All or Nothing

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Your cholesterol is high. The doctor says, ‘No butter, no cheese, no cholesterol-raising foods – full stop.’ You complain, ‘Can’t I just cut down and take some tablets?’ The doctor yields nothing. ‘If you want me to help, do as I recommend. Otherwise you are clearly not serious about preventing strokes and heart attacks. Maybe you’ll see it my way after you have one.’

Not so long ago that was the stance dependent drinkers could expect to face. It was not just a matter of what patients should be advised, but whether they should be denied treatment until revelation or deterioration impressed on them the need to stop drinking altogether.

The heat the issue generated was fired by concerns on the one hand that allowing some drinking would set the dependent up to fail, and on the other that insisting on abstinence did nothing to improve outcomes while denying treatment to all but a minority. Underlying these views were opposing visions of dependence as a distinct disorder characterised by inevitable loss of control, or one end of a continuum of behaviour which even at its most extreme could – given the right circumstances and/or support – revert to moderation.

The first crack

Mike Ashton is co-editor of Drug and Alcohol Findings.
Mike Ashton is co-editor of Drug and Alcohol Findings.

The first significant research-driven crack in the abstinence consensus opened in 1962 in the form of a report by British psychiatrist DL Davies on seven ‘severely addicted’ patients said to have sustained controlled drinking. These men were very much in the minority of 93 patients discharged before 1955 from south London’s Maudsley hospital, but that they existed at all was considered remarkable.

Davies started by restating the views of the time: due to presumed ‘irreversible’ changes after years of regular heavy drinking, there was ‘…wide agreement that these patients will never again be able to drink “normally”’. But the seven had – and for between seven and eleven years – conversions associated with major changes in their domestic or working lives that resolved painful issues or removed them from constant contact with alcohol. Yet he ended by partially endorsing the orthodoxy he challenged: ‘…the majority of alcohol addicts are incapable of achieving “normal drinking”. All patients should be told to aim at total abstinence.’ Nevertheless, he claimed his findings gave the lie to the aphorism, ‘once an alcoholic, always an alcoholic’. With sufficiently radical changes in their lives – aided in these cases by two to five months in hospital – some who had evidenced severe dependence could (re)join the ranks of ‘normal’ drinkers.

Critical Edge

For his successor at the Institute of Psychiatry, Davies had been ‘a pioneer who made a daring exploration of what was at the time virtually forbidden territory’, questioning ‘not just a medical consensus, but the central and hallowed organising idea of the American alcoholism movement’. These comments came from the prestigious figure of the late Griffith Edwards, but there was a critical edge to this homage to his ‘mentor’.

That edge had become apparent in 1979 when the journal Edwards edited published an interview with Davies. The interviewer – probably Edwards himself – told Davies of a personal encounter at the Maudsley with one of the seven patients. Contrary to the impression given to Davies’ follow-up worker, the man had confessed to ‘drinking like a fish the whole time’ and threatening to ‘bash the living daylights’ out of his wife if she contradicted his reassuring account. Significantly, Professor Davies also confessed to something – ‘I never regarded myself…as a research worker.’

The encounter with the patient prompted Edwards to re-check records and re-interview surviving patients, relatives and carers, and the results were published in 1985. Having died in 1982, Davies could not challenge findings which cast doubt on whether some of the seven had ever been severely dependent, and whether most had really sustained ‘normal’ drinking. How starkly different was the picture from two decades before can be appreciated by the notes on ‘case 2’. In 1961 Davies had seen a success story: ‘Drinks 1–2 pints of an evening but no spirits. Never drunk.’ In 1983, Edwards saw a ‘catastrophic’ outcome: ‘Heavy drinking recommenced not later than 1955; much subsequent morbidity culminated in 1975 with Wernicke-Korsakoff syndrome.’

Research-Naive

Nearly a decade later Professor Edwards revisited this episode, asserting that his follow-up had revealed Davies’ account to be ‘substantially inaccurate’. A research-naive clinician ‘had been substantially misled’ by ‘intentionally unreliable witnesses,’ which his flawed methodology was not up to exposing. Be that as it may, later not-so-flawed work was to come to the same conclusions as Davies.

