​The Disease Model

timer Asked: Jan 5th, 2018
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The Disease Model

The disease model is the central premise for Alcoholics Anonymous and other 12-step groups that have aided in the recovery of millions of people. This model elicits a great deal of controversy, however. In this Discussion, you will reflect on the debate centering on the disease model and develop your position about whether you believe it to be a valid model.

To prepare for this Discussion:

• Review this week's Learning Resources, focusing on the information relating to the disease model of addiction.

• Review the Web article, "Alcoholics Anonymous and the Disease Concept of Alcoholism." Reflect on the Alcoholics Anonymous position on the disease model

• Consider the validity of the points made in each of the Learning Resources concerning the disease model of addiction. Analyze and evaluate these points.

• Reflect on your own position regarding the disease model of addiction and how the evidence in the Learning Resources supports or challenges it.

With these thoughts in mind:

Post by Day 4 your analysis and evaluation of the validity of the disease model of addiction. Support your evaluation with specific examples and evidence from the Learning Resources.

Note: Be sure to protect the identity of any individuals you describe in your post.

Be sure to support your postings and responses with specific references to the Learning Resources.

Alcoholism Treatment Quarterly ISSN: 0734-7324 (Print) 1544-4538 (Online) Journal homepage: http://www.tandfonline.com/loi/watq20 Alcoholics Anonymous and the Disease Concept of Alcoholism Ernest Kurtz PhD To cite this article: Ernest Kurtz PhD (2002) Alcoholics Anonymous and the Disease Concept of Alcoholism, Alcoholism Treatment Quarterly, 20:3-4, 5-39, DOI: 10.1300/J020v20n03_02 To link to this article: https://doi.org/10.1300/J020v20n03_02 Published online: 02 Oct 2008. Submit your article to this journal Article views: 2429 View related articles Citing articles: 11 View citing articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=watq20 Download by: [Walden University] Date: 05 January 2018, At: 15:32 Downloaded by [Walden University] at 15:32 05 January 2018 BROADER TREATMENT PERSPECTIVES Alcoholics Anonymous and the Disease Concept of Alcoholism Ernest Kurtz, PhD SUMMARY. Although the idea of “illness” helped many early and later members of Alcoholics Anonymous (A.A.) to understand their alcoholism, Alcoholics Anonymous neither originated nor promulgated the disease concept of alcoholism. The main contribution of A.A. in this area was the broadening of the extant concept to one of “threefold” malady, with an emphasis on “the spiritual.” Examining the political and medical contexts of Ernest Kurtz has authored numerous articles, book chapters and monograms on the treatment of alcohol problems, with particular emphasis on the significance of Alcoholics Anonymous and on the spiritual dimensions of recovery. His books include Not- God: A History of Alcoholics Anonymous (1978) and The Spirituality of Imperfection (1992), co-authored with Kathleen Ketcham. A collection of his articles have been published in The Collected Ernie Kurtz (1999). The writing of this article was subsidized by a grant from the Behavioral Health Recovery Management project, a partnership of Fayette Companies and Chestnut Health Systems funded by the Illinois Department of Human Services Office of Alcoholism and Substance Abuse. This article was discussed at the Works in Progress Seminar, Brown University, Providence, RI, June 13-15, 2002. An earlier version of this article appears on the Web site of Behavioral Health Recovery Management: http://www.bhrm.org/papers/addpapers.htm [Haworth co-indexing entry note]: “Alcoholics Anonymous and the Disease Concept of Alcoholism.” Kurtz, Ernest. Co-published simultaneously in Alcoholism Treatment Quarterly (The Haworth Press, Inc.) Vol. 20, No. 3/4, 2002, pp. 5-40; and: Alcohol Problems in the United States: Twenty Years of Treatment Perspective (ed: Thomas F. McGovern, and William L. White) The Haworth Press, Inc., 2002, pp. 5-40. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: getinfo@haworthpressinc.com].  2002 by The Haworth Press, Inc. All rights reserved. 5 6 ALCOHOL PROBLEMS IN THE UNITED STATES Downloaded by [Walden University] at 15:32 05 January 2018 the time as well as A.A. literature shed light on the culture’s changing understanding of alcoholism in the second half of the twentieth century. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2002 by The Haworth Press, Inc. All rights reserved.] KEYWORDS. Alcoholics Anonymous and the disease concept, alcoholism, spirituality Given the issues and prejudices involved, it is unlikely that the question of the historical relationship between Alcoholics Anonymous and the disease concept of alcoholism will ever be definitively resolved. But this does not mean that study of the topic is useless. We can discover, organize, and evaluate presently available information with aspirations to increased clarity even if not to perfect pellucidity, hoping to approach ever greater accuracy even if–until time-travel be perfected by omniscient observers–we are barred from the Rankin paradise of we es eigentlich gewesen sei. On the basic question, the data are clear: Contrary to common opinion, Alcoholics Anonymous neither originated nor promulgated what has come to be called the disease concept of alcoholism. Yet its members did have a large role in spreading and popularizing that understanding. How and Why and So What are the burden of this paper as a whole. As is often stated in introductions but too rarely recognized in analyses, Alcoholics Anonymous is its members. That membership tries to live their program’s Twelve Steps, guided by their fellowship’s Twelve Traditions. The Tenth of those Traditions reads: “Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy.” (A.A. World Services, 1953). The nature of alcoholism is an “outside issue.” Thus, Alcoholics Anonymous as Alcoholics Anonymous has no opinion on it, as most members will tell anyone who asks. But anyone who passes any time with members of Alcoholics Anonymous soon becomes aware of two other realities. First, most members of Alcoholics Anonymous do speak of their alcoholism in terms of disease: the vocabulary of disease was from the beginning and still remains for most of them the best available for understanding and explaining their own experience. But the use of that vocabulary no more implies deep commitment to the tenet that alcoholism is a disease in some technical medical sense than speaking of sunrise or sunset implies disbelief in a Copernican solar system. Second, most members, in the year Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 7 2002 no less than in 1939, will also tell an inquirer that their alcoholism has physical, mental, emotional, and spiritual dimensions. This advertence to complexity, and especially the emphasis on “the spiritual,” is A.A.’s largest contribution: it is the necessary framework within which any discussion of A.A.’s relationship to the disease concept of alcoholism must be located. The closest the book Alcoholics Anonymous (A.A. World Services, 2001) comes to a definition of alcoholism appears on p. 44, at the conclusion of the first paragraph of the “We Agnostics” chapter, where we are told that alcoholism “is an illness which only a spiritual experience will conquer.” Alcoholics Anonymous also has a literature, some of which enjoys a kind of “official” status because it is approved, published and distributed by the General Service Office of Alcoholics Anonymous. Most important among this literature, based on member usage, are the A.A. “Big Book,” Alcoholics Anonymous, the essays written by longer-lived co-founder and “Big Book” author William Griffith Wilson published as Twelve Steps and Twelve Traditions (A.A. World Services, 1953), and the telling of A.A.’s history primarily by Wilson in Alcoholics Anonymous Comes of Age (A.A. World Services, 1957). Among A.A.’s less official literature are The A.A. Grapevine, an officially “unofficial” monthly published continuously since June 1944, and other publications and statements of co-founder Wilson. These latter, though also officially unofficial, derive a degree of authority from their acceptance and repetition by members of Alcoholics Anonymous over the years. Their authority derives less from “Bill said” than from the practical reality that many members’ experience attests that what Bill said on some topics merits credence. Among these statements is a reply Wilson gave when specifically asked about alcoholism as a disease after he had addressed the annual meeting of the National Catholic Clergy Conference on Alcoholism in 1960: We have never called alcoholism a disease because, technically speaking, it is not a disease entity. For example, there is no such thing as heart disease. Instead there are many separate heart ailments, or combinations of them. It is something like that with alcoholism. Therefore we did not wish to get in wrong with the medical profession by pronouncing alcoholism a disease entity. Therefore we always called it an illness, or a malady–a far safer term for us to use. (N.C.C.A. Blue Book, 1960, 199) As the parallel with “heart ailments” as well as the proffered synonyms suggest, Wilson is here hardly denying an understanding that includes a medico/physiological element in alcoholism. Given his expressed hesitancies, why? And why do so many members of Alcoholics Anonymous speak of their alcoholism in the vocabulary of disease? The Downloaded by [Walden University] at 15:32 05 January 2018 8 ALCOHOL PROBLEMS IN THE UNITED STATES answer is both simple and complex: simple because Alcoholics Anonymous, like any reality, reflects the context of its time; complex because A.A. has existed long enough that its context has changed . . . and, indeed, changed more than once. All realities are shaped by their context. Some entities also make contributions, significantly shaping later contexts. So it is with Alcoholics Anonymous and the culture’s understanding of alcoholism. For diverse reasons, circumstances of origin tend to be the most important, to have the most pervasive and lasting effects. Thus we will begin at the beginning–not at the beginning of the disease concept of alcoholism, a far larger and more complex topic, but at the beginnings of Alcoholics Anonymous (for the history of the disease concept of alcoholism, see White, 1998). Alcoholics Anonymous came into being in the mid- to late 1930s. In that era of the Great Depression, the recent end of the Prohibition controversy by the 21st Amendment’s repeal of the 18th Amendment to the Constitution of the United States of America left most people bored with the topic of alcohol–they were tired of hearing about it. Some members of the cultural elite, philanthropists such as John D. Rockefeller and scientists such as those who in 1937 formed the Research Council on Problems of Alcohol, were concerned about the possible societal effects of Repeal (Johnson, 1973; Roizen, 1991; 1996), but even among the social workers who knew that Prohibition had not been a “failure” (Clark, 1976; Lubove, 1965), the drinking of alcohol was not a subject of frequent discussion. The earliest A.A. candidates, of course, were not bored by the topic of alcohol. If their own drinking did not trouble them, their apparent inability to stop getting drunk was for most a real concern. And for many who “got” A.A., who sobered up and stayed sober in Alcoholics Anonymous after their many other efforts had failed, why A.A. worked became a question of interest. As do most people, they turned for answers to the common professional or scientific understanding of the matter. One version of that understanding was mediated to them by Dr. William Duncan Silkworth in the introductory pages of the book, Alcoholics Anonymous (A.A. World Services, 2001). Yet even this is not precisely accurate, for what Dr. Silkworth offered was not some theoretical explanation of “alcoholism” but a potent description of the alcoholic. “What alcoholism is” was not among the chief worries of the earliest A.A. members. In fact, “what alcoholism is” has never been among the main concerns of later members of Alcoholics Anonymous. Consistently over time, members of Alcoholics Anonymous, especially as members of Alcoholics Anonymous, have been interested not in alcoholism but in alcoholics–in people rather than in things. At the time of the birth and youth of Alcoholics Anonymous, from 1934 through its self-proclaimed “Coming of Age” in 1955, the understandings that “the alcoholic” was a person who “had alcoholism” and that alcoholism was a Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 9 disease were commonplace in the professional literature. As a report of the Scientific Committee of the Research Council on Problems of Alcohol put it in 1938: “An alcoholic should be regarded as a sick person, just as one who is suffering from tuberculosis, cancer, heart disease, or other serious chronic disorder” (Johnson, 1973, p. 244). Those doubting that “disease” was the orthodoxy before Alcoholics Anonymous came onto the scene should read Genevieve Parkhurst’s (1937) “Drinking and Alcoholism” in Harpers