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Addiction Research and Theory February 2006; 14(1): 35–49

Behavioural self-management with problem drinkers: One-year follow-up of a controlled drinking group treatment approach

JOACHIM KOERKEL

University of Applied Sciences in Nuremberg, Bavaria, Germany

(Received in final form 14 November 2005)

Abstract The present study tested the effectiveness of a German behavioural self-control training (BSCT) for subgroups of drinkers differentiated by sex, ICD-10 diagnosis, and severity of dependence. Hazardous, harmful, and dependent drinkers were recruited through local mass media or referred by other treatment agencies. N¼53 subjects (60% men, mean age 48.9 years, 76% employed, 64% alcohol dependent) participated in 10 weekly group treatment sessions and were assessed at intake, end of treatment, and 1-year follow-up (with 81% successfully contacted). Improvements made during BSCT remained stable over the 1-year follow-up period with 52% of subjects classified as improved (8% abstinent, 44% with a decline in alcohol consumption of at least 30%). In women, alcohol abusers and low dose drinkers (<800 g ethanol/w), alcohol intake had declined less than in men, alcohol dependent subjects, and high dose drinkers (>800 g/w). This study, as others, indicates that alcohol dependence in itself is no contraindication for controlled drinking (CD) treatment.

Keywords: Behavioural self-control training, controlled drinking, implementation

Introduction

Currently the disease model of alcoholism, with its focus on total and lifelong abstinence from alcohol, dominates addiction treatment in Germany and many other countries. This holds true despite numerous theoretical and empirical arguments put forward in favour of supplementing abstinence-oriented treatment approaches by interventions aimed at moderate, asymptomatic or controlled

Correspondence: Prof. Dr Joachim Koerkel, University of Applied Sciences, Baerenschanzstr. 4, D-90429 Nuremberg, Germany. Tel: þ49-911-27253829. Fax: þ49-911-27253813. E-mail: [email protected]

ISSN 1606-6359 print: ISSN 1476-7392 online � 2006 Taylor & Francis DOI: 10.1080/16066350500489253

drinking (CD; see Heather & Robertson, 1983; Hester, 2003), which are set out as follows.

First, there is compelling scientific evidence that CD treatment, especially behavioural self-control training (BSCT), is effective compared to alternative interventions or no treatment in decreasing both amount and frequency of alcohol intake (Rosenberg, 1993; Saladin & Santa Ana, 2004). According to Walters’ (2000) meta-analysis BSCT ‘is equivalent to abstinence-oriented forms of intervention in terms of overall effectiveness, stability of outcomes, and potential clientele’ (p. 146). Even clients with higher levels of dependence may benefit from moderation-oriented treatment (Dawe, Rees, Mattick, Sitharthan, & Heather, 2002; Heather, Robertson, MacPherson, Allsop, & Fulton, 1987), and reductions in alcohol consumption may already be expected when clients work on their own with written self-help manuals (Apodaca & Miller, 2003).

Second, offering goal options (i.e. abstinence or CD) may attract more people into treatment and thereby improve range and effectiveness of the existing health care system (Institute of Medicine, 1990). For example, in Germany, 21.7% of the adult population (18–59 years) are potential candidates for alcohol-related interventions, as defined by the Alcohol Use Disorders Identification Test (Kraus & Bauernfeind, 1998). But even among those with a pattern of alcohol dependence, only about 5% are in treatment for their addiction and nearly no drinkers with harmful or hazardous alcohol intake (Koerkel, 2002). One of the reasons for this low rate of heavy drinkers seeking treatment is that many of them do not regard themselves as ‘alcoholics’ and do not want to completely abstain from alcohol.

Third, from a therapeutic point of view it is much easier to work with clients when they feel free to talk about their ‘true’ consumption goals, i.e. people are much more committed in treatment when working on self-selected goals (Miller & Rollnick, 2002; Sobell, Sobell, Bogardis, Leo, & Skinner, 1992).

