Live Sensibly (with alcohol): Glossary Page, Alphabetical

-Glossary Intro

The words we use tell a lot about us.

Sensibility and Precision

In order to live sensibly, we need a sensible, precise vocabulary: Honest, direct, pragmatic.

Did you know that the word binge has evolved dramatically in recent years? That the thresholds used to define moderate and problematic drinking vary? That diagnostic criteria focus on alcohol abuse and dependence, and shy away from the term alcoholism?

Fresh words, fresh lives

Developing fresh ways of living requires that we also put new words to work, and tune up our usage of familiar ones.

We’ll keep track of those things here in the glossary. You’ll notice that each entry in the glossary is labeled with the date created and the most recent date updated. Definitions will be tuned up as we go, and I’ll cross-link them with our conversations to put them in context.

12-step

The twelve steps originally devised by the founders of Alcoholics Anonymous, variations of which are used widely by other addiction and compulsion support groups.

Within Live Sensibly, “12-step” refers to a general approach that includes the disease model, powerlessness to moderate the addictive behavior, the necessity of a spiritual response, and a need for life-long abstinence and support.

30 days of abstinence

One of Moderation Management’s recommendations is that taking a 30-day break from drinking can provide a window in which to examine one’s relationship with alcohol.

That’s the way it’s worked for me. My first abs in 2000 opened my eyes to fresh concepts. It challenged me to try out simple tools and techniques (related to living, not just drinking or abstaining) that were new to me.

Doing 30 days of abs is not a magic bullet, though. It didn’t magically erase the challenges I face in living sensibly with alcohol. It provided the foundation, though.

Worth noting about doing a 30:

• We’re not all geared to jumping immediately into a 30
• It’s smart to plan ahead: What kinds of tools, activities, alternatives and contingencies are going to be used during a 30?
• Shorter or longer abs are great, too. (I’ve done a couple 30s, a 110, and a 99% abs — 361/365 days — year.)
• Doing a 30 has the potential to bring cool gifts along with the challenges.
• It’s OK to admit that we’re not yet ready to jump into a 30 even if it sounds like a good idea. We may be in an early stage of preparing to change. It’s important to examine whatever ambivalence we may be feeling, and work with it and through it.
• When we’re not yet ready to jump into a 30, we can prepare for it by charting, reducing harm, and increasing the frequency of DAFT days.

AA: Alcoholics Anonymous

Alcoholics Anonymous, co-founded by Bill W. and Dr. Bob Smith, in 1935, pioneered the use of peer support to help alcoholics.

It synthesized the personal experiences of its founders and early members with the science of its day to offer help through the 12 steps and, beginning in 1939, the Big Book.

Its official website is AA.org, where the Recovery Program page begins:

The relative success of the A.A. program seems to be due to the fact that an alcoholic who no longer drinks has an exceptional faculty for “reaching” and helping an uncontrolled drinker.

In simplest form, the A.A. program operates when a recovered alcoholic passes along the story of his or her own problem drinking, describes the sobriety he or she has found in A.A., and invites the newcomer to join the informal Fellowship.

The group identifies itself as a Fellowship using this definition:

Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism.

The only requirement for membership is a desire to stop drinking. There are no dues or fees for A.A. membership; we are self-supporting through our own contributions. A.A. is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy; neither endorses nor opposes any causes. Our primary purpose is to stay sober and help other alcoholics to achieve sobriety.

Copyright © by the A.A. Grapevine, Inc.

Alcoholics Anonymous can also be defined as an informal society of more than 2,000,000 recovered alcoholics in the United States, Canada, and other countries. These men and women meet in local groups, which range in size from a handful in some localities to many hundreds in larger communities.

Worth noting, also, is that A.A. does not consider its work to include treatment or education:

A.A. is concerned solely with the personal recovery and continued sobriety of individual alcoholics who turn to the Fellowship for help. Alcoholics Anonymous does not engage in the fields of alcoholism research, medical or psychiatric treatment, education, or propaganda in any form, although members may participate in such activities as individuals.

The Fellowship has adopted a policy of “cooperation but not affiliation” with other organizations concerned with the problem of alcoholism.

