This book (which continues as a best seller on the Amazon.com substance abuse and addiction lists) is the classic statement of the antidisease point of view. In this chapter, Stanton reviews the history of attitudes towards alcohol in the United States, from widespread and generally unproblematic drinking in Colonial America, to a century of warfare between temperance and nontemperance forces (culminating in national Prohibition from 1920-1933), to a post-Prohibition era in which AA repackaged temperance into the alcoholism movement, to an era when the disease of addiction permeates the American spirit.
In: Peele, S. (1989, 1995), Diseasing of America: How we allowed recovery zealots and the treatment industry to convince us we are out of control. Lexington, MA/San Francisco: Lexington Books/Jossey-Bass.
Diseasing of America
2. Alcoholism in America
How We Discovered that Alcohol Is Addictive and that So Many People Are Alcoholics
|WOMAN IN THE BALCONY: Is there much drinking in Grover's Corners?
MR. WEBB: Well, ma'am, I wouldn't know what you'd call much. Sattidy nights the farmhands meet down in Ellery Greenough's stable and holler some. Fourth of July I've been known to taste a drop myselfand Decoration Day, of course. We've got one or two town drunks, but they're always having remorses every time an evangelist comes to town.
|Thornton Wilder, Our Town|
|Let's face it, pizza and a Sprite after games just don't get it.|
|Carlton Fisk, Chicago White Sox catcher
after his team banned beer in the clubhouse
Overview: The Changing Tides of Drinking in the United States
OUR TOWN was published several years after the repeal of Prohibition (in 1933) and shortly before Alcoholics Anonymous published its bible, or "Big Book" (in 1939). At that time, most Americans thought about alcoholism as Thornton Wilder did: it was a rare occurrence, something found among a few social pariahs. In addition, some lower types (like the farmhands down in Ellery Greenough's stable) were likely to get drunk on weekends and create a commotion. Most upstanding townspeople, like Mr. Webb, might be occasional drinkers, but they wouldn't make a regular habit of it.
Of course, people of different regions and religions felt differently about alcohol. Fundamentalist Protestants deplored all drinking; theylike rural Americans and those in the South and Midwest had formed the backbone of the temperance and antisaloon movements. Women were prominent in these movements, although few joined because they themselves had a drinking problem; rather, as a group they suffered from men's drunkenness, especially in working-class families where men often wasted their time and wages on their visits to the saloon. For this reason, temperance was an important component in the Progressive movement's effort to improve the lives of the working class.
Yet most immigrants, city dwellers, and other elements of the liberal coalition in the United States felt quite differently about alcohol. For many immigrant groups, liquor was the glue of life, the spirit of any celebration, and the mild lubricant that aided digestion and accompanied every dinner. For these people and other cosmopolitan Americans, the temperance movement was a product of small-minded Americans and religious zealots. Nonetheless, in 1920, national Prohibition was enacted in the United States. Prominent liberals like Clarence Darrow, who were implacably opposed to Prohibition, railed against the moral crusaders who would impose their morality on everyone else in the country.
After Prohibition's repeal, it seemed as if the cosmopolitan attitude toward drinking represented by urban liberals like Darrow and the newer European immigrants had won out. The secular society at large accepted alcohol as a regular part of ordinary life. True, some people sometimes drank too much. For most people, however, such overimbibing was often excused as an acceptable excess on special occasions like New Year's Eve or the office Christmas party or the ethnic funeral, and for somelike high-spirited young menas a stage they had to go through and grow out of. Toward some few others who habitually became drunk or who couldn't control their drinking, most people adopted an attitude between knowing condescension and outright scorn: why were these people so weak or immoral as not to know when enough was enough?
But Americans weren't preoccupied with alcoholics or with the negative potential of alcohol. Drinkingeven periodic intoxicationwas portrayed as innocent and normal in movies, television, novels, and plays. The "Thin Man" and his wifeplayed onscreen by William Powell and Myrna Loywere tipplers, often portrayed as being "high," as were many other adorable American characters. Even the Walt Disney film Fantasia depicted the Greek god of revels, Bacchus, in an intoxicated but merry state. Consider the following baseball story:
Kirby Higbe once recalled a game in the 1940's, when the Pirates were also-rans, in which he pitched against the Reds and "five of our regulars were plastered." They kept blowing plays. It was a close game, Higbe remembered, "and the bases were loaded, like our fielders." A fly ball was hit to the center fielder, who stumbled in as the ball flew over his head. "Everyone scored," he said. "I couldn't take it no more. I walked off the mound. Billy Herman, the manager, didn't know what I was doing. He said, 'What's wrong, Hig?'
"I said, 'They're drunk.'
"He said, 'Who's drunk?'
"I said, 'Everyone!' "
The stories of Babe Ruth entering the locker room after his all-night benders are legendary. This view of drinking continued well into the 1960s and early 1970s. Mickey Mantle revealed in his autobiography that he played important games with hangovers.
How differently we react to the same stories today! Tales of playing under the influence are now recounted by players who have entered treatment. Only these are regarded no longer as tales of athletic high jinks but as horror stories of the evils of addiction and alcoholism. Today we are most likely to hear about drinking and drunkenness in the context of people who are suffering from an inexorable disease and who need treatment that will aid them to recovery. We discover that stars like Elizabeth Taylor, Liza Minnelli, Mary Tyler Moore, and many others have been treated for alcoholism. Most go to the Betty Ford Center, named after the First Lady who courageously admitted her alcoholism and who now stands as a model to all Americans to seek treatment for their drinking problems.
We hear constantly on television and radioboth from nonprofit organizations like the National Council on Alcoholism and from profit-making private treatment centersthat if we think we have a drinking problem, then indeed we do, and that this problem can only get worse unless we get help. We are told that there are from 15 to 22 million alcoholic Americans and that the families of such people are as disturbed as the alcoholic himself or herself, leading to estimates that as many as one in three Americans suffers as a result of alcoholism and requires treatment for this malady. We see frequent TV shows about families disrupted and almost destroyed by a family member's alcoholism and about the need for the family to overcome their denial that this person is an alcoholic so that all together can seek treatment.
