12 steps

Challenging the Disease Concept of Alcoholism?

A journalistic piece entitled,  “The Irrationality of Alcoholics Anonymous “, written by  Gabrielle Glaser, purports to challenge the “disease concept” of alcoholism. Glaser in one section of the article devotes one section to  the historical prominence of Alcoholics Anonymous (AA)  in the US in the conceptualisation of alcoholism as a disease and in it’s treatment.

She later attempts to challenge the disease or medical model of alcoholism by suggesting that alcoholics can control their drinking via various therapeutic and chemical aids.

In this first, in as series of blogs, I will address and challenge her arguments.

“AA filled a vacuum in the medical world, which at the time had few answers for heavy drinkers. In 1956, the American Medical Association named alcoholism a disease, but doctors continued to offer little beyond the standard treatment that had been around for decades: detoxification in state psychiatric wards or private sanatoriums. As Alcoholics Anonymous grew, hospitals began creating “alcoholism wards,” where patients detoxed but were given no other medical treatment. Instead, AA members—who, as part of the 12 steps, pledge to help other alcoholics—appeared at bedsides and invited the newly sober to meetings.

A public-relations specialist and early AA member named Marty Mann worked to disseminate the group’s main tenet: that alcoholics had an illness that rendered them powerless over booze…Mann also collaborated with a physiologist named E. M. Jellinek. Mann was eager to bolster the scientific claims behind AA, and Jellinek wanted to make a name for himself in the growing field of alcohol research….Jellinek drew sweeping conclusions about the “phases of alcoholism,” which included an unavoidable succession of binges that led to blackouts, “indefinable fears,” and hitting bottom. Though the paper was filled with caveats about its lack of scientific rigor, it became AA gospel….

Jellinek, however, later tried to distance himself from this work, and from Alcoholics Anonymous. His ideas came to be illustrated by a chart showing how alcoholics progressed from occasionally drinking for relief, to sneaking drinks, to guilt, and so on until they hit bottom (“complete defeat admitted”) and then recovered. If you could locate yourself even early in the downward trajectory on that curve, you could see where your drinking was headed.”

((I will return to the Jellinek Curve in a later blog and discuss how this statistical model has been shown in recent studies to still have validity and reliability many decades later, which is quite an unusual feat in science, a point Glaser inadvertently does not mention!)

“The problem is that nothing about the 12-step approach draws on modern science…”

Bill Wilson, AA’s founding father, was right when he insisted, 80 years ago, that alcohol dependence is an illness, not a moral failing. Why, then, do we so rarely treat it medically? It’s a question I’ve heard many times from researchers and clinicians. “Alcohol- and substance-use disorders are the realm of medicine,” McLellan says. “This is not the realm of priests.”

(Glaser then proceeds to suggest that certain people with alcohol problems and do not believe they have a disease called alcoholism, she gives and account of one and the treatment she subsequently received.)

” When Jean confessed her habit to her doctor last year, she was referred to an addiction counselor. At the end of the first session, the counselor gave Jean a diagnosis: “You’re a drunk,” he told her, and suggested she attend AA.

The whole idea made Jean uncomfortable. How did people get better by recounting the worst moments of their lives to strangers? Still, she went. Each member’s story seemed worse than the last: One man had crashed his car into a telephone pole. Another described his abusive blackouts. One woman carried the guilt of having a child with fetal alcohol syndrome. “Everybody talked about their ‘alcoholic brain’ and how their ‘disease’ made them act,” Jean told me. She couldn’t relate. She didn’t believe her affection for pinot noir was a disease…”

(It is difficult not to view Jean as not as chronic as others at the meeting, although AA members may suggest to Jean that the stories that horrified her in AA meetings and the damage that these stories told of are called “yets” in AA parlance i.e. an alcoholic may not have done similar damage to others and themselves that some other alcoholics have, yet? It points towards the progression of this disease of alcoholism in terms of the negative consequences experienced – this also point to a difficulty in this article that Glaser has when describing alcoholism as a spectrum when it should more accurately be called a continuum, as people progress from use to an abuse of alcohol phases to final endpoint addiction, or compulsive addictive behaviour.

That is not to say that everyone showing the symptoms of abuse or alcohol dependence at a particular time  is actually an alcoholic as certain individuals may be heavy drinkers not alcoholic and meet various diagnostic criteria or the may be drinking very  heavily due to existing personal circumstances due to e.g., bereavement of trauma and then return to their normal drinking.

They may show up as temporarily alcohol dependent but are not actually on a pathological trajectory towards chronic alcoholism. This is a fundamental point in discussing alcoholism and studies that research it. It is very difficult to accurately diagnose anyone as alcoholic, there are many disparate methods of doing so and different researchers use different criteria in different studies but then compare and contrast findings when they may not have studying the same subjects. As a result various alcohol studies are littered with studies on non-alcoholics or on individuals who have moderate alcohol problems compared to chronic alcoholics.

