Martin's Alcoholic Diary

Martin, a 30-something guy in the vicinity of Manchester, England, has been writing a diary of his journey with alcoholism since October, 2002.

He has mentioned his drinking history prior to getting inpatient treatment in June 2002, but not dwelt not on it. Dire circumstances precipitated the hospitalization, which led to 10 weeks of sobriety.

Early months: Alcoholism as a battle

True to his introductory words about living with alcoholism being a battle, the early journal entries recounted 4-10 drinking episodes in each month from November 2002 through March 2003. Sometimes he journaled while sipping the first glass of wine; other times he recounted having drunk 2 bottles (occasionally more) a day or two afterward. Some drinking incidents, like the single glass during Christmas lunch, were less substantial and others, like those in March, were heavier and occurred on consecutive days.

Throughout it all Martin seems grounded in the need to get good care. He talks about staying in touch with his GP to coordinate anti-depressant dosage and monitor side effects, and about having a good relationship with his company doctor. When drinking incidents seemed to accelerate in March 2003, he got back in touch with the treatment facility and returned for a 3-week inpatient stay ending in early April, and continued with its aftercare program.

A full spectrum: Good life amidst the challenges

By his own account, he has sustained a rich, productive life along the way. He and his partner have had a new home built, moving in a year ago. His young daughters are the light and joy of his life. His employer has adapted, if begrudgingly at times, to his health care needs. The relationship with his partner has seen ups and downs, yet some of its dark moments have turned out to be not as severe as they first seemed to him.

The stresses have been real, as well. The relationship with his ex-wife can be contentious, turning life upside-down on top of the trials that come with being a noncustodial parent. The drinking strains the relationship with his partner, whose career-related challenges have surged at times. Conflicts with members of the extended families, familiar to many gay couples, tend to spike around holidays and celebrations of milestones.

Turning point: Second round of treatment?

The second treatment episode, ending in early April 2003, seems to mark a turning point. Prior to it there were fairly regular cravings, little mention of aftercare at the treatment facility, regular attendance at AA meetings, and 4-10 days in each of the five preceding months during which he drank. For the year beginning in late March 2003, there was only one day on which drinking occurred (a single glass of wine), heavy involvement in aftercare at the facility, fewer mentions of cravings, and a tapering back of anti-depressant dosage for a while in the fall.

Things got a little more challenging in April of this year, with 3 drinking days, and drinking has come into the picture on 6 days total from May through August.

Overall trend: Up

There appears to be a positive trend over the past two years:

Martin still describes a significant gap between where he is and where he intends to be. Keeping 95% of his days alcohol-free is noticeably better his past, but the drinking days remain disruptive to his health, his relationships, and his peace of mind. The fact remains, though, that the 17 months since April 2003 have been 98% alcohol-free.

October 2003: One glass

Seven months after the start of the second inpatient treatment, Martin bought wine and drank a glass. Finding the experience to be very distressing, he consulted the folks at the facility and elected to get relapse-related care from them on an outpatient basis over the next 10 weeks or so. Also working closely with his GP, his antidepressant dosage was adjusted, and he followed his doctor’s orders to focus on self-care, away from work, for two weeks in December.

Many phases, multiple choices and solutions

The powerful thing about Martin’s story, to me, is the reminder that dealing with alcohol-related issues is a dynamic affair. From the outside, it may look like a lot of folks find recovery through an awakening that puts life on an entirely new plane, but even for those whose recovery journeys appear placid and peaceful the path has often been rocky.

His path has included working with treatment folks, peer support from AA, and leaning on sponsors for guidance. He’s worked with Acamprosate and tried out dietary options. Some aspects of the disease concept have appeared baffling at times, but he also has asked questions (about powerlessness, for example) and gotten answers that have been helpful.

The battle remains for him. Cravings spike, and frustrations sprout on good days and bad. Being a work in progress isn’t just an addiction thing, though, it’s a life thing. For so many issues, resolution comes from a process instead of a one-time result.

Martin’s journal shows a lot of tenacity — a steadiness about continuing to engage in the recovery journey amidst questions and challenges — as well as in choosing to do so publicly. Week in, week out, he has kept coming back to talk a little bit more about where things are at. Sometimes it draws feedback that may feel a bit intrusive, but he keeps listening.

It could have been a lot easier to give it up when questions came up about his family reading it, or when things have not gone well. I admire him tremendously for sticking with it, for giving voice to a recovery path that seems to be headed in a positive direction.

This is a good guy, a fighter, a thoughtful dad, a real person. There is much for me to learn from him.

The horse? It seemed sober

This just in from Latvia:

Police in eastern Latvia were trying to determine Wednesday what charges to bring against a drunken horse-and-buggy driver who caused a drunken motorist to crash into a ditch, flipping his car.

Nobody hurt, the car driver fined and license revoked, but Latvian law doesn’t criminalize taking the reins while intoxicated.

Via Sarpy Sam at Thoughts from the Middle of Nowhere.

Julie R's Naltrexone Mini-Journal

Dean Esmay links to an article which reviews current and developing drug therapies.

One of the drugs, Naltrexone (Nal), has shown promise both for folks seeking to abstain permanently as well as those who are drinking moderately or working toward a moderate drinking goal. Julie R., a Moderation Management member, has journaled vividly about her recent experience with it and has graciously agreed to let me share a bit of it with you.

Her experience with it strikes me as similar to that of folks using antidepressants — some trial and error is necessary to find the best dosage, results can vary from day to day, and the drug supports, not replaces, insight and effort — and you’ll see that she describes trade-offs in using Naltrexone, as well.

Dr. Alexander DeLuca, M.D. is a great online source for papers on this topic, updated regularly as new stuff is published.

July 27 2004

I didn’t have a drink last night. It was my first abs night in months, I think. And it may be the beginning of an indefinite abs.

I preceded it the way so many abs periods start, with heavy drinking, which is actually not a very pleasant experience when you’re taking naltrexone. You keep reaching for that high, and reaching, and instead, all you get is stoned, stupid, dehydrated, and hungover. When I finally couldn’t hold anymore, I poured the rest out. When I woke up yesterday morning, I talked into a tape recorder for a while about how awful an experience it was and how much I wanted my freedom from what has become an unpleasant habit.

Thanks to naltrexone, alcohol has lost its value as a recreational drug. It took a while (I started taking it six weeks ago), and it is not an easy process, but it bloody well works if you take it as directed and have effective help for the issues underlying the drinking (sleeping, depression, neurotic fears).

I can’t remember what it feels to drink without nal. Those memories have been replaced by how it feels to drink with nal. Which ain’t all that great. I mean, it’s something — it gets you to sleep, it makes you forget, it relieves anxiety. But if you’re getting adequate support for the sleep and the anxiety and whatever, as I am, booze is a relatively poor self-medication, if you subtract the endorphin high, which nal does.

I suspect that the way it feels for me to drink on nal is the same as it feels for a non-drinker without any endorphin deficiencies or sensitivities to drink. You know, non-drinkers honestly just don’t like drinking as much as we do. If they did, they’d be drinking, by golly.

July 29 2004

I was watching a movie last night, and at some point three characters have reached the cocktail hour at the end of a long day and one of them says, “Harry, could you organize some drinks for us?” And I suddenly remembered what it feels like to drink without naltrexone. Of course I know it’s different, but I generally can’t remember what it was like to drink without naltrexone. Watching others do it on the screen reminded me — all the relaxing and forgetting of the first cocktail. “Let the healing begin!” as the guy in the New Yorker cartoon says as he order his first double martini, dry.

I wonder how long it will be before I have that feeling again. It is entirely my choice when I do or do not.

In the meantime, I’m more interested in figuring out what it is like to live without alcohol again.

I don’t much want a drink, because it would be a drink with naltrexone, which is not all that pleasant. I think I’d like to just stay the way I am for a while, give my liver a break, think things through with a clear head, do my job.

August 19 2004

I regret to report that my drinking is back up to my pre-naltrexone levels. My psychiatrist says, however, that I’ve got so much going on right now hormonally and neurochemically that it’s too soon to call the experiment a failure, and he has encouraged me to keep taking it and see what happens, so I will.

Update

Ooops, it was actually Joe Gandelman, who also writes at The Moderate Voice, who posted the link at Dean’s site. Dean weighed in with a comment shortly after.

