History of Alcoholism in the United States
One Nation Under God, Indivisible, with Plenty of Alcohol for All.
Alcohol has a fascinating history here in the United States.
ALL of the Founding Fathers consumed alcohol. We tend to think of Puritans as being anti-alcohol, but early Puritans referred to alcohol as the “Good Creature of God.” With their roots based in European culture, early colonialists approached alcohol as a normal aspect of daily life. Every single person who signed the Declaration of Independence enjoyed distilled beverages on a regular basis.
George Washington himself advocated the constitutional benefits of moderate drinking, and even owned the largest distillery in the country. Troops in the Colonial Army were given a daily ration of either whiskey or rum at Washington’s behest. (Did you know that the Star Spangled Banner was set to a drinking tune?) Women and men drank daily, and often gave alcohol to their children. Few people blinked an eye at the consumption of alcohol for breakfast, as the safety of their drinking water was questionable at best.
What about problem drinking? It was a rarity. In fact, there are NO accounts of heavy drinkers “losing control” of their drinking prior to the 1800s. Most colonial drinking occurred in social situations, and cultural attitudes towards drinking in moderation translated into controlled drinking behaviors. Communities were tight-knit, and expectations within social groups protected people from harming themselves or others. Those who overdrank were held accountable by people they cared about. Alcohol was not viewed as the CAUSE of bad behavior; rather, the individual was blamed for choosing to engage in bad behavior that happened to involve alcohol. Social connections protected people from problem drinking.
The Temperance Movement
The earliest critics of the liberal European attitude towards alcohol consumption were thought of as radical outliers. The word temperance originally referred to moderation – not abstinence. In 1784, Dr. Benjamin Rush published a pamphlet decrying the negative effects of liquor (he felt that beer and wine did not cause problems). Dr. Rush recommended cures for heavy liquor consumption such as “whipping the patient severely,” blistering the ankles, and bleeding the patient. (Dr. Rush also purported that being black was a disease). In 1786, Thomas Sewell promoted abstinence from alcohol by distributing 150,000 pamphlets with images of “alcohol diseased stomachs” to poorhouses, prisons, hospitals, and schools. Activists like Dr. Rush and Thomas Sewell were considered to be part of a small, eccentric minority.
Temperance activists moved from the fringes of society to the center of political discourse in the 1800s, which coincided with Industrialization. The Era of Industrialization devastated tight-knit communities, as the work day forced people to shift their focus to the earning power of a single family unit. Isolation increased. Because workers were expected to be punctual and maximally efficient, problem drinking suddenly became a threat to economic productivity. In 1836, temperance was redefined as referring to abstinence.
As Industrialization degraded the quality of life for most working class Americans, problem drinking became the scapegoat for societal problems of the underclass – crime, poverty, unemployment, and high infant mortality. Because daily moderate drinking was discouraged, because it was believed to compromise worker efficiency, workers instead began to engage in weekend alcohol binges. The awfulness of most industrial jobs was balanced out by the perception of the worker’s “freedom” achieved through weekend benders. This highly visible and dramatic change towards unhealthy drinking behavior led politicians to believe that the poor were responsible for their own problems.
- In colonial times, heavy drinking had been understood as SIDE EFFECT of bad behavior. Leaders in the community took responsibility for holding people accountable for violating social conventions.
- In the Era of Industrialization, heavy drinking was redefined as the CAUSE of bad behavior. Leaders in the community abdicated any sense of responsibility, instead holding the poor responsible for their degraded life circumstances.
As stigma for alcohol use increased, the number of drinking occasions for the average American decreased. With reckless binges and benders on the rise and politicians decrying the immorality of alcohol use, Americans, broadly, came to believe that alcohol was an “evil” substance.
Today, Americans are unified in their understanding of one key fact regarding Prohibition: it didn’t work.
But what is less well-known is how Prohibition also increased rates of binge and bender-pattern drinking, as secretive drinking became glorified and alcohol had to be hidden.
Drinking behavior during Prohibition was unrecognizable from the socially sanctioned, controlled drinking of colonial times. During Prohibition, there were two cultures – abstaining, or drinking heavily. If you were a teetotaler, you shunned drinkers. If you were a heavy drinker, you surrounded yourself with other heavy drinkers. Between Industrialization and Prohibition, the social sanctions around alcohol that prevented Alcohol Use Disorders in the colonial days had completely evaporated.
“Alcoholism” Treatment and the Birth of AA
Bill Wilson and Robert Smith came together in 1935 and developed a philosophy that would permanently grip the national consciousness of the United States – that some people were “allergic” to alcohol, and that these individuals were “born alcoholics.” These alcoholics had an irreversible condition, or disease, that progressively worsened over time. The only “solution” was for the alcoholic to admit powerlessness over alcohol and to attend meetings for life. These meetings became referred to as Alcoholics Anonymous (AA).
