Alcohol Dependence Treatment

The most recent US Department of Health and Human Services National Survey on Drug Use and Health (2006),1 reports 18.2 million persons age 12 or older met the criteria for alcohol dependence in 2005. Although the estimated economic costs of alcohol abuse are not available for 2005, they were $184.6 billion in 1998, which represented a 25% increase from 1992.2

Major contributing factors in these estimates included lost earnings due to alcohol-related illness ($86.4 billion) and premature death ($36.5 billion).2 The 2005 National Survey on Drug Use and Health estimated that 22.2 million Americans were classified with substance dependence—15.4 million of whom were dependent on or abused alcohol but not illicit drugs, whereas 3.3 million were classified with dependence on or abuse of both alcohol and illicit drugs.

Only 3.9 million people received treatment for a problem related to the use of alcohol or illicit drugs in 2005—1.3 million for the use of alcohol but not illicit drugs, plus an additional 1.5 million for the use of both alcohol and illicit drugs. Fewer than one-third (1.1 million) were treated in an inpatient facility. Of the more than 18 million people who did not receive treatment, nearly 1 million felt they needed treatment services but made no effort to seek treatment.

So where does this leave the person who seeks help? The current state of healthcare and medical insurance in this country is such that the majority of people seeking treatment for addictions visit their primary care physician or local emergency room for the initial evaluation. Unfortunately, most patients do not recognize they have a potential problem and may not disclose alcohol

or substance use history information to medical professionals. It is up to medical professionals to recognize the contributing symptoms of alcoholism and be knowledgeable about the treatment options that may be available to patients.

Medical professionals must understand the critical role they play in recognizing the signs of alcoholism and helping patients suffering from alcoholism gain access to treatment (a comprehensive review may be found). A comprehensive treatment approach must include a medical, pharmacologic component coupled with a psychosocial behavioral management plan.

Psychosocial support (such as counseling) is a necessary element in alcohol treatment. The exclusion of one aspect over another or the elevation of one aspect over another does an immense disservice to the person in distress.

How best to manage and apply both approaches is the primary goal in the management and treatment of the person in need. This article details the psychosocial management of addiction.

Alcohol Dependence Defined

To understand the importance of utilizing a combined medical and psychosocial approach to alcohol treatment, healthcare

professionals should look to the definition of alcohol dependence approved by the American Medical Association (AMA), and the diagnostic criteria presented by the American Psychiatric Association (APA) in its publication, the Diagnostic and Statistical Manual IV-TR.

In 1957, the AMA declared alcoholism a disease not unlike other diagnosable illnesses, such as diabetes. The defining work was done by Elvin Jellinek, MD, of the Yale Center of Alcohol Studies. In his book, The Disease Concept of Alcoholism,

published in 1960, Jellinek described alcoholics as individuals with tolerance, withdrawal symptoms, and either “loss of control” or “inability to abstain” from alcohol. This disease exhibits both physical and behavioral symptoms. The former include tolerance, physical dependence, and pathologic organ change.

The latter include loss of control, compulsion, and continued use despite negative consequences. These identified symptoms have been incorporated by the APA into its diagnostic criteria for substance dependence (cf. DSM IV-TR). Medical professionals are often the first to recognize a patient who presents with alcoholism and to recommend treatment options. In recent years, there have appeared several effective pharmacotherapy options that are indicated for this course of treatment.

Most of the pharmacotherapy options operate in the chemical pathways of the brain to primarily curb the cravings of the person suffering from alcoholism. However, there are also other important aspects of alcohol dependence, as indicated in the

definition of the disease offered by the National Institute on Alcohol Abuse and Alcoholism. The curbing of cravings is vital to a person’s sobriety, yet if that person’s thought processes and behaviors are not modified, he or she will either resume drinking or will be miserable, as the reasons for drinking will continue to exist, but the drink will not be present to numb the reality. This

condition is commonly referred to as the “dry drunk” syndrome. As will be demonstrated later, the use of pharmacotherapy

is vital to assist a person in maintaining sobriety long enough to receive the proper psychosocial treatment. Once the alcoholic is sober, with the assistance of pharmacotherapy, traditional psychotherapy is possible.

Psychosocial Techniques

In recent years, the use of various cognitive and behavioral approaches has proven effective in helping alcohol-dependent

persons maintain sobriety. These psychosocial support techniques can be incorporated into both individual and group therapies. The approaches utilized in both of these settings involve the use of homework assignments and didactic experiences. The former not only personalizes the treatment, but also provides continuity from session to session. Didactic experiences provide

the patient with knowledge about the disease that will enable him or her to begin to understand its complexity.

Patients are also taught about their irrational thought patterns, learning coping techniques for situations or feelings that previously prompted them to drink. The addict “is taught deconditioning techniques, stress reduction exercises, and communication skills, as means to dissipate the craving response when it arises. Because environmental triggers or cues often precipitate drug cravings, addicts are taught to recognize their individual triggers, develop mechanisms to avoid those cues, and learn strategies

to prevent use.”

Treatment, at its most affective, consists of the following critical components: assessment, patient-matching, relapse prevention,

and comprehensive services.

Assessment

The assessment phase of treatment can begin in the office of the primary care physician and should include a history and physical examination, along with a brief family history that may reveal the criteria for alcohol dependence.

Patient-Matching

Once patients enter into the treatment milieu, it is not as important for the patient to be a willing participant in this process per se, but important for the patient to feel a connection with the person providing the necessary services.

