The Disease Model

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. The Disease Model

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: <getinfo@haworthpressinc.com>Website: © 2002 by The Haworth Press, Inc. All rights reserved.] KEYWORDS. The Disease Model

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 Disease Model

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. The Disease Model

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 Disease Model

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: The Disease Model

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. The Disease Model

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). The Disease Model

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). The Disease Model

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. …</getinfo@haworthpressinc.com> The Disease Model