CANADIAN PSYCHOLOGICAL REVIEW PSYCHOLOGIE CANADIENNE VOL. 19, NO.

3, JULY, 1978

ETIOLOGY, PERSONALITY AND ALCOHOLISM

S. W. SADAVAi Brock University, St. Catharines, Ont.

ABSTRACT Personality is one necessary component of an adequate theory of problem drinking/ alcoholism. The role of personality in the etiology of alcoholism is examined in terms of prediction, explanation and causal inference. Issues are reviewed, which support the multivariate conceptions of alcohol abuse and the necessity for a multivariate theoretical framework for personality research. In the development of theory, it is important to recognize the character of alcohol abuse as both unique and consistent with other phenomena. Despite the conceptual and methodological inadequacies, the literature supports the relevance, in the alcohol problems, of dependency, defensive denial, depression, sex-role identity confusion, inadequate impulse control and subjective dissatisfaction. In order to understand the temporally dynamic processes of alcohol abuse, reciprocal interaction systems of personality, environment ond behaviour are necessary.

RESUME La personnalite est une composante necessaire d'une theorie valable sur 1'alcoolisme. Le role de la personnalite dans I'etiologie de 1'alcoolisme est envisage sous I'angle de la prediction, de I'explication et de la causalite. Un examen des travaux sur ce sujet confirme la pertinence des conceptions multivariees du phenomene de Tabus d'alcool et la necessity de recourir a un cadre theorique multivarie pour conduire les recherches sur la personnalite. Dans ['elaboration d'une theorie, il est essentiel d'envisager la phenomene de I'abus d'alcool comme ayant un caractere a la fois unique et consistant avec d'autres phenomenes. Malgre les imperfections conceptuelles et methodologiques des travaux faits a ce jour, les donnees permettent d'identifier, dans les problemes d'alcoolisme, des elements de dependance, de deni defensif, de confusion dans I'identite des roles sexuels, de controle inadequat des impulsions et d'insatisfaction subjective. Pour comprendre le processus dynamique temporel de I'abus d'alcool, il est necessaire d'elaborer les systemes ou la personnalite, I'environnement et le comportement interogissent.

" . . . the investigation of any trait in alcoholics will show that they have either more or less of it." (Keller, 1972, p. 1147) Statements such as "Keller's Law" reveal a certain pessimism about the relevance of personality to alcohol problems.2 Beyond theoretical and methodological difficulties, the very purpose of these
iSupported by Leave Fellowship 45-760, Canada Council and by a grant from the Faculty Research Fund, Brock University. The paper was drafted while I was a Visiting Scholar at the Wright Institute, Berkeley, California, U.S.A., and stimulated by discussions with Nevitt Sanford. The constructive comments of two anonymous C.P.R. reviewers, and the help of Eileen Brown and Susan Dafoe are gratefully acknowledged. Terms such as "abuse", "problem drinking" and "alcoholism" are used with the confusing interchangeability evident in the literature. Some degree of order and precision will emerge later.

investigations is under attack. One psychoanalyst (Kubie, 1974) dismisses such research as "naive and erroneous", claiming that alcohol "superimposes this illusion of identity and similarity" upon alcoholics. The atmosphere is heavy with impending "paradigm crisis" (Kuhn, 1970). The purpose of the present essay is to evaluate the role of personality in the etiology of alcoholism. This will involve a consideration of the concept of etiology, and of some current issues in "mainstream" personality and social psychology. Previously published reviews of the literature in various types of relationships of individual differences and alcohol use will not simply be duplicated (see Sutherland, Schroder and Tordella, 1950; Syme, 1957;

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Armstrong, 1958; Lisansky, 1960, 1967; Blum, 1966; Roebuck and Kessler, 1972; Braucht, Brakarsh, Follingstad and Berry, 1973; Kohn, 1974; Beckman, 1975; Hoffman, 1976; Sugerman and Schneider, 1976; Knox, 1976; Miller, 1976; O'Leary and O'Leary, 1976; Smart, 1976; Zimering and Calhoun, 1976; Williams, 1977). Rather, a critical overview of the current status of theory and research in the area will be provided. The argument to follow is that inquiry into the role of personality in alcohol use/ abuse is theoretically necessary, logically defensible and empirically supportable. Consider a pair of ,"null hypotheses": (1) in a given environment, everyone is equaly vulnerable to alcohol problems, and (2) those who abuse alcohol are different only in their drinking. While the notions of cause and effect implicit in such statements are rather primitive, absolute uncertainty must be rejected as a prerequisite to explanation, understanding or science. Alcohol problems simply do not "happen" randomly and spontaneously, to people. Explanations have been sought elsewhere. Given the limits of situationism (Bowers, 1973), the influence of culture, family, stress and other factors is well established. However, findings of environmental variables as significant do not eliminate individual differences within common environmental conditions. Biochemical factors are generally viewed as predispositional, not as full explanations. While drinking behaviour is learned, individual differences persist in choices of learning environments, and in the perception, information processing and reinforcing properties of environmental events, alternative behaviours and the consequences of drinking. Thus, while the validity and usefulness of environmental, learning and biochemical models is not at issue, such models do not fully account for the inevitable inter-individual variations. Therefore, systematic investigation of the role of personality in alcoholism is necessary. Subsequent discussion will delineate issues in such systematic work, and then review substantive findings in terms of their systematic contributions. First, the concept of etiology will be con-

