Alcoholism is a Disease, not a Character Defect
Copyright ©2000 by Doug Thorburn
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(The following is a response to Stanton Peele's piece "After the Crash," in Reason Magazine, November, 2000. In his article, Peele suggests that Audrey Kishline, founder of Moderation Management, might not have killed two innocents with a blood alcohol level of .28 per cent had she not given up her attempt at moderating drinking in lieu of abstinence. He also holds that "problem drinking" is a learned response to stressful situations and negative feelings, which is patently false. It was an extraordinarily misleading and potentially dangerous article, which Reason, with which I usually wholeheartedly agree, should be ashamed to have published.)
Stanton Peele claims that alcohol addicts can control their use. He suggests that we should focus on getting drinkers to use alcohol "more responsibly," claiming that moderation training can succeed where abstinence has failed. Unfortunately, such training cannot work because alcoholics are not capable of using "responsibly" on every occasion. While they may be able to control their drinking for periods of time, especially in early stage addiction, they cannot control their propensity to engage in destructive behaviors.
Alcohol addiction is a biological and genetic disorder. Some inherit an inability to properly convert sugar into glucose. Other unfortunates are incapable of converting alcohol into a harmless substance, acetate, without something going wrong in the process. An all-too-slow conversion causes the addict to engage in bizarre, unethical, criminal and/or psychopathological-appearing behaviors. He can neither be taught nor therapeutically cajoled into being able to process the drug differently than his biology allows.
Alcohol is converted by the liver into a poison called acetaldehyde at a fairly uniform rate for addicts and non-addicts alike. This poison is then turned into the above-mentioned acetate which, while harmless, causes feelings of nausea and hangover. It is this latter conversion where addicts and non-addicts part company. In most people, it occurs quickly, with an automatic biological feedback mechanism informing them that they'd better stop or dramatically slow the drinking. In others, it takes place very slowly. Since the drinking doesn&Mac182;t cause them to feel sick, there is no feedback suggesting that these persons stop.
On the other hand, the slow conversion results in a buildup of acetaldehyde, which causes an opiate-like substance called isoquinolines to be released. This makes the addict feel really good, causing him to "feel no pain" for as long as the blood alcohol level remains elevated. This leads to that propensity to keep on drinking, which can often be observed in alcoholics. The slow conversion and the continuation of drinking also creates a build-up of poison at the cellular level, particularly the cells of the heart, liver and brain. It is probably the poisoning of the brain that causes distorted perceptions, resulting in impaired judgments, manifesting as destructive behaviors. We refer to those who process the drug in this way as having the disease of alcoholism.
The distortions that alcoholics experience include blackouts, which non-addicts rarely, if ever, suffer. These are periods during which the addict may appear stone- cold sober and yet will never remember a thing. All manners of bizarre and destructive behaviors can occur during these periods, including criminal activity. At the very least, they can result in confusion and conflict at home. Consider this scenario: an addict who gets drunk and obnoxious and then experiences a blackout, denies accusations of poor behavior asserted by his non-addict spouse the next day. Since neither are aware of or understand blackouts, they are both absolutely convinced that the other is lying.
The key distortion is referred to by the late great alcoholism authority, Vernon Johnson, as "euphoric recall." This causes the addict to remember that everything he does during a drinking episode is good and right, while nothing he does is bad or wrong. Since it isn't he who has screwed up his life, he blames others for his problems. Euphoric recall also causes the addict to have a godlike view of self, resulting in an inordinately large sense of self-importance. This is referred to by author James Graham as an "inflated ego."
This inflated ego appears to result in the need to continually engage in behavior that serves as its fuel. The primary method of doing this is to wield power over others, especially capriciously. Specific methods include relatively benign behaviors such as belittling and disparaging others, all the way to murder and mayhem. They are all ways of saying, "I'm better and more powerful than you are." The belief that he can do no wrong also creates in the addict a sense of invincibility.
