Issue With The Definition

[Upekkha]

[

Sorry, about the facts. I'll try to stick to hearsay and superstition from now on. That'll be a lot more helpful for problem-drinkers.

I've described my own experience with alcohol so there's no "alcohloics vs. non-alcoholics" going on here.

Hm... Interesting.

I wondered how long it would be before you replied.

It would seem you are determined to have the last word, even though you have already written thousands, and even though it is patently apparent that no-one wants to hear from you any more on this subject.

So Mr R, preach away to yourself, for I doubt anyone cares any more.

It would seem that you have some kind of serious problem, and as such, can only be pittied.

[sabaijai]

I am not too sure what their motives really are, or what they hope to achieve by this.

I think my objective was clear if you bothered to read my posts, i.e., to suggest evidence-based alternative treatments for problem drinkers, as proposed by a host of alcohol addiction experts. Most if not all of these treatments comprise definitions and terms related to problem drinking based on scientific research. I don't see that either the Issue With The Definition thread or the 'I drink too much' forum branch was limited to AA members/supporters.

Can't speak for robitusson's motives.

[robitusson]

Putting out all available information and countering misinformation, primarily form the AAers, are my motives. If anyone is doing hijacking in this forum it's the 12 steppers bullying anyone who hasn't swallowed the doctrine.

I've tried to let it it go but there's always someone like you Upekkha, who's willing to make personal comments and attacks. Grow up and accept that some people disagree with accepted things and happen to know what they're talking about.

Edited August 12, 2006 by robitusson

[sbk]

And you are welcome to do so, when appropriate. please try to understand that there have been complaints about your behavior and that you are alienating more people than you are convincing by your behavior.

I don't have an issue with offering alternatives. I do have an issue with altering every single thread you encounter to become a platform for your beliefs.

[Upekkha]

Well gentlemen, I think this may be a case of: "Methinks thou doest protest too much"

As I said in my first post in this thread, I am just an interested observer, and I neither hold a brief for the AA or indeed any other organisation or methodology that claims to be able to help alcoholics with their 'problem.'

This will be my final posting on this thread as it has clearly long overrun its course.

But maybe those of you who have written so much to convince everyone of the evils of the AA, would do well to consider the foillowing:

Read the original post, and see how far you have strayed from what the OP posted, and ask yourselves if your crusade against the evils of the AA is really in the spirit of this thread, and is it in any way answering the OP's question? I note that the OP has been conspicuous by his absence for many a day.

Read the posts from those who have asked you to stop. In the first instance they did ask you quite politely, but you continued to ignore their pleas, even though , by any measurable standards, you had more than made your case. Also note that some of those who have made these requests, have stated catagorically that they hold no brief for the AA, but still found your incessant posting offensive. So I would seriously question your assertion that you are being "bullied by those who have swallowed the doctrine", or Mr S, that this forum is "limited to AA members/supporters."

Mr R, are you really absolutely sure that I am the one that needs to "grow up?"

As I said in a previous post, I feel sorry for those who cannot concede that they may be, for once in their lives, at least partly in the wrong.

That's me. I'm all done.

[robitusson]

Mr R, are you really absolutely sure that I am the one that needs to "grow up?"

As I said in a previous post, I feel sorry for those who cannot concede that they may be, for once in their lives, at least partly in the wrong.

As I'm dealing with facts, point out where the facts are wrong. I couldn't care less if you feel pity. Deal with the facts. Edited August 13, 2006 by robitusson

[Neeranam]

QUOTE(Upekkha @ 2006-08-12 20:14:27) *

As I said in a previous post, I feel sorry for those who cannot concede that they may be, for once in their lives, at least partly in the wrong.

As I'm dealing with facts, point out where the facts are wrong. I couldn't care less if you feel pity. Deal with the facts.

You are not dealing with the facts, Mr. 'last word'.

I think we should have a poll - how many people have stopped drinking for more than say 2 years by themselves and by other methods.

[robitusson]

You are not dealing with the facts, Mr. 'last word'.

I think we should have a poll - how many people have stopped drinking for more than say 2 years by themselves and by other methods.

