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Psychosocial Treatments for Alcohol Use Disorder

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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.

Basic Principles Regarding Treatment

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.

Styles of Treatment: From Recovery to Relapse

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.

 

Psychological and Behavioral Treatments

Research shows that preventing relapse to substances following an initial abstinence period heavily rests on the individual’s successful reintegration to their environment without using substances. This can be difficult when things in one’s old familiar environment, including people, places, and things, have previously contributed to the problem. For example, a person with an alcohol addiction may have drunk in the past to cope with interpersonal conflict with her spouse. Thus, when she returns from rehab, it is critical that she has been made aware of this tendency before she is to enter similar situations again. It is ideal that she learns ways to regulate her emotions during conflicts without alcohol. It is also important that she develop an alternative “game plan” when communicating with her husband.

Formal psychotherapy with a trained mental health professional (clinical psychologist, licensed counseling psychologist, social worker) will involve strategies of behavioral, cognitive (talk therapy), cognitive-behavioral nature. These treatments focus on the patient’s addiction, drawing awareness around patient’s patterns and triggers for use, while teaching skills for the future in dealing with stressful or difficult situations. Many psychological treatments provide support and training to family, friends, or spouse.

Evidence-Based Interventions for Alcohol Use Disorder

EB 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). Described below are those strategies deemed as EBTs for alcohol use disorders, specifically. Hallmark to these strategies are therapy modules that teach the patient new ways to cope with old situations and aim to improve communication and cooperation in relationships. Other treatments have been recommended for addictive behaviors in general, which may have promise for alcohol use reduction as well. Read more about these treatments on the American Psychological Association’s (APA) website.

  • Moderate Drinking (MD) is a patient-tailored approach to monitoring alcohol intake. MD is provided through a web application and the treatment plan is governed by the goals of the patient. Concept for MD is based on principles of behavioral self-control training. The APA 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 involves inclusion of the intimate partner of the patient in weekly sessions spanning 12-20 weeks of therapy. ABCT takes a cognitive-behavioral therapy approach to couples therapy, wherein the ABCT therapist works alongside the couple to target the partner’s behaviors that cue or reinforce the client’s drinking. ABCT also aims to strengthen the partner’s support of the client’s efforts to modify their behaviors through positive reinforcement; increasing frequency and quality of positive couple interactions through activities designed to improve communication; and instilling alcohol-alternative coping skills so as to promote the patient’s abstinence.
  • Contingency management (CM) has received modest research support for treatment of alcohol use disorders. They are one of the earliest forms of treatment established in the field. CM programs 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 the patient’s alcohol status. If the patient reaches their pre-established target goal at a given check point, with goals ranging from total abstinence status or reduction of use to a specific amount, they are given a monetary reward (prizes can range from $1 to $100). Frequent monitoring coupled with rewards incentivize patients’ future success. In modern day, CM is typically provided as a supplement to other psychosocial treatments or 12-step (A.A.) programs.

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 page 3 for other resources and general tips for treatment of AUD

Other Resources and General Tips

Alcoholics Anonymous (A.A.)

A.A. is not a psychological treatment for alcohol use disorders. Rather, it is a nonprofessional, self-supporting international fellowship program which offers group support to men and women who have had a drinking problem. A.A. meetings provide members with acceptance, understanding, forgiveness, confrontation, and a means for positive identification. New A.A. members are asked to admit to a problem, give up a sense of personal control over the disease, do a personal assessment, make amends, and help others. Telephone numbers are exchanged, and new members pick “sponsors” (more experienced members who guide them through their recovery). Although Alcoholics Anonymous does not appeal to all alcoholics, it is obvious that the A.A. approach has been extremely successful with many.

A.A. is the most-frequently utilized resource by alcoholics aiming to become sober. In addition, it has proven to be a powerful avenue of intervention for many. Reasons for its effectiveness may include cultivation of social support and member-to-member mentorship through sponsors. Components of its “12-Step” program, such as acknowledging and relinquishing control over one’s addiction, use of prayer and spiritual connectedness, and making amends to others, may also contribute to some members’ sobriety success. Given its popularity and cost-effectiveness, physicians routinely refer patients with alcohol use problems to A.A. Psychologists also generally support their patients’ attendance at A.A. as a socially-supportive adjunct to psychotherapy.

 

General Tips

There are a variety of ways to treat addictive problems, including alcohol use disorders.

Here are some general tips for therapists/counselors, patients, and family of patients:

  • Become knowledgeable about available options for treating alcohol addiction. Choose a form of treatment that has at least some research supporting its effects. Check for the existing list on APA’s website.
  • There is no “right” method that works for everyone. Every intervention will have its strengths and limitations. Tailor choice of treatment to the individual patient’s risk factors for drinking. For example, ABCT may be ideal if the patient’s relationships have served as a trigger in the past for their problematic use patterns.
  • Wondering whether an individual needs therapy if they have already gotten sober? Outpatient psychosocial treatments are especially essential in cases where the patient’s environment and relationships have served as a trigger in the past for their problematic use patterns.
  • Substance use disorders are among the most difficult to treat. Try a variety of strategies and alternatives when a given treatment has failed.
  • Put simply, a patient is most likely to comply with a treatment they find tolerable and attractive. Patients should gravitate towards strategies that reinforce their successes.
  • The patient should be the greatest advocate of their recovery from an alcohol use disorder. Treatments are most successful when they instill a sense of personal responsibility, capability, and motivation in the patient.
  • The patient should take advantage of social support to heighten their abstinence success. Communicate openly and frequently to those who give you encouraging support. Another way to leverage social support is by developing new connections, such as through A.A. or in other support groups among fellow individuals recovering from alcohol use disorders. Al-Anon is an organization for the spouses of alcoholics that is organized along the same lines as Alcoholic Anonymous. Alateen has been developed for the children of alcoholics so that they may better understand their parents’ alcoholism.

 


Johnna Medina, Ph.D.

Johnna Medina, Ph.D. is an author, researcher, and graduate of the University of Texas at Austin. She is currently completing her postdoctoral research fellowship at Stanford School of Medicine.

APA Reference
Medina, J. (2018). Psychosocial Treatments for Alcohol Use Disorder. Psych Central. Retrieved on February 17, 2019, from https://psychcentral.com/disorders/addictions/alcohol-use-disorder-psychosocial-treatments/
Scientifically Reviewed
Last updated: 24 Oct 2018
Last reviewed: By a member of our scientific advisory board on 24 Oct 2018
Published on Psych Central.com. All rights reserved.