Power Point Slides Alcohol - Meagher Lab

Health-Compromising Behaviors 

characteristics 

substance abuse and dependence 

alcohol abuse and dependence 

smoking

Characteristics of 

Health-Compromising Behavior 

! Many of these behaviors share a 

window of vulnerability in adolescence 

! Drinking to excess 

! Smoking 

! Illicit drug use 

! Unsafe sex 

! Risk-taking behaviors 

! Tanning 

! Eating disorders

Characteristics of 

Health-Compromising Behavior 

! Behaviors are tied to the peer culture 

! Image of these behaviors as “cool” 

! Insecure more vulnerable to peer pressure 

! Behaviors, though dangerous, are pleasurable 

(+reinforcement) and often reduce anxiety (- 

reinforcement) 

! Linked to major causes of death 

! Behaviors develop gradually rather than being 

acquired “all at once” 

! Substance abuse of all kinds are predicted by some 

of the same factors 

! Interventions need to be matched to stage of 

vulnerability

Substance abuse: Links 

! Conflict with parents and family problems 

! Impulsivity 

! Stress 

! Seems to serve as a coping mechanism, 

other coping skills are lacking 

! Deviance in adolescence is linked to low 

self-esteem and conflict in the family 

! Poor academic performance 

! Difficult temperament 

! Low SES, but less common among culturally 

identified ethnic minorities 

! Unemployment

What Is Substance Dependence? 

! Physical dependence 

! Body has adjusted to substance and 

incorporates its use into normal functioning of 

body’s tissues 

! Tolerance: Larger doses needed to produce 

same effects 

! Craving: Conditioning process is involved so 

that environmental cues trigger intense desire

What Is Substance Dependence? 

! Addiction 

! A person has become physically or 

psychologically dependent on a substance 

following use over a period of time 

! Withdrawal 

! Unpleasant symptoms, both physical and 

psychological, that people experience 

when they stop using a substance on 

which they have become dependent

Addiction Theories 

(a) The opponent process/hedonic view that drug pleasure and 

subsequence unpleasant withdrawal symptoms are the chief 

causes of addiction (Solomon & Corbita, and incorporated into 

Koob’s 2004 model). 

(b) Addiction is due to aberrant learning, especially the 

development of strong stimulus response habits. 

(c) Berridge and Robinson incentive-sensitization view suggests 

that sensitization of a neural system that attributes incentive 

salience causes compulsive motivation or “wanting” to take 

addictive drugs. 

(d ) Setlow: dysfunction of frontal cortical systems, which 

normally regulate decision making and inhibitory control over 

behavior, leads to impaired judgment and impulsivity in 

addicts.

Opponent Process Theory 

Solomon & Corbit, 1974, 1978 

Theory of acquired motivation/emotion 

Emotions opposite pairs (fear/relief) 

Standard pattern of affective dynamics 

a-process 

b-process 

Grows with experience 

Application to addiction 

Heroin Addiction

Opponent Process Theory

Skydivers jump from planes. 

Beginners experience extreme fear on 1st jump, followed by extreme relief when they land 

With experience, the fear decreases and the post-jump pleasure increases. 

Addiction Examples 

thrill-seeking behaviors, runners high, drugs 

Drug addiction 

The drug initially produces pleasurable feelings, but followed by negative 

emotions. 

With repeated drug use the drug user takes drugs not for their pleasurable effects, 

but to avoid withdrawal symptoms.

B-process grows in strength with repeated drug use 

Cancels out euphoric effects of drugs (a-process)

Figure 1 Opponent process model of addiction. According to the opponent process theory 

the affective (hedonic or emotional) response to a stimulus (a drug in this case) is the 

underlying a-process, which in turn elicits the opponent b-process (bottom). The underlying 

processes add together to cause the initial pleasant A-state, which is actually experienced, 

followed by an opponent unpleasant B-state. Initially the pleasant A-state is large, followed 

by a small B-state. With repeated drug use and in addiction, however, the opponent b-process 

increases in magnitude and duration, leading to an experience dominated by the unpleasant 

symptoms associated with withdrawal. (Adapted from Solomon 1977 and Solomon & Corbit 

1973.)

Koob’ Model (2004) 

Animal studies indicate that drug use leads to dysregulation of distinct neurochemical mechanisms 

in specific reward and stress neural circuits that provide the negative motivational state that 

drives addiction. 

