Live Sensibly (with alcohol): Glossary Page, Newest First

Disease Model: Looking Forward

Here is the final installment of a four-pronged approach to nailing down some of the key concepts and history of disease as it relates to drinking and addiction:

1. Disease Model: Basics
2. Disease Model: Chronology
3. Disease Model: Debates
4. Disease Model: Looking Forward - (this page)

OK, if you’ve been following me through the previous three pages, I’ve become a broken record singing the praises of Bill White.

Once again, he’s put out some intriguing thoughts related to the disease concept of alcoholism, this time synthesizing its history with the current state of the world in order to envision what might come next. He does that in a 2001 article in Counselor Magazine, where he writes a column for his fellow professionals in the addiction and recovery field. A Disease Concept for the 21^st Century (26K PDF) lays out the following blueprint for a disease model which could better represent science and accumulated experience:

• The Tower of Babel: The new disease concept will forge consensus on a language that can be used to differentiate types and intensities of alcohol- and other drug-related problems.
• Alcoholism to addiction: The new disease concept will shift from an alcoholism model to a more encompassing addiction model.
• Boundary integrity: The new disease concept will carefully map its conceptual boundaries, defining the conditions and circumstances to which it should and should not be applied.
• Addictions versus problems: The new disease concept will place alcoholism/addiction within a larger umbrella of alcohol- and other drug-related problems.
• Disease variability: The new disease concept will portray addiction as a cluster of disorders that spring from multiple, interacting etiological influences and that vary considerably in their onset, course and outcome.
• Comorbidity: The new disease concept will define the complex inter-relationships between addiction and other acute and chronic disorders and champion integrated models of care for the multiple problem client/family.
• Role of human will: The new disease concept of alcoholism/addiction will define the role human will and personal responsibility play in the onset, course and outcome of AOD problems and of alcoholism/addiction.
• The variety of recovery experiences: The new disease concept will celebrate the variety of styles and pathways of long- term recovery management.
• Recovery management: The new disease concept will view addiction as a chronic rather than acute disorder and incorporate the principles of chronic disease management that are being used to understand and manage other chronic disorders.

It probably just proves that I’m geeky about alcohol issues, but that’s pretty exciting stuff to me.

If I were writing it, I’d juice up the “variety of recovery experiences” portion of this, specifying that ethical health care includes fully informing folks about available evidence, support, and treatment options. If I’m getting my heart checked out by a doc who tells me all about angioplasty but nothing about using healthy diet to prevent or manage a heart problem, I won’t be getting good care. In the same vein, if I’m talking to my doc about my drinking patterns, and he identifies a problem, I’m not getting good care if I leave his office believing that only one treatment option exists.

I hope the future brings a broader scientific and popular understanding of the shades of gray lying between the white light of abstinence and the dark fury of addiction. In general, folks seem to “get it” when someone says that being able to abstain or moderate effortlessly — on autopilot — is a good thing, as well as when somebody else talks about losing control over, or escalating quantity or frequency of, heavy drinking being a bad thing.

When somebody whose drinking falls somewhere between the extremes of safe/easy moderation and obvious addiction asks:

“Where is the line between sensible and unhealthy drinking?”

One common professional non-answer is:

“Well, just scale your drinking back — dramatically, instantly, & permanently — and everything will be fine!”

But, of course, the stages of change model tells us that change usually doesn’t happen that way, so the non-answer leans toward being a prescription for failure. The guy may hesitate to challenge the dramatic/instant change idea because doing so could earn him a merit badge for denial. He walks away from the conversation without viable alternatives, and even if he looks up moderate drinking, the diversity of definitions may be more confusing than helpful. Bottom line, he’s likely to continue living in murky gray territory, wondering and/or worrying about having a problem.

I can’t put words in the experts’ mouths on this, except to say: As a health care consumer, I expect better than the status quo. I’m looking for straight, simple answers to questions like “Where are the thresholds?” and “What are the risks in some of the different gray areas?” and “Help me identify solutions that fit my values and my life.”

Disease Model: Debate Points

Here is the third of a four-step approach to nailing down some of the key concepts and history of disease as it relates to drinking and addiction:

1. Disease Model: Basics
2. Disease Model: Chronology
3. Disease Model: Debates - (this page)
4. Disease Model: Looking Forward

Again, we’re deeply indebted to the work of Bill White. With research support from the Illinois Department of Human Services, Office of Alcoholism and Substance Abuse, he compiled a summary of key points (30K PDF) in the debates over the disease concept of alcholism.

Caveats apply to the listing below: White notes that folks on either side do not speak with a single voice. I have not attempted to make this a quantitative accounting of the information he documented. While covering a broad spectrum, the following table is indicative, not definitive, of the public discourse on the topic. Absorbing this gives us a sense of the diversity of thought in both communities without giving us a tool for generalizing about the precise thoughts of everyone who fits on a given side. Plenty of thoughtful folks (perhaps White himself) draw elements of truth and value from both sides of the divide.

If you’re interested in the details, please follow the link to his piece and/or dig up the source documents it references. As time moves forward, I hope to adapt this, expand it, and add links to supporting documents. Think of it as a broad map with smatterings of pushpins indicating places that have been visited. It gives us a satellite view of a broad expanse on which several points of interest stand out.

My approach to life leans toward common-sense, low-key, pragmatic understanding of problems and solutions. When I run into debates that seem to inspire a lot of screechy rhetoric, I get wary. Truth tends to be simple and fall somewhere in robust shades of gray more often than it can be defined in legalistic blacks and whites.

Conversations around the disease model have often devolved to the extremes, as Bill White describes:

Training events that touch on this debate have deteriorated into intense acrimony between participants wedded to extreme pro- and anti-disease positions, disease critics have been personally accused of killing people with their ideas, and each new article and book seems more strident than those that came before.

White speaks to the heart of the matter, though, with this:

It is this author’s view that the disease concept that emerged in the mid-20th century was a beautiful concept for its time. It “worked” in the truest sense and it worked at personal, professional and cultural levels. However, this concept enters the 21^st century with:

1. a poor scientific foundation;
2. a narrowly defined clinical profile that does not reflect the diversity of individuals seeking help for alcohol- and other drug-related problems; and
3. a poorly defined boundary that leaves it open to continued corruption and commercial exploitation.

The future of the disease concept will hinge on the ability of the addiction field to redefine this concept in light of accumulated scientific research and accumulated clinical and recovery experience.

