Participation in Treatment and Alcoholics Anonymous

So keep taking the medicine…

“A 16-Year Follow-Up of Initially Untreated Individuals

Abstract

This study focused on the duration of participation in professional treatment and Alcoholics Anonymous (AA) for previously untreated individuals with alcohol use disorders. These individuals were surveyed at baseline and 1 year, 3 years, 8 years, and 16 years later. Compared with individuals who remained untreated, individuals who obtained 27 weeks or more of treatment in the first year after seeking help had better 16-year alcohol-related outcomes. Similarly, individuals who participated in AA for 27 weeks or more had better 16-year outcomes. Subsequent AA involvement was also associated with better 16-year outcome…some of the association between treatment and long-term alcohol-related outcomes appears to be due to participation in AA.

We focus here on participation in professional treatment and AA among previously untreated individuals after these individuals initially sought help for their alcohol use disorders and address three sets of questions:

  1. Is the duration of treatment obtained in the first year after seeking help, and the duration of subsequent treatment, associated with individuals’ long-term (16-year) alcohol-related and psychosocial outcomes? Is participation in treatment in the second and third years … after initiating help seeking associated with additional benefits beyond those obtained from participation in the first year?
  2. Is the duration of participation in AA in the first year, and the duration of subsequent participation, associated with individuals’ long-term (16-year) outcomes? Is participation in AA in the second and third years associated with additional benefits beyond those obtained from participation in the first year?
  3. Many of the individuals who participate in one modality of help (professional treatment or AA) also participate in the other modality. Accordingly, we focus on whether the associations between the duration of participation in treatment and AA and 16-year outcomes are independent of participation in the other modality of help. We also consider interactions between the duration of treatment and AA in that, for example, one modality could compensate for or amplify the influence of the other.

 

Independent Contribution of Treatment and Alcoholics Anonymous

Patients who participate in both self-help groups and treatment tend to have better outcomes than do patients who are involved only in treatment (Fiorentine, 1999;Fiorentine & Hillhouse, 2000). According to Moos et al. (2001), patients with substance use disorders who attended more self-help group meetings had better 1-year outcomes.

Similarly, among patients discharged from intensive substance use care, participation in self-help groups was associated with better 1-year (Ouimette et al., 1998), 2-year, and 5-year (Ritsher, Moos, & Finney, 2002; Ritsher, McKellar, et al., 2002) outcomes, after controlling for outpatient mental health care. We focus here on whether the duration of participation in one modality of help (treatment or AA) contributes to long-term outcomes beyond the contribution of participation in the other modality.

Prior Findings With This Sample

In prior work with the current sample, we found that individuals who entered treatment or AA in the first year after seeking help had better alcohol-related outcomes and were more likely to be remitted (in recovery) than were individuals who did not obtain any help. Individuals who participated in treatment and/or in AA for a longer interval in the first year were more likely to be abstinent and had fewer drinking problems at 1-year and 8-year follow-ups (Moos & Moos, 2003; 2004a; 2005b; Timko, Moos, Finney, & Lesar, 2000).

In this article, the distinctive focus is on associations between the duration of participation in treatment and AA and 16-year outcomes. We also consider the independent contribution of participation in treatment and AA to 16-year outcomes.

Discussion

Compared to individuals who did not enter treatment in the first year after they sought help, individuals who obtained treatment for 27 weeks or more experienced better 16-year alcohol-related outcomes. Individuals who participated in AA for 27 weeks or more in the first year, and in years 2 and 3, had better 16-year outcomes than did individuals who did not participate in AA. Some of the contribution of treatment reflected participation in AA, whereas the contribution of AA was essentially independent of the contribution of treatment.

Participation in Treatment and 16-Year Outcomes

About 60% of individuals who sought help for their alcohol use problems entered professional treatment within one year. These individuals obtained an average of 20 weeks of treatment. Compared to untreated individuals, individuals who obtained 27 weeks or more of treatment in the first year were more likely to be abstinent and less likely to have drinking problems at 16 years than were individuals who remained untreated. These findings extend earlier results on this sample (Moos & Moos, 2003; 2005b; Timko et al., 1999) and are consistent with prior studies that have shown an association between more-extended treatment and better substance use outcomes (Moos et al., 2000, 2001;Ouimette et al., 1998).

Participation in Alcoholics Anonymous and 16-Year Outcomes

The findings extend earlier results on this sample (Moos & Moos, 2004a; 2005b) and those of prior studies (Connors et al., 2001; Fiorentine, 1999; Ouimette et al., 1998;Watson et al., 1997) by showing that more extended participation in AA is associated with better alcohol-related and self-efficacy outcomes. The results support the benefit of extended engagement in AA, in that a longer duration of participation in the first year, and in the second and third years, was independently associated with better 16-year outcomes. In addition, our findings indicate that attendance for more than 52 weeks in a 5-year interval may be associated with a higher likelihood of abstinence than attendance of up to 52 weeks.

 Part of the association between AA attendance and better social functioning, which reflects the composition of the social network, is likely a direct function of participation in AA. In fact, for some individuals, involvement with a circle of abstinent friends may reflect a turning point that enables them to address their problems, build their coping skills, and establish more supportive social resources (Humphreys, 2004; Humphreys, Mankowski, Moos, & Finney, 1999). Participation in a mutual support group may enhance and amplify these changes in life context and coping to promote better long-term outcomes.

Independent Contribution of Treatment and Alcoholics Anonymous

Consistent with prior studies (Fiorentine, 1999; Fiorentine & Hillhouse, 2000; Moos et al., 2001; Ritsher, McKellar, et al., 2002; Ritsher, Moos, & Finney, 2002), longer participation in AA made a positive contribution to alcohol-related, self-efficacy, and social functioning outcomes, over and above the contribution of treatment.

