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9 TREATMENT MODALITIES: PROCESS AND OUTCOME Evaluation research represents a key to the advancement of therapeutic effectiveness in alcohol treatment. Since 1980, more than 250 new studies have been published reporting outcome data on various approaches to the treatment of alcohol problems. This body of research has provided important new knowledge regarding optimal approaches to alcohol treatment, in addition to clarifying areas in which further research is most needed. A major continuing problem for the field is a gap between available knowledge and current practice. Much of what is presently done in alcohol treatment has not been evaluated; thus, the efficacy of standard components of many current treatment programs has not been established. Other approaches for which there is promising evidence of effectiveness remain largely unused in treatment. In an effort to close this gap, the sections below survey research focusing on a number of topics of interest: specific treatment approaches, traditional treatment programs, the intensity and duration of treatment, aftercare, and the treatment process itself. In the final section, the committee presents its conclusions and summarizes the opportunities for further progress in treatment research. OUTCOME RESEARCH ON SPECIFIC TREATMENT APPROACHES Most of the studies conducted since 1980 have focused on the effectiveness of particular treatment approaches or programs. This research includes many uncontrolled studies but also more than 60 studies that use controlled designs and more methodologically sophisticated approaches. "Controlled studies comprise those employing randomization or matching procedures to assign individuals to alternative treatment methods or to treatment versus control conditions. Uncontrolled studies typically report outcome data following a single intervention, or employ quasi-experimental designs (Cook and Campbell, 1979) to provide partial control of extraneous variables. Although both types of research can yield informative findings, controlled studies are less subject to confounding and tend to produce more reliable and interpretable results. In this review, therefore, greater emphasis will be placed on the findings of properly controlled evaluations. Evaluations of interventions for alcohol problems can also be divided according to the point at which intervention occurs. Preventive interventions, generally administered prior to the onset of serious alcohol problems, are discussed in Part`I of this report. Within formal treatment, three phases can be distinguished: (1) detoxification, (2) active treatment and rehabilitation, and (3) relapse prevention. Intervention procedures during the first phase, detoxification, are designed to carry the individual safely through the process of alcohol withdrawal, minimizing the risks associated with the abstinence syndrome for those who are more severely dependent on alcohol. Detoxification typically yields little or no long-term change in alcohol consumption and related problems and is usually viewed as a prelude to active treatment. -169

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Phase 2, active treatment, seeks to bring about change in the individual's use of alcohol and other drugs and to reduce problems associated with that use. Typically, the goal of treatment programs has been total abstention from alcohol and other drugs of abuse. A wide range of treatment strategies is available to achieve this goal, and research on these alternative modalities is discussed in the subsections below. After each discussion are questions that identitr opportunities for research in these treatment areas. During the 1980s, increased attention has been devoted to the importance of relapse prevention as a third phase of treatment. The goal of these efforts is to help the individual avoid a relapse to previous patterns of problematic drinking. When this phase follows inpatient treatment, it is sometimes called aftercare. In essence, relapse prevention is a logical extension of treatment efforts in that it attempts to sustain and stabilize the beneficial changes that have occurred during the initial phases of treatment. Relapse prevention strategies have been incorporated into treatment programs. Principles underlying some of these strategies are described in Chapter 3. In this section of the report, they are discussed among the alternative treatment modalities. Pharmacotherapies The use of medications in the treatment of alcohol problems can be divided into three major strategies. Antidipsotropic medications cause adverse results when alcohol is consumed. Their intended effect is to suppress drinking. Effect-altering medications likewise are intended to suppress alcohol consumption but through a different mechanism. Rather than precipitating aversive reactions to alcohol, these