From: Engs, Ruth C. [Ed.], Controversies in the Addiction's Field . CHAPTER 6: Herbert Fingarette. "Why We Should Reject The Disease Concept of Alcoholism"
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CHAPTER 6 Why We Should Reject The Disease Concept of Alcoholism*
Herbert Fingarette, Ph. D.
Why do heavy drinkers persist in their behavior even when prudence, common sense, and moral duty call for restraint? That is the central question in debates about alcohol abuse. In the United States, but not in other countries such as Great Britain (Robertson and Heather, 1982), the standard answer is to call the behavior a disease—"alcoholism"—whose key symptom is a pattern of uncontrollable drinking. This myth, now widely advertised and widely accepted, is neither helpfully compassionate nor scientifically valid. It promotes false beliefs and inappropriate attitudes, as well as harmful, wasteful, and ineffective social policies.
The myth is embodied in the following four scientifically baseless 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.
The idea that alcoholism is a disease has always been a political and moral notion with no scientific basis. It was first promoted in the United States around 1800 as a speculation based on erroneous physiological theory (Levine, 1978), and later became a theme of the temperance movement (Gusfield, 1963). It was revived in the 1930s by the founders of Alcoholics Anonymous (AA), who derived their views from an amalgam or religious ideas, personal experiences and observations, and the unsubstantiated theories of a contemporary physician (Robinson, 1979).
*This is a slightly edited version of an article in press to be published In The Harvard Medical School Mental Health Letter. By permission of Harvard University, copyright owner.
The AA doctrine won decisive support in the 1940s when a reputable scientist, E.M. Jellinek, published an elaborate statistical study of the "phases of alcoholism" (Jellinek, 1946). He portrayed an inevitable sequence of ever more uncontrollable drinking that led progressively to such symptoms as blackouts, tolerance, and withdrawal distress, until the drinker "hit bottom" as a derelict, became insane, or died. Jellinek's work seemed to put a scientific seal of confirmation on the AA portrait of the alcoholic. That was hardly surprising, since he had taken his data from questionnaires that were prepared and distributed by AA and answered by fewer than 100 self-selected members. Jellinek conscientiously acknowledged the source of his data and reservations about its scientific adequacy (Jellinek, 1946). Nevertheless, his dramatic-tragic portrait of the alcoholic became widely accepted and is now part of American folk beliefs.
Recent scientific literature shows that in reality the typical pattern of heavy drinking fluctuates. Some drinkers with numerous and severe problems deteriorate; others markedly improve, or develop different problems. Some claim loss of control; others do not. Many heavy drinkers report no serious social problems associated with theirdrinking and are not recognized as alcoholics by friends, colleagues, or even their families (Cahalan and Room, 1974; Rudy, 1986).
The idea that alcoholics are constantly drunk is quite false. One leading researcher points out that in any "given month one half of alcoholics will be abstinent, with a mean of four months of being dry in any one-year to two-year period" (Schuckit, 1984). During any ten to twenty year period, about a third of alcoholics "mature out" into various forms of moderate drinking or abstinence. The rate of maturing out is even higher among heavy problem drinkers not diagnosed as alcoholics (Fillmore, 1988). Undoubtedly there is a small group who follow a pattern resembling Jellinek's four phases; one objection to the disease concept of alcoholism is that it focuses attention mainly on this marginal group.
It is now widely believed that a biological cause of alcoholism has been discovered; some people are said to have a biochemistry or a genetic predisposition that dooms them to be alcoholics if they drink. The truth is less dramatic. There are certain so-called biological markers associated with heavy drinking, but these have not been shown to cause it. One supposed marker is the metabolism of alcohol into acetaldehyde, a brain toxin, in the bodies of people who are independently identifiable as being at higher risk of becoming alcoholics (Lindros, 1978; Schuckit, 1984). Another proposed marker is the high level of morphine-like substances supposedly secreted by alcoholics when they metabolize alcohol (Schuckit, 1984). It is implausible that any residual effects, whether physical or psychological, could be so powerful as to override a sober person's rational,moral, and prudential inclination to abstain.