An initial episode of professional treatment may have a beneficial influence on alcohol-related functioning; however, continued participation in a community-based self-help program, such as AA, appears to be a more important determinant of long-term outcomes.

Moreover, compared with individuals who participated only in treatment in the first year, individuals who participated in both treatment and AA were more likely to achieve 16-year remission (i.e. still be in recovery) (Moos & Moos, 2005a).

In interpreting these findings, it is important to remember that participation in treatment likely motivated some individuals to enter AA; thus, some of the contribution of AA to 16-year outcomes should be credited to treatment. Another consideration involves the differential selection processes into treatment versus AA. Individuals with more severe alcohol-related problems tend to obtain longer episodes of treatment, but this selection and allocation process is much less evident for AA.

These divergent selection processes may help to explain the finding that AA is more strongly associated with positive long-term outcomes than is treatment.”

…keep making the meetings!

References

Moos, R. H., & Moos, B. S. (2006). Participation in Treatment and Alcoholics Anonymous: A 16-Year Follow-Up of Initially Untreated Individuals. Journal of Clinical Psychology, 62(6), 735–750. doi:10.1002/jclp.20259

 

A Brief History of Controlled Drinking – the Irrationality of Science

In a recent blog a few days ago I challenged some of Gabrielle Glaser’s “evidence” in her article   “The Irrationality of Alcoholics Anonymous “, which purported to demonstrate the so-called effectiveness of “controlling drinking”.

Glaser cited the following in her article

“ To many, though, the idea of non-abstinent recovery is anathema. No one knows that better than Mark and Linda Sobell, who are both psychologists. In the 1970s, the couple conducted a study with a group of 20 patients in Southern California who had been diagnosed with alcohol dependence.

Over the course of 17 sessions, they taught the patients how to identify their triggers, how to refuse drinks, and other strategies to help them drink safely. In a follow-up study two years later, the patients had fewer days of heavy drinking, and more days of no drinking, than did a group of 20 alcohol-dependent patients who were told to abstain from drinking entirely.”

I responded to this as follows

” What Glaser failed to mention was that in a subsequent study (4) 10-year follow-up of the original 20 experimental subjects showed that only one, who apparently had not experienced physical withdrawal symptoms (thus possibly not alcoholic), maintained a pattern of controlled drinking;

eight continued to drink excessively–regularly or intermittently–despite repeated damaging consequences;

six abandoned their efforts to engage in controlled drinking and became abstinent;

four died from alcohol-related causes;

and one, certified about a year after discharge from the research project as gravely disabled because of drinking, was missing.

Why did Glaser failed to mention this research, a follow up study to the one she mentions and cites?”

The authors attempted to justify this choice in a statement that seems to clearly demonstrate their bias: “we are addressing the question of whether controlled drinking is itself a desirable treatment goal, not the question of whether the patients directed towards that goal fared better or worse than a control group.. .” (Pendery et al., 1982, 172-173)

The interesting aspect about her article for me (and most worrying) was that it highlighted a controversy that goes back to the 1960s – can alcoholics ever control their drinking?

In this blog we will address the origins of this “controlled drinking debate” and demonstrated how it is a castle built on sand.

The original study which supposedly demonstrated so-called controlled drinking or asymptomatic drinking in it’s alcoholic participants did no such thing.

So we now have an ongoing debate about controlled drinking when it has continuously been based on dubious research, bogus findings and bad science.

It is the researchers that Glaser champions that could be accused of irrationality.

The methodological madness started way back in the 1960s.

 While scattered reports of controlled drinking outcomes had occasionally appeared in the scientific literature before 1962, most commentators date the beginning of the controlled drinking controversy to the publication that year of a paper entitled “Normal Drinking in Recovered Alcohol Addicts.” In this paper, D.L. Davies, a British psychiatrist, reports that, in the course of long-term follow-up of patients treated for “alcohol addiction” at Maudsley Hospital in London, 7 of the 93 patients investigated “have subsequently been able to drink normally for periods of 7 to 11 years after discharge from the hospital.” (Davies, 1962, p. 94).

At least two different studies have challenged the findings of Davies:-

“Evidence suggests that five subjects experienced significant drinking problems both during Davies’s original follow-up period and subsequently, that three of these five at some time also used psychotropic drugs heavily, and that the two remaining subjects (one of whom was never severely dependent on alcohol) engaged in trouble-free drinking over the total period”

http://www.ncbi.nlm.nih.gov/pubmed/4010292

“A subsequent follow-up of these cases suggested that Davies had been substantially mislead”

http://www.ncbi.nlm.nih.gov/pubmed/7956756

So four decades of research into controlled drinking were inspired by a study which did not actually demonstrate controlled drinking in the first place!

In addition to the Sobells, Glaser also mentioned the Rand Report of the 1970s.

“In 1976, for instance, the Rand Corporation released a study of more than 2,000 men who had been patients at 44 different NIAAA-funded treatment centers. The report noted that 18 months after treatment, 22 percent of the men were drinking moderately. The authors concluded that it was possible for some alcohol-dependent men to return to controlled drinking. Researchers at the National Council on Alcoholism charged that the news would lead alcoholics to falsely believe they could drink safely. The NIAAA, which had funded the research, repudiated it. Rand repeated the study, this time looking over a four-year period. The results were similar.”

The first Rand Report was attacked as being methodologically weak  – e.g  it suffered from sample bias (80% of subject dropped out).

The Rand Corporation did a follow up 4 years later.  This time they reported that a smaller figure of 14% of the sample  continued to drink in an unproblematic manner  but other researchers reanalyzing the data arrived at a corrected estimate of 3-4% of the sample were drinking in a nonproblematic manner.

