Recovery of Cognitive Functioning in Alcoholics

The Relationship to Treatment

MARK S. GOLDMAN, PH.D.

Alcoholics’ successful recovery depends on their regaining cognitive functioning. Although their cognitive deficits often are subtle and improve with a period of abstinence from alcohol, they can hamper the effectiveness of treatment programs. If patients cannot comprehend the information imparted during therapy, they may not be able to use treatment strategies successfully in “real world” challenges. Cognitive recovery can be enhanced using strategies such as repeated mental exercises. Adding such practice to treatment regimens could improve some alcoholics’ chances of recovering successfully. KEY WORDS: AOD impairment; cognitive process; treatment program; treatment method; treatment outcome; AODD (alcohol and other drug use disorders) recovery

tive impairment, between 75 and 100 functions (for definitions and further quick review of this issue of Alcohol Health & Research percent of the cases (depending on the descriptions, see the diagram of the brain

World reveals the impact of samples and measures used) perform on p. 137). Deficits in problem­solving,

chronic excessive alcohol use below normal for their age group on abstracting (i.e., ascertaining the principles on cognitive functioning. The most severe sensitive tests of cognitive functioning or rules that govern a particular task), and impairments are the profound memory (McCrady and Smith 1986). shifting of sets (i.e., recognizing the need dysfunction caused by Wernicke­ Until recently, researchers often have for using new rules when the previous A attributed the many levels and types of Korsakoff syndrome (for a definition of rules no longer apply) were associated cognitive deficits seen among alcoholics this syndrome, see the glossary, pp. with frontal lobe damage caused by alco­ to differing forms of alcohol­related dam­ 136–137) or the more global intellectual hol consumption or related factors. Some deterioration (including memory impair­ age to the drinkers’ neuroanatomy (i.e., the brain’s various parts) and neurophysi­ ment) of alcoholic dementia (i.e., general ology (i.e., the functions of these parts). MARK S. GOLDMAN, PH.D., is Distinguished loss of memory functioning, judgment, and abstract thinking). Even among peo­ Researchers considered such differences Research Professor, director of the Alcohol in impairment to be responsible for any and Substance Use Research Institute, and ple admitted to alcoholism treatment 1 facilities who show no dramatic cogni­ performance discrepancies observed director of training in clinical psychology, among alcoholics. In addition, researchers Department of Psychology, University of 1 attributed Wernicke­Korsakoff amnesia to South Florida, Tampa, Florida. In general, the patients described in this article as having been admitted to alcoholism treatment facili­ thiamine deficiency and to the lesions ties meet the criteria for alcohol dependence listed in accompanying this syndrome in a variety Portions of this work were supported by the American Psychiatric Association’s Diagnostic of brain structures, such as the dienceph­ National Institute on Alcohol Abuse and and Statistical Manual of Mental Disorders, Fourth alon, mammillary bodies, and basal fore­ Alcoholism grants R01AA06911 and

Edition (DSM–IV). brain, which are associated with memory R37AA08333.

