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Prevention and Treatment of Alcohol Problems: Research Opportunities (1990)

Chapter: 9 Treatment Modalities: Process and Outcome

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Suggested Citation:"9 Treatment Modalities: Process and Outcome." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"9 Treatment Modalities: Process and Outcome." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"9 Treatment Modalities: Process and Outcome." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"9 Treatment Modalities: Process and Outcome." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"9 Treatment Modalities: Process and Outcome." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"9 Treatment Modalities: Process and Outcome." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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Suggested Citation:"9 Treatment Modalities: Process and Outcome." Institute of Medicine. 1990. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, DC: The National Academies Press. doi: 10.17226/1486.
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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

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

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

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

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

· 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

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

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

· 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

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

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

. The following questions represent opportunities for research on mutual help groups: . What are the long-term impact and cost-effectiveness of participation in mutual help groups, relative to alternative approaches? There is a particular need for outcome research employing a range of contemporary treatment assessment approaches. . What role does mutual help group participation play in the context of multimodal treatment programs? · What are the characteristics of individuals who maintain a stable affiliation with mutual help groups and experience favorable outcomes? What is the impact of mandated mutual help group attendance among offenders, relative to alternative interventions or legal sanctions alone? · What are the key mechanisms of effective change for those who maintain successful affiliation with mutual help groups? · What differentiates long-term affiliates from those who do not attend or who drop out after brief attendance? · What common stages or processes of change may underlie (a) remission without formal treatment, (b) remission following formal treatment, and (c) remission associated with participation in mutual help groups? Behavioral Self-Control Training Behavioral self-control training (BSC~ as applied to the treatment of alcoholism consists of a set of self-management procedures that are intended to help problem drinkers reduce or stop alcohol consumption (Sanchez-Craig, 1984). Since 1980 there have been more studies on the effectiveness of BSCl than on any other single treatment modality for alcohol abuse. A number of controlled studies compared alternative BSCI~ procedures or contrasted BSCI~ with other approaches. Brown (1980) found significantly greater reductions in drinking among driving-while-intoxicated (DWI) offenders who were given BSCI than among those receiving conventional alcohol education. Connors, Maisto, and Ersner-Hershfield (1986), who also worked with DWI offenders, reported that BSCI' resulted in significantly reduced consumption, whereas two random control groups showed no change. Four controlled studies offering BSCI to outpatient problem drinkers and randomly assigning them to abstinence versus moderation goals found no long-term differences in outcome based on the assigned goal (Sanchez-Craig, 1980; Stimmel et al., 1983; Sanchez-Craig et al., 1984; Orford and Keddie, 1986; Graber and Miller, 1988) Other research efforts have produced somewhat different results. Foy, Nunn, and Rychtarik (1984), working with inpatient alcoholics, assigned them at random to receive or not receive moderation-oriented BSCT training in addition to the abstinence-based award program. Those given the additional moderation training fared worse at short-term follow-up but showed no different long-term outcome from those receiving only abstinence-oriented treatment (Rychtarik et al., 1987~. Other studies found comparable impacts from therapist-administered and self-administered BSCI~ (Miller and Taylor, 1980; Miller, Taylor, and West, 1980; Miller, Gribskov, and Mortell, 1981; Carpenter, Lyons, and Miller, 1985; Berg and Skutle, 1986; Skutle and Berg, 1987~. The outcomes of BSCT, even in controlled trials, have thus ranged from significant benefit (e.g., Brown, 1980) to a detrimental effect (Foy, Nunn, and Rychtarik, 1984~. Comparisons with alternative treatment modalities have sometimes but not always yielded differences -180

favoring BSCI. A plausible reason for this diversity of findings is the heterogeneity of populations included in these studies. Other causes of diversity include variations in content and in implementation effectiveness of the BSCT method. Treated populations have included inpatients on an alcohol unit (Foy, Nunn, and Rychtarik, 1984), heroin addicts on methadone maintenance (Stimmel et al., 1983), drunk-driving offenders (Brown, 1980), and self-referred problem drinkers from the community (Miller, Taylor, and West, 1~, Miller, Gribskov, and Mortell, 1981~. Further study should be directed toward an examination of the characteristics of individuals and populations for whom BSCI~ procedures are optimally effective. The following opportunities exist for research on behavioral self-control training: · Studies are needed to address the following question: How effective is abstinence-oriented BSCr, relative to other approaches to abstinence? Conjoint Therapies Recent research supports a strong association between favorable family adjustment and sustained abstinence or problem-free drinking after treatment (Moos, Finney and Gamble; 1982; Billings and Moos, 1983; Moos and Moos, 1984~. This association suggests that interventions to improve the relationship functioning of couples and families may enhance treatment outcome. New data are available regarding conjoint couples therapy as an adjunct to alcohol treatment. One study found that, over six months of follow-up, alcoholics given behavioral marital therapy showed more rapid reductions in drinking and somewhat better maintenance of sobriety than two control groups (McCrady et al., 1987~. Similarly, Stout and colleagues (1988) reported that alcoholics who undertook behavioral marital therapy showed superior outcomes at longer follow-up points, relative to those treated with only an alcohol problem focus. However, a four-year follow-up study supported earlier findings that joint hospitalization of alcoholics and their spouses did not improve outcome relative to hospitalization of the alcoholics alone (McCrady et al., 1982~. Conjoint therapy has also been found to decrease the probability of treatment dropout (Noel et al., 1987; Weidman, 1987~. O'Farrell, Cutter, and Floyd (1985) compared group behavioral marital therapy with an "interactional" couples group focusing on mutual support, discussion of feelings, and insights. Couples in behavioral marital therapy showed greater improvement in marital functioning than those in the interactional group, relative to controls who received no marital therapy. On a measure of alcohol-free days, all groups showed improvement, but individuals in behavioral marital therapy improved significantly more than those treated by interactional couples group therapy. Interventions with spouses of alcoholics have also been tested. In one controlled study (Dittrich and Trapold, 1984), wives of alcoholics who were given eight weeks of treatment showed significantly greater reductions in anxiety and enabling behavior and significantly enhanced self-concents relative to a random waiting list control group. ~. Although recent studies provide support for the effectiveness of behavioral marital therapy current alcohol treatment programs include a much wider range of interventions for couples and families. These include confrontational family sessions, AlAnon and AlaTeen meetings, -181

groups for young and adult children of alcoholics, and a variety of other conjoint and group approaches to marital and family counseling. The effectiveness of these approaches, however, is unknown. Reports of studies that compare alternative approaches have only recently begun to appear (e.g., Zweben, Pearlman and Li, 1988~. Current research has focused largely on couples in which both spouses were cooperative and willing to participate in treatment. Yet a common problem in treatment is the uncooperative partner. Unilateral interventions have been described for working with one spouse (Thomas and Santa, 1982; Thomas et al., in press). The effectiveness of such unilateral marital/family therapy interventions, with either the alcoholic or the alcoholic's spouse, is unclear at present. Furthermore, only couples therapies have been systematically evaluated (most evaluations have focused on behavioral marital therapy), and the effectiveness of treating alcoholics within the context of the whole family is unknown. New research is needed to explore the effects of conjoint therapies, not only on the drinking of the alcoholics but also on the adjustment of spouses, children, and other family members. The following questions represent opportunities for research on conjoint therapies: · What couples and family therapy approaches contribute significantly to favorable outcomes for treated alcoholics and their families? · What is the relative effectiveness of treating the individual alcoholic, the couple, or the entire family? · In what ways and by what processes do conjoint therapies contribute to long-term favorable outcomes? · What dimensions of adjustment should be assessed as prognostic and outcome measures in family members? · For what subpopulations is conjoint therapy effective. ineffective. or contraindicated? ~ In the continuum of detoxification, active treatment, and relapse prevention, at what point is it most effective to introduce conjoint therapy? - · When the spouse (without alcohol problems) is unwilling to enter treatment, what unilateral interventions are effective in improving relationship functioning for the couple or family and in decreasing the likelihood of relapse? Broad-Spectrum Treatment Strategies The term Broad spectrums applies to treatment strategies that address not only alcohol consumption but other problem areas that may be functionally related to alcohol abuse. Broad-spectrum treatments have been generally (although not necessarily) derived from a social learning theory approach to alcohol problems. Evidence increasingly indicates that appropriately planned broad-spectrum treatment is associated with lower rates of relapse to alcohol abuse (Miller and Hester, 1986a). Broad-spectrum treatment strategies should not be seen as treating an "underlying causer of alcohol problems. Rather, these strategies appear to be useful in relapse prevention after the stabilization of alcohol problems. This is consistent with other findings which suggest that posttreatment problems and experiences are major determinants of long-term outcomes (Cronkite and Moos, 1980; Finney, Moos, and Mewborn, 1980~. -182

Social skills training appears to be an effective adjunct in promoting sobriety among alcoholics who are deficient in social skills. Oei and Jackson (19803 found significantly greater improvement on drinking and other measures among those assigned at random to receive social skills training, relative to those assigned to traditional supportive therapy. These findings were replicated in a later study that showed significant beneficial effects of both social skills training and cognitive restructuring, with an apparent additive effect of the two interventions (Oei and Jackson, 1982~. Ferrell and Galassi (1981) reported substantially higher one-and two-year abstinence rates among alcoholics given assertiveness training in addition to standard treatment procedures. A Norwegian study similarly found that inpatients given social skills training, relative to controls who received only standard hospital treatment, had thrice as many days of sobriety and employment in the subsequent year, sustained abstinence for longer periods, and experienced fewer than one-fourth as many days of institutionalization (Eriksen, Bjornstad, and Gotestam, 1986~. Jones, Kanfer, and Lanyon (1982) reported that both a social skills training program and a social coping discussion group significantly improved drinking outcomes for inpatient alcoholics, relative to controls who received only hospital treatment. Chick and his colleagues (1988) found that alcoholics who received "extended treatments that included group social skills training showed significantly greater reductions in alcohol-related problems at the one-year follow-up point, relative to two control groups who received brief "advice" interventions. Skills training has also been found to be effective in substance abuse prevention (Botvin et al., 1984a,b; Gilchrest et al., 1987~. Stress management training likewise may be helpful to alcoholics in staying sober, particularly when anxiety is a significant concomitant problem (Miller and Hester, 1986a). Although three studies found no overall effect of relaxation training on drinking measures (Miller and Taylor, 1980; Miller, Taylor, and West, 1980; Sisson, 1981), Rosenberg (1979) found that biofeedback-assisted relaxation training did contribute to reductions in drinking, but only for individuals who were high in anxiety. Controlled studies with nonalcoholic drinkers have found modest short-term suppression of alcohol consumption through aerobic exercise but not through meditation (Murphy, Pagano, and Marlatt, 1986), although uncontrolled studies suggest a correlation between the long-term practice of meditation and a reduction in substance abuse (Aron and Aron, 1980, 1983~. A general stress management training program has also produced promising results (Rohsenow, Smith, and Johnson, 1985). The community-reinforcement approach (CRA) is a comprehensive broad-spectrum treatment strategy that addresses many life-style areas related to alcohol abuse, including unemployment, marital problems, isolation, use of leisure time, and social support. The CRA combines a variety of behavioral strategies in an attempt to make the person's nondrinking life-style more rewarding than drinking. It includes job-search training, behavioral marital therapy, monitored disulfiram, and counseling focused on alcohol-free social and recreational activities. Prior evaluations of the CRA (Hunt and Azrin, 1973; Azrin, 1976) indicated a large effect on treatment outcome. More recently, Azrin and coworkers (1982) randomly assigned alcoholics to a CRA group versus traditional outpatient treatment. At the six-month follow-up point, the CRA group showed nearly total abstinence and employment, whereas most controls had relapsed and showed high rates of drinking and unemployment. In another controlled experiment, Mallams and colleagues (1982) found that one specific component of the CRA, the encouragement to attend an alcohol-free social club, likewise led to greater sobriety. -183

