In 1960 Jellinek defined further and developed the second disease concept from the view of which addiction, was seen to arise from either a pre-existing psychological abnormality or that of a pre-existing physical abnormality. The emphasis which was before on the characteristics of the addictive substance was no longer, and the individual themselves was brought into the concept (cited in Ogden, 2012). Jellinek still purported that for those individuals who were able to control their drinking, did not have the illness of an alcoholic, however he did also add to the second concept, his belief in which environmental factors could influence the pathology of the disease (Bauers, 2009).
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Alcoholics Anonymous, although they do not officially promote the fact, due to their wish of avoiding any public controversy, surrounding the disease concept of addiction, base their 12 step programme around the disease model and beliefs (Kurtz, 2002). In 1933 Dr Silkworth told Bill Wilson, the co-founder of Alcoholics Anonymous, that his opinion on addiction, was that he seen it having no connection to habit, vice or a weak character but an illness which shared both physical and mental compositions. Dr Silkworth is quoted by Michael O’Neil (1998, paragraph 2) as to describing the combinations of the said illness as “an obsession of the mind that condemns one to drink and an allergy of the body that condemns one to die”.
The disease concept believes that those who are suffering from addiction are born with the addiction even before ever having taken the addictive substance. Those who are suffering from the illness, have always been susceptible to addiction and the only way to cure themselves from the illness is to be abstinent, and believe that once and addict always an addict. Others around them who is seen to be controlling their use around the addictive substances, and have no problematic behaviour or outcomes are different to in the fact that they do not suffer from the disease and can control their usage of the addictive substance. In 2011 The American Society of Addiction Medication defined addiction as a primary chronic brain disorder and not purely down to a behaviour problem which was immersed in consumption of drugs and alcohol. Dysfunction in the brain’s memory, reward and motivation circuits steer the individual towards seeking their relief or rewards from their chosen substance and other addictive behaviour. They distinguish addiction through the individuals’ incapability to remain abstinent, cravings, reduced recognition of the substantial problems with their own behaviour and being unable to deal adequately with their emotional responses. As with other chronic disease, the illness of addiction will also quite often include the cycles of remission and relapse, and being left untreated the illness of addiction could become progressively worse over time resulting in long term disabilities and or early death of the individual (ASAM, 2011).
References towards chronic drunkenness as a disease can originally be found in the culture of ancient Egypt and Greece, they referred to people as suffering from drink madness and people had specialized roles to look after those suffering from the illness. These references were continued over the centuries before the emigration of the first European in America. With the consumption of alcohol increasing in America between 1790 and 1830 this broke down the standard patterns which had been contained drunkenness. In light of these changing patterns this prompted a number of well known individuals to discover addiction and looked for a new way of treating and understanding chronic drunkenness. In 1774 Anthony Benezet, social reformer and philanthropist, voiced his concern in the changing drinking patterns which was taking place in colonial America. He had changed his view of alcohol being as a gift from god to being a form of poison (White, 2000) Following on from Anthony Benezet in 1784 Dr. Benjamin Rush, an American physician, produced a pamphlet Inquiry into the Effects of Ardent Spirits on the Human Mind and Body which was highly influential. In this pamphlet he expressed his views as having no concerns over beer and wine however distilled alcohol over a period of time could be destructive and was then the first American to label drunkenness as a disease (Rush, 1785) Thomas Trotter, a Great British physician also proposed that excessive consumption of alcohol may in fact be a disorder and not a deliberate act of sinful behaviour. Dr Benjamin Rush and Thomas trotter are credited to the origin of the disease model concept (Meyer, 1996). In 1840 Magnus Huss, a Swedish physician, proposed the term alcoholism to define the disorder as a syndrome and not only as a disorder of excessive use, which in it included a multiple of physical consequences of this excessive usage(Carson- DeWitt, 2001). In the 19th century the disease concept was also applied to opioid and cocaine addiction (Mayer, 1996). The symptoms which came with alcohol such as cravings and withdrawal were primarily a part of the addiction concept and the damaging effect of the consumption of alcohol was promoted by the temperance movement which was in the 19th century (Levine, 1984). Moving on to the 1940’sthe newly established self-help group Alcoholics Anonymous set up and distributed a questionnaire to their members. They asked Evlin Morton Jellinek to analyse these results and the study was published in the name of “phases of alcoholism” in this study he theorized an expected progression of uncontrolled