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Moderation Management vs. Total Abstinence Dilemma

January 7, 2015



If you've worked in alcohol rehab therapy for any amount of time, it's likely you’ve come across the arguments of 'moderation management', 'harm reduction' and 'total abstinence'.  Whilst many in the industry, most notably Alcoholics Anonymous (AA), subscribe to the view of total abstinence there’s many people arguing in favour of 'moderation' strategies, particularly in academia.   

The crux of the matter really comes down to whether or not it is possible to control problem drinking, or does the ‘sufferer’ need to give up completely? Can moderation be a legitimate treatment goal? Or will that ‘one drink’ lead to a deadly relapse? Are moderation strategies a dangerous temptation to the lives of addicts and former addicts alike?


And to explore the matter further, we here at Cassiobury Court have researched the issue and reached out to various 'authorities' in the area for their valued input.


A Brief History Lesson


The 'total abstinence' view upheld by a large section of the rehab industry, including Alcoholics Anonymous, has its roots back in the nineteenth century. Rapid industrialisation and 'improved' distilling techniques caught society completely off guard. People trapped in 'slums' turned to new potent liquor, which was more often than not gin.


As the nineteenth century progressed, so did the negative attitude towards excessive and dangerous alcohol consumption; a shift which occurred on both sides of the Atlantic. Middle class sentiment towards alcoholism was accompanied by working class groups encouraging 'teetotalism'.


This cumulated, at least in the United States, in the total prohibition of alcohol sales in the late 1910s. The law was famously repealed in the early 1930s, and by the middle of that decade AA was formed, supporting the 'total abstinence' rhetoric which exists today.


Since the 1950s a multitude of 'moderation management' and ‘harm reduction’ therapies have popped up, most notably "Moderation Management" (MM) which was established in 1994, a movement aided by the spread of the Internet.


MM vs. AA


Although lots of treatments have sprung up to tackle the issue of ‘problem drinkers’, AA has perhaps received the most attention within the industry. As you’re all aware AA espouses total abstinence. If a former addict returns to the bottle in a more moderate fashion, AA argues the person was misdiagnosed as an ‘alcoholic’ in the first place. AA has had its fair share of controversies, although this will not be the subject of the present article. AA holds the individual as totally powerless against their drinking and any attempt at moderation is bound for failure. For AA, a sip of alcohol isn’t distinguished from an all-out binge.


MM on the other hand aims to tackle what has been defined as mere ‘problem drinking', something distinct to ‘dependant drinking’, although MM stresses its doors are open to all. MM undertakes a triage of new applicants to determine which category the applicant falls under; 30% of their students do go onto the employment of total abstinence once it becomes apparent that moderation is not a viable option, although MM does fully embrase its services to the acute sufferer. AA and MM both consist of peer group meetings and online support. MM holds their strategies out as less effective for the long-term and dependant problem drinker where ‘cutting back’ is usually not enough.


MM utilises cognitive behavioural therapy techniques and new participants must abstain from drinking for the first 30 days, after which men and women should not exceed more than three drinks a day, or nine drinks a week for women and fourteen drinks a week for men. If the patient fails, abstinence is recommended.


Some have struggled with this concept of ‘moderation’, especially when one tries to employ its use without the aid of a trained therapist. Jurgis Kirsakmens, partner in Happy Moments, an app development company, and one of the authors of DrinkControl app feels an ‘alcoholic’ should say well clear of the bottle.


"For the recovered alcoholic it is important to stay completely away from alcohol to avoid relapse. As for others - it is important to understand what ‘moderate drinking’ really is and when the line of moderation is crossed."


"We (as authors of DrinkControl app) strongly believe that understanding of our alcohol consumption is important step for changing and controlling our own behaviours towards alcohol use" concluded Kirsakmens.


Tavy Vorng of New Life Thai Foundation, a ‘mindful-recovery’ centre in Thailand, points out that a solid consensus on abstinence vs. moderation management is hard to find amongst therapists even within his own clinic and success of either aim is bound to come down to the patient’s unique circumstances and drinking history.


"At the foundation the rule is total abstinence for the entire program from all mind- and behaviour altering substances" Vorng said.


"Regarding long-term recovery, since the team are comprised of therapists from a wide variety of different backgrounds, they themselves are divided on the issue of whether or not an alcoholic in long-term recovery can drink in moderation."


