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Page 7 of 11
Treatment cultures
One of the remarkable aspects of the Rand studies was that so much controlled drinking appeared in a patient population treated in centers where abstinence almost certainly was emphasized as the only acceptable goal. The first Rand report contrasted those who had minimal contact with treatment centers and those who received substantial treatment. Among the group with minimal contact who also did not attend AA, 31% were normal drinkers at 18 months and 16% were abstinent, while among those who had minimal contact and attended AA, there were no normal drinkers. Several other studies have found less contact with treatment agencies or AA is associated with greater frequency of CD outcomes [12,29,68]. Similarly, none of Vaillant's clinical population became controlled drinkers; among those in his community population who did so, none relied on a therapy program.
Pokorny et al. [10], on the other hand, noted with surprise that they found so much controlled drinking among patients treated in a ward that conveyed the view that life-long abstinence was absolutely necessary. In the Pokorny et al. study, abstinence was the typical form of remission immediately after discharge, while controlled drinking became more evident the more time that had elapsed since treatment. This pattern suggests more controlled drinking will appear the longer patients are separated from abstinence settings and cultures. In an unusually long (15 year) follow-up reported in the 1970s, Hyman [69] found as many treated alcoholics were drinking daily without problems as were abstaining (in each case 25% of surviving ambulatory subjects). This and other findings from recent long-term follow-up studies [39,40] directly contradict the notion that controlled drinking becomes less likely over the life span.
Similar increases in controlled drinking over time have also been noted in patients treated with behavior therapy aimed at controlled drinking [41]. The learning theory interpretation of these data is that patients improve with practice their use of the techniques they have been taught in therapy. One interpretation, however, can account for long-term increases in controlled drinking after both kinds of therapy: the longer people are out of therapy of any kind, the more likely they are to develop new identities other than those of alcoholic or patient and thereby to achieve a normal drinking pattern. This pattern will not appear, of course, when patients continue to be involved (or subsequently become involved) in standard abstinence programs. For example, nearly all patients in the Sobells' study later entered abstinence programs, as a result of which many patients actively rejected controlled-drinking and the therapists who taught it to them when questioned later [70].
Nordström and Berglund found abstainers reported less internal control of behavior and less social stability. In this long-term follow-up study of a treated population, abstinence outcomes prevailed initially and those who became controlled drinkers showed little improvement after treatment, despite advantages (such as social stability) that ordinarily predict favorable treatment outcomes. However the majority of the subjects who achieved remission gradually shifted from alcohol abuse to controlled drinking, in most cases 10 and more years following treatment. Since average age of onset of problem drinking was nearly 30, with treatment following on the average 5 years later, CD remissions apparently occurred most often when subjects were 50 and 60 years old. Indeed, this corresponds with the age period when a large number of untreated drinkers show remission for their drinking problems [71]. In a sense, Nordström and Berglund's subjects seem to have relied on their social stability and internal behavioral orientation to reject treatment inputs and to persevere in their drinking until it attenuated with age.
The analyses by Elal-Lawrence et al. [42] and by Orford and Keddie [43] suggest different possibilities for the reduction of controlled-drinking through participation in abstinence programs. Elal-Lawrence emphasized the goodness of the match between treatment goal and patients' beliefs and experiences: when these were aligned, patients succeeded better at either abstinence or controlled-drinking; when they were opposed, relapse was most likely. In this case, forcing a person who does not accept abstinence into a treatment framework that accepts only abstinence can eliminate controlled drinking but will have little impact on the numbers who successfully abstain. Orford and Keddie, on the other hand, emphasized primarily the persuasion of patients that they can attain one goal or the other. In this model, the more intense and consistent the persuasion effort toward one type of outcome, the greater will be the prevalence of that outcome.
Helzer et al. [35] presented as one possibility in their research that 'For any alcoholics who are capable of drinking moderately but are incapable of abstinence, treatment efforts directed only at the latter goal will be doomed to failure' (p. 1678). These investigators offered little support for this idea on the grounds that so few patients achieved the study's definition of moderate drinking, although none was encouraged to do so. In other words, their research did not directly test this idea as a hypothesis. However, their absolute remission rate for those in alcoholism treatment of 7% might be considered evidence that conventional treatment discourages non-abstinence outcomes without producing an increase in abstention.
Sanchez-Craig and Lei [72] compared the success of abstinence and CD treatment for problem drinkers with lighter and heavier consumption. They found lighter problem drinkers did not differ in successful outcomes between the two treatments, but that heavier drinkers did better in CD treatment. Abstinence treatment did not succeed generally in encouraging abstinence for any group, while it did reduce the likelihood of heavier drinkers becoming moderate drinkers. Unlike the other recent studies reported here that have found controlled drinking among alcohol-dependent patients, this study was limited to 'early-stage problem drinkers' and classified subjects according to self-reported drinking levels. Nonetheless, a later reanalysis of the data (Sanchez-Craig, private communication, November 24, 1986) found that the same results held for level of alcohol dependence, including some drinkers with high levels of dependence.
Miller [73] has presented a theoretical review of motivational issues in treatment. Conventional alcoholism treatment dictates goals and rejects self-assessments by clients—such as that they can moderate their drinking— that contradict prevailing treatment philosophy. A body of experimental and clinical evidence indicates that such an approach attacks clients' self-efficacy [74,75], and that commitment to action is enhanced instead when therapy accepts and reinforces clients' perceptions and personal goals. The large majority of patients refuse or prove unable to cooperate with the insistence in conventional treatment programs that they abstain. The therapy then defines this as failure and, paradoxically, attributes the failure to the absence of patient motivation.
Non-treatment cultures and denial
Other data support the idea that less involvement in therapy is a positive prognosticator of controlled use patterns. Robins et al. [67] found that the large majority of formerly narcotic-addicted subjects became controlled or occasional heroin users, while Helzer et al. [35] found controlled drinking was almost non-existent among alcohol patients. Helzer et al.'s subjects were all hospitalized, while subjects in Robins et al. seldom underwent treatment. Indeed, Robins et al. concluded their paper with the following paragraph:
Certainly our results are different from what we expected in a number of ways. It is uncomfortable presenting results that differ so much from clinical experience with addicts in treatment. But one should not too readily assume that differences are entirely due to our special sample. After all, when veterans used heroin in the United States two to three years after Vietnam, only one in six came to treatment. (p. 230)
Waldorf [76] found the principal difference between heroin addicts who achieved remission on their own or through treatment was that the latter considered abstinence essential, while the former often tried narcotics again.
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