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3 What Is Trealment? Just as it is necessary to clarify what is being treated in the realm of alcohol problems, it is also important to review and crystallize what is meant by treatment because there are many differing definitions. In most research studies, no single definition is offered; instead, one often finds a series of procedures or a specific program and setting being described and "evaluated." At other times, a rather complex and all-embracing definition is presented. As a result, there are arguments and controversy about what constitutes treatment for alcohol problems and who needs such treatment. Is Alcoholics Anonymous a form of treatment? Are minor tranquilizers, when prescribed for anxiety reduction after detoxification is completed, treatment or symptom substitution? Are social model recovery centers and halfway houses treatment for alcohol problems? Is providing a supportive, alcohol-free living environment for homeless persons with alcohol problems treatment? Is family therapy a required element of the treatment of alcohol problems? Is education and counseling for incipient problem drinkers who have been arrested for a drinking-and-driving offense treatment? Sometimes treatment is defined by what is reimbursable under a third-party payment plan. This definition, however, does not so much answer the question as raise alternative questions. Are biofeedback and stress management training for college students who are drinking excessively at weekend fraternity parties reimbursable treatment procedures under private health insurance? Is individual psychotherapy conducted by a certified alcoholism counselor in a private-practice setting a reimbursable service? Is chemical aversion therapy a safe and effective treatment for alcohol problems that should be reimbursed under Medicare and private health insurance? Is Antabuse monitoring by a certified alcoholism counselor working in a state-licensed outpatient clinic a treatment for which private health insurance or the state alcoholism authority, or both, should provide reimbursement? Is social model detoxification in a freestanding facility a form of treatment for which Medicare should provide reimbursement? Much of the argument surrounding this issue appears to reflect a failure to agree on the definition of treatment for alcohol problems and on the active ingredients of the treatment process (Moos and Finney, 1987/1988; Filstead, 1988a,b; IOM, 1989~. Consider the following definitions, which have been offered in federal government reports over the years: "Treatment" means the broad range of emergency, outpatient, intermediate, and inpatient services and care, including diagnostic evaluation, medical, psychiatric, psychological, and social service care, vocational rehabilitation and career counseling, which may be extended to alcoholic and intoxicated persons. (U.S. Department of Health, Education, and Welfare [USDHEW1, 1971:106) Treatment/Treatment Services-The broad range of planned and continuing services, including diagnostic assessment, counseling, medical, psychiatric, psychological, and social service care for alcohol-related dysfunction, that may be extended to program patients and influence the behavior of such individuals toward identified goals and objectives. (Bast, 1984:11) Alcohol treatment refers to the broad range of services, including diagnostic assessment, counseling, medical, psychiatric, psychological, and 42

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WHAT IS TREATMENT social services care for clients or patients with alcohol-related problems. Treatment activities involve intervention after the development and manifestation of alcohol abuse and alcoholism in order to arrest or reverse their progress, or to prevent illness or death from associated medical conditions . . . Treatment is essentially composed of two elements, (1) the therapeutic procedure, i.e., a specific set of protocols and activities, and (2) the therapeutic process, i.e., the milieu, setting, and interpersonal context in which a procedure can be implemented for optimal success. Treatment is a complex, interpersonal admixture of procedures and processes. (U.S. Department of Health and Human Services [USDHHS], 1986:42) 43 The first definition given above was included in the Uniform Alcoholism and Intoxication Treatment Act and as such became the basis for the definitions adopted by state licensure and national accreditation bodies, thus setting the broad parameters that underlie existing treatment and financing efforts. The Uniform Act had as its focus decriminalization of public drunkenness and destigmatization of all persons with alcohol problems (Plaut, 1967; Grad et al., 1971; Finn, 1985~. Its definition was to a large extent based on the image of the typical alcoholic as the indigent, socially deteriorated public inebriate who required extensive psychological and social support services along with treatment of physical disabilities and direct treatment of the alcohol problem. This image was embodied in the original legislation and in resource development carried out by the federal government and the states. The breadth of the various ~official" definitions of treatment for alcohol problems reflects the importance that has been placed on including within the treatment process additional supportive activities (e.g., vocational counseling, family therapy). Thus, the definitions reflect the professional judgment that the treatment of alcohol problems cannot be limited only to those direct activities that are designed to reduce alcohol consumption. Supportive activities are seen as required if relapse is to be avoided and continued sobriety and recovery are to be maintained by individuals who have few personal and social resources and who are experiencing very severe physical, vocational, family, legal, or emotional problems around their use of alcohol (e.g., Boche, 1975; Kissin, 1977b; Costello, 1982; McClellan et al., 1980; Pattison, 1985; Moos and Finney, 1986/1987~. Socially deteriorated public inebriates or homeless alcoholics do require many additional supportive services if they are not to relapse and return to destructive alcohol consumption (Blumberg et al., 1973; Costello et al., 1977; Costello, 1980, 1982; Pattison et al., 1977; Shandler and Shipley, 1987; IOM, 1989~. The extent of the person's dysfunction in other key life areas (e.g., employment, physical health, emotional health, marital and family relations) determines the breadth of the treatment response required (Pattison et al., 1977; Costello, 1980, 1982; Longabaugh and Beattie, 1985; Kissin and Hansen, 1985; Sanchez-Craig, 1988; see also Kissin, 1977a,b; Armor et al., 1978; Brown University Center for Alcohol Studies, 1985; Pattison, 1985~. The second and third definitions given earlier (Bast, 1984; USDHHS, 1986) are derivative of the Uniform Act definition and reflect the variety of treatment services that have been supported by federal and state categorical funding in the early years of the struggle to establish the treatment of alcohol problems as a distinct, legitimate activity (Chafetz, 1976; Booz-Allen and Hamilton, Inc., 1978; Anderson, 1981; J. Lewis, 1982; Weisman, 1988~. To a certain extent, federal and state governments have supported this wide array of approaches to treatment because of differing theories about the causes of alcohol problems. As Saxe and colleagues (1983:4) note: The treatments for alcoholism are diverse, in part because experts have different views about the causes of alcoholism. At least three major views of the etiology of alcoholism can be identified: medical,

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44 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS psychological, and sociocultural. Treatments are generally based on one or a combination of these views." There has been a continuing effort not only to define the treatment of alcohol problems as a primary condition (i.e., not a symptom of underlying psychopathology) but also to develop a separate, nonpsychiatric specialist system of treatment resources. The specialty programs directly treat the primary condition (Anderson, 1981; Weisman, 1988; see Chapters 4 and 7~. The emphasis has been on creating a specialized continuum of care that can assist individuals in dealing with the complex set of biological, psychological, and sociocultural forces that create and maintain problem drinking behavior. As Glasscote and colleagues (1967:13) have stated: [I]t is abundantly clear that no single treatment approach or method has been demonstrated to be superior to all others. Although numerous kinds of therapy and intervention appear to have been effective with various kinds of problem drinkers, the process of matching patient and treatment method is not yet highly developed. There is an urgent need for continued experimentation for modifying and improving existing treatment methods, for developing new ones and for careful and well designed evaluative studies. Most of the facilities that provide services to alcoholics have made little if any attempt to determine the effectiveness of the total program or its components. These observations remain appropriate today. Treatment for alcohol problems, as described in many of the studies and practice settings that have been reviewed for this report, has been found to be just such an unspecified admixture of medical, psychological, and sociocultural approaches. Research that organizes and evaluates the components of treatment in a systematic fashion is only now beginning to be carried out (Saxe et al., 1983; Walsh et al, 1986; Moos and Finney, 1987/1988; Filstead, 1988a,b; Holder et al., 1988; IOM, 1989; T. McLellan, Philadelphia VA Medical Center, personal communication, May 25, 1989~. This committee's emphases on heterogeneity in etiology, presentation, and course and on the need for individualized comprehensive treatment are not new developments. Rather, they represent an approach that, although long advocated, has not been systematically applied in the design of funding policies and effective treatment programs. Refining the Definition of Treatment for Alcohol Problems Treatment for alcohol problems has come to include a very broad range of activities that vary in content, duration, intensity, goal, setting, provider, and target population. Research data are available on the effectiveness of "treatments" or Interventions that cover a broad spectrum: from brief, one-session outpatient treatment episodes for married, socially stable adult males in which the intervention is information about the hazards of continuing to drink excessively and advice on how to control drinking given by a physician or nurse (e.g., Edwards et al., 1977; Edwards, 1987) to months-long hospital and residential stays that remove the affected person from the stresses and seductions of an environment in which alcohol is easily available (e.g., Wallerstein, 1956, 1957; Blumberg et al., 1973~. Given this range, it has become customary to distinguish between intervention and treatment when reviewing research and discussing available services. Intervention is generally discussed in connection with primary prevention; a prominent example of this approach is the most recent report on alcohol and health submitted to Congress by the secretary of health and human services (USDHHS, 1987b).

