Doctor DeLuca's Addiction Website
Old Battles: The Controlled Drinking Debate
"Originally, controlled drinking research was used to test critical hypotheses of the popular, but untested, disease concept of alcoholism," the Sobells note.
But "such research quickly became a notorious battlefield between scientific- and belief-based views of alcohol problems.... Controlled drinking, in particular, threatened an entire culture based on the philosophy of Alcoholics Anonymous.
"This editorial is not intended to review those conflicts, but rather to speculate about why controlled drinking approaches no longer seem to arouse intense debate, and about the role of moderation approaches in contemporary alcohol treatment. We believe that the major reason why the debate about controlled drinking has waned is because the old battles have little relevance to today's leading issues in the alcohol field. Many things have contributed to the change. They include epidemiological studies identifying a large population of people with low severity alcohol problems, the introduction of the alcohol dependence syndrome concept, and consideration of alcohol as a public health concern.
"In our view, the findings of 25 years of moderation research can be summarized by the following three statements:
1) Recoveries of individuals who have been severely dependent
on alcohol predominantly involve abstinence.
The first commentator, M.M. Glatt, of Charter Nightingale Hospital in London, England, suggests that a goal of controlled drinking might put some moderately dependent clients in danger of exacerbating damage to the liver, heart, brain and other body functions. As well, the drinker's family might be less likely than the drinker to support a goal of controlled drinking after having lived through previous failed attempts, Glatt believes. He takes offense at the way controlled drinking researchers have "found it relatively easy to lump and condemn all abstinence approaches as 'belief-based': ignoring, like the Sobells, the existence of a somewhat heterogeneous group of clinicians largely favoring an abstinence approach based on critical clinical observations." He concludes: "On the basis of personal observations after 44 years working with alcoholics, I remain skeptical."
But Nick Heather, of the Centre for Alcohol and Drug Studies, in Newcastle, England, believes that the Sobells may not have gone far enough - that their advice on offering controlled drinking strategies only to non-severe alcoholics "continues to neglect its potential application among the more seriously affected." He points out that:
Peter Anderson, of the World Health Organization's Regional Office for Europe, voices his concern that controlled drinking might lend credence to public health messages promoting "sensible" drinking. Such messages are dangerous because "there is no safe or sensible limit of alcohol consumption" and because they "are likely to lead to an increase in per capita consumption with all its attendant risks." Other downsides of the controlled drinking debate include "an expansion of the idea of moderate drinking as being the goal for all drinkers ... and a possible neglect in service provision for those severely dependent on alcohol." On the positive side, the debate has "strengthened the view that a dichotomy between 'alcoholic' and 'not alcoholic' was no longer valid. Instead, one could view a continuum of problems." As well, the debate "resulted in power being taken away from vested interest groups, which allowed a much broader base for the approach to alcohol problems."
Constance Weisner, of the Alcohol Research Group in Berkeley, California, says graver issues have usurped the debate on controlled drinking. "These include bottom-line concerns of whether alcohol treatment continues as a specialty field or is 'mainstreamed' with other health problems and general medical care, whether it is included in health reform packages and whether it is managed by the alcohol field or by outside utilization review and insurance companies." Systemic changes may reframe the debate, she believes. "For example, if alcohol specialists are placed within primary health clinics rather than those clinics referring individuals to treatment, we may expect that different treatment strategies and ideologies will emerge, especially in regard to moderation approaches."
Fanny Duckert, of the Institute of Psychology at the University of Oslo, Norway, says controlled drinking has fit well with the approach to alcohol problems in Norway, whose National Institute on Alcohol Research "has always underlined great individual variations in drinking behavior among people labelled as alcoholics." A 1987 survey found that 90 per cent of Norwegian treatment centres allowed outpatient clients to choose between abstinence and reduced drinking. "One consequence of the controlled drinking debate has been the introduction of a more hopeful and optimistic attitude towards people with drinking problems." She locates the controlled drinking discussion within a broader debate on the roles of client and therapist: "Is the problem drinker to be met as an ally or as an untrustworthy adversary? Shall we trust the person's ability to evaluate his or her own situation and capacity to make adequate choices, or shall we as therapists be the ones who decide what is the best alternative?"
