Alcoholism: A Different Approach

A different approach to treating alcoholism. (Viewpoint).

by Heather Ogilvie.  Consumers' Research Magazine, June 2002 v85 i6 p10(4)

Most Americans think of problem drinking as the disease of alcoholism.  They believe the problem drinker is a sick person who requires treatment.  The public is also under the impression that the primary evidence corroborating that a heavy drinker has the disease is his unwillingness to admit it – his denial.  Treatments based on the classic disease concept of alcoholism, with its notions of irreversibility and loss of control, prescribe one goal:  total abstinence.

Furthermore, when most Americans think of treatment for drinking problems, two things come to mind:  28-day inpatient recovery programs (such as the Betty Ford Center) and the "12 Step" program of Alcoholics Anonymous (AA).  There are, however, at least a dozen alternative approaches to treatment that have been proven at least as effective as AA and inpatient programs (most of which are also based on the "12 Steps").

There is also another, strikingly different, concept of treatment that goes sharply counter to the now-traditional disease concept and its total abstinence prescription.  This competing view, which has gained adherents in recent years, holds that what is called alcoholism is often a result of modifiable behavior patterns that are within the power of the individual to change, and that in such cases the optimum solution may well be, not total abstinence, but sensible moderation in drinking.

At issue in debates about these matters – and of urgent interest to anyone who must deal with them as they relate to family or friends – is which of these two different approaches is more effective in managing the problem.  In some cases it may be one, in some cases it may be the other.

Since its founding in the mid-1930s, the fellowship of AA has undoubtedly saved countless lives.  The people who are able to maintain sobriety through AA should certainly continue to attend meetings.  But AA does not work for everyone.  Various estimates suggest that more than half of the people who attend AA meetings drop out within the first year.  Of the people who regularly attend meetings, only about 25% succeed in a goal of long-term abstinence.  Most professionals performing alcohol-related research today aim to make available treatment options that can help the problem drinkers for whom AA does not work or does not appeal, as well as for those who never even try AA.

Unfortunately, few treatment options have better outcomes than AA:  25% is about the best any one program can boast.  This is not great news, as it is estimated that a third of all problem drinkers cut down or quit drinking on their own.  To even suggest that some problem drinkers recover on their own is heresy to the advocates of the disease model, as alcoholism is, by their definition, irreversible.  They argue that those drinkers who appear to have reduced their drinking to moderate, nonproblematic amounts were never true alcoholics to begin with.  This thinking is not particularly helpful, as it makes it impossible to tell a "true" alcoholic from a mere heavy drinker until serious damage has been done.

Are Alcoholics Diseased?  The idea of the irreversibility of alcoholism has been propagated by Alcoholics Anonymous with such phrases as "Once an alcoholic, always an alcoholic," "always recovering, never recovered," and "one drink, one drunk."  Dr. D.L. Davies challenged that notion in his 1962 report that followed up on diagnosed "alcohol addicts" who had been treated in a London hospital seven to 10 years earlier.  Dr. Davies noted in his report that seven out of the 93 male patients seemed to be drinking normally.

Nearly 80 studies had been published in the scientific literature prior to 1980, demonstrating that non-problem drinking is a stable treatment outcome.  These studies reported rates of observed normal drinking among previously diagnosed alcoholics varying between 2% and 32%.  The Rand Corporation assessed data collected from alcoholism treatment centers nationwide between 1970 and 1974, and found that the data suggested "the possibility that for some alcoholics, moderate drinking is not necessarily a prelude to a full relapse and that some alcoholics can return to moderate drinking with no greater chance of relapse than if they had abstained."

Dr. George Vaillant, analyzing data from Harvard Medical School's Study of Adult Development – which followed 660 men from 1940 to 1980, from their adolescence into late middle age – found that alcohol abuse among college-age men was a very poor predictor of heavy drinking at middle age.  This finding supports other studies that have found that most college-age binge drinkers outgrow their heavy drinking behavior once they leave college and begin jobs or start families.  K.M. Fillmore's follow-up of college students with drinking problems found that only 20% still had problems 20 years later.  Dr. Vaillant wrote: "The course of alcohol abusers in the college sample contradicted my previous assertions that sustained alcohol abuse without abstinence is a progressive disorder."

The notion of loss of control also figures prominently in the classic disease model of alcoholism.  Researchers have devised many experiments to assess whether a drinker has indeed experienced a physical loss of control following a "priming dose" of alcohol.  An experiment conducted at Johns Hopkins University in 1971 tried to determine the incentives it would take to get an alcoholic not to drink.  Researchers found that abstinence could be bought for as little as $7 and no more than $20 a day.

Other studies have replicated this finding.  In a five-week experiment, inpatient subjects were given the option to drink up to 10 ounces of alcohol every weekday.  Every other week, the subjects were given access to an improved environment – including telephone, television, pool table, games, and reading materials – provided they drank fewer than 5 ounces of alcohol for the day.  If the subject exceeded that amount, he was put in a more Spartan environment and was not allowed to drink the following day.  On the alternate weeks, the subjects remained in ascetic environments no matter how much they drank.  All five subjects drank less during the weeks when privileges were available than during the weeks when no privileges were available.

