Recently I read a brief article by George E. Vaillant called “The Natural History of Narcotic Drug Addiction” in the 1970 volume of Seminars in Psychiatry. It was based on follow-up studies of patients admitted to the federal narcotic hospital in Lexington, Kentucky, between 1936 and 1952. I was curious about how or whether it anticipated Vaillant’s conclusions in his influential 1983 book, The Natural History of Alcoholism, which was based on longitudinal data about Harvard students, working-class men, and detox patients starting just before World War II. Before getting far, though, I was struck by the second paragraph:
There seem to be many different kinds of narcotics addicts and in each decade patterns of addiction change. At first glance this makes delineation of the natural history impossible. There are adolescent and middle-aged addicts; there are “criminal” and “medical” addicts; there are heroin and Demerol addicts; there are white Anglo-Saxon Protestant addicts from small towns and black immigrant addicts from urban ghettos; there are male addicts and female addicts; there are high school dropout addicts with inadequate personalities and an allergy to employment and physician addicts who self-prescribe and remain employed throughout their addiction. However, one of the conclusions of this review will be that both the addiction pattern and underlying personalities of these disparate groups are more similar than dissimilar.
Vaillant’s reference to an “underlying personality” among opiate addicts jumps out, because it is a phenomenon he concludes is absent among alcoholics in his later book. But leaving that observation aside, what captured my attention was the rhetorical shape of the long third sentence. It reminded me of a passage written a generation earlier, by Richard R. Peabody in his 1931 book The Common Sense of Drinking:
When we investigate any particular group, we find the most strikingly contrasted persons succumbing to excessive drinking. The rich and the poor, the highly intellectual and the ignorant, the frail and the robust, the shy and the apparently bold, the worried and the seemingly carefree, all furnish their quota of inebriates. We find that this unhappy group includes people of accomplishment as well as those who achieve nothing, the religious and the unbeliever, those with an interest in life and those without one, those who love and are loved, and those who are alone in the world.
Both of these prominent figures in the history of addiction studies drew a series of opposites to illustrate the breadth of social locations that users and boozers hail from. These soup-to-nuts sketches of the social order have been a consistent feature of addiction and recovery discourse over the years. For me, they are signs of the way that the addiction concept has remained bound at a deep level with efforts to define and reform social relations. They are moments when the effort to describe addiction invokes not just a society but a demos, the populace of a democracy.
Vaillant and Peabody’s versions of this rhetorical figure were not in the service of precisely the same point but, if we are willing to temporarily overlook the large distances of time, topic, and technique, their purposes were similar enough. While Vaillant emphasized social categories, and Peabody focused on psychological characteristics, both were tracing out a society-wide swath of users in order to then drill down into the particular profile that addicts shared. So while they were not arguing that addiction is distributed randomly in society, they still conveyed with these figures the notion that its distribution is broad enough to defy social stereotype. One could even call the figure a vehicle for psychology’s claiming turf from sociology, insofar as the social categories simply describe all of society, whereas it takes specialized psychological tools to excavate the causes of addiction.
Two more concise phrases have played similar but less nuanced roles, one in the middle of the twentieth century and another in the past three decades. Since the early A.A. writings (and long before them, in fact) alcoholism, like the God of the King James New Testament, was deemed “no respecter of persons” (i.e. not someone who discriminated by social status). This phrase is all over the Alcoholism Movement. It is the launching pad for Marty Mann’s own version of the aforementioned rhetorical figure, in her 1950 Primer on Alcoholism: “it is no respecter of persons. All manner of people fall victim to alcoholism: rich and poor, educated and illiterate, godly and ungodly, young and old, men and women, ‘good’ people and ‘bad,’ charming people and those without attraction, and everything in between. …. It is human beings who are affected, not groups, classes or types.” “No respecter of persons” was one of those stock allusions that competent but bland writers of the era drew on frequently, the equivalent of high diction in the language of middlebrow expertise. It was needlessly coy in its flaunting of obsolete usage that nevertheless everyone knew the meaning of. It had a late nineteenth century feel to it, and sure enough it appeared in that era’s temperance writings.
