Journal of Psychoactive Drugs
ISSN: 0279-1072 (Print) 2159-9777 (Online) Journal homepage: http://www.tandfonline.com/loi/ujpd20
The Disease Controversy and Psychotherapy with Alcoholics Michael S. Levy To cite this article: Michael S. Levy (1992) The Disease Controversy and Psychotherapy with Alcoholics, Journal of Psychoactive Drugs, 24:3, 251-256, DOI: 10.1080/02791072.1992.10471645 To link to this article: http://dx.doi.org/10.1080/02791072.1992.10471645
Published online: 20 Jan 2012.
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MichaelS . Levy, Ph.D.* Abstract- This article discusses conducting psychotherapy with alcoholics in light of the controversy about whether alcoholism is a disease. The belief that alcoholism is a disease forces many clinicians to offer abstinence from alcohol as the only option for alcoholics who seek treatment. From this perspective, the alcoholic must be helped to accept the idea that he or she has a disease and that to recover from this problem, drinking must stop. Others maintain that alcoholism may not be a disease and view alcoholic drinking as maladaptive behavior. From this vantage point, helping the patient to control or to moderate drinking might be considered. These two distinct paradigms lead to divergent treatment goals, which leaves the clinician in a quandary about how best to treat an individual who experiences a drinking problem. To resolve this dilemma, it is suggested that the clinician who works with alcoholics entertain a multiplicity of perspectives and should not be blinded by any one paradigm. While control of alcohol intake must take place if such patients are to improve their functioning, the author argues that recovery can occur either by abstinence or through moderating drinking. Keywords- alcoholism, disease controversy, moderating drinking, psychotherapy, recovery
While the idea that alcoholism is a disease currently dominates thinking in the field of alcoholism treatment (American Society of Addiction Medicine 1990; Gallant 1987; Nace 1987; Talbott 1986; Vaillant 1983), there remains considerable dissension (Peele 1989; Fingarette 1988; Szasz 1987, 1985; Shaffer 1985). In fact, the general concept of disease is difficult to define (Campbell, Scadding, & Roberts 1979), and people hold different opinions concerning what is or is not a disease. Whether or not one views alcoholism as a disease or as a problem in living is not merely a matter of semantics. Conceptualizing alcoholism as a disease has shifted the focus on alcoholism from a moral and legal problem to a medical problem (Nace 1987). Many organizations, such as hospitals and alcoholism treatment centers, have a vested interest in maintaining that alcoholism is a disease because funding may depend on whether or not alcoholism can be substantiated as a medical condition. While there are some ethical, social, and political reasons to maintain that alcoholism is a disease, it must not be forgotten that conceptualizing alcoholism as a disease has immense treatment implications. For example, any
treatment goal short of complete abstinence will not be considered if one subscribes to the view that alcoholism is a disease (Smith, Milkman & Sunderwirth 1985). Alcoholism is seen as an illness with a predictable, progressive, chronic course if individuals afflicted by this illness continue to drink. In fact, if a patient requests to attempt controlled drinking, this will typically be viewed as a manifestation of denial. As Tiebout ( 1951 :56) stated 30 years ago: "The alcoholic must be brought to accept that he is a victim of a disease and that the only way for him to remain healthy is to refrain from taking the first drink; that if he attempts to drink moderately, though he may succeed for a time, sooner or later the disease will be rekindled and he will be in trouble again. The job of the therapist is to recognize this inevitable recurrence and to aid his patient in accepting that fact." This statement is still true today for any practitioner who adheres to the paradigm that alcoholism is a disease. However, if one maintains that alcoholic drinking is learned maladaptive behavior, then helping patients to control or moderate their drinking may be considered. More attention might then be placed on psychological and socicr cultural variables playing a role in the drinking problem. The controversy concerning whether or not alcoholism is a disease leaves the clinician in a state of ambiguity about how best to treat an individual experiencing a problem with alcohol consumption.
•Clinical Instructor in Psychology, Harvard Medical School. Please address reprints requests to MichaelS. Levy, Ph.D., 2 Elm Square, Musgrove Building, Andover, Massachusetts 01810. Journal of Psychoactive Drugs
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Levy
Th e Disease C ontrove r sy and Psychotherapy
This article will first discuss the disease concept of alcoholism and demonstrate how and why this model clearly defines the treatment goal of abstinence from alcohol for this disorder. Then the thinking and research that questions the idea that alcoholism is a disease and implies that perhaps some alcoholics can learn to moderate their drinking will be examined. Subsequently, it will be shown how both perspectives, despite their theoretical divergence, can be incorporated into a single, patient-centered therapeutic approach.