3% is somewhat less than the 22% – why does Glaser not cite these other follow up studies again?  It is difficult to accept any of her arguments as  she picks only studies that support her biased arguments.

jaywalker-t-shirt-men-s_design

It was also noted that alcoholics can often be expected to drink in a non problematic manner for brief periods. In my own experience, I have often heard of alcoholics share about a relapse and state that they thought they had their alcoholic problem licked as they started off drinking in what appeared to be a controlled manner only to find in a matter of weeks that their alcoholism had progressed far beyond it’s original severity prior to the relapse. In other words it can take a relapse some weeks to kick start into even more profound alcoholism than previously.

Researchers need to spend more time around alcoholics to observe what we have learnt through very painful experience, instead of theorising about this reality from academic ivory towers.

As the Big Book of Alcoholics Anonymous states in Chapter 3  “Most of us have been unwilling to admit we were real alcoholics. No person likes to think he is bodily and mentally different from his fellows. Therefore, it is not surprising that our drinking careers have been characterized by countless vain attempts to prove we could drink like other people. The idea that somehow, someday he will control and enjoy his drinking is the great obsession of every abnormal drinker. The persistence of this illusion is astonishing. Many pursue it into the gates of insanity or death. We learned that we had to fully concede to our innermost selves that we were alcoholics. This is the first step in recovery. The delusion that we are like other people, or presently may be, has to be smashed. We alcoholics are men and women who have lost the ability to control our drinking. We know that no real alcoholic ever recovers control. All of us felt at times that we were regaining control, but such intervals –usually brief—were inevitably followed by still less control, which led in time to pitiful and incomprehensible demoralization. We are convinced to a man that alcoholics of our type are in the grip of a progressive illness. Over any considerable period we get worse, never better.”

 

Why Alcoholics Anonymous Works

A journalistic piece entitled,  “The Irrationality of Alcoholics Anonymous “, written by  Gabrielle Glaser, also harshly criticizes Alcoholics Anonymous. AA and similar 12-step programs.

I cite a blog on her criticisms here (1)

Why Alcoholics Anonymous Works

“Glaser’s central claim is that there’s no rigorous scientific evidence that AA and other 12-step programs work.

First, she writes that “Unlike Alcoholics Anonymous, [other methods for treating alcohol dependence] are based on modern science and have been proved, in randomized, controlled studies, to work.” In other words, “modern science” hasn’t shown AA to work.”

Glaser appears to lessen her argument by suggesting that AA is difficult to study (so how can she be so sure it is not effective then?).

” Alcoholics Anonymous is famously difficult to study. By necessity, it keeps no records of who attends meetings; members come and go and are, of course, anonymous. No conclusive data exist on how well it works.”

Equally there, in her world view, would also be no conclusive data to suggest if doesn’t work? So why make bold claims either way?

” In 2006, the Cochrane Collaboration, a health-care research group, reviewed studies going back to the 1960s and found that “no experimental studies unequivocally demonstrated the effectiveness of AA or [12-step] approaches for reducing alcohol dependence or problems.”

According to (1), Glaser is simply ignoring a decade’s worth of science, not only here but throughout the piece.

“No, that’s not true,” said Dr. John Kelly, a clinical psychologist and addiction specialist at Massachusetts General Hospital and Harvard Medical School. “There’s quite a bit of evidence now, actually, that’s shown that AA works.”

Kelly, alongside Dr. Marica Ferri and Dr. Keith Humphreys of Stanford, is currently at work updating the Cochrane Collaboration guidelines (he said they expect to publish their results in August).

” Kelly said that in recent years, researchers have begun ramping up rigorous research on what are known as “12-step facilitation” (TSF) programs, which are “clinical interventions designed to link people with AA.”

Dr. Lee Ann Kaskutas, a senior scientist at the Alcohol Research Group who has conducted TSF studies, suggest that TSF outperforms many alternatives.

“They show about a 10 to 20 percent advantage over more standard treatment like cognitive behavioral therapy in terms of days abstinent, and typically also what we find is that when people are engaged in a 12-step-oriented treatment and go to AA, they have about 30 percent to 50 percent higher rates of continuous abstinence,” said Kelly.”

The original Cochrane paper that Glaser cites came out before the latest round of studies did, so that research wasn’t factored into the conclusion that there’s a lack of evidence for AA’s efficacy. In a followup email, Kelly said he expects the next round of recommendations to be significantly different:

Although we cannot as yet say definitively what the final results will bring in the updated Cochrane Review, as it is still in progress, we are seeing positive results in favor of Twelve-Step Facilitation treatments that have emerged from the numerous NIH-sponsored randomized clinical trials completed since the original review published in 2006. We can confirm that TSF is an empirically-supported treatment, showing clinical efficacy, and is likely to result also in lowered health care costs relative to alternative treatments that do not link patients with these freely available recovery peer support services. Another emerging finding is that a central reason why TSF shows benefit is because it helps patients become actively involved with groups like AA and NA, which in turn, have been shown to enhance addiction recovery coping skills, confidence, and motivation, similar to professional interventions, but AA and NA are able to do this in the communities in which people live for free, and over the long-term.

In other words, the most comprehensive piece of research Glaser is using to support her argument will, once it takes into account the latest findings, likely reverse itself.”

In other words, it will also help contradict Glaser’s arguments.

“In an email and phone call, Glaser said that TSF programs are not the same thing as AA and the two can’t be compared. But this argument doesn’t quite hold up: For one thing, the Cochrane report she herself cites in her piece relied in part on a review of TSF studies, so it doesn’t make sense for TSF studies to be acceptable to her when they support her argument and unacceptable when they don’t.

For another, Kelly, Katsukas, and Humphreys, while acknowledging that TSF programs and AA are not exactly the same thing, all said that the available evidence suggests that it’s the 12-step programs themselves that are likely the primary cause of the effects being observed (the National Institutes of Health, given the many studies into TSF programs it has sponsored, would appear to agree).”

