The Best-Kept Secret
7 Weeks to Sobriety,
by Joan Mathews Larson
Craig had every reason to be depressed. He was drinking a quart of scotch a day, often without eating anything. Both of his parents were alcoholic, and his father also suffered from severe depression, Craig was pale and thin. He had completed three alcoholism treatment programs, but nothing had succeeded in bringing his cravings under control. He was desperate for help.
George, a burly young electrician, had been treated for alcoholism six times. Nothing worked. His parents had given up on him, and now his girlfriend threatened to leave him. When I first met him at ten o'clock in the morning, he smelled strongly of alcohol and spoke of suicide as the only way out of his misery.
- Alcoholism treatment counselors had expelled Sonnie from their program. Her bizarre behavior was driving them, and the other clients crazy. The last straw came when Sonnie was found giggling hilariously and painting zigzag lines on the walls of the basement furnace room. She had been assigned to paint the walls in exchange for treatment, work she had pledged to do because she couldn't afford to pay.
Craig, George, and Sonnie are all treatment failures. They are more the rule than the exception. The best-kept secret of alcoholism treatment today is that it doesn't work. Not for Craig, George, Sonnie and 75 percent of all those who check themselves in with high hopes for recovery.
Ironically, the blame for treatment failure is often placed on the patients. They're "not ready to stay sober" or '"haven't reached bottom yet" say the counselors who staff these treatment programs. They assume that treatment works but patients fail. It is a curious perspective given the fact that most patients in treatment make an enormous commitment of time and money to be there. Doctors don't blame patients who are physically ill for failure to recover in response to treatment. They try another form of treatment, and another, and another in an effort to affect a cure.
Psychiatrists don't blame their mentally ill patients for failing to recover. They too try other forms of treatment.
This is not true of treatment for alcoholism. Despite acknowledged shortcomings, despite a shockingly high failure rate, there have been few innovations in the treatment of alcoholism in the past three decades. To understand this sad situation, you need to understand what treatment is available and why it so often misfires.
The Minnesota Model
Most alcoholism treatment in the United States today is a version of the Minnesota Model developed in the 1940s and 1950s by the Hazelden Foundation of Center City, Minnesota. This form of treatment is based on the presumption that drinking is a way of dealing with pain and emotional or psychological problems and that once those problems are identified and confronted, the alcoholic will no longer be driven to drink irresponsibly. Typically clients in treatment spend their days with counselors in group therapy. Everyone gets a chance to tell the story of how his life has become unmanageable because of alcoholism. Counselors and other members of the group help with the process of self-discovery by asking probing questions. The emotional release this process can trigger is thought to lower the need for compulsive drinking. The self-knowledge and insights gained about alcoholic behavior are believed to help alcoholics remain sober after treatment.
Most programs also require attendance at Alcoholics Anonymous meetings several times a week, if not daily.
Most people do not realize that Alcoholics Anonymous does not provide treatment. It is a support group, a fellowship through which alcoholics can become and remain abstinent with the help of other members. From the start, AA members acknowledge their powerlessness over alcohol. This acknowledgment is the first of the famous twelve steps members take toward spiritual awakening.
Bill Wilson, a stockbroker, and Bob Smith, a physician, two alcoholics who helped each other to sobriety and then carried their message to others founded AA in 1935. Since then, AA has helped millions of alcoholics stop drinking. The organization keeps no statistics but it is commonly reported that 25 to 30 percent. It is not widely known that before his death, Wilson was actively investigating the biochemical basis of alcoholism. When he died, his wife, Lois, wrote about his hopes to the researcher-physicians who were to carry on his work: her letter to Bill's psychiatrist friends was published in a pamphlet, The Vitamin B Therapy: A 3rd Communication to AA's Physicians.
Aldous Huxley, a great admirer of AA introduced Bill to two psychiatrists who were researching the biochemistry of alcoholism. Bill was convinced of the truth of their findings and realized he could again help his beloved alcoholics by telling them about the physical component of alcoholism. As you know, Bill's last years were mainly devoted to the spread of this information among alcoholics and other ill persons. With help, he wrote and distributed to AA doctors a brochure, which has twice been enlarged and brought up to date. Bill's great hope was that continued research would find a means whereby those thousands of alcoholics who want to stop drinking, but are too ill to grasp the AA program, could be released from their bondage and enabled to join AA.