medications are designed to diminish the reinforcing or intoxicating properties of ethanol. Psychotropic medications, by contrast, are designed to treat such concomitant disorders as depression, psychosis, or anxiety. Their intended effect is to alleviate psychopathology that may accompany alcohol abuse, thereby diminishing the likelihood of relapse to drinking and improving the person's overall functioning. Antidipsotropics Within the United States, the principal antidipsotropic agent is disulfiram (Antabuse). Taken on a regular basis, disulfiram induces an adverse reaction of variable severity if the person consumes alcohol. New studies have provided mixed evidence regarding the usefulness of disulfiram in promoting improvement. Like earlier research, recent studies (e.g., Duckert and Johnsen, 1987; Thurston, Alfano, and Ne~viano, 1987) have reported a relationship between voluntary compliance with disulfiram and favorable treatment outcome. In such investigations, however, medication effects were confounded with individual difference variables affecting motivation and compliance. Several new controlled trials have failed to show benefits from disulfiram. Powell and colleagues (1985) found no differences in outcome over 12 months of follow-up among groups that were assigned at random to receive medication (disulfiram plus the option of chlordiazepoxide), medication plus supportive counseling, or a control group receiving only monitoring of medical problems. In studies of alcoholics who were being treated in Veterans Administration methadone clinics, Ling and coworkers (1983) observed no differences in abstinence, treatment compliance, or breath test results between groups that were randomly assigned to receive disulfiram and those assigned to receive a placebo. -170

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Schuckit (1985) also reported no difference in the 12-month outcome between alcoholics who were prescribed and agreed to take disulfiram and those who refused to take it. Recent research further suggests that most or all of the therapeutic impact of disulfiram prescription (at least without compliance assurance) may not be attributable to specific medication effects. Fuller and Williford (1980), in a urinalysis of a randomized clinical trial, reported that two groups of alcoholics who were given disulfiram showed significantly higher abstinence rates at 12 months, compared with those who were given no disulfiram Only one of the two medicated groups received a therapeutic dose, however, whereas the other was given only 1 milligram (mg), an inert dose. Thus, both groups who believed they were receiving disulfiram showed higher abstinence rates. In the largest and most carefully designed clinical trial of disulfiram to date, Fuller and coworkers (1986) replicated their earlier study in a nine-site collaborative research program. Outpatient alcoholics were again randomly assigned to receive 250 mg (therapeutic) doses, 1 mg (inert) doses of disulf~ram, or a vitamin supplement and no disulfiram. Over 12 months of follow-up, the three groups did not differ on measures of total abstinence, employment, or social stability. Comnliance with medication {even the inert (1~.CP. or the. vitamin supplement) was highly associated with abstinence. Within the subgroup of individuals who were highly compliant with research procedures and provided complete data, those given the therapeutic dose reported significantly fewer drinking days than their counterparts in the two control groups. Other studies have employed the surgical implantation of disulfiram in an attempt to avoid problems with compliance. Wilson, Davidson, and Blanchard (1980) found a substantially higher rate of abstinence in two groups undergoing surgical operations--one for the implantation of disulfiram, the other for an inert implant-- relative to a random control group that was given no operation. No difference in outcome was observed between the disulfiram and inert implant groups. Johnsen and colleagues (1987) similarly found no differences in a double-blind randomization study comparing disulfiram and inert implantation. The failure of disulfiram implants to show a specific medication effect, however, may be due to the low probability of a disulfiram-ethanol reaction, even when the person drinks (Wilson et al., 1984; Johnsen et al., 1987~. Future research may discover more effective methods administering long-acting doses of disulfiram. A danger attached to long-acting parenteral administration, however, is the difficulty of reversing an acute disulfiram-ethanol reaction if the individual consumes alcohol. Thus, at present, oral administration is the standard procedure for administering antidipsotropics in the United States, and compliance is a crucial issue in the effectiveness of oral disulfiram. Recent studies have found few or no differences between