Magazine. From the mid-1940s on, at first from a base within Yale University’s Center of Alcohol Studies, the National Committee on Education on Alcoholism–later the National Council on Alcoholism–actively pushed this understanding under the guiding hand of Mrs. Marty Mann (Roizen, 2001). Few in that era questioned the terminology or its assumptions: Alcoholism-understood-as-disease “worked” and thus passed the pragmatic criterion of truth that ruled the age of World War II and its immediate aftermath. What it “worked” at doing, as Dwight Anderson had set forth even before Ms. Mann arrived on the scene, was to elicit the kind of attention and concern that led to help for the alcoholic (Anderson 1942). But the setting of the RCPA and Howard Haggard’s early Yale efforts were only background, and in fact a context to which A.A. almost from its beginnings contributed. For as co-founder Bill Wilson’s personal history and the opening of the book Alcoholics Anonymous attest, A.A.’s early understanding of alcoholism came to it directly from Dr. William Duncan Silkworth, who viewed alcoholism as a manifestation of allergy. As set forth in “The Doctor’s Opinion” introduction to Alcoholics Anonymous (2001), what A.A. learned from Dr. Silkworth was that: . . . the body of the alcoholic is quite as abnormal as his mind. It does not satisfy us to be told that we cannot control our drinking just because we were maladjusted to life, that we were in full flight from reality, or were outright mental defectives. These things were true to some extent, in fact, to a considerable extent with some of us. But we are sure that our bodies were sickened as well. In our belief, any picture of the alcoholic which leaves out this physical factor is incomplete. The doctor’s theory that we have a kind of allergy to alcohol interests us. As laymen, our opinion as to its soundness may, of course, mean little. But as ex-alcoholics, we can say that his explanation makes good sense. It explains many things for which we cannot otherwise account. (A.A. World Services, 2001, p. xxvi) As centrally important as Silkworth’s “allergy” and “obsession” ideas were to prove in the continuing understanding that members of Alcoholics Anonymous had of themselves, there is an even deeper significance and contribution tucked away in his “Doctor’s Opinion” letter in the A.A. Big Book, where he also noted that: “We doctors have realized for a long time that some form of moral psychol- Downloaded by [Walden University] at 15:32 05 January 2018 10 ALCOHOL PROBLEMS IN THE UNITED STATES ogy was of urgent importance to alcoholics. . . .” (A.A. World Services, 2001, p. xxvii). Therein lie both the problem and the promise of any investigation of Alcoholics Anonymous and the disease concept of alcoholism. For disease in its many names has also long served as metaphor (Sontag, 1978; Kurtz, 1979), and “moral psychology” hints of a realm beyond the physical. Our study of Alcoholics Anonymous and the disease concept of alcoholism, then, will necessarily involve more than the obvious, first-level, physical-science aspect of that question. Again, recall that p. 44 “definition” of alcoholism as “an illness which only a spiritual experience will conquer” (A.A. World Services, 2001). A supplementary note on the meaning of disease in early Alcoholics Anonymous, at least to its most medically educated member: In 1938, while preparing the manuscript of the A.A. Big Book, Bill Wilson asked Dr. Bob Smith (a proctologist) about the accuracy of referring to alcoholism as disease or one of its synonyms. Bob’s reply, scribbled in a large hand on a small sheet of his letterhead, read: “Have to use disease–sick–only way to get across hopelessness,” the final word doubly underlined and written in even larger letters (Smith [Akron] to Wilson, 15 June 1938). Reading through the Big Book stories that mention Dr. Smith, one finds consistent emphasis on the thematic reminder that an alcoholic cannot safely drink alcohol ever again. (See for example the almost paradigmatic story of Bill D., “Alcoholics Anonymous Number Three,” p. 187 of the second edition.) A.A. may be a “day at a time program,” but the admission of powerlessness over alcohol, the surrender to hopelessness, could not be a retractable event, and if the way to get this across was to talk in terms of “disease” or “allergy,” then thus would A.A.s carry their message. Certainly Dr. Bob, who had his own “slip” after his first meeting with Bill Wilson, had no doubt about the importance of remembering this facet of his own alcoholism. As has long been recognized by scholars, any study of Alcoholics Anonymous presents unique difficulties (Bebbington, 1976; Miller & Kurtz, 1994). Not only the anonymity of the fellowship but the emphasis on “spirituality” in its program and its utterly anarchical structure render all generalizations problematic. Especially in recent years also, since the burgeoning of so-called “Twelve-Step Programs,” the common popularity of Alcoholics Anonymous has led to much misinformation (Kurtz, 1996). Nor, indeed, is all the error “misinformation”: Varieties have become the keynote of the contemporary Alcoholics Anonymous experience. Virtually the only valid generalization about Alcoholics Anonymous is that there is none, save that its members have “the desire to stop drinking,” the listed membership requirement–and even that has been recently challenged by some non-alcoholic drug addicts who wish to attend closed (members only) A.A. meetings. Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 11 But we need not wrestle with these later complexities, for our topic is first an historical one. Our first question, then, is what members of Alcoholics Anonymous thought and taught in the years when the disease concept of alcoholism attained prominence and became, for most, the usual way of understanding the phenomenon of alcoholic drinking–a term then understood to be characterized by a lack of control over one’s drinking (Keller, 1960; 1972; 1976; 1982). And our first research question becomes what sources are to be used in our study. No A.A. member sober before 1942 is still alive. Some of that first generation recorded their memories in later years, and those recollections are useful, although the accuracy of many of those narrations is open to question. At times, interviewers patently led their subjects into their own agenda; in other cases, the “high-event” setting of a special occasion evoked ritual remembrance rather than actual memories. Where, then, do we turn? Members of Alcoholics Anonymous have been and are those who say that they are members of Alcoholics Anonymous; those who say they are members of Alcoholics Anonymous are those who are self-defined members of Alcoholics Anonymous. The main source of such self-descriptions–“stories [that] disclose in a general way what we used to be like, what happened, and what we are like now” (A.A. World Services, 2001, p. 58), in the hallowed words of the A.A. Big Book–are, of course, the stories told by members of Alcoholics Anonymous. We find these stories in especially two places: the book Alcoholics Anonymous and the monthly publication The A.A. Grapevine. Both sources have flow: The A.A. Grapevine by its periodical nature, and the A.A. Big Book by virtue of its successive editions. Originally published in 1939, the second edition of Alcoholics Anonymous appeared in 1955, the third in 1976, and the fourth in 2001. The model stories, of course, are those contained in the book Alcoholics Anonymous, and not least “Bill’s Story,” with which that book opens, and the story of Dr. Bob Smith that begins its “Personal Stories” section. Key to both founding stories is the principle reflected in A.A.’s Fifth Tradition: “Each [A.A.] group has but one primary purpose–to carry its message to the alcoholic who still suffers.” Alcoholics Anonymous began because Bill Wilson carried his message to Dr. Bob Smith, and A.A. began to grow because they both went to carry their message to “A.A. Number Three,” Bill D. The message, of course, is that recovery is possible. And that message is conveyed by the presence of someone who has recovered from alcoholism telling the story of that recovery. In order to understand the relationship of Alcoholics Anonymous to the disease concept of alcoholism–indeed, in order to understand anything about Alcoholics Anonymous–it is necessary to get inside the minds of its first generation, those drinkers who turned to the fellowship and its program out of desperation and then went on, as part of their recovery, to carry the message of their recovery Downloaded by [Walden University] at 15:32 05 January 2018 12 ALCOHOL PROBLEMS IN THE UNITED STATES to other alcoholics. This is not an easy task in an age when the popularization of alcoholism treatment and various forms of legal and/or moral coercion incline most to think that they “know about” alcoholism. Even the word desperation may cause pause: with so many and so varied helps available for those whose lives are disrupted by their drinking of alcohol, why should anyone in such a situation feel desperate? But such were not the realities when Alcoholics Anonymous came into being. And understanding the story of A.A.’s relationship with the disease concept of alcoholism requires an imaginative leap into that history, a stripping away of what we think we know about alcoholism, a forgetting of all the supposed gains of the modern alcoholism movement, an ignoring of what the National Council on Alcoholism and Drug Dependence in its various incarnations and other agencies, governmental and private, have propagandized for well over the past half century. The stories in the first edition of the book Alcoholics Anonymous help ease that leap. What was it like to be an alcoholic in the 1940s? The term alcoholic may trouble some, but we need not get into distinctions between alcohol abuse and alcohol dependence, problem drinking or chronic alcoholism. The designation alcoholic was used at the time, and it meant simply the description offered in the A.A. Big Book of “alcoholics like us”–drinkers who can stop drinking but who apparently cannot stay stopped. They want to stop getting drunk. They mean to stop getting drunk. They resolve to stop getting drunk. But their experience tells them, time and time and time again, that they cannot stop getting drunk. We are not looking here for scientific precision: our goal is rather human experience as expressed and understood in that era (see Peabody, 1931; Strecker & Chambers, 1938). And the main thing that the human experience of the alcoholic tells him–certainly in the 1940s but likely also in the 2000s–is that he, or she, does not understand, cannot grasp, what is going on. To an extent probably inconceivable to most who glibly converse about alcoholism, the alcoholic at what A.A. calls “bottom” is terrified. We are taught to value control. To be civilized, to be human, is to be in control, certainly in control of oneself. And we do control much. In fact, the successful drinking alcoholic who remains employed is a wizard of control. To devote most of one’s energy to appearing to be successfully in control but to know within oneself that one is out of control–this is terror. The terror resides in “What is wrong with me?!” Just stop there, with those words, with that word. Don’t gloss the phrase or ask, “Why?” Just realize that something is terribly, horribly wrong with you, and you do not have any idea what it is. Of course, other people do. Others are all too willing to tell you what is wrong with you. We need not rehearse their diagnostic explanations, which range from the religious to the psychological to the physical to the volitional and back again. What we do need to understand, if we would grasp the origins of Alco- Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 13 holics Anonymous and its earliest members’ understanding of alcoholism, is the dark pit of confused despair on the brink of which every alcoholic teetered back in the enlightened decades of the 1930s and 1940s.1 Let me reiterate the point for the sake of accurate emphasis: the chief characteristic of those whose lives were disrupted by the drinking of alcohol sufficient to move them to look into Alcoholics Anonymous, however cursorily, was that they did not understand what was going on within themselves. For whatever reasons of compassionate listening or experience-based theoretical insight, Dr. William Duncan Silkworth captured what this experience of alcoholism felt like to the early members of Alcoholics Anonymous in his famed “The Doctor’s Opinion” Preface to the A.A. Big Book. Recall again the words of the earliest A.A. members: “The doctor’s theory . . . interests us. As laymen, our opinion as to its soundness may, of course, mean little. But as ex-alcoholics [later changed to “ex-problem drinkers”], we can say that his explanation makes good sense. It explains many things for which we cannot otherwise account (A.A. World Services, 2001, p. xxvi, emphasis added). A chief point of this paper is that at least into the mid-1970s, most individuals who approached Alcoholics Anonymous were confused to the point of being terrified because they did not understand what was happening to them. Some, many, reached out desperately to any explanation that came along, from oral fixation to “momism” to latent homosexuality–at least it afforded “an answer.” But continuing experience soon taught the thinness of those answers. What Alcoholics Anonymous did, generally by using the words and ideas of Dr. Silkworth, was to suggest an understanding, an explanation, that “fit”–that explained many things for which we could not otherwise account . . . that meshed with the actual, lived experience of these alcoholics. The question for these individuals was not “moral or medical”: most were individuals of high ideals all too ready to recognize and acknowledge their moral or behavioral deficiencies. They also knew that they were not “Skid Row bums,” though many feared that they might end up as such. Most also knew, despite the rhetorical flourishes of Marty Mann and a few others, that they were not evil people, moral reprobates. As their stories make consistently and abundantly clear, they were idealists, and recognized themselves as such even as they struggled with the pain of their constant falling short (see especially the second edition: A.A. World Services, 1955). But there is a larger point in Dr. Silkworth’s words: “We doctors have realized for a long time that some form of moral psychology was of urgent importance to alcoholics. . . .” (A.A. World Services, 2001, p. xxvii). We no longer speak of “moral psychology”; but Alcoholics Anonymous has been a large force in accustoming us to speak of spirituality (Kurtz, 1996). For what the earliest members of Alcoholics Anonymous did was not so much to embrace the already extant disease concept of alcoholism as to expand it. In the Downloaded by [Walden University] at 15:32 05 January 2018 14 ALCOHOL PROBLEMS IN THE UNITED STATES text of the book Alcoholics Anonymous itself, the word disease appears only once–in the term spiritual disease. And nearby, also on page 64, we read, “. . . we have been not only physically and mentally ill, we have been spiritually sick.” The contribution of Alcoholics Anonymous is not the idea of disease but of threefold disease–the realization that the alcoholic had problems in the physical, the mental, and the spiritual realms, the clear understanding that alcoholism is “an illness which only a spiritual experience will conquer.”2 Two things characterize the stories in the first edition of the book Alcoholics Anonymous, and neither of them is mention of disease, illness, or even “sick.” The first is sheer amazement at the discovery that someone else had thoughts and feelings about their drinking of alcohol similar if not identical to their own. The “secret” of Alcoholics Anonymous, the thing that makes A.A. work, is identification. As Marty Mann is reputed to have said to her fellow sanitarium inmate on returning to Blythwood from her visit to the Wilson home in Brooklyn Heights for her first A.A. meeting: “Grennie, we aren’t alone any more” (A.A. World Services, 1953, p. 18). The second striking characteristic of the stories in the first edition of the A.A. Big Book is a not dissimilar amazement over the centrality of “the spiritual.” Most of the stories in the first edition of the book Alcoholics Anonymous came from the nascent fellowship’s Akron members: there were twice as many sober in Akron as in New York, and even as the book-writing process unfolded, the Akronites also revealed a steadier sobriety, less tendency to relapse. A constant theme in Akron, soon echoed and expanded by those who visited there from Cleveland, Chicago, Detroit and other midwestern points in order to be hospitalized and have their detoxification supervised by Dr. Smith, concerned the impact made on them by the simple fact that this M.D., this physician, when he spoke with them about their drinking, spoke mainly if not only about “the spiritual.” Explicit emphasis on the spiritual evidences itself differently in the stories of the New Yorkers, most of whom had been proudly agnostic when they first encountered Alcoholics Anonymous (A.A. World Services, 1955). The centrality of spiritual change as essential to its program was recognized by the first scholars who examined Alcoholics Anonymous, though as good scientists they did not let the word “spiritual” escape their pens. Bowman and Jellinek in their 1941 Quarterly Journal of Studies on Alcohol article, “Alcohol Addiction and Its Treatment,” after citing the A.A. Big Book as well as Silkworth’s (1939) two articles mentioning A.A. (and his two 1937 pieces on “allergy”), observed: “Religious conversion without the aid of ‘preaching’ and of the ‘holier-than-thou’ attitude is the fundamental idea of the Fellowship of AA. Although they insist that alcohol addiction is also a physical disease, probably of an allergic nature, they consider the main cause to be emotional maladjustment” (Np.). As we shall see, the vocabulary of “emotional maladjustment” will consis- Broader Treatment Perspectives 15 Downloaded by [Walden University] at 15:32 05 January 2018 tently reappear in professional studies of Alcoholics Anonymous. It may clothe the idea of “disease,” but its underlying import will always be that which A.A. members view as healed–made whole–by “the spiritual.” THE A.A. GRAPEVINE The book Alcoholics Anonymous, then, except for “The Doctor’s Opinion,” says little about disease and certainly attests that Alcoholics Anonymous did not originate the disease concept of alcoholism. The point is important not least because readers of the earliest issues of The A.A. Grapevine could be forgiven for thinking otherwise. Especially in its early years, the AAGV seemed dedicated to spreading the disease concept of alcoholism. The very first article of the very first issue headlined: “Two Yale Savants Stress Alcoholism a True Disease,” and the piece went on with a detailed description of the then-new Yale Plan Clinics.3 Similar articles follow in succeeding months, and early Grapevine news stories describe mainly members of Alcoholics Anonymous setting up or aiding hospital programs for alcoholics. Indeed, most mentions of “sick” and “disease” appear in the context of seeking necessary medical and hospital care for the physically deteriorated drunks whom A.A. members were more and more seeking out.4 Mann stated her point most clearly in a 1948 article on “The Alcoholic in the General Hospital” that appeared in Southern Hospitals: “It is our belief that the general hospital is the proper place for alcoholics in the acute stage of their illness. Hospitalization need not be of long duration–in most cases five days is found to be sufficient. Hospitalization for acute alcoholism is in no sense the same as the treatment of alcoholism itself, which may be, and usually is, a protracted affair” (Mann, 1948, p. 28). There is, however, not that large a difference between the A.A. Big Book and The A.A. Grapevine on the question of disease if we take their very different contexts into account. In the first place, among the “six ink-stained wretches” who began the AAGV were Marty Mann and three of her women friends. Mann apparently saw this venture as another way of spreading the ideas that led her to form the National Committee for Education on Alcoholism, which is given much prominence in early AAGV stories. But Mann’s involvement with the AAGV diminished as her NCEA activities expanded, and the publication’s emphasis on the physical aspect of the physical-mental-spiritual triad decreased as time went on, though the pattern of attending to NCEA (and later NCA) interests endured. Second, the mid-1940s were medically a very different time than the late 1930s. The Great Depression had ended and the “medical miracles” of the World War II years had sensitized people to the benefits of intensive medical care. Be- Downloaded by [Walden University] at 15:32 05 January 2018 16 ALCOHOL PROBLEMS IN THE UNITED STATES fore the war, hospitalization had been regarded as unusual, a last resort. Now, sulfa drugs, penicillin and the advances in surgery that wars invariably bring began the long process of making medical treatment in hospitals the rule rather than the exception. Hospitals were where the very sick were treated, and many of their long-drinking friends to whom members of Alcoholics Anonymous carried their message were very sick with the physical manifestations of their decades of alcoholic drinking. Third and perhaps most importantly, the AAGV began as a newsletter–at first as a local New York organ intended to serve as such other local A.A. publications as Cleveland’s Central Bulletin and The Eye-Opener of Los Angeles, later as an effort to maintain a kind of unity at least by awareness of what was going on elsewhere, a task that became increasingly important with the ever-accelerating geographic spread of Alcoholics Anonymous in the post-World War II years. The concern for what would soon be codified as A.A.’s second legacy, unity, remained as “unofficial” as everything else about the AAGV, but its centrality is evident in both the journal’s content and its internal documents. Only later and only slowly did The A.A. Grapevine become what its current cover proclaims “Our meeting in print.” Early issues contained no explicit stories. Those that began to sneak in appeared because another purpose of the AAGV was to keep A.A. members in the military services in some way connected with the fellowship. Quite a few of those military members wrote letters, that great infantry war pastime. Every issue from the first featured a “Mail Call for All A.A.’s in the Armed Forces.” In briefest outline, these letters detailed some problem that had arisen, told of a circumstance or happening that led to its resolution, and then reflected on the gift of a life now enriched by having gone through that experience as well as by the sobriety that made it possible. Not exactly “what we used to be like, what happened, and what we are like now,” but close enough to that outline to cement the relationship among “experience, strength, and hope.” After the war, in the September 1945 issue, this became “Mail Call for All A.A.s at Home or Abroad,” and the pattern continued for a time, until overtaken by the desire of members to discuss how they conducted meetings or initiated newcomers in their areas. But “Mail Call” was not the only source of letters to the AAGV. Under the early heading “Points of View,” the journal published comments about some of its articles. Early lead articles by non-A.A. members Philip (Generation of Vipers) Wylie and humorist S. J. Perelman invited comments, and features such as “The Children Say What A.A. Means to Them” kept up the flow. The April 1945 issue supplemented “Letters to The Grapevine” with “Tall, But True, Tales: As Told in A.A.” It did not last under that title, but the next several issues each feature a fairly long letter telling the kind of story described in the A.A. Big Book–tales of “what we used to be like, what happened, and what we are like Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 17 now” as they are told at A.A. meetings. Shortly after, in September 1945, there begin to appear “Vino Vignettes: Thumbnail A.A. Biographies,” which more closely followed the pattern set forth in the Big Book’s Chapter Five outline. This lengthy excursion into the early AAGV is important because, despite the obvious NCEA-inclined bias of the journal as revealed in many of its news stories, there is rarely a mention of “disease” or “illness” or even “sick” in the more story-formatted selections. The topics were life-change, living through difficulties without taking a drink, handling “emotional extremes,” what to do when a fellow member friend “slips,” home-care of a detoxifying drunk, the dangers of some medications, and other subjects that had to do with “living sober.” Before continuing our exploration of the stories of members of Alcoholics Anonymous in The A.A. Grapevine and succeeding editions of the A.A. Big Book, chronology requires noting other events that bear on our topic of Alcoholics Anonymous and the disease concept of alcoholism. Invited, under the auspices of Dr. Harry Tiebout (A.A. World Services, 1957, pp. 2-3), to present a paper at the Annual Meeting of the Medical Society of the State of New York on May 9, 1944, co-founder Bill Wilson responded with the article published as “Basic Concepts of Alcoholics Anonymous” (Wilson, 1944). The piece delineates A.A.’s debts to both medicine (at times, “psychiatry”) and religion, opening, after a brief, one-paragraph description of Alcoholics Anonymous, with the words: “Alcoholics Anonymous, or ‘A.A.,’ popularly so-called, has but one purpose–one objective only–‘To help other alcoholics to recover from their illness’ ” (Wilson, 1944, p. 1805). Wilson then continues in a way that foreshadows what will soon become the significant A.A. central emphasis on the threefold nature of the alcoholic malady: It is from you gentlemen we learn that alcoholism is a complex malady; that abnormal drinking is but a symptom of personal maladjustment to life; that, as a class, we alcoholics are apt to be sensitive, emotionally immature, grandiose in our demands on ourselves and others; that we have usually “gone broke” on some dream ideal of perfection; that, failing to realize the dream, we sensitive folk escape cold reality by taking to the bottle; that this habit of escape finally turns into an obsession, or, as you gentlemen put it, a compulsion to drink so