Alcoholism and Substance Abuse Dependency CEUs - Page 2

A Counseling Approach

 

1. OVERVIEW, DESCRIPTION, AND RATIONALE

 

1.1 General Description of Approach
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This approach to counseling is based on the belief that a condition of susceptibility to chemical addiction exists prior to the first use, sometimes referred to as a "genetic predisposition." It is also based on the belief that chemical addiction is a disease repeatedly reinforced by self-judgment; therefore, it is a disease of self-judgment.

This model views addicts and alcoholics as individuals chronically addicted to chemicals in spite of their attempts to change. They are in a vicious cycle of use, self-judgment, and avoidance that is repeated time and again. The model focuses on three elements of the cycle:

  1. Chemical use.
  2. Self-judgment.
  3. Avoidance behaviors.

The approach to counseling is strongly based on the 12 steps of Alcoholics Anonymous (AA).

The three elements of the addictive cycle are impacted by a process created by using:

  1. A therapeutic environment.
  2. A thorough assessment.
  3. A group process.
  4. Education.
  5. Self/peer assessment.

All five items are incorporated into a therapeutic process, which begins with the first contact.

The creation of an environment that supports the therapeutic process is essential to this approach. Clients must be provided with an opportunity to explore their self-judgments without fear of the judgment of others. They must feel they are listened to with empathy and respect. In earlier models of this approach, the counselor was the only one who possessed so-called counselor characteristics. Although this element is still critical, it now applies to the whole multidisciplinary team, a staff of professionals who are naturally therapeutic.

The counselor conducts an initial assessment, identifies the presenting problem, and, if indicated, schedules the client for treatment.

A thorough psychosocial assessment is conducted, and identified blocks to treatment or problems are noted. The counselor begins the bonding with the client during the assessment process. All counseling skills come into play. The counselor then prepares a therapeutic or treatment plan (i.e., the change model) to help the client deal with those identified problems or blocks that will prevent response to the treatment process.

The client follows a simple change model that closely aligns with the 12 steps of AA.

Model AA Step
Identify the problem Step 1
Develop trust (renewed hope) Steps 2 and 3
Ventilate Steps 4 and 5
Gain new insight Steps 6 and 8
Change behavior Step 7 and Steps 9 through 12

Clients are guided through the first 5 steps of the 12-step model and receive educational materials on the remaining 7.

The first five steps help clients focus on the goals of this approach.

Step 1. Acceptance is clearly necessary in identifying the problem.

Step 2. The perception is a return to a sense of hope.

Step 3. Turn over to a new behavior.

Steps 4 and 5. Facilitate ventilation or catharsis and give clients new insight and, as a result, new behaviors.

After completing the treatment process, clients are referred to continuing care groups that meet once a week. Additional meetings can be scheduled if indicated.

Psychotherapy or marital counseling can also be a part of the continuing care process, if appropriate.

Twelve months of continuing care and a minimum of three AA meetings a week are a part of the treatment program.

 

1.2 Goals and Objectives of Approach

Goals. Identify the primary problem as chronic addiction to mind- or mood-altering chemicals.

Gain a renewed sense of hope; come to believe wellness is possible.

Experience lifestyle changes that promote a renewed sense of self-esteem by practicing healthy emotional management and increasing personal responsibility.

Objective. Identify the problem.

No one can change what cannot be seen. The program leads clients through a sequence of tasks that are designed to help identify the problem.

  • Life story.
  • Ten consequences.
  • AA first step.

All of these tasks are shared with staff and peers.

Strategies/Techniques. The counselor asks the client to look at a mirror image that he or she has created through drug use (i.e., self-discovery). All of the tasks will be reviewed with or by the counselor and peers. The counselor may choose to have the client review them in a one-on-one session first. This session can provide emotional insulation from a more public sharing with a group of peers, but it is not intended to take the place of receiving peer feedback.

Objective. Develop trust.

A common philosophy that is shared by all staff members is the basis for helping the client develop trust. Clearly written policies and procedures that are understood by all the staff members facilitate trust and create an environment of consistency. Beginning to trust brings a renewed sense of hope.

Strategies/Techniques. The counselor can use all the counseling skills to facilitate this objective. The initial assessment, or in some programs the psychosocial assessment, is where this development of trust with the counselor begins. Attending, empathy, genuineness, and honesty are some of the counselor's tools. The psychosocial assessment is an excellent opportunity for the counselor to create a therapeutic relationship with the client. The counselor should make it a joint effort to explore the different areas of the client's life. It must be more than a process to collect data.

Objective. Experience a catharsis/ventilation.

The client must be given the opportunity to begin looking at and bringing out the secrets that are the bases for his or her self-judgments. It is the primary purpose of the fourth and fifth steps of AA. Self-disclosure is cathartic and can lead to self-discovery.

Strategies/Techniques. The counselor should guide the client to deeper levels of self-disclosure through the use of treatment plan objectives and helping skills and must stay focused on those areas related to the addiction or the identified blocks that prevent the client from responding to the program. Remember that catharsis/ventilation does not necessarily mean crying. For example, ask the client to share with the group five words that describe how his or her parent feels about having a child in treatment. Then have the group help the client explore this issue.

Objective. Gain new insight.

It is important that this be the client's self-discovery and that he or she begins to see the consequences of his or her behaviors, the defects of character, and the people who have been harmed. This insight, facilitated by Steps 4 and 5 (catharsis), leads the client to Steps 6 and 8 (insight).

Strategies/Techniques. Treatment plan objectives, group tasks, and facilitated exploration of the issues identified by the client can lead to new insight. Have the client share one of the items from his or her list of 10 consequences with the group and ask for feedback. Have the client read the story from the Big Book of AA that is closest to him or her and share with the group. Ask each client to share a secret not previously shared and tell the group what he or she has learned.

Objective. Change behavior.

The program must contain activities designed to facilitate learning of new behaviors. Being assigned to a small group helps clients learn to use groups as support. The buddy system used in some programs helps clients begin to learn the behavior of using a support system outside of themselves.

Strategies/Techniques. The counselor should monitor the client's behavior throughout the treatment process, frequently giving feedback. This is the beginning of learning to use a sponsor, which is deemed critical by most AA members. Treatment plan tasks can require the client to try using a new behavior to cope with certain problems.

 

1.3 Theoretical Rationale/Mechanism of Action

By facilitating the client in experiencing a change in the way he or she believes, feels, and behaves, this approach is implemented with the following premises:

  1. What the client believes is the basis for his or her self-judgment. Self-esteem is not taken away by others. It is taken away by self-judgment based on the client's belief system.
  2. A key to this approach is the premise that negative feelings that are not dealt with do not go away. These avoided feelings become the basis for the loss of self-esteem.
  3. Successful new behavior is the basis for a renewed positive sense of self.
Change Model
  1. Identify the problem as chemical use.
  2. Gain a sense of trust.
  3. Ventilate feelings.
  4. Gain new insight into life and behaviors.
  5. Change behaviors.

1.4 Agent of Change

The primary agent of change is the combination of spirituality, the individual, and the treatment process (the therapist, the group, the 12 steps, and the treatment program).

 

1.4.1 Spirituality.

In general, spirituality is defined as a healthy relationship with the things and people who are valued. By helping the client improve his or her relationships, spirituality becomes a primary agent of change.

 

1.4.2 The Individual.

Drug addiction, which is classified as a disease, requires three components to meet the definition:

  1. An agent or drug.
  2. A host or individual.
  3. An environment.

If any one of the three components is removed, the chronic progression of the disease is interrupted. By focusing on the individual, he or she becomes a primary agent of change.

 

1.4.3 Treatment Process.

The treatment process is a primary agent of change in this counseling approach; the therapeutic community, which encourages honesty, openness, and bonding, becomes a primary agent of change.

 

1.5 Conception of Drug Abuse/Addiction, Causative Factors

This model is based on the belief that drug addiction is a disease. Most probably the client is genetically predisposed. Certainly the client is biochemically altered. The client is also psychologically affected by the emotional mismanagement and distortion of the defense systems. By inhibiting or supplanting the social coping skills of the client, drug addiction has a disastrous effect on all social areas. Drug addiction is a biopsychosocial disease characterized by physical deterioration, a prevailing sense of hopelessness, and severe emotional isolation. The client also experiences a gross violation of his or her value system.

 

2. CONTRAST TO OTHER COUNSELING APPROACHES

 

2.1 Most Similar Counseling Approaches

Counselors who have been fortunate enough to be trained in a program that is based on an interdisciplinary philosophy will have the benefit of both counseling psychology and the 12-step model. Hazelden would probably be the closest. All counselors trained at both the Navy Alcohol Treatment Specialist School and the Johnson Institute during the 1970s would share this approach to counseling.

 

2.2 Most Dissimilar Counseling Approaches

These include:

  • Approaches that are not based on total abstinence.
  • Approaches that do not deal with feelings.
  • Approaches that do not use the 12 steps of AA.

3. FORMAT

 

3.1 Modalities of Treatment

This approach primarily uses the small group process. Individual sessions are used when warranted.

 

3.1.1 Individual Sessions.

The individual session is used in the assessment phase at the beginning of treatment and for individual planning sessions during the course of treatment. Some individual counseling may be offered to give the client an emotional insulation. A client's first attempts at being more open will be frightening. By sharing with a counselor beforehand, the client may be able to disclose within his or her group more readily.

  • Goals. These include individual planning, clarification, reassessment, or help in exploring a client's highly traumatic issues.
  • Process. The individual session can be scheduled at the request of the counselor or the client. The goal is stated, and the process begins. The process is dictated by the goal, but all have a beginning, a middle, and an end.
3.1.2 Group Sessions.

All activities are designed to have the client learn to use small groups as a support system. Each group remains as autonomous as possible to encourage the client to be more open and share at a deeper level. This also prevents triangulation and defocusing. It is easier to hide in a large group.

  • Goals. Help the client learn to use small groups for support, for feedback, and for communication skills, as task oriented or process oriented.
3.1.3 Other Group Sessions.

Other special groups can be utilized for topics like grief or sexual abuse and other types of physical and emotional abuse. These are sometimes called special treatment population groups or focused groups.

  • Goal. To help the client use peers who have a similar experience for support.
  • Process. Having clients who share a significant experience facilitates the bonding and thus the self-disclosure or catharsis.
3.2 Ideal Treatment Setting

The ideal setting would be to match the treatment to the individual. This approach works best in inpatient and outpatient programs; however, the approach can be utilized as a base in any setting.

Some of the activities would be altered, but the process would be the same.

  1. Identify the problem.
  2. Develop a sense of trust and hope.
  3. Ventilate.
  4. Gain new insight.
  5. Change behavior.

3.3 Duration of Treatment

The ideal format for this approach is a small group. The duration would be 1-1/2 hours (15 minutes). The group should number between 8 and 10 people (the number could affect the duration). Each client's level of functioning would also have an impact on the duration.

The use of open-ended groups in alcohol and other drug counseling is almost universally utilized and is probably the best format. Clients should attend the primary group for at least 6 weeks. This could include 2 to 3 weeks of inpatient treatment and 3 to 4 weeks of outpatient treatment. The number of sessions would generally vary with the settings. Key, however, is to include 12 months of continuing care.

There have been some studies suggesting that it takes 21 days (3 weeks) to let go of old attitudes and 21 days to develop new ones. This premise would strongly indicate the need for a program with a 6-week duration.

Inpatient groups should have one primary counseling group every day. Outpatient groups should meet once a day, four times a week.

 

3.4 Compatibility With Other Treatments

This approach would be compatible with family programs, diversion programs, probation and correctional programs, adolescent programs, and driving under the influence programs, within a broad range of treatment settings.

This counseling approach would not be compatible with programs that used psychoactive drugs or programs that did not focus on abstinence as a primary goal.

 

3.5 Role of Self-Help Programs

This approach is a balanced integration of 12-step programs and a solid counseling approach. NA, AA, and other self-help groups are key elements in this approach. Since NA and AA have abstinence as a primary goal, both are a part of the counseling approach. Using attendance at meetings as part of the treatment plan sets the groundwork for using meetings as a continued support after treatment.

 

4. COUNSELOR CHARACTERISTICS AND TRAINING

 

4.1 Educational Requirements

The educational requirements for the counseling approach would ideally include:

  • Bachelor's or master's degree in either the behavioral sciences or the counseling psychology fields.
  • Certification by a State or national certifying organization.
  • Specific training in working with special treatment populations.
4.2 Training, Credentials, and Experience Required

Counselors should have a certificate in chemical addiction education and should be certified as addiction counselors by a State or national organization. Counselors should also have a minimum of 3 years of experience.

All counselors using this counseling approach need:

  • Comprehension of the addictive process and how it is to be treated.
  • A comprehensive curriculum of the addictive process and how it is to be taught.
  • A viable, realistic opportunity to demonstrate knowledge, comprehension, and expertise to practice the counseling skills in a classroom setting with clients in a supervised practicum.
  • A method of analysis and an opportunity to apply it.
  • A method of analyzing client data and the opportunity to apply it.

The opportunity to demonstrate an ability to synthesize knowledge, comprehension, application, and analysis into a viable approach to counseling.

 

4.3 Counselor's Recovery Status

The counselor need not be recovering, but counselors who are not in recovery must have a demonstrated understanding of the disease. Counselors who are recovering might be quicker but not necessarily better.

 

4.4 Ideal Personal Characteristics of Counselor

To utilize this counseling approach, an individual needs some innate helping skills. He or she must have the ability to touch people emotionally.

To utilize this approach successfully, the counselor should have the following characteristics:

  • Empathetic understanding.
  • Respect and acceptance for others.
  • Sincerity.
  • Good timing.
4.5 Counselor's Behaviors Prescribed

The counselor needs to be able to facilitate clients' exploration of their disease. He or she must be:

  • Tactful, yet confrontive.
  • Evaluative.
  • Emotionally present, yet objective.

4.5.1 Comment/Confrontation. Confrontation is the most confused and misused of the counseling skills. When it comes to misused skills, it is probably second only to doing therapy without the necessary skills to do it correctly. Confrontation must be done with respect for the client. It is a tool, not an end item. The avoidance behaviors must be confronted; the elephant in the living room must be brought to someone's attention. If the counselor's empathy is accurate, he or she will know how to gauge the confrontation. Confrontive therapy can be long and expensive and generally does not work with addicts and alcoholics.

 

4.6 Counselor's Behaviors Proscribed

 

4.6.1 Judgmental Behavior.

If the counselor does not believe addiction is a disease, or he or she has personal beliefs that go against the program's philosophy, the counselor needs to work elsewhere.

 

4.6.2 Coaddiction.

If the counselor has enabling behaviors that shortcut the process or enable the client's avoidance system, the counselor should either find another helping field or get help.

 

4.6.3 Dishonesty.

If the counselor cannot be honest with his or her peers and with the clients, the counselor should either find another helping field or get help.

 

4.6.4 Fear.

If the counselor is frightened by addicted clients, he or she cannot help them.

 

4.6.5 Feedback.

If the counselor cannot work as a part of a team and accept and consider feedback, he or she will prevent clients from receiving the best possible therapy.

 

4.7 Recommended Supervision

Supervision works best when it is provided by a trained staff member who is outside of the management team. Too many programs use the clinical supervisor as the program supervisor. The combination of direct supervision and case review gives the counseling staff the most credible supervision and feedback.

 

4.7.1 Direct Supervision.

Frequent and rotational direct participation in counseling groups and sessions gives the supervisor the opportunity to evaluate the counselor's skills and his or her application of them.

 

4.7.2 Case Review.

Counselors should follow a schedule of case presentation. They can present one on one to the supervisor or in a group of their peers.

 

5. CLIENT-COUNSELOR RELATIONSHIP

 

5.1 What Is the Counselor's Role?

The counselor's role is to facilitate, that is, to be a teacher, coach, peer, and even adviser.

 

5.2 Who Talks More?

Because the bulk of time is spent in group process and the client's peers are utilized, most of the talking is done by the client. This would depend somewhat on the style and personality of the counselor.

 

5.3 How Directive Is the Counselor?

The amount of direction by the counselor depends primarily on where the client is in the treatment process and who the client is emotionally.

 

5.4 Therapeutic Alliance

The client must trust the counselor. The counseling characteristics and their application are key to having a good relationship with the client. If the counselor frequently checks in with the client and involves the client in the planning of the treatment, the quality of the relationship will be maintained. When the relationship is poor, the counselor should ask the client to help get the relationship back on track.

 

6. TARGET POPULATIONS

 

6.1 Clients Best Suited for This Counseling Approach

The general population and its subgroups are suited for this approach. All forms of chemical addiction are suited for this approach, including alcohol and tobacco.

 

6.2 Clients Poorly Suited for This Counseling Approach

Individuals who have significant organic brain damage or a significant psychiatric or psychological block to insight based on a comprehension of behaviors and their resultant feelings are not well suited.

 

7. ASSESSMENT

This model uses a comprehensive psychosocial assessment tool that reviews:

  1. Initial assessment/problem evaluation. The presenting problem is often the basis for the initial assessment. This first contact reviews a client's current status and is the basis for an initial diagnosis.
  2. Physical/medical history. A physical examination of the client's medical condition is conducted, and a physician takes a medical history.
  3. Nursing assessment. The client's mental status and emotional and psychological history are tested, including any evaluated blocks to treatment.
  4. Spiritual assessment. The client's relationship with his or her spiritual connection and his or her religious experiences are reviewed, including any possible block to treatment.
  5. Psychosocial assessment. The client's mental status and emotional and psychological history are assessed, including any evaluated blocks to treatment.
  6. Social/chemical background. This includes chemical history, activities, financial, vocational, military, legal history, sexual history, marital history, losses, emotional behavior, and family of origin.
  7. Clinical formulation. The clinical formulation is the bringing together of a description of the identified behaviors and problems and formulating them into a behavioral and problematic description of the client.

8. SESSION FORMAT AND CONTENT

 

8.1 Format for a Typical Session

The format would be a group session. All the assigned members of the group would be seated in a circle. The session would begin with a reading of group rules and possibly a reading from a daily meditation book.

A session could have a purpose or be open to the group need. Some clients may have scheduled tasks. The counselor may ask a group member to report on a previously discussed issue. Some group sessions will have an educational component, while others may be more task oriented.

All sessions would be closed in a specific manner. A closure activity, normally agreed on by the group, would add a specific emotional and symbolic closure of process.

 

8.2 Several Typical Session Topics or Themes

As a facilitator, the counselor may suggest a topic or point the group toward certain tasks. The session may be predesignated, assigning a certain day to a first-step group.