Traditionally, Alcoholics Anonymous does not accept or seek financial support from outside sources, and members preserve personal anonymity in print and broadcast media and otherwise at the public level.

Abs

Short for abstinence. Can be used to describe a period of time planned to be alcohol-free: A 30 day abs.

Al-Anon

A support group for the families and friends of alcoholics.

From the Al-Anon/Alateen website:

Al-Anon’s Purpose

To help families and friends of alcoholics recover from the effects of living with the problem drinking of a relative or friend. Similarly, Alateen is our recovery program for young people. Alateen groups are sponsored by Al-Anon members.

Our program of recovery is adapted from Alcoholics Anonymous and is based upon the Twelve Steps, Twelve Traditions, and Twelve Concepts of Service.

Alcoholics Victorious

A Christian recovery group.

From its home page:

Founded in 1948, Alcoholics Victorious support groups offer a safe environment where recovering people who recognize Jesus Christ as their “Higher Power” gather together and share their experience, strength and hope. Both the 12 Steps and the Alcoholics Victorious Creed are used at most AV meetings.

Ambivalence

From the Merriam-Webster Online Dictionary:

noun

1. Simultaneous and contradictory attitudes or feelings (as attraction and repulsion) toward an object, person, or action
2. a : continual fluctuation (as between one thing and its opposite) b : uncertainty as to which approach to follow

For some, ambivalence is synonymous with being uncommitted, doubtful, unconscious of, or hiding from one’s problems — the second definition.

In facing issues related to drinking, many of us learn to value our ambivalence in the context of the first definition. We treat it as an earthy, grounded, conscious place to be, opening us up to looking honestly at the good, the bad, and the neutral aspects of alcohol in our lives.

During my first abs in 2000, I spent time examining my relationship with alcohol. I had been hesitant to admit that there are things I really enjoy about drinking, worried that such an admission might be proof of dependence on alcohol.

Embracing my ambivalence meant fully appreciating both the benefits and drawbacks of different kinds of drinking experiences, and that enjoying the benefits didn’t mean that I was denying the drawbacks.

Antabuse (disulfiram)

From Medline Plus:

Disulfiram is used to treat chronic alcoholism. It causes unpleasant effects when even small amounts of alcohol are consumed. These effects include flushing of the face, headache, nausea, vomiting, chest pain, weakness, blurred vision, mental confusion, sweating, choking, breathing difficulty, and anxiety. These effects begin about 10 minutes after alcohol enters the body and last for 1 hour or more. Disulfiram is not a cure for alcoholism, but discourages drinking.

The National Council on Alcoholism and Drug Dependence, on its History and Mission page drawn from White’s Slaying the Dragon, notes that, in 1948:

Disulfram (Antabuse) [was] introduced as an adjunct in the treatment of alcoholism in the U.S. Other drugs used in the treatment of alcoholism during this period include barbiturates, amphetamines (Benzedrine), and LSD.

BAC: Blood Alcohol Content

Blood Alcohol Content (BAC) is the concentration of alcohol in a person’s blood.

Blood Alcohol Units

In the U.S., the most common gauge for measuring BAC is the concentration measured by volume as a percentage. A blood alcohol level of .08 percent (too impaired to drive in most states) means that 8 parts per 10,000 in the blood is alcohol. It may be abbreviated BAC% or %BAC.

Another common measure is percentage by weight, or grams of alcohol per 100 milliliters of blood, sometimes noted as g/100ml. Although blood alcohol test results are often described as a percentage by volume, most of the instruments used to determine it actually measure the weight.

The difference between percentage by weight and by volume is inconsequential for most of us, because they produce the same numbers. A BAC of 0.05% by volume is the same as 0.05 mg/ml.

BAC may also be given as mg%, which is similar to g/100ml. A level of 0.05% could be listed as 050 mg%.

Alcohol Metabolism Rates

HowStuffWorks.com briefly highlights how alcohol is metabolized:

Once absorbed by the bloodstream, the alcohol leaves the body in three ways:

• The kidney eliminates 5 percent of alcohol in the urine.
• The lungs exhale 5 percent of alcohol, which can be detected by breathalyzer devices.
• The liver chemically breaks down the remaining alcohol into acetic acid.

