then began to decline at a rate of stable remission of 2 to 3% per year. older alcoholics are relatively rare because of the rate of remission and a higher mortality rate. seventy-two alcoholics in the core city sample were successfully followed to age 70. by this age 54% had died, 32% were abstinent, 1% were controlled drinkers, and 12% were still abusing alcohol. by comparison 19 alcoholics in the college sample were successfully followed to age 70. by this age 58% had died, 21% were abstinent, 10.5% were controlled drinkers, and 10.5% were still abusing alcohol. on the topic of whether controlled drinking is advisable as a therapeutic goal, vaillant concluded that "training alcohol-dependent individuals to achieve stable return to controlled drinking is a mirage." successful return to controlled drinking is possible, just a rare and unstable outcome that in the long term usually ends in relapse or abstinence, especially for the more severe cases. vaillant tracked two samples within his study group: 21 alcohol abusers who had attained stable abstinence, and 22 who had returned to a stable pattern of controlled drinking. at the end of 15 years of follow-up, in 1995, one of the 21 abstainers had returned to controlled drinking, and one had relapsed. in contrast, of the 22 controlled drinkers 3 became abstinent and 7 relapsed. for the less severe cases, vaillant concluded that controlled drinking is a worthwhile and valid goal, but "by the time an alcoholic is ill enough to require clinic treatment, return to asymptomatic drinking is the exception not the rule." clinical treatment in the clinic sample, 100 severe alcoholics treated at the clinic were followed for 8 years. the clinic's methods were multi-modal: detoxification and hospital treatment followed by referral to aa. at the end of the 8 years, 34% of subjects had achieved stable abstinence, 29% had died, and 26% were still abusing alcohol, and the evidence was that other clinical studies had reported similar lack of success. subjects who had a stable social environment or who frequently went to aa meetings had the highest rates of abstinence. overall, however, treatment other than aa did not significantly improve the subjects’ outcome. in fact vaillant reports the dismal fact that fully 95% of the clinic sample had relapsed at some time during the 8-year study period. vaillant noted that clinical treatment helped only in the short term, as crisis intervention and detox. there was one indicator, a financial one, of short-term success: clinical intervention had significantly reduced the cost of future health care for the alcoholics. vaillant's conclusion was that “there is compelling evidence that the results of our treatment were no better than the natural history of the disease.” if clinical treatment had failed to improve on the long-term recovery rates of alcoholics, then what would be the most hopeful route to sobriety? paths to recovery research by vaillant and others found that there were no obvious factors or personality differences to distinguish alcoholics from abstainers; “to a large extent, relapse to and remission from alcoholism remains a mystery.” as was observed in the 1940s in patients with tuberculosis—at that time incurable—recovery depended largely on the patient's own resistance and morale. the same applies to alcoholism, which at present still has no known ‘cure’. as with diabetes, professional help is in training to prevent a relapse and in crisis intervention until patients are strong enough to heal themselves. if natural forces are dominant in the healing process, then treatment should aim to strengthen and support these natural forces, vaillant argued. the alcoholic needs support in making the required personality change. thus, achieving long-term sobriety usually involves finding a substitute dependency, such as group attendance; experiencing negative consequences of drinking, such as legal problems or a painful ulcer; new, close relationships and social support; a source of inspiration and hope such as a religious group. vaillant argues that an important contribution health professionals can make is to explain alcoholism to patients as a disease, which encourages the patient to take responsibility for their problem without debilitating guilt, in the same way that a diabetic becomes responsible for proper self care when they become aware of their condition. alcoholics anonymous vaillant, who is a non-alcoholic trustee of aa, made the effectiveness of aa one of the key questions to be investigated in his research. vaillant argues that aa and other similar groups effectively harness the above four factors of healing and that many alcoholics achieve sobriety through aa attendance. however, he also notes that the “effectiveness of aa has not been adequately assessed” and that “direct evidence for the efficacy of aa… remains as elusive as ever. for example, if an alcoholic achieves sobriety during aa attendance, who is to say if aa helped or if he merely went to aa when