Herbert Fingarette, a mild-mannered professor of philosophy at UC Santa Barbara, has helped uncork a controversy of considerable proportions with his book, "Heavy Drinking: The Myth of Alcoholism as a Disease." In it, he challenges the long-accepted theory that alcoholism is a disease, states that chronic heavy drinkers can often return safely to moderate drinking--and stops just short of charging that alcoholism treatment providers are guilty of a money-grasping conspiracy.
Publication of the book this month by University of California Press dovetails with two events that have reignited media interest in the debate over alcoholism--is it a disease or a behavior?--and catapulted Fingarette into guest spots on radio and television.
One event was the perjury trial of Michael K. Deaver, former deputy White House chief of staff, whose lawyers argued, apparently without convincing jurors, that alcoholism had clouded Deaver's memory when he had been questioned earlier by a grand jury and a House subcommittee about illegal lobbying activities.
VA Rules Challenged
The other is a case argued in December before the U.S. Supreme Court and pending a decision, in which two veterans, both recovering alcoholics who have been sober since the early 1970s, are challenging the Veterans Administration for denying them an eligibility extension for using education benefits. They say their alcoholism prevented them from taking advantage of these benefits within the prescribed 10-year period after military discharge.
The Veterans Administration's position is that extensions are granted only to those with physical or mental problems, "not the result of their own willful misconduct." The plaintiffs contend that alcoholism is an affliction beyond the control of the drinker. The American Medical Assn. and the American Psychiatric Assn. agree, and joined in filing a friend-of-the-court brief.
The case could profoundly affect insurance payments for alcoholism treatment. (Last year 1.5 million Americans were in in- and out-patient programs, with private insurers paying most of the $1-billion bill.)
At the very least, it has heated up a debate between those who accept as gospel that a physiological/psychological predisposition in alcoholics eventually causes uncontrolled drinking for which there is no cure other than abstinence--and those who, like Fingarette, believe heavy drinking is a behavior, not an illness, that some people can moderate.
"The VA is actually saying what I'm saying," Fingarette says. "They based a lot of their case on my research (but) they're talking legalese and I'm talking English. 'Willful misconduct' makes it look as though these people chose to be drunkards." He makes an analogy: "You don't start out deciding to be a three-pack-a-day smoker. You just drift into it."
The idea that alcoholism is an illness is firmly entrenched in American society. Since 1957, the American Medical Assn. has recognized alcoholism as a disease characterized by preoccupation with alcohol and such loss of control over its consumption that one drink usually leads to intoxication. Recent research has focused on the degree to which children of alcoholics inherit the tendency.
Modern treatment programs emphasize family involvement and almost universally require patients to attend Alcoholics Anonymous meetings, while recommending Al-Anon for spouses of alcoholics, and Alateen and other support groups for children.
Nearly 90% of Americans, according to a 1987 Gallup Poll, agree that alcoholism is a disease. But Fingarette--whose interest in alcoholic behavior was piqued 40 years ago with his research on mental disabilities and criminal responsibility--states right off, on Page One: "Almost everything that the American public believes to be the scientific truth about alcoholism is false."
One recent afternoon in his Santa Barbara home, Fingarette, who at 67 is in "phased retirement" after 40 years on the UC Santa Barbara faculty, discussed his convictions and motivation for putting them before a public that, he believes, has been hoodwinked by a fraternity of evangelistic care providers and a cadre of gullible doctors.
In his book, Fingarette takes care to stick to the term heavy drinkers, explaining that anyone attempting to define an alcoholic is "faking it," as are those who say there are 10 million alcoholics in the United States. "All phony statistics," he says.
He acknowledges that he has done no experimental or clinical research on alcoholism but has, rather, analyzed and interpreted existing scientific literature. That, he believes, is "a strength I have," as "people involved in the (research) are all institutionally committed in some way. I have no personal or institutional or other commitments."
The classic disease concept has been "scientifically discredited," he says, citing numerous studies in 15 pages of references. He says that many who work in the field are paraprofessionals who define themselves as recovering alcoholics-- a label he rejects--and are not about to negate personal experience and personal triumph in overcoming their "disease."
What does make some people drink destructively, or abstain? In Fingarette's view, the heavy drinker will choose to be dry for certain periods for reasons that are important to him or her.
And, he states unequivocally, problem drinkers "do not constitute one homogeneous group suffering from one disease." Rather, he says, chronic heavy drinking fulfills different needs in different drinkers. "It's like crime," he says. "It isn't as if there's some one cause, if only we could find it."
Furthermore, telling an alcoholic that he or she is a helpless victim of disease somehow absolves that person of social responsibility, Fingarette says: "If I want to have a fight with my spouse or my boss, I get drunk. The same with drinking and driving."
He dismisses as another myth the idea that alcoholics have an irresistible physical craving for liquor. A drinker is apt to crave a drink if sitting at a bar eating peanuts, he says, but not in an antiseptic-smelling lab.
Fingarette does not deny there is a heredity factor in alcoholism, but says, "Most children born of alcoholic parents will not themselves become alcoholics (and) no one should be misled into thinking that alcoholism is genetic, (that) anyone who has the genes is lost."