As a rule of thumb, an average person can eliminate 0.5 oz (15 ml) of alcohol per hour. So, it would take approximately one hour to eliminate the alcohol from a 12 oz (355 ml) can of beer.

BAC Charts

Moderation Management has a set of charts for approximating BAC based on our gender (male & female bodies metabolize alcohol differently), size, amount consumed, and elapsed time. The units used in the MM charts are “mg%”; a level of 080 there is the same as a BAC% of .08, the threshold at which most U.S. states prosecute for driving under the influence (DUI).

Comparing the one-hour-to-eliminate-one-drink rule to the MM charts, though, it appears the “average” person in question is 200-pound male or a 240-pound female, because if either of them has 3 drinks over 3 hours, their BAC will be under .01. A 120-pound woman is still going to be at .015 after consuming 3 drinks in a 6-hour period, and 160-pound man is likely to be at .012 after having 4 drinks in a 5-hour period.

Effects of alcohol based on BAC levels

The BRAD21.org website — Be Responsible About Drinking — was created by friends and family of Bradley McCue, who died of alcohol poisoning at 21. It includes a page which lays out the effects of alcohol, noting that “some users may become intoxicated at a much lower Blood Alcohol Concentration (BAC) level than is shown”.

Big Book of AA

The foundational book of AA, titled Alcoholics Anonymous.

The entire book is available online.

Binge

Usage of the word “binge” has evolved in recent years.

Binge: The Dictionary Version.

Merriam-Webster defines it this way:

a drunken revel : SPREE; an unrestrained and often excessive indulgence <a buying binge>

Princeton’s WordNet 2.0 speaks of immoderate indulgence:

The noun “binge” has 2 senses in WordNet.

1. orgy, binge, splurge — (any act of immoderate indulgence; “an orgy of shopping”; “an emotional binge”; “a splurge of spending”)
2. bust, tear, binge, bout — (an occasion for excessive eating or drinking; “they went on a bust that lasted three days”)

The verb “binge” has 1 sense in WordNet.

1. gorge, ingurgitate, overindulge, glut, englut, stuff, engorge, overgorge, overeat, gormandize, gormandise, gourmandize, binge, pig out, satiate, scarf out — (overeat or eat immodestly; make a pig of oneself; “She stuffed herself at the dinner”; “The kids binged on icecream”)

Twenty-four Hours: A Short Binge?

In the substance abuse field, the longest-standing definition of “binge” refers to an episode of heavy drinking, usually lasting more than a day. In the NIAAA’s ETOH database glossary we find:

A pattern of heavy drinking that occurs in an extended period set aside for the purpose of drinking. In population surveys the period is usually defined as more than one day of drinking at a time. The activity of binge drinking also is referred to as “bout drinking” or “spree drinking.” The term “drinking bout” is used to refer to the occasion. A binge drinker or bout drinker is one who drinks predominantly in this fashion, often with intervening periods of abstinence.

My buddy Brian was a binge drinker in this sense of the word. He would buy 2-5 bottles of Scotch (and not small ones) and start drinking at while playing at the computer, and later, watching TV. A gap of a couple hours between drinks was possible when passed out, but the heavy drinking continued not too long after getting up. When we were closest, in the mid 1990s, a 24-hour binge was less common and most of them fell in a range of 36 to 72 hours. Then, as in the definition, abstinence would prevail for several weeks.

College Binge Drinking: The 5/4 Definition

In the early 1990s, studies of alcohol use on college campuses began adapting the use of “binge” to describe having 5 or more drinks “in a row”, without specifying a timeframe.

The College Alcohol Survey, which collected data from over 17,000 students on 140 campuses in 1993, led by Dr. Henry Wechsler, Ph.D. with support from the Robert Wood Johnson Foundation, split the definition to account for gender differences. Its report titled "Health and Behavioral Consequences of Binge Drinking in College" in the Journal of the American Medical Association noted:

(p. 1674, col 1) Binge drinking was defined as the consumption of five or more drinks in a row for men and four or more drinks in a row for women. …the term “binge drinker” is used to refer to students who binged at least once in the previous 2 weeks.

