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WRITERS AND ALCOHOL

By Ann Waldron

Special to The Washington Post – March 14, 1989, pp. 13-15 (c) The Washington Post

Many giants in American literature have turned to the bottle, yet the link between creativity and alcoholism remains unproven

Do writers drink more than other people? It would seem so. Raymond Carver, acclaimed author of stories about America’s working poor, died last August at the age of 50. “He began achieving recognition as a writer in 1967 when his story Will You Please Be Quiet, Please? was selected for the anthology Best American Short Stories, his obituary said. “But that was also the year he began to drink heavily…After being hospitalized for the fourth time, he turned to Alcoholics Anonymous and quit drinking.”

The same month, Adela Rogers St. John, a very different kind of writer, a “sob sister” and author of romances, died. “Her personal triumphs were accompanied by tragedy…and the conquest of alcoholism,” said her obituary.

David Roberts’ just-published biography of novelist and journalist Jean Stafford reveals the harrowing details of her alcoholism. She started drinking in college, and in her twenties was sipping sherry in the morning while she wrote. Her drinking progressed until “she hardly drew a sober breath,” as a friend recalled. If she went out to dinner, friends had to help her home. She told her sister that she hated to drink, that it made her unspeakably miserable but that she could not stop.

A doctor put her on Antabuse. It worked for a while, but she went back to drinking until she suffered from delirium tremens and endured falls and injuries. Several times she passed out on the floor and stayed there all night. Even after a heart attack and a stroke she drank.

In his biography of Truman Capote, published last spring, Gerald Clarke detailed the horrors of Capote’s drinking. While Capote was writing In Cold Blood, he would have a double martini before lunch, another with lunch and a stinger afterward. After he was arrested for drunken driving on Long Island, he went to Silver Hill, an expensive clinic in Connecticut for alcoholics. Dried out, he was soon drunk again; he fell, cracking his teeth and bloodying his head. He tried Antabuse.

He could stay off the booze for three or four months, and then he went back on it. He went to the Smithers Alcoholism Rehabilitation Unit of St. Luke’s Roosevelt Hospital in New York, which he called the Devil’s Island of alcohol clinics. Capote’s cure did not last. He appeared on a talk show; drunk and rambling. “I drink,” he said after one binge, “because it’s the only time I can stand it.”

Was it ever thus?

A friend of mine was teaching a survey course in American literature one summer session at the University of Houston. In the class were several older students, schoolteachers mostly. A teacher came up to him after class one day and said, “Listen, I just want to know why every single author on our reading list was an alcoholic!” The professor ran his eye down the list. Edgar Allen Poe. Stephen Crane. Theodore Roethke. Herman Melville. Delmore Schwartz. Scott Fitzgerald. William Faulkner. The school-teacher was right. Every writer on his list was an alcoholic.

In 1913, Jack London published a book called John Barleycorn, which his wife suggested he call Alcoholic Memoirs. In it, he tells how he got drunk the first time. He was 5 years old and drank some of the beer in the bucket he was carrying to his stepfather at work in the fields. In his teens, he learned to drink strong men to the floor. For a long time after he turned to writing, he refused to drink until he had done his thousand words a day. Soon he learned to get a “pleasant jingle,” as he called it, after the 1,000 words were on paper but before lunch. Then he acquired another “jingle” before dinner. “It was the old proposition,” he writes. “The more I drank, the more I was compelled to drink in order to get an effect.”

Insomnia and hangovers followed, along with the need for a drink in order to write. “I had the craving,” he said. “And it was mastering me. ” He vividly describes the “white logic” (skepticism) and the “long sickness” of alcohol. Then he quit drinking. But the ravages of the past held sway: He committed suicide three years later at the age of 40.

Tragic Literary Heroes

The prototype in American letters of the alcoholic writer as tragic hero is Ernest Hemingway. The newest biography of Hemingway by Kenneth Lynn deals very forthrightly with his drinking. Hemingway had the same capacity for alcohol that his characters did, and in The Sun Also Rises Jake Barnes and Brett Ashley drank three martinis apiece before lunch, which was accompanied by five or six bottles of red wine.

In 1939, Hemingway was ordered to cut down on his drinking. He tried to hold himself to three Scotches before dinner but he couldn’t do it and, in 1940, he began breakfasting on tea and gin and swigging absinthe, whiskey, vodka and wine at various times during the day. He even let his boys drink hard liquor when one of them was only 10.

His alcoholism brought on hypertension, kidney and liver diseases, edema of the ankles, high blood urea, mild diabetes mellitus and possibly hemochromatosis, recurrent muscle cramps, chronic sleeplessness and sexual impotence. He shot himself to death at age 62.

William Faulkner, who won the Nobel prize in literature in 1950, was hospitalized innumerable times for alcoholism. Then there were Allen Tate, Caroline Gordon, Ring Lardner, Dorothy Parker, Robert Lowell, Eugene O’Neill, John O’Hara, O. Henry, Conrad Aiken, John Berryman, Edmund Wilson–all acclaimed writers in the 1930s. All had trouble with alcohol.

Sometimes it seems that no American writers escaped the bottle.

One notable exception was Upton Sinclair, the muckraking author of The Jungle and a score of other novels, who was a rabid teetotaler. He wrote The Cup of Fury in the 1950s to warn young people against the evils of alcohol. He, too, noticed the prevalence of drinking among writers and talks in the book about all the writers he had known who had problems with alcohol. His list includes O. Henry, Sinclair Lewis (“never had anybody gotten so blind drunk as Sinclair Lewis”), Scott Fitzgerald, Stephen Crane, George Sterling, Maxwell Bodenheim, Sherwood Anderson, Hart Crane, Dylan Thomas and Joaquin Miller, the “frontier poet.”

Donald W. Goodwin, chairman of the department of psychiatry at the University of Kansas Medical Center and author of the recent book Alcohol and the Writer (Andrews & McNeel, $16.95) points out that while objective data on the numbers of writers afflicted with alcoholism is hard to come by, statistics show that, after bartenders, more writers die of cirrhosis of the liver, a disease closely associated with alcoholism, than people in other occupations.

Goodwin looked at the seven Americans who have won the Nobel prize for literature and found that four of them–Sinclair Lewis, Eugene O’Neill, William Faulkner and Ernest Hemingway–were definitely alcoholic, while a fifth–John Steinbeck–drank to excess. The two Nobel winners who weren’t alcoholics were Pearl Buck and Saul Bellow.

Goodwin also discusses the drinking lives of Edgar Allen Poe, Scott Fitzgerald, Hemingway, Steinbeck, Faulkner, O’Neill and Malcolm Lowry. He concludes that alcoholism is an epidemic among 20th-century writers.

Yet the link between alcoholism and creativity remains unproven. Many of the most notable American writers managed to stay away from the bottle. The list includes Nathaniel Hawthorne, Mark Twain, Mary McCarthy, Upton Sinclair, Emily Dickinson, Henry Thoreau, Zane Gray, Ralph Waldo Emerson, Saul Bellow, William Golding, Robert Frost, Edith Wharton, Willa Cather, James Michener, Lillian Hellman, Tom Wolfe and Flannery O’Connor.

Some alcoholic writers, moreover were able to conquer their addiction. John Cheever, for example, after years of alcohol abuse, signed himself into Smithers (Capote’s Devil’s Island) and never took another drink after the 28-day treatment was over. He was like a different man afterward, his daughter Susan wrote in Home Before Dark. “It wasn’t just that he didn’t drink anymore …it was like having my old father back, a man whose humor and tenderness I dimly remembered from my childhood. He was alert and friendly…He was interested in what we were doing and how we felt…In three years, he went from being an alcoholic with a drug problem who smoked two packs of Marlboros a day to being a man so abstemious that his principal drugs were the sugar in his desserts and the caffeine in the…tea that he drank instead of whiskey.”

A little more than a year after he left Smithers, Cheever finished Falconer, his most successful novel. When it was published in 1977, he was on the cover of Newsweek and the book was No. 1 on the best-seller lists. He died at 70, shortly after his last novel, Oh What a Paradise It Seems, was published in the spring of 1982.

