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.”
