(Revised from a paper presented at the Alcohol Epidemiology Section Meetings of the International Council on Alcohol and Addictions; 4-8 June 1984, Edinburgh, Scotland. Preparation of this paper was supported by the hospitality of the Finnish Foundation for Alcohol Studies, Helsinki, and by a U.S. National Alcohol Research Center grant (AA-05595) from the National Institute on Alcohol Abuse and Alcoholism to the Alcohol Research Group, Institute of Epidemiology and Behavioral Medicine, Medical Research Institute of San Francisco, 1816 Scenic Avenue, Berkeley, CA 94709.)
This paper is an initial response to a courteous challenge offered by Norman Kreitman, in a letter last December, concerning the usefulness of the "social problems construction approach". Continuing that "this is a perspective which seems now to be the orthodoxy among U.S. sociologists concerned with alcohol matters; I am aware that there are other people writing in a different kind of way but they are very much a minority". Kreitman poses an important question: "as a non-specialist I find it hard to say whether the constructionist theory is going to carry matters very much further, or more accurately, by what evidence you would judge whether it was to be regarded as valid or invalid".
Somewhat ironically, Kreitman then continues with a brief analysis somewhat in the spirit of the tradition he is questioning: compared to what he sees as its status as an orthodoxy among U.S. sociologists, "it is certainly striking that elsewhere the approach seems to generate a great deal less enthusiasm. I suppose some of the Scandinavian folk go along with it, and I can think of one or two British writers too who perhaps fall into the same general group, but all the same it does seem to be that we have here something of a U.S. phenomenon (or is it solely West Coast?)
"If this is correct then one ought to think about the how and why. I suppose the experience of prohibition in the States set a pattern of going to extremes which perhaps persists even when the issues have changed. It could also be that there are many more social scientists in the alcohol world and perhaps orthodoxies give them some kind of collective protection. Another possibility is that the American scene does not contain political parties offering radical political critiques in the way one finds in Europe, so conceivably people who want to go a bit beyond benevolent liberalism have to do so through their professional work.
The questions Kreitman raises are important but difficult, and it is with a sense of hesitation and even of hubris that I try to tackle them. A first task is to zero in on what we are talking about, and to put it in a more general context of movements in ideas. In the broadest sense, "constructionist" has been used as a general label covering a variety of tendencies in modern sociology which are critical of or opposed to positivist traditions. In contrasting "constructionist" with "realist" sociology, Thomason (1982), for instance, is pointing to traditions which in his view emphasize active as against passive views of the relation of the individual to society -- the emphasis is on individuals making society, rather than vice-versa. Bottomore (1982), commenting on Thomason's work, points to the rooting of intellectual traditions with this "active" view of the individual's relation to society in the activism of such periods as the 1960s.
In the more specific context of American sociology, "constructionist" approaches may be seen to have come to the forefront in the wake of the emergence of "labelling" and other "societal-reaction" perspectives in the 1960s. These perspectives took as their focus the subfield of sociology which had earlier been called "social pathology", and then "social problems", but which had now been renamed "deviance". "Societal-reaction" approaches initially focussed on the role of law courts, mental hospitals and other societal agencies in the maintenance of deviance ("secondary deviance"), after the initial deviant act. Labelling theorists were thus interested in processes of social definition of deviance, but the focus was usually at the individual level and ahistorical: what were the social processes which cemented the individual into a deviant career, and often into a deviant subculture? (Critiques of labelling theory -- e.g., Robins, 1975 -- often question the assumption, which labelling theorists shared with such clinical thought, of the one-directionality and irreversibility of the deviant career.) Furthermore, societal-reaction theories tended to focus little attention on autonomous action by the deviant individual or subculture; the processes of social definition were implicitly one-sided, ignoring any "dialectic of resistance" (Piven, 1981). Thus such autonomous counterreactions by the deviant as the formation of or adherence to Alcoholics Anonymous could only be fitted into orthodox labelling theory by the invention of new terminology ("delabeling" and "relabeling", Trice and Roman, 1970).
In the context of American sociology, then, what is variously called "historical social constructionism" (Conrad and Schneider, 1980) or "constructivism" (Gusfield, forthcoming), as a self-conscious stance, may be defined in terms of a series of self-conscious differentiations from other stances concerning the study of social problems.
In common with the societal-reaction stance, but in contrast to older traditions of thought on social pathology, it pays attention to the processes of social definition of social and health problems. It differs from the societal-reaction stance in its focus on the historical dimension in the definitions of and societal responses to social problems, in its emphasis on multiple levels of action -- societal, subcultural and institutional, and interactional and individual -- in the definition of social problems, and in its attention to dissensus and conflict -- and thus to the underdog's as well as the hegemonic perspective -- in the definition of social problems. It differs from classical Marxist perspectives in its emphasis on "relative autonomy" (Morgan, 1978) of the level of ideas from the material level.
