The Disease Concept of Alcoholism (Terminally Unique, Pt. 7/21)

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There’s such a thick residue of resentment I see in myself in that last chapter, but I don’t think it I can be too critical of the perspective I had. Addiction can be wildly confusing and it can be frustrating from the perspective of someone going through it, to be told by countless different sources that there are equally as many reasons for why the addiction developed, why it’s continued, and how it can be resolved—it’s confusing stuff, based on hand-me-down information that is rooted more firmly in folk stories than science. One of the condition’s most easily digestible definitions reads that “Alcoholism is a chronic, progressive and potentially fatal disease characterized by tolerance and withdrawal, and/or pathological organ change.” This is a somewhat antiquated description though (it comes from the National Council on Alcoholism, which morphed into the National Council on Alcoholism and Drug Dependence over 30 years ago), as more modernized, person-first, non-stigmatizing language would rather reframe the term “alcoholic” as a “person with alcohol use disorder.” I don’t think this is wrong. I also recognize though that when framing alcohol use disorder as the problem, and not the person, the invitation of formal diagnosis brings with it its own set of problematic issues.

To oversimplify the medical model of addiction, it’s supported by the diagnosis of clinical symptomology, based on criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (referred to as the DSM). These criteria are used to determine whether or not a disorder exists, with a minimum presence of criteria required for diagnosis, and severity determined by how many criteria are satisfied. The list of criteria in the most recent version of the DSM include such symptoms as: “Alcohol is often taken in larger amounts or over a longer period than was intended”; “A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects”; and “Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.” But the thing to remember about this is that the DSM is descriptive, not prescriptive; it provides a bucket of symptoms to classify a disorder, but offers no guidance or insight regarding what to do with it from there.

I’ll add to it that the DSM isn’t set in stone… though, nor should be. This is a point critical when recognizing that the medical model, or attempting to rely purely on a modern clinical perspective to determine and treat a disorder, isn’t always a bulletproof process. In its most recent update, the criterion for alcohol use disorder eliminated legal problems and added cravings, as an example, speaking to the capacity for understanding of disorders to evolve and change with time. But the manual’s history is significantly more curious than a few minor updates like that. It was only in 1973 with the DSM-II that “homosexuality” was “replaced by the category Sexual Orientation Disturbance,” while it took until 1987 before the manual eliminated any sign of homosexuality-focused pathology completely. (I’ll say this in the DSM’s defense, however… it wasn’t until three years later, in 1990, that “the World Health Organization removed homosexuality […] from the International Classification of Diseases.”) Overall, however, I take less of an issue with the DSM’s curious relationship with empirical classification, and more with its increasingly inseparable relationship with medical billing.

Per the American Psychiatric Association, the DSM-5 “was developed to facilitate a seamless transition into immediate use by clinicians and insurers to maintain continuity of care.” What they mean is that an aim of the classification system is to reconcile with the medical insurance billing system. On one hand, this is a great thing, as it helps incorporate mental and behavioral health into a broader continuum of care, encouraging the financial burden of such care to be covered by insurance companies. The thing is, that classification system is compulsory to satisfy insurance billing requirements, so for clinicians who want to accept insurance, to do so places a mandatory requirement on some form of diagnosis. On the surface, this makes sense. But the necessity to provide diagnosis from an insurance perspective can promote oversimplifying a person’s situation, it can increase the risk of misdiagnosis (for example: how much time might a clinician have to meet with a client or patient before they can confidently diagnose a complicated disorder? And is that enough time for even the most skilled professional to accurately deliver a diagnosis?), and can promote labelling, stigmatization, and even legal consequence. This model of classification wasn’t originally created to align with the insurance process, but as was outlined in the DSM-III, was instead created to boost the “specificity required by clinicians, research workers, epidemiologists, program planners, medical record librarians, and administrators of inpatient, outpatient, and community programs,” so they could better do their jobs. Not unlike A.A. which bears conflict when factoring in its continued influence on the rehab industry, a similar strain between intention and outcome also appears within the medical (or disease) model of alcoholism.

One reason I see this as problematic from the perspective of the individual seeking help is because of how such labeling further muddies understanding of their underlying disorder, also potentially influencing concepts surrounding autonomy and personal accountability. A diagnosis can, and for many is, a helpful thing; it can alleviate confusion by addressing a set of underlying symptoms in the identification of a broader disorder. But does this model allow for enough room for circumstances when taking into consideration the symptoms someone is reporting? Take, for example, clinical depression… at what point do the symptoms of someone grieving a significant loss in their life become “dysfunctional” so as to be benefited by a formal diagnosis? I mean, this does open up broader questions like: what even is “mental health” or “a healthy psyche”? But part of what I’m also getting at is, does this process reconcile with individual variation, who defines normalcy or what a baseline should be, and how does the system stand to incorporate neurological and cultural diversity to reconcile with people of all walks of life? Could it be that “mental health” looks different in South Dakota than it might in Madagascar? Further, back to the concept of grieving a loss, can it be reasonable for situational causes to result in a set of symptoms, recognizing also that when those circumstances change, so too might the symptoms, or must they inherently be indicative of a broader disorder? Through the lens of the medical model, on one side there is a diagnosis, while on the other remission, and what exists in between is not always clearly defined.