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WHAT IS TREATMENT? 45 However, the term intervention has come to have two distinct meanings in the treatment of alcohol problems in addition to its usual meaning in medicine and education (i.e., an activity designed to moditr a condition). First, intervention is used to describe a specific technique for confronting persons who are thought to have problems around their use of alcohol and to motivate them to enter treatment (Johnson, 1980, 1986; Beyer and Trice, 1982; Trice and Beyer, 1984; see Appendix D). As a technique used to bring people into treatment, intervention involves nonjudgemental confrontation by family, friends, or coworkers to break down an individual's rationalization and denial of the problems related to excessive drinking (Blume, 1982~. Second, intervention may be used to describe case finding and treatment of "early-stage" problem drinkers, as noted by Cohen (1982:127~: Early intervention consists of the identification of persons or groups whose drinking behavior places them at risk and of persons in the early stages of destructive drinking practices. It includes their involvement in corrective learning and emotional experiences designed to help them develop abstinence or more benign drinking patterns. In this use of the term, early intervention is identified with secondary prevention, and treatment is identified with tertiary prevention. The distinction is made primarily on the basis of the target population, and secondarily on the goal chosen (abstinence or controlled drinking), rather than on the basis of the activity that is actually performed. Thus, intervention is described as being aimed at the "early-stage drinker" or less impaired youthful drinker; treatment and rehabilitation are described as being directed toward "those with established disabling, psychosocial disordersn: Early intervention is conceptualized as the equivalent of secondary prevention, the attempted reversal of the early stages of dysfunctional drinking by individuals or homogeneous groups at risk. Secondary prevention contrasts with primary prevention, i.e., the educational approaches that attempt to reinforce healthful drinking attitudes especially, but not exclusively among youths. Tertiary prevention consists of the formal treatment and rehabilitation measures for those with established disabling, psychosocial disorders. (Cohen, 1982:128) Intervention activities are those that seek to detect alcohol-related problems in their early stages and to intervene in such problems in such a way as to arrest their progression .... Treatment activities involve intervention after the development and manifestation of alcohol abuse and alcoholism in order to arrest or reverse their progress, and/or to prevent progressive illness or death from associated medical conditions. (USDHHS, 1986:69) It is important to distinguish between intervention activities and primary prevention activities, which are aimed at those persons, whether abstainers or social drinkers, for whom no alcohol-related problems have as yet been identified by themselves or by others. Although sometimes labeled as early intervention, primary prevention more accurately describes those specific activities that are aimed at persons who are not engaged in risky or problematic drinking but who are designated as high risk because of such factors as a family history of alcohol problems or childhood behavior problems. Secondary prevention activities~ctivities that could more accurately be labeled Early interventions- involve the identification of individuals who are drinking in a risky fashion and are beginning to

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46 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS experience problems and symptoms. Actually, however, in view of the heterogeneity of course discussed in the previous chapter, the designation "early is inappropriate. Many persons so identified will not progress to more serious problems although some will (see Chapter 6~. Examples of "early intervention" (secondary prevention activities) are counseling heavy drinkers among college students (Marlatt, 1988a) or counseling patients who are receiving medical treatment for alcohol-related physical illnesses or injuries (D. C. Lewis and Gordon, 1983; Williams et al., 1985~. There are many organizational entities in this country that sponsor and conduct early intervention programs-social service agencies, drinking-driver programs, student assistance programs, employee assistance programs, to name a few. It has been customary, however, to view these locales and activities as intervention programs rather than treatment; they are considered to be separate from the overall treatment system and engaged in performing only referral and case monitoring (e.g., Saxe et al., 1983; USDHHS, 1987b), even though many also provide counseling and education. The committee considers it an error to continue to omit these resources from consideration as elements of the continuum of treatment services that should be available in each community to all persons who need them. Therefore, intervention programs which offer referral, education, and short term counseling as well as continuity of care assurance and follow-up monitoring (e.g., employee assistance programs, student assistance programs) are included in the committee's definition of the treatment system, along with more traditional locales (e.g., hospital and freestanding detoxification and rehabilitation units, outpatient clinics, halfway houses) (see Chapter 9~. The most direct and simple definition of intervention and treatment for alcohol problems is "any activity that is directed toward changing a person's drinking behavior and reducing their alcohol consumption. Treatment and intervention are both aimed at changing the person's drinking behavior after a problem has been identified. Moreover, both intervention and treatment generally involve additional activities that are designed to alleviate other physical, psychological, and social problems as well as the conditions that are assumed to cause or maintain the hazardous level of drinking. Thus, activities that previously were classified separately as either intervention or as treatment are included in the definition of treatment used in this report. The committee clearly identifies and distinguishes any use of the term intervention to describe the confrontational technique for motivating persons to seek treatment. At all other times, intervention is used synonymously with treatment. To guide its deliberations and recommendations, the committee has adopted the following definition of treatment, which builds on the definitions reviewed earlier in the report and incorporates both intervention and treatment: Treatment refers to the broad range of services, including identification, brief intervention, assessment, diagnosis, counseling, medical services, psychiatric services, psychological services, social services, and follow-up, for persons with alcohol problems. The overall goal of treatment is to reduce or eliminate the use of alcohol as a contributing factor to physical, psychological, and social dysfunction and to arrest, retard, or reverse the progress of any associated problems. The committee has formulated this expanded definition of treatment because it agrees with those who have suggested that efforts to treat alcohol problems in this country have been too narrowly focused on those persons with the most severe problems (see Chapter 9~. The guiding principle it has espoused is that all of those individuals who are identified as having a problem around their use of alcohol should receive some assistance with their problems. The traditional approach to the management of alcohol problems has often been the so-called Minnesota model of treatment (discussed later in this chapter),

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WHAT IS TREATMENT? 47 which focuses on the smaller number of individuals who show major symptoms of alcohol dependence, physical disability, and psychosocial dysfunction. The committee favors a broader approach that also deals with the much larger group of individuals who have engaged in excessive\drinking and experienced some negative consequences (e.g., Skinner, 1985, 1988; Babor et al., 1986; Skinner and Holt, 1987; IOM, 1989~. This approach will include the use of sites that provide brief interventions and brief therapy for persons with low or moderate levels of alcohol problems. The successful utilization of brief interventions will require changes in our conceptualization of the treatment system as well as additional training in the conduct of brief interventions for workers in the specialty alcohol problems treatment sector as well as in the general medical and social services sectors (see Section III). Other countries have developed similar strategies, some of which are described in Appendix C. The effort to expand treatment availability in France is described by Babor and coworkers (1983~. During the 1970s, the French developed a national network of outpatient clinics to provide secondary prevention, in the form of early intervention services to Habitual excessive drinkers who were to be identified through screening in various industrial, legal, and health care settings. Generally staffed by a physician, a nurse, and a social worker, these specialty clinics provide a combination of clinical diagnosis of alcohol problems, medical treatment and counseling about the effects of continued excessive alcohol use, dietary counseling, health education, family counseling, and assistance in resolving social and legal problems. The focus of the clinics' education and counseling is that excessive alcohol consumption is the primary source of the patient's physical health, work, and family problems; sobriety or temperance, rather than abstinence only, are stressed as the means of eliminating these problems. Thus, a person is told to reduce drinking to the amount he or she can tolerate without risk. Another example of the development of an expanded network of services is the methodology used by drinking-driver programs (see Chapter 16~. This approach identifies persons arrested for a driving-while-impaired (DWI) offense and assigns them to an education (intervention) or treatment experience on the basis of a screening that categorizes individuals as social drinkers, incipient problem drinkers, or problem drinkers. The military, which initially modeled its approach on that used by drinking-driver programs, uses a similar methodology to assign individuals to education, outpatient counseling, or inpatient treatment, (Borthwick, 1977; Armor et al., 1978; Zuska, 1978; Orvis et al., 1981~. The approaches of all these programs are based on the view that alcohol problems must be broadly addressed within an expanded treatment context. Defining the Expanded Continuum of Care Given the complexities of dealing with the wide range of medical, psychological, and social difficulties presented by persons with alcohol problems, it has become customary to speak of the need for a comprehensive continuum of available treatment services. This continuum has become the operationalized definition of treatment for alcohol problems: It is important that any funding mechanism for alcohol and drug services cover a broad enough spectrum of services and service providers to insure that the individual patients or clients are provided with a continuum of care which is adequate and appropriate to their needs. Such care may include a combination of inpatient hospital services, direct medical care, residential care in various sheltered environments, counseling, job training and placement assistance and aid in dealing with various life problems. (Boche, 1975:3)