The "constructivist" approach is thus a new turning in a long road rather than a wholly new path. And one can certainly find anticipations of the distinctively "constructivist" approach in earlier American sociology -- for instance, in Fuller and Myers' (1941) classic article on the "natural history of a social problem". But the main corpus of "constructivist" work, as we have defined it, finds its beginning in the late 1960s, and becomes a self-conscious movement only in the 1970s.
Alcohol studies have played a role in the American sociological constructivist tradition. The argument of Gusfield's 1967 paper on "Moral passage: The symbolic process in public designations of deviance", which had been regarded as a foundation-stone of the tradition, is illustrated by an interpretation of American alcohol history in terms of "drinking as a changing form of deviance". The program of Herbert Blumer's (1971) call for a redefinition of "social problems as a collective behavior" might be seen as having been anticipated by Gusfield's classic interpretation (1963) of the concerns of the temperance movement in terms of a "symbolic crusade", and as having been carried forward into textbook form (Mauss and Wolfe, 1977) by another sociologist, Armand Mauss, with considerable experience in alcohol research. I have elsewhere written (Room, 1983) of the extent to which, as early as 1960, alcohol sociologists such as John Seeley (1962) were seeing the disease concept of alcoholism as a matter of social definition rather than a statement of fact; this tradition was picked up in a more explicitly historical frame by Levine (1978) and Schneider (1978), and became an important part of the first self-consciously "historical social constructivist" text (Conrad and Schneider, 1980). Whereas alcohol studies had been far from the central concerns of labelling theory or of any other traditions of deviance research, alcohol issues have been quite central to the constructivist tradition. We shall speculate below on why this might have occurred.
So far we have confined our attention, in setting the intellectual context of constructivist alcohol studies, to the rather parochial framework of American sociology, and particularly of social problems research and theory -- a framework which is to a considerable extent moored to such extraneous millstones as how to link a low-prestige subject matter with the central concerns of the discipline and how best to teach (and thus to sell textbooks for) undergraduate courses in "nuts, sluts and preverts." Yet writers in the constructivist tradition in alcohol sociology have invoked and operated within a variety of broader frameworks, signifying, in my view, that the specific alcohol studies constructivist tradition must be seen as a part of general intellectual trends in our time. Kettil Bruun's discussion of models of alcoholism and addiction (1971) applies a classification of competing models of addiction and alcoholism adapted from the clinical literature (Siegler and Osmond, 1968; Siegler, Osmond and Newell, 1968) to the specific historical experience of the succession of models in Finland; Harry Levine's often-quoted article (1978) on "The Discovery of Addiction" pays homage to both Foucault's "birth of the clinic" and Rothman's "discovery of the asylum". Gusfield (1976, 1981) draws on Kenneth Burke for his "dramaturgical analysis" of drunk driving. Behind the concern with the history of conceptualizations and their relation to social conditions and practices can be discerned not only Weber, Durkheim and other sociological antecedents but also influences as diverse as Gramsci (ideological hegemony), Thomas Kuhn (paradigm shifts), and British social and cultural historians such as Raymond Williams and E.P. Thompson (with his aim of rescuing old ways of thought from "the enormous condescension of posterity"). The recent Berkeley conference on the social history of alcohol found a substantial convergence in intellectual frameworks between social historians, sociologists and anthropologists from a variety of national traditions. For instance, the sociological constructivist tradition is congenial to the current emphases in social history on 'histoire des mentalités', on class cultures, and on the interplay between working-class culture and the machinery of social control. Exemplary of the convergence with current emphases in cultural anthropology is Harry Levine's tracing (1983) of historical changes in American definitions of alcohol's effects on comportment, which may be seen as a close analogue -- varying time rather than culture -- of anthropological examinations of cross-cultural variation in drunken comportment (MacAndrew & Edgerton, 1969; Marshall, 1983).
While constructivist studies in the alcohol field actually occupy a much broader territory, many of the best known studies have focused on a set of issues often summed up under the rubric of the "medicalization of deviance". Although this is by now a somewhat standard topic in U.S. sociological journals, a considerable part of the initial sociological questioning of the disease concept paradigm came from outside the U.S. (e.g., Seeley, 1962; Christie & Brunn l969; Robinson, 1972). The concerns of the "medicalization" literature on alcohol, again, converge with those of other research traditions.
Humanistically-oriented critiques of the therapeutic response to crime have been a feature of criminological studies, especially in Scandinavia, for two decades -- and the ensuing triumph of "neoclassical criminology" has had dramatic effects, not always in directions the progenitors find comfortable (Christie, 1981), on criminal justice systems throughout North America and Scandinavia. Critiques of the adverse effects of "total institutions" by Goffman and other sociologists helped set the stage for dramatic alterations in the handling of mental illness in places as diverse as California, Zambia and Italy. Analyses of the "growth of the welfare state" in a variety of intellectual traditions have shared with the sociological "medicalization" literature a sensitivity to the frequent intertwining of social support and social control functions in welfare state agencies.
