Science writer, Nancy Shute's, U.S. News cover story on moderation- (as opposed to abstinence-) oriented alcohol treatment was published at the magazine's WWW site on Sunday, 31 August 1997.¹

It's always interesting to see a story focused on alcohol make the cover of a major American newsmagazine.

The event can offer a handy indicator of how alcohol is playing in mainstream popular culture these days--the way Time's cover story² of a dozen years ago marked the appearance a new temperateness in American drinking.

As cultural markers go, however, I initially found Shute's topic-selection a little baffling.

First of all, and as Shute herself concedes, moderationist treatment programs reportedly handle only a tiny fraction of the nation's total alcohol treatment caseload--"gnats compared to the elephant of AA," as the author put it.

Second, today's alcohol social arena is crowded with new issues that draw at least as much, and probably more, concern than the longstanding controlled- drinking controversy.³

For instance, U.S. alcohol treatment enterprises in general (whether abstentionist or moderationist) appear to be in a time of troubles--facing such threatening factors as

• the managed-care revolution,

• the rise of a new preventionist sensibility (which promises a radical tranformation in the mindset that once launched and fostered the remarkable growth of alcohol treatment in post-War America), and

• recent court decisions holding that 12-step-based treatment approaches constitute religious activity and thus may not be imposed on inmates of correctional institutions on grounds of the separation clause.
Why, then, Shute's article's focus on a tiny moderationist treatment movement?

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Yet, and on closer reading, I found that Shute's article did indeed address wider shifts in alcohol's sociocultural location in contemporary America.

It simply did so through the somewhat awkward medium of moderationist treatment advocacy.

The relevant recent history (as usual) has an ironic twist:

In a period when U.S. drinking norms appear to be tightening, drinking patterns that were once regarded as acceptable become newly marginalized in society.

Drinkers who abided by older norms or exceed new ones in turn become redefined as new potential candidates for treatment.

And since these new treatment candidates don't fit the traditional image of besotted alcoholism, new treatment enterprises eschew applying either the alcoholic label or its traditional abstinence requirement to them.

Bingo!

Moderationist treatment advocates may advertise new salience and utility for their approaches!

The irony, of course, is that a drying period in general drinking norms should also nevertheless manage to occasion a wettening trend in treatment approaches! At least in prospect.

But irony always makes an important appearance in alcohol's social history in America!

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What we have in Shute's article, then, is at bottom a story about emergent role of moderationist treatment in relation to the shrinking cultural borders of appropriate or nondeviant drinking in American society.

As such, it is a story about the place of treatment in the social control of drinking.

I was struck in particular by two tell-tale indicators of this social-control subtext in Shute's article:

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1st Indicator: Citing Social Harms/Costs

Shute's article noted the current roster of social harms that new temperance advocates blame on alcohol--i.e., 41% of traffic fatalities, 50% of homicides, and 30% of suicides & accidental deaths.

Alcohol's economic costs were cited too--indeed, her article's subtitle read, "By calling abstinence the only cure, we ensure that the nation's $100 billion alcohol problem won't be solved."

Never mind that Shute neglected to caution her readers that these sorts of numbers represent highly dubious exercises in pseudoscientific propaganda.

Focus instead on the curious little fact that such social cost numbers appear at all in Shute's brief for an unconventional treatment enterprise.

As I recall, these sorts of social-cost numbers made no rhetorical appearance in the three major episodes of the controlled-drinking controversy that occurred in the early 1960s, the mid-1970s, and the early 1980s.

So something has changed in the controversy's latest manifestation...but what?

In point of fact, we don't usually justify and rationalize society's proffering of medical treatment for conventional medical problems--say, broken arms--by citing all the various social costs that such maladies impose.

To do so would be vaguely uncaring somehow...and perhaps a misreading of medicine's ethos and society's expectations thereof..

Hence Shute's mere use of social cost figures offers a subtle but significant signal that alcohol treatment's ethos is shifting from the individual-centered and benevolent value orientation of the modern alcoholism movement to the social control orientation of an emergent neo-dry sensibility.⁴

^{The target of societal attention is shifting from a traditional focus on the misunderstood and falsely stigmatized alcoholic to the harms that the neo-dry sensibility charges against drinking in general.}

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2nd Indicator: Shute's 40 Million New Treatment Candidates

Shute's article also reports that there are 10 million alcoholics and 40 million problem drinkers in the country.