Christopher Kahler, of the Centre of Alcohol Studies and Rutgers University in New Jersey, suggests that the Sobells "underestimate the degree to which the early research on controlled drinking, in large part initiated by themselves, revolutionized the way that alcoholism and alcoholism treatment is conceptualized and researched." He notes that the question of cost has begun to drive decisions on addictions treatment, and "the stepped-care approach outlined by Sobell & Sobell is useful in addressing economic concerns." However, he warms, "the increase in economic influences on how society copes with alcohol-related problems carries a danger.... Namely, those people who are least likely to benefit from treatment or who require the most costly and intensive interventions may find that their treatment options will become limited."
Brian Hore, of Withington Hospital in Manchester, England, concedes that the Sobells' work has contributed to "more willingness to consider patients as individuals." But he is concerned that the pendulum of responsibility has swung too far towards the client. "To infer, as the Sobells seem to do, that one should rely on the consumer to choose their own treatment goal seems a negation of a therapist's role." As well, "denial and the inherent conflict within [clients] may be an important aspect in low compliance." Hore also points out that while the Sobells place their strategy in the context of new trends in public health, "the most effective public health approach to modify drinking behavior seems to be price control."
Gerhard Bühringer and Heinrich Küfner, of the Institut für Therapieforschung in München, Germany, feel that the Sobells played a major role in shattering the stereotype of the alcoholic. "The 'discovery' of [a] variation of abuse ... is the major and - even for controlled drinking skeptics - important merit of the Sobells and the resulting research activities." They take issue with the Sobells' assertion that treatment outcome and dependence severity appear to be independent of treatment advice. They point out that one of the studies cited by the Sobells in support of their conclusion showed that "the group with abstinence as a treatment goal had a better outcome," at least in the first six months following treatment.
In their last word, Linda and Mark Sobell respond to several specific comments:
"Anderson ... suggests that the endorsement of moderation strategies in treatment programs may send a message to the general population that alcohol consumption should be normative. This would be expected to lead to an overall increase in consumption. Anderson's argument not only overlooks the fact that alcohol use already is normative, but also seems premised on the idea that the best public health strategy is to restrict, rather than find ways to regulate, supply and demand. Although this might be morally comforting, it may not be the most effective way of ... minimizing alcohol-related damage to individuals and society."
The view that the choice of treatment goal shouldn't be left to the patient "overlooks the reality that it is the client who ultimately decides what path to follow, no matter what power therapists may perceive themselves to have over clients," the Sobells suggest.
As well, the concern that moderation strategies would exacerbate denial among severe alcoholics "has been discussed for more than three decades, but there have been few reports of such occurrences. The real issue, we believe, involves the management of clients [and] the honesty of the relationship between client and therapist."
In response to Glatt's assertion that controlled drinking research ignores critical clinical observations, they note that most moderation researchers "are both clinicians and scientists, not laboratory workers using data collected by others.
"Our experience has been that problem drinkers exist in abundance if one knows what to look for, looks for them in settings where they are likely to be found, and offers appropriate services."
They conclude with a quote from Dr. Enoch Gordis, director of the National Institute on Alcoholism and Alcohol Abuse, "a person not known as a proponent of moderation approaches:"
The history of medicine demonstrates repeatedly that
unevaluated treatment, no matter how compassionately
administered, is frequently useless and wasteful, and sometimes
dangerous and harmful. The least we have learned is that what is
plausible may be false, and what is done sincerely may be
useless or worse.
|Alexander DeLuca, M.D., FASAM.
Copyright © 1999. All rights reserved. [Top of Page]
Revised: June 8th, 2001.