In November, 1983, under assault for CD therapy, an international group of behavior therapists conducted a panel at the annual meeting of the Association for the Advancement of Behavior Therapy in Washington DC. Stanton finagled an invitation (joining Alan Marlatt, Bill Miller, Fanny Duckert, Nick Heather, Martha Sanchez-Craig, Mark and Linda Sobell) and delivered an audacious talk equating behavior therapy and God both tell you the hardest way to do anything. In place of standard behavior therapy protocols, Stanton described natural processes by which people achieve remission. If only the Sobells had been listening, they could have cut short the ten years it took them to discover recovery without treatment. At the same time, Stanton's talk anticipated harm reduction, motivational interviewing, and just about every other current cutting edge idea in substance abuse treatment.
In G.A. Marlatt et al., Abstinence and controlled drinking: Alternative treatment goals for alcoholism and problem drinking? Bulletin of the Society of Psychologists in Addictive Behaviors, 4, 141-147, 1985 (references added to original)
Behavior therapythe hardest way: Controlled drinking and natural remission from alcoholism
I have a new way to try to minimize some of the conflicts between different groups that are fighting in the alcoholism field. What I'm going to do today is I'm going to try to insult them both if at all possible, and so that way maybe create more of a middle ground. Alan [Marlatt] talked a lot about those people who are not seeking alcoholism treatment, the 80 percent, the silent majority. And I want to try and just reach out there and see what we know about those people because unfortunately all of the discussion that we've had today has been basically limited to people who come to us and seek help, and some people don't like to do that. And the way that we traditionally react to that fact is to say, "Darn those people. Don't they understand how much we can help them if they would just turn themselves over to us?" The evidence for that is not completely clear, and also I think, looking at that group out there gives us some other ways of getting a handle on some of the questions that have been introduced in this panel.
Let me illustrate my central theme by referring to a self-help book that I recently reviewed for a British publication, entitled Selfwatching which is by two eminent behavior therapists, Ray Hodgson and Peter Miller (1982). Selfwatching is a manual of behavioral techniques for combating addictive and compulsive behaviors. The term 'selfwatching' describes a behavioral approach where the individual notes when they engage in the problem behavior and they record how they feel at that time and they report what the situation is like. And that is part of an overall behavioral approach where people eliminate behavior through desensitization, and they develop alternative ways to combat stress, and they substitute newly learned healthy patterns of behavior, and they learn to anticipate and forestall relapse.
Among their many discussions of smoking cessation in that manual Hodgson and Miller mention one case of an individual who quit smoking by himself and that case was originally reported by Alan (Marlatt,1981) here. It's about a man who sort of had a vision of God in the middle of the night, and he was able to quit smoking because of that. Now, that's one view of how people quit smoking. Lots of people quit smoking on their own. Now, how do they do it? How many of them do we think had religious conversions, and how many of them, in the absence of going to behavior therapists cleverly on their own devise these kinds of self-help manuals and record all the times that they smoke and desensitize themselves? I don't believe, I really don't believe that that many of them did that. In talking to several of them I don't think that's the common way they do it. And actually I think there's something very similar about asking a behavior therapist how to do something and asking God, because both of them always tell you the hardest way to do it. That's why it's interesting to note that in the 1982 Surgeon General's report on the health consequences of smoking they report that outcomes are sometimes better with less rather than with more therapeutic contact. That's a pregnant quote, rather coy I think.
Recently, Stanley Schachter (1982) has done what I consider to be a landmark study on remission in smoking and obesity. And Schachter came to this research assuming that certain people never overcome overweight. That was the basic model he was working from. He found that in two community populations totaled, over 60 percent of those who said that they had either tried to quit smoking or to lose weight or to get down out of the obesity range had succeeded. In the case of smoking they'd done so on the average for over 7 years. Schachter found, although it's only a small part of his population, that those who did not seek therapeutic assistance did better than those who did. Can you beat that? Now, how much of this applies to alcohol, and what do we know about this with regard to alcohol?
