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

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Coping-Skills Training and Cue-Exposure Therapy in the Treatment of Alcoholism Coping-Skills Training and Cue-Exposure Therapy in the Treatment of Alcoholism 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 relapse prevention training, social or communication 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 skill 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 friendships 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 Alcohol Abuse 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
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