Fourth, from an ethical point of view everybody should be granted the right of self-determination (autonomy). In terms of treatment, this implies respecting freedom of choice concerning treatment goals – not excluding discussion of the pros of abstinence and cons of moderate consumption if done in an egalitarian way (Miller & Rollnick, 2002).

On grounds of the arguments outlined above we developed a BSCT called the ‘Outpatient Group Treatment Program for Controlled Drinking’ (in German ‘Ambulantes Gruppenprogramm zum kontrollierten Trinken’, AkT; Koerkel, Schellberg, Haberacker, Langguth, & Neu, 2002). The first AkT group started in Nuremberg (located in southern Germany) in October 1999 as an additional service of a ‘traditional’ abstinence-oriented outpatient counselling centre for legal drugs and ended after ten weekly group sessions in January 2000. In a first empirical study the effect of AkT was compared with that of a waiting list (WL) control group to determine whether the decision to seek treatment and getting intensive pre-assessment of about 3 h (including instructions to use a drinking diary) influenced consumption patterns (Koerkel, 2002).

Results supported the effectiveness of AkT. Subjects randomly assigned to the first AkT group (n¼ 13; 11 with a diagnosis of alcohol dependence according

36 J. Koerkel

to the International Classification of Diseases, ICD-10) fared significantly better ( p< 0.05) than those in the waiting list control condition (WL; n¼ 11, 8 of whom were alcohol dependent; Koerkel, 2002). Alcohol consumption in the week after end of treatment dropped to about half of that in the week before the intake interview (from 678 g [intake] to 354 g [end of treatment]); number of abstinent days per week increased (from 1.0 [intake] to 2.7 [end of treatment]) and GGT values declined (from 44.2 [intake] to 35.4 [end of treatment]). All changes in the WL group were statistically not significant. The same pattern of results emerged in a second analysis where five AkT groups (n¼ 46) were compared with a WL condition (n¼ 12; Haberacker, 2003).

The present study assessed the stability of change after CD treatment. With that aim, pre-treatment, post-treatment, and one-year follow-up data of the first five AkT groups offered in Nuremberg were analyzed. The second aim was to test the effectiveness of AkT for subgroups of clients (differentiated by sex, ICD-10 diagnosis, and severity of dependence).

Method

Recruitment of subjects

About three-quarters of clients were recruited through local mass media (newspaper, radio, and television), the other quarter were referred by local treatment agencies who do not offer CD treatment.

Inclusion/exclusion criteria

Subjects with hazardous or excessive alcohol consumption (including an actual diagnosis of alcohol dependence) were accepted for the trial if they were motivated to change drinking behaviour and stated that they preferred moderation over abstinence. However, once admitted to the trial, clients were free to select abstinence if they desired and to switch from one goal to the other at any time (as has been reported in an Australian trial; Dawe & Richmond, 1997, p. 83). People with alcohol-related physical damage (like diabetes or liver disease) were also admitted to AkT if they could not be motivated to completely abstain from alcohol. Exclusion criteria from AkT were: (1) Prior diagnosis of alcohol dependence and currently abstinent (‘recovering alcoholic’); (2) severe psychiatric comorbidity (like depression); (3) severe cognitive impairment; (4) current dependence on other drugs (excluding nicotine); (5) other barriers for participating in a 10-sessions group treatment program (like hearing disabilities or no eligibility for all 10 sessions because of vacations planned during the treatment period).