The more serious point in relation to Glaser’s argument is that she seems to struggle with the idea of the progression of alcoholism through the various phases of this condition and an insistence that alcoholism is just about alcohol.  What can be achieved with a young person in the dearly stages of problem drinking is obviously different to what can be achieved therapeutically with a chronic alcoholic but whether that treatment is effectively the underlying emotional condition that propels chronic alcohol consumption is another matter?

Another major issue with Glaser’s argument is that she solely bases her arguments in relation to the disease concept solely at the feet of AA who according to their governing traditions and tradition 10  in particular “Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy.”

Why has Glaser in arguing the irrrationality of AA not mentioned the hundreds of thousands of neuroscientific articles since and before the do-called decade of the brain which conclusively show that the brain of an alcoholic is hijacked partly by the neuro toxic consequences of chronic alcohol consumption?

Is it not irrational of Glaser to not discuss the other side of the scientific debate. She seems to be deliberately attacked a soft target in AA. Why not enter into a debate with the multitude of researchers since the 1970s who clearly state that the actions of alcohol and other drugs used chronically have deleterious effects on health and  brain function. She mentions these researchers in only promoting her ideas that alcoholism can be treated chemically.

Why not mention all this research which clearly shows alcoholism is a transitory condition, clearly passing through different and distinct phases of chronicity. An example of this is the shift in reward processing from ventral to dorsal striatum in the transition from abusive to compulsive alcoholism. This clearly suggest that “invisible line” that recovering alcoholics often talk about in AA meetings?

Glaser also forgets to mention that the bulk of research into alcoholism has been stimulated by working with recovering alcoholics recruited from AA, that many ideas or observations that researchers had conducted research on have actually come for recovering alcoholics describing their every day realities and then being participants in these studies. AA has stimulated more scientific research into alcoholism than any other organisation. It would be difficult to conceive the extent of research of treatment without AA’s instigating much of it. One third of addictionologists are reportedly in recovery themselves.  So how can Glaser fail to see this? AA’s contribution, via it’s members to science has been huge.

” Surely, Jean thought, modern medicine had to offer a more current form of help.

Then she found Willenbring. During her sessions with him, she talks about troubling memories that she believes helped ratchet up her drinking. She has occasionally had a drink; Willenbring calls this “research,” not “a relapse.”…In his treatment, Willenbring uses a mix of behavioral approaches and medication. Moderate drinking is not a possibility for every patient, and he weighs many factors when deciding whether to recommend lifelong abstinence.”

(At least, unlike Glaser, Willenbring knows the transitory nature of alcoholism and tailors his treatment accordingly. This awareness is often lacking among researchers and those treating alcoholics.)

“He is unlikely to consider moderation as a goal for patients with severe alcohol-use disorder. (According to the DSM‑5, patients in the severe range have six or more symptoms of the disorder, such as frequently drinking more than intended, increased tolerance, unsuccessful attempts to cut back, cravings, missing obligations due to drinking, and continuing to drink despite negative personal or social consequences.)” “We can provide treatment based on the stage where patients are,” Willenbring said. It’s a radical departure from issuing the same prescription to everyone.

As we have alluded to this diagnostic criterion can be quite limited in assessing long term pathology. One of the reasons why AA works is the need for recovering alcoholics to self diagnose, not to rely on others to tell them what they suffer from. It is also illuminating that alcoholics also often self diagnose as they feel very similar to other alcoholics in terms of emotion difficulties, decision making deficits, self esteem, behaviours etc all of which are generally ignored by diagnostic criterion, which often relegates those emotional regulation  issues to that of co-morbidity, although these so-called co-morbidites such as anxiety and depression, often dissipate in weeks of recovery and often should be called substance used disorders and not co-morbidity.

Glaser acknowledges these problems of matching diagnostic criterion with treatment herself in the article –

” The difficulty of determining which patients are good candidates for moderation is an important cautionary note. But promoting abstinence as the only valid goal of treatment likely deters people with mild or moderate alcohol-use disorder from seeking help. The prospect of never taking another sip is daunting, to say the least.”

Again this point makes no reference to underlying conditions of alcoholism which are often present in relatively mild of moderate alcoholism.  Glaser does not seem to have any awareness that the treatments she is espousing are simply treating the symptoms of alcoholism not it’s root causes, the underlying pathomechanism of this disease?

Researchers who fail to treat the underlying conditions are not treating alcoholics fully.

Glaser then goes on to cite researchers and their studies which we will challenge before ending this blog.

 

We use one particular study cited by Glaser to highlight how research zeal and lack of awareness about the reality of alcoholism can actually lead to giving alcoholics false hope for therapeutic success and can hasten a return to drinking, to chronic alcoholism, death even.

It highlights how researchers and those treating alcoholics need to aware of the need to “first do no harm!”

