American Psychologist, 39, 1337-1351, 1984. Reprinted in W.R. Miller (Ed.), Alcoholism: Theory, research, and treatment, Lexington, MA: Gunn, 1985.
The Cultural Context of Psychological Approaches to Alcoholism
Can We Control the Effects of Alcohol?
Morristown, New Jersey
The unique history of alcohol use in the United States has led to the ascendance of the disease theory as the dominant conception of alcoholism. Social-scientific research has consistently conflicted with the disease theory, but psychological and other nondisease conceptions of alcoholism are not well represented in the public consciousness, in treatment programs, or in policies for affecting nationwide drinking practices. Conflict in the field has intensified in the last decade, most notably surrounding the issue of controlled drinking in alcoholism treatment. Our current cultural attitude toward alcoholism, one strongly influenced by disease notions, has not led to an improvement in our society's drinking problems. There continues to be a need for psychologists to present alternative views of alcoholism.
The issue . . . is not whether we know enough; the real questions are whether we have the courage to say and use what we do know and whether anyone knows more.
Alvin Gouldner, 1961, p. 205
Styles of drinking and attitudes toward alcohol vary tremendously across cultures. The United States has been a battleground of warring conceptions of drinking. Such diversity is not as apparent in contemporary American views of alcoholism, because alcohol problems are now widely considered to be primarily the result of an uncontrollable response to alcohol among those who are classified as alcoholic. This modern disease theory has deep historical roots and represents the experiences of particular groups of drinkers. The disease theory disagrees with social scientific research that finds responses to alcohol to be based on a range of cognitive and environmental factors and thus to be more variable than the disease theory describes. Conflict has been especially intense between the disease theory and behavioral approaches in which abstinence is not seen as essential for the treatment of alcoholism. Despite efforts to accommodate to the disease positionefforts that have significantly influenced psychological theorizing about alcoholismcontrolled-drinking approaches are now endangered by dominant treatment attitudes in the field.
Disagreements also exist among social scientific conceptions of alcoholism. For example, there are differences between social-learning and control-of-supply views of the cultural variability in alcoholism rates. Important aspects of social-learning concepts of alcoholism include the extent to which drinkers doubt their own ability to control their drinking and believe that alcohol is a potent and efficacious mood modifier. All social-scientific viewpoints are overridden, however, by a larger cultural ethos that agrees with the disease viewpoint. Yet this ethos, including its emphasis on abstinence and on the potency of alcohol's effects, is one that is often found to coexist with high levels of drinking problems. There is a need for social-psychological examination of our culture's drinking dispositions at the same time that psychologists must maneuver within the reality of this cultural context in dealing with alcoholism.
The Experience of Drinking and Conceptions of Alcoholism in America
Social scientists have traditionally been concerned with cultural recipes that distinguish between socially disruptive and socially integrated drinking (cf. Bales, 1946; Blum & Blum, 1969; Maloff, Becker, Fonaroff, & Rodin, 1982). Moderate drinking is notable in ethnic and cultural groups such as the Chinese (Barnett, 1955), the Greeks (Blum & Blum, 1969), the Jews (Glassner & Berg, 1980), and the Italians (Lolli, Serianni, Golder, & Luzzatto-Fegiz, 1958), where such drinking is modeled for the young and maintained by social custom and peer groups. Children are gradually introduced to alcohol in the family setting; drinking is not presented as a rite of passage into adulthood and is not associated with masculinity and social power. Adult drinking is controlled by group attitudes both toward the proper amount of drinking and proper behavior when drinking. Strong disapproval is expressed when an individual violates these standards and acts in an antisocial manner.
The American experience with alcohol parallels the results of such cross-cultural findings. In colonial America, drunkenness was accepted as a natural consequence of drinking, and habitual drunkenness was not considered to be an uncontrollable disease. Despite higher per capita consumption, alcoholism was not a serious social problem, and problem drinking was less evident than it is today (Beauchamp, 1980; Lender & Martin, 1982; Levine, 1978; Zinberg & Fraser, 1979). Drinking was a universally accepted social activity that took place within a tightly knit social fabric; families drank and ate together in the neighborhood tavern. Between 1790 and 1830, due to expanding frontiers and other social changes, the male-oriented saloon became the typical setting for drinking. Here alcohol was consumed in isolation from the family (the only women likely to be present were prostitutes), and drinking came to symbolize masculine independence, high-spiritedness, and violence. Alcoholism rates rose dramatically.
The temperance movement arose in response to the explosion of alcohol problems in 19th century America. It propagated the view that habitual inebriates were unable to control their drinking, the early version of the disease theory that originated with physician Benjamin Rush (Levine, 1978). Large numbers of Americans came to view alcohol as "demon rum" and regarded drinking as frequentlyor inevitablyleading to uncontrolled drunkenness. The solution they proposed was national abstinence. There were regional, social class, religious, sex, and ethnic variations in these views and in the composition of the wet and dry forces that battled throughout the century (Gusfield, 1963). In 1920at a point when, paradoxically, drinking patterns had moderated substantially national prohibition was enacted. When prohibition was repealed in 1933, the goal of universal abstinence died with it. The disease theory became transmuted at this time to the view that chronic drunkenness was not an inescapable property of alcohol but was rather a characteristic of a small group of people with an inbred susceptibility to alcoholism (Beauchamp, 1980).
This was the modern disease theory, and it was spread effectively by the Alcoholics Anonymous (AA) self-help movement. AA had many commonalities with 19th century temperance brotherhoods, such as the Washingtonians, an organization in which reformed drunkards took the vow of abstinence. Like members of the Washingtonians, AA members gathered in a highly charged, revival-type atmosphere to relate their struggles with alcohol and to support each other's continued abstinence (as well as to convince others to join them). There are peculiarly American features of AA that made its resounding success in the United States unique. AA's emphasis on public confession, contrition, and salvation through God has its roots in Southern and Midwestern evangelical Protestantism (Trice & Roman, 1970). In no other Western country have AA and the recovering alcoholic attained such a central role in the formulation of alcoholism policy and alcoholism treatment as in the United States (Miller, 1983b).
