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Alcohol has been a part of human culture since the dawn of time, and the abuse of alcohol followed shortly thereafter. For generations, societies have struggled to find the balance between alcohol’s place in daily life, and doing something about the individual problems it can cause. That struggle has defined the history of alcohol abuse and treatment, an evolution of drinking norms, laws, and psychology.
In the United States, the roots of alcohol abuse go back to the days of colonialism. Alcohol consumption had existed among Native Americans but only in ritualistic contexts. However, the idea of drinking recreationally and excessively was introduced by European settlers who plied indigenous Americans with alcohol as a way of weakening their resistance to unfair demands for land, resources, and women.
The American Journal of Public Health notes that colonists “drank immoderately and engaged in otherwise unacceptable behavior while drunk,” behavior that heavily influenced how Native Americans looked at the alcohol that was being offered to them for trade. Natives had no communal structures in place to control excessive drinking or the behavior that followed, which contributed significantly to their losses of land and culture, even long after the North American continent was settled.
Tribal elders took the lead in addressing the damage to their societies, encouraging younger members (more prone to falling under the sway of alcohol) to use the beliefs and mythologies of respective native nations as a way of fighting the temptation to drink and behave inappropriately. Leaders would gather the members of their respective tribes and have everyone sit around in circles (throughout history, circle shapes have been believed to ward off evil spirits), where those who were struggling with intoxication were told that focusing on their religious ideologies would bring them back to the tribe, mentally and socially.
Native Americans coming together to help members of their tribe kick drinking habits was the first time there had been a form of organized substance abuse treatment in America.
Generations later, the concept of connecting with a higher power was adapted by Alcoholics Anonymous, which also adopted a circle as part of their official logo.
Even before the damaging effects of alcohol abuse on Native American tribes in the colonial era, humanity’s love affair with drinking stretched back millennia. Alcohol: Science, Policy and Public Health explains that for thousands of years, human beings have been dependent on alcohol in one form or another: from religious rituals to medicinal uses; as a source of energy and simply quenching thirst; from being used to relax to being used as a social lubricant; as an addition to meals and a complement to courtship and mating practices. For millions upon millions of people throughout history, alcohol has existed for “enhancing the quality and pleasures of life.”
For a long time, this was the prevailing notion regarding alcohol consumption. When people inevitably struggled with the lure of intoxication, the fault was held to be theirs – that such individuals were of a weak constitution and a poor moral fiber.
That mindset pervaded beyond the colonial period and into the early days of the United States, but one of the most influential men of the time felt otherwise. Benjamin Rush, whose signature is on the Declaration of Independence and who is remembered as one of the Founding Fathers of the nation, challenged the conventional thinking of the time when it came to popular perceptions of alcohol abuse. In 1805, Rush published a book entitled An Inquiry into the Effects of Ardent Spirits upon the Human Body, wherein he challenged the notion that a weakness for alcohol was a symptom of an impure soul, claiming instead that the problem lay in the human mind and could therefore be treated. His Inquiry advanced the theory that the chemical properties within alcohol caused certain drinkers to lose their inhibitions, which therefore cast alcohol abuse as a symptom of a medical disease and not a condition of morality. Thus, concluded Rush, the cure for alcohol abuse lay not with prayer or punishment but with treatment.
The National Library of Medicine notes that Rush is considered “the father of American psychiatry” for his pioneering work in changing the entire tone of the conversation on alcohol abuse and its treatment.
The effects of Rush’s Inquiry were quickly felt in an American society where drinking was still commonplace among the upper class and where the sentiments of the 1791 Whiskey Rebellion (hostility toward the imposition of a federal tax on distilled spirits that the fledgling government put down with armed force) still ran strong.
However, Rush’s words carried a lot of weight, and despite the popularity alcohol enjoyed at the time, the beginnings of the temperance movement emerged. Prior to Rush’s Inquiry, anti-alcohol groups existed, as did social organizations that tried (and failed) to spread the word that alcohol was the catalyst behind of the maladies and ills of the day. But, says the American Journal of Public Health, those groups never gained much traction among the majority of the American populace who were more than happy to celebrate their newfound independence from the British Empire with drink, and who thought of drunkards as wretches beyond help and undeserving thereof.
