The Alcoholism Revolution
By James R. Milam, Ph.D., Clinical Psychologist
From: Professional Counselor, August 1992.
This conformity makes them not false in a few particulars, authors of a few lies, but false in all particulars. Their every truth is not quite true…so that every word they say chagrins us and we know not where to begin to set them right. — Emerson
No problem in America has been more costly in lives, misery and money than alcoholism, and no problem has generated more stubborn conflict and confusion in all areas of society. In a historic development during the 1970s, the intense focus on alcoholism research exposed the underlying polarity, the clash of irreconcilable premises that has always generated so much conflict. Although not yet widely known, by the early 1980s this root conflict had been resolved by a scientific and professional revolution, a paradigm shift.
This paper describes the polarity and the shift to the new model that is transforming our entire view of alcoholism (and other drug addictions). I have adapted the terms “psychogenic” (of psychological origin) for the old paradigm and “biogenic” (of biological origin) for the new.
The psychogenic model is based on the nearly universal belief that alcoholism is a symptom or consequence of an underlying character defect, a destructive response to psychological and social problems, a learned behavior. The biogenic model recognizes that alcoholism is a primary addictive response to alcohol in a biologically susceptible drinker, regardless of character and personality. It will help at the outset to realize that compromise is not possible, that the two are not complementary but mutually exclusive alternatives, like a perceptual figure-ground reversal.
The contrast between the two paradigms can be illustrated by Robert Louis Stevenson’s classic parable of addiction, “Dr. Jekyll and Mr. Hyde.” In the psychogenic view, the insane, murderous Hyde is the real person, with Jekyll merely a facade. It taps deep currents in American thought–the notions of original sin and the Freudian Id–that beneath the inhibiting veneer of civilization man is inherently evil. Alcoholism merely releases this deeper ugliness by removing the inhibitions. In vino veritas [in wine is truth]. The task of therapy is to engage and civilize Hyde. Treatment fails because the contemptible Hyde is willfully incorrigible. He deserves the stigma and scorn of society.
Within the biogenic paradigm Jekyll is the real person, Hyde a neuropsychological distortion created by the addictive chemical. Hyde exhibits the same kind of deterioration of personality and character as victims of such other progressive brain pathologies as brain syphilis or a brain tumor. Body, mind and spirit (including will-power) are biologically compromised and subverted to serve the addiction. Given time for the healing, in alcoholism the brain syndrome is reversible. The task of therapy is to restore Jekyll to sanity and selfhood, and to start him on a path that will preclude a return to the addictive, transforming chemical.
Although it is conformity to the psychogenic belief that continues to distort and falsify all scientific and clinical knowledge of alcoholism, as the given truth throughout history it has had the advantage of being invisible, of not appearing to be a belief system at all, but simple reality. This was the fatal flaw in the Jellinek “disease concept” of alcoholism. For all his helpful descriptions of the progression of the disease, he endorsed the false belief that alcohol is primarily a sedative drug, and that alcoholism is caused by excessive “relief drinking,” drinking to relieve psycho-social stress. Thus, as a secondary consequence or symptom, the biology of alcoholism could be largely ignored by the establishment in its diligent search for the presumed primary psychiatric cause of the relief drinking.
Following Jellinek, many leading proponents of the disease concept still try to have it both ways, to assimilate the fragments of biological knowledge within the lingering psychogenic hegemony. This conformity necessarily condones the misinformation that continues to tear the country to pieces and helps to delay the emergence of the biogenic paradigm.
By 1960, research studies had determined that the rate of mental illness among predrinking alcoholics was the same as among nonalcoholics. During the 1960s and 70s, a great many additional research studies confirmed that the defective character, the mental illness of alcoholism, is not primary, or underlying, or a “dual diagnosis,” but the neuropsychological consequence of the alcoholism.
When controlled for heredity (abundant independent evidence makes this mandatory), no predrinking psychological or social variable of any kind could be found to correlate with later alcoholism–not child abuse, depression, antisocial attitude, poor self-image, or any other. These problems are familiar consequences and complications of alcoholism, but research clearly showed they are not contributing causes or “risk factors.” Also, the persistent belief in an “alcoholic (or addictive) personality” was found to be false.