The AA hegemony over alcoholism treatment and the ascendance of the disease theory accelerated in the second half of the 20th century. The theory was officially endorsed by the American Medical Association in 1956. Its rapid growth and wide acceptance were due to the melding of its strong ethnoreligious support with its backing as medical dogma. Following World War II, public opinion polls indicated a continuous increase in the belief that alcoholism is a disease (Room, 1983). More recently, in August 1982, a Gallup poll (Alcohol Abuse, 1982) found that 79% of Americans accepted alcoholism as a disease requiring medical treatment. In the 1970s, federal financing for the treatment of alcoholism shifted to service contracts and third-party payments. The primary locus for treatment changed from public institutions to private facilities and contractors. A premium was placed on aggressive marketing of alcoholism services, the early identification of those with drinking problems, and compulsory treatment (Hackler, 1983; Weisner, 1983; Wiener, 1981). The emphasis was on the identification of new, previously unrecognized groups of alcoholics and others needing treatment in connection with alcoholism, such as women, functioning workers and professionals, and families of alcoholics.
The aim of the alcoholism movement since the 1940s, as embodied by the National Council on Alcoholism, has been to make people aware of the prevalence of alcoholism and the need to have it treated. The movement has been extremely successful in this endeavor, and postage stamps, media programs, and public service announcements regularly drive its points home. Room (1980) estimated that there was a 20-fold increase in the number of alcoholics in treatment between 1942 and 1976. The sense of the lurking danger of alcoholism has increased further since 1976. The 1982 Gallup poll found that one third of American families had had a problem with alcohol, a figure that had doubled over the previous 51/2 years (Drinkers at 38-Year Record Level, 1982). Some representatives of the alcoholism industry now think there are more than 15 million alcoholics in America requiring treatment (Hackler, 1983).
The disease model has modified our basic conceptions about the nature and prevalence of drinking problems and about the need for treatment, the proper type of treatment, and the efficacy of treatment for alcoholism. Nondisease conceptions have not fared well in this atmosphere. Although psychologists and others present alternate views of alcoholism (many of which will be discussed in this article), educational and other public information programs typically ignore nondisease perspectives (Room, 1983). The markets for psychological services in alcoholism appear to be eroding and beleaguered (Marlatt, 1983; Miller, 1983b; Nathan, 1980).
Conflict Between the Disease Theory and Social Science Research
Given the emotions it is capable of arousing, the disease theory of alcoholism is surprisingly amorphous and variable. Pattison, Sobell, and Sobell (1977) pointed out that, in order to criticize the theory, the critic must often first define it, leaving the critic open to the accusation of having created a "straw man" to attack. This is especially true because prominent defenders of the disease viewpoint acclaim the lay wisdom of AA and endorse its positions although they formally propose models of alcoholism significantly at odds with lay disease notions (cf. Jellinek, 1960; Keller, 1972; Vaillant, 1983). The basic AA (1939) version of alcoholism as a disease is that the true alcoholic cannot control his or her drinking (unlike those who choose to get drunk), an inability that exists before the first drink is taken. The condition is irreversible and progressive and requires complete and utter abstinence.
The idea of an inherited biological mechanism is not always a part of disease theories, although it has been a major impetus for medical research (Goodwin, 1979; Schuckit, 1984). The central trait of disease theories is the alcoholic's loss of control. Jellinek and Keller, founders of the Yale Center of Alcohol Studies, have provided the scholarly underpinnings for the disease theory. Jellinek's (1946) original empirical work traced the stages of alcoholism reported by 98 respondents to questionnaires sent to about 1,600 AA members. Influenced by prevailing views of drug dependence, Jellinek's (1960) book, The Disease Concept of Alcoholism, presented a typology of alcoholism. It identified "gamma" alcoholism as the essential disease type and defined it in terms of physical dependence, along with loss of control. This disease model, unlike the AA version, is unclear about the inbred or irreversible nature of the condition.
Many subsequent investigations have failed to confirm either the stages or the types of alcoholism that Jellinek outlined (Room, 1983). Disease notions have been further undermined by a series of laboratory studies that found that the drinking of chronic alcoholics is not characterized by loss of control (Mello & Mendelson, 1972; Nathan & O'Brien, 1971; Paredes, Hood, Seymour, & Gollob, 1973). Even when intoxicated, these alcoholics regulated their levels of drinking and responded to external rewards. Summarizing this research, Heather and Robertson (1981) found that "alcoholics' drinking behavior is subject to the same kind of laws which . . . describe normal drinking behavior, or . . . goal-directed behavior of any kind" (p. 85). As a response to increasingly complicated findings about alcoholic behavior, Keller (1972) added a note of indeterminacy to loss of control notions. He proposed that alcoholics might be able to control their drinking on occasion but are unable to guarantee when they can do so.
Field investigations of the natural course of drinking problems have evolved separately from the behavioral models of alcoholism generated in laboratory studies. Generally sociological in nature, such field research has agreed with laboratory studies in finding alcoholism to be malleable and situationally determined. In this view, people's alcohol-related problems are so diverse, fluctuate so much with time, and are so strongly influenced by social context that such problems are best conceived of as problem drinking rather than as a disease state of alcoholism (Cahalan, 1970; Cahalan & Room, 1974; Clark & Cahalan, 1976). Cahalan and his co-workers, along with other sociologists, have used the term problem drinker in a fundamentally different way from both disease- and nondisease-oriented clinicians. Problem drinking is not a less severe type of alcohol problem than gamma or addictive alcoholism. It is a separate dimension for classifying drinkers where loss of control is one among several kinds of drinking problems and is not necessarily the most severe or the core, defining problem (Clark, 1976).
Field studies have found demographic categories to play an important role in alcoholism. Cahalan and Room (1974) identified youth, lower socioeconomic status, minority status (black or Hispanic), and other conventional ethnic categories (Irish versus Jewish and Italian) as predicting drinking problems. Greeley, McCready, and Theisen (1980) continued to find "ethnic drinking subcultures" and their relationship to drinking problems to be extremely resilient and to have withstood the otherwise apparent assimilation by ethnic groups into mainstream American values. Cahalan and Room also discovered a paradoxical tendency for drinkers from conservative Protestant sects or from dry regions to be binge drinkers. The Rand report's analysis of treated alcoholics in comparison with a Harris poll of nationwide drinking practices made the similarly anomalous discovery that alcoholism was more frequent in the South and among Protestants, demographic categories also associated with abstinence (Armor, Polich, & Stambul, 1978). The predictive power of demographic traits is not limited to problem drinking or alcoholics seeking treatment. Vaillant (1983) found Irish Americans in his Boston sample to be alcohol dependent (i.e., alcoholic) seven times as often as those from Mediterranean backgrounds (Greeks, Italians, and Jews), and those in Vaillant's working class sample were alcohol dependent more than three times as often as those in his college sample.
