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6 Is Treatment Necessary?
Faced with this chapter's title question, one is tempted to respond reflexively, with
both urgency and gruffness, "Of course it is! How can one seriously question the necessity
of treatment for problems that destroy hundreds of thousands of lives and cost our country
hundreds of millions of dollars each year?" Yet the diversity of alcohol problems (see
Chapter 2) requires that this question be considered more thoughtfully.
In the previous chapter, which is supplemented by the material in Appendix B.
the considerable evidence that some people with alcohol problems respond in a definite
and gratifying manner to some treatments has been extensively presented. In this chapter
the committee addresses some additional facts that serve to fill out a more comprehensive
and at the same time more complex picture of response to treatment. These include the
findings that (aJ some people with alcohol problems overcome them without arty formal treatment
experience; (bJ some people who receive formal treatment have worse drinking problems afterward*
and (cJ some people who are coerced into treatment do not fare better than those who receive no
treatment.
Improvement in Alcohol Problems
Without Formal Treatment
The phenomenon of improvement without treatment is characteristically referred
to as "spontaneous remission," a label that is misleading with respect to both of its two
terms (Stall and Biernacki, 1986~. Available data suggest that the resolution of alcohol
problems without recourse to formal treatment (Tuchfeld, 1981) is neither spontaneous (it
often occurs as a consequence of readily identifiable antecedents) nor best viewed as a
remission (it often is not a temporary hiatus in the natural course of a relentlessly
progressive problem). In this report, therefore, the phenomenon will be referred to as
Improvement in alcohol problems without formal treatment." That such improvement does
in fact occur is beyond serious doubt, although (as will be seen) many questions about the
phenomenon remain unanswered.
The reversal of disease states without formal therapeutic intervention is well known
in medicine. Specifically effective medical interventions have in general been available only
during the twentieth century, yet humanity has survived. Furthermore, a decline of
mortality rates from many diseases long preceded the introduction of specific treatment,
probably as a result of such nonspecific factors as improved diet (McKeown, 1976~. It was
at one time customary for medical students entering their training to be congratulated on
choosing their profession wisely because a significant proportion of the problems they
would be called on to address would take care of themselves.
Walter B. Cannon (1871-1945) coined the term homeostas~s to reflect the tendency
of the human organism to return itself to a dynamic steady state following various kinds
of perturbations, including illnesses. Multiple mechanisms, such as the production of
antibodies to potentially harmful invading organisms on the physical level or the
development of various defense mechanisms on the psychological level, subserve this
purpose. Wound healing is an important example. When extravagantly praised for his
therapeutic efforts on the battlefield, Ambroise Pare (1517-1590), the father of modern
surgery, commented: "I dressed the wound; God healed it."
So powerful is the tendency for human problems to revert to normal unaided by
intentional therapeutics that special means must be employed in therapeutic evaluations to
152
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IS TREATMENT NECESSARY?
153
take reversions that are not due to treatment into account. The randomized controlled trial
ARCH described in the previous chapter is commonly used for this purpose. Rigorous
testing of efficacy is required even in instances in which success seems likely or is critically
important (e.g., in tests of vaccines or of anticancer agents), in large measure because of
the reality of improvement without formal treatment.
Given the foregoing, it should not be surprising that improvement without formal
treatment may also occur in alcohol problems. A number of lines of evidence suggest that
it does. One is clinical observation. The first North American treatise on alcohol
problems, prepared by Benjamin Rush (1745-1813), contains a number of examples of the
cessation of alcohol problems in the absence of formal intervention. Two are presented
here.
A farmer in England, who had been many years in the practice of coming
home intoxicated, from a market town, one day observed appearances of
rain, while he was in market. His hay was cut, and ready to be housed.
To save it, he returned in haste to his farm, before he had taken his
customary dose of grog. Upon coming into his house, one of his children,
a boy of six years old, ran to his mother, and cried out, "O mother, father
is come home, and he is not drunk." The father, who heard this
exclamation, was so severely rebuked by it, that he suddenly became a
sober man.
A noted drunkard was once followed by a favorite goat, to a tavern, into
which he was invited by his master, and drenched with some of his liquor.
The poor animal staggered home with his master, a good deal intoxicated.