Madness and Creativity

Nancy J. Andreasen, a professor of psychiatry at the University of Iowa with a PhD in English, did a 15-year study of 30 creative writers on the faculty of the Iowa Writers’ Workshop, where students and faculty have included well-known writers Philip Roth, Kurt Vonnegut, John Irving, John Cheever, Robert Lowell and Flannery O’Connor. She found that 30 percent of the writers were alcoholics, compared with 7 percent in the comparison group of nonwriters, she wrote in the October 1987 issue of the American Journal of Psychiatry.

Andreasen had begun her investigation to study the correlation between schizophrenia and creativity. She found none. But she did find that 80 percent of the writers had had an episode of affective disorders, i.e. a major bout of depression including manic-depressive illness, compared with 30 percent in the control group. Two thirds of the ill writers had received psychiatric treatment for their disorders. Two of the 30 committed suicide during the 15 years of the study.

The study is small but the relatively high rates of alcoholism and depression buttress the folk wisdom that creative artists are mad, with alcoholism an inevitable part of that insanity.

Freudian psychology has held that creativity is a sublimation of aggressive and sexual impulses or a response to emotional pain. A domineering, cold mother or any kind of unhappy childhood, according to this view, causes neurosis and anxiety, and neurosis is a veritable hotbed, or incubator, for creativity.

Proponents of this theory point out that those same anxieties would cause alcoholism in writers and other artists.

Writers do behave oddly. They can be monomaniacal about their work, obsessional about rewriting, insecure about any success they might have, paranoid about editors and publishers, riddled with anxiety about their talent. They are often nonconformists.

But is this mental illness? Ronald R. Fieve, in his 1975 book Moodswings, concedes that creative individuals tend to be eccentric and erratic, but he does not agree with the general Freudian idea that creativity is simply a response to emotional pain. That thesis “would say that art is rooted in sickness,” he writes. “I would conclude that individuals are creative despite their disorders, but certainly not because of them.”

In 1904, Havelock Ellis, who wrote copiously about psychology and sex around the turn of the century, did a study of 1,030 geniuses in England’s history and found that only 4.2 percent of them were crazy. That’s the same proportion of disturbed people in the general population, according to some estimates.

At the same time, if creativity itself does not cause alcoholism, are there occupational hazards that lead writers to become alcohol abusers?

Perhaps. For one thing, writers usually work alone, facing an empty page that must be filled. There’s no camaraderie at work for the fiction writer. He or she must keep at it day after day alone in a room with a keyboard, writer’s block and fears of failure to even get published. Then there is the horror of hostile criticism. Virginia Woolf suffered from depression of psychotic intensity after unfavorable criticism. Although she did not turn to alcohol as self-treatment for depression, many writers do. No wonder that Jack London’s “pleasant jingle” could become so comforting–and so illusory.

Journalists are not so apt to write alone, but they face other hazards in the midst of the old newspaper culture, where hard drinking is glamorous and macho. Journalists are often away from home and family for long periods in strange places. Hard drinking with colleagues provides some relief from the tedium.

Dr. Anita Stevens, a psychiatrist in New York who is the author of Your Mind Can Cure, treats a number of people in the creative professions. “My writer patients work in isolation, and isolation leads to alcohol,” she said. “Anybody can become addicted, but writing seems to lend itself to addiction. Writers’ enthusiasm will carry them away into the bottle. Then instead of getting more ideas from alcohol, they find their ambition dulled.”

It’s the lulls between writing that are dangerous, Stevens said. Writers try to fill the gap with alcohol. It begins as a pastime and then becomes alcoholism. “It takes a great deal of insight to be able to give it up,” she said.

Steven Levy, a New York psychologist who has worked with several writers, says that different kinds of writers react differently to alcohol. “Journalists have this `belly up to the bar’ attitude,” he said. “Authors do the cocktail party thing, but of course it’s their personal life histories that determine how they’ll handle it.” In what seems to echo the Freudian refrain, Levy added: “Part of creativity is pain.”

To Goodwin, drinking is often an integral part of a writer’s life. He points out that writers make their own hours, so it is easier for them to drink. It’s expected that writers will drink, and writers live up to the expectation. Some writers think they get inspiration from alcohol. Writers are loners and therefore drinkers.

Still, the evidence is anecdotal. Everyone agrees that more work and more biomedical investigation is needed to discover the causes of alcoholism among writers and assess the connection between writing and drinking.

Toll on Literature

The impact of alcoholism on American letters is a subject that attracts increasing attention from literary scholars.

A 1987 article in The American Scholar titled F. Scott Fitzgerald’s Little Drinking Problem takes a new look at Fitzgerald’s drinking and tries to assess how it affected his writing. Between 1933 and 1937, Fitzgerald was hospitalized eight times for alcoholism and arrested at least as often. He abused gossip columnist Sheilah Graham, who lived with him. “We know that alcoholism made Fitzgerald’s days hellish and clearly brought about his early demise,” writes Julie M. Irwin, the author of the article. “Yet given that Fitzgerald worked with this considerable handicap, his productivity becomes all the more impressive…Knowing that Fitzgerald worked under the pressure of alcoholism makes him seem not like an elegant wastrel…but a literary craftsman devoted to producing art regardless of the obstacles that stood in his way. This, finally, is the lesson to be learned from Fitzgerald’s alcoholism: He was a writer who was also the victim of a disease, not a self-destructive drunk bent on wasting the talent he was given.”

Upton Sinclair in The Cup of Fury wrote about Sinclair Lewis and his drinking: “Through a miracle of physical stamina, [Lewis] made it to the age of 66. More tragic than any shortage of years was the loss of productivity, the absence of joy.”

If he had not become such a drunk, would Truman Capote have finished Answered Prayers? If she had not turned to alcohol in such a destructive way, would Jean Stafford have finished the novel she worked on for 20 years? Would Caroline Gordon have finished her long novel about explorer Meriwether Lewis?

Imagine a world where Hart Crane continued to write poetry into middle age; where Jack London lived beyond 40 and worked as his talent matured on novels a cut above White Fang, where Ernest Hemingway did not sink in his later years to novels like Across the River and Into the Trees.

It’s impossible to predict what should have happened, of course, if so many writers had not become addicted to alcohol, but it’s impossible not to mourn as teetotaler Sinclair put it, “the loss of productivity, the absence of joy.”

Ann Waldron is a writer in Princeton N.J., and the author of Close Connections, a biography of Caroline Gordon.

TO ALL CONCERNED WITH THE DRUG-CRIME EPIDEMIC

By James R. Milam, Ph.D.

November 17, 1995

  • “In my opinion, interdisciplinary work does not mean the meeting of specialists in different disciplines, but rather the meeting of different disciplines in the same individual–an adventure that our system discourages, when it does not absolutely forbid it.” – LUCIEN ISRAËL, Conquering Cancer (1978)

Since its publication (some 30,000 original circulation) copies of the enclosed paper, The Alcoholism Revolution, are continuing to spread, and there is now clear evidence that this definitive statement is transforming scientific and professional understanding of addiction, inspiring a cleanup of the peer review scandal, and profoundly influencing pending healthcare and criminal justice reforms. Major media stories are already reflecting the more positive attitudes toward treatment and recovery.

Meanwhile, with only stop-gap measures available to address the social and fiscal crises of our time, there is a continuing urgency for this rectifying information to be more widely available in its present form. So I have mailed evolving versions of this letter with its enclosures to scientists, professionals, government officials, media members and others who by their cumulative actions and influence will help to finally put a stop to this cultural calamity. To this end, I ask that you read this information thoughtfully, and share it with still others.

As early responses indicate, The Alcoholism Revolution speaks eloquently for itself, but it is also necessary to address what may otherwise still seem to be an insurmountable obstacle to the more general dissemination of this “heretical” material. Some members of the broader scientific and professional community have been constrained, without substantive comment, to hold the paper in abeyance as extreme, or premature. The reason is as obvious as it is absolute. Everything in the paper is anathema to the long established peer review consensus in alcoholism. There is no interdisciplinary mechanism of substantive appeal, no higher scientific authority, and it is unthinkable for official scientific spokespersons to violate the sacrosanct hegemony of an intradisciplinary peer review procedure. Neither they nor the communications media have had any way to know that in the field of addiction research this obstacle has been more apparent than real. Thus the fact that the peer review process has long been corrupted and subverted is a necessary part of the story of the alcoholism revolution.

