The afterword was added in September 1996 when the article was included in this website.

The Consensus Against Controlled-Drinking Therapy in America

Morristown, New Jersey

Abstract

Controlled drinking has long been rejected as a therapeutic goal in traditional American alcoholism treatment. More striking has been the adoption of this position by behaviorists who once fostered controlled-drinking (CD) therapy, such as Peter Nathan, former director of the Rutgers Center of Alcohol Studies. This shift has occurred even while the evidence for rejecting the value of moderation training is unclear. Rather than being justified empirically, this rejection must instead be understood as a strategy behaviorists have used to jettison a politically explosive element in the behavioral package in order to gain overall acceptance for the behavioral approach to treating alcoholism. However, this strategy entails significant scientific, clinical, social, and ethical costs.

Again and again there comes a time in history when the man who dares to say that two and two make four is punished with death. The schoolteacher is well aware of this. But the question is not one of knowing what punishment or reward attends the making of this calculation. The question is that of knowing whether two and two do make four.

Albert Camus, The Plague

In a 1989 book applying social-learning and behavioral techniques to treatment of alcohol dependence, Monti, Abrams, Kadden, and Cooney (1989) dispatched the controlled-drinking issue quickly and firmly (p. 189).

We believe that the overwhelming data to date do not argue for controlled drinking as a viable treatment for individuals diagnosed with alcohol dependence (Foreyt, 1987). Nathan (1986) states:

The consensus among informed observers is that alcoholism treatment with controlled drinking as a prime treatment goal is neither efficacious nor ethical when offered to chronic alcoholics....the weight of the available data now suggests both that we have not developed treatment programs that can reliably teach chronic alcoholics to become controlled drinkers and that status as a controlled drinker is not in the best interests of most chronic alcoholics. (p. 44)

For a more comprehensive review of the issues and research studies involving controlled drinking, see Heather and Robertson (1983).

Monti et al. argue from authority, without discussing the evidence, in rejecting CD therapy. Their principal authority is Peter Nathan, a leading behaviorist and former controlled-drinking therapy advocate who became an outspoken critic of CD therapy after becoming director of the Rutgers Center of Alcohol Studies in 1983 (Nathan resigned this position in 1989). For his part, Nathan (1986) proposes as the primary standard for accepting CD treatment that such programs "reliably teach chronic alcoholics to become controlled drinkers," implying that programs exist for reliably teaching chronic alcoholics to abstain.

Monti et al. concluded their argument with a reference to Heather and Robertson (1983), British researchers who might seem to be part of "the consensus among informed observers" and to present some of the "overwhelming data" to refute the value of CD therapy. In fact, the referenced volume, Controlled Drinking, supports the application of controlled-drinking in alcoholism treatment, and not "only to those with less serious problems. The controlled drinking treatment goal has a much more important role to play than this" (p. viii). Heather and Robertson described 26 studies that have applied CD methods with clinical populations, and found strong evidence that, "Many seriously dependent alcoholics respond to certain controlled-drinking treatments by successfully controlling their drinking" (p. 200). The volume also added to the 74 publications cited by Pattison, Sobell, and Sobell (1977) that have uncovered a return to controlled drinking by former alcoholics who did not receive CD therapy.

Monti et al.'s confident assertion of a consensus against CD therapy for alcoholics, a consensus announced by Nathan, is the focus of the current article. This focus includes two topics: (a) Whether CD therapy has been broadly rejected in the United States on the basis of the evidence, or whether political and economic pressures have moved many behaviorists to reject CD therapy, and (b) as an example of how science does not occur in a vacuum, the forces at work in Peter Nathan's turnabout on CD therapy, from a position until about 1980 of openness to the evidence and endorsement of the therapy's value, to a position in the mid-1980s of actively discouraging the practice of CD therapy.

Why Are Behaviorists So Sensitive About Controlled Drinking?

That Monti et al. did not seriously evaluate the evidence on controlled drinking in a book on behavioral treatment of alcohol dependence indicates the highly charged nature of this issue for American behaviorists. The application to alcoholism of the social-learning approach, with its emphasis on self-regulation skills, would seemingly compel consideration of moderation training. Monti et al. acknowledged that: "Controlled or social drinking, rather than total abstinence, would be a logical extension of the coping skills approach." Yet, these authors relegated controlled drinking to a parenthetical discussion on page 189 of a 192-page book. In his foreword to the book, Marlatt confronted the issue more directly: "readers who are unfamiliar with the cognitive and behavioral skills training approach to alcohol dependence may be surprised to find these methods can be used in support of an abstinence goal [because] many popular accounts have equated behavioral approaches with a controlled drinking goal."

As Marlatt indicates, behaviorists have special reasons to be sensitive to being labelled as supporters of controlled drinking. The progress of Nathan's career traces this sensitivity as well as the rise and decline of controlled-drinking therapy. Nathan became the first behaviorist (or clinician of any kind) to head the Rutgers Center, the flagship of academic alcohol studies programs. Nathan's early research observed alcoholics' drinking in the laboratory setting (Nathan & O'Brien, 1971). This popular experimental paradigm was employed in the early 1970s by Mello and Mendelson (1971), Marlatt, Demming, and Reid (1973), the Baltimore City Hospital group (Bigelow, Liebson, & Griffiths, 1974; Cohen, Liebson, Faillace, & Allen, 1971), and the Jefferson Medical College group (Gottheil, Murphy, Skoloda, & Corbett, 1972). Such research conclusively demonstrated that (a) alcoholics do not drink excessively due to an inherent, biological inability to control their drinking and (b) that, instead, alcoholics drink purposely to attain desired feelings and that they respond to environmental cues and rewards even when they have been drinking or are withdrawing from previous intoxication.