It is argued that since. Heather & Robertson's 'new' approach incorporates a set of assumptions parallel to those of the disease concept it is equally tautological, ...
British Journal of Addiction (1989) 84, 843-845
Is the 'New' Problem Drinking Concept of Heather & Robertson More Useful in Advancing Our Scientific Knowledge Than the 'Old' Disease Concept? DENNIS M. GORMAN Department of Sociology, University of Essex, Colchester, Essex and Division of Clinical Cell Biology, Clinical Research Centre, Harrow, Middlesex, United Kingdom
Suminary Heather & Robertson maintain that the problem drinking concept represents a shift from a 'pre-scientific' to a 'scientific'paradigm within the field of alcohol studies. They consider that the usefulness of a concept can best be assessed in terms of the extent to which it facilitates the testing of hypotheses. The disease concept is of no value when judged in these terms due to the aetiological assumptions that are built into it. It is argued that since Heather & Robertson's 'new' approach incorporates a set of assumptions parallel to those of the disease concept it is equally tautological, and therefore does not represent the type of change in paradigm they propose.
Introduction In a recently published book. Heather & Robertson' have set forth the principles of a theoretical model of problem drinking, presenting this as the first stage of a science proper in the field of alcohol studies. Adapting a concept developed by Kuhn,^ they argue that what is taking place is a paradigm shift away from the 'folk science' of the disease model of alcoholism. This process entails a fundamental redefinition of the discipline, with new theoretical problems, research methods, and criteria and standards of evaluation. Although, as Edwards' notes, the use of the term 'paradigm shift' to describe the introduction of new ideas in the 'alcohol world' is problematic due to the multiplicity of disciplines contributing to this field of enquiry, the essence of the distinction drawn by Heather & Robertson is between concepts that are useful in
advancing scientific understanding and those that are not. Fundamental to their critique of the disease model as 'non-scientific' is the notion of petitio principii, this being the fallacy in which the truth of a proposition yet to be demonstrated is assumed in the very premise of that proposition. The disease model, they argue, is founded upon such assumptions, in that the actual definition of the disease confounds two putative aetiological agents ('loss of control' and 'craving') with their putative effect ('alcoholism'). As a result, the explanations it offers of, for example, the causes of alcoholism are inherently tautological and therefore non-scientific:
Address for correspondence: Dr D. M. Gorman, Institute for Health, Health and Aging Research, Rutgers University, 30 College Avenue, New Brunswick, New Jersey 08903, U.S.A.
843
'In suggesting that alcoholism is something a person has, rather than something he or she does, [the disease concept] insidiously implies that what is wrong is caused by some mysterious process located "inside" the person. In this way, the occurrence of harmful drinking is explained by the presence of some unknown but confidently
844
Dennis M. Gorman
asserted physical or psychological malfunction called conveniently "the disease of alcoholism". Of course, this "explanation" merely goes round in circles and, in reality, explains nothing whatever. How do we know when someone is suffering from the disease of alcoholism? When he drinks in a harmful fashion. And what causes this harmful drinking? The disease of alcoholism. This kind of circular thinking is characteristic of pre-scientific modes of reasoning and serves to reassure us that we are making progress in understanding problem drinking when in fact we are not' [1: 139-140, emphasis in original]. In a publication contemporary to this. Heather'' argues that the value of a scientific concept can best be evaluated in terms of its usefulness in generating testable hypotheses. This approach to assessing the value of concepts is derived from Popper's' writings on the philosophy of science, and it is easy to see how from such a perspective the disease concept is of limited scientific value. Consider, for example, the testing of a simple causal hypothesis of the type X—»Y: the disease concept simply does not allow a true test of this, since by defining Y in terms of two X-type variables it presupposes one aetiological explanation to be true and precludes consideration that other causal factors might be at work. Heather & Robertson are undoubtedly correct in calling for description and explanation to be kept separate in the definition of concepts. The former involves statements which define the characteristics of a phenomenon and describe what it looks like, whilst the latter entail statements about what causes the phenomenon and what is responsible for its occurrence. For the purpose of hypothesis testing, the two are best considered as distinct domains of discourse (a principle well-established in the study of affective disorders*-'). This is not to say that aetiological classifications are undesirable/>er5e, but rather to recognize that their development must inevitably depend upon a fairly sophisticated understanding of the causes of the condition in question.^ Such a state cannot be said to exist within the field of alcohol studies, where we are still concerned with testing causal hypotheses and hence require concepts which are useful in this enterprise. Moreover, it should not be thought that the practice of integrating assumptions about causality into reputedly descriptive classificatory schemes is exclusive to biologically-orientated research—one need only consider Durkheim's suicide typology in order to appreciate this (cf. Lukes'). Nor for that matter
