Behavioral Therapy And Alcoholisim Treatment

A broad range of psychological therapies currently are used to treat alcoholism. Many of these therapies have been in use for some thirty years. Others are more recent developments. Many older treatments for alcoholism were developed before modern standards of evaluating treatment outcomes were accepted in the alcohol field. Thus, the various approaches to treating alcoholism have different levels of scientific support for the effectiveness. Treatments that have been evaluated include client-treatment matching and professional treatments modeled on the twelve steps of Alcoholics Anonymous. Newer treatments that have been developed and evaluated include brief or minimal intervention, motivation enhancement therapy, and cognitive-behavioral therapy.

Brief or Minimal Intervention. One in five men and one in ten women who visit their primary care providers are at-risk drinkers or alcohol-dependent. Brief intervention, which is designed to be conducted by health professionals who do not specialize in addictions treatment, can help at-risk drinkers to decrease their risk and to motivate alcohol-dependent patients to enter formal alcoholism treatment. The main elements of brief intervention can be summarized by the acronym FRAMES: feedback, responsibility, advice, menu of strategies, empathy, and self-efficacy. Although research has shown that brief interventions can be effective it has not yet been widely implemented.

Patient-Treatment Matching. Patient-treatment matching is using a patient s individual characteristics (such as gender, anger level, social functioning, and severity of alcohol dependence) to select an appropriate treatment therapy. A commonly held view in alcoholism treatment is that matching patients to treatments will improve treatment outcome. This view was supported by thirty small-scale research studies conducted during the 1980s that found a variety of matching effects. A large multi-site clinical trial, Matching Alcoholism Treatments to Client Heterogeneity (Project MATCH), was initiated in 1989 to rigorously test the most promising hypothetical matches. Patients were randomly assigned to one of the following three different types of behavioral therapy:

Motivational Enhancement Therapy (MET), a brief intervention using techniques of motivational psychology to encourage individuals to consider their situation and the effect of alcohol on their life, to develop a plan to stop drinking, and to implement the plan.

Cognitive -Behavioral Skills Therapy (CBST) in which alcoholism is viewed as a type of maladaptive, learned, behavioral response to stressful triggers. In CBST, the patient is taught ways to respond to drinking-provoking situations with non-drinking actions. Patients practiced drink-refusal skills, learned to manage negative moods, and learned to cope with urges to drink.

Twelve-step Facilitation Therapy (TSF), which encouraged patients to become involved in Alcoholics Anonymous (AA). In TSF, trained therapists helped patients to find AA sponsors, arranged for regular AA attendance, introduced patients to AA literature and other materials, and helped patients to work the first five of AA's twelve steps. (TSF was designed specifically for Project MATCH. Although grounded in the twelve-Step principles, it was a professionally delivered, individual therapy different from the usual peer-organized AA meetings and was not in tended to duplicate or substitute for traditional AA.)

No decisive matches between patients and treatments were found; the three treatments were approximately equal in their efficacy for all patients. Further, treatment in all three approaches resulted in substantial, long-term reductions in drinking and related problems.

Twelve-step Programs. Professional Treatment based on the twelve steps of AA is the dominant approach to alcoholism treatment in the United States. Higher levels of AA attendance during and following professional treatment are consistently associated with better outcomes, but AA affiliation without professional treatment has not routinely resulted in improvement. Twelve-step approaches also have been found to be more effective than motivational enhancement therapy for individuals whose social networks support drinking.

Medications for Alcoholism Treatment.

One of the major changes in alcoholism treatment is the current and future availability of medications that can improve treatment outcome. Medications that interfere with craving can reduce the likelihood that a recovering alcoholic will suffer a relapse. Two such medications are currently available: naltrexone in the United States and acamprosate in Europe. A third medication, nalmefene, is currently under study. Naltrexone. Naltrexone is the first medication approved to help maintain sobriety after detoxification from alcohol since the approval of disulfiram (Antabuse ®) in 1949. Originally developed for use in treating heroin addicts by reducing their cravings for this drug, naltrexone was observed to reduce alcohol use by heroin addicts. Further research confirmed this observation: naltrexone used in combination with verbal therapy prevented relapse more than standard verbal therapy alone. Acamprosate. Acamprosate was developed in Europe. Clinical trials are now underway in the United States to gain approval by the FDA to market acamprosate in the United States. The results of the European clinical trials of acamprosate were very similar to those found in the U.S. with naltrex-one; about twice as many people did well with acamprosate as they did with placebo. They also found, as with naltrexone, that the medication is effective only in combination with behavioral therapy.

Nalmefene. A new opiate antagonist—nalmefene— has recently been tested for use in alcoholism treatment. This medication significantly reduced relapse to heavy drinking among recovering alcoholics, decreased the risk of relapse, and produced no significant side effects. In studies in which naltrex-one and nalmefene were compared, nalmefene entered the bloodstream more quickly and had a somewhat lower risk of liver toxicity than did nal-trexone.

Combined Therapeutic Approaches. Combining behavioral therapies with phar-macotherapies is likely to be the next important advance in alcoholism treatment. There are several ways in which behavioral and pharmacological therapies could work together: One therapy might continue to function if the other failed; each therapy might increase the effectiveness of the other; or each might act on the same neural circuits. Naltrex-one, used in combination with behavioral therapy, has been shown to prevent relapse more than behavioral therapy alone. The effectiveness of combined therapeutic approaches, including approaches which combine both acamprosate and naltrexone, are currently being examined.

BIBLIOGRAPHY

National Institute on Alcohol Abuse and Alcoholism. (2000). Tenth special report to the U.S. Congress on alcohol and health. National Institutes of Health Publication No. 00-1583. Bethesda, MD: National Institutes of Health. National Institute on Alcohol Abuse and Alcoholism. (1995). The physicians' guide to helping patients with alcohol problems. NIH Pub. No. 95-3769. Bethesda, MD: National Institutes of Health. National Institute on Alcohol Abuse and Alcoholism. (1999). Alcohol alert no. 43, brief intervention for alcohol problems. Bethesda, MD: National Institutes of Health. National Institute on Alcohol Abuse and Alcoholism. (1997). Alcohol alert no. 36, patient-treatment matching. Bethesda, MD: National Institutes of Health.

Enoch Gordis

Alcohol, An Overview Alcohol abuse and Alcoholism are serious problems. Alcohol abuse refers to heavy, problematic drinking by nondependent persons, while alcoholism suggests Tolerance, Physical Dependence, and impaired control of drinking. There are an estimated 9 million alcohol-dependent persons and 6 million alcohol abusers in the United States (Williams et al., 1989).

Problems that arise from misuse of alcohol vary widely, but they often include the following areas: financial, legal, family, employment, social, and medical. Medical complications include alcoholic liver disease, gastritis, pancreatitis, organic brain syndrome, and the Fetal Alcohol Syndrome (FAS). It is estimated that more than 100,000 alcohol-related deaths occurred in the United States in 1987 (Centers for Disease Control, 1990). The most common alcohol-related death is a motor vehicle fatality.

Despite the complex nature of alcohol abuse and dependence, research has burgeoned over the past decade and has deepened our understanding of the causes, prevention, and remediation of alcohol abuse and alcoholism. Here, we briefly review assessment of alcohol problems, detoxification, and treatment.

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