1

"Disease Concept of Alcoholism and Drug Abuse." Encyclopedia of Drugs, Alcohol, and Addictive Behavior. 2nd Ed. Ed. Rosalyn Carson De!itt. "acmillan #homson $ale, 2%%&. e'otes.com. 2%%(. &) *eb, 2%&& http+,,---.enotes.com,drugs alcohol encyclopedia,disease concept alcoholism drug abuse #hroughout most of recorded history, e.cessive use of A/C010/ -as vie-ed as a -illful act leading to into.ication and other sinful behaviors. #he Bible -arns against drun2enness3 4slam bans alcohol use entirely. 5ince the early nineteenth century, the moral perspective has competed -ith a conceptuali6ation of e.cessive use of alcohol as a disease or disorder, not necessarily a moral failing. #he disease 7or disorder8 concept has, in turn, been evolving -ith considerable controversy since then, and has itself been challenged by other conceptual models. Because this article is concerned primarily -ith the disease concept, the other models -ill be mentioned only briefly. Among the first to propose that e.cessive alcohol use might be a disorder, rather than -illful or sinful behavior, -ere the physicians Ben9amin Rush, in the :nited 5tates, and #homas #rotter, in $reat Britain. Both Rush and #rotter believed that some individuals developed a pernicious "habit" of drin2ing and that it -as necessary to undo the habit to restore those individuals to health. !ords such as habit and disease -ere used to convey inter-oven notions. #rotter sa- "the habit of drun2enness" as "a disease of the -ill," -hile Rush sa- drun2enness as a disease in -hich alcohol -as the causal agent, loss of control over drin2ing behavior the characteristic symptom, and total abstinence the only effective cure. 4n &;<=, a 5-edish physician, "agnus 1uss, introduced the term alcoholism >"alcoholismus"? to designate not only the disorder of e.cessive use but an entire syndrome, including the multiple somatic conse@uences of e.cessive use. /ate nineteenth century physicians, although not the first to see habitual use of other drugs 7such as 0A4A#E5, #0BACC0, C0**EE8 as disorders, are credited -ith stressing the idea that each -as but a subtype of a more generic disorder of inebriety. 1o-ever, they also minimi6ed #rotterBs and RushBs notions of learned behavior as a central feature of a generic disorder of inebriety and emphasi6ed instead the idea of a disorder rooted in ac@uired or inherited biological malfunction or C:/'ERAB4/ 4#D. #his more biologically based vie- of inebriety -as used in Britain and the :nited 5tates by advocates of publicly funded treatment facilitiesEinebriate asylums. "any temperance leaders also supported the establishment of treatment facilities. 1o-ever, -hile physicians advocated treatment,

temperance leaders, still convinced that alcohol itself -as the root of the problem, pushed for its control and, eventually, for its prohibition. 4n the :nited 5tates, the ratification in &=2% of the Eighteenth Amendment, -hich prohibited the production, sale, and distribution of alcohol, temporarily dampened scientific in@uiry into the nature of alcoholism. But concern about the problematic and e.cessive use of other drugs, such as 0A404D5, C0CA4'E, and BARB4#:RA#E5, continued to stimulate -ritings both in the :nited 5tates and abroad. !as e.cessive drug use a disease, a moral failure, or something elseEperhaps something in bet-eenF By the mid t-entieth century, the rise of A/C010/4C5 A'0'D"0:5 7AA8, the publications of E. ". Gelline2, and the establishment of the Dale Center for Alcohol 5tudies revived interest in e.ploring the nature of A/C010/45". 4n the early &=(%s, the idea reemerged that, for certain "vulnerable" people, alcohol use leads to physical addictionEa true disease.

EARLY MODELS OF THE DISEASE CONCEPT

Central to the disease concept of alcoholism put for-ard by Gelline2 -ere the roles of #0/ERA'CE A'D A1D54CA/ DEAE'DE'CE, usually considered hallmar2s of ADD4C#40'.Tolerance indicates that increased doses of a drug are re@uired to produce effects previously attained at lo-er doses. Physical dependence refers to the occurrence of !4#1 DRA!A/ symptoms follo-ing cessation of alcohol or other drug use. Although Gelline2 recogni6ed that alcohol problems could occur -ithout alcohol addiction, addiction to alcohol moved to the center of scientific focus. Despite being couched in the language of science, the reemergence of the disease concept of alcoholism -as not a result of ne- scientific findings. Gelline2 believed it -as necessary to see alcoholism as a disease in order to increase the availability of services for alcoholics -ithin established medical facilities. 1e also recogni6ed that efforts to prevent alcoholism -ould still have to address the comple. cultural, demographic, political and economic issues contributing to the problem. Although he sometimes appeared to ta2e a broad vie- of the disease concept of alcoholism, he reserved the disease category for those individuals manifesting tolerance, -ithdra-al symptoms, and either "loss of control" or "inability to abstain" from alcohol. #hese individuals could not drin2 in moderation3 -ith continued drin2ing, their disease -as progressive. 0thers -ho dran2 merely in response to psychological stress 7"alpha alcoholism"8 and those -ho sustained to.ic conse@uences from alcohol but -ere not physically dependent 7"beta alcoholism"8 did not @ualify for his more

e.plicit and restrictive definition of disease. Gelline2Bs vie- of alcoholism as a progressive disease is sometimes referred to as the "classic" disease model to distinguish it from later perspectives of a disorder or syndrome more po-erfully influenced by learning and social factors. Alcohol researcher and theorist #homas Babor has pointed out that -hen definitions specify alcohol addiction or dependence as a disease entity, it can be argued more convincingly that "dependence is an organically based entity -hich produces a characteristic set of signs and symptomsH and increases the probability of repetitive drin2ing behavior." #he American Asychiatric Association included alcoholism in the first edition 7&=I28 of the D4A$'05#4C A'D 5#A#45#4CA/ "A':A/ of Mental Disorders. 4n the second edition 7DSMII8, published in &=(;, the group follo-ed a precedent set by the !orld 1ealth 0rgani6ationBs 4'#ER'A#40'A/ C/A554*4CA#40'0* D45EA5E5 7ICD-88 and included three subcategories of alcohol related disorders+ alcohol addiction, episodic e.cessive drin2ing, and habitual e.cessive drin2ing. Both of these publications included alcoholism among the personality disorders and certain other nonpsychotic disorders, implying that the alcohol use -as either secondary to an underlying personality problem or a response to e.treme internal distress. #his vie- of e.cessive drug use as a symptom of some other psychiatric disorder is sometimes referred to as the symptomatic model. According to this concept, drug or alcohol dependence is not really a disorder in and of itself. "ean-hile, from the late &=I%s and throughout the &=(%s, the E.pert Committee on Addiction Aroducing Drugs of the !0R/D 1EA/#1 0R$A'4JA #40' 7!108 continued to formulate and refine definitions of addiction and 1AB4#:A#40' that could facilitate !10Bs responsibility 7re@uired by international treaties8 for control of 'ARC0#4C5, cocaine, and CA''AB45. 4n the &=I%s, the presence of physical dependence -as emphasi6ed in the definition of drug dependence, and the !10 E.pert Committee -as still concerned -ith differentiating bet-een psychic dependence and physical dependence. At one level, the concept of psychic dependence -as compatible -ith the psychodynamic vie- that these disorders -ere a response to psychic distress 7such as negative mood states8. According to the psychodynamic model, e.cessive alcohol or drug consumption -as merely a response to underlying psychopathology. #his model -as also consistent -ith Gelline2Bs vie- of one of the "species" of alcoholism, in -hich individuals drin2 to relieve emotional pain 7alpha alcoholism8. 4n &=(=, the committee abandoned the effort to differentiate habits from addictions and adopted terminology first proposed by 'athan Eddy

and colleagues in &=(I, in -hich the term drug dependence designates "those syndromes in -hich drugs come to control behavior." #he committee recogni6ed that dependencies on different classes of drugs 7such as alcohol, opiates, cocaine8 can differ significantly and that -ithdra-al symptoms are not al-ays present or necessary aspects of dependence 7see #able &8. 4n &=K2, alcoholism -as included in a listing of diagnostic criteria for use in psychiatric research published by *eighner and co-or2ers. #he defining criteria for alcoholism included -ithdra-al symptoms, loss of control, severe medical conse@uences, and social problems. 4n the same year the 'A #40'A/ C0:'C4/ 0' A/C010/45" also outlined criteria for diagnosing alcoholism, -hich emphasi6ed tolerance and physical dependence and incorporated certain concepts developed by A/C010/4C5 A'0'D"0:5. #his definition, and one issued 9ointly -ith the American "edical 5ociety on Alcoholism in &=K( 7see #able &8, represented an attempt to emphasi6e the seriousness of the disorder, the e.perience of clinicians and of recovering alcoholics, and the vie- that alcoholism is a primary or independent disorder, not merely a manifestation of an underlying personality problem. #hese statements come close to being current definitions of the classic disease model.

PROBLEM DRINKING AS A DISTINCT DIMENSION

#he importance of -hat can no- be called the classic "disease model" of alcoholism as a primary focus for health programs -as challenged in &=KK by a report of a !10 E.pert Committee on alcohol related disabilities. #his report stressed that not everyone -ho develops a disability related to alcohol use e.hibits alcohol dependence or addiction, nor -ould such an individual necessarily develop a dependence in the future. #he report asserted that some alcohol related disabilities represent a dimension of problem drinking distinct from the disease of alcoholism or alcohol dependence syndrome. #his perspective provided support for policies aimed at reducing overall alcohol consumption, not 9ust at promoting abstinence among vulnerable individuals. #he report described the alcohol dependence syndrome itself as a learned phenomenon, not a disease state, -hich is either present or absent, but "a condition -hich e.ists in degrees of severity." 4t is important to recogni6e that this syndrome perspective does not ta2e a position on -hether alcoholism should be considered a disease. #he concept of dependence as a syndrome is @uite similar to that put for-ard in &=(I by drug abuse researcher Gerome Gaffe, -ho vie-ed addiction as standing at one end of a continuum of involvement in drug use+ "4n most instances it -ill not be possible to state

-ith precision at -hat point >along the continuum? compulsive use should be considered addiction," Gaffe observed. 1e emphasi6ed that "the term addiction cannot be used interchangeably -ith physical dependence. 4t is possible to be physically dependent on drugs -ithout being addicted andH to be addicted -ithout being physically dependent." 4n this vie-, the behavioral disorder, not physical dependence, is the syndrome. Gaffe defined addiction as "a behavioral pattern of drug use characteri!ed by over"helming involvement "ith the use of a drug #compulsive use$ the securing of its supply and a high tendency to relapse after "ithdra"al." #his proposed generic notion of dependence is applicable to 5#4":/A'#5 and 1A//:C4'0$E'5 7for -hich physical dependence is not a significant factor8, as -ell as to alcohol, opiates, and 5EDA#4CE 1DA'0#4C drugs 7for -hich physical dependence is a factor8. #he Diagnostic and Statistical Manual of Mental Disorders, )rd edition, revised 7D5" 444 R8, published by the American Asychiatric Association more than t-enty years later, in &=;K, also used such a generic definition.

