Combination pharmacotherapy in alcoholism: a novel treatment approach

Combination pharmacotherapy has proven effective in a number of psychiatric disorders, including depression and schizophrenia. However, compared with other affective disorders, few studies have explored the use of combination therapy in alcoholism, and the majority have been limited to animal models. There is evidence to support a role for combination therapy in alcoholism. For example, several neurochemical systems, including the dopaminergic, serotonergic, and opioidergic, appear to affect alcohol intake. Studies in several different types of alcohol-preferring rats have suggested that coadministration of agents to target more than one of these systems simultaneously may produce beneficial effects on alcohol intake, while avoiding problematic effects, such as alterations in food or water intake. Data from preliminary clinical studies have shown trends toward combination therapy reducing alcohol intake in humans. While such findings are encouraging, they must be explored further in larger, randomized, double-blind trials.     

A community-reinforcement approach to alcoholism

Several theoretical approaches to alcoholism exist. An opérant reinforcement approach was used in the present study to develop a new procedure that rearranged community reinforcers such as the job, family and social relations of the alcoholic such that drinking produced a time-out from a high density of reinforcement. The results showed that the alcoholics who received this Community-Reinforcement counseling drank less, worked more, spent more time with their families and out of institutions than did a matched control group of alcoholics who did not receive these procedures. This new approach appears to be an effective method of reducing alcoholism. An analysis in reinforcement terms is presented of the etiology, epidemiology, and treatment of alcoholism.     

Improvements in the community-reinforcement approach to alcoholism

This study evaluated a modified Community-Reinforcement program for treating alcoholics. The previously tested Community-Reinforcement program included special job. family, social and recreational procedures and was shown to reduce alcoholism. To increase the effectiveness of the program further, the present study incorporated a Buddy system, a daily report procedure, group counseling, and a special social motivation program to ensure the self-administration of Disulfiram (Antabuse). The alcoholics who received the improved Community-Reinforcement program drank less. worked more, spent more time at home and less time institutionalized than did their matched controls who received the standard hospital treatment including Antabuse in the usual manner. These results were stable over a 2-year period. The program appeared even more effective and less time-consuming than the previous program. The present results replicate the effectiveness of the Community-Reinforcement program for reducing alcoholism and indicate the usefulness of the additions to the program.     

Skid-row rescue missions: A religious approach to alcoholism

The focus of this study is on the religious service at which many skid-row rescue missions require attendance to receive benefits. Data were obtained from an observation study of thirty-seven skid-row rescue missions in Los Angeles and Seattle, interviews with ten mission directors, and mission newsletters. The missions use material benefits to attract potential converts. The theme of spiritual conversion is predominant in the mission service (sermons, songs, testimonies). Mission personnel feel they have been called by God, often have backgrounds similar to the people they serve, and view the skid rowers' problems as primarily personal and spiritual. Skid rowers resent the use of religion as bait, view their problems as primarily structural, and use the missions only as a last resort. The missions need to be compared to other alcoholism rehabilitation and religious institutions. A key component to their continued existence is outside Christian supporters.     

A topographical map approach to representing treatment efficacy: a focus on positive psychology interventions

A recent meta-analysis by Bolier et al. indicated that positive psychology interventions have overall small to moderate effects on well-being, but results were quite heterogeneous across intervention trials. Such meta-analytic research helps condense information on the efficacy of a broad psychosocial intervention by averaging across many effects; however, such global averages may provide limited navigational guidance for selecting among specific interventions. Here, we introduce a novel method for displaying qualitative and quantitative information on the efficacy of interventions using a topographical map approach. As an initial prototype for demonstrating this method, we mapped 50 positive psychology interventions targeting well-being (as captured in the Bolier et al. [2013] meta-analysis, [Bolier, L., Haverman, M., Westerhof, G. J., Riper, H., Smit, F., & Bohlmeijer, E. (2013). Positive psychology interventions: A meta-analysis of randomized controlled studies. BMC Public Health, 13, 83]). Each intervention domain/subdomain was mapped according to its average effect size (indexed by vertical elevation), number of studies providing effect sizes (indexed by horizontal area), and therapist/client burden (indexed by shading). The geographical placement of intervention domains/subdomains was determined by their conceptual proximity, allowing viewers to gauge the general conceptual “direction” in which promising intervention effects can be found. The resulting graphical displays revealed several prominent features of the well-being intervention “landscape,” such as more strongly and uniformly positive effects of future-focused interventions (including, goal-pursuit and optimism training) compared to past/present-focused ones.     