Joe Six Pack in the News

Keith Emerich has bounced in and out of the news in recent weeks. His physician contacted the Pennsylvania Department of Transportation (PennDOT) to identify Emerich as having a condition that could impair his ability to drive safely. Radley Balko has also tracked the story.

The condition which the law requires the doctor to report is alcohol misuse — which Pennsylvania legal code doesn’t define any further — not addiction or dependence.

Let’s take a look at the sequence of events, how Emerich stacks up against the criteria for alcoholism, then sensible drinking, treatment options, and finally ethical perspectives.

The chronology:

• 1960s: PA passes a law requiring doctors to report patients with impairments that could compromise their ability to drive safely such as seizure disorders and Alzheimer’s; licenses are recalled indefinitely until the driver proves competency to drive.
• 1976: PA legislature creates the Medical Advisory Board to decide which conditions warrant license suspension.
• February 2004: Emerich seeks medical care for an irregular heartbeat. Asked about his drinking, he says 6-10 beers nightly is typical. Alcohol is identified as damaging his heart, and he is advised to cut back.
• 01-April: Emerich receives a notice from PennDOT saying that his driver’s license will be recalled in a month for medical reasons related to substance abuse. A physician has followed PennDOT instructions (20K PDF), which encourage the doc to report and protect him/her from being sued.
• 06-May: Emerich’s license is recalled by the PennDOT.
• July: The PennDOT Medical Advisory Board reviews criteria for license suspension; no changes made.
• 29-July: Emerich appears at hearing to appeal the suspension. “It’s the law that’s wrong,” not his doctor, he says.
• 18-August: County Judge Bradford Charles rules that PennDOT should not suspend driving privileges indefinitely, but citing doubt about Emerich’s claim to have dramatically reduced his drinking, orders him to install an ignition interlock (a $1,100 annual expense) if he wishes to resume driving.

Does Emerich have alcohol dependence (alcoholism)?

Philly.com, 20-Aug: Psychiatrist Charles O’Brien, a University of Pennsylvania addiction-treatment expert and head of mental health research at the Philadelphia Veterans Medical Center. “Anyone who has 10 beers at a sitting is, by definition, an alcoholic.”

That definition doesn’t exactly square with the DSM-IV criteria for alcohol abuse and dependence. The abuse criteria looks for continued use despite failure to meet obligations, causing physical hazards, legal or interpersonal problems. The threshold for dependence is any of that plus high tolerance, withdrawal symptoms, or inability to cut back despite knowing the consequences. But, no negative impacts on his job or family relationships have been reported from his drinking, and on July 29^th:

Philly.com, 08-Aug: At the hearing, he said his Bud habit was all but gone, reduced to a six-pack a week, tops.

“I’m not saying that just to get my license back,” he said afterward. “It’s for my health.”

At the lower end of his 6-10 beer range, Emerich probably doesn’t meet the latest NIAAA definition of binge drinking, for which the threshold is a BAC of 0.08:

Philly.com, 08-Aug: At six feet tall, 250 pounds, he is a big enough man to drink six Buds in two hours and keep his blood-alcohol level within the legal limit of 0.08 percent, by the National Highway Traffic Safety Administration’s formula.

I’ve found no indications that his doctor told him specifically to quit, or that a clinical evaluation has resulted in a diagnosis; he reports that he has cut back significantly without a lot of distress, and seems to be taking personal responsibility for improving his health.

The judge didn’t see it that way, and it’s not clear what evidence he was relying on when he made these comments:

Philly.com, 18-Aug: “If Emerich’s alcohol addiction had progressed to the point where he could not stop drinking even though it was killing him, how could we reasonably expect Emerich to forgo alcohol simply to ensure safe driving?” wrote Charles in his ruling.

LDNews.com 19-Aug: The judge also wrote: “… the abyss of Emerich’s alcoholism was so cavernous that he would and/or could not moderate his alcohol consumption so that he could safely drive.”

Was he drinking sensibly?

Not by any of the standard yardsticks. He was somewhere in the range of 40-70 drinks weekly, pretty similar to where I was at in 2000. Among his U.S. peers, 6-10 beers per day put him in with a lot of men who drink, but only a few at that daily level:

So, he was well into the 90^th percentile in drinking quantity and frequency, not something that many folks can sustain for decades and yet remain healthy. His drinking was starting to cause him problems, as mine did, and continuing with the same pattern was likely to accelerate the consequences.

In one study, a small group of 40-year-old men had an average of 4 drinks daily for 20 years without consequences, while their peers who averaged 5 or more daily generally ran into problems. That evidence doesn’t tell us that 28 drinks weekly is wise or healthy generally (there’s evidence to the contrary), but it suggests that some guys in Emerich’s age range have sustained that pattern for decades without major consequences.

It’s not unusual for us to find ourselves in places like this in our 40s. It’s also fairly common for us to mature out of heavy or addictive drinking patterns — most often without professional treatment — as described by Dr. Stanton Peele.

Is some sort of treatment or support warranted?

Keith Emerich sounds like he’s in good shape to answer that question himself.

If I were him, I’d be getting follow-up care on the irregular heartbeat that started this in February. I’d want to keep track of whether the heart issue is stable and have my doc tell me about the risks and/or benefits of continuing to drink moderately.

Sometimes folks get shocked into abrupt behavior changes, and maybe the heart problem was everything he needed to accomplish that. More often, we end up working through stages of change, so it wouldn’t surprise me if cutting back his drinking has been more of a struggle than he’s mentioned publicly. Sometimes a little bit of the right help moves the change process along more quickly.

If his heart problems were to escalate, his doc is sure to ramp up treatment and/or get specialists involved. The drinking can be handled the same way — if self-care ends up not getting the job done, it would be worth his while to try some sort of peer support or get professional care.

Bottom line, assessment and choices of treatment reside with him and the experts he chooses to consult.

Is treatment available that would fit him?

CentreDaily.com, 14-July: “They want me to go to counseling to prove that I’m OK,” Emerich said. “I tried to go to a place … and they wanted $250 for a three-month program.”

Hmmmm… harm reduction therapy can be done in pieces much shorter than 3 months. Services offered by folks like Tamara Grams in St. Paul and the RRCI in Cincinnati (from Friday’s article) aren’t blocked off that way, either. Perhaps he was talking to folks oriented to doing 12-step work.

Thus far Emerich sounds determined and conscious, not much given to powerlessness, but perhaps still working through some ambivalence. Long-term abstinence could still be on the horizon as a good option, but chances are good that A.A. is either not a good fit, or not a good fit yet.

The chances are also pretty good that somebody like Psychiatrist Charles O’Brien, quoted above, would not hold Emerich’s attention or respect for long. Dr. O’Brien’s complete thoughts might be more nuanced, but the quote used by Philly.com suggests that he’s working from a broader disease model than the DSM-IV that would require clients with substance abuse to admit denial and would discount the evidence that drinking problems often don’t lead to addiction.

Finding client-centered care that meets us where we’re at is still a challenge in most areas. A few cursory web searches for alternatives to 12-step support in Emerich’s area didn’t produce anything promising.

What about the ethical issues?

Radley Balko: DWI Insanity

The guy did nothing that’s against the law. Yet if he wants to drive, he’s now required to pay an extra $1,100 … for the privilege.

The case also puts a chill on doctor-patient privilege. What Emerich admitted to — drinking — isn’t even illegal. Guess if you’re a Pennsylvanian, you’ll now need to think twice before telling your doctor everything he needs to know — even if that means an inaccurate diagnosis.

Doctors’ Responsibilities, Patients Rights Debated:

For many doctors, the crux of the reporting dilemma is maintaining trust with patients.

David Axelrod, an internal medicine doctor at Thomas Jefferson University, confronted that quandary yesterday when a patient who had read about Emerich refused to answer a routine question about alcohol consumption.

“He did not want to answer that question at all because of the fear that what he says can be used against him,” Axelrod said. “I didn’t press it.”

Lebanon Daily News Editorial:

Penalizing an innocent person based on the “likelihood” he will commit an offense DUI, in this case is a slippery slope. … There is language in Charles’ opinion that suggests a strong bias against alcohol use of any kind. … One must wonder whether the judge thinks anybody who consumes alcohol is ever fit to drive…

“Likelihood” is indeed a slippery slope. In this case, it led to a presumption of future guilt. We find that troubling.

The Robesonian: Oh, (Big) Brother

The odds just got shorter that the attending doctor will be aware of his client’s fondness for a cold one. And that could be a dangerous mix.

