Best Practices : Substance Abuse Treatment and Rehabilitation

b) Behaviour Therapies

A broad range of specific treatment strategies fall under this general heading. They are connected by their reliance on principles of learning. As can be seen from Table 3, 13 specific types of behavioural treatments fall into this category. These are grouped under two headings: aversion therapies and other behaviour therapies.

Aversion therapies, when used in the treatment of alcohol problems, are designed to induce a conditioned avoidance of alcohol by pairing the actual or imagined drinking of alcohol with unpleasant experiences. A variety of unpleasant experiences has been used, including electric shocks, nausea and vomiting, respiratory paralysis (apnea) and imagined adverse consequences (covert sensitization).

Covert sensitization. The seven relevant studies located by Holder et al. were judged to provide a fair degree of support for this type of treatment. However, studies of covert sensitization received a negative score (-5) on the index developed by Finney and Monahan. The differences reflect the fact that Finney and Monahan drew different conclusions from two studies judged positive by Holder et al., and included two studies omitted from the Holder et al. review (both showing no benefits for covert sensitization).

Electrical aversion. Holder et al. located 15 controlled studies of electrical aversion therapy and concluded that, overall, the results did not show this to be effective.

Nausea induction was also judged to be ineffective in light of the results of five controlled studies.

Finney and Monahan also gave quite low effectiveness scores for both of these types of treatment (electrical aversion and nausea induction), although nausea induction ranked rather higher on their effectiveness index than on the index used by Holder et al. However, these differences do not appear sufficient to warrant changes to Holder et al.'s overall conclusions.

No controlled evaluations of aversion treatment for drugs other than alcohol could be located.

Other behaviour therapies include those that seek to identify and modify maladaptive thoughts, beliefs, behaviours or, in some cases, emotional states, that contribute to problem drinking or drug use.

Behavioural contracting involves the use of specific environmental contingencies such as behaviour prompts and the reinforcement of behaviours that are incompatible with drinking or drug use. As described by Landry (1995), behavioural contracting might involve an agreement to participate in a urine-monitoring program and to accept aversive consequences for non-participation. Aversive consequences might include additional treatment, ejection from home or spouse-initiated divorce proceedings. Holder et al. identified four relevant studies and concluded that there was a fair amount of support for this type of treatment. Finney and Monahan concluded that only two of the four studies identified by Holder et al. qualified as controlled studies of behavioural contracting and that both studies showed this type of treatment to be effective. No index score was computed because there were fewer than three relevant studies. Landry considers that behavioural contracting can be effective in the context of a comprehensive treatment program.

Behavioural relapse prevention targets cognitive mediational processes such as expectancies and self-efficacy and are often part of a more comprehensive program. Consistent with the classification scheme used by Holder et al., other strategies typical of "relapse prevention" programs, such as social skills training, are considered under separate headings. However, it is recognized that, in practice, "relapse prevention" programs have a variety of specific components (i.e., identification of high-risk situations, instruction in and rehearsal of strategies for coping with those situations, relaxation training, stress management and efficacy-enhancing imagery, skills training and relapse rehearsal, contracts to limit extent of use and cognitive restructuring to cope with relapse). Relapse prevention can stand alone or be part of a treatment modality.

A full discussion of relapse prevention is to be found in Marlatt and George (1984) and Carroll (1996) who reviewed controlled studies of relapse prevention programs for smokers and people with alcohol and drug problems. Carroll found that 9 out of 12 studies of relapse prevention for smoking cessation had significant positive effects. Three of the 6 studies involving alcohol abusers reported positive effects, but only 1 of 5 studies involving users of other drugs showed positive effects.

There do not appear to have been any peer-reviewed scientific studies of the approach to relapse prevention promoted by the popular speaker Gorski (1989). Although Gorski's approach has features in common with the approach described by Marlatt and Gordon (1984), Gorski's approach differs in being firmly rooted in the AA, 12-step approach.

Behavioural self-control training involves the teaching of specific self-management skills to reduce or avoid alcohol consumption. Of 17 studies of behavioural self-control training (BSCT), 12 showed positive effects while 5 showed no effects; Holder et al. concluded that, overall, these studies provided good evidence for the benefits of this type of treatment. However, Finney and Monahan computed a negative effectiveness score (-7) for BSCT. The most likely explanation for this difference is that some studies included in the Holder et al. review were excluded from the review by Finney and Monahan and vice versa. This also reflects differences in the way in which these two groups of reviewers judged the quality and relevance of particular studies.

Hester (1995) also reviewed 30 studies of self-control training for the treatment of alcohol dependence. Hester concluded that brief interventions and self-directed BSCT are often as effective as more extensive therapist-directed treatments; and, BSCT with a goal of moderation has been found to be less effective than an abstinence-oriented approach for more severely dependent clients.

Best Practice Guideline (No. 2)

There is some support in the literature for behavioural relapse prevention programs for smokers and people with alcohol problems. The literature also provides support for the effectiveness of behavioural self-control therapy for those with less severe drinking problems, as a cost-effective alternative to extensive therapist-led approaches, and for behavioural contracting in the context of a comprehensive treatment program.

Cognitive therapies include approaches that seek to identify and change maladaptive thoughts or beliefs that contribute to problem drinking. Holder et al. reviewed seven studies of cognitive therapies and concluded that, on aggregate, the evidence for their effects was indeterminate. This is consistent with Finney and Monahan who computed a negative effectiveness score (-8) for cognitive therapy.