"It’s hard to say whether total abstinence would work for everyone, it is often a case-by-case issue."


Recovered ‘dependant drinker’ Bobby Teague Jr, an advocate of total abstinence and from Recovery Directions in Texas, USA, points out his favourite quote from ‘The Big Book of Alcoholics Anonymous’ which says:


"We are like men who have lost their legs; they never grow new ones. Neither does there appear to be any kind of treatment which will make alcoholics of our kind like other men. We have tried every imaginable remedy. In some instances there has been brief recovery, followed always by a still worse relapse. Physicians who are familiar with alcoholism agree there is no such thing as making a normal drinker out of an alcoholic. Science may one day accomplish this, but it hasn't done so yet."


Teague claims the passage mirrors his own personal struggles with the bottle.


"I thought after some time of complete abstinence I could ‘drink in moderation,’ but I always ended up drunk and back on the horrific path of daily drinking" he said.


Much research suggests moderation management is a viable alternative for those who suffer from a less severe form of addiction than the acute ‘problem drinker’. James Morris is a trainer and consultant at Alcohol Academy and he has worked in the alcohol field for over 10 years, and has own personal experiences of alcohol dependency. Morris agrees with this notion but points out even prior acute alcoholics can return to the bottle in moderation if sufficient time has lapsed since the addict has recovered.


"Dependency is a broad spectrum. The research seems to suggest that the more severe a person’s dependency has become, the less likely they would be to ever return to problem free drinking" said Morris.


"As such, 'alcoholics' could be considered those whose dependency was severe enough that they are never able to drink again in a problem free-way."


"It seems logical enough that someone who has given up drinking alcohol for 20 years might be more successful at moderating their drinking than if they'd only given up for 2 weeks."


"It seems logical that someone who has a heavy drinking peer group, physical or psychological health problems would be less likely to be able to control their drinking than someone who had friends and peers who drank moderately, had no health-related problems and had a fulfilling and stable life."


"Indeed population level studies show that dependency figures are linked to key societal level factors like price, availability and advertising".


"The crucial thing to remember is when it comes to addiction, no two people are the same and so there is no 'one size fits all'."


"I would re-iterate to anyone who has successfully found abstinence what they already know - the safest amount of alcohol is always none at all. Alcohol may bring some mild 'social' benefits, but for the problem drinker, these are usually significantly outweighed by the potential for harm" concluded Morris.


Jeff Packer, director and therapist at Jeff Packer & Associates in Oshawa, feels uncomfortable with the concept of labelling suffers as ‘alcoholics’.


"A thorough assessment is essential to determine the underlying or contributing factors relative to a particular individual's substance misuse" said Packer.


"One retired professor from Harvard recently claimed his entire career and research showed as little as eight percent of those struggling with alcoholism benefit from AA [citation needed]."


"While I think AA is a great mutual aid program for many, I also feel the message that you ‘are an alcoholic’ and ‘always will be’ is, from a mental health and wellness perspective, quite unhealthy".


Minnesota based Dirk Hanson, editor of the Addiction Inbox and author of The Chemical Carousel: What Science Tells Us About Beating Addiction, draws a distinct division between the casual heavy drinker and the serious addict, pointing out that the ‘disease model’ and abstinence is probably the only route for the latter.


"The fact that some non-alcoholics drink too much and ought to cut back, just as some recreational drug users need to ease up, is certainly a public health issue—but one that is distinct in almost every way from the issue of biochemical addiction" said Hanson.


"By concentrating on the fuzziest part of the spectrum, where problem drinking merges into alcoholism, we’ve introduced fuzzy thinking with regard to at least some of the existing addiction research base."


"Those who find the disease model unconvincing at best, and some sort of fraud at worst, are more likely to bristle at the notion that total abstinence is the only course available to the addict in treatment. But disease model proponents point out that, for most alcoholics, not drinking at all turns about to be easier than drinking a little."


"The anti-disease model authors seem not to care that addicted individuals are often immensely helped by, and hugely grateful for, disease conceptions of their disorder. They have often tried, and failed, at moderation on their own."


Dr Reid K. Hester Director of Research at Behavior Therapy Associates LLC in Albuquerque New Mexico, an organization of psychologists providing clinical services, stresses moderation should be given a chance, and if it doesn’t work, abstinence should be seen as the correct course of action.


