The Sciences (New York Academy of Sciences), March/April, 1984, pp. 14-19
The New Prohibitionists
Our attitudes toward alcoholism are doing more harm than good
Morristown, New Jersey
Most Americans assume that abstinence is the alcoholic's only hope. And in July 1982, a paper published in the prestigious journal Science was widely received as proof of this indelible truth. Mary Pendery, head of alcoholism treatment at the Veterans Administration Medical Center, in San Diego, interviewed a group of alcoholics who had participated in an experimental program at Patton State Hospital, in California. Twenty alcoholics had been taught, using behavioral-modification techniques, to drink moderately. Virtually all of them, Pendery and her co-workers discovered, had bouts of drunkenness within six months. In the ten years since their treatment, four of them had diedfrom what Pendery claimed to be alcohol-related causes.
John Sloan, McSorley's Saturday Night, 1929
Newspapers, magazines, and radio and television programs took up the researchers' findings and dwelled on the deaths, sometimes in graphic detail. The CBS weekly newsmagazine, 60 Minutes, interviewed several of the alcoholics, who described their drinking relapses and denounced the psychologists who had supervised their treatment, Linda and Mark Sobell, then students at the University of California at Riverside.
The news stories were fueled by accusations of fraud, veiled and explicit, which the authors of the Science article had leveled at the Sobells. These accusations had been expunged from their paper by the editors of Science, but the researchers repeated them to the press. They hoped to eradicate the influence of the Sobells' study, which, they claimed, had spawned a whole series of investigations into what is often called controlled-drinking therapytreatments in which some patients are encouraged to become restrained, social drinkers rather than teetotalers. What concerned Pendery and her colleagues, and many of the reporters who gave the story so much attention, was the horrifying possibility that alcoholics were being treated by a method guaranteed to lead them back down the garden path to alcoholism.
Yet it hardly seems necessary today to discourage controlled-drinking therapy. In the United States, at least, the idea has already been beaten dead. Practically no treatment centers in this country now pursue it as an official policy. Not only do the rank and file of health professionals reject this sort of therapy out of hand, but even the small group of behavioral researchers who developed controlled-drinking programs in the first place say it is not appropriate for the severe alcoholic. What is more, there is little interest among alcoholics themselves in treatment aimed at moderating their drinking. Regardless of the merits or demerits of the Sobells' study, 79 percent of Americans accept the view that alcoholism is a disease and that it calls for medical treatment, according to a 1983 Gallup poll. For this reason, they are likely to assume that strict abstinence is the only possible happy ending.
Few Americans realize that this view of alcoholism and abstinence is not shared worldwide. Controlled-drinking programs are widely accepted throughout Europe. Britain's National Council on Alcoholism, for example, believes that "controlling one's drinking pattern . . . may be an alternative which many people prefer, and are able to achieve and sustain, and for this reason they deserve our support and guidance." And when two Scottish researchers distributed a questionnaire to treatment facilities in the United Kingdom in 1979, they learned that in 93 percent of these programs, moderation is considered a reasonable goal. This casts the American repugnance toward controlled drinking in a more culturally relative light.
As social scientists have known for decades, attitudes toward alcohol come in as many shapes as bottles; and attitudes, more than scientific evidence, have formed Americans' rigid notion of the proper treatment of alcoholics. An investigation of three Greek villages by Richard Blum, now at Stanford University, found that the villagers did not view alcoholism as a problem, or even as a potential problem. Moderate drinking is a Greek family custom, closely knit into the community's social fabric, and spirits are seen as a harmless acåompaniment of good times. Greek society encourages neither the extreme of abstinence nor the extreme of drunkenness: drinking is not a moral issue, and the abuse of it is rare. This comfortable attitude is palpable in the atmosphere of Greek clubs in America, where families gather to listen to music and to dance.
There are other notable pockets in the United States in which alcoholism is unusual, particularly among Italians, Jews, and Chinese Americans. In all of these ethnic groups, young people are introduced to alcohol, in the form of wine or other mild spirits, early in life and as part of rituals, religious holidays, and celebrations. Drinking takes place among both sexes and all ages and is strongly regulated by social custom. It seems that these people's perceptions of alcohol, and their very experience of its effects, are less intense than most Americans'. Fewer than one out of a hundred American Jews is alcoholic, for example, while the national average is one in twelve.
