Back From the Drink

Treatments for alcoholism that work.

By Jill Neimark, Claire Conway, published on September 01, 1994

o In the arena of alcoholism, motivation to quit reigns supreme. The latest research shows that brief, motivationally based interventions, where counselors work with patients for one to four sessions -- to both establish and to reinforce reasons for quitting -- can be as effective as far more intensive therapy.

o The motivation to quit drinking varies considerably among alcoholics. For one, losing job and family isn't enough; for another, an embarrassing moment at a corporate party may change a man's life. It's always subjective.

o One of the key genetic factors in alcoholism is an ability to metabolize liquor too well, because of the presence of the liver enzyme alcohol dehydrogenase. Indeed, a common trait among alcoholics is the early ability to "drink others under the table."

o Twenty percent of all alcoholics can and do quit successfully on their own. Researchers are just beginning to explore what is "special" about them and how to apply it to all alcoholics.

o In sum, no matter where and how an alcoholic recovers, this powerfully complex condition imposes three requirements for recovery: high, sustained motivation for quitting; readjustment to -- and building -- a life without liquor that includes family and peer support; and relapse prevention based on specific, well-rehearsed strategies of "cue" avoidance. These factors are being incorporated into treatment programs around the country.

As the tectonic plates of alcohol treatment shift, with new flexible views sending a shudder through the mental health field, the person who may finally benefit is the alcoholic. New insights into alcoholism are yielding exciting treatment approaches, creative uses of medication, and innovative psychological interventions.

No one can ascertain exactly when man discovered that carbohydrates could be fermented into alcohol, although we know that in 6000 B.C., beer was made from barley in ancient Sumeria. What is clear is that societies have long venerated and feared alcohol. Ancient Egypt and Mesopotamia allowed liquor into temple rites but regulated its general use; the Greeks linked their entire intellectual flowering to grape and olive growing; medieval monks brewed beer.

In the U.S., in turn, alcohol has a history marked by ambivalence that has shaped treatment so powerfully that a singular model has prevailed for nearly a century.

DURING COLONIAL days, alcohol consumption was extremely prevalent -- and there was no concept of the "alcoholic." The dawn of the 19th century brought with it a temperance movement that, according to Harry Levine, Ph.D., professor of sociology at Queens College in New York City, viewed alcohol as an addictive substance as dangerous as today's heroin or crack. Abstinence was the only solution.

Prohibition flowered directly out of the rich soils of the temperance movement, and yet it only set the stage for a very dismal failure: Consumption of hard liquor (which was easier to smuggle) rose, while overall drinking fell. A typical "temperance" culture, the U.S. gave birth to Alcoholics Anonymous, which has flourished in other temperance cultures, such as England, Canada, and Scandinavia. Notes Levine, "AA is really a religious movement that has tremendous continuity with the 19th century temperance movement. And AA's understanding of alcoholism is the central understanding of addiction in American culture overall."

Alcohol consumption, especially hard liquor, has seen a steady decline to 74 percent of its mid-1970s record high. Still, 13 million Americans are alcoholics. As researchers increasingly realize, a society's attitudes about alcohol strongly impact how individuals handle drinking. In Mediterranean, nontemperance cultures, wine is as common as bread, and individuals drink every day without becoming "problem" drinkers. The per capita rate of alcohol consumption is high; cirrhosis is common; but behavioral problems from alcohol are rare, and society does not lay the blame for its ills at alcohol's door.

In sharp and astonishing contrast, a temperance culture is highly ambivalent about "demon" alcohol, which is seen as a significant cause of our society's problems. In America, for instance, addiction is considered a root cause of violence. "In temperance cultures, people drink to get drunk. They tend to drink in short bursts of explosive, hinge drinking. Wine cultures rarely get fall-down drunk," says Levine.

Levine cites the typical European view: "Papa comes in with liver disease, and the doctor calls in the family and says, 'Look, he's got to make life-style changes, stop drinking for a while, eat less fatty food, exercise, and minimize stress, and the whole family needs to work together to help him because these changes are hard.' Apparently this works. Tell these European practitioners that what they really need to do is send their patient to 90 meetings in 90 days and turn themselves over to a higher power and they'll say, 'I've got somebody with health and dietary problems and you've got a religious solution?'"

In a temperance culture where alcoholism is widely -- if incorrectly -- regarded as a disease, the cure until now has been relentless abstinence. Levine calls this model a "useful fiction" that works for some, but by no means all, alcoholics.

For any person, the first step in reducing alcohol intake is to understand alcohol itself. Advances in neuroscience have given us new insight into the actual impact of alcohol on the body -- and the mind.