Psychology Today, September/October 1996, pp. 35-43, 68-70 (material added not present in original article)
Recovering from an All-or-Nothing Approach to Alcohol
Morristown, New Jersey
American attitudes toward alcohol are paradoxical: we focus almost exclusively on abstinence, yet we frequently drink to excess. Every year $2 billion is spent advertising and promoting alcohol's intoxicating nature at the same time $10 billion is used to treat people who can't handle their liquor.
Still, Americans are drinking less these daysit's just that we're drinking worse. Individual consumption has declined 20 percent since 1980from a high of 8.2 liters to a low of 6.6 liters in 1994. But the number of alcoholics and alcohol abusersproblem drinkers who don't go through withdrawal with abstinence but who do have social, legal and/or family problems as a result of their drinkinghasn't decreased.
The Young and the Excessive
Indeed, indications are that problem drinking is on the rise, especially among the young. Americans coming of age today seem to be drinking more excessively than previous generations.
- When over 17,500 college students were surveyed by social psychologist Henry Wechsler, Ph.D., and colleagues at the Harvard School of Public Health in 1993, 44 percent said they'd engaged in what Wechsler characterized as binge drinking during the prior two weeks. For men, this meant five or more drinks in a row; for women, four or more.
- The National Institute of Mental Health's 1991 Epidemiological Catchment Area (ECA) study intensively examined emotional and behavioral problems in five areas of the U.S. in the late 1980s. When it came to the prevalence of alcoholism and alcohol abuse, John Helzer, M.D., of the University of Vermont and his colleagues found that 27 percent of men age 18 to 29 either had abused alcohol or were alcoholics at some point in their lives, compared with 21 percent of men age 45 to 64, and only 14 percent of men age 65 and up.
- A recent report issued by Columbia University's Center on Addiction and Substance Abuse claims that women age 18 to 29 are now drinking almost as much as men. However, the ECA figure for lifetime abuse for women age 18 to 29 is 7 percent.
The Impetus for Abstinence
This increase becomes even more startling when you consider this country's Draconian drinking policies. The United States is the only Western country that restricts the purchase and public consumption of alcohol to adults age 21 and older. Countries as diverse as Switzerland, Britain, and Austria permit 16-year-olds to buy alcohol and/or drink in public, though many do require that a parent accompany quaffing kids.
In Portugal and Belgium, there are no age restrictions on purchasing or drinking alcohol, and in New Zealand, children of all ages can drink in public with their parents.
These countries believe that kids allowed to drink with their families become socialized to drinking moderately. In the United States, despiteor perhaps because ofcontinual admonitions not to drink, the young and inexperienced often go overboard.
Of course, our all-or-nothing approach to alcohol is rooted in America's tradition of temperance. But our obsession with inebriants didn't disappear with the repeal of Prohibition in 1933. In fact, when Alcoholics Anonymous (AA) was founded in 1935, it's credo, like that of the private alcohol sanatariums of the day, was abstinence. Then as now, AA saw alcoholics as "out of control," with treatments usually consisting of lectures and group confrontation sessions. Drinkers never fully overcome their problem; instead they are perpetually in recovery.
AA and its 12-step philosophy now dominate the entire U.S. alcohol treatment system, especially 28-day private hospital programs. This system, which is predicated on the notion that alcoholism is a disease, that cravings are inbred and cannot be modified, and that eliminating alcohol is the goal of treatment, appeals to something deeply American: our fear of alcohol and its power, and our almost fundamentalist moralism about liquor. What better than the edification of an individual by public confession and contrition?
The linking of nineteenth-century revivalistic Protestantism to alcohol problems has been a marketer's dream. In our minds, a connection has now taken hold that runs so deep it can never be broken, despite the fact that new ways of approaching alcohol treatment have been suggested for more than a quarter century.
In 1990, for example, the prestigious National Academy of Sciences' Institute of Medicine (IOM) convened a blue-ribbon panel on alcohol problems. The IOM's primary recommendation was to diversify the kinds of treatments available for alcohol problems. In particular, it found that most drinking problems are not serious enough to justify America's intensive, one-size-fits- all hospital treatment programs.
But there's barely been a shift in the way problem drinkers are treated, except for one significant change in treatment setting.
In 1986, University of New Mexico psychologists William Miller, Ph.D., and Reid Hester, Ph.D., reviewed all research comparing the results of intensive hospital treatment with those of less-intensive alternatives. They determined that both were equally successful. The few differences that were found favored the less-intensive treatments.
In part because of findings like Miller and Hester'sbut also owing to pressures to reduce health care costs90 percent of U.S. alcohol treatment now occurs in an outpatient setting. These programs remain geared towards AA, however, with abstinence as the sole goal of treatment.
Quitting in Other Countries
The hospital programs that predominate in America are practically nonexistent in Britain, Canada, and other Western countries. In these countries, treatment is more often community-based, dealing with the alcoholic/abuser in his or her life context.