A systemic approach to the treatment of depression with only one family member present

The purpose of the present article was to demonstrate a systemic treatment of depression for a 70 year-old woman. In this treatment, other family members were unavailable, but a family therapy systems perspective was used throughout. Results of the demonstration ABAB single case design and two year followup were suggestive of treatment effectiveness in decreasing depression. The need for additional replication of the study was noted.     

Opioid antagonists and alcoholism treatment

The increasing evidence for a neurobiologic basis for alcoholism has spurred the search for pharmacologic agents to treat alcohol abuse. The complex set of symptoms and behaviors that characterizes alcoholism has been linked to dopaminergic and opioid neurotransmitter systems, suggesting that opioid antagonists, such as naltrexone, may alter the positive reinforcement effects and craving involved in alcoholism. Laboratory and clinical investigations of naltrexone have demonstrated the potential for this agent to reduce craving, increase the aversive effects of alcohol, decrease drinking days, and increase abstinence. While naltrexone and other opioid antagonists, such as nalmefene, may be effective components of an alcohol-treatment program, they should only be used in combination with psychosocial interventions, such as support groups and psychotherapy.     

In-home treatment for families in crisis and its supervision: A systemic multi-level approach

The author discusses his experience with a five-phase model which built on congruency at all systemic levels of in-home family treatment and its supervision. Five phases are presented, as well as the group process during supervision. In-home family treatment confronts the family helper with different tasks in each phase of the treatment process and with different expectations within the professional network and the institutional context.The author's work as a supervisor and trainer of in-home family treatment was made possible by Diakonisches Werk Hannover. Grateful acknowledgment is made to Heike Müller, Claudia Eckert, and all their colleagues for their trust and support, to Winiger Beuse for his professional friendship, and most importantly to Dr. Carole Gammer and Prof. Dr. Martin Kirschenbaum for their helpful comments on an earlier version of this paper. Thank you Sandy and Susan. In this article the German expression Sozialpädagogischer/r Familienhelfer/in is translated into family helper. In Hannover, as in many other German cities, family helpers are graduate social workers. Family therapy training is not obligatory but appreciated.     

Family participation in the treatment of alcoholism

The effect of family involvement on the efficacy of alcoholic treatment was investigated. Degree of family involvement, as measured by the participation of the wives of 60 alcoholics in a hospital family lecture series, was compared to recidivism rates and to completion of the in-patient treatment program. The wives' participation was closely related to whether or not their husbands completed in-patient treatment. Participation also appeared to be related to recidivism although additional services in the area of counseling for discharged alcoholic patients and their families are obviously needed.     

Experience-dependent neuropsychological recovery and the treatment of chronic alcoholism

This paper reviews the relationship between cognitive status and treatment outcome in chronic alcoholics, the natural history of recovery, and the role of cognitively oriented remediation programs in facilitating recovery. Seven studies of experience-dependent recovery are described in which behavioral improvement was noted. Various recommendations for treatment over the course of recovery are made, guided by anticipated changes in capacity to process complex information over time.     

Chemical aversion treatment of alcoholism: Lithium as the aversive agent

Animal work indicating flavour aversion produced by chemical aversion therapy (CAT) with lithium might be effective in the treatment of alcoholism led to this treatment being given to 25 patients. The abstinence rate six months later of 36% was significantly better than the 12% rate for an equivalent group of patients, treated with a disulfuram-like drinking deterrent, calcium carbimide. The rate for the CAT group improves to 47% if 8 patients are excluded who did not develop sickness reactions to lithium. CAT with lithium appears safe given proper medical precautions.     

The therapist's responsibility: a systemic approach to mobilizing family creativity

Three techniques, sculpting, geneograms, and family drawing are considered within a systemic approach to therapy. Frequently, emphasis is laid on either the activity of the therapist or the behaviour of the family in treatment. We focus on ways in which the therapist draws on the clients' creativity, relying for this on a correct assessment of their 'language' or 'idiom'. Certain assumptions are proposed, and case illustrations are used in their support. Our approach is that any material, or apparently no material, produced when using these techniques represents essential information which can be turned to therapeutic advantage by means of positive reframing. Although a framework within which to practise is viewed as essential, a 'game-plan' will almost certainly result in sterility and impasses in therapy. Therapist flexibility, it is proposed, is a prerequisite for creativity. We prefer to label resistance to treatment as failure by the therapist to recognize the clients' needs.