An extension of Solomon and Corbit’s opponent-process model. Here both panels represent the affective response to the presentation 

of a drug. The top represents the initial experience of a drug with no prior drug history. The a-process represents a positive mood 

state, and the b-process represents the negative mood state. An individual experiencing a positive mood state from a drug of abuse is 

hypothesized to retain the a-process. In other words, an appropriate counteradaptive opponent-process (b-process) that balances the 

activational process (a-process) does not lead to an allostatic state. The bottom panel represents changes in the affective stimulus 

(state) in an individual with repeated frequent drug use that may represent a transition to an allostatic state in the brain reward 

systems and, by extrapolation, a transition to addiction. Note that the b-process never returns to the original homeostatic level before 

drug-taking is reinitiated, thus creating a greater and greater allostatic state in the brain reward system. Thus, the counteradaptive 

opponent process (b-process) does not balance the activational process (a-process) but in fact shows a residual hysteresis. The 

hypothesis here is that even during post-detoxification, a period of ‘protracted abstinence’, the reward system is still bearing 

allostatic changes. In the non-dependent state, reward experiences are normal, and the brain stress systems are not greatly engaged. 

During the transition to the state known as addiction, the brain reward system is in a major underactivated state while the brain stress 

system is highly activated. DA, dopamine; CRF, corticotropin-releasing factor; GABA, g-aminobutyric acid; NPY, neuropeptide. The 

following definitions apply: allostasis, the process of achieving stability through change; allostatic state, a state of chronic deviation 

of the regulatory system from its normal (homeostatic) operating level; allostatic load, the cost to the brain and body of the 

deviation, accumulating over time, and reflecting in many cases pathological states and accumulation of damage.

Robinson & Berridge Model 

30 ROBINSON ⌅ BERRIDGE 

Figure 2 Adaptation of Figure 4 (panel B) in Koob & Le Moal (1997, p. 56), in which they 

depict sensitization as amplifying the hedonic a-process. They state that this panel shows an 

“affective stimulus in an individual with an intermittent history of drug use that may result 

in sensitized response. The shaded line illustrates ...the initial experience. The dotted line 

represents the sensitized response” (p. 56). Note that sensitization is hypothesized to increase 

the hedonic A-state by this view, which would be experienced as enhanced drug pleasure.

Figure 3 Comparison of the critical change in addiction leading to compulsive drug pursuit 

according the stimulus-response (S-R) habit learning hypothesis (left) and the incentivesensitization 

hypothesis (right). According to the S-R habit learning model addiction (compulsive 

drug pursuit) is primarily due to the development of very strong S-R habits [indicated 

by the thick arrow from a drug cue (CS) to a response (drug pursuit)]. According to the 

incentive-sensitization view the critical change is in the ability of representations of drug 

cues (the dashed US evoked by a drug cue) to engage a sensitized motivational response 

of incentive salience (as indicated by the starburst). This enhanced motivational response is 

primarily responsible for compulsive drug pursuit (thick arrow) in addiction according to our 

view.

ADDICTION 39 

Figure 4 Graphic representation of the sites on neurons at which drugs have been shown 

to produce morphological changes. (A) The most common type of neuron in the nucleus 

accumbens, a medium spiny neuron. Past experience with amphetamine, cocaine, or morphine 

has been shown to alter the number of dendritic branches seen radiating away from the cell 

body. (B) Magnified view of a dendrite that is studded with many dendritic spines. As indicated 

by the schematic drawing in (C ), dendritic spines are the site of synapses, and spines on 

the distal dendrites on medium spiny neurons receive both glutamate and dopamine inputs. 

Treatment with amphetamine, cocaine, or morphine also produces persistent changes in the 

number of dendritic spines on these neurons and therefore presumably in the number of 

synapses (Robinson & Kolb 1997, 1999a,b; Robinson et al. 2001). Camera lucida drawings 

(A and B) courtesy of Grazyna Gorny.

