Controlled Drinking: More Than Just a Controversy

Michael E. Saladin; Elizabeth J. Santa Ana


Curr Opin Psychiatry. 2004;17(3) 

In This Article

Guided Self-Change

GSC is a brief cognitive-behavioral motivational intervention designed to assist problem drinkers to recognize and use their own personal strengths to resolve drinking problems.[50] GSC typically targets problem drinkers with either identifiable alcohol use problems or those with mild-moderate alcohol dependence but without severe alcohol consequences or withdrawal symptoms.[51] The conceptual underpinnings of GSC are based on the finding that a significant proportion of individuals who misuse alcohol can and do recover naturally as a result of self-change.[51] This self-change process is bolstered in GSC via the application of motivational strategies[52] such as advice-giving, removing barriers to change and decreasing the attractiveness of drinking.

Increased interest in GSC and similar interventions based on the natural recovery process stems from the observation that there are four times as many problem drinkers as severely dependent drinkers[53] and yet, most traditional treatments target severely dependent drinkers.[50] Problem drinkers are less likely to seek traditional treatment services because they tend not to view themselves as alcoholic and, therefore, they view such treatments as unappealing or inappropriate.[50] The lack of treatment alternatives means that problem drinkers are frequently left untreated and are underserved.[54] Guided self-change may be more attractive to these individuals because it is a non-intensive treatment alternative that aids the problem drinker in asserting control over his or her behavior.[50]

Another reason why GSC may be attractive to problem drinkers pertains to its compatibility with both abstinence and non-abstinence treatment goals. There is some evidence suggesting that problem drinkers are less successful in abstinence-focused traditional treatment than moderation-focused treatment.[27,55] For example, a study comparing drinking outcomes in abstinence versus moderation treatment goals found that although problem drinkers with either goal significantly reduced their drinking over the 2-year follow-up, individuals with an abstinence goal drank significantly more during treatment than participants who received counseling on how to regulate their drinking.[27] It may be that the occurrence of any drinking represents a more significant deviation from an abstinence than a non-abstinence goal, thereby producing a negative affective state (i.e. disappointment, frustration) that drives further drinking. In any case, it appears that a moderation goal may help reduce drinking earlier in the treatment process, at least for some problem drinkers.

The manualized version of GSC[50] consists of an initial assessment and four 60-min individual treatment sessions, followed by two follow-up telephone calls. In the initial assessment, drinking behavior, high risk drinking situations and self-efficacy are assessed and drinking goals are identified (e.g. abstinence or moderation). Treatment sessions address the content of two reading assignments, the first of which presents a general behavioral analysis of drinking, and the second of which focuses on problem-solving skills and relapse prevention. Each reading is followed by two homework assignments involving identification and analysis of high- versus low-risk problem drinking situations, generating a set of options or alternatives to high-risk drinking situations and their likely consequences, and completing a checklist that asks about lifestyle behaviors as they relate to alcohol use. As noted previously, motivational strategies[52] are used to enhance commitment to change while cognitive relapse procedures are taught to assist in identifying triggers and facilitating recovery from relapse.[56] Individuals with medical contraindications (e.g. severe liver disease) are advised to adopt an abstinence goal, while clients choosing a moderation goal are taught drinking guidelines (e.g. consume no more than three standard drinks/day on four or fewer days/week, drink at a rate of no more than one drink per hour if driving).

The efficacy of GSC has been previously documented in studies showing a 53.8% reduction in alcohol consumption following intervention and significantly higher abstinence rates 1 year after treatment.[50] Only three investigations examining the effectiveness of GSC have been conducted since 2000. In the first study,[56] problem drinkers and their spouses were randomly assigned to either a directed social support condition or a natural support condition. The social support condition involved teaching the spouse to play an active role in recovery by being supportive and helping to identify and carry out plans for dealing with high risk drinking situations. The natural support condition involved giving the spouse reading materials without instruction for being supportive. All clients received an identical program of guided self-change. Although the two groups did not differ on indices of drinking by level of spousal social support, participants from both groups improved significantly from pretreatment to the end of treatment in that they exhibited a significant decrease in drinking, a decrease in heavy drinking days (five to nine drinks), and a decrease in very heavy drinking days (≥10 drinks). Results also showed that abstinent days doubled (e.g. from 22 to 45%) and positive gains were maintained over the 1-year follow-up.

In the second study,[57] investigators examined whether four sessions of GSC were more effective for reducing alcohol consumption and alcohol-related problems than one session of advice. Problem drinkers in the advice-only condition received assessment and one session of feedback/advice guided by motivation enhancement principles, including a 24-page self-help manual. Participants in both conditions reported significant and similar reductions in number of standard drinks, degree of alcohol dependence, negative consequences, and significant improvements in health-related quality of life. However, most outcome measures tended to favor the four-session GSC condition and patients in GSC also expressed significantly greater satisfaction with GSC treatment.

To this point, the discussion has focused on the efficacy of GSC when delivered via the individual/couple therapy format. However, the Sobells and their colleagues have recently conducted a study of GSC[58] delivered as a community-level mail intervention. From a public health perspective, this intervention was designed to promote community-wide self-change among problem drinkers who were resistant to using formal treatment services. The supporting logic for the study was based on evidence showing that one of the major pathways to recovery from addiction is natural recovery via self-help behaviors without formal treatment.[51]

The intervention offered free and confidential treatment to individuals with alcohol use problems through the mail. Participants responded to community advertisements soliciting the public to call for drinking-related treatment materials that could be completed at home. The advertisements were designed to be attractive to problem drinkers because they (1) were free, (2) referred to 'changing' one's drinking rather than forcing an abstinence goal, and (3) indicated that a sizable number of individuals can change their drinking on their own. Respondents who met screening criteria over the phone received an assessment packet in the mail that was to be completed and returned. Participants were randomly assigned to either a motivational enhancement/personalized feedback condition or a bibliotherapy/drinking guidelines condition. The motivational enhancement condition consisted of feedback on drinking levels in comparison with national norms and health risks, high-risk situations, and motivation for change, while the bibliotherapy condition consisted of two alcohol informational packets containing low-risk drinking guidelines.

The 1-year follow-up results revealed significant declines for mean number of drinking days per week (28.3% decline), drinks per drinking day, drinks per week, number of binge drinking days (e.g. five or more drinks consumed, 33.2% decline) and number of alcohol-related consequences, with no differences between the motivational and bibliotherapy conditions. The absence of differential treatment effects indicates that the more costly and time intensive personalized feedback was not required for significant reductions in drinking and alcohol-related consequences. On a related note, three of the greatest benefits of this type of intervention were its low cost, its amenability to being delivered to large numbers of problem drinkers who are not able/willing to attend formal treatment, and its yield of significant health benefits.

Overall, the results of the most recent research on GSC[56] are consistent with previous research[59] in terms of an overall reduction in amount of alcohol consumed (48.5% reduction), an increase in abstinent days, and a decrease in days of heavy drinking. Especially noteworthy were the observed increases in abstinence despite the fact that many participants chose moderation goals. The treatment effects of the community level intervention based on GSC were substantial and lasting. Collectively, studies of GSC conform with those of previous studies showing that the requirement of abstinence is not necessary for the problem drinker to achieve increases in abstinent days and reductions in alcohol consumption.[27,55,60,61]