National Academies Press: OpenBook

Broadening the Base of Treatment for Alcohol Problems (1990)

Chapter: Chapter 3--What is treatment?

« Previous: Chapter 2--What is being treated?
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 42
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 43
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 44
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 45
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 46
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 47
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 48
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 49
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 50
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 51
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 52
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 53
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 54
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 55
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 56
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 57
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 58
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 59
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 60
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 61
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 62
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 63
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 64
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 65
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 66
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 67
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 68
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 69
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 70
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 71
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 72
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 73
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 74
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 75
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 76
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 77
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 78
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 79
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 80
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 81
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 82
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 83
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 84
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 85
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 86
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 87
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 88
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 89
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 90
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 91
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 92
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 93
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 94
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 95
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 96
Suggested Citation:"Chapter 3--What is treatment?." Institute of Medicine. 1990. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: The National Academies Press. doi: 10.17226/1341.
×
Page 97

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

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

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,

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).

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

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),

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)

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)

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.,

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

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).

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

WHAT IS TREATMENT? 53 has evolved, the biopsychosocial orientation, which has its roots directly in work with persons with alcohol problems (Kissin 1977a,b; Kissin and Hansen, 1985) as well as in behavioral medicine (Engel, 1977; Donovan, 1988; see Chapter 2~. Generally, the biopsychosocial model provides a framework within which the biological, psychological, and sociocultural approaches to health can be integrated (Engel, 1977; Zucker and Gomberg, 1986; Marlatt et al., 1988~. More specifically, the model offers a way to bring together varying orientations or philosophies for treating the individual with alcohol problems. This approach implies that the problems are determined by multiple factors and recognizes the heterogeneity of causes and courses that are involved. Problem etiology and the maintenance of the excessive, harmful pattern of drinking behavior are seen as a complex interaction among the biological, psychological, and sociocultural risk factors. Physiological factors include, for example, the genetic predispositions that are presumed to reflect differences in the metabolism of alcohol owing to the absence or presence of certain neurochemicals as well as the physiological changes (e.g., tolerance, dependence, and withdrawal) that follow repeated consumption. Psychological factors may include an individual's personality and character structure as well as variations in mood states and expectations. Sociocultural factors may include variations in drinking norms and expectations, in work environments, and in family structure. The biopsychosocial model recognizes that, for each individual, all three sets of factors are potentially involved but that in different individuals one or the other sets of causes may predominate. Similarly, the major consequences of excessive alcohol use for an individual may be biological (e.g., physical dependence, neuropsychological deficits, physical illnesses such as pancreatitis and cirrhosis), psychological (e.g., depression, anxiety, cognitive dysfunction), or social (e.g., marital dysfunction, job difficulties, legal problems). Recently, a new approach, the transtheoretical "stages of change" model, has shown promise for studying and organizing the treatment of alcohol problems within the biopsychosocial framework (Prochaska and DiClemente, 1982, 1983, 1986; Marlatt et al., 1988; IOM, 1989~. This model emerged from a comparative analysis of 18 theories about psychotherapy and behavioral change, including theories that serve as the basis for the physiological, psychological, and sociocultural models described above. Several researchers have begun to use the model as a framework for studying the treatment process. Such researchers are generally those who utilize the integrative biopsychosocial model to understand the etiology and maintenance of excessive, harmful drinking and other addictions (e.g., smoking and drug use) (Marlatt et al., 1988; IOM, 1989~. The stages of change model posits that there is a common sequence of changes that individuals experience in developing a problem behavior, in ending that behavior, and in either maintaining the cessation of the behavior or relapsing. The behavior change sequence is divided into four stages: (1) precontemplation, in which the individual is not considering change because the drinking behavior is not seen as a problem; (2) contemplation, in which the individual begins to think seriously about changing his or her drinking behavior because of the perception that it is causing increasing difficulties in a variety of life function areas; (3) action, in which the individual takes positive steps to change drinking behavior, either on his or her own or with the assistance of formal treatment; and (4) maintenance, in which the individual engages in active efforts to avoid drinking, again, either alone or with assistance. Preparation for maintenance requires an explicit assessment of the conditions under which an individual is likely to relapse. A person who relapses goes through the same stages where maintenance represents active efforts to continue drinking. In practice there appear to be programs and practitioners that offer either a single treatment type or modality (e.g., traditional individual psychotherapy in the private practice setting; disulfiram in the primary care physician's office) or a wide range of modalities that

