-Glossary Intro

The words we use tell a lot about us.

Sensibility and Precision

In order to live sensibly, we need a sensible, precise vocabulary: Honest, direct, pragmatic.

Did you know that the word binge has evolved dramatically in recent years? That the thresholds used to define moderate and problematic drinking vary? That diagnostic criteria focus on alcohol abuse and dependence, and shy away from the term alcoholism?

Fresh words, fresh lives

Developing fresh ways of living requires that we also put new words to work, and tune up our usage of familiar ones.

We’ll keep track of those things here in the glossary. You’ll notice that each entry in the glossary is labeled with the date created and the most recent date updated. Definitions will be tuned up as we go, and I’ll cross-link them with our conversations to put them in context.

12-step

The twelve steps originally devised by the founders of Alcoholics Anonymous, variations of which are used widely by other addiction and compulsion support groups.

Within Live Sensibly, “12-step” refers to a general approach that includes the disease model, powerlessness to moderate the addictive behavior, the necessity of a spiritual response, and a need for life-long abstinence and support.

30 days of abstinence

One of Moderation Management’s recommendations is that taking a 30-day break from drinking can provide a window in which to examine one’s relationship with alcohol.

That’s the way it’s worked for me. My first abs in 2000 opened my eyes to fresh concepts. It challenged me to try out simple tools and techniques (related to living, not just drinking or abstaining) that were new to me.

Doing 30 days of abs is not a magic bullet, though. It didn’t magically erase the challenges I face in living sensibly with alcohol. It provided the foundation, though.

Worth noting about doing a 30:

• We’re not all geared to jumping immediately into a 30
• It’s smart to plan ahead: What kinds of tools, activities, alternatives and contingencies are going to be used during a 30?
• Shorter or longer abs are great, too. (I’ve done a couple 30s, a 110, and a 99% abs — 361/365 days — year.)
• Doing a 30 has the potential to bring cool gifts along with the challenges.
• It’s OK to admit that we’re not yet ready to jump into a 30 even if it sounds like a good idea. We may be in an early stage of preparing to change. It’s important to examine whatever ambivalence we may be feeling, and work with it and through it.
• When we’re not yet ready to jump into a 30, we can prepare for it by charting, reducing harm, and increasing the frequency of DAFT days.

AA: Alcoholics Anonymous

Alcoholics Anonymous, co-founded by Bill W. and Dr. Bob Smith, in 1935, pioneered the use of peer support to help alcoholics.

It synthesized the personal experiences of its founders and early members with the science of its day to offer help through the 12 steps and, beginning in 1939, the Big Book.

Its official website is AA.org, where the Recovery Program page begins:

The relative success of the A.A. program seems to be due to the fact that an alcoholic who no longer drinks has an exceptional faculty for “reaching” and helping an uncontrolled drinker.

In simplest form, the A.A. program operates when a recovered alcoholic passes along the story of his or her own problem drinking, describes the sobriety he or she has found in A.A., and invites the newcomer to join the informal Fellowship.

The group identifies itself as a Fellowship using this definition:

Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism.

The only requirement for membership is a desire to stop drinking. There are no dues or fees for A.A. membership; we are self-supporting through our own contributions. A.A. is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy; neither endorses nor opposes any causes. Our primary purpose is to stay sober and help other alcoholics to achieve sobriety.

Copyright © by the A.A. Grapevine, Inc.

Alcoholics Anonymous can also be defined as an informal society of more than 2,000,000 recovered alcoholics in the United States, Canada, and other countries. These men and women meet in local groups, which range in size from a handful in some localities to many hundreds in larger communities.

Worth noting, also, is that A.A. does not consider its work to include treatment or education:

A.A. is concerned solely with the personal recovery and continued sobriety of individual alcoholics who turn to the Fellowship for help. Alcoholics Anonymous does not engage in the fields of alcoholism research, medical or psychiatric treatment, education, or propaganda in any form, although members may participate in such activities as individuals.

The Fellowship has adopted a policy of “cooperation but not affiliation” with other organizations concerned with the problem of alcoholism.

Traditionally, Alcoholics Anonymous does not accept or seek financial support from outside sources, and members preserve personal anonymity in print and broadcast media and otherwise at the public level.

Abs

Short for abstinence. Can be used to describe a period of time planned to be alcohol-free: A 30 day abs.

Al-Anon

A support group for the families and friends of alcoholics.

From the Al-Anon/Alateen website:

Al-Anon’s Purpose

To help families and friends of alcoholics recover from the effects of living with the problem drinking of a relative or friend. Similarly, Alateen is our recovery program for young people. Alateen groups are sponsored by Al-Anon members.

Our program of recovery is adapted from Alcoholics Anonymous and is based upon the Twelve Steps, Twelve Traditions, and Twelve Concepts of Service.

Alcoholics Victorious

A Christian recovery group.

From its home page:

Founded in 1948, Alcoholics Victorious support groups offer a safe environment where recovering people who recognize Jesus Christ as their “Higher Power” gather together and share their experience, strength and hope. Both the 12 Steps and the Alcoholics Victorious Creed are used at most AV meetings.

Ambivalence

From the Merriam-Webster Online Dictionary:

noun

1. Simultaneous and contradictory attitudes or feelings (as attraction and repulsion) toward an object, person, or action
2. a : continual fluctuation (as between one thing and its opposite) b : uncertainty as to which approach to follow

For some, ambivalence is synonymous with being uncommitted, doubtful, unconscious of, or hiding from one’s problems — the second definition.

In facing issues related to drinking, many of us learn to value our ambivalence in the context of the first definition. We treat it as an earthy, grounded, conscious place to be, opening us up to looking honestly at the good, the bad, and the neutral aspects of alcohol in our lives.

During my first abs in 2000, I spent time examining my relationship with alcohol. I had been hesitant to admit that there are things I really enjoy about drinking, worried that such an admission might be proof of dependence on alcohol.

Embracing my ambivalence meant fully appreciating both the benefits and drawbacks of different kinds of drinking experiences, and that enjoying the benefits didn’t mean that I was denying the drawbacks.

