Recovering alcoholics and those who have been subject to repeated patterns of alcohol intoxication to damaging social, mental and physical effect suffer from a range of identifiable challenges and problems related to maintaining sobriety. These can be attributed to a degree of negative health related factors that can be attributed to alcohol use without which the addictive patterns of behaviour associated with alcoholism would not be of great concern to the role of the nurse. These are known as risk factors.
Similarly, there can be a number of protective factors that can be used to shield the risk factors associated with alcohol abuse.These factors are recognised, outlined and made distinct by the Washington Department of Health (2007) who state the relationship as: Risk and protective factors often are mirror images of each other. For instance, a sedentary lifestyle is a risk factor for disease, while physical activity is protective. For some risk and protective factors, the picture is more complex. Moderate alcohol drinkers, for example, have the lowest risk of heart disease, abstainers have the next lowest risk, and heavy drinkers have the highest risk.However, in the case of the recovering alcoholic or patient attempting to maintain sobriety, the risk factors are then associated with returning to alcohol consumption rather than the directly damaging effects of alcohol, which in relation to maintaining sobriety can be assumed.
Protective factors are conceptually distinct from risk factors in this instance as protective factors are characteristics or conditions that interact with risk factors to reduce their influence on undesired behaviour (Garmezy & Rutter, 1983).Therefore, there are protective factors that exist in sobriety that may halt the re-occurrence of alcoholic behaviours. This knowledge is therefore crucial to nursing as it relates to halting the risks associated with alcohol abuse. This means that by looking into research related to protective factors in sobriety better nursing techniques and knowledge can be applied to the domain of nursing practice.
This is the aim of this thesis via analysis of a range of literature and research associated with risk and protective factors relevant to sobriety.The hypothesis of this thesis is therefore that protective factors exist that can foster and maintain sobriety, whether in early life or after detoxification treatments. From this directive, we shall be looking into many of the psychological, cultural, social and socio-economic factors that create risk in returning to alcoholic behaviours and that create protection in maintaining to sobriety behaviours. The role of preventive factors in nursing and health care are significant in relation to overcoming alcohol addiction (Pogge et al, 1992).However, the return to alcohol abuse is also a concern for those involved in alcohol addiction. Much of the research in the past has been heavily influenced by the medical model and positivist psychological research.
Behaviourism and cognitive strategies have been the most significant of factors in this body of research. However, an array of factors have stemmed from counselling based therapies that have introduced the role of spirituality to the dimension of nurse care intervention. This has seen something of a change in scope and definition of alcoholic research, if not direction.This is not to undermine the biological, medical and cognitive-behavioural body of findings related to nursing alcoholism. Rather, it is instead recognising a contemporary need to incorporate new paradigms into the research that has brought about new protective factors through assessing the many social and cultural ways of analysing the causes of alcoholism, alcoholic behaviour and protective factors. Effects associated with returning to alcohol consumption have been identified and analysed by psychologists and health care authorities.
These can be seen as being essential to the domain of nursing. For instance, the success in stopping alcohol consumption and keeping protective factors is underscored as being crucial to the role of nursing in Bergland et al (2003) study that states that advice from a health care provider to reduce or stop drinking is effective in preventing major drinking problems. There are a range of issues pertaining to the development of unhealthy or undesirable alcohol consumption in the first instance that constitute risk and protective factors in giving up such behaviours.For example, social influences may be strong predictors of initial drinking in a body of subjects. However, later stages of problem drinking have been developmentally linked to intra-personal deficits (Rosenbaum, 1980).
For example, Masten et al (2006) found that disadvantaged children with lower IQ and less positive family qualities, were more likely to indulge alcoholic behaviours so as to create high stress levels (Masten et al, 2006).This intra personal relationship with risk factors in relation to alcohol behaviours can also be seen as ranging in nature across a cultural, familial and socio-economic spectrum. For instance, Chaloupka et al (2002) state that risk and protective factors also vary among Washingtonians of different races and ethnicities. This is extended by a conceptual separation put forward by Garmezy (1985) in the positing of protective factors of undesired behaviour operating at three different levels: the individual, the familial, and the societal (Garmezy, 1985).
In a range of studies concerned with current approaches to alcoholism and alcoholic behaviours, the notion of stress was put forward as a major risk factor in both becoming an alcoholic in early life and returning to alcoholic behaviours in later life in sober seeking adults. For instance, the empirical findings of contemporary theory suggested that individual risk and protective factors were organised into conceptually meaningful intra-personal clusters, which were then modelled as unique predictors of alcohol use (Pogge, 1992).This has been conceptualised in early childhood studies by Rutter (1987) as: Protective factors may contribute to resilience either by exerting positive effects in direct opposition to the negative effects of risk factors (additive model) or by buffering individuals against the negative effects of risk factors (interactive model) (Rutter, 1987). Patterns of similar behaviour have also been found in studies associated with adults and adolescents who had already adapted to a pattern of alcoholic behaviour in earlier life.
