Why is the disease model of alcoholism/addiction controversial?

Why is the disease model of alcoholism/addiction controversial?

 

BACKGROUND

            The disease model of alcoholism has a history dating back more than two hundred years, and is considered by many to be the dominant paradigm guiding scientific inquiry and treatment approaches for much of the 20th century ( 2002). An early proponent was the physician Benjamin Rush in 1795. The concept gained popularity through its promotion by Alcoholics Anonymous (A.A.) founded in 1935. It received additional popularity following a 1946 study  ( 1995).

            The disease model of alcohol dependence, or “alcoholism”, remains the dominant conceptual model or paradigm of both alcohol and drug treatment, especially in the USA. However, this situation is changing in response to empirical evidence, managed care cost containment policies and greater pressures to demonstrate treatment efficacy and effectiveness (2004).

As articulated by Jellinek, the new paradigm of alcoholism posited a sharp distinction between “normal” drinkers and “alcoholics,” whose addiction was evinced by an intense craving for drink and a complete loss of control over drinking. Alcohol, that is, was seen to be addictive only for a certain group: those who developed an increased tolerance, who experienced withdrawal symptoms if they tried to quit drinking, and who exhibited bodily deterioration as a result of heavy and habitual consumption. The “disease” of alcoholism was thought to be progressive (it moved from psychological to physiological dependence) and irreversible (the alcoholic could never safely return to normal drinking). The only effective treatment, according to the Alcoholism Movement, was lifelong abstinence (1994).

            This disease concept has continued to compete with moralistic characterizations that maintain that chronic drunkenness is sinful and can only be corrected by the individual through an act of personal willpower (1998). The disease model of alcoholism views craving as a result of acute withdrawal or an internal physiological need for alcohol (2004).

            An important motive in promoting the idea of alcoholism as a disease was to decriminalize alcoholic behavior and increase the probability that alcohol abusers would seek help. Alcoholics would be seen as victims of a disease rather than individuals with a bad habit, weak willpower, or a moral failing. Another motive was to make treatment eligible for financial support through medical insurance. Society is generally willing to help people with a disease (which is “not their fault”), whereas those with a bad habit, weak will, or a moral failing are expected to accept responsibility for their behavior and to fend for themselves (1995).

            Today, a treatment industry based on the disease theory generates more than billion a year in revenues, and both supports and serves hundreds of thousands of individuals who have an emotional commitment (in the case of alcoholics) or an economic commitment (on the part of treatment providers) to the medical model of alcoholism (1995).

 

MAIN SUPPORT FOR THE DISEASE MODEL

            Jellinek is generally credited with the development of a disease model of alcoholism that was sufficiently rigorous to stimulate intensive scientific work based on the model, and many researchers have carefully investigated his various hypotheses and made necessary refinements to the disease concept of alcoholism. Much of the work in alcohol studies over the past 35 years has been specifically addressed to whether or not alcoholism can be considered a disease (1998).

            Jellinek, in summarizing his own research, indicated that the three most commonly occurring behaviors that characterized “alcohol addiction” are blackouts, loss of control, and benders. Blackouts are given additional importance because in the “great majority” of “alcohol addicts,” they mark the initial phase, occurring prior to loss of control and benders by many months or years.

            Jellinek’s model has made important contributions both in terms of its acceptance and influence in the literature and its acceptance by practitioners working with individuals who have drinking problems. “Virtually every book or pamphlet, lay or professional, published in the last 25 years on the manifestations of alcoholism has presented the Jellinekian phases as unchallenged fact”. Some authors like Pattison, Lender, Pokorny and Kanas view Jellinek’s phase model and disease definitions of alcoholism as the most profound influence on the alcoholism field to date. Another author regards the phase model as “the most comprehensive and clear-cut ordering of characteristic experiences of alcoholics” (1986).

