Vedel, Emmelkamp / TREATMENT OF CLINICAL CASE STUDIES 10.

1177/1534650103259633 / July 2004 ALCOHOL DEPENDENCE

Behavioral Couple Therapy in the Treatment of a Female Alcohol-Dependent Patient With Comorbid Depression, Anxiety, and Personality Disorders
ELLEN VEDEL PAUL M. G. EMMELKAMP
University of Amsterdam

Abstract: Behavioral Couple Therapy (BCT) has shown to be effective in the treatment of alcohol dependence. However, it is still unclear whether this intervention is effective in severe cases with comorbid other conditions. The aim of the present study is to illustrate the assessment, case conceptualization, prioritizing of interventions and treatment in a female treatment resistant alcohol-dependent patient, with comorbid depression, anxiety, personality disorders, and marital problems, using a BCT manual. In total, the treatment consisted of 19 sessions, during a 7-month period. Results show BCT to be successful in treating alcohol dependence and to some extent increasing marital satisfaction. At posttreatment the patient did no longer meet criteria for major depressive disorder. At 3month follow-up she had been abstinent for 5 months, with a 2-day lapse, and her depressive disorder was still in full remission. This case demonstrateseven with severe comorbid conditionsthat targeting the drinking problem is the treatment of choice. However, we stress the importance of a thorough assessment of other Axis I and II disorders. Keywords: behavioral couple therapy, alcohol dependence, comorbidity

THEORETICAL AND RESEARCH BASIS

Alcohol dependence is characterized by a maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by symptoms such as tolerance, withdrawal, impaired control, neglect of activities, and continued drinking despite recurring problems caused or exacerbated by alcohol use (American Psychiatric Association, 1994). There is relatively high comorbidity between alcohol use disorders on one hand and major depression (Schuckit et al., 1997; Swendsen & Merikangas,
AUTHORS NOTE: Correspondence concerning this article should be addressed to Ellen Vedel, Department of Psychology, Clinical Psychology, University of Amsterdam, Roetersstraat 15, 1018 WB Amsterdam, the Netherlands; e-mail: e.vedel@uva.nl.
CLINICAL CASE STUDIES, Vol. 3 No. 3, July 2004 187-205 DOI: 10.1177/1534650103259633 2004 Sage Publications

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2000), and anxiety disorders (Kushner, Abrams, & Brochardt, 2000; Schuckit & Hesselbrock, 1994), on the other hand. These associations are most commonly explained by either a causal relationship or a shared etiological factor underlying both disorders. Depression or anxiety symptoms may be caused by alcohol use disorderrelated symptoms (intoxication, withdrawal, and/or lifestyle problems) (S. A. Brown et al., 1995; Verheul et al., 2000). Alternatively, patients may start drinking to regulate their mood or anxiety (self-medication hypothesis). Comorbidity has been associated with elevated drinking rates and alcohol-related problems, as well as poorer prognosis after treatment. There is some evidence that adding specific Cognitive Behavior Therapy (CBT) treatment sessions directed at the comorbid depression, in addition to regular alcohol treatment, increases overall treatment success rates (R. A. Brown, Evans, Miller, Burgess, & Mueller, 1997). However, Bowen, DArcy, Keegan, and van Stenhilsel (2000) found no additional benefit of adding CBT sessions focusing on comorbid panic disorder, in reducing problem drinking. Alcohol use disorders and personality disorders also often co-occur in the same individual (Verheul, 2001). Recent studies have shown that personality pathology is, although associated with pre- and posttreatment problem severity, not a robust predictor of the amount of treatment improvement. Substance abusers with Axis II comorbidity may benefit at least as much from treatment as those without any Axis II disorder (Verheul, van den Brink, Hartgers, & Koeter, 1999). Traditionally, behavioral models postulated problematic drinking as behavior learned and maintained through classical and operant conditioning. Contemporary cognitive-behavioral models (incorporating social learning perspectives) have stressed, although acknowledging that alcoholism may have some genetic component, the importance of cognitions and feelings preceding and directing drinking behavior (Carroll, 1999). From a cognitive-behavioral perspective, alcohol abuse/dependence is defined as a habitual, maladaptive method for attempting to cope with the stresses of daily living. This maladaptive way of coping is triggered by internal and external cues and reinforced by positive rewards and/or avoidance of punishment (Monti, Abrams, Kadden, & Cooney, 1989). In the treatment of alcohol use disorders, CBT emphasizes overcoming skill deficits. Different techniques are used to increase the persons ability to detect and cope with high-risk situations that commonly precipitate relapse; these include interpersonal difficulties as well as intrapersonal discomfort, such as anger, (social) anxiety, and depression (Kadden et al., 1992). CBT is an empirically supported therapy in the treatment of alcohol use disorders, producing significant reduction in alcohol consumption and alcoholrelated problems (Chambless & Hollon, 1998; Emmelkamp, 2004; Roth & Fonagy, 1996). Apart from other Axis I and II comorbidity as discussed above, CBT effectiveness might be impeded by relationship problems, although results of these studies are inconclusive (Emmelkamp & Vedel, 2004). In general, alcoholic couples report low marital