And the children! Drunkenness has become a regular activity for high school students, to judge from national surveys. As a result, we are sending out a new brand of temperance lecturers, like David Toma, who often combine antidrug with antialcohol messages in the hope of discouraging young people from ever drinking. Alcohol (along with drug) education is now a part of elementary school curricula, and what children are told is that alcohol is bad, pure and simple. Only a decade and a half ago, the National Institute on Alcohol Abuse and Alcoholism attempted to get young people to learn responsible drinking habits at home and in college. Today, a more typical message is this one from an alcohol educator from Southern California: "A home instruction course in safe drinking makes as much sense as teaching your child to skin-pop heroin (the method of injecting heroin into the fatty tissue, rather than directly into the vein) in hopes that the youngster will not become addicted."
What has happened here? Has our drinking really gotten this far out of control? Or were we in America always simultaneously enthralled and ravaged by alcohol, only we didn't know it (in a kind of national denial)? More important, where are we headed? Is it really true that we need massive alcoholism treatment, earlier and earlier interventions into the lives of young people, greater restrictions on our drinking behavior, and more coercive regulations both at work and in the courts to make sure that more people learn that they are alcoholics and must enter treatment? Will this then solve our problems with alcohol? Or if the malady is truly inbred, must a sizable portion of our population live with the constant awareness that a single drink will lead them into an alcoholic binge, while all the rest of us anxiously guard against tempting these ill people by serving liquor and enjoying it ourselves?
Just as there is a pluralism of political attitudes in a democracy, there remains a range of attitudes about alcohol and its effects and a considerable spectrum of views about what constitutes appropriate drinking. This is true both around the world and within the United States. However, this range has narrowed considerably in the United States in the last decade and shows signs of becoming even more constricted. How could attitudes not change, with the degree of public education on the dangers of alcohol that every American now receives from childhood on? While many people continue to teach their children to regard alcohol as a mild and enjoyable intoxicant, they face a growing tide of antidrinking sentiment.
From the Colonial Tavern to the Temperance Lectern
The changing tides of opinion about alcohol and drinking in America began in colonial America. Colonial Americans were not concerned about their drinkingfar from it! They believed alcohol to be a natural substance and imbibed it freely: "The 'liquor problem' was not a public issue or fact of consciousness in colonial America. In the 17th and 18th centuries alcoholic beverages, and especially rum, were highly esteemed and universally valued and were in no way stigmatized or regarded as tainted or evil. All liquor was regarded as good and healthy.... It was drunk at all hours of the day and night, by men and women of all social classes, and it was routinely given to children." The average colonial drank several times as much alcohol per year as the current American, and even the Puritans called liquor the "Good Creature of God."
If so much liquor was drunk, why didn't people recognize alcoholism as a problem? In the first place, most people controlled their drinking most of the time. For example, the tavern was a social center in New England, where families joined together with their neighbors before a fire to discuss the news, enjoy hearty fellowship, and drink. In this setting, problematic drinking was rare, and the tavern keepera person of esteem and authoritymade sure drinking did not get out of hand. On the other hand, when people did drink too much and behave violently, alcohol was not blamed. "Drunkenness was not so much seen as the cause of deviant social behaviorin particular crime and violenceas it was construed as a sign that an individual was willing to engage in such behavior." The conventional punishments of the pillory and flogging were meted out to drunkards who could not control their behavior.
All of this changed dramatically in the fifty years dating roughly from 1785 to 1835. During this period, drinking became a disruptive force for many Americans. The tight-knit community tavern disappeared, and instead the new industrialized work force and the western ranch laborer went to boisterous saloons to get drunk. Imagine as a model of nineteenth-century male drinking the Dodge City dance hallwhere the only women likely to be present were prostitutes and where gunplay and fights were common. Middle- and upper-class Americans cut back their drinking drastically because it was no longer considered appropriate for an industrious life. As alcohol was eliminated from the ordinary daily routines of the middle class, when people did drink, they were more likely to go on binges where they drank all out. Drunkenness was defined as a time for letting go"To get drunk was to abandon both respectability and self control."
These changes in drinking habits and images of alcohol were part of a vast social and institutional revolution that was taking place in the United States. The country was expanding dramatically: Americans were leaving established communities to explore new territories, while older communities were being invaded by waves of new immigrants. Overall, the population of the United States nearly doubled, and growth was even more rapid in the West and in eastern cities. The fifty years between 1785 and 1835 marked the end of family and community regulation of social problems like poverty, crime, insanity, and alcoholism. In place of such community self-regulation, these problems were now handled by the poorhouse, prison, asylum, and sanitarium. It was in this context that alcohol-related misbehavior grew out of hand and Americans became acutely conscious of the ravages of alcoholism.
The image of "demon rum" was born in the 1800s, the result of this new discovery of the dangers of drinking. Alcohol came to be seen as the root cause of modern evils, and the idea arose that America could be perfected if everyone ceased drinking alcohol (or, originally, distilled spirits). The temperance movement dates from the formation of the American Temperance Society in 1826; by 1835, more than a million merchants, lawyers, teachers, and others had promised not to drink distilled liquor; 500,000 had pledged not to drink alcohol of any kind. The temperance movement was strongly nativist, Protestant, and middle class, and new tides of European immigrants ran afoul of temperance when they insisted on continuing their European drinking habits. By the middle of the nineteenth century, drinking had declined per capita to about a third of its colonial level.
As people decided alcohol was evil, they also came to believe that liquor could enslave a person against his or her will. In 1784 Benjamin Rush (a physician and signer of the Declaration of Independence) first advanced the idea that habitual drunkenness is a disease. The temperance movement propagated and expanded this view during the next century: drinking was so dangerous, it said, people should not even sample a first beer, or else they would likely embark on an inevitable path toward alcoholism. When the drinker eventually became a drunkard (the word alcoholic did not become popular until this century), he simply could not control his drinking. Despite an ardent search, however, temperance adherents never identified an account of a drunkard before the 1800s who reported that he had lost control of his drinking. "The idea that alcoholism is a progressive diseasethe chief symptom of which is loss of control over drinking behavior, and whose only remedy is abstinence from all alcoholic beveragesis now about 175 or 200 years old, but no older."
