DDN February 2021 DDN February 2021 - Page 7


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 notso-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
‘ 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 . ’
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 nonabstinence objectives would ‘ continue to force problem drinkers to keep their pursuit of low-risk
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
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 .’
Mike Ashton is co-editor of Drug and Alcohol Findings . https :// findings . org . uk ? s = dd .
See https :// findings . org . uk / PHP / dl . php ? f = cont _ drink . hot & s = dd for a fuller account .
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