Is alcoholism a disease? We don’t believe so!
AA, treatment centers and alcohol counseling are the only known successful methods of arresting the compulsion to drink or take drugs. Alcoholism was totally untreatable and fatal until 1935, when A.A. was founded. —Ruth Harris, WomenSpace Shelter Project, Cleveland
What we “know” about alcoholism, like the points in Ruth Harris’s quote above, has been determined by an active group of proselytizers for AA and the alcoholism movement, most of whom are alcoholics. These advocates have had very specific experiences with drinking. At the same time, many of their experiences and views were distinctive even before they became alcoholics and were in fact quite different from those of people less likely to become alcoholics.
Nonetheless, public opinion surveys show that Americans at large have accepted all or most of the contentions of the modern alcoholism movement. The core beliefs that the alcoholism movement has successfully promulgated are:
- Alcoholics don’t drink too much because they intend to, but only because they can’t control their drinking.
- Alcoholics inherit their alcoholism and thus are born as alcoholics.
- Alcoholism always grow worse without treatment, so that alcoholics can never cut back or quit on their own.
- Alcoholism as a disease can strike any individual—it is an “equal-opportunity destroyer”—and respects no social, religious, ethnic or sexual bounds.
- Treatment based on AA principles is the only effective treatment for alcoholism—in the words of one proponent, a modern medical “miracle”—without which no one can hope to arrest a drinking problem.
- Those who reject the AA approach for their drinking problems, or observers who contradict any of the contentions about alcoholism listed here, are practicing a special denial that means death for alcoholics.
These keynotes to the AA and National Council on Alcoholism perspective existed before any research had been conducted to verify them—they represent folk wisdom. This folk wisdom has come to be accepted by most Americans.
For example, according to a 1987 Gallup poll on Is alcoholism a disease, 87 percent of Americans endorse the idea that alcoholism is a disease (although only 68 percent express strong agreement with this idea). This figure has increased steadily, jumping from 79 percent who agreed in 1982, as Americans are told they must accept the “truths” of alcoholism, which are said to represent modern scientific breakthroughs in our understanding of drinking problems. For example, Gallup presented Americans growing acceptance of the disease viewpoint under the heading “Misconceptions About Alcoholism Succumb to Educational Efforts.”
The standard wisdom is that AA is unmatched in effectiveness for dealing with alcoholism and that alcoholism would be licked if only everyone joined AA. The actual scientific evidence, however, strongly contradicts the contentions of the alcoholism movement.
Certainly, many people who belong to AA tell us that AA stopped them from drinking. However, this no more demonstrates the general effectiveness of AA than testimony that some people decide not to kill themselves after they discover Christ is evidence that Christianity is the cure for suicide.
In fact, research has not found AA to be an effective treatment for general populations of alcoholics. Consider the following summary by researchers at the Downstate (New York) Medical Center Department of Psychiatry:
The general applicability of AA as a treatment method is much more limited than has been supposed in the past. Available data do not support AA’s claims of much higher success rates than clinic treatment. Indeed, when population differences are taken into account, the reverse seems to be true.
Not one study has even found AA or its derivatives to be superior to any other approach, or even to be better than not receiving any help at all for eliminating alcoholism when alcoholics are assigned to different kinds of treatment. At the same time, other methods that have regularly been found to be superior to AA and other standard therapies for alcoholism have been completely rejected by American treatment programs.
To preview the startling proposition that therapies that are universally advocated have already been shown to be ineffective and that more effective approaches are available, consider the prevailing approach to drunk-driving convictions in America—remanding drinking drivers for treatment.
Advocates of a humane, informed approach to the problem continually plead for more referrals and bemoan primitive programs that simply arrest, imprison, or place on probation those caught driving while intoxicated (DWI). Meanwhile, comparative studies of standard treatment programs versus legal proceedings for drunk drivers regularly find that those who received ordinary judicial sanctions had fewer subsequent accidents and were rearrested less.
While standard disease treatments and education programs for drunk drivers have conclusively been shown to fail at their mission, nondisease rehabilitation programs—such as those teaching DWIs social skills (like those needed to reject additional drinks), enhanced personal responsibility in decision making, and methods for drinking moderately—have shown beneficial results.4
Yet almost no such nondisease programs for drunk drivers remain in the United States, and those few are under strong attack. In 1985, the attorney general of New York and the State Division of Alcoholism and Alcohol Abuse attempted to close such a program in Rochester, although the program had operated successfully for years under the auspices of the county DA’s office. (Eventually, the New York State Supreme Court ruled in favor of the program, Creative Interventions, mainly on technical grounds.)
AA’s undeserved status as a universal cure for alcoholism and the beleaguered state of skill-training approaches for drunk drivers are some of the many indicators that alcoholism practices are based on the prejudices of a few rather than on scientific data. That this situation prevails in the United States is clear in a remarkable quote from the current director of the National Institute on Alcohol Abuse and Alcoholism, Enoch Gordis:
In the case of alcoholism, our whole treatment system, with its innumerable therapies, armies of therapists, large and expensive programs, endless conferences . . . and public relations activities is founded on hunch, not evidence, and not on science. . . . Yet the history of medicine demonstrates repeatedly that unevaluated treatment, no matter how compassionately administered, is frequently useless and wasteful and sometimes dangerous and harmful. The lesson we have learned is that what is plausible may be false, and what is done sincerely may be useless or worse.(emphasis in original)
While alcoholism movement experts strive to declare that the dominant American approaches to alcoholism represent the end point of a long process of scientific discovery, other countries have repudiated the disease approach entirely. Consider this quote from British psychiatrist Robin Murray:
There can be no doubt that current British and American perspectives on alcoholism differ widely. . . . Even R. E. Kendell, one of the British psychiatrists most interested in categorical diagnostic systems, states that for alcoholism it is “increasingly clear that most of the assumptions of the ‘disease model’ are unjustified and act as a barrier to a more intelligent and effective approach to the problem.”
The following is a list of some of the widely promulgated and generally accepted ideas about the disease of alcoholism, along with the research that contradicts them.
Loss of Control
The core idea of the AA version of the disease of alcoholism is that alcoholics cannot cease drinking once they start. The first step of AA, admitting that the alcoholic is “powerless over alcohol,” means that alcoholics simply cannot regulate their drinking in any way. According to AA, even a single taste of alcohol (such as that in an alcoholic dessert) sets off uncontrollable binge drinking.