subtly powerful that no disaster, however great, even near death or insanity, can, in most cases, seem to break it; that we are the victims of the age-old alcoholic dilemma: our obsession guarantees that we shall go on drinking, but our increasing physical sensitivity guarantees that we shall go insane or die if we do. When these facts, coming from the mouths of you gentlemen of science, are poured by an A.A. member into the person of another alcoholic they strike deep–the effect is shattering. (Wilson, 1944, pp. 1807-1808) Downloaded by [Walden University] at 15:32 05 January 2018 18 ALCOHOL PROBLEMS IN THE UNITED STATES Four years later, invited (again under the auspices of Dr. Tiebout) to present a paper at the 105th annual meeting of the American Psychiatric Association, held in Montreal, PQ, Canada, Wilson again reiterated and made clear whence Alcoholics Anonymous had derived its understanding of alcoholism not only as complex but as sickness–from the physicians themselves. After describing his own initial lack of success in attempting to work with alcoholics, Bill continued: . . . religious practice [Bill’s shorthand description of his own “spiritual experience”] would not touch the alcoholic until his underlying situation was made ready. Fortunately all the tools were at hand. You doctors supplied them. The emphasis was straightway shifted from “sin” to “sickness”–the “fatal malady,” alcoholism [italics in original]. We quoted doctors that alcoholism was more lethal than cancer; that it consisted of an obsession of the mind coupled to increasing body sensitivity. These were our Twin Ogres of Madness and Death. (Wilson, 1949, p. 260) Years later, describing his Montreal talk, Wilson recalled how after his presentation a past-president of the A.P.A. had noted to him that “outside of the few A.A.s in the room, and myself, I do not think a single one of my colleagues believed a word of your explanation.” Bill expressed surprise, for he had been warmly applauded. “. . . the old man replied, ‘Well, Mr. Wilson, you A.A.s have a hundred thousand recoveries and we in the psychiatric profession have only a few. They were applauding the results much more than the message’ ” (Wilson to Dr. John G., 9 October 1967). Another version of this story, retold by a longtime sober A.A. member, ran that Bill had been cautioned about the applause: “Don’t take it too seriously: they were not applauding your ideas but your results. You see, they know that they have not had much luck with alcoholics, and they are grateful to A.A. for getting the alcoholics out of their hair.” “Improved” as both these stories may be, each well captures the point at issue here. Especially in the era in question, for physicians or psychiatrists, the question of alcoholism as disease involved more than a mere question of human physiology or psychology. The treatment of disease was a function of the science of medicine (Haynes, 1988). But here was a disability, “alcoholism,” that had proven singularly unamenable to medical treatments. If physicians or psychiatrists could not cure or even treat it, how could it be disease? One attempted answer, the major psychiatric one, was to suggest that alcoholism was not disease but symptom. Yet this hardly solved the problem if even as symptom the phenomenon resisted medical/psychiatric intervention but became amenable to the approach of Alcoholics Anonymous. Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 19 In 1941, Bowman and Jellinek had cited the A.A. Big Book in explaining that members of Alcoholics Anonymous, “Although they insist that alcohol addiction is also a physical disease, probably of an allergic nature . . . consider the main cause to be emotional maladjustment” (Bowman & Jellinek, 1941). By the early 1950s, Bowman and Jellinek’s “emotional maladjustment” as well as later psychiatric explanations of alcoholism had given way in A.A.’s own understanding to a focus on the spiritual dimensions and aspects of the alcoholic disease, malady, illness, sickness, whatever . . . and of recovery from it. Unsurprisingly, the desire arose to codify the emerging understanding–or at least to set it forth in a form available and acceptable to all members. And so Bill Wilson set out to write a book on the heart of the spirituality of both the program and the fellowship of Alcoholics Anonymous: Twelve Steps and Twelve Traditions.5 TWELVE STEPS AND TWELVE TRADITIONS The book Twelve Steps and Twelve Traditions (12&12) (A.A. World Services, 1953) says little about the disease concept of alcoholism; it offers much on all aspects of the spiritual dimensions of the alcoholic condition. One commentator suggested that this book “was A.A.’s New Testament–bringing to fruition the original revelation of the Big Book, Alcoholics Anonymous (Kurtz, 1991, p. 124). A more nuanced observation might suggest that one purpose of this later work was to shift attention from a possible overemphasis on the literal-physical to “the spiritual” aspect in danger of being overshadowed. This is not the place to explore the many issues discussed in the “12&12,” as it is usually referred to by members of Alcoholics Anonymous. Important for our purposes are two points: (1) the 12&12 says virtually nothing about alcoholism as physical disease; (2) the 12&12 does, sometimes in the vocabulary of psychology but most often in the language of spirituality, delineate at some length and in greater detail the spiritual aspects of the alcoholic condition, drinking or recovered. Thus, the book’s discussion of Step One does mention that “our sponsors pointed out our increasing sensitivity to alcohol–an allergy, they called it” (p. 22). But the emphasis of the essay is on “personal powerlessness” and “complete defeat.” Like the vocabulary of “instincts” that Wilson used in discussing the “moral inventory” of Step Four in the 12&12, the language of disease, wherever it appears in not only in the 12&12 but in Alcoholics Anonymous in general, is more important for what it points to than for the signifier itself–and that to which both point is the spiritual condition of the alcoholic. Bill began formal work on the articles that became Twelve Steps and Twelve Traditions only in 1952. Published first as a series of articles in The A.A. Grape- Downloaded by [Walden University] at 15:32 05 January 2018 20 ALCOHOL PROBLEMS IN THE UNITED STATES vine, the book itself appeared in 1953, just as Wilson set off on two other projects, the examination of which will carry forward our exploration of Alcoholics Anonymous and the disease concept of alcoholism: (1) the revision of the “story section” for the second edition of the book Alcoholics Anonymous, published in 1955; and (2) the telling of A.A.’s own story in the book that would be published in 1957 as Alcoholics Anonymous Comes of Age (AACA) (1957). Although not a formal or documented history, exhaustive research went into the production of AACA, and so what is says about the disease concept of alcoholism merits attention. In both Twelve Steps and Twelve Traditions (1953) and Alcoholics Anonymous Comes of Age (1957), more important than what is there is what is not there. Here, in two of the three major texts of Alcoholics Anonymous, there appeared no discussion and bare mention of “disease,” much less of the disease concept of alcoholism. This is a not insignificant omission. Yes, many members of Alcoholics Anonymous did speak in terms of their alcoholism as disease. But its paucity of mention in the officially published works of the period suggests that this understanding was hardly central to the thought of Alcoholics Anonymous. The books were self-conscious central statements of the A.A. program and the A.A. fellowship’s own story. Each was intended to be as definitive as the context allowed. Such situations do not invite silence about assumptions, no matter how widely assumed to be held. The vocabulary of “disease” was common because it was handy. The reality of disease was a matter of assumption but not necessarily of conviction. If it were as central as some claim, we would hear more about it in these two cornerstone works of what some like to call “the A.A. ideology” (Ogborne & Glaser, 1981; Skinner, 1994). That context may be even better appreciated if we take a moment to revisit to The A.A. Grapevine of the early 1950s. Following its newsletter style, that journal in March 1952 offered an article: “Stethoscope and Periscope: The Doctors Look at Alcohol.” Subtitled “A Grapevine Medical Report,” the piece noted “[t]hat there is a strong new beat to the pulse of the medical profession’s recognition of alcoholism as a disease is indicated by even a casual survey of current medical journals.” It went on to offer brief–and accurate–report-summaries of the articles (A.A. World Services, 1952a, Np.). Two months later, in May 1952, an article titled “AA and GPs: Family Doctors Study the ‘Problem Drinker’ ” listed speakers at the Fourth Annual Scientific Assembly of General Practice. Bill Wilson noted in the piece that “It was a little doctor who loved drunks, the late William Duncan Silkworth, who first told me that alcoholism was a disease, and gave me thereby an indispensable basis for AA’s later developed therapy” (A.A. World Services, 1952b, Np.). The listed program on “The Problem Drinker,” into which Alcoholics Anonymous had no input, stated: “The alcoholic becomes a problem to the family physician. Alco- Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 21 holism is now recognized as a form of illness. As such it is medicine’s responsibility to study, treat, and attempt preventive measures in this disorder of human behavior” (Np.). Also first published by the General Service Office (later “Alcoholics Anonymous World Services”) in 1952 was the still-in-print-in-2000 A.A. pamphlet, “A.A.–44 Questions.” Since some tend to refer to this brochure out of context, here is its complete answer to the question, “What is Alcoholism?” What is Alcoholism? There are many different ideas about what alcoholism really is. The explanation that seems to make sense to most A.A. members is that alcoholism is an illness, a progressive illness, which can never be cured but which, like some other illnesses, can be arrested. Going one step further, many A.A.s feel that the illness represents the combination of a physical sensitivity to alcohol and a mental obsession with drinking, which, regardless of consequences, cannot be broken by willpower alone [italics in the original]. (A.A. World Services, 1952c, p. 4) Note the too-often overlooked qualifications: “many different ideas”; “seems to make sense to most A.A. members”; “many A.A.s feel.” Such is not the vocabulary of doctrine. Did A.A.s use the disease concept of alcoholism? Yes. Did A.A.s or A.A. originate or rediscover or dogmatically push the disease concept of alcoholism? Clearly, no. THE SECOND EDITION OF ALCOHOLICS ANONYMOUS The main difference in the “new and revised” second edition of the book Alcoholics Anonymous was its expanded section of “Personal Stories.” The first 164 pages of the text, as is well-known, remained unchanged with a few exceptions: the second printing’s reduction of the first printing’s old-style capitalizations remained, as did the eleventh printing’s change from “ex-alcoholics” to “ex-problem drinkers.” Silkworth’s “The Doctor’s Opinion” was now paginated in Roman numerals, with the intended result that the book proper now began on page one with “Bill’s Story.” The stated main purpose of the expanded story section was to broaden the bases for identification. With one exception, the first edition’s storytellers had been middle-class, middle-aged white males whose alcoholic drinking had cost or at least seriously jeopardized comfortably stable employment. By the early 1950s there were women in A.A.–about one in five members were female. And there were Blacks in A.A.–in fact, there was “a Negro Group” in three separate cities. But most importantly, since the mid-1940s, “high-bottom” drunks had appeared in A.A.