Fessing Up to Doctor Costs Drinker His License:

Edmund G. Howe calls it “a crapshoot.”

“What one doc considers abuse might not seem as severe to another doc,” said the editor-in-chief of the Journal of Clinical Ethics and a psychiatry professor at the Uniformed Services University at Bethesda, the U.S. military’s medical school.

“I tend to think docs can’t do two jobs and do them both well,” Howe said. “They can’t be adjuncts to the police force and at the same time form trusting relationships with patients.”

Say Anything blog: Pre-Emptive Revocation

What a joke. In most states they even let you drive after you get a couple of DWI’s. What’s with Pennsylvania? This is akin to requiring child-abuse victims to register as sex offenders because they might become pedophiles themselves.

Clients Power Cincinnati Recovery Center

“I hate A.A.!”

Jay Stahl hears that from time to time as an addictions counselor, but his clients learn it’s no way to bond with him.

“Be specific” is his reply. “Let’s talk about what works or doesn’t work for you about A.A.”

If the client has attended A.A. meetings where the group members seemed out of touch with his/her concerns, Stahl points out that any peer support group will have its own character, strengths and weaknesses. If the personality mix at a meeting wasn’t a good fit for the client, Stahl may recommend other A.A. meetings that could fit better.

“I’m not powerless.” “I’m not an alcoholic.”

Stahl welcomes these sorts of specifics. They are conversation-starters, not symptoms, in his work as a clinician.

So, Sharon feels responsible and empowered, but wants help asserting herself to quit drinking. Or, Shawn shuns the “alcoholism” label, but is ready to talk about solving the problems his drinking is causing. And, Mike resists committing to much of anything, but promised his wife he would talk to somebody.

Empowered recovery resources in southern Ohio

Stahl is the Executive Director of the Recovery Resource Center, Inc. (RRCI), which provides abstinence-focused care and support in Cincinnati. The RRCI is the brainchild of John Salter, a social worker and addictions care expert who is also an advocate for Rational Recovery, a self-directed approach. He told a bit of his recovery story to Cincinnati weekly CityBeat in January 2003.

Salter envisioned using a mental health model consistent with his social work background in which a Sharon, a Shawn, or a Mike would get help that would:

• Meet them where they’re at.
• Treat them as whole beings, not single problems.
• Place the severity of their drinking on a scale from use to abuse to dependence.
• Identify mental health, relationship, and any other issues or concerns without presuming that addiction is always the cause of the others.
• Empower clients to make informed treatment choices, which might include any of:
  • 12-step meetings,
  • psychotherapy,
  • relationship counseling,
  • Women For Sobriety,
  • SMART Recovery®,
  • LifeRing Secular Recovery,
  • personal practice of Rational Recovery, or
  • other self-directed recovery.

Salter spent 5 years providing services from his basement, in addition to his full-time social work job, starting in 1996. He also spent that time collecting support and funding to open the Recovery Resource Center.

The alternative recovery community in Cincinnati helped Salter build a coalition along the way. Local affiliates of SMART, Women For Sobriety, and LifeRing were already active in the area, and leaders from each stepped forward to serve on the RRCI board. (The RRCI website includes a side-by-side breakout of the high-level distinctions between AA and these alternatives.)

Stahl was brought on board as director in November 2001. The center opened in December, offering a resource library, office space for one-on-one services, and a conference room to host meetings. Early in 2002, the RRCI hosted author Anne Fletcher, as told by the Cincinnati Post, to deliver a couple of lectures.

Jay Stahl’s recovery: Outside the box

The email message I got from RRCI director Jay Stahl in response to my request for a phone interview was friendly:

    From: Jay
    Sent: Monday, August 16, 2004 10:31 AM
      To: Steve Boese
 Subject: Re: Kudos on your services and your website

---

Steve,
Thank you for the kind words — and the link. Please call me … I’ll answer all your questions and maybe even share tidbits of my own (17-year) recovery story. Jay

And yet, to be honest, the whole sharing-our-recovery-stories thang is a little unnerving to me. I can appreciate that Amazing Grace-style “‘twas drunk but now I’m sober” testimonies are heartfelt and real for a lot of folks, but the implicit “you are lost and need to be found” message that often follows them is a turn-off.

It turns out I needn’t have worried. As his September 2003 remarks show, Stahl has seen tough times yet leaves melodramatic hitting-bottom and recovery-as-redemption allusions behind when telling his story.

He chose to quit because drinking was getting in the way of making other changes that mattered to him. A therapist helped him work through issues related to troublesome family dynamics that had preceded and perhaps catalyzed the drinking problems. An avid reader, he dug through books on addictions, relationships, and coping skills. He leaned on friends who modeled the type of person he wanted to be. He also dealt with shades of panic and obsessive-compulsive issues along the way, in each case finding answers from a mix of professional care, peer support, looking at the evidence, and taking responsibility for his mental health.

In the 2003 remarks, he expressed gratitude for friends who supported him:

Their qualities — unconditional love, empathy and understanding, validation and acceptance — nurtured in me the needs of my soul — human dignity, personal liberty, hope and empowerment.

This in turn has allowed me to construct the core of my character — a core which includes responsibility, self-reliance, authenticity, and integrity.

Not yet credible after 17 years?

When he speaks to groups about recovering outside the 12 Steps without relying on a disease model of alcoholism, the pushback has become familiar to Stahl.

“You must not have been an alcoholic” is one of the responses that frustrates him, not so much because of the challenge to his former drinking problems — few alcoholics hit bottom homeless-in-the-gutter style anyway — but because it marginalizes his recovery.

The RRCI doesn’t teach its clients that alcohol itself is an inherently cunning beast, and Stahl doesn’t find a one-size-fits-all disease model of alcoholism to be necessary in his own recovery.

“Then why don’t you just drink?” is a common response when he explains this.

If he chose to cap off a hot day of lawn mowing with a single beer, he isn’t convinced it would catapult him into personal ruin or begin a steady progression to insanity or death. The basic issue with addictions, he notes, is that an attachment to a habit persists despite repeated negative consequences. If he chose to drink, being responsible would need to include consciousness of potential attachments and consequences. While there is no sure way for him to know whether moderate drinking would be viable for him apart from testing it, he doesn’t seem to be interested in finding out.

As he talks about it, his relaxed confidence speaks to a sense of contentment that abstinence is his genuine choice, a proven and joyful path for him, more than his only redemption from dire consequences of the alternatives. That choice also put him squarely in sync with the first of the fundamental principles driving the formation of the Recovery Resource Center: “Abstinence is the best route to recovery.”

And, it bothers him that recovery outside a 12-step model often isn’t accepted as valid or credible, even for a clinician like himself with 17 years of continuous sobriety.

“An incredible uphill battle” for recognition

The Recovery Resource Center’s struggle for recognition and referrals mirrors Stahl’s personal attempts to be integrated and included in communities of recovering folks.

Stahl and Salter have worked to build bridges between the RRCI and public and private addictions policy, education, and treatment groups. Despite making themselves known, they receive few referrals from local agencies, even from those supported by public funds. They have developed their own networks with peers to publicize and promote the RRCI’s educational seminars for addictions professionals after finding that many of the existing communication channels are not receptive to them.

John Salter noted to a CityBeat reporter in 2003:

The four non-traditional programs supported by RRCI have existed for about 15 years, but many of the most influential people in the field of addiction care don’t want to hear about alternatives.

Even the Addiction Studies program at the University of Cincinnati seems to tread lightly, if at all, into the topic of Women For Sobriety and other alternatives to 12-step programs.

It can be bewildering. SMART Recovery and Women for Sobriety have been recognized by the American Academy of Family Physicians. The National Institute on Drug Abuse (NIDA) cites SMART side-by-side with 12-step programs as a valid self-help option, and, after being proven effective with adolescents and in correctional settings, SMART has been adapted for those uses, drawing federal funding in seven digits. It’s hard to make sense of the gap between credentials like those and the barriers to getting the word out about them.

Creating their own system

When it opened, the Recovery Resource Center hosted 3 support meetings per week: One each for Women For Sobriety, SMART Recovery, and LifeRing. Today they’re up to nine.

Stahl says they started out with a vision of becoming an integral part of the addictions care system in southern Ohio, collaborating with local agencies and building up referral traffic between themselves and outpatient and inpatient treatment providers.