“It’s worth pointing out that while critics of AA point it as a bit cultlike…to the researchers who believe in its efficacy, there’s actually very little mystery to the process. “We have been able to determine WHY these 12-step facilitation interventions work,” said Kaskutas in an email. “And we have also been able to determine WHY AA works.”

Simply put, “People who self-select to attend AA, or people who are randomized to a 12-step facilitation intervention, end up having people in their social network who are supportive of their abstinence,” she said.

Reams of research show that social networks…are powerful drivers of behavior, so to Kaskutas — who noted that she is an atheist — the focus on AA’s quirks and spiritual undertones misses the point.

“When you think about a mechanism like supportive social networks, or the psychological benefit of helping others… they have to do with the reality of what goes on in AA, with people meeting others in the same boat as they are in, and with helping other people (are but two examples of these mechanisms of action),” she said.”

At the heart of recovery via 12 step groups may be because it “works for a lot of people, simply by connecting them to others going through the same struggles.”

 

 

France - Alcoholic Anonymous celebrates its 75th year

 

 

 

The Irrationality of Controlled Drinking?

The Irrationality of Controlled Drinking?

by alcoholicsguide

“Most of us have been unwilling to admit we were real alcoholics…Therefore, it is not surprising that our drinking careers have been characterized by countless vain attempts to prove we could drink like other people. The idea that somehow, someday, he will control and enjoy his drinking is the great obsession of every abnormal drinker. The persistence of this illusion is astonishing. Many pursue it into the gates of insanity or death.” (Alcoholics Anonymous, 1976, p. 30)

 

A number of very concerned people, people in recovery and family members of people in recovery have sent me a link to a journalistic piece entitled,  “The Irrationality of Alcoholics Anonymous “, written by  Gabrielle Glaser, who has moved onto writing about the highly emotive issue of alcoholism and so-called “controlled drinking” after having previously written on such diverse subjects as health and beauty, and interfaith marriage and appeared in magazines like Mademoiselle, Glamour, The Washington Post, and Health, among other publications.

They worry about the effect of this article may have on vulnerable alcoholics and new comers to recovery in particular.

In order to help newcomers and those out there in active addiction make an informed decision about an abstinence based recovery path, which is what I would strongly suggest for alcoholics, I will pick certain studies Glaser cites as being good example of research that demonstrate a return to controlled drinking in alcoholics and  why they are not.

I will then address many of her arguments  over the next series of blogs.

I believe there is no such phenomenon as a return to controlled drinking in alcoholics. To suggest otherwise is highly dangerous.

The Natural History of Alcoholism Revisited (1995) is a book by psychiatrist George E. Vaillant that describes two multi-decade studies of the lives of 600 American males, non-alcoholics at the outset, focusing on their lifelong drinking behaviours. By following the men from youth to old age it was possible to chart their drinking patterns and what factors may have contributed to alcoholism.

In other words, this studies show the “progression” of the disease of alcoholism.

The National Review hailed the first edition (1983) as “a genuine revolution in the field of alcoholism research” and said that “Vaillant has combined clinical experience with an unprecedented amount of empirical data to produce what may ultimately come to be viewed as the single most important contribution to the literature of alcoholism since the first edition of AA’s Big Book.”[1] Some of the main conclusions of Vaillant’s book are:

“Alcoholism can simultaneously reflect both a conditioned habit and a disease.”

That alcoholism was generally the cause of co-occurring depression, anxiety …not the result.

… it is therapeutically effective to explain it as a disease to patients. The disease concept encourages patients to take responsibility for their drinking, without debilitating guilt.

That there is as yet no cure for alcoholism…

That for most alcoholics, attempts at controlled drinking in the long term end in either abstinence or a return to alcoholism.

Successful return to controlled drinking is…just  a rare and unstable outcome that in the long term usually ends in relapse or abstinence, especially for the more severe cases.[48]

“by the time an alcoholic is ill enough to require clinic treatment, return to asymptomatic drinking is the exception not the rule.”[47]

Vaillant, when asked whether controlled drinkingis advisable as a therapeutic goal, he concluded that “training alcohol-dependent individuals to achieve stable return to controlled drinking is a mirage.”[47]

Glaser struggles with this concept of progression of alcoholism I feel in her article. She describes alcoholism as a spectrum when it is in fact more accurately a continuum – it not a static disorder but a disorder which has transitory phases, most commonly called use, abuse and addiction. If one does not understand this progression then they could be saying that abusers and not alcoholics can return to controlled drinking which is different. If that is even the case.

Some people can also  meet a diagnostic criteria for alcohol dependence for certain periods of time in their lives but are not alcoholic per se.  For example, they may be drinking heavily for a period of time due to a bereavement over the loss of a loved one.

As I will go into later in other blogs, neuroscience can certainly give us a good indication of the progression to chronic alcoholism in terms of brain imaging regions of the brain. A classic example is the switch in reward – motivation processing from the ventral to dorsal striatum in the brain of chronic alcoholics.

The dorsal striatum is more involved in compulsive behaviour common to endpoint addiction.

Other diagnostic help in assessing alcoholism in terms of chronicity is the severity of automatically occurring thoughts about alcohol related subject matter or obsessive thinking about drinking as measured by the Obsessive Compulsive Drinking Scale which also shows that more chronic alcoholics activate not only the dorsal striatum when viewing alcohol related cues but also obsessively think about these cues more also.

This the shift to dorsal regions of the striatum is reflected in cognitive terms and is also reflective of affective mechanisms such as a low heart rate variability which is a measure of emotion regulation in the face of these cues.

Alcoholics simply react differently to alcohol cues, salivate more etc than those who are not alcoholic. These measures are reflective to “that invisible line” alcoholics cross in switching for abusive to alcoholic drinking.

Unless scientific enquiry starts using these and other biomarkers of alcoholism it will be impossible for them to conclude that their studies are actually observing the behaviour of alcoholics. You can not predict behaviour accurately unless you have accurately defined what it is you are observing?

