The American Journal on Addictions 12:S41^S52, 2003 Published by Brunner-Routledge

# 2003 American Academy of Addiction Psychiatry 1055-0496/03 $12.00 + .00

DOI: 10.1080/10550490390202406

The Role of Psychosocial

Treatments in
Pharmacotherapy for
Alcoholism
Mary E. McCaul, Ph.D., Nancy M. Petry, Ph.D.

Medication treatment for alcohol use disorders often includes a psychotherapy

component. The most appropriate psychotherapy to use may depend upon
characteristics of the patient, the medication, the setting, and the experiences
of the provider. To date, little empirical research has investigated these
issues with respect to outcomes in clinical trials that combine
pharmacotherapy and psychotherapy. This paper reviews seven major
types of psychotherapy for treatment of alcohol use disorders: brief
interventions, motivational enhancement therapy, cognitive-behavioral
therapy, cue exposure therapy, behavioral treatments, behavioral marital
therapy, and twelve-step therapy. The theoretical basis for and empirical
evidence supporting the efficacy of the therapies are reviewed, with an empha-
sis on studies that provided pharmacotherapy in conjunction with
psychotherapy. Directions for future research in this area are also suggested.
(Am J Addict 2003;12[Suppl1]:S41^S52)

P harmacotherapy trials for alcohol

use disorders typically incorporate
psychosocial therapy into the overall treat-
ment regimen of study patients. This pro-
cedure is based on the assumption that
medication alone will not be sufficient for
patients to acquire the new knowledge,
skills, and motivations often needed to suc-
cessfully address their alcohol problems.
A variety of psychotherapies have been
developed and empirically validated for
treating alcohol use disorders. The most
typical pharmacotherapy research design
incorporates one such e‘mpirically
validated psychosocial treatment and then
varies the type or dosage of the medication.
Very few studies have manipulated both
the psychosocial treatment and the pharma-
cotherapy, examining the potential interac-
tions of the two interventions. However, a

Received August 15, 2002; accepted December 30, 2002.

From the Johns Hopkins University School of Medicine, Baltimore, Md. (Dr. McCaul); and the University of
Connecticut School of Medicine, Farmington, Conn. (Dr. Petry). Address correspondence to Dr. McCaul,
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 911 N.
Broadway, Baltimore, MD 21205. E-mail: betsymc@jhmi.edu.

S41
Psychosocial Treatments in Alcohol Pharmacotherapy
recent meta-analysis of naltrexone and
acamprosate research1 suggests that
structured psychosocial treatment is a pre-
dictor of medication efficacy. This finding
highlights the need to better understand
the types and intensities of psychotherapies
that will be most efficacious in combi-
nation with alcohol treatment medications.
This paper briefly reviews the theoretical
basis and evidence supporting the efficacy
of common types of psychotherapies. The
review focuses on research in which the
psychosocial treatments have been com-
bined with pharmacotherapy. Of particular
interest are studies in which the interactions
of psychotherapy and pharmacotherapy are
investigated.
PSYCHOSOCIAL TREATMENTS FOR
ALCOHOL USE DISORDERS
Brief Interventions
Brief interventions are time-limited,
patient-centered counseling strategies that
focus on changing behavior. These
interventions can be as brief as five minutes
or last for up to four, sixty-minute sessions.
Five general steps2 are included:
1. provide assessment and direct feedback
2. negotiate and set a goal, typically within
the NIAAA safe-drinking guidelines
3. invoke behavior modification tech-
niques, such as identifying high risk
situations and pros and cons of drinking
4. provide bibliotherapy using infor-
mational materials on alcohol use and
its consequences
5. ensure follow-up and reinforcement to
check on progress.
Over 20 clinical trials have demon-
strated the efficacy of brief techniques in a
variety of settings. Meta-analyses3^5 all
report beneficial effects of brief inter-
ventions in reducing alcohol use in heavy
drinkers who are not alcohol dependent.
S42 VOLUME 12
SUPPLEMENT 1
2003
Typically, the interventions demonstrate
efficacy for at least a twelve-month
period,2 with some studies showing longer-
term positive effects.6,7Studies in comm-
unity-based primary care clinics present
compelling evidence for the use of brief
interventions in general medical settings.
The beneficial effects may not be limited to
reductions in alcohol use, but may also
extend to decreases in alcohol-related
health problems.6,7 These interventions
typically require little training8 and appear
to be cost-effective.6,7
Brief interventions have been used in
several pharmacotherapy trials.9^12 In a
preliminary, open-label study of naltrexone
treatment by primary care providers,
O’Connor and colleagues10 combined stan-
dard naltrexone treatment of 50 mg/day
with a brief intervention consisting of an
extended new patient visit followed by
seven follow-up visits over a ten-week
trial. They observed moderately high rates
of treatment completion (72%) and a sig-
nificant improvement in drinking outcomes,
including percent days abstinent (37%
vs. 89%), percent days without heavy
drinking (49% vs. 97%), mean number
of drinks/ occasion (9.5 vs. 2.5), and dec-
reased gamma-glutamyl transferase levels
(GGT:67.1 vs. 45.3 U/L) from baseline
to end-of-treatment. In a subsequent
randomized clinical trial,13,14 brief inter-
vention subjects were equally likely
to respond to naltrexone treatment as
those receiving more intensive cognitive-
behavioral therapy during an initial 10-week
open-label medication period; however,
those brief intervention responders who
were subsequently randomized to placebo
treatment during a six-month double-blind
naltrexone trial did not maintain the initial
treatment gains. Most recently, Kranzler
and colleagues11 used a brief, four-session
coping skills training intervention that tar-
geted nonhazardous drinking goals and
management of high-risk drinking situa-
tions in combination with either daily or