Group differences in alcoholism are not readily explained in disease or biological terms. Indeed, even Oriental groups such as Native Americans and Chinese Americans, which are noted for their shared, exaggerated metabolic reaction to alcohol, show widely divergent alcoholism rates connected with different socially regulated styles of drinking. Such findings provide a powerful argument against a genetic basis for alcoholism (cf. Mendelson & Mello, 1979). For disease proponents, the idea that social norms control drinking problems translates into the notion that some groups have a greater tendency to deny alcoholism. Efforts in the alcoholism movement are generally directed toward uncovering hidden numbers of alcoholics in groups, such as Jews or women, that have traditionally measured low in alcoholism rates. Yet investigators emphasizing genetic contributions to alcoholism or seeking to identify secret alcoholics have continued to note substantially lower alcoholism rates for such groups (Cloninger, Christiansen, Reich, & Gottesman, 1978; Glassner & Berg, 1980).
The most powerful predictor of drinking problems for Cahalan and Room (1974) was not social background, however, but current social environment. The potency of social drinking contexts has been identified not only as a key to causing drinking problems but as a force in socializing moderate drinking and modifying alcohol problems (Jessor & Jessor, 1975; Harford & Gaines, 1982; Zinberg & Fraser, 1979). The idea of using drinking environments to prevent the development of unhealthy drinking styles in the young remains a strong thrust in social learning approaches to alcoholism, one that has continued to exist despite a rising tide of disease conceptions (cf. Kraft, 1982; Nathan, 1983). Social context analyses at the macro level, which point to shifting historical alcoholism rates and changing cultural conceptions of alcohol problems, have viewed alcoholism as a social construction rather than an actual disease entity (Beauchamp, 1980; Gusfield, 1981; Levine, 1978; Wiener, 1981). This viewpoint is as far from the disease conception as it is possible to get and has come in for a kind of criticism from disease proponents that is ordinarily directed at radical political groups (see comments by Keller, cited in Room, 1983, pp. 52-53).
Social "constructivist" approaches notwithstanding, the full fury of the disease movement has been reserved for studies showing that some alcoholics moderate their drinking. Abstinence has been the fundamental treatment precept in the disease approach as it was with temperance (Roizen, 1977). However, nearly every outcome study has uncovered a return to moderate drinking by alcoholics (Heather & Robertson, 1981; Pattison et al., 1977). Despite the frequency of these discoveries and their often matter-of-fact reporting by researchers (cf. Goodwin, Crane, & Guze, 1971; Schuckit & Winokur, 1972), several key studies of this sort have been ferociously attacked. The most significant of these were the two Rand studies. The first, originally released in 1976 (Armor et al., 1978), found that 22% of alcoholics treated at National Institute of Alcoholism and Alcohol Abuse (NIAAA) treatment centers were drinking without problems at 18 months after treatment (compared to 24% who were stably abstaining). The National Council on Alcoholism (NCA) organized an immediate, concerted assault on this study.
Among a host of often wildly distorted accusations, genuine methodological and theoretical issues were raised about the Rand study. The Rand investigators conducted a second study that included a 4-year follow-up period, breathalyzer tests, reconstructed criteria for moderate drinking, and a careful analysis of drinking outcomes against levels of alcohol dependence shown by clients on admission (Polich, Armor, & Braiker, 1981). Close to 40% of the subjects who were free of drinking problems at 4 years were still drinking, including a substantial minority of those who had been most dependent on alcohol. Peer evaluations of both reports, but particularly the second, were highly positive (see Beauchamp et al., 1980; Hodgson, 1980) as reflected in the statement "this four year follow-up study is one of the best outcome studies in the alcoholism field" (Hodgson, 1980, p. 343). Yet the two Rand studies have simply been buried by most in the alcoholism field. Vaillant (1983) typified this response by consistently dismissing the first study's findings on methodological grounds and generally ignoring the second study.
The Rand studies' primary significance may thus be in their status as cultural documents. Whatever their actual findings, upon their respective releases they provoked from the two different directors of the NIAAA the assertion that abstinence remained the "appropriate goal in the treatment of alcoholism" (Brody, 1980; U.S. Department of Health. Education, and Welfare news release, reprinted in Armor et al., 1978, p. 230), and funding for controlled-drinking treatment was immediately assailed (Room, 1983, p. 63n). How thoroughly controlled drinking has been repudiated in the aftermath of the Rand studies is apparent when considering in today's climate evaluations of the first Rand report solicited by the NIAAA from two prominent research psychiatrists. In one evaluation, Gerald Klerman asserted, "This is a very important document. I think the conclusions are highly justified. I understand you are under great political pressure. . . . I would strongly urge you and the NIAAA and ADAMHA to stand firm wherever possible" (in Armor et al., 1978, p. 223). In another evaluation, Samuel Guze declared, "What the data do demonstrate is that remission is possible for many alcoholics and that many of these are able to drink normally for extended periods. These points deserve emphasis, because they offer encouragement to patients, to their families, and to relevant professionals" (in Armor et al., 1978, p. 221).
The Rand studies reported outcomes of standard abstinence-oriented treatment at NIAAA centers. Their findings confirm those of Cahalan and Room (1974)albeit with a treated and more severely alcoholic populationin indicating that the status of people's drinking problems varies considerably over time. The standard disease theory criticism of the Rand studiesthat there was no guarantee that nonproblem drinking outcomes would be permanentdoes not contravene the picture they present of alcoholics regularly shifting from alcoholic drinking to abstinence or moderation and back again. In addition, there has been a tradition of behavioral research dating from the early 1970s that has aimed at moderating alcoholic drinking. In 1982, the prestigious journal Science published a reinvestigation by Pendery, Maltzman, and West of a study by Sobell and Sobell (1973, 1976) that had claimed such techniques produced better outcomes for a group of alcoholics than had the standard hospital abstinence-oriented therapy used with a comparison group. Pendery and her colleagues found that most controlled-drinking subjects in the experiment reported instances of severe relapse soon after treatment and were not moderate drinkers 10 years later. The Science article was highly publicized and was often accompanied by accusations from its authors that the Sobells had falsified their results.