These feelings of invincibility and self-importance may account for the fact that the average alcoholic illegally drinks and drives, by the best estimates, 80 times per year. When we counsel people to not drink and drive, even addicts who are in- between drinks will agree never to do so again. But once they begin drinking and drugging beyond a certain point (varying among addicts as to degree, but often requiring as little as .04 per cent Blood Alcohol Level), the view that they can do no wrong takes over. They will drink and drive, verbally or physically abuse their spouse, stir up problems in the workplace, "borrow" money from friends and others without ever paying it back, destroy their landlord's home or engage in other destructive behaviors.
The studies Peele uses to show that many alcoholics can control their drinking are flawed. According to Peele, one such study by the RAND Corporation allegedly found that "many alcoholics continued to drink without problems." The RAND Report says that many of the men in their 1978 study were able to return to "social drinking" after a period of eighteen months. However, when their criteria for social drinking is considered, anyone who knows anything about drinking and Blood Alcohol Levels (BAL) would seriously question their standards. One of these describes the upper limit of social drinking as doing so regularly for six months without exceeding seven martinis a day. If drunk over the course of a day, the BAL would be negligible; if over a three-hour period for a 120-pound person, the BAL would be .17 per cent (.10 per cent for a 200-pound person). Anyone drinking to such an extent who exhibits any serially destructive behaviors is probably an alcoholic.
Furthermore, the RAND study required no "serious symptoms." These were regarded as absent if, during the past month, the subject had fewer than three blackouts, fewer than three days missed from work due to alcohol and not more than four episodes of morning drinking. By my criteria, any one of these symptoms exhibited in a year would be considered strong evidence of alcohol addiction.
All that this and other studies have shown is that alcoholics can, for periods of time and when they know they are under scrutiny, control their drinking. Such control always ends in failure, as evidenced by a researcher (Ewing), who in 1975 set out to prove that alcoholics could drink in moderation if taught how to do so. Within four years every one of his subjects had gotten drunk. He called off the experiment declaring that it would be unethical to continue. Another researcher (Helzer et al, 1985) studied 1,289 diagnosed and previously treated alcoholics. He found that only 1.6 percent were successful moderate drinkers, most of whom were female and showed few clear symptoms of alcoholism. Despite the clear evidence found in these studies, Peele still advocates trying to teach alcoholics to drink in moderation, even with a 98.4 percent failure rate.
Peele also referred to the Sobell study, which similarly followed alcoholics taught to control their drinking. He asserted that later investigations "exonerated the Sobells of wrongdoing." This doesn't mean that the Sobells were right. They may have intended well. But their 20 alcoholics had all relapsed within ten years, except for one, whom the follow-up psychologists, Pendery and Maltzman, concluded had probably been originally misdiagnosed as an alcoholic. Thirteen of the subjects (65%) were hospitalized within the first year, suggestive of continuing problems with the drug alcohol. Three others had repeated arrests, including drunk driving charges. The remaining three experienced other alcohol-related problems during the Sobells' two-year follow-up. Ten years later, five of the twenty were dead from addiction-related causes, all under age forty-two. The odds that so many would die and/or be hospitalized in a non-addict population in this short time frame are near- zero.
Peele and others fail to understand that alcoholism is a biological disorder that requires the afflicted to accept full responsibility for his misbehaviors. Only then, can crises occur. These are essential for successful intervention. The pain from using must become greater than the pain from not using before the addict will surrender. Due to the way in which he processes the drug, a level of distress is required that observers generally can't bear to watch. Because of this, along with repeated promises to "clean up my act," these well-intentioned persons shield the addict from consequences. This results in continued use or repeated relapses.
Audrey Kishline experienced a relapse because she never understood the biological component of her disease that causes her to process alcohol differently than her non-addict friends. This lack of knowledge is evident from her book. It's time for Stanton Peele to come to terms with the evidence and accept the fact that alcoholics cannot in the long run control either their drinking or, more importantly, the resulting misbehaviors.