Advantages and Disadvantages of Conceptualising Addiction as a Disease

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8th Feb 2020 Health Reference this

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The question of whether alcoholism or drug addiction can be correctly defined as a disease has been the subject of debate for well in excess of 70 years.

It has, however, been a very fertile debate with many writers, thinkers and researchers contributing arguments on both sides which we will discuss in the course of this paper. Although he was not the first person to propose that alcoholism was a disease, Jellinek (1960) in his landmark book established the debate as we know it today and few writers on the subject can overlook his work and discussion. Jellinek did not use a broad brush to describe all who presented with alcoholism as addicts of the brain disease concept, rather he broke it down into five categories. Of these five categories he suggests that two of the groupings might be described as a disease. Other experts differ in opinion feeling that the disease label (White 2001) should be abandoned, that it fails to provide an adequate framework for prevention and is a term misused.

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Since Hogarth’s (1751) depiction of the perils of gin in his famous painting ‘Gin Lane’ there have been many wide ranging and inhumane attempts at addiction treatment. From spiritual crisis to spiritual awakening, taking the pledge or imprisonment the cures and success chronicles of the last 200 years are varied. In this essay I set out some of the advantages and disadvantages of conceptualising addiction as a disease.

In his article (White 2000) suggests the disease concept challenged public health authorities to take responsibility for the treatment of addiction and altered public perception of the alcoholic. In the USA in the late 1970’s and early 1980’s White tells us there was a huge growth of treatment programmes from private rehab facilities and hospitals who implemented and promoted the disease based concept.

One advantage of the 28 day residential model was that treatment could more easily be accessed through private medical insurance. The disease concept was, in part,

intended to remove the moral stigma of a condition previously regarded as self-inflicted. By 2001 White (White 2001) states that the disease concept was accepted by many including people in recovery, Doctors, Psychiatrists, counsellors and other professionals. It also went some way to support disturbed family members by offering acceptance and removing shame and guilt around their relationships with the addict. White argues that the disease concept encourages self-seeking behaviour and relieves guilt, replacing moral censure with unprejudiced access to health care institutions. He also claims the disease concept works as an umbrella to understand the various potential causes of the problem, as well as the evolution and the interventions that are available as treatment options.

Mansell Pattison et al (Mansell 1977) also note that whilst ‘disease’ does not have a written-in-stone definition, just as any deviation for health may be regarded as a disease, any condition that progresses over time may also fall into that category.

Pattinson recognises that E M Jellinek’s book (Jellinek 1960) had been a most important and pervasive influence on the so-called disease model. Its primary intent being to influence both contemporary medical practices with social and political developments. Jellinek alludes to five sub categories of ‘alcoholisms’ though he defines only two, the gamma and the delta varieties of alcoholism as a disease. This model effectively captured the notion that addictive disease was not a one size fits all malaise. Further Jellinek acknowledges that the definition of ‘disease’ as effective for the medical profession is not necessarily the identical definition of disease as held by the general public.

Burnham (1994) determines that the inability to abstain and loss of control in the context of an illness appears to normalize and legitimize the compulsive drinking behaviour. It reduces the sense of isolation, blame, stigma, guilt and shame, and subsequent resistance to seeking help. It provides a healing rationale and justification for self-punishing actions whilst at the same time instilling hope and optimism that recovery is possible. Burnham also suggests that it is probable that treatment promotes identification and connection with others who are similarly afflicted. Burnham concedes that the advantages of the disease concept are far-reaching and can have positive effects for both female and male alcoholics. Placing the inability to abstain and loss of control in the context of an illness, which can be treated, is comforting to the sufferer and family members. It reduces the sense of isolation, blame, stigma, guilt and shame, and subsequent resistance to seeking help. It instils hope that recovery is possible and probable with help, as so many have demonstrated. It also promotes identification and connection with others and provides information as to the causative factors behind the continued consumption.

