People with drinking problems typically don't want to abstain. This isn't big news for anyone who's ever personally dealt with, confronted, or has witnessed this issue unfold. Typically, we talk about those who are unwilling to quit as being resistant, or in denial of, their problem. But could something else be at play?
We know that the recent reformulation of the DSM, with all of its controversy, reconceptualized Alcoholism (previously Alcohol Dependence) into the Alcohol Use Disorder continuum with mild, moderate, and severe presentations. Many people were miffed, but nothing changed and here we are, in a new reality.
Except that every time I present this at a conference, clinicians tell me that they already knew their clients had varying levels of "Alcoholism" and that the new definition simply better fit their conceptualization of the problem. They've already been dealing with mild to severe alcoholism for years—the DSM was just slow to catch on.
While this is always encouraging to me, it also made me wonder about the differences between these groups that might be easy to see when someone shows up to treatment. You know, the stuff we can see, feel and measure (I'm a stats geek after all).
Fortunately for me, I set up Alternatives with an entire data collection operation that allows me to look at everything from health to depression, anxiety, emotional well-being, family and employment issues, and more. All that was left to do was to sit down with our data and dig. So off I went...
In a whole series of posters and talks, we have now been able to show that there are some real differences in how those who come looking for moderation show up for, and in how they end up doing in, treatment with us. I think the findings are incredibly interesting and I hope you'll think so too. This piece will be an overview, and future pieces will dig in more specifically into individual findings.
Moderate drinking research findings
A case of successful moderation: Alternatives has now been following one of our clients for 18 months, and we are seeing an ongoing successful transition in this person from years of heavy, daily drinking into moderation. More importantly for us, this same client is displaying ongoing reductions in depression and anxiety while showing substantial improvement in health functioning and positive emotions (Jaffe, Khalil, Sita and Todd, 2016)
Treatment helps everyone: Both moderation AND abstinence clients benefit from treatment in essentially the same way. What do I mean? Our research shows that depression, anxiety, alcohol (and drug) use severity and self-reported quality of life improve in both groups. If anything, there is an indication that moderation clients improve more when it comes to positive emotions and psychiatric well-being. Interestingly, when it comes to some measures of alcohol severity it looks like people who seek abstinence are coming in with more severe problems (Jaffe et al., 2015). This suggests that people might know what option is best for them when they come in.
Moderation treatment reduces drinking: Our research uses the technology of mobile breathalyzer monitoring that allows us to monitor our clients 24/7 even when they're not in our clinic. Our findings show that, for moderation clients, the average Maximum BrAC (Breath Alcohol Content) is below the driving limit (Mean = 0.06) and that their Average BrAC for each reading was less than 0.002 with only about 1.5% of tests (average is 2-3 tests per day) are coming back positive. (Jaffe, Molnar, Gabbert, Tornquist & Todd, 2015).
That is a completely different picture of moderation than typical thinking about problematic drinking suggests we should be seeing and much closer to the Witkiewitz research about drinking (see here).
Moderation clients feel "more good": When it comes to emotional well-being, abstinence and moderation clients feel "less-bad" from the beginning to the end of treatment. Since I believe that most clients drink to overcome negative feelings (especially those who are not heavily genetically predisposed to alcohol, say through variations in their OPRM1 gene), feeling "less-bad" is important to help keep drinking at bay. But only our moderation clients have been showing improvements in positive emotions, or as I like to call it, feeling "more good," which is a very interesting finding that we will be following up on (Todd, Molnar, Hall, Tolentino, Shemtov & Jaffe, 2015). We're still not sure if that's true for all moderation clients or only those who find great success with the practice.
So what does this mean for drinkers?
Given our findings, I think it would be hard to argue that people who struggle with alcohol problems have to accept abstinence as their goal in treatment and in life. We are finding very good support for the notion that there is a place for moderation treatment and that, overall, seeking moderation results in outcomes that are at least as good as seeking abstinence. In some areas, the results are even better for moderation seekers.
This suggests that the field as a whole needs to get past this argument. The question should no longer be whether moderation treatment should be an option but rather what treatment offers the best outcomes for those seeking moderation. With the aid of medications like naltrexone and more, we can get substantial improvements in drinking behavior even if we don't achieve abstinence.
As you know from my previous writing, I believe that keeping abstinence as the only de-facto goal available is keeping millions of people from asking for help. If moderation treatment can help bring even some of those who are resistant to treatment, it's worth it.