One of the things that this has relevance to is the question of whether alcoholics as a specific identifiable group can return to controlled drinking. George Vaillant in a recent edition of the Harvard Medical School Newsletter, mentioned that he's never found a client that could do that. However, such outcomes regularly appear in natural history studies. They cannot be contravened; there's something that seems to be happening out there. Vaillant (1983) studied two groups of people, two large groups, three actually: a hundred alcoholism patients that he treated at his clinic. He notes, by the way, that they did not show a significantly greater improvement than did comparable groups of alcoholics who did not receive treatment. That's one of the first things that we get from his book. Secondly, he studied two groups: a college group, and an inner-city group of alcohol abusers. There were 110 alcohol abusers in the inner-city group, 71 of whom were alcohol dependent. At the last assessment 20 percent of this group were drinking moderately while 34 percent were abstaining. Now, most of these people had no formal therapeutic experience. Obviously the 20 percent doing controlled drinking were not heavily involved in Alcoholics Anonymous. Vaillant also reports that of the abstainers, 37 percent succeeded in abstaining wholly or in part through A.A. Thus even among the abstainers a good majority seemingly had no contact with, had no assistance from A.A.
Who are these people? What are they up to? Obviously, as we've seen, part of what's going on is that these people may not be comfortable with abstinence and that is why they're refusing to turn themselves in for therapy, because they can anticipate what they're going to hear there. However that's not the only thing that's going on. A lot of the controlled drinking outcomes that we encounter, such as the ones reported in the Rand report (Armor et al., 1978) and the ones originally reported by David Davies in 1962 that created such a furor, were people who had been exposed, who had been engaged in abstinence oriented treatment, and who became controlled drinkers anyhow. Those people go into therapy and they kind of nod their head and agree about the value of abstinence therapy and then they go out and they live their lives, and they project their own desires and their own values. Now among this 63 percent even of the abstainers who do not seek A.A., what's on their minds? What's going on with them?
One of the things that seems to be taking place again, in addition to the possibility that they might want to drink, is the fact that they do not like to call themselves alcoholics. Now we have a reaction to that, and to me it's sometimes rather similar between disease-oriented therapists and non-disease oriented therapists. Our reaction is to say, "Don't you realize you have a problem, you see, and this is the nature of your problem, and you're denying your problem and this is what you should do about it." That's a somewhat different model from how we approach many other kinds of therapeutic issues, and I was very glad to hear Fanny Duckert address that. I mean, what happened to Rogerian psychology, where we say to people, "What's your understanding of your situation? What's your understanding of what's going wrong in your life? And what's your understanding of some of the ways that you can progress in dealing with that?"
We're going against that even in psychology by saying, "Our main aim is to categorize people and decide what is going to work best for them." What's happening by the fact that we're not including these people who don't go into therapy, is that we're losing sight of the fact that many people are perfectly willing on their own, even when they go into therapy, as in the Rand reports (Armor et al., 1978; Polich et al., 1981), to define their own goals and pursue them on their own whether they don't enter therapy at all or whether they bend the recommendations that people are giving them to assert the kinds of aims that they want. And so the thing I want to question most strenuously is something that Vaillant, I think rather oddly derives from his own analysis which is that the major benefit of therapy under the medical model is that it gives people a chance to identify themselves as having a problem and then turn themselves over to treatment.
Let me say a little bit more about the Vaillant study because it's very interesting, because the Vaillant study is being presented as a very strong defense for the medical model. Now as I mentioned, among the inner-city group Vaillant reports that 20 percent are drinking moderately and 34 percent are abstaining. Vaillant is very critical of the Rand report definitions, and the second Rand report (Polich et al., 1981) defined controlled drinking as being no problem drinking episodes dependence or problems from drinking in the previous 6 months. Vaillant defines it as no incidents of these kinds in the previous year. However, those that he defines as abstainers are allowed to have had up to a week of alcoholic binge in his definition. But more important than those differences is the fact that Vaillant defines abstinence as drinking less than once a month. So we could apparently eliminate a whole host of the arguments that exist out in our field and I think go along with a lot of the things people have said here by just saying, "Well wait. If that's abstinence, well, I thought you meant abstinence. You mean 'abstinence.' Oh That's where the person's trying not to drink but they sometimes don't quite make it." (Don't we all.) That's a whole different way of thinking about abstinence.