But then came Rush’s book, and the fringe groups that had claimed that it was alcohol that was the responsible factor for violence and debauchery were suddenly taken much more seriously. Empowered, the temperance movement called on the government to impose restrictions on the public consumption of alcohol; the movement also created “sober houses,” based on Rush’s idea that people suffering from alcohol abuse be placed in special hospitals, as opposed to simply throwing them in prison or what passed for mental asylums at the time. Rush theorized that alcoholics could be kept away from society (and the access to alcohol) in these houses until such time they could regulate their own behavior and resume their place in the world.
The most immediate sign of alcohol abuse being taken seriously for the first time in American life was the opening of the New York State Inebriate Asylum in 1858. Located in Birmingham, the asylum was, at the time, the only institution specifically built to treat alcoholism as a mental health disorder, and it was run on the “theory that inebriety, like insanity, is a disease, requiring like that, for its cure, medical and moral treatment.” Three years later, the Martha Washington Home in Chicago, the first dedicated rehab facility for alcoholic women in America, was opened.
The pendulum had swung enough that by the mid-19th century, finding a “cure” for alcoholism had become a very popular cause. As much as it attracted many eminent thinkers, the movement also drew people who practiced dubious methods. One of them was Dr. Leslie Keeley who made headlines in 1879 with a “secret” formula that would cure alcoholism and all other forms of addiction. The only comment Keeley would make about his formula was that it contained gold, which, in itself, was a sign of the times; gold had long been believed to possess healing properties and was one of many chemical elements (including silver and strychnine) that doctors attempted to use to cure the ailments of the day. Benjamin Rush himself dismissed the negative health effects of mercury, advocating it as a “Samson of medicine.” Centuries later, the Proceedingsjournal wondered if Rush was more of an assassin than a “beloved healer,” noting that despite the statues and schools being named after “the founder of American medicine,” hundreds of people died under his care.
Similarly, contemporary investigations into Keeley’s cure show the formula contained morphine and arsenic, which caused patients to experience a loss of cognitive function, a relapse into substance abuse, and even death. The Fix calls it one of “history’s scariest addiction treatments.” Even as the family members of patients complained, Keeley boasted that his formula had a 95 percent success rate.
Keeley’s “cure” is remembered as one of the more difficult steps in the history of the treatment of alcohol abuse, but he struck gold with another innovation: a month-long stay in a specialized treatment center, where patients received healthy food, exercise, and “individual attention and encouragement from doctors.” While treating alcoholism with gold soon fell out of favor, Keeley’s centers (which came to be known as Keeley Institutes) prevailed. By 1965, more than 200 such facilities were in operation across the United States and Europe.
Over in Europe, the Swiss psychiatrist and psychologist Carl Jung developed an interest in world religions, which led him to the conclusion that a person’s spiritual wellbeing was as important as concepts of psyche, the self, and extraversion and introversion – concepts that had been developed by Jung himself. Jung so deeply believed in the importance of spiritual balance for mental health that he told an alcoholic client of his that, with all other approaches having failed, the only recourse left for that patient was to undergo “a transforming experience of the spirit.”
The patient, Rowland Hazard III, joined a Christian evangelical movement known as the Oxford Group, which advocated the basic Christian philosophies of practicing charity, purity, honesty, and love as a way of achieving personal transformation. Once this transformation was achieved, it was incumbent upon members of the Oxford Group to spread the word, a form of “personal evangelism,” especially to people outside the group who were in need of such transformations in their own lives.
As the Oxford Group put it, “All men are sinners; all sinners can be changed; confession is a prerequisite to change; the change must change others.”
One of the people who heard this message was an old friend and drinking mate of Rowland Hazard’s, a man named Bill Wilson. Wilson’s struggles with depression and alcoholism had cost him his college education and a job, and put him in a treatment facility for his drinking problem. In conversation with Hazard, Wilson learned of Carl Jung’s theories on spiritual wellbeing, which connected well with Wilson’s own conversion to Christianity in 1934. This planted the seed of what was to become Alcoholics Anonymous, which adapted some of the core teachings of the Oxford Group into its own mantra: The person must admit that they are powerless over alcohol; the person must accept that restoration comes by turning control over to a higher power; the person must confess to God, themselves, and someone else that their drinking was wrong; and the person must spread the world to other drinkers.
It was Jung’s insights that formed the basis of what would become Alcoholics Anonymous, said The New York Times in 1993. The History of Psychology journal writes that, as the co-founder of AA, Bill Wilson (or Bill W., as he came to be known) considered Carl Jung’s treatment of Rowland Hazard to be “integral to the foundation of AA in theory and practice.”
