AA – a universal solution – perhaps not?
We have been sent a paper produced by an AA member who has carried out research into the concept of alcoholism. We invite you to make your own assessments of the arguments presented. For our part we welcome this kind of intelligent and well-founded investigation as a pleasing alternative to the dogmatic and unsubstantiated propaganda that is currently deployed by the cult groups in support of their spurious claims on recovery rates and methods.
Alcoholism, moral issue or disease? An investigation into the ethical issues surrounding problem drinking.
Alcohol consumption has been with us since primordial times. Ever since man crushed the grape the result has been a mixed blessing for society. Transcendental experience, ecstasy, social cohesion for some, rape, pillage, and murder for others, followed in its wake. Could all these things have been caused by a seemingly innocuous beverage, or are these behaviours part and parcel of what man is capable of without the aid of drink?
Today the problem of alcohol abuse is a favourite topic for media, politics and budding authors falling over themselves in a slightly different way to spew out their stories. When confronted by the empirical evidence of the problem, firms of park bench drinkers, Saturday night mayhem in shopping centres, the man on the street may have an ambiguous attitude to what is presented. The unfortunates are looked on as; evidence of societal breakdown, as parasites responsible for their situation, or as sick people suffering from a pathological disease incapable of being combated without help.
The argument between free will and determinism with regard to alcoholism is the question to be addressed here. I will begin by sketching the history of alcohol consumption, discussing the argument, briefly look at the many social implications surrounding the subject, concluding with a weighing up of the evidence to answer the question.
A drunken past.
The making of alcoholic beverages by Mediterranean and Northern European civilisations through fermentation, brewing, and distillation from early times comes as no surprise. Transforming surplus agricultural produce into alcoholic drink is an efficient way of preventing wastage, through spoilage, together with providing an alternative to a sometimes scarce, and at best unpalatable water supply in densely populated regions. (1) Wine drinking in antiquity was transformed into a social and religious event, Christianity giving sanction to this through the Eucharist, where wine becomes literally (in Catholicism), or symbolically (in Calvinism), the blood of the Saviour. Social drinking often spilled over into drunkenness and has been the target for writers, artists, moralists, magistrates and social reformers, albeit for different reasons, up to the present. As in all cases of appetite getting the better of reason, drunkenness was considered a sin, an attitude which in different guises has also persisted up to today. However in pre - industrial society, the drunk was tolerated, the worst that could happen to him would be to spend the night in a lock - up, even the law looked upon him leniently. (2) This perhaps reflected the fact that a weakness for alcohol affected every strata of society.
When, and why did a general mild disapproval, change into the hardened views which were expressed in the temperance movements of the nineteenth century, and the prohibition movements of the twentieth, culminating in the debacle of American prohibition, and the definition of alcoholism as a disease? The answer seems to lie in industrialisation and the shift to an urban environment from the second half of the eighteenth century onwards. It was at this time that the consumption of spirits became endemic. The London “gin craze” is a good example of the creation of the acute health problems leading to unemployment, destitution and the lumping together of the legion of public - order offences, with heavy drinking. There was a real fear, in the minds of the propertied classes, that mere unruliness in the masses would turn into revolutionary spirit (as indeed it did, although one could question the part played by alcohol in the equation), hence the elevation of alcohol consumption into a disturbing social problem.
The drunk became, in the eyes of the establishment, an outcast responsible for his own dilemma in squandering his wages on drink. The economic conditions of the time, were conveniently ignored, starvation wages, exploitation, and dreadful living conditions had, for the privileged observers no part to play in the equation. The notion of the drunk as degenerate prevailed.
Parallel to this view, from the end of the eighteenth century, came the belief that the drunk could be redeemed from this terrible malaise. Secular and religious reformers alike put this view into practice in the form of the temperance movement. From this reading of the problem, the drunk was not immoral but rather suffering from a sickness. In addition to the social reformer, doctors such as Thomas Trotter began to look upon heavy drinking as a mental craving or obsession, perhaps brought on by excessive alcohol consumption. (3) This “medicalization” was to transform problem drinking into the model of alcoholism as a treatable disease, which has survived up to the present day, (although not without its critics). We shall examine an alternative view in the latter part of this paper, but let us now look at the medical model of alcoholism, together with an example of a method of combating the “disease” based on this model.