54 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS can be selectively pursued (e.g., multidisciplinary, multimodality milieu therapy in the freestanding or hospital-based alcohol rehabilitation unit). Often, treatments are combined, with psychologically oriented treatment programs using medications as adjuncts and drug treatments being offered together with psychological and sociocultural strategies (Saxe et al., 1983; Kissin and Hansen, 1985~. Although research is lacking to confirm the perception, multicomponent programs have been seen as more successful than single-component programs because they can address the wide variety of difficulties generally presented by persons with chronic alcohol problems (Costello et al., 1977; Costello, 1980; Paredes et al., 1981~. Nevertheless, in most of those programs that do offer a range of modalities, it is usually (although not always) possible to discern which of the various treatment philosophies is the dominant orientation. To understand the intense feeling that underlies the ongoing controversy about treatment in the alcohol problems field, it is helpful to view these differing treatment philosophies as professional ideologies that guide the development of both particular programs and of movements~within the field (Strauss et al., 1964; Klerman, 1984; Weisner and Room, 1984; Borkman, 1988~. A professional ideology not only includes beliefs and theories about etiology but also provides prescriptive norms for what should be applied in clinical practice, teaching, and research. Strauss and colleagues (1964) used the concept of professional ideologies to explain the variations in psychiatric treatment that could be observed in hospital settings. They demonstrated how the treatment philosophies held by those who worked at a given institution shaped the ways in which services were organized and delivered, the definition of "proper" treatment, and the appropriate divisions of labor. Other aspects of the effects of professional ideologies are that adherents of a particular approach seek each other out, participate in both informal social networks and formal associations, and seek legitimization and institutionalization of their viewpoint. Strong emotions become attached to adherents' beliefs about etiology and practice and sometimes lead to conflicts over the proper way to provide treatment. One of the potential benefits of such strongly held beliefs may involve matching. It has been suggested that dominant treatment orientation can be an important variable for matching persons with alcohol problems to the most effective form of treatment (Kissin, 1977a; Kissin and Hansen, 1985; Pattison, 1985; Annis, 1988~. For example, Welte and colleagues (1978) studied the relationship of the orientation of treatment units to outcome (see also Lyons et al., 1982~. Scales were developed to measure each orientation. Medical orientation was measured by the frequency of the use of drug therapies, the number of beds used for detoxification, the number of medical and nursing staff, and the degree of importance placed on staff academic training. Rehabilitation orientation was measured by the frequency of use of relationship therapy, family therapy, occupational therapy, and vocational counseling, and by the number of staff who were psychologists, social workers, rehabilitation counselors, and occupational or recreational counselors. The unit's peer group or sociocultural orientation was determined by measuring the frequency of the use of alcohol education, Alcoholics Anonymous, and Al-Anon; the level of self-government activity; and the type of grievance activity. These three orientations roughly correspond to the treatment models described earlier (i.e., the biological, psychological, and sociocultural). In the Welte team's study, individuals in treatment were classified according to whether they exhibited either behavioral signs and symptoms of alcohol dependence, physical signs and symptoms, or both behavioral and physical signs and symptoms. The expectation that strongly medically oriented rehabilitation units would be more successful in treating those who exhibited physical signs and symptoms was not borne out; rather, those individuals who exhibited physical signs and symptoms were more successfully treated in the high peer group orientation units. Units with a high medical orientation appeared to be more effective in treating persons who showed signs of little physiological impairment. However, treatment units were not "purer types and treatment orientation was

WHAT IS TREATMENT? 55 not as strong a predictor of treatment outcome as were patient characteristics and length of stay. The work of Brickman and colleagues (1982) also suggests that treatment orientation is an important variable for matching persons to the most effective form of treatment. These investigators developed a social psychological framework to investigate how beliefs about etiology and the treatment of alcohol problems both the part of the treatment provider and on the part of the person seeking treatment influence treatment outcome. Their approach, which has been continued by Marlatt and his colleagues, suggests that there are four models that underlie contemporary efforts to help people to change their drinking behavior. They have labeled these the moral model, the medical model, the enlightenment model, and the compensatory model (Brickman et al., 1982; Marlatt et al., 1988~. These models are differentiated by the extent to which the individual is considered responsible for the development of the problem and the extent to which the individual is considered responsible for resolving it. As interpreted by Brickman and his colleagues, the moral model's position is that individuals are held responsible for both the etiology of the alcohol problem and for creating the solution. Drinking in this model is seen as a weakness in character, and people are expected to change their drinking behavior through personal effort, by an exercise of will power. Examples of this orientation are the temperance movement and Prohibition. The moral model has little support in contemporary literature on treatment and is often dismissed as sold fashioned." Yet because there is an inescapable moral element in all behavior, such a dismissal may be premature. In the enlightenment model, a person is considered to be responsible for developing the alcohol problem but requires external help in changing his and her behavior. Alcoholics Anonymous is given by the Brickman team as an example of the enlightenment model because of its emphasis on requiring the help of a "higher power" in maintaining sobriety. In the medical model, as described by Brickman and his coworkers (1982), neither the development of the problem nor the responsibility for its resolution is seen as the person's responsibility. The disease model of alcohol problems, with its emphasis on a progressive disease process that arises from an underlying genetic predisposition and is exemplified by increasing physical dependence, is given as an example of this approach: alcohol problems are the result of uncontrollable biological and genetic factors, and treatment is administered by experts who apply biomedical treatments that arrest the underlying condition (Marlatt et al., 1988~. The disease model was explicitly developed as an alternative to the moral model and is the dominant approach in U.S. treatment programs. The characteristic structure of the medical model is most evident in those hospital and nonhospital inpatient units in which the physician is either the primary therapist or is influential in determining the treatment plan to be carried out by an alcoholism counselor who acts as the primary therapist. In these units pharmacologically assisted detoxification is the standard regimen, and antianxiety, antidepressant, and sensitizing medications are used as a major component of lon~-term treatment (e.~.. J e A_ ~e ~ · . · · . · . Or Ciallant, 1987!. lee program milieu and any psychotherapies that are offered are seen as supporting these physiological treatments. The characteristic structure of the medical model is also seen in those inpatient units that offer a blend of the sociocultural and medical models. In these programs, the physician is not the primary therapist but retains medicolegal responsibility for the overall regimen (Bast, 1984~; the primary therapist is very often a counselor who is a recovering alcoholic. Here, the physician most often diagnoses and treats the physical consequences and complications of prolonged excessive alcohol use, prescribes and monitors medications if needed, and serves as a consultant and backup while participating with the multidisciplinary team in planning and evaluating the person's long-term treatment.