disulfiram acceptors and refusers on the basis of personality and demographic variables (O'Neil et al., 1982; Schuckit, 1985), which suggests that contextual or attitudinal factors may be important determinants of compliance (Brubaker, Prue, and Rychtarik, 1987~. Motivational strategies to promote medication compliance appear to increase the impact of disulfiram treatment. Azrin and coworkers (1982) tested a simple disulfiram assurance procedure whereby the alcoholic took the medication daily in the presence of a significant other who provided praise and support for compliance. At the six-month follow-up point, those in the disulfiram assurance group showed substantially better outcomes than randomly chosen controls for whom disulfiram was prescribed but who were given no compliance intervention. The difference was greatest for married persons, perhaps because of the spouse's availability to serve as the reinforcing partner. -171

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In another study, Kofoed (1987) found that a chemical monitoring system to verify disulfiram intake increased medication compliance in a controlled trial but did not affect compliance with other aspects of treatment. Keane and colleagues (1984) reported favorable results with a home-based disulfiram compliance program that involved monitoring and contracting with the spouse. Determination of the effects of mandated monitoring of disulfiram compliance on long-term outcomes, either by chemical testing or by direct observation (e.g., Sereny et al., 1986), has not yet been evaluated in a properly controlled trial. Calcium carbimide, an alternative antidipsotropic medication, has been tested in other countries but has not yet been approved for therapeutic use in the United States. A pharmacologic comparison of carbimide and disulfiram indicated similar adverse reactions when alcohol is consumed, with the carbimide-ethanol reaction being somewhat more severe (Peachey et al., 1983~. However, the pharmacodynamics of carbimide differ significantly from those of disulfiram. The more rapid onset and increased intensity of aversive effect with carbimide may offer advantages for certain therapeutic applications. Peachey and Annis (1985) proposed its use as part of a relapse prevention procedure whereby an individual could take it acutely in anticipation of a high-risk situation. Furthermore, carbimide appears to be less toxic and to yield fewer side effects than disulBram (Peachey and Annis, 1984~. Well-controlled clinical trials of carbimide have not yet been reported. If future trials reflect positive outcomes, however, carbimide should be made available in the United States as an alternative pharmacotherapeutic agent for the treatment of alcohol problems. The potential benefits of antidipsotropics must be weighed against their side effects and the potential hazards associated with their longer term use, particularly in light of studies reflecting no differences between medication and control groups. Recent reports suggest that antidipsotropic medication may increase sexual dysfunction (Snyder, Karacan, and Salis, 1981; Jensen, 1984) and a craving for alcohol (Nirenberg et al., 1983; Stockwell, Sutherland, and Edwards, 1984), in addition to other commonly reported side effects. However, at least one double-blind study found no differences in side effects between disulfiram and placebo groups (Christensen, Ronsted, and Vaag, 1984~. The following questions represent opportunities for research on antidipsotropic medications: . What motivational procedures most effectively increase compliance with antidipsotropic medications? . What are optimal combinations of antidipsotropic medication with other treatment strategies? What are the characteristics of individuals who accept and respond favorably to the various classes of antidipsotropic medications? What are the effects of mandatory monitoring of compliance with antidipsotropics? Does this procedure increase abstinence during and after the period of mandatory monitoring? What are the effects of various antidipsotropic medications on subjective desire and craving for alcohol? What methods of administration, if any, could be used safely to sustain effective and long-acting doses of antidipsotropic medications? _ ~ -172

