However, they no longer found themselves in need of this help and did not express ambivalence regarding their decision to stop attending meetings. As none of these clients stressed criticism or objections towards AA as a reason for not attending meetings anymore, this might support the suggestion by Laudet et al. (2002) that over time, meeting attendance is less important for the recovery process among those that have embraced the programme and live according to the 12-step principles. On the other hand, some clients in the present study had adopted the 12-step principles, intensified their attendance and made it more or less central in their life.
On the other hand, the superiority for the abstinence goal group on DDD was significant only at 3 months’ follow-up and only when covariates were not controlled for. Thus, it appears that the greater likelihood of successful outcome in the abstinence goal group may be primarily the result of reduced frequency of drinking rather than reduced drinking intensity. Thus, while it is vital to empirically test nonabstinence treatments, implementation research examining strategies to obtain buy-in from agency leadership may be just as impactful. It is important to highlight that most of the studies cited above did not provide goal-matched treatment; thus, these outcomes generally reflect differences between individuals with abstinence vs. non-abstinence goals who participated in abstinence-based AUD treatment. The harm reduction movement, and the wider shift toward addressing public health impacts of drug use, had both specific and diffuse effects on SUD treatment research.
In addition, while controlled drinking becomes less likely the more severe the degree of alcoholism, other factors—such as age, values, and beliefs about oneself, one’s drinking, and the possibility of controlled drinking—also play a role, sometimes the dominant role, in determining successful outcome type. Finally, reduced drinking is often the focus of a harm-reduction approach, where the likely alternative is not abstinence but continued alcoholism. The importance of definitional criteria is evident in a highly publicized study (Helzer et al., 1985) that identified only 1.6 percent Of treated alcoholism patients as “moderate drinkers.” Not included in this category were an additional 4.6 percent of patients who drank without problems but who drank in fewer than 30 of the previous 36 months. In addition, Helzer et al. identified a sizable group (12%) of former alcoholics who drank a threshold of 7 drinks 4 times in a single month over the previous 3 years but who reported no adverse consequences or symptoms of alcohol dependence and for whom no such problems were uncovered from collateral records. The results of the Sobell’s studies challenged the prevailing understanding of abstinence as the only acceptable outcome for SUD treatment and raised a number of conceptual and methodological issues (e.g., the Sobell’s liberal definition of controlled drinking; see McCrady, 1985). A “controlled drinking controversy” followed, in which the Sobells as well as those who supported them were publicly criticized due to their claims about controlled drinking, and the validity of their research called into question (Blume, 2012; Pendery, Maltzman, & West, 1982).
Researchers have long posited that offering goal choice (i.e., non-abstinence and abstinence treatment options) may be key to engaging more individuals in SUD treatment, including those earlier in their addictions (Bujarski et al., 2013; Mann et al., 2017; Marlatt, Blume, & Parks, 2001; Sobell & Sobell, 1995). Advocates of nonabstinence approaches often point to indirect evidence, including research examining reasons people with SUD do and do not enter treatment. This literature – most of which has been conducted in the U.S. – suggests a strong link between abstinence goals and treatment entry. For example, in one study testing the predictive validity of a measure of treatment readiness among non-treatment-seeking people who use drugs, the authors found that the only item in their measure that significantly predicted future treatment entry was motivation to quit using (Neff & Zule, 2002). The study was especially notable because most other treatment readiness measures have been validated on treatment-seeking samples (see Freyer et al., 2004).
Sixteen 113- to 174-word case histories were constructed so that they crossed two levels of problem-drinking severity (low, high), two levels of social support (low, high) and both sexes. In the UK, the two levels of problem severity and social support were validated by asking an independent sample of seven practicing clinical psychologists to read the 16 case histories and rate each on 5-point scales for degree of problem severity and of social support. In both countries, respondents’ mean ratings corresponded to the levels that were intended when the case-history scenarios were written. Screeners recorded the drinking goal as abstinence or non-abstinence based on an open-ended discussion with the client. Screeners were trained to ensure that the recorded goal reflected the client’s wishes rather than being imposed by the clinician.
If you believe that harm reduction therapy may help, you may be interested in our alcohol addiction program. The majority of programs are web-based and rely heavily on motivating people to take responsibility for creating change in their own lives. There were 41 respondents (50% male, 50% female), who identified themselves as nurses (42%), physicians (32%), counsellors (13%) or another type of healthcare provider (13%, e.g. behaviour therapist, occupational therapist).
For example, all studies with SUD populations could include brief questionnaires assessing short-and long-term substance use goals, and treatment researchers could report the extent to which nonabstinence goals are honored or permitted in their study interventions and contexts, regardless of treatment type. There is also a need for updated research examining standards of practice in community SUD treatment, including acceptance of non-abstinence goals and facility policies such as administrative discharge. While there have been calls for abstinence-focused treatment settings to relax punitive policies around substance use during treatment (Marlatt et al., 2001; controlled drinking vs abstinence White et al., 2005), there may also be specific benefits provided by nonabstinence treatment in retaining individuals who continue to use (or return to use) during treatment. For example, offering nonabstinence treatment may provide a clearer path forward for those who are ambivalent about or unable to achieve abstinence, while such individuals would be more likely to drop out of abstinence-focused treatment. This suggests that individuals with non-abstinence goals are retained as well as, if not better than, those working toward abstinence, though additional research is needed to confirm these results and examine the effect of goal-matching on retention.
It might be thought that they are consistent with the traditional view that the client should, in normal circumstances, be advised to abstain since that advice is more likely to result in a successful outcome. It is even possible that some therapists might actively have worked against participants’ achievement of a non-abstinent goal, for example by undermining clients’ self-efficacy regarding the attainment of their drinking goal. In addition, as noted above, the abstinence-preferring group may have been more motivated to achieve their goal than those who opted for non-abstinence or were uncertain about which goal was better for them. These considerations, and possibly others, make it hazardous to interpret our findings as unequivocally supporting abstinence for those who are uncertain about their drinking goal. Equally, it would have been valuable to have measured the degree of abstinence orientation of therapists and their willingness to adapt their treatment approach to fit the goal choice of their client.
Edwards et al. (1983) reported that controlled drinking is more unstable than abstinence for alcoholics over time, but recent studies have found that controlled drinking increases over longer follow-up periods. Finney and Moos (1991) reported a 17 percent “social or moderate drinking” rate at 6 years and a 24 percent rate at 10 years. In studies by McCabe (1986) and Nordström and Berglund (1987), CD outcomes exceeded abstinence during follow-up of patients 15 and more years after treatment.