The search was broadened in the vain hope of finding some other kind of evidence to validate the psychogenic paradigm. None could be found. Responsible drinking could not prevent alcoholism, and alcoholic drinking could neither be learned nor unlearned. All prevention and treatment efforts to modify the alcoholic’s progressive response to alcohol failed.
Deep, broad, and powerful vested interests in the philosophy of environmental determinism were increasingly threatened by the mounting evidence against the psychogenic paradigm. In their desperate effort to forestall its collapse, defenders of the paradigm resorted to an increasingly blatant double standard, a kind of artificial life support system. Editors, reviewers, critics, and other guardians of the academic alcoholism literature increasingly rejected, distorted, minimized, lacerated with extreme criticism, and ignored–one at a time–the thousands of research and clinical reports that, only when allowed to freely come together, form the biogenic paradigm, a complete definition and explanation of alcoholism.
In contrast, thousands of inadequate, shoddy, or even fraudulent studies were uncritically approved and widely cited if they but seemed to support the psychogenic premise. As an aid in warding off the troublesome biogenic research evidence, alcoholism was renamed “alcohol abuse,” a psychogenic term of moral censure. The word “addiction” was then degraded and stripped of its profound biogenic meaning by applying it to all manner of excessive or repetitive behaviors. Of course it became impossible to identify or diagnose alcoholism and many researchers resorted to drink counting instead, with arbitrary amounts of consumption to identify alcohol “abusers.” Alcoholism was trivialized out of existence as the academic literature became a literature not about alcoholism but about itself.
In spite of this concerted attempt to disguise the fact, by the early 1980s the psychogenic premise had been totally discredited and dismantled by legitimate research. This is the documented conclusion of, among others, one of its most distinguished former advocates, philosophy professor emeritus Herbert Fingarette. It is only from the biogenic perspective that his landmark contribution can be fully appreciated.
In 1988, in his notorious book, “Heavy Drinking,” Fingarette declared, from within the psychogenic paradigm, there is no such thing as alcoholism. In his world he was right. The biogenic model has never been assembled within the academic alcoholism literature because it is impossible to do so. Its parts are either distorted or missing. With no direct clinical experience of his own, Fingarette’s 15 year investigation was limited to what he found in this mandarin literature, and he didn’t find alcoholism. He unwittingly wrote the obituary not for alcoholism but for the psychogenic paradigm in which alcoholism in fact does not exist.
There is wry humor in this whole academic spectacle. It has been a kind of acting out on a grand scale of the old joke about the specialist: one who learns more and more about less and less until eventually he knows everything about nothing. But these misguided academic reveries have had devastating effects on public understanding of alcoholism. For example, with Fingarette as its official consultant on addictions, the United States Supreme Court wistfully argued in 1988 that “…apparently nobody understands alcoholism…it appears to be willful misbehavior.”
Overshadowed by the multitude of researchers who were busy confirming that the psychogenic paradigm is devoid of any data base, many others were quietly compiling evidence that alcoholism is a primary, biogenic disorder. However, the task of assembling the biogenic paradigm is elusive and difficult because not only the academic literature but the whole of society has been limited by the psychogenic view. It is impossible to see out of it. As Thomas Kuhn explained, and Fingarette demonstrated, a new paradigm and its supporting evidence are invisible from within the old. Be forewarned that because the dominant premise is false, “…every truth is not quite true.” It is impossible to assemble this myriad of half-truths into a coherent perception of alcoholism.
To discern the biogenic model, a substantial amount of valid research evidence and clinical knowledge must be winnowed from the psychogenic chaff in the alcoholism literature, and gleaned from original sources scattered throughout the life sciences. It can then be transformed and assembled in the new biogenic configuration, much as all knowledge of geography and navigation were transformed for the earth to become a globe after being flat for so long. No flat fields were lost, but it was necessary to ignore them long enough to form the new model. Once the global perception came together there was a certainty and finality about it, which to those still in the other paradigm seemed totally unjustified by the obvious facts. It couldn’t be helped. The flat earth was gone.