Recent studies have also been said to imply that alcoholism is a hereditary disease. But that is not what the genetic research shows. In the first place, these studies provide no evidence of a genetic factor in the largest group of heavy drinkers—those who have significant associated problems but are not diagnosable as alcoholics. Even among the minority who can be so diagnosed, the data suggest that only a minority have the pertinent genetic background. And even in this category, a minority of a minority, studies report that the majority do not become alcoholics (Goodwin, et al., 1973; Cloninger, et al., 1981; Deitrich and Spuhler, 1984).
It is not only misleading but dangerous to regard alcoholism as a genetic disorder. Heavy drinkers without alcoholism in their genetic backgrounds are led to feel immune to serious drinking problems, yet they have the greatest total number of problems. On the other hand, people who do have some hereditary disposition to alcoholism could easily become defeatist. Their risk is higher, and they should be aware of that, but their fate is still very much in their own hands.
The idea of a single disease obscures the scientific consensus that no single cause has ever been established, nor has any biological causal factor ever been shown to be decisive. Heavy drinking has many causes which vary from drinker to drinker, from one drinking pattern to another. Character, motivation, family environment, personal history, ethnic and cultural values, marital, occupational, and educational status all play a role. As these change, so do patterns of drinking, heavy drinking, and "alcoholism" (Fingarette, 1989). For example, alcohol is used in many so-called "primitive" societies, but theirdrinking patterns are not ours, and what we can alcoholism seems to be absent prior to contact with Europeans (Heath, 1989). That would not be true if alcoholism was a disease caused by chemical and neurological effects of drinking in conjunction with individual genetic vulnerability. The crucial role of psychology in alcoholics' drinking is demonstrated by experiments in which they are deceived about whether the beverage they are drinking contains alcohol. Their drinking patterns then reflect their beliefs; the actual presence or absence of alcohol is irrelevant (Marlatt et al., 1973).
Alcoholics do not "lack control" in the ordinary sense of those words. Studies show that they can limit their drinking in response to appeals and arguments or rules and regulations. In experiments they will reduce or eliminate drinking in return for money, social privileges, or exemption from boring tasks (Fingarette, 1989). To object that these experiments are invalid because they occur in protected settings is to miss the point, which is precisely that the drinking patterns of alcoholics can vary dramatically with settings, regardless of their previous patterns of drinking, and regardless of whether any alcohol is in their bodily systems or is accessible.
True, alcoholics often resist appeals to cease their alcohol abuse, and they ignore obvious prudential and moral considerations. The simplistic explanation that attributes this to an irresistible craving obscures a more complicated reality: they have developed a way of life in which they use drinking as a major strategy for coping with their problems (Fingarette, 1989). They have become accustomed to values, friends, settings, and beliefs that protect and encourage drinking. When they encounter drastically changed circumstances in a hospital, clinic, or communal group, they are capable of following different rules. Even some who "cheat" where abstention is expected nevertheless limit their drinking (Paredes et al., 1973). They do not automatically lose control because of a few drinks. Our focus on attention must shift from drinking per se to the meaning of drink for certain persons and the way of life in which its role has become central.
Responsible scientists who are familiar with the research but want to preserve the disease concept of alcoholism have had to redefine their terms. They define "disease" as whatever doctors choose to call a disease (Jellinek, 1960)! The point of using the word, they acknowledge, is "social" rather than medical. There is a lack of consistent self-control that leads to harmful consequences (Vaillant, 1990). Of course such sweeping uses of the temm make almost every human and social problem into a "disease."
As for "loss of control", this phrase no longer coincides either with the ordinary meaning of those words or with what the public is encouraged to believe. Thus Mark Keller, one of the early leaders of the alcoholism movement, now reinterprets loss of control to mean that alcoholics who have decided to stop "cannot be sure they will stand by their resolution" (Keller, 1972). This is said to be compatible with anything from constant heavy drinking to remission in the form of permanent moderation or total abstention. Although the medical term "remission" is used, this is not a medical or scientific explanation: we an know that someone who resolves to change a long-standing way of life cannot be sure whether the promise will be kept. Similarly, craving, still popularly understood as an overwhelming and irresistible desire, has now been extended by researchers to include mild inclinations, although this makes nonsense of the supposed compulsion to drink (Hodgson et al., 1978).
