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Dr. Milam’s Position Papers
More On The Alcoholism Revolution
Dr. James R. Milam
As many readers will remember, "The Alcoholism Revolution"
was published as a special feature in the August 1992 issue of
Professional Counselor. This paper defined the polarity in the field
of addictions: the conflict between two irreconcilable points of view,
the psychogenic and the biogenic. Virtually all of the responses to
that article have ranged from moderately to enthusiastically positive.
Copies have been spreading among readers in the general public, in top
levels of the three branches of state and national governments, and in
scientific and professional communities. There are already indications
that it may significantly influence pending healthcare and criminal
justice reforms. (See "Reactions.")
Briefly, the psychogenic model is based on the nearly universal belief
that alcoholism is a symptom or consequence of an underlying character
defect, a self-destructive response to psychological and social
problems, a learned behavior. The biogenic model recognizes that
alcoholism is a primary addictive response to alcohol in a
biologically susceptible drinker, regardless of character and
personality, or of cultural or psychosocial influences.
Overshadowed by the multitude of researchers who were busy confirming
that the psychogenic paradigm is devoid of any legitimate data base,
many others were quietly compiling a massive amount of empirical
evidence that alcoholism is a primary, biogenic disorder. As all
longitudinal studies have verified, all of the psychopathology of
alcoholism, as alcoholism, is of neuropsychological origin. However,
this fact is disguised because alcoholism is never diagnosed until
after character and personality are distorted and normal emotions are
neurologically augmented to abnormal levels of chronic anguish, fear,
resentment, guilt, and depression. It is these distortions that
clinically identify alcoholism, not the original character and
personality. The earlier effects of trauma or abuse, or of being
raised in a dysfunctional alcoholic family, are complications—but not
contributing causes—of alcoholism. Most often alcoholism is
hereditary, but many individuals become chronic alcoholics through
cross-addiction to other drugs (prescription or illicit) or as the
result of other brain or liver insults.
Compromise attempts fail
Endless attempts at compromise have failed because the two views are
not complementary, but mutually exclusive alternatives, like a
perceptual figure-ground reversal. Compromise was the fatal flaw in
the Jellinek "disease concept" of alcoholism. For all his helpful
descriptions of the progression of the disease, he endorsed the false
belief that alcohol is primarily a sedative drug and that alcoholism
is caused by excessive "relief drinking," drinking to relieve
psychosocial stress. Thus, as secondary consequence or symptom, the
biology of alcoholism could be largely ignored by the establishment in
its diligent search for the presumed primary psychiatric cause of
relief drinking. Following Jellinek, many leading proponents of the
disease concept still try to have it both ways, to assimilate the
fragments of the biological knowledge within the lingering psychogenic
hegemony. Some still mindlessly refer to addiction as "substance
abuse." This conformity necessarily condones the misinformation that
continues to tear the country to pieces and helps to delay the
emergence of the biogenic paradigm.
"The Alcoholism Revolution" does make extraordinary demands on the
reader. It presents an original conceptualization without a
preexisting frame of reference. Ordinarily, scientific truth can exist
only after it is confirmed through procedures of qualified peer review
and consensual validations. That paper explained at length why the
biogenic paradigm has had to make its debut without the usual
scientific pedigree or academic blessing. The normal avenues of
critique and authentication have not been available.
Historically, these internal channels have been open to important
outside contributions, even revolutionary ideas, provided only that
they met high screening standards of scientific integrity and academic
scholarship. In recent decades these standards have been progressively
compromised in obeisance to the higher priorities of
publish-or-perish, grantsmanship, and, more noticeable recently,
political correctness. Shielded within this more general degradation,
the circumscribed field of chemical dependency witnessed the avenues
of impartial review gradually narrow as a result of discriminatory
screening until finally, during the early 1970s, the whole mechanism
of consensual validations was hijacked by a tiny band of extremists,
and it remains their captive.
Prof. Irving Maltzman’s confirmatory paper, "The Winter of Scholarly
Science Journals," published in Professional Counselor in October
1992, documents the capture of the academic peer review procedure and
its continued subversion to protect the otherwise discredited
psychogenic premise. It is this distortion of reality that sustains
both alcoholic denial and the delusion of recreational drug use, thus
perpetuating the drug epidemic.
