By Steve K.

The medical view of addiction suggests it’s a chronic and progressive ‘brain disease’ which requires treatment. In using the term chronic, I mean long-term and incurable.

“Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry.”  American Society of Addiction Medicine. (1)

This view is supported by Alcoholics Anonymous (AA), which considers alcoholism to be progressive, incurable, and often fatal.

“We alcoholics are men and women who have lost the ability to control our drinking. We know that no real alcoholic*ever recovers control. All of us felt at times that we were regaining control, but such intervals usually brief were inevitably followed by still less control, which led in time to pitiful and incomprehensible demoralization. We are convinced to a man that alcoholics of our type are in the grip of a progressive illness. Over any considerable period we get worse, never better.”

Alcoholics Anonymous, p.30, 3^rd ed.

In contrast to the medical view there are those that don’t consider addiction to be a disease or an illness and contend that the idea of addiction being chronic and progressive is false.

“The idea that addiction is typically a chronic, progressive disease that requires treatment is false, the evidence shows.” (2)

The above quote by addiction journalist Maia Szalavitz is based on research which suggests that most with addiction problems ‘age out’ of their problematic use. However, this is only true in relation to the general population and community studies. Most studies carried out upon those with addiction problems are in clinical settings, and for these people the prognosis is often quite different.

Those with severe addiction problems requiring treatment and/or mutual support group attendance tend to have many more ‘risk factors’ causing vulnerability for chronic, severe, and complex forms of addiction. These risk factors include: a family history of addiction, developmental trauma, early onset use of alcohol and other drugs (AOD), co-occurring disorders, lifetime adversities, and lower ‘recovery capital’. (3) People with chronic and severe forms of addiction do tend to ‘self-accelerate’ their condition. In other words, it tends towards progressive symptoms and use over time.

According to the addiction research expert William L White, there are different types of addiction problems with different pathways of origin… “What I have learned is that there are many “species” (Jellinek’s term) of alcohol problems and that knowledge of one is not applicable to others.”

Unfortunately, some within the addiction treatment arena tend to confuse these different types of AOD problems and make assumptions based upon either community populations or clinical populations. This is an error that leads to narrow and dogmatic views about addiction, rather than the complex reality which requires different treatment options for the various forms of addiction.

“[The] mistaken view that AOD problems in the community are the same as those seen in treatment settings reflects what has been called “Berkson’s Fallacy” or the “Clinician’s Illusion.” The science is unequivocal on this point: conclusions drawn from studies of persons in addiction treatment cannot be indiscriminately applied to the wider pool of AOD problems in the community, nor can findings from community studies be indiscriminately applied to the population in treatment. Studies of AOD problems in the general population reveal distinct subtypes of persons with AOD problems, only a small, non-representative sample of whom are seen in addiction treatment settings.” (4)

It’s clear from my research that problematic alcohol and other drug use, even to the extent of a clinical diagnosis, does not necessarily result in a severe, chronic, and progressive trajectory. In the general population most people do naturally resolve their alcohol and other drug problems, by either reducing their intake or by maintaining abstinence.

However, the view that addiction is a chronic, progressive condition is also true for many found in treatment and mutual help settings, whose AOD use tends to be more severe than those within the general population. This clinical/treatment population tends to suffer with co-occurring illnesses and greater risk factors leading to severe addiction.

AA and The Real Alcoholic.

Thinking about AA ideas… the early founding members of AA were typically severe alcoholics and their suggestion of addiction being a progressive and fatal illness was true for them.  AA literature describes the ‘real alcoholic’ type when suggesting the chronic and progressive nature of alcoholism. The founders’ experience did include repeated detox and clinical treatment and was characterized by relapse and ‘pitiful and incomprehensible demoralization.’ The ‘real alcoholic’ type is differentiated in AA literature from those with moderate to heavy drinking patterns who can stop or reduce their drinking, when need be, or their circumstances change.

Upon reading AA literature carefully, it becomes clear that what is being described is a certain type of addict who cannot control his/her drinking. Specifically, the ‘real alcoholic’ is identified by the mental obsession with alcohol, characteristic denial, and the irrational thinking (lack of whole thinking) that proceeds taking the first drink, despite a long history of suffering and loss due to addiction.

When it’s suggested by AA that drinking problems inevitably progress from the early stages to severe and chronic addiction, it’s directed towards a certain type of drinker, not all people with alcohol issues. AA literature repeatedly describes ‘alcoholics of our type’. This distinction approximately aligns with the research which identifies a relatively small subset of people with drinking problems who do develop severe, chronic, and complex forms of addiction, which are more likely to be fatal.

It can be argued that AA literature should be modernised to reflect the wider array of people with drinking problems that now enter this mutual help Fellowship. As Alcoholics Anonymous has evolved as a proven method of help for those with addiction issues (5), more diverse types of drinking problems are most likely present within AA meetings than in the earlier years of AA formation. Some of these types may not necessarily be chronic and progressive in their trajectory, but are still serious, damaging to the individual and their family, and are for a variety of reasons, best suited to the abstinence approach promoted by AA. Ultimately, there is no guaranteed method of predicting if someone’s addiction problem will progress into a severe, chronic, and fatal condition.

A counter-position is that AA literature, and in particular tradition three, already accommodate all who have a drinking problem and have a desire to abstain. (6)

1. ‘Most people with addiction simply grow out of it. Why is this widely denied?’  By Maia Szalavitz, updated June 14^th, 2017.  Pacific Standard.
2. Ibid.
3. ‘Addiction Risk Factors and Recovery Story Construction. By William L. White, Emeritus Senior Research Consultant Chestnut Health Systems.
4. ‘Recovery Management and Recovery-oriented Systems of Care: Scientific Rationale and Promising Practices.’ By William L White.
5. ‘Does AA Work?’  YouTube Video explaining the latest research into AA effectiveness.
6. The only requirement for AA membership is a desire to stop drinking. AA Tradition Three.  Twelve Steps and Twelve Traditions, pp. 143-149.

* (The term ‘alcoholic’ is regarded as obsolete and not currently used by the mainstream medical profession. The DSM V for use by clinicians refers to the term ‘alcohol use disorder’ (AUD), to represent the wider spectrum of people with alcohol problems which range from mild, to moderate, and severe disordered drinking patterns.)