Exposure and response prevention in anxiety disorders: Implications for treatment and relapse prevention in problem drinkers

ClinicalPsychology R&m, Vol. 13, pp. 619-632, Printed in the USA. All rights reserved.

1993 Copyright

0272-7358193 $6.00 + .oo 0 1993 Pergamon Press Ltd.

EXPOSURE AND RESPONSE PREVENTION IN ANXIETY DISORDERS: IMPLICATIONS FOR TREATMENT AND RELAPSE PREVENTION IN PROBLEM DRINKERS Nicole K. Lee Tian P. S. Oei University

of Queensland

ABSTRACT.

Exposuretherapy has been successfully used in the treatmentof a number of disorders not the least of which are in the anxiety area, such as panic disorder with agoraphobia, obsessive-

compulsive disorder, and simple phobias. More recently, these techniques have gained acceptance in the alcohol area, based on the assumption that the learning mechanisms behind both anxiety disorders and addictive drinking are similar in many ways. Promising evidence has been presented in the literature, but generally not adequatelyfollowed up, and studies have failed to concentrate on clinical trials. The procedure is thus still in its infancy with regard to the treatment of problem drinkers. The present article attempts to draw together the parallels between the anxiety and alcohol areas and discusses the potential utilisation of the technique in the alcoholfield; further, it raises some key issues that need to be considered in the implementation offuture research and treatment in the area.

The exposure

principle has been used inadvertently

as a behaviour

ries, but has only recently been accepted into mainstream

behavioural

modifier

for centu-

therapy as a useful

tool in the treatment of a range of psychopathologies (Marks, 1987). The most successful use of the technique has been with phobic and obsessive-compulsive disorders - so much so that it has become the treatment of choice in this area. Yet it is also being accepted in far wider circles, for the treatment

and therapists have begun to incorporate the technique in programmes of other psychological problems. One such expansion in particular has

been in the alcohol dependence area, where some (e.g., Hodgson & Rankin, 1976) have proposed a parallel between anxiety disorders and alcohol dependence, and have suggested that, because of the similarities between the two, the successful use of exposure for anxiety disorders may advocate its effectiveness in the treatment of alcohol-related prob-

Correspondence should be addressed to Tian P. S. Oei, Department of Psychology, University of Queensland, Brisbane QLD 4072, Australia. 619

620

N. K. Lee and T. P. S. Oei

lems and relapse. Within this frame of thinking, problem drinking can be thought of, in a sense, as a compulsive behaviour (Hodgson, 1989) maintained by its negative reinforcing properties. In some ways, it may be analogous to fear, with drinking relieving craving as avoidance does anxiety in phobics (Laberg, 1990). While application of exposure in the treatment of anxiety is now well established and widely accepted, use of this procedure is still in its infancy in the field of alcohol dependence and problem drinking. a treatment for relapse with, the anxiety area. theoretical orientations cal issues that may aid

This article will examine

the application

of cue exposure

are examined; and finally, the implications of these issues and of treatment anxiety for the implementation of the same in the alcohol area are discussed.

EXPOSURE Exposure

as

prevention in problem drinkers by comparison to, and analogy First, a brief review of the current exposure-based treatments and in the anxiety area is presented; second, the theoretical and practior hinder the application of exposure therapy to the alcohol area

THERAPY

FOR ANXIETY

strategies

in

DISORDERS

therapy in the anxiety area has had a great deal of success in terms of reducing

anxiety and avoidance symptoms, and the findings indicate that gains may be maintained 1988). Marks and O’Sullivan (1988) have also for up to 8 years (Marks & O’Sullivan, shown that treatments that omit exposure as a component are not consistently helpful, while a success rate of up to 80% has been recorded for programmes that have used exposure as a major part of treatment. There are four main forms of exposure therapy currently in use-systematic desensitisation, graded exposure, flooding, and participant modelling. Although the different disorders under the classification of “anxiety” tend to favour one method of treatment over another-for example, systematic desensitisation appears to be most frequently used for simple phobias, while the treatment of choice for obsessive-compulsives is flooding and response prevention - it appears that the important element of treatment is controlled exposure, per se, rather than the type of exposure (Rachman, 1990). Generally, these exposure treatments focus on the anxiety-provoking stimuli whilst preventing avoidance or escape behaviour in order to extinguish the aversive response. In therapy, the client is exposed, either gradually or at full intensity, to the stimuli which are thought to cause the maladaptive response until any aversive response has subsided to a predetermined, usually baseline, measure (Martin & Pear, 1988). A return to baseline anxiety is agreed to be an essential component of successful treatment (Marks, 1987). The exposure treatment programme follows a similar procedure for all methods (Thyer, Baum, & Reid, 1988). First, a behavioural assessment is performed by interview and/or direct observation to establish parameters of the fear-evoking stimulus and the nature of the fear itself; for example, with a dog phobia, specific details need to be obtained about the size, shape, breed(s), and colour of the feared stimulus, as well as whether the fear is of being bitten, jumped on, licked, barked at, and so on. Other information would include specific situations in which the stimulus is able to provoke maximum, minimal, and no fear. Second, some cognitive intervention may be appropriate if the fear is based on erroneous beliefs; at least some sort of explanation of the disorder and the rationale behind the programme is required. Finally, the therapist and client develop a number of fear-evoking situations, often in a graded hierarchy, which are then used for exposure. The therapist’s role is to guide the exposure and encourage the client to desist in avoidance behaviour-even subtle behaviours such as avoidant eye contact and fidgeting. the literature.

