Moderation vs. Abstinence: What's More Effective?
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If you’ve heard of Moderation Management (MM), chances are you’ve heard of Audrey Kishline, the 30-something professional who founded the controversial group in 1994. Kishline self-identified as a problem drinker, but subscribed to neither the disease theory of alcoholism nor Alcoholics Anonymous’ abstinence-only approach, which she had abandoned after a period of months. Kishline’s innovation was providing an alternative to AA: a program that would teach problem drinkers how to effectively manage—to “moderate”—their drinking, without having to maintain abstinence, do the steps or attend AA.
In January 2000, after six years’ struggling and failing to moderate her own problem drinking—as well as fielding considerable hostility from AA members and controversy in the press as the public face of MM—Kishline, in a soul-baring letter posted on the site, confessed that she had come to appreciate that her problems with drinking were too severe to be managed by moderation. While she continued to support MM as a viable treatment, she had decided to pursue an abstinence-only program to treat her own alcoholism.
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Just two months later, on March 25, the founder of MM and Dr. Stanton Peele’s one-time poster girl for harm-reduction—who now self-identified as an alcoholic and attended AA—got behind the wheel while drunk. The results were devastating.
That evening, Kishline, 43, driving her one-ton pickup on an interstate outside Seattle, Washington, caused mayhem as she drunkenly ran cars off the road, veered into the tree-lined divider, sped onto the interstate heading in the opposite direction, did a U-Turn and crashed head-on with a car containing a mother and child, killing both. It emerged in the investigation that Kishline had spent a great deal of time in Moderation Management neither moderating nor managing, but instead hiding her continuing struggles with binge drinking and alcoholism. This was hardly a revelation, given her announcement in January 2000. However, Kishline’s DUI homicides, combined with MM’s early promise, major press and high praise from advocates like Peele, well known for his frequent lambasting of AA and abstinence (though he had severed his ties to the group and to Kishline long before her crackup), inevitably cast a pall over MM, whose purported mission had never been even remotely militant: “MM empowers individuals to accept personal responsibility for choosing and maintaining their own path, whether moderation or abstinence. MM promotes early self-recognition of risky drinking behavior, when moderate drinking is a more easily achievable goal.”
Yet in the War between the Recoveries, Moderation Maintenance played the role of the young Turks plotting a palace coup of Alcoholics Anonymous. Peele’s provocative articles only exacerbated the antagonism as his have-it-both-ways program, Smart Recovery, confusingly redefined abstinence as a form of harm reduction.
This whole sorry mess has served to obscure the obvious fact that Moderation Management is effective for many people who abuse alcohol and need help in maintaining limits with their drinking, while Alcoholics Anonymous works for those whose alcoholism is intractable except under the constant pressure of abstinence. Each treatment works, but only if the correct diagnosis is first made—a basic medical principle, after all.
The confusion, controversy and hostility arise only when either of the two approaches is held up as an alternative to the other. One has only to click on the testimonials link to sample the “grateful” people whose only hope before MM was—the horror! —AA.
“Don” writes: I went to a local "addiction" expert who wanted to know about my relationship with my parents, etc. and concluded after 40 minutes my only hope was AA. All I asked was some advice about moderation techniques which your site hit right on the button. It’s already making a difference— just needed help on focus on the issue.
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“Debbie” writes: I walked into this whole thing skeptical, thinking I was an alcoholic, unable to get the daily drinking out of my life, this will never work....I was wrong. The whole process has worked. I won't say it doesn't take A LOT of effort and true willingness to change, because it does. But, what I've walked away with (from the whole study), the websites, the list, etc., is the knowledge I needed to change my drinking habit (and I will always call it a habit as opposed to addiction), it CAN be one, the mental need for alcohol CAN be replaced, the cravings CAN be diminished, the desire to overdrink CAN be eliminated.
The overt hostility to AA and to the label of alcoholic is evident—because alcoholism cannot be cured or even managed by MM, as Kishline’s experience demonstrates. To accept alcoholism is to close the door on moderate drinking forever. And as any alcoholic knows, saying goodbye to booze and drugs is like leaving the womb. It’s not easy, pretty or pleasant, but it’s essential in order to live and grow.
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.”
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.
How do you decide which program—AA or MM—is right for you? Dr Keith Humphreys, a Stanford Professor who studies addiction and the role of self-help groups, compares the diverse range of AA’s membership with the comparative homogeneity of the much smaller MM. “The typical MM member is employed, has a college degree and has few or no symptoms of alcohol dependence (e.g., blackouts, shakes, sweats). This is exactly the sort of person who has the best chance of becoming a successful moderate drinker,” he says. “AA members in contrast tend to show signs of physical dependence on alcohol and have also had their lives more damaged by alcohol, e.g., they have blown out their marriage/job/housing situation. They are the sort of people who are unlikely to become moderate drinkers and would be better off abstaining.” Kosok noted similar disparities in her research.
It’s worth noting that both MM and AA agree on fundamental principles. MM’s primary text, “Moderate Drinking,” and AA’s “Big Book” both make explicit distinctions between problem drinkers who are able to return to moderate drinking and alcoholics who are not. Both texts also agree that failure at the goal of moderate drinking indicates that a drinking problem is serious, harmful and best addressed by abstinence.
Inevitably there will be those who end up in the wrong place. Dr Keith Humphrey’s notes in his MM paper that “about 15 percent of MM members had experienced three or more of the following symptoms at least once in the six months before joining MM: shaking when not intoxicated, delirium tremens, blackouts, convulsions or fits after drinking, and cravings for alcohol upon waking. The vast majority of these persons also reported that drinking had caused problems with their job, health, and family situation. This subgroup of MM members would almost certainly meet formal diagnostic criteria for alcohol dependence.
Even MM’s website points out that many attempting MM will decide that it’s not for them and abstinence only is required: “Not surprisingly, approximately 30% of MM members go on to abstinence-based programs."
The take-home, then, is plain: To argue for or against AA or MM is an exercise in futility unless you are arguing in the case for a particular person who is either an alcoholic or a problem drinker. Successful treatment depends, once again, on correct diagnosis.
Dr. Keith Humphreys sums it up: “Tragedies such as the deaths in the car accident involving Audrey Kishline can occur when alcoholics fail to abstain, but they can also occur when nondependent problem drinkers are denied assistance because they have not deteriorated enough to become committed to a goal of abstinence. Of course, these potential benefits of MM must be viewed in light of the probability that some individuals who participate in MM will fail to attain moderate drinking.”
Just as individuals who attend AA may fail to attain sobriety.
When it boils down to it, both MM and AA are, at their core, programs reliant on the individual’s ability to take responsibility for their actions. Blaming the program for individual failure is simply a dodge. So the alcoholic must avoid the biggest trigger of all: alcohol. And the problem drinker must be cursed with the fiddly online tools, counting methods and drinking diaries in order to safely enjoy what the normal drinker takes for granted.
Although as an alcoholic, I have to say, I don’t envy the problem drinker one bit. Enjoy counting your drinks and keeping your diaries, kids!
Ruth Fowler has written for The Village Voice, The Guardian, The Huffington Post and The Observer. Her memoir, No Man's Land, about her pre-sobriety experiences as a stripper in Manhattan, was published by Viking in 2008. She is a frequent contributor to The Fix.