Alcoholism and Problem Drinking: 

Scope and Costs of the Problem 

! >20% of Americans drink at levels that exceed 

government recommendations 

! Alcohol consumption is linked to 

! high blood pressure, stroke, cirrhosis of the liver, 

fetal alcohol syndrome, some cancers, cognitive 

impairments, 15% of health care costs = Etoh 

abuse treatment, underestimate of health costs 

! Alcohol-related accidents: 

! 1 in 2 Americans will be in one in their lifetimes 

! 41% of traffic-related deaths related to alcohol 

! 50% of all MVAs 

! Economic: $42 billion annually in lost productivity, 

absenteeism

What Are Alcoholism and Problem 

! Alcoholic 

Drinking? 

! Physical addiction to alcohol 

! Withdrawal symptoms when abstaining from 

alcohol 

! High tolerance for alcohol 

! Little ability to control drinking 

! Problem drinkers: may not have symptoms listed 

above, but do have substantial social, medical or 

psychological problems resulting from alcohol 

! More information: 

http://www.nlm.nih.gov/medlineplus/substanceabuseproblems.html

DSM-IV Definitions 

! ALCOHOL ABUSE: 

! episodic problems, no physical symptoms of withdrawal or 

tolerance, but social & occupational impairments, problem 

drinkers 

! ALCOHOL DEPENDENCE (Alcoholics) 

! i) TOLERANCE -need to increase amounts 

! ii) DRUG WITHDRAWAL -affective and physical symptoms 

following use: DTs, gross disorientation, cognitive 

disruption, impaired motor coordination, tremor, fleeting 

hallucinations 

! iii) Blackouts 

! iv) memory impairment 

! v) loss of control over drinking 

! vi) over involvement with the alcohol 

! vii) impaired social, occupational, physical/emotional f(x)

What Are Alcoholism and Problem 

Drinking? 

! Symptoms of Alcohol Abuse 

! Difficulty in performing one’s job because 

of alcohol consumption 

! Inability to function well socially without 

alcohol 

! Legal difficulties encountered while 

drinking 

! Drunk driving convictions: DUI, DWI

EPIDEMIOLOGY 

! Stats: 

! 1 out of 10 is a problem drinker/alcoholic 

! 90% of HS seniors have tried it, but a small number do most of 

the drinking. 1/10th drinks 1/2 of the alcohol consumed 

! other estimates suggest problem drinkers = 9 million, alcoholics 

= 9 million; 3:1 male:female ratio 

! Ethnicity/SES 

! higher rates =native Americans, Europeans, Irish, lower rates 

among southern Europeans, Jewish. Lower rates among Latino 

and African Americans. More prevalent in middle class. 

! Gender 

! women tend to develop drinking problems later, but progress 

more rapidly, usually with mood disorders in women and 

antisocial PD in men.

Lifetime prevalence of alcohol 

dependence by age and sex

High School Alcohol Use 

80% of 12th, 2/3 of 10th graders

High School Alcohol Intoxication

Prevalence of alcohol use and dependence by age 

Men 

Women

Alcohol Use by Ethnicity 26 or >

Epidemiology 

! Personality factors 

! longitudinal studies indicate that childhood hyperactivity 

(impulsivity) and antisocial behavior are evident in 

alcoholics, especially males 

! Dual diagnosis issues 

! most secondary to other psychopathology 

! 30-50% Major Depression 

! 33% Anxiety Disorders, including PTSD 

! Antisocial PD; Polysubstance abuse; Bipolar 

! http://www.nlm.nih.gov/medlineplus/dualdiagnosis.html

Alcohol and the brain

Physiological Aspects of Alcohol 

Consumption 

! CNS Effects: 

! CNS depressant, slows the activity of the CNS, high doses 

can cause a reduction in tension & inhibitions, and impair 

judgment, motor control, and concentration. 

! Reduces anxiety by increasing the synaptic activity of 

GABA, an inhibitory neurotransmitter and by decreasing 

excitatory neurotransmission by both NMDA and non-NMDA 

receptors 

! The GABA-benzodiazepine receptor complex contains 

separate binding sites where alcohol, barbiturates & 

benzodiazepines bind to make it more sensitive to GABA. 

! Because GABA is an inhibitory neurotransmitter the final 

effect is to increase neural inhibition and decrease anxiety.

Physiological Aspects of Alcohol 

Consumption 

! Absorption & Effects: 

! Alcohol (ETOH) is absorbed into the blood by the 

stomach and small intestine 

! Initial effects = higher CNS, control of judgment 

& inhibition & fine motor control, DISINHIBITION. 

