Coping- Training and Cue-Exposure Therapy in the Treatment of

Peter M. Monti, Ph.D., and Damaris J. Rohsenow, Ph.D.

Coping-skills training (CST) and cue-exposure treatment (CET) are two relatively new approaches in alcoholism treatment. With CST, the therapist tries to strengthen the patient’s skills in coping with situations associated with a high risk of drinking. These skills can be specific to certain high-risk situations or involve general social skills. Specific CST treatment approaches include training, social or skills training, urge- specific coping-skills training, and cognitive-behavioral mood management training. Several studies have shown that CST can be more effective than comparison treatments in improving the outcome (e.g., the frequency and severity of relapses) of alcoholic patients. CET exposes the patient to alcohol-related cues (e.g., the sight or smell of alcohol), thereby allowing the patient to practice responses to such cues in real-life situations. In addition, CET teaches a variety of coping skills for dealing with urges caused by such cues. Few studies have examined the effectiveness of CET, but the existing results demonstrate favorable treatment outcomes (e.g., reduced drinking severity). KEY WORDS: Coping skills; alcohol cue; AODU (alcohol and other drug use) treatment method; relapse prevention; patient education; treatment outcome; skills building; interpersonal skills; cognitive therapy; behavior therapy; AOD (alcohol and other drug) craving; social learning theory; literature review

n recent years, several exciting during therapy, thereby allowing the Coping-Skills Training advances have provided clinicians patient the opportunity to practice Iwith new tools in alcoholism treat- using coping skills in response to the Conceptual Overview ment that have resulted in improved urge to drink within the safe environ- outcomes (e.g., lower relapse rates, ment of a treatment setting. Research- CST and the related treatment reduced drinking levels, and improved ers hypothesize that as a result of approach of social skills training have health status) for alcoholic patients. coping-skills practice, patients will feel evolved from several decades of research Two of these new tools are coping-skills less overwhelmed by urge-provoking based on social learning theory. According training (CST) and cue-exposure treat- situations and, therefore, less likely to social learning theory, several factors ment (CET). CST aims to enhance the to relapse after treatment. This article can increase the likelihood that an alco- patient’s coping skills and provide him reviews the conceptual bases and methods holic will relapse when confronted with or her with specific strategies for cop- of CST and CET and also summarizes a stressful situation or with another sit- ing with the urge to drink. Conversely, the results of outcome studies that uation that is associated with a high CET exposes the patient to alcohol- have assessed the effectiveness of both risk of drinking (e.g., attending a party related cues (e.g., alcoholic beverages) approaches. where alcohol is served). Influential fac-