Beautiful.

Let’s be as aware of this stuff as we need to be, folks, but not distracted or derailed from moving steadily forward in living consciously and sensibly.

Other pages in the disease model series:

• Basics: Intro to the Disease Model
• Chronology - How has the disease concept developed?
• Debates - (this page) - What are some of the perspectives on each side?
• Looking Forward: How might the disease concept be tuned up?

Disease Model: Chronology

We started our look at the disease concept of alcoholism with the basics page. Let’s expand on it now by understanding a bit of the history behind it. As it turns out, references to severe drinking problems as diseases extend back to the 1700s in the U.S., and some historians who have studied A.A. suggest that early members used it as a metaphor more than a fixed medical entity.

This is the second of a four-pronged approach to nailing down some of the key concepts and history of disease as it relates to drinking and addiction, setting up a foundation for each of us to use in thinking about how we choose to live sensibly with alcohol:

1. Disease Model: Basics
2. Disease Model: Chronology - (this page) - Sources, 1700s-present, & Layperson’s perspective
3. Disease Model: Debate Points
4. Disease Model: Looking Forward

On this page: (a) Primary Sources; (b) History from the 1700s-1940, A.A. Influences, 1940s-1970s, 1970s-present; and, (c) Layperson’s Perspective.

Primary Sources: Bill White and Ernest Kurtz

William L. White

is a Senior Research Consultant with the Lighthouse Institute at Chestnut Health Systems in Bloomington Illinois who has written extensively on addiction history. In the early 1990s, leaders within the Chestnut Health organization envisioned a textbook “that could collectively tell the story of addiction in America and the profession that was birthed to respond to it.” That led to White’s publishing of Slaying the Dragon: The History of Addiction Treatment and Recovery in America in 1998.

A detailed review of the book by Marty N. is available at the LifeRing Recovery site, including a short response from White. More recently, White has co-authored Drunkard’s Refuge with John Crowley.

White talked about his relationship with history in the preface of a 2000 paper:

I have lived and worked in the worlds of addiction treatment and recovery for more than three decades — all of my adult life — and it was my experiences in these worlds that first incited my fascination with history and my discovery of history as the ultimate elder. For many years, I have sat at history’s feet, listened to her stories, and tried to be an ardent student. The following pages are filled with my, admittedly inadequate, comprehension of the lessons that I believe history can offer…

Ernest Kurtz

is known as an eminent A.A. historian, and Bill White credits him as mentor and helpful reviewer in several of his papers. He is identified in this paper as follows:

Ernest Kurtz, after earning his Ph.D. in the History of American Civilization from Harvard University in 1978, taught American History and the History of Religion in America at the University of Georgia and Loyola University of Chicago. He is the author of Not-God: A History of Alcoholics Anonymous and many articles related to the history of A.A.

Historical Development of the Disease Model

The Behavioral Health Recovery Management site, BHRM.org, a project funded by the Illinois Office of Alcoholism and Substance abuse, includes a set of articles by White, Kurtz, and others which trace the evolution of the disease concept of addiction from the 5th century B.C. to the present. While its roots run deep, controversy and questions have travelled with the disease concept throughout its history.

From the 1700s to 1940

In Addiction as a Disease: Birth of a Concept (PDF, 35K), White notes that social reformer Anthony Benezet and Dr. Benjamin Rush were the first in the U.S. to characterize chronic drunkenness as a disease in the late 1700s. In 1829, Dr. William Sweetser recognized emerging medical descriptions of addictive disease, yet questioned whether such a disease should ever be defined apart from some sort of “moral turpitude.” The prominence of the disease concept faded at the close of the 1800s as prohibition movements gained momentum, which were more prone to describe drinking problems as the result of vice and sin, or name alcohol itself as a poison.

The temperance movement culminated in the passage of the Prohibition amendment in 1919. Its popularity was driven by beliefs that widespread temperance would enhance social order, but it was also tinged with anti-immigrant sentiments that eastern and southern Europeans emigrating to the U.S. were creating an alcohol-driven culture. Plagued with enforcement problems and impacted by changing moral standards, the amendment was repealed in 1933.

Ron Roizen’s 1991 dissertation, The American Discovery of Alcoholism, 1933-1939, traces a transition from a “temperance paradigm” at the repeal of Prohibition in 1933 to an “alcoholism paradigm.” In the temperance paradigm, which was still favored by many alcohol researchers in 1933, alcohol had qualities popularly associated with heroin today: The drug itself was considered widely addictive, offering no social benefits or framework in which moderate use might be socially acceptable. The alcoholism paradigm, by contrast, identified alcohol as “an addictive and destructive substance in only a minority of persons, known as alcoholics.”

Alcoholics Anonymous and the Disease Model

A.A., which took its first baby steps in 1935, has sometimes been credited with birthing the 20^th-century alcoholism-as-disease concept. Ernest Kurtz tells us otherwise. In Alcoholics Anonymous and the Disease Concept of Alcoholism (144K PDF), he points out that the principles of A.A. didn’t include dogmatic insistence on naming alcoholism as a unitary disease with a predictable course. On page 3 of that paper is a 1961 quote by Bill W.:

We have never called alcoholism a disease because, technically speaking, it is not a disease entity. For example, there is no such thing as heart disease. Instead there are many separate heart ailments, or combinations of them. It is something like that with alcoholism. Therefore we did not wish to get in wrong with the medical profession by pronouncing alcoholism a disease entity. Therefore we always called it an illness, or a malady — a far safer term for us to use.

Kurtz describes a complex intermingling of roles and messages between A.A., the Big Book (which didn’t focus heavily on a specific disease model) and publishers of the A.A. Grapevine, an “officially unofficial” newsletter which often promoted a medicalized unitary disease concept.

In fact, the disease concept promoted by A.A. co-founder Dr. Bob (a proctologist) was alcoholism as “an illness which only a spiritual experience will conquer,” more a metaphor than a medical mechanism. Bob was noted by his fellow A.A. members as deeply spiritual, given to soul-searching prayer with a alcoholics taking their first steps toward sobriety. For him the importance of the disease concept lay in conveying the hopelessness of terminal illness which only a higher power could touch.