The procedure

may become

clearer

with a recent example

from

Relapse Prevention

t&t, Salkovskis, and Hellstrom compared with therapist-directed

621

(199 1) .investigated the relative efficacy of self-exposure exposure in 34 spider phobics. Subjects were randomly

assigned to one of the two conditions. Based on self-report, behavioural, and clinicians’ ratings, therapist-directed exposure was found to be significantly better than self-directed exposure at both posttreatment and one-year follow-up. The method involved a detailed rationale for the procedure and an explanation of the concepts of habituation, stimuluscontrol, and self-control hierarchy, first catching

prior to exposure. Exposure was then implemented as a graded the spider in a glass, then chasing it around the glass with one

finger, then allowing the spider to crawl over hands and arms. Each step was first modelled by the therapist, and repeated with four to five spiders of increasing size. The therapist was continually emphasising how the patient was able to control and predict the behaviour of the spider throughout the exposure. This study is not only a clear example of the exposure procedure in the anxiety field, but also demonstrates the potential usefulness of secondary approaches, such as cognitive intervention, and the recently popular integration of more than one exposure method in a treatment (in this case, graded exposure and participant modelling). Mehta (1990) has in also commented on this latter point, noting that use of systematic desensitisation conjunction with exposure and response prevention produced more reliable results, as exposure, per se, in the initial stages of therapy was often not well accepted by his patients. Further, in a review of the recent obsessive-compulsive literature, Cooper (1990) found that the most popular treatment consisted of modelling, exposure, and response prevention, with a success rate of around 75 70. The actual mechanisms behind both the treatment effects of exposure

therapy and the

acquisition of the fear itself have so far been somewhat elusive (Rachman, 1990). Thyer et al. (1988) note that it is generally accepted that the successful use of the therapy is based on the learning experience of the client, but a specific theoretical explanation of the learning mechanisms involved has not been coherently explained. Likewise, Rachman (1990) notes that there are a number of explanations that have been put forward, but all have their associated problems. These include reciprocal inhibition (i.e., the substitution of anxiety with an anxiety inhibitor), habituation, and extinction. In terms of the acquisition of the fear itself, an interesting explanation has been put forward by Thyer et al. (1988). They draw an analogy between infrahuman and human studies of fear and suggest that the confusion surrounding human mechanisms of anxiety is a lack of reliable information about the fear history. Similar findings in the two areas might lead one to apply the explanations of animal avoidance learning (i.e., that fear is initiated as a result of a traumatic event and maintained by reinforcement contingencies), since the conditioning history of the latter is known. In fact, based on a review of the literature, and work of their own, they have found that extinctions of operant fear and avoidance behaviours in laboratory animals and humans were highly similar, if not identical, leading them to conclude that the parsimonious learning theory might be an adequate explanation of fear acquisition.

CUE EXPOSURE

IN ALCOHOLICS

In a similar vein to theorising in the anxiety area, the application of cue exposure treatments in the alcohol area is based on the assumption that craving is, at least in part, a behavioural response that has been classically conditioned to internal and environmental stimuli related to the drug-taking situation. The effects of conditioning to these stimuli are thought to remain after detoxification, making it a substantial contributor to relapse (Heather & Greeley, 1990); and, in fact, anecdotal and case study reports (e.g., Wikler,

622

N. K. Lee and T. P. S. Oei

1965) suggest that relapse often occurs even after detoxification and sometimes years without alcohol, ruling out a physiological explanation for drinking. The underlying assumption is that the behaviours in question are maintained by reinforcement contingencies, so that the treatment process involves exposing the client to the conditioned cues while withholding reinforcement by response prevention (Kazdin, 1989). Like the twofactor theory of avoidance learning in anxiety patients (Marks, 1987), where avoidance maintains the fear by positive reinforcement contingencies involving relief from anxiety, current

theorising

suggests that, in a broad sense, drinking

is a means of avoiding

the

craving (possibly related to withdrawal symptoms) that certain stimuli evoke (Young & Oei, 1990). Ideally, the behaviour will be extinguished when the reinforcing consequences of drinking (i.e., relief from craving) no longer occur. Unfortunately, exposure therapy

however, very little work has been done on the implementation of to clinical populations of problem drinkers so far, possibly because

of the uncertainty

regarding

the theoretical

mechanisms

behind the procedure.