As Wilson saw it, the biggest motivator to stay sober was to help other alcoholics with their troubles. He told his story to Dr. Bob Smith, a member of the Oxford Group who had his own problems with drinking. Wilson’s explanation of the spiritual aspect to his recovery and his belief that addiction was a disease of the mind appealed to Smith who applied the concepts to his own recovery. Smith had his last drink on June 10, 1935, a date that is remembered as the “birth” of Alcoholics Anonymous.
In 1938, Wilson (native to New York) and Smith (from Ohio) had helped over a hundred drinkers quit their habit. Looking to capitalize on their success and spread word of the program even further, Wilson (and, to a lesser degree, Smith) authored a book entitled Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism, better known as “The Big Book.” Within the book, Wilson listed 12 steps that encouraged reformed drinkers to embark on a path of spiritual growth. The rising popularity of the movement adopted the name of Wilson’s book and became known as Alcoholics Anonymous.
Since its beginnings, AA’s membership has grown to more than 2 million people in the world, with a self-published success rate of 75 percent. AA’s own figures state that 33 percent of its 8,000 North American adherents were sober for a decade or longer since joining the program.
The organization has gained criticism for its refusal to share internal data, which has led to accusations of pseudoscience from certain parts of the medical community, but Alcoholics Anonymous remains positively regarded in mainstream treatment science. The Recent Developments in Alcoholism journal called the 12-Step model “an ideal recovery resource,” and according to Alcohol Research & Health, peer-led support groups based on the AA model are among the most commonly sought source of help for alcoholism, even as other addiction treatment methods (such as psychotherapy and pharmacology) have become popular in their own rights. But even taking such methods into account, Scientific American argues that AA is better than “rival treatments,” pointing out that while it is not perfect, no form of treatment is; and given that the 12-Step method is widely available and free of charge, “AA is worth considering for many problem drinkers.”
AA has evolved beyond its origins as a movement exclusively based on Christian principles, offering programs with secular and agnostic replacements for much of the faith-based language in the 12 Steps (the original form of the 12 Steps mentions God in six of the steps). Non-Christian models espouse concepts of personal self and identity, some of them borrowing from Buddhist teachings that echo similar beliefs.
Even though Alcoholics Anonymous never purported to champion science as part of its methodology, the way the organization framed alcoholism as a disease and not a moral condition greatly influenced the thinking of alcohol abuse treatment for generations to come. In 1956, for example, the American Medical Association adopted the official position that alcoholism “is a treatable disease, not a moral failing.” Decades of research have backed up Wilson’s claim, even as some of that same research has cast doubt on the 12-Step method. In saying that “addiction is not about willpower,” Pacific Standard presents five studies that look at the treatment of substance use disorder as a disease, but points out elsewhere that AA’s results are mixed at best. On that point, The Atlantic notes that there is an enormous difference in the success rates that AA touts and what peer-reviewed studies have been able to determine. While AA’s self-reported statistics claim that 33 percent of its members maintain sobriety for a decade, third-party research puts the number as “somewhere between 5 and 10 percent,” meaning that out of every 15 people who enter a 12-Step program, only one achieves and maintains sobriety.
However, the impact of what Alcoholics Anonymous has done for treatment cannot be denied. Marty Mann, one of the earliest female graduates of the program and the first known LGBT person to complete the program, pushed hard against the notion that alcoholics were failed people with weak constitutions. She was instrumental in the launch of the National Committee for Education on Alcoholism in 1944, which embarked on a public outreach program to dispel many of the myths that surrounded alcohol abuse in the mid-20th century. The Committee also advocated for better treatment for alcoholics, such as calling upon hospitals to admit addicts and for more dedicated facilities for treatment and long-term care. The Committee is now known as the National Council on Alcoholism and Drug Dependence, but its mission of “fighting the stigma of alcoholism and other drug addictions” remains unchanged.
Nonetheless, changes in the treatment of alcohol abuse are afoot. The model of alcoholism (and addiction) being a disease, long held as sacrosanct, has been met with scrutiny by some in the medical community. Frontiers in Psychology, for example, says that there are elements of choice in the behavior of alcoholics, which better takes into account the neurochemical effects of alcohol abuse than the disease model allows.