–those who, in the heading over their stories–“stopped in time” Downloaded by [Walden University] at 15:32 05 January 2018 22 ALCOHOL PROBLEMS IN THE UNITED STATES (Kurtz, 1979, p. 132; A.A. World Services, 1957, p. 199). The fellowship was especially interested in attracting more of these, mainly for the altruistic reason of saving others from the horrors they themselves had undergone. Despite the genuineness of this effort, only three of the stories that appeared in the second edition recount “high bottom” experiences (Kurtz, 1979, p. 132). But more to our purposes, of the thirty-seven stories in the second edition, twenty-one make absolutely no mention of disease, illness, malady, or even “sick.” Of those that do mention “disease,” all but two emphasize the progressive nature of the alcoholic malady–a clear reflection of the aim to motivate those who had not yet reached absolute bottom. This edition did offer Marty Mann’s story, “Women Suffer Too”: if anything, its strident emphasis on “disease” makes the absence of that advertence in most of the other stories all the more striking (A.A. World Services, 1955). The other heavy “disease” story presents a similar problem. The author of “A Flower of the South,” which appears in the “They Stopped in Time” section, tells how she was given the Jack Alexander (1941) Saturday Evening Post article on A.A. I could see that horrible picture of the awful drunk on the first page; he couldn’t get the drink to his mouth, he had a towel around his hand and he needed a shave. But, from the very first paragraph on, something happened to me. I realized that there were other people in this world who behaved and acted as I did, and that I was a sick person, that I was suffering from an actual disease. It had a name and symptoms, just like diabetes or T.B. I wasn’t entirely immoral; I wasn’t bad; I wasn’t vicious. It was such a feeling of relief that I wanted to know more about it and with that, I think for the first time, came the realization that there was something horribly, horribly wrong with me. Up to that time, I was so completely baffled by my behavior that I had never really stopped to think at all. (A.A. World Services, 1955, p. 351; see also Roizen, 2001) One wonders whence that realization came, since there is no mention of “disease” or “illness” or “malady” or even “sick,” not to mention of “immoral” or “vicious” in the Jack Alexander article (Alexander, 1941, pp. 89-90). As with many of the first edition stories, Dr. Bob’s personal spirituality was emphasized by all who mention him (A.A. World Services, 1955, pp. 217-219). When illness or disease are mentioned, it is almost in passing, never even nearly as central as in the stories of Mann and “A Flower of the South.” Sometimes, the topic entered as humor: My sister heard about this [his wife leaving], and she came running over to the house and says to my wife, “Now wait a minute, before you do a tragic thing like this and leave my brother! Do you realize he is a sick man?” Boy, Broader Treatment Perspectives 23 Downloaded by [Walden University] at 15:32 05 January 2018 I thought that I was out of this world–such kind words as “a sick man”! You ought to hear what my family called me before that! (A.A. World Services, 1955, p. 446) ALCOHOLICS ANONYMOUS COMES OF AGE Published in 1957 but based largely on oral presentations given at A.A.’s “Coming of Age” Twentieth Anniversary Convention held in St. Louis in 1955, Alcoholics Anonymous Comes of Age is A.A.’s first telling of its own story. History, the accurate history of the A.A. Fellowship, was important to Bill Wilson. For one thing, he had abandoned his exploration of Christian Science as a possible cure for his drinking problem when he found, so he thought, that the organization had falsified its history (Thomsen, 1975). More importantly and practically, as Alcoholics Anonymous spread and grew, different local “origin stories” sprang up in some locales, and occasional arguments over historical points seemed in places to threaten the Fellowship’s unity. And so Wilson set out, beginning in 1954, to record his own recollections and those of as many old-timers as he could arrange to interview. Drawing on the General Service Office’s files of inquiry correspondence, he also sent countless letters to those who had started or attempted to start groups, especially in new places, asking for information on the early groups that had begun . . . or failed. Bill presented the tentative results in his talks at St. Louis in 1955. The book Alcoholics Anonymous Comes of Age consists mainly of those presentations, but changes and additions were made in response to conflicting or simply diverse memories elicited by Wilson’s St. Louis talks and his distribution of a preliminary draft of the manuscript. But historiography is not the point here. What is significant is that, given the often assumed centrality of the disease concept of alcoholism to Alcoholics Anonymous, one would expect prominent mention if not explicit discussion of so central an idea. If it were really so central, one would no doubt find it. At the very least, if “disease” had substantive importance, someone in the vast correspondence over the draft would surely have remarked on the absence of its mention. But such is not the case: the dog does not bark. Wilson describes his interaction with Dr. Silkworth in familiar Big Book terms, but with no glosses or added evidence. In the book’s eagerness to recognize both “medicine and religion” as sources of Alcoholics Anonymous, presentations by the Rev. Samuel Shoemaker and Father Edward Dowling balance those of American Medical Association President Dr. W. W. Bauer and Dr. Harry M. Tiebout. The book offers much on the acceptance of A.A. by the medical profession; it offers nothing on “disease” beyond the familiar Silkworth ideas of obsession and allergy. Downloaded by [Walden University] at 15:32 05 January 2018 24 ALCOHOL PROBLEMS IN THE UNITED STATES A significant mention does turn up in Wilson’s retelling of his first meeting with Dr. Bob Smith. In both Big Book tellings of Dr. Bob’s story–“A Vision for You” and “Dr. Bob’s Nightmare”–the details of Bill’s presentation at their first meeting are sparse. In St. Louis, however, Wilson offered a new detail, one relevant to our larger topic: In our first conversation I bore down heavily on the medical hopelessness of Dr. Bob’s case, freely using Dr. Silkworth’s words describing the alcoholic’s dilemma, the “obsession plus allergy” theme. Though Bob was a doctor, this was news to him, bad news. Always better versed in spiritual matters than I, he had paid little attention to that aspect of my story. Even though he could not make them work, he already knew what the spiritual answers were. What really did hit him hard was the medical business, the verdict of inevitable annihilation. And the fact that I was an alcoholic and knew what I was talking about from personal experience made the blow a shattering one. (A.A. World Services, 1957, pp. 69-70) As noted, this is a significant mention. What seems more significant is that so far as I am aware, no one in or out of Alcoholics Anonymous has ever picked up on this passing mention to make anything of it concerning A.A. and the disease concept of alcoholism. Perhaps that was because the main mention of “disease” at the 1955 convention and in the 1957 book came from Dr. W. W. Bauer, who offered the first of two presentations on “Medicine Looks at Alcoholics Anonymous.” Bauer represented the American Medical Association. Unlike Dr. Harry Tiebout, who followed him to the platform, Bauer was not a psychiatrist. He might as well have been, for his theme was that the alcoholic is “a sick person,” someone afflicted by “emotional illness.” Concluding, he again reminded his audience “how important it is that people realize what alcoholism really is: a devastating emotional illness that must be treated according to psychosomatic principles” (A.A. World Services, 1957, pp. 237-244). If members of Alcoholics Anonymous came away from St. Louis in 1955 convinced that they suffered a “real disease,” it was not by other A.A. members that understanding had been reinforced. A JOSTLING FROM OUTSIDE: THE COURTS, THE SUPREME COURT, AND THE CONGRESS OF THE U.S.A. The disease concept of alcoholism became a legal issue when the social changes of the 1960s moved attention from alcoholism itself to public drunkenness. As an issue connected with broader understandings of addiction, it ranges Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 25 far beyond the borders of our focused inquiry on Alcoholics Anonymous and the disease concept of alcoholism. We must nevertheless touch on it, for the role of the many A.A. members in the National Council on Alcoholism and the testimony of A.A. co-founder Bill W. before a Senate subcommittee preparing what become known as “The Hughes Act” are a part of our story. For a surprisingly long period after its “Coming of Age” in 1955, Alcoholics Anonymous grew peacefully, with little direct attention to its understanding and presentation of alcoholism. The fellowship weathered its trustee-ratio change and the first attacks launched on it in the national press. At Toronto in 1965, it adopted its “Declaration”: “I Am Responsible. When anyone, anywhere, reaches out for help, I want the hand of A.A. always to be there. And for that: I am responsible.” There were a few who wished to see that sense of responsibility extended even further, but true to A.A. tradition on “outside issues,” most in the fellowship were happy to leave the “politics of disease” front to the National Council on Alcoholism and its redoubtable director, Mrs. Marty Mann. One claim imputed to Marty was that “N.C.A. will do the things A.A. cannot do.” Some, but not even nearly all, members of N.C.A. were also members of A.A.; most members of A.A. were not members of and had little interest in N.C.A. (Kurtz, 1979, Ch. 6). The issue of the era, by the late 1960s, had become public intoxication or drunkenness as crime. Could someone be arrested and jailed simply because they were drunk in public? Most jurisdictions had statutes against public drunkenness, but there now evolved what Carolyn Wiener has well described as “building an arena around a social problem” (Wiener, 1981). Largely because of the presence of the National Council on Alcoholism and its passion to make alcoholics, if not alcoholism, respectable, Alcoholics Anonymous could remain uninvolved in this arena and the significant court decisions that issued from the struggles in it–the Easter, Driver, and Powell cases. For those forgetful of the details, in 1965 and 1966, in the cases of DeWitt Easter and Joe Driver, respectively, the United States Court of Appeals for the District of Columbia and the United States Court of Appeals for the Fourth District both unanimously reversed earlier convictions for public intoxication. The DC court held that because Easter “was a chronic alcoholic,” he could not be convicted for behavior that was an involuntary product of his disease (Johnson, 1973, pp. 114, 142). The Fourth Circuit Court of Appeals stated in its decision: “The addiction–chronic alcoholism–is now almost universally accepted medically as a disease” (Johnson, pp. 115, 142). In 1968, after much maneuvering by attorney Peter Barton Hutt and the American Civil Liberties Union (but not the N.C.A.), the case of Leroy Powell was accepted by the United States Supreme Court. The court, in a 5 to 4 decision, upheld Powell’s conviction for public drunkenness by the State of Texas on the grounds that he did have access to a residence and so did not have to be intoxicated in a 26 ALCOHOL PROBLEMS IN THE UNITED STATES Downloaded by [Walden University] at 15:32 05 January 2018 public place. Key to the Texas decision had been three “findings of fact” made by the trial judge in the original county court: 1. “That chronic alcoholism is a disease which destroys the afflicted person’s will power to resist the constant, excessive consumption of alcohol. 2. That a chronic alcoholic does not appear in public by his own volition but under a compulsion symptomatic of the disease of chronic alcoholism. 3. That Leroy Powell, defendant herein, is a chronic alcoholic who is afflicted with the disease of chronic alcoholism.” Four Supreme Court Justices (Fortas, Brennan, Douglas and Stewart) agreed with those findings and sought to bring Powell under the protection of the Court’s 1962 reversal in Robinson v. State of California, in which it stated that the criminal justice system could punish acts, but not a “status” (Powell v. State of Texas, 1968, retrieved from http://wings.buffalo.edu/law/bclc/web/ powell.htm) and (Robinson v. State of California, 1962, retrieved from http:// wings.buffalo.edu/law/bclc/web/robinson.htm). The lead decision, however, written by Justice Marshall and concurred in by Chief Justice Warren and Justices Black and Harlan, strongly repudiated that attempt to extend Robinson and stated in what became, with Justice White’s partial concurrence, the official decision that (1) that the Texas court’s “ ‘findings of fact’ are not ‘findings of fact’ in any recognizable, traditional sense in which that term has been used in a court of law; they are the premises of a syllogism. . . .” and (2) that “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,’ ” citing E. M. Jellinek (1960) on the topic as its authority. Justice White’s opinion, in concurring with Justices Black’s and Harlan’s concurrence with the opinion of Justice Marshall, implied acceptance of alcoholism as a disease but focused on “public” aspect of the charge against Powell and the fact that he did have access to a residence. Argument still flourishes about both the interpretation of the Court’s opinions and the role of the National Council on Alcoholism in this outcome. For in the Powell case, somewhat shifting its previous stand, the N.C.A. less than wholeheartedly joined the list of amicus curiae when the case went to the Supreme Court, apparently because of its concern with the image of the alcoholic in the eyes of the American people. Leroy Powell was literally a Skid Row bum. But throughout N.C.A.’s history, Marty Mann, Ruth Fox, Yev Gardner, and others had worked to portray the “typical alcoholic” as an industrious and conscientious person who was the unfortunate victim of a disease. Supporting Powell, it was feared, could reinforce the down-and-out stereotype. A more active stance by N.C.A., some argue, would have brought Justice White into the explicitly “disease” column headed by Justice Fortas. According to Nancy Olson, Professional Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 