ALCOHOLISM - A DISEASE?
INTRODUCTION
The first part of the essay will define alcoholism. I will continue by giving some of the historical background to the origins of the debate on the issue of alcoholism described as a disease. In the mainbody of the essay I will outline the arguments for and against the concept of alcoholism as a disease. I will conclude with the suggestions by the proponents and opponents regarding the future diagnosis and definition of alcoholism.
ALCOHOLISM
Definition:
The term addiction comes from the Latin ad dicere, which means ‘to give oneselfup’ or ‘over’. Addiction is present when a person is completely taken over by an activity or substance, which takes control of his life and eventually destroys him if he does not take steps towards recovery.
According to Hardiman (1998 p2) ‘there appears to be four main components to any addiction, namely, compulsion, dependence, regularity and destructiveness’. A compulsion is a very strong overwhelming desire to drink. Dependence on alcohol is the need to drink, rather than the desire to. If the person does not get a drink there is the belief that something negative or undesirable might happen. With drinking, regularity may vary according to the person. It might mean a binge every six months or a daily top up of alcohol and as the addiction grows so too can the regularity of drinking. The last element is the destructive nature of addiction. Hardiman (1998 p.4) states that it is impossible to draw a line between addiction and non addiction, and that one person can be mildly addicted to alcohol and another very strongly addicted. He continues by suggesting that most of us are in some way involved in addictive behaviour (Hardiman 1998 p.4). The opinions of Hardiman are challenging for many of us who believe we have escaped the classic stereotypical alcoholism. His comments put into perspective the nature of addiction and ask that we withhold judgment. He also creates curiosity around getting a better understanding of the nature of alcoholism.
HISTORICAL BACKGROUND
The first American to clearly articulate the modern conception of alcoholism as a disease state was Dr. Benjamin Rush in 1784 (Thombs 2006 p.2). According to Levine (1978), Rush’s new construction was based on four propositions that are used to day to explain problematic alcohol use:
“1. Hard Liquor is an addictive substance
- There exists a compulsion to drink that arises from a loss of control
- Frequent drunkenness is a disease
- Total abstinence from alcohol is the only way to cure the drunkard”.
John B. Gough, who was part of the temperance fraternity in America considered “drunkeness as a sin, but I consider it also disease. It is a physical as well as moral evil (Gough p.443).
From the end of the Civil War to the turn of the century, people belonged to these fraternity groups, which were essentially secret societies and highly organised. The primary goal was to help members stay sober and total abstinence was required (Levine 1978). In the latter half of the 19th century the Sons of Temperance, the Good Templars and many similar organisations operated in practically the same way that AA operates today. Jellinek argued that temperance supporters felt “the idea of inebriety as a disease weakened the basis of the temperance ideology” (Jellinek 1960 p.6). Levine questioned this and argued that while not every temperance writer called intemperance a disease, many did (Levine 1978). He continued by proposing that the core of the disease concept – the idea that habitual drunkards are alcohol addicts, was from Benjamin Rush on, at the heart of temperance ideology (Levine 1978).
By the early 20th century, the original moral proponents of alcohol addiction, the temperance movement had lost interest in the concept of addiction. In Gusfield’s (1970) view no one “owned” the addiction model of alcoholism. Levine (1978) felt that there seemed to be a general acceptance at that time of the disease model, but the specifics and details were not defined.
In the 1930s and 1940s alcoholism as an addiction and disease were resurrected by Alcoholics Anonymous and the YaleCenter of alcohol Studies. It became a medical model, where the source of the addiction was in the individual body and not in the drug. Alcohol became a socially acceptable drug which was only addictive to some people for unknown reasons. In 1944, the US Public Health Service declared alcoholism as the country’s fourth largest public health problem. In 1952, E.M. Jellinek supported the view of alcoholism as a disease and described it as a symptomatic progression of phases leading from psychological to physical addiction. In 1956 the American Medical Association recognised alcoholism as a disease. It was not a result of immorality or lack of discipline but it was a disease.
ALCOHOLISM - A DISEASE?
