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Addictions: Tools for "Controlled" Drinking
In Germany public health is impaired by high alcohol consumption and alcohol related damage. Yet very few people who participate in excessive forms of alcohol consumption obtain any alcohol specific treatment. The present German controversy surrounding Controlled Drinking (CD) as an appropriate treatment goal and a means to improve the range and effectiveness of the existing health care system is discussed. In this article the author provides an overview of the German CD trials. The German behavioral self-control programs (the ‘AkT’ group program and the bibliotherapeutic “10 Steps Program”) that triggered the present debate on CD are discussed as well. It is concluded that with regard to public health, ethical, therapeutic, and effectiveness concerns, CD approaches should become adjunct to the traditional German abstinence oriented treatment system for alcohol and drug addicts.
Definition Of Controlled Drinking
Reasons For Implementing CD Programs To Health Care
A second, ethical, argument has to be considered when talking about treatment goals (Koerkel, 2000c; Toriello, Hewes & Koch, 1997). According to a fundamental ethical principle in our culture, one has to respect the autonomy of all human beings. This principle implies that treatment providers do not have the right to obtrusively impose goals on their clients. In other words, from an ethical point of view the treatment provider must seriously consider the goals clients want to strive for and offer a treatment program that fosters success in achieving those goals — possibly after engaging them in a discussion about the pros and cons of these goals (i.e. abstinence and CD). This ethical argument is of special importance when one takes into consideration the fact that about one third of all inpatients in German long-term alcohol and drug rehabilitation programs do not intend to remain abstinent for the remainder of their lives (Koerkel & Schindler, 1999). Sondheimer (1989) reports similar results from the biggest inpatient alcohol rehabilitation centre in Switzerland (Forel-Klinik), where 20 to 50% of patients — especially younger ones — favor CD over abstinence. In a study just finished by Feder (in press), the importance of taking a closer look at consumption goals of drug addicts is discussed. Feder asked 82 inpatients in 10 long-term drug rehabilitation centers in the State of Bavaria (located in southern Germany) about their intention to consume alcohol and other psychoactive substances (all that are listed in DSM-IV) after their treatment was concluded. Their main drugs before treatment had been heroin and cocaine. Interestingly, 86.4% said they did not want to completely abstain from alcohol after treatment (see Figure 1).
The corresponding rates of non-abstinence goals in respect to other psychoactive substances were 90.2% for tobacco, 11.7% for opioids, 46.2% for cannabinoids, 9.1% for sedatives, 21.8% for cocaine, and 31.4% for designer drugs. Interestingly, the verbalized intention to resume substance use was found to be independent of the severity of the problems that had been caused by earlier use of these drugs. If taken seriously, these results imply that more efforts have to be made to motivate drug addicts to completely abstain from all psychoactive drugs (a presumably unrealistic endeavor), and/or to teach them how to control their drug intake if they should later decide to consume drugs again. One empirical application of the ethical argument outlined above was provided by Ihlefeld (1999), who introduced a form of CD for alcohol dependent inhabitants residing in an old people's home in the northeastern part of Germany. There, the staff controls the distribution and amount of alcohol that is dispensed (a similar institution exists in Switzerland). In this way the wishes of inhabitants to consume alcohol are respected, while at the same time their inability to control their intake is taken into account. Some of these persons have even been able to regain self-control of their alcohol intake over time.
There is a third, therapeutic, argument in favor of allowing clients to identify their own treatment goals. It is much easier to work with the motivational ambivalence of clients and to gain their compliance with all stages of treatment when they feel free to talk about their “true” consumption goals (namely abstinence or CD; Miller, Leckman, Delaney, & Tinkcom, 1992; see also Miller & Rollnick, 1991). Therapists who are able to wholeheartedly accept abstinence and CD as treatment possibilities are less likely to attempt to exert control over their clients (“You have to live abstinent!”). Therapists are also less likely to behave “codependently,” that is, feeling good when clients stay abstinent and feeling bad when they drink again (Lieb, 1994).
Fourth, there is evidence from numerous studies, although very few of these have been done in Germany, that treatment approaches aimed at CD have been successful in many cases (see also Heather & Robertson, 1983; Koerkel, 2002a; Miller, 1983; Rosenberg, 1993; Walters, 2000). In his overview of different research studies that have dealt with persons who were not severely dependent problem drinkers, Miller (1983) reports an average success rate of 65% (with a range of 25% to 90%). In many programs, the average reduction in alcohol intake amounted to 50%, (e.g., Alden, 1988; Heather, Robertson, MacPherson, Allsop & Fulton, 1987; Koerkel et al., 2001), and a remarkable number of clients opted for abstinence, taking further steps toward recovery. According to a statistical meta-analysis of all methodologically controlled studies short-term and long-term success following CD treatment is at least as probable as success after abstinence-oriented treatment: “The results of this meta-analysis denote that, at the very least, behavioral self-control training is equivalent to abstinence-oriented forms of intervention in terms of overall effectiveness, stability of outcomes, and potential clientele …. Behavioral self-control training met with greater success than abstinence-oriented intervention at a level that bordered on statistical significance in follow-ups lasting a year or longer” (Walters, 2000, p. 146 and p. 144). Moreover, CD involvement does not increase the risk of relapse: “Uncontrolled drinking is a frequent occurrence following periods of both abstinence and CD, and periods of relapse are likely whether an alcoholic attempts CD or abstinence” (Rosenberg, 1993, p. 130). Success at controlled drinking during the first year after attending a CD program is a good predictor for long-term success (Miller et al., 1992), just as booster sessions favor successful CD (Booth, Dale, Slade & Dewey, 1992). On the other hand, higher levels of dependence, low self-efficacy for CD and rejection of the CD goal diminish the probability of an excessive drinker ever becoming a stable controlled drinker (Kavanagh, Sitharthan & Sayer, 1996; Miller et al., 1992; Rosenberg, 1993). As the term probability indicates, there are a lot of exceptions to this rule questioning the “severity of dependence hypothesis.” In one of the latest studies, Heather and his British colleagues (2000) came to the following conclusion: “On the basis of this finding, it would seem that, always assuming they prefer moderation to a goal of abstinence and that it is not contra-indicated on other grounds, there is no reason why higher dependence clients should not be offered the goal of moderation” (p. 569). Finally, elements of CD may be effectively implemented into brief interventions, such as those provided by GPs (Fleming, Barry, Manwell, Johnson & London, 1997; Ockene, Wheeler, Adams, Hurley & Hebert, 1997)
Reflection Exercise #1
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