Move Over, AA: Abstinence Isn't the Only Answer
Upstairs from one of my favorite Oakland dive bars, 10 people of varying ages and backgrounds are sitting in a circle, talking about their drinking problem.
“I make plans for my non-drinking days so that I’m not thinking about it so much – I work out, I schedule late work meetings, so it’s not even a temptation,” a tall, thin older woman says. Later, she explains that there was a time not long ago when the idea of getting through any day without five or six drinks seemed impossible to her.
“Go out later, hold off on that first drink, set up a game for yourself like ‘I can only buy one drink and then I have to get any others I want bought for me’,” adds a young man in stubble and a newsboy cap. “Hold off on your second drink, too,” adds the older man sitting next to him. “I used to order my next drink halfway through my first, so I’d be halfway through my second before the effects of the first one would kick in and then forget about it.”
This is Moderation Management (MM), a program whose rising popularity and success rate is posing the first real challenge in decades to the traditional, black and white approach to addiction.
The program typically starts with 30 days off booze altogether – “doing a 30” in MM parlance – followed by a slow reintroduction of alcohol, and eventually a plan to limit your intake: no more than 14 drinks a week for men, nine a week for women, and no drinking more than three or four days a week for either. There’s increasing talk of applying MM to marijuana use as well, although that’s not officially condoned by the nonprofit of the same name, which administers the program.
“People do come in lately who want help moderating marijuana and because it’s still illegal in California, we shy away from it,” explains Marc Kern, the organization’s director. “That doesn’t mean they can’t come to meetings and listen and stuff like that. But in states that have legalized it, I can see a time where there’s a different MM – Marijuana Moderation.”
While there is a framework to MM, based on Kern’s book Responsible Drinking, it’s also a program that prides itself on flexibility and enabling people to find their own paths forward. Three out of the 10 people at the meeting I attended said they weren’t ready to do a 30 yet, but were planning shorter breaks. One man celebrated the fact that he’d taken one day off from smoking weed and drinking. He does both in moderation daily, and his concern was more about the frequency and the fact that he can never seem to take a day off than the amount of any particular substance consumed.
Another woman nearly started to cry when explaining that her son had gone off to college and she missed him badly, that she was left with her husband who doesn’t drink at all and who she doesn’t really get along with. She said her job was very stressful and that the only thing getting her through was the bottle of wine she drinks every night. She’d had a few occasions recently where she blacked out from drinking, then spent the next three days in bed depressed. The group gave her ideas for ways she could take a few days away from all of it – the stress, the husband and the drinking – and suggested more therapy to deal with the psychological triggers of her drinking and depression.
A young man in the group explained that he had bipolar disorder, that he was feeling great on his new medication, but that there might be a problem when it comes to alcohol. “I’m not someone who drinks when they’re depressed, I drink when I’m up,” he said. “If I’m feeling good, I want to be out being social, and that means drinking.” The group offered some tips and tricks for sticking to the four-drink-a-night maximum, and for finding ways to be social without drinking. When the older man sitting next to him talked about his daily marijuana use and how it keeps him from being too irritable about anything, the bipolar man raised an eyebrow and gently suggested that using marijuana as a mood stabilizer was different, and more problematic, than just smoking pot because you like it and think it’s fun.
There was no therapist in the room, and the moderator, a two-year MM “veteran”, gently steered people away from delving too deeply into issues that might be better addressed in therapy.
Moderation Management has been around since 1994, but it was living more or less in the shadows from 2000 to 2012, mired in controversy over its founder, Audrey Kishline. After starting MM, Kishline left the group, realizing that she could not moderate her drinking after all. She returned to AA, then fell off the wagon, drunk-driving in March 2000 and killing a man and his 12-year-old daughter. She was released from prison in 2003, and in 2012, plagued by guilt and other demons, Kishline killed herself.
In the few years since Kishline’s death, MM has had something of a resurgence, bolstered by the launch of the US National Institute of Health’s Rethinking Drinking program and a 2014 report from the Centers for Disease Control calling out “excessive drinking” as something both independent of alcohol dependence and a major public health issue that is not being addressed by currently available tools and programs.
MM began to add more in-person meetings and last year, the organization launched a campaign around Dryuary, encouraging people to take the month of January off from drinking. It was so successful, they now plan to do it every year.
