Mechanisms for Behavior Change in Alcohol Use Disorder Treatment

According to Martin & Pear (2015), “behavior modification involves the systematic application of learning principles and techniques to assess and improve individuals’ covert and overt behaviors in order to enhance their daily functioning” (2014, p. 4). Simply put, behavior modification programs are utilized to create positive change in individuals by targeting specific, undesirable behaviors for change. The goal of this article is to lend more insight into which behavioral treatments are effective and what components of these treatments are attributed to the positive changes in reduced rates of alcohol consumption.

Before discussing the effectiveness of behavioral treatments and their specific components, it is important to understand alcohol use disorders. The DSM-5 indicates that alcohol-related disorders are no longer classified into alcohol dependence and alcohol abuse disorders; both are combined into a single alcohol use disorder (AUD) label (APA, 2013b). To meet criteria for an AUD, an individual must present with “a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a twelve-month period” (APA, 2013a). An individual needs to meet two of eleven additional criteria. Some of these symptoms include a persistent desire or unsuccessful efforts to cut down or control alcohol use; a great deal of time spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects; and craving or strong urge to use alcohol, among other things (APA, 2013a).  

Current treatments that appear to be most prevalent in the alcohol treatment field include the Minnesota model, certain behavioral approaches, Twelve Step groups, cognitive behavioral therapy (CBT), and motivational interviewing (MI; Fisher & Harrison, 2012). These different treatment modalities all have different approaches and outcomes, but may share similar components.

The Minnesota model heavily emphasizes the principles of Alcoholics Anonymous (AA), from a disease concept standpoint. This treatment modality is the basis of the traditional way of looking at alcohol use treatment, utilizing a twenty-eight-day inpatient treatment setting. This model often emphasizes the use of group therapy to move toward change (Fisher & Harrison, 2012). Drawbacks to this method of treatment are the heavy AA focus, which may be off-putting to some clients, and a lack of flexibility in treatment options (McKay & Hiller-Sturmhöfel, 2011).

Individuals struggling with alcohol use frequently attend Twelve Step groups. There are a wide variety of Twelve Step groups offered, the most common being AA. These programs are informal, and usually have flexibility for clients to adapt the program to fit their needs. While these groups are used to support individuals, they are not formalized treatment, and should not be used in place of therapeutic modalities (Fisher & Harrison, 2012). Unfortunately, Twelve Step groups have been found to have high dropout rates, with around 50 percent of individuals dropping out before three months of participation (McKay & Hiller-Sturmhöfel, 2011).

CBT is another treatment modality that is often used in AUD treatment. This type of treatment is based off of social learning theories that build coping skills, which help clients avoid relapsing back into alcohol use. Self-efficacy is highlighted in CBT strategies (Fisher & Harrison, 2012). CBT treatment requires quite a bit of training on the part of the therapist, which can lead to implementation barriers within the treatment field (McKay & Hiller-Sturmhöfel, 2011). MI often goes hand-in-hand with CBT because it works to help clients identify positive coping skills and resources that they already possess to lead to change. However, the creators of MI stress that it is a strategy to drive clients toward change, rather than a set of specific interventions and/or techniques to create change (Fisher & Harrison, 2012).

Behavioral approaches are currently being used in the AUD treatment field. However, the current behavioral strategies emphasized are aversion techniques, which work to condition negative responses to alcohol. An example of this is the use of the medication, Antibuse, which creates physiological discomfort when taken in conjunction with alcohol (Fisher & Harrison, 2012). The use of Antibuse has been criticized because it takes a highly motivated individual to willingly take the medication daily (Martin & Pear, 2014).

The Substance Abuse and Mental Health Services Administration (SAMHSA) is responsible for publishing the National Registry of Evidence-Based Programs and Practices (NREPP), a comprehensive list of evidence-based treatment modalities. The focus of our literature review is on four evidence-based, behavioral change treatments from this registry that focus on behavior change as the treatment and have shown efficacy and effectiveness for treating alcohol use disorders across a multitude of populations. The focus of these treatments is not only to deter individuals from using alcohol, but also to alter their behavior completely. These four treatments include relapse prevention therapy, network therapy, MI, CBT, and motivational enhancement therapy (MET).

Relapse prevention therapy (RPT) is a behavioral treatment program that helps individuals with substance abuse issues learn how to anticipate and cope with the potential for relapse. RPT can be used by itself as a substance use treatment program or as a follow-up program to consolidate and build upon the progress made during initial substance use treatment. RPT is centered on coping skills training. The coping skills taught throughout the program include cognitive and behavioral techniques. Some of the specific coping skills utilized include recognizing that relapse is part of the recovery process, identifying situations that the individual considers high-risk for relapse, coping with urges and cravings, finding ways to minimize the negative effects when relapse does occur, staying committed to treatment even after relapse occurs, and creating a more balanced lifestyle (Marlatt, Parks, & Witkiewitz, 2002). Most of the specific behavioral mechanisms used in RPT are related to creating a more balanced lifestyle. Often individuals in RPT are encouraged to increase activities in their lives such as exercise and meditation to enhance their set of coping skills and give them alternative activities to substance use (Marlatt et al., 2002). 