Since the medicalization literature has occupied so prominent a place in sociological constructivist writings on alcohol, and since I suspect that it is particularly this tradition that Kreitman had in mind to challenge, it is worth pondering why the medicalization of alcohol problems has been so attractive an issue for sociologists, and perhaps particularly for American sociologists. It must first be recognized that there is an objective basis for the interest, both in terms of changes in official characterizations of an institutional responsibility for alcohol problems and in terms of the relatively recent expansion in the health-oriented treatment system for alcohol problems (Mäkelä" et al., 1981). This expansion has been particularly rapid in the U.S., in part as a by product of the peculiar American history of health care financing (Room, 1980; Weisner & Room, 1984). Part of the reason that sociologists have paid particular attention to what they have called "medicalization", then, was that it was in front of their noses. Their interest may indeed have also been heightened by the American pattern of 'going to extremes', as Kreitman puts it, on alcohol issues: the history of shifts in the definition of and societal reaction to drinking problems in America (and not only there -- Bruun, 1971) is undoubtedly dramatic, and thus, as Gusfield's pioneer analysis (1967) implied, particularly suggestive of a constructivist approach.
There are other qualities of the interplay between alcohol and the health domain that may have made it particularly attractive for a constructivist approach. Along with other psychoactive substances, as well as many other commodoties, alcohol is at one and the same time an article of commerce, a locus of both positive and negative cultural symbolism, and a potential source of and focus for health problems; the interplay between the various material and ideological interests involved has been a topic for historical constructivist analysis not only for alcohol but also for tobacco (Nuehring & Markle, 1974; Markle & Troyer, 1979), for marijuana (Faulkner, Krohn & Mathers, 1980), for opiates (Morgan, 1978) and, indeed, for margarine (Ball & Lilly, 1982).
The attractiveness of alcohol issues for constructivist approaches may also reflect the polymorphous quality of alcohol-related problems. More perhaps than any other problematic set of behaviors, problematic drinking behavior perches uneasily astride the intersection of the major institutions and professions which in industrialized urban societies are typically charged with the handling of social problems. The failure of alcohol problems to settle easily into the jurisdiction of any one of the medical , criminal, welfare or religious authorities reflects not only the wide variety of social and health problems which can be linked to drinking; it also reflects that the drunkard, at least in American society, does not seem to and is not seen to fit the particular client role appropriate for any one social-handling institution. As Ron Roizen remarked regarding the moral economy of the handling of alcohol problems in American cities, the drunkard was seen as too good for the jail but not good enough for the hospital (Roizen & Weisner, 1979). The resulting "consistent frustrations", as Bruun (1971, p. 552) puts it concerning the Finnish historical experience, "made us move compulsively from one model to another".
But it must be acknowledged that, among the competing concepts and rubrics that have been used to discuss alcohol problems, it has been particularly the disease concept and health rubric which have attracted the attention of constructivist sociologists. And part of the reason for this may lie in aesthetic criteria specific to sociology concerning what constitutes an interesting sociological analysis. Sociologists tend to treasure an "ironic" stance (Gusfield, forthcoming), which points out hidden layers of social meaning -- latent functions and unsuspected dimensions -- which are not part of everyday understandings. From this perspective, there is not much sociological mileage these days, for instance, in an announcement that crime is a matter of social definition: this dimension of crime is a matter of common knowledge. To bring out the element of social definition in disease has been seen as a much less trite activity. Disease paradigms have offered a particularly attractive target for such analysis because of the strong Platonism and biological reductionism of such clinical thought (Room, 1972). This particular set of emperor's clothes seems to have the ability to bring out the nominalist small boy in most sociologists.
Just as it is the relation of alcohol problems to the medical rubric that has particularly interested constructivists, so the alcohol terrain has been a particular focus for constructivist medical sociology. This focus on alcohol problems, out of the whole range of phenomena of medical interest, reflects particular attractions of alcohol problems, along with other "mental disease" problems, for a constructivist approach. Using Bloor's terminology (1976) concerning the sociology of scientific knowledge, we might say that constructivists have been committed to exploring the "strong program" with respect to the sociology of medical knowledge. To explain this in the context of medical sociology, there are several stances that sociologists - and social scientists more generally - can take and have taken toward medical knowledge. One is the stance of the social epidemiologist, looking at social factors in the causation of disease. A related stance is the explanation of social factors in the handling and outcome of disease. Beyond this, the social researcher can study the organization, ideologies and recruitment practices of medical professions and organizations. All of these are time-honored pursuits in medically-oriented social science research, pursuits that are highly relevant to all illnesses, times and places. But these stances in general accept as given the disease categories of western medicine, and in this sense are "weak programs" with respect to the sociology of knowledge. The "strong program", to which the constructivist tradition aspires, instead examines the content of the medical knowledge, looking for evidence that this knowledge is "culture-bound", that social factors are built into the very structure and content of this knowledge.