Over twenty years ago Mark and Linda Sobell began publishing research reports alleging that controlled drinking was a viable treatment option for alcoholics because having trained twenty to do so, “…many engaged in limited, nonproblem drinking throughout the followup period.” The Maltzman, Pendery, and West investigations (The Winter of Scholarly Science Journals, enclosed) found that both during the Sobell followup and continuing through 1981, with the exception of one patient whose initial diagnosis was questioned, all had been drinking alcoholicly, with multiple hospitalizations and incarcerations. Four had died of alcohol related causes, another had disappeared while drinking, and six had resorted to programs of total abstinence. None had been drinking non-problematically.

Peer review then denied relevant journal access to Maltzman and the other whistle-blowers, as an “investigative” panel of Sobell cohorts castigated the critics and absolved the Sobells, characterizing their research reports as “perhaps too enthusiastic.” The Sobells were defended on the ground that the control group, instructed by the Sobells to abstain, fared no better than those taught to moderate their drinking. This diversionary point is, of course, irrelevant to the fact that the Sobells blatantly lied about their critically important data.

It would be hard to overstate the enormous impact of the Sobells’ “demonstration” on both science and public policy. It was insider knowledge that all other attempts to justify the denial of physical addiction had instead confirmed it that put such heavy pressure on the Sobells to falsify their data, and that made their bogus reports the most widely cited and most influential in shaping the academic addiction literature through the 1970s and ‘80s.

In parallel, by the 1970s the academic chorus of denial, with Timothy Leary singing the lead, had successfully promoted marijuana as a completely harmless, nonaddictive recreational drug with no physical consequences. There was then a sharp rise in cocaine use. At the first sign of public alarm President Carter’s drug czar, psychiatrist Peter Bourne, quelled the concern with a reassuring White House bulletin: “Don’t worry about cocaine. It’s among the most benign of all drugs in widespread use.”

Herbert Fingarette’s 1988 book, Heavy Drinking, was pivotal in the abrupt national regression from the emphasis on intervention and treatment of addicts to almost complete reliance on condemnation and punishment of “abusers.” He cited the Sobells’ reports twenty times in his argument that there is no such thing as physical addiction, that abstinence treatment is both unnecessary and ineffective. Since it had been scientifically proven that alcoholics can learn to drink moderately, society should demand that they do so, and punish them if they don’t. Thus his primary contribution was to elevate the big lie to public prominence and respectability, supporting Stanton Peele’s raucous sound-bite presentation of it in the media. Incredibly, Fingarette has been the US representative on addictions to the United Nations, which explains the global ignorance of the scientific paradigm shift that has occurred behind the scenes of denial in this country, and our meager distorted information about how other countries are coping with the drug crisis.

Fingarette’s gullibility was one thing, but why was society so ready and willing to be duped? The answer was in the changing composition of society. By 1988 members of the aging baby-boom generation were ascending to society’s levers of control. Reared within the academically sanctioned drug culture of denial of addiction—the diabolic spawn of the older moralistic ignorance of addiction—they were programmed to believe that theirs was the enlightened view, and from the beginning consensual validation had precluded any concern with evidence. In flipping society back into its old moralisms, the task was not so much to persuade as merely to pander to the mind set of this rising majority—denial imbedded in ignorance. Never mind that Fingarette’s evidence and argument were specious. Who but a cross-threaded voiceless minority could know?

Although never mentioned in the long lists of psychosocial risk factors blamed for the growing problem of “drug-abuse,” clearly all such factors are preempted by this big lie—the denial of physical addiction—the seminal crime in the drug-crime epidemic. This deception alone, the cultural message that drugs are nonaddictive, and harmless when not being abused, fully accounts for the drug epidemic. Absent the truth freedom of choice is counterfeit, freedom of speech a mockery, and support for the proposal to decriminalize drugs a capitulation to the hoax that generates the problem.

Citing the failure of alcohol prohibition, blaming the current crime epidemic on the fact that drugs are illicit, is as disingenuous as reciting the psychosocial risk factors. While cocaine and other such drugs were legal up through the first decade of this century there was a major drug epidemic. Finally realizing that the drugs were destructively addictive for most users, the public rallied in full support of the Harrison Act, outlawing the drugs, and the epidemic subsided. According to historian David Musto, “Drug prohibition was a complete success.” The difference was that smirking members of academia and a huge entertainment industry were not flouting the law and, through a disinformed press, continuing to promote recreational use of drugs. On the other hand, one major reason alcohol prohibition failed is that for nine out of ten drinkers, regardless of how, why, how much or how long they might choose to drink, alcohol is not an addictive drug, and for them moderate recreational drinking truly is a valid option.

No, psychosocial “risk factors” are not causes of addiction. Along with the big lie, they help to determine exposure, but the cause is the addictive chemical in a biologically susceptible individual, and most drug users are addicted. It is not just the acute drug effect or the illicit drug seeking that are a problem. They are just the beguiling visible tips of the massive addiction-crime connection. Note that tendencies toward violent behavior have always been with us, and that psychosocial factors have always been precipitating causes. As explained in The Alcoholism Revolution, persisting even after drugs have cleared the blood stream, the chronic brain syndrome of untreated addiction increases (neurologically augments) all destructive response tendencies, thus escalating both the frequency and intensity of overt expression of these normally more controlled impulses. Rates of suicide and homicide and all other crimes and excesses are greatly increased regardless of the ready availability of drugs or alcohol. But with addiction commonly excluded from the consideration of causes, and drug use and “abuse” viewed as incidental symptoms, the cause of the whole inflamed response is attributed to the person and to the familiar psychosocial triggers, as though age old sexual tension, domestic conflict and social injustice somehow in recent generations have become extremely provocative of destructively insane behavior. Alternately, it seems that a failed morality has unleashed this abusive torrent, when in fact, naively thrust to the decoy front in this quixotic war, morality has been blind sided and savaged by the camouflaged foe of addiction. Unable to account for the pandemic destructive behaviors, the media can only describe them, as weird, strange, out of character, irrational, bizarre and mysterious.

The familiar comes to seem normal, but the cumulative loss of civilities and moral sensibilities has been devastating as for three decades the whole of society has been contagiously coarsened to accommodate this misattribution of the insanity of addiction. Through screaming music the nihilistic effluvium of toxic brains has been imprinted as social commentary on the brains of each new generation of innocents, the maudlin agonizing of dying brain cells has been flatteringly mistaken for existential angst, senseless violence has been viewed as social protest, and peeing on cultural icons has been hailed as an avant-garde art form.

And it is through this misattribution that society has unwittingly subsidized and enabled addiction by guiltily trying to assuage its abusive consequences instead of demanding and enabling clean and sober recoveries. Predictably, insane behavior, crime, and poverty have increased in proportion to ever increasing expenditures devoted to their reduction. Thus did the drug culture of denial and misattribution assure that all of the heroic social engineering and fiscal gymnastics intended to create the great society would instead produce the great alibi society, this blundering bankrupt world of psychobabble and victimhood.

And no, informing the addict that he has a disease does not let him off the hook for his bad behavior, as widely proclaimed. On the contrary, it is the only convincing way to put him on the proper moral hook, the enforceable imperative to do whatever it takes to get clean and sober, and stay that way, as the only way to heal the brain syndrome that produces the destructive behavior. When coerced into treatment, once detoxified and returned to sanity and selfhood virtually all patients gratefully accept this truth and its moral obligation—if presented unequivocally and explained thoroughly—and become self-motivated. Most fully recover, even many of the “hopeless.” None recover when their psychosocial alibis and complications are mistaken for causes.