Antabuse (disulfiram)

From Medline Plus:

Disulfiram is used to treat chronic alcoholism. It causes unpleasant effects when even small amounts of alcohol are consumed. These effects include flushing of the face, headache, nausea, vomiting, chest pain, weakness, blurred vision, mental confusion, sweating, choking, breathing difficulty, and anxiety. These effects begin about 10 minutes after alcohol enters the body and last for 1 hour or more. Disulfiram is not a cure for alcoholism, but discourages drinking.

The National Council on Alcoholism and Drug Dependence, on its History and Mission page drawn from White’s Slaying the Dragon, notes that, in 1948:

Disulfram (Antabuse) [was] introduced as an adjunct in the treatment of alcoholism in the U.S. Other drugs used in the treatment of alcoholism during this period include barbiturates, amphetamines (Benzedrine), and LSD.

BAC: Blood Alcohol Content

Blood Alcohol Content (BAC) is the concentration of alcohol in a person’s blood.

Blood Alcohol Units

In the U.S., the most common gauge for measuring BAC is the concentration measured by volume as a percentage. A blood alcohol level of .08 percent (too impaired to drive in most states) means that 8 parts per 10,000 in the blood is alcohol. It may be abbreviated BAC% or %BAC.

Another common measure is percentage by weight, or grams of alcohol per 100 milliliters of blood, sometimes noted as g/100ml. Although blood alcohol test results are often described as a percentage by volume, most of the instruments used to determine it actually measure the weight.

The difference between percentage by weight and by volume is inconsequential for most of us, because they produce the same numbers. A BAC of 0.05% by volume is the same as 0.05 mg/ml.

BAC may also be given as mg%, which is similar to g/100ml. A level of 0.05% could be listed as 050 mg%.

Alcohol Metabolism Rates

HowStuffWorks.com briefly highlights how alcohol is metabolized:

Once absorbed by the bloodstream, the alcohol leaves the body in three ways:

• The kidney eliminates 5 percent of alcohol in the urine.
• The lungs exhale 5 percent of alcohol, which can be detected by breathalyzer devices.
• The liver chemically breaks down the remaining alcohol into acetic acid.

As a rule of thumb, an average person can eliminate 0.5 oz (15 ml) of alcohol per hour. So, it would take approximately one hour to eliminate the alcohol from a 12 oz (355 ml) can of beer.

BAC Charts

Moderation Management has a set of charts for approximating BAC based on our gender (male & female bodies metabolize alcohol differently), size, amount consumed, and elapsed time. The units used in the MM charts are “mg%”; a level of 080 there is the same as a BAC% of .08, the threshold at which most U.S. states prosecute for driving under the influence (DUI).

Comparing the one-hour-to-eliminate-one-drink rule to the MM charts, though, it appears the “average” person in question is 200-pound male or a 240-pound female, because if either of them has 3 drinks over 3 hours, their BAC will be under .01. A 120-pound woman is still going to be at .015 after consuming 3 drinks in a 6-hour period, and 160-pound man is likely to be at .012 after having 4 drinks in a 5-hour period.

Effects of alcohol based on BAC levels

The BRAD21.org website — Be Responsible About Drinking — was created by friends and family of Bradley McCue, who died of alcohol poisoning at 21. It includes a page which lays out the effects of alcohol, noting that “some users may become intoxicated at a much lower Blood Alcohol Concentration (BAC) level than is shown”.

Big Book of AA

The foundational book of AA, titled Alcoholics Anonymous.

The entire book is available online.

Binge

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

Binge: The Dictionary Version.

Merriam-Webster defines it this way:

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

Princeton’s WordNet 2.0 speaks of immoderate indulgence:

The noun “binge” has 2 senses in WordNet.

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

The verb “binge” has 1 sense in WordNet.

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

Twenty-four Hours: A Short Binge?

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

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

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

College Binge Drinking: The 5/4 Definition

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

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

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

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

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

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

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

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

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

NIAAA’s 2004 Binge Definition

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

A “binge” is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to .08 grams percent or above. For the typical adult this pattern corresponds to consuming 5 or more drinks (male) or 4 or more drinks (female) in about 2 hours. Binge drinking is clearly dangerous for the drinker and for society.

• A drink is defined as half an ounce of alcohol (e.g., one 12 oz. beer, one 5 oz. glass of wine, one 1½ oz. shot of distilled spirits).
• Binge drinking is distinct from “risky” drinking (peak BAC between .05 and .08 grams percent) and “benders” (2 or more days of sustained drinking to intoxication).
• For some individuals (e.g., older people; those taking other drugs or certain medications), the number of drinks needed to reach a binge-level BAC is lower than for the “typical adult.” People with risk factors for the development of alcoholism have increased risk with any level of alcohol consumption, even that below a “risky” level.
• For pregnant women, any drinking presents risk to the fetus.
• Any drinking by persons under the age of 21 is illegal.

So, using what we know about blood alcohol content, this definition tells us that binge starts at a level of slight impairment of balance, speech, vision, reaction time, and hearing. In general terms, the binge threshold of .08 is half-way to the “sloppy drunk” characteristics of .16. BAC tables like these suggest that the binge threshold could be reached by:

• A 120-lb woman having 2½ drinks in an hour
• A 220-lb woman having 8 drinks in 5 hours
• A 160-lb man having 4 drinks in an hour
• A 240-lb man having 11 drinks in 5 hours

Blip

From Dictionary.com:

blip, n.

• A spot of light on a radar or sonar screen indicating the position of a detected object, such as an aircraft or a submarine
• A temporary or insignificant phenomenon, especially a brief departure from the normal.

My definition:

A break in a drinking pattern, such as drinking during a period intended to be abstinent. Worth examining and learning from, but not necessarily a setback or helpful to interpret as a failure.

Some blips turn out to be anomalies, like false echoes on a radar screen, or inconsequential. Sometimes a blip is the first sign of a threat, needing to be addressed proactively.

The keys to reading a blip are consciousness and context: How does it fit with our typical or recent patterns?

Charting

A simple but essential tool for changing a habit: Tracking the progress.

DAFT

Delightfully Alcohol-Free Today.

My personal word for describing abstinent days. They’re often about feeling free from needing to be a somber, responsible adult. To me, a DAFT day is generally more a gift than a burden.

Any number of “D” words may fit, as well: Deliciously, deliriously, delectably, daintily…

See the how the word came to be, in So Bored? and More DAFT than sober.

Denial

“Refusal to admit the truth or reality

(as of a statement or charge)” (per Merriam-Webster).

