Family Therapy UK

Treatment of Alcoholism


Treatment of Alcoholism

From The Harvard Mental Health Letter Internet Site

Part 1

During the 1980s the average consumption of alcohol in the United States declined, while more people than ever were making efforts to change their drinking habits. The membership of Alcoholics Anonymous doubled to nearly a million during that decade. In 1979 about 2% of Americans had ever sought help for alcoholism, and by 1990 more than 5% had (about 8% of men and 3% of women). These trends provide reasons for optimism about the prevention, recognition, and treatment of alcohol problems.

One definition of those problems is given in DSM-IV, the American Psychiatric Association's most recent diagnostic manual. There alcohol abuse is defined as a drinking habit with consequences that include marital conflict, legal problems, dangerous driving, violence, accidents, job loss, and emotional or physical illness. Alcohol dependence involves additional symptoms: tolerance, withdrawal reactions, taking more than intended, unsuccessful efforts to stop or cut down, continuing to drink despite serious health effects, and allowing to occupy most of one's time and life.

But people with drinking problems are not easily classified as abusers or dependent, healthy or diseased. Patterns of abusive drinking are complicated and individually variable. Alcoholics are not always drinking uncontrollably or even drinking at all. Partly because of this complexity, diagnosis is difficult and the need for help is often unrecognised or unacknowledged. Friends, family members, and others may maintain silence for fear of being intrusive or having to assume responsibility. Alcoholics themselves often deny, conceal, rationalise, or blame others. Many accept treatment only reluctantly, under compulsion by the law or pressure from family members and employers. Physicians and mental health professionals are sometimes reluctant to treat people they may see as both demanding and ungrateful. Only 20% of doctors routinely talk about alcohol with their patients.

Changing the emphasis

Merely asking how much a person drinks is usually unhelpful, because alcoholics may not keep track or tell the truth. Better questions are: "Do you sometimes feel uncomfortable when alcohol is not available? Do you drink more heavily than usual when you are under pressure? Are you in more of a hurry to get to the first drink than you used to be? Do you try to avoid certain people while drinking? Do you sometimes feel guilty about your drinking? Are you annoyed when people talk about your drinking? When drinking socially, do you try to sneak in some extra drinks? Have you ever woken up in the morning and not remembered parts of the evening before? Do you often regret things you did or said while drinking? Are you constantly making rules for yourself about what and when to drink?"

Some questions for friends and relatives: "Are you ever worried or embarrassed by this person's drinking? Does he or she often promise to quit? Do you lie to conceal the drinking? Do you try to justify it? Has he or she ever driven drunk? Do others talk about the drinking? Does he or she sometimes apologise after a drunken episode?"

Some alcoholics need help only in acknowledging the problem and can do the rest themselves. A further brief intervention immediately following recognition or diagnosis may also be useful in persuading incipient problem drinkers to enter treatment.

A doctor or other professional offers advice and information, provides referrals to self-help groups, and suggests therapeutic alternatives. In one type of brief intervention, family members and friends are asked to make a list of frightening or embarrassing events associated with the drinking and invited to attend a meeting with the problem drinker for a dramatic confrontation.

Beyond recognition and brief intervention, the variety of alcohol problems is matched by the variety of proposed treatments, which range from the biochemical (use of agents that block the effects of alcohol) to the religious (encouraging repentance and spiritual renewal).

Some alcoholics are so severely dependent that they must be detoxified, or treated for acute withdrawal symptoms (mainly anxiety, racing heart, tremors, nausea, dry mouth, sweating, and weakness). Although these symptoms will usually subside in a week or two, they are extremely uncomfortable and provoke an urge to resume drinking. One way to ease withdrawal is to substitute another sedative drug, usually a benzodiazepine such as diazepam (Valium) or chlordiazepoxide (Librium), and gradually reduce the dose to zero. Atenolol and other beta-adrenergic blockers may speed up the process and reduce the need for benzodiazepines by eliminating tremors and lowering heart rate, blood pressure, and body temperature.