1940s to 1970s

Bill White names 1942-1970 as The Modern Alcoholism Movement in The Rebirth of the Disease Concept of Alcoholism in the 20th Century (23K PDF). Propelled by a coalition of three alcohol-oriented research and educational organizations, the concept that alcoholism is a disease attracted increasing attention and approval. The Minnesota Model of 12-step-based treatment emerged from approaches pioneered by three Minnesota facilities in 1948-50.

Dr. E.M. Jellinek’s book, Disease Concept of Alcoholism, first published in 1960, is identified by White as:

the most widely cited (and least read) literary artifact of the modern alcoholism movement. In it, Jellinek noted the growing acceptance of the disease concept of alcoholism but expressed his reservations about this oversimplified understanding of the disorder.

He suggested there were a variety of “alcoholisms,” only two “species” of which he thought merited the designation of disease, and went on to criticize the tendency to characterize alcoholism as a single disorder.

Jellinek also expressed concerns about the disease concept which were echoed in the 1955 thoughts of psychiatrist and friend to A.A., Henry Tiebout:

[T]he idea that alcoholism as a disease was reached empirically by pure inference […] had never been really proved. …I cannot help but feel that the whole field of alcoholism is way out on a limb, which any minute will crack and drop us all in a frightful mess.

1970s to the Present

Bill White summarizes:

During the late 1970s and early 1980s, there was an explosive growth of treatment programs, particularly hospital-based and private programs, which used the disease concept.

The most widely replicated treatment approach in both private and public programs was the Minnesota Model, which perceived addiction was a primary disease. In short, the disease concept altered the public’s conception of the alcoholic and challenged medical and public health authorities to take responsibility for the treatment of alcoholism — a significant achievement.

Every significant social movement has the potential to generate a counter-movement, and this happened with the alcoholism movement. The backlash came in two forms. The first was a financial backlash against the business-practice excesses of the treatment industry. Aggressive programs of managed care that restricted treatment access and duration led to a plummeting daily census within, and the eventual closing of, many inpatient programs. Particularly impacted was the prototype 28-day inpatient treatment program that had most exemplified the disease concept. The second backlash was ideological and took the form of growing philosophical and scientific attacks against the disease concept and the treatment programs based upon it.

The 20th century ended without popular or professional consensus on the nature of alcohol and other drug problems and the strategies that could best resolve these problems at a personal or cultural level.

The Layperson’s Perspective: What Can We Take From History?

Looking at the historical perspective, it becomes clear that there is no easy slam-dunk support for a unitary primary, progressive, chronic disease concept of alcoholism.

If anything, the clearest support emerging over time seems conditioned to recognize the existence of many problematic drinking patterns, with the disease concept best equipped to describe the most severe end of the spectrum.

In that context, it seems reasonable that the course of some drinking problems may play out similarly to adult onset diabetes. Some forms of diabetes require lifelong treatment at the most intensive level. Others require close attention initially but taper off in severity, responding effectively to control via precise diet and exercise. Still others find that treating morbid obesity with long-term weight loss restores a natural balance in which the body’s insulin production and regulation are essentially normal.

Stanton Peele has written about folks who mature out of problematic drinking patterns. He points to a study which found a familiar group of folks — previously alcohol-dependent, received treatment, now abstinent — but an even larger group who were previously dependent, did not receive treatment, and were currently drinking but not showing dependence. (Lack of dependence would not be the same as complete freedom from drinking problems in all cases, but still indicates a measurable decrease in severity.) He notes:

In the maturing out approach, people come to see that “recovery” is a natural process that is more likely than not to occur as long as they make realistic progress in the key areas of their lives.

As I concluded on the previous Disease Model page, finding ourselves in less-than-optimal drinking patterns doesn’t necessarily mean we’re all dealing with the same problems or that we’ll all find the same answers to be effective.

Other pages in the disease model series:

• Basics: Intro to the Disease Model
• Chronology - (this page) - How has the disease concept developed?
• Debate Points: What are some of the perspectives on each side?
• Looking Forward: How might the disease concept be tuned up?

Disease Model: Basics

When we’re in reasonably stable, healthy space, it might not matter much to us as laypeople whether drinking problems fit into a disease model or not: Either a disease model makes sense, given our experience, and helps to keep us focused on abstinence-based recovery, or disease concepts aren’t such a good fit and we’re making pragmatic choices to sustain abstinence, moderation, and/or harm reduction.

When there is a disconnect between where we’re at with our drinking and where we’d like to or need to be, though, making sense of the disease concept can bear directly on the choices we make in moving forward.

This is a seminal issue for a lot of folks. In the world of alcohol-related care, careers and industries have built to varying degrees on both sides of the “Is addiction a disease?” question. Even for us as nonprofessionals, speaking too broadly about drinking problems outside a disease model can earn us the denial label.

My goal here is to speak to the better-known perspectives on the disease model, not to launch fresh salvos in the battle. It is too easy for those of us who have found ourselves in unhealthy places with our drinking to get mired in thinking instead of doing; as I look at the diversity of perspectives here, the thing that becomes most clear is that we can act to resolve our problems from either a disease- or a non-disease-based paradigm.

I’ll take a four-pronged approach to nail down some of the key concepts and history of disease as it relates to drinking and addiction. That still amounts to just the tip of the iceberg, which you can see by digging through the links, but hopefully it sets up a foundation for each of us to use in thinking about how we choose to live sensibly with alcohol. The topics are:

1. Disease Model: Basics - (this page) - (a) Disease definitions; (b) A popular 1980s view; (c) Vaillant & Peele debate; and, (d) Disease and the layperson
2. Disease Model: Chronology - What is the history behind disease models of addiction?
3. Disease Model: Debate Points - What are some of the key words and concepts underlying disease concept controversy?
4. Disease Model: Looking Forward - How might the disease concept be applied more critically in the future?

Disease: Dictionary and Wiki Definitions

Per Merriam-Webster Online, a disease is:

a condition of the living animal or plant body or of one of its parts that impairs normal functioning; (synonyms: sickness, malady)

From Wikipedia:

A disease is any abnormal condition of the body or mind that causes discomfort, dysfunction, or distress to the person affected or those in contact with the person. Sometimes the term is used broadly to include injuries, disabilities, syndromes, symptoms, deviant behaviors, and atypical variations of structure and function, while in other contexts these may be considered distinguishable categories.

So, the medical sense of disease is that it is a defect or impairment which prevents an organ or bodily system from functioning normally, causing discomfort or dysfunction. Here is a side-by-side comparison of how the disease model — in a strict medical sense — has been applied to diabetes and alcoholism:

The disease model traditionally referred to in the alcoholism treatment industry is broader than a strict medical construct, however.