The following questions represent opportunities for research on broad-spectrum treatment strategies: · What broad-spectrum treatment strategies (social skills training, stress and mood management training, etc.) effectively decrease the likelihood of relapse following treatment? · Is a high level of pretreatment distress, life problems, or skills deficits a differential predictor of favorable outcome for broad-spectrum interventions? · At what point in the treatment and relapse prevention process is it optimal to undertake broad-spectrum treatment strategies? Relapse Prevention In the early 1980~s Marlatt introduced a conceptual model and new treatment procedures that were broadly described as "relapse prevention." Marlatt suggested that relapse was best understood not as a sudden discrete event but rather as a developmental process. He described a sequence of cognitive and behavioral events that lead to relapse and a set of strategies that might be used to decrease its likelihood (Cummings, Marlatt, and Gordon, 1980; Marlatt and Gordon, 1985~. Other cognitive-behavioral models for relapse prevention have been introduced more recently, including Annis's self-efficacy approach (1986b) and Litman's ~sunrival~ model (1986~. As discussed in the writings of Gorski (e.g., Gorski and Miller, 1982), relapse prevention strategies have been popularized and integrated into the 12 step approach used by AA The approach's intended effect is that the addition of relapse prevention procedures to a treatment program will reduce the probability and rapidity of relapse. At present, only three controlled studies of cognitive-behavioral relapse prevention procedures with problem drinkers have been reported. Rosenberg and Brian (1986) reported no differences on drinking outcome measures between an "unstructured therapy" control group and two treatment groups for DWI offenders, one of which was based on Marlatt relapse prevention model. Missing data from the control group, however, compromised the interpretability of this study. In a large, controlled evaluation, Annis and coworkers (1988) found a modest impact of cognitive relapse prevention procedures on treatment outcome. However, Ito, Donovan, and Hall (1988) found no differences in outcome between groups given a cognitive-behavioral relapse prevention program based on Marlatt's model and an interpersonal process aftercare program based on a more psychodynamic approach. Reactivity to alcohol stimuli has been found to be predictive of relapse. A plausible but still experimental relapse prevention strategy is cue exposure, in which the goal is to diminish alcoholics' responsivity to cues that may precipitate the desire to drink or relapse to drinking (Rankin, 1986~. Empirical support for the cue exposure approach is currently limited to case reports (Blakey and Baker, 1980) and evidence that cue exposure decreases the subjective desire to drink and reduces the perceived difficulty of resisting relapse (Rankin, Hodgson, and Stockwell, 1983~. -184

The following questions represent opportunities for research on relapse prevention: · What relapse prevention procedures--when added to alcohol treatment programs significantly reduce the frequency, severity, or duration of posttreatment relapses? · Are cue exposure strategies effective in reducing the desire for and relapse to drinking after treatment? · At what point in the treatment process are relapse prevention strategies best taught? Is it more effective to offer relapse prevention training during intensive treatment or after formal treatment as a follow-up strategy? · What individual characteristics most strongly predict relapse and which traits predict a favorable response to relapse, prevention procedures? · What change processes do individuals use successfully to avoid or cope with relapses? · Do relapse prevention strategies constitute an effective treatment in themselves? What is the optimal combination of relapse prevention strategies with other procedures? RESEARCH ON TRADITIONAL TREATMENT PROGRAMS In practice, alcoholism treatment programs in the United States typically offer a combination of modalities that includes detoxification and health care, AA groups, lectures and films, group therapy, individual counseling, recreational and occupational therapy, medication, and aftercare group meetings. Claims of high success rates are sometimes made for such programs. For example, in testimony before the Senate Committee on Governmental Affairs, McElrath (1988) stated that the Hazelden approach (the Minnesota model) "is the most successful form of treatment for chemical dependency in recorded history. Scientific evidence regarding traditional multicomponent programs thus far has been limited to uncontrolled studies, several of which have been reported since 1980. Gilmore, Jones, and Tamble (1986) reported the results of 6-and 12-month follow-up questionnaires completed by patients of Hazelden and two other treatment facilities. Excluded from the study were short-stay patients, those who were deceased or absent without leave, and those who refused to complete the questionnaire. In the remaining Hazelden sample, 70 percent of the 6-month follow-up questionnaires were completed, among which 73 percent (51 percent of the total sample) reported abstinence from alcohol. At 12 months (74 percent completed), 58 percent (43 percent of the total sample) reported continuing abstinence. Validity checks were made by interviewing significant others in an unspecified number of cases. A similar uncontrolled study by CompCare (1988) reported a telephone follow-up survey of 1,002 patients discharged from 50 care units. Short-stay patients not receiving normal discharge were excluded from the study. At 12 to 15 months after discharge, with a 72 percent follow-up completion rate, 43 percent (31 percent of the total sample) reported continuous abstinence from alcohol and drugs,with an additional 18 percent (13 percent of the sample) having had one to four relapses. These two groups were combined to constitute a 61 percent "recovering" rate (44 percent of the total sample). No verification of the accuracy of the self-reports of the respondents was included in the report of the study. Compliance with treatment and aftercare recommendations was reported to be a strong predictor of favorable outcome. -185

A third recent study was an uncontrolled evaluation of patients treated at Edgehill Newport, a private for-profit hospital (Wallace, et al.~. From ~ target treated sample of 380, an interviewer was able to screen 257 (68 percent) eligible respondents for the, stiffly. Of these, 65 cases (25 percent) were excluded because they were unmarried, were living apart from their spouses, or failed to complete treatment; 11 others refused to participate. Of the remaining 181, 169 were interviewed by telephone derring a follow-up survey six months later. This figure represents 93 percent of the attempted interviews, although only 44 percent of the original target sample. A collateral informant was interviewed in 98 percent of the found cases, and the less optimistic report of outcome was accepted as accurate. The reported rate of abstinence varied, depending on the criteria used, from 57 percent (continuous abstinence from alcohol and other drugs for six months) to 72 percent (current abstinence from alcohol only). Rate of abstinence was found to be correlated with the frequency of attendance at meetings of Alcoholics Anonymous or Narcotics Anonymous. Two recent studies employed more conservative methodological standards. Alford (1980) reported two-year follow-up data for 56 patients who completed 5 to 11 weeks of inpatient treatment and received staff-approved discharges. Verification of self-reports was obtained from significant others, and evaluation focused on employment and social stability as well as drinking variables. At two years, 66 percent were reported to be either ~essent~ally abstinent" (51 percent) or light to moderate drinkers (15 percent). When more stringent criteria were employed that required abstinence with few slips, employment, and good social adjustment, 41 percent were rated as successful at two years. In the second study, Pettinati and coworkers (1982) accounted for 100 percent of 255 patients who were followed annually for four years after inpatient treatment at the Carrier Foundation. As in the Alford study, collateral verification was obtained, and evaluation included a broad range of outcome dimensions. Abstinence (allowing for a few slips) was reported in 40, 45, 51, and 55 percent of cases at one-, two-, three-, and four-year follow-ups, respectively. When cases that showed "drinking with good adjustment" were included, these figures rose to 48, 51, 56, and 60 percent. However, about half of the cases in the study showed fluctuation in outcome status over follow-up points, and only 22 percent evidenced continuous abstinence (29 percent were mostly abstinent with slips) over the four-year period. These studies exemplify how reported success rates are significantly influenced by the stringency of outcome criteria. Reports of uncontrolled studies pose difficulties in interpretation. Because random assignment and control groups are absent (they are often regarded as unacceptable in traditional treatment settings), the absolute effectiveness of treatment cannot be inferred. Positive outcomes may be attributable, at least in part, to favorable pretreatment characteristics or posttreatment experiences of the clinical population (Finney, Moos, and Mewborn, 1980~. Consequently, despite some very useful information that can be gleaned from uncontrolled program evaluations (e.~., predictors of outcome within a program), such studies cannot support causal inferences or yield reliable estimates of the absolute or relative magnitude of treatment effects. Furthermore, it is difficult to determine which elements of a multicomponent program may account for the positive outcomes that are observed. Methodological shortcomings can also inflate the reported rates of favorable outcomes. For example, patients who cannot be located for follow-up generally have a poorer prognosis than those who participate in follow-up studies; thus, the exclusion of the cases that are lost to follow-up is likely to yield overestimates of success within the total population. The exclusion of short-stay and noncompliant cases, dropouts, and irregular -186

discharges likewise biases a study sample toward inflated remission rates in that compliance with treatment recommendations is known to be a favorable prognostic indicator regardless of treatment modality. Some studies have also eliminated unmarried or less stable cases, again with the likely effect of inflating success rates (e.g., Wallace et al., in press). The reliability and validity of self-reports (e.g., questionnaires or telephone interviews) without objective verification are also questionable. As a quasi-experimental alternative to a randomized design, Grenier (1985) contrasted AA-based residential treatment for adolescents with a waiting list group. For the treated group, a 65.5 percent abstinence rate was estimated, based on two multiple choice questions administered to parents by telephone. The report did not specify the duration of reported abstinence, the length of follow-up, the percentage of cases that were not interviewed, or whether lost cases were included among nonabstinent cases. The waiting list group consisted of parents who had contacted the treatment center expressing a Sincere interest in admitting an alcohol-or drug-abusing adolescent for treatment" (p. 383), but who for unstated reasons had not done so for 3 to 18 months after initial contact. The telephone follow-up completion rate for this group was reported to be 36 percent, although outcome data were reported for only 26 percent. Among the waiting list parents, 47 percent reported improvement, including 20 percent who reported total abstinence. Several abstinent cases were excluded because they had received alternative treatment, leaving a 14 percent abstinence rate among located, untreated cases. Contrasting the study's 65.5 and 14 percent abstinence rates, Grenier (1985, p.389) concluded that residential treatment for adolescents Was a significant causal factor in the reduction of chemical use." Causal interpretations of such findings, however, cannot be made with confidence. Individuals who remain on a waiting list for 18 months do so for a wide variety of reasons, which introduces substantial selection differences between treated and ~control" groups. In addition, the accuracy of unverified self-reports is impossible to ascertain--perhaps even more so when data are gathered by mailed questionnaires or by telephone rather than in personal interviews. A high rate of uncompleted interviews also introduces interpretation difficulties because unlocated cases are not likely to be representative of those interviewed. Uncontrolled and quasi-experimental designs may yield useful information about treatment impact, particularly when controllable methodological problems are properly addressed. Important new knowledge may be obtained regarding predictors of outcome. In addition, special populations that are seen in private treatment programs may not be found in public programs in which controlled research is more commonly conducted. Yet uncontrolled studies cannot substitute for properly controlled, randomized designs in determining the absolute and relative effectiveness of treatment programs and modalities. Increased attention should be devoted to the possibility of conducting controlled trials in a broader range of treatment facilities. Even in cases in which conditions constrain randomization to untreated or alternative treatment groups, it may be feasible to conduct well-controlled evaluations by comparing the addition or deletion of specific treatment components designed to enhance motivation or prevent relapse (Miller, 1980, 1985~. Such studies yield information of immediate clinical utility by indicating the value of adding specific components to ongoing treatment programs. -187

