Typologies of Alcoholics II Thomas F. Babor and Roger E. Meyer, Section Editors
Overview Thomas F. Babor and Roger E. Meyer Readers whose curiosity is likely to be aroused by the concept of alcoholic typologies will be richly rewarded by a careful reading of the chapters in this section. Its authors have been chosen to represent the best that contemporary alcohol studies have to offer with respect to typological research and theory. Yet, despite more than a century of research and speculation, the field is still struggling to carve out an identity for itself, develop a set of coherent concepts, and construct a scientific methodology that will bring order out of the complexity that is alcoholism. One encouraging sign evident in these chapters, and the sole focus of the first, is the sense of historical perspective that typology theory must develop if research is to move beyond the cultural, disciplinary and methodological straightjacket it has so often been confined to. As Chapter 5 by Babor and Lauerman shows, those who fail to heed the lessons of history are doomed to repeat its failures. Typology theorists have tended to work in a time warp, independent of one another and independent of the work of their predecessors. Their failures are evident. With the notable exception of Jellinek's typological synthesis, very little of the past has been recognized by contemporary researchers, theorists, or clinicians as a significant contribution to the understanding or treatment of alcoholism. Although the verdict is not yet in, a similar indictment can be made about the recent past of typology research, which has been so heavily dominated by abnormal personality theory and the Minnesota Multiphasic Personality Test. Fortunately, the chapters in this section not only recognize the limits of what has gone before them but also illustrate a broader and more sophisticated approach to the tasks of (1) finding whether or not distinct alcoholic typologies exist and, if they do (2) determining whether different approaches to identification, treatment, and prevention can do any more to relieve the personal and social costs of alcoholism than the present undifferentiated approach. These tasks should not be c o n f u because ~ e d, the second is relatively fruitless unless the first is accomplished successfully. It is therefore not surprising that contemporary typology research has focused on the problem of defining and Thomas F. Babor and Roger E. Meyer. Alcohol Research Center, Department of Psychiatry, University of Connecticut Health Center, Farmington, Connecticut 06032. M. Galanter et al. (eds.), Recent Developments in Alcoholism Springer Science+Business Media New York 1986 107
108 II Typologies of Alcoholics validating distinctive and clinically meaningful subgroups of alcoholics rather than launching into treatment matching studies prematurely. In the process, the field has been advanced considerably by the development of conceptual ground rules, research methods, and validation procedures. Conceptually, typology researchers are beginning to realize that the entire question of empirical validation and clinical relevance depends on the definition of typology. Before one can validate or use a typology of alcoholics, one must have a concept of types. Although the concept of type is rarely defined and loosely constructed in these chapters, there is some consensus concerning its nature. In part, this consensus has been forged by nomenclature, the rules for defining terms within a discipline. The long tradition of typological thinking within the social, behavioral, and medical sciences has clearly identified a "type" as an artificial construct. Types are idealized constructions of an observer, defined by numerous characteristics that only imperfectly describe the individuals fitted to them. As currently employed, the term is used to describe the integration of characteristic personality traits, habitual drinking behaviors, and alcohol-related consequences into meaningful Gestalten or clusters. Although types are impressionistic and synthetic, they do assemble into meaningful clusters numerous individuals who are similar in the majority of relevant respects. The beauty of a type is that, like any abstract concept, it summarizes a great deal of information about the individual case. To the extent that alcoholic types are readily identifiable, scientifically valid, and clinically meaningful, they can be extremely useful for the purpose of diagnosis and treatment. Once there is agreement concerning the defmition of a type, one can begin the search for the optimal typological classification system. The chapters in this section suggest that by past as well as current standards, a useful classification system should have the following characteristics: 1. Homogeneity within categories. Individuals within the purview of a given type should be similar with respect to the major distinguishing features of alcoholism. While there is still disagreement about the essential characteristics of alcoholism, a broad interpretation of the homogeneity criterion would suggest that, like other medical conditions, subtypes of alcoholism should be similar with respect to etiology or origins, natural history (progression of the biological disease process), the drinking career (the sequence of drinking experiences and role expectations resulting in the self-identification of the drinker as an alcoholic). 2. Heterogeneity between categories. A typological classification should differentiate among different homogeneous groups of alcoholics, not only with respect to etiology, natural history, and drinking career, but also in terms of treatment response and prognosis. The greater the differences between subtypes, the more easily they will permit reliable classification. 3. Stability. The chronicity of alcoholism results in a longitudinal sequence of age- and role-related consequences. Despite the variability and at times the
II Overview 109 progressiveness of the disorder, the defining characteristics of many typologies (e.g" hereditary vulnerability, psychopathology) imply that there are common underlying type structures that remain fairly stable over time. One may therefore question the value of ephemeral typological defining characteristics, such as reactive depression, that may only be temporary states, or of characteristics that change as the disorder progresses, such as impaired memory function. In these cases the same individual may be classified as a different type at several different times in the drinking career. 4. Comprehensiveness and specificity. Typological classification systems should account for most, if not all, the cases in a representative sample of alcoholics, who are distinguished in relevant respects from a like sample of nonalcoholic controls. The more inclusive the typology, the more useful it will be for both theory and practice. It should be emphasized, however, that the defining characteristics should be closely related to alcoholism. While male and female alcoholics may differ from each other in many respects, this may tell us little about their varieties of alcoholism. If depression is a distinguishing characteristic of female alcoholics, it is important to determine if depressed female alcoholics differ from depressed male alcoholics before using gender to define a typology. Depression may do just as well. Thus it is important when searching for a typology to sample from the universe of characteristics that are specific to alcoholism. Antisocial alcoholics in treatment may be characterized by their youthfulness, but this is not necessarily germane to a typology of alcoholism unless sociopathic alcoholics require treatment at an earlier age. When comparing subtypes, care must be taken to control for confounding variables, such as age and socioeconomic status, that may distinguish certain subgroups regardless of their alcoholism. 