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48 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Similarly, Sections 1, 8, and 10~5) of the Uniform Alcoholism and Intoxication Treatment Act explicitly called on the states to ensure that a continuum of coordinated treatment services with reasonable geographic access was established within each state (USDHEW, 1971~. The act emphasized a coordinated network of services within each community to ensure that individuals would receive all the care appropriate to their needs and not be denied access to services because of agency boundaries. The Uniform Act was a major source for the treatment definitions presented earlier in this chapter; it is also the major source for contemporary definitions of the components of the continuum of care and the practices that currently represent the operational definition of treatment for alcohol problems. The continuum of care called for in the Uniform Act had four major elements: (1) emergency treatment provided by a facility affiliated with or part of the medical service of a general hospital; (2) inpatient treatment; (3) intermediate treatment; and (4) outpatient and follow-up treatment. The description of the continuum was based on observed practices and on contemporary efforts by several states to redefine what treatment should be, based on research (Plaut, 1967) and surveys of existing programs (Glasscote, 1967; Grad et al., 1971~. As the first element of the continuum, the Uniform Act used the concept of emergency treatment in a hospital-related facility rather than the more popular "detoxification center" (the latter was seen as stigmatizing persons with alcohol problems by setting them apart from people with other illnesses or difficulties). These specialized emergency services were to be readily available 24 hours a day to anyone who needed them; they comprised medical services, social services, and appropriate diagnostic and referral services. Inpatient treatment, the second element called for in the act, was to provide 24-hour care in a short-stay community hospital for that limited percentage of persons who were thought to need to begin treatment in a restricted environment. Long-term hospital inpatient services were considered to be inappropriate for persons with alcohol problems; the short-term units were to be designed to facilitate the individual's return to his family and the community or to other appropriate care services as rapidly as possible. Intermediate treatment was the term used to refer to residential treatment that was less than full time and that could be provided in a variety of community facilities (e.g., halfway houses, day or night hospitals, foster homes). Intermediate treatment settings, the third element in the continuum of care, were seen as alternatives to hospital inpatient settings and as extensions of initial inpatient services. The Uniform Act's final element, outpatient and follow-up treatment, was to include the same wide range of treatment services and modalities offered in the inpatient or intermediate service settings. The difference was that these services would be offered in a wide variety of settings in the community: for example, clinics, social centers, and even in the patient's own home (USDHEW, 1971~. In its 1986 report to Congress setting forth a comprehensive national plan to combat alcohol abuse and alcoholism, the Department of Health and Human Services (USDHHS) continued to discuss the need to provide and fully finance a "comprehensive continuum of care approach" to the treatment of alcohol abuse and alcoholism. The approach it described was derived primarily from the continuum of care that had been developed over the years in Minnesota (Anderson, 1981; Research Triangle Institute, 1985~: A comprehensive alcohol treatment program provides care that recognizes the physical, social, psychological, and other needs of the patient. The major components of a comprehensive continuum of care approach are recognition, diagnosis and referral, detoxification, primary residential treatment, extended care, outpatient care or day care, aftercare, and a family program. (USDHHS, 1986:42)

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WHAT IS TREATMENT? 49 More recently, the continuum of care needed for the treatment of alcohol problems has been described in another USDHHS report: Although necessarily limited by cost effectiveness considerations, alcoholism treatment has become increasingly multimodal and multidisciplinary. As is generally recognized, a comprehensive system of services includes at least the following: detoxification; inpatient rehabilitation; outpatient services including clinic, day hospital, and partial hospital services; family treatment; aftercare; residential or supervised living services; and sobering up services. These categories of services are not mutually exclusive. (USDHHS, 1987b:124) These slightly different descriptions show that the continuum has not been clearly and consistently defined neither in terms of the elements that constitute it, the combinations of elements required for particular groups within the population of persons with alcohol problems (see, for example, Section IV), nor the sequence in which the elements are required. The original Uniform Act description of the continuum focused on the settings in which treatment took place, whereas the later descriptions called for additional elements. Yet even in these key reports, many of the terms used to describe the components are not defined. There is no clear statement in either the 1986 national plan or the more recent report to Congress about how the continuum should be organized or the desired relationship among the listed elements. For example, in the most recent description of the continuum (USDHHS, 1987b), the "sobering up services" element is introduced but without definition or discussion. Both detoxification and sobering-up services are included as necessary elements, but no distinction is made between them. Both are emergency treatment in terms of the original Uniform Act definitions. The context of the report suggests that the inclusion of sobering-up services as an essential element is to reflect the distinction that is now commonly made among the two or more levels of detoxification care included by many of the state alcoholism authorities in their planning and funding efforts. In fact, the reference in the DHHS report is most likely drawn from a particular element (now, no longer used) of the New York state continuum,~ the sobering-up station. The sobering-up station was a particular form of the non-hospital-based, subacute, inpatient detoxification unit and was initially introduced as a lower cost alternative to jail or to expensive hospital-based detoxification for public inebriates (Zimberg, 1983~. Recently, the New York state alcoholism authority developed a new model to describe its view of the ideal continuum of care. The new plan introduced a more comprehensive emergency treatment element, the alcohol crisis center, which replaces the sobering-up station; the plan also maintains a reduced hospital detoxification element (New York Division of Alcoholism and Alcohol Abuse, 1986~. This new model recognizes, as has been shown in the research literature, that only a limited percentage of all persons who require detoxification-and not just public inebriates need hospital-based services. Withdrawal for the majority can be safely managed in a subacute, nonhospital social setting or in an ambulatory medical model setting (O'Briant et al., 1973; Feldman et al., 1975; Whitfield et al., 1978; DenHartog, 1982; Diesenhaus, 1982; Alterman et al., 1988; Hayashida et al., 1989; Klerman, 1989~. Another example of the lack of agreement on definitions among the various continua are the descriptions of a "family programs or "family treatment." Again, it is not clear what is meant. In the alcohol problems field, family therapy, in common with other treatment modalities, is considered appropriate for some but not necessarily all persons in treatment (McCrady, 1988~. In addition, family therapy may constitute different activities in different programs or settings. The importance of the family in supporting recovery (i.e.,

