If we go back in time, one of the earliest references to the disease we now consider alcoholism is in the Bible. The individual usually credited with pioneering the disease concept of alcoholism was Benjamin Rush, a physician and signer of the Declaration of Independence. Prior to his work, drunkenness was viewed as being sinful and a matter of choice. Rush believed that the alcoholic loses control over himself and identified the properties of alcohol, rather than the alcoholic’s choice, as the causal agent.
Members of Alcoholics Anonymous supported the view that alcoholism is a disease, but in an attempt to legitimize it, many members began to describe alcoholism specifically as a “physical allergy to alcohol combined with a mental obsession to keep on drinking” (Alcoholics Anonymous World Services, 1976). One did not have to be a medical professional to realize that alcoholism did not fit the model of allergy—alcoholics neither break out in hives nor develop choking problems as a result of drinking—and some people used that incongruity to deny that alcoholism was a disease. In 1960, E. M. Jellinek further advanced the disease concept in a seminal book of that same name in which he elaborated a clinical typology of subtypes of alcoholism which much better fits the clinical presentations as seen by clinicians (1960). He also developed the “Progressive Symptoms of Alcoholism Chart,” often still used by clinicians in their work with patients. Merriam-Webster defines disease as a “condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms: sickness, malady” (n.d.). The National Council on Alcoholism (NCA)—now the National Council on Alcoholism and Drug Dependence (NCADD)—and its director, Marty Mann and AA itself may have done the most to promote the disease concept.
All of this did little to alter the general perception that alcoholism was a question of will, weakness, and immorality and that alcoholics were hopeless, whatever the nature of the disorder, a belief held even among medical professionals. In the early 1960s I recall taking a patient of the treatment center at which I worked to a local hospital because of impending DTs. In the ER we were very rudely told that this was a hospital for sick people, not drunks, and I literally had to threaten the ER physician with a lawsuit in order for him to agree to treat my patient. This is somewhat understandable because addicts are often not likeable. They don’t do what they promise, they lie and steal, and they don’t follow directions. Maybe a tongue-in-cheek “proof” of alcoholism as a disease is that medical insurance pays for its treatment.
There are numerous examples of how our use of language served to further the resistance to accepting that addiction was a disease. I refuse to refer to the “disease concept.” For me, a concept is an abstraction, an idea, notion, all of which indicate that the disease may not be real. In my work I have substituted the term “disease model” for “disease concept,” which is more accurate. Furthermore, when a person relapsed, it was sometimes referred to as “recidivism,” a criminal justice term for a return to criminal behavior. Yet almost all drug-related crime is linked to the drug trade, not the drug user. This causes the problem to be viewed through the lens of criminality rather than as a health care problem. For a long time, the Armed Forces and the Veteran’s Administration (VA) considered alcoholism an issue of misbehavior instead of a health care problem. They also had an interesting approach to treatment once they accepted that is was at least a medical problem: people diagnosed with substance dependence were automatically referred to inpatient treatment while those who were considered to have substance abuse were automatically referred to outpatient treatment with no further assessment of the individual’s needs and where and how they could best be met.
People who believed that alcoholism was a disease believed that once people had it, they could never again return to nonproblem drinking. However, some were able to; reinforcing the resistance to acceptance that alcoholism was a disease. While the term “alcoholic” may have great value (e.g., individuals standing up at an AA meeting and identifying themselves as alcoholics), the basic problem here is with language. The term “alcoholism” is neither diagnostic nor precise—some people labeled “alcoholics” were in reality alcohol abusers (DSM-IV) or had an alcohol use disorder, mild (DSM-5) and were never addicted. In the book Alcoholics Anonymous there is the statement “No real alcoholic ever recovers control” (1976). If we were to substitute alcohol addiction or alcohol use disorder, severe for the term “real alcoholic,” then I think most clinicians would agree. But as we see from the severities of alcohol use disorder, there are other who have alcohol problems who are not “real alcoholics.”
Unfortunately, the DSM-5 contributed to the problem by calling all severities of substance use disorders, “addiction.” But mild severities of substance use disorders—“abuse” in the DSM-IV—do not rise to the level of addiction. Addiction is comprised of four elements: loss of control, compulsion, continued use in spite of adverse consequence, and craving. Allen Frances, MD, who chaired the DSM-IV work group, stated that this change will characterize an additional twenty to thirty million people as addicts (Frances, 2014).
For some people, abusive use may be prompted by environment (e.g., college, military) and when they leave that environment most will have no continuing problems with alcohol. For others, the abusive use of alcohol results from an inability to cope with problems such as divorce, retirement or death of a significant other. And for other people, drinking is an attempt to treat the symptoms of a co-occurring mental health disorder. To be clear about this last group, there is the possibility that if the drinking continues, a diagnosable substance use disorder may develop so that by the time they present for treatment they may have both a substance and co-occurring mental health disorder.
Even further complicating the issue is that there is no way of directly diagnosing or measuring addiction—or for that matter, any mental health disorders—as there is with diabetes or hypertension. A fasting blood sugar test can identify a potential diabetes problem. For hypertension, measurement with a sphygmomanometer (blood pressure meter) can identify high blood pressure. In contrast to these mechanisms for diagnosing a disorder, with addiction we must interpret behavior, use assessment instruments or rely on collateral information and while there are mechanisms to identify current use such as breathalyzers or urine drug screens, none of these can identify a diagnosable substance use disorder.
Addiction has now come to be regarded by professionals in the field as a chronic, relapsing brain disease, but even people who believe this have not advanced the cause. We said it was chronic but treated it as an acute illness with the use of fixed lengths of treatment; when people relapsed they were often shamed; “graduation” ceremonies were held when someone was about to be discharged from treatment (have you ever heard of a diabetic patient “graduating” from a hospital stay?); and the common use of the term “aftercare” (when did you last hear of a diabetic going to aftercare?). Better terms for a chronic illness are “continuing care” or “maintenance care” and “postacute care.”
Furthermore, although we stated that it was a “chronic, relapsing brain disease,” treatment only addressed the cerebral cortex, that part of the brain responsible for thinking, perceiving, producing, and understanding language and other cognitive functions. We would address this in treatment by the use of individual and group therapy, psyschoeducation, and reading and writing assignments, all of which have value. But treatment historically did not address the limbic system from which drives emanate: hunger, thirst, sex and drug craving. One could make a case that we were treating addiction as a chronic, relapsing cerebral cortex disease, addressing only one part of the brain with abysmal outcomes compared with other chronic diseases. It has only been recently that medications that target the limbic system have begun to slowly gain acceptance.
This is progress. We have come a long way, but not far enough. Stigma is still probably the single most common reason why only about 10 percent of the people who need treatment for substance use disorders demand it. This stands in direct contrast to other chronic illnesses. It is my belief that until we effectively address stigma by broad-based acceptance of alcoholism as a disease, we will continue to treat only a small percentage of people who need treatment.
Alcoholics Anonymous World Services. (1976). Alcoholics anonymous. New York, NY: Author.
Frances, A. (2014). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York, NY: William Morrow.
Jellinek, E. M. (1960). The disease concept of alcoholism. New Brunswick, NJ: Hillhouse Press.
Merriam-Webster. (n.d.). Disease. Retrieved from http://www.merriam-webster.com/dictionary/disease