A more clinical description from AlcoholMD.com:

Psychological defense mechanism … includ[ing] a range of psychological maneuvers that decrease awareness of the fact that alcohol use is the cause of a person’s problems… Denial becomes an integral part of the disease and is nearly always a major obstacle to recovery. Denial in alcoholism is a complex phenomenon determined by multiple psychological and physiologic mechanisms… Denial is the reluctance or failure to attribute problems to alcohol consumption; it is often a psychological defense against acknowledging the pain caused by the problem.

The NIAAA offers a Denial Rating Scale Decision Tree. It defines a scale of denial from Level 1 (an alcohol-dependent person saying that drinking is not a problem) to Level 8 (a person connecting with his self-image as an alcoholic, knowing how easy it would be to fall back to drinking without being threatened by it).

It’s certainly possible for us to gloss over tangible negative effects that drinking may have had on us or our loved ones. (I’ve dabbled in it at times.) It’s critical for us, as responsible, self-sufficient adults, to use all of the resources at our disposal to do personal reality checks and adjust our distorted perceptions whenever possible.

The challenge in identifying denial, though, is that the word has sometimes been used to describe:

• Any resistance to a recommended treatment approach.
• Academic disagreement about the necessity of adopting powerlessness and a higher power to achieve recovery.
• Resisting 12-step approaches, or refusing to identify one’s drinking problems as a disease, even mixed with willingness to pursue long-term abstinence.
• Believing that drinking problems don’t all progress to dependence and death (which they don’t).

There is no doubt that denial can be real — it’s possible for us to short-circuit our own logic, and even for long-term alcohol abuse to contribute to that — but slinging denial allegations can also be done sloppily. Once they’ve slung it, folks often feel vindicated by the inevitable resistance expressed by their target. “You’re questioning me? You just proved my point!”

Even when some form of denial is in play, the circumstances are often more complex than a simplistic lack of consciousness or smarts. If we’re not willing or ready to face the ways in which our actions are affecting others, we may still be cognizant that our behavior patterns aren’t smart. We may not be embracing the gut-level assessment by friends or family members, yet entirely willing to admit that things are breaking and/or broken in some fashion. And, the issues on which we disagree may be founded on rational, realistic perceptions.

Presuming that denial is always a player when we’re in a pattern of less-than-optimal choices can raise the spectre of shame. “Damn it, I made another choice that I promised I wouldn’t, so there still be a huge well of denial lurking within me. How could I be that stupid?” In truth, human behavior is often complex. It is not easily understood, and our actions are based on more than simply what we know or what we don’t, what we accept or refute. Taking on shame — thinking “since I did the not-so-smart thing again, I must not be smart enough to admit the reality of the situation” — does a disservice to the complexity of our honest, sincere, yet humanly flawed lives.

Denial isn’t even a universal component of alcohol abuse. On page 33 of his 1995 book, The Natural History of Alcohol Alcoholism, Revisited, George Vaillant notes that problem drinkers have reported their drinking accurately in non-threatening circumstances.

Other researchers have found that alcoholics describe their own excessive drinking practices more accurately than their relatives describe them (Guze et al. 1963; Haberman 1966). Sobell and Sobell (1975) have also documented that the symptomatic diagnosis of alcoholism can in fact be reliably made from the patient if certain rules are followed. Subjects should be without a clouded sensorium and relatively sober at the time of interview. They should be questioned by a sophisticated interviewer who asks the “right” questions, who is not in a position to threaten the alcoholic’s right to drink, who obtains reasonable rapport, and who has time to conduct an adequate interview.

Stanton Peele and Archie Brodsky, in a 1991 article in Reason Magazine, talk about the emphasis on denial in Alcoholics Anonymous:

This proselytizing tendency, originating in the religious roots of the movement, was legitimized by the association with medicine. If alcoholism is a disease, then it must be treated — like pneumonia. Unlike people with pneumonia, however, many people identified as alcoholics don’t see themselves as sick and don’t want to be treated. According to the treatment industry, a person with a drinking or drug problem who does not recognize its nature as a disease is practicing “denial.”

In fact, denial of a drinking problem — or of the disease diagnosis and A.A. remedy — has come to be a defining characteristic of the disease. But indiscriminate use of the denial label obscures important distinctions among drinkers. While people sometimes do fail to recognize and acknowledge the severity of their problems, a drinking problem does not automatically prove a person is a lifelong alcoholic. Indeed most people “mature out” of excessive, irresponsible drinking.

The disease approach uses the concept of denial not only to force people into treatment, but to justify emotional abuse within treatment.

Peele and Brodsky don’t point to denial as something that never happens or doesn’t need to be considered, but to the dangers of indiscriminate use of denial.

Emphasizing the potential, and looking intently, for signs of denial has been found to be counterproductive by some researchers. Instead, they have found it more helpful to consider the natural role of ambivalence as folks progress through the stages of change, and look for ways to increase personal motivation.

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?

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: 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: 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.”

Harm Reduction

In my mind, Harm Reduction is taking steps to reduce the actual or potential harm caused by drinking. In my life, that has included drinking slower, lighter, later, and eating well before or during drinking when purely harm-free drinking has not been viable. Read more about that on this page.

As it’s worked for me, harm reduction hasn’t been an optimal long-term solution (I’d rather eliminate harm than reduce it) but it’s a great step when better answers are out of reach.

The UK Harm Reduction Alliance cites this definition from The Reduction of Drug-Related Harm, published in 1992:

Harm reduction is a term that defines policies, programmes, services and actions that work to reduce the:

• health;
• social; and
• economic

harms to:

• individuals;
• communities; and
• society

that are associated with the use of drugs.

The Canadian Centre on Substance Abuse (CCSA) identified these core principles (excerpted here) in 1996:

The main characteristics or principles of harm reduction are as follows:

• Pragmatism: Harm reduction accepts that some use of mind-altering substances is a common feature of human experience…
• Humanistic Values: The … user’s decision to [drink] is accepted as fact… No moralistic judgment is made either to condemn or to support [drinking]…
• Focus on Harms: The fact or extent of a person’s [drinking] per se is of secondary importance to the risk of harms consequent to use…
• Balancing Costs and Benefits: Some pragmatic process of … assessing the relative importance of [alcohol]-related problems, their associated harms, and costs/benefits of intervention…
• Priority of Immediate Goals: …Achieving the most immediate and realistic goals is usually viewed as first steps toward risk-free use, or, if appropriate, abstinence.

