Abstinence works for many, including writer and recovering alcoholic Suzanne Harrington. But are there alternatives to dealing with alcohol misuse and what is the evidence to support them?
Is there a case for controlled drinking? Or if you have to control it, does this mean it’s problematic? Many of us have tried controlled drinking before painfully realising abstinence is the only thing that works; trying to control our drinking brought us nothing but frustration and despair.
Yet the alternative — never drinking again — seemed so overwhelming that we kept going around in circles, until we got so dizzy we fell into 12-step, abstinence-based recovery. And it works — for millions of us, it is a lifesaver, a gamechanger. Based on altruism, it is free and anonymous for anyone who needs it. The problem is that by the time you turn up at a meeting, the wheels may have already come off. Do we really have to reach rock bottom before we stop?
As our understanding of problematic drinking expands, so too does our approach to it. Alcohol-use disorder, as it is now called, has more untreated patients than any other mental health disorder — a meta-analysis of 22 studies involving 4,204 patients concluded that we need to broaden our thinking in terms of treatment. That’s according to the study published in the National Library of Medicine from the Society for the Study of Addiction.
It says: “Available evidence does not support abstinence as the only approach in the treatment of alcohol-use disorder. Controlled drinking, particularly if supported by specific psychotherapy, appears to be a viable option where an abstinence-oriented approach is not applicable.”
Really? Controlled drinking works? Addiction researcher Rob Calder is head of communications at the Society for the Study of Addiction and an editor of the Addiction Journal. He says that in recent times there have been more conversations around exploring the idea of controlled drinking, and more subtlety in treatment models.
“Treatment is no longer just about getting people off alcohol, and that’s our job done,” he says. “It’s about getting people involved with training, education, employment services, about helping people to recover and get better, to lead the kind of lives they want. Abstinence, harm reduction and controlled drinking can all be tools to do that.
“A lot of it is making sure that your goals, how you get there, and the support you use, are all aligned. If abstinence makes sense to someone, if it resonates, and they do things to help themselves get abstinent, like getting rid of drinking friends, changing their routines, saying no to all the drinks, and have a care plan built around that, then that’s a great way to go.
“But similarly, if the idea of abstinence scares someone, if it seems too difficult, but they think they could manage controlled drinking and have a care plan to get them there — maybe having less strong drinks, starting drinking later, having spaces between drinks, trying ways to stop after a certain amount, drinking only on certain days — then that would be more effective for them.”
While these tactics tend not to work at all for those of us who are problem drinkers — once we start, we can’t stop — the important aspect here is to explore, to engage, to try various things. “When people are addressing their alcohol use, it’s relatively rare that they get it right first time,” says Dr Calder. “Someone who tries abstinence a few times might respond better to trying controlled drinking, and similarly someone who has tried controlled drinking may realise that actually yes, they do need to be abstinent. It’s part of the journey of exploration — and that will be very personal to you.”
Dr Calder says it’s like Couch to 5K — that is, a gradual process of realistic goal-setting, of shared decision-making with your support people — doctor, employer, family, peers. And to remember that: “The more normal something seems, the more likely people are to use that substance.”
Alcohol, unlike other drugs, is as normalised as tea — it’s everywhere, and present at every occasion from birth to death, and all the bits in between. No wonder so many of us struggle with it. Yet the 12-step recovery model can seem both daunting and dated, especially for women.
Sobriety coach Kate Bailly is a holistic sobriety coach and co-founder of LoveSober, which focuses on habit change around addictive behaviours. She works with women, using an abstinence model of recovery but never the word ‘alcoholic’, which she says has not been used by medical professionals in 20 years. Instead she calls it “freedom” from alcohol.
“Mindful drinking is bulls**t,” she says. “The moment you drink, you are not mindful, because alcohol affects the prefrontal cortex of the brain. In my experience, it just doesn’t work. It’s where misery lies.” She pauses. “But there is a place for controlled drinking if it is part of the path towards freedom from drinking.”
