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"Disease Concept of Alcoholism and Drug Abuse." Encyclopedia of Drugs, Alcohol, and

Addictive Behavior. 2nd Ed. Ed. Rosalyn Carson-DeWitt. Macmillan-Thomson Gale,

2001. eNotes.com. 2006. 13 Feb, 2011

http://www.enotes.com/drugs-alcohol-encyclopedia/disease-concept-alcoholism-drug-abuse

Throughout most of recorded history, excessive use of ALCOHOL was viewed as a willful act

leading to intoxication and other sinful behaviors. The Bible warns against drunkenness;

Islam bans alcohol use entirely. Since the early nineteenth century, the moral perspective

has competed with a conceptualization of excessive use of alcohol as a disease or disorder,

not necessarily a moral failing. The disease (or disorder) concept has, in turn, been evolving

with considerable controversy since then, and has itself been challenged by other

conceptual models. Because this article is concerned primarily with the disease concept, the

other models will be mentioned only briefly.

Among the first to propose that excessive alcohol use might be a disorder, rather than willful

or sinful behavior, were the physicians Benjamin Rush, in the United States, and Thomas

Trotter, in Great Britain. Both Rush and Trotter believed that some individuals developed a

pernicious "habit" of drinking and that it was necessary to undo the habit to restore those

individuals to health. Words such as habit and disease were used to convey interwoven

notions. Trotter saw "the habit of drunkenness" as "a disease of the will," while Rush saw

drunkenness as a disease in which alcohol was the causal agent, loss of control over

drinking behavior the characteristic symptom, and total abstinence the only effective cure.

In 1849, a Swedish physician, Magnus Huss, introduced the term alcoholism ["alcoholismus"]

to designate not only the disorder of excessive use but an entire syndrome, including the

multiple somatic consequences of excessive use.

Late-nineteenth-century physicians, although not the first to see habitual use of other drugs

(such as OPIATES, TOBACCO, COFFEE) as disorders, are credited with stressing the idea that

each was but a subtype of a more generic disorder of inebriety. However, they also

minimized Trotter's and Rush's notions of learned behavior as a central feature of a generic

disorder of inebriety and emphasized instead the idea of a disorder rooted in acquired or

inherited biological malfunction or VULNERABIL-ITY. This more biologically based view of

inebriety was used in Britain and the United States by advocates of publicly funded

treatment facilities—inebriate asylums. Many temperance leaders also supported the

establishment of treatment facilities. However, while physicians advocated treatment,

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temperance leaders, still convinced that alcohol itself was the root of the problem, pushed

for its control and, eventually, for its prohibition.

In the United States, the ratification in 1920 of the Eighteenth Amendment, which prohibited

the production, sale, and distribution of alcohol, temporarily dampened scientific inquiry into

the nature of alcoholism. But concern about the problematic and excessive use of other

drugs, such as OPIOIDS, COCAINE, and BARBITURATES, continued to stimulate writings both

in the United States and abroad. Was excessive drug use a disease, a moral failure, or

something else—perhaps something in between?

By the mid-twentieth century, the rise of ALCOHOLICS ANONYMOUS (AA), the publications of

E. M. Jellinek, and the establishment of the Yale Center for Alcohol Studies revived interest in

exploring the nature of ALCOHOLISM. In the early 1960s, the idea reemerged that, for

certain "vulnerable" people, alcohol use leads to physical addiction—a true disease.

EARLY MODELS OF THE DISEASE CONCEPT

Central to the disease concept of alcoholism put forward by Jellinek were the roles of

TOLERANCE AND PHYSICAL DEPENDENCE, usually considered hallmarks of

ADDICTION.Tolerance indicates that increased doses of a drug are required to produce

effects previously attained at lower doses. Physical dependence refers to the occurrence of

WITH-DRAWAL symptoms following cessation of alcohol or other drug use. Although Jellinek

recognized that alcohol problems could occur without alcohol addiction, addiction to alcohol

moved to the center of scientific focus.

Despite being couched in the language of science, the reemergence of the disease concept

of alcoholism was not a result of new scientific findings. Jellinek believed it was necessary to

see alcoholism as a disease in order to increase the availability of services for alcoholics

within established medical facilities. He also recognized that efforts to prevent alcoholism

would still have to address the complex cultural, demographic, political and economic issues

contributing to the problem. Although he sometimes appeared to take a broad view of the

disease concept of alcoholism, he reserved the disease category for those individuals

manifesting tolerance, withdrawal symptoms, and either "loss of control" or "inability to

abstain" from alcohol. These individuals could not drink in moderation; with continued

drinking, their disease was progressive. Others who drank merely in response to

psychological stress ("alpha alcoholism") and those who sustained toxic consequences from

alcohol but were not physically dependent ("beta alcoholism") did not qualify for his more

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explicit and restrictive definition of disease. Jellinek's view of alcoholism as a progressive

disease is sometimes referred to as the "classic" disease model to distinguish it from later

perspectives of a disorder or syndrome more powerfully influenced by learning and social

factors.

Alcohol researcher and theorist Thomas Babor has pointed out that when definitions specify

alcohol addiction or dependence as a disease entity, it can be argued more convincingly that

"dependence is an organically based entity which produces a characteristic set of signs and

symptoms… and increases the probability of repetitive drinking behavior."

The American Psychiatric Association included alcoholism in the first edition (1952) of the

DIAGNOSTIC AND STATISTICAL MANUAL of Mental Disorders. In the second edition (DSM-II),

published in 1968, the group followed a precedent set by the World Health Organization's

INTERNATIONAL CLASSIFICATIONOF DISEASES (ICD-8) and included three subcategories of

alcohol-related disorders: alcohol addiction, episodic excessive drinking, and habitual

excessive drinking. Both of these publications included alcoholism among the personality

disorders and certain other nonpsychotic disorders, implying that the alcohol use was either

secondary to an underlying personality problem or a response to extreme internal distress.

This view of excessive drug use as a symptom of some other psychiatric disorder is

sometimes referred to as the symptomatic model. According to this concept, drug or alcohol

dependence is not really a disorder in and of itself.

