Disease Model: Basics

When we’re in reasonably stable, healthy space, it might not matter much to us as laypeople whether drinking problems fit into a disease model or not: Either a disease model makes sense, given our experience, and helps to keep us focused on abstinence-based recovery, or disease concepts aren’t such a good fit and we’re making pragmatic choices to sustain abstinence, moderation, and/or harm reduction.

When there is a disconnect between where we’re at with our drinking and where we’d like to or need to be, though, making sense of the disease concept can bear directly on the choices we make in moving forward.

This is a seminal issue for a lot of folks. In the world of alcohol-related care, careers and industries have built to varying degrees on both sides of the “Is addiction a disease?” question. Even for us as nonprofessionals, speaking too broadly about drinking problems outside a disease model can earn us the denial label.

My goal here is to speak to the better-known perspectives on the disease model, not to launch fresh salvos in the battle. It is too easy for those of us who have found ourselves in unhealthy places with our drinking to get mired in thinking instead of doing; as I look at the diversity of perspectives here, the thing that becomes most clear is that we can act to resolve our problems from either a disease- or a non-disease-based paradigm.

I’ll take a four-pronged approach to nail down some of the key concepts and history of disease as it relates to drinking and addiction. That still amounts to just the tip of the iceberg, which you can see by digging through the links, but hopefully it sets up a foundation for each of us to use in thinking about how we choose to live sensibly with alcohol. The topics are:

1. Disease Model: Basics - (this page) - (a) Disease definitions; (b) A popular 1980s view; (c) Vaillant & Peele debate; and, (d) Disease and the layperson
2. Disease Model: Chronology - What is the history behind disease models of addiction?
3. Disease Model: Debate Points - What are some of the key words and concepts underlying disease concept controversy?
4. Disease Model: Looking Forward - How might the disease concept be applied more critically in the future?

Disease: Dictionary and Wiki Definitions

Per Merriam-Webster Online, a disease is:

a condition of the living animal or plant body or of one of its parts that impairs normal functioning; (synonyms: sickness, malady)

From Wikipedia:

A disease is any abnormal condition of the body or mind that causes discomfort, dysfunction, or distress to the person affected or those in contact with the person. Sometimes the term is used broadly to include injuries, disabilities, syndromes, symptoms, deviant behaviors, and atypical variations of structure and function, while in other contexts these may be considered distinguishable categories.

So, the medical sense of disease is that it is a defect or impairment which prevents an organ or bodily system from functioning normally, causing discomfort or dysfunction. Here is a side-by-side comparison of how the disease model — in a strict medical sense — has been applied to diabetes and alcoholism:

The disease model traditionally referred to in the alcoholism treatment industry is broader than a strict medical construct, however.

A Layperson’s Description from the Eighties

When I started looking at my drinking in 2000, as I mentioned in my intro, I had no “I never knew this could happen” excuse. I knew I needed to be wary related to drinking. I was also well-acquainted with the disease model of alcoholism.

Household cleaning and organizing guru Mary Ellen Pinkham spelled out the disease concept I was familiar with in her 1986 book, How To Stop The One You Love From Drinking:

Doctors … say a disease is something that is primary, progressive, and chronic…

By primary, doctors mean that the alcoholism is a disease itself rather than a symptom of some greater social, emotional, or physical problem…

By progressive, doctors mean that the problem’s going to get worse. The fact is, it will inevitably lead to insanity or death…

By chronic, doctors mean exactly what you would expect. There is no known cure for the disease. You can, however, control it. Alcoholism is the most treatable — and yet the most untreated — disease that exists.

(Actually, while primary, progressive, and chronic have been used to describe alcoholism, the existence of other forms of disease — acute, relapsing-remitting, and secondary diseases — is well known.)

The thing I didn’t have a clue about until I started examining things in 2000 is that the disease concept is also the source of long-standing, deeply rooted disagreement among alcohol researchers.