targeted naltrexone/placebo administration
in heavy drinkers. Patients randomized to
targeted medication administration reduced
their drinking as long as medication (nal-
trexone or placebo) was available at least
three days per week. Among patients
randomized to daily medication admin-
istration, drinking was reduced only among
those patients receiving active naltrexone
therapy. Based on these findings, brief
interventions may offer an effective treat-
ment option for use with alcohol pharma-
cotherapies, particularly in alternative care
settings, with heavy drinkers and possibly
in combination with medication strategies
aimed at targeted, high-risk situations.
Motivational Enhancement Therapy
Motivation enhancement therapy
(MET) is based on the Transtheoretical
Stages of Change Theory,15 which states
that individuals pass through a series of
stages of thought, planning, and action in
the course of modifying behaviors. The
MET intervention is designed to bolster
the person’s motivation and commitment
to change, activate the individual’s own
resources (including natural helping
relationships), and move the person along
the readiness-to-change continuum. This
approach is built on motivational inter-
viewing techniques incorporating feedback
on problems/strengths and clear, directive
advice from the therapist. Ideally, this
includes a menu of change options, the use
of an empathetic and nonconfrontational
therapeutic style, and enhancement of the
patient’s own responsibility and self-efficacy
for change.16
MET was manualized for inclusion in
Project MATCH as a four-session inter-
vention.17 In comparison to twelve-session
interventions using either cognitive-beha-
vioral or twelve-step facilitation therapy,
this relatively brief therapy was equally
efficacious in improving drinking-related
THE AMERICAN JOURNAL ON ADDICTIONS
McCaul & Petry
outcomes and appeared to be more effec-
tive with angry subjects.18
MET has been adapted for use in
several recent pharmacotherapy trials, in
part because of the potential to move this
relatively brief therapy out of specialized
alcoholism treatment programs and into a
broader array of health care settings that
would be conducive to medication use.
The multi-site, six-month, double-blind,
placebo-controlled U.S. acamprosate study19
employed a four-session, manual-guided
brief intervention that incorporated a moti-
vational enhancement approach as well as
an emphasis on medication compliance,
feedback from drinking assessments, edu-
cational handouts, and a psychoeducational
approach. Medication efficacy was observed
in those subjects motivated to have absti-
nence as their treatment objective, sug-
gesting an important role for motivational
therapies in combination with acamprosate.
Cognitive-Behavioral Therapies (Coping
Skills, Relapse Prevention)
Cognitive-behavioral therapy is
grounded in the principles of social
learning theory, which views drinking as
functionally related to problems and
situations in the individual’s life. The
focus of the cognitive-behavioral model is
training clients in intra- and interpersonal
skills that reduce relapse risk, maintain
abstinence, and enhance self-efficacy. Clients
are taught to identify triggers that set the
occasion for drinking or drug use. Such
triggers may be external (drinking or
drug-using friends; high-risk places) or
internal (feeling lonely, angry, or sad;
ruminating about past problems or argu-
ments). Coping and problem-solving skills
are taught to help the client deal more
effectively with drinking or drug urges
when these triggers are present.
Cognitive-behavioral therapy models
have been widely evaluated and have gen-
erally received strong empirical support for
S43
Psychosocial Treatments in Alcohol Pharmacotherapy
