ED 158 200-
ANTOORTITLE
INSTITUTSPOOt AGLRCF
*_1313 DATE-VOTE
DRS- PRICEmon
IDENTIFIERS -
ABSTRACT
Nelson{ G.;Ronald G Jansen, William B.Empirical Approaches to the Treatment of AlcoholAbuse: Altertatives,to Abstinence.,Ilabamap Univ., Oniversity.-Dept. of Psychology.National Inst.' of Mental Health (DREW) ,
Md.(77]'52p.
MP -$O.83 MC-13.50 Plus Postage.Adults; *Alcoholism; Counselors;: *Drinking;Literature Reviews; Methods; Program-Descrtp io*Rehabilitation Programs; Research-Methodology;*Social Behavior*Controlled Drinking
This report presents research studies from the past15 years hicb.indicate that some alcoholics have been able to returnto contr fled, moderate drinking_after behavioral treatment.Presente in this report are :. (1) the :techniques used to trainalcohol busers to moderate drinking (2) the research methodologiesused to measure the treatment effects_of controlled drinkingprogram (3) a discussion of the characteristics of controlladrinkin candiates; and (4) two sample optional controlled drinkingprograms. It is hop6d that if treatment with options other thanabstinence is made available, many, alcoholics uho are currentlyuntreated will seek and receive help. (Author/RF)
***** * * ** ** *** *******Reprlductions supplied by ERRS are the best tha
* from the original doCument.********** ******** *********************
******de
EMPIRICAL APPROACHES TO HE TREATMENT OFAl.001.161. ABUSE: ALTEFIMAT, YES TO ABSTINENCE
6"
RONALD 6. NEL OMAN D WILLIAM B. JANZEN
lEmiSsION TO REPRODUCE TRisMATERIAL HAS BEEN GRANTED BY
TO' 71.41 EDUCATIONAL REIDIACESINFORMATION CENTER IERIC) AND
USE Rs OF THESICSY STEM."
W. CI PANTAAINIT OF MOWN,III IfATIDM & PAVANE
NA,IDIOAL INSTI/UTI OFMOTION
Tp4s3 DOCUMENT NAS BO ETA 4E PRO.DU CEO fXACTLy AS RECtiviD FROMTOMENIONDMINAGANIZATION ONION.AT MO IT PcNN1$ OF VIEW OR OPINIONSSTATED CO NOT IldfCESSANILYSPIT ~OFFICIAL NA.TioNwposTITuTE O(E ix itsON gboSa t614 OR POLICY
THIS PAPER wAS SUPPORTED BY THE NATIONAL
II RIME OF MENIAL HEALTH UNDER API NIAAA GRANT,
Traditionally, tb goal of treatment_ of alcoholism hap' been
abstinence.' Total cessation of drinking has been the criterion
for recovery in,themajority of treatment programs -for Years.
Howaver, over the past 15 to 2p years, reports have been, surfacing
Dpthe alcoholism literature suggesti g that alcoholics have been
able to return to "normal" or "moderate"driaking. More recently
data have been reported which indicate that alcoholics have 1:)en
able to, achieve "controlled" drinking aftet behavidral treatment.
These findings have led other s-tb-question many of the basic
tenet_ of the traditional "disease" concept of alcoholism. Thus
a major controversy has arisen in the-alcol lism field; a contra-
hiah ma have come to latel the "controlled drinking
controversy".
Abstinence Only
Central to the abstinence concept in alcoholism treatment has
been its adVocacy-by Alcoholics AnomymouS The stand of "AA"
from its inception has been quite clear, as witnessed by this
statement in the organization's basic text (Alcoholics Anonymous,
1955), "... there is no such thing as _aking a normal drinker out
of an Alcoholic" p. 480). This stand has proven to hold wide-
4
-.Controlled Drinking
-3
spread influence throughout the field, primarily because of AA's
sue ess in helping thous nds of alcohol abusers overcome destructive
lifestyles via "sobriety".
However, AA is not alone in its advocacy of abstinence.
Throughout the alcoholisfi literature of the past 35 yeaFs one finds.ph-
,
almost unanimous support for position that abstinence is the
only acceptable goal for the.recovering alcoholic. In.1941
Strecher insisted, "The highest h
clearing is the acceptance of a -c mpletelymust finally succeed
that _the alcoholic patient
non-alcoholic' fu ' (p. 14). li (1949) strongly suggested
the same, "Because the addict drinker cannots, revert to controlled
drinking, his goal must be permanent a nence" (p. 408)- This
view was reaffirmed by many in the 194- (Bowman, 1956;
1951; and Bacon, 1958).
g iinning in the 1960's fhe "Dean
iebout,
of s the alcohologists"
himself, E. M. Jellenick (1960) , continued the abstin_nce--only.,
trend in. his classic text, The Disease Com p Alcoholism.
Many others followed suit. Glatt (1967) stet d that although
a small :minority of alcoholics may be/able-to return to moderate
drink Abstinence remains the only safe way for the alcohol
addict" (p. 272) The National Institute of Mental Health strongly
supported absiinende in their public statement of 1969, "Most
_hold thatthat`no alcoholic can learn to drink moderately.
and regard statements to the contrary as unwise and dangerous II
This view c-retinues to prevail
4
The National Council
on Alcoholism (NCA, 1974)- has s: ongly'suPported abstinence
throughoUt the 1970's and in a recent review of the contr versy,
fox (1976) emphasized '" ..I think it is very unsafe to advocate
any treatment goal except abstinence" (p. 237). In a
O'Brien (1976) declared we should discourage research
trolled drinkihg because, "abstinence is the beet decision" 4).
_
erate Drinking by Alcoholics
In 1962 Davies,-in his article "Norte Drinking in Recovered
Alcoholics," began'the process of bringing into focus something
which-had been developing for several years an alternative to
abstinence a the only goal in treatment of alcoholism. He found
in a follow-up study of 93 alcoholics seven to 11 years after their
discharges from Maudsley Hospital, London; that even of them had
returned. to "norm-1" drinking. All seven were men who had ex
peri need severe alcohol abuse problems prior to treatment.' Al-
Though he continued to adyise alcohol abusers to aim for to,tal
abstinence, De iee'suggested that the generally accepted view that
hp alcohcil addict can ever again drib normally be modified.
