The American Psychiatric Association's attacks on Moderation Management — does the APA oppose moderate drinking treatment goals?

When the support group, Moderation Management (MM), began gaining widespread attention, the American Psychiatric Association (APA) began a concerted campaign to attack MM and its support of reduced drinking outcomes, even though in other contexts the APA endorsed moderation outcomes. The following exchange appeared, in part, on the pages of Psychiatric Times.

This letter was sent to Richard Francis, Chair of the American Psychiatric Association's Council on Addiction Psychiatry.

Dear Dr. Frances (Richard):

I read a quote of yours in articles in two national publications -- the Los Angeles Times (January 31, 1995) and Psychiatric Times (February, 1995) -- about Moderation Management (MM), a self-help group supporting moderation outcomes among former problem drinkers. Both articles quoted you as follows: "Every time something like this comes out, many of my patients relapse."

[When I spoke with you by phone], you were reluctant to describe exactly how many patients of yours relapsed because of Moderation Management, although you said such relapses definitely have occurred. You also said that over your career that you had many patients relapse due to published academic research indicating moderation outcomes. Your statement thus is a summary of your lifetime's experience.

As the author of the Introduction to Moderate Drinking: The New Option for Problem Drinkers, the handbook used by MM, I was quite concerned with your statement. This was doubly true since you are chair of the American Psychiatric Association (APA) Council on Addiction Psychiatry. Statements from someone in this position obviously carry some weight, and therefore your claim that MM inspires relapse is quite a serious one.

Your representation that many of your patients who were in remission relapsed due to hearing about MM suggests that you have an extremely good treatment, and that alternatives simply interfere with the excellent workings of this existing therapy. When I asked you about measured outcomes at your program at Hackensack, you said you hadn't compiled that information.

At the same time, quite a few professionals believe that problem drinking and alcoholism remain a persistent problem -- and may even be increasing -- under current treatment alternatives. As a result, some clinicians believe that offering additional options can enhance both the outcomes for those in treatment and also draw more people into treatment. Allowing such choice, according to this view, can strongly enhance patients' commitment to the chosen course of treatment. As you yourself mentioned, those who fail at one outcome (you mentioned moderation) may be observed to more strongly commit themselves to the other.

I would also like to direct your attention to the APA's own Diagnostic and Statistical Manual of Mental Disorders. The third edition, revised, used the following definitions under "Diagnostic criteria for Psychoactive Substance Dependence" (DSM-III-R, p. 168):

In partial remission: During the past six months, some use of the substance and some symptoms of dependence.

In full remission: During the past six months, either no use of the substance, or use of the substance and no symptoms of dependence.

As you can see, this wording recognizes drinking moderation as a full-remission category. For it to be given this status, it would seem as though the manual accepts it as a legitimate -- and perhaps not extremely uncommon -- outcome.

In DSM-IV, the section on "Course Specifiers" defines remission without any mention of use, and instead simply indicates that remission results "if none of the criteria for Dependence or Abuse have been met." My impression is that this rewording did not significantly change the meaning of the DSM-III-R version. One reason I believe this is that I was an advisor on the "Substance-Related Disorders" section, and I corresponded about the change with the head of the Substance Use Disorders Work Group, Dr. George Woody, who wrote me as follows:

I think the language of the criterion items for dependence, abuse, and remission clearly require[s] problematic use, and clearly omits reference to use alone. I don't think that further clarification is needed on this point. I can't promise that some people will [not] continue to equate use with dependence, however, I'm not convinced that adding further language...will prevent that from happening. [I think Dr. Woody's sense was to put "not" after "will".]

My understanding is thus that your position is at odds with that of your own parent organization. Under any circumstances, I do caution you -- as an official representative of APA -- about how you express your opinion that a self-help group, and maybe other clinicians, are provoking relapse by practicing an approach different from your own. I think that the least you might want to do is to present careful data to support such claims that your therapy is succeeding so well that another approach serves only to interfere with what you know to be efficacious.

Letter to George E. Woody, chair of the substance-related disorders section of DSM-IV, to which I contributed as part of the advisory group. I wrote this letter to Woody after he co-authored with Richard Frances a letter in response to mine to Frances in Psychiatric Times.

Dear Dr. Woody:

I was shocked to see you co-author a letter in Psychiatric Times attacking Moderation Management, a support group for reduced drinking for problem drinkers, which stated: "Addicted patients reading about controlled drinking approaches often relapse." The letter particularly pointed to my support of MM, indicating that "when experts in the field reinforce the notion," such negative outcomes are more likely to occur.

I hope you will forgive me, but I found your letter jumbled and evasive. In all honesty, rereading my letter, I thought I expressed a heartfelt, honest position in a humane and straightforward way. If you have the chance, perhaps you could have your wife or a respected colleague not involved in psychiatry or the alcoholism field compare the two letters and give you their impression.

What shocked me most about your letter was that it seems quite baldly to say that my impact -- and that of MM -- on problem drinkers is wholly negative. Are you planning on joining the NCADD campaign against MM, as it would seem that you should, given the views you published in PT. I must confess that such a position simply astounds me, implying as it does one true path to recovery, a position I would not think a research psychiatrist of your stature could maintain. Apparently I'm wrong.

I am doubly surprised because your position seems quite inconsistent with views we have discussed in our correspondence (not that we agree on all or even most issues) and with your invitation for me to be a part of the advisory group on substance-abuse disorders in DSM-IV. I don't see how you could lend such credibility to someone like me who you see as leading alcoholics astray.

I was so shocked by this affair that I discussed it with a friend more involved with organized psychiatry than I am. He told me that, when someone sees the APA or any organization to which they belong attacked, they are willing to shade truthfulness in order to protect the organization.

Are you taking a similar position to your stand on MM with regard to brief intervention, the therapy for problem drinkers which the meta-analysis in Hester and Miller's 1995 book, Handbook of Alcohol Treatment Approaches, ranked first based on clinical research? As you are no doubt aware, brief intervention generally aims at a reduced drinking goal.

I am so sorry this happened, for I had always considered you someone with integrity who avoided attacks on alternative approaches and who based his judgments on the research. As a result of this, I could not really offer any inputs to you as an editor of a future edition of DSM or any other effort against addiction or mental disorder, unless you were prepared to clarify these remarks publicly.

Best regards,

Stanton Peele