Is alcoholism a disease? The debate is over whether alcoholism is a disease or simply a serious behavioral problem. It’s continued for over 200 years. And it doesn’t appear likely to end anytime soon.

The disease theory of alcoholism is just that… an unproven theory.

I. Disease Theory Propositions

Dr. Herbert Fingarette notes that the disease theory of alcoholism has propositions.

1. 1. Heavy problem drinkers show a single distinctive pattern of ever greater alcohol use. That leads to ever greater bodily, mental, and social deterioration.
   2. The condition once it appears, persists involuntarily. The craving is irresistible. And the drinking is uncontrollable once it has begun.
   3. Medical expertise is needed to relieve the condition.  That is, to “cure the disease” or at least reduce its symptoms.
   4. Alcoholics are not responsible legally or morally for their drinking. Nor its consequences. Similarly, epileptics are not responsible for the results of their movements during seizures.¹

First Proposition

The first proposition gained some credibility in the 1940s. That’s when E.M. Jellinek² published a study of the “phases of alcoholism.” In it he theorized an inevitable sequence of increasingly uncontrolled drinking. He thought it progressively led to such symptoms as blackouts, tolerance, withdrawal, distress, insanity and death.³

Jellinek’s idea was based on self-report questionnaires. They were prepared and distributed by Alcoholics Anonymous (AA). From these a hand-selected group of fewer than 100 questionnaires all from were analyzed. All responses from women were discarded. That, in spite of the fact that about half of alcoholics are women!

Jellinek recognized the scientific inadequacy of his idea. Thus he saw it as a starting point for research. But it was soon accepted as proven fact by many people. And especially by those in AA.

Yet Jellineck came to see the problems with his idea. As a result, he later distanced himself from it.

Jellinek was wise to do so. Research has later shown that the so-called typical pattern of heavy drinking varies greatly. Some drinkers get worse. Some improve. Others don’t change. And still some develop problems different from those Jellinek speculated.⁴ But the false belief “has become part of the enduring mythology of alcoholism.”⁵

Second Proposition

The second idea is that drinking necessarily becomes uncontrollable once it has begun. Yet this was disproved over half a century ago. It was proven false by over 100 studies. In doing so they report that many alcoholics return to controlled drinking without problems.⁶ Since then, the number of such studies has more than doubled.

The proposition has also been disproved by a nation-wide survey of alcoholics conducted by the US government. It found that 17.7% of alcoholics are now drinking in moderation. The federal agency (NIAAA) found the following.

Twenty years after onset of alcohol dependence [alcoholism], about three-fourths of individuals are in full recovery. More than half of those who have fully recovered drink at low-risk levels without symptoms of alcohol dependence.

About 75 percent of persons who recover from alcohol dependence do so without seeking any kind of help. That includes alcohol rehab programs and AA. And only 13 percent of people with alcohol dependence ever receive specialty alcohol treatment.⁷

The director of NIAAA’s Division of Treatment and Recovery Research was amazed. In the light of this, he said “These and other recent findings turn on its head much of what we thought we knew about alcoholism.”⁸ To learn more visit Alcoholics Can Recover from Alcoholism & Drink in Moderation.

Third Proposition

The third idea is that medical help is necessary to deal with alcoholism. Clearly that is not the case. Indeed, most alcoholics control their drinking without any help from anyone else.

Those who use AA or other 12-step groups are using a non-medical approach. Dr. Stanton Peele poses a simple question. “Why supposed medical treatment consists mainly of going to group meetings and why people can’t develop their own spiritual approaches to life if they choose are questions disease theory adherents ignore.”⁹

A survey of general practice physicians and nurses found that a most believed there are no medical treatments that are effective in treating addiction.¹⁰

Fourth Proposition

The fourth proposition is that alcoholics aren’t responsible for their behavior. But that’s false. Back in 1988, the US Supreme Court found that alcoholism is always the result of the alcoholics “own willful misconduct.”

In so doing it reaffirmed the lower court’s finding. That is, that there exists “a substantial body of medical literature that even contests the proposition that alcoholism is a disease, much less that it is a disease for which the victim bears no responsibility.”¹¹It also noted the following. “Indeed, even among many who consider alcoholism a ‘disease’ to which its victims are genetically predisposed, the consumption of alcohol is not regarded as wholly involuntary.”¹²

The Supreme Court also held that the arguments in favor of the disease theory are a syllogism. And “the inescapable fact is that there is no agreement among members of the medical profession about what it means to say that ‘alcoholism’ is a ‘disease.'”¹³

II. Negative Results of the Disease Theory

The disease concept of alcoholism removes the responsibility of alcoholics for their own actions.¹⁴ Dr. Peele says that “Perhaps the most dire consequence of the disease model of addiction is that it has encouraged the abdication of individual responsibility for outrageous conduct.” He thinks that “Creating a world of addictive diseases may mean creating a world in which anything is excusable.”¹⁵

Self-Interested

Many people have a strong self-interest, financial or emotional, in maintaining the disease theory. As a result, they become closed minded. Thus they can’t objectively analyze facts about the theory. This shuts the door to developing effective approaches to alcohol abuse. As well as helping those who suffer from it.