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visuospatial impairments were connected tently revealed using specific tests of Goldman (1987, 1990) has suggested with a wasting away (i.e., atrophy) of the abstract reasoning and visual perception. that the tests most sensitive to alcohol­ frontal and/or right hemisphere. In recent In addition, alcoholics have not consis­ related cognitive dysfunction have several years, however, investigators have used tently shown learning and memory deficits characteristics in common. They all pre­ more sophisticated brain imaging and despite the fact that more severe versions sent stimulus material that the patient has of these impairments are symptoms of cerebral blood flow techniques and found not previously experienced. They require Wernicke­Korsakoff syndrome (see similar neuroanatomical damage in all that multiple kinds of information be Parsons et al. 1987). alcoholics, including those whose deficits integrated (e.g., learning to connect a name These descriptions of alcohol­induced are detectable only on sensitive behav­ with a face). And, in most cases, they deficits derive primarily from the re­ ioral tests. Thus, differences in cognitive require that the information be processed searchers’ intuitive analyses of what the capacity among alcoholics cannot be rapidly. These challenges require a process tests seem to measure, such as abstracting attributed exclusively to differences in traditionally called “attention”; the more their neurophysiology. ability or memory. Some investigators use recently used term is “controlled.” (In fact, How similar forms of damage to the more sophisticated strategies based on a distinguishing characteristic of Wernicke­ nervous system can result in differing cognitive psychology to better understand Korsakoff syndrome is impaired controlled behavioral consequences, including cog­ the nature of the cognitive dysfunctions. memory processes, whereas implicit nitive deficits, in different alcoholics memory—using remembered information remains unclear. The behavioral changes or a newly learned skill without being that researchers observe may result from lcoholics aware of when or how it was learned— the general effects of alcohol­related remains relatively intact. For further dis­ toxicity and other factors (e.g., head A may be deficient cussion, see the article by Ingle and injury, liver damage, psychiatric factors, Weingartner, pp. 155–158.) or neurochemical abnormalities) com­ in exactly those The capacity to deal with new situa­ bined with individual differences, such as tions that demand the processing of multi­ age and drinking history (Bowden 1990; cognitive capabilities ple sources of information underlies National Institute on Alcohol Abuse and humans’ ability to adapt to changing cir­ Alcoholism 1993). Some researchers also they need the most have suggested that a portion of the im­ cumstances. Recovering alcoholics require pairments are present in people with a such adaptability to change from a lifestyle to recover family history of alcoholism even before that includes continual drinking to one that they begin consuming alcohol (the accu­ involves no drinking. Hence, alcoholics successfully. mulated evidence for preexisting dysfunc­ may be deficient in exactly those cognitive tion has been mixed, however; see Drake capabilities they need the most to recover et al. 1995). For example, Parsons (1987) and co­ successfully from alcoholism. Alcohol researchers do not know workers noticed that alcoholics appear to whether cognitive impairments impede change a strategy (that may be correct) alcoholism treatment. Can a cognitively before it has been sufficiently tested or to TIME­DEPENDENT RECOVERY impaired alcoholic readily absorb all the continue using ineffective approaches even information that is usually imparted during When alcoholics cease continual heavy after it is obvious that they are inadequate. treatment? Do these deficits make the On difficult verbal learning tasks, Butters drinking (e.g., as a result of admission to necessary adjustments and adaptations to a and Granholm (1987) have suggested that detoxification programs), they typically

“dry” (i.e., nondrinking) way of life more cognitive deficits stem from the inadequate experience a period of acute withdrawal difficult? If so, can anything be done to encoding strategies alcoholics use when that may last a few days. During this time, help the alcoholic recover from these storing information rather than from a they feel ill and frequently show poor deficits? This article discusses the partial specific inability to learn or remember. In performance on most cognitive tests, answers to these questions, first reviewing other words, correct information may be probably as much a result of a general the course of recovery from alcohol­related placed in a file drawer, but an inadequate sense of malaise as any other factor. It is deficits, then considering how these label on the file might make retrieval of not surprising, therefore, that they im­ deficits may affect treatment outcomes. It this information difficult. prove on these tests after the acute with­ concludes by reviewing research on ways Cognitive psychology’s techniques drawal phase. Beyond this relatively brief to improve treatment outcome by facilitat­ thus attempt to uncover impairments in period, however, real improvement may ing cognitive recovery. general cognitive processes that may be observed as time passes. The rate of affect many other brain functions. Statis­ improvement and the ultimate level of tical research supports the possibility that functioning the alcoholic reaches vary THE NATURE OF THE the more specific deficits in abstracting with the type of cognitive processing DEFICITS AND HOW THEY ability, visuoperception, learning, and involved in completing a task and with ARE DETERMINED memory may be caused by more general the age of the alcoholic. Sometimes com­ and pervasive information­processing plete recovery of cognitive functioning Test findings from a wide group of stud­ deficits. Studies indicate that a single can take weeks, or even months or years. ies show that alcoholics are remarkably underlying process may be associated In some instances, the alcoholic never free of impairment of general intelligence. with most, if not all, the observed deficits Their cognitive deficits are more consis­ on specific tests. completely recovers.