The model has evolved, though. Frustrated with limited results after working within the existing system so far, the RRCI is staking out a more assertive role for themselves. They have recently achieved state certification as an outpatient treatment provider and are increasing the availability of certified staff to work one-on-one and in groups with their clients.

They intend to get their options listed with the courts so that clients required to seek alcohol-related care in the wake of being arrested or convicted of driving under the influence will have options.

The plan is to deliver solid, evidence-based treatment and measure its outcomes. Stahl is confident about demonstrating the RRCI’s effectiveness and substantially expanding its base of satisfied clients.

Common recovery processes, but distinct barriers

One of the intriguing things Stahl sees in the addictions field is that core recovery concepts and language are shared by most professionals, peer support groups, and programs: Each promotes getting well, giving up bad habits, examining values, developing healthy coping skills, and getting whatever help, support, and information is needed.

However, the distinctions between disciplines create most of the barriers to folks getting help. That is where he sees the power of offering options. As a clinician, Stahl’s approach doesn’t vary much toward clients who choose 12-step, SMART Recovery, Women For Sobriety, or self-directed approaches.

The program-to-program differences lie not in language nor effectiveness, it seems to him, but in the individual clients’ levels of resistance.

Resistance drops when empowered options are offered to folks who are ready to change but opposed to powerlessness. Progress is made sooner by skeptics of the disease concept when dismantling their objections is no longer a prerequisite. Barriers to treatment soften when questions about the risks of heavy drinking lead to direct answers and encouragement to change based on an internal locus of control. Evidence draws critical thinkers into self-identifying their problems and making informed choices about health care, habits, peer support and professional treatment.

Too often, Stahl points out, treatment providers and well-meaning laypeople “miss it” when given an opportunity to make a positive difference. He’s not immune from missing the target himself. A year into their marriage, he offered his wife the “perfect” solutions to a personal challenge that mirrored one that he had faced earlier: Read these books, write a journal, meditate, and get some physical activity.

“I missed it,” he tells folks when describing the advice he offered her. Her problem-solving style doesn’t include digesting books-full of evidence; introspective journaling was his thing, not hers.

Too often, he says, addictions professionals do the same when they don’t spend time getting to the bottom of their clients’ built-in coping styles and match them to corresponding treatment approaches: Presented with an opportunity to reach a client with workable solutions, they miss it.

As the Recovery Resource Center has proved by reaching over a thousand folks in under three years, the options matter. Empowering their clients to make informed choices works.

Cigarette, Bourbon, Beer, and Sinatra Tunes

I love Toddorado’s style:

Scene: A smoky pool room at a local neighborhood bar. Cigarette, Bourbon, Beer and Sinatra Tunes are shooting a game of doubles

Cigarette: (oddly enough, smoking a cigarette) Hey guys! How long has Coffee been missing? There were five of us here, even though you guys, Beer and Bourbon, are related. Now there’s only four of us!

Bourbon: (looks up from the pool table, where he is lining up a shot) Who cares? We were never that close anyway - he was the natural one to leave the group, damn stimulants. It was always the two of you in the morning - no one ever heard of Coffee and Bourbon hangin’ out.

Go read the rest. Really. It’s quirkygood.

Preempting Harm Reduction

Last year, the Naperville Illinois City Council attached penalties to an ordinance prohibiting under-21 folks from attending parties where alcohol was served. From an article by Anna Johnson in the Chicago Sun-Times:

Naperville … already prohibited minors from attending drinking parties, but last year the City Council changed the wording to create a specific ordinance to ticket minors at the parties who aren’t drinking.

City officials say the strict rule is meant to protect minors by targeting unsupervised teen parties.

”We’re trying to be involved in the situation and recognize the tragic and sometimes horrific outcomes of these underage parties,” said Naperville Police Lt. Dave Hilderbrand. ”We’re trying to take a bit more of an ambitious step.”

It’s not making sense to Rob at the Say Anything Blog.

At The Right Spin, Adam noted in June that the ordinance inadvertantly targets designated drivers:

Nineteen year old Julie Beata has received two citations from the city police. Both times she was not drinking but she was picking up her friends who [had] been drinking…

I guess now, the only way for underage drinkers to get home is to either walk (public drunkenness) or drive (DUI).

Vouchey at the Chicagoist also pointed out in June:

Naperville, a town that seems to have little for their police to do, is acting a bit silly, we think. And we wonder if there are better ways to combat underage drinking other than issuing college and high school kids fines.

These are the difficult, but necessary, sorts of conflicting interests we face when considering the use of harm reduction: How to reduce risks and direct harms through pragmatic balancing of costs and benefits.

The sometimes horrific outcomes are real and devastating to families. In a perfect world, harm might be eliminated by preventing under-21 folks from drinking, but effective enforcement mechanisms for that are simply not available. Given that harm-free solutions are not viable, harm reduction principles encourage us to strike a balance for protecting health and life, like:

• Encouraging under-21 folks not to drink regardless of what their friends are doing (like those that have been ticketed already).
• Setting firm never-drink-and-drive standards.
• Teaching adults and under-21 folks about alcohol safety and the thresholds of safe, risky, and dangerous drinking.

The city has called for a public hearing on the issue next month. Questions have been raised about the constitutionality of penalizing being present where drinking occurs. Some parents are upset that their young adult children are punished despite being responsible; one city official blames parents for not controlling their kids through age 20:

”We don’t want them in the presence of others committing crimes,” [Naperville’s city attorney Frank] Cuneo said. ”If parents did their jobs, we wouldn’t need this ordinance.”

Online Support: Not Just Vapor

Can internet-based contacts really make a difference once folks walk away from their keyboards? They did for me in 2000 when I connected with other folks from Moderation Management (MM). During my first period of abstinence, I reported my challenges and discoveries to my friends in the group. Knowing that I wasn’t going it alone, and wanting to report progress, often helped me to stay on track. When things didn’t turn out well, I could review what happened and get ideas for setting new priorities from the group; when things went well, I never celebrated alone.

This weekend, another MM member put that principle to work. He wrote to the group just before heading out for the weekend and again after his return, and was good enough to let me share his thoughts here.

He started out sounding hopeful and conscious of the weekend’s challenges, yet not exactly confident:

From: MNE
To: MM Email List
Sent: Friday, August 13, 2004 10:29 AM
Subject: [MM]Weekend challenge

---

Hi all who wants to read!
This weekend will be a challenge for me.

I am traveling somewhere and will meet a lot of people and can’t really escape the situation. It will be expected to celebrate and having a great party. But at this very moment I DON’T WANT to drink at all. Not even moderate or even taste anything with alcohol in it. It’s a little hard to deal with because I am dealing with following:

1. If I say to everyone that I won’t drink or I’m cutting down, maybe they will think I am a drunk and I will get into the situation to explain why I don’t want to drink. Especially since I usually never really say no.
2. I just can’t see the point of drinking at this time. I have purchased a new membership at a gym, and after slipping 1½ weeks ago into one night of heavy drinking, only to go back into the gym after that and feel GREAT! At this point I feel absolutely healthy and great!
3. I have naturally started a completely new life after moving to a city about a month ago. After arriving here it’s been more natural to break or at least identify old patterns of not being healthy. I do have better sleeping and eating patterns and as a matter of fact, I do drink less! I even got myself a new girlfriend and she doesn’t drink especially much. But when we do share a bottle of wine, those moments of drinking at all I want to have with her. The rest of the time I don’t really want to drink “by habit”.

But I want to move to the next “health” - level. I want to continue going to the gym. I want to do a 30 day abs and just stay healthy with eating and sleeping patterns. I feel so damn much better.

Ok, I should go. First off to the gym. Then having a lunch, then getting away to see a lot of relatives and other people seeing how this weekend turns out to be.

Thanks for listening

MNE

But, listen to the difference a weekend makes:

From: MNE
Sent: Monday, August 16, 2004 2:11 AM
To: MM Email List
Subject: Re: [MM]Weekend challenge - YES, YES!!!

---

Hi all you who replied to my original posting!

It was great to come home to read mail on late Sunday night. I appreciate each one of the replies, and each one is something to keep in mind!

And the weekend…? Well;

Friday: Writing here to MM-list about the fear of the weekend. Then heading off for the gym. Then into the car getting off, driving for 5 hours. Did I drink on Friday night? Nooooo! Did I want to drink on Friday night? Nooooo. Did anyone mind me not drinking or even questioning it? Nooooo! Did I feel great? Yessssss! Did I have a great time? Yesssss!

