Tuesday, March 27, 2007

Beyond the Influence: Understanding and Defeating Alcoholism

By Katherine Ketcham and William Asbury, with Mel Schulstad and Arthur P. Ciaramicoli ISBN 0553380141

Reviewed by Marty N.

By its title and authorship, Beyond the Influence compels attention as a sequel to the classic Under the Influence (1981), see review. The principal author of that pioneering work, Dr. Kenneth Milam, has meanwhile died, and its junior author, Katherine Ketcham, now emerges as principal writer of the four-author committee that assembled this sequel.

Like Dr. Milam's original, Beyond expounds the thesis that alcoholism is a primary physiological disease, as distinct from a symptom of underlying emotional or psychological problems. Like the original, the sequel lays heavy stress on the inherited character of the disease. Also like the original, the current work lays emphasis on the nutritional dimensions, and this is among its greatest strengths. The structure of the work, beginning with the ingestion of alcohol and its physiological effects, also generally follows the plan of the 1981 classic.

The sequel's main contribution is a digest of some of the research work done in the past 20 years, with emphasis on "some." For example, the authors discuss in much more detail the role of aldehydes in breaking down alcohol in the body; they survey the recent psychometric work further demolishing the hypothesis of an "alcoholic personality;" and they report at some length on the work of Kenneth Blum and Mark Schuckit, among others, on the genetic dimensions of alcoholism. These are useful and important contributions.

Missing, unfortunately, is the fearless thinking and the broad perspective that made Dr. Milam the clinical revolutionary that he was. For example, it was obvious to Milam, as it is to most thinking persons, that the method of Alcoholics Anonymous is founded on the mistaken belief that alcoholism is rooted in a character flaw or other psychological inadequacy or maladjustment. Milam had the courage to say so in print. One looks in vain through the sequel for a discussion or even an acknowledgement of this relevant therapeutic issue.

Milam nevertheless recommended AA to his readers because he saw in AA mainly a support group for abstinence, and his classic work took little note of the organization's spiritual/religious underpinnings. The sequel, by contrast, reads like a Christian Science tract, urgently commanding the alcoholic to move beyond "mere sobriety" (!) to pursue spirituality and godliness (Ch. 13). Milam's classic avoided this blunder. Prescribing treatment methods that are specific for the remission of sins can only undermine the case for alcoholism as a primary physiological disorder.

The authors display the same kind of mental disconnect on other issues. After hammering home the theme that alcoholism is a medical problem, the authors introduce as a "model" treatment program an inpatient facility that has neither a physician nor a nurse in residence. Later, the authors tell us that attention to nutrition is an indispensable part of competent treatment; but if the model facility includes such a component, the authors forgot to mention it.

Among the most significant bodies of research in the past twenty years has been the discovery of the links between addiction to alcohol and addiction to nicotine, and the urgency of encouraging and supporting alcoholics and other addicts to quit smoking. The reader learns nothing of these scientific and clinical advances in Beyond the Influence. The only awareness that the authors' "model" treatment facility shows about the number one killer addiction today is that the staff prods patients to pick up their cigarette butts.

A great deal has also been learned in the past 20 years about the common brain mechanisms underlying all the substance addictions. Blum's research particularly emphasizes this point. During this time span also, poly-addiction has become the norm rather than the exception, as the authors' own figures show. However, the reader will learn little or nothing about addiction to substances other than alcohol from this volume, and some of what is mentioned in passing is not accurate. Withdrawal symptoms, for example, are not found with all drugs of addiction (e.g. cocaine), nor would most specialists agree with the authors that drugs such as heroin are addictive in 100 per cent of the cases. The authors' speculation that there may be particularized genetic predispositions for each of the drugs has little if any support in the research.

Altogether, the authors greatly overstate the importance of heredity, as if this were the sole causative factor in alcoholism. This overstatement may have been pardonable for Milam twenty years ago; he was writing a polemic at a time when genetics was little understood. Today, every textbook on the subject readily admits that genetics plays some role in alcoholism and may play the predominant role in individual cases. But researchers in this area are careful not to overstate the thesis. Blum observed that his groundbreaking work on the genetics of addiction could be replicated only with the most severe cases of alcoholism, men who had died of cirrhosis, and that even there the correlation was far from perfect (click for article). Schuckit, who first identified the physiological signs of alcoholism in sons of alcoholics, emphasizes that alcoholism is a group of disorders with multifactorial origins (click for article). Milam himself, in his paper The Alcoholism Revolution, suggested that alcoholism could be caused either by inheritance or by trauma (injury to the organism).

Since Milam, there has been a great deal of research with laboratory animals showing that addictive behavior identical to that found in the genetically predisposed animals can be readily produced by saturating the bloodstreams of normal animals with the addictive substance for a relatively brief period. (Click for source.) In other words, we now know that the addictive physiology need not be inherited; it can also be acquired through excessive drinking/using.

Although the authors of Beyond the Influence cite some of this research in a footnote, it does not penetrate their argument. The average reader will come away from the book believing that genetics is the sole explanation for alcoholism. This overemphasis wrongly encourages readers to feel that if they do not have a family history of alcoholism, they cannot themselves be alcoholics. Full-blown alcoholics who do not have the family history may come away from the book believing that they have been misdiagnosed and that they can safely go back to (or continue) drinking.

The genetic explanation of addiction, especially in cases where it is clearly indicated, also often leads to fingerpointing, guilt and related issues between parents and children. It would have been helpful to provide readers on both sides of the genome with tools for handling these stresses.

The authors also fail to discuss the public policy implications of the solely-genetics hypothesis. As the historian William White recounts, the genetic explanation in the past has typically provoked a cry for sterilization as the sole effective remedy. Is this where we want to go?

