Behavioral Self-Control Training
Behavioral Self-Control Training (“Controlled Drinking”)
This was the first line of research that I undertook, beginning with my dissertation in 1974 (Miller, 1978). I was interested in an early intervention for people who were drinking too much, but were unlikely to seek treatment before their problems became more severe. Behavioral self-control training, which had been used for behavior change in other areas (such as weight loss and eating patterns) seemed a sensible approach to help people learn to moderate their drinking and keep it within limits unlikely to cause them health or other problems.
Although primary care physicians are now routinely urged to identify heavy drinkers and help them moderate their alcohol use, this was highly controversial in the 1970s. An impassioned debate raged around the term “controlled drinking,” and the common belief was that a person was either an alcoholic (in which case moderate drinking was impossible, or at best ill-advised) or not an alcoholic (in which case one could drink with impunity). This all-or-none view was a hold-over from U.S. prohibition, during which the public had been taught that no one could drink alcohol safely, and that the only alternatives were abstinence or insanity and death. When prohibition was repealed and alcohol became freely available in American society, there was a national crisis of cognitive dissonance. It seems to have been resolved in the (mistaken) belief that only certain people (namely, alcoholics) cannot drink safely, because they are constitutionally different from normal people. The major prevention approach thus became to identify “alcoholics” and persuade them to abstain, but otherwise to leave drinkers (and the alcohol industry) to their own devices.
Some of the publications below speak to the passionate controversy that surrounded anyone who sought to help people moderate their drinking (Miller, 1983; Miller & Caddy, 1978; Miller, 1986; Miller, Leckman & Tinkcom, 1987), and its more recent reincarnation in the “harm reduction” debate (Miller, 2008). These are now largely of historical interest, although “abstinence only” still remains a hot issue in addiction treatment, as is “zero tolerance” in prevention.
Fortunately, quite a lot of good science was devoted to the development and evaluation of behavioral self-control training to help people moderate their drinking (Miller & Wilbourne, 2002; Miller, Wilbourne & Hettema, 2003). The studies described here and listed below are those done in our laboratory at the University of New Mexico, which are but a few of the studies and publications on behavioral self-control training.
The first controlled clinical trial of behavioral self-control training (BSCT) in this series was my dissertation at the University of Oregon (Miller, 1978), in which we randomly assigned self-referred problem-drinking clients to receive one of three free outpatient treatments to help them moderate their drinking: (1) self-administered electrical aversive counterconditioning, (2) BSCT counseling, or (3) weekly 2-3 hour sessions of moderation training using a variety of methods in a simulated bar setting. All three produced substantial reduction in alcohol use, with no outcome differences between treatments. This suggested that the simpler BSCT, which requires no special equipment, alcohol, bar setting, or electric shocks, would be preferable and certainly easier to deliver.
An unexpected finding in my dissertation involved a self-help manual that we wrote to help people maintain any gains they had made. We had planned to give this to everyone at the end of 3-month outpatient treatment, but decided it would be best to randomly give or not give it, just to make sure that it had no effect on follow-up. As it turns out, those who were given the manual showed continued reduction in their drinking over the course of months 4-6, whereas those not given the manual simply maintained the reduction in drinking that they had achieved at the end of treatment. By 6 months, the difference was statistically significant.
This raised an interesting question: What would happen if we only gave people the self-help manual instead of treatment? In a second randomized trial at the University of Oregon (done in 1975-76) we assigned people to receive either the outpatient BSCT counseling method we had developed, or a single session in which they were given the self-help manual and were told to go home and follow its suggestions. To our surprise, at 3-month follow-up both groups showed substantial and equivalent reductions in their drinking (Miller, Gribskov & Mortell, 1981). While on internship in Palo Alto, California, I conducted an uncontrolled evaluation of a group therapy version of BSCT, offered as a class at a community continuing education center, and using the self-help manual as a textbook. Again, the heavy drinkers in this study showed significant reductions in their alcohol use (Miller, Pechacek & Hamburg, 1981).
When I joined the faculty of the University of New Mexico, I decided to re-do these studies to see whether we would replicate their findings with a very different population. In two randomized trials we compared the self-help intervention with various outpatient versions of BSCT, ranging up to 18 weeks in length (Miller & Taylor, 1980; Miller, Taylor & West, 1980). In both studies, the self-help group showed substantial reductions in drinking comparable to those receiving outpatient counseling. Reductions in drinking were well maintained at 2-year follow-up (Miller & Baca, 1983). We also found that the counselor’s skill in empathy (ability to listen to and understand their clients) was a strong predictor of outcome among those receiving treatment (Miller, Taylor & West, 1980).
