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Women & Booze: Is Everything We Know About Alcoholism Wrong?

Ruth Graham
September 14, 2015
Ruth Graham
Written by
Photo by Getty Images
September 14, 2015

Jenny didn’t think of herself as an alcoholic, but she knew she was falling into some bad habits. She was drinking alone, and sometimes found it hard to concentrate at work after a night of booze. She brought it up with her therapist, but says he dismissed her, saying he was more concerned about the extra calories and weight gain.

Over the years, her consumption ebbed and flowed. During a decadelong marriage to a nondrinker, she cut down; when they divorced, she again found herself drinking heavily alone.

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Throughout this time, she remained functional — she always made it to work, for example — and didn’t identify as the kind of chronic “rock-bottom” drinker she associated with Alcoholics Anonymous.

She had evidence she could live without alcohol, but she also struggled to understand what was driving her to drink excessively, and whether her consumption was a problem. She worried that she couldn’t seem to fully control her drinking.

“I’d always thought at some point I’d like to talk to an alcohol counselor, and they’d either tell me to go to AA or say, ‘What you’re doing is absolutely fine, it’s normal,’” she said recently. “I didn’t realize there was a middle way. … I thought it’s either you quit drinking completely and you go to AA, or you just drink.”

And so, for years she just drank.

For women whose lives include alcohol, Jenny’s story may sound familiar: You realize with a pang of discomfort that it now takes two or three glasses of wine to wind down every night instead of just one occasional glass.

Your drinking may concern you, but the idea of standing up in front of a group meeting in a church basement, calling yourself an alcoholic, and renouncing even a sip of beer for the rest of your life ... well, that sounds so extreme.

Is AA's Message Antifeminist?

AA’s increasingly vocal critics say its approach is troublingly one-size-fits-all, that it ignores the majority of people who might benefit from changing their drinking habits, and that it has an alarmingly low success rate.

In the 80 years since Alcoholics Anonymous was founded, its central argument — that the path to recovery requires abstinence and the admission of powerlessness — has not changed despite seismic cultural shifts and new medical understandings of alcohol use.

Suffice it to say that the world has changed for women, even more dramatically than it has for men, and AA has done little to adapt. Most damaging, perhaps is that central message, which can seem fundamentally at odds with feminist ideology: that the addict is powerless, with no ability to control her condition.

“We spend all this time telling women today, ‘You can do this, and you can do this, and you can do this. You have the power and the capability,’” said journalist Gabrielle Glaser, who wrote a recent story in The Atlantic, The Irrationality of Alcoholics Anonymous.

The AA message, she says, and its focus on powerlessness over alcohol, “is exactly the opposite message of everything we want young women to believe.”

A Man's Program In a Man's World

In North America, Alcoholics Anonymous, with its 12-step abstinence-only prescription, is overwhelmingly the dominant approach to problem drinking. And it’s indisputable that the program has helped significant numbers of people.

Today, about 1.4 million people are members of more than 65,000 groups that meet all around the U.S. and Canada, in cities and small towns, suburban rec centers and rural churches.

Alcoholics Anonymous was founded in the 1930s by a former stockbroker named Bill Wilson who had no medical training, but a devastating history as a “chronic drunkard.”

Wilson had experienced a powerful spiritual awakening while hospitalized for his drinking. Soon afterward, he became a follower of the Oxford Group, a Christian movement founded in England whose tenets included the notion that all people are sinners, that sinners can change, and that confession is necessary for change.

With a doctor and fellow alcoholic named Robert Smith, he founded a support group whose tenets were remarkably similar to the Oxford Group’s. A few years later, the now-famous “12 steps” to recovery were formalized, and the group’s methods and orthodoxy began to spread.

As Glaser recounts in her 2013 book Her Best-Kept Secret: Why Women Drink — and How They Can Regain Control, the early AA community was an unfriendly place for women. The group’s first guidebook was tailored to men, with a chapter titled “To Wives” that suggested women were likelier to be married to alcoholics than to have a problem themselves.