Alcoholism professionals have attempted to translate AA’s view into scientific-sounding terms.
For example, in a popular book on alcoholism, Under the Influence, James Milam claims: “The alcoholic’s drinking is controlled by physiological factors which cannot be altered through psychological methods such as counseling, threats, punishment, or reward. In other words, the alcoholic is powerless to control his or her drinking.”
In fact, this statement has been demonstrated to be false by every experiment designed to test it.
For example, alcoholics who are not aware that they are drinking alcohol do not develop an uncontrollable urge to drink more. Psychologist Alan Marlatt and his colleagues found that alcoholics drinking heavily flavored alcoholic beverages did not drink excessive amounts—as long as they thought the drinks did not contain alcohol. The alcoholics in this experiment who drank the most were those who believed they were imbibing alcohol—even when their beverage contained none. From this study, we see that what alcoholics believe is more important to their drinking than the “facts” that they are alcoholics and that they are drinking alcohol.
Rather than losing control of their drinking, experiments show, alcoholics aim for a desired state of consciousness when they drink. They drink to transform their emotions and their self-image—drinking is a route to achieve feelings of power, sexual attractiveness, or control over unpleasant emotions.
Alcoholics strive to attain a particular level of intoxication, one that they can describe before taking a drink. Nancy Mello and Jack Mendelson of Harvard Medical School and McLean Hospital—the former a psychologist and the latter a physician—found that alcoholics would continue working to gain credits with which to buy alcohol until they could stockpile the amount they needed to get as drunk as they wanted. They continued to work for credits as they were undergoing withdrawal from previous binges, even though they could stop and turn in their credits for drink at any time.
Alcoholics are influenced by their environments and by those around them, even when they are drinking and intoxicated. For example, researchers at Baltimore City Hospital offered alcoholics the opportunity to drink whenever they wanted in a small, drab isolation booth. These street inebriates curtailed their drinking significantly in order to spend more time in a comfortable and interesting room among their companions. In these and other studies, alcoholics’ drinking behavior was molded simply by the way the alcohol was administered or by the rewards alcoholics received or were denied based on their drinking styles.
What does this research prove? Alcoholism is the term we use to describe people who get drunk more than other people and who often suffer problems due to their drinking. Alcoholism exists—overdrinking, compulsive drinking, drinking beyond a point where the person knows he or she will regret it—all these occur. (In fact, these things happen to quite a high percentage of all drinkers during their lives.) But this drinking is not due to some special, uncontrollable biological drive. Alcoholics are no different from other human beings in exercising choices, in seeking the feelings that they believe alcohol provides, and in evaluating the mood changes they experience in terms of their alternatives. No evidence disputes the view that alcoholics continue to respond to their environments and to express personal values even while they are drinking.
The Genetics of Alcoholism
AA originally claimed that alcoholics inherit an “allergy” to alcohol that underlies their loss of control when they drink. Today this particular idea has been discarded. Nonetheless, a tremendous investment has been made in the search for biological inheritances that may cause alcoholism, while many grandiose claims have been made about the fruits of this search. In 1987, almost two-thirds of Americans (63 percent) agreed that “alcoholism can be hereditary”; only five years earlier, in 1982, more people had disagreed (50 percent) than agreed (40 percent) with this statement. Furthermore, it is the better educated who agree most with this statement. Yet widely promulgated and broadly accepted claims about the inheritance of alcoholism are inaccurate, and important data from genetic research call into doubt the significance of genetic influences on alcoholism and problem drinking. Moreover, prominent genetic researchers themselves indicate that cultural and environmental influences are the major determinants of most drinking problems, even for the minority of alcoholics who they believe have a genetic component to their drinking.
Popular works now regularly put forward the theory — presented as fact — that the inherited cause of alcoholism has been discovered. In the words of Durk Pearson and Sandra Shaw, the authors of Life Extension, “Alcohol addiction is not due to weak will or moral depravity; it is a genetic metabolic defect… [just like the] genetic metabolic defect resulting in gout.” One version of this argument appeared in the newsletter of the Alcoholism Council of Greater New York:
Someone like the derelict. . . , intent only on getting sufficient booze from the bottle poised upside-down on his lips. . . [is] the victim of metabolism, a metabolism the derelict is born with, a metabolic disorder that causes excessive drinking.
Is it really possible that street inebriates are destined from the womb to become alcoholics? Don’t they really have a choice in the matter, or any alternatives? Don’t their upbringings, or their personal and social values, have any impact on this behavior?
Several well-publicized studies have found that close biological relatives of alcoholics are more likely to be alcoholics themselves. The best-known research of this kind, examining Danish adoptees, was published in the early 1970s by psychiatrist Donald Goodwin and his colleagues. The researchers found that male adoptees with alcoholic biological parents became alcoholics three to four times more often than adoptees without alcoholic relatives. This research has several surprising elements to it, however. In the first place, only 18 percent of the males with alcoholic biological parents became alcoholics themselves (compared with 5 percent of those without alcoholic parentage). Note that, accepting this study at face value, the vast majority of men whose fathers are alcoholics do not become alcoholic solely because of biological inheritance.
Some might argue that Goodwin’s definition of alcoholism is too narrow and that the figures in his research severely understate the incidence of alcoholism. Indeed, there was an additional group of problem drinkers whom Goodwin and his colleagues identified, and many people might find it hard to distinguish when a drinker fell in this rather than in the alcoholic group. However, more of the people in the problem drinking group did not have alcoholic parents than did! If alcoholic and heavy problem drinkers are combined, as a group they are not more likely to be offspring of alcoholic than of nonalcoholic parents, and the finding of inherited differences in alcoholism rates disappears from this seminal study. One last noteworthy result of the Goodwin team’s research: in a separate study using the same methodology as the male offspring study, the investigators did not find that daughters of alcoholic parents more often became alcoholic themselves (in fact, there were more alcoholic women in the group without alcoholic parents).