The disease concept is sometimes rationalized on the ground that although scientifically invalid, it is a practical way of encouraging alcoholics to enter treatment (Fingarette, 1989). This argument is based on false assumptions and has harmful consequences. The many heavy drinkers who see themselves (often correctly) as not fitting the criteria of alcoholism under some current diagnostic formula are likely to conclude that they have no cause for conce.o inclination to deny their problems
is thus encouraged. As for people who are diagnosable as alcoholics, the vast majority never became permanently abstinent, even after treatment or after they join AA (Polich et al., 1980; Fingarette, 1989: Peele, 1989). Yet the disease doctrine may cause them to develop a fatalistic conviction that even one slip is a disaster, since they have been led to believe, falsely, that occasional or moderate drinking is never possible for them.
When behavior is labeled a disease, it becomes excusable because it is regarded as involuntary. This is an important reason for its promulgation. Thus special benefits are provided to alcoholics in employment, health, and civil rights law, provided they can prove that theirdrinking is persistent and very heavy. The effect is to reward people who continue to drink heavily. This policy is insidious precisely because it is well intended, and those who criticize it may seem to lack compassion.
The United States Supreme Court, after reviewing detailed briefs pro and con, has consistently held in favor of those who say that alcoholics are responsible for their behavior, and has concluded that medical evidence does not demonstrate their drinking to be involuntary (Powell vs. Texas, 1968; Traynor vs. Turnage, 1988). Spokesmen for the National Council on Alcoholism (NCA) state publicity that they too believe alcoholics should be held responsible for their misdeeds, but they are being hypocritical. In the less visible forum of the federal courts, the NCA has repeatedly argued (Traynor vs. Turnage, 1988) that alcoholics should be protected from criminal and civil liability for their acts and excused from the normal regulatory requirements.
But the greatest scandal of the argument for the disease concept as a useful lie is the claim that it helps alcoholics by inducing them to enter treatment. On the contrary, both independent and government research shows expensive disease-oriented treatment programs to be largely a waste of money and human resources (Fingarette, 1989). Their apparent success proves illusory when they are compared in statistically rigorous studies with other programs, and with the rate of improvement in untreated alcohol abusers (which is a much higher rate than the disease concept has led the public to believe). Very often, perhaps always, brief outpatient counseling works just as well as a long stay in a hospital orother residential clinic costing thousands of dollars. Some studies conclude that professional intervention is slightly better than no treatment, although it makes nodifference what the treatment method, duration, setting, or cost is. Other studies find no significant difference in results regardless of whether there is treatment.
We must refocus our compassion and redefine our policies on alcohol abuse. While continuing biological research, we should loosen the grip of physicians on the chief government agencies and research funding sources, and we should reject their deep bias in favor of the disease concept. Much greater resources must be shifted to psychological and sociocultural research. We should consider promising new approaches to treatment that are being used in other countries. The public should be better informed about the scientific facts and above all about our scientific ignorance. Our policies should reflect the fact that heavy drinking is not primarily a biochemical or medical problem but a human and social one.
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Cloninger, C.R. et al. (1981). Inheritance of Alcohol Abuse: CrossFostering Analysis of Adopted Men. Archives of General Psychiatry, 38 861-868.
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Fingarette, H. (1989). Heavy Drinking: The Myth of Alcoholism as a Disease. University of California Press: Berkeley.
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Powell vs. Texas, 392 US 514 (1968).
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Robertson, D. (1979). Talking Out of Alcoholism: The Self-Help Process of Alcoholics Anonymous. Croom Helm: London.
Rudy, D.R. (1986). Becoming Alcoholic. Southem Illinois University Press: Carbondale.
Schuckit, M. (1984). Drug and Alcohol Abuse. Plenum Press: New York.
Traynor vs. Turnage, 99L.Ed 2d 618 (1988).
Vaillant, G. (1990). We Should Retain the Disease Concept of Alcoholism. The Harvard Medical School Mental Health Letter, (In press).
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