An Introduction and Conclusions to Psychological treatments of alcohol use disorders

By: Deirdre Conroy, Kirk J. Brower, Jane Marshall and Mike Crawford

Introduction

Many interventions appear effective in the treatment of severe alcohol dependence except brief interventions and psychodynamic psychotherapy. Brief interventions are effective in alcohol users at risk to develop problems and in those whose alcohol-related problems are mild to moderate. More severe alcohol usage and subsequent dependence responds to motivational enhancement therapy or motivational interviewing, cognitive-behavioral therapy, and twelve step facilitation therapy. Other behavior therapies and couples and marital therapies are also effective here. In the USA, psychodynamic psychotherapy (for which there is very little if any evidence for effectiveness) is probably the most common form of therapy for alcohol misuse conducted outside formal alcohol treatment programs, while twelve step facilitation therapy is probably the most common form of treatment conducted within alcohol treatment programs. In the UK, motivational interviewing is the predominant mode of therapy.

Treatment for alcohol dependence is usually composed of three phases: management of the alcohol withdrawal syndrome, motivation for and initiation of abstinence, and prevention of relapse. Both pharmacological and psychosocial interventions are used in the prevention of relapse, either separately or in combination. These interventions do not operate in a clinical vacuum, and their effectiveness is associated with a number of variables, including premorbid client/patient characteristics; severity of alcohol dependence; therapist characteristics and the process of treatment delivery. Treatment outcomes are likely to be different in different countries. For instance, European outcomes have historically been less favorable than outcomes in the USA. Although severe alcohol problems are chronic and intermittent, randomized studies have not been designed to study the long-term treatment perspective. Most studies assess treatment interventions between 1–3 months duration with 1-year follow-up. There is a need for long-term studies. In this article we focus on the psychosocial treatments.

Psychological treatments, which include psychosocial and behavioral treatments, involve a professional relationship between a therapist and a patient who work together to accomplish specific improvements in behavior, thinking, mood regulation and self-esteem. They constitute the primary professional interventions for alcohol dependence, whereas pharmacotherapy and other interventions are generally thought of as adjunctive to psychological treatment. Treatment goals that include sobriety or moderate drinking, depend on a thorough assessment of the patient’s drinking history and severity of problems, drinking diagnosis (abuse vs. dependence), co-occurring medical and psychiatric disorders, readiness to change, and psychosocial stressors and supports. How to conduct these assessments is beyond the scope of this article and is reviewed elsewhere (Brower & Severin, 1997), but screening for and assessment of at-risk drinking, alcohol abuse, and alcohol dependence should be an essential part of standard healthcare in all relevant clinical settings (NIAAA, 2007).

The behavioral and psychosocial interventions are essentially ‘‘talking therapies’’, based on conceptual models of addiction, which can be delivered on a one-to-one basis, in a group setting, or as part of a couples/family therapy approach. Elements of effective treatments are aimed at building motivation, enabling behavioral change and modifying the social context. They are thought to enable or enhance the naturally occurring processes of recovery. It can sometimes be difficult to distinguish between some of these interventions, so it is important for definitions of treatments as well as the severity of the alcohol use disorder in the target group to be defined clearly both in systematic reviews and meta-analyses.

A range of psychological treatments for which there is an evidence base including brief intervention (BI), motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT), twelve step facilitation (TSF) therapy, interactional group therapy, contingency management, cue exposure therapy, behavioral couples therapy, and family/network-based interventions, It is interesting that although psychodynamic therapies have less supporting evidence, they are commonly used in the USA. Some other psychological therapies are Complex Interventions because they are either multidimensional (e.g. community reinforcement approach) or designed to be used in combination with medication (e.g. medical management). Alcoholics Anonymous (AA) does not strictly meet the definition of a psychological therapy because it does not involve a relationship with a professional therapist. Alcoholics Anonymous is on Complex Interventions because of its multidimensional nature.

Conclusions 

The evidence base for psychosocial treatment in alcohol use disorders has been under increasing scrutiny in the addictions literature over the past 10–20 years, during which time relevant studies have been subjected to systematic review and meta-analysis. The Mesa Grande Project (Miller et al., 1995a; Miller et al., 1998; Miller & Wilbourne, 2002) is an ongoing systematic review which summarizes the current evidence of treatments for alcohol use disorders. In the most recent update, data from 361 randomized controlled trials were analyzed, and 87 treatments ranked. For psychosocial treatments, the strongest evidence of efficacy was found for brief interventions, MET and social skills training (a CBT-type intervention).

Evidence supporting the role of behavioral approaches, CBTs, BCT and case management are also reported. There are problems in interpreting the data with respect to alcohol dependence because the Mesa Grande does not separate out findings from studies among those with dependent and non-dependent drinking. But building on the data from Mesa Grande, a recent review of interventions for alcohol misuse published by the National Treatment Agency (2006), which guides delivery of substance misuse services in England, concluded that the way in which psychological treatments for alcohol use disorders are delivered may be as important as the model which is used. Nonetheless the authors state that motivational enhancement therapy provides a good starting point for treatment and that cognitive-behavioral approaches offer the best chances of success.

A systematic review of treatments for alcohol and other addictive substances by the Swedish Council on Technology Assessment in Health Care (SBU, 2001) synthesized findings from 139 randomized trials. A further 25 were added in March 2002, for the purposes of an English version of this report (Berglund et al., 2003). The authors of this review concluded that ‘‘specific treatment’’ for alcohol-related problems is better than standard treatment. They defined specific treatment as treatment with a theoretical base, conducted by therapists with specific training and manual guided. The following treatments were considered to be effective: MET, CBT, twelve-step treatment, structured interactional therapy, marital therapy and family intervention. It was recommended that services should aim to reduce the delay between detoxification and interventions for the prevention of relapse.

The Health Technology Board for Scotland (2002) assessment of psychosocial interventions to prevent relapse in people with alcohol dependence identified four broadly defined treatments, with proven evidence of effectiveness: coping/social skills training; behavioral self control training (BSCT); marital/family therapy and motivational enhancement therapy. These interventions were not only clinically effective, but also cost-effective. However, practical limitations regarding their implementation were noted, and no one treatment was considered appropriate for every situation.

Guidelines produced by the National Drug and Alcohol Research Centre in Australia recommend that psychosocial intervention be used in an attempt to prevent relapse for all those with moderate to severe dependence on alcohol (Shand et al., 2003). Motivational interviewing, problem-solving skills training and behavioural self-management are all recommended for preventing harmful and dependent use of alcohol.

References

Peter Tyrer and Kenneth R. Silk, Cambridge Textbook of Effective Treatments in Psychiatry, Cambridge University Press 2008.

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