Engs, Ruth C. [Ed.] Controversies in the Addiction's Field. Martha Sanchez-Craig, Ph.D. "CHAPTER 24: Toward Client Choice In Treatment For Alcohol-Related Problems"
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CHAPTER 24 Toward Client Choice In Treatment For Alcohol-Related Problems*
Martha Sanchez-Craig, Ph.D.
Current Principles in Treatment
"With alcoholics, choice is no longer possible, whether to drink or not to drink, or of the amount consumed, or the effects of that amount upon them, or the occasions upon which drunkenness occurs." This quotation is taken from The New Primer on Alcoholism by Marty Mann (1968, p. 9), a respected authority in the alcohol field; it synthesizes the beliefs of most alcoholism treatment personnel today. Mann's assertion is extremely questionable in light of available evidence. It is argued in this presentation that the widespread acceptance of the belief that "choice is no longer possible" in the matter of drinking can act as a deterrent to seeking treatment. Furthermore, I propose that if clients have choices thrust upon them, treatment can be made more acceptable and effective.
The first choice that prospective clients must make is whether for them it is true that "choice is no longer possible." In traditional alcoholism programs, asserting that "choice is possible" is unacceptable and labelled as "denial"—a symptom of the disease. In flexible treatment programs, clients beliefs are accepted whether they indicate that choice is possible or not possible, and treatment decisions are profoundly influenced by these perceptions. Within a flexible framework, the issue for clinicians is to learn about the sort of advice that clients should receive in order to be able to make informed choices.
We have found that many clients, particularly those who are new to treatment, consider conventional programs incompatible with their selfconcept and unsuited to their needs (Sanchez-Craig, Wilkinson, and Walker, 1987). Often they report having postponed treatment because of restrictions of personal choice which they expected from treatment professionals.
*This article is a summary of a paper presented at the 40th Anniversary Conference of the Addiction Research Foundation, held in Toronto, Canada, October, 1989. It is published in the proceedings of the Conference. Permission for re-printing by Kendall-Hunt Publishing Company, Dubuque, Iowa, was granted by the organizers of the Conference.
Specifically they fear that: they will have to accept the label "alcoholic"; they will be given no option but life-long abstention as the goal; and the schedule of treatment will be incompatible with meeting personal and professional obligations, i.e., there will be no choice about the scheduling of treatment. All these fears are usually justified, and they can make the prospect of accepting treatment seem more undesirable than the problems from drinking. Thus, the consequences of drinking have to be dire before treatment becomes the lesser of two evils.
For the past 12 years our objective has been to develop and test treatment methods that meet the perceived needs of problem drinkers, by providing them with greater choice in treatment. Our methods derive from the assumption that clients have the capacity for self-control, are good judges of their own capabilities, but have learned a harmful habit. We try to ensure that the philosophy of the program and the self-concept of the clients are compatible. The methods, which are described in a manual for therapists (Sanchez-Craig, 1984), have been refined on the basis of evaluations of the procedures, their outcomes, and the expressed needs of the clientele (Sanchez-Craig et al., 1987; Sanchez-Craig and Wilkinson, 1986-87; Sanchez-Craig and Wilkinson, in press; Sanchez-Craig, in press).
Choices we ask clients to make relate to: the nature of treatment— upon completion of the initial assessment, the nature and philosophy of our program are described to the client, treatment alternatives are discussed, and the client chooses; the goal of treatment—this may be abstinence or some considered and specified level of consumption, and can be modified in light of experience; the scheduling of sessions—clients negotiate with their therapist times that are of mutual convenience; the involvement of others—it is never a condition of participation that clients must involve others in their treatment (e.g., spouse, family, employer, Alcoholics Anonymous); and the termination of treatment—in consultation with the therapist clients decide when treatment should terminate, either because of successful completion, or failure to achieve the goals, or incompatibility with the treatment method.
Constraints of Choice in Treatment Programs
The view of alcoholism as a progressive and irreversible disease dictates essential elements of effective intervention: clients must learn and accept that they have "the disease" (i.e., a permanent physiological abnormality) and, based on the construct of "loss-of-control" or "impaired control", they must accept that life-long abstinence is the only realistic goal. Rejection of these conditions is seen as symptomactic of the disease, namely, "denial." In addition, many program insist that important personsin the client's life become involved in the treatment process in order to undermine the client's
denial and avoid inadvertent "enabling" of the condition. Many programs insist upon participation in Alcoholics Anonymous to help maintain sobriety and adherence to the disease ideology. The idea that there are a number of essential educational and therapeutic components of effective intervention justifies programs of predetermined duration (typically lasting from three to twelve weeks, with follow-up periods of one to two years).
