Not so long ago, alcoholism was seen as a psychosis, a moral failing or a criminal offense -- or all three. What passed for treatment was all too often admission to a state psychiatric asylum or a lock-up in a local jail.
Today, alcoholism is widely considered a treatable illness. Treatment plans to help problem drinkers and their families have proliferated, making alcoholism care a billion-dollar-a-year industry.
Not that the field is free of controversy. Stigma abounds, and the disease concept of alcoholism is not universally accepted. It is challenged by the Veterans Administration in a case argued last week before the Supreme Court and is also called into question by a forthcoming book, "Heavy Drinking: The Myth of Alcoholism as a Disease" by Herbert Fingarette, a philosopher and addiction expert at the University of California at Santa Barbara.
But mounting evidence in the laboratory suggests genetic and physiological patterns that make some people more vulnerable than others to alcohol.
"It is unlikely that 10 million Americans all have a character disorder," said Enoch Gordis, director of the National Institute on Alcohol Abuse and Alcoholism, who believes that the idea of a biological basis for alcoholism is "a very plausible one."
Posing the issue in the simplistic terms of genetic determination versus moral failure is misleading, experts say. A consensus is emerging that alcoholism is neither a simple lack of will nor a single disease but an extraordinarily complex illness that takes many forms and has no one cause. According to this view, alcoholism stems from a cluster of interrelated factors, including genetic inheritance, environment, social conditions, behavior and personality.
To make the diagnosis, doctors look for a combination of physical and behavioral clues, ranging from enlargement of the liver to chronic irritability and depression.
Treatment programs increasingly reflect the concept of alcoholism as a multifaceted problem, and helping the alcohol abuser involves a cooperative effort cutting across numerous fields -- medicine, education, occupational health, social work and family counseling. Treatment plans also include family members who often need counseling to deal with the emotional scars of living with an alcoholic.
In all, more than 7,000 facilities in the country offer treatment for alcoholism, the federal government has estimated. These include freestanding alcoholism treatment centers, general hospitals, specialized hospitals, mental health centers, correctional institutions and independent counseling agencies.
Many factors spurred the growth, including the American Medical Association's landmark recognition of alcoholism as a disease in 1956, the decision in the 1970s by insurance plans such as Blue Cross/Blue Shield to cover alcoholism treatment, and the proliferation of worksite employe assistance programs geared to offering confidential help to workers who have drinking or drug problems.
There are two basic kinds of alcoholism treatment in the U.S.: inpatient and outpatient. Inpatient treatment requires an extended stay at a hospital or residential treatment facility. Many inpatient alcoholism programs last 28 days, during which patients undergo a medical checkup, detoxification and intensive counseling, education and group and one-on-one discussions.
Outpatient care involves therapy and counseling on a daily or weekly basis without hospitalization or an overnight stay. Outpatient programs range from hospital-based counseling and education to small meetings, commonly run by Alcoholics Anonymous.
AA, founded in 1935 by a New York stockbroker and an Ohio surgeon, now has more than 73,000 chapters in 115 countries. An estimated 750,000 Americans are members, according to an AA spokesman, and in the Washington area alone, AA sponsors about 1,100 meetings a week.
"AA groups grow like topsy," the spokesman said, adding that the only requirements for a new AA group are "a resentment and a coffee pot." A heavy drinker should never try suddenly to quit "cold turkey" at home without medical supervision, experts say. Detoxification or physical withdrawal from alcohol, which usually lasts about three days, often entails headaches and insomnia and can cause seizures, blackouts and a violent form of delirium known as delirium tremens, or DTs.
The granddaddy of alcoholism treatment programs in the United States is the Hazelden Foundation in Minnesota, which opened in 1949. Hazelden helped develop what has become known as the "Minnesota model" of treatment: a 28-day residence, including detoxification, education and intensive counseling, followed by "aftercare" of further counseling and meetings with AA. To address the range of problems in alcoholism, the Hazelden staff includes doctors, nurses, psychologists, social workers, clergy and counselors, many of whom are themselves recovered alcoholics.
The premise of the Hazelden model -- and of most treatment programs in the country today -- is that alcoholism can be overcome only by life-long sobriety. "We don't really say we cure people when they come to Hazelden," said Jerry Spicer, director of professional services at Hazelden. "Recovery is a long-term process, involving awareness, education, change of attitude and a commitment to abstinence. When people leave, they've still got a lot of work to do."
Recovery from alcoholism, Spicer said, is a longterm rehabilitative process not unlike overcoming a back injury or living with diabetes. "It's something people need to work on for the rest of their lives," he said.
Follow-up care, often in an outpatient setting and almost always with participation in a group such as Alcoholics Anonymous, is an essential element of any recovery program.
"The big trick is not when you're sitting quietly in the treatment center," said Sandy Clunies, director of community relations for Seneca Melwood Treatment Centers in Montgomery County. "It comes later, when you're home and the phone rings and someone says, 'Let's party.' " ::
Unfortunately, success rates have not caught up with the new mood of optimism. Solid estimates are hard to come by, in part because of the difficulty of defining and measuring success. Total abstinence? Essential sobriety, with only an occasional slip-up? Two years? Five years?
Overall success rates are low -- as few as 12 to 25 percent of patients remain sober for three years. But some studies show success rates of better than 50 percent for patients who receive intensive treatment and then participate in follow-up counseling and meetings.
Millions never even get the chance. Despite changing attitudes, greater awareness and the recent boom in alcoholism treatment programs, an estimated 85 percent of the 18 million Americans with a serious drinking problem never find their way to treatment.
"That's the sad part of the story," said Hazelden's Spicer.
"Treatment is a luxury for a lot of people," said Clunies of the Seneca Melwood Treatment Centers. "After all, you have to have insurance or money."
Taking the first step toward treatment is often the hardest. Alcoholics rarely seek help without the encouragement of a relative, friend or colleague -- or sometimes the spur of a driving-while-intoxicated arrest or a sour job evaluation.
"Nobody sits at home and says, 'I've got a problem and I'll go to AA,' " Clunies said. "Somebody has to nudge them."