FROM PSYCHIC AND PHYSICAL DEPENDENCE TO DEPENDENCE SYNDROME

#he changing perspectives on the general concept of drug dependence, given momentum by the &=KK !10 report on alcohol and by other research, -ere ultimately reflected in changes in the definitions and other positions of the !orld 1ealth 0rgani6ation and in its &=;%International Classification of Diseases, =th edition 74CD =8. !ith its publication, the concept of an alcohol dependence syndrome formally emerged at an international level. #he 4CD = concept of dependence -as based on a &=K( proposal by researchers $riffith Ed-ards and "ilton $ross, -ho defined seven characteristics of the alcohol dependence syndrome and proposed that there are certain implicit assumptions to the syndrome+ *irst, it is a symptom comple. involving both biological processes and learning. 5econd, it should be defined along a continuum of severity, rather than as a discrete category. #hird, dependence should be differentiated from alcohol related disabilities. Both dependence and disabilities e.ist in degrees, rather than on an allor none basis. #here is some evidence that people -ith more severe degrees of alcohol dependence -ho see2 treatment have a different clinical course from those -ith less severe dependence. By the late &=K%s, the American Asychiatric AssociationBs Diagnostic and Statistical Manual, )rd edition 7D5" 4448, moved a-ay from more descriptive and psychodynamic orientation to-ard a nomenclature in -hich specific diagnostic criteria -ere laid out for specific syndromes. 4n the case of alcohol and drug dependence, the original drafts of D5" 444 considered inclusion of a dependence syndrome that varied in degree of severity and in

-hich tolerance and physical dependence -ere important, but not essential, criteria for diagnosis. At the last moment, ho-ever, it -as decided that tolerance and physical dependence -ere both necessary and sufficient for a diagnosis of drug dependence3 the presence of other criteria listed -ere by themselves insufficient -ithout tolerance and physical dependence. 'evertheless, by distinguishing drug 7or alcohol8 dependence from drug 7or alcohol8 abuse, D5" 444 recogni6ed the t-o dimensional conceptuali6ation previously put forth in the !10 report of &=KK and in 4CD =. 4n &=;%, during the short interval bet-een the publication of D5" 444 and the beginning of -or2 on D5" 444 R, a !10 -or2ing group met to further refine terminology. 0ne result of the meeting -as the publication of a !10 memorandum on nomenclature and classification of drug and alcohol related problems that endorsed the concept that drug dependence is a syndrome that e.ists in degrees and that can be inferred from the -ay in -hich drug use ta2es priority over a drug userBs once held CA/:E5. #he criteria for ma2ing this inference included many of those mentioned by Ed-ards and $ross in their &=K( paper and some that had been developed for D5" 444. #he !10 memorandum, -hile recogni6ing the importance of tolerance and physical dependence, did not vie- these phenomena as al-ays essential and re@uired. 4t endorsed again the t-o dimensional perspectiveEnot all drug or alcohol problems are manifestations of dependence3 and harmful or ha6ardous use can occur independently of the decreased fle.ibility and constricted choice that are the hallmar2s of the dependence syndrome. #his perspective -as underscored by pointing out that the presence of physical dependence per se 7as in the case of patients ta2ing drugs for pain8 -as not in itself sufficient for the diagnosis of dependence. #he memorandum also presented a model of dependence emphasi6ing that the dependence phenomenon is not a property of the individual but resides in the relationships among the elements in the model Esocial, psychological, and biological. #his vie- has been called the biopsychosocial model.

CRITERIA FOR DIAGNOSIS OF A GENERIC DEPENDENCE DISORDER

#he American Asychiatric AssociationBs D5" 444 R, published in &=;K, built on both D5" 444 and the !10 memorandum. 4t presented nine criteria for diagnosing a generic dependence syndrome, applied to a -ide variety of drugs. #he user must have e.perienced at least three criteria in order for the practitioner to consider any degree of dependence to be present. 'either tolerance nor physical dependence -as a re@uired criterion. #he presence of more than three criteria -ould indicate a more severe degree of dependence. Drug

abuse -as a residual category used for designating drug related problems -hen dependence -as not present. #he D5" 444 R conceptuali6ation of dependence -as controversial. Because for many years physical dependence and tolerance had been considered evidence of "true disease," many clinicians believed that changing these criteria from the necessary and re@uired status they had had in D5" 444 -as a mista2e that erroneously broadened the category of drug dependence. "uch of the focus in the development of D5" 4C, published in &==<, -as on ho- to restore the primacy of these phenomena in the diagnosis of drug and alcohol dependence. D5" 4C defines seven generic criteria for alcohol and other drug dependence. #hree are re@uired for a diagnosis of alcohol or other drug dependence. Although tolerance and -ithdra-al are listed first, they are not re@uiredEbut the clinician must specify -hether either is present. Despite these concerns, there -as little argument about the importance of psychological and sociological factors in the development and perpetuation of the syndromeEthat is, there -as still consensus about the biopsychosocial model. At the same time, at the international level, the framers of 4CD &% continued the evolution begun in 4CD = and adhered closely to the concepts of dependence outlined in the &=KK !10 report and &=;& !10 memorandum. Aublished in &==2, 4CD &% includes a generic model of drug dependence -ith similar criteria for alcohol, tobacco, opioids, and other drugs that affect the brain. /i2e D5" 4C, 4CD &% presents a number of criteria 7si.8 for determining the presence of the alcohol 7or drug8 dependence syndrome3 at least three of these must be present for the clinician to 9udge that the syndrome e.ists to some degree. 4CD &% does not include a diagnostic category of alcohol or drug abuse but instead includes a category of harmful useEa pattern of use that is causing damage to mental or physical health. :nli2e D5" 4C, -hich defines drug or alcohol 7substance8 abuse as "a maladaptive pattern of use" causing significant impairment or distress and interpersonal, family, and legal problems 7e.g., arrests8, 4CD &% does not consider such patterns of use and conse@uences necessarily to be evidence of harmful use. 4CD &% and D5" 4C share important characteristics that represent a further evolution in understanding drug and alcohol dependence syndromes. 4n contrast to some disease oriented defintions that see alcoholism as uniformly progressive, in 4CD &% and D5" 4C the course of the disorder is not one of uniform progression or predictable cure, but there are a

variety of significant states of remission. *or e.ample, D5" 4C distinguishes early remission 7-ithin the first &2 months8 from sustained remission 7at least &2 months83 -ithin each of these it differentiates full remission from partial remission 7i.e., all criteria for dependence have not been met, although at least one has been met intermittently or continuously8. D5" 4C also recogni6es the circumstances supporting remission and allo-s for distinctions such as remission -hile the user is in a controlled environment 7-here substances are highly restricted8 or remission from drug of dependence -hen the user is maintained on a similar agonist. #he categori6ation of states of remission 7abstinence8 in 4CD &% is some-hat similar, although the distinction bet-een early and sustained remission is not made.

CHALLENGES TO THE DISEASE CONCEPT

#he classic disease model of alcoholism and drug dependence has served as a challenge to some behavioral researchers and social scientists3 they have raised a number of @uestions about biologically based theories of such behaviors. Critics of the disease concept point to studies sho-ing that some former alcoholics could apparently return to normal drin2ing. 5uch findings challenged the concept of alcoholism as a progressive disease. #he concept of inevitable "loss of control" over drin2ing -as also challenged by "erryBs study 7&=((8 in -hich alcoholics -ere given drin2s containing either vod2a or a placebo 7no alcohol8 on alternate days and reported having no more desire to drin2 after consuming the vod2a than after the placebo. #he results suggested that if "loss of control" did occur in alcoholics, it -as not triggered as a biological response to alcohol but rather as a learned response -ith associated ELAEC#A'C4E5 concerning drin2ing behavior. Researchers 'ancy "ello and Gac2 "endelson also reported, in &=K&, that alcoholics did not manifest "loss of control" in their drin2ing behavior and did not drin2 to avoid -ithdra-al symptoms. #he -or2 of "ello and "endelson and of other researchers led to the conclusion that drin2ing behavior could be shaped li2e any other operant in a behavioral paradigm. 0ther researchers challenged the notion of alcoholism as a distinct entity 7-ith clear differentiations bet-een alcoholics and nonalcoholics8, as -ell as the concepts of inevitable progression to loss of control and of alcoholism as a permanent and irreversible condition precluding the possibility of moderate drin2ing. 7*or these and other references, see "eyer, &==2.8 #hese findings by behavioral researchers in the laboratory had counterparts in large surveys of drin2ing practices conducted by the RA'D Corporation. Evidence in the general

population indicated that some alcoholics might be able to drin2 moderately -ithout relapsing to e.cessive drin2ing. #hese and other such challenges to the disease concept of alcoholism sharpened the debate and clarified the construct. Efforts to replicate some of these earlier studies sometimes led to conflicting results, calling into @uestion the conclusions they had dra-n or leading to refinements. RA'D Corporation found at later follo- up that severely dependent alcoholics had to remain abstinent in order to maintain improvement. 5everal studies appeared to confirm that severely dependent alcoholics might be different from those -ho -ere less dependent. 5ome researchers, such as 1odgson, reported that small doses of alcohol had a "priming" effect 7i.e., stimulated a strong urge to drin2 more8, the magnitude of -hich correlated -ith the severity of alcohol dependence. 0ther researchers critici6ed the methodology used in previous studies. 7*or references, see "eyer, &==2.8 #hese findings help to e.plain -hy, beginning in the late &=K%s, the classic disease concept -as being ree.amined and redefined as a symptom comple. called "dependence" or "dependence syndrome." 1o-ever, this shift has not satisfied some critics -ho ob9ect to any conceptuali6ation that comes close to vie-ing compulsive alcohol or other drug use as a disease or disorder. #he debate over the disease concept continues to be more heated in the alcohol field than in other areas of addictive disorders, such as compulsive use of opioids. 4n the early &==%s, ho-ever, an analogous and e@ually heated debate has developed about the conceptuali6ation of tobacco smo2ing. !hile health professionals throughout the -orld no- generally agree that some forms of drug and alcohol use should be seen as disorders 7at least for record 2eeping and some public policy purposes8, dissent from this vie- persists. #he most compelling arguments against the disease concept have come from social and behavioral scientists. #his may be partly because behavioral clinicians tend to -or2 -ith less seriously impaired individuals, -hile physicians usually deal -ith people -hose dependence has become more severe3 and also because the physicianBs primary care office may be -here early identification of substance abuse problems and effective behavioral interventions is most li2ely to ta2e place.

