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Research and political realities: What the next twenty years hold for behaviorists in the alcohol field
Adv. Behav. Res. Thu. Vol. 9, pp. 165-171, 1987. Rintcd in Great Britain. All rights reserved.
Cowi&
0146-6402/87 sO.00+.50 01987 Pcrgmnon Journals Ltd.
RESEARCH AND POLITICAL REALITIES: WHAT THE NEXT TWENTY YEARS HOLD FOR BEHAVIORISTS IN THE ALCOHOL FIELD G. Alan Marlatt University of Washington, Washington, USA Abstract - Contemporary political realities are addressed in terms of implications for future research in behavioral approaches to alcohol problems. Increased funding trends for addiction research and recommendations for establishing a National Institute on Addiction are reviewed. Evaluation of treatment effectiveness will become the criterion for future program funding rather than treatment philosophy or traditional beliefs about alcoholism. Cost-effective considerations will promote the need for early intervention and minimal intervention programs. Turning to the topic of controlled drinking, controversy over the use of this term (or related terms such as ‘responsible drinking’) is discussed. It is recommended that we replace these terms with the more acceptable label of moderation training. Use of moderation training as a secondary prevention approach with high-risk drinkers is outlined, along with criteria for selecting treatment goals of moderation or abstinence.
What is the future status of the behavioral approach to alcohol probems as we approach the 21st century? What major themes and issues reveal themselves as we peer into the crystal ball? I have attempted to comment on what I see to be some of these future trends in two previous articles (Marlatt, 19781982). Rather than going over the same ground I covered in these earlier papers, I will focus my comments here on two major topics: (a) political realities as they affect behavioral research in the alcohol field and.(b) the future of controlled drinking. POLITICAL
REALITIES
The alcohol and drug field in the United States is currently undergoing a major transformation. In October of 1986, President Reagan signed into law (Public Law 99-570) massive legislation authorizing a $1.7 billion effort to combat drug and alcohol abuse to beef up drug enforcement activities. Widespread national publicity following the cocaine-induced death of a prominent American athlete (Len Bias), coupled with First-Lady Nancy Reagan’s personal crusade against drug use by American youth, triggered what some have called a ‘drug hysteria’ that swept the country in the second half of 1986. Although most of the outcry has been directed at illegal drugs such as cocaine and heroin, the Anti-Drug Bill signed by Reagan included Address reprint requests to: G. A. Marlatt, Addictive Behaviors Research Center, Department of Psychology, NI-25, University of Washington, Seattle, WA 98195, USA. 165
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alcohol problems as a focus of concern. Despite the fact that the bulk of the increased funding in the Anti-Drug Bill is slated for drug enforcement activities (including drug-testing to detect drug users in the workplace), the ‘good news’ for those of us engaged in prevention and treatment research is that more funds are available to support work in the alcohol field. The law also contains provisions to establish a new Office of Substance Abuse Prevention within ADAMHA (Alcohol, Drug Abuse, and Mental Health Administration) and increased funding to develop and evaluate effective alcohol and drug abuse treatment programs. Research funding was increased substantially for both the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA). Both institutes provide substantial support for behavioral research and training. Recognizing that alcohol and other drug problems are closely linked, some authorities have called for the development of a combined attack on the addiction problem at the federal policy level. In an article published in the New York Times (September 23, 1986), Joseph A. Califano (former Secretary of Health, Education and Welfare under the Carter administration) urged the formation of a National Institute on Addiction: The creation by Congress of a National Institute on Addiction would provide the kind of commitment required for a major research effort. The institute could take on the research work of the present National Institutes on Drug Abuse, Mental Health, and Alcohol Abuse and Alcoholism, and look at all addictive substances and multiple drug abuse. Rutting research on addiction in a single institute would help generate the steady stream of funds necessary to study addiction, make clear that we’re serious about it, provide basic research essential to nourish efforts in the private sector and attract our best and brightest to the effort.. . . Millions of our citizens spend billions of dollars to get and stay hooked on everything from cigarettes to crack. Long overdue and welcome as the attention of the President and Nancy Reagan and Congressional leadership is, all the huffing and pufftng and all the police, prisons and electrocutions are unlikely to change that grim reality. A major research effort just might.