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satisfaction. Moreover, drinking has been associated with other marital issues such as domestic violence (Leadley, Clark, & Caetano, 2000; Leonard & Senchak, 1993) and sexual dysfunction (OFarrell, Choquette, & Birchler, 1991; OFarrell, Choquette, Cutter, & Birchler, 1997) and has been found to affect communication between partners (Jacob & Leonard, 1988, 1992). It must be noted, however, that many of the above-cited studies used samples of male alcoholics and their female partners. Little research has been done on the specific characteristics and treatment of the female alcoholic and her male partner (Epstein & McCrady, 1998). There is some evidence that specific behaviors of the spouse can function either as a cue or reinforcer in drinking behaviorconversely, they also can cue or reinforce abstinence/nondrinking behavior (Epstein & McCrady, 1998). In studies into alcohol abusers natural recovery, social support, especially from a spouse, was significantly related to successfully changing the drinking behavior (M. B. Sobell, Sobell, & Leo, 2000). Furthermore, overall marital adjustment (e.g., low marital distress) and marital stability were found to be positively related to success of treatment and are hypothesized to be promoted by (behavioral) couple therapy (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998; OFarrell, Cutter, Choquette, Floyd, & Bayog, 1992; OFarrell, Cutter, & Floyd, 1985). Finally, as in depression, there is some evidence that restoring marital satisfaction and reducing conflicts reduces the probability of relapse (Beach, Fincham, & Katz, 1998). Behavioral Couple Therapy (BCT) has been shown to be an effective intervention in the treatment of alcohol use disorders (Baucom et al., 1998; Chambless & Hollon, 1998; Epstein & McCrady, 1998). In general, BCT focuses not only on behavioral selfcontrol and coping skills to facilitate and maintain abstinence, as does CBT, but also on improving spouses coping with drinking-related situations, improving relationship functioning in general, and improving functioning within other social systems the couple is currently involved in. The degree of emphasis on each of these domains and the techniques used to target the domains vary across different treatment manuals (e.g., McCrady & Epstein, 1995; Noel & McCrady, 1993; OFarrel, 1993). The aim of this study is to illustrate the assessment, case conceptualization, prioritizing of interventions and treatment in a female treatment-resistant alcoholdependent patient with comorbid depression, anxiety, personality disorders, and marital problems.

CASE STUDY AND PRESENTING COMPLAINTS

Dianne (52 years old, former community nurse, married, no children) was referred to us by a colleague, who had been treating Diannes husband Mick. Mick (58 years old, a computer specialist) had been suffering from work-related stress, and during the course of his treatment he had more than once complained about his wifes drinking. She

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increasingly called him at work, sometimes several times a day, complaining of being lonely, and craving for a(nother) drink. Sometimes Mick would stop work and go to his wife to support her. During the weekends, when together with her husband, Dianne was able to control her drinking. However, Micks presence was slowly losing its abstinencereinforcing property. Dianne had now also started drinking during the times Mick was at home, and marital discord was increasing rapidly. Dianne was fearful her husband was going to leave her and thus was willing to try new treatment for her alcohol dependence. Dianne had been drinking excessively for the past 4 years. She had developed the habit of drinking between 12 and 24 units a day (mostly beer and wine), for several days in a row. After a number of days she then would collapse (too sick to drink) for 2 days, after which she would resume drinking. Besides drinking, Dianne complained about feeling depressed, not being able to structure her day, having difficulty sleeping and eating, having sore muscles, being lonely, feeling guilty and worthless, being on edge all the time, not being able to control her worrying, and having occasional panic attacks.