The medical model.
The disease theory of alcoholism, although having its beginnings in the late eighteenth century, had by the 1950’s become accepted internationally in the World Health Organisations definition. “Alcoholics are those excessive drinkers whose dependence on alcohol has attained such a degree that it shows notable disturbance or an interference with their bodily and mental health, their personal relationships and smooth economic functioning or who show prodromal (or early) signs of such a development. They therefore need treatment”. (4) This stance was derived from the research of doctor E. M. Jellineck, an American, who in the 1930’s, was the first to attempt a classification of the problems seen in chronic alcoholics. (5) The categories he described were not distinct entities, as drinkers could display different patterns at different times. The categories were as follows:
Alpha: Purely psychological dependence to relieve physical or emotional pain. No loss of control.
Beta: Physical complications resulting from cultural drinking patterns and poor nutrition but no dependence.
Gamma: (“Anglo-Saxon”) Loss of control drinking, craving and withdrawal symptoms, but with an ability to abstain.
Delta: (“Continental”) Inability to abstain, with withdrawal symptoms, but comparatively little social disruption,
Epsilon: Bout drinking (dipsomania). (6)
The above for Jellineck, was not a definitive description of drinking patterns, but constituted what he considered to be truly pathological patterns. Hence the disease label for problem drinking. The cultural distinctions above are considered irrelevant by a contemporary view. “Background, environment, race, sex, social status - these make no appreciable difference when once the disease takes hold of the individual. For all intents and purposes he might just as well be labelled with a number: he has become just another victim of the disease of alcoholism. Abstention is the only hope, because the disease is incurable”. (7) It is interesting to note that, although this attitude confirms the notion of disease, it contains the kernel of the alternative approach to the problem, which we shall examine later.
This was the conclusion doctor William. D. Silkworth came to in his work with alcoholics in the 1930’s. Silkworth’s experience in the field gave rise to the explanation of alcoholism which was adapted by the founders of Alcoholics Anonymous. Alcoholism was the manifestation of an allergy, brought about by the ingestion of alcohol which, in turn brought about the phenomenon of craving. The circular nature of allergy and craving when alcohol was taken lead directly to alcoholism in the allergic subject, a downwardly progressive spiral which without medical help would result in physical and mental problems, and finally death. (8) Here as above the only treatment for the disease was total abstinence.
To summarise; the medicalization of alcoholism saw a change in attitude toward the drinker from someone socially tolerable to a threat. We now see the alcoholic as someone suffering a disease irrespective of socio-economic, cultural, racial, or gender circumstances, for whom the only solution is total abstinence from alcohol. This deterministic model of alcoholism seemingly takes the problem out of the moral arena, together with responsibility on the part of the sufferers for their actions. The notion of free will in this case is absent; the sufferer can’t help himself unless he seeks help. How then is the alcoholic to abstain from drinking, if he has lost all self-control and his condition is incurable? Following through this reading let us look at a solution which evolved closely with doctor Silkworth’s account of alcoholism.
Alcoholics Anonymous was founded in 1935 by Bill Wilson and Doctor Bob, both helpless drunks, who worked closely with Silkworth in the early days of A.A. The notion of illness was considered to be three fold; physical, psychological and spiritual. Given the incurable nature of the problem any method of arresting its progression would need to function on all three of these levels. The resultant “Twelve Steps of Recovery” evolved to do the job. Silkworth’s account was used as a remedy for the physical aspect, Carl Jung’s psychological approach, for the cognitive, and the fundamentalist Christian Oxford group provided the basis for the spiritual solution. (9)
However on closer observation what seems to be a paradox arises. To accept the physical side of the disease model one would have to accept that total abstinence is the only way to arrest the illness. The spiritual and psychological approaches mentioned, to be used in consort with the physical, presuppose a notion of free will, which in turn weakens the disease concept. (10) At this stage the success of AA is not in doubt. This worldwide organisation has some two million members and is recognised by many professionals in the field as invaluable in the battle against alcoholism. (11) What is brought into question is the notion of alcoholism as a disease. Although up to recent times the disease model has been predominant, the tide has changed. New thinking on the subject has surfaced since the 1950’s to which we turn our attention.
Fingarette’s attack on the medical model.