Saturday: There was a ceremony in church during the day and in the evening the beer, wine and food was a fact. Did I drink? Well yes; 1½ beers during the entire evening! Which was exactly the amount of beer I enjoyed, then I said no to any more. Did anyone get bothered? Nooooo.

Sunday: No hang-over. Just feeling great! Then driving home, meeting up with my new girlfriend. Enjoying the evening together and ending up having great sex. Still very sober and no wishes to drink (didn’t really think of alcohol..)!

After all, the weekend challenge wasn’t that hard. It was very easy! But that is because of being able to lean on you people on this list while being off. When traveling off on Friday I just knew that there are others out there getting similar challenges - I am not alone. And for now this is the third major break of pattern within two weeks!

THANK YOU for being there!!!!!!!

MNE

Feeling reticent about talking through drinking problems is not unusual in any peer support group. The reluctance to open up is reinforced, for a lot of MM folks, by the suggestion that detailed planning or rule-setting is a problem, not a solution.

Obsessing publicly about diet, exercise, weight, physique, and an assortment of other health-related habits is widely accepted. The leading tabloids’ tracking of Oprah Winfrey’s weight is echoed by Oprah’s comments about how the discipline of daily workouts can be a struggle, not something that happens naturally. When it comes to drinking, though, folks in MM often have to reconcile with a curious cultural paradox — that putting forth the effort to create healthy habits might be considered suspect, or at the extremes, a “selfish, weak excuse to avoid the ugly face of alcoholism.”

Against that backdrop, online community-building often delivers the simplest, yet most profound result: Convinced that we are not going it alone, we empower ourselves to take small but decisive steps forward.

Sticking, not Stuck

On July 2^nd of 2000,

I started 30 days of abstinence. With the support of folks in MM, it turned out that having alcohol-free days was kind of freeing, not the burden I had anticipated.

Taking my abstinence past the 30-day mark began to appeal to me by the half-way point. I was figuring some stuff out about myself and adding new habits and skills. All of that would be helpful once I was drinking (but moderately this time) in the future, and I figured a longer period of abstinence would probably be good for me.

Rather than commit to another specific timeframe, I set this framework in place: I could choose to have my next beer (or whatever) at any time, but the decision had to be made a week ahead of time. No moral significance was attached to the timing — I could do it the next week or the next year — but the timeclock was available, and seven days after hitting it I would be free to crack open a cold one or pour myself a glass of wine.

Sticking with the 7-day countdown worked for me. It wasn’t a commitment I felt stuck with or burdened by, and the 30 days turned into 110.

In mid-November of 2000,

less than a month past the 110-day abs, I lost my best friend and partner to suicide. I didn’t drink much, generally staying within MM’s moderate limits for the first couple of weeks. By the second week of December, though, buffeted by cheery holiday decor and songs about the most joyous time of the year, the only achievable goal I could imagine was conscious harm reduction.

For the rest of December, I didn’t set hard limits on how much I drank. I looked forward to the first beer of the evening, but also planned a good meal to eat with it. No stigma was attached to specific numbers, but free of self-judgment, I set drinking slowly and enjoying it fully as the priority. In January, with the holidays done and the edgiest of my grief softening, I did a 21-day abs followed by more moderation.

On March 1^st of 2002,

I kicked off a year of abstinence.

I had just lost another great friend, this time to alcoholism. I sent him off with a helluva eulogy, celebrating the gifts he’d given as well as the challenges he had brought to all of us who had cherished him. I wanted to do more than a bang-up eulogy, though. I wanted his death to spark something deeper in me, and a year’s abs felt just right.

It turned out to be a tumultuous year, moving from Iowa to upstate New York, starting a new job, and facing down an assortment of changes and crises.

Again, sticking with the choice to abstain worked. Some facets of it felt organic and natural, like the symmetry between not spending money on beer and my often paper-thin budget, and there were other times when it felt somewhat artificial, but manageable, to be celebrating, relaxing, or stressing in alcohol-free mode.

In October,

half-way through the abstinent year, I was hanging out with new neighbors at their Halloween party. Not drinking was not working for me in that situation. I needed to either skip out of there to catch a movie (something removed from the noise that would continue for a few hours directly above my place) or have a couple beers with them. Either choice was valid and viable for me, I realized, offering its own benefits and drawbacks. I elected to stay, and I elected to drink on three other days over the next few weeks.

December 2002 brought a markedly different decision from December 2000. I was comfortable with my choice to drink on the four days, but wanted the 80-some days remaining in the year to be alcohol-free. The commitment wasn’t difficult to make. It was the home stretch, and a couple months of being DAFT didn’t sound long.

The year ended up being 99% abstinent — 361 out of 365 days. I was happy with it. The four days were the perfect reminder that my choices on all 365 days were genuine and conscious.

Sticking with (not stuck with) my choices

Some folks are good at making a sudden change in their behavior solely because it makes rational sense. “Since my doc gave me my cholesterol levels and told me to change my diet, I’m stuck with eating low-fat food. I’m not happy with it, but I’m living with it.”

Most of us, though, need more than intellectual awareness about the wisdom of a particular behavior change in order alter ingrained habits. We have mixed feelings about giving up something familiar, and that ambivalence, like grief, is a natural human state. Neither responds well to being shamed, mocked, or short-circuited, but both will generally give way to peace, health, and productivity when accorded the respect, time, and energy they deserve.

Working vigorously with my ambivalence helps me to mold an “I’m stuck with…” into an “I am sticking with…” statement. Here are the distinctions, for me, between the two:

The specific goal doesn’t control whether I’m in the stuck or sticking category. If it had turned out that moderate drinking wasn’t viable for me, I might have started out feeling stuck with abstinence. It would have been crucial, though, for me to figure out how I could best own and embrace my commitment to being alcohol-free.

It doesn’t matter that some solutions work beautifully for millions of other folks; in order to integrate a new skill or habit, I have to tailor it to my unique values, coping styles, and experience.

A.A. Alternatives: An Empowered Round-up

Live Sensibly reader Faith notes that abstinence is her thing but powerlessness is not. (She writes about her life pragmatically, with refreshing transparency — go take a peek.)

So, it’s as good a time as any to do a quick review of some of the solidly abstinence-based support out there which follows something other than the 12 steps. Along with that, a request to my readers: I’m looking for individuals who are talking about their experiences in these different groups at their personal websites. If you know of any, please drop links into a comment or an email message.

So, here’s a list of empowered alternatives:

• LifeRing Secular Recovery: “Freedom from alcohol, peer support with feedback in a secular setting, and Open architecture: structure your own program.
• Secular Organizations for Sobriety, or Save Our Selves, also located here: “SOS credits the individual for achieving and maintaining his or her own sobriety… SOS supports healthy skepticism and encourages the use of the scientific method to understand alcoholism.”
• SMART Recovery®: Approach “teaches self-empowerment and self-reliance… teaches tools and techniques for self-directed change… evolves as scientific knowledge evolves.”
• Women For Sobriety: “We are capable and competent, caring and compassionate, always willing to help another; bonded together in overcoming our addictions.”

There are also faith-based groups which adapt the 12 steps to their needs. There are professionals who support a wide range of alternatives. Look closely, and you’ll even find folks on the God squad talk about spiritual empowerment and having an adult relationship with God. Find ‘em in the side bar here, or let me know who’s not there yet and needs to be added.

2004.08.15 Update:

The Recovery Resource Center in Cincinnati Ohio has a great page which takes a high-level look at the distinctions between these groups: The Recovery Spectrum.

Demystifying My Drinking

I first connected with Moderation Management (MM) in early June of 2000. In July, eager to test out its 9 Steps, I kicked off a 30-day abs, and ended up extending it past 3 months.

One of the concepts I worked through while abstaining was my fear that I’d slip right back into bad habits after the abs period finished, or even see my drinking escalate beyond where it had been before. It’s a pretty common sentiment; an MM member who is 10 days into his first 30 expressed a similar fear, and I responded:

From: Steve Boese
Sent: Wednesday, August 11, 2004 9:14 PM
To: MM
Subject: RE: [MM]abstinence

---

> Maybe I am a natural worrier, but it
> seems like things are going too easy
> right now. Like it is just a matter
> of time before I cave in and have that
> bender that will put me over the edge
> and set me back again….

That was me, exactly, four years ago.