"The scientific data are clear that there is an inverse relationship between the severity of the person's drinking problems and being able to get rid of those problems by moderating their drinking" Reid said.


"Alcohol-related problems are what motivate people to change their drinking. Many can reduce their problems and risk for future problems by cutting back, but not everybody can."


"That said, if a person with really significant alcohol-related problems wants to try cutting back as a first step then, with appropriate clinical supervision, I'd say give them the skills and let them try it."


"It only takes a matter of a couple weeks to see if a heavy drinker is going to make progress with an effective program."


"And if plan A (a moderate drinking goal) isn't working for them, they're much more likely to consider plan B (stopping entirely) as a way to get rid of their alcohol related problems."


31 year old Jillian Bauer has been sober since March 24th, 2013 and now runs The Rooms Project, out of Philadelphia. Bauer recounts her experiences with ‘moderation’, which all ended in failure.


"The second I take that first sip of alcohol, I have an allergic reaction. It's an old joke in the rooms of recovery support groups and meetings that when an alcoholic drinks, they 'break out in handcuffs'" she said.


"But for me, as soon as that first drink enters my blood stream, my allergy causes me to crave a second drink, a third, and a twelfth, and I won't stop until I've drunk myself into oblivion."


"From 18 to 29 I tried to control my drinking. I tried only drinking beer, alternating alcohol with water, only drinking on weekends, taking a month off here and there and then drinking again--everything."


"I tried everything and none of it worked. What I found was that I was obsessing over alcohol 24/7, even when I wasn't drinking. It was exhausting. Finally I just surrendered to the fact that for me, drinking in moderation was not in the cards. And my life has been a whole lot easier since accepting that."


Some therapists argue the risk associated with even the most minor of drinking is far too great. Such a move could spiral out of control. Dr. James R. Milam, author of Under the Influence and founder of Lakeside-Milam Recovery Center in Renton, Washington State, takes a hard line in arguing ‘alcoholics’ are probably carrying that label due to their hard genetic coding, and any ‘behavioural’ solution will always be overrun by the sufferers genetic disposition.


"People often fail to appreciate that alcoholics do not drink alcohol due to the fact that they’re dissatisfied or depressed with life… but rather due to their genetic propensity to the alcoholic substance… resulting in addiction" he said.


"This genetic propensity is physiological and can’t simply be addressed via psychological factors such as Pavlovian conditioning or counselling."


"The sufferer is without power to control his propensity to drink alcohol".


Linda Bartee Doyne, author of The Immortal Alcoholic's Wife and blogger at the Immortal Alcoholic in North Carolina warns that for the chronic drinker, trying to drink in moderation may carry an unacceptable level of risk.


"In my opinion, there are two factors that would have a direct effect on whether or not an alcoholic can drink in moderation. The factors are both biological and psychological" she said.


"Some people have a low biological tolerance to alcohol and cannot drink more than a drink or two without being inebriated."


"That brings us to the psychological factor because if the person knows his limit is a certain amount of alcohol but most often drinks past that point then the answer would be ‘No’ that person cannot drink in moderation."


"I use the term ‘person’ instead of alcoholic because there would be an argument made that if a person can drink in moderation and maintain sobriety, then he would not be an alcoholic."


"A true alcoholic has both a physical and mental inability to stop or recognize that are at their limit."


"I believe that drinking in moderation for anyone is a dangerous trial and error situation. If the person tries it and fails (or not) that determines the answer for that person" Doyne cautions.


"But the reality for most alcoholics is that the little trial/test can destroy every bit of success the alcoholic may have achieved in trying to reach sobriety."


"The real question for the alcoholic ‘Is the answer really worth the risk of destroying your life?’"


"If the answer is ‘yes’ then ‘No, that alcoholic cannot drink in moderation.’ If the answer is ‘no’ then it doesn’t matter if that alcoholic can drink in moderation because he/she won’t want to risk losing sobriety" Doyne concluded.


Tom Linde, a Seattle based therapist in Private Practice, argues one must be cautious if one is to toy with the idea of moderate drinking, especially if one was hitherto an acute alcoholic.


"There are some individuals with problematic levels of drinking who are able to completely quit without the aid of treatment or a 12-step program. And, there are some who are able to learn how to manage a healthy, controlled, stable pattern of drinking, i.e. no more than a few units a week" said Linde.