 

8.2.1 First Step.

The client is asked to write a first step related to his or her drug use following the guidelines of AA, usually with a form that asks for answers to specific questions. The client is asked to read this to the group and receive feedback. More than one first step may be read in a session.

 

8.2.2 Life Story With Feedback.

The client writes a life story using a guidesheet that leads him or her through important/significant life events. In some programs the reading may be done in a leaderless group. The peers are then asked to fill out a feedback sheet. The following day, in regular group, under the supervision of the counselor, the client's peers offer supportive feedback.

 

8.2.3 Secrets Group.

(This is a very brief description of the process.) The secrets group usually asks the client to share a secret not previously shared. One format asks the group members to write a secret on a slip of paper and put it in a bowl. The bowl is then passed around the group, each member taking out a secret and reading it aloud to the group and then making a comment. All group members who want to comment are then given a chance to share how they feel about this particular secret. It gives the writer of the secret a chance to receive feedback and still keep the secret.

 

8.2.4 Typical Group.

The session begins with a group member reading the rules. A round-robin may be used, going around the group in order. Issues can be identified and in some cases worked on. Before closing, the counselor sees where each member is in the group. Usually some ritual is used, like a group hug, a chant, or a prayer.

 

8.3 Session Structure

Sessions are generally not highly structured, which does not preclude the use of structure if indicated.

The counselor may choose to use an experiential exercise to address an issue of common concern or to get the group moving. The ideal group would be self-starting and possibly task oriented.

 

8.4 Strategies for Dealing With Common Clinical Problems

Most logistical and clinical problems are dealt with as group issues. However, some problems may be dealt with one on one or with the clinical team, if available. Whatever happens in group or is brought to the group becomes a workable issue.

 

8.5 Strategies for Dealing With Denial, Resistance, or Poor Motivation

 

8.5.1 Peer Feedback.

The counselor can use the group to confront, support, or give feedback on particular issues. An issue may come up in group; after the client processes it, the counselor may ask how the group feels about it, the process, how their peer handled it, and so forth.

 

8.5.2 Staffing.

The counselor can ask the client to receive feedback from the clinical team involved in his or her case. Staffing may also be a part of the client evaluation system. The goal is to resolve the issue in a therapeutic manner. Some programs require the staff to conduct a staffing as a part of assigning poor progress. Staffing is usually feedback from the clinical team.

 

8.5.3 Conjoint Sessions With Family Members.

These sessions are usually used to ensure that all members of the family are aware of the continuing care plan. They also clarify any issues that may be problems in posttreatment.

 

8.5.4 Group Tasks or Experiential Exercises.

Group tasks are usually from a specific objective listed in the treatment plan. Experiential exercises are normally for an issue that is applicable to the whole group.

 

8.6 Strategies for Dealing With Crises

The primary strategy for dealing with crises is good training and a good clinical relationship with the client, guided by sound policies. The counselor and the facility in which he or she works should have clear policies regarding the management of a crisis. Good training in this area is needed, coupled with the knowledge of available resources.

 

8.7 Counselor's Response to Slips and Relapses

The counselor should use a nonjudgmental attitude in a confronting manner to focus the client on the disease. With the advent of the relapse prevention model, a special track may be utilized. Repeated slips also could be grounds for terminating the counseling or treatment process. In most inpatient facilities, when a client uses alcohol or other drugs while in treatment, he or she is asked to leave on the grounds of low motivation. In other facilities, the client may be asked to sign a nonuse contract, and the relapse is used as a clinical issue.

A slip or relapse can be another catalyst to help the client identify the problem.

 

9. ROLE OF SIGNIFICANT OTHERS IN TREATMENT

This counseling approach presumes a concurrent family education and treatment program. The success rate increases significantly when family members are involved. A questionnaire should be sent to those significant others (SOs) considered to have the closest association with the client. The answers on the questionnaire assists the counselor in confronting the denial system and also helps stop the triangulation often used by clients to continue their avoidance system.

SOs who are themselves in recovery from coaddiction will provide a supportive, nonenabling support group for the client after treatment. The family who is in recovery together has a better chance.

 

A Psychotherapeutic and Skills-Training Approach to the Treatment of Drug Addiction

 

1. OVERVIEW, DESCRIPTION, AND RATIONALE

 

1.1 General Description of Approach
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This approach integrates psychotherapeutic and coping skills-training techniques with abstinence-based addiction counseling. The primary goals of treatment are to enhance and sustain patient motivation for change, establish and maintain abstinence from all psychoactive drugs, and foster development of (nonchemical) coping and problem solving skills to thwart and ultimately eliminate impulses to "self-medicate" with psychoactive drugs. The approach combines cognitive-behavioral, motivational, and insight-oriented techniques according to each client's individual needs. The therapeutic style is empathic, client centered, and flexible. Strong emphasis is placed on developing a good working alliance with the client to prevent premature dropout and as a vehicle for promoting therapeutic change. The counselor attempts to work with and through rather than against a client's resistance to change. Aggressive confrontation of denial, the hallmark of traditional addiction counseling, is seen as counterproductive and antithetical to this approach. Group and individual counseling are delivered within the context of a structured yet flexible multistage outpatient treatment program that also includes psychoeducation (PE) for both the primary client and his or her family; supervised urine testing to encourage and verify abstinence; and, where indicated, pharmacotherapy for coexisting psychiatric disorders. Patient participation in self-help is encouraged but not mandated, and accepting the identity of addict or alcoholic is not required.

 

1.2 Goals and Objectives of Approach

Enhance the client's motivation for change.

  • Teach the client how to break the addictive cycle and establish total abstinence from all mood-altering drugs.
  • Teach the client adaptive coping and problem solving skills required to maintain abstinence over the long term.
  • Support and guide the client through troublespots and setbacks that might otherwise lead to relapse.
1.3 Theoretical Rationale/Mechanism of Action

This approach views psychoactive drug addiction as a multidetermined addictive behavior and maladaptive (self-medication) coping style with biological, psychological, and social components. Accordingly, treatment must provide the structure, support, and feedback required to break the behavioral cycle of compulsive psychoactive drug use and provide opportunities to learn adaptive (nonchemical) problem solving skills to prevent relapse.

 

1.4 Agent of Change

This approach actively promotes the development of a strong therapeutic alliance between client and counselor along with positive bonding among clients within a group. To ensure continuity of care, each client receives both group and individual therapy from the same counselor.

 

1.5 Conception of Drug Abuse/Addiction, Causative Factors

Drug addiction is seen as a multidetermined addictive behavior and maladaptive (self-medication) coping style with biological, psychological, and social components. Although initial exposure to psychoactive drugs may have resulted largely from social and cultural factors (including peer pressure), the driving force behind continued and repeated use of these drugs (before pharmacological and physiological addiction set in) is an attempt to qualitatively and quantitatively alter one's experience and internal feeling states. Psychoactive drugs are used by certain (predisposed) individuals to amplify, modulate, obliterate, or transform certain feelings in ways they have been unable to achieve by other (nonchemical) means.

 

2. CONTRAST TO OTHER COUNSELING APPROACHES

 

2.1 Most Similar Counseling Approaches

This approach contains many original elements (Washton 1989) and incorporates features of other approaches, including motivational counseling techniques described by Miller and Rollnick (1991), relapse prevention (RP) strategies described by Marlatt and Gordon (1985), and psychodynamic techniques described by Brehm and Khantzian (1992).

 

2.2 Most Dissimilar Counseling Approaches

The hallmarks of this approach are clinical flexibility and careful attention to individual differences. As such, it contrasts sharply with aggressive confrontational approaches commonly found in traditional treatment programs. Participation in Alcoholics Anonymous (AA) or other self-help programs is actively encouraged and is seen as helpful and highly desirable, but it is not mandatory.

 

3. FORMAT

Treatment involves a combination of group therapy two to four times a week supplemented by individual counseling once a week. A supervised urine sample is taken from every client at least twice a week, and breathalyzer tests are administered on a random basis throughout the program. Although group therapy is the core treatment modality for most clients, those who refuse to enter group therapy are given the option of individual counseling two to three times a week. Many of these clients subsequently agree to enter group therapy once they have formed a positive relationship with their individual counselor and worked through their initial concerns about participating in a group. Some clients are not able to tolerate group as a result of psychiatric and/or interpersonal impairments. Treatment for these clients may consist of individual therapy two to three times a week, including urine and breathalyzer testing.

 

3.1 Modalities of Treatment

Group and individual counseling are delivered within the context of a structured yet flexible multistage outpatient treatment program that also includes PE for both the primary client and his or her family; supervised urine testing to encourage and verify abstinence; and, where indicated, pharmacotherapy for coexisting psychiatric disorders.

 

3.2 Ideal Treatment Setting

This approach was developed within an outpatient treatment setting and as such recognizes that the client is continuously faced with the pressures and stressors of daily life and with easy access to a wide variety of psychoactive drugs. It also recognizes that in the outpatient setting the client is always free to drop out of treatment; accordingly, strong emphasis is placed on therapeutic engagement and retention strategies, particularly at the beginning of treatment when outpatient dropout rates are highest.

 

3.3 Duration of Treatment

A distinguishing feature of this program is its variable-length format. The length of a client's participation in the program from admission through completion ranges from 12 weeks to 24 weeks as determined by objective measures of clinical progress (i.e., providing clean urines, attending scheduled sessions, developing a sober support network that includes involvement in self-help, and exercising adaptive [nondrug] problem solving skills). A prespecified set of behavioral contingencies adjusts the length of treatment according to individual need. The average number of sessions from admission to completion is approximately 40.

 

3.4 Compatibility With Other Treatments

Operating from a basic philosophy of using whatever seems to work best, this approach is naturally compatible with a variety of other treatments. The program has no antimedication bias so long as the medications being offered are clinically appropriate and noneuphorigenic. Where appropriate, naltrexone and disulfiram are utilized to foster RP. Clients with diagnosed psychiatric disorders are treated with psychotropic medication (e.g., antidepressants, antipsychotics) as clinically required. The program does not dispense methadone or other addictive drugs.

 

3.5 Role of Self-Help Programs

The program actively encourages but does not mandate the client's participation in AA, Cocaine Anonymous (CA), Narcotics Anonymous (NA), or other self-help groups. All clients are given a basic orientation to self-help and what it has to offer that professional treatment does not. They are also given a list of meetings in their community and provided with a buddy (fellow group member) if they feel hesitant or uncomfortable about attending self-help meetings alone. Clients are not threatened with termination from treatment for failure to attend self-help meetings, nor is their reluctance or refusal to attend self-help meetings seen as intractable resistance or denial. The overwhelming majority of clients in the program do, in fact, attend self-help meetings.

 

4. COUNSELOR CHARACTERISTICS AND TRAINING

 

4.1 Educational Requirements

A master's degree in social work, counseling, or psychology is the minimum educational requirement for all clinical staff.

 

4.2 Training, Credentials, and Experience Required

All counselors must have State certification in clinical social work (C.S.W.), clinical psychology (Ph.D.), or addiction counseling (C.A.C.), plus a minimum of 3 years of full-time clinical experience working in an addiction treatment program (preferably an outpatient program).

 

4.3 Counselor's Recovery Status

The counselor's status is irrelevant. Counselors are chosen solely on the basis of their demonstrated clinical competence and not on the basis of their recovery status.

 

4.4 Ideal Personal Characteristics of Counselor

Ideally, the counselor should be warm, empathetic, engaging, tolerant, nonjudgmental, and flexible in interacting with clients. The counselor should have a well-developed observing ego and be able to receive and use constructive feedback, particularly with regard to the types of countertransference and control problems likely to arise with highly ambivalent (resistant) clients. The counselor must have excellent verbal communication skills and be capable of defining and implementing appropriate behavioral limits with clients in a consistently therapeutic (nonpunitive) manner.

 

4.5 Counselor's Behaviors Prescribed

The counselor's role is to motivate, engage, guide, educate, and retain clients during all phases of the program. Using an array of motivational, client-centered, and problem solving techniques, counselors are expected to:

  • Emphasize the client's strengths rather than weaknesses.
  • Join rather than assault (confront) resistance.
  • Avoid aggressive confrontation and power struggles.
  • Negotiate rather than pontificate treatment goals.
  • Emphasize the client's personal responsibility for change.
4.6 Counselor's Behaviors Proscribed

The counselor is cautioned against being dogmatic and controlling, especially in response to reluctant and resistant clients. It is easy for the counselor to lose sight of the fact that the first and foremost goal of treatment is to engage the client in a friendly, cooperative, positive interaction that increases the client's willingness to examine and change his or her drug-using behavior. Counselors are taught how to avoid the most common therapeutic blunders and negative countertransferential responses with drug-abusing clients. These include:

  • Predicting abject failure and misery if the client does not follow the counselor's advice.
  • Telling the client that what he or she really needs is more drug-related negative consequences to acquire the motivation for change.
  • Ignoring discrepancies between the program's goals and the client's goals.
  • Feeling frustrated and angry at clients who do not fully comply with the program.
  • Wanting to impose negative consequences on noncompliant clients (e.g., depriving them of further help by "throwing them out of treatment") rather than negotiating a change in a treatment plan based on clarification of the client's ambivalence about change.
4.7 Recommended Supervision

The counselor's job is a demanding one, and clinical supervision is required not only to sharpen clinical skills and ensure consistency in treatment approach but also to provide the counselor with emotional support and encouragement. All counselors receive 1 hour of group supervision and 1 hour of individual supervision each week. Supervisors use statistical reports (computer printouts) to monitor each counselor's client caseload and work performance. These reports include data on client retention/completion rates, attendance at sessions, urine test results, and goal attainment ratings. Measures of all counselors' work performance include data on quantity of clinical services provided to clients (i.e., numbers of sessions), responses to positive urine test results and missed sessions, timeliness of followup on clients who drop out or fail to show up for sessions, and counselors' compliance with chart-noting requirements. Supervisors pay special attention to client dropout rates, since retention is a key factor in determining treatment success. Supervisors occasionally sit in on counselors' group sessions to directly observe their therapeutic skills in action. Videotaping and audiotaping of sessions (with the client's written consent) is also used in supervision. In addition to supervisory meetings, there is a daily case conference attended by all counselors for assigning new cases and discussing special problems. Once each month, there is an inservice training session on a specific clinical topic.

 

5. CLIENT-COUNSELOR RELATIONSHIP

 

5.1 What Is the Counselor's Role?

The counselor serves a multidimensional role as collaborator, teacher, adviser, and change-facilitator.

 

5.2 Who Talks More?

In general, the client talks more. However, the counselor does not hesitate to offer education, advice, and guidance where appropriate.

 

5.3 How Directive Is the Counselor?

The counselor takes an active role, offering specific advice and direction, particularly during the early phases of treatment where immediate behavioral changes are required to establish and maintain abstinence.

 

5.4 Therapeutic Alliance

One of the most important aspects of the therapeutic alliance (TA) approach is the development of a cooperative relationship between client and counselor. Building a positive TA requires the counselor to start where the client is (i.e., to accept and work within the client's frame of reference). This stands in marked contrast to traditional approaches, which demand that the client submit to the counselor's (program's) frame of reference as the starting point of treatment. For example, if the client at first minimizes the seriousness of his or her drug use problem or rejects the idea that it is a problem at all, the counselor refrains from accusing the client of being in denial (a tactic likely to heighten rather than reduce the client's defensiveness) and instead asks the client to cooperate in a time-limited experiment (usually involving a trial period of abstinence) to assess the nature and extent of his or her involvement with psychoactive drugs. Coerced or mandated clients pose the greatest challenge to getting a TA started. Typically, these clients appear for treatment angry, suspicious, mistrustful, and ready to do battle. Building a relationship under these trying circumstances requires a great deal of clinical finesse on the part of the counselor, who makes every effort to:

  1. Empathize with the client's plight and the fact that no one likes to be told what to do.
  2. Accept without challenge the client's primary motivation for coming to treatment—to get the coercing agent (e.g., court, employer) "off my [the client's] back."
  3. Compliment the client for facing the realities of the situation by showing up at the session.
  4. Detach himself or herself as much as possible from the coercing agent and offer to help the client solve the problem or problems that led to the current situation.

6. TARGET POPULATIONS

 

6.1 Clients Best Suited for This Counseling Approach

This treatment is best suited for clients who meet DSM-IV criteria for psychoactive drug addiction and are able to show up for scheduled sessions at an outpatient clinic. The program admits clients who are actively using alcohol and other drugs and those who have already achieved abstinence as inpatients or outpatients. The program treats all types of chemical addiction and cross-addictions irrespective of the client's drug of choice (e.g., alcohol, cocaine, heroin) and has been used successfully with both adult and adolescent populations (treated separately). Chronically unemployed, dysfunctional clients are treated in separate groups from clients with substantially higher levels of psychosocial functioning. The program is coeducational, but a special women's group is available for those who prefer to be treated in an all-female environment. A special dual-focus group (separate from the mainstream program) accommodates the special needs of clients with concurrent psychiatric illness.

 

6.2 Clients Poorly Suited for This Counseling Approach

Poorly suited candidates for this approach include clients whose psychosocial functioning is so impaired that they are unable to show up for treatment sessions and those who are actively suicidal, psychotic, or otherwise psychiatrically unstable and in need of more structured, intensive care such as an inpatient or partial hospitalization program.

 

7. ASSESSMENT

The pretreatment evaluation process begins by asking the client to fill out an extensive self-administered assessment questionnaire (the Washton Institute Intake Evaluation Form) (Washton 1995) immediately prior to a 1-hour, face-to-face clinical interview with the intake counselor. The assessment questionnaire covers the domains of:

  1. Drug use.
  2. Motivation and readiness for change.
  3. Psychiatric history and status.
  4. Family history.
  5. Vocational history.
  6. Criminal history.
  7. Treatment history.

During the subsequent clinical interview, the counselor seeks to clarify and expand the information already provided by the client on the assessment form. Perhaps more importantly, the counselor makes an active attempt to motivate and engage the client in a therapeutic interaction. Where indicated, the pretreatment evaluation process may require one or more additional sessions and may also include a formal psychiatric assessment. An extremely important aspect of the pretreatment evaluation is assessment of the client's motivation and readiness for change. This involves identifying with the client both internal and external factors currently driving him or her to at least explore the possibility of change. It also involves helping the client identify his or her ambivalence about stopping psychoactive drug use by objectively exploring both the positive and negative effects of the use and by defining the client's treatment goals and to what extent these are consistent with the program's goals. With regard to treatment goals, some clients want to reduce rather than completely stop using their drug of choice, while others want to give up only the one drug causing them the most obvious problems (e.g., cocaine) but not the drugs they view as relatively innocuous and nonproblematic (e.g., alcohol and marijuana). Clients who want to enter an early abstinence group must agree to stop using all psychoactive drugs (total abstinence) for at least a trial period. Clients who do not agree to meet this requirement are offered the option of time-limited individual counseling (up to 6 weeks) to help move them toward accepting trial abstinence as a short-term treatment goal.