27 Staff Associate on matters dealing with alcoholism for the Hughes Subcommittee, “Hutt [later told me] that Marty told him, after the Hughes Act had created the National Institute on Alcohol Abuse and Alcoholism, that she had been wrong” (Personal communications of April 7 & 8, 2001). Five-to-four decisions, of course, often continue to be argued among interested parties. An independent observer, historian Bruce Holley Johnson, in his 1973 dissertation on The Alcohol Movement in America: A Study in Cultural Innovation, held that “The Supreme Court of the United States, in other words, remained unconvinced that habitual drunkenness is, in fact, a disease” (Johnson, 1973, p. 373). Whether medical “truth” can be decided by Court judgment seems best left to the discussions of social constructionists and their adversaries. For our purposes here, the main social and cultural result of the Powell decision is that it provided the proximate context for Senator Harold Hughes’s involvement in alcoholism legislation. In mid-1969, the National Institute on Mental Health was planning to start funding alcoholism service grants under the Community Mental Health Centers Act of 1963. The newly-elected Senator Hughes, former three-term Governor of Iowa who had publically identified himself as “a recovered alcoholic,” had just become chairman of the Special Subcommittee on Alcoholism and Narcotics (later named the Subcommittee on Alcoholism and Drug Abuse) of the Senate Labor and Public Welfare Committee (as it was then named). In Iowa, Governor Hughes had established an alcoholism treatment program, presenting it as an “alternative to the state mental hospitals” and an attempt to “reach alcoholics before they reach rock bottom” (Remembering Harold Hughes, Nd., Para 13). Now in the Senate, Hughes introduced the “Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act.” This bill, after appropriate hearings, passed both Houses of Congress and was signed into law by President Richard M. Nixon on December 31, 1970, as Public Law 91-616. From the beginning, it was popularly known as the “Hughes Act” (Remembering Harold Hughes, Nd., Para. 2). The provisions of the Hughes Act, especially its establishment of grant programs in support of treatment, would profoundly change everything concerning alcoholism and its treatment in the culture of the United States. Before turning to examine the effects this had on the relationship between Alcoholics Anonymous and the disease concept of alcoholism, it is useful to glance at the testimony of “Bill W., Cofounder of Alcoholics Anonymous,” before the Hughes Committee on July 24, 1969. Wilson followed Marty Mann to the microphone that morning. His presentation had two parts: (1) a recital of current statistics on Alcoholics Anonymous (“15,000 A.A. groups throughout the world and an active membership of 285,000”); and (2) the by now familiar retelling of his own story, beginning with Rowland H.’s efforts with Dr. Karl [sic] Jung, through his own “spiritual experi- Downloaded by [Walden University] at 15:32 05 January 2018 28 ALCOHOL PROBLEMS IN THE UNITED STATES ence,” to his May 1935 meeting with Dr. Bob Smith, to the publication of the A.A. Big Book, concluding with the “final suggestion, that the resources of Alcoholics Anonymous for mass society have hardly been touched.” The main problem A.A. faced, Wilson testified, was the “mass capacity of the alcoholic to rationalize himself out of his predicament.” The answer? “It is a process of education, but what kind of education we simply do not know. Another part of the resistance to Alcoholics Anonymous stems from the fact that it has a spiritual content and a great many of our professional friends are apt to believe that Alcoholics Anonymous is for the religiously susceptible only” (U.S. Government Printing Office, 1969). Not a mention, nor even a hint, then, of “disease” or “illness” or even “sick.” And given the linking by proximity of the final two ideas quoted, a case could be made that Wilson’s largest concern was the “education” of “our professional friends.” But Senator Hughes chose not to hear that and instead reframed a point Bill had made to connect it with his own interest in treatment: I take it from your testimony that as a cofounder of A.A. you certainly believe that in any program this committee and this Congress might develop, that there would be a place and a willingness for A.A. members to work in recovery, education, and counseling of the ailing alcoholics and prevention also? Possibly wondering whether that was all Hughes understood as “the resources of Alcoholics Anonymous for mass society,” Wilson replied: “I should think so. Of course, this is the pleasure of our friends.” Presciently he added: “I don’t like to see outside agencies just loaded up with A.A.” The topics of the rationale for treatment or A.A.’s or Bill’s own ideas on alcoholism-as-disease did not arise, perhaps because of Senator Hughes’s own respect for A.A.’s co-founder and its Twelve Traditions. But led by the N.C.A. and pushed on by Brinkley Smithers, the momentum for passage had been achieved, and those committed first and foremost to “treatment” triumphed as “The Hughes Act” was signed into law. The multifarious details and ultimate ramifications of Public Law 91-616 thankfully need not detain us here. Our interest remains Alcoholics Anonymous and the disease concept of alcoholism. Whether the Hughes Act gave federal government blessing to the disease concept, it was certainly thought to do so at the time–though this is a question less of research than of exegesis. As Wilson’s 1969 testimony hinted, enthusiasm for the Hughes Act was not universal within Alcoholics Anonymous. Certainly many members beyond Hughes, Mann and Smithers welcomed the promise of greater help for alcoholics without seeing the dangers inherent in the doors it opened to the exploitation of Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 29 alcoholics–and ultimately others–by a new generation of unscrupulous health care entrepreneurs. Apparently caught up in the excitement of the moment, the October 1970 AAGV printed an “adapted” version of an article originally published as “For Beginners” in the August 1958 AAGV: “Alcoholism is a Disease: The Essence of AA” (A.A. World Services, 1958). The piece opened: “Alcoholism is a disease. AA was the first to give me this bit of information” (p. 13). The writer did go on to note that “alcoholism is a disease with physical, mental and spiritual dimensions,” referring to it as a “serious, insidious, progressive disease” that becomes a “disease of despair and fear” (p. 15), but the emphasis clearly was on “the physical.” The reprinting of this article has been interpreted as marking “the movement of the disease concept from the periphery of A.A. thought to its center” (White, 2001, p. 5). I would suggest that, more accurately, it reflects the complexity of the impact of treatment programs on A.A. as that impact intensified. This led, in time, to a narrowing of what had been a far different reality that had been present in the fellowship since 1935: the “Varieties of the Alcoholics Anonymous Experience.” We will return to that facet of this article and its significances below. But here, first, it is useful to consider the article’s proximate context. Note that it was an “adapted” reprint. Three articles preceded it in the October 1970 AAGV, and each of them sheds useful light on wider A.A. opinions of the possibilities about to be opened up by the pending expansion of alcoholism treatment. The issue’s lead article, by John L. Norris, M.D., Nonalcoholic Chairman of the A.A. General Service Board, addressed “The Hazards of AAs’ Counseling for Pay” (pp. 2-3). The second article was by an A.A. member recently recruited from the factory floor to be a “rehabilitation counselor.” “We’re Chipping Away at the Stigma” ran its title, but there was no mention of “disease” (pp. 4-5). Finally the pp. 6-8 article, “Me, Expert?,” gently mocked an effort to get the author member of Alcoholics Anonymous “to teach what he knows” in an academic setting. If humor triumphs, as it usually does, this was the most telling AAGV commentary on the potential of the programs to be enabled by Public Law 91-616. Two months previously, in August 1970, non-A.A. physician G. E. Deering, M.D. had tackled the question, “Doctor, Why Can’t I Stop Drinking?” Deering replied under the heading “Psychiatry and Alcoholism,” in terms of “mental health” and relationships. There was no mention of disease. Meanwhile, outside of Alcoholics Anonymous, perhaps because of greater awareness of the dangers looming in rampant medicalization, scholars accelerated a reexamination of the disease concept of alcoholism. Classic among these efforts is David Robinson’s “The Alcohologist’s Addiction: Some Implications of Having Lost Control Over the Disease Concept of Alcoholism,” which noted that since Jellinek’s 1960 expansion of his original 1952 definition: “An ever-in- Downloaded by [Walden University] at 15:32 05 January 2018 30 ALCOHOL PROBLEMS IN THE UNITED STATES creasing range of conditions and behaviors may be conceptualized as related to stages in a disease process” (Robinson, 1972). In a world where the medical profession was increasingly considered to have competence in an ever-widening sphere of life, the term alcoholism had become so vague that it has lost its meaning (Cahalan, Cisin & Crossley, 1969). There were other such articles, but the disease traditionalists also battled back (Keller, 1972; 1982). In 1972, the Criteria Committee of the N.C.A. published its “Criteria for the Diagnosis of Alcoholism” in both American Journal of Psychiatry and Annals of Internal Medicine (Criteria Committee, National Council on Alcoholism, 1972; 1973; Seixas, 1972). In 1973, Dr. Stanley Gitlow observed: “The American Medical Association, American Psychiatric Association, American Public Health Association, American Hospital Association, National Association of Social Workers, World Health Organization, and the American College of Physicians have now each and all pronounced alcoholism a disease. The rest of us can do no less” (Gitlow 1973, Np.). But both the controversy and the research continued. Alcoholics Anonymous, meanwhile, after the death of co-founder Bill Wilson in January 1971, for a brief time seemed hesitant to publish any further literature. When A.A. did issue its first post-Wilson book, Living Sober, in 1975, the content accented the spiritual. There is little mention of disease or illness, but a more subtle change adumbrated the future. In discussing the all-important topic of sponsorship, anonymous author Barry L. introduced the subject by in-passing mention that “Often, the sponsor is the first person to call on a problem drinker who wants help . . . or the A.A. member volunteering to ‘sponsor’ an alcoholic about to be released from a detox or rehab unit, a hospital, or a correctional facility”(A.A. World Services, 1975, p. 23). A “rehab unit”: “treatment,” as it soon would be called, had attained sufficient presence to merit distinct mention. By the next year, some A.A.s, at least, had other things on their minds. 1976 saw the publication of the long-awaited third edition of the Big Book, Alcoholics Anonymous (1976). Even more than had been the case in 1955, many members eagerly hoped that the new edition’s “Personal Stories” section would better reflect the diversity of A.A. membership. A.A. members employed in the still-aborning treatment system especially emphasized the urgency of that broadening. Our concern here is whether those new personal stories attested to greater or broader commitment to the disease concept of alcoholism. THE THIRD EDITION OF ALCOHOLICS ANONYMOUS Many things in what had become “the alcoholism field” had changed by 1976. More would change in the next two decades. Already in 1974, Senator Harold Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 31 Hughes himself had warned about “a new civilian army that has now become institutionalized,” observing that “The alcohol and drug industrial complex is not as powerful as its military-industrial counterpart, but nonetheless, there are some striking similarities. . . .” (Hughes, 1974). Hughes probably did not have “the treatment industry” in mind, but he might well have. In 1966, there had been fewer than 200 alcoholism treatment programs in the U.S.; by 1977, there were 2,400; by 1987, there would be 6,800 (Schmidt & Weisner, 1993). Unsurprisingly, as A.A.’s own surveys would increasingly confirm, more and more people would come to Alcoholics Anonymous not at the suggestion of a physician or clergyperson but by way of a treatment program (McIntyre, 2000). However people who needed A.A. got to A.A., they were of course welcomed. But treatment programs had two problems that in places led to a rethinking of that welcome. In the first place, after detoxification and education (which usually emphasized alcoholism-as-disease), what? Experience suggested that the only way most alcoholics could attain lasting recovery was by following the program of Alcoholics Anonymous. But A.A. could not be packaged, much less sold, and the fellowship’s members were fiercely protective of the independence guaranteed by their Twelve Traditions. We shall examine more directly some of these tensions between Alcoholics Anonymous and treatment below, when we examine the later 1980s and 1990s. Treatment’s second problem involved its financing. Although popular celebrity alcoholics were lessening stigma by making the headlines–the late 1970s saw Betty Ford, Mary Tyler Moore, and Jason Robards publically in treatment, and N.C.A. continued to sponsor periodic celebrity “comings-out”–most people did not have such financial resources. Nor did they have health insurance that covered the costs of alcoholism treatment. Changing that became the top agenda item of the treaters, and bringing about that change involved convincing medical and insurance and especially public authorities as well as the public at large that alcoholism was a genuine disease. The effort was huge, and members of Alcoholics Anonymous, as well as members of Al-Anon and anyone who had any, however tenuous, contact with treatment or alcoholism, alcoholic or not, were mobilized into participating. Some did, but most did not, join the effort: As the later failure of S.O.A.R.