Similarly, the biogenic paradigm includes and is shaped by all valid knowledge of alcoholism. It has an extremely broad data base. Nothing is forced in or left out to argue about. And because all parts are valid, the whole is also validated by internal consistency. It is not a philosophy or a theory. It is a new gestalt, a compelling total perception.
Data is found in many areas in many disciplines. Both animal and human studies have shown repeatedly that alcohol addiction is hereditary. A number of inborn, predrinking biological differences have been discovered in alcoholics, along with many initial and progressive differences in their biological responses to alcohol. Differences have been found in brain wave patterns, in various enzymes, in nerve transmitters, in liver functions, in alcohol metabolism, and in the effect of alcohol on performance, mood and mental abilities.
The problem is not a shortage of data as frustrated researchers suppose, but the fact that they have not been able to integrate the abundance of scattered data. Both gathered and viewed within the compromising psychogenic paradigm, each cluster of research data stands alone in the scientific literature as an isolated anomaly, barely acknowledged in the academic alcoholism literature. Because it seems so self-evident that psychosocial factors must be contributing causes, even biological researchers still think there must be more than one kind of alcoholism.
Once all biological data is assembled within the biogenic paradigm, it explains why all learning theories have failed to distinguish alcoholics from nonalcoholics, why alcoholic drinking can be neither learned nor unlearned. It is the unconditioned response to alcohol that is different, initially and progressively. Alcohol is selectively addictive, and the selection is biological.
Regardless of why, how, or how much an alcoholic initially drinks, the addiction neurologically augments his original reasons for drinking, pushing him to drink amounts consistent with his rising tolerance, and beyond. In human experience there is nothing unusual about physiological imperatives, like hunger or sex, creating mental obsessions and driving and shaping behavior. There are not two or more types of alcoholism. There are merely different complications and different types of people who are alcoholic, with different levels of concern and strategies of damage control.
All of the psychopathology of alcoholism, as alcoholism, is of neuropsychological origin, but this fact is disguised because alcoholism is never diagnosed until after character and personality are distorted and normal emotions are neurologically augmented to abnormal levels of chronic anguish, fear, resentment, guilt and depression. It is these distortions that clinically identify alcoholism, not the original character and personality.
Most often alcoholism is hereditary, but many individuals become chronic alcoholics through cross-addiction to other drugs (prescription or illicit), or as the result of other brain or liver insults. Whether or not accelerated by the potentiation of other drugs or injuries, organic deterioration causes a loss of tolerance and substantially reduced alcohol intake. To the drink counters, both alcoholics progressing into the more ominous low-tolerance stages of their disease and those who necessarily reduce their alcohol intake while using substitute drugs are cases of “spontaneous remission” or improvement.
In addition to the early acute effects of alcohol–the mind expanding life enhancing stimulation and energy–three kinds of progressive brain impairment participate in the personality and character transformation, while augmenting the strength of the emotions, and of the addiction. Between drinking episodes:
(1) All brain cells are in a toxic, malnourished state. Their detoxification and stabilization takes several weeks of total abstinence from alcohol and all other drugs,
(2) Billions of brain cells are damaged. Repair and healing takes several months of abstinence,
(3) Many millions of brain cells die. The loss is permanent, but during a period of some 4 years of total abstinence surviving cells compensate for those that are lost.
Ameliorating during the first several weeks of abstinence, the three kinds of impairment have a combined effect on overall brain function, producing both first-order and second-order psychological symptoms:
(1) First-order symptoms are the direct neuropsychological disturbances, such as mental anguish, memory defects, mental confusion, disorientation, and emotional augmentation.
(2) Second-order symptoms are the patient’s psychological reactions to the first order symptoms and include fear, denial, projection, rationalization, depression, personality distortion, deteriorating self-image and self-confidence, regressive immaturity and other mental and emotional aberrations.
