Burkhard Dafert

Epidemiology

Addicted patients pose very special challenges to treatment providers, which is why many psychotherapists consider them to be difficult clients and many colleagues shy away from treating them in outpatient practice.

At the same time, addicts, whether as a primary or secondary diagnosis, represent a not insignificant portion of the population in need of treatment.

In Austria, alcohol is regarded as a cultural drug, which is why its use, in contrast to so-called illegal drugs, is considered unproblematic or part of everyday life in many cases.

It is therefore necessary to differentiate between harmless use, harmful use and dependence on alcohol. Use is considered unproblematic if the consumption of alcohol by men does not exceed 24 g of pure alcohol per day. This corresponds to about 0.3 liters of wine or 0.6 liters of beer. For women, this value is lower due to the different metabolism. Namely, at 16 g of pure alcohol per day, which corresponds to 0.2 liters of wine or 0.4 liters of beer. These values can only be used as a guideline and at least 2 alcohol-free days per week must also be taken into account.

Consumption by men is classified as hazardous to health if the daily amount of pure alcohol consumed exceeds 60 g, which corresponds to 1.5 liters of beer or 0.75 liters of wine. This limit is also much lower for women, at 40 g of pure alcohol or 1 liter of beer or 0.5 liter of wine per day. In Austria, 19% of men and 9% of women fall into the category of harmful use (Uhl et al. 2019).

5% of adult Austrians over the age of 15 are considered alcohol dependent. In whole numbers, this corresponds to 365,000 people. The lifetime prevalence, i.e. the risk of developing alcohol dependence in the course of one’s life, is 10%. The gender distribution has increasingly adjusted in recent years. The ratio of men to women is now 3:1 (Uhl et al. 2019).

Diagnosis and diagnostics

In contrast to DSM 5, where it is assumed that dependence and abuse represent manifestations on a one-dimensional continuum and consequently only one alcohol use disorder is spoken of, ICD 10 differentiates between harmful use and dependence, and this distinction is also maintained in the successor ICD 11.

According to ICD 10, harmful use (ICD 10 F10.1) occurs when substance use can be shown to be responsible for the physical or psychological harm. The nature of the injury can be clearly identified and designated and the pattern of use has existed for at least one month or has occurred repeatedly in the past 12 months. Criteria for other disorders due to the same substance must not apply to the disorder.

In addition, we distinguish between quantitative abuse and qualitative abuse. Quantitative abuse occurs when alcohol is consumed regularly in amounts that are harmful to health. Qualitative abuse occurs when the psychological effects of alcohol are deliberately sought, whether for tension regulation, emotion modulation, or to influence behavior in social situations. This is then also referred to as functional drinking.

To be considered dependent (ICD 10 F10.2), at least three of the following diagnostic criteria must have been met in the last 12 months.

• Strong desire (compulsion) to use substances
• Decreased ability to control onset, cessation, and amount of use
• A physical withdrawal syndrome upon cessation of use or reduction in withdrawal symptoms due to substance use
• Evidence of tolerance, in terms of increased doses for desired effect.
• Progressive neglect of other pleasures or interests in favor of substance use, increased time spent using the substance or recovering from its effects
• Continued substance use despite evidence of clearly harmful consequences (physical, social, psychological)

(Dillinger et al. 2015)

As mentioned above, the two-dimensional construct, the basic distinction between abuse and dependence, is also maintained in ICD 11. In the Substance-Induced Disorders chapter, 6C40 Alcohol-Related Disorders distinguishes between “Episode of Harmful Use of Alcohol” 6C40.0 and “Harmful Use” 6C40.1. In addition, there will be alcohol dependence 6C40.2 as a separate category with differentiations between regular use 6C40.20 and episodic use 6C40.21. Furthermore, there will still be distinctions regarding the duration of remission (Gmel 2015).

It should be especially noted that the diagnosis of alcoholism is independent of the amount of alcohol consumed daily.

Typologies

For treatment planning, however, the mere diagnosis according to ICD 11 or DSM – 5 is not sufficient in many cases. Attempts were made very early on to define different types of alcoholics.

One of the first typologies was provided by Jelinek (1960) with his distinction into alpha, beta, gamma, delta, and epsilon drinkers. Alpha, the conflict or problem drinker, and beta, the occasional drinker, represent in this model rather precursors to dependence, while gamma, the intoxicated or addicted drinker, and delta, the mirror drinker, represent the actual forms of alcohol dependence. A special form is the epsilon drinker with his episodic use, in which case a bipolar disorder is often assumed to be the underlying disease. Alcohol consumption then correlates with the stages of bipolar disorder.