A few withdrawing alcoholics have to be hospitalised. Some have failed in outpatient detoxification and will not stop drinking as long as they have access to alcohol. Others have serious psychiatric disorders or medical problems such as high blood pressure or diabetes. In about 5% of cases hospitalisation and use of anti-psychotic or anticonvulsant drugs is necessary because of withdrawal delirium (delirium tremens), which has symptoms that include agitation, disorientation, hallucinations, and occasionally seizures.

Available medications

Two drugs have been used to prevent relapse in alcoholics. Disulfiram (Antabuse) blocks the normal metabolism of alcohol; the toxic breakdown product acetaldehyde accumulates, and the resulting nausea makes the patient avoid alcohol. Because the body eliminates disulfiram slowly, its effects may persist a week or more after the patient stops using it. Side effects are usually mild, although numbness and pain from inflammation of nerve tissue (neuritis) may develop. Unfortunately, the dropout rate is high. Disulfiram is effective mainly when the patient is committed to long-term change and needs protection against momentary lapses while undertaking other forms of therapy.

In 1995 the FDA approved another drug for the prevention of relapse: naltrexone, an opioid antagonist that has been used for years in the treatment of heroin addiction. It blocks the activity of natural opioids (endorphins) that are apparently stimulated by alcohol as well as narcotics. Alcoholics who take naltrexone feel less craving, drink less, and are less likely to lose control if they do take a drink. Typically about 50% of patients taking a placebo but only 25% of those given naltrexone relapse in the first three months. Among those who slip and take a drink, 90% of placebo patients but only 40% on naltrexone relapse. According to some studies, the effects of naltrexone may last for several months after the patient stops taking it. But there is also some evidence that it loses its effectiveness with time.

Five percent to 10% of people taking naltrexone suffer uncomfortable side effects, including depression, nausea, and vomiting. The drug causes liver damage when taken in large quantities, but rarely at the standard dose, and most patients show improved liver function because they are not drinking. Another opioid antagonist, nalmafene, has been introduced recently and is not yet approved by the FDA. It works in the same way as naltrexone but may have fewer side effects. Like disulfiram, opioid antagonists must be used as part of a broader program that includes psychological and social treatment. Otherwise patients do not continue to take them and they are of no use.

Thinking it through

Many alcoholism programs make use of behavioural and cognitive techniques based on the assumption that alcohol abuse is promoted by certain thinking habits or learned through patterns of conditioned association and reinforcement (reward). Alcoholics are said to be using drink, ineffectually, as a way to solve problems in their lives. The abusive habit is supposed to be modified or unlearned by a change in contingencies--the factors in a situation that determine whether or not a person drinks. The therapist may concentrate on the pattern of drinking itself, the consequences, or the causes (situations and conditions that maintain or reinforce alcohol abuse). Lapses or relapses are treated as further opportunities to learn.

One common behavioural method is exposure and desensitisation. Patients are presented with the situations, thoughts, and feelings that lead to alcohol abuse while their usual response is prevented repeatedly until it is eliminated or extinguished.

Patients can gradually expose themselves to more and more risky situations for a series of small gains, each of which heightens a bracing sense of self-efficacy, or confidence in the ability to handle stress and resist alcohol. As fewer and fewer circumstances become cues for drinking, craving gradually diminishes.

One related technique is covert sensitisation -- pairing images of alcohol use with images of unpleasant experiences to promote conditioned avoidance. Another behavioural method is the alteration of reinforcement patterns by a contingency contract; for example, a patient may agree to forfeit money in case of relapse or make it available for use only after abstinence. Taking disulfiram could be regarded as a contingency contract, since the patient has in effect agreed to suffer nausea and vomiting as a consequence of drinking.

Taking responsibility

In behavioural self-control training, patients are shown how to monitor and limit their alcohol consumption. They are taught to notice and record the situations and feelings that cause them to drink -- both bad and good feelings, physical discomfort, social pressure and conflict. They learn how to avoid some of these situations, cope with others, and develop alternative responses.