(p. 1673, col 2) The use of [“in a row”], without specification of a time elapsed in a drinking episode, is consistent with standard practice in recent research on alcohol use among this population.

(p.1672, col 3) [Previous] studies of college alcohol use … [have generally] used the same definition of binge drinking for men and women, without taking into account sex differences in metabolism of ethanol or in body mass.

The 5/4 definition has resonated in the media and among public health advocacy groups, but failed to win widespread acceptance among academics and researchers. The International Center for Alcohol Policies questioned it in a 1997 report:

Defining a drinking pattern solely by the number of drinks consumed … falls short of being adequate. This approach fails to take into account the context of drinking, the individual engaging in the behavior (a 250-lb male is likely to experience very different consequences from five drinks than is a 100-lb female), and the salience of alcohol within the drinking occasion. The time interval over which the drinks are consumed is a critical variable, but also one on which there is no consensus. The effects of consuming five drinks over the course of a three-hour dinner are likely to manifest themselves very differently from the effects of consuming five drinks in rapid succession over half an hour.

An October 2000 press release by the Higher Education Center for Alcohol and Other Drug Prevention noted:

Most researchers in the field are now rejecting use of the word “binge” to describe having 5/4-plus drinks over some unspecified period of time. It is true that various government reports use it, but the National Institute of Alcoholism and Alcohol Abuse (NIAAA), the federal government’s primary research institute in this area, never does, nor does the Journal of Studies on Alcohol, which is the lead journal in the field. Moreover, a special panel on alcohol prevention and treatment in higher education convened by NIAAA voted unanimously last year not to use the term “binge” in this way.

NIAAA’s 2004 Binge Definition

During its February 4-5, 2004 meeting, the National Advisory Council on Alcohol Abuse and Alcoholism (which advises the NIAAA), unanimously approved this updated definition:

A “binge” is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to .08 grams percent or above. For the typical adult this pattern corresponds to consuming 5 or more drinks (male) or 4 or more drinks (female) in about 2 hours. Binge drinking is clearly dangerous for the drinker and for society.

• A drink is defined as half an ounce of alcohol (e.g., one 12 oz. beer, one 5 oz. glass of wine, one 1½ oz. shot of distilled spirits).
• Binge drinking is distinct from “risky” drinking (peak BAC between .05 and .08 grams percent) and “benders” (2 or more days of sustained drinking to intoxication).
• For some individuals (e.g., older people; those taking other drugs or certain medications), the number of drinks needed to reach a binge-level BAC is lower than for the “typical adult.” People with risk factors for the development of alcoholism have increased risk with any level of alcohol consumption, even that below a “risky” level.
• For pregnant women, any drinking presents risk to the fetus.
• Any drinking by persons under the age of 21 is illegal.

So, using what we know about blood alcohol content, this definition tells us that binge starts at a level of slight impairment of balance, speech, vision, reaction time, and hearing. In general terms, the binge threshold of .08 is half-way to the “sloppy drunk” characteristics of .16. BAC tables like these suggest that the binge threshold could be reached by:

• A 120-lb woman having 2½ drinks in an hour
• A 220-lb woman having 8 drinks in 5 hours
• A 160-lb man having 4 drinks in an hour
• A 240-lb man having 11 drinks in 5 hours

Blip

From Dictionary.com:

blip, n.

• A spot of light on a radar or sonar screen indicating the position of a detected object, such as an aircraft or a submarine
• A temporary or insignificant phenomenon, especially a brief departure from the normal.

My definition:

A break in a drinking pattern, such as drinking during a period intended to be abstinent. Worth examining and learning from, but not necessarily a setback or helpful to interpret as a failure.

Some blips turn out to be anomalies, like false echoes on a radar screen, or inconsequential. Sometimes a blip is the first sign of a threat, needing to be addressed proactively.

The keys to reading a blip are consciousness and context: How does it fit with our typical or recent patterns?

Charting

A simple but essential tool for changing a habit: Tracking the progress.

