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Drinking beverages containing alcohol has been prevalent in many societies throughout history. Today, as in the past, most people engage in some drinking, and most do so without serious consequences. Some people’s drinking, however, is not only excessive, but is associated with serious consequences for themselves and for others. The drinking of a small percentage of individuals is therefore responsible for a large percentage of alcohol problems.

What Is Alcohol?

Alcohol (ethanol) is a psychoactive drug—its principal effect on the brain is as a central nervous system depressant. Although people can drink large quantities of alcohol in short periods of time, alcohol is metabolized and eliminated (used and released) from the body at a slow and fixed rate: about one drink per hour. The unmetabolized alcohol circulates in the bloodstream and is known as the blood alcohol level. Not all types of alcoholic beverages contain the same amount of alcohol. For example, 12 ounces of regular beer contains about the same amount of alcohol as 4 ounces of table wine, which contains about the same amount as 1 ounce of 86-proof liquor.

What Does Alcohol Do?

The effects of alcohol depend on the amount consumed, the period of time over which the alcohol is consumed, the past experience of the user, and the circumstances in which the drinking occurs (affected by such variables as the drinker’s mood or the presence of others). Used in moderation, many people enjoy the effects of alcohol. However, as the blood alcohol level increases, the effects become increasingly negative and normal functioning is impaired. Possible effects include slurred speech or blackouts (time-limited periods of amnesia).

Repeated heavy drinking over extended time periods can have long-term negative effects. The chronic effects of heavy drinking can range from mild medical problems such as stomach inflammation to serious ones such as cirrhosis or brain damage. When heavy drinking is combined with cigarette smoking the risk of serious disease increases. Psychosocial consequences of heavy drinking can range from mild consequences such as missed work to serious ones such as divorce or job loss.

Tolerance and dependence are two features that characterize alcohol problems. Tolerance means that with repeated alcohol use, the drinker needs to consume more alcohol to achieve the same effect previously produced by smaller amounts. Individuals who have developed substantial tolerance can sometimes function with few observable signs of intoxication, despite having consumed a large amount of alcohol.

Regular heavy drinkers can easily become psychologically and/or physically dependent on alcohol. Psychological dependence is best characterized as a compulsive need for alcohol, especially when the person consumes alcohol in the face of obvious unfavorable consequences. Psychological dependence may be separate from physical dependence, although the two forms often occur together. Physical dependence occurs when the body has adapted to the presence of alcohol. To stop drinking at this point can bring on an alcohol withdrawal syndrome, which can be severe (i.e., hallucinations, seizures, and delirium tremens).

Who Is at Risk and Why Do People Drink Excessively?

Is there a genetic predisposition?

Although some evidence suggests that there is a genetic basis or vulnerability for alcohol problems, little is known about what specifically might be inherited. There is some convincing evidence that males with alcoholic fathers are at increased risk for developing alcohol problems; this is especially true if the pattern goes back to the father’s father. However, a major limitation of this finding is that such individuals can account for only a small percentage of those with alcohol problems. Since the majority of alcohol abusers do not have a family history of alcohol problems, environmental factors also contribute significantly to the development of alcohol problems. Since current evidence strongly suggests that alcohol problems are neither solely biologically nor solely environmentally determined a biopsychosocial approach seems necessary for an adequate understanding of the development of alcohol problems. In summary, while some drinkers are at greater risk that others anyone can develop alcohol problems.

Is alcohol abuse a progressive disorder?

Present evidence suggests that alcohol abusers’ drinking careers most often involve periods of drinking problems of varying severity, separated by periods of abstinence of drinking without problems. Only a minority experiences a progressive, lock step worsening of problems.

If excessive drinking causes so many long-term consequences, why do people continue to drink heavily?

People drink heavily for a variety of reasons. Although it has long been thought that problem drinking is primarily in response to negative emotional states (such as anxiety or depression), interpersonal problems, or social pressure, some recent research suggests that many problem drinkers report drinking primarily when in a positive mood in order to feel even better. Whether someone drinks to get over “feeling bad” or to enhance good feelings, the rewards for drinking usually occur sooner than do the negative effects. This short-term rewarding effect is thought to be one reason why people are willing to risk the long-term negative consequences of heavy drinking.

What Can Be Done?

Various treatment approaches and goals have been used in treating alcohol abusers (including anti-alcohol drugs, individual and group therapy, Alcoholics Anonymous, and behavior therapy). However, most treatments have shown only limited success. Even the topic of treatment goals is controversial. For some time, abstinence—no drinking at all—was thought to be the only appropriate goal. Research conducted over the past two decades suggests, however, that reduced drinking is an appropriate goal for some alcohol abusers, especially those whose problem is not severe. Some recent evidence also indicates that some alcohol abusers recover without formal help or treatment. Behavioral research has contributed significantly to major changes that have taken place in the alcohol field over the past few decades, most notably in the areas of assessment and treatment strategies.

Behavioral treatments start with a detailed assessment of the person’s drinking and related behavior. This information is used to develop an individualized treatment plan to promote positive and beneficial change in the target behavior as well as in the related behaviors.

Common guiding principles suggest that treatment (a) should be individualized; (b) should be least restrictive (requiring the least total life change while still achieving goals and maintaining accomplishments); (c) should be designed to include components that enhance commitment to change, allowing clients to guide their own treatment as much as possible; and (d) should address issues related to relapse, since relapse rates are very high following treatment.

Behavioral treatments have tended to vary with the severity of the person’s alcohol problem. For example, for severely dependent alcoholic inpatients, abstinence- oriented social-skills training treatments have been used with some success, while brief, outpatient self-management treatments incorporating moderation goals have shown more success with problem drinkers. In recent years, behavioral approaches have focused substantially on persons whose drinking problems are not extremely serious (i.e., problem drinkers—the majority of those with drinking problems).

How long will treatment take?

Treatment length varies, depending of the client’s needs. For some this might mean a few sessions; for others it might involve a longer or more intensive process. It is recommended that treatment start with the minimal intervention suitable for the severity of the problem, with additional techniques implemented only if needed.

What is Cognitive Behavior Therapy?