AA's approach is firmly entrenched in traditional treatment. Clients are often asked to take Step Four and "make a fearless and searching moral inventory of ourselves" and then to take Step Five and "admit to God, to ourselves, and to another human being the exact nature of our wrongs.
Unfortunately, at this early stage of abstinence, many alcoholics simply aren't capable of this task. They're too damaged by alcohol to think clearly. These drinkers are the ones Bill W. worried about. They are too ill to benefit from AA.
A Dismal Success Rate
Take a look at this graph, which summarizes the results of 617 treatment follow-up studies. As you can see, even the most successful programs did not help even half of their clients remain sober for one to two years. Only 24 percent of those treated managed to stay away from alcohol for two years.
Ironically, studies of alcoholics who stopped drinking without treatment have produced almost identical results. A fascinating study at the Kansas City Veterans Administration Medical Center demonstrated what could be expected from different approaches to treatment. The researchers compared three groups of alcoholics:
- Those who got no treatment at all beyond a fifteen-minute medical appointment once a month
- Those who received Antabuse, a drug that makes you sick when you drink alcohol
- Those who got a full range of treatment services, including an outpatient treatment program, family counseling, individual counseling and therapy, vocational and rehabilitation guidance, AA, and the option of taking Antabuse
At the end of one year, here's how the three groups compared:
- No treatment: Thirty-seven of the fifty alcoholics were still drinking (76 percent failure rate)
- Antabuse only: Thirty-nine of forty-nine alcoholics were still drinking (80 percent failure rate)
- Full treatment services: Thirty-nine out of forty-nine were still drinking (80 percent failure rate)
The results speak for themselves: the success rate (22 percent) was very poor. Inexplicably, the alcoholics who got no treatment at all did slightly better than those in either of the other groups.
Why should the untreated group do better than those who got state-of-the-art treatment? Could the problem lie at the root of current thinking about alcoholism? In the bible of modern American psychiatry, The Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III), alcoholism is classified as a mental disorder. Almost exclusively, treatment consists of talk: counseling, confrontation. And despite the depressingly high percentage of treatment failure (and counselor burnout), the approach has never wavered.
Alcoholism and Health
It is no secret that alcoholism takes a terrible toll on physical health. According to the 1989 report in Alcohol World, a publication of the National Institute on Alcohol Abuse and Alcoholism, alcoholics, who generally die before age sixty-five from alcohol related causes, lose an adverage of twenty years of life. Cirrhosis of the liver is the primary killer, but heavy drinking is also associated with heart disease and several types of cancer. Tragically, some alcoholics don't even live long enough to get most of these terrible diseases. Among young alcoholics, the death rates from suicide, accidents, and cirrhosis are ten times higher than normal.
Less well known is the fact that the death rate among recovered alcoholics is almost as high as it is among those who continue to drink. This surprising and disappointing finding emerged from a five-year study of a group of alcoholic employees of the Dupont Company. Some of the alcoholics continued to drink, but about one third were abstinent. The group was compared to an equal number of non-alcoholics of the same age, sex, and payroll class. At the end of the five years, the death rate among the alcoholics was almost 12 percent, compared to 3.7 percent among the non-alcoholics. And when the researchers compared the abstinent alcoholics to those who continued to drink, they found only a slight difference in the death rate, which was 3.6 times higher than normal among the drinkers and 2.9 times higher among the recovered alcoholics.
Can the high death rate among the treated alcoholics be prevented? Unfortunately, this issue has not been addressed in conventional treatment programs, and in the research I reviewed, I found no strategies aimed at halting physical deterioration and reducing early mortality among recovered alcoholics. Clearly, new methods are needed to treat the physical damage from alcohol that causes early death.
Alcohol and the Mind
After my son's death, I believed that everyone else in treatment was recovering successfully and that Rob's suicide was an isolated occurrence. I discovered how wrong I was. The shocking truth emerged in 1984, nine years after Rob died: one in four deaths among treated alcoholics is a suicide. Most of these suicides take place in the first year after treatment.