Vol. 23, No. 2, 1999 107 tors include limited skills in coping quently, be more likely to effectively stressful job) can exacerbate many of these with stressful or high-risk situations, utilize those skills in high-risk situations. high-risk situations (Monti et al. 1995). expectations that alcohol will have a Several lines of evidence support Another common risk factor for positive or pleasurable effect in these the importance of skills training for relapse is the presence of alcohol or situations (i.e., positive outcome alcoholics. First, studies indicate that drinking-associated stimuli (i.e., alcohol expectancies), and the belief that the alcoholics’ coping skills are inferior to cues), which may be combined with person cannot effectively cope with the the coping skills of nonalcoholics, par- either direct or indirect peer pressure situation without drinking (i.e., low ticularly in situations that commonly (Marlatt and Gordon 1985; Monti et al. self-efficacy expectations) (Marlatt and pose a risk of relapse, such as a family 1995; Niaura et al. 1988). Consequently, Gordon 1985). conflict or parties at which alcohol is the drinker must acquire the skills nec- Skills training is designed to address served (Monti et al. 1989). Second, the essary to avoid or “walk away from” the aforementioned risk factors in several levels that patients display in role such high-risk situations and develop a ways. First, clinicians can train patients plays of high-risk situations predict healthy lifestyle (e.g., sober in using coping skills specific to certain patient outcome after alcoholism treat- and recreational activities not involving high-risk situations (e.g., refusing drink ment. For example, Monti and col- alcohol) that will decrease the probability offers) to improve the patients’ skillful- leagues (1990) found that patients with of exposure to alcohol cues. A drinker ness in handling similar situations in low levels of coping skills in role plays cannot avoid all alcohol-related cues, the future. Second, therapists can teach consumed more alcohol during their however. For example, he or she may their patients general social skills that first 6 months after treatment than did see other people drink in public or social will result in improved sober relationships patients who had developed strong settings. Such situations can disrupt the and reduced conflict in both family and coping skills. Similarly, low skill levels, drinker’s ability to use his or her coping work relationships. This improvement as measured by an inventory of coping skills effectively. Consequently, CST in social skills can diminish both the skills during treatment followup, also must take into account alcohol cues; for drinkers’ stress levels and the number predicted relapse during the subsequent example, by incorporating CET, which of high-risk situations they encounter 2 months (Miller et al. 1996). Third, is discussed in more detail in the second while simultaneously increasing their alcoholics with low self-efficacy or with half of this article. social supports for abstinence. Third, a high urge to drink during role plays as a result of stronger coping and social of high-risk situations drank more dur- CST Treatment Methods skills, patients will likely develop increased ing the 6 months following treatment self-efficacy expectations and, conse- (Monti et al. 1990) than did their high All CST approaches generally begin with self-efficacy, low-urge counterparts. an assessment of the patient’s areas of Social learning theory also suggests vulnerability (Monti et al. 1995). This PETER M. MONTI, PH.D., is a professor that several types of personal and envi- assessment can focus on several domains, of psychiatry and human behavior and ronmental factors and situations place a such as coexisting biological or psychiatric associate director of the Center for Alcohol drinker at a particularly high risk for conditions, intrapersonal and interpersonal and Addiction Studies, Brown University, relapse. An understanding of these high- risk factors, and the expected amount of and a senior career research scientist at risk situations can help treatment providers exposure the patient will have to alcohol the Veterans Affairs Medical Center, design skills training programs that teach cues. Several biological or psychiatric Providence, Rhode Island. their patients the specific skills needed to conditions exist that if co-occurring with cope with those situations. alcoholism can increase a patient’s risk DAMARIS J. ROHSENOW, PH.D., is a One personal factor that contributes for relapse or interfere with his or her research professor of community health to a high risk of relapse is the lack of abil- effective use of coping skills. For example, and research director of the addictive ity to control one’s positive (e.g., excite- in people with an affective disorder,1 behavior research laboratory at the Center ment and euphoria) and negative (e.g., emotional situations can be associated for Alcohol and Addiction Studies, Brown depression and anger) emotional states with a higher risk of relapse; accordingly, University, and a career research scientist (Monti et al. 1995). Analyses of high-risk those patients require an enhanced focus at the Veterans Affairs Medical Center, situations for relapse have shown that on the management of their emotional Providence, Rhode Island. negative emotional states in particular states. Similarly, psychotic states or cer- precede many relapse episodes (Marlatt tain neurological conditions can impede Work on this manuscript was supported by and Gordon 1985). Consequently, coping by causing cognitive impairment. National Institute on and enhanced social and coping skills could Alcoholism grant 2–R01–AA–07850; by prevent relapse in interpersonal high-risk 1An affective disorder is any one of a group of psy- a VA Merit Review grant from the Medical situations (e.g., conflict with others) as chiatric disorders that are characterized by severe Research Service Office of Research and well as ameliorate relapse risk in intra- and inappropriate emotional responses, prolonged Development, Department of Veterans personal high-risk situations (e.g., boredom, or persistent mood disturbances, or other symp- toms associated with depressed or manic states. Affairs; and by two Department of Veterans , and depression). Chronic life Affective disorders include, for example, depression Affairs Career Research Scientist Awards. stress (e.g., from a death in the family or a and bipolar disorder.