Of 65 subjects who passed pre-assessment, seven were not accepted for the trial because of: hearing defect (n¼ 1), severe social and cognitive impairment (n¼ 1), comorbid psychiatric disturbance (anxiety disorder, depression; n¼ 2), concurrent use of high doses of cannabis (n¼ 2), and alcohol use at only two or three short episodes during the year (binge drinking; n¼ 1). Because there were no drop-outs between pre-assessment and start of treatment, a total of

Behavioural self-management with problem drinkers 37

N¼ 58 subjects (23 women, 35 men) entered one of five AkT groups run in an outpatient addiction counselling centre in Nuremberg. With five clients (2 women, 3 men) finishing treatment prematurely, attrition rate was small. Reasons for drop-out were referral to abstinence-oriented detox (n¼ 2) or rehabilitation treatment (n¼ 1), a non-alcohol-related physical disease that needed inpatient treatment (n¼ 1), and lack of interest in staying in the program (n¼ 1). All other 53 subjects (21 women, 32 men) attended at least 8 of the 10 AkT sessions and were included in the following analyses. Mean age of the remaining 53 subjects was 48.9 years (SD¼ 8.9, range 31–63 years); 66% were married; and 76% were employed. Their weekly alcohol consumption amounted to 26.54 German standard units (SD¼ 16.78, range 0–69.1; 1 German SU¼ 20 g ethanol). According to ICD-10 nearly two out of three clients (n¼ 34 or 64%) were alcohol dependent; the rest (n¼ 18 or 34%) were classified as showing harmful use or abuse (ICD-10 missing data for one client). About two-thirds of the clients (n¼ 34 or 64%) had never been in addiction treatment before. All Ss considered their drinking a major problem that had created other life problems (e.g. at work or in the family).

Procedure

Mostly in a brief telephone interview, sometimes in a short personal interview, potential clients were informed about details of AkT and screened for eligibility. Appropriate subjects were scheduled for two (sometimes three) pre-assessment sessions. Clients who clearly did not meet eligibility criteria were screened-out and offered other forms of treatment.

Pre-treatment assessment

Pre-treatment assessment encompassed three individual sessions lasting about 60 min each. Sessions 1 and 2 consisted of a structured interview that assessed current and past alcohol consumption (last week, last 4 weeks, and last 12 months), other drug use, problems associated with drinking and earlier treatment experiences, treatment goals (including a discussion about pros and cons of abstinence), and demographic data. At the end of session 1 subjects were handed a drinking diary (used throughout the program) to collect baseline drinking data. In cases of lack of program suitability no further assessment sessions were scheduled after session 1 and the client was offered another form of treatment or was referred to other agencies. In session 3 a physical examination by the medical doctor affiliated to the counselling centre was carried out to assess health status and to take a blood sample for measurement of alcohol markers (GGT, GOT, and GPT).

At the end of the pre-treatment assessment phase all clients signed informed consent. The first treatment session started about one to two weeks after assessment.

During assessment sessions 1 and 2 the following instruments were applied for data collection.

38 J. Koerkel

Short version of the European Addiction Severity Index (EuropASI). Most data were collected with a shortened European version of the Addiction Severity Index (EuropASI; Gsellhofer, Küfner, Vogt, & Weiler, 1997), a widely used structured interview addressing demographic background, substance use and negative consequences of use. The main outcome variables were derived from data collected with the EuropASI: total drinks per week (TDW), drinks per drinking day (DDD), and abstinent days per week (ADW). All drinking data reported in this article refer to the week before assessment (at pre-treatment, post-treatment, and follow-up).

International Classification of Diseases (ICD-10). Alcohol abuse and dependence were diagnosed according to ICD-10 (Dilling, Mombour, & Schmidt, 1991).

DIA-X-Interview. To screen out clients with comorbid psychiatric problems, the DIA-X-Interview (Wittchen & Pfister, 1997) was applied. DIA-X-Interview consists of 16 questions each assessing the existence of a key symptom of the main DSM-IV diagnoses (axis I). If a client agreed with the existence of a key symptom a more detailed exploration followed.

Abstinence confidence questionnaire (KAZ-35). The modified KAZ-35 (KAZ- 35(kT); Koerkel & Schindler, 1996) is a self-rating questionnaire with good psychometric properties. It serves to assess the confidence of clients in being able to limit alcohol intake in 35 high-risk situations to the limits fixed by oneself. The 35 items can be summed to a total score or they may be grouped into four factorial dimensions (‘unpleasant emotions’, ‘social pressure’, ‘testing personal control’, and ‘positive emotional states’).

