Goal Setting: Abstinence, Moderation and Reduced Drinking

Identifying and agreeing upon treatment goals regarding alcohol consumption is an important step for many patients. 

Patients with no or low levels of dependence who are not experiencing significant or irreversible alcohol-related harms may be able to achieve a goal of moderation. Consumption within NHMRC guidelines can be recommended, as it is associated with less than 1% risk of serious alcohol-related harms. Patients that self-select abstinence as the goal of treatment show more favourable outcomes at follow-up than those that select moderation and no specific goal. Abstinence should, therefore, be suggested as an outcome for patients with no set goal for treatment. 

The most realistic drinking goal for patients with severe alcohol dependence and/or those presenting with associated problems (such as organ damage, cognitive impairment and co-existing mental health problems) is likely to be abstinence. For many such patients, achieving abstinence will be accompanied by the risk of alcohol withdrawal syndrome. If this is the case, it should be managed before longer-term abstinence or reduced drinking can be achieved (see Chapter 8 Alcohol withdrawal management). 

In clinical practice, patients often present with firm ideas about their drinking goal. They may wish to drink at levels that can continue to cause harm, or may not be realistically sustained. Several options can be considered when a patient’s expressed preference for moderation is at odds with clinician advice. When serious consequences from continued alcohol use are highly likely, options include: 

• • • declining assistance and explaining that it would be unethical for you to support such a goal; this approach is unlikely to engage or retain the patient in treatment 

    • accepting the goal provisionally and for a stipulated period 

    • negotiating a period of abstinence (for example, 1 to 3 months) to allow the patient to get through withdrawal (if relevant), provide some recovery from the effects of alcohol, and provide time to acquire new skills, such as controlled drinking strategies 

    • agreeing to gradually reduce drinking to achieve abstinence, setting realistic, intermediate goals and monitoring the number of drinks consumed daily 

    • negotiating a period of trial moderation, include daily drink monitoring and controlled drinking strategies (coping skills training). 

Ongoing review and monitoring of drinking against identified goals is central to successful intervention. If the goals are too difficult to achieve, abstinence may seem a more reasonable goal; this should be clearly identified and agreed upon with the patient from the outset. 

Some interventions require protracted but important negotiations for goal setting. For strategies to manage patients who continue to drink at harmful levels, see Chapter 9 and Chapter 10.