In March 2000, Audrey Kishline, founder of "Moderation Management", a controlled-drinking oriented, self-help program alternative to Alcoholics Anonymous, drove her pickup truck the wrong way down Interstate 90 near Seattle, Washington, USA, killing Richard Davis, 38, and LaSchell, his 12-year-old daughter, in a head-on collision. Kishline was driving drunk. She pled guilty to two counts of vehicular homicide in August 2000 and was sentenced to four-and-a-half years in prison in Washington. The incident sparked significant controversy around the world regarding the efficacy of controlled-drinking programs (see references): People who believe in the myth of the disease model of alcoholism tend to consider controlled-drinking programs "dangerous." Kishline's behavior allegedly proved their point: "Alcoholics" cannot drink responsibly.

I helped Kishline launch MM years ago and subsequently severed all relations with her and her organization. Recently I was asked by an editor at Counselor: The Magazine for Addiction Professionals to respond to the following question: "Is it possible for people who suffer from alcohol abuse or alcoholism to choose moderation over abstinence as a correct mode of treatment for themselves; and how can a treatment provider effectively determine the competence of a person who abuses alcohol to self-select treatment?" This article constitutes my reply.

In a word, the answer to the first part of this question is "yes". However, the question overlooks two important facts: (1) There is no such thing as alcoholism. (2) Since alcoholism is not a literal disease it is not literally treatable. What passes as treatment for alcoholism is moral management masquerading as medicine. Of course, it is possible for people who drink too much to choose moderation over abstinence. Everyone has the ability to control himself or herself. One either controls oneself or is controlled by others: The relevant issue here is whether heavy drinkers will choose to control themselves or not. Will they choose to resist the temptation to drink in excess, and risk harming themselves or others by drinking too much? No one knows. A treatment provider cannot effectively determine the competence to select treatment of a person who abuses alcohol.

To be sure, if someone chooses to remain abstinent he or she will not get into trouble with alcohol. And similarly, a person who henceforth always drinks in moderation will also not get into trouble with alcohol. Refusing to be abstinent is no more a disease or sign of impaired volition than refusing to moderate one's drinking is.

Controlled-drinking advocates assert their program is for "problem drinkers", not "alcoholics", that is, people with the putative disease called "alcoholism". The distinction between "problem drinkers" and "alcoholics" is a false one fabricated by self-appointed experts in the addiction field: Problem drinkers are called that because they create problems when they drink, either for themselves or others. Alcoholics are people who do the same. There is no objective physiological test that can be administered to determine the alleged difference between the two. Obviously some people have a worse drinking problem than others, and we may choose to call those with the worst drinking problems "alcoholics", those with less severe drinking problems, "problem drinkers". But the exact line between them would be impossible to determine precisely, and is arbitrary in any case. We have no evidence that different methods work better with those having the most severe problems than with those having less severe problems.

The bottom line is this: Drinking is a choice. It is a behavior. It is a metaphorical disease and it is never involuntary. What many people, especially those in the "addiction-is-not-a-disease-we-support-the-idea-of- controlled-drinking camp" avoid acknowledging is that since addiction is not a literal disease it can only be treated in a metaphorical sense, for instance by talking persuasively to the person called an addict. Anyone who claims that addiction is a metaphorical disease, yet is literally treatable, is addicted to nonsense.

I'm neither for nor against abstinence or moderate- drinking approaches to helping people labeled alcoholic or addict. I think people should have the freedom to worship as they see fit, and those who want to go to Alcoholics Anonymous (AA) and/or MM, for example, are no exception. No "one way" is right for everyone. An abstinence-oriented approach may be best for some people, just as a moderate- drinking approach may be best for others. Some people feel more comfortable with Christianity, others prefer Judaism.

The population of people labeled alcoholic, alcohol abuser, and addict is a heterogeneous not a homogeneous one. No two people are identical. Everyone is different. Research shows that moderate drinking and abstinence- oriented approaches are equally effective (or ineffective, depending on how one looks at the evidence) in reducing the problems associated with heavy drinking. It also shows that metaphorical treatment, that is, conversation, is as effective as a "dose of advice."

In my opinion, addiction treatment professionals tend to be dishonest: They say they care about their "patients" but in actuality they care more about earning a living. I don't think there's anything wrong with wanting to earn a living. Since they're selling their products, they have an interest in getting consumers to buy their products, so we would do well to bear in mind the possibility that they may be tempted to misrepresent their own and their competitors' products.

