The 2014 Census Bureau recorded 323 million people living in the United States. Approximately six percent (17 million) are alcoholics—enough people to fill the entire state of Florida. This group and their loved ones will experience devastating consequences. On the positive side, most traditional treatments and self-help groups are geared for their recovery. However, there is an even larger group of people who struggle with alcohol use: the 22% who need a different kind of help. Their drinking may be beginning to affect their mood, relationships and productivity. They may have even gotten a legal charge, but they are not physically dependent on alcohol. This 22% encompasses a staggering 90 million people—the amount that resides in the Central Time Zone.
Moderation Management (MM), the first moderation-based support group recognized by the National Institute on Alcohol Abuse and Addiction (NIAAA) found that the 22% will avoid getting help for fear of being labeled an alcoholic, forced into treatment, made to attend 12-step meetings and have to stop drinking completely. As behavioral health providers, we need to find ways to assist this large number of alcohol users who are not yet experiencing addiction, but may be dealing with a mild or moderate alcohol use disorder.
There is a controversial, emerging treatment option: moderation. Moderation is described as a return from out of control or harmful drinking to consuming within safer drinking guidelines. Moderation has also been called moderate drinking, asymptomatic drinking, controlled drinking or reduced risk drinking.
The Dietary Guidelines for Americans defines moderate alcohol consumption as having up to one drink per day for women and up to two drinks per day for men. NIAAA offers another definition: up to four alcoholic drinks for men and three for women in any single day, according to and a maximum of 14 drinks for men and seven drinks for women per week. I have found NIAAA’s guideline to be more risky. Many people start to feel an effect of the alcohol after two drinks and may be intoxicated by four drinks, thus having a harder time sticking within his or her predetermined number of drinks.
A standard drink= 12ounces of beer=5ounces of wine=1.5ounces 80-proof liquor
Based on my 20 years experience of working with people experiencing problems from alcohol use, I developed the “How Do I Know If I Can Keep Drinking Quiz.” The quiz offers predictions for whether someone is a candidate for moderate drinking. It is personalized to the client’s specific experiences and goals and should be reviewed with someone who is trained in dual diagnosis as well as moderation.
Negative predictors for being able to moderate include: drinking daily, consuming to deal with emotions and having legal, employment or familial concerns. The worst predictor for being able to continue drinking is having withdrawals–potentially life threatening withdrawals such as delirium tremens “the shakes,” sweating, increased pulse, hallucinations and seizures. This reaction almost always means that the body has a physical dependence on alcohol and that the person likely meets Diagnosis and Statistical Manual 5 criteria for a severe alcohol use disorder, placing them into the six percent of the population who is physiologically unable to moderate.
Positive predictors that increase the chances for successful moderation include: experiencing a period of abstinence to develop and implement coping skills, monitoring amount and frequency of drinking and staying within the guidelines listed above and consuming when alcohol is part of a celebration and not the main focus.
Research shows that the number one predictor for being able to moderately drink is having a support system that can offer perspective, accountability and motivation. Another positive predictor is when a person has not had his/her first drink until after age 15. One study of more than 40,000 adults found that nearly half of the people who began drinking under age 15 met criteria for a severe alcohol use disorder while that percentage dropped to less than 10% if they waited until age 21.
Treatment providers need to be able to distinguish who is a candidate for moderation and who may be a severe alcohol user in denial. If it is determined that someone is not physically dependent on alcohol and is willing to do the work to attempt moderation, we need to give them tools, support, and accountability. First we need to help them understand understand why they were drinking, why they want to continue and ways to make it safer for them.
Tools for Success
Some tools for successful moderation include:
- Learning new ways to relax and have fun without alcohol
- Sipping slowly and enjoy the flavor. If you don’t’ enjoy it- don’t drink it.
- Alternating between alcoholic and non-alcoholic drinking
- Avoiding “shots”
- Putting money that would have been spent on drinks towards a fun event
Clinicians should also to prepare patients for how to drink again—something that is very unusual for addictions specialists to do! Some of my patients have been surprised at how they feel when they begin drinking again. For months, they faithfully tracked their clean days. It was a way to earn back trust from family members and increase their damaged self esteem from the past choices they made in relation to their drinking. As they resume alcohol use, clinicians need to be aware of the emotional impact as well as should watch out for any emerging mental health symptoms, an increase in amount and frequency, the impact of consumption and the intent of drinking.