In his 1995 book, Liberating Solutions to Alcohol Problems, British physician Douglas Cameron describes a community-based alcohol program that's been operating in Britain for the last two decades. This program doesn't require people to stop drinking, no matter how severe their problem. Instead, they report to an Alcohol Advice Clinic which helps them find the resources necessary to deal with any of a host of problems they may have. For instance, a man who wet his bed after heavy drinking bouts was advised to wake himself during the night by setting an alarm clock.
Obviously other problems require more serious therapy. But it's not what you might think. A man who consistently fought with his family after drinking was counseled about how to lessen family conflict, not how to quit drinking. What often happens, however, is that following this kind of intervention, people do decide to cut back.
Reduced drinking goals are recommended to those who feel their drinking is excessiveincluding those who would be considered alcoholics in the United States. While some of the people who enter this program do choose to abstain, they must propose this goal themselves. But abstinence is not a lifetime requirement. This program is based on the idea that when people acquire the personal resources they need to gain some control of their lives, they can then gain control of their drinking.
A Natural Way to Recover?
Investing power in the individual and not the treatment enables people to rethink their drinking problem on their own, what's known as self cure or natural remission. In our book, The Truth About Addiction and Recovery, Archie Brodsky, Mary Arnold and I build from these natural recovery data to create a self-help manual for changing addictions. The resulting "Life Process Program" is almost diametrically the opposite of the disease model. (Table 1)
|Table 1. Differences Between the Disease and the Life Process Approach to Alcoholism|
|Disease Model||Life Process Program|
|Alcoholism is inbred||Person uses alcohol permanent trait to cope with life|
|Everyone gets the same therapy||Treatment is tailored to individual|
|Person must accept he/she is alcoholic||Focus on problems, not labels|
|Therapy and goals are dictated to person||Person participates in therapy goals and plans|
|Person with drinking problem must be alcoholic||There are all kinds of drinking problems|
|Focus on drinking||Focus on coping|
|Abstinence is only resolution for a drinking problem||Improved control and successful relapse reduction sought as well as abstinence|
|Primary social supports are fellow alcoholics||Primary social supports: work, family, friends|
|Person must always think self as alcoholic||Person need not think of self as alcoholic|
Source: Peele, Brodsky, and Arnold, The Truth About Addiction and Recovery (New York: Simon & Schuster, 1991), p. 174.
Studies of alcohol abusers in community settings show that they frequently outgrow their drinking problems on their own. Psychiatrist George Vaillant was part of a Harvard study that followed a group of men for four decades, beginning in adolescence. In his 1983 book The Natural History of Alcoholism, Dr. Vaillant reported that over 60 percent of those who overcame their alcoholism didn't enter any kind of treatment, including AA.
Later in the decade, research by Kaye Fillmore, Ph.D., of the University of California, San Francisco, found that from 60 to 80 percent of problem drinkers stopped abusing alcohol, usually without treatment.
Canadian addiction research investigators Linda Sobell, Ph.D., and Mark Sobell, Ph.D., recently reported that more than three-quarters of randomly selected adults in a national study who had recovered from alcohol problems for a year or more did so without formal help or treatment.
According to Helzer and the ECA study, over half of all problem drinkers who stop abusing alcohol do so within five years of the start of their problemusually by reducing their drinking, not quitting altogether.
America's alcohol treatment industry attacks the idea of self-cure, saying people who believe they've recovered on their own are in denial.
New Approaches That Work
Newer treatment approaches see a person's ability to change primarily as a matter of personal commitment and community support. It's believed that people must choose their own consumption goals because they will sabotage any medical recommendation they don't accept.
Indeed, we're more likely to adhere to treatment goals that we participate in setting. For example, British psychologists Jim Orford, Ph.D., Nick Heather, Ph.D., and Guliz Elal-Lawrence, Ph.D., each conducted research that found that alcoholics succeed better at either controlled drinking or abstinence when they believe they will succeed better at one of these two goals.
In order to increase the likelihood for change, alcohol treatment must appeal to a person's own values. Three methods providing this perspective have been found to be effective:
Brief interventions do not view patients as out of control. They avoid classifying people as alcoholics or problem drinkers. Controlling one's drinking is the person's responsibility. A primary care physician or other health care worker first assesses whether someone is drinking excessively. The care worker then provides feedback about normal levels of drinking and the likely health outcomes from excessive drinking. In some cases, liver function test results are presented. Patient and doctor then agree on a reduced-drinking goal. Brief interventions work best when they are integrated into ordinary health care so that the person's success is assessed at regular follow-up visits.
In the 1990s, a number of tests, including international trials conducted for the World Health Organization that were published last summer, found that brief interventions helped many people succeed in reducing their drinking.
Motivational Enhancement fosters people's own motivation to change. Therapists are careful not to confront alcoholics, but rather explore and accept their views of their own drinking. Therapists encourage drinkers to compare the consequences of their drinking with their core values. When the gap is sufficiently great, drinkers usually develop their own impetus to change.