During treatment, clinical progress is measured throughout each client's participation in the program. A computerized office management system stores, analyzes, and reports clinical data on all clients during the course of their participation in the program. These data include:

  1. Urine test results.
  2. Attendance at scheduled sessions.
  3. Counselor ratings of the client's progress toward achieving specified treatment goals.
  4. Client's self-ratings of progress toward achieving treatment goals.

The data are reviewed monthly (or weekly, if needed) to continuously adjust the treatment to individual client needs, provide supervisory feedback to counselors, and improve overall treatment effectiveness.

Followup treatment studies have been conducted on sample populations at 1- to 2-year intervals after treatment. Followup measures include assessments of:

  1. Drug use.
  2. Psychosocial functioning.
  3. Involvement in self-help.
  4. Utilization of other treatment resources.

8. SESSION FORMAT AND CONTENT

 

8.1 Format for a Typical Session

A typical group session in the early abstinence phase of the program begins with each client stating the length of his or her clean and sober time (i.e., how long ago the client last used any psychoactive drugs whatsoever) and what issue he or she wishes to discuss in that session. Every client is expected to identify at least one issue for discussion at each session. The therapist (group leader) may pull together the issues of two or more group members into a theme for that session or, alternatively, may begin the session with a specific topic as part of a revolving PE sequence. In general, two group sessions per week are devoted to day-to-day concerns and struggles raised by the clients themselves (with appropriate guidance and framing of the discussion supplied by the group leader); one session is devoted to a specific PE or skills-training topic where the counselor presents a brief lecture and guides a focused discussion.

 

8.2 Several Typical Session Topics or Themes

Following is a partial list of topics and themes in the PE sequence (Washton 1989, 1991): tips for quitting; finding your motivation to quit; how serious is your problem—taking a closer look; identifying your high-risk situations; coping with your high-risk situations; dealing with cravings and urges; why total abstinence—is it really necessary to give up everything?; warning signs of relapse; rating your relapse potential—a realistic assessment; tips for handling slips; managing anger and frustration; finding balance in your life; how to have fun without getting high; defining your personal goals; managing problems in your relationships; building your self-esteem; nutrition and personal health; AIDS and other sexually transmitted diseases—how to avoid them; overview of treatment and recovery; how your family can help without hurting—a look at coaddiction.

 

8.3 Session Structure

The purpose of each session is to enhance the client's motivation for change and improve his or her ability to cope adaptively with the problems of everyday life without reverting to psychoactive drug use. To accomplish this task success-fully, sessions are neither highly structured nor totally unstructured. The PE sessions serve more to stimulate discussion than present material in a didactic manner. The group leader takes an active role in helping each group member relate the lecture topic to his or her own personal situation. The goal is to foster emotional and behavioral change rather than merely supply factual information.

 

8.4 Strategies for Dealing With Common Clinical Problems

Lateness and absenteeism are addressed therapeutically as behavioral manifestations of a client's ambivalence about change. The importance of clients arriving at sessions on time and attending reliably is emphasized throughout the program, starting with the initial intake interview. Clients are instructed not to come to the clinic within 12 hours of any alcohol or other drug use. If a client arrives showing clear-cut behavioral signs of intoxication (e.g., slurred speech, uncoordinated movements, breath smelling of alcohol), he or she is asked to leave the premises and return the next day. If the client is severely intoxicated, a counselor will try to contact a family member to escort the client home. According to the program's variable-length treatment protocol, each unexcused absence extends by 2 to 4 weeks the time required for program completion. On the occasion of a third unexcused absence or fifth unexcused lateness, the client is transferred from the early abstinence group to a stabilization group that focuses more intensively on overcoming early obstacles to change.

 

8.5 Strategies for Dealing With Denial, Resistance, or Poor Motivation

Enhancing a client's motivation for change is an essential part of the counselor's role in this approach. Labeling a client as being in denial, resistant to change, or poorly motivated is seen as distinctly unhelpful. Problems in complying with the treatment program are framed in terms of the client's ambivalence, reluctance, and fears about change. The counselor works collaboratively and cooperatively with the client to overcome these obstacles. In the face of noncompliance, the counselor actively seeks to join the client's resistance and find creative ways around it. This approach recognizes that, especially in the outpatient setting, aggressive confrontation is likely to precipitate dropout from treatment and may nullify efforts to engage and retain clients. It is important to mention that although this approach avoids the use of confrontational tactics, it does not promote a laissez-faire, anything-goes attitude toward client noncompliance. Limit setting and constructive feedback are essential features of the approach that are used in the spirit of enhancing a client's motivation for change rather than insisting that he or she admit to being an addict in serious denial.

 

8.6 Strategies for Dealing With Crises

In the event of emergencies or crisis situations during nonclinic hours, counselors and supervisors can be paged via a 24-hour telephone answering service. Crises are met with supportive interventions to stabilize the crisis situation and prevent relapse and dropout. The client is provided with frequent individual counseling sessions until the immediate crisis situation is stabilized.

 

8.7 Counselor's Response to Slips and Relapses

Slips are treated as avoidable mistakes and manifestations of ambivalence. The thoughts, feelings, circumstances, and chain of setup behaviors leading up to the slip are carefully reviewed. The first goal of this debriefing is to help the client recognize and accept the role of personal choice and responsibility in determining drug-using behavior. To decrease the likelihood of further use, an abstinence plan is formulated that incorporates specific decisionmaking, problem solving, and behavioral avoidance strategies. The variable-length treatment protocol stipulates that each slip increases a client's length of stay in the program by 2 to 4 weeks. On the occasion of a third slip (or sooner if the counselor deems it necessary), the client is transferred to a stabilization group. This group focuses intensively on developing day-by-day (hour-by-hour) behavioral action plans for achieving abstinence. Upon achieving 2 consecutive weeks of total abstinence and perfect attendance in the stabilization group, the client is eligible to return to his or her early abstinence group. In the event of a second slip while in the stabilization group, the client is suspended from group treatment for at least 2 weeks and may be referred for inpatient care. During the suspension, the client may also be given the option of attending the clinic for twice-a-week urine testing and once-a-week individual counseling for a maximum of 4 weeks. If the client achieves 2 consecutive weeks of abstinence during the suspension period, he or she can return to the early abstinence group.

 

9. ROLE OF SIGNIFICANT OTHERS IN TREATMENT

Active efforts are made to involve significant others (SOs) in the treatment. All newly admitted clients are encouraged to attend a family program together with their SOs (e.g., partner, family members, best friend). The program consists of a conjoint multiple family group that meets once per week for 12 consecutive weeks. The group provides support, education, and counseling geared toward enhancing family members' ability to cope adaptively with their loved one's addiction and teaching them how to break the vicious cycle of enabling and provoking behaviors that perpetuate the problem. Participants learn and practice specific problem solving and communication skills using guided role-play exercises. Couples and family therapy are also used to deal with problems that require more individualized attention. Acknowledgement

 

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Genetic Factors and Vulnerability to Alcohol Use Disorders

Alcoholism is a complex disorder with many pathways leading to its development. Genetic and other biological factors are likely involved in the emergence of alcohol dependence, along with cognitive, behavioral, temperament, psychological, and sociocultural factors. Alcohol use patterns, including alcohol abuse and alcohol dependence, are 'familial' in nature (cf. Heath et al., 1997; cf. Kendler, Heath, Neale, Kessler, & Eaves, 1992; Hesselbrock, 1995). That is, similar styles of alcohol use and the presence of alcoholism are often found within the same family, running from parent to child and across multiple generations of biologically related individuals. However, many other traits or behaviors, such as religious or political affiliation, which have little or no biological basis and, therefore, cannot be under heavy genetic control, also run in families. While genetic and other biological factors cannot fully explain the presence or absence of alcohol use disorders, their contribution to susceptibility for developing alcohol use problems appears to be significant.

Genetic Factors:
Evidence for genetic influences on the emergence of alcoholism is derived from a variety of sources. While no single source of information definitively confirms a genetic hypothesis, the confluence of findings from (1) extended pedigree studies, (2) twin studies involving monozygotic (identical) and dizygotic (fraternal) twin pairs, and (3) studies of adopted individuals raised apart from their alcoholic parents, persuasively argues for a genetic component to the vulnerability continuum for developing alcoholism.

Pedigree studies: Family pedigree studies of alcoholic clients, compared to general population rates, typically show an increase in the lifetime prevalence of alcoholism across all classes of biological relatives. The increase in risk for developing alcoholism may be four- to seven-fold among first-degree relatives of an alcoholic compared to the general population (Cotton, 1979; Merikangas, 1990). First-degree relatives are those with the closest genetic ties-for example, parents and siblings.


The increase in risk for developing alcoholism may be 4 to 7-fold among first-degree relatives of an alcoholic.

Twin studies: Monozygotic twins are genetically identical, despite the appearance of some phenotypic differences-differences in how genotype is actually expressed. Dizygotic twins, on the other hand, are genetically like any other set of siblings-on average, they share about 50% of their genes. Twin studies examine the extent of concordance (degree and extent of similarity) between the two types of twins. If the degree of concordance is similar, a genetic basis cannot be conclusively identified. If, on the other hand, concordance is directly related to type of twin and monozygotic twins have greater concordance than dizygotic twins, there is a strong probability that a significant portion of the appearance of a feature is genetically driven. Monozygotic twins generally have a higher concordance rate of alcoholism compared to dizygotic twins. The concordance rate for dizygotic twins is the same rate as other non-twin sibling pairs (cf. Kendler et al., 1992; McGue, Pickens, & Svikis, 1992).

Adoption Studies: In an attempt to separate genetic from environmental effects in the susceptibility for developing alcoholism, studies of the offspring of alcoholic parents (typically an alcoholic father) adopted away at birth have been conducted (see Table 1). Studies conducted in Scandinavia and in the U.S. of adopted infants placed in nonalcoholic homes have typically found that the adopted children born of an alcoholic parent develop alcoholism as adults at a higher rate than do adopted children with neither biological parent affected with alcoholism (cf. Goodwin et al., 1974; Cloninger, Bohman, & Sigvardsson, 1981; Cadoret, Cain, & Grove, 1980).

Table 1:Adoptee Risk of Alcoholism by Alcoholism in Biological Parents

Study

Positive

Negative

Relative Risk

Males

 

 

 

Roe (1945)

0.0% (n=21)

0.0% (n=11)

1.0

Goodwin et al (1973)

18.0% (n=55)

5.0 (n=78)

3.6*

Cloninger et al (1981)

23.3% (n=291)

14.7% (n=571)

1.6*

Cadoret et al (1985)

61.1% (n=18)

23.9% (n=109)

2.6%

Cadoret et al (1987)

62.5% (n=8)

20.4% (n=152)

3.1%

Females

 

 

 

Roe (1945)

0.0% (n=11)

0.0% (n=14)

1.0

Goodwin et al (1977)

2.0% (n=49)

4.0% (n=47)

0.5

Bohman et al (1981)

4.5% (n=336)

2.8% (n=577)

1.6*

Cadoret et al (1985)

33.3% (n=12)

5.3% (n=75)

6.3*

The findings from the three types of studies hold for both males and females, although the evidence for the importance of genetic factors in alcoholism risk currently appears to be stronger for males compared to females. These gender differences may reflect a real difference in male/female genetic risk, although to date, no sex-linked genes have been identified for alcoholism. More likely, the gender differences found are due to the moderating role of cultural and social factors that may limit females' exposure to heavy drinking. More recent epidemiological studies suggest that gender differences in the incidence and prevalence of alcoholism are declining among more recent birth cohorts.

It is also important to remember that all studies to date report only an increase in the statistical probability or risk for developing alcoholism among family members. While the statistical probability or risk of developing alcohol problems is higher among biological relatives of alcoholic than non-alcoholic biological relatives, in fact, most offspring of an alcoholic parent do not develop alcohol use problems or disorders in their lifetimes.

Finally, although great progress is being made in the search for the genetic bases of the susceptibility for developing alcoholism (NIAAA, 2000; Hesselbrock et al., 2001), specific genes predisposing to alcohol use disorders have yet to be identified. This is also true of specific genes that may provide protection from this predisposition. Therefore, it is probably most useful to consider that multiple genes in various locations contribute to the continuum of vulnerability. Genetic models that postulate a single gene are not supported by the research results.

Most offspring of an alcoholic parent DO NOT develop alcohol use problems or disorders in their lifetime.

Mechanisms of Heritability - Gene-Environment Interaction
While family pedigree studies, twin studies, and adoption studies implicate genetic factors in the development of alcoholism, their findings also indicate that the genetic factors are not deterministic. If certain genes actually predestined an individual to develop alcohol use problems, then all alcoholics would have a close relative with alcoholism, the concordance rates for monozygotic twins would approach 100%, and almost all offspring of an alcoholic parent-including adoptees-would eventually develop an alcohol use disorder. Since this clearly is not the case, environmental and other biological factors must also play an important role in alcoholism susceptibility (see Figure 1).

Many investigators have stressed the importance of the interaction between an inherited biological vulnerability and environmental risk factors for developing alcohol use disorders (cf. Kendler, 1995; Slutske et al., 1998; Cadoret, Yates, Troughton, Woodworh, & Stewart, 1995).

This gene-environment interaction (G x E) model assumes a synergy between genetic and environment factors that may contribute either to an increased susceptibility for developing an alcohol use disorder or attenuate possible genetic risk by producing a level of protection for vulnerable individuals (cf. Hesselbrock & Hesselbrock, 1990).

However, specific environmental factors that possibly affect the development of alcohol use disorders, such as those related to a family environment, social relationships, and parenting styles, have not been definitively identified.

G x E model
G: Gene
E : Environment
x : Interaction

Interestingly, cohort of birth and ethnicity are two major individual factors that also affect the susceptibility for developing alcohol dependence. Even though it is extremely unlikely that the human genome has changed significantly over the past 100 years, more recent birth cohorts have higher prevalence rates of alcoholism than birth cohorts from the earlier part of the twentieth century (Reich et al., 1988; Grant, 1997). The differences in prevalence rates are thought to be due to variations in the availability of beverage alcohol resulting from Prohibition, economic depression, or wartime shortages.

Differences in prevalence rates and the course of alcohol dependence have also been noted in relation to ethnicity (Hesselbrock, et al., 1998; NIAAA, 1998). For example, there appears to be little difference among ethnic groups with regard to first age of the early stages of alcoholism, but differences in first age begin to appear with later stages of the disorder.

The variability in apparent susceptibility to alcoholism is thought to be due to biological differences in alcohol metabolism, as well as social factors (e.g., involvement in religion, family relations). This suggests that, in addition and related to genetic factors, there exists a host of biological factors involved in alcoholism susceptibility. Considerable research is currently addressing the neurobiological pathways of alcohol sensitivity, alcohol craving, and addiction.

It is expected that these studies will eventually lead to the development and testing of biological and/or pharmacological treatment alternatives. For example, specific medications typically used for treating depression, obsessive-compulsive disorders, or seizure disorders are being tested for their psychopharmacological effects on alcohol dependence.

There may be a host of biological factors involved in alcoholism susceptibility.

Cognitive Functioning and the Risk for Developing Alcoholism

A growing number of studies have implicated heritable cognitive factors, including electrophysiological features related to central nervous system functioning, as being related to the vulnerability for developing alcohol and other substance use problems. Several studies have found poorer cognitive performance among alcoholics compared to controls on neuropsychological tests of memory, attention span, abstract thinking, verbal reasoning, and visual-spatial skills (DeObalia, Parsons & Yohman, 1983). Although specific cognitive deficits in persons at risk for developing alcoholism have not been consistently reported, tests measuring brain functioning in the frontal and temporal lobes among young adult males with a susceptibility for developing alcoholism were predictive of the age of taking their first drink and their frequency of drinking to get intoxicated (Hesselbrock, Hesselbrock, Bauer, & Gillen, 1991; Deckel, Bauer, and Hesselbrock, 1995).

Differences in central nervous system functioning as measured by electroencephalographic (EEG) and event-related potential (ERP) methods have been found between alcoholic adults and control individuals (Begleiter, Porjesz, Bihari, & Kissin, 1984). Similar findings have been reported among individuals at risk for developing alcoholism and prior to the onset of heavy drinking (cf. Begleiter et al., 1984; Bauer & Hesselbrock, 1999). Typically, differences in EEG and ERP brainwave patterns are found in the frontal region of the brain, regions that are thought to be responsible for the cognitive skills of attention, planning, and foresight. Although these electro-physiological measures of brain activity do provide a 'marker' of risk for a poor adult outcome, including an increased risk for developing alcoholism, the exact relationship between electrophysiological measures and behavioral measures (i.e., neuropsychological) of cognitive functioning are not well established (cf. Hill, Shen, Lowers, & Locke, 2000; NIAAA, 1997, 2000). There exists some controversy as to the consistency concerning observations of EEG differences among children of alcoholic and of non-alcoholic parents (Sher, 1991).

Psychopathology and Temperament as Risk Factors

Childhood behavior problems:
Many studies over the past 40 years indicate that childhood problem behavior and aspects of a child's temperament may predict both behavior problems and problems with alcohol and substance abuse during adolescence and young adulthood. An association between behavioral problems (i.e., conduct problems, attention deficit disorder, and hyperactivity) occurring in childhood and adolescence and consequent poor adult outcomes, including alcoholism, has been repeatedly found in longitudinal studies (see Table 2). These associations appear in a variety of samples, including child guidance clinic subjects (Robins, 1966), community samples (Jones, 1968), and among adopted individuals at risk for alcoholism (Cadoret et al., 1995).

