The Disease Theory of Alcoholism

The Disease Theory of AlcoholismThe debate over whether or not alcoholism is a disease or simply a serious behavioral problem has continued for over 200 years and doesn't appear likely to end anytime soon.

The Theory

The disease theory of alcoholism is just that....an unproven theory and nothing more.

Dr. Herbert Fingarette has observed that the disease theory of alcoholism is embodied in four propositions:

"1) Heavy problem drinkers show a single distinctive pattern of ever greater alcohol use leading to ever greater bodily, mental, and social deterioration. 2) The condition once it appears, persists involuntarily: the craving is irresistible and the drinking is uncontrollable once it has begun. 3) Medical expertise is needed to understand and relieve the condition ('cure the disease') or at least ameliorate its symptoms. 4)Alcoholics are no more responsible legally or morally for their drinking and its consequences than epileptics are responsible for the consequences of their movements during seizures." (*See Footnote 1.)

The first proposition gained credibility in the 1940s when E.M. Jellinek, the “father" of the disease model of alcoholism, published a study of the "phases of alcoholism" (*See Footnote 2.) in which he hypothesized an inevitable sequence of increasingly uncontrolled drinking progressively leading to such symptoms as blackouts, tolerance, withdrawal distress, insanity and death.

Jellinek's hypothesis was based on self-report questionnaires that were prepared and distributed by Alcoholics Anonymous (AA). From these a hand-selected group of fewer than 100 questionnaires, all from men, were analyzed. Although Jellinek recognized its scientific inadequacy and saw it as a starting point for research, it was soon accepted as scientific fact by others. Ironically, Jellineck came to recognize the inadequacies of what became known as the Jellineck curve and distanced himself from it.

However, rigorous scientific research has subsequently demonstrated that the typical pattern of heavy drinking fluctuates. Some drinkers get worse, some improve, some don"t change, and still others develop different problems than those Jellineck identified. (*See Footnote 3.)

The second proposition has also been disproved by research evidence for decades demonstrating that some alcoholics return to moderate or controlled drinking. It has also been disproved by a nation wide survey of alcoholics conducted by the United States government. It found that 17.7% of alcoholics are now drinking in moderation.

The third proposition, that medical help is necessary to deal with alcoholism, is clearly not the case. Most alcoholics control or modify their behavior without any help from anyone else than themselves. Those who use Alcoholics Anonymous or other 12-step groups are using a non-medical approach.

The fourth proposition is certainly not true. In 1988, the United States Supreme Court found that alcoholism is always the result of the veteran's "own willful misconduct." It reaffirmed the lower court"s finding that there exists "a substantial body of medical literature that even contests the proposition that alcoholism is a disease, much less that it is a disease for which the victim bears no responsibility." (*See Footnote 4.) It also noted that "Indeed, even among many who consider alcoholism a "disease" to which its victims are genetically predisposed, the consumption of alcohol is not regarded as wholly involuntary." (*See Footnote 5.)

The American Medical Association

In 1956 the American Medical Association voted to define alcoholism as a medically treatable disease so that such treatment by physicians would become eligible for payment from third parties (insurance companies). The decision was made on self-serving economic rather than scientific grounds. In defending the action, Jellineck said, “a disease is anything that doctors choose to call a disease." (*See Footnote 6.) Calling alcoholism a disease was a bonanza that quickly poured many billions of dollars into the pockets of physicians, hospitals and pharmaceutical companies and continues to do so.

It"s an important fact that many physicians in anonymous surveys reject the disease theory. For example, one survey of physicians found that only 20% believed substance addiction to be a disease. In addition, 55% said that there is “no effective treatment" for it. (*See Footnote 7.) Another study found that only 25% of physicians viewed alcoholism as a disease. Only one-quarter of the physicians considered alcoholism to be a disease. The majority viewed alcoholism as a social or psychological problem rather than disease. (*See Footnote 8.)

An American Medical Association poll found that nearly half of the responding physicians did not believe they were competent to treat alcoholism. (*See Footnote 9.) Many believe that alcoholism is not a disease but is a lifestyle problem.

As Dr. Bankole Johnson, chairman of the department of psychiatry at the University of Virginia explaines, “Many doctors have been loath to prescribe drugs to treat alcoholism, sometimes because of the belief that alcoholism is a moral disorder rather than a disease" (*See Footnote 10.)

Definitions

One reason that the disease theory of alcoholism became so popular was because it changed how people think about alcoholics. Historically, alcoholics were called drunkards and believed to lack character and willpower; they were seen as moral defectives. However, If they are seen instead as suffering from a disease, then they are not alcoholic because of some personal failing such as a lack of willpower or moral weakness. Of course, in the minds of many people, it also relieves them of responsibility for their behaviors.

