Cognitive Behavioral Therapy for Alcohol Dependence

Introduction: Alcohol Dependence as a Public Health Problem

Alcohol belongs to a family of chemical compounds known as depressants, though it is commonly mischaracterized as a stimulant. Many people consume it for different reasons: some enjoy alcoholic beverages in social settings with family members, friends, and colleagues, while others become addicted, claiming it helps them cope with depression and anxiety. These individuals cannot resist the urge to overuse alcohol, and by doing so they ultimately develop a dependency on it — a condition appropriately called alcohol dependence. When consumed, alcohol depresses the central nervous system and causes a loss of concentration, effectively dulling the cognitive functions of its user.

Mankind has long been burdened by the rising incidence of alcohol dependence and abuse. Despite the gravity of this concern, alcohol use continues to increase. Governments and NGOs spend millions of dollars combating dependence on alcohol, and researchers work tirelessly to find lasting solutions. The environmental and health hazards caused by alcohol dependence are well documented. According to Room, Babor, and Rehm (2005), there are more than sixty different health conditions associated with alcohol consumption. In the United States alone, alcohol use and overindulgence contribute to two major categories of disease: cardiovascular conditions and cancer (Mokdad et al., 2005).

In view of these staggering facts, it is understandable why research into the treatment of alcohol dependence is so essential. Studies involving leading scientists and academic researchers have demonstrated that a variety of approaches can help people with a history of alcohol dependence either reduce their intake or stop entirely. Among the approaches that have been proposed are Twelve-Step Facilitation (TSF) (Nowinski et al., 1995), Motivational Enhancement Therapy (MET) (Miller et al., 1995), and Cognitive Behavioral Therapy (CBT) (Carroll, 1998). Of these treatment modalities, CBT has been reported as producing the most consistently positive outcomes in patients.

Basic Information About CBT

Cognitive behavioral therapy is grounded in the principle that, to treat alcohol dependence effectively, there must be an interaction between the patient's cognitive functions and his or her behaviors. A patient's thoughts — shaped by lived experience — can serve as stimuli that trigger specific behaviors. CBT focuses on the patient's ways of thinking, beliefs, attitudes, and the underlying assumptions that form the foundation of those thoughts. It is built on the premise that, regardless of external stimuli, a person's thoughts ultimately control their behaviors and feelings.

CBT is typically result-oriented and short-term in nature. It consists of structured sessions — as many as sixteen — all supervised by a qualified therapist. For the therapy to succeed, a meaningful level of trust must be established between the therapist and the patient, ensuring a free flow of information. This allows the therapist to gather sufficient detail about the patient's situation and thought patterns. The therapist helps the patient understand his or her own perceptions and the ways those perceptions drive behavioral change (Room, Babor, and Rehm, 2005).

How CBT Is Used to Treat Alcohol Dependence

Using CBT to treat alcohol dependence proceeds from the perspective that a patient's actions are driven by behaviors, which themselves arise from experience. People who are alcohol-dependent often use alcohol because it appears to resolve depression, anxiety, or other emotional difficulties. For CBT to be successful, the therapist must (1) uncover the specific need being satisfied by alcohol, and (2) devise alternative ways of meeting those needs. Two major learning patterns can be identified in patients: learning by association and learning by consequence. These patterns must be thoroughly understood before meaningful assistance can be provided.

Through learning by association, a patient develops the urge to drink by spending time in places where alcohol is sold or with people with whom he or she regularly drinks. This becomes a repetitive cycle until the urge grows uncontrollable. Through learning by consequence, the patient responds to the perceived after-effects of alcohol — such as the temporary relief of worries, anxieties, and problems — and therefore craves more alcohol to satisfy those emotional needs. The first therapeutic step is to identify these patterns so the patient can recognize and learn from them. This can be achieved through two distinct approaches: exposure therapy and coping-skill therapy (Miller, Zweben, DiClemente, and Rychtarik, 1995).

Exposure therapy — also called cue exposure therapy — involves exposing the patient to the stimuli that originally triggered alcohol use, without permitting alcohol consumption. This process is believed to reduce the power those cues hold over the patient, so that the patient gradually loses the urge to drink in response to them. Laboratory findings have confirmed cue exposure as an effective approach for preventing relapse. With consistent exposure to the triggering stimuli and continued abstinence from alcohol, the stimuli eventually lose their ability to initiate cravings (Monti, Abrams, Kadden, and Cooney, 1989).

Coping-skill therapy differs from cue exposure in that it does not attempt to eliminate the stimuli. Instead, the patient is trained in alternative ways of responding to those triggers. Armed with sufficient training, the patient is more likely to employ these alternative responses when confronted with the urge to drink. Coping-skill therapy is divided into two broad categories for clarity: (1) intrapersonal skills and (2) interpersonal skills.

Conclusion

The method of cognitive behavioral therapy is based on a conceptualization of addictive behavior as involving the wrongful or excessive use of alcohol and drugs. Using CBT in treating alcohol dependence has proven to be very effective. The results of the reviewed studies indicate that relapse was not reported in the majority of cases. All major features of CBT were explored in this paper, with particular emphasis on the development of alternative coping mechanisms. Both laboratory and field research confirm that the approaches described here are currently employed with meaningful success in treating alcohol dependence.

References

Room, R., Babor, T., and Rehm, J. (2005). Alcohol and public health. Lancet, 365(9458), 519–530. PMID: 15705462

Mokdad, A. H., Marks, J. S., Stroup, D. F., and Gerberding, J. L. (2005). Actual causes of death in the United States, 2000. JAMA: Journal of the American Medical Association, 291(10), 1238–1245. Erratum in: JAMA, 293(3), 298, 2005. PMID: 15010446

Miller, W. R., Zweben, A., DiClemente, C. C., and Rychtarik, R. G. (1995). Motivational Enhancement Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals with Alcohol Abuse and Dependence. National Institute on Alcohol Abuse and Alcoholism Project MATCH Monograph Series, Volume 2. NIH Pub. No. 94-3723. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

Miller, W. R., and Pechacek, T. F. (1987). New roads: Assessing and treating psychological dependence. Journal of Substance Abuse Treatment, 4, 73–77.

Nowinski, J., Baker, S., and Carroll, K. M. (1995). Twelve Step Facilitation Therapy Manual. NIH Pub. No. 94-3722. Rockville, MD: U.S. Department of Health and Human Services, National Institute on Alcohol Abuse and Alcoholism.

Carroll, K. M. (1998). A Cognitive-Behavioral Approach: Treating Cocaine Addiction. NIH Pub. No. 98-4308. Rockville, MD: National Institute on Drug Abuse.

Monti, P. M., Abrams, D. B., Kadden, R. M., and Cooney, N. L. (1989). Treating Alcohol Dependence: A Coping Skills Training Guide. New York: Guilford Press.