Cognitive-Behavioral Treatment Strategy for Alcohol-Induced Mood Disorder
Adapted Case Description
Mrs. R, 40 years old, is a business woman and mother of four children (Frances & Ross, 2001). Recently she was admitted for treatment at the insistence of her family. She has been drinking a quart of gin a day and has suicidal ideation. She is dependent on her husband, who is her business partner. Subsequently, after discovering her husband’s affair 10 years ago Mrs. R began drinking heavily and has had a decline in an emotional, physiological, and psychological health. Within the past two years she began drinking in the morning, has short term memory loss, and was arrested for driving while intoxicated. In the last year she has attended Alcoholics Anonymous (AA) and relapsed after two months. In the last 10 months she has had increased weight gain and early morning awakening. She believes she is a burden to her family, but does not have the courage to commit suicide. She has a family history of alcoholism and abuse.
Treatment Strategy
Mrs. R’s alcohol dependence, her current depressive psychological features, and her physiological reaction exemplify Alcohol-Induced Mood Disorder. An initial intensive program should be implemented with Mrs. R due to her sustained misuse of alcohol and failed out-patient treatment options. Hospitalization may be the first step in treatment due to the dangers of withdrawal (Seligman & Reichenberg, 2007). After stability is obtained Cognitive-behavioral therapy (CBT) should be the principal course for treatment. Treatment will consist of changing Mrs. R’s negative self-perception, self-efficacy, and abstinence. Effective treatment requires Mrs. R to complete assignments between sessions, as well as abstaining from alcohol. Due to her relapse history prescribing Naltrexone (ReVia) will help her maintain control of her drinking.
Psychoeducation
Mrs. R has been extremely unmotivated to change her habits over the past ten years. The therapist will recommend motivational therapy at the start, to enhance compliance on the treatment plan. Shuckit (as cited in Seligman & Reichenberg, 2007) advises that the therapist educate Mrs. R, her husband, and her children about the effects of alcohol use on personality and mood (depressive thoughts and suicidal ideation), as well as the course of alcohol use disorders. Understanding the perception of alcohol as a negative reinforcer that reduces anxiety, tension, stress, or depression, gives insight as to why Mrs. R drinks heavily (Kadden, 2002). Mrs. R struggles with the belief that she is worthless and she has become a burden to her family. An increase in familial support as well as understanding how her brain and body are responding to the alcohol will help to change her self-hatred and increase motivation.
By increasing motivation it will be possible to emphasize Mrs. R’s responsibility of her actions (Seligman & Reichenberg, 2007). Taking responsibility will allow Mrs. R to take effective steps to begin the process of changing her maladaptive cognitions and behaviors. Bishop (as cited in Seligman & Reichenberg) reinforces the necessity for the therapist to be optimistic, flexible, and inspire hope while being honest and direct.
Mrs. R has developed associations between alcohol consumption and various situations (i.e. fighting with the husband, feeling unloved by her children). These triggers in her environment may be eliciting her inclination to consume more alcohol more frequently (Kadden, 2002).
Shuckit (as cited in Seligman & Reichenberg, 2007) recommends it may also be useful to include medication to deter drinking once abstinence has been successful for a period of time. However, the therapist will inform Mrs. R that the main focus of treatment will be by using a cognitive-behavioral treatment plan. This will be a 16 week intensive therapy that will include: functional analysis, specifying goals, and coping skills training. Further therapy (relapse prevention, couples therapy, family therapy, individual therapy, nutritional counseling, or a self help group) may be needed to continue to facilitate Mrs. R’s ability to prevent relapse and continued emotional stability.
Cognitive Therapy-Functional Analysis
Due to Mrs. R’s overwhelming desire to consume alcohol to assuage her depressive moods, it is necessary to identify and corrective maladaptive cognitive functions. The therapist will need to identify the thoughts, feelings and circumstances of Mrs. R before and after she drinks. Cognitive therapy implies that it is the emotional tones and expectations that one learns to associate with specific events that create problems rather than the events themselves that cause distress (Cilente, 2009). To identify the antecedents to Mrs. R’s use of alcohol and the functional relationship of drinking and the consequences that follow, an assessment of Mrs. R will be performed by the therapist. These assessments will include a structured interview and questionnaires. The Inventory of Drug-Taking Situations will be used to identify the stimuli associated with the desire to consume alcohol one and the Inventory of Alcohol/Drug Use Consequences. These questionnaires are both are composed of 50 items (Kadden, 2002).