a nd the substance is used compulsively. Jellinek (1952:679-680) differentiated "alcohol addicts" from "habitual symptomatic excessive drinkers," the former being afflicted with the disease . The " loss of control" phenomenon occurs only in the former group and is a "conversion phenomenon" where "any drinking of alcohol starts a chain reaction which is felt by the drinker as a physical demand for alcohol." This process makes it " impossible for him to control his alcohol intake." Consequently, the treatment goal is to help alcohol addicts admit that they have lost their willpower to control their drinking and to accept this truth. Talbou (1986) also noted that the difference between the controlled, abusive drinker and the uncontrolled addictive drinker must be appreciated. In fact, the idea that alcoholics cannot control their drinking and that this is beyond the power of the will is what makes alcoholism a disease as opposed to a bad habit. In 1829, Beman wrote that "drunkenness is itself a disease .. . when the taste is formed, and the habit is established, no man is his own master." In 1883, an anonymou s Connecticut minister wrote that drunkards are unable to control their drinking: "The whole question pivots, thus, on the power or powerlessness of the will in the confirmed drunkard to resist his propensity to drink." He further noted that "the essence of disease is involuntariness" and that drunkards are "physically helpless to refrain from drink ." Somewhat more recently, Keller (1972: 162) discussed the phenomenon of loss of control: "Therefore one can say that the essential loss of control is that an alcoholic cannot consistently choose whether he shall drink or not. There comes an occasion when he is powerless, when he cannot help drinking. For that is the essence or nature of a drug addiction." The American Society of Addiction Medicine (ASAM) (1990:9) recently developed a new definition of alcoholism and stated that it is a disease, which meant an "involuntary disability." ASAM noted that alcoholism is marked by impaired control over drinking, which was defined as "the 'inability' to limit alcohol use or to consistently limit on any drinking occasion the duration of the episode, the quantity consumed, and/or the behavioral consequences of drinking. " Thus, what appears evident is that if one has the disease of alcoholism, then that person's ability to drink without difficulty is lost. The disease of alcoholism makes one unable to drink responsibly. Clearly, alcoholics are not the masters of themselves when it concerns drinking. With certain biological underpinnings that interact with psychological and sociological variables, the habitual use of alcohol over which one has control can coalesce into a disease, at which time the alcoholic can no longer exercise control over drinking. Once individuals have the disease, their ability to drink responsibly is beyond the power of the will. Alcoholics must learn that they cannot drink and the goal of treatment must be abstinence.
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ALCOHOLISM IS A DISEASE The definition of alcoholism as a disease states that "alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations" (American Society of Addiction Medicine 1990:9). In this view, while psychological, sociological, religious or health variables play a role in drinking, without the biological vulnerability, the disease will never develop. As Talbott (1986:493) stated: 'To manifest itself, the disease must have the genetic predisposition accompanied by abuse, as abuse itself will not produce the disease. There are millions of people in this country who have the genetic predisposition, but who for cultural , health, personal, or religious reasons will not abuse, so they never manifest the disease." Some support for the idea that alcoholism is, at least in part, an inherited or biologically based disorder comes from a study by Goodwin ( 1979), who found that sons of alcoholic parents adopted at birth and rai sed in nonalcoholic families had four times the incidence of alcoholism as compared to children of nonalcoholic parents adopted at birth and raised by alcoholic parents. Schuckit, Goodwin and Winokur ( 1972) observed that children with a biologic alcoholic parent who were raised by parents who were not alcoholic had an incidence of alcohol abuse three times higher than children with nonalcoholic parents who were raised by an alcoholic step-parent. Vaillant (1983) looked at individuals prospectively and found that the single best predictor of alcoholism was a positive family history of alcoholism. Schuckit (1980) studied sons of alcoholics who drank but who had not yet developed significant problems related to alcohol or other drug use and compared them to individuals with a negative family history of alcoholism. After both groups drank .75 ml/kg of alcohol, he found that the sons of alcoholics reported that they felt less intoxicated than did the sons of nonalcoholics. It has also been demonstrated that sons of alcoholics experience less body sway after alcohol is consumed than do sons without a positive famil y history of alcoholism (Schuckit 1985). A centra l, if not the key, component of the illness is the diseased individual's total inability to control his or her drinking. Alcohol use continues in uncontrolled ways Journal of Psychoactive Drugs
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ALCOHOLISM IS NOT A DISEASE
Though the task was boring, all subjects could eat, watch television or socialize at the same time. Subjects participated for one or two months and results did not confirm the loss-of-control phenomenon. None of the subjects drank themselves into a state of unconsciousness or collapse and all subjects did demonstrate some control over drinking. In another experiment, Cohen and colleagues ( 1971) allowed alcoholics access to up to a flfth of liquor. However, all subjects were told that if they drank more than five ounces, they would have to leave the pleasant social situation they were in. Results showed that most of the time, subjects limited themselves to moderate drinking. These studies in the laboratory and those experiments studying alcoholics in natural settings cause one toquestion the universality of the loss-of-control phenomenon and the idea that one drink will inevitably lead to a fullblown relapse. Some additional opposition to the disease concept paradigm focuses on how this model may cause some individuals to reject treatment Fingarette (1988) noted that some individuals cannot accept the idea that they are "diseased" or are "alcoholic" and thus are turned away from treatment, never receiving the help they need. Shaffer (1985) has reported that labelling someone alcoholic may be stigmatizing and can make the individual feel abnormal or defective. Fingareue (1988) wrote that people who struggle with an alcohol abuse problem will never even try to control their drinking because they believe this is impossible, owing to the promulgation of the disease concept with its implication that limiting drinking is a hopeless endeavor. He also noted that many alcoholics will never enter treatment because the idea of giving up drinking entirely is too overwhelming to consider. In summary, there is considerable evidence to suggest that alcoholism may not be a disease. The notion that alcoholics cannot succeed in moderating their drinking is called into question, and thus, the treatment goal of abstinence for all alcoholics is challenged. Apart from the appropriate treatment goal, criticism is also directed toward the idea that people experiencing an alcohol problem must be told that they have a disease called alcoholism and that they must learn to accept this fact.
