Abstract
The terminology and typologies used to describe alcoholics and diagnose alcoholism have changed dramatically from when William Carpenter first published “On the Use and Abuse of Alcoholic Liquors in Health and Disease” in 1850 to the publication of the DSM V in 2013. E.M. Jellinek had a profound impact on emphasizing the importance of treating alcoholism as a disease that should be studied scientifically, thus paving the way for the changes of these typologies and how people are diagnosed. The first treatment institutions were “Sober Houses” implemented by Benjamin Rush – the so called “father of American psychiatry.” These were followed by the Washingtonians and Fraternal Temperance organizations. While both of these ultimately failed, this was the beginning of seeing alcoholism as a disease. In addition, they paved the way for future treatment centers including the American Association for the Cure of Inebriates and the Keeley Institutes. It wasn’t until after the prohibition era that Alcoholics Anonymous was founded, creating a global and long-lasting process of recovery without stigmatization.
Introduction
Alcoholism dates back to over 12,000 years ago and since then the disease has held a fascinating place in human history. This paper will detail in particular the history of alcoholism in America. I will begin by addressing many of the various ways that the classification of alcoholics and alcoholism has changed. This terminology will be broken down into three time periods – Pre-Jellinek, Jellinek Era, and Post-Jellinek. By addressing this first, it will provide a base of understanding of how the disease was perceived not only socially, but also through the eyes of physicians and psychologists. Similar to the pattern of recovery from alcoholism, the history of the disease is tumultuous at best. I will discuss alcoholism in three sections – the beginning of the disease concept of alcoholism in America, followed by the controversy that led to the prohibition era, and finally the emergence of alcoholics anonymous. For each of these sections I will include discussion regarding notable psychologists and their impact. In addition, I will detail the popular treatment centers of the time.
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Classification of Alcoholics and Alcoholism
Pre-Jellinek
E.M. Jellinek was a prominent activist in the disease concept of alcoholism and is known for developing the first scientific terminology to describe the disease and the people who suffer from it (Babor, 1996.) However, there was a long period of time prior to Jellinek’s contributions where the classifications were largely founded solely on observation and reflection.
William Carpenter was one of the first physicians to create typologies for people struggling with alcoholism (Babor, 1996.) Carpenter’s publication “On the Use and Abuse of Alcoholic Liquors in Health and Disease” was published in 1850 and described the “wine mania” he had observed as a physician. His classifications included acute, periodic, and chronic. Persons dealing with the acute category dealt with irregular sudden urges to become intoxicated. Periodic was categorized as regular binge-drinking, and chronic abusers could be described as constant drinking that took over one’s life (Babor, 1996.) Carpenter’s terminology, while not based on empirical research, provided a foundation for alcoholism to be studied on a professional level. The path to understanding not only the disease itself, but also the people suffering from it had begun.
20 years after Carpenter’s publication, several American physicians, including Thomas Crothers, founded the Association for the Study of Inebrity. Through this association, Crothers formed a journal in hopes of providing professional, clinical information regarding alcoholism (White, 2014. ENTER PAGE) Based on his clinical observations, Crothers classified three types of alcoholics as well as separated the difference between acquired and hereditary alcoholism. These typologies were presented to the public in 1911. Crothers claimed alcoholics could be classified as either continuous, explosive, or periodic. For continuous drinkers, alcohol was a daily part of one’s life. Crothers’ explosive drinkers were most similar to Carpenter’s acute typology in that drunkenness came irregularly and suddenly. For periodic drinkers, drinking was heavily correlated with environmental factors and was unpredictable, yet infrequent (Babor, 1996.)
While many of Crothers’ typologies seem to rely heavily on Carpenter’s previous publications, Crothers went a step further and claimed that alcoholism could be either acquired or be hereditary. Acquired alcoholism was claimed to come from the environment, specifically stress and a lack of hygiene (Babor, 1996.) Hereditary alcoholism was founded on “psychopathic disorders” that one was born with (Babor, 1996.) It is important to note that while Crothers’ certainly spread information regarding alcoholism and the causes, the information he presented was still largely unscientific as there were no empirical studies.
In 1938, Robert Knight developed the idea that alcoholism was a symptom that could be treated by reforming the personality (White, 2014, p. 132.) Many of his beliefs and publications seem very related to Freud’s beliefs and teachings. Knight termed three types of alcoholics – essential, reactive and symptomatic. The essential alcoholic, also called psychopaths, had an oral fixation which was the cause for chronic drinking (White, 2014, p. 132.) Reactive alcoholics drink in response to a tangible event and symptomatic drinkers are similar to Crothers’ hereditary alcoholism in that it is caused by psychotic disorders (Babor, 1996.) Knight’s terminology was important to the history of alcoholism because it demanded a psychoanalytical approach of treatment due to the involvement of a person’s personality. Following Knight’s logic, recovery from alcoholism was very rare and highly unlikely as being able to change a person’s personality is extremely difficult (White, 2014, p. 133.)
