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For much of the 1960s and into the 1980s, the alcohol treatment field was riven by the “controlled drinking controversy” (Roizen, 1987). One side argued that any treatment goal short of abstinence was a death sentence for problem-drinking patients, and the other responded that refusing to acknowledge the possibility of a return to controlled drinking turned some problem drinkers away from treatment and thereby created significant damage of its own. In retrospect, the combatants were to some extent talking past each other because they were focusing on different subgroups within the diverse population of people with drinking problems. Eventually, it became clear that it was not a question of which treatment goal was correct in an absolute sense, but which was best for which individual drinker. Ironically enough, this was the position of the founders of Alcoholics Anonymous (AA), who, although often cited during the controlled drinking controversy as supporting abstinence for all problem drinkers, in fact specifically acknowledged that some could return to moderate drinking (Humphreys, 2003).
This chapter helps clinicians and patients navigate the difficult decision of whether a problem drinker is a good candidate for a return to non-problem drinking and also provides advice on how to help such individuals achieve their goal. It also attends to other nonabstinence outcomes that, although not as beneficial as establishment of lifelong abstinence or moderate drinking, can nonetheless be considered successes within particular clinical contexts.
Table 16.1 summarizes the key considerations for determining whether a moderate drinking goal may be appropriate for a given patient. The table takes an abstinence goal as the default choice because that will be the case in most clinical settings. For clinicians working in specialty treatment settings (e.g., in-patient alcoholism units), the column on the right of the table may seem like a fantasy, but it must be remembered that the treatment of drinking problems occurs in a broad range of locations, including some (e.g., college counselling centres, primary care settings) where the left side of the table will describe a significant proportion of help seekers.
| Factors unfavourable to a moderate drinking goal | Favourable factors in support of a moderate drinking goal |
|---|---|
| Severe dependence | Mild or absent signs of dependence |
| Previous failures at controlled drinking | Recent sustained controlled drinking |
| Strong preference of the drinker for abstinence | Strong preference of the drinker for moderate drinking |
| Poorly developed capacity for self-control in other areas | Evidence of strong self-control in other areas of life |
| Co-occurring addictive or psychiatric disorder | Good mental health |
| Severe alcohol-related physical illness | Mild or no physical complications of alcohol misuse |
| Heavy drinking family, friends, and co-workers | Abstemious social network |
Degree of dependence
No single factor is completely definitive when judging whether a moderate drinking goal is reasonable, but degree of dependence is certainly a useful indicator (Edwards et al., 1983; Rosenberg, 1993). Simply put, the more a patient has experienced shakes, sweats, convulsions, blackouts, morning drinking, and the like, the less likely they are to succeed at a moderate drinking goal.
Experience with recent efforts at sustained controlled drinking
A useful question for patients regarding their drinking is “Who has control, you or the alcohol?” Being able to gut out a week or two of abstinence is not control, particularly not when this dry period is followed by a weekend-long bender. Rather, control means being able to drink and not to drink when one wants and to maintain control of drinking once alcohol consumption has begun.
If within the last couple of years the patient has been able to drink in a relaxed and controlled manner continuously for 3 months or more, this may indicate that they retain a capacity for a normal style of drinking and that this capacity may now, with due care, be strengthened and extended. The evidence must, however, be approached warily. Careful questioning may reveal that this previous period of “sustained controlled drinking” was less sustained and less “controlled” than the patient at first suggested, and it may have been only a slide toward reinstatement of dependence.
Respecting a patient’s realistic preference
Most patients with drinking problem would like to return to moderate drinking more than they would like to abstain. But it would be irresponsible for clinicians to agree to such an arrangement in cases where the odds of success seem low. Indeed, the clinician may justly be accused of conniving in a delusion. However, when success at moderate drinking is a realistic possibility, the preference of the patient for that goal or abstinence should be given significant weight. The golden rule for the clinician when talking through these patient choices is to be open-minded but not gullible. The clinician should also bear in mind that patient preferences can change over the course of treatment, and there is value in keeping the patient engaged in care even if the clinician harbors some modest doubts about the likelihood about the current drinking goal being achieved.