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Effect-Altering Medications Effect-altering medications reduce the reinforcing properties of ethanol without producing illness. Rockman and coworkers (1979) reported that zimelidine, a serotonin uptake inhibitor, diminished alcohol intake by animals in a free-choice drinking paradigm. Similar results have been reported in rodent studies of other serotonin uptake inhibitors including norzimelidine, citalopram, alaproclate, fluoxetine, indalpine, viqualine, and fluvoxamine. In studies with nondepressed, nondependent, heavy-drinking humans, zimelidine and citalopram have been found to reduce alcohol intake (Naranjo et al., 1984, 19873. The principal effect of zimelidine was found to be an increase in the number of abstinent days for heavy drinkers. Moreover, zimelidine was effective within the first two weeks of treatment, before its antidepressant effects normally occur (Naranjo et al., 1984~. Amit and colleagues (1985) found that drinkers given a single dose of zimelidine reported a reduced euphoriant effect from alcohol as well as a decreased desire to drink These effects of zimelidine may be due to an effect on the reinforcing properties of ethanol or to a generalized suppressant effect on both food and alcohol consumption (Gill and Amit, 1987~. Because zimelidine produced flulike symptoms and neuropathy in a significant number of subjects who were being treated for depression, it has been withdrawn from human use. Other serotonin uptake inhibitors such as fluoxetine and fluvoxamine would appear to be reasonable candidates for therapeutic trial in alcoholic patients (Linnoila, et al., 1987) but thus far have been tested only; in heavy drinkers. Fluoxetine does not act synergistically with alcohol on physiologic, psychometric, or psychomotor activity; it also does not increase blood alcohol levels (Lemberger et al., 1985~. Recent work by E. M. Sellers of the Addiction Research Foundation of Ontario (personal communication, 1988) suggests that fluoxetine affects the initiation of drinking behavior as opposed to moderating drinking episodes. nuvoxamine is approximately three times as selective in serotonin uptake inhibition (relative to norepinephrine reuptake) as zimelidine. At the time of this report, one serotonin uptake inhibitor (fluoxetine) has been approved for the treatment of depre~ssive disorders in the United States. Effect-altering medications could be used in the treatment of alcohol-dependent persons much as opiate antagonists have been used in treating opiate addiction. It may be useful to combine such pharmacotherapy with psychological inte~ventions designed to enhance motivation and medication compliance. The following questions represent opportunities for research on effect-altering medications: . What is the impact of various effect-altering medications on subjective desires and cravings for alcohol and on the perceived reinforcing effects of alcohol consumption? What motivational procedures most effectively increase compliance with effect-altering medications? . What are the side effects and long-term risks involved in the use of various effect-altering medications? Do effect-altering medications promote long-term sobriety? What is an optimal duration for treatment with effect-altering medications to maximize therapeutic effects while minimizing side effects and medication-related risks? -173

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What are the characteristics of individuals who accept and respond favorably to various classes of effect-altering medications? What are optimal combinations of effect-altering medications and other treatment strategies? Psychotropics Psychotropic medications have three potential uses in the treatment of alcohol problems. First, certain medications are of demonstrated utility during alcohol detoxification (Liskow and Goodwin, 1987~. The usefulness of such medications during acute withdrawal is now generally accepted, although detoxification can often be accomplished without medication in nonhospital settings (Whitfield et al., 1978; Whitfield, 1980; Sparadeo et al., 1982~. Second, as indicated in the discussion of effect-altering drugs, it has been suggested that some psychotropic medications may decrease the desire for and use of alcohol (McMillan, 1981~. In addition to the antidepressants and serotonin uptake inhibitors discussed earlier, lithium has been investigated in this regard. Fawcett and colleagues (1987) found no differences on drinking measures between alcoholics given lithium and alcoholics given a placebo. Compliance with either medication was highly associated with abstinence. Among compliant individuals, those sustaining high blood levels of lithium did show a higher rate of abstinence than those with low lithium levels or placebo doses. No differences were observed between depressed and nondepressed alcoholics. Other investigations, including a major Veterans Administration collaborative study, have found no therapeutic impact of lithium on the drinking outcomes of either depressed or nondepressed alcoholics (Peck et al., 1981; Pond et al., 1981; Powell et al., 1986; Dorus, 1988~. A variety of other psychotropic medications have been tested for their effects on drinking behavior and the desire to drink (Liskow and Goodwin, 1987~. A third potential use of psychotropic medications is in the treatment of "dual diagnosis individuals, who manifest both alcohol abuse and another significant form of