However, where women alcoholics are concerned, Burnham (1994) discusses the impact of the disease concept and the need for women in particular to engender self- efficacy and feelings of empowerment, several problems with the disease concept emerge. Its emphasis on illness evokes images of a dependent whose wellness is under the control of medical or mental health professionals, contradicting the disease rhetoric of clients taking responsibility for their recovery. Burnham further observes that given women’s socialized patterns of dependency and subordination this additional dependent role reinforces any learned helplessness formulated during early childhood and later years. The obsessive and compulsive lack of control of drinking, a primary symptom of the disease concept, can readily be symbolically generalized to a lack of control of the totality of her life in the woman’s belief system. Instead of believing in herself, in her personal creative abilities and strengths, she focuses on her childlike, immature and needy traits. Underhill and Lester argue that women need to feel empowered with their life situation (Burnham 1994)

In his article (White 2001 Counsellor 3) White argues that the disease concept strips the addict of freedom and responsibility and can be misapplied. He suggests that labelling alcohol/drug problems as incurable diseases could dissuade heavy drinkers from seeking help, and furthermore that by restricting the definition of vulnerability to a small group it has let alcohol and drug industries escape blame for the promotion of their products. White goes on to recommend (White, Apr 2001)

that disease concept critics claim that the majority of people who resolve alcohol-drug related problems do so without seeking recourse to any treatment programme or group. The paper continues to say that addiction is not a disease but rather a choice founded in weakness of character, a habit under the control of the Will that could be broken like any other habit.

Another adverse result was that there was a financial backlash against access to the ‘industry’ managing access to treatment, in particular, the prototype 28-day inpatient programme. Right of entry became more restricted towards the end of the twentieth century unless it could be paid for, insurers did not like the heavy costs. Professional consensus was again resurfacing that some of the addiction problems might be best resolved at a personal, cultural and environmental level. In a later paper (White, Counsellor Apr 2001) proposes that one of the first definitions needed is that of disease. The addiction field must follow the rest of medicine in moving away from the depiction of disease as an entity to an understanding of disease as a metaphor. “Disease” is a word and an idea used to convey substantial, deteriorating changes in the structure and function of the human body and the accompanying deterioration in biopsychosocial functioning.

Burnham (1994) argued that diseases were usually thought of as being inside the body but alcoholism and addictions present through mainly environmental factors.

Lewis (2016) asserts that the disease model is scientifically baseless and sustains stigma. Lewis suggests that we are starting to recognise addiction as a consequence of social ills rather than individual flaws. Furthermore, he observes that medical care only makes sense for medical illnesses.

The enduring debate about whether there are advantages or disadvantages in using the disease concept terminology will rumble on and until we have some definitive wisdom as to the cause of addiction. We know that the disease concept has lent hope and identity to many addicts and their families, we also know that some people recover from drug/alcohol addiction without any treatment intervention at all.

Lewis (2006) argues that the disease model undermines hope, fails to end stigma and doesn’t always get addicts the help they need. Lewis further suggests that the brain changes observed in long term substance abusers are nearly identical with those suffering from obesity, gamblers, porn aficionados, gamblers and internet addicts, pointing to the idea of responding to cues predicting their preferred rewards. Dopamine flows in anticipation of pleasure, (Maté 2012) a response to an outside stimulus rather than a disease which originates within, children are constantly chasing dopamine. Adult children seek to recreate the same. Conceivably the ritual of pouring a drink or assembling drug paraphernalia offers this promise, and this is outside the body and in the environment.

Should we look more closely at lives rather than genetics and addictions as the disease, keeping in mind the human brain is shaped by environment.

Some addicts, in a moment of sudden insight can change course and turn away from addiction, this is undeniably at odds with the disease concept.

Is there an argument to look at what is right about addiction?

Are there undeclared forces at work to encourage the disease model, such as the alcohol industry, advertising and marketing companies, pharmaceutical companies, costly private rehab residential centres and the Inland Revenue. Lewis (2015) argues that the disease label locates the problem of addiction in the individual and therefore it is hard to see how that counteracts stigma. Most addicts eventually recover with or without help and it is therefore confusing for them to be labelled as chronically ill.

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An opportunity to explore this model was presented when (Finagrette, 2010) when the Supreme Court considered the issue of whether alcoholism is a disease and whether being alcoholic excuses one from criminal responsibility.Although, when entering this fray, Herb Finagrette’s sense was that alcoholism had been established to be a disease, his examination of the issues thoroughly convinced him otherwise. There was no genetic or other biological explanation for why a person drinks too much either on a particular occasion or habitually, why a person commits violent or criminal acts when drunk, why a person decides that he or she is an alcoholic and that drinking is an excuse for misbehaviour. Instead, Herb saw, drinking was an all-purpose excuse, a special case of self-deception anointed by science but actually steeped in the lore of magical “loss of control”—”I couldn’t help myself”—as though this description of irresponsibility was somehow an explanation and an excuse for it.

