There is an old joke: How many therapists does it take to change a light bulb? The answer is just one, but the bulb really has to want to change.
Changing anything is usually hard but changing behavior can be very difficult. And when the behavior to be changed is an addiction of any kind, change becomes nearly impossible alone. Even the words used to describe people caught in addiction’s web belie the current mindset of society toward the struggle. We refer to them as junkies or alkies, regardless of the nature of their usage. Anyone who is the loudmouth at all of the cocktail parties is said to have “trouble” with alcohol and could be labeled an alcoholic even if they do not drink otherwise.
For over 70 years, the public has viewed addiction as an all or nothing condition, much like pregnancy. For example the attitude toward alcohol has been either you are or you aren’t an alcoholic. Even medical doctors and psychiatrists/psychologist used to look at the issue in this binary sense. Patients either abused substances or, worse, were dependent on them. Treatment programs therefore concentrated on a single solution: abstinence.
This rigid perspective is gradually changing to meet the hard facts of science. Addiction is now viewed by many as a disease that has a broad spectrum and should be treated as such. No other medical or mental health issue is treated with a “one size fits all” model. Doctors such as Princeton-based psychologist Arnold M. Washton expand the options used to treat people who fall along the spectrum, people who are well shy of complete physical dependency but who want to alter their behavior.
Washton represents an approach that perceives changing human behavior as an incremental process rather than a quantum leap. “No one likes to be told what to do. Coercion often elicits resistance. Persuasion works better,” he says. “Abstinence is often the best treatment goal, but it should not be a precondition for receiving professional help. In other words, incremental progress toward abstinence is certainly better than alienating people by insisting on an all or nothing approach.” The advantage, Washton says, is that “barriers to getting help are lowered. People get into treatment earlier. It changes the landscape.”
So what is a drink? We have all heard someone say, jokingly or not, “I can’t be an alcoholic because I only drink beer.” However, the body doesn’t care how the alcohol is packaged.
According to public health agencies in the U.S., a standard drink is defined as a serving that contains approximately 14 grams of ethyl alcohol. This amount of alcohol is found in a 12-ounce serving of beer, a 1.5-ounce serving (“shot glass”) of hard liquor (e.g., vodka, scotch, vermouth, brandy, bourbon, rum, etc.), or a 5-ounce glass of wine. Cocktails (mixed drinks) often contain two to three standard drinks depending on how they are made. A bottle of table wine (750 ml) holds about five standard drinks. A “fifth”of liquor (750 ml) contains 17 standard drinks.
According to public health agencies, moderate (low risk) alcohol consumption is generally defined for healthy adult men as no more than four standard drinks in a single day with a maximum of no more than 14 drinks in a given week. For adult women, the limits are lower — up to three drinks in a single day and no more than seven drinks in a given week.
It is important to note that this is not the recommended levels of consumption. These guidelines are the upper range of moderate, responsible drinking that is not likely to cause problems. As with anything related to individual physical makeup, these limits may be substantially lower for some people.
Problem drinking is defined as alcohol consumption that exceeds the moderate limits and causes significant problems for the drinker and/or others, even if these problems are not dramatic or severe. For example, drinking that causes hangovers and/or creates conflict with others are potential signs of problem drinking or alcohol abuse. Literature on the subject also refers to this as harmful or hazardous drinking.
Contrary to popular perception, problem drinkers do not necessarily have a driving compulsion to drink. They do not drink excessively on a daily basis. Neither are they are physically dependent on alcohol. They do not neglect responsibilities at home or work due to drinking. The National Institutes of Health reports in its pamphlet Rethinking Drinking that in a major nationwide survey that it conducted of 43,000 U.S. adults only about 2 in 100 people who drink within both the “single-day” and weekly limits have alcoholism or alcohol abuse. But people can still have problems drinking within these limits, particularly if they drink too quickly, have health problems, or are older.