Others maintain that alcoholism is not a disease; they tend to see problem drinking as a problem in living or as a learned habit. There are many different models to understand and address drinking problems, including psychological, conditioning, sociocultural, social learning, and general systems, to name a few (Miller & Hester 1989). However, a critical distinction between the disease concept paradigm and those models that do not maintain that alcoholism is a disease concerns the loss-of-control phenomenon. Essentially, the nondisease perspectives do not rest absolutely on the notion that once control of alcohol consumption is lost it can never be regained. These models question the idea that all people experiencing a problem with alcohol consumption must become abstinent for a recovery to occur. Support for the idea that some alcoholics can learn to control their drinking comes from a study by Lovibond and Caddy (1970). Using a variety of techniques in a controlled-drinking program, these researchers found that21 out of 28 alcoholics were able to drink in a conlrolled manner at follow-up. Armor, Polich and Stambul (1978, 1976) studied male alcoholics who had been treated in abstinence-oriented programs across 45 alcoholism treatment centers in the United States. An 18-month follow-up of these patients showed that not all of the improved patients were totally abstinent at follow-up . The authors summarized their findings (1978:294) as follows: "mhe majority of improved clients are either drinking moderate amounts of alcohol-but at levels far below what could be described as alcoholic drinking ... this finding suggests the possibility that for some alcoholics moderate drinking is not necessarily a prelude to full relapse and that some alcoholics can return to moderate drinking with no greater chance of relapse than if they abstained." Many other studies have also documented that some alcoholics can return to asymptomatic drinking (Nordstrom & Berglund 1987; Vaillant 1983; Sobell & Sobell 1976; Cahalan 1970; Bailey & Stewart 1967; Kendell1965 ). In a review of22 studies designed to help problem drinkers control their drinking, Miller and Hester ( 1980) found that only one study failed to support this approach. In the other 21 studies, success rates ranged from 25% to 90%, with an average success rate of65% for those studies that followed subjects for 12 months or longer. Experimentation with alcoholics has also been undertaken in the laboratory and many results force one toquestion the absolute validity of the loss-of-control phenomenon. Mello and Mendelson (1972) had alcoholics press a button according to instructions that would earn them credit toward measured amounts of alcohol. Subjects could earn an ounce of bourbon every five to fifteen minutes depending on their speed in pressing the button. JourNJI of Psychoactivl! Drugs
A CLINICAL PERSPECTIVE The clinician working with individuals experiencing a problem with alcohol is left in a difficult position. On the one hand, considerable research points to the idea that alcoholism is a disease and that alcoholics are genetically different from nonalcoholics. As a result of a biological difference that interacts with psychological and sociological factors, alcoholics or future alcoholics have a reaction to alcohol that makes it impossible for them to drink without difficulty. From this vantage point, alcoholics need to accept their condition, their denial must be broached, and 253
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they must be helped to achieve abstinence. There is also significant sociopolitical pressure to view alcoholism as a disease. As Gitlow (1973:8) has documented,"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." On the other hand, as discussed in the previous section, there is considerable research that causes one toquestion the disease model of alcoholism with its explicit assumption that all alcoholics must achieve abstinence for recovery to occur. In addition, it is argued that it may 'b e anti therapeutic or counterproductive to force an alcohol abuser to accept the diagnosis of alcoholism and the related treatment goal of abstinence. From this perspective, perhaps treatment can work toward helping such patients to control their drinking. In light of this controversy, which results in very different treatment strategies, the clinician is left in a quandary about how best to treat an individual experiencing a drinking problem. The solution is quite simple: the clinician who works with alcohol abusers needs to entertain a multiplicity of perspectives when conducting clinical work with such patients. Whether the patient recovers through abstinence or by moderating alcohol intake is not important; what is important is that the clinician directly focus on the alcohol use and make appropriate adjustment of alcohol consumption a treatment priority. A commonality between the disease and nondisease perspectives is that the alcoholic is not in control of his or her life as a result of alcohol consumption. Both models realize that the patient's relationship to alcohol must be changed if the patient is going to improve. Thus, the explicit and direct goal must be to help such individuals with their alcohol problem either by enabling them to become abstinent or by helping them to control their drinking. While clinicians must be cognizant of the various theories of and treatment strategies for alcoholism, when they are in the office with patients, they must not allow themselves to be blinded by or solely guided by any one theoretical or treatment model. Rather, clinicians should remain attuned to their patients and help them with their alcohol problem in a way that works best for the patient. Patients do not need to fit into one or another theoretical model, which, in any case, should only guide and not dictate. Thus, the first step in treating the presenting symptom of alcohol abuse should be to explore with the patient how he or she understands the problem. Initially, resonating with patients' own understanding of their problems is essential to the task of engaging them in the therapeutic work that lies ahead. As therapy progresses, their perception of their problems may change and this shift should elicit a Journal of Psychoa ctive Drugs