Definitions can also deceive or mislead us. We may try to explain why a person drinks too much saying that she is alcoholic. But this is circular reasoning and is as useless as saying that a person is alcoholic because he drinks too much. We could say that people fear being in tight enclosed places because they are claustrophobic which is nothing more than saying that claustrophobic people fear being in tight enclosed places. Or that people have blond hair because they"re blondes. (*See Footnote 11.)

The disease theory of alcoholism never explains how or why people are alcoholic. It never describes specifically what causes people to drink compulsively. Instead, it says that they drink compulsively because they have a compulsion.

The existence of chemical dependencies is a medical fact, but they are only considered to be diseases when not approved by doctors. Some mentally ill people are told that they will need to be on psychiatric medications for the rest of their lives. Yet this dependency is considered a treatment, not a disease. In short, dependency is only considered a disease when it is not socially approved.

The commonly used definition of alcoholics as people who can never drink in moderation creates serious problems. Research has produced evidence for decades that some alcoholics do, in fact, return to moderate or controlled drinking. However, this evidence is routinely rejected. Proponents of that definition or belief tend to argue that if researchers identify alcoholics who can now drink in moderation, that simply means that the alcoholics were falsely diagnosed and really weren"t alcoholics or they wouldn"t have been able to drink in moderation. For true believers, it"s a case of “heads I win; tails, you lose."

Smoking is not a disease but the lung cancer that it can cause is a disease. Similarly, drinking too much isn"t a disease although it can cause diseases such as high blood pressure, liver cirrhosis, and fetal alcohol syndrome.

If we define a disease as “an impairment of health or a condition of abnormal functioning," then alcoholism is a disease, along with stealing, nail-biting and partner abuse. But then it means nothing to say that alcoholism is a disease if virtually every problem is a disease.

Some proponents of the disease theory of alcoholism refer to it as “a disease of the family." This seems to stretch the concept of disease far beyond what most people would consider a disease. The group itself has a disease. Is alcoholism a “disease of the work place"? Can a city, state or country have the disease of alcohol?

Disease Theory Inadequate

The general public appears to have accepted the disease theory much more than have physicians. A Gallup poll found that almost 90% of the American public considers alcoholism to be a disease. On the other hand, as indicated above, many physicians reject the disease theory. (*See Footnote 12.)

Dr. Joel Best has pointed out that “not only does the disease theory of alcoholism fail to correspond with mainstream medicine"s concept of a disease, but alcoholism itself resists medical intervention." (*See Footnote 13.)

Using a faulty theory and the “treatment" that flows from it is a recipe for failure. Alcoholics anonymous" self-claimed success rate of 5% represents a failure because about one-third of alcoholics achieve success completely on their own. This is less effective than no treatment!

It"s not surprising that the disease theory of alcoholism has proved to be a failure. Those few people who achieve their goal of not drinking (or of drinking in moderation) in a 12-step program do so in spite of the ineffective programs.

Footnotes: 1. Fingarette, Herbert. Why We Should Reject the Disease Concept of Alcoholism. In: Engs, Ruth C. (Ed.) Controversies in the Addictions Field. Dubuque, IA: Kendall-Hunt, 1990. 2. Jellinek, E. M. Phases in the drinking history of alcoholics: analysis of a survey conducted by the official organ of Alcoholics Anonymous, Quarterly Journal of Studies on Alcohol, 1946, 7, 1-88. 3. Cahalan, D. and Room, R. Problem Drinking Among American Men. News Brunswick, NJ :Rutgers Center of Alcohol Studies, 1974; Rudy, David R. Becoming Alcoholic. Carbondale, IL: Southern Illinois University Press, 1986. 4. Traynor v. Turnage, 485 U.S. 535 (1988) 5. Alcoholics lose some VA benefits - Veterans Administration. Science News, April 30, 1988. 6. Jellinek, E.M. The Disease Concept of Alcoholism. New Haven, CT: Hillhouse, 1960. 7. McLellan, T. Re-Considering Addiction Treatment: How Can Treatment be More Accountable and Effective? A continuing medical education (CME) course. Cranston, RI: Association for Medical Education and Research on Substance Abuse (AMERSA), 2006. 8. Mignon, S. I. Physicians" perceptions of alcoholics-the disease concept reconsidered. Alcoholism Treatment Quarterly, 1996, 14(4), 33-45. 9. Barrier to Treatment. Alcoholmd: Information about alcohol and medicine. 10. Hathaway, William. Headache pill eases alcohol cravings. Hartford Courant, October 10, 2007. 11. Weiten, Wayne. Is Alcoholism a Disease? Critical Thinking Application section. In: Weiten, Wayne. Psychology: Themes and variations. Belmont, CA: Wadsworth, 2010. 12. McLellan, T. Re-Considering Addiction Treatment: How Can Treatment be More Accountable and Effective? A Continuing medical education (CME) course. Cranston, RI: Association for Medical Education and Research on Substance Abuse (AMERSA), 2006. 13. Best, Joel. Images of issues. New York: Aldine de Gruyter, 1989, p. 67.

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