Google tells me that the phrase “equal opportunity” surpassed “no respecter of persons” (in printed frequency among its scanned books) in 1904. But this second phrase is still very popular, and it seems a more recent addition to the alcoholism/addiction lexicon, as in the formula popular since the 1980s, “addiction is an equal opportunity destroyer.” Like “no respecter,” “equal opportunity” has seen wide usage among experts and lay spokespeople devoted to promoting the disease concept and reducing stigma. For this reason, anti-disease-concept scholars including Stanton Peele and Gene Heyman have targeted it as a marker for a specific kind of misinformation emanating from both advocates and researchers.
I don’t want to mount a defense of “equal opportunity” addiction language. But I think it is worth noting the context in which it became a go-to term in the second half of the twentieth century. This phrase did not originate as a casual rhetorical reach by lazy writers, but as a specific allusion to the Equal Opportunity Employment provisions of the 1964 Civil Rights Act and its follow-up laws regarding age and disability (which qualified certain kinds of addicts as a protected class). One of the earliest uses I’ve found of “equal opportunity addiction” is in the title of a women’s studies thesis in the late 1970s. In this context it is an ironic usage, not meant to claim universal susceptibility, but a prior history of discrimination. Consider the poster above, released in 2010 by the Illinois Alcoholism & Drug Dependence Association and entitled “Addiction: An Equal Opportunity Disease for Women and Girls.” It argues not for a universal affliction but for gender-specific causes, challenges, and treatment data. The term “equal opportunity” in the title refers to equality of understanding and treatment access, and against identical experience and random distribution.
One of my wider interests is in the relationship between the rise of recovery culture and the progress of liberalism in the twentieth century. The liberalism of the long New Deal era sought to bring classical liberalism’s ideal of equal opportunity (not outcome) closer to reality via certain state interventions like the above-cited laws. I argue elsewhere that recovery culture came into existence imagining an ideal liberal demos – albeit one largely walled off from the full population and its concerns beyond addiction – in which alcoholism had brought everyone to the same state of “equality,” and hard experience had revealed a set of ethical habits for social and political life within it. (A version of Peabody, Mann, and Vaillant’s “opposite types” figure appears in chapter two of A.A.’s Big Book, and the forewords to the second, third, and fourth editions each focus on elaborating this claim of maximum social reach.) I don’t mean to argue that the addiction concept or recovery culture are liberal in a partisan or even theoretical way, but that liberalism and recovery share certain origins, ideals, and historical trajectories. This is evidenced in the strong overlaps on both the right and the left between hostility to liberalism and hostility to recovery culture.
The phrase “equal opportunity” marks an epoch in the history of the wider society’s liberalism. When awareness groups and recovery speakers use this term in regard to addiction, I believe that often they are not so much making an empirical claim about addiction, as they are adapting this once-powerful language of liberal justice to the imaginary democracy of sufferers. Because this distinction is rarely explicit, the phrase probably does mislead more than it illuminates. But I think both experts and laypeople will continue to use it and new, related terms, and their meanings will continue to evolve along with the wider society’s social and political values. As Vaillant concluded in 1970, again contra the strong “equal opportunity” thesis: “Perhaps no mental illness is more a product of its social setting than addiction to narcotics. … Thus, in part the natural history of drug addiction is like that of a society; it must be rewritten every few years.”