“Historically, MM has been looked upon as enabling alcoholics, and then the tragedy with Audrey knocked us in the stomach and we really pulled back after that,” Kern says. “Only now, in the last year and a half to two years, have we started to come out again. The notion of figuring out if you can moderate, rather than going straight to abstinence as step one of dealing with an alcohol problem, is pretty universal. I haven’t talked to every single person in AA, but I’m sure they’ve all tried moderation on their own. But before MM there was no book or guidelines or anything, so people would just go out and try moderation naively on their own, and without any support a lot of them would fail.”
Kern has been helping patients with moderation in a clinical setting for more than a decade, which entails a formal therapeutic protocol that includes using a Breathalyzer and closely monitoring patients’ progress. He also managed to get MM approved by the city of Los Angeles and the state of California as a program for first-offender drunk drivers 15 years ago. Still, Kern says most of the drunk-driving schools in the state automatically send people to abstinence programs (typically Alcoholics Anonymous or the non-religious version, Smart).
“The current status of the addiction field is based 97% on this black and white idea that you’re either an addict or you’re not, and if you’re an addict the only path is abstinence,” Kern says. “The success rate is far from optimal with that approach, so for the first time ever the US government is encouraging people to look outside the box.”
The US might be another decade away from, as Kern puts it, “taking full ownership as a society that there are many roads to recovery”, but other countries have been quicker to embrace MM. The UK National Health Service promoted “dry January” this year, while Australia has “Sober October”. There are currently MM meetings in England, Scotland, Ireland, Thailand, Germany, Belgium and Canada.
“The British have been struggling with over-consumption for so many decades, and they’re not so religious-based as we are here, so they’ve really welcomed MM,” Kern says. “They are much more open to a harm-reduction approach, and the idea of incremental steps and adopting a strategy that doesn’t make the threshold of getting treatment so high. They take the approach of, ‘Let’s get people started thinking about their drinking’ and they see reducing drinking as a success, whereas in this country if you reduce you’re still an alcoholic with a problem, which is not actually what the addiction literature suggests.”
When he was 18, someone attacked my twin brother on the US marine corps base where he was stationed. They stabbed him 14 times through the neck, bashed his head in with a blunt object and then tossed him out of a second-story window. We still don’t know who it was. He had been lying outside for hours by the time he was found, and he was dumped off at a hospital with someone else’s dog tags. At the time, the marines tried to frame it as an attempted suicide. His doctors later testified that it was physically impossible for his injuries to be self-inflicted, and the marine corps relented and agreed to pay his medical bills.
In addition to making my family forever suspicious of anyone in uniform, the experience sent three out of the four members of my nuclear family straight into substance abuse. My dad started drinking heavily. My brother, once he got out of the hospital, began combining alcohol with whatever drugs he could come by, in an effort to deal with the fact that he’d be spending the rest of his life as a quadriplegic.
I spent the first semester of my sophomore year of college snorting speed. I also used marijuana to come down, drank excessively while high, and took a lot of ecstasy. By the time winter break rolled around, I was emaciated and had shingles. I went to my parents’ house and slept for two days straight.
All of our reactions were within the range of normal. According to the vast majority of addiction studies, of the various factors leading to substance abuse, stress and trauma are right up there. And just as we each had a different drug of choice, we each took a different path out.
I got sick, realized hard drugs were a bad idea and decided to take a break from all substances for a while. It wasn’t that hard to do holed up at my parents’ house for a month, but I’m also the sort of person who needs to make their own decisions and who tends to stick to them. By the time I went back to school, I had the wherewithal to move out of my apartment (my roommate’s boyfriend was my dealer) and reintroduce alcohol in moderation. I set little rules for myself: I never drank more than two days in a row, never had more than five drinks in a night and took weeks off if I started feeling unhealthy about the whole thing. I didn’t know about MM at the time, but it probably would have worked for me.
My brother had a more difficult time of it, but after a two-year stint that included a DUI and two stays in the psych ward, he eventually went to rehab, found a substance counselor who was also in a wheelchair and joined AA. For him, abstinence came fairly easily once he decided it was the right path for him: he knew from experience that, given his severe head injury, he could get very sick if he mixed alcohol or drugs with the prescription medication he was on. He joined AA when he got out of rehab and still attends meetings occasionally, but he also continues to go out with friends to bars and has always discouraged me from abstaining in front of him.
