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Section 9
Strategies for Controlled Drinking Therapy

Question 9 | Test | Table of Contents

Bibliotherapy
In 1978, Heil and Jaensch published a paperback book called Weniger Alkohol. Ein Programm zur Selbstkontrolle (Less Alcohol: A Program for Self-Control), which has been out of print for some time. It is similar to a BSCT and resembles the self-help guides of Heather and Robertson (1996), Miller and Munoz (1990), and Sanchez-Craig (1995). The Federal Office for Health Education (Bundeszentrale fuer gesundheitliche Aufklaerung, 2001) published a brochure that contains information and hints for responsible drinking based on behaviorally oriented principles on how to drink less (although the term "CD" is never mentioned). In 2001 Koerkel (2001 d) published more comprehensive material for bibliotherapy called the "10 Steps Program for Alcohol Self-Control." In this work, readers are guided through 10 steps designed to systematically help them to control their drinking behavior. Comparable to other BSCT, the 10 steps encompass hints about how to get off to a good start, self-monitoring, goal setting, identification of high-risk situations, training in rate control and problem solving strategies, establishment of non-drinking leisure time activities, and coping with slips.. Information and worksheets complete the material. The program is also available via the internet (www.kontrolliertes-trinken.de).

Therapist-Assisted CD Treatment
In Austria, Czypionka and Demel (1976) have used a predominantly operant conditioning approach to CD with 10 gamma and 10 delta "alcoholics". During 10–14 individual treatment sessions (2 hours each), patients were punished by a 10 second unpleasant tone if their BAC exceeded 0.06%, while a BAC below 0.06% resulted in positive reinforcement by the therapist. During the six-month follow-up, 15 subjects reported they had exceeded a BAC of 0.06% at least once and therefore were classified as having relapsed, one had never reached a BAC of 0.06% and 4 remained abstinent the entire time.

In a research trial conducted by the Max-Planck Institute of Psychiatry (located in Munich, southern Germany) that had no impact on contemporary treatment practices in Germany, Vollmer et al. (1982a, 1982b) treated 42 young adults (aged 19–30 years) with a CD regimen, while 16 others participated in an abstinence program. All of the subjects had been classified as "alcoholics" (daily alcohol consumption: 210g of ethanol on average, with a range of 80g to 430g). Important criteria for (non-random) assignment to treatment groups were the client's own choice and/or medical concerns (such as previous liver damage). Treatment methods included covert control, covert sensitization, cognitive therapy, training in non-drinking behavioral alternatives, and social skills training. With the exception of social skills training, all treatment was delivered in an individualized format. The treatment phase continued for five months, with 2–3 sessions per week on average. Two years after the completion of treatment, 45% of those in the CD program were judged to be treatment successes (with striking decreases in alcohol intake or total abstinence), compared to 25% of those who had participated in the abstinence condition. In their conclusions the authors mention that many of their patients, even some of those choosing abstinence later on, had entered therapy only because CD was recognized as a legitimate treatment goal.

Arend (in press) has offered the controlled drinking option for young adults with alcohol problems in Neunkirchen, a city located in the State of Saarland (Germany). The treatment is designed for individuals (not groups), and is flexibly organized along the principles of behavior therapy. An important part of the treatment consists of graduated exposure exercises. There has been no evaluation of this approach to date. Sondheimer (2000), who was until 1997 the medical director of the Forel Clinic, has for years treated alcohol dependent people with the goal of CD in his private practice in Zurich (Switzerland). He uses some components of BSCT (such as a drinking diary), and integrates psychodynamic methods to solve problems and conflicts that emerge after alcohol intake subsides. In some German cities, structured courses designed to help participants acquire self-control in their drinking behavior are offered to drivers who lost their license for DWI offenses (see Kraemer, 1980).

Since 1996, Wessel and Westermann (2002), who are affiliated with the psychiatric hospital of Bielefeld in northern Germany, have offered a psycho-educational group program (called PEGPAK) that allows free choice between abstinence and moderation as behavioral change options for people experiencing all kinds of alcohol problems. The PEGPAK groups (maximum 18 participants) meet for 9 educational sessions, two hours each. Wessel and Westermann report that the program has proven both attractive to clients, and effective as well: In a 1-year follow-up 78% of subjects strived for abstinence and 22% for CD, with half of subjects of each group being successful with their respective goals at time of follow-up. Wessel and Westermann also founded a special self-help group to support people who prefer moderation to abstinence.