The debate on whether alcoholism is a disease or a personal conduct problem has continued over 200 years. Theorists have emphasised different elements of the disease model. The models differ with respect to the importance of physical, psychological and spiritual factors in the etiology of alcoholism (Thombs 2006 p.19). Peele (1996) suggests there are two different constructs, susceptibility and exposure. Susceptibility emphasises the role of genetic factors in the development of substance dependence (Peele 1996). Exposure holds that chemicals and their actions on the brain are the primary cause of addiction (Peele 1996). The main emphasis from the AA perspective is on spirituality. The medical profession look at biological factors in the etiology of alcoholism. Milam and Ketcham (1983) and Talbott (1989) proposed that addiction itself was a disease and that heavy drinking was a secondary symptom to the underlying disease, addiction. On the other hand the medical community points to the significance of biological factors in alcoholism (Thombs 2006 p.19). According to Thombs (2006) there is a subtle difference between the disease model of the AA and the medical community. The AA use the term disease to describe their alcoholism because the experience of compulsive chemical use feels like having a disease. It is characterised by the feelings of loss of control and hopelessness. On the other hand the medical profession use the term in the literal sense i.e. Alcoholism is disease.
Stanton Peele (2006) asserts that the “recovery” community’s adoption of the disease concept began with an early AA member Marty Mann. Marty Mann funded a scientific study which was conducted by E.M.Jellinek. Jellinek published his findings in his book “The Stages of Alcoholism”. In a subsequent book, “The Disease Concept of Alcoholism” published in (1960), Jellinek described alcoholics as individuals with tolerance, withdrawal symptoms, and either “loss of control” or “inability to abstain” from alcohol. He proposed that these individuals could not drink in moderation, and, with continued drinking, the disease was progressive and life-threatening (Hobbs 1998).
AA formed in 1935 by stockbroker Bill Wilson and physician, Robert Smith supported the proposition that an alcoholic is unable to control his or her drinking and recovery is only possible with total abstinence and peer support.
Ernest Kurtz suggests that AA neither originated or prompted what has come to be called the disease concept of alcoholism (Kurt 2009). He supports this by describing the meaning of the tenth step which reads “Alcoholics Anonymous has no opinion on outside issues; hence the AA name ought never be drawn into public controversy” (AA Big Book ). He, therefore, concludes that the nature of alcoholism is an “outside issue”. Kurtz agrees that most members do speak of their alcoholism in terms of disease but the use of that vocabulary no more implies deep commitment to the tenet that alcoholism is a disease in some technical medical sense (Kurtz 2009). He also contends that most members will also tell an inquirer that their alcoholism has physical, mental, emotional and spiritual dimensions. With emphasis on the spiritual, which is AA’s largest contribution, he believes that it is within this framework that any discussion on the relationship of AA to the disease concept of alcoholism must be located (Kurtz 2009).
Hobbs (1998) maintained that a recent Gallop poll found almost 90% of Americans believed that alcoholism is a disease. In contrast he outlined physicians’ views of alcoholism which were reviewed at an annual International Doctors of Alcoholics Anonymous. 80% of responding doctors at this conference perceived alcoholism as bad behaviour. Dr. Raoul Walsh, in an article published November 1995 of Lancet supported the view that physicians have a negative view about alcoholics. Hobbs proposed the reasons for this negativity is that the bulk of their clinical exposure is with late-stage alcohol dependence. The other more important, in his view, factor is the lack of education (Hobbs 1998). He cites several studies in the late 1980s giving evidence that medical students and practitioners have inadequate knowledge about alcohol and alcohol problems.
Stanton Peele, one of the main protagonists against alcoholism as a disease, asserts that research has shown that it is a choice not a disease. He maintains that the disease concept strips the substance abuser of responsibility and inevitably they become unwilling victims and take on that role (Peele 2006). According to the 12 Steps, the disease is all powerful and without meetings it will destroy them. Peele (2006) rejects this by pointing out that if someone is ‘powerless’ they would, by definition not be able to control themselves, not even one day at a time. He further argues that if alcoholism is classified as a disease it should have characteristics and symptoms that are measurable and observable (Peele 2006). In the same article Peele discusses the recent attempts to prove a genetic link for alcohol and drug abuse. He maintains that most of these studies only provide roundabout evidence of a predisposition, not a cause for alcoholism (Peele 2006). He cites Dr. Brian Goodwin, a theoretical biologist at SchumacherCollege, in Devon who says “Knowing the sequence of individual genes does not tell you anything about the complexities of what life is”(Peele 2006). Goodwin goes on to explain gene mutations are not accountable for, and cannot explain, complex behaviours – the truth is apredisposition for substance abuse, if it does exist, has no bearing on subsequent behaviours (Peele 2006).