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for it are not entirely clear. The brains of Determining Recovery Patterns Patterns of Time­Dependent Recovery people with shorter drinking histories may To see how alcoholics’ performances be more resilient physically or may better change over time after they cease drink­ When these methodological issues are carry out neurophysiological adjustments. taken into account and the recovery litera­ ing, it is necessary to measure their per­ Or, up to a certain number of drinking ture is considered, the following patterns of formance on at least two occasions over a years, alcoholics may be able to learn to time­dependent cognitive recovery emerge specific length of time. Recovery may not compensate for underlying neurological progress at a steady pace, so it is best to (see Goldman 1987, 1990). First, some damage to produce unimpaired behavior measure performance on more than two cognitive capacities seem relatively unim­ (e.g., by performing a task a different occasions. However, people improve their paired, even early in detoxification, as long way). Perhaps a dysfunctional performance as the general malaise of the first few days performance of most behaviors after they only appears after excessive drinking has 2 practice those behaviors. Therefore, if an of abstinence is past. Gross IQ, as meas­ gone on for a certain length of time, pro­ ured primarily by verbal tests that draw alcoholic improves after repeatedly per­ ducing a threshold above which cognitive upon prior knowledge, falls into this cate­ impairments become observable. Or it may forming a particular task, the improve­ gory. This means, for example, that the be that some as­yet­undetermined process ment may be the result of either true vocabulary levels of very recently detoxi­ is at work. (generalized) cognitive recovery over time or only increased familiarity and fied alcoholics are about the same as they It is clear, however, that a return to were prior to and after recovery from the practice with the specific instrument used alcohol use, even at reduced levels, after acute alcoholic episode that brought them to measure the targeted behavior. some period of sobriety sets back the into detoxification. In contrast, any task recovery process regardless of drinking that requires processing new information, history. Very recent findings further Controlling for the Effects abstracting, or problem­solving, whether indicate that the effect of drinking re­ of Practice verbal or visuoperceptual, still is impaired sumption may be more debilitating for during the first week or two after drinking alcoholics who also have family histories Two general approaches have been used ceases. Some sensorimotor functions (e.g., to separate recovery from the effects of of alcoholism, although such alcoholics sensitivity to touch) also may be deficient apparently recover just as well as alco­ practice. In one case, each matched group during this period. Other factors, such as of alcoholics is tested for the first time at holics without such histories if they main­ age and drinking history, also affect time­ tain abstinence (Drake et al. 1995). different time lags after stopping drink­ dependent recovery. ing, followed by repeat testings also at different times. For example, group one Age. Two to 3 weeks after alcoholics stop XPERIENCE EPENDENT may be tested at weeks 1, 2, and 3 after E ­D drinking, they show considerable recov­ RECOVERY drinking