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5 Does Treatment Work? A potential hazard of framing simple questions is that they may evoke simplistic answers. The committee has nevertheless entitled this chapter Does Treatment Work?" because "this question is put to us by patients, legislators, referring physicians, social planners, and many others" (Gottheil, 1985~. Some have chosen to answer the question as it stands, usually with an unqualified affirmative. The committee, however, concurs with the opinion of Sanchez-Craig (1986) that Moth the question and its answer are exceedingly ~ . ~ ~ ~ . , ~ . ~ ~ ~ ~ ~ ~ . . . ~ ~ ~ ~ ~^ ~ ~ ~ ~ ~ complex" and believes that a more helpful and productive answer Will be tortncomlng it tne question is reframed. Reframing the Question An examination of several problems inherent in the usual form of this question is instructive and can guide the reframing process. As it stands, the question seems to imply that there is a single or unitary phenomenon that is to be dealt with; however, as discussed in Chapter 1, alcohol problems are multiple and diverse. The question also focuses only on the problems themselves and not on the individuals who manifest them. It appears to overlook the reality of the current therapeutic effort, which consists of many treatments rather than a single standardized form of treatment (see Chapter 3~. In addition, the question seems to imply a "one-shot approach to the treatment of alcohol problems, in which a single episode of treatment is the exclusive focus of attention. Some individuals may achieve lasting positive results from such an episode, but for others a satisfactory outcome hinges on many episodes of treatment, often of different kinds and often delivered over an extended period of time. As a useful (albeit limited) analogy, some forms of cancer may be effectively dealt with by a single treatment episode, but other cancers may require repeated episodes of care, as well as combinations or sequences of several treatments (surgery, radiation, and chemotherapy). The simple form of the question Does treatment work?" also places too much weight on treatment; it does not put the treatment process into an appropriate perspective. As has been particularly emphasized in the work of Rudolf Moos and his associates (Cronkhite and Moos, 1978, 1980; Moos et al., 1982; Moos et al., 1990), treatment is only one of many factors that contribute to outcome. Among the others are the characteristics of the individual who manifests the problem, the characteristics of the problem itself, and the characteristics of the individual's posttreatment experiences. ~ ~ For example, the probability of a positive outcome in a psychotic, homeless individual presenting for treatment with delirium tremens is likely to be lower than that for a mildly anxious, socially stable individual presenting in a sober state without withdrawal symptoms, even assuming that each person receives appropriate treatment. Finally, there is an implication in the question that there may be a uniform criterion for "working," that is, some absolute standard for outcome. In a very general sense, one could say that such goals as ~health" or "increased well-being" or "reduction or elimination of alcohol consumption" represent such standards. Clinicians, however, are aware of the need for flexible goals adapted to individual circumstances. A goal of no further episodes of delirium tremens in the first individual mentioned in the preceding paragraph would represent a major achievement for him but would be totally irrelevant for the second individual. For these as well as other reasons, the question as it stands requires elaboration. Reframing questions of this kind is an approach that has been taken in other areas of 142

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DOES TREATMENT WORK? 143 therapeutics such as psychotherapy, in which the simple question "Does psychotherapy work?" has given rise to similar problems (Kiesler, 1966; Paul, 1967~. Here, the expanded question may be framed as follows: Which kinds of individuals, with what kinds of alcohol problems, are likely to respond to what kinds of treatments by achieving what kinds of goals when delivered by which kinds of practitioners? (Cf. Pattison et al., 1977.) Answering the Reframed Question: Methods If there has been a tendency to frame and to respond in a simplistic manner to questions regarding whether treatment works, there has also been a similar tendency in operation with respect to choosing the appropriate method for making such determinations. To wit: to determine whether treatment works, one conducts a randomized controlled trial (RCI~). The Randomized Controlled Trial The RCT has an important and even crucial role to play in the overall process of examining the results of treatment. Nevertheless, it is only a partial role; realistically, the RCP should be seen as only one of a number of methods for exploring the results of treat- ment. Given the complexity of treatment, such a perspective should not be surprising, but there has been a tendency to view the RCI as the "gold standards for all judgments regarding treatment outcome. Perhaps it should be viewed more as a bronze standard, that is, as a significant part of an alloy that has other important constituents as well. In a randomized controlled trial, individuals who manifest the target problem are randomly assigned either to the treatment method being studied or to a control (no-treatment) or comparison (other-treatment) condition or conditions. A number of methods may be used for implementing random assignment, such as tables of random numbers, the drawing of lots, or even the flipping of a coin; what is crucial is that every subject in the study have an equal probability of being assigned to each group in the