When the Rand Report on alcoholism treatment was released, indicating that many alcoholics reduced their drinking following treatment rather than abstaining, outraged treatment advocates attacked the report, its researcher-authors, and any suggestion that alcoholics could become social drinkers. As I wrote in Psychology Today in 1983:
"One study that brought on such opposition was the 1976 Rand Report. The Rand Corporation was commissioned by the National Institute on Alcohol Abuse and Alcoholism to analyze data that had been collected at the NIAAA’s treatment centers. Initially examining 2,339 male alcoholics, and following up 597 of them 18 months later, Rand researchers found that 24 percent had been abstaining for a substantial period of time, compared with 22 percent who were drinking normally.
On the morning that the report was released, the National Council on Alcoholism denounced it as being ‘dangerous, misleading, and not scientific.’ Thus began a campaign against the Rand Report and its results for which it is difficult to find a recent parallel in science. In response, the Rand researchers conducted an extensive four-year follow-up study. They broadened their sample, scrutinized their definitions, analyzed subgroups of subjects, and extended the period over which subjects were examined. Their conclusions upheld the viability of controlled drinking for all types of alcoholics. This version of the Rand Report suffered the unusual fate of having its results reinterpreted by its own funding body, the NIAAA, to the effect that ‘those who were dependent on alcohol cannot go back to normal drinking.’"
This article, me, Psychology Today, and the American Psychological Association -- which at the time owned PT -- were in turn attacked loudly and publicly. In a slightly "moderated" form, such attacks have continued through the years -- here is one, for example, in 2000, vilifying the Rand Report, along with me. (The name of this blog, "Prevent Tragedy," gives a sense for how challenges to abstinence-only treatment precepts are responded to even currently.)
But such attacks were -- and to a good degree remain -- unnecessary. As the NIAAA's reaction to its own study indicated, no suggestion that alcoholics could reduce their drinking in a beneficial way would be tolerated, and controlling drinking for alcoholics became a dead issue in the United States. Indeed, the leading behaviorists and controlled-drinking (CD) practitioners in America (like Bill Miller) indicated that these techniques should not be used with "real" alcoholics, and others -- like Barbara McCrady (Barbara is currently director of the Center for Alcoholism, Substance Abuse and Addictions, or CASAA, at the University of New Mexico) and Peter Nathan when they headed the Rutgers Center of Alcohol Studies -- warned against psychologists using CD techniques on the grounds that they were setting themselves up for legal penalties.
Flash forward 20-25 years, to the present. Virtually all alcoholism treatment in the United States remains abstinence-oriented (with one notable exception that I am aware of). This is certainly the approach taken -- to use the word "endorsed" is to understate the case -- by the American Society of Addiction Medicine (ASAM). And, yet, at the same time an entirely new concept has emerged in clinical thinking. This concept is "harm reduction," which takes the less perfectionist stance that reducing the harms associated with substance use is the most realistic and beneficial public health policy for addictive behaviors.
Although the notion of harm reduction arose around injectible drug use -- and particularly the idea of providing addicts with clean needles -- it has also spread to the alcoholism field. That this should be the route for the spread of this innovative approach is, in itself, odd. For the key concept governing treatment of alcoholism -- motivational interviewing (MI), developed by Bill Miller and his colleagues at CASAA -- strongly implies self-selection of goals, since the most effective treatment dynamic is one in which alcoholic and other addiction-treatment clients determine the course for their own recovery, rather than having abstinence imposed on them. (At some level, it is self-evident that people will select their own treatment goals -- the alcoholics in the Rand study, for instance, received abstinence treatment.)
Brief intervention (BI) is another technique now often combined with MI based on their shared principle that people must accept responsibility for their own addictions in order to remedy or improve them. And BI is most assuredly not set up to instill abstinence precepts. As I wrote (quoting the Drug and Alcohol Findings Effectiveness Bank) in my recent blogpost on the rise of harm reduction in addiction treatment:
Brief intervention works with alcohol-dependent hospital patients: Commonly presumed unsuitable for dependent drinkers, the evidence is stacking up that brief advice after screening can lead even these drinkers to cut back. This study of heavy drinking Taiwanese hospital patients provides one of the most convincing demonstrations yet that brief intervention can work in this setting, and the drinking reductions were particularly steep among dependent patients.
Repeated findings that alcoholics can be assisted to reduce their drinking by even minimal interventions may make us wonder what have been the costs of our decades-long abstinence fixation, where nothing short of total cessation of drinking or any other addiction has been recommended, tolerated, or assisted by helpers. That is, in direct opposition to claims by disease advocates that CD treatment kills alcoholics, and just as heroin addicts denied access to clean needles (and their children) have died from HIV/AIDS, have our public health and treatment blinders actually hurt and killed people, and do they still?
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