Psychotherapy and the Treatment of Alcohol Dependence
Psychotherapy is used here to refer to verbal interactions between a therapist and a patient intended to alter the patient's emotions, maladaptive beliefs or behavior.
Psychotherapy, particularly of the psychoanalytic variety, has a tarnished reputation as a treatment for alcohol dependence. Psychoanalysts and psycho-dynamically oriented psychotherapists theorized that alcoholism was a symptom of an underlying conflict and that gaining insight into the origin and nature of the conflict would provide a "cure" of the alcohol dependence. Treatment of alcohol dependent patients using this paradigm was rarely effective in producing alcohol abstinence, and many patients remained in psychotherapy for years while the severity of their alcoholism progressed.
Other treatments for alcohol dependence, evolving primary from a twelve-step recovery model, held that regardless of the initial cause, alcohol dependence eventually developed a life of its own and must be treated as a primary disorder. In the 1980's, private inpatient treatment of alcoholism greatly expanded and was driven primarily by the tenants of twelve-step recovery, in what became widely known as the Minnesota or Hazelden treatment model (Stinchfield & Owen 1998). Inpatient alcohol abuse treatment programs offered initial detoxification followed by drug abuse counseling, most often provided by a counselor who was also recovering from alcohol or some other drug dependence disorder.
The Hazelden Model explicitly evoked the disease model of addiction, although there was little emphasis on medical treatment beyond detoxification and medical management of co-existing medical conditions, such as hypertension or diabetes. The approach emphasized direct confrontation of the alcoholics' beliefs and thinking that enabled them to drink while denying the adverse effects that their drinking was having on their health, family, and sometime work performance. Patients were usually required to attend Alcoholics Anonymous meetings during their inpatient stay, and daily attendance was mandated or strongly encouraged during aftercare. The mantra of 90 meetings in 90 days was standard. Family involvement was often included as part of the treatment.
Professional psychotherapy, particularly of the insight-oriented or psychoanalytic variety, was discouraged during early recovery, as was medication treatment of insomnia, depression, or anxiety. Inpatient treatment of alcohol dependence has been greatly curtailed by managed care and the evolution of effective outpatient treatment strategies with demonstrated effectiveness. Pharmaco-therapy-particularly with antidepressants and mood stabilizers and medications to deter alcohol use, such as naltrexone or disulfiram-has become more accepted.
Psychotherapeutic approaches that evolved during the 1980's were a pragmatic blend of principles from social leaning theory and behavioral psychology. Relapse prevention, popularized by a book, Relapse Prevention, Maintenance Strategies in the Treatment of Addictive Behaviors (Marlatt & Gordon 1985), is a systematic application of cognitive-behavior techniques including self-monitoring to identify early drug cravings, violent outbursts often leading to domestic violence issues, identifying situations that are high-risk for use, and developing strategies for coping with or avoiding high-risk situations.
A set of psychotherapy techniques that has evolved from motivational interviewing (Miller & Rollnick 1992) have been codified into a brief intervention called Motivational Enhancement Therapy (Miller 1994). Motivational Enhancement centers on engaging the patients ambivalence about treatment and stopping drug use. This is a brief therapy, usually consisting an initial assessment followed by two to four individual treatment sessions. Motivational interviewing principles are used to strengthen motivation and build a plan for change. More recent evolutions include what is popularly known as the MATRIX model (Obert, Rawson & Miotto 1997). None of these therapies emphasizes direct confrontation and the psychotherapeutic models are acceptable to some patients who are distanced by the religious underpinnings of Alcoholics Anonymous.
In alcoholism treatment, the boundary between drug abuse counseling and psychotherapy is often fuzzy. The distinction is usually based more on training and degrees than what occurs during treatment sessions. Many drug abuse counselors, particularly those who are themselves recovering from alcohol or another drug dependency disorder, draw heavily on their own experience with addiction and recovery.
