DrinkChoice Prospectus

DrinkChoice Prospectus

A. Introduction
DrinkChoice is a brief intervention program intended to prevent and eliminate alcohol problems among its clients by offering a choice to either cut down or quit drinking altogether. Brief intervention consists of a 1-hour assessment, then four 1-hour sessions, or five-1.5 hour group sessions, or three 40-50 minute self help sessions. The program is consistent with the community based model for alcohol services described in the study by the Institute of Medicine entitled Broadening the Base of Treatment for Alcohol problems (1990).

B. Target Population
The target population for DrinkChoice is known as problem drinkers – the substantial population that lies between moderate drinkers on one side, and alcoholics on the other. Moderate drinkers are defined as people whose drinking practices are consistent with low risk or moderate guidelines, as specified in Exhibit A. By definition, the overwhelming majority of people who adopt moderate practices do not experience alcohol problems. Alcoholics are defined as all drinkers who meet the criteria for severe alcohol dependence, along with some of those drinkers who fall just short of meeting that criteria. These criteria are found in the Diagnostic and Statistics Manual of Mental Disorders IV of the American Psychiatric Association. These are commonly referred to as the DSM IV criteria, and are presented in Exhibit B.
Members of the DrinkChoice target population have experienced alcohol problems, or are at increased risk of developing problems by virtue of their drinking practices. A subset of the target group realizes that they have experienced problems with alcohol, are motivated to change, desire help, but are turned off by traditional treatment approaches. These are DrinkChoice clients. DrinkChoice is designed to eliminate current alcohol problems, and reduce the risk of future problems by providing clients with the knowledge and skills required to adopt moderate drinking practices or to cut out drinking altogether. Risk can be elevated in two ways: first, as the number of risk drinking practices increases (see Exhibit A) and second, as the scope of involvement with each increases.
Although some drinkers who exceed moderate guidelines (and are at risk) are not experiencing alcohol problems, the majority do. Drinkers who experience alcohol problems can be divided into two groups. The first group is the minority. They experience severe problems and tend to be diagnosed as severely dependent in relation to DSM IV criteria. This group is not a part of the DrinkChoice target population. The second group is the Majority and is estimated at 4 to 5 times larger. They makeup the DrinkChoice target population and are characterized by mild-to-moderate problems resulting from their drinking.

The DrinkChoice target population can be summarized as follows:
Drinkers who exceed moderate guidelines, who may or may not have developed mild-to-moderate alcohol problems, and who are not severely dependent on alcohol. DrinkChoice clients have three other defining characteristics:

First, They are concerned about their drinking and its actual or potential consequences on their lives. This characteristic reflects that DrinkChoice is a voluntary program and that people attend because they want to learn how to better manage alcohol.

Second, DrinkChoice clients display no significant contraindications which would preclude their participation in the program. Reasons for exclusion include:

• Severely alcohol dependent (>18 SADD Scale)
• Current abstinence in Alcoholics Anonymous
• Acute personal crises
• A high degree of social instability
• Serious health consequences that have resulted
• from drinking or dependence on other drugs.
• Current problems with other drugs

These contraindications have been identified in the background research for DrinkChoice as substantially reducing the likelihood of success.

Third, DrinkChoice clients believe they possess the ability to better manage their drinking, regardless of the fact that they have not fully succeeded in exercising this ability. They do not see themselves as powerless over alcohol. Rather, they believe that with additional knowledge and applied skills, they will be able to eliminate their alcohol- related problems. They have sufficient motivation and determination to vigorously address their alcohol problems.
The research literature tells us additional things about problem drinkers as compared to more severely dependent alcohol abusers:

• Problem drinkers do not have a history of severe alcohol withdrawal symptoms.
• Problem drinkers tend to have a shorter problem drinking history, typically around 5 years, and seldom over 10 years.
• Problems drinkers tend to have greater social and economic stability.
• Problem drinkers tend to have greater personal, social, and economic resources to call upon in treatment ( i.e., they have more opportunity to help themselves).
• Problem drinkers are not likely to view themselves as different from persons who do not have drinking problems ( i.e. they do not self- identify as alcoholic, and their self-esteem is usually higher than persons with more severe histories).
• Problem drinkers can become caught in a motivational dilemma knowing that they still have a great deal to lose but also feeling that conditions in their life are not so bad as to justify extensive life changes or sacrifices to deal with their drinking.