! Increased ETOH = effects on lower CNS confused, 

inappropriate, memory impairment, emotionally 

labile, motor & sensory impairment. 

! Extent of impairment determined by blood ETOH, 

intoxication=0.09%, at 0.55% = death, due to 

depression of respiratory centers in the medulla.

How alcohol affects the brain

Moderate drinking and health 

! health benefits pf moderate ETOH use 

! Nondrinkers & heavy drinkers have poorer health 

! more strokes, higher rates of CHD, 

! J-shaped relationship. 

! Mortality rates of nondrinkers and moderate drinkers are 

50% higher 

! 200% higher in heavy drinkers. 

! Due to accidents, cancer, respiratory, and cirrhosis 

! Alameda county, Framingham, and Albany studies 

confirmed results. 

! relationship is stronger in men under age 60. Seen in 

smokers & non-smokers. 

! Albany study -abstainers = high CHD, but non-CHD 

mortality didn't differ; mod ETOH reduces CHD, may 

elevate HDL, prevents arterial blockade heart attacks. 

! Mechanism ?

J-Shaped Curves 

J-shaped associations between alcohol intake and adverse health 

outcomes, including CHD, diabetes, HTN, congestive heart 

failure, stroke, dementia, Raynaud’s phenomenon, and allcause 

mortality." 

O’Keefe JH et al.,"Alcohol and cardiovascular health: the razorsharp 

double-edged sword", Journal of the American College of 

Cardiology, 2007;50(11) [in press]. 

Graphs examine only the effect of alcohol consumed, not other 

benefits of those documented for red wine. 

One "drink" contains 15 grams of alcohol (ethanol): approximately 

12 oz. of beer, 5 oz. of wine, 1.5 oz. 80-proof liquor, or 1 oz. 

100-proof liquor.

Alcohol and Mortality

Alcohol and all cause mortality 

The relationship of daily alcohol consumption to the relative risk of all-cause 

mortality in men and women. DiCastelnuovo A, et al., "Alcohol dosing and total 

mortality in men and women", Archives of Internal Medicine 2006;166:2437-45.

Risk of Stroke 

Relationship between daily alcohol and ischemic stroke.OR = odds ratio. 

Sacco RL, Elkind M, Boden-Albala B, et al., 

"The protective effect of moderate alcohol consumption on ischemic stroke", 

JAMA: the Journal of the American Medical Association 1999;281:53-60.

Alcohol:Incidence of Diabetes II 

Alcohol intake and incidence of new type 2 diabetes. 

Koppes LL, Dekker JM, Hendriks HF, Bouter LM, Heine RJ, 

"Moderate alcohol consumption lowers the risk of type 2 diabetes: 

a meta-analysis of prospective observational studies", 

Diabetes Care 2005;28:71925.

Wine and Cholesterol


Is Modest Alcohol Consumption a Health 

Behavior? 

! Modest alcohol intake (1-2 drinks/day) may 

add to a long life 

! For older adults 

! Coronary artery disease reduced 

! HDL “good” cholesterol increased 

! Fewer strokes, etc 

! Moderate drinking among younger adults 

! Enhances risks of death, probably due to alcoholrelated 

injuries

Alcohol increases other risks 

Bofetta, P, and Garfinkel, L. "Alcohol drinking and mortality among men 

enrolled in an American Cancer Society prospective study." 

Epidemiology 1:342-348, 1990.

Heavy Drinking and Health 

! Alcohol intoxication 

! -50% of suicides, homicides, and accidental deaths. 

! Poison to nearly all organ systems 

! Neural effects- brain and neuropsychological dysfunction 

! ANTEROGRADE AMNESIA-blackouts impaired consolidation 

! CNS PATHOLOGY DUE TO B VITAMINE DEFICIENCY - 

Thiamine, 10% of alcoholics are affected by this syndrome, 

treat with thiamine 

! -WERNICKE'S ENCEPHALOPATHY - short term- acute occular 

disturbances, ataxia, confusion, excitement untreated = 

Korsakoff's syndrome 

! -KORSAKOFF'S SYNDROME -extreme confusion, memory 

impairment, confabulations not affected by thiamine, 

damage to mammilary bodies, thalamus, -CORTICAL 

ATROPHY -especially frontal lobes

Heavy Drinking and Health 

! Neuropsychological Impairments 

! even when sober, chronic alcohol abuse/dependence 

results in cognitive impairments 

! While verbal abilities & IQ in normal range 

! Impairment in abstract reasoning, executive functions: 

concept formation, cognitive flexibility, and perceptualmotor 

abilities. 