modification in the therapist's orientation. If someone believes that he or she has the disease called alcoholism, this assessment should be accepted and the patient should be helped to achieve abstinence. Clinicians can also share with patients what they know about alcohol problems. In fact, it can frequently be useful to educate someone about the disease concept of alcoholism and to help him or her to accept it and strive for abstinence. Many patients respond to the idea that they have a disease because it can alleviate guilt and it provides an unambiguous path torecovery (Shaffer 1985). However, clinicians must also be sensitive to the inability of some patients to acknowledge that they have a disease, and the concept should not be forced on them. However, these patients may still be interested in becoming abstinent even though they prefer to view their drinking problem as a bad habit or as a problem in living (Levy 1990). Educating patients about alcohol problems might also include information about controlled drinking and the fact that some alcoholics seem to be able to achieve and maintain such control. While one can never know for certain whether any particular patient will be able to successfully accomplish this task, there is some research to serve as a guide. Vaillant (1983) found that young problem drinkers are frequently able to change their alcohol abuse problem if their peer group is altered before physical dependence develops. An absence of sociopathy and high social stability may also bear a relation to a return to moderate drinking. Sobell and Sobell ( 1982) reviewed the controlled drinking literature and found that overall, individuals with less severe alcohol problems on entry into treatment are the individuals most likely to be able to control their drinking. Individuals who are older and who demonstrate the alcohol withdrawal syndrome on cessation or reduction of alcohol intake are usually less able to succeed at moderating their drinking (Polich, Armor & Braiker 1981). Consequently, if a patient wants to attempt to control drinking, this alternative should not be ruled out automatically. In fact, a controlled drinking contract can be developed and monitored with the patient. Even if, based on history, success at controlled drinking appears unlikely, it can still be productive to formulate a therapeutic contract with this goal as the objective if the patient insists. While one cannot know for certain whether a particular patient will be able to moderate his or her drinking, it can be crucial to give the patient the opportunity to try to control drinking. Individuals experiencing a problem with alcohol consumption typically need to discover for themselves whether or not controlled drinking is possible. Khantzian (1980) has noted that giving patients control over their drinking can help to avoid power struggles and can aid in fostering a good working alliance. He also discovered that many patients choose abstinence as the best means of control after repeated unsuccessful efforts to control alcohol consumption. Certainly if controlled drinking proves im254
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suits a particular patient should be chosen. While this approach may seem antitheoretical to some, it is in fact guided by a theory which holds that alcohol problems are multidimensional in terms of etiology and manifestation. Based on each individual's unique biological vulnerability, psychological structure, value system, and sociocultural environment, an alcohol problem can come to be exhibited in a specific way and understood by the individual in a particular manner. In tum, the clinician should take this information into account when a patient is assessed and an individualized treaunent plan needs to be developed. The controversy about whether or not alcoholism is a disease does not necessarily need to be resolved. Patients will let clinicians know whether or not they have the disease called alcoholism, whether or not they need to become abstinent for a recovery to occur, and whether or not controlled drinking is a viable option for them. Perhaps clinicians should be guided more by their patients than by any one unidimensional addiction theory.
possible with any patient, then abstinence will need to be considered. Gambino and Shaffer (1979) and Shaffer (1986) have noted that the addictions field is in a preparadigmatic state, with no particular paradigm as yet having ultimate authority. It is very tempting, however, to work out of one theoretical model, and many clinicians act as if it is a scientific fact that alcoholism is a disease and refuse to consider other models. Clearly the field must adopt a hueristic stance when working with individuals who struggle with an alcohol problem and individually tailor trea.tment for patients. Margulies and Havens (1981) emphasized that clinicians must set aside expectations or presuppositions and should avoid making conclusions about the patient when conducting psychotherapy. Clinicians should live in uncertainty and suspend closure (Margulies 1989). While one may assume to know what the patient struggles with and what he or she needs to do, one must always be open to revising hypotheses and never be too sure of where the therapy may lead. In a similar vein, one must be careful about presuming to know what alcoholics need to do in order to recover from their drinking problems. Clinical thinking should not be obscured by either the disease or nondisease paradigms. The clinical utility of both models must be continually entertained, and the model that best
ACKNOWLEDGEMENT The author wishes to express his gratitude to Ellen Kenny, LCSW, for her suggestions on an earlier draft of this article.
REFERENCES American Society of Addiction Medicine. 1990. ASAM News 5 (MarchApril): 1,9. Armor, D .J.; Polich, J.M . & Stambul, H. B. 1978. Alcoholism and Treatment . New York: John Wiley & Sons. Armor, D.J.; Polich, J.M . & Stambul, H. B. 1976. Alcoholism and Treatmefll. Santa Monica, California: Rand Corporation. Bailey, M . & Stewart, J. 1967. Normal drinking by persons reporting previous problem drinking. Quarterly Journal ofStudies on Alcohol 28:305-315. Beman, N.S. 1829. Beman on Intemperance . New York: n.p . Cahalan, D . 1970. Problem Drinkers: A National Study. San Francisco: Jossey Bass. Campbell, E.J.M.; Scadding, J.G. & Roberts, R .S. 1979. The concept of disease. British Medical Journal2:757 -762. Cohen, M.; Liebson,l; Fallace, L. & Allen, R. 1971 . Moderate drinking by chronic alcoholics: A schedule-dependent phenomenon. Journal of Nervows arrd Mefllal Disease 153:434-444. Connecticut Pastor (Pseud.). 1883 . Drtmkenness a Curse, Not a Blessing: A Review of a Paper by Rev. Jolm E. Todd on "Drunkenness a Vice, Not a Disease." Hartford: Case, Lockwood & Brainard. Fingarelle, H. 1988. Heavy Drinlcing. The Myth of Alcoholism as a Disease. Berkeley: University of California Press. Gallant, D.M. 1987. Alcoholism: A Guide to Diagnosis,/ntervention , arrd Treatmefll. New York: W.W. Norton. Gambino, B. & Shaffer, H. 1979. The concept of paradigm and the treatment of addiction. Professional Psychology 10:207-223. Gitlow, S.E. 1973. Alcoholism: A disease. In: P.B. Bourne & R. Fox (Eds .) Alcoholism: Progress in Research arrd Training . New York : Academic Press . Goodwin, D.W. 1979. Alcoholism and heredity. Archives of General
Journal of Psychoactive Drugs
Psychiatry 36:57-61. Jellinek, E.M. 1952. Phases of alcohol addiction. Quarterly Journal of Studies on Alcoholl3 :673-684. Keller, M . 1972. On the loss-of
ISSN: 0279-1072 (Print) 2159-9777 (Online) Journal homepage: http://www.tandfonline.com/loi/ujpd20
The Disease Controversy and Psychotherapy with Alcoholics Michael S. Levy To cite this article: Michael S. Levy (1992) The Disease Controversy and Psychotherapy with Alcoholics, Journal of Psychoactive Drugs, 24:3, 251-256, DOI: 10.1080/02791072.1992.10471645 To link to this article: http://dx.doi.org/10.1080/02791072.1992.10471645
Published online: 20 Jan 2012.
