Alcohol use disorder: a therapist's manual

1. The programme at a glance

Indication. Mild to severe alcohol use disorder in adults, on an outpatient basis, in a person whose physical health has been assessed and whose withdrawal, if needed, is medically supervised.

Reference model. Cognitive behavioural therapy for addictions (Carroll and Kiluk, 2017), combining motivational interviewing at the start (Miller and Rollnick, 2013; section 29), functional analysis of drinking situations (section 30), skills acquisition (Monti et al., 2002) — craving, refusal, emotions, sleep — and relapse prevention (Witkiewitz and Marlatt, 2004; section 32). The work is done alongside the doctor following the physical and pharmacological side.

Format. Twelve 50-minute sessions, one a week. One session, the ninth, involves those close to the person. Then progressive spacing out, provided by three booster sessions (section 28), at one month, three months and six months after the twelfth session, because that is the period when everything is decided.

Mechanism targeted. Replacing an automatic response with a chosen one, in situations identified in advance. We do not work on willpower: we work on situations, on cravings, and on what happens in the ten minutes after the first drink.

Session	Focus	Session output
1	Assess and decide the goal	Goal written down, withdrawal safety settled
2	The decisional balance	The pros and cons, in their own hand
3	The record and functional analysis	Four situations taken apart
4	The first changes	Three concrete rules applied
5	Craving	One craving ridden out without drinking
6	Refusing	Three refusals prepared and tried
7	Emotions without alcohol	What alcohol was settling, listed
8	Sleep and the body	Sleep rebuilt, tests reviewed
9	Those close to the person	One joint session, one written agreement
10	High-risk situations	Written plan for five situations
11	The lapse	Course of action written before it happens
12	Review, relapse, maintenance	Maintenance plan, measures repeated

What the person takes away. Seven printable worksheets, listed in section 39: my record, my balance sheet, my situations, my craving, my refusals, the corner for those close to me, my plan for what comes next.

What distinguishes this programme from the other manuals on this site. A question of vital safety placed before everything else. For the rest, it shares with the manuals Cannabis use disorder: a therapist's manual and Gambling disorder: a therapist's manual a goal that can be negotiated and a whole session devoted to the lapse, written before it happens. A lapse is one isolated drinking occasion, which is distinguished from a relapse, a return to the previous pattern (section 32).

2. Before you begin

The four preliminary decisions

Is there physical dependence? That is the first question, before any other. Section 4. If so, no cessation and no rapid reduction is decided without a doctor.

What is the goal? Abstinence or reduction. Section 5. This question is raised at the first session and it is reviewed.

Have the physical tests been done? Section 10. Liver, blood, nervous system, nutritional state.

And what else is there? Other substances, depression, anxiety, trauma, suicide risk. Section 9.

What this programme does not treat

It does not conduct a withdrawal. Withdrawal is a medical act. This manual describes what happens before and after.

It does not treat emergencies. Delirium tremens, seizures and encephalopathy, described in section 4, or severe acute intoxication are medical emergencies and they do not belong in an appointment next week.

It does not on its own treat a severe disorder with heavy psychiatric comorbidity. What is needed then is an integrated service, in which the addiction and the psychiatric disorder are treated together, by the same team or by coordinated teams.

And it does not treat other substances, even if the principles partly transfer.

How to use it

Read the whole thing before the first session, in particular sections 4, 5, 29, 30 and 32: withdrawal, the goal, motivational interviewing, functional analysis, and relapse prevention.

Each session is described on the same framework: the aim, the sequence of steps, what you say, the common errors, and the criterion for moving on.

Three warnings specific to this presenting problem.

Shame is massive and it organises everything. Many patients understate the amounts at the first session, not out of manipulation but because they have spent years hiding. That corrects itself with time and with the way you ask, not with suspicion.

Ambivalence is not resistance. Nobody comes wanting to stop a hundred per cent. A patient telling you they are not sure they want to stop is giving you the material for session 2.

And relapses are part of the picture. A treatment that has never met a relapse is a short treatment. The question is not to avoid them all, it is to shorten them.

3. Four situations not to be confused

1. Risky use, without a disorder

What you observe. Drinking that goes beyond lower-risk guidance, that is, the daily and weekly limits recommended by each country's health authorities, without loss of control, without withdrawal signs, without major impact.

What that implies. A brief intervention: measure, inform, set a numerical goal, review. It is effective, it takes fifteen minutes, and it is greatly underused.

2. Use disorder without physical dependence

What you observe. Loss of control, unsuccessful attempts to stop, time and thoughts taken over, an impact on functioning — but no withdrawal signs when the person stops.

What that implies. The programme described here, with a goal that may be reduction. Section 5.

3. Use disorder with physical dependence

What you observe. Tremor in the morning, night sweats, morning anxiety that lifts with the first drink, morning drinking, high tolerance, and sometimes a history of seizures or delirium.

What that implies. Section 4, before everything else. Withdrawal is prepared medically, and abstinence is the goal to recommend (section 5).