AA created a chasm that divided the field of mental health from substance abuse treatment. Although members of AA felt strongly that alcoholism was a “disease,” their credo repudiated the expertise of licensed physicians and medicine in general. The influence of AA was so pervasive that in 1956, the American Medical Association defined alcoholism as a disease, but discouraged its doctors from treating it.
To this day, almost ALL doctors who are willing to confront their patients about alcohol use tell their patients who struggle with problem drinking that the only solution is for them to go to AA. Although a hospital will detoxify a patient, insurance rarely pays for that hospital to continue treatment: patients are discharged once their blood alcohol concentration (BAC) is down to zero and their vital signs are stable.
Therapeutic Communities (TCs): “The Most Dangerous and Violent Cults America Has Ever Seen”
After the birth of the concept of alcoholism-as-disease, millions of Americans found themselves struggling with a problem that had previously lacked definition. Out of this void, a leader of treatment emerged – Chuck Dederich – an AA member who founded the Therapeutic Community. His particular Therapeutic Community was an institution called Synanon, a program that involved breaking down “addicts and alcoholics” through humiliation, starvation, sexual abuse, and physical abuse. Synanon was instituted in 1958 – two years after the AMA advised doctors to refuse care to patients outside of medical detoxification. Synanon was disbanded permanently in 1991 due to criminal activities including attempted murder, child abuse, financial abuse, physical assault, and domestic terrorism.
Synanon was founded as a 2-year residential program, where program members could never “graduate,” because a full recovery was considered to be impossible. This program generated about $10 million per year. By 1980, Synanon had accrued $50 million in assets.
Men were forced to have vasectomies and women were forced to shave their heads. (George Lucas hired several members of Synanon as extras for his movie THX 1138 because he needed actors with shaved heads). In several instances, pregnant women were coerced into having abortions. All members were pressured to cut off relationships with people outside of the program. Babies were removed from their mothers and raised in the “Hatchery.” More than 230 married couples who entered the program together were forced to divorce.
One of the most influential aspects of Synanon was its implementation of a treatment modality called “The Game,” which involved members sitting in a chair in front of others to endure psychological abuse. The member in the chair would talk about themselves, and then endure a barrage of uninterrupted, abusive criticism. (A variation of this program exists to this day – one that I was forced to implement as a new graduate in 2009. I witnessed this method trigger a psychotic break in a patient). The Game could last for up to 72 hours.
The founder of Synanon was arrested in 1978 (while intoxicated – he had consumed a fifth of liquor) and charged with conspiracy to murder and assault with a deadly weapon. Today, at least 50 rehab programs are based on the principles originally espoused by Synanon.
Mel Wasserman, an ardent follower of the tenets of Synanon, founded CEDU Education, one of the first models for private-pay inpatient rehabilitation. CEDU was associated with child abduction, torture, suicide, and murder. Before CEDU, almost no private-pay rehab centers existed.
The Profitable Concept of “Denial”
People who struggled with problem drinking faced a dearth of treatment resources: they could either detox in a hospital or go to AA. Even today, numerous therapists refuse to work with clients who engage in problem drinking or drug use – they tell their clients that they “can’t do real therapy” until the patient has achieved a significant amount of “clean time” through AA. (Can you imagine these same therapists turning away depressed patients because they “can’t do real therapy” until the depression is resolved?)
This is where corporate executives of the rehab industry found a massive opportunity. With so many people unable to access outpatient care, rehabs began to promote the 28-day experience as the only viable solution other than AA. The problem? Only 1% of Americans met criteria for chemical dependence to alcohol at any given time. Of those individuals, few of them had the financial resources to pay for an expensive stay in rehab due to loss of employment and social support as their alcohol use worsened.
Corporate executives of the rehab industry decided to promote a new element of the “disease” of alcoholism – denial. If alcohol treatment centers could convince wealthy Americans that they were actually in denial of their drinking problem, then they could recruit a larger swath of people into treatment.
The genius of promoting “denial” as a medical concept was its unique double-bind: those who minimized their use of alcohol were clearly alcoholics, because they were in denial, while those who identified as being alcoholics were also alcoholics. In this way, a $35-billion-dollar industry was born. There are over 14,500 rehabs in the United States today.