56 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS The orientation expressed in the compensatory model, the fourth model in the Brickman team's scheme, does not hold the individual responsible for the etiology of his or her alcohol problems; however, the person is responsible for the changes required to resolve them. This approach views the cause of alcohol problems as a combination of biological, psychological, and social factors. In treatment, individuals are taught how to avoid alcohol problems and are then expected to monitor and control their own performance. The compensatory model is reflected in treatment that uses the biopsychosocial model and social learning theory (Marlatt et al., 1988~. Because therapists and persons seeking help may each subscribe to a different model of treatment (i.e., to a different view of the cause of problems and the source of their solution), Brickman and his coworkers (1982) have hypothesized that matching by orientation would improve the chance of a successful outcome. Yet such matching is not easy to effect. All practitioners and researchers neither endorse the Brickman taxonomy nor agree with the classification of specific treatment approaches. Other interpretations of the medical model, for example, would say that the person is not responsible for the development of the problem, but that the person is responsible for its resolution. Many in the medical profession and in Alcoholics Anonymous would see the compensatory model as more nearly approximating their orientation. More research is needed to determine how best to describe the orientation of a given program and whether orientation is a critical matching variable (Annie, 1988~. The orientation that over the recent past has probably evoked the most controversy is the social model of recovery. In the late 1960s and early 1970s, a shift occurred in the orientation of many treatment providers as they began to consider and take into account environmental and social influences on drinking behavior (Beigel and Ghertner, 1977~. The dramatic impact of Alcoholics Anonymous as well as the development of the therapeutic community approach for psychiatric patients and drug abusers contributed to and were themselves strengthened by this shift. These approaches shared a critique of the medical and psychological models' use of diagnosis, professional domination by physicians, reliance on somatic forms of treatment, and the passivity of the patient role (Borkman, 1982, 1986; Klerman, 1984~. The formalized approach that developed out of this change in orientation, the so-called social model or social setting model, was applied both to detoxification and to long-term treatment (O'Briant et al., 1973 Armor et al., 1978~. The social treatment or social setting model advocated by O'Briant and colleagues (1973) was also a reaction against what was seen as treatment taking place only within the short time frames of the structured program in the hospital or residential treatment center; in the social model, emphasis was placed on continued active involvement in the "social living space" of the alcoholic after discharge from the structured inpatient treatment program. The deemphasis on inpatient rehabilitation extended to detoxification; in addition, proponents of the social setting model of detoxification argued that pharmacologically assisted detoxification in the acute hospital setting, in which the alcoholic assumed the passive role of patient, actually interfered with the process of recovenr, the process of learning to live without relying on alcohol. , ,, They pointed to the success achieved by the Addiction Research Foundation of Ontario in developing nonhospital detoxification centers in which staff support and encouragement, good food, and pleasant surroundings, rather than physiological treatments, were emphasized. In 1969, the model received a boost of support from the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) sponsorship of a demonstration of the safety of social model detoxification (O'Briant et al., 1973; DenHartog, 1982~. The basic methods and goals of the social model approach were soon appropriated by many state alcoholism authorities when they adopted the Uniform Act provisions for decriminalizing public intoxication and qualified for federal incentive grants to provide alternatives to jail for public inebriates (USDHHS, 1981; DenHartog, 1982; Finn, 1985; Sadd and Young, 1986~. Nevertheless, there were critics