Post-treatment assessment

About one week following the last AkT session, post-treatment assessment, lasting about 2 h, took place. The abbreviated version of the EuropASI and the KAZ-35(kT) were administered again and the physical examination (including blood samples) was repeated.

Follow-up

Again after 6 months and 12 months post-assessment AkT participants were interviewed with the abbreviated EuropASI and – if seen personally – a blood sample was taken to test changes in GGT, GPT, and GOT. In most cases follow- up interviews were carried out in the addiction counselling centre. Some subjects who could not arrange to come to the centre were interviewed by phone. The follow-up sessions lasted about 60 min. Follow-up data reported in this article restricted to the one-year follow-up.

Behavioural self-management with problem drinkers 39

Statistical analyses

Parametric and nonparametric statistics were calculated for all comparisons and statistical significance was set at the 5% level.

Treatment

Treatment structure, content, and methods. Each AkT group consisted of 10 structured group sessions of BSCT with one session of 2¼ h weekly (including a 15 min break). The AkT sessions were delivered according to a detailed procedures manual (Koerkel & Projektgruppe kT, 2001) based on principles of behaviour therapy as well as solution-oriented therapy and grounded in the spirit of motivational interviewing (Miller & Rollnick, 2002). The first half of each of the 10 AkT sessions was reserved for reviewing the records of the previous week’s drinking, goal setting for the next week, and recommendations for reliable use of the drinking diary. In the second half of each AkT session topics typical for BSCT were covered: basic information about alcohol, reasons for change, weekly goal setting, coping with high risk situations for excessive alcohol consumption, strategies to avoid or limit alcohol intake (e.g. rate control, resisting temptations and social pressure), coping with lapses, planning alcohol-free leisure time activities, and problem solving without alcohol. In order to make the program more interactive and capitalize on the advantages of group support, the sessions included small group exchange, role playing, working on written material, reporting experiences with one’s drinking plan and the like.

Therapists. Two of three AkT therapists (one social worker, one physician, one psychologist), sometimes assisted by a trainee, conducted each of the group sessions as well as the assessments. All therapists were experienced in treating alcohol problems, two of them with extensive training in behaviour therapy.

Treatment integrity. Besides delivering treatment by experienced addiction therapists and in accordance with the detailed AkT manual, treatment integrity was addressed by weekly supervision of therapists based on written protocols of each AkT session.

Results

A total of 43 clients (81% of 53 participants finishing the AkT per protocol) could be contacted at all assessment points, i.e. at pre-treatment, post-treatment, and 12-month follow-up. Reasons for loss to follow-up were: refused (n¼ 2), unable to trace (n¼ 7), and moved away (n¼ 1). Preliminary analyses revealed that subjects not found for follow-up did not differ significantly from the follow-up sample in any of the drinking outcome variables (i.e. TDW, ADW, and DDD; all p> 0.05).

All results reported in the following sections refer to the clients with pre-treatment, post-treatment and follow-up data (n¼ 43). Only self-report

40 J. Koerkel

data of drinking behaviour are reported because in this (cf Haberacker, 2003) as in other CD studies (e.g., Alden, 1988; Heather et al., 2000) self-reports have been shown to be generally valid as corroborated by liver function tests (Haberacker, 2003; Heather et al., 2000) or significant others’ reports (Alden, 1988).

Changes from pre-treatment to post-treatment

Total sample. There was 45% reduction in drinks per week from pre-treatment to post-treatment assessment (t(42)¼ 5.42, p< 0.001), a 25% reduction in amount of alcohol consumed on drinking days (t(42)¼ 3.39, p< 0.01), and a 89% increase in abstinent days (t(42)¼�5.53, p< 0.001) (see Table I). Concomitant with the changes in drinking behaviour, self-efficacy to maintain self-control in high-risk situations increased (KAZ-35(kT), total score; t¼�2.5, p< 0.05; Haberacker, 2003).