Evidence Favouring Choice in Treatment
Generally speaking, behavioral scientists would agree that treatments tend to be more effective if they are consistent with the clients' selfconcepts and beliefs about the condition being treated. This indicates that, where alternative effective treatments are available, choice should be permitted so as to match clients' perceptions with the dispensed treatment. In the treatment of alcohol problems this general proposition is most relevant to: the model of alcohol dependence, the goal of treatment, end the clients'concems about the privacy of the treatment. The most contentious and extensively evaluated of these issues is that of goal.
The consistent finding of controlled-drinking outcomes among some treated alcoholics, even after their participation in abstinence-directed programs (e.g., Armor, Polich, and Stambul, 1976; Nordstrom and Berglund,1987) is the impetus to offering moderation of drinking as the goal. In a study with 70 "early-stage" problem drinkers (Sanchez-Craig, Annis, Bornet, and MacDonald, 1984) we found that when abstinence was imposed upon them, most did not achieve it; they disregarded the assigned goal and approximately 70% developed patterns of moderate drinking on their own. In the study, clients were randomly assigned to one of two conditions of a treatment program: in one condition abstinence was the only available goal ("no choice group"); in the second condition clients could choose between abstinence and controlled drinking ("choice group"). The two groups did not differ significantly on relevant pretreatment characteristics, or levels of drinking reported over a two-year follow-up period.
First, we found that abstinence was considerably less acceptable to the clients than controlled drinking: only 34% of those who had abstinence assigned to them accepted it as their longer-term goal; of those who were offered a choice, 85% opted for controlled-drinking. The drinking outcomes for the two groups were very similar, with most clients reporting moderate drinking at six months follow-up; such outcomes remained stable to the end of the follow-up period (Sanchez-Craig et al., 1984). It should be noted, however, that clients in the abstinence condition had more difficulty in
developing moderate drinking than clients who were specifically trained in the procedures. Furthermore, the abstinence group requested significantly more aftercare sessions than the group who chose their own goals. In short, we found that restriction of choice interfered with treatment gains (Sanchez-Craig and Lei, 1986).
Figure 24.1 illustrates the average weekly consumption for each client in the "choice" (top panel) and "no choice" (lower panel) groups at assessment and six month follow-up. In each graph the clients are placed in ascending order of scores on mean number of drinks per week at followup. Note that in the "no choice" group the finding is typical—heavier consumption at intake to the program was predictive of heavier consumption after. However, this relationship was not seen in the "choice" group because of the very marked reduction in drinking by some of the heaviest drinkers coming to the program. Thus, we concluded that, for the types of clients we recruited to the program, heavier drinking before treatment should not preclude giving choice of goal.
In our subsequent treatment studies with "early-stage" problem drinkers (Sanchez-Craig, Leigh, Spivak, and Lei, 1989; Sanchez-Craig, Spivak, Davila, and Bianca, in preparation) we found that, when given choice, most select moderate drinking as their longer-term goal. Thus, if programs of secondary prevention are to be successful in attracting clients, we believe that it must be generally known that moderation is considered a feasible objective of treatment. As part of the same strategy for early intervention, it is important to offer clients the opportunity to participate in programs where it is clear they will not be labelled as "alcoholic", except if they choose the term.
Strategies for Increasing Opportunities for Client Choice
There is an entrenched and committed alcoholism treatment establishment and industry, whose members are very unlikely to modify their views of what constitutes appropriate intervention. The best strategy for increasing clients' choice will be to introduce notions of flexible treatments into the training of health-care professionals, and encourage those professionals to identify and target problem drinkers who are currently avoiding the treatment system. This is a grandiose plan because professional education largely ignores alcohol and drug dependence as an important area of concem. Also, since the recommended strategy focuses upon secondary prevention, it will confront the problems inherent in attempting to develop prevention programs generally. For example, in the area of heart disease, transplantation is a more glamorous activity than prevention education. Similarly, it is inevitable that heroic recoveries from alcoholism involving public confessions are more newsworthy than private resolutions before the problem becomes severe.
Probably the best hope for achieving the objective of developing strong programs of secondary prevention will be to persuade governments to give greater priority to funding this activity, and the training of necessary staff. Today such programs are rare.
As our prevention program has developed, we have gradually increased the amount of responsibility that is placed upon clients during treatment. The amount of therapist contact has been reduced with the aid of "self-help" materials which we tested in a controlled study (Sanchez-Craig et al., l 989). We found that females were generally more successful than males in moderating drinking over the one-year follow-up. Females were particularly successful in the conditions of the study where the treatment was aided by "self-help" materials. We are now replicating this study to determine whether, in fact, women do best when they are guided to resolve the problem largely on their own.