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so BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS changing drinking behavior) is recognized; yet there is little research on the effectiveness of the various techniques or structured programs with particular kinds of persons with alcohol problems the various subgroups (McCrady, 1988~. Looking beyond settings in defining the desired elements of the continuum of care is of value, but there is not enough evidence available to single out specific treatment modalities as appropriate for inclusion. Yet this is exactly what has occurred in a number of definitions of the ideal continuum of care. In addition, these descriptions tend to condense and confuse the settings in which treatment takes place, the procedures or modalities that are used, the stages or phases of treatment that are offered, and the philosophical model that underlies a given treatment approach. The descriptions also do not sufficiently recognize that different subgroups will require different elements in combination to sufficiently address their alcohol problems. This imprecision is one of the factors that creates tensions between providers, regulators, funders, and policymakers regarding the resources that are needed and the proportions of treatment costs that should be financed either through public or private third-party payment. That the federal government continues to view the concept of a continuum of care as important, however, can be seen in several of the recommendations made in the 1986 national plan proposed by the Department of Health and Human Services: States and the private sector should develop a continuum of care based on an assessment of need which accurately reflects age, ethnicity, sex, service needs and other significant variables based on appropriate State and local level data. (USDHHS, 1986:47) Third party payers should selectively expand financing throughout the continuum of care, thereby increasing the availability of treatment in a variety of settings. (p. 46) Public and private treatment programs should improve the match between client and treatment by evaluating diagnostic techniques and the continuum of care that is provided. (p. 50) In keeping with this view, each state has defined its own continuum of care, some (e.g., New York, Colorado, Indiana) very consciously tying the elements together to reflect the stages or functions of treatment (in part to serve planning, funding, and evaluation purposes). Others (e.g., California, Minnesota) continue to view the components more as distinct entities. Some states include identification and intervention services in their treatment continuum; others do not. The federal government has implicitly defined its existing continua of care through the policies of the various federal agencies that fund and/or operate treatment programs (e.g., the Veterans Administration, the Department of Defense, the Health Care Financing Administration, the Alcohol, Drug Abuse, and Mental Health Administration) and through the definitions used in its national surveys. Yet consistency is lacking even in the federal arena; thus the definitions are not consistent from state to state, agency to agency or from survey to survey (Kusserow, 1989; Lewin/ICF, 1989a), a limitation that prevents the development of a comprehensive national approach. If progress is to be made in defining treatment for alcohol problems, the elements of the continuum of care that constitutes such treatment must be specified. In addition, agreement must be reached on how those elements are defined and sequenced and how they can best be used in matching various subgroups of persons with alcohol problems to an appropriate series of interventions. Because there are still no widely accepted models for describing either the course of treatment and recovery for persons with alcohol problems or the settings in which each stage of that course can be most reasonably and

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WHAT IS TREATMENT? 51 least expensively accomplished, the committee has provided a preliminary framework for a taxonomy of treatment elements as a starting point for defining the expanded continuum of care. Defining the Elements of Treatment in the Continuum of Care In the attempts that have been made to describe the continuum of care needed for the treatment of alcohol problems, there appears to have been some confusion among its various elements: the philosophy or orientation of treatment, the stages of treatment, the settings in which treatment takes place, the levels of care required by persons of varying clinical statuses, the modalities to be used to decrease or eliminate alcohol consumption, and the supportive services that are required by some individuals with extensive physical, psychological, or social problems. To organize systematically the elements that should make up the continuum of care, the committee proposes to employ a multidimensional framework that distinguishes among treatment philosophy and orientation, treatment stage, and treatment setting and level of care. This approach separates the specific treatment modalities and supportive services that are used from the environmental context in which they are applied (USDHHS, 1981, 1987b). In addition, the framework can serve multiple purposes. Among them is its potential for organizing the studies that are necessary to determine how best to match an individual with appropriate treatment. The framework also provides a structure for analyzing the variety of placement methods that have recently been introduced (Weedman, 1987; Hoffmann et al., 1987a). Treatment Philosophy or Orientation A model for treatment consists of a certain perspective on or orientation toward the etiology of alcohol problems that in turn specifies the preferred methods of intervention and suggests expected outcomes (Armor et al., 1978~. A variety of models have been identified as guiding the development of treatment for alcohol problems-for example, the disease model endorsed by the majority of treatment programs, the social learning model developed by behavioral psychologists (Nathan, 1984; Donovan and Chancy, 1985), and the social-community model of recovery that is now widely used in California (Borkman, 1986, 1988~. Three major orientations have been identified as providing the rationale for the differing approaches to the treatment of alcohol problems: the physiological, the psychological, and the sociocultural (Armor et al., 1978; Saxe et al., 1983~. Before proceeding with a discussion of these orientations, the committee would emphasize that any description of these models constitutes an abstraction that does not necessarily describe current practice. Nevertheless, the models have historical value in that they inform us about the development of contemporary approaches-for example, the evolving biopsychosocial model that is now endorsed by many practitioners. The physiological or biological perspective, which underpins what is generally known as the medical model of treatment, often considers "alcoholism" to be a progressive disease that is caused by physiological malfunctioning and that requires treatment by or under the direct supervision of a physician. Genetic risk factors are seen as important in the etiology of the disease. Physiological treatment strategies focus on the person with severe alcohol problems as the unit of treatment and may incorporate the use of pharmacotherapy to produce change in the individual's drinking behavior. Medical treatments include drugs to diminish anxiety and depression and such alcohol-sensitizing agents as disulfiram (Antabuse).

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52 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS The psychological perspective views alcohol problems as arising from motivational, learning, or emotional dysfunctions in the person. Like the physiological approach, psychological treatment strategies also focus on the individual and use psychotherapy or behavior therapy to produce changes in drinking behavior. The psychological model can also be further differentiated into variants that reflect differing theories about the etiology of problem drinking behavior for example, whether alcohol problems are symptoms of underlying psychopathology (intrapsychic conflicts) or are the results of social learning (the behavioral model). Treatment based on psychoanalytically oriented dynamic theory is another such variant. In this approach the individual psychotherapeutic relationship is seen as the key element; adjunctive psychotherapies (e.g., group therapy, psychodrama, occupational therapy) and supportive social rehabilitative services (Alcoholics Anonymous, vocational counseling) help the individual to consolidate the gains he or she has made (e.g., Khantzian, 1981, 1985; Zimberg et al., 1985; Khantzian and Mack, 1989; Nace, 1987~. The characteristic structure of a psychological model treatment regimen is a course of intensive psychotherapy sessions (either individual or group, or a combination of both) over an extended period of time in either a private practice or clinic setting. The primary th~.r~ni.ct is usualiv a mental health professional (psychiatrist, clinical psychologist, - ~-~r-~ , psychiatric social worker, psychiatric nurse, or clergyman). An antianxiety, antidepressant, or antipsychotic medication is often used as an adjunctive therapy. Disulfiram is sometimes used to provide external controls on drinking until the individual can develop internal controls. However, the stress here is on the adjunctive or secondary nature of these psychopharmacological approaches. Family therapy may also be used. Other strategies include blood-alcohol-level discrimination training, biofeedback, and desensitization training. One development of the past few years relating to the psychological treatment model has been the increasing use of behavior therapy techniques, primarily by psychologists (Poley et al., 1979; Lazarus, 1981; Marlatt and Gordon, 1985; Abrams and Niaura, 1987; Marlatt et al., 1988~. The predominant approach is the social learning model, which proposes that what a person believes about the effects of alcohol use on his or her ability to cope with the demands of everyday life is a crucial determinant of how involved with alcohol he or she will become. The social learning approach stresses the important contribution of cultural norms, role models, and learned expectations about the effects of alcohol in a given situation in determining drinking patterns. Social learning theory views persons with deficits in general coping skills, such as the inability to manage everyday stress, as vulnerable to the use of alcohol as an artificial method to modulate their everyday functioning. Biological factors are seen to interact with these psychosocial determinants, resulting in harmful drinking patterns (Abrams and Niaura, 1987~. The sociocultural perspective, the third major treatment orientation, considers alcohol problems to be the result of a lifelong socialization process in a particular social and cultural milieu. Sociocultural treatment strategies focus on both the person and his or her social and physical environment as the units of treatment; they use a variety of techniques, including environmental restructuring, to change the individual's drinking behavior by creating new social relationships. Sociocultural interventions include changing the social environment by providing an alcohol-free living arrangement such as a halfway house; active involvement in Alcoholics Anonymous (AA) or other mutual help groups; social setting (as opposed to hospital-based) detoxification; and a social model of rehabilitation. The sociocultural perspective emphasizes the importance of social groups (e.g., church, family) in influencing not only the person's drinking behavior but also the response to treatment and the potential for relapse. The most prominent example of the use of the sociocultural model in formal treatment is the California social model of recovery (see the discussion later in this chapter). In recent years there have been a number of attempts to develop an integrative model that could bring together these diverse orientations and perspectives. Such a model

