Not Your Father’s Disease Theory
By Kenneth Anderson, MA
The disease theory of alcohol addiction can be traced back to the late 1700s with the publication of Dr. Benjamin Rush’s 1785 An Inquiry into the Effects of Ardent Spirits on the Human Body and Mind, followed by Dr. Thomas Trotter’s 1804 An Essay, Medical, Philosophical, and Chemical, on Drunkenness, and Its Effects on the Human Body.
By the late 1800s, we saw the emergence of a unified theory of chemical addictions: addictions to alcohol, opiates, cocaine, and tobacco were all seen as the same underlying entity: the disease of inebriety. The Quarterly Journal of Inebriety was published from 1876 to 1914; it was the official organ of the American Association for the Cure of Inebriates (AACI; later renamed the American Association for the Study and Cure of Inebriety [AASCI] in 1888) which was founded in 1870 and faded out of existence in the 1920s. Thomas Davison Crothers, MD (Sep 22, 1842 – Jan 12, 1918) was the editor of the Quarterly Journal of Inebriety throughout its entire run and served as secretary of the AACI from 1875 until his death in 1918. The disease theory of inebriety was an absolute dogma of the AACI; Robert Patterson Harris, MD (1822 – Feb 20, 1899), the superintendent of the Franklin Reformatory Home in Philadelphia, was kicked out of the AACI for stating that drunkards needed to be reformed rather than treated for a disease.
Crothers, the de facto leader of the inebriate asylum movement from 1875 to 1918, insisted that the only effective cure for inebriates was to lock them behind bars in an inebriate asylum for a year or more until their desire for drugs or alcohol went away; those who persistently relapsed should be locked away for life. The idea that incarceration was treatment mirrored the treatment of the mentally ill of the era. However, Crothers and his followers insisted that mixing inebriates in with the insane or with criminals was detrimental and that rather than sending inebriates to insane asylums or prisons, specialized inebriate asylums were required.
However, the inebriate asylum movement proved to be an utter bust. The first inebriate asylum in the US was opened in Binghamton, New York by Joseph Edward Turner, MD (Oct 5, 1822 – Jul 24, 1889) in 1864; however, it stood nearly empty until 1879 when the state turned it into an insane asylum. Turner was a role model for Crothers. A dozen other inebriate asylums were established in the US; however, all but three either shut down or were converted to insane asylums due to lack of patients. People were unwilling to enter voluntarily to be locked up for a year or more, and judges in most states also preferred to give drunkards a few days in jail rather than extended incarceration in an inebriate asylum. The three exceptions were in Iowa, Massachusetts, and Connecticut, where judges happily incarcerated drunkards and drug addicts for long periods of time. The inebriate asylum in Knoxville, Iowa was much like a prison and the treatment consisted of breaking rocks on the rockpile; it was in operation from 1906 to 1919, when treatment demand fell to an all-time low throughout the US. The inebriate asylum in Foxboro, Massachusetts was in operation from 1893 to 1919. The State Farm for Inebriates at Norwich Connecticut was in operation from 1915 to 1939.
The AACI considered that addictions to alcohol, opiates, cocaine or cigarettes were all forms of inebriety. Although the AACI did not advocate incarceration for cigarette smokers, the Quarterly Journal of Inebriety contained a number of articles on tobacco inebriety. Moreover, a July 18, 1904 article in the Des Moines Register reported that cigarette fiends were also being committed to the inebriate asylum (Iowa operated its inebriate asylums in its insane asylums from 1904 to 1906, when they moved to Knoxville).
Other forms of addiction treatment which were popular in the late 1800s and early 1900s were inebriate homes and secret cures. Inebriate homes had no locks on the doors and no bars; residents were on the honor system, and a typical stay was 30 days, although some offered indefinite stays. Inebriate homes were far more popular than inebriate asylums; the Boston Washingtonian Home (later Hospital) was in operation from 1857 to 1980. The Keswick Colony of Mercy, a religion-based inebriate home, opened in 1897 and is still in operation today.
However, by far the most popular addiction treatments of the era were the secret cures, such as the Keeley Gold Cure. It is likely that over 90% of people who received addiction treatment during this era took one of the secret cures. Keeley sold differently formulated Gold Cures for the liquor, morphine/cocaine, and tobacco habits. The active ingredients in the Keeley Cures were almost certainly strychnine and atropine. Whereas strychnine has been demonstrated to produce an aversion to alcohol, and atropine has been shown to ease opioid withdrawal symptoms, it is likely that the Keeley Cure only had much effectiveness with alcohol. Unfortunately, a unified theory of addictions does not mean that there is a unitary treatment for addictions; for example, methadone does not treat alcohol addiction. Still, the Juliet Murray Lang Institute took out half- to full-page ads in the Saint Paul, Minnesota city directories promising a “Permanent Cure of the Liquor, Opium. Morphine, and Tobacco Habits.”
The unified theory of addiction was lost during the post-Prohibition era lasting from the mid-1930s into the 1970s. Cigarette smoking had become normalized to the extent that everyone did it–over 60% of adult males in the 1960s were cigarette smokers, and one cannot watch a movie from the 1940s without seeing a Humphrey Bogart or a Bette Davis with a cigarette in their mouths. Moreover, alcoholics and drug addicts were comprised of very different demographics from the 1930s to the mid-1960s and felt they had nothing in common with each other.