drinking leads on to symptoms such as withdrawal, blackouts, tolerance, insanity and also death. This report however was based on less than 100 members whose were all male. The inadequacy of the scientific research was recognised by Jellinek and used the study as a starting block for further research. Having said this it was soon taken on bored by people, in particular, members of the AA as being factual. (Hanson, n.d) The Yale Summer School on Alcohol Studies and Jellinek agreed with the AA and their view as alcoholism as a disease which has a developing character rather than ones moral inadequacy. A report by the World Health Organisation (WHO)in 1954 mirrored this new view of the individual being the focus that consists of the individuals make-up being the determining factor accompanied by the pharmacological feature of the alcohol taking a significant part (cited in Mann, Hermann, Heinz, 1999). 1960 was the year in which Jellinek published his book titled The Disease Concept of Alcoholism, and in this book he referred recurrently to the reports in which WHO placed the variation of cell metabolism, withdrawal symptoms and tolerance at the core of his theory as these draw out the loss of control, cravings as well as the inability to remain abstinent. This new disease concept now allowed for these complications to have been caused by the person’s disposition rather than to the long term effect alcohol would have on everyone who consumed it (Jellinek, 1960).
The core beliefs of the disease model of addiction are that in which the individual is suffering physical abnormality alongside psychological abnormalities. Dr Silkworth felt it was unsatisfactory to label an individual with the symptoms of loss of control over their consumption of alcohol to psychological dysfunctions alone, although these were a recognised factor within a majority of individuals, the belief was also within a physical illness to make the belief complete. The theory being the individual suffering an allergy, and this theory was found to make sense to believers as they felt it explained many elements which otherwise could not have been clarified. It is believed that the manifestation of this allergy produces the symptoms of cravings and loss of control, which is absent in moderate users. It is thought that these allergic individuals can never use any substance safely, and having already formed the habit once they will never be able to break it and the only successful outcome is complete abstinence based treatment, as the individual will never out -grow their addiction and are in constant danger of relapsing. The individual is seen to be powerless and to overcome their addiction they are to acknowledge the fact that they are powerless and unable to control this (Alcoholics Anonymous, 2001). The disease model eradicates the consideration of outside factors such as culture background, personal issues and social circle which could be affecting the pattern of substance use and by taking away the consideration of these factors is taking away the responsibility of the individual being able to help themselves and that the addiction was going to happen no matter what. Arran Beck (Beck et al., 1993) suggested that the an addiction originated from holding on to negative psychological beliefs rather than the individual having a biological disease and with treating these painful beliefs can relieve the addiction. Richard Hammersley also has a similar view as to addiction being more comparable to obesity which holds more social and behavioural components, rather to cancers and such like diseases (Hammersley, 2004). Agreeing with this view is psychiatrist Gene Heyman who, in an interview, argues that addiction is directed by personal choice and therefore does not fit into a clinical conception of a behavioural illness. Heymans researched drug use, choice and cognition and in return proposed a model of decision making, which explains how individuals with any form of addiction can voluntarily undertake an action which could progress on to long term torment. In his research surrounding the behaviour if an individual with an addiction he found that many of them has ceased using due to family issues, choice between drugs or families or a new environment where their activities would not be accepted. He looked at the epidemiological details and found them to show the same conclusion of showing a high percentage of between 60% and 80% and those who had fitted the criteria for lifelong dependence had come out of that category by the time they were 30 (cited in Gillis, 2009).
Kevin T. McCauley, M.D claims that medically it can be proven that the addiction defect can be found in the hedonic system of the brain and due to this defect the individual will unconsciously think of the substance and when the substance is unavailable they will begin to crave it. Still taking into account the individual having that choice of consuming or not consuming the substance they cannot control the craving and once the craving reaches its climax no one is strong enough to fight it returning to individual to using again. His view on others being unable to accept the disease concept is down the lack of understanding towards the true concept of cravings. The craving is the point when the individuals use the substance even when they really do not wish to. He claims that the brains of those who are addicted to substances are different to those who are not and this can explain most of the symptoms which would be evident in heavy users as well as fitting addiction into the Disease Illness Model (McCauley, n.d).