Women who did show signs of alcoholism were suspected of being promiscuous, a threat to male members and their marriages. As late as 1959, some chapters refused to allow women to attend meetings. As one prominent early female member and leader put it, “This was a man’s problem and AA was a man’s program and this was a man’s world.”

Today, no one claims that women who drink too much are morally inferior to their male peers, and women are welcome at AA meetings. But some critics argue AA’s approach is not as helpful for women as it is for men, generally speaking.

For starters, the emphasis on “powerlessness” ignores the fact that many women who struggle with drinking aren’t necessarily addicted to alcohol, but instead are using it to mask and cope with underlying issues such as anxiety and depression.

“Women drink to medicate their negative feelings away — the negative feelings of anxiety and the sad feelings of depression,” said Glaser, pointing out that women are significantly likelier than men to be diagnosed with both disorders.

“To go to a place where the program tells you you’re powerless over something ... it just doesn’t make sense.” If anything, women tend to be experts to a fault when it comes to acknowledging their weaknesses.

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Rethinking Alcoholism

Not only does the abstinence model promote a strict definition of “sobriety,” there’s also the question of whether problem drinking is properly understood as a “disease” in the way AA and others describe it.

The American Medical Association calls it an “illness.” But the DSM-5, the definitive diagnostic manual issued by the American Psychiatric Association, identifies alcohol use disorder along a spectrum, indicating that “alcoholic” is not a simple yes-or-no diagnosis.

Even the term “alcoholism,” so widely used in pop culture, has not been used by serious researchers for decades. Following the DSM’s lead, they use more precise terms like “alcohol abuse” and “alcohol dependence.” But the popular notion that if you drink too much, you have an incurable disease is not just scary and stigmatizing, it also implies that no sufferer has the power to heal themselves.

The public information coordinator at AA’s General Service Office wrote in an email: “As a non-professional organization of alcoholics helping alcoholics through sharing our personal experience with each other, we are not qualified to speak on matters of scientific or medical research regarding the effectiveness of our approach.” He emphasized that while AA cooperates with treatment professionals, it does not own or operate treatment facilities.

“It’s hijacked the language, where sobriety means a certain thing: It means you don’t drink anymore,” Glaser said. She mentioned a woman she interviewed who is a member of a program called HAMS (Harm reduction, Abstinence, and Moderation Support), who at one point was drinking a bottle and a half of wine every night, but who now drinks only in moderation. “That’s exactly what I would call ‘sober,’” Glaser said. By AA’s definition, though, she is anything but.

It is true that chronic and severe overdrinkers typically have chemical dependencies on alcohol. For that group, lifelong abstinence may be the only reasonable goal. But they do not represent the majority of those who drink too much: the stay-at-home mother who finds herself pouring her first glass of pinot grigio a little earlier every day, or the professional who can’t seem to stop at one cocktail at work events.

Dr. Mark Willenbring, former director of the Division of Treatment and Recovery Research of the National Institute on Alcohol Abuse and Alcoholism at the NIH, points to a 2007 study that found that more than 70 percent of those who have a period of alcohol dependence have just a single period that lasts less than five years — and then never recurs.

“AA was founded by people whose lives had just been completely exploded by their drinking,” he said. “But most people who develop an alcohol-use disorder never explode their lives because of it.”

That’s why it’s a problem that the AA paradigm is the only one many people know. Willenbring points out that AA members are predominantly the “sickest 10 percent” of people with alcohol-use disorder. “We’ve really focused exclusively all of our attention on the most severe 10 percent,” he said. “They don’t represent the broad group of people who struggle with drinking.”

Framing the discussion in such a binary way (“You’re an alcoholic or you’re not”) means that some people whose lives could be improved by moderating their alcohol intake don’t get the help they need. And the sheer dominance of AA may lead people to believe that there is no other way.

Support Without The Stigma

Many women face this dilemma, wanting to reduce alcohol consumption without placing severe limits or labels on themselves.

It took years for Jenny (not her real name) to discover there was a “middle way” between total, eternal abstinence and the discomforting lack of control she was experiencing. For her, it was a program called Moderation Management, which emphasizes personal responsibility and balance.