Cognitive therapists work to alter self-defeating beliefs that make life without alcohol seem unbearable ("I cannot tolerate anxiety"; "I need to overcome my shyness") or supply excuses for succumbing to temptation ("I deserve a drink after a hard day"). Patients are made aware of these thoughts and shown how to test them. They can also be taught general problem-solving strategies and shown how to achieve pleasure or a feeling of accomplishment without alcohol--another way of changing reinforcement contingencies by providing alternative rewards.

Some alcoholics benefit from social skills training -- instruction in ways to handle stress, solve problems, and manage social situations without alcohol. They may be taught how to refuse drinks politely and urged to monitor the amount they have drunk by paying close attention to physical sensations.

An increasingly popular program called relapse prevention consists mainly of various combinations of these behavioural and cognitive techniques -- especially skills training, cognitive reframing, and self-monitoring. After keeping a diary for a week or two to identify the skills they lack and the situations that put them at risk, patients learn what they need through rehearsal, modelling (imitation of others), and other techniques. Eventually they can be trained to be their own therapists, anticipating and coping with whatever problems arise in their efforts to keep themselves from drinking.

Support in numbers

Group therapy, whether based on behavioural or other principles, is a treatment of choice in most alcohol programs. Patients learn to accept themselves as recovering alcoholics and help themselves while helping others. The group provides a sense of belonging and a source of friendships. Realising that they are not alone, patients feel less ashamed and despairing. By watching and imitating others, they correct distorted ideas about themselves. Acting as a surrogate family, group members can monitor one another for signs of relapse.

Alcoholics Anonymous (AA) is the oldest and largest of the mutual aid groups that have become increasingly important in the treatment of addictions. Founded in 1936, it has more than 70,000 chapters with more than two million members in over a hundred countries. By 1990, 70% of Americans ever treated for alcoholism had attended at least one AA meeting. Recently the membership has become younger and the proportion of women has been rising. In a 1989 survey of nearly 10,000 members, 22% were under 31 and 3% were under 21; 35% were women and 46% were using other drugs (as compared with 18% in a 1977 survey).

The famous 12-step strategy, spelled out in a volume known as the Big Book, has been adopted, with variations, by many other self-help groups. Members admit that they are powerless over alcohol and seek help from a higher power, which they can understand in any way they want--an idea derived from the Evangelical Christian beliefs of the founders. Members are urged to pray or meditate, make a "moral inventory," admit their sins and errors (without harsh self-criticism), beg forgiveness and make amends to people they have hurt, and (the final step) carry the message to other alcoholics. That message can be briefly summarised as follows: be honest about your problems, take responsibility for them, change yourself, and help others.

Lasting a lifetime

According to AA doctrine, alcoholism is a disease that is never entirely cured. An alcoholic is always recovering, never recovered, and a person who has once been alcoholic must never drink: "It's the first drink that gets you drunk." Another famous slogan, "One day at a time," implies that members should not burden themselves with unrealistic promises of lifelong abstinence and then blame themselves for a moral failure if they suffer a lapse or relapse.

Some members attend the meetings of several groups, and others seek a group whose membership matches their temperament and background. At the meetings, one or two members tell their stories while others show approval and affection. No one asks why, when, or how much a person drinks. Blaming and personal questions are avoided. New members are advised to attend daily for the first three months and to find a sponsor--a veteran who has been sober for some time. Although most members do not go to meetings for the rest of their lives, many want to do so and some must. According to one estimate, 25% attend meetings three times a week or more.

Keeping tradition

AA is known partly for the many activities it does not engage in. It does not solicit members, charge fees, sponsor research, make diagnoses, offer religious services, or promote medical or psychiatric treatments. It does not provide alcohol education, domestic or vocational counselling, or letters of reference. It endorses no public policies and accepts no outside contributions. It keeps no attendance records except at the request of a judge or probation officer. Although there are local central offices and national conventions, each chapter is autonomous and no membership lists are kept.

AA provides rituals (storytelling at meetings) and commandments (the 12 steps). It offers inspirational testimonials and a sense of fellowship with people who know and care and cannot be deceived. The daily meetings during the early months of abstinence are a source of support and distraction at the time when alcoholics are most vulnerable to relapse.

