alcoholism The term ‘alcoholism’ was first used by a Swedish professor of medicine, Magnus Huss (1807–90), to mean poisoning by alcohol. Huss distinguished between two types of alcoholism. Acute alcoholism was a result of the temporary effects of alcohol taken within a short period of time — drunkenness and intoxication; chronic alcoholism was a pathological condition caused by the habitual use of alcoholic beverages in poisonous amounts over a long period of time. Using case studies to illustrate the condition of chronic alcoholism, Huss provided the first systematic description of the physical damage caused by excessive drinking. This first use of the term ‘alcoholism’ in 1852 emerged from a combination of specific historical circumstances within which changes in perceptions of excessive alcohol consumption were taking place.

Prior to the nineteenth century, symptoms and problems related to ‘habitual drunkenness’, or excessive alcohol use, were known and recorded, but habitual drunkards were seen as morally weak or criminal, rather than suffering from an illness or a disease. Public concern revolved around drunkards' moral attitudes and social behaviours, which were regarded as licentious, sinful, or criminal, punishable by a period in the stocks, whipping, or fines — or by the eternal damnation preached in fiery sermons. On the whole, however, the dominant social response

to drunkenness was tolerance and social disapproval; heavy drinking was not, in itself, regarded as a problem. The emergence of a new understanding of habitual drunkenness (or inebriety) as a disease was led by medical and psychiatric practitioners at the beginning of the nineteenth century, most notably by Benjamin Rush (1745–1813) in America and Thomas Trotter (1760–1832) in Scotland. According to some historians, it was Rush who provided the first clearly developed modern conception of alcohol addiction. This included the idea of gradual and progressive addiction; bouts of drunkenness characterized by an inability to refrain from alcohol; the description of the condition as a ‘disease’; and total abstinence as the cure. For the first time, ‘treatment’ became a possible option in responding to the harm associated with habitual drunkenness. Throughout the nineteenth century efforts were made to provide more scientific descriptions of the disease and its cure, leading, in 1901, to the use of the term ‘alcohol addiction’ to describe the inability to give up harmful drinking.

Twentieth century developments

During the first half of the twentieth century interest in alcoholism and the alcoholic waned. Prohibition in America and changing social conditions and consumption patterns in Britain drew attention towards control of the substance and away from the disease and its treatment. But with the repeal of prohibition in America, any attempt to address problems associated with drinking had to be concerned with the behaviour of individuals rather than with the consumption patterns of the nation or the nature of the substance itself. In post-prohibition America and, later, in post war Britain, the freedom of the majority to drink as they pleased was paramount. The nineteenth century temperance approach, which had inveighed against the dangers of alcohol itself, was now rejected as moralistic and unscientific and the focus of attention was, once again, on the disease of alcoholism.

The ‘new’ disease approach to alcoholism started in America and was led by three linked groups, often referred to as the ‘alcoholism movement’: a research group established at the Yale Centre for Alcohol Studies; Alcoholics Anonymous (AA) (a self-help group which was set up in 1935), and the National Committee for Education on Alcoholism (later the National Council on Alcoholism), which became the leading voluntary organization offering alcoholism treatment. The ‘alcoholism movement’ quickly spread to Britain and subsequently throughout the world.

In essence there was little difference between descriptions of the disease in Rush's work and later use of the term. The main objectives in labelling it as the ‘new’ approach to alcoholism were practical and political rather than based on any ‘scientific’ discovery. On the practical side was the desire to gain a better deal for people suffering from alcoholism. Promoting the disease concept was part of a strategy to combat the stigma and prejudice that hindered alcoholics and their families from seeking help and that was a barrier to securing the interest and involvement of the helping professions. On the political side, the concept served as a device to unite diverse interests, including the alcohol industry, because the focus was on a few unfortunate individuals rather than on the drinking habits of the majority.

The strategy was successful. The disease theory was accepted by the American Medical Association in 1956 and by a number of influential doctors and voluntary groups in Britain over the course of the 1950s and 60s. In the early 1950s, the World Health Organization formally declared its support and provided a definition of ‘alcoholism’ which noted that alcoholics were excessive drinkers, dependent on alcohol to the extent that they suffered noticeable mental disturbance or interference with bodily or mental health, interpersonal relations, and economic functioning. They were people who required treatment.