This is basic Science.

Glaser determines whether the people she is talking about are or were actual alcoholics by relying on self reports.

She also takes these people on face value although she may have heeded Vaillant when he suggests alcoholics present special challenges for researchers because they are good at concealing their drunkenness.[16] Vaillant asserts that “Alcoholics are expert forgetters,”[17] have inaccurate memories,[18] and give persuasive denials[16] that manifest “an extraordinary ability to deny the consequences of their drinking.”[19]

For the above reasons we have to be especially skeptical of studies supposedly about alcoholics. Most studies on alcoholics showing the markers I have mentioned above have no chance of returning to asymptomatic drinking whatsoever, to do so would lead to relapse and possible early death. This highlights the importance of detailed research, mainly because superficial research can have terrible if not life threatening effect on vulnerable alcoholics looking for help.

I will give an example of this by looking more closely at a study by certain researchers cited by Glaser in her article. To directly quote from Glaser’s article,

“ To many, though, the idea of non-abstinent recovery is anathema. No one knows that better than Mark and Linda Sobell, who are both psychologists. In the 1970s, the couple conducted a study with a group of 20 patients in Southern California who had been diagnosed with alcohol dependence.

Over the course of 17 sessions, they taught the patients how to identify their triggers, how to refuse drinks, and other strategies to help them drink safely. In a follow-up study two years later, the patients had fewer days of heavy drinking, and more days of no drinking, than did a group of 20 alcohol-dependent patients who were told to abstain from drinking entirely. (Both groups were given a standard hospital treatment, which included group therapy, AA meetings, and medications.) The Sobells published their findings in peer-reviewed journals.

In 1980, the University of Toronto recruited the couple to conduct research at its prestigious Addiction Research Foundation. “We didn’t set out to challenge tradition,” Mark Sobell told me. “We just set out to do good research.”

The Sobells returned to the United States in the mid-1990s to teach and conduct research at Nova Southeastern University, in Fort Lauderdale, Florida. They also run a clinic.”

What Glaser failed to mention was that in a subsequent study (4) 10-year follow-up of the original 20 experimental subjects showed that only one, who apparently had not experienced physical withdrawal symptoms (thus possibly not alcoholic), maintained a pattern of controlled drinking;

eight continued to drink excessively–regularly or intermittently–despite repeated damaging consequences;

six abandoned their efforts to engage in controlled drinking and became abstinent;

four died from alcohol-related causes;

and one, certified about a year after discharge from the research project as gravely disabled because of drinking, was missing.

Why did Glaser failed to mention this research, a follow up study to the one she mentions and cites?

Also why has Glaser not mentioned either that the the Sobells have stated since that it is those with less severe problems who often improve by moderating their drinking. Alcoholic abusers.

The Sobells’ implication – that the focus on non-dependent problem drinkers and on harm reduction could take the teeth out of the controlled drinking controversy – was again strangely also not mentioned by Glaser?

It is worth noting that some supporters of controlled or moderation drinking have also hidden their own difficulties with the drink. Audrey Kishline, the founder of Moderation Management (MM), a non-abstinence-oriented self-help group for individuals whose alcohol problems stop short of dependence, killed two people in a head-on vehicular collision with a not very moderate blood alcohol content measured at .26.

She started attending AA soon afterwards.

I will be dissecting the Glaser over the next few weeks – next up will be a blog on the infamous Rand Report of the 1970s and other studies which have purportedly demonstrated a return of controlled drinking in a small minority of so-called alcoholics?

 

Until then, all I can say is  a very heart felt but at the same time sad thank you to those friends in AA who were chronic alcoholics like me, who showed me what I need to know about this disease. They all relapsed and died,  to never become abstinent and in recovery again?

This was, is and will always be proof enough for me! Ultimately when it comes down to it, my experience and what my eyes see will always outrank academic theorising.

The BB states clearly ” If anyone who is showing inability to control his drinking can do the right-about- face and drink like a gentleman, our hats are off to him. Heaven knows, we have tried hard enough and long enough to drink like other people!”

What I am trying to do and will continue to do is demonstrate where research  is often inaccurate and sometimes downright dangerous.

Also, to end, these studies and diagnostic criteria all seem to focus on alcohol not the underlying condition of alcoholism. If alcohol was my only problem I would simply have stopped drinking as I stopped smoking, stopped taking drugs, stopped eating meat.

Going to an AA meeting and subsequently has shown me that I needed to accept first my alcoholism before accepting that alcoholism is more than alcohol, that I need a solution to my every day living problem.

I have a stress and emotional dysregulation problem, which precedes alcohol and which remains after alcohol.

Until we grasp, finally, what is wrong with alcoholics, we may be destined to go around in the same circuitous fashion.

AA has taught me how to live with others in this world, in a way I never previously could, and no amount of words can never convey how grateful I am for that blessing.

 

References

1. Alcoholics Anonymous. (2001). Alcoholics Anonymous, 4th Edition. New York: A.A. World Service

2.Vaillant, George E. (1995). The Natural History of Alcoholism Revisited. Cambridge, Massachusetts: Harvard University Press. ISBN 0-674-60378-8.

Vaillant, George E. (2003). “A 60-year follow-up of alcoholic men”. Addiction, 98, 1043–1051.

4. Pendery, M. L., Maltzman, I. M., & West, L. J. (1982). Controlled drinking by alcoholics? New findings and a reevaluation of a major affirmative study.Science, 217(4555), 169-175.

 

 

Childhood Maltreatment and later Alcoholism/Addiction

One old timer I know often says two things that I often take issue with – 1. there are as many alcoholisms as alcoholics and that 2. we all come to AA in different boats but end up in the same dock.