Mrs. R believes that she is burden to her family and is a worthless human being. Her alcoholism stems from feelings of inadequacy as a wife and as a mother, as well as feeling that her death would alleviate the pain. These beliefs lead have lead her down a downward spiral for the past ten years, which has now amounted into early morning awakening insomnia as well as drinking a quart of gin a day. These overwhelming feelings of self-worthlessness are reinforced when she drinks and she becomes volatile with her family. The goal of cognitive therapy will be to show Mrs. R alternative responses that can be developed and examined from a cost-benefit perspective and empower her to make conscious choices about how she chooses to respond to stressful situations (Cilente 2009). This empowerment lends to a sense of control and thus unrecognized options become viable alternatives in managing distress during family conflict. As sessions continue Mrs. R will also be shown options to focus on specific events as an opportunity to redefine (minimization, distancing, selective attention, and searching for positive value from a bad situation) how she can achieve self-efficacy by taking power over a crisis and changing it into opportunity or challenge. Ultimately, the result is that Mrs. R will have an increased sense of control over the situation and therefore stress is reduced (Cilente).
Behavior Modification-Coping and Skills Training
The therapist will include coping and skills training as the emphasis of behavioral modification. Miller and Hester (as cited in Kadden, 2002) show deficits in skills for coping with the antecedents and consequences of drinking are considered to be a major contributor to the development and maintenance of addictive behavior. Mrs. R has become undependable, makes errors in judgments, and creates scenes as part of her current coping and defense mechanisms. She becomes easily emotional and breaks into tears when she is confronted by her family of even minor issues. Mrs. R has become psychologically dependent on alcohol as her only way to cope. Thus, coping skills training is develops alternative ways of meeting needs and thereby modifying the psychological dependence factor (Kadden, 2002).
Mrs. R should have specific training in managing thoughts and craving, negative thinking, decision making, with intimate relationships and with her significant other. To manage her thoughts and desires to consume alcohol, Mrs. R must challenge the way she thinks about alcohol by recalling unpleasant experiences (fighting with her husband, embarrassing her daughter) that resulted from drinking, anticipating the benefits of not drinking, distracting herself, delaying the decision whether or not to drink, leaving the situation, and seeking support (Kadden, 2002). Using role-play she can better manage these thoughts and preoccupations with drinking when she is confronted by family members. By using positive self-talk in these role-plays as well as in real life situations (with her daughter, or while at work with her husband) Mrs. R can gain control of her actions (such as bursting into tears when criticized). Prior to drinking she felt a sense of pride when she was well-groomed, it is important that Mrs. R resume this activity. Decision-making training will help Mrs. R think ahead to possible consequences of her decisions. This will allow her to be ready to make good decisions, thus she will become more confident about her ability to cope with problems. Her increased confidence and decision making ability will help her feel valued as a business partner, wife and mother.
Mrs. R will need coping strategies to approach her relationship with her husband. Since problems within her intimate relationship (such as maladaptive communication patterns, lack of intimacy, and control struggles) having her husband participate in skills-oriented treatment will enhance her treatment outcome (Kadden, 2002). At the end of each session, Mrs. R will be given a written reminder of the skills she has learned, which will list the specific behaviors involved, for future reference (Kadden). Mrs. R will do weekly homework assignments on different coping skills and thought record exercises (this should be keeping a journal of her own behaviors, actions and feelings, followed up by her family’s responses and perceived feelings). Mrs. R’s efforts combined with her families support will increase progress and likelihood of recovery. As Mrs. R begins to better cope and make better decisions her feelings of self-worthlessness and depression will gradually reduce.
