Promoting controlled drinking

A recent study of interventions with significant others to promote change in resistant drinkers reported success with using a "pressures to change" approach (Barber & Crisp, in press). With this approach, incompatible activities and environmental contingencies are arranged hierarchically by significant others to bring increasing pressure on drinkers to reduce their drinking or seek treatment. Although clients were recruited by means of a press release inviting anyone living with a heavy drinker to participate, all but three of the volunteers were female partners of male drinkers. Similarly, Sisson and Azrin (1986) developed a "reinforcement training" approach to assist female partners who sought help in dealing with their partners' drinking. This overrepresentation of female partners of problem drinkers in studies of unilateral therapy for alcohol abuse (see Jacobson & Martin, 1976; Farid, Sherini, & Raistrick, 1986; Thomas, Santa, Bronson, & Oyserman, 1987) makes it difficult to extrapolate treatment techniques to other family constellations. This case study, however, reports on the pressures-to-change approach with a mother, who was a heavy drinker, and her adult daughter.

Client History

Andrea, a 32-year-old single woman who lived with and cared for her mother, sought help for her mother's (Mrs. D's) drinking, which had disrupted Andrea's life and caused her considerable stress. Andrea also reported that she was concerned about her mother's health, particularly in view of the fact that Mrs. D had undergone surgery for breast cancer and suffered from chronic heart disease.

Andrea was the second of four girls and was brought up in a rural, unhappy, and violent home. Her father was abusive to all family members. The family moved many times when Andrea was young. When her parents divorced approximately seven years earlier, Andrea and her mother moved to the city and rented a three-bedroom house where they currently lived. Andrea's older sister was a registered nurse who worked in a rural hospital. Andrea's two younger sisters were married and lived in semirural areas. Andrea's brother died in an accident a number of years earlier.

When Andrea approached us for help, she was studying full time to obtain a certificate in community care. Her studies had given her a new perspective on her life and made her less dependent on her mother in that she had taken a step toward independence. Andrea had previously seen two other counselors, both of whom advised her to leave home and live independently. Although Andrea saw advantages in moving, she felt responsible for her mother and felt guilty whenever she considered leaving. Andrea was not close to her sisters. Although they were aware of their mother's drinking, her sisters offered little practical or emotional support. Andrea's minimal social life consisted of being a delegate to church conferences, teaching Sunday School, and taking part in other church activities.

Mrs. D also attended church regularly and participated in church functions, including a ladies' auxiliary. Since her surgery, however, Mrs. D attended church less often and had reduced her involvement in other church activities. Mrs. D had recently joined a cancer support group and planned to attend regular meetings. Andrea was hopeful that involvement with the group would enable her mother to regain interest in life. Andrea reported that her mother no longer cared about her appearance because she believed the mastectomy had made her ugly and she could see no reason for trying to look attractive. Mrs. D had a keen interest in gardening but had little mobility as a result of her health problems. Her garden had been left untended and untidy.

Andrea traced her mother's heavy drinking back 12 years, noting an increase at the time of her brother's death. Mrs. D sometimes acknowledged that she drank too much but she had never tried to reduce her intake or sought formal treatment for alcohol dependence. According to Andrea, Mrs. D's contact with her grandchildren had become less frequent because Andrea's sister felt the children were not safe when Mrs. D was drunk. Although the reason for the reduced contact had never been explained to Mrs. D, the situation was a source of sadness for her. Mrs. D had some elderly relatives in a nursing home but had no means to visit them. Her only companions were neighbors who, according to Andrea, also drank excessively.

Assessment

Upon arrival at the assessment interview, Andrea was administered an adapted version of the 13-item SMAST (Selzer, Vinokur, & van Rooijen, 1975), in which the pronoun of each question was altered from "you" to "he or she" to ascertain Andrea's perception of her mother's alcohol dependence. A score of 3 or higher of a possible 13 is generally taken as evidence of alcohol dependence, so Mrs. D's score of 6 was well inside the realm of dependent drinking. In addition to the SMAST, Andrea was asked to complete a drink diary describing her mother's drinking for the week immediately preceding the assessment interview. For each day of the week, Andrea used a four-point scale to indicate whether her mother (1) drank no alcohol, (2) drank only moderately, (3) was obviously intoxicated, or (4) collapsed. The scale showed that on one day of the previous seven days, Mrs. D had drunk moderately, on another day she had been obviously intoxicated, and on five days she had drunk to a state of collapse. According to Andrea, her mother drank beer and burgundy, and because Andrea was responsible for cleaning the house and throwing out the bottles, she was quite precise about the amount her mother was drinking. Mrs. D had consumed 2 four-liter casks of wine and 42 bottles (30.5 litres) of beer during the week immediately preceding treatment. Andrea stated that this level of consumption was typical. Mrs. D generally drank several bottles of beer with lunch. After lunch, she spent the afternoon watching television serials while drinking burgundy with lemonade. The burgundy was purchased in four-liter casks, which, together with the beer, was generally delivered by a local wine shop. When Mrs. D's supplies ran low, Andrea sometimes went out to buy her another cask of wine.

