Cultural Conceptions of Relapse and Remission in Alcoholism

Morristown, New Jersey

Summary

Variations in the reported rates of controlled drinking by former alcoholics are notable, at times startling. Reports of such outcomes (which in some cases involved a large percentage of subjects) were common for a brief period ending in the mid- to late 1970s. By the early 1980s, a consensus had emerged in the United States that severely alcoholic subjects and patients could not resume moderate drinking. Yet—at a point in the mid-1980s when the rejection of the possibility of a return to controlled drinking appeared to be unanimous—a new burst of studies reported resumption of controlled drinking was quite plausible and did not depend on the initial severity of alcoholics' drinking problems. Variations in controlled-drinking outcomes—and in views about the possibility of such outcomes—involve changes in the scientific climate and differences in individual and cultural outlooks. These cultural factors have clinical implications as well as contributing to the power of scientific models of recovery from alcoholism.

Key words: Expectations—Beliefs and alcoholism—Controlled drinking—Behavior therapy—Therapy efficacy—Natural remission

Introduction and Historical Overview

Twenty-five years after Davies' [1] report that 7 out of a group of 93 treated British alcoholics had returned to moderate drinking, Edwards [2] and Roizen [3] analyzed reactions to Davies' article. Nearly all of the 18 comments on the article published in the Quarterly Journal of Studies on Alcohol were negative, most extremely so. Respondents, who were all physicians, based their objections to Davies' findings on their clinical experience with alcoholic patients. The respondents furthermore expressed a consensus against controlled-drinking in America that, according to Edwards, expressed 'an ideology with nineteenth century roots, but [which] in the 1960s.... had been given new strength and definition under the conjoint influence of Alcoholics Anonymous (AA), the American National Council on Alcoholism and the Yale School' [2, p.25]. At the time it appeared, the Davies' article and its critiques created relatively little stir [3], probably because the article posed no real challenge to accepted medical [4] and folk wisdom that abstinence was an absolute necessity for recovery from alcoholism.

Two responses to Davies' article, however, endorsed and even extended Davies' findings. Myerson [5] and Selzer [6] claimed that the hostile atmosphere surrounding such results stifled genuine scientific debate and stemmed in part from the involvement of many recovering alcoholics in the field who tended to 'preach rather than practice' [5, p. 325]. Selzer recounted similar hostile reactions to his own 1957 report [7] of treated alcoholics who achieved moderation (the percentage of moderation outcomes in this study was twice as high—13 of 83 subjects—as that reported by Davies). Giesbrecht and Pernanen [8] discovered that outcome or follow-up research (like Selzer's and Davies') increased in the 1960s, at the same time as clinical studies more often relied on changes or improvements in drinking patterns as outcome criteria.

Through the 1960s and 70s, a number of studies revealed substantial rates of non-abstinent remission for alcoholism [9]. These included controlled-drinking outcomes for 23% (compared with 25% abstainers) of treated alcoholics interviewed 1 year after leaving the hospital by Pokorny et al. [10], 24% (compared with 29% abstainers) of women alcoholics treated at a psychiatric hospital at a 2-year follow-up conducted by Schuckit and Winokur [11], and 44% (compared with 38% abstainers) of alcoholics studied 1 year after undergoing inpatient group therapy by Anderson and Ray [12]. Among a group of alcoholics that was largely untreated, Goodwin et al. [13] noted at a follow-up period of 8 years that 18% were moderate drinkers (compared with only 8% abstainers) and that a large additional group (14%) drank to excess on occasion but were still judged to be in remission.

The debate about resuming controlled drinking became far more heated when the first Rand report appeared in 1976 [14]. This study of NIAAA-funded treatment centers found 22% of alcoholics to be drinking moderately (compared with 24% abstainers) at 18 months after treatment, leading immediately to a highly publicized rebuttal campaign organized by the National Council on Alcoholism (NCA). A 4-year follow-up of this study population by the Rand investigators continued to find substantial nonproblem drinking [15]. These well-publicized findings did not change prevailing attitudes in the treatment field—the directors of the NIAAA at the time of the two Rand reports each declared that abstinence remained 'the appropriate goal in the treatment of alcoholism' [16, p. 1341].

At around the same time the Rand results were being compiled in the early and mid-1970s, several groups of behavior therapists published reports that many alcoholics had benefited from controlled-drinking (CD) therapy [17,18]. The most controversial of these behavioral-training investigations was conducted by Sobell and Sobell [19,20], who found that moderation training for gamma (i.e. loss of control [21]) alcoholics led to better outcomes 1 and 2 years after treatment than did standard hospital abstinence treatment. This and similar findings by behavioral researchers remained for the most part esoteric exercises, and like the Rand reports, had little or no impact on standard treatment for alcoholics.

Nevertheless, CD treatment and research continued throughout the 1970s. In 1983, Miller [22] indicated 21 of 22 studies had demonstrated substantial benefits from CD therapy at follow-ups of from 1—2 years (see Miller and Hester [23, Table 2.1] and Heather and Robertson [24, Tables 6.3 and 6.4] for detailed outlines of these studies). This research found greater benefits for problem drinkers who were less severely dependent on alcohol, although no comparative study had shown moderation training to be less effective than abstinence as a treatment for any group of alcoholics. Despite the absence of a single case of strong evidence to contraindicate CD therapy for alcoholics, beginning in the mid-1970s behavioral researchers became increasingly conservative in recommending this therapy for severe cases of alcoholism [16]. By the early 1980s, the leading practitioners of CD therapy in the United States claimed it was not suitable for physically dependent alcoholics (i.e. those who displayed withdrawal symptoms following abstinence [25,26]).

At the same time, several outcome studies disputed the Rand reports' contention that CD remission was no more unstable than was that due to abstinence. Paredes et al. [27] reported that abstinence led to more stable remission than controlled drinking. Another research group that had previously reported substantial CD outcomes [28] also found, in 1981, that abstinence remission was more stable than moderate-drinking outcomes between 6 months and 2 years [29]. However, in a study of hospital-based treatment conducted by Gottheil et al. [30], alcoholics who moderated their drinking did not relapse more frequently than abstainers between 6 months and 2 years. Gottheil and his colleagues furthermore compared their results with those from the Rand studies and Paredes et al., noting that despite differences in treatment goals (the Gottheil study did not require abstinence) and follow-up criteria, 'similarities seemed to far outweigh differences in the findings' (p. 563).

referernces