The temperance ideology differed from the modern alcoholism movement in that it maintained that alcohol is inevitably dangerous and inexorably addictive for everyone. That is, some people might believe they can drink moderately, but it is only a matter of time before they encounter increasing problems and completely lose control of their drinking. As strange as it seems to us today, the temperance message thus was that alcohol is inevitably addicting, in the same way that we now think of narcotics. A regular part of temperance propaganda was newspaper cartoons, plays, songs, and articles that portrayed the innocent social drinker who gradually slid from casual drinking to tippling to inveterate drunkenness and ended up destroying himself and his family. The temperance movement was not nearly as antidrunkard as it was opposed to those who claimed to be happy moderate drinkers, and the term intemperate was applied equally to habitual drunkards and to those who drank with meals.
The key element in the temperance view of alcoholism was the drinker's loss of control, which rendered the inebriate incapable of making moral distinctions or of seeing the damage he was causing himself and those around him. The solution for this condition was a religious conversion that led the drinker to see the light and declare he would never drink again. Since alcoholism grew inevitably and inexorably from drinking, the only safe course was total abstinence. Abstinence, of course, actually belies the literal meaning of the word temperancewhose meaning is closer to "moderation"and was only adopted as the official goal of the movement in 1836. Before this date, manyincluding Rush himselfthought that only distilled spirits led to the disease we call alcoholism and that people might still drink beer and wine moderately.
One group that became important within the temperance movement around the 1840s was the Washingtoniansa brotherhood of reformed drunkards who supported one another's abstinence and preached to other heavy drinkers to join them. Like other temperance associations, they followed the pattern of the Protestant revival meeting: the sinnerin this case, the inebriatepublicly and emotionally confessed his transgressions, sought and gained group acceptance and absolution for his sins, and was redeemed with a new identity and a vow forevermore to hew to a straight and godly path. At its peak, the Washingtonian movement had 600,000 members, perhaps 150,000 of whom remained totally abstinent. After the Civil War, reformed drunkards joined the Women's Christian Temperance Union and other temperance and reform clubs, as well as forming their own organizations, such as the Oxford Group.
These reformed alcoholics (invariably men) became a mainstay on the American scene. Sharing the lecture circuit with the likes of Mark Twain, they reenacted the throes of their drunken degradation and eventual reclamation through God and good living, leading to the new sober selves that stood before the audience. (Observers noted that audiences seemed far more interested in the lecturers' stories about the former drunken lives.) The reclamation of the alcoholic became a common tale in America, one regarded by many with cynicism, as in Wilder's description of the few town drunkards in Grover's Corners: "they're always having remorses every time an evangelist comes to town." Some insisted on seeing them and their spiritual mentors as hypocrites and on regarding their resolves to perpetual sobriety as temporary expedients to gain favor and attention.
One devastating portrait of this process is in Mark Twain's Huckleberry Finn, where Huck describes a judge's efforts to remake his father after Pap is sent to jail on one of his drunken binges. The judge and his wife welcome Pap into their home, feed and clothe him, and give him a temperance lecture. In a blubbery scene, Pap holds out his hand and swears:
"Look at it gentlemen, and ladies all.... There's a hand that was the hand of a hog; but it ain't so no more; it's the hand of a man that's started on a new life, and'll die before he'll go back. You mark them wordsdon't forget I said them...."
So they shook it, one after the other; all around, and cried. The judge's wife she kissed it. Then the old man he signed a pledge made his mark. The judge said it was the holiest time on record, or something like that.... In the night... [Pap] got powerful thirsty and clumb out onto the porch-roof and slid down a stanchion and traded his new coat for a jug of forty-rod, and clumb back again and had a good old time;... drunk as a fiddler,... [he] rolled off the porch and broke his left arm in two places and was froze most to death when somebody found him after sun-up. The judge he felt kind of sore. He said he reckoned a body could reform the old man with a shot-gun, maybe, but he didn't know no other way.
Mark Twain, needless to say, was not a temperance advocate; nor were many of those he met in his riverboat days, his time in the West in mining camps and as a San Francisco journalist, and his later years in the East among William Dean Howells and his other intellectual and business associates. For example, Twain published the highly successful memoir of one prominent heavy drinker, Ulysses S. Grant, who did not find it necessary to reveal and repudiate his drinking problems. These associations and locales produced people with a sense of drinking entirely different from that embodied by temperance. Indeed, to describe one's attitude toward alcohol was to make a major statement about oneself, as in the declaration "I'm a drinking man. " Whether a person recognized drinking as a problem or felt that abstinence was likely to be a solution to the problem was often a matter of who he was and where he came from. People occupied different drinking worlds, and those in each viewed those in the other as inhabitants of a strange planet.
Prohibition, Its Effects, and Its Aftereffects
These differences underlay the war between wets and drys in Americaa battle whose ferociousness we might today find hard to comprehend. Following the Civil War, the temperance movement turned its sights toward the prohibition of alcoholic beverages. "The temperance movement was the largest enduring, secular mass movement in 19th century America." At first, there was little opposition to temperancesince so much of nineteenth-century drinking revolved around abandoned drunkenness, the temperance argument seemed just good sense. A national Prohibition Party was formed, and the Women's Christian Temperance Union singled out the urban saloon as the seat of the evils of drinking. In the 1880s, prohibition was passed in several states, starting with Kansas. But the laws were ineffective and were repealed within a few years.
Carry Nation represented the growing militancy of the prohibition forces in Kansas and elsewhere after the failure of the prohibition laws of the 1880s. Her first husband died a drunkard (her second husband, the minister David Nation, eventually divorced her for desertion), and she began to see visions that dictated she destroy saloons. The prohibition struggle itself became more divisive and nativistic: it was heavily rural and Protestant, antiforeigner and antiCatholic. When the Reverend Burchard denounced the Democrats in the late nineteenth century as the party of "rum, Romanism, and rebellion," he spoke for many Americans. The National Anti-Saloon League was founded in 1895. It was the most effective force ever for prohibition and became a model for modern single-issue lobbying organizations.
Backed by powerful political, moral, nativist, and capitalist forces, prohibition became a movement for preserving the family and the nation and for eliminating sloth and moral dissolution. On the eve of national Prohibition in 1919, Billy Sunday lectured before a live audience of ten thousand people and a huge radio audience:
The reign of tears is over. The slums will soon be a memory. We will turn our prisons into factories and our jails into storehouses and corncribs. Men will walk upright now, women will smile and the children will laugh. Hell will forever be rent.
