‘Once an alcoholic, always an alcoholic’ is outdated. Here’s why

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EDITOR’S NOTE: If you or someone you know is struggling with substance abuse, call the US Substance Abuse and Mental Health Services Administration’s National Helpline at 800-662-HELP (4357) and find more resources here .

Brad Pitt’s recent revelation that he’s drinking again in “a more restrained manner,” after seven years of sobriety following heavy drinking , sparked intense pushback. The actor’s past behavior aside, the larger controversy was in challenging the long-held idea that someone who struggled with alcohol in the past can’t ever drink normally — that recovery is defined solely by sobriety.

The controversy Pitt stepped into comes down to old versus relatively new approaches to dealing with drinking problems. What makes someone “recovered” from alcohol addiction has seen “an evolution in health care,” said Dr. Smita Das, addiction psychiatrist in the Addiction Medicine Dual Diagnosis Clinic at Stanford University in California.

Relevant medical fields in recent years have widely embraced the idea of a spectrum of recovery, including sobriety and non-abstinence, but some clinicians, abstinence support organizations (most notably Alcoholics Anonymous), and patients with alcohol issues haven’t caught up to the science — or are downright opposing it.

Pitt simply gave voice to the expanded understanding of recovery from what is commonly called alcohol addiction or alcoholism, but has been officially known as alcohol use disorder , or AUD, since 2013, according to the DSM-5. That’s the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — the authoritative handbook of mental disorders published by the American Psychiatric Association and used by mental health professionals in the United States.

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The body of research on non-abstinent recovery has been growing as well. A small study in February examined how low to moderate drinking can be part of successful recovery for some. Compared with the abstinent group in that study, those who continued to drink felt more confident they could limit their intake. Participants who drank also felt that positive life changes and supportive relationships bolstered their efforts to maintain recovery.

In a larger 2025 study about non-abstinent recovery, about 1,900 participants reported drinking in the past month — and their health and functioning were similar to those of abstinent participants, though they were slightly more likely to be experiencing psychological distress.

Alcohol use disorder is defined by the DSM-5 as “frequent or heavy alcohol drinking that becomes difficult to control and leads to problems such as in relationships, work, school, family, or other areas.”

Someone can have mild, moderate or severe AUD depending on how many criteria they’ve experienced in the past year. This definition was a broader move away from previous DSMs’ binary diagnoses of alcohol abuse and alcohol dependence. The “abuse” diagnosis required that a patient was experiencing severe or dangerous consequences such as alcohol-related legal problems or failure to fulfill major obligations. The “dependence” diagnosis referred to serious but less severe issues, such as abandoned interests and repeatedly failed attempts to quit drinking.

The DSM-5 definition of AUD supports the idea that sobriety “is a part of the definition of recovery, but it is not the whole thing,” Das said — since patients can also reach remission by reducing drinking and whatever criteria that led to their diagnosis.

Researchers with the US National Institute on Alcohol Abuse and Alcoholism, or NIAAA, published a paper on a new definition of recovery from AUD in 2022 — calling it a process or outcome in which someone pursues or achieves both remission from AUD and cessation of heavy drinking.

Remission requires that a patient have no AUD criteria besides craving. Someone who hasn’t had any criteria for up to three months is in initial remission — three months to one year is early remission, one to five years is sustained, and more than five years is stable. For men, cessation of heavy drinking means having no more than four standard drinks on a single day or 14 drinks weekly, and for women, maximum three drinks on one day or seven drinks weekly, the authors wrote.

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The fulfillment of basic needs also factors into recovery, the authors added, as do enhancements or improvements in social support, spirituality, physical and mental health, and other aspects of well-being.

Before, while some studies had examined non-abstinent recovery in various ways, there wasn’t an operational or measurable definition that would help researchers better chart and study recovery. This lack meant “we really had no systematic studies on what constitutes recovery, how long it lasts and, more importantly, how to improve recovery,” said Dr. George Koob, NIAAA director and senior author of the paper. He and his coauthors worked with other researchers, clinicians and recovery specialists and incorporated the DSM-5 criteria.