Herbert Fingarette, puts forward a convincing argument against the disease model of alcoholism. (12) He boldly states that there is no adequate empirical substantiation for the basic tenets of the classic disease model of alcoholism. The notion of disease frees the sufferer from social stigma and guilt but can also discourage people to seek help, by reinforcing the subjects “denial” of the problem, or accepting the inevitability of his predicament. For Fingarette, problem drinking has a heterogeneous nature with psychological, social, political and economic factors all playing a role.
Heavy drinking is a behaviour that serves different functions and fulfils different needs at different times, and as such is a general label that can be given to chronic alcohol abuse and excessive consumption. “Drinking is not automatically triggered when alcohol enters the system of diagnosed alcoholics, it has been suggested that what is at issue is “inconsistency of control drinking”, or that loss of control is “relative and variable” as well as “multifactorial” (i.e. it depends on social and psychological as well as biological factors)”. (13)
The notion of alcoholism is, for Fingarette, a semantic, cognitive construct, which points to the conclusion that a disease is what the medical profession recognises as such. If this is so then can the medical profession be wrong? Given that in a monograph published in 1980, by the National Institute on Drug Abuse, were there were forty three proposed definitions of alcoholism, it seems that confused would be the best word to describe the medical profession, rather than wrong. The very existence of such a variety of divergent, unsupported hypotheses is not the mark of solid scientific research; on the contrary “It is characteristic of pseudo-science and faddism”. (14) In no sense does Fingarette dismiss the problem of heavy drinking in society; indeed we shall look at his proposals for addressing it. He does however see in the language of disease and treatment a legitimisation of a fast-growing health services industry keen to attract clients and funding. Moreover, the efficacy of these treatments is brought into question. (15) If the success rate of treatment is in line with a natural improvement, (many of the subjects have nowhere to go but up, and drop out figures aren’t taken into consideration), then the optimistic figure of 35% is not such a success. (16)
Not only is Fingarette critical of the medical and economic motives behind the legion of treatments available, non-professional bodies who don’t share these motive are also brought to book. A.A. is discussed as an archetypal example. Described as “ [This] passionate and complete reorientation is not a unique phenomena; it is rather like what critics of sects would call ideological re-education or a modest form of elective brainwashing”. (17)
He is critical of the fact that success figures for the A.A, programme are not available, citing his evidence of natural improvement as the most likely reason for its seeming success. This coupled with the paradox already mentioned of treating a medicalized problem in non-medical terms points to “a way of life replacing alcohol’s place at centre stage” (18) belies the fact that only those who affirm themselves alcoholics in the AA mould are suited to that programme, others drop out. Bearing in mind that A.A, accounts for perhaps 5% of heavy drinkers its philosophy and practice are far from being a monopoly in the field of problem drinking. Other approaches need to be sought to accommodate the 95% not suited to A.A.
A clue is found in the quote of an expert in the subject, a doctor Valliant, “ He wondered if what many heavy drinkers needed was to participate in an emotionally charged but communally shared ritual, and a shared “belief system”, one that offered confidence faith and hope - although hope is unscientific”. (19)
Fingarette puts forward an outline of measures bearing Valliant’s observation in mind, to formulate a new approach to heavy drinking. This new approach doesn’t promise any easy answers but a realism and flexibility that the medical model lacks. The “all or nothing” policy of the latter model is replaced by compassion, psychological, moral, and sociological approaches. The underlying themes in heavy drinking, such as class, ethnicity, cultural and economic considerations together with religious belief need to be considered. These very complexities of the causes and course of alcohol abuse can be used in methods to tackle the problem. They also by implication point to a blind spot in current political and moral thinking, with regard to alcohol.
The idea of customising the method to the individual is of the greatest importance, the drinker should be matched with the therapist. Individualised behaviour therapy, broad-spectrum therapy, relapse prevention therapy and behavioural self-control strategy are among the new therapies mentioned. These aren’t described in detail, they are according to Fingarette in their infancy and the success rate is yet to be proven. However given the results between controlled drinking and abstinence seen above they could be a welcome addition to existing therapies. Despite not having functional details of these therapies one can nevertheless glean the thinking behind them.