Jellinek and the DSM
While all of these aforementioned terminologies were highly unscientific, confusing at times, and created a difficulty for reliable diagnoses, they did place an emphasis on the importance of studying alcoholism. In 1952 the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was published. This was the first time that psychologists in America had attempted to create a unifying, broad terminology to understand alcoholism (Nathan, Conrad, & Skinstad, 2016.) The call for the inclusion of alcoholism in this DSM was largely due to the soldiers returning home from World War II, many of which were now struggling with the disease (Nathan et al., 2016.) The first DSM seemed to draw largely on similar ideas as Knight presented – the DSM I classified alcoholism and addiction under the “sociopathic personality disturbance” category of disorders (Nathan et al., 2016.) Another major fault of the first edition of the DSM was that nomenclature was still largely based on clinical observations rather than empirical research. This publication further allowed for alcoholism to be studied non-scientifically and for individuals who were struggling with the disease to be shamed by the public.
E.M. Jellinek was an American scholar who arguably had the most impactful contributions to the early study of alcoholism. His theories were far more sophisticated than previous scholars and physicians and his emphasis was that alcoholism should be studied scientifically (Ward, Bejarano, Babor, & Allred, 2016.) Jellinek was involved in many of the leading world research on alcoholism, including the Yale Summer School of Alcohol Studies, the World Health Organization, and the International Institute for Research on Problems of Alcohol (Ward et al., 2016.) Drawing heavily on his observations, knowledge from working for these institutions, and his own statistically based survey data, Jellinek published The Disease Concept of Alcoholism in 1960 that outlined 5 types of alcoholism as well as the Jellinek curve outlining the phases of alcoholism. Jellinek’s publications were widely accepted not only in America but also in many European countries. In addition, they were extremely influential in promoting that alcoholism was a disease that could be treated, and individuals could recover (Ward et al., 2016.)
In 1968, the idea of alcoholism as a disease had another set-back through the publication of DSM II. Similar to DSM I, alcoholism was a subsection of “Personality Disorders and Certain Other Non-Psychotic Disorders” (Nathan et al., 2016.) The publishers were almost unanimously white males who did not provide hardly any empirical research to support what they considered necessary to diagnosis someone with alcoholism. This publication again brought shame to alcoholics as the disease was classified with other syndromes such as sexual deviations and dissocial reactions (Nathan et al., 2016.) In addition, DSM II used “brief and sketchy” diagnosis criteria which lead to, again, an inability to properly diagnose individuals (Nathan et al., 2016.)
Post Jellinek: DSM III – DSM V
DSM III was published in 1980 and heavily relied on Jellinek’s teachings and research – a huge step in the right direction for people hoping to truly understand alcoholism as a disease. This was the first publication of the DSM that categorized alcoholism in a separate section from personality disorders, instead it was grouped with other substance abuse disorders in the “Diagnostic Categories: Text and Criteria” chapter (Nathan et al., 2016.) In addition, DSM III used research to defend their clear outlining of signs, symptoms and reasons for diagnosis (Nathan et al., 2016.) This allowed for physicians and psychologists to better diagnosis individuals suffering from the disease and therefore generated more valid, reliable research-based data.
DSM IV was published in 1994 followed by the publication of DSM V in 2013. Both publications had goals of being better able to diagnosis individuals suffering from the disease. By this time, society and scientists were largely on the same page that alcoholism was a disease that could result in recovery if patients were helped accordingly – partly due to the emergence of Alcoholics Anonymous in 1935. While all previous publications had maintained that dependency was clearly founded almost entirely on the presence of tolerance and withdrawal, the newest publications wanted to provide clear criteria that also outlined social, psychological, and interpersonal problems as well (Schuckit, Nathan, Helzer, Woody, et al., 1991.) These changes are arguably based heavily on the changes in treatment that was offered to patients. With the emergence of Alcoholics Anonymous and continued research from psychologists such as Jellinek, it was argued that focusing solely on the physical impacts of the disease was not enough to allow for recovery. Although the publication of DSM V came with much backlash from the psychological community, it did provide a clear outline of someone suffering from alcoholism – a huge milestone for anyone hoping to understand the disease as well as properly diagnosing someone suffering from the disease.