Harm Reduction Psychotherapy

From the Harm Reduction Therapy Center’s (HRTC) home page:

Harm Reduction Psychotherapy is based on the belief that substance abuse develops in each individual from a unique interaction of biological, psychological, and social factors.

Harm Reduction Psychotherapy is a non-judgmental approach to helping substance users reduce the negative impact of drugs and alcohol in their lives. It respects that people use drugs for reasons. It addresses the complex relationship that people develop with drugs and alcohol. Drug and alcohol issues are addressed simultaneously with social and occupational concerns and psychological and emotional issues.

The HRTC’s About page identifies the target audience for Harm Reduction Therapy:

Harm Reduction Therapy is suited for anyone who:

• is questioning whether their use of drugs and alcohol is a problem.
• has tried abstinence-based approaches and found them to be ineffective or undesirable.
• relapses frequently after attempts to be clean and sober.
• also suffers from emotional or psychiatric problems and wants help with these issues simultaneously.
• prefers an alternative way of thinking about their drug use.

Intervention

From the Hazelden Foundation website’s page titled, What is an ‘intervention’?:

An intervention is a deliberate process by which change is introduced into peoples’ thoughts, feelings and behaviors. The overall objective of an intervention is to confront a person in a non-threatening way and allow them to see their self-destructive behavior, and how it affects themselves, family and friends. It usually involves several people who have prepared themselves to talk to a person who has been engaging in some sort of self-destructive behavior.

JACS: A Jewish Recovery Group

Jewish Alcoholics, Chemically Dependent Persons and Significant Others.

From the group’s About page

JACS, an organization led by volunteers, is dedicated to:

• encourage and assist Jewish alcoholics, chemically dependent persons and their families, friends and associates to explore recovery in a nurturing Jewish environment by conducting retreats and other events that provide support to Jews in recovery;
• promote knowledge and understanding of the disease of alcoholism and chemical dependency as it involves the Jewish Community; and
• act as a resource center and information clearinghouse on the effects of alcoholism and drug dependency on Jewish family life.

MM Meetings

Moderation Management’s face-to-face meetings.

Peer support and information-sharing gatherings for people who are concerned about their drinking.

Synopsis of typical meetings (see the full outline at Moderation.org):

• Opening Statement. Welcome… group consists of folks concerned about drinking… members don’t diagnose, treat, or judge each other… importance of individual choice.
• Ground Rules. Confidentiality… respect and tolerance… share experience and knowledge, avoid giving advice.
• Nine Steps. Meetings or online groups… abstain for 30 days… examine drinking’s effects… set personal life priorities… examine drinking behavior… learn MM guidelines and limits… set personal limits and take weekly steps… review progress & goals… continue as needed.
• Moderate Drinker Description. Enjoys a drink… relaxes without alcohol, too… avoids excessive drinking… doesn’t drink secretly or obsess about drinking.
• MM Limits. Obey drinking/driving laws… don’t endanger self/others… abstain 3-4 days/week… no more than 3/day, 9/week for women, 4/day, 14/week for men… avoid BAC in excess of .055%.
• Closing Statement.

Meetings are designed to include time for folks to talk about where they’re at, ask for feedback or ideas, and share their targets for the coming week.

Meetings are free and open to all; members are asked to contribute a small amount to offset costs of meeting space.

MM: Moderation Management

A group for and by people who are concerned about their drinking.

From the MM page page titled What is MM:

What is Moderation Management?

Moderation Management (MM) is a behavioral change program and national support group network for people concerned about their drinking and who desire to make positive lifestyle changes. MM empowers individuals to accept personal responsibility for choosing and maintaining their own path, whether moderation or abstinence. MM promotes early self-recognition of risky drinking behavior, when moderate drinking is a more easily achievable goal.

What does MM offer?

A supportive mutual-help environment that encourages people who are concerned about their drinking to take action to cut back or quit drinking before drinking problems become severe.

A nine-step professionally reviewed program, which provides information about alcohol, moderate drinking guidelines and limits, drink monitoring exercises, goal setting techniques, and self-management strategies.

As a major part of the program, members also use the nine steps to find balance and moderation in many other areas of their lives, one small step at a time.

Medline Plus

Medline Plus is an online health database maintained by the National Library of Medicine.

The seeds of Medline Plus were planted with the creation of MEDLARS (the Medical Literature Analysis and Retrieval System) in 1964. Medline began serving medical professionals and libraries with online access to a subset of the MEDLARS database starting in 1971.

Medline Plus was launched in 1998 as a pilot project to give internet users free access to consumer health information.

The National Library of Medicine (NLM) was established in 1836 as the Library of the Office of the Surgeon General of the Army. By the end of the nineteenth century it was recognized as a national resource of biomedical literature. In 1968 the NLM was brought under the umbrella of the National Institutes of Health (NIH), of which the National Institute on Alcohol Abuse and Alcoholism (NIAAA) is also a part.

The NLM is now the world’s largest medical library, collecting “information and research services in all areas of biomedicine and health care.”

Moderate Drinking: Beyond the Numbers

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

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

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

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

Moderate: From the dictionary

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

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

WordNet 2.0 expands on that:

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

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

MM’s Concept of Moderation

Moderation Management characterizes moderate drinking this way

A Moderate Drinker:

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

Moderate Drinking: Rules-free, Permanent

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

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

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

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

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

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

Asserting Personal Responsibility to Drink Moderately

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

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

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

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

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

Moderation as a Way of Life

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

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

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

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

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

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

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

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

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

Moderate Drinking: By the Numbers

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

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

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

Note that:

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

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

One/Two Drinks Daily

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

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

WHAT IS MODERATION?

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

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

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

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

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

U.K.: Three/Four Units Daily

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

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

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

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

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

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

Three/Four Drinks Daily, 9/14 Weekly

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

MM Limits:

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

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

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

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

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

Evidence of Low Risk at Higher Levels

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

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

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

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

The problem drinker

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

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

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

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

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

Summary

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

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

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

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

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

NIAAA: National Institute on Alcohol Abuse and Alcoholism

The NIAAA is part of the National Institutes of Health (NIH).

