“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.