ALTERNATIVE MODELS
5-edish researcher /ars /indstrMmBs summary of current perspectives on the nature of alcoholism is e@ually applicable to the divergent vie-s about other forms of e.cessive

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and,or compulsive drug use. Each of these models attempts to e.plain -hy people use alcohol or drugs, -hy use escalates to e.cessive and,or harmful levels, -hy some people continue drug use despite the harmful conse@uences, ho- and -hy they stop using drugs, and -hy they relapse after a period of abstinence. #he perspectives include the moral model, -hich holds that individuals have choice and are accountable for their behavior3 the disease model 7both the classic and its variants83 the symptomatic model, -hich vie-s e.cessive drug or alcohol use as a symptom of underlying psychiatric disorder3 the learning model 7drug addiction and alcoholism are learned behaviors83 the social model, -hich emphasi6es the primacy of environmental factors, such as availability, social controls, interpersonal relationships3 and thebiopsychosocial model, -hich attempts 7in several variants8 to synthesi6e elements of other models, ta2ing into account biology, vulnerability, psychopathology, and cultural, social, economic, and pharmacological factors. #he dependence syndrome model is probably best vie-ed as a variant of the biopsychosocial model. /indstrMm points out that these models are no- rarely encountered in pure form+ each commonly incorporates elements from other perspectives. *urthermore, proponents of a particular model may, in practice, give greater emphasis to the central features of another. *or e.ample, A/C010/4C5 A'0'D"0:5 7AA8 generally espouses the disease model. Det because AA holds people accountable for the conse@uences of their drug use and emphasi6es the central role of spiritual alienation in the perpetuation of alcoholism, AABs approach may also be seen as a variant of the moral model. Although the term disease concept is often used synonymously -ith biological or medical model, these terms do not al-ays convey the same ideas, especially -ith respect to implications for treatment. *or e.ample, the medical model of treatment is fre@uently contrasted -ith the social or social recovery model, no- -idely used and advocated in California. "edical model programs are generally characteri6ed not only by a philosophy about the problem but also by hospital based deto.ification, often pharmacologically assisted, and outpatient components in -hich there are formal treatment plans. Attention is paid to careful record 2eeping and professional credentials of the treatment staff. Ahysicians retain medical and legal responsibility for the overall program. 4n contrast, social model recovery programs re9ect the involvement of professional staff and many of the activities of the medical model, such as the data gathering, licensing, and record 2eeping that lin2 funding to units of service for specific patients. 4nstead, these programs emphasi6e the e.perience and 2no-ledge that staff derive from the recovery process built on #!E/CE

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5#EA mutual help principles. #here are no patientsEonly participantsEand the role of staff is to manage the environment. Det social models, in emphasi6ing the critical role that people "in recovery" play in the helping process, are employing a termErecoveryEthat is itself derived from the classic disease concept, -hich vie-s alcoholism as a permanent disease state for -hich the only cure is total abstinence and the t-elve step AA program as the best route to such abstinence.

PERSISTENCE OF THE MORAL PERSPECTIVE

Despite the preponderance of medical opinion that some drug and alcohol users have a disorderEa diminished capacity to choose freely -hether or not to use a particular substanceEthe moral models retain some vitality. 4n &;;2, -hen the disease concept -as first gaining momentum, the Reverend G. E. #odd -rote an essay entitled "Drun2enness a Cice, 'ot a Disease." 4n the late &=;%s, the disease concept critics *ingarette and Aeele put forth almost precisely the same thesis. Aeele has argued that the disease concept e.culpates the individual from responsibility, runs counter to scientific facts, and is perpetuated for the benefit of the treatment industry. 1o-ever, his thesis has been critici6ed for using the classic disease model as a "stra- man" because it does not ta2e into account the more recent adoption of the bio psychosocial model. 5ome sociologists in the :nited 5tates have noted that the term alcoholic is still commonly used as a synonym for drunkard rather than as a designation for someone -ith an illness or disorder. #he -ord addict is similarly used in a pe9orative -ay, even -hen it is used more loosely to refer to a -ide range of relatively benign behaviors, such as running or -atching television. 4n the minds of most people, the concept of alcoholism or drug addiction as a disorder or disease can coe.ist @uite comfortably -ith the concept of drun2enness or drug use as a vice. 5ince the nature of drug dependence is so closely lin2ed to @uestions about the nature of free -ill and human volitionEissues that have fascinated philosophers and scientists through the agesEit is li2ely that the disease concept of addiction -ill continue to be debated for a long time to come. 75EE A/50+ %ddiction& Concepts and Definitions 3 %lcoholism3 Causes of Substance %buse3Tolerance and Physical Dependence3 Treatment 'istory of in the (nited States8

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$RA'#, B. *., N #0!/E, /. 1. 7&==&8. A comparison of diagnostic criteria+ DSM-III-5, proposedDSM-I6, and proposed ICD-+,7 %lcohol 'ealth and 5esearch -orld +27<8, 2;< 2=2. 10D$50', R., E# A/. 7&=K=8. Alcohol dependence and the priming effect. *ehavioral 5esearch Therapy +8, )K= );K. GA**E, G. 1. 7&==28. Current concepts of addiction. 4n C. A. 0BBrien N G. 1. Gaffe 7Eds.8,%ddictive states. 'e- Dor2+ Raven Aress. GA**E, G. 1. 7&=(I8. Drug addiction and drug abuse. 4n /. 5. $oodman N A. $ilman 7Eds.8, The pharmacological basis of therapeutics , )rd ed. 'e- Dor2+ "acmillan. GE//4'EO, E. ". 7&=(%8. The disease concept of alcoholism. 'e- Bruns-ic2, 'G+ 1illhouse Aress. OE//ER, "., N D0R4A, G. 7&==&8. 0n defining alcoholism. %lcohol 'ealth and 5esearch -orld +27<8, 2I) 2I=. /4'D5#RP", /. 7&==28. Managing alcoholism. 'e- Dor2+ 0.ford :niversity Aress. "E//0, '.O., N "E'DE/50', G. 1. 7&=K&8. Drin2ing patterns during -or2+ Contingent and noncontingent alcohol ac@uisition. 4n Aublic 1ealth 5ervice 15" K&=%<I, 5ecent advances in alcoholism. !ashington, DC+ :.5. $overnment Arinting 0ffice. "ERRD, G. 7&=((8. #he loss of control myth. 9ancet +, &2IK &2I;. "EDER, R. 7&==28. #he concept of disease in alcoholism and drug addiction. 4n Drugs and alcohol against life 7Dolentium hominum, no. &=8. Catican City+ Catican Aress. AEE/E, 5. 7&=;=8. Diseasing of %merica. Boston+ 1oughton "ifflin. R00", R. 7&=;)8. 5ociology and the disease concept of alcoholism. 4n R. $. 5mart et al. 7Eds.8, 5esearch advances in alcohol and drug problems, vol. K. 'e- Dor2+ Alenum. 5C1:CO4#, ". 5., E# A/. 7&==&8. Evolution of the DSM diagnostic criteria for alcoholism.%lcohol 'ealth and 5esearch -orld +27<8, 2K; 2;).

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!4O/ER, A. 7&=;%8. .pioid dependence& Mechanisms and treatment. 'e- Dor2+ Alenum. !0R/D 1EA/#1 0R$A'4JA#40'. 7&==28. The ICD-+, classification of mental and behavioural disorders& Clinical descriptions and diagnostic guidelines . $eneva+ Author. !0R/D 1EA/#1 0R$A'4JA#40'. 7&=K;8. Mental disorders& 3lossary and guide to their classification #in accordance "ith :th revision of the International Classification of Diseases$ . $eneva+ Author. GER0"E 1. GA**E R0$ER E. "EDER

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15 The Controlled Drinking Debates: A Review of Four Decades of Acrimony b$ %!oo& He!se$, Ps$ ' , A(!il 2001 - )"ail* b he!se$+,e!i-on net
%!oo& He!se$ ea!ned he! Ps$ ' .!o" /ut0e!s 1ni,e!sit$ 2!aduate 3chool o. A((lied and P!o.essional 4linical Ps$cholo0$ in 2004

5555555555555555555555555555555555555555555555555555555555555555555555555555 5 67his a!ticle was w!itten a.te! a t!a0ic "oto! ,ehicle accident in,ol,in0 Aud!e$ 8ishline Aud!e$ 8ishline, the .ounde! o. 9ode!ation 9ana0e"ent 699:, a non-abstinence o!iented sel.-hel( 0!ou( .o! indi,iduals whose alcohol (!oble"s sto( sho!t o. de(endence, &illed two (eo(le in a head-on ,ehicula! collision Aud!e$ had !eco0ni-ed that he! d!in&in0 was 0ettin0 out o. hand and she be0an attendin0 Alcoholics Anon$"ous, (!io! to the accident 7he accident see"ed to (oint to .act that "ode!ation in d!in&in0 is not a sa.e alte!nati,e .o! an$one who has had a (!oble" with alcohol ;the!s "i0ht a!0ue that Aud!e$ was not a 0ood candidate .o! "ode!ation but the!e a!e othe!s who would bene.it .!o" "ode!ation !athe! than abstinence '! He!se$ atte"(ts to loo& at the histo!$ o. the cont!olled d!in&in0 cont!o,e!s$ 7he a!ticle was not !e(!oduced in its enti!et$ : <"ost co""entato!s 6/oi-en, 1987, /osenbe!0, 1993: date the be0innin0 o. the cont!olled d!in&in0 cont!o,e!s$ to the (ublication 6in 1962: o. a (a(e! entitled =>o!"al '!in&in0 in /eco,e!ed Alcohol Addicts = ?n this (a(e!, ' @ 'a,ies, a %!itish (s$chiat!ist, !e(o!ts that, in the cou!se o. lon0-te!" .ollow-u( o. (atients t!eated .o! =alcohol addiction= at 9audsle$ Hos(ital in @ondon, 7 o. the 93 (atients in,esti0ated =ha,e subseAuentl$ been able to d!in& no!"all$ .o! (e!iods o. 7 to 11 $ea!s a.te! discha!0e .!o" the hos(ital = 6'a,ies, 1962, ( 94: The years after Davies ?n the 1960s and 1970s, (s$cholo0ists be0an to subBect the (!e"ises o. the disease "odel to scienti.ic sc!utin$, and to use eC(e!i"ental "ethods to assess t!eat"ent outco"e As 9a!latt 61983: and 9ille! 61986: !e,iew, a nu"be! o. eC(e!i"ente!s tested the (!e"ise that alcohol ine,itabl$ (!eci(itates loss-o.-cont!ol d!in&in0, and .ound that alcoholicsD belie.s about whethe! o! not the$ a!e consu"in0 alcohol a..ect consu"(tion Also, ,a!$in0 schedules o. !ein.o!ce"ent (!oduced di..e!ent d!in&in0 (atte!ns, a!0uin0 a0ainst the notion that all alcoholics eC(e!ience total loss o. cont!ol 9a!latt 61983: !ecalls that this (e!iod was one o. =ad,entu!ous eCcite"ent= as beha,io!all$ o!iented (s$cholo0ists be0an to a((l$ (!inci(les o. lea!nin0 theo!$ to a wide !an0e o. se,e!e diso!de!s ?ncluded in these e..o!ts we!e (!otocols desi0ned to t!ain