Will behavioral researchers get their share of the financial pie? There are several promising trends indicating they will indeed share in the funding bonanza. Despite the prevailing influence of the disease model of alcoholism, fully harf of the extramural research funded by NIAAA is earmarked for psychosocial and behavioral studies (a similar funding balance exists in NIDA). With the increased dollars available for treatment outcome research, behavioral scientists are in an excellent position to assume a major leadership role in directing new and innovative studies with a potential for influential impact on future policies in the treatment field. The cost for existing for-profit alcoholism treatment programs (i.e. the typical 30-day inpatient program) continues to sky-rocket. Third-party payments for such costly programs (upwards of $20,000 per patient per month in some existing programs) cannot continue unabated. In the light of a recent government report showing that inpatient programs for alcoholism may be no more effective than less-costly
Research and Political Realities
167
outpatient programs @axe et al., 1983), insurance companies are increasingly asking: what type of treatment is the most cost-effective? Along similar lines, the Joint Commission on Accreditation of Hospitals (the JCAH accredits more than 80% of the health care facilities in the U.S.; accreditation is vital because many insurance companies and the government’s Medicaid and Medicare programs provide payments only to accredited care facilities) announced that future criteria for accreditation will be based on assessment of treatment effectiveness: How well hospital’s patients fare during and after their treatment will become the new focus for granting hospital accreditation, the Joint Commission on Accreditation of Hospitals announced Tuesday. Scrutiny of things such as deaths during surgery, infections acquired in a hospital and the generaloutcome ofpatient treatment represents a significant new direction for the accreditation process in this country. (Chicago Tribune, November 5, 1986; italics added).
Since hospital-based alcoholism treatment programs will be subject to the same criteria for accreditation as other hospital programs, treatment outcome statistics will become the new ‘bottom line’ for future funding decisions. Behavioral researchers are in a unique position to contribute to the evaluation of treatment effectiveness, given our specialized training in behavioral assessment and controlled treatment outcome studies. The crystal ball indicates that economic realities, rather than ideological controversies concerning the nature of alcoholism and how it should best be treated, will force the field to ask the key question of cost-effectiveness: what works best at the least cost? Despite the unpopularity of behavioral therapy among traditionalists in the field (particularly the behavioral endorsement of minimal intervention strategies and a corresponding emphasis on outpatient versus inpatient treatment), the political and monetary realities appear to be running in our favor. CONTROLLED
DRINKING:
WHERE DO WE GO FROM HERE?
Imagine the following scene as we tune our crystal ball two decades into the future. We are surprised to find that a cure for alcoholism has finally been discovered! The main criterion for an effective cure for alcoholism, lest we forget, is that the former alcoholic is able to consume alcohol again in a non-addictive manner, without ‘loss of control’ over drinking. Today, of course, we are told that since no known cure for alcoholism exists, the alcoholic can only ‘arrest the disease state’ by a lifelong commitment to total abstinence. Future workers in the field, assuming that a cure for alcoholism has been discovered by that time, will look back with amusement and disbelief upon the controversies that raged in the latter half of the 20th century around the topic of controlled drinking. Why such a fuss, our futurists will ask, about what must be considered to be the outcome of a successfully treated or ‘cured’ alcoholic - the ability to drink in moderation?
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G. A. Marlatt
There is no doubt that controlled drinking has gotten a ‘bum rap’ or at least a bad reputation in the United States in the 1980s. The current controversy has been well documented in the literature (e.g. Cook, 1985; Heather and Robertson, 1983; Marlatt, 1983; Sobell and Sobell, 1984), and will not be repeated here. Although the primary focus of the controversy has centered on the issue of controlled drinking for ‘gamma’ alcoholics, the criticisms have gone beyond this to include questions about the general concept of controlled or responsible drinking for any drinker, addicted to alcohol or not. In an address at the First National Conference on Alcohol and Drug Abuse Prevention, held in August, 1986 in Arlington, Virginia, Loran Archer (then Acting Director of NIAAA) urged that the phrase ‘responsible use of alcohol be banned for all drinkers. As reported in the August 13, 1986 issue of The Alcoholism Report: Acting NIAAA Director Loran Archer said the term, ‘responsible use of alcohol’, should be ‘purged’ from the lexicon of the field, arguing that it is inappropriate as a goal for adults as well as underage youth.. . . Archer said “responsible implies a positive aspect” of alcohol, which he said is the “number one drug of abuse causing a major portion of deaths across this nation.” Drinking is “not a responsible behavior, but a risk-taking behavior, whether it be by youths or adults”, Archer said, adding: “I hope we can all be clear about one major issue in our prevention message, and that is that we once and for all drop the use of ‘responsible use of alcohol’.” (The Alcoholism Report, 1486,14 (20), p. 7).