Sex. During treatment there was a statistically significant decrease of 47% TDW in men (t(24)¼ 4.71, p< 0.01) and 42% in women (t(17)¼ 2.81, p< 0.05). Decrease in DDD was also highly significant in men (t(24)¼ 3.01, p< 0.01), but not in women (t(17)¼ 1.65, p> 0.05). There was an increase in ADW in men (t(24)¼�5.82, p< 0.001) as well as women (t(17)¼�2.11, p¼ 0.05; see Table I).

ICD-10 diagnosis (alcohol misuse/alcohol dependence). A statistically significant decrease in TDW was observed in subjects with alcohol abuse (t(13)¼ 2.64, p< 0.05), as well as those with alcohol dependence (t(27)¼ 4.95, p< 0.001). Changes in DDD were significant for both subgroups (alcohol abuse,

Table I. Consumption measures: Means (and standard deviations) at pre-treatment, post- treatment, and 12-months follow-up (by total sample and sex).

Sex

Total sample (n¼ 43)

Men (n¼ 25)

Women (n¼ 18)

Outcome variable M SD M SD M SD

Total drinks per week Pre-treatment 26.68 (17.92) 30.66 (19.31) 21.14 (14.53) Post-treatment 14.56 (13.19) 16.18 (16.28) 12.31 (6.81) 12-months follow-up 16.45 (15.98) 17.47 (19.00) 15.04 (10.87)

Drinks per drinking day Pre-treatment 4.24 (2.56) 4.82 (2.65) 3.43 (2.24) Post-treatment 3.18 (1.87) 3.56 (2.16) 2.64 (1.26) 12-months follow-up 3.16 (2.42) 3.41 (2.87) 2.81 (1.63)

Abstinent days per week Pre-treatment 1.49 (2.12) 1.18 (1.86) 1.92 (2.43) Post-treatment 2.82 (1.95) 2.90 (1.93) 2.72 (2.04) 12-months follow-up 2.81 (2.14) 2.88 (2.16) 2.71 (2.19)

Behavioural self-management with problem drinkers 41

t(13)¼ 2.43, p< 0.05; alcohol dependence: t(27)¼ 2.70, p< 0.05) whereas the increase in ADW approached significance in alcohol abusers (t(13)¼�2.07, 0.10 > p> 0.05) and was highly significant in subjects with alcohol dependence (t(27)¼�5.45, p< 0.001; see Table II).

Severity of dependence (high/low). Even more support for the assumption that people with excessive alcohol consumption can benefit from a CD program comes from a comparison of people categorized as ‘high dose drinkers’ (defined as consuming more than 40 SU or 800 g per week; n¼ 10) and those categorized as ‘low dose drinkers’ i.e. <40 SU/w, n¼ 33 (see Heather et al., 2000 for this categorization; Table II and Figure 3). From the beginning to end of AkT both groups significantly decreased their weekly alcohol intake (low dose group: t(32)¼ 3.96, p< 0.001; high dose group: t(9)¼ 6.45, p< 0.001) and the amount of alcohol consumed at drinking days (low dose: t(32)¼ 1.23, p< 0.05; high dose: t(9)¼ 6.85, p< 0.001) while abstinent days increased (low dose: t(32)¼�4.28, p< 0.001; high dose: t(9)¼�4.13, p< 0.01; see Table II).

Follow-up analyses

To test the stability of change, drinking outcomes at end of treatment and one-year follow-up were compared.

Total sample. All changes made during treatment remained stable during the follow-up period: drinks per week (t(42)¼�0.96, p> 0.05), amount of alcohol consumed on drinking days (t(42)¼ 0.07, p> 0.05), and weekly abstinent days (t(42)¼ 0.05, p> 0.05).