Once again not a single issue relating to any of the facts suposedly in dispute. Although in fairness to you Neeranam, you did mention one thing to do with the definition that was relevant a few days ago which is better than most.

[sabaijai]

Maybe we need a new thread on the definition of 'facts'. Anecdotal information isn't scientifically valid, reliable or even empirically testable. Ditto an academically unqualified poll.

The problem with arguments based on anecdotal evidence is that anecdotal evidence is not necessarily typical; only statistical evidence can determine how typical something is.

[francois]

hi'

well, I consider groups for help as the Aa or any else as an help for people with low self-estime, if you consider that you can't do it by yourself begin to consider that may be you can't stop not that you don't want, but you can't, it's a bit loose brain in here, where is your own self-estime? your strength?

gone?

look inside yourself, and find how low you are!

isn't it obvious to you

calling for help to get involved in a group where everybody has a different problem is a bit "loose", then you may get addicted to the group and then live as an help for others, so really did you quit alcohol world? NO!

you depend on something else, a doctrine!

they might even bash you if you fail one small time!

can't you it by yourself?

it had been the same with an organisation for help drug addicts

take your guts and get out of your shell, life is wonderful out of intoxication

francois

ps; just to add that some people will never stop, because it's their world and they live it until die!

try to attrack them into a program to stop is non human!

you'd better try to understand first, everyone is different!

[norainu]

I am not too sure what their motives really are, or what they hope to achieve by this.

I think my objective was clear if you bothered to read my posts, i.e., to suggest evidence-based alternative treatments for problem drinkers, as proposed by a host of alcohol addiction experts. Most if not all of these treatments comprise definitions and terms related to problem drinking based on scientific research. I don't see that either the Issue With The Definition thread or the 'I drink too much' forum branch was limited to AA members/supporters.

Can't speak for robitusson's motives.

Hey Robitusson all I can say is thanks for presenting the facts. I agree and have done a fair bit of my own research over the last 20 years in facing my own behavors with intoxicants. Moving the goal posts when confronted with facts is a common denominator used in group think recruiting organizations.

The famous Twelve Steps are the core of the AA experience. The twelve steps are drawn directly from the Oxford Group that Bill W. and Dr. Bob participated in before branching out to create AA (Bufe: 62). In the Oxford Group these steps were used as a cure for sin.

On appeal the New York Court of Appeals reversed the Appellate Division and ruled that the Twelve Steps of AA amount to a religious exercise "as a matter of law" and that "adherence to the AA fellowship entails engagement in religious activity and religious proselytization"

[sabaijai]

The famous Twelve Steps are the core of the AA experience. The twelve steps are drawn directly from the Oxford Group that Bill W. and Dr. Bob participated in before branching out to create AA (Bufe: 62). In the Oxford Group these steps were used as a cure for sin.

On appeal the New York Court of Appeals reversed the Appellate Division and ruled that the Twelve Steps of AA amount to a religious exercise "as a matter of law" and that "adherence to the AA fellowship entails engagement in religious activity and religious proselytization"

The New York Federal Appeals Court also recently ruled that government-mandated participation in AA violates the Establishment Clause of the First Amendment.

These citations come from the University of Virginia's New Religious Movements (NRA) website brief on Alcoholics Anonymous

SOS Sobriety explores non-religious paths to sobriety and is currently becoming a popular alternative to AA in the US justice system.

[robitusson]

Hey Robitusson all I can say is thanks for presenting the facts. I agree and have done a fair bit of my own research over the last 20 years in facing my own behavors with intoxicants. Moving the goal posts when confronted with facts is a common denominator used in group think recruiting organizations.

I'm almost afraid to reply after all the aggressive flaming and flak my contrary view has generated but it's good to hear a tempered voice.

The famous Twelve Steps are the core of the AA experience. The twelve steps are drawn directly from the Oxford Group that Bill W. and Dr. Bob participated in before branching out to create AA (Bufe: 62). In the Oxford Group these steps were used as a cure for sin.

On appeal the New York Court of Appeals reversed the Appellate Division and ruled that the Twelve Steps of AA amount to a religious exercise "as a matter of law" and that "adherence to the AA fellowship entails engagement in religious activity and religious proselytization"

Not that the official stamp of the Law is needed to recognise religious proselytizing when you see it but acknowledgement from this kind of source might well be needed to protect people at their most vunerable.

