Alcohol abstinence vs. moderation

Alcohol abstinence vs. moderation

A debate that started in the 1960s remains an important one in the addiction field: is it possible to control problem drinking, or must the drinker give up alcohol completely?
Clinicians often find that patients who enter alcohol treatment for the first time say they would like to find ways to cut back on their drinking rather than abstaining. And many people who have not yet developed symptoms of alcohol dependence, such as high tolerance or withdrawal symptoms, are nevertheless in danger of crossing the line into dependence.

Yet it may be difficult to encourage people at any stage of a drinking problem to seek help, owing to a combination of denial and stigma. Offering counseling on moderation may help convince some problem drinkers to seek help before they suffer painful consequences.

Severity predicts relapse

Research into moderate or "controlled" drinking has shown that this strategy can be successful for patients who have not yet developed a pervasive pattern of alcohol abuse, or who have experienced few negative consequences from drinking. The goal is to help patients set goals and drinking limits before they cross the line into dependence.
But the research shows clearly that moderation is unlikely to be successful for patients who already meet criteria for dependence.

One study, for example, followed the outcomes of drinkers for three to eight years after they participated in behavioral self-control training, a therapy designed to instill moderate drinking behavior. The researchers found that as severity of dependence increases, likelihood of patients' being able to reduce their drinking to moderate levels, and keep it there, goes down dramatically. For the most dependent drinkers, abstinence may be the only option.

Moderation as motivation

Moderation can be used, however, to motivate patients to change. Many patients are ambivalent about giving up alcohol, even though they recognize that dependence is straining their marriages or jeopardizing their jobs. A patient who expresses a desire to start drinking in a more controlled way is indicating a desire to change a behavior. Motivational interviewing can help patients progress toward change. With this technique, clients set the agenda, and the therapist acts as a partner in dialogue rather than an authority.

Demanding abstinence too soon may just end up driving away a patient who is at the brink of dealing with addiction more directly. When a patient expresses a desire to moderate drinking, it can alert the clinician to a teachable moment. Patients who try to limit drinking for a while and find they are unable to do so may then realize that they have already developed dependence. This may be enough to motivate them to try to abstain.

February 2009

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