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By: Garry Cooper, LCSW
Table Of Contents
Behavioral Self-Control Training (BSCT)
Moderation-Oriented Cue Exposure (MOCE)
Guided Self-Change (GSC)
Harm Reduction In Adolescents And College Students
Conclusion
References & Resources
In the 2004, Current Opinions in Psychiatry, psychologists Michael Saladin and Elizabeth Santa Ana of the Medical University of South Carolina offer an overview of harm reduction, commonly called controlled drinking, in the field of alcohol treatment. They point out that several controlled drinking treatments, such as behavioral self-control training and moderation-oriented cue exposure, have amassed strong evidence as effective treatments, and that harm reduction in general, as it continues to acquire an empirical support for its effectiveness, is finally leaving its controversial past behind. That controversial past, they imply, arose because of the dominance of the disease model of alcohol, which sees drinking as a biologically-based condition that inexorably leads to self-destruction. Instead of viewing every alcoholic as being in the grips of the disease model, harm reduction sees alcoholics existing along a continuum.
Controlled drinking is characterized as an attempt to meet people where they are in terms of their level of motivation to change. Controlled drinking, write Saladin and Santa Ana, “emphasizes the notion that a hazardous pattern of excessive alcohol consumption can be changed to a sustained pattern of relatively modest consumption that does not yield appreciable negative consequences….[T]hese treatments do not assume that everyone who misuses alcohol can achieve a sustained pattern of safe drinking but rather acknowledges [sic]this potential outcome as an acceptable and realistic goal that is in parity with abstinence.” If controlled drinking meets people where they are in their motivation, abstinence, on the other hand, might be characterized as trying to bring people to where therapists or other treatment professionals or paraprofessionals think they need or ought to be. One advantage to harm reduction, say its proponents, is that it reaches people who are so intimidated by the notion of abstinence that they tend to fall through the cracks and never seek treatment.
Saladin and Santa Ana trace harm reduction’s beginnings to the 1980 “Junkiebond” movement in the Netherlands, formed to represent the needs and health concerns of hard drug users in that country. Junkiebond was based upon the notion, long familiar to social workers and community organizers, that the people whose needs are being addressed ought to have a major voice in constructing the programs, deciding which needs should be met, and deciding how best to meet those needs. The Junkiebond movement led to the first needle exchange program in 1984. The field of alcoholic treatment in the United States soon began to adapt some of the principles of harm reduction.
But even before this, say Saladin and Santa Ana, the groundwork had been prepared by three key events in the history of controlled drinking. A 1962 study noted that 7 of 97 serious alcoholics at London’s Maudsley Hospital were able to control their drinking over a period of 7-11 years. The study, flying in the face of widely accepted abstinence-only treatment, generated considerable attacks. A decade later, a Rand report on an 18-month follow-up of men who had received abstinence-only treatment at 45 centers around the country reported that 22 percent of the men had reported subsequent non-problem drinking. The report further stated that a return to problem drinking was no more likely among the men reporting controlled drinking than among the men who slipped from abstinence-only treatment. Then in the mid-1970’s, a series of studies by psychologists Mark and Linda Sobell reported that severe alcoholics who had learned to moderate their drinking had better outcomes at two- and three-year follow-ups than people who had undergone abstinence-only treatment. The Sobells were severely criticized for faulty methodology, but, report Saladin and Santa Ana, their work was eventually exonerated.
Behavioral Self-Control Training (BSCT)
While some harm reduction treatments view controlled drinking as a way station on the way to abstinence, BSCT teaches skills that target controlled drinking as a treatment goal (Hester, 1995). The BSCT skills include self-monitoring of drinking and of urges to drink; specific goal setting; controlling the amount of drinking and knowing when to refuse to drink—and practicing it; setting up reward and consequences contracts in relation to goals; identifying and managing the triggers for excessive drinking; analyzing one’s drinking behavior; and relapse prevention training.
BSCT, says Saladin and Santa Ana, “is by far the most intensely studied controlled-drinking treatment approach, with more than 30 studies published to date.” It has been found as effective as abstinence-based treatments for both moderate and severe drinkers. They also cite a 1997 study finding that alcoholics who also abused drugs such as marijuana and cocaine and who brought their drinking under control with BSCT did not, as might be expected, increase their use of the other drugs. This suggests that alcoholics who learn self-control through BSCT may learn to generalize their new behavioral management skills.