108 Alcohol Research & Health Coping-Skills Training and Cue-Exposure Therapy

Because some intrapersonal factors • Urge-specific coping-skills training, Through this process, the patients can influence relapse risk, the clinician which is described later within the are taught to define the situational should assess those that are relevant, context of CET problem by identifying its relevant ele- including the patient’s current skill in ments (e.g., wanting to retain the friend- controlling mood states, such as euphoria, • Cognitive-behavioral mood manage- ship of a person offering a drink but also anger, depression, and stress. In addition, ment training, in which each treatment wanting to avoid drinking), to generate the treatment provider should evaluate session focuses on skills for managing several possible responses, and to think the extent to which situations involving specific emotions and which is dis- about the consequences of each response. various mood states have posed a risk of cussed in more detail in the article in To practice their new skills, participants heavy drinking to the patient in the past. this issue by Longabaugh and Morgen- discuss and role play a sample situation At the beginning of CST, the clini- stern, pp. 78–85. before identifying specific personal cian also should assess the patient for examples of that type of situation. Each interpersonal risk factors, including The following sections describe the patient role plays his or her specific general social skills, conflict resolution first two approaches. high-risk situation and receives feedback skills, and refusal skills, as well as the on how to enhance the effectiveness of types of interpersonal situations that Relapse Prevention Training. This CST his or her response. The patient then have contributed to heavy drinking in approach, originally developed by Chaney repeats the same role play using the new the past. Finally, the treatment provider and colleagues (1978), typically includes and more effective response. In addition, must determine the extent to which eight sessions, each of which generally the patient reports what he or she was the patient will be exposed to alcohol focuses on only one type of situation that thinking when generating the response cues. For example, patients whose jobs poses high risk for relapse. These high- so that thoughts or emotions such as involve being around alcohol (e.g., risk situations fall into four major cate- anger or hopelessness can be addressed. waiters) or whose family or extended gories: (1) frustration and anger (e.g., social network includes drinkers or interpersonal conflict), (2) interpersonal Communication Skills Training. In alcoholics may require cue-specific temptation (e.g., an offer of a drink), (3) contrast to relapse prevention training, coping skills or CET. negative emotional states (e.g., depression, communication skills training does A valuable way to obtain specific boredom, and loneliness), and (4) intra- not focus on high-risk situations but, information about these various risk personal temptation (e.g., craving or instead, focuses on communication factors, particularly for outpatients, who finding a bottle of an alcoholic beverage). skills that can be used to handle a are not treated in a controlled environ- The various high-risk situations, as well variety of risky situations (Monti et ment, is to have the patients themselves as the appropriate coping skills for deal- al. 1990). This approach addresses at monitor both high- and low-risk situa- ing with them, have been described in least eight high-priority skills that are tions by maintaining a detailed daily detail by Marlatt and Gordon (1985). discussed in separate training sessions. log. Such logs can help the treatment Relapse prevention training can be These skills include (1) refusing a drink, provider and the patient identify both conducted in either group or individual (2) giving positive feedback, (3) giv- the risk factors and the protective factors sessions. In either setting, each session ing criticism effectively, (4) receiving to which the patient is exposed. includes a variety of components, as criticism about alcohol and other drug Although clinicians have developed follows: use, (5) developing listening skills, several types of CST, the following four (6) improving conversation skills, (7) approaches have been used most exten- • Direct instruction in effective developing sober supports, and (8) sively (for a more detailed description, coping skills for specific situations learning effective approaches to con- see Monti et al. 1995): flict resolution. Five additional skills • Modeling of those skills by thera- that can be covered in separate sessions, • Relapse prevention training, in which pists and/or group members if time permits, include (1) nonverbal each treatment session focuses on a aspects of communication, (2) expres- specific type of situation that poses a • Rehearsal of the behaviors in role sion of feelings, (3) introduction to high risk for relapse and teaches var- plays , (4) request refusal, and ious skills to use in that situation (5) management of criticism in general. • Feedback about the patients’ However, these skills also can be covered • Social or communication skills train- responses and asking the patients within the first eight modules (for more ing, in which each treatment session about their thoughts information, see Monti et al. 1989). focuses on a general interpersonal Communication skills training gen- skill designed to improve social rela- • Instructions in the cognitive process erally is conducted in a group setting. tionships; this approach strives to used in generating the responses (e.g., Each session begins with a summary of reduce conflicts, improve the alcoh- thinking through possible alternative the meeting’s goals and the reason why olic’s sober supports, and change his responses and the consequences of the skill is important for sobriety, fol- or her lifestyle each response). lowed by a brief presentation and dis-