HISTORY

Until 1994 Dianne worked as a community nurse. She was not much of a drinker then; maybe once or twice a week she and her husband would share a bottle of wine when out for dinner. Because of some reorganizations Diannes job changed. The workload increased and Dianne describes herself as becoming more and more stressed, making longer hours in an effort to keep up with the work, resulting in a breakdown. Dianne started seeing a therapist for work-related stress but did not find the treatment very helpful. Dianne stopped working and, in the years to follow, the frequency and the quantity of her drinking increased. She started drinking at home on a daily basis and started using a tranquilizer (Oxazepam). During 1998 Dianne was admitted for detoxification (1-week hospitalization) and subsequently treated in a day care program at an addiction treatment facility. She was treated for alcohol dependence and, having lost control over her use of Oxazepam, for anxiolytic dependence. Dianne successfully stopped using the anxiolytic; however, a few weeks into the program she was expelled from further treatment because of continued drinking. In 1999 she was prescribed Clomipramine for her depression, but again she was not able to control her drinking. She experienced little or no improvement and stopped using the antidepressant. At the same time she started attending an outpatient group treatment program for alcoholics based on Rational Emotive Therapy, but this was of little avail. She kept on drinking, her depressive and anxiety symptoms only increased, and her relationship with Mick deteriorated. Although eager to start treatment at our facility, Dianne, and to some extent Mick, was pessimistic about possible treatment results and Diannes capacity for change.

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When we first saw Dianne and Mick in 2000, Dianne had just started using Acamprosate (an anticraving drug) prescribed by her general practitioner. In addition to this prescription, Dianne received a full medical checkup. In the case of heavy drinking, pretreatment medical testing (blood and liver functions) is required. As for Dianne, there were no abnormalities.

ASSESSMENT
SUBSTANCE USE DISORDERS

We used the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV; American Psychiatric Association, 1994) Axis I Disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 1996) to confirm our diagnoses: 303.90 Alcohol dependence, with physiological dependence, and 304.10 Anxiolytic dependence, sustained full remission. In addition, we used the Timeline Followback Method developed by Sobell and Sobell (1996) to establish quantity/frequency measures, as well as overall drinking pattern. To assess Diannes confidence to control her drinking (self-efficacy) we used the Situational Confidence Questionnaire (SCQ) (Annis & Graham, 1988). The SCQ revealed that Dianne had little confidence in remaining abstinent in critical emotional situations (feeling sad or lonely). In addition, she was not convinced she would be able to limit her drinking after one or two drinks (loss of control).
COMORBIDITY, AXIS I AND II

As mentioned before, Dianne was also suffering from depressive symptoms, uncontrollable worrying, and situational panic attacks. She described herself as always having been worrying about work and household chores. On the other hand, she had always been able to control it until now. Indeed, during the period she had difficulty managing her job, she had been feeling depressed too, but nothing like the way she was feeling now. To assess the severity of her depressed mood, Dianne completed the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). Dianne had a score of 31, which is considered rather severe. There was no suicidal ideation. In view of the presence of a possible substance-related artifact, the hypothesis that part of the observed psychopathology is an artifact of the addictive problems and therefore will (strongly) decline after discontinuation of alcohol misuse (Verheul et al., 2000), we postponed diagnosing major depression and generalized anxiety disorder. Dianne did not meet the criteria for panic disorder. We tried making a timeline, pinpointing the onset of the different symptoms and to discriminate between possible different disorders, but were not very successful in doing

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so. Dianne had partly started drinking because of feeling anxious and depressed, but her drinking had also made her more anxious and depressed. Using the Questionnaire on Personality Traits (VKP; Duijsens, Eurelings-Bontekoe, & Diekstra, 1997), a self-report questionnaire, and the International Personality Disorder Examination (IPDE; Loranger, 1999), a semistructured diagnostic interview, Dianne was diagnosed as having an avoidant and obsessive-compulsive personality disorder.
ASSESSMENT OF DIANNES HUSBAND MICK