Analysis

of these issues may thus be appropriate at this point in order to examine the unanswered questions hindering further application of such a potentially successful treatment.

THEORETICAL Three Competing

ISSUES IN CUE EXPOSURE

FOR ALCOHOLICS

Models of Relapse

There are three main competing theories of the mechanisms involved in the conditioning process, which have slightly different implications for the conditioned response. Wikler (1965) proposed that interoceptive and extroceptive stimuli that have been repeatedly associated with physiological withdrawal become conditioned stimuli (CSs) for withdrawal, the conditioned response (CR). After repeated pairings between these stimuli and episodes of withdrawal, the CSs acquire the capacity to produce withdrawal-like symptoms (CR), even in the absence of physiological withdrawal from the drug. From experience, alleviation of withdrawal has been achieved by drug taking; therefore, the CSs or cues elicit an aversive CR and provide the motivation for drug taking. Thus, aversive CRs to cues act as discriminative

stimuli for operant drinking behaviour

(Drum-

mond, Cooper, & Glautier, 1990). Although animal studies have demonstrated that withdrawal can be conditioned to certain stimuli and that these stimuli are able to elicit the conditioned

craving response (e.g.,

Goldberg,

1976), there is little direct evidence to

support the main prediction of this model that craving would occur in situations previously associated with withdrawal (Heather & Greeley, 1990; Niaura et al., 1988); in fact, anecdotal and clinical reports suggest that craving is more likely to be associated with drug taking than drug withdrawal. Siegel and his associates (Poulos, Hinson, & Siegel, 1981; Siegel, 1983) have proposed a compensatory response model that is better able to account for research findings. Stimuli that have been associated with drug-taking behaviour are eventually able to elicit withdrawal-like symptoms which motivate further drug-taking behaviour. Rather than being associated with withdrawal symptoms, however, the cues are associated with actual drug-taking behaviour. When these cues are presented, the body compensates or prepares for the anticipated drug effects in the interest of homeostasis within the body, and withdrawal symptoms result (Poulos & Cappell, 1991). This theory has the advantage of being able to account for tolerance-that is, if craving resulting from these conditioned withdrawal symptoms is satisfied, then a larger compensation will occur next time and a larger drug dose will be needed to produce

the same effects.

This,

then, accounts

for reports of conditioned

623

Relapse Prevention

craving in drug-related

rather than withdrawal-related

contexts.

this and Wikler’s model basically lies in the temporal relationship

The difference

between

between the CS and the

unconditioned stimulus (UC%). Finally, Stewart, DeWit, and Eikelboom (1984) h ave suggested a theory of conditioned craving that is, in some ways, diametrically different than the other two. According to this model, drug taking behaviour is initiated and maintained by a positive motivational state and, after repeated pairings, the motivational state becomes the CR serving to activate drug-related thoughts and motivate drug-seeking behaviour. Withdrawal states may be conditioned to some cues, but these do not serve as initiators of relapse. They also suggest that central to the direction of the CR is the site of action of the drug, so that antagonistic responses are produced when the drug acts on the efferent arm, and agonistic responses when on the afferent. Thus, this model has the advantage of being able to explain relapse when either drug-like or drug-opposite effects are elicited by relevant cues (Heather & Greeley, 1990). Despite the controversy over the direction

of the conditioned

response

(which,

in any

case, appears to depend upon which response is measured [Eikelboom & Stewart, 1982]), all theoretical models suggest that extinction procedures be applied for successful treatment, based on the assumption that the essential component of relapse is the reactivity to certain cues which then elicit conditioned craving. There now exists a sizeable body of evidence showing that drinkers do indeed display reactivity to alcohol-related cuesphysiologically, behaviourally, and subjectively. Walitzer and Sher (1990), for example, found that clinical subjects reported an increased desire to drink and consumed more per sip after cue exposure. In addition, Laberg and Ellertsen (1987) used a priming dose paradigm with detoxified alcoholics, where the priming dose acted as a salient cue for continued drinking. They found that, generally, those given the priming dose before exposure showed larger subjective and physiological arousal throughout the study than nonprimed subjects. Importantly, physiological arousal in all groups showed a decrease with exposure over the six sessions as well as within each session. These findings confirm that responses do occur to drug-related stimuli and that these responses show an extinction pattern within and across exposure sessions. Specific implications follow from these findings that may further support the conditioning

position.