The underlying message here seems to be a neoprohibitionistic view - that all use of alcohol is irresponsible, ‘risk-taking’ behavior, and that, by implication, the only responsible act is to abstain. Such a view is consistent with the current conservative political trend which questions the validity of prevention and educational programs with a wide variety of ‘moral’ behaviors, particularly those dealing with sex and drug-taking behavior. Is there any need for complex, long-term programs in drug education, an observer of the contemporary American drug scene might ask, given that all we need to do is “Just say no”, as Nancy Reagan has urged? It’s clear to anyone working in the field of alcohol treatment in the United States today that the term ‘controlled drinking’ or ‘responsible use of alcohol’ is a red flag that sends the bull charging in the direction of behaviorists. At a recent address to the American Psychological Association meeting in Washington, D.C. (Marlatt, 1986), I urged that behaviorists ‘deep-six’ the label ‘controlled drinking’ once and for all. Confusion concerning the meaning of ‘controlled’ is widespread; for most, the term conjures up images of alcoholics attempting in vain to overcome urges to drink by the sheer expression of ‘willpower’ or other means of ‘volitional control’. Another reason to drop the term as it stands is that the controlled drinking controversy has become not only a red flag, but a red herring as well. The real issue, often obfuscated in the heat of the controversy, concerns basic questions about the prevention and treatment of alcohol problems. In arguments about
Research and Political Realities
169
the best g&for alcoholism treatment (abstinence vs controlled drinking), we often lose sight of a more fundamental issue; namely, the search for the best method or approach to changing drinking behavior. Abstinence is not a method of treatment, it is a treatment goal. Behavioral approaches to treatment advocate a particular set of methods or procedures of intervention, regardless of whether the goal is abstinence or moderation. The disease model advocates abstinence as the only viable goal to arrest the development of the progressive disease -a model that tells us why to abstain, but not necessarily how to abstain. Behavioral methods, on the other hand, consist of empirically derived strategies of change, with an emphasis on the ‘how to’ aspects of modifying behavior. Both abstinence and moderation goals are considered possible, given the tools of behavioral self-management. A goal of ‘control’ can even be subsumed under a larger goal of abstinence. As an illustration, consider an abstinence-oriented program that attempts to teach clients to minimize the magnitude and extent of a relapse episode by teaching control skills. In this case, controlled drinking skills are employed to manage relapse (tertiary prevention). Relapse prevention (Marlatt and Gordon, 1985) represents a behavioral approach to abstinence, even though many of the methods (e.g. teaching coping skills, relaxation training, stress management, cognitive restructuring, etc.) are essentially similar to those employed in controlled drinking programs (Sobell and Sobell, 1978). My recommendation is that we replace ‘controlled drinking’ with the term moderation training. Moderation training involves teaching self-management skills to moderate excessive behavior across the spectrum of addictive behaviors. Treatment for eating disorders (e.g. bulimia), for example, by their very nature must include moderation training, since total abstinence cannot be considered a viable goal. From this change of perspective, new questions arise: what types of addictive behavior problems are candidates for moderation training (for whom and under what conditions)? In terms of alcohol problems, the emphasis has shifted from moderate drinking as a long-term goal for most chronic (physically dependent) alcoholics (although, as stated above, it may be a short-term goal to manage the severity of relapse) to the approach of choice when it comes to secondary prevention. Individuals at risk for developing alcohol problems may benefit from early intervention to teach behavioral self-management skills before the problem gets ‘beyond control’. Research now suggests (e.g. Heather and Robertson, 1983; Miller, 1983) that moderation training is most effective with ‘high-risk’ populations, including younger heavy drinkers (generally those under 40 with less than 10 years’ history of problem drinking), those with a family history of alcohol dependence, or people who are involved in jobs or living situations where alcohol is readily available or frequently used (e.g. military personnel, high