Cloninger (1996) suggests 2 categories, type I, with late onset and slow disease progression, a low family disposition, good social integration, and good prognosis. Type II according to Cloninger predominantly affects men, is characterized by very early disease onset and has a high genetic predisposition. Type II is often combined with dissocial or even emotionally unstable personality structure and has a worse prognosis. Schuckit (1995) distinguishes between primary and secondary alcoholism. Primary alcoholism develops as a result of excessive alcohol consumption, whereas secondary alcoholism occurs as a result of psychological, physical, or social difficulties.

For treatment planning, the typology according to Lesch (1990), who is also oriented towards the functionality of alcohol abuse, proves to be very effective. Lesch distinguishes 4 types of alcoholism. Type I exhibits increased organic vulnerability to addiction due to alterations in acetaldehydrogenase. Type II can also be referred to as an anxiety or conflict drinker. This group consumes alcohol mainly for its anxiety-relieving or even calming effect. Type III according to this typology uses alcohol for self-treatment of mental illness. Type IV, the habitual drinker considers alcohol consumption normal, with frequent pre-alcoholic damage. Psychotherapeutic interventions are particularly indicated in type II and type III.

Therapeutic approaches and models

General framework model

With regard to the development of addiction and dependent behavior, there is agreement in only one respect, namely that, as with all mental disorders, it is a multifactorial process in the sense of the bio-psycho-social model. In general, it can be said that the development and maintenance of abuse and dependence is influenced by three main factors: Individual, addictive substance and environment (Mann et al. 2006).

Whether a person uses alcohol or how likely they are to become dependent on alcohol depends on individual factors such as frustration tolerance, personality structure, available coping strategies, learned dysfunctional behavior, and genetic factors. The clustered occurrence of alcoholism within families cannot be explained by model learning alone, but is also due to genetic vulnerability.

Whether an addictive substance is consumed depends on its availability, addictive potency and addictive substance-specific effects. In the case of alcohol, the main effects are relaxation, anxiety relief, disinhibition at the beginning, euphoria and apparent self-esteem enhancement. In the initial stages of alcoholization, alcohol appears to interfere with basic assumptions about the self, filtering out negative cognitions about the self. So the disinhibiting effect of alcohol comes from the fact that it inhibits our inhibitions. This is also reflected at the physical level, where alcohol primarily exerts its primary inhibitory effect in the GABAergic system of the central nervous system.

Consumption and frequency of consumption of alcohol are strongly influenced by role models in the immediate environment and the drinking behavior prevalent in the culture. Alcohol is integrated into social life in Austria and the state of intoxication by alcohol is also tolerated. This circumstance may explain part of the very high per capita consumption of alcohol in Austria. In the case of adolescents, the influence of the peer group should be mentioned in particular, whereby both influencing effects such as peer pressure and selection effects play a role here.

Disturbance model VT

Activated basic assumptionsOwn self situation

Emotions

Automatic thoughts

Trigger situationInternal External External

Dependent behavior is explained on the one hand by classical learning processes. Psychological factors, modified environmental influences and the reinforcing effect of the pharmacological property of alcohol contribute to the development and maintenance of alcoholism. On the other hand, basic cognitive assumptions about oneself and one’s own coping strategies, as well as dysfunctional schemata about substance use and the pharmacological effects of alcohol, contribute to the genesis of the addictive disease. The cognitive model of addiction is outlined in the following figure:

This cognitive-behavioral model is supplemented by findings from neurobiology. Both changes in receptor density and receptor sensitivity in the GABAergic and glutamatergic systems and altered enzyme induction, caused by the increased intake of alcohol, lead first to increased alcohol tolerance and later to physical dependence. Alcohol also directly affects the body’s reward system, the dopaminergic system. Using classical conditioning, situations are coupled with the ingestion of alcohol and its rewarding effects. This results in increased dopamine release in anticipation of the positive effects of alcohol. This increased dopamine release itself leads to an increase in alcohol craving. This and the simultaneous sensitization of the dopaminergic system leads to the formation of the so-called addictive memory.

Thus, alcoholism is also based on neural changes induced by processes of operant and classical conditioning.

