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Section 8
Arguments for Controlled Drinking Treatment Approaches

Question 8 | Test | Table of Contents

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
Controlled Drinking (CD) may become an important method for improving the range and effectiveness of the existing health care system. But what exactly does CD mean? The term is not used uniformly in the international literature (see also Heather & Tebbutt, 1989). In the present German discussion, Koerkel (2000b) proposed that the term "CD" be reserved for drinking behavior that follows the establishment of specific drinking rules by the consumer before he or she begins alcohol intake. Practically speaking, this may mean that one drinks within limits established one week in advance, specifying the number of expected abstinent days and the maximum number of drinks that may be consumed during a drinking day (DDD) and during a week (see also Koerkel, 2000b; Sanchez-Craig, 1995). Besides limiting the amount of alcohol intake, "the controlled drinker must choose carefully and even compulsively the time, the place, and the circumstances of drinking" (Reinert & Bowen, 1968, p. 286). In contrast to CD, "moderate drinking" does not necessarily demand conscious control of one's drinking behavior, but only requires that alcohol intake be kept below risky limits (like 20/40g per day) so that it does not harm the user (National Institute on Alcohol Abuse and Alcoholism, 1992). Given these definitions, we see that there is some overlap between CD and moderate drinking, although these terms are not identical. For example, drinking behavior under the CD model may be in accord with the drinking plan, but in doing so exceed the official limits for moderate drinking.

Reasons For Implementing CD Programs To Health Care
Koerkel (2001b) has delineated four reasons for integrating CD approaches into the traditional abstinence oriented alcoholism treatment system. First, one of the main reasons why German problem drinkers do not feel they are candidates for alcohol related treatment is that they do not regard themselves as "alcoholics" and do not want to completely abstain from alcohol. This attitude brings them into conflict with most treatment and health insurance providers for whom abstinence is the only acceptable treatment goal, and CD is taboo. But CD may be an attractive option in bringing more people into treatment. Empirical data from different countries, Germany included, support this view (see also Koerkel, Langguth & Schellberg, 2001; Vollmer et al., 1982a, 1982b). For example, 65.4% of the participants in the German Behavioral Self-Control Training (BSCT) called "AkT" (see below), had never undertaken alcohol specific treatment, although all of them had experienced alcohol problems for many years. These persons were attracted to AkT solely because of the openness of the program (Koerkel et al., 2001). These data are in accord with the position formulated by the U.S. Institute of Medicine (1990): "Uniform goals for all individuals may be a simpler approach, but the notion of different goals for different individuals seems more consistent with the heterogeneity of alcohol problems and the individuals who manifest them" (p. 296).

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)
- Koerkel, Joachim; Controlled Drinking As A Treatment Goal In Germany; Journal of Drug Issues, Spring2002, Vol. 32 Iss. 2

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 150 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about arguments for controlled drinking treatment approaches. Write three case study examples regarding how you might use the content of this section in your practice.

Update
Predictors of abstinence, no heavy
drinking days, and a 2-level reduction
in World Health Organization
drinking levels during treatment for
alcohol use disorder in the COMBINE study

Wallach, J. D., Gueorguieva, R., Phan, H., Witkiewitz, K., Wu, R., & O'Malley, S. S. (2022). Predictors of abstinence, no heavy drinking days, and a 2-level reduction in World Health Organization drinking levels during treatment for alcohol use disorder in the COMBINE study. Alcoholism, clinical and experimental research, 46(7), 1331–1339. https://doi.org/10.1111/acer.14877

Peer-Reviewed Journal Article References:
Breuninger, M. M., Grosso, J. A., Hunter, W., & Dolan, S. L. (2020). Treatment of alcohol use disorder: Integration of Alcoholics Anonymous and cognitive behavioral therapy. Training and Education in Professional Psychology, 14(1), 19–26.

Cho, S. B., Su, J., Kuo, S. I-C., Bucholz, K. K., Chan, G., Edenberg, H. J., McCutcheon, V. V., Schuckit, M. A., Kramer, J. R., & Dick, D. M. (2019). Positive and negative reinforcement are differentially associated with alcohol consumption as a function of alcohol dependence. Psychology of Addictive Behaviors, 33(1), 58–68.

Leeman, R. F., Berey, B. L., Frohe, T., Rowland, B. H. P., Martens, M. P., Fucito, L. M., Stellefson, M., Nixon, S. J., & O'Malley, S. S. (2021). A combined laboratory and field test of a smartphone breath alcohol device and blood alcohol concentration estimator to facilitate moderate drinking among young adults. Psychology of Addictive Behaviors.

Marczinski, C. A., Stamates, A. L., & Maloney, S. F. (2018). Differential development of acute tolerance may explain heightened rates of impaired driving after consumption of alcohol mixed with energy drinks versus alcohol alone. Experimental and Clinical Psychopharmacology, 26(2), 147–155.

QUESTION 8
 According to Koerkel, what are four reasons for integrating Controlled Drinking (CD) approaches into the traditional abstinence oriented alcoholism treatment system? To select and enter your answer go to Test.

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