The Health section, consistent with virtually all popular American press coverage, has reported only the majority view of alcoholism: that it is a "disease" for which abstinence offers the only hope. But there is another, more promising alternative: the psychological approach, often called "moderation" or "controlled-drinking" treatment.
John Finney of Stanford University and other prominent social science researchers suggest that the psychological approach is particularly promising for the moderately afflicted, who make up the majority of those treated for alcoholism.
Most Americans are convinced that abstinence is the best response to alcoholism, and yet more than 100 studies of abstinence programs one year after treatment demonstrate an average success rate of only 5 to 10 percent. This figure is undisputed by pro-abstinence experts. Most lay observers believe -- as private clinic representatives say -- that a 75 percent success rate is attainable by the best programs, and it is. But this impressive rate holds up only for about six months. Thereafter, relapses occur at a dramatic pace.
On the other hand, nine studies of the controlled-drinking approach have yielded an average success rate for the moderately afflicted of 65 percent one year or more after treatment.
Based on this research and numerous related studies, 78 percent of the treatment centers in Great Britain have already established controlled drinking programs, as have many centers in Canada, Norway, New Zealand and Australia.
Most American treatment authorities are highly critical of the controlled-drinking studies. Some fault the research methods used. Others think the drinkers studied were not true alcoholics.
Also, complex biological evidence and reasoning convince most professionals that drinking is controlled primarily by physiological forces, and it is assumed that these forces can be combated only by complete abstinence. But this conviction depends entirely on anticipated results of research that will not be completed for at least 10 years.
Meanwhile, of those who go through abstinence programs, our nation's only widely available treatment, 40 to 50 percent eventually die alcohol-related deaths.
This tragic reality has moved some professionals to suggest that we explore alternatives.
The psychological understanding of alcoholism does appeal to common sense. Many of us can give examples of the strong connection between drinking bouts and specific personal troubles. Controlled-drinking psychologists help excessive drinkers with their specific problems in straightforward ways.
It is easy to dismiss psychological approaches -- as most articles do -- by misrepresenting them. Sad tales of misguided alcoholics wasting many years and thousands of dollars ruminating on their childhoods are contrasted with the now standard 28-day residential treatment and follow-ups in Alcoholics Anonymous. No contest.
What is not generally known in the United States is that the controlled-drinking treatments are also brief and seldom require more than a three- to five-day residential detoxification program. The severely afflicted sometimes require a lengthier treatment.
Also, the contrast between the client-professional relationships in the abstinence and moderation programs bears consideration.
In the increasingly popular Employee Assistance Plans (EAPs), promoted by the Association of Labor & Management Administrators & Consultants on Alcoholism (ALMACA), the counseling relationship is both adversarial and collaborative.
Professionals in such abstinence programs believe that coercion is sometimes necessary to save the most afflicted alcoholics from imminent dismissal. An EAP psychologist and an employe's supervisor come up with a strategy together, pooling information received from the employe. The psychologist can recommend forcing the worker to choose between dismissal and a 28-day residential program.
In the 28-day programs, clients are pressured to admit that they are alcoholics. Most people resist, partly because they find this label humiliating. Persistent opposition to the professional's perspective requires "breaking down the alibi system of alcoholics," as The Washington Post reported in a story early this year. Thus, "24 hours a day, all they hear about is alcohol and what it does."
After the client assents to the professional's perspective, empathetic discussions can take place. But coercion has its questionable impact, and the big increase in relapses six months after treatment may be traceable to the fact that clients were taught to rely on the authority of others rather than themselves.
This coercive approach contrasts with the methods of the best psychological treatments, which use collaboration. Relations are confidental and depend entirely on trust and mutual respect. Client and counselor identify the specific psychological pressures that clients have tried to escape by drinking too much.
Because clients freely consider and then choose new ways of coping with the pressures, solutions tend to last. The clients' own inner authorities are with them long after treatment has ended.
When the disease theory was first introduced 30 years ago, it appeared to offer relief from the then-prevailing attitude that alcoholism was the result of moral weakness and that moralistic pressure was the only valid response. But it is now apparent that, for all our good intentions, we have sanctioned an approach that is not very different from the old one.
Instead of increasing the pressure to conform to what amounts to a single belief system, we may better help the victims of alcohol abuse by reasserting our culture's strong spirit of open inquiry.The Rev. John McFadden, a Presbyterian minister, is a licensed counselor in private practice in Santa Rosa, Calif., where he treats alcoholics.