A third order of symptoms is imposed by the psychogenic paradigm, the cultural heritage of both patient and family members, the mistaken belief that the first- and second-order symptoms are caused not by the brain disorder but by an underlying or concomitant psychiatric problem. Both subjectively and to the casual observer, the symptoms are the same. This wrongly places the blame for the abnormal behavior on the person rather than on his organic disease (hence the term “alcohol abuse”) and draws the family into sharing the blame. Third order symptoms include feelings of guilt, shame, remorse, alienation, resentment, helplessness, despair, and depression. Complex states, such as fear, depression, and regressive immaturity are composites of first-, second-, and third-order factors.
When alcoholics quit drinking on their own, as many do, they must live with the cultural stigma and the unrelieved symptoms of anguish, guilt, shame, remorse and depression. In this troubled state, without an enlightened support group, it is not surprising they so seldom achieve a lasting sobriety. These interludes “on the water wagon” between drunks are also included as spontaneous remissions or improvements by the drink counters.
The attempt to force research findings into the psychogenic mold has been paralleled by a similar distortion and suppression in clinical practice.
Psychiatrists have always been regarded as the ultimate authorities on alcoholism in spite of the fact they have never had academic courses or field training in alcoholism. Their credibility has always depended entirely on the culturally shared premise that alcoholism is secondary to psychological and social problems, areas in which they are qualified.
Surveys during the 1960s found that alcoholics consulted psychiatrists from 40 to 100 times as often as nonalcoholics and were hospitalized some 12 times as often. They were never given a primary diagnosis of alcoholism. There wasn’t a hospital in the United States that would admit a patient under a diagnosis of alcoholism, and health insurance would not pay for alcoholism treatment. Alcoholism recovery rates were acknowledged to be zero for all types of psychiatric treatment. Alcoholic drinking, obvious “psychiatric” disorders, and failure to recover were all regarded as evidence of a mysterious perversity in the patient’s character. Alcoholics were considered hopeless, pending further psychiatric research.
Still under the psychogenic paradigm, the whole of the health care and social service establishment, public and private, continues to be a gigantic revolving door for undiagnosed and untreated, or wrongly treated, alcoholics and drug addicts, who, together with their victims, comprise conservatively 60 percent of all caseloads. The vast majority of all prison inmates are there for crimes secondary to addiction. The annual cost to society of tending to the multiple effects of addiction– rampant “psychiatric” problems, family neglect and abuse, poverty, violence and other crimes, illnesses and organ and system failures, accidental injuries and deaths–is in the hundreds of billions of dollars.
Because psychiatrists and other mental health specialists have such an enormous vested interest in the psychogenic paradigm, it could be anticipated that they would be among the last to discover the biogenic alternative. But this alone does not explain why they continue to be such stubborn believers in the face of the mountain of evidence that they are wrong. Their most stultifying problem is that they are trapped in a vicious circle, a self-fulfilling prophesy, that can only be seen from the perspective of the other paradigm.
Alternate states of being supplant each other. The person as transmogrified, transformed by the brain syndrome, enters treatment alone. The original, authentic person is not present. He or she has been superseded, replaced. All therapeutic dialogs with patients during the first weeks of treatment, until Jekyll is allowed to reappear, are dialogs with Hyde, through his “mask of sanity.”
Within the psychogenic paradigm, both therapist and patient mistake the characteristics of the wretched, contorted self of the brain syndrome for attributes of the real self. After a few days of acute detoxification, this miserable self-image is further authenticated as the focus shifts to psychiatric treatment. The third-order symptoms of guilt, shame, denial, defensiveness, resentment and depression, created by the psychogenic paradigm in the first place, are not dispelled by healing and reeducation, but are reinforced as emanating from deep sources in the patient’s character and personality, an underlying or concomitant psychiatric problem. It’s a self-validating practice. The patient now has an iatrogenic (therapist induced) disease.
By locking the patient into this mistaken identity, the therapist creates the chronic psychiatric problem that he then thinks he has merely uncovered. Therefore the dual diagnosis rate is very high, and the recovery rate is near zero. Of course, the patient gets the blame for the treatment failure, the continuing “willful misbehavior,” and the therapist feels justified in his contempt for these uncooperative patients.
In a sense, the recovery rate is worse than zero as many alcoholics die of the iatrogenic disease. They are destroyed by the potentiation of their alcoholism with routinely prescribed addictive drugs, in combination with psychotherapy, which converts the otherwise reversible organic insanity into a hopeless “mental illness” (Judy Garland, Marilyn Monroe).
