Moderation vs. Abstinence: What's More Effective? - Page 2

By Ruth Fowler 07/13/11
Some experts claim that while total abstinence works best for 'true alcoholics,' moderation may be more effective for 'problem drinkers.' But is reality ever so simple? Not everyone thinks so.
Moderation and abstinence: is it all relative?

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An April 2011 Vogue article (pdf available from the MM website) exemplifies the type of person MM aims to help. Rebecca Johnson writes about how her nightly glasses of wine led to a cycle in which: “I couldn’t sleep, I got tired of feeling vaguely lousy the next day, and, most important, I had the nagging sense that alcohol, once a boon companion I could take or leave, had settled in for a longtime stay. It was a rare evening I did not have at least two glasses of wine.” Johnson describes the spectrum of drinkers which traditional treatment has ignored. Historically, one is either an alcoholic and must abstain, or one is not and can drink. But according to the NIAAA, about 16% of the adult population is “nondependent problem drinkers”—and it is this 16% with which Johnson identifies. She finds the online tools of MM and the 30-day detox combined with motivational interviewing and therapy lite from the Center for Motivation and Change as entirely sufficient to get her drinking under control.

Her endnote, however, sounds suspiciously like denial to an AAer’s ears:  “These days, I aim for one drink a night but occasionally end up at two. Ironically, the majority of people who come to the CMC seeking moderation ends up choosing abstinence after all. I can see why. I found it a lot easier to say no than maybe.”

If Moderation Management works for the Rebecca Johnsons of the recovery movement, how does it do so? Ironically enough, MM, much like AA, is comprised of meetings, peer support and online services. Click on the site’s FAQs to help clarify whether your drinking is a problem or not. A 30-day period of abstinence is suggested—but not required—as  “a gentle test. Testing to see, first of all, can you walk away from alcohol for a short period of time? A time to look at your lifestyle: is alcohol your predominant concern or hobby? Can you fill the nondrinking hours with some other activities? Are you really serious about moderation? And finally, by abstaining for the 30 days, your tolerance to alcohol is reduced so when you do resume drinking it, you won't 'need' as much to get the desired effects. So the 30 is not just a 30. It is one of the tools to help you sort out your priorities, your strengths and your weak areas. You now have more information and know what to focus on the most in order to reach your goal of becoming a moderate drinker.”

“Becoming a moderate drinker” sounds eminently reasonable and appealing. In fact, to an alcoholic like myself, it sounds like drinking nirvana. Why isn’t it more widely known about or available? According to research published in 2006 by Ana Kosok in the International Journal of Drug Policy, membership of MM is predominantly online: “Groups do not start up easily and may be short lived when they do. Since groups are member-run, the person who starts one is tasked with finding a meeting space, attracting other members, facilitating the group, and answering questions about an unfamiliar program, as well as working on his or her own drinking problem. The loss of anonymity in being identified with a program for problem drinkers is also a major concern.” When Kosok carried out her survey, only 24 meetings were listed, of which only 12 were still active.

Kosok attributes this to several reasons: “The scarcity of meetings is a limiting factor for membership. At least two other factors contribute to MM’s small size: MM is not a program that is court-mandated for DUI infractions; and the program was not designed for long-term, continuous member participation. Therefore, meetings will never swell with the ranks of successful long- term members or those whose attendance is required by an outside agency. Finally, there has been little recent publicity about MM. Few professionals and even fewer of the lay public know of its existence."

This isn’t because MM doesn’t work, but it may at least partly be because it doesn’t work for alcoholics (nor does it claim to). Kosok discovered that “over 75% of people in MM came to help reduce and manage their drinking” and of these, “just 8%…indicated that they wished to shift their drinking goal from abstinence to moderation.” These stats tend to invalidate the commonly voiced criticism of MM that previously abstinent problem drinkers would be tempted to drink again if they had access to a program offering controlled drinking as a goal. In fact, Kosok’s study found that only 19% came to MM hoping to receive help in deciding between these goals, a figure that , says Kosok, “implies a recognition in the undecided group that not every problem drinker can learn to drink moderately.”

For an alcoholic, it’s “one drink and all bets are off.” It’s certainly not “one drink and let’s reach into my purse for my little moleskin notebook so I can keep my diary."

Sean is a high school math teacher in Fresno, CA. He is also a sweet and misguided boozer; when drunk, inept but entertaining. But Sean is not an alcoholic. Sean has his shit together; he drinks three to five times a week. He doesn’t drive drunk. He has never lost a job. He has great credit. But Sean’s concerned—too many hangover, memory lapses. The drinking just seems to be taking too much of a toll. Sean asked me whether he should try AA. After choking on my Ginger Beer at the image of this wonderfully middle-class American who’d pass out drunk if he got a whiff of an AAers breath, I told Sean to stop thinking about AA for the time being and instead try online support at MM.

After a few weeks, Sean reported back that he’d found it hard work but helpful. “You have to be really self-motivated to join up all the online tools [such as Dr. Reid Hester’s The Drinkers Checkup and the Behavioral Self Control Program] and really conscientious about counting your drinks, keeping a diary and being aware,” he said. “In a way, it took the fun out of drinking so I was actually relieved just to take a night off and not figure all that stuff out. I definitely don’t think I’m an alcoholic, and I think MM can work, but it’s pretty fiddly, and some of the online stuff you have to pay for.”

For an alcoholic, it’s “one drink and all bets are off.” It’s certainly not “one drink and let’s reach into my purse for my little moleskin notebook so I can keep my diary.”

Dr. Hester., CEO of Moderation Management and the author of the above-mentioned online self-help programs  as well as the information site Moderate Drinking, suggests that those who have had less contact with Alcoholics Anonymous have been found to be more successful in Moderation Management:  “People who affiliate with AA tend to be more severely dependent drinkers and moderation for that group is unlikely to be helpful. The other side of the coin is that less severely dependent drinkers are more likely to choose a goal of moderate drinking when they do decide to change their drinking. And it's this group that's more likely to be successful with cutting back.” According to a 2004 report by the National Institute of Alcoholism and Alcohol Abuse, there are three to four times as many problem drinkers at the low end of the spectrum as there are 3-4 times as many problem drinkers at the lower end of the severity spectrum as there are alcohol-dependent drinkers at the high end. And the gap is increasing. While the prevalence of alcohol dependence is declining, the prevalence of alcohol abuse is increasing.

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Ruth Fowler is an ex-stripper, Cambridge-grad and writer. Find Ruth on LinkedIn and Twitter.