Meanwhile, from the late 1950s and throughout the 1960s, the Expert Committee on

Addiction-Producing Drugs of the WORLD HEALTH ORGANIZA-TION (WHO) continued to

formulate and refine definitions of addiction and HABITUATION that could facilitate WHO's

responsibility (required by international treaties) for control of NARCOTICS, cocaine, and

CANNABIS. In the 1950s, the presence of physical dependence was emphasized in the

definition of drug dependence, and the WHO Expert Committee was still concerned with

differentiating between psychic dependence and physical dependence. At one level, the

concept of psychic dependence was compatible with the psychodynamic view that these

disorders were a response to psychic distress (such as negative mood states). According to

the psychodynamic model, excessive alcohol or drug consumption was merely a response to

underlying psychopathology. This model was also consistent with Jellinek's view of one of

the "species" of alcoholism, in which individuals drink to relieve emotional pain (alpha

alcoholism). In 1969, the committee abandoned the effort to

differentiate habits from addictions and adopted terminology first proposed by Nathan Eddy

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and colleagues in 1965, in which the term drug dependence designates "those syndromes in

which drugs come to control behavior." The committee recognized that dependencies on

different classes of drugs (such as alcohol, opiates, cocaine) can differ significantly and that

withdrawal symptoms are not always present or necessary aspects of dependence (see

Table 1).

In 1972, alcoholism was included in a listing of diagnostic criteria for use in psychiatric

research published by Feighner and coworkers. The defining criteria for alcoholism included

withdrawal symptoms, loss of control, severe medical consequences, and social problems. In

the same year the NA-TIONAL COUNCIL ON ALCOHOLISM also outlined criteria for diagnosing

alcoholism, which emphasized tolerance and physical dependence and incorporated certain

concepts developed by ALCOHOLICS ANONYMOUS. This definition, and one issued jointly

with the American Medical Society on Alcoholism in 1976 (see Table 1), represented an

attempt to emphasize the seriousness of the disorder, the experience of clinicians and of

recovering alcoholics, and the view that alcoholism is a primary or independent disorder, not

merely a manifestation of an underlying personality problem. These statements come close

to being current definitions of the classic disease model.

PROBLEM DRINKING AS A DISTINCT DIMENSION

The importance of what can now be called the classic "disease model" of alcoholism as a

primary focus for health programs was challenged in 1977 by a report of a WHO Expert

Committee on alcohol-related disabilities. This report stressed that not everyone who

develops a disability related to alcohol use exhibits alcohol dependence or addiction, nor

would such an individual necessarily develop a dependence in the future. The report

asserted that some alcohol-related disabilities represent a dimension of problem

drinking distinct from the disease of alcoholism or alcohol dependence syndrome. This

perspective provided support for policies aimed at reducing overall alcohol consumption, not

just at promoting abstinence among vulnerable individuals. The report described the alcohol

dependence syndrome itself as a learned phenomenon, not a disease state, which is either

present or absent, but "a condition which exists in degrees of severity." It is important to

recognize that this syndrome perspective does not take a position on whether alcoholism

should be considered a disease.

The concept of dependence as a syndrome is quite similar to that put forward in 1965 by

drug-abuse researcher Jerome Jaffe, who viewed addiction as standing at one end of a

continuum of involvement in drug use: "In most instances it will not be possible to state with

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precision at what point [along the continuum] compulsive use should be considered

addiction," Jaffe observed. He emphasized that "the term addiction cannot be used

interchangeably with physical dependence. It is possible to be physically dependent on

drugs without being addicted and… to be addicted without being physically dependent." In

this view, the behavioral disorder, not physical dependence, is the syndrome. Jaffe defined

addiction as "a behavioral pattern of drug use, characterized by overwhelming involvement

with the use of a drug (compulsive use), the securing of its supply, and a high tendency to

relapse after withdrawal." This proposed generic notion of dependence is applicable to

STIMULANTS and HALLUCINOGENS (for which physical dependence is not a significant

factor), as well as to alcohol, opiates, and SEDATIVE-HYPNOTIC drugs (for which physical

dependence is a factor). The Diagnostic and Statistical Manual of Mental Disorders, 3rd

edition, revised (DSM-III-R), published by the American Psychiatric Association more than

twenty years later, in 1987, also used such a generic definition.

FROM PSYCHIC AND PHYSICAL DEPENDENCE TO DEPENDENCE SYNDROME

The changing perspectives on the general concept of drug dependence, given momentum

by the 1977 WHO report on alcohol and by other research, were ultimately reflected in

changes in the definitions and other positions of the World Health Organization and in its

1980International Classification of Diseases, 9th edition (ICD-9). With its publication, the

concept of an alcohol dependence syndrome formally emerged at an international level. The

ICD-9 concept of dependence was based on a 1976 proposal by researchers Griffith Edwards

and Milton Gross, who defined seven characteristics of the alcohol dependence syndrome

and proposed that there are certain implicit assumptions to the syndrome: First, it is a

symptom complex involving both biological processes and learning. Second, it should be

defined along a continuum of severity, rather than as a discrete category. Third,

dependence should be differentiated from alcohol-related disabilities. Both dependence and

disabilities exist in degrees, rather than on an allor-none basis. There is some evidence that

people with more severe degrees of alcohol dependence who seek treatment have a

different clinical course from those with less severe dependence.

By the late 1970s, the American Psychiatric Association's Diagnostic and Statistical Manual,

3rd edition (DSM-III), moved away from more descriptive and psychodynamic orientation

toward a nomenclature in which specific diagnostic criteria were laid out for specific

syndromes. In the case of alcohol and drug dependence, the original drafts of DSM-III

considered inclusion of a dependence syndrome that varied in degree of severity and in

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which tolerance and physical dependence were important, but not essential, criteria for

diagnosis. At the last moment, however, it was decided that tolerance and physical

dependence were both necessary and sufficient for a diagnosis of drug dependence; the

presence of other criteria listed were by themselves insufficient without tolerance and

physical dependence. Nevertheless, by distinguishing drug (or alcohol) dependence from

drug (or alcohol) abuse, DSM-III recognized the two-dimensional conceptualization

previously put forth in the WHO report of 1977 and in ICD-9.

In 1980, during the short interval between the publication of DSM-III and the beginning of

work on DSM-III-R, a WHO working group met to further refine terminology. One result of the

meeting was the publication of a WHO memorandum on nomenclature and classification of

drug- and alcohol-related problems that endorsed the concept that drug dependence is a

syndrome that exists in degrees and that can be inferred from the way in which drug use

takes priority over a drug user's once-held VALUES. The criteria for making this inference

included many of those mentioned by Edwards and Gross in their 1976 paper and some that

had been developed for DSM-III. The WHO memorandum, while recognizing the importance

of tolerance and physical dependence, did not view these phenomena as always essential

and required. It endorsed again the two-dimensional perspective—not all drug or alcohol

problems are manifestations of dependence; and harmful or hazardous use can occur

independently of the decreased flexibility and constricted choice that are the hallmarks of

the dependence syndrome. This perspective was underscored by pointing out that the

presence of physical dependence per se (as in the case of patients taking drugs for pain)

was not in itself sufficient for the diagnosis of dependence. The memorandum also

presented a model of dependence emphasizing that the dependence phenomenon is not a

property of the individual but resides in the relationships among the elements in the model

—social, psychological, and biological. This view has been called the biopsychosocial model.