Other studies also discourage global conclusions about inheritance of alcoholism. One is by a highly respected research group in Britain under Robin Murray, dean of the Institute of Psychiatry at Maudsley Hospital. Murray and his colleagues compared the correlation between alcoholism in identical twins with that between fraternal twins. Since the identical pair are more similar genetically, they should more often be alcoholic or nonalcoholic together than twins whose relationships are genetically equivalent to ordinary siblings. No such difference appeared. Murray and his colleagues and others have surveyed the research on inheritance of alcoholism. According to a longtime biological researcher in alcoholism, David Lester, these reviews “suggest that genetic involvement in the etiology of alcoholism. . . is weak at best.” His own review of the literature, Lester wrote, “extends and. . . strengthens these previous judgments.” Why, then, are genetic viewpoints so popular? For Lester, the credibility given genetic views is “disproportionate with their theoretical and empirical warrant,” and the “attraction and persistence of such views lies in their conformity with ideological norms.”
Several studies of male children of alcoholics (including two ongoing Danish investigations) have not found that these children drink differently as young adults or adolescents from their cohorts without alcoholic relatives. These children of alcoholics are not generally separated from their parents, and we know that for whatever reason, male children brought up by their alcoholic parents more often will be alcoholic themselves. What this tells us is that these children aren’t born as alcoholics but develop their alcoholism over the years. In the words of George Vaillant, who followed the drinking careers of a large group of men over forty years:
The present prospective study offers no credence to the common belief that some individuals become alcoholics after the first drink. The progression from alcohol use to abuse takes years.
What, then, do people inherit that keeps them drinking until they become alcoholics? Milam asserts in Under the Influence that the source of alcoholism is acetaldehyde, a chemical produced when the body breaks down alcohol. Some research has found higher levels of this chemical in children of alcoholics when they drink; other research (like the two Danish prospective studies) has not. Such discrepancies in research results also hold for abnormalities in brain waves that various teams of researchers have identified in children of alcoholics — some find one EEG pattern, while other researchers discover a distinct but different pattern. Psychiatrist Mare Schuckit, of the University of California at San Diego Medical School, found no such differences between young men from alcoholic families and a matched comparison group, leading him to “call into question. . . the replicability and generalizability” of cognitive impairments and neuropsychologic deficits “as part of a predisposition toward alcoholism.”
Washington University psychiatrist Robert Cloninger (along with several other researchers) claims that an inherited antisocial or crime-prone personality often leads to both criminality and alcoholism in men. On the other hand, antisocial acting out when drinking, as well as criminality, are endemic to certain social and racial groups — particularly young working-class and ghetto males. The Cloninger view gets into the slippery realm of explaining that the underprivileged and ghettoized are born the way they are. In addition, Schuckit has failed to find any differences in antisocial temperament or impulsiveness to differentiate those who come from alcoholic families and those without alcoholic siblings or parents.Instead, Schuckit believes, one — perhaps the — major mechanism that characterizes children of alcoholics is that these children are born with a diminished sensitivity to the effects of alcohol (although — once again — other researchers do not find this to be the case).
In Schuckit’s view, children of alcoholics have a built-in tolerance for alcohol — they experience less intoxication than other people when drinking the same amounts. (Note that this is the opposite of the original AA view that alcoholics inherit an allergy to alcohol.) In the Schuckit model, alcoholics might unwittingly drink more over long periods and thus build up a dependence on alcohol. But as a theory of alcoholism, where does this leave us? Why do these young men continue drinking for the years and decades Vaillant tells us it takes them to become alcoholics? And even if they can drink more without experiencing physical effects, why do they tolerate the various drinking problems, health difficulties, family complaints, and so on that occur on the road to alcoholism? Why don’t they simply recognize the negative impact alcohol is having on their lives and resolve to drink less? Certainly, some people do exactly this, saying things like “I limit myself to one or two drinks because I don’t like the way I act after I drink more.”
One insight into how those with similar physiological responses to alcohol may have wholly different predispositions to alcoholism is provided by those who manifest “Oriental flush” — a heightened response to alcohol marked by a visible reddening after drinking that frequently characterizes Asians and Native Americans. Oriental flush has a biochemical basis in that Asian groups display higher acetaldehyde levels when they drink: here, many believe, is a key to alcoholism. But individuals from Asian backgrounds who flush do not necessarily drink more than — or differ in their susceptibility to drinking problems from — those who don’t flush. Moreover, groups that show flushing have both the highest alcoholism rates (Native Americans and Eskimos) and the lowest rates (Chinese and Japanese) among ethnic groups in the United States. What distinguishes between how people in these two groups react to the same biological phenomenon? It would certainly seem that Eskimos’ and Indians’ abnegated state in America and their isolation from the American economic and achievement-oriented system inflate their alcoholism rates, while the low alcoholism rates of the Chinese and Japanese must be related to their achievement orientation and economic success in our society.
Not even genetically oriented researchers (as opposed to popularizers) deny that cultural and social factors are crucial in the development of alcoholism and that, in this sense, alcoholism is driven by values and life choices. Consider three quotes from prominent medical researchers. Mare Schuckit: “It is unlikely that there is a single cause for alcoholism. . . . At best, biologic factors explain only a part of ” the alcoholism problem; George Vaillant: “I think it [finding a biological marker for alcoholism] would be as unlikely as finding one for basketball playing. . . . The high number of children of alcoholics who become addicted, Vaillant believes, is due less to biological factors than to poor role models”; Robert Cloninger: “The demonstration of the critical importance of sociocultural influences in most alcoholics suggests that major changes in social attitudes about drinking styles can change dramatically the prevalence of alcohol abuse regardless of genetic predisposition.” In short, the idea that alcoholism is an inherited biological disease has been badly overstated, and according to some well-informed observers, is completely unfounded.
Alcoholic Progression — A Drinking Problem Can Only Get Worse
The nineteenth-century view of alcoholic progression — that occasional drinkers become regular drinkers become alcoholics — is alive and well in the modern alcoholism movement. Now the idea is that anyone who ever has any problems with their drinking must either seek treatment or progress to inevitable, life-threatening alcoholism. “The ultimate consequences for a drinking alcoholic,” Dr. G. Douglas Talbott says, “are these three: he or she will end up in jail, in a hospital, or in a graveyard.”
Of course, when you talk to alcoholics, you discover that they were early problem drinkers before they progressed to alcoholism. But the fact is, the large majority of problem drinkers outgrow their drinking problems, according to the national surveys conducted by Don Cahalan and his associates. Men often go through problem drinking periods, depending on their stage in the life cycle and the people they associate with, only to emerge from these when their life circumstances change. Incidentally, the large majority of these untreated former problem drinkers do not choose to abstain but continue drinking while diminishing or eliminating their problems. The largest group of problem drinkers is young men, but young drinkers show the highest rate of natural remission as they age.