WHAT IS TREATMENT? 57 who questioned the degree to which medical procedures were being rejected (Pittman, 1974, Pisani, 1977~. There was a similar effort to shift the philosophical orientation underlying long-term treatment (O'Briant et al., 1973; Beigel and Ghertner, 1977; Kissin, 1977a,b; Borkman, 1982, 1983~. The social rehabilitation model was quickly incorporated into the design of many freestanding and hospital-based programs, surviving in its purest form primarily in California (Borkman, 1988; Reynolds and Ryan, 1988~. The parallel development in other areas of psychiatric care of the psychosocial rehabilitation and social model concepts has been described by Noshpitz and coworkers (1984) and Gottlieb and colleagues (1984), among others. Current California social model programs are seen as third-generation mutual-help or self-help organizations that have evolved from the original first-generation efforts of Alcoholics Anonymous and the second-generation social setting detoxification centers, "Twelve Steps houses, halfway houses, and recovery homes that were founded by recovering alcoholics in the 1950s and 1960s (Rubington, 1974; Borkman, 1982, 1983; Orford and Velleman, 1982~. In a later report Borkman (1986a) described the nine elements of the community-social model prevalent in the California programs: 1. 2. 3. 4. 6. 7. 8. 9. The experiential knowledge of successfully recovering alcoholics is the basis of authority. The primary foundation of recovery is the 12-step mutual aid process (AA or Al-Anon). Recovery is viewed as a lifelong learning process, which is experiential in nature. In recovery, staff manage the recovery environment, not the individuals; there is an absence of superordinate-subordinate, therapist-client roles or accompanying paraphernalia, such as case files with progress notes on each individual. Participants who embrace recovery become presumers," persons who simultaneously give aid to others and receive services from others. Participants feel they own their program and contribute to its upkeep voluntarily. Participants, alumni, volunteers, and staff enjoy a relationship analogous to an extended family network. Participants, alumni, and volunteers (and not just selected staff in specialized roles) represent the recovery process and program to the community. The alcohol problem is viewed as occurring at the level of collectivities (e.g., family, community), rather than solely at the level of the individual; activities to change policies, norms, and practices of collectivities regarding alcohol use are carried out as part of the recovery process. The current emphasis on social model recovery services in California represents the efforts of an evolving ideology that is actively seeking to confront and change the current system for organizing, accrediting, evaluating, and financing alcohol treatment services (Wright, 1985; Holden, 1987; Borkman, 1988; Reynolds, 1988a,b; Reynolds, and Ryan, 1988~. In California, social model concepts have become institutionalized in the public sector, and many of the major counties (e.g., San Diego, Los Angeles, Alameda) have adopted the social model philosophy as the basis for funding treatment programs. Medical and psychological model programs are favored in the private sector. One of the major points of contention regarding the California social model programs is that they eschew the involvement of professional staff (i.e., medical

58 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS practitioners, psychotherapists, case managers) (Dodd, 1974, 1986; Borkman, 1986; DeMiranda, 1986; Reynolds and Ryan, 1988~. They see themselves as differentiated from second-generation social setting detoxification and rehabilitation programs in California and in other states by their rejection of the "professional/clinical model" that is embodied in the data-gathering, licensing, and accreditation requirements of the majority of third-party payers--for example, staffing by degreed professionals, elaborate recordkeeping and documentation, the case management form of monitoring, and funding tied to individual patients and individual units of service. Second-generation social setting programs subscribe to these requirements to retain their funding. California's social model programs, on the other hand, are funded mainly through specific jurisdictional mechanisms; because they do not have to meet traditional health insurance requirements, they are presented as cost-effective alternatives to standard treatment programs (Reynolds, 1988a,b; Reynolds and Ryan, 1988~. Evaluations of these claims are currently in progress. Although treatment programs continue to vary along ideological lines, the field has seen in recent years the evolution and emergence of hybrid programs that claim to reflect the biopsychosocial model. The major hybrid is the Minnesota Model of Chemical Dependence Intervention and Treatment (Laundergan, 1982), a treatment strategy that blends AA and professional concepts and practices. It is widely believed that today the vast majority of U.S. treatment programs, both in the public and private sectors, subscribes to the philosophy and organization of treatment services that has become known simply as the Minnesota model (Anderson, 1981; Laundergan, 1982; Hoffmann et al., 1987b). For example, the continuum of care proposed by the Funding Task Force of the North American Congress on Alcohol and Drug Problems (Boche, 1975), which is discussed later in this chapter under Treatment Stages, was to a large extent based on the Minnesota system in place at that time. Any attempt to understand treatment for alcohol problems in this country must include a review of the Minnesota model as well as an understanding of the role played by Alcoholics Anonymous in promoting particular concepts about the nature of alcohol problems and their treatment. Although one could trace a number of early precursors of the Minnesota approach (e.g., Zimberg, 1983, Weisman, 1988), the model had its origins in the 1950s in work carried out at three institutions in the state: Willmar State Hospital, the Hazelden Foundation, and the Johnson Institute. The approach blends professional diagnostic and treatment activities with the 12-step recovery program developed by Alcoholics Anonymous (see Chapter 4~. The standardized treatment program, which is typically delivered to all individuals in the course of a four-week inpatient stay, either in a hospital or in a freestanding facility, consists of detoxification, education (based on the disease concept) about the harmful medical and psychosocial effects of excessive alcohol consumption, confrontation, attendance at AA meetings and use of AA materials in developing a recovery plan (nstepworkn), and disulfiram therapy (Weisner and Room, 1984; Babor, 1986~. The approach places strong emphasis on the use of recovering alcoholics as primary counselors, who guide the person through a multidisciplinary program that attempts to merge the medical, psychological, and sociocultural models. Laundergan (1982:2) describes it as follows: The alternative treatment program that became seminal to the Minnesota Model was a blend of professional behavioral science and AA principles. . . .Their program involved unlocking the treatment wards and using as counselors recovering alcoholics with five years or more of sobriety and at least a high school education. They also used lectures and group and individual therapy integrated with a working knowledge of Alcoholics Anonymous principles.