[sbk]

Maybe we should just change the title of this thread to the "anti-AA thread" and that way people who support AA can avoid it and those who dislike it can feel free to post.

[Mobi]

I would have thought that after all this time and 5 pages of thread that the definition had been defined and debated to death, as have all issues to do with the AA, the 12 steps to purgatory, the 5 % success rate and God knows what else.

Ah well, some people have strange ways of spending their spare time.

May the thread be with you

Edited August 23, 2006 by Mobi D'Ark

[sabaijai]

Maybe we should just change the title of this thread to the "anti-AA thread" and that way people who support AA can avoid it and those who dislike it can feel free to post.

Or call it the 'pro-AA vs pro-choice thread'. Throughout this forum branch we're hearing more of the AA view than anything else.

What I find disturbing--cult-like you will--is that the AA lobby (with Bill W himself a notable exception) typically refuse to admit that any programme besides AA might produce lasting sobriety. In fact almost any other programme does work as well if not better. Pointing that out doesn't necessarily make one 'anti-AA'.

[leftknee]

Q why is alcoholism one of the most difficult addictions to get rid of?

A because you cant just move away from it.

Q why do people get addicted in the first place?

A because thats the path they choose when they let poor willpower get the best of them.

Q why do some people have poor will-power when it comes to alcohol?

A because they like to drink and hence they want to drink.

Q why call alcoholism a disease?

A because its ######ing easier that way.

ITS NOT MY FAULT! ITS A DISEASEEEE!

/leftknee

IV heroin-junkie and Alcoholic.

but its not my fault, im just sick.

[sbk]

Maybe we should just change the title of this thread to the "anti-AA thread" and that way people who support AA can avoid it and those who dislike it can feel free to post.

Or call it the 'pro-AA vs pro-choice thread'. Throughout this forum branch we're hearing more of the AA view than anything else.

What I find disturbing--cult-like you will--is that the AA lobby (with Bill W himself a notable exception) typically refuse to admit that any programme besides AA might produce lasting sobriety. In fact almost any other programme does work as well if not better. Pointing that out doesn't necessarily make one 'anti-AA'.

Actually, my issue all along has been the continuous hijacking of threads by people with an agenda. Be that AA or robitusson with his mission. If every single thread in this forum is going to be diverted in this way, then what is the point of even having this forum?

I, for one, suggest that we have ONE thread with this topic. No more hijacking of threads to be tolerated. But hey, thats just my opinion.

[robitusson]

Throughout this forum branch we're hearing more of the AA view than anything else.

Exactly. But offering an altenate view is "hi-jacking" or "a mission". It's quite ridiculous.

[robitusson]

Q why call alcoholism a disease?

A because its ######ing easier that way.

ITS NOT MY FAULT! ITS A DISEASEEEE!

/leftknee

IV heroin-junkie and Alcoholic.

but its not my fault, im just sick.

[robitusson]

Actually, my issue all along has been the continuous hijacking of threads by people with an agenda. Be that AA or robitusson with his mission. If every single thread in this forum is going to be diverted in this way, then what is the point of even having this forum?

I, for one, suggest that we have ONE thread with this topic. No more hijacking of threads to be tolerated. But hey, thats just my opinion.

There's was NO objection from you to all the pro-AA posts that filled this forum when it opened initially, even though the view went completely unchallanged. Don't pretend to be impartial. It was only when a contrary opinion about AA was heard that you mention 'continuous hi-jacking'.

Edited August 25, 2006 by robitusson

[sabaijai]

I think 'digression' would be a more appropriate term than 'hijacking' for how this particular thread (Issue with the Definition) has progressed. Lots of threads on TV digress in similar manner, in fact having participated in TV since 2003, I'd say most do.

Neeranam (Thai for 'anonymous') was the first to move away from the definition of addiction/alcoholism, and into the arena of treatment, in Post #12. His post was preceded by several echoing the definition as prescribed by AA ('powerlessness'). It was only after Neeranam's digression that an alternative viewpoint came up, although the OP obviously was questioning the AA's 'disease' definition in the first place.