Their formal training about alcohol or drug dependency treatment may vary widely. They refer to themselves as "counselors" and to the people they treat as "clients." Licensed psychotherapists, such as psychiatrists and psychologists, refer to their work as "psychotherapy" and the people they work with as "patients." Because of the blending between psychotherapy and counseling, non-pharmacotherapy techniques are often called "psychosocial treatments." Peer led, self-help recovery groups, such as alcoholics anonymous, are generally not called "treatment."
In common usage, psychotherapy is sometimes narrowly defined as something provided by a professional licensed to provide such services, or more broadly defined as verbal interaction between a therapist or counselor and a client or patient that is designed to change behavior and feeling (Zimberg 1999). With a broad definition, the distinction between a drug abuse counselor and a psychotherapist largely disappears. Counseling and treatment for alcohol dependency is often conducted at alcohol rehab centers where specialists can take care of the patient's needs
Table 1 lists of some of the more common forms of psychotherapy that have been applied in treatment of alcohol dependence. The modalities are adaptations of techniques that have been developed for treatment of other psychological disorders. There is considerable overlap in techniques, particularly between cognitive-behavior, skill training and relapse prevention.
In general, many patients who engage in any type of psychosocial treatment show improvement in their drinking behavior, and demonstration of differences between treatment modalities in controlled clinical trials has been difficult. The largest study has been a study sponsored by the National Institute on Alcohol and Alcohol Abuse called project MATCH, an acronym for Matching Alcoholism Treatment to Client Heterogeneity (1993). Data from project MATCH showed similar treatment outcome with cognitive behavior and coping skills therapy, motivational enhancement therapy, and twelve-step facilitation (1997).
Table1 : Types of Psychotherapy
|Cognitive-behavioral therapy||Provides information and skill training.||(Rohsenow et al. 1991)|
|Contingency contracting||Reward or punishment based on alcohol use behavior||(Caddy & Block 1983)|
|Coping skill||Identifying skill deficiencies and providing remedial skill training, e.g., assertiveness training||(Monti & O'Leary 1999)|
|Modified psychodynamic||Emphasis on resolving current conflicts.||(Fox 1965)|
|Motivational enhancement||Non confrontational. Provide information, encourages patient to make decisions about behavior based on new information, engages patient’s ambivalence about treatment.||(1998)|
|Network therapy||Engages the patient in a support network composed of family members and peers||(Galanter 1993)|
|Psychodrama||Role playing||(Loughlin 1992)|
|Relapse Prevention||Information, identification of high-risk situations, anticipatory guidance||(Marlatt & Gordon 1985)|
|Supportive||Encouragement and support for patients own strategies for remaining alcohol abstinent, advice given if requested.||(O'Malley 1995; O'Malley et al. 1992) What is psychiatry|
Combined Psychotherapy and Pharmacotherapy Psychosocial treatment is increasingly combined with pharmacotherapy. Pharmacotherapy may be directed at relapse prevention (e.g., disulfiram, naltrexone, or in Europe, acamprosate), or treatment of the underlying psychiatric condition (e.g., antidepressants, lithium, or valproate).
Pharmacotherapy may enhance psychosocial treatment. For example, a recent article reporting the results of oral naltrexone in combination with cognitive behavior therapy found that 62 percent of the naltrexone treated patients did not relapse into heavy drinking compared to 40 percent of the patients treated with placebo (Anton et al. 1999). The initial studies supporting the efficacy of naltrexone in treatment of alcohol dependence were in combination psychotherapies (O'Malley et al. 1992; Volpicelli et al. 1992).
A recent review of pharmacological treatment of alcohol dependence in the Journal of the American Medical Association concluded "We herald the advances in the pharmacotherapy of alcohol dependence as valued developments, but we note that treatment of patients with alcoholism should continue to incorporate a biopsychosocial perspective in an effort to change a life from a pattern of addiction to a pattern of sobriety and improved physical, mental, and social health" (Garbutt et al. 1999).
A variety of psychotherapeutic approaches have demonstrated efficacy in treatment of alcohol dependence. For personal reasons, some patients will find one approach more acceptable or effective than another. For many patients, the combination of psychotherapy and pharmacotherapy improves the chances of successful outcome.