It appeared that we had a reliable finding, but what did it mean? Why did those receiving such a brief intervention respond just as well as those getting longer treatment? Had they come through the door already changed by virtue of entering the study? Might it be keeping a personal diary of drinking (which all groups did, for research purposes)? Thus we designed a sixth study randomly assigning problem drinkers to self-help BSCT, outpatient BSCT, or two waiting list groups, only one of which kept drinking diaries (Harris & Miller, 1990). Both self-help and outpatient BSCT groups showed the characteristic reductions in drinking, but neither of the waiting list groups budged. Then we treated the waiting list groups after 3 months, and their drinking moderated. It was not the mere passage of time or the keeping of drinking diaries that accounted for change. Clients were successful working on their own, when given suggestions for how to proceed. The original version of the self-help book was published by Prentice-Hall in 1976, and the most recent edition by Guilford Press in 2005.
In one study we randomly assigned problem drinkers to an abstinence or controlled drinking goal, providing behavioral self-control training for both groups (Graber & Miller, 1988). We found, in essence, that clients felt equally free to set their own outcome goal no matter what we had assigned.
Longer-Term Follow-up: For Whom Does It Work?
When the last of these studies was published in 1990, the idea of “controlled drinking” was still anathema in the alcohol treatment community, although in that same year the National Academy of Sciences published its report, Broadening the Base of Treatment for Alcohol Problems, clearly recommending a variety of evidence-based approaches to address the full spectrum of alcohol problem severity. It seemed to me that this line of research had reached a natural conclusion, and that further trials would be unlikely to make a difference. Two decades later, the National Institute on Alcohol Abuse and Alcoholism (who funded my initial studies with great trepidation) publicizes safe-drinking guidelines and encourages practitioners to counsel their heavy-drinking patients toward moderation (or, of course, abstinence).
Could we predict who would succeed in maintaining moderate drinking? We addressed this question in a longer-term follow-up study that was also designed to address the criticism that we had not followed our clients long enough, and that they would invariably relapse over time. We assembled a follow-up team to find and interview clients from our four New Mexico studies at up to 8 years after treatment. The team included a local psychiatrist, Dr. Lane Leckman, who had been publicly critical of our work, to conduct his own independent clinical evaluation with each patient so that we could compare findings and seek consensus regarding outcomes. We were both surprised by our findings – I to discover that over time, more people had actually quit drinking than had maintained moderation, and he to find that there really were people who had had significant alcohol problems, had established moderate and problem-free drinking, and had maintained it over the years (Miller, Leckman, Delaney & Tinkcom, 1992).
Our longitudinal prediction findings also made sense. The earlier people had come into our program (fewer problems and symptoms of dependence), the more likely they were to successfully moderate their drinking and the less likely they were to maintain abstinence. On the other hand, those who had already established higher levels of alcohol problems and dependence were less likely to maintain moderation (even though all of them entered the study with that intention) and were more likely to succeed with abstinence. This allowed us to publish tables, based on two self-evaluation instruments, to help people estimate ahead of time their likelihood of success with moderation or abstinence (Miller & Muñoz, 2005, 2013). There was a level of severity above which no one in our studies had managed long-term moderation.
There were also a few other interesting wrinkles. Why did people who came to control their drinking wind up abstaining instead? We guessed that some would try moderation, fail, and decide thereby that abstinence was necessary for them. We guessed wrong. Most of those who ultimately abstained had actually achieved moderation by our research definitions, and there were two common themes that we heard. The first was that moderation was just too difficult. “I could do it, but I felt like I was always walking on a tightrope, and it was just easier not to drink at all.” The second was that moderation was pointless. “What’s the point in drinking so little? I drank to get drunk. It just isn’t worth it.” In other words, they decided that they were working very hard for a pointless goal.
And there was one more thing that we noticed over time. Most of the people who were continuous abstainers during the final year of follow-up had had some prior “slips” along the way, but it was rarely the classic full-blown relapse. One day they would have a drink or two, and maybe again the next, and then they asked themselves why they were doing this and went back to abstaining. It was as if the allure of moderation was gone.
Self-Help Book for Consumers
Miller, W. R., & Muñoz, R. F. (2013). Controlling your drinking (2nd ed.). New York: Guilford Press.
Miller, W. R., & Muñoz, R. F. (2005). Controlling your drinking. New York: Guilford Press. (Translated into Dutch, Italian, Japanese, and Polish)
Miller, W. R., & Muñoz, R. F. (1976). How to control your drinking. Englewood Cliffs, NJ: Prentice-Hall.
Miller, W. R., & Muñoz, R. F. (1982). How to control your drinking. (Rev ed.) Albuquerque, NM: University of New Mexico (British Edition: London: Sheldon Press, 1983)
Studies and Articles on BSCT (in chronological order)
Miller, W. R. (1977). Behavioral self-control training in the treatment of problem drinkers. In R. B. Stuart (Ed.), Behavioral self-management: Strategies, techniques and outcomes (pp. 154-175). New York: Brunner/Mazel.