CRITERIA FOR DIAGNOSIS OF A GENERIC DEPENDENCE DISORDER

The American Psychiatric Association's DSM-III-R, published in 1987, built on both DSM-III

and the WHO memorandum. It presented nine criteria for diagnosing a generic dependence

syndrome, applied to a wide variety of drugs. The user must have experienced at least three

criteria in order for the practitioner to consider any degree of dependence to be present.

Neither tolerance nor physical dependence was a required criterion. The presence of more

than three criteria would indicate a more severe degree of dependence. Drug abuse was a

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residual category used for designating drug-related problems when dependence was not

present.

The DSM-III-R conceptualization of dependence was controversial. Because for many years

physical dependence and tolerance had been considered evidence of "true disease," many

clinicians believed that changing these criteria from the necessary and required status they

had had in DSM-III was a mistake that erroneously broadened the category of drug

dependence. Much of the focus in the development of DSM-IV, published in 1994, was on

how to restore the primacy of these phenomena in the diagnosis of drug and alcohol

dependence. DSM-IV defines seven generic criteria for alcohol and other drug dependence.

Three are required for a diagnosis of alcohol or other drug dependence. Although tolerance

and withdrawal are listed first, they are not required—but the clinician must specify whether

either is present.

Despite these concerns, there was little argument about the importance of psychological

and sociological factors in the development and perpetuation of the syndrome—that is,

there was still consensus about the biopsychosocial model.

At the same time, at the international level, the framers of ICD-10 continued the evolution

begun in ICD-9 and adhered closely to the concepts of dependence outlined in the 1977

WHO report and 1981 WHO memorandum. Published in 1992, ICD-10 includes a generic

model of drug dependence with similar criteria for alcohol, tobacco, opioids, and other drugs

that affect the brain. Like DSM-IV, ICD-10 presents a number of criteria (six) for determining

the presence of the alcohol (or drug) dependence syndrome; at least three of these must be

present for the clinician to judge that the syndrome exists to some degree.

ICD-10 does not include a diagnostic category of alcohol or drug abuse but instead includes

a category of harmful use—a pattern of use that is causing damage to mental or physical

health. Unlike DSM-IV, which defines drug or alcohol (substance) abuse as "a maladaptive

pattern of use" causing significant impairment or distress and interpersonal, family, and

legal problems (e.g., arrests), ICD-10 does not consider such patterns of use and

consequences necessarily to be evidence of harmful use.

ICD-10 and DSM-IV share important characteristics that represent a further evolution in

understanding drug and alcohol dependence syndromes. In contrast to some disease-

oriented defintions that see alcoholism as uniformly progressive, in ICD-10 and DSM-IV the

course of the disorder is not one of uniform progression or predictable cure, but there are a

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variety of significant states of remission. For example, DSM-IV distinguishes early remission

(within the first 12 months) from sustained remission (at least 12 months); within each of

these it differentiates full remission from partial remission (i.e., all criteria for dependence

have not been met, although at least one has been met intermittently or continuously).

DSM-IV also recognizes the circumstances supporting remission and allows for distinctions

such as remission while the user is in a controlled environment (where substances are highly

restricted) or remission from drug of dependence when the user is maintained on a similar

agonist. The categorization of states of remission (abstinence) in ICD-10 is somewhat

similar, although the distinction between early and sustained remission is not made.

CHALLENGES TO THE DISEASE CONCEPT

The classic disease model of alcoholism and drug dependence has served as a challenge to

some behavioral researchers and social scientists; they have raised a number of questions

about biologically based theories of such behaviors. Critics of the disease concept point to

studies showing that some former alcoholics could apparently return to normal drinking.

Such findings challenged the concept of alcoholism as a progressive disease. The concept of

inevitable "loss of control" over drinking was also challenged by Merry's study (1966) in

which alcoholics were given drinks containing either vodka or a placebo (no alcohol) on

alternate days and reported having no more desire to drink after consuming the vodka than

after the placebo. The results suggested that if "loss of control" did occur in alcoholics, it

was not triggered as a biological response to alcohol but rather as a learned response with

associated EXPECTANCIES concerning drinking behavior. Researchers Nancy Mello and Jack

Mendelson also reported, in 1971, that alcoholics did not manifest "loss of control" in their

drinking behavior and did not drink to avoid withdrawal symptoms. The work of Mello and

Mendelson and of other researchers led to the conclusion that drinking behavior could be

shaped like any other operant in a behavioral paradigm. Other researchers challenged the

notion of alcoholism as a distinct entity (with clear differentiations between alcoholics and

nonalcoholics), as well as the concepts of inevitable progression to loss of control and of

alcoholism as a permanent and irreversible condition precluding the possibility of moderate

drinking. (For these and other references, see Meyer, 1992.)

These findings by behavioral researchers in the laboratory had counterparts in large surveys

of drinking practices conducted by the RAND Corporation. Evidence in the general

population indicated that some alcoholics might be able to drink moderately without

relapsing to excessive drinking.

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These and other such challenges to the disease concept of alcoholism sharpened the debate

and clarified the construct. Efforts to replicate some of these earlier studies sometimes led

to conflicting results, calling into question the conclusions they had drawn or leading to

refinements. RAND Corporation found at later follow-up that severely dependent alcoholics

had to remain abstinent in order to maintain improvement. Several studies appeared to

confirm that severely dependent alcoholics might be different from those who were less

dependent. Some researchers, such as Hodgson, reported that small doses of alcohol had a

"priming" effect (i.e., stimulated a strong urge to drink more), the magnitude of which

correlated with the severity of alcohol dependence. Other researchers criticized the

methodology used in previous studies. (For references, see Meyer, 1992.)

These findings help to explain why, beginning in the late 1970s, the classic disease concept

was being reexamined and redefined as a symptom complex called "dependence" or

"dependence syndrome." However, this shift has not satisfied some critics who object to any

conceptualization that comes close to viewing compulsive alcohol or other drug use as a

disease or disorder. The debate over the disease concept continues to be more heated in

the alcohol field than in other areas of addictive disorders, such as compulsive use of

opioids. In the early 1990s, however, an analogous and equally heated debate has

developed about the conceptualization of tobacco smoking.