Table 2: Childhood Aggression, ASPD, and Alcoholism by Gender

N

None
5,308

ASP
86

Alcohol
3,161

Both
601

Vadalism

N

15.7

69.7

30.3

68.9

F

4.6

55.0

17.2

57.3

Physical fights

M

8.1

57.6

22.8

58.6

 

F

3.5

40.0

15.6

55.3

Used a weapon

M

2.5

36.4

9.4

39.2

 

F

1.8

15.0

7.3

34.0

Injured others

M

2.7

28.8

6.0

23.7

 

F

1.3

20.0

4.2

19.4

Bully others

M

3.1

19.7

6.8

21.7

F

4.4

30.0

6.3

34.0

Source: Hesselbrock, et al., 2000

Many, but not all, of these individuals who develop alcoholism will go on to develop a severe form of the disorder (Hesselbrock & Hesselbrock, 1994). Even though problem behaviors typically begin during childhood for boys and adolescence for girls, the relationship to later alcohol and drug problems holds for both boys and girls, and across at least some ethnic minority groups (Hesselbrock, Segal, & Hesselbrock, 2000; Bucholz et al., 1996). It is important to note that recent studies indicate that the alcohol use disorders developed by conduct-disordered adolescents are not benign and do not necessarily resolve over time. For many, these alcohol use disorders persist into young adult life and possibly beyond (Rohde et al., 2001).

Conduct problems in childhood and adolescence are often accompanied by other externalizing behaviors such as attention deficit disorder, hyperactivity, and oppositional behaviors (American Psychiatric Association, 1994; Windle, 1996; Murphy & Barkley, 1996). Childhood hyperactivity and attention deficit disorder have also been linked to an increased risk for developing alcoholism, particularly among children of an alcoholic parent (Tarter, McBride, Buopane, & Schneider, 1977; DeObaldia et al., 1983). However, many of these studies fail to take into account the effect of co-occurring conduct problems or sample children with only hyperactivity or only attention deficit disorder. There is little evidence for the independent contribution of either hyperactivity or attention deficit disorder alone to the susceptibility for alcoholism (August & Stewart, 1983; Boyle et al., 1992).

Temperament

While considerable research has shown that a predisposition to alcoholism is partially due to genetic factors, several studies suggest that this genetic susceptibility may be expressed, in part, through an individual's temperament. Tarter and Vanyukov (1994), for example, propose a temperament model of alcoholism risk based on five temperament traits that increase an individua's liability for developing alcoholism.

There may be a host of biological factors involved in alcoholism susceptibility.

These traits include behavioral activity level, sociability, attention span/persistence, emotionality, and "soothability." Genetics influence each of these five traits, and an individual's liability is increased or decreased by the deviation of each trait from the population norm. Thus, individuals whose personality traits are closer to the population norm are thought to have more control over their own behavior, including substance use. Individuals who have difficulties with behavioral and emotional regulation may be more prone to developing alcoholism in relation to environmental influences and stressors, including seeking environments conducive to alcohol and drug use. Indeed, each of these traits, or trait clusters, that constitute a "difficult" temperament relate to an increased risk for developing a problem with substance use and/or abuse (Ohannessian & Hesselbrock, 1995; Tarter, Kabene, Escallier, Laird, & Jacob, 1990). It should be noted, however, that prenatal, peri-natal, and neonatal circumstances can have profound and persistent influences on temperament, as well (e.g., maternal stress and prenatal exposure to stress hormones; medications delivered during pregnancy and/or delivery; anoxia; hypoxia; birth trauma; child maltreatment; etc.). Etiological models (psychoanalytic, behavioral, cognitive, and social learning) have led to the development of different treatment methods for alcohol use disorders.

Psychological Models of Etiology

A number of models exist to explain the development of alcohol use disorders, including those grounded in the field of psychology. Each of these models involves different treatment methods.

Psychoanalytic models

  • Oral fixation
  • Ego malfunction

Psychological models:
- Psychoanalytic
- Behavioral
- Cognitive
- Social learning
- Alcohol expectancies

Early psychoanalytic formulations concerning the etiology of alcoholism were based on the clinical experience of therapists trained in this tradition. In psychodynamic thought, alcoholism was viewed as a fixation on, or a regression to, the oral stage of development. More recently, though, malfunctions of the ego or an emphasis on the self have been proposed to explain alcoholism. Wurmser (1984-85), for example, views the use of alcohol or drugs as an attempt to escape from intense feelings of rage and fear arising from severe intra-psychic conflict due to an overly harsh superego. Khantzian, Halliday, and McAuliffe (1990), posited a self-deficit approach; that is, inadequacies of the ego underlie abuse of alcohol or drugs. Individuals choose a specific drug with particular properties to self-medicate their particular type of ego deficit. Other formulations indicate that alcoholism is a psychosomatic defense against psychic conflict (McDougall, 1989), or the result of disturbed object relations (Krystal, 1982). Although there is little empirical support for these etiological theories, many members of the larger treatment community continue to use these terms as clinical descriptors for their clients and to suggest a cause for the client's conditions. The interventions that emerge out of these models primarily include psychotherapeutic analysis approaches.

Behavioral Models

  • Substance use is learned
  • Substance use is maintained through conditioning mechanisms

Traditional behavioral models of alcohol and other substance use disorders have postulated that alcohol and other substance use behavior is learned and maintained either through classical or operant conditioning. In the typical classical conditioning paradigm, the development or "learning" of drinking behavior occurs through repeated pairings of: (1) a conditioned stimulus (CS), such as a particular person and an unconditioned stimulus (US), such as a particular location or time of day with (2) alcohol consumption. After repeated pairings, a conditioned response (CR) develops where exposure to the CS or US results in the CR (drinking behavior). This model has been postulated to explain the initial development and maintenance of craving and conditioned tolerance (both conditioned responses), for alcohol as well as other drugs (Wikler, 1973; Siegel, 1983).

Operant conditioning principles have been applied to explain alcohol and other drug use as reinforcing. That is, an individual may drink in response to an antecedent stimulus such as bad mood, anger, social anxiety, physical pain, or even withdrawal symptoms. An association is then developed between the reinforcing effects (e.g., perceived better mood, anxiety reduction, lessening of the severity of the withdrawal symptoms or pain) with the antecedent stimulus. Thus, drinking is thought to increase as a result of either the positive (bringing a perceived reward) or negative (removing a perceived negative factor) reinforcing effects of alcohol. Recent 'self-medication' theories of alcoholism are based on the assumption that alcohol becomes a positive (or negative) reinforcement. One limitation of this model is the observation that the development of alcoholism in both clinical and non-clinical populations often precedes the development of a diagnosable affective or anxiety disorder (cf. Schuckit, Anthenelli, Bucholz, Hesselbrock, & Tipp, 1995; Schuckit & Hesselbrock, 1994).

In the learning paradigm, negative effects of drinking (e.g., hangover, social consequences, personal costs, legal problems) are viewed as being too far separated in time from the drinking behavior to seriously reduce its frequency-and the positive reinforcing effect is experienced first. This is the premise underlying the use of certain pharmacological interventions to curtail drinking (Gitlin, 1996). For example, drugs such as Antabuse (disulfiram) result in the relatively rapid onset of unpleasant physical symptoms after alcohol consumption (e.g., generalized malaise, flushing, sweating, headache, nausea, vomiting, palpitations and/or chest discomfort).

Cognitive Models

  • Cognition and feelings direct behavior
  • Alcohol use perceived as positive / negative reinforcement

Cognitive behavioral models of alcoholism emphasize the importance of cognitions (thoughts, understanding, beliefs) and feelings as preceding and directing behavior. In these models, the initial use of alcohol or other drugs is viewed as the result of several interacting factors (e.g., genes, temperament, and other psychological or social factors). These factors influence the individual's perception of alcohol use as either a positive or a negative reinforcer. As alcohol use increases, other coping mechanisms are used less frequently. Consequently, self-efficacy is reduced and positive expectancies increase as alcohol use increases. As high levels of use become more frequent, classical conditioning processes (e.g., conditioned craving, tolerance, and withdrawal) play an important role in the development and maintenance of heavy problem use (see Rotgers, 1996 for a review).

Social Learning Models

  • Focus on cognitive constructs
  • Expectancies
  • Self-efficacy
  • Attributions

Social learning theories focus on cognitive constructs such as expectancies, self-efficacy, and attributions to mediate the pathway from stimuli to alcohol use as a response. Expectancies of the positive effects from using alcohol develop as conditioned cognitions from repeated classical or operant pairings of alcohol use with a positive experience (i.e., reinforcement). Self-efficacy refers to the expectation by individuals that they can successfully perform a particular coping behavior in certain situations and that the behavior will be reinforced. The Social Learning viewpoint describes alcoholism as a result of a failure to cope. The self-efficacy for coping without alcohol is low among alcoholic individuals, contributing to continued use and the eventual development of dependence. Petraitis, Flay, and Miller (1995) have postulated a social learning theory model of adolescent experimentation and the eventual problem use of alcohol and other drugs.

Alcohol expectancies:

  • Positive expectancies of effects of alcohol
  • Social facilitation
  • Enhanced sexual performance
  • Increased personal power
  • Social assertiveness/relaxation

Many experimental laboratory studies of alcohol intake assess the ability of alcohol to influence certain behaviors such as the induction of aggression, increased sexual arousal, or tension reduction. These approaches all assume a cognitive influence surrounding alcohol use. An underlying assumption of such studies is that individuals have certain positive expectations of the effects of alcohol related to the behavior being studied. Consequently, a number of specific alcohol-related expectancies have been identified. These include social facilitation, enhanced sexual performance and pleasure, increased personal power and aggression, social assertiveness, relaxation and tension reduction, as well as a general positive outcome that may result from drinking.

Several instruments are available to assess the expectancies of alcohol's effects (cf. Brown et al., 1980; Southwick et al., 1981; Christiansen et al., 1982). These expectancies probably reflect not only a person's own experience with alcohol, but may also result from exposure to beverage alcohol advertising and from observing the behavior of others when they are drinking (both real life and media models).

Alcohol expectancies may come from the person's own experience with alcohol, from advertising, or from observing the behavior of others when they are drinking.

Several instruments are available to assess the expectancies of alcohol's effects (cf. Brown et al., 1980; Southwick et al., 1981; Christiansen et al., 1982). These expectancies probably reflect not only a person'sown experience with alcohol, but may also result from exposure to beverage alcohol advertising and from observing the behavior of others when they are drinking (both real life and media models).

Exposure to these modeling events can begin early in life, even during childhood. Miller et al. (1990) examined the alcohol expectancies of elementary school children across the first through fifth grades. They found that the positive expectancies of the effects of alcohol increased with age, most notably among 8-10 year olds. Importantly, a variety of studies have shown that positive expectancies of alcohol's effects predict initiation of drinking, intention to drink, and drinking rates among middle school (Christiansen et al., 1989) and college students (Stacy et al., 1990).

Although originally linked to attitudes and beliefs about the reinforcing properties of alcohol, expectancies are more recently believed to be related to memory processes. Thus, positive expectancies of alcohol use may be encoded in close association with usual drinking practices and be easily retrieved from memory in future drinking situations.

On the other hand, negative expectancies arising from unpleasant drinking experiences are probably less likely to be associated with usual drinking practices, but may be more closely tied to heavy drinking episodes. Consequently, among light-to-moderate drinkers, negative expectancies of alcohol's effects are less likely to be activated or to play an inhibitory role in most drinking situations.

It is important to recognize that each of these etiological models (psychoanalytic, behavioral, cognitive, and social learning) have led to the development of different treatment methods for alcohol use disorders. To date, however, no single particular psychological treatment method has consistently been demonstrated to be superior to another across groups. Furthermore, newer pharmacological agents, such as naltrexone and acamprosate, appear to be effective in reducing drinking in some clients, particularly when used in conjunction with psychotherapy or other behavioral intervention approaches. Together, these findings also point to the importance of integrating biological and psychological factors in the treatment of alcoholism, and in understanding its etiology.

No single psychological treatment method has been consistently demonstrated to be superior across all groups.

SOCIOCULTURAL MODELS OF ETIOLOGY

Some cautions are urged when reviewing possible environmental risk factors for alcohol use disorders (Sher, 1991). The most significant caution is to recognize that, although certain environmental conditions and risk factors are associated with alcoholic families, these conditions are not necessarily related to the later development of alcohol problems or alcohol use disorders in the offspring. Variations in the environmental conditions expressed in alcoholic families, such as poor parenting or disorganized family life, need to be empirically related to specific outcomes to have etiologic significance. Second, even when the environmental factor of interest has been empirically associated with a particular outcome, its role as a cause cannot be assumed-causality cannot be inferred from correlation alone.

Possible Explanations for an Association Between Variables A and B:
A -----> B
B -----> A
A <-----> B
A <----- C ------>B

For example, it may be that the factor does indeed cause the outcome. But, an equally plausible explanation may be that the second variable actually causes the first, or that the two variables are interrelated in a dynamic mutual influence pattern. Still another possibility is that a third variable, such as a co-morbid psychiatric condition in either parents or children, may falsely lead to the appearance of causation when the effect is almost entirely due to this third unmeasured variable influencing both the first and second.

An example of this is the association between parental alcohol abuse and the presence of oppositional behavior disorders in children. On one hand, the oppositional behavior might be blamed on the parental drinking pattern. On the other hand, Lang, Pelham, Johnston, and Gelerrnter (1989) observed that interactions with oppositional children may result in increased alcohol consumption among the adults providing their care.

Family violence:

Alcohol use is present in a substantial proportion of domestic violence incidents reported in the general population. An estimated 67% of persons who victimize an intimate partner (e.g., spouse, boy/girlfriend, ex-partner) have used alcohol acutely or chronically at the time of the arrest, compared to 38% who victimized an acquaintance or 31% who victimized a stranger (NIAAA, 2000). Because both alcoholism and family violence have some demonstrated family "transmission" patterns, social workers may assume that there is a strong relationship between family of origin alcoholism and present family violence. However, a careful and critical reading of the research literature does not provide clear and consistent evidence. Many published studies are based upon small samples, do not adequately separate different types of partner abuse, sample from populations or agencies that are likely to have high rates of both alcoholism and violence, and/or do not use adequate comparison groups. While alcohol use and violence are clearly associated, the causal relationships between parental alcoholism, family violence, and alcohol problems among the offspring have not been firmly established.

Sociocultural Models of Etiology
- Family violence
- Family interaction
- Family disease
- Family systems
- Behavioral family
- Peer influence
- Social environments

It is also possible that some aspects of family violence, including sexual abuse of children and adolescents, may differentially affect girls and boys. These differences may appear as differences in susceptibility to poor adult outcomes, including the development of alcohol use disorders. Several studies indicate that the prevalence of early sexual abuse is much higher among female alcoholic clients than that found in the general population of adult females.

Family interaction:
Implicit in the discussion to this point is the notion of alcohol (and other drug) use disorders as being multiply determined by a complex association of genetic, environmental, personality, and other factors. Frequently, more than one member of the nuclear or extended family experiences a substance dependency. This complicates the identification of specific influences that family environment, child-rearing practices, or inter-parental interaction may play in the development of alcoholism. Three general contemporary models of family influences can be identified: a family disease model, a family systems model, and a behavioral family approach (McCrady & Epstein, 1996; McCrady, Kahler, & Epstein, 1998).

The family disease model is based on an assumption that all family members suffer from some degree of either alcoholism or codependency. Further, alcoholism and codependency are interrelated in such a manner as to enable (perpetuate) the alcohol problem. Although in this model the specific etiology is regarded as biological, alcoholism is being maintained by the family disease (Sheehan & Owen, 1999).

In the family systems model, the etiology of alcoholism and substance abuse is focused on the behavior of family members around drinking, with particular attention paid to the family of origin and the role of the spouse/partner (O'Farrell & Fals-Stewart, 1998; Steinglass, Bennett, Wolin, & Reiss, 1987; Steinglass, Weiner, & Mendelson, 1971). The model assumes that, over time, alcohol use stabilizes the family system and that the family organizes their interactions and structure around alcohol use to achieve and preserve system 'homeostasis.' In other words, the family maintains the alcohol problem despite the associated problems because it is requires less effort than changing or because it allows the family to avoid changing a more disturbing problem (e.g., sexual abuse).

The behavioral family approach focuses on the family members' behaviors (especially those of the spouse/partner), as both antecedents to and reinforcers of, alcohol or substance use. These responses are thought to help develop and maintain the drinking problem. Bennett and Wolin (1990) found that continuing interaction between adult offspring and their alcoholic parents is associated with increased rates of alcoholism, at least among the male offspring. On the other hand, certain family rituals, such as eating dinner together or celebrating holidays together, may serve to protect offspring against the development of alcoholism (cf. Bennet et al., 1987). It is important to note that family member behavior can influence the alcoholic individual to consider change, act to change, maintain the change, or relapse to drinking (Walitzer, 1999).

Family member behavior can influence the alcoholic individual to consider change, act to change, maintain the change, or relapse to drinking.

Peer influence:
Adolescents often cite an increased ability to socialize with friends, reducing tension and anxiety (especially in mixed gender situations), reducing boredom, and/or getting high as reasons for their alcohol and other substance use. As indicated above, expectations of alcohol's effects in these areas are associated with both initiation of alcohol use and drinking rates, particularly among adolescents. Peer influences are consistently cited as risk factors for initiating alcohol, tobacco, and other drug use among children and adolescents (cf. Kandel & Yamaguhi, 1999; Wills, Vaccaro, & McNamara, 1992; Averna & Hesselbrock, 2001). Peers influence adolescents' values, behaviors, attitudes, and choice of other friends. However, the closeness of the specific peer relationship is an important determinant of the strength of peer influences on drinking behavior. Alcohol use by an adolescent's best friend is more predictive of alcohol use and maintenance of drinking behavior than reports of use by other friends. Characteristics of peers may also be relevant. Reports of use by same-age peers do not appear to be related to either initiation or maintenance of drinking during adolescence (Morgan & Grube, 1991; NIAAA, 1994). Associating with deviant friends tends to promote the acceptance of deviant behaviors, including the use of alcohol and other drugs (Loeber, Stouthamer-Loeber, Van Kammen, & Farrington, 1991; Robins & McEvoy, 1990). However, it is not clear if associating with deviant peers is a risk factor for, or the result of, maladaptive behaviors. Deviant peer group involvement co-occurs with several other risk factors such as family problems, other mental health problems, low self-esteem, stress, and alcohol availability. Deviant peer group involvement is typically higher among alcohol-using adolescent boys than girls. Peer and friend relations (Ohannessian & Hesselbrock, 1993) probably exert less influence on drinking behavior in adulthood than during adolescence. At least among adult persons living together in a stable relationship, social support from close family members is more predictive of drinking behavior than social support from friends.