The Disease Model/Minnesota Model/The Twelve Step Model is a multi-disciplinary and complete approach for treatment of addiction, as a disease, in which complete abstinence is the main focus. Alcoholics Anonymous also bases their principles of this approach. There is a wide collection of components which are commonly combined with treatment this model is used and they include: the use of a twelve step program, group reading of the twelve step literature each day, group therapy, counselling from a recovering individual, multidisciplinary agencies, lectures, holistic therapy and surroundings, family counselling, attending AA and/or NA meetings, and recreational and physical activities. These components will usually be affiliated into a structured routine for the individual (Guthmann, n.d)
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The chemical dependency is viewed as the leading problem in this model and is non judgmental and does not seek to blame nor retaliative, individuals who have sought treatment are viewed as having had an appropriate response. The journey through the twelve steps guides the individual through a process to try and enable them to understand their own patterns and scale of their drug or alcohol problem, it will also take them through a journey in which has the individual can utilise their own strengths and barriers in their road to recovery. The individuals are taught the significance of the rather than relying on willpower to seek trust in powers more proficient than themselves. This approach to treatment brings prominence to accepting being powerless over the substance of abuse, and endorses embarrassing themselves in the social groups’ ethics and standards to fulfil the goal of abstinence. For treatment model programs which are hospital based can include inpatient detoxifications, outpatient services and rehabilitation services, the length of time the patients are treated can vary for each individual. As well as the therapeutic side of this programme the model will also pay attention to the medical and physical needs of the individual in treatment, there may be a need for this if there has been liver damage or malnutrition over time. The desired outcomes of the treatment incorporate the acceptance of addiction, acknowledging powerlessness over the chosen substance and to maintain abstinence as the objective (Guthmann, n.d).
There has been minimal scientific research into the effectiveness a 12 step treatment programme has on recovery for the individual. Regardless of this, psychiatrist Dr. G. Kirby Collier can be quoted as saying “I have felt that AA is a group unto themselves and their best results can be had under their own guidance, as a result of their philosophy. Any therapeutic or philosophic procedure which can prove a recovery rate of 50% to 60% must merit our consideration.”(Alcoholics Anonymous, appendix III). With regards to this statement on the AA success rate, which uses the 12 steps as a foundation of their principles, Dr. G. Kirby Collier has no scientific results to reinforce for these figures. Studies which had been done by avid professionals who supported the 12 step treatment programme were also rather surprised by the low results which were returned by their studies. Professor George E. Vaillant, a Harvard psychiatrist, was a strong advocate on for the AA and the 12 step programme concluded in his study that individuals diagnosed with alcohol dependency and received no treatment were just as likely to cease drinking as the individuals who went through the 12 step treatment programme (Vaillant, 1995.) With very little positive research outcomes, and the ones which are have no scientific backing it has lead to the question if addiction is a disease then could the individual be in natural remission? Every disease has an unconstrained remission rate and in a report from The Harvard Medical School was the rate of impromptu remission in alcoholics was marginally over the 50% mark translating to an annual remission rate of 5% annually. This 5% in which studies have seen a success rate could just be taking credit for a process which could have occurred naturally for the individual and not down to the 12 step treatment programme at all. In The Harvard Mental Health Letter (1995) it was stated that from 50% of alcoholics it was only 10% of the individuals who sought treatment for the addiction, they also claimed that in different study they found in 80% of alcoholics who were in recovery for over a year had done so own their own with no treatment interventions.
Figures of successful outcomes are based on the achievement of total abstinence which is the main ideological of the 12 step treatment programmes, however for individuals who have gone on to successfully manage controlled drinking after treatment are still seen to have failed in the treatment. Controlled drinking falls into the harm reduction bracket which views the abstinence approach as an unrealistic and maybe impossible and by offering a range of goals the individuals are more liable to continue in the treatment lessen their risk of an elevation of uncontrolled usage of the chosen substance (Marlatt, Larimer, Witkiewitz, 2012).
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