Davies article was not
become normal drinkers.-
first indication that alcollolios might
In 1956 Norwig and Nielson r ported that
42 of 221 former alcoholism patients who were drinking occasionally
were doing well '5140 to five years after treatment. In 1957
Controlled D
5
Pfeffe and Berger found on ollow-tp that seven of_ 60 patients had.
chan g ed their. pattern of-drinking. Selzer and Holloway (1967)
reported that 16% of 83 patrents.had re-tarried to ,"social drinking
fter treatment. Other researchers had reported similarAtindings
(Lemere, 1953; Moore & RamseUr, 1960). But it was Davies article,
which attracted widespread attention -and thus gave rise to what would
later be celled the controlled drinking controversy
Davies article had such impact that 16 leaders Th the alcoholism
field (Various Correspondents, 1961) quickly responded in,a series
of articles. Thefcriticism of Davies was intense. Some suggested
that the incidents he cited were simply "spontaneous recoveries"'
similar to those observed in cancer patients; others insisted- t
his cases;were not true addicts; and still others-.chastized Davies
for the potentially negative -ffect is article might have on sober'
alcoholics.
But the momentum had swung, and soon Several other studie
which concluded that Some alcoholics Could,control their dri
ihg were published. In .1965,, R. E. Kendell in the course
follow-up of 62 untreated alcohol addicts found four who had been
drinking normally for three to eight Years. In 1967 - Bailey and,
Stewart Pound on follow-up of 12 subjects, whom they had earlier class
Pied as alcoholics with some histoty of moderate drinking, six
who were drinking "normally" .Pattiso,n, Headley, Gleser, and
Gottschalk (1968) found in a follow-up study of 32 alcoholics,
Controlled. Drinking
approximately 20 mbn _s; after 4ischarge fro treatment, 11, who had
successfully returned to moderate drinking. Reinert and Bowen
11;68), al=though dloenly skeptical of normal drinking by alcoholics,
diclfind our moderate, drinkers in a sample of 156 alcoholic
patients interviewed one year after treatment at Topeka Adminastra-
tion Hospit 1. And several` other studies'(Kende Stanton,
1966 ;' Pokorny et al., 19687-Orford,et al, 1970; Fi Gerald et
e971; Goodwin, 1971; Kisha Hermann, 1971) proviided' tional
'evidence of "normal " drinking by alcoholics.
Thp most widely known and discussed study which has reported
successful return to drinking by alcoholics is the "Rand Report"
& Stambul, 1976).. While Davies served to stir a
of controversy in the scientific community, the Rand Report
propelled the controversy into the wider professional and lay cm-.,
muniy. The study was a survey designed by the prestigious Rand.
Corporation for the purpose of evaluating the effectiveness of
numerous `treatment centers supported by the National Institute
on Alcohol Abuse and Alcoholism (NIAAA). Questionnaires were
administered to 11,500 men who had sought help at these centers.
The gueslionnaires were-filled out 6 and 18 months after men
?
had completed .tea.tment or been discharged without treatment.
Thee- found that the majority of the former patients described _hem-.
selves not as, long-term'abstainers but as moderate drinkers or as
individuals engaged in alternate periods of drink' and abstention.
Controlled Drinking
The report stated that the results suggest,"...tme alcoholics
can return to moderate drinking with no greater dha-
than if they abstained" (Armor et al., 1976, p VI) .
The Rant researchers welt
7
relapse
rest 4engths to qualify their
statements. They acknowled-d the study' -mall sample.4ze, short
follow-up periods, insisted that labstinence is still. the t tment
of choice, and stated that no sober- alcoholicmhOul&return to
drinking. They pleadedOthat they were simply reporting the fact
that some alcoholics meat 'have stabilized at moderate-drink-
ing levels 18 months after treatment, but this was 119t heard in the
ensuing uproar. The report drew the wrath of the alcholism
"establishment." The iatial Council on Alcoholism, Alcoholics
Anonymous, and numerous other groups, professionals, 'and private
citizens denounced it outright. The report has been rightly or
wrongly blamed for numerous instances of return to drinking by
recovered alcoholics throughout the country. Researcher ave also
criticized the report's methodology, incl ng extended comments
by several authors published recently (Various Correspondents,
1977). Some of the criticisms'include: the over-reliance on self-
reports, the basing of conclusions on a small portion of the total
number of subjects because of poor response to"questionnaires, and
the misleading use of sfat'stios such as masking small numbers with
percentages.
Despite shortcomings, the-Rand 'Report is without question the
Controlled Drinking
8
single event in the history of this controversy that ia.s brought
the issue of Moderate drinking by alcoholics to the layman's
awAieness.
Summary of Follow -up 'Studies
Table 1 presents a summary of the data from the studies we
have reviewed which ted "normal," "social," or "moderate"
drinking by alcoholics.
Insert Table 1 About here
The'-table should be interpreted cautiously in view of the
small sample sizes and questionable follow-up techniques in many
cases. Also, the definition of the "moderate drinker" varies among
the studies'. Despite these reservations, Table I presents s
ficient samples over extended periods to-offer some tentative
Conclusions. First, tine might conclude that in a given population
of alcoholics one would expect approximately 11% to achieve moderate
drinking with or without treatment. This is in agreement with
Patti- n s (1976) estimate of 10-15%. , Consequently, any program
designed to train alcoholics to moderate tFieir drinking would have
to demonstrate a success rate in excess of 11% in order to be judged-
effective. Second, one can conclude that moderate drinking appeared
to be as viable an option for the alcoholic population as abstinence..
Contr lled Drinking
9
There waS no zsignificant 'difference between the percentage of
subjects who succeeded at moderating their drinking and those who
were. able to maintain abstinence 111.-2% vs 11.8%). 'This would
suggest that Moderate drinking might not be as unique an odtcome
as is widely belie.vea. It must be emphasized, however, that well-
are needed in this area beforedesigned, long-term follow-up studies
any f conclusions can be made.