has stopped, whereas group two ery in most verbal processing cognitive may be tested at weeks 2, 3, and 4. This functions; these areas may even return to In a series of studies performed over the way, the effects of practice on the tests normal functioning levels. At this point, last 20 years, Goldman (1990) found that can be separated from recovery that oc­ however, the recovery paths of alcoholic cognitive recovery does not result only curs over time. If at the first test, group subgroups diverge, based primarily on from some intrinsic neurophysiological two performs better than group one, then their age. Younger alcoholics (those under healing process but can be influenced by time­dependent recovery is evident. age 40) show substantial recovery of all environmental factors as well. These Repeat testings are necessary to ensure cognitive functions; only the most de­ environmental factors may be likened to that differences between the supposedly manding tests detect residual deficits. For physical exercise, but in this case, the matched groups are not the result of older alcoholics, the picture differs. “exercise” involves cognitive stimulation. unintended discrepancies between the Although their performance on cognitive Recovery seems to be accelerated if newly groups (e.g., differences in premorbid tests may continue to improve, deficits abstinent subjects are asked to “use their intelligence). In the other approach, non­ can be observed on visuoperceptual and heads” at a level that is equal to, or slightly alcoholics (usually matched with the problem­solving tasks for much longer beyond, their current level of functioning. alcoholics in education and sociodemo­ periods of time, even as long as many This experience­dependent recovery may graphic status) are given the same series months or years. In certain studies exam­ happen spontaneously because of naturally of tests as the alcoholics to determine ining deficits in short­term memory, occurring events, as when a job requires what improvement on the tests would be visuospatial functioning, and attention that a task be performed repeatedly. Alter­ if only practice (and no time­dependent among older alcoholics, problems have natively, recovery can be facilitated by been identified even after 5 years (Brandt recovery) was occurring. The difference planned cognitive activities, such as re­ et al. 1983). peating mental exercises, similar to the in the rate of improvement between the alcoholics and the nonalcoholics is then use of physical therapy to recover after a Drinking History. Most studies have not sports injury. In a loose sense, the cogni­ an indication of the “true” recovery of cognitive functioning. found that an alcoholic’s drinking history tive “switchboard” of the alcoholic appears relates significantly to the speed or extent impaired but apparently can be stimulated 2 A total failure to improve with practice would be a of recovery. Alcoholics with more years of to more efficient activity by the repetition sign of rather severe brain dysfunction. As noted heavy or problem drinking are not more of appropriate cognitive demands. earlier, even the most severely impaired alcoholics likely to have more lasting impairment Experience­dependent recovery is by typically show some recovery of function when they than are those with fewer years. This no means unique to alcoholism research. cease drinking. finding is counterintuitive, and the reasons Inducing recovery from brain damage by