5. Multidimensionality. In order to be comprehensive, a typological classification should be capable of differentiating alcoholics along a variety of alcohol-related dimensions. Alcoholism, after all, is a generic term that encompasses a variety of behaviors, symptoms, physical conditions, and social consequences. As the chapters in this section point out, typologies based on single dimensions such as personality functioning or family history may be of limited usefulness if they do not take into account other relevant aspects of the disorder. 6. Utility. Typological formulations are capable of serving a variety of useful purposes. As Kurt Lewin once said, nothing is as useful as a good theory. To the extent that typologies describe homogeneous varieties of alcoholism, they provide a theoretical basis for understanding how different individuals develop alcoholism and how different alcoholics progress through completely different drinking careers. In addition to their heuristic and predictive value, typological theories may be useful in suggesting more effective approaches to treatment and prevention. To be useful, typological classification systems should permit the efficient identification and assignment of patients to the most appropriate aspects of the treatment system. Because the health care system in which alcoholics are treated is complex and multifaceted,
110 II Typologies of Alcoholics the most useful typology would be one that suggests program assignment (e.g., inpatient vs. outpatient; psychiatric vs. medical care), treatment matching (e.g., psychotherapy vs. vocational counseling), treatment goals (e.g., abstinence vs. moderate drinking), intensity of treatment (short-term care vs. long-term care), and aftercare modality (Alcoholics Anonymous vs. behavioral programs). Typologies may also have utility for prevention or prophylactic measures. Should the natural history of some types be especially virulent, secondary prevention measures could be initiated at an early stage of development. Should there be a type characterized by a history of familial alcoholism, this information could be used to educate the children of alcoholics. Not all typological classifications will have equal theoretical value, clinical relevance, and administrative feasibility. The search for an all-purpose, definitive typology may distract researchers from the practical value of developing different typologies for different purposes. 7. Validity. To be credible, a typological classification should permit external validation, and its robustness should be demonstrable across different samples of alcoholics. Ideally, a typology should have cross-cultural generalizability. This would constitute p ~ r s u aevidence s i v e that the typology is reflecting essential and universal elements of alcoholism. Validity can be established in a variety of ways, many of which are discussed in the chapters that follow. In addition to these conceptual ground rules, a level of methodological sophistication heretofore unknown in typology research is displayed in the chapters that follow. The technology of differential assessment has improved dramatically in recent years. With the addition of biological tests, standardized medical and psychiatric ratings, personality and attitudinal inventories, neuropsychological assessments, family history interviews, and longitudinal research designs, it is possible for the first time to gain a comprehensive description of the variations among alcoholics. These data would be virtually impossible to summarize and interpret without the aid of high-speed computers and multivariate statistical techniques, which were not available until the last decade on a wide scale. These advances have added a new dimension to the armamentarium of typology research. A final cause for optimism is the emergence of a cadre of researchers working independently on related aspects of typology. The scientific community can be a lonely place unless there is sufficient communication to provide stimulation, encouragement and a healthy climate for competitiveness. Considerable time, resources, and career investments are needed to produce the researchers represented herein. Without a basic infrastructure of like-minded research groups, progress in any field is unlikely. Despite these encouraging developments, it would be false to conclude that typology research has come of age. The current resurgence of interest in alcoholic typologies has not resulted in any compelling systematic theories.
II Overview 111 To a large extent the field is still characterized by disciplinary parochialism and methodological faddism. Typologies historically have been dictated more by the ideological biases of the typologists than by the rich clinical data available to the scientific observer. The dominating role personality typologies have assumed during the past two decades may have less to do with the importance of psychological disorder than with the popularity of the MMPI. Perhaps the greatest shortcoming of contemporary typology theory is its failure thus far to exert any influence on differential diagnosis, clinical practice, or treatment policy. Few researchers have found the rationale or the resources to move beyond the pages of their journal manuscripts to the development of diagnostic criteria, therapeutic interventions, or specialized treatment programs. The so-called matching hypothesis, still heralded as the salvation of the treatment industry, is practically impossible to test without some credible theory suggesting the types of alcoholics who should be matched to the variety of available treatments. To date, matching research has focused on esoteric therapies while ignoring the major parameters of the treatment system through which most alcoholics are processed. Until typologies are developed having clinical relevance to the rational determination of such factors as length of treatment, compatibility with Alcoholics Anonymous, appropriateness of inpatient treatment, and the need for specialized therapies, typology research will continue to serve as not much more than an academic pastime. While it is indeed encouraging to see some evidence for the Jellinek typology in Chapter 6 (Morey and Skinner) it should be noted that, despite its nearly universal acceptance, the gamma-delta typology has inspired virtually no research in the 25 years of its popularity. The central question is how effective will contemporary typology researchers be in fulfilling the promise that has sustained interest in this subject for so long. ACKNOWLEDGMENT. The writing of this paper was supported in part by Grant No.1 P50 AA 03510 from the National Institute on Alcohol Abuse and Alcoholism.