sidered in this area, particularly as it pertains to causal inference and to the explanation of alcohol abuse. Then, some of the conceptual and design problems in personality-alcoholism research will be assessed. An overview of the research will extract six, well-documented individual difference themes; the conceptual and etiological significance of each will be considered. Finally, future directions in the development of etiological systems will be outlined. PERSONALITY AND ETIOLOGY Etiology pertains to the study of origins or causes. It thus becomes necessary to provide an explicit consideration of the implicit issues surrounding the role of personality as a "cause". These will include the problems of distinguishing among causal, consequent and correlated phenomena, the processes of development and change over tune, and the inference of explanation from temporal antecedence. Finally, the role of personality as a "necessary" and "sufficient" explanation is assessed. While specific suggestions will be offered for a logical framework of etiology, the preoccupation with linear causality will be questioned. Clearly the finding of a given personal characteristic which coincides with or even precedes the pattern of problem drinking, is not in itself, an explanation. In the case of alcoholism, a previous history of problem drinking is a powerful predictor and a logical "cause" of later problem drinking. Involvement in alcohol abuse can "cause" changes in personality. Perhaps the very concept of etiology can be seen as an unnecessary obstacle to adequate theorybuilding. Causes, correlates and consequences A literature consisting largely of clinical and cross-sectional studies has obvious limitations. Those receiving treatment for alcoholism, or participating, at one point in time, in survey research, cannot be assumed to be representative of a larger population. And, of even greater significance, is the issue of causal inference about a personal attribute observed in clinical alcoholics or problem drinkers,

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which may or may not have preceded the drinking pattern. While self-evident, this issue is sadly ignored or finessed in much of the literature, perhaps because of an unwarranted assumption of consistency over time in personality (e.g. Endler and Magnusson, 1976 (a); Mischel 1973). Cross-sectional studies are not unimportant, even to etiology; for example, Smart (1976) and Williams (1970) observe important parallels in adolescent and college-age problem drinkers and adult alcoholics. However, cause and effect cannot be directly inferred. When a given characteristic is observed among "alcoholics" or problem drinkers, alternative interpretations are available. If the characteristic preceded alcohol use in time (e.g. in childhood or adolescence), it may well be a cause of later drinking problems. Or, alcohol abuse may have caused personality change; the pharmacological and psychological effects of chronic excessive drinking, combined with social stress, are entirely conceivable sources of personality change. It is also possible that simultaneous changes in personality and alcohol-related behaviour were caused by social, developmental or other factors. For example, consider the findings of masculine identity problems in pre-alcoholic boys (Jones, 1968; McCord and McCord, 1960). While these longitudinal findings support a causal interpretation, the nature of the causal process cannot be directly discerned. Perhaps masculine identity problems led immediately to heavy, escapist patterns of drinking, and later to adverse consequences. Perhaps masculine identity problems caused an "acting out" style of drinking which produced adverse consequences, independent of the quantity consumed. Perhaps masculine identity problems constitute part of a personality pattern which is more likely to be labeled as alcoholic, less likely to self-correct drinking problems, or less likely to "recover". While the temporal ordering of events does suggest possible cause, systematic, repeated observations would reveal what happened between pre-adolescence and adult "alcoholism". Even longitudinal research cannot be expected to produce a simple causal theory of problem drinking. Personality

can lead to problem drinking, and problem drinking can lead to personality problems. Both a given personal characteristic and a given pattern of drinking may be caused by other factors, or may intensify these factors. For example, an alcohol-abusing group may be selected by a dependent, abuse-prone person who may find social models and reinforcement for excessive drinking. Personality can thus be most useful within a network of interrelated person, environment and behaviour variables. In the interpretation of both clinical and "premorbid" studies, temporal sequence is a primary etiological consideration. Several reviewers offer different interpretations. Kinsey (1966) suggests that personality is only predispositional to the later social learning that leads to alcoholism. Lisansky (1960) states that different personality antecedents all lead to one common "alcoholic personality" pattern. But, Clark argues that one common personal disposition may lead to widely heterogeneous alcohol problems. Perhaps a major problem in such formulations is the neglect of a temporal dimension to alcoholism or problem drinking. Rather than mere descriptions of the correlates or predictors of "premorbid" and "pathological" states, the role of personality can be investigated within a temporally dynamic process. For example, Jellinek (1952) described four phases of the alcoholism disease process; while subsequent data support challenges to this formulation of an invariant sequence, the notion of sequence has received renewed support by Mulford (1977). Processes of transition or change can be defined with some precision. At one polarity, the transition between abstainer and drinking statuses is highly significant (e.g. Gorsuch & Butler, 1976; Sadava & Forsyth, 1977; Jessor & Jessor, 1977; Stacey & Davies, 1970). Longitudinal study can distinguish between predictors of the transition itself, and predictors of subsequent problems. Thus, it becomes necessary to study quantitative changes in drinking behaviour, and in drinking problems. In relation to the alcoholic role, one can study changes in seeking help for drinking problems, and in how the person

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and significant others assess the individual's drinking. And, once the labelling process and self-concept changes have occurred, the maintenance of the alcoholic role and alcoholic behaviour is a distinct stage. An "etiology" must be specific to these temporal processes. Consider, for example, the reports of dependency conflict in alcoholic males. This may predispose heavy drinking, to deny or cope with the conflict. It may accompany heavier drinking, as alternative means of coping with the conflict are neglected. It may lead to increasing problems caused by drinking, as rejection or the protective reactions of others intensify the conflict. It may influence the recognition and acceptance of one's "alcoholism", contingent upon the dependent or counter-dependent orientation of the person. And it may contribute to a maintenance of "alcoholism", as social alternatives disappear. Systematic long-term study could investigate these
hypotheses.