16 de(endent d!in&e!s to d!in& in a cont!olled .ashion @o,ibond and 4add$, two Aust!alian (s$cholo0ists, (ublished a (!o"isin0 !e(o!t on this as ea!l$ as 1970 7o !ead 3obell and 3obellDs account o. thei! eC(e!i"ents at Patton 3tate Hos(ital in the 1970s is also to 0et a st!on0 sense o. the a"bition and sco(e o. this beha,io!al wo!& 7he t!eat"ent unit included a si"ulated ba! and coc&tail loun0e, set u( so subBects could both be ,ideota(ed while d!in&in0, and also eAui((ed with elect!ic shoc& eAui("ent .o! a,e!si,e conditionin0* =7he si"ulated ba! en,i!on"ent < !e.lected an atte"(t to st!uctu!e the !esea!ch en,i!on"ent to (!o"ote inc!eased 0ene!ali-ation o. t!eat"ent e..ects to the subBectsD usual d!in&in0 en,i!on"ent = 63obell and 3obell, 1978, ( 50: Ehile the 3obellsD eC(e!i"ental wo!& that was to 0ene!ate such cont!o,e!s$ be0an in 1970, ? will hold o.. on !e(o!tin0 it because the u(!oa! it e,o&ed did not ta&e (lace until the ea!l$ 1980s The Rand Report ?n the 1970s, the >ational ?nstitute on Alcoholis" and Alcohol Abuse 6>?AAA: established a netwo!& o. t!eat"ent cente!s a!ound the 1nited 3tates, which included a "onito!in0 s$ste" to collect data on clients se!,ed 6Polich, A!"o! and %!ai&e!, 1981: 7he /and 4o!(o!ation assu"ed !es(onsibilit$ .o! e,aluatin0 the e..icac$ o. the t!eat"ent o..e!ed, and the so-called /and /e(o!t, (ublished in 1976, loo&ed at 18-"onth .ollow-u( data on a sa"(le o. (atients t!eated at 44 t!eat"ent cente!s ?n su""a!i-in0 conclusions, the autho!s w!ote* F?Gt is i"(o!tant to st!ess that the i"(!o,ed clients include onl$ a !elati,el$ s"all nu"be! who a!e lon0-te!" abstaine!s<7he "aBo!it$ o. i"(!o,ed clients a!e eithe! d!in&in0 "ode!ate a"ounts o. alcoholHbut at le,els .a! below what could be desc!ibed as alcoholic d!in&in0Ho! en0a0in0 in alte!natin0 (e!iods o. d!in&in0 and abstention = 6A!"o!, Polich and 3ta"bul, 1976, ( ,: 3(eci.icall$, the autho!s .ound that 22 (e!cent o. t!eated indi,iduals we!e =no!"al d!in&e!s= at 18-"onth .ollow-u(, with low-to-"ode!ate le,els o. d!in&in0 and little o! no s$"(to"atolo0$ 7he (ublication o. this !e(o!t was the occasion .o! !enewed debate and cont!o,e!s$ 7he

17 >ational 4ouncil on Alcoholis" denounced the !e(o!t on the "o!nin0 it was !eleased, desc!ibin0 it as =dan0e!ous = 6Peele, 1983: Acco!din0 to /oi-en 61987:, the debate eCtended be$ond the scienti.ic lite!atu!e to the (o(ula! (!ess, with "ost accounts and edito!ials e"(hasi-in0 the i"(o!tance o. abstinence Ehile the !e(o!t was c!itici-ed b$ so"e on "ethodolo0ical 0!ounds, anothe! "aBo! .ocus o. c!iticis" a!0ued that =the !esea!ch was Ii"(e!sonalD o! IstatisticalD o! that a wide 0a( se(a!ated the /and autho!s .!o" actual alcoholis" (atients o! that the autho!s lac&ed (e!sonal eC(e!ience and contact with the .ield = 6/oi-en, 1987, ( 262: ?n othe! wo!ds, the le0iti"ac$ o. usin0 a scienti.ic a((!oach was Auestioned, and the (otential dan0e!ousness o. such Auestionabl$ de!i,ed =&nowled0e= was a!0ued to be a !eason that this &nowled0e should not be disse"inated A late! !e(o!t, which included data on the 4-$ea! .ollow-u( o. t!eated (atients and which atte"(ted to add!ess "ethodolo0ical c!iticis"s o. the ea!lie! !e(o!t, showed that a si"ila! (e!centa0e o. (atients we!e de"onst!atin0 non-(!oble"atic d!in&in0 6Polich et al , 1981:, althou0h the autho!s cautioned a0ainst the conclusion that the sa"e (atients who we!e stable at 18 "onths we!e stable at 4 $ea!s Ehat beca"e e,ident o,e! the cou!se o. the lon0e! .ollow-u( was the eCtent to which indi,idual (atientsD d!in&in0 statuses .luctuated* =Ehen we eCa"ined lon0e! ti"e (e!iods and "ulti(le (oints in ti"e, we .ound a 0!eat deal o. chan0e in indi,idual status, with so"e (e!sons continuin0 to i"(!o,e, so"e (e!sons dete!io!atin0, and "ost "o,in0 bac& and .o!th between !elati,el$ i"(!o,ed and uni"(!o,ed statuses = 6Polich et al , 1981, ( 214: As was the case with the 'a,ies (a(e!, these .indin0s occu!!ed .ollowin0 t!eat"ent that was .ocused on abstinence Howe,e!, the ,e!$ .act that the /and autho!s we!e willin0 to !eco0ni-e success in the (!esence o. an$ d!in&in0 at all was cont!o,e!sial /oi-en notes that while the 'a,ies cont!o,e!s$ .ocused on whethe! o! not =no!"al d!in&in0= was e,e! an outco"e .o! addicted d!in&e!s, =/and autho!s a!0ued that (a!ticula!l$ lon0-te!" abstinence was too in.!eAuent to "a&e it the sole .ocus and "easu!e o. success.ul t!eat"ent = 6/oi-en, 1987, ( 262: 3o whe!e eCactl$ a!e the battle lines d!awn he!eJ 7he su((osed (!o(onents o. cont!olled d!in&in0 we!e not sa$in0 that it should be ad,ocated o! tau0ht, but that un(!oble"atic

18 d!in&in0 was obse!,ed in the a.te!"ath o. abstinence-o!iented t!eat"ent, and that indi,iduals could be Bud0ed to be i"(!o,ed without bein0 abstinent ;((onents o. cont!olled d!in&in0 a((ea! to ha,e .ocused on the (otential dan0e! o. these .indin0s .o! alcoholics 7hei! tactics included e..o!ts to disc!edit the /and autho!sD "ethodolo0$, but also to atte"(t to "ini"i-e (utati,e dan0e! to alcoholics b$ a!0uin0 thei! (!o-abstinence case in the (ublic a!ena The Sobell and Sobell controversy ?n the ea!l$ 1970s, (s$cholo0ists 9a!& and @inda 3obell set out to !esea!ch a .o!" o. =indi,iduali-ed beha,io! the!a($= .o! alcoholis" ;ne t!eat"ent "odule tested was ai"ed at t!ainin0 alcohol-de(endent subBects to d!in& in a =cont!olled= .ashion 63obell and 3obell, 1973, 1978: 3ubBects we!e 70 "ale (atients, ,olunta!il$ ad"itted to Patton 3tate Hos(ital in 4ali.o!nia, who we!e classi.ied as "eetin0 c!ite!ia .o! Kelline&Ds 0a""a-t$(e alcoholics 6=loss o. cont!ol= d!in&e!s: A.te! subBects we!e acce(ted .o! (a!tici(ation in the stud$, the$ we!e assi0ned to eithe! a cont!olled d!in&in0 64': o! an abstinence-0oal condition 7his (a!t o. the stud$ did not e"(lo$ !ando" assi0n"entL !athe! the assi0n"ent was "ade b$ the !esea!ch sta.., based on both the (atientDs stated wishes and 0oals, and cha!acte!istics o. the subBect, his d!in&in0 histo!$, and the stabilit$ o. his en,i!on"ent A.te! this initial assi0n"ent, subBects we!e then !ando"l$ assi0ned to a beha,io!al t!eat"ent condition, o! to a cont!ol condition o. t!eat"ent as usual 6which was, o. cou!se, abstinence-o!iented: %oth eC(e!i"ental 0!ou(s 64' and abstinence-0oal: !ecei,ed 17 sessions o. beha,io!al t!eat"ent 6includin0 t!ainin0 in (!oble" sol,in0 and a,e!si,e conditionin0 with elect!ical shoc&s:, but the 4' subBects we!e also t!ained in d!in&in0 s&ills o!iented towa!ds non(!oble"atic d!in&in0 Mollow-u( was eCtensi,e, and collate!al sou!ces we!e used in addition to (atient sel.-!e(o!t Ehile the autho!s collected a wide !an0e o. outco"e data, the$ used the nu"be! o. =da$s .unctionin0 well= as a (!i"a!$ outco"e "easu!e ?ndi,iduals in the 4'-eC(e!i"ental 64'-): condition had si0ni.icantl$ "o!e =da$s .unctionin0 well= du!in0 a two $ea! .ollow-u( (e!iod than thei! counte!(a!ts in the 4'-cont!ol 6i e t!eat"ent as usual ai"ed at abstinence: condition 63obell & 3obell, 1978, 1973:

19 ?n the 'a,ies and /and !e(o!ts, =cont!olled d!in&in0= was used to desc!ibe a non(!oble"atic le,el o. d!in&in0, but this was not an outco"e that had been sou0ht b$ t!eat"ent %$ cont!ast, the 3obellsD wo!& in,ol,ed the t!ans"ission o. s(eci.ic s&ills and techniAues to indi,iduals with se!ious and endu!in0 alcohol (!oble"s 67his stud$ does not 0et at the inte!estin0 Auestion o. whethe! eC(licitl$ 4' .ocused t!eat"ent is a ,aluable addition to a beha,io!al (!o0!a"* 7he lac& o. !ando" assi0n"ent to 4' o! abstinence 0oals (!ecludes us .!o" d!awin0 conclusions about !elati,e e..icac$ : ?n 1982, Pende!$, 9alt-"an and Eest (ublished an a!ticle in the Bou!nal 3cience entitled =4ont!olled '!in&in0 b$ AlcoholicsJ >ew Mindin0s and a /ee,aluation o. a 9aBo! A..i!"ati,e 3tud$ = 7his !e(o!t, based on a ten $ea! .ollow-u( with subBects o. the 3obell and 3obell stud$, states that =a !e,iew o. the e,idence, includin0 o..icial !eco!ds and new inte!,iews, !e,eals that "ost subBects t!ained to do cont!olled d!in&in0 .ailed .!o" the outset to d!in& sa.el$ = 6( 169: 7en $ea!s out, onl$ one subBect .!o" the 4'-) condition was "aintainin0 a (atte!n o. cont!olled d!in&in0 )i0ht subBects we!e .ound to be d!in&in0 eCcessi,el$, siC we!e abstinent, one was lost to .ollowu(, and .ou! we!e dead 4e!tainl$, in !eadin0 Pende!$ et al Ds a!ticle, one 0ets the i"(!ession o. subBects who a!e doin0 ,e!$ (oo!l$ indeed Howe,e!, the Pende!$ !e(o!t is se,e!el$ co"(!o"ised on se,e!al sco!es, "ost i"(o!tantl$ b$ the .act that it (!o,ides data .o! the eC(e!i"ental 0!ou( but not the cont!ol 0!ou( 7hese autho!s atte"(t to Busti.$ this choice in a state"ent that see"s to clea!l$ de"onst!ate thei! bias* =we a!e add!essin0 the Auestion o. whethe! cont!olled d!in&in0 is itsel. a desi!able t!eat"ent 0oal, not the Auestion o. whethe! the (atients di!ected towa!ds that 0oal .a!ed bette! o! wo!se than a cont!ol 0!ou( that all a0!ee .a!ed badl$ = 6Pende!$ et al , 1982, 172-173: Althou0h the 3cience (a(e! too& !elati,el$ "easu!ed tones in (!esentin0 what it stated was disc!e(ant data, outside the !a!i.ied !eal" o. the scienti.ic Bou!nal, the autho!s too& a less neut!al stance 7he$ ci!culated a "o!e in.la""ato!$ (a(e! to the !esea!ch co""unit$ 6/oi-en, 1987: 9alt-"an was Auoted in 7he >ew No!& 7i"es as statin0, =%e$ond an$ !easonable doubt itDs .!aud = 6%o..e$, 1982, Auoted in 9a!latt, 1983, ( 1098: 9a!latt 61983: also desc!ibes a 1983 edition o. 60 9inutes which c!itici-ed the

20 3obells, and which included .oota0e o. co!!es(ondent Ha!!$ /easone! ,isitin0 the 0!a,e o. one o. the (atients in the cont!olled d!in&in0 condition 9a!latt also notes that one o. the (atients .!o" the 4' condition .o!"ed an o!0ani-ation called =the Alcoholis" 7!uth 4o""ittee,= ai"ed at disse"inatin0 the =t!uth= about the 3obellsD stud$ b$ atte"(tin0 to ha,e desc!i(tions o. thei! wo!& o"itted .!o" teCtboo&s and elsewhe!e 3e,e!al in,esti0ations o. the inte0!it$ o. the 3obellsD wo!& .ollowed 7he 3obells as&ed thei! e"(lo$e!s, the Addiction /esea!ch Moundation, to a((oint a co""ittee to in,esti0ate thei! !esea!ch %ecause so"e o. the 3obellsD !esea!ch was 0!ant-.unded, a subco""ittee o. the 4o""ittee on 3cience and 7echnolo0$ o. the House o. /e(!esentati,es, and a .ede!al (anel also !e,iewed the 3obellsD data All these in,esti0ations eCone!ated the 3obells 6/oi-en, 1987: Acco!din0 to 9a!latt et al 61993:, while the!e was eCtensi,e "edia co,e!a0e c!itical o. the 3obells, the!e was little "edia co,e!a0e o. the eCone!atin0 ,e!dicts, lea,in0 the (ublic with the i"(!ession that the 3obellsD wo!& had been not onl$ .lawed but .!audulent, and that cont!olled d!in&in0 was a "is0uided and (otentiall$ deadl$ t!eat"ent 0oal Reframing the debate 7he /and and 3obell and 3obell cont!o,e!sies had a chillin0 e..ect on (s$cholo0ists and !esea!che!s ?n 1984, Peele w!ote 6( 1342:* =7oda$ no clinician in the 1nited 3tates (ublicl$ s(ea&s about the o(tion o. cont!olled d!in&in0 .o! the alcoholic = 7wo $ea!s late!, 9ille! 61986, ( 117: w!ote* =A"e!ican (!o.essionals who ad,ocate an$ alte!nati,e to abstinence a!e li&el$ to be 6and ha,e been: attac&ed as naO,e .ools, "is0uided intellectuals sadl$ "isin.o!"ed about the I!ealit$D o. alcoholis", unwittin0 "u!de!e!s, o! (e!ha(s the"sel,es alcoholics den$in0 thei! own disease = 9ille! 61986, ( 118: also contends that 1 3 !esea!che!s ha,e .ound it ha!d to obtain .undin0 .o! cont!olled d!in&in0 studies, =and the cont!o,e!s$ !e0a!din0 the 3obell and 3obell stud$ 6Pende!$ et al , 1982: is li&el$ to discou!a0e .utu!e 1 3 !esea!ch on this to(ic .o! so"e ti"e to co"e = %ut i. !esea!che!s ha,e "o,ed awa$ .!o" tal&in0 about cont!olled d!in&in0 as a 0oal o. choice .o! alcohol de(endent clients, two se"antic and conce(tual shi.tsHalluded to in

21 the 1995 3obell and 3obell edito!ial discussed abo,eHha,e (e!"itted continued in,esti0ations o. t!eat"ents that a!e not sin0ula!l$ .ocused on abstinence 7he conce(t o. =ha!" !eduction= has been e,o&ed to su00est that, 0i,en that so"e se,e!el$ de(endent indi,iduals "i0ht be unable o! unwillin0 to abstain, it was a((!o(!iate to t!$ to "ini"i-e the ha!" caused b$ thei! continued d!in&in0 3econdl$, the inc!eased awa!eness o. a la!0e (o(ulation o. (!oble" d!in&e!s whose alcohol use does not "eet c!ite!ia .o! de(endence has led to a .ocus on inte!,entions ai"ed at !eduction !athe! than eli"ination o. alcohol use Eith this conce(tual !e.!a"in0 co"es a te!"inolo0ical shi.t as ,a!ious autho!s "ade the choice to "o,e towa!ds less contentious lan0ua0e ?n 1987, 9a!latt 6( 168: noted that use o. the te!" =cont!olled d!in&in0= =is a !ed .la0 that sends the bull cha!0in0 in the di!ection o. beha,io!ists = His su00estion .o! a !e(lace"ent is ="ode!ation t!ainin0 = ?n "an$ wa$s, these two shi.ts !e(!esent a tid$ co"(!o"ise, in that the$ allow .o! de,iations .!o" an unco"(!o"isin0 abstinence 0oal, while no lon0e! challen0in0 the disease "odel in such a .unda"ental wa$ ?n the case o. ha!" !eduction, abstinence is held out as the 0old standa!d, and continued d!in&in0 .o! de(endent d!in&e!s is identi.ied as a (!oble"atic 6i. .!eAuent: outco"e As 9a!latt et al 61993, ( 465: w!ote* =7he 0oal o. ha!"-!eduction "ethods is to .acilitate "o,e"ent alon0 a continuu" .!o" 0!eate! to lesse! ha!".ul e..ects o. d!u0 use Althou0h abstinence is conside!ed an ancho! (oint o. "ini"al ha!", an$ inc!e"ental "o,e"ent towa!d !educed ha!" is encou!a0ed and su((o!ted = 7he second a((!oach can be said to ta!0et indi,iduals who a!e not =alcoholic = ;. cou!se, thin0s a!e not !eall$ so si"(le, so"e disease-"odel (!o(onents "i0ht a!0ue A!e the subBects o. these inte!,entions !eall$ a di..e!ent (o(ulation than the alcoholics, o! a!e the$ (eo(le with alcoholic tendencies whose =disease= has not $et (!o0!essedJ 7hose conce!ned with en0a0in0 (!oble" d!in&e!s in t!eat"ent also a!0ue that o..e!in0 0oals othe! than abstinence "a$ att!act a wide! audience* =;..e!in0 cont!olled d!in&in0 alte!nati,es to the 0ene!al (ublic "a$ act as a "oti,atin0 (ush to 0et (eo(le Iin the doo!,D a low-th!eshold st!ate0$ that is consistent with the (!inci(les o. ha!" !eduction = 69a!latt

