
LIKELIHOOD OF TAKING PREVENTIVE ACTIONS

This model was used to help explain why Patient DD accepted preventative health
services and adopt healthy behaviors. Social psychologists originally developed the Health Belief
Model to predict the likelihood of a person taking recommended preventative health action and
to understand a persons motivation and decision-making about seeking health services. The
Health Belief Model proposes that people will respond best to messages about health promotion
or disease prevention when the following four conditions for change exist: The person believes
that he or she is at risk of developing a specific condition, the person believes that the risk is

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serious and the consequences of developing the condition are undesirable, the person believes
that the risk will be reduced by a specific behavior change and the person believes that barriers to
the behavior change can be overcome and managed.
Individual interventions employed focused on reducing the demand for alcohol by
through access to information and/or skills that influence decision-making and behaviours
(Larimer & Cronce, 2007). Prevention interventions include those activities focused on
providing with the information and skills they need to make good decisions about drinking. They
include: basic education and awareness programs and cognitive behavioural skills-based
programs. Education/awareness programs encompass relatively distinct methods providing with
basic information about alcohol. Employment of such strategy are useful to Patient DD.
Specifically, these include giving him traditional information about the alcohol, re-educating him
about identified misconceptions about alcohol and giving him opportunities to evaluate his goal
and incorporate responsible decision making about alcohol into his goals or values. Cognitivebehavioral skills-based programs often incorporate educational/awareness type activities. And in
this context, it is employed to Patient DD thru teaching so as to modify beliefs or behaviors
associated with high-risk drinking. The patient learns skills in self-monitoring and selfassessment; sets limits and avoids and handles high-risk situation. Popular misconceptions are
cleared such as various methods to sober up. Part of the intervention was to teach about
pharmacologic treatments such as aversion therapy as part of the regimen.
Family Therapy. The attitudes and behaviours of peers are among the strongest
correlates of drinking attitudes and behaviours; however, the developmental literature has clearly
identified the importance of the family network in adolescent substance use, even as late as
university (Turrisi, 2010). During family therapy sessions, the family's strengths are used to help

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them handle their problems. All members take responsibility for problems and some family
members may need to change their behavior more than others. This is done by focusing less on
the member who has been identified as ill and focusing more on the family as a whole, also by
identifying conflicts and anxieties and helping the family develop strategies to resolve them.
Also, part of being a nurse is to provide patient DD with a means of contacting health
care providers who are available for questions or problem resolution, compliment patient on
positive accomplishments to reinforce his behaviors and to involve his family and friends in
health planning conferences. Also, emphasis on the importance of a balanced diet (e.g. low in
cholesterol) to prevent vascular disease and even advise to take Vitamin B complexes to support
good appetite and proper brain functioning, sustained cessation of alcohol, regular exercise to
increase agility and stamina, proper hygiene, regular physical checkups to identify and treat
problems early, reporting of unusual symptoms to a health professional.
Within the public health approach to prevention, there is room for multiple theories and
combinations of theories. The public health approach originally derived from epidemiologic
studies of communicable diseases, indicating that proper prevention planning requires
knowledge of the host (or individual person), the agent (in this discussion, alcohol), and the
environment (the social milieu). Prevention, as we know it today, also requires knowledge of the
interaction between the three factors. Because prevention in public health is an evolutionary field
that is continuously growing from the thinking and experiences of researchers, planners,
practitioners, and evaluators, the current knowledge base will change, expand, and emerge in
new combinations, providing better tools with which to address the prevention of alcohol
problems. The theories that seek to explain behavior and changes in behavior are taken largely
from psychology. Until recently, most theoretical work in alcohol abuse prevention has been

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aimed at identifying the likely antecedents and correlates. More recently, the goal has been to
develop strategies based on theories and models of prevention that can reverse or prevent
adolescent alcohol use.
Social learning. Albert Bandura's social learning theory is probably the most widely used
among current prevention program planners. According to Bandura (1977), learning is acquired
and shaped by positive and negative reinforcements (rewards and punishments), as well as by
observation of other people's behavior . Thus, people can anticipate the consequences and shape
their own behavior to earn rewards and punishments. Bandura recognized the potential for using
modeling as a way of directing and changing behavior. We observe the behavior of others in
person, on television, and in movies, and we become more likely to adopt that model's behavior
based on the attractiveness of the model. Bandura's early work indicated that children readily
imitate aggressive models as well as more positive models and that status envy was an important
factor. Later, his theory formed the underpinning for the use of "near peers" to transmit messages
to somewhat younger children by depicting behavior and attitudes for young people to imitate,
such as saying "no" to alcohol (refusal skills). In addition to the use of "near peers" in television
mass media efforts, Bandura's work most likely is the theoretical basis for prevention efforts
using the team or buddy approach, teaming individuals, small groups, families, and even
communities, in which new health related behaviors can be modeled and reinforced, helping to
set new norms.
Cognitive dissonance (McGuire, 1985). Much of William McGuire's work in psychology
is based on Festinger's concept of cognitive dissonance , which describes a tendency of humans
to harmonize expectations about people and experiences with them. In other words, we want our
beliefs to be in harmony with our experiences. Cognitive dissonance theory holds that people