While health professionals throughout the world now generally agree that some forms of

drug and alcohol use should be seen as disorders (at least for record-keeping and some

public policy purposes), dissent from this view persists. The most compelling arguments

against the disease concept have come from social and behavioral scientists. This may be

partly because behavioral clinicians tend to work with less seriously impaired individuals,

while physicians usually deal with people whose dependence has become more severe; and

also because the physician's primary-care office may be where early identification of

substance-abuse problems and effective behavioral interventions is most likely to take

place.

ALTERNATIVE MODELS

Swedish researcher Lars Lindström's summary of current perspectives on the nature of

alcoholism is equally applicable to the divergent views about other forms of excessive

and/or compulsive drug use. Each of these models attempts to explain why people use

alcohol or drugs, why use escalates to excessive and/or harmful levels, why some people

continue drug use despite the harmful consequences, how and why they stop using drugs,

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and why they relapse after a period of abstinence. The perspectives include the moral

model, which holds that individuals have choice and are accountable for their behavior;

the disease model (both the classic and its variants); the symptomatic model, which views

excessive drug or alcohol use as a symptom of underlying psychiatric disorder; the learning

model (drug addiction and alcoholism are learned behaviors); the social model, which

emphasizes the primacy of environmental factors, such as availability, social controls,

interpersonal relationships; and thebiopsychosocial model, which attempts (in several

variants) to synthesize elements of other models, taking into account biology, vulnerability,

psychopathology, and cultural, social, economic, and pharmacological factors. The

dependence syndrome model is probably best viewed as a variant of the biopsychosocial

model.

Lindström points out that these models are now rarely encountered in pure form: each

commonly incorporates elements from other perspectives. Furthermore, proponents of a

particular model may, in practice, give greater emphasis to the central features of another.

For example, ALCOHOLICS ANONYMOUS (AA) generally espouses the disease model. Yet

because AA holds people accountable for the consequences of their drug use and

emphasizes the central role of spiritual alienation in the perpetuation of alcoholism, AA's

approach may also be seen as a variant of the moral model.

Although the term disease concept is often used synonymously with biological or medical

model, these terms do not always convey the same ideas, especially with respect to

implications for treatment. For example, the medical model of treatment is frequently

contrasted with the social or social recovery model, now widely used and advocated in

California. Medical-model programs are generally characterized not only by a philosophy

about the problem but also by hospital-based detoxification, often pharmacologically

assisted, and outpatient components in which there are formal treatment plans. Attention is

paid to careful record keeping and professional credentials of the treatment staff. Physicians

retain medical and legal responsibility for the overall program. In contrast, social-model

recovery programs reject the involvement of professional staff and many of the activities of

the medical model, such as the data gathering, licensing, and record keeping that link

funding to units of service for specific patients. Instead, these programs emphasize the

experience and knowledge that staff derive from the recovery process built on TWELVE-STEP

mutual-help principles. There are no patients—only participants—and the role of staff is to

manage the environment. Yet social models, in emphasizing the critical role that people "in

recovery" play in the helping process, are employing a term—recovery—that is itself derived

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from the classic disease concept, which views alcoholism as a permanent disease state for

which the only cure is total abstinence and the twelve-step AA program as the best route to

such abstinence.

PERSISTENCE OF THE MORAL PERSPECTIVE

Despite the preponderance of medical opinion that some drug and alcohol users have a

disorder—a diminished capacity to choose freely whether or not to use a particular

substance—the moral models retain some vitality. In 1882, when the disease concept was

first gaining momentum, the Reverend J. E. Todd wrote an essay entitled "Drunkenness a

Vice, Not a Disease." In the late 1980s, the disease concept critics Fingarette and Peele put

forth almost precisely the same thesis. Peele has argued that the disease concept

exculpates the individual from responsibility, runs counter to scientific facts, and is

perpetuated for the benefit of the treatment industry. However, his thesis has been

criticized for using the classic disease model as a "straw man" because it does not take into

account the more recent adoption of the bio-psychosocial model.

Some sociologists in the United States have noted that the term alcoholic is still commonly

used as a synonym for drunkard rather than as a designation for someone with an illness or

disorder. The word addict is similarly used in a pejorative way, even when it is used more

loosely to refer to a wide range of relatively benign behaviors, such as running or watching

television. In the minds of most people, the concept of alcoholism or drug addiction as a

disorder or disease can coexist quite comfortably with the concept of drunkenness or drug

use as a vice. Since the nature of drug dependence is so closely linked to questions about

the nature of free will and human volition—issues that have fascinated philosophers and

scientists through the ages—it is likely that the disease concept of addiction will continue to

be debated for a long time to come.

(SEE ALSO: Addiction: Concepts and Definitions; Alcoholism; Causes of Substance

Abuse;Tolerance and Physical Dependence; Treatment, History of, in the United States)

BIBLIOGRAPHY

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JEROME H. JAFFE

ROGER E. MEYER

Addiction, Pain, & Public Health website - www.doctordeluca.com/

The Controlled Drinking Debates: A Review of Four Decades of Acrimony

by Brook Hersey, Psy.D., April 2001 - Email: b.hersey@verizon.net.

Brook Hersey earned her Psy.D. from Rutgers University Graduate School of Applied and Professional Clinical Psychology in 2004.

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_____________________________________________________________________________

(This article was written after a tragic motor vehicle accident involving Audrey Kishline. Audrey Kishline, the founder of Moderation Management (MM), a non-abstinence oriented self-help group for individuals whose alcohol problems stop short of dependence, killed two people in a head-on vehicular collision. Audrey had recognized that her drinking was getting out of hand and she began attending Alcoholics Anonymous, prior to the accident. The accident seemed to point to fact that moderation in drinking is not a safe alternative for anyone who has had a problem with alcohol. Others might argue that Audrey was not a good candidate for moderation but there are others who would benefit from moderation rather than abstinence. Dr. Hersey attempts to look at the history of the controlled drinking controversy. The article was not reproduced in its entirety .)

…most commentators (Roizen, 1987, Rosenberg, 1993)

date the beginning of the controlled drinking controversy to the publication (in 1962) of a

paper entitled "Normal Drinking in Recovered Alcohol Addicts." In this paper, D.L.