The biogenic approach is entirely different. By the 1940s Alcoholics Anonymous had clearly demonstrated that alcoholics could stay sober and be restored to sanity with continued total abstinence from alcohol and all other addictive drugs. Special treatment programs came into being to meet the need that AA was not designed to address, the need for control and professional treatment during acute detoxification and the troublesome early weeks of recovery.
The therapist is a kind of mid-wife in the rebirthing of the patient into sanity and true self-hood (Jekyll). With medical management, directive counseling, appropriate nutritional therapy, regulated rest, moderate exercise, and complete reeducation to the neurological origin of the “mental illness,” within a few weeks the brain syndrome and the craving subside. Understandably, in varying degrees all patients experience a crisis of identity during the transition into unfamiliar self-hood. Patients are extremely unstable, biologically and psychologically, during this period. The four-week inpatient program evolved to facilitate the healing and to protect patients from an otherwise high probability of relapse during this period. There is no attempt to reform or to do psychotherapy with the fading, counterfeit self (Hyde). Like a bad dream, it is discredited as “unmanageable” (AA’s first step), left behind and disowned by the patient as not-self (Betty Ford, Elizabeth Taylor).
Restored to sanity, and reeducated to the permanent nature of addiction and how to recover, the alcoholic for the first time has a valid moral choice. He can see that he has a moral imperative to live the way of life that will assure his continued sobriety and recovery. He must understand why he cannot rely on willpower alone. Willpower is a fickle servant that can be quickly redirected at its biological source to serve an awakened Hyde instead of Jekyll. As patients stabilize in sobriety they are ushered into Twelve Step programs for long term sobriety maintenance and self- realization. It is this unbroken sequence that works so well with both alcoholism and other drug addictions.
There is no question that in early recovery patients must face the very depressing psychological and social damage caused by alcoholism–their own and often their parents. But this is reality, not mental illness. With proper addiction treatment, and continuing in health and sanity within a Twelve Step program, patients can cope with the damage and outgrow it. Reality centered counseling and other ancillary services may be needed or helpful during this difficult period. As with all other chronic diseases, even with the best of treatment relapses are often part of the recovery process. Nonetheless, with this treatment model the addiction recovery rate is high, and the actual rate of mental illness, the true dual diagnosis rate, is low, around 5 percent.
From within the psychogenic paradigm the special treatment model is incomprehensible, and the sequence seems arbitrary. Both AA and treatment programs have been endlessly misrepresented in the academic literature. AA is not a “treatment program,” and the special treatment programs are not “Twelve Step programs.” While AA properly stayed true to its original nonprofessional form, by the 1970s, after several decades of evolution, the treatment programs had become fully professional, multidisciplinary, and highly cost-effective.
Both the form and content of treatment evolved out of trial and error experiences of tens of thousands of professionals treating hundreds of thousands of patients in thousands of treatment programs over a period of several decades. Born of the psychogenic paradigm and guided by Jellinek, the movement of these programs toward the biogenic model was not by central control or conscious design, but by the grass-roots discoveries of what worked and what didn’t work in producing recoveries. Those who have more coherently grasped the biogenic paradigm have been rewarded by a quantum improvement in the rate and quality of recoveries.
Nothing is arbitrary. The common sequence of four weeks minimum of intensive inpatient treatment, followed by outpatient aftercare and a start in a Twelve Step fellowship, is simply an optimum program to enable the wisdom of the body and the reeducation process to resurrect the real person from the ashes of the disease, and to prepare him or her to start life in sobriety. Effective alcoholism treatment is hard work, and it takes time.
Through the special treatment programs, millions of alcoholics and other addicts have escaped the revolving doors of the establishment into total abstinence from alcohol and other drugs. After successful addiction treatment, their social service and health costs drop to levels below those of the general population. Cumulative costs saved have been in the tens of billions of dollars. Of course, costs saved by the special programs have been revenues lost to the establishment, which, together with the threat to the psychogenic paradigm, explains the hostile rejection of this major breakthrough in public health. Because referral for effective addiction treatment has become a very real option, the traditional professions and agencies must now be seen as primary “enablers,” and the endless problems they subsidize as iatrogenic.