their effectiveness with substance abuse
patients. Randomized clinical trials comp-
aring CBT to no-treatment controls have
consistently found CBT superior to mini-
mal or no treatment.20 When CBT is
compared with other active therapeutic
interventions, results are more mixed.
Some studies have supported the greater
effectiveness of CBT, while others have
found it comparable in effectiveness to
other treatment approaches.20 For example,
in Project MATCH, CBT was found to be
comparable to Motivational Enhancement
Therapy and 12-Step Facilitation Therapy
for decreasing alcohol use and alcohol-
related problems. All three outpatient
therapies resulted in profound improvement
in participants during the twelve-week
intervention period.18
Several studies21,22 suggest that CBT
produces delayed, positive effects that
emerge after treatment completion. Speci-
fically, patients who received CBT con-
tinue to improve relative to
end-of-treatment, whereas patients receiv-
ing other therapies are stable or gradually
return to baseline substance use levels.
These effects are in line with the principles
of CBT to teach patients coping and relapse
prevention skills that they will continue to
use throughout their recovery.
The use of CBT has been popular in
pharmacotherapy trials using a variety of
medications with alcohol-dependent pa-
tients.23^28 In a randomized, placebo-
controlled clinical trial of naltrexone,29 all
alcohol-dependent patients received twelve-
session, manual-guided cognitive-beha-
vioral therapy. Both placebo- and nal-
trexone-treated patients had high rates of
treatment completion and high attendance
at therapy sessions (X ¼ 10, SD ¼ 3),
suggesting the effectiveness of the psycho-
social treatment for engaging patients in
treatment. Naltrexone- compared with place-
bo-treated subjects reported fewer drinking
days and fewer drinks per drinking day;
they also had a longer time between the
S44 VOLUME 12
SUPPLEMENT 1
2003
first and second relapse occasions. Foll-
owing the twelve-week active treatment
phase, naltrexone-treated subjects continued
to report reduced drinking, though group
differences between naltrexone-treated and
placebo subjects were no longer signi-
ficant.30 As Anton et al.30 noted, there is a
sound theoretical basis for predicting
positive, complementary effects of nal-
trexone and cognitive-behavioral therapy
in that naltrexone should provide an
improved opportunity for patients to prac-
tice their relapse prevention strategies
during a drinking lapse.
Cue Exposure Therapy
Through repeated stimulus-response
pairing in an associative learning paradigm,
alcohol-related cues can come to elicit
subjective (eg, craving and urges to drink)
and, to a lesser extent, physiological (eg,
increased heart rate and salivation)
responses.31 Importantly, the strength of
these cue-induced responses appears to pre-
dict post-treatment outcomes in recently
treated alcohol-dependent patients32,33 Cue
exposure therapy (CET) teaches coping
skills for dealing with urges and other
responses induced by such cues as the sight
and smell of alcohol. It then systematically
exposes the patient to these alcohol-related
cues in order to extinguish these triggered
responses and give the patient an oppor-
tunity to practice alternative, pro-recovery
responses in the presence of these cues.
Although research is limited, several
studies have supported the efficacy of
CET with alcohol-dependent patients.
Monti et al.34 used the combination of
cue exposure and coping skills training
to improve six-month post-treatment
drinking outcomes compared with stan-
dard treatment. Similarly, Rohsenow and
colleagues35 found that CET in combi-
nation with intensive alcoholism treat-
ment reduced heavy drinking days when
compared with intensive treatment alone.