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WHAT IS TREATMENT? 87 Annis, H. M. 1986. A relapse prevention model for treatment of alcoholics. Pp. 407~33 in Treating Addictive Behaviors, W. R. Miller and N. Heather, eds. New York: Plenum Press. Annis, H. M. 1988. Optimal treatment for alcoholism and drug dependencies. Presented to the Kaiser Permanente Southern California Medical Group, Los Angeles, March 30. Annis, H. M., and C. S. Davis. 1988. Assessment of expectancies. Pp. 84-111 in Assessment of Addictive Behaviors, D. M. Donovan and G. A. Marlatt, eds. New York: Guilford Press. Armor, D. J., J. M. Polich, and H. B. Stambul. 1976. Alcoholism and Treatment. Santa Monica, Calif.: RAND Corporation. Azrin, N. H., R. W. Sisson, R. W. Meyers, and M. Godley. 1982. Alcoholism treatment by disulfiram and community reinforcement therapy. Journal of Behavior Therapy and Experimental Psychiatry 13:105-112. Babor, T. F. 1986. Management of alcohol use disorders in developing and developed countries: Research evidence as a basis for the rational allocation of treatment services. Presented at the Symposium on Alcohol and Drug Abuse of the National Institute of Mental Health and Neuro-sciences of India and the U.S. Alcohol, Drug Abuse, and Mental Health Administration, Bangalore, India, November 18-21. Babor, T. F., M. Treffardier, J. Weill, L. Feguer, and J. P. Ferrant. 1983. The early detection and secondary prevention of alcoholism in France. Journal of Studies on Alcohol 44:600~16. Babor, T. F., E. B. Ritson, and R. J. Hodgson. 1986. Alcohol-related problems in the primary health care setting: a review of early intervention strategies. British Journal of Addiction 81:2346. Bandura, A. 1982. Self-effica~r mechanism in human agency. American Psychologist 37:122-147. Bandura, A. 1985. Social Foundations of Thought and Action. Englewood Cliff, NJ.: Prentice-Hall. 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, R. E. Popham, W. Schmidt, and R. G. Smart, eds. Toronto: John Wiley and Sons. Bast, R. J. 1984. Classification of Alcoholism Treatment Settings. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. Beigel, A., and S. Ghertner. 1977. Toward a social model: An assessment of social factors which influence social drinking and its treatment. Pp. 197-233 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. Berman, H., and D. Klein. 1977. Project to Develop a Comprehensive Alcoholism Benefit Through Blue Cross: Final Report of Phase I. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Chicago: Blue Cross Association. Beyer, J. A., and H. M. Trice. 1982. Design and implementation of job-based alcoholism programs: Constructive confrontation strategies and how they work. Pp. 181-239 in Occupational Alcoholism: A Review of Research Issues. (Proceedings of a workshop held May 24-26, 1980, by the National Institute on Alcohol Abuse and Alcoholism.) Washington, D.C.: U.S. Government Printing Office. Blakey, R., and R. Baker. 1980. An exposure approach to alcohol abuse. Behavioral Research and Therapy 18:319-325. Blumberg, L., T. Shepley, and I. W. Shandler. 1973. Skid Row and Its Alternatives. Philadelphia: Temple University Press. Blume, S. B. 1982. Alcoholism. Pp. 921-925 in Current Therapy, H. Conn, ed. Philadelphia: W. B. Saunders. Blume, S. B. 1983. Is alcoholism treatment worthwhile? Bulletin of the New York Academy of Medicine 59:171-180. Blume, S. B. 1985. Group psychotherapy in the treatment of alcoholism. Pp. 7-107 in Practical Approaches to Alcoholism Psychotherapy, S. Zimberg, J. Wallace, and S. B. Blume, eds. New York: Plenum Press.

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88 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Boche, H. L., ed. 1975. Funding of Alcohol and Drug Programs: A Report of the Funding Task Force. Washington, D.C.: Alcohol and Drug Problems Association of Nonh America. Booz-Allen and Hamilton, Inc. 1978. The Alcoholism Funding Study: Evaluations of the Sources of Funds and Barriers to Funding Alcoholism Treatment Programs. Prepared for the U.S. Department of Health Education and Welfare. Washington, D.C.: Booz-Allen and Hamilton, Inc. Borkman, T. 1982. Third generation mutual self-help organizations: Social model recovery organizations. Presented at the Southern Sociological Society Annual Meeting, Memphis, Tennessee, April 15. Borkman, T. 1983. A Social-Experiential Model in Programs for Alcoholism Recovery: A Research Repon on a New Treatment Design. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. Borkman, T. 1986. The Alcohol Services Reporting System (ASRS) Revision Study. Prepared for the California Department of Alcohol and Drug Programs, Health and Welfare Agency, Sacramento. Borkman, T. 1988. Executive summary: social model recovery programs. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, May. Borthwick, R. B. 1977. Summary of Cost-Benefit Study Results for Navy Alcohol Rehabilitation Programs. Technical Report No. 346. Washington, D.C.: U.S. Navy Bureau of Naval Personnel. Brandsma, J. M., and E. M. Pattison. 1985. The outcome of group psychotherapy with alcoholics: An empirical review. American Journal of Drug and Alcohol Abuse 11:151-162. Brickman, P., V. C. Rabinowitz, J. Karuza, D. Coates, E. Cohn, and L. Kidder. 1982. Models of helping and coping. American Psychologist 37:368-384. Brown University Center for Alcohol Studies. 1985. Substance Abuse Treatment in Rhode Island: Population Needs and Program Development. Providence, R.I.: Rhode Island Department of Mental Health, Retardation and Hospitals and Department of Health. Cahalan, D. 1987. Understanding America's Drinking Problem: How to Combat the Hazards of Alcohol. San Francisco: Jossey-Bass. Cautella, J. R. 1977. The treatment of alcoholism by covert sensitization. Psychotherapy: Theory, Research, and Practice 7:86-90. Chafetz, M. E. 1976. Alcoholism. Psychiatric Annals 6:107-141. Chatham, L. R. 1984. Foreword. Pp. iii-v in Classification of Alcoholism Treatment Settings, by R. J. Bast. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. Cohen, S. 1982. Methods of intervention. Pp. 127-143 in Prevention, Intervention, and Treatment: Concerns and Models, J. de Luca, ed. Washington, D.C.: U.S. Government Printing Office. Colorado Alcohol and Drug Abuse Division. 1978. State Plan for Alcohol and Drug Abuse Treatment, Prevention, and Quality of Care: FY1979. Denver Colorado Department of Health. Conger, J. J. 1951. The effects of alcohol on conflict behavior in the albino rat. Quarterly Journal of Studies on Alcohol 12:1-29. Conger, J. J. 1956. Alcoholism: Theory, problem and challenge. II. Reinforcement theo~y and the dynamics of alcoholism. Quarterly Journal of Studies on Alcohol 17:291-324. Costello, R. M. 1980. Alcoholism aftercare and outcome: Cross-legged panel and path analysis. British Journal of Addictions 75:49-53. Costello, R. M. 1982. Evaluation of alcoholism treatment programs. Pp. 1197-1210 in Encyclopedic Handbook of Alcoholism, E. M. Pattison and E. KauEman, eds. New York: Gardner Press. Costello, R. M. and J. E. Hodde. 1981. Costs of comprehensive alcoholism care for 100 patients over 4 years. Journal of Studies on Alcohol 42:87-93.