The issue of treatment isn't so off-topic since how we treat addiction is largely dependent on how we define it. Possibly vice versa as well--certainly the pro-AA camp defines addiction by treatment parameters (ie, you're not an addict unless you can't treat yourself).

[Mobi]

I think 'digression' would be a more appropriate term for how this particular thread (Issue with the Definition) has progressed.

Neeranam was the first to move away from the definition of addiction/alcoholism, and into the arena of treatment, in Post #12. His post was proceeded by several directly concerned with the defintion as prescribed by AA/12-step prgrammes ('powerlessness').

Lots of threads on TV digress in similar manner, in fact having participated in TV since 2003, I'd say most do. The issue of treatment isn't complete off topic since how we treat addiction is largely dependent on how we define it. Possibly vice versa as well--certainly the pro-AA camp defines addiction by treatment parameters (ie, you're not an addict unless you can't treat yourself).

Yawn Yawn Yawn - digression indeed.

Is anyone still reading it except Sabaijai and Robitusson?

hereby removed from my email alerts

[sabaijai]

I think 'digression' would be a more appropriate term for how this particular thread (Issue with the Definition) has progressed.

Neeranam was the first to move away from the definition of addiction/alcoholism, and into the arena of treatment, in Post #12. His post was proceeded by several directly concerned with the defintion as prescribed by AA/12-step prgrammes ('powerlessness').

Lots of threads on TV digress in similar manner, in fact having participated in TV since 2003, I'd say most do. The issue of treatment isn't complete off topic since how we treat addiction is largely dependent on how we define it. Possibly vice versa as well--certainly the pro-AA camp defines addiction by treatment parameters (ie, you're not an addict unless you can't treat yourself).

Yawn Yawn Yawn - digression indeed.

Is anyone still reading it except Sabaijai and Robitusson?

hereby removed from my email alerts

Watch out, Mobi, you're hijacking the thread!

[sbk]

Actually, sabaijai, it wasn't just this thread that "digressed" in this manner. Hence my raising it as an issue. I'd hate to see interested people get turned off and away because they are caught in the middle of someone's need to score points.

[sabaijai]

Actually, sabaijai, it wasn't just this thread that "digressed" in this manner. Hence my raising it as an issue. I'd hate to see interested people get turned off and away because they are caught in the middle of someone's need to score points.

I respectfully disagree that this is about someone's need to score points (but if it is, there again so are the majority of lively discussions on TV.com), and don't understand how a presentation of treatment alternatives could be discouraging to addicts seeking treatment. Why would thaivisa.com members interested in cutting down/abstinence not want to hear about as many options as possible?

[sbk]

Actually, sabaijai, it wasn't just this thread that "digressed" in this manner. Hence my raising it as an issue. I'd hate to see interested people get turned off and away because they are caught in the middle of someone's need to score points.

I respectfully disagree that this is about someone's need to score points (but if it is, there again so are the majority of lively discussions on TV.com), and don't understand how a presentation of treatment alternatives could be discouraging to addicts seeking treatment. Why would thaivisa.com members interested in cutting down/abstinence not want to hear about as many options as possible?

Not my point. I guess I am not making myself understood here.

Never mind, next time a thread gets hijacked I won't bother.

[francois]

Maybe we should just change the title of this thread to the "anti-AA thread" and that way people who support AA can avoid it and those who dislike it can feel free to post.

hi'

good idea, as they have 5% success, I guess that the new anti AA will be fillles up soon

francois

[sabaijai]

Addiction Is a Choice

by Jeffrey A. Schaler, Ph.D.

October 2002, Vol. XIX, Issue 10

Psychiatric Times

Is addiction a disease, or is it a choice? To think clearly about this question, we need to make a sharp distinction between an activity and its results. Many activities that are not themselves diseases can cause diseases. And a foolish, self-destructive activity is not necessarily a disease.

With those two vital points in mind, we observe a person ingesting some substance: alcohol, nicotine, cocaine or heroin. We have to decide, not whether this pattern of consumption causes disease nor whether it is foolish and self-destructive, but rather whether it is something altogether distinct and separate: Is this pattern of drug consumption itself a disease?