In research by Hawkins et al (2007), it was concluded that:Preventative interventions should focus on intervening simultaneously at the community, family, and individual levels to build resilience and protective factors at each level. Of particular importance is the building of reflexivity along with other cognitive processes that allow the individual to think through problems and to reach a life decision to not abuse alcohol (Hawkins et al, 1997). Past studies have also confirmed through empirical findings that protective influences make a unique contribution to the prediction of alcohol use, through controlling levels of psycho-social risk (Scheier et al, 1994).This notion of stress as an indicator for indulging alcohol and alcoholic patterns of behaviour can also be seen during period of abstinence. For instance, during monitored periods of early abstinence, Brees (2005) found that alcoholics who were confronted with stressful circumstances showed increased susceptibility for relapse.
Furthermore, Scheier at al (1994) found that using categorical measures of drinking behaviour to designate non-use, experimental and moderate-to-heavy use exposed a relationship between chronic social influence and competency risk.These were found to correlate with an increased likelihood of accelerated drinking, whereas improved psychological functioning diminished the likelihood of increased drinking behaviour (Scheier, 1996). There is clearly a social and contextual mechanism that poses as a risk to the individual that may make them return to alcohol consumption and the associated mental, social and health risks. However, it is also clear that these risks are not simply individualistic and can reduce health across a social domain.
For example, the domestic environment, including the children of recovering alcoholics, has been found to show diminished global functioning (Costa et al, 1999). Many of these patterns show such frequent issues as marital conflict, parent and child conflicts, poor adaptive functioning on the part of the parent within the familial domain and in physical abuse. Revealing the effective risk factors associated with this environment, a study by Reich (2001) concluded that:A comparison of the home environments of the children of alcoholics with and without psychiatric diagnoses shows that the homes of the 'disturbed' children are characterised by a greater exposure to the effects of parental drinking, more parent-child conflict and less parent-child interaction than the homes of children who received no diagnoses. (Reich, 2001) This shows the way in which alcohol effects the social environment and the social environment helps affect the likelihood of successful sobriety. However, it also shows the way in which the social environment reciprocates the conditions of stress.Therefore, the relationship between alcoholic consumption is reciprocated by the social environment forming a dependent condition increasing the social risk factors pertaining to the children.
If nothing else, this shows that diminished psychological functioning essential to protective factors in sobriety are highly social and cultural. Much of the subsequent research has been geared towards the identification of risk factors in the both the social and psychological influences of the alcoholic patient.Measurements in self-efficacy are particularly common amongst research in this domain. Multivariate tests have revealed that self-efficacy expectancy and long term previous time spent in abstinence independently discriminate alcoholics who have maintained abstinence from those who did not (Viet & Ware, 2003).
In tests conducted by Viela et al (2001), other effective cognitive behavioural variables found in such tests revealed bivariate association with abstinence. However, this did not add any predictive power to the two measures.The results of the study were found to be consistent with other research findings that confirmed that predictor power of self-efficacy is relative to alcoholic patterns of behaviour. It was concluded by Viela et al (2001) that: Unexpectedly, [the research] did not find independent positive relationships between other psychological variables and abstinence. Given that self-efficacy can predict outcome in the medium term, it is suggested that treatment could target this variable (Viela et al, 2001).
This link between social factors and psychological motivations in the role of nursing practices associated with risk and protective factors can be seen in relation to other studies. This is backed up by other research based upon self-efficacy, which highlights the role that social status, identity and life style has upon the success of sobriety. For instance, research conducted by Walton (2003) into sobriety failure indicated that: Results suggest that poorer self-efficacy, greater involvement in substance-using leisure activities, being single, and less income predicted alcohol use directly.Income, gender, problem severity, marital status, and race also predicted alcohol indirectly. Findings highlight differential predictors of post-treatment substance use that may be useful in developing alternative approaches to prevent relapse. (Walton et al, 2003) This indicates that alongside self -efficacy these identity based risk factors are also indicative of failure and success.
Therefore, the likelihood of maintaining sobriety is associated with life style as well as the social condition of the patient.However, what is also clear is that the approach to prevalent relapse is indicative of good prevention factors. Essentially, by adopting a form of counselling, the approach to sobriety is more likely to increase protective factors and also awareness of protective factors within the lifestyle of the patient. It is clear from this that a sizable proportion of recovering adults and adolescence are vulnerable to the short term and long term socio-environmental factors relating to risk and prevention. These include stress, as well as a degree of other psycho-social factors.
