Overview of Alcohol Use Disorders

Alcohol Abuse
A Maladaptive pattern of drinking, leading to clinically significant

Alcohol Dependence
Need for markedly increased amounts of alcohol to achieve intoxication or desired effect The characteristic withdrawal syndrome for alcohol Drinking in larger amounts or over a longer period than intended. Persistent desire of one or more unsuccessful efforts to cut down or control drinking Important social, occupational, or recreational activities given up or reduced because of drinking

impairment or distress, as manifested by at least one of the following occurring within a 12month period:
Recurrent use of alcohol resulting in

a failure to fulfill major role obligations Recurrent alcohol use in situations in which it is physically hazardous Recurrent alcohol-related legal problems Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol).

A great deal of time spent in activities necessary to obtain, to use, or to recover from the effects of drinking
Continued drinking despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to be caused or exacerbated by drinking..

Theoretical Model 7 Major Considerations

1. 2.

3.
4.

5. 6. 7.

Problem severity Concomitant life problems Client expectations Motivation and the therapeutic relationship FRAMES Motivation Enhancement Feedback Responsibility Advice Menu Empathic Self Efficacy Variables maintaining the current drinking problem Social support systems Maintenance of change
Marlatt and Gordons (1985) relapse prevention Model or Disease Model

Steps in Treatment
Case identification and

Developing a functional

motivation to enter Tx Assessment Selection of Tx setting Selection of Tx modalities Enhancing and maintaining motivation to change Selection of drinking goals Initiation of abstinence

analysis Early sobriety strategies Coping strategies Partner/Family involvement Long-term maintenance Managing complicating conditions Self-help groups

Case Identification
CAGE
2 affirmative answers suggest a high probability

for an alcohol use disorder.

AUDIT
May be useful for clients who are reluctant to

self-identify drinking problems.

Motivating a Drinker
Motivational interviewing
Involve family and concerned others

Confrontation/intervention
Other creative approaches

Assessment Tools
Timeline Follow-Back Interview (TFBI)
Structured Clinical Interview for DSM-IV (SCID) Alcohol Dependence Scales (ADS)

Addiction Severity Index (ASI)

Readiness to Change Questionnaire (RCQ) Drinking Patterns Questionnaire (DPQ)

Inventory of Drinking Situations (IDS)

Selection of Treatment Setting

Residential rehabilitation
Usually 28-30 days Historically was the treatment of choice

Outpatient programs
Now the most common settings for treatment,

but there are factors to consider

A myriad of stepped-care considerations

Selection of Treatment Modalities

Self-Help Groups Individual Therapy

Group Therapy
Couple Therapy Family Therapy Intensive Treatment Programs

Enhancing and Maintaining Motivation to Change

Techniques: Feedback Use of motivational interviewing Mutual goal setting and decision making Treatment contracting Instillation of hope

Selection of Drinking Goals

Abstinence
Moderation training Although controversial, a number of studies suggest that the long-term outcomes of alcoholism include reduced drinking Studies have found that giving clients a choice in treatment goals increases compliance with treatment

Initiation of Abstinence
Inpatient detoxification
Ambulatory detoxification Cold Turkey detoxification Graduated program of reduction of drinking

until the client reaches abstinence

Developing a Functional Analysis

Assesses the antecedents to and the

consequences of the clients drinking Incorporates clinical interviewing, questionnaires, and self-recording of drinking and drinking urges

Early Sobriety Strategies

CBT techniques include:
Stimulus control
Dealing with urges Addressing cognitive distortions about

alcohol Alternative/Distracting behaviors Identifying alternative ways to obtain reinforcers Drink refusal skills

Coping Strategies
Dealing with negative affect Many clients have used alcohol as selfmedication, so alternative strategies must be learned Strategies include relaxation, prayer or meditation, increasing the experience of pleasurable events, or the use of anger management or assertiveness skills to cope with angry feelings

Partner/Family Involvement
Information
Responses to drinking and abstinence Decreasing cues for drinking

