What does the Big Book mean by alcoholism as an illness?

The words the book uses

Across the forewords, Chapters 1–11 and the appendices, the book's word is illness (Chapters 2, 3, 4, 7, 8, 10) or malady (Chapters 2, 5, 7, 10), and it often calls the alcoholic a sick man. The word disease appears once in those pages: "From it stem all forms of spiritual disease, for we have been not only mentally and physically ill, we have been spiritually sick" (p. 64). "It" there is resentment, not alcoholism.

"Disease" for alcoholism does appear in the personal stories. In "Alcoholic Anonymous Number Three" (Part I), Bill W. and Dr. Bob tell the man in the bed, "No, you have a disease" (p. 187), and Bill speaks of being cured "of this terrible disease" (p. 191). That story dates itself to about 1954 ("Nineteen years ago last summer," p. 188). In "Acceptance Was the Answer" (Part II), a member writes that it helped him to see "alcoholism was a disease, not a moral issue" (p. 416). These are members' own words in the stories, not the program text.

An illness of the body

The first voice in the book is a doctor's. Dr. Silkworth's theory is that alcohol works on these drinkers like an allergy, setting off a craving that "never occurs in the average temperate drinker" (p. xxviii). The A.A. members who introduce him agree that "the body of the alcoholic is quite as abnormal as his mind" and add that "our bodies were sickened as well" (p. xxvi). They're careful about the theory itself: "As laymen, our opinion as to its soundness may, of course, mean little" (p. xxvi).

Chapter 2 says the same from experience. Once the alcoholic takes any alcohol at all, "something happens, both in the bodily and mental sense" that makes it almost impossible to stop (pp. 22–23). Chapter 7 tells the helper to talk about "the conditions of body and mind which accompany it" (p. 92).

An illness of the mind

But the book is clear about where the real trouble lies. Since the illness can't start unless the alcoholic takes the first drink, "the main problem of the alcoholic centers in his mind, rather than in his body" (p. 23). Most alcoholics "have lost the power of choice in drink" (p. 24). "We are without defense against the first drink" (p. 24). There is "the obsession that somehow, someday, they will beat the game" (p. 23). Chapter 3 shows that mental blank spot at length, in Jim, the jay-walker and Fred (pp. 35–43).

It's also an illness that gets worse and doesn't go away. Chapter 3 calls it a progressive illness in which we get worse, never better, and compares alcoholics to men who have lost their legs and never grow new ones (p. 30). "Once an alcoholic, always an alcoholic" (p. 33). Even after recovery, "We are not cured of alcoholism" (p. 85).

Underneath: a spiritual sickness

The book goes one level deeper. Resentment is the chief offender, and "When the spiritual malady is overcome, we straighten out mentally and physically" (p. 64). Drinking itself "was but a symptom" (p. 64). The root, the book says, is "Selfishness—self-centeredness!" (p. 62). That's why the illness can only be met by a spiritual experience (p. 44) and why Dr. Silkworth says recovery requires "an entire psychic change" (p. xxix).

How the book uses the idea

The illness idea runs through the book's practical advice: - To the newcomer: the helper should tell him how "you finally learned that you were sick" and "Continue to speak of alcoholism as an illness, a fatal malady" (p. 92). You can be frank about how hopeless the illness is because you have a solution to offer, and the more hopeless he feels, the more likely he is to take your suggestions (pp. 92, 94). - To families: wives are reminded that "alcoholism is an illness over which we could not possibly have had any power" (p. 118). They're told to treat the man as a sick person (p. 100) and to tell friends "the nature of his illness" (p. 115). - To employers: "explain alcoholism, the illness" (p. 142), and treat the man as gravely ill. - In resentment: the people who wronged us were "perhaps spiritually sick" too (p. 66), to be treated as a sick friend (p. 67).

What it doesn't mean

The illness doesn't take away responsibility. The book that calls alcoholism an illness also says our troubles "are basically of our own making" (p. 62), and Chapter 7 ends: "After all, our problems were of our own making" (p. 103). The illness explains why willpower failed. It's the reason the program asks for so much action (pp. 58–103), not a reason to wait.

And the book doesn't claim to settle the medical question. On why the alcoholic reacts as he does, "Perhaps there never will be a full answer to these questions" (p. 22).

Read it yourself

• "The Doctor's Opinion," pp. xxv–xxxii: https://www.aa.org/sites/default/files/2021-11/en_bigbook_foreworddoctorsopinion.pdf
• Chapter 2 (pp. 17–29), "There Is a Solution": https://www.aa.org/sites/default/files/2021-11/en_bigbook_chapt2.pdf
• Chapter 3 (pp. 30–43), "More About Alcoholism": https://www.aa.org/sites/default/files/2021-11/en_bigbook_chapt3.pdf
• Chapter 5, "How It Works," on resentment as "spiritual disease": https://www.aa.org/sites/default/files/2021-11/en_bigbook_chapt5.pdf
• Related: What is "The Doctor's Opinion," and who wrote it?

Sources

Recovery Starts is independent and not affiliated with Alcoholics Anonymous. Quotations are brief and cited; the Big Book is © A.A. World Services, Inc.

These pages answer questions about A.A. from A.A.'s own published literature, read in full, with every quote checked word for word against the page it cites. Recovery Starts is independent and not affiliated with Alcoholics Anonymous. What we read, and when each source was written.