The current heated discussion of CD arose in response to a report appearing in the German version of Psychology Today (Huber, 2000) about the "Outpatient Group Treatment Program for Controlled Drinking" (in German, "Ambulantes Gruppenprogramm zum kontrollierten Trinken" or AkT; Koerkel et al., 2001; Koerkel, Schellberg, Haberacker, Langguth & Neu, 2002). This program was started in October 1999 in Nuremberg (located in southern Germany), and was written up by the local mass media. The program is open to all kinds of problem drinkers including those who are alcohol dependent, although it is not designed for "recovering alcoholics." If people with other "contraindications" (such as alcohol-related physical damage) cannot be motivated to completely abstain from alcohol, they are admitted to the program as well. Thus, this effort works within the framework established by the clients' own goals (just as has been reported in Australia, see also Dawe & Richmond, 1997, p. 83). For the documentation and selection of subjects, as well as evaluation of the program, an assessment phase of one to three hours precedes any actual treatment. The AkT is a behaviorally and solution-oriented group therapy program (12–14 participants), delivered in 10 structured sessions (one session per week, 2 hours each), conducted by 1–2 therapists. It belongs to the class of BSCT, "the standard moderation-oriented treatment in countries in which the goal [of CD] is an accepted part of treatment services" (Heather et al., 2000, p. 562) and one of the most researched single treatment modalities in the field of alcohol problems (Miller et al., 1995). The AkT contains the following elements: basic information about alcohol, self-monitoring (in the form of a drinking diary), weekly goal setting, coping with high risk situations for excessive alcohol consumption, strategies to avoid or limit alcohol intake (e.g., rate control), coping with lapses, planning alcohol-free leisure time activities, and problem solving without alcohol. In order to make the program more interactive and capitalize on the advantages of group support, the sessions include small group exchange, role playing, working on written material, reporting experiences with ones' drinking plan and the like. People in AkT may opt for abstinence at any time during treatment and are encouraged to include abstinent days in their weekly drinking plan.

Controlled Drinking As A Topic During Abstinence Oriented Treatment
As outlined before, in most pans of the German treatment system (especially inpatient treatment centers) the discussion of CD is taboo, rather than a topic discussed by therapists in an explicit, non-dogmatic, systematic, and informative way. Two exceptions may be mentioned here. In the biggest Swiss inpatient alcoholism treatment center (Forel-Klinik), since the 1980s the so-called "ABC-dialogue" has been practiced. In the ABC-dialogue, patients are asked to choose one of three ways to handle their alcohol problem: A (abstinence, total and lifelong), B (limited abstinence, for a minimum period of one year after the end of treatment), or C (controlled drinking). According to Sondheimer (1989), an earlier medical director of the center, the "ABC-dialogue" produced many advantages: the therapeutic atmosphere was more open, patients with the goal of CD felt more respected, ambivalence concerning treatment goals was discussed more openly, counterproductive distinctions (drinking = bad, abstinence = good) were counteracted, and the therapeutic relationship was not automatically terminated (as is the case in most German inpatient alcoholism rehabilitation centers) if the patient wanted to continue with CD after inpatient treatment.
Koerkel and Schindler (in press) have developed a structured cognitive-behavioral relapse prevention training for abstinence-oriented treatment, encompassing 15 ninety minute modules that cover different topics (e.g., high-risk situations, abstinence violation effect, talking with relatives about relapse). To inform clients about CD research results, to correct inaccurate assumptions (such as equating CD with "normal drinking"), and to prepare clients for how to handle future desires for CD, one of the modules deals with CD and includes elements of a self-constructed drinking plan, along with the message not to start CD without professional assistance.
- Koerkel, Joachim; Controlled Drinking As A Treatment Goal In Germany; Journal of Drug Issues, Spring2002, Vol. 32 Iss. 2.

Personal Reflection Exercise #2
The preceding section contained information about strategies for controlled drinking therapy.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Efficacy of Cognitive Behavioral Therapy
for Alcohol and Other Drug Use Disorders:
Is a One-Size-Fits-All Approach Appropriate?

- Magill, M., Kiluk, B. D., & Ray, L. A. (2023). Efficacy of Cognitive Behavioral Therapy for Alcohol and Other Drug Use Disorders: Is a One-Size-Fits-All Approach Appropriate?. Substance abuse and rehabilitation, 14, 1–11. https://doi.org/10.2147/SAR.S362864

Peer-Reviewed Journal Article References:
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.

Nixon, S. J., & Lewis, B. (2019). Cognitive training as a component of treatment of alcohol use disorder: A review. Neuropsychology, 33(6), 822–841.

Parast, L., Meredith, L. S., Stein, B. D., Shadel, W. G., & D'Amico, E. J. (2018). Identifying adolescents with alcohol use disorder: Optimal screening using the National Institute on Alcohol Abuse and Alcoholism screening guide. Psychology of Addictive Behaviors, 32(5), 508–516.

QUESTION 9
 What are the elements of the AkT Controlled Drinking Program? To select and enter your answer go to Test.

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