I remember the day I chose to identify as an alcoholic. A bunch of us were sitting around the table discussing the qualifications of alcoholism – otherwise known as sharing drunkalogues. The room was filled with sunlight. The dogs were patiently waiting for scraps from our breakfast. I remained quiet. My silence was not because I didn’t have an opinion. My silence was because I identified with the particular stories that classified alcoholic behavior.
I was able to recall my first drink. When I was seven and I got a little sip of wine for Christmas dinner. Drinking young – check. I recalled the binge drinking of my high-school years. Overindulgence – check. I recalled sneaking liquor from my parent’s liquor cabinet. Stealing – check. I remembered the time I went to a party out of town. I woke up the next morning unable to remember the night before. Lack of control – check. I remembered the countless times I drove drunk with the windows rolled down and the music blaring, just so I could stay awake. Drunk driving – check. All of these memories and more came flooding back to me while friends recounted their days of heavy drinking and drug use. It was at that moment that I decided I must be an alcoholic.
I never thought of alcoholism as a disease. I had always thought of it as a moral failing. After all, didn’t I make the choice to drink? This specific argument and the debate over how to classify alcoholism and addiction – as a disease or as a choice – can be traced as far back as the late 18th century (Bride, Nackerud, 127). Personally, I believe that addiction is a combination of both choice and disease.
Let me be clear. I intend to use the term addiction to describe the uncontrollable use of mood altering substances. This includes alcohol and various other drugs, legal or not. The only caveat being, much of the early research revolves around alcohol and alcoholism.
To make an educated decision, we must understand how we culturally relate to addiction and to understand that relationship, we need to look at how it has evolved both scientifically and socially.
In the late 1800s, alcohol and opium were the primary drugs of choice and little medical research was done relating to their effect on the individual. Once morphine was isolated from opium, it was “prescribed commonly as a substitute for ‘alcohol addiction’” (Casey, 3). Only when negative patterns of behavior developed, did doctors, researchers and general science start to take notice.
Embarking on such research began to change the terminology by which addicts were defined, thereby changing the concepts with which they were perceived socially. In their article, Addiction in Europe, 1860s-1960s: Concepts and Responses in Italy, Poland, Austria, and the United Kingdom, authors Berridge, et al. discuss how social concepts change as a result of change in terminology. A compilation of one hundred years of research in each of the respective countries shows how the use of specific terminology shaped both scientific and sociological approaches to addiction.
In Poland, from the mid 19th century to the early 20th century, the use of terminology shifted from “inebriety” and “drunkenness” to “alcoholism”. As the terminology changed, so did perception beginning with the idea that inebriety and drunkenness were the “source of the mental disorder[s]” and concluding that alcoholism was the disorder itself, which “covered all medical and social consequences, including major social conditions such as poverty and crime” (Berridge, et al., 556). This is a prime example of the subtle yet powerful cognitive shift in social perception indicating that how we speak is how we believe.
In the United States, the results were similar and they set the foundation for the disease model of addiction. The early 1900s showed a significant shift in the approach to alcoholism and addiction. Prohibition and the Temperance Movement reached their height in the twenties.
Prohibition was a tumultuous time, not only in relation to historical events but in the minds of the people as well. As a nation we couldn’t quite decide if we wanted to adopt the disease concept or criticize alcoholism as a moral failing – though moral failing seemed to pull ahead in the races for generalized diagnosis. Temperance and its religious tenet seemed to refute and support the disease concept at the same time. It is clear through general research that the use of alcohol and other drugs are considered to be immoral in a broad range of religious beliefs. However, the disease concept allowed the Temperance Movement to plant a seed of fear “claiming that alcohol in any form would lead to habitual drunkenness in anyone who drank” (Bride, Nackerud, 128). Any level headed person could see that fear carried political sway and that adopting the disease model could help their cause. As a result, the Temperance Movement helped to usher in a new concept.
Conversely so, the era of the Temperance Movement and Prohibition saw the first laws passed around the use of alcohol and other drugs (Casey, 5). This brought about the first major criminalization of addiction. Even though the Movement seemed to align with the disease model, turning alcoholics and addicts into criminals alluded to an issue of moral failing rather than disease. Society took its cue from current events and the collective mindset seemed to be focused on addiction as a moral failing.
Policy generally dictates the conviction of the general population and society adopted the idea that addiction was immoral up until the introduction of the Oxford Group, which led, indirectly, to the formation of Alcoholics Anonymous in the late 1930s. As drunkards struggled to get and stay sober, many of them ended up in hospitals and asylums. This gave the medical community the much-needed material for research. In addition to the birth of Alcoholics Anonymous, people like Marty Mann, the first female member of the group, started to speak up about their recovery and the over-critical view of addiction as iniquitous. In her own words, Marty Mann challenged that alcoholics and addicts “should be dealt with like other sick persons, in hospitals and clinics, not in jails” (The Anonymous People). However, society is slow to accept new concepts and it would appear that, while an argument existed against the perception of moral failing, another two decades would pass before the nation would accept anything else. The shift from prohibition to concession took time.