DAFT

Delightfully Alcohol-Free Today.

My personal word for describing abstinent days. They’re often about feeling free from needing to be a somber, responsible adult. To me, a DAFT day is generally more a gift than a burden.

Any number of “D” words may fit, as well: Deliciously, deliriously, delectably, daintily…

See the how the word came to be, in So Bored? and More DAFT than sober.

Denial

“Refusal to admit the truth or reality

(as of a statement or charge)” (per Merriam-Webster).

A more clinical description from AlcoholMD.com:

Psychological defense mechanism … includ[ing] a range of psychological maneuvers that decrease awareness of the fact that alcohol use is the cause of a person’s problems… Denial becomes an integral part of the disease and is nearly always a major obstacle to recovery. Denial in alcoholism is a complex phenomenon determined by multiple psychological and physiologic mechanisms… Denial is the reluctance or failure to attribute problems to alcohol consumption; it is often a psychological defense against acknowledging the pain caused by the problem.

The NIAAA offers a Denial Rating Scale Decision Tree. It defines a scale of denial from Level 1 (an alcohol-dependent person saying that drinking is not a problem) to Level 8 (a person connecting with his self-image as an alcoholic, knowing how easy it would be to fall back to drinking without being threatened by it).

It’s certainly possible for us to gloss over tangible negative effects that drinking may have had on us or our loved ones. (I’ve dabbled in it at times.) It’s critical for us, as responsible, self-sufficient adults, to use all of the resources at our disposal to do personal reality checks and adjust our distorted perceptions whenever possible.

The challenge in identifying denial, though, is that the word has sometimes been used to describe:

• Any resistance to a recommended treatment approach.
• Academic disagreement about the necessity of adopting powerlessness and a higher power to achieve recovery.
• Resisting 12-step approaches, or refusing to identify one’s drinking problems as a disease, even mixed with willingness to pursue long-term abstinence.
• Believing that drinking problems don’t all progress to dependence and death (which they don’t).

There is no doubt that denial can be real — it’s possible for us to short-circuit our own logic, and even for long-term alcohol abuse to contribute to that — but slinging denial allegations can also be done sloppily. Once they’ve slung it, folks often feel vindicated by the inevitable resistance expressed by their target. “You’re questioning me? You just proved my point!”

Even when some form of denial is in play, the circumstances are often more complex than a simplistic lack of consciousness or smarts. If we’re not willing or ready to face the ways in which our actions are affecting others, we may still be cognizant that our behavior patterns aren’t smart. We may not be embracing the gut-level assessment by friends or family members, yet entirely willing to admit that things are breaking and/or broken in some fashion. And, the issues on which we disagree may be founded on rational, realistic perceptions.

Presuming that denial is always a player when we’re in a pattern of less-than-optimal choices can raise the spectre of shame. “Damn it, I made another choice that I promised I wouldn’t, so there still be a huge well of denial lurking within me. How could I be that stupid?” In truth, human behavior is often complex. It is not easily understood, and our actions are based on more than simply what we know or what we don’t, what we accept or refute. Taking on shame — thinking “since I did the not-so-smart thing again, I must not be smart enough to admit the reality of the situation” — does a disservice to the complexity of our honest, sincere, yet humanly flawed lives.

Denial isn’t even a universal component of alcohol abuse. On page 33 of his 1995 book, The Natural History of Alcohol Alcoholism, Revisited, George Vaillant notes that problem drinkers have reported their drinking accurately in non-threatening circumstances.

Other researchers have found that alcoholics describe their own excessive drinking practices more accurately than their relatives describe them (Guze et al. 1963; Haberman 1966). Sobell and Sobell (1975) have also documented that the symptomatic diagnosis of alcoholism can in fact be reliably made from the patient if certain rules are followed. Subjects should be without a clouded sensorium and relatively sober at the time of interview. They should be questioned by a sophisticated interviewer who asks the “right” questions, who is not in a position to threaten the alcoholic’s right to drink, who obtains reasonable rapport, and who has time to conduct an adequate interview.

