Alcohol & Drug Abuse: A Research-Based Analysis of the Moderation Management Controversy

MM's primary text, Moderate Drinking (1), and AA's Big Book (4) actually agree on several important points. Both books make explicit distinctions between problem drinkers who are able to return to controlled drinking and alcoholics. Both texts also concur that failure at the goal of moderate drinking indicates that a drinking problem is serious and is best addressed by abstinence. These shared assumptions have been supported in prospective studies showing that, broadly speaking, when problem drinkers recover, abstinence is more common among those who are highly dependent on alcohol, are male, are older, and are socially and economically unstable, whereas moderate drinking is more common among problem drinkers who do not belong to these sociodemographic groups—for example, young women with low levels of dependence (5,6,7).

MM's proponents differ from advocates of abstinence-only approaches in their views on who can be trusted to judge the difference between a moderation-bound problem drinker and an alcoholic rather than in their views on whether such a distinction exists. A large proportion of the 12-step treatment community in the United States has incorporated the psychodynamic concept of denial into its theory of alcoholism; AA's texts describe alcoholics as having a grandiose penchant for overestimating their ability to control drinking (4). Thus many 12-step advocates fear that despite MM's intention to serve only nondependent problem drinkers, the organization's members are in fact alcoholics who are deceiving themselves into thinking that they can drink moderately.

Our project team found that MM members scored a full standard deviation below AA members on standardized measures of alcohol dependence symptoms, alcohol-related problems, and frequency of drinking prior to their joining their respective organizations (3). In addition to having far fewer signs of physical dependence, members of MM were more likely to be female (49 percent), younger than 35 years (24 percent), and currently employed (81 percent) than were members of abstinence-oriented self-help organizations. Thus MM members as a group demonstrated encouraging average scores on every clinical and demographic variable that has been shown to predict success at attaining controlled drinking.

However, some notable exceptions to this general finding deserve comment. About 15 percent of MM members had experienced three or more of the following symptoms at least once in the six months before joining MM: shaking when not intoxicated, delirium tremens, blackouts, convulsions or fits after drinking, and cravings for alcohol upon waking (3). The vast majority of these persons also reported that drinking had caused problems with their job, health, and family situation. This subgroup of MM members would almost certainly meet formal diagnostic criteria for alcohol dependence.

Is MM dangerous for its alcohol-dependent members? This question might be answered by citing MM's official policy of allowing individual members to choose either moderation or abstinence. Our research showed that this is not an adequate response, because only 3 percent of MM members chose abstinence as their drinking goal (3).

Engaging alcohol-dependent persons in controlled drinking interventions has long been highly controversial in the United States, even though epidemiologic research shows that in the general population many alcohol-dependent persons later become moderate drinkers (8). Population studies cannot eliminate concern about the risks of controlled-drinking goals, because moderate-drinking outcomes in help-seeking alcohol-dependent samples are both less common and less stable over time than abstinence outcomes (9). Furthermore, the finding that persons who meet formal diagnostic criteria sometimes become moderate drinkers does not necessarily call into question AA's experience that alcoholics cannot engage in controlled drinking, because AA's concept of alcoholism is defined more strictly than is the medical concept of alcohol dependence. For example, many young men meet formal diagnostic criteria for alcohol dependence or abuse at some time during their college years and then become lifetime moderate drinkers after graduation. AA would not consider such individuals alcoholics.

MM would be dangerous if it discouraged severely dependent persons from seeking help or uncritically endorsed moderation for everyone. We found that more than three-quarters of MM members (77 percent) had never participated in a professional alcohol treatment program, and MM members we interviewed usually expressed negative feelings about their contacts with AA (3). Therefore, in the absence of MM, most of the organization's members would probably not be seeking help from abstinence-oriented interventions.

Furthermore, alcohol-dependent persons may change their drinking goals after they have become engaged in a supportive setting, even if they were originally attracted by the possibility of moderate drinking. For example, Hodgins and colleagues (10) found that a significant number of alcoholic patients who entered treatment with a goal of moderation moved to a goal of abstinence after a few weeks of intervention and that these patients tended to have positive outcomes. By providing an entry route into assistance for alcohol-dependent individuals who currently refuse to cross the threshold of an abstinence-only program, MM may be facilitating recovery even for people who will ultimately move on to seek abstinence at a later time or in a different setting.

The vast majority of MM members have low-severity alcohol problems, high social stability, and little interest in abstinence-oriented interventions. They would probably be willing to attempt only a program that offered moderate drinking as a goal, and they have the characteristics of individuals who succeed at such a goal. Tragedies such as the deaths in the car accident involving Audrey Kishline can occur when alcoholics fail to abstain, but they can also occur when nondependent problem drinkers are denied assistance because they have not deteriorated enough to become committed to a goal of abstinence.

Of course, these potential benefits of MM must be viewed in light of the probability that some individuals who participate in MM will fail to attain moderate drinking. Many MM members themselves are concerned about this issue, and, in my opinion, in the coming years the organization will have to develop a stronger set of norms and procedures for recognizing and advising participants whose problems are too severe for MM to address.

That said, it would be unrealistic to assume that all individuals who begin participating in MM—or, for that matter, any alcohol-related intervention—are appropriate for this intervention and will benefit from it. The fact that MM may be inappropriate as a long-term solution for a minority of its participants does not necessarily cast doubt on the organization's potential value to its other members. The question of whether MM is beneficial or detrimental to public health therefore becomes one of values more than of empirical data per se, and it echoes the question that society has often asked about alcohol: Should something be denied to those who may benefit from it so that it cannot be obtained by others who may be harmed and do harm? This is a matter about which reasonable people of good will may disagree, and in fact have. But given the demonstrated realities that there are many more nondependent drinkers than alcoholics, that nondependent drinkers underutilize existing interventions (1), and that alcoholics were attempting controlled drinking long before MM existed (4), the inclusion of MM in the array of options for people attempting to resolve drinking problems seems on balance a benefit to public health.

Preparation of this column was supported by grants AA-11700-01 and AA-13315-01 from the National Institute on Alcohol Abuse and Alcoholism and by the Veterans Affairs Mental Health Strategic Healthcare Group. The author thanks Elena Klaw, Ph.D., Ernest Kurtz, Ph.D., Fred Rotgers, Psy.D., and William White, M.A., for their helpful comments.

Dr. Humphreys is affiliated with the Veterans Affairs Health Care System and Stanford University School of Medicine in Palo Alto, California. Send correspondence to him at the Center for Health Care Evaluation, VA Palo Alto Health Care System (152-MPD), 795 Willow Road (152), Menlo Park, California 94025 (e-mail, [email protected]). Sally L. Satel, M.D., is editor of this column.