Similar programs have varying guidelines, but what unites them is that they give people the tools to cut down and take control, without telling them they are hopelessly in the grip of a disease and that they must abstain forever to recover.

Moderation Management, a support group founded in 1994, believes “self-esteem and self-management are essential to recovery.” It distinguishes between “problem drinkers” and alcoholics, and encourages its adherents to set their own drinking goals. (Moderation Management has its own troublesome history: Its founder ultimately rejected her own method, turned to AA, and then caused a drunken driving crash that killed two people.)

HAMS, a New York-based group that functions primarily online, offers support for “anyone who wants to change their drinking habits for the better.” HAMS uses the “harm reduction” model, a philosophy in public health that focuses on reducing the risks of overdrinking, much like condoms reduce the risks of sex.

Rather than push adherents to abstain, it asks them to identify the negative consequences of their drinking (like risky sex) and come up with a plan to avoid them (like always carrying condoms). Willenbring now runs a treatment facility in Minneapolis that offers help to a much broader spectrum of people with alcohol and other substance abuse disorders. And some doctors prescribe an “opioid antagonist” called naltrexone that has been shown to reduce heavy drinking simply by decreasing cravings.

It’s hard to find reliable success-rate comparisons for these approaches, but with AA’s long-term success rate between 5 and 10 percent, who could argue against making alternatives more widely available? Meanwhile, these non-abstinence approaches are earning plenty of fans, particularly among women. One 2004 survey found that 66 percent of participants in Moderation Management were female, double the percentage in AA.

Brooke, who works in telecommunications in Atlanta and has a part-time job in the restaurant industry, attends occasional AA meetings just to listen in. “As far as being an honest person, trying not to lie and not to be selfish, those principles helped me to become a better person,” she said.

But she wasn’t physically addicted to alcohol, and AA made her feel guilty every time she had a drink, even though she wasn’t convinced she needed to quit cold turkey. She has made more meaningful progress to take control of her own drinking by taking Wellbutrin, starting cognitive behavioral therapy, and connecting online with Moderation Management.

These days, her goal is to drink no more than about 12 drinks a week, no more than four a day. (Moderation Management suggests no more than three a day for women, but Brooke says “it’s a struggle at times.”) She tries to abstain completely for four days a week.

And it’s not just about counting drinks; it’s also important to her to feel good about her behavior while she’s drinking. That means no severe misbehavior, like driving under the influence, but also no acting “obnoxious or bitchy.”

Jenny, who is now in her 50s and working in the arts, leads a Moderation Management group for women in New York, where members gather to share their stories and support each other’s goals.

Last year, she started seeing a new therapist. Within a week, she was able to cut down to just one drink a day. (In the beginning, Jenny’s therapist discounted her bill if she stuck to her intake goals.)

Lately she has been having as few as two or three drinks a week, using concrete tools like delaying her first drink until later in the evening, eating first, arriving late to parties, and pouring the rest of a bottle of wine down the drain if she’s home alone.

Donna Dierker, who lives in the St. Louis area, decided she wanted help getting her drinking under control the year she turned 40. But the “steps” in AA just didn’t resonate with her and she didn’t identify as an alcoholic. After seeing an article in the local newspaper on Moderation Management, she reached out to the organization, and got involved.

Today, Dierker helps keep herself in check by abstaining completely every January, April, and either August or September. She enjoys those months because she concentrates better and eats more healthfully, and the abstinence serves as a “reset” to her tolerance level. But she also enjoys the taste of wine and beer, and the social aspects of drinking.

For drinkers like Donna, Jenny, and Brooke, aiming for moderation is empowering. Every year Dierker hosts a tasting party with friends, where they sample two-ounce servings of unfamiliar varietals and discuss them. Plus, she said, “Dry red wine makes lasagna taste better.”

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Ruth Graham
Ruth Graham

Ruth Graham is a freelance journalist based in New Hampshire. She is a contributing writer to Slate and to the Boston Globe's Ideas section. Follow her on Twitter @publicroad.