“Alcoholism is a disease, but it’s the only disease you can get yelled at for having. ‘Goddamn it, Otto, you are an alcoholic!’ ‘Goddamn it, Otto, you have Lupus!’ One of those two doesn’t sound right.” –Mitch Hedberg

In the situation of those diagnosed as having an alcohol use disorder, the portrait of confusion that can follow physically stopping drinking isn’t clearly defined by clinical diagnosis alone. The DSM-5’s diagnostic criteria speaks to the conditions which helped develop and sustain the disorder, but not really what happens once someone stops drinking. “Craving” and “withdrawal” are both mentioned by name, but what exactly are cravings and withdrawals? A clinical question asking “are you experiencing any cravings?” seems straight forward, but how a craving is defined is incredibly subjective. Is a craving a powerful physical desire for a drug, or just to change how you might feel? Does it more closely align with the dictionary definition of “an intense, urgent, or abnormal desire or longing“? While in a professional capacity, when I tried explaining it to patients or clients, I would include the concept of a desire to change one’s current feeling or state of mind by using a substance. But is that even close? And the concept of withdrawals is also tricky to nail down, including symptoms such as fatigue, sleep-disturbances, and mood swings, which can last anywhere from a few days to a few years.

In going back to read all my old journals, captured in the entries of the first several months of my recovery was a picture of significant emotional flailing. At four days sober I wrote “I’m so scared, confused and angry that I’ve lost myself.” There was a hair-trigger on my emotions and banal everyday situations would cause me to burst into tears. A week later I noted how I got choked up at a gas station, simply thinking about the prospect of applying to find a job, and how the dullest spark of hope set me off. On the flip-side were the sleepless nights, riddled by intrusive thoughts that carried on into the waking hours. Physical aches compounded by fear, shame, and uncertainty left my body and my mind in a state of constant disequilibrium. That’s all really difficult to quantify.

The slang term “wet brain” is used to describe a state experienced by some following long-term heavy drinking, where their coordination or behavioral base-line is permanently affected as a result of their alcohol use. Long before these sort of effects are experienced, many problem drinkers do go through legitimate physiological changes as a result of their drinking. This, taken into consideration within the broader context of the medical model, is how the picture of the disease concept of alcoholism is painted. While A.A.’s Bill Wilson shied away from using the term “disease” in lieu of calling alcoholism a “malady,” “sensitivity,” or even “allergy” to alcohol, the brain and metabolic adaptations as a result of continued heavy drinking can create a lasting medical problem. Those critical of the disease concept can point to alcoholism being wildly different than something like heart disease or cancer, and they’re right. Behavior and personal responsibility play in a role in alcoholism in ways dissimilar to how many diseases take form. But also, that would open the door to comparing it to something like Type 2 diabetes, where the problem is chronic, potentially fatal, requiring intensive medical care and treatment revolving around behavior modification, where the disease can be arrested rather than cured, with the exact nature of environmental and hereditary predisposition each recognized as influencing factors (Chandler McMillin and Ronald L. Rogers, Under Your Own Power: A Secular Approach to Twelve Step Programs). Where is the line drawn between disease and disorder? There is no exact answer to that, but I’ve heard it put in colloquial terms comparing it to the point in which a cucumber steeped in vinegar turns into a pickle. The precise moment in time it makes that change is unclear, but once it does it can’t turn back.

These are all the things we are to think and believe about alcoholism, depending on the source defining it: It’s a moralistic failing; a problem of willpower; an incurable disease; a progressive illness; the result of a spiritual conflict; a biochemical intolerance; the result of poor lifestyle choices; a physical allergy; and a malady that is otherwise “cunning, baffling, and powerful in nature.” Diagnosing and labelling of the problem can create a sense of understanding about what is happening within someone’s body, but attempting to filter these potential influences through a “terminally unique” mindset can also result in someone projecting blame externally to explain away behaviors they might otherwise be held responsible for.

Looking back at the evolution of understanding about what alcoholism is and what it isn’t, it’s hardly a leap to suggest that our understanding will continue to develop further in the coming decades. Speaking to addiction as a whole, psychologist Gabor Maté calls it not a choice, or a disease, but a response. This, I’d align with Bill Wilson’s A.A.-ism which says, “our liquor was but a symptom.” The surrounding semantic argument of what the problem may or may not be might be helpful for some, but we can’t overlook that a significant level of practical, applicable action is still required on an individual’s behalf when faced with this sort of problem. Clinical (and bureaucratic) considerations aside, I believe one constant will continue to be required in response to the problem, and that’s a legitimate willingness on behalf of the person with the condition and an honest desire from that person to change. That’s something I agree with A.A. on, but just how that decision to change is pursued once it’s made, and how it’s supported along the way, however, welcomes another set of issues altogether.

Terminally Unique - Alcoholism - AA - Addiction

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[The track opening and closing the episode is called “styles.”]

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