The next day he followed him to his accustomed tavern. When the goat
came to the door, he paused: his master made signs to him to follow him
into the house. The goat stood still. An attempt was made to thrust him
into the tavern. He resisted, as if struck with the recollection of what he
suffered from being intoxicated the night before. His master was so much
affected by a sense of shame, in observing the conduct of his goat to be
so much more rational than his own, that he ceased from that time to
drink spirituous liquors. (Jellinek, 1943:339)
Most contemporary evidence for improvement without formal treatment comes
from studies of alcohol problems in the general population. By definition, it is not
possible to study the phenomenon in a population undergoing formal treatment. However,
this does flat mean that so-called spontaneous remission does not occur in treatment
populations. Although improvement that occurs in an individual in treatment is
characteristically attributed to the treatment provided, it may in fact be due to other causes.
It is just such a possibility that RCIs and other research designs are used to explore.
The results of a large number of studies in general populations and their
implications for the understanding of improvement without formal treatment have been
extensively summarized by Fillmore and her associates (1988) in a review prepared for the
use of this committee. In general, two types of studies have been done: cross-sectional
and longitudinal. In the first the status of alcohol problems of individuals in a large
population has been examined at one point in time. In the second the status of alcohol
problems of individuals in a smaller population has been examined at more than one point
in time (usually two points). Although these studies do not directly examine improvement
without formal treatment, a relatively consistent picture emerges from them.
First, the prevalence of alcohol problems declines with age. People in younger age
categories are more likely to have alcohol problems. As they grow older, their alcohol
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154 BROADENING THE BASE OF lllEATMENT FOR ALCOHOL PROBLEMS
problems are likely to decrease in severity or to cease altogether. Excess mortality from
alcohol problems accounts for some proportion of this observation but not for all of it.
The commonly advanced explanation for this "maturing out" of alcohol problems is the
tendency of the young to "sow their wild oats" and subsequently, with increasing experience,
to conform to social expectations. "Maturing out" is a pattern that has also been observed
in persons with drug problems (Winick, 1962~.
Second, although these changes with age occur in both men and women, the
prevalence of alcohol problems among women is substantially less than among men. For
example, the prevalence of Alcohol abuse and/or dependence during the year prior to
interview in the f~ve-site Epidemiological Catchment Area (ECA) survey was 11.9 percent
for men and 2.2 percent for women (Helzer and Burnham, in press). Correspondingly, the
rate of "spontaneous remissions is higher among women (see esp. Fillmore, 1987~. Here,
the explanation tends to be that the drinking of alcohol is more consistent with the tradi-
tional social definition of the male role than of the female role; "the most obvious reason
is that there are positive norms for heavy drinking among men, but not among women.
Heavy drinking is considered appropriate masculine behavior" (Ferrence, 1980:117~.
Therefore, there is less social pressure on females to begin drinking and more pressure on
them to stop.
Third, improvement without formal treatment is not a minor or insignificant
phenomenon. In the population-based ECA study, for example, "remissions rates for all
cases meeting DSM-III criteria for ~alcoholism" averaged between 45 and 55 percent at all
five sites (Helzer and Burnham, in press). A summary statement on age, sex, and
improvement without formal treatment, drawn from all currently available information, is
that there is
a higher prevalence of problems in youth, but erratic and non-chronic
with a 50-60 percent chance of remission both in the long and short term
among men and more than 70 percent chance of remission among women;
in middle age, a much lower prevalence, but chronic with a 30-40 percent
chance of remission among men and about a 30 percent chance of
remission among women; in older age, a great deal lower prevalence of
problems, which were more likely chronic, with a 60-80 percent chance of
remission among men and a 50-60 percent chance of remission among
women. (Fillmore et al., 1988:29)
Fourth, although these general patterns are both clear and have been relatively
stable across time and across jurisdictions, they are by no means universally descriptive.
Not all persons with alcohol problems "mature out" of them, and some women do have
very severe and very persistent alcohol problems. Although age and sex do seem to have
an effect on the course of alcohol problems, there are many variations in such courses
within each sex and age group.
For example, in one longitudinal study that looked at drinking problems at two
points in time (age 18 and age 31), 63.4 percent of the sample had a different problem
status at age 31, but 36.6 percent of the sample had the same problem status (Temple and
Fillmore, 1985~. In another longitudinal study (Vaillant, 1983) that looked at a population
sample at multiple points in time, four separate courses were observed among those who
had developed severe alcohol problems. In short, the drinking problems of some persons
change over time, becoming worse or better or fluctuating; the drinking problems of other
persons do not change over time.