The NIAAA definition has been accepted by many medical authorities and has been facilitating research, as the authors hoped, experts said.

The DSM-5 and NIAAA work increase access to care by not making patients feel like they have to be perfect to be considered recovered, which can be intimidating and prevent effort to heal, experts said. The work also lowers barriers in technical ways — the ability to be diagnosed with mild or moderate AUD makes you eligible for insured care before you hit rock bottom and need more expensive and intensive help. Not defining recovery by abstinence only is also aiding efforts to develop or broaden access to AUD medications .

Abstinence works best for most people, experts say. And those choosing abstinence experience the most progress in physical health, quality of life and psychosocial functioning, which is the ability to manage one’s daily life, psychological well-being and social environment, the NIAAA researchers wrote. But, they added, a growing body of evidence shows that remission from heavy drinking also is linked to meaningful, long-term improvements.

Another study, from 2019 , found those who achieved abstinence and people who achieved just remission from heavy drinking had similar health care costs five years after treatment, and similar psychosocial functioning at one year and nine years post treatment. A 2025 study on recovery attempts as defined by NIAAA, however, found that participants who still drank were more likely to relapse.

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There isn’t much research on predictors for who can drink normally, said Das, who is also a clinical professor of psychiatry and behavioral sciences at Stanford’s School of Medicine. But per her clinical experience and the 2025 study, light or moderate consumption of alcohol may be more feasible for people who didn’t have severe AUD, for those who don’t have underlying mental health issues or have healed or learned to manage them, for those who have been sober for years, or for individuals no longer in the situation in which they started drinking.

Of course, regarding overall health, no amount of alcohol is good for you, as even low consumption has been linked with higher risk for issues including dementia , cancer , high blood pressure and stroke .

Much of the general public, however, hasn’t caught up to these developments, which remain strongly discouraged and criticized by the abstinence support group space — especially proponents of AA.

The ideas of “once an alcoholic, always an alcoholic” and that abstinence is the only way to recovery stem from the predominant messaging and influence of AA, which began in 1935, said Dr. Michael Joshua Ostacher, a member of the American Psychiatric Association’s Council on Addiction Psychiatry.

“‘Alcoholic’ is a term that’s adopted by Alcoholics Anonymous to identify its own members, and by which their own members identify themselves,” added Ostacher, who is also a professor of psychiatry and behavioral sciences at Stanford’s School of Medicine.

This approach is based on the idea that AUD is an incurable illness, Das said, and, in some people’s minds, that all cases result from a brain already prone to addiction. Hence the belief — and often lived experience — that even just a sip of alcohol can make anyone relapse regardless of any recovery work done or number of years sober. These factors have created a culture in which people who return to normal drinking are often told by sober people that if they can do so without their consumption becoming excessive and destructive, they were never an “alcoholic” or “true addict” in the first place — maybe just someone who was emotionally dependent on alcohol.

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On one hand, while the “always an alcoholic” phrase “is clinically outdated,” for vulnerable people it’s a protective behavioral boundary preventing them from attempting risky experiments, Das said.

Abstinence and 12-step programs, including AA, have proven to be significantly effective for many people worldwide, Ostacher said — AA had nearly 2 million active members and more than 120,000 groups worldwide as of 2021, according to the organization’s data .

On the other hand, the debate reflects a clash between the medical and cultural frameworks used to make sense of addiction, Das said.

“Addiction is not universally a fixed, unchangeable neurological state,” Das said. Someone can meet criteria for severe AUD at age 21, and then, with treatments, brain maturation, lifestyle changes and/or years of abstinence, be diagnosis-free at age 40. The brain is a muscle with adaptable neurocircuitry that can be healed by those interventions, Das added — but there are also people whose deeply affected neural reward and habit pathways may not heal entirely.

“To claim someone who went through that hard work ‘never had a problem’ minimizes the real medical struggle they overcame,” Das said. “It would be like telling someone who was obese and now thin after a lot of hard work, that they never were obese.”

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Additionally, AA and its principles don’t work for everyone, experts said. But “from AA’s perspective, it didn’t work for them because they didn’t work the program hard enough, or they weren’t honest enough to work the program,” Ostacher said.