Vaillant and Peele Debate

In his 1995 book, The Natural History of Alcoholism, Revisited, George Vaillant’s first chapter asks, “Is Alcoholism a Unitary Disorder?” He concludes (edited here for length & clarity):

We must learn to regard alcoholism as both disease and behavior disorder. To include any behavior disorder within the medical framework and to codify it with a unitary medical diagnosis, four criteria should be met:

1. Diagnosis should imply causitive factors independent of the presence or absence of social deviance (and alcohol dependence is significantly more likely when biologic relatives have also been alcoholic).
2. Diagnosis should convey shorthand information about symptoms and course (and alcoholism predicts a constellation of symptoms).
3. Diagnosis should be valid cross-culturally and not dependent on mores or fashion.
4. Diagnosis should suggest appropriate medical response for trement (and physical dependence often requires medical detoxification, and specific treatment is often required to sustain abstinence).

Stanton Peele reviewed the first edition of Vaillant’s book for New York Times Book Review on June 26, 1983. The 1996 forward for the review, available in full at Peele’s site, notes:

Stanton’s review of George Vaillant’s “The Natural History of Alcoholism” revealed that the emperor was naked, and that the book was intellectually dishonest. Vaillant systematically created summaries that disputed his own data, while citing cases selectively to try to support what he perceived to be the safe positions to take. As a result of Stanton’s review, Dr. Vaillant has for over a dozen years systematically attacked Stanton in speeches and workshops he gives around the nation, trying to square the circle by compulsively reinterpreting his (Vaillant’s) data to show that alcoholics never resume controlled drinking.

Additional excerpts from Peele’s review:

Vaillant … endorses the disease model, … but he also reaches for the middle ground by taking into account the research-based, social-psychological perspective that opposes the disease theory.

Dr. Vaillant finds that more than half of the alcoholics in the inner city group [(one of the decades-long study groups covered in the book)] evolved out of their drinking problems, generally without the assistance of treatment. He finds strong evidence in the inner city group for sociocultural causality in alcoholism… However, since Dr. Vaillant reports … that “genetic factors play a significant role in alcoholism,” he creates an impression that is at odds with his own research.

The cases [cited by Vaillant emphasize] the need for an alcoholic to acknowledge he has an uncontrollable disease and to seek redemptive [lifelong] treatment for it. When Dr. Vaillant reports that some alcohol abusers and alcoholics do return to moderate drinking, he notes that his subjects did so for period averaging more than a decade. Dr. Vaillant argues that this duration means that these results must be taken seriously but then illustrates his point with the paradoxical example of a man who claimed to have moderated his drinking but instead collapsed and died.

And, Peele concludes:

In alcoholism research, where one side regularly parades a new study and the other than vilifies it, Dr. Vaillant’s work can be cited approvingly by both. This is due in part to his admirable balance, fairness and honesty and in part to his willingness to accept contradiction and to defy his own research findings.

The Disease Model and the Layperson

So, what do the academic arguments about the disease model mean to us as laypeople? For most of us, the debates are pretty distant from our day-to-day existence. We aren’t making our living in the treatment industry, and if you’re like me, trying to decipher the technical side of the arguments can just leave you dizzy.

This stuff matters, though, if we need or want to change our drinking patterns but hesitate to get information or help because (a) the disease model isn’t a good fit for us, but (b) it appears to be the only game in town.

That described me in the early part of 2000. I was not content waking up most mornings with dry eyes, a pasty mouth, and hazy brain. I was willing to take steps to reverse the pattern, but hesitant to label my problem permanent and destined to escalate to tragic proportions. I wanted to solve the problem sooner than later. I figured it was possible that long-term abstinence might prove to be my only viable solution, but at that point jumping into it would have felt premature.

Of course, my experience is anything but universal. Some folks leave their drinking behind by taking a cognitive-behavioral or personal responsibility-based approach to abstinence. Others have stood in shoes like mine, clawing and scratching to escape from a growing sinkhole of problems related to their drinking. Finally emerging into the light of a clear-headed day, they have made peace by recognizing their escalating behaviors (and the natural consequences of them) as something which were destined to get much worse unless they were arrested completely. The primary, progressive, chronic disease model has offered them a clear choice and helped them to focus their energy on being healthy and balanced as they move forward.

The next three segments in this examination of the disease model:

• Chronology: How has the disease concept developed?
• Debate Points: What are some of the perspectives on each side?
• Looking Forward: How might the disease concept be tuned up?

Destroying species is like tearing pages out of an unread book, written in a language humans hardly know how to read, about the place where they live. by poker hands