controlled drinking?

The “Yets” Illustrate the Progression Of Alcoholism.

Posted on by alcoholicsguide

In recent weeks I have queried the effectiveness of controlled or moderate drinking as a treatment for alcoholics.

I cite and use excepts from an article in The Fix on Audrey Kishline the founder of Moderation Management.

It is a very revealing piece, the extent of alcoholic denial and how this denial (or delusion) can manifest in the most elaborate plans to convince one they are not alcoholic is very apparent.

Secondly  she originally identified herself not as alcoholic but as a “problem drinker” because she had not gone as a far in her drinking or caused as much damage as other alcoholics she had met.

In AA parlance this is the “yets”, you haven’t gone as far in your drinking and related damage to yourself and those around you, yet!?

This use of the expression, the “yets” clearly shows the progression of this condition of alcoholism. The progression is often measured in terms of negative consequences experienced by the alcoholic and those loved ones around them or in the surrounding society at large.

Kishline did not advocate Moderation Management for alcoholics per se. Although this would not preclude it’s application with alcoholics as many alcoholics identify themselves as problem drinkers not alcoholics.

I was one of these people.

I did not know what the difference between alcoholic and problem drinker was and I am sure many other alcoholics are the same. Plus like many AAs, I thought AA could teach me how to drink in a controlled manner.

So many alcoholics want help moderating without realising this ship has sailed, that this treatment outcome is not realistic. That it is abstinence only if you have progressed to being an alcoholic.

So for Kishline to have said that it was not for alcoholics but only problem drinkers does not cut it for me.

“On December 19th, 2014, a 59-year-old woman almost nobody had ever heard of named Audrey Conn died in her mother’s home in Happy Valley, Oregon. Audrey Conn, however, was better known under another name: Audrey Kishline, the well-known founder of Moderation Management who later killed a 12-year old girl and her father while driving in an alcoholic blackout.

Moderation Management was founded by Audrey Kishline in 1994—it has been described by many as the first harm reduction mutual aid support group. (“Harm reduction” is an approach that seeks to reduce dangers posed by risky behavior through management of those behaviors, rather than abstinence.) Kishline identified herself as a “problem drinker”—not an alcoholic per se—and in 2006, 18 years later, said in an interview with Dateline, “Of course, after I had been there (rehab) for about a month, I said, ‘There’s no way I’m as bad as these people. They’ve lost their homes, their jobs, their this and their that. I’m not that bad. I’ve been mislabeled.’”

Moderation Management was born from her rejection of the label of “alcoholic,” and the goal of MM was to use cognitive-behavioral tools—a psychotherapy method that emphasizes practical problem-solving—to help problem drinkers achieve and sustain moderate, controlled alcohol use. And, in December of 1995, Kishline’s book Moderate Drinking: The Moderation Management Guide for People Who Want to Reduce Their Drinking was published.

The program offered online as well as face-to-face meetings, and Kishline was a spokesperson for the program as well as its most outspoken success story. Kishline was always careful to point out that MM was not intended for “alcoholics” but rather for “problem drinkers” and in her book said that those who were already sober were not encouraged to try MM.

Jeffrey A. Schaler, Ph.D (who wrote the introduction to Audrey’s first book—now removed in reprints—and also among the founders of MM) severed all ties with Audrey and MM in 1996.

Schaler agreed to be a part of the MM movement because he and Kishline were in agreement that there was no “disease” of alcoholism and all “problem drinkers” could learn to moderate.

As criticism of MM grew, Kishline began to speak out that MM was not meant for alcoholics (a designation Schaler and Kishline initially opposed) and that “alcoholics” should pursue the path of sobriety. In 1998, more controversy followed Kishline and MM.

What would become clear in the years following the founding of MM, however, was that Kishline’s own drinking—MM’s growing popularity and the success of her message notwithstanding—was “out of control.” By January of 2000, Kishline recognized—publicly—that despite MM’s philosophy and methods, for her, at least, it wasn’t working. She posted a message to an official MM email list, saying that she had concluded that her best drinking goal was abstinence, and that she would begin attending Alcoholics Anonymous, SMART Recovery, and Women for Sobriety meetings, while continuing to support MM for others. Her email read:

“Hello Everyone, fellow MMers,

I have made the decision recently to change my recovery goal to one of abstinence, rather than moderation.

 As you all know, Moderation Management is a program for beginning stage problem drinkers who want to cut back OR quit drinking.