Community reinforcement. This approach combines several methods to focus on the social functioning of the client. It has been evaluated only for people with alcohol problems. The approach aims to change the drinker's environment to make abstinence more rewarding than drinking. It involves the use of social, recreational, familial and vocational reinforcers to assist clients in the recovery process. The approach involves the use of a functional analysis to determine antecedents and consequences of drinking, setting goals for sobriety, an option to choose to use disulfiram, and the development of a treatment plan involving basic skills of communication, problem solving and refusing drinks. In some studies, clients could also attend a job-finding club, receive social and recreational counselling, marital therapy and relapse prevention training. Combining the strengths of a number of therapies may explain the effectiveness of this approach. Holder et al. located four studies using this approach, and judged them to provide good evidence of its effectiveness. This approach has been recently reviewed by Smith and Myers (1995) who report that it is also being used with users of other drugs.

Community reinforcement also received the highest score on the effectiveness index developed by Finney and Monahan (+59).

One component of the community reinforcement approach is job finding. This was a prominent feature in one recent study involving violent criminal offenders with alcohol problems (Funderburk et al. 1993). The study involved the mobilization of community resources to improve the offenders' job-finding skills. A one-year follow-up showed that employment levels were significantly improved compared to intake.

Cue exposure. Holder et al. did not include any studies of cue exposure in their review because no controlled studies of this method were available at the time. This approach is based on the assumption that craving and withdrawal are conditioned responses that can be extinguished by exposing drinkers and drug users to drinking or drug use cues without also providing alcohol or drugs. These cues include the sight, taste and smell of alcohol, syringes or pictures of bars or drug-taking environments. In some cases, drinkers have been given small doses of alcohol and then prevented from further drinking. Research results from studies involving heavy drinkers have been mixed, but some experts suggest that they show cue exposure has potential as a treatment intervention (e.g., Drummond, 1990; Rohsenow et al., 1990-91). However, it appears that extinction and habituation to drug-related cues are unstable and dependent on context (Tobena et al., 1993). One recent controlled study involving opiate users showed no differences between those treated with cue exposure and those in a control group when a variety of measures were applied six weeks and six months after treatment (Dawe et al., 1993).

Best Practice Guideline (No. 3)

The community reinforcement approach has consistently been shown to be effective, particularly with clients having fewer social supports and more severe drinking problems.

Marital behavioural therapy seeks to improve communication and problem-solving skills, and to increase the exchange of positive reinforcement between partners. Components of marital therapy can include teaching alcohol-specific communication skills as well as general marital relationship skills. Seven relevant studies were identified by Holder et al. who concluded that, on aggregate, these studies provided good evidence of the effectiveness of marital behaviour therapy. Finney and Monahan also give a high positive score for this type of intervention. Marital therapy has been shown to be equally effective in both brief and more extended formats (Zweben, Pearlman and Li, 1988). The NIDA Review (1996) indicates that the benefits of marital therapy may not be immediately apparent, but may become evident only in the long term as new skills become integrated into the partners' repertoire.

Best Practice Guideline (No. 4)

Marital therapy, particularly marital behavioural therapy, in both brief and extended formats, is well supported by research.

Social skills training involves teaching clients how to form and maintain satisfying personal relationships. Often, the emphasis is on assertiveness. Holder et al. identified 10 relevant studies and concluded that they provide good evidence for the effectiveness of this approach. The weighting given to these studies was, in fact, the highest of all on the Holder et al. index and second highest on the Finney and Monahan index. Heather (1995) has also assessed this approach to be one of the most effective.

Monti et al., (1995) provide a good description of the specific strategies used in social skills training. These focus on both interpersonal and intrapersonal coping skills. Interpersonal skills include drink-refusal skills, giving positive feedback, giving and receiving criticism, listening and conversation skills, expressing feelings and assertiveness. Intrapersonal skills involve mood management, managing thoughts about drinking, coping with craving, dealing with negative thoughts, coping with urges to drink and decision making. This approach has been used effectively with a variety of substance abuse and psychiatric disorders, and particularly with (early-stage) problem drinkers. It was included as one of the types of treatment studied in Project MATCH (see section 2).

Best Practice Guideline (No. 5)

Social skills training is strongly supported by research, particularly with problem drinkers.

Stress management involves teaching clients how to reduce personal tension and stress. Specific techniques include relaxation training, systematic desensitization and cognitive strategies. The goal is to enable clients to gain control of their reactions to stress by: altering the perception of threat posed by the stressor; altering lifestyle to reduce the severity of external stressors; and, developing coping strategies to inhibit or replace disabling responses to stressors (Stockwell, 1995). This approach is often used as one component of a treatment program, making it difficult to assess its effectiveness in isolation.

Ten controlled studies of stress management were identified by Holder et al. and these were judged to provide good evidence for the effectiveness of this type of treatment for people with alcohol problems. Finney and Monahan computed a relatively low positive score for stress management, but ranked it in the same place as Holder et al. (rank 6 of 24 modalities). Stockwell (1995) suggests that there is a need for more well-designed studies of this type of treatment.

Best Practice Guideline (No. 6)

There is good support for stress management interventions as a component of treatment for alcohol problems.

Video self-confrontation. This strategy involves making a videotape of a drinker while intoxicated and playing it back to the drinker when he/she is sober. Studies of video self-confrontation were judged by Holder et al. to have shown no evidence that this type of treatment is effective, while Finney and Monahan did not include it in their review.