Denial - of Reality and of Freedom - in Addiction Research and Treatment

Written by Stanton Peele

Afterword added 1996

Morristown, New Jersey

Abstract

Drug and alcohol use are emotional topics, particularly in the United States today. Those who study and treat substance abuse must navigate extremely tricky waters. Among the most dangerous areas for psychologists are controlled drinking by former alcohol abusers and controlled use of illicit drugs such as cocaine and narcotics. Popular beliefs in this country, which strongly oppose these conceptions and the data that underlie them, have had a major impact on professional attitudes and policies. While it is risky to discuss such outcomes or to accept that clients may be capable of them, there are extreme dangers in denying their existence. The inability to air these issues is a mark of our society's failure to stem substance abuse.

Personal and Historical Background

I arrived at the study of addictive behaviors by an unusual route. I didn't study addiction in an academic or clinical program. In fact, I came to addiction as a social psychologist and not as a clinician, and my ideas often diverge from those of other psychologists who study and treat addiction. The impetus for my entrance into the field was my observations about the compulsive love relationships many young people of my era (the sixties) formed and about the ways in which drug use by my peers and others often did not conform with popular stereotypes about these substances. These observations forged the basis for a book, Love and Addiction, which drew me into the substance abuse field and its clinical concerns and emphases.

I began lecturing at addiction workshops and conferences, first at a local level and in continuing education programs, then at national (and some international) conferences. My appeal at these conferences was, I believe, my ability to translate social scientific research into experiential terms that clinicians could utilize, along with my very broad view of the nature and sources of addiction. At the same time, I quickly realized that these new settings in which I found myself differed very substantially from my staid academic background. For example, very shortly into the first extension course I taught, one woman rose and said she had to leave or otherwise she would have to kill either herself or me. Although the class ("Social and Psychological Aspects of Addiction") was part of a certificate program in alcoholism counseling, I discovered that many in the class were former alcoholics without any psychological training who differed markedly in their approach to learning from ordinary students or therapists in training.

Because most of these people were wedded to a particular view of alcoholism and addiction (indeed, they felt their sobriety depended on this view), open discussions about many topics were not possible. The chief of these restrictions was against questioning the validity of the disease theory of alcoholism and its hallmark, the necessity of complete abstinence for alcoholics. Thus the typical counselor emerges from such programs completely innocent of any other point of view than the disease perspective. In this way, major institutions of higher education lend their imprimatur to programs that do not meet fundamental requirements of an open educational process. If social-scientific researchers with opposing viewpoints appear at such programs (and generally they do not), they learn, as I did, to censor unpopular views that their audiences might choke on.

The views I expressed in the mid-1970s that were must controversial to the general public were not about alcoholism but rather concerned the nonaddicted use of narcotics. Since I understood addiction to be the result of a complex interaction of culture, immediate environment, individual disposition, and substance, data on the controlled use of narcotics made good sense to me. At the time I wrote Love and Addiction, the data about Vietnam veterans' narcotics use was becoming evident—data disconfirming all conventional pharmacological notions of narcotic addiction. Conducted under a team headed by Lee Robins, this research discovered that fewer than 10% of the veterans who used narcotics stateside became addicted. Among those soldiers who had been addicted in Vietnam, 61% of whom used a narcotic and 43% of whom used heroin stateside (including quite a few regular users), only 12% became readdicted in the United States (Robins et al., 1980).

Perhaps the most startling aspect of these data was how little impact they had on popular, clinical, and even research-oriented conceptions. Although these data were based on an unusually thorough investigation of a highly publicized subject group about which great concern was demonstrated, their implications were for the most part ignored. These implications concerned, first, the extent of nonaddicted heroin and other street narcotics use, and, second, the likelihood of recovery from addiction without abstinence. Furthermore, unless one accepted that alcoholism was essentially different in nature from narcotic addiction (which I did not), these data seemed also to reflect on the possibility of alcoholics' return to controlled drinking.

During the same period when the Robins group published its findings on Vietnam veterans, two sociologists and a psychologist at the Rand Corporation published their findings on outcomes at National Institute on Alcohol Abuse and Alcoholism treatment centers. The first of the two Rand studies (Armor et al., 1978) reported that those in remission at 18 months were as likely to drink without problems as to maintain stable abstinence. The reaction to this study when it appeared in 1976 was stunning. The June 12, 1976 issue of the Los Angeles Times carried a front-page story reporting that the California Alcoholism Advisory Board had declared the Rand study "methodologically unsound and clinically unsubstantiated" and indicated that "the lives of many persons with this disease are now endangered" (Nelson, 1976). On June 23 Ernest Noble, the Director of the NIAAA, released a bulletin expressing distress at the report's findings since they had "the potential for affecting so many lives in a negative manner." The National Council on Alcoholism presented a press release and convened a press conference in Washington on July 1 condemning in brutal terms the value and impact of the study (see Armor et al., 1978, Appendix B).

The modern alcoholism movement in the United States is directly descended from the temperance movement. As embodied by Alcoholics Anonymous and the National Council on Alcoholism, it is built on unquestioning dedication to abstinence. In no other country in the world do recovering alcoholics, AA, and abstinence dominate treatment for alcoholism the way they do in the United States (Miller, 1986). An indication that different climates of opinion on these questions exist in other countries comes from the British National Council on Alcoholism, which declared that "controlling one's drinking pattern and thereby one's behavior may be an alternative which many people prefer, and are able to achieve and sustain, and for this reason they deserve our support and guidance" (Boffey, 1993, p. C7). Fanny Duckert, a Norwegian researcher, described her approach to therapy: "It might be easier to agree upon a goal that states 'we want to reduce alcohol consumption, and we want to reduce problems connected with drinking.' But one can have this reduction in different ways ... For me it's not a dramatic difference between not drinking altogether, or reducing alcohol consumption to a level that's not going to create problems" (Marlatt et al., 1985, p. 132).