Additionally, CET-treated patients reported
greater reductions in the urge to drink in
simulated high-risk situations and an
increase in the use of coping strategies
during the one-year follow-up period.
Encouraged by laboratory-based evidence
that naltrexone dampened cue-induced
craving in recently abstinent alcoholics,36
a recent study has combined CET with
naltrexone treatment for alcohol-dependent
patients.37 Among compliant patients who
ingested at least 70% of prescribed doses,
CET and naltrexone independently reduced
self-reported urges to drink, heavy drinking
days, and drinks per drinking day com-
pared with standard treatment or placebo;
however, no interaction of medication
and psychosocial treatment was observed.
Behavioral Treatments: Community
Reinforcement Approach (CRA) and
Contingency Management (CM)
Behavioral treatments are based on
the principle that alcohol induces positive
subjective and physiological effects that
reinforce continued alcohol use. To
reduce alcohol consumption, reinforce-
ment from alcohol use is decreased while
reinforcement from other sources is
increased. In CRA, the therapist rearranges
the patient’s environment so that drinking
is less reinforcing than abstinence, and re-
inforcing disulfiram compliance is one of
the primary components of CRA. Positive
reinforcement for not drinking comes in
the form of scheduling other recreational
activities and reorganizing daily life by
breaking down practical barriers. For
example, the therapist may assist the
patient in obtaining a telephone line, a
place to live, or transportation. Strong
evidence exists for the efficacy of CRA.38
In controlled studies conducted on an
inpatient39 or outpatient basis,40,41 patients
receiving CRA evidenced substantial
improvements in abstinence rates and
psychosocial functioning compared with
THE AMERICAN JOURNAL ON ADDICTIONS
McCaul & Petry
patients in more traditional treatments. A
manual for this approach is available.42
CM treatments are based on the same
behavioral principles as CRA, but CM
extends the use of non-drinking positive
reinforcements to include tangible rewards.
For example, every time the patient pro-
vides a substance-negative specimen or
consumes medication, s/he earns a reward,
such as a voucher exchangeable for retail
goods and services.43 Although there is an
extensive literature on the use of CM for
treatment of drug use disorders, few
studies have evaluated the efficacy of CM
in alcoholism treatment.44 Petry et al.45
found that among alcohol-dependent
veterans who received CM for providing
negative breathalyzer readings in addition
to standard psychosocial therapy, there
was a significantly greater time to first
drinking episode and first heavy drinking
episode compared with veterans who
received standard treatment alone.
Studies show that patients can be
reinforced for compliance with medicat-
ions as well.46 Liebson et al.47 found that
methadone-maintained, alcohol-dependent
patients significantly reduced alcohol use
when methadone treatment was contin-
gent upon disulfiram consumption. To
date, the most common application of con-
tingency management techniques to phar-
macotherapy has been the provision of
vouchers or cash, contingent upon nal-
trexone consumption in recently detoxi-
fied opioid-dependent patients.48^50 These
studies have generally reported significant
increases in treatment retention and
reductions in opioid use among CM-
enhanced patients as compared to standard
treatment patients.
Behavioral Marital Therapy
Behaviorally-based couples therapy
(BCT) has been the most often investi-
gated form of family therapy for alcohol
dependence.51 BCT is grounded in social
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Psychosocial Treatments in Alcohol Pharmacotherapy
learning theory and family systems
models. The model assumes a reciprocal
connection between alcohol use and
relationship functioning: alcohol use
impacts the quality and nature of a
couple’s relationship, and the functioning
of the relationship in turn impacts alcohol
use. The therapy focuses on improving
interactional behaviors, such as communi-
cation and problem-solving skills and
enhancing social support.
Several studies show that BCT is
associated with positive outcomes in
relationship adjustment and reductions
in alcohol use.52,53 Moreover, compared to
individual or group counseling, BCT is
more cost-effective.54 However, little is
known about necessary or sufficient com-
ponents of BCT, and most studies have
limited its use to homogenous populations
with little psychiatric comorbidity. Of
course, this treatment is only applicable to
patients who have cooperative significant
others.
A number of studies have examined
the impact of the involvement of a spouse
or significant other in observing medi-
cation ingestion. In a six-month study of
disulfiram treatment supervised by a
significant other elected by the patient,55
disulfiram 200 mg/day significantly in-
creased abstinent days and decreased total
drinks consumed compared with placebo.
To date, there are very few published
pharmacotherapy studies that have
included BCT or other styles of family
counseling in the psychotherapeutic inter-
vention. Carroll et al.48 incorporated family
counseling into naltrexone treatment for
opioid dependence. Subjects (N ¼ 127)
were randomized to one of three con-
ditions: 1) standard thrice-weekly nal-
trexone treatment, 2) naltrexone treatment
plus CM, and 3) naltrexone treatment,
CM, and family counseling. Importantly,
only 62% of subjects assigned to the
family counseling group attended at
least one counseling session, suggesting
S46 VOLUME 12
SUPPLEMENT 1
2003
considerable difficulty in engaging family
members and significant others in care.
Among these treatment-exposed subjects,
family counseling appeared to increase
treatment retention and rates of opioid-free
urine toxicology screens in comparison to
standard treatment or CM-enhanced treat-
ment. Further, there was strong evidence
of treatment-specific effects, with subjects
in the family counseling group reporting
significant reductions in family problems
over the twelve-week trial as compared
with subjects in the other two treatment
groups.
Twelve-Step Therapies
Alcoholics Anonymous (AA) is an
independent organization that promotes a
fellowship of people whose common
goal is recovery from the disease of
alcoholism. It is the most widely accessed
resource for individuals with alcohol
problems.56 The AA philosophy is based
on alcoholism as a chronic, progressive,
spiritual, and medical disease. Because
alcoholics are believed to have lost the
ability to control drinking, they can
only be effectively treated through long-
term abstinence from alcohol. Over the
years, AA has set forth principles and
steps to help guide persons in recovery.
The ‘‘twelve steps’’ describe a series of
actions and beliefs that persons can follow
to achieve long-term recovery. Twelve-
Step Facilitation, a manualized intervention
to promote AA participation,57 was equally
efficacious with cognitive-behavioral and
motivational enhancement therapies in
Project MATCH.18
It is often thought that AA discourages
the use of medications, which they consider
‘‘crutches.’’ However, in an anonymous
survey of a large sample of active AA
participants, Rychtarik and colleagues58
found that over half the members reported
that the use of relapse-preventing medicat-
ion either was a good idea or might be a

