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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 the patient and the problematic psychological and behavioral patterns of the patient.
Alcoholics Anonymous (A.A.), though not developed as a clinical treatment, is the most widely-used method by patients 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. However, A.A. is not the only option.
There are psychosocial interventions that are highly effective. 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 an either patient-focused or systems-focused format. Systems-focused refers to a treatment that mainly targets the surrounding social and structural sphere of the patient, rather than the patient’s mental health status. Specific psychosocial treatments for alcohol use disorders that are backed by clinical research evidence include Behavioral Couples Therapy for Alcohol Use Disorders, Moderate Drinking, and Prize-Based Contingency Management.
Overall, appropriate choice and context of therapy will depend on several factors, including the severity of the alcohol use problem, patient motivation to stop drinking, level of dysfunction in the patient’s sociocultural environment, patient’s cognitive functioning and level of impulse control, and presence of co-occurring mental illness in the patient. Oftentimes, a mental health professional will incorporate feedback from the patient themselves, as well as close individuals to the patient, when devising a treatment plan. Though popular in previous decades, methods for what is known as “aversive conditioning,” or ways to punish drinking behavior with physical pain, are no longer widely used. These include medications, such as apomorphine and emetine, that induce vomiting and electrical shock stimulation to produce pain upon alcohol ingestion. Accumulating research supports positive reinforcement over punishment for treating addiction.
Presence of negative abstinence predictors, such as having a severe mood disorder, low impulse control, and lack of a strong support system back home, suggests that the patient is at high risk for resuming their problematic alcohol use without additional intervention. If the patient is deemed high risk, they may be advised to remain in a controlled or semi-controlled setting until they are able to gain 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), patients have a higher chance of abstaining from alcohol if they reside temporarily in a place that is not conducive to drinking. This is especially the case if the individual is aiming for complete abstinence (as opposed to reducing their drinking). Thus, a residential center or halfway house can be an important treatment resource for the alcoholic 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 the patient can live among other people who are in recovery. This can be a positive step for several reasons. The patient has a chance to build a support network with other individuals who are in recovery and understand what they have been through. Also, the patient is included in regular, ongoing activities, such as A.A. meetings and support groups; these can encourage abstinence and serve as a reminder for their motivation to remain sober. In addition, the patient has 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 the patient’s old familiar environment has likely served as a previous association for using alcohol, temporary relocation in the community can be a great ally to the patient during their most vulnerable time.
After discharge from inpatient rehab, follow-up treatment is essential for relapse prevention. Follow-up treatment can range in intensity, from routine outpatient visits with a social worker or psychiatric professional, to residential treatment in a strict alcohol-free environment. If an individual does not choose residential treatment in an alcohol-free setting, such as a sober living home, there are outpatient resources available. Ongoing follow up with professionals and community resources can boost patient accountability and motivation to abstain from alcohol. In general, it is a good idea to follow up with a mental health professional to monitor the patient’s abstinence status and psychological adjustment. More frequent checks are advised, especially in the early stages following cessation from alcohol use. However, any follow up is generally seen as being better than none.
Follow-up treatment can range in intensity, from routine outpatient visits with a social worker or psychiatric professional, to residential treatment in a strict alcohol-free environment. As noted, psychosocial treatments aim to alter patients’ psychological and behavioral tendencies by intervening on the greater social and environmental context surrounding the problem.
The most tightly-controlled and structured outpatient psychosocial interventions are primarily of behavioral nature with a focus on case management. These often take a team approach, involving various professionals with differing areas of expertise working collaboratively with the patient. This team may include a case manager, social worker, psychiatrist, and psychotherapist. Many court-mandated interventions for alcohol-related criminal charges involve such a structure.