Robin Room
Addiction Research Foundation
33 Russell Street
Toronto, Ontario M5S 2S1, Canada
This discussion is concerned with addiction as a set of ideas which have a history and a cultural location. "Addiction" is used here as a general term to cover a territory for which a number of other terms have been used -- notably "alcoholism", and before that "inebriety", in the long history of thinking about alcohol; "dependence", in current nosologies. We are not concerned here with the truth value of addiction and cognate terms, or with their empirical applicability. Thus we are not concerned, for instance, with whether there is really a single entity called "alcoholism", or with whether alcoholism is really a disease.(2) Instead, the concern is with what is meant when we talk about addiction, and with the ways in which this conceptualization of behavior and events may be culturally framed. In the context of a conference on addiction in literature and other cultural products, I will also consider some of the functions that addiction and related concepts serve in American storytelling.
The idea that a concept of addiction in its modern sense first appeared in the early nineteenth century had been foreshadowed in an earlier paper, published by Mairi McCormick in 1969. McCormick's paper on "First representations of the gamma alcoholic in the English novel"(4) focused on British rather than American material, contrasting representations of drinking and its consequences in Smollett and Fielding with those in Elizabeth Gaskell, with the representations in Dickens seen as a transitional. McCormick attributed the shift in framing, which she gave about the same dating as Levine, to the effects of the industrial revolution: "when we look at fiction about 1830, when the industrial revolution was in full swing, we find that the same drinking may be described as existed 80 years before but that a new and more desperate kind of solitary, tragic and inexplicable drinking has come into existence beside it" (pp. 958-959).
Levine's analysis has not gone without challenge. Porter(5) and Warner(6) have pointed to discussions of habitual intoxication in Europe and North America in earlier centuries in terms which prefigure modern addiction concepts. But in my view the main thrust of the analyses by Levine and McCormick holds up, at least in terms of popular conceptions applied by broad sections of the population in everyday life. As an accepted way of understanding human behavior, addiction concepts are a phenomenon specifically of the late modern period.
If we broaden the frame to a global one, and take into account conceptualizations of problems from drinking and drugs in other cultures, again we find good evidence that the concept of addiction is culturally specific. In fact, I have argued(7) that, in the terminology used in considering classifications of disease in a cross-cultural perspective, it may be considered a "culture-bound syndrome", a phenomenon which is specific to particular cultures. While the term "culture-bound syndrome" has primarily been applied to conceptualizations in non-European societies, in the case of addiction we have a condition which is tied to ways of thinking in European cultures.
In a second article,(8) Levine argues that here again there was a shift in American culture at the time of the rise of the temperance movement. In the context of that movement, Levine argues, drinking came into focus as a potential explanation of bad events or behavior. Americans came to see alcohol as an exceptionally powerful substance which not only made drinkers clumsy, but also made them behave in ways in which they would not wish to behave when sober.
Once the connection of drinking or drug use to bad behavior and events is made, this becomes a powerful argument against drinking or drug use and for the user to give up use. In its early, optimistic phase, the temperance movement followed this line. Through thousands of temperance pamphlets and novels, and innumerable presentations by "experience lecturers" dramatizing the degradations of the drinking life and the rewards of the sober one, the early temperance movement sought to build a sober society by education and example. Once the drinker could be taught the error of his ways, he would give up what he must now recognize as noxious behavior.
It can be argued that conceptually the idea of addiction follows from the less than complete success of this rationalistic logic. For not all drinkers did reform, despite the harm their drinking could now be seen as causing. The addiction concept emerges as a way of understanding this failure: the failure of the drinker or drug user to behave rationally (from the perspective of the observer), to stop a recurrent pattern of use despite the harm it is seen as causing. As Edwin Lemert put it over 40 years ago,
So far I have emphasized the inception of these ideas well over a century ago, but it is worth reemphasizing their vitality today. In the two major current classifications of psychiatric disorders -- the International Classification of Diseases, 10th revision (ICD-10),(12) and DSM-IV, the fourth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association(13) -- alcohol or drug "dependence", the currently preferred technical term for addiction, is described in terms of a list of criteria -- six in ICD-10, and seven in DSM-IV. One of the criteria for dependence in these lists is exactly this circumstance which I have described as the starting-point for addiction concepts -- continued use despite knowledge of harmful consequences of the use (item 1a on Chart 1).