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school, college and professional-school students, lawyers, and other ‘highrisk’ occupational groups). In our own research with college students considered at risk for developing alcohol problems, we found that a moderation training program based on cognitive-behavioral principles is effective in reducing alcohol consumption rates over a one-year follow-up period (Kivlahan et al., 1987). Minimal intervention programs with a moderation theme for early-stage problem drinkers are currently being investigated by the World Health Organisation in a multi-country trial. Moderation programs are already currently available in Europe, along with other countries such as Canada and Australia (Miller, 1986). As data showing the effectiveness of moderation training programs become more available, it is likely that American policy will follow suit. One potential ally to consider in terms of promoting moderation training in the U.S.A. is the emergence of Health Maintenance Organizations (HMOs). Since HMOs provide comprehensive health coverage for their members on a lifetime basis, it is to their economic advantage to develop effective prevention and early-prevention programs for their clientele before problems become more severe and in need of more costly interventions. Along these lines, it is interesting to note that Group Health Cooperative, a large HMO located in the Puget Sound region of Washington State, recently applied for funding to develop and evaluate a moderation training program for clients who are considered most at risk for alcohol problems - especially younger male drinkers, ages 18 through 28. Group Health also operates a costly alcoholism treatment program, but officials hope to cut these costs eventually by focusing on the young, high-risk drinker (most of whom would reject an abstinence goal). There is an interesting similarity between an early intervention approach to alcohol problems and how physicians currently treat borderline hypertension. Someone with a borderline blood-pressure problem is typically told to begin with a relatively simple intervention (e.g. dietary change and exercise), before a more intensive form of medication is introduced (e.g. use of diuretics or beta-blockers). If the problem responds well to minimal intervention, it is not necessary to introduce more costly and invasive procedures. The traditional disease-model approach to treating drinking problems seems to take the opposite course: the response to any drinking problem (even those considered less severe) is to recommend a full 30-day inpatient treatment program! The economy cannot continue to support such blunderbuss tactics. CONCLUSIONS There are those who have concluded that behavioral approaches to alcohol problems (particularly those associated with controlled drinking) have outlived their usefulness and/or should be finally put to rest, once and for all. Some of these critics include those formerly associated with the
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behavioral camp (e.g. Nathan, 1986). Others have argued that behaviorists should recognize and accept the dominance of the traditional disease approach; McCrady (1986), for example, admonishes us that, “The widespread acceptance of the disease model and abstinence as a treatment goal are realities of the 1980s that behavior therapy must recognize” (p. 174). To these critics, the foregoing analysis and prognosis of our field must seem to reflect an optimistic bias on my part. To these critics, I reply with a question: where is the evidence that traditional treatment approaches derived from the disease model are effective? Behavioral approaches are rarely used in most alcoholism treatment programs in the U.S., if ever; even though empirical studies have, for the most part, demonstrated their effectiveness or superiority over traditional approaches. Could it be that the Emperor has no clothes? In my view, the economy can no longer afford to support outdated theories and craft-oriented treatment programs. The politics of economic deficits and the necessity for cost-effective, value-free, data-based interventions will ultimately determine the future of the behavioral approach to alcohol problems. - Support for preparation of this paper comes, in part, from NIAAA grant No. AA 05591. A version of this paper was presented at the annual meeting of the Association for Advancement of Behavior Therapy, Chicago, November, 1986.