Looking to the court of public opinion
Although it was clearly by necessity and not by choice, the fact
remains that the biogenic paradigm was conceived and nurtured in
alienation from the scientific establishment and that it has been
presented to the public as a mandate for insurgent reform without
first passing through the naturalizing process of peer review.
Therefore, although it has waited in vain for an impartial assessment
for more than 20 years, it may be that the paradigm and its supportive
evidence must continue to wait in limbo pending scientific ethical
reform. But for both principled and urgently practical reasons this is
not necessarily the case. Given the widening distribution of
enlightening information about the scientific paradigm shift, the
court of public opinion may at any time simply preempt the corrupted
lower institutional court of peer review and initiate this cultural
reform. To further enable and encourage this to be done, the following
examples and clarifications address what appear to be the remaining
veridical reservations and skepticisms about the paradigm shift
itself.
As a first illustration, it was widely reported that upon returning
home, drug-using Vietnam veterans demonstrated that illicit drugs are
non-addictive by simply stopping their use on their own, without
addiction treatment or withdrawal reactions. Aside from the widely
accepted anecdotal reports, support for the argument has come from
studies involving unreported cross-addiction. To those who deny the
very existence of physical addiction, the idea of cross-addiction is
also meaningless, and thus neither reportable nor subject to
surveillance.
Cross-addiction at VA facilities
As a local option, along with psychotherapy, many VA psychiatrists
routinely and unremarkably switched traumatized, addicted returning
veterans to cross-addicting prescription drugs—tranquilizers,
sedatives, and antidepressants, with methadone for heroin addicts.
With this unlimited largess, financial support, a disability pension
in the offing, and therefore ample money for alcohol, these now
lawfully addicted veterans could stop the use of illicit drugs "on
their own, without addiction treatment or withdrawal reactions."
However, over the longer period of a decade or so, the subsidized
poly-addiction produced a familiar result.
A normal brain processes trauma and grief, gradually disposing of them
as fading memories. A toxic brain cannot accomplish this work. On the
contrary, as addictive disease progresses, old hurts fester and become
ever more inflamed and unmanageable. In Vietnam veterans this iatropic
(therapist induced) exacerbation was not recognized or reported as
such; instead it was simply given a new name: Post-traumatic Stress
Syndrome. The new diagnosis played well to a guilty society whose
negative attitudes toward Vietnam veterans did in fact complicate and
slow their postwar healing.
By thus ascribing the later inflammation to the earlier trauma and
negative social attitudes, and by not mentioning the prescription
drugs or alcohol, by default both illicit and prescription drugs were
exonerated as non-addictive. No one seemed to notice that while
drug-prescribed veterans were deteriorating into their post-traumatic
stress syndrome, equally traumatized and equally addicted veterans who
were effectively treated for their addiction, and taken off all drugs
and alcohol, recovered and got on with their lives.
Exploiting onset variabilities
A second type of spurious evidence exploits the variabilities in the
onset of addiction. The strength of addiction is progressive, often
starting near zero and growing stronger at varying rates in different
individuals. Usually there is a threshold below which each user can
and will stop on his own, given a sufficient deterrent. Again, sans
physical addiction there is no threshold to report. It has been easy
for these researchers to contrive samples of sub-threshold drug users
who simply quit on their won. And of course, drug "abusers" who
temporarily or permanently switch to alcohol can also be said to have
quit drugs on their own.
Third is the illustration that although NIAAA is fostering more
studies of the biology of alcoholism, including some good quality
studies of heredity, they are still isolated and compromised by
psychologized explanations. A recent research report in the news
confirmed that, as with men, 60 percent of alcoholism in women could
be accounted for by heredity. Without hesitation or equivocation, the
authors and all respondents gratuitously assigned the 40 percent error
variance to presumed psychosocial causes, considered more important
because "that’s the part we can do something about."
Typically, there was no mention of the several obvious biological
explanations for the error variance:
First: the significant amount of error that inevitably flows
from inadequacies in the prevalent psychogenic DSM-IIIR and other
commonly used diagnostic criteria.
Second: the errors stemming from imperfect diagnostic training,
experience, and skill, and limitations in research design and
implementation, as well as in subject availability and selection.
Third: errors systematically produced by the fact that totally
abstaining alcoholic parents and offspring are commonly classified as
non-alcoholics, resulting in false negatives in the experimental
offspring controls.