Washton stresses that when a problem arises, abstinence is by far the safest goal. But cold turkey is not an easy recipe and current 12-step programs can be authoritarian in nature. We humans do not like to have control taken away from us. Tackling this type of issue does not have instantaneous results and the more power that patients have over their own progress, the more invested they are in the outcome. Alcoholic Anonymous’s approach is a miracle for those for whom the process resonates but if patients find it too religious in nature or even cultish, they abandon it completely.
Now some history. In a cover article for the April issue of the Atlantic magazine, titled “The Irrationality of Alcoholics Anonymous,” Gabrielle Glaser outlined the genesis of Americans’ approach to addiction, especially drinking. Alcohol long formed the backbone of liquid consumption for much of human history because it was frankly safer than drinking the water. At the beginning of the 20th century, religious reactions to drunkenness, coupled with the increasing safety of water systems, fed the temperance movement that resulted most dramatically in the enactment of Prohibition.
This short but thirsty episode in American history resulted in an unintended consequence, a drinking culture that thrived in secrecy and binge-ing. Flappers and fraternities have more in common than expected, despite the drinking being much too public now. In 1935 a washed-up, alcohol dependent stockbroker named Bill Wilson began a movement that became Alcoholics Anonymous. At the time, medicine knew little about the brain and could offer little help for heavy drinkers beyond detox, sometimes again and again. AA presented at least a resource to assist patients after sobering up.
The premise that was skillfully promulgated nationwide was that this behavior was the result of a disease, not merely a moral flaw in the person affected. Ironically the AA “cure” was based in great part on the beliefs of the Oxford Group, an evangelical movement that taught sinners could be set upon the path of righteousness by confession and God’s grace. This interesting combination of medicine and morality became the definitive attitude toward addiction, one that was reinforced in the popular culture by Hollywood in movies such as “Lost Weekend” or “Days of Wine and Roses.” The 12-step program was off and running.
Helping to solidify the AA tenet of the phases of alcoholism was a 1946 survey by a physiologist named E. M. Jellinek who mailed out questionnaires to 1,600 AA members, of which 158 were returned. It is worth noting that, of these, the 15 filled out by women were thrown out because the responses were different from men’s and thus posed a risk of complicating the data. Based on this very small sample, conclusions were drawn about binge-ing, blackouts and hitting bottom. Jellinek later attempted to regain a scientific perspective and advocated for objective research.
As the AA model gained prominence in political circles, Congress passed a law that resulted in the creation of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). In the familiar duet between public and private initiatives, the NIAAA funded the National Council on Alcoholism, a public education non-profit founded by the PR genius and AA member Marty Mann, who had brought Hollywood into the fray. As a result, abstinence-only came to dominate the entire addiction narrative. Once insurers accepted that “alcoholism” was a disease, they began paying for treatment. The for-profit treatment industry juggernaut was born.
All during this evolution, there were attempts to bring science into play. An example is the 1976 Rand Corporation study showing that of 2,000 men in more than 40 different NIAAA funded treatment centers, 22 percent drank moderately after 18 months of abstinence treatment. The researchers at Rand concluded that controlled drinking was possible for some individuals. Fears that such a conclusion would lead to alcoholics to think about drinking “safely” resulted in repudiation of the study despite Rand’s repeating the study over a much longer period of time and finding the same results.
Various other studies around the 1970s also revealed success in behavior modification but these studies were the provenance of scholarly journals garnering scant attention except among the medical community. The general public continued to be exposed to the AA model as the holy grail of substance abuse treatment.
And now some science. In basic layperson’s terms, the biology of drinking shows that alcohol acts on many of the brain’s areas. This is more complex than the effect of cocaine or heroin. Alcohol slows the nervous system, hence the feeling of being relaxed. In addition, it causes dopamine to be released — producing pleasurable sensations. Drinking heavily causes the brain to slow the production of dopamine and to adjust to more and more alcohol in the system. This produces the irony that over time you don’t drink to feel good, but rather drink not to feel bad. The areas of the brain that govern risk assessment and behavior are impaired.