Advertising blitzes notwithstanding, he says, treatment programs, all of which seek permanent abstention, provide help that is "modest at best." Experiments suggest, Fingarette writes, that "anything more than an hour or two of common-sense advice from an authoritative person may be a waste of time, money and resources." All in all, he says, "the same number would have predictably improved without treatment."
Because drinking is an "avoidance activity" that in time becomes the alcoholic's central activity, he thinks a new life style is the most effective treatment. Success will depend, he says, on such factors as age, education and income.
"Total abstinence in and of itself is not necessarily a sign of success," Fingarette says, and in fact may cause serious psychological or stress-related problems. "It is possible that at least for some drinkers (especially those younger than 40 with moderate physical symptoms), a form of moderated or controlled drinking might be preferable."
"Some alcoholics can quit without treatment and they are the ones Dr. Fingarette and I don't need to write books about or worry about," says Dr. Joseph A. Pursch, medical director of Family Care Clinic in Newport Beach and a syndicated columnist, in response.
"The alcoholics we end up treating are the ones who cannot stop drinking," he says, and in many of these "there is indeed a wayward gene . . . for those people, the disease becomes rapidly obvious and debilitating. Usually, by their mid-20s, these people are wiped out."
Heavy drinkers who do not have this biological predisposition, Pursch says, "take 15, 20, 30 years to reach that stage where the drinking indeed does become life's central activity" and they then need treatment to redirect their lives. He makes an analogy: "Arnie Palmer would need treatment if he gave up golf."
As for alcoholics successfully phasing into moderated drinking, Pursch says: "All I know is that every effort by skilled experimental researchers, by behavior modifiers, by scientists to pull this off has not been successful. . . . It turned out that (the drinkers) either quit eventually or they have dropped from follow-up, or they died.
"Alcoholism is not one illness any more than cancer is one illness," he says, and a few alcoholics as well as a few cancer patients get well on their own--but they are the exception.
Pursch says that labeling alcoholism a disease means "more people are willing to accept some form of help." But, he says, he does "not accept alcoholism as a license for aberrant behavior or criminal behavior or even unkind behavior." While Pursch says there are no good long-term studies on the extent to which treatment works, "there are a number of Billy Carters and Betty Fords and Buzz Aldrins and Wilbur Mills" who recovered through treatment, not as a result of "persuasions, injunctions or religious conversions."
Since 1970, he says, airlines have treated about 1,500 pilots with a 92% success rate. "These men went into treatment very much against their own will, as a result of a coercive intervention," Pursch says, but even after retirement did not return to drinking.
Fingarette smiles and asks, "Why should my opinion count? A legitimate question."
By writing the book, he says, he hopes to change the agenda of public discussion and make the public and the policy makers aware of what has been happening in science.
The MDs who accept the disease doctrine, says Fingarette, "are doing what they have been told is the thing to do" but a smaller, more sophisticated cadre is "redefining the whole disease concept privately, tacitly."
In the middle, he says, is a public that doesn't have a clear notion of what disease means and thinks the doctors understand it.
However, he says, the disease concept "admirably suits the interests of the liquor industry" and its lobbyists by reassuring thousands of drinkers who decide they do not fit the classic profile of an alcoholic that they can drink with impunity.
The Need to Control
In conversation, Fingarette speaks of "a certain sadism" common to many who treat alcoholics, a "need to control. They're not satisfied if (the cure) happens by itself." He views intervention, in which the alcoholic is confronted by family and friends, as "rough stuff (that) on the whole has not shown it contributes to improvement."
Ed Storti is a highly regarded interventionist who heads Intervention Specialists in San Pedro. Usually, he says, "I'm a last-resort person," called in when the drinker's behavior is causing the whole family pain. And in 12 years as an interventionist, Storti says, "I've never been called by mistake. I've been called too late."
Of Fingarette's theories about treatment Storti says, "I think it's plain sad that in 1988 we're still dealing with these issues. This man makes it sound like, one, it's hogwash, and two, it's voodoo. Millions of people have died over the centuries proving his theory. What I fear is people will read it and say, 'See, Mabel, I can still drink. All these people in these hospitals just want money.' "
Alcoholism, Storti says, is "a very describable, definable disease that's terminal . . . behavior is always about the same in the addictive person, as well as the family. There's always the buildup of tolerance to the drug, there's blackouts or vague remembrances of the night before or the past, there's physical deterioration at a certain stage, and there's withdrawal."
Himself a recovering alcoholic, Storti says he tried the just-one-glass approach but "one would lead to two, two would lead to four and four would lead to destructiveness. When you take the first jolt, it's got ya."
He says his experience with most hospitals offering drug dependency treatment has been "genuine. Yes, many have to make a profit, doctors want to be paid, therapists want to be paid. But who cares, if lives are being saved? I'm not going to quibble about the physician making a dollar for taking out my gallbladder."
Fingarette criticizes Alcholics Anonymous, too, for rendering alcoholics "semi-crippled," for making them feel they are failures if they falter along their road to abstention.