Over time I decided that I had been framing my drinking as something mystical, something that could rise up like a beast and erase all of my progress, and that such framing was neither helpful nor accurate. I started DE-mystifying it, and the more I demystified my drinking, the more effective I became at marshalling some control over it as a simple habit.

OK, so it was a habit with a compelling edge — the allure of alcohol is stronger for me than, say, Play-Doh or broccoli, after all — but demoting my old drinking patterns to simple habits also got me thinking about healthier patterns as tuned-up, very do-able habits.

Another way I framed things: I reminded myself that every day of abstinence (as well as moderation and harm reduction) changed me. Once I added those experiences to my life, nothing could erase them, nothing could take me back to where I was in June, 2000. Even if I went back to nonproductive drinking patterns exactly like before, the new experiences told me unequivocally that I would never be content again living in the old ways.

So, I’d encourage you to trust that these 10 days have changed you. They are not a magic bullet, of course, but you are not going to erase these experiences from your consciousness. You are proving yourself able and powerful, self-reliant and wise. You will — all of us will — take what we learn from the good days and make better days, better lives, with them.

—Steve

That’s different from concepts that many A.A. members find helpful, that alcohol is “cunning, baffling, and powerful” and the path to better health includes accepting powerlessness, eh? We each need to figure out what works best for ourselves.

Acamprosate Approval in the News

Recent approval by the Food and Drug Adminstration of Acamprosate to treat alcohol dependence is making its way around the media.

The Washington Post runs a short piece by Alicia Ault (free registration required) which includes:

Campral appears to work by restoring the balance between excitation and inhibition in nerve signals, a balance that gets altered by alcohol abuse. An older drug, Antabuse (disulfiram), makes people violently ill if they drink alcohol. Another, naltrexone, works by making people want to drink less, said Litten.

Only 5 to 10 percent of people treated for alcoholism are prescribed naltrexone or Antabuse, which don’t work for everyone and are not widely marketed, said Litten. Forest aims to market Campral broadly to addiction centers and physicians, said company president Ken Goodman, and persuade insurers to pay for the drug.He would not comment on price.

And, from Business Week’s coverage by Amy Tsao:

The U.S. is well behind other nations in using drugs to help battle alcoholism. Including Campral, only three anti-alcoholism drugs have earned FDA approval — and Campral is the first new one in almost a decade. Moreover, fewer than 5% of the nation’s 14 million alcoholics are being treated with drugs, with the vast majority relying on behavioral therapy and support groups like Alcoholics Anonymous to help them quit. Though alcoholism is increasingly viewed in the U.S. as a disease, the predominant belief is that “you don’t treat a sin with medication,” says A. Tom McLellan, professor of psychiatry at the University of Pennsylvania and director of the Treatment Research Institute, a nonprofit group that evaluates addiction therapies.

Many American alcoholics are starting to demand more help in achieving what for most is the greatest challenge: Long-term abstinence.

Tsao notes that Campral has been available in Europe since 1989.

The five percent number doesn’t surprise me. By the time by buddy Brian’s drinking finally killed him in 2002, he had at least a decade of treatment, 12-step support, sponsorship, and one-on-one therapy. His care came mostly from one of the leading hospital-based chemical dependency treatment facilities in Iowa. At age 44, his last year included several close calls laden with all of the standard -itises and -opathies.

A month before his death, he and I talked about alternatives like Naltrexone and harm reduction therapy. Thoughtful, intelligent guy that he was, the value of options struck a chord with him. After all of his years working within that system — and being trained as a peer support group facilitator — he said the only possible outcome of asking about the options would be earning a merit badge for denial, making it out of the question for him.

Maybe his medical condition (such as liver damage at the end) would have precluded the use of Naltrexone at that point. It seemed clear, though, despite being available since 1995, not only was the option not on the table, his caregivers had convinced him that merely asking questions was also strictly verboten. It struck me as a classic case of insanity defined as doing the same thing repeatedly, yet expecting a different result.

Anyway, it’s good to see that more research is in progress:

Researchers are also wrapping up a large, multicenter trial of Campral, Naltrexone, and both drugs combined. That study, for which 1,380 patients took the drugs in conjunction with various behavioral therapies as well as without any additional therapy, should help elucidate what combination of therapies works best.

Hopefully we’re on a path toward treating the truly life-threatening forms of addiction more like cancer and HIV: No single approach is going to work for everyone, but information about any approach which shows promise ought to be in the hands of the folks who could benefit so they can make fully-informed decisions about their preferred course of treatment.

Sidebar Item: Furled Links

One of the internet-based tools I’ve found to be tremendously helpful is Furl. Furl takes the place of bookmarks in my browser: When I find a webpage that I want to come back to later, I press one button to save it to my personal Furl archive.

In addition to saving the address of the page, Furl captures the content of the page. So, if it is a newspaper article that will expire after a week, I’ll still be able to get back to it. Handy, eh? And, best of all, it’s free!

Today, I figured out how to put links to my Furled pages in the sidebar here at . If you look under latest links furled you’ll see the last ten webpages that happened to catch my eye. There will often be overlap between the Furled links and what I’m talking about in the main blog, but sometimes you’ll get a glimpse of what I’m working on for a future article.

Please note, though, that some of the links there will be to stuff I’ve not yet read. I’m not vouching for the credibility or value of the material there — think of it as a wicker basket of newspaper clippings I’ve cut out and saved to read some other day.

You can also follow the more link at the bottom of that box to see all of the odds-n-ends that have accumulated in my clippings basket since I started using Furl in January. You’ll find that some of the links are now dead, but let me know if there’s a page you’d like to read, and I’ll see if I can at least dig up excerpts.

Odds-n-Ends in the News

Drying out stigma for problem drinkers:

Researchers say drugs that handle alcoholism as a medical condition will encourage people to seek help.

Dr. Henry R. Kranzler, professor of psychiatry and an alcoholism researcher at the University of Connecticut Health Center in Farmington Connecticut

…said he would like alcoholism and diabetes to be regarded in the same manner — as conditions in which genes, lifestyle choices and biochemistry play a role in causing disease.

Researchers agreed that medications alone cannot cure alcoholism. But they can be a boost to 12-step programs such as Alcoholics Anonymous and to traditional psychotherapy, which for generations have been the backbones of treatment for heavy drinkers.

Note to reporter Hilary Waldman: Other future trends in alcohol-related care will be growing awareness of alternatives to 12-step programs, alternatives to abstinence, and harm reduction.

Dr. Stanton Peele interviewed by Jeffrey Taylor at wsRadio.com

Jeffrey Taylor is a thoughtful 12-stepper. His bio includes a 40-year span of heavy drinking, ending less than two years ago. He kicked off a weekly internet radio show in June, Cocktails at 5. Just four weeks into this new venture, he interviewed AA alternatives champion Dr. Marc Kern, co-author of Responsible Drinking, the latest guide to the Moderation Management approach. This week, for his seventh show, he snagged Dr. Stanton Peele.

Head on over and listen in. Jeff and Stanton had fun together. Jeffrey’s also written his story, A Gentleman Drunk, the first 7 chapters of which are available online.

Teen drinking problem not improving, despite prevention efforts

Media coverage of drinking issues often doesn’t include getting input directly from drinkers, much less letting teens speak for themselves. Here is an exception:

Drinking is usually a big part of a teenager’s social life…

Getting the alcohol isn’t a problem either, with older friends, and knowing the places that don’t card. One teen says her group of friends go into smaller towns to drink, because it’s safer.”It’s more fun to go to a smaller town cause no one knows who you are , it’s easier to drink than your own hometown,” said the teen drinker…

For many area teens, drinking is a very normal part of their lives, and stopping drinking isn’t an option, so they try to be safe and not get caught.”Kids seem to be careful nowadays, they’re becoming smart about it cause they know cops will pull them over,” said the teen drinker.

If we think we’re going to effect changes in underage drinking, we’re going to have to reconcile with simple observations like these.

Getting Real About Alcohol:

I have a problem with drinking, but I can’t stop. What can I do?

Michele asked (in part):

I have a problem with alcohol. I am a diabetic and should not be drinking.

Frederica Mathewes-Green, whose site lists no counseling credentials and includes no discussion of substance abuse issues, replies:

…you are no longer able to control your consumption of alcohol. This is a serious sin, as well as a serious illness…

You have to stop drinking, and never drink again for the rest of your life. This is the only solution… You need to choose to hold yourself accountable to others, perhaps in an Alcoholics Anonymous group…

Pssst… Ms. Mathewes-Green… perhaps Michele should be encouraged to speak with a medical doctor for evaluation, diagnosis, and treatment recommendations.