Further, personality factors, crucial at one stage, may later become irrelevant. Allport's (1937) concept of functional autonomy suggests that the carelessly dropped match which caused the forest fire may no longer be relevant to the "etiology" of that fire. Allport states that compulsive, maladaptive behaviour patterns are particularly representative of the "acquired rhythms" or habits which become selfmaintaining. Thus, systematic study of personality in relation to processes of change over time may identify the temporal boundaries of specific personality causes, influences and changes. Personality as predictor vs. explanation It is important to consider that antecedent events cannot, in themselves, explain subsequent events. Longitudinal research can establish personality dimensions which precede the onset of drinking problems. Such evidence can be used to generate hypotheses about the development of alcohol abuse. But inquiry must be directed toward an understanding of "drinking in the context of personality" (Sanford, 1968, p. 14), which demands more than temporal antecedence. Consider, again, a possible dependency conflict in pre-alcoholic subjects. Drink-

ing may develop as a means of escaping emotional conflict. Or, it may be useful as a "game", a socially acceptable outlet for dependent behaviour, or the experience of psychodynamic "infantomimetic" dependency. It may have been a hard-drinking, stereotyped acting-out, in reaction to dependency needs. It may have represented oral gratification, an impulsive, uncontrolled reaction to feelings of futility, or a functionally autonomous habit. Thus, even the discovery of antecedent predictors cannot fully explain why the individual drinks excessively or with problems. The purpose of etiology is explanation. To explain drinking problems, or any other behaviour, one must understand the personal meanings or functions represented by the behaviour. For example, in the literature, drinking in response to external stress or psychic distress is frequently assumed to be linked to problems with drinking. The concept of "psychological dependence" refers to any pattern of drinking which is intended to change mood or relieve psychological problems (Cahalan and Room, 1974). Terms such as the "personal effects" functions of drinking (Mulford and Miller, 1960, 1963; Jessor, Carman and Grossman, 1968; Burns and Carman, 1976) "assuagement" drinking (Fallding, 1964) "ataraxic motivation" for drinking, (Edwards, Chandler, Hensman and Peto, 1972) and "escapist" drinking (Sanford, 1967) all refer to this pattern of drinking in response to stress or discomfort. Indeed, some of the diagnostic measures of "alcoholism" combine items pertaining to coping or escapist functions of drinking with those directly assessing drinking behaviour (Miller, 1976). Research on the explanatory role of personality can benefit from integration with the experimental literature (Nathan and Lisman, 1976; Cappell and Herman, 1972). In the example of stress-induced drinking, studies show that drinking can increase anxiety, even in stressful situations (e.g. Polivy et al., 1976). If drinking occurs in response to stress, and if the tension-reducing properties of alcohol are minimal and unreliable (Cappell and Herman, 1972), then stress-related drinking may not represent escapism (Sadava, Thistle and Forsyth, in press).

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Necessary vs. sufficient condition The limits to the explanatory or predictive role of personality in the etiology of alcoholism must be recognized. If a given characteristic is discovered in alcoholism, this implies neither that all alcoholics have it nor that only alcoholics have it. The typological studies reviewed below suggest that one, unique "alcoholic personality" is an empirical improbability. But further, an "alcoholic personality" could not be assumed as a sufficient condition. A given predisposition may have alternative consequence; adolescent sexrole identity problems may lead to aggression, compulsive promiscuity, involvement in stereotyped masculine activities, hostility to women's rights, or, perhaps, to maturity. Predisposition implies combination with other factors to "cause" a given consequence. If a young man with masculine identity problems has permissive personal norms regarding drinking, lives where alcohol is accessible and cultural norms prescribe "drinking like a man", and is with peers who support heavy drinking, then alcohol abuse becomes increasingly probable. Thus, we began with the insufficiency of environment or biochemistry; now we must recognize the insufficiency of personality. Dimensions of personality must be components in an etiological system. Personality predispositions will interact with environmental predispositions, along with the previous and contemporary behavioural patterns, in sets of reciprocal causal patterns. Alcohol research, traditionally multi-disciplinary, now needs interdisciplinary theory-building. A most appropriate emerging paradigm is that of person-environment interaction (e.g. Endler and Magnusson, 1976; Magnusson and Endler, 1977; Rotter, Chance and Phares, 1972; Bowers, 1973; Ekehammar, 1974; reference note 2). Personality and environment are supplementary in predicting behaviour: further, interactionist components of specific combinations of person and environment increase prediction and understanding. Consider, for example, that sex-role identity problems are unlikely to lead to drinking problems in cultures where excessive drinking does not represent adult "masculinity". Peer