Save for Prohibition, alcoholism and addiction never had much of a sociological focus. However, “through the first half of the 19th century, the disease concept gained acceptance in the medical community” (Bride, Nackerud, 128). The difference in perception between the medical community and society at large created a polarization that can be felt today as the debate over the diagnosis continues.
By the mid-50s, research continued to point toward moral failing and bespoke the ability, of once addicted individuals, to get better and recover without medical intervention. This alluded to the possibility of underlying psychological disorders that, over time, would self-correct. However, inquiry is never finite and though findings suggested full recovery, hypotheses around the disease model grew stronger. The allusion to a psychological aspect seemed to draw the two opposing theories together and became an altogether different thread of scrutiny. In 1952 the first publication of the Diagnostic and Statistical Manual of Mental Disorders was published (Fitzgerald, Morgan, 605). Four years later, alcoholism would be recognized as a disease.
Over the next thirty years, the social mindset would shift again. During the 1960s and 1970s, we move from criticism to social embrace of alcohol and other drugs. This ushered in the era of free love. Once the eighties rolled around, it seemed like we were back at the place of moral failure. President Ronald Reagan’s War on Drugs criminalized the use of heroin, cocaine and marijuana and addicts were once again stigmatized and blamed for their affliction. No longer did society view users as sick or powerless, they viewed them as criminals.
While the general community was still clinging to the ideas of addiction as an unscrupulous choice, the medical community began to embrace the disease concept. In 2012, Ryan E. Lawrence MD, Kenneth A. Rasinski PhD, John D. Yoon MD, and Farr A. Curlin MD conducted a study entitled, Physicians’ Beliefs About the Nature of Addiction: A Survey of Primary Care Physicians and Psychiatrists. The study concluded that, “more than half of PCPs (56%) and psychiatrists (64%) attribute ‘a lot’ of addiction to disease” (259).
However, the debate continues. The idea that alcoholics and addicts can get well continues to drive the choice theory. Recently, two doctors have come to the foreground to dispute the disease model. One such argument comes from Gene Heyman, PhD. In his article, Addiction and Choice: Theory and New Data, Heyman summarizes that the compulsive tendencies surrounding addiction are patterns of behavior, rather than indication of disease (1). Though he doesn’t confound the disease model completely, he adds a tone of reasonable doubt to the current accepted model. Neuroscientist and Ph.D, Mark Lewis, bolsters this concept as well. In his book, The Biology of Desire, he states, “addiction results rather from the motivated repetition of the same thoughts and behaviors until they become habitual”(Lewis, x). Repetition of harmful behavior is indicative of a psychopathological issue and as such would be considered a disorder, not a disease. This again compels the reader to question the disease model in favor of a psychological approach to a disorder.
There are those too, who seek to distinguish differences between physical and behavioral addiction “otherwise known as process addictions” (Najavits, et al., 479). Much of the past and current research, in support of the disease model, seeks to address three different aspects; physical changes in the brain that produces dependence, genealogical pre-disposition and psychological co-morbidity. The pathology surrounding addiction has been argued and debated for over a century and there is a passion that exists behind every argument. Today society is beginning to embrace the concept that alcoholics and addicts aren’t bad people. This has come primarily from the destigmatization brought about by the disease model. The cultural perception has shifted to parallel views around people with diseases like cancer or heart disease, as well as psychological diseases like bi-polar disorder. De-stigmatization has been one of the most effective tools of recovery. Yet, we still debate over the topic.
Great strides have been made in medical research and they have spilled over into the political arena. In October 2015 the first rally for recovery was held at the National Mall in Washington, D.C. Though the rally was relatively small (4000 people), it was a clear example of a cultural shift. Prior to the rally, addiction was spoken behind the closed doors of doctor’s offices, jails, treatment centers, anonymous groups and households. The negative aspects of addiction were sensationalized and used as entertainment fodder by the media. However, the rally called forth the voices of recovering addicts from across the nation and for the first time in history, a group of people were recognized and heard.
Instead of looking at specific research articles, it might be helpful to pull back to gain a better perspective. As we view history of medical and cultural relation to alcoholism and addiction, it is possible to see that the argument may no longer be a case of either disease or moral failure. It would seem that, as a culture, we get caught up in minutiae. Rather than picking apart the details of how different parts of the brain are affected by heroin, maybe we should be looking at how the entire organism is affected. As history reveals addiction may no longer be a case of either/or. It may just be a case of both/and.
At the age of nineteen, I halfheartedly identified as an alcoholic but I really didn’t know what that term meant. Today, I identify as a person in long-term recovery. This phrase encompasses substance abuse and behavioral disorders but it does so in such a way that does not attach a specific stigma. I am sure I have a genetic pre-disposition. I am sure that I made a choice at one point that triggered a genetic response. I am sure that, over the course of my life, habitual behaviors progressed to neurochemical dependence. I am sure that I continue to have cravings. And, I am sure that addiction contains the elements of both disease and choice.
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