Mick and Dianne had known each other for 16 years. Working in different cities, they had never actually lived together. During the week they each had their own apartment, during the weekends and holidays Mick stayed at Diannes place. Preparing his upcoming retirement, Mick was now going to move in with Dianne. Prior to their relationship, Mick himself had had difficulties controlling his drinking. During the mideighties he had received treatment for his alcohol dependence/abuse, after which he had been able to regulate his drinking. He only drank on weekdays, when at his own apartment (maximum of 3 units a day). Using the SCID-I, Mick did not meet criteria for any Axis I disorders other than 303.90 Alcohol dependence, sustained full remission. According to the VKP, he did meet criteria for a schizoid personality disorder. However, no formal diagnostic interview was conducted. We therefore prefer to be conservative and refer to Mick as having schizoid personality features.
MARITAL ADJUSTMENT

Using the Maudsley Marital Satisfaction Questionnaire (MMQ; Arrindell, Emmelkamp, & Bast, 1983), we found marital satisfaction to be poor for both partners. Mick was clearly more negative about their relationship than was Dianne, for Mick had a score of 42 whereas Dianne had a score of 20 on marital dissatisfaction. In comparison with Dutch norm groups, Mick scored nearly one standard deviation above the mean of maritally distressed couples, whereas the score of Dianne was exactly on the cutoff point differentiating maritally distressed from nonmaritally distressed couples (Emmelkamp, Krol, Sanderman, & Raephan, 1987). The Level of Expressed Emotion (LEE; Cole & Kazarian, 1988) showed Mick to experience little emotional support from his wife. Dianne was more positive, finding Mick supportive in some areas. Their marriage was stable, as assessed with the Marital Status Inventory (MSI; Weiss & Cerreto, 1980). There had been no past separations and, contrary to Diannes beliefs about Micks commitment to their marriage, there were no plans for future separation. To establish if there was any form of violence or fear of violence, and verbal or physical abuse, we used the Conflict Tactics Scale (CTS; Straus, 1979) and interviewed both partners. In the past year Dianne had hit her husband twice while being drunk; in one of these instances Mick had hit her back. Both partners agreed these had been isolated incidences and were convinced there would be no future violence.

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Figure 1. Macroanalysis of Dianne.

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CASE CONCEPTUALIZATION

Concerning Dianne there were four major related issues intertwining: her drinking, her depressive mood, her anxious symptoms, and Dianne and Micks marital problems. In addition, Dianne met criteria for both avoidant personality disorder and obsessive-compulsive personality disorder.
PRIORITIZATION OF TARGETS FOR TREATMENT

Many of Diannes symptoms (e.g., sleeping difficulties, muscle tension, poor concentration, and low self-esteem) could be accounted for by each of the four problem areas discussed above. We decided to focus our attention on Diannes drinking as a first step. In generaleven with severe comorbid conditionstargeting the drinking problem is the treatment of choice. There is no evidence that if the patient is not able to control his or her alcohol consumption, targeting other pathology in co-occurrence with alcohol dependence will be effective and should be considered as a first choice for treatment. In the case of Dianne, we hypothesized that if she would stop her alcohol use or start to control her drinking, her depressive symptoms would diminish, as would her worrying and presumably some of the marital problems. Furthermore, we decided to take the personality features of both partners into account in treatment planning and in the therapeutic relationship, if needed.
PRIORITIZATION OF TREATMENT STRATEGIES

Given our focus on alcohol dependence as the first target, we had to decide whether we would provide individual therapy, group therapy, or spouse-aided therapy. In view of the fact that she already had had a negative experience with group therapy, this was not a serious option. BCT is as effective as individual CBT not only with alcohol abuse, but also with depression and anxiety disorders (Emmelkamp & Vedel, 2004). Because of Micks early retirement and the consequences this was going to have on their relationship, we anticipated this could become a source of stress, especially because he was characterized as a loner, who had for the first time elected to live together with his partner. Given this state of affairs and taking into account their overall low marital satisfaction, we decided to offer Dianne and her husband BCT, focusing on the drinking problem as well as their relationship, meanwhile carefully monitoring Diannes craving, and depressive and anxiety symptoms. If still needed, the spouse-aided therapy for alcohol abuse could be supplemented by spouse-aided therapy for depression or anxiety. Because Dianne had already started using Acamprosate, we agreed that she would continue using the anticraving agent during the course of our treatment.