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manipulating environmental variables has ment suggests that providing practice for reviews the findings relating cognitive been seen before in both animal and controlled, attention­demanding cognitive functioning to treatment outcome in gen­ human research (see Rose and Johnson tasks could enhance the impaired subjects’ eral. Unless impaired cognitive functioning 1992). Evidence exists now that such cognitive capabilities in other areas. In prevents or retards effective treatment recovery is not only a consequence of the younger people, whose improvement could outcome, improved cognitive functioning subject’s adjusting behavior to learn a occur spontaneously over time, cognitive would not affect how an alcoholic re­ new method of performing a task. Indeed, improvement seemed to be accelerated by sponds to treatment. studies using a variety of designs to ex­ practicing. In older alcoholic subjects, amine the effects of environmental practicing helped increase their cognitive changes on neurological functioning have functioning, even on tests that would have DOES COGNITIVE STATUS AFFECT found performance enhancement coupled revealed impairment for a much longer TREATMENT OUTCOME? with actual changes in the nervous system time if they had not practiced. Cognitive (for further information, see Rose and As noted earlier, alcoholics’ cognitive performance did not always improve to Johnson 1992). deficits most often are subtle. Whether normal levels as a result of practicing, but it did improve significantly (Goldman 1987). deficits of this type have any relationship with treatment outcome is a question that Experience­Dependent Techniques must be answered with empirical research. for Inducing Cognitive Recovery Other Strategies. Goldman and col­ To date, some research does indicate that leagues (1987; 1990) investigated Practice. The basic strategy for influencing cognitive functioning (or dysfunctioning) whether other experience­dependent an alcoholic’s cognitive recovery has been relates to various aspects of treatment, strategies to induce recovery might be to repeatedly administer tests that demon­ including treatment outcome. For example, superior to simple repetitive practice. To strate the subject’s impairment. This proce­ different studies have shown that less cogni­ this end, they broke a complex task into dure is nothing more than practice, tively impaired alcoholics are more likely to its component parts and trained subjects discussed earlier as a possible experimental attend outpatient treatment, to complete a to perform these components so that the confound in time­dependent recovery treatment program, to be rated by treatment retraining process was easier and more studies. Reexamined in this new context, personnel as having a better prognosis, and accessible to people who might be frus­ however, practice does more than facilitate actually to have a better outcome. Other trated by their cognitive dysfunction. trivial performance improvement on a studies have found that cognitive measures Although subjects recovered after this specific test. If a particular cognitive test is predict how long after treatment a patient strategy beyond what they would have uniquely sensitive to some underlying will resume drinking and the chances of a with no training, the strategy was no neurological damage, the improvement patient remaining abstinent for more than 6 better than simple practice. Apparently, caused by repeated performance of that test months following treatment discharge. alcoholics generally were not impaired to is not trivial. No one would consider in­ Alcoholics with better cognitive functioning the extent that they required a more ele­ significant an increase in the strength of an are more likely to have full­time employ­ mental strategy than that of practice (as atrophied muscle as a result of an exercise ment and a higher monthly income at fol­ severely brain­damaged subjects might). regimen; this process would be called lowup than are more cognitively impaired A second strategy depended on prac­ rehabilitation. Similarly, the improvement alcoholics (see Goldman 1990 for a review ticing a task that was specifically de­ in performance resulting from practice on of specific studies). signed to require attention and effortful one cognitive test uniquely sensitive to On the other hand, some researchers cognitive functioning. As seen in the first some underlying neurological damage have reported the relationship between strategy, recovery using these techniques should transfer to improved performance cognitive deficits and treatment success to was approximately the same as recovery on other tests that seem based on a similar be modest at best or even inverse. They with simple practice on more traditional cognitive function. note that adding indicators of patients’ cognitive (neuropsychological) tests. This In the early studies of experience­ cognitive status to statistical analyses finding was consistent with the theory dependent recovery (Forsberg and Goldman does not increase the accuracy of the that a basic cognitive deficit in alcoholics 1985), subjects practiced one version of a treatment outcome predictions that result is in the brain system(s) that control(s) particular test and then were tested on from using only basic sociodemographic effortful processing and integration of another version of the same test to demon­ multiple sources of information. variables. Other researchers have urged strate the transferability of their perform­ caution before any adjustments are made ance improvement. In more recent studies Implications of Cognitive Recovery to existing treatment programs that are (Forsberg and Goldman 1987), practice on based on what they consider to be an demanding visuospatial learning tests has The general improvement seen in alcoholics’ uncertain relationship (see Donovan et al. resulted in performance improvements on a cognitive functioning after experience­ 1987, Goldman 1990, and Goldstein 1987 wide variety of other cognitive tests, but dependent recovery raises two fundamental for more extensive discussions of the only if the tests were presented within the questions with implications for successful inconsistencies between these studies). same sensory modality. For example, treatment. First, does the cognitive im­ practice on some visually presented tests provement extend to behaviors that are The Bases for the resulted in improved performance on other directly associated with treatment (e.g., Inconsistent Findings visually presented tests but did not seem to communication skills)? Second, can cogni­ improve performance on tests that de­ tive rehabilitation strategies be used delib­ To understand why findings on cognitive pended primarily on touch. Nevertheless, erately with alcoholics to improve their impairment have been mixed, it is neces­ the broad transfer of performance improve­ treatment outcome? The following section sary to appreciate that adequate cognitive