Thanks to having a wife in Al Anon I have had the benefit of her insight and from other al-anons who state how remarkably similar we alcoholics are in our behaviour, particularly in dealing/coping with distress and stress, our emotional reactivity and at times immaturity (or so-called defects of character), I disagree that we are so different in our addictive behaviours.

All addictive behaviours from alcoholism, substance addiction, eating disorders to hypersexual disorder seem to be based on an inherent problem with emotion and stress dysregulation.

I believe I have a distress based condition. It results in what appear to be distress based reactions such as perfectionism, distress intolerance and frustration intolerance, normally exemplified in my shouting at my PC when it doesn’t work quickly enough or crashes!

I also believe I have distress based impulsivity, I want that thing, whatever it is, NOW. That anything!

In fact I have noticed when I want something, anything, I end up pathological wanting it in no time at all! It seems then like I NEED it. I too think this is based on distress and heighten stress reactivity.

In fact it is through this pathological wanting that my so-called defects of character that my examples  of emotional dysregulation appear.

If I can’t get what I want, all range of negative emotions spill forth such as intolerance, impatience, arrogance, pride, shame, selfishness etc .  They only appear when I want something and you are getting in the way of me having it!!

So there is a link between my motivation (which is dysregulated due to the effects of chronic stress which turns simple wanting into something more akin to “needing”) and my subsequent emotional dysregulation.

So where does this distress come from? Is it purely the effects of chronic stress dysregulation caused by years of neuro toxic brain damage or does it go back further, into childhood?

I do not think we all have separate alcoholisms, I feel we have remarkably similar reactions to life and these centre on an inherent difficulty regulating stress and emotion.

I also believe we have come to recovery in similar boats. In fact the majority of us have come to recovery in a remarkable similar boat so much so that it would resemble a gigantic ship rather than a boat. That boat is the ship of childhood maltreatment.

Child maltreatment has been frequently identified in the life histories of adolescents and adults in treatment for substance use disorders, as well as in epidemiological studies of risk factors for substance use and abuse.

 Child Maltreatment

One study (1) suggests there is ample evidence exists for higher rates of substance abuse and dependence among maltreated individuals.

In clinical samples undergoing treatment for substance use disorders, between one third and two thirds evince child abuse and neglect histories (Dembo, Dertke, Borders, Washburn, & Schmeidler, 1988Edwall, Hoffman, & Harrison, 1989Pribor & DiWiddie, 1992Schaefer, Sobieragi, & Hollyfield, 1988).

In the US a survey of over 100,000 youth in 6th though 12th grade, Harrison, Fulkerson, and Beebe (1997) Harrison, Fulkerson, and Beebe (1997) found that those reporting either physical or sexual abuse in childhood were from 2 to 4 times more likely to be using drugs than those not reporting abuse; the rates were even higher for youth reporting multiple forms of child maltreatment. Similar findings have been reported by Rodgers et al. (2004) and Moran, Vuchinich, and Hall (2004).

Among youth with Child Protective Services documented maltreatment, Kelly, Thornberry, and Smith (1999) reported one-third higher risk for drug use among those with an abuse history. In a large epidemiological study, Fergusson, Boden, and Horwood (2008) have shown physical abuse and particularly sexual abuse to be related to illicit drug use, as well as abuse and dependence.

Another Study (2) study would suggest the figures are much higher –   data were collected on 178 patients–101 in the United States and 77 in Australia–in treatment for drug/alcohol addiction. The purpose of the study was to determine the degree to which a correlation exists between child abuse/neglect and the later onset of drug/alcohol addiction patterns in the abuse victims. The questionnaire explored such issues as family intactness, parental violence/abuse/neglect, parental drug abuse, sibling relationships and personal physical/sexual abuse histories, including incest and rape. The study determined that 84% of the sample reported a history of child abuse/neglect.

A third study (1) stated that, using the Childhood Trauma Questionnaire-Short Form (CTQ-SF; Bernstein & Fink, 1998; Bernstein et al., 2003) to assess childhood maltreatment in a community sample of active drug users, Medrano, Hatch, Zule, and Desmond (2002) found that 53% of women and 23% of men were sexually abused, 53% of women and 43% of men were physically abused, 58% of women and 39% of men were emotionally abused, 52% of women and 50% of men were physically neglected, and 65% of women and 52% of men were emotionally neglected.

Substance abusers, in addition to having higher rates of childhood maltreatment than members of the general population, have been found to have levels of psychological distress that increase with increasing severity of all types of childhood maltreatment (Medrano et al., 2002). This association is important considering that stress increases an individual’s vulnerability to addiction and addiction relapse (Goeders, 2003; Sinha, 2001;Wills & Hirky, 1996).

There is also evidence that the way in which people cope with stress is related to substance use. For example, researchers have found that greater use of avoidance stress-coping strategies (i.e., disengaging from investing effort to cope with a problem) is related to a greater likelihood of drug use initiation, higher levels of ongoing drug use, and a greater probability of relapse, whereas greater use of active stress-coping strategies (i.e., taking steps to deal with a problem) most consistently functions to protect individuals from substance use initiation and relapse (Wagner, Myers, & McIninch, 1999; Wills & Hirky, 1996).

Childhood maltreatment may influence substance use behavior through its effect on stress and coping. There is emerging evidence that childhood maltreatment may negatively affect the maturation of self-regulatory systems that enable an individual to modulate and tolerate aversive emotional states (Cicchetti & Toth, 2005; Hein, Cohen, & Campbell, 2005). Childhood maltreatment may disrupt neurobiological development and elevate subjective stress by biologically altering the brain’s response to stress (Bugental, 2004;DeBellis, 2002; Heim & Nemeroff, 2001; Heim et al., 2000; Sinha, 2005; Wills & Hirky, 1996). Childhood maltreatment may also affect an individual’s characteristic style of coping with stress so that he or she may be more likely to rely upon maladaptive strategies, such as avoidance of problems, wishful thinking, and social withdrawal, rather than active strategies, such as seeking information and advice from others (Bal, Crombez, Van Oost, & Debourdeaudhuij, 2003; Futa, Nash, Hansen, & Garbin, 2003; Krause, Mendelson, & Lynch, 2003; Leitenberg, Gibson, & Novy, 2004; Thabet, Tischler, & Vostanis, 2004).