By the time national Prohibition finally went into effect in 1920, it was an accepted development across the country. (Thirty-one states were already dry or had passed the enabling legislation.) But this didn't mean that all peopleor groups of people and regionsagreed to abstain. The strongest impact of Prohibition was felt by working-class people, who found alcohol harder to obtain (or at least to afford) and who drank considerably less. By several measures, such as cirrhosis deaths, alcoholic fatalities dropped for the nation as a whole during Prohibition.
Home production and moonshine, however, reduced the impact of Prohibition for some rural areas and among urban ethnics. Some cities, like Detroit, hardly seemed affected by Prohibition at all, and alcohol was everywhere available. New York State repealed its enforcement laws because juries wouldn't convict Prohibition violators. Moreover, middle-class drinking actually increased during Prohibition, supplied both by domestic production and by the importation (mainly from Canada) of illegal liquor. Distilled spirits replaced beer and wine as the most popular drinks because they were more concentrated and easier to transport illegally. Illegal clubs or "speakeasies," where only "hard" liquor was served and intoxication was normal, became the principal drinking places for middle-class consumers.
Thus, the 1920s actually marked a heavy drinking period for many Americans, like those Diana Vreeland knew:
What a generation that was! It was the martini era. In those days people would get out of the car to see you home, and they'd weave around a bit and fall down on the sidewalk.... It was so appalling, the martini of the twenties. If I gave you some gin with a drop of Vermouth that wouldn't cover the head of a pin, that would be the martini. The people who drank them were carried home, usually unconscious..
I fell in love with... a "bottle club".... you'd be admitted by someone looking at you through an eyehole in the door; you'd go down a long, very dark flight of stairs, bringing your own bottle, which would then be served to you in bouillon cups. People in those days drank bouillon by the quart.
According to psychiatrist Norman Zinberg, the kinds of social sanctions that operated to prevent alcoholism in the colonial tavern were completely reversed in the Prohibition speakeasy and for other illicit drinking in that era. Families didn't drink together, food was not served with alcohol, and the whole point of going out to drink illegal (and expensive) liquor was to get drunk.
It would be incorrect, however, to attribute the increase in middle-class drinking and problem drinking solely to Prohibition. Just as occurred during the rise of temperance and Prohibition itself, drinking attitudes and patterns were reactions to other, more fundamental social currents. The 1920sparadoxically, the era of Prohibition also marked the advent of the "flapper" and the death of Victorian standards for women and the middle class at large. A code of liberated personal behavior grew and with it the idea that drinking should accompany a full life: drunkenness was taken as a sign of personal freedom. Some influential examples of this code were the Hollywood film and the notorious bohemian lifestyle that grew up in Greenwich Village.
Prohibition was repealed in 1933, and the idea that we should prohibit the sale, production, and use of alcohol disappeared from the American scene. In the first place, it became evident that Prohibition had failed to transform American society in the monumental way Billy Sunday and other temperance advocates had predicted. The Great Depression made clear that Prohibition was not an unmitigated economic boon, either. That is, influential businessmen had supported national Prohibition because they believed it would energize the work force. Now many felt that renewed liquor sales taxes would lower personal income taxes and stimulate the economy. Moreover, labor unrest and other social upheavals were being blamed on the general disregard for the law fostered by Prohibition.
Although Prohibition was finally and decisively rejected in the United States, American ambivalence about drinking persists. In the first place, prohibition remains a live issue in individual counties and even in entire states. Mississippi repealed statewide prohibition as recently as 1966, Oklahoma in 1959, and many American municipalities and counties remain dry to this day. In some places an active debate on sale of drinks by the shot continues: on July 1, 1987, Kansas enacted a constitutional amendment allowing liquor to be sold by the drink. Other nations such as Canada, Britain, and the Scandinavian countries have had important temperance and prohibition movements. These Northern European countries contrast with the lowland and Mediterranean European nations, which are among the wettest in the world and in which prohibition is unthinkable imagine prohibition in Italy! However, even the European countries that have had their own temperance movements do not display the degree of repugnance that many Americans still feel toward alcohol and drinking. To this day, the percentage of abstainers in the United Statesabout one-third of the adult populationis, along with Ireland's, the highest among Western nations.
This number of abstainers might seem impossibly high in the experience of many readers who know hardly any abstainers: again, this is due to large variations in abstinence rates for different ethnic, religious, and regional groups. Some groups have hardly any abstainers, while almost half those in conservative Protestant sects abstain. America is the most emphatic among Western nations in its emphasis on abstinence as the bestor more often the onlysolution for the individual with a drinking problem. The United States is also singularly marked by its sense of the desperateness of the alcoholic's condition and the irreversibility of alcoholism. This outlook has been propagated consistently and successfully in the United States by Alcoholics Anonymous, a group that was born following Prohibition.
The AA Credo Becomes National Dogma
Two alcoholicsBill Wilson, a stockbroker, and Robert Smith, a physicianmet in Akron in 1935 and agreed that they were powerless over their drinking. Out of this insight was created the AA fellowship, dedicated to the proposition that an alcoholic is unable to control his or her drinking and that only through the support and acceptance of those in the same condition can the person achieve sobriety (which requires total abstinence). Both AA's philosophy and its style closely resembled that of the Washingtonians and the temperance societies of the previous century. It seems that once national abstinence was rejected, a core group of Americans who are deeply ambivalent about their drinking reappeared. In tapping this ever-present group, the success of AA is not surprising. Indeed, in an earlier, less populous America, the Washingtonians obtained 600,000 sobriety vows from alcoholics within ten years of its founding; ten years after AA's founding, it had fifteen thousand members, and AA's American membership only reached the half-million point in the 1980s.
The chief innovation in the AA philosophy is the idea that alcoholics constitute a special group who are unable to control their drinking from birtha condition that Alcoholics Anonymous (the so-called Big Book of AA) describes as an allergy to alcohol. The alcoholic needs to forswear alcohol totallya single taste is sufficient to set him or her off on an uncontrolled binge. Since alcoholism is inbred, it is also irreversible. As a result, alcoholics are obligated to think of themselves as having a lifetime condition. This notion is expressed in AA members' descriptions of themselves as "recovering," as opposed to "recovered." The process is carried forward "one day at a time," while alcoholics are taught to believe that they are exactly one drink away from total relapse and the need to start again at day one.