While evidence in this line can be found in a variety of medical terrains, it is nevertheless a program that is easier to carry into action in some parts of the terrain of medical knowledge than in others. Consider, for instance, the list of conditions chosen by Conrad and Schneider (1980) for their extended consideration of the "medicalization of deviance": madness, alcoholism, opiate addiction, homosexuality, juvenile delinquency, crime, hyperkinesis, and child abuse. It is a list that, in terms of the internal jurisdictions of medicine, belongs almost completely to psychiatry: we might more exactly speak of the "psychiatrization" than of the "medicalization" of deviance. It is the application of a medical rubric to behavior -- and usually to behavior which is already regarded in some way as problematic (Conrad & Schneider, 1980, p. 272) -- which has particularly attracted constructivist sociologists. Given its obvious behavioral components and dramatic history as a problem, the field of alcohol problems was thus a particularly attractive territory for this approach.
Djurfeldt and Lindberg (1975, pp. 20-21) have noted a similar specialization of subject-matter in what, in the terms used here, might be called the "strong program" in medical anthropology. Thus "ethnomedical" studies, where "illness tends to be viewed as a cultural category and as a set of culturally related events", typically do not equal with the "mass killers and cripplers" of the developing world, but "typically deal with topics such as sorcery, witchcraft, shamanism, folk psychiatry, and 'culture-specific syndromes', like the Mexican susto, the Papuan lulu, the New Guinean nenek and guria".
To summarize the argument so far, we might say that historical constructivist approaches are the particular manifestation in American sociology, particularly in the sociology of social problems, of more general intellectual trends. Gusfield (forthcoming) has conveyed in part the sweep of these trends in noting that "the constructivist approach to the study of social problems is an aspect of the great impetus toward a reconstituted sociology which has been one of the dominant theoretical movements in the realm of ideas during the past decade. It has gone by many names and in many directions -- ethnomethodology, phenomenology, various kinds of structuralism, cognitive sociology, hermeneutics, symbolic interaction". Within the constructivist tradition, alcohol issues have been a major terrain of work. In explicitly constructivist studies on alcohol, a major focus of studies has been on what is often termed the "medicalization of deviance".
Before turning to Kreitman's questions about the utility and testability of constructivist work, let us take a critical view of the emphases and accomplishments of work on alcohol in this tradition. This work has proceeded in a number of different directions. Indeed, even restricting our attention for the moment to work which fits under the "medicalization" rubric, there are several distinct traditions of analysis.
(1) From the perspective of general American sociology, the most widely recognized tradition of constructivist research on alcohol focuses on the interplay of interest groups in the adoption in the U.S., over the last 40 years, of the disease conception of alcoholism. This is by now an often-told tale (told by participants in the movement as well as by sociologists), which fits well into some of the leading themes of the self-conscious constructivist tradition (see Schneider, 1978): the emphasis on "moral entrepreneurs", i.e., small bands of activists who bear a large responsibility forthe adoption of a new paradigm; the relative attractiveness of the disease concept to beverage industry interests; and the expansive jurisdictional aims of the newly-formed therapeutic field (Wiener, 1981; Gusfield, 1981; Chauncey, 1980).
This tradition is not without its problems. Studies which draw on detailed work with primary sources tend to be concerned with relatively limited parts of the story (Rubin, 1979) or to deal only with the more recent history. The more general interpretations which have had a wider circulation in sociology (Schneider, 1978; Watts 1981) rely mostly on secondary sources, and in my view get the story wrong in significant details. Sometimes the story of the alcoholism movement is a side-issue: thus the primary material for Gusfield's most recent analysis (1981) is the somewhat separate arena of drunk driving, and his focus is on the relation of scientific claims-making to public policy. In general, the attention in this tradition to the claims of the moral entrepreneurs might well be balanced with more attention to the reception and fate of those claims. As discussed below, there has also been little attention as yet to the extent and nature of differences between the U.S. and other national experiences in the same period.
(2) Another, somewhat older tradition, has focused on analyses of the disease concept of alcoholism at a conceptual and empirical level. This tradition in fact was under way by the late 1950s (see Room, 1983), and has been a rather multinational effort (e.g., Seeley, 1962; Sargent, 1968; Christie and Bruun, 1969). The hallmark of sociological approaches to the disease concept has been a nominalist stance, as against the Platonic idealism which characterizes much clinical thought (Room, 1972), and a concomitant interest in examining the empirical interconnections between the components of an alcoholism or alcohol dependence syndrome concept. Although work in this tradition often had more ambitious aims, perhaps its most notable practical effect has been its role in trimming from official definitions of alcoholism some of the "oddments of aggregation" found in earlier definitions (Seeley, 1959). Thus it can be seen as having influenced the distinction between the broad field of "alcohol-related problems" and the narrower concept of the "alcohol dependence syndrome" which is now standard in World Health Organization reports and other consensus documents. Much of the work in the tradition has paid primary attention to scholarly presentations of the concepts, although there has been some linkage with survey studies of the popular reception of and meaning given to the disease concept of alcoholism (see Room, 1983, pp. 69-72). Thus it might be said that the tradition has generally lacked a historical dimension, has paid little attention to the material context of the ideas, and has often lacked a sensitivity to the connection between popular and scholarly conceptions. Like the clinical literature it is critiquing, it has also tended to stay mostly within the frame of reference of Anglophone cultures.
