AUDREY' Kishline used to drink too much. She often drank alone, suffered daily hangovers, drove when she was over the limit.
In her late 20s, Audrey Kishline was letting things slide. After six years of heavy drinking, she entered a hospital treatment programme and emerged a binge drinker. She struggled with abstinence and eventually discovered moderation. Now she "has a couple of glasses of wine occasionally instead of a fifth of bourbon".
That would be the end of the story if Audrey Kishline had been content with a personal triumph. Instead this Michigan housewife recently wrote a guide called Moderate Drinking and founded the Moderation Management Network, a movement that questions the most basic tenets of addiction treatment and has caused a major debate in the powerful American recovery industry. Advocates of Kishline's philosophy say that it may replace current alcoholism treatment while critics worry that it is already undermining decades of trust in proven methods.
"In my opinion, my ability to change my drinking behaviour was delayed considerably because of traditional treatment," says Audrey Kishline. I went on a huge detour." She first sought help at two treatment centres, consulted 30 professionals, including doctors, psychologists and social workers, then spent 28 days in a detoxification clinic and several years attending Alcoholics Anonymous meetings.
"If I didn't," she says, "the dire prediction was that I would end up dead, in jail, insane or in the gutter." But the repeated message in therapy and AA meetings of her powerlessness over alcohol the "one drink, one drunk" belief became what she now terms a self fulfilling prophecy. Abstaining and bingeing became a pattern until she gradually appreciated her own ability to drink moderately.
Labels played a large part in Kishline's misery. "If I had been properly assessed as a problem rather than a chronic, drinker and offered the option of moderation as a self"management goal I never would have experienced such years of emotional pain," she insists.
One of the questions on the Michigan Alcoholism Screening Test which she took "Have you ever gone to anyone for help about your drinking?", guaranteed that anyone seeking advice would be termed chronically dependent. Diagnostic assessments allowing for lower levels of dependence are now more widely used but professional liability and medical insurance considerations make moderation programmes unattractive to mainstream treatment centres.
"That doesn't arise with MM because as a lay person, I'm not charging and I'm not treating," explains Kishline. "The groups just help people who have made the Moderation Management is quietly but rapidly establishing itself nationwide. There are currently 10 groups in the US, with SO more being set up and 100 letters a week asking Audrey Kishline for information.
"There is no money being made here," she stresses. "The book took three years to write, sold about 10,000 copies so far and I get 63 cents per copy so I'm not getting rich." Those attending the weekly meetings embrace a nine step programme that stresses behaviour modification, personal responsibility and the monitored, gradual alteration of habits. Standardised forms help participants to chart their weekly drinking behaviour and to plan "small steps toward positive lifestyle changes after an initial 30 days of abstinence. Meetings are anonymous anyone who is intoxicated may not attend and MM discourages members from socialising together in drinking situations.
"This programme is not intended for chronic drinkers or others who should not drink alcohol," reads MM's seventh ground rule. That disclaimer, critics say, is naive and irresponsible.
"A significant number of problem drinkers cross the state line into chronic alcoholism," argues Barry Carr, director of the chemical dependency unit at Bournewood Hospital in Brookline, Massachusetts. "Theoreticians can perhaps distinguish between the two positions but an alcoholic can't and it is misleading to sanction drinking when somebody is on an uncertain course.
SUSAN, a 54 year old alcoholic, sober for the past 13 years with the support of A dismisses MM's distinction altogether. "Problem drinker means alcoholic or one who hasn't ripened yet," she insists. "You could say that I was just a problem drinker. I never crashed the car, never went to jail, never had money problems or blackouts. But I was a problem drinker at 8.30, in the morning. So what would this do for me? Slow me down? It sounds like one of the games that alcoholics play."
The authors of AA's Big Book, agree when they write "The idea that somehow, someday he will control and enjoy his drinking is the great obsession of every abnormal drinker."
Audrey Kishline responds that MM's programme can lead to abstention for chronic drinkers who move on to AA when they find moderation unachievable. While insisting that one programme can complement the other, she nonetheless rejects AA's classification of alcoholism as a disease and attacks its three tenets of irreversible progression, total loss of control and genetic transmission.
"The ability to control alcohol isn't lost, it just isn't exercised," she says. "We are seeing the beginning of a backlash against the `diseasing' of all negative behaviours. People don't want to be life long victims anymore.
Discard the disease model, Kishline argues and you can move beyond the crisis management and planned intervention approaches that characterise mainstream addiction treatments. Instead, brief intervention and treatment matched with the severity of the problem can be implemented, particularly in the early stages of excessive behaviour.
"As it is now in the US, once they're in treatment, all clients are coerced into attending the institutionalised version of AA," she says. "This is not the same thing as the fellowship of AA, which is supposed to be a programme of attraction rather than promotion."
The disease/habit debate in alcohol studies is not new. The publication of the first Rand Report on national alcohol abuse treatment programmes in the US in 1976 revealed that of the treated alcoholics studied 24 per cent were abstaining after 18 months, while 22 per cent were drinking normally. This ignited a debate on controlled drinking treatment for alcoholics which continued into, the 1980s.
Clara, a 58 year old New Yorker, was in AA for three years' and found the sense of vulnerability oppressive. "Women are powerless enough in this society of without being made to feel even more so when they go for help," she says. "I don't do well with dogma and hated the feeling in, AA meetings that you should grovel and feel ashamed of this terrible illness." She finds MM's approach more appealing but the regime more demanding.
"Limiting yourself to one or two drinks is far harder," she says, "even though you have tricks like going late to the cocktail party. It is easier not to drink at all but you, have a different life and I didn't want that."
MOST of the people in Clara's group are binge or daily drinkers who feel they can rely on self control. Barry Carr is familiar with that view but has learned to distrust it.
"Addicts love to say `I'm going to meetings, I've cut down to three a week'," he concludes. "But show me these people in 10 years' time. One of the dangers here is that there is no way of assessing this support group's results."
Audrey Kishline responds that there is a middle ground where MM can advise problem drinkers without demonising them. At the moment she has funding not fundamentals on her mind and concedes that by the time she starts paying herself a salary, she may wish she had left well enough alone.
