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Article Excerpt
Man at work has been praised as peaceful, and so have forests, but a detailed study of either will show that conflict can occur without being either swift or bloody.
--WILIAM J. GOODE (1960:902)
The term addiction medicine is often used by newspapers, magazines, and other media to refer to a broad body of medical and scientific knowledge on substance abuse in which nearly all physicians might have some expertise (e.g., Denizet-Lewis 2006; Katz 2005). Although widespread, this understanding is not accurate. In actuality, two distinct medical disciplines treat addiction in the United States: one is called addiction medicine and the other is called addiction psychiatry.
Addiction medicine was born in 1954 out of "the alcoholism movement" of the mid-twentieth century. The alcoholism movement was a new approach to alcohol addiction that was systematized in the 1940s and 1950s by Alcoholics Anonymous, the Research Council on Problems of Alcohol, the Yale Section of Alcohol Studies, and the National Council on Alcoholism (Johnson 1973; Levine 1978; Page 1988; Page 1997; Roizen 1991; Seeley 1962; White 1998; Wilkerson 1966). Addiction medicine grew rapidly between the 1960s and 1980s, largely due to the efforts of physicians from New York, California, and Georgia to "re-medicalize" addiction. As this article will show, during these formative years, many physicians working in addiction medicine were themselves recovering from alcoholism or drug abuse. They were among the ranks of thousands of former alcoholics and drug addicts who permanently reoriented their careers toward addiction treatment (White 2000a). Today, the field's leading organization, the American Society of Addiction Medicine (ASAM, pronounced A-SAM), has about 3,000 members. According to reliable estimates from prominent ASAM officers and former officials, approximately one-third of ASAM's membership is in recovery from addiction. (1)
Addiction psychiatry comes from very different roots. This discipline formally originated in 1985 when a small, influential group of psychiatrists founded their own organization of addiction specialists. The psychiatrists, believing that they could treat addiction far more effectively than addiction medicine physicians, especially those in recovery, were unnerved that "addictionologists" had displaced them at the forefront of treatment. In 1991, addiction psychiatrists successfully persuaded the American Board of Medical Specialties that they possessed a body of specialized knowledge on addiction. This won them subspecialty recognition from the American Board of Psychiatry and Neurology, giving addiction psychiatry substantial status and power over the field of addiction treatment. Addiction medicine, in contrast, holds no specialty or subspecialty status in organized medicine.
This article stems from a larger sociological and historical research project analyzing the development and current training and treatment practices of addiction medicine and addiction psychiatry. In the course of conducting pilot interviews for that research, the topic of physicians in recovery who provide addiction treatment surfaced, and did so in nearly 24 subsequent interviews without my initiating the subject. (See the appendix for a complete discussion of data collection and analysis.) Accordingly, this article argues that physicians in recovery have played a key role in creating the field of addiction medicine in America, and that the development of addiction medicine inadvertently contributed to the formation of addiction psychiatry. It suggests that questions about the type of knowledge which physicians in recovery call on to treat addiction are central to an ongoing professional conflict between addiction medicine and addiction psychiatry over what Goode (1960) labels the "right to responsibility" for the medical treatment of addiction.
The first reformed physicians to treat addiction
Physicians who were reformed drunkards first became prominent in the late nineteenth and early twentieth centuries (White 2000b). Starting in 1891, the Keeley Institutes, famous for their mysterious and likely phony Double Chloride of Gold remedy for alcohol and drug addicts, employed as many as 131 doctors with a history of addiction to alcohol, opium, morphine, or cocaine. Most of these physicians were hired between 1891 and 1894, and a majority took to their medical duties within one year of having been treated themselves--"many did so within a few weeks or months" (White 2000b:5).
These physicians ignited a controversy. Some doctors, chiefly superintendents of inebriate asylums like T. D. Crothers, did not approve of reformed drunkards as treatment providers. Crothers sought to professionalize addiction treatment, and cure institutes like Keeley's competed with inebriate asylums for patients, proceeds, and medical credibility (White 2000b). Crothers (1897, in White 2000b) claimed that inebriate and addicted physicians like those cured and hired by Keeley were mostly incompetent, with physical and mental "deficits" that severely limited their medical abilities. He argued that the medical treatment of addiction could not be professionalized or profitable with this unreliable contingent of ex-drunkards in the discipline. As White (2000b) reports, "a debate raged in the 19th century between those who believed that recovering addicts brought special knowledge and sensitivities that could enhance their work in addiction treatment, and those who believed that the recovering addict brought vulnerabilities that outweighed any such assets" (p. 9).
By the 1920s, the debate over what role, if any, reformed physicians should have in addiction treatment was silenced by the Eighteenth Amendment and national alcohol prohibition. With beverage alcohol banned throughout the United States, prohibitionists argued that drunkards would disappear, making treatment unnecessary and obsolete. That hope was illusory and debate over the role of previously addicted physicians as providers of addiction treatment resumed after prohibition's repeal, especially in the second half of the twentieth century.
The addictionologists and the rise of addiction medicine (2)
Despite frequent bouts of heavy drunkenness, in 1953 G. Douglas Talbott finished his medical residency in cardiology and internal medicine at the University of California, San Francisco. Having damaged his health, family life, and professional reputation just as his career was starting, Talbott was sent to several psychiatric hospitals for treatment. Finally he was committed to Dayton State Hospital in Ohio where he was housed with the criminally insane and endured physical and emotional assaults (Talbott 1998). But as Talbott (1998) explained years later, something else happened there:
I will never forget lying there bleeding, in severe pain, and even suffering through the humiliation of being urinated on. I kept thinking, God, where are you? Lying on the floor that night, I clearly remember making a vow to myself that if I ever got out of this place alive, I would dedicate my life to helping doctors and other health care professionals in this situation. I vowed I would find a way to help suffering doctors like myself and dreamed of one day creating a place where healers could be healed (p. xvii).
Talbott had experienced a "spiritual awakening" that was strikingly similar to the "hot flash" reported by Alcoholics Anonymous (AA) co-founder William Griffith Wilson and "the light" seen by Marty Mann, founder of the National Council on Alcoholism (see Alcoholics Anonymous World Services, Inc. [1957] 1971; Alcoholics Anonymous World Services, Inc. 2001). Talbott attributed his sobriety to his family and a Catholic priest who renewed his spiritual faith and convinced him to join AA. This priest also supported Talbott's decision to leave...
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