Miller, W. R., & Caddy, G. R. (1977). Abstinence and controlled drinking in the treatment of problem drinkers. Journal of Studies on Alcohol, 38, 986-1003.
Miller, W. R. (1978). Behavioral treatment of problem drinkers: A comparative outcome study of three controlled drinking therapies. Journal of Consulting and Clinical Psychology, 46, 74-86.
Miller, W. R., & Joyce, M. A. (1979). Prediction of abstinence, controlled drinking, and heavy drinking outcomes following behavioral self-control training. Journal of Consulting and Clinical Psychology, 47, 773-775.
Miller, W. R., & Taylor, C. A. (1980). Relative effectiveness of bibliotherapy, individual and group self-control training in the treatment of problem drinkers. Addictive Behaviors, 5, 13-24.
Miller, W. R., Taylor, C. A., & West, J. C. (1980). Focused versus broad spectrum behavior therapy for problem drinkers. Journal of Consulting and Clinical Psychology, 48, 590-601.
Miller, W. R., Gribskov, C. J., & Mortell, R. L. (1981). Effectiveness of a self-control manual for problem drinkers with and without therapist contact. International Journal of the Addictions, 16, 1247-1254.
Miller, W. R., Pechacek, T. F., & Hamburg, S. (1981). Group behavior therapy for problem drinkers. International Journal of the Addictions, 16, 827-837.
Miller, W. R. (1983). Controlled drinking: A history and critical review. Journal of Studies on Alcohol, 44, 68-83.
Miller, W. R., & Baca, L. M. (1983). Two-year follow-up of bibliotherapy and therapist-directed controlled drinking training for problem drinkers. Behavior Therapy, 14, 441-448.
Carpenter, R. A., Lyons, C. A., & Miller, W. R. (1985). Peer-managed self-control program for prevention of alcohol abuse in American Indian high school students: A pilot evaluation study. International Journal of the Addictions, 20, 299-310.
Marlatt, G. A., Miller, W. R., Duckert, F., Gotestam, G., Heather, N., Peele, S., Sanchez-Craig, M., Sobell, L. C., & Sobell, M. B. (1985). Abstinence and controlled drinking: Alternative treatment goals for alcoholism and problem drinking? Bulletin of the Society of Psychologists in Addictive Behaviors, 4, 123-150.
Miller, W. R. (1986). Haunted by the Zeitgeist: Reflections on contrasting treatment goals and concepts of alcoholism in Europe and the United States. Annals of the New York Academy of Sciences, 472, 110-129.
Miller, W. R., Leckman, A. L., & Tinkcom, M. (1987). Controlled drinking and the treatment of alcoholism. Journal of the American Medical Association, 257, 3228-3229.
Graber, R. A., & Miller, W. R. (1988). Abstinence or controlled drinking goals for problem drinkers: A randomized clinical trial. Psychology of Addictive Behaviors, 2, 20-33.
Harris, K. B., & Miller, W. R. (1990). Behavioral self-control training for problem drinkers: Components of efficacy. Psychology of Addictive Behaviors, 4, 82-90.
Miller, W. R., & Brown, J. M. (1991). Self-regulation as a conceptual basis for the prevention and treatment of addictive behaviours (pp. 3-79). In N. Heather, W. R. Miller, & J. Greeley (Eds.), Self-control and the addictive behaviours. Sydney: Maxwell Macmillan Publishing Australia.
Miller, W. R., & Page, A. (1991). Warm turkey: Other routes to abstinence. Journal of Substance Abuse Treatment, 8, 227-232.
Miller, W. R., Leckman, A. L., Delaney, H. D., & Tinkcom, M. (1992). Long-term follow-up of behavioral self-control training. Journal of Studies on Alcohol, 53, 249-261.
Miller, W. R., & Wilbourne, P. L. (2002). Mesa Grande: A methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction, 97, 265-277.
Apodaca, T. R., & Miller, W. R. (2003). A meta-analysis of the effectiveness of bibliotherapy for alcohol problems. Journal of Clinical Psychology, 59, 289-304.
Miller, W. R., Wilbourne, P. L., & Hettema, J. E. (2003). What works? A summary of alcohol treatment outcome research. In R. K. Hester & W. R. Miller (Eds.),Handbook of Alcoholism Treatment Approaches: Effective Alternatives (3rd ed., pp. 13-63). Boston, MA: Allyn & Bacon.
Miller, W. R., & Carroll, K. M. (Eds.) (2006). Rethinking substance abuse: What the science shows and what we should do about it. New York: Guilford Press.
Miller, W. R. (2008). The ethics of harm reduction. In C. M. A. Geppert & L. W. Roberts (Eds.), The book of ethics: Expert guidance for professionals who treat addiction(pp. 41-53). Center City, MN: Hazelden.
Miller, W. R., Forcehimes, A. A., & Zweben, A. (2011). Treating addiction: A guide for professionals. New York: Guilford Press.