study. The purpose of the random assignment is to make any differences between the treatment groupies) and the control or comparison groupies) chance differences rather than systematic differences. Outcome is then determined for all groups. Because there are no systematic differences relevant to outcome between the groups (because of the randomization procedure), and because one group has received the treatment being examined and the other (or others) has not, differences in outcome beyond what might be expected by chance alone can with some confidence be attributed to the effects of the treatment. This methodology can be used to address a wide variety of issues that arise in treatment. In one study, for example, individuals seen at a treatment center without access to inpatient beds were referred elsewhere when it seemed indicated but were invited to return following their inpatient experience. Because many did not do so, it was felt that Ha personal letter expressing concern for the patient's well-being and repeating our invitation for further assistance" might increase the rate of return. To test this idea, half of the next 100 patients were selected at random to receive such a letter. Of the group that received the letter, 50 percent returned; only 31 percent of those who did not receive the letter returned. Because this result was well beyond what could have been expected on the basis of chance, it was concluded that the letter was effective in promoting further contact with the program (Koumans and Muller, 1965~. Although this example seems both straightforward and useful, RCEs have not been widely utilized in clinical treatment programs. Furthermore, when they have been used, it has often been to examine only the outcome of treatment rather than to examine other

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144 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS issues. The reasons for such restricted use of what is clearly a broadly applicable methodology have not been systematically studied. They seem to lie partly in the method itself but, significantly, in the social ecology of treatment and research as well. Even though taking therapeutic action with respect to a given problem and observing the effects of that action would seem to be closely related activities-perhaps even two aspects of the same activity they are not always perceived as such. The activities of clinicians and researchers have sometimes been viewed as antagonistic: clinicians treat, and researchers observe. The pathways to becoming a clinician and to becoming a researcher have in like manner been perceived as sharply divergent. One becomes a clinician, it is sometimes argued, through experience; one becomes a researcher through study. Treatment is a practical discipline; research is an academic discipline. The clinician's knowledge is intuitive; the researcher's knowledge is experimental. Although these dichotomies may be artificial and exaggerated, and the activities involved may in fact be complementary (cf. Blackburn, 1971), with few exceptions the gulf between clinician and researcher is a regrettable reality in the treatment of alcohol problems (cf. Kalb and Propper, 1976; Cook, 1985~. Differing Cultures have grown up around the treatment of alcohol problems on the one hand and research on such problems on the other. These cultures shape the actions of those who are part of them. The RCI' is part of the culture of research; it is not part of the culture of treatment. Regrettably, it seems a common perspective that RCls are carried out by researchers and not by clinicians. The committee believes these cultural differences have much to do with the relative absence of RCEs from clinical settings in the field of alcohol treatment. Yet there are also practical reasons for the absence of RCIs from the clinical setting. The conduct of such trials involves the exercise of a level of methodological sophistication that is beyond the capability of many clinical treatment programs. That no treatment at all might be as effective as the treatment they offer is understandably not a proposition most clinical programs will readily entertain; in addition, because most do not offer alternative interventions (cf. Glaser et al., 1978), comparison studies often are not feasible. There is evidence that many persons who seek treatment do not understand the process of random assignment, even when it has been extensively explained (Appelbaum et al., 1983~. At the same time there is evidence that those who volunteer for random assignment to treatment have a systematically poorer prognosis than those who decline to volunteer (Longabaugh and Lewis, 1988~. Deeply felt ethical concerns may make it difficult for clinicians to entertain the possibility of referral to controlled trials. Clinicians are sought out for their informed opinions as to what kind of treatment might be best for a particular individual. As they often have definite opinions on such questions, whether substantiated by well-controlled studies or not, they may feel remiss if they do not provide their personal view, albeit in a highly qualified form, when it is ur~entlv solicited. A medical ethicist has commented on this problem: One could readily concede that the preference of a physician' unsupported by adequate scientific evidence, is relatively unreliable, but one might nevertheless insist that patients are entitled to know of such preferences (accompanied by appropriate warnings as to their merely intuitive nature). For a physician to withhold such information would be to violate his patient's right to the best possible care. (Schafer, 1982:723) Under these circumstances, referral to a trial in which treatment is selected by chance alone is quite unlikely to ensue (cf. Marquis, 1983; Angell, 1984; Taylor et al., 1984~.

