The 2000 Stanton Peele Addiction Lecture was delivered by Maggie Brady, of the Australian Institute of Aboriginal and Torres Strait Islander Studies, Canberra. Maggie begins her story with the avid reception accorded Canadian Indian alcoholism activists who visited Australia with tales of 12 steps, sweat lodges, and other popular native North American alcoholism techniques. Maggie describes the history of Australian aboriginal efforts in alcoholism, their previous adoption of 12-step and disease principles — just as the rest of the country was coming under the sway of harm reduction models — and the political, economic, and cultural self-image issues involved in aboriginals being convinced that, as a class of people, they suffer from a pervasive and ineradicable "disease."

The 2000 Stanton Peele Addiction Lecture

The Diseasing of Australia?

Debates over biological vs environmental determinants of Aboriginal alcohol misuse

Maggie Brady
Visiting Research Fellow
Australian Institute of Aboriginal and Torres Strait Islander Studies, Canberra

I have long been an admirer of Stanton Peele's iconoclastic work in addiction, and so I feel honoured to have been asked to present this Stanton Peele Addiction Lecture. Thank you for inviting me to speak to you tonight.

Introduction

In 1975, the Aboriginal activist, ex-wharfie and ex-drinker Chicka Dixon was one of the first prominent Aboriginal Australians to examine drug and alcohol programs in the United States and Canada. He travelled there on an Aboriginal Overseas Study Award. Among other places, he visited Alberta — in particular a First Nations alcoholism training and treatment centre there. Dixon observed in his diary that this was the best program he saw overseas. He enthused about the possibility of such an organisation being started in Australia. He noted that the Canadian Indians offered to train Aborigines in their year-long program or to send four of their experts to Australia to train Aborigines on the spot. Australia was depicted as being 'still in the dark ages in the alcohol treatment field' — about ten years behind the North Americans. Dixon, and other Aboriginal visitors who followed, were impressed with the large-scale training of indigenous counsellors, as well as the apparent success of residential treatment based on the 12 step model.

In 1990 Chicka Dixon's suggestion that a similar program be developed in Australia finally came to pass when indigenous alcohol trainers from the Canadian organisations took up consultancies in this country. In April 1991 Andy and Phyllis Chelsea, two Shushwap First Nations people from the Alkali Lake community in British Columbia visited Australia to attend a conference in Alice Springs. A film entitled 'The Honour of All' which documented their achievements in controlling alcohol abuse was viewed by hundreds of Aboriginal people in Central Australia at that time, and was also shown on Imparja TV. Aboriginal alcohol activists invited other North Americans to Australia in the early 1990s as well. For example Phil Diaz (previously a senior bureaucrat in the US Office of National Drug Control Policy, Office of the President), and Anne-Marie Latimer (executive director of Native American Children of Alcoholics) attended an Aboriginal drug-free conference in Cairns. These spokespeople linked the solutions to indigenous drug and alcohol problems to a reclamation of Aboriginal culture and spirituality, a revival of 'traditional' ways, and to the need for abstinence based Aboriginal-run treatment centres.

Chicka Dixon's earlier visit, and the arrival of Canadian Indian and other North American consultants in Australia 15 years later, had a number of impacts. The most important of these was that the indigenous treatment consultants brought with them North American approaches to addiction. The Canadians and Americans who came to influence Aboriginal programs were unanimously anti-moderation or the possibility of 'social' drinking. They expressed doubts about the idea of 'prevention'. The developments and links with North America reinforced disease- and abstinence-based models of treatment for Australian Aboriginal people. It is to this I refer — somewhat tongue in cheek — in my title: 'The diseasing of Australia?'

Some have questioned whether these First Nations (and other) consultants really presented an indigenous perspective, or simply a North American perspective - a re-run of the war against drugs, a unitary focus on abstinence, the progressive disease model, on residential treatment, and an antipathy to harm minimisation. Indeed, one could ask how relevant Australian government policy is for Aboriginal people if there is a rejection of harm minimisation, and if abstinence is considered the only solution?

In this lecture, I am going to explore both the symbolic and the real impact of these developments. I will show how a small group of alcoholism treatment entrepreneurs were able — for a time — to influence approaches to Aboriginal alcohol problems in ways which ran counter to policies long-established in Australia. I will suggest why this came about.