It remains the case that treatment is not available to the majority who seek it.

Recovery from alcohol dependence bears no necessary relation to abstinence, (Pattinson 1977) although such a concurrence is frequently the case. (Levine 1978) reminds us that there are different conditions facing people in the 20th century, particularly giant organisations and the consequent degree of human interdependence, evolving what were once viewed as individual problems into problems of a more social nature.

(Vaillant 1995) reminds us that alcoholism produces enormous suffering and to deny treatment to alcoholics is inhumane. Virtually all follow-up studies show alcoholics better off for several months after clinic treatment than they were just before treatment. The disease model of treatment facilitates the understanding of facts rather than illusions about the addiction which, in turn, serves to assist the natural healing process.

Summing up the advantages and disadvantages of conceptualising addiction as a disease we must look at how the addict might benefit from either point of view.

Drug treatment programmes (Coomber et al 2013) discuss ideologies that vary considerably in terms of treatment, some programmes are abstinence based whereby drug use is not tolerated. This might include the AA 12 step programme or a disease model rehab programme. The alternative philosophy draws on the principles of harm reduction without using a closed environment.

The addict will have their own views on which treatment offers them the better opportunity of success. It is important not to discount the degree of self efficacy the addict may possess or the goals he/she may be determined to attain in order to enable recovery. There may be a situation of natural ‘maturing out’ and reaching a stage where other things replace the drug of choice such as a relationship, children or a job. (Coomber 2013) advocate that successful outcomes depend, in part, on the appropriate match between an individual’s needs and a particular drug treatment modality. Abstinence from drugs must always be placed second to the health of users, so it goes without saying that a person suffering from alcohol addiction should not undertake a detox without medical supervision.

The disease model 28dday recovery programmes offer enlightenment and understanding of some of the reasons that may have led to addiction. This may prompt further self-seeking discoveries, whether a relapse occurs or not, seeds will have been planted during therapy sessions that can be revisited. The security of knowing that there are others in the group who are trying to move out of addiction may offer the feeling that it is not a lone journey and a sense of being able to help each other.

AA’s Twelve Step Program not only provides accessible group support but also a clear ideology regarding addiction. The programme addresses the individuals’ need for identity, integrity, an inner life and interdependence within a larger social and moral, or spiritual context. The ideology largely encompasses a disease-like point of view promoting total abstinence and surrender to a higher power. Not all attendees feel the need to embrace all AA conventions but may draw on the collective wisdom and companionship of the group as they feel appropriate.

Where the addict can move out of depression and engage in a more meaningful life it can follow that he/she will be less interested in mind numbing substances. The Rat Park experiment (Alexander 2018) showed that where a group of rats lived together in a park offering lots of interesting stimulation and food they avoided taking her heroin that was offered. Medicating with mind altering substances is usually driven by not feeling complete emotionally.

Though there are strong arguments on both sides regarding the advantages and disadvantages of conceptualising addiction as a disease, the outcome I feel is that a non-disease concept is marginally more favourable.

Reference list

The question of whether alcoholism or drug addiction can be correctly defined as a disease has been the subject of debate for well in excess of 70 years.

It has, however, been a very fertile debate with many writers, thinkers and researchers contributing arguments on both sides which we will discuss in the course of this paper. Although he was not the first person to propose that alcoholism was a disease, Jellinek (1960) in his landmark book established the debate as we know it today and few writers on the subject can overlook his work and discussion. Jellinek did not use a broad brush to describe all who presented with alcoholism as addicts of the brain disease concept, rather he broke it down into five categories. Of these five categories he suggests that two of the groupings might be described as a disease. Other experts differ in opinion feeling that the disease label (White 2001) should be abandoned, that it fails to provide an adequate framework for prevention and is a term misused.

Since Hogarth’s (1751) depiction of the perils of gin in his famous painting ‘Gin Lane’ there have been many wide ranging and inhumane attempts at addiction treatment. From spiritual crisis to spiritual awakening, taking the pledge or imprisonment the cures and success chronicles of the last 200 years are varied. In this essay I set out some of the advantages and disadvantages of conceptualising addiction as a disease.