pressures are less likely to affect the individual with strong independence needs. The experience and effects of stress is determined by a combination of environmental events and the individual's tolerance or adaptability. Edwards (1974) suggests a model of interactions among person, environment and drug parameters which is consistent with this paradigm. Much of the contemporary work in interactional psychology involves relatively simple "treatments by within-subjects" experimental designs. The study of molar patterns of drinking behaviour over time would involve molar, temporally extended patterns of relative consistency in personal and environmental attributes. Thus, the person-environment interaction paradigm must be extended to Cronbach's (1957) "other discipline", of individual difference correlational field research psychology (Reference Note 1). CONCEPTION AND DESIGN ISSUES Several major problems have impeded progress in personality-alcoholism research. Simple, unitary conceptions of "alcoholism" are conceptually inadequate and empirically inaccurate. Haziness over both the unique and common properties of drinking and abuse, among other behaviours, causes confusion. And, the ultimate sterility of single-trait, empirical studies must be recognized. The criterion: conceptions of alcoholism and drinking Miller (1976) reviews the difficulties in definition which plague efforts to assess "alcoholism". Diagnostic criteria, while of some immediate clinical use, (Criteria Committee Report, 1972) are broad, vague and may not be interchangeable (see Clark, 1975). Room, (1970) points out that the "disease of alcoholism" is defined as (1) medical business, (2) undesirable, (3) a condition suffered by an individual, and (4) somewhat beyond the will of the afflicted person. Jellinek was compelled to suggest that "alcoholism" is "what the medical profession recognizes as such" (1950, page 12). Apart from theoretical, metaphorical, ethical and social implications, the disease concept of alcoholism creates major difficulties for system-

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atic research. The assessment of alcoholism, in relation to normative patterns of drinking, cannot be ignored (Vogel-Sprott, 1974; Cahalan, Cisin and Crossley, 1969; Encel, Kotowicz and Resker, 1971). The longitudinal study of McCord and McCord (1960, 1967) provides a useful illustration. An "alcoholic" was defined as an individual who was, (1) a member of Alcoholics Anonymous, (2) referred to an alcoholism treatment agency, or (3) convicted twice in a court as a "public inebriate". While the operations are clear, Clark (1975) points out cogently that the defining and selection of subjects is left to A.A., treatment agencies and the criminal justice system, and thus are biased by individual dispositions to join groups, cultural values, the limits of family tolerance, willingness to accept therapy, inconsistent police and court practices, and socioeconomic status. Individuals meeting any of the three criteria cannot be considered as representative of those with drinking problems. And the assumption that the three are equivalent and interchangeable criteria of one "alcoholism" phenomenon is insupportable. Research into alcoholic typologies further erodes the assumption of homogeneity. Some of these are based directly upon the pattern of drinking behaviour (Jellinek, 1966). Diagnostic distinctions are made between "continuous" and "episodic", "addicted" and "non-addicted", and "loss of control" and "inability to abstain" types (e.g. Walton, 1968; Tomsovic, 1974; Vogel, 1971). Other systems are based upon personality, using multi-dimensional measures such as the M.M.P.I. (Mogar, Wilson and Helm, 1970; Whitelock, Overall and Patrick, 1971) and the Jackson Differential Personality Inventory (Partington and Johnson, 1969). Blum (1966) suggests a typology based on the stage of psychosexual fixation in development, while Blane (1968) distinguishes among dependent, counter-dependent and dependency-fluctuation alcoholics. Sanford (1967) outlines a functional typology of "escapist", "facilitative" and "integrative" drinking, while Emery (1960) delineates the "social", "reparative" and "indulgent" drinker types. While evidence of conver-

gence among the various typologies is sparse, these studies do show that simple "alcoholic vs. control" comparative group designs must be abandoned. In the assessment of alcoholism, Miller (1976) advocates a focus upon actual drinking practices. This is consistent with the "problem drinking" approach of Cahalan, Jessor and others (Cahalan and Room, 1974; Cahalan and Roizen, 1974; Clark, 1976; Jessor and Jessor, 1973; Fillmore, 1975; Ahlstrom-Laasko, 1975; Sadava and Forsyth, Reference Note 2). Rather than external criteria, a set of dimensions of drinking behaviour and consequences can be defined; quantity of intake, frequency of drinking, frequency and duration of intoxicated episodes or binges, perceived loss of control such as being unable to stop or abstain, inappropriate situations for drinking, adverse consequences of alcohol use in various areas of life. These can be treated as continuous dimensions, or with clearly defined cut-off points. This clarity and replicability of these criteria are obviously advantageous for systematic research. The research cited above has yielded important insights about the dimensions of drinking. Problem drinking may be defined in terms of the actual drinking behaviour, the control or "plasticity" (Edwards, 1974) of drinking, or the problems attributed to drinking. Within and between sets of criteria, remarkable independence of variability have been found. For example, among 61 problem drinkers, 59% reported problems due to drinking in only one area, (e.g., legal, financial or family). While quantity consumed and problems are correlated, this relationship is surprisingly modest. The longitudinal data shows frequent changes toward fewer drinking problems, and to a regaining of the control over drinking previously reported as lost. Indeed, experimental evidence of drinking among alcoholics challenges the very existence of a progressive "loss of control" mechanism which underlies the disease model (Mello, 1972; Marlatt, Demming and Reid, 1973). Surely, personality research designs and theories must incorporate these new insights.