The following types of studies, which offer opportunities for research on traditional treatment programs, are particularly needed at this time: · evaluations conducted in ongoing treatment settings, involving collaborations of research teams with traditional treatment personnel and programs; · specification of the treatment methods and procedures that constitute typical and traditional alcohol treatment programs; · evaluations of the effectiveness of generic, traditional treatment procedures as offered by typical U.S. programs; · controlled additive designs evaluating the effectiveness of traditional treatment programs with and without additional innovative treatment strategies: and . programs. ~7 - 7 - unpackaging designs to identity the "active ingredients" of traditional treatment RESEARCH ON THE INTENSITY AND DURATION OF TREATMENT It is a commonsense assumption that if one kind of treatment is longer, more intensive, offered in a hospital, or more expensive than another, that treatment should also be more effective than the other. Reimbursement policies of health care insurers have often followed this maxim, paying preferentially for more intensive and expensive forms of alcohol treatment. Uncontrolled studies have long reported a positive correlation between length of stay in treatment and favorable outcome, and studies since 1980 have continued this trend (e.g., Finney, Moos, and Chan, 1981; McLellan et al., 1982), although there are exceptions (e.g., Booth, 1981~. As discussed earlier, however, such correlational findings confound treatments with important individual determinants of outcome (e.g., compliance) and thus are difficult to interpret. Fortunately, more than two dozen controlled studies have addressed this issue. In the typical study, individuals eligible for either form of care (excluding those who urgently need intensive treatment) have been assigned at random to more versus less intensive treatments or settings or to longer versus shorter treatment. With great consistency. these controlled studies have found no differences in outcome based on the duration or intensity of treatment or the setting (e.g., inpatient versus outpatient) in which it is offered (for reviews, . . ~_% ~ ^ ~ ~. . . ~ ~ _ . . En, ,, see up.. Congress, Trace of technology Assessment, A;; Annals, 1986a; Miller and Hester, 1986b). Recent studies continue to find no overall advantage of residential treatment over nonresidential alternatives (McLachlan and Stein, 1982; Longabaugh et al., 1983; Eriksen, 1986; Chapman and Havens. 19881. ~ similarly, recent controlled studies have found that increasing the length of alcohol treatment does not result in improved outcomes relative to briefer interventions (Miller and Baca, 1983; Walker et al., 1983; Powell et al., 1985; Eriksen, 1986; Zweben, Pearlman, and Li, in press). Treatment settings may differ importantly, however, in cost and cost-effectiveness. Treatment is often substantially more expensive in residential and longer treatment programs. Several studies have reported that individuals treated in residential settings show increased future use of hospital-based treatment with no offsetting advantage in long-term outcome, relative to those treated in nonresidential settings (Miller and Hester, 1986b). If these increased costs are not offset by superior outcomes, less expensive forms of treatment are preferable on a cost-effectiveness basis. -188

Even if there is no overall advantage in outcome from longer, more intensive, or hospital-based treatment programs, there remains the question of whether certain subpopulations of alcoholics may benefit differentially from such approaches. Currently available data are limited but suggest that intensive residential treatment may be warranted for socially unstable individuals (e.g., unemployed or homeless persons; drinkers with more severe psychopathology) and for individuals with more severe alcohol dependence. Socially stable and less severely dependent persons, by contrast, appear to do as well or better in less intensive treatment (Miller and Hester, 1986b). The interactions of severity and treatment approaches are complex, however (see McLellan et al., 1983), and require further investigation. The following questions represent opportunities for research on the intensity and duration of treatment: · For what types of individuals is residential treatment differentially effective or more cost-effective than nonresidential alternatives? · For particular treatment approaches, what minimum length or intensity is sufficient to yield most of the benefits attendant to the treatment? What length and setting are optimal for maximum cost-effectiveness? · What is the relative cost-effectiveness of different treatment settings (e.g., residential, day hospital, social model, outpatient) when consistent content is offered? RESEARCH ON AFI'ERCARE Relapse prevention as more broadly conceived includes any intervention that is designed to diminish, forestall, or attenuate relapses following treatment. Program components that are referred to as Aftercare have traditionally been designed to promote this same goal of maintaining gains following treatment. Aftercare is not itself a form of treatment but rather a phase of treatment--continued contact with, and services to, clients or patients following the termination of a formal phase of treatment. The term is typically used only in conjunction with residential treatment, in which discharge is a discrete event. Research on aftercare, then, is essentially research on the optimal timing of venous treatment procedures. Most of the treatment strategies previously discussed in this section could, in this sense, be offered as ~aftercare.n Progress has been made toward defining interventions that decrease relapse during the aftercare period. Correlational and quasi-experimental studies generally point to a strong relationship between aftercare attendance and sustained remission (Costello, 1980; Ornstein and Cherepon, 1985; Ito and Donovan, 1986) although there are exceptions (Gilbert, 1988~. Experimental studies of aftercare procedures have begun to appear. In a randomized trial (Ahles et al., 1983), individuals who were given a behavioral contracting intervention and a calendar designating scheduled aftercare sessions were significantly more likely to attend, to be abstinent at 3-, 6-, and 12-month follow-ups, and to sustain continuous abstinence. In that study, this simple intervention doubled the treatment success rate during the first year (after residential treatment) from 39 to 78 percent. One placebo-controlled study reported that acupuncture significantly suppressed drinking episodes, readmissions, and urges to drink following treatment (Bullock et al., 1987~. However, the effectiveness of specific alternative aftercare approaches may vary with the pretreatment characteristics of participants (e.g., McLachlan, 1972, 1974), which suggests a need for individualized matching of aftercare strategies. -189

Other studies have failed to support the impact of aftercare procedures. Fitzgerald and Mulford (1985), in a randomized trial, found no effect of biweekly telephone contacts over a year of follow-up after inpatient treatment. Another controlled study found no differences in outcome between inpatients assigned at random to medical monitoring only versus aftercare that consisted of biweekly group therapy, individual counseling, family therapy, and social service support (Braunstein et al., 1983~. Ito, Donovan, and Hall (1988) found no differences in outcomes from two alternative aftercare programs based on cognitive-behavioral versus interpersonal process models. Although controlled and correlational studies now indicate that participation in aftercare increases the effectiveness of residential treatment, it is unclear to what extent hospital treatment contributes to long-term prognosis above and beyond the effects of aftercare itself (Miller and Hester, 1986b). The following questions offer opportunities for research on aftercare: What variables predict and what interventions increase aftercare participation? Do alternative aftercare procedures differ in their impact or cost-effectiveness? · Is there an optimal sequencing for specific treatment interventions? Are certain modalities best offered after a period of prior detoxification and treatment? · What characteristics of individuals predict differential response to alternative aftercare approaches? · What are the relative contributions of residential treatment versus outpatient aftercare procedures to long-term outcome? Does a preceding period of inpatient treatment improve prognosis, given an effective "aftercare" program? If so, for what types of individuals are there differential benefits? TREATMENT PROCESS RESEARCH Whereas outcome research provides data regarding the overall impact of therapeutic interventions, process research yields information about the active ingredients of treatment efficacy. Process and outcome research are not wholly separable approaches and in fact are best conducted conjointly. The central concern of the former, however, is to investigate the underlying processes involved in treatment. Three emerging areas of treatment process research are considered here: (1) mechanisms of treatment efficacy, (2) therapist variables, and (3) motivation. Mechanisms of Treatment Efficacy Most therapeutic interventions include at least three kinds of components: (1) active ingredients that have specific and direct effects on outcome, (2) placebo or nonspecific elements that also contribute to outcome but are not unique to the particular treatment, and (3) inert components that have no impact on outcome. Treatment interventions may also inadvertently contain components that are detrimental to recovery. Such research strategies as dismantling or additive designs can be used to identify which elements of treatment are crucial to positive outcomes. Research on brief-treatment strategies indicates that, for some individuals, sufficient conditions for change can be contained within relatively minimal interventions. Common -190

elements within currently documented brief-treatment strategies appear to be (1) motivational feedback to increase the perception of risk, (2) clear advice or guidelines for change, and (3) an empathic approach that fosters self-efficacy and perceived choice (Miller, 1985; Orford, 1986; Miller, Sovereign and Krege, in press). Within particular treatment modalities, specific mechanisms of efficacy can be tested for consistency with the theoretical model underlying the treatment. A client-centered treatment perspective, for example, would posit a strong relationship between treatment outcome and the level of Critical conditions" (e.g., empathy) offered by the therapist during therapy. Empirical support exists for this position (Miller, Taylor and West, 1980; Valle, 1981; Miller and Sovereign, 1988~. Oei and Jackson (1984) found that therapist self-disclosure and reinforcement of positive client self-statements are crucial components of cognitive therapy with alcoholics. The effectiveness of social skills training would presumably rely on the improvement of the individual's interpersonal skills (e.g., Greenwald et al., 1980~. In treatment programs that subscribe to a traditional disease model, it would be predicted that certain processes (e.g., reduction of denial, acceptance of oneself as alcoholic, recognition of alcoholism as a disease, working the early steps of AA's "twelve Steps" program) would be crucial prerequisites for recovery. The Pavlovian learning theory basis of aversion therapies would require the establishment of a conditioned aversion response to alcohol as a precondition for successful outcome. Studies of both chemical aversion (Baker et al., 1984; Cannon et al., 1986) and covert sensitization (Elkins, 1980; Miller and Dougher, 1984) show a strong relationship between treatment outcome and the strength of the conditioning that is established during treatment. When administered in a manner that is unlikely to produce conditioned aversion, covert sensitization appears to be ineffective (Telch, Hannon and Telch, 1984~. This type of process research supports the integrity of a specific treatment approach and clarifies the critical elements that should be included when the treatment is replicated. A limited but nonetheless potentially fruitful strategy for clarifying treatment process is to ask treated individuals which elements of the program they have found most useful or have continued to use during the follow-up period. Self-reports do not necessarily identify the true determinants of outcome, but such inquiries can provide useful leads for further exploration. ~ The following questions represent opportunities for research on the mechanisms of treatment efficacy: · For a particular treatment approach (e.g., cognitive therapy, marital/family therapy, AA), what are predicted to be the necessary and sufficient conditions for recovery to occur? Do these process dimensions, when operationally defined and measured, prove to be strong predictors of treatment outcome? · What do those who have been treated perceive to be the crucial elements of treatment that is, the elements that most account for their outcomes? Therapist Variables Although therapist skills and characteristics have long been regarded as important factors in treatment outcome, these variables have remained largely unexamined within the alcohol treatment field (Cartwright, 1981~. A few studies prior to 1980 pointed to important -191

relationships between therapist attributes and treatment motivation, dropout, or outcome (Miller, 1985~. Some studies have focused on client/patient perceptions of therapist empathy, a variable with a plausible but still unclear relationship to treatment outcome. Two studies (Lawson, 1982; Kirk, Best, and I'win, 1986) reported that alcoholics' perceptions of counselor empathy were unaffected by whether the counselor was a recovering alcoholic, although other perceived therapist dimensions may be influenced by this factor (Lawson, 1982~. Recent reports continue to reflect no significant difference in treatment outcomes between treatment by counselors who are themselves recovering substance abusers and treatment by those who are not (Aiken et al., 1984~. Other research has included direct measures of the interpersonal functioning of therapists. One therapist characteristic that appears to be related to favorable motivation and treatment outcomes is therapist empathy. Empathy in this context refers not to the ability to identify with others based on similar personal experiences but rather empathic understanding as operationally defined by Carl Rogers and his students (Truax and Carkhuff, 1967~. A therapist attitude of empathic understanding has been a common element in brief interventions that have been reported to have substantial impact on alcohol problems (Chafetz, 1961; Chafetz et al., 1962; Edwards et al., 1977; Kristenson et al., 1983~. In a study assigning alcoholics at random to different counselors, Valle (1981) found a significant relationship between therapist empathy skill and treatment outcomes at 6, 12, 18, and 24 months. Miller, Taylor, and West (1980) found that therapist empathy during behavioral treatment accounted for two-thirds of the variance in 6-month treatment outcome (r = .82) and that a strong relationship persisted in outcomes measured at 12 and 24 months (Miller and Baca, 1983~. Analyzing tapes of therapeutic interventions, Miller and Sovereign (19~) found that confrontive and directive therapist behaviors (experimentally controlled) were associated with increased client/patient resistance and higher rates of drinking at the 12-month follow-up point, whereas therapist supportive and listening behaviors were associated with lower resistance and more positive outcomes. Other therapist behaviors may be important determinants of outcome. As noted in the previous discussion on mechanisms of treatment efficacy, Oei and Jackson (1984), in an experimental study, found greater improvement among individuals whose therapists practiced self-disclosure and reinforced clients' positive self-statements. Cartwright (1980) reported a relationship between therapist self-esteem and positive attitudes toward alcoholics. McLachlan (1972, 1974) reported differential effects of therapist "conceptual levels (directiveness versus nondirectiveness), depending on a corresponding personality type among alcoholic patients. A variable found to be important in research on the treatment of other problems (e.g., depression) is the extent to which the therapist consistently adheres to specific treatment procedures. Still another dimension for exploration is the impact of the therapist's personal history of alcoholism. The following questions represent opportunities for research on therapist characteristics: · What role do therapist characteristics (e.g., empathy, self-disclosure, optimism, confrontiveness) play in influencing client/patient dropout, motivation for change, and treatment outcome? · Do certain types of people respond better to therapists with particular characteristics or styles (e.g., empathic versus confrontational)? -192