Although AA proposes a biological explanation for alcoholism, its climate is that of nineteenth-century revivalistic Protestantism. The twelve steps in the AA credo are an obeisance to God (God is mentioned six times) and the need for taking moral inventory and for contrition. The final two steps urge "prayer and meditation to improve our conscious contact with God... [and] knowledge of His will for us" and that alcoholics spread their "spiritual awakening" to all alcoholics. But primary in the AA liturgythe first stepis the admission of being "powerless over alcohol," leading each participant at a meeting to declare "I am an alcoholic." The public confessional and repentance, the spiritual rebirth leading to a new identity, and the need to convert others are all part of AA's fundamentalist religious roots.
While the Washingtonians had a meteoric rise and fall (the group had practically disappeared within two decades of its founding), AA has come to dominate the American alcoholism landscape completely. In part, AA has succeeded because it selected its battleground so wellit explicitly rejected universal prohibition and maintained that only the true alcoholic needs to abstain. This ostensible rejection of blue-nose moralism has been crucial for recruiting liberals into the movement to treat alcoholics as diseased, whether they want to be treated or not. AA also developed an excellent public-relations apparatus. In the late 1930s, the Yale Center of Alcohol Studies was established (its best-known member was Elvin Jellinek) and endorsed the disease view. In the 1940s, the center collaborated with prominent AA members like Marty Mann to create what eventually came to be called the National Council on Alcoholism (NCA). The NCA's aims were to convince Americans that alcoholism is a disease and the alcoholic a sick person who needs help and treatment. The NCA also wanted to alert America to the dangers of alcoholism as a major public health problem.
The NCA succeeded beyond any hopes it could originally have harbored. When the Big Book appeared in 1939, AA had approximately a hundred members. In 1941, a prominent member of the alcoholism movement claimed with alarm that over 100,000 persons were suffering from alcoholism in the United States, while in 1946, a Yale spokesman indicated that there were "more than a million excessive drinkers." In the 19SOs, this number was placed at 5 or 6 million, and by the 1980s alcoholism was thought to be affecting ten to twenty million Americans. The NCA formed local chapters throughout the country, sponsored by public education programs, and took out advertisements to drive home its vision of alcoholism that the alcoholic is a sick person and "is not responsible for his condition," that alcoholism can effectively be treated as a disease, and that the chief obstacle to progress against alcoholism is public apathy and lack of knowledge about the nature and prevalence of the disease.
One reason for the Washingtonian movement's failure had been its hostility toward medicine and institutionalized religion. AA shared at least the former attitude: the Yale summer school almost never invited physicians to lecture in the 1940s, and even today AA members frequently attack physicians for their ignorance about alcoholism. The American Medical Association endorsed the idea that alcoholism is a disease only belatedly, in 1956. Although the relationship between AA and medicine remains uneasy, most medical treatment today typically functions as an adjunct to AA. Physicians conduct an initial examination and detoxify the alcoholic in the hospital, then turn the patient over to paraprofessional counselors who are themselves recovering alcoholics. As a part of treatment, the patient must attend AA meetings. Only in the United States has the sober alcoholic achieved such a prominent role in alcoholism treatment, and many of the field's leaders are treatment and AA veterans.
The reasons for AA's success in selling the nation on its views of alcoholism include its remarkable appeal to the media. From the founding of the NCA, Marty Mann (a professional publicist) and others regularly presented the disease concept in magazine articles. NCA founders also consulted with the film industry in making motion pictures such as The Lost Weekend that presented the alcoholic's plight sympathetically. As a result of AA's popular success and the acceptance of the disease viewpoint, prominent alcoholics today do not place the emphasis on anonymity that AA officially demands of its members: many public figures have described their alcoholism and their treatment before the camera. Public information programs continually pronounce that alcoholism is a disease, while school counselors, personal advice columns, and medical figures regularly recommend AA and emphasize that medical treatment offers effective help for alcoholics. A 1987 Gallup poll found that almost 90 percent of Americans believe that alcoholism is a disease, and those who refuse to accept this view are often portrayed in the press as benighted and moralistic.
The Expanding Marketplace of Alcoholism Treatment
In 1970, the government established the National Institute on Alcohol Abuse and Alcoholism (or NIAAA, within what is now called the Department of Health and Human Services), representing the growing success of the alcoholism movement. But when confronted by legislators with some fundamental questions, like how many alcoholics needed treatment, the movement was somewhat at a loss. Estimates based on deaths due to cirrhosis of the liver had placed the number of alcoholics at 5 or 6 million through the 1960s. Meanwhile, a group of researchers under the direction of Don Cahalan at Berkeley had been conducting a series of national surveys of America's drinking problems. When asked how many alcoholics there were currently in the United States, the Berkeley investigators gave very approximate estimates of 9 or 10 million problem drinkers. Of this group, the NIAAA concluded, about halfor 5 millionwere alcoholics. However, around this time the NCA began claiming there were 10 million alcoholics in the United States.
How many people with the extreme variety of alcoholism shown by early AA members and portrayed in movies like The Lost Weekend are there actually? Robin Room, an epidemiologist and current director of the Berkeley Alcohol Research Group, compared the drinking of those in alcoholism treatment with the drinking problems found in general population surveys in the 1970s. About 1 percent of the adult population, or around 1.5 million Americans, drank as much as the typical clinical alcoholic. Since there were already 1.7 million people in treatment in 1976, Room concluded that "the number of people in the general population who resemble those in clinical populations may be no larger than the number in treatment or recently out of it." In other words, just before a tremendous growth spurt in alcoholism treatment and services in the mid-1970s, Room saw little evidence that there were scores of alcoholics who were going untreated.