By 1988 the lucrative exploitation of the addiction treatment industry by the “substance abuse” mentality had burgeoned out of control, and it was easy to contrive the public backlash against this “rip-off industry.” Contrived, because it was the same Sobell alliance that fostered the exploitation and then orchestrated the media blitz. They focussed the attack not on their own zero recovery psychogenic programs, but exclusively against the “disease concept.” During the two decades of peer review subversion, scientific evidence proving the high cost/effectiveness of the abstinence oriented programs had been purged from public view. Bereft of scientific legitimacy, they were helpless to differentiate themselves or to defend against the attack, and the voice of recovery disappeared from the national dialogue. Well over half of the better private inpatient programs, ranging downward from eight thousand dollars per treatment sequence and yielding full recovery rates of some two-thirds, have been forced to close, and most of their financially starved public funded counterparts have been compromised to become cheap but extremely costly revolving doors. Meanwhile, at some $25,000 per inmate, per year, the prisons are bulging with alcoholics and drug addicts whose predictably recurrent crimes and incarcerations are secondary to the insanity of unrecognized or wrongly treated addiction.

The surviving treatment programs remain impotent pending public disclosure of the truth, and in their silence we hear the loud replay of the hostile code words of the truly failed psychogenic strategies of the 1970s, “We need to try alternative treatments.” The 44 of these highly varied “alternative” programs in the notorious Rand followup study (including anger management, harm reduction, and dual diagnosis treatments) cruelly provided temporary diversions, but uniformly yielded zero recoveries from this progressive fatal disease. Their future failures are predictable because in their inverted view of cause and effect, addiction doesn’t cause dysfunctional behavior, dysfunctional behavior causes substance abuse (John Bradshaw). If we learned anything from the 1970s it was that increased funding of this wrong premise in whatever guise only produces more colossal failures. So keep your eye on the really big money, in the “dual-diagnosis” replay, and the other Trojan Horses–the “harm reduction” and “moderation management” programs that also smuggle the alcoholics’ old alibis back in as causes.

But enough already of the 50-year obsession with alternatives to what works–the cosmetic tweaking and fiddling within the failed paradigm. As sincere curiosity and respect replace programmed ignorance and contempt, academics can discover and help improve, and multiply, the effective abstinence programs. Just honest scientific validation replacing dishonest disparagement will significantly increase patient confidence and therefore treatment effectiveness.

Take heart from the many signs that the revolution is under way, and gaining momentum. In a historic preemptive move, early in 1994 the principal culprits in the subversion of peer review were very visibly hooked off the academic center stage into the wings. Confronting the ensuing disarray, top officials of the American Psychological Association then suspended their campaign to subordinate addiction to mental health, appealed to their biologically oriented members to assert new leadership in this area (APA Monitor, July, 1994), and began a reassessment of peer review procedures. To the same end, top government agencies have just announced prophylactic peer review changes required for future research funding.

Alas, in a face-saving stall some members of the old guard are now attempting to trivialize the biogenic model by equating addiction with the nerve-transmitter effects of heavy drinking, the normal effects also produced by heavy drinking in nonalcoholics, and similar to the effects of excessive running or stamp collecting. But this denial of genetic susceptibility to addiction will not long prevail because enlightenment is spreading too fast, and government alcoholism and drug funding priorities are already shifting to support remedial professional education and training in the disease of addiction. Of course, the broader default position is still psychogenic. Even with unlikely retractions by the Sobells and their cohorts or published repudiations, it could take many years to glean enough valid information from the chaff comprising the vast inverted “substance abuse” literature to assemble the biogenic paradigm. On the other hand, as growing awareness of the true gestalt reaches a kind of critical mass, in an edifying figure-ground reversal the whole academic literature can be quickly flipped right side up.

In a most promising parallel development, the American Bar Association Task Force on the Drug Crisis has recently discovered and adopted the biogenic model.

It is also evident that the broader public pendulum has started to return from its extreme swing to interdiction and punishment. Drug courts are proliferating, and growing numbers of reformers are discovering the hard data confirming the enormous reduction in crime and healthcare costs following comparatively small investments in effective addiction treatment. So now the really huge question is this: To what will the pendulum return? Will selected addicts merely escape the revolving prison doors to join the throng still cycling in the traditional zero recovery healthcare and welfare caseloads, and the financially compromised revolving door programs? Or will there be a substantial reduction of all caseloads through enlightened leadership and rigorous measures of prevention, intervention and treatment of the core problem, addiction? Heaven help us if we merely continue to follow the advice attributed to Yogi Berra, “If you come to a fork in the road, take it.”

Alcoholics Synonymous: Heavy drinkers of all stripes may get comparable help from a variety of therapies

By BRUCE BOWER

From: JANUARY 25, 1997 SCIENCE NEWS, VOL. 151 62-63

Psychotherapy studies rarely generate as much anticipation as Project MATCH did. Mental health clinicians and addiction researchers anxiously awaited the results of this 8-year, $27-million investigation that asked whether certain types of alcoholics respond best to specific forms of treatment. The federally funded investigation promised to yield insights that would bring badly needed .guidelines to alcoholism treatment and perhaps allow clinicians to tailor the current hodgepodge of approaches to the particular needs of each excessive imbiber.

The coordinators of Project MATCH have finally served up their findings, but with a shot of disappointment and a twist of irony. At a press conference held last December in Washington, D.C., they announced that alcoholics reduce their drinking sharply and to roughly the same degree after completing any of three randomly assigned treatments.

Trained psychotherapists administered the three programs. In 12-step facilitation therapy, the therapist familiarizes the client with the philosophy of Alcoholics Anonymous (which treats alcoholism as an illness treatable only through abstinence, support from other addicts, and personal surrender to God’s spiritual authority) and encourages attendance at AA meetings. Cognitive-behavioral coping skills therapy focuses on formulating strategies for avoiding or dealing with situations that tempt one to drink. Motivational enhancement therapy helps clients to identify and mobilize personal strengths and resources that can reduce alcohol consumption.

Treatment matching has operated on the assumption that alcoholics fall into categories best served by particular strategies. For instance, 12-step facilitation therapy and AA might work best with alcoholics searching for spiritual and religious meaning in their lives, cognitive-behavioral therapy may suit alcoholics who display serious psychiatric symptoms and thinking difficulties, and motivational enhancement could act as a tonic for heavy drinkers who express little desire or hope for improvement.

The new findings, however, “challenge the notion that patient treatment matching is necessary in alcoholism treatment,” states Enoch Gordis, director of the National Institute on Alcohol Abuse and Alcoholism (N1AAA) in Bethesda, Md. “The good news Is that treatment works. All three treatments evaluated in Project MATCH produced excellent overall outcomes.”

Despite Gordis’ optimism, opinions diverge sharply regarding the study’s implications and the adequacy of its design. Some alcoholism researchers agree with the NIAAA director. They view Project MATCH as a critical step toward the ultimate goal of developing sophisticated therapeutic approaches that thwart the suspected biological causes of uncontrolled alcohol use.

Others dub the federal effort an expensive dud. The absence of a control group of alcoholics who received no specific intervention raises the likelihood that volunteers improved because of intensive personal attention and encouragement rather than any specific treatment techniques, these investigators argue. At best, they contend, the data suggest that AA and other free self-help groups prove effective enough to replace professionally administered alcoholism treatments that command big insurance bucks.

A third perspective holds that flaws in the design of Project MATCH leave open the possibility that many alcoholics benefit from treatment matching or could abandon their addiction on their own, outside the world of clinical interventions and AA.

Scientific interest in developing treatments attuned to alcoholics individual characteristics goes back at least 50 years. More than 30 small-scale studies published during the 1980s reported that treatment matching based on a number of individual characteristics held promise for alleviating alcoholism. In 1989, the NIAAA Initiated Project MATCH (which stands for matching alcoholism treatments to client heterogeneity) to examine closely the most promising of those leads.

A total of 1,726 people diagnosed as alcohol-dependent (a condition marked by daily intoxication or extended drinking hinges that disrupt home and work activities) were recruited from outpatient clinics or facilities that provide care following hospital stays. The volunteers were randomly assigned to one of the three designated treatments, which were delivered over 12 weeks at 30 locations by 80 psychotherapists.

Individuals also dependent on drugs other than alcohol were excluded from the study, although more than one in three volunteers reported having recently used an illicit substance.