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DOES TREATMENT WORK? 145 There is a further problem regarding the generalizability of results from RCTs. Although the subjects of controlled trials can certainly be individuals who are enrolled in standard treatment programs (as in the example given above), in many instances they tend to be highly selected. This selectivity is often introduced with the intent of making the results of the study more clear-cut and understandable. It nevertheless involves a distortion of the usual clinical situation that may limit the applicability of the study. For example, researchers with the Cardiovascular Disease Databank at Duke University Medical Center, which contains information on all patients with suspected coronary artery disease seen at the center, compared the characteristics of their patients with the eligibility criteria of three large randomized trials of coronary bypass surgery. They found that (respectively) only 13 percent, 8 percent, and 4 percent of their patients met these criteria. The researchers concluded that "the results of these RCEs. . .apply directly to only a small fraction of the patients with coronary disease, and it is uncertain whether one can extrapolate from the results in a highly selected subgroup to the general population of patients" (Hlatky et al., 1984:377~. Even in instances in which such selection is not a problem, generalization may still be difficult. The RCT has proven to be an indispensable method of documenting the effectiveness of drugs and procedures in general medicine. Such procedures, however, and especially such medications are highly likely to be uniform across different treatment settings. Treatments of the sort generally used to deal with alcohol problems are much less likely to be uniform. Without special efforts of the kind that are becoming increasingly common in most areas of behavioral research (see Chapter 11), such interven- tions as group therapy, individual psychotherapy, and even Alcoholics Anonymous meet- ings are likely to be highly variable from one setting to the next. Although the comparability of medications cannot be taken for granted (Koch-Weser, 1974), two standard doses of, for example, insulin, are much more likely to be comparable than two sessions of "usual" group therapy. Thus, there are difficulties in the application of RCIs to clinical treatment programs. Some of these problems have to do with the inherent attributes of the methodology itself, such as its complexity and the difficulties experienced by persons seeking treatment in understanding the concept of randomization. Many other problems have to do with factors external to the methodology, such as the way in which it tends to be used. The committee regrets that RCIs are not more frequently utilized in clinical settings to explore critical issues, and it favors efforts to assist in the more frequent deployment of this methodology. But it views these efforts as necessarily long-term and believes that, in the shorter term, alternative methodologies that avoid some of the problems noted above (although they may be subject to other difficulties) could usefully be broadly deployed in clinical treatment programs as an important complement to RCIs. Defining some of the terms employed in discussing the results of treatment may be a useful way of placing the RCI in perspective. Among the more prominent are efficacy and effectiveness. E~`ca~ refers to the probability of benefit to individuals in a defined population from a treatment provided for a given problem under ideal conditions of use (modified from Lohr et al., 1988~. A test of efficacy answers the question "Can treatment work?" Effectiveness reflects the probability of benefit when the treatment is applied under ordinary conditions by the average therapist to a typical individual requiring treatment (modified from Lohr et al., 1988~. A test of effectiveness answers the question nDoCs treatment work?" In terms of methodology the RCI is the method that can most convincingly demonstrate either efficacy or effectiveness. It has in general been used to demonstrate efficacy, which is another way of saying that it has tended to be used in research settings by academically trained clinical researchers. Although it could be used by clinicians in clinical settings to demonstrate effectiveness, and the committee would strongly support

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146 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS its use in this manner, there are many difficulties in the way (see above) that are not likely to be readily resolved. An alternative course is to deploy a methodology in treatment settings that, ergot as powerful as the RCT, nevertheless provides data that am useful in themselves, that speak to the issue of effecfiven~ess, awl that complemera what can be Earned from RCTs conducted in other setting As will be discussed further in Chapter 12, systematic monitoring of the outcome of treatment is such a method. To know that a high percentage of individuals who pass through a particular treatment program subsequently achieve a positive outcome is knowledge worth having for its own sake. Because in the usual outcome monitoring study there is no identical comparison group, this type of study does not prove that the good results observed were due to the treatment provided, although it does suggest that the program me be effective. However, if randomized controlled trials have suggested that the method of treatment being provided is effective, a greater level of confidence can be entertained that the treatment provided in the program monitored is eff~caciou~that it may have been a significant factor in producing the positive outcomes that were observed. Although outcome monitoring is a far less complex methodology than the conduct of RCTs, it has not been widely used in examining the treatment of alcohol problems. There are, however, signs that this is changing, both in the public sector (e.g., the state of Minnesota requires all publicly funded programs to participate in some form of outcome monitoring) and in the private sector (e.g., the Chemical Abuse/Addictions Treatment Outcome Registry, or CATOR, an outcome-monitoring service, is increasingly subscribed to by private treatment programs). The committee applauds such efforts and considers the broad application of outcome monitoring to be both feasible and desirable. (See Chapter 12 for a more detailed discussion.) If coupled with a more general use of RCIs in research settings (IOM, 1989), regular outcome monitoring in clinical settings would represent a highly significant advance in the treatment of alcohol problems. The Role of Quality Assurance For a convincing demonstration of efficacy or effectiveness to occur, mechanisms should be in place to assure "truth in packaging that the treatment allegedly being delivered is actually being delivered and that it is being delivered appropriately. Accomplishing this assurance involves such activities as the selection, training, and monitoring of treatment staff. (These activities and others like them are part and parcel of RCIs, but the term quaky assurance is usually applied only to realistic treatment situations.) The necessity for quality assurance activities arises from long experience. Not all alcohol treatment programs succeed in providing what they claim to be providing (Moffett et al., 1975~. Programs vary. Key staff leave; new staff are hired. Various staff differ considerably in background, training, orientation, personal characteristics, and so forth. In the absence of quality assurance mechanisms the treatment activities of individual staff members may evolve in differing and idiosyncratic therapeutic directions. The need for quality assurance is not unique to the treatment of alcohol problems but is common to all therapeutic situations (cf. Eddy and Billings, 1988; Lohr et al., 1988; Roper et al., 1988~. Other Methods In addition to the RCI and outcome monitoring, there are other methods that can yield useful and important information regarding the impact of treatment on persons with

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DOES TREATMENT WORK? 147 problems. The individual case study is an example. Surveys of consumer satisfaction are another. In recent years much attention has been given to quasi-experimental methods of studying treatment. In short, many methods are available that can add to our understanding of the results of treatment, and they may all be required to fully comprehend so complex an undertaking. A single method, by itself, will not suffice. Answering the Reframed Question: Results Workers in the alcohol treatment field have done yeoman service in attempting to answer questions of treatment efficacy and effectiveness. One estimate is that more than 600 treatment outcome studies have been completed, about half of which have been completed in the 1980s; among these there have been approximately 200 comparative clini- cal trials, about two-thirds of which have employed random assignment (Miller, 1988; IOM, 1989~. In addition to these original studies, the subject has been repeatedly reviewed over the last four decades (cf. Bowman and Jellinek, 1941; Voegtlin and Lemere, 1942; Hill and Blane, 1967; Pattison, 1974; Baekeland et al., 1975; Emrick, 1975; Clare, 1976; Baekeland, 1977; Emrick, 1979; Diesenhaus, 1982; Miller and Hester, 1986; Annis, 1987; IOM, 1989~. This body of work represents a commendable and important effort. What conclusions can be drawn? As with any large and diverse body of information, the data admit of differing interpretations. During the course of the present study the assembly and analysis of information on treatment efficacy and effectiveness was undertaken jointly by this committee and IOM's Committee to Identify Research Opportunities for the Prevention and Treatment of Alcohol-Related Problems. The results appear as part of this second committee's report (IOM, 1989~. The relevant chapter of that report is reproduced here as Appendix B for the convenience of the reader. Many of the conclusions noted in the appended material are directly applicable to the work of this committee; a few are specifically responsive to our sister committee's charge and are therefore beyond the purview of this group. Other conclusions have been modified to reflect accurately the particular views of the committee for the present study. Its somewhat modified conclusions, which are supported by the material and the citations to be found in the appendix, are as follows: 1. There is no single treatment approach that is effective for all persons with alcohol problems. A number of different treatment methods show promise in particular groups. Reason for optimism in the treatment of alcohol problems lies in the range of promising alternatives that are available, each of which may be optimal for different types of individuals. For example, a series of studies on heterodox eous treatment populations has shown rho overall advar~tage in terms of outcome for residential or inpatient treatment over outpatient treatment. Each treatment setting may be most appropriate for particular persons. Specifi- cally, nonhospital residential care may be most appropriate for individuals who are socially unstable (i.e., who are homeless, unemployed, etc.) but who do not have coexisting acute medical or severe psychiatric problems. Inpatient hospital care may be most appropriate for persons with coexisting acute medical or severe psychiatric problems, regardless of their level of social stability. Outpatient care may be indicated for socially stable individuals who do not have coexisting acute medical or severe psychiatric problems. 2. The provision of appropriate, specific treatment modalities can substantially improve outcome. A variety of specific treatment methods for alcohol problems has been associated with increased improvement, relative to no treatment or alternative treatments, in controlled studies.