The notion of free will is put back on centre stage. The key to success in Fingarette’s view is a motivation to change on behalf of the heavy drinker. This coupled with the acceptance of responsibility in playing an active role in bringing about the desired change in the face of imperfection, insoluble personal problems and possibly sentiments of inadequate rewards, has the ground of success and realism. Before we conclude by comparing the two schools of thought, let us briefly mention some of the wider issues which the scope of this paper prevents us looking at in more detail.
Anyone who has been in a city centre, or a casualty ward, on a Saturday evening can guess at the cause of the mayhem that is regularly seen. This usually coincides with “closing time” (it should be noted that recent legislation on 24 hour drinking has resulted in multiple “closing times”). The connection of alcohol and crime is on closer inspection not such a simple one. Statistics for alcohol related crime are restricted to driving offences and public drunkenness. Research on the role played by alcohol in more serious crime (such as murder, rape and violent abuse within the family) give conflicting conclusions. Overall I found in my research an overwhelming consensus that the various magistrates, criminologists and statisticians of today are unconvinced of the major part played by alcohol in violent crime (it should be noticed that this has now changed, and ambivalence seems to be the current thinking despite the regular political point scoring pointing to the behaviour of binge drinking youth). (20) Criminals have violent tendencies, with or without alcohol they tend to be less efficient and be caught when under the influence. The sociopath is not necessarily a drinker.
Given the above, it seems that alcohol is not directly responsible for violence in society, but what is the financial cost on medical resources? Accidents and hospitalisation from alcohol related causes have yet to be adequately measured. The attitude to this seems to be similar to that on crime, we don’t know for sure. This belies the ambivalent view society has on alcohol. On the one hand it is an acceptable drug, a must at all social occasions; on the other it is a social evil which causes untold misery to heavy drinkers their families and society at large. A compromise is sought between the continuance of tolerance (prohibition in the U.S. being a good example of how not to proceed), education and control of alcohol consumption through legislation. (21) The conclusion is that alcohol is here to stay - it is a tolerable evil. (22)
Changing your life - a moral or a clinical way back ?
Putting these arguments aside let us conclude with a contrast between the determinist and free-will debate on alcoholism. The determinist sees alcoholism as a progressive disease which is outside the sufferer’s power to control. The only solution is total abstinence which precludes free will. This ontological solution logically weakens the premise of the disease concept; the A.A. approach is only effective for those who buy into its philosophy. The success rate for this type of approach is questionable.
Alcoholism as a disease is a myth for the proponent of the free-will approach, therapies such as A.A, are subtle forms of elective brainwashing. What is required is a multifactoral and realistic approach giving responsibility back to the problem drinker and in consort with various therapies find a solution whether it be controlled drinking or abstinence.
Whichever approach one accepts, the key to the answer for myself, is not the debate of what alcoholism is or isn’t, but how best to find a solution to the reality of problem drinking. The two main approaches, in my view are not mutually exclusive. The quote from Valliant which Fingarette uses as the basis for his “new approach” is firmly in place in A.A practice, for example. The only factor missing in the critique of A. A is the spiritual element of the programme which Fingarette actually includes in one of his multifactoral approaches! In the final analysis, the way forward seems to be that of the pragmatist, whichever method or methods work should be sought because eloquent philosophising will have no effect without action and the slogan for the problem drinker is “It works if you work it”, (23) how it is worked should be left to the people concerned.
Throughout this investigation I have tried to stay neutral, it is now time to play my hand in the debate. For myself, from pre-teen years, having discovered the effect alcohol had on me, continued to use this drug until the age of thirty-three. My drinking career lasted some twenty years which was augmented by other narcotic and psychotropic drugs. However my primary drug of choice was alcohol. It was eventually this legal and powerful drug which gave me a serious drink problem. During the latter four years of drinking the problem could have been termed chronic. I was told on countless occasions by friends and family that I had a problem, however in my view the problem was with them. I used hundreds of well argued defences including, political, cultural and psychological reasons why I drank. The truth was that I at first didn’t want to stop drinking and then on numerous attempts to control and stop I found that I couldn’t.
By this time I had already lost my family, friends, and let us say my psychological equilibrium, I needed help. It came in the shape of A.A, through a mish-mash of other agencies, including; parental support groups, Narcotics Anonymous, a cornucopia of alternative body-work therapies and voluntary sector counselling. I found an answer to my problem, using all of these groups but A. A, was where I stayed. I was an alcoholic!