In summery, people can be considered as appropriate for DrinkChoice if their drinking practices place them at risk, if they are experiencing alcohol problems of no more than mild-to-moderate severity, and if they are concerned about their drinking. The program is not appropriate for people who are severely dependent, who believe themselves powerless over alcohol, who are currently abstinent in Alcoholics Anonymous, or who face other significant impediments to participation in a program of this nature.

C. Program Goals
The program goal of DrinkChoice is to eliminate alcohol problems among clients. This goal is realized either by cutting down on alcohol or by cutting it out completely. Initially, potential DrinkChoice clients must complete a thorough assessment process to insure that their participation in the program is appropriate. The assessment process eliminates those applicants whose participation in the program is contraindicated (See section B). Alcoholics in particular are drawn to DrinkChoice by the hope that they might regain control over alcohol and begin to moderate their drinking. The DrinkChoice assessment process is an important intervention for those applicants with severe alcohol dependency to help them recognize the loss of control and the need for abstinence. An immediate treatment plan is developed for all contraindicated individuals that can include referrals for medical or further psychiatric assessment, 12- Step programs, therapy, and other treatment components of the community Œs alcohol referral resource network. Once accepted, and depending upon their choice, clients admitted to the program then proceed to a group, individual, or telephone training format.
DrinkChoice employs an adult educational approach. The program provides clients with knowledge and skills which they can apply to modifying their drinking or to cutting it out altogether. For this approach to be effective, clients must believe that their drinking practices are behaviors which they are capable of learning to modify. People who are uncomfortable with this perspective, or who believe they are powerless to affect their drinking, are unlikely to do well in the DrinkChoice program.
In the majority of cases it is the client who chooses whether to select reduced consumption or abstinence as a means of eliminating alcohol problems. Research has shown that self-selection of treatment goals increases a problem drinker’s commitment. From a perspective of motivation for change, the major concern is not the type of goal a client will pursue, but rather with how that decision is made. In guided self-management treatment, clients are asked to specify their own goal. This is done for two reasons. First, the literature suggests that there is no basis for expecting that assigning goals to clients will effect their behavior. Second, self-selection of goals appears to increase commitment to change (i.e., motivation). The notion of personal respondsibility, choice and dedication is constantly reinforced.

D. Summary of DrinkChoice Content
An underlying principle of DrinkChoice is that some people can learn to change their drinking practices in order to eliminate alcohol problems. The learning process essentially involves the transfer of knowledge and the development of skills, both of which are applied to personal behavior change, and refined through continuous practice.
DrinkChoice is a cognitive-behavioral approach that teaches clients how to think and act in ways which result in healthy behavior change.