Interventions

First of all, a distinction must be made between detoxification and qualified withdrawal treatment. While the detoxification phase focuses on physical withdrawal and the treatment of any physical sequelae, treatment in the withdrawal phase concentrates on changing addiction-specific thought and behavior patterns and building alternative, less self-harming thought and behavior strategies. Treatment of any underlying psychiatric conditions must also be considered during the weaning phase.

The need for a separate motivation phase, distinct from the rest of the treatment phases, is often discussed but is not feasible in practice in isolation. Rather, it is important to recognize in which phase of the transtheoretical model of change according to Prochaska & Clementi (1983) the client is currently in order to then be able to intervene in a phase-appropriate manner.

So any addiction therapy is also motivational therapy. Building a stable, internal positive motivation to change represents one of the central tasks in addiction treatment. In the treatment, special emphasis is placed on teaching a dynamic concept of motivation. Motivation is not a stable construct, but a dynamic process that is subject to permanent fluctuations, for which both clients and practitioners should be prepared. As Rollnick and Miller (1991) point out in their book on motivational interviewing, people are ambivalent about any behavior change. The therapist should be particularly aware of this ambivalence of the patient towards all behavioral changes that have been set as therapy goals, especially when working with addicts.

Total Abstinence vs. Harm – Reduction

For decades, total abstinence was the sole treatment goal for addicts. It is only in recent years that the concept of harm reduction has been successfully established, initially mainly in the area of illicit drugs, but increasingly also in the area of alcohol dependence. This is probably due to the change in the diagnosis of alcoholism in the DSM – 5. Going forward, the DSM – 5 will eliminate the distinction between alcohol abuse and alcohol dependence, and instead diagnose the severity of a substance use disorder (APA 2013).

According to current knowledge, biology speaks in favor of the concept of total abstinence. In practice, it is probably more important to keep patients in the treatment setting than to lose them from treatment by pushing too hard for a treatment goal that is not conceivable to the patient at that time. In contrast to inpatient treatment, where total abstinence is the stated therapeutic goal at all facilities, a more pragmatic approach tends to be taken in the outpatient setting. In principle, the goal of total abstinence remains, but if this is not yet possible, the concept of harm reduction is applied. Therefore, in the case of severe use disorder as defined by the DSM – 5, the following pragmatic treatment goals emerge:

• Abstinence is considered the overriding therapeutic goal, but this can often only be achieved after a long process, sometimes lasting years. In this process, the patient needs therapeutic support.
• Substance abuse is considered and treated as self-harming behavior.
• If relapses do occur, the goal is to limit the damage and return to near total abstinence as soon as possible.
• Relapse is considered part of therapy.

Burtscheid (2002) suggests the following treatment goal pyramid.

Survival: In this phase, positive experiences with abstinence and therapy are to be conveyed. Furthermore, a reflection of the current life situation takes place.

Mitigation: In this phase, the motivation for further measures takes place.

Prolongation of abstinence phases: This section focuses on analyzing and working through relapse situations.

Permanent abstinence: psychotherapy of addiction-maintaining structures and conflicts.

If abstinence- or addiction-specific goals are clearly the focus of treatment at the beginning, the processing of fundamental dysfunctional schemas, as they can be recorded by vertical behavior analysis, becomes increasingly important as treatment continues.

Controlled drinking as a therapy goal

Self-directed consumption is also repeatedly brought into play as a possible therapy goal. Self-controlled use refers to disciplined, planned, and limited substance use in which a person aligns his or her use with a pre-determined consumption plan/rules. In each case, consumption quantity and frequency are planned for one week in advance. The context of consumption, where, when and with whom is also determined in advance (Körkel 2014). Controlled consumption must not be confused with unproblematic, socially adapted consumption. In practice, the model of self-directed use proves to be less effective in the long term, but often provides a good entry point into treatment, where the desired change to the model of total abstinence can be made at a later stage.

Abuse function

Of course, it makes a difference in treatment whether a client uses alcohol for the purpose of “sensation seeking,” whether substance use serves to reduce anxiety or insecurity, or whether, in the sense of the self-medication hypothesis, legal or illegal drugs are used to alleviate the symptoms of an underlying psychiatric illness.