! Improves w/abstinence 

! Increased Mortality 

! heart disease, stroke, cancer, and cirrhosis of the liver. 

cofactor in cancer of larynx, pancreatic cancer, increased 

accidental death.

Women More Vulnerable? 

Women are more vulnerable than men to many of the medical consequences 

of alcohol use. 

e.g.,, alcoholic women develop cirrhosis, alcohol–induced damage of the heart 

muscle (i.e., cardiomyopathy), and nerve damage (i.e., peripheral neuropathy) 

after fewer years of heavy drinking than do alcoholic men. 

Studies comparing men and women’s sensitivity to alcohol–induced brain 

damage, however, have not been as conclusive: 

1. Using imaging, two studies compared brain shrinkage, a common indicator of 

brain damage, in alcoholic men and women and reported that male and 

female alcoholics both showed significantly greater brain shrinkage than 

control subjects. 

2. Studies also showed that both men and women have similar learning and 

memory problems as a result of heavy drinking. 

3. The difference is that alcoholic women reported that they had been drinking 

excessively for only about half as long as the alcoholic men in these studies. 

This indicates that women’s brains, like their other organs, are more 

vulnerable to alcohol–induced damage than men’s. 

4. Other studies have not seen this. 

http://pubs.niaaa.nih.gov/publications/aa63/aa63.htm


Origins 

! Genetic factors appear to be involved 

! Twins studies 

! if one twin is alcoholic, the likelihood that the other 

twin is alcoholic is 2 times as high if identical (54%) vs. 

fraternal (28%), relationship not always this strong 

! genetics=20% of the variance some studies, 50% others 

! What is inherited? GABA, serotonin gene that regs 

dopamine receptors? Early environment? 

! Frequency of alcoholism in sons of alcoholics 

! Men traditionally were at greater risk 

! With changing norms, women are “catching up” 

! Multifactorial: Physiological, behavioral, and 

sociocultural factors are involved


Origins 

! Drinking occurs as an effort to buffer 

the impact of stress 

! Drink to enhance positive emotions 

! Drink to reduce negative emotions 

! Alcoholism is tied to the drinker’s 

social and cultural environment. 

! Window of vulnerability: Ages 12 to 21 

! Window of vulnerability: Late middle age


Origins 

! Depression and alcoholism may be 

linked 

! Alcoholism may represent untreated 

symptoms of depression 

OR 

! Depression may act as an impetus for 

drinking to improve mood 

Symptoms of both disorders 

must be treated simultaneously

Gene Environment Interactions 

! Early environment: 

! Maternal and neonatal stress.. Impact on twin 

studies? 

! Stress: 

! Exposure to chronic uncontrollable stress 

increases the reinforcing properties of most drugs 

of abuse, relation to early risk factors 

! Learning: 

! classical conditioning of craving to drug cues 

! withdrawal symptoms when exposed to drug cues 

! plays a role in relapse 

! how to prevent

Maternal Separation Studies 

Stress causes pups to produce hormones that altered their 

genes that affects their later behavior, making them less able 

to cope with stress later in life. The mice exposed to stress 

have poorer memories, anxiety, and physical health than the 

control group. 

Recent research shows how stress in early life could program 

behavior later in life. The stress causes the animals to produce 

high levels of stress hormones, and this in turn causes 

epigenetic changes, meaning that the experience had changed 

the DNA of a gene coding for the stress hormone vasopressin, 

which is important in controlling mood and cognitive behaviors, 

causing the brain developed more vasopressin receptors. 

Vasopressin involved in social connections such as parent/child 

bonding but higher levels increase aggressive behavior. 

The change in the vasopressin gene resulted in the mice being 

"programmed" to produce high levels of the stress hormone in 

their adult lives. When the adults were given a drug to block 

the vasopressin effects, their behavior became more normal… 

showing the vasopressin change is causal. 

Dynamic DNA methylation programs persistent adverse effects of 

early-life stress, Nature Neuroscience, Published online: 8 

November 2009; doi:10.1038/nn.2436 

Moffett et al 2007. 