AA also provides a source of companionship and social activity as a substitute for drinking. It restores self-esteem, enhances hope, and reduces guilt and shame. Members gain confidence and relieve isolation and powerlessness by helping one another. The doctrine of AA unites them and provides them with a way to understand their problems. Anonymity allows confidentiality and prevents the development of a leadership cult. Members successfully coping with their own alcoholism provide a model and give advice, but no clear distinction is made between helper and helped. Having a sponsor and being a sponsor, according to some research, is especially important for success. By carrying the message to others, members discharge their obligation to the group and relieve any guilt or shame they may have felt for accepting its help.

AA can serve as the main resource for recovery, as part of a treatment plan, or as an aid in sustaining recovery achieved by other means. Its formerly tense and distant relationship with physicians and mental health professionals has become close and co-operative in the last 20 or 30 years. Professional treatment often draws on 12-step principles, and AA is often combined with psychotherapy or behaviour therapy. AA members actually use more professional services than other alcoholics. A 1989 survey indicated that more than a third of them had been referred by an alcoholism counsellor, psychiatrist, psychologist, social worker, or physician.

Part II

In Part I we discussed the definition and diagnosis of alcoholism, drug treatments, behaviour therapy, and Alcoholics Anonymous (AA). Here we discuss chemical dependency treatment, family therapy, and the issue of abstinence versus controlled drinking We also examine dual diagnosis and estimate the effectiveness of alcohol abuse programs.

Chemical dependency treatment, also called Minnesota Model after the location of the hospitals where its prototype was developed, is almost as well known as AA, although it is far less commonly available because of its expense. Patients stay for a month, usually on a ward in a medical or psychiatric hospital or in a specialised alcoholism unit. They are counselled by recovering alcoholics under the direction of medical and mental health professionals and provided with educational lectures, individual and group therapy, family counselling, and self-help meetings using AA's principles. The follow-up usually includes further group therapy or AA.

Whatever treatment is chosen, engaging the family can be crucial. Alcoholism often produces a combination of guilt and resentment in the family that can lead to serious conflict. Families are in danger of overreacting or under-reacting to the alcoholic's behaviour, and group or individual counselling may help them learn how to respond. AA has become more sensitive to the needs of families, and there are now parallel self-help groups for husbands and wives (Alan) and adolescent children (Alateen). Groups of several families may be especially useful. They reduce isolation and over-involvement with the alcoholic patient, and they allow family members to gain perspective by seeing how others cope with the same situation.

In a variant of family consultation known as network therapy, friends and neighbours as well as family may be involved. A small group meets with the alcoholic patient and a therapist at regular intervals. Its members encourage the patient to acknowledge the problem and get help; they themselves try to understand what causes relapse and plan ways to prevent it. Patients in network therapy may be especially reluctant to quit treatment because they know it would disappoint so many people they care about.

Abstinence vs. moderate drinking

The greatest and most persistent debate in the treatment of alcoholism involves moderate or controlled drinking. AA and many medical and mental health professionals favour abstinence as the only solution: they insist that loss of control is inevitable

once an alcoholic starts to drink. Most advocates of controlled drinking are behavioural or cognitive therapists who see alcohol dependence not as a disease to be cured by withholding a poison but as a habit that can be modified by changing the circumstances that maintain it.

Each side questions the research methods and results of the other. Advocates of abstinence say the illusion that controlled drinking is possible results from insufficient follow-up. They point out that most people who seek treatment for alcoholism have already tried unsuccessfully to make rules for themselves about when, where, and how to drink. Abstinence advocates add that controlled drinking in either treated or untreated alcoholics is so rare that it cannot be reliably predicted and is not a reasonable goal. Anyone who is able to maintain control is not a true alcoholic.

Advocates of moderation say that most of the illusions are on the other side. They believe that few alcoholics ever become abstinent and that abstinence advocates simply lose track of those who return to social drinking. They contend that the belief in inevitable loss of control after a single drink becomes a self-fulfilling prophecy, adding that when an ideology of abstinence is dominant, people who only want to moderate their habit are discouraged from seeking help.