Aboriginal responses to North American contributions

By 1990, the path between North America and Australia had become well-trodden. This was partly as a result of Aboriginal study visits like Chicka Dixon's, and partly as a result of the growing international indigenous networks facilitated by the United Nations. The Aboriginal responses to the visits of Canadian and American treatment consultants were initially positive. Aboriginal audiences were impressed by the flair and professionalism of the Native Americans, and by their slick presentations. They were also fascinated with the exoticism of the visitors, the intriguing talk of sweat lodges and pipe ceremonies, of eagle feathers and healing circles.

There is no doubt that the visitors injected a new sense of optimism and energy among Aboriginal alcohol program managers. The persuasive presentations by one or two of the Canadian Indian consultants resulted in invitations to speak to Aboriginal groups and at conferences in different parts of Australia. Following these visits, the Commonwealth government began receiving funding applications for millions of dollars from Aboriginal groups wanting to establish new residential treatment and training centres. By October 1992, one of the consultants had been instrumental in sending Aboriginal counsellors to Canada for training programs. He assisted local people in getting a new residential treatment and training program up and running in Alice Springs, on a model largely imported from Canada. That is, a 12 steps based program including some selected elements of Indian cultural practice, including a version of the 'smudge' or smoking ceremony. Aboriginal people successfully applied for funds from ATSIC and other sources in order to hire Canadian Indian consultants or to travel to Canada themselves. Dozens went from Australia to the First Healing Our Spirit Worldwide conference for indigenous people which was held in Edmonton in July 1992.

While most Aboriginal alcohol activists welcomed the Canadians for their experience in treatment and training, and greeted them as indigenous brothers and sisters who shared a history of dispossession and colonisation, some were not so sure. Several Central Australian people had reservations about the wisdom of transplanting a model from another indigenous group, especially when it contained elements of their cultural practices. In Canada, the actual content of the training program is, however, more oriented to popular western psychology than to indigenous culture. Indigenous clients there are urged to 'Walk the Walk' as well as 'Talk the Talk', and are provided with a persuasive mix of 12 steps rhetoric, and some non-specific indigenous culture-jargon. One prominent Aboriginal alcohol worker referred to the Canadian model as 'AA with a smokescreen'. Indeed, consultants who were hired by Aboriginal residential programs urged clients to forgo medication of any kind (including that prescribed for diabetes and depression) - a position common among proponents of 12 step programs. The training modules derived from Canada were sold and re-sold to Aboriginal groups in different states and the Northern Territory, at a high cost to the national Aboriginal health budget.

What explains this impact?

So how did it come about that a small group of indigenous (and some non-indigenous) treatment entrepreneurs from another country had such an impact? I think the answers to this question lie in the ideological and political underpinnings of what we might call the Aboriginal alcoholism movement.

The North American consultants were able to build on existing views shared by the Aboriginal proponents of alcoholism treatment. Firstly, versions of AA and the 12 steps were already well-entrenched in the residential centres and halfway houses set up for Aboriginal clients. The disease model was also prominent among the key Aboriginal alcohol spokespeople of the 1970s and their positions have remained unchanged to the present day. In addition, the idea of biological difference with respect to a supposed vulnerability to alcoholism had been favoured by some since the 1970s, and a number of Aboriginal spokespeople publicly expressed views along these lines. (It's worth pointing out however, that the official position on such notions today is less than favourable). It was stressed by Aboriginal spokespeople of all persuasions that Aboriginal people were qualitatively, culturally and even biologically different from other Australians.

In the 1970s, when the local Aboriginal alcoholism movement began, there was a number of extraordinary suggestions around. One non-Aboriginal suggested to a House of Representatives enquiry that there was an adaptive difference between Aborigines and other Australians in their gulping behaviour, associated with drinking water out of rockholes. This was supposed to make people drink alcohol faster (House of Representatives 1976-1977: 94). People in the tropical north were said to handle their alcohol 'better' than those in central regions, which led to musings about biological differences (House of Representatives 1976-1977:44). One doctor working in the first of the Aboriginal primary health services (in Redfern, Sydney) believed that Aborigines lacked the liver enzyme which is responsible for detoxifying alcohol and wanted to give Aboriginal alcoholics massive doses of Vitamin C in order to 'detoxify' the kidneys. Aboriginal activists are also on record as saying that their people were not able to consume large quantities of alcohol because white man's food was inadequate in nutritional value (House of Representatives 1976-1977:2847). The National Aboriginal Consultative Committee pursued the biological differences argument, denouncing government suggestions in the mid 1970s that communities should be able to decide for themselves whether to be 'dry' or 'wet'. This was said to be a 'grave error' and tantamount to 'letting babies into a hospital dispensary to play with dangerous drugs'.