Outlining a number of such factors, Hawkins et al (2007) lists psycho-social problems correlating with problem drinking as threats to well being, physical health, schooling and working, the attainment of life goals (Hawkins et al. , 1992). In this and similar studies, the identification of psycho-social risk and protective factors were attempted and brought together so that an account for emerging and developmental problem drinking amongst adolescents could be compared to adults aiming to attain sobriety.It was suggested that the identification of such factors would contribute to limiting the cycles of experimentation with alcohol in periods of adolescence and decrease young people's vulnerability to the negative outcomes associated with the problem use of alcohol (Hawkins et al, 2007). It would appear that the direct role of protective factors in the etiology and development of adolescent problem drinking and their possible role in moderating the relation between risk factors and problem drinking in adult sobriety are critical.The possibility that protective factors can mitigate the impact of risk has recently been extended beyond the domain of developmental psychopathology (Garmezy, 1985; Garmezy and Masten, 1987) to research on adolescent alcohol (Felix-Ortiz and Newcomb ; Felix-Ortiz, 1992).
However, other sources based upon the relationship between risk factors and preventive factors in relation to sobriety have drawn upon findings from cross cultural, philosophically driven and holistic paradigms. For example, the role, group dynamic and success of AA meetings has been examined in many studies and applied to counselling frameworks associated with sobriety.This research has revealed a degree of influences that do not depend upon pre-determined, psycho-social or positivist self-efficacy models pertaining to learned patterns from youth. Rather, they generate a more existentially goal driven model that looks at philosophical models of self, while incorporating the risk factors of family, society and social experience from a holistic and immediate functional perspective (Byron, 2008; Miller ; Bogenschutz, 2007). This is much like the ongoing and affective domain of counselling used by the AA.
However, this has also extended to include cultural variants to protective factors in certain subject groups. For example, a study conducted in Alaska looked to the perceptual framework and contextual notion of the image of alcoholism versus sobriety in the native community. The results suggested that the world view of the Alaskan natives incorporated a circular synthesis and balance of processes. However, these processes included four distinct holistic relations in terms of the individual that were defined as the physical cognitive, emotional, and spiritual.These were all found to be maintained within a protective layer of family and communal beliefs and practices embedded within the larger geographical and ideological environment.
This notably contrasts with the three way version of the self found in the aforementioned psycho-social models. Further, it was found that the fourth process; the spiritual process, was the dominant relation in this holistic mechanism. This meant that it was missing from prior research as a measurable protective factor.Outlining the significance of findings from cross cultural and communal research in relation to sobriety, Mohatt ; Kelly (2004) stated that: Cultural-spiritual coping in sobriety is a process of appraisal, change, and connection that leads the person toward achieving an overarching construct: a sense of coherence. Cultural and spiritual processes provide important areas for understanding the sobriety process as well as keys to the prevention of alcohol abuse and addiction.
(Mohatt ; Kelly, 2004) This has also been studied in relation to other research frameworks incorporating a review of empirical research.This was conducted in relation to the spiritual protective factor found by Mohatt et al. For instance, it was found by Bliss (2008) that the four roles of spiritual variables in alcohol abuse and recovery were crucial in the relationship between alcoholism and spirituality. Further analysis using a heuristic model of protective factors from alcohol abuse found in further studies that a multi-level and multi-factorial model best described interactive and reciprocal influences of these four factors.These were found to be: (a) individual, family, and community characteristics; (b) trauma and the individual and contextual response to trauma, (c) experimental substance use and the person's social environment; and (d) reflective processes associated with a turning point, or a life decision regarding sobriety. (Mohatt et al, 2004) Therefore, the role and importance of cultural factors pertaining to all of these psycho-social models were emphasised as indicative of a protective processes.
For nurses involved in sobriety, the process of resilience to alcohol drew from personal stores of self-confidence, self-efficacy, and self-mastery that derived from the ability to successfully negotiate and navigate through stressful and potentially traumatising social environments (Vielva & Iraugri, 2001). However, in other cultures self-efficacy was found to be described in more socially embedded terms, better understood as communal mastery (Walton et al, 2003).This was related to mastery in individualistic orientations versus more collectivistic orientations (Mohatt et al 2004). It would therefore appear from this analysis of the literature devoted to risk and prevention factors related to sobriety and alcoholism that protective factors exist that can foster and maintain sobriety, whether in early life or after detoxification treatments. However, this is dependent upon a degree of personal cultural as well as psycho-social factors and so it would appear that models that utilise a variety of processes are more successful.
