Saturday, November 28, 2009

More on Moderation

Most people who come to see me about their drinking, and who have had little prior treatment or connection to self-help groups, are not coming with a goal of abstinence. This is totally understandable – anyone who has run into a problem with any gratifying activity would want to give up only the problem part of the activity, rather than the whole experience. As I often point out, alcoholics and addicts are, in most respects, no different from the rest of humanity. Remember the days when eggs were bad for your cholesterol? (I think that changed, but I’m no authority on that.) Did you choose to give up eggs altogether, in order to be safe? Or did you just cut back?

Of course, the problem that most alcoholics and addicts run into is that cutting back on behaviors that have become addictive (whether alcohol, drugs, lottery tickets, internet porn, etc.) is, in fact, different from cutting back on eggs. Addictions, in fact, are different from “regular” behaviors, which is why applying logic or reasoning has much less impact on alcoholic behavior than on most decisions we make. If we were to learn, for example, that one brand of bottled water contained more carcinogens than another brand at the same price, we would choose to purchase the safer brand. If we had repeatedly been robbed when walking alone in a certain part of town, we would stop walking alone there. But drinking poses much greater danger for the alcoholic, yet s/he does not seem to learn from the negative experience. There are at least two reasons for this: [1] behavior tends to be shaped more by immediate consequences (which, in the case of alcohol and addictive drugs are mostly experienced as rewarding) than by later consequences (e.g., losing one’s family, job, or health); [2] addictive behavior is driven largely by parts of the brain other than those involved in reasoning. (For more on the evolving science of the neurobiology of addictions, visit the web site of the National Institute on Drug Abuse – you might start with the review found here.

Of course, most people who use alcohol are not alcoholics. They are able to decide how much to drink (which, in the case of college students, is often enough to get drunk), and after a relatively small amount of alcohol they experience satiation, with no drive to continue. Most alcoholics, on the other hand, feel a very strong pull to continue drinking once they have consumed one or two drinks. Some say they can’t really fathom why someone would bother drinking if having only one or two. Why the difference? Most clinicians and scientists in the field (but not all) agree that it is biological rather than psychological, likely a difference in genes, nervous system, metabolism, rather than a matter of so-called “willpower.” Most alcoholics have had no problem applying willpower to other aspects of their lives, and have tried repeatedly but unsuccessfully to apply it to their drinking. To further complicate the matter, many alcoholics can limit their drinking temporarily by paying extra-close attention while seeking to prove the ability to exert control. Over time, however, they relax into doing what comes naturally, as anyone would. Even a review of the epidemiologic studies suggesting that some of those with diagnosable alcohol problems can achieve non-problem drinking indicates that abstinence is the most stable resolution, especially for those with more symptoms of alcohol dependence.

That’s what makes moderation such a difficult goal. Nevertheless, almost no one is prepared to “surrender” to these probabilities at the outset. So, as a therapist, I hang in with them as they do what I describe as a series of experiments, in which the hypothesis is, “I can keep the good part of my drinking and delete the bad part.” I don’t have to tell you what the outcome usually is. But everyone has to do his or her own “research.”

Sunday, November 22, 2009

The Question of Moderation as a Goal for Alcoholics

Obviously this question is too big for me to address comprehensively in one blog, or a series of blogs, and in fact it represents an ongoing conundrum dating back long before my time and that may well persist long after.

Every so often, new “evidence” crops up that alcoholics (and, by extension, other kinds of addicts) can transform themselves into moderate, non-problem drinkers. To the extent that this occurs, it seems to happen most often among those who have never sought treatment – and perhaps that is one reason why it is relatively alien to my experience and that of my colleagues.

Sometimes these reports come from treatment studies, such as the famous (well, to me, anyhow) Sobell & Sobell studies of the early 1970’s that purported to successful teach alcoholics to drink in moderation. (A follow-up study a few years later indicated that those relatively few individuals who had initially pulled off moderate drinking were now abstinent or drinking alcoholically or deceased.) More recently, some epidemiologic studies (in which large numbers of people in the community are interviewed retrospectively) have indicated that a significant minority of people who at some point met diagnostic criteria for alcohol dependence were currently drinking in a low-risk (i.e., non-problem) manner.