A Layperson’s Description from the Eighties

When I started looking at my drinking in 2000, as I mentioned in my intro, I had no “I never knew this could happen” excuse. I knew I needed to be wary related to drinking. I was also well-acquainted with the disease model of alcoholism.

Household cleaning and organizing guru Mary Ellen Pinkham spelled out the disease concept I was familiar with in her 1986 book, How To Stop The One You Love From Drinking:

Doctors … say a disease is something that is primary, progressive, and chronic…

By primary, doctors mean that the alcoholism is a disease itself rather than a symptom of some greater social, emotional, or physical problem…

By progressive, doctors mean that the problem’s going to get worse. The fact is, it will inevitably lead to insanity or death…

By chronic, doctors mean exactly what you would expect. There is no known cure for the disease. You can, however, control it. Alcoholism is the most treatable — and yet the most untreated — disease that exists.

(Actually, while primary, progressive, and chronic have been used to describe alcoholism, the existence of other forms of disease — acute, relapsing-remitting, and secondary diseases — is well known.)

The thing I didn’t have a clue about until I started examining things in 2000 is that the disease concept is also the source of long-standing, deeply rooted disagreement among alcohol researchers.

Vaillant and Peele Debate

In his 1995 book, The Natural History of Alcoholism, Revisited, George Vaillant’s first chapter asks, “Is Alcoholism a Unitary Disorder?” He concludes (edited here for length & clarity):

We must learn to regard alcoholism as both disease and behavior disorder. To include any behavior disorder within the medical framework and to codify it with a unitary medical diagnosis, four criteria should be met:

1. Diagnosis should imply causitive factors independent of the presence or absence of social deviance (and alcohol dependence is significantly more likely when biologic relatives have also been alcoholic).
2. Diagnosis should convey shorthand information about symptoms and course (and alcoholism predicts a constellation of symptoms).
3. Diagnosis should be valid cross-culturally and not dependent on mores or fashion.
4. Diagnosis should suggest appropriate medical response for trement (and physical dependence often requires medical detoxification, and specific treatment is often required to sustain abstinence).

Stanton Peele reviewed the first edition of Vaillant’s book for New York Times Book Review on June 26, 1983. The 1996 forward for the review, available in full at Peele’s site, notes:

Stanton’s review of George Vaillant’s “The Natural History of Alcoholism” revealed that the emperor was naked, and that the book was intellectually dishonest. Vaillant systematically created summaries that disputed his own data, while citing cases selectively to try to support what he perceived to be the safe positions to take. As a result of Stanton’s review, Dr. Vaillant has for over a dozen years systematically attacked Stanton in speeches and workshops he gives around the nation, trying to square the circle by compulsively reinterpreting his (Vaillant’s) data to show that alcoholics never resume controlled drinking.

Additional excerpts from Peele’s review:

Vaillant … endorses the disease model, … but he also reaches for the middle ground by taking into account the research-based, social-psychological perspective that opposes the disease theory.

Dr. Vaillant finds that more than half of the alcoholics in the inner city group [(one of the decades-long study groups covered in the book)] evolved out of their drinking problems, generally without the assistance of treatment. He finds strong evidence in the inner city group for sociocultural causality in alcoholism… However, since Dr. Vaillant reports … that “genetic factors play a significant role in alcoholism,” he creates an impression that is at odds with his own research.

The cases [cited by Vaillant emphasize] the need for an alcoholic to acknowledge he has an uncontrollable disease and to seek redemptive [lifelong] treatment for it. When Dr. Vaillant reports that some alcohol abusers and alcoholics do return to moderate drinking, he notes that his subjects did so for period averaging more than a decade. Dr. Vaillant argues that this duration means that these results must be taken seriously but then illustrates his point with the paradoxical example of a man who claimed to have moderated his drinking but instead collapsed and died.

And, Peele concludes:

In alcoholism research, where one side regularly parades a new study and the other than vilifies it, Dr. Vaillant’s work can be cited approvingly by both. This is due in part to his admirable balance, fairness and honesty and in part to his willingness to accept contradiction and to defy his own research findings.

The Disease Model and the Layperson

So, what do the academic arguments about the disease model mean to us as laypeople? For most of us, the debates are pretty distant from our day-to-day existence. We aren’t making our living in the treatment industry, and if you’re like me, trying to decipher the technical side of the arguments can just leave you dizzy.

This stuff matters, though, if we need or want to change our drinking patterns but hesitate to get information or help because (a) the disease model isn’t a good fit for us, but (b) it appears to be the only game in town.

That described me in the early part of 2000. I was not content waking up most mornings with dry eyes, a pasty mouth, and hazy brain. I was willing to take steps to reverse the pattern, but hesitant to label my problem permanent and destined to escalate to tragic proportions. I wanted to solve the problem sooner than later. I figured it was possible that long-term abstinence might prove to be my only viable solution, but at that point jumping into it would have felt premature.

Of course, my experience is anything but universal. Some folks leave their drinking behind by taking a cognitive-behavioral or personal responsibility-based approach to abstinence. Others have stood in shoes like mine, clawing and scratching to escape from a growing sinkhole of problems related to their drinking. Finally emerging into the light of a clear-headed day, they have made peace by recognizing their escalating behaviors (and the natural consequences of them) as something which were destined to get much worse unless they were arrested completely. The primary, progressive, chronic disease model has offered them a clear choice and helped them to focus their energy on being healthy and balanced as they move forward.

The next three segments in this examination of the disease model:

• Chronology: How has the disease concept developed?
• Debate Points: What are some of the perspectives on each side?
• Looking Forward: How might the disease concept be tuned up?

Moderate Drinking: Beyond the Numbers

What does reasonably healthy, moderate drinking look like? Some of the best answers to that question have little to do with numbers of drinks and plenty to do with quality of life. On this page, we’ll look at some of the subjective descriptions of what it means to sustain reasonable balance in our drinking.

We’ve also looked at moderate drinking by the numbers.

Dr. Ruth Engs also has a pageful of hints taken from her 1987 book, Alcohol and Other Drugs: Self Responsibility, titled Hints for Sensible, Moderate, and Responsible Alcohol Consumption and Party Hosting.