At the AA general service office in New York, a spokeswoman says, "We have a long-held tradition of not being drawn into public controversy." Fingarette, she says, is "not the first person to dispute the disease theory, and he has the right to do that."
AA data for 1987 show 775,000 U.S. members in 38,300 groups nationwide. But, the organization acknowledges, figures are based on chapter reports of those attending meetings at the time. The organization's 1986 random survey of 7,000 members showed that 67% of those who remain active in the fellowship have been sober for a year or longer, up from the first six surveys, when that number fluctuated between 59% and 63%.
Dr. Max Schneider, an internist who is educational consultant for family recovery services at St. Joseph's Hospital in Orange, past president of the American Medical Society on Alcoholism and Other Drug Dependencies, co-chair of the medical-scientific committee of the National Council on Alcoholism and on the faculty at UC Irvine, listens to Fingarette's theses and replies, "I don't agree with any of that--except that drinkers are not one homogeneous group suffering from any one disease."
Schneider says, "All people who drink are not alcoholics, but there is very well documented evidence that approximately 13% to 15% of people who drink for whatever reason are unable to control their drinking in spite of all the education in the world and that if these people, whom we call alcoholics, attempt to go back to social drinking, loss of control will repeat itself. That is not their fault, and they are not responsible for developing the disease of alcoholism, which is a compulsion to re-use with loss of control, in spite of negative life consequences."
Is this compulsion physiological?
"Of course," Schneider says, "in true alcoholism, it must be total abstinence and a new way of dealing with life without using mind-altering drugs.
"The danger for (those) with the disease of alcoholism attempting to go back to controlled drinking is deadly, absolutely deadly. The question is: Why is the emphasis put on having to learn how to drink when the chances and the costs to life and limb for these people are so great?"
Saving Lives, Money
Treatment saves lives, he says, and treatment is cost-effective and in his view the only valid debate about treatment is "which works best," in- or out-patient. Schneider says, "The 21-day or 28-day program is not necessary for everybody, and too short for many."
What is not debatable, in Schneider's opinion, is that alcoholism is "a chronic, incurable disease" and "the first drink is the first step to relapse."
He is "appalled," he says, that in the face of "copious evidence" to the contrary, and the "potential for destruction and death," the theory of controlled drinking by recovering alcoholics is still being put forward. Fingarette, he charges, is using "selected statistics to prove his own point."
Providing treatment to alcoholics "has nothing to do with filling the pockets of physicians," Schneider says. "If I really wanted to fill my pocket, I'd stop treating the alcoholism" and treat patients for the resulting physical damage.
Dr. Marc A. Schuckit is a professor of psychiatry at UC San Diego and on staff at the San Diego VA Medical Center. His research on alcoholism is referred to extensively in Fingarette's book.
Schuckit says it is a "straw dog" to argue about whether alcoholism is a disease on the basis that it does, or does not, result from a chemical aberration or a wayward gene. If there is a predictable process that can be diagnosed and treated, he says, "I guess you would call it a disease . . . . We're just learning what's going on with this process, disorder, whatever you call it. It's something that's very prevalent, God awful and cuts life short."
It is a condition, he says, caused by a combination of genetic factors, social factors and, in some, personality factors--and it is "very, very rare" for the alcoholic to return successfully to controlled drinking.
He disputes Fingarette's assertion that only a small number of children of alcoholics become alcoholics: "If you want to call 30% to 40% of sons small, I guess you look at things differently than I do. . . .In general, the risk (for sons and daughters) is four times higher than in the population at large."
"I know if I were the son of an alcoholic, I would hope I would make a decision not to drink."
Fingarette has something of an ally in Dr. G. Alan Marlatt, a clinical psychologist who is director of the Addictive Behaviors Research Center and professor of psychology at University of Washington.
"There are some individuals who drink moderately after going through treatment programs," Marlatt says, and although that number is only 15% to 25%, "that raises the question of alcoholism being defined as a condition from which you can never recover. It raises a lot of questions. One is: Could certain people be trained to be more moderate in their drinking?"
With National Institute on Alcohol Abuse and Alcoholism funding, Marlatt is working with young male drinkers identified as at high risk of becoming alcoholic, teaching them safer drinking skills, such as spacing drinks to keep blood-alcohol levels down, rather than just telling them that drinking is bad and risk their tuning out.
He does have reservations, though, about whether chronic alcoholics, especially in the 40-plus age group, can return safely to moderated drinking. Abstention is "a whole lot better and easier," he says, as only 1 in 5 are able to become social drinkers.
But, he says, treatment programs "are not reaching 80% of the adult alcoholics. They're just out there drinking away," and to offer controlled drinking might be a way "to get more people in the door."
Marlatt, who identifies himself as one of "a small group of critics of the diseasing of America," says, "Suddenly we're creating a new species--people have this disease and have this progressive downward course but everyone else can drink with impunity. That is crazy. The evidence doesn't support it." And, he adds, "If they think they have a disease over which they are powerless, many well give up.
"The disease theory was good in that it replaced the old moral theory . . . what it really is is an addiction. The real issue is trying to define an addiction."