By Steve K
The ‘Doctor’s Opinion’ is the opening chapter of the book ‘Alcoholics Anonymous’ (4th ed, pp xxv – xxxii). The main part of the chapter is written by Dr William D. Silkworth, M.D. Silkworth was considered an expert in the treatment of alcohol and drug addiction during the 1930’s and worked as the medical director of the Towns Hospital in New York.
Dr Silkworth was in charge of AA co-founder Bill Wilson’s treatment for alcoholism during 1934. Before the book Alcoholics Anonymous was published in April 1939, Wilson asked Dr Silkworth for a supporting statement to help with the credibility of the AA Fellowship and its program of recovery.
Silkworth’s opinion was based primarily on his clinical experience and observations from treating thousands of patients suffering from alcoholism – including some of the early members of Alcoholics Anonymous (AA).
He was also expressing the medical view of alcoholism (a condition with physical, psychological, and social dimensions) that was starting to emerge during the early part of the 20th century. In America, alcoholism (‘habitual drunkenness’) was first described as a disease of the ‘mind and body’ in 1784, by the physician Benjamin Rush in his monograph ‘An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind’.
During the 1800’s, although alcoholism was mostly viewed as a vice and moral weakness by wider society, some physicians started to treat alcoholism as a medical condition. This was during the time of ‘Inebriate Asylums’ and the ‘Temperance Movement’. Various temperance societies and reform clubs, including the Washingtonians, came and went during this period and paved the way for future mutual aid organisations such as Alcoholics Anonymous.
Silkworth’s hypothesis in the Doctor’s Opinion (obsession of the mind and ‘allergy’ of the body) helped to popularise the disease-like medical view of alcoholism among the general public during the 1940’s – 50’s. During this period, researchers including E.M. Jellinek began the systematic study of alcoholism. In 1960, Jellinek published his influential book ‘The Disease Concept of Alcoholism’. He categorized types or species of alcoholism: alpha, beta, gamma, delta, and epsilon. Gamma being the classic ‘disease-model’ type, progressive, incurable and most closely associated with AA. Jellinek’s book firmly established alcoholism as a medical disease in academic, clinical, and public discourse.
During the 1970’s and 80’s the ‘disease concept’ expanded to include drug addiction, not just alcohol. Treatment centres and other 12 Step programs adopted this perspective.
In 1987, the American Medical Association formally declared addiction a disease.
In the 21st century, modern neuroscience and leading researchers such as Nora Volkow (National Institute on Drug Abuse), have emphasized addiction as a ‘chronic brain disease’ involving changes in reward, motivation, and memory circuits.
The disease model is often criticised as being reductionist, downplaying social, cultural, psychological, and choice-based factors. The bio-psycho-social model (Developed by Dr George Engel in the late 1970’s) includes the disease model of addiction but expands this to consider the multidimensional aspects of alcohol and drug use disorders and the whole person and is adopted by most mainstream treatment services today.
The disease model is still widely used, especially in the U.S., but is generally understood as one part of the broader biopsychosocial framework. This framework informs the ICD-11, the international diagnostic manual used by health professionals worldwide and is published by the World Health Organisation (WHO). It’s the global standard for classifying diseases and health conditions.
Dr Silkworth’s hypothesis in The Doctor’s Opinion indicates an obsession of the mind and ‘allergy’ (1) of the body. His suggestion of an allergy-like sensitivity to alcohol was his expression of the physical ‘phenomenon of craving’ his alcoholic patients experienced. Silkworth’s allergy theory in the sense of an immune system sensitivity was subsequently proven not to be the case (Robinson and Voegtlin: ‘Investigation of an Allergic Factor in Alcohol Addiction’, 1952). However, his suggestion of a physical/biological factor involved in addiction was insightful and represented medical opinion emerging at the time.
In general, Alcoholics Anonymous literature doesn’t use the term ‘allergy’ to describe the physical aspect of alcoholism outside of the chapter The Doctor’s Opinion. This was Silkworth’s theory, and Bill Wilson’s comments within the chapter acknowledge this and its lack of certainty.
“The doctor’s theory that we have an allergy to alcohol interests us. As laymen, our opinion as to its soundness may, of course, mean little. But as ex problem drinkers, we can say that his explanation makes good sense. It explains many things for which we cannot otherwise account.”
Alcoholics Anonymous, p. xxvi, 4th ed.
Even so, this chapter has had an influential effect on AA members’ understanding of their alcoholism. Although, many current members of AA no doubt realise that the term allergy is best understood as a helpful medical metaphor.
“Technically, in strictly scientific terms, alcoholism is not a true allergy, the experts now inform us. However, “allergy” is a pretty good figure of speech to describe our condition; if we imbibe the stuff, regrettable consequences certainly do follow.”
As mentioned earlier, The Doctor’s Opinion and the AA Fellowship did inadvertently help to popularise the ‘disease concept’ of alcoholism within wider society. However, the common belief that AA is responsible for the disease-concept of alcoholism, or that it overtly promoted it, is false.
“It is difficult to pick up a book advocating or attacking the disease concept of alcoholism without having Alcoholics Anonymous credited as the source of the modern disease concept of alcoholism. Yet considerable evidence challenges this popular belief.”
‘Addiction as a Disease: The Birth of a Concept’, William L White.
“On the basic question, the data are clear: contrary to common opinion, Alcoholics Anonymous neither originated nor promulgated what has come to be called the disease concept of alcoholism. In the major texts of AA, there appear no discussions and bare mention of “disease,” much less of the disease concept of alcoholism…. Did AA’s use the disease concept of alcoholism? Yes. Did AA’s or AA originate or rediscover or dogmatically push the disease concept of alcoholism? Clearly, No.”
‘Alcoholics Anonymous and the Disease Concept of Alcoholism’, 2002, Ernest Kurtz Ph.D.
‘When AA co-founder Bill Wilson was asked in 1960 about AA’s position on the disease concept, he offered the following response’:
“We have never called alcoholism a disease because, technically speaking, it is not a disease entity. For example, there is no such thing as heart disease. Instead, there are many separate heart ailments, or combinations of them. It is something like that with alcoholism. Therefore, we did not wish to get in wrong with the medical profession by pronouncing alcoholism a disease entity. Therefore, we always called it an illness, or a malady – a far safer term for us to use.”
‘National Clergy Conference on Alcoholism, The “Blue Book”, Vol. 12, 179-210, 1960.’
It is more accurate to say that AA suggests alcoholism is a ‘three-fold illness’ of the mind, body, and soul (I would suggest a ‘4-fold’ bio-psycho-social-spiritual illness). It is a deeply holistic understanding of addiction that affects the whole person and their relationships. The solution offered by AA is essentially spiritual in nature – an approach outside of the medical model that brings about positive and deeply felt ‘psychic change’ within the individual and enables a sober way of life for many.
12-STEP PHILOSOPHY 