Acknowledgements
REFERENCES Cook, D. R. (1985) Craftsman versus professional: Analysis of the controlled drinking controversy. J. Stud. AIcohoI 46,433~442. Heather, N. and Robertson, N. (1983) Controlled drinking, 2nd ed. Methuen, New York. Kivlahan, D. R., Coppel, D. B., Fromme, K., Williams, E. M. and Marlatt, G. A. (1987) Secondary prevention of alcohol-related problems in young adults at risk. In K. D. Craig and S. M. Weiss (Eds), Prevention and early intervention: Biobehavioral perspectives. Springer, New York. Marlatt, G. A. (1978) Behavioral approaches to alcoholism: A look to the future. In: G. A. Marlatt and P. E. Nathan (Eds), Behavioralapproaches toalcoholism,pp. 183-209. Rutgers Center of Alcohol Studies, New Brunswick, NJ. Marlatt, G. A. (1983) The controlled-drinking controversy. Am. Psychol. 38, 1097-l 110. Marlatt, G. A. (1986, August) Controlled drinking: Where do we go from here? Invited address, American Psychological Association, Washington, DC. Marlatt, G. A. and Gordon, J. R. (Eds) (1985) Relapseprevention: Maintenance strategies in the treatment of addictive behaviors. Guilford Press, New York. McCrady, B. S. (1986) Implications for behavior therapy of the changing alcoholism health care delivery system. The Behav. Therapist, 9, 171-174. Miller, W. R. (1983) Controlled drinking: A history and critical review. J. Stud. Alcoho144,68-83. Nathan, P. E. (1986) Some implications of recent biological findings for the behavioral treatment of alcoholism. The Behav. Therapist 9, 159-161. Saxe, L., Dougherty, D. and Esty, J. (1983) The effectiveness and costs of alcoholism treatment, Congressional Office of Technology Assessment case study, Publication No. 052-00300902-1. U.S. Government Printing Oftice, Washington, D.C. Sobell, M. B. and Sobell, L. C. (1984) The aftermath of heresy: A response to Pendery et al.% (1982) critique of “Individualized behavior therapy for alcoholics”. Behav. Res. Ther. 22, 413-440.
Cowi&
0146-6402/87 sO.00+.50 01987 Pcrgmnon Journals Ltd.
RESEARCH AND POLITICAL REALITIES: WHAT THE NEXT TWENTY YEARS HOLD FOR BEHAVIORISTS IN THE ALCOHOL FIELD G. Alan Marlatt University of Washington, Washington, USA Abstract - Contemporary political realities are addressed in terms of implications for future research in behavioral approaches to alcohol problems. Increased funding trends for addiction research and recommendations for establishing a National Institute on Addiction are reviewed. Evaluation of treatment effectiveness will become the criterion for future program funding rather than treatment philosophy or traditional beliefs about alcoholism. Cost-effective considerations will promote the need for early intervention and minimal intervention programs. Turning to the topic of controlled drinking, controversy over the use of this term (or related terms such as ‘responsible drinking’) is discussed. It is recommended that we replace these terms with the more acceptable label of moderation training. Use of moderation training as a secondary prevention approach with high-risk drinkers is outlined, along with criteria for selecting treatment goals of moderation or abstinence.
What is the future status of the behavioral approach to alcohol probems as we approach the 21st century? What major themes and issues reveal themselves as we peer into the crystal ball? I have attempted to comment on what I see to be some of these future trends in two previous articles (Marlatt, 19781982). Rather than going over the same ground I covered in these earlier papers, I will focus my comments here on two major topics: (a) political realities as they affect behavioral research in the alcohol field and.(b) the future of controlled drinking. POLITICAL
REALITIES
The alcohol and drug field in the United States is currently undergoing a major transformation. In October of 1986, President Reagan signed into law (Public Law 99-570) massive legislation authorizing a $1.7 billion effort to combat drug and alcohol abuse to beef up drug enforcement activities. Widespread national publicity following the cocaine-induced death of a prominent American athlete (Len Bias), coupled with First-Lady Nancy Reagan’s personal crusade against drug use by American youth, triggered what some have called a ‘drug hysteria’ that swept the country in the second half of 1986. Although most of the outcry has been directed at illegal drugs such as cocaine and heroin, the Anti-Drug Bill signed by Reagan included Address reprint requests to: G. A. Marlatt, Addictive Behaviors Research Center, Department of Psychology, NI-25, University of Washington, Seattle, WA 98195, USA. 165
166
G. A. Marlatt
alcohol problems as a focus of concern. Despite the fact that the bulk of the increased funding in the Anti-Drug Bill is slated for drug enforcement activities (including drug-testing to detect drug users in the workplace), the ‘good news’ for those of us engaged in prevention and treatment research is that more funds are available to support work in the alcohol field. The law also contains provisions to establish a new Office of Substance Abuse Prevention within ADAMHA (Alcohol, Drug Abuse, and Mental Health Administration) and increased funding to develop and evaluate effective alcohol and drug abuse treatment programs. Research funding was increased substantially for both the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA). Both institutes provide substantial support for behavioral research and training. Recognizing that alcohol and other drug problems are closely linked, some authorities have called for the development of a combined attack on the addiction problem at the federal policy level. In an article published in the New York Times (September 23, 1986), Joseph A. Califano (former Secretary of Health, Education and Welfare under the Carter administration) urged the formation of a National Institute on Addiction: The creation by Congress of a National Institute on Addiction would provide the kind of commitment required for a major research effort. The institute could take on the research work of the present National Institutes on Drug Abuse, Mental Health, and Alcohol Abuse and Alcoholism, and look at all addictive substances and multiple drug abuse. Rutting research on addiction in a single institute would help generate the steady stream of funds necessary to study addiction, make clear that we’re serious about it, provide basic research essential to nourish efforts in the private sector and attract our best and brightest to the effort.. . . Millions of our citizens spend billions of dollars to get and stay hooked on everything from cigarettes to crack. Long overdue and welcome as the attention of the President and Nancy Reagan and Congressional leadership is, all the huffing and pufftng and all the police, prisons and electrocutions are unlikely to change that grim reality. A major research effort just might.