In his article (White 2000) suggests the disease concept challenged public health authorities to take responsibility for the treatment of addiction and altered public perception of the alcoholic. In the USA in the late 1970’s and early 1980’s White tells us there was a huge growth of treatment programmes from private rehab facilities and hospitals who implemented and promoted the disease based concept.

One advantage of the 28 day residential model was that treatment could more easily be accessed through private medical insurance. The disease concept was, in part,

intended to remove the moral stigma of a condition previously regarded as self-inflicted. By 2001 White (White 2001) states that the disease concept was accepted by many including people in recovery, Doctors, Psychiatrists, counsellors and other professionals. It also went some way to support disturbed family members by offering acceptance and removing shame and guilt around their relationships with the addict. White argues that the disease concept encourages self-seeking behaviour and relieves guilt, replacing moral censure with unprejudiced access to health care institutions. He also claims the disease concept works as an umbrella to understand the various potential causes of the problem, as well as the evolution and the interventions that are available as treatment options.

Mansell Pattison et al (Mansell 1977) also note that whilst ‘disease’ does not have a written-in-stone definition, just as any deviation for health may be regarded as a disease, any condition that progresses over time may also fall into that category.

Pattinson recognises that E M Jellinek’s book (Jellinek 1960) had been a most important and pervasive influence on the so-called disease model. Its primary intent being to influence both contemporary medical practices with social and political developments. Jellinek alludes to five sub categories of ‘alcoholisms’ though he defines only two, the gamma and the delta varieties of alcoholism as a disease. This model effectively captured the notion that addictive disease was not a one size fits all malaise. Further Jellinek acknowledges that the definition of ‘disease’ as effective for the medical profession is not necessarily the identical definition of disease as held by the general public.

Burnham (1994) determines that the inability to abstain and loss of control in the context of an illness appears to normalize and legitimize the compulsive drinking behaviour. It reduces the sense of isolation, blame, stigma, guilt and shame, and subsequent resistance to seeking help. It provides a healing rationale and justification for self-punishing actions whilst at the same time instilling hope and optimism that recovery is possible. Burnham also suggests that it is probable that treatment promotes identification and connection with others who are similarly afflicted. Burnham concedes that the advantages of the disease concept are far-reaching and can have positive effects for both female and male alcoholics. Placing the inability to abstain and loss of control in the context of an illness, which can be treated, is comforting to the sufferer and family members. It reduces the sense of isolation, blame, stigma, guilt and shame, and subsequent resistance to seeking help. It instils hope that recovery is possible and probable with help, as so many have demonstrated. It also promotes identification and connection with others and provides information as to the causative factors behind the continued consumption.

However, where women alcoholics are concerned, Burnham (1994) discusses the impact of the disease concept and the need for women in particular to engender self- efficacy and feelings of empowerment, several problems with the disease concept emerge. Its emphasis on illness evokes images of a dependent whose wellness is under the control of medical or mental health professionals, contradicting the disease rhetoric of clients taking responsibility for their recovery. Burnham further observes that given women’s socialized patterns of dependency and subordination this additional dependent role reinforces any learned helplessness formulated during early childhood and later years. The obsessive and compulsive lack of control of drinking, a primary symptom of the disease concept, can readily be symbolically generalized to a lack of control of the totality of her life in the woman’s belief system. Instead of believing in herself, in her personal creative abilities and strengths, she focuses on her childlike, immature and needy traits. Underhill and Lester argue that women need to feel empowered with their life situation (Burnham 1994)

In his article (White 2001 Counsellor 3) White argues that the disease concept strips the addict of freedom and responsibility and can be misapplied. He suggests that labelling alcohol/drug problems as incurable diseases could dissuade heavy drinkers from seeking help, and furthermore that by restricting the definition of vulnerability to a small group it has let alcohol and drug industries escape blame for the promotion of their products. White goes on to recommend (White, Apr 2001)

that disease concept critics claim that the majority of people who resolve alcohol-drug related problems do so without seeking recourse to any treatment programme or group. The paper continues to say that addiction is not a disease but rather a choice founded in weakness of character, a habit under the control of the Will that could be broken like any other habit.