A 1977 review of scientific literature cited 58 studies that have corroborated the finding that alcoholic drinking is a function of "environmental contingencies."

Can Alcoholics Control Their Drinking?  As the classic disease concept of addiction was eroded by reports of "normal" drinking among previously diagnosed alcoholics, researchers began to wonder whether "normal" or moderate drinking was a viable treatment goal for some alcoholics.  The first widely cited report of successful training for controlled drinking appeared in 1970.  Researchers applied behavioral therapy techniques in treating 31 alcoholics, after which 24 managed to drink in a "controlled" manner for periods ranging from four months to a little over one year (the length of follow-up).  These results sparked an interest among other researchers who were eager to duplicate the study's outcome.

One study compared a controlled-drinking treatment program with one whose goal was abstinence.  Roughly one-third of each treatment group was abstinent for a year following treatment.  Immediately following treatment, the members of both groups who were not abstinent had cut down to approximately half their pre-treatment alcohol consumption.  Three months later, the drinkers in the group trained for abstinence were drinking 70% as much as they had before treatment, while the drinkers in the controlled-drinking group had further reduced their consumption to about 20% of their pre-treatment levels.  Over six months' time, the drinkers in the controlled-drinking group continued to reduce their consumption by a greater amount than did those in the abstinence-oriented group.

The most controversial controlled-drinking study was reported in 1972, by researchers Mark and Linda Sobell.  Their 40 volunteer subjects were male inpatients at Patton State Hospital in California.  The Sobells treated their controlled-drinking subjects with their own "Individualized Behavior Therapy" (IBT).  The Sobells concluded:  "[S]ubjects who received the program of ... IBT with a treatment goal of controlled drinking ... functioned significantly better throughout the two-year follow-up period than did their respective control subjects ... who received conventional abstinence-oriented treatment."  They also noted:  "[O]nly subjects treated by IBT with a goal of controlled drinking successfully engaged in a substantial amount of limited, non-problem drinking during the two years of follow-up, and those subjects also had more abstinent days than subjects in any other group."

Another controlled-drinking study involved randomly dividing 70 problem drinkers, who were each drinking roughly 70 ounces of alcohol per week, into an abstinence group and a controlled-drinking group (whose members were asked to abstain for the first four sessions of treatment).  During the first three weeks, the members of the abstinence group drank much more than the controlled-drinking group and significantly more of the controlled-drinking group actually abstained.  A year later, no significant difference existed between the groups, but the abstinence group had sought help more frequently than had the controlled drinkers.

Another study of male veterans divided participants into two groups:  one receiving abstinence-oriented treatment and the other receiving controlled-drinking treatment.  After six months, the severely dependent members of the controlled-drinking group experienced more days of heavy drinking than did those in the abstinence group;  however, after one year, the differences disappeared, and at six years there were no significant differences between the two groups.

One might think that controlled-drinking treatment would appeal to every alcoholic, but this is not the case.  In one study of 63 alcohol-dependent men given the choice in treatment goals between abstinence and controlled drinking, roughly 70% chose abstinence.  Indeed, controlled-drinking studies have shown that most people who moderate their drinking eventually abstain.  According to one researcher:  "Our long-term follow-up research with clients treated with a moderation goal found that more wound up abstaining than moderating their drinking without problems."

Other researchers have reached similar conclusions.  In one study, 75% of participants who reported previous drinking problems recovered without formal treatment (i.e., eliminated all problems resulting from overdrinking), and 50% achieved stable, moderate drinking.  University of Washington Professor G. Alan Marlatt concludes:  "Contrary to the progressive disease model, these findings indicate that a majority of individuals with drinking problems recover on their own ... Even when they are trained in controlled drinking, many alcohol-dependent individuals choose abstinence.  Over time, rates of abstinence (as compared to controlled drinking) tend to increase."

Who responds best to controlled-drinking therapy?  In general, people under 40 who have suffered less severe dependence-related problems, people with stable marital or family relationships, people with stable employment, and women.

Younger people and those whose problems are not that severe are notoriously difficult to attract into conventional treatment and to persuade to adopt a goal of abstinence.  One study found that young, unmarried men with a low level of dependence were 10 times more likely to relapse if they had adopted abstinence as a goal than if they had become moderate, nonproblem drinkers 18 months after treatment.  Offering young drinkers the option of controlled-drinking counseling may therefore draw them into treatment sooner and thus prevent them from developing worse drinking problems down the line.

Even in cases in which abstinence is clearly the most pragmatic treatment goal (for example, for a 55-year-old male who has been in and out of detox wards for 35 years), offering the option of moderation may at least bring the person into treatment he might otherwise shun.  Once the person is in treatment, a failed attempt at controlled drinking may prove the case for abstinence more persuasively than would a confrontational therapist citing disease-theory dogma for hours on end.  As Dr. Marlatt puts it:  "From a public health perspective, it makes sense to offer moderation-oriented programs to alcohol abusers and mildly dependent individuals as a means of increasing client recruitment and retention.  Individuals who do not benefit from these programs can be 'stepped up' to more intensive abstinence-oriented services."