Cruz et al., 2008 

Alters drug intake patters in adult rats, increasing self 

administration of cocaine and alcohol. 

Implications for human: Explains how trauma in childhood can 

lead to problems in later life, such as depression and risk of 

substance abuse. Understanding the molecular basis for the 

phenomenon lead to new treatments for mental disturbances 

arising from early stress or trauma. 

See website for papers.

Prevention of Alcohol Abuse 

! Legal barriers 

! drinking age 21, enforcement, DUI, DWI 

! Inoculation programs 

! help reduce drunk driving, but work best 

with light drinkers 

! If you catch drinking early, before a 

heavy use pattern develops, people 

can control it 

! http://www.collegedrinkingprevention.gov/OtherAlcoholInformation/ 

tipsForCuttingDownonDrinking.aspx#planning


Preventive Approaches 

! Social influence programs in Junior Highs 

have shown some success 

! Adolescents’ self-efficacy enhanced (drink 

refusal skills) 

! Programs can change teens’ social norms 

! focus on controlled drinking/abstinence rather than 

excessive consumption 

! Approaches are low cost programs for low-income 

areas 

! Social engineering promise for prevention 

! Higher taxes on alcoholic beverages


Drinking and Driving 

! Mobilizes the public against alcohol abuse 

! 50% MVA fatalities result from alcohol abuse 

! Political impact from groups like MADD 

! Pressure for hosts and friends to intervene 

! Self-regulatory techniques 

! Designated driver 

! Taxis 

! Delaying driving after consuming alcohol

Alcohol-Related Problems of College 

Students


The Drinking College Student 

! Most U.S. college students drink alcohol 

! 15%-25% are heavy drinkers 

! 45% engage in occasional binge drinking (vs. 

15% of overall adult population) 

! Successful interventions: 

! Encourage students to gain self-control over 

drinking rather than eliminating alcohol 

! Self-monitoring often reduces drinking 

! Harm reduction strategy


The Drinking College Student 

! Skills Training 

! Identify circumstances when drinking to excess 

occurs 

! Placebo drinking 

! Consuming nonalcoholic beverages while others are drinking 

! Alternating alcoholic and nonalcoholic drinks 

! Lifestyle rebalancing 

! Excessive alcohol consumption is incompatible with a 

healthy lifestyle 

! Add exercise, mindfulness meditation, smoking 

cessation, social experiences without alcohol


Treatment Programs 

700,000 

people 

in U.S. 

receive 

treatment 

on any 

given 

day 

! Self-Help Groups are most 

commonly sought source of 

help 

! especially AA 

(Alcoholics Anonymous) 

! Hard-Core Alcoholics 

! Detoxification 

! Short-term, Inpatient Therapy 

! Continuing Outpatient 

Treatment

Detox and Medical Management 

! Alcohol Withdrawal Syndrome- physical dependence, hours 

later withdrawal: shaking of hands, tongue, and eyelids, weak, 

nauseous, sweat & vomit. HR & BP rise, anxious, depressed or 

irritable, hallucinations, convulsions 2-3 days 

! Delirium Tremens - DTs - gross memory disturbance, mental 

confusion, clouded consciousness, disoriented, hallucinate 

seizures, loss of consciousness, 2-3 days 

! Treatment- Symptom management: -relief of agitation,tremors 

w/ sedative-hypnotics, benzodiazepines; B vitamins, 

anticonvulsants, delirium - tranquilizers 

! after withdrawal, goals = sobriety & treat psychological conditions 

! serotonin reuptake blockers reduce drinking (Prozac) 

! Buspar anti-anxiety drug not related to benzos 

! RO 15-4513 drug reverses alcohol intoxication by blocking a type of 

benzodiazepine receptor which modulates the activity of 

GABAergic neurons 

! Naltrexone - opioid antagonist, dampens high

Psychological Treatments 

! Insight Treatment 

! treat associated psychological & personality problems. Brownell 

(1982) indicates success rates varied from 65% to 82% at 1-year followup, 

but cut in half (40%) at 3-year follow-up (Armor et al., 1978; 

Wiens & Menusik, 1983). 