Several surveys conducted by Kaye Fillmore, of the Institute for Health and Aging (University of California, San Francisco), indicate that drinking problems that appear in college and late adolescence — problems up to and including blackout — rarelypersist through middle age. Exactly similar data pertain to youthful drug abuse, and all research shows the tendency to use, to use regularly, and to be addicted to drugs drops off after adolescence and early adulthood. Apparently, as people mature they find they can achieve more meaningful rewards than those offered by drugs and overdrinking. These rewards are generally the conventional ones of family life and accomplishment at work that dominate adult life for most people, even most of those who had a drinking or drug problem earlier on.
Nor are children of alcoholics destined to progress to alcoholism when they drink. A large, long-term study of Tecumseh, Michigan, residents conducted by epidemiologists at the University of Michigan found that children of heavy-drinking parents most frequently choose to drink moderately themselves. Although alcoholics have more alcoholic offspring than average, the researchers noted, “alcoholic parental drinking only weakly invites imitation.” It seems that people are quite capable of learning from observing a parent’s alcoholism to avoid such problems themselves. In doing so, the researchers found, children are helped when the heavy drinker is the parent of the opposite sex. In addition, there was lessimitation in this study of a heavy-drinking parent when the children as adults recalled the parent as having drinking problems. Finally, several studies of children of alcoholics have shown that, even after they themselves develop a drinking problem, they do better in treatment aimed at moderating drinking rather than at abstinence than do other problem drinkers.
Although by far the largest percentage of those who outgrow a drinking or drug problem without treatment are younger, natural recovery in alcoholism and addiction is not limited to the young or to those who fall short of developing severe alcoholism. Those who have progressed to definite alcohol dependence also regularly escape from alcoholism on their own; indeed, natural remission for alcoholics may be more typical than not. In the words of British physician Milton Gross, who has focused on the biological aspects of alcohol dependence:
The foundation is set for the progression of the alcohol dependence syndrome by virtue of its biologically intensifying itself. One would think that, once caught up in the process, the individual could not be extricated. However, and for reasons poorly understood, the reality is otherwise. Many, perhaps most, do free themselves.
A number of studies have now documented that such self-cure among alcoholics is common. These untreated but recovered alcoholics constitute, according to researcher Barry Tuchfeld, a “silent majority.” Based on his research in Australia, psychiatrist Les Drew has described alcoholism as a “self-limiting” disease, one that creates pressures for its own cure even in the absence of outside interventions.” In the words of Harold Mulford, “Contrary to the traditional clinical view of the alcoholism disease process, progress in the alcoholic process is neither inevitable nor irreversible. Eventually, the balance of natural forces shifts to decelerate progress in the alcoholic process and to accelerate the rehabilitation process.”
Alcoholism Isn’t Due to Anything but Alcoholism — Alcoholism as a “Primary Disease”
Members of AA and representatives of the alcoholism movement argue that alcoholism is not the result of other problems that the alcoholic drinks to forget or disguise. Rather, they claim, alcoholism is a self-contained disease that exists independent of other aspects of the alcoholic’s life and personal functioning. In this view, alcoholics have no special difficulties other than those produced by their drinking, and improving their lives in any other way aside from getting them to stop drinking will not affect their disease.
At this point, I introduce the personage of George Vaillant, the psychiatrist and author of The Natural History of Alcoholism, to whom I have already referred. (Vaillant is now at Dartmouth Medical School.) Vaillant is a remarkable figure in the modern history of alcoholism research. He is actually one of the first epidemiologists to investigate the sources of alcoholism from a disease perspective, as opposed to the social perspective used by the Berkeley Alcohol Research Group. Vaillant emphatically endorses the disease model of alcoholism and of medical treatment for it. He sees alcoholism as a primary disease that has “a life of its own and is not a moral or psychological problem.” However, Vaillant’s claims are frequently contradicted by his own data.
For example, while Vaillant repeatedly stresses that alcoholism is an independent disease and not a response to some other set of problems, he reports the following research results from his own and other studies:
The most important single prognostic variable associated with remission among alcoholics who attend alcohol clinics is having something to lose if they continue to abuse alcohol…. Patients cited changed life circumstances rather than clinic intervention as most important to their abstinence…. Improved working and housing conditions made a difference in 40 percent of good outcomes, intrapsychic change in 32 percent, improved marriage in 32 percent, and a single 3-hour session of advice and education about drinking… in 35 percent.46
In other words, people get over alcoholism because of changes in other parts of their lives that make it worthwhile to quit, that counterbalance their urge to drink, or that remove the stresses (such as marital problems) that led them to drink alcoholically. Vaillant urges those who want to help alcoholics to “learn to facilitate natural healing processes” since these processes are the key to alcoholic recovery. Yet Vaillant seeks mainly to warn these helpers “not to interfere with the recovery process,” because his research shows that “it may be easier for improper treatment to retard recovery than for proper treatment to hasten it.” More than anything, Vaillant’s actual findings are that the course of alcoholism depends mainly on how well people can resolve their life problems. (This was the theme of Vaillant’s previous work, Adaptation to Life, written before he got into the alcoholism field.)
Alcoholism, the “Equal-Opportunity” Disease
One of the most popular items produced by the alcoholism movement is a poster entitled “The Typical Alcoholic American.” It depicts a range of people from different ethnic, racial, and social groups, of different ages, and of both sexes. The point of the poster is that anyone from any background may be alcoholic — a point often driven home in educational programs about alcoholism. Strictly speaking, this idea can be true (although there are virtually no cases of adolescents who demonstrate a physical dependence on alcohol). But there are demographic categories that enhance the possibility of becoming alcoholic so significantly that it is hard to imagine that someone experienced with alcoholism would fail to notice these. Indeed, were it possible to isolate a measurable biological factor that distinguished those at risk for alcoholism as well as the drinker’s sex, social class, ethnic background, and disadvantaged minority status, the discoverer of such a mechanism would win the Nobel Prize.
