Principal Investigator: William R. Miller, Ph.D.
Funding Agency: National Institute on Alcohol Abuse and Alcoholism (NIAAA)
This line of research extended for two decades, from initiation of the first clinical trial in 1974, to publication of long-term follow-up results for four clinical trials in 1992. The central goal of these studies was to develop an effective counseling method for problem drinkers who want to learn how to moderate their use of alcohol.
The first clinical study (Miller, 1978) was a randomized trial comparing three different outpatient treatment methods, all designed to help problem drinkers exercise greater self-control of their alcohol use. All three had been reported in prior studies to be effective in reducing alcohol use among heavy drinkers. The three methods compared were: (1) aversion therapy in a simulated bar setting, pairing drinking with self-administered electric shocks; (2) a more extensive treatment including blood alcohol concentration feedback, aversion therapy, and practice in moderation, again in a simulated bar setting; and (3) behavioral counseling in methods for self-control, offered in an ordinary counseling room. At follow-ups to 12 months, the simplest counseling method (3) proved to be at least as effective as the other two methods, requiring no use of alcohol, unpleasant aversion therapy, or simulated bar setting. At the end of treatment, patients were randomly assigned to receive or not receive a self-help guidebook (Miller & Mu�� 1976) for managing their own drinking behavior. To our surprise, those who were given the self-help manual showed significantly greater continued reduction in drinking after treatment.
This suggested a second randomized trial (Miller, Gribskov & Mortell, 1981), in which we compared outpatient behavioral self-control training (BSCT) with a control group receiving assessment and one consultation session, and given a self-help guidebook (Miller & Mu�� 1976). To our surprise, both groups of problem drinkers showed substantial reduction in drinking, with no significant outcome differences between groups.
Next we developed and evaluated a group treatment version of BSCT for problem drinkers. In this uncontrolled outcome study, we also observed significant reductions in drinking (Miller, Pechacek & Hamburg, 1981).
A fourth study (Miller & Taylor, 1980) was a randomized trial comparing the self-administered BSCT (bibliotherapy) from Study 2, individual outpatient BSCT, individual BSCT plus relaxation training, and group BSCT. (Clients were assigned to the group therapy condition not randomly, but after the other three conditions had been filled.) Once again all groups showed significant reductions in drinking, with no differences between groups. Across follow-up points to 12 months, the bibliotherapy group showed reductions equivalent to those of the three therapist-treated groups. As in prior studies, self-reports were confirmed by collateral interviews.
In the fifth study in this series (Miller, Taylor & West), we tested different intensities of treatment. Problem drinkers were randomly assigned to bibliotherapy, six outpatient sessions of BSCT, or one of two 18-week treatments combining BSCT with training in other coping skills. Once more outcomes were good in all groups, with an advantage of therapist-treated groups over bibliotherapy on one outcome measure. Those given 18-week coping skills training showed more improvement on life problems other than drinking, but similar reductions in alcohol use when compared with the 6-week BSCT group. Level of therapist empathy (as defined by Truax and Carkuff) proved to be a robust predictor of behavior change: clients of the most empathic counselors showed the largest reductions in drinking. These findings were maintained at 2-year follow-up (Miller & Baca, 1983), with bibliotherapy clients showing similar outcomes to those for counselor-treated clients.
This raised the question of whether behavior change might be just a product of the passage of time ? that problem drinkers who present themselves for counseling may reduce their drinking regardless of the treatment offered, or may be responding only to the reactivity of self-monitoring of drinking (which was part of both BSCT and bibliotherapy). Harris and Miller (1990) therefore compared self-guided bibliotherapy and counselor-guided BSCT with two control groups in a randomized trial. Both control groups were asked to wait 10 weeks for treatment. One group simply waited; the other kept and submitted self-monitoring weekly records of their drinking. Neither control group showed a reduction in drinking, whereas both self-guided and counselor-guided BSCT groups showed substantial and similar change as before.
Longer-term follow-ups we completed for four of these trials for periods ranging from 3 to 8 years after treatment (Miller, Leckman, Delaney & Tinkcom, 1992). At each follow-up point, approximately 15% of clients had maintained moderate and problem-free drinking for at least the 12 months prior to interview. Another 15% showed similarly large reductions in their volume of consumption, but continued to experience one or more problems related to their drinking. Approximately one-third had abstained from alcohol for at least the preceding 12 months. Many who were abstaining reported that their initial experience in attempting moderation had helped them decide to abstain.
A doctoral dissertation compared the effects of assigning problem drinkers at random to moderation versus abstinence goals (Graber & Miller, 1988). No effects of goal assignment were found. Clients seemed to feel equally free to reject the assigned goal, whether it was abstinence or moderation.
A pilot study with at-risk Native American high school students evaluated the feasibility of BSCT procedures in reducing alcohol use (Carpenter, Lyons & Miller, 1985). Modest effects were reported.
Across all of these studies, we observed that clients who succeeded in maintaining moderate and problem-free drinking were those whose alcohol problems had been less severe prior to treatment, whereas those who ultimately abstained showed more severe alcohol problems at intake (Miller & Joyce, 1979; Miller et al., 1992; Ogborne, Annis & Miller, 1982). There were also trends for higher rates of problem-free moderation among women, and for those with less family history of alcoholism.
References:
Funding Agency: National Institute on Alcohol Abuse and Alcoholism (NIAAA)
This line of research extended for two decades, from initiation of the first clinical trial in 1974, to publication of long-term follow-up results for four clinical trials in 1992. The central goal of these studies was to develop an effective counseling method for problem drinkers who want to learn how to moderate their use of alcohol.