114-Year-Old Ukranian female still drinks strongest alcohol beverages

Yevdokiya … does not suffer from any diseases - she has never been to hospitals, she has never asked for doctors’ help…

Extremely strong drinks do not show negative influence on the woman - she is not an alcoholic at all. She says one should have a very good substantial appetizer after a strong drink Yevdokiya prefers Siberian pelmeni (meat dumplings).

Pioneer?

We talk a lot about drinking, we talk about drinking a lot, we talk about other people’s drinking problems but not about our own. Until we quit, that is. Then we talk a lot about our old drinking problems. And, if we drink again after quitting, we either talk about quitting again, or we quit talking about drinking again.

I’m here to break a couple of those traditions. I have caused myself real problems with my drinking in the past, but I turned it around by taking responsibility for my behavior. I didn’t do it alone, but the control was mine to seize. Today, I am unabashed about relishing a couple of cold beers on a hot summer evening, and I am content with — even empowered by — the fact that more than half of my days are comfortably alcohol-free.

I need your help: Prove how wrong it would be for me to think I’m the first person to put up a personal website where I talk about solving a drinking problem without quitting. Post links to folks who are have already done it here in the comments, or drop them in an email message to me.

2004.08.12 Update

Neo makes a great point in a comment at Showcase.mu.nu (emphasis mine):

I can relate, in general, to the stopping drinking so much, too much, too often. Abstinence was not the answer to my problems because if you tell me not to do something — well, you get the picture. I won’t focus on it, however, because I know you become what you fill your mind with. I prefer to fill my mind with more positive, helpful aspects of life. I doubt that you’re the pioneer in this matter, as the resources listed on your website/blog/forum indicate.

2004.08.15 Update

Here’s the answer to my question: I’m not the first.

Lilian and Murdoch MacDonald are already online from Scotland with their site, Alcoholics Can Drink Safely Again. I corresponded with them and got a friendly email back. They are shopping a book ‘round to publishers and have posted several articles about themselves from the U.K. press at their site.

Live at Last!

I’ve been building content here at Live Sensibly (with alcohol) for several months already, tweaking templates, researching, brainstorming, but hanging on to it, not quite ready to let it go and be officially public.

At last, if still a tad reluctantly, the time has come to let it loose.

I’m not writing this website because I’ve got answers, I’m writing because I have questions.

I want to dig up answers to questions about drinking, culture, addictions, and experiences. The evidence gathered by experts matters to me, but so do the day-to-day lives of all of us. I want to challenge folks, myself included, to think things through, discussing and debating thoroughly.

I’m convinced that good answers are out there, that good options are available for us to live sensible, healthy lives. I really think we can prevent some of our personal challenges from escalating into huge problems, and at a cultural level we can do a better job of demystifying the passages from problematic to healthier behaviors, and valuing abstinence, moderation, and general balance.

Take a look around. Tell me what you think! Leave lotsa comments! Come back again soon!

—Bose

Answers for Amber

Hey, Amber…

Are your ears burning? I’ve been talking about you and your appearance on Oprah several months ago. I thought you asked a great question:

I am hoping that someone can tell me, if I have 3 drinks, you’re OK, if I have 4 drinks, you’re not OK. I want somebody to tell me exactly where that line is.

And it seemed to me the answer you got was muddy.

I’m not a professional, but I’ve got some relevant experience, and somehow I’ve become an alcohol-issues geek. For what it’s worth (take it or leave it as you wish), I’ll take a shot at clearer answers to your question.

Abuse and dependence

First of all, there are two broad categories of problems folks run into with their drinking: Abuse and dependence.

Alcohol abuse

describes folks who continue drinking despite having recurring problems (legal, health, social, family, relationship) or despite the fact that their drinking creates hazards to themselves or to others. The problems caused by alcohol abuse can occur without us being addicted or dependent, and in fact, there are four problem drinkers for every alcoholic.

Alcohol dependence

is problem drinking plus either high tolerance or withdrawal symptoms. That is what you heard a lot about on the Oprah show. It’s real, it sometimes sneaks up on folks, but I disagree with those who suggest that it is never possible to see it coming.

Does abuse lead to addiction?

It can, but this large 5-year study (580K PDF) suggests it generally doesn’t.

Drinking by the numbers

Is it OK to have 3 drinks, but not 4? Actually, you’re in the ball park with those numbers, but as an intelligent woman you won’t be surprised to hear it’s not quite that simple.

If you want to be very safe,

the USDA

recommends that you have no more than one (233K PDF, pg 40) drink per day (the limit is two for guys).

In Britain,

the recommended guideline is about twice that (360K PDF, pg 3) for women and slightly higher for men.

A 1995 study

found that problem-free drinking occurred at levels of up to 3 drinks per day for women, with a max of 12 per week (4/day, 14/week for guys), with some non-drinking days each week, and

Moderation Management

(MM), a group of folks concerned about their drinking, also recommends 3/day but 9/week. Guidelines set by government ministries in

Italy, Denmark, Spain, and Japan

are closer to the 3/day mark; other countries are closer to the one/day limit suggested by the USDA.

Tailoring drinking to life

Maybe the bigger question for each of us than “What is a problem?” or the scientific stuff surrounding the various numbers is “What is important to me?” We each must answer that question for ourselves, but we may find it helpful to ask, “Why not have alcohol-free days?” “What matters most to me?” “How is my drinking contributing to my quality of life?” “Subtracting from it?”

The answers that work best for you aren’t going to be the answers that work best for me. No surprise there; it’s a matter of examining our values and shaping our lives to fit them.

Making changes

It’s not unusual for us to take a look at our lives and decide we want to make things different. Typically, though, we don’t make the big changes by snap decision, just because they make sense to us intellectually. Sustained change tends to come from working through healthy ambivalence as we navigate recognizable stages of change. The MM folks recommend trying out periods of abstinence as one way to explore change, but they also point to the benefits of reducing harm, which I’ve found helpful at times when optimal solutions were temporarily beyond reach.

I couldn’t really tell where things were at for you (not that it matters, given that I’m a layperson in this area), but from the bit that I heard, I’m guessing I’ve got you beat when it comes to not-so-smart drinking habits. The thing is, you and I know that we’re both responsible for and capable of doing what’s necessary to live sensibly. That means being willing to admit that we sometimes get off-track (or at least, I do) and have to adjust our course.

Summing up

I gotta admit, Amber, I feel a little silly dumping all of this to somebody who showed up on the TV several months ago. Is this a geeky thing to do, or just plain dorky?

Ah, well, you can probably tell from my website that I care about these kinds of issues, a bunch. You raised a simple, very valid, question that I’ll bet millions of other folks watching that day would have liked answered, and a golden opportunity was missed to put solid information in people’s hands.

I hope you are well, and I’d love to hear from you or anyone else on the show that day.

—Steve

Where is the Line?

In April, The Oprah Show broadcast a episode called Moms Who Drink Too Much. Oprah opened the show with:

It’s estimated that, for millions of moms across the country, the need to escape with a little alcohol has now crossed the line. Have you crossed the line? How many drinks is considered normal? What should have you worried?

The first segment of the show tracked Sarah, a 30-year-old mom who had been filmed at home and created a video diary about her drinking problem. Sarah appears to have worked through the first two stages of change — precontemplation and contemplation — and is now poised to move from preparation into action. The bulk of her ambivalence has been resolved and she is looking forward to life without alcohol. (Oprah says later that the show is going to help Sarah get the help she needs and follow up later on her progress.)

Great stuff. So, Sarah’s frequent heavy drinking, hiding it from her kids, blackouts, and using alcohol to numb her feelings is an example of being way over the line.

Oprah throws out this teaser before going to commercial:

Next, three moms, who like to unwind with cocktails at night, who want to know where they stand. Where is the line? Do they have a drinking problem?

When the show returns, a video montage has the three moms talking briefly about their drinking patterns. One of them is Amber, a 28-year-old mother of two. Her comments include:

I pretty much drink every night, anywhere from on average about 2 glasses of wine a night… I drink because I’m bored. It makes me a better mom, especially when I’m really edgy… I try not to drink before 5, and I try not to drink more than 1-2 glasses when my children are awake.

I am hoping that someone can tell me, if I have 3 drinks, you’re OK, if I have 4 drinks, you’re not OK. I want somebody to tell me exactly where that line is.