Vol. 23, No. 2, 1999 109 cussion of the skill involved. Depending comparatively higher education level situations can predict reduced drinking on the participants’ initial skill level, the or who had experienced relatively low severity after treatment. therapist can role play a sample vignette urges and less anxiety benefited equally Other studies, such as the Project illustrating the skill to be discussed. The from communication skills training MATCH trial, however, did not find patients then generate personal examples and mood management training greater benefits of skills training of possible scenarios in which the skill (Rohsenow et al. 1991). Conversely, approaches compared with other may be needed. As with relapse prevention patients who had achieved a compara- approaches. In the multisite Project training, the sessions include instruction tively low education or who had expe- MATCH study, alcoholic patients who in effective coping skills, modeling of rienced relatively high urges or anxiety either had completed inpatient therapy those skills by therapists and group mem- only benefited from communication (i.e., the aftercare sample) or had received bers, behavior rehearsal in role plays with skills training. These findings suggest only outpatient care (i.e., the outpatient feedback, and coaching of responses that compared with cognitive-behavioral sample) were randomly assigned to receive and of cognitive aspects of the response. mood management training, skills train- either cognitive-behavioral therapy (i.e., ing may be useful for a broader range skills training), motivational enhance- Evidence for the Effectiveness of CST of patients. ment therapy, or 12-step facilitation. Measures of patients’ skill levels as This study did not find any differences Several studies have evaluated CST’s determined by standardized tests (e.g., in overall outcome between the three effectiveness in improving patient out- process measures) gathered during treatment approaches among either the come and have compared it with the some of these studies provide further aftercare or the outpatient sample (Project effectiveness of other approaches. Miller information about the mechanisms MATCH Research Group 1997). How- and colleagues (1995), in a comprehensive underlying CST’s beneficial effects. ever, several factors limit the conclusions review of various treatment methodolo- For example, in the study by Chaney that can be drawn from these results: gies, found that several studies supported and colleagues (1978), patients receiv- the effectiveness of social coping-skills ing CST generated longer and more • The cognitive-behavioral approach in training. For example, one study among specific responses in standardized role the Project MATCH study combined alcoholics receiving inpatient treatment plays of high-risk situations (e.g., meet- communication skills training mod- in a Veterans Affairs (VA) hospital ing an old friend who suggests going to ules with cognitive-behavioral mood compared the effectiveness of three a bar) than did patients in the control management training. As described approaches—relapse prevention train- groups. Furthermore, the time it took previously, however, mood manage- ing, a discussion group, and no additional a patient to make any response in these ment training benefits only a limited treatment—all of which were delivered role plays strongly predicted the patient’s number of patients and may thereby in addition to standard inpatient therapy outcome (i.e., duration and frequency reduce the effectiveness of the overall (Chaney et al. 1978). In that study, of relapse). These observations suggest cognitive-behavioral approach. patients who had received relapse pre- that one of the most important results vention training experienced relapses of treatment is that in future high-risk • The three treatment approaches in of significantly lower severity and dura- situations, the patient is able to rapidly Project MATCH were administered tion than did patients in the two con- generate a coping response. only to outpatients (i.e., patients who trol groups. Monti and colleagues (1990) used had less severe alcohol problems) or A second study (also conducted similar measures to determine the mech- to patients who had already success- among alcoholics receiving inpatient anisms underlying treatment effective- fully completed an intensive inpatient treatment in a VA hospital) compared ness. In that study, alcoholics who treatment program. Consequently, the communication skills training, either received communication skills training study allows no conclusions regarding for the alcoholic alone or for both the showed greater improvement in the the effectiveness of these approaches alcoholic and his or her family mem- effectiveness of their responses to stan- when they are administered as a com- bers, with another approach, cognitive- dardized role-play tests, particularly in ponent of (i.e., concurrently with) behavioral mood management training the use of interpersonal strategies, than intensive inpatient or partial hospital- (Monti et al. 1990). Again, the com- did patients receiving mood manage- ization programs. Studies in which munication skills training, regardless ment therapy. Moreover, patients who skills training was administered dur- of whether it involved family members, exhibited more effective skills and ing such intensive programs gener- resulted in less frequent and less intense quicker responses in role plays at the ated more favorable results (Miller et drinking than did the alternative treat- end of treatment drank less over the al. 1995). ment approach. The investigators in that next 6 months than did patients with- study also conducted patient-treatment out these characteristics. Thus, these • Each of the treatment approaches in matching analyses to determine which studies indicate both that CST results Project MATCH was the sole form type of therapy might be most effective in improved coping skills and that a of treatment that the patients received for which type of patient. Those analyses patient’s ability to respond quickly and during the study period. In regular found that patients who had achieved a effectively in role plays of high-risk treatment settings, however, the vari-