Submit your article to this journal
Article views: 8
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ujpd20 Download by: [Deakin University Library]
Date: 07 November 2015, At: 12:03
The Disease Controversy and Psychotherapy with Alcoholics Downloaded by [Deakin University Library] at 12:03 07 November 2015
MichaelS . Levy, Ph.D.* Abstract- This article discusses conducting psychotherapy with alcoholics in light of the controversy about whether alcoholism is a disease. The belief that alcoholism is a disease forces many clinicians to offer abstinence from alcohol as the only option for alcoholics who seek treatment. From this perspective, the alcoholic must be helped to accept the idea that he or she has a disease and that to recover from this problem, drinking must stop. Others maintain that alcoholism may not be a disease and view alcoholic drinking as maladaptive behavior. From this vantage point, helping the patient to control or to moderate drinking might be considered. These two distinct paradigms lead to divergent treatment goals, which leaves the clinician in a quandary about how best to treat an individual who experiences a drinking problem. To resolve this dilemma, it is suggested that the clinician who works with alcoholics entertain a multiplicity of perspectives and should not be blinded by any one paradigm. While control of alcohol intake must take place if such patients are to improve their functioning, the author argues that recovery can occur either by abstinence or through moderating drinking. Keywords- alcoholism, disease controversy, moderating drinking, psychotherapy, recovery
While the idea that alcoholism is a disease currently dominates thinking in the field of alcoholism treatment (American Society of Addiction Medicine 1990; Gallant 1987; Nace 1987; Talbott 1986; Vaillant 1983), there remains considerable dissension (Peele 1989; Fingarette 1988; Szasz 1987, 1985; Shaffer 1985). In fact, the general concept of disease is difficult to define (Campbell, Scadding, & Roberts 1979), and people hold different opinions concerning what is or is not a disease. Whether or not one views alcoholism as a disease or as a problem in living is not merely a matter of semantics. Conceptualizing alcoholism as a disease has shifted the focus on alcoholism from a moral and legal problem to a medical problem (Nace 1987). Many organizations, such as hospitals and alcoholism treatment centers, have a vested interest in maintaining that alcoholism is a disease because funding may depend on whether or not alcoholism can be substantiated as a medical condition. While there are some ethical, social, and political reasons to maintain that alcoholism is a disease, it must not be forgotten that conceptualizing alcoholism as a disease has immense treatment implications. For example, any
treatment goal short of complete abstinence will not be considered if one subscribes to the view that alcoholism is a disease (Smith, Milkman & Sunderwirth 1985). Alcoholism is seen as an illness with a predictable, progressive, chronic course if individuals afflicted by this illness continue to drink. In fact, if a patient requests to attempt controlled drinking, this will typically be viewed as a manifestation of denial. As Tiebout ( 1951 :56) stated 30 years ago: "The alcoholic must be brought to accept that he is a victim of a disease and that the only way for him to remain healthy is to refrain from taking the first drink; that if he attempts to drink moderately, though he may succeed for a time, sooner or later the disease will be rekindled and he will be in trouble again. The job of the therapist is to recognize this inevitable recurrence and to aid his patient in accepting that fact." This statement is still true today for any practitioner who adheres to the paradigm that alcoholism is a disease. However, if one maintains that alcoholic drinking is learned maladaptive behavior, then helping patients to control or moderate their drinking may be considered. More attention might then be placed on psychological and socicr cultural variables playing a role in the drinking problem. The controversy concerning whether or not alcoholism is a disease leaves the clinician in a state of ambiguity about how best to treat an individual experiencing a problem with alcohol consumption.
•Clinical Instructor in Psychology, Harvard Medical School. Please address reprints requests to MichaelS. Levy, Ph.D., 2 Elm Square, Musgrove Building, Andover, Massachusetts 01810. Journal of Psychoactive Drugs
251
\bl. 24(3), Ju1-Sep 1992
Levy
Th e Disease C ontrove r sy and Psychotherapy
This article will first discuss the disease concept of alcoholism and demonstrate how and why this model clearly defines the treatment goal of abstinence from alcohol for this disorder. Then the thinking and research that questions the idea that alcoholism is a disease and implies that perhaps some alcoholics can learn to moderate their drinking will be examined. Subsequently, it will be shown how both perspectives, despite their theoretical divergence, can be incorporated into a single, patient-centered therapeutic approach.
