Table of Contents
- Basic Principles
- Styles of Treatment: From Recovery to Relapse
- Evidence-Based Psychological Treatments
- Other Resources and General Tips
Formerly, in the 4th Edition of the American Psychiatric Association Diagnostic and Statistical Manual (DSM-IV), alcohol and other substance use disorders (SUDs) were divided into two distinct categories–substance abuse and substance dependence. At one time, an individual could meet criteria for one or the other (not both) for a given substance. Substance dependence was considered the more severe use disorder; its criteria included physiological, tolerance, and withdrawal, as well as continued use despite incurring health consequences. Now, in the updated (2013) DSM-5, SUDs are not characterized by the abuse vs. dependence distinction. See updated symptom criteria for substance use disorders.
Most professionals recognize a dynamic interplay of factors as contributing to addictive tendencies involving alcohol and other substances. This is why, in addition to detoxification and inpatient rehab, psychosocial treatments are critical for recovery from an alcohol use disorder.
Psychosocial treatments are programs that can target components of the social and cultural structures surrounding an individual and the problematic psychological and behavioral patterns of that individual.
Several psychological and behavioral therapies have received support from scientific studies and have been deemed appropriate by the American Psychological Association (Division 12) for treating alcohol use disorders. These generally take a patient-focused or a systems-focused format. Systems-focused refers to a treatment that mainly targets the surrounding social and structural sphere of the individual, rather than their mental health status.
Psychosocial treatments that are backed by clinical research evidence include: moderate drinking, behavioral couples therapy for alcohol use disorders, motivational interviewing, cognitive behavioral therapy, and prize-based contingency management.
Alcoholics Anonymous (A.A.), though not developed as a clinical treatment, is the most widely-used method for remaining abstinent from alcohol. A.A. has been a great resource for many and can be used alone or in combination with therapy in promotion of abstinence.
When starting treatment, you and your therapist will collaborate on a treatment plan. In addition to incorporating your feedback, they might add feedback from individuals closest to you (if that’s something you’d like).
Overall, appropriate choice and context of therapy will depend on various factors, including the severity of the alcohol use problem; your motivation to stop drinking; level of dysfunction in your environment; your cognitive functioning; level of impulse control; and the presence of co-occurring mental illness.
Some of these factors also can make abstinence and recovery more difficult—namely low impulse control, a severe mood disorder, and lack of support at home. This is when it can help to remain in a controlled or semi-controlled setting until you’ve gained a foundational skill set for remaining abstinent or reducing harm.
During the early recovery or “remission phase” from an alcohol use disorder (within the first 12-months post-cessation of alcohol), you have a higher chance of abstaining from alcohol if you reside temporarily in a place that isn’t conducive to drinking. This is especially the case if you’re aiming for complete abstinence (as opposed to reducing your drinking).
Thus, a residential center or halfway house can be an important treatment resource when you’re newly discharged from inpatient care. The halfway house provides emotional support, counseling, and progressive entry into society.
Sober living community homes are similar in that they are semi-controlled residences where you can live among other people who are in recovery. This can be a positive step for several reasons. You have a chance to build a support network with other individuals who are in recovery and understand what you’ve been through. Also, you’re included in regular, ongoing activities, such as A.A. meetings and support groups; these can encourage abstinence and serve as a reminder for your motivation to remain sober.
In addition, you have a minimal chance of encountering direct alcohol cues, such as a liquor store or an open bottle of wine in the home. Moreover, because social and cultural components of your old, familiar environment have likely served as a previous association for using alcohol, temporary relocation in the community can be a great ally during your most vulnerable time.
If you don’t choose residential treatment in an alcohol-free setting, such as a sober living home, outpatient resources are available. Ongoing follow up with professionals and community resources can boost your accountability and motivation to abstain from alcohol. In general, it’s important to follow up with a mental health professional so you can monitor your abstinence and well-being—more frequent checks are especially invaluable in the early stages following cessation from alcohol use.
Typically, outpatient psychosocial treatments will take a team approach, involving various professionals with differing areas of expertise who will collaborate with you on your treatment goals. The team may include a case manager, social worker, psychiatrist, and psychotherapist. Many court-mandated interventions for alcohol-related criminal charges involve this kind of structure.
