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RSA Lecture Series 2006

“Behavioral Treatments for Alcohol Dependence”

June 23 and June 24, 2006

Allen Zweben, DSWAssociate Dean for Research and Professor

Columbia Universityof Social Work

Edited by Gerard Connors, Ph.D.Director and Professor

Research Institute on AddictionsUniversity at Buffalo

State University of New York

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Aims of the Lecture

• To acquaint participants with the contemporary state of affairs in behavioral treatments for alcohol dependence

• To provide empirical support for the use of state-of-the-art intervention devices in treating alcohol dependence

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Conducting a Multidimensional Assessment for Treatment

Planning

• Alcohol dependence is a biopsychosocial disorder

• A multidimensional assessment is necessary to understand the nature of the individual’s alcohol use disorder and to develop responsive treatment

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Conducting a Multidimensional Assessment for Treatment

Planning• What domains need to be assessed?

– Alcohol use and related problem severity

– Situations, moods and behaviors that perpetuate alcohol use

– Social and individual coping resources

– Motivational resources

– Other drug use

– Barriers to treatment

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Promising Treatment Approaches

• All types of well structured treatments

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Efficacious Treatments

• Brief Motivational Interventions (BMI)

• Cognitive Behavioral Therapy (CBT)

• Significant Other (SO)-Involved Therapies • Combination Approaches:

> Community Reinforcement Approach (CRA)

> Combined Behavioral Intervention

(CBI)

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BMI: How Does It Work?

• Draws upon principles of motivational psychology

• Motivation is viewed as a dynamic “state” not a static “trait”

• Emphasis on client choice

• Optimism for change is crucial

• Use of empathy, not authority and power

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BMI: How does it work?

• Major focus on resolving ambivalence about change

• Incorporates specific strategies to address motivational issues

• Use of interactive style of communication – i.e., persuasion, argumentation and confrontation are avoided

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BMI: Strategies• Express empathy

• Deploy discrepancy

• Avoid argumentation

• Roll with resistance

• Support self-efficacy

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BMI: Strategies (continued)

• Ask open ended questions

• Listen reflectively and empathically

• Affirm

• Elicit “change talk”

• Use of decision-balancing

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Application of BMI

• Can be employed as a stand-alone treatment or as add-on to other approaches (e.g., adherence facilitation)

• Employed in both specialist and nonspecialist (health care) settings

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BMI: What the Data Say

• Within past 10 years over 100 randomized controlled trials of BMI

• Outcomes significantly better than no- treatment control or equivalent to more intensive treatment modalities

• Illustrations:

– Project MATCH (1988-98) • TSF=CBT=MET

– Cost Evaluation Study (1992-97)• MET>CBT or TSF

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Cognitive Behavioral Therapy (CBT): How Does

It Work? CBT is based on the principles of social

learning theory

Individuals lack coping skill deficits to manage intrapersonal (e.g., moods) and interpersonal e.g., (family) high risk situations, which in turn can lead to an increase in alcohol consumption

Primary aim is develop client skill in identifying high risk situations and addressing problem areas

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CBT: How Does It Work?

Expectations about the effects of alcohol on behavior and self-efficacy perceptions must be assessed and modified to develop successful coping behaviors

Challenge is to develop and apply new behaviors and strategies for dealing with stressors without resorting to alcohol use

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CBI: How Does it Work?

• Targets A Wide Range of Objectives– Social skills training– Mood management– Anger reduction– Social support– Assertiveness

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Cognitive Behavioral Therapy (CBT): What the Data Say

• Good evidence of efficacy but does not differ from other effective approaches when delivered as a stand-alone treatment (Longabaugh and Morgenstern, 1998)

• Illustration: – Project MATCH: CBT = TSF or MET

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CBT: Findings

• Other studies: CBT more effective as an additive approach

– CBT combined with contingency management to improve retention (Carroll, 2006)

– CBT compatible with pharmacotherapy (Anton et al., 2002)

– CBT durable effects (O’Malley et al., 2003)

– Homework related to outcome (Carroll, 2006)

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Significant Other (SO) Involved Approaches: How Does It Work?