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FIAT IS TREATMENT? 89 Costello, R. M., P. Biever, and J. G. Baillargon. 1977. Alcoholism treatment programming: Historical trends and modern approaches. Alcoholism: Clinical and Experimental Research 1:311-318. Cushman, J. 1988. Alcohol withdrawal: A look at recent research. Presented at the "Treatment" meeting of the National Institute on Alcohol Abuse and Alcoholism Ad Hoc Scientific Advisory Board, Rockville, Md., May 3. DeMiranda, J. 1986. California's social model of recovery from alcoholism: Report of a conference. Alcohol Health and Research World 10:74-75. Diesenhaus, H. I. 1982. Current trends in treatment programming for problem drinkers and alcoholics. Pp. 219-90 in Prevention, Intervention, and Treatment: Concerns and Models, J. de Luca, ed. Washington, D.C.: U.S. Government Printing Office. Diesenhaus, H. I., and R. Booth, eds. 1977. Cost-benefit Study of State Hospital Drug and Alcohol Treatment Programs. Prepared for the Joint Budget Committee, Colorado Legislature. Denver Alcohol and Drug Abuse Division, Colorado Department of Health. DenHattog, G. L. 1982. "A Decade of Detox": Development of Non-hospital Approaches to Alcohol Detoxification-A Review of the Literature. Substance Abuse Monograph Series. Jefferson City, Mo.: Division of Alcohol and Drug Abuse. Dodd, M. H. 1974. The community model of alcoholism. Working paper. Sun Street Centers, Salinas, California. Dodd, M. H. 1986. What does social model mean? Presented at the Conference on California's Social Model Recovery from Alcoholism. University of California Extension, San Diego, Program on Alcohol Issues, February 23-25. Donovan, D. M. 1988. Assessment of addictive behaviors: Implications of an emerging biopsychosocial model. Pp. 3 48 in Assessment of Addictive Behaviors, D. M. Donovan and G. A. Marlatt, eds. New York: Guilford Press. Donovan, D. M., and E. F. Chaney. 1985. Alcoholic relapse prevention and intervention: Models and methods. Pp. 351-416 in Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, G. A. Marlatt and J. R. Gordon, eds. New York: Guilford Press. Dorus, W., D. G. Ostow, R. Anton, P. Cushman, J. F. Collins, M. Schaefer, H. L. Charles, P. Desai, M. Hayashida, U. Malkerneker, M. Willenbring, R. Fiscella, and M. R. Sather. 1989. Lithium treatment of depressed and nondepressed alcoholics. Journal of the American Medical Association 262:1646-1652. Edwards, G. 1987. The Treatment of Drinking Problems: A Guide for the Helping Professions. Oxford, England: Blackwell Scientific Publications. Edwards, G., J. Orford, S. Egert, S. Guthrie, A. Hawker, C. Hensman, M. Mitcheson, E. Oppenheimer, and C. Taylor. 1977. Alcoholism: A controlled trial of "treatment" and "advice." Journal of Studies on Alcohol 38:1004-1031. Engel, G. L. 1977. The need for a new medical model: A challenge for biomedicine. Science 196:129-136. Feldman, D. J., E. M. Pattison, L. C. Sobell, T. Graham, and M. B. Sobell. 1975. Outpatient alcohol detoxification: Initial findings on 564 patients. American Journal of Psychiatry 132:407-412. Femino, J., and D. C. Lewis. 1982. Clinical Pharmacology and Therapeutics of the Alcohol Withdrawal Syndrome. Program in Alcoholism and Drug Abuse Medical Monograph No. 1. Providence, R.I.: Brown University Program in Medicine. Filstead, W. J. 1988a. Monitoring the process of recovery. Pp. 181-191 in Recent Developments in Alcoholism, vol. 6, M. Galanter, ed. New York: Plenum Press. Filstead, W. J. 1988b. Statement presented at the open meeting of the Committee for the study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, Institute of Medicine, Washington, D.C., Janua~y 25. Finn, P. 1986. Decriminalization of public drunkenness: Response of the health care system. Journal of Studies on Alcohol 46:7-22.

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9o BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Finny, J. W., R. H. Moos, and D. A. Chan. 1981. Length of stay and program components in the treatment of alcoholism: A comparison of two techniques for process analyses. Journal of Consulting and Clinical Psychology 49:120-131. Forrest, G. G. 1985. Antabuse treatment. Pp. 451-460 in Alcoholism and Substance Abuse: Strategies for Clinical Intervention, T. E. Bratter and G. G. Forrest, eds. New York: Free Press. Fuller, R. K, L. Branchey, D. R. Brightwell, R. M. Derman, C. D. Emrick, F. L. Iber, K E. James, R. B. Lacoursiere, K K Lee, I. Lowenstam, I. Maany, D. Neiderhiser, J. J. Nocks, and S. Shawl 1986. Disulfiram treatment of alcoholism: A Veterans Administration cooperative study. Journal of the American Medical Association 256:1449-1455. Gallant, D. M. 1987. Alcoholism: A Guide to Diagnosis, Intervention, and Treatment. New York: Norton and Company. Gilbert. F. S. 1988. The effect of type of aftercare follow-up on treatment outcome among alcoholics. Journal of Studies on Alcohol 49:149-159. Glaser, F. B., S. W. Greenberg, and M. Barrett. 1978. A Systems Approach to Alcohol Treatment. Toronto: Addiction Research Foundation. Glasscote, R. M., T. F. A. Plaut, D. W. Hammersley, F. J. O'Neil, M. E. Chafetz, and E. Cumming. 1967. The Treatment of Alcohol Problems: A Study of Programs and Problems. Washington, D.C.: Joint Information Service of the American Psychiatric Association and the National Association of Mental Health. Glatt, M. M. 1974. A Guide to Addiction and Its Treatment. New York: John Wiley and Sons. Gorski, T. T. 1986. Relapse prevention planning: A new recovery tool. Alcohol Health and Research World 10:6-11, 63. Gorski, T. T., and M. Miller. 1982. Counseling for Relapse Prevention. Independence, Mo.: Herald House. Gottlieb, F., M. Kirkpatrick, J. Marmor, and M. Galanter. 1984. Self-help groups. Pp. 815-831 in The Psychiatric Therapies, T. B. Karazu, ed. Washington, D.C.: American Psychiatric Association. Grad, F. P., A. L. Goldberg, and B. A. Shapiro. 1971. Alcoholism and the Law. Dobbs Ferry, N.Y.: Oceana Publications. Harrison P. A., and N. G. Hoffmann. 1986. Chemical dependency inpatients and outpatients: Intake characteristics and treatment outcome. Prepared for the Chemical Dependency Program Division, Minnesota Department of Human Services. St. Paul-Ramsey Foundation, St. Paul, Minnesota. Hart, L. A review of treatment and rehabilitation legislation regarding alcohol abusers and alcoholics in the United States: 1920-1971. International Journal of the Addictions 12:667-678. Hayashida, M., A. I. Alterman, A. T. McLellan, C. P. O'Brien, J. J. Purtill, J. R. Volpicelli, A. H. Raphaelson, and C. P. Hall. 1989. Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal syndrome. New England Journal of Medicine 320:358-365. Hoffmann, N. G., J. A. Halikas, and D. Mee-Lee, 1987a. The Cleveland Admission, Discharge, and Transfer Criteria: Model for Chemical Dependency Treatment Programs. Cleveland, Ohio: The Greater Cleveland Hospital Association. Hoffmann, N. G., F. Ninonuevo, J. Mozey, and M. G. Luxenberg. 1987b. Comparison of court-referred DWI arrestees with other outpatients in substance abuse treatment. Journal of Studies on Alcohol 48:591-594. Holden, C. 1987. Alcoholism and the medical cost crunch. Science 235:1132-1133. Holder, H. D., R. Longabaugh, and W. R. Miller. 1988. Cost and effectiveness of alcoholism treatment using best available information. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, July. Hunt, G. M., and N. H. Azrin. 1973. The community reinforcement approach to alcoholism. Behaviour Research and Therapy 11:91-104.