Conceptually, there are many bridges to cross between the finding that alcoholism has a neurophysiological basis (hereditary or acquired), and the theory that it is a progressive, fatal disease. Left-handedness, for example, has a hereditary neurophysiological basis. The reader searching for a thoughtful, reasoned, and comprehensively informed brief to sustain the variety of notions encapsulated in the "disease theory" will come away disappointed. The authors merely wave their hands in the general direction of "hundreds of studies" and move on as if the case were established. Much of the research they rely on, such as the alleged pivotal role of TIQ (THIQ) in the brain of alcoholics, is not widely accepted. Although researchers have made tremendous progress in tracking the pathways of addiction within the brain, no one as yet has found the "smoking gun" that will bring a Nobel Prize. The authors of Beyond the Influence would gain in credibility by acknowledging more readily how much still remains to be learned.

I also would have liked the authors to address the therapeutic utility of the disease concept. The authors' belief that the disease concept helps to reduce the stigma associated with alcoholism appears well-intentioned but is naive and clearly mistaken. Ask someone with HIV whether having a disease protects against stigma. As the writer and cancer patient Susan Sontag pointed out years ago, stigma attaches to many diseases, particularly to those whose etiology is murky and cure uncertain. Thus, tuberculosis patients were victims of intense stigma until the cause of the disease was discovered and antibiotic treatment introduced; and cancer was until very recently a diagnosis that both patient and physician concealed in shame and dread. Telling alcoholics they have a disease, under present conditions, may be more likely to burden the patient with guilt and shame than to relieve these stresses.

Every worker in the field has also seen typical individuals for whom the disease concept serves as a primary rationale for relapse. ("I relapsed because I have a relapsing disease.") It does not seem to occur to the authors, for example, that tragic deaths such as that of Terry McGovern may have occurred in part because of, rather than despite, the victim's belief in the disease concept. It would also have been helpful if the authors had discussed further Harvard researcher George Vaillant's finding that a substantial proportion of alcoholics experience "spontaneous remission" rather than deterioration. Similarly, the authors' refreshing pronouncement that after six years of abstinence an alcoholic is "recovered" might have usefully been contrasted with their thesis that the disease is progressive. And would it have taken the authors too far afield to cite and discuss AA co-founder Bill W.'s 1961 statement that AA has never called alcoholism a "disease" because, like "heart disease" and "cancer," the label comprises a variety of distinct disorders?

The volume would also have benefited by discussing the extensive research of the last twenty years into the stages of change (DiClemente and Prochaska), so helpful in understanding how recoveries happen. The heavy-handed version of the disease concept that the authors expound in this book obscures the pathways that lead up to some drinkers' ultimate decision to stop. At point A, the alcoholic is in the grip of an uncontrollable neurological and genetic compulsion; he can no more stop drinking, say the authors, than a butterfly can turn back into a caterpillar (p. 88). But at point B, the alcoholic nevertheless does stop drinking and shortly begins to lead a sober, productive life. How was this possible? Where did it come from suddenly? The authors make the thoughtful observation that the "hit bottom" metaphor is not very useful and can be harmful, but they provide few positive clues to understanding how or why recoveries begin. The authors' belief that alcoholics should be forced to attend AA meetings will sadden and repel many friends of that movement.

One also searches Beyond the Influence in vain for an honest, realistic assessment of the state of alcoholism treatment today. Despite decades in which the Minnesota Model has been the dominant paradigm, the statistics on alcoholism remain as horrible today, if not more so, than those that Dr. Milam cited in his book twenty years ago. Ownership needs to be taken here. The authors proceed as if the comprehensive study of American treatment methods authored by Drs. Hester and Miller (Handbook of Alcoholism Treatment Approaches, see review), which raised major questions about the effectiveness of the most prevalent approaches, had never been written. There is no serious disclosure or discussion of the large body of outcomes research, showing that relapse is the industry's most common product. The huge Project Match study, finding that one approach was about as effective as another, is not mentioned. The several comparative studies finding no benefit in AA attendance are not discussed. AA's own membership surveys showing an overwhelming dropout rate are not mentioned. The calculated rationale of Managed Care in shutting down most inpatient treatment programs for lack of effectiveness is not seriously discussed. The widespread ferment within the treatment industry questioning the Minnesota Model is ignored. The growth of non-AA abstinence support groups is not mentioned. The book proceeds in the manner of a campfire rally for true believers, banishing the swelling host of uncomfortable realities to the darkness.

Toward the end of the book, the authors take some well-deserved jabs at the alcohol industry and at some of the politicians whom it subsidizes. However, in fairness the authors should point out that their own genetic thesis, which locates the problem in the drinker rather than in the substance, is entirely compatible with industry dogma. In candor, the authors also might have pointed out that in the past two decades the issue of "disease" v. "sin" has become a partisan political football, with the Democrats since LBJ generally in the "disease" camp and the Republicans since Reagan typically defining the problem as "sin." It might have been candid also to have pointed out that billions of dollars, including some of the authors' own bread and butter, ride on the "disease" controversy.

In short, many relevant things have happened in the past twenty years that somehow did not find their way into this book. In some ways, Milam's free-speaking 1981 classic has a more contemporary ring than this heavily blindered and shuttered sequel. With Milam there was a definite sense of excitement and forward motion. In the sequel, the wagons are drawn in a circle. The original is also more engagingly and fluently written; the sequel, like the two-humped camel, shows signs of being built by committee.

There are some good insights, touching anecdotes and sage words of advice in the book. Certainly the book is on sound footing in recommending abstinence as the only safe policy. There is good discussion of nutrition. But the eminent name of Dr. Milam in the book's lineage creates higher expectations. Dr. Milam would have looked reality in the eye, asked the tough questions, and let the chips fall where they may.

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