Scientifically, the contention that addiction is a disease is empirically unsupported. Addiction is a behavior and thus clearly intended by the individual person. What is obvious to common sense has been corroborated by pertinent research for years (Table 1).

The person we call an addict always monitors their rate of consumption in relation to relevant circumstances. For example, even in the most desperate, chronic cases, alcoholics never drink all the alcohol they can. They plan ahead, carefully nursing themselves back from the last drinking binge while deliberately preparing for the next one. This is not to say that their conduct is wise, simply that they are in control of what they are doing. Not only is there no evidence that they cannot moderate their drinking, there is clear evidence that they do so, rationally responding to incentives devised by hospital researchers. Again, the evidence supporting this assertion has been known in the scientific community for years (Table 2).

My book Addiction Is a Choice was criticized in a recent review in a British scholarly journal of addiction studies because it states the obvious (Davidson, 2001). According to the reviewer, everyone in the addiction field now knows that addiction is a choice and not a disease, and I am, therefore, "violently pushing against a door which was opened decades ago." I'm delighted to hear that addiction specialists in Britain are so enlightened and that there is no need for me to argue my case over there.

In the United States, we have not made so much progress. Why do some persist, in the face of all reason and all evidence, in pushing the disease model as the best explanation for addiction?

I conjecture that the answer lies in a fashionable conception of the relation between mind and body. There are several competing philosophical theories about that relation. Let us accept, for the sake of argument, the most extreme "materialist" theory: the psychophysical identity theory. Accordingly, every mental event corresponds to a physical event, because it is a physical event. The relation between mind and the relevant parts of the body is, therefore, like the relation between heat and molecular motion: They are precisely the same thing, observed in two different ways. As it happens, I find this view of the relation between mind and body very congenial.

However, I think it is often accompanied by a serious misunderstanding: the notion that when we find a parallel between physiological processes and mental or personality processes, the physiological process is what is really going on and the mental process is just a passive result of the physical process. What this overlooks is the reality of downward causation, the phenomenon in which an emergent property of a system can govern the position of elements within the system (Campbell, 1974; Sperry, 1969). Thus, the complex, symmetrical, six-pointed design of a snow crystal largely governs the position of each molecule of ice in that crystal.

Hence, there is no theoretical obstacle to acknowledging the fact that thoughts, desires, values and other mental phenomena can dominate bodily functions. Suppose that a man's mother dies, and he undergoes the agonizing trauma we call unbearable grief. There is no doubt that if we examine this man's bodily processes we will find many physical changes, among them changes in his blood and stomach chemistry. It would be clearly wrong to say that these bodily changes cause him to be grief-stricken. It would be less misleading to say that his being grief-stricken causes the bodily changes, but this is also not entirely accurate. His knowledge of his mother's death (interacting with his prior beliefs and values) causes his grief, and his grief has blood-sugar and gastric concomitants, among many others.

There is no dispute that various substances cause physiological changes in the bodies of people who ingest them. There is also no dispute, in principle, that these physiological changes may themselves change with repeated doses, nor that these changes may be correlated with subjective mental states like reward or enjoyment.

I say "in principle" because I suspect that people sometimes tend to run away with these supposed correlations. For example, changes in dopamine levels have often been hypothesized as an integral part of the reward/reinforcement process. Yet research shows that dopamine in the nucleus accumbens does not mediate primary or unconditioned food reward in animals (Aberman and Salamone, 1999; Nowend et al., 2001; Salamone et al., 2001; Salamone et al., 1997). According to Salamone, the theory that drugs of abuse turn on a natural reward system is simplistic and inaccurate: "Dopamine in the nucleus accumbens plays a role in the self-administration of some drugs (i.e., stimulants), but certainly not all" (personal communication, Nov. 26, 2001).