One problem to be dealt with was whether or not alcohol itself was inherently addicting or whether its addictive powers somehow narrowed down to form a hold on the few who were susceptible to the 'illness'. The alcoholism movement (AA included) stresses that alcohol is only pernicious to a few drinkers. Alcohol is viewed not as a threat to the entire community, only to those vulnerable to it. What many Aboriginal alcohol activists did was to suggest that they were all vulnerable to it. The belief that Aboriginal alcoholism was different meant that the proponents of the 'dry' position could argue that while 'controlled' or 'moderate' drinking was fine for non-Aboriginal people, abstinence was the only solution for Aboriginal people with drinking problems.

Of course, this was not an uncontested position. The disease/abstinence model was championed by those people managing community-controlled residential services. These were, and are, run on strict lines which insist that all workers, managers and directors should be abstinent. On the other hand, there were Aboriginal-controlled medical services being established from 1972 onwards. These services were initiated by radical activists and volunteer doctors, and after considerable struggle finally obtained government support. The radicals involved with the medical services rejected the disease model and abstinence. They attributed excessive drinking to overwhelming political, social and economic pressures. Here in Melbourne for example, the Fitzroy Aboriginal Medical service declined to promote a rehabilitation program for alcoholics in the late 1970s. 'We do not regard people who drink excessively, because of overwhelming political, social and economic pressures, as alcoholics' they said. 'We consider their problem a social, political and economic problem to be treated as such' (Nathan 1980:25).

So Aboriginal spokespeople were, and still are, grappling with different conceptual frameworks, different 'alcohol-explaining models'. Those involved with the Aboriginal 12 step programs were convinced by the apparent simplicity of the disease metaphor. Others struggled to establish whether, or how, Aboriginal alcohol problems could be placed in a political context. Some spoke of social and historical deprivation 'leading' to alcoholism. In 1977 for example, Charles Perkins observed that 'Aboriginal alcoholism is related to an identification loss and therefore is a peculiar form of alcoholism' (House of Representatives 1976-1977:4-6). The argument put forward that Aborigines 'catch' the disease of alcoholism as a result of their dispossession, leads inevitably to the proposition that they must suffer from an idiosyncratic form of alcoholism. Overall, Aboriginal spokespeople were agreed that their use of alcohol was different, that it came about for different reasons, and required different approaches to those for non-Aborigines. Notions of 'race', 'culture' and even 'identity' became blurred in this discourse.

The most persistent version of these alcohol-explaining models appeared in the National Aboriginal Health Strategy report of 1989. This states that 'alcoholism is an introduced illness caused primarily by political, social, economic and cultural deprivation' (National Aboriginal Health Strategy Working Party 1989). This Aboriginal definition of alcoholism can be seen as a sense-making strategy, allowing for the injection of historical and political elements. Nevertheless, the disease model remained in the ascendancy among the main actors in the alcoholism movement. When the North American treatment spokespeople began to visit Australia, they found a welcome within this core group.

The Canadians also reinforced the already established view that Aboriginal ex-drinkers are in the best position to understand and treat other Aboriginal people with drinking problems. If their people suffered from a particular form of alcoholism, which had different antecedents to those of other Australians, then it was natural to assert that only they could offer the most effective programs of rehabilitation. Indeed, these principles had led to the establishment of Aboriginal-controlled residential alcohol treatment or 'rehabilitation' programs from the 1970s. Policies of domestic self determination (inaugurated by the Whitlam Labor government in 1972, and continued as 'self management' by the Fraser Coalition government from 1976) made it possible for Aboriginal community organisations to be established. These included the legal services, primary health care services and alcohol rehabilitation centres. They received federal funds directly, and independently of each other, by-passing the states.