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WHAT IS TREATMENT? 91 Institute of Medicine (IOM). 1980. Alcoholism, Alcohol Abuse, and Related Problems: Opportunities for Research. Washington, D.C.: National Academy Press. Institute of Medicine (IOM). 1989. Research Opportunities in the Prevention and Treatment of Alcohol-Related Problems. Washington, D.C.: National Academy Press. Jaffe, J. H., and D. A. Ciraulo. 1985. Drugs used in the treatment of alcoholism. Pp. 355-389 in The Diagnosis and Treatment of Alcoholism, 2nd ea., J. H. Mendelson and N. K Mello, eds. New York: McGraw-Hill. Johnson, V. E. 1980. I'll Quit Tomorrow. San Francisco: Harper and Row. Johnson, V. E. 1986. Intervention: How to Help Someone Who Doesn't Want Help. St. Paul, Minn.: Johnson Institute. Joint Commission on the Accreditation of Hospitals (JCAH). 1983. Consolidated Standards Manual for Child. Adolescent and Adult Psychiatric, Alcoholism, and Drug Abuse Facilities. Chicago: JCAH. Judd, L., R. B. Hubbard, L. Y. Hucy, P. A. Attewell, D. S. Janowsky, and K I. Takashi. 1977. Lithium carbonate and ethanol induced "highs" in normal subjects. Archives of General Psychiatry 34:463~67. Kansas, N. 1982. Alcoholism and group psychotherapy. Pp. 1011-1021 in Encyclopedic Handbook of Alcoholism, E. M. Pattison and E. Kaufman, eds. New York: Gardner Press. Kaufman, E. 1985. Famitr therapy in the treatment of alcoholism. Pp. 376-397 in Alcoholism and Substance Abuse: Strategies for Clinical Intervention, T. E. Bratter and G. G. Forrest, eds. New York: Free Press. Kelso, D., and K M. Fillmore. 1984. Alcoholism Treatment and Client Functioning in Alaska: A Summary of Findings and Implications of a Followup Study of Individuals Receiving Alcoholism Treatment. Report prepared for the Alaska State Office of Alcoholism and Drug Abuse. Anchorage, Alaska: Alam Associates. Khantzian, E. J. 1981. Some treatment implications of the ego and self-disturbances in alcoholism. Pp. 163-188 in Dynamic Approaches to the Understanding and Treatment of Alcoholism, M. H. Bean and N. E. Zinberg, eds. New York: Free Press. Khantzian, E. J. 1985. Psychotherapeutic interventions with substance abusers the clinical context. Journal of Substance Abuse Treatment 2:83-88. Khantzian, E. J., and J. E. Mack. 1989. AA. and contemporary psychodynamic theory. Pp. 67-89 in Recent Developments in Alcoholism, vol. 7, M. Galanter, ed. New York: Plenum Press. Kissin, B. 1977a. Medical management of the alcoholic patient. Pp. 53-103 in Treatment and Rehabilitation of the Chronic Alcoholic. Vol. 5 in The Biology of Alcoholism, B. Kissin and H. Begleiter, eds. New York: Plenum. Kissin, B. 1977b. Theory and practice in the treatment of alcoholism. Pp. 1-51 in Treatment and Rehabilitation of the Chronic Alcoholic, Vol. 5 in The Biology of Alcoholism, B. Kissin and H. Begleiter, eds. New York: Plenum Press. Kissin, B., and M. Hansen. 1982. The big-psychosocial perspective in alcoholism. Pp. 1-19 in Alcoholism and Clinical Psychiatry, J. Solomon, ed. New York: Plenum Press. Kissin, B., and M. Hansen. 1985. Integration of biological and psychosocial interventions in the treatment of alcoholism. Pp. 63-103 in Future Directions in Alcohol Abuse Treatment Research, B. S. McCrady, N. E. Noel, and T. D. Nirenberg, eds. Washington D.C.: U.S. Government Printing Office. Klerman, G. L. 1984. Ideological conflicts in combined treatment. Pp. 17-34 in Combining Psychotherapy and Drug Therapy in Clinical Practice, B. D. Beitman and G. L. Klerman, eds. New York: Spectrum Publications. Klerman, G. L. 1989. Treatment of alcoholism. New England Journal of Medicine 320:394-395. Kusserow, R. P. 1989. An Assessment of Data Collection for Alcohol, Drug Abuse, and Mental Health Services. Washington, D.C.: Office of the Inspector General, U.S. Department of Health and Human Services. Kwentus, J., and L. F. Major. 1979. Disulfiram in the treatment of alcoholism: A review. Journal of Studies on Alcohol 40:428446.

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92 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Laundergan, J. C. 1982. Easy Does It: Alcoholism Treatment Outcomes, Hazelden and the Minnesota Model. Minneapolis: Hazelden Foundation. Laundergan, J. C., and T. Williams. 1979. Hazelden: Evaluation of a residential family program. Alcohol Health and Research World 3~4~:13-16. Lawrence Johnson and Associates, Inc. 1983. Evaluation of the HCFA Alcoholism Services Demonstration: Final Evaluation Design. Prepared for the Office of Research and Demonstrations, Health Care Financing Administration. Washington, D.C., March. Lazarus, A. 1981. The Practice of Multimodal Therapy. New York: McGraw-Hill. Lemere, F., and W. L. Vogetlin. 1950. An evaluation of the aversion treatment of alcoholism. Quarterly Journal of Studies on Alcohol 11:199-204. Lewin/ICF. 1989a. Analysis of State Alcohol and Drug Data Collection Instruments, vols. 1-6. Prepared for the Office of Finance and Coverage Policy, National Institute on Drug Abuse (NIDA). Washington, D.C.: NIDA. Lewin/ICF. 1989b. Feasibility and Design of a Study of the Delivery and Financing of Drug and Alcohol Services. Prepared for the National Institute on Drug Abuse (NIDA). Washington, D.C.: NIDA. Lewis, D. C., and A. J. Gordon. 1983. Alcoholism and the general hospital: The Roger Williams intervention program. Bulletin of the New York Academy of Medicine 59:181-197. Lewis, J. S. 1982. The federal role in alcoholism research, treatment and prevention. Pp. 385~01 in Alcohol, Science and Society Revisited, E. Gomberg, H. White, and J. Carpenter, eds. Ann Arbor, Mich., and New Brunswick, NJ.: University of Michigan Press and Center of Alcohol Studies, Rutgers University. Liskow, B. I., and D. W. Goodwin. 1987. Pharmacological treatment of alcohol intoxication, withdrawal, and dependence: a critical review. Journal of Studies on Alcohol 48:356-370. Littman, G. K 1986. Alcoholism survival: The prevention of relapse. Pp. 294-303 in Treating Addictive Behaviors, W. R. Miller and N. Heather, eds. New York: Plenum Press. Longabaugh, R., and M. Beattie. 1985. Optimizing the cost effectiveness of treatment for alcohol abusers. Pp. 104-136 in Future Directions in Alcohol Abuse Treatment Research, B. S. McCrady, N. E. Noel, and Ted D. Nirenberg, eds. Washington, D.C.: U.S. Government Printing Office. Los Angeles County Office of Alcohol Programs. 1987. 1987-1988 Los Angeles County Plan for Alcohol-Related Services. Los Angeles: Department of Health Services. Lyons, J. P., J. Welte, J. Brown, L. Sokolow, and G. Hynes. 1982. Variation in alcoholism treatment orientation: Differential impact upon specific subpopulations. Alcoholism: Clinical and Experimental Research 6:333-343. Manov, W. F., and N. N. Beshai. 1986. Alcohol-free living centers: Long term, low cost, alcohol recovery housing. Presented at the 114th Annual Meeting of the American Public Health Association, September 28-October 2. Marlatt, G. A. 1985. Relapse prevention: Theoretical rationale and overview of the model. Pp. 3-70 in Relapse Prevention: Maintenance Stategies in the Treatment of Addictive Behaviors, G. A. Marlatt and J. R. Gordon, eds. New York: Guilford Press. Marlatt, G. A. 1988a. Executive summary: Intervention strategies for college students. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, February. Marlatt, G. A. 1988b. Matching clients to treatment: Treatment models and stages of change. Pp. 474483 in Assessment of Addictive Behaviors, D. M. Donovan and G. A. Marlatt, eds. New York: Guilford Press. Marlatt, G. A., and D. M. Donovan. 1982. Behavioral psychology approaches to alcoholism. Pp. 560-577 in Encyclopedic Handbook of Alcoholism, E. M. Pattison and E. Kautman, eds. New York: Gardner Press. Marlatt, G. A, and J. R. Gordon, eds. 1985. Relapse Prevention: Maintenance Stategies in the Treatment of Addictive Behaviors. New York: Guilford Press.