I think there have been some very interesting points that have come our of what has been said here thus far. Particularly, I think one of the most fascinating is Martha's study. If you'll recall, what Martha Sanchez-Craig (Sanchez-Craig et al., 1984) found is that: you take two groups of people and you tell one of them they should abstain and you tell the other group about controlled drinking and give them techniques for how to do that. Well, the results are, at 6 months, 12 months, 18 months, and 24 months, that although there is a significant reduction in drinking among both groups, there is not a significant difference in abstinence between the groups. Here we see people in action working through in their minds what's going to work for them, what's going to be the best benefit to them. What this really suggests to us, and again I think it came out in several of the other studies, that the key ingredient is the individual's motivation. The key ingredient to making anything work is the person identifying with the goals of therapy and really wanting to do something about them.
There's one other aspect besides an individual's motivation that I think we cannot avoid comprehending when we're trying to deal with people with all kinds of addictive problems. That's something that Vaillant talked about quite a bit in his book, and so did Gerard and Saenger (1966): recovery from alcoholism resulted in most cases from a "change in the alcoholic's attitude toward the use of alcohol based on a person's own experiences which in the vast majority of cases took place outside of any clinical interactions." And we don't know enough about what people are feeling and experiencing out there.
I just want to mention one study which I think perhaps is focused on that perhaps better than any other, and that's Barry Tuchfeld's study of natural remission in alcoholism. Tuchfeld, in 1981, published a study where he found 51 people who had had severe drinking problems involving blackouts and loss of control, and at the present time 40 were currently abstinent and 11 were drinking moderately. And these subjects often described a moment of truth when they all of a sudden saw their life in a very clear way which caused them to change their behavior. And actually this has a very distinct parallel to things we hear about in A.A. One pregnant woman remembers drinking a beer one morning to pacify her hangover and she said, "I felt the baby quiver and I poured the rest of the beer out, and I said, 'God, forgive me. I'll never drink another drop.' And from that day to this I haven't."
Parenthood and motherhood is very significant in a lot of cases of natural remission, I found, in addictions of all sorts. However, that implies a very specific event, a very monumental kind of situation. When you're pregnant hey, that's heavy. There are situations reported throughout Tuchfeld that are very significant to the individual and yet which have no objective correlate. Which just reminds us how important subjective assessment of self and situation is. Nick Heather was referring to a study which he did where your belief about whether you're an alcoholic or how physically dependent you are is far more important in predicting whether you will relapse after drinking than any attempt to objectively assess your level of dependence (Heather et al., 1983). So one man said, "I drank a fifth and a half and I told them that night that when I drank this I'm not going to drink anymore, and I haven't had a drop since." It's that simple. If we could only find out how he did it, huh?
Another thought, "My God, what am I doing here? I should be home with my children." And we could tell them how to do it these guys heard this a million times before, haven't they? And so much of our therapy is designed for denying this fact of self-cure we're denying, not the clients. They say this and they make it stick at some moment in their lives. And one of the most, I think, important things that comes out of the Tuchfeld data is the fact that many of the people who are doing this revel in their self-efficacy. We've got one guy down there who said, "People told me I could never quit drinking on my own." He lifts his hands up and says, "I'm the champ. I'm the greatest. I did it on my own."
Now, Tuchfeld advertises for his subjects. He says, "Come to me and tell me how you quit drinking." So there's a tendency that they're a little bit more dramatic about it than other people out there in the field. The Cahalan and Room (1974) kind of model says people just get out of problem drinking. But even Vaillant's study which looks at people in terms of their natural history finds that people very often report these kinds of epiphanies, these moments of truth. And I think, unfortunately, Vaillant tends to de-emphasize them. It is important to realize that these people may have had moments of truth in the past and gone right on drinking again. However, I think they are telling us something very important about themselves and their values when they describe a moment when they made a very strong resolution to stop drinking.
I've been talking about these people, and I just want to tell you about one of them. Let me introduce you to a guy. This guy's strange, I mean he might not fit into any category we've described today. He comes from a very early study by Genevieve Knupfer (1972) who studied ex-problem drinkers in an epidemiological group. And one of these guys talked about his heavy drinking period. He reported, "I was in the Merchant Marine. Every night or day on shore we'd drink a week or ten days straight. We drank till we fell on our face. We never ate and never slept; I was down to 92 pounds." Bad prognosis for controlled drinking. I think he might be alcohol dependent. He also stated that he was lonely and had no friends another real negative predictor.