WHAT IS TREATMENT? 59 This new active (rather than custodial) treatment program that developed and evolved throughout the 1950s at Willmar introduced the distinction between detoxification and rehabilitation (Anderson, 1981~. The Minnesota model also included a definition of a continuum of care with specialized service components integrated into a network (Anderson, 1981~. These elements included a diagnostic and referral center, a detoxification center, a primary residential rehabilitation program, an extended care program, residential intermediate care (e.g., halfway houses), outpatient care (diagnostic, primary, and extended), aftercare, and a family program. The new model that had been developed at Willmar was soon adopted by the Hazelden Foundation; following further development, it was refined into what became known as the Hazelden variant of the model. With this approach, after detoxification, which lasted from 2 to 7 days, patients were transferred to a "primary care program." In the original version of the Hazelden variant, this stage of treatment lasted 60 days.) The primary care program was an intensive, highly structured inpatient treatment regimen that included a psychological evaluation and two treatment ~tracks," a general program track and an individualized prescriptive track. The components of the general program track were small, task-oriented group meetings (two to three times a week) and lectures (five mornings a week). The components of the individualized prescriptive track were meetings with the assigned Focal counselor" (twice a week, or more, if necessary), a work assignment, and referral to a professional staff member if additional medical, psychiatric, or social services were needed. Another major variant of the Minnesota model developed at Minnesota's Johnson Institute. Like the Hazelden version, the Johnson model stressed the need to view alcohol problems as a primary disorder that required treatment in its own right and not simply the symptomatic expression of an underlying psychiatric disorder. Johnson (1980:2) described it as follows: "Very simply, the treatment involves a therapy designed to bring the patient back to reality. The course of treatment consists of an average of four weeks of intensive inpatient care of the acute symptoms in the (general) hospital, and up to two years of aftercare as an outpatient. The recommended setting for intensive treatment of the disorder's acute symptoms was the general hospital; the inpatient stay was divided into two phases, observation and detoxification followed by initiation of rehabilitation. Although the Johnson model saw treatment as a multidisciplinary endeavor involving physicians, nurses, psychiatrists, psychologists, counselors, and administrators, it considered rehabilitation to be a nonmedical process that was best carried out under the direction of the counselor. The third phase, outpatient treatment, was described as weekly contact with the nonmedical program for up to two years after inpatient discharge. This nonmedical outpatient program included weekly group therapy sessions, consultation and counseling as needed, weekly AA meetings, and spouse and family weekly participation in Al-Anon and Alateen. Participation in the entire two year period was seen as necessary for all individuals, with extensions of the length of formal treatment required for some. The Johnson variant of the Minnesota model eventually spread throughout the country through consultations by Johnson Institute personnel with newly developing treatment programs and through the influential writings of Vernon Johnson. The first of these units was opened in 1968 at St. Mary's Hospital in Minneapolis; other units based on the same philosophy were subsequently opened in Nebraska, Louisiana, Ohio, and California. Another important development in the evolution and dissemination of the Minnesota model was the movement of several key staff from the Willmar State Hospital program to Park Ridge, Illinois, where they helped to found the Lutheran General Hospital program. This inpatient treatment center was the forerunner of Parkside Medical Services, which is now the largest single nongovernment provider of alcohol and drug abuse treatment services in the country, operating a nationwide network of hospital and freestanding facilities and units that subscribe to the Minnesota model philosophy.

60 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Proprietary firms also served to diffuse the Minnesota model throughout the nation by the development of management contracts to initiate and operate hospital-based, f~xed-length of stay Alcohol rehabilitation units (Saxe et al., 1983; Weisner and Room, 1984; Cahalan, 1987~. All of these organizations engaged in outreach and educational efforts to employers and professionals, stressing that "alcoholism" was treatable and that treatment in the end was cost-effective. All of these organizations produced education and training materials and conducted seminars, influencing potential reformer and also shaping the ideologies of those entering the field. ~· ~. --so r- . _ All stressed the involvement of recovering counselors, who came into their new roles strongly imbued with the philosophical orientation of and belief in the Minnesota model of treatment for Alcoholism: inpatient rehabilitation followed by outpatient aftercare for a condition defined as a physical disease and characterized by progressive deterioration if abstinence were not the goal of treatment. These principles were also finding voice in many of the treatment programs that were being developed in other parts of the country simultaneously with the Minnesota model. These programs tended to follow a similar course, growing out of the union of recovering persons and professionals working in specialized programs in acute care or psychiatric hospitals. Stuckey and Harrision described the type of program that often developed in the eastern states: A typical rehabilitation center is a residential therapeutic community of recovering alcoholics sharing experiences and feelings in a chemical-free environment. The average stay is approximately 28 days utilizing the following key ingredients: 1. Strong AA orientation 2. Skilled alcoholism counselors as primary therapists 3. Psychological testing and psychosocial evaluations 4. Medical and psychiatric support for coexisting problems 5. Therapists trained in systematized methods of treatment including Gestalt, psychodrama, reality therapy, transactional analysis, behavior therapy, activity therapy, and stress management Use of therapeutic community and crisis intervention Systems therapy, especially with employers and later including a strong family component Family- and peer-oriented aftercare. (Stuckey and Harrison, 1982:865-867) Today, the modal pattern of treatment has become the fixed-length inpatient rehabilitation program, with disagreement about the amount of aftercare required. Current inpatient primary care programs that follow this orientation usually involve a three- to six-week length of stay. Aftercare following the completion of the inpatient phase of treatment varies greatly in both format and duration (Vannicelli, 1978; Harrison and Hoffmann, 1986~. Aftercare may consist of diverse activities ranging from monthly telephone contact or attendance at alumni meetings to continuing treatment in weekly counseling sessions for patients and significant others provided at the programs. Alternatively, aftercare can be referral to a hallway house or referral to another agency for continuing outpatient treatment. Most commonly aftercare is referral to Alcoholics Anonymous. Treatment Stages Programs for treating alcohol problems have long used a stage or phase model.