a nd the substance is used compulsively. Jellinek (1952:679-680) differentiated "alcohol addicts" from "habitual symptomatic excessive drinkers," the former being afflicted with the disease . The " loss of control" phenomenon occurs only in the former group and is a "conversion phenomenon" where "any drinking of alcohol starts a chain reaction which is felt by the drinker as a physical demand for alcohol." This process makes it " impossible for him to control his alcohol intake." Consequently, the treatment goal is to help alcohol addicts admit that they have lost their willpower to control their drinking and to accept this truth. Talbou (1986) also noted that the difference between the controlled, abusive drinker and the uncontrolled addictive drinker must be appreciated. In fact, the idea that alcoholics cannot control their drinking and that this is beyond the power of the will is what makes alcoholism a disease as opposed to a bad habit. In 1829, Beman wrote that "drunkenness is itself a disease .. . when the taste is formed, and the habit is established, no man is his own master." In 1883, an anonymou s Connecticut minister wrote that drunkards are unable to control their drinking: "The whole question pivots, thus, on the power or powerlessness of the will in the confirmed drunkard to resist his propensity to drink." He further noted that "the essence of disease is involuntariness" and that drunkards are "physically helpless to refrain from drink ." Somewhat more recently, Keller (1972: 162) discussed the phenomenon of loss of control: "Therefore one can say that the essential loss of control is that an alcoholic cannot consistently choose whether he shall drink or not. There comes an occasion when he is powerless, when he cannot help drinking. For that is the essence or nature of a drug addiction." The American Society of Addiction Medicine (ASAM) (1990:9) recently developed a new definition of alcoholism and stated that it is a disease, which meant an "involuntary disability." ASAM noted that alcoholism is marked by impaired control over drinking, which was defined as "the 'inability' to limit alcohol use or to consistently limit on any drinking occasion the duration of the episode, the quantity consumed, and/or the behavioral consequences of drinking. " Thus, what appears evident is that if one has the disease of alcoholism, then that person's ability to drink without difficulty is lost. The disease of alcoholism makes one unable to drink responsibly. Clearly, alcoholics are not the masters of themselves when it concerns drinking. With certain biological underpinnings that interact with psychological and sociological variables, the habitual use of alcohol over which one has control can coalesce into a disease, at which time the alcoholic can no longer exercise control over drinking. Once individuals have the disease, their ability to drink responsibly is beyond the power of the will. Alcoholics must learn that they cannot drink and the goal of treatment must be abstinence.
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ALCOHOLISM IS A DISEASE The definition of alcoholism as a disease states that "alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations" (American Society of Addiction Medicine 1990:9). In this view, while psychological, sociological, religious or health variables play a role in drinking, without the biological vulnerability, the disease will never develop. As Talbott (1986:493) stated: 'To manifest itself, the disease must have the genetic predisposition accompanied by abuse, as abuse itself will not produce the disease. There are millions of people in this country who have the genetic predisposition, but who for cultural , health, personal, or religious reasons will not abuse, so they never manifest the disease." Some support for the idea that alcoholism is, at least in part, an inherited or biologically based disorder comes from a study by Goodwin ( 1979), who found that sons of alcoholic parents adopted at birth and rai sed in nonalcoholic families had four times the incidence of alcoholism as compared to children of nonalcoholic parents adopted at birth and raised by alcoholic parents. Schuckit, Goodwin and Winokur ( 1972) observed that children with a biologic alcoholic parent who were raised by parents who were not alcoholic had an incidence of alcohol abuse three times higher than children with nonalcoholic parents who were raised by an alcoholic step-parent. Vaillant (1983) looked at individuals prospectively and found that the single best predictor of alcoholism was a positive family history of alcoholism. Schuckit (1980) studied sons of alcoholics who drank but who had not yet developed significant problems related to alcohol or other drug use and compared them to individuals with a negative family history of alcoholism. After both groups drank .75 ml/kg of alcohol, he found that the sons of alcoholics reported that they felt less intoxicated than did the sons of nonalcoholics. It has also been demonstrated that sons of alcoholics experience less body sway after alcohol is consumed than do sons without a positive famil y history of alcoholism (Schuckit 1985). A centra l, if not the key, component of the illness is the diseased individual's total inability to control his or her drinking. Alcohol use continues in uncontrolled ways Journal of Psychoactive Drugs
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Though the task was boring, all subjects could eat, watch television or socialize at the same time. Subjects participated for one or two months and results did not confirm the loss-of-control phenomenon. None of the subjects drank themselves into a state of unconsciousness or collapse and all subjects did demonstrate some control over drinking. In another experiment, Cohen and colleagues ( 1971) allowed alcoholics access to up to a flfth of liquor. However, all subjects were told that if they drank more than five ounces, they would have to leave the pleasant social situation they were in. Results showed that most of the time, subjects limited themselves to moderate drinking. These studies in the laboratory and those experiments studying alcoholics in natural settings cause one toquestion the universality of the loss-of-control phenomenon and the idea that one drink will inevitably lead to a fullblown relapse. Some additional opposition to the disease concept paradigm focuses on how this model may cause some individuals to reject treatment Fingarette (1988) noted that some individuals cannot accept the idea that they are "diseased" or are "alcoholic" and thus are turned away from treatment, never receiving the help they need. Shaffer (1985) has reported that labelling someone alcoholic may be stigmatizing and can make the individual feel abnormal or defective. Fingareue (1988) wrote that people who struggle with an alcohol abuse problem will never even try to control their drinking because they believe this is impossible, owing to the promulgation of the disease concept with its implication that limiting drinking is a hopeless endeavor. He also noted that many alcoholics will never enter treatment because the idea of giving up drinking entirely is too overwhelming to consider. In summary, there is considerable evidence to suggest that alcoholism may not be a disease. The notion that alcoholics cannot succeed in moderating their drinking is called into question, and thus, the treatment goal of abstinence for all alcoholics is challenged. Apart from the appropriate treatment goal, criticism is also directed toward the idea that people experiencing an alcohol problem must be told that they have a disease called alcoholism and that they must learn to accept this fact.