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OURSE OF TREATMENT AND ASSESSMENT OF PROGRESS

Initially, Dianne and Micks treatment followed a BCT manual (de Koning & Vedel, 1999). This protocol consists of 10, 90-minute sessions of spouse-aided therapy. It is a stand-alone treatment delivered during individual couple sessions. Most of the techniques used are derived from the Counseling Alcoholic Marriages (CALM) protocol developed by OFarrell and colleagues (e.g., OFarrell, 1993; OFarrell & Fals-Stewart, 1999).
PSYCHOEDUCATION AND SOBRIETY TRUST CONTRACT

The first two sessions were used for psychoeducation, explaining the treatment rationale and introducing the sobriety trust contract. Dianne and Mick were asked what their ideas were about drinking and alcohol dependence. The differences between disease model versus the cognitive-behavioral approach were discussed, as well as controlled drinking versus total abstinence. Although aware of the fact that her husband was successful in controlling his drinking, Dianne was determined to give up drinking completely. We agreed with Dianne in regarding this to be preferable, especially because the nature of her depressive and anxiety symptoms was still unclear. We introduced the sobriety trust contract; each day at a specific time Dianne was to initiate a brief discussion with Mick and reiterate her intention not to drink. Dianne was then to ask Mick if he had any questions or fears about possible drinking that day and answer the questions in an attempt to reassure him. Mick was not to mention past or possible future drinking beyond that day. They were to agree to refrain from any discussing of drinking at any other time, to keep the daily trust discussion very brief, and to end with a positive statement to each other. It took several sessions before Dianne and Mick incorporated this exercise into their daily routine.
BEHAVIORAL ANALYSIS

To obtain more information about Diannes drinking pattern, we asked her to keep a diary. Every time she felt the urge to drink she had to write down where she was (situation), what her feelings were (emotions), what she was thinking or seeing (cognitions or images), and any physical sensations she might be experiencing. She was also asked to rate (1-10) the amount of craving she had experienced, which appeared to be highly related to fluctuations in her depressed mood. The diary was used to identify high-risk situations and to detect seemingly irrelevant decisions that sometimes cumulated into high-risk situations (e.g., not getting out of bed in the morning or skipping a planned trip to the supermarket). Using the above-mentioned daily recordings, we introduced the behavioral analysis as a framework of hypotheses with respect to antecedents and consequences of (drink-

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STRESSORS:

PERSONALITY: Avoidant personality disorder Obsessive compulsive personality disorder

Low marital satisfaction husband

Depressive disorder

Worrying/anxiety

DRINKING

Social isolation

Figure 2. Behavioral analysis of Dianne.

ing) behavior. Important during this first phase was to show Dianne and Mick the loop in which Dianne had caught herself, the consequences of her drinking (e.g., feeling bad about oneself) being also a reason for her to start drinking. During this phase, we also addressed Micks part in his wifes drinking behavior. We wanted to decrease behaviors of Mick that triggered or rewarded drinking and to increase behaviors that triggered or rewarded nondrinking. For example, it was explained to the couple that although acting out of concern, Micks tendency to come home when Dianne complained about feeling lonely increased the frequency of phone calls and her dependency on him.
INCREASING POSITIVE INTERACTIONS

From Session 2 onwards we also tried to increase positive interaction between the couple. We wanted to shift Diannes and Micks attention from recording only one anothers negative behaviors (attentional bias), to also being able to recognize positive behaviors. As a homework assignment we asked both of them to write down pleasant or positive behaviors they had observed in each other (e.g., asking how your day was, getting up to make some coffee). During the next session they were to tell each other what they had written down, starting each sentence with I liked it when you . . . . or It made me feel good when I saw you . . . . The first time Dianne and Mick tried this homework

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assignment, they returned the next session without having observed anything positive about their partner. Although the assignment had failed, it was of great value. Dianne and Mick were shocked about how much their relationship had changed over the past years. Discussing the difference about there not being any positive behaviors and not being able to detect these behaviors, Dianne and Mick were suddenly able to recollect past week positive behaviors of one another. Dianne and Mick were quite motivated to repeat the homework assignment. We intended not only to increase the attention toward positive behaviors, but we also attempted to increase the actual amount of positive behaviors of Dianne and Mick as a couple. Trying to identify possible pleasant activities, we asked the couple to talk about pleasant things they did together during the time they were dating each other. In the case of Dianne and Mick they liked going out for dinner and going to the movies. We asked them to take turns in planning comparable pleasant activities.
IDENTIFYING HIGH-RISK SITUATIONS