Table II. Consumption measures: Means (and standard deviations) at pre-treatment, post- treatment, and 12-months follow-up (by diagnosis and severity of dependence).

ICD-10 diagnosis Severity of dependence

Misuse (n¼ 14)

Dependence (n¼ 28)

Low (n¼ 33)

High (n¼ 10)

Outcome variable M SD M SD M SD M SD

Total drinks per week Pre-treatment 19.49 (13.88) 30.87 (18.75) 18.94 (11.03) 52.21 (11.05) Post-treatment 10.91 (5.56) 16.37 (15.67) 12.14 (6.80) 22.56 (23.56) 12-months follow-up 15.05 (9.57) 17.23 (18.75) 15.09 (9.90) 20.95 (28.55)

Drinks per drinking day Pre-treatment 3.36 (1.86) 4.76 (2.13) 3.23 (1.84) 7.56 (1.56) Post-treatment 2.37 (0.93) 3.59 (2.13) 2.89 (1.35) 4.12 (2.94) 12-months follow-up 2.89 (1.51) 3.28 (2.82) 2.82 (1.51) 4.28 (4.19)

Abstinent days per week Pre-treatment 1.82 (2.25) 1.30 (2.11) 1.94 (2.24) 0.00 (0.00) Post-treatment 2.64 (1.82) 2.94 (2.07) 2.94 (1.99) 2.45 (1.88) 12-months follow-up 2.51 (1.96) 2.93 (2.29) 2.58 (2.04) 3.55 (2.41)

42 J. Koerkel

Sex. For men and women improvements made during treatment remained constant over the one-year follow-up period in TDW (men: t(24)¼�0.48, p> 0.05; women: t(17)¼�0.92, p> 0.05), DDD (men: t(24)¼ 0.38, p> 0.05; women: t(17)¼ 0.36, p> 0.05), and ADW (men: t(24)¼ 0.04, p> 0.05; women: t(17)¼ 0.03, p> 0.05; see Table I and Figure 1). This also means that there was no decrease in DDD for women from pre-treatment to one-year follow-up.

ICD-10 diagnosis (alcohol misuse/alcohol dependence). At one-year follow-up TDW, DDD, and ADW of alcohol dependent clients as well as alcohol abusers did not differ significantly from outcome values at post-treatment (TDW: alcohol abuse, t(13)¼�2.10, p> 0.05, alcohol dependence: t(27)¼�0.30, p> 0.05, p> 0.05; DDD: alcohol abuse, t(13)¼�1.93, p> 0.05, alcohol dependence: t(27)¼ 0.71, p> 0.05; ADW: alcohol abuse, t(13)¼ 0.27, p> 0.05, alcohol dependence: t(27)¼ 0.04, p> 0.05; see Table II and Figure 2). This also implies that alcohol abusers did not increase the number of abstinent days during treatment and one-year follow-up.

1716

12 15

Pre-treatment Post-treatment 12 Months

Men (N = 25) Women (N = 18)

G er

m an

s ta

nd ar

d un

its /w

ee k

(1 S

U =

20 g)

Figure 1. Changes in weekly alcohol consumption during AkT and follow-up (by sex; N¼ 43).

1716

Pre-treatment Post-treatment 12 Months

Alcohol dependence (N = 28) Alcohol misuse (N = 14)

G er

m an

s ta

nd ar

d un

its /w

ee k

(1 S

U =

20 g)

Figure 2. Changes in weekly alcohol consumption during AkT and follow-up (by diagnosis; N¼ 42).

Behavioural self-management with problem drinkers 43

Severity of dependence (high/low). From end of AkT to follow-up, low and high dose drinkers maintained their treatment gains (TDW for low dose: t(32)¼�1.50, p> 0.05, for high dose: t(9)¼ 0.29, p> 0.05; DDD for low dose: t(32)¼ 0.24, p> 0.05, for high dose: t(9)¼�0.19, p> 0.05; ADW for low dose: t(32)¼ 0.95, p> 0.05, for high dose: t(9)¼�1.19, p> 0.05; see Table II and Figure 3).