Social Skills Training teaches the skills necessary to avoid drinking situations; to cope with stressful settings; and to deal with spouses, children, bosses, and other relationships. These include learning how to manage anger, how to relax, how to reverse negative thinking, how to be assertive and express needs constructively, and how to give criticism and accept feedback.
|Table 2. Cognitive/Behavioral Skills Training for Alcoholics*|
(Dealing with Others)
|Managing compulsive thoughts
Reversing negative thinking
Emergency contingency planning
Epressing needs constructively
Building support networks
* Adapted from Peter Monti et al., Treating Alcohol Dependence: A Coping Skills Training Guide, New York: Guilford, 1989.
In their 1995 Handbook of Alcoholism Treatment Approaches, Miller and colleagues performed a meta-analysis ranking all current alcoholism treatments. They rated only those studies that had randomly assigned alcoholics to at least one comparison group in addition to the treatment being evaluated. A total of 219 studies met the criteria.
Forty-three treatments were ranked, although 13 of them had too few studies to be definitively rated. Brief interventions had the highest score, followed by social skills training. At the bottom of the list in effectiveness were general alcoholism counseling and educational lectures and films about alcoholism. AA received the lowest score among the 13 treatments inadequately tested. Miller et al. were quick to note that the treatments with the worst clinical records are almost universally the ones used by American alcoholism programs.
|Table 3. Most and Least Effective Alcoholism Treatments|
|Social skills training||+128|
|Relaxation training||- 109|
|Confrontational counseling||- 125|
|General alcohol counseling||- 214|
|Alcoholism education programs||- 239|
|Methods with Too Few Tests to be Reliably Rated|
|Calcium Carbamide||- 32|
|Antipsychotic medication||- 36|
Source: Miller, W.R., Brown, J.M., Simpson, T.L., Handmaker, N.S., Bien, T.H., Luckie, L.F., Montgomery, H.A., Hester, R.K., and Tonigan, J.S. (1995). What works?: A methodological analysis of the alcohol treatment outcome literature. In R.K. Hester and W.R. Miller (Eds.), Handbook of alcoholism treatment approaches (2nd Ed., pp. 12-44).
Matching People to Treatment
Research has consistently shown that people who are married, hold down jobs, and in general have stable lives have by far the best chance for overcoming alcohol problems. In other words, these individuals will succeed best on average no matter which treatment they receive. Other factors that contribute to the success of treatment are a person's social skills and motivation to change. Though people vary in their abilities, those with different traits may simply respond better to different types of treatment. Moreover, Orford and Heather have shown that people's response to treatment depends more on how they think about themselves than on the severity of their actual symptoms. For example, people who believe they can drink moderately are more likely to actually succeed at controlling their drinking, contrary to AA's denial theory.
|Table 4. Traits Leading to Greater Success at Treatment|
Social stability / Community involvement
Employment / job skills
Higher socioeconomic status
Motivation to change
Ability to cope with stress
Higher intellectual functioning
Other research has compared the success of treatment with the person's views of whether alcoholism is a disease. Heather and his co-worker Stephen Rollnick, Ph.D., found that hospitalized alcoholics who believed alcoholism was a disease were more likely to drink excessively after having a single drink than those who didn't believe their alcoholism was a disease, thus making moderate drinking harder for them.
Miller and colleagues found that problem drinkers who didn't see their alcoholism as a disease did better with therapists who allowed them to reflect on the effects of their drinking rather than accusing them of being alcoholic. However, they found that even those who viewed alcoholism as a disease did not do better with the confrontational 12-step approach.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) created an elaborate $27 million research project, called Project MATCH, to test the notion that alcoholics will do better when they are assigned to a treatment appropriate to them and their drinking problem. Three treatments were tested: 12-step, cognitive-behavioral coping skills (this includes social skills training) and motivational enhancement. Each client was tested extensively and randomly assigned to one type of treatment. The hypothesis was that people's distinct profiles would predict the therapy that worked best for them.
Results of the study are now in: no treatment did better than any other, no set of traits predicted which therapy worked best for a person. However, this trial may have fallen prey to the Hawthorne Effect: people given special attentionand the very best therapy programsprogress uniformly well. But was the 12-step therapy in this trial comparable to the typical treatment offered at hospitals?
Trying to put the best light on the results at the recent 1996 Joint Scientific Meeting of the Research Society on Alcoholism and the International Society for Biomedical Research on Alcoholism, NIAAA director Enoch Gordis, M.D., pointed to the number of people who succeeded with each treatment as proof that alcoholism therapy in general works. Observers immediately countered that the study didn't include a control group that didn't receive any treatment. No one can say that a group of people selected for special attention would not have done as well with any therapy or with no therapy.
Project MATCH did not support the idea that a scientific assessment can do better than individuals can do for themselves in selecting the right treatment. Despite elaborate research to prove that programs can be scientifically matched to problem drinkers, the evidence indicates that people do best when they select the type of treatment they feel will work best for them and when they can pick the goal they believe they can best reach. Science will tell us no more.
Obviously, no one treatment is universally successful. Unlike pneumonia or insulin-dependent diabetes, there is no single best practice that works equally well for all people with alcohol problems. The safest conclusion, then, is that a wider array of treatments needs to be made available in America.