Epidemiologists such as Cahalan and Room have been able to predict extremely well which American men will develop drinking problems based purely on demographic categories: those who live in disadvantaged social settings, blacks and Hispanics, specific religious and ethnic groups, and certain social groups like young working-class men are highly predisposed to problem drinking. Sociologist Andrew Greeley led an investigation at the National Opinion Research Center into “ethnic drinking subcultures” around the country. He found that “there is overwhelming evidence of differences among American ethnic groups and drinking patterns, particularly among Italians, Jews, and Irish.” George Vaillant found that the Irish subjects in his study were seven times as likely to become alcoholic as their Italian neighbors. Moreover, Italians were more likely than others to moderate their drinking — rather than to abstain — after they developed a drinking problem. Vaillant described this Italian-Irish difference as follows: “It is consistent with Irish culture to see the use of alcohol in terms of black or white, good or evil, drunkenness or complete abstinence, while in Italian culture it is the distinction between moderate drinking and drunkenness that is most important.”
Others, like James Milam in Under the Influence, have proposed farfetched racial theories to account for why the Irish, Indians, and other high-alcoholism groups more often become drunkards. Here, of course, the disease theory — developed to remove the stigma from alcoholism — starts sounding a lot more invidious. Are blacks and Hispanics and Indians and Eskimos in the United States really alcoholics more often because of inherited racial differences? Are lower-class or ghettoized or non-college-bound people really in these positions because of genetic differences that make them prone to drunkenness or criminality? Although proponents do not intend harm, such racial interpretations of human differences can be and have been used in prejudicial and very damaging ways.
Along with social and ethnic differences, gender differences in the incidence of alcoholism are monumental. In every type of measure, from drunk driving to treatment referrals to consumption levels, women display from one-third to one-tenth or less the drinking problems of men. No epidemiological research has ever disputed this fact. Yet contemporary alcoholism specialists frequently bemoan the large number of “hidden” women alcoholics who refuse to seek treatment because of the greater stigma attached to female drunkenness. In this view, apparent gender differences in alcoholism rates are the result of women and other groups with a reputation for fewer drinking problems underreporting their drinking problems because they are too ashamed to acknowledge their alcoholism.
Research has established that women with drinking problems are actually more likely to seek treatment than men, just as they seek more psychotherapy of every kind. In addition to the lower alcoholism rates for women in general, research finds that alcoholism occurs for middle-class women even less frequently. Once again, any summary of actual findings of research in an area of alcoholism reveals conclusions exactly the opposite of those presented to the public and maintained as gospel by the alcoholism movement. According to Barbara Lex, of the Harvard Medical School, in her, exhaustive survey of alcoholism in special populations:
The stereotype of the typical “hidden” female alcoholic as a middle-aged suburban housewife does not bear scrutiny. The highest rates of problem drinking are found among younger, lower-class women who are single, divorced, or separated.
Without an awareness of such fundamental ethnic, social, and gender differences, it is hard to imagine how a researcher or clinician can make sense out of the most elementary aspects of alcoholism.
Jews have been the object of a similar campaign to uncover hidden alcoholics, marked by the special shame they carry because they belong to a group that is not supposed to be alcoholic. Programs like the Chemical Dependency division of Jewish Family Services of Cleveland have energetically mounted campaigns “to deal with whole community denial and to emphasize that the disease can strike any member of the community.” In 1980, two sociologists — convinced that the number of Jewish alcoholics was increasing — conducted a survey of Jewish drinking in an upstate New York city. They found no sign that any of their eighty-eight respondents had ever abused alcohol. Following up leads from doctors, alcoholism counselors, and rabbis about Jewish alcoholics, the sociologists never actually located one. Nearly all these informants claimed to know of at most one or two Jewish alcoholics, and one — who reported, “There is an alarming problem with alcoholism in the Jewish community” — claimed that there were five in this city with about ten thousand Jews. In other words, the most dire, unsubstantiated claim was that the Jews in the city had an alcoholism rate of one-twentieth of one percent, or perhaps 0.1 percent of adults.
Interviews by these researchers reveal that Jews have an extreme aversion to problem drinking and problem drinkers. They avoid people who drink too much and/or become obstreperous when they drink, and they make jokes about non-Jews’ excessive drinking, embodied in the phrase “shikker [drunk] as a goy.” What is more, nonOrthodox Jews in this study did not accept the disease theory of alcoholism. (It was actually Orthodox Jews, generally lower in socioeconomic status, who were more willing to believe in this disease.) In the words of the authors, “Reform and nonpracticing Jews define alcoholism in terms of psychological dependence and view suspected alcoholics with condemnation and blame.” If they suddenly were to accept the idea that problem drinking is the result of an unavoidable, inbred biological mechanism, one wonders if they would then begin to show the rates of alcoholism common to other ethnic groups in the United States!
The modern alcoholism movement insists that all people recognize that alcoholism is a disease, and it emphasizes the need for a value-free view of alcoholism. Jews and other groups with extremely low alcoholism rates (like the Chinese) avoid alcohol problems within a very different social context. These cultures divest alcohol of its magical powers and instead incorporate drinking in a low-key way in a family context where the young drink mild alcoholic beverages in the company of parents and older relatives. They disapprove strongly of overdrinking, especially when it leads to inappropriate behavior. There is a strong moralism here, but the moralism is not toward alcohol as evil incarnate; it is toward larger values of community, proper deportment, and self-control. Sociologist Milton Barnett describes the drinking in New York City’s Chinatown:
They drink and become intoxicated, yet for the most part drinking to intoxication is not habitual, dependence on alcohol is uncommon and alcoholism is a rarity. . . . The children drank, and they soon learned a set of attitudes that attended the practice. While drinking was socially sanctioned, becoming drunk was not. The individual who lost control of himself under the influence of liquor was ridiculed and, if he persisted in his defection, ostracized.
Barnett examined the police blotters in the Chinatown police district between the years 1933 and 1949; among 15,515 arrests, not one involved drunkenness.
It’s hard to understand what people mean when they discount cultural differences in alcoholism and insist that those groups with apparently low alcoholism rates are merely disguising their drinking problems out of shame. Sometimes they argue that they know an Italian alcoholic, or that there are French alcoholics in the Paris subways and Jewish alcoholics in Tel Aviv, or that some Jews have joined AA. Yet there is no aspect of drinking and alcoholism more self-evident than that it varies tremendously across groups, particularly ethnic groups. Indeed, Jellinek himself, inThe Disease Concept of Alcoholism, was convinced that cultural differences are fundamental, major, and crucial to the nature of alcoholism.