Individual changes. The use of an improvement classification scheme provided an index of the status of each individual at one-year follow-up. Each client was assigned to one of six improvement categories similar to those used by Miller (1978; see Figure 4).

According to this classification scheme, twelve months after end of treatment 8% of all clients followed-up had chosen to prefer abstinence over moderation, i.e. they abstained from alcohol completely. Twenty-five percent had considerably improved insofar as they showed a 50% reduction in alcohol intake.

21 23

12 15

Pre-treatment Post-treatment 12 Months

Weekly alcohol intake > 800 g (n = 10)

Weekly alcohol intake < 800 g (n = 33)

G er

m an

s ta

nd ar

d un

its /w

ee k

(1 S

U =

20 g)

Figure 3. Changes in weekly alcohol consumption during AkT and follow-up (for high and low dose drinkers; N¼ 43).

21 17

4 8

Ab st

in en

Re du

ct io

n >

50 %

Re du

ct io

n 30

–5 0%

Re du

ct io

n 10

–3 0%

Re du

ct io

n 1–

10 %

No t i

m pr

ov ed

Mi ss

in g

Figure 4. Individual changes in drinks per week (TDW) from pre-treatment to 1-year follow-up (N¼ 43).

44 J. Koerkel

Moderate improvement was observed in 19% of subjects who had cut down their alcohol intake between 30% and 50%. Six percent were classified as ‘slightly improved’. Those 25% clients with less than a 10% reduction were rated as ‘not improved’. Follow-up data were missing from 17% of clients treated.

Discussion

The CD program reported here, the AkT, attracted people with alcohol abuse (one-third) or alcohol dependence (two-thirds) who reported excessive alcohol

Figure 5. AkT trainers in Germany.

Behavioural self-management with problem drinkers 45

consumption and associated life problems. In accordance with one of the goals of offering CD programs, namely to get more people into treatment, the AkT seems to be attractive to many people who had not previously sought help for their alcohol problem; two-thirds of AkT participants had never been treated by an addiction professional before. So, even if outcome in such a program is not favourable, most clients can be motivated to stay in the wheel of change and may then be referred to abstinence-oriented forms of treatment. This can be done in a very simple and effective way within the treatment centre where this study was done because abstinence and CD programs are offered in the same institution by the same staff.

Drinking outcome variables reported in this study provide evidence that AkT is an effective approach to foster self-control skills and to cut down alcohol intake in different subgroups of clients at least over a one-year period – including drinkers with severe and chronic alcohol problems that often are excluded in other trials (e.g. Alden, 1988). Fifty-two percent of AkT participants could be classified as improved overall, including 8% of subjects who were completely abstinent. This outcome of AkT compares well with those of other trials of BSCT in the USA (e.g. Miller, 1978), Canada (e.g. Alden, 1988) and UK (e.g. Heather et al., 2000). Nevertheless many clients continued drinking at dangerous levels, so that benefits of treatment sometimes took the form of harm reduction.

Although statistically not significant, considerable differences in change did emerge between women and men, between clients with alcohol abuse and alcohol dependence and between high dose and low dose drinkers. In women, alcohol abusers and low dose drinkers, alcohol intake had declined much less than in the other subgroups. One might well argue that a larger sample size would be needed to draw substantial conclusions concerning subgroup differences, and indeed statistical power needs to be increased by collecting and analyzing more follow-up data in the future. Anyway, follow-up results of this and other studies (e.g. Dawe et al., 2002; Heather et al., 2000; Miller, Leckman, Delaney, & Tinkcom, 1992) indicate that alcohol dependent subjects do not perform worse than subjects with alcohol misuse and that alcohol dependence in itself is no contraindication for CD treatment. In our study even drinkers with very high levels of alcohol intake (at least 800 g/w) showed an enormous and stable reduction in weekly alcohol consumption from pre-treatment to post-treatment and follow-up that was much more impressive than the decrease observed in the low dose group (with intake consumption <800 g/w).