WHAT IS TREATMENT? 61 For some programs this model has been explicit; for others it has been implicit (Diesenhaus, 1982~. Nevertheless, it has become customary to break down episodes of treatment for alcohol problems into stages or phases that mirror current practices and the natural process of recovery (e.g., Mulford, 1979, 1988; Pattison, 1985; Anderson, 1981; Costello and Hodde, 1981; Blume, 1983; Vaillant, 1983~. The simplest and most commonly used division is the distinction between detoxification, rehabilitation, and aftercare or relapse prevention (e.g., Glatt, 1974; IOM, 1989~. This sequence of components of a treatment episode now appears not only in the model benefit design developed by the Blue Cross/Blue Shield Association (Berman and Klein, 1977) but also in the accreditation standards of the Joint Commission for Accreditation of Health Care Organizations and the Commission on the Accreditation of Rehabilitation Facilities. The sequence also appears in state licensure standards and insurance mandates, in state resource allocation models, in the U.S. military's CHAMPUS benefit design, and most recently in the Medicare prospective payment system using diagnosis-related groups. Such a sequence provides a framework for what was referred to earlier in this chapter as a continuum of care for persons with alcohol problems. The efforts of the Blue Cross/Blue Shield Association in developing its model benefit plan are one of the first instances in which the phases of treatment were made explicit. In 1977 NIAAA funded Blue Cross/Blue Shield to determine the feasibility of providing private health insurance benefits for alcoholism treatment. To estimate the costs of specific benefit designs more precisely, this effort clearly differentiated between those procedures that addressed acute physical problems arising out of excessive alcohol consumption and those procedures that focused on alleviating the chronic problems that arise out of the compulsive use of alcohol. Thus, the association's design for a model benefit package differentiated between "acute phase services (e.g., emergency medical treatment, withdrawal management) and "chronic phase activities" (Berman and Klein, 1977~. Making such distinctions among the phases or stages of treatment had two important advantages: (1) it allowed the differentiation of the specific costs associated with treating the varied consequences of alcohol misuse and (2) it emphasized that one activity cannot substitute for the other; that is, neither the treatment of intoxication and withdrawal nor the treatment of the medical consequences of excessive alcohol use are substitutes for comprehensive treatment for alcohol problems (although they may need to precede such treatment). A number of models of sequenced or phased treatment have been developed by researchers, practitioners, and planners. A review of several such models can be helpful in two ways: in understanding the variation that exists in practice and as a first step in designing a framework for an expanded continuum of care. Pattison (1974, 1985) has attempted the most ambitious description of the existing and required continua, seeking to link agencies, facilities, programs, settings, target populations, and phases of treatment into an organized whole or nsystemn of treatment. His model has seven phases: Phase A, Identification- the determination of whether an individual has an alcohol use problem of any degree (mild, moderate, or severe) that requires treatment. Phase B. Triage Referral-active referral of the individual to the Appropriate treatment facility, Appropriateness being determined through mutual exploration with individuals of their perceptions, needs, and desires regarding acceptable types of facilities and treatment. Phase C, Program Entry the response of an agency to the individual's immediate needs and its involvement of the person in an emotionally receptive "social climates oriented to his or her personal needs. At program entry the individual's immediate

62 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS needs for acute medical care or psychiatric care are established. Motivation is to be enhanced and program dropout avoided. Phase D, Initial Treatn~ra Processes (acute care)-the implementation of specific procedures to guard against the person's dropping out of treatment and to provide a preparatory treatment experience that is supportive, symptom relieving, and nonthreatening, as well as reality oriented and option oriented. The goal of this phase is positive involvement of the individual with the program's social environment (i.e., staff, other persons in recovery) so as to instill a shared motivation to continue in the ongoing process of rehabilitation. Phase E, Selection' of Goals arid Methods (rehabilitation)-cooperatively working with the now stabilized alcoholic to develop and carry out a long-range individualized plan, specifying which of the wide variety of treatment methods and goals are appropriate and desirable, based on a comprehensive differential assessment of drinking behavior, personality, degree of socialization, extent of disability in each area of life (e.g., work, physical health, emotional health), and social status. Phase F. Treatment Maintenance arid Monitoring-regular review of progress toward the individual's goals, including determinations of whether specific treatment methods are being adequately carried out and redefinition of the methods and goals when necessary. Phase G. Termination' and Follow-up-similarly, the assessment of gains achieved and maintained, with termination of formal treatment when treatment goals are reached. The Funding Task Force of the North American Congress on Alcohol and Drug Problems also defined a continuum of care that included the following components (roughly corresponding to stages in a treatment episode): (1) outreach, assessment, and referral; (2) crisis management/detoxification; (3) primary treatment and rehabilitation; (4) transitional/aftercare/ extended care; and (5) supportive services (Boche, 1975~. The task force defined its three active treatment components much as they were defined in the original Minnesota model of care: Crisis management is defined as activities associated with addressing an emergent or immediate situation perceived by a client as being threatening to himself or others. This category includes activities generally identified as protective services, subacute detoxification, and acute detoxification. Primary treatment and rehabilitation is defined as a set of intensive activities, of limited duration, designed to provide the person in treatment with a positive substitute or alternative to addiction, dependency and associated behavioral activities. Transitional/aftercare is defined as a set of ongoing supportive activities, including professional and self-help programs, designed to maintain behavioral change. (Boche, 1975:5) In keeping with the perspective of the Uniform Act, the task force asserted that the continuum of care must include supportive services to reduce the patient's personal and social impairments as well as primary treatment activities that focus on changing drinking