This episode was relatively gentlemanly and largely limited to professional circles, but in the USA bitter disputes hit the headlines and spread across TV networks, in one case spawning legal proceedings. A major spat centred on a 1976 report from the influential Rand Corporation on new government treatment centres. It found fairly complete remission was the norm, that most patients achieved this without altogether giving up alcohol, and that as many resumed normal drinking as sustained abstinence.

Breaking Storm

Aware of the storm their findings might provoke, the authors disavowed any intention to recommend ‘alcoholics’ resume drinking. Nevertheless, the storm broke, as holding out the prospect of controlled drinking was likened to ‘playing Russian roulette with the lives of human beings’.

Rand’s authors could anticipate the controversy from the reaction three years before to an audacious study by US husband and wife team Mark and Linda Sobell. Among a randomly selected half of the patients considered suitable for a controlled-drinking objective, it tested a radical procedure which allowed patients to drink, showed them videos of how they looked drunk, and trained them how to manage or avoid situations conducive to excess. All the other patients were allocated to abstinence-oriented treatment, either through a similar procedure or conventional treatment.

The results seemed a clear vindication of the judicious allocation of even physically dependent patients to try to learn moderation. Suitability for a controlled-drinking objective had been based partly on a patient’s ‘sincere dissatisfaction with [Alcoholics Anonymous] and with traditional treatment modalities’; the study showed this rejection of US orthodoxy need not condemn them to the progressive deterioration predicted for the untreated.

Scientific Fraud?

As with Davies, a follow-up of the same patients conducted by other researchers cast doubt on the findings, leading one critic to publicly allege scientific fraud. However, investigations – including one commissioned by a committee of the US Congress – cleared the Sobells, whose research was judged fairly presented.

In 1995 and again in 2011 they revisited controlled drinking as a treatment objective in editorials for Addiction. Accepting that ‘Recoveries of individuals who have been severely dependent on alcohol mainly involve abstinence,’ they argued this was not necessarily something that was inherent to the condition, but because these individuals tend to have poor social support and little stake in society – an echo of Davies’ contention that social circumstances can generate dependence, and changing these can reverse it. Treatment providers unwilling to countenance non-abstinence objectives would ‘continue to force problem drinkers to keep their pursuit of low-risk drinking a private struggle’, adding lack of support from the treatment sector to the lack of social support which perpetuates dependence.

Suitable goals

After this vitriolic research journey, this is how Drug and Alcohol Findings summed up the evidence: ‘Treatment programmes for dependent drinkers should not be predicated on either abstinence or controlled drinking goals but offer both. Nor does the literature offer much support for requiring or imposing goals in the face of the patient’s wishes. In general it seems that (perhaps especially after a little time in treatment) patients themselves gravitate towards what for them are feasible and suitable goals, without services having to risk alienating them by insisting on a currently unfavoured goal.’


David Lewis Davies
David Lewis Davies

David Lewis Davies was a psychiatrist of distinction, and a man who inspired loyalty and very special affection. It was the match of professional and personal qualities that made him such an influential figure.

Davies was crucially involved with the fortunes of the Maudsley and Bethlem Royal Hospitals, and with the post-war development of the Institute of Psychiatry. He identified strongly with Aubrey Lewis’s ideal of eclectic scholarship and insistence on high standards of patient care.

In 1979 his contributions to alcohol research were recognized by the award of the Jellinek memorial prize. He was elected president of the Society for the Study of Addiction, and sat on the editorial board of the British Journal of Addiction.

After retiring from the Maudsley, he became chairman of the Attendance Allowance Board, for which work he was, in 1982, awarded the CBE. By J Griffith Edwards from biography at the Royal College of Physicians, https://history.rcplondon.ac.uk

Mike Ashton is co-editor of Drug and Alcohol Findings – findings.org.uk and you can read more detail here.