Fifth, at present it is not possible to predict with certainty whether the alcohol
problems of a given individual will or will not improve over time. One reason is that,
although relatively adequate data are available on the course of alcohol problems by age
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IS TREATMENT NECESSARY?
155
and by sex, there appear to be a large number of additional variables that affect whether
or not such problems persist and on which relatively few data are available. These
variables may include such factors as social class, social stability, social setting, significant
life events, severity of the alcohol problem, ethnicity, and comorbidity (the concurrent
presence of other problems, especially psychiatric disorders and drug problems).
The systematic study of the impact of these variables on the course of alcohol
problems is a task for the future. If (as is probable) they prove to be important
determinants, their number and variety underscore the probability of divergent courses for
different individuals. Another way of saying this is that improvement without formal
treatment is not a unitary phenomenon that uniformly affects all persons with alcohol
problems. Rather, it is a heterogeneous phenomenon that affects different persons in a
highly variable manner and for many different reasons.
Thus, although formal treatment is helpful to some persons with alcohol problems,
others improve without it. Formal treatment is not always necessary, but in our current
state of knowledge it is not possible to predict for whom it is and for whom it is not
necessary. Another significant consideration is that treatment is not only at times
unnecessary but may actually be harmful.
Deterioration in Alcohol Problems with Formal Treatment
When an individual recognizes his or her alcohol problem and actively seeks
assistance in resolving it, treatment is often viewed as a moral imperative and is considered
by some to be a right (cf. Fried, 1975~. It has been argued that this is so whether or not
the treatment has been shown to be effective (Halmos, 1966~. But what if the treatment
being offered carries a significant risk of harming the person? In this circumstance,
treatment is not simply unnecessary but can result in matters becoming worse than they
would have been if no treatment or a different treatment had been provided. The point
is that all treatment must be considered within the cony of a r~sk/benef~ analysis (cf. Institute
of Medicine, 1989~.
Risks are understood to accompany many forms of medical treatment. Penicillin,
as well as other highly effective drugs, may result in sensitivity reactions or other side
effects in some proportion of individuals. Nor are treatment risks necessarily limited to the
individual under treatment; the adverse effects on unborn children of thalidomide and of
the use of estrogens to prevent miscarriages come to mind. Some surgical procedures carry
with them significant hazards. General anesthesia itself carries a small but definite risk of
mortality. As with medical and surgical treatment, it is clear that there are numerous
potential negative effects of treatment for alcohol problems (Emrick, 1988~.
Potentially harmful alcohol treatment interventions include the use of vigorous
negative confrontation techniques with individuals who lack the means to cope with the
confrontation in a constructive manner (Annie and Chan, 1983; Miller and Sovereign,
1985~. Focusing on an individual's drinking problem to the exclusion of other disorders
that require direct treatment (e.g., coexisting psychiatric disorders) may also be harmful.
The routine rather than the selective use of antialcohol medications can be fraught with
difficulty, and in general the rigid application of a treatment philosophy or a technical
intervention without due consideration for individual differences is hazardous.
Potentially harmful characteristics or behaviors of the treaters of alcohol problems
also constitute a risk factor. For example, dependent individuals may be exploited to satisfy
the needs of the therapist or of the treatment program. Other common difficulties
attributable to treaters include being rejecting, cold, impersonal, unsupportive, or actually
hostile with individuals in treatment, or insisting that the individual is just like the
therapist and can only improve by doing exactly what the therapist has done to overcome
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156 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
his or her alcohol problems. Certain characteristics or behaviors of the individual in
treatment may also contribute to harmful treatment effects; some examples include low
self-esteem, low involvement in or compliance with treatment, a lack of interpersonal skills,
or reliance escape as a method of coping with stress.
Inasmuch as alcohol treatment can result in harm, a reflexive "yes" to the question
"Is treatment necessary?" may not only result in the wasteful use of treatment resources
(through the delivery of unnecessary or ineffective treatment) but may actually lead to
injury, albeit unintentioned. Treatment is therefore not to be undertaken lightly. Once
again the absence of data does not permit a prediction of who will be harmed by
treatment, anymore than it permits a prediction of who will not require formal treatment.