he was ready to heal? in the clinic sample, 48% of the 29 alcoholics who achieved sobriety eventually attended 300 or more aa meetings, and aa attendance was associated with good outcomes in patients who otherwise would have been predicted not to remit. in the core city sample the more severe alcoholics attended aa, possibly because all other avenues had failed—after all, aa meetings are rarely attended for hedonistic reasons. the implication from all three samples was simply that many alcoholics find help through aa. book reviews vaillant’s academic peers saw the natural history of alcoholism as “objective, scholarly, and factual,” “wise” and “comprehensive”, an “outstanding and highly recommended text”, and “one of the few and by far the most thorough and scientific.” james royce wrote that vaillant "cites innumerable studies and examines opposing viewpoints on every issue," but that this objectivity made the book harder to read for the general reader since the conclusions were difficult to extract. there were varying opinions on the book's readability. according to david n. saunders “the book is hard to follow because so much research material is included.” the new york times advised that the casual reader should skip over most of the technical discussion, whereas the national review noted only an “occasional thicket of psycho-statistical jargon.” royce wrote that vaillant failed to summarize new (in 1983) research findings on alcohol's interaction with the brain, and that vaillant had not quoted some notable researchers who have argued for the disease model of alcoholism. saunders held that more discussion of the treatment issues was needed and noted that many of the measurements made before vaillant took over the studies were very crude. perhaps the sharpest critic of vaillant's work was controlled drinking proponent stanton peele. in a 1983 review in the new york times, peele wrote that "the results of this research do not provide ready support for the disease theory of alcoholism. ... finds strong evidence in the inner city group for sociocultural causality in alcoholism." in his book diseasing of america peele claimed that "vaillant emphatically endorses the disease model... he sees alcoholism as a primary disease... however, vaillant's claims are not supported by his own data." other reviewers held the opposite, that vaillant did not see alcoholism as a disease. addiction researcher james e. royce wrote that "vaillant avoids a simplistic medical model of alcoholism, pointing up instead its complexity as a socio-psycho-biological illness." david n. saunders of the school of social work, virginia commonwealth university, wrote that vaillant "maintains that alcoholism is both a disease and a behaviour disorder." in his summary at the end of the book, vaillant in fact wrote that "alcoholism can simultaneously reflect both a conditioned habit and a disease; and the disease of alcoholism can be as well defined by a sociological model as by a medical model." footnotes teachout, 1984 vaillant 1995, p 376. vaillant 1995, p 241-244 goodwin 1984 vaillant 2003, p 1044. vaillant 1995, p 131. vaillant 1995, p 317 saunders, 1884. note that in this article alcoholics will be referred to as male to reflect the bias of the samples. vaillant 1995, p 312 vaillant 1995, p 188 vaillant 1996. vaillant 2003 vaillant 1995, p 29 & 32. goodwin 1894. vaillant 1995, p 362 vaillant 1995, p 240. vaillant 1995, p 24. vaillant 1995, p 292 vaillant 1995, p 33. vaillant 1995, p 364 vaillant 1995, p 33 vaillant 1995, p 77. vaillant 1995, p 37. vaillant 1995, p 35-36. vaillant 1995, p 31. vaillant 1995, p 39-40. vaillant 1995, p 36. vaillant 1995, p 37-39. vaillant 1995, p 19 o.reilly 1983. vaillant 1995, p 47 vaillant 1995, p 51 and 76. vaillant 1995, p 58 and 73 vaillant 1995, p 84, 86-88, and 96-98. vaillant 1995, p 60 vaillant 1995, p61. vaillant 1995, p 63 vaillant 1995, p 67. vaillant 1995, p 110 - 112. vaillant 1995, p 114. vaillant 1995, p 84 vaillant 1995, p 119 and 156 vaillant 2003, p 1047. vaillant 1996, p 157-158 vaillant 2003, p 1043. vaillant 1996, p 383. vaillant 1996, p 167, 170, 233, and 297. vaillant 1996, p 294. vaillant 1996, p 158. vaillant 1995, p 352. vaillant 1996, p 158 vaillant 1995, p 350. note that the figure of 95%—the number of clinical patients who relapsed at any time during the 8 year study—has been quoted on some personal websites as evidence that aa is ineffective. vaillant 1995, p 360-361. vaillant 1996, p 350. vaillant 1996, p 252 and 371. vaillant 1996, p 252 and 385. vaillant 1996, p 384. vaillant 1996, p 366 and 378. vaillant 1996, p 385. vaillant 1996, p 10. vaillant 1995, p 255. vaillant 1995, p 265. vaillant 1995, p 253. vaillant 1996, p 158. vaillant 1995, p 257. vaillant 1995, p 268. vaillant 1996, p 262-263. vaillant 1995, p 388. saunders, 1984 goodwin, 1984 mendelson, 1996 royce, 1983. saunders, 1984. lehmann-haupt, 1983. teachout, 1984. royce 1983. peele, 1983 peele 1989, p68. royce, 1983 saunders 1983 vaillant 1995, p 376