Will behavioral researchers get their share of the financial pie? There are several promising trends indicating they will indeed share in the funding bonanza. Despite the prevailing influence of the disease model of alcoholism, fully harf of the extramural research funded by NIAAA is earmarked for psychosocial and behavioral studies (a similar funding balance exists in NIDA). With the increased dollars available for treatment outcome research, behavioral scientists are in an excellent position to assume a major leadership role in directing new and innovative studies with a potential for influential impact on future policies in the treatment field. The cost for existing for-profit alcoholism treatment programs (i.e. the typical 30-day inpatient program) continues to sky-rocket. Third-party payments for such costly programs (upwards of $20,000 per patient per month in some existing programs) cannot continue unabated. In the light of a recent government report showing that inpatient programs for alcoholism may be no more effective than less-costly
Research and Political Realities
167
outpatient programs @axe et al., 1983), insurance companies are increasingly asking: what type of treatment is the most cost-effective? Along similar lines, the Joint Commission on Accreditation of Hospitals (the JCAH accredits more than 80% of the health care facilities in the U.S.; accreditation is vital because many insurance companies and the government’s Medicaid and Medicare programs provide payments only to accredited care facilities) announced that future criteria for accreditation will be based on assessment of treatment effectiveness: How well hospital’s patients fare during and after their treatment will become the new focus for granting hospital accreditation, the Joint Commission on Accreditation of Hospitals announced Tuesday. Scrutiny of things such as deaths during surgery, infections acquired in a hospital and the generaloutcome ofpatient treatment represents a significant new direction for the accreditation process in this country. (Chicago Tribune, November 5, 1986; italics added).
Since hospital-based alcoholism treatment programs will be subject to the same criteria for accreditation as other hospital programs, treatment outcome statistics will become the new ‘bottom line’ for future funding decisions. Behavioral researchers are in a unique position to contribute to the evaluation of treatment effectiveness, given our specialized training in behavioral assessment and controlled treatment outcome studies. The crystal ball indicates that economic realities, rather than ideological controversies concerning the nature of alcoholism and how it should best be treated, will force the field to ask the key question of cost-effectiveness: what works best at the least cost? Despite the unpopularity of behavioral therapy among traditionalists in the field (particularly the behavioral endorsement of minimal intervention strategies and a corresponding emphasis on outpatient versus inpatient treatment), the political and monetary realities appear to be running in our favor. CONTROLLED
DRINKING:
WHERE DO WE GO FROM HERE?
Imagine the following scene as we tune our crystal ball two decades into the future. We are surprised to find that a cure for alcoholism has finally been discovered! The main criterion for an effective cure for alcoholism, lest we forget, is that the former alcoholic is able to consume alcohol again in a non-addictive manner, without ‘loss of control’ over drinking. Today, of course, we are told that since no known cure for alcoholism exists, the alcoholic can only ‘arrest the disease state’ by a lifelong commitment to total abstinence. Future workers in the field, assuming that a cure for alcoholism has been discovered by that time, will look back with amusement and disbelief upon the controversies that raged in the latter half of the 20th century around the topic of controlled drinking. Why such a fuss, our futurists will ask, about what must be considered to be the outcome of a successfully treated or ‘cured’ alcoholic - the ability to drink in moderation?