The Pendery et al. (1982) report was an unusual one. It questioned only subjects in the experimental, controlled-drinking group in the original study without reporting follow-up data for the abstinence comparison group. The data were primarily recollections by subjects of events up to nine years in the past and descriptions of individual episodes of relapse. The only summary data the paper presented were the amount of hospitalization controlled-drinking subjects underwent after treatment. A report by an independent committee (Dickens, Doob, Warwick, & Winegard, 1982) convened by the Addiction Research Foundation of Toronto, which employs the Sobells, noted that the original articles by the study's authors actually reported more hospitalizations for controlled- drinking subjects than did Pendery et al. The committee was frankly critical of the Pendery group's approach for its failure to reexamine subjects treated with abstinence techniques, its reliance on testimony from subjects emotionally involved in the controversy, and the lack of consideration of the larger body of evidence about controlled drinking (cf. Peele, 1983b).
The Science article has been invested with significance beyond its own questionable validity because of the cultural context in which it appeared. The article, although agreeing with the near-unanimous portrayals by the media of the disease nature of alcoholism, is one of the few answers to an avalanche of studies contradicting disease notions. The dispute is impossible to understand without considering the history of the controlled-drinking controversy in this country, as even an APA Monitor article (Fisher, 1982) on the controversy failed to do. For example, the senior author of the Science paper was a primary spokesperson in the NCA campaign against the Rand studies, including an effort to have the first report delayed so that its results could be reanalyzed (see Roizen, 1977, p. 171).
The Status of Controlled-Drinking Therapy in the United States
A leading alcoholism researcher interviewed in the Monitor article (Fisher, 1982) about the Pendery-Sobell dispute noted about controlled drinking that "there is no alcoholism center in the United States using the technique as official policy" (p. 8). This situation contrasts with that in other Western countries, such as Britain, where a recent survey found that 93% of treatment facilities accepted the principle that controlled-drinking therapy can be beneficial (Robertson & Heather, 1982). At the same time, even those who continue to endorse such therapy in the United States and Canada, including the Sobells, indicate it should be restricted to problem drinkers and not used with gamma alcoholics or those addicted to or physically dependent on alcohol (Marlatt, 1983). Again, the situation contrasts with that in Britain, where a part of the spectrum of treatment opinions "regret(s) the tendency to relegate the new methods to a minor and ancillary role . . . as being applicable, for example, to only those with less serious problems" (Heather & Robertson, 1981, p. viii; cf. Miller, 1983b).
The Demise of Controlled-Drinking Therapy for Alcoholics
The consensus in American opinion against the applicability of controlled drinking for more serious alcoholism problems began to emerge in the mid-1970s around the time the first Rand study was published. Prior to that time, psychologists reported positive prospects for treating alcoholics through moderation techniques (Caddy & Lovibond, 1976; Schaefer, 1971; Sobell & Sobell, 1973, 1976; Steiner, 1971; Vogler, Compton, & Weissbach, 1975). After 1976, reflecting either a change in terminology, in emphasis, or in their understanding of alcohol problems or a desire to achieve rapprochement with disease notions, psychologists downplayed the possibility (Miller & Caddy, 1977; Vogler, Weissbach, Compton, & Martin, 1977), and they now totally reject it (Lang & Marlatt, 1982; Miller & Muntildeoz, 1982). Today no clinician in the United States publicly speaks about the option of controlled drinking for the alcoholic.
The factual basis for this shift is the general agreement that the more severe a person's drinking problem, the more successful abstinence outcomes are as compared to moderation outcomes. What makes this resolution less than decisive, however, is the consistent finding that drinking problems occur along a continuum, one that is not well ordered (Clark, 1976; Clark & Cahalan, 1976; Miller, 1983b; Vaillant, 1983). There is no distinct point at which genuine alcoholism or addiction to alcohol can be said to exist. Furthermore, some drinkers at even the most severe levels of alcohol dependence do successfully adopt controlled drinking. The most highly dependent subjects in the Rand Study (those with 11 or more signs of dependence on admission) were far less likely than less dependent subjects to be drinking without problems at four years. (In this sense, and others, the study indicated that its nonproblem drinking measures did not lead to random predictions about the possibility of controlled drinking.) Yet the study still found over one quarter of those with the most severe problems initially who achieved remission from alcoholism to be drinking at four years.
Aside from the question of whether alcoholics can become social drinkers, a separate question is whether they can benefit from behavior therapy techniques aimed at moderating drinking. Miller (1983a) reported that 21 out of 22 studies demonstrated benefits, generally substantial, from controlled-drinking therapies (see Miller & Hester, 1980). The populations for these studies were mixed, and although controlled-drinking benefits were greatest for those with moderate drinking problems, there is no indication that moderation training is less effective than abstinence for all types of drinking problems (Heather & Robertson, 1981; Miller, 1983b). In addition to the Sobells' study, other studies have found positive results with alcoholic populations (Caddy & Lovibond, 1976). In their rebuttal to Pendery et al. (1982), Sobell and Sobell (1984) concluded that the reinvestigations of their work "actually strengthen the validity of our original reports and conclusions" (p. 413).
We may wonder then on what grounds the application of controlled-drinking techniques for severe alcoholism has been conclusively rejected, especially considering the poor prognosis resulting from standard treatments for alcoholism (cf. Vaillant, 1983). Reflecting our current cultural attitude toward alcoholism, Time magazine quoted John Wallace, an NCA critic of the Rand Study, on the topic of controlled drinking as saying, "The suggestion that an alcoholic might be able to return to social drinking safely is 'a serious ethical problem, because at least 97% of alcoholics, if you let them drink, could die' " ("New Insights into Alcoholism," 1983, p. 69). Compare this with Vaillant's forlorn finding for his severely alcoholic clinical sample that "tragically, abstinence does little to reduce the increased mortality of alcoholics" (Vaillant, 1983, p. 164). Whether greater risk can be demonstrated for the alcoholic who is aiming for controlled drinking, the therapist faces the intolerable risk that he or she will be accused of causing any failures in drinking by the client including those leading to death.