Below: (a) Dictionary; (b) Moderation Management; (c) Rules-free; (d) Personal Responsibility; and, (e) A Way of life.

Moderate: From the dictionary

M-W.com offers this as its first definition for the adjective moderate:

1 a : avoiding extremes of behavior or expression : observing reasonable limits <a moderate drinker> b : CALM, TEMPERATE

WordNet 2.0 expands on that:

verb: 3. control, hold in, hold, contain, check, curb, moderate — (lessen the intensity of; temper; hold in restraint; hold or keep within limits; “moderate your alcohol intake”; “hold your tongue”; “hold your temper”; “control your anger”)

adjective: 1. moderate (vs. immoderate) — (being within reasonable or average limits; not excessive or extreme; “moderate prices”; “a moderate income”; “a moderate fine”; “moderate demands”; “a moderate estimate”; “a moderate eater”; “moderate success”; “a kitchen of moderate size”; “the X-ray showed moderate enlargement of the heart”)

MM’s Concept of Moderation

Moderation Management characterizes moderate drinking this way

A Moderate Drinker:

• considers an occasional drink to be a small, though enjoyable, part of life.
• has hobbies, interests, and other ways to relax and enjoy life that do not involve alcohol.
• usually has friends who are moderate drinkers or nondrinkers.
• generally has something to eat before, during, or soon after drinking.
• usually does not drink for longer than an hour or two on any particular occasion.
• usually does not drink faster than one drink per half-hour.
• usually does not exceed the .055% BAC moderate drinking limit. (see Note 1 below)
• feels comfortable with his or her use of alcohol (never drinks secretly and does not spend a lot of time thinking about drinking or planning to drink).

Moderate Drinking: Rules-free, Permanent

Addiction specialist Debra Jay offered a description of moderate drinking on an episode of the Oprah show titled Moms Who Drink Too Much:

If you don’t have a problem, you never even think about making up a rule [about when and how to drink]… [W]ith somebody who doesn’t have a problem, they don’t even have to think about it. They just really can use [alcohol] responsibly… They’re not going to be thinking at 2 o’clock about what they’re going to be drinking at 5 o’clock if they don’t have a problem.

In expanding on the rules-free concept of moderate drinking, Jay suggested that rule-making itself may not be a problem as much as rules that are repeatedly broken and take on an air of emotional unmanageability. She also identified a set of rules that could shift a person from problematic to moderate drinking:

[If] alcohol [is] creating repeated problems in any area of [your] life, … and you think, “Well, maybe I don’t have a problem,” you know what? Change your drinking behavior, cut way back … [committing that:]

• I’m going to drink when I’m not around my kids,
• I’m going to only drink with other people,
• I’m going to drink once or twice a week,
• I’m going to have one or two glasses of wine,
• And, [that] it’s a permanent change in my life.

If you can do it, you don’t have a problem.

Asserting Personal Responsibility to Drink Moderately

Dr. Stanton Peele offers an alternative to Ms. Jay’s never-make-a-rule guideline in his response to a drinker who says “there have been some occasions where I have drank more than I intended,” and wonders if they are a red flag:

Evaluating feedback about how your drinking is going is critical as you decide on your plans and goals…

A lot of drinkers occasionally drink more than they intend or than they wish they had. The issues are:

1. Is this a regular occurrence,
2. Can they stop, resist, and reverse this overdrinking,
3. Are they showing problems in their life as a result of overdrinking,
4. Do those close to them feel their overdrinking is harmful to the drinker and themselves?

Your answers seem to be “no” to these things…

Moderation as a Way of Life

In an important sense, quantifying moderate drinking is critical. The numbers help us to determine where the drinking risks lie and make well-informed choices.

But instead of being a numbers game, I find the essence of moderate drinking to be more about living than drinking or abstaining. After an extended phase when I wasn’t being very sensible about my drinking, getting healthy took time. There was no magic switch to flip, no mystical word of salvation to take me from being “lost” to being “found.”

What worked for me were Abstinence, Balance, and Consciousness.

I found abstinence helpful in grounding myself. It’s not as useful for everyone as it’s been for me, but once I started making peace with being DAFT — Delightfully Alcohol-Free Today — on a regular basis, I had more clear-headed energy to invest in the rest of the work. Some periods of abstinence have been weeks or months long; many have been embedded in weeks that also included a day or two of drinking.

Balance involved developing a number of skills, and freshening up existing ones. Goal-setting, self-examination, testing out rules, adjusting targets, and focusing on things that I value most were all a part of that. Gathering good information and getting support from my peers made a big difference.

It turns out that healthy balance isn’t always about setting iron-clad rules, at least for me. My life is often a pendulum which can swing into very positive space, or be blown into difficult or crisis-laden space. I can’t always prevent a wild swing from occuring, but I can use harm reduction to keep problems from compounding, and I recover more readily when I accept that the pendulum exists.

Learning to be more conscious is the glue that brings the abstinence and the balance together for me. I’ve grown to appreciate and resolve some of my ambivalence and demystify my relationship with alcohol. Awareness of the stages of change has allowed me to see where I’m at in the process, and keep taking small steps forward.

Bottom line, skill-building is empowering. Becoming a moderate drinker hasn’t been a personal purity campaign for me, trying to conform to a fixed numeric standard. It’s been about taking a lot of simple, pragmatic steps, being alert to various risks and agile about reducing and eliminating harm — all in the name of sustaining balance.

(Companion page: Moderate Drinking: By the Numbers.)

One Drink

How big is a standard drink, as generally cited in the U.S.?

The U.S. Department of Agriculture guidelines, in which moderate drinking is defined, say:

Count as a drink—

• 12 ounces of regular beer (150 calories)
• 5 ounces of wine (100 calories)
• 1.5 ounces of 80-proof distilled spirits (100 calories)

Moderation Management is a bit more specific in its definition of moderate limits:

Standard drink:

• one 12 oz-beer (5% alcohol); or,
• one 5-oz glass wine (12% alcohol); or,
• 1½ oz of 80-proof liquor (40% alcohol)

Each of these contains 0.6 ounces of pure alcohol. The Moderate Drinking book adds this information about drink sizes:

Special Note

To calculate a standard drink for other types of beverages, divide 0.6 [for 0.6 ounces of pure alcohol] by the percentage of alcohol in the beverage. (The alcohol content of most beverages is printed on the label. If it is not, contact the producer and ask for this information.) For example, if you want to know how many ounces of fortified wine there are in a standard drink, you would take 0.6 and divide by 0.2, since there is 20% alcohol in fortified wine. The result is 3 ounces of fortified wine. The amount of light beer (4.2% alcohol) that equals one standard drink is: 0.6 divided by 0.042, which equals 14 ounces. If the concentration of alcohol is listed as “proof,” as in 80-proof liquor, divide the proof by 2 to get the percentage of alcohol — 80 divided by 2 equals 40 percent.