Janet Fish, Smirnoff's Vodka and Don Q Rum, 1973
Even more remarkable is the way such attitudes have altered in America over the years. In colonial America, drinking was a family affair and took place in the community tavern. With small children, husbands, wives, and grandparents gathered together, liquor was consumed in a manner resembling moderate ethnic drinking styles today. The eighteenth-century American, according to a recent history, Drinking in America, by Mark Lender and James Martin, regarded alcohol as "God's good creature." But between 1790 and 1830, expanding frontiers and the accompanying social dislocations wreaked havoc with these healthy customs. Taverns became male preserves in which the only women likely to be present were prostitutes. In this atmosphere, drinking came to symbolize masculinity and male independence, and alcoholism rates rose dramatically. As abuse grew rampant, the Anti-Saloon League flourished, along with self-help groups organized to support the reformed alcoholic. These earnest fellowships followed the pattern of Protestant revival meetings, with their stylized public confessions, protestations of repentance, and exhortations for sinners to take and maintain the vow of sobriety. "God's good creature" disappeared, replaced by an evil genie in a bottle.
"Wets" and "drys" battled, often ferociously, until, in 1919, the temperance movement prevailed in passing the Eighteenth Amendment to the Constitution: national prohibition. Prohibition lasted just thirteen turbulent years, and with its failure and collapse, in 1933, the striving for national abstinence was over. This goal was gradually succeeded by the idea, first propounded in the eighteenth century by the Philadelphia physician Benjamin Rush, that some people have a specific disease, the nature and causes of which are mysterious, that makes it impossible for them to drink moderately. The disease theory of alcoholism has the merit of bringing troubled people into the care of hospitals and doctors, an advantage appreciated particularly by physicians themselves, who tend to see human problems in terms of the medical model: disease, treatment, cure. Yet it posits an inborn organic cause, a bodily deficiency, where there may be none, and for this reason the theory is troubling. Alcoholism may at its roots be a social and cultural problem, not a medical one.
Despite this drawback, the disease theory of alcoholismthat uncontrolled drinking is inbred and irreversiblebecame the banner of Alcoholics Anonymous, itself a continuation of the self-help alcoholism movements of the previous century. By the latter half of the twentieth century, with both AA and the American medical establishment embracing it, the disease theory became orthodoxy in this country. And because AA preserves much of the religious fervor of the nineteenth-century temperance movement, the concept became virtually a spiritual tenet. The disease theory maintains the same extreme view toward alcohol that prevailed in temperance days: whether alcoholism is seen as a deadly sin or a deadly disease, the only recourse is abstinence. "I am an alcoholic," the AA member is taught to declare; "I cannot drink."
By 1960, this view had gained such force that most health professionals had come to believe the goal of moderation to be entirely inappropriate for alcoholics. In effect, the fervor of Prohibition had moved off the streets and into the hospitals. If abstinence was not possible for the nation as a whole, it was crucial for the small but growing group considered to have the disease of alcoholism. Within the confines of hospitals and clinics, then, abstinence became once again a powerful political and emotional issue.
The first study that drew attack on these ideological grounds was published in 1962 by an Englishman, David L. Davies, who followed up on patients treated for alcoholism at Maudsley Hospital, in London. Of ninety-three patients, roughly a decade after treatment, seven had returned to normal drinking habits. Davies's report disconcerted those who believed such moderate reform to be a medical impossibility.
A louder outcry followed the Rand Corporation report Alcoholism and Treatment, released in 1976. The National Institute on Alcohol Abuse and Alcoholism, a government agency, had commissioned the Rand Corporation to find out how patients fared a year and a half after treatment at NIAAA centers across the country. Alcoholics, the Rand report found, canand doreturn to healthy and moderate drinking habits. In fact, of those patients in the study in remission from alcoholism, almost half had become moderate drinkersthis despite the fact that the NIAAA treatment centers had encouraged only abstinence.
