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One of the things that seems to be taking place again, in addition to the possibility that they might want to drink, is the fact that they do not like to call themselves alcoholics. Now we have a reaction to that, and to me it's sometimes rather similar between disease-oriented therapists and non-disease oriented therapists. Our reaction is to say, "Don't you realize you have a problem, you see, and this is the nature of your problem, and you're denying your problem and this is what you should do about it." That's a somewhat different model from how we approach many other kinds of therapeutic issues, and I was very glad to hear Fanny Duckert address that. I mean, what happened to Rogerian psychology, where we say to people, "What's your understanding of your situation? What's your understanding of what's going wrong in your life? And what's your understanding of some of the ways that you can progress in dealing with that?"
We're going against that even in psychology by saying, "Our main aim is to categorize people and decide what is going to work best for them." What's happening by the fact that we're not including these people who don't go into therapy, is that we're losing sight of the fact that many people are perfectly willing on their own, even when they go into therapy, as in the Rand reports (Armor et al., 1978; Polich et al., 1981), to define their own goals and pursue them on their own whether they don't enter therapy at all or whether they bend the recommendations that people are giving them to assert the kinds of aims that they want. And so the thing I want to question most strenuously is something that Vaillant, I think rather oddly derives from his own analysis which is that the major benefit of therapy under the medical model is that it gives people a chance to identify themselves as having a problem and then turn themselves over to treatment.
Let me say a little bit more about the Vaillant study because it's very interesting, because the Vaillant study is being presented as a very strong defense for the medical model. Now as I mentioned, among the inner-city group Vaillant reports that 20 percent are drinking moderately and 34 percent are abstaining. Vaillant is very critical of the Rand report definitions, and the second Rand report (Polich et al., 1981) defined controlled drinking as being no problem drinking episodes — dependence or problems from drinking — in the previous 6 months. Vaillant defines it as no incidents of these kinds in the previous year. However, those that he defines as abstainers are allowed to have had up to a week of alcoholic binge in his definition. But more important than those differences is the fact that Vaillant defines abstinence as drinking less than once a month. So we could apparently eliminate a whole host of the arguments that exist out in our field and I think go along with a lot of the things people have said here by just saying, "Well wait. If that's abstinence, well, I thought you meant abstinence. You mean 'abstinence.' Oh — That's where the person's trying not to drink but they sometimes don't quite make it." (Don't we all.) That's a whole different way of thinking about abstinence.
I think there have been some very interesting points that have come our of what has been said here thus far. Particularly, I think one of the most fascinating is Martha's study. If you'll recall, what Martha Sanchez-Craig (Sanchez-Craig et al., 1984) found is that: you take two groups of people and you tell one of them they should abstain and you tell the other group about controlled drinking and give them techniques for how to do that. Well, the results are, at 6 months, 12 months, 18 months, and 24 months, that although there is a significant reduction in drinking among both groups, there is not a significant difference in abstinence between the groups. Here we see people in action working through in their minds what's going to work for them, what's going to be the best benefit to them. What this really suggests to us, and again I think it came out in several of the other studies, that the key ingredient is the individual's motivation. The key ingredient to making anything work is the person identifying with the goals of therapy and really wanting to do something about them.
There's one other aspect besides an individual's motivation that I think we cannot avoid comprehending when we're trying to deal with people with all kinds of addictive problems. That's something that Vaillant talked about quite a bit in his book, and so did Gerard and Saenger (1966): recovery from alcoholism resulted in most cases from a "change in the alcoholic's attitude toward the use of alcohol based on a person's own experiences which in the vast majority of cases took place outside of any clinical interactions." And we don't know enough about what people are feeling and experiencing out there.
I just want to mention one study which I think perhaps is focused on that perhaps better than any other, and that's Barry Tuchfeld's study of natural remission in alcoholism. Tuchfeld, in 1981, published a study where he found 51 people who had had severe drinking problems involving blackouts and loss of control, and at the present time 40 were currently abstinent and 11 were drinking moderately. And these subjects often described a moment of truth when they all of a sudden saw their life in a very clear way which caused them to change their behavior. And actually this has a very distinct parallel to things we hear about in A.A. One pregnant woman remembers drinking a beer one morning to pacify her hangover and she said, "I felt the baby quiver and I poured the rest of the beer out, and I said, 'God, forgive me. I'll never drink another drop.' And from that day to this I haven't."
Parenthood and motherhood is very significant in a lot of cases of natural remission, I found, in addictions of all sorts. However, that implies a very specific event, a very monumental kind of situation. When you're pregnant — hey, that's heavy. There are situations reported throughout Tuchfeld that are very significant to the individual and yet which have no objective correlate. Which just reminds us how important subjective assessment of self and situation is. Nick Heather was referring to a study which he did where your belief about whether you're an alcoholic or how physically dependent you are is far more important in predicting whether you will relapse after drinking than any attempt to objectively assess your level of dependence (Heather et al., 1983). So one man said, "I drank a fifth and a half and I told them that night that when I drank this I'm not going to drink anymore, and I haven't had a drop since." It's that simple. If we could only find out how he did it, huh?
Another thought, "My God, what am I doing here? I should be home with my children." And we could tell them how to do it — these guys heard this a million times before, haven't they? And so much of our therapy is designed for denying this fact of self-cure — we're denying, not the clients. They say this and they make it stick at some moment in their lives. And one of the most, I think, important things that comes out of the Tuchfeld data is the fact that many of the people who are doing this revel in their self-efficacy. We've got one guy down there who said, "People told me I could never quit drinking on my own." He lifts his hands up and says, "I'm the champ. I'm the greatest. I did it on my own."
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