Using Diannes diary, the behavioral analysis, and Micks insight into Diannes drinking behavior, we identified the most important high-risk situations. In Diannes case these were being home alone and feeling sad or worrying about household chores. Within the context of practicing self-control we discussed the fact that an urge or craving is a time-limited phenomenon: rather than increasing steadily and only disappearing after drinking has occurred, it will peak and die down like a wave. We introduced different ways of coping with craving, the three most important being (a) getting involved in some distracting activity, (b) talking about it with someone who can support you, and (c) challenging and changing self-defeating thoughts. Because of Diannes depressed mood she did not pick up on the changing of her cognitions very well. We decided to focus our attention on distracting activities and talking with Mick about how she felt. During these first weeks Dianne was relatively successful in remaining abstinent. Sometimes she would lapse into a 1-day drinking episode but the next day she would be able to restrain herself from further drinking. Much time was spent relabeling these failures. Dianne, as well as Mick, had difficulty accepting change to be a slow process. Rather than focusing on failure we tried to shift attention to determining which antecedents had made Dianne drink in the first place (adding them to the behavioral analysis) and which thoughts/actions had helped her the next day to restrain herself.
MANAGEMENT OF DEPRESSED MOOD

During the course of treatment more attention had to be given to Diannes depressive symptoms. Counter to our expectations Diannes depressed mood did not disappear after a period of abstinence. Although her sleeping and eating improved to some extent, her worrying lessened, and her panic attack disappeared, Dianne kept on feeling sad and

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low on energy. At this moment the probable diagnosis of General Anxiety Disorder was not confirmed; however, the diagnosis of depressive disorder was reaffirmed. Therefore after seven sessions of alcohol treatment, the manual Spouse-Aided Therapy With Depressive Disorders (Emanuels-Zuurveen & Emmelkamp, 1997) was incorporated into Diannes and Micks treatment program. Inactivity being one of Diannes most salient high-risk situations, we introduced an activity training as an intervention to tackle negative mood as well as her drinking problem. Activation training is a fairly common behavioral technique in treating depression. Derived from Lewinson theory on depression, it is assumed that depression is caused by a reduction in response-contingent positive reinforcement, an increase in aversive experiences, or a combination of both. We encouraged Mick to help his wife in organizing her week: combining basic daily activities (e.g., getting dressed in the morning), taking care of neglected activities (e.g., cleaning up the bedroom), and increasing the amount of pleasant activities (listening to music, going out for a cup of coffee with a friend). Given Diannes social anxiety, a gradual approach was used in having her engage in social situations.
COMMUNICATION TRAINING

From Session 9 onwards communication training was introduced. This training is made up of four basic elements: first, basic listening skills and nonverbal communication; second, talking, expressing your thought and feeling in a nonaccusing way; third, discussing basic themes within the couples relationship; and fourth, problem solving, teaching a set of sequential steps for solving problems that minimizes negative emotional undercurrents while maximizing the identification, evaluation, and implementation of the optimal solutions. During the communication training both partners personalities became more salient; this may be due to the fact that the drinking and depressive symptoms had lessened. In addition, we addressed assertiveness, not only because of Diannes social anxiety, but also because both partners found it difficult to express disapproval and make a request. During these sessions it became clear that Mick had great difficulty handling Diannes preoccupation with details and her reluctance to delegate tasks unless he submitted to exactly her way of doing things. We had the couple express their expectations about the future and about their (renewed) relationship toward one another. We found it important to address realistic goal setting, especially because Dianne had very high expectations about Mick moving in with her. To enhance her social support network, we encouraged Dianne to start visiting her old friends again, since she had been neglecting these contacts in the past few years. We also encouraged Dianne to start thinking about working again. She enrolled in a volunteer-working program and started as a hostess in a hospital.

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RELAPSE PREVENTION

During the end of the treatment, much time was spent planning for emergencies and coping with future (re)lapses. Dianne and Mick designed their own personal (re)lapse prevention manual using problem-solving techniques (Regard it, as taking out a travel-insurance, the fact you do, does not imply youre expecting something terrible to happen. On the other hand, its a safe feeling knowing you have it at your side in the event of an emergency.). Different alternatives were discussed, such as Dianne talking about her craving with Mick, Mick being allowed to confront Dianne with high-risk behaviors (e.g., not getting out of bed in the morning) and expressing his concern about the matter, and reintroducing the sobriety trust contract.
EVALUATION

