Canadian Journal of Sociology Online September-October 2000

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Mariana Valverde.
Diseases of the Will: Alcohol and the Dilemmas of Freedom.

Cambridge, UK: Cambridge University Press, 1998. 251 pp., $Cdn 29.95 paper (0521644690), $Cdn 88.95 cloth (0521623006)

As I was writing this review Canadian news was inundated with stories about the suspension from competition of champion horse rider Eric Lamaze for admitted cocaine use. Among the various reactions was a statement by one of Lamaze’s fellow riders: “It’s a sickness,” he said, and then offered a curious analogy. “If it was somebody who had cancer who went into remission and the cancer came back, you’d feel sorry for him. To me this is the same situation.” Of course to a lot of other people it’s not the same at all, and that difference of opinion evokes the core question of Diseases of the Will: when is some unwanted behaviour the result of an uncontrollable condition of the body, and when does it result from a failure of the will?

Valverde is a professor of criminology at University of Toronto, and her extraordinary scholarship seems to owe most to history, well-informed by philosophy. Her book is a richly detailed examination of society’s troubled attitudes toward alcohol consumption, alcoholism, and the nature of disease. Valverde frames her discussion with references to philosopher Michel Foucault’s ideas of discipline, surveillance, and technologies of the self, but her findings often reverse Foucauldian received wisdom. For example, she argues that the history of alcoholism does not bear out the hypothesis of an historical transition “from the act-based governance of the criminal law to the more modern identity-based governance typical of disciplinarity” (p. 68). Foucault, who loved historical details far more than theories, would be so pleased to have his ideas questioned in such a carefully argued manner.

Valverde begins with a brief history of the will, a concept we continue to invoke even though its academic analysis is out of style. Much of her book is about attempts to medicalize alcohol consumption — mostly failed attempts on her convincing analysis — and medicalization invokes the idea that disease processes override the freedom of the will. As early as 1750 the famous American physician and statesman Benjamin Rush was asking if “habitual drinking” was “merely a bad habit” or a disease (p. 39). Rush came to no clear conclusion nor has anyone since — witness contemporary uncertainty of how to judge Lamaze’s cocaine use. Valverde suggests why the question is badly put, involving a false dichotomy. “The habit vs. disease contrast aligns habit with freedom of the will. Anything that is managed as a disease is something we have little or no control over; by contrast a habit… is… subject to some degree of personal control” (p. 39). Victorian/Edwardian medicine came to a sort of compromise that many people today would probably still accept: “alcohol damages the will, and pre-existing deficiencies in the will are revealed and aggravated by drinking” (p. 96). This statement points toward another crucial but troubled dichotomy, that between “normal” drinking and alcoholism.

One of Valverde’s most important contributions is to show how convenient the concept of alcoholism is to all concerned. For the liquor industry, it pathologizes a select and limited number of consumers, locating the problem in specific drinkers, not in the drink itself. For mutual-help groups like Alcoholics Anonymous, the idea that some people are, in their essence, alcoholics, creates a clientele.

Different parts of the book will intrigue readers according to their own interests, but for me Valverde’s discussion of AA is her finest chapter. AA depends on the distinction that alcoholism is a disease, but this particular disease cannot be treated by medicine. The medical profession has pretty well accepted AA’s understanding by restricting itself to treating the physiological effects of alcoholism (e.g., the liver) and referring the need for behavioural change to AA. Alcoholism has never been successfully medicalized in part because no effective medical treatment exists, and — among other reasons — because no one has been able to define threshold levels of alcohol consumption that define alcoholism. The when’s, where’s, and feelings associated with drinking seem more important in defining the alcoholic than actual amounts consumed. AA brilliantly circumvents the problem by relying on the alcoholic’s self-definition: people are alcoholics when they “bottom out” and admit they are (though there is a residual category of those “in denial”).

Valverde makes a good case that many of us interested in health, in what she usefully differentiates as mutual-help organizations (versus self-help activities), and in the narrative construction of identity tend to underestimate how generalized the effect of AA has been on our cultural conceptions. Although her own interests seem to be more in the changing nature of government controls — the shift to regulating the distribution of alcohol and conditions of consumption rather than disciplining individual drinkers — I found this later part of her story anti-climactic following her AA discussion. Her book ends quietly, as befits her scholarship, with the understated observation is “it is occasionally possible to discuss one’s feelings, hopes, and regrets without either rationalizing oneself in the name of free will or psychologizing oneself in the name of some diagnosis” (p. 205). Yet as reactions to the Lamaze case show, discourse is more comfortable understanding behaviour as either freely undertaken (and worthy of full punishment) or diagnosable (and thus excusable).

Alcohol consumption, with all its historical and cultural variability of acceptable limits, is a wonderful venue for asking questions about the social construction of persons and regimes of governmentality. The transition from sociological “alcohologists” of the 1950s and 60s to Valverde’s elegant sociology of knowledge is a measure of the increased sophistication of sociology. Her book provides no answers, but she helps us understand the history of the assumptions and dichotomies from which escape is so difficult.

Arthur Frank
University of Calgary
September 2000
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