Davies, a British psychiatrist, reports that, in the course of long-term follow-up of

patients treated for "alcohol addiction" at Maudsley Hospital in London, 7 of the 93

patients investigated "have subsequently been able to drink normally for periods of 7 to

11 years after discharge from the hospital." (Davies, 1962, p. 94)

The years after Davies

In the 1960s and 1970s, psychologists began to subject the premises of the disease model

to scientific scrutiny, and to use experimental methods to assess treatment outcome. As

Marlatt (1983) and Miller (1986) review, a number of experimenters tested the premise

that alcohol inevitably precipitates loss-of-control drinking, and found that alcoholics’

beliefs about whether or not they are consuming alcohol affect consumption. Also,

varying schedules of reinforcement produced different drinking patterns, arguing against

the notion that all alcoholics experience total loss of control.

Marlatt (1983) recalls that this period was one of "adventurous excitement" as

behaviorally oriented psychologists began to apply principles of learning theory to a wide

range of severe disorders. Included in these efforts were protocols designed to train

dependent drinkers to drink in a controlled fashion. Lovibond and Caddy, two Australian

psychologists, published a promising report on this as early as 1970.

To read Sobell and Sobell’s account of their experiments at Patton State Hospital in the

16

1970s is also to get a strong sense of the ambition and scope of this behavioral work. The

treatment unit included a simulated bar and cocktail lounge, set up so subjects could both

be videotaped while drinking, and also equipped with electric shock equipment for aversive conditioning: "The simulated bar environment … reflected an attempt to

structure the research environment to promote increased generalization of treatment

effects to the subjects’ usual drinking environment." (Sobell and Sobell, 1978, p. 50).

While the Sobells’ experimental work that was to generate such controversy began in

1970, I will hold off on reporting it because the uproar it evoked did not take place until

the early 1980s.

The Rand Report

In the 1970s, the National Institute on Alcoholism and Alcohol Abuse (NIAAA)

established a network of treatment centers around the United States, which included a

monitoring system to collect data on clients served (Polich, Armor and Braiker, 1981).

The Rand Corporation assumed responsibility for evaluating the efficacy of the treatment

offered, and the so-called Rand Report, published in 1976, looked at 18-month follow-up

data on a sample of patients treated at 44 treatment centers. In summarizing conclusions,

the authors wrote:

[I]t is important to stress that the improved clients include only a relatively small

number who are long-term abstainers…The majority of improved clients are

either drinking moderate amounts of alcohol—but at levels far below what could

be described as alcoholic drinking—or engaging in alternating periods of drinking

and abstention." (Armor, Polich and Stambul, 1976, p. v)

Specifically, the authors found that 22 percent of treated individuals were "normal

drinkers" at 18-month follow-up, with low-to-moderate levels of drinking and little or no

symptomatology.

The publication of this report was the occasion for renewed debate and controversy. The

National Council on Alcoholism denounced the report on the morning it was released,

describing it as "dangerous." (Peele, 1983). According to Roizen (1987), the debate

17

extended beyond the scientific literature to the popular press, with most accounts and

editorials emphasizing the importance of abstinence. While the report was criticized by

some on methodological grounds, another major focus of criticism argued that "the

research was ‘impersonal’ or ‘statistical’ or that a wide gap separated the Rand authors

from actual alcoholism patients or that the authors lacked personal experience and contact

with the field." (Roizen, 1987, p. 262) In other words, the legitimacy of using a scientific

approach was questioned, and the potential dangerousness of such questionably derived

"knowledge" was argued to be a reason that this knowledge should not be disseminated.

A later report, which included data on the 4-year follow-up of treated patients and which

attempted to address methodological criticisms of the earlier report, showed that a similar

percentage of patients were demonstrating non-problematic drinking (Polich et al., 1981),

although the authors cautioned against the conclusion that the same patients who were

stable at 18 months were stable at 4 years. What became evident over the course of the

longer follow-up was the extent to which individual patients’ drinking statuses fluctuated:

"When we examined longer time periods and multiple points in time, we found a great

deal of change in individual status, with some persons continuing to improve, some

persons deteriorating, and most moving back and forth between relatively improved and

unimproved statuses." (Polich et al., 1981, p. 214) As was the case with the Davies paper, these findings occurred following treatment that

was focused on abstinence. However, the very fact that the Rand authors were willing to

recognize success in the presence of any drinking at all was controversial. Roizen notes

that while the Davies controversy focused on whether or not "normal drinking" was ever

an outcome for addicted drinkers, "Rand authors argued that particularly long-term

abstinence was too infrequent to make it the sole focus and measure of successful

treatment." (Roizen, 1987, p.262)

So where exactly are the battle lines drawn here? The supposed proponents of controlled

drinking were not saying that it should be advocated or taught, but that unproblematic

drinking was observed in the aftermath of abstinence-oriented treatment, and that

18

individuals could be judged to be improved without being abstinent. Opponents of

controlled drinking appear to have focused on the potential danger of these findings for

alcoholics. Their tactics included efforts to discredit the Rand authors’ methodology, but

also to attempt to minimize putative danger to alcoholics by arguing their pro-abstinence

case in the public arena.

The Sobell and Sobell controversy

In the early 1970s, psychologists Mark and Linda Sobell set out to research a form of

"individualized behavior therapy" for alcoholism. One treatment module tested was

aimed at training alcohol-dependent subjects to drink in a "controlled" fashion (Sobell

and Sobell, 1973, 1978). Subjects were 70 male patients, voluntarily admitted to Patton

State Hospital in California, who were classified as meeting criteria for Jellinek’s

gamma-type alcoholics ("loss of control" drinkers). After subjects were accepted for

participation in the study, they were assigned to either a controlled drinking (CD) or an

abstinence-goal condition. This part of the study did not employ random assignment;

rather the assignment was made by the research staff, based on both the patient’s stated

wishes and goals, and characteristics of the subject, his drinking history, and the stability

of his environment. After this initial assignment, subjects were then randomly assigned to

a behavioral treatment condition, or to a control condition of treatment as usual (which

was, of course, abstinence-oriented). Both experimental groups (CD and abstinence-goal)

received 17 sessions of behavioral treatment (including training in problem solving and

aversive conditioning with electrical shocks), but the CD subjects were also trained in

drinking skills oriented towards nonproblematic drinking. Follow-up was extensive, and

collateral sources were used in addition to patient self-report. While the authors collected

a wide range of outcome data, they used the number of "days functioning well" as a

primary outcome measure. Individuals in the CD-experimental (CD-E) condition had

significantly more "days functioning well" during a two year follow-up period than their

counterparts in the CD-control (i.e. treatment as usual aimed at abstinence) condition.