Alcohol use was monitored for 1 year after treatment ended, with particular attention paid to the influence of the following individual characteristics on recovery: sex, extent of prior alcohol consumption, the presence of psychiatric symptoms, aggressive and criminal tendencies, difficulties In thinking and reasoning, motivation to change, desire to lind meaning in life, and number of family members and friends likely to promote continued alcohol abuse.

Comparably large drops in alcohol consumption occurred for participants after courses of either 12-step facilitation, cognitive-behavioral, or motivational therapy, according to the N1AAA investigation, which appears in the January JOURNAL OF STUDIES ON ALCOHOL Before treatment, volunteers, on average, drank on 25 out of 30 days, a number that fell to 6 days of drinking per month by the end of the follow-up. The amount imbibed on drinking days also dropped markedly after treatment.

In the year of follow-up, 35 percent of volunteers reported not drinking but 40 percent still had periods of heavy drinking on at least 3 consecutive days.

Only one individual characteristic affected treatment responses, notes psychologist Gerard Connors of the Research Institute on Addictions in Buffalo, N.Y., a Project MATCH investigator. Alcoholics exhibiting few or no signs of psychological disturbance achieved abstinence through 12-step facilitation therapy more often than those with pronounced mental symptoms.

It remains possible that treatment methods not included in Project MATCH, such as group or marital therapy, work especially well for certain types of alcoholics, Connors notes.

For now, Gotelis contends, it appears that individual therapies based on a variety of philosophies make approximately the same dent in alcohol use. The development of new drugs that diminish alcohol cravings (SN: 3/16/96, p. 167) will add to the impact of current psychosocial approaches, he holds.

“Treatment matches may become apparent when we get to the core of the physiological and brain mechanisms underlying addiction and alcoholism,” Gordis asserts

Since the Project MATCH results were first openly discussed at a meeting of alcoholism researchers in Washington, D.C., last June, a dissenting interpretation of their significance has been advanced. Because encouragement to attend AA meetings achieves as much as the two professionally administered treatments under study, according to this view, free self-help groups for heavy drinkers may pack enough punch to justify abolishing insurance coverage for paid treatments. The self-help groups are organized by volunteers and supported through donations. “The Project MATCH findings support the idea that selling treatment for heavy drinking alongside free self-help programs such as AA is like selling water by the river, to coin a Zen saying,” contends psychologist Jeffrey A. Schaler of American University in Washington, D.C. “Why buy when the river gives it for free?”

Moreover. the lack of a nontreatment control group that received as much regular attention and support during the 1-year follow-up as the group given treatment makes it impossible to tell whether any of the Project MATCH interventions had a specific impact, asserts psychologist Stanton Peele, a clinician and writer in Morristown, N.J.

Even if the interventions did work, the findings apply only to the minority of alcoholics who voluntarily enter treatment in clinical settings, Peele argues. A majority of those who seek professional or AA-type treatment for substance abuse in the United States do so on the orders of judges (following arrests for drunk driving or other offenses) or employers, according to federal data. .

Recovery from alcohol dependence or milder alcohol abuse most often occurs outside the confines of hospitals, psychotherapists’ offices. or self-help groups, further undermining confidence in such treatments, Peele adds.

For instance, a pair of Canadian telephone surveys—one nationwide and one in Ontario—find that of the randomly selected adults, three in four who had recovered from an alcohol problem 1 year or more previously did so without any outside help or treatment. About one in three of those who recovered in the national sample continued to drink in moderation, a figure that rose to two in three in Ontario, report psychologist Linda C. Sobell of Nova Southeastern University in Ft. Lauderdale, Fla., and her coworkers in the July 1996 AMERICAN JOURNAL OF PUBLIC HEALTH.

Similar results emerged from an analysis of interviews conducted in 1992 with 4,585 U.S. adults who had at some time been diagnosed as alcohol-dependent. In the year before the interviews, about one in four still had mild to severe alcohol problems, a similar proportion had drunk no alcohol, and the rest had imbibed in moderation, asserts NIAAA epidemiologist Deborah A. Dawson.

Those who had received some sort of treatment were slightly more likely than their untreated counterparts to have had alcohol problems in the past year, Dawson reports in the June 1996 ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH. For those whose recovery lasted 5 years or more, prior treatment raised the likelihood of abstinence, whereas lack of treatment upped the chances of drinking in moderation.

“Treatment studies may not be generalizable to alcoholics who do not seek treatment,” Dawson concludes.

Peele, who views alcoholism not as a medical disease but as a learned behavior employed to cope with life’s challenges, goes further. Such evidence, combined with the fact that the expansion of treatment rolls during the past 20 years has failed to reduce substance abuse rates, indicates that professional and AA-type approaches often present more risks than advantages to alcoholics, particularly those coerced into treatment, he contends.

George E. Vaillant, a psychiatrist at Brigham and Women’s Hospital in Boston and director of a 50-year study of male alcoholics (SN: 6/5/93, p. 356), takes a much less radical stance than Peele, although he still has reservations about the design of Project MATCH.

Alcoholics Anonymous and behavioral interventions such as those in the NIAAA investigation provide more help over the long haul than any other forms of treatment, without regard to the personal characteristics of alcoholics, Vaillant argues.

“The Project MATCH findings are exactly what I would have predicted,” the Boston researcher says.

In his opinion, researchers need to examine differences between alcoholics who succeed in recovering and those who fail, rather than limiting themselves to a search for contrasts among professionally ran treatments.

Sustained recovery requires at least two of the following experiences, Vaillant theorizes: some sort of compulsory supervision (such as parole) or a painful alcohol-related event (such as a bleeding ulcer or a spouse’s departure); finding a substitute dependency, such as meditation or AA meeting attendance; forming new, stable relationships that diminish addictive behaviors; and reformulating personal identity and the meaning of one’s life through religious conversion or serf-help group participation.

Such factors went unexamined in Project MATCH, according to Vaillant. Most notably, large segments of all three treatment groups attended AA meetings (and were not discouraged by researchers from doing so), thus obscuring the role played by AA in successful recoveries, he argues.

“Project MATCH was poorly designed, to say the least,” asserts psychologist G. Alan Marlatt of the University of Washington in Seattle, a pioneer in the development of behavioral treatments for alcoholism. “Everybody can now project their own views about alcoholism onto this study.”

Aside from the lack of a control group, the federal study also failed to evaluate directly the practice of patient matching, Marlatt holds. Volunteers were assigned to certain treatments not according to specific personal characteristics but at random; researchers tried to ferret out traits linked to improvement after therapy began.

In addition, the relatively “pure” alcoholics recruited for Project MATCH may respond to treatment differently than the majority of alcohol abusers, who regularly use one or more illicit drugs as well, Marlatt says.

While many questions remain about the effectiveness of alcoholism treatments, several psychotherapy studies—including a large federal study of depression treatments (SN: 1/11/97, p. 21)–find that some therapists are far better than others at fostering Improvement In their clients. The quality of the relationship between a therapist and an alcoholic client probably exerts a major influence on how well a particular treatment works, Marlatt suggests.

To put it another way, therapist-client matching may turn out to hold at least as much research promise as patient-treatment matching–especially since the value of patient-treatment matching, at least for now, remains unclear.

The Alcohol and Tobacco Industries Should Have Same Standard

By Jim Gogek and Ed Gogek

While the tobacco industry cowers under a fusillade of million-dollar lawsuits, government regulations and condemnation from all sides, another industry sells its highly addictive and dangerous drug in peace and harmony.

This billion-dollar industry openly manipulates the drug content of its product, catering to addiction. They pitch their ads to youth, presenting the drug as glamorous and hip. And unlike tobacco, they can still advertise on TV.

While the tobacco industry has rightfully become our nation’s corporate pariah, the alcohol industry has been ignored.

Beer, wine and liquor companies nave managed to avoid the spotlight with slick advertising campaigns that condemn underage drinking and drunk driving while encouraging “responsible” use.