Insinuations that controlled-drinking therapy contributed to the deaths of patients were an important part of the attack on the Sobells' study. Pendery et al. (1982) noted four deaths among the 20 controlled-drinking subjects in the 11 years following treatment. Television depictions highlighted this statistic by shooting scenes at cemeteries or at the sites of patients' deaths. By simply writing to California authorities, Sobell and Sobell (1984) discovered that six of the abstinence-treatment subjects had died in this same period. Moreover, the first of the deaths of controlled-drinking subjects reported by Pendery et al. occurred more than 6 years after treatment (this subject had been abstinent during the prior year), and two of the deaths occurred more than 10 years after. Both these later deaths were apparently due to acute alcohol intoxication; both men had been in traditional alcoholism programs the week before their deaths. Overall, the death rate for subjects in the controlled-drinking condition was lower than that reported for alcoholics undergoing conventional abstinence treatment (Sobell & Sobell, 1984).
Relapse in Alcoholism
Those who propose abstinence as the exclusive goal for alcoholism treatment maintain that any effort to drink carries with it an intolerable danger of relapse. The two Rand studies offered the opportunity to assess the relative risk of relapse at 4 years for those adopting different strategies at 18 months. Relapse was not limited to those drinking moderately at 18 months; in fact, some groups of subjects were identified as being more likely to relapse when they tried to abstain even though interviews indicated that these subjects were serious in their intentions of abstaining (Polich et al., 1981). The Pendery et al. (1982) critique of the Sobells' study took on a special force by considering instances of relapse and death in the absence of comparable data for the group treated with abstinence. Yet alcoholics who progress to the point of hospital treatment are characterized by frequent relapse. Vaillant (1983) reported that among a group of 100 alcoholics treated by hospital detoxification, compulsory AA attendance, and an active follow-up program, only 5% did not relapse to alcoholic drinking.
Although abstinence proponents may aspire to the elimination of drinking in all those with drinking problems, this seems an elusive goal. Only 7% of the total Rand sample did not drink at all in the 4 years following treatment, a figure that seems typical for abstinence-oriented programs (cf. Emrick & Hansen, 1983). At the other extreme, studies of alcoholic patients indicate that a comparable 5% to 10% will evolve into a stable life pattern of controlling their drinking (Vaillant, 1983, p. 220). Miller and Hester (1980) noted a 5% to 15% range of moderation outcomes in abstinence programs. For the 80% to 90% in between, improvement entails the effort to make sure that any drinking they do does not get out of hand. Indeed, this is an issue even for those securely controlling their drinking or abstaining: Vaillant (1983) found that "relatively few men with long periods of abstinence had never taken another drink" (p. 184).
In this light, therapy for alcoholism is best conceived as the effort to minimize relapse. What the Sobells' study ultimately demonstrated was not that controlled-drinking subjects never got drunk or never had drinking problems again, but that they both drank moderately and abstained more frequently and thus had fewer instances of alcoholic relapse (Sobell & Sobell, 1976)a crucial finding that the Pendery et al. (1982) critique did not purport to challenge. Much of controlled- drinking therapy has taken on this cast of preventing a slip or single drink from turning into total abandonment of drinking restraint. Social-cognitive models of alcoholism maintain that alcoholics' expectations and self-conceptions will influence how they respond to a single drink. Alcoholics who are convinced that there is no alternative after having a drink other than embarking on a binge will be more likely to undergo this chain of events (Marlatt, 1978; Rollnick & Heather, 1982). Relapse prevention, then, takes the form of preparing drinkers to avoid high-risk (of relapse) situations, to avoid drinking when exposed to such situations, and to avoid binge drinking after having had a drink (Chaney, O'Leary, & Marlatt, 1978; Marlatt & Gordon, 1980).
What Areas of Clinical Disagreement Remain?
Behavior therapists in America have abandoned efforts to turn alcoholics into moderate drinkers and almost exclusively restrict their treatment to those with less severe drinking problems. Given that the hallmark of the disease approach is that only the genuine alcoholic is characterized by loss of control and the need to abstain, why is there so much conflict between controlled-drinking and disease approaches? Some psychologists, social scientists, and others still do not accept the extreme preoccupation with abstinence as the only goal and measure of success in treatmentwhat Roizen (1977) termed the "abstinence fixation"that typifies the field. For example, relapse prevention approaches argue for acknowledging that a single drink will not necessarily be a person's undoing and thus downplay the absolute requirement of abstinence. In addition, many continue to believe that the lessening of drinking problems in the absence of abstinence still constitutes improvement for a client. Viewing people's drinking or abstinence in the context of their overall functioning and their other compulsions or substance abuse (Peele, 1981a, 1983a; Peele & Brodsky, 1975) may present a different picture than the disease-oriented clinician sees. Although he defended the abstinence goal, Vaillant (1983) found that abstaining alcoholics commonly formed alternate compulsions but that controlled drinkers did not.
In the view that alcoholism is a progressive condition, the individual who is not fully alcoholic may be a person at an early stage of the disease for whom drinking will inexorably lead to alcoholism. In practice, programs based on a disease model simply deal with all those who present themselves with alcohol problems as though they were alcoholics (Hansen & Emrick, 1983). (This is in contrast to the elaborate arguments made by abstinence proponents that any drinker who has had severe problems but who now drinks moderately could not have been genuinely alcoholic; cf. Pendery et al., 1982, p. 173.) Yet it is just these "early-stage" drinkers for whom controlled-drinking strategies have proven most effective. Indeed, most younger, socially stable problem drinkers reject abstinence therapies (Sanchez-Craig, 1980). Psychologists and sociologists argue that a national alcoholism policy geared toward the extremely alcoholic individual overlooks the vast majority of those with drinking problems, only a small portion of whom seek treatment (Marlatt, 1983; Room, 1980).
The Classification of Alcoholics
Some of those with drinking problems do better if they endeavor to abstain, and some do better if they try to moderate their drinking. In the absence of a clear distinction between these groups, abstinence tends to be encouraged for all, and therefore psychologists have led the effort to classify drinking problems in terms of the relative benefits of abstinence and controlled-drinking treatment aims (Heather & Robertson, 1981; Miller, 1983a). Severity of drinking problems or alcohol dependence is a major factor in such classification, with those whose drinking problems are worse generally faring better with abstinence. The severity factor does not overwhelm all other considerations, however. The Rand study found that single men under 40even when highly dependent on alcoholwere more likely to relapse if they adopted an abstinence strategy than a controlled-drinking one (Polich et al., 1981). Abstinence is apparently less effective for younger, single men because it does not conform with their life-styles and the opportunities and pressures they face to drink. Age is an especially important factor in a person's ability to moderate drinking. For example, symptoms of alcoholism such as drinking blackouts in college show a negligible correlation with drinking problems for the same person 20 years later (Fillmore, 1975).