• Includes:

– Behavioral Couples Therapy (BCT)

– Community Reinforcement and Family Training (CRAFT)

– Twelve-Step Facilitation

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How Does It Work? • Facilitate medication and treatment compliance

• Buttress motivation

• Increase interaction patterns that promote and reinforce sobriety • Decrease interaction patterns that foster drinking

• Strengthen emotional ties

• Improving coping capacities

• Increasing network support for abstinence

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Significant Other (SO) Involved Approaches: What the Data Say

Suitable for:

SOs supportive of client’s sobriety

SOs whose support is highly valued by the client

Unsuitable for:

SOs experiencing severe hardships

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SO Involved Approaches: Outcome Studies

• 11 out of 14 Studies of BCT Showed Superior Results for SO Approaches over a Control Group on a Number of Outcome Measures:- Drinking- Marital stability- Motivation- Compliance

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Combination Therapies: How Does it Work?

• Need to move away from the purity of previous treatment models

• Need to integrate effective therapeutic ingredients

• Need to incorporate contextual factors in treatments

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Combination Therapies

• Need to employ components associated with preferences and assessed needs and capacities of patients

Flexible model in order to be applicable to “real world” treatment settings

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COMBINED Behavioral Intervention(CBI): An Illustration

Incorporates the putative strengths of the MATCH treatments

- Motivational interviewing (MET)

- Mutual help (TSF)

- Coping skills plus (CRA)

- Supportive other involvement

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COMBINE Behavioral Intervention (CBI): An Illustration

Other characteristics of CBI

Matching modules to participants

Menu of options (I.e., empirically sound components)

Process of functional analysis

Session attendance flexible

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COMBINE Behavioral Intervention (CBI): An

Illustration

Four phases of CBIEnhancing commitment to change

Development of a treatment plan

Implementation of selected treatmentmodules

Maintenance and monitoring of progress

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Relapse to Heavy Drinking, Comparison with CBI no pills Placebo + CBI vs. CBI no pills p=0.05, Placebo vs. CBI no pills p=0.46

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Good Clinical Outcome During last 8 Weeks of Treatment

Comparison with CBI Therapy no pills

p=0.07NS

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Where Do We Go From Here?

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Principles of Change That May Be Common Across Treatments

• Establish and enhance strong therapeutic relationship (alliance, cohesion, and positive regard)

• Employ therapists with high level of skill in such areas as empathy, acceptance, warmth, spirit, and egalitarianism

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Principles of Change

• Address ambivalence or enhance motivation and commitment (e.g., increase “change talk” or “commitment language” )

• Involve supportive other(s) in treatment (significant others who are supportive of abstinence including AA fellowship)

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Principles of Change

• Promote or facilitate an ensured period of abstinence

• Provide case management services that are accessible and readily available to promote reinforcement for and maintenance of sobriety

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Principles of Change

• Routinely monitor both therapist’s and client’s progress in treatment (i.e., provide both positive and negative feedback on change

• Restructure the social environment in ways that attend to the cessation and prevention of drinking (i.e., promote activities that are incompatible with drinking behavior and vice versa)

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Principles of Change

• Attend to the adherence issues as they arise during the course of treatment (continuance in treatment often related to outcome and may be independent of specific type of treatment offered)

• Use well structured, evidence-based treatments

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Sources for the Principles

Miller, W.R. and Carroll, K. M. (2006). Rethinking substance abuse: what science tells us and what we should to about it. New York: Guilford Press.

Berglund, M. Treatment for addictions: What works and why? International Conference on

Treatment of Addictive Behaviors, January 29-February 2, 2006, Santa Fe, New Mexico.

Norcross, J. Psychotherapy: Relationships and therapist effects in the treatment of addictions, International Conference on Treatment of Addictive Behaviors, January 29-February 2, 2006, Santa Fe, New Mexico.