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Goodwin et al. [13], in finding a non-abstinent remission rate of 33% among untreated alcoholics (a rate dwarfing non-problem drinking rates in such treated populations as Davies' [1] and the Rand reports [14,15]), were also aware that their results violated treatment precepts and wisdom. The investigators sought another explanation 'rather than conclude that treatment had adverse effects on alcoholics', while noting 'symptomatically the untreated alcoholism may be just as severe' as that which drives some to treatment (p. 144) (subjects in this study were all categorized as 'unequivocal alcoholics'). Goodwin et al. did not, however, report how their untreated alcoholics differed from treated alcoholics in ways that influenced outcomes. The group of felons that Goodwin et al. studied seemed especially unlikely to accept therapy and conventional treatment goals. The possibility is that this therapeutic recalcitrance contributed to their unusually high CD rates.
Cynical wisdom is that those who refuse to seek treatment are practicing denial and have no chance at remission. Roizen et al. [77] examined the remission of drinking problems and alcoholism symptoms in a general population of men at two points 4 years apart. There were both substantial drinking problems and substantial remission of drinking problems across the board for this subject population. Nonetheless, when the investigators eliminated treated alcoholics, of 521 untreated drinkers only one who displayed any drinking problems at point 1 was abstaining 4 years later. Room [78] analyzed this and other puzzling discrepancies between the alcoholism found in clinical populations and problem drinking described by survey research. Once treated drinkers are removed from such surveys, almost no cases appear of the classic alcoholism syndrome, defined as the inevitable concurrence of a group of symptoms including loss of control. The non-appearance of this syndrome is not due to respondents' denial of drinking problems in general, since they readily confess a host of drinking problems and other socially disapproved behaviors.
Room [78] discussed how such findings seemingly indicate that all of those with fully developed alcoholism have entered treatment. Mulford [79] examined comparable data gathered for both clinical alcoholics and general population problem drinkers. Whereas 67% of the clinical population reported the three most common clinical symptoms of alcoholism from the Iowa Alcoholic Stages Index, 2% of the problem drinkers did so (which translates into a general population rate of less than 1%). About three-quarters of the clinical population reported loss of control, while the general population prevalence rate was less than 1%. Mulford summarized: 'The findings of this study indicate that the prevalence of persons in the general population having the symptoms of alcoholism like clinic alcoholics is probably around 1%, as Room [78] has speculated'. Furthermore, Mulford maintained, 'If 1.7 million Americans are already being treated for alcoholism, there would appear to be little unmet need for more alcoholism treatment' (p. 492).
A more radical explanation for these data, of course, is that problem drinkers may only report the full alcoholism syndrome after, and as a result of, having been in treatment. In his anthropological study of Alcoholics Anonymous, Rudy [80] noted the typical explanation for the more severe and consistent symptomatology reported by AA members relative to non-AA problem drinkers is that 'AA affiliates have more complications or that they have fewer rationalizations and better memories. However, there is another possible explanation for these differences: members of AA may learn the alcoholic role of AA ideology perceives it' (p. 87). Rudy observed "AA alcoholics are different from other alcoholics, not because there are more 'gamma alcoholics' or 'alcohol addicts' in AA, but because they come to see themselves and to reconstruct their lives by utilizing the views and ideology of AA" (p. xiv). Rudy cited the confusion new AA members often showed about whether they had undergone alcoholic blackout—a sine qua non for the AA definition of alcoholism. Recruits were quickly instructed that even the failure to recall blackout was evidence for this phenomenon, and those who became actively engaged in the group uniformly reported the symptom.
Data presented by natural remission studies suggest that untreated drinkers, even those reporting severe addiction and alcoholism problems, frequently achieve remission—perhaps as frequently as do treated addicts and alcoholics. These drinkers may best be characterized by a preference for dealing with addictive problems in their own ways, rather than by the classical concept of denial. A study by Miller et al. [81] bears on this question of patient self-identification and outcome. This study (like others discussed in this article) examined the relationship between CD outcomes and severity of alcohol dependence and the possibility of controlled drinking by heavily dependent drinkers. Miller et al. reported follow-up of from 3 to 8 years for problem drinkers treated with CD therapy. Twenty-eight percent of the problem drinkers were abstinent compared with only 15% who became 'asymptomatic drinkers'.
This level of controlled drinking is far below that Miller and Hester [23] previously reported from CD therapy. On the other hand, although subjects were solicited on the basis that they were not severely alcohol dependent, 76% of this sample was judged alcohol dependent according to appearance of withdrawal signs and 100% according to appearance of tolerance, two-thirds were classified either gamma or delta alcoholics, and three-quarters had reached the chronic or crucial stages of Jellinek's [82] developmental model of alcoholism. As a result, 11 of 14 of asymptomatic drinkers 'were clearly diagnosable as manifesting Alcohol Dependence, and nine were classifiable at intake as either gamma (3) or delta (6) alcoholics'. Thus, although the CD rate from this therapy was unusually low, the population in which this outcome appeared was strongly alcoholic, unlike the typical CD clients Miller and Hester had described.
Miller et al.'s work differed from other recent studies cited in this article in finding that level of alcohol dependence was strongly related to outcome. However, in keeping with several of these studies, the strongest single predictor was 'intake self-label', or clients' self-assessment. Indeed, despite the high level of alcohol dependence in asymptomatic drinkers, 8 of 14 described themselves as not having a drinking problem! What appears to have occurred in this study is that the denial of often quite severe alcohol problems in a group who acknowledged a need to change their drinking habits was a positive predictor of achieving a very strict definition of controlled-drinking (no signs of alcohol abuse or dependence for 12 months). Other psychological research suggests that those who see their problems as having remediable causes are more likely to overcome problems in general [83].
We see in both natural groups and treated patients who deny they are alcoholic that people regularly refuse to turn over either their labeling or their therapeutic goals to others. This refusal is tied in very basic ways to both the person's outlook and prognosis. Furthermore, to identify this attitude as anti-therapeutic (as by labeling it denial) is not justified according to the lack of success of treatment that runs counter to patients' personal beliefs or goals or according to people's demonstrated ability to change their behavior in line with their own agendas. One study of respondents in a typical community offering almost no CD service found a number of people who reported having eliminated a drinking problem without entering treatment [84]. Most of these self-cures had reduced their drinking. A majority of these subjects, not surprisingly, claimed controlled drinking was possible for alcoholics. A large majority of those from the same community who had never had a drinking problem thought such moderation was impossible, the view held by an even larger majority who had been in treatment for alcoholism.
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