If someone is trying to change his or her mood, it may be a slippery slope back to risky patterns.
Obviously, the safest known level of alcohol is no alcohol. If you do not drink, you do not face any further health, legal, social or familial problems.
Before developing a Moderate Drinking Plan with your client, I recommend that he or she:
- Has been educated about the biological, psychological and social consequences of his drinking on both him and the people in his life.
- Has not developed a physical dependence on alcohol.
- Can commit to not engaging in unsafe behavior after drinking any amount of alcohol, such as driving a vehicle, operating machinery, caring for another person and other such things.
- Does not misuse other mood-altering substances.
- Does not act in self-destructive ways after drinking even a small amount of alcohol.
- Has experienced a period of abstinence where he has identified triggers and made a plan to deal with risky situations.
- Has experienced a range of emotions and learned how to cope with negative ones and enhance positive feelings in healthy ways.
- Determined that it is safe to continue drinking.
- Chosen a support person to review and assist with accountability for the moderate drinking plan
Some components that I include on a Moderate Drinking Plan are:
- Why the client wants to continue drinking
- Situations where the client will not drink
- A time that the client will not start drinking until or after, such as not on weeknights or until the sun goes down and not driving after consuming.
- Alternating between an alcoholic and no-alcoholic drink
- Having no more than one drink per hour
- With whom you will review the plan
- If we notice, we will
The Moderate Drinking Plan should be revised as goals change and lifestyle demands. For example, as someone becomes a parent, his or her consumption patterns are likely to decrease. Parents of pre-teens and adolescents will want to be aware of the messages they are sending regarding alcohol. Obviously if a medical issue arises, the plan will need to be adapted. A Moderate Drinking Plan is not written in stone. We need to watch out for denial and involve a friend or family member in the moderation process. Once clients have successfully implemented their plan, I often move them into a maintenance phase of therapy. I will see them periodically to monitor progress and watch for relapses in risky patterns.
A simple tool that I use to help people monitor the efficacy of their plan is what I call the Gut Check. They can ask themselves questions regarding the following four areas.
Amount: Am I sticking to the amount I agreed upon? Often people find that they will say they will have two and find themselves pouring larger amounts and not being as aware in situations where someone else is refilling their glass.
Frequency: Am I finding more and more situations where I want to drink or situation where I can drink? Am I seeking it out? How do I feel when I don’t drink? There may be more work to do to address these areas.
Impact: When I drink what happens? Am I experiencing consequences? What are my loved ones saying about my drinking? They often can spot subtle changes in mood and behavior and catch things before they get out of control.
Intent: Why am I drinking? Do I truly enjoy the taste and the experience of my drink? Or am I trying to change my mood? Can you find other ways to celebrate, manage stress or mark the transition from work to relaxation?
Practicing moderation involves risk. I use an analogy that catches people off guard, but helps them gain perspective. Remember: alcohol is like eating donuts. Having one or two occasionally isn’t going to hurt you. But having a few every day is going eventually going to lead to serious consequences.
Moderation Management found that there are four times as many drinkers experiencing problems than people who drink at levels that meet criteria for a severe alcohol use disorder. They also note that nine out of 10 drinkers will not seek help—that’s 90%. There are varying degrees of alcohol use and consequences. Behavioral health care providers need to offer alternatives to the traditional models of alcohol treatment. While it may seem counterintuitive, by engaging your clients in a discussion about moderation as a treatment option, you might actually reduce their risk of becoming an alcoholic.
Cyndi Turner, LCSW, LSATP is the co-founder and clinical director of Insight Into Action Therapy and has been in the addictions field for more than 20 years. She co-developed and facilitates the Dual Diagnosis Recovery Program©, is an expert witness, a clinical supervisor for licensure and provides therapy for players involved in the National Football League Program for Substances of Abuse. Her book Can I Keep Drinking? How You Can Decide When Enough is Enough challenges the traditional belief that all drinkers experiencing problems must be alcoholics who need to quit drinking forever. www.canikeepdrinking.com or www.insightactiontherapy.com