Others maintain that alcoholism is not a disease; they tend to see problem drinking as a problem in living or as a learned habit. There are many different models to understand and address drinking problems, including psychological, conditioning, sociocultural, social learning, and general systems, to name a few (Miller & Hester 1989). However, a critical distinction between the disease concept paradigm and those models that do not maintain that alcoholism is a disease concerns the loss-of-control phenomenon. Essentially, the nondisease perspectives do not rest absolutely on the notion that once control of alcohol consumption is lost it can never be regained. These models question the idea that all people experiencing a problem with alcohol consumption must become abstinent for a recovery to occur. Support for the idea that some alcoholics can learn to control their drinking comes from a study by Lovibond and Caddy (1970). Using a variety of techniques in a controlled-drinking program, these researchers found that21 out of 28 alcoholics were able to drink in a conlrolled manner at follow-up. Armor, Polich and Stambul (1978, 1976) studied male alcoholics who had been treated in abstinence-oriented programs across 45 alcoholism treatment centers in the United States. An 18-month follow-up of these patients showed that not all of the improved patients were totally abstinent at follow-up . The authors summarized their findings (1978:294) as follows: "mhe majority of improved clients are either drinking moderate amounts of alcohol-but at levels far below what could be described as alcoholic drinking ... this finding suggests the possibility that for some alcoholics moderate drinking is not necessarily a prelude to full relapse and that some alcoholics can return to moderate drinking with no greater chance of relapse than if they abstained." Many other studies have also documented that some alcoholics can return to asymptomatic drinking (Nordstrom & Berglund 1987; Vaillant 1983; Sobell & Sobell 1976; Cahalan 1970; Bailey & Stewart 1967; Kendell1965 ). In a review of22 studies designed to help problem drinkers control their drinking, Miller and Hester ( 1980) found that only one study failed to support this approach. In the other 21 studies, success rates ranged from 25% to 90%, with an average success rate of65% for those studies that followed subjects for 12 months or longer. Experimentation with alcoholics has also been undertaken in the laboratory and many results force one toquestion the absolute validity of the loss-of-control phenomenon. Mello and Mendelson (1972) had alcoholics press a button according to instructions that would earn them credit toward measured amounts of alcohol. Subjects could earn an ounce of bourbon every five to fifteen minutes depending on their speed in pressing the button. JourNJI of Psychoactivl! Drugs
A CLINICAL PERSPECTIVE The clinician working with individuals experiencing a problem with alcohol is left in a difficult position. On the one hand, considerable research points to the idea that alcoholism is a disease and that alcoholics are genetically different from nonalcoholics. As a result of a biological difference that interacts with psychological and sociological factors, alcoholics or future alcoholics have a reaction to alcohol that makes it impossible for them to drink without difficulty. From this vantage point, alcoholics need to accept their condition, their denial must be broached, and 253
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they must be helped to achieve abstinence. There is also significant sociopolitical pressure to view alcoholism as a disease. As Gitlow (1973:8) has documented,"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." On the other hand, as discussed in the previous section, there is considerable research that causes one toquestion the disease model of alcoholism with its explicit assumption that all alcoholics must achieve abstinence for recovery to occur. In addition, it is argued that it may 'b e anti therapeutic or counterproductive to force an alcohol abuser to accept the diagnosis of alcoholism and the related treatment goal of abstinence. From this perspective, perhaps treatment can work toward helping such patients to control their drinking. In light of this controversy, which results in very different treatment strategies, the clinician is left in a quandary about how best to treat an individual experiencing a drinking problem. The solution is quite simple: the clinician who works with alcohol abusers needs to entertain a multiplicity of perspectives when conducting clinical work with such patients. Whether the patient recovers through abstinence or by moderating alcohol intake is not important; what is important is that the clinician directly focus on the alcohol use and make appropriate adjustment of alcohol consumption a treatment priority. A commonality between the disease and nondisease perspectives is that the alcoholic is not in control of his or her life as a result of alcohol consumption. Both models realize that the patient's relationship to alcohol must be changed if the patient is going to improve. Thus, the explicit and direct goal must be to help such individuals with their alcohol problem either by enabling them to become abstinent or by helping them to control their drinking. While clinicians must be cognizant of the various theories of and treatment strategies for alcoholism, when they are in the office with patients, they must not allow themselves to be blinded by or solely guided by any one theoretical or treatment model. Rather, clinicians should remain attuned to their patients and help them with their alcohol problem in a way that works best for the patient. Patients do not need to fit into one or another theoretical model, which, in any case, should only guide and not dictate. Thus, the first step in treating the presenting symptom of alcohol abuse should be to explore with the patient how he or she understands the problem. Initially, resonating with patients' own understanding of their problems is essential to the task of engaging them in the therapeutic work that lies ahead. As therapy progresses, their perception of their problems may change and this shift should elicit a Journal of Psychoa ctive Drugs