Relapse Prevention

As the potential for relapse is quite high in many cases, treatment needs to incorporate relapse-prevention techniques.

Comprehensive Services

In What Works for Whom? A Critical Review of Psychotherapy Research, Roth and Fonagy note that: “… treatments

with good evidence of effectiveness include: social skills, self-control, and stress management training; brief motivational interviewing; … and a community reinforcement approach.”

Combining individual and group therapy with community resources ensures that the patient suffering from alcohol dependence receives the comprehensive treatment necessary for sobriety.

Individual Therapy

Recent studies examining the effectiveness of treatment for alcohol dependence point to the use of cognitive behavioral therapies as the most effective forms of treatment for this population. “CBT (Cognitive Behavioral Therapy) assumes that substance abusers are deficient in coping skills; [and] choose not to use those they have …”

With CBT, the therapist guides the patient through their thought process, examining those areas in need of modification. The

essential belief of CBT is that humans are happiest when we establish and then actively strive to attain important life goals. Accordingly, we become disturbed not by things or situations, but rather by our beliefs about those things or situations.

“One develops anxiety not because of unconscious motivations, but because one has learned inappropriate ways of

handling life experiences.” It is believed that we make absolute demands upon ourselves and the world (referred to as

“irrational musturbatory evaluations”). The inability to live up to these expectations therefore creates anxiety. Patients suffering from alcohol dependence are said to use the effects of alcohol as the learned coping technique for dealing with this anxiety. The role of the therapist, in an active-directive manner, is to lead patients to identify the philosophic source of their issues, and through didactic techniques, aid them in challenging and changing their thought processes.

The trained therapist, working in this manner, possesses many characteristics, some of which include genuineness, empathy, modeling the desired behavior, and an appropriately humorous outlook. It is important for the therapist to guide patients on the

path toward solutions, rather than direct or tell them what they need to do. It is presumptuous of the therapist to believe he or she knows the patient better than the patient knows himself.

It is the position of the therapist, therefore, to guide patients to the solutions already existent within themselves. [cf. Solution-Focused Brief Therapy] Those suffering from alcohol dependence have greater odds of following their own solutions rather than the solutions given to or imposed on them. Therefore, the therapist who guides the patient to his or her own solutions provides

long-lasting tools for the patient’s recovery, because these tools are now to be found within the learned thought process of the patient.

Utilizing CBT allows the therapist to stress personal responsibility on the part of the patient. In so doing, the use of defense mechanisms by the patient is thereby diminished. It should now be evident as to the need for pharmacotherapy in conjunction with CBT. A patient encountering multiple, intense cravings, or continuing to drink, will not benefit from CBT. This person, still under the influence of alcohol, will be unable to process his or her thoughts and not learn to break his or her defense mechanisms.

Group Therapy

Group therapy is defined as “a meeting of two or more people for a common therapeutic purpose or to achieve a common goal.” Since the inception of Alcoholics Anonymous in 1935, those attempting sobriety have found solace, comfort, and support in meeting as a group “in an atmosphere of support and hopefulness.” The group process breaks the isolation experienced by many while in the throes of their active addiction. It is a forum for people to recognize they are not alone in their struggles, and to celebrate with others their own personal successes along the road of recovery.

Levine and Gallogly have noted that groups specific to alcohol-dependent patients help reduce denial, increase motivation, and increase the capacity to recognize, anticipate, and cope with situations that may precipitate drinking behavior. Research suggests that the use of short-term group therapy (2-3 months) has the potential to be as successful as longer term group therapy.

Group therapy utilized on a short-term basis should be more goal-oriented, structured, and directive.

Once it is determined whether the patient will attend long-term or short-term group therapy, there are two distinct group modalities from which to choose: task-oriented and CMRPT (CENAPS Model of Relapse Prevention Therapy). Task-oriented groups rely on the group participants themselves to act as the group leaders, with the therapist acting more as an observer. The rationale behind this approach is that the more involved the therapist becomes in the working of the group, the more dependent are the members upon the therapist. Task-oriented groups are structured, revolving around completing specific tasks by following the predescribed group procedure. The group procedure is known to all participants prior to group session.

CMRPT is “a clinical procedure that integrates the disease model of chemical addiction and abstinence-based counseling methods with recent advances in cognitive, affective, behavioral, and social therapies.” This method utilizes problem solving through the use of group rules, group responsibility, and a standard group format. This is similar to the task-oriented groups,

yet focuses on identifying problems so as to identify alternative coping skills, then learning how to take action on these new skills. In this group modality, the therapist plays a greater role in the functioning of the group, yet is not necessarily the leader.

In his classic work, Theory and Practice of Group Psychotherapy, Irvin Yalom identified 11 “therapeutic factors”

in group therapy.11 These include:

Instillation of hope Universality (versus isolation)

Imparting of information

Altruism

Imitative behavior

Catharsis

Yalom believed these to be “curative” factors that are present in all group interventions. How the therapist utilizes these curative factors will have a direct result on the quality of the group therapy. It should be noted that these factors encompass many aspects of a person’s life. The addition of pharmacotherapy rounds out the effective management plan. Effective treatment of alcoholism, as the disease is defined, approved, and endorsed by both the AMA and APA, requires a comprehensive management plan consisting of medical support supplemented with psychosocial treatment.

Christopher Shea is the clinical director of Fr. Martin’s Ashley, one of the country’s leading residential alcohol and drug rehabilitation facilities.