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Abstinence and the Alcoholic

For many commentators and treatment professionals abstinence from alcohol and drugs is viewed as the only acceptable solution. How we view any problem influences the probable solution or treatment system that we believe is acceptable and viable. In respect of most drugs, the reasoning is not difficult to understand, since most drug use is an illegal activity in almost every country. However, to understand why abstinence is advocated for alcoholism means that we need to understand the models of alcohol problems, in particular the alcoholism disease model.

The disease model makes some basic assumptions about the nature of alcoholism, in particular that alcoholics suffer from an abnormal and uncontrollable obsession to drink that actually leads them to the first drink and that once they start drinking, they develop a phenomenon of craving that compels them to continue drinking. They are, for all intent and purpose, pathologically driven to drink and have relatively no control over their consumption. If we accept these assumptions, as most alcoholism treatment centers do, then it is easy to see why we would believe that alcoholics cannot ever drink in safety again. Add to this, the belief that the disease is progressive; that the disease of alcoholism continually gets worse and is forever irreversible (once an alcoholic always an alcoholic) and the only possible conclusion that we can come to is that the only safe outcome for the alcoholic and drug addict is to abstain for the rest of their lives.

The truth is much more realistic. Most people with drug addictions and alcoholism have other underlying psychological problems that often drive them or compel them to use their trusted coping mechanisms. As stress increases so does the likelihood they will use there trusted coping mechanism even if that coping mechanism brings them harm in the long-term. It satisfies an immediate need to minimize their current psychological distress regardless of its source.

Sobriety

Alcoholics Anonymous (AA), believes that the alcoholic needs to stop drinking and stay stopped for the rest of their life (or for a day at a time).

AA makes a distinction between abstinence and sobriety. Alcoholics Anonymous views abstinence as an absence of alcohol from the diet, whereas AA sees sobriety as a State of Being,or State of Mind. Sobriety for AA is a state of both mind and spiritual well being that is achieved by the AA member working through the Twelve-Step program. Working through the Steps entails a self-examination and change in attitudes and behavior that is facilitated by relationships with the group and a higher power. So whereas abstinence is losing a negative or a removal of alcohol, sobriety is a gaining of a positive outlook and behavioral pattern that enriches the life of an alcoholic. However while this may be a positive it also points up one of the major problems of abstaining as a goal, major lifestyle changes.

Some Problems with Abstinence as a Goal

In order to achieve abstinence the alcoholic and drug addict needs to make major lifestyle changes. Like all followers of any pursuits alcoholics and drug addicts often mix with others who indulge in similar lifestyles generally through self help or mutual help groups.

However if they are to participate in the wider world they are liable to come into contact with alcohol and drugs. In fact, they will undoubtedly do just that. Non-alcoholic friends may be supportive and not actively encouraging an alcoholic or drug addict friend to indulge, however just being in the physical proximity and company of others who are getting intoxicated, or just consuming alcohol or smoking pot, can represent a major temptation to relapse. This temptation is even more acute for alcoholics since alcohol is so endemic in western society. Indeed the alcoholic often fears that his or her social life will be over if they remain abstinent. It may take a considerable length of time until they feel comfortable socializing at all and even longer where alcohol is present. Thus abstinence is a difficult goal to maintain.

Alan Marlatt, an American psychologist, highlights a second problem of this goal. In his research on relapse he suggested that the inflexibility of the goal led to a belief on the part of the alcoholic that any drinking, regardless of how slight, was proof positive of a return to full-blown alcoholic relapse. He argued that this outcome, rather than being a physiological process, was in fact a psychological process arising from a belief in the disease model and the need for complete abstinence. He called this phenomenon the ‘abstinence violation effect’. Thus someone who has remained abstinent for over a year and then took a drink would view this as a total failure rather recognize the very substantial reductions they have achieved in consumption and frequency of consumption.

Categorizing other non-substance based behaviors as addictions also brings the appropriateness of abstinence, as the only treatment goal for addition, into question. An abstinent goal for behaviors such as over-eating and over-exercising is obviously not only inappropriate but extremely dangerous. Thus other goals, such as moderation management, harm reduction and controlled use, have entered the treatment repertoire of addiction and have filtered back into the chemical addictions.

Alternative Treatment Goals

The best known, or most infamous, of these alternative treatment goals is controlled drinking. Evidence was beginning to emerge in the 1960s suggesting that the disease model of alcoholism was flawed (as alcoholics were found to be recovering without treatment AND had been found to be drinking in moderation and safety). So, in a famous experiment in the 1970s, Mark and Linda Sobell carried out a study to test the feasibility of teaching controlled drinking to alcoholics. The study caused a furor at the time but it was also a success, although not necessarily in the manner that was expected. Over some years a number of people in the controlled drinking treatment condition died, and this became a matter of heated public debate in the media. However it was generally ignored that over the same period a greater number of people in the conventional treatment died.

The Sobells writing about the study some decades later pointed to the fact that, many of the controlled drinking group had in fact opted for abstinence. Their interpretation of the results of the study was that a/ controlled drinking was possible for some alcoholics, although it was currently impossible to predict who, b/ that stopping drinking entirely was the more common outcome and c/ that patients were more likely to remain abstinent when they felt that they had been given a choice of outcome. They argued that this choice appears to give the patient ownership of the goal and hence ensured greater adherence to it.
Other goals have arisen out of pragmatic, rather than theoretical or ideological positions. The current approach to drug use is a prime example of this. Harm reduction arose out of the need to prevent the further spread of HIV/AIDS and other blood-borne viruses rather than a desire to give alternative treatments to addicts. Nevertheless the approach is now firmly established in drug treatment programs.

Abstinence is Sometimes Essential

While one can speak about alternate goals and choices, for some there are sound medical reasons why abstinence is essential. In cases where there is severe liver damage and further consumption of alcohol will only exacerbate the problem, abstinence is strongly recommended. Similarly for patients with severe cognitive impairments due to Wernicke’s encephalopathy or Korsakoff’s psychosis further consumption will only increase the damage. Thus there can sometimes be very good grounds for abstinence for health reasons and in cases where moderation cannot be achieved. Nevertheless even under these circumstances it is a difficult goal to maintain.

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