As in the previous century, there was continuing interest in refining the disease concept and in producing classifications or ‘typologies of drinkers’. The most famous typology was derived from the research of E. M. Jellinek, a member of the Yale Centre for Alcohol Studies and a consultant to the WHO during the 1950s. Influenced strongly by AA philosophy, Jellinek distinguished between five different types of alcoholism. Only two types (Gamma and Delta) were diseases because, in his view, they were addictions in the pharmacological sense that physical dependence on alcohol was present and too sudden cessation of alcohol use would result in withdrawal symptoms. The defining characteristics of Gamma and Delta alcoholism were: acquired increased tissue tolerance; adaptive cell metabolism; withdrawal and craving; and loss of control (Gamma alcoholism) or an inability to abstain (Delta alcoholism). Typically, Gamma alcoholics drank mainly in bouts and were often drunk; Delta alcoholics drank regularly to achieve a blood alcohol level at which they felt comfortable, usually without getting drunk. According to Jellinek, ‘alcoholics’ were those who suffered from Gamma or Delta forms of alcoholism. Other forms of alcoholism were considered to be symptomatic, the dependence on alcohol being psychological without the presence of physiological addiction; individuals in those groups were not, therefore, alcoholics.

Alcohol dependence and related disabilities

Jellinek's classification has continued to have a significant influence over beliefs about alcoholism and about appropriate treatment approaches for alcoholics. But the ambiguities in the terms led to repeated efforts to clarify the concepts, resulting eventually in the substitution of ‘alcoholism’ with the term ‘alcohol-dependence syndrome’, approved by the World Health Assembly in 1976 and incorporated, three years later, into the International Classification of Diseases as a new medical diagnosis. One important feature of the syndrome is that it includes both psychological and physiological dependence. It has seven elements: subjective awareness of the compulsion to drink; narrowing of the drinking repertoire (drinking becomes predominantly a response to the need to avoid withdrawal so that daily intake becomes ‘scheduled’); primacy of drinking (drinking becomes more important than any other activity); altered tolerance to alcohol; repeated withdrawal symptoms; relief or avoidance of withdrawal symptoms by further drinking; reinstatement after abstinence (return to the drinking pattern established before abstinence, which can happen very quickly after starting to drink again).

At the same time as the alcohol dependence syndrome emerged as a new concept, a WHO group were formulating criteria for the identification and classification of alcohol-related disabilities. The report, published in 1977, described the range of mental, physical, and social disabilities related to alcohol use and emphasized that there were degrees of disabilities. It was not only the ‘alcoholic’ or alcohol-dependent person who was adversely affected by alcohol; damage might be incurred even if the individual was neither dependent nor an excessive drinker.

The emphasis on degrees of disability related to alcohol use rather than dependence is significant since it signalled changes in perceptions of the nature of the alcohol problem. The notion that ‘alcoholics’ suffering from a ‘disease’ were different from the remainder of the population was no longer generally accepted (although some groups still base their therapeutic approaches on disease theories). By the 1980s, many people preferred the term ‘problem drinking’, which covered a continuum of drinking harms, from relatively minor harm, such as behaving in socially embarrassing ways when drunk, missing work because of a hangover, or suffering a fall when drinking, to the severe harms associated with excessive and dependent drinking. Problem drinking was not a disease; it was a ‘learned behaviour’, and anyone who drank was at risk of becoming alcohol dependent. Concern now focused on the much greater number of people drinking above recommended levels, or in ways likely to incur harm to themselves, to other people, or to the wider community.

Today, the term ‘alcoholism’ and ‘alcoholic’ are regarded by many people as stigmatizing labels which are unhelpful in developing appropriate responses to alcohol-related harms. But their continuing use by some groups indicates the co-existence of alternative beliefs about the nature of harmful alcohol use and of different approaches to helping those who become ‘problem drinkers’ or ‘alcoholics’.

Betsy Thom

Bibliography

Heather, N. and and Robertson, I. (1997). Problem drinking: the new approach, (3rd edn). Oxford University Press.