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In the view that alcoholism is a progressive condition, the individual who is not fully alcoholic may be a person at an early stage of the disease for whom drinking will inexorably lead to alcoholism. In practice, programs based on a disease model simply deal with all those who present themselves with alcohol problems as though they were alcoholics (Hansen & Emrick, 1983). (This is in contrast to the elaborate arguments made by abstinence proponents that any drinker who has had severe problems but who now drinks moderately could not have been genuinely alcoholic; cf. Pendery et al., 1982, p. 173.) Yet it is just these "early-stage" drinkers for whom controlled-drinking strategies have proven most effective. Indeed, most younger, socially stable problem drinkers reject abstinence therapies (Sanchez-Craig, 1980). Psychologists and sociologists argue that a national alcoholism policy geared toward the extremely alcoholic individual overlooks the vast majority of those with drinking problems, only a small portion of whom seek treatment (Marlatt, 1983; Room, 1980).
The Classification of Alcoholics
Some of those with drinking problems do better if they endeavor to abstain, and some do better if they try to moderate their drinking. In the absence of a clear distinction between these groups, abstinence tends to be encouraged for all, and therefore psychologists have led the effort to classify drinking problems in terms of the relative benefits of abstinence and controlled-drinking treatment aims (Heather & Robertson, 1981; Miller, 1983a). Severity of drinking problems or alcohol dependence is a major factor in such classification, with those whose drinking problems are worse generally faring better with abstinence. The severity factor does not overwhelm all other considerations, however. The Rand study found that single men under 40—even when highly dependent on alcohol—were more likely to relapse if they adopted an abstinence strategy than a controlled-drinking one (Polich et al., 1981). Abstinence is apparently less effective for younger, single men because it does not conform with their life-styles and the opportunities and pressures they face to drink. Age is an especially important factor in a person's ability to moderate drinking. For example, symptoms of alcoholism such as drinking blackouts in college show a negligible correlation with drinking problems for the same person 20 years later (Fillmore, 1975).
The drinker's self-conception of being an alcoholic also affects the course of drinking problems (Skinner, Glaser, & Annis, 1982). Subjective beliefs about the disease of alcoholism and about the nature of the person's drinking problem can be more important than objective levels of dependence for selecting treatment goals. Those who believe in the disease theory and that they are alcoholics have a poorer prognosis for controlled drinking (Miller, 1983a). Heather, Winton, and Rollnick (1982) found in Britain that alcoholic patients who did not believe or did not know about the theory that one drink leads to relapse were more likely than other alcoholics to be nonproblem drinkers 6 months after treatment. A scale measuring alcoholics' beliefs about alcoholism and their own drinking distinguished whether alcoholics, if they drank, relapsed to alcoholic drinking, whereas an objective measure of alcohol dependence showed no such relationship (Heather, Rollnick, & Winton, 1983). Vaillant (1983) discovered another factor that determined controlled-drinking versus abstinence outcomes for alcohol abuse: whether the drinker's ethnic group had a disease-like conception of alcoholism or whether it was simply concerned with the differences between moderate drinking and drunkenness.
In its early stages, the modern alcoholism movement relied on the individual's willingness to admit having an alcohol problem voluntarily (Room, 1983). The emphasis today in treatment is on confronting alcoholics' denial—their unwillingness to see clearly the nature of their drinking problems. When faced with a recalcitrant individual who has a lower level of dependence on alcohol, a self-conception of not being an alcoholic, or a group or ethnic identity that does not view alcoholism in terms of a disease, this approach pushes for a transformation of the person's belief system about drinking. This contrasts with a psychological tradition—represented by Rogerian, client-centered therapy—of accepting and using clients' conceptions of their situations. Miller (1983c) analyzed how working at cross-purposes with the client's conception of a drinking problem interferes with the motivation to change. Yet, although it is inconceivable that a therapist would urge someone who is endeavoring to abstain to drink socially, the reverse is standard procedure.
An over-reliance on "objective" assessments of appropriate treatment goals could similarly lead psychologists unwisely to deny their clients' self-selected goals for improvement. We see in fact that clients regularly act on their own agendas within a larger treatment framework. What may be so remarkable about the Rand results is that almost 40% of those who were being told to abstain and who were in remission at 4 years did so through modifying their drinking patterns on their own. Subjects assigned to the abstinence condition in Sanchez-Craig, Annis, Bornet, and MacDonald's (1984) study overwhelmingly rejected their assigned therapy goal and displayed as much moderate drinking as those being taught how to do so. On the other hand, controlled-drinking clients who subsequently chose to abstain have shown unusual success at abstinence (Miller, cited in "The Behaviorists," 1984).
Treatment, Self-Cure, and Denial
Although controlled-drinking therapies have demonstrated the most success of any approach to drinking problems, these assessment studies have not used no-treatment comparison groups (Miller & Hester, 1980). Cahalan (1970) found up to 50% natural remission from problem to nonproblem drinking within 4 years. Furthermore, brief controlled-drinking interventions have been as successful as elaborate ones (Miller, cited in "The Behaviorists," 1984; Nathan, 1980), suggesting that the client's motivation to change is the chief factor in the moderation of drinking. Major outcome studies that have used nontherapeutic (natural history) comparison groups, covered long follow-up periods, and taken into account environmental factors in clients' improvement have struggled to trace additional improvement to the therapy beyond the effects of life changes and the client's prior motivation (Baekeland, Lundwall, & Kissin, 1975; Gerard & Saenger, 1966; Orford & Edwards, 1977; Vaillant, 1983). Such findings have led Moos and Finney (1982) to challenge the whole idea that specific therapeutic interventions significantly alter a person's overall drinking career. From this point of view, the problem with both the Sobells' study and the Pendery et al. critique of it is that a brief period of laboratory training cannot possibly account for behavior up to 10 years later (Marlatt, 1983; Vaillant, 1983).
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