Alcohol Use Disorders

Alcohol Abuse Alcohol Dependence A Maladaptive pattern of

drinking, leading to clinically significant impairment or distress, as manifested by at least one of the following occurring within a 12-month period: Recurrent use of alcohol

resulting in a failure to fulfill major role obligations

Recurrent alcohol use in situations in which it is physically hazardous

Recurrent alcohol-related legal problems

Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol).

Need for markedly increased amounts of alcohol to achieve intoxication or desired effect

The characteristic withdrawal syndrome for alcohol

Drinking in larger amounts or over a longer period than intended.

Persistent desire of one or more unsuccessful efforts to cut down or control drinking

Important social, occupational, or recreational activities given up or reduced because of drinking

A great deal of time spent in activities necessary to obtain, to use, or to recover from the effects of drinking

Continued drinking despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to be caused or exacerbated by drinking..

Overview of Alcohol Use Disorders

Theoretical Model – 7 Major Considerations1. Problem severity2. Concomitant life problems3. Client expectations4. Motivation and the therapeutic relationship

FRAMES Motivation Enhancement Feedback Responsibility Advice Menu Empathic Self Efficacy

5. Variables maintaining the current drinking problem6. Social support systems7. Maintenance of change

Marlatt and Gordon’s (1985) relapse prevention Model or Disease Model

Steps in TreatmentCase identification and

motivation to enter TxAssessmentSelection of Tx settingSelection of Tx

modalitiesEnhancing and

maintaining motivation to change

Selection of drinking goals

Initiation of abstinence

Developing a functional analysis

Early sobriety strategies

Coping strategiesPartner/Family

involvementLong-term

maintenanceManaging

complicating conditions

Self-help groups

Case IdentificationCAGE

2 affirmative answers suggest a high probability for an alcohol use disorder.

AUDITMay be useful for clients who are

reluctant to self-identify drinking problems.

Motivating a DrinkerMotivational interviewingInvolve family and concerned others

Confrontation/interventionOther “creative approaches”

Assessment ToolsTimeline Follow-Back Interview (TFBI)Structured Clinical Interview for DSM-IV

(SCID)Alcohol Dependence Scales (ADS)Addiction Severity Index (ASI)Readiness to Change Questionnaire (RCQ)Drinking Patterns Questionnaire (DPQ)Inventory of Drinking Situations (IDS)

Selection of Treatment SettingResidential rehabilitation

Usually 28-30 daysHistorically was the treatment of choice

Outpatient programsNow the most common settings for

treatment, but there are factors to consider

A myriad of stepped-care considerations

Selection of Treatment Modalities

Self-Help GroupsIndividual TherapyGroup TherapyCouple TherapyFamily TherapyIntensive Treatment Programs

Enhancing and Maintaining Motivation to Change

Techniques:FeedbackUse of motivational interviewingMutual goal setting and decision

makingTreatment contracting Instillation of hope

Selection of Drinking GoalsAbstinenceModeration training

Although controversial, a number of studies suggest that the long-term outcomes of alcoholism include reduced drinking

Studies have found that giving clients a choice in treatment goals increases compliance with treatment

Initiation of AbstinenceInpatient detoxificationAmbulatory detoxification“Cold Turkey” detoxificationGraduated program of reduction of

drinking until the client reaches abstinence

Developing a Functional Analysis

Assesses the antecedents to and the consequences of the client’s drinking

Incorporates clinical interviewing, questionnaires, and self-recording of drinking and drinking urges

Early Sobriety StrategiesCBT techniques include:

Stimulus control Dealing with urgesAddressing cognitive distortions

about alcoholAlternative/Distracting behaviors Identifying alternative ways to obtain

reinforcersDrink refusal skills

Coping StrategiesDealing with negative affect

Many clients have used alcohol as self-medication, so alternative strategies must be learned

Strategies include relaxation, prayer or meditation, increasing the experience of pleasurable events, or the use of anger management or assertiveness skills to cope with angry feelings

Partner/Family InvolvementInformationResponses to drinking and

abstinenceDecreasing cues for drinkingSupport for abstinenceAccessing new social systems