“ To many, though, the idea of non-abstinent recovery is anathema. No one knows that better than Mark and Linda Sobell, who are both psychologists. In the 1970s, the couple conducted a study with a group of 20 patients in Southern California who had been diagnosed with alcohol dependence.

Over the course of 17 sessions, they taught the patients how to identify their triggers, how to refuse drinks, and other strategies to help them drink safely. In a follow-up study two years later, the patients had fewer days of heavy drinking, and more days of no drinking, than did a group of 20 alcohol-dependent patients who were told to abstain from drinking entirely. (Both groups were given a standard hospital treatment, which included group therapy, AA meetings, and medications.) The Sobells published their findings in peer-reviewed journals.

In 1980, the University of Toronto recruited the couple to conduct research at its prestigious Addiction Research Foundation. “We didn’t set out to challenge tradition,” Mark Sobell told me. “We just set out to do good research.”

The Sobells returned to the United States in the mid-1990s to teach and conduct research at Nova Southeastern University, in Fort Lauderdale, Florida. They also run a clinic.”

What Glaser failed to mention was that in a subsequent study (4) 10-year follow-up of the original 20 experimental subjects showed that only one, who apparently had not experienced physical withdrawal symptoms (thus possibly not alcoholic), maintained a pattern of controlled drinking;

eight continued to drink excessively–regularly or intermittently–despite repeated damaging consequences;

six abandoned their efforts to engage in controlled drinking and became abstinent;

four died from alcohol-related causes;

and one, certified about a year after discharge from the research project as gravely disabled because of drinking, was missing.

Why did Glaser failed to mention this research, a follow up study to the one she mentions and cites?

Also why has Glaser not mentioned either that the the Sobells have stated since that it is those with less severe problems who often improve by moderating their drinking. Alcoholic abusers.

 

The Sobells’ implication – that the focus on non-dependent problem drinkers and on harm reduction could take the teeth out of the controlled drinking controversy – was again strangely also not mentioned by Glaser?

It is worth noting that some supporters of controlled or moderation drinking have also hidden their own difficulties with the drink. Audrey Kishline, the founder of Moderation Management (MM), a non-abstinence-oriented self-help group for individuals whose alcohol problems stop short of dependence, killed two people in a head-on vehicular collision with a not very moderate blood alcohol content measured at .26.

She started attending AA soon afterwards.

I will be dissecting the Glaser article over the next few weeks – next up will be a blog on the infamous Rand Report of the 1970s and other studies which have purportedly demonstrated a return of controlled drinking in a small minority of so-called alcoholics?

To journalists like Glaser and to researchers eager to make a name in a new area of research I suggest referring to one of the most powerful and compelling studies ever carried out by an academic researcher. That researcher was George E Vaillant.

His classic and lauded work The Natural History of Alcoholism Revisited (1995) is a book  that describes two multi-decade studies (60 years) s of the lives of 600 American males, non-alcoholics at the outset, focusing on their lifelong drinking behaviours. By following the men from youth to old age it was possible to chart their drinking patterns and what factors may have contributed to alcoholism.

In other words, this studies show the “progression” of the disease of alcoholism.

The National Review hailed the first edition (1983) as “a genuine revolution in the field of alcoholism research” and said that “Vaillant has combined clinical experience with an unprecedented amount of empirical data to produce what may ultimately come to be viewed as the single most important contribution to the literature of alcoholism since the first edition of AA’s Big Book.”[1] Some of the main conclusions of Vaillant’s book are:

“Alcoholism can simultaneously reflect both a conditioned habit and a disease.”

That alcoholism was generally the cause of co-occurring depression, anxiety …not the result.

… it is therapeutically effective to explain it as a disease to patients. The disease concept encourages patients to take responsibility for their drinking, without debilitating guilt.

That there is as yet no cure for alcoholism…

That for most alcoholics, attempts at controlled drinking in the long term end in either abstinence or a return to alcoholism.

Successful return to controlled drinking is…just  a rare and unstable outcome that in the long term usually ends in relapse or abstinence, especially for the more severe cases.[48]

“by the time an alcoholic is ill enough to require clinic treatment, return to asymptomatic drinking is the exception not the rule.”[47]

When asked whether controlled drinking is advisable as a therapeutic goal, Vaillant concluded that “training alcohol-dependent individuals to achieve stable return to controlled drinking is a mirage.”[47]

 

References

2.Vaillant, George E. (1995). The Natural History of Alcoholism Revisited. Cambridge, Massachusetts: Harvard University Press.ISBN 0-674-60378-8.

Vaillant, George E. (2003). “A 60-year follow-up of alcoholic men”. Addiction, 98, 1043–1051.

4. Pendery, M. L., Maltzman, I. M., & West, L. J. (1982). Controlled drinking by alcoholics? New findings and a reevaluation of a major affirmative study.Science, 217(4555), 169-175.

 

 

 

 

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