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Specificity vs. generality of alcoholic phenomena An etiology, as any theory, can refer to a narrow phenomenon, or to a broad class of related phenomena. For example, one may propose a theory of "alcoholism", "problem drinking" or other global criteria, or of the quantity of alcohol consumed, adverse consequences to health, marital problems attributed to alcohol or membership in A.A. While both directions are legitimate, precision in purpose and in defining the target phenomenon is necessary. While the discovery of the one, true "addictive personality" is unlikely, recent reviews (Kohn, 1974; Braucht, Brakarch, Follingstad and Berry, 1973; Sadava, 1975) have suggested general theories of substance abuse (alcohol, cannabis, psychedelics, tobacco, opiates, cocaine, barbiturates, emphetamines, etc.). Such efforts could profit from attempts to make functional, conceptual distinctions among drugs (e.g., Lipscomb, 1971). In that many alcoholics are also, at some time, polydrug abusers (see Kohn, 1974), the relevance is clear to the alcohologist. Blum reviews psychoanalytic writings which suggest a further broadening to a class of compulsive or "addictive" behaviours, defined as "repetitive, unadaptive attempts at active mastery" (Blum, 1966, page 263). Such behaviours as kleptomania, gambling, "Don Juan" type promiscuity, over-eating, over-sleeping, "workaholism", compulsive shopping and, perhaps, even viewing television "soap operas" would be included. Alternatively, lessor and his colleagues (Jessor and lessor, 1977) work within a general model of deviant or problem-prone systems of adolescent behaviours, including militant political activism, premarital sexuality, alcohol and marijuana use and engagement in a variety of deviant behaviours such as lying, stealing, cheating and aggression. Here, alcohol abuse is conceived as a component of a broader system of problem behaviour in adolescent development. Conceptually, each increment in generality raises new questions. A general model of deviant or addictive behaviour, while theoretically impressive, cannot fully account for the occurrence of chemical

abuse, rather than, for example, excessive work habits, gambling or aggression. A general model of substance abuse cannot fully account for the one or more substances selected for abuse. And, a general theory of "alcoholism" or "problem drinking" cannot fully account for differences in treatment referral, legal problems or marital disruption specific to some "alcoholics" or "problem drinkers". Systematic theory construction and research within this perspective is sorely needed. Univariate trait studies vs. personality The concept of personality implies an integrated system. However, most of the research uses one trait or a set of individual differences subscales. While these studies provide useful cumulative information, the discouragingly low levels of prediction reflect Mischel's (1968) pessimism regarding individual differences. Of course, as Hagen, DeSoto and Solano (1977) warn, a ceiling of 9% shared variance between one trait and drinking does not mean that the remaining 91% is environmentally determined. But, beyond the necessity of multivariate personality research, a given individual difference becomes meaningful within the context of a theory-based personality system. To illustrate the problems of isolated trait studies, consider the literature relating drinking to Rotter's (1966) locus of control construct. One could predict that alcohol abuse either reflects futility and helplessness (external) or a purposive action intended to modify mood (internal). The research findings are highly inconsistent. Weissbach, Vogler and Compton (1976) suggest that the construct lacks a clear theoretical rationale relating it to drinking. However, Hinrichsen (1976) points out that these studies, as do most in the locus of control literature (Rotter, 1975), wrench the concept out of the context of social learning theory. In the absence of other components of the theory other generalized expectancies, specific goal expectancies, reinforcement values, situational parameters locus of control becomes another, barren indicator of "maladjustment". Some theorists provide rather elegant contexts for essentially univariate models.

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Blane (1968) and McClelland et al (1972) conceive of sets of personality variables as expressions of, or secondary to dependency conflict or personality power motivation. While some evidence supports both models as partial explanations, support for the primacy of these characteristics would have to come from extensive longitudinal research. Avowedly multivariate approaches use patterns of personality characteristics, often from test batteries. Studies using the M.M.P.I. report several, unrelated profiles among alcoholics. (Hoffman, 1976; Miller, 1976). From an "arbitrarily limited domain", Cahalan and Room (1974) selected nine variables representing general areas of "ego resiliency" and "ego control" which emerged from Block's (1965) factor analytic studies of the M.M.P.I. Lisansky (I960) proposes a pre-dispositional core, consisting of intense dependency needs, low frustration tolerance and unresolved ambivalence (love vs. hate) about the self and others. In contrast with the above approaches, multivariate theories construct networks of systems of variables which are logically related, and derived from more fundamental psychological theory. Blum (1966) in her review of the psychoanalytic explanations of alcoholism, stresses their logical derivation from basic psychoanalytic theory. Equally crucial, she criticizes the practice of selecting isolated variables from complex, multivariate theories. lessor's "problem behaviour" theory is similar in that a system of personality structures (instigative, belief, controls) is construed within expectancy-value social learning theory, and, in turn, constitutes one component of a larger social-psychological framework. Clearly these approaches are necessary to provide an explanatory context for univariate findings. Overview: Personality and Drinking Problems. The preceding has discussed a set of methodological and conceptual impediments to the development of a psychological etiology of alcohol abuse. Of immediate importance is the necessity of specifying, and understanding, the meaning of alcohol abuse as a criterion. The literature