The following is an overview of the DrinkChoice program:
Each DrinkChoice client completes a Guided Self-Assessment as an initial assignment for the program. In providing a detailed account of patterns and consequences that have developed as a result of drinking, the Assessment specifies the program goal for each client: to eliminate all alcohol problems experienced to date, and to reduce the likelihood that these or any others will emerge in the future.
Initially, Clients learn how risky drinking practices can cause harm and how they have negatively impacted health, social, legal and financial well being. In so doing, clients increase their perceptions of the seriousness and undesirability of these practices. This establishes a strong and growing sense of personal susceptibility to these consequences.
Early in the program clients learn to analyze their drinking practices, identifying specifically when they drink too much, the function of such drinking, and what they tell themselves about such drinking. They are encouraged to undergo a period of abstinence (usually 2 weeks) to learn more about how they naturally cope with pressures and temptations to drink. Clients begin to build a repertoire of techniques and mechanisms for cutting back, based on current and past experiences. Following the period of abstinence, clients begin keeping a drinking or abstinence diary which, on a daily basis, records the particulars of each action or drink and its function. This allows for a continual monitoring of progress. As the program
continues, clients add to their base of knowledge and kills. Depending upon their stated goal of moderation or abstinence, clients begin to develop and refine coping techniques. They develop cognitive and behavioral coping skills to effectively challenge the self talk which in the past has rationalized and given them permission to lose control.
Once a solid foundation of knowledge and skills has been laid, clients begin to concretize their long-term drinking or abstinence goals. All the while, they are applying, monitoring, and adjusting their skills and receiving support and encouragement. In addition, clients learn how to plan in advance for drinking occasions to develop a set of personal techniques for maintaining their preselected limits. Finally, clients learn relapse management strategies which they can directly apply to incidents where they fail to keep within their goals. Such incidents are treated as slips, and are used as a basis for continuing analysis and refinement of skills.
By the end of the program, DrinkChoice clients have selected a long- term drinking or abstinence goal, with a personalized set of skills and techniques which they can effectively apply to achieving their goal. They will continue to monitor themselves, to plan ahead for drinking occasions, and to assess and manage all drinking situations they encounter. Should they ever experience difficulties, relapse prevention and management strategies will allow for corrective action to systematically eliminate recurrences.

E. Background Research
DrinkChoice is based on over two decades of scientific research, the results of which are published in a variety of journals and texts. All research was subjected to prior review for methodological and ethical integrity in accordance with contemporary academic and scientific standards. Published articles appear in peer-reviewed journals,
where independent experts endorse both the methods and the conclusions prior to acceptance for publication. Books and texts describing this research have been published by highly-credible sources, including the World Health Organization (WHO), and the National Institute for Alcoholism and Alcohol Abuse (NIAAA), among others. A bibliography of the background research for the DrinkChoice program and related publications, is found in Exhibit C.

This body of research steers clear of techniques used by some researchers to increase apparent rates of success in treatment outcome studies. These include: excluding clients who started the program but dropped out prior to completion, excluding clients who could not be reached in the follow-up phase, and relying solely on self reports for outcome status. By avoiding these techniques, published results are legitimate reflections of program impact, and do not incorporate the data massaging techniques frequently used by treatment programs which claim high success rates.
From the background research, two principal findings have direct relevance to the DrinkChoice Program. First, the research affirms the validity of the moderate drinking guidelines used by DrinkChoice. They demonstrate that when male problem drinkers do not exceed 4 drinks per day, and female problem drinkers do not exceed 3 drinks per day, and where both groups stay within 12 drinks per week, few if any alcohol problems are experienced.
Second, the research demonstrates that problem drinkers (as described in Section A) are able to reduce their alcohol consumption in line with moderate guidelines, and to maintain this reduced consumption over time. Moreover, the same techniques apply equally well to abstaining from alcohol, and allow most DrinkChoice clients the choice of moderate drinking or abstinence as the means to eliminating alcohol problems. At a two year follow-up period of recent research conducted by the Addiction Research Foundation in Toronto, Canada, between 60 and 70% of research subjects were either abstaining or drinking within responsible guidelines, and were experiencing few if any problems. These outcomes are based on a cumulative sample that exceeds 900 subjects, and spans more than two decades. The effectiveness of the DrinkChoice approach is irrefutably established by the research.

F. The Development of DrinkChoice
Prior to the development of DrinkChoice, treatment interventions for problem drinkers were based primarily on the disease concept of alcoholism, which stated individuals were powerlessness over alcohol. As a result, research indicates that problem drinkers were often misdiagnosed with severe alcohol dependency. Intervention strategies designed primarily for the severely dependent alcoholic population were frequently utilized to break through the problem drinker’s resistance to the acceptance of powerlessness and lifelong abstinence. These goals were often unacceptable to problem drinkers. During such interventions, problem drinkers routinely found themselves labeled as alcoholics who were in denial of their
impending alcoholism. While well-meaning, such interventions failed to treat problem drinkers. Quite the contrary, inappropriate interventions and a lack of alternative referrals often left problem drinkers wondering if they even had a drinking problem at all, because they felt certain that they were very different from the severely dependent drinkers they encountered at treatment venues. As a result, many early intervention opportunities to help problem drinkers develop self-management strategies were lost. Problems drinkers were often labeled treatment failures”, and left, receiving no
help at all.