Unfortunately, the success and high profile of the special addiction treatment programs during the 1980s attracted investors and professionals who brought into the field the psychogenic paradigm. Their low rates of addiction recovery, their “discovery” of a high rate of dual diagnosis, and their extraordinarily high costs of vainly treating the iatrogenic disorders have created major public relations problems for the whole field of addiction treatment.
Not knowing that the dual diagnosis problems they find so prevalent and so frustrating are iatrogenic, mental health professionals imagine that special programs must also be confronting these same psychiatric problems. It is therefore inconceivable to them that “Twelve Step” programs could be having any more success with these stubborn patients than they are. They even imagine that the special programs need their expertise to better treat the difficult psychiatric problems. They don’t. They don’t create them.
Whatever their assumptions, some mental health professionals have diverted attention away from their own failure to get recoveries (e.g., the Rand report) with outrageous allegations that enlightened treatment programs also fail to get recoveries, calling them a “rip-off industry.” This loud minority has jeopardized the lives of untold millions of alcoholics and drug addicts and inflated health care costs by shifting public attention away from effective addiction treatment over to a preoccupation with redesigning the whole health care establishment to more broadly serve the endless iatrogenic problems. It has also helped to unbalance the drug war by justifying the neglect of intervention and treatment (of Jekyll) in favor of an almost exclusive reliance on interdiction and punishment (of Hyde).
Citing the failure of alcohol prohibition in the attempt to justify legalizing other drugs seems reasonable only from the psychogenic premise–the denial of physical addiction that created and still nurtures the drug epidemic. Again, the biogenic view is entirely different. The 10 percent alcoholism rate among drinkers in America always has been a marginally acceptable rate of addiction, barely tolerable by society. Witness the anguish of prohibition and its repeal. Using the disaster of alcoholism to justify legalizing brain-damaging drugs with addiction rates edging toward 100 percent is totally irrational.
THE END GAME
That there is no legitimate research evidence available to support the psychiatric premise is highlighted by the fact that bogus research reports are being cited in the media as part of the current political battle to regain control of the patient population. A couple of recent examples:
(1) The report of drinking by fathers and sons purporting to show that alcoholism is not a primary hereditary disorder. This was a ridiculous drink counting study, not an alcoholism study. Alcoholism was not diagnosed in either fathers or sons. It was found that amounts consumed by sons were not affected by whether their fathers drank 2 or more drinks per drinking occasion or customarily drank 1 drink or less. Abstaining genetic alcoholic fathers whose sons are drinking alcoholics are–of course–placed in the “one drink or less” group.
(2) Psychiatrist Frederick Goodwin, then director of the Alcohol Drug Abuse and Mental Health Administration, has co-authored a report alleging that about a third of alcoholics have a dual diagnosis, a psychiatric problem along with their alcoholism. Patients in an alcoholism treatment program were merely asked if “ever in their lifetime” they had been given a psychiatric diagnosis. Thus the rate of historic and continuing misdiagnosis of alcoholics in the revolving doors became, for these authors, a measure of the rate of dual diagnosis.
In recent congressional testimony, psychologist Michael Hogan has inflated this contrived statistic. Arguing that alcoholism funds should be put back under mental health jurisdiction, he stated that “…in over 60 percent of all people with a substance abuse disorder, there is a concomitant mental illness.” It is a frightening prospect for the still sick alcoholic and drug addict that these agents of iatrogenic disease aim to control and “improve” the special addiction treatment programs.
It is impossible to counter the outrageous “research” reports one at a time as they flow into the national communications media from the professional and political high ground. No single research study can refute a nonstudy, and the network of research knowledge that shows it to be absurd is too complicated for a brief rebuttal. Only the familiar standoff can be achieved: “Apparently nobody understands alcoholism.” Once and for all, it is the whole biogenic paradigm that must be communicated.