168
G. A. Marlatt
There is no doubt that controlled drinking has gotten a ‘bum rap’ or at least a bad reputation in the United States in the 1980s. The current controversy has been well documented in the literature (e.g. Cook, 1985; Heather and Robertson, 1983; Marlatt, 1983; Sobell and Sobell, 1984), and will not be repeated here. Although the primary focus of the controversy has centered on the issue of controlled drinking for ‘gamma’ alcoholics, the criticisms have gone beyond this to include questions about the general concept of controlled or responsible drinking for any drinker, addicted to alcohol or not. In an address at the First National Conference on Alcohol and Drug Abuse Prevention, held in August, 1986 in Arlington, Virginia, Loran Archer (then Acting Director of NIAAA) urged that the phrase ‘responsible use of alcohol be banned for all drinkers. As reported in the August 13, 1986 issue of The Alcoholism Report: Acting NIAAA Director Loran Archer said the term, ‘responsible use of alcohol’, should be ‘purged’ from the lexicon of the field, arguing that it is inappropriate as a goal for adults as well as underage youth.. . . Archer said “responsible implies a positive aspect” of alcohol, which he said is the “number one drug of abuse causing a major portion of deaths across this nation.” Drinking is “not a responsible behavior, but a risk-taking behavior, whether it be by youths or adults”, Archer said, adding: “I hope we can all be clear about one major issue in our prevention message, and that is that we once and for all drop the use of ‘responsible use of alcohol’.” (The Alcoholism Report, 1486,14 (20), p. 7).
The underlying message here seems to be a neoprohibitionistic view - that all use of alcohol is irresponsible, ‘risk-taking’ behavior, and that, by implication, the only responsible act is to abstain. Such a view is consistent with the current conservative political trend which questions the validity of prevention and educational programs with a wide variety of ‘moral’ behaviors, particularly those dealing with sex and drug-taking behavior. Is there any need for complex, long-term programs in drug education, an observer of the contemporary American drug scene might ask, given that all we need to do is “Just say no”, as Nancy Reagan has urged? It’s clear to anyone working in the field of alcohol treatment in the United States today that the term ‘controlled drinking’ or ‘responsible use of alcohol’ is a red flag that sends the bull charging in the direction of behaviorists. At a recent address to the American Psychological Association meeting in Washington, D.C. (Marlatt, 1986), I urged that behaviorists ‘deep-six’ the label ‘controlled drinking’ once and for all. Confusion concerning the meaning of ‘controlled’ is widespread; for most, the term conjures up images of alcoholics attempting in vain to overcome urges to drink by the sheer expression of ‘willpower’ or other means of ‘volitional control’. Another reason to drop the term as it stands is that the controlled drinking controversy has become not only a red flag, but a red herring as well. The real issue, often obfuscated in the heat of the controversy, concerns basic questions about the prevention and treatment of alcohol problems. In arguments about
Research and Political Realities
169
the best g&for alcoholism treatment (abstinence vs controlled drinking), we often lose sight of a more fundamental issue; namely, the search for the best method or approach to changing drinking behavior. Abstinence is not a method of treatment, it is a treatment goal. Behavioral approaches to treatment advocate a particular set of methods or procedures of intervention, regardless of whether the goal is abstinence or moderation. The disease model advocates abstinence as the only viable goal to arrest the development of the progressive disease -a model that tells us why to abstain, but not necessarily how to abstain. Behavioral methods, on the other hand, consist of empirically derived strategies of change, with an emphasis on the ‘how to’ aspects of modifying behavior. Both abstinence and moderation goals are considered possible, given the tools of behavioral self-management. A goal of ‘control’ can even be subsumed under a larger goal of abstinence. As an illustration, consider an abstinence-oriented program that attempts to teach clients to minimize the magnitude and extent of a relapse episode by teaching control skills. In this case, controlled drinking skills are employed to manage relapse (tertiary prevention). Relapse prevention (Marlatt and Gordon, 1985) represents a behavioral approach to abstinence, even though many of the methods (e.g. teaching coping skills, relaxation training, stress management, cognitive restructuring, etc.) are essentially similar to those employed in controlled drinking programs (Sobell and Sobell, 1978). My recommendation is that we replace ‘controlled drinking’ with the term moderation training. Moderation training involves teaching self-management skills to moderate excessive behavior across the spectrum of addictive behaviors. Treatment for eating disorders (e.g. bulimia), for example, by their very nature must include moderation training, since total abstinence cannot be considered a viable goal. From this change of perspective, new questions arise: what types of addictive behavior problems are candidates for moderation training (for whom and under what conditions)? In terms of alcohol