Stanton Peele and Archie Brodsky, in a 1991 article in Reason Magazine, talk about the emphasis on denial in Alcoholics Anonymous:

This proselytizing tendency, originating in the religious roots of the movement, was legitimized by the association with medicine. If alcoholism is a disease, then it must be treated — like pneumonia. Unlike people with pneumonia, however, many people identified as alcoholics don’t see themselves as sick and don’t want to be treated. According to the treatment industry, a person with a drinking or drug problem who does not recognize its nature as a disease is practicing “denial.”

In fact, denial of a drinking problem — or of the disease diagnosis and A.A. remedy — has come to be a defining characteristic of the disease. But indiscriminate use of the denial label obscures important distinctions among drinkers. While people sometimes do fail to recognize and acknowledge the severity of their problems, a drinking problem does not automatically prove a person is a lifelong alcoholic. Indeed most people “mature out” of excessive, irresponsible drinking.

The disease approach uses the concept of denial not only to force people into treatment, but to justify emotional abuse within treatment.

Peele and Brodsky don’t point to denial as something that never happens or doesn’t need to be considered, but to the dangers of indiscriminate use of denial.

Emphasizing the potential, and looking intently, for signs of denial has been found to be counterproductive by some researchers. Instead, they have found it more helpful to consider the natural role of ambivalence as folks progress through the stages of change, and look for ways to increase personal motivation.

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?

Disease Model: Chronology

We started our look at the disease concept of alcoholism with the basics page. Let’s expand on it now by understanding a bit of the history behind it. As it turns out, references to severe drinking problems as diseases extend back to the 1700s in the U.S., and some historians who have studied A.A. suggest that early members used it as a metaphor more than a fixed medical entity.

This is the second of a four-pronged approach to nailing down some of the key concepts and history of disease as it relates to drinking and addiction, setting up a foundation for each of us to use in thinking about how we choose to live sensibly with alcohol:

1. Disease Model: Basics
2. Disease Model: Chronology - (this page) - Sources, 1700s-present, & Layperson’s perspective
3. Disease Model: Debate Points
4. Disease Model: Looking Forward

On this page: (a) Primary Sources; (b) History from the 1700s-1940, A.A. Influences, 1940s-1970s, 1970s-present; and, (c) Layperson’s Perspective.

Primary Sources: Bill White and Ernest Kurtz

William L. White

is a Senior Research Consultant with the Lighthouse Institute at Chestnut Health Systems in Bloomington Illinois who has written extensively on addiction history. In the early 1990s, leaders within the Chestnut Health organization envisioned a textbook “that could collectively tell the story of addiction in America and the profession that was birthed to respond to it.” That led to White’s publishing of Slaying the Dragon: The History of Addiction Treatment and Recovery in America in 1998.

A detailed review of the book by Marty N. is available at the LifeRing Recovery site, including a short response from White. More recently, White has co-authored Drunkard’s Refuge with John Crowley.

White talked about his relationship with history in the preface of a 2000 paper:

I have lived and worked in the worlds of addiction treatment and recovery for more than three decades — all of my adult life — and it was my experiences in these worlds that first incited my fascination with history and my discovery of history as the ultimate elder. For many years, I have sat at history’s feet, listened to her stories, and tried to be an ardent student. The following pages are filled with my, admittedly inadequate, comprehension of the lessons that I believe history can offer…

Ernest Kurtz

is known as an eminent A.A. historian, and Bill White credits him as mentor and helpful reviewer in several of his papers. He is identified in this paper as follows:

Ernest Kurtz, after earning his Ph.D. in the History of American Civilization from Harvard University in 1978, taught American History and the History of Religion in America at the University of Georgia and Loyola University of Chicago. He is the author of Not-God: A History of Alcoholics Anonymous and many articles related to the history of A.A.

Historical Development of the Disease Model

The Behavioral Health Recovery Management site, BHRM.org, a project funded by the Illinois Office of Alcoholism and Substance abuse, includes a set of articles by White, Kurtz, and others which trace the evolution of the disease concept of addiction from the 5th century B.C. to the present. While its roots run deep, controversy and questions have travelled with the disease concept throughout its history.