has used global terms such as "alcoholic", defined inconsistently and without precision. Alcohol abuse is a complex phenomenon. Therefore an adequate personality-based etiology must be directed toward the specific set or patterns of behaviour: the problems and the "control" aspect cannot be ignored or indiscriminately aggregated into one homogeneous "disease of alcoholism". Once adequate conceptions of the problem-drinking phenomena are developed, an adequate etiology can begin to be developed. An explicitly multivariate approach is necessary, in which patterns of personality variables can become meaningful within a more general framework of theory. And, the task of theory construction should account for both the unique and generalized aspects of alcohol abuse and drinking problems. THEMES AND VARIABLES "Keller's Law" suggests that the vast personality-alcoholism literature, while replete with statistically reliable trait differences, does not provide useful, convincing pattern of individual differences. The present overview of the same literature suggests otherwise. Despite the inconsistencies and inadequacies in design, measurement and data, a pattern of individual differences associated with alcohol problems can be identified. The term "theme" has been adopted to denote a common core of psychological meaning underlying disparate constructs and measures. The following will review evidence of six individual difference themes associated with alcoholism: dependency, denial, depression, sex-role identity problems, inadequate personal impulse control, personal dissatisfaction. The alternate conceptual approaches to each theme will be delineated, and the etiological significance of each will be considered in the light of the earlier discussion of the issues of etiology. A fundamental fact to note is that, despite wide variation in theoretical constructs, measures and samples, each of the themes is supported by extensive, multi-method, cross-sample replication. They constitute a body of knowledge which cannot be ignored.

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Dependency In her excellent review of psychoanalytic theories of alcoholism, Blum (1966) describes a crucial role for dependency. Parental thwarting, over-indulgence or inconsistency in response to early dependency needs tends to impede psychological maturation, perpetuating dependency needs into adulthood (Knight, 1937). Fenichel proposes a symbolic parallel between oral dependency and satisfaction in a bottle. Alternatively, Levy (1958) suggests that alcohol enables an experience of dependency free of a "narcotized ego". However, empirical evidence of significantly more intense dependency needs among alcoholics is not particularly convincing (Tahka, 1966). Blane (1968) proposes that, apart from the intensity of dependency needs, a psychological conflict over those needs is crucial to the male alcoholic. Subject to pressures toward culturally-defined masculine identity, he cannot express and satisfy these dependency needs. This conflict may be resolved by an exaggerated surrender to dependency needs in which excessive drinking is useful in avoiding independence. An exaggerated super-masculine counter-dependency may emerge, in which "drinking like a man" becomes excessively important, or the person may fluctuate between dependency and counter-dependency. Some supportive evidence is reported (McCord and McCord, 1960; Blane and Chafetz, 1971; Irgen-Jensen, 1971; Bacon, 1974). Research on field dependency has found this perceptual orientation in substantial majorities of alcoholic samples (Sugerman and Schneider, 1976). The evidence does not consistently link field dependency to interpersonal dependency (Rhodes and Yarioka, 1968; Goldstein and Chotlos, 1966). However, a recent review suggests relationships with stress adaptation, intrinsic motivation and incidental social learning. Thus, the effects of field dependency upon drinking may be through subtle mediational processes. If stereotyped female roles encouraged dependent behaviour in women, then conflict would not exist. Some writers suggest overwhelmingly intense dependency needs among female alcoholics, sufficient

to cause role incongruity (Beckman, 1975). Blane (1968) suggests that feelings of inadequacy, rather than dependency conflicts, cause alcoholism among women. Perhaps the conflict lies between needs and the demands of adult roles, male and female. Lisansky (1960) points out that psychoanalytic writers define "orality" in terms of both dependency and general immaturity. Steiner's (1971) conception of alcoholic "games" is consistent with this interpretation. Depression Multi-method research has yielded frequent reports of depression among clinical samples of alcoholics (Weingold, Lachin, Bell and Coxe, 1968; Hewitt, 1943; Goss and Morosko, 1969; Wine and Edwards, 1964; Mogar, Wilson and Helm, 1970; Pitts and Winokur, 1966). Freed (1970) reviews primary vs. symptomatic interpretations of these findings. A logical and parsimonious view would attribute depression to the social, psychological and pharmacological consequences, to the individual, of chronic, excessive drinking. One relevant longitudinal study of alcoholics found elevation of the D scale (M.M.P.I.) at the clinic, although not in college 13 years earlier (Kammeier, Hoffman and Loper, 1973). However, depression may not be exclusively a consequence of alcoholism. Psychodynaaiie theorists describe a self-punitive component common to alcoholism and depression (Menninger, 1938; Simmel, 1948). In a psychometric study with two measures of depression, similar factor structures were found with clinical samples of primary depressives and alcoholics. Williams (1970) reports depression in pre-alcoholic college problem drinkers. There is abundant evidence of the link between alcoholism and suicidal behaviour (Batchelor, 1954; Glatt, 1954; Palola, Dorpat and Larson, 1962; Pokorny, 1964). Again, while the life situation of the chronic alcohol-abusing person is implicated, a more complex cause and effect pattern is possible. Studies of alcoholics report links between suicide and both affective depression (Woodruff, Guze, Clayton and Carr, 1973) and cognitive