Closely associated conceptually with this criterion for dependence is the criterion which is at the heart of addiction concepts: the concept of loss of control, or, in recent formulations, impairment of control. For Jellinek, who in the 1950s turned into scholarly language the concept of alcoholism propounded in the fellowship of Alcoholics Anonymous, loss of control is the "pathognomic symptom" of alcoholism.(14) In Jellinek, as well as in ICD-10 and other professional discussions, the emphasis is on loss of control over drinking or drug use (item 2a in Chart 1). But in the first step of the 12 steps of Alcoholics Anonymous, there is a dual loss of control: not only over one's drinking, but also over one's life because of one's drinking. It is this dual sense which has resonance in American culture in general: not only is the alcohol or drug use behavior seen as in itself out of control -- the user is failing to stop or regulate the use despite the problems it is causing -- but it is also seen as having taken over the user's life, so that the recurrent problems themselves also become part of the condition.
The ideas that good behavior is a matter of individual self-control, and that the individual is responsible for control of his or her own life, are very much embedded in a particular cultural matrix. They make sense in a culture where individuation and individualism are taken for granted, where each citizen has the right to "life, liberty, and the pursuit of happiness". Loss of control over one's own life makes less sense in a cultural matrix where social control is more an external than an internalized matter, and where individual aspirations and autonomy are subordinated, for instance, to the collective interests of the family.
On the other hand, addiction as a loss of control has resonance with ideas which are widespread in other cultures and were well-established in earlier periods in European cultures. It can be seen as a secularized and rationalized form of ideas about possession. Possession had traditionally been thought of in terms of usurpation of a person's being by an alien spirit, something which entered the afflicted person from the outside and took control of the person's behavior against his or her will. The continuity with these ways of thinking is suggested, indeed, by the temperance movement's characterization of alcohol as the "demon rum". Emerging in a secularizing and rationalistic cultural milieu, addiction concepts to some extent filled the ideological gap left by the decline of traditional ideas about possession, with a tangible substance -- a drug or alcohol -- as the alien presence which takes over the afflicted person's personality and behavior.
A third criterion for dependence in ICD-10 relates to the use of time: the neglect of alternate activities in favor of drinking or drug use, and the amount of time spent seeking, using or recovering from use of the drug (item 3 in Chart 1). This criterion is particularly culture-specific. It makes sense as an indicator or component of addiction only in the context of a culture attuned to the clock, a cultural frame in which time is viewed as a commodity which is used or spent rather than simply experienced. Implicit in the criterion is also a set of norms about preferences among activities, with drinking or drug use seen as derogated. For that matter, there is an assumption that desirable activities are alternatives to drinking or drug use, whereas in some cultural contexts most leisure activities involve drinking.
So far our focus has been on the elements of addiction which are primarily descriptive of what is to be characterized: repeated behavior despite adverse consequences, the neglect of alternative functions or pleasures in life, the loss of control over oneself which these are seen to entail. The other elements of addiction or dependence in modern characterizations can be seen as built-in assumptive explanations of these characterizations. In a modern, secularized cultural frame, it is not very satisfying simply to describe a pattern of behavior and leave it as a mystery.
One direction of explanation has been biological. To classify alcoholism or addiction as a disease puts the affliction into the territory of physicians and health, and in our culture this in itself automatically involves a strong privileging of the biological. There are two primarily biological criteria in current concepts of addiction. One centers on withdrawal symptoms, that is, the physical and psychological discomforts which often occur when use of a drug is ceased, and which can usually be relieved by further use of the drug (item 4a in Chart 1). The existence of these withdrawal symptoms is taken as a criterion for addiction, and the fact that further drug use relieves them offers a explanatory mechanism for understanding why use might continue despite adverse consequences. The extent to which this mechanism has been viewed as an important factor in addiction has varied over time and by drug in American culture. In thinking about heroin, the classic image of the "monkey on the back", the need for the drug arising out of the fear of going into withdrawal, has often been seen as all that needs to be known to understand addiction. On the other hand, the present-day scientific literature on alcohol tends to assign "taking a hair of the dog that bit you" a rather peripheral role in explaining addictive behavior.(15)
The other at least apparently biological criterion for addiction is tolerance, that is, that an experienced and habitual user reports needing a stronger dose of the drug to get the same effect as before (item 4b on Chart 1). There is no doubt about the existence of the various phenomena lumped together as tolerance, but their meaning as an explanation of addiction is quite unclear. Needing a larger dose to get the effect sought from using the drug does not explain much at all about why the drug use would be continued despite adverse consequences or apparently against the will of the user. In many cultural milieux, also, having built up a tolerance is a valued rather than derogated personal attribute. Even in our culture, there are those who would find it peculiar to view as signs of pathology that a drinker is able to maintain upright and decorous even after many drinks, or that he or she is able to drink others under the table.