It was established in 1970 when Congress passed the “Comprehensive Alcohol Abuse and Alcoholism Prevention Treatment and Rehabilitation Act”. Sponsored by Iowa Senator Harold Hughes, Bill Wilson testified in support of its passage.

(Am I boring you already? Check out the “Why would I care about the NIAAA?” page.)

To put things in a 1970 perspective, consider that:

• Distribution of the Big Book, first published in 1939, crossed the one million mark in the early 70s, making average annual sales over its first three decades under 30,000. (Total distribution would hit 5 million in 1985, 10 million in 1991, and 20 million in the late 1990s.)
• Betty Ford’s journey into recovery was still eight years away.
• The Mary Tyler Moore Show hit the airwaves in 1970, and the booze bottle Lou Grant kept in the bottom drawer of his desk remained a comic fixture throughout the show’s 7-year run.
• The 1964 Grand Rapids Study suggested that BAC levels as low as .04 could impair driving safety, but DUI thresholds remained as high as .15.
• The founding of MADD (Mothers Against Drunk Driving) happened a decade later, in 1980.
• Dedicated alcoholism treatment centers were few. Before the Betty Ford Center center could open in 1982, California statutes had to be changed to permit the first non-hospital-based alcoholism treatment center to operate.

The NIAAA’s history page notes that the National Council on Alcoholism (NCA), formed in 1944 by Marty Mann, the American Medical Association (AMA), World Health Organization (WHO), and the American Psychiatric Association were all devoting some resources to alcohol issues. And yet,

By the 1960’s the National Institute of Mental Health (NIMH) in the U.S. Public Health Service had begun a very small program of grants in the alcohol area, leading to the establishment in 1965 of the National Center for the Prevention and Control of Alcohol Problems. The Center, however, had limited program authority and a limited budget. The situation with research was even more dismal. As asserted by the Cooperative Commission on the Study of Alcoholism in its 1967 report:

“Additional information about the nature and causes of problem drinking is urgently needed. Past research in this area has been uneven and sporadic…. While special attention to alcohol problems is currently required … research in this field cannot be developed in isolation from investigations of a basic science nature and those on other medical and psycho-social problems (Plaut 1967, pp. 50 and 52).”

There was a general feeling among advocates that the only way to sway public opinion and to address comprehensively alcohol abuse and alcoholism was from the national level through a highly placed and therefore highly visible Federal organization.

Today, the budget for the NIAAA is in the $400M range, per its 2005 Budget (908K PDF, page 4):

Its mission statement includes:

NIAAA provides leadership in the national effort to reduce alcohol-related problems by:

• Conducting and supporting research in a wide range of scientific areas including genetics, neuroscience, epidemiology, health risks and benefits of alcohol consumption, prevention, and treatment
• Coordinating and collaborating with other research institutes and Federal Programs on alcohol-related issues
• Collaborating with international, national, state, and local institutions, organizations, agencies, and programs engaged in alcohol-related work
• Translating and disseminating research findings to health care providers, researchers, policymakers, and the public

The NIAAA’s website includes a reasonably robust search function, giving ordinary folks access to evidence, research, and clinical approaches to alcohol issues.

The site includes a database page with links to several online resources for looking up alcohol-related data.

The National Institutes of Health (NIH), founded in 1887:

is the Federal focal point for medical research in the United States. The NIH, comprising 27 separate Institutes and Centers, is one of eight health agencies of the Public Health Service which, in turn, is part of the U.S. Department of Health and Human Services..

Simply described, the goal of NIH research is to acquire new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold. The NIH mission is to uncover new knowledge that will lead to better health for everyone. NIH works toward that mission by:

• conducting research in its own laboratories;
• supporting the research of non-Federal scientists in universities, medical schools, hospitals, and research institutions throughout the country and abroad;
• helping in the training of research investigators; and
• fostering communication of medical and health sciences information.

Naltrexone

Naltrexone is a pharmaceutical drug,

also referred to by its brand name, ReVia, or abbreviated as Nal, which was approved by the FDA in 1995:

Naltrexone offers new hope for preventing relapse in many of the more than 1 million Americans treated each year for the disease. Of treated patients, approximately 50 percent relapse within the first few months of treatment.

“While not a ‘magic bullet,’ naltrexone promises to help many patients in their struggle against a chronic relapsing disease. Identification of this pharmacologic treatment builds momentum to elucidate the myriad, complex brain mechanisms of alcohol addiction,” said NIAAA Director Enoch Gordis, M.D.

Separate NIAAA-supported, 3-month trials conducted by Joseph Volpicelli, M.D., Ph.D., and colleagues at the University of Pennsylvania and Stephanie O’Malley, Ph.D., and colleagues at Yale reported in 1992 that naltrexone helped to prevent early return to heavy drinking in a significant proportion of treated patients. In addition, patients who received naltrexone reported less alcohol craving and fewer drinking days than patients given a placebo.

Both NIAAA-supported studies were conducted in conjunction with psychosocial treatments.

Medline Plus offers basic info:

Naltrexone is used to help people who have a narcotic or alcohol addiction stay drug free. Naltrexone is used after the patient has stopped taking drugs or alcohol. It works by blocking the effects of narcotics or by decreasing the craving for alcohol.

This medication is sometimes prescribed for other uses; ask your doctor or pharmacist for more information.

Dr. Alex DeLuca points to evidence that it may support problem drinkers as well:

[T]here is a body of research on the use of naltrexone specifically as an aid to controlled drinking. Instead of taking the medication every day, this research suggests that people carry Nal with them at all times, and take a pill before entering into a drinking situation, or whenever craving for alcohol occurs. This ends up being a lot cheaper, as you are not taking it every day.

Dr. DeLuca’s site includes a Naltrexone FAQ page with links to background information and evidence.

Researchers are studying the effectiveness of injectable forms of Naltrexone. One study, which tested a product branded Vivitrex, has reported promising results, but in men only, with an injection which lasts 30 days:

A study of 600 men and women found that [Vivitrex] reduced heavy drinking among men by nearly 50 percent compared to a placebo.

But the Naltrexone injection had no effect on women. Researchers are conducting a larger study to determine why.