(3) A more specifically historical dimension has been added by Harry Levine's work (1978) linking the modern disease concept of alcoholism to 19th century temperance conceptions of addiction. Whereas previous analyses, including those in the constructivist tradition (e.g. Gusfield, 1967), had accepted the alcoholism movement's contrasting of the temperance movements "moralism" with the new alcoholism concept, Levine's analysis showed continuities between the new concept and 19th century thought -- not only with the small inebriates' home movement led by physicians, but also with the general conceptual underpinnings of 19th century American temperance thought. Linking his analysis to the broader frame of Foucault's discussion of a general "shift of gaze" in the era around 1800 concerning the sources, nature and appropriate management of problematic behavior, Levine argues that the idea of addiction as a loss of control by the individual over his or her own behavior reflects the needs and concerns of an industrializing society for internalized and individual self-control.
While Levine's analysis has been widely incorporated into other accounts, the fact that it actually creates some difficulties for constructivist accounts of the alcoholism movement's successful drive for medicalization has not been widely discussed. If an addiction concept was already strongly entrenched in the culture, what was the nature of the movement's victory -- and how much was it really due to the movement's "moral entrepreneurs" (or, as they might have styled themselves, "anti-moral entrepreneurs")? If the heart of the movement's conception is about self-control, how are we to interpret its claim that it was replacing the "old moral conception"? A further unsolved puzzle posed by Levine's analysis is the continuity of the addiction concept over time: if it derived from and responded to the historical circumstances of the early 19th century, one might have expected the substantial subsequent changes in American society to have resulted in considerable changes in the concept (here Beauchamp [1980] enters the argument to aver that the shift from the temperance idea that addiction was inherent in the substance to the alcoholism movement's idea that addiction is a matter of defective individuals is in fact a more significant change than Levine acknowledges). As these questions imply, there is also a need to extend an analysis in Levine's style to the histories of conceptions of alcohol problems in other societies.
(4) A fourth strand of work focuses on the big systematic shift in the last 30 years toward the handling of problematic drinkers in health systems rather than criminal systems. While the historical period this tradition focuses on is much the same as the first tradition described above, the emphases are substantially different. The shift is commonly linked with the "rise of the welfare state", or sometimes of a "therapeutic state", and accordingly the analysis pays more attention to the playing out within the alcohol arena of general societal trends, and less attention to the particularistic activities in the alcohol field of "moral entrepreneurs". The literature is also somewhat more international and comparative than the other literature we have been considering.
Broadly speaking, studies in this tradition do find that there was a general move in most industrialized countries towards a "medicalization" of the handling of alcohol problems, in the sense that the ratio between medical-system and criminal-system expenses in handling alcohol problems seems to have tipped in most places towards the medical system (Mäkelä et al., 1981). But the trend is not without exceptions, and is often tinged with ironies. In Italy, the highly politicized "deinstitutionalization" of mental health treatment in recent years meant the closing, often without effective replacement, of the one institution explicitly providing alcoholism treatment. In California, it can be argued that the triumph of the disease concept has meant that the alcoholic is now in an institutional frame where he or she is less likely than formerly to be treated by a doctor. Furthermore, the hugely increased alcoholism treatment capacity in California is now rapidly becoming an adjunct of the criminal court system, so that it is increasingly plausible to argue that treatment has become a mode of rather than a replacement for punishment (Weisner and Room, 1984).
Analyses in this tradition have often explicitly seen the postwar "medicalization" of alcohol problems as a chapter in the longer story implied by an analysis like Levine's (Müller and Tecklenberg, 1978; Mäkelä, 1980); thus the postwar shift towards alcoholism treatment -- occurring in most countries quite late in the welfare state era -- might be seen as representing the actualization, in an era of increased state investment in health systems, of a cultural model of alcohol addiction which finds its roots in the last century. At this point, the studies link up with broader constructivist presentations, such as Conrad and Schneider's (1980, pp. 32-35, 261-265), of the "medicalization of deviance" in a historical perspective. In the alcohol field, empirical work on the day-to-day conceptualization and phenomenology of treatment and other social handling, in historical and comparative frames, is only now in progress (see McLaughlin, 1991; International Group for Comparative Alcohol Studies meeting on "Societal Responses to Alcohol Problems and Development of Treatment Systems", Stockholm, 23-27 October, 1984). In my view, such work will be a useful corrective to the tendency in the general constructivist literature evidenced in Conrad and Schneider's book, to put too great a focus on the "claims-making" activities of what is admittedly often "only a small segment of the medical profession" (pp. 267, 272).
So far, we have been considering only studies which fall broadly speaking under the "medicalization" rubric. Before turning to other alcohol studies in the constructivist tradition, it seems appropriate to venture a few generalizations which represent both conclusions from and critiques of medicalization studies.
(1) It is by now clear that medicalization by no means precludes a moral approach to behavior (see Room, 1983, pp. 70-73) -- in fact, it has been argued that, for alcoholism in the present-day U.S., "moralism is more strongly a part of the classical disease concept than it is part of the background . . . climate of opinion" (Roizen, 1977). At an institutional level, there is no doubt that a switch of the social handling of inebriates to a medical frame has often meant more humane treatment. But sociologists must face the task not only of pointing out that this has by no means always been the case, but also of tracing the complicated and often overlapping jurisdictional boundaries between medical, criminal and other social-handling institutions.