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want their personal attitudes and beliefs to be compatible with their own behavior. If they are not,
there is "cognitive dissonance" that a person will want to eliminate. As a prevention technique,
McGuire proposed that certain "pretreatments" would establish or strengthen beliefs and attitudes
with which a person's behavior would have to harmonize to avoid cognitive dissonance.
"Cognitive inoculation" is one of these pretreatments. He found that verbal "inoculations" had
certain immunizing effects against strong counter-arguments, and strengthened the subjects'
ability to defend their beliefs. When applied to the use of alcohol and other drugs, cognitive
inoculation aligns a person's beliefs and behavior with regard to these substances. For instance, if
a teenager believes that drinking will diminish athletic ability, and places a high value on athletic
ability, resolution of dissonance would require that the teenager either abstain from drinking or
place a lower value on athletic ability. Another pretreatment approach requires that a behavior
commitment be made; the commitment often is in the form of a contract or public announcement
of one's beliefs and intentions ("I will not use alcohol until I am of age"). McGuire found that a
commitment made to others was stronger than a private commitment.
Behavioral intention. Martin Fishbein and Icek Ajzen (1980) developed a system for
measuring attitudes as well as subjective norms. Their behavioral intention theory postulates that,
when properly measured, a person's attitudes and subjective norms about a behavior can be used
as predictors of behavior. Attitudes are the beliefs a person holds about the outcome of a
behavior, along with the value he or she places on that outcome. The most prominent dimension
of attitude is like-dislike, the tendency to accept or to reject or to seek to avoid. Subjective norms
are the person's assumptions about the views of significant others regarding the behavior, along
with the person's motivation to comply with these views. For attitudes and subjective norms to
be valid predictors of behavior, they must be measured in terms of specific behavioral situations.

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For example, a person drinks (action) beer (target) in a car (context) on a weekend (time).
Attitudes and subjective norms must be assessed to keep the action, target, context, and time in
focus. The theory provides a good framework for understanding the important role that perceived
social norms play in directing behaviors. For example, adolescents generally perceive a
prevalence of alcohol and drug use among their peers that far exceeds actual consumption.
Students who overestimate the use of alcohol and other drugs by their peers may view that use as
"normal" and become more accepting of drinking and other drug use. Changing behavior,
therefore, means not only changing norms but the perception of norms. Correcting overestimates
can be a useful prevention message. Another indication that the theory provides a good
framework for understanding the important role that perceived social norms play in directing
behaviors came from a recent study by Lloyd Johnston and coworkers. Although this study dealt
with marijuana use, the main finding may be important in suggesting a direction for future
alcohol use prevention efforts. The researchers found that the decline in marijuana use since
1979 among high school seniors is most likely because of a change in norms and their perception
of norms. To be precise, negative attitudes toward marijuana use among high school seniors are
increasing.
Disapproval by peers and an increase in the perception of risk involved in using
marijuana are most likely the deciding factors that have led to decreased marijuana use (21).
According to Bachman and coworkers, increasing proportions of high school seniors perceive
that their friends disapprove of marijuana use, and increasingly, information concerning harmful
consequences is believed. These 'changes in the social environment" suggest that future
prevention efforts may effectively emphasize perception of harm and social disapproval.