Social environments:

A variety of social and environmental factors may affect a person's risk for developing alcohol use disorders. Both social learning and social control theories consider that social environments provide a wider context for biological, psychological, and personality factors to interact in determining a person's susceptibility for developing alcohol abuse problems. Peer influences to initiate or maintain use, stressful and negative life events, and family environment (including poor parenting styles) appear further to enhance the likelihood of developing alcohol or drug-related problems among adolescents and young adults who are at high risk due to a family history of alcoholism. However, an adolescent's exposure to alcohol tends to be more limited in the presence of good relations with non-using peers (particularly best friends), family rituals that actively seek to prevent alcohol use, and consistent parental supervision and discipline. Reduced exposure to alcohol use, in turn, limits the opportunity for expression of genetic, psychological, and personality susceptibility risk factors for developing alcoholism (see Hesselbrock & Hesselbrock, review, 1990).

Social environments provide a wide context for biological, psychological, and personality factors to interact to determine susceptibility for developing alcohol problems.

Social Policy Issues

Social policy, even though often ignored in etiological formulations, can have a wide influence on the risk for developing problems with alcohol abuse and its concomitants (e.g., illness, injury, etc.). Social policy can influence the availability of beverage alcohol and provide punitive measures for violation of purchase and consumption regulations. To some extent, limited access to alcohol serves to protect against the development of alcohol problems and abuse or dependence (Holder, 1999). Over the years, local, state, and federal governments have used a variety of measures to restrict the availability of beverage alcohol. Prohibition, local option, and minimum legal age for purchase have had both short- and long-term effects in restricting the availability of alcohol. Lowering the legal age for purchase in the early 1970s led to increases in both alcohol consumption and auto injuries and fatalities among adolescents. These trends were reversed when the minimum legal drinking age was again raised. The direct effect of changes in legal drinking age on other alcohol-related behaviors (e.g., assaults, teen pregnancies, sexually transmitted diseases, and accidental drowning) is more difficult to assess because the minimum drinking age and reporting practices have varied considerably from state to state.

Social Policy Issues for Controlling Alcohol Abuse:
- Availability
- Legal constraints
- Taxation

Taxation has also been viewed as a method for controlling the availability of alcohol, since higher taxes on alcohol typically lead to higher prices. For some individuals, raising taxes on beverage alcohol has been associated with decreased drinking. However, light and heavy drinkers appear to be less responsive to increased prices than are moderate drinkers (Manning, Keeler, Newhouse, Sloss, & Wasserman., 1991). In addition, Kenkel (1996) found that drinkers who are better informed about the risks of excessive alcohol use showed greater reductions in drinking due to price increases than did less informed drinkers. The use of taxes to increase the cost of obtaining alcohol-containing beverages is not straightforward. Even though federal taxes are applied uniformly to all units of beverage alcohol produced, manufacturers and retailers operating in different locales and competitive markets may choose to differentially pass along the cost to the purchaser. Further, the cost of a unit of beverage alcohol can vary considerably by beverage type, geographic region, bottling type, and type of establishment where the beverage is purchased.

Clinical Heterogeneity

The above sections have provided a general overview of different factors thought to be related to the etiology and natural history of alcohol. Two additional factors must also be considered: clinical heterogeneity and gender. The many pathways to heavy drinking and alcohol dependence can often be reflected in the clinical heterogeneity or subtypes of alcoholism observed by the clinician. Differences in the development of the disorder can also be traced to factors more typically found in one gender versus the other.

Clinical heterogeneity / multivariate subtypes:
While alcoholics share many attributes related to their disorder, clinicians have also noted many individual differences in symptom patterns, drinking patterns, comorbid psychiatric problems, pathways to alcoholism, and personality characteristics. Bowman and Jellinek (1941) were among the first to propose a set of conceptual alcoholism typologies that were hierarchical and based on drinking patterns and personality factors.

The schema resulted in a representation of 17 subtypes. Jellinek revised this scheme in 1960 to include the Alpha, Beta, Gamma, and Delta types that are more widely known today. The Alpha and Beta types were not considered to be severe forms of alcoholism (see Table 3). The Alpha type was thought to have psychological dependence, while the Beta type could also experience physical/medical problems due to poor nutrition and health rather than directly from drinking. Neither type was thought to experience loss of control over drinking, suffer from an inability to abstain, or experience withdrawal symptoms.

Early conceptual alcoholism typologies based on drinking patterns & personality:
- Alpha
- Beta
- Gamma
- Delta
- Epsilon


Table 3: Alcohol-Related Features of Type A and Type B Alcoholics

 

Males

Females

Characteristic

Type A

Type B

Type A

Type B

Onset of alcohol symptoms (years)

17.9 (5.5)**

15.5 (2.9)

19.6 (6.3)

17.9 (6.1)

Onset of regular drinking (years)

17.3 (4.6)**

15.5 (3.7)

18.9 (5.4)

17.8 (6.2)

Onset of problem clustering (years)

25.1 (9.2)**

20.6 (6.3)

25.6 (8.8)*

23.0 (7.6)

Longest abstinence (months)

21.7 (43.4)

20.0 (24.1)

19.2 (31.3)**

36.7 (48.0)

% alcohol treatment (any)

58.9**

96

25.9**

88.6

% inpatient treatment

47.6**

86.7

13.9**

7-.9

% currently abstinent (6 months)

24.8*

38.7

9.1**

26.6

*p< .05, **p< .01 (Source: Schuckit et al, 1995)

Neither of the Alpha or Beta forms of alcoholism was considered to lie within the disease concept of alcoholism, however, both the Gamma and Delta forms were considered in this manner (Jellinek, 1960). The Gamma type of alcoholism was thought to be the predominant form of alcoholism and was characterized by physical dependence, craving for alcohol, and withdrawal following cessation of a drinking episode. Even though loss of control over the amount consumed is absent among Delta alcoholics, they are unable to totally abstain from drinking. The physical consequences of drinking are typically less severe among Delta alcoholics than among Gamma alcoholics. Another type, Epsilon, was proposed to denote a special type of alcoholism based on binge drinking. Jellinek invoked heredity and genetics only when he was unable to explain the process of addiction in relation to a psychological or sociological etiology. However, Jellinek considered the Gamma type of alcoholism to be relatively homogeneous and did not adequately address either the heterogeneity or the multidimensional nature of alcoholism often found within this category.

Over the past twenty years, a number of clinicians and researchers have made attempts to identify more homogeneous subtypes of alcoholism. More recently, multivariate statistical methods such as cluster analysis (Babor et al., 1992), discriminant function analysis (Cloninger et al., 1981), and latent class analysis (Bucholz et al., 1996) among others (Hesselbrock, M.N., 1995) have been applied to clinical data to identify homogeneous subtypes of alcoholism that may eventually prove to be differentially responsive to particular treatment modalities. Most prominent among these are the Type 1 / Type 2 alcoholisms proposed by Cloninger and associates (1981) and the Type A / Type B forms of alcoholism proposed by Babor et al., (1992). The two formulations are remarkably similar, even though the Cloninger et al. sample was derived from a Swedish community-based adoption study sample, while the Babor et al. typology was based upon an inpatient sample. Both samples contained males and females. Both Type 1 and Type A were considered to be milder forms of alcoholism, were more prevalent among females, had a later onset of the disorder, and typically had significant anxiety and depressive symptoms. Type 2 and Type B alcoholism were characterized as having an earlier onset, the presence of childhood problem behavior risk factors, adult anti-sociality, familial alcoholism, and a more chronic treatment history.

Homogeneous subtypes of alcoholism that may eventually be differentially responsive to particular treatment modalities:

  • Type 1 / Type 2
  • Type A/ Type B

Over the past twenty years, a number of clinicians and researchers have made attempts to identify more homogeneous subtypes of alcoholism. More recently, multivariate statistical methods such as cluster analysis (Babor et al., 1992), discriminant function analysis (Cloninger et al., 1981), and latent class analysis (Bucholz et al., 1996) among others (Hesselbrock, M.N., 1995) have been applied to clinical data to identify homogeneous subtypes of alcoholism that may eventually prove to be differentially responsive to particular treatment modalities. Most prominent among these are the Type 1 / Type 2 alcoholisms proposed by Cloninger and associates (1981) and the Type A / Type B forms of alcoholism proposed by Babor et al., (1992). The two formulations are remarkably similar, even though the Cloninger et al. sample was derived from a Swedish community-based adoption study sample, while the Babor et al. typology was based upon an inpatient sample. Both samples contained males and females. Both Type 1 and Type A were considered to be milder forms of alcoholism, were more prevalent among females, had a later onset of the disorder, and typically had significant anxiety and depressive symptoms. Type 2 and Type B alcoholism were characterized as having an earlier onset, the presence of childhood problem behavior risk factors, adult anti-sociality, familial alcoholism, and a more chronic treatment history.

The personality traits (reward dependence, harm avoidance, novelty seeking) so prominent in Cloninger's conceptualization do not appear to be sufficient to define Type 1 / Type 2 (Hesselbrock, M.N., 1995). Although Type 1 and Type A alcoholism are very common among women, a significant number of female alcoholics can be classified as having Type 2 / Type B alcoholism. A number of studies have attempted to replicate the Type 1 / Type 2 typologies in other samples (clinical and non-clinical) with limited success (Glenn & Nixon, 1991; Schuckit, Irwin, & Mahler, 1990). Type 1 / Type 2 do not appear to be heritable (Gilligan, Reich, & Cloninger., 1988).

Schuckit et al. (1995a) were able to identify the Type A / Type B subtypes of alcoholism in a large sample derived from a family study of alcoholism. Mezzich and colleagues (1993) found Type A / Type B among adolescents with alcohol dependence. The heritability of Type A / Type B has not yet been examined. Other subtypes of alcoholism have been identified through the application of multivariate statistical methods to a variety of clinical assessments, such as the MMPI (Blashfield, 1984) and clinical interview data (Bucholz et al., 1996). (A review of typological classifications of alcoholism can be found in volume 20, issue 1 of Alcohol Health & Research World (NIAAA, 1996); see also Hesselbrock, 1995.)

Gender differences:
Gender differences in drinking patterns, the metabolism of alcohol, the course of developing alcohol problems, the point and lifetime prevalence of alcohol problems (including alcohol abuse and dependence), co-morbid psychiatric conditions, the physical consequences of chronic alcohol use, and treatment utilization have been noted in the literature (see review in Wilsnack & Wilsnack, 1997). Typically, women are less likely to consume alcohol than men, and when they do, women typically drink smaller amounts per occasion. Mortality rates among women are higher than among men who drink heavily, due to a variety of causes such as accidents, violence, suicide, and medical illnesses (NIAAA, 2000).

Still, there are many similarities among male and female alcoholics. Schuckit et al (1995a) reported a high level of correspondence in the temporal sequencing of the occurrence of 19 major alcohol-related life problems among male and female alcoholics, as well as among drinking but non-alcoholic individuals (see Table 4). Although the age of first appearance of the different symptoms examined may vary by gender, the order of appearance was very similar between males and females. Further, once alcohol dependence develops, the clinical manifestations of the disorder show few gender differences at either the low or high end of severity (Hesselbrock, M.N., 1991a; Del Boca & Hesselbrock, 1996; Hesselbrock, Segal, & Hesselbrock, 2000).

At an intermediate level of severity of alcohol dependence, women often manifest more anxiety and depressive symptoms but lower levels of antisocial behaviors compared to men. An antisocial type of alcoholism predominates at the more severe end of the alcohol dependence spectrum and few gender differences are noted (Bucholz et al., 1996; Hesselbrock et al., 2000). However, women tend to do as well as men following treatment for alcoholism, and in some settings, they may have a better outcome (Gomberg, 1999)

� � � � � � � � � � � � � � � �

Table 4: Sequence of Development of Alcohol-Related Life Experiences for Men & Women

Item #

Life Experience4

Men (n=317)

Women (n=161)

Rank

Age

Rank

Age

1

Physical fights while intoxicated

1

19.44

1

20.90

2

Use in hazardous situations

2

20.60

5

22.56

3

Hit others (non-fight)

3

20.87

6

22.72

4

Arguments while drinking

4

21.00

8

22.80

5

Started when not want to

5

21.72

2

22.06

6

Drink more than intended

7

22.32

3

22.30

7

Problems at school/work

8

22.87

9

22.93

8

Hit/threw things while drinking

6

21.77

30

25.99

9

Lost friends due to drinking

9

23.20

11

23.50

10

Blackouts

10

23.46

10

22.98

41

Liver, ulcer, pancreatitis

40

33.32

40

30.44

42

3rd abstinence of 3+ months

43

37.37

43

33.25

43

Convulsions following abstinence

36

38.93

36

28.33

44

4th abstinence of 3+ months

44

39.72

44

37.18

Overrall rho = .84, p< .01 (Source: Schuckit et al, 1995)


Concluding Thoughts About What We Know

  • To date, the scientific evidence clearly shows that drinking behavior, including alcohol dependence, is highly heritable. Biological offspring, both sons and daughters, of an alcoholic parent are at increased risk for developing alcoholism compared to offspring of non-alcoholic parents. Offspring of an alcoholic parent have a 2-4 fold increased risk for developing alcoholism themselves.
  • There is no evidence that a specific genes or genes "predetermine" alcoholism for an individual. It is likely that a variety of genes, each making a small contribution, increase a person's susceptibility for alcohol dependence. Transmission is most likely polygenic, with many susceptibility loci, each with small/medium effects and low penetrance. Most likely, there are a number of genes that predispose an individual to psychopathology. Some may increase the likelihood of developing alcohol dependence. Regions on several chromosomes seem to be promising.
  • Social, psychological, and environmental factors interact along with genetic susceptibility to influence a person's overall risk for developing alcohol problems. Environmental factors likely play a significant role, as is true with other common diseases and disorders (e.g., heart disease, cancer, diabetes, asthma)
  • Current findings indicate that individual variations in alcoho's effects on the central nervous system (alcohol sensitivity) and differences in alcohol metabolism (affective tolerance) are likely to be important determinants of the risk for developing alcohol problems.
  • Genetic studies may help us understand the biological basis of alcohol dependence. For example, is individual variation rooted in the genetic basis for differences in ethanol metabolism (e.g., absorption and elimination rates)? Or, does it lie in differential central nervous system (CNS) effects of ethanol (e.g., neurotransmitter and receptor mechanisms)? In fact, "protective" genes may exist, as well. Identification of susceptibility and protective genes may lead to the development of targeted prevention and intervention strategies.
  • Treatment works for those with a family history of alcoholism.

What We Measure

Assessments need to be sufficiently broad to capture the extent and complexity of the many factors that accompany, potentially maintain, and are affected by alcohol use. A multidimensional assessment/diagnostic approach to alcohol problems should focus on four domains: (1) physiological, (2) behavioral, (3) psychological, and (4) social factors. In addition, we assess client motivation and commitment to the change process, also called Readiness to Change. Important data and information come from the client, the clinician, and the client's social networks (family, peers, co-workers, and others).

It is important in the diagnosis and assessment phase to develop an understanding of the etiology, course, and severity of the disorder, along with a certain level of client commitment to treatment. At the same time, it is necessary to clarify the interrelationship between an individual's everyday life problems and alcohol use. In addition, the client's strengths in the areas of daily living and social relationships should be acknowledged. Therefore, the various assessment domains should cover the following areas:

  • The kinds of situations, moods, and behaviors that pose the highest risk for the individual's relapse, as well as those that are protective from relapse
  • The strengths and deficits in individual and social coping resources needed to address potential or high risk occurrences
  • The individual's level of readiness to change

In this way, hypotheses can be formed about what action steps will need to be taken in order to achieve sobriety or improvement. The following table (Table 1) provides a short list of suggested instruments for assessing alcohol use problems, high-risk situations, personal coping resources, and motivational readiness to change.

Table 1: Multidimensional Assessment of Alcohol Use Problems
(Adapted from Donovan, 1999)

EXAMPLE OF INSTRUMENTS

REFERENCES

Assessment Domain: Alcohol Use Problems

Serum Chemistry Profile (AST & ALT, GGT, MCV)

Anton et al., 1995

Form-90

Miller, 1996

Time-line Followback

Sobell & Sobell, 1992

Alcohol Dependence Scale (ADS)

Skinner & Horn, 1984

Drinking Inventory of Consequences (DrInC)

Miller et al., 1995

Assessment Domain: Relapse Risk Situations

Inventory of Drinking Situations (IDS)

Annis et al., 1987

Desired Effects of Drinking

Simpson et al., 1996

Profile of Mood States (POMS)

McNair, et al., 1981

Assessment Domain: Coping Resources

Alcohol Abstinence Self-Efficacy Scale (AASE)

DiClemente et al., 1994

Situational Confidence Questionnaire (SCQ-39)

Annis & Graham, 1998

Coping Responses Inventory

Moos, 1995

Assessment Domain: Motivational Resources

Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)

Miller & Tonigan, 1996

University of Rhode Island Readiness to Change Assessment (URICA)

McConnaughy et al., 1983

Readiness to Change Questionnaire (brief RTC)

Rollnick at al., 1992

Measures of alcohol use problems generally deal with quantity, frequency, and symptoms of alcohol use, as well as social, psychological, and physical consequences related to the drinking behavior. These data are used to assess both the dependence syndrome and a variety of negative consequences along a continuum of severity. The assessment data can be useful as feedback to promote client awareness of the extent and severity of alcohol use problems.

Measures of relapse risk situations and coping abilities (i.e., individual's confidence and temptation in handling situations associated with high risk for drinking) highlight those areas that pose the greatest threat to sobriety. The measures include domains that address negative emotional states, interpersonal matters, and intra-personal concerns. Assessing risk situations and deficits in the person's coping abilities allows the social worker and client to develop a treatment package specifically targeted to these areas. Some evidence suggests that individuals do better when they receive targeted services than when they do not (McLellan, Alterman, Metzger, Grissom, Woody, & Luborsky, et al., 1994). The likelihood of improvement may be greater when the special needs, problems, and circumstances of the client are matched to particular aspects or elements of treatment. For example, individuals with a mood disorder such as depression might be advised to participate in a treatment program that includes mood management training. At the same time, the social worker must help the client to identify social and individual coping resources that are present, or need to be developed, to engage successfully in a treatment regime.

Some evidence suggests that the likelihood of improvement may be greater when clients receive services targeted to their needs.

This resource issue is critical because some clients may be willing, but unable, to address their alcohol concerns due to a lack of individual or social coping resources. Without adequate resources and support, individuals may not be able to handle treatment task demands, such as those associated with participating in a partial hospitalization program five days a week

Sequential Approach: Assessing Alcohol Problems, Selecting Goals

A sequential approach is typically employed to assess individuals for alcohol problems (Donovan, 1999). This involves first employing screening procedures to identify persons with possible alcohol problems. Subsequently, assessment procedures are implemented to establish a diagnosis and develop a treatment plan. The goal is to develop an individualized, tailored treatment plan. Proper assessment helps to formulate working hypotheses as to why a client drinks. Furthermore, clients need to have information specifically about themselves and their own drinking problems, not just global "truths" about alcohol use disorders. It is interesting to note that merely asking individuals about their drinking problems may serve to increase their problem awareness, which is an important element in motivating them for treatment (DiClemente, Bellino, & Neavins, 1999). Finally, adequate assessment is an important tool in the ongoing process of evaluating treatment effects, as it provides important baseline data for use in aggregate reporting about treated populations.

