If you have been around the alcohol and drug field for any length of time you will have discovered that it arouses passions. This is particularly true when people discuss the cause of alcoholism and drug addiction and treatment of addiction.
More than any other social or medical problem, the field is populated by recovering or ex-users. Although that can be important as they can bring their personal experiences to help. It often results in personal perspectives taking precedence over research evidence with claims that “if you have not walked the walk, then you cannot talk the talk”. This translates as you have not had an addiction problem then you do not have the authority or right to have an opinion on it.
Whatever your opinion on that position, it does not translate so well when we look at other fields. In fact , there can be few, if any, other fields where personal experience is a prerequisite for and takes precedence over research and professional training. For example, should psychiatrists only be recruited from the ranks of the mentally ill, should males be barred from being gynaecologists and should only those who have committed crimes be policemen or prison warders?
One of the main areas where this controversy spills over is the nature of alcoholism. There is little agreement about what causes alcoholism and drug addiction and there are many different theories. The most prevalent theory, especially with the lay person and recovering alcoholics, is probably the disease model, which we will now explore.
Models of Alcoholism
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 viewed as a great gift from God to condemned as being evil. How and why attitudes change can often be a fascinating story of social change but sometimes there appears to be no logical explanations why particular attitudes or viewpoints are adopted at a given point in time.
It is all too easy for us to believe that our current view of alcohol or drugs 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, which is actually a relatively recent view of a behaviour (substance use) that has been with us for millennia.
Before the nineteenth century both alcohol and drugs (in particular opiates) were seen as good substances, praised by the clergy and laity alike. Opiates were sold openly by pharmacists and 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 we do 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 argument for this view was that no rational person would deliberately engage in a behaviour that was both anti-social and harmful to themselves. Therefore, they must be consuming substances against their will. They reasoned that since it seemed that unlike normal people they had no control over their consumption, so they must have a ‘disease’.
It is hard in this age to understand just how radical this suggestion was at the time. 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 actually punishing sufferers for being sick. Thus, it would be like punishing a person for having tuberculosis. This was revolutionary thinking that some have welcomed as a humanitarian approach while others have viewed it as a change in the social order and seat of influence.
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 the point 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.
However, 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. Although 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. 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 either 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 what does it mean that alcoholism is a disease?
There are three basic types of alcoholism disease models that have been proposed at various times. They all tend to share the same basic characteristics but the aetiology (underlying mechanisms which cause the condition) are different.
Pre-Existing Physical Abnormality
The first and oldest model is that there is some (often unspecified) Pre-Existing Physical Abnormality. This model suggests that alcoholics/addicts are born with an inherent flaw in the way their body reacts with substances.
The manual for AA, called Alcoholics Anonymous, begins with a discussion by Dr Silkworth of what form the disease takes. In this section, called the Dr’s Opinion, he suggests that the alcoholic is allergic to alcohol and this is the reason alcoholics drink and behave in an abnormal fashion. This led to much speculation that alcoholics/addicts were genetically programmed to be addicted. For many years research found no evidence for this proposition and the model’s support waned, although AA continued to promulgate it. More recent research, using more advanced technology such as gene probes, has found that there may indeed be a genetic component, if not an alcoholic gene, to addiction. The exact mechanism is still unclear. Even if there is a genetic predisposition it would appear to be only one prerequisite for what is a complex behaviour.
Psychopathology or Mental Illness
The second model suggests that alcoholism/addiction is a Psychopathology or Mental Illness. To some extent this model has echoes of the original theories of Trotter and Rush who suggested a disease of the mind or will. Many theories have been proposed to support this model. For example the work of Freud has been used to suggest that alcoholics/addicts were fixated at the oral stage (lack of self-control, self-destructive). The influence of Freud continues today in the language of addiction, for example a typical view of the alcoholic is that they are in denial (refuse to admit their problem) and practice projection (blame others).
Another theory that continues to be given credence, at least with laymen, is the addictive personality. That is, some people are prone to be addicted to numerous substances (alcohol, drugs, tobacco) and/or behaviours (eating, exercise, gambling, internet). No convincing evidence has been produced that unequivocally supports this model, as it is difficult to separate what is cause and what is consequence. That is, does having a particular type of personality predispose a person to addiction, or does addiction cause a person to exhibit certain personality traits.
The third and final model suggests that addiction can be acquired through alcohol/drug use. Unlike the other two models this one suggests that the disease does not precede and cause the problematic use but is instead a consequence of it. Certainly, this model tends to given more credence than the others, both by professionals working in the addiction field and by laymen. Witness for example the current views of heroin or crack cocaine and how addictive it is. This model is the forerunner and influence of the Dependence Syndrome.
The Essential Characteristics of the Disease Models.
Although there are differences between the above models there are four essential elements that are common to all disease models. These elements are based on Jellinek’s gamma alcoholic, or as he suggested – the real alcoholic.