! Behavioral & Cognitive Treatment 

! Self-Monitoring 

! Person begins to understand situations that give rise to drinking 

! Self-Management 

! control stimuli, develop other coping responses, rewards and 

punishments 

! Contingency contracting 

! Person agrees to a costly outcome (financial or psychological) in 

the event of failure, can involve family 

! Systematic Desensitization and relaxation 

! cope with tension/anxiety

Psychological Treatments 

! Aversion therapy 

! Antabuse, conditioned aversion, 63% success rate at 1 year 

follow-up (Wiens & Menustik, 1983), adherence problems 

! Relapse Prevention - 

! 50% drop out, less than 50% finishing are successful at 1 

year follow-up. 

! Successful = best adjustment, older, higher SES, no other 

substance abuse hx, stable relationships and 

employment, no psychopathology/only depressed, no hx 

treatment failures, motivated (Holden, 1987, Stark, 

19992, Nathan, 1986). 

! Social and problem-solving skills training: 

! most relapse in 90 days when encounter high risk 

situations. Teach social and problem-solving skills 

training -use imagination, role playing and rehearsal. 

! Multicomponent Treatment 

best chance of long-term success = combining variety of techniques

Inpatient treatment? 

Evidence suggests that inpatient therapy is not 

essential for most alcoholics, only extremely 

impaired ones (Holden, 1987). 

Nor is there any advantage to long treatment 

programs (Miller and Hester, 1986).Women 

do better in separate programs (Dahlgren & 

Willander, 1989). 

However, some recent finding challenge this 

notion. 

Recent approaches? treatment matching, stage 

of change, relapse prevention, mindfulness 

meditation, combination therapy

Motivational Enhancement Therapy 

! MET helps develop intrinsic motivation to change to lead client to 

initiate, persist, and comply with behavior change. 5 principles 

1) Express Empathy 

2) Develop a Discrepancy – help client see discrepancy between where 

they are and where they want to be – raise awareness of personal 

consequences of drinking for pre-contemplators. Such information can 

create a crisis that will motivate change. The person will be motivated 

to enter into frank discussions of change options in order to reduce the 

perceived discrepancy and maintain emotional equilibrium. When client 

enters tx in the later contemplation stage, it takes less time and effort 

to move client along. 

3) Avoid Argumentation - if handled poorly, ambivalence and 

discrepancy can turn into defensive coping (rationalization, denial) 

which will reduce discomfort but not alter drinking. This happens when 

the client perceives that your are attacking them.

Motivational Enhancement Therapy 

4) Roll with Resistance- don’t confront resistance head on, 

rather work toward shifting patients perceptions, allow 

patient to invite new ways of solving the problem. 

Ambivalence is viewed as normal not pathological – openly 

explored -- reflected. Solutions are evoked from the client 

rather than provided by therapist. 

5) Support Self-Efficacy – people who are persuaded that 

they have a serious problem won’t move toward change 

unless they believe there is hope for success. Belief that 

you can perform a particular behavior or task --- it is 

possible to change your drinking and thereby reduce other 

problems. Without it, patients use defensive coping.

" 

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– Recognising that people making changes in their lives have different levels of readiness to change 

their behaviour (the ‘stage of change’). 54 Some may have never thought about changing the behaviour 

in question, some may have thought about it but not taken steps to change it and others may be 

actively trying to change their behaviour and been trying unsuccessfully for years. Motivational 

interviewers ‘roll with resistance’ in that they accept that reluctance to change is natural. 

– Taking a non judgmental, non confrontational and non adversarial approach. Motivational 

interviewing aims to increase a person’s awareness of the potential consequences and risks faced as 

a result of their behaviour and to help people see a better future and become increasingly motivated 

to achieve it. The focus is on supporting people to think differently about their behaviour. 

– Motivation to change is elicited from the patient rather than imposed externally. Motivational 

interviewing relies on identifying and mobilising the patient’s intrinsic values and goals in order 

to support behaviour change. 

– Being semi directive. The motivational int erviewer attempts to influence people to consider 

making changes, rather than loosely exploring themselves and their feelings. However there is no 

coercion or direct persuasion. 

– Expressing empathy and understanding of the patient’s perspective. 

– Developing discrepancy whereby the motivational interviewer helps people see the difference 

between how they want their lives to be and how they currently are or between their values and their 

day to day behaviours. It is the patient’s responsibility to articulate and consider solutions to any 

discrepancies or ambivalence. 