Another adverse result was that there was a financial backlash against access to the ‘industry’ managing access to treatment, in particular, the prototype 28-day inpatient programme. Right of entry became more restricted towards the end of the twentieth century unless it could be paid for, insurers did not like the heavy costs. Professional consensus was again resurfacing that some of the addiction problems might be best resolved at a personal, cultural and environmental level. In a later paper (White, Counsellor Apr 2001) proposes that one of the first definitions needed is that of disease. The addiction field must follow the rest of medicine in moving away from the depiction of disease as an entity to an understanding of disease as a metaphor. “Disease” is a word and an idea used to convey substantial, deteriorating changes in the structure and function of the human body and the accompanying deterioration in biopsychosocial functioning.

Burnham (1994) argued that diseases were usually thought of as being inside the body but alcoholism and addictions present through mainly environmental factors.

Lewis (2016) asserts that the disease model is scientifically baseless and sustains stigma. Lewis suggests that we are starting to recognise addiction as a consequence of social ills rather than individual flaws. Furthermore, he observes that medical care only makes sense for medical illnesses.

The enduring debate about whether there are advantages or disadvantages in using the disease concept terminology will rumble on and until we have some definitive wisdom as to the cause of addiction. We know that the disease concept has lent hope and identity to many addicts and their families, we also know that some people recover from drug/alcohol addiction without any treatment intervention at all.

Lewis (2006) argues that the disease model undermines hope, fails to end stigma and doesn’t always get addicts the help they need. Lewis further suggests that the brain changes observed in long term substance abusers are nearly identical with those suffering from obesity, gamblers, porn aficionados, gamblers and internet addicts, pointing to the idea of responding to cues predicting their preferred rewards. Dopamine flows in anticipation of pleasure, (Maté 2012) a response to an outside stimulus rather than a disease which originates within, children are constantly chasing dopamine. Adult children seek to recreate the same. Conceivably the ritual of pouring a drink or assembling drug paraphernalia offers this promise, and this is outside the body and in the environment.

Should we look more closely at lives rather than genetics and addictions as the disease, keeping in mind the human brain is shaped by environment.

Some addicts, in a moment of sudden insight can change course and turn away from addiction, this is undeniably at odds with the disease concept.

Is there an argument to look at what is right about addiction?

Are there undeclared forces at work to encourage the disease model, such as the alcohol industry, advertising and marketing companies, pharmaceutical companies, costly private rehab residential centres and the Inland Revenue. Lewis (2015) argues that the disease label locates the problem of addiction in the individual and therefore it is hard to see how that counteracts stigma. Most addicts eventually recover with or without help and it is therefore confusing for them to be labelled as chronically ill.

An opportunity to explore this model was presented when (Finagrette, 2010) when the Supreme Court considered the issue of whether alcoholism is a disease and whether being alcoholic excuses one from criminal responsibility.Although, when entering this fray, Herb Finagrette’s sense was that alcoholism had been established to be a disease, his examination of the issues thoroughly convinced him otherwise. There was no genetic or other biological explanation for why a person drinks too much either on a particular occasion or habitually, why a person commits violent or criminal acts when drunk, why a person decides that he or she is an alcoholic and that drinking is an excuse for misbehaviour. Instead, Herb saw, drinking was an all-purpose excuse, a special case of self-deception anointed by science but actually steeped in the lore of magical “loss of control”—”I couldn’t help myself”—as though this description of irresponsibility was somehow an explanation and an excuse for it.

It remains the case that treatment is not available to the majority who seek it.

Recovery from alcohol dependence bears no necessary relation to abstinence, (Pattinson 1977) although such a concurrence is frequently the case. (Levine 1978) reminds us that there are different conditions facing people in the 20th century, particularly giant organisations and the consequent degree of human interdependence, evolving what were once viewed as individual problems into problems of a more social nature.

(Vaillant 1995) reminds us that alcoholism produces enormous suffering and to deny treatment to alcoholics is inhumane. Virtually all follow-up studies show alcoholics better off for several months after clinic treatment than they were just before treatment. The disease model of treatment facilitates the understanding of facts rather than illusions about the addiction which, in turn, serves to assist the natural healing process.