In total, the treatment consisted of 19 sessions, during a 7-month period; the couple was very treatment compliant. At the end of treatment Dianne had been abstinent for 2 months and did no longer meet criteria for major depressive disorder: her BDI score dropped to 10, which is considered to be within the normal range. Diannes confidence to control her drinking increased (SCQ). Results show Dianne to be confident about remaining abstinent even when depressed or sad. She was still convinced she would not be able to limit her drinking after one or two drinks. During the course of the treatment Micks marital dissatisfaction decreased from 41 to 22 (MMQ). Diannes score did not change significantly. At posttreatment both partners were near the cutoff point differentiating maritally distressed from nonmaritally distressed couples. The LEE showed Mick to experience more emotional support from his wife compared to that at pretreatment. Dianne seemed to find Mick somewhat less supportive, compared to that at pretreatment.

COMPLICATING FACTORS

During the 2nd month of treatment Diannes father died. However, she did not experience much grief. Dianne had never felt very close to her father, and during the months she had been nursing him (2 days a week) she had been detaching herself from him. After 3 months into treatment Mick got very ill. Within a few weeks he lost a lot of weight. X rays were made and the possibility of lung cancer was mentioned. Dianne held she would not be able to cope and asked her general practitioner for an emotional backup. Clomipramine was prescribed. Both stressful episodes were used in therapy as examples of how to cope with stressors other than by drinking.

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Another complication was that Dianne was an avoidant and obsessive-compulsive personality and Mick had schizoid personality features. Although we did not focus on the personality disorders as treatment target, the personality makeup of the couple was taken into account in the treatment. Part of Diannes social isolation and lack of social support were due to her avoidant personality, but may be also partly due to the schizoid features of her partner. In treatment, attention was given to Diannes avoidance/social anxiety, for example by gradually increasing more difficult social interactions as homework assignments, providing assertiveness training in the context of communication skills training, and by increasing her social network. Diannes obsessive-compulsive features interfered in that it imposed limits on what can be achieved in improving relationship functioning. As to the therapeutic relationship, the therapist was keen not to prescribe assignments, but had the patient herself find out the assignments that might be effective. For example, a number of different assignments could be discussed and the patient had to decide which activity she was willing to do.

MANAGED CARE CONSIDERATIONS

It is still customary to refer complicated cases such as Dianne to an inpatient program. Hospitalization or intensive day treatment, although the latter being more economic than full hospitalization, however, were not considered. Until now there has been no clear support for inpatient treatment programs or day-treatment programs being superior to outpatient treatment program. Studies assessing the efficacy of treatments for alcohol use disorders have found less expensive treatments such as motivational interviewing, coping skills training, and spouse-aided therapy to be more effective than aversion therapy or insight-oriented psychotherapy and at least as effective as hospitalization (Emmelkamp, 2004). Given the fact that Dianne had already tried an inpatient and daytreatment program before without any benefit, we preferred evidence-based outpatient treatment. Although there were a number of comorbid conditions at intake (i.e., depression, generalized anxiety disorder, avoidant personality disorder, and obsessive-compulsive personality disorder), we decided to focus on alcohol abuse as first step, and to focus on other targets later on, if still needed. This stepped-care approach is not only the most cost-effective, but also in the interest of the patient, avoiding unnecessary and prolonged treatments. Eventually, we had to address the depressive disorder of the patient, but this could easily be incorporated into the BCT manual for alcohol dependence. One could argue that our assessment was rather expensive owing to the use of structured interviews and a large battery of questionnaires. In our view, it would have been penny-wise but pound-foolish to skip part of the assessment. If we, for example, had missed the depressive state of the patient, we would not have monitored it closely and changed our treatment protocol when needed. Similarly, if we would have missed the

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personality disorders/features of the couple, this presumably would have led to unrealistic treatment expectations with respect to marital satisfaction, affected the therapy outcome in a negative way as discussed below, and could even have led to dropping out of treatment.

FOLLOW-UP

Dianne and Mick were seen at a 3-month follow-up. Dianne was still using her antidepressant, but had stopped using the Acamprosate shortly after finishing treatment. After being abstinent for 5 months, 2 weeks ago she had suffered a 2-day lapse after returning from a trip to the Caribbean. The lapse had been a disappointment, especially for Mick, but the couple was glad that Dianne had been able to restrain herself after these 2 days, without intervention of a therapist. Diannes score on the BDI did not differ significantly from the one at posttreatment. She was still within the nondepressive range. She had continued working as a volunteer at the hospital and was now considering applying for a job there. Both Diannes and Micks scores on the MMQ and the LEE did not differ significantly from that at posttreatment.