Garris et al. (1999) reached similar conclusions: "Dopamine may therefore be a neural substrate for novelty or reward expectation rather than reward itself." They concluded:

[T]here is no correlation between continual bar pressing during [intracranial self-stimulation] and increased dopaminergic neurotransmission in the nucleus accumbensýour results are consistent with evidence that the dopaminergic component is not associated with the hedonistic or 'pleasure' aspects of rewardýLikewise, the rewarding effects of cocaine do not require dopamine; mice lacking the gene for the dopamine transporter, a major target of cocaine, will self-administer cocaine. However, increased dopamine neurotransmission in the nucleus accumbens shell is seen when rats are transiently exposed to a new environment. The increase in extracellular dopamine quickly returns to normal levels and remains there during continued exploration of the new environmentýdopamine release in the nucleus accumbens is related to novelty, predictability or some other aspects of the reward process, rather than to hedonism itself.

Perhaps, then, some people have been too ready to jump to conclusions about specific mechanisms. Be that as it may, chemical rewards have no power to compel--although this notion of compulsion may be a cherished part of clinicians' folklore. I am rewarded every time I eat chocolate cake, but I often eschew this reward because I feel I ought to watch my weight.

Experience with addiction treatment must surely make us even more dubious about the theory that addiction is a disease. The most popular way of helping people manage their addictive behavior is Alcoholics Anonymous (AA) and its various 12-step offshoots. Many observers have recognized the essentially religious nature of AA. The U.S. courts are increasingly regarding AA as a religious activity. In United States v Seeger (1965), the U.S. Supreme Court stated that the test to be applied as to whether a belief is religious is to enquire whether that belief "occupies a place in the life of its possessor parallel to that filled by the orthodox belief in God" in religions more widely accepted in the United States. This requirement is met by members of AA and other secular programs that help people with addictive behaviors and encourage their members to turn their will and lives over to the care of a supreme being. What kind of disease is this for which the best available treatment is religion (Antze, 1987)? Clinical applications are based on explanations for why the behavior occurs. An activity based on a religious belief masquerading as a clinical form of treatment tells us something about what the activity really is--an ethical, not medical, problem in living.

What passes as clinical treatment for addiction is psychotherapy, which essentially consists of various forms of conversation or rhetoric (Szasz, 1988). One person, the therapist, tries to influence another person, the patient, to change their values and behavior. While the conversation called therapy can be helpful, most of the conversation that occurs in therapy based on the disease model is potentially harmful. This is because the therapist misleads the patient into believing something that is simply untrue--that addiction is a disease, and, therefore, addicts cannot control their behavior. Preaching this falsehood to patients may encourage them to abandon any attempt to take responsibility for their actions.

The treatment of drug effects, at the patient's request, is well within the domain of medicine, what passes as evidence for the theory that addiction is a disease is merely clinical folklore.

Dr. Schaler teaches at American University's School of Public Affairs in Washington, D.C., and at Johns Hopkins University in Baltimore. Addiction is a Choice (Open Court Publishers, 2000) is among his published works on addiction.

References

Aberman JE, Salamone JD (1999), Nucleus accumbens dopamine depletions make rats more sensitive to high ratio requirements but do not impair primary food reinforcement. Neuroscience 92(2):545-552.

Antze P (1987), Symbolic action in Alcoholics Anonymous. In: Constructive Drinking: Perspectives on Drink From Anthropology, Douglas M, ed. New York: Cambridge University Press, pp149-181.

Campbell DT (1974), 'Downward causation' in hierarchically organized biological systems. In: Studies in the Philosophy of Biology: Reduction and Related Problems, Ayala FJ, Dobzhansky T, eds. London: Macmillan.

Davidson R (2001), Conspiracy, cults and choices. Addiction Research & Theory 9(1):92-92 [book review].

Garris PA, Kilpatrick M, Bunin MA et al. (1999), Dissociation of dopamine release in the nucleus accumbens from intracranial self-stimulation. Nature 398(6722):67-69.

Nowend KL, Arizzi M, Carlson BB, Salamone JD (2001), D1 or D2 antagonism in nucleus accumbens core or dorsomedial shell suppresses lever pressing for food but leads to compensatory increases in chow consumption. Pharmacol Biochem Behav 69(3-4):373-382.

Salamone JD, Cousins MS, Snyder BJ (1997), Behavioral functions of nucleus accumbens dopamine: empirical and conceptual problems with the anhedonia hypothesis. Neurosci Biobehav Rev 21(3):341-359.