The contemporary idea of alcoholism as a disease does not really come from Bill Wilson or AA itself, but rather from Marty Mann and the NCA. In 1961, Wilson stated, ” We have never called alcoholism a disease because, technically speaking, it is not a disease entity… 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.” However, the very first paragraph of Mann’s immensely popular 1950 book Primer on Alcoholism states, “Alcoholism is a disease which manifests itself chiefly by the uncontrollable drinking of the victim, who is known as an alcoholic. It is a progressive disease, which, if left untreated, grows more virulent year by year, driving its victims further and further from the normal world, and deeper and deeper into an abyss which has only two outlets: insanity or death.” Mann spent a lifetime travelling throughout the country giving lectures on the disease theory. The three points Mann always emphasized were:
- Alcoholism is a disease and the alcoholic a sick person.
- The alcoholic can be helped and is worth helping.
- This is a public health problem and therefore a public responsibility
The popular mythology dominant from the Repeal of Prohibition in 1933 into the 1970s characterized alcoholism as a physical disease due to a metabolic defect rather than as a mental disorder or a type of drug addiction. Mann expressed great relief to find out that she had the disease of alcoholism, because prior to this she suspected that she was losing her mind.
The idea of alcoholism as a physical disease is well expressed in the November 14, 1974 interview of Dick Van Dyke on the Dick Cavett Show, where Van Dyke says, “[Alcoholism] is a physical disease. An alcoholic has a certain metabolism and glandular setups that make them chemically adapt themselves to alcohol.” When Cavett asks, “Does that mean that you were destined to become an alcoholic at birth if you ever took a drink?” Van Dyke replies, “That’s true.” Van Dyke goes on to say that the worst thing an alcoholic can do is go to a psychiatrist to find out why he drinks. The Van Dyke quote gives us an insight into what people like Van Dyke were taught about alcohol in rehab and is a better example of popular thought about alcohol and addiction than a scholarly article would be. The popular belief of the 12-step movement of the era was that alcoholics were not bad or crazy, but that they had a physical disease that made them different from “normal” drinkers.
Drug addiction, on the other hand, was characterized as entirely different from alcoholism. In the popular propaganda from the 1930s into the 1960s only narcotics were addictive. Narcotic, of course, is a medically meaningless term which legally lumped three unrelated drugs together: opiates, cocaine, and marijuana. Harry Anslinger, the drug czar from the 1930s to 1962, insisted that marijuana be classed as a narcotic because he hated Mexicans and jazz musicians, the only people who used marijuana during that era. According to the popular mythology of the era, everyone who used heroin even once became an addict for life, whereas only people with a metabolic defect became alcoholics.
Amphetamines, barbiturates, and cigarettes, on the other hand, were characterized as habit-forming rather than addictive. In fact, barbiturates were sold over the counter until 1951, and amphetamines were sold over the counter until 1965. And the 1964 Surgeon General’s report Smoking and Health stated “The tobacco habit should be characterized as an habituation rather than an addiction.” There was no way that the Surgeon General was willing to equate your kindly, chain-smoking uncle Harry with a heroin addict shooting up in a back alley.
This is a far cry from the 1890s when one could buy morphine over the counter and heroin could be ordered from Sears Roebuck. In that era, the morphine habit was no more stigmatized than the liquor habit, and it was recognized that many people used opiates without becoming addicted. The difference between the 1890s and the 1950s was that the narcotic prohibition laws, starting with the Harrison Narcotics Act (effective 1915), pushed opiate addicts into a small and marginalized subset of people in the inner cities who had to steal to survive. It was not due to any chemical property of the drug itself.
Then, in 1965, drug use exploded across US college campuses. By the 1970s, smoking pot was widespread, and many experimented with more powerful drugs as well. The first combined treatment of alcoholics and drug addicts was initiated by Donald Jay Ottenberg, MD (Jul 2, 1919 – Aug 20, 2004) in December 1968 at Eagleville Hospital in Pennsylvania; this was a confrontational program based on Synanon. Ottenberg noted that there were major demographic differences between the two groups, with the alcoholics being far older, beaten down, and passive, whereas the drug addicts were active, aggressive, hostile, and had well-defined subculture with its own language, mythology, codes, and hierarchy.
Yet as we progressed into the 1970s and 1980s, combined treatment became the norm, and the demographic differences between drinkers and drug users began to disappear. In 1980, tobacco dependence was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM), and we finally began to move back to the unified theory of chemical addiction which we had recognized in the 1890s.
Then, in 1997, Alan Leshner, director of the National Institute on Drug Abuse, published “Addiction Is a Brain Disease, and It Matters.” What could possibly be scarier to kids than telling them that if they used drugs, they would get a brain disease? Yet, there are substantial problems with the brain disease theory. First, it predicts that people with addiction will continue using substances until it kills them. However, the epidemiology shows us that the normal outcome of drug or alcohol addiction is recovery without treatment and without AA/NA. Second, chemical addictions hardly resemble real brain diseases such as encephalopathy, meningitis, Alzheimer’s disease, or brain cancer.
Addictions are, simply put, stronger than average conditioned reflexes. Maia Szalavitz likes to call them learning disorders. Is the brain disease theory helpful to anyone but rehab owners who want to get their hands on your bank account or groups like AA which want more members? I personally find that a belief in my own ability to overcome my bad habits is far more helpful than believing that I have a hopeless disease and could only be saved from it by an omnipotent deity, such as a magic doorknob. In fact, the latter idea nearly killed me, whereas the former saved my life.
Unfortunately, our disease theories have been shaped more by our drug and alcohol prohibition laws, the profit motive, and our other beliefs (e.g., about a higher power), than by scientific evidence. My reading of the scientific evidence is that, whatever version of the disease model you are considering, you might be better off without it (just as your father would have been).
Liked this article? You might also be interested in: Addiction is Learning, Not a Disease, by Thaddeus Camlin, Psy.D.
