In your work as a therapist, perhaps you have you wondered how you might help clients with alcohol problems who are not ready to be abstinent. For many problem drinkers, Moderation Training may be an alternative. This non-traditional approach helps individuals with problematic patterns of drinking moderate their use of alcohol in order to decrease the negative consequences associated with their drinking.
Assessing Appropriateness for Moderation Training
Before I spell out more about how this approach works for appropriate clients, it may be useful to consider how you would assess appropriateness, or get help in doing so.
To assess appropriateness, experts who work with moderation techniques often use standardized paper and pencil tests to augment their in-depth interview assessment of clients. Two measures that are commonly used are the Michigan Alcohol Screening Test and the Alcohol Use Inventory. The client’s scores are then compared to norms for each measure to help determine where along the drinking continuum (from problem drinking to alcoholism) the particular client falls. This provides feedback to clients that can be helpful in deciding how likely they are to succeed with a moderation approach.
To find an appropriate therapist to help assess the appropriateness of your client for a moderation approach, the Moderation Management website can be helpful. Often these therapists work adjunctively -– helping your client work specifically on the alcohol problem alongside of your ongoing treatment.
How Moderation Approaches Work
Moderation approaches for the treatment of alcohol problems augment traditional abstinence-based treatment models by offering a treatment alternative to many individuals who traditional models have not effectively reached. My 2001 paper, Moderation Training for Problem Drinkers, details one such approach called Moderation Training. This collaborative, non-labeling approach ‘lowers the gate’, making it easier for clients to enter treatment.
Unlike the traditional abstinence-based models for the treatment of alcohol problems, it is not necessary to have ‘hit bottom’ or to see oneself as ‘diseased’ in order to get help. The therapist helps the patient gather and look at data — trying out new behaviors to see what he or she can learn from it. Moderation Training gives the patient an opportunity for mastery rather than taking something away.
Difficult Past Situations are Examined Along with New Ways to Cope
The client is asked to think about many aspects of her drinking and many aspects of herself that may relate to her drinking. She is encouraged to look at situations that in the past have posed difficulty for her, and to think about ways to either modify the situation or to modify her behavior so that problematic drinking will not occur.
The therapeutic work also focuses on exploring alternative ways to do things that might ordinarily have been done with the help of alcohol, as well as learning new behaviors to take the place of drinking to provide alternative forms of gratification.
The client eventually creates a detailed set of clear limits that she can commit to in relation to quantity and frequency of drinking, as well as detailed parameters for guiding behavior in potentially difficult situations.
With the Help of a Coach, the Client Sees Himself as Steering His Own Course
Control struggles are lessened considerably when the patient feels that he is steering his own course. Working in this model, I see myself as a coach, helping the patient to come up with sensible rules to govern his drinking and then to examine them to see how well they work. If the patient proposes a parameter that exceeds usual notions of what moderate drinking would look like (Kishline’s 1994 guidelines, p.115, are helpful), I simply say, “That is not what ordinarily would be thought of as moderate drinking. I won’t tell you that it can’t be your goal, but it might be useful to think more carefully about whether it will get you where you ultimately want to be.”
Importance of a Treater Well Versed in a Range of Treatment Options
Moderation Training is very different from the old practice of simply encouraging the patient to “use control” — or supporting her ‘bargains’ at control. The moderation approach is both detailed and labor intensive for patient as well as therapist, and as patients soon learn, requires a great deal more work than abstinence.
The therapist using this model must also be familiar with and able to comfortably endorse the abstinence model as well. This is because all patients begin their work with a 30-day abstinence period and some, through the course of the work, realize that this is the appropriate long-term goal for them. Thus the therapist must be fully knowledgeable about supports available for achieving abstinence and for sustaining it permanently (i.e. knowledge of local self help programs such as Alcoholics Anonymous and Smart Recovery as well as psychopharmacological supports, including Naltrexone and Antabuse).
The goal of this article has been to present an expanded view of treatment options for problem drinkers. Moderation Training is not presented in opposition to an abstinence-based model, but as a viable alternative for problem drinkers. Nor does embracing moderation approaches for problem drinkers imply giving up 12-step approaches for the many alcoholics for whom this support is enormously helpful. Moderation Training is a collegial, pleasurable way of working for the therapist as well as for the client.
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Dr. Vannicelli, founder and for 25 years Director of the Outpatient Substance Abuse Clinic at McLean Hospital, is an internationally recognized author and lecturer, who has written highly acclaimed books and articles, along with scores of workshops and lectures about her work with this population.
© 2019 Marsha Vannicelli