Coerced Treatment for Alcohol Problems
Perhaps the question "Is treatment necessary? would not be so crucial were it not
for the fact that many individuals who are currently being treated for alcohol problems are
forced to receive treatment (Boscarino, 1980; Furst, 1981; Weisner, 1987; State of Connecti-
cut Drug and Alcohol Abuse Criminal Justice Commission, hereafter referred to as State
of Connecticut, 1988~. Because of the major and increasing role played by coercion in the
treatment of alcohol problems, the committee has included as Appendix C to its report a
review of the topic prepared by one of its members. Much of the following discussion is
based on this document. It is worth noting that a consideration of "statutory and voluntary
mechanisms" for the provision of treatment was a specific element of the congressional
charge to the committee.
Coerced treatment has become an important issue not only in the United States
but at an international level as well. A World Health Organization study found that 20
of the 43 countries investigated had some kind of diversion legislation allowing treatment
to serve as an alternative to judicial action (Curran et al., 1987~. Moreover, criminal
justice referrals in particular jurisdictions may be extensive; a study in one state found that,
if all such referrals were accepted by alcohol treatment programs, they would occupy 64
percent of the total available rehabilitation beds (State of Connecticut, 1988~.
Most prominent among the coerced at present are those who are sent to treatment
by the courts for drunken-driving offenses (Fillmore and Kelso, 1987~. For example, one
state experienced a 400 percent increase of driving while intoxicated (DWI) offenders into
treatment programs for alcohol problems during 1986-1987 (State of Connecticut, 1988~.
In some jurisdictions arrested drinking drivers are given their choice of alcohol treatment
or criminal justice sanctions; in others they are automatically referred to treatment
programs for alcohol problems (U.S. Department of Transportation, 1976; Weisner, 1986;
Stewart et al., 1987~. Without denying that drunken driving is a critical social problem, it
must nevertheless be emphasized that those persons who drink and drive constitute a group
that overlaps with but is not identical to the group of individuals who have serious alcohol
problems (Donovan et al., 1983; Vingilis, 1983; Wilson and Jonah, 1985; Perrine, 1986~.
Other important sources of referral to treatment under coercion include civil
commitment, diversion from the criminal justice system for public drunkenness and crimes
other than DWI offenses in which alcohol has played a role, workplace referrals
Unconstructive coercions), and referrals that come about as a result of carefully structured
and highly confronting small group sessions (Johnson, 1973, 1986~. Presumably, the sum
total of these referrals constitutes a very large and rapidly growing number. Unfortunately,
there are at present no reliable data on this number for the country as a whole.
Studies that have been carried out on the effects of treatment with coerced
individuals vary greatly in terms of comparison groups and the outcome measures that are
used. Drawing conclusions is not an easy matter. The committee's sense of the available
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IS TREATMENT NECESSARY?
157
information is that, although certain groups of individuals (e.g., professionals, the regularly
employed) may benefit on the whole from coerced treatment, and although certain types
of coercion are more effective than others (e.g., effective coercion often involves severe
penalties for failure to comply with treatment-so-called contingencies-that are an invariable
consequence of that failure), involuntary treatment is by no means uniformly beneficial and
in some instances may actually be harmful (Wells-Parker, 1989. Even when forced
treatment proves to be beneficial, it may not be the most efficient way to resolve the
problems at issue. For some individuals it may be unnecessary to provide more than a
minimally coercive intervention to reach maximum effectiveness (Peck et al., 1985), yet
coerced treatment characteristically involves much more than a minimal intervention.
Coerced treatment also presents particularly difficult ethical and even legal issues
(cf. Marco and Marco, 1980~. For example, are the individual's basic civil liberties
endangered? Is the person being inappropriately labeled through a particularly aggressive
coercion effort? Are coerced individuals treated with as much dignity and diligence as are
persons who undertake treatment voluntarily? What of the issue of informed consent when
persons are coerced into treatment? If people are treated against their will and harm
ensues, who is liable?
These and other ethical and legal considerations underscore the complexities that
surrounds the forced treatment of any person with an alcohol problem. Treatment must
be handled thoughtfully, objectively, and compassionately. An unthinking ~yes" to the
question His treatment necessary?" places one at considerable risk for making improper
treatment interventions.
