Learning to Say ‘I’ve Had Enough,’

The New York Times, July 14, 2000

By Sally Satel

Sally L. Satel is a psychiatrist who works in a methadone clinic in Washington. She is the author of the forthcoming book “PC M.D.”

Can people who drink too much be taught to control their alcohol consumption? Unthinkable, say mainstream treatment organizations like the Betty Ford Center and Hazelden, which have long insisted on total abstinence.

Now controversy about a treatment approach that allows for some controlled drinking has flared again. In Washington State last week, a leading proponent of this option, Audrey Kishline, pleaded guilty to killing two people while driving drunk. She is the founder of Moderation Management, set up in 1993 as an alternative to the abstinence-only Alcoholics Anonymous. Then Alex DeLuca, the director of the respected Smithers Addiction Treatment and Research Center in New York City, resigned after failing to persuade his clinic to offer some alternative to total abstinence.

The case of Ms. Kishline may argue strongly against the idea, but some problem drinkers can be trained to control their intake. The difficulty is in figuring out which ones.

The working definition of the heavy drinker, according to the government’s National Household Survey, is the consumption of five or more drinks on a single occasion, five or more times within a month. This kind of use, excessive as it is, doesn’t make someone an alcoholic. A heavy drinker could be a college student who drinks to the point of getting sick on Saturday nights but keeps up his grades and football practice. Or an employee who drinks a bottle of wine alone at night but never misses a deadline.

Call these people “problem drinkers”—but not alcoholics. It is possible, but far from guaranteed, that they will become full-blown alcoholics, drinking compulsively despite serious consequences like deteriorating job performance and withdrawal symptoms.

The distinction between the problem drinker and the alcoholic, while not razor sharp, exists—but hard-core opponents of the drinking-in-moderation policy don’t want to acknowledge it. To them, you are either an alcoholic or not. Virtually no treatment program will accept a patient who rejects abstinence as a goal. And counselors tend to engage in double-think: if the patient says he’s an alcoholic, he is; if he refuses to admit he has a problem, he’s an alcoholic “in denial” and headed toward the gutter.

But there are data that contradict this view. The “Handbook of Alcoholism Treatment Approaches,” a textbook for clinicians, provides evidence that some problem drinkers can successfully control their consumption. Admittedly, this approach only works when the risks are relatively low. If an individual has crossed the line, admittedly fuzzy, into alcoholism, then the risks of allowing someone to have an occasional drink or two become too high.

The warning signs that the line has been crossed are a history of domestic violence, suicide attempts, missed work, neglected children—an “unmanageable” life in the words of Alcoholics Anonymous. Ms. Kishline must have known that the risks for her were too high because she had quit Moderation Management and joined Alcoholics Anonymous earlier this year, several months before the fatal accident.

Advocates of total abstinence are afraid that some people will use the Moderation Management option as an excuse to drink. But the majority of problem drinkers, let alone alcoholics, have already rejected abstinence. Surveys from Alcoholics Anonymous indicate that its annual dropout rates average around 75 percent.

True, some doctors worry that sober recovering alcoholics will start to think that moderate drinking is O.K. and try it. The task for the therapist is to have the patient think hard about why he wants to sabotage so much. Some drinkers will never lose hope that they can one day enjoy alcohol minus the devastation, but the chances for relapse are reduced if we are adamant that controlled drinking is not an option for everybody.

At the same time, intolerance of moderate drinking also has a price.

“If some problem drinkers are told by treatment professionals that their choice is abstinence or no treatment, they will take nothing, and the opportunity to help is lost,” says Jon Morgenstern, director of alcohol treatment research at the Mount Sinai School of Medicine in New York City.

So, the choice is rather stark. Admit that some problem drinkers aren’t alcoholics, and help them learn how to drink moderately. Or insist on abstinence for those with even mild drinking problems—and drive millions of people away who need help.