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Beyond the Influence: Understanding and Defeating Alcoholismby Katherine Ketcham
Still Under the Influence
All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.
Don't remember where I was flying to, but was taken off the plane in Twin Cities, ambulanced to Hennepin County Detox--nightmare--went to Hazelden from there--started stealing, then drinking--then to detox center in Hastings, Minnesota. Scotty picked me up, got drunk at his home nearby, had to leave on bus to Madison, got drunk couldn't stay at Sharon's. My wallet stolen that night. Tried to sleep outside at Ray's old apt. Neighbors called. Woke up in detox. Began series of staying with AA people.
Ran out of places to go, no insurance, no halfway house, no money. Went to D.C.--stayed sober one month.
Terry McGovern wrote these words in her journal when she was forty-three years old. Two years later she was dead. Around 8:30 p.m. on December 14, 1994, Terry left the Crystal Corner Bar in Madison, Wisconsin, and wandered into an unlit parking lot, where she either fell or lay down in the snow and froze to death. Her body was discovered around noon the next day. The coroner's report stated that death was due to "hypothermia while in a state of extreme intoxication."
Many of us will hear Terry McGovern's story and shake our heads in dismay--perhaps even in disgust. Why, we wonder, did this gentle, intelligent, much-loved daughter of former senator and presidential candidate George McGovern choose to kill herself with booze? How did she get caught up in such a self-destructive way of life when she was so talented and privileged, surrounded by people who loved her and wanted to help her? What, exactly, was wrong with her? What demons possessed her?
The answers to these questions are hotly debated by those who insist that alcoholism is a primary, progressive, physiological disease and those who argue that alcoholism is not a true medical disease at all but a symptom of underlying psychological and emotional problems to which the individual responds by engaging in increasingly self-destructive behavior. The disease theorists engage in vociferous exchanges with those who do not see alcoholism as a disease, and each side carefully amasses research studies and dramatic anecdotes to fortify its position.
After the smoke clears, little if anything seems to have been resolved. Witnessing the bitter disagreements among experts, most of us end up bewildered by the conflicting theories. If alcoholism is a behavior, what quirk of personality or circumstance would lead good, decent, intelligent people such as Terry McGovern to destroy everything in their lives for alcohol? Are alcoholics inherently weak, selfish, emotionally immature individuals?
If, on the other hand, alcoholism is a disease, why do its victims suffer from such intense guilt, shame, and self-loathing? Why can some diagnosed alcoholics return to "moderate" or "controlled" drinking for weeks or even months? Why do some alcoholics stop drinking and recover with no treatment at all? And why are psychological counseling and spirituality considered such important elements of recovery?
These questions and the contentious debates they engender lead many people to throw up their hands, concluding as the Supreme Court did in April 1988, that alcoholism is a consequence of "willful misconduct."
Alcoholism is not a mysterious illness, nor is it "willful misconduct." Alcoholism is a true medical disease rooted in abnormalities in brain chemistry--biochemical aberrations that are inherited by the great majority of alcoholics and, in some cases, acquired through intense and sustained exposure to alcohol and other drugs. When the alcoholic drinks, something different happens. This difference between alcoholics and nonalcoholics is not created by personality disorders, emotional instability, character defects, or traumatic circumstances; it is a difference in the way the alcoholic's body responds to the drug alcohol.
Physiology, not psychology, determines whether one drinker will become addicted to alcohol and another will not. This is not theory but fact, based on thousands of research studies detailing the nature, causes, and progression of this ancient yet perpetually misunderstood disease. More than fifty years of experimentation and investigation by distinguished scientists in such diverse fields as neurology, biochemistry, pharmacology, and psychology have provided the basic facts needed to understand the drug alcohol and the disease it creates in biologically susceptible individuals. We know what this disease is, we know how to treat it, and we know how to prevent it. The knowledge is in our hands.
Yet the myths and misconceptions that distort our thinking about alcoholism, complicating both treatment and recovery, remain firmly in place. Two decades ago the myths and realities about alcoholism were presented in Under the Influence: A Guide to the Myths and Realities of Alcoholism, coauthored by James R. Milam and Katherine Ketcham. Despite stunning scientific advances in alcoholism research in the last twenty years, these myths continue to influence the way we treat alcoholics.
Myth: Alcohol has the same chemical and psychological effects on everyone who drinks.
Reality: Alcohol, like every other substance we take into our bodies, affects different people in different ways.
Myth: Addiction to alcohol is often psychological.
Reality: Addiction to alcohol is physiological and involves profound chemical disruptions in the brain.