modification in the therapist's orientation. If someone believes that he or she has the disease called alcoholism, this assessment should be accepted and the patient should be helped to achieve abstinence. Clinicians can also share with patients what they know about alcohol problems. In fact, it can frequently be useful to educate someone about the disease concept of alcoholism and to help him or her to accept it and strive for abstinence. Many patients respond to the idea that they have a disease because it can alleviate guilt and it provides an unambiguous path torecovery (Shaffer 1985). However, clinicians must also be sensitive to the inability of some patients to acknowledge that they have a disease, and the concept should not be forced on them. However, these patients may still be interested in becoming abstinent even though they prefer to view their drinking problem as a bad habit or as a problem in living (Levy 1990). Educating patients about alcohol problems might also include information about controlled drinking and the fact that some alcoholics seem to be able to achieve and maintain such control. While one can never know for certain whether any particular patient will be able to successfully accomplish this task, there is some research to serve as a guide. Vaillant (1983) found that young problem drinkers are frequently able to change their alcohol abuse problem if their peer group is altered before physical dependence develops. An absence of sociopathy and high social stability may also bear a relation to a return to moderate drinking. Sobell and Sobell ( 1982) reviewed the controlled drinking literature and found that overall, individuals with less severe alcohol problems on entry into treatment are the individuals most likely to be able to control their drinking. Individuals who are older and who demonstrate the alcohol withdrawal syndrome on cessation or reduction of alcohol intake are usually less able to succeed at moderating their drinking (Polich, Armor & Braiker 1981). Consequently, if a patient wants to attempt to control drinking, this alternative should not be ruled out automatically. In fact, a controlled drinking contract can be developed and monitored with the patient. Even if, based on history, success at controlled drinking appears unlikely, it can still be productive to formulate a therapeutic contract with this goal as the objective if the patient insists. While one cannot know for certain whether a particular patient will be able to moderate his or her drinking, it can be crucial to give the patient the opportunity to try to control drinking. Individuals experiencing a problem with alcohol consumption typically need to discover for themselves whether or not controlled drinking is possible. Khantzian (1980) has noted that giving patients control over their drinking can help to avoid power struggles and can aid in fostering a good working alliance. He also discovered that many patients choose abstinence as the best means of control after repeated unsuccessful efforts to control alcohol consumption. Certainly if controlled drinking proves im254
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suits a particular patient should be chosen. While this approach may seem antitheoretical to some, it is in fact guided by a theory which holds that alcohol problems are multidimensional in terms of etiology and manifestation. Based on each individual's unique biological vulnerability, psychological structure, value system, and sociocultural environment, an alcohol problem can come to be exhibited in a specific way and understood by the individual in a particular manner. In tum, the clinician should take this information into account when a patient is assessed and an individualized treaunent plan needs to be developed. The controversy about whether or not alcoholism is a disease does not necessarily need to be resolved. Patients will let clinicians know whether or not they have the disease called alcoholism, whether or not they need to become abstinent for a recovery to occur, and whether or not controlled drinking is a viable option for them. Perhaps clinicians should be guided more by their patients than by any one unidimensional addiction theory.
possible with any patient, then abstinence will need to be considered. Gambino and Shaffer (1979) and Shaffer (1986) have noted that the addictions field is in a preparadigmatic state, with no particular paradigm as yet having ultimate authority. It is very tempting, however, to work out of one theoretical model, and many clinicians act as if it is a scientific fact that alcoholism is a disease and refuse to consider other models. Clearly the field must adopt a hueristic stance when working with individuals who struggle with an alcohol problem and individually tailor trea.tment for patients. Margulies and Havens (1981) emphasized that clinicians must set aside expectations or presuppositions and should avoid making conclusions about the patient when conducting psychotherapy. Clinicians should live in uncertainty and suspend closure (Margulies 1989). While one may assume to know what the patient struggles with and what he or she needs to do, one must always be open to revising hypotheses and never be too sure of where the therapy may lead. In a similar vein, one must be careful about presuming to know what alcoholics need to do in order to recover from their drinking problems. Clinical thinking should not be obscured by either the disease or nondisease paradigms. The clinical utility of both models must be continually entertained, and the model that best
ACKNOWLEDGEMENT The author wishes to express his gratitude to Ellen Kenny, LCSW, for her suggestions on an earlier draft of this article.
REFERENCES American Society of Addiction Medicine. 1990. ASAM News 5 (MarchApril): 1,9. Armor, D .J.; Polich, J.M . & Stambul, H. B. 1978. Alcoholism and Treatment . New York: John Wiley & Sons. Armor, D.J.; Polich, J.M . & Stambul, H. B. 1976. Alcoholism and Treatmefll. Santa Monica, California: Rand Corporation. Bailey, M . & Stewart, J. 1967. Normal drinking by persons reporting previous problem drinking. Quarterly Journal ofStudies on Alcohol 28:305-315. Beman, N.S. 1829. Beman on Intemperance . New York: n.p . Cahalan, D . 1970. Problem Drinkers: A National Study. San Francisco: Jossey Bass. Campbell, E.J.M.; Scadding, J.G. & Roberts, R .S. 1979. The concept of disease. British Medical Journal2:757 -762. Cohen, M.; Liebson,l; Fallace, L. & Allen, R. 1971 . Moderate drinking by chronic alcoholics: A schedule-dependent phenomenon. Journal of Nervows arrd Mefllal Disease 153:434-444. Connecticut Pastor (Pseud.). 1883 . Drtmkenness a Curse, Not a Blessing: A Review of a Paper by Rev. Jolm E. Todd on "Drunkenness a Vice, Not a Disease." Hartford: Case, Lockwood & Brainard. Fingarelle, H. 1988. Heavy Drinlcing. The Myth of Alcoholism as a Disease. Berkeley: University of California Press. Gallant, D.M. 1987. Alcoholism: A Guide to Diagnosis,/ntervention , arrd Treatmefll. New York: W.W. Norton. Gambino, B. & Shaffer, H. 1979. The concept of paradigm and the treatment of addiction. Professional Psychology 10:207-223. Gitlow, S.E. 1973. Alcoholism: A disease. In: P.B. Bourne & R. Fox (Eds .) Alcoholism: Progress in Research arrd Training . New York : Academic Press . Goodwin, D.W. 1979. Alcoholism and heredity. Archives of General
Journal of Psychoactive Drugs
Psychiatry 36:57-61. Jellinek, E.M. 1952. Phases of alcohol addiction. Quarterly Journal of Studies on Alcoholl3 :673-684. Keller, M . 1972. On the loss-of