The term alcoholic has no negative connotations; it in fact reinforces the empirically proven fact that I have lost the power to drink (or use recreational drugs) safely. The notion of having a disease I can take or leave (dis-ease makes more sense to me), it is after all as Fingarette say’s, merely a word. When remembering “sticks and stones will break my bones, but names will never hurt me”, it is the first part I pay attention to, when considering a duet of past or future rum bottles. If I sound flippant I ask the reader to be patient. The, allergy model of alcoholism seems to make empirical sense to me, even though I can intellectualise the arguments against it.
As for the debate surrounding the moral issues, I suggest that Fingarette look closer into the twelve-step programme of A.A. Having gone through the process I can find no moral difference between the methods put forward by A.A and the multifactoral methods, which Fingarette suggests. Cultural, religious, political, sexual, and psychological factors are, all taken into consideration, in the recovery programme. Far from being a way to deny responsibility, for actions past and present the A.A programme requires one to become empowered, to take full responsibility for ones actions past and present. The only argument I can see between the two is the notion of alcoholism as a disease and the controlled drinking approach. The former, I have given my opinion on, the latter, I have tried and failed at miserably. Within the context of this investigation I can accept the notion of a disease together with an ontologically moral approach to combat it.
This approach becomes consequentialist, in its very effects on the people I interact with (I recovered all that was lost except for my former wife, and for that we are both grateful). This approach is working for me and I accept that it doesn’t suit everyone. However if the problem drinker has the motivation to address his problem whichever method is used could be beneficial, A.A does not have the monopoly on solutions to problem drinking. As stated above the way forward is the pragmatic, whatever works, in the widest sense should be pursued. However in face of the vast and complex socio-economic, political and cultural currents, I feel that the problem of alcohol abuse will be with us for a long time to come. The last word goes to Fingarette. “For all that has been said, written, and done about the treatment of alcohol problems, we still appear to be at the beginning of the beginning”. (24)
Footnotes
1 ” Small beer” was a safer alternative to Thames water in 17th century London, alcohol being an effective preventative against cholera, and typhoid. It is still popular in Eastern Europe, for instance in Kiev, for much the same reasons.
2 ” The Scottish plea of diminished responsibility in the case of homicide evolved in the 18th century, in order to accommodate the high percentage of felonies committed while in a state of inebriation”. Quoted by Roy Porter. In J.C.Sourina, A History of Alcoholism: Oxford, Basil Blackwell, 1990. pp xi, of the introduction.
3 Thomas Trotter, An Essay on Drunkenness and its Effects on the Human Body, London, Routledge, 1988. Originally published in 1798.
4 A History of Alcoholism, p 149.
5 In 1960 Jellineck published a subsequent work, The Disease concept of Alcoholism.
6 A History of Alcoholism, p 150.
7 Mann M, Primer on Alcoholism, New York: Rinehart, 1950, quoted in Fingarette H, The Myth of Alcoholism as a Disease, London: University of California Press, 1988.
8 Alcoholics Anonymous, Third Edition, New York: Alcoholics Anonymous World Services Inc., 1976. The Doctors Opinion, p xxiii - xxx.
9 Alcoholics Anonymous, p xvi, and p 26 - 27, Jung prescribed for an early member, what he termed “moral psychology”, which was a phenomena causing huge emotional displacements in the patient, which on rare occasions enabled a problem drinker to abstain. The Oxford Groups provided the spiritual content for the Steps, although a “radical pragmatic” approach taken from William James’ Varieties of Religious Experiences, modifying the exclusively Christian notion of God. Indeed the term God became the meaning to the concept the individual brings to it. The key to combat the problem was to have the emotional displacement, to transcend the self, with or without a traditional concept of God, (I know of Marxists and Buddhists who have sobered up in A.A), the loss of ego, which Jung described, coupled with self analysis, (through the taking of “moral inventory”) confession of defects, restitution to those harmed, and to help other alcoholics. It is tempting, at this stage to discuss these various areas in depth, however, given the purpose of this paper, I shall comment on some aspects when I look at the counter-argument to this deterministic model.