How Patient Control Can Help Recovery.  In "12 Step" recovery programs, the client is told (a) his drinking is beyond his control – in fact, he is powerless against it,  (b) his condition is irreversible and incurable,  and (c) the success of the treatment depends solely on a Higher Power.  While that Higher Power may be the god of any religion, the group, or another person, it must be a power other than the individual.  A person who prefers to see himself as the effective power, therefore, would not find AA helpful in improving his sense of self-efficacy, his (supposedly absent) self-control, or his will power not to take another drink.

Disease theory proponents argue that attributing the drinker's problems to a disease outside her control frees her from the guilt and stigma of moral weakness.  It clears her conscience enough to admit the problem and not be ashamed to seek help.

But doesn't the disease perspective merely swap one stigma – that of moral failing – for another – that of being diseased?  By assigning responsibility for the problem to something outside the person, the disease perspective tells him, in effect, that he is powerless and therefore helpless.  The person learns to think of himself as a victim.

Stanton Peele, one of the most outspoken critics of conventional addiction treatment, has observed that recovering alcoholics are able to "use their addicted identity to explain all their previous problems without actually doing anything concrete to improve their performance."  He accuses traditional treatment of ignoring "the rest of the person's problems in favor of blaming them all on the addiction" and limiting clients' "human contacts primarily to other recovering alcoholics who only reinforce their preoccupation with drinking";  in effect, trapping them "in a world inhabited by fellow disease sufferers" until they "feel comfortable only with others in exactly the same plight."

Wouldn't it be more productive for the drinker to think he has a personality weakness he can overcome, rather than a lifelong disease he can never shake?  Might not the shame of a moral failure be put to good use?  Some people have wondered:  Why shouldn't alcoholics feel ashamed of their behavior?  Wouldn't a greater sense of shame have prevented the behavior in the first place?

What good is it to tell someone he is sick and powerless, but then send him to a self-help group, rather than to a doctor, for treatment?  In his book, Heavy Drinking, Herbert Fingarette asks: "If the alcoholic's ailment is a disease that causes an inability to abstain from drinking, how can a program insist on voluntary abstention as a condition for treatment?  (And if alcoholics who enter these programs do voluntarily abstain – as in fact they generally do – then of what value is the [disease] notion of loss of control?)"

The danger of constantly telling people that they have no control is that eventually they may come to believe it.  Falling off the wagon thus only proves to the drinker what he has been told: that he has no control.  Henceforth, what is his motivation to keep attending AA or to seek further treatment? Treatment professionals who advocate "12 Step" programs typically regard relapse not as a failure of treatment, but as a failure of the patient to comply with treatment.  Given these conditions, it is no wonder so few people are able to maintain long-term sobriety through "12 Step" recovery programs.

On the other hand, when you tell someone that, with time and effort, he can change his habits, make improvements to troublesome aspects of his life, and reverse the course of his drinking problems, he will probably be more willing to give treatment a try and recognize the signs of his progress.  By showing him he has choices for treatment, you provide more hope and give him back a sense of control simply by allowing him to choose.

Mary Pendery, the director of an alcohol-treatment center in Southern California, did an extensive follow-up investigation of the Sobells' study.  Ten years after the Sobell study, her findings were published in the respected journal Science.  She and her co-authors all but accused the Sobells of fraud.  Soon after, in March 1983, "60 Minutes" aired a segment on the Sobell study, interviewing Mary Pendery but not the Sobells.  In response to media attacks, the Sobells asked the Addiction Research Foundation in Toronto to set up an independent committee to investigate the charges against them.  The committee's findings became known as the Dickens Report.

Among its many criticisms, the Dickens Report faulted Pendery's study for citing data out of context.  Pendery reported, for instance, that four of the 20 subjects who received controlled-drinking training had died as the result of alcohol-related problems.  The Dickens Report revealed, however, that Pendery had failed to point out that the deaths occurred between six and 11 years after treatment, and that more – in fact, six – of the 20 subjects in the abstinence-oriented control group had died during the same period.  The Dickens Report found accusations that the Sobells had suppressed certain findings to be completely without merit and found no reasonable cause to doubt the scientific or personal integrity of the Sobells.  A congressional investigation into the matter supported this conclusion.

For more information see Alternatives to Abstinence:  A New Look at Alcoholism and the Choices in Treatment, by Heather Ogilvie (hardcover: $21.95, ISBN 1578260816; softcover: $15.95, ISBN 1578261139).  This book provides additional discussion on the issue of whether alcoholism is a disease or a behavior choice, and provides information on what types of treatments are available for problem drinkers and where they can find such treatments.  It is available from most bookstores, or from Hatherleigh Press (1-800-528-2550; http://store.yahoo.com/hatherleighpress/self-help.html).  The book is also available from Amazon.

Ms. Ogilvie is a writer and journalist who has edited several health-related books, including Living with Hepatitis C, Managed Care Ethics, and Women and Anxiety.  This article is an adapted excerpt from her book Alternatives to Abstinence:  A New Look at Alcoholism and the Choices in Treatment, published by Hatherleigh Press, © 2001 by the author.

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