–“The Society of Americans for Recovery”–demonstrated, most alcoholics “in recovery” mainly want to get on with their lives (Remembering Harold Hughes, Nd., Para. 30). Bill Wilson himself had set this pattern, often lamenting that of all the early members of Alcoholics Anonymous, he alone had been unable to return to his previous profession–a goal he did finally at least partially achieve in the final years of his life. Robert Thomsen’s Bill W. (1975) and Ernest Kurtz’s Not-God (1979) brought this home to readers at just this time. It was also true that, certainly as the 1980s unfolded and the concept of addiction broadened to include Downloaded by [Walden University] at 15:32 05 January 2018 32 ALCOHOL PROBLEMS IN THE UNITED STATES relationships and processes, most A.A. members did not want to do anything that might include them in the I’m Dysfunctional, You’re Dysfunctional world so effectively skewered by Wendy Kaminer (1992). It was within this evolving context that the third edition of Alcoholics Anonymous appeared in 1976. The new volume contained fifteen new stories, again divided into the “They Stopped in Time” and “They Lost Nearly All” sections. None of these stories reflected the changes just getting underway in the emerging “alcoholism field”–the growth of the treatment industry and the absorption of alcoholism into “addiction” conceptualized as something that could pertain to any process or any person as well as to any substance. Except for the wider variety of individuals depicted–two young people (male and female), a late-life drinker, an inhabitant of India, a Native American talking like a movie Tonto, a five-time felon, an impoverished “Afro-American” woman, etc.–there was little to distinguish these stories from those of the preceding editions, except that most were very short. Two mentioned the importance of learning that their alcoholism was a disease rather than “a weakness” or “a moral issue.” The only mention of “alcoholism work” was by the five-time felon, who had become “an alcoholism counselor.” Meanwhile, as the treatment industry grew and helping alcoholics and an ever-increasing number of “addicts” became more and more professionalized, a distinction emerged, one nicely implied by Daniel Yalisove’s 1998 title: “The Origins and Evolution of the Disease Concept of Treatment.” Although Yalisove does claim too uncritically and generically that “the disease concept is implicit in A.A.,” his study appropriately emphasizes the disease concept’s history in treatment. There was a difference, time had demonstrated, between the disease concept of alcoholism, which helps alcoholics understand their condition, and the disease concept of treatment, which seeks ways to term “disease” anything that might conceivably be labeled an “addiction” for the “curing” of which someone might be persuaded–or coerced–to pay. This may sound harsh, but it is accurate, and it is a necessary point to make if we are to understand some who harshly criticize all aspects of the disease concept of alcoholism (White, 1998, Ch. 28). A FINAL GLANCE VIA THE AAGV The AAGV, from 1976 on, tells a somewhat more complicated story, and from the nature of a journal that selects what it publishes, part of that tale concerns what was unpublished. Since the early 1970s, Grapevine editors rarely have found themselves short of submissions. Perhaps surprisingly, since entries are published anonymously and without any remuneration, each month sees an inflow of from 150 to 200 articles. The editors’ main task is selection. Beginning in Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 33 the late 1980s, they noted, more and more submissions mentioned treatment–hardly surprising, since more and more people were coming to Alcoholics Anonymous via treatment programs. What struck the editors, however, was the increasing number of these submissions that talked the language of treatment rather than that of the Twelve Steps, of “self-esteem,” for example, or the “inner child.” Many seemed written by people unfamiliar with Alcoholics Anonymous. Of interest here, these same submissions also tended to speak more directly and dogmatically about alcoholism as disease. But more was going on here. Remember that October 1970 reprinted story, “Alcoholism Is a Disease: The Essence of AA”? In researching the present paper, I conversed with the current editor of the AAGV and his immediate predecessor. The first spontaneous observation of the present editor was: “That could never appear in the year 2000.” Both went on to comment “how different things have become since the 1980s,” agreeing that “that article probably would never have been published after about 1985.” “Why?,” I queried. They replied, basically, that with the explosion of treatment, many in Alcoholics Anonymous began to feel themselves to be under siege. Many members, as well as their “trusted servants” in Service Offices, saw the frequent confusion of A.A. with treatment as threatening the very essence of the fellowship. They also felt, on the basis of some evidence, that some treatment programs were encouraging that confusion. The membership of Alcoholics Anonymous seemed divided on the matter of viewing treatment as a boon or a bane. Most at G.S.O., knowing their history, tended to take the more tolerant point of view, looking favorably on treatment. But as they did, members worldwide seemed to become more critical of their Service Offices. The lines were of course muddied by the copyright concerns and lawsuits of the time, but even as a segment of the membership began a “back to basics” movement that at times seemed a direct challenge to the very idea of a General Service Office, many at G.S.O. responded by themselves retreating from new departures. The great implicit fear was “rocking the boat,” and anything new and different threatened to do that. An impression then, but one based on considerable study and experience: So far as the relationship between Alcoholics Anonymous and the disease concept of alcoholism is concerned, the impact of treatment programs led first to an expansion of that acceptance, but then fairly soon to a retreat from it, as A.A. members, as A.A. members, became more and more nervous about distinguishing their fellowship and program from some of what some treatment had become. The published AAGV reflects this complex story. Before the mid- to late 1980s there had been occasional letters or comments of complaint over such matters as local treatment centers dropping busloads of their patients at A.A. meetings. Reader opinion was divided on this issue as on most others. But by the late 1980s that began to change. More consistently now, older members observed that new- Downloaded by [Walden University] at 15:32 05 January 2018 34 ALCOHOL PROBLEMS IN THE UNITED STATES comers who had been in treatment programs seemed to come to A.A. to teach rather than to learn. And one of the big things about which they wanted to teach was the disease concept of alcoholism, which old-time members realized had very little if anything to do with living A.A.’s Twelve Steps, the heart of its program. After the middle of the 1980s, criticisms of treatment became more direct and frequent, and more of them made it into print in the AAGV. In January of 1986, a contributor questioned whether some detox units and treatment settings might not be acting as enablers. “Perhaps we A.A.s need to take a long, hard look at our Twelfth Step history and current practices. . . . Perhaps we should ask, ‘What can I do for this alcoholic?’ before asking, ‘Where can I put this alcoholic?,’ ” the author of “A Foot in the Revolving Door” suggested (A.A. World Services, 1986, pp. 22-23). Late 1989 witnessed lengthy exchanges on the pros and cons of treatment. A kind of climax came in November, when a writer lamented the death of an A.A. friend who had died drunk: “Carl learned at closed meetings that he lacked the necessary knowledge of alcohol and body chemistry that he could only get ‘in treatment.’ ” The past decade has seen in the AAGV a backing away from or at times a very careful balancing of opposite points of view on any topic possibly controversial. Has that balancing accurately reflected the submissions? No answer is yet available, but my sense is that it does not. The net result so far as Alcoholics Anonymous and the disease concept of alcoholism is concerned in the year 2002? My sense is that most knowledgeable A.A. members will acknowledge that while “allergy” is not really accurate, the description that Dr. William Duncan Silkworth offered in “The Doctor’s Opinion” does reflect their own experience, and so that is the message they carry to other alcoholics. To most others, they do not bother talking about the subject. The closest the book Alcoholics Anonymous comes to defining alcoholism is “an illness which only a spiritual experience will conquer.” That, for most members of Alcoholics Anonymous, says enough about the nature of their “disease.” And over time, despite occasional excursions into seemingly more promising understandings, most members of Alcoholics Anonymous seem to come back to their Big Book for their ultimate answers to daily living and especially to understanding themselves. NOTES 1. An excellent contemporary description of this process and this confusion can be found in “The Jack Alexander article”–Alexander (1941)–see especially pp. 89-90, be- Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 35 ginning with “Few think anyone is ‘born alcoholic’ ” and continuing to “. . . the alcoholic begins to realize that he does not understand himself.” The passage continues: “If he applies to Alcoholics Anonymous, he is first brought around to admit that alcohol has him whipped that his life has become unmanageable. Having achieved this state of intellectual humility, he is given a dose of religion in its broadest sense. He is asked to believe in a Power that is greater than himself, or at least to keep an open mind on the subject . . . ” Note that there is no mention of disease, illness, malady, sickness. 2. The term threefold can pose a problem that becomes evident when one notes that the aspects are sometimes named as “physical, mental, and spiritual,” at other times as “physical, emotional, and spiritual,” and at still other times as “physical, mental, and emotional.” In long years of carefully listening to and observing this reality, I have come to believe that some people conflate “the emotional” and “the spiritual,” while others conflate “the mental” and “the emotional.” Most academics and professionals fall into the first group, as will be evidenced later in this paper. Most members of Alcoholics Anonymous who speak of “the physical, the mental, and the spiritual,” on the other hand, when asked and pressed, will reply that “the emotional” is contained in “the mental,” that “the spiritual” is something not reducible to the others, that it is somehow distinct though it does touch all the others. The idea of “threefold disease” was not original with Alcoholics Anonymous: it can be found explicitly in the literature of the Emmanuel Movement, an early twentieth-century Christian effort that helped alcoholics among others–see Elwood Worcester and Samuel McComb, Body, Mind and Spirit (New York, London: C. Scribner’s Sons, 1932); Some have claimed it can also be found in the work of psychologist Gustav Fechner, in whose Leipzig laboratory Elwood Worcester, a founder of Emmanuel, studied. Whether there be a line, on this particular topic, from Emmanuel via the Jacoby Clubs to Alcoholics Anonymous awaits further research. Forthcoming work by Richard Dubiel may cast more light on this question. The idea of “threefold,” of course, goes back to ancient and especially Medieval scholastic thinking. On “threefold disease” in the A.A. literature, the first printed use and explanation was Dr. Clarence P., “The Medical Approach to Alcoholism,” paper presented at the First National and International Meeting of Physicians in Alcoholics Anonymous, held at Cape Vincent, NY, 19-21 August 1949: Conference Record in A.A. archives. The context of its use makes it clear that the physicians present were all familiar with both the term and concept. 