(Sobell & Sobell, 1978, 1973).

19

In the Davies and Rand reports, "controlled drinking" was used to describe a nonproblematic level of drinking, but this was not an outcome that had been sought by

treatment. By contrast, the Sobells’ work involved the transmission of specific skills and

techniques to individuals with serious and enduring alcohol problems. (This study does

not get at the interesting question of whether explicitly CD focused treatment is a

valuable addition to a behavioral program: The lack of random assignment to CD or

abstinence goals precludes us from drawing conclusions about relative efficacy.) In 1982, Pendery, Maltzman and West published an article in the journal Science entitled

"Controlled Drinking by Alcoholics? New Findings and a Reevaluation of a Major

Affirmative Study." This report, based on a ten year follow-up with subjects of the Sobell

and Sobell study, states that "a review of the evidence, including official records and new

interviews, reveals that most subjects trained to do controlled drinking failed from the

outset to drink safely." (p. 169) Ten years out, only one subject from the CD-E condition

was maintaining a pattern of controlled drinking. Eight subjects were found to be

drinking excessively, six were abstinent, one was lost to followup, and four were dead.

Certainly, in reading Pendery et al.’s article, one gets the impression of subjects who are

doing very poorly indeed. However, the Pendery report is severely compromised on

several scores, most importantly by the fact that it provides data for the experimental

group but not the control group. These authors attempt to justify this choice in a

statement that seems to clearly demonstrate their bias: "we are addressing the question of

whether controlled drinking is itself a desirable treatment goal, not the question of

whether the patients directed towards that goal fared better or worse than a control group

that all agree fared badly." (Pendery et al., 1982, 172-173)

Although the Science paper took relatively measured tones in presenting what it stated

was discrepant data, outside the rarified realm of the scientific journal, the authors took a

less neutral stance. They circulated a more inflammatory paper to the research

community (Roizen, 1987). Maltzman was quoted in The New York Times as stating,

"Beyond any reasonable doubt it’s fraud." (Boffey, 1982, quoted in Marlatt, 1983, p.

20

1098) Marlatt (1983) also describes a 1983 edition of 60 Minutes which criticized the

Sobells, and which included footage of correspondent Harry Reasoner visiting the grave

of one of the patients in the controlled drinking condition. Marlatt also notes that one of

the patients from the CD condition formed an organization called "the Alcoholism Truth

Committee," aimed at disseminating the "truth" about the Sobells’ study by attempting to

have descriptions of their work omitted from textbooks and elsewhere.

Several investigations of the integrity of the Sobells’ work followed. The Sobells asked

their employers, the Addiction Research Foundation, to appoint a committee to

investigate their research. Because some of the Sobells’ research was grant-funded, a

subcommittee of the Committee on Science and Technology of the House of

Representatives, and a federal panel also reviewed the Sobells’ data. All these

investigations exonerated the Sobells (Roizen, 1987). According to Marlatt et al. (1993),

while there was extensive media coverage critical of the Sobells, there was little media

coverage of the exonerating verdicts, leaving the public with the impression that the

Sobells’ work had been not only flawed but fraudulent, and that controlled drinking was a

misguided and potentially deadly treatment goal.

Reframing the debate

The Rand and Sobell and Sobell controversies had a chilling effect on psychologists and

researchers. In 1984, Peele wrote (p. 1342): "Today no clinician in the United States

publicly speaks about the option of controlled drinking for the alcoholic."

Two years later, Miller (1986, p. 117) wrote: "American professionals who advocate any

alternative to abstinence are likely to be (and have been) attacked as naïve fools,

misguided intellectuals sadly misinformed about the ‘reality’ of alcoholism, unwitting murderers, or perhaps themselves alcoholics denying their own disease." Miller (1986, p.

118) also contends that U.S. researchers have found it hard to obtain funding for

controlled drinking studies, "and the controversy regarding the Sobell and Sobell study

(Pendery et al., 1982) is likely to discourage future U.S. research on this topic for some

time to come."

21

But if researchers have moved away from talking about controlled drinking as a goal of

choice for alcohol dependent clients, two semantic and conceptual shifts—alluded to in

the 1995 Sobell and Sobell editorial discussed above—have permitted continued

investigations of treatments that are not singularly focused on abstinence. The concept of

"harm reduction" has been evoked to suggest that, given that some severely dependent

individuals might be unable or unwilling to abstain, it was appropriate to try to minimize

the harm caused by their continued drinking. Secondly, the increased awareness of a

large population of problem drinkers whose alcohol use does not meet criteria for

dependence has led to a focus on interventions aimed at reduction rather than elimination

of alcohol use. With this conceptual reframing comes a terminological shift as various

authors made the choice to move towards less contentious language. In 1987, Marlatt (p.

168) noted that use of the term "controlled drinking" "is a red flag that sends the bull

charging in the direction of behaviorists." His suggestion for a replacement is

"moderation training."

In many ways, these two shifts represent a tidy compromise, in that they allow for

deviations from an uncompromising abstinence goal, while no longer challenging the

disease model in such a fundamental way. In the case of harm reduction, abstinence is

held out as the gold standard, and continued drinking for dependent drinkers is identified

as a problematic (if frequent) outcome. As Marlatt et al. (1993, p. 465) wrote: "The goal

of harm-reduction methods is to facilitate movement along a continuum from greater to

lesser harmful effects of drug use. Although abstinence is considered an anchor point of

minimal harm, any incremental movement toward reduced harm is encouraged and

supported."

The second approach can be said to target individuals who are not "alcoholic." Of course,

things are not really so simple, some disease-model proponents might argue. Are the

subjects of these interventions really a different population than the alcoholics, or are

they people with alcoholic tendencies whose "disease" has not yet progressed?