This might be a result of regression towards the mean in the ‘high dose group’. But in face of their constantly high alcohol consumption level at pre-treatment it is unlikely that their values could be expected to decrease without treatment. Assuming our results are valid it seems justified to accept even heavy drinkers with presumably high levels of dependence in CD treatment programs – a conclusion also drawn in other studies addressing this topic (cf Heather et al., 2000, p. 568f.). In accordance with this line of reasoning and starting in January 2004, we have successfully implemented

46 J. Koerkel

different individual and group treatment CD programs in sheltered houses for chronically alcohol dependent homeless people in Munich, Germany (Koerkel, Gehring, König, & Drinkmann, 2005). A great number of them deliberately join the programs and decrease their alcohol intake considerably or opt for abstinence later on.

One of the limitations of this study is the attrition rate of 19% in the one-year follow-up – a rate comparable to other CD follow-up studies (e.g. Alden, 1988; Miller, 1978). It is unclear to what extent overall success rates may have been overestimated by excluding possible failures from the analyses. On the other hand subjects unlocated at follow-up did not show any differences in drinking behaviour at post-treatment than cases followed-up, so that our findings may represent true remission rates.

To stabilize treatment effects an aftercare system – with booster sessions, self-help groups, online counselling, and the like – for subjects who complete a CD program is needed. Consistent with this line of reasoning, in several German cities AkT participants have founded self-help groups (first in June 2000 in Nuremberg) for people that completed a CD treatment. Members of these groups are free to opt for CD or abstinence. The groups exchange experiences concerning ways and problems of maintaining CD or abstinence in everyday life. The meetings (monthly in Nuremberg with an average of 10 members) are informal and do not follow a fixed agenda as in Moderation Management (cf Kishline, 1994).

Considered as a whole, the follow-up data of the AkT reported here, as well as similar results with other forms of BSCT, provide support for integrating CD treatment approaches in routine addiction treatment delivery. This also includes implementing CD programs into drug treatment to enable drug addicts to control their alcohol intake whenever problems with alcohol consumption become evident. This happens very often. For example, people who are dependent on illegal drugs are exposed to a much higher risk of dying when consuming illicit drugs in combination with alcohol, medicinal HIV treatment can become ineffective when high doses of alcohol are consumed, and many heroin addicts treated in outpatient methadone or heroin programs develop serious alcohol problems that need to be addressed (Gossop, 2004).

Given the fact that ‘pessimism over the viability of controlled drinking treatment . . . seems based on political rather than scientific considerations’ (Heather, 1989) much effort still has to be made to ensure that CD programs become an integral part of (German) addiction treatment systems and that health insurances also pay for moderation-oriented interventions. One step in this direction has been made: since 2001 we have trained about 400 German- speaking addiction professionals (social workers, psychologists, physicians, and others) in three-day to seven-day workshops to carry out AkT groups and its variants (especially one variant called ‘EkT’ that is suitable for individual treatment and encompasses 10 sessions as in the AkT; Gehring & Projektgruppe kT, 2003). CD trainers are widespread over west Germany (see Figure 4) and

Behavioural self-management with problem drinkers 47

can be located on the internet (www.kontrolliertes-trinken.de), so that it is not too difficult to find a CD trainer close by.

Acknowledgements

The author would like to thank Wilfried Langguth and Birgit Schellberg of the Caritas Nuremberg Outpatient Counselling and Treatment Centre for Addictions (Psychosoziale Beratungs- und Behandlungsstelle für Suchtkranke im Caritasverband Nuremberg e.V.) for their considerable help in designing this research and running the assessment and treatment sessions (together with Claudia Kerlin and Birgit Neu). The author would also like to thank the Caritasverband Mittelfranken e.V. and its head Mr Werber for funding this research as a program development project.

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