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Persuasion-communications. McGuire (1985) has worked extensively on the theory

underlying communication campaigns. He believes that the more successful campaigns are those
which focus on the availability of solutions rather than on the seriousness of the problem. He
found that such techniques as defining specific audiences and targeting messages may increase
the effectiveness of public communications campaigns, but the techniques have limited efficacy
for changing the audience's health-related behavior. McGuire described components necessary to
construct a communication capable of changing attitudes and behavior, along with successive
responses people must make if they are to "yield" to the communication. According to McGuire,
the effectiveness of a communication campaign depends on its ability to lead an audience
through a 12-step process. The process starts with exposure to the communication and proceeds
through learning how to incorporate the target behavior in one's life, and being able to make
decisions based on the retrieval of the information. The process concludes with reorganizing
one's related beliefs and "engaging in post behavioral activities" or consolidation.
III. LIMITATIONS ENCOUNTERED
The duration of encounter between the nurse and the client started last week of
September and ended during the last days of October with irregular meeting intervals. Meetings
were basically dependent on the client's availability. Hence, time is limited and so some
interventions may have been implemented poorly. Also the models and theories aforementioned
have not been fully utilized to full extent and may have become eclectic or integrated in
approach during the actual process.
It is important to note that a state of dissonance can impact an individuals behavior, as
she or he attempts to regain consonance. For example, most alcoholics are fully aware of the

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health risks caused by their alcohol consumption (Greening & Dollinger, 1991). However, they
are more likely to perform the act of admitting these risks if they are intending to quit drinking
(Swinehart & Kirscht, 1966). This is an example of how cognitive dissonance can impact the
behavior of an individual. As our society looks for ways to reduce the rate and amount of alcohol
consumption, specifically among college students, Festingers (1957) theory of Cognitive
Dissonance could serve a valuable role.
In the example of dangerous drinking, an individual may feel dissonance due to knowing
the risks of their drinking levels, but would be resistant to change their behavior due to the
potential loss of a social outlet. Another reason an individual might resist dissonance reduction,
according to Festinger, is that the present behavior may be satisfying. Applying this through the
lens of dangerous drinking behaviors, an individual may feel the benefits of dangerous drinking
are satisfying enough to continue in a state of dissonance. Finally, Festinger suggested that
change may not be possible. This could apply to addictive behaviors, effecting alcoholics,
smokers, drug users, etc. Festinger proposed that if an individual is unable to successfully reduce
the existence of dissonance, they will then attempt to avoid the triggers that arouse dissonance,
and minimize the magnitude of it.
IV. CONCLUSIONS AND RECOMMENDATIONS
No single approach has been identified as effective for preventing use of alcohol by
youth. In fact, different factors in separate programs appear to be effective in certain
communities with certain age groups. A multifaceted approach to prevention is necessary.
Prevention planners should focus on the multiple factors that contribute to alcohol and other drug
use by youth. Community leaders should take into consideration existing community efforts and

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in their programs address ways in which various programs can interrelate. The goal of any
community in prevention is to make the parts work together. Although more research is needed
to determine which strategies and approaches work best, the following are essential components:
communicating a clear, nonuse message for youth through all community channels, policies, and
practices, role modeling of moderate, low-risk use of alcohol by adults of legal age, skill building
to enhance social and interpersonal communication skills, peer resistance problem solving,
media promotion efforts and portrayal analysis, and ability to ask for help, promoting bonding
and attachments to family, peers, school, and religion, and belief in general social norms, values,
and expectations, increasing the perceived benefits of health enhancing behaviors and decreasing
the perceived benefits of health-compromising behaviors, providing referral, counseling, or
treatment services for children or families in need of help.
The diagnostic features of alcohol use disorder highlight major areas of life functioning
likely to be impaired. These include driving and operating machinery, school and work,
interpersonal relationships and communication, and health. Alcohol-related disorders contribute
to absenteeism from work, job-related accidents, and low employee productivity. Rates are
elevated in homeless individuals, perhaps reflecting a downward spiral in social and
occupational functioning, although most individuals with alcohol use disorder continue to live
with their families and function within their jobs. Alcohol use disorder is associated with a
significant increase in the risk of accidents, violence, and suicide. It is estimated that one in five
intensive care unit admissions in some urban hospitals is related to alcohol and that 40% of
individuals in the United States experience an alcohol-related adverse event at some time in their
lives, with alcohol accounting for up to 55% of fatal driving events. Severe alcohol use disorder,
especially in individuals with antisocial personality disorder, is associated with the commission

