Alcohol use disorder (AUD) is a common presentation in clinical practice. Twelve month DSM-5 prevalence rates are similar to mood and anxiety disorders, at 17.6 per cent for men and 10.4 per cent for women (Grant et al., 2015). Mild disorders often remit in young adulthood, but more severe disorders can require long-term management. While many theories of AUD emphasise biological mechanisms for problematic drinking, which are important, there is a rich psychology involved that is sometimes overlooked. Psychological treatments have strong evidence of efficacy (Connor, Haber, & Hall, 2016; Kavanagh, Connor, & Gullo, 2014), but diagnosis and treatment are delayed by an average of around 18 years after onset (Chapman, Slade, Hunt, & Teesson, 2015). This is due, in part, to the stigma attributed to the disorder both by practitioners and people needing treatment (Keyes et al., 2010). An approach that could reduce stigma places AUD along a continuum of symptoms and underlying psychological processes rather than as a dichotomous diagnostic category. In this article, we review some of the key psychological processes involved in alcohol use (and AUD). We then discuss how efficacious psychological treatments that target these processes can be affected by the everyday complexities encountered ‘on the ground’: comorbidity, cognitive impairment during withdrawal and ambivalence toward treatment.
Alcohol and two psychological processes we all engage in
Picture celebrating your next birthday with no alcohol at the party; do you think you would have more fun or less? What about your guests? Would you worry that they would think it unusual that no alcohol is being offered? If so, why? We all have well-established beliefs about alcohol, its effect on us when we drink it (including to excess), including its effect on social functioning. These alcohol outcome expectancies (beliefs people hold about the impact of drinking alcohol) can be verbally represented and reported as “if-then” statements: If I drink alcohol at a party, then I will have more fun; If I am tense after a long day, then drinking alcohol will relax me. However, they are often experienced as images of past or future events or as a sensation of craving when at a party or feeling tense (Kavanagh, Andrade, & May, 2005).
We all hold expectations about alcohol effects just as we do about other things like chocolate or coffee, or effects of activities like physical exercise. Alcohol expectancies are initially formed through vicarious learning – by watching adults and media portrayals –and we begin forming them long before consuming alcohol for the first time; perhaps as young as four years of age (Voogt et al., 2017). As we enter adolescence, the behaviour and opinions of our peers also shape these beliefs. Most Australians consume alcohol for the first time during adolescence, and those with stronger positive expectancies start drinking earlier and transition to binge drinking more quickly. These first-hand experiences with alcohol are coloured by expectancies, but also modify them. The operation of this feedback loop is influenced by genetic (e.g., our physiological response) and environmental (e.g., social approval) factors (Young-Wolff et al., 2015). Our own research has found that individuals higher on the personality trait of reward sensitivity/drive more readily form positive alcohol expectancies, presumably the result of enhanced conditioning effects and a generalised memory bias for rewarding experiences (Gullo, Dawe, Kambouropoulos, Staiger, & Jackson, 2010). People with an AUD tend to hold more intensely positive expectancies (Jones, Corbin, & Fromme, 2001). At the time of treatment entry these expectancies can be quite distorted. In the clinic it is not uncommon to hear a patient or client speak of alcohol as the only thing that can relax them or the only effective means of regulating their mood: Cognitive therapy techniques are often needed to address these beliefs.
People with alcohol problems have also typically developed negative expectancies of drinking. Unfortunately, while these expected outcomes are typically stronger than the expected positive effects (e.g., losing a relationship versus feeling better now), they are also usually more delayed and, as a result, lose affective impact at the time of decision-making. Motivational interviewing helps people to consider the balance of positive and negative expectancies at the one time, and draws attention to the greater personal importance of the negative ones.
