1 University of Wales, Bangor, UK and 2 Bowling Green State University, Bowling Green, Kentucky, USA
* Author to whom correspondence should be addressed at: School of Psychology, Brigantia Building, University of Wales, Bangor LL57 2AS, UK. E-mail: m.cox{at}bangor.ac.uk.
(Received 25 July 2003; first review notified 11 October 2003; in revised form 15 December 2003; accepted 16 December 2003)
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ABSTRACT |
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INTRODUCTION |
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Several client characteristics have been associated with controlled drinking, including lower severity of dependence, rejection of an alcoholic identity, selection and expectation of controlled drinking as an outcome goal, psychosocial stability, and a supportive post-treatment environment (Heather and Robertson, 1981; Rosenberg, 1993
). However, this list may not be exhaustive and the interaction among interpersonal, intrapersonal, and environmental factors may prove more useful in conceptualizing and predicting drinking over time than any specific characteristics per se (e.g. Elal-Lawrence et al., 1986
).
Numerous studies and reviews have assessed the effect of therapeutic interventions to help clients moderate their drinking, typically behavioural self-control training and, to a lesser extent, cue exposure therapy (e.g. Sanchez-Craig et al., 1987; Sitharthan et al., 1997
; Sobell and Sobell, 1993). A recently published meta-analysis (Walters, 2000) evaluated the efficacy of behavioural self-control training (BSCT) for problem drinkers and reported a combined effect size of 0.33, indicating a statistically significant and clinically meaningful relationship between this therapy and improved functioning.
Despite the clinical advantages of offering controlled drinking to problem drinkers (Heather, 1993) and the empirical support for BSCT to help problem drinkers moderate their consumption (Walters, 2000), acceptance and availability of controlled drinking varies considerably depending on the setting and country in which one seeks treatment. For example, surveys of UK alcohol treatment agencies have found widespread acceptance of moderate drinking in the UK (Robertson and Heather, 1982
; Rosenberg et al., 1992
). Similarly, Duckert (1989)
found that 90% of Norwegian respondents reported allowing outpatient clients to choose between abstinence and moderate drinking, and 59% reported allowing inpatients a choice between outcome goals. Controlled drinking is also widely acceptable in New South Wales, Australia (Donovan and Heather, 1997
).
Unlike most UK, Norwegian and Australian alcohol service agencies, abstinence is apparently the predominant outcome goal prescribed for alcohol misusers and other problem drinkers in US alcoholism treatment programmes. Rosenberg and Davis (1994) surveyed a nationwide sample of US agencies and found that controlled drinking was considered unacceptable for clients in almost every responding residential agency (including inpatient detoxification and rehabilitation services, as well as halfway houses). However, almost half of the responding outpatient programmes (including services for drunk-driving offenders) reported moderate drinking as appropriate for a minority of their clientele.
The acceptance of controlled drinking by Canadian alcohol treatment agencies appears to fall between those of the US and those of Norway, the UK and Australia. For example, Rush and Ogborne (1986) found that a little over one-third of the responding alcohol programmes in the province of Ontario reported that non-abstinence was appropriate for some patients in their programme, although acceptability of non-abstinence goals varied widely depending on whether the programme was a residential or community-based outpatient service. Approximately 10 years later, employing a random sample of Canadian alcohol treatment services across the provinces, Rosenberg et al. (1996)
found that about 40% of responding agencies endorsed controlled drinking as an acceptable goal for their clientele. Furthermore, one-third of the respondents working in agencies that did not offer controlled drinking reported moderate drinking as acceptable for clients in other services or for their own clients after they left the agency.
Although these surveys provide an overview of the acceptance of controlled drinking per se, clinicians probably judge the suitability of controlled drinking for clients based on their specific characteristics. Only two studies of which we are aware have assessed whether acceptance of CD varied as a function of client characteristics. Specifically, Perkins et al. (1981) asked alcoholism therapists working in the state of Indiana how strongly they would recommend abstinence or controlled drinking for 18 clients described in short case histories. Except for the subset (17/62; 27.4%) of respondents who recommended abstinence in all cases, recommendations of controlled drinking or abstinence varied as a function of both clients' social class and their drinking history. More recently, Rosenberg and Melville assessed whether acceptance of controlled or moderate drinking varied depending on whether clients presented with alcohol misuse or alcohol dependence (based on DSM-IV criteria) and whether controlled drinking was the client's intermediate goal on the way to abstinence or their final outcome goal (H. Rosenberg and J. Melville, unpublished data). Results from their national survey in the UK revealed that controlled drinking was widely acceptable for alcohol misusers, regardless of whether it was their intermediate or final outcome goal. Controlled drinking was less acceptable as an outcome goal for alcohol-dependent drinkers, especially if controlled drinking was their final goal.
In light of these studies, which show greater acceptance of controlled drinking in the UK than in the US and suggest that client characteristics influence treatment providers' acceptance of controlled drinking, we designed the current study to assess whether three key characteristics the severity of the problem drinking, the level of family and other social support that the drinker received and the drinker's sex influenced UK and US healthcare providers' recommendations of abstinence versus controlled drinking as an acceptable outcome goal. Based on the research reviewed above, we predicted that controlled drinking would be viewed as more acceptable in the UK than in the US and that respondents in both countries would rate controlled drinking more acceptable for problem drinkers with lower severity and more social support.