First, alcohol-dependent individuals should show greater reactivity to alcohol-related cues than normals. Cooney, Baker, Gillespie, and Kaplan (1987) have presented evidence to confirm this. They found that problem drinkers showed increased physical and cognitive reactivity to cues (such as increased guilt and decreased confidence about coping with temptation) compared to normal controls. In addition, Kaplan, Meyer, and Stroebel (1983) found that, in a comparison of normals and problem drinkers randomly assigned to either an alcohol or placebo condition, as well as physiological arousal. Presumably,

if dependence

problem

drinkers

is truly on a continuum

reported

(Edwards

increased

& Gross,

cravings

1976),

it will

also be the case that in the normal population, heavier drinkers will show greater reactivity to cues than light drinkers. Greeley, Swift, Prescott, and Heather (in press) measured physiological responding (heart rate, skin conductance, blood pressure) and self-reported cravings for alcohol in heavy (> 28 standard drinks per week) and light drinkers when exposed to their preferred beverage and a neutral cue. Heavy drinkers reported an increased desire to drink in the presence of the alcohol cue, while light drinkers showed an initial increase with a decrease over time. Heavy drinkers also showed a lower skin conductance than light drinkers. Both showed heart rate changes during exposure. Secondly,

alcohol-dependent

subjects

should show greater reactivity

to alcohol-related

624

N. K. Lee and T. P. S. Oez

stimuli than nonrelated

stimuli.

Ericksen

and Gottestam

(1984)

have provided evidence

to support this. They presented alcohol-related slides (as the CS) to abstinent alcoholics and found increased subjective craving and behavioural changes, such as heightened tension. Laberg and Ellertsen (1987) also found evidence to suggest an increase in autonomic arousal for the primed group as compared to nonprimed controls. The Role of Conditioned

Craving in Relapse

Although reactivity to cues appears to be a fairly robust phenomenon, its actual relationship to relapse is a separate matter. In order to justify the use of exposure therapy in the treatment situation, it is necessary to first show that reactivity to cues has a role as a determinant of relapse. Generally, evidence to support the role of conditioned craving in relapse has been presented in an anecdotal fashion, and by far the majority has been in the opiate area (e.g., Childress, McLellan, &O’Brien, 1985). These studies have reported that up to half of their subjects are able to specify situations that inevitably lead to craving and relapse, indicating a direct link between reactivity to cues and relapse. In addition, clinical studies of cue reactivity in problem drinkers that have measured reactivity

before,

during,

and after exposure,

as well as relapse at follow-up,

have gener-

ally found that subjective and physiological responding to cues during treatment are predictive of abstinence or relapse at follow-up. Kennedy (1971), for example, found that diagnosed alcoholics who exhibited pupillary dilation in response to alcohol cues were more likely to relapse at 3-month follow-up. Evidence thus tends to point to a leading role of reactivity to cues (in terms of conditioned craving) in the relapse of problem drinkers after detoxification. Operant

Versus Classical Conditioning

Although the justification of exposure treatment is based largely on the ideas of classical conditioning (i.e., learning from events independent of an organism’s behaviour), Drummond et al. (1990) have suggested that making a distinction between this and operant conditioning (i.e., learning from events which are a direct consequence of the organism’s behaviour) may be useful in terms of intervention. The relationship is a complex one, and has been difficult to define (Drummond et al., 1990), but a two-process model recently reviewed by Oei and Baldwin (1993) p rovides an interesting angle on the interaction of the two types of learning and implications for treatment. In short, the theory proposes that operant, conscious decision-making

processes in the

course of learning are salient only at the acquisition stage of drinking behaviour. As the decision to drink is made more frequently, for whatever reason, the process becomes, in effect, automatic and subject to the principles of classical conditioning. In the first phase, there which (e.g., as the

is a clear distinction between stimulus (S), response (R), and consequences (C), is consciously mediated by cognitive processes involved in the decision to drink alcohol expectancies). By the second stage, when classical conditioning has evolved main determinant of drinking, the S-R-C link is no longer controlled by a conscious

decision to drink, and the links become undefined and automatic. Treatment implications of this theory are potentially huge and may be able to explain high relapse rates and less than impressive treatment success in the area of problem drinkingfor example, cognitive strategies such as modification of alcohol-related expectancies may be ineffective by the time drinking has reached problem status (i.e., the classical conditioning stage), yet behavioural treatments such as exposure may not completely resolve the drinking problem, since they only target the second stage. Oei and Baldwin (1993) suggest that the automatic cycle that has developed by the