(2) While there are undoubtedly some commonalities in ideology and procedure throughout the medical/health jurisdiction, there are also big internal differences; the "action models" (Room, 1978) differ for different diseases; often, in ill-organized territories like alcoholism, these action models are indicated by analogies: "alcoholism is a disease like "diabetes" or "an allergy" or "bronchitis". Popular thought also distinguishes among diseases in terms of moral standing (Levine and Kozloff, 1978). Sociological discussions of "the medical model" should therefore be balanced by attention to the variation in action models within medicine.
(3) Although sociological attention to medicalization reflects the focus of public discussions of alcohol problems, at least in the U.S., on this dimension, the medical/criminal interface is not the only locus of change in the definition and handling of alcohol problems. For instance, these have often been substantially affected by changes in the general provision of welfare services; thus rules on food-stamp (means-related food subvention) eligibility in the U.S. greatly affect the viability of nonprofit "recovery homes" (halfway houses). Attention to changing definitional rhetorics needs to be complemented by attention to changes in the concrete processing of cases.
(4) Constructivist analyses should resist any tendency to ignore or discount objective realities which act at least as limits on processes of social construction. People die of alcoholic cirrhosis, or in drunken car-crashes; others are harmed by the drinker's behavior; a drunken person indeed is less capable of performing skillful tasks. These events are all indeed subject to social construction as to their definition and implications, and the recognition and import of the alcohol link, in particular, is subject to construction. But there is still an objective residue, no matter how it is constructed: the person is dead or harmed, the task undone or done clumsily (Room, 1978). From this perspective, the health system has always had jurisdiction over many physical ailments and casualties now defined as alcohol-related, irrespective of any definition as alcohol-related.
From my point of view, then, the distinctive subject matter of a constructionist sociology of alcohol problems, or more generally of social problems, is not only "the process by which members of groups or societies define a putative condition as a problem" (Spector & Kitsuse, 1973), but also the interaction between these processes and objective conditions. Work since Spector and Kitsuse wrote (e.g., Gusfield, 1981) has certainly underlined in the context of alcohol problems their point that "evidence of objective conditions" is itself a product of and subject to collective definitions (Kitsuse & Spector, 1973, pg.414), but in my view this point in no way eliminates the need to pay attention to the dialectic between social definitions and material circumstances. While Kitsuse and Spector propose that attention to objective conditions "would deflect attention from investigation of the definitional process", in actual practice, I believe that a focus on the interplay between ideas and objective circumstances has been a consistent feature -- though often covert and ironic -- of the most influential constructivist analyses.
(5) It may be time for a frank discussion of the half-spoken ideological engagements of constructivist sociologists, and of the influence of these on their work. Here I may differ in part from Gusfield's presentation (forthcoming) of constructivism as "on the side", a sociology "not engagée but detachée whose ironic skepticism about the factual basis of social problems places the sociologist in an Olympian position". The main line of Gusfield's argument about the gulf of misunderstanding between constructivist perspectives and conventional American liberal positions on alcoholism is instantly recognizable, indeed poignantly so, for American alcohol sociologists. But in my view, Gusfield's formulation is to some extent self-contradictory. The "ironic skepticism about the factual basis of social problems" in my view does not mean that "the 'reality' of the conditions . . . are not within the scope of constructivist perspectives"; in practice, it has usually meant that the constructivist has an implicit picture of "reality", with respect to which the official claims of social problems agencies are seen as being inflated. As Gusfield himself goes on to say, "even a rhetoric of detachment contains a moral message, and hence a mission, though diluted. . . . It is the social problems industry itself that emerges as the object of critique. . . . The critics of medicalization come to be the champions of the deviants against the arbitrariness, partiality and authoritative claims of the professional experts whose mandate rests on belief in the factual existence of the conditions they attempt to alleviate. When these are placed in doubt the agents are dispossessed.
This is in my view a fair statement of the implicit orientation of much American constructivist work. But it is an orientation which is itself rooted especially in a particular time and place, in the era of the mature blossoming of the welfare state, and in a political culture where the "problem amplification" against which much constructivist work has been directed has been the common currency of competition for public and policy attention to a given problem area. Now the U.S. is to some extent in a new era; Reagan's "budget reconciliation" exercise was essentially an announcement that problem claims would be ignored. (Oblivious to the confluence of their views on the institutions of the welfare state with the tenor of much sociological analysis, Reagan's men made special attempts to cut "social science" wherever they found it in the federal budget, and sociology as a discipline found itself making amplifying claims about its usefulness.)