My main concern is that people be allowed to do whatever they want as long as they do not harm others in the process. If people want to attend moderate-drinking programs I think by all means they should be allowed to do so. If they prefer abstinence-oriented programs they should be allowed to attend those. What I object to is government involvement in either program, voluntary or court-ordered. I object to governmental involvement in metaphorical treatment for addiction for the same reason I object to state entanglement with religion. One should have nothing to do with the other.

AA and disease-model proponents claim that teaching alcoholics they can control their drinking causes people like Audrey Kishline to kill themselves and others. MM and controlled-drinking defenders point their finger to the fact that Kishline had left MM and joined AA when she drank to excess. Therefore, they say, AA is to blame for the celebrated "abstinence violation effect." (The abstinence- violation effect refers to the tendency for some people to drink problematically when they believe abstinence is too difficult a goal to achieve or maintain.) It is important to remember that Kishline went to AA because she was drinking heavily -- She drank heavily when she was in MM. It is reasonable for MM supporters to point out that Kishline had reverted to AA before she killed two people. It's also reasonable to point out that she drank before she reverted to AA. When all's said and done, this person went to AA, she kept drinking excessively, she founded MM, she kept drinking excessively, she reverted to AA, she kept drinking excessively. Then while drunk she had an accident and killed two people. It doesn't follow that either an abstinence-oriented approach or a moderate-drinking approach is necessarily at fault, but it does seem that this person shouldn't have been setting herself up as an authority on how to cure excessive drinking.

My academic and intellectual interest continues to be focused on the relationship between liberty and responsibility, and public, clinical, and legal policies based in the idea that the person is a moral agent. This is not the same thing as saying that heavy drinkers or drug users are good or bad people. As psychiatrist Thomas Szasz once remarked, behaviors have reasons, things are caused. People can control their drinking because drinking is a behavior. There's abundant research to support that idea and I list some of it in my book entitled Addiction Is a Choice (Open Court). My colleagues Bruce K. Alexander, Ph.D. in British Columbia, Herbert Fingarette, Ph.D., in California, and Patricia Erickson, Ph.D. in Toronto, among others, have written about this extensively. Whether heavy drinkers or drug users WILL control their drinking or not is another matter. But this is not an issue of whether they CAN control themselves or not. Each drinker alone is solely responsible for the consequences of his or her behaviors.

References:

Birkland, D. and Koch, A. (2000, June 17). Alcohol- abstinence critic accused of DUI in fatal I-90 crash. Seattle Times. http://www.seattletimes.com

DeMillo, A. (2000, June 30). 'Moderate drinking' author pleads guilty. Seattle Times. http://www.seattletimes.com

DeMillo, A. (2000, August 12). 4 ½ years for deaths by 'moderation drinker.' Seattle Times. http://www.seattletimes.com

Koch, A. (2000, June 20). "Moderate drinking" author had decided to abstain. Seattle Times. http://www.seattletimes.com

Maltzman, I. and Rotgers, F. (2000, December). Drinking: Abstinence vs moderation. Counselor: The magazine for addiction professionals, 1, 33-38. http://www.counselormagazine.com

Peele, S. (2000, November). After the crash. REASON. http://www.reason.com/0011/fe.sp.after.html

Penta, M. (2000, June 27). Fatal accident forces debate over movement for problem drinkers. Associated Press. http://www.ap.org

Schaler, J.A. (1994). Foreword. In A. Kishline Moderate drinking: The new option for problem drinkers. Tucson, Arizona: See Sharp Press.

Schaler, J.A. (2000). Addiction is a choice. Chicago, Illinois. Open Court Publishers. (See especially the chapter entitled "Moderation Management and Murder," pp. 107-114, reprinted at http://www.schaler.net/mmurder.htm)

Smolowe, J., Dodd, J., Berestein, L., and Champ, C. (2000, July 17). Under the Influence: Audrey Kishline, who steered clear of abstinence, drove drunk and killed two people. PEOPLE Magazine, 63-65. http://www.schaler.net/inthenews/kishline people.htm

Steele, D.R. (2000). A fatal collision. Liberty Magazine, August, 10-11. http://www.schaler.net/inthenews/Liberty. htm

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Jeffrey A. Schaler, Ph.D., a psychologist, teaches at American University's School of Public Affairs in Washington, DC and at Johns Hopkins University in Baltimore, Md. He is the author, most recently, of Addiction Is a Choice, published by Open Court (2000). http://www.schaler.net