625

Relapse Prevention

second phase may be “broken” by cognitive Here the client is given the knowledge

strategies

involving

of the conditioning

“consciousness

raising.”

process involved in order to be

able to identify the internal and external states which lead to drinking, and once again to make a conscious decision to drink or not to drink. It seems likely, however, that a number of other strategies may be able to break the link, the most obvious being exposure therapy, since its basis is in the classical conditioning paradigm which is thought to be in operation in this phase. Thus, therapy for problem drinkers may well be better implemented in a combined programme involving exposure in the initial stages of treatment and a number of cognitive-behavioural strategies later. The theory itself is coherent and intuitive, and while it is generally presented in the cognitive-behaviour~ framework of the alcohol expectancy treatments

literature,

it appears

to be equally

applicable

to exposure-based

and, as such, warrants further attention.

The Rofe of Cognitive

Variables

In recent times there has been a general

shift in psychology

from the traditional

behav-

ioural explanations of drinking to incorporate more cognitive aspects, and the area of alcohol research proves to be no exception. Several authors (e.g., Laberg & Ellertsen, 1987) have suggested that the traditional classically conditioned responses in question here may also interact in some way with other variables,

such as some (as yet unspecified)

cognitive set. Both Hodgson (1989) and Blakey and Baker (1980) suggest that exposure in treatment can assist in at least three ways. The first, of course, is the extinction of conditioned craving, on which the procedure was initially based. The second is the rehearsal of self-control to build self-efficacy and coping strategies to resist drinking when confronted

with alcohol.

The third is the alteration

of expectations

about the outcome

of

drinking that precipitate uncontrolled drinking. Both outcome and efficacy expectations are thought to develop at least as early as adolescence and probably by childhood from a variety of learning sources, particularly modelling and vicarious learning (Christiansen & Goldman, 1983; Christiansen, Smith, Roehling, & Goldman, 1989). These cognitive variables have been found to substantially relate to a range of drinking behaviours (Goldman, Brown, & Christiansen, 1987; Goldman, Brown, Christiansen, & Smith, 1991; Oei & Pacey, 1988; Rather & Sherman, 1989). Efficacy expectations are said to be beliefs about one’s potential to achieve a desired outcome-regardless of actual ability. In the alcohol field self-efficacy expectations are, more specifically, how sure a person is that he or she could resist drinking alcohol (Lee & Oei, 1993; Young, Oei, & Crook, 1991), particularly in high risk situations for relapse (e.g., at a party); and for this reason may be better termed drinking refusal self-efficacy (Lee & Oei, 1993). When a person’s drinking refusal self-efficacy is high, then resisting the temptation to drink will be easier; if, however, the drinker feels that he is unable to resist drinking when faced with alcohol, then he is more likely to relapse to uncontrolled drinking. Empirical evidence in the area has been sparse but consistent. Studies from both smoking and drinking literature have shown that self-efficacy may be predictive of drinking behaviour; for example, Heather, Rollnick, and Winton (1983) have shown that beliefs about personal drinking problems were directly related to relapse after treatment. Also, Solomon and Annis (1990) found that self-efficacy was predictive of consumption in a group of male alcoholics at posttreatment follow-up. It is quite possible that exposure therapy aids in modifying these self-efficacy expectations by rehearsing resistance in high risk situations and showing patients that they are able to resist drinking. Expectancies about the outcome of drinking have been found to be related to the initiation, maintenance, and acceleration of drinking (Goldman et al., 1987; Oei &Jones,

626

N. K. Lee and T. P. S. Oet

1986; Oei, Lim, &Young, 1989). Changes behaviour (Oei,

1991), as well as playing a role in relapse (Rather

& Sherman,

in expectancies have also been found to relate to changes in drinking Foley, & Young, 1990). By exposure to high risk situations, such as the

sight/smell/taste of alcohol within a controlled environment, a patient may be able to change his/her expectations about drinking. In this sense, outcome expectations might refer more to beliefs about results of ceasing to drink rather than the results of drinking itself. Hodgson (1989) gives an example of one of his alcoholic patients who feared withdrawal if he stopped after drinking four single vodkas, and so he continued to drink to prevent the experience. In the hospital environment he was allowed to drink (exposure to the physical cues of the alcohol) but made to stop after four vodkas, and his expectations were able to be changed when minimal withdrawal occurred. Marlatt (1978) has, in fact, presented a theoretical model where these two constructs are the primary precipitants of drinking and relapse, and the fact that it is possible for a severely dependent individual to resist drinking and achieve abstinence (Heather & Greeley, 1990) in the presence of conditioned stimuli is an indication that another set of variables, such as these, is needed to fully account for relapse. However, although many concede that these variables do play an active part in drinking behaviour, Heather and Stallard (1989) have suggested that the Marlatt model may underestimate the importance of conditioned craving in the relapse process. They propose that perhaps cognitive variables may actually be acting as a conditioned stimulus in the learning paradigm, rather than as precipitants of drinking, per se. In this way, the two seemingly competing ideas of relapse may be unified.