One Drink

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

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

Count as a drink—

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

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

Standard drink:

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

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

Special Note

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

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

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

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

Powerlessness

The first of the Twelve Steps of Alcoholics Anonymous is:

1. We admitted we were powerless over alcohol — that our lives had become unmanageable.

As described in A.A.’s message of hope page, powerlessness is equated with an inability to assert control over drinking:

Before … people came to A.A., most of them had tried to control their drinking on their own and, only after repeated unsuccessful efforts at such control, finally admitted that they were powerless over alcohol.

The Big Book of A.A., while introducing the 12 Steps in Chapter 5: How It Works, notes:

Remember that we deal with alcohol — cunning, baffling, powerful! Without help it is too much for us.

For Bill W. and the early members of A.A., recovery required them to name alcohol as powerful and themselves powerless, needing to give up their power to something outside themselves. Bill didn’t appear to qualify the powerlessness concept, either, following the “cunning, baffling, powerful” message with:

Half measures availed us nothing. We stood at the turning point. We asked His protection and care with complete abandon.

Over time, though, multiple interpretations of and responses to powerlessness have emerged.

Powerlessness, Broadly Speaking

James J. Messina, Ph.D., & Constance M. Messina, Ph.D. offer a broad (2,000+ word) definition of powerlessness at their Coping.org site, excerpted here:

Powerlessness is:

• Being out of control, unable to regain control.
• Lack of control over how others will treat or act towards you.
• Lack of control over jobs, schools, weather, acts of God.
• Inability to change compulsive behaviors despite repeated attempts.
• Impulsive, addictive, compulsive behaviors beyond control.
• Lack of ability to cure AIDS, bring back a loved one who has died.

They point to consequences of not accepting powerlessness ranging from simple frustrations and self-pride to forgetting that one is a human being. Their suggestions for coping with powerlessness point several times to the corresponding need for a higher power.

Narrowing the Definition

Not all 12-step proponents interpret powerlessness as broadly as the Messinas. Freelance writer Anne Wayman self-published Powerfully Recovered, which affirms the 12 Steps while adapting them somewhat. For her, the first step is a powerful action to take. She describes the admission of powerlessness as:

…the total, unrestricted acceptance that, by ourselves, we cannot behave in a normal manner. It’s “hitting bottom” and it’s the place of humility that allows us to accept the help a 12 Step Program offers.

She continues:

Notice, however, that Step 1 says our powerlessness is only about our addiction. The 1st Step doesn’t say we are powerless over anything else but our addictive drug or behavior. Then the Step makes clear that our lives are a mess because of the addiction.

These distinctions are important because taking the 1st Step is indeed a powerful action. The admission and acceptance of our need for help is, in fact, probably the most powerful positive action we can take on our own behalf.

Admittedly, this is not the usual way Step 1 is talked about in most meetings today. The prevailing view is that as recovering addicts we are powerless forever, over everything. But this is a myth that has grown up in the Fellowship over time, and it’s truly sloppy thinking and far from what the founders intended.

I suspect the reasons behind the myth of Perpetual Powerlessness comes from fear of relapse (a fear we’re promised we don’t need to have IF we follow the Steps) and the recognition that many of us do need a good dose of humility.

Powerless to Drink Moderately

For some folks, the best application of powerlessness is to conclude that it is within their personal power to choose not to have the first drink, but that they are unable to drink moderately after. Somewhere along the line, whether after the first sip, or the first drink, or the third, the ability is lost to exert conscious control over stopping.

Asserting Personal Power and Responsibility

Albert Ellis, Ph.D. developed Rational Emotive Behavior Therapy (REBT), defined as:

an action-oriented therapeutic approach that stimulates emotional growth by teaching people to replace their self-defeating thoughts, feelings and actions with new and more effective ones. REBT teaches individuals to be responsible for their own emotions and gives them the power to change and overcome their unhealthy behaviors that interfere with their ability to function and enjoy life.

In 1992 he collaborated with Emmett Velten, Ph.D. in writing When AA Doesn’t Work for You: Rational Steps to Quitting Alcohol. On page 42, they question the disease model of alcoholism:

This attitude — it’s not my fault or my responsibility — often causes more misbehavior. It damages the fabric of our society because it helps people avoid answering for their poor behavior.

If you see yourself as having internal control, you assume responsibility for your behavior — good, bad or indifferent. If you see yourself as being externally controlled, you find — yes, actively find — something outside yourself to account for your behavior.

The cognitive-behavioral approach assembled by Ellis encourages folks to accept responsibility for behavior and for changing it, accept themselves as people who engage in self-defeating behaviors, and not to label themselves as losers or victims. That has been developed further by SMART Recovery®, which teaches self-empowerment and self-reliance.

Powerlessness as a Self-Fullfilling Prophecy

Echoing Ellis’ concerns, Jeffrey Schaler, Ph.D. made a presentation to the 1995 Conference for Treaty 6 First Nations of Alberta titled, Thinking About Drinking: The Power of Self-Fulfilling Prophecies:

Self-efficacy is people’s confidence in their ability to achieve a specific goal in a specific situation. For example, the more people believe in their ability to moderate their use of drugs, the more likely they will be able to moderate. The inverse is true too: The more people believe in their inability to moderate their use of drugs, the more likely they will not be able to moderate it.

Powerlessness in Perspective

So, what can we make of the powerlessness concept? In an essay at the SMART Recovery® site, Joe Milon distinguishes between powerlessness as perceiving an external locus of control — finding strength and guidance outside oneself — and SMART’s perception of an internal locus of control — looking inside oneself for strength and self-control. He notes:

Either method works well depending on the type of person you are. If one thinks most of their problems are a result of other people, places or things, then that type of person is likely to do better with an external locus of control.

If one realizes that he or she would do best to take responsibility for their own feelings, that is, they know that they create their feelings, they are likely to do better with an internal locus of control.

It helps to realize that since people are different, one may do well with an internal locus of control, external locus of control of a a combination of both.

That sounds like reasonable middle ground to me. I prefer to avoid demonizing or empowering alcohol, and yet I don’t dispute that drinking itself can impair my power to make sound decisions. If I choose long-term abstinence at some point in the future because drinking moderately seems to be beyond my reach, I don’t foresee myself calling that powerlessness, but I won’t dismiss folks who frame their challenges differently as unreasonable.