In the field of alcoholism, “unsupported beliefs are more acceptable than hard data. In some areas beliefs are so deeply entrenched that it is impossible to introduce factual knowledge at all.”¹⁶

A Philosophy

One observer has noted that “Alcoholism, like other ‘isms,’ is not a disease but rather a philosophy that has affixed itself to a particular human problem –that of habitual, self-destructive drinking of alcohol.”¹⁷ (The emphasis was in the original).

But “the assertion that alcoholism is a disease is ‘sacred.’ It has achieved a level equivalent, in theological terms, to dogma. A fundamental, non-negotiable, undergirding belief. Alcoholism as disease is so foundational that one cannot deny it without distancing oneself from the believing community.”¹⁸

Self-fulfilling Prophesy

The belief that consuming any alcohol triggers an uncontrollable urge to continue drinking to excess becomes a self-fulfilling prophesy. Research shows alcoholics who reject the belief are much more likely to drink without problems than are those who believe it.¹⁹

Reluctance

Another result of the disease theory is this.

“Problem drinkers, especially those at relatively lower levels of alcohol dependence, are reluctant to seek help in such programmes (those based on disease concept). They fear that they will be labelled ‘alcoholic’ and that the time typically required for treatment would interfere with their professional and family responsibilities. In addition, they are often unwilling to accept that the only appropriate goal for them is lifelong abstention.”20

Relapses

In some studies alcoholics are randomly assigned to AA, to other forms of treatment, or to no treatment. They report that alcoholics assigned to AA either do no better or actually suffer more relapses. That’s in in comparison to those assigned to other treatment or to no treatment at all.²¹

Attending AA or other disease theory programs may be worse than doing nothing. That’s  because members (or patients) are taught that they cannot succeed on their own. The reason is because they suffer from a chronic disease that can’t be cured.

Must Accept Belief

Those who attend alcohol disease or 12-step programs soon learn what they must accept belief in the disease theory. As Dr. Peele explained.

“Newcomers who don’t report the correct symptoms are treated with knowing condescension or are actively hazed – sometimes quite abusively – until they ‘get’ and repeat the party line. When Dwight Gooden entered the alcoholism and cocaine program at the Smithers Alcoholism Center, he described being assailed by his fellow residents there during the constant group-therapy sessions. “My stories weren’t as good as theirs. . . . They said, ‘C’mon, man, you’re lying.’ They didn’t believe me. . . . I cried a lot before I went to bed at night.

After he left the Betty Ford Center, Chevy Chase reported that he had often been angry at the counselors, who heckled the residents mercilessly, constantly denigrating them and claiming they had been living worthless lives.”2222

To see the effect of AA on one person’s life visit What NOT to Do.

III. Interest Group Pressures

The pressure to define alcoholism as a disease did not result from medical research. Conversely, it was in spite of it. AA first promoted the definition, the popular acceptance of which “largely rests on the passionate embrace of the disease model by a significant group. AA members, their (often Al-Anon) families, and persons in AA-based groups (e.g., Narcotics Anonymous, Cocaine Anonymous).”²³

As one observer notes, “The AA-influenced ‘recovery community’ is loyal to the disease concept and, largely through its efforts, the idea that ‘alcoholism is a disease’ has spread.”²⁴

AA is Powerful

It is difficult to over-emphasize the powerful influence of AA and its disease theory on the alcoholism field. Dr. Lynn Appleton stresses this.

“The impact of AA’s model has intensified as impatient treatment centers proliferated. For many years, persons ‘in recovery’ have been the majority of front-line workers in alcoholism and drug dependency treatment centers. And they have been a significant proportion of other treatment workers. Thus, AA’s disease model dominates treatment ‘not only as a philosophy but also as a method.’ It dictates not only how treatment workers think about alcoholism but how they treat it. Treatment philosophy is dominated by AA’s insistence that alcoholism is a disease with a biological basis, albeit with other significant dimensions. As the Encyclopedia of Addictions notes, “[T]he disease concept of alcoholism provides the basis for most of the current approaches to the treatment of alcoholism….”25

Treatment Facilities

The number of alcoholism rehabs mushroomed in the 60s, 70s, and 80s. But most people lacked the funds or insurance to pay for these very expensive programs.

