Almost certainly the most common view of alcoholism in western society is as a disease. However, society’s view of substance use has taken many forms over the centuries, from being positively feted to condemned as being evil. How and why attitudes change can often be a fascinating study of social change but sometimes there are no logical explanations why particular attitudes or viewpoints are adopted at a given point in time. It is easy for us to believe that our current view is the only logical one, however attitudes change with new discoveries and social conditions. A prime example of this is the disease model of addiction, a relatively recent view of a behaviour (substance use) that has been with us for millennia.
Prior to the nineteenth century both alcohol and drugs (in particular opiates) were seen as good substances, praised by the clergy and laity alike. Opiates were used to treat all ailments (real or imaginary) and drinking alcohol was almost certainly safer than drinking the water in most cities and large towns before proper sewage systems were built. So both alcohol and opiates tended to be consumed in prodigious amounts (certainly at levels that are far higher than today). Those who were prone to over-consumption were regarded as weak-willed or sinful but were not felt to be a threat to society. They could be dealt with quite easily within the existing judicial system by whipping or the stocks, or for persistent offenders jail, although in some areas, the church would be regarded as the proper authority to deal with drunkards. Indeed in some areas both the civil and the ecclesiastical authorities would deal with the drunkards, thus they could be punished twice.
This approach is referred to as the ‘moral model’ of addiction. Those who subscribe to the moral model suggest that people over indulge because they are ‘bad’ or ‘sinful’ and need to be taught the error or their ways through punishment or, in more religious societies, by preaching and sermons, designed to bring them back to the fold. Some remnants of this model can still be seen in modern society’s attitudes to drunkenness and more particularly in drug use.
The Origins of The Disease Model.
In the eighteenth century science was emerging as a method for explaining the world and, to a lesser extent, human behaviour. Independent of each other two physicians, Thomas Trotter in the UK and Benjamin Rush in Philadelphia, began to write about inebriety (drunkenness). Both began to refer to the condition as a disease, Trotter suggested that it was a disease of the mind while Rush called it a disease of the will. The rationale for this view was that no rational person would deliberately engage in a behaviour that was both anti-social and harmful to themselves. Hence they must be consuming substances against their will, that is unlike normal people they had no control over their consumption so they had to have a ‘disease’.
It is hard in this age to comprehend just how radical this suggestion was at the time. However here were two physicians suggesting that behaviour was not being governed by ‘goodness’ or ‘badness’ (god or the devil) but was instead out with the control of the drunkard. The implication being that sermons or punishments would not only have no effect in changing the person’s behaviour, they were punishing sufferers for being sick. Thus it would be like punishing a person for having tuberculosis.
Some commentators regard this as a time of enlightenment resulting in the sick being treated rather than punished. However, others regard it as a time when any behaviour that ran contrary to society’s norms, in other words - sin, was excused as a disease. Some go further and suggest that this was when the medical profession began to replace priests, as they took on the role of arbiters of what was good and how society should behave, what they should eat et cetera.
This radical change of thinking had little immediate effect as it was not for another 150 years that the disease model was widely accepted in the USA. Some changes did occur in the interim. The first ‘inebriate asylum’ was opened in Boston in 1841, by a psychiatrist called Samuel B Woodward, to treat people suffering from this new disease. However no others would open for over twenty years, but by the end of the century there were 50 across America. Nevertheless it was not till 1958 that the American Medical Association declared that alcoholism was a disease that there was wide acceptance of this position.
The Contribution of Jellinek
E. M. Jellinek is regarded by many as the father of the modern disease model. His research produced two major constructs, the stages of the disease and the species of diseases. The stages of the disease had a major impact on how alcoholism (and addictions in general) were viewed. According to his theory there are four stages in alcoholism,
- pre-symptomatic stage – no problems with alcohol;
- prodromal stage – characterised by blackouts (amnesic episodes), guilt and increasing drunken episodes
- crucial stage – characterised by failed attempts at controlling use, loss of willpower; and the
- chronic stage – mental and physical complications and increasingly lengthy binges.
Many of these symptoms can be seen in heavy drinkers but Jellinek distinguished heavy drinkers from ‘real alcoholics’ by their ability to control their drinking (ie stop at will or decide whether or not to drink).
Jellinek suggested that although there were exit points at each of these stages (ie the alcoholic could stop drinking) the majority of alcoholics would continue to the chronic stage. It was at this stage, when physical and mental damage had occurred that change would be most likely to occur. Another physician, Max Glatt, working in the UK, drew a curve depicting Jellinek’s stages as a descent into alcoholism and a rise back to sobriety. It was from this diagram, which was hung on the wall of every treatment agency, that the term ‘hitting bottom’ (seen as the only means of change for the alcoholic) originated.
The second contribution of Jellinek was the species (or types) of alcoholism. Jellinek was both aware of and fascinated by the fact that other countries had different drinking patterns and different drinking problems. Thus he argued that there are five types of alcoholism which he named after the first five letters of the Greek alphabet, alpha, beta, gamma, delta and epsilon. However of these he stated that only the gamma and delta species are true alcoholism. The gamma alcoholic is to be found predominantly in the anglo-saxon countries (USA, UK) and is the most damaging in physical, financial and social terms, we will describe this species in more detail in the next pages. The delta alcoholic tends to be found mainly in the wine regions of France and some other wine growing nations. The main characteristic of this species is that while they are seldom drunk, they are seldom entirely sober for they drink regularly throughout the day (wine with lunch, dinner) but seldom enough to be intoxicated. It is only when there is an enforced period of abstinence that withdrawal symptoms will be seen and a diagnosis of alcoholism may be made.
So is alcoholism a disease? For more discussion of the topic click on the link.