A setting wherein one drink is a violation of recovery and necessitates starting over can make people feel ashamed, even if they’re really trying — which can lead to more serious relapses. Kenneth Anderson, a 68-year-old man from Philadelphia, said, “I never drank as much in my life as when I was in AA.”

The requirement for belief in a higher power also doesn’t resonate with everyone. Anderson, an atheist, added that he felt the insistence that “humans are powerless and can only be rescued from alcohol by an omnipotent deity” was a “terrible, damaging message.” Anderson struggled with AUD from roughly the 1980s to 2000s, but now has only one or two drinks every few months if he wants, while practicing other important elements of recovery. For him, those include managing the online HAMS (Harm Reduction, Abstinence and Moderation Support) group he founded that has more than 13,000 members.

Importantly, various factors contribute to AUD and may not be addressed by AA, experts said. Those include genetics, neurological vulnerabilities, life stressors and mental health issues — 50% of people with a substance use disorder have a mental health condition.

When a patient who has recovered and improved their life asks Das about drinking again, she asks about their true motives, any potential risks and the behaviors that sustain their goals.

Sometimes a patient wants to have a drink with friends to feel included or less anxious. In those cases, Das might recommend they buy a mocktail or practice coping skills instead. If they’re thinking alcohol could help them unwind, Das encourages them to consider what else might relax them and maybe even benefit them in other ways.

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Part of the risk is that alcohol inherently reduces our ability to make wise judgments, including whether we have had enough or more than planned, Das said. And even if you can drink and still be clinically recovered, there may be other reasons to choose abstinence — maybe your issues harmed loved ones, and they would be emotionally destabilized or offended by you drinking again.

“If they are very set on returning to drinking, then we have a conversation about, ‘OK, what are the things that you’re going to do to try to reduce the consequences that occurred before?’” Das said. She reviews with the patient the DSM-5 criteria they previously met so that they can recall the situations that led to problems — for example, if drinking alone makes them drink too much and spiral emotionally. “So then we say, ‘OK, drinking is only in social situations, and you have a limit,’” Das added. She and the patient then schedule follow-up appointments and keep a log of how everything’s going.

If you drink, watch for signs that it may be becoming problematic again, experts said — such as if you’re often not sticking to your rules or making them too flexible. If you’re currently struggling with alcohol, know that 1 in 10 Americans ages 12 and older have AUD, Das said. Discussing it honestly can lead you to the right treatments : outpatient or inpatient rehab, medications and therapies including cognitive behavioral therapy with relapse prevention, which is the most used therapy.

Both abstinence and moderation support groups can be helpful. Moderation Management , a member-run nonprofit founded in 1994, is a popular and professionally endorsed alternative to the abstinence approach. It has virtual and in-person sessions and encourages members to follow a nine-step program. They include doing an initial 30-day period of sobriety, examining how drinking has affected one’s life, making positive lifestyle changes and setting moderate drinking limits.

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编者注：如果您或您认识的人正在与药物滥用作斗争，请拨打美国药物滥用和精神健康服务管理局全国求助热线 800-662-HELP (4357)，并在此处查找更多资源。

布拉德·皮特近日透露，在戒酒七年后，他又开始以“更加克制的方式”饮酒，此举引发了强烈争议。撇开这位演员过去的酗酒行为不谈，更大的争议在于，它挑战了长期以来人们的固有观念：曾经酗酒的人永远无法正常饮酒——戒酒的定义仅仅在于保持清醒。

皮特卷入的这场争议归根结底是处理酗酒问题的传统方法与相对较新的方法之间的差异。加州斯坦福大学成瘾医学双重诊断诊所的成瘾精神病学家斯米塔·达斯博士表示，对于如何判断一个人是否从酒精成瘾中“康复”，医疗保健领域已经发生了“演变”。

近年来，相关医学领域普遍接受了康复谱系的概念，包括戒酒和非戒酒，但一些临床医生、戒酒支持组织（最著名的是匿名戒酒会）以及有酒精问题的患者还没有跟上科学的步伐，甚至公然反对它。