Abstinence ttacked
Explorationin d alternatives to abstinence, initiated by
Davies' article and supported by later reports, to -the critical
examination of the abstinence concept itself and of Jellenick's
(1960) "disease concept" upon which it'wa s based. This latter
concept emphasizes "loss of control" drinking, where one alcoholic
drink initiates a chain reaction so that alcoholics are unable to
only have one or two drinks, but continue drinking: Eo ever, Mello=7)
and Mendelson (1971), after a quantative analysis..of the drinking
patterns of 1- alcoholics given unrestricted access to alcohol,0
concluded that their observations gave no empirical support to the
traditional notion f craving. Merry (1966 ) gave alcohol to alto-
holies disguised as a vitamin preparation and was unable to detect
any, evidence of increased craving for alcohol Sobeli, Sobell.
and Ch5istlman (1972) were not able to determine any evidence of
loss of control in their alcoholic patients after intake of either
4
small or large amounts of alcohol. Gottheil, Alterman, Skoloda
and Murphy (1973). found that 44% of their. alcoholic patients wh
given an opportunity to drink, drank no alcohol at all and 23%
began and stopped, even though zlcohol continue to be available
in the experimental setting. Thus, many researchers have concluded
that loss: of control after _the-first dh irik. is not inevitable and,
have called for a thorough rethinking of the disuse concept
(Robinson', 1972; Davies, 1974; Keller, 1976) .
Pattison (1968, 1976) has attacked the abstinence concept in
several article 'which suggest that insistence on abstinence as the
.sole criterion of succes may prevent alcoholics from obtaining
therapeutic"assistance. Many patients cannot achieve abstinence
and thus avoid returning to counselors with an "abstinence only"
approach. Furthermore, Pattison has stressed that the social,
vocational and psychological -elfare of the patient is as important
as changing his drink,tpg pate -n, and'the assumption that abstinence
will immediately bring improvements in these areas is not warranted.
As evidence Patttis cites Gerard (1962) who found that in 'a/group
of totally abstinent "successes," 43% were "overtly disturbed,"
24% "conspicuously inadequate," 12% "AA addicts" and only 10%
"independent successes." Thus many signifidant and even critical
treatment goals may be eally overlooked when abstinence alone is,P.
emphasized. He also criticizes the abs nence-only approach because
it leads to the punishment or rejection of the nonabstinent
Cor trolled Dtibking,
11
alcohOlicv may drive many discouraged treatment perSonnel out of the
fidld of alcoholism; may be :in itself.preVenting the ;possibility of.
controlled-drinking byA0anyalcoholics; and may be forcing many to-
adoPt-.a.lifestyle in-conflict with,a_society that values ability to
drink. Other authors, (Evans, 1973; Popham and Schmidt, 1976
Canton, 1968; andTreedi-1973) have also come to s4destion abstinence
as the only acceptable goal of alcoholism treatment.
Attein is to Train Alco- lics to Control Their Drink in
Challenges of the abstinence'and the disease-concepts have
resulted in eforts to train alcoholics to become "controlled".
- drinkers. Such efforts a e certainly needed -Alidate the claims
that alternatives to abstinence in alcoholism eatment are feasible.
Until the ,early 1970's when behavioral treatment efforts began, the
critics of the controlled drinking option had-mti h to criticize.
There were many weaknesses in the reports of alcoholics returning
normal drinking. Since the numbers were small and treatment had
not emphasized moderate drinking, the results might just be
"spontaneous remissions" similar to those found in cancer resear
The survey procedures were fraught with problems: results were
often based totally on self-reports and recall of the former patients
which raised the guestiob of validity; interviews were often done
by individuals who provided the treatment which raised the pos-
sibility of bias;. and operational definitions of terms like "normal
dri Win " soci al dxir king ,"
were corn picuous ly alosent< from
This made corap.arison of survey
The 1os -of control ° researchwho insist that the riiod.erataori
hig lily cor c1 1e4 exper-irrten to
alc ohclIcs i in the wor
(Pa iede& , 19 / ) = -thus
des igried
ale
tea= 1 eval
god 16
I1 tL oi 1
©VJbc Ili cA L=
Control Jed 1Dri nk Ong
"(loin 11" and
12
d adjuistrie Tit"
the survey s ©r were very ane
results pract<i=cally inposs ib le .
has also been criti cited by thoseeyed by aic hoLics L c er title
ccnditioris would be irripo sib le for
wttere 3U&i1
6 1J t--- t.,A 1 i C.2 A
1ii
t= ul
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ptOd to estimate van
Controlled Drinking
13
In the second segment the
ects were allowed to drink but were shocked intermittently when
they e'coeeded a specific SAL,.
12 tw hour sessions °vet a lb wok
the subjects comp -et d t1_ t1tteli
he t consisted of six to
period= Twenty-eight of
nowc:vel_, ur t.11c 13
subjects who received ideiltzio l treatment ex
adti
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Controlled Drinking
14
'ias a basis for firm conclusions. The a,uthors concede this but still
Label these subjects as "complete successes." Second, two-thirds of
the control subjects dropped out of the experimeht. Third, d, the use
of a therapist with an inVeSLment In the outcome to u-diry out_ treat
meat w1 LIl L., t11 the c1Cpc1-1
introduced
up procedure
actually
L1.1 __tiol sAIL_JkAp.b 111 1/.1z
Fourth, eze Seid 11U
BAAL ci1 11111 t1L lute
w11 L11 r they di 1 1AR LJ
poinld
e6t.L11.:311 a
a d
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11,-.1ve
1,/,,rbkla, Ida
= A 1,--14 1 ( k, 11,
ion wIi tai r tiles follow
had
Liklukihy
erMinInkj LinAL
aid L1,
A4 ( PL.)) fla NtC'
Lfie k,"(k f t=1,
lAt 1 IAA
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A
cH 1 1.4,1kid
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(
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m1auLe_
Controlled Drinking
15
was stithdrawn. after discharge tile subjects were to send in pre-
_addressed postcards containiny specific. i nitor=mmla ti-1 about drinking
171abits. Attempts were alsu made to turL -ui urCte tt11.s information
through Conta- with 11-1ati_ve cYlld LLlti1d5. AL the cild Olt
dO-duy peLlod only Oilc. had
d rniciny and Ltic Ulu L.
BAL
ad d1. LA 131 evid-,.
._7111Lho
11,
Ls;411 Lc _II a111.1511A9
114( illur1, Z v Lt
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ro11ed Drinking
16
chrQn is Mama" alcoholics respectively from the emergency roomsp
f the Baltimore, 11--
meet
_ls, participati an d environ-
made contingent upon dbstiflence or moderate driakina
Each study was of 5-week dura t 1 1t Iid duLin(4 thre!e of the
U
money Iii
td ntt1t5 wr
.111y
alt
2 weks
satic:to
ficid
1,_21 1y limIL
111 1 _ttta1 a t; t_ vill6,
cll. ICiilicLy, uso cl pi Vdte phone dnd
It cht.-_-:,
WI
C_ -11.111-Q11.11 wl t
-CJ 117 C4.44
4010..11,3
1L
4 / I
weeks ,1 cr
1l ,1,d11 1
Atibt.1
11A,I
A
ii
AN.