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48 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS 3. Brief ir~erventior~s car' be quite effective compared with no treatment, and they can be quite cost-effective compared with more intensive Moment. For some people with alcohol problems, relatively minimal interventions have been shown to be significantly more effective than no intervention and on a cost-effectiveness basis may compare favorably with more intensive treatment (see Chapter 9~. The low cost and simple nature of brief interventions render them accessible to a broad range of persons with alcohol problems who might otherwise not receive treatment. 4. Treatment of other life problems related to drinking can improve outcome ir' persons with alcohol problems. 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 favorable outcome. Such broad-spectrum strategies seem to affect outcome by helping to resolve other significant life problems that, if left untreated, could precipitate relapse. 5. Therapist characteristics are determinants of outcome. Treatment is not offered by neutral agents. Therapist skills and attributes can be important factors in influencing treatment outcome. The interaction of therapist variables with treatment variables and with variables of the individuals manifesting alcohol problems, as well as the more direct effects (main effects) of therapist characteristics, has been shown to account for a substantial amount of variance in motivation, drop-out, compliance, and outcome. 6. Outcomes are determined in part by treatment process factors, posttreatmer~t adjustment factors, the characteristic of individuals seeking treatment, the characteristics of their problems, and the irzleractior~s among these factors. Individual difference variables that are non~necitic (e.~.. resistance to treatment) or specific to particular approaches (edit., the r ~ D ~ ~ ~ ~ , ~ ~ A, establlsnment of a conoltloneo aversion response) nave oeen snown lo prealcl Irealmen~ outcome. Recent research on pretreatment matching likewise indicates that responses to a particular treatment may depend on the personal and problem characteristics of those seeking treatment. 7. People who are treated for alcohol problems achieve a continuum of outcomes with respect to drinking behavior and alcohol problems and follow different courses of outcome. Drinking behavior following treatment ranges from an increase in drinking, to no change in drinking, to a reduction in drinking but with continuing problems, to problem-free drinking, to total abstinence. Alcohol problems may increase or decrease following treatment. Some treated individuals show initial improvement with subsequent deterioration (nfadersn). Others show a gradual increase in improvement (nsleepersn). Still others oscillate between outcomes (e.g., between abstinence and problem-free drinking or between abstinence and problem drinking). 8. Those who significant, reduce their level of alcohol consumption or who become totally abstinent usually enjoy improvement in other life areas, particulars as the period of reduced consumption becomes more extended. Treatment for alcohol problems thus wisely emphasizes the importance of significantly reducing or eliminating alcohol consumption. The committee views these conclusions as somewhat tentative but highly encouraging. They are tentative both because additional replications of completed studies are needed and because many treatment methods have not been evaluated under a range of circumstances-for example, with many different kinds of persons. Moreover, new treatment methods are constantly being developed, and various combinations and sequences of treatment methods require exploration. There is no foreseeable end to the need for information regarding the impact of treatment. Its investigation is part and parcel of the provision of treatment (see Chapter 12~. The conclusions are viewed as highb encouraging because they suggest that treating people with alcohol problems is an endeavor that can produce very positive results. Although it is not