皮特只是表达了人们对酒精成瘾或酗酒康复的更广泛理解，但根据《精神疾病诊断与统计手册》（DSM-5）的规定，自 2013 年以来，它已被正式称为酒精使用障碍（AUD）。DSM-5 是《精神疾病诊断与统计手册》的第五版，是美国精神病学会出版的权威精神疾病手册，被美国精神卫生专业人员使用。

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一位神父帮助她认识到自己的酗酒问题。与耶稣的谈话让她保持清醒。她并非个例。

关于非戒酒康复的研究也在不断增加。二月份的一项小型研究探讨了少量或适量饮酒如何成为部分人成功康复的一部分。与该研究中的戒酒组相比，继续饮酒的人更有信心控制自己的饮酒量。饮酒的参与者还认为，积极的生活改变和支持性的人际关系增强了他们维持康复的努力。

在 2025 年一项关于非戒酒康复的大型研究中，约有 1900 名参与者报告说在过去一个月内饮酒——他们的健康和功能与戒酒参与者相似，尽管他们更有可能经历心理困扰。

DSM-5 将酒精使用障碍定义为“频繁或大量饮酒，难以控制，并导致人际关系、工作、学习、家庭或其他方面出现问题”。

根据过去一年中符合的酒精使用障碍（AUD）诊断标准数量，患者可分为轻度、中度和重度。这一定义比以往《精神疾病诊断与统计手册》（DSM）中将酒精滥用和酒精依赖二元化的诊断方式更为宽泛。“滥用”诊断要求患者出现严重或危险的后果，例如与酒精相关的法律问题或无法履行重要义务。“依赖”诊断则指严重但程度较轻的问题，例如兴趣爱好丧失和屡次戒酒失败。

Das 表示，DSM-5 对 AUD 的定义支持这样一种观点，即清醒“是康复定义的一部分，但不是全部”，因为患者也可以通过减少饮酒以及任何导致他们被诊断的标准来达到缓解。

美国国家酒精滥用和酒精中毒研究所 (NIAAA) 的研究人员在 2022 年发表了一篇关于 AUD 康复新定义的论文——称其为一个人追求或实现 AUD 缓解和停止大量饮酒的过程或结果。

缓解的条件是患者除了对酒精的渴求外，不再符合其他任何酒精使用障碍（AUD）的诊断标准。如果患者在三个月内没有出现任何诊断标准，则处于初始缓解期；三个月至一年为早期缓解期；一至五年为持续缓解期；五年以上为稳定缓解期。作者指出，对于男性而言，戒除重度饮酒意味着单日饮酒量不超过四杯标准饮品或每周不超过十四杯；对于女性而言，单日饮酒量不超过三杯或每周不超过七杯。

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作者补充说，基本需求的满足也是康复的因素之一，社会支持、精神信仰、身心健康以及其他方面的改善也是如此。

此前，虽然一些研究以各种方式探讨了非戒断康复，但缺乏一个可操作或可衡量的定义，以帮助研究人员更好地记录和研究康复过程。美国国家酒精滥用与酒精中毒研究所（NIAAA）所长、该论文的资深作者乔治·库布博士表示，这种缺失意味着“我们实际上没有系统的研究来探讨康复的构成要素、持续时间，以及更重要的，如何改善康复”。他和他的合作者与其他研究人员、临床医生和康复专家合作，并纳入了《精神疾病诊断与统计手册第五版》（DSM-5）的标准。

专家表示，NIAAA 的定义已被许多医学权威机构接受，并如作者所希望的那样，促进了相关研究。

专家表示，DSM-5和NIAAA的工作提高了患者获得治疗的机会，因为它避免了让患者感到必须完美才能被视为康复，这种想法可能会让他们感到畏惧，并阻碍他们努力康复。这项工作还在技术层面降低了障碍——能够被诊断为轻度或中度酒精使用障碍（AUD）意味着患者在病情恶化到需要更昂贵、更密集的治疗之前，就有资格获得医保治疗。此外，不将康复仅仅定义为戒酒，也有助于开发或扩大酒精使用障碍药物的获取途径。