 MM provides moderate-drinking limits based on research, and a fellowship of members who work the program’s steps together. Some of our members have been able to stay within healthy limits, some have not.

Those who acknowledge they cannot stay within moderate guidelines have always been encouraged to move on to an abstinence-based program. 

I am now following a different path, and to strengthen my sobriety I am attending Alcoholics Anonymous, but will also attend Women for Sobriety and SMART Recovery. I am sure I can learn much from all of these fine programs. 

Initial results from a National Institutes of Health funded study on MM out of Stanford University show that indeed members of MM are highly educated, have jobs, families, and most of their resources are intact. It is also very unlikely that they would define themselves as ‘alcoholic’ and, in fact, shun any program that would label them as such. But they are concerned about their drinking. They are attracted to MM because they know they will be allowed to take responsibility for making their own choice of recovery goals. 
For many, including myself, MM is a gateway to abstinence. Seven years ago, I would not have accepted abstinence. Today, because of MM, I do.

Whether abusive drinking is a disease or a learned behavior does not matter. If you drink too much and this is causing problems in your life, you need to do something about it. We’re intelligent people, but sometimes we need to quit debating in our heads, and look at what’s in our hearts.
 If you, like myself, find eventually that you cannot stay within our guidelines there is no shame in admitting this. In fact, it is a success.
 A big success, because you have found through our program what you need to do to really live life to its fullest. As Dr. Ernest Kurtz, one of the foremost experts on AA who wrote the forward to our handbook, once predicted ‘MM will one day refer more people to AA than any other program.’ He may be right!
 My heartfelt best wishes to each and every one of you as you discover your own recovery goal.

— Audrey Kishline; Founder, Moderation Management”

Two months later, on the way from her home outside Seattle to her father’s home in Spokane, Kishline drove her truck the wrong way down an interstate in Washington State. She hit another vehicle head-on, killing both the driver and passenger in the other car – Richard “Danny” Davis, 38, and his twelve year old daughter LaShell. Kishline’s blood alcohol content was 0.26 – more than three times the legal limit, and she admitted to “driving a hundred miles an hour in a total blackout,” causing the vehicular manslaughter.

In the 2006 Dateline interview, Kishline reversed much of what she’d said publicly about her own drinking in previous years, and during the rise of Moderation Management:

Dateline: As you look back on it, was MM something you devised to give yourself license to drink because you didn’t want to abstain?

Kishline: I do think that deep down as an addict that was the purpose.

Dateline:  All the good research that you did and the presentation of it to a national audience, it was really to justify it for you as a drinker.

Kishline:  It would legitimize my drinking.

Kishline was released on parole in August 2003, after serving 3 ½ years, but was unable to resist the temptation to drink, and one night, walked into a liquor store; a friend called her parole officer, and as any drinking was a violation of her parole, she returned to prison for 42 days. Kishline later said that this marked the end of her life with her family, although her marriage had already been crumbling prior to the accident. She and her husband divorced, and she began to live alone in Portland, Oregon. As a convicted felon, finding work was a struggle and it was only after months of fruitless searching that she finally found her first job—at a dry cleaner’s, a half-hour walk from her home. (Kishline was forbidden by the terms of her parole to drive, but she said that at the time she vowed never to get behind the wheel of a car again.)

In 2007, Kishline and Sheryl Maloy—the wife and mother of accident victims Richard Davis and 12-year-old LaShell—co-authored the book Face to Face,which chronicled both the fatal accident and the subsequent forgiveness and friendship that grew between the two women (Maloy had visited Kishlane in prison). In the book, Kishline frankly admitted that she was still drinking regularly…

Ironically, it seems a self-proclaimed alcoholic founded a program that works effectively for the problem drinker. The skill lies in identifying the difference.”

The last line is the heart of the issue.

Identifying someone as an alcoholic or self identifying as an alcoholic. There are a few diagnostic scales out there that can aid in this self diagnosis but as Kishline says herself this self diagnosis comes not from the head but from the heart, “sometimes we need to quit debating in our heads, and look at what’s in our hearts.
 If you, like myself, find eventually that you cannot stay within our guidelines there is no shame in admitting this. In fact, it is a success…”

In fact subsequent recovery continues this journey from a deluded head to a contented heart.  Who in there right mind would not want that?  