Bailly works with women who are using alcohol as a stress release, or as a coping mechanism, but who would “not in a million years” identify as ‘alcoholic’. “This language is outdated and shaming,” she says. “Women who need agency and power, rather than powerlessness and rock bottoms.”
In her book Quit Like A Woman, Holly Whitaker, founder of the Tempest online sobriety platform, echoes Bailly’s take on traditional 12-step recovery in a chapter entitled ‘AA Was Created For Men’. “Women aren’t sick from an overdeveloped sense of ego or a pathological lack of humility because all we’ve ever done is chase our desires; we are sick because we don’t have these things. We drink not because we have too much power but because we have so little.”
Bailly works with ‘grey area drinking’, defined by the WHO as alcohol users who are psychologically rather than physically dependent; those who are concerned by their drinking, but not in need of actual detox. “The wheels haven’t yet come off,” she says.
She defines herself as “a woman in recovery”, with her sobriety a daily practice of “joyful engagement” which uses a personalised toolkit of peer support, structure and yoga. She began her recovery online via She Recovers and Soberistas, before starting her own platform.
LoveSober is about “compassion, creativity, mindfulness and community”, and is trauma-informed — not ‘what’s wrong with me?’ but ‘what’s happened to me?’ “It’s about how to be well and sober in a 21st-century woman’s body,” she says, reminding us that until 1992, women were not even included in alcohol research — because of our endocrine systems, our bodies were regarded as ‘unstable’.
I ask about altruism, one of the main tenets of 12-step recovery, where members are encouraged to ‘give it away to keep it’ — in other words, support each other without any kind of financial transaction, ever. “We recover out loud,” says Bailly. She explains how there is a small monthly fee to be part of a private online support group, but that they never turn anyone away who is in need.
Joanne Nash is a sober coach based in Derry, who runs private online groups as well as face-to-face sessions. “The thought of never-again can be overwhelming, and I would never specify what someone should do,” she says. “Maybe you want to attempt a moderation approach to drinking in order to come to your own conclusions — that’s how I got there [became abstinent].”
Nash is keen to help women overcome feelings of shame and stigma, and to change the conversation around drinking. “I run book clubs for the sober curious, where people can come together and explore their relationships with alcohol without fear,” she says. “For people who are interested in early intervention, who think, ‘this has become too much of a habit and I don’t like it’, but are not physically dependent.”
She says that in Ireland, daily drinking and binge drinking is so normalised that “most of our society has some kind of psychological dependence”, particularly after lockdown blurred the drinking time boundaries. She describes how those who have managed to quit drinking can feel so ashamed and othered that they keep their abstinence a secret, relying on excuses like driving, or being on medication, rather than just saying they no longer drink. “There’s so much pressure to join in,” she says. “And while we’re definitely waking up, we are still behind the times in relation to the UK and the US.”
She does believe, however, that boozing may be going the same way as smoking, particularly among younger people. “The younger generation have a lot more of a take-it-or-leave-it attitude,” she says. “Particularly when drunken behaviour can now be recorded and uploaded.”
Hilarious blackout anecdotes no longer seem quite so funny if made public in digital perpetuity; add to this the WHO’s revision of the science — red wine is not ‘good for your heart’, because no amount of alcohol, a toxin, is ‘good’ for any part of the body — and you can see how alcohol is less appealing to those who grew up online with greater health awareness.
According to a Health Research Board report from April 2021, 25pc of Irish people were abstinent from alcohol in the previous year. Yet three people a day in Ireland still die of alcohol-related causes, with the average annual consumption the equivalent of 40 bottles of vodka, or 113 bottles of wine, or 436 pints. That’s a lot of drink when you remember that one quarter of us don’t drink at all. A lot of people suffering in secret and a lot of conversations yet to be had. Whatever your approach to behavioural change may be, what matters is getting the conversation going.
For more information on changing alcohol habits, check out lovesober.com, jointempest.com and thesobercoachcouk.wordpress.com