Those concerned with engaging problem drinkers in treatment also argue that offering

22

goals other than abstinence may attract a wider audience: "Offering controlled drinking

alternatives to the general public may act as a motivating push to get people ‘in the door,’

a low-threshold strategy that is consistent with the principles of harm reduction." (Marlatt

et al., 1993, p. 483)

Although not universally successful in defusing the controversy, this re-framing might be

understood as a diplomatic solution. Each side could declare itself victorious. Writing in

1995, one commentator postulated: "[A]pparently—little moved by the ‘great debate’—

both sides continue with their initial preferences: the ‘American establishment,’ AA and

clinicians predominantly with the abstinence approaches, whereas psychologists,

researchers and sociologists often regard controlled drinking as a feasible and often

preferred alternative." (Glatt, 1995, p. 1157) The severity of dependence issue

Sobell and Sobell (1995) noted that low severity of dependence is an important predictor

of an individual’s ability to moderate successfully. In their 1981 literature review,

Heather and Robertson also found low severity to be correlated with controlled drinking

outcomes, although they note that some of the studies they reviewed only looked at men,

thus limiting the generalizability of their findings. Miller (1983, p. 77) observed that in

the Rand study, "patients with high alcohol dependence were found to be less likely to

relapse from abstinence than from nonproblem drinking, suggesting that for this

population abstinence was the more stable outcome." Rosenberg (1993, p. 132) reviewed

a number of more recent studies and reported finding general (although not universal)

support for the severity hypothesis. He went on to state that:

the nature of the relationship between severity and CD has not yet been

established. One possibility is that the likelihood of CD decreases monotonically

as severity of dependence increases, and at some point severity is so great that the

probability of CD is zero. Alternatively, although CD generally declines as

severity increases, there may be plateaus in severity in which changes in level of

severity do not matter. Also, even at the highest levels of severity, perhaps some

alcoholics are able to control their drinking as a result of other factors. Finally, a

23

significant association between the two variables does not necessarily mean that

lower severity is the cause of CD.

Sobell and Sobell (1995, p. 1150) also urged caution in interpreting causality from these

results: "[A]lthough it is tempting to view dependence severity as the critical determinant

of whether a moderation recovery is attainable, it is possible that this relationship is an

epiphenomenon to other life circumstances often associated with severe dependence (e.g.

lack of social support, poor vocational history)."

Sobell and Sobell (1995) made the interesting point that this association between severity

level and outcome seems to hold true, regardless of what is advocated in treatment.

Sanchez-Craig et al. (1984) randomly assigned low-dependence drinkers to treatment

aimed at either abstinence or controlled drinking. At two year follow-up, the two

conditions were quite similar, and most successful outcomes involved moderate drinking.

In a study in which severely dependent drinkers were assigned to treatment with either

abstinence or CD goals, at 5-6 year follow-up the groups were also similar, with most

successes involving abstinence. (Rychyarik et al, 1987).

The real world implications of the above findings are far from clear. While individuals

with less severe alcohol problems appear to have more frequent CD outcomes, does it

follow logically that CD training should not be used with dependent populations? Might

CD techniques play a role in harm reduction? In 1987, Peele stated that while past

research "found greater benefits for problem drinkers who were less severely dependent

on alcohol," at the same time, "no comparative study had shown moderation training to

be less effective than abstinence as a treatment for any group of alcoholics." (Peele, 1987,

p. 175) Heather (1995) argued that some studies have shown that severely dependent

individuals can sustain non-problematic drinking, and that there may be applications for

CD-focused interventions with this population; much of this work is currently being done

outside the United States. Peele (1992) argued that the consensual move away from CD treatments for more

seriously dependent drinkers resulted from political pressures rather than from the weight

24

of unequivocal empirical evidence. In responding to Peele, Miller (1992, p. 80) argued

that data linking severity to treatment outcome do "provide for clinicians the basis for a

probabilistic argument in favor of abstinence, as severity increases." That said, he

affirmed that he favors a de-escalation of the CD controversy: "There is little to be gained

by continually exacerbating points of disagreement. The effect is only to deepen already

wide chasms among significant factions, all of whom are trying to alleviate alcohol

problems." (Miller, 1992, p. 81)

The importance of what the patient believes

In his 1993 review of the literature on predictors of controlled drinking, Rosenberg

observed that individuals’ beliefs about the feasibility of CD is a potentially useful

predictor of their ability to moderate. While the nature of individual beliefs were

operationalized in different ways by different investigators, the majority of studies that

Rosenberg reviewed supported the so-called persuasion hypothesis. Rosenberg noted a

number of questions that grew out of these findings: What is the source of drinkers’

beliefs? To what extent are beliefs shaped by pre-existing notions, what the drinkers are

told in treatment, and/or experiences after treatment as they attempt to achieve their

goals? And how stable are these beliefs? Typically, these beliefs are measured once in the

course of most studies, and then used as a predictor of behavior months after the

measurement (Rosenberg, 1993). In fact, these measures may change frequently. For

instance, Ojehagen and Berglund (1989) reported on a Swedish treatment program in

which participants chose their own treatment goals (abstinence or CD) and were allowed

to change these goals every three months. Forty-four percent of patients changed goals at

least once during the treatment program, a finding suggesting that beliefs about what is

both possible and helpful changed over time, presumably as a result of experience.

Interestingly, the implications of this association between belief and behavior can be spun

in different ways. A belief in the necessity of abstinence may help an individual stay

sober, which is obviously a desirable outcome. However, a belief in the efficacy of CD

may serve harm-reduction ends, if a dependent drinker believes that he or she can cut

25

down intake,. As Peele (2000, p. 43) writes, "[T]he very subjective elements that

American alcoholism treatment derides as ‘denial’ can improve the chances of recovery:

It is easier to achieve what you believe."

Audrey Kishline and Moderation Management

Despite the aforementioned decades of research and debate, when Audrey Kishline

sought help for her problematic drinking in the late 1980s, it took her years to learn that

there were any professionally sanctioned alternatives to abstinence. As she describes it in

her 1994 book, she consulted 30 to 40 professionals, many of whom steered her towards

AA, and emphasized that she would have to attend meetings for the rest of her life. When

she began to explore moderation options, she states she was "amaze[d]" to find the extent

to which these approaches had been explored by addiction professionals and put into

practice in other countries. She writes:

The first major revelation that I came across was that many experts in the alcohol

studies field do not believe that alcohol abuse is a disease. From my previous experience with traditional treatment, I had been under the impression that the

disease model of alcohol abuse represented a biological and medical fact, proven

beyond a shadow of a doubt. I was amazed to find out that the disease theory was

just that: a theory—one that has been highly criticized, and discarded, by many

researchers in the field. (Kishline, 1994, p. 12)

Kishline’s experience may be representative: Despite many encounters with the treatment

community, she did not learn that there are multiple ways to conceptualize substance

abuse problems, and she did not learn that there are ways to recover that do not

necessitate AA.

