Just Say Cut Down?

Time for a voice of reason on the addiction front. If you drink too much, or you're an alcoholic, or you know or have been affected by an alcoholic (and this is most of us), you've probably noticed an increase lately in magazine and newspaper stories about the so-called moderation approach to problem drinking. The new view -- which challenges the most central tenets of alcohol treatment in the US -- suggests that it may be possible for people who abuse alcohol to cut down on their drinking without resorting to total abstinence. It suggests that recovering alcoholics may be able to return to drinking at moderate levels, and that budding alcoholics can learn to control their consumption before it gets out of hand. The new tack has been gaining popularity among some researchers; it's also been gaining visibility. Last month alone, the moderation movement got full -- spread treatment in Self<>, Newsweek<>, and the New York Times<>; Self<> headlined it a "radical new approach" to alcohol treatment.

Like I said: time for a voice of reason.

This is bullshit. And, I think, dangerous.

One qualification before I launch my attack: I don't think the moderation philosophy is completely without merit. I think plenty of people who drink too much are capable of cutting down, and I don't think everyone who drinks too much can or should be considered an active alcoholic. But as someone who struggled mightily -- and, for nearly 15 years, failed -- to drink in moderation, as someone who's taken that particularly gruesome journey through denial and desperation and out the other side, I find the moderation movement pretty scary. It holds out false hope. It appeals to every alcoholic's most powerful fantasy -- that it might be possible to drink like "normal" people, to go back and do it all differently, to drink in safety. And it reinforces a dangerous suspicion, one that lurks not only in the culture at large but deep inside almost every alcoholic's soul: that we became alcoholics because we were weak, because we lacked the self-restraint and moral backbone to control our drinking, and not because this is a disease.

A friend who no longer drinks put it this way: "If I could drink in moderation, I wouldn't be an alcoholic." Precisely. To someone who understands the experience of alcoholism -- who knows how it feels -- the moderate approach seems oxymoronic at best (and just plain moronic at worst): moderation is simply not part of our vocabulary. I don't know one alcoholic who didn't launch a full-scale effort to control his or her drinking, who didn't set limits and make promises and develop countless strategies to cut back: drinking only on weekends; drinking only after 6 p.m.; switching from hard liquor to beer or wine; anything to avoid doing what the true alcoholic is so thoroughly loath to do -- give it up entirely.

Me? Way back in 1988 I read about a test people could take to determine whether or not they were alcoholics: the rule is three drinks a day for six months; no more, no less, and no variation no matter what the circumstances. Someone dies, you still don't have more than three. You get fired from your job, just three. I can't even remember how many times I took that test -- many times. I also can't remember consciously deciding to stray from the rule or to cheat, to have the fourth glass of wine, or to pour the three glasses in such enormous goblets that I might as well have had six. I just couldn't do it, couldn't stick with it for more than two or three days at a stretch. And it took me five years to even begin to accept that this little "problem with drinking," as the mind so brilliantly classifies it, was quite simply beyond my control.

It took another year, or more, to understand that the lack of control had powerful physiological roots. You always hear that alcoholism is a disease, but that's a hard concept to wrap your mind around, in part because the physiology of alcoholism is poorly understood and in part because the illness is experienced primarily on psychological and emotional levels, without the kinds of physical symptoms and treatments we associate with "real" diseases, like cancer or diabetes. But a disease it is. And even the most rudimentary understanding of the illness exposes deep flaws in the moderation philosophy. A lot of the current wisdom these days comes from neurologists, who are discovering that the alcoholic's brain is somehow "wired" differently from that of the non-alcoholic's, that alcohol interferes with the natural production of certain neurotransmitters that regulate feelings of craving and reward and that create feelings of well-being. To put it crudely, if you're an active alcoholic or on the road to being one, your brain stops doing the things it's supposed to do to make you feel good -- producing the endorphins and natural opioids that act as biological euphoriants. It's not entirely clear whether alcoholics are wired differently before they begin drinking or whether alcohol is the culprit, a villain that slowly wreaks havoc on the system to trigger the cycle of addiction. But the idea is simple: at some point, you lose the ability to exert will on your drinking; moderation is simply not a biological option.

The moderation movement appears to ignore not only that alcoholism is a physiological disease but that it's an insidious, progressive one, creating vast gradations among alcoholic drinkers. Most of us still think of the "true" alcoholic as the skid-row bum, out on the street slugging gin from a paper bag. In fact, the skid-row drunk represents only three to five percent of the alcoholic population. The vast majority are in far less visible phases of the disease, functioning perfectly well by the material standards we use to measure success. We are strong, smart, capable people who keep drinking -- and who delay looking at the dozens of intangible ways alcohol affects our lives -- precisely because we are strong, smart, and capable. I am utterly typical in that respect. In my last, heaviest year of drinking, I wrote my first book, managed my deceased mother's estate, never missed a deadline or day's work, never reneged on a financial obligation. If I drank too much -- well, I had plenty of reasons. My parents had both died. I had a ludicrously complicated romantic life. The drinking was circumstantial: I was depressed.

Drinkers like me know (although we struggle not to know) that the problem runs deeper than circumstance. We lie awake at 2 a.m. and stare at the ceiling, worrying that we're alcoholics, something "moderate" drinkers simply don't do. We employ every self-help strategy there is -- therapy, exercise, anti-depressants, meditation -- believing that we'll drink less if we're less unhappy. We try to moderate again and again. We fail. And if we are very, very lucky, we get desperate enough to get help. Me, I hit bottom on a December morning in 1993, just woke up one morning and understood that I couldn't bear to go on the way I'd been going. In Alcoholics Anonymous, this is called the "gift of desperation," a single moment when the equation you've been living by -- I drink because I am unhappy -- shifts for an instant and you see it another way: I am unhappy because I drink.

The moderation movement scares me because it presents the illusion of a false safety net to the alcoholic who's falling. It scares me because I'm quite sure that if someone had come up to me that December morning and promised me an easier route, I would have tossed away 15 years of evidence to the contrary and given it a try (and failed again). It scares me because I imagine it has great appeal to health insurers, who no doubt would prefer to bypass expensive rehabs and see people herded into self-help programs like one offered by a company called Moderation Management, a group that's already established workshops in half a dozen cities to help people control their drinking. And it scares me because I know in my bones that anyone who's worried enough about his or her drinking to enroll in a program like that has already lost control.

Like I said: it's bullshit. And it's dangerous.

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