My dad also ended up in AA, but it’s never seemed like quite the right fit. His bigger issue has always been depression more than drinking, but he’s part of a generation of men that think therapy is for the weak. So for him, meetings have always seemed more like a way to get group therapy without either paying for it or admitting to needing it. In some ways, that’s fine, but it’s made his relationship with alcohol weird – he cannot be around alcohol, he’ll count the beers that anyone else is drinking in a restaurant or at a party, and pretty much suspects that anyone who drinks anything, ever, has a problem. It’s also kept him from getting help for other issues.
None of which is to say that any particular path is the “right” one, or that our experiences are in any way representative of the entire spectrum of alcohol abuse, only that there are myriad reasons people fall into addiction, so it makes sense that there might be more than one way out. For Kern, it’s not a case of MM versus AA, or moderation versus abstinence. “I often think of MM not as a treatment program but as a strategy tool,” he says. “We will help people strategize about a party coming up, for example. And for some people, going through MM is almost like a diagnostic tool – they realize they can’t moderate and end up going to AA or another abstinence group. But there’s at least a sense of ‘I gave it a try’, and a lot of people need to do that before they’re willing to accept that they need to abstain.”
Despite the reticence to tackle anyone’s psychological issues in MM meetings, people do tend to get deep pretty quickly about their relationships to alcohol. “I had this psychological attachment to this character I had created around beer-drinking,” Andy, the co-facilitator of the Oakland MM meeting, told me. “As I got into doing my first 30, which ended up being more like six and a half months, I realized I’d built this character around being a man’s man out drinking beer. And now I’m at an age where I don’t need that bluster any more, that facade.”
Asp has had a steadfast no-beer rule for the past two years, just in case.
“I have a feeling that there is something else going on, that there is some reason that I feel like I want to be numb every evening,” a woman with a thick Roman accent shared in the Oakland meeting. “I think deep down I don’t feel comfortable in my own skin and so I need these things to feel comfortable,” the young man in the newsboy cap said. “So I need to get to the bottom of that.”
After each of these statements the group nodded or chuckled. Despite the wide variety of issues and strategies represented there, it was easy to see oneself in everyone’s story. It was also empowering to hear about the very practical ways in which people had turned their lives around.
That’s the part that seems to appeal most to MM members: the sense that they have options available to them and that the ultimate decision is theirs to make. Even “doing a 30” works to this end. “I was worried about reintroducing alcohol,” Asp says. “But after taking that time off, I knew I could abstain if necessary.”
“MM is not for everyone,” Kern says. “Lots of people come into my group and really should be abstaining. But in my opinion, they need to figure that out themselves. We give them parameters and enable them to come to a reasonable decision for themselves.”
When I met my husband, he was in the habit of taking a month off from drinking every year in order to, as he put it, “prove I’m not an alcoholic”. Initially I thought it was cool, but after years of keeping him from passing out in the middle of busy streets, or getting a call from jail after a heavy night of boozing, the appeal wore off. “If you have to go to one extreme or the other, you have a problem with alcohol,” I told him. “What you should really do is go a month moderately drinking.”
Once I heard about MM, I suggested it to him. Having grown up in Glasgow, there was no way abstinence was ever going to be his thing, but MM seemed like something he could handle. It also solved his ongoing dilemma of never knowing how much was too much. We decided to do a 30 together, and after two false starts – there was a party to go to! And a nice Italian dinner, which of course cannot go without wine – we are now 20 days in and feeling fine. Healthier and smarter, even. It feels like something that might be very good to do once a year, in fact.
“Are we, like, in the MM program now?” my husband asked me the other night, concerned. “Do we have to go to meetings and stuff?”
“No! Even people who are really into it don’t go to meetings all the time. Some people can’t go to meetings at all because they don’t exist in a lot of places, they just follow the program online. It’s more of a tool than a program,” I said.
“OK, good. Because I don’t really want to count my drinks the rest of my life,” he said. “But having a general idea that sticking to four drinks in a night is reasonable and helps me plan for a night out when I know I really don’t want to get too drunk or be hung over the next day.”
That said, he reserves the right to go have a piss-up in Scotland once a year.