The standard drink unit has been changed in this edition of Moderate Drinking from 0.5 ounces of pure alcohol to 0.6 ounces. This is the standard used in Canada and it translates to more practical portion sizes. Beer is most often sold in 12-ounce bottles, and most regular beers are now 5% alcohol (not 4%). In restaurants, wine is typically poured in 5-ounce portions, and drinks containing hard liquor usually contain 1½ ounces of distilled spirits. The BAC charts … reflect this change.

The International Center For Alcohol Policies notes that the concept of a standard drink varies from country to country:

Though a number of governments have issued “standard drink” specifications based on the amount of pure ethanol, these vary greatly from country to country. For example, the United States government defines a “standard drink” as 14 grams of ethanol: 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of spirits. But this standard does not apply in many other countries. In the United Kingdom, a “standard unit” contains the equivalent of 8 grams of ethanol; in Japan, the equivalent of 19.75 grams of ethanol constitutes a standard drink.

Moderate Drinking: By the Numbers

How much is too much? Two drinks? Five? Ten?

Oprah Winfrey asked that question on her show, but the answers she got seemed muddy to me.

It sounds like a simple question, but to be fair, the most accurate answers aren’t going to be monolithic or apply universally. Even the experts’ answers aren’t all the same. Let’s poke around some of the available answers from U.S. dietary guidelines, a study about harm thresholds, and recommendations in Britain and other countries.

Note that:

• The definition of a drink is on this page.
• Dual thresholds (one per day for women, two for men, for example) are used because of the physiological differences in the ways men and women metabolize and are impacted by alcohol.
• The companion to this page is: Moderate Drinking: Beyond the Numbers.

Below: Frameworks for moderate drinking: (a) One/Two drinks daily; (b) U.K.: Three/Four units daily; (c) Three/Four daily with 9/14 weekly; and, (d) Higher Levels, and then a Summary.

One/Two Drinks Daily

The NIAAA cites the Dietary Guidelines for Americans (233K PDF), also known as the Food Pyramid, as the source for its numeric definition of moderate drinking. The Food Pyramid was developed jointly by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services. From page 40 of the guidelines:

If adults choose to drink alcoholic beverages, they should consume them only in moderation.

WHAT IS MODERATION?

Moderation is defined as no more than one drink per day for women and no more than two drinks per day for men.

Current evidence suggests that moderate drinking is associated with a lower risk for coronary heart disease in some individuals.

The guidelines also list risks of drinking more than the moderate amount, as well as the conditions under which folks are better off abstaining.

The NIAAA’s 1992 Alcohol Alert, "Moderate Drinking" discounts the usefulness of quantifying moderate drinking, and makes the following points:

• Moderate drinking (i.e., that which does not generally cause problems) is often confused with — but is distinct from — social drinking (patterns that are generally accepted in the society in which they occur).
• The accuracy of numeric definitions of moderation is tempered by the wide range of effects a given dose of alcohol may have on people of different sizes, genders, and drinking histories.
• Evidence suggests that moderate drinking may have psychological and cardiovascular benefits.
• Negative effects of moderate drinking may include higher incidence of stroke, vehicle crashes, medication interactions, birth defects, and future alcohol abuse and/or dependence.

U.K.: Three/Four Units Daily

In the U.K., an interdepartmental group of officials was convened in 1994 to review medical and scientific evidence on the long-term effects of drinking alcohol. Its results were published in the December, 1995 report "Sensible Drinking". (If you’re interested in a detailed review of the evidence, follow the link to the PDF version of the report — it is a thorough accounting of global scientific evidence as of 1995.)

Drink units are measured in increments of 8 grams of pure alcohol in the U.K., compared to 14 grams of alcohol per drink in the U.S. The Sensible Drinking report’s recommendations included:

MEN: Regular consumption of between 3 and 4 units a day by men of all ages will not accrue significant health risk.

WOMEN: Regular consumption of between 2 and 3 units a day by women of all ages will not accrue any significant health risk.

The International Center for Alcohol Policies (ICAP) analyzed the distinctions between the U.S. one/two drink and the U.K. three/four unit recommendations in this report (360K PDF):

The alcohol levels deemed safe for women by UK standards are approximately 70% higher than the levels deemed safe in the US. The difference in levels deemed safe for men, on the other hand, is only 17%.

Three/Four Drinks Daily, 9/14 Weekly

Moderation Management names slightly higher daily limits than the NIAAA, while its recommended weekly limits are in sync with the NIAAA definition.

MM Limits:

• Strictly obey local laws regarding drinking and driving.
• Do not drink in situations that would endanger yourself or others.
• Do not drink every day. MM suggests that you abstain from drinking alcohol at least 3 or 4 days per week.
• Women who drink more than 3 drinks on any day, and more than 9 drinks per week, may be drinking at harmful levels.
• Men who drink more than 4 drinks on any day, and more than 14 drinks per week, may be drinking at harmful levels.

Notes: (1) BAC info, BAC charts; (2) Standard drink definition

The MM limits are based on research by Martha Sanchez-Craig, DA Wilkinson and R Davila: Empirically based guidelines for moderate drinking.

Dr. Reid Hester, a researcher and clinician who supports MM and SMART (short bio here), also offered this definition of moderate drinking in 2000:

It’s no more than 2 or 3 standard drinks per drinking episode, no more than 9 drinks per week for women and 12-14 for men. Also, moderate drinking means limiting how fast you drink and, as a result, keeping your blood alcohol concentration (BAC) below .045-.055.

Evidence of Low Risk at Higher Levels

Dr. Stanton Peele and Dr. Archie Brodsky published a paper on the psychological benefits of moderate drinking. In it, they noted the challenges of defining moderate drinking.

Within the U.S., …the level of drinking linked with lowest mortality has sometimes been measured to be substantially higher than [the one/two drink daily limit] (Greenfield et al., 1999). …Rehm and Bondy (1998) reported, “Heavier-drinking cohorts tend to display their minimum risk at relatively higher levels of alcohol intake than cohorts with lower alcohol consumption” for which there was “no satisfactory explanation” (p. 223).