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SUBJECTS AND METHODS |
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Materials and procedure
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 the US, the respondents themselves provided these ratings. In both countries, respondents' mean ratings corresponded to the levels that were intended when the case-history scenarios were written.
First, the managers at various local healthcare facilities were asked about their willingness for their agency to participate. The materials were then distributed to the staff at the participating agencies, and staff volunteering completed and returned the questionnaires. Respondents were first introduced to the study and given the following written instructions.
We are interested in understanding how people who treat alcohol problems make decisions about treatment goals for their clients with varying backgrounds and histories. There has been some question by workers in the field about the relative appropriateness of total abstinence and controlled drinking as treatment goals. The accompanying case histories include clients from a variety of backgrounds. For each case, please indicate the treatment goal that you consider most appropriate.
Respondents were then asked to read each of the 16 case histories and, after reading each one, to rate it using a 7-point Likert scale: (1) strongly recommend abstinence; (2) recommend abstinence; (3) probably recommend abstinence; (4) uncertain; (5) probably recommend controlled drinking; (6) recommend controlled drinking; (7) strongly recommend controlled drinking. Respondents were also asked to provide basic demographic information, including their sex, job title, the number of clients with alcohol problems they had treated and what they considered the best overall treatment goal for people with alcohol problems (on a 5-point scale ranging from abstinence to controlled drinking).
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RESULTS |
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Because each respondent gave multiple ratings of controlled drinking or abstinence, the results were analysed using repeated measures analysis of variance. There were three within-participants factors (clients' problem severity, level of social support and sex), and one between-participants factor (respondents' country). There were main effects for country, F(1,70) = 8.26, P = 0.005; clients' problem severity, F(1,70) = 358.01, P < 0.001; clients' level of social support, F(1,70) = 6.79, P = 0.01; and clients' sex, F(1,70) = 9.63, P < 0.03. Abstinence was endorsed more often (1) in the US (mean = 2.94, SD = 1.09) than in the UK (mean = 3.56, SD = 0.76); (2) for higher-severity (mean = 2.19, SD = 0.89) than for lower-severity (mean = 4.40, SD = 1.24) problem drinkers; (3) for those with higher support (mean = 3.20, SD = 1.01) than lower social support (mean = 3.38, SD = 1.02); and (4) for women (mean = 3.19, SD = 1.06) than for men (mean = 3.40, SD = 0.97).
One of the two-way interactions was significant. The country x sex interaction, F(1,70) = 5.06, P < 0.03 (Fig. 1) indicates that the stronger recommendation of abstinence for women than for men was confined to the US. The severity x sex interaction, F(1,70) = 3.51, P < 0.065 (Fig. 2) approached significance and indicates that the stronger recommendation of abstinence for women than for men tended to occur for lower-severity but not higher-severity drinkers.
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DISCUSSION |
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Another characteristic that affected the respondents' treatment recommendations was clients' level of social support. Vignettes depicting clients with lower social support included descriptions such as, Mr D. has always found it hard to make friends and socialize and feels that he has never had anyone that he could talk to. Those depicting clients with higher social support used descriptions such as, Mr H. lives with his wife and his three children. He describes his wife as a caring and loving woman, and feels that he depends upon her for support. He also has regular contact with his parents. Abstinence was recommended less strongly for clients with lower support, contrary to our hypothesis that controlled drinking would be recommended more often for those with stronger support. It would appear, therefore, that the more stringent goal of abstinence was seen as more appropriate for clients with more social support.
Clients' sex also affected the ratings, with abstinence being recommended more strongly for women than for men depicted in our case studies. Sex also served to moderate the impact of the other variables. For instance, the stronger recommendation of abstinence for women than for men was seen in the US but not in the UK. Abstinence was seen as a more preferred goal for women than for men only among lower-severity drinkers and only in the US. Finally, sex differences related to problem severity were also related to drinkers' level of social support. For instance, among drinkers with lower social support, abstinence was particularly recommended for women with less severe problems, but for men with more severe problems.
The acceptability of controlled drinking as a goal for problem drinkers clearly differs between UK and US healthcare workers. Controlled drinking, as opposed to total abstinence, is more readily accepted in the UK healthcare system than in that of the US, even for drinkers with more severe drinking histories. In fact, prior research has shown that controlled drinking is far less accepted in the US than it is in the UK (Rosenberg et al., 1992), Australia (Donovan and Heather, 1997
) or Norway (Duckert, 1989
). Thus, clients in the UK may be more inclined than those in the US to ask if they can moderate their drinking in light of population norms and assumed openness of staff to such requests. This cultural difference in the acceptability of controlled drinking is probably an outgrowth of the dominance of the US disease model of alcoholism, which advocates total abstinence from alcohol for all problem drinkers. The abstinence-only approach is more entrenched in the US than in many other countries, where harm reduction and social-learning models of alcohol misuse influence treatment providers' attitudes.
Finally, it should be noted that, in addition to the variables assessed in the present study, many providers help clients to choose treatment goals on the basis of the clients' own wishes and motivation. That is, the choice of treatment goals is often fluid and involves collaboration between the therapist and client in the naturalistic setting. It should also be noted that respondents in the study indicated the recommendations that they would make in hypothetical situations. These recommendations, however, should not be taken as necessarily the treatment goals that would lead to optimal outcomes for all such clients.
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REFERENCES |
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