One way to split the difference is to distinguish between problem drinkers and true alcoholics, or perhaps, in the terms used by DSM-IV, between alcohol abuse and alcohol dependence. Most professionals in alcoholism treatment in the United States consider controlled drinking to be possible only milder cases of alcohol abuse. Once the problem has become serious enough to require admission to a clinic, they believe, a return to moderate drinking is too difficult.. But incipient alcoholics may be able to cut back without abstaining. There are now programs devoted to helping them reduce their drinking through short-term counselling, and in some of these programs they are asked to choose for themselves between the goals of abstinence and moderation.

Mental illness as a factor

Serious complications in the treatment of alcoholism are created by its association with other psychiatric disorders. The 1990 Epidemiologic Catchment Area Survey of more than 20,000 Americans found that 55% of alcoholics in treatment and 24% of those not in treatment had another psychiatric disorder as well. Among people with other psychiatric disorders. 22% also had an alcohol problem. That included 84% of antisocial personalities, 61% of people with bipolar disorder, nearly half of schizophrenic patients, and 25% of people with panic disorder.

In some cases psychiatric symptoms and alcoholism have common biological, psychological, or social roots; in other cases alcohol abuse produces psychiatric symptoms, or psychiatric symptoms result in alcoholism because they impair judgement or lead to misguided attempts at self-treatment. It may help to know which disorder came first and whether one persists while the other is in remission.

Although depression or anxiety can raise the risk of alcoholism, more often it is the other way around, and the mood or anxiety disorder clears up when the alcoholism is treated. Eventually psychiatric symptoms and alcoholism may perpetuate each other in a pattern that makes cause and effect difficult to separate. But whatever the original cause of alcoholism, it usually complicates all other problems so much that it must be dealt with immediately. Any associated depression can be treated with antidepressants or lithium after abstinence or even, according to some experts, before. The various antidepressants are all about equally effective, although selective serotonin repute inhibitors such as fluoxetine (Prozac) and sertraline (Zoloft) may be more useful because they have fewer side effects. Some experts consider it acceptable to prescribe benzodiazepines for anxiety disorders in alcoholics for periods of up to a few weeks, but others consider this risky. An alternative anti-anxiety drug is buspirone (Buspar). Alcoholic patients with adult attention deficit disorder can continue to take dextroamphetamine, methylphenidate (Ritalin), or pemoline (Cylert). Heroin addicts can be treated for alcoholism while taking methadone.

Individual psychotherapy is useful mainly for alcoholics suffering from anxiety and depression. Effective psychotherapy is nearly impossible if drinking continues, and it is important not to distract attention from the alcohol itself. But all the problems associated with drinking do not necessarily disappear when the drinking stops, and psychiatric conditions that hinder permanent recovery from alcoholism can sometimes be successfully treated with psychotherapy.

Alcoholism is a serious danger for people with schizophrenia and other severe chronic mental illnesses, especially when drinking makes them neglect their medications. Schizophrenic patients who are also alcoholic have less contact with their families and higher rates of criminal activity and suicide. Unfortunately, there are many institutional obstacles to the treatment of these dual disorders. Programs for alcoholism and psychiatric disorders are generally separate, with different funding and licensing procedures. Many professionals in one field know little about the other; co-ordination, referrals, and sharing of information are inadequate. Alcoholism programs prefer not to admit the mentally ill, and programs for the mentally ill prefer not to admit alcoholics, in both cases because they are considered disruptive. Many alcoholics will not acknowledge having psychiatric disorders, and patients in mental health clinics may deny and conceal their alcohol abuse. But halfway houses and shelter care facilities are now available for chronic mental patients who are alcoholic. There is also a growing interest in incorporating drug and alcohol education and treatment into the social skills training, family psycho-education,, and community-based case management used with schizophrenic patients. The National Institute of Mental Health has recently granted funds to several states for demonstration projects of this kind.

Does treatment work?

The effectiveness of alcoholism treatment has become an important question, because insurance payments and other funding increasingly depend on the answer.