. Is therapist effectiveness influenced by the consistency with which the therapist adheres to specific treatment strategies? · How great are differences in therapist effectiveness within specific treatment strategies? . What factors influence clientlpatient perceptions of therapist empathy, likability, and effectiveness? Are such perceptions predictive of long-term outcome? · Do recovering persons differ from others in their effectiveness as therapists? If so, in what ways do they use their recovering status in the process of treatment? · What forms of training or credentialing for treatment providers will improve the effectiveness of their services? Motivation Motivation has long been recognized as a key factor in recovery. Early writings conceptualized motivation in alcoholics as a trait or personal characteristic of the individual. Consistent with this perspective, many studies continue to focus on dispositional or demographic predictors of treatment noncompliance (e.g., Bander et al., 1983, Beck et al., 1983; Ornstein and Cherepon, 1985~. Yet the dispositional markers of compliance identified in such studies have shown few consistencies, suggesting that individual pretreatment characteristics interact with attributes of the particular treatment setting (Fink et al., 1984~. Research has generally failed to support a trait view of alcoholics as poorly motivated, prone to particular defense mechanisms (e.g., denial), inherently resistive, or possessing a characteristic personality. Rather, motivation or resistance appears to be determined by a range of factors in the treatment situation, many of which are influenced by the therapist (Miller, 1985~. Studies do, however, continue to find positive relationships between treatment compliance and outcome (Finney, Moos, and Chan, 1981; Westermeyer and Neider, 1984; Fuller et al., 1986; Fawcett et al., 1987~. Consequently, the emphasis in research has shifted from alcoholic traits to a search for intervention procedures that increase compliance and the motivation for change. Intervention that provide personal feedback about risk appear to have a particular impact on motivation and may be sufficient to induce change in many problem drinkers (Kristenson et al., 1983; Miller, 1985~. Two recent controlled evaluations of a "Drinker's Checkups intervention indicate that problem drinkers significantly reduce their alcohol consumption after receiving feedback about personal harm and risks (Miller and Sovereign, 1988; Miller, Sovereign, and Krege, in press). Such interventions appear to interact with therapist style as well. Risk feedback that is given in a supportive, empathic style appears to induce more change than risk feedback presented in a confrontational and directive style (Miller, 1983; Miller and Sovereign, 1988~. Compliance Relatively simple interventions have been demonstrated in controlled studies to have powerful effects on treatment entry, persistence, and compliance (Miller, 1985~. Moreover, recent studies have added new tools to the armamentarium of motivation-boosting techniques. Pretreatment exposure to videotape role modeling (Craigie and Ross, 1980), participation in a Rescreening group (Olkin and Lemle, 1984), and participation in an orientation group (Panepinto et al., 1980) have been found to increase the frequency of -193

return for treatment. Zweben and Li (1981) found that a "role induction" preparation for treatment increased continuation in therapy. For white-collar workers, a role induction conducted by an ax-patient proved less effective than inductions administered by a therapist or by staff using videotape. In another study, Ossip-Klein and colleagues (1984) provided a wall calendar marked with the dates of aftercare meetings and negotiated a behavioral contract for aftercare attendance. This simple intervention doubled the rate of aftercare compliance, relative to a random control group. Procedures adapted from A~rin's community reinforcement approach were found in three studies to increase treatment entry (Sisson and Azrin, 1986), attendance at AA and AlAnon meetings (Sisson and Mallams, 1981), and medication compliance with subsequent abstinence (Azrin et al., 1982~. In another controlled study, a simple contingency contracting procedure substantially increased aftercare participation (Ahles et al., 1983~. Correlational studies point to the potential importance of other variables in precipitating or preventing dropout: staff attitudes toward alcoholics (Velleman, 1984), the length of delay between appointments (Leigh, Ogborne and Cleland, 1984), spouse involvement in treatment (Zweben, Pearlman, and Li, 1983), and the availability of treatment groups that include peers of one's own gender or age (Duckert, 1987; Kofoed et al., 1987~. Other studies have contributed to our knowledge of motivation by finding a surprising lack of beneficial impact from what would be expected to be an effective intervention. Rees (1985), for example, demonstrated that health beliefs predicted treatment compliance and outcome; in a subsequent experimental study, however, the same investigator found that an intervention which increased the relevant health beliefs had no impact on compliance (Rees, 1986~. i Mandated Treatment An increasingly common practice is the mandating of treatment interventions by requiring individuals to choose between accepting treatment or suffering adverse consequences (e.g., imprisonment, loss of employment). Despite their widespread current use, intervention strategies such as "constructive confrontations (Trice and Beyer, 19843 and group confrontational intervention (Johnson, 1980) have not as yet been subjected to adequately controlled evaluations of their impact on outcome. Uncontrolled studies reflect roughly comparable outcomes among mandated and voluntary participants in treatment (Freedberg and Johnston, 1980~. Yet direct comparisons of mandated interventions with control groups have yielded inconsistent results. Salzberg and Klingberg (1983), replicating the findings of two previous studies, found that DWI offenders who were given deferred sentencing and then referred for alcohol treatment, showed significantly higher rates of recidivism relative to a comparison group that was given _ only legal sanctions. Swenson and colleagues (libel) round no Olllerences between two treatment programs for DWI offenders and a home-study control group given a single 30-minute session and educational reading matter. With few exceptions (e.g., Brown, 1980), educational and treatment intervention have not been shown in properly controlled trials to improve long-term outcome and to suppress recidivism to a greater extent than such ordinary legal sanctions as monitored probation (cf. Brandsma et al., 1980; Ditman et al., 1967~. With increasing frequency, employee assistance programs (EAPs) refer employees to treatment when an alcohol or other drug problem is detected, often with the condition that continued employment depends on participation and improvement. Uncontrolled studies -194

of EAPs (e.g., Spickard and Tucker, 1984) continue to report high rates of favorable outcomes in such programs. Several recent studies have focused in particular on the outcomes of impaired physicians who seek treatment in order to retain or regain their license to practice. Among those completing such programs, reported ~success. rates near 80 percent are not uncommon (Shore, 1982, 1987; Gualtieri, Cosentino, and Becker, 1983; Morse et al., 1984~. Such rates are sometimes inflated by the exclusion of lost, deceased, or uncooperative cases (e.g., Morse et al., 1984~. 1 The contribution of particular intervention components is difficult to assess in this context. Improvement may be motivated simply by the crisis of being identified as having a problem or by the desire to maintain employment, license, or liberty. Morse and coworkers (1984) found that physicians who were closely monitored and in jeopardy of loss of license showed a higher improvement rate than a comparison group of nonphysicians in treatment for alcohol and drug dependence without such scrutiny and contingencies. As with court probation cases, formal treatment may make little or no contribution to outcome above the effects attributable to the threatened loss of liberty or livelihood. Another important factor to consider is the extent to which threatened penalties for noncompliance in "mandated programs are actually enforced. Perceived stringency of enforcement may be an important determinant of the impact of mandatory treatment. Thus, the level of enforcement of participation should be documented, and perceived enforcement should be assessed. The following questions represent opportunities for research on motivation, compliance, and mandated treatment: . What interventions, therapist characteristics, or situational factors increase the probability that a problem drinker will enter, continue, and comply with treatment? · What measures of motivation best predict a favorable response to treatment? What proportion of variance in outcome is accounted for by dispositional versus situational aspects of motivation and by compliance with specific components of treatment? · What approaches will instill a motivation for change in individuals who display hazardous alcohol consumption patterns but do not regard themselves as problem drinkers or in need of treatment? · What are the short-and long-term effects on outcome of coercive motivational strategies (e.g., court-mandated treatment, employee assistance programs, confrontational interventions), relative to less coercive or intrusive alternatives? CONCLUSIONS The foregoing discussion constitutes a comprehensive review, within the context of knowledge from earlier research, of what has been learned in treatment outcome studies since 1980. In this section, specific conclusions based on the preceding review will be drawn in order to summarize the opportunities for further progress in treatment research. Does Treatment Work? As an introduction to such conclusions, it is important to address what is an inevitable and broader question: Does treatment work? Although attention to this issue was not part of the committee's specific charge, this fundamental question necessarily underlies any consideration of research opportunities. Indeed, the answer to this question may be what many readers of this report most wish to obtain through an examination of well-designed research. -195

Clearly, clinicians believe sincerely in the efficacy of their interventions; otherwise they would probably not be involved in the treatment enterprise. The history of medicine, as well as recent psychological and medical research, however, abundantly shows that clinician confidence in a treatment is not a reliable indicator of its specific effectiveness. Judgments of whether treatment works must rely on more valid criteria than the certitude of treatment agents or the testimonials of clients or patients. Given the hundreds of clinical studies now available, what meaningful answer can be given to this question? The answer depends, of course, on what is meant by the question. The first problem to be considered in seeking an answer is the great heterogeneity of treatments for alcohol problems. A very broad array of different treatment approaches has been evaluated in clinical research, and a still wider range has been implemented in practice. If the question, Does treatment work? is understood to mean, Do all of these treatments work?, the answer is plainly, no. Some methods (several of which remain in widespread use) have consistently failed to show a significant impact on alcohol problems. Other currently or previously used treatment methods remain unproved. More than half of controlled clinical trials of alcohol treatment approaches have yielded negative results; that is, no significant differences in outcome among groups. Clearly, no blanket blessing can be given to all or unspecified treatments as "effective. If, on the other hand, the question is taken to mean, Are any of these treatments effective?, one can more confidently answer, Yes. Several different treatment modalities have been found in a number of clinical trials to produce significantly better outcomes than occur in the absence of the treatment or with alternative treatment. Thus, we are in the happy position of having at our disposal a variety of promising treatment strategies with a positive record of success in well-designed studies. A third interpretation of the question might be: Is there a single treatment of choice that is superior to all other approaches? Here, the answer is an unambiguous no. No treatment method is universally effective. Few have been found to yield favorable outcomes in even a majority of cases over the long run. Some approaches have poor records of success, whereas others have demonstrated encouragingly consistent benefits, but no particular treatment can lay justifiable claim to superiority over all others. Instead of a single outstandingly effective strategy, there are a number of promising alternatives, each of which appears to be effective with different types of individuals. Behavioral self-control training, for example, appears to be most effective with individuals showing less severe alcohol-related problems and dependence, whereas AA tends to be more effective with individuals who have histories of more severe alcohol problems and dependence. This picture is consistent with human therapeutics in other fields. In medicine, for example, no single medication is effective against all infections. Nevertheless, the judicious use of the entire range of available medications, effectively deployed on an individual case basis, produces an excellent record against infection. There is no one therapeutic method for dealing with cancer, but the combined use of surgery, chemotherapy, and radiation in differing degrees in individual cases has produced notable reductions in suffering and mortality. Likewise, there are now not one but multiple potentially effective ways to treat diabetes mellitus, depression, anxiety disorders, heart disease, and hypertension. All of these examples are no longer regarded as uniform or unitary problems; rather, each is properly regarded as a family of related disorders that are diverse in etiology as well as optimal treatment. Alcohol problems are fruitfully understood in this same light as heterogeneous disorders, admitting of variety in etiology and proper treatment. -196