Evidence supports RPT as an effective treatment in reducing drinking behavior across age, gender, and geographic location (Marlatt et al., 2002). However, the biggest criticism of RPT is that it fails to take into account the complexity and unpredictability of relapse. Early models of RPT were one-dimensional and did not look at how interactions between risk factors impact the likelihood of relapse. Wikiewitz & Marlatt (2004) created a model that addresses this concern. Specifically, this model outlines the dynamic relationship between factors such as high-risk situations, cognitive processes, physical withdrawal, affective states, coping behaviors, and substance use behavior. Not only has RPT been effective as a stand-alone treatment for reducing alcohol consumption, it has also been effective as an adjunct treatment. One randomized controlled trial found that for couples with an alcoholic husband, a combination of behavioral marital therapy and relapse prevention was more effective than behavioral marital therapy alone in terms of number of days spent abstinent following treatment (O’Farrell, Choquette, Cutter, Brown, & McCourt, 1993). 

Network therapy is a behavioral intervention that combines psychodynamic and cognitive-behavioral interventions in individual and group therapy. Clients form a network of people who lend unconditional support throughout the treatment process. This network consists primarily of family, friends, and peers, who all value clients’ recovery as a priority. This type of therapy focuses on group cohesiveness to encourage clients to comply with treatment. The clients’ network joins in therapy sessions occasionally to assist with undermining denial and spurring therapeutic change (Galanter & Brook, 2001).

Research shows that, “the more support an addict or abuser can muster, the greater the likelihood of achieving and maintaining abstinence, as well as the possibility of achieving deeper characterological changes” (Galanter & Brook, 2001). Network therapy is a cost-effective form of therapy that can be performed in an outpatient office. The cohesiveness of the group often prevents individuals from quitting treatment in times of increased risk of relapse (Galanter & Brook, 2001). Galanter reviewed the treatment of sixty of his patients, 92 percent of which were treated with a network. His research yielded results supporting network therapy as an efficacious treatment method for addiction: “A large majority of the patients (77 percent) achieved major or full improvement, meaning that they were abstinent or had virtually eliminated substance use and that their life circumstances were materially improved and stable” (Galanter & Brook, 2001). Network therapy had higher rates of success for clients with mild to moderate drug use as opposed to a severe drug use problem (93 percent versus 61 percent).

In a more extensive follow-up study, 262 clients with a cocaine addiction were treated with network therapy. Urinalysis was performed and 79 percent were negative for cocaine, 67 percent produced three consecutive clean urinalyses, and 42 percent were clean the last three screenings prior to treatment termination (Galanter and Brook, 2001). This study also found that treatment retention was higher for clients who received network therapy compared to the control group. The studies done by Galanter and Brook reveal the value network therapy can have for drug-addicted clients. It is a cost-effective and relatively brief intervention that can be administered in an office setting and yields positive recovery results for many clients.  

Motivational enhancement therapy (MET) combined with CBT is an accepted first-line intervention for adolescents with cannabis use (Ramchand, Griffin, Suttorp, Harris, & Morral, 2011). This brief intervention (MET/CBT5) was used in a study in which adolescents were given two sessions of MET to “resolve ambivalence about whether they think they have a drug problem and increase their motivation to stop using marijuana,” followed by three sessions of group CBT “to teach basic skills for refusing drug offers, establishing supportive networks for recovery, developing a plan for non-drug using activities and plan for high risk situations, and coping with unanticipated high-risk situations” (Ramchand et al., 2011).

In the present study, MET/CBT5 was compared to three “exemplary” community-based treatments, which were well-established outpatient treatment services participating in SAMHSA’s adolescent treatment model program (Ramchand et al., 2011). The results of this study provide evidence that MET/CBT5 is an effective treatment for youth cannabis use. Participants who received MET/CBT5 had significantly better outcomes pertaining to substance use and criminal activity compared to the other three treatment conditions. However, there was no evidence supporting that MET/CBT5 has better outcomes for likelihood of recovery, decreased emotional problems or rates of institutionalizations. Although this brief and cost-effective treatment was effective for reducing the frequency of cannabis use and illegal activities, “after a twelve-month follow-up, only a third met recovery criteria and a quarter had been institutionalized in the past ninety days” (Ramchand et al., 2011).

This research concludes that MET/CBT is a viable treatment option for youth cannabis users, specifically in the early stages of treatment to increase motivation and resolve ambivalence regarding their drug problem. This intervention provides clients with skills that can reduce the frequency of use, as well as criminal activity. There were not significant long-lasting benefits compared to other treatments for likelihood of recovery, presentation of emotional problems or rates of institutionalization (Ramchand et al., 2011). 