 

STRENGTHS OF THE MODEL

            Clearly, a strictly medical model is not sufficient to explain the multivariate, behavioral manifestations of alcoholism. Some of the appeal of the disease model is that it accommodates well the observations that drug abuse is not normal that it is a special type of behavior that does not seem to follow normal rules. Because it is a disease state, the usual rules that govern behavior do not apply to the behavior of addicts, at least as far as their use of drugs is concerned.

            The disease model also fits well with the observation that some people become addicted and others do not in the same way that a disease may strike only some. Thinking about drug abuse as a disease also has profound implications for therapy. At the heart of the issue is whether the addict really has any control over drug taking. If the abuse of drugs can be considered a sickness rather than an immoral or criminal activity, it is therefore beyond the control of the abuser, who then requires treatment rather than punishment.

Furthermore, there are numerous examples that show “how the beliefs of people about alcohol and alcohol consumers influence the assumptions about etiology.” Most studies now recognize the “bio-psycho-social” complexity of alcoholism, and although the disease concept that Jellinek described has been amended, it is still one of the most important considerations in any discussion of alcoholism. His ideas that alcoholism was characterized by a loss of control, and a progressive nature have been refined, but they are still regarded as essentially productive ( 1998).

 

ALCOHOLICS ANONYMOUS AND THE DISEASE MODEL

            Alcoholics Anonymous (A.A.) has been in existence since the 1960s, it is an institution that deals with education, prevention and treatment of alcohol and drug abuse. Jellinek’s phase model of alcoholism and the A.A. model of alcoholism are one and the same and that they are constructions or reifications of A.A. values ( 1986).

            Jellinek’s model of alcoholism “has been the standard textbook description of the alcoholism process. It has essentially gone unchallenged until recently”. Jellinek’s model and his other writings on alcoholism, specifically The Disease Concept of Alcoholism, have highly influenced most conceptualizations of alcoholism and its treatment within the past several decades. The phase model reflects Jellinek’s assessment and interpretation of data collected by the Grapevine, the official organ of A.A. The initial study was based on ninety-eight usable questionnaires from a “sample” of more than sixteen hundred A.A. members (1986).

            The phase model characterizes the “alcoholic” as generally passing through four phases. These include the prealcoholic symptomatic phase, the prodromal phase, the crucial phase, and the chronic phase. Within these four phases, Jellinek described a list of forty three behaviors that occur in a somewhat determinant sequence.

            Members of A.A. believe alcoholism to be a progressive and eventually fatal disease that follows a progressive series of stages that lead to institutionalization in a mental hospital, jail, or death. While cultural variations (as well as the assumption that “alcoholism” is a social construction that emerged during a specific historical period) should be acknowledged, it should also be pointed out that the “disease” model of AA has been applied cross-culturally. One might argue that the “disease” model must have some material validity for so many members in so many different cultures to find it descriptive of their own experiences (2000).

 

CRITICISMS TO THE DISEASE MODEL

Although most alcoholism counselors argue that it is a disease, alcoholism is clearly unlike other known diseases. There is no alcoholism virus, fungus, or germ. It is not caused by parasites. It is not caused by any physical accident or injury. Even those who support the theory cannot explain what causes the alleged disease, how it operates, or where it is located in the body (1995).

            As early as the 1960s, the disease model came under attack due to the emergence of unusual scientific and clinical findings. Outside of the United States, the disease model is considered by many to have been discredited, and has long been abandoned in favor of alternative models ( 2002).

            Several studies disputed the position by Jellinek that blackouts are the major symptom of alcoholism. Of the one hundred hospitalized “alcoholics” in their research, one third never experienced a blackout. Additionally, among those who reported blackouts, these generally occurred “well along in the course of alcoholism rather than at an early stage”, and they occurred after heavy drinking–”frequently after several days.” Other aspects criticized involve the ambiguous nature of the research questioning concerning blackouts as well as the occurrence of benders, tremulousness, and severe repercussions from drinking prior to the occurrence of blackouts (1986).