Research shows that preventing relapse after an initial abstinence period heavily rests on successfully reintegrating into your environment without using substances. This can be really difficult when things in your old environment, including people, places, and things, previously contributed to the problem.
For example, in the past, you drank after fighting with your spouse. When you return from rehab, it’s critical that you identify this trigger, learn healthy ways to regulate your emotions (without alcohol), and develop an alternative “game plan” when communicating with your spouse.
Formal psychotherapy with a trained mental health professional (clinical psychologist, licensed counseling psychologist, social worker, therapist) will involve behavioral, cognitive (talk therapy) and cognitive-behavioral strategies. These treatments focus on your addiction, drawing awareness around your patterns and triggers for use, while teaching skills for the future in dealing with stressful or difficult situations. Many psychological treatments also provide support and training to your family, friends, or spouse.
Evidence-Based Interventions for Alcohol Use Disorder
Evidence-based interventions are those that have been developed and subjected to scientific evaluation in randomized clinical trials by doctorate-level professionals. Interventions that receive at least moderate support are regarded as Evidence-Based Treatments (EBTs).
Below, you’ll find strategies that’ve been deemed as EBTs for alcohol use disorders. Essentially, these strategies teach you new ways to cope with old situations and aim to improve communication and cooperation in your relationships. Other treatments have been recommended for addictive behaviors in general, which may have promise for alcohol use reduction as well (e.g., mindfulness-based interventions).
- Moderate drinking (MD)is a patient-tailored approach to monitoring alcohol intake. MD is provided through a web application and the treatment plan depends on your goals. The concept for MD is based on principles of behavioral self-control training. The American Psychological Association describes MD as a, “structured yet interactive, individualized program that guides users to set goals, self-monitor their behavior, and get detailed feedback on their progress on the basis of their input.”
- Behavioral couples therapy for alcohol use disorders (ABCT) has received strong research support. It is an outpatient treatment which includes your partner in weekly sessions spanning 12-20 weeks of therapy. ABCT takes a cognitive-behavioral therapy approach to couples therapy. That is, the ABCT therapist works with you to identify your partner’s behaviors that trigger or reinforce your drinking. ABCT also aims to strengthen your partner’s support of your efforts to modify your behavior through positive reinforcement; increase positive couple interactions by improving communication; and adopt coping skills to promote your abstinence.
- Motivational interviewing (MI) is a brief, client-centered approach that helps individuals explore and resolve their ambivalence about change in an empathic, non-judgmental, collaborative way. That is, MI meets you where you are, and helps you find the internal motivation to change your habits. It helps you better understand the consequences of your drinking, and identify personal values and goals. MI is often combined with other approaches, such as motivational enhancement therapy (MET). This therapy consists of four sessions, which include the therapist’s feedback on the initial assessment, along with discussions of your concerns and goals.
- Cognitive behavioral therapy (CBT) is one of the most studied and supported treatments for alcohol use disorders. CBT typically begins with an analysis of your alcohol use, specifically clarifying patterns of thoughts, feelings, and behaviors that spark and perpetuate excessive drinking. CBT focuses on learning skills to cope with cravings and mood changes. It also focuses on identifying triggers and urges and developing a plan to navigate these thoughts, emotions, and situations, and prevent relapse.
- Contingency management (CM) has received modest research support for treatment of alcohol use disorders. CM programs are one of the earliest forms of treatment established in the field. They evolved from behavioral research in animals. Behaviorists consider any behavior to be a result of reinforcement learning. For example, any behavior that is rewarded will increase in frequency. CM is a structured form of behavioral therapy, involving frequent “checks” on your alcohol status. If you reach your pre-established target goal at a given check point—goals range from total abstinence to reduction of use to a specific amount—you’re given a monetary reward (prizes can range from $1 to $100). Frequent monitoring coupled with rewards incentivize your future success. Today, CM is typically provided as a supplement to other psychosocial treatments or 12-step programs (e.g., A.A.).
It is important to enhance effectiveness of interventions for difficult-to-treat problems, such as alcohol addiction. Indeed, clinical research continues to investigate new strategies and refine already-existing ones. One way to increase the potency of an alcohol program may be to combine different psychosocial treatments or to supplement CBT with a community support group.
See the next page for additional resources and general tips for treatment of AUD.