专家表示，对大多数人来说，戒酒是最佳选择。美国国家酒精滥用与酒精中毒研究所（NIAAA）的研究人员指出，选择戒酒的人在身体健康、生活质量和心理社会功能（即管理日常生活、心理健康和社会环境的能力）方面进步最大。但他们补充说，越来越多的证据表明，戒除酗酒也与显著的长期改善有关。

另一项2019年的研究发现，戒酒者和仅达到戒断缓解的重度饮酒者在治疗五年后的医疗保健费用相似，且在治疗一年和九年后，他们的社会心理功能也相似。然而，一项2025年针对美国国家酒精滥用与酒精中毒研究所（NIAAA）定义的康复尝试的研究发现，仍在饮酒的参与者更容易复发。

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减少饮酒量，保护你的大脑

斯坦福大学医学院精神病学和行为科学临床教授达斯表示，目前关于哪些人可以正常饮酒的预测因素的研究并不多。但根据她的临床经验和2025年的研究，对于没有严重酒精使用障碍的人、没有潜在心理健康问题或已经康复或学会控制心理健康问题的人、已经戒酒多年的人，以及不再处于当初开始饮酒的环境的人来说，少量或适量饮酒可能更可行。

当然，就整体健康而言，任何量的酒精都对你没有好处，因为即使是少量饮酒也与痴呆症、癌症、高血压和中风等疾病的较高风险有关。

然而，大多数公众还没有跟上这些发展，这些发展仍然受到戒酒互助团体（尤其是匿名戒酒会的支持者）的强烈反对和批评。

美国精神病学会成瘾精神病学委员会成员迈克尔·约书亚·奥斯塔彻博士表示，“一旦酗酒，终身酗酒”以及“戒酒是康复的唯一途径”这种观念源于始于 1935 年的匿名戒酒互助会 (AA) 的主流信息和影响。

“‘酗酒者’是匿名戒酒会用来指代其成员的术语，也是其成员用来指代自己的术语，”奥斯塔彻补充道。他同时也是斯坦福大学医学院精神病学和行为科学教授。

达斯说，这种观点基于酒精使用障碍（AUD）是一种不治之症的观念，而且在某些人看来，所有病例都是由于大脑本身就容易上瘾造成的。因此，人们普遍认为——而且往往也有切身经历——即使只是抿一小口酒，也可能导致复发，无论之前做过多少康复工作，或者戒酒多少年。这些因素催生了一种文化，在这种文化中，那些恢复正常饮酒的人常常会被清醒的人告知，如果他们能够做到适度饮酒而不至于过度或有害，那么他们一开始就不是“酒鬼”或“真正的瘾君子”——也许只是对酒精有情感依赖而已。

为什么一款名为“Feel Free”（自由自在）的饮料会让许多人声称自己深陷毒瘾、债务和戒毒的泥潭？

一方面，达斯说，虽然“总是酗酒”这种说法“在临床上已经过时了”，但对于弱势群体来说，这是一种保护性的行为界限，可以防止他们尝试冒险的尝试。

奥斯塔彻表示，戒酒和十二步疗法（包括匿名戒酒会）已被证明对全世界许多人都非常有效——根据该组织的数据，截至 2021 年，匿名戒酒会在全球拥有近 200 万活跃会员和超过 12 万个小组。

达斯表示，另一方面，这场辩论反映了用来理解成瘾的医学框架和文化框架之间的冲突。

“成瘾并非普遍是一种固定不变的神经状态，”达斯说道。一个人可能在21岁时符合重度酒精使用障碍（AUD）的诊断标准，然后通过治疗、大脑发育成熟、生活方式改变和/或多年的戒断，在40岁时不再被诊断为酒精使用障碍。达斯补充说，大脑就像一块肌肉，其神经回路具有可适应性，可以通过这些干预措施得到修复——但也有一些人，其神经奖赏和习惯通路严重受损，可能无法完全恢复。

达斯说：“声称那些付出巨大努力的人‘从未遇到过问题’，是对他们克服的真正健康挑战的轻描淡写。这就像告诉一个曾经肥胖，经过一番努力现在变得苗条的人，他们从未肥胖过一样。”