TREATMENT STUDIES Laberg

(1990)

has rightly noted that the mere demonstration

of conditioning

to alcohol-

related cues, which provide support for the role of conditioned craving and reactivity to alcohol-related cues in problem drinkers, does not establish these stimuli in a causal relationship with drinking practices. Drummond et al. (1990) have likewise concluded that the studies to date that have provided evidence to support the theoretical models have not been able to demonstrate a causal link between CSs and relapse. This is not to say that exposure therapy may not be a viable treatment method, nor that therapy should be halted until research has produced more conclusive findings. Successful use in therapy may in itself provide some indication of the mechanisms behind exposure, as has often been the case in the anxiety area, and the two-theory and therapy-should be developing in parallel. Unlike the anxiety area, however, treatment studies in the alcohol area are unfortunately few and far between. Two studies, in particular, have used the exposure paradigm in the anxiety

area quite effectively.

Both are alcohol treatment

case studies and have

implemented the exposure procedure in a similar way to that usually employed in the anxiety area. Their success provides evidence of a link between the treatment of anxiety and alcohol problems and, thus, predicts an encouraging future for exposure techniques in the treatment of alcohol dependence. One of the earliest demonstrations of cue exposure in therapy came from Hodgson and Rankin (1976), in the description of a case of a 43-year-old male alcoholic who had twice received traditional abstinence-oriented in-patient hospital treatment but had each time relapsed within a month of discharge. They identified several cues, the most salient being the taste of alcohol (one double was able to elicit strong desire for further drinking), and used a priming dose paradigm with response prevention (no more drinking) as the exposure treatment. Clear extinction, in terms of desire for drink and expected aversive

627

Relapse Prevention

consequences, was noted within and across sessions. At &month follow-up, the subject reported feeling in control of his drinking, and although he lapsed into drinking on six occasions, it was not continuous and abstinence was quickly regained. This study primarily indicates that, although exposure therapy in itself may not be sufficient for relapse prevention, it could play an important part in a more comprehensive treatment package. Second, Blakey and Baker (1980) used a series of rather encompassing treatment case studies to support the efficacy of cue exposure in alcoholics and to show the importance of a well-rounded approach to treatment. Six referred patients participated in the study with the assistance of relatives in some cases. A behavioural assessment was first performed identifying possible antecedents, behaviours, and consequences associated with the patients’ drinking; these were used to develop an individualised exposure programme for each patient. For example, if a pub was identified as a salient antecedent to drinking, treatment might include being in that pub and either not drinking or drinking nonalcoholic beverages. This appears to be in contrast with other studies, particularly experimental investigations that have tended to assume that the most salient cue for drinking for all subjects was the sight/smell/taste of alcohol itself. Indeed this may possibly explain their lack of success. In addition to the response prevention paradigm, any behavioural gains (e.g., signs of self-control, completion of a given task) were socially reinforced, and other behavioural techniques (e.g., role playing for high risk situations) were also used. Results were very encouraging-most patients gave up drinking altogether by the end of treatment (the self-set goal was abstinence), and those that did not managed to maintain a schedule of controlled drinking. Successes had been maintained at O-9 months posttreatment. In addition, there was a change in cognitions, in terms of self-reported desire to drink, where patients lacked strong desire to drink. for the integration of cue exposure into mainstream

This study provides initial hope treatment programmes, but was

unfortunately not supported by a lengthy follow-up or further experimental work, making conclusive statements about its success inappropriate. It appears from these case studies that exposure therapy has a promising role in the future treatment of problem drinkers. There are several issues raised in the alcohol and the anxiety literature, clinical application.

however,

that need to be considered

CLINICAL ISSUES IN EXPOSURE

THERAPY

in both future research

and

FOR ALCOHOLICS

The Identification of the CR and the CS It appears

from the theoretical

models

of conditioned

craving,

and from the obvious

complexity of drinking behaviour itself, that there may be some difficulty in defining the CR; indeed, it is on this point that the three competing models of relapse in alcoholics cannot agree: Wikler (1965) and Siegel (1983) both suggest that the CR is conditioned craving which is the opposite effect to the alcohol effects (i.e., something akin to, if not actually, withdrawal), while Stewart et al. (1984) believe that the CR is a positive motivations factor and thus in the same direction as the effects of the alcohol itself. In addition, both Wikler and Stewart et al. agree that there may be CRs that are both counterdirectional and isodirectional to the alcohol effects, but those which are relevant or irrelevant to relapse are the point of dispute (Niaura et al., 1988). There is, in fact, evidence to support CRs in both the same and opposite direction but there is little indication of the salience of each for relapse.