good idea, and only 12 percent would tell
another member to stop taking it. Given
the positive outcomes of twelve-step facili-
tation observed in Project MATCH and
the apparent tolerance of medication
among the majority of AA members,
the use of this treatment approach in com-
bination with pharmacotherapy seems
appropriate.
In a large, multi-site, placebo-con-
trolled study of naltrexone conducted by
the U.S. Veterans Administration,59 parti-
cipants received twelve-step facilitation
counseling for twelve months, with further
encouragement to attend AA meetings.
The intervention was adapted to also
promote acceptance of pharmacotherapy,
introduce basic relapse-prevention infor-
mation, and reinforce abstinence and
continuedtreatmentparticipation.Although
no treatment outcome differences were
observed between naltrexone- and placebo-
treated patients, overall results for the
thirteen-week initial treatment phase
suggest moderately high rates of medi-
cation and counseling compliance, high
rates of alcohol abstinence, and a relatively
low proportion of drinking days across
the two treatment groups. A recent trial
of sertraline treatment for alcohol
dependence60 also incorporated manual-
guided twelve-step facilitation therapy and
community-based support group atten-
dance, supplemented by brief physician
visits to monitor medication compliance
and any adverse effects. This research
suggests that AA-oriented interventions
can be successfully combined with pharma-
cotherapy to engage and retain patients
in care.
INTERACTIONS OF PSYCHOSOCIAL
AND PHARMACOLOGICAL
TREATMENTS
At times, the decision to allow variability
in the delivery of psychosocial treatments
THE AMERICAN JOURNAL ON ADDICTIONS
McCaul & Petry
across sites in a multi-site trial can permit a
crude analysis of psychotherapy by
medication interactions. In several large-
scale studies of acamprosate,61^63 treatment
sites have been allowed to retain routine
counseling practices. For example, one
twelve-site German study was conducted
in the context of usual care resulting in a
variety of therapeutic services across
sites, although some general similarities
(behavioral rather than interpersonal
emphasis, mean frequency of once per
week and mean duration of one hour
per session) were noted. The emergence
of a medication effect despite inter-site
variability suggests that acamprosate out-
comes are not highly sensitive to psycho-
therapy effects.
A more elegant but less frequent
experimental approach has been to
manipulate the type of psychosocial
therapy in order to explicitly examine the
interaction with medication. In one of the
first published studies of naltrexone treat-
ment for alcohol dependence, O’Malley
et al.64 randomized subjects to receive either
individual cognitive-behavioral coping
skills treatment or supportive therapy in
combination with either 50 mg of nal-
trexone daily or placebo. An interesting
interaction of medication and psycho-
therapy was observed. Subjects who received
naltrexone and supportive therapy evi-
denced greater continuous abstinence in
comparison with the other treatment
groups. In contrast, those subjects who
received naltrexone and coping skills
therapy reported greater reductions in
craving and evidenced reduced relapse risk
if they consumed alcohol.
More recent studies have examined the
effectiveness of more intensive, highly
structured psychotherapies vs. brief inter-
ventions with alcoholism pharmaco-
therapies. O’Malley and colleagues13,14
explored the interaction of cognitive-beha-
vioral therapy vs. brief medical manage-
ment with naltrexone therapy. During an
S47
Psychosocial Treatments in Alcohol Pharmacotherapy
initial open-label naltrexone treatment
phase, comparable effects were obtained
with the brief and more intensive inter-
ventions; however, when treatment respon-
ders were subsequently randomized to
naltrexone or placebo during an extended
treatment phase, placebo-treated subjects
who had received the brief intervention
deteriorated, whereas placebo-treated
subjects who had CBT continued to evi-
dence improved drinking outcomes. In a
multisite trial, DeWildt and colleagues65
compared the effectiveness of acamprosate
across three psychosocial treatment con-
ditions: none; three-session brief moti-
vational enhancement therapy; and
seven-session cognitive-behavioral therapy.
Drinking outcomes at the end of acam-