22 et al , 1993, ( 483: Althou0h not uni,e!sall$ success.ul in de.usin0 the cont!o,e!s$, this !e-.!a"in0 "i0ht be unde!stood as a di(lo"atic solution )ach side could decla!e itsel. ,icto!ious E!itin0 in 1995, one co""entato! (ostulated* =FAG((a!entl$Hlittle "o,ed b$ the I0!eat debateDH both sides continue with thei! initial (!e.e!ences* the IA"e!ican establish"ent,D AA and clinicians (!edo"inantl$ with the abstinence a((!oaches, whe!eas (s$cholo0ists, !esea!che!s and sociolo0ists o.ten !e0a!d cont!olled d!in&in0 as a .easible and o.ten (!e.e!!ed alte!nati,e = 62latt, 1995, ( 1157: 7he se,e!it$ o. de(endence issue 3obell and 3obell 61995: noted that low se,e!it$ o. de(endence is an i"(o!tant (!edicto! o. an indi,idualDs abilit$ to "ode!ate success.ull$ ?n thei! 1981 lite!atu!e !e,iew, Heathe! and /obe!tson also .ound low se,e!it$ to be co!!elated with cont!olled d!in&in0 outco"es, althou0h the$ note that so"e o. the studies the$ !e,iewed onl$ loo&ed at "en, thus li"itin0 the 0ene!ali-abilit$ o. thei! .indin0s 9ille! 61983, ( 77: obse!,ed that in the /and stud$, =(atients with hi0h alcohol de(endence we!e .ound to be less li&el$ to !ela(se .!o" abstinence than .!o" non(!oble" d!in&in0, su00estin0 that .o! this (o(ulation abstinence was the "o!e stable outco"e = /osenbe!0 61993, ( 132: !e,iewed a nu"be! o. "o!e !ecent studies and !e(o!ted .indin0 0ene!al 6althou0h not uni,e!sal: su((o!t .o! the se,e!it$ h$(othesis He went on to state that* the natu!e o. the !elationshi( between se,e!it$ and 4' has not $et been established ;ne (ossibilit$ is that the li&elihood o. 4' dec!eases "onotonicall$ as se,e!it$ o. de(endence inc!eases, and at so"e (oint se,e!it$ is so 0!eat that the (!obabilit$ o. 4' is -e!o Alte!nati,el$, althou0h 4' 0ene!all$ declines as se,e!it$ inc!eases, the!e "a$ be (lateaus in se,e!it$ in which chan0es in le,el o. se,e!it$ do not "atte! Also, e,en at the hi0hest le,els o. se,e!it$, (e!ha(s so"e alcoholics a!e able to cont!ol thei! d!in&in0 as a !esult o. othe! .acto!s Minall$, a si0ni.icant association between the two ,a!iables does not necessa!il$ "ean that lowe! se,e!it$ is the cause o. 4' 3obell and 3obell 61995, ( 1150: also u!0ed caution in inte!(!etin0 causalit$ .!o" these !esults* =FAGlthou0h it is te"(tin0 to ,iew de(endence se,e!it$ as the c!itical dete!"inant

23 o. whethe! a "ode!ation !eco,e!$ is attainable, it is (ossible that this !elationshi( is an e(i(heno"enon to othe! li.e ci!cu"stances o.ten associated with se,e!e de(endence 6e 0 lac& o. social su((o!t, (oo! ,ocational histo!$: = 3obell and 3obell 61995: "ade the inte!estin0 (oint that this association between se,e!it$ le,el and outco"e see"s to hold t!ue, !e0a!dless o. what is ad,ocated in t!eat"ent 3anche--4!ai0 et al 61984: !ando"l$ assi0ned low-de(endence d!in&e!s to t!eat"ent ai"ed at eithe! abstinence o! cont!olled d!in&in0 At two $ea! .ollow-u(, the two conditions we!e Auite si"ila!, and "ost success.ul outco"es in,ol,ed "ode!ate d!in&in0 ?n a stud$ in which se,e!el$ de(endent d!in&e!s we!e assi0ned to t!eat"ent with eithe! abstinence o! 4' 0oals, at 5-6 $ea! .ollow-u( the 0!ou(s we!e also si"ila!, with "ost successes in,ol,in0 abstinence 6/$ch$a!i& et al, 1987: 7he !eal wo!ld i"(lications o. the abo,e .indin0s a!e .a! .!o" clea! Ehile indi,iduals with less se,e!e alcohol (!oble"s a((ea! to ha,e "o!e .!eAuent 4' outco"es, does it .ollow lo0icall$ that 4' t!ainin0 should not be used with de(endent (o(ulationsJ 9i0ht 4' techniAues (la$ a !ole in ha!" !eductionJ ?n 1987, Peele stated that while (ast !esea!ch =.ound 0!eate! bene.its .o! (!oble" d!in&e!s who we!e less se,e!el$ de(endent on alcohol,= at the sa"e ti"e, =no co"(a!ati,e stud$ had shown "ode!ation t!ainin0 to be less e..ecti,e than abstinence as a t!eat"ent .o! an$ 0!ou( o. alcoholics = 6Peele, 1987, ( 175: Heathe! 61995: a!0ued that so"e studies ha,e shown that se,e!el$ de(endent indi,iduals can sustain non-(!oble"atic d!in&in0, and that the!e "a$ be a((lications .o! 4'-.ocused inte!,entions with this (o(ulationL "uch o. this wo!& is cu!!entl$ bein0 done outside the 1nited 3tates Peele 61992: a!0ued that the consensual "o,e awa$ .!o" 4' t!eat"ents .o! "o!e se!iousl$ de(endent d!in&e!s !esulted .!o" (olitical (!essu!es !athe! than .!o" the wei0ht o. uneAui,ocal e"(i!ical e,idence ?n !es(ondin0 to Peele, 9ille! 61992, ( 80: a!0ued that data lin&in0 se,e!it$ to t!eat"ent outco"e do =(!o,ide .o! clinicians the basis .o! a (!obabilistic a!0u"ent in .a,o! o. abstinence, as se,e!it$ inc!eases = 7hat said, he a..i!"ed that he .a,o!s a de-escalation o. the 4' cont!o,e!s$* =7he!e is little to be 0ained b$ continuall$ eCace!batin0 (oints o. disa0!ee"ent 7he e..ect is onl$ to dee(en al!ead$

24 wide chas"s a"on0 si0ni.icant .actions, all o. who" a!e t!$in0 to alle,iate alcohol (!oble"s = 69ille!, 1992, ( 81: The importance of what the patient believes ?n his 1993 !e,iew o. the lite!atu!e on (!edicto!s o. cont!olled d!in&in0, /osenbe!0 obse!,ed that indi,idualsD belie.s about the .easibilit$ o. 4' is a (otentiall$ use.ul (!edicto! o. thei! abilit$ to "ode!ate Ehile the natu!e o. indi,idual belie.s we!e o(e!ationali-ed in di..e!ent wa$s b$ di..e!ent in,esti0ato!s, the "aBo!it$ o. studies that /osenbe!0 !e,iewed su((o!ted the so-called (e!suasion h$(othesis /osenbe!0 noted a nu"be! o. Auestions that 0!ew out o. these .indin0s* Ehat is the sou!ce o. d!in&e!sD belie.sJ 7o what eCtent a!e belie.s sha(ed b$ (!e-eCistin0 notions, what the d!in&e!s a!e told in t!eat"ent, and#o! eC(e!iences a.te! t!eat"ent as the$ atte"(t to achie,e thei! 0oalsJ And how stable a!e these belie.sJ 7$(icall$, these belie.s a!e "easu!ed once in the cou!se o. "ost studies, and then used as a (!edicto! o. beha,io! "onths a.te! the "easu!e"ent 6/osenbe!0, 1993: ?n .act, these "easu!es "a$ chan0e .!eAuentl$ Mo! instance, ;Beha0en and %e!0lund 61989: !e(o!ted on a 3wedish t!eat"ent (!o0!a" in which (a!tici(ants chose thei! own t!eat"ent 0oals 6abstinence o! 4': and we!e allowed to chan0e these 0oals e,e!$ th!ee "onths Mo!t$-.ou! (e!cent o. (atients chan0ed 0oals at least once du!in0 the t!eat"ent (!o0!a", a .indin0 su00estin0 that belie.s about what is both (ossible and hel(.ul chan0ed o,e! ti"e, (!esu"abl$ as a !esult o. eC(e!ience ?nte!estin0l$, the i"(lications o. this association between belie. and beha,io! can be s(un in di..e!ent wa$s A belie. in the necessit$ o. abstinence "a$ hel( an indi,idual sta$ sobe!, which is ob,iousl$ a desi!able outco"e Howe,e!, a belie. in the e..icac$ o. 4' "a$ se!,e ha!"-!eduction ends, i. a de(endent d!in&e! belie,es that he o! she can cut down inta&e, As Peele 62000, ( 43: w!ites, =F7Ghe ,e!$ subBecti,e ele"ents that A"e!ican alcoholis" t!eat"ent de!ides as IdenialD can i"(!o,e the chances o. !eco,e!$* ?t is easie! to achie,e what $ou belie,e = Audrey ishline and !oderation !anagement

'es(ite the a.o!e"entioned decades o. !esea!ch and debate, when Aud!e$ 8ishline sou0ht hel( .o! he! (!oble"atic d!in&in0 in the late 1980s, it too& he! $ea!s to lea!n that

25 the!e we!e an$ (!o.essionall$ sanctioned alte!nati,es to abstinence As she desc!ibes it in he! 1994 boo&, she consulted 30 to 40 (!o.essionals, "an$ o. who" stee!ed he! towa!ds AA, and e"(hasi-ed that she would ha,e to attend "eetin0s .o! the !est o. he! li.e Ehen she be0an to eC(lo!e "ode!ation o(tions, she states she was =a"a-eFdG= to .ind the eCtent to which these a((!oaches had been eC(lo!ed b$ addiction (!o.essionals and (ut into (!actice in othe! count!ies 3he w!ites* 7he .i!st "aBo! !e,elation that ? ca"e ac!oss was that "an$ eC(e!ts in the alcohol studies .ield do not belie,e that alcohol abuse is a disease M!o" "$ (!e,ious eC(e!ience with t!aditional t!eat"ent, ? had been unde! the i"(!ession that the disease "odel o. alcohol abuse !e(!esented a biolo0ical and "edical .act, (!o,en be$ond a shadow o. a doubt ? was a"a-ed to .ind out that the disease theo!$ was Bust that* a theo!$Hone that has been hi0hl$ c!itici-ed, and disca!ded, b$ "an$ !esea!che!s in the .ield 68ishline, 1994, ( 12: 8ishlineDs eC(e!ience "a$ be !e(!esentati,e* 'es(ite "an$ encounte!s with the t!eat"ent co""unit$, she did not lea!n that the!e a!e "ulti(le wa$s to conce(tuali-e substance abuse (!oble"s, and she did not lea!n that the!e a!e wa$s to !eco,e! that do not necessitate AA ?n .oundin0 99, 8ishline inte0!ated "an$ beha,io!al techniAues into a sel.-hel( .o!"at* =7he (u!(ose o. 9ode!ation 9ana0e"ent is to (!o,ide a su((o!ti,e en,i!on"ent in which (eo(le who ha,e "ade the health$ decision to !educe thei! d!in&in0 can co"e to0ethe! to hel( each othe! chan0e 7hatDs it ?t is ,e!$ si"(le and st!ai0ht.o!wa!d, and ? ad"it that 99 stole it .!o" the .o!e!unne! o. the "utual hel( "o,e"ent, AA = 68ishline, 1994, ( 25: 7he (!o0!a" eC(licitl$ states that it is not .o! de(endent d!in&e!s ?t ad,ocates a "onthlon0 abstinence (e!iod be.o!e the institution o. a (!o0!a" o. "ode!ate d!in&in0 ?t o..e!s a "echanis" b$ which (!oble" d!in&e!s can t!$ to cut downL in theo!$, .ailu!e at this e..o!t su00ests the ad,isabilit$ o. abstinence 7he 99 "o,e"ent has 0a!ne!ed attention as a 0!ass!oots "o,e"ent !eachin0 out to and (!o,idin0 .!ee su((o!t and technical assistance to the la!0e (o(ulation o. non-de(endent d!in&e!s A!ticles on the o!0ani-ation