VOL. 19, NO. 2, 1995 151 functioning does not, by itself, ensure a (Cooney et al. 1991; Kadden et al. 1989) person’s cognitive impairment. Thus, the better treatment outcome. It does provide a provide somewhat unintended evidence for idea that cognitive impairment may not foundation on which other treatment­related the importance of matching treatment add to the predictive accuracy of sociode­ 3 factors may operate. The capacity to learn complexity to patients’ cognitive mographic factors on these outcomes does resources. Cognitively impaired patients the kinds of skills and information that are not mean that cognitive deficits have no did better in loosely structured interac­ taught by most treatment programs may be effect on job performance. These appar­ tional group therapy than in highly struc­ increased if the patient’s thinking and ently different indices may be measuring tured behavioral coping skills training (the learning mechanisms are intact. At least the same thing, and the results from one set investigators originally had indicated that four factors may be responsible for the lack may mask the value of results from the the structured training should offer an of consistent observations on the relation­ other set. advantage for cognitively impaired alco­ ship between cognitive functioning and holics). Perhaps this result is not so sur­ treatment outcome. prising, however, when the large amount First, the cognitive tests used in the THE IMPACT OF COGNITIVE of information that must be acquired dur­ studies described above are not necessar­ DEFICITS ON TREATMENT ing coping skills training is compared with ily those best suited (most valid) for de­ OUTCOME tecting the aspects of dysfunction closely the considerably lighter informational related to treatment outcome and general demands of interactional therapy. It is possible that even subtle cognitive life functioning. These tests were origi­ deficits could affect how alcoholics seek nally selected because they were sensitive and participate in treatment and resume to brain damage caused by stroke, tumors, normal lives in the weeks and months head injuries, neurological diseases, and lcoholics’ after they stop drinking. Three examples other physical conditions and not because A of different types of deficits and their they could assess optimally the wide cognitive impact on elements of treatment are pre­ range of behaviors needed in day­to­day deficits sented below. living. Some neuropsychologists (Heaton First, treatment professionals under­ and Pendelton 1981) suggest the need for most often stand “classic alcoholic denial” as a kind tests that are similar to daily activities. of psychological avoidance or evasion of For example, when a test based on knowl­ are subtle. unpleasant reality. Part of this denial, edge of familiar advertising used in maga­ however, may result instead from the zines was used to assess cognitive alcoholic’s limited ability to process the functioning in alcoholics, this test proved Third, in the first weeks and months full range of available information about more statistically predictive of treatment after they stop drinking, alcoholics face a his or her drinking problem and a behav­ outcome than did entire batteries of stan­ variety of environments, ranging from the ioral inflexibility in making necessary dard cognitive tests (Sussman et al. 1986). very supportive to the very harsh. The changes in stopping the drinking. If denial Second, some research suggests that more demanding the environment, the is viewed as a part of the temporary brain many current treatment modalities only greater the recovering alcoholic’s need damage caused by alcohol’s toxic effects minimally impact the factors influencing will be for cognitive resources. The rela­ rather than as a refusal to accept responsi­ an alcoholic to drink. Therefore, it would tionship between an alcoholic’s cognitive bility, different treatment approaches may not matter whether the cognitively im­ status and treatment outcome will become be indicated for engaging the alcoholic in paired alcoholic could or could not learn clear only when the alcoholic experiences treatment other than the currently popular the behavior taught by the treatment pro­ posttreatment events, such as finding and confrontational methods. These new gram. If a method for teaching algebra is learning a new type of job, that will chal­ approaches are more consistent with unclear and ineffective, both highly intelli­ lenge the alcoholic’s cognitive capacity. newer recommendations to avoid con­ gent and less intelligent children will fail to Finally, cognitive functioning is only frontational strategies and instead use learn, reducing the observed relationship strategies that increase motivation (Miller one among many influences that may between intelligence and learning algebra. and Rollnick 1991). affect treatment outcome. Motivation, the If alcoholism treatments are ineffective, Second, almost all treatment ap­ availability of social support networks, reduced relationships between cognitive proaches depend, at some fundamental employment opportunities, comorbid impairment and positive treatment out­ level, on interpersonal communication psychiatric disorders, and numerous other come may only reflect the ability of alco­ skills. Cognitive confusion may impede factors also may play a role in how the holics to recover on their own without the alcoholics’ ability to effectively express alcoholic responds to treatment. benefit of treatment­acquired coping strate­ their own thoughts and feelings as well as On the other hand, research reports may gies. Treatments themselves must be im­ to clearly receive communications from occasionally obscure the impact of cogni­ proved, and/or they must be matched to the treatment personnel. All aspects of treat­ tive deficits because the deficits interact functional cognitive level of the alcoholic ment may be affected by this difficulty. with or overlap other treatment­related before the true importance of differences in Third, the essence of all treatment is factors. For example, measures that predict cognitive functioning can be identified and the need for change—change in how one treatment outcome—such as whether a evaluated. For example, two recent reports person is able to perform an intellectually views the world and interacts with other on a patient­treatment matching study demanding job—contain components of people when not drinking and change in cognitive ability. These predictors could be many routine habits. Unfortunately, the 3 In statistical terms, adequate cognitive functioning considered both sociodemographic factors most frequent common denominator of serves as a moderator. and factors resulting from the extent of a cognitive impairment, including that