DsvchoDatholo~v. Current evidence indicates that untreated concomitant Dsvc}~onatholo~v . ~ . in, ~ , ~ ~ .. .. . . . _ . _ _. . . generally predicts a poor prognosis for alcoholics (Hounsavllle et al., 1Ys7) and is associated with ~ high rate of treatment dropout (Kofoed et al., 1986). It is logical (although not yet conclusively demonstrated) that alcoholics with major depression that persists into sobriety would be significantly more likely to remain sober if their depression could be treated effectively by antidepressant medication or other means. Similarly, it is quite plausible that individuals with concomitant alcohol abuse and schizophrenia would benefit from antipsychotic medication and that alcoholics with bipolar affective disorder would have an improved prognosis if given lithium. It is important to note here that apparent psychopathology that coincides with active alcohol and drug abuse frequently remits during the early weeks of sobriety (Nakamura et al., 1983~. Sufficient time should be allowed for full withdrawal from abused drugs, and the diagnosis should be firmly established before psychotropic medication is considered. Nonpharmacological alternatives should also be considered in treating concomitant psychopathology (e.g., depression or anxiety). Extreme caution is warranted in the prescription of psychiatric medications with a high potential for abuse and dependence. However, many medications of known therapeutic value for other conditions (e.g., lithium, antipsychotic and antidepressant agents) pose few risks of abuse or dependence. Given -174

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proper consideration and precautions, there is no persuasive reason to deny such medications to alcoholics who manifest concomitant psychopathology for which these drug treatments are known to be effective therapeutic agents. Finally, it is worth noting that no medication currently constitutes a primary treatment for alcohol problems. Pharmacotherapy is only an adjunctive treatment that is best used in combination with other strategies. Medications are not regarded as a "cures for alcohol problems, but when properly used, they may be valuable aids in the recovery process. The following questions represents opportunities for research on psychotropic medications: . For persons with dual diagnoses (e.g., major depression' bipolar disorder' schizophrenia), does appropriate psychotropic medication reduce the risk of relapse and improve other aspects of outcome? What is the relative effectiveness in reducing relapse potential of psychotropic medication versus alternative drug-free strategies of treatment (e.g., cognitive-behavioral therapy) for individuals with concomitant psychopathology? Are certain psychotropic medications of value in reducing drinking or the desire to drink among alcoholics without concomitant psychopathology? What therapeutic doses, verified by appropriate means (e.~.. serum monitoring. ~ in, O., are essential to produce improvement in treatment outcome? When are the optimal time (in the continuum of detoxification, active treatment, and relapse prevention) and duration for administering psychotropic medications as an aid to recovery? Aversion Therapies Aversion therapy for alcohol abuse is based on the principle of counterconditioning. Attraction to, and positive associations with, alcohol are replaced by conditioned aversive reactions. Unlike the antidipsotropic medications, aversion therapy is designed to produce an enduring adverse reaction to alcohol in the absence of medication. In aversion therapy, alcohol is associated with unpleasant experiences or images. The typical and intended effects are a loss of desire for alcohol and avoidance of drinking. Various methods have been used to produce conditioned aversive responses to alcohol. Electrical and apneic aversion have fallen into justifiable disuse, and no new studies have appeared since 1980 (Miller and Hester, 1986a; Wilson, 1987~. Chemical aversion pairs alcohol with nausea and vomiting induced by emetic drugs. Aversion therapy is a mainstay of alcohol treatment in the Soviet Union and continues to be used in some U.S. treatment centers. In the 1980s, however, chemical aversion therapy has come under sharp attack (National Center for Health Care Technology, 1981; Wilson, 1987~. Although uncontrolled studies have reported relatively high rates of abstinence (Miller and Hester, 1980; Neuberger et al., 1980, 1981, 1982), support from controlled studies has been weak, and the absolute impact of chemical aversion treatment beyond or in the absence of adiunctive therapeutic _ ~ J ~ approaches Is unclear. cannon, Baker, and Wehl (1981) found no long-term differences between a group treated with chemical aversion and a control group receiving only standard hospital treatment, although both fared better than a group that received electrical aversion. Richard (1983) found no effects of an aversion procedure based on nausea induced by -175