The drinker's self-conception of being an alcoholic also affects the course of drinking problems (Skinner, Glaser, & Annis, 1982). Subjective beliefs about the disease of alcoholism and about the nature of the person's drinking problem can be more important than objective levels of dependence for selecting treatment goals. Those who believe in the disease theory and that they are alcoholics have a poorer prognosis for controlled drinking (Miller, 1983a). Heather, Winton, and Rollnick (1982) found in Britain that alcoholic patients who did not believe or did not know about the theory that one drink leads to relapse were more likely than other alcoholics to be nonproblem drinkers 6 months after treatment. A scale measuring alcoholics' beliefs about alcoholism and their own drinking distinguished whether alcoholics, if they drank, relapsed to alcoholic drinking, whereas an objective measure of alcohol dependence showed no such relationship (Heather, Rollnick, & Winton, 1983). Vaillant (1983) discovered another factor that determined controlled-drinking versus abstinence outcomes for alcohol abuse: whether the drinker's ethnic group had a disease-like conception of alcoholism or whether it was simply concerned with the differences between moderate drinking and drunkenness.
In its early stages, the modern alcoholism movement relied on the individual's willingness to admit having an alcohol problem voluntarily (Room, 1983). The emphasis today in treatment is on confronting alcoholics' denialtheir unwillingness to see clearly the nature of their drinking problems. When faced with a recalcitrant individual who has a lower level of dependence on alcohol, a self-conception of not being an alcoholic, or a group or ethnic identity that does not view alcoholism in terms of a disease, this approach pushes for a transformation of the person's belief system about drinking. This contrasts with a psychological traditionrepresented by Rogerian, client-centered therapyof accepting and using clients' conceptions of their situations. Miller (1983c) analyzed how working at cross-purposes with the client's conception of a drinking problem interferes with the motivation to change. Yet, although it is inconceivable that a therapist would urge someone who is endeavoring to abstain to drink socially, the reverse is standard procedure.
An over-reliance on "objective" assessments of appropriate treatment goals could similarly lead psychologists unwisely to deny their clients' self-selected goals for improvement. We see in fact that clients regularly act on their own agendas within a larger treatment framework. What may be so remarkable about the Rand results is that almost 40% of those who were being told to abstain and who were in remission at 4 years did so through modifying their drinking patterns on their own. Subjects assigned to the abstinence condition in Sanchez-Craig, Annis, Bornet, and MacDonald's (1984) study overwhelmingly rejected their assigned therapy goal and displayed as much moderate drinking as those being taught how to do so. On the other hand, controlled-drinking clients who subsequently chose to abstain have shown unusual success at abstinence (Miller, cited in "The Behaviorists," 1984).
Treatment, Self-Cure, and Denial
Although controlled-drinking therapies have demonstrated the most success of any approach to drinking problems, these assessment studies have not used no-treatment comparison groups (Miller & Hester, 1980). Cahalan (1970) found up to 50% natural remission from problem to nonproblem drinking within 4 years. Furthermore, brief controlled-drinking interventions have been as successful as elaborate ones (Miller, cited in "The Behaviorists," 1984; Nathan, 1980), suggesting that the client's motivation to change is the chief factor in the moderation of drinking. Major outcome studies that have used nontherapeutic (natural history) comparison groups, covered long follow-up periods, and taken into account environmental factors in clients' improvement have struggled to trace additional improvement to the therapy beyond the effects of life changes and the client's prior motivation (Baekeland, Lundwall, & Kissin, 1975; Gerard & Saenger, 1966; Orford & Edwards, 1977; Vaillant, 1983). Such findings have led Moos and Finney (1982) to challenge the whole idea that specific therapeutic interventions significantly alter a person's overall drinking career. From this point of view, the problem with both the Sobells' study and the Pendery et al. critique of it is that a brief period of laboratory training cannot possibly account for behavior up to 10 years later (Marlatt, 1983; Vaillant, 1983).
A number of studies in addition to Cahalan's (1970) have demonstrated substantial natural remission among problem drinkers and alcoholics (cf. Hyman, 1976; Knupfer, 1972; Roizen, Cahalan, & Shanks, 1978; Tuchfeld, 1981; Vaillant, 1983). The limitations of therapy and the potency of people's natural curative powers created a fascinating dilemma for Vaillant (1983) in one of the rare long-term studies by a disease proponent of both the natural history of alcoholism and the effects of disease-oriented treatment. Vaillant's results forced him to jettison such traditional disease notions as that alcoholism represents a clearly demarcated variety of alcohol abuse, that alcoholism inevitably worsens without treatment, and that alcoholics cannot drink again without endangering their sobriety. In defending the medical model of alcoholism as a disease, Vaillant claimed that "attempts to understand and to study alcoholism . . . [require] us to employ the models of the social scientist and of the learning theorist" but that a medical model is necessary "in order to treat alcoholics effectively" (p. 20). His own clinic, however, using hospital detoxification, inpatient treatment, compulsory AA attendance, and an active follow-up program demonstrated results after 2 and 8 years that "were no better than the natural history of the disorder" (pp. 284-285).
Vaillant also studied college and core-city populations of alcohol abusers for which data covering 40 years were available. Among the core-city group, on which most of his analysis is based, 20% were drinking asymptomatically and 34% were abstaining at their last assessment. Although Vaillant defended abstinence and criticized the Rand reports, his figures resembled those from the second Rand study. They represented an untreated population, however, and thus the degree of alcohol abuse in Vaillant's sample is less. On the other hand, Vaillant's definitions of controlled drinking and abstinence affect their relative prevalence. Those who were controlled drinkers were not permitted to have shown any signs of alcohol dependence in the previous year. Abstinence was defined as less than a week's binge drinking in this period and an overall drinking frequency of less than once a monthdecidedly non-AA criteria that increased the appearance of abstinence at the expense of controlled-drinking outcomes. Both controlled drinkers and abstainers in Vaillant's study rarely sought therapy for their drinking, and only 37% of abstainers relied on AA.