Cohorts? I tell ya, the number of cohorts lurking in my daily vocabulary is … ahhh … well … none. To me, the basic point is that some folks drinking above the one/two daily threshold have not experienced a proportional increase in risk.

Related to its three/four unit recommendation, the U.K. Sensible Drinking report noted (emphasis added):

The problem drinker

(10.7) Our recommendations are for the individual drinker in the normal drinking population. They are not framed particularly to influence clinical treatment of problem drinkers or indeed their recognition. We wish to move away from a culture of advice on consumption levels which has been interpreted by some as categorising all those who drink above the currently recommended levels as heavy or problem drinkers when, clearly, the vast majority of them are not.

In The Natural History of Alcoholism, Dr. George Vaillant spoke of a study which followed 204 men from their sophomore year of college — 1940 — through 1980:

The men in the College sample have reported their alcohol use relatively accurately every 2 years for 40 years. Between the ages of 40 and 60, several men regularly recorded drinking six ounces (four drinks) of whiskey a day — or more than a gallon a month — for more than 20 years without problems. However, no man in our College sample reported drinking over five drinks a day without reporting unwanted symptoms and concern over his capacity to control his drinking.

So, in this limited sample (men aged 40-60 who had attended an elite college), a 20-year pattern of four drinks per day — equal to MM’s daily limit, but double the MM and USDA weekly limits — produced no measurable consequences.

Finally, ICAP (the International Center For Alcohol Policies) analyzed moderate drinking recommendations around the globe, and published the results in this report supplement (31K PDF). A table on the second page of the report notes that recommended moderate levels in Austria, Canada, Denmark, New Zealand and Romania are in ranges roughly similar to those in the U.S. and U.K, while those in Australia, Italy, and Japan are higher.

Summary

The Food Pyramid gives us a structure within which to understand what our bodies typically need to be healthy. It is based on some of the best data we’ve got, and yet it’s not the only data we’ve got. It doesn’t dictate the only valid path we can take — some of us have rearranged it substantially to follow low-carb or vegan diets, for example — nor does it make value judgments if we choose to eat more pizza or fewer vegetables than recommended.

(In round numbers, the guidelines in the official food pyramid document use the word “can” about 40 times, “should” 20 times — 3 of them related to drinking — and an unconditional “must” only once, when noting that vegans must supplement with B₁₂.)

That seems like a good model, to me, for understanding its one/two daily drink guideline. If we want to compete as athletes, survive the rigors of medical residency, qualify as astronauts, or other endeavors requiring top-notch physical conditioning, we will need to heed the pyramid, including the drink limits. Those of us who seek reasonably good (but less than Olympian) health and functioning should understand the risks of stretching the pyramid’s boundaries, but there is some wiggle-room built in: Consuming a little more pizza, few less vegetables, or a bit more wine is generally not going to turn an otherwise contented life sour and short.

Balance, of course, is the key. The best way to create it is by examining the experts’ recommendations in the context of our values and goals so that we can make well-informed choices.

(Companion page: Moderate Drinking: Beyond the Numbers.)

Stages of Change: Core Concepts

On the Stages of Change: Background page, we established that none of these, on their own, are consistent predictors of change:

• New Years resolutions
• Hitting bottom
• Willpower
• Specific psychotherapy approaches
• Breaking denial

(Of course, any of these may contribute to change, but none is an absolute prerequisite.)

Instead of using any single technique, Prochaska and his colleagues found that successful changers moved through an identifiable series of stages. I’ve drawn the summary information in this table from chapter 2 of the Stages Of Change book as well as my own experience, naming typical perceptions, intentions, motivations, potential pitfalls, and emotions at each stage:

Some of the lessons learned from following people through the stages have included:

• Don’t want to change? That is to be expected. Looking at how this works and understanding the options may plant seeds for future change.
• Feeling stuck? Been hoping to change for years? That’s no surprise. There are options for us to consider that will help us get unstuck.
• Mired in hopelessness? Relax for a bit. Feeling dejected is normal in the first stage, but is not permanent.
• Are we pressuring ourselves to leapfrog — skip over or rush through — the early stages? That is neither necessary or wise.
• Is the action stage scary or overwhelming? No problem. The only requirement is for us to (1) Determine which stage we’re at; and, (2) Take baby steps toward the next stage.
• Prefer self-guided change? Professional assistance or coaching? Some of both? All of those are valid paths.

In a world innundated with self-help gurus offering one-size-fits-all formulas, the stages of change model breaks the mold. It says that any number of specific methods are likely to work, and that tailoring our timeframe and methods to our unique needs and coping skills increases our chances of success. It gives us room to ask questions and make conscious choices, and it meets us exactly where we’re at.

Coming next: Stages of Change: The Processes

Stages of Change: Background

New Years resolutions are a time-honored tradition. After eating our way through the holidays, we promise to change our diet or pick up a new exercise routine. Statistics don’t offer us much hope, though — few resolutions stick with us for long, except for those of us who have made the same resolutions, year after year, without making much progress in between.

Watching Oprah and reading self-help books brings us into contact with another supposed trigger of change: Hitting bottom. The bottom can be high (not-so-severe consequences), low (homeless, lying in a gutter), or in between, but the common wisdom is that we’re likely to change afterward. But, if that’s the case, why have addiction treatment success rates (measured as continuous abstinence for a year) generally fallen under fifty percent?

James Prochaska wondered about those kinds of things as he watched his dad struggle with depression and addiction, and die prematurely. His questions about how we might better understand what is working when folks do change their behavior propelled him deeper into his psychology research. If we could just understand the common characteristics of those who have changed, how might the folks who are still struggling use that to improve their odds?

He started by taking a broad look at all of the major approaches to psychotherapy. Lester Luborsky set the stage for his work in 1975, noting that:

when patients are professionally treated, they get better, but symptomatic improvement is not related to the type of therapy they receive, […with] the improvement [being] about the same whether patients receive psychodynamic psychotherapy, cognitive therapy, behavioral therapy or pharmacotherapy.

In 1979, Prochaska published the first edition of Systems of Psychotherapy: A Transtheoretical Analysis, in which he showed that most therapeutic approaches rely on a few core processes.

