Letters to the Editor
Behavioural Therapy for the Treatment of Alcohol Abuse and Dependence
Cognitive-behavioural therapy (CBT) is a problem-focused psychotherapeutic
approach based on learning theory that has been effectively used
to treat alcoholism (13). CBT is directed primarily at modifying
distorted or maladaptive conditions and altering environmental contingencies
to diminish behavioural dysfunction. Dialectical behaviour therapy
(DBT) is a form of CBT developed for patients with a diagnosis of
borderline personality disorder (BPD) (46). It may be very
effective as a treatment for alcohol abuse and dependence in general,
as well as for patients with alcohol abuse or dependence who also
meet criteria for BPD. Impulsiveness in areas that are potentially
self-damaging (including substance abuse) is a criterion for BPD
(7). BPD patients are frequently polydrug abusers and usually combine
drug and alcohol abuse (4). A recent study has found that patients
with alcoholism who relapse within 6 months of detoxification show
a higher rate of personality disorders, especially BPD and antisocial
personality disorder (8).
DBT is based on a biosocial theory of personality functioning:
a systemic dysfunction of the emotion regulation system stems from
the interactions over time of biological irregularities in conjunction
with certain types of environments (46). DBT as a theory and
therapy favours the most nonpejorative explanations for behaviour.
In DBT, there are 4 behavioural targets: 1) to decrease life-threatening
behaviours; 2) to decrease therapy-disrupting behaviours that may
compromise treatment effectiveness (for example, arriving intoxicated
for a session); 3) to decrease behaviours that interfere with quality
of life (for example, alcohol abuse); and 4) to increase coping
skills. The 3 modes of outpatient DBT are psychosocial groups (for
skill training), individual therapy (to address motivational issues
and strengthen skills), and telephone contact with the individual
therapist (to address generalization). A combination of DBT and
pharmacologic treatments may help some patients with alcohol abuse
1. Kadden RM. Behavioral and cognitive-behavioral
treatments for alcoholism. Research opportunitites. Addict Behav
2. Feeney GFX, Young RMcG, Connor JP, Tucker J, McPeterson
A. Outpatient cognitive behavioral therapy programme for alcohol
dependence: impact of naltrexone use on outcome. Aust N Z J Psychiatry
3. Anton RF, Moak DH, Waid LR, Latham PK, Malcolm RJ,
Dias JK. Naltrexone and cognitive behavioral therapy for the treatment
of outpatient alcoholics: results of a placebo-controlled trial.
Am J Psychiatry 1999;156:175864.
4. Linehan MM. Dialectical behavior therapy for treatment
of borderline personality disorder: implications for the treatment
of substance abuse. In: Behavioral treatments for drug abuse and
dependence. National Institute on Drug Abuse research monograph
137. Rockville (MD): National Institutes of Health; 1993. p 20116.
5. McMain S, Korman LM, Dimeff L. Dialectical behavior
therapy and the treatment of emotion dysregulation. J Clin Psychol
6. Shearin EN, Linehan MM. Dialectical behavior therapy
for borderline personality disorder: theoretical and empirical foundations.
Acta Psychiatr Scand 1994;89 (Suppl 379):618.
7. American Psychiatric Association: Diagnostic and
statistical manual of mental disorders. 4th ed. Text Revision. Washington
(DC): American Psychiatric Association; 2000. p 70610.
8. Wölwer W, Burtscheidt W, Redner C, Schwarz
R, Gaebel W. Outpatient behaviour therapy in alcoholism: impact
of personality disorders and cognitive impairments. Acta Psychiatr
Leo Sher, MD
New York, New York