As important as expectancies and related craving may often be, they are not the only factors in problem drinking. A second key set of factors involves skills and confidence or self-efficacy (the belief that you can succeed) in controlling drinking (drinking refusal self-efficacy). Intense craving makes it harder to stay in control – as do other situational factors such as our physiological and emotional state, whether alcohol is immediately available, and whether others are making it harder to stay in control. As hard as those things can make it, if we are realistically confident, we can abstain or restrict intake. Refusal self-efficacy is a robust predictor of both the development of problem drinking and of its successful long-term control in AUD (Kadden & Litt, 2011). While self-efficacy is strongly influenced by the outcome of past attempts at drinking control, it is not necessarily an objective assessment of our actual capacity for control. For example, self-efficacy can be undermined by negative moods, and people with alcohol problems who are depressed may need assistance in recalling and acknowledging relevant successes. Conversely, some people with alcohol problems who have never tried to control their consumption may be unrealistically optimistic about their ability to do so, and may need assistance in predicting and preparing for potential challenges. Motivational interviewing helps people to build sufficient self-efficacy to contemplate starting a control attempt, and if they do, to develop a realistic plan.
Thus, a key goal of psychological treatments for AUD is to increase motivation to control drinking, together with related skills and self-efficacy. So, a psychologist may teach craving management skills to increase confidence in drinking control, or may apply cognitive restructuring to exaggerated positive expectancies (e.g., alcohol can relax me, but so can many other activities). If a patient’s alcohol use is primarily motivated by the desire to manage high anxiety or low mood, effectively addressing these symptoms will increase refusal self-efficacy (I can handle my anxiety without needing to drink). The goal is simple, but not so easy to achieve in practice.
Importantly, just as overly positive expectancies of alcohol can emerge very early, discounting of delayed negative effects and situational vulnerability to loss of control may each occur long before problems become obvious. In alcohol use – as with other potentially dysfunctional behaviours – these factors may be important targets for prevention.
Complexity is the rule, rather than the exception
Over a third of people with an AUD also have a comorbid mental disorder, increasing to over half in treatment populations (Regier et al., 1990). Problematic alcohol use and depression frequently co-occur, and presence of either disorder doubles the risk of the second disorder (Boden & Fergusson, 2011; Conner, Pinquart, & Gamble, 2009). While there are few trials on co-occurring alcohol and depression or anxiety, the existing evidence supports the use of fully integrated treatment or of treatment that gives priority to AUD (Baker et al., 2014).
Recent evidence also shows moderate cognitive impairment in alcohol patients across several domains that can persist for up to one year after drinking cessation (Stavro, Pelletier, & Potvin, 2013). We might expect that cognitive impairment would be an indicator for poor response to psychological treatment, but there is no consistent evidence for this (Donovan, Kivlahan, Kadden, & Hill, 2001). When treatment is appropriately adapted to the specific needs of the individual, it is just as effective in those with mild or moderate cognitive impairment as it is for those with no impairment. While severe cognitive impairment does impact treatment outcome – in part because of its tendency to undermine self-efficacy – for most people in need of intervention it is not a significant barrier to positive outcomes from psychological intervention.
A way forward
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Most of the psychological processes involved in AUD are also involved in non-problematic drinking. The differences in these processes between problematic and non-problematic drinking are differences in degree, not in kind. We have previously outlined evidence-based treatment guidance for AUD (Kavanagh, Andrade, May, & Connor, 2014). Finding the best way to apply evidenced-based treatment to the unique individual in front of you remains a challenge.
The preceding discussion highlights some of the complex presentations in AUD where there is less evidence to guide treatment. A thorough case conceptualisation that incorporates the impact of these complexities on psychological processes like expectancies and self-efficacy can be particularly beneficial here providing valuable insights into why that individual is not responding to treatment. For example, continued heavy drinking in the context of high refusal self-efficacy and low negative expectancies might suggest motivational ambivalence. Some components of efficacious treatment should be more effective in addressing this than others; e.g., motivational interviewing, perhaps enhanced with the use of imagery (Kavanagh et al., 2014).
Our emphasis on expectancies and self-efficacy here is not to imply that other psychological processes are not important to AUD. Similarly, it is not to downplay the importance of biological processes either. Rather, our focus is to emphasise the rich psychology involved in AUD and the important role of psychologists in prevention and treatment. Psychologists are ideally placed to conceptualise the complex interaction of biopsychosocial factors on the mental processes involved in alcohol use, AUD and treatment.
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The first author can be contacted at [email protected]