as the effects of alcohol,

Some (e.g., Ileather & Greeley, 1990) have suggested that these differences might not be as important as one might expect; rather, the common implication for treatment (i.e.,

628

N. K. Lee and T. P. S. Oei

extinction) may be sufficient for its viable use. Drummond et al. (1990), however, have noted that the direction of the CR may be important in terms of identifying the operant response and that extinction CR is aversive or appetitive,

could have unpredictable results depending on whether the and also how this is related to the operant response.

All conditioning models imply that factors that normally affect conditioned responses such as the number of conditioning trials, reinforcement contingencies, timing between the CS and the reinforcer, and similarity of CSs to stimuli in original learning trials-are also in operation here. Thus, knowledge of drinking history with respect to these details may also be important in deriving a successful treatment plan. Regardless of the theoretical battles over the direction of the CR,

however,

a more

important, and fairly obvious concern in exposure therapy is the identification of the conditioned stimuli or cue(s) which elicit the response (Laberg, 1990), as well as the conditioned reinforcers to that cue or cues that have maintained the behaviour. All models agree that there are a large number of antecedent stimuli conditions, both internal and external, that may elicit the CR. These include the physical including initial drug effects, the specific drinking environment,

properties of alcohol, and other associated

paraphernalia (e.g., bottles, glasses, the bar itself). Several case studies (see Niaura et al., 1988) have found that the physical properties of the alcohol can, indeed, elicit the CR-these include the taste, sight, and smell of the alcohol. Intuitively, one would expect that the cue that would elicit the most craving would be most effective in the extinction procedure. Laberg (1990) has raised the important issue of what constitutes the most salient cue (e.g., preferred vs. most used beverage) and which interaction of cues will produce the maximum, or at least sufficient, amount of conditioned craving to initiate uncontrolled drinking. Marlatt (1990) notes that, generally, exposure methods utilise cues that are most often related to the actual ingestion of alcohol (e.g.,

sight/smell/taste

such as mood states (Cooney particular situations or people,

of alcohol), although some have suggested that variables & Brown, 1991), et al., 1987), personality (McCusker

and general social climate may also 1990; Marlatt, 1990; Marlatt & situations for drinking (Laberg, addition, Marlatt suggests that the same physical cues may elicit depending on context-for example, the smell of beer may induce party but not during exercise.

Thus,

exposure

treatments

represent high risk Gordon, 1985). In differential craving strong craving at a

that are able to take situational

cues into account may be more effective as a clinical tool. The Method and Length of Exposure Based on current

theorising,

may be of greater importance

it appears that exposure than the particular

and response

mode of exposure

prevention, in treatment-it

per se, has

been found that, for anxiety-related disorders, regardless of method, the most crucial element in treatment is the exposure itself (Rachman, 1990). Taking into account extraneous variables, such as therapist characteristics, client motivation, and severity of the disorder, all exposure methods are thought to be effective, although in vivo treatments have consistently been found to be most effective. Indeed, this appears to be the case for cue exposure for alcoholics as well. Rankin, Hodgson, and Stockwell (1983) compared imaginal to in vivo exposure in alcoholics using the priming dose paradigm. Subjects were given two drinks and asked to resist the third under tempting (high risk) conditions. Exposure graduated from staring at the beverage for 3 min, to holding the glass at arms length for 3 min, to holding the glass near the mouth and intermittently sniffing for 3 min. In this study, imaginal exposure was compared to in vivo exposure. They found that consumption time for the initial two

629

Relapse Prevention

drinks increased-that more

is, they took longer

so for the in vivo group.

Subjects

to consume in the latter

the drinks-in group

all groups,

also reported

and

increased

confidence to cope with high risk situations. Black and Bruce (1989) have also found that, in the anxiety area, use of response prevention constitutes a major part of treatment success, and generally, the most effective treatments involve response prevention (Marks, 1987). Indeed, the favoured exposure treatments in the alcohol area also utilise response prevention techniques. Since it appears that, for anxiety-related disorders, exposure per se, and not the mode of exposure, is generally responsible for treatment success, of possibly greater importance in treatment is the length of exposure. Early animal studies and subsequent investigations in the clinical population have confirmed its essential role in therapy (Baum, 1988). Black and Bruce (1989) note that exposure of at least 80 min in conjunction with a strict, not tolerant, therapist is associated with better outcomes, and Marks (1987) has found that not only long but also frequently spaced exposure programmes tend to have a higher success rate. There has been a paucity of research into this aspect of exposure therapy in the alcohol literature, and a great deal more is needed to determine whether principles of exposure in anxiety disorders, in terms of method and length of exposure, sure for the prevention of relapse in alcoholics.

will generalise

to expo-

The Use of Cognitive Interventions General cognitive interventions are sometimes implemented disorders-for example, cognitive restructuring, paradoxical

in the treatment of phobic intention and coping self-

statement trainingbut to what extent these variables contribute to treatment success is still unclear. At least, maladaptive cognitions could be interfering with full participation in the exposure treatment,

and modification

of these may allow more effective treatment.