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hopelessness (Beck, Weissman and Kovacs, 1976). These parallels with studies of non-alcoholics suggest an etiological significance. Indeed, Menninger's (1938) description of chronic alcohol abuse as, in itself, "slow suicide" may well have a psychological validity. Defensive denial or ambivalence Conflict about drinking alcohol begins prior to the onset of alcohol problems. The early drinking experiences tend to occur in situations which arouse feelings of guilt and anxiety (Ullman, 1953). Parents of individuals prone to excessive drinking tend to be either excessive drinkers (McKay, 1961; Robins, Bates and O'Neal, 1962; Rosenberg, 1969), or totally abstinent, (Wittman, 1939), and tend to be more frequent users of other mood modifiers (Smart and Fejer, 1972). They also tend to diverge greatly from each other in their attitudes toward alcohol (Jackson and Conner, 1953). This profound ambivalence toward alcohol is related to drinking problems (Menaker, 1967; Cutler, 1969). The clinical problem of denial (Sterne and Pittman, 1965) can be inferred as a reaction to learned ambivalence. Evidence indicates more generalized defensiveness. Clinical studies of alcoholics report both boastful grandiosity and an "abysmally low" self esteem (Machover and Puzzo, 1959). Blum (1966) reviews psychoanalytic interpretations of denial of latent homosexuality. Longitudinal studies found evidence, in pre-alcoholic youth, of a pattern of denial of anxiety and stress (Jones, 1968; McCord and McCord, 1960, 1962). Thus, defensive denial appears to be more generalized than simply as a reaction to alcohol abuse and the alcoholic role. Sex-role identity problems Blum (1966) reviews psychoanalytic writings which suggest latent homosexuality among alcoholics. Levy (1958) suggests that alcohol serves to sublimate these anxiety-provoking homosexual impulses. However, Lisansky (1960) notes that "latent homosexuality" has been defined by various writers as equivalent to heterosexual maladjustment, feminine identification, strong maternal attachment, depend-

ency, passivity, seeking male friends and homosexual experiences. It is difficult to discern conceptual or empirical consistency in this melange. However, problems in male sexual identity are clearly implicated. The stereotyped "two-fisted" drinker who can "hold his liquor" is an unfortunate but persistent cultural hangover. In both of the longitudinal studies of pre-alcoholic boys (Jones, 1968; McCord and McCord, 1960) evidence is presented of confusion and inadequacy in the masculine selfimage, with "overplaying" of the stereotyped male role. O'Leary and O'Leary (1976) review evidence of early development and later progressive deterioration in this masculine facade, as the effects, on libido, of heavy drinking become increasingly self-evident. The research on power motivation and alcohol use (McClelland, Davis, Kalin and Wanner, 1972) also suggests masculine sex-role identity problems. The power imagery, exhibited by heavy drinkers, is that of a personalized domination rather than a "socialized" goal attainment. Macoby's description of the Mexican "machismo" alcoholic is illustrative of the stereotyped masculine acting-out of personalized power needs. Indeed, McClelland (Chapter 13) points out the relationship between cultural sex-role demands and personalized power needs, observing the combination of demands for masculine assertiveness and an absence of supports for male role behaviour. Sex-role identity problems are observed in female alcoholics (Beckman, 1975; Kinsey, 1966; Blane, 1968). Mogar, Wilson and Helm (1970) interpret 75% of 100 M.M.P.I. profiles in terms of forms of "hyperfeminity". Pre-alcoholic girls are described as confused and self-negating, while, in later adolescence, an "escape into ultra-femininity" is observed (Jones, 1971). In studies of the fantasy of female alcoholics, Wilsnack (1963) reports strong feelings of sex-role inadequacy; drinking increased stereotyped "femininity" imagery and decreased power imagery. The difference in this area between male and female alcoholics in terms of cultural sex-role definitions reveal a common theme of sex-role identity conflict.

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Again, these problems may well be aspects of a more generalized confusion in mature adult roles. In an era of major changes in sex-role expectancies, the research may well be dated (Knox, 1976). Indeed, the current confusion and ambiguity in cultural definitions of sex roles may have implications for alcohol abuse. Clearly, research must study and recognize the changing stereotyped role prescriptions, both for sexuality and for general maturity. Inadequate personal controls Axiomatic in conceptions of alcoholism, alcohol abuse or drinking problems is an inadequate control. Jellinek (1960) postulated "loss of control" as crucial to his "disease concept. While recent experimental work (e.g., Nathan and Lisman, 1976) challenges the notion of an "all-ornothing" control mechanism triggered by alcohol, the conception of a relative impairment in personal control over drinking persists (e.g., Keller, 1976; Cahalan and Room, 1974). It also makes sense. Again, problems with impulse or behavioural controls appear to be more generalized. Contemporary "ego" psychology theorists (e.g., Hartmann, 1964) conceive of deficits in ego autonomy, to explain both a generalized absence of impulse control, and, among alcoholic writers and artists, the "paradox of creativity in the midst of deterioration" (Blum, 1966). Personal impulse control problems are included in theories as disparate as power motivation (McClelland et al., 1972) and cognitive social learning (Jessor, Graves, Hanson and Jessor, 1968; Mischel, 1973). Empirically, a wide assortment of variables demonstrates a relative deficit in personal controls. Several studies report impulsivity and aggression in problem drinkers (Williams, 1970; Cisin and Cahalan, 1968; Cahalan and Room, 1974). Others report a constricted future time perspective (Gliedman, 1956; Smart, 1968; Sadava and Forsyth, Note 2). Krauss, Mozdierz and Maccitelli (1971) report an elevated sensitivity to a risk of external censure, as opposed to internalized controls. Correlations with attitudinal tolerance of deviance and with religiosity are reported (Jessor and Jessor, 1973; Carman, 1971). Relationships are report-

