August 3, 2004
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:
- Disease Model: Basics
- Disease Model: Chronology - (this page) - Sources, 1700s-present, & Layperson’s perspective
- Disease Model: Debate Points
- 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 20th-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?
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