We’ve got to find our own paths with this stuff, and I support anyone who is finding the conceptual framework that leads him or her to better health and balance.

SMART Recovery®

An abstinence-based program for moving beyond problem drinking:

From A SMART Recovery website - Helping Individuals Help Themselves:

Our Purpose:

To support individuals who have chosen to abstain, or are considering abstinence from any type of addictive behaviors (substances or activities), by teaching how to change self-defeating thinking, emotions, and actions; and to work towards long-term satisfactions and quality of life.

Our Approach:

• Teaches self-empowerment and self-reliance.
• Works on addictions/compulsions as complex maladaptive behaviors with possible physiological factors.
• Teaches tools and techniques for self-directed change.
• Encourages individuals to recover and live satisfying lives.
• Meetings are educational and include open discussions.
• Advocates the appropriate use of prescribed medications and psychological treatments.
• Evolves as scientific knowledge evolves.

SOS: Secular Organizations for Sobriety

An abstinence-based program which is independent of spiritual approaches. From the SOS website:

What Is SOS?

SOS is an alternative recovery method for those alcoholics or drug addicts who are uncomfortable with the spiritual content of widely available 12-Step programs. SOS takes a reasonable, secular approach to recovery and maintains that sobriety is a separate issue from religion or spirituality. SOS credits the individual for achieving and maintaining his or her own sobriety, without reliance on any “Higher Power.” SOS respects recovery in any form regardless of the path by which it is achieved. It is not opposed to or in competition with any other recovery programs.

SOS supports healthy skepticism and encourages the use of the scientific method to understand alcoholism.

The SOS Groups

SOS is a non-profit network of autonomous, non-professional local groups dedicated solely to helping individuals achieve and maintain sobriety. There are groups meeting in many cities throughout the country.

All those who sincerely seek sobriety are welcome as members in any SOS Group. SOS is not a spin-off of any religious group. There is no hidden agenda, as SOS is concerned with sobriety, not religiosity. SOS seeks only to promote sobriety amongst those who suffer from alcoholism or other drug addictions. As a group, SOS has no opinion on outside matters and does not wish to become entangled in outside controversy.

Although sobriety is an individual responsibility, life does not have to be faced alone. The support of other alcoholics and addicts is a vital adjunct to recovery. In SOS, members share experiences, insights, information, strength, and encouragement in friendly, honest, anonymous, and supportive group meetings. To avoid unnecessary entanglements, each SOS group is self-supporting through contributions from its members and refuses outside support.

Skillpower

How are skills developed?

• Practicing?
• Coaching?
• Training?
• Toning muscle?
• Tuning?
• Strength?
• Agility?
• Studying?

Perhaps, all of the above, or any number of combinations and permutations of the above?

Spirituality

AA’s approach to spirituality.

From page 121 of Bill W: A Biography of Alcoholics Anonymous Cofounder Bill Wilson:

As AA sees it, alcoholism is neither a curse nor a punishment. Nor is it a sin or the product of a weak, debased, or immoral character. Alcoholism is a malady that, in its essence, is a soul sickness, one that causes a kind of spiritual eclipse. Relief can come suddenly, as in Bill W’s case, or through a gradual process, which is the path AA’s Twelve Steps attempt to define. Healing is characterized by a reconnection with one’s spiritual, and benevolent, nature, coupled with an awareness of the universe as a spiritual place, to which we are all profoundly and positively connected.

An alternate approach from an Episcopal priest.

The perspectives of some spiritually-oriented folks who work with problem drinkers are relatively nuanced. Father Leo Booth contributed an essay to Spirituality and Chemical Dependency titled “A New Understanding of Spirituality”. On pages 10-12, he said:

There is a lot of confusion about the difference between the powerlessness of addiction and the corresponding need to let go of control which permits recovery, and spiritual empowerment which puts people in charge of the changes in their lives… The myths about spirituality and dysfunctional religious messages have given people the idea that powerlessness equals helplessness…

…Nearly everything in our religious and inspirational teachings tells us we are little children who must be guided, fixed, rescued — that if we do something good, God did it for us — we’re only capable of making mistakes.

This creates a different kind of unmanageability — the kind which grows from a belief that we have no control over our lives — that we must constantly look to someone who can do it for us…

Real spiritual power comes from what I call a co-creatorship with God — a partnership which signifies equality and balance of power.

…Step Three (turning our will and lives over to the care of our Higher Power) isn’t about handing our will and our lives over to a Spiritual Power who is now going to call all the shots. It’s about making the decision to change… It involves developing a relationship with a support group of guides who can dialogue with us about what action to take to effect that change. This is an adult relationship with God.

Explicity religious approaches

Some spiritual approaches are geared specifically to religious practics:

• JACS (Jewish) Spirituality Pages.
• Alcoholics Victorious (Christian) Creed.

Non-spiritual options.

Others groups, like SOS and SMART Recovery® to name a couple, take a non-spiritual approach to recovery.

Bottom line: No simple definitions.

Spirituality, naturally, defies simple definition. It’s no surprise, amidst a wide spectrum of spiritual heritage and experiences, that some of us knit spirituality into every part of our lives, some of us do not, and all of us make valid, heartfelt choices.

Stages of Change: Background

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

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

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

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

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

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

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

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

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

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

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

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

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

Continue reading: Stages of Change

Stages of Change: Core Concepts

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

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

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

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

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

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

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

Coming next: Stages of Change: The Processes

The 12 Steps

The Twelve Steps of Alcoholics Anonymous, from the AA.org page titled The Recovery Program:

1. We admitted we were powerless over alcohol — that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

Additional info from the same page:

Newcomers are not asked to accept or follow these Twelve Steps in their entirety if they feel unwilling or unable to do so.

They will usually be asked to keep an open mind, to attend meetings at which recovered alcoholics describe their personal experiences in achieving sobriety, and to read A.A. literature describing and interpreting the A.A. program.

A.A. members will usually emphasize to newcomers that only problem drinkers themselves, individually, can determine whether or not they are in fact alcoholics.

At the same time, it will be pointed out that all available medical testimony indicates that alcoholism is a progressive illness, that it cannot be cured in the ordinary sense of the term, but that it can be arrested through total abstinence from alcohol in any form.

WFS: Women For Sobriety

A non-profit organization dedicated to helping women overcome alcoholism and other addictions (per the WFS home page).