Thus, depending on the meaning of the question, Does treatment work?, the answer can be gloomy or optimistic. The grounds for optimism are not to be found in the efficacy of all treatments or in the established superiority of any particular approach. Instead, this committee, in reviewing its charge, is optimistic about the encouraging array of promising treatment procedures that have been identified through research and about the opportunities for continued research to improve the effectiveness of treatment. The following conclusions should be read within this general context. Specific Conclusions Significant progress has been made in alcohol treatment research since 1980. Based on currently available empirical research, the nine following conclusions appear to be supported: 1. The provision of appropriate, specific treatment modalities can substantially improve outcome. A variety of specific alcohol treatment methods have been associated with increased improvement, relative to no treatment or alternative treatments, in controlled studies. Future research should continue to evaluate the effectiveness of alternative current and new treatment modalities. 2. There is no single superior treatment approach for all persons with alcohol problems. Although a number of different treatment methods show promise with particular groups, no single approach stands out as significantly more effective overall. Reason for optimism about alcohol treatment lies in the range of promising alternatives that are available, each of which may be optimal for different types of individuals. Rather than seeking to establish the superiority of a single approach by testing specific interventions in heterogeneous populations, treatment outcome studies should delineate the characteristics of the subpopulation for whom particular modalities are maximally effective. 3. Therapist characteristics have been underestimated as determinants of outcome. Treatment is not offered by neutral agents. Therapist skills and attributes appear to be important factors that influence treatment outcome. Interactions of therapist factors with treatment and client/patient variables, as well as the main effects of therapist characteristics, may account for a substantial amount of variance in client/patient motivation, dropout, compliance,-and outcome. Future research should examine the impact of therapist attributes and behaviors on treatment outcome. 4. Alcoholics Anonymous, one of the most widely used approaches to recovery in the United States, remains one of the least rigorously evaluated. Given its widespread availability and potential cost- effectiveness, there is a need for well-designed studies to elucidate the impact and mechanisms of change within AA There is a particular need for outcome research that employs a range of contemporary treatment assessment strategies. 5. Treatment of other life problems related to drinking can improve alcohol treatment outcome. Posttreatment problems and experiences have been shown to be important determinants of outcome. Social skills training, marital and family therapy, antidepressant medication, stress management training, and the community reinforcement approach all show promise for promoting and prolonging sobriety. Such broad-spectrum strategies appear to affect sobriety by helping to resolve other significant problems that, left untreated, could precipitate relapse. Future research should continue to explore the impacts of posttre~atment adjustment and the treatment of other life problems on outcome. 6. Outcome may be predictable from treatment process factors. Individual difference variables that are nonspecific (e.g., resistance) or specific to particular approaches (e.g., the establishment of a conditioned aversion response) may predict treatment outcome. Future. studies should seek to clarify treatment process factors that are key determinants -197

of outcome within specific treatment modalities and to build stronger theoretical models of treatment efficacy. 7. The overall effectiveness of treatment with unselected patients appears to be no different in residential versus nonresidential programs or in longer versus shorter inpatient programs. Although health care reimbursement systems have emphasized more expensive forms of treatment, studies to date fail to show an offsetting increase in overall effectiveness relative to less expensive alternative forms of intervention. Residential care may be differentially effective for individuals who are socially unstable (e.g., homeless, unemployed) as well as those who have more severe levels of alcohol dependence and psychopathology. Socially stable individuals without severe alcohol dependence or psychopathology appear to be treatable by less intensive approaches without compromising effectiveness and at substantially less cost. The validation of differential criteria for admission to various treatment settings and for flexible movement between them during the course of an individual's treatment is an important task for future research. 8. Both experimental and quasi-experimental designs contribute important new knowledge regarding treatment outcome. Randomized, controlled trials yield data from which conclusions of specific effectiveness can be drawn more confidently than from uncontrolled demonstrations; moreover, such studies have tended to yield more consistent results. Experimental studies may be more expensive (although a number of published controlled trials have been conducted at relatively low cost), but given the incremental new knowledge they yield, well-designed controlled clinical trials remain a- cost-effective investment of research funds. Contemporary quasi-experimental designs offer sound alternatives in instances in which controlled trials are not feasible. Properly designed nonexperimental studies likewise can yield useful incremental information regarding treatment outcome. 9. The implementation of any treatment procedure warrants careful consideration of the relative risks and benefits that are likely to be derived. A treatment is justifiable when the probable benefits demonstrably outweigh the risks and costs involved in the proposed treatment procedures. Probable benefits may be judged, in general or for specific subpopulations, from the weight of current evidence in treatment outcome research. Treatments with documented special risks merit particular consideration of the risk-benefit balance. Future research should address the relative benefits, risks, and costs attached to specific alternative treatment modalities. REFERENCES Ahles, T. A, D. G. Schlundt, D. M. Prue et al. Impact of aftercare arrangements on the maintenance of treatment success in abusive drinkers. Addict. Behav. 8:53-58, 1983. Aiken, L. S., L. A. LoSciuto, M. ~ Ausetts et al. Paraprofessional versus professional drug counselors: The progress of clients in treatment. Int. J. Addict. 19:383-401, 1984. Alford, G. Alcoholics Anonymous: An empirical study. Addict. Behav. 5:359-370, 1980. Amit, Z., Z. Brown, A. Sutherland et al. Reduction in alcohol intake in humans as a function of treatment with zimelidine: Implications for treatment. In C. ~ Naranjo and E. ~ Sellers, eds. Research Advances in New Psychopharmacological Treatments for Alcoholism. Amsterdam: Elsevier, 1985. -198

Annis, H. M. Is inpatient rehabilitation of the alcoholic cost effective? Con position. Advances in Alcohol and Substance Abuse 5:175-190, 1986a. Annis, H. M. A relapse prevention model for treatment of alcoholics. Pp. 407-433 in W. R. Miller and N. Heather, eds. Treating Addictive Behaviors: Processes of Change. New York Plenum, 1986b. Annis, H. M., and D. Chan. The differential treatment model: Empirical evidence from a personality typology of adult offenders. Criminal Justice and Behav. 110:159-173, 1983. Annis, H. M., C. S. Davis, M. Graham et al. A controlled trial of relapse prevention procedures based on self-efficacy theory. Unpublished manuscript. Toronto: Addiction Research Foundation, 1988. Aron, A, and E. N. Aron. The transcendental meditation program's effect on addictive behavior. Addict. Behav. 5:3-12, 1980. Aron, E. N., and ~ Aron. The patterns of reduction of drug and alcohol use among transcendental meditation participants. Bull. Soc. Psychol. Addict. Behav. 2:8-33, 1983. Aspirin, N. H. Improvements in the community-reinforcement approach to alcoholism. Behav. Res. Ther. 14:339-348, 1976. A~rin, N. H., R. W. Sisson, R. Meyers et al. Alcoholism treatment by disulfiram and community reinforcement therapy. J. Behav. Ther. Exp. Psychiatry 13:105-112, 1982. Baker, T. B., D. S. Cannon, S. T. Tiffany et al. Cardiac response as an index of the effect of aversion therapy. Behav. Res. Ther. 22:403-411, 1984. Bander, K W., N. A. Stilwell, E. Fein et al. Relationship of patient characteristics to program attendance by women alcoholics. J. Stud. Alcohol 44:318-327, 1983. - Beck, N. C., W. Shekin, C. Fraps et al. Prediction of discharges against medical advice from an alcohol and drug misuse treatment program. J. Stud. Alcohol 44:171-180, 1983. Becker, J. T., and J. H. Jaffe. Impaired memory for treatment-relevant information in inpatient men alcoholics. J. Stud. Alcohol 45:339-343, 1984. Berg, G., and A. Skutle. Early intervention with problem drinkers. Pp. 205-220 in W. R. Miller and N. Heather, eds. Treating Addictive Behaviors: Processes of Change. New York: Plenum, 1986. Billings, ~ G., and R. H. Moos. Psychosocial processes of recovery among alcoholics and their families: Implications for clinicians and program evaluators. Addict. Behav. 8:205-218, 1983. Blakey, R., and R. Baker. An exposure approach to alcohol abuse. Behav. Res. Ther. 18:319-326, 1980. -199

Booth, R. Alcohol halfway houses: Treatment length and treatment outcome. Int. J. Addict. 16:927-934, 1981. Boscarino, J. Factors related to "stable" and Unstable affiliation with Alcoholics Anonymous. Int. J. Addict. 15:839-848, 1980. Botvin, G. J., E. Baker, N. L. Renick et al. A cognitive-behavioral approach to substance abuse prevention. Addict. Behav. 9:137-148, 1984a. Botvin, G. J., E. Baker, E. M. Botvin et al. Prevention of alcohol misuse through the development of personal and social competence: A pilot study. J. Stud. Alcohol 45:550-552, 1984b. Brandsma, J. M., M. C. Maultsby, and R. J. Welsh. The Outpatient Treatment of Alcoholism: A Review and Comparative Study. Baltimore, MD: University Park Press, 1980. Braunstein, W. B., B. J. Powell, J. F. McGowan et al. Employment factors in outpatient recovery of alcoholics: A multivariate study. Addict. Behav. 8:345-3S1, 1983. Brown, R. ~ Conventional education and controlled drinking education courses with convicted drunken drivers. Behav. Ther. 11:632-642, 1980. Brubaker, R. G., D. M. Prue, and R. G. Rychtarik. Determinants of disulfiram acceptance among alcohol patients: A test of the theory of reasoned action. Addict. Behav. 12:43-52, 1987. Bullock, M. L., ~ J. Umen, P. D. Culliton et al. Acupuncture treatment of alcoholic recidivism: A pilot study. Alcoholism Clin. Exp. Res. 11:292-295, 1987. Cannon, D. S., and T. B. Baker. Emetic and electric shock alcohol aversion therapy: Assessment of conditioning. J. Consult. Clin. Psychol. 49:20-33, 1981. Cannon, D. S., T. B. Baker, and C. K Wehl. Emetic and electric shock alcohol aversion therapy: S~x-and twelve-month follow-up. J. Consult. Clin. Psychol. 49:360-368, 1981. Cannon, D. S., T. B. Baker, ~ Gino et al. Alcohol-aversion therapy: Relation between strength of aversion and abstinence. J. Consult. Clin. Psychol. 54:825-830, 1986. Carpenter, R. A, C. ~ Lyons, and W. R. Miller. Peer-managed self-control program for prevention of alcohol abuse in American Indian high school students: A pilot evaluation study. Int. J. Addict. 20:299-310, 1985. Cartwright, ~ K J. The attitudes of helping agents towards the alcoholic client: The influence of experience, support, training, and self-esteem. Br. J. Addict. 75:413-431, 1980. Cartwright, ~ K J. Are different therapeutic perspectives important in the treatment of alcoholism? Br. J. Addict. 76:347-361, 1981. Chafetz, M. E. A procedure for establishing therapeutic contact with the alcoholic. Q. J. Stud. Alcohol 22:325-32S, 1961. -200

