What You Can Change _. And What You Can't - Martin E. Seligman [111]
The Right Treatment
ALCOHOLISM SUMMARY TABLE*
Given this minefield, I will hazard an evaluation anyway. My best guess is that AA is only marginally effective overall, but that it may be quite effective for certain subgroups of alcoholics.
I start with the sad fact that there has not been a single, sound, controlled study of AA. This is unfortunate because AA is the most widespread treatment for alcoholism, and current practice among clinicians, ministers, and family doctors is to send most of their alcoholic clients directly to AA. Advocates publish glowing numbers from uncontrolled studies, but their methodology is so flawed that I am forced to dismiss them.
George Vaillant’s inner-city men provide a sample—with no control group—followed for a very long time. Among the men who were ever abstinent and the 20 percent who became securely abstinent, more than one-third rated AA as “important.” Indeed, AA was second only to “willpower” on this score. In another of his studies, Vaillant followed a clinic sample for eight years, and 35 percent became stably abstinent: Of these, two-thirds had become regular AA attenders. I cannot tell which causes which, but it is an often-repeated finding that of the one-third of alcoholics who have a good long-term outcome, many participate religiously in AA, attending hundreds of meetings a year.25
AA is not for everyone. It is spiritual, even outright religious, and so repels the secular-minded. It demands group adherence, and so repels the nonconformist. It is confessional, and so repels those with a strong sense of privacy. Its goal is total abstinence, not a return to social drinking. It holds alcoholism to be a disease, not a vice or a frailty. One or more of these premises are unacceptable to many alcoholics, and these people will probably drop out. For those who remain, however, my best guess is that many of them do benefit. It would be a mistake to be formulaic about who will find AA congenial. All sorts of unlikely types show up and stay—poets and atheists and loners. AA changes the character of some of those who stick with it. After all, it fills two of Vaillant’s four criteria for bolstering recovery: It provides a substitute dependency, and it is a source of hope.
Total Abstinence
One of my closest friends, Paul Thomas, is a bartender. Paul is nothing if not fanatical. When he took up bridge, he became a Life Master in under two years. When he took up golf, he became a scratch golfer in a summer. When he fathered a Down’s syndrome child, he became president of the Philadelphia chapter for helping Down’s children. When he took up drinking, he drank for ten solid years. He has not touched a drop in the last fifteen years. When asked how he does it, he says he doesn’t need reminders of hitting bottom because he sees them every day among his customers.
When I read the intensely passionate literature on whether total abstinence or a return to social drinking should be the goal of recovery, I decided to get his opinion. I had dinner with him at his bar. I told him that the literature showed, quite definitively, that a fraction of recovered alcoholics can return to social drinking. His view was uncomplicated. “I hope they keep this a secret from the rest.”
Paul’s reaction makes a good deal of sense to me. First, the facts: Some fraction of recovered alcoholics are able to return to drinking without major problems like binges, blackouts, and violence. Just how small this minority is is a matter of debate. George Vaillant found that between 5 and 15 percent of his alcoholics returned to social drinking. In a twenty-year follow-up of Swedish alcoholics, 25 percent had become social drinkers and only 20 percent were abstainers. Fewer