Alcoholism as a Disease
While alcoholism dates back over 12,000 years ago, it was first considered a disease in America during the beginning of the 1800s. (White, 2014, p. 2) Dr. Benjamin Rush is often considered the “father of American psychiatry” (Nathan et al., 2016) and was an early advocate for the rights of mentally ill persons (Hergenhahn & Henley, 2014) and people suffering from alcoholism were no different in his eyes. In 1784, Rush first described the uncontrollable urges for people to consume alcohol. Rush was a prominent person in the United States – he was a member of the Continental Congress and an original signer of the Declaration of Independence (White, 2014, p. 2), and therefore his beliefs and publications had a huge effect on America’s views of alcoholism.
Rush was one of the first to emphasize that alcoholism is not due to a person’s character but rather is a medical condition that needs to be treated scientifically (Nathan, et al., 2016.) Rush emphasized that alcoholism was a separate disease itself, attempting to remove the stigma associated with its previous relation to moral character flaws (White, 2014, p. 3.) In addition to publishing the first American psychiatry textbook in 1812, Rush can also be accredited for developing the first institutions, “Sober Houses,” that focused solely on treating alcoholism in 1841 (Nathan, et al., 2016.) Clearly Rush had a huge impact on how the history of alcoholism would unfold. He sought rights for people struggling with the disease, emphasized the importance of removing the sufferer from the environment by giving them time to recover in an institution, and fought to treat alcoholism as a disease.
Rush himself was not an advocate for complete abstinence, but rather that beer and wine should be drank in moderation and hard liquor should be avoided completely (Nathan, et al., 2016.) This was the beginning foundations for the first temperance movement in the 1820s (White, 2014, p. 5.) Unfortunately, society took the temperance to the next level during the 1830s and 1840s, preaching abstinence and once again shaming alcoholics (White, 2014, p. 13.)
With the reformed temperance movement came some of the first treatment centers in America – the Washingtonians and Fraternal Temperance organizations. The Washingtonian society was arguably the first step towards modern Alcoholics Anonymous (Maxwell, 1950.) The Washingtonian Society was founded in 1840 by a group of alcoholics in Baltimore who allegedly wanted to get sober (Maxwell, 1950.) This treatment program focused on sharing personal stories, which was the first of its’ kind and probably the reason for its massive, rapid growth across the America. At one point, the treatment program claimed to have reformed over 600,000 men. The success rate of the program was notably low, however, as 450,000 later relapsed (White, 2014, p. 22.)
The treatment program provided hope of recovery for people and families struggling with alcoholism and promoted the temperance movement and it’s push for abstinence in America (Maxwell, 1950.) Unfortunately, the Washingtonian society was highly unorganized in leadership and, in addition, was founded on a separation of temperance from religion which ultimately caused its demise in the beginning of the 1850s (Maxwell, 1950.)
With the crumbling of the Washingtonian Society came a void for long-term treatment for people struggling with alcoholism. This void was filled by the fraternal temperance organizations (White, 2014, p. 22.) Unlike the Washingtonian Society whose members marched in parades and spoke openly of their drunken mistakes to the public, these fraternal organizations were “secret societies” that demanded anonymity in hopes that more people would join without being stigmatized (White, 2014, p. 22.) This is perhaps the foundation for the “anonymous” in Alcoholics Anonymous. Arguably the most profound impact that the fraternal temperance organizations had on the history of alcoholism was their focus on continued abstinence from alcohol (White, 2014, p. 24.) Many past treatment programs and teachings had focused solely on quitting drinking, with much less emphasis on remaining sober.
The fraternal organizations began to lose memberships during the 1870s due to political conflict regarding women and black membership rights. In addition, the secrecy and the dues that were required by members made the groups too exclusive to join for many individuals (White, 2014, p. 24.)
On the Path to Prohibition
As previously mentioned, the treatment programs in place during the latter half of the 19th century brought many changes to the previous beliefs society held regarding alcoholics. The fraternal organizations taught that sobriety must be considered an on-going process and therefore patients should be considered “recovering” rather than “recovered” (White, 2005.) Dr. Robert Parrish continued building off the foundation that had been built by Rush’s contributions as well as the treatment programs’.
Parrish founded the idea that today would be considered relapse prevention and emphasized that people struggling with alcoholism needed medical treatment and support in an environment that was removed from society (White, 2005.) In 1870 Parrish launched the “first professional organization within the addiction treatment field” (White, 2014, p. 37) called The American Association for the Cure of Inebriates (AASCI.) The number of institutions grew rapidly – in 1878 the number had grown from the original six to 32. AASCI put a focus on scientific treatment by attracting medical professionals to work in the institutions. They also created a journal in hopes of better exchanging accurate, verifiable information regarding the disease (White, 2014, p. 38.)
Parrish founded AASCI explicitly on the idea that alcoholism was a disease that could be cured in a similar fashion to any other disease a person may struggle with. This disease concept ultimately caused many problems that created a path towards demise for AASCI. Many of the institutions began to rebel against Parrish’s founding principles with statements such as, “We do not, either in our name or management, recognize drunkenness as the effect of a diseased impulse; but regard it as a habit, sin and crime” (White, 2014, p. 37.)
