By James E. Royce

Can alcoholics be conditioned to drink socially? Under such titles as "harm reduction" and "moderation management" that old question has been resurrected. Moderate drinking is certainly a more appealing goal to many problem drinkers than total abstinence. But medical professionals and addictions counselors are unanimous in their opposition. Are they just rigid prohibitionists? 

As a lifetime member of the board of directors of the National Council on Alcoholism and Drug Dependence, I must point out that the big problem is that alcoholism is a progressive disease, often labeled as "problem drinking" in its early stages. Monday's cold is the flu on Wednesday and pneumonia on Friday. Most alcoholics are sure they can control their drinking on the next occasion. The result is killing alcoholics, who can expect a normal lifespan if they remain abstinent. For decades I have defined an alcoholic as one who says, "I can quit anytime I want to." Self-deception is so typical of alcoholics that the American Society of Addiction Medicine included the term "denial" in its latest definition. Talk of harm reduction just feeds the denial. 

Most research fails to adequately separate true alcoholics from problem drinkers, which makes reports of success misleading. We can't know how many of the latter may progress into true alcoholism. The most thorough research (Helzer and Associates, 1985) studied five- and seven-year outcomes on 1,289 diagnosed and treated alcoholics, and found only 1.6 percent were successful moderate drinkers. Of that fraction most were female and none showed clear symptoms of true alcoholism. In any case, it would be unethical to suggest to any patient a goal with a failure rate of 98.4 percent. 

We psychologists know that conditioning is limited in its ability to produce behavioral changes. To attempt to condition alcoholics to drink socially is asking of behavior modification more than it can do. Some have thought one value of controlled-drinking experiments could be that the patient learns for himself what he has not been able to accept from others, that he cannot drink in moderation giving all that extra scientific help might destroy the rationalizations of the alcoholic who still thinks he can drink socially "if I really tried." Actually, most uses of conditioning in the field have been to create an aversion against drinking, to condition alcoholics to live comfortably in a drinking society and to learn how to resist pressure to drink. In that we have been reasonably successful, since this is in accord with the physiology and psychology of addiction. 

The discussion about turning recovered alcoholics into social drinkers started in 1962, but no scientific research had been attempted until 1970, when Mark and Linda Sobell two psychologists at Patton State Hospital in California with no clinical experience in treating alcoholics, attempted to modify the drinking of chronic alcoholics, not as a treatment goal but just to see whether it could be done. The research literature is largely a record of failure, indicating that the only realistic goal in treatment is total abstinence. 

The prestigious British alcoholism authority Griffith Edwards (1994) concluded that research disproved rather than confirmed the Sobell position. Drs. Ruth Fox, Harry Tiebout, Marvin Block and M.M. Glatt were among the authorities who responded in a special reprint from the 1963 Quarterly Journal of Studies on Alcohol to the effect that never in the thousands of cases they had treated was there ever a clear instance of a true alcoholic who returned to drinking in moderation. Ewing (1975) was determined to prove it could be done by using every technique known to behavior modification, but he also did careful and lengthy follow up - and at the end of four years every one of Ewing's subjects had gotten drunk and he called off the experiment Finally, Pendery and Maltzman (AAAS Science, July 9, 1982) exposed the failure of the Sobell work, using hospital and police records and direct contact to show that 19 of their 20 subjects did not maintain sobriety in social drinking, and the other probably was not a true alcoholic to begin with. 

The research of Peter Nathan indicates that whereas others may be able to use internal cues (subjective feelings of intoxication) to estimate blood-alcohol level while drinking, alcoholics cannot; so that method of control is not available to them. To ask a recovered addict to engage in "responsible heroin shooting" or a compulsive gambler to play just for small amounts is to ignore the whole psychology and physiology of addiction. Alcoholism is not a simple learned behavior that can be unlearned, but a habitual disposition that has profoundly modified the whole person, mind and body. That explains the admitted failure of psychoanalysis to achieve any notable success in treating alcoholics, and renders vapid the notion of Claude Steiner in "Games Alcoholics Play" that the alcoholic is a naughty child rather than a sick adult. Even the Sobells' claimed successful cases are now reported to have given up controlled drinking. For them abstinence is easier - for them trying to take one drink and stop is sheer misery. The reason is that one cannot "unlearn" the instant euphoric reinforcement that alcohol gives. 

James E. Royce, S.J., Ph.D. is professor emeritus of psychology and addiction studies at Seattle University and author of a leading textbook on alcoholism. 

Source: Seattle Post-Intelligencer©, July 29, 1995

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