4. Drinking secondary to another disorder

What you observe. Alcohol is used to sleep, to bear social anxiety, to switch off intrusive memories, or to lift a collapsed mood.

What points to it. The chronology, that is, which of the two disorders appeared first, and the function: always ask what the drink is for.

What that implies. Both are treated, and the order depends on severity. Massive drinking prevents treating anything else; moderate drinking in the service of social anxiety is treated along with it.

The three sorting questions

"What happens when you do not drink for twenty-four hours?" The question that isolates physical dependence, and the most important of the three.

"What is the drink for?" The question that isolates the function.

"What have you already tried, and what happened?" The question that tells you about severity, about previous withdrawals and about what worked.

And a remark about denial

What is called denial covers three different things: shame, which makes people hide; ambivalence, which makes them minimise; and genuine lack of awareness, which is rare. All three can be worked with, and none is worked with by confronting.

4. Withdrawal: what is dangerous

Why this section is placed here

Because this is the only indication on this site where stopping a behaviour can kill. A dependent patient who decides on a Sunday evening to stop completely, alone, may have a seizure on Tuesday.

What you need to know

The withdrawal syndrome appears in the hours following the fall in blood alcohol, often six to twelve hours after the last drink, and it peaks within two to three days.

Its usual manifestations. Tremor, sweating, anxiety, nausea, tachycardia, insomnia, irritability.

Its serious complications. Seizures, which most often occur in the first two days. And delirium tremens, which combines confusion, hallucinations, agitation and autonomic instability (fluctuations in pulse, blood pressure and temperature), generally appearing between two and four days, and which is life-threatening (Mayo-Smith et al., 2004).

The factors that increase risk. A history of complicated withdrawal, high and long-standing daily drinking, morning drinking, older age, associated physical illness, and combination with other sedatives.

What you do

You ask the questions. Tremor on waking, night sweats, the need to drink in the morning, a history of seizures or delirium, attempts to stop and what happened.

You never advise abrupt cessation to someone showing these features.

You refer to the doctor to assess and organise a withdrawal — outpatient with support, or inpatient when one of the grounds listed just below is present.

You know the grounds for admission. A history of delirium or seizures, severe physical comorbidity, no one around them, failure of an outpatient withdrawal, associated psychiatric disorders, and use of several substances.

And you know how to recognise an emergency. Confusion, hallucinations, disorientation, fever, agitation: that is not sorted out over the phone.

What you say to the patient

"I am not going to ask you to stop tomorrow morning. In someone who drinks as you do, stopping all at once on your own can be dangerous, and it is prepared with a doctor."

The question of vitamin B1

Thiamine deficiency, that is, vitamin B1 deficiency, is frequent in this population, and its neurological consequence, Wernicke's encephalopathy, is an emergency: it is serious, and it can become irreversible if it is not treated in time. Supplementation is the doctor's business; your role is to know it exists, and to be concerned by disturbances of gait, problems with eye movements or confusion.

After withdrawal

A successful withdrawal is not a treatment. It is the beginning: without support, resumption is the rule. That is exactly what the rest of this manual describes.

5. Abstinence or reduction: the question of the goal

Why it arises

Because imposing abstinence on someone who does not want it produces two things: a patient who does not come back, and a patient who lies. And because reduction, for some people, is an achievable and beneficial goal.

When abstinence is the goal to adopt

Established physical dependence, in particular with a history of complicated withdrawal.

Advanced liver disease, or another physical condition made worse by alcohol.

Pregnancy.

A drug treatment that is incompatible with alcohol.

A history of repeated failure of attempts at control. When someone has tried ten times to drink moderately, there is no reason for the eleventh to work.

Drinking associated with dangerous behaviour — driving, violence.

And the person's own choice, which is a sufficient reason.

In the first six situations, you recommend abstinence clearly, saying why. If the person refuses it, you do not refuse care for all that: you work with the doctor to reduce the harm, and the question is raised again at the agreed review date (National Institute for Health and Care Excellence, 2011).

When reduction is a legitimate goal

In a person who is in none of the six situations above — in particular without physical dependence, without physical complications, without a history of failed control — and who refuses abstinence. In that case, a well-conducted reduction goal is worth infinitely more than a refusal of care.

How the question is put

You inform, you do not settle it at the outset. You set out what medicine says, you recall what the person observed during their past attempts, and you say what you observe in them.

You put numbers on the goal. A reduction goal without figures does not exist: number of drinks per occasion, number of alcohol-free days per week, situations in which no drinking happens.

You set a review date: session 6, then session 12. If the goal is not held to, the question is raised again — and that is agreed in advance, which keeps it from sounding like a reproach.

And you write it down. The goal is dated and signed, and the person keeps a copy of it.

What must not be done

Imposing abstinence as a condition of access to care, even when it is the recommended goal.

Accepting a reduction goal without figures.

And refusing to reopen the goal when it is not being held to. Review is not a failure: it is part of the protocol.

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