One day he decided to quit this whole life, so he became a cook, and these are Genevieve Knupfer's words: "He became a cook in a cafeteria, a job he continues to hold. He bought a home; he enjoys having it. He enjoys his neighbors and a few friends, but does not seem to be really intimate with anyone. He drinks once or twice a week, never less than four drinks, usually six. He says he never drinks on work nights, but by this he means that he doesn't take more than one drink, and then only to oblige a friend. For example, 'There was a death in the person's family; I had to calm him down a bit; he was all upset. He's an Irishman and I guess they supposedly drink to the spirits. [A little social analysis here.] I just had one drink. He was disappointed because he wanted to go all out.' On New Year's Eve our subject had eight or nine drinks just to go along with the crowd, but he was sorry the next day because he wasn't up to working in his garden."
Now what's funny about this person is that in the post-Rand environment it's very possible that this man might not show up as a controlled drinker, but obviously he's changed, he's changed a lot, he's changed in a way that's really been good for him. He can take just one drink, and if he goes over his limit of six, even to just have eight drinks on New Years he regrets it, and it hurts him. How do we handle such a man as a clinical patient? Would we still identify him as a problem drinker, and attempt to get him to modify his behavior now?
Actually, I think, this man's experience which is unclassifiable by a lot of the categories we've talked about, is a good illustration of something that's true about all kinds of problem drinkers. They're drinking to mediate their experience of life, and their patterns of drinking shift with short and long term needs. They are actually, these human beings, are actually self-regulating organisms however inexact and dysfunctional they at some times may seem. And they're going to remain self-regulating organisms even after they get done talking with us, if they should be so fortunate as to run into us. A particular therapeutic strategy is exactly as effective as this client makes it, and as well as it fits into his internal needs, and his view of himself and his view of his situation. And we may hope to inspire the client, and we, at the same time, can hope to respond to his or her needs, but I think it may be a little grandiose for us to claim any larger role for ourselves in what happens to this person. And I just want to quote one of Barry Tuchfeld's clients. The way he described it was, about people who quit drinking or moderate their drinking, "You have got to have some inner strength, some of your own strength and resources that you can call up in yourself." And, you see, our job is to respect that strength and to respect the individual, enough to support the idea that he has that strength.
Armor, D. I., Polich, J. M., & Stambul, H. B. (1978). Alcoholism and treatment. New York: Wiley.
Cahalan D., & Room, R. (1974). Problem drinking among American men. New Brunswick, NJ: Rutgers Center of Alcohol Studies.
Gerard, D. L., & Saenger, G. (1966). Out-patient treatment of alcoholism: A study of outcome and its determinants. Toronto: University of Toronto Press.
Heather, N., Rollnick, S., & Winton, M. (1983). A comparison of objective and subjective measures of alcohol dependence as predictors of relapse following treatment. British Journal of Clinical Psychology, 22, 11-17.
Hodgson, R., & Miller, P. (1982). Selfwatching. London: Century.
Knupfer, G. (1972). Ex-problem drinkers. In M. A. Roff, L. N. Robins, & M. Pollack (Eds.), Life history research in psychopathology (Vol. 2, pp. 256-280). Minneapolis: University of Minnesota Press.
Marlatt, G.A. (1981). Perception of "control" and its relation to behavior change. Behavioral Psychotherapy, 9, 190-193.
Polich, J. M., Armor, D. J., & Braiker, H. B. (1981). The course of alcoholism: Four years after treatment. New York: Wiley.
Sanchez-Craig, M., Annis, H. M., Bornet, A. R., & MacDonald, K. R. (1984). Random assignment to abstinence and controlled drinking: Evaluation of a cognitive-behavioral program for problem drinkers. Journal of Consulting and Clinical Psychology, 52, 390-403.
Schachter, S. (1982). Recidivism and self-cure of smoking and obesity. American Psychologist, 37, 436-444.
Tuchfeld, B. S. (1981). Spontaneous remission in alcoholics: Empirical observations and theoretical implications. Journal of Studies on Alcohol, 42, 626-641.
Vaillant, G. E. (1983). The natural history of alcoholism: Causes, patterns, and paths to recovery. Cambridge, MA: Harvard University Press.