When one sees a film like Moonstruck, the benign and universal nature of drinking in New York Italian culture is palpable on the screen. If one can’t detect the difference between drinking in this setting, or at Jewish or Chinese weddings, or in Greek taverns, and that in Irish working-class bars, or in Portuguese bars in the worn-out industrial towns of New England, or in run-down shacks where Indians and Eskimos gather to get drunk, or in Southern bars where men down shots and beers — and furthermore, if one can’t connect these different drinking settings, styles, and cultures with the repeatedly measured differences in alcoholism rates among these same groups, then I can only think one is blind to the realities of alcoholism.
The Infallibility of AA and Medical Treatment for Alcoholism
Although alcoholism is billed as an incurable disease, we are told that there is effective medical treatment for it. Private treatment centers claim remarkable remission rates of 70, 80, and 90 percent. Meanwhile, Father Martin, the lecturing alcoholic priest, calls AA a “modern medical miracle,” and one often hears claims that everyone who seriously embarks on an AA program will become sober. Along with television specials about the treatability of alcoholism, we now have a popular feature-length film, Clean and Sober, that trumpets the success and importance — the essentialness — of getting treated for alcohol and drug abuse.
Yet the research on treatment paints a very different picture. It has been remarkably hard to find systematic proof that treatment for alcoholism and other addictions accomplishes anything at all. The discrepancy between grandiose claims by treatment centers and the research results occurs because treatment centers cannot be counted on to do assessments of their programs that truly take into account the number of people who drop out of their programs; whether patients remain sober after leaving the treatment center; how different their patients are from average alcoholics (since well-off, employed, and middle-class patients have a superior prognosis under any circumstances); and how often people cut back or stop drinking on their own even if they don’t enter treatment.
When researchers trace every case that enters treatment (including those who drop out) and compare treated populations with comparable groups of untreated alcoholics, the results often surprise even the treatment advocate. Consider George Vaillant’s reactions to his research results for the patients he treated in Cambridge Hospital with an AA-based program:
It seemed perfectly clear that by meeting the immediate individual needs of the alcoholic. . ., by disregarding “motivation,” by turning to recovering alcoholics rather than to Ph.D.’s for lessons in breaking self-detrimental and more or less involuntary habits, and by inexorably moving patients from dependence upon the general hospital into the treatment system of AA, I was working for the most exciting alcohol program in the world.
But then came the rub. Fueled by our enthusiasm, I. . . tried to prove our efficacy. Our clinic followed up our first 100 detoxification patients. . . every year for the next 8 years. . . . After initial discharge, only 5 patients in the Clinic sample never relapsed to alcoholic drinking, and there is compelling evidence that the results of our treatment mere no better than the natural history of the disease. (emphasis added)
What Vaillant did was to compare his treatment results over eight years with remission rates in “natural history” studies of alcoholics, in which drinking alcoholics were simply followed in their natural settings for a number of years. Certainly, a percentage of Vaillant’s treated patients were not actively alcoholic when followed up eight years later. Only this percentage was not significantly different from that for untreated alcoholics. Remarkably, in this book that is cited as a beacon of defense for the often-assailed efficacy of medical treatment for alcoholism, the author — a research psychiatrist — reveals that alcoholics who are left to their own devices do about as well as did those in his expensive treatment program! Why, we may wonder, did Vaillant begin his book by indicating that “in order to treat alcoholics effectively we need to invoke the model of the medical practitioner”? (We may also wonder if Vaillant is any more skeptical about “turning to recovering alcoholics for lessons in breaking self-detrimental and more or less involuntary habits.”)
Why does everyone believe AA and related treatments for alcoholism are so tremendously successful? The universal praise for AA focuses on its successes and disregards its failures, while we hear little about the successful recovery of those who don’t attend AA. People who overcome drinking problems on their own, despite their numbers, are not an organized and visible group on the American alcoholism landscape. For example, George Vaillant found that many of his alcohol abusers cut back their drinking — nearly all without treatment. But even a solid majority of those among Vaillant’s subjects who quit drinking altogether did not join AA. Yet not one of the successful cases of remission Vaillant highlights in his book involves a person who quit a drinking problem without AA or treatment — Vaillant simply ignores the bulk of his data when it comes to his case studies.
In order to evaluate a treatment’s general effectiveness, research must assign patients randomly to different treatments and/or to a group that receives no treatment (called a control group). Two psychologists, William Miller and Reid Hester, reported every controlled study of alcoholism treatment — that is, studies that employed various treatment and no-treatment comparison groups. These researchers discovered only two controlled studies of AA’s effectiveness. Keith Ditman, a physician and head of the Alcoholism Research Clinic at UCLA in the 1960s, studied outcomes for three groups of alcoholics — those assigned by a court either to AA, to an alcoholism clinic, or to an untreated control group. Forty-four percent of the control group were not rearrested in the follow-up period, compared with only 31 percent of AA clients and 32 percent of clinic clients. In the other controlled study of AA, Jeffrey Brandsma and his colleagues reported in 1980 that those randomly assigned to AA engaged in binge drinking significantly more frequently at three months than those assigned either to the nontreatment control group or to other therapies. (At twelve months they did as well, but no better, than the other groups.)
Nor does comparative research find that group counseling sessions, such as those portrayed in the film Clean and Sober, are better for recovery than doing nothing. Three researchers have evaluated the most popular group technique in alcoholism and addiction treatment, confrontation therapy, in comparison with other group therapies, from transactional analysis to T-groups. Confrontation therapy is based on the Synanon “game,” in which one member of the group at a time is put on the hot seat and has all his or her defenses shot down by other group members. While all the other group therapy techniques in this study came out even in the evaluations, confrontation therapy was found to produce the most significant negative outcomes, requiring psychiatric treatment for some group members
In addition to AA, group, and confrontation therapy, Miller and Hester found that alcoholism education, drug therapy, and individual alcoholism counseling have not shown positive results in controlled studies. However, the standard treatments for alcoholism in the United States consist entirely of these therapies for which Miller and Hester found no evidence of effectiveness! In the researchers’ words, “American treatment of alcoholism follows a standard formula that appears impervious to emerging research evidence, and has not changed significantly for at least two decades.” Miller and Hester’s survey also showed that hospital (or inpatient) treatment is no better than far less expensive outpatient treatment. As a 1987Science article also indicated, a large body of research has established that intensity of treatment has no bearing on results. Instead, the Sciencearticle summarizes, the best predictors of patient outcome are the characteristics of the patient who enters the treatment.”