Myth: Alcohol is an addictive drug, and anyone who drinks regularly for a long enough period of time will become physically addicted to it.
Reality: Alcohol is a selectively addictive drug; only a minority of drinkers will experience the need or desire to consume alcohol in sufficient quantities and over a long enough period of time to become physically addicted to it.
Myth: People become alcoholics because they have psychological or emotional problems that they try to relieve by drinking.
Reality: Alcoholics have basically the same psychological problems as nonalcoholics before they start drinking, but these problems are aggravated (and new disturbances are created) by addiction to alcohol.
Myth: If people would drink responsibly, they would not become alcoholics.
Reality: Many responsible drinkers become alcoholics. Because of the nature of the disease--not the person--they begin to drink irresponsibly.
Myth: Some alcoholics can learn to drink normally as long as they limit the amount.
Reality: Alcoholics, who by definition suffer from a permanent brain addiction, can never safely return to drinking.
A little history may help here. Originally published in 1981, Under the Influence detailed the biochemical and neurophysiological factors--metabolic abnormalities, alterations in brain chemistry, heredity, ethnic susceptibility, and prenatal influences--that determine why some people become addicted to alcohol while others do not. The book helped fuel the "recovery boom" of the 1980s, a time of remarkable advances in alcoholism treatment and prevention efforts and a period marked by a growing commitment to the scientifically proven understanding that alcoholism is a primary, progressive, physiological disease requiring lifelong abstinence for recovery.
As the recovery boom gained momentum, growing numbers of behaviorists, social critics, and popular writers raised their voices to criticize the "disease concept," arguing that it failed to account for psychological and emotional factors. Many critics contended that focusing attention on the physical addiction released problem drinkers from moral responsibility for their behavior. What about willpower and simple human decency? If we call alcoholism a disease, the critics continued, we might as well call fingernail biting, obsessive TV viewing, and chronic boredom "diseases." One psychiatrist used a sunburn analogy: Redheads tend to burn more easily than brunettes or blondes, so shouldn't they protect themselves by staying out of the sun? And shouldn't those redheads who continually get sunburned take responsibility for and accept the consequences of their misbehavior?
Alcohol problems should be redefined as "maladaptive lifestyle habits," argued behavioral psychologist Alan Marlatt of the University of Washington. An outspoken critic of the "disease concept," Marlatt insisted that excessive drinking is a behavior that people do, not a symptom of what they are, and that alcoholics and problem drinkers can be taught how to modify their maladaptive habits through stress management, lifestyle changes, and basic learning principles. For those who want to reduce their drinking and avoid the health problems associated with excessive use of alcohol, Marlatt and other behavioral psychologists argued that moderation is the key.
In Heavy Drinking: The Myth of Alcoholism as a Disease Herbert Fingarette, a professor at the University of California and a consultant on alcoholism and addiction to the World Health Organization, dismissed fifty years of research on the neurological and biochemical nature of alcoholism with this statement: "No leading research authorities accept the classic disease concept." In The Diseasing of America: Addiction Treatment Out of Control psychologist Stanton Peele argued that disease definitions actually "undermine the individual's obligations to control behavior and to answer for misconduct."
Popular writers quickly latched on to the behaviorist trend. Audrey Kishline, a moderate drinker who believes she was mistakenly diagnosed as an alcoholic, observed in Moderate Drinking, "The act of lifting a drink to your lips too often is not a 'disease.' Drinking too much is a behavior, something that a problem drinker does, not something that he or she has."
As concepts such as "moderation," "responsible drinking," and "maladaptive habits" caught the public's imagination, society as a whole became less tolerant of alcoholics and their "misbehaviors." Changing attitudes toward alcoholics were reflected clearly in the increasingly popular use of the word abuse.* Beginning in the 1980s, government agencies charged with overseeing alcohol education and treatment programs abandoned the word alcoholism in favor of the term alcohol abuse and, more recently, substance abuse. In recent years the word alcoholism seems to have disappeared from official language while the term substance abuse has become as familiar as Budweiser's trio of frogs.
As alcoholism gradually became linked in the public mind with alcohol "abuse," efforts to teach "irresponsible" and "abusive" drinkers how to moderate their drinking grew in popularity. Critics of the disease concept argued vehemently that controlled-drinking therapy--tellingly translated as "behavioral self-control"--should be considered a valid alternative to lifelong abstinence. In the 1990s "harm reduction" programs such as DrinkWise, S.M.A.R.T., and Moderation Management expanded to the point where a 1997 U.S. News and World Report article predicted that controlled-drinking programs would someday "be as commonplace as Weight Watchers and Smokenders."
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