Alcohol and Crime: Treatment and Rehabilitation

Central to this entry is the assertion that all alcohol problems spring from deviance, this being independent of medicalized and moral conceptions that may be attached to alcohol problems. As mentioned, alcohol problems have been subject to shifting definitions and categorizations across cultures and over history, experiences well documented in the history of American society. Colonial historians have observed that eighteenth-century drinking in the American colonies was far more extensive than drinking patterns known in subsequent periods, that drinking was woven into the fabric of nearly all phases of personal and social activity, and that "alcohol problems" were largely unknown, with the exceptions of grossly destructive behavior associated with drunkenness, and of persons who were unable to work and were community wards because of their excessive drinking (Rorabaugh).

As is well known, alcohol soon emerged as a social problem of major proportions, part of a massive set of social and ideological changes in the new republic occurring in the 1820s and 1830s. Interpreters have seen this period as one of the emergence of multiple social problems, not necessarily because of increased prevalence but because of transformed definitions. As part of these changes, alcohol consumption became problematic in America (Clark; Lender and Martin). Problem definitions began with labeling the consumption of liquor or "ardent spirits" as physically and mentally destructive, allowing, however, for the consumption of beer, cider, and wine.

After several decades, all alcohol consumption came to be seen as personally damaging and socially dangerous, and the temperance movement essentially defined all drinking as deviant. Eventually national Prohibition came to be seen as the solution to this alleged morass of problems, and it was enacted in 1920, leading to the distinctive definition of all alcohol-related activities within the conceptual arena of crime.

When Prohibition was repealed in 1933 (for a complex set of reasons still being debated), the definition of alcohol consumption within a criminal conception became obviously untenable. One set of responses moved toward the enactment of a great many rules as to when, how, and by whom alcoholic beverages could be consumed. A second set of responses set about to differentiate between problematic and nonproblematic drinking.

It was in this new area of research that the conception of the disease of alcoholism emerged (Jellinek summarizes these developments). Alcoholism was not defined by the consumption of a set amount of alcohol, but by behavioral patterns wherein persons completely "lost control" over their drinking. Such behavior often could be observed in terminally ill individuals who drank constantly, ate little, manifested severe psychiatric symptoms, and usually died or were permanently disabled due to organ damage. Other types of alcoholics could remain abstinent for considerable periods, but manifested this "loss of control" once drinking began again.

While there was consensus regarding the gravity of this behavioral syndrome, it was clear that any kind of effective intervention would have to address the problem at a considerably earlier stage in its development. Over several decades a well-organized campaign promoted the definition of alcohol problems into the medical arena and out of the criminal arena. Alcoholism as a crime was formally "decriminalized" in the 1960s, and by the 1970s the study of alcoholism as an illness was assigned to a federal research and treatment agency that ultimately became a unit of the National Institutes of Health.

Thus, from the beginning of the nineteenth century, when alcohol problems were barely recognized, there was a rapid shift toward viewing such problems as sin, then as crime, only to transform them into medical disorders by the last quarter of the twentieth century. These rapid and complex definitional changes have never been fully institutionalized in American culture, with the consequence that there are mixtures of definitions and ambivalences about how problems should be managed. These confusions have considerable implications for the likelihood that criminals will receive treatment for their alcohol problems.

One of the manifestations of these confusions is in the "double deviance" definition of alcohol problems. Alcohol problems are defined not by the amount of alcohol consumed or the pattern by which it is consumed, but by the problems in role performance that can be linked to the individual's drinking. Problem drinkers are essentially defined by how much trouble they have gotten into in association with their drinking. Double deviance arises in this way: one or more acts of deviance define an alcohol problem, which in turn defines the individual's drinking behavior as deviant. Persons who repeatedly engage in these patterns of behaviors are seen as unresponsive to negative feedback, and thus "alcohol dependent." Behavioral repetition by alcohol-dependent persons easily segues into "alcoholism."

While role performance impairment appears to be consistent with (in medical language) differential diagnosis at the individual level, it is clear that this definition is almost wholly dependent on social events. While self-diagnosis and self-referral of persons with serious alcohol problems is not unknown, it is very exceptional. Definitions of poor performance emanate from the judgments of significant others surrounding an individual, and thus are a "paradigm case" of socially defined deviance. The crucial understanding is that a problem drinker must also be a social deviant, placing all persons defined as problem drinkers on a continuum with criminals who have alcohol problems.