,.;,1i1 11Itt1'1.
in an nItouvekts
i. gal is
dui i1ii1 t i CO
llAot
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di=
L ,ed 1 it
Liar-Inc] tLc
6-21'11_ week,.
(n_ 24
do.
de, ,a
Controlled Drin_ in
17
These three studies demonstrated that under extremely, controlled
experimental situations some alcholics can moderate their
habits witwith the aid of riA_id manipulotiQn of wnvitouu _al,
tone --enc rite nes Ltits ly t1 111 eiigt Lh t 11v
1'1 ©t CIlly 01.0 1.
will *lose cOntrol" cat their drinking= The ,utnors u lycst thc11
power tul r nforly ex
51 ViCeS likad cadl
a motley, X11 ulfer, 141.11La
11 Li riy All LA1.,0L1iii3+-cL
01 111,JatA-1,1011 of 111J9. Li Cell ..ii. Ali,t+ 8,, LA
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= 1 A,}% A ii.A3
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at;(1 t1 iced
Lip
101
11,111 tr 111111
1
(A-J 11- I A,1N .1 k 131 IN 1 CAw A 1976 )
, l AA-AL-.1 A *AA._ 1 A
A.c2S1S \J1 ' Ve 0, ciIA I =J . A 11= t jc=1 nkenA
1 lit_
I
1 L 1 ,"
L Al 1_1cl nq s tylt. 1,1,)
it A A. 1 IA d 1 l.i,h I
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ona
1. A I.
I A. .AA* 11,A
or tt, I.A
Con -oiled Drinking
18
drinking for aA)eriod of time 'after treatment. H s.rver, the-small
sample size, short follow=up period arid relia-1 on self-teporth
during follow -up prevent conclusive
John
In 19 /0 EwIlig
verhity NVIL1-1 Ca
through wh AL 11e No
Ltle C _
Ina attenpted
LQ eVal
,a 1 L11u11 L 11ava1claL E cicin..14..g nab
lavIcaftl LaLAlil1 Hu tt has _
rig La111
19741) Inci
ll r t.,LL tn, t l ta. L Ills clieni,, malliL,AILA L-1A
^J I,i l .1 ID t I. ,, 1 -J -4141,-,t,,,
v,110 !Id,' CI IA/CI 1 ,Itiza a( AI,,,no11 An a. -4.- .0 ,,,,i li-A
k),iL.4k, h
-yeal
(L
101
awl
,s ,t Uni-
C11_
Ity ut twat.
RuUs / rv411,--j
stud
_ng
/
luw Up study (1 197b) In whim
pal LI
LItc,
Jto
ocab-z-, _ uuL,
4, l 1 _I
ty
LL catc,l
_I 1 t 11 L.
7.
patterns. Of the
Controlled Drinking
three were found to he-drinkin
19
in a control=
-:--..,led manher and three ot,her4 'wet doing poorly. wing categorized
such results a "showing premise" tor the possibility of training
-0h014,cS to (IL Ink In
ftuwver, lu a la
conpleted
during c Z 1
contiolled m Mae V_1.,d outpatient t -atment,_
'1E sLudy ut 14
nWubdt cwt Lieatment se 6s furls )
111 11L113 afiet Lite 1141 a L1 ea
C011 I 1 111 c pi 1 AaLudy 1,4az. a
sy I.= c.m 4411 1 I .
wink av1,1
-11
de...:ided that th_y wu_t_ be t.-.tally 111.1
wC e p
ALL.i.IL
ary riA
e11tCi 11t_ 4_=
I. 1 -
t L
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-n
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a very
1...11
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1_4, 1
1.,
Control ed Drinking
20
categorized identically to an alcoho ie who dra to excess every
'day. His criterion for success appears to be exorbitantly high, as
witnessed by his statement, ...for the alcoholic, even one bout
of loss of control can be damaging in many ways and, we believe,
-tints a poor outcome of therapy" (Elwiny, 1/ P- 1 31) - Thus
pears that his scoring system is biased toiard failure. It is
also curious that he dropped the MininUM number of needed
for completion of treatment from 12 to lx for tulluw up
Despite the fact that Swing's outcom
Spiead publicity,
Q01-0_1ULle
Svc ik,;eived
Is qustiuncibi tii much (AA,-
dlInk110.3 kk 1,14
ly
.111,d c,c thud
ology, HI did not claim that he was car rying,cu.t a wel l-designed
tiedf..lu i
a !AU
agains L L:01 _
duic, lout 1eliely
Q1.0..o( s1.41
mill. .A.,1 ,_rt1,1
Su
01 11
c4iia
c_ ,A 1 1L,,,
,
LAIC.
v ILA .n't,u,ly
ex (1.,(
Ad:
Controlled Drinking.
21
realistic bar setting at-the hospital. Types and number of drinks
were recorded as well as the number of sips per drink. The re-
searchers found that the alcoholics ordered straight drinks,- gulped
rather than sipped their dri- and ordered more drinkS. In a
later study, (Sobell, Schaefer & Mills, 1972) 2 hospital
alcoholics were compares with 23 social drinkers and the authors
again noted similar behavioral diffeeences between alcoholics and
social drinkers- These studies were impressive in that Lney were
the first systnatiL attempts to det--I dt I
and drinking pat --=lz befuL clay modit1L:aL1L,11 pry
This prtivide s tur individualized tre
111
WL 414
plaits P11,1 1lclaccuracy in measuring t Jneht effects. Subsequently, Mills,
Sobell and Schaefer (1971) designed a treatment Frog -11 t11iou9
which they hujelcd to 111udify by avoidan-- t1ond1 tlu111119 L1A thLe
maladaptive drinking behaviors ides-_Lified in the t dseiill studs ,0
Thirteen "chronic" alcoholics (alcohol abusers who had experienced
withdreiwa1 byw numels,uS /1(.,n
a real stIL: ettin9 11Q6pItol? 11
gulping, heavy aLlukin9 0111 0L la
ish
a
41 elcctilc £11 e1
al ta111 u11 they
size iccalvea
to MudcLate
cd L11,;
1 raa1111 LI4L. k11
14
01 tti cat_ L1_cal
Lit 1 11,3
L I -
44
Controlled Dri_
22
6-week follow -up via personal interview, 12 of the.-1 experimental
subjects and none of the control subjects were found to be drinking
socially and three eNperimental plus two of the control subjects
were abstinent. In a vaguely eported 6- month follow -up, the'
subjects reported more alcoholic behavior including "drunk days"
than during the 6-week follow-up. In a later 12-month foldow-
up reported by Sch (1972) f our of the 13 al L oholi cs
to be drinking socially and three were absti
only two Were t tlen t and none were d1 ink
or social man The t_11,,xs viewed t1 lenultb
t_taup_s wal e
behavioral path Il of drinking acquired by the
edged
Of the controls,
-L seiLiu9. Thcli ,.:;u11 Judea that aleu11.,11cs c
L iry JA.
su,n for arter luant_
Theke
L
t11,_
dIrr.