Promoting Unbroken Brain, a book that challenges traditional standards of substance abuse and treatment, journalist Maia Szalavitz told NPR that even though 12-Step programs are incredibly common in the treatment of addictions, they tend to be counterproductive. While praising the Alcoholics Anonymous model for being “fabulous self-help” and very important as a form of support, Szalavitz notes that much of the treatment industry “indoctrinates” recovering alcoholics into thinking that 12-Step programs are a necessary component of rehabilitation. She points out that therapy and counseling are “equally effective” without the insistence on accepting a higher power as a lifeline. The faith-based foundations of the 12 Steps still compels presenting addiction and treatment from a moralistic point of view, even though the program itself advocates the disease model. “If we want to destigmatize addiction,” Szalavitz says, “we need to get the 12 Steps out of professional treatment.”
To that point, the New York Post declared that “we’re treating addicts incorrectly.” Dr. Marc Lewis, a neuroscientist and author of The Biology of Desire, takes issue with AA’s insistence that its members are powerless in the face of alcohol. A more effective line of treatment, says Lewis, is to teach addicts “to seize control of the future.” He writes that most of the people who are able to control their addictions say that feeling empowered was essential to their recovery. According to Lewis, it is worth asking whether “the disease nomenclature,” which has defined Alcoholics Anonymous and the understanding of substance abuse for a generation, “has alienated more members than it’s helped.”
Dr. Lewis’s solution is to create a hybrid model of addiction, one that is partly based on disease and partly based on morality. This, he believes, allows for addicts to invest deeply in their recovery and health because it acknowledges the role they played in the development of their addiction and the behaviors their addiction compelled them to do.
Similarly, Jeff Schaler, a psychologist and author of Addiction is a Choice, told ABC News that developing a new model of treatment (one that takes behavior and choice into account) might be what gives clients more control over their behavior.
The consensus among many treatment and mental healthcare practitioners is that Cognitive Behavioral Therapy, or CBT, is the model of choice for helping alcoholics overcome their compulsion to drink. CBT was developed in the 1960s by Aaron Beck, a psychiatrist who observed that his clients often engaged in an “internal dialog,” a conversation conducted exclusively within their own minds, and then fashioned their behavior after the results of that conversation. Beck theorized that becoming aware of these trains of thoughts, and identifying how they started, continued and ended, was key in helping the client change negative thought patterns – ones that culminated in problematic behavior, such as, but not limited to, drinking to resolve stress.
Beck called this approach “cognitive therapy,” a term that has been expanded to “Cognitive Behavioral Therapy,” because of how the approach focuses on changing thinking patterns as well as actions, habits, and responses.
CBT enjoys widespread mainstream acceptance in the treatment and mental health fields. It is the preferred therapeutic method among the most experienced and highly regarded counselors, says the American Psychological Association, citing its usefulness in treating people who have both substance use and mental health disorders. Citing a number of clinical trials and literature reviews, the Psychiatric Clinics of North America journal notes that CBT is used by a majority of therapists and mental health professionals in the treatment of alcohol abuse as well as abuse of many other drugs.
Adding their support, the BMJ journal asks if CBT is all that is needed because of how it is an efficient practice, one that is both easy to understand and practice, and one that “produces good results in many instances.” The journal concludes that CBT is the gold standard of therapy to treat substance abuse conditions like alcoholism because of how it has raised the skills of therapists the world over.
The widespread acceptance of CBT – The Independent notes that the British government earmarked $257 million to train 3,600 therapists in the approach – and the legacy of Alcoholics Anonymous and the 12-Step method have led many in the treatment community to suggest that clients seek both. Author David Sheff wrote a book critical of AA’s “undue influence on addiction treatment,” but was nonetheless compelled to note that Bill Wilson’s formation of the philosophy of Alcoholics Anonymous was an “unwitting design” of Cognitive Behavioral Therapy, group therapy, and other forms of psychotherapy that have since been employed in the treatment of alcohol abuse, even while trying to distance themselves from their 12-Step origins.
To that point, The Fix compared each of the 12 Steps to principles in Cognitive Behavioral Therapy and found that the respective therapies “share plenty of DNA.” Psychology Today even asked if the reason Alcoholics Anonymous is so successful is “because it’s a form of Cognitive Behavioral Therapy,” the latter of which is “one of the most empirically supported and evidence-based therapies in the psychological arsenal.” The balance of AA’s focus on a higher power and personal motivation, and CBT’s preferred status among researchers and clinicians, speaks to the present state of the treatment of alcohol abuse and hints at the future of improving care for alcoholics and other people suffering from substance use disorders.