To gauge the extent of problems caused by her mother's drinking, Andrea was administered the 12-item Drinker's Partner Distress Scale (DPD) (Barber & Crisp, in press). The DPD asks significant others to indicate on five-point scales the type and level of distress caused by the drinker's behavior. The DPD consists of two subscales: a seven-item depression subscale and a five-item relationship-discord subscale. Andrea scored 12 for both the depression and relationship discord subscales. Both scores were comparable to a normative sample of mainly female partners living with heavy male drinkers (mean depression = 11.93, sd = 5.36; mean discord = 10.94, sd = 5.02).

At the first interview, Andrea presented as highly stressed. She was eager to talk about her problems, which she attributed to her mother's drinking and consequent demands for care, time, extra work, and surveillance. Andrea defined her problems as lack of time to devote to her studies, lack of privacy, insufficient sleep, extra work in caring for her mother, and feelings of guilt associated with the conflict between her role as primary caregiver and her need to establish her own career and independence. Andrea reported that her studies had been disrupted to such an extent that she was considering withdrawing from some of her courses, which was a source of considerable distress to her because she was eager to complete her courses and find work. Her sleep was also disrupted by her mother's drinking. Andrea's bedroom opened off the kitchen, where Mrs. D spent most of her time. Even with the bedroom door closed, Andrea heard her mother moving about and groaning. Andrea often got up in the early hours of the morning to help her mother to bed, resulting in Andrea feeling tired and irritable the next day. Mrs. D performed very little housework, leaving most of these responsibilities as well as meal preparation for Andrea.

Intervention

Pressures-to-Change Approach

The pressures-to-change approach involves training significant others in how to use five levels of pressure on drinkers to encourage them to seek help or moderate their drinking. The five levels are arranged in ascending order, with the highest level (confrontation) reserved for use when all else has failed. The treatment is normally completed within four to six weeks; at each session clients are provided with pamphlets on the level of pressure covered in that session.

Level one: Feedback and education. The first level of pressure consists primarily of providing the client with feedback on his or her test scores. The objective at this stage is to maximize the client's motivation for change, prepare him or her for frustrations and setbacks, and explain the principles of the technique. Next, clients are introduced to the pressures-to-change approach itself. Treatment objectives are carefully explained as (1) helping clients cope by being more in control of their own reactions, (2) encouraging significant others to reduce their drinking, and/or (3) enticing their significant others into treatment. Facilitators explain how drinkers change as a result of pressure from their environment and how change is generally an iterative process.

This level makes use of Prochaska and DiClemente's (1988) notion of stages of change and prepares clients for the need to persist when progress is followed by a relapse. Facilitators stress that pressure does not mean nagging or controlling behavior. The difference between pressure and nagging is explained in general terms, and clients are instructed that pressures to change should not be confused with punishment. Facilitators emphasize that the client must not hold him- or herself accountable for the drinker's behavior. Clients are told that such ideas will always be challenged if they arise during treatment as a rationalization for significant others' drinking. Considerable pains are taken to emphasize that the intention of treatment is not necessarily to keep the relationship together. Rather, it is solely the client's decision whether he or she chooses to stay in the relationship. Finally, the notion of incremental pressure is introduced, and clients are provided with an overview of what will be covered in subsequent sessions.

Level two: Incompatible activities. Toward the end of the first session, clients are provided with a simple drink diary in which they are asked to record the following in the week ahead: (1) situations in which the drinker consumes alcohol, (2) whether the drinker becomes intoxicated, (3) the problems that the drinker's behavior creates for the client, and (4) the client's responses to the drinking behavior. This information is used to conduct a functional analysis of the drinker's behavior during the next session. Clients are taught to identify the drinker's high-risk periods (including the cues and consequences of drinking too much) and to plan incompatible activities to coincide with these occasions. As far as possible, the incompatible activities chosen seek to provide the drinker with some of the benefits of alcohol as identified by functional analysis. For example, when alcohol helps the drinker relax, the therapist would help the client identify other ways to relax that do not involve drinking.