Yet in the 1980s, even the 10 million figure for alcoholicsgeneralized from the number of problem drinkers estimated by the Berkeley groupseemed to many in the treatment industry far too small. According to G. Douglas Talbott, a physician and recovering alcoholic who now heads a drug and alcohol program:
The old figure was 10,000,000 alcoholics. I was interested in where that figure came from and found out it was thought up one night in Washington when the first alcohol support bill was presented to Congress... and that figure got frozen into literature. It is way beyond that now, and, as far as we are concerned, 22 million people have an alcohol problem related to the disease of alcoholism.
Talbott here makes light of earlier alcoholism estimates, even though these data were originally heavily promoted by those in the alcoholism movement and by legislators. Ironically, the Berkeley researchers themselves all along gave these estimates reluctantly, because most of those who have a drinking problem are very far from qualifying for a diagnosis of alcoholism.
The viewpoint of Cahalan, Room, and their coworkers is sociologicalone that sees alcohol abuse in a social context. It finds alcohol abuse to vary widely for different ethnic groups, at different times of the individual's life, and with different drinking companions. This approach is at the opposite extreme from that of seeing alcoholism as an inbred disease. In contrast to the uniformity of AA accounts, the Cahalan group's research reveals drinking problems to be extremely variable. Problems in the national surveys range from frequent intoxication and binge drinking to marital, police, financial, and health problems due to drinking. People's drinking problems in these surveys appear very unlike the obligatory AA story of inexorable progression and inevitable loss of control.
Only a small percentage of those who have had some kind of drinking problem who are sampled in general population surveys have been in treatment (although this number began to increase appreciably in Alcohol Research Group surveys in the late 1980s). Apparently, such surveys tap a largely different problem drinker from those who typically enter AA. Most of these people seem able to come to grips with their drinking problems on their own and in any case do not choose to label themselves as alcoholics who need treatment. These people are also likely to reduce their problem drinking rather than quit altogether. This is not to say that they even think of themselves as having a drinking problem. Their shifts in behavior stem mainly from maturation or other life changes that bring them into contact with different people and different environments and that encourage moderation.
The growth in alcoholism treatment has involved persuading the public that people like these problem drinkers require treatment as alcoholics. Here the ideology of AA and the alcoholism movement has shifted perceptibly. That is, if people are born alcoholics from their first drinks, then this group should be obviously identifiable as a distinct part of the population. Early AA members did not talk about denialtheir alcoholism had been obvious, even to themselves. But this view has gradually shifted to emphasize the progressive nature of alcoholism (a view that, ironically, returns to the temperance view of drinking), one that means alcoholism often begins with subtle problems that will grow unless checked. Disease proponents now argue that someone with a milder drinking problema person earlier AA members would clearly distinguish from themselvesneeds treatment to avoid getting worse. Thus, all drinkers who ever have had a problem are suitable for alcoholism treatment, and it is these "early-stage" alcoholics that treatment personnel most anxiously seek.
The number of alcoholics in treatment per capita in the United States multiplied twentyfold between 1942 and 1976, Robin Room has calculated. Since then, the number of people treated for alcoholism has continued to rise precipitously. (For example, AA membership doubled between 1977 and 1987.) Moreover, the shift from government funding of public facilities to support for third-party financing of alcoholism treatment created a tremendous expansion of private inpatient treatment. Between 1978 and 1984 the number of for-profit residential treatment centers increased by 350 percent and their caseloads by 400 percent. Today most such therapy is paid for by insurers. In response, private hospitals and hospital conglomerates like Fair Oaks and CompCare have arisen to handle these patient loads through twenty-eight-day inpatient programs. These hospital stays cost from $7500 to $35,000, and the new alcoholics who fill these programs are quite different from the typical public inebriates who were shunted off to government hospitals.
Since the mid-1970s, the emphasis has been on recruiting prosperous, functioning individuals who do not appear to be alcoholics (the prototypical case being Kitty Dukakis). In fact, because these people are so unexceptional, they must often be persuaded of the potential severity of their drinking problems. Advertisements, educational programs, and the testimony of attractive notables like Betty Ford and Elizabeth Taylor are used to convince people that they should seek treatment for their disease, just as if they had diabetes or gout. However, since such alcoholics are often judged to be in "denial" and blind to the true nature of their problem, they often need to be forcibly confronted with their alcoholism by loved ones and treatment personnel. This contrasts with the early philosophy of Alcoholics Anonymous, which emphasized that the alcoholic needed to accept his condition voluntarily.
The change has meant that coercive tactics are now a regular part of the treatment arsenal. The main source of referrals for alcoholism treatment has become drunk-driving arrests. The arresteesmost often younger menare given the choice of incarceration or submitting to treatment in which they are forced publicly to admit that they are alcoholics. But others besides drunk drivers are now often referred to treatment. Heavy drinkers convicted of felonies from writing bad checks to child abuse to rape have been placed in treatment rather than in prisonin several cases, murderers have been remanded for court-ordered alcoholism treatment.
Rapidly growing employee assistance programs (EAPs) have the potential for reaching even more people. Here the same activist approach is followed of offering the problem drinker the choice of accepting treatment or losing his job. At the workplace, more young people are brought into the net through the discovery of their drug use. A young man found smoking marijuana in a company with a treatment program of this sort will be told he has a diseasechemical dependencethat he must confront. Although combining alcohol and drug treatment has presented problems for AA groups and remains an issue within AA, medical treatment programs and EAPs typically group drug and alcohol abusers together for diagnostic and treatment purposes.
When one considers that the 22-million figure cited by Dr. Talbott for alcoholism represents one in seven adult Americans and that over 60 percent of high school seniors use illicit substances, the phenomenal growth in chemical-dependence treatment in America is not surprising. Corporations have forged chains of such treatment centers, and the largest new category for hospitalizations has become chemical dependence. Between 1980 and 1984, for example, there was a 350 percent jump in the hospitalization of teenagersat a time when hospitalizations overall declined. These figures were presented on the May 20, 1985, CBS Evening News; on the same show, a producer phoned a treatment center to say that he suspected his teenage daughter had used marijuana and that she was disrespectful and was dating an older boy. On this evidence, the girl was placed in a hospital. The girl wore a concealed microphone, and when she claimed she didn't have a drug problem, a counselor was heard saying that this is the response inmates always give (i.e., denial).