Salamone JD, Wisniecki A, Carlson BB, Correa M (2001), Nucleus accumbens dopamine depletions make animals highly sensitive to high fixed ratio requirements but do not impair primary food reinforcement. Neuroscience 105(4):863-870.

Sperry W (1969), A modified concept of consciousness. Psychol Rev 76(6):532-536.

Szasz TS (1988), The Myth of Psychotherapy: Mental Healing as Religion, Rhetoric, and Repression. Syracuse, N.Y.: Syracuse University Press.

United States v Seeger, 980 US 163 (1965).

[Neeranam]

Managing Alcoholism as a Disease

By Thomas R. Hobbs, Ph.D., M.D.

Thomas R. Hobbs, Ph.D., M.D., is medical director of the Physicians’ Health Programs (PHP). The PHP, a program of The Educational and Scientific Trust of the Pennsylvania Medical Society, is a confidential advocacy service for physicians suffering from impairing conditions.

Published February 1998

The debate on whether alcoholism is a disease or a personal conduct problem has continued for over 200 years. In the United States, Benjamin Rush, MD, has been credited with first identifying alcoholism as a "disease" in 1784. He asserted that alcohol was the causal agent, loss of control over drinking behavior being the characteristic symptom, and total abstinence the only effective cure. His belief in this concept was so strong that he spearheaded a public education campaign in the United States to reduce public drunkenness.

The 1800s gave rise to the temperance movement in the United States. Alcohol was perceived as evil, the root cause of America’s problems. Accepting the disease concept of alcoholism, people believed that liquor could enslave a person against his or her will. Temperance proponents propagated the view that drinking was so dangerous that people should not even sample liquor or else they would likely embark on the path toward alcoholism. This ideology maintained that alcohol is inevitably dangerous and inexorably addictive for everyone. Today, we know that strong genetic influences exist, but not everyone becomes addicted to alcohol.

The temperance movement picked up steam in the late 1800s and evolved into a movement advocating the prohibition of alcohol nationally. Banning alcohol would preserve the family and eliminate sloth and moral dissolution in the United States, according to supporters. Backed by strong political forces, legislation was passed and prohibition went into effect in 1920. Paradoxically, the era of prohibition also marked the death of Victorian standards. According to A. Sinclair in his book, Prohibition: The Era of Excess, a code of liberated personal behavior grew and with it the idea that drinking should accompany a full life. Drunkenness represented personal freedom. Due to public outcry, prohibition was repealed in 1933.

Soon after prohibition ended, Alcoholics Anonymous (AA) was born. Formed in 1935 by stockbroker Bill Wilson and a physician, Robert Smith, AA supported the proposition that an alcoholic is unable to control his or her drinking and recovery is possible only with total abstinence and peer support. The chief innovation in the AA philosophy was that it proposed a biological explanation for alcoholism. Alcoholics constituted a special group who are unable to control their drinking from birth. Initially, AA described this as "an allergy to alcohol."

Although AA was instrumental in again emphasizing the "disease concept" of alcoholism, the defining work was done by Elvin Jellinek, M.D., of the Yale Center of Alcohol Studies. In his book, The Disease Concept of Alcoholism, published in 1960, Jellinek described alcoholics as individuals with tolerance, withdrawal symptoms, and either "loss of control" or "inability to abstain" from alcohol. He asserted that these individuals could not drink in moderation, and, with continued drinking, the disease was progressive and life-threatening. Jellinek also recognized that some features of the disease (e.g., inability to abstain and loss of control) were shaped by cultural factors.

During the past 35 years, numerous studies by behavioral and social scientists have supported Jellinek’s contentions about alcoholism as a disease. The American Medical Association endorsed the concept in 1957. The American Psychiatric Association, the American Hospital Association, the American Public Health Association, the National Association of Social Workers, the World Health Organization and the American College of Physicians have also classified alcoholism as a disease. In addition, the findings of investigators in the late 1970s led to explicit criteria for an "alcohol dependence syndrome" which are now listed in the DSM IIR, DSM IV, and the ICD manual. In a 1992 JAMA article, the Joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine published this definition for alcoholism: "Alcoholism is a primary chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, mostly denial. Each of these symptoms may be continuous or periodic."