Twenty-eight years on studies on BSCT, write Saladin and Santa Ana, show that BSCT “is a highly efficacious treatment for alcohol-related problems….[The research] is unequivocal with regard to its efficacy…among individuals with mild to severe alcohol problems. Importantly, these treatment gains do appear to persist over time and are no less stable than treatment gains attained via abstinence-focused treatment.”
Moderation-Oriented Cue Exposure (MOCE)
Cue exposure is a widely used behavioral treatment based on the assumption that certain cues elicit conditioned responses. (Drummond, 1994 and Monti, 1993). Regarding treatment for alcoholics, certain cues create a craving for alcohol, and MOCE aims to separate the cues from the craving. Clients, for example, are systematically exposed to cues such as the sight and smell of their preferred beverage, but not allowed to consume it. MOCE also involves homework that allows people to practice controlled drinking. Clients are to note and write down times when cues trigger an urge to drink and to allow themselves a previously agreed upon, limited amount of alcohol.
Three studies comparing the efficacy of MOCE to BSCT, write Saladin and Santa Ana, find that both treatments produced substantial reductions in drinking at a six to eight month follow-up. MOCE seems more effective than BSCT when delivered in a group format, and given that the preponderance of alcohol treatment takes place in groups, this is an important consideration. However, it’s important to note that BSCT seems more effective than MOCE with heavier drinkers.
GSC comes partly from cognitive-behavioral techniques but it also incorporates ideas from motivational enhancement therapy (MET). It is designed to assist problem drinkers to recognize and use their own personal strengths to resolve drinking problems (Sobell, et. al. 1993 and 1996). Unlike BSCT, which is used no matter how mild or severe the alcoholic problems, GSC is primarily used for people with mild to moderate alcohol dependence, and without severe alcohol-related physical or social problems or withdrawal symptoms. GSC is based on the findings that a significant proportion of people who misuse alcohol can and do recover naturally as a result of self-change. GSC helps people sharpen their awareness and appreciation for the strategies they have already used, and through this increased awareness, they gain more confidence and success with their strategies. Therapists also discuss ways to remove barriers to change and utilize strategies to decrease the attractiveness of drinking. Some techniques of motivational enhancement strategy help accomplish this. Clients who hang out with drinking partners, for example, may be helped to see that many people like them do not drink. (An essential part of MET involves objective psychoeducation about social and behavioral norms). Clients may be encouraged to begin socializing with people who share their interests or personality traits but do not drink.
An important foundation of GSC rests on the MET assumption that alcoholics are not hopelessly dependent but can turn their attention to their own motivation to change, and by turning their attention to it, strengthen it. By assisting problem drinkers in asserting control over their own behavior, GSC may be a more attractive alternative to people who do not see themselves as dependent on others or on higher powers; these may well be people who, because of this self-view, would never seek out abstinence-based treatment. Because GSC encourages people to set their own goals and course, it draws in people who resonate with both abstinence and non-abstinence goals.
Befitting its concept of guided self-change, GCS is a relatively brief intervention. The manualized version of GSC, described in Sobell (1993) consists of an initial assessment and four 60-minute treatment sessions, with two telephone call follow-ups. The initial assessment looks at drinking behavior, high risk drinking situations and means of self-efficacy. Clients decide whether they want to have abstinence or moderation as a goal, and they clarify for themselves what these mean to them. The two treatment sessions are organized around two reading assignments, one a general behavioral analysis of drinking, and the second a focus on problem-solving skills and relapse prevention. Each session has a homework assignment that helps clients look at high versus low-risk problem drinking situations and develop alternatives to high-risk drinking situations. Clients complete a checklist that helps them examine their lifestyle behaviors in relation to their drinking.
Harm Reduction In Adolescents And College Students
Saladin and Santa Ana note that abstinence-based, zero-tolerance programs aimed at adolescents and young adults are particularly ineffective. Unfortunately, perhaps because they are such a high-risk group for alcohol abuse and because the consequences of underage drinking—a high rate of traffic accidents and deaths, failure in school or arrest that can end up limiting future opportunities and choices, and suicide–can be so tragic, there’s historically been a tendency to turn to draconian abstinence-based programs, despite increasing evidence that such programs don’t work very well with youth. It’s similar to sex education programs that teach abstinence; they are ineffective and derive more from parental values and perhaps fears than from proven efficacy. Saladin and Santa Ana point to the example of DARE (Drug Abuse Resistance Education), which grew for years despite a lack of evidence that it worked. (Finally, its lack of empirical support has caught up with it). One reason why such programs don’t work very well may be teenagers’ characteristic impulsiveness, which overrides admonitions and scare tactics.