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马修·佩里戒酒前曾15次进出戒酒中心。这就是为什么戒酒如此困难。

此外，专家指出，匿名戒酒会及其原则并非对每个人都有效。但奥斯塔彻表示：“从匿名戒酒会的角度来看，对他们无效是因为他们没有足够努力地参与戒酒会，或者他们不够诚实，所以才没有认真参与。”

如果在一个哪怕只喝一杯酒都被视为违反戒酒戒酒计划、必须重新开始的环境中，即使人们真的在努力戒酒，也会感到羞愧——这可能导致更严重的复发。来自费城的68岁男子肯尼斯·安德森说：“我这辈子喝酒的量从来没有像参加匿名戒酒会时那么多。”

对更高力量的信仰并非人人都能接受。身为无神论者的安德森补充说，他认为“人类无能为力，只能依靠全能的神灵才能从酒精中解救出来”的说法是“可怕且有害的”。安德森从上世纪80年代到本世纪初一直饱受酒精使用障碍的困扰，但现在他每隔几个月才会喝一两杯，同时还践行其他重要的康复措施。对他而言，这些措施包括管理他创立的拥有超过13000名成员的在线HAMS（减害、戒酒和适度饮酒支持）小组。

专家指出，酒精使用障碍的成因多种多样，而匿名戒酒互助会（AA）可能无法解决所有问题。这些因素包括遗传、神经系统脆弱性、生活压力和心理健康问题——50%的物质使用障碍患者同时患有心理健康疾病。

当一位康复并改善了生活的病人向达斯询问再次饮酒的问题时，她会询问他们的真实动机、任何潜在的风险以及维持其目标的行为。

有时，病人想和朋友喝一杯，以寻求融入感或缓解焦虑。在这种情况下，达斯医生可能会建议他们点一杯无酒精鸡尾酒，或者练习一些应对技巧。如果他们认为酒精可以帮助他们放松，达斯医生会鼓励他们考虑其他可能让他们放松甚至在其他方面受益的方法。

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如何选择最适合你的心理咨询师

达斯说，部分风险在于酒精本身会降低我们做出明智判断的能力，包括判断我们是否已经喝够了或者喝得比计划的更多。即使你还能喝酒，并且临床上已经康复，也可能有其他原因让你选择戒酒——也许你的问题伤害了你的亲人，他们会因为你再次喝酒而情绪崩溃或感到被冒犯。

“如果他们铁了心要重新开始喝酒，我们会和他们谈谈，‘好，你打算采取哪些措施来减少之前发生的后果？’”达斯说。她会和患者一起回顾他们之前符合的DSM-5诊断标准，以便他们回忆起导致问题的情境——例如，独自饮酒是否会导致他们饮酒过量并陷入情绪低谷。“然后我们会说，‘好，以后只在社交场合喝酒，而且要设定一个饮酒量上限，’”达斯补充道。之后，她和患者会安排后续复诊，并记录一切进展情况。

专家表示，如果你饮酒，要注意饮酒可能再次成为问题的迹象，例如你是否经常不遵守自己的规则或过于随意地改变规则。如果你目前正在与酒精问题作斗争，要知道，12岁及以上的美国人中，每10人就有1人患有酒精使用障碍（AUD），达斯说道。坦诚地讨论这个问题可以帮助你找到合适的治疗方法：门诊或住院康复、药物治疗以及包括认知行为疗法（CBT）在内的各种疗法，其中CBT结合了复发预防，是目前最常用的疗法。

戒酒互助小组和适度饮酒互助小组都能有所帮助。“适度饮酒管理”（Moderation Management）是一个成立于1994年的会员制非营利组织，它提供了一种广受欢迎且获得专业人士认可的戒酒替代方案。该组织提供线上和线下课程，并鼓励会员遵循一个九步计划。这九步计划包括：首先进行为期30天的戒酒期；反思饮酒对生活的影响；做出积极的生活方式改变；以及设定适度饮酒的界限。

每周精选健康生活小贴士，助您轻松享受美好生活。订阅 CNN 的“生活更美好”电子报，获取提升幸福感的资讯和实用工具。