WHAT IS TREATMENT? 63 behavior: "Supportive services are services provided to the client as part of ongoing care, either as a direct part of a program or as "ancillary" services arranged for by the program, such as vocational rehabilitation, income maintenance and family counseling (Boche, 1975:5~." The task force saw such services as essential to the effectiveness of treatment offered by specialty programs and to the avoidance of relapse. It therefore sought multiple-source funding for all primary and supportive treatment services (e.g., health insurance for medical care, social services funding for supportive services, categorical grants for noncovered activities). Glaser and colleagues (1978) developed what they called a "practical taxonomy" of treatment programs as a means of organizing their findings from a survey of 80 Pennsylvania alcoholism treatment programs. This taxonomy uses as its major organizing principle the "function" of the principal means of intervention provided by a given treatment program. These investigators defined six unitary functions that alone or in combination were seen to characterize all 80 of the programs surveyed: (1) acute intervention the immediate resolution of an acute physical, social, or psychological emergency; (2) evaluation-the development of an individualized treatment strategy by thorough assessment of the person's clinical and social status; (3) intensive intervention-the application of therapeutic activities to bring the individual to a better level of functioning; (4) stabilization-the consolidation of gains through continued participation in supportive activities in a sheltered living environment; (5) maintenance-the continued provision of some therapeutic input to maintain the gains in functioning achieved through intensive intervention or stabilization (or both); and (6) domiciliary care-the provision of an ongoing supportive, protected living environment for those too disabled by alcohol use to return to independent community living. The analysis of the Pennsylvania programs by the Glaser team ( ~ A m) also invo~v~u an attempt to describe and classify the existing service delivery system. The analysis pointed out that the separate functions were usually embedded in characteristic organizational structures and that the functions represented the possible sequence of movement through a comprehensive treatment system. Each function with its characteristic structure was a component of the system. These six components, which are listed in table 3-1, can be viewed as another way to describe the stages and settings that make up the ~ ~1 mom\ ~1 ~: ~1 AA continuum of care. Blume (1982, 1983, 1985) used a similar model of the treatment episode to organize her recommendations on how to perform and evaluate treatment. She divided the alcoholism treatment episode into four phases (identificationfintervention, detoxification, TABLE 3-1 Stages and Settings of the Contimuum of Care Component Function Acute intervention II Evaluation III Intensive intervention IV Stabilization V Maintenance VI Domiciliary Care Structure Medical or nonmedical detoxification unit Centralized diagnostic center Residential facility; Day program Halfway house Outpatient clinic; AA State hospital; Rescue mission

64 BROADENING ME BASE OF TENT FOR ALCOHOL PROBLEMS rehabilitation, and long-term follow-up) and indicated that the phases must be applied in the appropriate sequence for each individual. She also identified private practice and organized program settings in which each phase could take place, as well as the treatment modalities appropriate to each phase. Blume noted that one of the reasons for negative perceptions in the past regarding the effectiveness of treatment for persons with alcohol problems has been the inappropriate use of selected modalities in a particular phase of treatment. Blume saw these combinations of treatment phase, setting, and modality as useful both for designing an overall treatment delivery system and for treating the individual: Therefore, as an overall treatment system we try to provide appropriate services for different types and stages of alcohol problems in a coordinated continuum. As individual practitioners, we try to motivate patients and their families to use these services, to stick with them, and to return immediately to the appropriate form of treatment in case of relapse (Blume, 1983:174~. In a paper prepared for this committee, Holder and colleagues (1988) reviewed various studies of the effectiveness of individual modalities, placing the modalities within the context of the stage and setting of treatment and considering the cost of each combination. They defined three treatment functions or stages: (1) entry and assessment to determine the next steps in the system; (2) acute care-to stabilize the patient and deal with life threatening conditions; and (3) rehabilitative care-to return the person to a life unhampered by the adverse consequences of alcohol use. These functions are further explained as follows: While the routes used by people to enter treatment are varied there are, in general, common steps. The first function is entry and assessment illustrated by triage. The function could be undertaken in an actual emergency room triage or by admission desk at an alcoholism treatment facility or in a private provider's office. It is possible to consider the triage function undertaken by a case manager or treatment broker who makes decisions on the basis of patient need. Such a case manager could select treatment types and interventions based on patient need, not on a particular program. If the client is neither intoxicated nor has an acute medical problem then he is able to skip detoxification and acute care and move directly into rehabilitative care if desired. If a physical health problem (other than the need to address detoxification exists) than medical care usually in an emergency room or trauma setting is required. Detoxification can occur concurrently with attention to trauma. If detoxification only is required, then except for the stabilization of the patient with medication (for example with librium), detoxification (removal of ethanol from the body) is metabolic and thus a natural process. It can occur in a variety of settings from an acute care hospital to a social model detoxification center. If the patient is not intoxicated then rehabilitative care can begin. (Holder et al., 1988:9-10) Despite the varying language these different proposals use to describe the stages or phases of treatment, they are nevertheless responding to common features of the recovery process, as well as to both research and clinical evidence for inducing and

