Rethink

A bit of introduction.

Alcohol dependence is one of the most prevalent disorders, often comorbid with other psychological and physical health problems, such as anxiety and depressive disorders. The disorder poses a great burden upon the individual, their family, occupational and social life (Teesson, Degenhardt & Hall, 2003). Alcoholism, to some seems to be a male-dominated problem, let’s rethink this topic.

However, most of the knowledge about alcoholism has been gathered from studies conducted with males only or with predominance of males. Recent research revealed mechanisms that may be contributing to women’s heightened vulnerability to alcohol, e.g. fluid content, weight, smaller liver, fat ratio, estrogens, diminished activity of gastric alcohol dehydrogenase in first-pass metabolism (Copeland, 1993; Frezza et al. 1990; Johnson & Williams, 1985 ; Patwardhan, Desmond, Johnson, & Schenker, 1980) further research revealed not only that role of deprivation may increase a woman’s risk for abusing alcohol (Wilsnack, & Cheloha, 1987) but also that the interval between onset of drinking-related problems and entry into treatment appears to be shorter for women than for men (i.e. ‘telescoping’) (Piazza, Vrbka& Yeager, 1989; Hasin, Grant & Weinflash, 1988). We can clearly see that men and women differ.

Therefore, researchers have begun to examine whether women and men require distinct treatment approaches. It has been suggested that women alcoholics may encounter different conditions that facilitate or discourage their entry into treatment. Concern regarding the problem of alcohol use during pregnancy has brought to the forefront the lack of treatment programs specifically targeted for women and pregnant women particularly (Finkelstein, 1993). Currently different types of treatments are available for women.

Review of available treatments.

Many believe that the road to recovery starts with detoxification of ‘chemically dependent’ individuals, yet as pointed out by Mattick and Hall (1996) detox in its own right is not a treatment, as individuals who had undergone detoxification are equally as likely to relapse as those who have not. It is therefore necessary to follow up detoxification with appropriate treatment (Blondell, 2005). Various forms of treatment are available to deal with the underlying psychological issues that lead to alcohol abuse and addiction, as well as to equip the individuals with new coping skills in order to prevent relapse. The most common treatments nowadays are: counselling, psychotherapy, and group therapy, often accompanied by support groups and medication.

Brief interventions. Brief interventions differ in length, content and style, they are backed up by economic argument of expenses; short therapy is simply cheaper than long-standing intervention. Brief interventions may be carried out in the community by non-specialist personnel, such as GPs, nurses, social workers etc. (Raistrick, Heather & Godfrey, n.d.). This form of intervention includes a plethora of forms, e.g. structured advice, structured one-off therapy session (20-30 minutes) etc. In primary health care, this type of intervention is equally effective among men and women (Ballesteros, Gonzalez-Pinto, Querejeta & Arino, 2004). Brief interventions, in their various forms of delivery appear to be effective in reducing alcohol consumption, on the other hand, ‘booster sessions’ may be required to sustain the effects over a longer period of time; moreover, more research is needed on the longevity of the effects of brief interventions (Raistrick, Heather & Godfrey, n.d.).

Non-intense treatment. A ‘condensed’ for of CBT has been found to be especially effective among female (Sanchez-Craig, Spivak & Davila, 1991). In the study of three brief cognitive-behavioural therapy sessions for problem drinkers, women who reported more physical symptoms at intake had superior treatment outcome than those reporting less physical consequences of heavy drinking (Sanchez-Craig, Spivak & Davila, 1991).

Motivational interviewing (MI) is one of the most popular, less-intense treatment. Mostly appreciated as preparation for intense treatment, MI increases the effectiveness of more extensive psychosocial treatment (Burke, Dunn, Atkins & Phelps, 2004).

Long-term treatment. Those include Motivational Enhancement Therapy (MET), which has been found to be more appropriate than Cognitive Behavioural Therapy (CBT) for patients high in anger. While CBT has been found to be most effective treatment, additionally marital version of CBT is available which is suited for women in long term relationships, even though most research of CMBT has been conducted on male alcoholics and their wives (O’Farrell, 1993; Slattery et al., 1993). Various trainings such as coping, self-control and social skills training appears to be effective as long as clear goals are established and training is tailored to individual needs (Slattery et al., 2003). Moreover it is cost effective. Client-centred counselling is effective but less so than specific structured therapy. Psychological therapy may need to be enhanced by medication.

Psychopharmacological intervention. Improvement in understanding of brain neurobiology led to new pharmacological treatments to assist treatment and relapse prevention. The efficacy of drugs such as acamprosate, naltrexone (an opiate antagonist) and topiramate in preventing relapse and reducing alcohol consumption has been demonstrated in double-blind, placebo-controlled, randomised controlled trials (Johnson et al. 2003; Mason, 2001). However, these drugs have been shown to only work for compliant subjects and only to be more effective than placebo.  Additionally, acamprosate had been shown to only work in individuals who attend support groups, have undergone detoxification, and are abstinent (Chick, Howlett, Morgan & Ritson, 2000; Mason, 2001). Naltrexone has also been found to be effective when combined with CBT and to less extent with motivational enhancement therapy (Raymond et al. 2005). CBT and naltrexone have common mechanisms, such as craving reduction and relapse prevention, and may be the most efficient combination in alcohol dependence treatment.

Criticism and concluswions.

Most of the early research has rarely used appropriate methodological approaches (e.g. randomised controlled trials, objective measures, placebo etc.), an error that the research of the past two decades has corrected. However, many trials of alcohol treatment have low statistical power to detect small or even medium sized effects of treatment at a statistically significant level (Raistrick, Heather & Godfrey, n.d.). Furthermore, as pointed out by the Institute of Medicine (1990), not every single treatment approach is effective for all individuals with alcohol problems, therefore to make meaningful comparisons between different treatments, it is vital for the research trials to test individuals with roughly similar key characteristics, as those individuals are more likely to respond similarly to treatment in general (Raistrick, Heather & Godfrey, n.d.).

The existing treatments have been largely developed by and for men. Little focus has been placed to psychological and physiological differences, and on the context of women’s life which may account for the failure of traditional services to attract women into treatment (Copeland, Hall, Didcott & Biggs, 1993). Research shows that the treatment approach is not as important as treatment settings and context, such as staff and fellow patients (Copeland, Hall, Didcott & Biggs, 1993). Nichols (1985) described potential for discrimination and sexual harassment by male staff and other patients. Providing women-only services, therapists, counsellors and other staff gives women an opportunity to concentrate on their own needs and desires away from their traditional concerns of social approval and the welfare of others (Copeland, Hall, Didcott & Biggs, 1993). Female only treatments should employ empathetic therapist style as previously demonstrated to be especially appropriate for women (Miller, Taylor, & West, 1980). Most importantly treatment should address feelings of guilt and shame surrounding their maternal role and if possible provide childcare during treatment, as women are more likely to seek treatment due to family problems (Gomberg, 1974). Due to different needs women mostly benefit from being treated in a medically oriented alcoholism facility, whereas the abstinence rate was higher for men treated in a peer group-oriented facility.

Photo credit to graur codrin, cheers!

References:

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