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motion sickness. Thurber (1985) expressed cautious optimism based on a meta-analysis of controlled studies of chemical aversive counterconditioning. The Council on Scientific Affairs of the American Medical Association (1987) likewise found Positive results. from aversion therapies but called for further controlled trials. Wilson (1987), in contrast, concluded that the use of chemical aversion therapy for alcoholism is unwarranted, given its stressful and potentially hazardous nature and the absence of clear evidence for its efficacy. One strength of the chemical aversion approach is its foundation in basic research and learning theory. Acquired and persistent taste aversion is a well-established phenomenon in mammals, including humans. Elkins (1984) demonstrated a strong relationship between the intensity of induced nausea and the persistence of taste aversion. Elkins and Hobbs (1982) likewise demonstrated a potent genetic influence on the susceptibility to taste aversion learning, perhaps mirroring human individual differences in response to this treatment modality. This inherited susceptibility factor appears to be quite specific to taste aversion and is not generalized to other learning paradigms such as electric shock aversion (Hobbs and Elkins, 1983; Elkins, 1986~. Recent human research has demonstrated that chemical aversion therapy does produce a conditioned aversive response to alcohol and that the strength of conditioning is predictive of treatment outcome (Cannon and Baker, 1981; Cannon, Baker, and Wehl, 1981; Baker et al., 1984; Cannon et al., 1986~. The robustness of these experimental findings and of the taste aversion conditioning phenomenon itself warrants further investigation of taste aversion therapy for alcohol problems. Covert sensitization is an alternative aversive counterconditioning procedure employing only imagery. It requires no use of drugs or shock, is less physically stressful, and can be administered in outpatient treatment. Recent studies have demonstrated that conditioned aversion to alcohol can be produced by covert sensitization and that (as with chemical aversion) the strength of conditioning is predictive of treatment outcome (Elkins, 1980; Miller and Dougher, 1984~. Olson and colleagues (1981) demonstrated greater suppression of drinking among alcoholics assigned at random to receive behavior therapy (including covert sensitization), relative to two groups receiving transactional analysis or milieu treatment alone. Covert sensitization administered in groups was found in two studies to be ineffective (Sanchez-Craig and Walker, 1982; Telch, Hannon, and Telch, 1984~. Finally, it should be noted that certain therapeutic procedures for alcohol problems (including some aversion therapies) require the administration of small amounts of alcohol to those undergoing treatment. Certain relapse prevention and cue exposure procedures may require exposure to the sight, smell, or taste of alcohol (see Chapter 12~. Research on these procedures may thus require the presentation of alcohol to alcohol-dependent persons. Recent reports have specified clear ethical guidelines for the administration or exposure to alcohol of persons with alcohol problems, for research purposes (NIAAA, 1988~. Available evidence indicates that when such guidelines are carefully followed, the administration of alcohol during research or treatment poses no significant risks to the indiv~dual's welfare. The following questions represent opportunities for research on aversion therapies: . Does the addition of chemical aversion therapy to an alcohol treatment program significantly improve long-term outcomes? Does covert sensitization suppress urges to drink and have beneficial effects on long-term outcomes? -176

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Do chemical aversion and covert sensitization differ in their relative impact on drinking behavior and on urges or the craving to drink? What individual factors predict the establishment of conditioned aversion and of favorable responses to aversion therapy? Psychotherapy and Counseling Controlled treatment outcome studies prior to 1980 failed to yield persuasive evidence for the effectiveness of psychodynamic psychotherapy with alcoholics (Miller and Hester, 1980~. Recent controlled studies have not substantially altered this trend, although more promising results have been obtained in drug abuse populations (see Chapter 12~. Olson and colleagues (1981) found that insight-oriented psychotherapy yielded no increase in effectiveness when added to a milieu treatment program and was less effective than behavioral approaches. Brandsma, Maultsby, and Welsh (1980) found somewhat fewer clanking days among mandated individuals assigned