A stage model is a model of the development of some condition or capacity that assumes the following:
- The stages are mutually exclusive. The development of the capacity or condition occurs in a discontinuous manner, such that the stages are discrete and separate from one another.
- People progress through the stages in a specific order, and the order is the same for everyone. In some cases, theorists may recognize that certain groups of individuals may progress through the stages in a different fashion than others; however, the progression is the same for that particular group.
- These particular stages are identifiable by specific indicators.
Stage models of development are often preferred by sources like the media and lay sources, because they are relatively uncomplicated and present a concrete picture of a particular type of disorder, human development, the development of personality, etc.; however, in actuality, these models often are hotly contested, and there is often little empirical validation for them. Nonetheless, these models remain popular, and several different stage models exist that attempt to define the progression of substance use disorders, particularly the progression of alcohol use disorders. There are several popular stage models of the progression of alcohol use disorders (alcoholism).
E.M. Jellinek’s Stages of Alcoholism
M. Jellinekwas a biostatistician and physiologist who developedboth a stage model of alcoholism and a designation of different types of alcoholics that remains quite popular in 12-Step groups such as Alcoholics Anonymous (AA). Jellinek’s model includes the following stages and progression:
Pre-alcoholic phase: In this phase, the individual begins drinking in social situations. A prospective alcoholic may find that they experience other beneficial effects of drinking, such as stress relief. The individual’s use of alcohol becomes a standard method for them to address these issues, and even though they are beginning to develop disordered behavior, it will not look like that to others. Tolerance to alcohol gradually develops. This stage can last indefinitely, but those with a predisposition to be alcoholics will eventually move on to the next stage.
The prodromal phase: In this phase, the individual no longer drinks specifically in social situations but uses alcohol as a method to cope. The person exhibits:
A significant increase in alcohol consumption
Hangovers as a result of significant alcohol use
Blackouts that begin to occur more frequently
Despite the appearance of these symptoms, the person still has some control over their drinking behavior.
The crucial phase: In this phase, several important developments occur that include:
Loss of control over drinking, such that when the individual begins to drink, they cannot stop
- Rationalizing their use of alcohol and making excuses for drinking
- Unsuccessful attempts to control drinking by setting up rules to follow, such as only drinking at certain times
- Developing physical and mental problems that may lead to hospitalization
- Significant tolerance and withdrawal symptoms
- A need to use alcohol just to function, such as having an eye-opener in the morning, taking routine breaks to drink during work, etc.
A number of other lay models have also accepted this particular type of progression. Despite its continued acceptance in AA, this model has received very little research support, and a number of Jellinek’s assumptions have been demonstrated to be inaccurate. For example, the notion that individuals develop blackouts as part of the progression to more significant alcohol abuse or that individuals lose control to the point of not being able to take one drink has never been substantiated. According to many sources, such as the book Recent Developments in Alcoholism: Genetics, Behavioral Treatment, Social Mediators, and Prevention Current Concepts in Diagnosis, the model is considered by most professional organizations to be invalid, and even Jellinek’s methodology would indicate that this model is not applicable. Jellinek based his model on survey results of a very small number of individuals who were already AA members and already believed most of his assumptions. Despite a general lack of acceptance by clinicians and researchers, the model continues to receive strong support from a number of 12-Step groups.
Psychiatrist George E. Valliant described a more general progression from occasional drinking to alcoholism that was based on a number of empirical observations. In his book The Natural History of Alcoholism Revisited, he proposed a simple three-stage model:
- Asymptomatic drinking: This stage consists of occasional social drinking and very few dysfunctional issues associated with alcohol use. The individual may experience occasional episodes where they drink too much, become intoxicated, experience hangovers, etc., but this is not their normal pattern of behavior.
- Alcohol abuse: Some individuals will begin to use alcohol to deal with specific issues in their lives, such as to cope with stress, try to forget their problems, manage their mood, etc. This dysfunctional use leads to a number of problems with functioning and a number of negative ramifications in various areas of life; however, the individual still sees their alcohol use as a viable need for them and continues to use the substance.