Reference

http://www.thefix.com/content/remembering-audrey-kishline#

 

Alcoholics Anonymous and Reduced Impulsivity: A Novel Mechanism of Change

Posted on by alcoholicsguide

Impulsivity or lack of behaviour inhibition, especially when distressed, is one psychological mechanisms which is implicated in all addictive behaviour from substance addiction to behaviour addiction.

It is, in my view, linked to the impaired emotion processing as I have elucidated upon in various blogs on this site.

This impulsivity is present for example in those vulnerable to later alcoholism, i.e. sons and daughters of alcoholic parents or children  from a family that has a relatively high or concentrated density of alcoholics in the family history, right through to old timers, people who have decades of recovery from alcoholism.

It is an ever present and as a result part of a pathomechanism of alcoholism, that is it is fundamental to driving alcoholism to it’s chronic endpoint.

It partly drives addiction via it’s impact on decision making – research shows people of varying addictive behaviours choose now over later, even if it is a smaller short term gain over a greater long term gain. We seem to react to relieve a distress signal in the brain rather than in response to considering and evaluating the long term consequences of a decision or act.

No doubt this improves in recovery as it has with me. Nonetheless, this tendency for rash action with limited consideration of long term consequence is clearly a part of the addictive profile. Not only do we choose now over then, we appear to have an intolerance of uncertainty, which means we have difficulties coping with uncertain outcomes. In other words we struggle with things in the future particularly if they are worrying or concerning things, like a day in court etc. The future can continually intrude into the present. A thought becomes a near certain action, again similar to the though-action fusion of obsessive compulsive disorder. It is as if the thought and possible future action are almost fused, as if they are happening in unison.

Although simple, less worrying events can also make me struggle with leaving the future to the future instead of endless and fruitlessly ruminating about it in the now. In early recovery  especially I found that I had real difficulty dealing with the uncertainty of future events and always thought they would turn out bad. It is akin to catastrophic thinking.

If a thought of a drink entered into my head it was so distressing, almost as if I was being dragged by some invisible magnet to the nearest bar. It was horrendous. Fortunately I created my own thought action fusion to oppose this.

Any time I felt this distressing lure of the bar like some unavoidable siren call of alcohol I would turn that thought into the action of ringing my sponsor. This is why sponsees should ring sponsors about whatever, whenever in order to habitualize these responses to counteract the automatic responses of the addicted brain.

I think it is again based on an inherent emotion dysregulation. Obsessive thoughts are linked to emotion dysregulation.

My emotions can still sometimes control me and not the other way around.

Apparently we need to recruit the frontal part of the brain to regulate these emotions and this is the area most damaged by chronic alcohol consumption.

As a result we find it difficult to recruit this brain area which not only helps regulate emotion but is instrumental in making reflective, evaluative decisions about future, more long term consequence. As a result addicts of all types appear to use a “bottom up” sub-cortical part of the brain centred on the amgydala region to make responses to decisions instead of a “top down” more cortical part of the brain to make evaluative decisions.

We thus react, and rashly act to relieve the distress of undifferentiated emotions, the result of unprocessed emotion rather than using processed emotions to recruit the more cortical parts of the brain.

Who would have though emotions were so instrumental in us making decisions? Two parts of the brain that hold emotions in check so that they can be used to serve goal directed behaviour are the orbitofrontal cortex and the ventromedial prefrontal cortex.

120px-Orbital_gyrus_animation_small2

 

These areas also keep amgydaloid responding in check. Unfortunately these two areas are impaired in alcoholics and other addictive behaviours so their influence on and regulation of the amgydala is also impaired.

This means the sub cortical areas of the amgydala and related regions are over active and prompt not a goal directed response to decision making but a “fight or flight” response to alleviate distress and not facilitate goal directed behaviour.

128px-Amyg

 

Sorry for so much detail. I have read so much about medication recently which does this or that to reduce craving or to control  drinking but what about the underlying conditions of alcoholism and addictive behaviour? These are rarely mentioned or considered at all.

 

We always in recovery have to deal with alcoholism not just it’s symptomatic manifestation of that which is chronic alcohol consumption. This is a relatively simple point and observation that somehow alludes academics, researchers and so-called commentators on this fascinating subject.

Anyway that is some background to this study which demonstrates that long term AA membership can reduce this impulsivity and perhaps adds validity to the above arguments that improved behaviour inhibition and reducing impulsivity is a very possible mechanism of change brought about by AA membership and the 12 step recovery program.