Y 1 1 pe,
LL011ad
efICOUld,3
;s i n
e Law.
tLil by,
1,_45 ,11 A. 1. t/ 1 9.1..
I, I A, All. 1., L.., ,..i 11 v. 1_411-,1 -L
11/ 1
k LA r L
Ac.
OuLe--1,
LiAQ aLt141.1
L A -
1
1
11u s l 1 I
11.
'A, d Li.
Controlled Drinking
23
the treatment itself. Second, one might question the validity of
using interviews after 6-meth periods which depend on the
-recall of cl its and collaterals in determining post-treatment
drinking patterns. Regular random checks c cried out with shorter
temporal durations Third, Lhe of evctiu
progregs appears to be questionable. Alcoholicsxc were 1 1.4eled
"abstinent" during a 2-wek period even it they hdd been dril.klaay
hao 1, .11 buggeLedhea ly for up to 50is
that e mi4ht question
thu
11611 d olLud
.) 1 toll V 1 d,s4 a L 1p-;1 0 a1,.1
who MIA y.akAl. a4A4 U (1.1 1 a
The S be116
work or tne
" gamma " d1C0hol s the a L to 111c)(.11 c -y
A v > 1 L y ,C
a
111k 111 k
L.
QUM I.A(.,:atIQUI..11
dr.('
L.
al a1 1 Ju
, I 1..."J
C-
I 1 , Lhe , .Ata u 1,
.-oventl,aol U
L
w 1 Lb
ze0 mai.
.paLLeiL.
A a 1
Controlled Drinking
24
groups in all: controlled drinking - experimental (CD-E), controlled
drinking- control (CD-C), non-drinking- _rimental (ND - E), and non-__
drinking-control (ND- C).
Six-month, 12-month (Sobell & obeli, 1973), and 24-month
(Sobell & Sobell, 1976) follow-up studi were carried out. The
follow-ups were done every 3 to 4 weeks via personal contact with
the subject and three to tour coll)ter 1 sources. At each periodic
check ratings of the sub
status, use
were -b-
drinking disposition, vocational
ty supports, and i terpersonal adjustment
Althouyh both expel: ne-t-1 groups apvalc.a Lu I
doiny equally will duLlny the first 12 pion
subjects continued to fu fiction significantly better than theil
ecntL015 thrcuyhuut
Tnc,
all
LAd
ycaL up pL_10....1.
kLLAIL,ly
a10-1 yd ell dealyneil pL,19L-1II t, evaluate ,,,,-Liolted dAlukinq L- daLe
Their eruphasi on
41411,1,
sublect_s uuriny rullow up
-Ii-,t,- l ki-, 1.I,, A,L,Ail,a
Ali, L", i 1 01,_,..1 L 1 1=1._
it Iit .vas 1 1 , ,.. 1 L , ,,-4 I I ..- L. ., k 4 I t .4 ,1 1 ,
10-A ilea J1, , In, ,__,,_ t A A,-,4 k =pi 4 L., I,
than any utnei 6 , 4,41, . Ii,r4 evk_ ti, k 4- a e "--e itmit. ai , ifiAft,
9L.=n ,LeAel
study F lLst, X11, #. x,11 [olio-
Onc OL
11,1 CL \,
4ki, 'A 11
as well as subje-
Controlled Drinking
25
bias in repOrting popiti-e results. Second, since
e-who became controlled drinking subjects initially chose that
particular goal and had either outside social support for such be-
havior or successful experience with social drinking in the past,
there is the possibility that motivation and speQifi- personality
characteristics y be cul,fLulidir1g f
since the c
e
groups received ttadrti
hytllplacebo effects of alLeL
final outcome, Fe u
Adl VI
the ou uittc Th1r
group LtiGlapies and Lbe
ualized ttl,aviural Al tail
albo hnVC played d 1e lit Lite
, (218 Boers (19/4) Lao , IL ila
for distinguishing -drunk" rrol "controllei _ by
011114a Of alcohol_ Ylfth Madam (19 4) tlas L. c!ell A
Subells belzy
when h "dkuith" t-iLo 22 "L LIS dA lllhltl day.n LIc,., .1.-0 ..
yea Ls Lhat.)Ate LLaill alooll only loo d bc.---ube
are belny coulpaked Lo al,oll"il- 4 L 4, 1 0 % 41,4 ,- _s and ,,,,,L Jw.1,i
on a reasoliable 1,1,..1 at. tA4 1,
VukjI,L,
A 1aLa t LuJy
by V..,91cL, t.
Controlled Dri
of well-designed research in controlled drinking begun by the
ing
Hobe lls and others at Patton. The study involved 56 inpatient
26"
alcoholics and was designed to evaluate the effectiveness of a
ccbi.nation of behaviormodification techniques in moderatthg,
alcoho1ics' drinkin4 patterns. Fourteen of the subjects dropped
out of-the study after a few sessions, but _the remaining 42 were
randomly assigned to one of two groups. In group -l. the 23 subjects
were trained by behavioral techniques such as videotaped con-
frontation of intoxicatedbehavior, HAI. discrimination training,
and aversion training for overconsumptio oup-24 which con-;
sisted of 19 subjects and served as a control, received only be-,
havioral counseling and educational procedures. Drinking histories
and baseline drinking sessions were obtained. Inpatient treatment /-
lasted for 4 to 6 weeks and "booster sessions" were held for a
1-year period. Follow -u by personal interview was done by a male
field representative who had no previous contact with the subjects.
He was also blind. regarding treatment. Some subjects who lived at
a distance were contacted by phone or questionnaire. CollateralI
sources were contacted in a similar manner.
