Effective treatments now abound for clients with alcohol or drug problems and seasoned therapists are using a variety of treatment approaches, tailoring them to the unique needs of the client.
Below is a wrap-up of the most common treatments, many of which are drawn from "Bridging the gap between alcoholism treatment research and practice: identifying what works and why," in this month's Professional Psychology: Research and Practice (Vol. 32, No. 3).
In the article, Jennifer P. Read, PhD, and Christopher W. Kahler, PhD, of Brown University School of Medicine and Butler Hospital, and John F. Stevenson, PhD, of the University of Rhode Island, discuss the most prevalent and studied treatments available for alcoholism.
"It's a good idea for clinicians to gain familiarity with each of the effective treatment approaches, because each offers unique advantages," Kahler notes. "However, it is also important that clinicians work to develop a true proficiency in at least one of the approaches, rather than trying to incorporate all of the approaches into their work without having a sound framework for case conceptualization."
The treatments include:
Individual skill-based treatments. Grounded in social learning theory, these approaches help clients interact more effectively without using alcohol or other drugs. Among the most common and widely studied is coping and social skills training, or CSST. The treatment helps clients quit or decrease drinking and manage life effectively without alcohol by teaching them strategies to address interpersonal, environmental and individual "skill deficits" that may provoke substance use. CSST is among the most well-supported of treatment modalities, taking into account treatment efficacy, cost and the methodological quality of the research, according to studies by University of New Mexico researcher William R. Miller, PhD, and Sandra Brown, PhD, of the University of California at San Diego.
Motivational Enhancement Treatments (MET). This approach, developed by Miller and colleagues, is based on a client-centered model that encourages the patient to explore the consequences of her drinking in a supportive, nonthreatening environment. One of MET's techniques, called motivational interviewing, takes what therapists traditionally conceptualize as denial and "normalizes" it so it is viewed as one stage in a person's ability to change--namely, ambivalence, Miller explains. The therapist follows up by asking patients what causes them difficulties about their drinking or drug use, enabling clients to examine their habits objectively. Once clients see how substance abuse or dependence affects their lives, they are motivated to change, the approach contends.
Environmental and relationship-based treatments. The field has also tested and put into practice interventions involving family members and significant others. One empirically tested treatment is community reinforcement, or CRA, wherein family members are taught coping skills and strategies to help influence their loved one's drinking and motivation to change. The approach contrasts with 12-step approaches such as Al-Anon that encourage family members to detach from the person's behavior, and with what Miller calls the "surprise party," where family members converge unexpectedly on the loved one and attempt to push him into treatment.
In a 1999 study in the Journal of Consulting and Clinical Psychology (Vol. 67, No. 5, p. 688-697), Miller and colleagues at the University of New Mexico compared the three environmental strategies--CRA, 12-step and the confrontational approach--in 130 family members of users. While family members showed improvements in functioning in all three approaches, the community reinforcement approach was better at getting drinkers engaged in treatment.
Behavioral marital and family therapy. This approach works with both the individual and the spouse or family to decrease or eliminate abusive drinking and drinking-related consequences and has also been shown to curb drinking and to improve relationships.
Twelve-step programs. Evaluating traditional 12-step programs has been difficult, given the organization's emphasis on anonymity and the methodological difficulties inherent in studying AA. These include being unable to randomly assign subjects to an AA condition, since attendance is based on one's personal motivation, and difficulties simulating AA meetings in the research lab. These programs, which include Alcoholics Anonymous (AA) and Narcotics Anonymous, focus on "working the steps" of recovery, relying on a mutual support system and developing one's spiritual base. They are the predominant help modality for substance abuse problems in the United States, seeing as many as 93 percent of treatment seekers come through their doors.
Twelve-step-based treatments, or TSAs, are modeled on AA principles but are facilitated by treatment professionals. They show some positive outcomes, but there's an absence of controlled research in this area, according to the Professional Psychology authors. TSAs combine the abstinence-oriented, spiritually focused approach of AA with other approaches that may include education, medication or psychotherapy.
Medications. Two medications--disulfiram and naltrexone--have been approved by the Food and Drug Administration for alcoholism. A third medication that shows promise, acamprosate, is pending FDA approval and is part of a newly launched National Institute on Alcohol Abuse and Alcoholism study called Project COMBINE (see article, page 36). Of the two approved drugs, naltrexone appears to be more effective and to have fewer side effects. Medication trials are also under way for treating other substance abuse disorders such as heroin and cocaine dependence. For cocaine addiction alone, some 60 drugs are under investigation, according to the National Institute on Drug Abuse. In these cases, too, research demonstrates that combining such treatment with therapeutic interventions tends to have the best outcome.
'What works about what works'
In a section of their paper titled, "What works about what works," the authors delineate the common threads to many of the treatments with documented efficacy. These include:
Addressing motivation and reinforcing variables. Efficacious treatments all speak to social, psychological and environmental factors that may serve to reinforce alcohol use or abuse. Coping and social skills training, for instance, teach specific skills for managing alcohol cravings, while 12-step programs reinforce the message of abstinence through step work and slogans like "one drink, one drunk."
Using a nonconfrontational approach. While confrontation that aims to puncture a user's denial has defined some treatment approaches over the years, it is not an effective therapy, the authors write. Rather, research shows that confrontation may undermine the therapeutic relationship by alienating the client. Conversely, effective treatments all use some version of an empathic, nonconfrontational style.
Teaching specific skills. Good treatments share the approach of teaching skills to keep people from drinking or using. Behavioral, marital and family therapy, for instance, teaches strategies for reducing and avoiding drinking, as well as interpersonal skills for relating to one's spouse.
Promoting active coping and goal-setting. All effective treatments call on the client's active efforts to achieve recovery and help the client set goals to do so. Community reinforcement, for instance, conducts "sobriety sampling," where the client works toward a goal of a time-limited sobriety.
Targeting socio-environmental factors. The most successful treatment approaches address the role others play in helping a person recover from alcohol or drug use. Community reinforcement and behavioral marital and family therapy mobilize clients' networks of family and friends to encourage change. Medication treatments can be enhanced by relying on family and friends to improve medication compliance, the authors state.
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