From the WFS site’s introduction page:

Why A Program For Women Only?

Until the founding of WFS, it was assumed that any program for recovery from alcoholism would work equally well for women as for men.

When it became obvious that recovery rates for male alcoholics were higher than for females, it was then declared that women were harder to treat and were less cooperative than male alcoholics.

WFS came forth with the belief that women alcoholics require a different kind of program in recovery than the kinds of programs used for male alcoholics.

The success of the WFS “New Life” Program has shown this to be true. Although the physiological recovery from alcoholism is the same for both sexes, the psychological (emotional) needs for women are very different in recovery from those of the male alcoholic.

Willpower

Willpower: From the Dictionaries

The definition of “willpower” wins a brevity award at M-W.com:

Energetic determination.

The Rosetta Edition of Webster’s Online Dictionary takes a slightly different tack:

Control of one’s behavior.

Synonyms: self-command (n), self-control (n), self-will (n).

The WordNet 2.0 dictionary database hosted by Princeton lists one sense for willpower:

self-control, self-possession, possession, willpower, self-command, self-will — (the trait of resolutely controlling your own behavior)

Twelve-Step Approaches: Willpower is Not Enough

Arnold Washton and Donna Boundy captured one of the memes I remember from the 1980s in the title of their 1989 book, Willpower’s Not Enough: Recovering from Addictions of Every Kind. In the introduction, they summarize:

Willpower isn’t enough because it springs from the very thinking that causes the addiction — the belief that there is a “quick-fix” to everything and that if we just exert enough control we can avoid all pain and discomfort… when we try to break an addiction we [also] … think, “There’s got to be an easy way.”

Using willpower alone to break an addiction is what’s called “first-order change.” It never works very well because the “solution” comes out of the same mindset as the problem. When an addict has already lost control over her use of a mood-changer, how can yet another attempt at controlling it be a lasting solution?

In “second-order change” the problem — and the solution — are reframed within a different set of concepts and beliefs. Second-order change for addiction means not trying harder to control the addiction, but throwing up your hands and admitting defeat — admitting that you are not in control.

This thinking can be traced back to Bill W’s framing of his recovery, as described on page 154 of Bill W: My First 40 Years:

It was not daylight-clear why the clergymen’s advice “You can do it, but only with God’s help” hadn’t worked. By contrast, Rowland, Ebby, and I had admitted that we of ourselves couldn’t do anything at all. Nearly all the cases cited by Professor James had made the same admission… The sociologists and psychologist who would restore self-confidence had been mistaken. God-confidence was the thing, not self-confidence.

Seeds of Willpower: Self-reliance

While that sense of giving up self-confidence ultimately worked for Bill and others within A.A., there are also folks like Father Leo Booth who take an approach that emphasizes making decisions to change and taking conscious action in the context of what Booth calls “an adult relationship with God.”

From a psychoanalytic perspective, psychiatrist Lance Dodes names “You Need To Surrender” as the fourth of ten Myths of Addiction. On page 95 of The Heart of Addiction, he expands on that myth:

The idea that you must surrender your will before you can give up your addiction arose from … Step Three [of the 12 Steps]. This step is based … on the belief that, “Our whole trouble had been the misuse of will power.” …

While some people can make use of this idea, it is clearly not for everyone. … [T]he appropriate solution is not to shamefully admit that you cannot manage your life, but to take over more management of your life — by understanding yourself and your addiction better so you can use that understanding to take power more directly in the place of the addiction. The last thing you want to do is give up taking control of your life.

Willpower: A Good Start

So, what can we do to make positive, coherent sense of the willpower concept? I like the answers offered by Prochaska, Norcross, and DiClemente in their 1994 book, Changing For Good. After studying thousands of folks who made significant changes in their own behavior, they laid out four myths which can “keep us from freeing ourselves from self-defeating behaviors.” Here is the second one, from page 61:

Myth: It just takes willpower [to create self-change].

When we ask successful changers, “How did you do it?” the universal answer is, “Willpower.” Our research seemed to confirm what everybody already knew. When we examine what “willpower” means to people, however, two different definitions are given. The first is technical: a belief in our abilities to change behavior, and the decision to act on that belief.

The second, sweeping definition is that willpower represents every single technique, every effort under the sun, one can use in order to change. If this is so, then it is inevitable that it takes willpower to change. This is a classic case of circular reasoning.

Self-changers do indeed use willpower in the first, true sense of the word, but it is only one of nine change processes, the one we call commitment. People who rely solely upon willpower set themselves up for failure. If you believe willpower is all it takes, then you try to change and fail, it seems reasonable to conclude that you don’t have enough willpower. This may lead you to give up. But failure to change when relying only on willpower just means that willpower alone is not enough.

Putting the Pieces Together

So, are you as dizzy as I am yet? Depending on the dictionary, you could say that willpower is about tenacity or about control. A strict reading of 12-step spirituality says willpower is suspect, and yet a priest who uses the same steps insists on taking responsibility and action. An analyst challenges us to manage life better, but of course long-recovering AA folks are doing the same on many fronts. What gives?

Did you notice that the 12-steppers and the self-changers ended up agreeing on something, though? They both say that willpower is not enough, each with their own reasons. And, the dictionary folks echo the self-changers in finding divergent ways to name it.

Seems to me the primary issue is that willpower is often a fuzzy target, not a foundation, easy to knock down like a straw man, but that its self-reliant, committed core is the theme that folks who are successful in any endeavor end up embracing in their own way.

Withdrawal Symptoms

From WebMD:

Withdrawal is an uncomfortable physical or psychological change that occurs when the body is deprived of alcohol or drugs that it is accustomed to getting. Symptoms of withdrawal are caused by decreased amounts of a substance in the blood or tissues of a person who has grown accustomed to prolonged heavy use and who then suddenly stops using or drastically reduces the amount of that substance.

Symptoms of alcohol withdrawal begin from 4 to 12 hours after you cut down or stop drinking or as long as several days after your last drink. The symptoms can last a few days and may include:

• Nausea or vomiting.
• Sweating.
• Shakiness.
• Anxiety.

In severe cases, delirium tremens, or DTs, can bring tremors, hallucinations, and seizures.

Bottom line: It’s a medical condition, can be life-threatening, and requires immediate medical treatment.