Chafetz, M. E., H. T. Blane, H. S. Abram et al. Establishing treatment relations with alcoholics. J. Ne~v. Ment. Dis. 134:395 409, 1962. Chapman, P. L. H., and I. Huygens. An evaluation of three treatment programmed for alcoholism: An experimental study with sex and 18-month follow-ups. Br. ]. Addict. 83:67-81, 1988. Chick, J., B. Ritson, J. Connaughton et al. Advice versus extended treatment for alcoholism: A controlled study. Br. J. Addict. 83:159-170, 1988. Christensen, J. K, P.- Ronsted, and U. H. Vaag. Side effects after disulfiram: Comparison of disulfiram and placebo in a double-blind multicentre study. Acta Psychiatr. Scand. 69:265-273, 1984. CompCare. Care Unit Evaluation of Treatment Outcome. Newport Beach, CA: Comprehensive Care Corporation, 1988. Connors, G. J., S. ~ Maisto, and S. M. Ersner-Hershfield. Behavioral treatment of drunk-drinking recidivists: Short-term and long-term effects. Behav. Psychotherapy 14:34-35, 1986. Cook, T. D., and D. T. Campbell. Quasi-experimentation: Design and Analysis Issues for Field Settings. Boston: Houghton-Mifflin, 1979. Costello, R. M. Alcoholism aftercare and outcome: Cross-lagged panel and path analyses. Br. J. Addict. 75:49-53, 1980. Council on Scientific Affairs, American Medical Association. Aversion therapy. J. Am. Med. Assoc. 258:2562-2566, 1987. Craigie, F. C., Jr., and S. M. Ross. The use of a videotape pre-therapy training program to encourage treatment-seeking among alcohol detoxification patients. Behav. Ther. 11:141-147, 1980. Cronkite, R. C., and R. H. Moos. Determinants of the posttreatment functioning of alcoholic patients: A conceptual framework. J. Consult. Clin. Psychol. 48:305-316, 1980. Cummings, C., G. ~ Marlatt and J. R. Gordon. Relapse: Prevention and prediction. In W. R. Miller, ed. The Addictive Behaviors: Treatment of Alcoholism, Drug Abuse, Smoking, and Obesity. Oxford: Pergamon Press, 1980. . Ditman, K S., G. G. Crawford, E. W. Forgy et al. A controlled experiment on the use of court probation for drunk arrests. Am. J. Psychiat~y 124:160-163, 1967. Dittrich, J. E., and M. ~ Trapold. A treatment program for wives of alcoholics: An evaluation. Bull. Soc. Psychol. Addict. Behav. 3:91-102, 1984. Dorus, W. Lithium carbonate treatment of depressed and non-depressed alcoholics in a double-blind, placebo-controlled study. Presented at the annual meeting of the Research Society on Alcoholism, June 3, 1988. -201

Duckert, F. Recruitment into treatment and effects of treatment for female problem drinkers. Addict. Behav. 12:137-150, 1987. Duckert, F., and J. Johnsen. Behavioral use of disulfiram in the treatment of problem drinking. Int. J. Addict. 22:445-454, 1987. Edwards, G., ]. Orford, S. Egert et al. Alcoholism: A controlled trial of "treatments and "advice. J. Stud. Alcohol 38:1004-1031, 1977. Elkin, I., M. T. Shea, J. T. Watkins et al. National Instiute of Mental Health Treatment of Depression Collaborative Research Program: General Effectiveness of Treatments. Arch. Gen. Psychiatry 46:971-982, 1989. Elkins, R. L. Covert sensitization treatment of alcoholism: Contributions of successful conditioning to subsequent abstinence maintenance. Addict. Behav. 5:67-89, 1980. Elkins, R. L. Taste-aversion retention: An animal experiment with implications for consummatory-aversion alcoholism treatments. Behav. Res. Ther. 22:179-186, 1984. Elkins, R. L. Separation of taste-aversion-prone and taste-aversion-resistant rats through selective breeding: Implications for individual differences in conditionability and aversion-therapy alcoholism treatment. Behav. Neuroscience 100:121-124, 1986. Elkins, R. L., and S. H. Hobbs. Taste aversion proneness: A modulator of conditioned consummatory aversion in rats. Bull. Psychonomic Soc. 20:257-260, 1982. Emrick, C. D. Alcoholics Anonymous: Affiliation processes and effectiveness as treatment. Alcoholism Clin. Exp. Res. 11:416-423, 1987. Eriksen, L. The effect of waiting for inpatient treatment after detoxification: An experimental comparison between inpatient treatment and advice only. Addict. Behav. 10:235-248, 1986. Eriksen, L., S. Bjornstad, and K G. Gotestam. Social skills training in groups for alcoholics: One-year treatment outcome for groups and individuals. Addict. Behav. 11:309-330, 1986. Fawcett, J., D. C. Clark, C. ~ Aagesen et al. A double-blind, placebo-controlled trial of lithium carbonate therapy for alcoholism. Arch. Gen. Psychiatry 44:248-256, 1987. Ferrell, W. L., and J. P. Galassi. Assertion training and human relations training in the treatment of chronic alcoholics. Int. J. Addict. 16:959-968, 1981. Fink, E. B., S. Rudden, R. Longabaugh et al. Adherence in a behavioral alcohol treatment program. Int. J. Addict. 19:709-719, 1984. Finney, J. W., R. H. Moos, and D. ~ Chan. Length of stay and program component effects in the treatment of alcoholism: A comparison of two techniques for process analyses. J. Consult. Clin. Psychol. 49:120-131, 1981. -202

Finney, J. W., R. H. Moos, and C. R. Mewborn. Posttreatment experiences and treatment outcome of alcoholic patients six months and two years after hospitalization. J. Consult. Clin. Psychol. 48:17-29, 1980. Fitzgerald, J. L., and H. ~ Mulford. An experimental test of telephone aftercare contacts with alcoholics. J. Stud. Alcohol 46:418-424, 1985. Foy, D. W., B. L. Nunn, and R. G. Rychtarik. Broad-spectrum behavioral treatment for chronic alcoholics: Effects of training in controlled drinking skills. J. Consult. Clin. Psychol. 52:218-230, 1984. Freedberg, E. J., and W. E. Johnston. Outcome with alcoholics seeking treatment voluntarily or after confrontation by their employer. J. Occup. Med. 22:83-86, 1980. Fuller, R. K, and W. O. Williford. Life-table analysis of abstinence in a study evaluating the efficacy of disulfiram. Alcoholism Clin. Exp. Res. 4:298-301, 1980. Fuller, R. K, L. Branchey, D. R. Brightwell et al. Disulfiram treatment of alcoholism: A Veterans Administration cooperative study. J. Am. Med. Assoc. 256:1449-1455, 1986. Gilbert, F. S. The effect of type of aftercare follow-up on treatment outcome among alcoholics. J. Stud. Alcohol 49:149-159, 1988. Gilchrest, L. D., S. P. Schinke, J. E. Trimble et al. Skills enhancement to prevent substance abuse among American Indian adolescents. Int. J. Addict. 22:869-879, 1987. Gill, K, and Z. Amit. Effects on serotonin uptake blockade on food water and ethanol consumption in rats. Alcoholism Clin. Exp. Res. 11~5~:444-449, 1987. Gilmore, K, D. Jones, and L. Tamble. Hazelden, 1986. Treatment Benchmarks. Center City, MN: Glaser, F. B., and ~ C. Ogborne. Does NN really work? Br. J. Addict. 77:123-129, 1982. Gorski, T. T., and M. Miller. Counseling for Relapse Prevention. Independence, MO: Herald House-Independence Press, 1982. Graber, R. A, and W. R. Miller. Abstinence and controlled drinking goals in behavioral self-control training of problem drinkers: A randomized clinical trial. Psychol. Addict. Behav. 2:20-33, 1988. Greenwald, M. A, J. D. Kloss, M. E. Kovaleski et al. Drink refusal and social skills training with hospitalized alcoholics. Addict. Behav. 5:227-228, 1980. Grenier, C. Treatment effectiveness in an adolescent chemical dependence treatment program: A quasi-experimental design. Int. J. Addict. 20:381-391, 1985. Gualtieri, ~ C., J. P. Cosentino, and J. S. Becker. The California experience with a diversion program for impaired physicians. J. Am. Med. Assoc. 249:226-229, 1983. -203

Hobbs, S. H., and R. L. Elkins. Operant performance of rats selectively bred for strong or weak acquisition of conditioned taste aversions. Bull. Psychonomic Soc. 21:303-306, 1983. Hoffman, N. B., P. ~ Harrison, and C. ~ Belille. Alcoholics Anonymous after treatment: Attendance and abstinence. Int. J. Addict. 18:311-318, 1983. Hunt, N. H., and N. H. Aspirin. A community-reinforcement approach to alcoholism. Behav. Res. Ther. 11:91-104, 1973. Ito, J. R., and D. M. Donovan. Aftercare in alcoholism treatment: A review. Pp.435~56 in W. R. Miller and N. Heather, eds. Treating Addictive Behaviors: Processes of Change. New York: Plenum, 1986. Ito, J. R., D. M. Donovan, and J. J. Hall. Relapse prevention and alcohol aftercare: Effects on drinking outcome, change process, and aftercare attendance. Br. J. Addict. 83:171-181, 1988. Jensen, S. B. Sexual function and dysfunction in younger married alcoholics. Acta Psychiatr. Scand. 69:543-549, 1984. Johnsen, J., ~ Stowell, J. Bache-Wiig et al. A double-blind placebo controlled study of male alcoholics given a subcutaneous disulfiram implantation. Br. J. Addict. 82:607~13, 1987. Johnson, V. I'll Quit Tomorrow. New York: Harper and Row, 1980. Jones, S. L., R. Kanfer, and R. I. Lanyon. Skill training with alcoholics: A clinical extension. Addict. Behav. 7:285-290, 1982. Keane, T. M., D. W. Foy, B. Nunn et al. compliance in alcoholic veterans. J. Clin. Psychol. 40:340-344, 1984. Spouse contracting to increase Antabuse Kirk, W. G., J. B. Best, and P. I~n. The perception of empathy in alcoholism counselors. J. Stud. Alcohol 47:834-838, 1986. Kofoed, L. L. Chemical monitoring of dishlfiram compliance: A study of alcoholic outpatients. Alcoholism Clin. Exp. Res. 11:481-485, 1987. Kofoed, L. L., J. Kania, T. Walsh, and R. Atkinson. Outpatient treatment of patients with substance abuse and coexisting psychiatric disorders. Am. J. Psych. 143:867-872, 1986. Kofoed, L. L., R. L. Tolson, R. M. Atkinson et al. Treatment compliance of older alcoholics: An elder-specific approach is superior to ~mainstreaming.~ J. Stud. Alcohol 48:47-51, 1987. Kristenson, H., H. Ohlin, M. B. Hulten-Nosslin et al. Identi~cation and intervention of heavy drinking in middle-aged men: Results and follow-up of 24-60 months of long-term study with randomized controls. Alcoholism Clin. Exp. Res. 7:203-209, 1983. -204

