After the Crash

Stanton Peele from the November 2000 issue

(Page 2 of 2)

The point is not that moderation training is always better than abstinence. But even if abstinence was the right goal for Audrey Kishline, she didn’t manage it. Therapists, whatever their orientation, are reluctant to admit that most alcohol abusers relapse, and that they need training to avoid harming themselves and others when they do. For example, people can learn in therapy to call their spouse when they get drunk to make sure they don’t drive while intoxicated. By failing to develop such fallback positions, therapists and support groups are saying, in effect, "If you make a mistake, you might as well give up all restraint–taking a drink, getting drunk, and driving drunk are all equivalent."

When Kishline repopularized the idea that some people could return to nonproblematic drinking, she aroused the ire of the NCADD, which denounced the idea in a July 1995 press release. "Millions of Americans," it said, "have recently seen life-threatening stories in the media that people with alcohol problems don’t have to stop drinking completely to get better." In perhaps the high point of national media attention Moderation Management was to receive, U.S. News & World Report featured controlled drinking and M.M. in a July 1997 cover story. The article focused on problem drinkers, who it indicated were a solid majority of those with alcohol problems. Nonetheless, the director of the government's National Institute on Alcohol Abuse and Alcoholism (NIAAA), Enoch Gordis, wrote a letter to the magazine emphasizing that "persons with the medical disorder ‘alcohol dependence’" need to abstain.

The NIAAA’s own research has contradicted that position. Project MATCH was the largest trial of alcoholism treatment ever conducted. Completed in 1996, less than a fifth of the 952 alcoholics who underwent only outpatient treatment, and a little more than a third of the 774 alcoholics who had hospital treatment followed by outpatient treatment, abstained for as long as a year. So the NIAAA used a different standard of success: It emphasized that the subjects entered treatment drinking, on average, 25 days per month and 15 drinks per occasion; after treatment they drank, on average, five to six days a month and three drinks per occasion. The NIAAA in this case seemed to be endorsing controlled drinking.

In 1992 the NIAAA conducted face-to-face interviews with a representative sample of nearly 43,000 Americans, asking them about their current and past drinking practices. Of the more than 4,500 who had been alcohol dependent at some point in their lives according to the current psychiatric definition, about a quarter had entered treatment as a result. A third of those who had been treated were drinking abusively at the time of the survey, compared to a quarter of those who hadn’t been treated. Untreated alcoholics were less likely to be abusing alcohol, but they were twice as likely to be drinking without qualifying as problem drinkers or alcoholics. Abstinence was more common among alcoholics who had been in treatment, but still only a minority (39 percent) were abstaining, while 28 percent were drinking without diagnosable problems. Those who had been treated did, on average, have worse problems to begin with. But all of the drinkers in the analysis had at one time qualified for the diagnosis of alcohol dependence and would certainly have been considered in need of treatment. A plausible explanation for the finding that treated alcoholics were more likely to be drinking abusively is the all-or-nothing message taught by A.A.-style programs: When people who have undergone traditional treatment fall off the wagon, they’re convinced that it marks the beginning of a binge, which then becomes a self-fulfilling prophecy.

Thus, federal research whose size and comprehensiveness will not readily be equaled gives the lie to the principal claims of America’s treatment establishment: that alcoholics can’t recover without treatment; that alcoholics can’t reduce their drinking to nonproblematic levels; and that alcoholism treatment reliably produces abstinence.

Ignoring this evidence, abstinence-only advocates are using the Kishline case to close the small cracks that have appeared in the 12-step monolith.

This year, under medical director Alexander DeLuca, the Smithers Center in New York–founded by the late R. Brinkley Smithers, a wealthy recovering alcoholic and A.A. supporter–began to make referrals to M.M. DeLuca did not himself offer moderation treatment at Smithers. Rather, in keeping with the ethical and legal requirement of informed consent, he thought it proper to discuss alternatives such as controlled drinking with patients who were not fully committed to quitting. DeLuca still hoped such patients would ultimately decide to abstain.

Despite these nuances, in July the board of the Smithers Foundation, headed by Brinkley Smithers’ widow, Adele Smithers-Fornaci, took out a full-page ad in The New York Times attacking the reconstituted Smithers program (with which her family is no longer associated). "The seductive appeal of controlled drinking to the alcoholic will cause needless loss of life and destruction of families," the ad warned. "This is no more sadly illustrated than in the tragically ironic case of the founder of the Moderation Management program, Audrey Kishline.…Using the Smithers name in conjunction with this type of treatment is an abomination, an insult and a disgrace to the memory of R. Brinkley Smithers." Within days of the ad’s appearance, the Smithers Center accepted DeLuca’s resignation.