It shows how we can learn about a pathology from the recovery from it!

Indeed when one looks back at one’s step 4 and 5 how many times was this distress based impulsivity the real reason for “stepping on the toes of others” and for their retaliation?

Were we not partly dominated by the world because we could not keep ourselves in check? Didn’t all our decisions get us to AA because they were inherently based on a decision making weakness? Isn’t this why it is always useful to have a sponsor, someone to discuss possible decisions with?

Weren’t we out of control, regardless of alcohol or substance or behaviour addiction? Isn’t this at the heart of our unmanageability?

I think we can all see how we still are effected by a tendency not to think things through and to act rashly.

The trouble it has caused is quite staggeringly really?

Again we cite a study (1) which has Rudolf H. Moos as a co-author. Moos has authored and co-authored a numbered of fine papers on the effectiveness of AA and is a rationale beacon in a sea of sometimes quite controversial and ignorant studies on AA, and alcoholism in general.

“Abstract

Reduced impulsivity is a novel, yet plausible, mechanism of change associated with the salutary effects of Alcoholics Anonymous (AA). Here, we review our work on links between AA attendance and reduced impulsivity using a 16-year prospective study of men and women with alcohol use disorders (AUD) who were initially untreated for their drinking problems. Across the study period, there were significant mean-level decreases in impulsivity, and longer AA duration was associated with reductions in impulsivity…

Among individuals with alcohol use disorders (AUD), Alcoholics Anonymous (AA) is linked to improved functioning across a number of domains [1, 2]. As the evidence for the effectiveness of AA has accumulated, so too have efforts to identify the mechanisms of change associated with participation in this mutual-help group [3]. To our knowledge, however, there have been no efforts to examine links between AA and reductions in impulsivity-a dimension of personality marked by deficits in self-control and self-regulation, and tendencies to take risks and respond to stimuli with minimal forethought.

In this article, we discuss the conceptual rationale for reduced impulsivity as a mechanism of change associated with AA, review our research on links between AA and reduced impulsivity, and discuss potential implications of the findings for future research on AA and, more broadly, interventions for individuals with AUD.

Impulsivity and related traits of disinhibition are core risk factors for AUD [5, 6]. In cross-sectional research, impulsivity is typically higher among individuals in AUD treatment than among those in the general population [7] and, in prospective studies, impulse control deficits tend to predate the onset of drinking problems [8–11]

Although traditionally viewed as static variables, contemporary research has revealed that traits such as impulsivity can change over time [17]. For example, traits related to impulsivity exhibit significant mean- and individual-level decreases over the lifespan [18], as do symptoms of personality disorders that include impulsivity as an essential feature [21, 22]. Moreover, entry into social roles that press for increased responsibility and self-control predict decreases in impulsivity [16, 23, 24]. Hence, individual levels of impulsivity can be modified by systematic changes in one’s life circumstances [25].

Substance use-focused mutual-help groups may promote such changes, given that they seek to bolster self-efficacy and coping skills aimed at controlling substance use, encourage members to be more structured in their daily lives, and target deficits in self-regulation [26]. Such “active ingredients” may curb the immediate self-gratification characteristic of disinhibition and provide the conceptual grounds to expect that AA participation can press for a reduction in impulsive inclinations.

…the idea of reduced impulsivity as a mechanism of change…it is consistent with contemporary definitions of recovery from substance use disorders that emphasize improved citizenship and global health [31], AA’s vision of recovery as a broad transformation of character [32], and efforts to explore individual differences in emotional and behavioral functioning as potential mechanisms of change (e.g., negative affect [33,34]).

Several findings are notable from our research on associations between AA attendance and reduced impulsivity. First, consistent with the idea of impulsivity as a dynamic construct [18, 19], mean-levels of impulsivity decreased significantly in our AUD sample. Second, consistent with the notion that impulsivity can be modified by contextual factors [25], individuals who participated in AA longer tended to show larger decreases in impulsivity across all assessment intervals.

References

Blonigen, D. M., Timko, C., & Moos, R. H. (2013). Alcoholics anonymous and reduced impulsivity: a novel mechanism of change. Substance abuse, 34(1), 4-12.

A Brief History of Controlled Drinking – the Irrationality of Science

Posted on by alcoholicsguide

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.”

 

The Irrationality of Controlled Drinking?

Posted on by alcoholicsguide

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.