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94 BROADENING TEIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS New York Division of Alcoholism and Alcohol Abuse (NYDAAA). 1986. Five Year Comprehensive Plan for Alcoholism Services in New York State 1984-1989: Final 1987 Update. Albany, New York: NYDAAA~ Noble, E. P. 1984. Pharmacotherapy in the detoxification and treatment of alcoholism. Pp. 346-359 in Psychiatry Update. Vol. 3 of the American Psychiatric Association Annual Review, L. Grinspoon, ed. Washington, D.C.: American Psychiatric Association. Noshpitz, J. D., T. Shapiro, M. Sherman, J. M. Oldham, L. Lazarus, and N. A. Newton. 1984. Milieu therapy. Pp. 619~29 in The Psychiatric Therapies, T. B. Karazu, ed. Washington, D.C.: American Psychiatric Association. O'Briant, R. G., H. L. Lennard, S. D. Allen, and D. C. Ransom. 1973. Recovery from Alcoholism. Springfield, Ill.: Charles C. Thomas. Oie, T. P. S., and P. Jackson. 1980. Long-term effects of group and individual social skills training with alcoholics. Addictive Behaviors 5:129-136. Oie, T. P. S., and P. Jackson. 1982. Social skills and cognitive behavioral approaches to the treatment of problem drinking. Journal of Studies on Alcohol 43:532-547. Okulitch, P. V., and G. A. Marlatt. 1972. Effects of varied extinction conditions with alcoholics and social drinkers. Journal of Abnormal Psychology 79:205-211. Orvis, B. R., D. J. Armor, C. E. Williams, A. J. Barras, and D. S. Schwarzbach. 1981. Effectiveness and Cost of Alcohol Rehabilitation in the United States Air Force. Santa Monica, Calif.: RAND Corporation. Paredes, A., D. Gregory, and O. H. Rundell. 1981. Empirical analysis of the alcoholism services delivery system. Pp. 371-404 in Research Advances in Alcohol and Drug Problems, vol. 6, Y. Israel, F. B. Glaser, H. Kalant, R. E. Popham, W. Schmidt, and R. G. Smart, eds. New York: Plenum Press. Pattison, E. M. 1974. Rehabilitation of the chronic alcoholic. Pp. 587-658 in Treatment and Rehabilitation of the Chronic Alcoholic. Vol. 3 of The Biology of Alcoholism, B. Kissin and H. Begleiter, eds. New York: Plenum Press. Pattison, E. M. 1985. The selection of treatment modalities for the alcoholic patient. Pp. 189-294 in J. H. Mendelson and N. K Mello, eds. The Diagnosis and Treatment of Alcoholism, 2d ed. New York: McGraw-Hill. Pattison, E. M., M. B. Sobell, and L. C. Sobell. 1977. Emerging Concepts of Alcohol Dependence. New York: Springer Publishing Company. Pendery, M. L., I. M. Maltzman, and L. J. West. 1982. Controlled drinking by alcoholics? New findings and reevaluation of a major affirmative study. Science 217:169-175. Pisani, V. 1977. The detoxication of alcoholic~aspects of myth, magic or malpractice. Journal of Studies on Alcohol 38:972-985. Pittman, D. J. 1974. Role of detoxification centers in alcoholism treatment. Presented at the North American Congress on Alcohol and Drug Problems, San Francisco, December. Plaut, T. F. A., ed. 1967. Alcohol Problems: A Report to the Nation. New York: Oxford University Press. Poley, W., G. Lea, and G. Vibe. 1979. Alcoholism: A Treatment Manual. New York: Gardner Press. Polich, M. J., D. J. Armor, and H. B. Braiker. 1980. The Course of Alcoholism: Four Years After Treatment. Santa Monica, Calif.: The RAND Corporation. President's Commission on Law Enforcement and Administration of Justice. 1967. The Challenge of Crime in a Free Society, Task Force Report: Drunkenness. Washington, D.C.: U.S. Government Printing Office. Prochaska, J. O., and C. C. DiClemente. 1982. Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy Theory and Practice 19:276-278. Prochaska, J. O., and C. C. DiClemente. 1983. Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology 51:390-395.

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WHAT IS TREATMENT? 95 Prochaska, J. O., and C. C. DiClemente. 1986. Toward a comprehensive model of change. Pp. 3-27 in Treating Addictive Behaviors: Processes of Change, W. E. Miller and N. Heather, eds. New York: Plenum Press. Rankin, H. J., R. Hodgson, and T. Stockwell. 1983. Cue exposure and response prevention with alcoholics: A controlled trial. Behaviour Research and Therapy 21:435 446. Research Triangle Institute (RTI). 1985. Toward a National Plan to Control Alcohol Abuse and Alcoholism: Draft Report. Prepared for the National Institute on Alcohol Abuse and Alcoholism. Research Triangle Park, N.C.: Research Triangle Institute. Reynolds, R. I. 1988a. Opening remarks: Evaluating recovery outcomes. Presented at the Conference on Evaluating Recovery Outcome, University of California, San Diego, Extension Program on Alcohol Issues, February 4. Reynolds, R.I. 1988b. Executive summary: Social model services as an alternative to medical/clinical model services in San Diego county. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, February. Reynolds, R. I., and B. E. Ryan. 1988. Executive summary: Policy implications of social model alcohol recovery services. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, July. Rubington, E.. 1974. The role of the halfway house in the rehabilitation of alcoholics. Pp. 351-383 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. Sadd, S., and D. W. Young. 1986. A Controlled Study of Detoxification Alternatives for Homeless Alcoholics. New York: Vera Institute of Justice. Sadd, S., and D. W. Young. 1987. Nonmedical treatment of indigent alcoholics: A review of recent research findings. Alcohol Health and Research World 11:4849,53. Sanchez-Craig, M. 1988. Procedures for assessing change after alcoholism treatment. Drugs and Society 2(2):53-67. Sanchez-Craig, M., and D. A. Wilkinson. 198611987. Treating problem drinkers who are not severely dependent on alcohol. Drugs and Society 1~2/3~:39~7. Sanchez-Craig, M., D. A. Wilkinson, and K Walker. 1987. Theory and methods for secondary prevention of alcohol problems: A cognitively based approach. Pp. 287-331 in Treatment and Prevention of Alcohol Problems: A Resource Manual, W. M. Cox, ed. New York: Academic Press. Saxe, L., D. Dougherty, K Esty, and M. Fine. 1983. The Effectiveness and Costs of Alcoholism Treatment. Washington, D.C.: U.S. Congress, Office of Technology Assessment. Schuckit, M. A. 1985. Treatment of alcoholism in office and outpatient settings. Pp. 295-324 in The Diagnosis and Treatment of Alcoholism, 2d ea., J. H. Mendelson and N. K Mello, eds. New York: McGraw-Hill. Sellers, E. M., and C. A. Naranjo. 1985. Strategies for improving the treatment of alcohol withdrawal. Pp. 157-168 in Research Advances in Psychopharmacological Treatments for Alcoholism, C. A. Naranjo and E. M. Sellers, eds. Amsterdam: Excerpta Medical Sellers, E. M. 1988. Issues of treatment modalities. Prepared for the "Treatment" meeting of the National Institute on Alcohol Abuse and Alcoholism Ad Hoc Scientific Advisory Board, Rockville, Md., May 3. Shadle, M., and J. B. Christianson. 1988. The Organization and Delivery of Mental Health, Alcohol, and Other Drug Abuse Services within Health Maintenance Organizations. Final Report. vol. 1. Prepared for the Alcohol, Drug Abuse, and Mental Health Administration. Minneapolis: Interstudy. Shandler, I. W., and T. E. Shipley. 1987. New focus for an old problem: Philadelphia's response to homelessness. Alcohol Health and Research World 11:54-56. Skinner, H. ~ 1985. Early detection and basic management of alcohol and drug problems. Australian AlcohoVDrug Review 4:243-249.

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