I should say that, in my student days, having read an early study by Davies, I was all for finding a behavioral strategy that could teach alcoholics to be normal drinkers. Over time, however, real life experience dampened those hopes, much as it has done for countless alcoholics.

Moderation Management is a self-help program that says it targets problem drinkers, as opposed to alcoholics. That may make some sense, since I suspect that some of those who reportedly manage to sustain moderate drinking may not be alcoholic in the same way as those I see most of the time -- for them, planning to regularly stop after 2 drinks is like planning to jump off a cliff and fall no more than 2 yards. MM reports that 30% of those who attend end up switching to a goal of abstinence. That includes the founder of that organization, who decided moderation might not make sense for her after she committed vehicular homicide.

More to come.

Thursday, October 8, 2009

Not a Disease? Again?

Recently I heard a radio interview with yet another mental health professional who has determined the addiction (a term that includes alcoholism) is not precisely a disease, but rather a matter of choice. Of course, debates about the nature of alcoholism/addiction go back a very long time. For ages, many viewed it as a moral failing rather than a condition, and perhaps for that reason a number of approaches to eradicate it came from the church. Although I'm sure addiction had been defined in medical terms before in some quarters, a major turning point in this country came in the 1930's, with the concurrent work of Dr. Jellinek at Yale and the formation of AA, itself an offshoot of a religious movement but one which embraced the disease model of alcoholism.

It was and is, of course, obvious to anyone that alcoholism is not the same kind of disease as, say, chicken pox. There is no germ, no contagion. It has, on the other hand, often been likened to diabetes or heart disease; though the analogy is far from perfect, these are illnesses for which there is no cure per se, but for which one can live a generally healthy life by making lifestyle changes. The diabetic avoids sugar (to over-simplify). The cardiac patient, depending on condition, perhaps avoids fats, maintains an exercise regime, etc. The alcoholic/addict refrains from using addictive substances. That is, to be sure, a choice. But it is a very different kind of choice from most of the choices we make – for example, whether to purchase furs, whether to buy a foreign car, or that pressing choice between “paper or plastic” at the supermarket. Those choices involve thought, belief, and behavioral follow-through. Avoiding alcohol, for the alcoholic, is an exceedingly more difficult task. A big part of his or her brain is creating an urge to drink, as powerful an urge as others might feel to eat when deprived of food, and powerful enough that there is often the risk that it will override rational thought (which is the province of a different part of the brain) -- hence, the familiar relapse-enabling rationalizations that seem so foolish in hindsight, which often take the form of: "I can have just one or two drinks this time because [insert reason that defies logic and previous experience]." This is nothing like even a tough non-addictive choice, such as "I got into Harvard, but my gut says I'll be happier at U Mass."

There is, I think, fairly wide agreement now among scientists who study addictions on some points (and a good place to read comprehensible reports on some of the latest research is at the website for NIDA, the National Institute for Drug Abuse). These include:
- Alcoholism, and probably most addictions, run in families, and while culture and learning, and other social/psychological factors are important, genes are of crucial importance;
- On the whole, the brains of alcoholics/addicts (and, it now seems, people with other conditions involving mood, thought, and behavior) are a bit different from the brains of those without addictions;
- Some of these differences are probably built-in from birth, while others are probably acquired as a result of repeated, substantial alcohol/drug use.

None of this means that one is doomed to keep drinking or drugging, or that no choice is involved, and of course recognizing the consequences of substance use can provide an incentive to make a less frightening choice. In fact, choice is critical, and to take a stance of "well, I have a disease, so we'll see what happens" is not at all likely to lead torecovery. But it's nothing like the choice you made this morning about what to wear, or the choice you made in the voting booth.