During the 12-month follow -u p -iod, seven subjects in each
group were found to be abstinent. Eight subjects from Group-1 and
fo subjects from Group-2 were found to be "controlled" drinkers,
OT
Controlled Drviking
.27
i.et,,average intake of leas than 50 ounces per -nth and no more
than one uncontrolled episode per month) and .a total of 16 "relapsed"
(eight in each group). In analyzing between-group differen9es in
specific drinking and drinking-related behaitiors, the authors found I
_k
that Group-1.1ost significantly fewer days from work and consumed
less alcohol. They cOncluded.thatbeHavior modification techniques
can be effective in moderating alcoholics drinking patterns over a
1 year period.
This research is i pressiye for several reasons: e, utiliza-
tion of random ass nment, 4 control group, baseline drinking ses-
'siont, a follow- nterviewer not directly connected with the study,
and operational definitions. One could argue that a definition of
controlled drinking which permits one uncontrolled drinking episode
monthly is too liberal. .eiloWever, the study does add support to
the controlled drinking alternative.
Another similar research project by this group (Vogler, Weissbach
& Compton, 1977) was done later but on an outpatient basis with
subjects whose drinking problems were less severe and whose families
and jobs were relatively intact. Many of these "problem drinkers"
were referred to the study as a result of the legal consequences of
drinking, prticularly drunk driving. Eight subjects participated
and were divided.intofour groups. Group-1 (23 subjects) received
videotaped feedback of drunken behavior, aversion training for over-
--consumption,
Controlled Drinking
28
discrimination training, alternatives training,
behavior counseling and alcohol education; Group-2 (19 subj cts)
received only the latter four methods; Group-3 (21 subjects) re-
ceived alcohol education only, and Group-4 (17 subjects) only
received the last three methods. The objective was to compare
the effectiveness of various combinations of behavioral treatments,
a condition missing from all other studies. The subjects were. 4
interViewed 'monthly. by-a field representative during a 12-month-follow-
Rperioci. At 12 months 50 (62.5%) of the 80 Subjects were found
to be "moderate" drinkers (intake less than 50 ounces absolute
.alcohol per month and no more than one drinking episode per month
during which the BAL exceeded 80 mgs.) and three (4%) were found to
be abstinent. No significant difference was found between groups.
The alcohol Antake,of subjects who received only alcohol education
was equal to that of subjects who received all the behavioral.
methods.
The most significant contribution of this study, besides its
positive outcome, is its attempt to discern the behavioral techniques
which were most effective in training alcohol abusers to moderate
their drinking. However, the study demonstrated that alcohol
education provided in one-half the time was just as effective as
behavioral treatments. The data suggest the possibility that be-
havioral techniques may be no more effective in training the moderate
alcohol abuser to control his drinking than education and counseling.
#Controlled Drinking Studies
Controlled Tyr irk ing
29
The number of well-designed research projects on controlled
rig reported in the literature is minimal but growing., A
nuer of the studies have suffered from lack of control grOups,
o anal definitions and pretreatment drinking baselines.i Other
criticisms include inadequate follow-up procedures, absence of
statistical analyses small sample sizes, and in some cases con-
clusions which are simply not supported by the data.
Despite existing difficulties in comparing the studies, Table
2 presents a summary of those studies using comparable dependent
measures and having a follow-up. Conclusions drawn from this table
must be tentative; but it does appear that researchers are reporting
Insert Table 2 about here
significantly higher success rates (43.3%) in training alcoholics
to control their drinking than the base rate of 11% obtained in
Table 1. This suggests that alcoholics can be taught to moderate
their drinking. Furthermore, a significant percentage (13.9%) of
the subjects'in controlled drinking studies are attaining abstinence.
This percentage is at least equal to abStinence rates found
abstinence oriented treatment programs.
e Charact6ris ics of the Controlled Uri Candidate?
veering this question has been extremely difficult through-
out the period of this controversy. Back in 1963 Selzer (various
correspondents, 1963) commented, "...as for the problem of distinguish-
ing the alcoholic who ultimately returns to normal drinking from
his more numerous fellows, I find myself at a loss" (p. 113).
'Trying to identify the significant personality characteristics of a-1
good controlled drinking candidate has been especially frustrating.
The Sobells (1973) found no significant correlation between partic-
ular personality characteristics and success at controlled drinking
in their studies, and Vogler et al. (1975) also did not. Popham
and Schmidt (1976) and Pattison (1968) found that educational
background, employment status and sex were not helpful predictors.
There is agreement among some researchers that pretreatment
level of consumption may be a good predictor. Popham and Schmidt
(1976) concluded that this was the only reliable predictor and thus
suggested controlled drinking only'for patients with a relatively
low pketreatment Consumption level and abstinence for the heavy
drinkers. Vogler et al. (1975, 1977) obtained similar results.
Orford (1973) and Orford et al. (1976) have reported that the success-
dul controlled drinking subjects reported less symptomology at
31
Controlled -brinking
Intake. However, Pattison (1968) found that symptomolc
31
intake'
was very similar in alcoholics found later to be abatinent,,con-
trolled dri -ers, or pathological drinkers.
Numerous researc rs believe that a.helpful predictor may
the alcohol abuser's present extentiof social support: support of
_family, friends and employer,. Strickler et (1976) concluded
that support of spouse and family was crucial and the Sobells (1973)
made adequate-social. support one prOrequisite for admission into
(1968) con
be the key,factors in
their controlled drinking experimental group.
citded that social competence and support may
return to normal dr ink hg, and -Lovibond and Caddy (1970) made con-
certed -efforts to include in treatment ,the familymembers of their
controlled drinking subjects.
Thus, there remains disagreement and speculation as to what
characteristics facilitate controlled drinking. Certainly more
research needs to b_ -dole before any firm conclusions can be drawn.
Tentatively, one might conclude that pretreatment consumption level
and extent of social support are probably significant factors.
Should Con-olled Drinkinf be Recommended
Th second question touches the core of the present controversy.
Sinc the amount of quality research on this issue to date is
limitep and the findings tentative, why consider controlled drinking
for anybody? Probably the best response is to note that.so many
alcohol abusers fail at abstinence. Orford et al. (1976) found in
a 2-year follow-up bf, 50. alcoholics that only 2% had been able X
_actually follow the total abstinence route, and eventually this
tentage became zero. Valiance (1965) ,obtained a similar result
in his 2 -year follow-up study. Pattison (1976) and others have
stressed that insistence on abstinence may prevent many from even
accept.seeking treatment, because it is a goal they simply will not
many may want_help., t , .$ee tot41.,44PO,Pence.Wtoo radical a step
.for them.
