Abstinence

For many commentators and treatment professionals abstinence from alcohol and drugs is viewed as the only acceptable outcome. How we view any problem obviously influences the solutions or treatments that we believe possible and/or acceptable. In respect of drugs, the reasoning is not difficult to understand, since drug use is an illegal activity in almost all countries. However to understand why abstinence is advocated for alcohol means that we need to understand the models of alcohol problems, in particular the disease model.

The disease model makes some basic assumptions about the nature of alcoholism, in particular that alcoholics suffer from an abnormal and uncontrollable craving that leads them to drink and that, once they begin drinking, they have no control over their consumption. If we accept these assumptions then it is easy to see why we would believe that alcoholics cannot drink in safety. Add to this, the belief that the disease is progressive (ie it continually gets worse) and irreversible (once an alcoholic always an alcoholic) and the only possible conclusion that we can come to is that the only safe outcome the alcoholic or drug addict to abstain for the rest of their lives.

Sobriety

Some Problems with Abstinence as a Goal

However if they are to participate in the wider world they are liable to come into contact with alcohol. Non-alcoholic friends may be supportive and not actively encouraging the alcoholic/addict to indulge, however just just being in the company of others who are getting intoxicated, or even just consuming, can represent a major temptation to relapse. This temptation is even more acute for alcoholics since alcohol is so endemic in western society. Indeed the alcoholic often fears that his/her social life will be over and it may take a considerable length of time until they feel that they can socialise at all and even longer where alcohol is present. Thus abstinence is a difficult goal to maintain.

Alan Marlatt, an American psychologist, highlights a second problem of this goal. In his research on relapse he suggested that the inflexibility of the goal led to a belief on the part of the alcoholic that any drinking, regardless of how slight, was proof positive of a return to full-blown alcoholic relapse. He argued that this outcome, rather than being a physiological process, was in fact a psychological process arising from a belief in the disease model and the need for complete abstinence. He called this phenomenon the ‘abstinence violation effect’. Thus someone who has remained abstinent for over a year and then took a drink would view this as a total failure rather than a recognise the very substantial reductions they have achieved in consumption and frequency of consumption.

Categorising other non-substance based behaviours as addictions also brings the appropriateness of abstinence, as the only treatment goal for addition, into question. An abstinent goal for behaviours such as over-eating and over-exercising is obviously not only inappropriate but extremely dangerous. Thus other goals, such as moderation management, harm reduction and controlled use, have entered the treatment repertoire of addiction and have filtered back into the chemical addictions.

Alternative Treatment Goals

The Sobells writing about the study some decades later pointed to the fact that, many of the controlled drinking group had in fact opted for abstinence. Their interpretation of the results of the study was that a/ controlled drinking was possible for some alcoholics, although it was currently impossible to predict who, b/ that stopping drinking entirely was the more common outcome and c/ that patients were more likely to remain abstinent when they felt that they had been given a choice of outcome. They argued that this choice appears to give the patient ownership of the goal and hence ensured greater adherence to it.

Other goals have arisen out of pragmatic, rather than theoretical or ideological positions. The current approach to drug use is a prime example of this. Harm reduction arose out of the need to prevent the further spread of HIV/AIDS and other blood-borne viruses rather than a desire to give alternative treatments to addicts. Nevertheless the approach is now firmly established in drug treatment programs.

Abstinence is Sometimes Essential

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