Elevated stress and maladaptive coping related to childhood maltreatment may translate to greater substance use behavior by making the coping motives of substance use appear more attractive (Wills & Hirky, 1996). Indeed, substance users commonly report using psychoactive substances such as alcohol, cannabis, and cocaine to cope with stress and regulate affect (Boys, Marsden, & Strang, 2001)

Most cocaine dependent inpatients reported multiple types of childhood maltreatment, and only 15% reported no maltreatment at all, (similar figures to study 2).

“Our findings suggest that the severity of overall childhood maltreatment experienced by recently abstinent cocaine dependent adults has a significant relationship with perceived stress and avoidance coping in adulthood.

Our findings suggest that having a more severe childhood maltreatment history may result in a greater sensitivity to stress…basic coping skills training may not be adequate in decreasing distress and avoidant coping in order to decrease substance use and relapse. Additional interventions that focus on stress tolerance, altering appraisals of stress, stress desensitization, and affect and emotion regulation skills may be of particular benefit to patients with childhood maltreatment histories.

The fact that childhood maltreatment is a preventable phenomenon that occurs early in life and affects psychological functioning well into adulthood makes our findings relevant to clinical practice with children as well. Early identification and treatment of maltreated children may help prevent stress sensitivity or the development of a less adaptive style of coping. Assessment of coping ability and the implementation of coping skills and stress tolerance training may also be indicated for maltreated children in an effort to increase their coping efficacy and decrease their vulnerability to stress later in life.”

I may have been in recovery for a number of years now but coping with stress/distress is still central to my recovery. Dealing with the effects of childhood maltreatment not only via negative self esteem and self schema but in the real sense of coping with every day stress/distress, mainly prompted in my interpersonal relationships (other people!) and with my PC!

 

References

1. Rogosch, F. A., Oshri, A., & Cicchetti, D. (2010). From child maltreatment to adolescent cannabis abuse and dependence: A developmental cascade model.Development and psychopathology, 22(04), 883-897.

2. Cohen, F. S., & Densen-Gerber, J. (1982). A study of the relationship between child abuse and drug addiction in 178 patients: Preliminary results. Child Abuse & Neglect, 6(4), 383-387.

3.  Hyman, S. M., Paliwal, P., & Sinha, R. (2007). Childhood maltreatment, perceived stress, and stress-related coping in recently abstinent cocaine dependent adults. Psychology of Addictive Behaviors, 21(2), 233.

Abstinence is getting Sober, Recovery is getting Emotionally Sober.

A very interesting concept in recovery is the idea of Emotional Sobriety which originated with Bill Wilson who found that after 20 years of recovery he suffered badly from  depression. His decades long association with Dr Tiebout, his psycho-analyst, led him to conclude that this was partly due to how he reacted to people. He found he either tried to dominate them or emotionally depend on them.

This emotional immaturity is something we have discussed in previous blogs and may be related to an overall problem regulating our emotional behaviour.

Our emotional responses may be related to an inherent brain allostasis which seems to affect pathological wanting in various aspects of life (not just substances or behaviours – the illness of “more”), to the common emotional and stress dysregulation seen in addicts in active use and in recovery or to habitualized, maladaptive emotional responding which is the legacy of our previous active addiction, which in themselves may have been the consequence also of maladaptive self schemata borne out of childhood maltreatment, or insecure attachment or all these in combination.

As we grow older in recovery, hopefully we also emotionally  mature or become more adaptive or healthy in regulating our emotions and in our decision making and subsequent behaviour.

Ultimately how we deal with our emotions (or how they deal with us!) depends on our motivations.

Roger B offers some great insights into how to overcome this emotional neediness and live in a more emotionally sober way.

Sobering Stories – the role of “sharing” in recovery

Narratives of Self-Redemption Predict Behavioral Change and Improved Health Among Recovering Alcoholics

In our previous blog “Shame keeps you ill” we  looked at how  shame about addictive behaviors interferes with addicts’ recovery by increasing their propensity to engage in the shame-inducing behaviors. Specifically, the more shame behaviors individuals displayed, the more likely they were to relapse and decline in health within the next 4 months. These findings indicate that responding to past problematic drinking with pronounced behavioral displays of shame is a strong predictor of future drinking, and that shame about one’s addiction may be a cause of relapse.

The 12 steps ultimately deals with feelings of shame about previous behaviour by acceptance of your disease of addiction and by processing these shameful emotions by working the steps, particularly steps 4-7 and by making amends to those affected by our behaviour in steps 8-9.

This sense of self redemption brought via the 12 step program of recovery is also  reinforced by “sharing” our stories at 12 step meetings.  We share with others what it was like drinking, what happened for us to come into recovery and what it is like now for us in recovery (often referred to as one’s experience, strength and hope). These three part shares are ultimately stories of  self redemption. They are also part of the formation of recovering self schema.

Here in this blog we look at an academic study (1) which addresses the positive behavioural changes brought about by these self redemptive stories. The authors are the same as in our previous blog.

ex images

 

“The present research (1) examined whether the production of a narrative containing self-redemption (wherein the narrator describes a positive personality change following a negative experience) predicts positive behavioral change. In Study 1, we compared the narratives of alcoholics who had maintained their sobriety for over 4 years with those of alcoholics who had been sober 6 months or less. When describing their last drink, the former were significantly more likely to produce a narrative containing self-redemption than the latter. In Study 2, we examined the relation between the profession of self-redemption and behavioral change using a longitudinal design, by following the newly sober alcoholics from Study 1 over time.