Now I know that depression severe enough to lead to suicide is common among abstinent alcoholics and that many never regain a feeling of emotional well-being. This was brought home to me forcefully one evening not long after Health Recovery Center was founded. At a reception in another city, I was introduced to a man who had just received his twenty-five-year AA medallion for successful sobriety. He was one of a group who had attended a meeting at which I explained my concept of treatment for alcoholism. Later that evening, he took me aside and confided that after all those years he still fought intense cravings for alcohol and fantasized about one last wonderful drinking binge after which he would drive his car into an abutment. I was stunned to hear that he was still struggling with such demons. I offered him treatment at HRC, but he turned me down.
I wish I could tell you that this man represents only a minority of abstinent alcoholics and that most are emotionally stable and have rediscovered a positive sense of purpose and a zest for life. I have searched and searched in vain for studies to confirm this, but I have found just the opposite. A vast number of abstinent alcoholics continue to battle depression and crave alcohol, never regaining lost territory in their personal lives and careers. Alcoholism casts a long, dark shadow on their lives for years after they quit drinking.
What Time Doesn't Heal
For the majority of alcoholics, abstinence is not all it's cracked up to be. In 1962, a team of psychiatrists studied 299 alcoholics who had completed treatment at six different centers and reported how they were faring one year later (D. Gerald and S. Saenger, "The Abstinent Alcoholic, "Archives of General Psychiatry). Sadly, 82 percent had resumed drinking. But the picture wasn't much rosier for the fifty-five who remained abstinent:
- Fifty-four percent were "overly disturbed," which, the researchers explained, meant that their abstinence was "sustained in context of an unstable state; they suffer with tension to a degree which concerns them; they are angry, driven by anxiety, restless, unable to relax, seek to distract themselves by spending inordinate amounts of time at work or in social activities of a community nature; and/or are overtly psychiatrically ill displaying disturbances of mood, thought and behavior to a psychotic degree."
- Twenty-four percent were classified as "inconspicuously inadequate: meagerness of involvement with life; no positive sense of excitement, purpose or interest in life."
- Twelve percent were deemed AA successes, having "acquired a sense of purpose and value in life through their AA membership. It is evident that they are as dependent on AA as they were before on alcohol and the pattern of relationships in which their alcoholism was integrated.
- Ten percent were rated "independent successes in that they do not appear disturbed, are more alive and interesting as human beings, engage in a variety of personal interactions on the basis of positive interest; efforts at self-realization are independent rather than institutionally supported." In conclusion, the researchers commented that they were "astonished to note how prolonged abstinence could accompany gross mental disturbances and maladjustments."
Ten Years Later
As the case of the twenty-five year AA veteran illustrates, time does not necessarily heal the consequences of alcoholism. When alcoholics first stop drinking, they are led to believe that they will soon be feeling good. For most, that doesn't happen-their anxiety and depression will be with them for many years. Results of a. ten-year study by researchers at Johns Hopkins University (C. De Soto et al.) demonstrated that the typical alcoholic experiences most of the following symptoms for years into recovery:
- Psychosis (lack of contact with reality)
- Feelings of inadequacy arid inferiority
- Phobic Anxiety
The researchers reported that the intensity of these symptoms diminished slowly over time; by the tenth year, many of the 312 alcoholics participating in the study showed significant improvement.
Given the grim outlook, it isn't surprising that so many alcoholics resume drinking: When sobriety doesn't deliver on its promise to ease their suffering, they opt for a quicker fix-alcohol. Can we blame them? It's human nature to seek relief from stress. Few of us would do much better.
Relapse Is the Norm
Relapse among treated alcoholics is so prevalent that professional journals label one-year follow-up studies of treatment outcome as "long term" The extent of the relapse problem was demonstrated In 1980 in the Rand Report, the results of a federally funded four-year study of 922 alcoholic men who had been treated in seven hospitals Here's what the research team found:
- Of the 922 men, only 28 percent refrained from drinking for six months after treatment
- After one year, only 21 percent remained abstinent
- After four years, only 7 percent remained abstinent
My educated guess is that the abstinent 7 percent have spent most of their four years involved with support. or therapy groups, using AA or psychotherapy to "adjust" their attitudes and "manage" their unstable emotions.