Implications for Treatment
To review: many people with alcohol problems improve without formal treatment.
Some people with alcohol problems are made worse by treatment. Compulsory treatment
of alcohol problems is not always helpful. These findings are not surprising, and they apply
to treatment situations other than the treatment of alcohol problems. Although they
hardly require the abandonment of the therapeutic effort, they do make it clear that, as
with all such efforts, a guiding principle should be to proceed with caution.
For example, treatment should be considered only if the existence of an alcohol
problem is highly probable. This dictum places a premium on the careful assessment of
all individuals who are seeking treatment (see Chapter 10) but is especially pertinent for
those acting under coercion. When the existence of an alcohol problem is uncertain,
primary or secondary prevention efforts (see Chapter 9) or other measures (e.g., general
psychotherapy, revocation of a driver's license) may prove to be more appropriate than
treatment directed at alcohol problems.
In addition, it is important to take care to find the optimal treatment for the
particular problem of a given individual (see Chapter 11~. lDue account should be taken
of the potential negative effects of all treatments; any treatment with the power to help is
likely to possess the power to harm when injudiciously deployed. Furthermore, if a given
intervention proves to be ineffective, an alternative intervention should be considered.
Appropriate caution can also take the form of favoring interventions that fall short
of the most intensive and costly treatment methods but that are effective for some
individuals. Conservative palliation in many instances is to be preferred to radical interven-
tion. Particular consideration is wisely given to less utilization of intensive and costly
intervention for those groups, such as the young, the female, and the elderly, in which
improvement outside of formal treatment is more likely. For such groups, emphasis may
more reasonably be placed on supporting nontreatment factors that promote improvement
(e.g., employment, recreation, interpersonal ties, other social supports).
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58 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
Further understanding and documentation of how people with alcohol problems
improve without formal treatment should be helpful in approaching treatment in a cautious
and logical manner. There is the intriguing possibility that such understanding may
encourage the development of novel approaches to treatment itself. In this sense
improvement with treatment and improvement outside of treatment are not adversaries but
collaborators.
Treatment Based on Knowledge
of Improvement Without Treatment
Therapy based on a knowledge of factors that are believed to be critical in
producing improvement without formal treatment has been proposed in the field of
smoking cessation (Marlatt et al., 1988; IOM, 1989~. A similar approach has been taken
in the treatment of alcohol problems. In developing what came to be called a community
reinforcement approach, its originators set out to "examine the natural deterrents of
airnh^1icm Ulna ~ll`~.r to. n~t,~rn1 deterrents to maximize their effectiveness (Hunt
a~lWIlVI1OJ.I-l ~ · · e Jut ~J~ Act ~_~_~_~- ·~ ^~ -~ ~ ~
and A~rin, 1973:91-92~. Their understanding of such natural deterrents was that Kiln the
alcoholic state, one may incur social censure from friends as well as from one's family.
Discharge from one's employment is likely. Pleasant social interactions and individual
recreational activities cannot be performed as satisfactorily, if at all, when one is alcoholics
(p. 9%~.
They therefore set about enhancing their subjects' social, marital, familial,
vocational, and recreational activities by providing specific counseling (e.g., job-seeking
skills) as well as additional supports (e.g., a non-alcohol-related social club meeting on
Saturday nights). However, they also took steps to ensure that these aids would be swiftly
and certainly withdrawn if the individual resumed drinking. For example, if recourse to
drinking caused marital difficulties, the spouse was advised to move out of the house until
the individual being treated became sober and requested that he or she return. In a word,
both the carrot and the stick were judiciously applied (Hunt and Azrin, 1973~.
Its developers note that "[this] procedure does not require hospitalization except
as a means of helping the patient through his withdrawal symptoms and physical disability,
if any" (Hunt and Azrin, 1973:99~. Thus, the approach is in accord with the contemporary
deemphasis on inpatient (hospital or freestanding residential) treatment (Saxe et al., 1983;
Annis, 1986; Miller and Hester, 1986) and the importance of environmental variables in
outcome (Cronkhite and Moos, 1978; Moos et al., 1979~.
