Further Reading

What are the leading treatments for alcoholism and addiction?

Dear Stanton:

What types of treatment are successful for alcoholism and addiction?

Jes Aaron


Jes:

Before identifying treatments that work, let me make the following five points:

  1. Allowing the person to select a treatment — and treatment goals — is critical to treatment success, with people showing superior results when they feel engaged in the treatment and the options it offers and when these are consistent with their values and self-image;
  2. Treatment is not necessary — indeed, most people recover on their own from every variety of addiction, including alcoholism, without formal treatment or support groups, although they often rely on informal resources for assistance;
  3. The nature of treatment is not usually the critical ingredient in treatment outcomes — the characteristics of the treated person are critical, such as whether they are married, have stable social supports, have work skills and a job, etc.;
  4. Also critical is the follow-up to treatment — even very brief, informational sessions can have a strong impact on addiction if the person is tracked and knows he or she is to be contacted regularly about progress;
  5. Treatment outcomes, as above, occur in a social milieu — the best treatment outcomes will occur in environments which offer the most practical assistance (e.g., housing, work, legal and medical assistance, et al.) and social support.

Having made these critical points about treatment choice, natural recovery, the person in treatment, the follow-up to treatment, and the environment in which the treated person lives, there are treatments which make use of these principles and offer more successful outcomes for the treatment buck.

Among these useful treatments are the following:

  1. Community Reinforcement Approach (CRA)

    This is the therapy best supported by research. It's a moderately low-cost form of outpatient treatment; it was devised and first tested over a quarter-century ago; every study of its efficacy — with alcohol and a variety of drugs — has shown extremely positive results; and it is not in regular use at a single treatment center in the United States.

    The basic premise of the community reinforcement approach — most often a one-on-one therapy, although it can be used in group settings — is that substance abuse does not occur in a vacuum, that it is highly influenced by marital, family, social, and economic factors. CRA attempts to help the client improve his or her life in all of these areas, in addition to giving up drinking or using drugs. Thus, a CRA program will typically include at least the following components: (1) communications skills training; (2) problem-solving training; (3) help finding employment; (4) social counseling (that is, encouraging the client to develop nondrinking relationships); (5) recreational counseling (that is, encouraging the client to find rewarding nondrinking activities); and (6) marital therapy. Other treatment components are sometimes used — for example, rewarding the client materially for abstinence or use of disulfiram or other drug therapy to reduce, substitute for, or eliminate drug use — but these six above-listed components form the core of the very successful CRA approach.

  2. Social Skills Training (SST)

    This form of group therapy is another very well supported approach. The basic premise of social skills training is that alcohol/drug-abuse clients lack basic skills in dealing with work, family, and other interpersonal relationships, as well as in dealing with their own emotions. Thus, they benefit from skills training in communications, anger management, conflict resolution, drink and drug refusal, assertiveness, relaxation, expressing feelings constructively, et al.

  3. Behavioral Marital/Family Therapy

    The single most frequent request/complaint I receive begins, "My boyfriend/husband. . ." Thus, marital counseling with an emphasis on altering behaviors related to drinking and drug use is important, particularly helping the non-substance-abusing spouse to abandon futile nagging about drinking and drug use and instead begin to reward sober behavior. This requires that the couple learn constructive marital negotiation techniques, so that the non-substance-abusing spouse will also make modifications/concessions in her behavior. The remainder of the therapy involves typical couples counseling, the goal being to repair substance-abuse-caused damage to the relationship, as well as dealing with non-substance-based problems.

  4. Brief Intervention/Motivational Enhancement

    Brief intervention (in many ways similar to motivational enhancement) was rated the most effective treatment in the Miller et al. (1995) analysis of alcoholism treatment research, while motivational enhancement was ranked the third most effective form of treatment. At the same time, they were also among the most inexpensive therapies, with only a self-help manual being lower in cost. Because brief intervention is used often in a conventional medical setting, and because it is not abstinence-oriented, its use with drugs is somewhat problematic. However, the principles remain valid with drugs as well as alcohol.

    Brief intervention shares elements with motivational enhancement in that the patient and the therapist create a mutually agreed-upon goal based on an objective assessment of the person's drinking habits, perhaps involving a medical (such as liver-function) test or a comparison of the individual's drinking levels with community standards or with optimum levels of drinking for health purposes. In brief intervention, the goal is usually reduced drinking; in motivational enhancement, it is either reduced drinking or total abstinence. The key is to allow patients to select a goal that is consistent with their own values and that they thus "own" as an expression of their genuine desires.

    In a brief-intervention session, the health-care worker simply sums up the goal: "So, we agree you will reduce your drinking from 42 drinks a week to 20, no more than four on a given night." Motivational enhancement is a bit more subtle: the therapist nudges the client, without directing them, by responding to and building on the person's own values and desire for change. Here is a highly encapsulated version of a motivational-enhancement session:

    THERAPIST: What is most important to you?
    PATIENT: Getting ahead in life. Getting a mate.
    T: What kind of job would you like? What training would that take?
    P: [Describes.]
    T: Describe the kind of mate you want. How would you have to act, where would you have to go, to meet and deal with a person like that?
    P: [Describes.]
    T: How are you doing at achieving this?
    P: Not very well.
    T: What leads to these problems?
    P: When I drink, I can't concentrate on work. Drinking turns off the kind of person I want to go out with.
    T: Can you think of any way to improve your chances of succeeding at work or with that kind of mate?

    Here we see that the goal of therapy is to draw the connection between what people genuinely want — their own goals — and the institution of helpful behaviors, or the elimination of behaviors that interfere with achieving their goals. In brief intervention, in addition, drinkers know that they and the helper will be regularly assessing progress towards the agreed-upon goals in systematic but nonjudgmental meetings. (To examine these nondirective approaches, see Horvath, Sex, Drugs, Gambling and Chocolate: A Workbook for Overcoming Addictions; Miller & Rollnick, Motivational Interviewing: Preparing People to Change Addictive Behavior; and Peele et al., The Truth About Addiction and Recovery: The Life-Process Program for Overcoming Destructive Habits.)

References

Hester, R.K., and Miller, W.R. (1995). Handbook of alcoholism treatment approaches (2nd Ed.). Boston: Allyn and Bacon.

Horvath, T. (1998). Sex, drugs, gambling, & Chocolate : A workbook for overcoming addictions. Atascadero, CA: Impact Publishers.

Miller, W.R., and Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford.

Peele, S., Brodsky, A., and Arnold, M. (1991). The truth about addiction and recovery. New York: Fireside.