Setting the Record Straight on Substance Use Treatment
Tartarsky and Mark Sehl
It is a sad day when politics and ideology stand in the way of
research-based treatment options for patients who need them. This is what we
believe was behind two recent events about which we want to set the record
A full page ad in the NY Times, July 9, 2000, placed by the Board of
Directors of the Christopher D. Smithers Foundation distorted the truth about
recent treatment innovations at the Smithers Alcoholism Treatment Center at
St. Luke's -Roosevelt Hospital in New York City. It criticized the center
for adopting "the alcoholism treatment strategy known as ‘Moderation
Management'.", and said, ". . . alcoholism is a disease that requires
abstinence-based treatment, and ... controlled drinking, under any name,
whether it be ‘moderation management' or ‘harm reduction', is not possible
where the disease of alcoholism exists."
We believe that one unfortunate result of this ad was the
"resignation” of Dr. Alex DeLuca, the director of the Smithers Center for
Treatment and Training. As reported by the New York Times on July 11th in an
article titled "Addiction Center's Director Quits in Treatment Debate," this
occurred because "a feud [had] erupted [between Dr. DeLuca and the St.
Luke's-Roosevelt Hospital] around the center's decision to include moderation
management" in their program. The article states that Dr. DeLuca "decided to
steer the clinic... toward an approach that advocates controlled drinking."
These statements echo the ad in their significant distortions of the
innovative changes that Dr. DeLuca had made at the center and the 25 years of
research and evolution in the field that they reflect.
We see these events as ill-informed attacks on substance abuse treatment
approaches that do not immediately demand total abstinence. They reflect a
lack of clinical knowledge about engaging patients in treatment and fail to
recognize well-founded scientific research.
We will attempt to set the record straight.
The Smithers Center never adopted Moderation Management as a method of
treatment. They couldn't have. Moderation Management is a self-help support
group. Rather, Dr. DeLuca introduced a more flexible treatment approach that
offered options, including moderation, to patients resistant to engage in
abstinence-oriented treatment, those who would be most likely to leave
treatment against medical advice.
In his recently published book, Dr. Alan Marlatt, a leading addictions
researcher, cites studies that find that moderation outcomes do occur in
abstinence-oriented treatment outcome studies. Additionally, one study found
that three quarters of participants with previous drinking problems recovered
on their own, and one half were stable moderate drinkers. In other words,
moderation outcomes do occur. Some people do drink moderately and recover on
their own, which is contrary to the progressive-disease model.
The sponsors of the ad make predictions that controlled drinking will
have dire consequences ending in tragedy for many. However, another study
cited by Marlatt found that offering people choice of goals
(controlled-drinking vs. abstinence) led to better patient recruitment for
and retention in treatment and an increased possibility of achieving both
treatment goals without a greater risk of returning to heavy drinking.
The implication of the statements by the Smithers Foundation and those of
Roosevelt Hospital administration is that the center had abandoned abstinence
as a treatment goal. This misapprehension is, in part, based on a tendency to
think of moderation strategies and abstinence-oriented strategies as at odds
with one another. Moderation approaches are not in conflict with those that
have abstinence as a goal. Conversely, the abstinence-only approach rules
out other approaches by demanding that abstinence must be achieved relatively
soon in treatment and maintained in order for the client to be allowed to
continue in treatment. The irony, as most professionals in the field well
know, is that this frequently leads to patients being "terminated" from
treatment for the very problem for which they sought help. By anyone's
statistics, that model has not been acceptable or useful to the overwhelming
majority of people with drug and alcohol problems.
Under the leadership of Dr. DeLuca, the Smithers Center had integrated
motivational and reduced use strategies into the full range of
abstinence-focused treatments long available at the center. These efforts
reflect an evolution toward a more scientific, comprehensive approach.
Moderation training engages some people who would not otherwise begin to work
on their problem drinking and it is often a framework within which they may
discover that moderation is not a realistic goal for themselves and come to
accept abstinence as a better one. This work that is being dismantled by the
hospital administration reflects the cutting edge in the field. It embodies
age old basic principles of good clinical practice.
We have a combined experience of over 48 years in working with substance
users, many of whom have found have found Alcoholics Anonymous to be a life
saving support system. For the many others who cannot or will not stop
drinking, Moderation Management provides support on the difficult path of
discovering if moderate drinking is a realistic goal. The job of
professional treatment or the self-help group is to support this process. We
believe that any treatment approach which does not investigate the patient's
wishes, fears and conflicts has great potential to fail. Without choice,
patients often comply with a program and fail later. We have worked with the
fallout from abstinence-only treatment; the "chronic relapsers," the
"resistant to recover."
Patients will have a better chance of embracing abstinence if a dogma
about treatment is not forced upon them. All substance use programs,
including A.A. have high failure rates. Our hope is that all professionals
who treat people with addictions can work together on this difficult problem
instead of dividing into opposing camps.
Andrew Tatarsky, Ph.D., Immediate Past President, The Addictions Division,
The New York State Psychological Association; Clinical Psychologist in
private practice specializing in treating substance use problems.
Mark Sehl, Ph.D., MSW, - private practice psychotherapy, New York City;
speciality substance use problems.