Controlled trials of the
community reinforcement approach, as well as its individual components (Azrin, 1976;
Azrin et al., 1982; Mallams et al., 1982; Sisson and Azrin, 1986) have been positive, and
a major replication study is under way (W. R. Miller, University of New Mexico, personal
communication, January, 1989~.
Another therapeutic approach has been developed that complements the
community reinforcement approach. Rather than dealing with those naturally occurring
factors that facilitate the remission of alcohol problems, this approach deals with the
naturally occurring factors that make them worse. It has been called relapse prevention
(Marlatt and Gordon, 1985; Annis, 1986b; Annis and Davis, 1988~.
Relapse prevention is based on the notion that the treatment strategies that will
keep a person with alcohol problems from drinking once he or she has stopped may differ
from the strategies that will enable him or her to stop drinking in the first place. There
is evidence that a wide variety of techniques are effective in producing at least short-term
elimination or reduction of alcohol consumption (Miller, 1988~. Relapse prevention builds
on such an initial success and attempts to extend the elimination or reduction into the
future. Alcoholics Anonymous and other self-help groups are often used therapeutically
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IS TREATMENT NECESSARY?
159
in this manner and in some senses at least could also be thought of as relapse prevention
measures.
In one such approach (Annie, 1986b; Annis and Davis, 1988) a painstaking
inventory is taken of those naturally occurring situations in which relapse to drinking is
likely to occur. The therapist then helps the individual learn other ways of coping with
such dangerous situations rather than by drinking. When the individual learns successfully
to negotiate situations that previously resulted in relapse, the probability of relapse is
lessened. One alternative coping strategy to resist drinking that has been explored is the
use of an antialcohol drug, Temposil (citrated calcium carbimide), which is not currently
available for therapeutic use in the United States (Peachey and Annis, 1985~. It is felt
that, ideally, such a strategy would give way to more complex and psychosocially based
treatment.
Treatments that evolve along these lines may prove to be quite effective. Whether
from the community reinforcement approach or the relapse prevention approach, or from
other approaches that are yet to be developed, an important contribution to the treatment
of alcohol problems may arise (along the lines suggested by Ambroise Pare) from
encouraging the individual to come increasingly under the sway of naturally occurring
factors that will facilitate the resolution of his or her problem. Pare helped nature along
by inventing the surgical ligature (Vaillant, 1983~. In like manner the answer in the
alcohol field to the title question of this chapter may be that treatment is sometimes a
necessary supplement to natural healing processes.
Summary and Conclusions
There is ample evidence that a significant number of individuals who develop
alcohol problems will be able to deal with those problems without undergoing formal
treatment. As well, some persons have less positive outcomes as a result of treatment.
The coercion of persons into treatment is an increasingly common phenomenon but is not
invariably associated with positive outcome.
It is also true, of course, that many persons benefit greatly from appropriate
treatment (the previous chapter and Appendix B provide copious documentation that this
is so) and that they may do so even under coercion and in some instances only under
coercion. Yet each of these sets of facts must be balanced against the other in trying to
respond to the title question of this chapter. Is treatment necessary? The committee
believes the answer is a qualified ~yes" that must take into account the complexities of the
issues involved in our current state of knowledge.
How should one proceed? Cautiously, the committee believes, and with humility.
Treatment for alcohol problems, like other treatments, should be applied judiciously, with
due consideration given to individual differences. Treatment should not be foresworn,
because it is helpful to many; but neither should it be provided-as a matter of course,
because for some it is not necessary and for others it may be harmful. The extremes of
unbridled therapeutic enthusiasm on the one hand and thoroughgoing therapeutic nihilism
on the other must be avoided. In addition, improvement outside of formal treatment,
negative therapeutic reactions, and the fact of coercion should be seen not only as
complicating factors but as opportunities for learning more about treatment. Such
strategies as the community reinforcement approach and relapse prevention are illustrative.
We especially need to learn a great deal more about how to predict who does not
need treatment, who will be harmed by treatment, and who will benefit from treatment only
under coercion. The directions and recommendations provided by the committee in Section
III of this report are in keeping with this goal. If implemented, the difficulties in making
appropriate therapeutic decisions should diminish over time. In the meantime the guiding
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160 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
admonition of Hippocrates must be kept firmly in mind: plum Ton sincere the first duty
of the treater is to do no harm.
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Representative terms from entire chapter:
relapse prevention
