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Outcome research today is far more likely to scrutinize whether subjects have actually improved in the face of continued drinking. As controlled drinking itself became the focus of outcome results in Davies' study and the Rand reports, investigators became concerned to measure exactly the extent of controlled drinking, often employing extremely stringent criteria. Investigations such as Vaillant's [33] and Helzer et al.'s [35], for instance, had as primary foci the exact nature and extent of non-problematic drinking. The behavioral investigation of alcoholism has also had this effect, because this research turned to precise measures of consumption to replace vaguer psychological diagnoses [54]. Thus, Elal-Lawrence's CD research reported successful CD outcomes based exclusively on consumption measures. Paradoxically, the Sobells' research was a part of this process, because it used as its primary measure 'days functioning well'—which simply meant the combined number of days in which subjects either abstained or drank less than the equivalent of 6 oz of 86-proof alcohol.
Potential drawbacks of revised standards for controlled drinking
If rigorous current methodologies reveal earlier CD research to be seriously flawed, then it may be best to discard this research. Helzer et al. discounted 'the existing literature on controlled drinking because of small or unrepresentative samples, failure to define moderate drinking, acceptance of brief periods of moderate drinking as a stable outcome, failure to verify subjects' claims, and.... [inadequacy] of duration or subject-relocation rates' [35, p. 1678]. Another perspective, however, is offered by sociologists Giesbrecht and Pernanen, when they commented about changes they measured between 1940 and 1972 (including utilization of CD, abstinence and other remission criteria in research): 'that they are caused less by accumulating scientific knowledge than by changes in conceptions and structurings of research and knowledge' [8, p. 193].
Are there complementary costs to discounting much pre-1980s research on controlled drinking, along with the assessment methods the research relied on? In focusing solely on whether subjects can achieve moderation, or else discarding this goal in favor of abstinence, the alcoholism field has drastically de-emphasized issues of patient adjustment that do not correlate exactly with drinking behavior. Is it completely safe to assume that absence of drunkenness is the sine qua non of successful treatment, or can sober alcoholics manifest significant problems, problems that may even appear after the elimination of alcoholism? Pattison [55] has been the most consistent advocate of basing treatment evaluations on psychosocial health rather than on patterns of drinking, but for the time being this remains a distinctly minority position.
A related possibility is that patients may improve—in terms of their drinking and/or overall functioning—without achieving abstinence or strictly defined controlled drinking. This question is particularly relevant because of the low rates of successful outcomes (and especially of abstinence) reported by several important studies of conventional alcoholism treatment. For instance, the Rand reports found only 7% of clients at NIAAA treatment centers abstained throughout the 4-year follow-up period. Gottheil et al. [56], noting 10% was a typical abstinence rate among treated populations, pointed out that between 33 and 59% of their own VA patients 'engaged in some degree of moderate drinking' following treatment:
If the definition of successful remission is restricted to abstinence, these treatment centers cannot be considered especially effective and would be difficult to justify from cost-benefit analyses. If the remission criteria are relaxed to include moderate levels of drinking, success rates increase to a more respectable range.... [Moreover] when the moderate drinking groups were included in the remission category, remitters did significantly and consistently better than nonremitters at subsequent follow-up assessments. (p. 564)
What is more, the research and researchers that have been most prominent in disputing CD outcomes have themselves demonstrated severe limitations in conventional hospital treatment geared toward abstinence. For example, the Pendery et al. critique of the Sobells' work failed to report any data on the hospital abstinence group with which the Sobells compared their CD treatment group. Yet such relapse was common in the hospital group; as Pendery et al. noted, 'all agree [the abstinence group] fared badly' (p. 173). Relapse was likewise very evident among 100 patients Vaillant [33] treated in a hospital setting with an abstinence goal: 'only 5 patients in the Clinic sample never relapsed to alcoholic drinking' (p. 284). Vaillant indicated that treatment at the hospital clinic produced outcomes after 2 and 8 years that 'were no better than the natural history of the disorder' (pp. 284—285). Edwards et al. [57] randomly assigned alcoholic patients to a single informational counseling session or to intensive inpatient treatment with outpatient follow-up. Outcomes for the two groups did not differ after 2 years. It is impossible to evaluate CD treatments or patients' ability to sustain moderation without considering these limitations in standard treatments and outcomes.
The intense concentration on CD outcomes does not seem to be matched with comparable caution in evaluating abstinence outcomes and treatment. For example, Vaillant [33] also reported (in addition to his clinical results) 40 year longitudinal data on drinking problems in an inner-city group of men. Vaillant found that 20% of those who had abused alcohol were controlled drinkers at their last assessment, while 34% were abstaining (this represents 102 surviving subjects who had abused alcohol; 71 of 110 of the initial subjects were classified as alcohol dependent). Vaillant was not very sanguine about CD outcomes, however, particularly for more severely alcoholic subjects, because he found that their efforts to moderate their drinking were unstable and frequently led to relapse.
Vaillant defined men as abstinent who in the previous year were 'using alcohol less often than once a month' and 'had engaged in not more than one episode of intoxication and that of less than a week in duration' (p. 184). This is a permissive definition of abstinence, and does not correspond with either most people's commonsensical notions or the Alcoholics Anonymous (AA) view of what comprises abstinence. Yet controlled drinkers in this study were not allowed to show a single sign of dependence (like binge or morning drinking) in the previous year (p. 233). Making the definitions of relapse more equivalent would seemingly increase relapse for those called abstainers and decrease relapse among controlled drinkers (that is, increase the prevalence and durability of moderation outcomes).
The non-comparability of definitions may be even more severe in the case of Helzer et al. [35] in comparison with the Rand studies. In discussing outcomes for alcoholic hospital patients in a 5—8-year period (the abstract referred to a 5—7-year period) following hospital treatment, the Helzer group classified 1.6% as moderate drinkers. In addition, the investigators created a separate category of 4.6% alcoholic patients who had no drinking problems and drank moderately, but who drank during less than 30 of the previous 36 months. Lastly, these investigators identified as a separate group heavy drinkers (12% of the sample) who had had at least 7 drinks on 4 or more days within a single month in the previous 3 years. These drinkers had given no indication of having any alcohol-related problems, nor did the investigators find any records of such problems.
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