The furor these statistics caused was remarkable and can be understood only in terms of the battle lines that have been drawn over alcoholism. On the morning the report was released, the National Council on Alcoholism declared it "dangerous, misleading, and not scientific." The NCA, a large, influential, private alcoholism group that supports the disease theory, lobbies to raise money for medical studies of alcoholism. It also sponsors ad campaigns urging heavy drinkers to recognize that they have a disease, to seek help from their doctor, and to join the local chapter of Alcoholics Anonymous.
Though the wilder criticisms of the Rand report were politically motivated, officials of the NCA and others did raise serious questions about the Rand researchers' methods. There was no way of telling from their data whether a "recovered" alcoholic's moderate drinking would last and whether it was indeed moderate enough to be harmless. Responding to these criticisms with a thoroughness that is rare in the social sciences in general and alcoholism research in particular, the Rand researchers extended and deepened their investigation. They followed the alumni of NIAAA clinics for four years, not just one and a half; and they devised stricter standards for defining moderation in drinking. Of those patients who were still free from drinking problems after four years, the new results showed, 40 percent were drinking socially.
The fate of this second book-length Rand report, The Course of Alcoholism: Four Years After Treatment, was more astonishing than that of the first. The directors of the NIAAA, which had funded the study, praised the research but offered their own very different version of its results. The NIAAA directors claimed that "abstinence is the appropriate goal in the treatment of alcoholism" and that attendance at Alcoholics Anonymous meetings offers the best prognosis. Yet the report itself found that those who had attended AA sessions were as likely to relapse as those who had not.
The head of the alcohol institute and his chief assistant were not researchers themselves. They were former administrators of alcoholism treatment centers and programs. This reflects a unique aspect of alcoholism policy in the United Statesthe degree to which people who are closely tied to grass roots programs like AA dominate views on the subject. The result is a national policy that sees alcoholism as the leaders of AA do, in black and white, without grays. By contrast, in most other Western countries, social workers and psychologists, who are inclined by training to notice social and cultural influences on behavior, and who regard moderate drinking as one possible goal for alcoholics, are influential in setting treatment policy.
Since the commitment that most Americans feel toward the philosophy of abstinence is rooted in strong feelings and cultural biases, not in hard information, they tend to downplay troublesome research. If the results of a study run counter to the prevailing notion that alcoholism is a disease, the study is rejected. It is not uncommon, for example, for alcoholics to maintain that they cannot taste alcohol in any form or in any quantity without endangering their sobrietyto believe that the drug sets off an allergic reaction in their bodies. But investigations of alcoholics' responses to liquor have consistently found that the opposite is true: not only are alcoholics capable of regulating their drinking, they actually do regulate it in many circumstances. One well known demonstration of this fact was performed by psychologist Alan Marlatt at the University of Washington. Marlatt gave alcoholics flavored beverages, some of which contained alcohol. If the drinker believed he was consuming alcohol, Marlatt found, he was likely to feel the need to drink moreeven if he was actually drinking tonic water with a dash of lime. If he was drinking liquor but did not know it, he did not have this reaction. Clearly, the psychological factors in such an experiment are more important than the physiological. The "allergic reaction" is simply a medical myth, part of the general mythology of the disease theory of alcoholism.
Janet Fish, Tanqueray Bottles, 1973
The more sophisticated versions of the disease theory acknowledge that social situations and attitudes do affect a drinker, but still hold that there are unavoidable, inbred factors that point certain susceptible people toward alcoholism. In this view, there are three objections to controlled drinking. First, while attempts at moderation may last for a while, the alcoholic is bound to relapse eventually. Second, some problem drinkers may be able to control their drinking, but severe alcoholics, who are physically addicted, will find it virtually impossible to do so. Third, controlled drinking, even if possible in a few cases, is always risky and unnecessary.
The results of the second Rand report contradicted all three assertions. It found a substantial minority who were drinking moderately four years after therapyincluding a significant number of those who were heavily addicted when they had entered treatment. The report, like nearly every other reputable study, found that most alcoholics undergo periods of heavy drinking followed by stretches of abstinence or moderation. The Rand subjects often relapsed. But it was not only those attempting to drink moderately who relapsedand, indeed, for certain types of drinkers, trying to abstain worked worse than drinking moderately. For single men under forty, the goal of abstinence was actually counterproductive.