10 It should be noted that for Jung’s patient, who went on to have such an experience of emotional displacement through Jesus, this wasn’t enough to arrest his illness, he drank himself to death. So here we are left with a question mark as to whether free-will is applicable or not. If not, then we can stay with the disease concept, if it is, then we must look elsewhere for a way of combating the problem. (The case mentioned in contained in Man and his Symbols, Carl Jung, Ed., London: Picador, 1978, p 72 - 73.
11 Alcoholics Anonymous, p xxii, In 1990, there were over 88,000 groups, in 134 countries. Ibid.
12 Fingarette H Heavy Drinking: The Myth of Alcoholism as a Disease, London: University of California Press, 1988.
13 Ibid. p 44.
14 Ibid. p 51.
15 Ibid. p 78, The example of a study carried out at the Maudsley Hospital, London, in 1978 concluded that out of two groups of heavy drinkers; (one of which was given one hour of a psychiatrists time, and the patient told to stop drinking, the other given the full range of services, including individual counselling, and exposure to A. A), where at the end of twelve months it was found that in 35% of cases there was a marked improvement in both groups equally. The figure for total abstinence was also the same for both groups at 11%. This being one conclusion of many such studies, which all point to the conclusion that, a percentage of problem drinkers will recover, or improve, whether they have “treatment” or not.
16 It should be noted that the majority of success’ came from higher socio -economic, educated classes.
17 Ibid. p 91.
18 Ibid. p 92.
19 Ibid. p 93.
20 See Low in Alcohol, by Summer and Parker, Department of Social Policy and Social Work, University of Manchester, 1995. (Funded by the Portman Group, the eight largest alcohol producers in the U.K.) Also the 1984 study commissioned by the Council of Europe, quoted in Sourina.
21 It should be kept in mind that revenue from alcohol for government in the U.K. runs into somewhere in the region of eight billion pounds annually. There is a powerful pro-alcohol lobby in parliament and bodies like the E.C. have been critical of under consumption, of wine drinking in Britain and Germany, even though wine drinking in these countries is on the increase.
22 Interestingly, a stance taken by those who advocate the de - criminalisation of prohibited recreational drugs.
23 To borrow a phrase from A.A.
24 The Myth of Alcoholism as a Disease, p.91.
Bibliography.
Sourina. J.C. A History of Alcoholism, Oxford, Blackwell, 1990. An extremely readable account of problem drinking in history, to the present from a professional medical perspective.
Trotter T An Essay on Drunkenness and its Effects on the Human Body, London: Routledge, 1988. An interesting study of the 18th century medical opinion on alcoholism.
Fingarette H. Heavy Drinking: The Myth of Alcoholism as a Disease, London: University of California Press, 1988. A well-argued alternative to the medical model of alcoholism.
Williams. G P. Brake. G.T, Drink in Great Britain, 1900 - 1979, London: Edsall, 1980. A professional, and scholarly socio - economic study of problem drinking.
Alcoholics Anonymous, Third edition: New York, Alcoholics Anonymous World Services Inc., 1976. Known as the “Big Book”, the bible of A.A, containing the 12, step programme.
Kyvig D. E, Ed, Law Order and Alcohol, London: Greenwood, 1985. Complex socio - scientific study on the dubious connection between drink and crime.
Sources.
Information supplied by N.A.C.R.O. (National Association for the Care and Resettlement of Offenders, including Low in Alcohol, a report by Summer M and Parker H, into the role of alcohol in crime causation, sponsored by the Portman Group, 1995. This report is quite an eye opener, for the dismissal of alcohol in any direct connection with crime. It didn’t dispel my beliefs, but puts forward some valid arguments. Digest information on the Criminal Justice System in England and Wales, Home Office Research and Statistics Department, 1995. A large and glossy report which simply lists direct alcohol related figures, i.e., offences where alcohol is the primary factor, e.g., drunken driving, public drunkenness, underage drinking.
Ramsay M. The relationship between alcohol and crime, Home Office Bulletin no 38.
An official report, which seems to back up the Low in Alcohol study, listed above.
Various literature from A.A, Alcohol Concern, and Accept.
I have enclosed a selection of material, from these sources, including abstracts from Alcohol Concern, to give the reader an idea, of the scope of this subject.
M.M. 2008.
