In November, 1983, under assault for CD therapy, an international group of behavior therapists conducted a panel at the annual meeting of the Association for the Advancement of Behavior Therapy in Washington DC. Stanton finagled an invitation (joining Alan Marlatt, Bill Miller, Fanny Duckert, Nick Heather, Martha Sanchez-Craig, Mark and Linda Sobell) and delivered an audacious talk equating behavior therapy and God — both tell you the hardest way to do anything. In place of standard behavior therapy protocols, Stanton described natural processes by which people achieve remission. If only the Sobells had been listening, they could have cut short the ten years it took them to discover recovery without treatment. At the same time, Stanton's talk anticipated harm reduction, motivational interviewing, and just about every other current cutting edge idea in substance abuse treatment.

In G.A. Marlatt et al., Abstinence and controlled drinking: Alternative treatment goals for alcoholism and problem drinking? Bulletin of the Society of Psychologists in Addictive Behaviors, 4, 141-147, 1985 (references added to original)

Morristown, NJ

I have a new way to try to minimize some of the conflicts between different groups that are fighting in the alcoholism field. What I'm going to do today is I'm going to try to insult them both if at all possible, and so that way maybe create more of a middle ground. Alan [Marlatt] talked a lot about those people who are not seeking alcoholism treatment, the 80 percent, the silent majority. And I want to try and just reach out there and see what we know about those people because unfortunately all of the discussion that we've had today has been basically limited to people who come to us and seek help, and some people don't like to do that. And the way that we traditionally react to that fact is to say, "Darn those people. Don't they understand how much we can help them if they would just turn themselves over to us?" The evidence for that is not completely clear, and also I think, looking at that group out there gives us some other ways of getting a handle on some of the questions that have been introduced in this panel.

Let me illustrate my central theme by referring to a self-help book that I recently reviewed for a British publication, entitled Selfwatching which is by two eminent behavior therapists, Ray Hodgson and Peter Miller (1982). Selfwatching is a manual of behavioral techniques for combating addictive and compulsive behaviors. The term 'selfwatching' describes a behavioral approach where the individual notes when they engage in the problem behavior and they record how they feel at that time and they report what the situation is like. And that is part of an overall behavioral approach where people eliminate behavior through desensitization, and they develop alternative ways to combat stress, and they substitute newly learned healthy patterns of behavior, and they learn to anticipate and forestall relapse.

Among their many discussions of smoking cessation in that manual Hodgson and Miller mention one case of an individual who quit smoking by himself and that case was originally reported by Alan (Marlatt,1981) here. It's about a man who sort of had a vision of God in the middle of the night, and he was able to quit smoking because of that. Now, that's one view of how people quit smoking. Lots of people quit smoking on their own. Now, how do they do it? How many of them do we think had religious conversions, and how many of them, in the absence of going to behavior therapists cleverly on their own devise these kinds of self-help manuals and record all the times that they smoke and desensitize themselves? I don't believe, I really don't believe that that many of them did that. In talking to several of them I don't think that's the common way they do it. And actually I think there's something very similar about asking a behavior therapist how to do something and asking God, because both of them always tell you the hardest way to do it. That's why it's interesting to note that in the 1982 Surgeon General's report on the health consequences of smoking they report that outcomes are sometimes better with less rather than with more therapeutic contact. That's a pregnant quote, rather coy I think.

Recently, Stanley Schachter (1982) has done what I consider to be a landmark study on remission in smoking and obesity. And Schachter came to this research assuming that certain people never overcome overweight. That was the basic model he was working from. He found that in two community populations totaled, over 60 percent of those who said that they had either tried to quit smoking or to lose weight or to get down out of the obesity range had succeeded. In the case of smoking they'd done so on the average for over 7 years. Schachter found, although it's only a small part of his population, that those who did not seek therapeutic assistance did better than those who did. Can you beat that? Now, how much of this applies to alcohol, and what do we know about this with regard to alcohol?

One of the things that this has relevance to is the question of whether alcoholics as a specific identifiable group can return to controlled drinking. George Vaillant in a recent edition of the Harvard Medical School Newsletter, mentioned that he's never found a client that could do that. However, such outcomes regularly appear in natural history studies. They cannot be contravened; there's something that seems to be happening out there. Vaillant (1983) studied two groups of people, two large groups, three actually: a hundred alcoholism patients that he treated at his clinic. He notes, by the way, that they did not show a significantly greater improvement than did comparable groups of alcoholics who did not receive treatment. That's one of the first things that we get from his book. Secondly, he studied two groups: a college group, and an inner-city group of alcohol abusers. There were 110 alcohol abusers in the inner-city group, 71 of whom were alcohol dependent. At the last assessment 20 percent of this group were drinking moderately while 34 percent were abstaining. Now, most of these people had no formal therapeutic experience. Obviously the 20 percent doing controlled drinking were not heavily involved in Alcoholics Anonymous. Vaillant also reports that of the abstainers, 37 percent succeeded in abstaining wholly or in part through A.A. Thus even among the abstainers a good majority seemingly had no contact with, had no assistance from A.A.

Who are these people? What are they up to? Obviously, as we've seen, part of what's going on is that these people may not be comfortable with abstinence and that is why they're refusing to turn themselves in for therapy, because they can anticipate what they're going to hear there. However that's not the only thing that's going on. A lot of the controlled drinking outcomes that we encounter, such as the ones reported in the Rand report (Armor et al., 1978) and the ones originally reported by David Davies in 1962 that created such a furor, were people who had been exposed, who had been engaged in abstinence oriented treatment, and who became controlled drinkers anyhow. Those people go into therapy and they kind of nod their head and agree about the value of abstinence therapy and then they go out and they live their lives, and they project their own desires and their own values. Now among this 63 percent even of the abstainers who do not seek A.A., what's on their minds? What's going on with them?