Support for abstinence

Accessing new social systems

Long-Term Maintenance
Relapse Prevention
2 Basic strategies are used: First, the client develops a list of signs of an impending relapse Second, the client must develop an appropriate response to drinking

Maintaining Contact with Clients

Especially important for alcohol

dependence, as it is viewed as a chronic disorder with high relapse rates

Managing Complicating Conditions

Clinicians must develop a treatment plan

with the multiple, complicated needs of their clients in mind Complications include transportation, income, employment, the legal system, the family, child care, and other comorbid psychological disorders

Self-Help Groups
Clients should be good candidates for

group therapy Even if the client is a good candidate, group therapy should not be forced if the client is adamantly reluctant

Other Variables
Therapist variables Rather than a confrontational style, an empathetic, motivational style is associated with better treatment outcomes
Client variables Clients who have positive expectations about treatment and a greater readiness of change have more positive outcomes

Conclusions
There are a wide variety of assessment tools

available to assist with alcohol use disorders Treatment is planned depending on the nature and severity of the clients drinking Complete abstinence is not the only option Complying with homework assignments, coming to sessions sober, and being honest about drinking behavior are good predictors of a success

Efficacy
Self Help AA Meetings Pagano, White, Kelly, Stout &Tonigan (2012) 226 Partcipants over 10 years in AA group

Alcohol consumption and AA participation, assessed at baseline, end of the 3-month treatment period, Also assessed at 1, 3, and 10 years post treatment Results showed significant direct effects of AA meeting attendance on reduced alcohol outcomes

Efficacy Cont.
A Randomized Trial of Individual and Couple Behavioral

Alcohol (McCray, Epstein, Cook, Jensen & Hildebrandt 2009)

This study was for women only with 102 heterosexual participants It accessed percentage of days abstinent (PDA) and percentage of days

of heavy drinking (PDH) over 6 months of treatment as well as a 12 month follow-up In both treatment conditions, women increased their PDA and decreased their PDH with significantly greater outcomes in the Alcohol Behavioral Couples Treatment (ABCT) in comparison to the Alcohol Behavioral Individual Treatment (ABIT) with maintained results at follow-up

Efficacy cont.
Group Vs. Individual Cognitive-Behavioral Motivational Intervention For Substance Abuse Sobell Sobell, Agrawal (2009)
Study consisted of 52 drug abusers and 212 alcohol abusers

who were given a guided self-change (GSC) treatment a CBT Motivational intervention Treatment outcomes demonstrated significant and large reductions in clients alcohol and drug use during treatment and at the 12-month follow-up, there were no significant differences between the group and individual therapy condition. However it took 41.4% less therapist time to treat clients using the group versus the individual format

Efficacy Cont.
Minnesota Model Treatment Grnbk1 & Bent Nielsen (2007)
This Study compared a Minnesota day clinic treatment

with the traditional public psychosocial treatment in Denmark 87 participants completed the study Self-reported drinking patterns and the seven composite scores from the addiction severity index (ASI) were collected for comparison Results indicated that the Minnesota day clinic condition had a higher percent of abstainers throughout the treatment as well as after the 120motn follow up but had no real difference in effect sizes

Meta-Analysis
Miller & Wilbourne (2002)

Compared 361 controlled studies on Alcohol Use

Disorders
Results

Modalities with Strongest Efficacy

Brief interventions, social skills training, the community reinforcement approach, behavior contracting, behavioral marital therapy and case management, opiate antagonists (naltrexone, nalmefene) and acamprosate

Modalities with the Weakest Efficacy

Methods designed to educate, confront, shock or foster insight regarding the nature and causes of alcoholism

Case Study with Cognitive Analytic Therapy

Client: Theresa a 57 year old women diagnosed with alcohol dependence

Intervention: Cognitive Analytic Therapy (CAT) an integration of cognitive and psychoanalytic techniques
Pre-Treatment Client Issues: Drank one bottle of vodka daily Reported guilty about her behavior and relationship with her daughter Reported deficits in confidence as well as suicidal ideation Post Treatment Results: Sustained Abstinence at 2 year follow up Increases in confidence and absence of suicidal thoughts Improvement in familial and other interpersonal relationships