Some steps have been taken in the right direction. During the early 1980s, the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse shifted their funding emphasis to support research in the biology of addiction. It is hoped they will finally recognize the effectiveness of nutritional therapy and the wisdom of the body in healing the brain syndrome and craving, and not just narrowly search for yet another toxic drug for psychiatrists to prescribe. The destructive methadone program for heroin addicts was never a legitimate model. It seemed promising only in relation to the zero recovery alternatives known to its instigators.
For the longer term, it is encouraging that in 1986 Harvard, Dartmouth and Johns Hopkins broke with academic tradition and announced they were going to inaugurate courses in alcoholism in their medical schools. In the same news release they frankly acknowledged that none of their faculty, including their many psychiatrists, were qualified to teach such courses. The word “inaugurate” underscores the fact that the many thousands of psychiatrists already on university faculties and out in society as authorities are not qualified in alcoholism either by academic courses or clinical training where they could witness recoveries. They are only authorities in the psychogenic paradigm in which alcoholism does not exist. Deeply understood, this paper is an attack not on these untutored professionals, but on the destructive cultural paradigm that has held them in thrall.
Facing up to their deficiency, a significant number of physicians, psychiatrists and psychologists have already defected to the enlightened treatment programs and organizations, first to learn and then to provide professional leadership. They have been generally ignored by mainstream professionals but will form an important nucleus for education and training as larger numbers come over to join them. Until the countless revolving doors are cleared of alcoholics, there will be plenty of productive and highly rewarding work for all who are willing to learn. As their numbers swell, they will finally provide the legitimate clinical window that has been so urgently needed both to guide and to integrate scientific research.
The biogenic paradigm has not yet been systematically articulated by any major organization or presented to the public through any of the national communications media, but having reeducated themselves to the realities of addictive disease, these professionals are now leading the inevitable movement toward the biogenic paradigm.
Two enlightened organizations, the American Society of Addiction Medicine and the National Council on Alcoholism and Drug Dependence, have jointly formulated a new definition of alcoholism that is consistent with the biogenic paradigm, as follows:
“Alcoholism is a primary, chronic disease with genetic, psycho-social and environmental factors influencing its development and manifestations.” The definition is further elaborated, but note especially that psychosocial and environmental factors are no longer primary, contributing causes of alcoholism.
Meanwhile, the ugly battle for control will continue in the political arena. The public has recently heard the hostile allegations that nobody understands alcoholism, that alcoholism does not exist, that it is merely willful misbehavior, that since treatment doesn’t work anyway, only the briefest and least expensive should be funded. “…every word they say chagrins us…” because all of these criticisms are true of the bankrupt psychogenic approach to alcoholism; none, however, is true of the biogenic.
These attacks on the “treatment industry” are merely a reactionary attempt to regain in the social and political arenas the control over alcoholism that has been irretrievably lost in scientific research and clinical practice. Their effectiveness depends entirely on public ignorance of the fact that the paradigm shift has already occurred.
With many millions of lives and hundreds of billions of dollars in the balance, surely it is time to embrace and to reveal the whole truth about addictive disease to decision makers and the public, to present the biogenic paradigm as the comprehensive successor to the disastrous psychogenic model. It will be quickly validated and ratified by an enormous latent fund of public experience and knowledge. Virtually everyone has witnessed the reality of addictive disease and the effectiveness of treatment, both first-hand and in media reports of the lives of a multitude of recovering celebrities.
James R. Milam, Ph.D., is a clinical psychologist specializing full time since 1966 in addiction research and treatment. For over 25 years, he was the leading national proponent of the view that alcoholism is a primary neuropsychological disorder, not a symptom or consequence of psychosocial “risk factors,” as commonly believed. It was his Position Paper, written for the Washington State Council on Alcoholism in 1972, that provided the rationale for moving alcoholism out of mental health jurisdiction in Washington State and elsewhere. He is best known as the author, with Katherine Ketcham, of the best seller “UNDER THE INFLUENCE,” Bantam Books, New York, 1983.
Cofounder of several demonstration treatment programs, his efforts were focused on the rehabilitation of scientific, professional and public understanding and attitudes about alcoholism and other drug addiction. For more background on Dr. Milam’s work, see his essay More on the Alcoholism Revolution.