110 Alcohol Research & Health Coping-Skills Training and Cue-Exposure Therapy

ous treatment approaches are com- types of models—learning theory models prop. In that study, drinkers who monly administered together with and social learning theory—have been responded more strongly to their favorite other measures as part of a full treat- used to explain the relationship between beverage also performed more poorly if ment program. Thus, skills training alcohol-related cues and relapse to the role play included their favorite bev- along with the other two approaches drinking. erage as a prop than if the same role might be more beneficial if they were Classical learning theory models of play did not include any props. This administered as one component in a alcohol cues and relapse suggest that observation indicates that alcohol cues comprehensive treatment program. environmental cues that were associated can disrupt a drinker’s ability to use with drinking in the past can elicit con- coping skills, suggesting that such cues • No process measures assessing the ditioned responses,2 which in turn may may increase the risk of relapse even in acquisition of skills were collected play a role in precipitating relapse (Niaura drinkers who are otherwise adept at using during the Project MATCH study et al. 1988; Rohsenow et al. 1995). The those skills. Other studies in which period; consequently, researchers exact nature of these responses, however, alcoholics were exposed to alcohol cues cannot determine whether the is still controversial. According to one in a laboratory setting found that those patients actually learned the skills hypothesis, they could be equivalent to cues impeded the alcoholics’ ability to that they were taught. Without such conditioned withdrawal—that is, expo- pay attention to other stimuli (e.g., a measures, it is difficult to determine sure to these cues would make the body certain sound), as indicated by increased whether patient outcomes had not “expect” alcohol and induce withdrawal- reaction times in response to those stim- improved because the patients had like symptoms when the expected alcohol uli (Sayette et al. 1994). These findings learned new skills but those skills is withheld. Alternatively, the cue- suggest that the presence of alcohol cues did not affect outcome or because induced responses could be equivalent may reduce the ability of alcoholics the patients did not attain the nec- to conditioned compensatory responses to utilize their coping skills. Finally, essary skills (i.e., the therapists were (i.e., physiological responses that coun- Rohsenow and colleagues (1994) found ineffective at teaching those skills). teract alcohol’s effects) or conditioned that alcoholics who reacted more strongly Other studies that did include pro- appetitive responses (i.e., responses (i.e., exhibited more salivation and less cess measures of skill acquisition similar to those produced by alcohol attention to the alcohol stimuli) when reported beneficial results from skills itself). Current evidence suggests that exposed to alcohol cues in a laboratory training (e.g., Chaney et al. 1978; cue-induced responses most resemble setting also drank more during followup. Monti et al. 1990). conditioned appetitive responses (Niaura These studies suggest several strategies et al. 1988). for designing more effective treatment • In Project MATCH, the skills training In addition to classical learning theory approaches. For example, treatment was conducted with individual models, social learning theory suggests could be designed to reduce the degree patients. Researchers generally consider that the presence of cues may increase of the reactions alcoholics experience group therapy superior, however, the risk of relapse by increasing the rel- in the presence of cues by repeatedly because it allows for multiple sources evance to the drinker (i.e., salience) of exposing the patients to those cues in a of feedback (Monti et al. 1989). the positive effects of alcohol, which safe environment. As a result of such an Consistent with that hypothesis, stud- can make the drinker want to consume approach, the disruptive effects of alco- ies that conducted skills training in a more alcohol. According to this theory, hol cues on attentional processes and on group setting showed beneficial results alcohol cues also can trigger cognitive the ability to use coping skills should be from that approach (e.g., Chaney et and neurochemical reactions that may reduced. Alternatively, treatments could al. 1978; Monti et al. 1990). undermine a drinker’s ability to use cop- provide alcoholics with practice in using ing skills as well as the drinker’s beliefs coping skills while in the presence of that he or she can effectively use those alcohol cues. Such an approach should skills in the situation (Monti et al. 1995; allow an alcoholic to use his or her coping Cue-Exposure Treatment Niaura et al. 1988). The explanations 2 of both social learning and other learning A conditioned response occurs when a stimulus that elicits a specific response is repeatedly paired Conceptual Overview theory models complement each other. with a neutral stimulus which normally does not Several lines of evidence support the elicit that response. If the neutral stimulus is paired An alcoholic can encounter numerous hypothesis that exposure to alcohol cues frequently enough with the response-inducing stim- alcohol-related cues in his or her envi- can increase the risk for relapse. For ulus, it becomes a conditioned stimulus that now also can elicit the response (which has now become ronment. These cues can include the example, Monti and colleagues (1995) a conditioned response). For example, in the classi- sight and smell of a favorite alcoholic evaluated the reactions of alcoholics in cal experiment of Pavlov’s dog, food served as a beverage; mood states or situations in response to holding and smelling a glass stimulus that elicited a response of salivation. If the which drinking previously occurred; of their favorite alcoholic beverage as dog heard the sound of a bell (i.e., the neutral stim- and people, places, times, and objects well as their performance in a drink- ulus) every time the dog was exposed to food, the sound eventually became a conditioned stimulus that had previously been associated refusal role play that either did or did that also could elicit a conditioned response of sali- with alcohol’s pleasurable effects. Two not involve their favorite beverage as a vation even in the absence of food.