Whereas older-style, abstinence-oriented treatment addressed the former, she says, newer-style, moderation-oriented treatments better address the latter.

Never mind (once again) that these numbers are nearly worthless from any genuinely scientific perspective.

Consider instead the intriguing matter of the magnitudes involved in her estimates--esp. when these are stacked-up against what census data and social surveys tell us about the U.S. population and prevailing American drinking patterns.

According to the Bureau of the Census, we are a nation of just under 270M souls these days.

Almost 200M of us are 18-years-old or older.

About a 35% of adults--or 70M of those 200M--don't consume alcohol at all in a year's time.

That leaves about 130M adults who do.

But surveys tell us that the U.S. is in a sense a light drinking country.

Only about 30% of the adult population--about 60M people--report drinking once a week or more frequently.

Survey classifications divide the remaining 70M infrequent drinkers across a series of subgroups (people who drink [a] 2-3 times per month, [b] roughly once-a-month, or [c] at least yearly but not as often as monthly).

Some of these 70M--perhaps as many as 20M (or 10% of the adult population)--may drink infrequently but nevertheless consume 5+ drinks on an occasion from time to time. These folks are sometimes labeled infrequent heavy drinkers in the survey argot.

So:

If we add the 60M at least weeklies to the 20Minfrequent heavies we get a total of some 80M Americans who enjoy beer, wine, or spirits on something more than an incidental basis--these 80M citizens comprise about 40% of the U.S. adult population..

These 80M also represent the population pool from which Shute must draw her 40M new moderationist-treatment candidates.

It doesn't take a rocket scientist to see that her 40M figure amounts to half of the members of that 80M pool!

Now, many of us, I'm sure, know someone whom we think should cut down on his or her alcohol consumption.

Some of us even feel we'd be wise to reduce our own intake sometimes.

Targeting half the nation's non-incidental drinking population for new alcohol treatment, however, is a horse of a very different color.

The dimensions involved bespeak not so much an exercise in therapeutic expansion as a vast social-change and social-control agenda.

Taken at face value, in other words, Shute's figures amount to a normative assault on the wetter segments of American society--under the seemingly benign and benevolent cover of the promotion a brand of alcohol treatment that is merely more flexible that its abstinence- oriented predecessor.

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Who can say whether Ms. Shute was actually fully aware of either (a) the moral-political implications of citing social cost figures in her text or (b) the social dimensions of the 40M new-treatment-candidate numbers she offered?

More than a few assertions her article offered found me uttering, "But wait a minute! There's more to it than that!"

Even the seemingly simple matter of a ten-question, self-screening drinking test Shute appended to her article merits a second look.

After all, if "problem drinking" isn't necessily an illness phenomenon or a syndrome, then what meaning should readers attach to a problem-drinking diagnostic test's results?

If there's no clinical there there, what does the test test?

Obviously, where no disease entity is claimed, the test may boil down to little more than an exercise in normative preference.

Shute gave the little self-screening test she offered the anxious title, "Should you worry?"

I think I'd urge readers of Shute's article to worry a little--though not necessarily about whatever score they may have earned on the self-screening test.

Nancy Shute's article raises issues that go well beyond the embattled matter of whether abstinence or moderated drinking presents the better outcome target for one or another alcohol treatment candidate.

At least some of these issues--as I've tried to show--were more obscured than illuminated by Shute's choice to examine current alcohol history through the narrow window of moderationist treatment's prospects.

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FOOTNOTES:

¹ With Laura Tangley.

² See Time's 20 May 1985 issue; the cover story was titled "Water, Water Everywhere: At Work and at Parties, Americans Are Drinking Less and Enjoying It More."

³ The well-known controversy dates from a 1962 British paper published in the Quarterly Journal of Studies on Alcohol reporting that 7 of 93 post-treatment alcoholics were engaged in unproblematic drinking. For a history of the dispute see Ron Roizen, "The Great Controlled-Drinking Controversy," pp. 245-279 in Marc Galanter (ed.), Recent Developments in Alcoholism, vol. 5, New York: Plenum, 1987.

⁴ An unabashed case for justifying and supporting alcohol treatment in terms of reducing social costs can also be found in the public health literature: A. Thomas McLellan, et al., "Is Treatment for Substance Dependence 'Worth It?': Public Health Expectations, Policy-Based Comparisons," Training About Alcohol and Substance Abuse for All Primary Care Physicians, New York: Josiah Macy, Jr. Foundation, 1995.