prosate administration and at six-month
follow-up were comparable across the three
psychosocial treatment groups, and the
groups did not differ in medication
compliance, dropout rates, or psychologi-
cal distress. These findings suggest that
psychotherapy does not enhance acam-
prosate effectiveness; however, results
should be interpreted with caution due to
high overall dropout rates and differential
therapy effects across study sites.
This research strategy of examining
the interactions of psychosocial and phar-
macological treatments is epitomized by
the COMBINE Study, a multi-site,
NIAAA-sponsored project. Study medi-
cations include naltrexone and acamprosate
alone and in combination. Subjects also
receive either low-intensity psychosocial
care that incorporates medication adher-
ence and side-effects monitoring with brief
intervention or high-intensity treatment
that includes the medication management
plus elements of cognitive-behavioral,
motivational, and twelve-step therapies. At
its completion, this project should provide
invaluable data on the complex ways in
which different medications interact with
different intensities and types of therapy in
different patient subgroups.
S48 VOLUME 12
SUPPLEMENT 1
2003
FUTURE DIRECTIONS
There has been considerable progress in the
design and conduct of pharmacotherapy
trials for substance use disorders; however,
much of the emphasis to date has been
placed on methodological enhancements
related to medication delivery, compliance
monitoring, and other aspects of drug
therapy. Comparable attention is now
needed for the rigorous delivery of
psychosocial treatments that may enhance
and extend medication effects. For
example, existing manualized therapies
might benefit from adaptation for use in
pharmacotherapy studies, adding content
to directly address issues such as
compliance, side effects, and participation
in self-help programs. Research also is
needed that systematically manipulates the
intensity, duration, format (ie, group vs.
individual), and providers of the
psychosocial therapy used in conjunction
with pharmacotherapy. Recent research has
tended to minimize exposure to psycho-
therapy to avoid the perceived risk of a
ceiling on drinking improvements that
could limit the ability to detect medication
effects. As noted earlier, however, the
recent meta-analysis by Hopkins1 suggests
that such an approach may in fact be
counterproductive and interfere with the
emergence of pharmacotherapy effects.
Thus, we may learn that the nonspecific
effects of psychotherapy that help to main-
tain patient engagement also bolster patient
adherence to the medication procedures, a
factor that has been repeatedly shown to
impact drinking outcomes.66,67 Greater
attention should also be focused on the level
of adherence to the selected psychotherapy.
It is critical to distinguish between a failure
to maintain the validity of two separate
therapies and no real difference in their
effects.
Greater attention is needed for the
potential emergence of psychosocial therapy
effects during the post-medication follow-up

period. To date, most studies have shown
diminishing medication effects over time
following drug discontinuation. It may be
that this period is key to demonstrating
important interactions of pharmacotherapy
and psychosocial treatments. For example,
it might be expected that subjects receiving
more intensive, cognitive-
behavioral therapies will sustain their beha-
vioral changes more successfully in the
absence of medication than subjects receiv-
ing brief interventions.
Another potentially fruitful area of
research focuses on patient characteristics
(eg, alcoholism typology, severity, family
history, and other psychiatric comorbidity)
as they interact with psychosocial and phar-
macological therapies. For example, limited
evidence has emerged for a potential inter-
action of cognitive-behavioral therapy with
medication effects as a function of the alco-
holic subtype of the patient. In a study of
fluoxetine for alcoholism treatment,68 Type
B alcoholics
who are characterized by
early onset of alcoholism, high levels of
premorbid psychopathology, and high
severity of alcohol-related problems
had
poorer outcomes when cognitive-beha-
vioral therapy was combined with active
fluoxetine compared with placebo. Inter-
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