at random to either cognitive-behavioral or insight-oriented therapy, relative to untreated controls after one year. Braunstein et al. (1983) observed no differences in outcome between those assigned at random to aftercare that included individual counseling and group psychotherapy and two control groups that were given only medical monitoring. Annis and Chan (1983) similarly found no effect of confrontational group therapy in a random assignment design with incarcerated alcohol-related offenders. Individuals low in self-esteem, however, showed detrimental effects from confrontational psychotherapy, whereas those higher in self-esteem evidenced some benefit. In another randomized trial, Swenson and Clay (1980) observed no differences at an eight-month follow-up interval between drunk-driving offenders assigned to confrontational group therapy and those given only a home-study course. There has been increased interest in and research on cognitive-behavioral therapy with alcoholics, although the results of outcome studies to date have been mixed. Oei and Jaclo;on (1982) found significantly greater improvement among two groups of alcoholics that were randomly assigned to receive cognitive restructuring, relative to controls who received the same residential treatment without cognitive therapy. Modeling and reinforcement of positive self-statements appear to be important to the effectiveness of cognitive therapy with alcoholics (Oei and Jackson, 1984~. Positive results have been reported from a prevention program based on cognitive-behavioral procedures (Botvin et al., 1984a). Other randomized clinical trials have reported no significant effect of cognitive therapies with drunk-driving offenders (Rosenberg and Brian, 1986) or halfway house residents (Sanchez-Craig and Walker, 1982; Walker, Sanchez-Craig, and Bornet, 1982~. Psychotherapy is also used in the treatment of concomitant psychopathology. For example, two types of psychotherapy (interpersonal and cognitive-behavioral) have been evaluated rigorously for their effectiveness in the treatment of outpatients with major depression; generally positive results have been reported (Elkin et al., 1989~. For alcoholics with concomitant depression, then, psychotherapy may be effective not only in treating depression, but also in diminishing the likelihood of relapse to drinking. Such therapeutic effects with alcoholics, however, have not yet been demonstrated in properly controlled studies. A common problem in research on psychotherapy and counseling is the definition and integrity of interventions. What constitutes the "psychotherapy" or "counselings given? Evaluations should, as much as possible, specify and standardize the treatment being studied. Efforts should also be made to ensure the integrity and consistenc,', of delivery of -177

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the specified psychotherapeutic procedures. The ~ ~~ counseling: following questions represent opportunities for research on psychotherapy and Are certain therapies (e.g., cognitive-behavioral therapy) differentially effective in preventing relapse to drinking for persons manifesting concomitant psychopathology (e.g., depression) for which the therapy is an effective treatment? In treating psychopathology concomitant to alcohol abuse, do psychotherapy and psychotropic medication differ in their impact on drinking? What are the components and processes of counseling as typically administered by alcohol counselors? What approaches to or components of alcohol counseling significantly improve treatment outcome? Are there additive effects of psychotherapy or counseling in combination with other therapeutic strategies (e.g., pharmacotherapy)? Within the continuum of detoxification, active treatment, and relapse prevention, when is the optimal time to initiate psychotherapeutic intervention? . What individual difference variables (e.g., degree of residual cognitive impairment) are predictive of response to psychotherapy? Didactic Approaches Treatment programs frequently include educational lectures on alcohol and related problems. Interventions with drunk-driving offenders sometimes rely solely on educational strategies. Siegal (1985a,b) reported lower recidivism in two educational intervention groups than in a nonrandom control group whose members apparently were given jail sentences. Yet controlled research to date has failed to yield any persuasive evidence of the impact of such educational strategies on drinking behavior among problem drinkers or alcoholics (Uecker and Solberg, 1973; Swenson and Clay, 1980; Miller and Hester, 1986a). One concern here is whether cognitive impairment from excessive drinking may deter alcoholics from comprehending and retaining information presented in traditional educational approaches. Two studies reported very poor retention of treatment-relevant information by