The first characteristic is that alcoholism/addiction is a discrete entity, that is people either are or are not alcoholics/addicts, as some say you can’t be a bit of an alcoholic in the same way you can’t be a bit pregnant. Thus alcoholics/addicts are viewed as somehow different (physically or psychologically) from non-alcoholics/addicts.
In the first model above (and in some versions of the second model) the alcoholics/addicts can never be normal in respect of alcohol/drug use and normal alcohol/drug users can never be alcoholics/addicts. Even in some versions of the third model alcoholics/addicts are viewed as qualitatively different from non- alcoholics/addicts rather than quantitatively different. That is they are seen to be different by what they are (alcoholics/addicts) rather than what they do (drink or use drugs excessively).
The second characteristic is that the alcoholic/addict suffers from loss of control and abnormal craving. These symptoms are often regarded as the hallmark of addiction. It is suggested that alcoholics/addicts have great difficulty abstaining from alcohol or drugs because of an abnormal craving and once they do begin to consume, the lack of control means that they cannot stop. This is summed up in the old saying “One drink, one drunk”.
The third characteristic is that this abnormal craving and loss of control is irreversible. That means that once a person is or becomes an alcoholic/addict, they are always an alcoholic/addict. The only recovery possible is that they abstain forever, since, even after a long period of abstinence the mechanisms of abnormal craving and loss of control are still present and any consumption will result in a return to the prior state of alcoholism/addiction.
The fourth and final characteristic is that if left untreated the disease is progressive. Jellinek described this progression in his phases of alcoholism and Glatt depicted it in his diagram that showed quite graphically that without treatment alcoholism/addiction would result in insanity or death.
The Disease Model of Alcoholism – The Evidence
Undoubtedly, the disease model of alcoholism has brought benefits to alcoholics. To some extent it has reduced the stigma experienced by sufferers and has opened the door to treatment rather than punishment. Before alcoholism was considered a disease, alcoholics were considered to be sinners and/or wasters that need to be ‘encouraged’ to change their ways either through finding religion or through punishment. Alcoholics were regularly imprisoned, locked in the stocks or even whipped. The introduction of the disease model meant that it was viewed as a matter for treatment rather than beatings.
The disease model is the mainstay of the belief system of AA and NA groups who have been responsible for helping many to recover. However, there are many critics of the disease model, both on the grounds that there is little evidence to support it and, they argue, that it may in fact be detrimental to recovery.
Far from supporting the model, much of the evidence that has been produced is in direct opposition to it. For example, a famous study of alcoholics found that alcoholics could and did control their craving and consumption.
In one experiment a number of alcoholic subjects were given the opportunity to work in exchange for alcohol and to consume it when and as they wanted. Instead of being constantly drunk, it was found that the subjects worked and consumed alcohol selectively, sometimes saving some for consumption at a later time.
Other studies have found that alcoholics (both treated and untreated) have returned to patterns of problem free consumption. These people are in the minority, but they do nevertheless represent a significant number.
Finally, a new topic in addiction research is what is known as natural recovery, that is changing addictive behaviour without the aid of treatment. Many studies have found that this is a common route out of addiction. Indeed, one large scale study found that not only is it common it is by far the most common route.
All of these findings undermine the validity of the disease model. Even the seminal work of Jellinek, which described the disease model originally, was based on work carried out entirely with members of AA. Hence he was actually describing a particular type of alcoholic (the typical AA member) and there may be many different types of alcoholics/addicts for whom these symptoms do not apply.
In respect of treatment, the current view is that in the disease model the alcoholic/addict is viewed as someone who has no control over his/her behaviour and hence requires treatment to recover. This is often viewed as engendering feelings of helplessness and encouraging an abnegation of responsibility.
In contrast the current view of treatment is that in order for recovery to occur the client needs to take responsibility for his/her behaviour and to be empowered to change. Moreover, rather than enforced abstinence the client should have a choice of possible outcomes (ie abstinence, reduction in consumption or controlled drinking). This way the client is felt to have greater ownership of his/her recovery and is more motivated to succeed. That is the philosophy of this website.
While the disease model has had some benefits by initially introducing treatment for alcoholics/addicts, ironically it is now viewed by many modern commentators as being detrimental to treatment. Many of the concepts of the disease model (such as compulsion to drink, powerlessness and denial) have been found to be falsely attributable to the disease of alcoholism and indeed can be explained by other mechanisms. Nevertheless, it continues to be the mainstay of AA and NA and provides benefits for its millions of members.
In this website we don’t mind if you call yourself an alcoholic or you don’t call yourself an alcoholic. We don’t see that as being important, rather we think that what is important is that you are honest with yourself about your drinking and the consequences. If you do not have that you will have great difficulty recovering, if you can recover at all.