February 24, 2020
To most people I imagine it doesn’t sound like much of a question. Disease or wound? Yawn. Who cares? In fact, though, it is a big deal. Let me explain:
Prior to the 1930s, explanations of chronic and problematic alcohol use were characterological/spiritual in nature. Some inherent weakness of character interacting with some cause of alienation from god (original sin, weakness of personality or intellect, demon infestation, or something of that nature) caused a person to lose their ability to control their alcohol use. Treatment options were limited to prayer, exorcism, long-term confinement to a sanitarium, and/or shorter-term confinement to hospitals for the treatment of withdrawal symptoms. I’m sure I’m leaving something out here, but these were the basic approaches. The idea behind these approaches was there’s not much you can do but stave off death during withdrawal and hope the afflicted person finds the strength (whatever that is) to abstain. Actually, until the end of the 19th century, most all mental disorders were viewed as having supernatural or characterological causes. Then, Sigmund Freud’s pioneering work established the field we now call clinical psychology. Ten to 20 years later, the World Health Organization published the first diagnostic system for mental disorders that could at all be described as scientific, the precursor to the Diagnostic and Statistical Manual (DSM) managed today by the American Psychiatric Association. You can still find people who think the way they did in the nineteenth century. But it hasn’t been mainstream thought for a while.
In the 1930s, two alcoholics in Akron Ohio started meeting together in a last, desperate attempt on both of their parts to get and to stay sober. Finding that together they could do what neither of them could do alone, they began inviting others to join them in private meetings. Of course, this was the beginning of Alcoholics Anonymous. When one of them (Bill W.) undertook to write a book for members to use, he approached a physician ( one Dr. Silkworth) to write a beginning section entitled “A Doctor’s Opinion.” In that chapter, Dr. Silkworth articulates what we now call the “medical model” of alcoholism. In a nutshell, Dr. Silkworth describes alcoholism as a disease akin in some ways to an allergy. The “allergic” reaction to alcohol in alcoholics is experienced as a compulsion to drink more, and more often than is consistent with normal so-called “social” drinking. The only treatment is to abstain from exposing oneself to the allergen, that is, to abstain from alcohol completely. The argument goes that by so doing, the alcoholic becomes free of the compulsion to over-imbibe. It does indeed appear that, given an alcoholic can become interested in a manner of living that involves both complete abstinence and a reliance upon both regular meetings and a “higher power” or a “god of ones own understanding ,” Alcoholics Anonymous has an admirable success rate of approximately 50% of people who attend more than one single meeting. Unfortunately, about 50% of people who manage to make it to their first AA meeting never go back, and approximately 90% of alcoholics never attend even one single meeting. Looking at the 50% recovery rate among people who attend more than one meeting, members of AA often proclaim that “it works!” However, if one looks at the 90% who never go and the half of those who go once who never return, and the half of those who go more than once who do not stay sober, one can see that 95% (and arguably 97.5%) of all alcoholics get no benefit from AA. It is difficult to describe that as “working",” at least, for me it is. AA members typically respond “It works if you work it.” I see no evidence that those members of AA who believe it to “work” are interested in moving toward any modification of their method that might appeal to more alcoholics than AA already does. However, in describing alcoholism as a disease one does move beyond the idea that it is a sign of weakness of character or a lack of god’s grace or any other moralistic or spiritual explanation. AA has been and remains a major force supporting that positive transition. Withoug a doubt, it’s progress.
A problem arises with the medical model as proposed by Dr. Silkworth. Dr. Silkworth specifies that the medical entity behind alcoholism is a disease. He presents only anecdotal evidence to substantiate his opinion. Also, there is a specific way in which his disease model simply doesn’t fit the reported experiences of alcoholics in AA. It is this: Although my data gathering has been informal, I have asked many AA members with over 10 years continuous sobriety about a particular occurrence that is in my experience commonplace. An abstinent member of AA goes to a party and mistakenly consumes some alcohol. Oftentimes it has been so long a time since the last drink that they don’t immediately spot the problem. They initially just think there’s something wrong with their juice. Then the realization dawns on them that they have in fact swallowed alcohol. Panic ensues. Once they settle down, upon reflection they discover that having made that error did not cause them to crave alcohol, and in fact, quite the opposite. This is not at all surprising, except it is completely inconsistent with what the disease model predicts! The disease model predicts that the compulsion to drink will invariably ensue. Apparently that only happens if the drinking is intentional. If it’s unintentional, nothing much happens. That’s not at all like an allergy. That’s not at all like a disease. Is the medical model wrong?