In founding MM, Kishline integrated many behavioral techniques into a self-help format:

"The purpose of Moderation Management is to provide a supportive environment in

which people who have made the healthy decision to reduce their drinking can come

together to help each other change. That’s it. It is very simple and straightforward, and I

admit that MM stole it from the forerunner of the mutual help movement, AA." (Kishline,

26

1994, p. 25)

The program explicitly states that it is not for dependent drinkers. It advocates a monthlong abstinence period before the institution of a program of moderate drinking. It offers

a mechanism by which problem drinkers can try to cut down; in theory, failure at this

effort suggests the advisability of abstinence. The MM movement has garnered attention

as a grassroots movement reaching out to and providing free support and technical

assistance to the large population of non-dependent drinkers. Articles on the organization

have appeared in Time in 1995, and in U.S. News and World Report in 1997; the

organization has also been featured on television shows with large audiences, such as

Good Morning America and the Oprah Winfrey Show.

To its supporters, MM represent a self-help-style embodiment of a promising approach to

drinking problems. To its detractors, it represents a mechanism by which alcoholics can

perpetuate their denial.. Although a number of academic researchers have provided

advice and support to MM, the movement can be understood as a form of CD that has

moved out of the research domain into the general public arena.

Is public opinion becoming more open to alternatives?

In the absence of survey research, we don’t actually know the current state of public

opinion on moderation approaches to problem drinking. We can speculate that Kishline’s

accident and the press coverage it received has convinced some that moderation is

dangerous. On the other hand, increased publicity may spawn increased interest and

debate about alternative conceptualizations of alcohol problems and routes to recovery.

An edition of 20/20 broadcast in June of 2000 featured interviews with a number of

proponents of moderation approaches, and highlighted the fact that, in many other

countries, treatment often involves the teaching of moderation skills. Szalavitz, the author

of the New York article about Smithers, wrote a follow-up piece for Brill’s Content, a

magazine widely read by journalists, detailing the conflation of the Kishline and the

Smithers stories; her piece may have educated writers and editors about the scientific and

political backdrop to the news events. And the recent publication of the book Sober for

27

Good (Fletcher, 2001) communicates in hopeful, accessible language that there are many

ways for former problem drinkers to deal with their drinking. A significant proportion of those she interviewed got sober without AA, and a smaller proportion have made major

improvements in their drinking and their lives without giving up alcohol altogether. It

seems quite possible that this book will reach and educate a broad audience.

Summary and open questions

The various iterations of the controlled drinking controversy can be summarized briefly.

Davies observed data that called certain premises of the disease model into question,

leading some in the field to resort to various semantic twists to minimize or deny the

import of his findings. When the Rand authors made the case that nonproblematic

drinking was widespread in its outcome studies, disease model adherents attempted to

minimize the impact of these findings on public opinion. Rand opponents echoed Davies

commentators in voicing the fear that the acknowledgment that some alcoholics can learn

to drink in a nonproblematic fashion might lure other alcoholics to postpone selfidentifying or to reject their commitment to abstinence. When the Sobells published

results showing that a behavioral treatment which included CD techniques produced

better outcomes than treatment as usual in a severely dependent population, another team

of researchers attacked their reputations in the course of arguing that CD was no panacea

for these very sick folk. Prodded in part by political realities and in part by evidence that

CD training doesn’t seem to significantly boost the efficacy of treatment, researchers

have backed off from advocating controlled drinking treatments for alcoholics. However,

strategies like harm reduction and moderation training for non-dependent drinkers have

kept residual CD strategies alive. It is now common practice in treatment studies to

acknowledge that abstinence is not the only successful treatment outcome, and that

reduced drinking in fact constitutes improvement (Peele, 2000). Despite these

compromise positions, the issue remains a hot-button topic in public discourse, with

Audrey Kishline’s recent tragedy being touted by opponents as a (supposed) reminder

that the mere existence of moderation approaches can support and prolong alcoholics’

28

denial.

A review of the history of this debate provides few incontrovertible answers. Thus, it

seems appropriate to conclude this review by highlighting some of the important

questions that remain salient 40 years into the debate:

(1) What does the research really say? Several enduring themes, which came up again

and again in the body of literature considered, seem fairly well supported: Pure,

uninterrupted abstinence is rarer than we would like in treated dependent drinkers, and

some problem drinkers do seem able to reduce their drinking, with an accompanying

reduction in the severity of life problems. However, other questions, such as the potential

role of CD as a harm reduction strategy and the role of severity of in determining the

ability to moderate, remain open to debate. In part, this is a result of embarrassment of

riches: Some studies examine multiple outcome measures at multiple points in time, with

the result that their findings are open to multiple interpretations. Different investigators

define "controlled drinking" in different ways (Heather & Tebbutt, 1989). As Cook

(1985) demonstrated in his re-analysis of the Sobells-Pendery controversy, readers from

either side of the divide can find support for their position in the same data.

(2) What role does money play in all this? To what extent do politics determine which

studies get funded? What kinds of public educational campaigns are funded and by

whom? To what extent has the clout of anti-CD organizations like the NCADD and the Smithers Foundation affected the willingness of those who benefit from their largess to

acknowledge evidence in favor of CD? To what extent does the changing economics of

treatment (i.e. the advent of managed care, with its preference for brief, effective

treatments) inform both sides of the debate?

(3) How can we step back from the divisiveness that an issue like this engenders? In the

course of reviewing this literature, I recognized the extent to which reactions to the

debate are based on values as well as facts. My personal values are such that I am

offended by attempts to prevent information from being disseminated, and by those who

have tried to cut off or to silence debate. What’s tricky, I recognize, is that those gut

29

emotional reactions lead me to cast heroes and villains in my head, and to lose sight of

nuance. When I "side" with the psychologists and scientific researchers, I have to remind

myself to step back and focus on the fact that I also believe that abstinence is a highly

desirable goal for those who accept it, and that I have deep and enduring respect for AA.

Perhaps a prerequisite for synthesizing reactions to this 40-year-old debate is for the

observer to know his or her biases, and to identify those issues that trigger affective

responses. Perhaps only when we lay claim to our own values can we adequately reflect

on this emotion-driven debate.

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After considering the information in both articles would it seem that controlled drinking could be a reasonable goal for alcohol abuse treatment? Why or why not? (make sure to reference the information from the articles that you use to formulate your answer)

If alcoholism is a disease that is marked by the loss of control the alcoholic will eventually return to uncontrolled drinking. However if controlled drinking candidates are screened carefully then it may be possible to select candidates for that program who haven't crossed the line to alcoholism and are problem drinkers. These individuals may benefit from a controlled drinking program.