Alcoholism Treatment The disease concept of treatment (DCT) has been the dominant treatment model for alcoholism in the United States for the last 30 years, however, remarkably little has been written about its nature. Writings have focused on its theoretical underpinning, the disease concept, rather than the treatment techniques and principles that seem to follow from it. Writings about DCT have been largely critical. Some state that it relies on invalidated approaches. Others claim that it depends on an untenable disease concept. Kalb and Propper and Pattison characterize alcoholism counselors, the primary treatment providers for DCT, as “not open to new knowledge but rooted in the traditional and inviolate knowledge conveyed by Alcoholics Anonymous (AA)” (34). AA is a spiritual self-help fellowship based on the 12 Steps and the 12 Traditions, promising recovery from the malady of alcoholism. Bill Wilson, the co-founder of AA, wrote both the 12 Steps and the 12 Traditions using as sources the practical experiences of early AA members and the teachings of the Oxford Group, a Christian reform movement. Its principles, as viewed by its adherents, are spiritual and not scientific. AA is non-professional and is not a treatment program. A core belief of AA is that alcoholism is a progressive illness characterized by loss of control over drinking, which can never be regained. The program for recovery (the model for change) includes attending AA meetings and working the steps such as accepting and using them as a guide for living. The organization suggests that the newcomer obtain a sponsor, an established AA member who can help him/her understand how the system works. The sponsor has no special training beyond his/her experience in recovery as an AA member. Each recovering alcoholic, however, develops one’s own recovery program. The philosophy and principles are spelled out in Alcoholics Anonymous, an official publication of AA. The disease concept, implicit in this organization, was promoted by the National Council on Alcoholism (NCA) from its inception in 1944. Mann, the founder of NCA, included these elements in the disease concept of alcoholism. First, Alcoholism is a disease. Second, alcoholics gradually develop loss of control over drinking; once they begin drinking, they may be unable to stop. Third, Alcoholism is a permanent and irreversible condition; alcoholics can never drink safely. Finally, Alcoholism is a progressive disease, which if untreated can lead to insanity or death. A striking feature of the disease concept of treatment is that physicians are neither mentioned nor there are any medical procedures indicated. Another unusual feature is that only two of the five elements of DCT are directly derived from the disease concept. Other names for DCT are the medical model, the Minnesota model, and the 12-step facilitation model. Key to the development of the model were individuals, not professionally trained, hired to treat alcoholics in institutional settings and individuals in AA, usually recovering alcoholics, called variously lay counselors, AA counselors and paraprofessionals.
From the beginning of Prohibition in 1919 until the late 1940s, there was virtually no institutional treatment for the alcoholic. There were a few private facilities that were mainly for the purpose of drying out alcoholics, an early term for detoxification. Most of these programs were unlicensed, however, and provided treatments of questionable merit Thus, AA, founded in 1935, filled a large vacuum in the treatment system. From AA’s inception, its members offered help to other alcoholics, and this outreach became codified in AA’s 12th step and 5th tradition. These early members formed clubhouses and AA homes, where they could bring newcomers and offer the AA program. They also made themselves available to hospitals as volunteers. In the early days, some recovering alcoholics became professional alcoholics, as some described them, dedicating their lives to helping alcoholics by offering their services as speakers on alcoholism and being available to help alcoholics in the community. For many, this activity started in a small way often on a volunteer basis and later led to a full-fledged occupational commitment, as for example running a halfway house. Bill Wilson and Dr. Bob Smith, the “cofounders of AA, Pat Cronin, the first AA recovering alcoholic in Minnesota, and Marty Mann, the first female alcoholic in AA, are examples “(Richeson 67). The evolution of DCT can be seen most clearly in the development of AA facilities. The model emerged, concurrently, in state mental hospitals and detoxification programs. The development of the model will be traced in these three types of institutions. Outpatient alcoholism clinics, which retained a traditional psychiatric model long after the other institutions had implemented DCT, will also be discussed. Two institutions developed from the informal AA facilities: the halfway house and the Alcoholism Rehabilitation Treatment Center (ARTC). At first, there was little distinction between the two, but eventually the halfway house developed a longer length of stay and work requirements. Formal treatment was shifted to affiliated outpatient alcoholism clinics, while the ARTC developed an intensive, structured inpatient treatment with a shorter length of stay, often 30 days. Hazelden was founded in 1949 as an exclusively AA-oriented facility. In 1961, Dr. Daniel Anderson, hired from Willmar State Hospital, began to modify Hazelden’s treatment program by hiring professionals and adding professional treatment elements. Even though Dr. Anderson was an advocate of AA principles, the recovering- alcoholic staff became concerned about the changes. They felt that the hiring of professionals challenged the purity of the AA philosophy.