The second direction of explanation is psychological. Here the master concept is of a craving or compulsion: the idea that there is something in the mind of the user which compels use, overriding apprehensions of the adverse consequences, the self-control of the user, and often even the user's will (item 5 in Chart 1). We are again back in the territory where other centuries or cultures might invoke ideas of witchcraft or possession by evil spirits, to explain what appears to be a compulsion which is not subject to the addict's control. Not all cultures would find congenial the assumption, built into ideas of craving and loss of control, that desires are something distinct from the will.
As a concept, craving appears to offer an explanation of loss of control over drinking or drug use. But it begs any questions it appears to answer. It is descriptive of what many heavy drinkers or drug users report experientially, but it does not offer any explanation of the experience beyond a label for it. The mystery of addiction is still maintained. The concept of craving simply pushes it one step further back, offering an apparently empirical and secular identification and firmly locating the source of addiction in the mind of the drinker or drug user.
In this discussion of addiction, I have taken as my guide to its deconstruction the criteria for dependence or addiction identified in a current authoritative source, the recently-adopted ICD-10. I have tried to give some sense of how strongly addiction and related concepts are framed by the outlook and experiences of American cultures and others like it. I should mention that a group of us did set out in recent years to study the question of the cross-cultural applicability of these concepts empirically in nine societies, chosen to be unlike both in their cultures and in their language groups. An overview of the results of this study has recently been published.(16) We found that there were indeed substantial difficulties in applying the concepts cross-culturally.
In general, the depiction of drinking and drug use, and of the phenomena surrounding them, is very widespread in American literature and other cultural products. As symbolically-charged behaviors, drinking and drug use serve many functions in telling a story: in setting a context, as indicators of character, as motivators of the plot, and sometimes simply as a technical device for the storyteller:(18) going to get a new drink, in art as in life, is often simply the signal of the end of a conversation.
But our focus here is on one aspect of the depiction of drinking and drug use: the depiction of addiction. Addiction, and particularly alcohol or drug addiction, is a commonplace in American storytelling. As a thematic emphasis, addiction has a long history. The line of descent, indeed, is unbroken between modern cultural products and the cautionary tales of the temperance movement, with their "drunkard's progress" to the poorhouse and grave.(19)
The overarching image of addiction is of degradation. Without further explanation, we can expect a character we have been told is an addict to do terrible things because of the addiction. The character will lie, cheat and steal, and indeed betray, maim or kill, while in the grip of craving or withdrawal and of the addiction. Often these terrible things break the normal expectations of trust in intimate relationships: they are done to parents, lovers, or children. Often the actions are obviously self-defeating: a writer will try to pawn his typewriter (The Lost Weekend); an actor will be so drunk he is unable to stay in character on stage (A Star Is Born). For the storyteller, then, addiction is an extremely serviceable plot motivator. The most outlandish and outrageous situation or episode of action can be made believable by portraying one of the characters as an addict. In stories, as in life, the addiction concept offers an apparent explanation of the otherwise inexplicable.