– Supporting self efficacy. Motivational interviewers encourage people to take responsibility 

for their actions and help them build confidence in their ability to change. Often motivational 

interviewers look for ‘commitment language’ from patients to illustrate that they are becoming more 

ready to make changes.


Profile of Alcoholics Anonymous 

! Philosophy 

! The best person to reach an alcoholic is a 

recovered alcoholic 

! Immersion: Attend 90 meetings in 90 days 

! 12-step program - spiritual focus, conversion 

! Disease model 

! Recovery depends on staying sober 

! Members provide social reinforcement for one 

another's abstinence 

! Alcoholism 

! A disease that can be managed, not never cured 

! Alcohol plays no part in the person’s future

AA 12 Steps 

1. We admitted we were powerless over alcohol - that our lives had become unmanageable. 

2. Came to believe that a Power greater than ourselves could restore us to sanity. 

3. Made a decision to turn our will and our lives over to the care of God as we understood Him. 

4. Made a searching and fearless moral inventory of ourselves. 

5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs. 

6. Were entirely ready to have God remove all these defects of character. 

7. Humbly asked Him to remove our shortcomings. 

8. Made a list of all persons we had harmed, and became willing to make amends to them all. 

9. Made direct amends to such people wherever possible, except when to do so would injure 

them or others. 

10. Continued to take personal inventory and when we were wrong promptly admitted it. 

11. Sought through prayer and meditation to improve our conscious contact with God as we 

understood Him, praying only for knowledge of His will for us and the power to carry that out. 

12. Having had a spiritual awakening as the result of these steps, we tried to carry this message 

to alcoholics and to practice these principles in all our affairs.

AA 

! Dropout rate unknown? 

! Comparing AA to insight oriented, behavior, and 

nontreatment (Brandsma et al., 1980). 

! AA highest drop out (68%) other groups =57%; AA was 

no more successful than any of the other group 

therapies for those finishing study 

! Project Match found all performed about the same 

! AA claims 2 out of 3 stop who want to stop? 

! Recent evidence 

! show better outcomes when patients participate in AA 

rather than in a formal treatment program alone 

! Treatment costs are lower for AA group(45%) 

! How does it work? 

! Conversion, meaning, maturity, social support, etc


Treatment Programs: Relapse Prevention 

! Relapse rates 

! 50% or more relapse 2-4 years after treatment 

! 50% or more relapse within first 3 months 

! Helpful for problem drinkers to know 

! An occasional relapse is normal 

! Relapse doesn’t signify failure 

! Important relapse prevention skills 

! Learning “drink-refusal skills” 

! Learning nonalcoholic beverage substitutions 

! ID high risk situations, develop skills to manage 

them, and advanced planning

PROJECT MATCH 

! Compared 3 manualized treatments: CBT, 

Motivational Enhancement, and AA 12-step 

! Randomly assigned 

! Monitored for a year and longer 

! Found improvements in all groups at one 

year in all groups, but no overall differences 

between treatments 

! Patient selection of treatment? 

! Need to focus more efforts on prevention!!


Can Recovered Alcoholics Drink again? 

! Alcoholics Anonymous Philosophy 

An alcoholic is an alcoholic for life 

! Drinking in moderation seems possible 

! For young, employed problem drinkers 

! Who have not been drinking for long 

! Who live in supportive environments 

! Drinking in moderation 

! May be a more realistic goal for college students 

! May prevent high dropout rates in more 

traditional programs


Treatment of Alcohol Abuse 

! “Maturing Out” of Alcoholism 

! 10 to 20% of dependent/alcoholics stop drinking 

on their own 

! 32% can stop with minimal help 

! Can be treated successfully through 

cognitive-behavioral modification 

But 

! High rate of recidivism – as high as 60% 

! Alcoholic’s environment must be considered 

! Without employment or social support, prospects for 

recovery are dim



! Minimal Interventions 

! Success of brief interventions remains 

unclear 

! Oslin et al, 2003 study results produced 

beneficial changes 

! Curry et al, 2003 study had high drop out rates 

! About 85% of alcoholics don’t receive 

formal treatment



! Social engineering may represent the 

best approach 

! Banning alcohol advertising 

! Raising the legal drinking age 

! Strictly enforcing the penalties for drunk 

driving 

! These approaches reach the untreated 

majority

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