Despite the numerous studies validating the disease model of alcoholism, controversy still exists. In his 1989 book, Diseasing of America, social psychologist Stanton Peele, Ph.D., argues that AA and for-profit alcohol treatment centers promote the "myth" of alcoholism as a lifelong disease. He contends that the disease concept "excuses alcoholics for their past, present, and future irresponsibility" and points out that most people can overcome addiction on their own. He concludes that the only effective response to alcoholism and other addictions is "to recreate living communities that nurture the human capacity to lead constructive lives."

Surprisingly, Dr. Peele’s view that alcoholism is a personal conduct problem, rather than a disease, seems to be more prevalent among medical practitioners than among the public. A recent Gallop poll found that almost 90 percent of Americans believe that alcoholism is a disease. In contrast, physicians’ views of alcoholism were reviewed at an August 1997 conference held by the International Doctors of Alcoholics Anonymous (IDAA). A survey of physicians reported at that conference found that 80 percent of responding doctors perceived alcoholism as simply bad behavior.

Dr. Raoul Walsh in an article published in the November 1995 issue of Lancet supports the contention that physicians have negative views about alcoholics. He cites empirical data showing physicians continue to have stereotypical attitudes about alcoholics and that non-psychiatrists tend to view alcohol problems as principally the concern of psychiatrists. He also contends that many doctors have negative attitudes towards patients with alcohol problems because the bulk of their clinical exposure is with late-stage alcohol dependence.

Based on my experiences working in the addiction field for the past 10 years, I believe many, if not most, health professionals still view alcohol addiction as a willpower or conduct problem and are resistant to look at it as a disease. Part of the problem is that medical schools provide little time to study alcoholism or addiction and post-graduate training usually deals only with the end result of addiction or alcohol/drug-related diseases. Several studies conducted in the late 1980s give evidence that medical students and practitioners have inadequate knowledge about alcohol and alcohol problems. Also, recent studies published in the Journal of Studies on Alcoholism indicate that physicians perform poorly in the detection, prevention and treatment of alcohol abuse.

The single most important step to overcoming these obstacles is education. Education must begin at the undergraduate level and continue throughout the training of most if not all specialties. This is especially true for those in primary care where most problems of alcoholism will first be seen. In recent years, promotion of alcohol education programs in medical schools and at the post graduate level has improved. In Pennsylvania, for example, several medical schools now offer at least one curriculum block on substance abuse. Medical specialty organizations, such as the American Society of Addiction Medicine, are focusing on increasing addiction training programs for residents, practicing physicians and students.

Also, an increasing number of hospitals have an addiction medicine specialist on staff who is available for student and resident teaching, as well as being available for in-house consultations.

The American Medical Association estimates that 25-40 percent of patients occupying general hospital beds are there for treatment of ailments that result from alcoholism. In the United States, the economic costs of alcohol abuse exceed $115 billion a year. Physicians in general practice, hospitals and specialty medicine have considerable potential to reduce the large burden of illness associated with alcohol abuse. For example, several randomized, controlled trials conducted in recent years demonstrate that brief interventions by physicians can significantly reduce the proportion of patients drinking at hazardous levels. But first, we as physicians must adjust our attitudes.

Alcoholism should not be judged as a problem of willpower, misconduct, or any other unscientific diagnosis. The problem must be accepted for what it is—a biopsychosocial disease with a strong genetic influence, obvious signs and symptoms, a natural progression and a fatal outcome if not treated. In the past 10 years, the medical profession’s and the public’s acceptance of smoking as an addictive disease has resulted in reducing nicotine use in the United States. I feel that similar strides can be made with alcohol abuse. We must begin, as we did with nicotine, by educating and convincing our own colleagues that alcoholism is a disease. We must also emphasize that physicians have played a significant role in reducing the mortality and morbidity from nicotine use through patient education. Through strong physician intervention, I believe that we can achieve similar results with alcohol abuse.

Edited September 11, 2006 by Neeranam