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DOES TREATMENT WORK? 149 realistic to expect outstanding results in every instance, some such results will occur, and most persons can be helped in some way. The conclusions contain many important indications of improvements that might be made in current treatment practices. These suggestions will be dealt with in more detail in the balance of this report. Summary and Conclusions The simplistic question "Does treatment work?" needs to be reframed. In its stark, albeit common, form, it does not reflect accurately the complexities of the therapeutic situation or current understanding of the results of treatment research. A preferable version of the question is the following: Which kinds of individuals, with what kinds of alcohol problems, are likely to respond to what kinds of treatments by achieving what kinds of goals when delivered by which kinds of practitioners? The ongoing effort to provide appropriate answers to this reframed question requires the deployment of a variety of investigative methods. Although the randomized controlled trial ARCH has many advantages and should be more broadly used to answer questions of clinical relevance, it has disadvantages that tend to limit its widespread application in clinical treatment settings. Alternative methodologies, if less powerful in terms of the demonstration of treatment efficacy, may nevertheless be more widely applicable and can provide information to complement that derived from RCIs. Based on treatment research efforts to date, which should be continued and extended, the committee believes that some necessarily tentative but highly encouraging conclusions may be drawn. Although no single treatment has been identified as effective for all persons with alcohol problems, a variety of specific treatment methods has been associated with positive outcomes in some groups of persons seeking treatment. Brief interventions have been shown to be effective compared with no treatment and compared with more complex treatments. Although it is important to approach alcohol problems directly, dealing with other life problems can also contribute to positive outcomes. Treatment outcomes are affected by a multiplicity of factors, both within the treatment situation (e.g., the skills and attributes of therapists) and outside the treatment situation (e.g., the posttreatment experiences of the individuals. A significant, extended reduction or elimination of alcohol consumption is usually associated with improvement in other areas of living; as in the treat- ment of other human problems, however, a varieW of outcomes is to be expected. REFERENCES Angell, M. 1984. Patients' preferences in randomized clinical trials. New England Journal of Medicine 310:1385-1387. Annis, H. M. 1987. Effective treatment for drug and alcohol problems: What do we know? Presented to the Annual Meeting of the Institute of Medicine, Washington, D.C., October 21. Appelbaum, P. S., L. H. Roth, and C. Lidz. 1983. The therapeutic misconception: Informed consent in psychiatric research. International Journal of Law and Psychiatry 5:319-329. Baekeland, F. 1977. Evaluation of treatment methods in chronic alcoholism. Pp. 385440 in Treatment and Rehabilitation of the Chronic Alcoholic. Vol. 5 of The Biology of Alcoholism, B. Kissin and H. Begleiter, eds. New York: Plenum Press. Baekeland, F., L. Lundwall, and B. Kissin. 1975. Methods for the treatment of chronic alcoholism: A critical appraisal. Pp. 247-327 in Research Advances in Alcohol and Drug Problems, vol. 2, R. J. Gibbins, Y. Israel, H. Kalant et al., eds. Toronto: John Wiley and Sons.

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150 BROADENING DIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS B}ackburn, T. R. 1971. Sensuous-intellectual complementarily in science. Science 172:1003-1007. Bowman, K, and E. M. Jellinek. 1941. Alcohol addiction and its treatment. Quarterly Journal of Studies on Alcohol 2:98-176. Clare, A. W. 1976. How good is treatment? Pp. 279-289 in Alcoholism: New Knowledge and New Responses, G. Edwards and M. Grant, eds. Baltimore: University Park Press. Cook, D. R. 1985. Craftsman vs. professional: Analysis of the controlled drinking controversy. Journal of Studies on Alcohol 46:43342. Cronkhite, R. C., and R. H. Moos. 1978. Evaluating alcoholism treatment programs: An integrated approach. Journal of Consulting and Clinical Psychology 46:1105-1119. Cronkhite, R. C., and R. H. Moos. 1980. Determinants of the posttreatment functioning of alcoholic patients: A conceptual framework. Journal of Consulting and Clinical Psychology 48:305-316. Diesenhaus, H. I. 1982. Current trends in treatment programming for problem drinkers and alcoholics. Pp. 219-290 in Prevention, Intervention, and Treatment: Concerns and Models, J. de Luca, ed. Washington, D.C.: U.S. Government Printing Office. Eddy, D. M., and J. Billings. 