Level three: Responding, On the basis of information obtained from drinking diaries, clients' responses to drinking are examined. Clients draw up a list of reinforcers that the drinker derives from the relationship (e.g., conversation, companionship, meal preparation, etc.) and are told how they can provide these reinforcers on a contingent basis. That is, when drinking becomes unacceptable, clients are instructed to point this out calmly and without rancor and then to remove all reinforcers. Ways in which to provide feedback to the drinker are discussed and rehearsed, with the aim of teaching drinkers how to discriminate between acceptable and unacceptable levels of alcohol consumption. In addition to learning how to respond when drinkers are sober or intoxicated, clients are taught to recognize and exploit times of crisis when the drinker may be responsive to the idea of treatment. Clients are provided with a 24-hour telephone number that the drinker can use should he or she become distressed enough to call. If the drinker becomes hostile or resistant, clients are instructed to remove themselves from the interaction and not pursue the issue further at that time.

Level four: Contracting. Pressure on the drinker is increased by clients' negotiating an explicit drinking contract with the drinker. Contracts that commit drinkers to abstinence or moderation at high-risk times are particularly helpful. Sometimes these contracts involve a degree of quid pro quo, whereby the partner agrees to exchange some reinforcer(s) for sobriety. In most cases, however, this is not necessary because drinkers typically wish to prove that they do not have a drinking problem. Clients are told how to construct contracts that are difficult but not impossible to achieve. In the event that the contract is broken, a crisis may ensue. Thus, clients are reminded about the "exploiting-crises" skills learned during level three. Moreover, with each acknowledgment of failure to control their drinking, drinkers must reexamine their assumption that they do not have a drinking problem.

Level five: Confrontation, Finally, clients are introduced to a confrontation technique similar to that developed by Johnson (1973) and are told that level five should be used only after levels two through four have been tried and proven unsuccessful. It is reemphasized that confrontation does not mean arguing or bickering; it consists merely of providing feedback about the effects of drinking on persons close to the drinker.

Partners identify individuals closest to the drinker who are adversely affected by the drinker's behavior. Participants are then taught to write personal testimonials consisting of three parts: (1) a declaration of the author's love for the drinker, (2) feedback about the ways in which drinking diminishes their relationship, and (3) a simple, unambiguous plea for the drinker to change or seek help. A meeting is then arranged, with or without the facilitators, and these testimonials are read aloud to the drinker by each author in turn. In the present case, confrontation was not used. In fact, it should be used only when all other pressures fail to effect changes in the drinker's behavior.

Summary. Each session begins with clients reporting on the effectiveness of the strategies. Depending on the client's situation, some strategies are more effective than others, but lower-level strategies are pursued for a period before increasing the pressure. If strategies are ineffective, however, clients are encouraged to move on to the next level. Given that some of the strategies may run counter to familiar patterns of behavior, constant monitoring and rehearsal is necessary. Treatment is terminated when the drinker decides to change or seek treatment or when all the levels have been exhausted. On completing treatment, partners are invited to make telephone contact with the researchers should they wish to discuss progress or clarify any of the coping strategies.

Overview of Treatment Sessions

At the assessment interview, the pressures-to-change intervention was explained to Andrea, who indicated a good understanding of the underlying principles and expressed enthusiasm about participating in the program. The importance of being consistent made good sense to Andrea, who, as a result of other counseling, had tried verbally to assert her right to independence and reasonable living and studying conditions at home. Andrea was given printed materials describing the intervention.

In the second interview, Andrea displayed considerable anxiety about her personal problems and tended to direct the interview toward herself. She reported that she had made some progress by consistently responding to her mother's drinking behavior. She had also thought about incompatible activities and was planning some of these for the future. Mrs. D had drunk heavily throughout the week, and Andrea responded by terminating contact with her mother and leaving Mrs. D to look after herself. Andrea found this response difficult to maintain but reported satisfaction with her new sense of control. She had spoken to the parish priest and had elicited his help in getting Mrs. D to begin attending church regularly again as well as encouraging her to participate in an upcoming church function. Andrea had also arranged for her mother to tend a small, manageable section of the front garden where she would be able to experience pleasure without exceeding her physical capacities.

Andrea spoke to her sisters and explained her needs in relation to their mother's care. She felt they understood and that their relationships improved. Andrea considered contracting with her mother to arrange a family gathering marking the anniversary of her brother's death, which would allow her mother to spend time with her extended family. The condition for this gathering was that Mrs. D would either abstain from or at least limit her alcohol intake on that day.

Andrea's early attempts at responding consistently, initiating incompatible activities, and contracting were consolidated and rehearsed during the second session and reported on during the third session. Andrea reported that she had spoken to her mother about her need for quiet study time and adequate sleep and had contracted to help her mother to bed on the strict condition that this would be done by 10:30 P.M. Mrs. D agreed to this stipulation without protest. She also began to have meals ready when Andrea returned from college and to do more of the housework. Andrea reported that she rewarded these behaviors by expressing her appreciation and by sharing activities, such as going for walks together. Her mother's gardening proved to be a successful incompatible activity, at least in the short term: Mrs. D delayed drinking until after the day's gardening was done. When Andrea spent time in the garden with her mother, drinking was delayed even further, and Mrs. D was eager to return to the garden whenever she could. For her part, Andrea was careful to notice any work done by her mother and any reduction in Mrs. D's drinking, praising her mother on her progress.