Kurtz, E. Why AA. works: The intellectual significance of Alcoholics Anonymous. J. Stud. Alcohol 43:38-80, 1982. Lawson, G. Relation of counselor traits to evaluation of the counseling relationship by alcoholics. J. Stud. Alcohol 43:834-838, 1982. Leigh, G., ~ C. Ogborne, and P. Cleland. Factors associated with patient dropout from an outpatient alcoholism treatment service. J. Stud. Alcohol 45:359-362, 1984. Lemberger, L., H. Rowe, R. F. Bergstrom et al. The effect of fluoxetine on psychomotor performance, physiologic response, and kinetics of ethanol. Clin. Pharmacol. Ther. 37:658 64, 1985. Ling, W., D. G. Weiss, V. C. Charuvastra et al. Use of disulfiram for alcoholics in methadone maintenance programs: A Veterans Administration cooperative study. Arch. Gen. Psychiatry 40:851-861, 1983. Linnoila, M., M. Eckardt, M. Durcan et al. Interactions of serotonin with ethanol: Clinical and animal studies. Psychopharm. Bull. 23:452-457, 1987. Liskow, B. I., and D. W. Goodwin. Pharmacological treatment of alcohol intoxication, withdrawal and dependence: A critical review. J. Stud. Alcohol 48:356-370, 1987. Litman, G. Alcoholism survival: The prevention of relapse. Pp. 391-405 in W. R. Miller and N. Heather, eds. Treating Addictive Behaviors: Processes of Change. New York: Plenum, 1986. Longabaugh, R., B. McCrady, E. Fink et al. Cost-effectiveness of alcoholism treatment in partial vs. inpatient settings: Six-month outcomes. J. Stud. Alcohol 44:1049-1071, 1983. Mallams, J. H., M. D. Godley, G. M. Hall et al. A social-systems approach to resocializing alcoholics in the community. J. Stud. Alcohol 43:111S-1123, 1982. Marlatt, G. A, and Gordon, J. Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press, 1985. McCrady, B. S., J. Moreau, T. J. Paolino, Jr., et al. Joint hospitalization and couples therapy for alcoholism: A four-year follow-up. J. Stud. Alcohol 43:1244-1250, 1982. McCrady, B. S., N. E. Noel, D. B. Abrams et al. Comparative effectiveness of three types of spouse involvement in outpatient behavioral alcoholism treatment. J. Stud. Alcohol 47:459-467, 1986. McElrath, D. The Hazelden treatment model. Testimony before the U.S. Senate Committee on Governmental Affairs, Washington DC, June 16, 1988. Mc~chlan, J. F. C. Benefit from group therapy as a function of patient-therapist match on conceptual level. Psychother. 9:317-323, 1972. McL`achlan, J. F. C. Therapy strategies, personality orientation, and recovery from alcoholism. Can. Psychiatr. Assoc. J. 19:25-30, 1974. -205

McLachlan, J. F. C., and R. L. Stein. Evaluation of a day clinic for alcoholics. ]. Stud. Alcohol 43:261-272, 1982. McLellan, ~ T., L. Luborsly, C. O'Brien et al. Is treatment for substance abuse effective? J. Am. Med. Assoc. 247:1423-1428, 1982. McLellan, A. T., G. E. Woody, L. Luborsly et al. Increased effectiveness of substance abuse treatment: A prospective study of patient-treatment "matching. J. New. Ment. Dis. 171:597 605, 1983. McMillan, T. M. Lithium and the treatment of alcoholism: A critical review. Br. J. Addict. 76:245-258, 1981. Miller, W. R. Maintenance of therapeutic change: A usable evaluation design. Prof. Psychol. 41:773-775, 1980. Miller, W. R. Motivational interviewing with problem drinkers. Behavioral Psychotherapy 11:147-172, 1983. Miller, W. R. Motivation for treatment: A review with special emphasis on alcoholism. Psychol. Bull. 98:84-107, 1985. Miller, W. R., and L. M. Baca. Two-year follow-up of bibliotherapy and therapist-directed controlled drinking training for problem drinkers. Behav. Ther. 14:441-448, 1983. Miller, W. R., and M. J. Dougher. Covert sensitization: Alternative treatment approaches for alcoholics. Paper presented at the Second Congress of the International Society for Biomedical Research on Alcoholism, Santa Fe, 1984. Miller, W. R., and R. K Hester. Treating the problem drinker: Modern approaches. In W. R. Miller, ed. The Addictive Behaviors: Treatment of Alcoholism, Drug Abuse, Smoking, and Obesity. Oxford: Pergamon Press, 1980. Miller, W. R., and R. K Hester. The effectiveness of alcoholism treatment: What research reveals. Pp. 121-174 in W. R. Miller and N. Heather, eds. Treating Addictive Behaviors: Processes of Change. New York: Plenum, 1986a. Miller, W. R.j and R. K Hester Inpatient alcoholism treatment: Who benefits? American Psychologist 41~7~:794-805, 1986b. Miller, W. R., and R. G. Sovereign. A comparison of two styles of therapeutic confrontation. Unpublished manuscript, University of New Mexico, 1988. Miller, W. R., and C. ~ Taylor. Relative effectiveness of bibliotherapy, individual and group self-control training in the treatment of problem drinkers. Addict. Behav. 5:13-24, 1980. Miller, W. R., C. J. Gribskov, and R. L. Mortell. Effectiveness of a self-control manual for problem drinkers with and without therapist contact. Int. J. Addict. 16:1247-1254, 1981. -206

Miller, W. R., K ~ Hedrick, and C. ~ Taylor. Addictive behaviors and life problems before and after behavioral treatment of problem drinkers. Addict. Behav. 8:403-412, 1983. Miller, W. R., ~ L. Leckman, and M. Tinkcom. Long-term follow-up of controlled drinking therapies, unpublished, 1988. Miller, W. R., R. G. Sovereign, and B. Krege. Motivational interviewing with problem drinkers. II. The drinker's check-up as a preventive intervention. Behav. Psychother, in press. Miller, W. R., C. ~ Taylor, and J. C. West. Focused versus broad-spectrum therapy for problem drinkers. J. Consult. Clin. Psychol. 48:590-601, 1980. Moos, R. H., and B. S. Moos. The process of recovery from alcoholism. III. Comparing functioning in families of alcoholics and matched control families. J. Stud. Alcohol 45:111-118, 1984. Moos, R. H., J. W. Finney, and W. Gamble. The process of recovery from alcoholism. II. Comparing spouses of alcoholic patients and matched community controls. J. Stud. Alcohol 43:888-909, 1982. Morse, R. M., M. ~ Martin, W. M. Swenson et al. Prognosis of physicians treated for alcoholism and drug dependence. J. Am. Med. Assoc. 251:743-746, 1984. Murphy, T. J., R. R. Pagano, and G. A. Marlatt. Lifestyle modification with heavy alcohol drinkers: Effects of aerobic exercise and meditation. Addict. Behav. 11:175-186, 1986. Nakamura, M., J. E. Overall, L. E. Hollister et al. Factors affecting outcome of depressive symptoms in alcoholics. Alcoholism Clin. Exp. Res. 7:188-193, 1983. Naranjo, C. A., E. ~ Sellers, C. A. Roach et al. Zimelidine-induced variations in alcohol intake by non-depressed heavy drinkers. Clin. Pharm. Ther. 35:374-381, 1984. Naranjo, C. A., E. ~ Sellers, J. T. Sullivan et al. The serotonin uptake inhibitor citalopram attenuates ethanol intake. Clin. Pharmaco. Ther. 41:266-274, 1987. National Center for Health Care Technology. Assessment of Chemical Aversion Therapy for Alcoholism. Washington DC: National Center for Health Care Technology, 1981. National Institute on Alcohol Abuse and Alcoholism. Draft recommended council guidelines on ethyl alcohol administration in human experimentation. Washington, DC: NIAAA, November 1988. Neuberger, O. W., J. D. Matarazzo, R. E. Schmitz et al. One-year follow-up of total abstinence in chronic alcoholic patients following emetic counterconditioning. Alcoholism Clin. Exp. Res. 4:306-312, 1980. Neuberger, O. W., N. Hasha, J. D. Matarazzo et al. Behavioral-chemical treatment of alcoholism: An outcome replication. J. Stud. Alcohol 42:806-810, 1981. -207

Neuberger, O. W., S. I. Miller, R. E. Schmitz et al. Replicable abstinence rates in an alcoholism treatment program. J. Am. Med. Assoc. 248:960-963, 1982. Nirenberg, T. D., L. C. Sobell, S. Ersner-Hershfield et al. Can disuIfiram use precipitate urges to drink alcohol? Addict. Behav. 8:311-313, 1983. Noel, N. E., B. S. McCrady, R. L. Stout et al. Predictors of attrition from an outpatient alcoholism treatment program for couples. J. Stud. Alcohol 48:229-235, 1987. Oei, T. P. S., and P. R. Jackson. Long-term effects of group and individual social skills training with alcoholics. Addict. Behav. 5:129-136, 1980. Oei, T. P. S., and P. R. Jackson. Social skills and cognitive behavioral approaches to the treatment of problem drinking. J. Stud. Alcohol 43:532-547, 1982. Oei, T. P. S., and P. R. Jackson. Some effective therapeutic factors in group cognitive-behavioral therapy with problem drinkers. J. Stud. Alcohol 45:119-123, 1984. O'Farrell, T. J., H. S. G. Cutter, and F. J. Floyd. Evaluating behavioral marital therapy for male alcoholics: Effects on marital adjustment and communication before and after treatment. Behav. Ther. 16:147-167, 1985. Ogborne, ~ C., and ~ Bornet. Abstinence and abusive drinking among affiliates of Alcoholics Anonymous: Are these the only alternatives? Addict. Behav. 7:199-202, 1982. Ogborne, A. C., and F. B. Glaser. Characteristics of affiliates of Alcoholics Anonymous: A review of the literature. J. Stud. Alcohol 42:661-675, 1981. Olkin, R., and R. Lemle. Increasing attendance in an outpatient alcoholism clinic: A comparison of two intake procedures. J. Stud. Alcohol 45:465-468, 1984. Olson, R. P., R. Ganley, V. T. Devine et al. Long-term effects of behavioral versus insight-oriented therapy with inpatient alcoholics. J. Consult. Clin. Psychol. 49:866-877, 1981. O'Neil, P. M., J. C. Roitzsch, J. P. Glacinto et al. Disulfiram acceptors and refusers: Do they differ? Addict. Behav. 7:207-210, 1982. Orford, J. Critical conditions for change in the addictive behaviors. Pp. 91-108 in W. R. Miller and N. Heather, eds. Treating Addictive Behaviors: Processes of Change. New York: Plenum, 1986. Orford, J., and A. Keddie. Abstinence or controlled drinking in clinical practice: A test of the dependence and persuasion hypotheses. Br. J. Addict. 81:495-504, 1986. Ornstein, P., and J. A. Cherepon. Demographic variables as predictors of alcoholism treatment outcome. J. Stud. Alcohol 46:425-432, 1985. -208

Ossip-Klein, D. J., W. VanLandingham, D. M. Prue et al. Increasing attendance at alcohol aftercare using calendar prompts and home based contracting. Addict. Behav. 9:85-90, 1984. Panepinto, W., M. Galanter, M. Bender et al. Alcoholics' transition from ward to clinic: Group orientation improves retention. J. Stud. Alcohol 41:940-944, 1980. Peachey, J. E., and H. M. Annis. Pharmacologic treatment of chronic alcoholism. Psych. - Clin. N. Am. 7:745-756, 1984. Peachey, J. E., and H. M. Annis. New strategies for using the alcohol-sensitizing drugs. Pp. 199-216 in C. ~ Naranjo and E. M. Sellers, eds. Research Advances in New Psychopharmacological Treatments for Alcoholism. Amsterdam: Excerpta Medica, 1985. Peachey, J. E., D. H. Zilm, G. M. Robinson et al. A placebo-controlled double-blind comparative clinical study of the disulfiram-and calcium carbimide-acetaldehyde mediated ethanol reactions in social drinkers. Alcoholism Clin. Exp. Res. 7:180-187, 1983. Peck, C. C., S. M. Pond, C. E. Becker et al. An evaluation of the effects of lithium in the treatment of chronic alcoholism. II. Alcoholism Clin. Exp. Res. 5:252-255, 1981. Pettinati, H. M., ~ ~ Sugerman, N. DiDonato et al. The natural history of alcoholism over four years after treatment. J. Stud. Alcohol 43:201-215, 1982. Polich, J. M., D. J. Armor, and H. B. Braiker. Patterns of alcoholism over four years. J. Stud. Alcohol 41:397-416, 1980. Pond, S. M., C. E. Becker, R. Vandervoort et al. An evaluation of the effects of lithium in the treatment of chronic alcoholism: I. Clinical results. Alcoholism Clin. Exp. Res. 5:247-251, 1981. Powell, B. J., E. C. Penick, M. R. Read et al. Comparison of three outpatient treatment interventions: A twelve-month follow-up of men alcoholics. J. Stud. Alcohol 46:309-312, 1985. Powell, B. J., E. C. Penick, S. Rahaim et al. The dropout in alcoholism research: A brief report. Int. J. Addict. 22:283-287, 1986. Rankin, H. Dependence and compulsion: Experimental models of change. Pp. 361-374 in W. R. Miller and N. Heather, eds. Treating Addictive Behaviors: Processes of Change. New York: Plenum, 1986. Rankin, H., R. Hodgson, and T. Stockwell. Cue exposure and response prevention with alcoholics: A controlled trial. Behav. Res. Ther. 21:435-446, 1983. Rees, D. W. Health beliefs and compliance with alcoholism treatment. J. Stud. Alcohol 46:517-524, 1985. Rees, D. W. Changing patients' health beliefs to improve compliance with alcoholism treatment: A controlled trial. J. Stud. Alcohol 47:436-439' 1986. -209