The movement for the community-controlled alcohol centres was initiated by Val Bryant, a charismatic Aboriginal ex-drinker and long term AA member. In 1974 she established Benelongs Haven, a halfway house which used what was described as a 'unique blend of AA and Aboriginal spirituality'. Recovered Aboriginal alcoholics treated Aboriginal clients. This, of course, is in the tradition of the 'wounded healer', long utilised by programs based on the Minnesota model and AA (White 2000; Kahn and Fua 1992). This first centre spawned a number of offshoots in different parts of Australia, had a lasting impact and is still going strong. The centres were run entirely independently of the Aboriginal medical services. As Australia began to change its policy orientation towards prevention (beginning in the late 70s) there was vigorous opposition from these Aboriginal treatment managers. They questioned the wisdom of moderation messages, doubted that 'social' drinking was possible for Aborigines, and described controlled drinking as a 'backwards step' in the 'war' on substance abuse.

Another reason why the Canadian treatment consultants were welcomed was because they gave credibility and validation to Aboriginal alcohol workers who were not part of the Australian treatment establishment. They felt neglected by, and were often at loggerheads with, State and Commonwealth public servants. They suffer from inadequate training as well as lack of status, and miss out on the official and widespread support given to generalist Aboriginal health workers. The Canadians gave up-beat presentations that emphasised the number of treatment centres, the mass treatment and training, and above all the structured and professional nature of their programs. They stressed the quality of the facilities available for those undergoing treatment in Canada, alluding to the makeshift quality of some of the Australian residential facilities.

The Canadians thus legitimised the existing ideology of Aboriginal people who were already oriented towards 12 step residential programs, the disease model and abstinence goals. They validated the long-standing argument for Aboriginal control of treatment services, and reinforced the perception that alcohol programs had been hard done by. They extolled the virtues of treatment centres describing them as 'miracle machines' which transformed communities with lost cultures and with universal drunkenness (Hazlehurst 1994; Hodgson 1996; Shirt 1993).

Above all, the Canadians were influential because they were indigenous. The growing perception that indigenous relatedness is a universal phenomenon has as a side-effect the loosening of links with that which is non-indigenous. This meant that the solutions to Aboriginal alcohol problems were less likely to be sought 'at home' among professionals close at hand, but inclined Aboriginal groups to receive the message from Canada warmly and uncritically. They reinforced the perception that mainstream networks with State agencies were a waste of time. Canadian stress on indigenous culture as a form of healing in itself - what has been termed 'culture as treatment' - further reinforced a separation between Aboriginal and mainstream thinking on addiction.

The impact on policy

In terms of policy approaches to the unresolved seriousness of indigenous substance abuse, this North American-instigated revival of the old disease/abstinence position undoubtedly set things back. At best, it can be seen as a hiccough in the slow process of disseminating a broader, less dogmatic perspective in the indigenous arena.

As we all know, Australian policies, like those in the UK and elsewhere, had swung in the 1980s towards prevention and the early identification of problem drinking, which accompanied the consumption-harm conceptualisation of the problem. This had brought about a reevaluation of the relevance of existing treatment approaches, and for the need to re-balance the mix of funding (Edwards et al 1995; Lewis 1992, Thom 1999). Australia had had good policy advice at the Commonwealth level in the presence of Dr Les Drew, who was medical advisor to the Commonwealth in the 1970s. Drew was famous among other things for his seminal paper 'Alcoholism as a self-limiting disease' (Drew 1968). In 1986, he wrote an article savaging the disease model (Drew 1986). Later, Australia became one of the key locations for research into controlled drinking and the range of secondary prevention activities known as brief interventions (Heather and Robertson 1985; Mattick and Jarvis 1993). Sydney was one of the 10 international locations for the WHO-sponsored randomised controlled trial of brief interventions (Saunders et al 1993).

