Contemporary Behavioral & CBT approaches to alcohol abuse (overview)

A recent request for proposals from NIH included this summary of contemporary approaches to treating alcoholism:

Most of the treatments available in the U.S. for alcoholism have been behavioral in nature. A large number of clinical trials conducted over the past 15 years have demonstrated effectiveness for several types of behavioral therapies, including cognitive behavioral therapy, motivation enhancement therapy, marital family therapy, brief interventions, and community- reinforcement approach (Hester and Miller, 1995; Fuller and Hiller-Sturmhofel, 1999; National Institute on Alcohol Abuse and Alcoholism, 2000).

Cognitive behavioral coping-skills therapy which aims to improve the patient’s skills for changing their problematic drinking behavior, has been successful in improving treatment outcome in alcoholic patients (Longabaugh and Morgenstern, 1999). Nonetheless, it has been suggested that its effectiveness can be increased by integrating it with components of other treatment approaches, such as motivational interviewing (Longabaugh and Morgenstern, 1999). This strategy is currently being implemented and tested by COMBINE, an ongoing 11-site randomized clinical trial, conducted as a cooperative agreement by NIAAA.

Motivational enhancement therapy was developed in Project MATCH and involves strategies to motivate patients to stop or reduce their drinking. Surprisingly, motivational enhancement therapy proved nearly as effective as the more intensive cognitive behavioral and twelve-step facilitation therapies in reducing the frequency and amount of drinking in alcohol dependent patients (Project MATCH Research Group, 1998). Motivational interviewing, a component of the motivational enhancement therapy, also appears to aid engagement and retention of patients in treatment (DiClemente et al., 1999; Miller, 1995).

Twelve-step facilitation interventions have been demonstrated to be effective in promoting abstinence and in increasing patient’s involvement in Alcoholics Anonymous (AA) programs (Humphreys, 1999). Results from Project MATCH showed that AA attendance was associated with more favorable treatment outcomes in all three therapies (Project MATCH Research Group, 1998).

Brief interventions have been successful in reducing drinking levels in patients at risk for or experiencing alcohol-related problems (Fleming and Manwell, 1999; Wilk et al., 1997; Bien et al., 1993). The therapy consists of providing brief counseling to patients by a physician or nursing staff in five or less office visits.

Marital family therapy appears helpful in enhancing treatment retention and improving drinking outcome. For example, behavioral couple therapy which employs a “sobriety contract” with the spouse, teaches marital communication, and emphasizes shared activities and positive feelings, increased abstinence and reduced couple separations and domestic violence (O’Farrell and Fals- Stewart, 2000).

The community reinforcement approach provides positive reinforcement for sobriety, eliminates reinforcers for drinking, and teaches new coping behavior. Studies have demonstrated that the community reinforcement approach is more successful in reducing drinking than traditional outpatient treatments (Miller et al., 1999). Integrating the community reinforcement approach with family therapy also appears promising (Smith et al., 2001).

Contingency management encourages behavioral change in drinking by either presenting patients with positive reinforcements (e.g., money, vouchers, and prizes) for meeting treatment goals or employing adverse consequences when patients relapse to drinking (e.g., withholding of vouchers and writing an unfavorable report to a parole officer). Although contingency management has been successfully used to reduce illicit drug use, researchers have only recently applied this technique to alcoholism. So far, results have been positive in retaining alcohol dependent patients in treatment and in reducing their drinking behavior (Higgins and Petry, 1999).

Finally, cue-exposure therapy involves exposing a patient to alcohol-related cues during therapy. Although few studies have investigated its effectiveness for alcoholism treatment, the results, so far, have been promising (Monti and Rohsenow, 1999).

Thus, progress has been made in a broad range of behavioral interventions to treat alcohol abuse and dependence. Still, many alcoholics do not respond adequately to currently available behavioral therapies.

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