Among professionals in the field, the fact that treatment doesn't work well is an open secret. No less an authority then Enoch Gordis, M.D., director of the National Institute on Alcohol Abuse and Alcoholism, has conceded this publicly. 'The treatment of alcoholism has not improved in any important way in twenty-five years. Only a minority of patients who enter treatment are helped to long-term recovery.
Teaching Alcoholics to Drink Socially
The presumption that alcoholism stems from an underlying emotional disorder reasonably suggests that once the "problem" is uncovered and dealt with in therapy, alcoholics should be able to drink moderately like everybody else. Every chapter of AA has members who have tested or are testing this theory without success.
Researchers have also attempted to show that alcoholics can be taught to drink moderately. In 1973, California psychologists Mark and Linda Sobell reported on a study in which they used behavior-modification techniques to train twenty alcoholic men as social drinkers. The Sobells have followed the men for two years and reported that 85 percent were "drinking moderately or not at all." The results made headlines nationwide. And why not? They contradicted established AA wisdom and suggested that alcoholism was a psychological disorder that could be treated and cured with behavioral therapy.
The trouble is, it wasn't true.
Ten years later, another team of researchers decided to take a second look at how the twenty men were doing. Their findings were shocking. Nineteen of the twenty men never drank moderately; the other subject had been mistakenly classified as an alcoholic and shouldn't have been in the study. Contrary to the Sobells' claims, records showed that most of the men had been re-hospitalized for alcoholism treatment within one year of discharge from the research project. Today, four are dead from suicide and other alcohol-related causes, and nine continued drinking, their lives in shambles. Only six managed to become abstinent with treatment and the aid of AA.
The harm that the Sobells' widely publicized study caused cannot be measured. For ten years, many alcoholics believed the distorted results and tried to become social drinkers. Even now, most alcoholics want to believe that controlled drinking is possible. But research tells us otherwise. In 1985, the prestigious New England Journal of Medicine published results of a study of 1,239 alcoholics who had completed hospital-based treatment programs. The researchers had followed the group for five to seven years and found that less than 2 percent were able to drink alcohol without losing control. The researchers also found that 79 percent of the alcoholics who survived were drinking heavily at the time of follow-up. Only 7 percent had stopped drinking; 14 percent were dead. One participating hospital reported an appalling 45 percent mortality rate among alcoholic study subjects within the five-to seven year span of the study. The researchers concluded that there is "little cause for optimism about the likelihood of an evolution to long-term stable, moderate drinking among alcoholics."
Putting It All Together
My search for answers to Rob's suicide led me through most of the current research about alcoholism and how it is treated today. Certain facts emerged repeatedly:
- Current treatment emphasized behavioral and psychological rehabilitation based on the assumption that emotional and/or sociological problems trigger heavy drinking
- Psychologists and psychiatrists working in the field describe alcoholism as a mental disorder and attempt to treat it as such
- Despite the variety of therapies available in treatment settings, recovery rates are consistently poor; relapse is the norm
- Present treatment methods fail to relieve depression and anxiety, end alcoholic cravings, or help alcoholics overcome unstable moods
- Whether alcoholics recover on their own or with treatment, only about 25 percent sustain some abstinence
- One in four deaths among treated alcoholics is due to suicide
- The mortality rate among both treated and untreated alcoholics is about three times higher than among the general population
It's a bleak picture, and a puzzling one. In science, when a theory is tested and fails to deliver on its promise, it is deemed disproved, a null hypothesis. At that point, researchers know they must discard the faulty hypothesis and search for a new answer. In scientific terminology, clinging to a disproved theory is an error of the first kind. Data from studies of alcoholism treatment have demonstrated again and again that we are locked into this kind of major error in our concept of alcoholism as a psychological disorder. Present methods have been failing us. Most alcoholics do not recover. Ultimately, they die of this disease. It is time to relinquish old beliefs and search for new answers.
A New Direction
The more I learned about alcoholism, the more I became convinced that it is not just a psychological disorder, or a sign of emotional weakness, or flawed character that can be resolved with talk therapy. Instead, I began to see alcoholism as a physical disease, the outcome of a powerful physical addiction to alcohol that gradually inflicts mortal damage to brain and body chemistry. Evidence of its genetic underpinnings convinced me that only certain people were vulnerable to this addiction. I found support for this view in some surprising quarters.