But at the time of these changes in mainstream thinking, Aboriginal alcohol policy was in the hands, not of the health portfolio, but lay within the Aboriginal affairs portfolio. This separation was, in retrospect, unhelpful. It contributed to the isolation of Aboriginal health policy (including substance abuse issues) from the professional input directed into the health portfolio. And it contributed to the growing unwillingness by government policy makers to offer guidance and professional expertise to the Aboriginal portfolio. This was fed by an increasing sensitivity to the claims of Aboriginal cultural 'difference' and created a fear of 'stepping on cultural toes'. Australia's National Campaign against Drug Abuse never managed to create a channel of communication with the Aboriginal alcoholism movement. Its policy and evaluation documents reveal the lack of progress (National Campaign Against Drug Abuse Task Force on Evaluation 1988). A huge gulf remained between the national campaign's harm minimisation policy, and a large body of Aboriginal opinion in the alcohol treatment field. This maintained that there was no culturally acceptable level of drinking, and that harm minimisation did not go far enough in eradicating unacceptable behaviour associated with alcohol abuse. Little, if any, of the 'new' primary and secondary prevention approaches permeated into the Aboriginal field. This was also because the Aboriginal alcohol programs developed independently, separate from the community-controlled medical services. While the medical services embraced the WHO-inspired notions of primary health care, the alcohol programs remained insulated from this changing climate of opinion taking place in the broader community.

There seemed to be a failure to present harm reduction or moderation messages to Aboriginal people. No one could work out how to couch these messages in what we might call 'culturally appropriate' ways. Many interpreted such approaches as the government 'pushing' social drinking onto people (cf. Landau 1996). Certainly it was not made clear that advice on reducing harm can include making the choice of abstinence. (For a number of very good social reasons, abstinence is still chosen by a majority of Aboriginal problem drinkers making a change). The 12 steps oriented residential programs continued to be funded and to receive around 70% of the available funding, year after year. By 1993, it was found that Aboriginal and Torres Strait Islander people were more likely to be attending residential treatment than were non-Aboriginal Australians. They were also found to have a limited array of treatment styles available to them. By pointing this out, I do not mean to suggest that there is no place for residential programs. We know that residential care is indicated for certain types of drinkers, and that for Aboriginal people in particular they provide a safe respite from the unrelenting pressure of drinking associates and kin. They save lives. They undoubtedly assist many people to make a decisive break from a drinking lifestyle, and they provide jobs and maintain sobriety for those who work in them. Ideally, though, they are just one segment of what should be a multi-dimensional and comprehensive approach to the management of Aboriginal alcohol problems.

What is really happening?

The renewed emphasis on 'treatment' which was championed by the Canadian indigenous consultants, in a sense distracted everyone's attention for a time from the main game: offering a broader range of interventions to a greater spread of drinkers experiencing problems. These could include: strengthening and supporting local social controls at the community level; targeting interventions at high-risk drinking and high-risk environments; and finding appropriate ways of providing much earlier interventions for Aboriginal people.

The reality is that harm reduction strategies are now in place in Aboriginal communities across the country — even if they are not always named as such. Local social movements are successfully coalescing around liquor licensing restrictions; community groupings have become more outspoken and are taking direct action involving night patrols, marches and demonstrations.

On the issue of providing earlier interventions — there has finally been some movement. A scattering of health services and health professionals working for Aboriginal people are beginning to show interest in providing opportunistic brief advice for alcohol problems showing up in primary health care settings. I have taken a personal interest in the role of doctors as interveners. This is as a result of some earlier research I did on Aboriginal people who had quit drinking without help (Brady 1995a). While these naturally recovered individuals I interviewed recalled that they were influenced by a range of social and personal disasters, including near-death experiences, and religious crises, a number of them remembered a 'strong talk' they received from a doctor. Of course, as Stanton Peele himself has pointed out, one can't really tell whether a story a person tells is the 'real' explanation for why they quit (Peele 1989:187). But let's say I gave them the benefit of the doubt. And I will cite in my defence an anonymous sociological saying: 'What is perceived to be true, even if it is false, has real consequences'(cited in Evans, Barer and Marmor (1994:317).

This work on giving up the grog alerted me to the fact that doctors have a potential and indeed a special role with Aboriginal problem drinking patients. This is because doctors are respected, trusted, and thought to be knowledgable. They are not 'of the community', and I believe that this fact is a positive advantage in the context of Aboriginal social life. This is because a doctor can fulfil the role of an 'authorising other' who provides the patient with an excuse for a change in drinking behaviour (Brady 1995b). We know that there are strong cultural and social disincentives for Aboriginal people to confront each other about drinking behaviour. Expressions of advice or concern can be interpreted as interference, criticism, or even rejection by kin. We know that people have a strong sense of personal autonomy that does not take kindly to the interference of others in the social or family group. But doctors are not kin, and they are not members of the community. They are expected to give advice in the privacy of the consultation room. Crucially, the 'blame' for a decision to change can be laid at the feet of the doctor. This can be a necessary deflecting device for an Aboriginal individual who faces unrelenting pressure to continue to drink at the same pace.