Thus, defining the function of abuse through behavioral or conditional analyses is another key centerpiece of the treatment. In horizontal behavior analysis, we place substance use in the place of the problem behavior under investigation. Besides the level of cognitive processes and the biological – physiological level, special consideration must be given to the level of emotional reactions. When analyzing the trigger situation, in addition to a precise analysis of the environmental influences, special attention should be paid to whether consumption tends to take place alone or in company. In the analysis of internal processing, both the dysfunctional basic assumptions about the self and the situation and addiction-specific basic assumptions are collected. These addiction-specific basic assumptions concern assumptions about the addictive substance itself and assumptions about the effects of the addictive substance. The elicitation of so-called “permission-granting thoughts,” cognitions that lead to the reduction of cognitive dissonance regarding consumption and thus facilitate action execution, can also take place in this section. If necessary, the short- and long-term consequences can also be further differentiated into internal and external consequences, as in classical behavioral analysis. The survey of any labilizing conditions allows for better identification of high-risk situations, which play a crucial role in relapse prevention. One possible form of the horizontal behavioral analysis of substance use is shown in the following figure.

In the everyday practical implementation of these condition analyses, it becomes apparent that deficits in the area of emotion regulation, here in particular anxiety management, represent one of the main triggers for substance use. Other causes include deficits in the ability to relax, deficits in social skills and the ability to deal with conflict, a desire for more intense experiences and a lack of strategies for organizing leisure time, as well as reduced self-esteem.

Building alternative skills

The above list shows that a main part of the treatment of addiction is the establishment of functional alternative behavior to abuse. Depending on the main functions of the abuse, teaching emotion regulation skills, building social skills, and/or improving the ability to experience using simple mindfulness strategies and pleasure training will be key components of treatment. Building a positive realistic self-image and working out daily structure should be part of any psychotherapeutic treatment anyway.

Rejection Training and Anticraving – Skills

As special features in the treatment of addictive disorders, the rejection training and the teaching of anticraving skills should be mentioned. Practice has shown the need for intensive role-play practice of difficult social situations related to substance use, such as refusing the request to use. This ensures that the skills needed are actually available in normal everyday life.

Many addicts also experience craving attacks, a desire for the consumption of the addictive substance that is experienced as almost irresistible. Anticraving skills are used to prepare for such attacks. Thus, when craving occurs, which can often be understood as a classically conditioned response, immediate exit from the situation and distraction by intense taste sensations and/or by physical activity is practiced. Another strategy is the classic “letting the craving wave pass”. This is understood as the conscious perception and localization of the addictive pressure and the associated desire to act, without also translating this impulse to act into reality, combined with positive self-verbalization with regard to one’s own coping options.

Cue – Exposure” is used to extinguish classically conditioned reactions with regard to addictive substances. This form of exposure therapy requires special preparation and a stable therapeutic relationship, since the client may also feel provoked or humiliated by a confrontational approach.

Another central component of treatment is the processing of addiction-specific basic assumptions and addiction-specific expectations by means of cognitive restructuring (Beck et al. 1997). In addition to working through the patient’s automatic thoughts and dysfunctional basic assumptions about the self and the patient’s own coping abilities, assumptions about the addictive substance itself, assumptions about the effects of the addictive substance, and permission-giving thoughts in particular are to be identified and changed.

Cognitive restructuring is also a major component of relapse prevention according to the social cognitive model of relapse (Marlatt & Gordon 1985). In addition to identifying and changing relapse-specific cognitions, general lifestyle changes, building coping skills, and identifying high-risk situations are the other core areas of relapse prevention.

The inclusion of partners or relatives from the immediate social environment in a more advanced part of the therapy is now “state of the art”. Separate reference should also be made to the positive effects of aftercare on the duration of abstinence, whether in therapeutic guided groups or in self-help groups.

In the following figure, the main components of a modern, individual-based alcoholism therapy are shown once again in conclusion.

Evidence of the approach

Cognitive-behavioral approaches or interventions that can be assigned to this spectrum represent the therapeutic basis for the treatment of alcoholism (Walter et al. 2015).

According to the DGPPN S3_guidelines, cognitive behavioral therapy approaches reach evidence level Ia: evidence from a meta-analysis of at least three randomized controlled trials. The recommendation is also that cognitive-behavioral therapy should be offered in the treatment of dual diagnoses, in this specific case the presence of an alcohol-related disorder and depression. Cognitive behavioral therapy is also recommended in the treatment guidelines in the context of post – acute treatment.

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