Substance abuse is indeed a disease but one that, like any other disease, is not a one and done, worst-case scenario. The AA model supposes that having the disease leads only to an inevitable downward spiral to complete physical dependency or worse. Therefore the argument is to avoid alcohol entirely. Science on the other hand recognizes that there is a wide spectrum of reactions and that drugs appear to be effective at mitigating behavior.
Research in other countries on drugs, known as opioid antagonists, demonstrates that they can effectively affect the chemical processes in the brain. In general, the theory is that endorphins released by substance use help strengthen particular synapses which in turn makes the individual think about cravings more. If those endorphins are blocked, the synapses weaken and cravings subside.
Research into the effect of these drugs has progressed slowly. There are three approved by the FDA. Antabuse induces nausea and dizziness if taken with alcohol. Acamprosate appears to reduce cravings. Naltrexone also is effective in limiting consumption. Patients who take it prior to drinking reduce their intake and some stop entirely. There are other drugs that, while prescribed for other reasons, seem to have an effect on drinking. For example, varenicline is a smoking-cessation medication but also can affect drinking behavior. The seizure medication topirimate and the muscle relaxant baclofen are also being studied.
One of the primary reasons drug therapy is resisted can be called the Valley of the Dolls reflex. In the 1950s and ’60s, psychiatrists prescribed Valium and other sedatives for heavy drinkers. This lethal combination resulted in patients addicted to both; drunk housewives relaxed into oblivion. The idea that giving drugs to addicts is a mad idea has not gone away.
Naltrexone has been available for years but it was never promoted the way Viagra is. Now that a generic form of the drug is available there is no incentive to promote it.
Alternative Treatment. The perceived wisdom of the AA or Twelve Step model is now being challenged by more and more medical and mental health professionals. Emblematic of this growing, vocal contingent is psychologist Arnold Washton, whose practice, located in both Princeton and New York City, determines treatment by looking at the individual patient specifically. He and many specialists like him consider factors outside the obvious behavior of over indulgence. Consideration of the issues that underlie the use of drugs or alcohol to self-medicate is crucial if the undesirable behavior is to stop. Full treatment must address the co-occurring psychological and emotional issues that caused the behavior to begin with.
“Alcoholism is not a medical term anymore,” Washton says. The spectrum ranges from drinking that is problematic up to physical dependency where the body cannot function without alcohol. It is at that point that medical intervention is a necessity. “It is the role that alcohol plays in the life of the patient that must be considered. What risks does it pose and what are the adverse consequences it produces.”
When the adverse consequences of even moderate drinking collides with family, work, or society, patients want help. However, throwing them into the black or white treatment scheme of total abstinence, and forcing the label of “alcoholic” on them, often fails to resonate. It is not a good fit and patients become disenchanted. They perceive the other people at the AA-style session have a different life story from them. Traditional 12-step programs would call that attitude denial and blame the patient for not following through.
Washton’s approach does away with the hard dividing line. “Patients want to engage in a discussion without judgment,” he says. He begins with no pre-formulated agenda and works toward a resolution that the patient desires. “Start with where the person is now, not where you want them to be.” Engaging the patient in the process enhances motivation. Key to engagement is not challenging the patient’s perceptions of themselves, thereby avoiding a power struggle.
However, Washton emphasizes “neither I nor anyone else can teach serious alcoholics how to become moderate or controlled drinkers. Some people do have the disease of alcoholism and are constitutionally incapable of exerting consistent control over their alcohol consumption. However, most people who seek help for a drinking problem, alcoholic or not, refuse to accept total abstinence as their immediate treatment goal.”
That said, the first step in treatment is often two to four weeks of no drinking. This tests the patient’s receptivity to abstinence and allows a cooling off period that can establish a baseline. After that period, the patience sees what their life is like without using their drug of choice and can be more objective about their goals.