Niedermayer (1990) describes the disease model proponents at a loss to explain why alcoholism is a disease. He continues that they maintain there are a number of biological and genetic predisposing factors serving to “mark” a portion of the population as alcoholic. According to Neidermayer (1990) this model proceeds to claim that persons so “marked” are alcoholics even before they have their first drink and as soon as they have their first drink begin the journey of alcoholism.
Herbert Fingarette (2005) argues that the idea that alcoholism is a disease has always been a political and moral notion with no scientific basis. He believes it is neither helpfully compassionate, and it promotes false beliefs and inappropriate attitudes, as well as harmful, wasteful and ineffective social policies (Fingarette 2005). In relation to predisposing factors, Fingarette believes that the truth in relation to this is less dramatic and there are certain so-called biological markers associated with heavy drinking, but these have not been shown to cause it. One of these supposed markers is the metabolism of alcohol into acetaldehyde, a brain toxin, in the bodies of people who are independently identifiable as being at higher risk of becoming alcoholics (Fingarette 2005). Another of the supposed markers is the high level of morphine-like substances secreted by alcoholics when they metabolise alcohol (Fingarette 2005). Fingarette (2005) maintains it is implausible that any residual effects whether physical or psychological, could be so powerful as to override a sober persons rational, moral, and prudential inclination to abstain. Fingarette proposed that it is not only misleading but dangerous to regard alcoholism as a genetic disorder. His reasoning for this is that heavy drinkers without alcoholism in their genetic backgrounds are led to feel immune to serious drinking problems (Fingarette 2005). In conclusion Fingarette (2005) observes’ that the idea of a single disease obscures the scientific consensus that no single cause has ever been established nor has any biological causal factor ever shown to be decisive. He continues by commenting that heavy drinking has many causes which vary from drinker to drinker, from one drinking pattern to another. Fingarette (1988) observes that alcoholics do not “lack control” in the ordinary sense of those words. According to him, studies show that they can limit their drinking in response to appeals and arguments or rules and regulations (Fingarette 1988).
In 1963, AA was publicly criticised in a magazine article. Cofounder Bill Wilson responded in the AA Grapevine. Wilson took the position that AA members should view critics as benefactors and that AA should use criticism to self-assess and improve AA (White, 2001). White (2001) believes that those who have long-professed that addiction is a disease would be well served by Wilson’s example.
CONCLUSION
William White proposed that rather than defending an overly rigid concept, it would be better to acknowledge the weaknesses of the disease concept as historically constructed (White 2001). He contends that a disease model should be reformulated that is more clinically and culturally dynamic and more scientifically defensible (White 2001). Hobbs (1998) argues that alcoholism should not be judged as a problem of willpower, misconduct, or any other unscientific diagnosis. He maintains the problem must be accepted for what it is – a biopsychosocial disease with a strong genetic influence, obvious signs and symptoms, a natural progression and a fatal outcome if not treated (Hobbs 1998). Fingarette (2005) contends that much greater resources must be shifted to psychological and sociocultural research. Hecontinues by proposing that the public should be better informed about the scientific facts and above all about scientific ignorance. Fingarette(2005) concludes that policies should reflect the fact that heavy drinking is not primarily a biochemical or medical problem but a human and social one. Peele (2006) concurs with the above opinions and states that a great deal of evidence, more consistent and extensive than anything yet established by biological research shows that social categories are the best predictors of drinking problems and alcoholism. Niedermayer (1990) acknowledges that there are serious limitations to the disease perspective yet also argues that this model is not without its own merit. He proposes that in trying to develop a new perspective, we must be careful to try and incorporate the best of the old model (Niedermayer 1990).
From the writers perspective the arguments for and against the disease model of alcoholism are equally convincing. The prime motivation for my study in this area was to find out if alcoholism was indeed a disease. The strongest argument from my perspective as a Counsellor is the value to the client in believing it is a disease. The diagnosis and naming of distress and disruption, either mental or physical is part of the first steps towards recovery for many people. I believe this applies to alcoholism. I felt it was necessary to know if alcoholism is a disease. The arguments are inconclusive, but more important is the continuing research, debate and discussion. I believe the focus needs to be on supporting and educating the individual to survive alcohol dependence and to self actualise. A biopsychosocial model of alcoholism offers the best outcome for alcohol dependents and practitioners. Using this approach, all aspects of the individual’s life can be assessed and a combined treatment process offered which will have the most successful and lasting outcome for the individual.
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