DrinkChoice was developed to meet the needs of problem drinkers and to support them in developing the knowledge and skills necessary to eliminate their problem drinking behavior. DrinkChoice is an essential referral resource for the mild-to moderately dependent problem drinking population and supports earlier intervention to eliminate drinking problems by helping clients to either cut down on drinking or to quit completely.

DrinkChoice recognizes and supports the applicability of the disease concept for the severely alcohol dependent 2, and also supports 12- Step treatment interventions for that population. On the other hand, the research clearly indicates that the best intervention strategy for many problem drinkers is a brief educational intervention. Drink Choice is that intervention.
The DrinkChoice development team produced a prototype of the program in a group format. In the process, a standardized individual format of the program was developed to complement the group format. A telephone format for the program was introduced following the most recent publications of research, which demonstrated that similar results to the face-to-face formats could be achieved through a specifically designed telephone intervention. DrinkChoice formats, interventions, and materials are continuously updated as feedback is received from clients and program staff. New developments and research in the field of chemical dependency continue to be adapted by the DrinkChoice development team.
2002 Copyright by DrinkChoice

EXHIBIT A
Moderate Guidelines
The DrinkChoice program follows research validated guidelines that allow clients to adjust their drinking practices in order to avoid problems. High risk practices account for virtually all alcohol problems.
Drinking Levels

• A. Maximum drinks per week: Clients who have 12 drinks per week are at low risk of developing alcohol problems. This guideline is subject to the constraints of other guidelines and is not intended as a target or goal.
• B. Maximum drinks per day: Research defines the low risk range as 4 drinks per day for men and 3 drinks per day for women. This guideline is an upper limit and not intended to be a goal or target. It is subject to 12 total drinks per week as well as the remaining guidelines.
• C. Maximum drinks per hour: On average the body metabolizes about 2/3 of a drink per hour. Blood Alcohol Concentration (BAC) measures additional accumulations of alcohol in the bloodstream. Limiting drinking to one drink per hour in combination with the daily limits of 4 drinks a day for men and 3 for women, reduces the likelihood of becoming intoxicated.
• D. Drinking everyday: Even in small amounts, drinking everyday increases the risk of developing drinking problems. One or more abstinent days per week is essential and encouraged.

Risk Drinking

• A. Drinking during pregnancy: There is no known level of alcohol consumption that is safe for a developing fetus. Total abstinence is recommended.
• B. Drinking and driving: Operating any vehicle while drinking impairs the operator¹s ability to react and coordinate actions. Any alcohol in the bloodstream is a serious high risk behavior.
• C. Drinking on medication: Prescription and non-prescription drugs can increase the intoxicating effects of alcohol. Medication advisories should be strictly observed.
• D. Drinking at work: Alcohol impairs work performance and reduces productivity with increased safety risks.
• E. Drinking at play: Alcohol impairs the drinkers’ ability to act and react. This dramatically increases the risk of injury or death during sports and leisure activities.

High Risk Drinking Patterns

• A. Drinking to get drunk: This motivation is associated with predictable outcomes. Onset of alcohol problems begins with frequent intoxication.
• B. Habitual drinking: Another motive that is associated with the onset of problems. Drinkers slowly integrate drinking into leisure activities. Drinking becomes a routine part of most activities. As a result, the drinker consumes alcohol beyond moderate guidelines.
• C. Drinking to manage feelings: Drinking to cope is a difficult response pattern to break and increases the likelihood of psychological dependence on alcohol.