Many thanks for your post, Eoin. I would suggest that the “alcoholism can strike anyone” theme harbored a number of additional rhetorical utilities for the modern alcoholism movement that NIAAA inherited from Mrs. Marty Mann and her Yale/AA driven enterprise of the 1940s and 1950s. It complemented the “disease concept” claim by suggesting that anyone and everyone might fall prey to alcoholism, just like with many other diseases. This could have the associated rhetorical advantage of strengthening alcoholism’s claim as a public health problem, as the disease was therefore not the province of one or another subset of the general population. In Mann’s hands, in particular, the anybody-can-get-it theme was useful for breaking down the old stereotype of the skid row alcoholic bum, thus also putatively reducing the prevailing stigma on alcoholism. In NIAAA’s hands the same theme tended to expand its institutional orbit by widening its potential or theoretical service-receiving population. Ironically, the same theme also served the interests of minority subgroups in the population, who could use their disadvantaged and underserved statuses as an argument for the extension of equal treatment services to their numbers. Interestingly, the “…can strike anyone” rhetorical theme didn’t comport at all well with new research findings stemming from survey studies in the 1960s and 1970s. These showed that drinking behavior and drinking-related problems were surprisingly (at least as far as I was concerned!) strongly structured by demographic characteristics. Thus, for example, the great majority of young men drank and drinking-related problems were more than a little concentrated in this subgroup; on the other hand, older women tended more often to be abstainers and were far less prone to reporting drinking problems. The two sets of realities – i.e., the one suggested by the “…can strike anyone” theme and the one suggested by the demography-driven results of survey studies – did not interfere with each other’s rhetorical “work” however. They – once again, somewhat surprisingly – happily coexisted in more or less the same rhetorical space. It would seem that incompatible or even contradictory rhetorical elements can co-exist quite nicely in a public problems arena if the conflicting elements each serve valued purposes. In some sense, I guess, nobody was minding the rhetorical store for consistency! Thanks again for your post. Ron
Thanks for this great overview of the bigger picture, Ron. I should have acknowledged that this is fairly well trodden Alcoholism Movement ground, by you and a few others. Here I was especially interested by the ways Peabody and Vaillant — really thoughtful writers at times — use the “series of opposites” move to negotiate both sides of the inconsistency you describe, and also by the way that the language of Civil Rights law replaced the language of the King James Bible as the Movement’s first generation gave way.
Guilty as Charged: “Addiction is an equal opportunity affliction.”
A central theme that I’ve been teaching in my courses on drug addiction for the past 30 years is exactly what you’ve portrayed so-well from a most interesting perspective offered from another discipline: “Drug addiction is an equally opportunity affliction.” Unfortunately, this is ‘news’ to too many of my advanced undergraduate psychology students. After just a few weeks of examining the diversity of case studies and then providing a simple heuristic model that unifies the many ‘paths to addiction’ to a single common ‘cause,’ students become excited about the ‘recent progress’ in understanding addiction and fully expect that neuroscientists will find ‘the cure’ in short order. That is, now having recognized what really drives addiction, shouldn’t scientists be able to quickly resolve this disorder which extracts such a horrific toll on the individual, on their friends and families, and on society?
The message is what we’ve (i.e., basic scientists) have known for years, but popular media, many clinicians, and even too many misguided drug-addiction specialists have managed to keep the pond muddied by stirring up the waters with popular discourse and dramatic portrayals played out in endless psychodrama that captivates audiences every time across time. In my primary drug addiction course alone I’ve taught nearly 3,000 400-level students at the University at Buffalo during the past 26 years. Surely there should be a multiplicative effect of my training as they go out and spread-the-word as the next generation physicians, clinical psychologists, counselors, sociologists, and even politicians. And there’s the scores of other professors just like me, some teaching this simple theme even longer. But at last, popular misconceptions like superstitions are just too damn hard to kill off. And “today’s insight” will probably remain a “new discovery” for another 25 years as this professor retires and hopefully the next one caries the torch educating and enlightening thousands more during his/her tenure as a university professor. The more things change, the more they stay the same.