But sociologists, at least in the alcohol arena, have not followed the lead of their neoclassical criminologist colleagues or of Reagan's budgetcutters: the critical view of medicalization has rarely been accompanied by a clear statement of preference for demedicalization. The detachment Gusfield describes in my view partly derives from American sociologists' political and ethical discomfort with the likely alternative to medicalization. Conrad and Schneider's book exemplifies the uneasy response to this dilemma in constructivist discussions of medicalization. After an extended critical description of the process of medicalization in a number of fields, they proceed to lay out both the "brighter side" and the "darker side" of medicalization (1980, p. 245-252), and then conclude somewhat lamely that "the medicalization of deviance will continue and is likely to expand and . . . the questions raised in this book will remain pertinent to the future" (p. 276).
In my view, the orientation of American constructivist sociology to the agendas of a particular time and culture has produced an imbalance in its analysis of the social definition and conditioning of knowledge about alcohol problems -- an imbalance which is now in the process of being remedied. Attention has been focused almost exclusively on amplificatory "problem claims" and their reception. But in a broader historical perspective, the process of social negotiation of problem definition and handling also includes a good deal of the opposite process of "problem deflation" (Room, 1984). The effect of shifts in both directions in what is politically acceptable as scientific knowledge is readily visible for alcohol in the present century: Mark Keller, himself from a deflating generation but working on in a new amplifying era, looked back at the changes since the publication of "Alcohol, Science and Society" in 1945 and offered the view (1982, p. 13) that "a fashion pendulum in the consideration of alcohol-related problems swings periodically from alcohol-is-to-blame to it's-not-alcohol-that's-to-blame. The thrust of social and scientific action is influenced accordingly. 'Alcohol, Science and Society' reflected a swing from the former to the latter viewpoint. Currently the trend is back to blaming alcohol and renewed efforts to suppress it. Sensitivity to history favors the prediction of a reverse swing in due course." Denise Herd's presentation at the present meeting (1984) of the history of scientific views on alcohol's relation to cirrhosis shows just how far the deflation went in post-Repeal America, and exemplifies the kind of balancing attention to "problem deflation" that in my view is needed.
But from my perspective this rebalancing is not all that is needed for American constructivist sociology to be extricated from culture-and-time-bound orientations. Beyond the issue of the construction and interrelations of scientific knowledge, problem claims and case-handling policies, and beyond the question of medicalization and demedicalization, the constructivist analysis of social problems needs to be attached to analyses of a broader range of societal phenomena. In this enterprise, alcohol sociology and related studies are already beginning to show the way. (It is of course an old theme in alcohol sociology that one must study drinking to understand drinking-related problems -- Bacon, 1943; Levine, 1981). For one thing, the fact that, like margarine (Ball & Lilly, 1982) or tobacco, alcohol is a commodity (and important to the state from a revenue standpoint) means that the vested interests involved in the definition of drinking and its relation to social problems extend well beyond the competing case-handling systems. This has invited analyses, for instance of the interplay of the various interests of the state in alcohol -- analyses that set the state's role in handling alcohol related public order and public health problems in the context of other state interests in alcohol (Mäkelä & Viikari, 1977, Morgan, 1980). In such a broader frame of reference, a cross-national analysis has remarked that the medicalization of alcohol problems in the postwar period "may be seen as a kind of cultural alibi for the normalization of drinking and the relaxation of controls" on drinking. "The locus of alcohol problems tended to be redefined from 'the bottle' to 'the man': if alcohol problems were a matter of specific defective individuals, then there was no need to control the drinking of the majority who were not defective. If, indeed, alcohol problems were specific to these individuals, an appropriate means of managing alcohol problems would be to provide treatment for them. . . . The study societies had a common need for such an alibi in the light of their historical experience, and the diffusion of professional ideas helped to provide one. Once the structure of thought about alcohol had shifted to this frame, subsequent increases in consumption and in associated problems simply became arguments for the further expansion of the treatment system" (Mäkelä et al., 1981, p. 65).
An important direction for the expansion of the constructivist perspective is in terms of the social construction of alcohol consumption per se. MacAndrew and Edgerton's (1969) classic discussion of the cultural determination of drunken comportment can be read also as an argument that the alcohol problems a society gets (including, of course, what it defines as alcohol problems) depend on the society's definition of the powers of alcohol (see also Room & Collins, 1983). While MacAndrew and Edgerton's analysis falls into the large corpus of analysis which is primarily based on cross-sectional data, the multiplicity of cultural factors involved in alcohol's status in any particular society makes it hard to assess linkages in such data. Thus the "hologeistic" tradition of cross-cultural quantitative analysis of ethnographic data, with cultures as the unit of analysis, became stymied by the fact that a large number of contradictory hypothesis could all be supported by focusing on different variables drawn from essentially the same data-set. From this perspective, a historical approach becomes attractive, since examining changes over time in any particular culture goes a considerable way toward limiting extraneous cultural variation.