Solving that problem became the top priority of the treatment industry. Notably, this required convincing the public, public officials, insurance companies, and medical groups that alcoholism was a disease.

American Medical Association Action

In 1956 the American Medical Association voted to define alcoholism as a medically treatable disease. Because of that such treatment by physicians would become eligible for payment from third parties. That is, insurance companies. The decision was not made on the basis of an analysis of the scientific evidence. Instead, it was made on self-serving economic grounds.²⁶ Jellineck justified this by saying that a disease is anything that doctors choose to call a disease.²⁷ Yet Dr. Jeffrey Schaler argues that “simply calling alcoholism a disease does not make it one.”²⁸

Dr. Rudy

Dr. David Rudy points out this.

“[L]ike most of us, physicians make errors. For example, Benjamin Rush, the father of American psychiatry, viewed ‘negritude’ [having black skin as an African or African American] as a special type of leprosy. Rush also viewed lying, murdering, and minority group dissent as mental illnesses. It is also interesting that Rush is responsible for the ‘first clearly developed modern conception of alcoholism [which he considered a disease]. At various later dates American physicians have viewed drug addiction, hyperactivity, suicide, obesity, crime, violence, political dissent, and child abuse as worthy of disease labels and hence treatment by physicians.”29

Nevertheless, defining alcoholism as a disease was a bonanza that quickly poured billions of dollars into the pockets of physicians, hospitals and pharmaceutical companies. And it does so today. In short, many people’s jobs and income depend on the belief that alcoholism is a disease.³⁰

Disease Definition Is Not Medical

Dr. Paul Roman has pointed out that “the medical definition of alcoholism is fundamentally sociological. Within official diagnostic manuals, alcohol dependence (alcoholism) is almost exclusively defined in terms of individuals’ social role performance and others’ definition of the extent to which this performance, due to repeated episodes of drinking, fails to meet social expectations.”³¹

In addition, most adherents of the disease model “hold a confusing muddle of beliefs about the alcoholic as ‘weak willed,’ about environmental or psychological causes for alcoholism, and about the ‘responsibility’ of the deviant drinker.”³²

Most Doctors Reject Theory

Many doctors reject the disease theory of alcoholism. Dr. Appleton writes that “Despite all public pronouncements about alcoholism as a disease, medical practice rejects treating it as such. Not only does alcoholism not follow the model of a ‘disease,’ it is not amenable to standard medical treatment.”³³

Appleton explains that “Medical doctors’ rejection of the disease theory of alcoholism has a strong basis in the biomedical model underpinning most of their training.” She says that “medical research on alcoholism does not support the disease model” Also “highly respected and influential medical authorities do not promote the theory and treatment of alcoholism as a disease.”³⁴

      Nation-wide Sample of M.D.s

A nation-wide sample of doctors in the US was asked if they personally believe that alcoholism is mainly a disease or mainly a personal or moral weakness. As a result, 15% believed that it was the latter. Then the sample was asked what proportion of alcoholism itself is a disease and what proportion is a personal weakness.  The average proportion that was judged to be personal weakness was 31%. Only 12% of doctors believed that alcoholism is 100% a disease.³⁵

A survey of over 88,000 doctors in the US found that “Only 49% of the physicians characterized alcoholism as a disease.” While over 75% believed that the major causes of alcoholism are “personality and emotional problems.”³⁶

      A Survey in VA

A survey of psychiatrists and of psychologists at the VA was made by Dr. Wilma Knox. “Their attitudes were remarkably similar. Both groups rejected the disease concept in preference to characterizing alcoholism as a behavior problem, symptom complex, or escape mechanism. Both groups were inconsistent in advocating neuropsychiatric hospitalization while considering treatment benefits very limited. Members of both groups were reluctant to participate personally to any degree in rendering this treatment.”³⁷

One survey of doctors found that only about 20% believed substance addiction to be a disease.³⁸ Another survey found that only 27% of doctors believed that alcoholism is a disease. However, the majority viewed alcoholism as a social or psychological problem rather than a disease.³⁹

      Significant Finding

Significantly a survey was made of doctors attending an annual conference of the the International Doctors in Alcoholics Anonymous (IDAA). Surprisingly, 80% believed that alcoholism is simply bad behavior. That is, not a disease.⁴⁰

It is reported that “Many doctors have been loath to prescribe drugs to treat alcoholism, sometimes because of the belief that alcoholism is a moral disorder rather than a disease.”⁴¹ Indeed, in a survey of doctors’ beliefs about alcoholism, 55% said that there is “no effective treatment” for it.