In our current cultural climate, the idea of self-cure for alcoholism has been discredited. One television spot likens it to trying to operate on oneself. The need for treatment is used as a justification for channeling problem drinkers into therapy through employee assistance programs and legal sentences (Gusfield, 1981; Weisner, 1983), and the refusal of treatment is regarded as proof of denial. Tuchfeld's (1981) interviews with severely alcoholic subjects who had cured themselves revealed that they often had a strong aversion to relying on others for help. Although no one can deny that alcoholics have the right to seek assistance or that any improvement they show comes from the help they receive, there are also no grounds on which to reject the contention of other alcoholics that they are more likely to succeed on their own. One danger is that nondisease-oriented clinicians will see their own version of denial in those alcoholics who resist behavioral or other interventions along with resisting disease ideologies.
Alcohol and Drug Dependence
The emerging opinion among behavioral psychologists that controlled drinking is not possible for the addicted or physically dependent alcoholic is essentially the same position endorsed by Jellinek (1960); both positions are indebted to theories of drug addiction and dependence. However, findings about drug dependence do not provide support for the claims being made in the case of alcohol. Although many of the Vietnam veterans who had been addicted to narcotics in Asia used an opiate at some time stateside, only a small percentage showed signs of narcotic dependence here. Robins, Davis, and Goodwin (1974) concluded that "contrary to conventional belief, the occasional use of narcotics without becoming addicted appears possible even for men who have previously been dependent on narcotics" (p. 236). Harding, Zinberg, Stelmack, and Barry (1980) confirmed this finding with regular heroin users who were currently not addicted but had been so previously. These users were not dependent on any other drug or on alcohol and had not undergone the kind of radical shift in setting that characterized the returned veterans.
The attribution of behavioral significance of any kind to physical dependence has been challenged. Writing in an authoritative pharmacology text, Jaffe (1980) claimed that "the term addiction cannot be used interchangeably with physical dependence" because such dependence is only tangentially related to the compulsive drug use and "high tendency to relapse after withdrawal" that define addiction (p. 536). Basic research on alcohol dependence likewise does not readily point to an explanation of alcoholic behavior. It has been extremely difficult to entice laboratory animals to drink excessive amounts of alcohol. Falk and Tang (1980) were able to induce physical dependence on alcohol in rats by creating a disturbing, intermittent feeding schedule for the animals. This schedule caused excessive, maladaptive behavior of all types, however. Even when physically dependent on alcohol, the animals preferred a dextrose mixture over an ethanol solution. Furthermore, as soon as the intermittent feeding schedule was terminated, the animals ceased drinking excessively, demonstrating principally "that a history of ethanol overindulgence was not a sufficient condition for the maintenance of overdrinking" (Tang, Brown, & Falk, 1982, p. 155).
The concept of alcohol dependence has been developed furthest by a group of British psychiatrists and psychologists (cf. Edwards & Gross, 1976; Hodgson, Stockwell, Rankin, & Edwards, 1978), perhaps because of a greater recognition in that country of the deficiencies of the disease model. The approach taken by this group has progressed beyond the traditional pharmacological categories used in drug dependence, for example, by regarding the object of dependence to be a psychobiological state rather than as comprising separate components of physical and psychic dependence. Still, critics note that, similar to the disease theory, this model continues to identify alcoholism as a persistent internal condition of drinkers that exists in isolation from other motivations and psychological dysfunction (Shaw, 1979). One problem with this model is that alcoholics' behavior, like that of other addicts, is marked by its intermittent nature. The alcoholic regularly alternates excessive drinking with moderate drinking or with abstinence. When and why does he or she behave as though alcohol dependent?
The variability in addictive behavior is most notable for alcoholics, like other addicts, when they withstand peak periods of withdrawal only to relapse at a later point, often due to stress or social pressure (Marlatt & Gordon, 1980). Behavioral theories of alcohol and drug dependence account for relapse that postdates active withdrawal by proposing conditioned withdrawal symptoms that appear in familiar drug- or alcohol-using contexts. An ingenious proposal impelled by a dedication to laboratory findings, this model must be maneuvered adroitly to account for street behavior. Most Vietnam veterans did not relapse to addiction even after actually using narcotics, so that Siegel's (1979) explanation of relapse for former addicts as a result of "talking about drugs" and "imagining themselves injecting drugs in their customary settings" (p. 158), as well as sacrificing the specificity that is the model's main appeal, provides seemingly pale motivation as an impetus for returning to addiction.
In fact, addicts rarely report somatic discomfort or unusual physical craving as the cause of relapse (Marlatt & Gordon, 1980). Even if classical conditioning models were able to demonstrate some reliable relationship between craving and specific environmental cues, we would then face the question of why some people respond to craving by yielding to it in the first place and by reestablishing their addiction in the second. On the other hand, how is it that "many, perhaps most, do free themselves" of alcohol dependence (Gross, 1977, p. 121) as most addicts of all sorts outgrow their addictions (cf. Schachter, 1982)? Criticizing pharmacological notions of dependence, Harold Kalant noted that the misguided effort to link addictive behavior to the fact of chronic exposure to a substance ignored "the most fundamental questionwhy a person, having experienced the effects of a drug, would want to go back . . . to reproduce that chronic state" (cited in "Drug Research Is Muddied by Sundry Dependence Concepts," 1982, p. 12). In other words, dependence theories to date do not tell us why people seek intoxication or other drug experiences or why they cease to need these experiences.
Culture and Alcoholism
How Does a Culture Cause Alcoholism?
The need to incorporate cultural factors has also confused alcohol dependence theorizing (Shaw, 1979). Similarly, Vaillant's early reports on his natural history research noted separate and significant genetic and cultural causality in alcoholism (Vaillant & Milofsky, 1982; cf. Peele, 1983a). His final report was more guarded about inherited factors, however. Vaillant (1983) did not find the distinct differences in alcoholism that Goodwin (1979) and Schuckit (1984) have traced to genetically related compared to adoptive relatives and to inheritance over environment. Vaillant (1983) also found that return to moderate drinking versus abstinence was not a function of having alcoholic relatives but was related to the cultural group of the alcohol abuser. This finding is reminiscent of the higher incidence of binge drinking alternating with abstinence among conservative Protestants and others from dry regions in the national survey by Cahalan and Room (1974) and the coincidence of high rates of alcoholism and abstinence for both Protestants and Southerners detected in the first Rand study (Armor et al., 1978). As Vaillant (1983) explained his finding, "It is consistent with Irish culture to see the use of alcohol in terms of black or white, good or evil, drunkenness or complete abstinence" (p. 226).
