Augmenting outpatient alcohol treatment as usual with online approach bias modification training: A double-blind randomized controlled trial

Psychological treatment guidelines (GGZ-standaarden, 2020) propose interventions like Cognitive Behavioral Therapy (CBT) and Motivational Interviewing (MI) as outpatient care for patients with alcohol use disorder (AUD). Both CBT and MI focus on the slower, reflective processes by strengthening patients' cognitive control over their alcohol use (Magill & Ray, 2009) and exploring and resolving the patients’ ambivalence, focusing on strengthening their motivation to change their harmful behavior (Miller & Rollnick, 2013). Research in the past years has also explored the more impulsive aspects of addiction. Problem drinkers and patients with an AUD have an approach bias (Wiers et al., 2009, Wiers et al., 2011) for alcohol-related stimuli. It takes them less time to approach alcohol-related stimuli than to avoid such stimuli. Various computerized tasks have been constructed to influence these automatically activated biases, referred to as Cognitive Bias Modification (CBM). Influencing the tendency to approach alcohol, also known as Approach Bias Modification (ApBM) (Wiers & Kordts, 2010) seems to be one of the most promising strategies (Gladwin et al., 2017). One form of retraining automatic approach tendencies is an adjusted version of the Approach Avoidance Task (AAT) (Eberl et al., 2013; Wiers et al., 2011). In this training task, participants are asked to react to pictures of alcoholic and non-alcoholic drinks on their computer screen, using a joystick.

In an initial proof-of-principal study of ApBM with students, a change in bias and short-term drinking behavior were demonstrated (Wiers & Kordts, 2010). Subsequently, several studies aiming to gain insight into the clinical effectiveness of ApBM were carried out with inpatients of addiction care clinics, either during their detoxification period (Manning et al., 2016, Manning et al., 2021) or during the subsequent treatment phase (Eberl et al., 2013, Rinck et al., 2018, Salemink et al., 2021, Wiers et al., 2011). Findings demonstrated a range of 8.4 %-13 % less relapse at 1-year follow-up in the TAU group and higher abstinence rates when offering training during the detoxification period compared to sham training (54–69 % vs 43–47 %).

To make it possible to deliver the ApBM training to the most convenient time and place for participants, an online version was developed. Researchers were therefore able to conduct experiments with problem drinking participants from the general public. A first online randomized controlled trial with self-selected problem drinkers receiving four sessions of different varieties of cognitive bias modification (including ApBM), showed a reduction in drinking, but not significantly larger than in the control group (Wiers et al., 2015). Possible explanations for the absence of significant differences were the small statistical power compared to the larger clinical studies and the training goal: abstinence for patients in the clinical trials versus reduced drinking for problem drinking participants. Also, the clinical trials all added the ApBM to TAU, while the problem drinking participants completed the ApBM as stand-alone.

Recent research tried to tackle some of these issues by setting up a larger online trial (427 participants) with a 2x2x2 factorial design and adding two modules of an online cognitive-behavioral intervention (Drinkingless), consisting of personalized feedback and goal setting. This research was not able to prove the added value of online CBM for problem drinkers (van Deursen et al., 2020). Participants in all conditions reduced their drinking, including the TAU-only condition.

Summarizing, ApBM seems to work as an add-on to TAU in a clinical abstinent-oriented AUD treatment, resulting in lower relapse rates. On the other hand, online ApBM combined with or without a short CBT intervention does not seem to yield any additional results for problem drinkers. However, the added value of ApBM for AUD patients in an outpatient setting has not yet been established. As most contacts (>80 %) with clients in Dutch addiction care take place in an outpatient setting (Wisselink et al., 2016), the target audience for this possible benefit is quite large. In addition, offering ApBM training in a setting that exposes patients to cues related to alcohol may bolster training effects, as studies on anxiety suggest that emotional arousal before and during training may play a role in the effectiveness of attention bias modification (Kuckertz et al., 2014, Nuijs et al., 2020).

This research aims to investigate the effectiveness of online ApBM, combined with CBT treatment as usual for AUD patients in an outpatient treatment setting. We expect patients in the ApBM intervention condition to show a larger decrease in alcohol consumption and alcohol-approach bias compared to patients in the placebo condition.

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