Ultimately, suspicion of the Rand reports is not founded on issues of procedure and accuracy; taken together, they were careful and soundly conceived studies. Rather, the ill will toward them stems from feelings that the Rand researchers were unaware of the horrors of the alcoholic's personal situation, his troubled homelife and work life. To anyone who has ever worked closely with an AA group, say critics, an emphasis on abstinence seems only common sense. To publicize any contradictory finding is to make treatment that much more difficult.
George Vaillant, formerly of Harvard University, expresses such reservations about the Rand reports in his recent book, The Natural History of Alcoholism. The book has been greeted as a landmark, reporting results of the first large-scale, systematic study since the Rand reports themselves. Sixteen years ago, Vaillant took over two large research studies that had been established in 1940 to follow the lives of some 660 men: 204 of them Harvard graduates, 456 of them members of the urban working class. Vaillant published Adaptation to Life in 1977, analyzing the reasons for personal success and failure in the Harvard group. In The Natural History of Alcoholism, he not only discusses the Harvard and working-class men but also follows up on patients of a medical clinic, the Cambridge Hospital alcohol program, of which he was a director.
Vaillant (now at Dartmouth Medical Center) is strongly sympathetic toward Alcoholics Anonymous and endorses the disease view of alcoholism and a medical model for treating it; if nothing else, he says, the term disease "is a useful device both to persuade the alcoholic to admit his alcoholism and to provide a ticket for admission into the health care system." Yet this position places Vaillant curiously at odds with his own data, tables of which fill a large fraction of the book.
Of the 456 core-city men, 110 became problem drinkers at some point in their lives; of the 204 college men, only 26 did. At the last assessment of them, Vaillant found 20 percent of the alcohol abusers in the core-city group to be drinking moderately and 34 percent to be abstaining. In other words, fully one out of five of Vaillant's own subjects was controlling his drinkingneither going on binges nor abstaining. What is more, Vaillant himself acknowledges that few abstaining alcoholics never drink again. Indeed, his own definition of abstinence is considerably more permissive than AA's: in Vaillant's study, abstinence means drinking less than once a month. Many might conside"!this to be controlled drinking.
All of Vaillant's case studies tend to make the same point: alcoholics must acknowledge that they have a disease and seek help (usually from AA). He finds, as did the Rand researchers, that those who manage long periods of abstinence tend to be people who stayed with AA for years. (The Rand reports note, however, that many who attend AA drop out and that those who become social drinkers rather than abstainers have little to do with AA.) Vaillant's subjects used AA in many different ways. Some attended only briefly and then went it on their own; others attended frequently without solving their drinking problems. Overall, among the core-city sample, he says, more than a third of the men who achieved a year of abstinence succeeded wholly or in part through AA.
We learn little from Vaillant, however, about those who dealt successfully with their alcohol abuse without help from AA. This was a sizable group: all the social drinkers and even the majority of the abstainers. For them, forces outside formal therapythe influences of family and friends, and their own personal motivationwere most important in recovery. Thus Vaillant's own results disprove the common notion that alcoholics cannot change on their own. Though Vaillant acknowledges throughout the book the importance of forces outside therapy, "natural forces," he seems strangely reluctant to discuss them. Time and again he plays down willpower and self-reliance.
Vaillant's reticence is doubly disappointing in light of his report that the results of treatment at his hospital clinic "were no better than the natural history of the disease." That is to say, the patients he treated showed no higher rate of recovery than did alcoholics who never received any sort of treatment at all: Vaillant found that of patients at his clinic who received detoxification treatment and were required to attend AA meetings and keep in frequent touch with the clinic, 95 percent relapsed into periods of heavy drinking. Clearly, the admonition to abstain is hardly a cure-all.
