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

Alcohol Research & Health, Spring, 1999 by Peter M. Monti, Damaris J. Rohsenow

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, urgespecific 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 examine d 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

In recent years, several exciting advances have provided clinicians with new tools in alcoholism treatment that have resulted in improved outcomes (e.g., lower relapse rates, reduced drinking levels, and improved health status) for alcoholic patients. Two of these new tools are coping-skills training (CST) and cue-exposure treatment (GET). CST aims to enhance the patient's coping skills and provide him or her with specific strategies for coping with the urge to drink. Conversely, GET exposes the patient to alcoholrelated cues (e.g., alcoholic beverages) during therapy, thereby allowing the patient the opportunity to practice using coping skills in response to the urge to drink within the safe environment of a treatment setting. Researchers hypothesize that as a result of coping-skills practice, patients will feel less overwhelmed by urge-provoking situations and, therefore, less likely to relapse after treatment. This article reviews the conceptual bases and methods of CST and GET and also summarizes the resu lts of outcome studies that have assessed the effectiveness of both approaches.

COPING-SKILLS TRAINING

Conceptual Overview

CST and the related treatment approach of social skills training have evolved from several decades of research based on social learning theory. According to social learning theory several factors can increase the likelihood that an alcoholic will relapse when confronted with a stressful situation or with another situation that is associated with a high risk of drinking (e.g., attending a party where alcohol is served). Influential factors include limited skills in coping with stressful or high-risk situations, expectations that alcohol will have a positive or pleasurable effect in these situations (i.e., positive outcome expectancies), and the belief that the person cannot effectively cope with the situation without drinking (i.e., low self-efficacy expectations) (Marlatt and Gordon 1985).

Skills training is designed to address the aforementioned risk factors in several ways. First, clinicians can train patients in using coping skills specific to certain high-risk situations (e.g., refusing drink offers) to improve the patients' skillfulness in handling similar situations in the future. Second, therapists can teach their patients general social skills that will result in improved sober relationships and reduced conflict in both family and work relationships. This improvement in social skills can diminish both the drinkers' stress levels and the number of high-risk situations they encounter while simultaneously increasing their social supports for abstinence. Third, as a result of stronger coping and social skills, patients will likely develop increased self-efficacy expectations and, consequently, be more likely to effectively utilize those skills in high-risk situations.

Several lines of evidence support the importance of skills training for alcoholics. First, studies indicate that alcoholics' coping skills are inferior to the coping skills of nonalcoholics, particularly in situations that commonly pose a risk of relapse, such as a family conflict or parties at which alcohol is served (Monti et al. 1989). Second, the skill levels that patients display in role plays of high-risk situations predict patient outcome after alcoholism treatment. For example, Monti and colleagues (1990) found that patients with low levels of coping skills in role plays consumed more alcohol during their first 6 months after treatment than did patients who had developed strong coping skills. Similarly, low skill levels, as measured by an inventory of coping skills during treatment followup, also predicted relapse during the subsequent 2 months (Miller et al. 1996). Third, alcoholics with low self-efficacy or with a high urge to drink during role plays of high-risk situations drank mote during the 6 months following treatment (Monti et al. 1990) than did their high self-efficacy, low-urge counterparts.