Assessment is important for:
- Establishing a diagnosis
- Formulating a hypothesis as to why the client is drinking
- Providing clients with information about themselves
- Developing an individualized treatment plan

The assessment process should include functional analysis, a method of identifying the determinants of alcohol use for purposes of selecting and prioritizing appropriate treatment goals and methods. Determinants might include intra-personal issues, such as negative emotional states, as well as interpersonal matters, such as social pressure to drink (see Annis scales or AASE). Functional analysis is followed by a matching process. Matching involves employing a decision tree to triage individuals through a menu of options based on their personal or social coping resources, treatment needs, and individual preferences. When evaluating coping resources, the social worker must assess the degree of confidence and temptation the individual is experiencing in various at-risk situations (Donovan and Rosengren, 1999). This permits the social worker to assess the client's ability to handle a threatening event or the "strength of the pull" to drink in various high-risk circumstances.

When selecting treatment goals, social workers need to formulate working hypotheses about the individual's troubling life problems and alcohol use:

  • What events or conditions are most likely to interfere with the continuation or cessation of problem drinking?
  • What is the degree of risk posed by certain events or situations (i.e., unemployment, family conflict), intra-personal and negative emotional states (i.e., depression, boredom), and interpersonal stress/pressure to drink?
  • What are the individuals' beliefs about their individual coping skills, social skills, and resources for handling an at-risk event (assessing the individual's self-efficacy)?
  • What are the individuals' outcome expectancies for handling an at-risk event?

The social worker and client must negotiate a sequence of goals, starting with those that are both most manageable and have the greatest likelihood of achieving success. Clients are more likely to achieve treatment goals when employing active coping strategies associated with immediate rewards (Meichenbaum and Turk, 1987). At this juncture, it should be pointed out that empirical support is lacking for employing a decision tree in referring patients to specific treatment modules based on their expressed problems, needs, and preferences.

How We Diagnose

Within the field of alcohol treatment, the Structured Clinical Interview for the DSM-IV (SCID; Steinberg, Rounsaville & Cicchetti, 1990) is a popular, widely used diagnostic instrument to determine client eligibility or decision-making about treatment(s) that might be most suitable for addressing an individual's alcohol use problems. The DSM-IV (American Psychiatric Association, 2000) is popular in the U. S. and closely parallels the ICD-10 classification system (WHO, 1992). It is based on a clustering of symptoms to generate a diagnosis. Not all of the component symptoms must be present to make a specific diagnosis, and each cluster of symptoms is discrete from those that describe other disorders.

Alcohol Dependent or Alcohol Abusing:
- Tolerance or withdrawal symptoms
- Drinking despite recurring problems
- Drinking more than intended
- Reduced social or work involvement due to drinking


Based on the construct "alcohol dependence syndrome" developed by the World Health Organization (WHO), the SCID has served as a mechanism to classify individuals as either alcohol dependent or abusing alcohol based upon whether or not they:
(1) exhibit symptoms of physical dependence, such as tolerance and/or withdrawal
(2) continue using the substance despite experiencing recurring problems as a result of use
(3) take the substance in larger amounts than was intended
(4) give up or reduce their involvement in social, occupational, or recreational activities because of their drinking practices

Individuals who do not experience the aforementioned physical symptoms or fewer consequences (but manifest at least one of the consequences) are diagnosed as alcohol abusers. Key definitional differences exist between alcohol abusing and alcohol dependent individuals. Three or more dependence criteria must be met within the same year and must occur repeatedly as specified by duration qualifiers (e.g., 'often', 'persistent', or 'continued'). Alcohol dependence may occur with or without physiological dependence, whether or not evidence of tolerance or withdrawal is present.

Alcohol abuse is characterized by a maladaptive pattern of using alcohol that leads to clinically significant impairment or distress. Alcohol abuse is defined as intentional overuse in cases of celebration, anxiety, despair, self-medication, or ignorance, resulting in one or more of the following occurring within a 12-month period:

  • Failure to fulfill major role obligations at work, school, or home
  • Recurrent drinking in physically hazardous situations
  • Recurrent alcohol-related legal problems
  • Continued alcohol use despite having persistent or recurrent social and/or interpersonal problems caused or exacerbated by the effects of alcohol.

These symptoms tend to decline with adverse consequences. Alcohol abuse requires that the symptoms have never met the criteria for alcohol dependence (e.g., in persistence, frequency, quantity, etc.).

Alcohol dependence is characterized by impaired control over alcohol use during intoxication and/or inability to abstain from drinking ("broken promises") as evidenced by:

  • The need for markedly increased amounts of alcohol to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount of alcohol (tolerance)
  • Characteristic alcohol withdrawal syndrome with onset less than 24 hours after last "dose" of alcohol (tremors, sweats, nausea, anxiety, sleep disturbance, hallucinations, seizures)
  • Persistent desire to drink, one or more unsuccessful efforts to cut down on drinking, and/or drinking in larger amounts than intended
  • Giving up important social, occupational, and/or recreational activities because of drinking
  • Spending a great deal of time in activities necessary to obtain alcohol or needing to drink to recover from the effects of alcohol
  • Continued drinking despite knowledge of having persistent or recurring physical or psychological problem likely to be cause or exacerbated by alcohol use.

Three or more dependence criteria must be met within the same year and must occur repeatedly as specified by duration qualifiers (e.g., "often," "persistent," or "continued"). Alcohol dependence may occur with or without physiological dependence; whether or not evidence of tolerance or withdrawal is present. It should be noted that there is an important distinction between alcohol dependence with partial remission and alcohol abuse. Although the current diagnostic criteria may be the same, the past history of having been dependent is significant and relevant. It has important implications for future outcomes and for treatment. The definition of alcohol abuse requires that the symptoms have never met the criteria for alcohol dependence.

The SCID has several important limitations. The first is an over-reliance on interviewer discretion in obtaining information for a particular diagnostic category. Second, there is a lack of sensitivity in measuring dependence within certain age groups, such as the elderly or adolescents. For example, adolescents do not commonly demonstrate clear dependence symptoms because of the considerable length of time that it may take to develop such symptoms (Miller et al., 1995). A third limitation is the SCID's inherent deficiency as a method for prescribing psychosocial treatment. Not enough is currently known about such factors as the antecedents and consequences of alcohol abuse and dependence to ensure good clinical determinations about what kinds of treatment strategies will lead to changing harmful drinking practices. However, the SCID is a useful, general measure, particularly for program planning. This is because the measure permits identification of individuals who may need more intensive treatment, such as those with more serious alcohol-related disabilities, or those with co-occurring disorders.

Other, more focused diagnostic tools measure:

Severity of dependence

Alcohol Dependence Scale (ADS)

Skinner & Horn, 1984

Number of withdrawal symptoms

Clinical Institute Withdrawal Assessment (CIWA)

Sullivan et al., 1989

Degree of alcohol-related consequences

Drinking Inventory of Consequences (DrInC)

Miller et al., 1996

Diagnosis

Triage Assessment of Addictive Disorders (TAAD)

Hoffmann, 1995

Diagnosis

Substance Use Disorders Diagnosis Schedule (SUDDS)

Hoffmann and Harrison, 1995

Diagnosis

Diagnostic Interview Schedule (DIS)

Robins et al., 1981

The National Institute of Mental Health Diagnostic Interview Schedule (DIS; Robins, Helzer, Croughan, & Ratcliff, 1981) is designed for use by non-clinicians. These diagnostic measures also serve as aids for addressing treatment inclusion/exclusion criteria, referring patients to specific treatments (e.g., inpatient or outpatient treatment) and/or monitoring patient progress throughout the treatment and follow-up phases (Maisto and McKay, 1995).

There are many Multidimensional Assessment options related to Table 1 (see Table 2). The advantage of some of the single, comprehensive measures is that their use is manualized, their validity and reliability are known, and their scoring and interpretation are clear. The ASI is the most widely used instrument in the substance abuse diagnosis and assessment arena (McLellan, Luborsky, O'Brien, & Woody, 1980; McLellan, Kushner, Metzger, & Peters, 1992).

Table 2: Multidimensional Assessment

Single, comprehensive measures:

-Addiction Severity Index (ASI)
-Comprehensive Drinker's Profile (CDP)
-Alcohol Use Inventory (AUI)

Multiple, complimentary measures:

-Physiological, biological markers
-Behavioral
-Social
-Psychological

The multiple, complimentary measures are flexible, but not necessarily standard approaches, and may not be available in the public domain. The CSAT website presents a number of relevant tools, along with translations into other languages (http://www.samhsa.gov/centers/ csat2002/csat_frame.html). The NIAAA has an annotative bibliography of assessment instruments that may still be accessible through University libraries (NIAAA, 1985). A compendium of rapid assessment measures for social work practice is in development by McMurtry, Rose, and Cisler. Finally, it is important to perform a full assessment to look for other psychiatric functions and diagnoses. Alcohol abuse does not exist in isolation, and very often occurs in conjunction with other drug use and/or psychiatric difficulties. Co-occurring drug use and psychiatric problems increase the complexity of diagnosis and assessment, and often predict poorer treatment outcomes.

Readiness to Change/Stages of Change

The field of health psychology has long recognized the fact that individuals who are engaged in voluntary behavior change generally progress through a recognizable process. The Stages of Change model (DiClemente and Prochaska, 1998; Prochaska et al., 1992) has proven utility when applied to a wide range of health promotion behaviors including smoking cessation, dieting, initiating exercise programs, adopting safe sex practices, reducing intimate partner violence, and overcoming substance abuse problems (Begun et al., in press; Carney and Kivlahan, 1995; Prochaska et al., 1994; Willoughby and Edens, 1996).

Research indicates that individuals typically progress through a predictable, but non-linear sequence of stages when modifying a specific problematic behavior. Each stage is characterized by a set of attitudes, intentions, and behaviors related to the change process itself, as well as to the specific target behavior. People progress through these stages whether or not the change process is being facilitated by formal treatment interventions. Individuals differ markedly in the amount of time and degree of effort exerted in each stage, but the sequence is remarkably similar for everyone.

Stages of Change
- Precontemplation
- Contemplation
- Preparation
- Action
- Maintenance

The first stage in the change process, Precontemplation, is characterized by a lack of intent to change the behavior because it is not viewed as being problematic (lack of awareness), the pros outweigh the cons (decisional balance), or the person is discouraged and demoralized by past failed attempts to change (self-efficacy). It is not uncommon for these individuals to appear in a treatment setting, but they are seldom there without pressure from family, job, or the law (Connors, Donovan, & DiClemente, 2001). A sub-group of individuals, who may be transitioning from this to the next stage, appear highly ambivalent about making change. They score high on precontemplation measures, but average on later stages.

The second stage is Contemplation. This stage is characterized by the individual considering making a change, seeking information related to the problem, and evaluating the pros and cons of changing-however, no overt change effort has begun. An individual who enters treatment may not be ready to take action (see later stages), but is seeking a means of reinforcing and continuing their contemplation processes (Connors et al, 2001).

Subsequent to this stage, individuals enter into the Preparation stage. Here a person solidifies the gains in Contemplation and begins to develop a concrete and upcoming (within one month) plan of action. The individual shows determination and may even begin some tentative changes and increase self-regulation. Furthermore, individuals at this stage are often able to recite valuable lessons learned from past failed attempts. This stage did not appear in early discussions of the model because it initially appeared as a blend of high Contemplation and Action processes, rather than as a distinct stage itself.

The most overtly obvious stage is Action. Behavior change has clearly begun as individuals acquire and practice skills and strategies needed to implement the change. They work to modify both their own behaviors and the environmental contexts of their behaviors (reducing and avoiding temptation experiences). These individuals also become aware of 'traps' that might work against their change efforts. The transtheoretical aspect of the Stages of Change model is most evident through this stage. Diverse intervention approaches seem effective in this stage even though many are ineffective for people in precontemplation or contemplation stages. Most of the treatment evaluation research explores interventions designed for people in this stage of the change cycle. The Action stage typically lasts an average of six months in the change of substance abuse behavior (Prochaska and DiClemente, 1992).

Finally, individuals may achieve the Maintenance stage. Individuals at this stage continue working to sustain the change gains made during the prior stages. They also actively work to avoid and prevent relapse (recurrences of the problem behavior). Termination of the change process does not occur until the person is fully confident and secure in the maintenance of change. This is the ultimate goal of the change process-to move through the spiral of stages, exiting through maintenance to termination.

Most people undergo several cycles of the stages of change process before achieving their ultimate change goals. It may take an average of 5-7 serious attempts (Prochaska, DiClemente, & Norcross, 1992).


The greatest potential contribution of the Stages of Change model is the possibility that it offers for intervention matching to enhance treatment effectiveness. Ideally, individuals at any stage of the process can be adequately assessed and offered an intervention that supports their progress to the next stage (Connors et al., 2001). Towards this goal, a variety of assessment instruments have been developed and tested for reliability and validity: URICA (McConnaughy, DiClemente, Prochaska,, & Velicer, 1983), RTC (Rollnick et al, 1992), and their ability to predict treatment outcome (DiClemente et al, 2001). Furthermore, intervention approaches are being identified and tested for their effectiveness with particular stages of the change process. Instruments such as the Situational Confidence Questionnaire (Annis and Graham, 1988) and the Alcohol Abstinence Self-Efficacy Scale (DiClemente et al, 1994) are useful to assess the self-efficacy component of the change spiral.

Conclusions

A comprehensive alcohol use assessment includes many elements. It includes a profile of drinking, or a "drinking checkup" to examine drinking patterns and a personalized picture of its effects. Remember that it is not the drinking that leads an individual to seek help, it is the consequences of the drinking. Thus, they should be addressed. A comprehensive assessment also includes identification of situations in which the problem occurs, and a focus on the client's strengths. The strengths are important since having early successes are critical to the individual's motivation to stay with the difficult process of recovery. Motivation to change and commitment to the change process are also critical aspects of the assessment process.

A critical feature of the diagnosis and assessment process is the nature of the helping relationship that becomes established. "The tenor of the assessment enterprise should be characterized as collaborative, with the assessor and client jointly committed to discovering those client features that will contribute to important decisions about future clinical management" (Allen, Columbus, & Fertig, 1995). Thus, the information obtained from assessment interviews should include specifics about procedures and practices that stimulate motivation and client commitment to the process.

Finally, when selecting the instruments for assessment and diagnosis, the social worker should keep several issues in mind. Reliability and validity should be assured. Reliability refers to the consistency or dependability of data collected in similar situations, under similar conditions. Validity refers to the extent to which measures accurately reflect the phenomena that they investigate. Reliability and validity are determined, in part, by the social worker's methods and process: "The interviewer is responsible for the integrity of the information collected and must be willing to repeat, paraphrase and probe until he/she is satisfied that the patient understands the questions and that the answer reflects the best judgment of the patient, consistent with the intent of the question." (ASI Manual, University of Pennsylvania, 1990).

When selecting an assessment strategy, the social worker should consider the:

  • clinical utility
  • target population
  • reliability and validity
  • ease of administration
  • time
  • cost
  • scoring and interpretation

Treatment Adherence

Treatment must be acceptable before an individual will make the considerable commitments of time, energy, money, and willingness to endure difficult or distressing experiences in the service of making change and improving life. Previous negative treatment experiences, negative relationship expectancies, external barriers to care, culture, attitudes, and ideological comments may all have an impact on clients' readiness to accept help for alcohol problems (Zweben & Zuckoff, 2002). A multitude of potential sources of non-adherence to treatment exist among individuals seeking help for alcohol problems. First among these is the possibility that the client holds reservations about the nature, extent, and severity of their alcohol problems.

 

Associated with this is the possibility of misperceptions concerning treatment needs. For example, an individual may be interested in medication while the practitioner is interested in providing "talk" therapy. At the very least, an individual must perceive that the proposed treatment would not be harmful before making a tentative commitment to following a particular change strategy.

Individuals who do not believe that they have a problem that needs changing, and who are placed in a treatment program that they do not believe will be helpful, are most susceptible to having adherence problems.

In general, individuals who do not believe that they have a problem that needs changing, and who are placed in a treatment program that they do not believe will be helpful, are most susceptible to having adherence problems. The client may be ambivalent about whether the drinking behavior really needs changing, since the perceived costs of drinking may not yet outweigh the familiar benefits. Clients also differ in terms of their expectancies and level of self-efficacy for handling treatment demands. Low self-efficacy may translate into low adherence.

Clients may experience high barriers to care, including financial problems, cultural differences, family hardships, conflicting demands, and mandate treatment conditions. Everyday concerns may be overwhelming to the extent that the task demands of a specific treatment plan may become unmanageable. An example might be trying to follow a complex pill-dosing regimen when there is no daily routine around which to anchor the schedule (e.g., no set meal times, irregular sleep preparations). As indicated above, clients may have barriers resulting from previous unsatisfactory or otherwise negative treatment experiences. Or, the current practitioner may have set into operation outcome expectancies with which the client is uncomfortable. For still others, the stigma that might be attached to seeking help for alcohol problems may interfere with entering or continuing in a treatment program.

Individuals with adherence problems are often categorized as being "hard to reach," "treatment resistant," and "unmotivated." These labels result in clients being deterred or deferred from treatment programs. However, new evidence, and the resulting insights, have shifted the focus from a trait perspective that promotes labeling and client-blaming, toward an interactional perspective. Social workers are developing and implementing practices that facilitate client adherence. Considerable research supports the efficacy of planning and delivering treatment that incorporates the stages of change and motivation/ readiness processes. One promising example is the practice of Motivational Interviewing.

Motivational Interviewing (MI)

Motivational Interviewing is a critical element for facilitating treatment adherence and outcomes. Mounting evidence suggests a strong, positive relationship between treatment adherence and treatment outcome (Zweben & Zuckoff, 2002). In the field of substance abuse treatment, significant relationships have been found between treatment retention and symptom improvement, life functioning and patient well-being (Westerberg, 1998). In short, among substance abusing patients, the chances of success in both pharmacological and psychotherapy interventions are higher for those who adhere to the treatment regimen. For these reasons, alcohol treatment providers have increasingly given systemic and administrative attention to moderating adherence problems.