The ads present an image of genteel drinkers who nurse one glass through a whole evening, or athletic hard bodies who can quaff a brew or two and never appear drunk

Since most Americans are either teetotalers or occasional drinkers there’s an automatic tendency to assume those ads present an accurate picture of drinking in America.

But they don’t. While most people drink moderately — one or two drinks on occasion — that’s not where the alcohol industry makes its money. The Alcohol Research Group in Berkeley has compiled surveys of thousands of drinkers. They found that heavy drinking supports the industry.

Among adults, 5 percent of the population drinks 60 percent of all alcoholic beverages sold. Half of all alcohol is consumed by heavy drinkers — those who drink an average of nine drinks every day.

Most of these are problem drinkers or alcoholics, people so addicted to alcohol they can’t quit without help. Many of the rest are reckless binge drinkers.

This research leads us to question the beer, wine and liquor ads that make it sound like the industry only wants people to drink in moderation. Does this industry really want to eliminate over half its income? Probably not.

What’s more likely is that the alcohol industry wants to avoid the tobacco companies’ nightmare. They want to avoid the public perception that they make their money off people who are addicted, or that they try to get young people started.

But if they’re not after the youth market, why have they introduced so many cheap, sweet wines and wine coolers? Alcohol that looks and tastes like soda pop appeals to kids as surely as Joe Camel ads. And if the industry isn’t catering to the addicted or to young abusers — people who drink only to get drunk— then why are they selling highly fortified wine and malt liquor?

Increasing the alcohol content of wine and beer is no way to encourage “responsible” drinking. And it’s no different than the accusation that tobacco companies manipulate nicotine content. If a cigarette smoker has grounds to sue the tobacco industry for attempting to addict people to nicotine, then a street drunk hooked on Night Train or Cisco could use the same argument.

The alcohol and tobacco industries have a lot in common. Both depend financially on people who are addicted. Both profit from people who use their products dangerously. Both target young people.

Tobacco companies have been accused of manipulating drug content; alcohol companies surely do. Both advertise heavily to the poor and minorities. And both sell products that kill huge numbers each year.

In deaths directly attributable to the drug, tobacco is the bigger killer, claiming 400,000 lives per year to alcohol’s 100,000. And the $20 billion a year in tobacco-related medical costs beats alcohol’s $10 billion.

But alcohol has some ugly statistics of its own. Alcohol is responsible for nearly half of all traffic fatalities. Two-thirds of all murders in the United States involve alcohol. It’s also a major cause of child abuse, domestic violence, welfare dependency and homelessness. Secondhand smoke pales in comparison.

It’s obvious why our society is taking aim at tobacco companies. But why is the alcoholic beverage industry getting off so lightly?


Jim Gogek is an editorial writer and columnist for the San Diego Union Tribune. Ed Gogek is a Phoenix-based psychiatrist who works in community mental health. © 1996 NY Times Features Syndicate.

ALCOHOLISM: SOCIAL AS WELL AS PSYCHO-MEDICAL PROBLEM– THE MISSING “BIG PICTURE”

By Arthur G. Nikelly

McKinley Health Center University of Illinois at Urbana

JOURNAL OF ALCOHOL & DRUG EDUCATION Spring 1994, pp. 1-12

ABSTRACT

Precapitalist societies did not experience severe problems with alcoholism as they exist today. The broad parameters associated with alcohol abuse have not been explicitly investigated by alcohol educators and researchers. Instead, they focus on group influences and stress individual responsibility to curtail alcohol abuse. Seeking the causes of alcohol abuse within the person diverts attention from the invisible economic, political, and social parameters that promote the lucrative industry of alcohol production and consumption. Advertising earnings and tax revenue from alcohol consumption are dominant economic motives that overlook the social costs. The remedy has been to treat the victims of alcohol abuse rather than to challenge the strong economic and political incentives that promote alcohol consumption. The proposed solution is for economic and political interventions to take precedence over individual education and treatment, making alcohol a highly taxed, and a less “visible” and available commodity. Educational institutions can create environments in which alcohol becomes less important in the lives of students.

HISTORICAL PERSPECTIVE

Ethnographic observations of primitive societies suggest that the consumption of alcohol was controlled by sanctioned social customs, that the pathological consequences of alcohol abuse were infrequent, and that the consumption of alcohol had ritualistic, medicinal, and religious uses (Singer, 1986). Although primitive societies produced alcohol, no pathological consequences were associated from its consumption because drinking occurred within a stable social structure and was socially controlled and ritualized. A case in point is African nations that did not experience serious problems with alcohol abuse until the introduction of western alcoholic beverages and their promotion by the mass media. Even earlier, however, colonialism fostered a cash economy that destroyed indigenous subsistence economies and created a large unemployed population that lost dignity and self-esteem. Brewing originally took place in family settings and was a traditional ritual, culturally sanctioned and socially controlled. Post-colonial systems made alcohol available through profitable commercial outlets. Thus, the economic system encouraged social and economic stratification. Producers and distributors enjoyed financial gains and the traditional mode of regulation was destroyed.

Multinational enterprises seek to penetrate and “westernize” underdeveloped countries by promoting consumer products that are not related to such basic needs as nutrition, education, health care, and housing. Moreover, these enterprises often cultivate a single crop for export, thus depriving the local people of the opportunity to raise traditional staples for their own diets. Having lost their arable land, they became low-paid wage earners who were forced to buy imported food from other countries (Elling, 1981). Foreign corporations that seek to make a profit in Third World countries often establish economic domination and create poverty, deculturation, social stratification, and the dissolution of community cohesiveness–ideal conditions for increased alcohol consumption (Singer, 1986).

The situation in pre-industrial England was not so different from the circumstances in underdeveloped countries today. In the easy-going household workshops and cottage manufacturing of pre- industrial England, drinking meant friendship and sociability. With the advent of the industrial revolution, however, a new class of working people was created, apart from the wealthy owners of the large industries, and their heavy drinking was, to a large extent, associated with their subordinate and exploited status and to the cheaply produced and readily available distilled spirits (Sennett & Cobb, 1972). Alcohol abuse occurred in England during the industrial revolution when workers were alienated from the products of their labor and the unemployed were living in poverty. Under these conditions alcohol was consumed to obtain relief from stress and oblivion from misery (Jacobson, Hacker, & Atkins, 1983).

The spread of capitalism, often in the service of “God and profit,” forced workers to concentrate in urban industrial centers and fostered the emergence of a working class. These populations subsequently became vulnerable to social instability and economic fluctuations (Wolf, 1982). Thus, the industrial revolution transformed people’s lives by expanding commodity markets to alcoholic beverages. Dependency on alcohol promotes consumerism and enhances profits. For the same reasons North American and European conglomerates today admit to seeking new markets for their products among women and Third World countries (Jacobson, Hacker, & Atkins, 1983).

OBSTACLES TO THE CONTROL OF ALCOHOLISM

Solutions for alcoholism are sought according to how alcohol abuse is defined. Alcoholism is generally studied as the manifestation of either a personal or social problem that often involves family conflicts, personality characteristics, or interpersonal problems. The emphasis has been on the individual alcoholic, as if the rest of the world that produces and promotes alcohol did not exist.

INDIVIDUALISTIC SOLUTIONS

The suggested remedy for the addictive use of alcohol has been, for the most part, to teach healthier life styles. The compelling influence of advertising and the devastating effects of social stress and economic pressures that bring on or are associated with alcohol abuse are rarely mentioned as etiological variables. Instead, most persons assume that illness aggravated by the social environment should be solved on a case by case basis by “professional” medical intervention or through individual actions. As a result, a collective assault on the causes of alcoholism–which are social–is way laid. Thus does the medical profession, perhaps unwittingly, serve the interests of those in power and strengthen the status quo (Sanders & Carver, 1985)?

Medical practices are currently based on the assumption that problem drinkers must learn to adapt to an environment that is often the primary cause of their alcohol abuse. Therapy groups, for example, are formed to accommodate students raised with alcoholic parents; yet no measures are taken to alter the economic conditions that in all likelihood are associated with problem drinking. The result has been an increase rather than a decrease in problem drinking (Hasin, Grant, Harford, Hilton, & Endicott, 1990).