problems, the emphasis has shifted from moderate drinking as a long-term goal for most chronic (physically dependent) alcoholics (although, as stated above, it may be a short-term goal to manage the severity of relapse) to the approach of choice when it comes to secondary prevention. Individuals at risk for developing alcohol problems may benefit from early intervention to teach behavioral self-management skills before the problem gets ‘beyond control’. Research now suggests (e.g. Heather and Robertson, 1983; Miller, 1983) that moderation training is most effective with ‘high-risk’ populations, including younger heavy drinkers (generally those under 40 with less than 10 years’ history of problem drinking), those with a family history of alcohol dependence, or people who are involved in jobs or living situations where alcohol is readily available or frequently used (e.g. military personnel, high
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school, college and professional-school students, lawyers, and other ‘highrisk’ occupational groups). In our own research with college students considered at risk for developing alcohol problems, we found that a moderation training program based on cognitive-behavioral principles is effective in reducing alcohol consumption rates over a one-year follow-up period (Kivlahan et al., 1987). Minimal intervention programs with a moderation theme for early-stage problem drinkers are currently being investigated by the World Health Organisation in a multi-country trial. Moderation programs are already currently available in Europe, along with other countries such as Canada and Australia (Miller, 1986). As data showing the effectiveness of moderation training programs become more available, it is likely that American policy will follow suit. One potential ally to consider in terms of promoting moderation training in the U.S.A. is the emergence of Health Maintenance Organizations (HMOs). Since HMOs provide comprehensive health coverage for their members on a lifetime basis, it is to their economic advantage to develop effective prevention and early-prevention programs for their clientele before problems become more severe and in need of more costly interventions. Along these lines, it is interesting to note that Group Health Cooperative, a large HMO located in the Puget Sound region of Washington State, recently applied for funding to develop and evaluate a moderation training program for clients who are considered most at risk for alcohol problems - especially younger male drinkers, ages 18 through 28. Group Health also operates a costly alcoholism treatment program, but officials hope to cut these costs eventually by focusing on the young, high-risk drinker (most of whom would reject an abstinence goal). There is an interesting similarity between an early intervention approach to alcohol problems and how physicians currently treat borderline hypertension. Someone with a borderline blood-pressure problem is typically told to begin with a relatively simple intervention (e.g. dietary change and exercise), before a more intensive form of medication is introduced (e.g. use of diuretics or beta-blockers). If the problem responds well to minimal intervention, it is not necessary to introduce more costly and invasive procedures. The traditional disease-model approach to treating drinking problems seems to take the opposite course: the response to any drinking problem (even those considered less severe) is to recommend a full 30-day inpatient treatment program! The economy cannot continue to support such blunderbuss tactics. CONCLUSIONS There are those who have concluded that behavioral approaches to alcohol problems (particularly those associated with controlled drinking) have outlived their usefulness and/or should be finally put to rest, once and for all. Some of these critics include those formerly associated with the
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behavioral camp (e.g. Nathan, 1986). Others have argued that behaviorists should recognize and accept the dominance of the traditional disease approach; McCrady (1986), for example, admonishes us that, “The widespread acceptance of the disease model and abstinence as a treatment goal are realities of the 1980s that behavior therapy must recognize” (p. 174). To these critics, the foregoing analysis and prognosis of our field must seem to reflect an optimistic bias on my part. To these critics, I reply with a question: where is the evidence that traditional treatment approaches derived from the disease model are effective? Behavioral approaches are rarely used in most alcoholism treatment programs in the U.S., if ever; even though empirical studies have, for the most part, demonstrated their effectiveness or superiority over traditional approaches. Could it be that the Emperor has no clothes? In my view, the economy can no longer afford to support outdated theories and craft-oriented treatment programs. The politics of economic deficits and the necessity for cost-effective, value-free, data-based interventions will ultimately determine the future of the behavioral approach to alcohol problems. - Support for preparation of this paper comes, in part, from NIAAA grant No. AA 05591. A version of this paper was presented at the annual meeting of the Association for Advancement of Behavior Therapy, Chicago, November, 1986.
Acknowledgements
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