Guest Article - Impediments to progress in psychotherapy and new ways to address them

by William Campbell, B.A. and Reid Hester, Ph.D.

Clinicians who don’t regularly treat patients with alcohol use disorders might be surprised to discover that one quarter of all clinical patients engage in heavy, problematic drinking. Even clinicians who are well aware of their patient’s misuse of alcohol often struggle with how to incorporate a treatment of the drinking behavior into their overall therapeutic plan. This is important, because unless clinicians have assessed and accounted for their client’s drinking habits, they may not suspect that a “hidden” behavior is inhibiting the course of treatment.

When most of us think of evidence supported treatments for substance abusing clients, we probably think of intensive motivational and behavioral regimens like the Community Reinforcement Approach and Motivational Interviewing, usually for severely dependent clients. But what about less dependent or abusive drinkers, who for one reason or another are struggling to control their drinking, but otherwise have no desire to quit? What treatments exist for them? This question is especially pressing in light of the fact that the vast majority of people struggling with their drinking belong to this latter group; they account for the larger proportion of the costs to society associated with alcohol abuse and, as a group, they tend to have much better treatment outcomes than more dependant drinkers. Epidemiological research suggests that there are four times as many individuals with alcohol problems with no evidence of dependence relative to those who meet the criteria for dependence (NIAAA, 2000). Furthermore, a recent report indicates that this group is increasing in size while the prevalence of alcohol dependence is declining (NIAAA, 2004).

With just such a treatment population in mind, Dr. Reid Hester has been working since the early 1990’s on interventions to help struggling drinkers moderate their consumption, specifically through the use of computer and internet-based interventions. Dr. Hester has developed programs like Drinker’s Check-up that combine assessment and feedback to help people curious about the severity of their drinking get an accurate idea of how they relate to other people with similar problems. More recently Dr. Hester developed the intervention Moderate Drinking (MD), that combines a similar assessment process with a self-directed intervention based on the methods of Behavioral Self-Control Training (BSCT). BSCT is a behaviorally focused protocol that utilizes elements of self-assessment, monitoring, goal setting, and the exploration of drinking “triggers” to help self-motivated drinkers either regain control of their habit, or find their way to abstinence. BSCT, delivered in various formats, has been tested in more clinical trials than any other intervention devoted to alcohol problems, and its efficacy has been consistently supported by this research. As one prominent researcher noted, "BSCT has become the standard moderation-oriented treatment” (Heather et al., 2000).

Funded by NIH, we recently conducted a randomized clinical trial with 80 heavy drinkers to test MD’s effectiveness. Participants randomly assigned to the experimental group had access to both the MD program and use of the resources of Moderation Management (MM), an on-line support-group for people wishing to change their drinking. Those in the control group were enrolled in MM but did not have access to the MD program. We hypothesized that both groups would reduce their drinking and alcohol-related problems and those who had access to the MD program would have better outcomes than the control group.  And they did (Hester, Delaney, Campbell, & Handmaker, 2009).

At 3-month follow-up, individuals in both groups reduced how much they drank per drinking occasion, as well as reducing how intoxicated they got on those occasions by drinking more slowly.  What’s more, the participants with access to the MD program actually drank on fewer days. They also reported a greater reduction in the following alcohol related problems compared to the control group: physical and psychological health; interpersonal issues; and taking care of one’s responsibilities.

There was a notable exception: binge drinkers, who are defined by the NIAAA as having 4-5 drinks on average per occasion, did not do as well in either group—an indication that the degree of severity of abuse may moderate success in a self-directed protocol like BSCT. However, the corollary is not true, in that severity of clinical distress, as measured by the Brief Symptom Inventory, was not a mediator of drinking outcome.  In other words, the level of psychological distress in our study participants did not have a negative impact on their success with changing their drinking.

This latter finding has a direct implication for clinical practice. Clinicians with depressed or anxious clients, who happen also to be struggling with their drinking, ought to explore the possible benefits of referring their clients to Moderate Drinking or other available BSCT protocols. Behavioral programs like the one employed by MD can be helpful to therapists because of the clarity of their therapeutic targets, and the client will have direct tie-ins between the companion motivational and affective exercises and the work done in session. Assigning such “homework” might help clients get a handle on their drinking, increase their sense of self-efficacy, and enhance the overall course of therapy.

We have completed our 12 month follow-ups and are currently preparing a manuscript that reports those outcomes. Twelve months is the minimum time period to examine long-term outcomes because relapse rates flatten out by that time. Stay tuned.

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William Campbell is enrolled in the clinical psychology doctoral program at the University of New Mexico and works as a research assistant at Behavior Therapy Associates

Dr.Reid Hester, a long time investigator of substance use disorders, is Director of the Research Division at Behavior Therapy Associates in Albuquerque, New Mexico.