Morristown, New Jersey

American attitudes toward alcohol are paradoxical: we focus almost exclusively on abstinence, yet we frequently drink to excess. Every year $2 billion is spent advertising and promoting alcohol's intoxicating nature at the same time $10 billion is used to treat people who can't handle their liquor.

Still, Americans are drinking less these days—it's just that we're drinking worse. Individual consumption has declined 20 percent since 1980—from a high of 8.2 liters to a low of 6.6 liters in 1994. But the number of alcoholics and alcohol abusers—problem drinkers who don't go through withdrawal with abstinence but who do have social, legal and/or family problems as a result of their drinking—hasn't decreased.

The Young and the Excessive

Indeed, indications are that problem drinking is on the rise, especially among the young. Americans coming of age today seem to be drinking more excessively than previous generations.

• When over 17,500 college students were surveyed by social psychologist Henry Wechsler, Ph.D., and colleagues at the Harvard School of Public Health in 1993, 44 percent said they'd engaged in what Wechsler characterized as binge drinking during the prior two weeks. For men, this meant five or more drinks in a row; for women, four or more.
• The National Institute of Mental Health's 1991 Epidemiological Catchment Area (ECA) study intensively examined emotional and behavioral problems in five areas of the U.S. in the late 1980s. When it came to the prevalence of alcoholism and alcohol abuse, John Helzer, M.D., of the University of Vermont and his colleagues found that 27 percent of men age 18 to 29 either had abused alcohol or were alcoholics at some point in their lives, compared with 21 percent of men age 45 to 64, and only 14 percent of men age 65 and up.
• A recent report issued by Columbia University's Center on Addiction and Substance Abuse claims that women age 18 to 29 are now drinking almost as much as men. However, the ECA figure for lifetime abuse for women age 18 to 29 is 7 percent.

The Impetus for Abstinence

This increase becomes even more startling when you consider this country's Draconian drinking policies. The United States is the only Western country that restricts the purchase and public consumption of alcohol to adults age 21 and older. Countries as diverse as Switzerland, Britain, and Austria permit 16-year-olds to buy alcohol and/or drink in public, though many do require that a parent accompany quaffing kids.

In Portugal and Belgium, there are no age restrictions on purchasing or drinking alcohol, and in New Zealand, children of all ages can drink in public with their parents.

These countries believe that kids allowed to drink with their families become socialized to drinking moderately. In the United States, despite—or perhaps because of—continual admonitions not to drink, the young and inexperienced often go overboard.

Of course, our all-or-nothing approach to alcohol is rooted in America's tradition of temperance. But our obsession with inebriants didn't disappear with the repeal of Prohibition in 1933. In fact, when Alcoholics Anonymous (AA) was founded in 1935, it's credo, like that of the private alcohol sanatariums of the day, was abstinence. Then as now, AA saw alcoholics as "out of control," with treatments usually consisting of lectures and group confrontation sessions. Drinkers never fully overcome their problem; instead they are perpetually in recovery.

AA and its 12-step philosophy now dominate the entire U.S. alcohol treatment system, especially 28-day private hospital programs. This system, which is predicated on the notion that alcoholism is a disease, that cravings are inbred and cannot be modified, and that eliminating alcohol is the goal of treatment, appeals to something deeply American: our fear of alcohol and its power, and our almost fundamentalist moralism about liquor. What better than the edification of an individual by public confession and contrition?

The linking of nineteenth-century revivalistic Protestantism to alcohol problems has been a marketer's dream. In our minds, a connection has now taken hold that runs so deep it can never be broken, despite the fact that new ways of approaching alcohol treatment have been suggested for more than a quarter century.

In 1990, for example, the prestigious National Academy of Sciences' Institute of Medicine (IOM) convened a blue-ribbon panel on alcohol problems. The IOM's primary recommendation was to diversify the kinds of treatments available for alcohol problems. In particular, it found that most drinking problems are not serious enough to justify America's intensive, one-size-fits- all hospital treatment programs.

But there's barely been a shift in the way problem drinkers are treated, except for one significant change in treatment setting.

In 1986, University of New Mexico psychologists William Miller, Ph.D., and Reid Hester, Ph.D., reviewed all research comparing the results of intensive hospital treatment with those of less-intensive alternatives. They determined that both were equally successful. The few differences that were found favored the less-intensive treatments.

In part because of findings like Miller and Hester's—but also owing to pressures to reduce health care costs—90 percent of U.S. alcohol treatment now occurs in an outpatient setting. These programs remain geared towards AA, however, with abstinence as the sole goal of treatment.