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which results from alcoholism, is the lessening of adaptability and flexibility. Even a quick review of Alcoholics Anonymous’ (AA’s) 12­step philosophy reveals how much abstract thinking, concentration, and memory are required to absorb this material cognitively and apply it to maintaining a new lifestyle (e.g., recognizing that one is “powerless over alcohol,” taking a “searching and fearless moral inventory,” and listing “all persons...harmed”; AA World Services 1978). Similar cognitive demands arise in connection with most cognitive behav­ ioral treatments and in treatments that include learning information about how alcohol affects the body and the mind. Not only must the alcoholic make changes as part of treatment, but the new behav­ ioral repertoire learned also must be implemented in constantly varying daily situations. The alcoholic must be able to recognize a potentially problematic situa­ tion, resist old maladaptive responses, and An even more critical change was that deficits frequently seen in some alcoholics implement new behaviors that may be far the alcoholic patients’ ability to learn and during withdrawal. Cognitive status, there­ from thoroughly learned. implement a treatment component became fore, could be assessed routinely to guide a criterion for judging whether the alco­ treatment planning. For cognitively im­ holic had successfully benefited from the paired alcoholics, the use of treatment

MPROVING REATMENT cognitive rehabilitation program. In their components that demand heavy cognitive I T UTCOMES BY ACILITATING study, Roehrich and Goldman (1993) used processing (these would include most O F COGNITIVE RECOVERY relapse prevention training as the treat­ current treatment methods) could be de­ ment component. They implemented this layed until at least 1 to 2 weeks after the training in the latter phases of the cogni­ patients cease drinking. During this time, As was demonstrated in the previous section, alcoholics may not benefit from tive rehabilitation program. Four remedia­ the treatment emphasis should be on assist­ tion strategies were compared, with a ing the recovering alcoholic to avoid alco­ certain aspects of treatment because of their cognitive deficits. As a result, alco­ different group assigned to each interven­ hol through a brief inpatient stay or by tion. The strategies included practice on close monitoring on an outpatient basis by holics with greater initial impairment would have a better chance of recovery standard cognitive (i.e., neuropsychologi­ family members or friends (this approach cal) tasks, practice on ecologically rele­ is similar to some strategies used by tradi­ from alcoholism if their cognitive im­ provement could be accelerated and vant tasks (figure 1), practice on placebo tional alcoholism treatment programs). After alcoholics have passed through this brought to levels approaching normal tasks (which required only automatic verbal responses), and no practice at all. critical period, treatment components may before they entered treatment. In a recent Results showed that the remediation be introduced in a systematic fashion, be­ study, Roehrich and Goldman (1993) strategies that involved real tests were ginning with the less cognitively demanding found that they could use experience­ equally effective in helping alcoholics and progressing to the more demanding. dependent recovery strategies to help learn the relapse prevention material; they Attention to the therapy’s cognitive de­ accomplish these ends. The procedure also were superior to both the placebo and mands on the patient and to the cognitive essentially was the same as that used in no treatment groups. Long­term treatment needs of each patient (i.e., those required earlier experience­dependent recovery outcome must await future research. by the patient to cope in his or her environ­ research, with impaired alcoholics begin­ ment) probably should continue well ning a sequence of repeated rehearsals of beyond traditional treatment periods, into cognitive tasks shortly after they com­ ONCLUSIONS AND INAL the aftercare phase. C F pleted detoxification (figure 1). One TREATMENT RECOMMENDATIONS In addition, information presented to significant change from prior studies was patients should be concrete rather than that the researchers gave the tasks to the Although the application of what is abstract; active strategies that emphasize participants in self­administered work­ known about cognitive recovery to alco­ practice may be used. Also, treatment books, rather than being administered by holism treatment is in its early stages, professionals must not depend on alco­ assistants in a face­to­face format. If cog­ several recommendations can be made holics being able to demonstrate “quick nitive improvements could be observed in that then must be tested with appropriate thinking” in high­risk situations that may this format, the remediation procedure research designs. trigger drinking. Alcoholics must be able could be far less labor intensive and costly For example, many studies have to practice with specific behaviors in for actual clinical settings. demonstrated the profound cognitive treatment that reduce risk until these

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