Richard, G. P. Behavioral treatment of excessive drinking. Unpublished dissertation, University of New South Wales, 1983. Rockman, G. E., Z. Amit, G. Carr et al. Attenuation of ethanol intake by 5-hydroxytryptamine uptake blockade in laboratory rats. T. Involvement of brain 5-hydroxytryptamine in the mediation of the positive reinforcing properties of ethanol. Arch. Int. Pharmacodyn. Ther. 241:245-259, 1979. Rohsenow, D. J., R. E. Smith, and S. Johnson. Stress management training as a prevention program for heavy social drinkers: Cognitive, affect, drinking, and individual differences. Addict. Behav. 10:45-54, 1985. Rosenberg, H., and T. Brian. Cognitive-behavioral group therapy for multiple-DUI offenders. Alcoholism Treat. Q. 3:47-65, 1986. Rosenberg, S. D. Relaxation training and a differential assessment of alcoholism. Unpublished doctoral dissertation (University Microfilms No. 8004362), California School of Professional Psychology, San Diego, 1979. Rounsaville, B. J., Z. S. Dolinsly, T. Babor et al. Psychopathology as a predictor of treatment outcome in alcoholics. Arch. Gen. Psychiatry 44:505-513, 1987. Rychtarik, R. G., D. W. Foy, T. Scott et al. Five-year follow-up of broad-spectrum behavioral treatment for alcoholism: Effects of training controlled drinking skills. J. Consult. Clin. Psychol. 55:106-108, 1987. Salzberg, P. M., and C. L. Klingberg. The effectiveness of deferred prosecution for driving while intoxicated. J. Stud. Alcohol 44:299-306, 1983. Sanchez-Craig, M. Random assignment to abstinence or controlled drinking in a cognitive-behavioral program: Short-term effects on drinking behavior. Addict. Behav. 5:35-39, 1980. Sanchez-Craig, M. Therapist's Manual for Secondary Prevention of Alcohol Problems: Procedures for Teaching Moderate Drinking and Abstinence. Toronto: Addiction Research Foundation, 1984. Sanchez-Craig, M., and K. Walker. Teaching coping skills to chronic- alcoholics in a coeducational halfway house. I. Assessment of programme effects. Br. J. Addict. 77:35-50, 1982. Sanchez-Craig, M., H. M. Annis, A. R. Bornet et al. Random assignment to abstinence and controlled drinking: Evaluation of a cognitive-behavioral treatment program for problem drinkers. J. Consult. Clin. Psychol. 52:390-403, 1984. Schuckit, M. A. -A one-year follow-up of men alcoholics given disulfiram. J. Stud. Alcohol 46:191-195, 1985. Sereny, G., V. Sharma, J. Holt et al. Mandatory supervised antabuse therapy in an outpatient alcoholism program: A pilot study. Alcoholism Clin. Exp. Res. 10:290-292, 1986. -210

Shore, J. H. The impaired physician: Four years after probation. J. Am. Med. Assoc. 248:3127-3130, 1982. Shore, J. H. The Oregon experience with impaired physicians on probation: An eight-year follow-up. J. Am. Med. Assoc. 257:2931-2934, 1987. Siegal, H. ~ The intervention approach to drunk driver rehabilitation. I. Evolution, operations, and impact. Int. J. Addict. 20:661-673, 1985a. Siegal, H. ~ The intervention approach to drunk driver rehabilitation. II. Evaluation. Int. J. Addict. 20:675-689, 1985b. Sisson, R. W. The effect of three relaxation procedures on tension reduction and subsequent drinking of inpatient alcoholics. Unpublished doctoral dissertation (University Microfilms No. 8122668), Southern Illinois University at Carbondale, 1981. Sisson, R. W., and N. H. Azrin. Family-member involvement to initiate and promote treatment of problem drinkers. J. Behav. Ther. Exp. Psychiatry 17:15-21, 1986. Sisson, R. W., and J. H. Mallams. The use of systematic encouragement and community access procedures to increase attendance at Alcoholics Anonymous and Al-Anon meetings. Am. J. Drug Alcohol Abuse 8:371-376, 1981. Skutle, A, and G. Berg. Training in controlled drinking for early-stage problem drinkers. Br. J. Addict. 82:493-501, 1987. Snyder, S., I. Karacan, and P. J. Salis. Disulfiram and nocturnal penile tumescence in the chronic alcoholic. Biol. Psychiatry 16:399-406, 1981. Sparadeo, F. R., W. R. Zwick, S. D. Ruggiero et al. Evaluation of a social-setting detoxification program. J. Stud. Alcohol 43:1124-1136, 1982. Spickard, W. A, and P. J. Tucker. An approach to alcoholism in a university medical center-complex. J. Am. Med. Assoc. 252:1894-1897, 1984. Stimmel, B., M. Cohen, V. Sturiano et al. Is treatment of alcoholism effective in persons on methadone maintenance? Am. J. Psychiatry 140:862-866, 1983. Stockwell, T., G. Sutherland, and G. Edwards. The impact of a new alcohol sensitized agent (nitrefazole) on craving in severely dependent alcoholics. Br. J. Addict. 79:403-409, 1984. Stout, R. L., B. S. McCrady, R. Longabaugh et al. Marital therapy helps enhance the long-term effectiveness of alcohol treatment. (Abstract) Alcoholism: Clin. and Exper. Res. 11:213,1987. Swenson, P. R., and T. R. Clay. Effects of short-term rehabilitation on alcohol consumption and drinking-related behaviors: An eight-month follow-up study of drunken drivers. Int. J. Addict. 15:821-838, 1980. -211

Swenson, P. R., D. L. Struclanan-Johnson, V. Ellingstad et al.- Results of a longitudinal evaluation of court-mandated DWI treatment programs in Phoenix, Arizona. J. Stud. Alcohol 42:642-653, 1981. Telch, M. J., R. Hannon, and C. F. Telch. A comparison of cessation strategies for outpatient alcoholism. Addict. Behav. 9:103-109, 1984. Thomas, E. J., and C. ~ Santa. Unilateral family therapy for alcohol abuse: A working conception. Am. J. Pam. Ther. 10:49-60, 1982. Thomas, E. J., C. ~ Santa, D. Bronson et al. Unilateral family therapy with spouses of alcoholics. J. Soc. Sew. Res., in press. Thurber, S. Effect size estimates in chemical aversion treatments of alcoholism. J. Clin Psychol. 41:285-2%7, 1985. Thurston, ~ H., ~ M. Alfano, and V. J. Ne~viano. The efficacy of A-N attendance for aftercare of inpatient alcoholics: Some follow-up data. Int. J. Addict. 22:1083-1090, 1987. Trice, H. M., and J. M. Beyer. Work-related outcomes of the constructive-confrontation strategy in a job-based alcoholism program. J. Stud. Alcohol 45:251-259, 1984. Traux, C. B., and R. R. Carkhuff. Chicago: Aldine, 1967. Toward Effective Counseling and Psychotherapy. Uecker, ~ E., and K B. Solberg. Alcoholics' knowledge about alcohol problems: Its relationship to significant attitudes. Q. J. Stud. Alcohol 34:S09-513, 1973. U.S. Congress, Office of Technology Assessment (OTA). The Effectiveness and Costs of Alcoholism Treatment. Washington, D.C.: OTA, 1983. Valle, S. K Interpersonal functioning of alcoholism counselors and treatment outcome. ~ J. Stud. Alcohol 42:783-790, 1981. Velleman, R. The engagement of new residents: A missing dimension in the evaluation of halfway houses for problem drinkers. J. Stud. Alcohol 45:251-259, 1984. Walker, K, M. Sanchez-Craig, and ~ Bornet. Teaching coping skills to chronic alcoholics in a coeducational halfway house. II. Assessment of outcome and identification of outcome predictors. Br. J. Addict. 77:185-196, 1982. Walker, R. D., D. M. Donovan, D. R. Kivlahan et al. Length of stay, neuropsychological performance, and aftercare: Influences on alcohol treatment outcome. J. Consult. Clin. Psychol. 51:900-911, 1983. Wallace, J., D. McNeill, D. Gilfillan et al. S~x-month treatment outcomes in socially stable alcoholics: Abstinence rates. J. Substance Abuse Treatment, in press. Weidman, ~ Family therapy and reductions in treatment dropout in a residential therapeutic community for chemically dependent adolescents. J. Substance Abuse Treat. 4:21-28, 1987. -212

Westenneyer, J., and J. Neider. Predicting treatment outcome after ten years among American Indian alcoholics. Alcoholism Clin. Exp. Res. 8:179-184, 1984. Whitfield, C ~ Non-drug treatment of alcohol withdrawal. 19:101-119, 1980. Curr. Psychiatr. Ther. Whitfield, C. C, G. Thompson, ~ Lamb et al. Detoxification of 1,024 alcoholic patients without psychoactive drugs. J. Am. Med. Assoc. 239:1409-1410, 1978. Wilson, A, W. I. Davidson, and R. Blanchard. Disulfiram implantation: A trial using placebo implants and two types of controls. I. Stud. Alcohol 41:429-436, 1980. Wilson, A, R. Blanchard, W. J. Davidson et al. Disulfiram implantation: A dose response trial. J. Clin. Psychiatry 45:242-247, 1984. Wilson, G. T. Chemical aversion conditioning as a treatment for alcoholism: A re-analysis. Behav. Res. Ther. 25:503-516, 1987. Zweben, A, and S. Li. The efficacy of role induction in preventing early dropout from outpatient treatment of drug dependency. Am. I. Drug Alcohol Abuse 8:171-183, 1981. Zweben, A, S. Pearlman, and S. Li. Reducing attrition from conjoint therapy with alcoholic couples. Drug Alcohol Depend. 11:321-331, 1983. Zweben, A, S. Pearlman, and S. Li. A comparison of brief advice and conjoint therapy in the treatment of alcohol abuse: The results of the marital systems study. Br. J. Addict., 83~8~:899-916, 1988. -213

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A thorough examination of nearly everything known about the prevention and treatment of alcohol problems, this volume is directed particularly at people interested in conducting research and at agencies supporting research into the phenomenon of drinking. The book essentially is two volumes in one. The first covers progress and potential in the prevention of alcohol problems, ranging from the predispositions of the individual to the temptations posed by the environment. The second contains a history and appraisal of treatment methods and their costs, including the health consequences of alcohol abuse. A concluding section describes the funding and research policy emphases believed to be necessary for various aspects of research into prevention and treatment.

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