Saladin and Santa Ana point to studies that have, however, documented the effectiveness of harm reduction programs geared toward primary and secondary school students (Marlatt, 2002). For example, the School Health and Alcohol Harm Reduction Project (SHAHRP), conducted in Australia, a large-scale intervention study aimed at secondary school students, teaches students alcohol education, imparts information on drinking choices, furnishes skills and assertiveness training, and provides other activities designed to minimize alcohol-related harm (McBride, 2000). Compared with a control group that received standard alcohol education classes. SHAHRP students, over a 3-year period, had significantly lower levels of alcohol consumption and suffered decreased harm from events such as hangovers, fighting, and troubles at school.
Marlatt, et. al. (1998) also tested the Brief Alcohol Screening and Intervention for High-Risk College Student Drinkers (BASICS). BASICS targeted college students who drank at least monthly and at least five to six drinks per drinking occasion, and who reported at least three alcohol-related problems on three to five occasions in the past three years. BASICS students received personalized feedback based on assessment data containing information about how their drinking levels compared with other college students, as well as information regarding risk factors, alcohol-related consequences, and tolerance—all principles of MET. They also received information about drinking moderately. In keeping with the MET style, information delivery was non-confrontational, empathic, and highlighted discrepancies between heavy drinking and the students’ own professed goals in life. At a two-year follow-up, BASICS students, compared to students who received assessment only, showed significantly reduced drinking rates and fewer harmful consequences of their drinking. At a four-year follow-up, BASICS students showed only a modest effect on drinking, but significantly reduced negative consequences. Sixty-seven percent of the high-risk BASICS students reported good outcomes versus 55 percent of the high-risk control students. This, write Saladin and Santa Ana, was the first study to demonstrate long lasting benefits of a brief, non-abstinence intervention for high-risk college drinking.
Saladin and Santa Ana stress that the most recent studies find no support for the popular hypothesis that the more severe the drinking, the less the possibility that the person can control it. They cite Walter’s 2000 review of 17 studies of BSCT which find no evidence of an association between severity of drinking problem and controlled drinking. Their own review of the BSCT and MOCE literature, say Saladin and Santa Ana, also failed to identify one study confirming the association. In fact, they write, “all three of the reviewed controlled trials comparing MOCE with BSCT specifically reported no relationship between severity of alcohol use and drinking outcome.”
What does predict the best outcome for successfully controlling drinking? A measurement of drinking-related self-efficacy reveals a surprising finding, and one that challenges the viewpoint of the alcohol disease model, which holds that any alcoholic who says he or she can control their drinking is in denial. Sidharthan, et. al (2003) find that those who use their self-efficacy measurement and rate themselves higher in their ability to control their drinking, are more likely to be able to do so. This finding seems to justify MET, which believes in clients setting their own goals. Saladin and Santa Ana conclude that monitoring clients’ changes in their perceptions of their own self-efficacy might help clinicians and researchers evaluate the success or failure of drinking outcomes better than “focusing on static pretreatment factors like drinking severity.”
Although Saladin and Santa Ana take care not to present controlled drinking as the only or even best answer and call for further research, they end their article with a ringing denunciation of the stern and often strident hold that abstinence-only proponents have exercised over research and treatment. “While the overall tone of the present review is one of optimism,” they write, “the stormy past of the controlled drinking treatment approach continues to have a disruptive effect on the social, political and economic factors that impact contemporary treatment research and service delivery.” They quote Searles (1993), who warns of “scientific fascism”—persistent and harsh opposition to “anything that challenges conventional wisdom even in the face of compelling scientific evidence.” It is likely, they write, “that the machinery of science will have to work overtime to ensure that reason and truth are not obscured by an impassioned ‘herd mentality’….At least in the case of controlled drinking, the persistent efforts of clinical science have resulted in a significant expansion of treatment options for persons who misuse alcohol.”
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