The hospital chain in question, CompCare, is among the most prominent in America. CBS interviewed CompCare's medical director, Joseph Pursch (the physician who treated Betty Ford) about this case. Pursch claimed that no one would be hospitalized without a medical examination (the girl received none). In fact, CompCare trains consultants to work with high school counseling staffs, teaching them how to run "interventions" sessions in which students suspected of drug use are surrounded by family, friends, teachers, and others who insist the child enter treatment immediately. (Intervention protocol recommends that a cab be kept waiting for the moment the student admits his problem so that he can be rushed to a center before he changes his mind.)
Obviously, parents are terribly concerned lest their child be abusing drugs unbeknownst to them. They are warned in publications like those by Straight Inc. that if they suspect a child has smoked marijuana, this "is probably only the tip of the iceberg." Salespeople for treatment programs encourage parents to make any financial sacrifice to get and keep their child in treatmentafter all, parents are told, "this could be a matter of life or death." Straight publishes a newsletter called Epidemicthe first issue of which featured the banner headline DENIAL and the boldly printed Straight credo: "In understanding the drug problem and in understanding Straight's role in dealing with that problem, we must understand that the single, biggest problem we have to confront is denial." It is this denial that makes children and their parents claim that the kids are not addicts when Straight decides they are.
Actually, the intoxicating substance used most heavily by children is not an illicit drug, but alcohol. National surveys conducted at the University of Michigan among high school seniors find that about 40 percent of seniors overall (and half of high school senior boys) have had at least five drinks in a single sitting within two weeks of being interviewed. A 1982 Gallup poll revealed that fully one in three American families suspect that one or more members have a drinking problem, perhaps reflecting the heavy drinking of so many teens. Special units of AA ("Alateen") have now been set up particularly for youngsters, constituting the fastest-growing segment of AA. In both Alateen and chemical-dependence treatment programs, youngsters are taught that they are alcoholics (or chemically dependent) and that they must commit themselves never again to drink or to use a psychoactive substance of any kind.
Yet the largest growth area of all in the field of alcoholism does not concern people who are active drug or alcohol abusers. This is the movement to bring "codependents" and "coalcoholics" (or spouses of addicts and alcoholics) and entire families into treatment. Al-Anon is the group created for spouses of alcoholics, overwhelmingly women. Because alcoholics are more likely to have drug- or alcohol-abusing children, treatment centers strive to recruit the "high risk" children of alcohol abusers to therapy, often before they have drunk or taken drugssometimes as preschoolers. One strong message these children receive in therapy is that they are tremendously susceptible to alcoholism themselves, should they ever drink.
Moreover, children of alcoholics safely beyond the age of influencelabeled "adult children of alcoholics"have been the most heavily recruited of all for therapy. According to a founder of the National Association for Children of Alcoholics, "Children of alcoholics deserve and require treatment in and of themselves," whether or not they have ever had a drinking problem. These "adult children" have been the focus of a string of best-sellers, national conferences, public service announcements, and new support groups. The rapid rise of this movement is described by one of its leaders: "'The wounded are everywhere,' said Sharon Wegscheider-Cruse.... 'In a sense, our movement is a social revolution.'" 
America the Addicted
>From the time in the recent past when Americans were blithely unaware of alcoholism as a significant social problem, we have come to feel that alcohol and related drug problems are epidemic. The new temperance lecturers speak to parents and children in packed audiences around the country about the need never to consume any type of drug or alcohol. Alcoholism treatment is mandated for largeand growingnumbers of people. This treatment conveys the idea of uncontrollable substance abuse as a regular feature of contemporary life, and as a permanent characteristic of innumerable Americans. The way out is treatmentexpensive treatment, but treatment that is necessary if people are to avoid the inexorable descent into alcoholic or addictive hell. A new vision of alcohol and alcoholism is upon the land.
This chapter has reviewed the history of attitudes toward drinking and alcohol abuse in the United States. America has had many different images of this one substance, beverage alcohol. Changing images of drinking and its dangers are not clearly related to levels of consumption. For example, colonial Americans drank three times as much as contemporary Americans but worried less about drinking and seemed actually to have fewer drinking problems. Consumption dropped precipitously in America between 1835 and 1845, never again to return to colonial levels. Yet although drinking was greatly reduced, alarm about the dangers of alcohol continued to grow. National Prohibition actually went into effect at a time when drinking and drinking problems were far from their peak nineteenth-century levels.
The image of alcohol with which I am most concerned is that it is addictive, that it makes drinkers "lose control." If alcoholism is a biological imperative beyond conscious control, then it is wrong to hold alcoholics accountable for their drinking style or for their behavior when drunk. Disease proponents maintain that this model eliminates the moral stigma many erroneously attach to chronic drunkenness and alcoholic misbehavior. In fact, the contemporary alcoholism movement preserves temperance's moral baggage. It views alcoholism as an evil reaction set off in the body and soul by alcohol, one that demands that the drinker swear off alcohol at all costs. To an unrecognized extent, we are living today with nineteenth-century ideas about drinking presented as if they were modern scientific discoveries. The dominant approach to drunkenness in America continues to be a religious one, steeped in American Protestant revivalism and accompanied by the sense of alcohol as a looming evil.
The primary additions to the disease model of alcoholism in the twentieth century have been the view that alcoholism is an inbred trait for some and the view that the neurosciences can explain why people drink too much. These ideas underlie much scientific research on alcoholism in the second half of this century; in this way, the disease theory was successfully merged with modern medical and scientific belief. As a result, organized medicine has become a strong voice added to AA's in proselytizing for the disease view of alcoholism. This urge to reduce moral problems to biological dimensions goes back a long way: Benjamin Rush, the eighteenth-century founder of the disease concept of alcoholism, also thought that lying, murder, and political dissent were diseases.
Today, no other country in the world has as active an alcoholism establishment as the United States, treats as many people for alcoholism, commands as much media attention for the problem, or has gained such wide acceptance for the conception that alcoholism is a disease. Moreover, no other nation has taken the implications of disease theories of behavior as far as the United States or applied the disease model to as many new areas of behavior. America has elevated the alcoholism movement to the status of a national icon; in the United States the diseases of alcoholism and addiction have become national themes. The issue that remains is whether this actually ameliorates alcoholism and related problemsor, indeed, exacerbates them.
