[ Doctor DeLuca's Addiction Website ]

STAKES      NAT     Nordisk alkohol- & narkotikatidskriftNAT     Nordisk alkohol- & narkotikatidskrift  linjakap.gif (1297 bytes)
-
-
COLUMN
Robin Room:
ABSTINENCE AS THE ONLY TREATMENT GOAL: NEW U.S. BATTLES
Moderation Management (MM) is a small U.S.-based mutual-help organization for people concerned about their drinking, founded in 1993 by Audrey Kishline. Research by Keith Humphreys and Elena Klaw suggests that in late 1999 it had about 300 active members, with almost half involved only through the internet, and the others involved either through face-to-face meetings or in a mixture of the two modes. Following a strategy pioneered by Martha Sanchez-Craig, MM recommends that newcomers abstain for 30 days, and then decide on their moderate-drinking goals, within suggested limits. MM states that its approach is not for "alcoholics" and "chronic drinkers", or for those unable to stay abstinent for the 30 days.
 
In the great shoal of mutual-support groups for alcohol problems in the U.S., MM is a tiny fish indeed. But it has a symbolic importance beyond its size. All other mutual-help groups -   not only Alcoholics Anonymous (AA), but also groups such as Women for Sobriety, LifeRing Secular Recovery (formerly SOS), and Overcomers in Christ, each founded as an alternative to one or more points of AA`s program - agree on lifelong abstinence as the only goal for those with drinking-related problems. Because of this divergence from U.S. treatment and mutual-help orthodoxy, and perhaps also because of the consonance between MM`s program and approaches used by cognitive behavioural psychologists, MM received considerable media attention in the second half of the 1990s, including a 1997 cover story in U.S. News.
 
On 20 January, 2000, Kishline sent an e-mail to the MM mailing list, announcing that she was changing her personal recovery goal to abstinence, had started attending AA and would also attend Women for Sobriety and SMART Recovery.
 
On 25 March, a 38-year-old man and his 12-year-old daughter were killed in a head-on collision with Kishline`s pickup truck, which she was driving on the wrong side of the highway. Kishline`s blood-alcohol level at the time was 2.6 per mille, more than three times the local legal limit.
 
Extremely remorseful, Kishline checked herself into an inpatient treatment program. In a court appearance on June 29, she plead guilty to vehicular homicide, and on August 11 she was sentenced to 4 1/2 years in prison.
 
These tragic events were widely discussed as a dramatic parable, although different observers drew different conclusions. For instance, Stanton Peele, a critic of mainstream disease conceptions, found it "ironic that her most extreme case of intoxication was after she quit Moderation Management". For those in the mainstream, however, the events were an irresistible invitation to attack MM and the idea that moderate drinking might ever be a therapeutic goal. Neil Scott of the Alliance for Recovery found that the events had proved MM`s "dark and dangerous theory" to be wrong. According to a statement issued by Stacy Murphy, the President of the National Council on Alcoholism and Drug Dependence, the tragedy "provides a harsh lesson for all of society, particularly those individuals who collude with the media to continually question abstinence-based treatment for problems related to alcohol and other drugs". Media coverage of the controversy, while often including a variety of views, tended to favour the mainstream interpretation.
 
A statement issued on July 11 by a group of 34 "scholars and long-time observers or participants in the alcohol problems field" briefly reviewed the events. "That Ms. Kishline was intoxicated at the time of the crash has been claimed to indicate the failure of the approach of one or the another of the mutual-help groups Ms. Kishline has attended", the statement continued. "Such claims are not in accord with everyday experience in the field, in which relapse is common, whichever approach the drinker adopts. Recovery from serious alcohol problems is a difficult goal, and there are different paths to it. We believe that the approach represented by Alcoholics Anonymous and that represented by Moderation Management are both needed". Three of the signers were from Nordic countries: Jan Blomqvist, Klaus Mäkelä, and Robin Room.
 
The statement drew very little press coverage. In the meantime, however, another battle had broken out. The July 10 issue of New York Magazine (posted on the web June 30) carried an article about the introduction of an option for a moderate-drinking goal at the Smithers Addiction Treatment and Research Center. The magazine gave the article, written by Maia Szalavitz, a journalist supportive of such "harm reduction" approaches, the provocative title "Drink Your Medicine". On 9 July, the New York Post published a mocking editorial about the change: "I hear they`re serving cocktails now.... Smithers sounds like a vacation to me`".
The Center had been first funded 30 years ago as a major initiative of R. Brinkley Smithers, the major philanthropist in the American alcoholism field, and a firm advocate of abstinence approaches. After successive waves of hospital mergers, it was now part of the Beth Israel/St.Luke`s-Roosevelt Hospital complex. Brinkley Smithers` widow, Adele Smithers-Fornaci, wrote a public letter to "friends in the alcoholism field" claiming that the program had "changed from abstinence-based treatment to a moderation management model.... The tragedy is that lives will be destroyed and people will die in the process", she continued, citing the Kishline case as an illustration of this. On July 9 the Smithers Foundation, with which the Center has no continuing connection, published a full-page advertisement in the New York Times denouncing the change, and restating "the conviction of R. Brinkley Smithers ... that alcoholism is a disease that requires abstinence-based treatment".
 