Newly sober alcoholics whose narratives included self-redemption were substantially more likely to maintain sobriety in the following months, compared to newly sober alcoholics who produced nonredemptive narratives; 83% of the redemptive group maintained sobriety between assessments, compared to 44% of nonredemptive participants.

Redemptive participants in Study 2 also demonstrated improved health relative to the nonredemptive group.

Collectively, these results suggest that the production of a self-redemptive narrative may stimulate prolonged behavioral change and thus indicate a potentially modifiable psychological process that exhibits a major influence on recovery from addiction.

Humans are natural storytellers (Bruner, 1990). They construct stories to bring a sense of comprehension and coherence to the events around them. In the same vein, they construct life stories to bring comprehension and coherence to their lives (McAdams, 2001).

In recent years, there has been a shift in narrative research, toward the examination of how life stories influence certain life outcomes, most notably psychological adjustment (Adler, 2012). This transition is consistent with McAdams’s (1985, 1993) original conception of the life story as functional, serving, in essence, as the “story we live by” (McAdams, 1985, 1993). From this perspective, once a narrative about one’s past is constructed, an individual feels compelled to maintain congruence with this self-defining story or, in Giddens’s (1991) words, to “keep a particular narrative going” (p. 54).

 

France - Alcoholic Anonymous celebrates its 75th year

 

Interestingly, if this is the case—that personal narratives are developed for the purpose of providing direction to one’s life—then for those who create a story that professes positive or adaptive self-change following a negative or harrowing experience (i.e., redemption), the life story may function to promote not consistency in one’s behaviors but, rather, change. In other words, those who construct redemptive stories may be motivated to change their behaviors to align with the bettered self-image that is described.

As a result, upon constructing a story in which a bettered self emerges following adversity, narrators may actually become better, in part by reducing their engagement in problematic behaviors.

We investigated the relation between the narration of a positive self-transformation following a difficult experience and behavioral change, and we did so by examining stories and behaviors among a unique sample of individuals for whom these issues are likely to be particularly relevant, as they are seeking (or have sought) to dramatically change and improve their lives: recovering alcoholics.

These individuals represent an ideal population within which to test this relation, both because they are, by definition, actively seeking to change their lives and behaviors in a fundamental way, and because many self-help addiction recovery programs (e.g., Alcoholics Anonymous [AA]) encourage recovering addicts to develop coherent personal narratives about their addiction that climax with a positive personal transformation and successful recovery (Denzin, 2009; O’Reilly, 1997)…. that addicts’ behaviors will come to align with the narrative plot of the personal stories they create; that once a story detailing personal growth following abstinence is constructed, the story will come to influence the narrator, thereby stimulating the recovery process.

In the present research, we asked alcoholics who were members of AA to construct and narrate a story regarding a (potentially) critical moment in their lives—their last drink. In the minds of some, this drink represents the turning point at which commitment to sobriety is renewed and  and recovery is stimulated. In the minds of others, however, this drink simply represents the most recent lapse, one soon to be followed by a long line of others. Drawing on the theoretical work outlined above (e.g., Giddens, 1991; McAdams, 1985), we predicted that individuals who narrated stories depicting personal improvement following their last drink would exhibit a change in behavior consistent with this description (i.e., extended sobriety, improved general health), relative to those whose narratives did not reflect a sense of positive self-change.

Alcohol addiction is one domain in which the construction of a story containing self-redemption has been deemed particularly relevant (Diamond, 2001). Surveying the personal stories of a group of alcoholics who had repeatedly failed to maintain sobriety, Singer (1997) observed that these individuals tended to struggle when tasked with authoring a redemptive personal story. Similarly, in his psychobiography of George W. Bush, McAdams (2011) proposed that the formation of a redemptive life story may have played a role in Bush’s recovery from alcohol addiction.

Furthermore, in small-scale qualitative investigations of alcohol recovery programs such as AA, researchers have noted an emphasis on the construction of stories that are redemptive, in which the self and one’s life improve following sobriety (e.g., Denzin, 2009; O’Reilly, 1997). Indeed, the emphasis on striving for self-redemption is particularly apparent within AA, a self-help alcohol recovery organization boasting over 2 million members worldwide. This focus on positive transformation in the wake of alcohol addiction is manifest in the organization’s official guidebook (Alcoholics Anonymous World Services, 2004), which includes a collection of transformative life stories written by its members. This emphasis is also manifest in AA’s regularly held speaker meetings, at which members are encouraged to share their experiences pertaining to alcohol and addiction, and professions of self-redemption from consistently abstinent members tend to be particularly well received (Denzin, 2009). Indeed, it has been proposed that the purpose of these meetings is to reward and foster such stories, leading O’Reilly (1997) to assert that “there is really only one story in AA” (p. 24).

 

The present research demonstrated that (a) there is a strong association between the tendency to perceive past traumatic life events as resulting in positive personality change and corresponding behavioral change, and (b) the perception of positive personality change predicts subsequent positive behavioral change.

…alcoholics who had maintained sobriety for 4 years or longer were significantly more likely to describe their most recent drinking experience (prior to sobriety) as stimulating a positive development in the self, compared to alcoholics who had maintained sobriety for 6 months or less...newly sober alcoholics who perceived a sense of self-redemption in the wake of their recent sobriety demonstrated improved health months later, and were over twice as likely to have maintained sobriety across the two waves of assessment than those who did not evince any sense of self-redemption in their stories during the initial wave.

These results are suggestive of the possibility that developing a story of self-redemption about one’s addiction may be a causal factor underlying long-term behavioral change.

 

References

1.  Dunlop, W. L., & Tracy, J. L. (2013). Sobering stories: Narratives of self-redemption predict behavioral change and improved health among recovering alcoholics. Journal of personality and social psychology, 104(3), 576.