Miller and Hester did find a number of therapies that have shown better results than chance or natural recovery: therapy that conditions aversive reactions to drinking, behavioral self-control training, marital and family therapy, social skills training, and stress management. A therapy that showed particular effectiveness with a group of hospitalized alcoholics was the community reinforcement approach, which offered training in problem solving and job skills, behavioral family therapy, and social skills training. The community reinforcement approach would seem to address the natural processes that Vaillant found were the keys to remission in alcoholism. Yet the therapies that have been shown to be effective, like the community reinforcement approach, exist only in research studies and are not used as standard treatments practically anywhere in the United States.
In addition to the most effective types of treatment, another question is how we should measure the results of treatment. And the most controversial question of all in the alcoholism field is whether alcoholics can or should drink again, perhaps with the goal of moderating their drinking. In the United States (unlike most other countries), virtually no treatment centers allow nonabstinence alternatives. Nonetheless, all systematic treatment assessments (like Vaillant’s) have found that nearly all alcoholics drink again following treatment and that some can sustain moderate drinking for long periods when they do drink again. At the same time, most alcoholics who drink again return to their previous levels of alcoholism. Is there some way to build upon the group who manages to continue drinking at less severe levels to get more of the alcoholics who perpetually relapse to moderate their drinking?
Dr. Edward Gottheil (who holds both an M.D. and a Ph.D. in psychology) of Jefferson Medical College reported that 33 to 59 percent of patients engaged in some moderate drinking during a two-year follow-up of alcoholism treatment at a VA hospital. Moreover, only 8 percent of this hospitalized group actually abstained throughout the two years. Gottheil commented:
If the definition of successful remission is restricted to abstinence, these treatment centers cannot be considered especially effective and would be difficult to justify from cost-benefit analyses. If the remission criteria are relaxed to include. . . moderate levels of drinking, success rates increase to a more respectable range. . . . [Moreover] when the moderate drinking groups were included in the remission category, remitters did significantly and consistently better than non-remitters at subsequent follow-up assessments.
Although Gottheil’s findings about abstinence following treatment are typical, his conclusions are anything but acceptable in American alcoholism treatment. That is, studies that find hardly any remission due to strict abstinence criteria still refuse to consider the possibility that patients might improve while continuing to drink. One remarkable illustration of this is a highly publicized study by John Helzer, of the Washington University Department of Psychiatry, and his colleagues. The most notorious result of this study, published in the prestigious New England Journal of Medicine and widely quoted in newspapers around the country, is that a minuscule 1.6 percent of the alcoholics treated at a hospital subsequently became moderate drinkers.
In addition to the 1.6 percent of alcoholics who drank moderately and regularly throughout the three years of this study, an additional 4.6 percent of treated alcoholics drank moderately for up to thirty of those thirty-six months and abstained the rest of the time. In other words, these treated alcoholics drank moderately but not in every month of the three years; Helzer et al. therefore did not categorize them as moderate drinkers. Furthermore, the researchers discovered that 12 percent of treated alcoholics reported that they had had more than six drinks three times in one month in the previous three years but had had no drinking problems. The investigators were very careful to scrutinize any claims by patients that they had drunk without problems — the researchers questioned those who knew such patients and checked hospital and police records. Nonetheless, despite the absence of information to contradict these former patients’ claims, the investigators decided that they were denying their continued alcoholic drinking.
Consider the overall results of the Helzer et al. study: 6 percent of treated alcoholics never got drunk but drank lightly over the previous three years; another 12 percent sometimes drank heavily but reported no dependence symptoms and were not discovered to have alcohol problems. Yet the researchers indicated that moderate drinking by former alcoholics was next to impossible to attain. Clearly, one might give these data a different cast. One could say that 18 percent of these hospitalized alcoholism patients drank sometimes but were no longer drinking alcoholically (compared with the 15 percent who abstained). When the notorious Rand Report presented almost exactly the same results in two studies in 1976 and 1980, the National Council on Alcoholism attempted to suppress the report before publication and viciously attacked it in the press after it appeared.
Of course, we need to know what is best for the alcoholic patient in assessing these data. That is, how well did these alcoholic patients do, once these investigators discarded the possibility of moderate-drinking outcomes? The overall prognosis for alcoholics treated in the hospitals Helzer et al. studied was shockingly bad following treatment. Before reciting these statistics, we must keep in mind that not all alcoholic patients in Helzer et al.’s study actually received alcoholism treatment; in fact, only one of four groups did. This group had the lowest remission rate of the four! Twice as many alcoholic patients treated in a medical-surgical ward were in remission from alcoholism when assessed after treatment as those who actually received alcoholism treatment: only 7 percent of those in the alcoholism treatment unit survived and were judged to be in remission from five to eight years after treatment.
Thus, in a study widely taken to legitimize standard alcoholism treatment in America, less than 10 percent of those treated specifically for alcoholism survived and mere not drinking alcoholically five to eight years after receiving treatment. The percentage of alcoholics aided in recovery by the hospital treatment in this study is actually far smaller than those Vaillant found when he examined natural-history studies of alcoholism. In this sense, the parading of minimal moderate-drinking outcomes in a setting where people were discouraged from believing they could moderate their drinking seems almost bizarre, as though the researchers and hospital staff were proud of eliminating one category of remission while finding they could not encourage any other. This is not the stuff of which announcements of great medical breakthroughs of the past were made.
The Catch-22 of Denial
What if you are told you are an alcoholic and that you must abstain for life, and you don’t agree? Then you are, according to treatment wisdom, practicing denial. Many, many people have been told they drink too much or that they are alcoholic. Scott Peck, a psychiatrist and author of the book The Road Not Taken, once remarked in an interview in People magazine that he regularly drank at home in the evening and that as a result he had had to deal with accusations that he was an alcoholic. After careful consideration, Peck rejected this idea. Many people without Peck’s confidence, however, may eventually accept others’ characterizations of their drinking or drug use. If, on the other hand, they continue to disagree with such diagnoses, this denial can then be used as evidence that they are really alcoholic or addicted. Modern treatment philosophy insists that denial is a keystone of alcoholism and must be attacked before recovery can occur.