The answer is no, the medical model is not wrong. Diseases aren’t the only medical entities. Medical entities can be wounds rather than diseases. However, if alcoholism is a wound, it follows that it is possible for that wound to heal. AA wisdom is that alcoholism is an incurable disease. It can’t heal. So, what’s the truth? As it turns out, that is an interesting question that has at least a couple of answers.
The truth is that the idea of a disease is a way of organizing a number of experiences that tend to occur in relationship to one another. The same is true for the idea of a wound. Tell you what I mean: When runny nose, sore throat, watery eyes, and a general feeling of bodily malaise onset at once or in rapid enough succession that they seem connected as parts of a whole, we tend to call that whole a disease. It’s either a cold or an allergy. If we call it a cold, we imagine the cause is a virus. We can’t see the virus. We test for the presence of a virus only rarely. But especially if these experiences ensue within a day or two of contact with another person who had similar experiences going on, we surmise communicability, we surmise the presence of a virus, we organize all these experiences using the concept of a viral infection as the organizing principle. We say we have a disease, to wit: a cold. When these experiences occur without any such prior exposure to another who also has them, and when nobody who is in contact with us develops any similar signs, and especially when we’ve been exposed to substances or objects that previously have preceded our developing these experiences, we call it an allergy. We can’t see an allergic sensitivity. We test for reactions to specific allergens only rarely. But we surmise lack of communicability, we suspect an allergen is present, and we call it an allergic reaction. In both cases, typical medical treatment is symptomatic, so it really doesn’t matter what the cause is.
The truth is that the idea of a wound is also a way of organizing a number of experiences that tend to occur in relationship to one another. When a sore appears on our skin after something known to be abrasive or hot or corrosive or sharp, we call that sore a wound. When a sore appears on our skin without any such prior exposure to a known wounding experience, we call it lesion or an abscess or an ulcer or something like that, and we consider it to be the product of some disease entity.
The truth is that the idea of a disease and the idea of a wound are just that: Ideas, organizing principles around which we can place an array of seemingly related experiences in an attempt to develop an understanding that hopefully functions to help resolve those uncomfortable experiences and get them to go away.
The truth is that the idea that alcoholism results from an intrapsychic wound that only a few have the resources, the determination, and the stamina to heal is just as valid as the idea that alcoholism results from a disease process. Just as is the case for most other (and especially mental) disorders, there is no way to be absolutely certain which is the case. For those (most alcoholics) who lack the capacities necessary to successfully to respond to alcoholism as if it were a wound that one can take care of and ultimately hope to heal, it is probably better to think of alcoholism as an incurable disease treated effectively only by abstinence. However, there exist not infrequent cases where people who most certainly drink like alcoholics stop drinking for long enough to do powerful and deep therapeutic healing work, emerging from the process with a desire to avoid becoming destabilized that prevents them from ever again drinking abusively. It is not impossible, and to argue that it is is simply wrong. The known cases where this happens are common enough that they can’t all be “the exception that proves the rule.” They are the exceptions that demonstrate that the rule is not a law.
This is quite useful. Many alcoholics (arguably most of them) will never be interested enough in a recovery program entailing complete abstinence to attend even a single AA meeting. If recovery can happen outside of the context of complete abstinence, this makes recovery a possibility for far more problematic drinkers. Of course, this is a good.
There are of course substances other than alcohol whose use may become disordered. Less is known of these. Most of them are illegal, and the populations of people willing to break the law to use a substance is arguably different from those unwilling to do so. This complicates interpreting any patterns that are present. More will be said of these is a subsequent post.
Be careful with substance use. Whether resulting from a wound, or a disease, or both, disordered use is dangerous and unhealthy. Stay safe. Stay strong. Choose wisely.