Beyond these general functions as a motivator of evildoing, addiction also has a more specific place in the storyteller's armamentarium. The sense of mystery that surrounds addiction as an explanation of bad behavior has not escaped the attention of storytellers. Addiction allows the telling of a gothic tale or horror story in what is seen as a naturalistic fashion. There is no need for a clanking impedimentia of ghosts, devils and zombies, demanding a suspension of disbelief from an uncredulous audience. Instead, all that is needed to set off the drama is a pill or a draught, or even the absence of a pill or a draught. Dr. Jekyll and Mr. Hyde is the archetype of this kind of naturalistic horror story, where the explanation of the transformation into evil incarnate is in naturalistic terms. With its eerie horror music signalling each fit of craving, the film The Lost Weekend set a standard for modern representations of alcoholism as a kind of sporadic possession -- a possession which needs no full moons and bat's blood.(20)
As a kind of secular possession, addiction also offers a further advantage to the storyteller: it is defined as alien to the "real" character of the afflicted person, and potentially it can be cast off. Except for the addiction, then, an addict can be a basically sympathetic character. Often addiction is presented as something which the character fell into unawares, rather than as a foreseeable outcome of behaviors the character sought out. Once present, overcoming the addiction then potentially becomes a test of character and fortitude. In many modern stories, this provides the raw material for the presentation of an alcoholic or addict as hero. As Marcus Grant noted, the addiction becomes "a credible and readily comprehensible tragic flaw". The "lowest common denominator" of alcoholics as heroes, Grant continues, "is that they should transcend their alcoholism. Yet, perversely, it is their compulsive drinking which opens the door for them to heroic action."(21)
Addiction is, then, both an explanation of failure and indeed of evildoing and also an arena for struggle and triumph. From a storyteller's point of view, the most satisfying form of this struggle seems often to be as a lonely battle with interior demons. From The Lost Weekend onwards, there has been a strong tendency for stories about alcoholism and addiction to present the eventual victory as a triumph of willpower, achieved by a hero acting alone. This tendency often creates problems of consistency in presentation. At the heart of the addiction concept, as we have discussed, is the idea that craving and loss of control have proved stronger than the addict's will. The storyteller faces the problem of presenting an eventual triumph of will in such a way that it does not undercut the representation and explanatory power of addiction in the story.
Related to this problem is a problem in real life for those who go through the experience of addiction. For Bill W. and others in Alcoholics Anonymous, the active alcoholic's besetting delusion is that he or she can control his drinking by willpower,(22) and the first step in recovery is to let go of that illusion and the illusion of self-sufficiency. On the other hand, AA's approach is not universal: much cognitive behavioral therapy and the ideology of groups such as Women for Sobriety emphasize strengthening willpower as a treatment approach.(23)
Not all American stories of triumph over addiction present it as a lonely battle. Often, instead, there is a little help from friends. In particular for the male addict, in a paradigm that dates back to the 19th century temperance tales,(24) there is help from a longsuffering good woman.(25) In modern popular psychology, this scenario is seen a good deal more skeptically: the good woman is now defined as "codependent". On the basis of this archetypal plot, indeed, Anne Wilson Schaef has developed a theory of gender relations in American society as whole.(26) Turning our attention back to the uses of addiction in storytelling, the paradigm implies, as Denise Herd has discussed, that addiction fits well into the classic development of the love story. The addiction serves as the impediment that comes between the lovers before their eventual reconciliation, often after working through the problem together.(27)
The depiction of addiction in American stories evokes familiar images, and is built from materials accessible to participants in the culture. In turn, depictions of addiction in the stories have a teaching function. Addiction as an explanation of behaviour at once naturalistic and mysterious; addiction as a cause of degradation and battleground for redemption; addiction as a cause of alienation from social bonds and recovery as a reintegration -- such themes become familiar to anyone who watches, listen to or reads American cultural products. With their worldwide diffusion, these products play a major role in the diffusion of addiction concepts across cultural boundaries. Though addiction emerged as a culture-bound syndrome, we may suspect that the bounds are fast fading.
0. A precondition for addiction concepts: Drug use as able to cause
behavior which would not occur otherwise
PHENOMENOLOGY OF ADDICTION
1. Repeated use of a drug as cumulating to a condition causing bad behavior or events
*1a. Continuing use despite health, psychological, social role problems attributable to repeated drug use
2. Impairment (or loss) of self-control:
*2a. over drug use
2b. over behavior and life
*3. Neglect of other activities for drug use, or misuse of time on drug
use
INTERPRETATIVE FRAMES FOR ADDICTION
4. Biological underpinning of the condition -- momentum provided by:
*4a. withdrawal, drug use to relieve withdrawal
*4b. tolerance
*5. Psychological underpinning of the condition -- craving: "a strong
desire or sense of compulsion to take the substance"
* These are the 6 criteria of the dependence syndrome in the International
Classification of Diseases, 10th revision (ICD-10).
References:
1. Revised from a paper presented at a conference on Addiction and Culture, Claremont Graduate School, Claremont, California, February 29-March 2, 1996.
2. For an interpretation of sociological thinking on these topics, see: Robin Room, Sociological aspects of the disease concept of alcoholism, pp. 47-91 in: R. Smart et al., eds., Research Advances in Alcohol and Drug Problems, vol. 7. New York & London: Plenum, 1983.
3. Harry Gene Levine, The discovery of addiction: changing conceptions of habitual drunkenness in America, Journal of Studies on Alcohol 39:143-174, 1978.