Motivational interviewing (MI) techniques have been shown to be effective in addressing adherence problems in individuals with alcohol problems. MI addresses both drinking and adherence by employing strategies aimed at producing motivational readiness. More specifically, MI attempts to modify unrealistic treatment expectations, resolve client ambivalence, and enhance client self-efficacy, in order to ensure and maintain participation in the treatment situation.

MI is a general concept or style of working with a client, not a specific set of techniques. MI has been employed both as an add-on to treatment and as an intermittent co-therapy with pharmacological intervention (Pettinati, Volpicelli, Pierce, & O'Brien, 2000) or conventional alcohol treatments (Brown & Miller, 1993). In these cases, MI has been shown to facilitate treatment retention and participation along with changing drinking behavior. MI has also been used as a stand-alone treatment specifically designed to address drinking problems (Project MATCH, 1997).

STAGES OF CHANGE
(DiClemente & Prochaska, 1998)
- Precontemplation
- Contemplation
- Preparation
- Action
- Maintenance

MI employs certain strategies to improve alcohol treatment adherence. These include issues of interview style that are culturally competent and appropriate, such as:

  • Asking open-ended questions
  • Conducting empathetic assessments
  • Discovering the client's beliefs
  • Reflective listening (rather than asking for more information)

MI techniques also include strategies for motivating individuals toward making changes in their alcohol use practices:

  • Normalizing client uncertainties
  • Amplifying client doubts
  • Deploying discrepancy (fostering cognitive dissonance)
  • Supporting self-efficacy
  • Reviewing past treatment experiences
  • Providing relevant feedback (e.g., results of own tests motivates people)
  • Summarizing and reviewing potential sources of non-adherence
  • Negotiating proximal goals (i.e., opportunity to achieve "quick successes")
  • Discovering potential roadblocks
  • Displaying optimism
  • Involving supportive significant others

Treatment Selection Processes

The selection of a treatment package is a negotiated decision between the client and social worker. The decisions are based, in part, on the clients' recognition of their own treatment needs, stated preferences, and outcome expectancies about the approach. Thus, to facilitate client involvement in this process, the social worker must explore the client's own views about defining the drinking problem and treatment expectations. Social workers should ask clients open-ended questions concerning the chain of events that brought them to the program. Inquire about the clients' perceptions of how they might change their drinking behavior.

Sharing information from the assessment battery will clarify any misconceptions, beliefs, or perceptions by the clients about their drinking problems and will increase their awareness of the extent and severity of their problems. Scores on standardized measures, such as the Inventory of Drinking Situations (Annis, Graham, & Davis, 1987) and the Desired Effects of Drinking (Simpson, Little, & Arroyo, 1996) have been used for these purposes. During the information exchange, the social worker empathetically reflects client concerns, frustrations, and differences. This discussion helps individuals to develop and recognize the discrepancy between their behavior, problems, or concerns and their personally-held goals and values. This method of deploying discrepancy highlights the gap between "where they are" and "where they want to be". For example, a client might wish to change his drinking practices without altering a lifestyle that involves visiting the local tavern after work. A summary by the social worker about potential reasons for non-adherence follows this process of inquiry. The practitioner recapitulates what the client has said about current and future obstacles to change (e.g., believing that "medication will change everything".)

Once a consensus is reached concerning problem definitions, treatment goals, and treatment expectations, an action plan is developed. The social worker presents a menu of treatment options. This provides clients with the opportunity to choose treatment plans that are most appropriate to their needs and capacities.

For individuals with lingering doubts about treatment, a tentative or incremental plan may be developed. This might entail having the person attend treatment sessions on a trial basis. Other clients may need to break down a long-term goal such as obtaining a commitment to permanent abstinence. In these cases, such a commitment could be overwhelming and cause extreme anxiety. Instead, the commitment could be broken down into manageable tasks, such as sustaining abstinence for four days during the week. The social work practitioner then conveys confidence in the clients' ability to make their own decisions, and expresses optimism about the potential for change.

The session closes with a "nonperfectionistic" message about change (Daley & Zuckoff, 1999). Here, the practitioner communicates that stumbling, negative reactions, second thoughts, setbacks, and delayed negative responses are naturally occurring events and, as such, are not unexpected. Clients are asked to view these occasions as learning opportunities in the change process. Unfortunately, there is a danger of reacting negatively to these events and becoming extremely self-critical. In many cases, extreme self-criticism changes a "slipup" into a full-blown relapse. This summary exercise serves the purpose of inoculating clients against reacting impulsively to their disappointment by leaving treatment prematurely.

Brief Interventions for At-Risk (Non-Dependent) Drinkers

Within the past two decades, there has been a growing awareness that individuals with alcohol use problems are a diverse population with differing levels of severity of alcohol or drug-related problems, and varying levels of capabilities and resources to cope with these problem behaviors. Within this vulnerable population, there is a sizeable proportion of individuals who occasionally drink in a manner that could potentially cause serious harm to themselves and others but, as yet, have only experienced mild or moderate consequences. Such consequences may entail missing a few days of work each month, arguing with a spouse, and intrapersonal problems such as guilt or anxiety about drinking. Other individuals are more seriously afflicted with substance-related problems such as medical complications, psychiatric disorders (e.g., depression) physiological difficulties (e.g., withdrawal symptoms) and legal difficulties (cf., Institute of Medicine, 1990; Heather, 1995; Skinner & Allen, 1982). Thus, persons with mild or moderate difficulties stemming from drinking or drug use can be differentiated from persons with severe problems by their patterns of use (e.g., quantity and frequency of consumption) and the numbers and kinds of biopsychosocial consequences stemming from the problem behaviors (e.g., dependence symptoms).

As the definitions of alcohol and drug abuse have expanded, so have the boundaries of alcohol treatment services. Consequently, more persons with alcohol use problems are being identified at earlier stages and treated by a wide variety of community resources (Rose, Zweben, & Stoffel, 1999). Individuals with lower levels of severity are receiving formal help in emergency rooms of general hospitals, public schools, child protection agencies, legal services, and employee assistance programs (Zweben & Rose, 1999). Public health policy has expanded the focus of attention to include individuals with mild or moderate problems as well as those with severe problems (cf., Institute of Medicine, 1990; Higgins-Biddle & Babor, 1996).

It is in this context that brief intervention has been devised and utilized with individuals who experience early or at-risk/non-dependent alcohol use. With the budgetary restrictions placed on alcohol treatment services, a premium has been placed on developing cost-effective treatment technology. Brief intervention represents a low-cost, effective treatment alternative for addressing alcohol problems. Based on research involving nicotine abusers (Ockene, Kristeller, Goldberg, Amick, Pekow, Hosmer, et al., 1991; Richmond & Heather, 1990) and alcohol studies conducted primarily in Europe (Bien, Miller, & Tonigan, 1993), brief interventions have been employed differentially in different settings with various kinds of clients. While initially employed as a minimal or control treatment condition (Orford & Edwards, 1997), brief interventions have become, by virtue of their effectiveness, a viable alternative to more intensive approaches in treating alcohol problems.

Application of Brief Interventions (BI) in Nonspecialized Treatment Settings

Brief interventions are time-limited, self-help prevention/intervention strategies that focus on reducing alcohol use in the non-dependent or at-risk drinker. The primary function of brief interventions is to influence motivation for behavior change. Brief interventions do not teach specific cognitive behavioral skills, nor do they devote much time toward attempting to change a client's social environment.

The components of the brief intervention typically comprise a 15-30 minute interview involving a brief screening and assessment, feedback on personal risk, advice about how to change the drinking behavior, assessing motivation for change, establishing drinking goals, a self-help pamphlet, and a referral for further counseling if warranted and desired (Heather, 1995; Anderson & Scott, 1992; Wallace, Cutler, & Haines, 1988; Fleming, Barry, Manwell, Johnson & London, 1997; NIAAA, 1995). Booster sessions or a referral for additional counseling is sometimes offered (Fleming, et al, 1997; Elvy, Wells, & Baird, 1988). Follow-up is also part of the process (Babor, 1990; Chick, Ritson, Connaughton, Stewart, & Chick, 1988; Edwards, Orford, Egert, Guthrie, Hawker, Hensmen,, et al., 1977; Fleming, 1995; Miller & Sovereign, 1989; Sanchez-Craig, 1990). These methods are particularly applicable to general clinical settings where alcohol treatment must fit into the context of a busy, high volume practice with multiple competing prevention agendas. The techniques can be used by a number of health care and non-health care specialists, including primary care practitioners, medical specialists, advanced nurse practitioners, physician assistants, dentists, social workers, psychologists, and marriage and family counselors.


Components of Brief Intervention (BI):

- Screening and assessment
-Direct feedback on personal risk
- Advice for change
- Assessing motivation for change
- Contracting and goal setting
- Self-help techniques
- Bibliotherapy
- Referral if warranted
- Follow-up

Treatment goals are mostly geared toward reducing drinking, rather than abstinence. Feedback is aimed at increasing a client's awareness of the negative consequences of the drinking behavior (Fleming et al., 1997). This helps to change misperceptions or misunderstandings of the severity of the alcohol problems. Advice is focused on identifying action steps to change the drinking pattern. This is followed by formulating goals about the drinking pattern (e.g., establishing criteria or cutting points for daily/weekly consumption level), and making plans for achieving them. Together these strategies help to mobilize the patients' coping resources and stimulate positive change.

Screening:

Query the individual's typical drinking practices:


"On average, how many days a week do you drink?"
"On a day when you drink alcohol, how many drinks do you have?"
"What is the maximum number of drinks you consumed on any given occasion during the past month?"

 

Cut-off limits for these questions are based on scientific data that examined the relationship of specific levels of alcohol use and health problems. For example, women who drink more than 7 standard drinks per week or more than 3 drinks per occasion, and men who drink more than 14 standard drinks per week or more than 4 drinks per occasion, are considered as "screening positive." A positive screen means that the individual should be assessed for problems related to alcohol use and symptoms of dependence.

Assessment:

Ask about alcohol-related health problems.
Is there a history of…

  • Liver dysfunction
  • Hypertension
  • Chronic abdominal pain
  • Depression
  • Sexually transmitted disease
  • Headaches
  • Suicide ideation
  • Trauma
  • Anxiety or panic attacks
  • Sleeping problems
  • Pancreatitis

 

Assess for family, social and employment problems:

  • Have you ever been arrested for driving while under the influence of alcohol?
  • Have any family members, friends, or people at work ever asked you to change your drinking habits?
  • Has your drinking caused problems in your life?
  • Have you ever participated in a work-related alcohol treatment program?
  • Have you ever had a problem with your job because of drinking?

The last area of the assessment is to ask about symptoms of alcohol dependence, such as loss of control and withdrawal. Persons who show evidence of alcohol dependence are referred to specialist practitioners.

Assess for evidence of dependence:

  • Do you ever drink in the morning to get over a bad hangover?
  • Do you develop shakes when you stop drinking for more than a day?
  • Have you ever been in DTs, been detoxed, or had an alcohol withdrawal seizure?
  • Have you ever been treated for alcohol or drug withdrawal?
  • How many days a week do you drink in the morning?

Advice-giving:
The practitioner states his or her concern about the client's alcohol use, provides personalized feedback about how drinking affects health (e.g., sleeping patterns, family problems, headaches, recent trauma, and accidents), and advises the client to change drinking behaviors. Some individuals will need to reduce drinking while others may need to become abstinent. The latter group includes individuals with extensive health problems, pregnant women, women intending to become pregnant, individuals using certain prescription drugs, and those who exhibit symptoms of alcohol dependence.

Assessing motivation for change:
Clients are asked about their readiness for change and then placed in the following five categories: 1) not interested; 2) considering change; 3) ready for action; 4) initiating action; and 5) already acting. Such categories are useful to determine what kinds of action steps need to be taken in relation to the drinking. For example, clients who are not interested in changing may be asked to just "think about" their drinking practices, rather than to cut down. Matching the intervention level to the client's readiness status is an important element in assuring compliance and adherence.

Establishing specific drinking goals:
Social workers and clients need to establish feasible and suitable drinking goals based on:

  • the severity of the drinking problems
  • performance demands (e.g., bus driver)
  • readiness to change

Social workers negotiate specific drinking patterns, develop a written contract, and offer the patient a self-help manual or reading materials. Specific dates are scheduled for modifying the drinking pattern. A workbook may be provided with exercises for the client to complete such as maintaining a diary of drinking behaviors.

Date ____________

I, _________________________________________________ agree to the following drinking goal:

_____Number of drinks ____________________________ Frequency OR _____ Abstinence

Starting date: _______________________________

Participant signature: _________________________________________

Clinician signature: ________________________________

 

Conducting follow-up:
Providers may offer follow-up services to review the drinking goals, assess any ongoing problems, and support ongoing change efforts. It may also become necessary to conduct an assessment of additional problems that might emerge-particularly problems that might have been masked by the drinking pattern (e.g., mental health concerns, marital difficulties, etc.).

State of Knowledge Concerning Brief Intervention (BI)

Multiple trials in multiple settings have shown that brief intervention can reduce alcohol use for at least one year (Bien et al, 1993; Kahan, Wilson, & Becker, 1995; WHO, 1996; Wilk, Jensen, & Havighurst, 1997; Fleming et al., 1977; Fleming, Manwell, Barry, Adams, & Stauffacher, 1999; Marlatt, Baer, Kivlaahan, et al., 1998; Ockene, Adams, Hurley, Wheeler, & Hebert, 1999; Gentilello, Rivara, Donovan, Jurkovich, Daranciang, & Dunn, et al., 1999). Several trials found changes in alcohol use among women (Babor & Grant, 1992; Fleming et al., 1997; Wallace et al., 1988; Chang, Goetz, Wilkins-Haug, & Berman, 2000; Manwell, Fleming, Mundt, Stauffacher, & Barry, 2000). Four trials found decreases in health care utilization: emergency room visits and hospital days (Fleming et al, 1997; Fleming, Mundt, French, Manwell, Stauffacher, & Barry, 2000 & 2002; Kristenson, Ohlin, Hulten-Nosslin, Trell, & Hood, 1983); hospital readmissions (Gentilello et al., 1999); and physician office visits (Israel, Hollander, Sanchez-Craig, Booker, Miller, Gingrich, et al., 1996).

Brief intervention can also reduce:

  • GGT levels (Kristenson et al, 1983; Wallace et al, 1988; Nilssen, 1991)
  • Sick days (Kristenson et al., 1983; Chick, Lloyd, & Crombie, 1985)
  • Drinking and driving Chick, Lloyd, & Crombie, 1985)
  • Mortality (Kristenson et al., 1983; Fleming et al., 2002)
  • Health care and societal costs (Holder, Miller, & Carina, 1995; Fleming et al, 2002)

The brief advice intervention procedures varied by trial with most interventions consisting of a single, 15-20 minute counseling session and a variable number of booster sessions. Physicians were the primary interventionists in most trials. In positive trials, the reduction in alcohol use varied from 10-30% between the intervention and control groups. Methodological limitations in many trials included small sample sizes, low follow-up rates, variations in the quality of the practitioner-delivered interventions, and lack of "blinding" of the control subjects.

Motivational Enhancement Therapy (MET)

The brief intervention approach discussed above is primarily dedicated to non-problem, non-dependent drinkers. It is also necessary to consider approaches that might be effective with dependent drinkers. Motivational Enhancement Therapy (MET) was developed in Project MATCH as one of three study treatment modalities (the other two were Cognitive Behavior Therapy and Twelve-Step Facilitation). MATCH is a multi-site collaborative patient-treatment matching study involving 10 clinical research units and 1,726 patients who were seen in treatment over a period of 12 weeks. The primary assumption underlying MET is that motivation is a dynamic "state," not a static "trait" for the individual with an addiction. The level of motivation can vary over time and can be influenced by factors such as social interactions and clinician style. Motivation is relevant to behavior change efforts in that it is related to the probability that a client will engage in a particular behavior. MET development was influenced by empirically-based evidence from motivational psychology and social learning theory, stages of change, and motivational interviewing. [Note that MET is not synonymous with Motivational Interviewing.]

MET was derived from the FRAMES model of alcoholism treatment (Miller & Sanchez, 1993) which includes six components found to be efficacious with alcohol patients:

  • Feedback about personal risk or impairment
  • Responsibility for change lies with the individual (client)
  • Advice on changing the drinking
  • Menu of alternatives and change options
  • Empathy on the part of the practitioner
  • Self-efficacy or optimism on the part of client, facilitated by practitioner

MET was designed as a brief intervention to increase a client's motivation to change and receptiveness to "help." In Project MATCH, MET involved four sessions. The first provided structured feedback. The second enhanced commitment for change by developing a treatment plan. The last two sessions continued reinforcement of the commitment to change and monitored progress. Based on principles of motivational psychology, and grounded in research concerning processes of change, MET attempts to improve drinking outcomes by employing five strategies to rapidly enhance motivational readiness to change: 1) express empathy, 2) develop discrepancy, 3) avoid argumentation, 4) roll with resistance, 5) support self-efficacy.

Expressing Empathy:
Empathy occurs when the social worker accurately reflects what the individual is feeling and experiencing. To engage in a therapeutic relationship, clients must perceive their practitioner as a person who deeply understands their circumstances. A client's sense of acceptance can facilitate change. Skillful reflective listening by the social worker is fundamental.

5 Elements Involved in MET:
- Expressing empathy
- Developing discrepancy
- Avoiding argument
- Rolling with resistance
- Supporting self-efficacy

Developing Discrepancy:
At the same time, the practitioners help clients to develop and recognize the discrepancy between their drinking behaviors and their personally held goals and values. This involves highlighting the gap between "where they are" and "where they actually are" (deploying discrepancy). For example, the practitioner externalizes the client's ambivalence about addressing drinking behavior by pointing out the discrepancy between a desire to be a better spouse and parent, and the amount of time spent at the local bar with "buddies." A significant first step in this process is to discover the client's personal values and goals. As a result, the client will be able to present and "own" the best arguments to support change. The practitioner's role is to evoke self-motivational statements from the client.

Avoiding Argumentation, Rolling with Resistance, Supporting Self-Efficacy:
In addition, emphasis is placed on avoiding disagreements with clients about the severity of their alcohol problems. Argumentation is counterproductive to the change process and defending positions may breed client defensiveness. Rather, disagreements are met by empathically reflecting the clients' negative reactions to the treatment situation. No efforts are made to persuade clients about the seriousness of their problems or their helplessness, or in getting them to accept the "alcoholic" label-aspects of many traditional therapies.