The psychobiological model that I teach is rather simple; it’s based largely on what is termed the “exposure model of addiction.” Basically, exposure to an addictive substance and the subsequent effect on brain reward and motivation pathways leads to addiction for many people. The varieties of personalities and subcultures that become addicted is also a product of exposure but with the added feature of psychosocial factors which govern such variables as (1) who has access to the drug, (2) who will experiment with the drug, (3) the cost and purity of the drug, (4) which drug or drugs are popular and how are they administered (e.g., “crack” cocaine is probably more addictive in some respects than is powered cocaine because of the routes they are administered despite being two forms of the same active chemical), and (5) who will find sufficient extrinsic rewards in the culture of their drug-taking behavior (e.g., peers who encourage actual drug taking and its ancillary behaviors) and thus continue their drug-taking behavior long enough for the critical neuroadaptive effects to occur which are ultimately responsible for an addiction. This is where the psychological and sociological variables exert an important influence on who is and is not likely to ultimately become an addict—during the early acquisition stage of developing an addiction (see Bozarth, 1990). There is plenty of room for popular psychosocial and cultural variables to play a role in addiction and to present cyclic variations in “types” of people who become addicts; the role is just much different that commonly perceived. There are also high-risk groups, some genetically predisposed to experience an exceptionally strong motivating effect from their early drug-use experience and there are co-morbid disorders which may introduce a variety of secondary influences on the drug’s pharmacological effects (e.g., ADHD?, psychological depression?). Nonetheless, the “exposure model” provides a point of convergence for the sundry personalities and subcultures that find the allure of the drug irresistible. The drug is guilty; the addict makes one critical mistake—they sustain their initial use of the ‘wrong’ drug sufficiently long for the neurochemical sequel to develop which leads to addiction.
Of course to me, a neuroscientist, it was ‘news’ that anyone else had expressed the vulnerability to addiction that we all face in the same terms that I use beginning each semester (I see from your article that the State of Illinois has even popularized the phrase.). It seems we all could benefit from reading a little more from time-to-time outside our specialty areas and even totally outside our disciplines in a truly interdisciplinary manner. Indeed, I was very much pleased to learn that someone whose training and interests are much different than my own is taking this message to another audience.
The popular media, from talk shows to Hollywood movies, will probably never get on the page and portray the real story behind addiction. They will continue to promulgate the popular myths about addiction finding better dramatic material in the cases that admittedly have an interesting story to tell about why they began their illicit substance use, while obscuring the fact that it wasn’t actually the perverted “Uncle Albert” but the drug which is the responsible agent for the addiction. The truth simply doesn’t make a good story. Mary sexually abused by her grandfather, Tom bullied as a child, Nancy stressed out by her failed transvestite surgery are much more entertaining to watch and read about, and they elicit much more empathy from viewers who can relate to various aspects of the anguish that leads to their addiction. Watching young people experiencing the intense rush produced by “crack” cocaine, bouncing from stranger to stranger on the street looking for money for the next fix to feed their addiction has the home audience chanting in unison “they get what they deserve” and then quickly turning to another program. The market writes the message.
During Alan Leshner‘s tenure as director of the National Institute on Drug Abuse (1994-2001), “addiction is a brain disease” became the mantra of the Institute. Whether it’s a “disease, disorder, or syndrome” may be debatable, but it’s certainly a “brain” something unless one wishes to accept pixie dust as the mechanism behind drives and motivations, lusts and desires. The “patterns” are easy to explain—simply examine the psychological and social-cultural variables that initiate and sustain the period of early drug-use; there your patterns will emerge, based on who tries the drug not on why they try the drug, no requisite personality types or pixie dust required. The ‘chemicals’ in the drug interact with the ‘chemicals’ of the brain—it’s that simple.
Michael, thank you for sharing your perspective in this rich commentary. You sum up one of the things I find most wonderful about Points, and really about drugs and addiction as subjects, when you write about the benefits of interdisciplinary reading.
Your description of the exposure model helpfully draws our different disciplinary concerns into contact. More generally, though, I think you’ll find that many historians, cultural critics, and social scientists are not as confident in the explanatory powers of the brain model as those in your field are. I won’t go into the different critiques people have, except to suggest that the socially defined routes to chemical dependency you discuss often seem better candidates for distinguishing what’s significant about addiction than the chemistry itself. And I should emphasize that my point above was not to argue that addiction does strike with “equal opportunity,” but that this language is important to different constituencies (recovering addicts, psychologists, advocacy spokespeople, etc.) for different reasons. Your comment offers a fascinating account of why neuroscientists also find it useful. Thanks again.