Fourth: through cross-addiction to prescription or other drugs,
many of the offspring of genetically non-alcoholic parents become
alcoholics (more false positives), while unknown numbers of genetic
alcoholic offspring switch from alcohol to addictive drugs (more false
negatives).
Finally: the errors produced by such other biological factors
as liver and brain diseases or injuries that affect both alcoholism
susceptibility and manifestation, and, of course, the usual
uncertainties about paternity.
Disguising genetic effects
In the fourth illustration, still wedded to the psychogenic paradigm,
NIAAA was constrained to devote much of the last winter issue of its
quarterly Alcohol and Research World magazine to still more studies of
occupational differences in alcoholism rates. The relatively small
differences were attributed to stress factors and job cultures. The
typical reader would see nothing unusual in this addiction to the flow
of trivia into the alcoholism literature because here the sin is one
of omission. Not mentioned were the differing racial representations
among groups, which earlier studies, long since purged from
consideration, have shown are the significant sources of variance in
alcoholism rates among occupational groups. Thus, disguised genetic
effects are spuriously assigned to job culture causes, with an appeal
for more alcoholism money to further analyze the latter. Similar
strategies of obscuring and misrepresenting genetic contributions to
alcoholism rates are employed in other epidemiological and demographic
studies. The common practice of lumping into categories, such as
"white" or "Asian," cancels most of the extreme genetic variance.
Knowing that, when controlled for heredity, cultural attitudes and
practices are not contributing causes but consequences of profoundly
differing historical experiences with alcoholism, some of the earlier
legitimate occupational studies are as amusing as they are
instructive. American clergymen of all faiths, with their mix of
Irish, Blacks, Scandinavians and other highly susceptible groups, have
an alcoholism rate not 40 percent higher, nor four times as high (the
typical range of differences in the NIAAA occupational comparisons),
but over 40 times as high as members of the Italian Mafia. So much for
stressful work factors.
Native Americans: genocidal disaster
That Native Americans have an extraordinarily high susceptibility to
alcoholism, conservatively above 80 percent of those who drink, in
itself is an unfortunate fact, like the fact that some groups can’t
digest milk from cows (except that milk has high nutritional value and
the ability to digest it might with more justification be construed to
have survival value). Their high alcoholism susceptibility was
immediately evident while they still owned the country as a proud,
brave, highly developed people and the white man was still a tiny
minority along the eastern seaboard. Thus their severe alcoholism
problem is not caused by a native inability to cope with
discrimination, or poverty, unemployment, or battered self-respect, as
virtually every news story deploringly implies. It is their genetic
alcoholism that has exacerbated all of these problems and destroyed
their ability to surmount them.
Again, it is iatrogenic circularity that has disenfranchised them,
laid the insanity of alcoholism on their character and culture, added
egregious insult to already fatal disease, and converted this
limitation—otherwise manageable through abstinence—into a genocidal
disaster. Incredibly, mental health specialists would now have us
believe that this profound inversion of reality should be the
prototype for the treatment of the many other "victim" groups.
Thus we are advised that addiction treatment should focus on the
special "underlying" problems of being a woman, an African-American, a
Chicano, a homosexual, a victim of sexual abuse, or whatever. Nothing
could be more destructive. On the contrary, first restore them to
sanity and selfhood through thorough addiction treatment, emphasizing
the commonalities with other addicts. Only then can they be helped to
realistically address and cope with their special social and personal
problems.
Why psychosocial variables are excluded
The fact that the biogenic paradigm excludes psychosocial variables as
causes of alcoholism does not make it extreme. They were excluded for
four very sound and mutually supportive reasons:
First, no such causes have been verified for inclusion.
Second, the new paradigm accounts for alcoholism without requiring
such causes.
Third, as illustrated above, it explains why so many such factors so
compellingly seem to be causes when in fact they are not.
Fourth, it explains why the unwarranted inclusion of psychosocial
factors as causes only creates an iatrogenic psychiatric problem that
blocks recovery.
Really extreme would be to continue to include such factors. Therefore
there is everything to gain and nothing to lose by taking the
inevitable step of abandoning the one paradigm for the other. Only
then will it be realized that any as yet unverifiable contributing
psychosocial causes would have a far better chance to be delineated
and confirmed within the new paradigm. Of course, because such factors
are not needed to fill any gaps, the assessment of their importance
could not possibly precede but only follow their discovery.