Summing up the advantages and disadvantages of conceptualising addiction as a disease we must look at how the addict might benefit from either point of view.

Drug treatment programmes (Coomber et al 2013) discuss ideologies that vary considerably in terms of treatment, some programmes are abstinence based whereby drug use is not tolerated. This might include the AA 12 step programme or a disease model rehab programme. The alternative philosophy draws on the principles of harm reduction without using a closed environment.

The addict will have their own views on which treatment offers them the better opportunity of success. It is important not to discount the degree of self efficacy the addict may possess or the goals he/she may be determined to attain in order to enable recovery. There may be a situation of natural ‘maturing out’ and reaching a stage where other things replace the drug of choice such as a relationship, children or a job. (Coomber 2013) advocate that successful outcomes depend, in part, on the appropriate match between an individual’s needs and a particular drug treatment modality. Abstinence from drugs must always be placed second to the health of users, so it goes without saying that a person suffering from alcohol addiction should not undertake a detox without medical supervision.

The disease model 28dday recovery programmes offer enlightenment and understanding of some of the reasons that may have led to addiction. This may prompt further self-seeking discoveries, whether a relapse occurs or not, seeds will have been planted during therapy sessions that can be revisited. The security of knowing that there are others in the group who are trying to move out of addiction may offer the feeling that it is not a lone journey and a sense of being able to help each other.

AA’s Twelve Step Program not only provides accessible group support but also a clear ideology regarding addiction. The programme addresses the individuals’ need for identity, integrity, an inner life and interdependence within a larger social and moral, or spiritual context. The ideology largely encompasses a disease-like point of view promoting total abstinence and surrender to a higher power. Not all attendees feel the need to embrace all AA conventions but may draw on the collective wisdom and companionship of the group as they feel appropriate.

Where the addict can move out of depression and engage in a more meaningful life it can follow that he/she will be less interested in mind numbing substances. The Rat Park experiment (Alexander 2018) showed that where a group of rats lived together in a park offering lots of interesting stimulation and food they avoided taking her heroin that was offered. Medicating with mind altering substances is usually driven by not feeling complete emotionally.

Though there are strong arguments on both sides regarding the advantages and disadvantages of conceptualising addiction as a disease, the outcome I feel is that a non-disease concept is marginally more favourable.

Reference list

  • Alexander, B., 2018. Addiction: The View from Rat Park (2010). [online] Brucekalexander.com. Available from: http://brucekalexander.com/articles-speeches/rat-park/148-addiction-the-view-from-rat-park [Accessed 20 Oct. 2018].
  • Coomber, R., McElrath, K., Measham, F., & Moore, K. (2013). Key concepts in drugs and society. Sage. P125-128
  • Finagrette, H., 2010. Is Addiction Really a Disease?. Alcoholism Treatment Quarterly, 28(2), pp.239-242.
  • Jellinek, E. M., 1960. The disease concept of alcoholism.
  • Hogarth’s, W., 1751. Gin lane.
  • Levine, H. G., 1978. The discovery of addiction. Changing conceptions of habitual drunkenness in America. Journal of studies on alcohol39(1), 143-174.
  • Lewis, M., 2015. The biology of desire: why addiction is not a disease. Hachette UK.
  • Maté, G., 2012. Addiction: Childhood trauma, stress and the biology of addiction. Journal of Restorative Medicine1(1), 56-63.
  • Pattison, E. M., Sobell, M. B., & Sobell, L. C. (1977). Emerging concepts of alcohol
  • dependence. Springer Publishing Company.
  • White, W. L., 2000. Addiction as a disease: The birth of a concept. Addiction51, 73.
  • White, W.L, 2001 Addiction Disease Concept: Advocates and Critics.” Counselor 2 (1), 42-46
  • White, W. L., Boyle, M., & Loveland, D. (2002). Alcoholism/addiction as a chronic disease: From rhetoric to clinical reality. Alcoholism Treatment Quarterly20(3-4), 107-129.
  • Alexander, B., 2018. Addiction: The View from Rat Park (2010). [online] Brucekalexander.com. Available from: http://brucekalexander.com/articles-speeches/rat-park/148-addiction-the-view-from-rat-park [Accessed 20 Oct. 2018].
  • Vaillant, G. E., 2009. The natural history of alcoholism revisited. Harvard University Press.

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