For all these reasons I believe that there is great potential for sensitively-conducted motivational conversations to take place with Aboriginal patients in the privacy of a doctor's room. These could just have an influence on those who are contemplating change, or who are beginning to suffer social or physical consequences of drinking.

There are other changes afoot as well. More Aboriginal people are enrolled in addiction studies courses at colleges and universities. I remember catching up with an Aboriginal friend who had just completed such a course and who was enthusing about Prochaska and DiClemente' 'stages of change' model.

Indigenous spokespeople such as Noel Pearson have begun to highlight the need for Aboriginal people to reevaluate and rework some aspects of social and cultural practice. Pearson is referring to some of the deeply-embedded social practices such as the sharing of resources and making demands on kin. These, he says, are often distorted and manipulated by drinkers — usually to the detriment of other community members, their families and children. This courageous proposal from Pearson is a far cry from suggestions that more treatment centres are needed, or that 'culture' — just as it is — is a panacea for problem drinking.

In conclusion

It does seem timely to question whether the disease metaphor has been helpful to Aboriginal struggles to manage problem drinking. After all, it has been challenged since 1973 both in Australia and the UK. Stanton Peele, writing pithily as usual, saw the expansion of the definition of disease to addiction as a 'gerrymander' (Peele 1989). Apart from these 'mainstream' criticisms, there are some particularly pressing disadvantages for indigenous people. Suggestions that alcohol problems are restricted to a few 'sick' people can be a major inhibitor to motivating collective community action to deal with the many manifestations of alcohol-related trouble. Everybody knows that these disturbances are not just the work of 'alcoholics'. A belief in the inevitability of alcoholism produces a sense of futility and fatalism in whole communities, not just in individuals. Many Aboriginal populations already experience a sense of political powerlessness over circumstances. When this is coupled with the suggestion that people who drink are vulnerable to a disease that can never be cured, there is a strong likelihood that community impotence, rather than motivation, will result. There are many Aboriginal people who would like help to get their drinking under control, and many who do not wish to abstain. Believing that all the available services are going to try to convince these people to abstain has been found to be huge barrier, preventing people from seeking support and advice.

Ranged against a unitary focus on tertiary treatment is increasing evidence of the benefit to Aboriginal people of regulating availability through local policies and licensing restrictions; of the many grass-roots actions in existence that help to reduce harm; and the powerful stories of those people who have given away the grog on their own. As I have mentioned, there is also the potential for more pro-active opportunistic interventions by doctors. None of these actually, or potentially, useful activities happening in Australia were inspired by the visiting treatment entrepreneurs from North America. There, biological explanations for drinking among American Indians are still widespread, which is probably the reason why seventy per cent of tribes still choose prohibition on their reserves. Phil May, a leading American researcher suggested this link - if people have an all-or-nothing view, that Indians drink because they have a physical weakness for alcohol, then prohibition is the 'only' answer (May 1992). We know from Stanton Peele and others, that North American clinicians as a whole refuse to encourage people to drink less, instructing all problem drinkers to abstain (Peele 1993; Rosenberg and Davis 1994).

The cutting edge of health research at the moment seems to be in the social determinants of health. Stanton Peele cites the work of Leonard Sagan who noted in 1987 that community supports and the ability to control one's life are the crucial ingredients in life expectancy (Peele 1989:270; cf. Evans, Barer and Marmor 1994). We have heard about this research at first hand recently from people such as Len Syme and Michael Marmot, who talk about the social gradient, about control over destiny, and feelings of marginalisation as important determinants of health. There are many features of this research that are highly relevant for Aboriginal people, and that could contribute to ways of understanding problem drinking. I believe that it would be fruitful to make the connections between the issue we are all interested in — addiction — and this emerging area of research into social and environmental determinants of health and well-being.

Thank you.

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