In recent years, a number of analyses have begun on the task of looking at shifts in the cultural definition of drinking, in relation to shifts both in concrete patterns of drinking and levels of problems and to shifts in the cultural definition of alcohol problems. As for other psychoactive substances, it seems that, while material conditions certainly play their part (Park, 1985), big changes in alcohol consumption -- either up or down -- often reflect changes in cultural meaning of and symbolism surrounding drinking. Tobacco use originally spread in Europe as cocaine is spreading in the U.S. today, as a high-price item of conspicuous consumption identified with a smart set; Americans were a nation of tea drinkers until it became a symbol in the movement for national independence (see Austin, 1979). With respect to drinking, we have heard several papers and discussions in recent years that suggest that changes in the social meaning of alcohol -- in the social construction of drinking acts and occasions -- can be a powerful engine of change. Thus Irma Sulkunen's paper in Vienna (1981) argued that the fidelity of Finnish working class organizations to temperance -- and thus the high rate of abstention -- in the early years of the Finnish state derived from the specific historical importance of temperance organizations in the emergence of class organizations. Susanna Barrows' paper at the Helsinki meeting (1982) told a contrasting story from France: the enormous rise in consumption and thus in cirrhosis mortality in late nineteenth-century France partly reflected a reaction to the MacMahon regime's crack-down on cafes as potential centers of subversion, which turned drinking into a symbolic statement of defiance and autonomy. Last year in Padua, Denise Herd (1983) showed the effects of changes in the social definition of drinking in both directions in a single culture: for black Americans, the temperance movement was intertwined with aspirations for freedom in the early 19th century, but became associated with racism and repression in the late 19th century, paving the way for the identification of drinking with positive aspects of black culture in the 20th century. While cirrhosis mortality among blacks had been historically lower than among whites, by the mid-20th century the rates for blacks had passed those for whites, and now greatly exceed rates for whites in the urban north.
These analyses, important as they are, offer simply a first indication of what can be accomplished in this line of analysis. There is room for more explicit attention to the relation between changes in the cultural definition of drinking and changes in the societal definition of drinking problems -- a task at which the International Study of Alcohol Control Experiences made a first attempt (Mäkelä et al., 1981 pp. 60-65). As the analyses by Sulkunen, Barrows and Herd warn us, there are often complicated interplays and struggles over social definitions in a given society, so that a satisfactory analysis cannot limit itself to the level of the society as a whole.
It is time now to turn our attention more specifically to the questions implied by Kreitman's challenge: is analysis in this style leading us anywhere useful; and can it be subjected to a crucial test of its validity? It should be noted at the outset that even the posing of such questions is contentious within sociology; while some would see them as entirely proper (Hirschi, 1973), others would see the questions as derived from positivist traditions which they would see as antithetical to constructivism. In such a view, as Gusfield (forthcoming) implies, the appropriate standards of evaluation might be closer to those for literary criticism than to those for experimental psychology: an analysis might be evaluated for its coherence and its ability to convince or satisfy in the terms which it sets for itself, and not according to a competitive test of the validity of alternative hypotheses in terms of "objective reality". Along this line, one can find wry comments in the sociological literature that "sociologists readily tolerate untestable theories" (Gibbs and Erickson, 1975). In a related vein, an alcohol sociologist of my acquaintance offered as a half-joking justification for our work that any society that drinks a substantial amount should pay a few people to worry about alcohol.
But while such answers may win sociologists new friends in the College of Humanities meetings, they will, I suspect, be as unsatisfying to medical epidemiologists as they would be to a problem-agency grant review committee. I hope that the discussion so far will in any case have gone some way towards an answer. Stating it explicitly, in my view the best historical social constructivist analyses do not confine themselves only to the level of social constructions, but gain from analyzing the interplay between these and material events and conditions. In principle, a constructivist analysis can thus be viewed as simply adding a new world of variables -- consisting of measurements of social definitions and understandings -- to those which are generally familiar. Often, indeed, a constructivist analysis will regard what is for conventional medical epidemiology an objective indicator instead as a congealed representation of social definitions. Thus, for instance, public drunkenness arrests may become an indicator of the attitudes and behavior of the public order authorities, to be titrated against actual behavior (Bruun, 1969), and the resulting analysis may turn what might be viewed as a demonstration of a lamentable lack of validity into an argument about changes, in the social definition of and official reaction to public drunkenness (see Mäkelä et al., 1981, pp. 41-42).
In principle, any survey analysis that uses measures of individual definitions of and attitudes towards drinking as indicators of cultural norms (e.g., Allardt, 1957) is including measures of the social construction of drinking; in this light, the inclusion of such a dimension in quantitative analyses is hardly novel, and many analyses show that the competitive strength of these variables is often very strong. There is no reason of principle -- though there are often reasons of practicality -- why such an equivalent competitive test could not be extended to include a historical dimension and qualitative data.
In my view, historical, social constructivist analyses offer a substantial way forward in our understanding both of how changes occur in drinking patterns and in societal responses to them, and of the consequences of such changes. Apart from their intellectual interest, they are thus of potential practical significance.
If this point of view can be accepted, it may well require adaptations and developments in
conventional understandings of what constitutes worthwhile knowledge. For instance, some
people in public health apparently still reach for their scissors when they hear the word "culture".
The anonymous referees for a major public health journal urged publication of Denise Herd's
charting of changes over time in black American cirrhosis mortality -- but without her analysis of
the underlying historical changes in black Americans' understandings of alcohol.
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