- The alcohol-dependent individual: Valiant proposed four specific symptoms that resulted in an individual being alcohol dependent:
- Significant tolerance to alcohol
- Significant withdrawal symptoms when one stops using alcohol
- A loss of control over drinking, such that individuals can no longer predict how much they will drink once they start
- Significant impairment in social and/or physical functioning as a result of any of the above symptoms
Valiant’s model initially received quite a bit of support due to its relative simplicity and its early utility in clinical diagnoses. However, later research into the development of addictive behaviors indicated that individuals do not have to display significant issues with physical dependence (tolerance and withdrawal) in order to be diagnosed with a significant alcohol use disorder (and many of them do not). As it turns out, the current conceptualization of addictions as substance use disorders indicates that an individual need not display either tolerance or withdrawal to be diagnosed with a significant and debilitating alcohol use disorder; thus, this model is not applicable to a great number of individuals.
A number of other stage models for the development of alcoholism exist that include three, four, five, and sometimes even more stages.
Most of these models have similarities to the Jellinek model of alcoholism or the Valiant model of alcoholism (or to both).
The Current Conceptualization
Currently , stage models of the development of substance use disorders are not consistent with the formal diagnostic criteria used to identify these disorders. Although it is generally recognized that individuals who develop severe issues with substance abuse have gone through some type of progression from occasional use to more dysfunctional use, the actual progression of their disorder is often based on a number of individual factors. The notions of substance abuse and addiction are now conceptualized as occurring on a continuum as opposed to occurring in a specific order of stages, and this is reflected in the diagnostic criteria used to identify these disorders currently listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (APA; DSM-5). The older notion that all individuals develop significant tolerance and withdrawal as a qualifying feature of alcoholism is based on stigmatized portrayals of individuals with alcohol use disorders and not on actual clinical data.
Currently, the DSM-5lists 11 discrete symptoms used in the diagnosis of an alcohol use disorder. These symptoms generally reflect a loss of control, strong desires to use the substance, giving up important activities in favor of substance use, the development of tolerance, and the development of withdrawal symptoms. The symptoms must be associated with significant functional impairment and/or distress as a result of the person’s alcohol use. An individual can be diagnosed with an alcohol use disorder if they display two or more of the symptoms within a 12-month period. There is no formal identification of a specific order of stages that these individuals go through, and the severity of the alcohol use disorder is based on the number of symptoms displayed as opposed to any perceived severity of any particular symptom or set of symptoms. Individuals diagnosed with severe alcohol use disorders, which would be similar to the notion of being an “alcoholic,” display six or more of the 11 symptoms.
This indicates that the clinical conceptualization of an alcohol use disorder does not identify a formal progression from occasional use to dysfunctional use and that physical dependence on alcohol is neither necessary nor sufficient for individuals to be diagnosed with severe alcohol use disorders (which would be the equivalent of the latter stages of alcoholism in the Jellinek and Valiant models).
How Does an Alcohol Use Disorder Progress?
controlling use to a period where there are obvious issues with control. Unlike many of the stage models of substance use disorders, this loss of control over use of alcohol or other drugs does not always manifest itself as an extreme compulsion to use the drug and as an inability to stop using the drug once the individual starts. Instead, the person continues to use the substance and rationalizes their use even though it is resulting in a number of negative ramifications. Individuals with substance use disorders often downplay these negative effects or the association of these negative issues with their substance use. Thus, these individuals often do not recognize that their use of alcohol or other drugs is dysfunctional even though other people may view this dysfunction as quite obvious. In other cases, individuals may recognize that their behavior is resulting in significant impairment in life.
There is no specific point in time where the dysfunctional use of alcohol or some other substance can be entirely separated from non-dysfunctional use in most individuals; like the current conceptualization of substance use disorders, this process occurs on a continuum. In any of the traditional stage models of alcoholism, the signs of physical dependence are considered to be crucial in the development of the disorder; however, many individuals with severe alcohol use disorders may not develop significant physical dependence on the drug (having both tolerance and withdrawal). Thus, there is no singular formal definition of what an alcoholic is since the actual signs that need to be present for a formal diagnosis can vary significantly from case to case. Trying to delineate specific stages of alcoholism or any other substance use disorder is far less important than helping an individual recognize that their substance use is causing problems and they need help to deal with these issues.