From the 1700s to 1940

In Addiction as a Disease: Birth of a Concept (PDF, 35K), White notes that social reformer Anthony Benezet and Dr. Benjamin Rush were the first in the U.S. to characterize chronic drunkenness as a disease in the late 1700s. In 1829, Dr. William Sweetser recognized emerging medical descriptions of addictive disease, yet questioned whether such a disease should ever be defined apart from some sort of “moral turpitude.” The prominence of the disease concept faded at the close of the 1800s as prohibition movements gained momentum, which were more prone to describe drinking problems as the result of vice and sin, or name alcohol itself as a poison.

The temperance movement culminated in the passage of the Prohibition amendment in 1919. Its popularity was driven by beliefs that widespread temperance would enhance social order, but it was also tinged with anti-immigrant sentiments that eastern and southern Europeans emigrating to the U.S. were creating an alcohol-driven culture. Plagued with enforcement problems and impacted by changing moral standards, the amendment was repealed in 1933.

Ron Roizen’s 1991 dissertation, The American Discovery of Alcoholism, 1933-1939, traces a transition from a “temperance paradigm” at the repeal of Prohibition in 1933 to an “alcoholism paradigm.” In the temperance paradigm, which was still favored by many alcohol researchers in 1933, alcohol had qualities popularly associated with heroin today: The drug itself was considered widely addictive, offering no social benefits or framework in which moderate use might be socially acceptable. The alcoholism paradigm, by contrast, identified alcohol as “an addictive and destructive substance in only a minority of persons, known as alcoholics.”

Alcoholics Anonymous and the Disease Model

A.A., which took its first baby steps in 1935, has sometimes been credited with birthing the 20^th-century alcoholism-as-disease concept. Ernest Kurtz tells us otherwise. In Alcoholics Anonymous and the Disease Concept of Alcoholism (144K PDF), he points out that the principles of A.A. didn’t include dogmatic insistence on naming alcoholism as a unitary disease with a predictable course. On page 3 of that paper is a 1961 quote by Bill W.:

We have never called alcoholism a disease because, technically speaking, it is not a disease entity. For example, there is no such thing as heart disease. Instead there are many separate heart ailments, or combinations of them. It is something like that with alcoholism. Therefore we did not wish to get in wrong with the medical profession by pronouncing alcoholism a disease entity. Therefore we always called it an illness, or a malady — a far safer term for us to use.

Kurtz describes a complex intermingling of roles and messages between A.A., the Big Book (which didn’t focus heavily on a specific disease model) and publishers of the A.A. Grapevine, an “officially unofficial” newsletter which often promoted a medicalized unitary disease concept.

In fact, the disease concept promoted by A.A. co-founder Dr. Bob (a proctologist) was alcoholism as “an illness which only a spiritual experience will conquer,” more a metaphor than a medical mechanism. Bob was noted by his fellow A.A. members as deeply spiritual, given to soul-searching prayer with a alcoholics taking their first steps toward sobriety. For him the importance of the disease concept lay in conveying the hopelessness of terminal illness which only a higher power could touch.

1940s to 1970s

Bill White names 1942-1970 as The Modern Alcoholism Movement in The Rebirth of the Disease Concept of Alcoholism in the 20th Century (23K PDF). Propelled by a coalition of three alcohol-oriented research and educational organizations, the concept that alcoholism is a disease attracted increasing attention and approval. The Minnesota Model of 12-step-based treatment emerged from approaches pioneered by three Minnesota facilities in 1948-50.

Dr. E.M. Jellinek’s book, Disease Concept of Alcoholism, first published in 1960, is identified by White as:

the most widely cited (and least read) literary artifact of the modern alcoholism movement. In it, Jellinek noted the growing acceptance of the disease concept of alcoholism but expressed his reservations about this oversimplified understanding of the disorder.

He suggested there were a variety of “alcoholisms,” only two “species” of which he thought merited the designation of disease, and went on to criticize the tendency to characterize alcoholism as a single disorder.

Jellinek also expressed concerns about the disease concept which were echoed in the 1955 thoughts of psychiatrist and friend to A.A., Henry Tiebout:

[T]he idea that alcoholism as a disease was reached empirically by pure inference […] had never been really proved. …I cannot help but feel that the whole field of alcoholism is way out on a limb, which any minute will crack and drop us all in a frightful mess.