Dr. Thomas Hobbs writes that “Based on my experiences working in the addiction field for the past 10 years, I believe many, if not most, health professionals still view alcohol addiction as a willpower or conduct problem and are resistant to look at it as a disease.”⁴²

Although much AA literature defines alcoholism as a disease, as do most members, the groups actually takes no official position about the subject. It states that “Some professionals will tell you that alcoholism is a disease while others contend that it is a choice” and “some doctors will tell you that it is in fact a disease.”⁴³

IV. Definitions: Is Alcoholism a Disease?

One reason that the disease theory of alcoholism became so popular was because it could change how people think about alcoholics. Historically, alcoholics were called drunkards. And people thought they lacked character and willpower. Generally they were seen as moral defectives or even sinners. But if they could be seen instead as suffering from a disease, then they would not be seen as having some personal failing. Of course, many people think it also provides an excuse. Thus it relieves them of personal responsibility.

Lack of Control

“Lack of control” is central to the disease theory of alcoholism. Yet Dr. Herbert Fingarette points out that alcoholics don’t actually lack control.

“Studies show that they can limit their drinking in response to appeals and arguments or rules and regulations. In experiments they will reduce or eliminate drinking in return for money, social privileges, or exemption from boring tasks. To object that these experiments are invalid because they occur in protected settings is to miss the point, which is precisely that the drinking patterns of alcoholics can vary dramatically with settings, regardless of their previous patterns of drinking, and regardless of whether any alcohol is in their bodily systems or is accessible.

        He continues

“True, alcoholics often resist appeals to cease their alcohol abuse, and they ignore obvious prudential and moral considerations. The simplistic explanation that attributes this to an irresistible craving obscures a more complicated reality. They have developed a way of life in which they use drinking as a major strategy for coping with their problems. They have become accustomed to values, friends, settings, and beliefs that protect and encourage drinking. When they encounter drastically changed circumstances in a hospital, clinic, or communal group, they are capable of following different rules. Even some who ‘cheat’ where abstention is expected nevertheless limit their drinking. They do not automatically lose control because of a few drinks.”44

Circular Reasoning

Definitions can deceive or mislead us. We may try to explain why people drink too much by saying that they are alcoholic. But this is circular reasoning. It’s useless as saying that a person is alcoholic because the person drinks too much.

We could say that some people fear being in tight enclosed places because they are claustrophobic. But that’s nothing more than saying that claustrophobic people fear being in tight enclosed places. Or that people have blond hair because they’re blondes.⁴⁵

Dr. Harold Mulford explains that “alcoholism as a disease entity remains a thing attributed to persons given the label ‘alcoholic’ to explain their drinking and related behavior. However, such an explanation will remain a mere tautology until ‘alcoholism’ is defined in terms independent of the drinking and related behavior it is supposed to explain.”⁴⁶

How or Why?

The disease theory of alcoholism never explains how or why people are alcoholic. It never describes exactly what causes people to drink compulsively. Instead, it says that they drink compulsively because they have a compulsion. It then uses the religion or spirituality of disease theory 12-step programs as a treatment.

By the same token, the commonly used definition of alcoholics as people who can never drink in moderation creates serious problems. That is, research has produced evidence for decades that many alcoholics can return to moderate drinking. But this evidence is routinely rejected. Proponents of that definition or belief tend to argue this way. If researchers identify alcoholics who can now drink in moderation, that simply means that the “alcoholics” weren’t rally alcoholics. Otherwise they wouldn’t have been able to drink in moderation. Thus, for true believers, it’s a case of “heads I win; tails, you lose.”

Unique Field

An astute observer has made an important statement. “Alcoholism is a unique field in which custom dictates that unsupported beliefs are more acceptable than hard data. In some areas beliefs are so deeply entrenched that it is impossible to introduce factual knowledge at all.”⁴⁷

Dr. Enoch Gordis, former Director of the National Institute on Alcohol Abuse and Alcoholism, wrote this.

“The entire alcoholism ‘treatment’ system, with its innumerable therapies, armies of therapists, large and expensive programs, endless conferences, innovation and public relations activities is founded on hunch, not evidence, and not on science.”⁴⁸

       Dr. Gordis continues that

“the history of medicine demonstrates repeatedly that unevaluated treatment, no matter how compassionately administered, is frequently useless and wasteful and sometimes dangerous or harmful. The lesson we have learned is that what is plausible may be false, and what is done sincerely may be useless or worse.”⁴⁹ (Emphasis in original.)