Rationale
Alcohol-Induced Mood Disorder is characterized by alcohol dependence, with onset of mood disorder features during intoxication. A study by Dorus, Kennedy, Gibbons, and Ravi (as cited in Brown, R., Evans, D., Miller, I., Burgess, E., & Mueller, T., 1997.) shows that there are clinically significant levels of depressive symptoms being reported in as many as 65–85% of patients entering alcohol. CBT has shown to be effective in the treatment of patients with alcohol dependence with depression (Brown, R., & Ramsey, S., 2000). For women, with a significant mental disorder, CBT was most effective (Seligman & Reichenberg, 2007).
In high-risk situations, as shown by Marlatt (as cited in Litt, M., Kadden, R., Cooney, N., & Kabela, E., 2003), CBT was used to tackle deficits in patients’ abilities to cope (cognitively or behaviorally) in challenges and to forestall relapse. CBT uses strategies to improve the person’s self-efficacy, manage thoughts and behaviors, controlling emotions, avoid alcohol, and achieve and maintain sobriety. An underlying assumption of CBT is that behaviors are learned, maladaptive behaviors, and thus coping skills are necessary (Ouimette, P., Finney, J., & Moos, R., 1997). Litt et al. (2003) exemplify the role of coping skills as a determinant of treatment and may significantly improve treatment outcomes. Thus CBT was chosen to be the most effective for the treatment for alcohol dependence and alcohol use disorders (Seligman & Reichenberg, 2007).
Conclusion
Although there is significant evidence that CBT is the most effective treatment for alcohol use disorders, alcohol dependence may also be treated by programs that include the twelve-step facilitation model and motivational enhancement therapy. Project MATCH found that twelve-step approach is best for those without psychological problems (Seligman & Reichenberg, 2007). Traditional twelve-step approaches developed from a self-help approach and combine the elements of Alcoholics Anonymous with the disease model of addiction (Ouimette et al., 1997). Individuals receiving twelve-step treatment are encouraged to accept the disease model of addiction, an alcoholic, and abstinence as their treatment goal, and they are expected to become involved in twelve-step activities (i.e., going to twelve-step meetings, getting a sponsor, and working the steps) (Ouimette et al).
Although there is evidence that both CBT and the twelve-step approach facilitate increased abstinence, certain methods have been proven to be more effective for particular types of people (Seligman & Reichenberg, 2007). CBT allows those with alcohol dependence to gain greater self-efficacy, decision-making skills, and the power to make effective changes throughout their life. These changes will support fulfilling relationships and goals without using alcohol as a coping mechanism.
References
Brown, R., Evans, D., Miller, I., Burgess, E., & Mueller, T. (1997). Cognitive–behavioral treatment for depression in alcoholism. Journal of Consulting and Clinical Psychology, 65(5), 715-726. http://search.ebscohost.com.lib.pepperdine.edu, doi:10.1037/0022-006X.65.5.715
Brown, R., & Ramsey, S. (2000). Addressing comorbid depressive symptomatology in alcohol treatment. Professional Psychology: Research and Practice, 31(4), 418-422. http://search.ebscohost.com.lib.pepperdine.edu, doi:10.1037/0735-7028.31.4.418
Cilente, J. (2009). Cognitive theory and therapy in substance abuse treatment. Mental-health-matters.com.
Frances, A., & Ross, R. (2001). DSM-IV-TR case studies: A clinical guide to differential diagnosis. Arlington, VA US: American Psychiatric Publishing, Inc.
Kadden, R. (2002). Cognitive-behavior therapy for substance dependence: Coping skills training. Behavioral Health Recovery Management.
Litt, M., Kadden, R., Cooney, N., & Kabela, E. (2003). Coping skills and treatment outcomes in cognitive-behavioral and interactional group therapy for alcoholism. Journal of Consulting and Clinical Psychology, 71(1), 118-128. http://search.ebscohost.com.lib.pepperdine.edu, doi:10.1037/0022-006X.71.1.118
Ouimette, P., Finney, J., & Moos, R. (1997). Twelve-step and cognitive-behavioral treatment for substance abuse: A comparison of treatment effectiveness. Journal of Consulting and Clinical Psychology, 65(2), 230-240. http://search.ebscohost.com.lib.pepperdine.edu, doi:10.1037/0022-006X.65.2.230