3. Although the Yale Center, especially under the leadership of Selden Bacon, would in later years tend to reject emphasis on physiology if not on the disease concept itself, during the early years, as Johnson (1973) notes (p. 257), emphasis on the medical model of chronic inebriety was crucial to Haggard and Jellinek for four reasons: (1) it was consistent with their effort to debunk traditional moralistic interpretations of issues related to alcohol; (2) it fit their humanistic concern that problem drinkers not be ostracized and condemned; (3) it fit their pragmatism that having the alcoholic view self as a sick person and be accepted as such by society put him in a favorable position to overcome his problem; (4) it complemented their advocacy of moderate or controlled drinking. 4. For example: the February 1945 AAGV announces “Medical Wards” in New York City and features an article, “Hospitalization in Akron Model for AA”; the March 1945 issue leads with the article, “Dr. Sam Parker of Kings County Suggests ‘Criteria for AA Work in Hospitals,’ ” and contains two articles on the “Philadelphia Story on Hospitaliza- Downloaded by [Walden University] at 15:32 05 January 2018 36 ALCOHOL PROBLEMS IN THE UNITED STATES tion,” noting that “This recognition that alcoholism is a disease furnished a tremendous impetus to the [A.A.] movement here,” and a story, “Dayton Has Interesting Hospital Record,” about getting entree into State Mental Hospital. A year later, February 1946, an article exulted, “AA Ward at Knickerbocker Proves Success.” The climax of this drive came in May 1947 with an article “by Bill”: “Adequate Hospitalization . . . One Great Need” [ellipsis in original] noting that: “Most of us feel that ready access to hospitals and other places of rest and recuperation borders on absolute necessity.” It is noteworthy that Marty Mann, in an article in Modern Hospital in January 1946, “Alcoholics Anonymous: A New Partner for Hospitals,” makes no mention of “disease,” but describes the need for hospitals and how A.A. will cooperate with and work within them. 5. Over the years, in his correspondence, Wilson mentioned two main reasons for writing the 12&12: (1) the membership’s adamant refusal to let him revise anything in the book Alcoholics Anonymous; (2) the need to publicize the then-new Twelve Traditions–Bill indicated in one letter to Fr. Dowling that he wrote the Step chapters in order to motivate members to get the book and so read the Tradition chapters. That this is a bit overstated is indicated by the presentation of the Step essays in the AAGV in 1952-1953. The whole context as well as Wilson’s later comments make it clear that the co-founder felt he had more to say about sobriety now seventeen years sober than he had four years sober at the time of the Big Book’s composition. But the explanatory letters do universally emphasize “the spiritual” and ignore what had been the large “disease” push at the time. Cf. also Wilson to Scott B., 4 December 1950, and perhaps most clearly to Charles W., 3 June 1952: “As to changing the Steps themselves, or even the text of the A.A. book, I am assured by many that I could certainly be excommunicated if a word were touched. It is a strange fact of human nature that when a spiritually centered movement starts and finally adopts certain principles, these finally freeze absolutely solid. But what can’t be done respecting the Steps themselves–or any part of the A.A. book–I can make a shift by writing these pieces which I hope folks will like.” REFERENCES Alcoholics Anonymous World Services. (1952a). Stethoscope and periscope: The doctors look at alcohol. The AA Grapevine. New York: Author. Alcoholics Anonymous World Services. (1952b). The problem drinker. The AA Grapevine. New York: Author. Alcoholics Anonymous World Services. (1952c). A.A.–44 Questions. New York: Author. Alcoholics Anonymous World Services. (1953). Twelve Steps and Twelve Traditions. New York: Author. Alcoholics Anonymous World Services. (1955). Alcoholics Anonymous (2nd ed). New York: Author. Alcoholics Anonymous World Services. (1957). Alcoholics Anonymous Comes of Age. New York: Author. Alcoholics Anonymous World Services. (1958). Alcoholism is a disease: The essence of AA. The AA Grapevine. New York: Author. Alcoholics Anonymous World Services. (1975). Living Sober. New York: Author. Alcoholics Anonymous World Services. (1976). Alcoholics Anonymous (3rd ed). New York: Author. Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 37 Alcoholics Anonymous World Services. (1986). A foot in the revolving door. The AA Grapevine. New York: Author. Alcoholics Anonymous World Services. (2001). Alcoholics Anonymous (4th ed). New York: Author. Alexander, J. (1941, March 1). Alcoholics Anonymous: Freed slaves of drink, now they free others. Saturday Evening Post, 9-11. Anderson, D. (1942). Alcohol and public opinion. Quarterly Journal of Studies on Alcohol, 3(3), 376-92. Bebbington, P. E. (1976). The efficacy of Alcoholics Anonymous: The elusiveness of hard data. British Journal of Psychiatry, 128: 572-80. Bowman, K. M. & Jellinek, E.M. (1941). Alcohol addiction and its treatment. Quarterly Journal of Studies on Alcohol, 2, 98-176. Brown, J. E. (1980). The Supreme Court and Alcohol: Case Study of a Shift in Systems of Social Control. Pittsburgh: University of Pittsburgh Press. Cahalan, D. Cisin, I.H. & Crossley, H.M. (1969). American Drinking Practices: A National Study of Drinking Behavior and Attitudes Related to Alcoholic Beverages. New Brunswick: Rutgers Center of Alcohol Studies. Clark, N. H. (1976). Deliver Us From Evil: An Interpretation of American Prohibition. New York, NY: W.W. Norton and Co., Inc. Criteria Committee, National Council on Alcoholism. (1972). Criteria for the diagnosis of alcoholism. American Journal of Psychiatry, 129, 127-135. Criteria Committee, National Council on Alcoholism. (1972). Criteria for the diagnosis of alcoholism. Annals of Internal Medicine, 77, 249-258. Criteria Committee, National Council on Alcoholism. (1973). Criteria for the diagnosis of alcoholism. Journal of the American Osteopathic Association, 72(5), 502-10. Durfee, C. H. (1936). Understanding the drinker. Mental Hygiene 20(1), 11-29. Gitlow, S. E. (1973). Alcoholism: A disease. In P. Bourne & R. Fox (Eds.), Alcoholism: Progress in Research and Treatment (pp. 1-9). New York: Academic Press. Haynes, T. L. (1988). The Changing Role of the Physician in the Treatment of Chemical Dependence. Retrieved May 18, 2002, from: http://www.wemac.com/adm_hist.html Hughes, H. (1974, December 13). Address to the North American Congress on Alcohol and Drug Problems, San Francisco, California, in Olson (forthcoming). Jellinek, E.M. (1960) The Disease Concept of Alcoholism. New Haven, CT: Hillhouse Press. Johnson, B. H. (1973). The Alcohol Movement in America: A Study in Cultural Innovation. University of Illinois at Urbana-Champaign. Kaminer, W. (1992). I’m Dysfunctional, You’re Dysfunctional: The Recovery Movement and Other Self-Help Fashions. Reading, MA: Addison-Wesley. Keller, M. (1960). Definition of alcoholism. Quarterly Journal of Studies on Alcohol 21, 125-34. Keller, M. (1972). On the loss-of-control phenomenon in alcoholism. British Journal of Addiction, 67, 153-66. Keller, M. (1976). The disease concept of alcoholism revisited. Journal of Studies on Alcohol 37(11), 1694-717. Keller, M. (1982). On defining alcoholism: With comment on some other relevant words. In E.L. Gomberg, H. R. White & J. A. Carpenter (Eds.), Alcohol, Science and Society Revisited (pp. 119-33). Ann Arbor, MI and New Brunswick, NJ: University of Michigan Press and Rutgers Center of Alcohol Studies. Downloaded by [Walden University] at 15:32 05 January 2018 38 ALCOHOL PROBLEMS IN THE UNITED STATES Knight, R. P. (1937). The psychodynamics of chronic alcoholism. Journal of Nervous and Mental Disease, 86, 538-48. Kurtz, E. (1991). Not-God: A History of Alcoholics Anonymous (Rev. Ed). Center City, MN: Hazelden Educational Materials, Inc. Kurtz, E. (1996). Twelve-step programs. In P.H. VanNess (Ed.), Spirituality and the Secular Quest (pp. 277-302). World Spirituality: An Encyclopedic History of the Religious Quest, Vol. 22. New York: Crossroad. Lawrence Robinson, Appellate, v. State of California. (1962). Retrieved from: http://wings.buffalo.edu/law/bclc/web/robinson.htm Leroy Powell, Appellate, v. State of Texas. (1968). Retrieved from: http://wings. buffalo.edu/law/bclc/web/powell.htm Lubove, R. (1965). The Professional Altruist. Cambridge, MA: Harvard University Press. Mann, M. (1948, November). The alcoholic in the general hospital. Southern Hospitals, 27-31. McIntyre, D. (2000). How well does A.A. work?: An analysis of published A.A. surveys (1968-1996) and related analyses/comments. Alcoholism Treatment Quarterly, 18(4), 1-18. Miller, W. R. & Kurtz, E. (1994). Models of alcoholism used in treatment: Contrasting AA and other perspectives with which it is often confused. Journal of Studies on Alcohol, 55, 159-66. National Clergy Council on Alcoholism and Related Drug Problems. (1960). N.C.C.A. Blue Book. Washington, DC. Ogborne, A. C. & Glaser, F.B. (1981). Characteristics of affiliates of Alcoholics Anonymous: A review of the literature. Journal of Studies on Alcohol, 42(7), 661-75. Olson, N. (forthcoming). Memoirs of Congressional Aide Years. Parkhurst, G. (1937, July). Drinking and alcoholism. Harpers Magazine, 158-166. Peabody, R. R. (1931). The Common Sense of Drinking. Boston: Little, Brown, and Company. Remembering Harold Hughes. (n.d). Retrieved May 14, 2002, from: http://www.well.com/user/woa/harolde.htm Robinson, D. (1972). The alcohologist’s addiction: Some implications of having lost control over the disease concept of alcoholism. Quarterly Journal of Studies on Alcohol, 33(4A), 1028-42. Roizen, R. P. (1991). The American Discovery of Alcoholism, 1933-1939. Berkeley: University of California. Roizen, R. P. (1996). Four unsung moments in the genesis of the modern alcoholism movement. Unpublished Manuscript. Roizen, R. P. (2001). Where did Mrs. Marty Mann learn alcoholism was a disease and why should it matter? Retrieved May 17, 2002, from: http://www.roizen.com/ron/ranesind.htm Schmidt, L. A. & Weisner, C. (1993). Developments in alcoholism treatment. In M. Galanter (Ed.), Recent Developments in Alcoholism, Volume 11: Ten Years of Progress (pp. 369-98). New York: Plenum Press. Seixas, F.A. (1972) Criteria for the diagnosis of alcoholism. Journal of the American Medical Association, 222(2), 207-8. Silkworth, W. D. (1937, March 17). Alcoholism as a manifestation of allergy. Medical Record. Downloaded by [Walden University] at 15:32 05 January 2018 Broader Treatment Perspectives 39 Silkworth, W. D. (1937, April 21). The reclamation of the alcoholic. Medical Record 145, 322. Silkworth, W. D. (1939). A new approach to psychotherapy in chronic alcoholism. The Journal-Lancet 59(7), 312-314. Silkworth, W. D. (1939, July 19). Psychological rehabilitation of alcoholics. Medical Record 150: np. Silkworth, W.D. (1941, August 6). A highly successful approach to the alcoholic problem. Medical Record 154: np. Skinner, W. (1994, September). Spirit(s) in The Postmodern: Recovery as a Retrieval of Self. Paper presented at the International Conference on Addiction and Mutual Help Movements in a Comparative Perspective, Toronto, Ontario. Smith (Akron) to Wilson, 15 June 1938; letter in A.A. archives. Sontag, S. (1978). Illness as Metaphor. New York: Farrar, Strauss & Girous. Strecker, E. A. (1937). Some thoughts concerning the psychology and therapy of alcoholism. Journal of Nervous and Mental Disease, 86, 191-205. Strecker, E. A. & Chambers, F.T., Jr. (1938). Alcohol: One Man’s Meat. New York: Macmillan. Thomsen, R. (1975). Bill W. New York, New York: Harper & Row. U.S. Government Printing Office. (1969). The impact of alcoholism: Hearing before the special subcommittee on alcoholism and narcotics of the committee on labor and public welfare, United States Senate, Ninety-First Congress, First Session on Examination of the Impact of Alcoholism, July 23, 24, 25, 1969. Washington, DC: Author. Wiener, C. (1981). The Politics of Alcoholism. New Brunswick, NJ: Transaction Books. White, W.L. (1998). Slaying the Dragon: A History of Addiction and Recovery in America. Bloomington, IL: Chestnut Health Systems. White, W.L. (Ed.). (2001). The Addiction Disease Chronologies of William White, Ernest Kurtz, and Caroline Acker. Retrieved May 14, 2002, from: http://www.bhrm.org/ papers/addpapers.htm Wilson, W. G. (1944). Basic concepts of Alcoholics Anonymous. New York State Journal of Medicine, 44, 1805-10. Wilson, W.G. (1949). The society of Alcoholics Anonymous. American Journal of Psychiatry, 106(5), 370-5. Yalisove, D. (1998). The origins and evolution of the disease concept of treatment, Journal of Studies on Alcohol, 59, 469-476.

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Please fiond attached. Thank you.







The disease model



The disease model in addiction assists in describing an addiction in the form of a disease
that affects human life. The model has assisted in understanding a condition based on the
biological, neurological and the environmental sources as well as the origins. Various diseases
have led to people being disoriented and unable to perform their daily functions. In most cases,
the addicts of alcohol have become challenged to the extent that they cannot perf...

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