Vol. 23, No. 2, 1999 111 skills more effectively even when experi- sure trials (Rohsenow et al. 1995). For • The patients consumed either one encing a strong reaction to alcohol cues. example, the settings associated with or four double vodkas, depending CET may exert its beneficial effects drinking are highly varied and may be on the treatment day (Hodgson and through two different mechanisms. First, idiosyncratic for individual drinkers. Rankin 1976). learning theory posits that repeated Accordingly, it is difficult to expose presentation of a cue (e.g., the sight of drinkers participating in studies or treat- • The patients only observed and a favorite drink) while preventing the ment to all possible real-life settings sniffed the beverage in some sessions usual response (e.g., drinking) should associated with drinking. To approximate and in other sessions were encour- result in decreasing reactions across ses- the diversity of environmental and aged to drink no more than one sions (i.e., habituation) and possibly emotional cues involved, some CET “double” in different settings (e.g., the permanent loss (i.e., extinction) of approaches use imaginary exposure— the hospital, the patient’s home the elicited response (e.g., salivation or that is, the patient is asked to imagine a while watching television, or a pub) urge) over time. However, such habitu- situation in which drinking has occurred (Rankin 1982). ated reactions are specific to the partic- previously. This approach is particularly ular cues used. Accordingly, the reaction useful for cues or settings that cannot be • The patients, who were experiencing is easily reinstated if the alcoholic is reproduced in treatment sessions, such alcohol-related problems but were not exposed to a different cue (e.g., seeing as fights or the death of a loved one. alcohol dependent, consumed three his or her favorite bar). Second, social Because the sight and smell of alco- standard drinks3 for men and two learning theory suggests that engaging hol, in addition to being a powerful standard drinks for women during in coping skills practice in the presence cue in its own right, is a cue that every each session, then looked at an addi- of alcohol-use cues should increase drinker is exposed to before he or she tional drink while being instructed both the effectiveness of those skills drinks, many CET approaches let the not to drink it. Some of the sessions when in the presence of cues and the patient hold and smell an alcoholic were conducted in a room at the treat- drinker’s beliefs about his or her ability beverage. Some CET approaches—par- ment facility, other sessions were con- to respond skillfully when confronted ticularly those that are based on the ducted (as homework) in the patient’s by similar cues in real-life situations. As idea that the response to be prevented home (Sitharthan et al. 1997). a result of this repeated practice, inter- is heavy drinking and that moderate nal reactions to alcohol cues likely will drinking is acceptable—even go a step Another approach, which was absti- interfere less with the drinker’s ability to further and use the ingestion of a small nence oriented, involved exposure to cues use his or her coping skills in the future. amount of an alcoholic beverage as the with no drinking allowed (Drummond cue (Rohsenow et al. 1995). Thus, the and Glautier 1994). In 40-minute ses- CET Methods choice of alcohol cues to be used is based, sions conducted over 10 days, the patients at least in part, on treatment philosophy were asked to “act out drinking” by Various approaches to CET exist (for (e.g., on whether the treatment goal is picking up, looking at, and smelling a a review, see Rohsenow et al. 1995). abstinence or moderate drinking) and drink and thinking about drinking it. Historically, CET has been based on on the constraints of the setting in which Based on the theory that habituation classical learning models, focusing on the CET is to be conducted (i.e., the extent alone can be beneficial, this approach habituation or extinction of responses to which real-life drinking settings can involved no coping-skills training. (Niaura et al. 1988; Rohsenow et al. 1995). be recreated). Several treatment approaches have According to these models, the patient Various CET approaches have in- combined CET with urge-specific only needs to be exposed repeatedly to volved only cue exposure and were CST. In one such approach, which was alcohol without being allowed to drink designed with a goal of moderate drink- aimed at achieving moderate drinking (i.e., undergo a series of nonreinforced ing (for a detailed review, see Rohsenow patterns, alcoholics received two drinks exposures) in order to prevent the previous et al. 1995). Several of these studies as a priming dose, then either looked at response (i.e., drinking) to those cues. involved alcohol administration to a third drink while being instructed to Social learning theory suggests, however, alcoholic patients. All the studies were resist drinking or imagined being that the chance to practice coping skills in conducted in Great Britain, where this exposed to alcohol and successfully the presence of alcohol cues also may be approach is considered acceptable, refusing the drink (Rankin et al. 1983). an important aspect of CET (Rohsenow although it is not acceptable in the United However, this approach involved only a et al. 1995). Consequently, some CET States. Specific treatment strategies used limited use of coping skills and only approaches have focused primarily on pure in these studies included the following: during imagined alcohol exposure, but exposure to alcohol cues, whereas other not when looking at a real drink. approaches have included coping-skills • The patients sniffed, then tasted, and training in the presence of alcohol cues. then drank 1-ounce drinks of bour- Another variation among different bon while decreasing the size of sips 3A standard drink is defined as 12 ounces of beer or approaches has been the nature of the and increasing the time between sips wine cooler, 5 ounces of wine, or 1.5 ounces of dis- cues that have been used during expo- (Pickens et al. 1973). tilled spirits.