As discussed, MI is a popular treatment for treating AUDs. Consistent with the prevalence of MI being used in substance abuse treatment, the research supports its effectiveness. MI is defined as “a goal-directed, client-centered counseling style for eliciting behavioral change by helping clients to explore and resolve ambivalence” (SAMHSA, 1999). This approach rests on the idea that clients’ ambivalence is the main barrier to behavioral change, which in the case of alcoholism involves decreasing or abstaining from alcohol intake. Therefore, resolving this ambivalence is the main goal of MI. MI typically includes listening reflectively, asking open-ended questions, affirming clients’ statements and behavior related to change, helping clients recognize the gap between their current behavior and their desired goals, asking permission before giving advice, not using direct confrontation in response to resistance, and developing an action plan in collaboration with clients (SAMHSA, 1999). 

There is evidence for the use of MI across age, race, gender, and settings. Fisher and Harrison (2012) noted that two separate meta-analyses found that MI was effective for reducing excessive drinking, but these effects were not long-lasting. However, a third meta-analysis found that MI produced significant effects that were small in magnitude, but were long-lasting over time (Fisher & Harrison, 2012). There have also been a number of adaptations; the most common is using MI as a brief intervention in medical settings. Carroll et al. (2006) conducted a multisite study in which MI techniques were used during the initial intake/assessment session at five different community-based treatment settings. In comparison to intake as usual, intake with incorporated MI techniques yielded a higher retention rate in treatment four weeks later (Carroll et al., 2006). This study shows the widespread benefits of using MI, even in acute settings. MI has been shown to increase retention rates in treatment and decrease alcohol consumption rates (SAMHSA, 1999). 

There are currently multiple modalities through which substance use is treated, many of which have been discussed as evidence-based throughout this paper. AUDs are complex, as are all clients who come through a treatment program. Therefore, treatment should be intricate and multifaceted. The authors recommend incorporating techniques from multiple theories into a treatment program rather than focusing on only one form of therapy.

It is recommended that elements of MI, CBT, network therapy, and RPT be integrated into current treatment programs. The authors suggest using MI at the beginning of treatment. Treatment providers should utilize MI to guide clients to the realization that they have a problem and treatment could help. MI can be used to eliminate clients’ ambivalence about behavior change and encourage seeking treatment. In addition, MI is effective at allowing clients to direct their own treatment process by allowing them to decide when and if they want to get better, in this case by choosing to abstain from alcohol use. 

Elements of CBT are also indicated in an effective treatment process. Clients who suffer from AUD often have problematic cognitive processes that in turn lead to negative behavior outcomes; CBT touches on both of these aspects in order to look at clients and their problems as a whole. Conceptualizing the problem of alcohol use and determining ways to avoid drinking behavior will be helpful in treatment programs to change behaviors. CBT could prove to be extremely beneficial in treatment programs that seek to look at clients from many different angles. 

Network therapy seeks to establish strong ties with others including family, friends, and peers and has been shown to increase compliance in treatment programs. The authors recommend utilizing the formation of a bond with others in order to increase attendance and adherence to treatment programs. Group therapy can be beneficial for those suffering from AUD because clients often feel isolated and as though nobody understands them. Strong ties and the realization that there are others in similar situations can increase the effectiveness of treatment programs.

While MI, CBT, and network therapy can be used early on and throughout the treatment process, RPT should be integrated in order to reduce the risk of clients returning to substance use behavior during and after they have left treatment. RPT should touch upon what clients will do in high-risk situations and how they can cope with their cognitive processes and affective state without turning to alcohol or drugs. This will allow clients to prepare for situations in their lives after they have gone through intensive treatment phases, to ensure the maintenance of their behavioral change. AA or other Twelve Step groups are strongly recommended as an adjunct service to treatment. These groups can help facilitate relapse prevention by allowing clients an outlet for difficult situations that may come up in their lives. It is important to note that AA is only recommended for clients who ascribe to this type of group setting. 

Future research should examine which elements contribute the most to client success. In the alcohol treatment field, behavioral treatments are currently being utilized, and these treatment programs demonstrate effectiveness through reduced rates of heavy drinking (NIMH, 2014). Although various behavioral interventions have been shown to reduce rates of heavy problem drinking, finding evidence to support long-lasting effects of treatment has been more difficult and necessitates more research. Much of the research has been conducted using randomized controlled trials, in which behavioral interventions have only been compared to control groups. Because of this, these studies are only able to draw the conclusion that behavioral interventions are better than no treatment at all. Few studies have compared different behavioral modification interventions to each other in an effort to determine which of these treatments lead to greater, more effective change.

Additionally, the specific procedures and components of interventions that contribute to positive behavior change in individuals have yet to be identified (NIMH, 2014). It will be extremely important for future research to isolate components of behavior change programs and compare these elements to determine which components are the most effective for treating individuals. While the current field is doing a provincial job at incorporating behavior change mechanisms into treatment, there is always more that can be done to better accommodate clients. Using empirically supported treatments in AUD services is the sole responsibility of the therapist (Patterson, 2015). It is also vital to evaluate clinical practices on a regular basis and make the necessary clinical adjustments when needed. Lastly, it is essential to note that all clients are different and will require unique needs from their treatment program; therefore treatment should be slightly modified and tailored to suit the needs of each individual.

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