What about those who cannot afford rehab? Over one-third of rehab spots are reserved for people who are mandated to treatment through the legal system, where the only alternative is a stay in prison. The prison-industrial complex and rehab executives benefit significantly from multi-million dollar contracts to bring for-profit treatment solutions to inmates who are unable to be commuted to rehabs. (My first job out of school was working for one such rehab, where my work involved working with low-level offenders who were charged with possession of marijuana).
The Revolving Door of Rehab
Once someone is in a 12-step based treatment center, they will be told that they are “powerless over alcohol” and that they must give up their “selfishness” by being “open, honest, and willing” to receive treatment. Failure to abstain is attributed to the patient’s lack of openness to treatment. They are educated on the “medical model” of alcoholism-as-a-disease, which also accounts for relapse as a normal part of recovery.
Because the disease model of addiction normalizes relapse at the same time that it promotes powerlessness over alcohol, treatment centers have built a stable flow for multiple readmissions into their model. Over 90% of people treated for Alcohol Use Disorder will relapse within the first year; of the 10% who are able to abstain in the first year, over 30% of them will relapse in the years following. This model ensured a constant influx of cash into through the recruitment of patients who have good jobs and family support, but who have also learned to have low self-efficacy due to their belief that they are powerless.
In spite of evidence-based research practices that reduce morbidity and mortality, the programs that continue to profit from the rehab industry are those that eschew evidence-based methods. Evidence-based methods reduce substance-related death by 50% - in stark contrast to the rehab programs that are based on an abstinence-oriented, 12-step methodology.
Q. Are you saying we should drink like colonialists?
A. No. We no longer have a society or social fabric that supports the kind of drinking colonialists enjoyed. Without close-knit communities to watch our behavior, enforce social norms, or model controlled drinking, most of us are left to our own devices regarding drinking.
Q. Are you saying that AA doesn’t work?
A. No. A small percentage of Americans truly benefit from AA because it provides social support and structure. Even though AA is ineffective – and sometimes harmful – when used as a treatment method, a vocal number of Americans report that AA has provided them with necessary social support.
Q. Are you advocating moderate or controlled drinking for everyone?
A. No. Those who suffer from severe psychological disorders and medical issues often cannot drink without exacerbating their condition. Additionally, those who have engaged in daily dependent drinking for several years have often rewired their brains in a way that makes controlled drinking impossible. This is true, in particular, for those who demonstrate chemical dependence to alcohol by their late 30’s and early 40’s.
Q. If 75% of problem drinkers are able to moderate or abstain on their own, without treatment, are you saying that treatment is a waste of time?
A. No. With 17 million Americans currently meeting criteria for Alcohol Use Disorder, that leaves well over 4.25 million Americans in need of treatment. Given the fact that only 1.5 million Americans receive treatment each year, there are over 2.75 million Americans who are in need of treatment in that same period of time.
Q. Are you saying that rehab is a waste of time?
A. No. Rehab is often the only solution when someone requires a higher level of care and supervision in a controlled environment. However, rehab is often overprescribed to those who would benefit more from evidence-based treatment and support in the community.
Q. My significant other/parent/friend/relative is an alcoholic/drug addict. Are you saying that their problem isn’t real?
A. No. Problem use of alcohol and drugs is, by definition, a problem. Loving someone who is struggling with a Substance Use Disorder is inherently a challenging, frustrating, and despair-inducing experience that creates a ripple effect of suffering. Most of the significant others of my clients demonstrate signs consistent with PTSD – hypervigilance, dysregulation, dissociation, and numbing. The negative effects of problem drinking and drug use cannot be minimized.
Q. So what is the solution?
A. The solution for Substance Use Disorders is the same solution we offer to those who suffer from medical conditions – individualized, tailored, and evidence-based treatment. There is hope that substance use disorders will eventually receive this kind of treatment, with the first step being coverage for substance misuse under insurance plans.
Evidence-based practices include:
- Mindfulness-based Cognitive Behavioral Therapy
- Motivational Enhancement Therapy
- Medication Assisted Treatment
- Contingency Management
- Eye-Movement Desensitization and Reprocessing (EMDR)
- Exposure and Response Prevention
- Dialectical Behavioral Therapy
- Behavioral Activation
- Relapse Prevention Planning
- Mindfulness-Based Stress Reduction
Evidence-base approaches to moderate drinking incorporate a menu of options to fit a treatment need based on neuroscience, learning theory, research, and individual presentation. In the same way that not all patients with diabetes need insulin injections and not all patients with heart failure need pacemakers, not all patients with Substance Use Disorders require AA. People suffering from Substance Use Disorders require thoughtful treatment based on individual need and research.
Is moderation for you? If so, I recommend screening yourself with the Drinker's Checkup (it's free!) to see if moderation can benefit you. SS