Resistance is a signal to change or shift strategies. Rolling with resistance means:

  • acknowledging that a disagreement exists
  • admitting to limitations of the assessments
  • emphasizing client responsibility for choices and change
  • encouraging contemplation
  • redirection

Throughout the sessions, the practitioner attempts to convey confidence in the client's abilities and capacities for change. All efforts to change the drinking behavior are affirmed by the practitioner. The client is the most valuable resource for finding solutions to the problems and is responsible for choosing and executing the change strategies. It is important for the team to build on the client's strengths, existing resources, and past successes.

An important ingredient of the motivational model is client choice. Emphasis is placed on obtaining client agreement about the severity of drinking problems and the kinds of strategies to be used for changing the drinking behavior. A client may leave treatment prematurely due to a lack of correspondence with the practitioner concerning the level of harm associated with the drinking, beliefs about the etiology of the problems, and methods for addressing the problems (Zweben, Bonner, Chaim, & Santon, 1988a). To this end, clients are offered a variety of options-including doing nothing. Better outcomes have been associated with the extent to which the individual freely chooses the course of action and is optimistic about the prospects for success (Donovan & Rosengren, 1999). Client commitment can be enhanced by facilitating the belief that there is "a way out" of the problem and by enabling the individual to "do something" about it. In practice, MET is structured in two phases…

Phase I:

- Establish rapport by exploring the chain of events that led to help seeking. Determine the client's view of the problem…
"What brought you here today?" or "What happened that you are seeking treatment?"
"How do you see your drinking?" or "What do you like about drinking?" or "What are your concerns?"
- Provide personal feedback:
" Share information from the screening and assessment processes (i.e., MAST, CAGE, TWEAK, AUDIT, S-MAST, RAPS, DAST results)
" Neutrally compare client scores to normative data
" Elicit client's reaction to the feedback
- Build motivation
" Raise awareness of personal harm/risk associated with the alcohol use pattern
" Address barriers to change
" Identify client strengths, resources, and successes

Phase II:

- Strengthen motivation
- Develop a specific change plan:

  • "The changes that I want to make are…"
  • "The reasons that I want to make them are…"
  • "The steps that I will take are…"
  • " "The ones who can help me are…"
  • "The things that can get in the way of my success are…"

- Ask for a commitment to the change process and plan

  • Link the change process to personal goals and aspirations held by the client
  • Identify of a series of "next steps" that are proximal and/or facilitative goals
  • Ask directly for a commitment
  • Attempt to envision a future that includes the desired changes

- Move to action

  • Educate the client about change strategies
  • Marshall support from friends and family
  • Anticipate difficulties
  • Provide structure and assistance
  • Monitor for unexpected symptoms/problems masked by the alcohol use disorder

Motivational approaches are at least as effective as more intensive or conventional strategies (Bien et al., 1993). In Project MATCH, few clinically significant differences were found between Motivational Enhancement Therapy (MET) and the more intensive Cognitive Behavioral Therapy (CBT) or Twelve-Step Facilitation (TSF). [Twelve-Step Facilitation is about getting a client to attend AA, not about providing the program directly.] While TSF and CBT treatments yielded slightly greater (2 days/month or 5%) reduction in alcohol consumption, post-treatment follow-up drinking rates did not differ significantly among these three treatment groups (Project MATCH, 1997).

The Project MATCH Cost Evaluation Study (Holder, Cisler, Longabaugh, Stout, Treno, & Zweben, 2000) looked at medical cost-offsets associated with the three MATCH treatment approaches (see Figure 1). No significant differences were found among the three MATCH treatments in total health care costs in the post-treatment period. The mean estimated monthly post-treatment costs for the three treatment conditions ranged from $359 for MET to $433 for CBT and $407 for TSF. MET had a clear cost advantage over CBT and TSF (Cisler et al, 1998). The cost savings associated with MET may place pressure on health care or managed care providers to adopt such methods in settings where individuals with alcohol problems are typically seen.

Motivational Enhancement Therapy & Treatment Matching

Treatment mismatching is a source of treatment failure and client drop-out. Many treatment modalities are founded on the assumption that the client is ready to take action, ignoring all other stages of the change cycle (precontemplation, contemplation, preparation, and maintenance). Treatment mismatching occurs when treatments offered are inconsistent with the client's stage of readiness. It also occurs when more treatment is given than a client wants or when barriers to treatment are ignored.

Treatment matching allows for varied responses to be matched to client readiness. For example, in response to precontemplation processes, an intervention can increase awareness and raise doubts about the problematic behavior. In response to contemplation, the interventions are designed to help tip the decisional balance toward action and away from inaction. In preparation, intervention should involve the negotiation of a concrete and workable plan for change. Action interventions, the ones with which we are generally most familiar, assist the client in behavior change through achieving a series of small, progressive steps toward a goal. Maintenance interventions are critical in that they help to prevent relapse and help support ongoing lifestyle change.

Findings from Project MATCH suggest that individuals high in anger fared better in MET than in the other two MATCH treatments (CBT and TSF; Project MATCH, 1998). Subjects in the highest third of the anger variable treated in MET had an average of 76.4% abstinent days, whereas their counterparts in CBT and TSF treatments had an average of 66% abstinent days. For angry clients, a non-confrontational approach such as MET may work more effectively to defuse anger or resistance than modalities that are typically more directive.

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is based on principles of social learning theory, indicating that the problem behaviors are determined by factors in the social environment. As such, the behaviors can be "unlearned" in the same ways that they were first acquired and are now maintained. CBT focuses on learning alternative coping strategies, rather than alcohol use, to deal with potentially high-risk situations.

A functional analysis is conducted to determine target areas for intervention. A wide range of goals are identified and prioritized, and a sequence of interventions is employed to achieve them. Interventions might include assertiveness training, mood management, job seeking skills, anger control, communication training, and planning of leisure-time activities. Opportunities are provided to practice skills inside and outside the sessions (i.e., homework).

To build the individual's confidence, easily attainable "quick win" goals are given priority in the treatment plan. Typical objectives associated with CBT include social skills training, reduced psychiatric symptoms, anger reduction, social support, and job finding.

CBT sessions follow a 20-20-20 rule (Carroll, 1999). The first third of each session is devoted to evaluating and discussing drinking behavior during the past week. Other concerns that might affect drinking behavior, such as marital or family conflict, are also reviewed. The second third of the session is devoted to skills training and rehearsal. For example, a role-play might be used to develop or improve drink refusal skills. The final third deals with planning for the week ahead, including a discussion of relapse prevention techniques. For example, one client spent the latter part of the session practicing how to deal with criticism on the job without drinking. A role-play was used to teach assertiveness skills to defuse the negative moods that result from such criticism.

CBT: The 20-20-20 Rule
First 1/3 of each session devoted to:
- Reviewing drinking during past week
- Identifying other concerns that affect drinking behavior
Second 1/3 of each session devoted to:
- Skills training and rehearsal

Final 1/3 of each session devoted to:
- Planning for the week ahead
- Relapse prevention techniques

CBT has demonstrated efficacy when it is delivered as part of a comprehensive treatment program, rather than as a stand-alone approach. Longabaugh and Morgenstern (1999) reviewed the CBT outcome literature and concluded that CBT was more effective than other treatments when it was delivered within the context of a program to change an individuals' social environment. The latter involved creating alternative lifestyles that would be incompatible with drinking. For example, an individual might choose to regularly attend church services with family members, find stable employment, focus on healthy nutrition, save money, and so on. Similar results have been reported in pharmacotherapy trials where CBT has been added to the medication regimen and compared to other add-on approaches (O'Malley, Jaffe, Chang, Schottenfeld, Meyer, & Rounsaville, 1992).

Cognitive Behavioral Therapy and Treatment Matching

In Project MATCH, individuals in aftercare with low alcohol dependence symptoms fared better in CBT than in TSF. Those with more alcohol dependence symptoms fared better in TSF. These differences were observed across a number of outcomes pertaining to drinking and health care costs (Project MATCH, 1997; Holder et al., 2000). Other studies reported that individuals with a higher degree of psychiatric severity (Kadden, Cooney, Getter, & Litt, 1989) did better in CBT than in interactional therapy, but these matching results have not been confirmed in subsequent research. One study showed that clients with high support for drinking performed better in CBT than in relationship enhanced therapy (Longabaugh, Wirtz, Beattie, Noel, & Stout, 1995). This also has not been confirmed by subsequent research.

Relationship Enhancement Therapy (RET)

Relationship Enhancement Therapy has found increasing support in the alcoholism treatment literature. RET involves a variety of different, but related approaches, all aimed at increasing social support for abstinence, buttressing motivational readiness, improving interactional patterns that promote and reinforce sobriety, and establishing and maintaining emotional ties with members of the social network.

RET efforts include:

  • Involving a supportive significant other (SSO) in brief treatment (Zweben & Barrett, 1993)
  • Providing behavioral marital or family therapy (O'Farrell, 1995; Miller, Meyers, & Tonigan, 1999)
  • Offering mutual help opportunities (Tonigan & Toscova, 1998; Project MATCH, 1997).

Although there are conceptual differences among these approaches (systems theory versus social learning theory versus Alcoholics Anonymous philosophy), each involves the promotion and active involvement of a supportive significant other in treatment. The SSO could be a child, parent, friend, clergyman, or member of a self-help group (e.g., sponsor). Toward this end, methods are used to enhance communication patterns that reinforce social support for sobriety.

More specifically, RET can help to: (1) increase the individual's level of awareness about the alcohol problems, (2) enable the individual to accept responsibility for changing the alcohol problems, and (3) generally enhance the individual's readiness to change. With regard to mutual help (i.e., AA involvement), facilitating a spiritual experience can become a source of emotional comfort for individuals who struggle with decisions about initiating and sustaining abstinence. RET enables the individual to obtain ongoing social support for abstinence. This is an important ingredient of change, especially for those whose natural social networks are not supportive of abstinence. Interestingly, RET has been used effectively to enhance clients' abilities to cope effectively with drinking problems, even if they are unwilling to seek help themselves (Miller, et al., 1999).

In RET, efforts are devoted to reducing interaction patterns that inadvertently reinforce problem drinking. RET helps non-drinking partners to identify behaviors that trigger or reward problem drinking. It teaches the non-drinking partner (or SSO) about withdrawing positive reinforcement when the client is using alcohol, and about providing positive reinforcement for nonuse. Examples of the former include not making excuses to an employer for the alcohol use problems (i.e., showing up late for work), not cleaning up after a drinking episode, and avoiding drinking-related events, such as bowling, ball games and parties. Examples of the latter include verbally acknowledging nonuse and sharing in activities associated with nonuse, such as attending church services together, exercising, going to movies, gardening, photography, or pursuing other active hobbies.

RET Goals and Objectives:
- Facilitating medication and treatment compliance
- Buttressing motivation
- Increasing interaction patterns that promote and reinforce sobriety
- Strengthening emotional ties
- Increasing social support networks for abstinence
- Improving coping capacities
- Facilitating spirituality

Some of the common goals and objectives associated with RET include: (1) the facilitation of medication and treatment compliance, (2) buttressing motivation, (3) increasing interaction patterns that promote and reinforce sobriety, (4) strengthening emotional ties, (5) increasing social support networks for abstinence, (6) improving coping capacities, and (7) facilitating spirituality (e.g., AA fellowship). It is important to note that effective SSO involved therapy requires that both drinking and relationship issues be addressed during the course of treatment. Interventions that include minimal SSO-involvement (i.e., the SSO is merely a "witness" or is not actively engaged in the sessions) do not perform nearly as well as approaches that actively involve SSO's in all phases of treatment (McCrady, Stout, Noel, Abrams, Nelson, 1991). Ideal candidates for SSO's are those who are: (1) genuinely supportive of the client's sobriety, (2) highly valued by the client, and (3) not experiencing severe alcohol-related hardships themselves.

Studies on RET have reported favorable outcomes, regardless of theoretical orientation (systems theory, social learning theory, or AA philosophy), especially if positive ties have existed between partners prior to the initiation of treatment (O'Farrell, 1995; Sisson & Azrin, 1986; Zweben, Pearlman, & Li, 1988b; Longabaugh et al., 1995; Miller, et, al 1998). Long-term results demonstrate the advantages of RET approaches over individual-focused alcohol therapy in terms of increasing length of stay (Zweben et al., 1983) and improving the marital relationship (O'Farrell & Fals-Stewart, 1999). Both factors are associated with sustaining sobriety. In addition, RET has been used effectively to enhance motivation for change, which is an important factor in reducing hazardous alcohol use (Miller, Andrews, Wilbourne, & Bennett, 1998). In summary, RET studies show superior results over control groups on a number of outcome measures including drinking, marital stability, motivation, and compliance.

Concerning mutual help, it is often unclear whether it is AA attendance or AA participation (e.g., having a sponsor, reading the Big Book, practicing the 12 steps, etc.) that becomes the most salient contributor to improved drinking outcomes (Tonigan & Toscova, 1998). Some researchers (Emrick, Tonigan, Montgomery, & Little, 1993) have proposed that active participation in AA (i.e., reaching out for help, having an AA sponsor, and doing the first step) is more important for sustaining abstinence than AA attendance. However, Project MATCH was unable to determine if AA attendance or AA involvement was more important for achieving sobriety. Both were found to be positively related to abstinence (Tonigan, et al, in press). The latter finding was replicated in the VA comparison alcohol treatment outcome study (Ouimette, Finney, & Moos, 1997).

Relationship Enhancement Therapy and Treatment Matching

A major finding in Project MATCH dealt with network support for drinking and AA attendance (Longabaugh, Wirtz, Zweben, & Stout,1998). Individuals whose social networks were supportive of drinking fared better in TSF than in MET. Because AA attendance was encouraged or promoted, TSF patients were more likely to attend AA meetings than were their counterparts in MET. This was fortunate because involvement in AA seemed to "immunize" those TSF patients (i.e., those whose networks were supportive of drinking) from experiencing relapse. At the 3-year follow-up, among patients with higher scores on the network support for drinking variable, there was a 16% difference in the number of abstinent days (74% vs. 58%) between TSF and MET conditions. These findings offer additional support for mutual help involvement. This may be why some researchers suggest that all clients be routinely encouraged (not required) to attend mutual help groups, especially those clients who lack a support system for abstinence (Westerberg, 1998).

Limitations of Treatment Outcome Studies
Maintaining the Purity of the Treatment Models

A major limitation of treatments employed in clinical studies has been the necessity to maintain the purity or integrity of the treatment model. Greater emphasis has been placed on adhering to the integrity of the particular treatment (i.e., internal validity) than addressing the differential needs or capacities of individual clients. Unlike "real world" clinical settings, no attempt is made to integrate components of different models to address client problems. In other words, a person in a CBT skill building program would not have motivation enhancement, while a person in MET would not acquire skills training. The models described here are "pure" models, but the clients are not, and the process in reality is far more eclectic. For example, in Project MATCH, to maintain a distinction or contrast between the different approaches, motivational issues were emphasized only in MET, AA involvement was promoted mainly in TSF, and coping skills training was provided primarily in CBT. This means that individuals might have had the ability to improve their coping capacities in CBT, but did not have the requisite motivation to use them. Others might have needed the support of AA Fellowship following exposure to MET, but were not encouraged to participate in AA. In short, the MATCH treatment outcomes were limited by the need to reduce similarities across the three modalities. At the same time, traditional alcoholism treatment programs have not been responsive to the diverse needs and capacities of the broad spectrum of clients seen in these clinical settings (Tucker, 1999). The "one size fits all" approach has often been the primary method of treating individuals with alcohol problems. However, the evidence suggests that to best serve individuals with alcohol problems, a repertoire of interventions should be developed, tailored to the differential needs and capacities of a heterogeneous client population, and delivered in a manner that is responsive to the complex problems or issues confronting this group (Tucker, 1999). A phase model of matching may be the means by which this is accomplished-see below.

Need To Develop A More Comprehensive Theory Of Matching

One of the inferences drawn from Project MATCH was that the a priori primary hypotheses were overly simplistic (Project MATCH, 1998). The fact that few matching hypotheses were supported, and that some contrasts were in the direction opposite of what was predicted, suggest that current matching theory is under specified. A more adequate theory should specify the circumstances and conditions under which matching effects might appear. Thus, higher order a priori matching hypotheses await testing. Based on the findings emerging from Project MATCH, it is conceivable that individuals with a profile of high self-efficacy, high motivational readiness for change, and high social support for drinking would benefit most from CBT, whereas those with low self-efficacy, low motivational readiness for change and high support for drinking would benefit most from TSF. To adequately test the effectiveness of matching clients to treatment condition based on motivation/readiness to change status, a much wider continuum of interventions need to be evaluated.

Use of a Phase Model of Matching
Evidence has shown that individuals vary in patterns of alcohol use and related consequences over the course of relapse and recovery (Babor, Longabaugh, Zweben, Fuller, Stout, Anton, et al., 1994). Some individuals are able to sustain long periods of abstinence, while others may move in and out of sobriety over a lifetime. Some individuals may continue to experience serious negative consequences, despite achieving abstinence, while others may demonstrate major improvements in various areas of life following abstinence. Thus, a phase model of intervention matching (Howard, Lueger, Maling, & Martinovich, 1993) offers a heuristic model for testing methods of enhancing treatment effectiveness. In this model, a broad array of assessment measures is employed. They deal with individual, interactional, and situational factors. These measures might address various domains such as motivational readiness, aspects of life functioning, vocational functioning, social/family/marital functioning, spirituality, physical functioning, emotional adjustment, and residential status. These measures are examined in terms of how alcohol use might be directly or indirectly associated with these different areas. For example, is marital conflict a precipitant or consequence of excessive alcohol use? Can we expect an improvement in the marital relationship to be followed by a reduction of alcohol use or vice versa?

Decisions about the kinds of strategies to be employed are based on an understanding of how these individual, interactional, and contextual variables interact with the treatment variables to produce good treatment outcomes. For example, in Project MATCH, the causal chain analysis for the social support hypotheses suggested the following: For those clients whose environments were highly supportive of drinking, positive change in treatment was predicated on consequent changes occurring outside of treatment-namely, AA involvement. MATCH treatments may have helped to initiate change, but AA participation was necessary to maintain or consolidate its benefits (Longabaugh, et al., 1998). Thus, in "phase model" terminology, symptom improvement (i.e., reduction in drinking) was followed by a change in the social environment (AA attendance) in order to achieve sobriety. In sum, a phase model might offer us some guidance to determine what kinds of strategies might address special problems linked with the drinking, and how best to deliver these strategies to maximize treatment benefits. Nevertheless, phase model matching requires an ongoing, dynamic process of assessment to work.

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