Drinking Games

A new kind of therapy is being developed to train drinkers not to focus on the bottle.

Researchers at the University of Wales say they have designed a computer program that can help alcohol abusers drink less.

For longtime heavy drinkers, visual triggers like this one can set drinking habits into motion. (Credit:

Excessive drinkers are easily distracted by the alcohol-related cues we see every day, says Miles Cox, professor of the psychology of addictive behaviors at the University of Wales, Bangor. These include such everyday sights as bottles in a liquor-store window and the word “beer” on a sign outside a tavern. Light drinkers or abstainers can pass by these images with little thought, says Cox. But just as a person with an overly developed sweet tooth might linger in front of a bakery window, alcohol abusers can’t ignore the cues they see. They “start thinking how good a drink would taste, then how good it would make them feel,” he says, and they might end up drinking.

“This idea goes back to the days of Pavlov,” says Damaris Rohsenow, associate director of the Center for Alcohol and Addiction Studies at Brown Medical School. Drinkers learn that alcohol rewards them with the pleasurable effects of intoxication. Over time, they link memories of good feelings with cues – pictures, smells, and even the feel of a wet glass in the hand. Eventually the cues can dredge up memories that lead to cravings, she says.

Brain-imaging studies back up this theory, says Raymond Anton of the Alcohol Research Center at the Medical University of South Carolina, who runs functional MRI tests on alcohol abusers. When shown pictures of alcohol, abusers show increased activity in brain areas associated with memory and reward – areas also thought to control cravings for alcohol and other addictive substances. Social drinkers and nondrinkers do not show increased brain activity in these areas.

Just as these responses can be conditioned, they can also be de-conditioned, reasons Cox. His computer program, developed with colleague Javad Fadardi, helps abusers deal with the sight of alcohol, since it’s often the first cue they experience in daily life. The program presents a series of pictures, beginning with an alcohol bottle inside a thick, colored frame. As fast as they can, users must identify the color of the frame. As users get faster, the test gets harder: the frame around the bottles becomes thinner. Finally, an alcohol bottle appears next to a soda bottle, both inside colored frames. Users must identify the color of the circle around the soda. The tasks teach users to “ignore the alcohol bottle” in increasingly difficult situations, says Cox.

Such tests have long been used to study attention phenomena in alcohol abusers, but they have never been used for therapy, says Cox. His group adapted the test for this new purpose by adding elements of traditional therapy. Before the tests, users set goals on how quickly they want to react; a counselor makes sure the goals are achievable. After each session, users see how well they did. The positive feedback boosts users’ motivation and mood, Cox says.

In an initial study funded by the U.K.’s Economic and Social Research Council, Cox’s group tested the program on about 100 excessive drinkers, who averaged 72 units of alcohol a week. (One unit of alcohol is roughly equivalent to a glass of red wine.) Subjects were not in treatment, were not seeking treatment, and did not know they were going to receive treatment, but all expressed a desire to drink less. Cox’s group took baseline data on the drinkers’ alcohol consumption, their confidence their in ability to resist alcohol, the extent to which they were distracted by alcohol-related cues, and other measures.

During a one-month waiting period before treatment, subjects showed no change, indicating that their mere desire to cut back didn’t affect their attention to alcohol or their drinking habits.

Then, over four weeks, the drinkers played four 40-minute sessions of the alcohol-bottle “game.” That amounted to 2,000 repetitions of the alcohol-ignoring tasks.

After the training, drinkers were less distracted by pictures of alcohol, as indicated by faster reaction times on an alcohol-distraction test. On questionnaires, they reported fewer alcohol-related problems, said they felt more in control of their drinking, and were more willing to change. And they drank less: on average, the excessive drinkers drank 12 fewer units of alcohol per week. All improvements were statistically significant and were maintained “in the real world” at a three-month checkup, Cox says.

The findings are “promising” but not conclusive, says Reid Hester, director of research at Behavior Therapy Associates in Albuquerque, NM. Cox’s results show “very modest changes in drinking,” he says. He also raises concerns about the study design. “The follow-up was very short-term,” he notes. Reassessment is typically done one year after treatment, because alcohol abusers often go back to old drinking habits after showing initial improvement.

But controlled, longer-term, randomized trials are in progress, says Cox. In these trials, Cox’s group will compare alcohol abusers who receive no treatment, those who receive a different kind of treatment, those who receive the computer-based treatment, and those who receive both treatments. They will follow up after three and six months, and Cox hopes to publish the results in three years.

Rohsenow, too, raises concerns about Cox’s work. The cues that trigger an alcohol abuser’s drinking are numerous and personal, she says: “For one person, it might be a fight with the wife about the stepkids. For another, it might be sitting at home, alone, listening to country-western music.” These are “real situations” observed in her practice, she says. Using a “mechanical” technique to stamp out one general cue – the sight of an alcohol bottle – may make little difference; no conceivable treatment can stamp out all possible cues. Therefore, the best treatments identify an abuser’s personal triggers, re-create them in a treatment center using real drinks, and teach abusers to cope and resist – again and again. This is a proven tool for making lasting changes in the lives of “people with the most serious problems,” Rohsenow says.

Cox’s program “is not going to suddenly cure people with serious alcohol problems,” he acknowledges. “It is a tool to help people who are trying to control their drinking.” It is not a “panacea” meant to stand alone, he says, but a “component” to be incorporated into existing treatment programs. For instance, he thinks it could be useful for inpatient programs, just after detoxification, when cravings hit abusers hard. His program could help patients regain control over their distraction by alcohol before they enter the next phase of treatment. The program could also be used after a full course of treatment, to help prevent relapse. Eventually, it might become part of an outpatient program for less severe drinkers – used at home between counseling sessions to fight cravings, he says.

Though testing is still under way, Cox has copyrighted his program and is talking to U.K. treatment agencies how it might be integrated into existing programs.

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