need 'disease concepts' inevitably build in such assumptions—Wing,'" for example, proposes a 'disease theory' approach to conceptualization which clearly emphasizes the distinction between classification (or description) and aetiology (or explanation). However, as presented by its proponents in the field of alcohol studies, the disease model has generally lacked such subtleties and been grounded instead upon a fairly crude understanding of the 'doctrine of specific aetiology' (i.e. the idea that each specific disease has a specific biological cause). Given the importance of this issue of distinguishing between the domains of the descriptive and the explanatory in testing hypotheses, and the central position that it occupies in Heather & Robertson's critique of the disease paradigm as non-scientific, it must inevitably be a key point on which the claims they make for their conceptual model as representing a shift in paradigm stand or fall. In this respect, careful reading of their work would suggest that the 'problem drinking' model they describe has similar short-comings to that which it is designed to supersede. The reason for this is that having rejected the disease model and its fundamental assumptions about causality. Heather & Robertson proceed to propose an alternative model with 'a parallel set of assumptions'. Included amongst these is the assumption that problem drinking, like all drinking, be considered as 'learned behaviour which is nested in complex ways within the idiosyncratic socio-psychological world of each individual' [1: 158]. Whilst the actual nature of the assumptions underlying this model might differ from those of the disease model, the two are identical in so far as both are, in effect, 'aetiological' classifications. The disease model classifies individuals in terms of whether or not their drinking is caused by loss of control and craving, whereas Heather & Robertson contend that 'when we think of problem drinking, we should think immediately of the particular behaviour which is causing the problem' [1: 139, enphasis added]. Through basing their conceptual model on such an assumption. Heather & Robertson merely substitute one all-embracing reductionist theory—a biological one (based on the assertion that 'alcoholism' is a disease entity—with an opposing all-embracing reductionist theory^—a psychological one (based on the assertion that 'problem drinking' is a learned behaviour). As such, they totally miss the point as to why the disease paradigm is of such limited heuristic value; for its limitations as a classificatory scheme emanate not from the fact that it presupposes the truth of causal explanations about inherent biological
'New' Problem Drinking Concept Debate processes, but from the fact that it presupposes the truth of any causal explanations at all. Whilst the substantive nature of the assumptions built into Heather & Robertson's definition may differ from those built into the disease model, the presence of any such assumptions about causal processes (whatever they might pertain to) is sufficient to undermine the heuristic value and utility of the concept. The definition assumes that learning is the cause of all drinking behaviour, and as such, there will never be a case of problem drinking (nor of'non-problem' drinking) which is not learned behaviour. Like its disease counterpart, such a model is tautological. It must be emphasized that the argument being presented is not that social learning plays no role in the aetiology of problem drinking, but rather that the latter concept as defined by Heather & Robertson does not allow a true test of such a hypothesis. When judged in terms of the same criteria which Heather & Robertson use to assess the value of the disease concept, the problem drinking concept they formulate is fundamentally flawed by its built-in assumptions about aetiological processes and cannot seriously be considered to represent the type of change in paradigm they propose. Just as the disease concept is of little value in testing simple causal hypotheses of the type X—^Y, so too must the usefulness of the concept of problem drinking be seen as extremely limited, since by defining Y (problem drinking) in terms of X-type variables (faulty learning processes) Heather & Robertson simply presuppose one aetiological explanation to be true and preclude consideration of all others. Edwards,' in his discussion of the processes surrounding the introduction of new and controversial concepts into the field of alcohol studies, distinguishes two perspectives from which these might be understood. The first is that of the 'paradigm shift' as used by Kuhn to describe the form of revolution within a science which leads one tradition of 'normal science' to supersede another. The second perspective focusses on the conflict between professions (in this case, medicine and psychology) for dominance in a particular field of
845
knowledge. The present analysis would suggest that Heather & Robertson's proposed new problem drinking approach is best understood in terms of the latter.
Acknowledgements This work was supported by a grant from the Economic and Social Research Council. I would like to thank Drs N. Hart, J. Busfield, and T. Harris and Professors G. W. Brown and T. J. Peters for their support and comments on earlier drafts of this paper. I would also like to thank Ms S. Raine and Dr C. Taylor for their comments.
References 1.
2. 3.
4.
HEATHER, N . & ROBERTSON, I. (1985) Problem
Drinking: the New Approach (Harmondsworth. Penguin Books). KUHN, T . S. (1970) The Structure of Scientific Revolution (2nd. edition) (Chicago, University of Chicago Press). EDWARDS, G . (1985) Paradigm shift or change in ownership? The conceptual significance of D. L. Davies's classic paper, Drug and Alcohol Dependence, 15, pp. 19-34. HEATHER, N . (1985) Introduction to part 1: Is there an alcohol dependence syndrome? in: N. HEATHBR, I. ROBERTSON & P. DAVIES (Eds) The Misuse of Alcohol:
Crucial Issues in Dependence, Treatment and Prevention, pp. 7-16 (London, Croom Helm). 5. MILLER, D . (1983) A Pocket Popper (Fontana Pocket Readers) (Oxford, Fontana Paperbacks). 6. BROWN, G . W . & HARRIS, T . (1978) Social Origins of Depression: a Study of Psychiatric Disorder in Women, chapter 2 (London, Tavistock Publications). 7. Nl BHROLCHAIN, N . (1979) Psychotic and neurotic depression: 1, some points of method, British Journal of Psychiatry, 134, pp. 87-93. 8. KENDELL, R. E . (1983) The principles of classification in relation to mental disease, in: M. SHEPHERD & O. L. ZANGWILL (Eds) Handbook of Psychiatry. 1. General Psychopathology, pp. 191-198 (Cambridge, Cambridge University Press). 9. LtJKES, S. (1973) Emile Durkheim: His Life and Work (Harmondsworth, Penguin Books). 10. WING, J. K. (1978) Reasoning About Madness (Oxford, Oxford University Press).