Risk avoidance is a key component to any progression. Washton helps patients develop strategies to deal with the triggers and situations that have led to out of control behavior in the past. Choice, support and honest evaluation of what works and what doesn’t empowers the patient to follow through.
Crucial to success is an awareness of triggers and knowing what coping strategies work. As an example, Washton recently discussed a potentially difficult social engagement with one of his patients. Attending an upcoming wedding would put the patient squarely back into the “old gang” of heavy drinkers. All the familiar pressures to keep up would be there. Helped by his work with Washton, the patient knew the limits of his willpower and agreed he would be able to recognize when he was at the point of throwing caution to the wind. In addition, the patient’s date was committed to being his backup. While wanting to have a good time, the patient recognized the dangers and in turn committed to leaving when his date saw that enough was enough.
Triggers for resuming harmful behavior come in many shapes and forms. Anger, loneliness, disappointment are internal triggers that are just as potent as the peer pressure of old cronies who push “just one more”. Recognizing these triggers and when the conditions are ripe for falling into old patterns is a large part of the battle. Vital too is having a concrete plan to avoid the situation. Reaching out to a friend or family member can be just the distraction needed. Move away to another room with other company, take a walk with a friend, read a book — all are simple but effective means of breaking out of the usual responses.
A child of the 1960s, Washton grew up in the Bronx. Drugs and alcohol were readily available and he lost two friends to heroin. His father was a florist and his mother stayed at home. They had limited education themselves but were determined that their son would have the advantages they did not. At NYU, Washton was disenchanted with his chemistry major and switched in his junior year to psychology.
Upon graduation, he chose an occupational deferment from the military and taught science in the underprivileged schools in New York. At the same time he began graduate school at night. Once he completed his graduate degree, he took a part-time position in Harlem at the National Institute on Drug Abuse, a research facility that evaluated the effects of pharmaceuticals to prevent addicts from relapsing. His focus there was studying the cardio-vascular responses, particularly in patients who had had a heart attack. Working at the NIDA gave him hands on experience with addiction. Energized by what he learned in this “short term” job, he stayed and 10 years later he was the director of the facility.
Washton is now a nationally and internationally known clinician, researcher, author, and lecturer in the substance abuse treatment field. He has served as clinical professor of psychiatry at NYU School of Medicine, and as substance abuse consultant to professional sports teams, government agencies, media organizations, and major corporations. He has served on the Substance Abuse Advisory Committee of the U.S. Food and Drug Administration, and has given expert testimony before committees of The U.S. Senate and House of Representatives.
Working side by side with Washton is his wife, Lori Washton, who has a Ph.D in clinical psychology and is licensed to practice in New Jersey, New York, and Pennsylvania. Her professional career in the mental health and addiction treatment fields started in 1986 and she has worked as both a treating clinician and program director in inpatient, outpatient, residential, and partial hospitalization programs for adults, adolescents, and children. In addition to treating alcohol and substance abuse, her areas of professional interest and expertise include the treatment of depression, anxiety, personality disorders, and trauma. She also has special interest in helping women who are grappling with the dual stressors of parenting and professional careers.
Her father was a jet fighter pilot in the U.S. Navy and then for 25 years was a commercial pilot for American Airlines. Raised in rural Pennsylvania, she has been an avid equestrian since childhood and competes actively in dressage.
The Washtons have a son who is a student at the Pennington School. Arnold Washton has two adult daughters by a former marriage. One is an emergency physician working in the ER at Newark Beth Israel Hospital and the other is a corporate attorney working in New York City.
Washton’s practice centers on intensely private, one-on-one sessions. A substantial portion of his patients are executives and professionals who demand discreet, private assistance. While some patients benefit from discussions with one or two others, most seek personal sessions. Both Washtons are among the handful of addiction specialists. The Atlantic magazine cover article by Glaser reports that, according to the American Medical Association, of almost 1 million doctors in the country, fewer than 600 identify themselves as specialists.