Encouraging news
The most encouraging news from NIAAA is that the funding structure to
foster synthesis across biological disciplines is taking shape. The
many scattered precursors and markers will be gradually brought
together for interdisciplinary study. Apace, and destined to provide
the mutually authenticating window between this scientific integration
and clinical practice, The American Society of Addiction Medicine (ASAM)
is setting a legitimizing example for all other enlightened
organizations and individuals by strongly advising healthcare
reformers to classify addiction treatment as a separate, mandatory
"core benefit," not as a subordinate part of some optional benefit,
such as mental health treatment.
(copyright 1993 by James R. Milam)
Reprinted from Professional Counselor Magazine, Vol. 8, No. 2, October
1993
Special Note with this reprint:
There is reason to hope that as copies of "The Alcoholism Revolution"
continue to circulate they will create a kind of critical mass of
enlightenment that will, through the communications media, explode
into public view.
To this end, please continue to distribute copies, especially to
government officials and community leaders who may influence the shape
of healthcare or judicial reform. And be sure to make copies available
to "multipliers," those who will distribute even more copies.
Please feel free to also photocopy and distribute this paper at your
discretion. Just remember that it is a sequel to "The Alcoholism
Revolution," not a stand-alone substitute.
Reprints of "The Alcoholism Revolution" are available by sending
your name and address to Dr. James R. Milam at:
Milam Recovery Program
12845 Ambaum Blvd. S.W.
Seattle, WA 98146
(206) 241-0890
Reactions to Milam’s "The Alcoholism Revolution"
I really find your paper exciting. I would simply add a comment
that the disadvantage of the biogenic paradigm not being widely
recognized is really not a fault of the paradigm itself but of those
of us who are still in the dark ages. I am delighted that the paper
has been written and hope that it gets wide publicity.
Max A. Schneider, MD
Past President
American Society of Addiction Medicine
Orange, CA
I truly believe that your recent article, "The Alcoholism
Revolution," is one of the best papers I have ever read in my life,
and it certainly states our belief here very clearly.
Stan Hugland, MD
Medical Director
Powell Chemical Dependency Center
Des Moines, IO
It is a persuasive paper…enlightening, if not particularly
edifying.
William F. Buckley
National Review
I will try to share your paper with some of my legislative leader
friends. I will shortly assume the Chair of the Kaiser Family
Foundation. I intend to bring your paper to the attention of the
foundation staff, and perhaps we will have some opportunity to examine
this field of addiction.
Daniel J. Evans
Former U.S. Senator
Seattle, WA
It’s superb. I have given out some 50 copies, and it’s receiving a
warm reception in Maryland and Washington, D.C.
Robert M. Marine, MD
American Society of Addiction Medicine
Annapolis, MD
I have distributed your paper to professionals in the Danbury
treatment field as I believe it to be of immense importance. The Drug
Policy Foundation could sure use your point of view, and I have taken
the liberty of sending your paper to them.
Henry N. Blansfield, MD
Addiction Specialist
Danbury, CT
I am grateful to you for your book, "Under the Influence," and your
current article. I shall use every opportunity to promote your
Biogenic Paradigm in my small segment of the treatment profession.
Norwood Grisham
Addiction Counselor
Oakland, CA
Your most recent article has been well distributed by me to
providers and legislators… We are establishing the annual James Milam
Award for Addiction… You are deeply appreciated, and it is difficult
to find persons to give this award who approximate even a portion of
the contribution you have made.
Linda Grant
Executive Director
Washington Association of
Alcoholism and Addiction Programs
Seattle, WA
It was with great pleasure I read your paper… In a
just-senate-approved, compulsory, 30-hour addiction program…for
medical students, we teach the "Biogenic Paradigm…" I have just been
elected to the Board of Directors of the American Society of Addiction
Medicine to represent Canada… would love to get you involved here.
Ray Baker, MD
Faculty of Medicine
University of British Columbia
Vancouver, BC, Canada
I must say that I was completely unprepared for the impact your
paper had on me. I was so impressed that I read it out loud to my wife
(I hadn’t done that in 20 years!). I just had to write to tell you,
the piece is superb.
Robert J. Markel
Literary Agent
New York, NY
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