Still, Vaillant's honesty in assessing the effectiveness of his clinic is laudable, and rare. Pendery and her colleagues, in disputing the Sobells' study, were not as careful. Though they tracked down subjects who had been taught to drink moderately and found that many had relapsed, they did not follow up on the subjects in the Sobells' comparison group, who had been treated with the standard goal of abstinence in mind. When reading their report or watching 60 Minutes, we were left to imagine that those who had received abstinence therapy experienced no such difficulties. In fact, the purpose of the Sobells' original study was to compare the rate of relapse for the controlled-drinking group and for the abstinent group. Six of the abstinent subjects had died in the period covered by the Pendery investigation (at least four of them from alcohol-related causes), while four died in the controlled-drinking group.
There have now been two investigations of the Sobell and Pendery claims and counterclaims. The Addiction Research Foundation, of Toronto, where the Sobells now work, appointed an independent panel whose chairman was a professor of law at the University of Toronto. The United States Congressional Committee of Science and Technology worked through its Subcommittee on Investigations and Oversights. The investigations have pointed out major problems in the Pendery follow-up study and have exonerated the Sobells of misconduct.
Though Vaillant's data show that alcoholics do return to social drinking, his data also show, like the Rand studies, that the more severe the degree of alcoholism, the harder it is to control or moderate drinking. Those who are heavily dependent on the drug are normally better off quitting entirely. But this applies to all sorts of addictions. Something in the nature of compulsive habits makes a return to moderation difficult: if a heavy smoker quits, he is unlikely to be able to have just a couple of cigarettes a day; if someone loses eighty pounds, he is unlikely to have just one cookie. A couple who have had an intense, unhappy relationship usually find it best to make a complete break. Whenever a habit has grown all-consuming, changing can become a matter of all or nothing.
This is not to say, however, that abstinence is a biological imperative. Expectations are crucial. The belief that one cannot moderate a habit makes it almost impossible to do so. Thus, problem drinkers who define themselves as alcoholics are those most likely to need to abstain. If alcoholism were inbred, mandated by genes, then moderating or reversing it would be impossible. Those who subscribe to the disease theory have yet to discover an inherited, metabolic mechanism that accounts for the alcoholic's loss of control of his drinking. Vaillant himself provides a good review of such metabolic theories, and shows them to be utterly inadequate.
One recent theory, proposed by Marc Schuckit, of the University of California at San Diego School of Medicine, holds that the alcoholic inherits an inability to discriminate the level of alcohol in his blood, and thus cannot tell when he's had too much. This may or may not be so; but it is a far cry from a genetic compulsion to drink. Why would such a person not simply limit himself to a single drink, for instance? He might get drunk inadvertently once or twice because of his insensitivity to the effects of alcohol, but presumably he would soon recognize the problem and, in the future, make sure he did not drink beyond his limit. Another recent finding, reported by David Rutstein, of Harvard Medical School, and others, is that severe alcoholics metabolize liquor differently from normal, social drinkers. But any apparent metabolic difference may well be a result of prolonged, heavy drinking, rather than a cause of the habit. Again, it is hard to see any evidence of a genetic compulsion. In Vaillant's study, a recovered alcoholic's choice of moderation or abstinence was not related to the number of alcoholic relatives he had. It was distinctly related, however, to the drinker's ethnic background. So, culture seems more important here than genes.
Ultimately, it is conceivable that the disease theory itself is contributing to the nation's skyrocketing rate of alcoholism. The very perception of the power of alcohol to corrupt and control may make a powerful difference in the way Americans deal with alcohol. Prohibition proved conclusively that we are not an abstinent nation. So the devaluation of moderate drinking as a treatment goal, and a social norm, is dangerous. Few reformed alcoholics, even "abstaining" alcoholics, never touch another drink. The typical American therapist reasons, "Why not tell everyone with a drinking problem to abstain? What can be lost with that approach?" What can be lost is the patient's resolve to cooperate.
Marty Mann, a prominent figure in AA, has estimated that there were three million alcoholics in America in 1943, five million in 1956, and six and a half million in 1965. Today, experts in the alcoholism field put that figure at ten to fifteen million. When we promote the belief that many peoplein numbers that seem to be growing all the timecannot taste alcohol without catastrophic results, we may be fulfilling our own prophecy.