26 ha,e a((ea!ed in 7i"e in 1995, and in 1 3 >ews and Eo!ld /e(o!t in 1997L the o!0ani-ation has also been .eatu!ed on tele,ision shows with la!0e audiences, such as 2ood 9o!nin0 A"e!ica and the ;(!ah Ein.!e$ 3how 7o its su((o!te!s, 99 !e(!esent a sel.-hel(-st$le e"bodi"ent o. a (!o"isin0 a((!oach to d!in&in0 (!oble"s 7o its det!acto!s, it !e(!esents a "echanis" b$ which alcoholics can (e!(etuate thei! denial Althou0h a nu"be! o. acade"ic !esea!che!s ha,e (!o,ided ad,ice and su((o!t to 99, the "o,e"ent can be unde!stood as a .o!" o. 4' that has "o,ed out o. the !esea!ch do"ain into the 0ene!al (ublic a!ena ?s (ublic o(inion beco"in0 "o!e o(en to alte!nati,esJ ?n the absence o. su!,e$ !esea!ch, we donDt actuall$ &now the cu!!ent state o. (ublic o(inion on "ode!ation a((!oaches to (!oble" d!in&in0 Ee can s(eculate that 8ishlineDs accident and the (!ess co,e!a0e it !ecei,ed has con,inced so"e that "ode!ation is dan0e!ous ;n the othe! hand, inc!eased (ublicit$ "a$ s(awn inc!eased inte!est and debate about alte!nati,e conce(tuali-ations o. alcohol (!oble"s and !outes to !eco,e!$ An edition o. 20#20 b!oadcast in Kune o. 2000 .eatu!ed inte!,iews with a nu"be! o. (!o(onents o. "ode!ation a((!oaches, and hi0hli0hted the .act that, in "an$ othe! count!ies, t!eat"ent o.ten in,ol,es the teachin0 o. "ode!ation s&ills 3-ala,it-, the autho! o. the >ew No!& a!ticle about 3"ithe!s, w!ote a .ollow-u( (iece .o! %!illDs 4ontent, a "a0a-ine widel$ !ead b$ Bou!nalists, detailin0 the con.lation o. the 8ishline and the 3"ithe!s sto!iesL he! (iece "a$ ha,e educated w!ite!s and edito!s about the scienti.ic and (olitical bac&d!o( to the news e,ents And the !ecent (ublication o. the boo& 3obe! .o! 2ood 6Mletche!, 2001: co""unicates in ho(e.ul, accessible lan0ua0e that the!e a!e "an$ wa$s .o! .o!"e! (!oble" d!in&e!s to deal with thei! d!in&in0 A si0ni.icant (!o(o!tion o. those she inte!,iewed 0ot sobe! without AA, and a s"alle! (!o(o!tion ha,e "ade "aBo! i"(!o,e"ents in thei! d!in&in0 and thei! li,es without 0i,in0 u( alcohol alto0ethe! ?t see"s Auite (ossible that this boo& will !each and educate a b!oad audience Summary and open "uestions 7he ,a!ious ite!ations o. the cont!olled d!in&in0 cont!o,e!s$ can be su""a!i-ed b!ie.l$ 'a,ies obse!,ed data that called ce!tain (!e"ises o. the disease "odel into Auestion,

27 leadin0 so"e in the .ield to !eso!t to ,a!ious se"antic twists to "ini"i-e o! den$ the i"(o!t o. his .indin0s Ehen the /and autho!s "ade the case that non(!oble"atic d!in&in0 was wides(!ead in its outco"e studies, disease "odel adhe!ents atte"(ted to "ini"i-e the i"(act o. these .indin0s on (ublic o(inion /and o((onents echoed 'a,ies co""entato!s in ,oicin0 the .ea! that the ac&nowled0"ent that so"e alcoholics can lea!n to d!in& in a non(!oble"atic .ashion "i0ht lu!e othe! alcoholics to (ost(one sel.identi.$in0 o! to !eBect thei! co""it"ent to abstinence Ehen the 3obells (ublished !esults showin0 that a beha,io!al t!eat"ent which included 4' techniAues (!oduced bette! outco"es than t!eat"ent as usual in a se,e!el$ de(endent (o(ulation, anothe! tea" o. !esea!che!s attac&ed thei! !e(utations in the cou!se o. a!0uin0 that 4' was no (anacea .o! these ,e!$ sic& .ol& P!odded in (a!t b$ (olitical !ealities and in (a!t b$ e,idence that 4' t!ainin0 doesnDt see" to si0ni.icantl$ boost the e..icac$ o. t!eat"ent, !esea!che!s ha,e bac&ed o.. .!o" ad,ocatin0 cont!olled d!in&in0 t!eat"ents .o! alcoholics Howe,e!, st!ate0ies li&e ha!" !eduction and "ode!ation t!ainin0 .o! non-de(endent d!in&e!s ha,e &e(t !esidual 4' st!ate0ies ali,e ?t is now co""on (!actice in t!eat"ent studies to ac&nowled0e that abstinence is not the onl$ success.ul t!eat"ent outco"e, and that !educed d!in&in0 in .act constitutes i"(!o,e"ent 6Peele, 2000: 'es(ite these co"(!o"ise (ositions, the issue !e"ains a hot-button to(ic in (ublic discou!se, with Aud!e$ 8ishlineDs !ecent t!a0ed$ bein0 touted b$ o((onents as a 6su((osed: !e"inde! that the "e!e eCistence o. "ode!ation a((!oaches can su((o!t and (!olon0 alcoholicsD denial A !e,iew o. the histo!$ o. this debate (!o,ides .ew incont!o,e!tible answe!s 7hus, it see"s a((!o(!iate to conclude this !e,iew b$ hi0hli0htin0 so"e o. the i"(o!tant Auestions that !e"ain salient 40 $ea!s into the debate* 61: Ehat does the !esea!ch !eall$ sa$J 3e,e!al endu!in0 the"es, which ca"e u( a0ain and a0ain in the bod$ o. lite!atu!e conside!ed, see" .ai!l$ well su((o!ted* Pu!e, uninte!!u(ted abstinence is !a!e! than we would li&e in t!eated de(endent d!in&e!s, and so"e (!oble" d!in&e!s do see" able to !educe thei! d!in&in0, with an acco"(an$in0 !eduction in the se,e!it$ o. li.e (!oble"s Howe,e!, othe! Auestions, such as the (otential

28 !ole o. 4' as a ha!" !eduction st!ate0$ and the !ole o. se,e!it$ o. in dete!"inin0 the abilit$ to "ode!ate, !e"ain o(en to debate ?n (a!t, this is a !esult o. e"ba!!ass"ent o. !iches* 3o"e studies eCa"ine "ulti(le outco"e "easu!es at "ulti(le (oints in ti"e, with the !esult that thei! .indin0s a!e o(en to "ulti(le inte!(!etations 'i..e!ent in,esti0ato!s de.ine =cont!olled d!in&in0= in di..e!ent wa$s 6Heathe! & 7ebbutt, 1989: As 4oo& 61985: de"onst!ated in his !e-anal$sis o. the 3obells-Pende!$ cont!o,e!s$, !eade!s .!o" eithe! side o. the di,ide can .ind su((o!t .o! thei! (osition in the sa"e data 62: Ehat !ole does "one$ (la$ in all thisJ 7o what eCtent do (olitics dete!"ine which studies 0et .undedJ Ehat &inds o. (ublic educational ca"(ai0ns a!e .unded and b$ who"J 7o what eCtent has the clout o. anti-4' o!0ani-ations li&e the >4A'' and the 3"ithe!s Moundation a..ected the willin0ness o. those who bene.it .!o" thei! la!0ess to ac&nowled0e e,idence in .a,o! o. 4'J 7o what eCtent does the chan0in0 econo"ics o. t!eat"ent 6i e the ad,ent o. "ana0ed ca!e, with its (!e.e!ence .o! b!ie., e..ecti,e t!eat"ents: in.o!" both sides o. the debateJ 63: How can we ste( bac& .!o" the di,isi,eness that an issue li&e this en0ende!sJ ?n the cou!se o. !e,iewin0 this lite!atu!e, ? !eco0ni-ed the eCtent to which !eactions to the debate a!e based on ,alues as well as .acts 9$ (e!sonal ,alues a!e such that ? a" o..ended b$ atte"(ts to (!e,ent in.o!"ation .!o" bein0 disse"inated, and b$ those who ha,e t!ied to cut o.. o! to silence debate EhatDs t!ic&$, ? !eco0ni-e, is that those 0ut e"otional !eactions lead "e to cast he!oes and ,illains in "$ head, and to lose si0ht o. nuance Ehen ? =side= with the (s$cholo0ists and scienti.ic !esea!che!s, ? ha,e to !e"ind "$sel. to ste( bac& and .ocus on the .act that ? also belie,e that abstinence is a hi0hl$ desi!able 0oal .o! those who acce(t it, and that ? ha,e dee( and endu!in0 !es(ect .o! AA Pe!ha(s a (!e!eAuisite .o! s$nthesi-in0 !eactions to this 40-$ea!-old debate is .o! the obse!,e! to &now his o! he! biases, and to identi.$ those issues that t!i00e! a..ecti,e !es(onses Pe!ha(s onl$ when we la$ clai" to ou! own ,alues can we adeAuatel$ !e.lect on this e"otion-d!i,en debate /e.e!ences Alcoholics Anon$"ous 61976: Alcoholics Anon$"ous 63!d ed : >ew