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of criminal acts, including homicide. Severe problematic alcohol use also contributes to
disinhibition and feelings of sadness and irritability, which contribute to suicide attempts and
completed suicides. Unanticipated alcohol withdrawal in hospitalized individuals for whom a
diagnosis of alcohol use disorder has been overlooked can add to the risks and costs of
hospitalization and to time spent in the hospital (APA, 2013).
During his high school life, he was often called to the principals office because of
absenteeism, and drinking alcohol on school ground. During his college life, he often shift
course and change school. He started college life with a BSN course at Saint Louis University. At
the middle of the second semester as a freshman he got dropped out of school and transferred to
Cagayan State University with BSA course. On his second year as an accounting student he
again stopped due to absenteeism. Patient DD claimed that dropping out from both universities
was due to absenteeism and further explained that most of his absences was when he was out
with friends the night before and had sessions of drinking and so he was not able to wake up
early or he was too lazy to go to school. The drinking session got too frequent that he was
unable to sustain a good academic performance that her mother said that he should stop for a
while. Patient DD went back to his hometown and stayed with his grandmother. He then looked
for a job and was accepted as an office worker at the city hall. However the job didnt last long
since he was always absent and with same reason- out with friends, drinking session, and unable
to wake early or too lazy to go. Currently, he works under his uncle who is a contractor as his
assistant.
There are many adverse consequences of drinking alcohol during childhood and
adolescence which would seem to outweigh the modest number of positive impacts. Although
most people abuse alcohol because it makes them feel better about themselves, the truth is that

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over-use of alcohol tends to negatively impact the abusers personality. Increased irritability,
poor judgment and reasoning are just a couple of ways that alcohol damages the human
personality and relationships by extension.
The damaging effects of alcohol abuse are not limited to the person and those living
closest to them. Alcohol abuse is linked to many social ills which affect people otherwise
unconnected to the drinker. There is a clear connection between alcohol abuse and higher rates of
workplace absenteeism. Abuse of alcohol is also linked to higher rates of violent crime in
neighborhoods. Because alcohol impairs good judgment, it is often connected to risky sexual
activity. Finally, alcohol is involved in a majority of automobile accidents (Promises Treatment
Center, 2012).
During the time when he got in jail, patient DD claimed he was under the influence of
alcohol. He was with his friends birthday party on a bar when his ex-girlfriend happened to be
there, on a different table, and with a different company. He claimed he had few drinks when
he decided to confront his girlfriend. During the confrontation DDs ex-girlfriends boyfriend got
in the discussion. There was a misunderstanding between DD and the boyfriend and so fight
became inevitable. Due to his shortcomings DD verbalized that he had sense that some of his
relatives became a bit distant from him. His cousins were contacting him less or they get together
less frequent. Even with his friends, he verbalized that he even wasnt contacted anymore by
some of them. Communicating via txt, social networks was even less. When DD verbalized that
he wanted to go back to school, his mother refused to give her the aid he needed.
Alcoholism carries with it a host of social problems. Both the drinker and the family unit
are affected. Alcohol can have devastating effects on the family. Numerous marriages have been

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destroyed by alcohol, both emotionally and financially. Children of alcoholics are emotionally
fractured by alcoholic parents. Approximately 20 percent of adults grew up with a family
member with an alcohol problem. These adults themselves are at risk for developing substance
abuse problems. Emotional issues such as guilt, depression, and relationship problems are often
found in children of alcoholics (Robert C. Byrd Health Sciences Center, 2011).
Communities suffer the cost of alcohol abuse. An enormous amount of money is lost each
year in the workplace because of alcohol. Insurance costs, decreased productivity, workplace
injuries, and work-related grievances are just a few of many problems associated with alcohol.
Alcohol is also a leading factor in motor vehicle accidents and injuries. Alcohol-related vehicular
accidents are especially prevalent among teenagers and young adults, for whom they are the
leading cause of accidental death. Falls, fires, drownings, and suicides are also frequently
associated with alcohol (Mongan , 2007).
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Prentice-Hall, Inc., Englewood Cliffs, NJ.
American Psychiatric Association. (2013).

Diagnostic and Statistical Manual of Mental

Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association

Bandura, A. (1977). Social learning theory. Prentice-Hall Inc., Englewood Cliffs, NJ.
Cloninger, C. (1993). A psychobiological model of temperament and character. Archives of
General Psychiatry. 975-90
Feist, G., Feist J., (2008). Theories of Personality (7th edition)

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Grant, J.E. and Potenza, M.N. (2010). Drug use disorders among young adults: Evaluation and
treatment. Young Adult Mental Health, 10, 448.
Hsu, F.C., Zhang, G.J., Raol, Y.S., Valentino, R.J., Coulter, D.A., and Brooks-Kayal, A.R. (2003).
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Promises Treatment Center. (2012). The social effects of alcoholism. Retrieved from:
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Kaplan & Sadock's comprehensive textbook of

psychiatry, 9th Edition

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Videbeck, S. (2008). Psychiatric-mental health nursing (5th edition).
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