On July 10, Dr. Alex DeLuca, medical director of the Smithers Center, was forced to resign. The hospital issued a terse statement that the "center had a long and proud tradition of treating alcoholism by advocating total abstinence. Since Dr. DeLuca does not support that program philosophy, we have accepted his resignation. "Under a triumphant headline, "From 10 days to shutdown", Neil Scott of the Alliance for Recovery distributed widely an e-mail account of the campaign of letter-writing and e-mails which generated the pressure to force DeLuca to quit. Noting pointedly that other "proponents of the moderation management approach" were still employed at the Center, Scott thanked recipients for helping to deliver" a clear and concise message: Alcoholism is a treatable disease, from which people can and do recover, with abstinence-based treatment!".
 
Why does the idea that some alcoholics may be able to learn controlled drinking generate so much heat in the U.S., and uniquely in the U.S.? And why does the controversy bubble up again now, after lying more or less quiescent since the early 1980s? The overt argument against offering a controlled drinking option is that active alcoholics will die because of this: they will all choose the easy way out if it is offered, and deaths will mount. But this is not on its face a convincing argument, since most heavy drinkers try in any case to control their drinking at one time or another, whether or not treatment or mutual help with that goal is offered - and since the Big Book of AA encourages the potential recruit to try to control his drinking, to find out whether he is an alcoholic or not.
 
During the controversies of the 1970s, Ron Roizen and I discussed the idea that the heat comes from a connection that is not so openly discussed: that the abstinence standard is linked to the special standing of the recovered alcoholic in American society. Rather than being stigmatized, the status of being a recovered alcoholic in the U.S. may be seen as a positive attribute. Unlike other people, the alcoholic has wrestled with demons within him- or herself, and has won a heroic battle. The special badge of that status is that the alcoholic has forsworn something which once mattered to him or her more than anything else, by becoming a lifelong abstainer from drinking. To admit the possibility of an option that some alcoholics can learn to drink like anyone else is to give up that special badge, and also to cheapen the accomplishment, turning it from a heroic struggle into simply learning some new skills.
This sense that moderation goal demeans the accomplishment and undercuts the status of the recovered alcoholic seems to lie behind the special heat the issue generates. "As a successful member of Alcoholic Anonymous, I found myself getting more angry with every word I read about her 'movement'", wrote Alex Dunphy in a letter to the Seattle Post-Intelligencer published August 18; "everything Kishline stands for turns my stomach".
 
As for why now, one answer may be that a new generation of controlled-drinking advocates has not learned the caution enforced on an earlier generation. After a few jobs were lost and grants denied over the issue in the 1970s, U.S. cognitive behavioural researchers and clinicians retreated to less controversial ground; training in "relapse prevention" became an acceptable compromise terrain which allowed scope for their expertise. Another factor may be the ongoing shifts in American health care, with managed care and institutional consolidation driven by the demand for cost containment and for evidence-based practice. An older grievance of Ms. Smithers-Fornaci against Beth Israel/St.Luke`s-Roosevelt was that consolidation had forced the Smithers Center out of its home in a former mansion, which Brinkley Smithers had chosen for it because he "felt that alcoholism should be treated as a respectable disease and that alcoholics should be treated with dignity". As for pressures in the treatment system, Szalavitz quotes William White, author of a comprehensive history of addiction treatment in the U.S., as noting that the traditional assumptions of U.S. alcoholism treatment are under "enormous" pressure from managed care and to prove their effectiveness. In this circumstance, "people are moving away from 'this is our program' to offering a menu, real options".
(Robin Room - Centre for Social Research on Alcohol and Drugs, Stockholm University)
Web references:
http://www.usnews.com/usnews/issue/970908/8drin.htm
(1997 USNews cover story questioning the abstinence standard)
http://seattlep-i.nwsource.com/local/mod12.shtml &
http://seattlep-i.nwsource.com/local/mod11.shtml
(local news story and analysis on Kishline's sentencing)
http://www.salon.com/health/feature/2000/07/14/moderation/index.html
(Salon magazine article on Kishline)
http://www.guardianunlimited.co.uk/Archive/Article/0,4273,4040984,00.html
(a British view, from the Observer)
http://www.ncadd.org/news42.html (NCADD statement on Kishline)
http://www.newyorkmag.com/page.cfm?page_id=3485
(Szalavitz article on controlled drinking at the Smithers Center)
http://alcoholism.about.com/health/alcoholism/library/weekly/aa000709a.htm
(Ms. Smithers-Fornaci's "anathema" on controlled drinking at the Smithers Center)
http://nypost.com/commentary/32325.htm (NY Post editorial about Smithers)
http://nypost.com/news/7544.htm (NY Post story on DeLuca`s forced resignation)
http://www.roizen.com/ron/cont-dri.htm (Ron Roizen`s analysis of earlier rounds of controversy over controlled drinking as a treatment goal)
http://www.unhooked.com/booktalk/slaying_the_dragon.htm (an informative review of William White`s history of addiction treatment, Slaying the Dragon)
linjakap.gif (1297 bytes)

[ Doctor DeLuca's Addiction Website ]