Long-Term MaintenanceRelapse Prevention

2 Basic strategies are used:First, the client develops a list of signs of an impending relapse

Second, the client must develop an appropriate response to drinking

Maintaining Contact with ClientsEspecially important for alcohol dependence, as it is viewed as a chronic disorder with high relapse rates

Managing Complicating Conditions

Clinicians must develop a treatment plan with the multiple, complicated needs of their clients in mind

Complications include transportation, income, employment, the legal system, the family, child care, and other comorbid psychological disorders

Self-Help GroupsClients should be good candidates for group therapy

Even if the client is a good candidate, group therapy should not be forced if the client is adamantly reluctant

Other VariablesTherapist variables

Rather than a confrontational style, an empathetic, motivational style is associated with better treatment outcomes

Client variablesClients who have positive

expectations about treatment and a greater readiness of change have more positive outcomes

ConclusionsThere are a wide variety of assessment

tools available to assist with alcohol use disorders

Treatment is planned depending on the nature and severity of the client’s drinking

Complete abstinence is not the only option

Complying with homework assignments, coming to sessions sober, and being honest about drinking behavior are good predictors of a “success”

EfficacySelf Help AA Meetings

Pagano, White, Kelly, Stout &Tonigan (2012)226 Partcipants over 10 years in AA groupAlcohol consumption and AA

participation, assessed at baseline, end of the 3-month treatment period,

Also assessed at 1, 3, and 10 years post treatment

Results showed significant direct effects of AA meeting attendance on reduced alcohol outcomes

Efficacy Cont.A Randomized Trial of Individual and Couple

Behavioral Alcohol (McCray, Epstein, Cook, Jensen & Hildebrandt 2009)

This study was for women only with 102 heterosexual participants

It accessed percentage of days abstinent (PDA) and percentage of days of heavy drinking (PDH) over 6 months of treatment as well as a 12 month follow-up

In both treatment conditions, women increased their PDA and decreased their PDH with significantly greater outcomes in the Alcohol Behavioral Couples Treatment (ABCT) in comparison to the Alcohol Behavioral Individual Treatment (ABIT) with maintained results at follow-up

Efficacy cont.Group Vs. Individual Cognitive-Behavioral

Motivational Intervention For Substance AbuseSobell Sobell, Agrawal (2009)

Study consisted of 52 drug abusers and 212 alcohol abusers who were given a guided self-change (GSC) treatment a CBT Motivational intervention

Treatment outcomes demonstrated significant and large reductions in clients’ alcohol and drug use during treatment and at the 12-month follow-up, there were no significant differences between the group and individual therapy condition.

However it took 41.4% less therapist time to treat clients using the group versus the individual format

Efficacy Cont.Minnesota Model Treatment

Grønbæk1 & Bent Nielsen (2007)This Study compared a Minnesota day clinic

treatment with the traditional public psychosocial treatment in Denmark

87 participants completed the studySelf-reported drinking patterns and the seven

composite scores from the addiction severity index (ASI) were collected for comparison

Results indicated that the Minnesota day clinic condition had a higher percent of abstainers throughout the treatment as well as after the 120motn follow up but had no real difference in effect sizes

Meta-AnalysisMiller & Wilbourne (2002)Compared 361 controlled studies on Alcohol

Use DisordersResults

Modalities with Strongest EfficacyBrief interventions, social skills training, the

community reinforcement approach, behavior contracting,behavioral marital therapy and case management,

opiate antagonists (naltrexone, nalmefene) and acamprosateModalities with the Weakest Efficacy

Methods designed to educate, confront, shock or foster

insight regarding the nature and causes of alcoholism

Case Study with Cognitive Analytic TherapyClient: Theresa a 57 year old women diagnosed with alcohol dependence

Intervention: Cognitive Analytic Therapy (CAT) an integration of cognitive and psychoanalytic techniques

Pre-Treatment Client Issues:Drank one bottle of vodka dailyReported guilty about her behavior and relationship with

her daughterReported deficits in confidence as well as suicidal

ideationPost Treatment Results:

Sustained Abstinence at 2 year follow up Increases in confidence and absence of suicidal

thoughts Improvement in familial and other interpersonal

relationships