More particularly, Mattick and Peters (1988) h ave found that at posttreatment combined exposure and cognitive restructuring in social phobics was more effective than exposure alone, but Barlow (1988) has presented evidence to suggest that not only do cognitive strategies add very little to exposure based treatments, but they also have, in some cases, been found to inhibit progress. Further, he suggests that although cognitive changes do appear to occur during treatment, deliberate techniques of cognitive restructuring do not appear to be the instigators of these changes. However, the reason for such unsuccessful attempts at cognitive intervention may be due to the timing of the treatment rather than the interventions, per se. Assuming the implications of the two-process model (Oei & Baldwin, 1993) mentioned earlier, it is possible that the major benefit of the modification of cognitions (such as alcohol expectancies and drinking refusal self-efIicacy) may not be in conjunction with exposure treatments, but rather as an adjunct to them in the later stages, or even as a postextinction treatment. It also appears that the clients’ knowledge of the processes involved in both the disorder and the extinction procedure (e.g., pointing out to the client that aversive consequences that are believed to result from the stimulus are not forthcoming} may be of some help in therapy (Thyer et al., 1988). These have been consistently used in the treatment of both anxiety and problem drinking.

The Use of Other Behavioural Interventions Depending on the nature of the disorder, behavioural treatments, apart from exposure, are sometimes implemented in anxiety treatments - for example, assertiveness training is often considered essential for social phobics and relaxation is incorporated as a matter of course in programmes using systematic desensitisation. There has been little research to

630

N. K. Lee and T. P. S. Oet

investigate the benefit that these treatments add to exposure, but they have been found, at times, to be moderately successful in their own right and may contribute in some way to exposure-based treatments. In the alcohol area, relaxation training has been used in the past, based on the assumption that anxiety may trigger relapse (Childress et al., 1985) -indeed, exposure is based, in part, on the assumption that drinking is avoidance of anxiety caused by craving/withdrawal-and several studies have shown reduced anxiety and reduced consumption after use of progressive relaxation (Marlatt & Marques, 1977; Parker, Gilbert, &Thompson, 1978). Likewise, deficits in coping skills and self-efficacy have been proposed as contributors to relapse, and assertiveness and social skills training techniques have been found to be linked to the modification of drug taking behaviours (Childress et al., 1985). Ferrell and Galassi (1981), for example, have shown that assertiveness training was related to higher abstinence rates than “human relations” training in alcoholics at a 2-year follow-up. Other studies have failed to include adequate control or collect alcohol use data, and none have investigated the usefulness of the procedures in conjunction with exposure treatments, indicating the need for further investigation into the potential usefulness of these techniques. CONCLUSIONS The present

article examined

the possible

parallels

between

alcohol dependence in terms of etiology, symptomatology, ment. Theorists in both areas have assumed and presented

the anxiety

disorders

and

and most importantly treatsome convincing evidence to

suggest that acquisition of anxiety-related disorders and problem drinking is a result of classical conditioning, and thus, in terms of treatment, suggest that exposure procedures work by extinction of the classically conditioned response. In terms of the symptomatology, an analogy has been drawn between the two disorders whereby drinking is viewed as a compulsive behaviour or one similar to phobic avoidance, maintained by the relief from anxiety that drinking brings. The similarities between the two indicate that work in the anxiety area may be able to contribute a great deal to the development of exposure in the addictive disorders and to provide a direction for future research in the area. Both theoretical and practical issues associated with implementation of exposure therapy in the alcohol dependence area were examined, and it was generally concluded that, while exposure has the potential to be a valuable treatment method, a great deal of additional research is needed to confirm this. Future investigations need to focus on the mechanisms of reactivity in alcoholics before theoretical issues can be resolved. In addition, preliminary trials have been promising, but there is also an explicit need for systematic clinical treatment studies applying the techniques and knowledge that can be gained from anxiety research in this area.

Acknowledgements-The

authors

would

like to thank

Anna

Lee

for helpful

comments

during

editing.

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Received Accepted

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February

1, 1993