“Studies show that they can limit their drinking in response to appeals and arguments or rules and regulations. In experiments they will reduce or eliminate drinking in return for money, social privileges, or exemption from boring tasks. To object that these experiments are invalid because they occur in protected settings is to miss the point. It is precisely that the drinking patterns of alcoholics can vary dramatically with settings, regardless of their previous patterns of drinking, and regardless of whether any alcohol is in their bodily systems or is accessible.

         He also says

“True, alcoholics often resist appeals to cease their alcohol abuse, and they ignore obvious prudential and moral considerations. The simplistic explanation that attributes this to an irresistible craving obscures a more complicated reality. They have developed a way of life in which they use drinking as a major strategy for coping with their problems. They have become accustomed to values, friends, settings, and beliefs that protect and encourage drinking. When they encounter drastically changed circumstances in a hospital, clinic, or communal group, they are capable of following different rules. Even some who ‘cheat’ where abstention is expected nevertheless limit their drinking. They do not automatically lose control because of a few drinks.”

Chemical Dependency

The existence of chemical dependencies is a medical fact. Some mentally ill people are dependent on psychiatric meds for the rest of their lives. Yet this is considered a treatment, not a disease. In short, dependency is only considered a disease when it is not socially approved.

Smoking is not a disease but the lung cancer that it can cause is a disease. Drinking too much isn’t a disease but it can cause diseases. They include high blood pressure, liver cirrhosis, and fetal alcohol syndrome.

A Definition

If we define a disease as “an impairment of health or a condition of abnormal functioning,” then alcoholism is a disease. However, so is stealing, nail-biting and partner abuse. But then it means nothing to say that alcoholism is a disease. That is, if virtually every problem is a disease.

Many proponents of the disease theory of alcoholism refer to it as “a disease of the family.” The entire family group itself is said to have a disease. This seems to stretch the concept of disease far beyond what most people would consider to be a disease. Is alcoholism also a “disease of the work place”? Can a city, state or country have the disease of alcoholism?

Medical Treatment Appropriate?

Another problem is that medical treatment does not appear appropriate for what AA describes as “a progressive illness – spiritual and emotional (or mental), as well as physical.”⁵⁰ Doctors have not been trained to treat “spiritual diseases.” So AA suggests that doctors send their patients to it for help. That would appear to be appropriate because AA is a spiritual group. Making such referrals is common. Thus, the role of doctors in treating alcoholism as a disease is to refer patients to a non-professional self-help group. And also a group that relies on what it calls God or a Higher Power.

Useful Fiction?

Other disease concept supporters assert that even if alcoholism isn’t a disease, calling it a disease is useful. For example, Dr. George Vailliant says that calling alcoholism a disease “is a useful device both to persuade the alcoholic to acknowledge the problem and to provide a ticket of admission to the health care system.”⁵¹

Dr. Fingarette notes that “The disease concept is sometimes rationalized on the ground that although scientifically invalid, it is a practical way of encouraging alcoholics to enter treatment.” He says “the greatest scandal of the argument for the disease concept as a useful lie is the claim that it helps alcoholics by inducing them to enter treatment. On the contrary, both independent and government research shows expensive disease-oriented treatment programs to be largely a waste of money and human resources.”⁵²

An Irony

Dr. Jeffrey Schaler has noted that “Ironically, the fact that addiction treatment does not work helps to convince people in the addiction treatment field that addiction is a disease. What else could account for the tenacity with which addicts cling to their addictions? Could it be that people sometimes freely choose to do foolish and self-destructive things? Inconceivable! It must be a disease that makes them do it.”⁵³

“[N]ot only does the disease theory of alcoholism fail to correspond with mainstream medicine’s concept of a disease, but alcoholism itself resists medical intervention.”⁵⁴ Using a faulty theory and the “treatment” that flows from it is a recipe for failure. AA’s self-claimed success rate of 5% represents a failure. That’s because about one-third of alcoholics achieve success completely on their own. Attending AA is less effective than not doing so!

Dissapointing Failure

It’s not surprising that the disease theory of alcoholism has proved to be such a disappointing failure. Those few people who achieve their goal of not drinking while attending 12-step programs such as AA do so in spite of those programs.

The good news is that alternative approaches exist. In addition, they have proven to be very effective in helping people reach their goal.  Whether it be either reducing or eliminating their drinking.

Note