Although "the existence of cultural differences [in drinking problems] is an undoubted 'social fact,'" sociocultural explanations for these differences have been challenged (Room, 1976, p. 1047). Indeed, the current thrust from social scientists in public policies for preventing alcoholism is on controlling the supply of alcohol, on the principle that there is a constant relationship between overall consumption and the amount consumed by drinkers at the extreme end of the drinking continuum (Beauchamp, 1980; Room, 1984). This control-of-supply approach has itself been challenged (Nathan, 1983). A supply hypothesis is inadequate to explain subcultural differences in alcoholism for groups for whom alcohol is equally available. It also cannot explain historical changes, such as those in America, where per capita alcohol consumption during the colonial period was two to three times its current rate, but problem drinking was below its current level (Beauchamp, 1980). There is a strong parallel here with 19th century developments in attitudes toward addiction and narcotics in England and America. In both countries, although 19th century opiate use was widespread and massive, modern conceptions of narcotic addiction developed only at the turn of the century when general consumption rates declined (Berridge & Edwards, 1981; Musto, 1973).
A social-cognitive dimension in alcoholism and addiction is evident in Levine's (1978) startling discovery that the idea of loss of control was uniformly absent from first-person descriptions of drunkenness in colonial America. In contrast, by 1835, loss of control was the unifying thread in the public confessions of reformed drunkards. If loss of control defines alcoholism, such alcohol abuse as there was took an entirely different form in the earlier era. Criteria such as violent and other aberrant behavior when intoxicated are central to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980) definitions of alcohol abuse and alcohol dependence. Similarly, disease proponents concede that "the most sensitive instruments for identifying alcoholics and problem drinkers are questionnaires and inventories of psychological and behavioral variables" (Mayer, 1983, p. 1118). Yet in their classic work, Drunken Comportment, MacAndrew and Edgerton (1969) showed that how alcoholic disinhibition is interpreted and enactedfor example, whether it leads to violenceis socially conditioned and takes completely different forms in different cultures.
Bales (1946) provided an early effort to synthesize cultural and individual attitudes about alcohol. He proposed that the incidence of alcoholism in a society depended upon the degree of cultural arousal of inner tensions, attitudes in the culture about the effectiveness of drinking for relieving such tensions, and the presence or absence of alternate societal means of satisfaction. McClelland, Davis, Kalin, and Wanner (1972) developed a model of alcoholism predicated on a society's ambivalence about power, alcohol's association in that society with displays of power, and the absence of alternate means for an individual to realize a need for power. Later social learning models have expanded the realm of the individual's expectations of desired effects from alcoholor other substancesto include feelings of sexual potency, personal control, tension relief, lessened self-awareness, and so on (Brown, Goldman, Inn, & Anderson, 1980; Gaines, 1982; Hull & Young, 1983; Maisto, Connors, & Sachs, 1981). These beliefs about alcohol's efficacy as an experience modifier may underlie the effects of parental and cultural attitudes on drinking behavior (Christiansen & Goldman, 1983; Zucker, 1976). At the same time, "virtually all the studies that use adequate control groups have found that alcoholics and problem drinkers are more external in locus of control than nonproblem drinkers are" (Rohsenow, 1983, p. 40). Thus, those who cannot control their drinking may invest alcohol with the power both to bring about otherwise unattainable emotional states and to control their behavior.
Where Is Our Society Headed With Alcohol?
The indications are that the United States is abandoning its former, culturally pluralistic attitudes toward alcohol to create a dominant attitude toward alcohol as having the supreme power to corrupt and control. That is, the attitudes that characterize both ethnic groups and individuals with the greatest drinking problems are being propagated as a national outlook. This approach may work to help those who already hold this view of their drinking, but it carries dangers as a therapeutic policy for others and as a model of drinking for the young. Annual measurements have revealed in the latter half of the 1970s and the beginning of the 1980s that 40% of high school seniors (50% of male seniors) reported drinking at least five drinks in one sitting in the prior two weeks. This behavior has been accompanied by a growth in the endorsement of binge drinking over mild, regular drinking (Johnston, Bachman, & O'Malley, 1981). Social context and learning approaches have tried to deal with these trends in the young by creating moderate drinking atmospheres on campuses (Kraft, 1982) and by encouraging attitudes toward health that are incompatible with excessive drinking (Williams & Vejnoska, 1981). In a household survey of drug and alcohol use, Apsler (1982) found that problem drinking was associated with the drinker's reliance on alcohol to bring about desired feelings as opposed to drinking in line with social or personal norms. Furthermore, the problematic style was more associated with youthful drinking, suggesting that emphasizing social standards in drinking over alcohol's ability to modify feelings would have a beneficial impact for youthful drinkers (Apsler & Harding, 1983). On the other hand, consistent findings of the tremendous malleability of drinking behavior with age indicate it is an error to label youthful drinkers as alcoholics, even when they display major drinking problems. However, the policy goal of altering culture-wide attitudes toward drinking and drinking patterns has proved elusive (Sulkunen, 1983). What is clear is that a range of cultural forces in our society has endangered the attitudes that underlie the norm and the practice of moderate drinking. The widespread propagation of the image of the irresistible dangers of alcohol has contributed to this undermining.
Alcoholism is a primary example of how political and social forces blunt and even reverse the thrust of social-scientific research and psychological conceptions. The alcoholism field is one particularly prone to drive social scientists to announce a paradigm shift (cf. Armor et al., 1978; Beauchamp, 1980; Moos & Finney, 1982; Pattison et al., 1977). What may make one less than hopeful about such a shift in conceptions is that prevailing notions about alcoholism have gained popularity despite a lack of empirical support from the beginning. Disease conceptions may be alluring to our contemporary society because they are congruent with general ideas about the self and personal responsibility (Peele, 1981b). Alcoholism viewed as an uncontrollable urge is after all part of a larger trend in which premenstrual tension, drug use and drug withdrawal, eating junk foods, and lovesickness are presented as defenses for murder (Peele, 1982). It may be that contesting disease imagery will remain an unpopular, but necessary, effort for some time.
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I thank Bruce Alexander, John Falk, Harold Kalant, Nick Heather, William Miller, Robin Room, and Martha Sanchez-Craig for ideas and information they provided; Archie Brodsky and Stanley Morse for their comments on this article; and Penny Page, librarian at the Rutgers Center of Alcohol Studies, for bibliographic assistance. The views expressed here, however, are strictly my own.