These individuals resented charting requirements, formal staff meetings and psychological testing of the patients. However, the program continued to evolve and from 1966 to 1970 Hazelden’s program solidified into an ARTC, utilizing the DCT approach. While professional standards were instituted, the important elements of the Structured AA Program remained, including instruction in the 12 steps, working the first five steps, and didactic lectures. Two added elements were the psychological. assessments, which helped the client realize problematic attitudes, and group sessions conducted by alcoholism counselors. Confrontation group “sessions were developed at Hazelden in 1967 in a special program for repeaters” (McElrath 132). In these sessions, the patients were confronted with the evidence of their alcoholism and encouraged to accept it. The confrontation groups may have become necessary because of the time-limited nature of ARTC programs. It is likely that patients had to acknowledge their alcoholism early in the treatment in order to cycle through the program smoothly. Such groups are a departure from AA principles since there are no time constraints nor requirement of admitting being an alcoholic in AA philosophy. Willmar State in Minnesota was the first state hospital to incorporate a special alcoholism unit. Before 1950, like other state hospitals, Willmar State had no treatment for alcoholics except for detoxification. At first, the interaction between the alcoholism counselors and the professional staff was characterized by challenge and crisis Professionals often became more relaxed, less distant and less formal, allowing first names to be exchanged among staff and patients on the unit. The 60-day program that was developed at Willmar State consisted of a didactic component of 28 lectures, including “Alcoholism as a Disease”, “The AA Way of Life”, “The 4th and 5th Steps”, and group therapy conducted by the alcoholism counselors. This program made alcoholism treatment distinctly separate from psychiatric treatment and facilitated the creation of separate units within hospitals. In the 1940s, hospitals were reluctant to admit alcoholics in need of detoxification or other medical complications of alcoholism because of society’s moralistic views of the disorder. It was not until 1956 that the American Medical Association stated that alcoholics in medical need merited consideration for admission to hospitals and not until the 1970s that detoxification units became common. In these units, medical treatment for “complications of withdrawal and alcoholism was followed by an introduction to AA by the volunteers or an introduction to the disease concept by alcoholism counselors” (Wiener 134). At first a medical atmosphere maintained in the DCT facilities, was guided by a naive belief that the aura of the hospital environment and medical treatment of withdrawal symptoms and related medical illnesses would cure the disease.
Relapsed patients were readmitted with the understanding that they had an illness and were not responsible for their relapses. However, as most of the patients showed no improvement after repeated hospitalizations, the staff became discouraged. In the face of these repeated treatment failures, the professionals began to doubt the disease approach while the alcoholism counselors, deeply committed to it through AA, did not. The alcoholism counselors met several times and drew up a position paper to develop a better treatment model. They felt the continuous admission policy might have unwittingly contributed to the alcoholic’s disease. They recommended refusing admission to repeaters, suggesting that it was important that alcoholics experience the negative consequences of their drinking as this might better motivate them to become sober. The professional staff realized that they had no viable notion of how to proceed once the acute effects of withdrawal were medically treated. The alcoholism counselors, on the other hand, could offer the principles of AA to help the alcoholic seek and obtain sobriety. They were allowed to do this and, informally, they began to restrict admissions. Unlike the state hospitals, where the alcoholism programs were created in cooperation with AA members, alcoholism clinics through the late 1960s were developed from various psychiatric models, employing mental health professionals and utilizing individual psychotherapy as the primary modality. There was antagonism between outpatient alcoholism clinics and local AA chapters, which may have hindered the adoption of DCT. In the 1970s, DCT programs developed all over the country, and in 1978 a monograph celebrated their coming of age by giving accounts of 13 DCT programs. By 1983 alcoholism counselors were the majority of the treatment providers in alcoholism treatment programs. In the 1980s, the status of alcoholism counselors was raised by creating a competency-based credential for alcoholism counseling in most states. It is ironic that the debate about the scientific credibility of the disease concept raged for several years, when, in fact, the implementation of DCT was essentially the practical application of AA principles in institutions. From the historical perspective, it appears that DCT consists of the systematic and structured indoctrination of AA principles, with the addition of some other elements, especially the confrontation groups. The degree to which these changes make DCT meaningfully different from AA practice is unclear. A useful way to begin to determine such differences would be to compare the opinions and practices of alcoholism counselors with those of AA members.
For example, Kurtz found “differences between AA members and professionals’ ideological views of alcoholism” (89). AA members in their efforts to help alcoholics created informal facilities that were the forerunners of all the current treatment facilities except the outpatient clinic. DCT programs evolved in AA facilities and in institutional settings. In AA facilities, Structured AA Programs represented a midway point between the first informal AA facilities and DCT programs. DCT was established when professionals were hired and some professional treatment elements were added. In institutional settings, AA members first volunteered and then were hired as alcoholism counselors, supplying a personal commitment to AA principles, which became formalized and structured into DCT. In some AA facilities like halfway houses, AA principles remained primary since professionals were never hired. The late emergence of DCT in outpatient clinics may have been caused by the lack of cooperation between AA chapters and the clinics. In both AA facilities and institutions, professionals and alcoholism counselors had to reconcile their “differences concerning professional knowledge and experiential knowledge of alcoholism” (Borkman 90). The alcoholism counselors relied on their personal experiences in AA to understand alcoholism while the professionals made use of knowledge learned in their professional schools. Even at Hazelden, where Dr. Anderson succeeded in introducing professional treatment elements, the resulting program is primarily based on the experiential knowledge of AA. Additional information on the interactions between alcoholism counselors and professionals would be useful to explore to what extent DCT represented a true collaboration between them.