1988. The quality of medical evidence: Implications for quality of care. Health Affairs 7:19-32. Emrick, C. D. 1975. A review of psychologically oriented treatment of alcoholism. II. The relative effectiveness of different treatment approaches and the effectiveness of treatment versus no treatment. Journal of Studies on Alcohol 36:88-108. Emrick, C. D. 1979. Perspectives in clinical research: Relative effectiveness of alcohol abuse treatment. Family and Community Health 2:71-88. Glaser, F. B., S. W. Greenberg, and M. Barrett. 1978. A Systems Approach to Alcohol Problems. Toronto: ARE Books. Gottheil, E. 1985. Introduction. Pp. 1-8 in Summaries of Alcoholism Treatment Assessment Research, D. J. Lettieri, M. A. Sayers, and J. E. Nelson, eds. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. Hill, M. J., and H. T. Blane. 1967. Evaluation of psychotherapy with alcoholics: A critical review. Quarterly Journal of Studies on Alcohol 28:76-104. Hlatky, M. A, K L. Lee, F. E. Harrell, Jr., et al. 1984. Tying clinical research to patient care by use of an observational data base. Statistics in Medicine 3:375-384. Institute of Medicine. 1989. Prevention and Treatment of Alcohol Problems: Research Opportunities. Washington, D.C.: National Academy Press. Kalb, M., and M. S. Propper. 1976. The future of alcohology: Craft or science? American Journal of Psychiatry 133:641-645. Kiesler, D. J. 1966. Some myths of psychotherapy research and the search for a paradigm. Psychological Bulletin 65:110-136. Koch-Weser, J. 1974. Bioavailability of drugs. New England Journal of Medicine 291:233-237,503-506. Koumans, A. J. R., and J. J. Muller. 1965. Use of letters to increase motivation for treatment in alcoholics. Psychological Reports 16:1152. Lohr, K N., K D. Yordy, and S. O. Thier. 1988. Current issues in quality of care. Health Affairs 7:5-18. Longabaugh, R., and D. C. Lewis. 1988. Key issues in treatment outcome studies. Alcohol Health and Research World 12:168-175. Marquis, D. 1983. Leaving therapy to chance. The Hastings Center Report 13~4~:40~7.

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DOES TREAltMENT WORK? 151 Miller, W. R. 1988. The effectiveness of treatment for alcohol problems: Reasons for optimism. Presented at the conference '~rug Abuse and Alcohol: New Prospects for Recovery," at the Royal Society of Medicine, London, May 10. Miller, W. R., and R. K Hester. 1986. The effectiveness of alcoholism treatment: What research reveals. Pp. 121-174 in Treating Addictive Behaviors: Processes of Change, W. R. Miller and N. Heather, eds. New York: Plenum Press. Moffett, A. D., S. W. Greenberg, and F. B. Glaser. 1975. Nonprograms in the management of drug and alcohol abuse. Pp. 617~27 in Developments in the Field of Drug Abuse: National Drug Abuse Conference, 1974, E. Senay, V. Shorty, and H. Alksne, ads. Cambridge, Mass.: Schenkman Publishing Company. Moos, R. H., R. C. Cronkhite, and J. W. Finney. 1982. A conceptual framework for alcoholism treatment evaluation. Pp. 1120-1139 in Encyclopedic Handbook of Alcoholism, E. M. Pattison and E. Kaufman, eds. New York: Gardner Press. Moos, R. H., J. W. Finney, and R. C. Cronkhite. 1990. Alcoholism Treatment: Context, Process, and Outcome. New York: Oxford University Press. Pattison, E. M. 1974. Rehabilitation of the chronic alcoholic. Pp. 587~58 in Clinical Pathology. Vol. 3 of The Biology of Alcoholism, B. Kissin and H. Begleiter, eds. New York: Plenum Press. Pattison, E. M., M. B. Sobell, and L. C. Sobell. 1977. Emerging Concepts of Alcohol Dependence. New York: Springer Publishing Company. Paul, G. L. 1967. Strategy of outcome research in psychotherapy. Journal of Consulting Psychology 31:109-118. Roper, W. L., W. Winkenwerder, G. M. Hackbarth, et al. 1988. Effectiveness in health care: An initiative to evaluate and improve medical practice. New England Journal of Medicine 319:1197-1202. Sanchez-Craig, M. 1986. The hitchhiker's guide to alcohol treatment. British Journal of Addiction 81:597~00. Schafer, ~ 1982. The ethics of randomized clinical trials. New England Journal of Medicine 307:719-724. Taylor, K M., R. Margolese, and C. L. Soskolne. 1984. Physicians' reasons for not entering eligible patients in a randomized clinical trial of surgery for breast cancer. New England Journal of Medicine 310:1363-1367. Voegtlin, W. L., and F. Lemere. 1942. The treatment of alcohol addiction: A review of the literature. Quarterly Journal of Studies on Alcohol 2:717~03.