Cue Exposure Therapy (CET) trains the patient in the clinical and post-clinical setting to deal with situations and triggers of the disorder using key triggering stimuli (cues) and to bring about long-term improvement. In the case of alcohol use disorder (AUD), specifically, this procedure is said to be highly effective, yet the study results are inconsistent.
Cue Exposure Therapy (CET) for alcohol use disorder
Cue Exposure Therapy (CET) has been investigated in various studies to desensitize the patient similar to exposure therapy for anxiety disorders using triggering key stimuli (cues) and to enable dealing with a trigger with appropriate methods (CBT, USCS, MBSR, etc.) and bringing about long-term improvement. In the case of CET sessions, substance-dependent patients are exposed to the sight or smell of the substance or other triggers (so-called cues or triggers) without allowing consumption to weaken the stimulus connection through erasion and thus dampen the craving for the substance. This procedure is said to be highly effective in the case of alcohol use disorder (AUD), yet the study situation is inconsistent.
The assumption underlying CET is that numerous triggers connected to craving and excessive alcohol consumption have accumulated over time. As a result, triggers paired with withdrawal and relief drinking can trigger a conditioned desire (craving) when the individual is exposed to those triggers. These triggers include, for example: Seeing or imagining one’s favorite alcoholic drink; experiencing specific emotional states; being in the presence of other problem drinkers; attending social events such as parties; places where one buys or consumes alcohol; illegal drug use; cigarette smoking and, of course, consuming an alcoholic beverage can also trigger craving and excessive drinking.
CET is based on the idea that repeated exposure to these triggers, disconnected from actual drinking, can break the link between experiencing these triggers, strong cravings for alcohol, and a drinking relapse. CET is designed to help affected individuals to resist the urge to continue drinking in the presence of alcohol and other drinking triggers.
Although the therapy occurs in a clinical setting, the client may be required to carry out self-managed cue exposure sessions to build self-efficacy and promote generalization to the natural environment. The next stage to achieve possible generalization is using therapist-directed cue exposure in real environments. Affected individuals may, for example, be accompanied to a bar or restaurant where they usually drink excessively. Similarly to the clinic-based session, the individual is asked to imagine things, experience emotions, or interact with people that could elicit a craving. As in the clinic, craving and self-efficacy are measured regularly during the in vivo cue exposure session, and the therapist and client monitor how the client reacts to the cue exposure.
Previous application and success rates
Anxiety disorders vs. addiction therapy
It has been shown clearly that CET is successful in the treatment of psychiatric disorders with a parallel Pavlovian conditioning etiology, e.g., anxiety disorders.
Surprisingly, in contrast, CET effectiveness in addiction treatment is rather low. The effectiveness of CET is measured differently in the literature. More recent studies have come to rather conservative conclusions.
Meta review of CET for AUD
A meta review by the Syddansk Universitet (University of Southern Denmark) shows the following results:
- No meta-analytic review to date [as at 2017] has examined the effect of cue exposure therapy (CET) on alcohol use disorders (AUD).
- CET showed no to small effects on primary changes in drinking behavior and small to moderate effects on secondary effects (6-12 months after therapy) compared to control conditions.
- Due to inconsistencies and inaccuracies in the study design as well as suspected publication bias, the overall quality of the evidence was rated low.
- Summary of review: Overall, CET showed little to no primary change in drinking behavior. After 6 and 12 months, minor additional effects were observed, which indicates that the effectiveness of CET may increase over the course of time. Regarding secondary outcomes assessed at the 6-month follow-up, CET had a small additional effect on total drinking score and an additional moderate impact on latency to relapse. Stratification and analysis showed that CET, combined with USCS, may be the better option for treating AUD than conventional CET. However, as relatively few CET studies on AUD were available and these were judged to be very low-quality evidence, more robust methodological studies are needed to draw firm conclusions about the effectiveness of CET on AUD.
Criticism of the limited evidence
Another review concludes that, to date, CET has not shown any efficacy in treating addiction diseases. However, the literature is limited by methodological problems that are consistent throughout. Furthermore, extinction research does not translate easily into clinical applications, and the CET process could potentially benefit from refinement to take into account theoretical issues underlying extinction and individual differences between drug-dependent and non-dependent individuals.
A comparative review of similarities and differences between exposure therapy for anxiety disorders and CET found that there are theoretical and practical similarities between exposure to anxiety cues and addictive cues, particularly concerning extinction learning. The authors note the limited evidence for CET in other substance use disorders and emphasize the need for further investigation of the mechanisms and efficacy of CET.
The research and evidence on CET in AUD are so far too weak to come to a generally valid conclusion. Considering the fact that every patient will be confronted with corresponding cues/triggers sooner or later after their clinical stay, it seems reasonable to treat a corresponding exposure in advance in a (protected) therapeutic setting. Processing the basic familiar triggers seems easy, but hidden cues often can only be processed with difficulty, if at all. Often, in the absence of appropriate preparation for life after the clinical stay in the clinical setting, as well as follow-up care that may be difficult to access or non-existent, many patients fall into an emotional hole where they may be very vulnerable to relapse according to the known mechanisms of AUD. CET could significantly mitigate this in the integrative context of treatment overall as well as in aftercare planned in advance.