Intervention was terminated after the fourth session when it was obvious that the combination of incompatible activities, responding, and contracting had produced a substantial reduction in Mrs. D's drinking. Andrea completed a drink diary for the week prior to this session, which indicated that Mrs. D had consumed alcohol on all seven days but on no occasion drank to the point of obvious intoxication. Based on the number of bottles and casks thrown out during the week, Andrea estimated that her mother was drinking approximately 50% of her baseline intake. Although her level of consumption was still too high, Andrea was satisfied with her mother's progress and felt confident that her own responses and her mother's apparently genuine effort to cut back on her drinking would result in further reductions in the weeks ahead. Andrea's distress scores had also declined from 12 for both the depression and relationship discord subscales of the DPD to 7 for depression and 8 for relationship discord.

Discussion

Because Mrs. D's behavior was no longer disruptive and the relationship between Andrea and her mother had improved markedly, Andrea felt that her mother's alcohol consumption had reached an acceptable level. Andrea was more comfortable with her situation and stated that she found caring for her mother easier. She also enjoyed sharing activities with her mother. Andrea reported a greater sense of control over her own responses and claimed that her major objectives had been achieved--adequate quiet study time and uninterrupted sleep. She expected to complete her year's schoolwork successfully. Andrea stated that she found responding, incompatible activities, and, to a lesser extent, contracting, easy to implement and that her sense of control over her mother's drinking enhanced her self-confidence. The ease with which Andrea understood and applied the levels-of-pressure intervention is encouraging and suggests that this technique can be extrapolated from partners to others in the drinker's social network.

Despite Mrs. D's progress, it is highly likely that she will suffer relapse at some point in the future. Relapse is the norm for all forms of addictive behavior (Costello, Biever, & Baillargeon, 1977; Emrick, 1914; Hunt, Barnett, & Branch, 1971). Even those persons who do manage to overcome their addiction normally do so only after trying and failing over an extended period (Prochaska & DiClemente, 1988). In Mrs. D's case, the likelihood of relapse seems particularly high given her apparent level of dependence and the fact that she was still drinking quite heavily when Andrea terminated treatment. However, whether Mrs. D eventually overcomes her addiction as a result of this particular intervention is beside the point. The objective of the pressures-to-change intervention is to initiate the process of change in previously resistant drinkers. Given this goal, the intervention was successful.

REFERENCES

Barber, J. G., Crisp, B. R. (in press). The pressures to change approach to working with the partners of heavy drinkers. Addiction.

Costello, R. M., Biever, P., & Baillargeon, J. C;. (1977). Alcoholism treatment programming: Historical trends and modern approaches. Alcoholism: Clinical and Experimental Research, I, 311-318.

Emrick, C. D. (1974). A review of psychologically oriented treatment of alcoholism: I. The use and interrelationships of outcome criteria and drinking behavior following treatment. Quarterly Journal of Studies on Alcohol, 35, 523-549.

Farid, B., Sherini, M. E., & Raistrick, D. S. (1986). Cognitive group therapy for wives of alcoholics. Drug and Alcohol Dependence, 4, 349-358.

Hunt, W. A., Barnett, L. W., & Branch, L. G. (1971). Relapse rates in addiction programs. Journal of Clinical Psychology, 27, 455-456.

Jacobson, N. S., Martin, M. B. (1976). Behavioral marriage therapy: Current status. Psychological Bulletin, 83, 540-557.

Johnson, V. W. (1973). I'll quit tomorrow. New York: Harper.

Prochaska, J. O., & DiClemente, C. C. (1988). Toward a comprehensive model of change. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Process of change. New York: Plenum.

Selzer, M. L., Vinokur, A., & van Rooijen, L. (1975). A self-administered Short Michigan Alcoholism Screening Tests (SMAST). Journal of Studies on Alcohol, 36, 117-126.

Sisson, R. W., Azrin, N. H. (1986). Family-member involvement to initiate and promote treatment of problem drinkers. Journal of Behavior Therapy and Experimental Psychiatry, 17, 15-21.

Thomas, E. J., Santa, C., Bronson, D., & Oyserman, D. (1987). Unilateral family therapy with the spouses of alcoholics. Journal of Social Service Research, 10, 145-162.

James G. Barber is Professor and Head of School, Robyn Gilbertson is a social worker, and Beth R. Crisp is a research fellow, School of Social Administration and Social Work, Flinders University, Adelaide, South Australia, Australia.

Copyright Family Service America Apr 1995
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