If alcohol abuse isn’t a disease, what is it? According to them, it is a habit, a learned behavior that is frequently repeated. In psychological terms it is a pattern of excessive alcohol consumption which produces maladaptive behavioral changes in which drinking can become the central activity in an individual’s life, usually after many years of heavy consumption ( 1996).

            According to the criticisms, perhaps the most persistent anomaly of the disease paradigm is the repeated finding, in violation of the entrenched expectations of irreversibility and loss of control, that persons diagnosed as alcoholic can sometimes return to normal, controlled patterns of drinking ( 2002).

            Other authors, while still somewhat supportive, have questioned various aspects of the Jellinekian model. Some authors view  A.A., and the National Council of Alcoholism (NCA) as cornerstones of a traditional model of alcoholism that is factually inaccurate but ideologically powerful.

Noticeably more critical is the following attack by  “Despite  regard for the right of the individual drinker, his conceptions appear to have been subtly influenced by the Protestant ethic. His phases of alcohol addiction, with its orderly–and, inferentially, irreversible–progression of malign symptoms, through the prealcoholic phase, the prodromal phase, the crucial phase, and finally the chronic stage is of a piece with Hogarth’s famous illustration of a drunkard’s progress on the downward path to perdition. While Jellinek does not say that the phases of alcohol addiction always occur in the same order, his vivid descriptions of the progress of alcoholism are so well attuned to the values of the middle-class Western physician and welfare worker that his cautions are largely overlooked by those who apply his conceptions and by the many writers who repeat his early concepts.”

            Much of the speculation that alcoholism could be explained by biochemical disorders involving hypoglycemia, vitamin deficiencies, metabolic pathways, or an allergy to alcohol were quickly put to rest. Nor, despite intensive efforts, has any single allele been discovered as an alcoholism gene. Numerous studies strongly support the hypothesis that some individuals are genetically predisposed to alcoholism, but these studies can only account for a small proportion of alcoholism in the general population (1998).

Such evidence does not address many etiological questions regarding the disease concept of alcoholism. Naturally, the excessive use of alcohol can cause a broad range of diseases, but heavy drinking results from learning rather than from disease. People must voluntarily consume alcohol before they can abuse it and have drinking problems. These and other obvious inadequacies of the disease model have led increasingly in recent years to statements that the “disease” of alcoholism is a myth (1995).

 

STANTON PEELE’S VIEWS ON DISEASE MODEL

            Dr. Stanton Peele, author of The Truth About Addiction and Recovery and a leading expert in the field of addiction, agrees that “Every major tenet of the `disease’ view of addiction is refuted by both research and everyday observation” (1996). “There’s no such thing as a genetic cause of alcoholism,” announces Stanton Peele said. “The best predictors of alcoholism are all psychosocial factors–who you hang out with, whether you have a job. The whole genetic argument is misguided and unjustified.” According to Peele, the genetic-based argument makes people victims and gives them an excuse for self-destructive behavior. He believes that moderating drinking is the wave of the future for treatment (1997).

Peele 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.

 

CONCLUSION AND SUMMARIZATION

            The disease model of Jellenik views the problem of alcoholism as a disease with aberrant behaviors and physical symptoms. The basis for his conclusions about the disease model is his researches. In the disease model, the alcoholic is not seen as morally weak but rather viewed as sick and the victim of a disease – that of alcoholism.

The disease model has its share of supports and strengths. There are some problems with the disease model though. The disease model of alcoholism is controversial and not without critics. Many authors dispute the disease model of alcoholism. One of the most well-known author who disputed the disease model is Peele. The main reason for the controversy is that the nature of the disease has never been identified. There have been a number of attempts to explain the use and abuse of specific drugs in terms of a disease process but such attempts have been limited to a specific drug only and have never been thoroughly convincing that alcoholism in itself is a disease.

 

 

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