Several other attempts were made at treating alcoholism during this time. Inebriate Homes and Societies utilized their belief of the importance of “alcoholic-to-alcoholic mutual support” that originated from both the Washingtonian and fraternal societies previously discussed. In the Inebriate Homes and Societies in the late 1800s, recovered individuals were given a place to work in a sort of peer-mentoring setting (White, 2014, p. 45.) This was one of the first of its kind to employ recovered individuals to help treat others that were suffering. While the idea was revolutionary and, at its core, a positive one. Unfortunately, it also brought backlash as the workers often relapsed therefore not able to provide the treatment needed to help others recover (White, 2014, p. 45.)
The Keeley Institutes were perhaps the most popular treatment facilities during this time period. The first Keeley Institute was founded by Dr. Leslie Keeley in 1879 and “franchises” continued to expand across America until the 1890s, ultimately treating over 400,000 people (White, 2014, p. 82.) The Keeley institutions taught that dependence on alcoholism was due to the change in cell structure that occurred after use of alcohol (White, 2014, p. 71.) The cure for alcoholism was a “Double Chloride of Gold Cure” that was given to patients of the institutions four times a day for four weeks and was supposed to cure them of the disease.
At the height of Keeley Institutions’ popularity, the founder was distributing the cure via mail to provide an option for people who did not wish to enter the treatment facility in person. As probably expected, this distribution quickly ended as the success rate of users was extremely low (White, 2014, p. 76.) The formula for this cure was never revealed (White, 2014, p. 74.) Ultimately, the Double Chloride of Gold Cure injection brought the Keeley Institutes criticism from other medical professionals claiming that Dr. Leslie Keeley was participating in fraud by making a large profit and not actually providing a reliable cure (White, 2014. P. 80.) The ‘beginning of the end’ for the popular treatment facilities began.
As in the past with every previous attempt at treating alcoholism and moving further away from prejudice notions, in the beginning of the 1900s most institutions and asylums closed. During this time, societies’ views of alcoholism again returned to the former state of stigmatization of the disease and its sufferers. The criticisms from the Keeley institutions brought a loss of confidence in treatment centers. Many institutions closed down and the concept of recovery began to again feel farfetched (White, 2005.) The ideas of Prohibition were beginning to build.
The Rise of Alcoholics Anonymous
Alcoholics Anonymous was founded in 1935 and “was part of a larger modern alcoholism movement that between 1935 and 1970 redefined America’s conception of alcoholism and the alcoholic” (White, 2005.) Alcoholics Anonymous (AA) was founded by Bill Wilson and Bob Smith when the two men met to discuss their own personal experience with alcoholism and their desire for recovery (Korsmeyer & Kranzler, 2009.) The founders emphasized the disease concept of alcoholism and worked to push the framing away from being “cured” to the idea of an ongoing recovery process (Korsmeyer & Kranzler, 2009.) The program grew extremely rapidly with over 50,000 members by 1950 (Korsmeyer & Kranzler, 2009.)
The founders seemed to have learned a lot through previous tried and failed attempts at treatment recovery programs. For instance, AA emphasized the importance of working with and sharing stories with other people also struggling from alcoholism with the argument that support comes from sponsorship. This idea traces back to the Inebriate Homes and Societies of the late 1800s. In comparison to the fraternal organizations, AA moved away from required fees and a “secret society” mentality in hopes of being more inclusive by holding numerous free meetings daily that were open to the public while still allowing for members to keep their anonymity. While the Washingtonian society suffered greatly from not being affiliated with a religion, AA found a middle ground in that many of their beliefs and steps of the program involve finding a “higher power” but the program itself claims to be entirely separate from religion (Korsmeyer & Kranzler, 2009.) The Keeley Institutes were in part so successful because of their business-like approach that allowed for unanimity across the country. Similarly, AA keeps meetings very structured and organized allowing for easy access to meetings.
AA teaches the belief that alcoholism holds more than just physical components, also accounting for moral and spiritual components (White, 2005.) This teaching had a profound effect on Jellinek who, as previously mentioned, paved the way for terminology regarding alcoholics being founded on empirical research (Ward et al., 2016.) While AA certainly received backlash similar to past treatment programs and institutions, including the debates that alcoholism is not a disease (White, 2005), the program prevailed. The prevalence can be recognized in part because of the aforementioned change in terminology and an increase of empirical research being conducted regarding the disease. According to the Alcoholics Anonymous website, the program is now immersed in approximately 180 nations worldwide with over 2 million members.
Conclusion
The history of alcoholism in America is tumultuous with as many setbacks as there are steps in the right direction. Benjamin Rush was the first American scholar to
References
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