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TREATMENT IMPLICATIONS OF THE CASE

This case demonstrates BCT to be effective in reducing drinking behavior and, to some extent, in increasing overall marital adjustment in a female alcoholic with comorbid anxiety, depression, and personality disorders, in which earlier treatment attempts failed. As hypothesized, some of Diannes symptoms decreased fairly quickly after discontinuation of drinking (e.g., sleeping and eating difficulties, uncontrollable worrying, panic attacks). Other symptoms though remained stable even after Dianne had stopped drinking. A few weeks into treatment, Diannes depressive symptoms were acknowledged as being part of a major depressive episode. Because Dianne started using Clomipramine we do not know if the depression manual we incorporated would have been successful on its own in reducing her symptoms. Nevertheless, we are inclined to believe that this intervention had some effect in decreasing her depressive symptoms and may at least in the future have some effect in reducing the chance of relapse, but, of course, this remains to be seen. Regarding marital satisfaction, Micks feelings toward Dianne improved considerably. The reduction in marital dissatisfaction of her husband demonstrates that his dissatisfaction was to a large extent determined by the drinking problem of his wife. Dianne being more positive at intake did not really improve on marital satisfaction at posttest and follow-up. One should consider the changes that had occurred during treatment: Mick had retired, had sold his apartment, and had moved in with Dianne. At follow-up

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Dianne seemed somewhat disappointed about how little these changes had influenced their relationship. She still felt detached from Mick; moving in with each other had not brought them closer. Given his schizoid personality features, it may not come as a surprise that Mick did not find this a problem.

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RECOMMENDATIONS TO CLINICIANS

With regard to the assessment of alcohol-related problems clinicians should assess the quantity, frequency, and pattern of alcohol consumption, which need to be confirmed by a family member. Furthermore, a comprehensive assessment should provide the therapist with a clear understanding of the factors that contributed to the development and maintenance of the alcohol and related problems. Therefore, in a case such as Dianne with a history of unsuccessful treatment in the past, a thorough assessment of other Axis I and Axis II disorders, as well as of relationship functioning, is a prerequisite for treatment planning. Furthermore, given the high prevalence of marital violence in alcoholic couples, a thorough assessment of incidences of marital violence is mandatory. In alcohol abuse, treatment compliance is often a complicating factor. Therefore, a clear understanding of the treatment rationale for each aspect of the treatment and encouraging an active self-management approach are essential. In addition, patients should not expect immediate treatment effects and should hold realistic goals of what can be achieved. In addition, in the present case we introduced the sobriety trust contract, to prevent the couple arguing about her drinking behavior throughout the day, which arguments, in our experience, are often antecedents for drinking episodes. Furthermore, even in cases such as Dianne with concurrent depression, anxiety, and personality disorders, it is important to target the substance abuse first in treatment. In establishing a diagnosis of comorbid conditions, it is important to realize that the occurrence of especially anxiety and depressive symptoms may be colored by the alcoholdependent state of the patient. In the present case, we postponed the diagnoses of generalized anxiety disorder and depressive disorder for that very reason. Eventually, although not dealt with in treatment, worrying was no longer a problem, suggesting that the worrying can be considered as a consequence of the alcohol dependence rather than as a separate disorder. On the other hand, the depressive symptoms turned out to be a part of a genuine depressive disorder, deserving treatment on its own. Although the co-occurrence of a personality disorder might complicate the treatment of substance abuse, there is usually no reason to target the personality disorder as a treatment goal. First, there are hardly any evidence-based treatment programs for treating personality disorders, apart from the avoidant and the borderline personality disorder (Emmelkamp, 2004). Only when the alcohol abuse is part of a borderline personality

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Ellen Vedel, M.A., is a researcher at the department of clinical psychology, University of Amsterdam. She works as a clinician in an addiction treatment facility. Paul M. G. Emmelkamp, Ph.D., is a professor of clinical psychology and head of the Department of Clinical Psychology, University of Amsterdam. He is a cognitive behavioral therapist and his main research interests are the etiology and treatment of psychopathology, including anxiety disorders, depression, personality disorders, and addiction. He is editor in chief of Clinical Psychology and Psychotherapy and is on the editorial board of a number of journals.