But the fact remained that rates of actual change were low — only 10-25% of folks with drinking, obesity, or mental health issues seek out therapy, and 45% of those who do drop out prematurely. (And many of the folks who never get help change independently anyway.)

Dr. Prochaska and his colleagues, John Norcross, Ph.D., and Carlo DiClemente, Ph.D., decided to turn the question around. Instead of starting by looking at specific therapies and processes, they studied folks who had changed their behavior successfully. Since none of the familiar factors — New Years resolutions, hitting bottom, or specific therapies or programs — would explain behavior change consistently on their own, what might the successful changers have in common?

They laid out their results, in readable form for laypeople like you and me, in their 1994 book, "Changing For Good". It turns out that 80% of us who could benefit from change are not acting on it at any given time because we’re not yet fully prepared. And, the effective changes we make (with professional help or independently — success rates are comparable for both) generally follow well-defined stages.

On page 14 of the book, Dr. Prochaska described the existing approaches to change as the “action paradigm,” which:

has dominated behavior change programs for the past three or four decades. Following this model, clients are enrolled in relatively brief programs designed to conquer smoking, weight, alcohol, or other problems; within weeks they are expected to take action and adopt healthier lifestyles. If they fail to take or maintain action, the clients themselves are blamed for lack of willpower or motivation.

Does that scenario sound as familiar to you as it does me? Ever bought a promising self-help book that never got finished, or produced only limited action? Signed up for a weight-loss program but still see the same numbers on the scale? Made a genuine promise to yourself, only to wonder later if you were in denial? Ever blamed — or shamed — yourself when things didn’t come together as hoped?

But that’s the outdated perception of how change works. Here’s the more accurate, evidence-based understanding: Most of us follow a predictable series of stages on our way to change. Willpower has little to do with our success; it is much more about whether we invest sufficient time and energy in the preparatory stages.

Continue reading: Stages of Change

Binge

Usage of the word “binge” has evolved in recent years.

Binge: The Dictionary Version.

Merriam-Webster defines it this way:

a drunken revel : SPREE; an unrestrained and often excessive indulgence <a buying binge>

Princeton’s WordNet 2.0 speaks of immoderate indulgence:

The noun “binge” has 2 senses in WordNet.

1. orgy, binge, splurge — (any act of immoderate indulgence; “an orgy of shopping”; “an emotional binge”; “a splurge of spending”)
2. bust, tear, binge, bout — (an occasion for excessive eating or drinking; “they went on a bust that lasted three days”)

The verb “binge” has 1 sense in WordNet.

1. gorge, ingurgitate, overindulge, glut, englut, stuff, engorge, overgorge, overeat, gormandize, gormandise, gourmandize, binge, pig out, satiate, scarf out — (overeat or eat immodestly; make a pig of oneself; “She stuffed herself at the dinner”; “The kids binged on icecream”)

Twenty-four Hours: A Short Binge?

In the substance abuse field, the longest-standing definition of “binge” refers to an episode of heavy drinking, usually lasting more than a day. In the NIAAA’s ETOH database glossary we find:

A pattern of heavy drinking that occurs in an extended period set aside for the purpose of drinking. In population surveys the period is usually defined as more than one day of drinking at a time. The activity of binge drinking also is referred to as “bout drinking” or “spree drinking.” The term “drinking bout” is used to refer to the occasion. A binge drinker or bout drinker is one who drinks predominantly in this fashion, often with intervening periods of abstinence.

My buddy Brian was a binge drinker in this sense of the word. He would buy 2-5 bottles of Scotch (and not small ones) and start drinking at while playing at the computer, and later, watching TV. A gap of a couple hours between drinks was possible when passed out, but the heavy drinking continued not too long after getting up. When we were closest, in the mid 1990s, a 24-hour binge was less common and most of them fell in a range of 36 to 72 hours. Then, as in the definition, abstinence would prevail for several weeks.

College Binge Drinking: The 5/4 Definition

In the early 1990s, studies of alcohol use on college campuses began adapting the use of “binge” to describe having 5 or more drinks “in a row”, without specifying a timeframe.

The College Alcohol Survey, which collected data from over 17,000 students on 140 campuses in 1993, led by Dr. Henry Wechsler, Ph.D. with support from the Robert Wood Johnson Foundation, split the definition to account for gender differences. Its report titled "Health and Behavioral Consequences of Binge Drinking in College" in the Journal of the American Medical Association noted:

(p. 1674, col 1) Binge drinking was defined as the consumption of five or more drinks in a row for men and four or more drinks in a row for women. …the term “binge drinker” is used to refer to students who binged at least once in the previous 2 weeks.

(p. 1673, col 2) The use of [“in a row”], without specification of a time elapsed in a drinking episode, is consistent with standard practice in recent research on alcohol use among this population.

(p.1672, col 3) [Previous] studies of college alcohol use … [have generally] used the same definition of binge drinking for men and women, without taking into account sex differences in metabolism of ethanol or in body mass.

The 5/4 definition has resonated in the media and among public health advocacy groups, but failed to win widespread acceptance among academics and researchers. The International Center for Alcohol Policies questioned it in a 1997 report:

Defining a drinking pattern solely by the number of drinks consumed … falls short of being adequate. This approach fails to take into account the context of drinking, the individual engaging in the behavior (a 250-lb male is likely to experience very different consequences from five drinks than is a 100-lb female), and the salience of alcohol within the drinking occasion. The time interval over which the drinks are consumed is a critical variable, but also one on which there is no consensus. The effects of consuming five drinks over the course of a three-hour dinner are likely to manifest themselves very differently from the effects of consuming five drinks in rapid succession over half an hour.

An October 2000 press release by the Higher Education Center for Alcohol and Other Drug Prevention noted:

Most researchers in the field are now rejecting use of the word “binge” to describe having 5/4-plus drinks over some unspecified period of time. It is true that various government reports use it, but the National Institute of Alcoholism and Alcohol Abuse (NIAAA), the federal government’s primary research institute in this area, never does, nor does the Journal of Studies on Alcohol, which is the lead journal in the field. Moreover, a special panel on alcohol prevention and treatment in higher education convened by NIAAA voted unanimously last year not to use the term “binge” in this way.

NIAAA’s 2004 Binge Definition

During its February 4-5, 2004 meeting, the National Advisory Council on Alcohol Abuse and Alcoholism (which advises the NIAAA), unanimously approved