Commentary
When I first heard of the disease model, I honestly shrugged. For an individual who finds themselves in a treatment program, being introduced to the label of a “disease” can feel relatively quaint. It doesn’t change the overwhelming burden on the individual to overcome it through some calibration of personal willpower, and it doesn’t lessen the impacts of addiction on loved ones or the community in which it occurs. Carl Erik Fisher writes something in his book that resonated with me:
“‘The brain disease model of addiction’ can mean different things. The most modest claims are reasonable, bordering on uninteresting: neuroscience can help us to understand addiction, including ways of helping with medical treatments, but it is not necessarily the only way to understand the problem.”
The disease model is as old as Benjamin Rush, a signatory of the Declaration of Independence who had trusted correspondence with Thomas Jefferson and John Adams.
Rush was a doctor who was unapologetic about Christian education being the bedrock of a democratic republic, but he also relied on his faith to argue against slavery, banning all women from education, and the inhumane treatment of prisoners. His faith drove his commitments to social justice, and that includes social views of those afflicted with “habitual drunkenness.” He made several observations that placed addiction into the realm of an “odious disease” or a “disease of the will” where immoral behavior was a symptom rather than a reason to condemn someone. He documented the impact of “habitual drinking” on bodily organs which meant there were undeniably impacts on physiological health, but he also included “madness” that drives one to suicide so that there was a connection between the physical and mental outcomes. Rush is often credited as one of the first American psychiatrists for exploring mental health as a systematic science tied to the body. Although some of his theories didn’t pan out (like mental illness being caused by blood vessel issues in the brain), I think that his arguments hold up today as a rebuttal to the moral model.
One of the reasons the moral model has persisted is that the disease model is really, really, really complicated. We still don’t have a universally-accepted definition for what constitutes addiction as a disease. Prohibition was based mostly in moral and temperance models of addiction, and the solutions were presumed to be legal, religious, and cultural. The eugenics movement worked in ideas about sterilizing alcoholics to prevent more from being born, and the liquor and bar industries were fighting back the regulations that cut into their profits. When those solutions failed and the institutions responsible lost the same enthusiasm to try more, researchers in the medical community kept looking at the evidence and data since alcoholics were still showing up in hospitals.
From Bellevue Hospital, Dr. Norman Joliffe formed the Research Council on Problems of Alcohol (RCPA) to finally start building secular and scientific infrastructure to study addiction as a public health crisis. Those like the Rockefeller Foundation rejected funding for the RCPA since addiction research was still politically controversial, polarizing, and suffered from very messy data as evidence. In 1939, the Carnegie Foundation agreed to fund an international literature survey that Elvin Morton Jellinek was hired for as a statistician. Jellinek’s 1942 book that catalogued decades of journals from different countries in different languages became the Classified Abstract Archive of the Alcohol Literature (CAAAL), which grew so foundational for addiction science and research that Yale University absorbed it under their Laboratory of Applied Physiology. Those like Dr. Silkworth, the same as the one from The Big Book of Alcoholics Anonymous, kept arguments for the disease model alive, but Jellinek was the researcher who consistently provided empirical evidence and statistical data for a disease model that made it impossible to ignore.
With Marty Mann, the first woman to achieve long-term sobriety through AA, and other prominent AA proponents, Jellinek and Dr. Howard Haggard at Yale launched the National Committee for Education on Alcoholism (NCEA). The goal would be to bring empirical evidence to the public that alcoholism was a disease that should be treated as a public health issue rather than a moral failing. It was hard though, especially because of AA’s anonymous design and a goal of minimizing professional and institutional influence over the program.
AA’s official magazine The Grapevine released a 36 question survey for 1600 readers to take. The response rate was less 10%, and over a third of the responses had to be discarded for being incomplete, contradictory, or impossible to decipher. Only 98 men and 15 women had fully completed and submitted the survey, but the women’s timelines were so different that combining them into a single pool of data would make it seem noisier. Jellinek was very aware of these extreme limitations and even included feedback: “Statistical thinking should not begin after a survey or an experiment has been completed but should enter into the first plans for obtaining the data.” Nevertheless, in a 1946 publication, he chronicled chronologically 43 symptoms of alcoholism as it progresses until fatality. In 1952, Jellinek conducted a survey of 2,000 male alcoholics to have actual data which would hold up to scientific scrutiny.
Dr. Max Glatt built on Jellinek’s work with his proposed signs of rehabilitation, turning a depressive progressive decline into a more hopeful U-shaped graph now called Jellinek’s Curve. Glatt ran one of the first specialized treatment units for alcoholism in the UK through the NHS. His diagram made it back across the pond to William Keaton of the State Commission on Alcoholism in Michigan, who published a Modified Jellinek Chart that replaced medical jargon in its descriptions of symptoms with clearly relatable examples like “sneaking drinks” and “morning tremors” for public distribution in clinics, jails, and hospitals.
The disease model has been around for a while and has won over academia, but the public and recovery communities alike are still negotiating the moral model with it. It’s hard to have an open discussion when the “War on Drugs” as a policy crusade used an outdated moral-temperance “Just Say No” model that’s still fresh in our memories. Regardless, science marches on. Check out some of the stuff that’s come since:
- The Minnesota Model