alcoholics (Sanchez-Craig and Walker, 1982; Becker and Jaffe, 1984~. The following questions represent opportunities for research on didactic approaches: What contributions to treatment outcome are made by educational lectures within the context of a multimodal treatment program? Does the level of cognitive impairment predict the response of alcoholics to educational interventions? What short-term changes, if any (e.g., information gain, attitude shifts, motivation increases) are predictive of long-term behavior change following educational interventions? What elements of newly developed educational technologies could be tested that might increase the effectiveness of traditional classes? Mutual Help Groups Although it has been in existence since 1935 and has been an important shaping force in alcohol treatment in the United States, Alcoholics Anonymous (AA) has been subjected -178

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to surprisingly little scientific study. In the 1980s, contributions to the literature on AA have continued to consist primarily of commentaries and summaries of available correlational data (Glaser and Ogborne, 1982; Kurtz, 1982; Emrick, 1987~. Some progress has been made toward identifying the characteristics of individuals who are most likely to maintain affiliation with AA (Boscarino, 1980; Ogborne and Glaser, 1981), although favorable outcomes in AA are by no means limited to particular types of persons (Emrick, 1987~. Correlational studies continue to support a relationship between abstinence and AA attendance (Afford, 1980; Polich, Armor and Braiker, 1980; Hoffman, Harrison, and Belille, 1983~. Both correlational and controlled studies have suggested a relationship between AA attendance and greater severity of symptomatology if subsequent drinking does occur (Brandsma, Maultsby, and Welsh, 1980; Ogborne and Bornet, 1982; Walker, Sanchez-Craig and Bornet, 1982; Stimmel et al., 1983~. The findings of correlational investigations are difficult to interpret because differences (e.g., between AA attenders and nonattenders) may be attributable to a variety of factors that are confounded in such studies. Treatment-compliant individuals, for example, generally show better prognosis than those who are less compliant (Fuller et al., 1986; Fawcett et al., 1987~. An observed relationship between treatment exposure and outcome, then, may be due not to specific characteristics of the treatment but to nonspecific individual difference factors that drive compliance. Prior to 1980 only one controlled study had been conducted of outcomes of AA (Ditman et al., 1967~. Only two controlled outcome studies of AA have appeared in the 198Os. Brandsma, Maultsby; and Welsh (1980) found no long-term differences between problem drinkers who were court-mandated to participate in AA and those who were assigned at random to a no-treatment condition. A second controlled evaluation (Stimmel et al., 1983) compared outcomes of alcohol-abusing methadone maintenance patients assigned at random to an AA-based therapy group, a controlled drinking training group, or a control group (no additional treatment beyond the methadone program). Among treatment completers (fewer than 20 percent), the controlled drinking and control groups showed decreased drinking on a measure of peak use, whereas the AA abstinence-focused group reported an increase on the same measure. (The relevance of this study for the principal target population of AA, namely alcoholics without other substance abuse problems, remains in doubt.) - Given its great importance in U.S. treatment programs, it is unfortunate that AA has not been the subject of more empirical research. The inherent anonymity of the treatment group presents special but not insurmountable challenges in studying its effectiveness. Advances in outcome assessment and in program evaluation methodology have increased the feasibility of conducting meaningful research on AA processes and effectiveness (Glaser and Ogborne, 1982~. Alcoholics Anonymous is available in nearly every U.S. city, offering a free and highly accessible support system for recovering alcoholics. Because it is free, on a cost-effectiveness basis AA is likely to compare favorably with alternative intervention approaches. Furthermore, the enduring success of this organization in attracting alcoholics to recovery is itself worthy of study. There is, therefore, a pressing need for high-quality research on the impact and mechanisms of AA. In addition to AA, other U.S. mutual help movements currently include AlAnon, Women for Sobriety, and Adult Children of Alcoholics. The impact of affiliation on members of these groups and their families is unknown. Systematic outcome research on mutual help groups for alcoholics and their families represents a promising avenue for future study. -179

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