Capacity for self-control
The determined person who is good at exercising self-control in other areas of life (e.g., weight management, finances) is more likely to possess the psychological resources to succeed in drinking normally. In contrast, the individual whose life revolves around impulsive choices and is littered with half-completed projects is a poor candidate for a moderate drinking goal.
Co-occurring addictive and/or psychiatric disorders
The patient who is suffering from a psychiatric disorder – particularly a serious one – is not typically in a good position to attempt moderate drinking. Concurrent drug dependence that has not been dealt with successfully also rules out a return to safe use of alcohol. Pathological gambling may threaten maintenance of control over drinking. The euphoria of the win, the depression of the loss, or the tension associated with continuous gambling all rather easily invite a return to the heavy use of alcohol. In contrast, an individual whose sole struggle with addiction occurs in the alcohol realm and who is in generally good psychological health has a greater chance of returning to moderate drinking.
Alcohol-related physical illness
The decision in this instance must be made in relation to the actual type and degree of illness. Alcohol-related physical illness usually suggests that the patient would be wise to avoid any further drinking (permanently or at least long enough to recover) and risk of progressive tissue damage.
Drinking patterns of the social network
It is generally easier to return to moderate drinking when the individuals in one’s life also drink moderately (or do not drink) than when they have a norm of heavy use. This reality should be discussed with the patient considering a moderate drinking goal, as should the eluctability of heavy drinkers in the social network; some friends, family members, and co-workers are easier to avoid than others.
Further considerations before committing to a moderate drinking goal
If a moderation goal seems a possible north star for treatment, a few other matters should be attended to before a mutual commitment is made. Each will make the process safer for the patient whether things go well or poorly.
Acknowledge the risk involved
To attempt a moderate drinking goal is to try to integrate into the patient’s life a drug that has a history of being destructive and difficult to control. Furthermore, moderate drinking outcomes in problem drinkers tend to be less stable over time than does abstinence (Miller at al., 1992). Both the clinician and patient are thus taking on some risk in the venture. As in other areas of life, risks to well-being need not rule out attempting something challenging, but, for ethical reasons and for the sake of setting reasonable expectations, they should be explicitly acknowledged in advance by the parties concerned.
Adopt an experimental, honest attitude
The clinician and patient should agree up front that they will continue to evaluate the reasonableness of a moderate drinking goal as treatment progresses, becoming more or less confident in its value depending on the evidence from the patient’s life. This approach is superior to committing absolutely to a moderate drinking goal up front, which may lead the patient who is unable to attain it to feel like a failure or to lie about the extent of drinking.
Consider an interval of initial abstinence
There is no evidence-based rule for whether a patient will be more likely to succeed at moderate drinking if he or she takes a few weeks off from drinking first, but the clinician and patient should always discuss this as a possible approach. For some patients, normal drinking emerges directly out of more chaotic drinking. Suddenly or gradually, the new pattern supersedes the old. Alternatively, the story may be of a shorter or longer initial period of abstinence followed by a tentative move toward moderate drinking. When drinking follows a period of sobriety, the clinician has the responsibility of working out with the patient whether this is a sadly familiar story of unguardedness and self-deception foreshadowing major relapse or whether this is indeed the evolution of re-established control.
Techniques for establishing and maintaining control
Patients are themselves often very inventive in designing ways to keep their drinking within a limit, and it is always useful to explore and encourage these personal strategies. The paragraphs that follow describe a variety of methods that may be employed (Alden, 1988; Connors, 1993; Marlatt & Gordon, 1985; Saunders, 1994).
Setting a clear, measurable goal for treatment
Almost everyone understand the term “abstinence” in the same way, but interpretations can vary across persons regarding what exactly constitutes “moderate,” “normal,” or “controlled” drinking. The clinician must therefore initiate a conversation about what precisely is being attempted and how treatment will support it (e.g., the patient will never drink two days in a row and will limit consumption to three drinks on drinking days; Sanchez-Craig, Wilkinson, & Davila, 1995). Such a process of careful goal-setting in itself can strengthen the therapeutic alliance and patient motivation at the same time (Kanfer & Schefft, 1988).
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