4. Mairi McCormick, First representations of the gamma alcoholic in the English novel, Quarterly Journal of Studies on Alcohol 30:957-980, 1969.
5. Roy Porter, The drinking man's disease: the `pre-history' of alcoholism in Georgian Britain, British Journal of Addiction 80:385-396, 1985.
6. Jessica Warner, "Resolv'd to drink no more": addiction as a preindustrial concept, Journal of Studies on Alcohol 55:685-691, 1994.
7. Robin Room, Dependence and society, British Journal of Addiction 80:133-139, 1985.
8. Harry Gene Levine, The good creature of God and the demon rum: colonial American and 19th century ideas about alcohol, crime and accidents, pp. 111-161 in: Robin Room and Gary Collins, eds., Alcohol and Disinhibition: Nature and Meaning of the Link, NIAAA Research Monograph No. 12. Washington DC: USGPO, 1983.
9. Edwin Lemert, Social Pathology: A Systematic Approach to the Theory of Sociopathic Behavior. New York: McGraw-Hill, 1951.
10. Robin Room, Bring back inebriety? British Journal of Addiction 82:1064-1068, 1987.
11. Robin Room, The social psychology of drug dependence, pp. 69-75 in: The Epidemiology of Drug Dependence: Report on a Conference: London, 25-29 September, 1972. Copenhagen: Regional Office for Europe, World Health Organization.
12. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization, 1992.
13. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: DSM-IV. Washington, DC: American Psychiatric Association, 1994.
14. E.M. Jellinek, Phases of alcohol addiction, Quarterly Journal of Studies on Alcohol 13:673-684, 1952.
15. Tim Stockwell, Alcohol withdrawal: an adaptation to heavy drinking of no practical significance? Addiction 89:1447-1453, 1994.
16. Robin Room, Aleksandar Janca, Linda Bennett, Laura Schmidt and Norman Sartorius, with 15 others, WHO cross-cultural applicability research on diagnosis and assessment of substance use disorders: an overview of methods and selected results [with commentaries and a response], Addiction 91:199-230, 1996.
17. Stanton Peele, The Diseasing of America: Addiction out of Control, Lexington MA and Toronto: Lexington Books, 1989.
18. Lisa M. Heilbronn, What does alcohol mean? Alcohol's use as a symbolic code, Contemporary Drug Problems 15:229-248, 1988.
19. Mark E. Lender and Karen R. Karnchanapee, "Temperance tales": antiliquor fiction and American attitudes toward alcoholics in the late 19th and early 20th centuries, Journal of Studies on Alcohol 38:1347-1370, 1977.
20. Denise Herd and Robin Room, Alcohol images in American film 1909-1960, Drinking and Drug Practices Surveyor 18:24-35, 1982.
21. Marcus Grant, The alcoholic as hero, pp. 30-36 in: Jim Cook and Mike Lewington, eds., Images of Alcoholism, London: British Film Institute and Alcohol Education Centre, 1979.
22. Klaus Mäkelä, Ilkka Arminen, Kim Bloomfield, Irmgard Eisenbach-Stangl, Jarin Helmersson Bergmark, Noriko Kurube, Nicoletta Mariolini, Hildigunnur Ólafsdóttir, John H. Peterson, Mary Phillips, Jürgen Rehm, Robin Room, Pia Rosenqvist, Haydée Rosovsky, Kerstin Stenius, Grayna witkiewicz, Bohdan Woronowicz and Antoni Zieliski, Alcoholics Anonymous as a Mutual-Help Movement: A Study in Eight Societies. Madison: University of Wisconsin Press, forthcoming.
23. Keith Humphreys and Lee Ann Kaskutas, World views of Alcoholics Anonymous, Women for Sobriety, and Adult Children of Alcoholics/Al-Anon mutual help groups, Addiction Research 3:231-243, 1995.
24. Joan Silverman, "I'll Never Touch Another Drop": Images of Alcoholism and Temperance in American Popular Culture 1874-1919. Ph.D. dissertation, New York University, 1979.
25. Robin Room, Alcoholism and Alcoholics Anonymous in U.S. films, 1945-1962: the party ends for the "wet generations", Journal of Studies on Alcohol 50:368-383, 1989.
26. Anne Wilson Schaef, When Society Becomes an Addict, San Francisco: Harper and Row, 1987.
27. Denise Herd, Ideology, melodrama, and the changing role of alcohol problems in American films, Contemporary Drug Problems 13:213-247, 1986.