The focus on diagnostic techniques and consultation and the emphasis given to counseling, psychotherapy, re-education, and rehabilitation fail to recognize the real issues–the endemic economic structures that support alcohol consumption. Indeed, the mental health professions have been little concerned with economics, focusing instead on the individual and overlooking the importance of the socioeconomic structure. Unwittingly, for the most part, these professions attribute the responsibility for change to the individual, yet, the conditions that increase pathology, stress, maladjustment, and alienation are part of a wider political and economic system (Lerner, 1973; Goldenberg, 1978).

Consider, for example, the following incident: Alarmed over increasing alcohol abuse among students at a large academic institution, officials with the aid of health advocates and educators initiated awareness programs, prevention workshops, and peer education. When the city’s mayor and bar-owners were asked to cooperate in the prevention of alcohol abuse, all agreed in principle with the alcohol awareness and prevention program but asserted that it was the responsibility of the consumer to decide on the amount of alcohol intake. The mayor argued that curtailing the consumption of alcohol would deprive the city of valuable tax revenues. The response to such inconsistencies has been mainly autoplastic, that is, the individual is expected to change, to cope, and to adapt; health is considered to be a personal rather than a structural issue.

SOCIAL CONTRADICTIONS

Western society tacitly propagates a self-contained individualism that gives impetus to an acquisitive drive that leads to economic exploitation. In the business world, for example, misleading and confusing information is often used to win consumers without considering the effects of the product on the health of the user. Alcohol advertising, for instance, is countered by warnings from the health professions, but the individual is expected to sort out the contradictory information and make a rational decision. Attempts to undertake prevention programs against alcohol abuse are often met with resistance from those who hold power in the society. Still another inconsistency inherent in the free enterprise system is disdain for those who cannot postpone immediate pleasures for future rewards. At the same time, an endless array of goods that urge wasteful spending and the surrender to hedonism are paraded that encourages immediate gratification and the deferment of less selfish goals.

THE POLITICS OF ALCOHOLISM AS A DISEASE

The notion that alcoholism is a disease has serious limitations because it implies treatment for an illness and absolves any blame for being “ill.” Alcoholism as a disease presupposes that medical intervention will effect a cure (Kendell, 1979). The accepted procedure, therefore, is to confront the alcoholic with diagnosis, treatment, re-education and rehabilitation, rather than punishing the abuser with fines and incarceration (Park, 1983). Thus, the “sickness” model commodifies treatment, creating a market that enhances the growth of the health industry. When alcoholism is defined as a medical issue, politicians are provided with an excuse not to make electorally unpopular legislative decisions, such as levying higher taxes on the sale of alcoholic beverages or restricting their availability. Further, politicians can rationalize their reluctance to forbid the advertising of alcohol because such regulation would violate the spirit of competition and free enterprise. Thus, the false impression is conveyed to consumers that normal persons who enjoy drinking are not likely to become alcoholic, and the alcoholic beverage industry is given free reign to produce, distribute, and promote its products without admitting to the public the potential dangers.

The evidence for alcohol abuse and dependence as due to metabolic disorders, physiological abnormalities, or heredity is generally inconclusive; rather, it is the prolonged and excessive use of alcohol that produces biological dependency (Kendell, 1979). These predispositions are likely to be the result of, rather than the cause of, heavy alcoholic consumption (U.S. Department of Health and Human Services, 1980). In addition, biological vulnerability to alcohol abuse is compounded by such overwhelming social factors as stressful life events and emotional conflicts. Vulnerability can also be reinforced through parental modeling and peer pressure and through repeated exposure to advertising (DeFoe & Breed, 1979; Singer, 1986). It should be emphasized that not all persons who are exposed to these circumstances will become alcoholics and that some may become alcohol abusers without experiencing any of them.

All alcoholics are not the same, and the causes of drinking are multiple. Inherited predisposition to alcohol is only one factor, and drinking patterns vary, often in terms of the social context and ongoing stress. Labeling alcohol dependency a “disease” does not absolve the abuser from moral responsibility. Thus, by assigning to the alcoholic a medical debility and moral weakness, the problem is privatized. In turn, the medical professions profit by offering their professional skills and the alcohol industry is absolved from blame and continues to market its products. The outcome: alcohologists become absorbed in the genetic pathogenesis of alcoholism on the one hand, and with the conflicts, stresses, traumata, personality structure, and ego defenses on the other. Thus, the victim is treated and may be changed, but the profiteering multinational alcohol-manufacturing complex is accepted as the normal condition of the society (Singer, 1986).

THE OVERLOOKED SOCIAL AND CULTURAL FACTORS

The consumption of alcohol is often associated with success and sophistication, it portrays the social norm, and it constitutes the “right” thing to do (Jacobson, Hacker, & Atkins, 1983). The production of alcohol is not only a lucrative venture but a manipulative strategy to placate people who are stressed and unemployed and who live in the margins of society (Kendell, 1979). Research shows a marked comorbidity between anxiety disorders and alcohol problems; the anxiolytic effects of alcohol reinforce drinking behavior which, in turn, has the potential to promote anxiogenic consequences from pathological drinking (Kushner, Sher, & Beitman, 1990). Heavy alcohol consumption that leads to serious behavioral problems that are beyond personal responsibility is best understood within the context of often overlooked “invisible” economic and political forces. These forces are associated with the dramatic increase in the incidence of alcoholism along with its secondary physical illnesses and its strong association with socioeconomic, cultural, and consumer values. However, even when alcoholism is the outcome of social, economic, and political forces, it does not make the alcoholic entirely blameless.

The correlation between the rising incidence of alcoholism, on the one hand, and mortality from hepatic cirrhosis alone can serve as an independent reliable index for alcohol consumption (Kendell, 1979). Describing trends in the field of mental health, Redlich and Kellert (1978) report that during the 25-year period between 1950 and 1975 there was a significant shift of diagnoses from schizophrenia to alcoholism, which has become a major nosological category that includes 46% of the inpatients in state hospitals, and this category also had the highest readmission rates.

The inexpensive process of distilling and brewing alcohol created an abundance of a cheap commodity available to working people. Consumption soon became heavier among the lower socioeconomic classes, as documented from the larger number of hospital admissions and police arrests. However, a closer examination reveals that persons among the poor classes are more apt to experience problems with alcohol intake because the outcome of their drinking is more visible to the public (Park, 1983). Class divisions have been used to show that alcoholism causes poverty, thereby exonerating an economic structure that exploits workers and maintains social and economic inequality.

The amount of alcohol and the manner in which it is consumed are largely shaped by cultural contingencies. For example, despite the associated stresses of industrialization, modernization, and technological progress in Taiwan and Korea, both Asian countries with the Confucian moral ethic of moderation and temperance, the prevalence of alcoholism in Korea is three times higher than it is in Taiwan (Helzer, Canino, Yeh, Bland, Lee, Hwu, & Newman, 1990). The difference is that Korean culture not only tolerates but encourages alcohol consumption; cultural support is shown by the public display of drinking that symbolizes male mastery, strength, and domination. On the other hand, not only is drunkenness disapproved of in Taiwan, but it denotes degeneration and personal weakness. A similar parallel is observed in the U.S. where alcohol consumption among students living in Greek-letter social organizations is higher than it is among the male college population in general. The explanation lies in peer-reinforced behavior supported by a subculture within the infrastructure of the fraternity system–a finding that has been confirmed by previous studies (Tampke, 1989).

THE ECONOMICS OF ALCOHOLISM

The study of patterns of alcohol consumption focuses mainly on naturalistic observations of drinking, on the sociological variants, and on the associated individual cognitive processes. Anthropologists have concentrated their study in isolated cultures and have related problem drinking with normative drinking which, in turn, is referred to the drinking pattern typical of the culture. But alcohol consumption is not a static phenomenon. Rather, the larger, insidious economic and political forces endorse the sale of alcohol as a lucrative commodity and influence consumption. Left out is an important aspect of the political economy that connects and integrates the consumption of alcohol with broader political and economic forces. Individual drinking behavior is best understood in terms of a broader commercial perspective, one that is defined by the relationship between capitalist production and consumption and by the expansion and hegemony of monopolies. The transnational character of the alcohol market and its vast promotional drive creates a $170 billion a year alcohol sales enterprise (Singer, 1986); over one billion dollars a year is spent in advertising campaigns in the U.S. (Jacobson, Hacker, & Atkins, 1983).