29 No!&* Alcoholics Anon$"ous Eo!ld 3e!,ices A!"o!, ' K , Polich, K 9 , & 3ta"bul, H % 61976: Alcoholis" and t!eat"ent 3anta 9onica, 4A* /and A!"st!on0, K ' 61963: 4o""ent on the a!ticle b$ ' @ 'a,ies Pua!te!l$ Kou!nal o. 3tudies on Alcohol, 24, 118-119 %ell, / 2 61963: 4o""ent on the a!ticle b$ ' @ 'a,ies Pua!te!l$ Kou!nal o. 3tudies on Alcohol, 24, 321-322 %loc&, 9 A 61963: 4o""ent on the a!ticle b$ ' @ 'a,ies Pua!te!l$ Kou!nal o. 3tudies on Alcohol, 24, 114-117 %!unne!-;!ne, 9 61963: 4o""ent on the a!ticle b$ ' @ 'a,ies Pua!te!l$ Kou!nal o. 3tudies on Alcohol, 24, 730-733 4oo&, ' / 61985: 4!a.ts"an ,e!sus (!o.essional* Anal$sis o. the cont!olled d!in&in0 cont!o,e!s$ Kou!nal o. 3tudies on Alcohol, 46, 433442 'a,ies, ' @ 61962: >o!"al d!in&in0 in !eco,e!ed alcohol addicts Pua!te!l$ Kou!nal o. 3tudies on Alcohol, 23, 94-104 'a,ies, ' @ 61963: /es(onse b$ '! ' @ 'a,ies 3tudies on Alcohol, 24, 330-332 Mletche!, A 9 62001: 3obe! .o! 0ood %oston* Hou0hton 9i..lin MoC, / 61963: 4o""ent on the a!ticle b$ ' @ 'a,ies Pua!te!l$ Kou!nal o. 3tudies on Alcohol, 24, 117 2latt, 9 9 61995: 4ont!olled d!in&in0 a.te! a thi!d o. a centu!$* 4o""ents on 3obell & 3obell Addiction, 90, 1157-1160 Heathe!, > 61995: 7he 0!eat cont!olled d!in&in0 consensus* ?s it (!e"atu!eJ Addiction, 90, 1160-1162 Heathe!, > & /obe!tson, ? 61981: 4ont!olled '!in&in0 @ondon* 9ethuen Heathe!, > & 7ebbutt, K 61989: 'e.initions o. non-abstinent and abstinent cate0o!ies in alcoholis" t!eat"ent outco"e classi.ications* A !e,iew and (!o(osal '!u0 and Alcohol 'e(endence, 24, 83-93 Pua!te!l$ Kou!nal o.

30 8ishline, A 61994: 9ode!ate d!in&in0* 7he 9ode!ation 9ana0e"ent 0uide .o! (eo(le who want to !educe thei! d!in&in0 >ew No!&* 4!own @e"e!e, M 61963: 4o""ent on the a!ticle b$ ' @ 'a,ies Pua!te!l$ Kou!nal o. 3tudies on Alcohol, 24, 727-728 9a!latt, 2 A 61983: 7he cont!olled-d!in&in0 cont!o,e!s$* A co""enta!$ A"e!ican Ps$cholo0ist, 38, 1097-1110 9a!latt, 2 A 61987: /esea!ch and (olitical !ealities* Ehat the neCt twent$ $ea!s hold .o! beha,io!ists in the alcohol .ield Ad,ances in %eha,io! /esea!ch and 7he!a($, 9, 165-171 9a!latt, 2 A , @a!i"e!, 9 ) , %ae!, K 3 , Pui0le$, @A 61993: Ha!" !eduction .o! alcohol (!oble"s* 9o,in0 be$ond the cont!olled d!in&in0 cont!o,e!s$ %eha,io! 7he!a($, 24, 461-504 9ille!, E / 61983: 4ont!olled d!in&in0* A histo!$ and a c!itical !e,iew Kou!nal o. 3tudies on Alcohol, 44, 68-83 9ille!, E / 61986: Haunted b$ the Qeit0eist* /e.lections on cont!astin0 t!eat"ent 0oals and conce(ts o. alcoholis" in )u!o(e and the 1nited 3tates ?n 7 M %a!bo! 6)d :, Alcohol and cultu!e* 4o"(a!ati,e (e!s(ecti,es .!o" )u!o(e and A"e!ica >ew No!&* 7he >ew No!& Acade"$ o. 3ciences 9$e!son, ' K 61963: 4o""ent on the a!ticle b$ ' @ 'a,ies Pua!te!l$ Kou!nal o. 3tudies on Alcohol, 24, 325 >ational 4ouncil on Alcoholis" and '!u0 'e(endence 62000: 3tate"ent !e* Rehicula! "anslau0hte! cha!0es a0ainst autho! o. 9ode!ation 9ana0e"ent htt(*##www ncadd o!0#news#news42 ht"l ;Beha0en, A , & %e!0lund, 9 61989: 4han0es o. d!in&in0 0oals in a two$ea! out-(atient alcoholic t!eat"ent (!o0!a" Addicti,e %eha,io!s, 14, 19 Peele, 3 61983: 7h!ou0h a 0lass da!&l$ Ps$cholo0$ 7oda$, 17, 38-42 Peele, 3 61984: 7he cultu!al conteCt o. (s$cholo0ical a((!oaches to

31 alcoholis"* 4an we cont!ol the e..ects o. alcoholJ A"e!ican Ps$cholo0ist, 39, 1337-1351 Peele, 3 61987: Eh$ do cont!olled d!in&in0 outco"es ,a!$ b$ in,esti0ato!, b$ count!$ and b$ e!aJ 4ultu!al conce(tions o. !ela(se and !e"ission in alcoholis" '!u0 and Alcohol 'e(endence, 20, 173-201 Peele, 3 62000: A.te! the c!ash* 7he alcohol t!eat"ent establish"ent uses a d!un& d!i,in0 accident to silence dissent /eason, 32, 41-44 Pende!$, 9 @, 9alt-"an, ? 9 , & Eest, @ K 61982: 4ont!olled d!in&in0 b$ alcoholicsJ >ew .indin0s and a !ee,aluation o. a "aBo! a..i!"ati,e stud$ 3cience, 217, 169-175 Polich, K 9 , A!"o!, ' K , & %!ai&e!, H % 61981: 7he cou!se o. alcoholis"* Mou! $ea!s a.te! t!eat"ent >ew No!&* Kohn Eile$ and 3ons /oi-en, / 61987: 7he 0!eat cont!olled-d!in&in0 cont!o,e!s$ ?n 9 2alante! 6)d :, /ecent 'e,elo("ents in Alcoholis", Rolu"e 5 6(( 245279: >ew No!&* Plenu" P!ess /osenbe!0, H 61993: P!ediction o. cont!olled d!in&in0 b$ alcoholics and (!oble" d!in&e!s Ps$cholo0ical %ulletin, 113, 129-139 /$chta!i&, / 2 , Mo$, ' E , 3cott, 7 , @o&e$, @ , & P!ue, ' 9 61987: Mi,e-siC-$ea! .ollow-u( o. b!oad s(ect!u" beha,io!al t!eat"ent .o! alcoholis"* )..ects o. t!ainin0 cont!olled d!in&in0 s&ills Kou!nal o. 4onsultin0 and 4linical Ps$cholo0$, 52, 106-108 3anche--4!ai0, 9 , Annis, H 9 , %o!net, A / & 9ac'onald, 8 / 61984: /ando" assi0n"ent to abstinence and cont!olled d!in&in0* e,aluation o. a co0niti,e-beha,io!al (!o0!a" .o! (!oble" d!in&e!s Kou!nal o. 4onsultin0 and 4linical Ps$cholo0$, 52, 390-403 3el-e!, 9 @ 61963: 4o""ent on the a!ticle b$ ' @ 'a,ies Pua!te!l$ Kou!nal o. 3tudies on Alcohol, 24, 113-114 3"ith, K A 61963: 4o""ent on the a!ticle b$ ' @ 'a,ies Pua!te!l$ Kou!nal o. 3tudies on Alcohol, 24, 322-324 3"ithe!s-Mo!naci, A 4 62000: @ette! to .!iends in the alcoholis" .ield

32 htt(*##alcoholis" about co"#lib!a!$#wee&l$#aa000709a ht" 3n$de!"an, > 62000, Kune 7: '!in&in0* A!e $ou in cont!olJ ?n 20#20 >ew No!&* A%4 >ews 3obell, 9 % & 3obell, @ 4 61973: Alcoholics t!eated b$ indi,iduali-ed beha,io! the!a($* ;ne $ea! t!eat"ent outco"es %eha,io! /esea!ch and 7he!a($, 11, 599-618 3obell, 9 % & 3obell, @ 4 61978: %eha,io!al t!eat"ent o. alcohol (!oble"s* ?ndi,iduali-ed the!a($ and cont!olled d!in&in0 >ew No!&* Plenu" P!ess 3obell, 9 % & 3obell, @ 4 61995: 4ont!olled d!in&in0 a.te! 25 $ea!s* How i"(o!tant was the 0!eat debateJ Addiction, 90, 1149-1153 3-ala,it-, 9 62000, Kul$ 10: '!in& $ou! "edicine >ew No!&, 33, 11-12 3-ala,it-, 9 62001, Kanua!$: 12 ste(s bac& %!illDs 4ontent, 3, 72-78 7iebout, H 9 61963: 4o""ent on the a!ticle b$ ' @ 'a,ies Pua!te!l$ Kou!nal o. 3tudies on Alcohol, 24, 109-111 Ehite, E @ 61998: 3la$in0 the d!a0on* 7he histo!$ o. addiction t!eat"ent and !eco,e!$ in A"e!ica %loo"in0ton, ?@* 4hestnut Health 3$ste"s Eillia"s, @ 61963: 4o""ent on the a!ticle b$ ' @ 'a,ies Pua!te!l$ Kou!nal o. 3tudies on Alcohol, 24, 111-113 Qwe!lin0, ? 61963: 4o""ent on the a!ticle b$ ' @ 'a,ies Pua!te!l$ Kou!nal o. 3tudies on Alcohol, 24, 117-118 Addiction, Pain, & Public Health website - www docto!deluca co"#

33

A.te! conside!in0 the in.o!"ation in both a!ticles would it see" that cont!olled d!in&in0 could be a !easonable 0oal .o! alcohol abuse t!eat"entJ Eh$ o! wh$ notJ 6"a&e su!e to !e.e!ence the in.o!"ation .!o" the a!ticles that $ou use to .o!"ulate $ou! answe!: ?. alcoholis" is a disease that is "a!&ed b$ the loss o. cont!ol the alcoholic will e,entuall$ !etu!n to uncont!olled d!in&in0 Howe,e! i. cont!olled d!in&in0 candidates a!e sc!eened ca!e.ull$ then it "a$ be (ossible to select candidates .o! that (!o0!a" who ha,enSt c!ossed the line to alcoholis" and a!e (!oble" d!in&e!s 7hese indi,iduals "a$ bene.it .!o" a cont!olled d!in&in0 (!o0!a"