The first clinical study (Miller, 1978) was a randomized trial comparing three different outpatient treatment methods, all designed to help problem drinkers exercise greater self-control of their alcohol use. All three had been reported in prior studies to be effective in reducing alcohol use among heavy drinkers. The three methods compared were: (1) aversion therapy in a simulated bar setting, pairing drinking with self-administered electric shocks; (2) a more extensive treatment including blood alcohol concentration feedback, aversion therapy, and practice in moderation, again in a simulated bar setting; and (3) behavioral counseling in methods for self-control, offered in an ordinary counseling room. At follow-ups to 12 months, the simplest counseling method (3) proved to be at least as effective as the other two methods, requiring no use of alcohol, unpleasant aversion therapy, or simulated bar setting. At the end of treatment, patients were randomly assigned to receive or not receive a self-help guidebook (Miller & Mu�� 1976) for managing their own drinking behavior. To our surprise, those who were given the self-help manual showed significantly greater continued reduction in drinking after treatment.
This suggested a second randomized trial (Miller, Gribskov & Mortell, 1981), in which we compared outpatient behavioral self-control training (BSCT) with a control group receiving assessment and one consultation session, and given a self-help guidebook (Miller & Mu�� 1976). To our surprise, both groups of problem drinkers showed substantial reduction in drinking, with no significant outcome differences between groups.
Next we developed and evaluated a group treatment version of BSCT for problem drinkers. In this uncontrolled outcome study, we also observed significant reductions in drinking (Miller, Pechacek & Hamburg, 1981).
A fourth study (Miller & Taylor, 1980) was a randomized trial comparing the self-administered BSCT (bibliotherapy) from Study 2, individual outpatient BSCT, individual BSCT plus relaxation training, and group BSCT. (Clients were assigned to the group therapy condition not randomly, but after the other three conditions had been filled.) Once again all groups showed significant reductions in drinking, with no differences between groups. Across follow-up points to 12 months, the bibliotherapy group showed reductions equivalent to those of the three therapist-treated groups. As in prior studies, self-reports were confirmed by collateral interviews.
In the fifth study in this series (Miller, Taylor & West), we tested different intensities of treatment. Problem drinkers were randomly assigned to bibliotherapy, six outpatient sessions of BSCT, or one of two 18-week treatments combining BSCT with training in other coping skills. Once more outcomes were good in all groups, with an advantage of therapist-treated groups over bibliotherapy on one outcome measure. Those given 18-week coping skills training showed more improvement on life problems other than drinking, but similar reductions in alcohol use when compared with the 6-week BSCT group. Level of therapist empathy (as defined by Truax and Carkuff) proved to be a robust predictor of behavior change: clients of the most empathic counselors showed the largest reductions in drinking. These findings were maintained at 2-year follow-up (Miller & Baca, 1983), with bibliotherapy clients showing similar outcomes to those for counselor-treated clients.
This raised the question of whether behavior change might be just a product of the passage of time ? that problem drinkers who present themselves for counseling may reduce their drinking regardless of the treatment offered, or may be responding only to the reactivity of self-monitoring of drinking (which was part of both BSCT and bibliotherapy). Harris and Miller (1990) therefore compared self-guided bibliotherapy and counselor-guided BSCT with two control groups in a randomized trial. Both control groups were asked to wait 10 weeks for treatment. One group simply waited; the other kept and submitted self-monitoring weekly records of their drinking. Neither control group showed a reduction in drinking, whereas both self-guided and counselor-guided BSCT groups showed substantial and similar change as before.
Longer-term follow-ups we completed for four of these trials for periods ranging from 3 to 8 years after treatment (Miller, Leckman, Delaney & Tinkcom, 1992). At each follow-up point, approximately 15% of clients had maintained moderate and problem-free drinking for at least the 12 months prior to interview. Another 15% showed similarly large reductions in their volume of consumption, but continued to experience one or more problems related to their drinking. Approximately one-third had abstained from alcohol for at least the preceding 12 months. Many who were abstaining reported that their initial experience in attempting moderation had helped them decide to abstain.
A doctoral dissertation compared the effects of assigning problem drinkers at random to moderation versus abstinence goals (Graber & Miller, 1988). No effects of goal assignment were found. Clients seemed to feel equally free to reject the assigned goal, whether it was abstinence or moderation.
A pilot study with at-risk Native American high school students evaluated the feasibility of BSCT procedures in reducing alcohol use (Carpenter, Lyons & Miller, 1985). Modest effects were reported.
Across all of these studies, we observed that clients who succeeded in maintaining moderate and problem-free drinking were those whose alcohol problems had been less severe prior to treatment, whereas those who ultimately abstained showed more severe alcohol problems at intake (Miller & Joyce, 1979; Miller et al., 1992; Ogborne, Annis & Miller, 1982). There were also trends for higher rates of problem-free moderation among women, and for those with less family history of alcoholism.
References:
- 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.
- 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. (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., & Baca, L. M. (1983). Two-year follow-up of bibliotherapy and therapist-directed controlled drinking training for problem drinkers. Behavior Therapy, 14, 441-448.
- 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., & 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., 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., & Mu�� R. F. (1976). How to control your drinking. Englewood Cliffs, NJ: Prentice-Hall.
- 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., & 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.
- Ogborne, A. C., Annis, H. M., & Miller, W. R. (1982). Discriminant analysis and the selection of patients for controlled drinking programs: A methodological note. Journal of Clinical Psychology, 38, 213-216.