In 1990 Enoch Gordis, the director of the National Institute on Alcoholism and Alcohol Abuse, described the available therapies as "a haphazard mixture of largely invalidated approaches." Since most alcohol abuse is episodic and patients usually enter treatment at a low point in their cycles, it is hard to tell how treatment is related to the improvement that follows. Researchers rarely have the time and resources to judge long-term effects. Dropout rates are high, and although patients who remain in treatment are more likely to recover, those with better initial prospects -- for example, stable marriages and jobs -- are more likely to remain in treatment.

Despite the difficulties, controlled studies give some indication of the results of treatment. Several experiments suggest that contingency contracting, Antabuse, and naltrexone are effective. In some studies, behavioural marital therapy, self-control training, social skills training, and stress management have proved helpful. But more than half of the controlled trials have shown no clear advantage for any one kind of therapy, either for alcoholics in general or for any particular group of alcoholics. Long-term therapy has not been shown to be better than short-term therapy, nor residential treatment better than non-residential treatment.

Still, it is clear that treatment can reduce alcohol consumption, crime, and the need for medical services and improve family harmony and work habits for at least several months. The improvement is greatest while the treatment continues; there is some decline afterward. A 1992 survey of 300 alcohol and drug programs in Minnesota found higher abstinence, higher employment, lower crime rates, and less drunk driving after treatment. Over a period of six months, treatment reduced crime rates by 66% and alcohol use by 40%. From one point of view, alcoholism can be regarded as a chronic or recurring illness, like major depression, that no one should ordinarily expect to cure with a single round of treatment. Even if only 30% of people who are treated remain abstinent after a year (a typical result), it can make a big difference to personal and public health and safety.

Brief intervention is surprisingly effective. For many alcoholics, elaborate and expensive forms of therapy may be no better than being told to read a manual or listen to a lecture. More than a dozen controlled experiments have compared such brief interventions with more extensive treatment, and most have found little difference. In one study, several weeks of inpatient treatment and a year's counselling were no more effective than a single session of advice followed by monthly telephone calls. Another study found that a self-help manual was as useful as 10 sessions of cognitive behavioural therapy.

AA vs. chemical dependency

Scientific research on AA is difficult. Local chapters are not all alike, and the membership is constantly changing. A controlled experiment is usually impossible because the members choose themselves and define their own problems. There is no definite point at which the "treatment" ends and rarely any follow-up. So it remains uncertain who is helped by AA and how much. Sceptics say that recovering alcoholics continue to attend meetings only because they are already capable of maintaining abstinence. They believe that many patients in alcoholism clinics are so seriously ill that AA has been or would be of no use. The only two available controlled studies are not favourable to AA, but the subjects were heroin addicts and criminals referred by the courts -- obviously not typical, highly motivated 12-step recruits.

Members' questionnaires are the main source of information on AA outcomes. According to one estimate, 40% to 50% of active long-term members achieve several years of abstinence and 70% improve somewhat. One study of 400 members found that of those who stayed sober for one year, 70% were still sober after two years and 60% after three. Another study found that at any given time 50% to 70% had been sober for at least a year. But another study found that only 20% to 30% remained sober for five years or more. The dropout rate is high -- according to one estimate as much as 70% after 10 meetings and, according to AA's own survey, 50% after three months.

The effectiveness of chemical dependency treatment is often questioned. In 1991 more than 60% of the people admitted to the programs in Minnesota had been in treatment before, and more than half of the repeaters were being rehabilitated for a third time. About half of these relatively wealthy and well-educated patients were drinking again within a year. But some believe that more severe alcoholics respond better to inpatient treatment, and others suggest that they simply need more time. In one survey of three million patients in a medical database, 48% of those who had received up to seven days of inpatient treatment required rehospitalization within a year. Among those receiving 8 to 21 days, 35% required rehospitalization, and among those receiving 22 to 30 days, only 21%.

Alcoholics use four times more health services than average, and there is strong evidence that treatment helps reduce the cost of those services, at least in the short run. Most research shows fewer illnesses, accidents, visits to doctors, and days spent in hospitals in the months after alcoholism treatment. A study based on 14 years of health insurance data found that medical expenditures were lowered by an average of $114 a month per person in the four years following treatment, even after correction for the cost of the treatment itself. Programs funded by the VA and Medicaid in the 1980s apparently did not produce similar savings, but the patients in those programs had lower incomes, more health problems, and fewer incentives to maintain recovery. Cost-effectiveness may turn out to be highest for brief intervention and AA, the least expensive forms of therapy, and lowest for chemical dependency treatment.