1970s to the Present

Bill White summarizes:

During the late 1970s and early 1980s, there was an explosive growth of treatment programs, particularly hospital-based and private programs, which used the disease concept.

The most widely replicated treatment approach in both private and public programs was the Minnesota Model, which perceived addiction was a primary disease. In short, the disease concept altered the public’s conception of the alcoholic and challenged medical and public health authorities to take responsibility for the treatment of alcoholism — a significant achievement.

Every significant social movement has the potential to generate a counter-movement, and this happened with the alcoholism movement. The backlash came in two forms. The first was a financial backlash against the business-practice excesses of the treatment industry. Aggressive programs of managed care that restricted treatment access and duration led to a plummeting daily census within, and the eventual closing of, many inpatient programs. Particularly impacted was the prototype 28-day inpatient treatment program that had most exemplified the disease concept. The second backlash was ideological and took the form of growing philosophical and scientific attacks against the disease concept and the treatment programs based upon it.

The 20th century ended without popular or professional consensus on the nature of alcohol and other drug problems and the strategies that could best resolve these problems at a personal or cultural level.

The Layperson’s Perspective: What Can We Take From History?

Looking at the historical perspective, it becomes clear that there is no easy slam-dunk support for a unitary primary, progressive, chronic disease concept of alcoholism.

If anything, the clearest support emerging over time seems conditioned to recognize the existence of many problematic drinking patterns, with the disease concept best equipped to describe the most severe end of the spectrum.

In that context, it seems reasonable that the course of some drinking problems may play out similarly to adult onset diabetes. Some forms of diabetes require lifelong treatment at the most intensive level. Others require close attention initially but taper off in severity, responding effectively to control via precise diet and exercise. Still others find that treating morbid obesity with long-term weight loss restores a natural balance in which the body’s insulin production and regulation are essentially normal.

Stanton Peele has written about folks who mature out of problematic drinking patterns. He points to a study which found a familiar group of folks — previously alcohol-dependent, received treatment, now abstinent — but an even larger group who were previously dependent, did not receive treatment, and were currently drinking but not showing dependence. (Lack of dependence would not be the same as complete freedom from drinking problems in all cases, but still indicates a measurable decrease in severity.) He notes:

In the maturing out approach, people come to see that “recovery” is a natural process that is more likely than not to occur as long as they make realistic progress in the key areas of their lives.

As I concluded on the previous Disease Model page, finding ourselves in less-than-optimal drinking patterns doesn’t necessarily mean we’re all dealing with the same problems or that we’ll all find the same answers to be effective.

Other pages in the disease model series:

• Basics: Intro to the Disease Model
• Chronology - (this page) - 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?

Disease Model: Debate Points

Here is the third of a four-step approach to nailing down some of the key concepts and history of disease as it relates to drinking and addiction:

1. Disease Model: Basics
2. Disease Model: Chronology
3. Disease Model: Debates - (this page)
4. Disease Model: Looking Forward

Again, we’re deeply indebted to the work of Bill White. With research support from the Illinois Department of Human Services, Office of Alcoholism and Substance Abuse, he compiled a summary of key points (30K PDF) in the debates over the disease concept of alcholism.

Caveats apply to the listing below: White notes that folks on either side do not speak with a single voice. I have not attempted to make this a quantitative accounting of the information he documented. While covering a broad spectrum, the following table is indicative, not definitive, of the public discourse on the topic. Absorbing this gives us a sense of the diversity of thought in both communities without giving us a tool for generalizing about the precise thoughts of everyone who fits on a given side. Plenty of thoughtful folks (perhaps White himself) draw elements of truth and value from both sides of the divide.

If you’re interested in the details, please follow the link to his piece and/or dig up the source documents it references. As time moves forward, I hope to adapt this, expand it, and add links to supporting documents. Think of it as a broad map with smatterings of pushpins indicating places that have been visited. It gives us a satellite view of a broad expanse on which several points of interest stand out.