Yet we have seen that people from different cultural backgrounds and with varied personal experiences may view drinking and alcoholism very differently. The picture of different views of alcoholism does not indicate that those who don’t accept that they have a “disease” should be attacked and converted to a particular treatment’s point of view. Nonetheless, the standard approach in the alcoholism movement is to bombard problem drinkers with the disease message until their previous beliefs are exorcised and, thus purified, they can join the movement. Often this approach backfires, since people tend to reject communications that attack their existing self-conceptions. But if people should refuse or drop out of or fail at treatment, then the supposedly benign model that alcoholism is a disease blames the drinkers for their failures — after all, they were told not to drink.
A group of studies have questioned people about their beliefs about drinking problems for which they are seeking treatment and their goals for treatment. In direct opposition to the denial hypothesis, three research teams in Britain have all found that problem drinkers’ beliefs that they are capable of moderating their drinking and their lack of involvement in previous abstinence training are crucial factors in managing to control their drinking. Those more oriented toward abstinence succeed better at totally abstaining. These British findings held for drinkers no matter how dependent on alcohol they were. In other words, people respond best to treatment that builds on their existing perceptions and experiences. This model applies as well, of course, to the people who are comfortable in AA.
Whether people seek help at all for a drinking problem is another decision steeped in people’s views of themselves and the world. Barry Tuchfeld interviewed former alcoholics who had quit or reduced their drinking on their own. Most had simply refused to seek help from some outside agency like AA or a therapist:
I’d never consider going to a doctor or minister for help. Good Lord, no! That would make me drink twice as much.
The one thing I could never do is go into formal rehab. For me to have to ask somebody else to help with a self-made problem, I’d rather drink myself to death.
I would sit there and listen to their stories. . . and I couldn’t fit myself into their patterns.
Certainly there are people who say they are going to improve on their own and don’t do so. But in the cases Tuchfeld investigated, people found their own routes to recovery and made them work. On the other hand, there are also those in treatment who claim they are trying to abstain or that they are abstaining but who are not. One, cannot compare the imperfections of those rejecting treatment or trying to cut back their drinking with some rose-colored idea that all those who go to treatment are successfully abstaining. As Griffith Edwards, Britain’s leading addiction researcher, asserts: “the numbers of times members have ‘slipped’ since joining AA [the majority of his AA subjects had done so] serves to emphasize that AA is as much a society of alcoholics who are having difficulty in remaining sober as it is one in which they are staying off drink.”
And Researchers Who Deny the “Truths” of Alcoholism Must Be Crazy Too
While problem drinkers may be assailed for denying the “truths” about alcoholism — particularly that they need treatment — researchers in the field who deny these truths can encounter even more trouble. (I think I can speak from personal experience about this.) Psychologists and psychiatrists who have practiced controlled-drinking therapy and sociologists who report moderate drinking by hospital patients who have been told to abstain have had their funding suspended, have been castigated and vilified in the press, and have been accused by treatment spokespeople of causing the deaths of many alcoholics. When a study was published by the Rand Corporation reporting that a strong minority of treated alcoholics return to drinking but reduce or eliminate their drinking problems, one critic reported that he had “learned that some alcoholics have resumed drinking as a result of. . . the Rand study” and that “this could mean death or brain damage for these individuals.” The implication was that perhaps such researchers should be jailed.
Consider, on the other hand, the following description of the Rand results in the 1985 book Alcohol Use and Abuse in America by Jack Mendelson and Nancy Mello:
There have been an increasing number of clinical reports that some former alcoholics can drink socially and function well for periods of two and one-half to eleven years. Many clinicians have reported that alcoholics who drink moderately are better adjusted and have better social functioning than ex-alcoholic abstainers. Despite this gradually accumulating data base, the 1976 publication of. . . the Rand Report was responded to with outrage by many self-appointed spokesmen for the alcoholism treatment community. . . . When this national sample was followed again after four years, there were no significant differences in relapse rates between alcohol abstainers and nonproblem drinkers. . . .
It is of some interest to compare the presumed data base for Jellinek’s original formulation of the notion of “craving” and “loss of control” [with that of the Rand study]. . . . Jellinek was an American pioneer in alcoholism studies. In 1946, Jellinek analyzed responses to a questionnaire circulated by Alcoholics Anonymous and concluded from the 98 responses received that “loss of control means that as soon as a small quantity of alcohol enters the organism. . . the drinker has lost the ability to control the quantity [he will drink].”. . . [In comparison, researchers] at the Rand Corporation chose a representative random sample of 14,000 clients. . . of geographically and demographically diverse patients.
Yet the Rand data are disregarded and Jellinek’s work is gospel in the alcoholism field. Mendelson and Mello are preeminent alcoholism researchers and editors of the most important journal in the alcoholism field (the Journal of Studies on Alcohol). However, few lay people or treatment professionals know of their views. For reasons that may by now be clear, those sympathetic to nondisease viewpoints in the United States present their ideas gingerly. As a result, the dogma that alcoholism is a disease goes unquestioned. George Vaillant, despite his own contrary data, simply quotes another disease-theory spokesperson:
The American Medical Association, American Psychiatric Association, American Public Health Association, American Hospital Association, American Psychological Association, National Association of Social Workers, World Health Organization, and the American College of Physicians have now each and all officially pronounced alcoholism as a disease. The rest of us can do no less.
Where has all this unanimity about alcoholism led us? We certainly don’t seem to be eliminating alcoholism, despite multiplying again and again the money, effort, and people we invest in treatment and education. For one thing, many people refuse or drop out of treatment or relapse (like Joan Kennedy, who is far more typical of outcomes from treatment than Betty Ford). We rarely hear from the many people who fail at conventional treatments. Nor do we hear from those who refuse to enter treatment — except as dreaded examples of the phenomenon of “denial.” We also don’t hear much on public service announcements from those who moderate their drinking or, heaven forbid, their drug use. When Kareem Abdul Jabbar mentioned in his 1983 autobiography, Giant Steps, that he used drugs in college, reviewers were highly critical. But if he had lost control, become addicted, and been suspended from basketball while he entered treatment, he could have become a role model for our children.