William Mayer, M.D., former chief of the US. Alcohol, Drug Abuse, and Mental Health Administration, speaks of alcoholism as "a disease genetically determined and clearly progressive. We can predict its course even though the speed of its course may vary from person to person. It is ultimately fatal. It leads to a predictable physical deterioration and often some mental impairment, and it occurs in people who have no discernible previous psychological or emotional disorders."
In 1982, the question of whether alcoholism is a physical or mental disorder was the subject of a major courtroom battle. The case pitted the federal government against Granville House, an alcoholism treatment center in Minneapolis that treats many injured clients who receive government disability funding. The government's position was that since alcoholism was classified officially as a mental disorder, Medicare could rightly refuse to reimburse Granville House for the treatment it provided.
The government's star witness was a psychiatrist, Dr. Robert Spitzer, who defended the view of alcoholism as a psychological disorder even though he recognized that "there exists no effective psychiatric treatment."
Two former presidents of the American Society of Addiction Medicine-LeClar Bissell, M.D., and Maxwell Weisman, M.D.-testified in support of the concept of alcoholism as a physiological disease. In summing up their testimony, federal judge Miles Lord noted that they had described, "the utter failure of treatment modalities based an defining, diagnosing, and treating alcoholism as a mental disease."
In his decision, Judge Lord noted that the American Medical Association had classified alcoholism as a physical disease in 1957. Here is an excerpt from his opinion.
Alcoholism is the third leading cause of death in the United States. This Court is unaware of any mental illness that so directly and persistently results in death... Disease of the body, if severe and continuing, will in time affect the mind ... The sole fact that a condition is accompanied by abnormal behavior does not justify its classification as mental. The great bulk of the testimony supports the conclusion that alcoholism is a diagnosis of a primary disease. It cannot be understood as a secondary effect of any other problems. The disease is predominantly physical as opposed to mental in nature ... It is therefore the Court's conclusion that the Federal Government's classification of alcoholism and other forms of chemical dependency as mental disorders is arbitrary and capricious.
So far, this decision and the long-standing position of the AMA and the World Health Organization have had little impact on treatment for alcoholism. Psychological talk therapy continues to prevail.
Old Questions, New Answers
Despite the enormous body of research showing the frightening toll alcohol takes on the body and the brain, the question of what might be done to repair the damage remains unasked and unanswered. As I read through all the studies documenting the damage caused by heavy drinking, I kept thinking, "What if?" What if we did more than counsel alcoholics? "What if" rehabilitation consisted of more than just talk therapy?
Most of my questions related to Rob's death.
Q. How could a normal kid who loved life become so depressed that he committed suicide?
A. Rob had shown no signs of depression before he began drinking. The alcohol must have altered his brain chemistry to cause the hopeless depression that precipitated his suicide.
Q. Why couldn't the therapy and emotional support he received in treatment and at AA restore him to his old self?
A. The damage to his brain and nervous system couldn't be talked away.
Q. What could have been done to cure his depression?
A. A number of brain chemicals known to prevent depression are depleted by heavy drinking. Was there a way to restore them? Could hypoglycemia have contributed to Rob's depression? Depletion of certain nutrients has been linked to depression. Lab testing might have provided clues to what imbalances had developed and what could be done to restore him to normal.
Q. If disorders of body and brain chemistry detected in lab tests could be corrected, would he have been able to recover?
A. That is the $64,000 question. To answer it I needed to develop a system for biological repair. I had read hundreds of research papers that described the functions of our brain and body chemicals and the symptoms that develop when they are depleted. There were hundreds of other papers that described the effect of alcoholism on these natural chemicals. Together, this research suggested a scientific basis for a new approach to treatment that combines biochemical repair with counseling.
At the outset I knew there would be resistance to this approach. The notion that the roots of alcoholism are in body chemistry is not easy to accept. My theory that it might be possible to fix what had been broken was, at that point, an educated guess that was met with great skepticism.
But I persisted and the answers I sought after Rob's death led to a treatment model that has proven far more effective than I dared dream. Today there is a way to overcome addictive cravings, depression, and the many other alcohol-induced symptoms that trigger relapse. The pages that follow will guide you to recovery, a gift to you from Rob.