112 Alcohol Research & Health Coping-Skills Training and Cue-Exposure Therapy

A more elaborate approach, com- or more trials involving imaginary expo- alcoholic is actively focusing on the cue bining the learning and practicing of sure are conducted in the same session, (i.e., active exposure) and during all urge-specific coping skills with exposure using similar procedures. In these trials, other parts of the session (i.e., passive to actual alcohol cues and to imagined the patient is asked to imagine being in exposure). Habituation or extinction high-risk situations, has since been one of the high-risk situations identi- processes come into play as a result of developed for alcoholics in abstinence- fied in the Drinking Triggers Interview, exposure without drinking. In addition, oriented treatment programs (Monti et starting with the situation that had alcoholics are taught useful coping skills al. 1993; for a detailed description of received the highest urge rating. After and can practice using those skills while the procedures, see Monti et al. 1995; the patient’s urge has peaked, he or she their urges are elevated, either by alco- Rohsenow et al. 1995). This treatment is asked to continue to imagine being hol exposure or by imagining being in generally involves six or eight individual in the situation and to either “wait out” high-risk situations. or group sessions and can be conducted the urge (first session only) or apply the Social learning theory predicts sev- in both inpatient and outpatient set- coping skill most recently taught. eral results of this approach: tings. The supervision of the treatment A variety of different urge-specific setting ensures that no actual drinking coping skills are taught in the sessions, • Practicing coping skills while experi- occurs. Furthermore, outpatients including the following: encing an urge for alcohol should should stay in the treatment setting for decrease the likelihood that future several hours afterwards to ensure that • Using delay as an active cognitive urges will disrupt the use of coping any lasting reactions are safely handled coping tool—that is, the drinker skills in the real-life environment. by therapists. Before treatment initia- tells himself or herself that the urge tion, the therapist conducts two types will “go away” if he or she just • Alcoholics will experience the bene- of assessment: “waits it out” fits of coping skills because their urges will decrease more rapidly • Cue reactivity assessment, in which • Thinking about the negative conse- when they apply the skills. This the patient holds and smells a glass quences of consuming alcohol in experience should increase both the of his or her usual alcoholic bever- the imagined situation patients’ confidence that they can age while salivation, urge to drink, apply the skills and their expectan- and other responses are measured • Thinking about the positive conse- cies that the urge will decrease if quences of staying sober in the they use the coping skills. • Drinking Triggers Interview, a ques- imagined situation tionnaire used to identify the situations • This procedure should allow treat- in which the patient experiences the • Using urge-reduction imagery ment providers to tailor the coping strongest urges to drink. developed by Marlatt and Gordon skills to be used in high-risk situa- (1985), such as imagining slashing tions to the individual needs of each Each treatment session begins with the urge with a sword patient. Thus, patients are asked to the alcoholic holding a glass of his or try various skills for coping with her usual alcoholic beverage; smelling it, • Using behavioral substitution—that each drinking trigger situation dur- if that will increase the urge; and focus- is, imagining engaging in an alterna- ing treatment and to identify the ing on the aspects of the beverage that tive activity skills that are most effective for each produce the strongest urge. During that particular trigger situation. At the time, the patient reports every change • Using consummatory substitution, end of treatment, each patient then in the level of urge in terms of a 0 to 10 such as consuming favorite foods receives a printed copy of his or her scale. Once the patient’s urge level has and sodas instead of alcohol individualized “tool box” for future peaked (usually after 1 to 5 minutes), one reference. of two events occurs. In the first session, • Employing mastery statements, the patient is asked to continue focusing such as “I am strong; I can get Evidence of the Effectiveness of CET on the beverage to “see what happens to through this without drinking” your urge.” Experience has shown that Few controlled CET studies—that is, the urge generally decreases within 15 • Using pleasant imagery—that is, studies in which researchers compared minutes, an effect that usually is quite imagining escaping to a pleasant place. CET’s effectiveness with that of other different from what the patient had treatment approaches—have been con- expected. In all later sessions, the patient This CET approach incorporates ducted. Two studies assessed CET’s is asked to imagine using the urge-specific both the classical learning theory and effectiveness when drinking was allowed coping strategy that he or she was taught social learning theory aspects. Thus, an during treatment because moderate most recently to reduce the urge. alcohol cue (i.e., the alcoholic beverage) drinking was a treatment goal. Rankin After the part of each session that is present throughout the treatment and colleagues (1983) compared the involves actual beverage exposure, one session, both during times when the effectiveness of actual alcohol cue expo-