It seems that many persons overcome their alcohol problem through their own efforts (e.g., Clark and Cahalan, 1976; Fillmore, 1974), and probably many do with some simple advice (e.g., from their physician). Today little is known about the extent to which these resolutions occur, and about the characteristics of those who benefit from simple advice. Thus, it seems essential to study how people respond to direct advice, and to purely motivational advice. With support from NIAAA, my colleague Dr. Karen Spivak is now conducting a community study which may provide some clues on this matter.
She placed three one-day advertisements in local newspapers offering educational materials to those who were concerned about theirdrinking, but wished to quit or reduce their consumption without professional help. The response to such advertisements was encouraging: approximately 180 persons expressed interest in receiving the materials and in becoming subjects of the study. It involves an initial one-hour interview to conduct a brief assessment and to give out the educational materials, plus two follow-up assessments (at 3 and 12 months). At random, subjects received one of the following: a 2-page pamphlet outlining guidelines and steps for achieving sensible drinking; a 30-page manual explaining the steps outlined in the pamphlet; and a package with information on alcohol effects. Many subjects said that they decided to participate in the study because they thought that having the assessment and the educational materials could help them to establish whether they had a problem, and if they needed professional help. At the time of preparing this paper, Dr. Spivak had conducted 3-month follow-up assessments for half of the participants; 10% indicated that they
would prefer to work with a professional, ratherthan to continue on their own. It remains to be seen how many subjects choose either of these routes by the end of the study.
In conclusion, the arguments laid out suggest the desirability of offering clients choice in treatment, particularly before their alcohol problem is very severe. The ultimate choice that a potential client must make is whether to take treatment or not. For those who are seeking treatment for the first time, a good initial strategy could be to motivate them to solve the problem on their own with the aid of self-help materials and opportunities to check their progress. This strategy may prove fruitful in two important respects: it could make treatment delivery more efficient, and it would satisfy the clients' need for self-control.
Armor, D.J., Polich, M., and Stambul, M.B. (1976). Alcoholism and Treatment. The Rand Corporation: Santa Monica, CA.
Clark, W.B. and Cahalan, D. (1976). Changes in problem drinking over a four-year span. Addictive Behaviors, 1 251-259.
Fillmore, K. (1974). Drinking and problem drinking in early adulthood and middle age. Quarterly Journal of Studies on Alcohol, 35 819-840.
Mann, M. (1968). New Primer on Alcoholism. Holt Rinehart and Winston: New York.
Nordstrom, G. and Berglund, M. (1987). Aging and recovery from alcoholism. British Journal of Psychiatry, l51 382-388.
Sanchez-Craig, M. (1984). A Therapist Manual for Secondary Prevention of Alcohol Problems. Procedures for Teaching Moderate Drinking and Abstinence. Addiction Research Foundation: Toronto.
Sanchez-Craig, M. Brief didactic treatment for alcohol and drug-related problems: An approach based on client choice. British Journal of Addiction, in press.
Sanchez-Craig, M., Annis, H.M., Bornet, A., and MacDonald, K.R. (1984). Random assignment to abstinence and controlled drinking: Evaluation of a cognitive-behavioral program for problem drinkers. Journal of Consulting and Clinical Psychology, 52 390-403.
Sanchez-Craig, M. andLei, H. (1986). Disadvantages to imposing the goal of abstinence on problem drinkers: An empirical study. British Journal of Addiction, 81 502-512.
Sanchez-Craig, M. and Wilkinson, D.A. (1986-87). Treating problem drinkers who are not severely dependent on
alcohol. In M.B. Sobell, and L.C. Sobell (Eds.), Drugs & Society, 1 The Hawor h Press, Inc.: New York.
Sanchez-Craig, M., Wilkinson, D.A., and Walker, K. (1987). Theory and methods for secondary prevention of alcohol problems: A cognitively based approach. In W.M. Cox (Ed.), Treatment and Prevention of Alcohol Problems: A Resource Manual. Academic Press: New York.
Sanchez-Craig, M., Leigh, G., Spivak, K., and Lei, H. (1989). Superior outcome of males over females after brief treatment for the reduction of heavy drinking. British Journal of Addiction, 84 395-404.
Sanchez-Craig, M., Spivak, K., Davila, R., and Bianca, A. Superior outcome of females over males after brief treatment for the reduction of heavy dunking: Independent replication and report of therapist effects. Ongoing research supported by Grant No. ALCP-1 5 ROlAA06750-03, in preparation.
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