- I. Berkow, "View from the bottom: A long lost season," New York Times, 7 April 1986, C12. Copyright 1986 by The New York Times Company. Reprinted with permission. (back)
- T. Alibrandi, Young Alcoholics (CompCare, 1983), 60. (back)
- H. G. Levine, "The alcohol problem in America: From temperance to alcoholism," British Journal of Addiction 79(1984):109-19. (back)
- H. G. Levine, "The good creature of God and the demon rum," in Alcohol and Disinhibition, eds. R. Room and G. Collins (National Institute on Alcohol Abuse and Alcoholism, 1983). (back)
- W. J. Rorabaugh, The Alcoholic Republic (Oxford University Press, 1979). (back)
- Levine, "Good creature," 127. (back)
- D. J. Rothman, The Discovery of the Asylum (Little, Brown, 1971). (back)
- H. G. Levine, "The discovery of addiction: Changing conceptions of habitual drunkenness in America," Journal of Studies on Alcohol 39(1978):143-174 (back)
- M. E. Lender and J. K. Martin, Drinking in America (Free Press, 1982). (back)
- J. Kaplan, Mark Twain and His World (Crown, 1983). (back)
- Levine, "Good creature," 130. (back)
- J. R. Gusfield, Symbolic Crusade: Status Politics and the American Temperance Movement (University of Illinois Press, 1963). (back)
- J. Kobler, Ardent Spirits: The Rise and Fall of Prohibition (Putnam, 1973). (back)
- M. M. Hyman et al., Drinkers, Drinking, and Alcohol-Related Mortality and Hospitalizations: A Statistical Compendium (Rutgers Center of Alcohol Studies, 1980). (back)
- D. Vreeland (with G. Plimpton and C. Hemphill), D.V. (Knopf, 1984). (back)
- N. E. Zinberg and K. M. Fraser, "The role of the social setting in the prevention and treatment of alcoholism," in The Diagnosis and Treatment of Alcoholism, 2nd ed., eds. J. H. Mendelson and N. K. Mello (McGraw-Hill, 1985). (back)
- F. L. Allen, The Big Change: 1900-1950 (Harper and Row, 1952); A. Churchill, The Improper Bohemians (Dutton, 1959); A. Sinclair, Prohibition: The Era of Excess (Little, Brown, 1962). (back)
- D. Cahalan, 1. H. Cisin, and H. M. Crossley, American Drinking Practices (Rutgers Center of Alcohol Studies, 1969). (back)
- Alcoholics Anonymous, The Story of How More than One Hundred Men Have Recovered from Alcoholism (Works Publishing Company, 1939). The idea that alcoholism is due to an inbred allergy was actually originated by a physician, William Silkworth, who treated Bill Wilson at a New York City sanitarium for alcoholics. Wilson also declared AA's indebtedness to the temperance-era Oxford Groups, from which it got "its ideas of self-examination, acknowledgment of character defects, restitution for harm done, and working with others." See Alcoholics Anonymous Comes of Age (Alcoholics Anonymous, 1957), 39. Other works describing the outlooks, backgrounds, and antecedents of Alcoholics Anonymous and its founders include E. Kurtz, Not God: A History of Alcoholics Anonymous (Hazelden, 1979) and B. H. Johnson, The Alcohol Movement in America (Ph.D. diss., University of Illinois, 1973). The last remarkable work is an encyclopedic reference for the backgrounds, attitudes, and interactions among those who spearheaded the alcoholism movement in America. (back)
- H. M. Trice and P. M. Roman, "Delabeling, relabeling, and Alcoholics Anonymous," Social Problems 17(1970): 538-46. (back)
- R. Room, "Sociological aspects of the disease concept of alcoholism," in Alcohol and Drug Problems, vol. 7, eds. R. G. Smart et al. (Plenum, 1983). (back)
- W. R. Miller, "Haunted by the Zeitgeist: Reflections on contrasting treatment goals and concepts of alcoholism in Europe and the United States," in Alcohol and Culture, ed. T. F. Babor (Annals of the New York Academy of Sciences, 1986). (back)
- D. Cahalan, Problem Drinkers: A National Survey (Jossey-Bass, 1970); Cahalan, Cisin, and Crossley, American Drinking Practices (Rutgers Center of Alcohol Studies, 1969). (back)
- R. Room, "Treatment seeking populations and larger realities," in Alcoholism Treatment in Transition, eds. G. Edwards and M. Grant (Croom Helm, 1980), 212. (back)
- G. D. Talbott, in The Courage to Change, ed. D. Wholey (Houghton Mifflin, 1984), 19. (back)
- More accurate accounts than Talbott's of how the estimate of 10,000,000 alcoholics came aboutand the whole process of inflating estimates of the prevalence of alcoholismare described in D. Cahalan, Understanding America's Drinking Problem (Jossey-Bass, 1987), 16-19; L. Gross, How Much Is Too Much? (Random House, 1985), 119-23; J. R. Gusfield, The Culture of Public Problems (University of Chicago, 1981), 55-60; C. Weiner, The Politics of Alcoholism (Transaction Books, 1981), 184-85. (back)
- D. Cahalan and R. Room, Problem Drinking Among American Men (Rutgers Center of Alcohol Studies, 1974); W. B. Clark, "Loss of control, heavy drinking and drinking problems in a longitudinal study," Journal of Studies on Alcohol 37(1976):1256-90; W. B. Clark and D. Cahalan, "Changes in problem drinking over a four-year span," Addictive Behaviors 1(1976):251-60. (back)
- C. M. Weisner and R. Room, "Financing and ideology in alcohol treatment," Social Problems 32(1984):167-84; R. Longabaugh, "Evaluating recovery outcomes," presented at Conference, Program on Alcohol Issues, University of California, San Diego, February 4-6, 1988. (back)
- C. M. Weisner, "The alcohol treatment system and social control: A study in institutional change," Journal of Drug Issues 13(1983): 117- 33. (back)
- L. D. Johnston, P. M. O'Malley, and J. G. Bachman, Use of Licit and Illicit Drugs by America's High.School Students, 1975-1984 (National Institute on Drug Abuse, 1985). (back)
- "Children of alcoholics: Strength in numbers," New York Times, 26 February 1986, C1, C10. (back)