Amber is just rephrasing Oprah’s opener — Where’s the line? What is normal, and at what point should a reasonable person worry?

Oprah and the show’s expert for the day, author and interventionist Debra Jay, discuss:

Oprah: OK, Debra says women who don’t have a problem don’t have to make up rules about drinking.

Debra: That’s right. If you don’t have a problem, you never even think about making up a rule, but when you do you start setting up little rules for yourself so it can look like you’re drinking like everybody else, that your drinking is normal. And what happens, is you find that you keep breaking your own rules.

Oprah: OK, and I see you’re frowning because of that. You don’t like that?

Amber: No, I totally disagree. I think anybody who’s going to be responsible, whether it be with prescription drugs or alcohol or anything different, I think that any responsible parent — or person — needs to have a boundary up, or it’s a free-for-all.

Debra: You know, it isn’t really, not with somebody who doesn’t have a problem. They don’t even have to think about it. They just really can use it responsibly. What I’m talking about is internally, inside of yourself. It’s 2 o’clock and I’m thinking, “Boy, I really want that glass of wine,” and I’m looking at my clock, and I’m thinking I’ve got 3 hours until five. And, I’ve got to hold on, I’ve got to hold on. That’s something completely different. Now I’m feeling all this emotional unmanageability inside of myself, trying to keep that rule. Somebody who [doesn’t have a problem], 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. That’s what I’m talking about.

OK, so the anwer to “Where’s the line?” seems to be “when we have to set rules for ourselves,” or perhaps more precisely, “when we set rules which we find emotionally unmanageable and end up breaking.”

A little later, Oprah and Debra come back to the five-o-clock-rule issue:

Oprah: You’re saying, the fact that you have to say, “I’m going to only do it after five”…

Debra: Right.

Oprah: …means that it could be a problem.

Debra: Yeah, and usually it’s not just going to be that rule, there are going to be lots of little rules around when I’m with my kids, and this, and that, you know, I’m going to have lots of little rules.

Oprah: Are you an alcoholic…

OK, now we’re getting down to the root of the question, or at least the root of the answers being given to the “Where is the line? question.

Amber is asking whether a problem is occuring at a certain point, and the answers coming back are about the specific problem of alcoholism. Amber seems to be concerned about crossing a line from use of alcohol to abuse, and in response she’s hearing about dependence (alcoholism). But, I’ve interrupted. Let’s hear the rest of the conversation:

Oprah: Are you an alcoholic… You are an alcoholic because your body has a predisposition for the way it handles alcohol.

Debra: Um hmm.

Oprah: Is it alcoholism if it hasn’t hurt anybody yet?

Debra: No, very, very early on, we can’t… it’s probably not going to hurt anybody. It’s progressive and there are certain stages, so as it moves forward it starts hurting people.

Oprah: So, I’m saying, you’re still functioning…

Debra: Yeah. We’re not going to see it, no, we’re not going to see it…

Oprah: OK, everybody’s doing fine…

Debra: No one will know it’s there yet.

Oprah: But you can still be an alcoholic…

Debra: You can still be an alcoholic and usually before anyone notices on the outside, you start having changes in how you feel about it on the inside.

Oprah: Really. Like what?

Debra: Well, again, preoccupation with it. Really thinking about it a lot.

Oprah: Uh huh.

Debra: Most people aren’t preoccupied with alcohol. They’re not thinking about it.

Oprah: Uh huh.

Debra: But people early on, they might look normal on the outside, but boy, they really like those drinking events a lot better than the dry events, for instance. That would be a little bit of a red flag. Does it mean you’re an alcoholic? Not necessarily, but it’s a red flag.

Taking stock thus far, crossing the line can include:

• Daily heavy drinking, hiding it, blackouts, numbing feelings with alcohol.
• Setting rules which are emotionally unmanageable and seldom kept.
• Lots of little rules about, and growing preoccupation with, drinking.

A later segment introduces the audience to Belinda, whose daily drinking is triggering marital tension. Here is part of the ensuing discussion:

Debra: One of the first rules is, if somebody thinks you have a problem with alcohol, you probably do. One of the things we say to people is, “If you don’t know if you have a problem, look around you. Is somebody close to you having a problem [with your drinking]?” It’s the first place it’s going to hit home. It’s not going to hit your job for a long time after it hits your marriage.

Oprah: Can you just have a glass of wine, though, and not have a problem?

Debra: Absolutely.

Oprah: OK.

Debra: Absolutely.

Oprah: If you have to have — this is the thing — if you have to have the glass of wine every night, is that a sign of a problem?

Debra: I think there are people who have a glass of wine every night, and they don’t have a problem, most definitely. It’s never recommended to drink every single day. That is a slippery slope.

Oprah: So, anything you have to do every day, then you should be worrying.

Debra: I’m not saying you’re an alcoholic, but you might be on that slippery slope.

The discussion continues on “After The Show,” a half-hour piece which airs on the Oxygen cable network. Amber sounds less than convinced that her question has been answered when she says:

Amber: I just keep thinking, I’ve never been much of a drinker, was always a good student, always working and being responsible.

Oprah: But the point we made earlier and I think everybody needs to know, [is that] you can …be [not] much of a drinker — as Debra said to Sarah at the very beginning of the show, Sarah had told us that her first drinking experience after graduation, she blacked out — that blacking out is not a normal relationship with alcohol.

Debra: No, no.

Oprah: You don’t have to be much of a drinker if you have the gene.

I recounted what happened next in Oprah Questions Denial. The bottom line from that exchange was that the brains of alcoholics have a malfunction which makes it impossible for them to see their alcoholism developing.

As the end of the “After The Show” show approaches, they take a last stab at answering the question which opened it:

Oprah: Let’s talk about “What is crossing the line?” which I think is a question you guys wanted answered, and I don’t know if you got it answered. What is crossing the line?

Debra: There’s a simple question you can ask: “Is alcohol creating repeated problems in any area of my life, and I continue to drink anyway. If you can answer “yes” to that, you probably have a problem. It’s simple as that. If you can answer “yes” to that question, you probably have a problem, you probably should take a good, hard look, and I would say if you answer “yes” to that 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, it’s a permanent change in my life.

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

So, recapping one last time, signs that one has crossed the line may include:

• Daily heavy drinking, hiding it, blackouts, numbing feelings with alcohol.
• Setting rules which are emotionally unmanageable and seldom kept.
• Lots of little rules about, and growing preoccupation with, drinking.
• A loved one believes there is a drinking problem.
• Drinking at all, for those whose bodies are predisposed to alcoholism.
• Inability to cut back dramatically, instantly, and permanently in the face of recurring alcohol-related problems.

Remember Amber’s question?

I am hoping that someone can tell me, if I have 3 drinks, you’re OK, if I have 4 drinks, you’re not OK. I want somebody to tell me exactly where that line is.

Being fair to Oprah and Debra Jay, let’s recognize that:

• An accurate answer in the format Amber asked about — drinking X glasses of wine is OK, but X+1 is over the line — doesn’t exist.
• The answers given were consistent with those that other addiction specialists may have offered.
• The over-the-line characteristics accurately describe folks who have had alcohol dependence.
• Given time and format constraints, producers of the show may have elected to focus on alcohol dependence, to the inadvertant or necessary overshadowing of alcohol abuse issues.

I can’t help but imagine Amber walking away from that show more frustrated than she walked in. She brought valid questions, particularly for folks not having significant problems with or because of their drinking. She repeatedly insisted on taking personal responsibility and asked for guidelines for being proactive about preventing problems.

Had it been me, I might have left the show with a sense of dark foreboding about a cloudy gloom gathering on the horizon, maybe soon, which I probably wouldn’t see coming, nor be able to push back. I might have felt cowed into cutting my drinking back to negligible amounts for a week or two, but fear generally isn’t a good long-term motivator for me. Anyway, since no daily or weekly drink limits were suggested (the one or two drink, once or twice a week thing was for someone with recurring alcohol-related problems, which I honestly don’t have) having 3-5 drinks four or five times a week will probably be fine.

Some line, eh?

(See also: Answers for Amber.)

(p.s., I welcome first-person reflection and responses from Amber, Debra Jay, Oprah producers, or anyone who participated in the show. I’d much rather let y’all speak for yourselves; feel free to contact me here, and I’ll publish your thoughts to whatever extent you choose.)

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?