ed between adolescent and adult drinking patterns and other problem-prone behaviours: gambling, cigarette smoking, adolescent sexual behaviour, illicit drug use, shoplifting, lying, cheating, property damage, over-eating, over-working (Jessor and Jessor, 1973; Wechsler and Thum, 1973; Haberman, 1969). Of some 155 published M.M.P.I. studies which included alcoholics (Dahlstrom, Welsh and Dahlstrom, 1975) at least fourteen report significant elevation in the Psychopathic Deviance Scale. That particular scale includes three items, pertaining to alcohol abuse, trouble with the law and having "not lived the right kind of life", which produce the discriminant validity, for alcoholics, of the scale. However, a pattern of impulsivity is evident in M.M.P.I. profiles, including those of prealcoholic college freshmen (Hoffman, Loper and Kammeier, 1974; Loper, Kammeier and Hoffman, 1973). Records, in a child's guidance clinic, of pre-alcoholics, show a substantially higher incidence of behaviour control problems such as theft, running away and assault (Robins, Bates and O'Neal, 1962). Jones (1968, 1971) reports that early adolescent pre-alcoholic males were "undercontrolled and impulsive", while females tended to have fathers with lax or erratic disciplinary practices, and tended to behave in ways described as "hyper-active" and with "unrestrained aggression". The converging evidence of these studies is of an inadequacy hi personal controls, which generalizes beyond alcohol use and which antedates drinking problems. Personal dissatisfaction Relationships are reported between subjective dissatisfactions or unhappiness and heavy drinking in a national U.S. survey (Brenner, 1967). Low expectancies for the satisfactions of needs or attainments of valued goals is related to higher levels of drinking and drinking problems (e.g., McClelland et al., 1972, Carman, 1971; Jessor, Carman and Grossman, 1968; Jessor, Young, Young and Tesi, 1970). Alienation, reflecting a generalized social dissatisfaction, has been linked to problem drinking in Jessor's work and in Cahalan (1969).

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What is not dear is the nature of the linkage. The life situation of the labelled alcoholic or the problems experienced by problem drinkers are entirely reasonable sources of dissatisfaction. However, the work of Jessor and his colleagues on adolescent drinking suggests that dissatisfaction also precedes or accompanies the development of problem drinking. (See also O'Leary and O'Leary, 1976.) Perhaps the primary source of dissatisfaction is found, not in the life situation of the individual, but in a pre-existing low tolerance for frustration (see Blum, 1966; Lisansky, 1960). Blane (1968) suggests that the alcoholic drinks because frustration triggers feelings of futility and worthlessness, consistent with McClelland's (1973) assertion that "men drink to feel stronger". Overview Six themes are common to the personality-alcohol abuse literature, dependency, denial ambivalence, depression, sexrole confusion, inadequate personal controls and personal dissatisfaction. With each of these themes, the following has been shown to be supported by some empirical evidence: (1) replication across measures, theoretical conceptions and samples, (2) consistency between alcohol and more general functioning within the person, and (3) implications of an antecedent or etiological role in the development or maintenance of abusive or excessive drinking patterns. Despite the serious problems and issues, "Keller's Law" is not an accurate representation of the literature. In the light of these data, abandonment of personality would be, at best, premature. CONCLUSIONS Siegler, Osmond and Newell (1968) have contrasted the assumptions underlying various "models" of alcoholism, which include a medical disease, a moral failing, a family interaction "game", a psychological disturbance and a social problem. Their provocative discussion shows how etiology, treatment, and social policy flow, more or less logically, from the original conception of the problem. Previous discussion has shown how inade-

quate conceptions have restricted progress in personality research and theory. The debate over the medical model will not be replayed. However, an unfortunate problem caused by this application of medical models has been the inadequate conceptions of causality inherent in the term "etiology". While it is reasonable to study antecedents of an end-state of alcoholism, we have argued that such inquiry will yield neither full explanation nor an accurate representation of the significance of personality. The model of physical sciences and the method of experimental manipulation of situations has created a frustrating "situationist" bias. Similarly, the model of a personality etiology of the end-state alcoholism disease has caused biases in theory, research design and interpretation. Both situationism and linear causality are not sufficient bases for a theory of drinking behaviour and problems. The preceding discussion argues for a "natural history" approach, within a matrix of personality, environment, possible biochemical and alcohol-using behaviour variables. Rather than traits as linear determinants of problem drinking, attention must be directed toward patterns of interaction and reciprocal influence. Personality may "cause" changes in drinking patterns. But the pattern of drinking may also "cause" changes in personality before the end-state of "alcoholism". Drinking patterns may become functionally autonomous of earlier "causes" in personality. And, even the discovery of clearly antecedent personality may not explain the processes by which alcohol becomes integrated into personality (or by which personality dissolves in alcohol). Perhaps the most salutary influence upon "alcohology" would be to bring these phenomena into the mainstream of contemporary psychological theory and research. Orford (1975) has cogently reviewed the alcoholism-marriage literature, building a powerful case against a narrow alcohologic specialism. While alcohol abuse generally fits criteria for deviant behaviour (Jessor, Graves, Hanson and Jessor, 1968), these patterns of behaviour and of problems are consistent with other human behaviours, problems and aspirations. Perhaps reflecting; persistent cultural

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