ISus, here may be an incalclable number of alcohol . abusers
who are not receiving treatment because of the insistence on
abstinence. This could be a good criterion for determining who
should become a controlled drinking candidate. As Pomereau et al.
(1976) have suggested, maybe the best candidates at this time for-
controlled drinking are those alcohol abusers who have continually
failed at abstinence or simply will not accept abstinence-oriented
treatment. It is obvious that the needs of these indiViduals
deserve to be met and they must, by definition, be met outside the
present abstinence - oriented treatment methodology.
It could be that in utilizing the above criterion, we will
discover the most appropriate candidates and also a possible
resolution to the controlled drinking controversy. Such a criterion
does not suggest that those who are succeeding at abstinence or
willing to try it should-do otherwi e. However, for those who
continually fail after numerous attempts, or simPl 't accept
an abstinence goal, here- -is an alternative.
For those who would c ndemn this suggestion out of fear hat
any attempts at implementi_g.controlled-drinking programs will- de-
crease the number of abstainers, there are some preliminary in-
ditators. that controlled drinking programs may actually increase.
the number of abstinent altoho ics while teaching some to moderate
their drinking. The Sobells (1V7 3). commented on .a peculiar phenone on
in their results.: a good number of their controlled drinking,
subjects chose abstinence in-the end. Vogler et Al. (1975) were im-
pressed with the large number of subjects who became abstinent in
spite of the moderation orientation of ,their study. In almost every
study reviewed iu the previous- section, a significant number of con-
trolled drinking subjects chose abstinence. PA. plausible explanation
for this phenomenon is that after making sincere effort at Utili:2ng
the behavioral techniques to control their drinking, some-of the
subjects simply became convinced that for them abstinence was the
only way., If this is true, the controlled drinking alternative-may
assist some alcoholics t o moderate their drinking while actually.
airing -other alcoholics to become abstinent.
For those who claim that any attempts at implementing such
programs would covertly encourage individuals with relatively mild
drinking pro
of thdir problem,
Controlled Drinking
to continue drinking and increase the seven
,would suggpst that the exact opposite may
34
y
actually be the case. As strong a case can be made for the idea
that alternatives to abstinence will encourage individuals wits
Jets severe drinking rcbl ems for seek treatment-before they, reach
chronic al cpholism status. Many persons on the. road to severe prob-
lems might consider methods of controlling
before the more dpttic abstinence goal.
their alcohol consumption
controlled drinking,
option could lead to the prevention ofmore serious alcohol abuse
through the teaching of moderating techniques.at a stage*when the
chances of success are high (Strickler et al., 1910.
In addition we have a commitment to treat the impoverished
cohol abuser who has minimal social support. However, we often
.
punish him for his pathology by not permitting him to remain An
residential treatment centers (half-way houses),when he drinks.
However, the great majority of chronic alcohol abusers will drink
and thus place themselves outside the care of traditional alcoholism
treatment. The controlled drinking alternative may be an answer,
to this dilemma. Facilities which would adcept the.fact that these
individuals will drink, and thus not insist on abstinence but at-
tempt to shape the residents' drinking into more constructive
patterns, may have the potential of reaching these individuals when
traditional abstinence-oriented facilities would not. Thus, con-
trolled drinkin does not have to be in competition 'with an
abstinenae orientation but
the number alcohol abusers being treated, and.thereby increase.
the number of !'succeSses," in the form of:, abstinent or controlled
c10. kers.
can work cooperatiVely and increase
It may be premature to del neat e an ideal controlled drinking
program i \light of the minimal amount of quality esearch that has
been done in this area -However, the idespread that many
alcohol abusers -are not receiving-treatment demands that we begin
to conceptualize and implement such programs. After reviewing the4
literature at least two treatment programs are suggested. fie first
(Program A) would be offered for the alcohol abuser who still has
significant social support and stability (home, family, and job)
And the second (Program By would be offered for the chronic, im-
poverished alcoholic with minimal social support. Bdth progra
would include procedures for referral to abstinence treatment
consistent failure at o eration is experienced. In neither
program would a person be punished through termination for excessive
alcohol abuse. Beginning both programs with inpatient treatment
might be preferable because it provides an opportunity for intensive
application of techniques over a short duration. However, Progra
A. would utilize outpatient area
Controlled- Drii: ing
36
ent becausemoSt moderate alcohol
abusers, for which this-program i designed, would probably not
accept admission to inpatient care. Furthermore, some success
lat training alcohol abu to control their drimking.in an'out-
patient setting has been onstrated (Strickl6r 'et al., 1976,
Vogler -et al.,- 1977). Program B would utilize an in tial inpatient
setting due to the chronic nature of the alcohol problems of the
population for whickit is designed' and the.laak of social support
for'imOst of- them.
Program A.:,....Thi progra n wouldlo gp( :with -intensive-twice-
weekly otiutpatient sessions to educate the alcoholic about the aversive
effects of'excessive alcohol intake and,to introduce behavioral
techniques to be implemented for modifying drinking patterns. During
the initial period the clients would complete detailed drinking
baselin and drinking histories. Subsequently, maladaptive
drinking patterns'would be identified. Individualized treatment
plans would then be implemented to alter the maladaptive drink
habits (gulping, ordering "straight" drinks; drinking alo
stopping at bar daily after work).
Various-b -avioral techniques would be utilized in assisting the
alcoholics to achieve their individualized weekly treatment goals.
This would involve behaVioral education to modify specific ex-
cgssive drinking ha -its, training to develop coriptructive response
Controlled Dr i iki n
repertoires to situations which previously provoked exces1ive
drinking (stimulus control), and modeling of mode to drinking be-
havior by therapists }as well .as role-playing by Clients 'of socially
acceptable dr ing behavior (Sobell and Sobelr, 1973). Modeling
37
a
and traininTwogld take_ place in a simulated barrOom setting.
AVersiOn training would =be implenented. for maladaptive- drinking,
habits (Mills- et .al., 1971) as well as videotaped feedback of
=drunken behaviOr at special sessions (Sobeli and Sobell, 1971).
We are not convinced that-blood alcohol level (BAL) estimation has
l.
