When I teach medical students about alcoholism, it is never easy. Students arrive with preconceived notions and stereotypes obtained from books, television and films — and their personal upbringings — about the subject.
So I am especially glad that medical, nursing and other graduate students from my institution, New York University, have been attending the play “Bill W. and Dr. Bob” as part of their studies. The drama, about the founding of Alcoholics Anonymous, is a great way to learn how designating something as a disease is only a starting point for understanding the patients who experience it. Yet as I watched the play recently at New York’s Soho Playhouse, I was struck by how little has changed through the years in our beliefs about alcoholism and what we can do about it.
Bill W. and Dr. Bob were Bill Wilson and Dr. Bob Smith, the two alcoholics who started A.A. in the late 1930s. Prior to that time, heavy drinking was largely seen as a moral failing. Organizations like the Women’s Christian Temperance Union promoted the notion that “drunks” and “sots” were sinners too weak to stand up to “demon rum,” beer and other alcoholic beverages. The “treatment” for this condition was to embrace both abstinence and an evangelical Christianity.
With the emergence of the Anti-Saloon League in the 1890s, the focus shifted to legislative control of alcohol, which culminated in 1919 with the Eighteenth Amendment to the Constitution prohibiting the production, sale and transport of “intoxicating” beverages. Although the “Dry’s” had triumphed, their success was limited. By 1933, Americans had turned against Prohibition, which was repealed by the Twenty-First Amendment.
Now able to obtain alcohol freely, heavy drinkers once again began experiencing high rates of liver disease, alcohol withdrawal, delirium tremens and other complications of their pastime.
Attitudes, however, were changing. What if heavy drinking — alcoholism — was not a sin or a sign of weakness but a disease? In 1937, scientists established the Research Council on Problems of Alcohol, which studied alcohol metabolism and drinking behaviors while trying to avoid moral judgments.
But the most notable development in the 1930s was the founding of A.A. As depicted in the play, A.A. resulted from the chance meeting of Bill Wilson, a New York stockbroker, and Dr. Bob Smith, an Akron surgeon in 1935. Both drank heavily and were destroying their marriages and lives. “You want to drink more than you want to live!” Bob’s wife, Anne, screams at him at one point.
Although it did not specifically term alcoholism a disease, A.A. popularized this notion. Bill had heard this language from his doctor. Alcoholism, he explains during the play, is like tuberculosis. Later on, he calls his condition an “alcohol allergy.” The point was that some men — and the disease was originally believed to affect almost entirely men — could simply not drink in moderation. The only solution was abstinence.
What made A.A. unique was its emphasis on alcoholics helping one another stay sober. Bill hopes that he and Bob can create a “chain reaction to reach all the drunks in the world.” As Bob says, “Our service keeps us sober.” There was a religious component to A.A. Five of the original “12 Steps” followed by A.A. members mention God. But “Bill W. and Dr. Bob” largely emphasizes a nondenominational spiritual awakening in which alcoholics admit that they are powerless as the first step to abstinence and recovery.
Of course, calling something a disease did not automatically eliminate the entrenched cultural beliefs about the condition. As with patients who developed lung cancer from smoking or diabetes from being overweight, alcoholics were still often viewed as lazy and merely lacking the willpower to stop an unhealthy habit. On rounds at my hospital, chronic alcoholics who promise future sobriety are generally met with eye-rolling and, at times, derision.
These reactions still occur, even though scientists have recently identified a genetic component to alcoholism. According to the National Institute on Alcohol Abuse and Alcoholism, there are a series of genes that are responsible for roughly half the risk of someone becoming an alcoholic.
Another facet of alcoholism that remains familiar is the lack of good treatment options. Detoxification and rehabilitation programs are expensive and not that effective. And while new research suggests that drugs can be used to facilitate drinking in moderation, I still refer the vast majority of my alcoholic patients to A.A., just as other doctors did 80 years ago. Yet even A.A.’s ability to maintain ongoing sobriety among its participants is only about 10 percent, although certain populations, with stronger social supports, do better.
Perhaps the greatest virtue of “Bill W. and Dr. Bob” is how it humanizes alcoholics. Both main characters display a wide range of behaviors, ranging from empowered to helpless to angry to remorseful. It is hard not to sympathize with them. Anne and Bill’s wife, Lois, realize that they, too, belong to a community of sufferers. They founded Al-Anon in 1951 to assist the spouses and families of alcoholics.
“Take the cotton out of your ears and put it in your mouth,” is an expression used by A.A. members to get recalcitrant alcoholics to keep quiet and listen to their brethren. It is good advice.
Originally published in the “Well” blog of the New York Times, February 13, 2014.