Individuating treatment

The problems and symptoms associated with alcoholism are so varied that no single treatment is likely to prove best. For example, certain personality types, especially people with borderline and antisocial tendencies, need limits and structure to achieve recovery. They will probably not respond well to AA meetings or individual psychotherapy but may do better in a behavioural or cognitive program. In general, there is increasing interest in finding ways to match patients and symptoms with appropriate practitioners, settings, and goals of treatment. Needs may vary with age, race, sex, and social circumstances as well as the nature and severity of alcohol problems and other psychiatric disorders. Some patients require different kinds of help at different times or several kinds of help at once. Multimodal programs have become common, and a large-scale NIAAA study on matching patients to treatments is now under way.

Most recovery from alcoholism is not the result of treatment. Only 20% of alcohol abusers are ever treated, but according to the Epidemiologic Catchment Area Survey, 50% recover on their own. Another study has found that only 30% of alcohol abusers (by the American Psychiatric Association definition) fall into dependence over a four-year period. Alcohol addicts, like heroin addicts, have a tendency to mature out of their addiction; one estimate suggests that 2% to 3% become permanently abstinent each year. People with stable jobs and family lives have the best chance, and women are more likely to recover than men, but otherwise the outcome is difficult to predict.

It is clear that moments of crisis, confrontation, and conversion are sometimes important. In one study 29 alcoholics were interviewed after a year of abstinence sustained entirely on their own. Sixteen said they stopped drinking because they "hit bottom" -- fell into despair or lost a job or a spouse. Six had become physically ill, and three had developed a physical aversion to alcohol (one while taking lithium). Three mentioned an incident (such as a drunk driving accident) that made them realise they had lost control, and four had a transforming religious or spiritual experience. After a year of abstinence, two still retained a physical aversion to drink, and eleven, surprisingly, had lost the desire to drink soon after stopping. Sixteen still had to make themselves resist temptation, mainly by picturing themselves drinking and imagining the nasty consequences -- a practice that behavioural therapists call covert sensitisation.

In another group of self-treated alcoholics, more than half said that they had simply thought it over and decided that alcohol was bad for them. A third said health problems and frightening experiences such as accidents and blackouts persuaded them to quit. Some used such phrases as "things were building up," "I was sick and tired of it," and "I didn't want to live that way any more." Others have recovered by changing their circumstances with the help of a new job or a new love or under the threat of a legal crisis or the break-up of a family.

Abstinence (or controlled drinking) does not immediately solve all the problems created by alcoholism. Depression, anxiety, and insomnia often persist for some time. Feelings numbed or suppressed by alcohol come back to trouble recovering alcoholics, and the new responsibilities entailed by sobriety may be oppressive at first. This condition is sometimes called a prolonged abstinence or dry drunk syndrome (some believe it is partly physiological). The tensions are worst in the first few months but may persist for much longer. One study found that former alcoholics who remained abstinent for as long as three years had many of the same psychological and social problems as active alcoholics, although they were physically much healthier.

But eventually recover can be complete; alcoholics who have not taken a drink in five years are generally difficult to distinguish from people who had never had an alcohol problem.

Further Reading

Marc Galanter, ed. Psychoactive substance use disorders (alcohol). In: Treatments of Psychiatric Disorders: A Task Force Report of the American Psychiatric Association. Washington, D.C.: American Psychiatric Association, 1989.

Marc Galanter and Herbert D. Kleber. The American Psychiatric Press Textbook of Substance Abuse Treatment. Washington, D.C.: American Psychiatric Press, 1994.

Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, D.C.: National Academy Press, 1990.

Stanton Peele. The Truth about Addiction and Recovery: The Life Process Program for Outgrowing Destructive Habits. New York: Simon and Schuster, 1991.

George E. Vaillant. The Natural History of Alcoholism Revisited. Cambridge, Massachusetts: Harvard University Press, 1995.



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