'._demonstrated much promise.and t would not be used in thi8 program%
Besides the: training and practicing of moderate drinking behavior
which would take place in the twice-weekly sessions, clients, would-
be -given specific'uhomework" involving maintenance of Agreed-
upon levels of consumption, practice of moderate drinking habits
At home or in social situations,-and practice of new constructive
responses to situations whiff prseviously provoked excessive drinking.
Spouses, relatives, or friends attending the sessions with the
clients would assist in onitoring.the completion of this homework.
In some cases contracts with souses -could be utilized to formalize
the spouses' role in supporting the clients' attempts at modifying,
drinking patterns (Miller,-1972). The thrust of this second phase
of treatment is to attempt to utilize- operant techniques,in a
multi-modal approach to decrease excessive drinking behavior and
Conttolled,Drinking
F
increase moderate drinking beheiriOr. This was-the common goal of
8
the most successful and-well-designed controlled drinking studies
reviewed earlier.
The third and final phase of .treatment would involve a gradual
decrease in fre uency.of sessions and an increase in emphasis on
generalization of moderate drinking behaviors to the home and. work
situation_.. sessions would shift to weekly and then .monthly
and fina ly intermittent "boo ter" -se Seions when-needed. In turn,
greater ttress would be placed on evaluation of homework _setting
of long-term.goaLs, and d veloping_therole of significant others
to support the clients' efforts. Sessions would be held with
spouses- and relatives to encourage them in theiitical roles and
provide them with necessary training to effectively" deal with the
.clients behavior (Cheek, 1971) The "booster" sessions would provide
remedial help for those clients 6xperiencing difficulties (Vogler
et al., 1975)..
Program B. This program would begin on a inpatient basis since
t would be serving alcoholics with long-term alcoholism histories
who also lack social support. The program would have a/contingency
management-orientation similar to the program Cohen et al. (1971a)
utilized successfully with skid-row alcoholics. The alcoholics
would earn the righ participate in an "enriched environment" and
to obtain spending money .(Cohen et al., 1971b) by moderating their
drinking. Behavioral techniques including videotaped feedback of
Controlled Drinking _
39
n behavior and aversive conditioning for over-consumption,
would be used to assist the clients in achieving and Maintaining
moderation. Aftela designated period-of inpatient treatment,
alcoholics who do not moderate their drinking would b'e encouraged
towards abstinence.
Those who Succeed in moderating their drinking in an 'inpatient
setting would be transferred to a half-way house where similar
- contingency managementproceduret would be available. Moderate
drinking would be permitted In the house but abstinenc_ would be
required when on pass in the community. Tarticipation in an en-,.
-niched' 'enVironMeht would be withdrawn for drinking on pass or ex-
cessive drinking in the house. However, the alcoholic would not be .
refused admiSsion into the house-because of excessive drinking.
Hopefully, as Cohen et 44. (r971a) have conjectured, mod9atedrink-
ing opportunities in the house would serve to reinforce:abstinenCe
in the community. Drinking would be restricted to one room in the
house in an effort to shape "social drinking habits. Eventually4
residents would `attempt moderate drinking the community under
supervision. This would not-be'allowed until's stable moderate-
drinkihg pattern ws established in the house.,
There exists fear that giving alcoholto a coholics in such
setting would lead to chaos. 0n the contrary, Paredes-et al. (19T4)
found that introducing al-cohol into an open ward setting did not
Controlled Drinking
40
increase the attrition rate or the amount of aggressive behavior
among residents. Those who continue to do well in the half -way
house would be given vocational counseling, assistance in finding
employment, and encouragement to find independent living quarters.
Booster treatment would be available as needed.
_
Final Comment
The controlled dLi f cuntkoversy ha a relatively briet
history and i s probably tar from resolved. ualQuality experimentation
in this
However, it is also widely suspected that thousands of al-
is minimal to date d thus the issue .nemain6 ou ver-
I O6
ent
leatd because uf the lack of optiulis in aloof 116m
tut, si ilk ;-,.3 1 vt LC) i 1 ,jlt1It LL uA Llttent
options other Lhan abstiti ttce and LO training capable staff in al
tentative techillyus, tun gulled drinking programs such a_
thy or , YisideiationIn Pi_u,jtaiil A Ina b ak L I
Controlled Drinking
41
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Controlled Drinking
42
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Table 1
Percentage of Moderate Drinkers and Abs)ainers
Found During Various Follow-up Studies
Study DateNo. %
SubjectsModerateDrinkers Abstainers
Follow-upPeriod
bemere 1953 500 11% RecordReviewa
Norwig & 1956 221 19% 17%, 2-5 yrs.aNielsonPfeffer & 1957 60 8% 80% 4 yrs.aBergerSelzer & 1957 98 12% 18% 6 yrs.aHollowayMoore & 1960 100 St 15t 3.5 yrs.aRamseurDavies 1962 93 7.5% NA 7 -11 yrs.a
Kendell 1965 62 6.5% NA 3-8 yrs.ba
Kendell & 1966 6 8t 15% 4 15 yrs.StantonBailey 4 13, 4t 5 yrs. b=
StewartPattison 1968 32 Jilt 14% 1 5 yrs.b
Pokornyet al.Reinert a
1968
190b
88
1'Jc
26% 28%
tut
1 yr.a
BowenFitzgeralaet al.
19/1 4
Goodwin i J 71 tot 4tU
:L
Kish 4 1971 17J 5t iLt
Hermann1.
Orfordet al.Rand
19 /b 100 10t
lut gutLA
Uo4 Lt.
Note: The totals do ::mot ini_:luje the 1):: ii9Oz) (1965)studies because abstinence data was :.ot avallai,le (NA)
aafter treatment
bafter no treatment
Table 2
Percentage of Moderate Drinkers and Abstainers
Found During Follow-ups of Controlled Drinking Studies
Study DateNo.
Subjects% ModerateDrink ers Abstainers
Follow-upPeriod
Lovibond & 1970 31 67.7% 1-8 mos.Caddy
Silversteinet al.
1974 4 25% 0% 2 5 mos.
Strickleret al.
1974 0% 6 mos.
Ewing 1975 11 0* 42.9% 5 yrs.
Mills et al. 1971 13 30.8% 23.1% 1 yr.
Vogleret al.
1975 56 21.4% 25% 1 yr_
VutAlrer al.
1 9 / / QZ 4t
Tutalb 104 lj 91S