DeFoe and Breed (1979) randomly examined college newspapers and found that alcohol advertisements accounted for half of all advertising. These advertisements suggested that those who drink were smarter and happier than those who abstain, that beer can be a substitute for learning, and that alcohol relieves the pressures of college life. Alcohol advertisements exploited the frustrations and stresses of higher education and offered ephemeral escape without making any substantial contribution to the basic goals of education. The alcohol industry claims that its advertising in college newspapers is designed to switch drinkers from other brands to their own product. Compared with the Midwest, however, campus newspapers in the South carried nearly three times the amount of advertising, in a region that has the lowest per capita alcohol consumption. The alcohol industry obviously wants to solicit more consumers, especially those who are experimenting with alcohol and may choose a brand to consume for life. During the last thirty years, millions of university students established drinking patterns that will persist throughout their lives. These investigators contend that the same trend can be expected in the next three decades.

A similar study seven years later showed that the national advertising of alcohol had declined but that the volume of local alcohol advertisements remained the same and encouraged heavier drinking. More emphasis was given to the quality and taste of alcohol and to sponsoring cultural events and sports activities. Attempts were made to form a friendly alliance with students and to make the college environment more accepting of alcohol. Although skepticism exists over the direct influence of alcohol advertising on drinking behavior, constant exposure to advertising of alcohol consumption can reinforce beliefs about drinking behavior in young persons (Breed, Wallack, & Grube, 1990).

The consumption of alcoholic beverages has risen steadily since World War II, and drinking begins at an earlier age (Walsh, 1989). The steady increase in alcohol production and consumption is related to the broader growth of commodity production in industrialized societies in which alcoholic beverages are consumed in tandem with other new forms of commodities and foods (Single, Morgan, & Lint, 1989). In modern industrial economies, alcohol consumption is a significant source of tax and advertising revenue. Despite these economic developments, the tacit role of the state in the logistics of alcohol has been grossly overlooked (Makela, Room, Single, Sulkunen, & Walsh, 1981). The state condones the use of alcohol as it does the consumption of other beverages and foods; however, current policies place restrictions on the consumer rather than curtail the availability of alcohol. Problem drinkers are treated or punished, but the economic interests of the alcohol industry are rarely examined. Moreover, those directly engaged in treatment are not strongly interested in the economics of alcohol consumption. Similarly, those responsible for the production, promotion, and distribution of alcoholic beverages have little interest in prevention. Because alcoholic beverages can be produced cheaply and in large quantities, there is strong pressure to prevent saturation of the market and to expand it in order to assure continued profits.

Economic gains, however, have not been evaluated against social costs. If the government controls opiates, prescription drugs, controlled substances, and harmful food additives, why not alcoholic beverages? One obvious answer is that the control of alcohol in the interests of public health will be strongly resisted by the producers and retailers who have a vested interest in the production and sale of alcohol.

The state plays a significant role in promoting the alcohol industry because it supports the manufacture of a highly taxable commodity that benefits the economy. On the opposite side of the coin, the alcohol industry has the political means to influence the government, to sway it to adopt legislation favorable to the industry. The pro-wine industry of California, for example, is involved with agribusiness, which combines state and private power, and supports the monopoly of the grape owners by forcing small farmers to go out of business (Bunce, 1979).

The Bank of America, one of the largest assets in the U.S., consolidated the wine industry by financing California wine producers and threatening to withdraw lines of credit from producers who did not join the monopoly. Yet, the economic incentives of financial institutions that expanded the market for alcoholic beverages have not been cited as determinants of alcohol consumption in our society in general and on college campuses in particular. For instance, in 1947 the four largest alcohol producing companies controlled 26% of the industry; by 1972 their control had doubled to 53% (Bunce, 1979). The merger of brewing, soft drink, and distilled spirits manufacturers into “multiple beverage conglomerates” (Singer, 1986, p. 121) emerged in the 1980s and granted them the power to target their advertisements to specific groups. With strong control over the wine industry and a large capital investment in vineyards, wine consumption doubled in the 1970s.

PROPOSED SOLUTIONS

Many educators have lost touch with the larger social and economic problems of which the alcohol abuse of the individual is only a small part. Counselors concentrate on treatment rather than tackling social issues or challenging a system that fails to provide non-pathological alternatives to drinking. The dilemma has been whether to concentrate on economic reform that leads to a permanent solution or to provide educational or psychological assistance–a temporary remedy. The outcome of the prohibition era indicates that economic and political solutions are difficult to implement in a “free” society. More often than not, the approach has been to educate or to treat the victims of alcohol rather than to indict the political and economic incentives that promote the consumption of alcohol.

The causes of alcohol consumption and abuse are availability, commercial promotion, and weakening of social and legal restrictions, and class stratification (Singer, 1986). The vast majority of recommendations for the prevention of alcoholism, however, have been individualistic remedies that overlook the “big picture,” i.e., the social, cultural, and economic underpinnings of alcohol abuse. For instance, Tampke (1989) proposes that alcohol abuse can be curtailed through education: resistance to social pressures, enhancement of self- esteem, learning to cope with stress, and making responsible decision. On the other hand, Kendell (1979) argues that alcohol abuse is a political issue that requires, in large part, economic and social rather than medical or psychological solutions. He cites the dramatic increase in alcohol use and abuse during times when social sanction against consumption are reduced, when alcohol is readily available, when intense advertising campaigns are under way, and when lower prices prevail. By analogy, Kendell maintains that to reduce the excessive use of alcohol through medical and psychological interventions, is like trying to prevent war by offering better medical services to the wounded. The remedy he proposes is to influence the government to take legislative actions to make alcohol less available, highly taxed, and a less “visible” commodity of consumption.

Urging students to “say no” to alcohol constitutes a hollow solution that blames the victim. Neither does raising the drinking age eradicate alcohol abuse (Davis & Reynolds, 1990). Instead, counselors in colleges and universities need to become advocates for social change. Instead of “treating” students, they must establish a level of intellectual and emotional communication that relieves tension; they must encourage administrative flexibility and constructive change; they must foster respect for individual uniqueness (race, sex, ethnicity, class) and, most important of all, they must give students the opportunity to participate in decisions that enhance their self- esteem and promote personal responsibility.

Raising political and economic awareness, promoting social equality, ensuring student participation in the educational process, reinforcing feelings of solidarity with the academic community, and fostering peace with the physical environment– these are the broader and more pervasive responses to alcohol abuse. The logical conclusion is that treatment must focus on the dynamics of the free market that reflects a hierarchy of class and enslaves many in a patriarchal economic structure from which they cannot escape and for which relief is sought in alcohol abuse. Seeking the causes within the person lessens social dissent, directs attention for the social and economic underpinnings of alcohol abuse, and serves the interests of the market system (Baer, 1989).

REFERENCES

Baer, R. (1989). The American dominative medical system as a reflection of social relationships in the larger society. SOCIAL SCIENCE & MEDICINE, 28, 1103-1112.

Bunce, R., (1979). THE POLITICAL ECONOMY OF CALIFORNIA’S WINE INDUSTRY. Toronto: Addiction Research Foundation.

Breed, W., Wallack, J., & Grube, J.M. (1990). Alcohol advertising in college newspapers: A 7-year follow-up. JOURNAL OF AMERICAN COLLEGE HEALTH, 38, 255-262.

Davis, J.E., & Reynolds, N.C. (1990). Alcohol use among college students: Responses to raising the purchase age. JOURNAL OF AMERICAN COLLEGE HEALTH, 38, 263-269.

DeFoe, J.R., & Breed, W. (1979). The problem of alcohol advertisements in college newspapers. JOURNAL OF THE AMERICAN COLLEGE HEALTH ASSOCIATION, 27, 195-199.

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Please address correspondence to author at: University of Illinois Health Center 1109 South Lincoln Avenue Urbana, IL 61801