Washton’s desire to reach as many people as possible with scientific data led him to develop the Rethinking Drinking Workshop. The NIAAA produced an informative pamphlet entitled Rethinking Drinking. Washton leverages that data in his educational workshop. This is not a therapy group. Participants are not required to reveal any personal information if they do not want to and they can choose to remain anonymous.
There is zero pressure on any participant to change his or her drinking behavior. The workshop is designed to be welcoming and non-threatening in order to encourage participation. It is a valuable experience for individuals who have avoided seeking help from a treatment program or AA. By stressing education, this workshop targets people who are still trying to decide whether or not their drinking is enough of a “problem” to warrant doing something about it. They receive information about what to do and assess the options themselves.
People who seek help but only know of the traditional abstinence only programs reject them because they “don’t work for me.” What approach does “work” is, in Washton’s view, completely individualistic. “Not working is not defined by me, but by the client. Treatment goals must always be the client’s goals, not the clinician’s goals,” he says. “I am not an advocate of either moderate drinking or abstinence. I offer help both to people who are determined to moderate their drinking without stopping completely and to people who want to stop drinking completely.” Washton believes the idea of withholding help from a client because the patient’s goals fall short of what the clinician thinks they should be is absurd and blatantly counter-therapeutic.
“Truth be told, the ‘all or nothing’ approach based on the traditional disease model of alcoholism fails to attract and engage the overwhelming majority of people with alcohol problems. Among those who do enter those programs, the majority drop out before completing treatment. Moderation is often the first step of an incremental approach leading to abstinence. I’m not at all against AA, but it’s irresponsible for anyone to promote it as the only way.”
Clients come to specialists like the Washtons hoping to reduce their drinking to safer levels, thereby reducing the likelihood of experiencing negative consequences due to drinking. While the ultimate goal is that their drinking never exceeds standard moderation limits, that is usually not realistic. The personal goal for many clients is to rarely or infrequently exceed moderate drinking limits (individually defined). In some cases where the patient is simply unable to significantly reduce the amount/frequency of alcohol consumption and problems related to drinking continue unabated, Washton will re-evaluate the current goals and discuss whether abstinence would make more sense.
The Times They are A’changing. Currently, the majority of treatment programs are staffed by addiction counselors or substance-abuse counselors. In many states, these designations do not require more than a high-school diploma. Many counselors are themselves recovering addicts. This in no way denigrates the value of straight talk from one who has been there but it does highlight the lack of scientifically based treatment. Receiving help under the guidance of an addiction specialist stands in stark contrast to the classic AA model where assistance is from peers only with no professional involvement at all
While the general public still takes the AA model of treatment as gospel, more and more attention is being given to alternative models. Articles such at that in the Atlantic and books in the popular press such as “Her Best Kept Secret: Why Women Drink — and How They Can Regain Control” are bringing the world of hard science into the mainstream.
Substance abuse treatment in the 21st century is now taking a variety of directions and Washton says that many traditional 12-step programs are now becoming more flexible. Medicine does not treat other diseases with a single protocol and approaches other than strict abstinence are gaining momentum.
The theory of harm reduction or harm minimization is being increasingly used in public health policies. This theory is familiar to the general public from its arguments in favor of needle exchanges for drug addicts and providing condoms for students. The objection to these steps is that they promote the very behavior that needs to be prevented. What gets ignored in the rhetoric is the fact that, while the debate can rage indefinitely, the life-destroying collateral consequences of the undesirable actions, AIDS and teen pregnancy, are prevented here and now. Such objections rely solely on Old Testament-like fire and brimstone themes of retribution for sin.
Change comes from within. The catalyst can be any number of things but it is always unique. Light bulbs and people burn brightest at their very core. What they reveal of themselves is illuminating.
Recovery Options, 1000 Herrontown Road North, Princeton 08540; 609-497-0433. Arnold M. Washton PhD, addiction psychologist. www.recoveryoptions.us.