Vol. 23, No. 2, 1999 113 sure with that of imaginary alcohol ment only. All patients also received were used—particularly those of think- exposure. The investigators first provided two assessment sessions that included ing about the negative consequences of a small group of patients with two passive exposure to alcohol cues. The drinking and the positive consequences drinks, then either exposed the patients researchers followed the patients for 6 of sobriety—correlated with decreases to an additional drink (i.e., had them months. During the first 3 months of in drinking. These observations suggest look at a drink) or asked them to imag- followup, both patient groups per- that the beneficial effects of the CET ine that they were exposed to, and suc- formed equally well in terms of drink- approach may have resulted in part cessfully refused, an additional drink. ing frequency and severity. During the from the urge-specific skills training In the study, actual alcohol exposure to second 3-month followup period, how- component and provide guidance alcohol cues was more effective than ever, patients who had received CET about which skills might be most use- imaginary exposure and refusal in terms were more likely to remain completely ful. Furthermore, the findings of this of decreasing the alcoholics’ urge to abstinent, experienced more abstinent study underscore that the collection of drink and increasing their self-efficacy. days, and tended to have fewer drinks process measures during controlled However, the investigators did not col- when they drank compared with con- studies is important for guiding the lect any outcome data (e.g., drinking trol patients. Thus, two controlled development of future treatment inter- levels after treatment). studies have demonstrated that CET— ventions and for refining existing ones. More recently, Sitharthan and col- both with and without the inclusion of leagues (1997) compared the effectiveness urge-specific CST—can produce favor- of a CET approach aimed at moderate able treatment outcomes in alcoholics Conclusions drinking with the effectiveness of in terms of reducing drinking severity. cognitive-behavioral training focused Measures of the variables the treat- As the studies reviewed in this article on developing moderate drinking pat- ments were intended to affect (i.e., process indicate, CST has a strong track record terns in drinkers who were not alcohol measures) gathered during the study of improving drinking outcomes when dependent. Moderate drinking in this conducted by Monti and colleagues used in combination with comprehen- study was defined as two drinks for (1993) have shed some light on the sive alcoholism treatment programs. women or three drinks for men per occa- mechanisms that might account for the Thus, CST approaches, regardless of sion. Thus, female patients in the CET aforementioned results. For example, whether they focus on coping with spe- group were allowed to consume two the researchers found that alcoholics in cific high-risk situations or on general drinks and male patients were allowed both the CET group and the control communication skills, have resulted in to consume three drinks before being group showed decreased responses to improved skills and decreased drinking exposed to an additional drink. Patients alcohol cues (i.e., decreased urges to severity. Few controlled trials have eval- who had received the CET approach drink) during treatment, although this uated the effectiveness of CET, how- showed greater reductions in drinking decrease was greater in the CET group ever, although the studies that do exist quantity and frequency than did patients than in the control group. Because urge indicate that CET is a promising who had received cognitive-behavioral levels at the start of treatment by chance approach and should be investigated treatment. had been higher in the CET group further. Moreover, those studies have Two additional controlled studies of than in the control group, however, the demonstrated that although cue exposure CET were conducted in abstinence- researchers do not know whether dif- alone can result in favorable outcomes, oriented programs and therefore did ferences in treatment or differences in the opportunity to practice urge-specific not involve any alcohol consumption. patient characteristics accounted for the coping skills while experiencing cue- In one study, CET (i.e., exposure to differences in urge reduction and treat- induced urges may be particularly alcohol cues) was compared with a ment outcome. Another factor that beneficial. Researchers are currently control treatment involving relaxation influenced treatment outcome was the developing and investigating additional training, both provided in addition subjects’ self-efficacy. Thus, patients approaches for combining skills train- to standard inpatient treatment (Drum- with more confidence in their ability ing with cue exposure, and the results mond and Glautier 1994). In that to cope with high-risk situations at dis- of those investigations should provide study, alcohol-dependent patients who charge drank less during followup than guidance for clinicians in the future. had received CET exhibited less drink- did patients with less confidence. How- Researchers also are investigating the ing severity during followup than did ever, confidence levels increased similarly usefulness of therapy approaches that patients who had received relaxation in both the CET and the control groups. combine CST and CET with pharma- training. Monti and colleagues (1993) also cotherapy involving the medication Monti and colleagues (1993) com- found that patients who had received naltrexone. This medication is one of pared the effectiveness of two therapy CET reported more frequent use of only two agents approved for alcoholism approaches: (1) CET combined with some urge-specific coping skills during treatment and has been shown to urge-specific CST, which was provided followup than did patients who had reduce relapse rates in alcoholics who in addition to standard inpatient treat- received the control therapy. Moreover, are also receiving psychosocial therapy. ment, and (2) standard inpatient treat- the frequency with which these skills Naltrexone acts on brain chemicals

114 Alcohol Research & Health Coping-Skills Training and Cue-Exposure Therapy

involved in mediating alcohol’s pleasur- MARLATT, G.A., AND GORDON, J.R., EDS. Relapse alcohol and smoking relapse. Journal of Abnormal able effects and may thereby reduce a Prevention: Maintenance Strategies in the Treatment of Psychology 97:133–152, 1988. Addictive Behaviors. New York: Guilford Press, 1985. drinker’s desire to consume alcohol. PICKENS, R.; BIGELOW, G.; AND GRIFFITHS, R. An Preliminary results of a recently com- MILLER, W.R.; BROWN, J.M.; SIMPSON, T.L.; experimental approach to treating chronic alcoholism: pleted study have suggested that nal- HANDMAKER, N.S.; BIEN, T.H.; LUCKIE, L.F.; A case study and one-year follow-up. Behaviour trexone treatment can significantly MONTGOMERY, H.A.; HESTER, R.K.; AND TONIGAN, Research and Therapy 11:321–325, 1973. J.S. What works? A methodological analysis of the reduce the number of patients reporting alcohol treatment outcome literature. In: Hester, Project MATCH Research Group. 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