"It seems that the more advanced, the addiction, the more ingrained into the individual's lifestyle, than the more unlikely it is that controlled drinking is a viable goal. And the risk of course, is that many addicts will delay or imperil their recovery by thinking that controlled use is feasible for them."


"So I say that it is certainly best to err on the side of caution by aiming for complete sobriety. And, it is often really easier to have such a clean, concrete rule of conduct, rather than to have to engage in the continual decision-making and careful self-observation that successful controlled use requires. "


"Finally, an attempt at controlled use should ONLY be made with the evaluation and oversight of fully credentialed expert" Linde advises.


Kenneth Anderson, founder of HAMS, a centre in Lower Manhattan promoting ‘harm reduction for alcoholism’ argues total abstinence is not always the ideal objective of treatment. The aim of Anderson’s organisation is to accept that intoxication is a part of our world and works to minimise harmful effects rather than simply ignore or condemn them.


"HAMS does not use the words ‘alcoholic’ or ‘addict’ because these words are so politically loaded; the scientific term is Alcohol Dependence and the research from NESARC [citation needed] shows that over half of people who recover from Alcohol Dependence do so by cutting back" Anderson said.


"What makes HAMS unique and different is that we offer harm reduction strategies to help those who are unable or unwilling to reach idealized goals of either moderation or abstinence."


"We recognize that any reduction in quantity is a positive change and do not kick people out for failing to reach moderate drinking limits as defined by the US government."


Abstinence can indeed be an intimidating word for those in early recovery, especially amongst ‘mild problem’ drinkers.


Dr Nick Heather, Emeritus Professor of Alcohol at Northumbria University, feels the goal of total abstinence is off-putting to the moderate problem drinker, and likely to put the patient off from taking any action at all.


"I feel the central benefit in prescribing moderation as a goal for the suitable problem drinker is that additional suffers may take up the chance to explore treatment who would otherwise be intimidated by total abstinence" said Heather.


"Research has demonstrated the moderation objective yields a satisfactory outcome for lots of folk with less sever dependence on alcohol [citation needed]."


"Worst, there is evidence that the total abstinence goal is not all too productive with this group showing signs of mild dependency" Heather warns.


"However, a period of abstinence is usually essential before moderation is practiced. If alcohol has caused irreparable damage to the sufferer, i.e. liver damage, the moderation should be avoided."


"And therapists should listen to the wishes of sufferers. If the patient expressly shows a preference for abstinence, the therapist should not insist on moderation."


"In my experience many patients reject calls for total abstinence and so moderation is a viable alternative. Particularly when mild problem drinkers are made to believe lifelong abstinence if the sole solution to their problem with drinking, the patient is likely to deny that they have a problem at all" said Heather, "surely this is counter-productive and any level of ‘harm reduction’ is better than doing nothing at all. Moderation management by far
an easier sell to this group and should be recommended."


Prominent psychologist Dr Stanton Peele and author of influential books and articles on the subject of alcoholism goes as far as to say abstinence is not only unworkable but immoral.


"Eliminating the middle in allowing people to choose how to they fight their own addictions hurts treatment (by ruling out real, sometimes superior, options), hurts policy (no one can use drug x moderately or responsibly so it has to be illegal), and hurts people in their deepest selves ("I'm an addict who can't use any substance, forever")"


"Abstinence-only theory, practice, and policy is immoral, unworkable, and must be changed."


Conclusion


Whether one can embark on a course of ‘harm reduction’ or ‘moderation management’ is clearly affected by a multitude of genetic, situational, cultural and social factors. Although the distinction between ‘problem-drinker’ and ‘dependant drinker’ has come under scrutiny [citation needed], the distinction does seem logical. Indeed the DSM-5 under Substance Use Disorder reflects the distinction by categorising addictions into ‘mild-moderate-severe’.


If moderation is to be attempted a professional triage process seems to be advisable to ensure the patient fits the mould of ‘problem-drinker’ rather than ‘dependant’. It additionally seems counter-productive to write off moderation strategies from the offset, especially for those who have not hit the infamous ‘rock-bottom’ as detailed in AA literature. Responsible drinking in the form of ‘non-abstinence’ treatment models may well prevent this ‘rock-bottom’ scenario from developing, and provide a powerful weapon in your treatment arsenal.

However, some addicts will never be able to achieve ‘healthy boundaries’ so moderation strategies should always be employed with caution.

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