August 5, 2004
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:
- Disease Model: Basics
- Disease Model: Chronology
- Disease Model: Debates - (this page)
- 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.
| Support for the Disease Model | Challenges to the Disease Model |
|---|---|
| Overview | |
Conveys seriousness. Creates public health focus. Helpful organizing construct:
| Scientifically indefensible. No framework for prevention. Strips patient of freedom, responsibility. Incurability creates stigma. Dissuades patients from seeking treatment. Causes misdirected funding of research, prevention, management. |
| Nature/Etiology of Alcohol Problems | |
Chronic, primary disease rooted in biological susceptibility. Unitary entity. Not a symptom of other disorder(s). Caused by abnormal brain chemistry which is:
Comparable to other diseases of mixed origin: Asthma, adult onset diabetes, hypertensive disease. | Possibilities include:
Continuum of problematic behaviors and consequences. Anyone may be vulnerable based on frequency, intensity, duration of drinking. Best to focus on altering harmful behavior. |
| Course and Natural Outcome | |
Disease progresses to insanity or death. Remission possible, not cure. Consistent symptoms and stages. Clear diagnosis possible at early, middle, & late stages. | Considerable variability in onset, course, and outcome of drinking problems. Alcohol problems are inherently self-limiting. Growing consumption over time increases the probability of deceleration or cessation. Most drinking problems lead to abstinence or moderation, not insanity, death, or treatment. |
| Craving and Loss of Control | |
Disease is defined by presence of:
| Scientific support is lacking. Craving = memory of past use. Loss of control concept is untenable. Loss of control concept prevents problem drinkers from taking responsiblity for moderating. |
| Treatment | |
Medical expertise often needed to resolve alcoholism. Patients deserve access to treatment. Only legitimate goal is sustained abstinence. Minnesota model (12-step-based) is most effective treatment. Treatment is both clinically effective and cost effective. Remission rates are comparable to other chronic diseases. Coerced treatment effectiveness is comparable to voluntary. | Highest-performing treatments:
are often not offered. Mainstream treatment must be expanded to include/emphasize scientifically proven alternatives. Moderate drinking must be supported as an option for some. Coercion violates human rights, is ineffective and can be harmful. |
| Mutual Aid Societies | |
Life-long A.A. affiliation or other 12-step program is the most viable sustained recovery option. Best predictor of long-term recovery is degree of sustained 12-step/A.A. participation. | Majority of recovered are not affiliated with a group. Life-long A.A. meetings replace one form of unhealthy dependence with another. Coerced 12-step treatment violates human rights and professional ethics. |
| Personal Culpability/Responsibility | |
Alcoholic is not responsible for becoming dependent, nor could s/he have prevented it from happening. Drinkers (even heavy ones) drink by choice, alcoholics drink despite contrary intent and known consequences. Addiction is not a habit, can not be consciously cast off. Upon diagnosis, alcoholics become responsible for initiating & managing recovery. | Disease concept rationalizes destructive conduct and continued drinking. Excessive drinking is a choice. All drinkers are responsible for choices and resulting consequences. At worst, addiction is a habit subject to will, and habits can be broken. Disease concept replaces personal freedom, responsibility with professional power, governmental coercion. |
| Stigma | |
Disease concept reduces social/moral stigma of addiction, opening doors to treatment and recovery. | Stigma removed from excessive drinking actually encourages self-destructive and antisocial behavior patterns. |
My approach to life leans toward common-sense, low-key, pragmatic understanding of problems and solutions. When I run into debates that seem to inspire a lot of screechy rhetoric, I get wary. Truth tends to be simple and fall somewhere in robust shades of gray more often than it can be defined in legalistic blacks and whites.
Conversations around the disease model have often devolved to the extremes, as Bill White describes:
Training events that touch on this debate have deteriorated into intense acrimony between participants wedded to extreme pro- and anti-disease positions, disease critics have been personally accused of killing people with their ideas, and each new article and book seems more strident than those that came before.
White speaks to the heart of the matter, though, with this:
It is this author’s view that the disease concept that emerged in the mid-20th century was a beautiful concept for its time. It “worked” in the truest sense and it worked at personal, professional and cultural levels. However, this concept enters the 21st century with:
- a poor scientific foundation;
- a narrowly defined clinical profile that does not reflect the diversity of individuals seeking help for alcohol- and other drug-related problems; and
- a poorly defined boundary that leaves it open to continued corruption and commercial exploitation.
The future of the disease concept will hinge on the ability of the addiction field to redefine this concept in light of accumulated scientific research and accumulated clinical and recovery experience.
Beautiful.
Let’s be as aware of this stuff as we need to be, folks, but not distracted or derailed from moving steadily forward in living consciously and sensibly.
Other pages in the disease model series:
- Basics: Intro to the Disease Model
- Chronology - How has the disease concept developed?
- Debates - (this page) - What are some of the perspectives on each side?
- Looking Forward: How might the disease concept be tuned up?
|