WHAT IS TREATMENT? 65 maintaining behavior change. The committee's review of the various programs indicated that treatment programs varied in the emphasis they placed on each stage and in the delineation of substages; however, the review also showed more similarity than dissimilarity, suggesting that it is possible to develop a general model that can be used not only for planning and resource allocation and development but also for matching persons to the appropriate treatment. A taxonomy of treatment stages must address both the acute and the chronic care needs of persons with alcohol problems. The stage models developed by Blume (1985) and Glaser and coworkers (1978) appear to come closest to actual practice as manifest in the planning and resource allocation models used by various states. They describe both the active treatment of acute states (detoxification and primary rehabilitation) and the supportive treatment of chronic states (aftercare, long-term follow-up) that are needed when dealing with persons whose psychosocial resources and level of impairments range so widely. Both models also recognize the need for careful assessment to plan the treatment course. In defining the continuum of care and its elements, it is critical to distinguish between those elements that are designed to provide detoxification, rehabilitation, and aftercare or relapse prevention and to acknowledge that in each of these stages the person's clinical status and physical, psychological, and social resources will determine which setting, level of care, and combination of treatment modalities are required. Drawing on the various proposals that have attempted to depict the course of treatment, the committee has used three major stages (acute intervention, rehabilitation, and maintenance) to organize its review of the current status of treatment services and research. The stages incorporate the commonly used activities, stages, and phases that have been identified by other researchers and practitioners: Stage 1: Acute Intervention Emergency treatment the immediate resolution of an acute physical, social, or psychological emergency caused by excessive alcohol use. Detoxification the management of acute alcohol intoxication and withdrawal while in either independent living or in a sheltered living environment; the medical process of taking the affected person safely through the predictable sequence of symptoms that occur when blood alcohol levels drop during withdrawal. Screening the identification, by the person seeking treatment or another individual (whether a family member, supervisor, or law enforcement or medical professional), of the existence of a problem with alcohol, followed by a referral for treatment. Stage 2: Rehabilitation Evaluation and assessment the development of an individualized treatment strategy aimed at eliminating or reducing alcohol consumption by a thorough assessment of the person's physical, psychological, and social status and a determination of the environmental forces that contribute to the drinking behavior. Primary care the application of therapeutic activities to help the individual reduce alcohol consumption and attain a higher level of physical, psychological, and social functioning while in either independent living or in a sheltered living environment. (Primary care includes both brief intervention and intensive intervention.) Extended care (stabilization)-the consolidation of gains achieved in primary care through continued participation in treatment and supportive activities while in either independent living or in a transitional supportive, sheltered living environment.

66 BROADENING TEIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Stage 3: Maintenance Aftercare the continued provision of some therapeutic input to maintain the gains in functioning achieved through intensive intervention and stabilization while in either independent living or in a transitional or long-term supportive, sheltered · . . 1vlng environment. Relapse p~wenfior~ the continued provision of therapeutic activities to avoid the return to prior patterns of drinking and to maintain the gains in functioning achieved through brief intervention or intensive intervention and stabilization while in either independent living or in a transitional or long-term supportive, sheltered · . . 1vlng environment. Domicilialy care-the provision of an ongoing supportive, protected living environment for those too disabled by prior alcohol use to return to independent community living. Follow-up (monitoring and reassessment) the maintenance of ongoing contact with the individual during and after each stage of treatment to determine how effective the treatment has been and to provide the opportunity to revise the treatment plan as necessary (e.g., to change treatment settings or modalities)-is not included as a distinct stage or activity. Follow-up has traditionally been linked with aftercare, but it is a distinct activity, not tied to any of the stages. Because different settings and modalities may be appropriate during the various stages, the committee wishes to stress the importance of including initial assessment at the beginning of each stage and reassessment at the end of each stage (i.e., follow-up). Follow-up will be discussed in more detail in Section III under the rubric "continuity assurance." In the past, when providers and policymakers have spoken about treatment for ~alcoholism," they focused on the totality of efforts required to end ongoing misuse and excessive consumption. "Treatment," however, was considered to be only the short-term activities involved in detoxification, in emergency treatment of alcohol-related physical and psychiatric problems, and in rehabilitation in fixed-length programs; everything else was ~aftercare." This report focuses on the entire treatment episode and attempts to distinguish among the three major stages (acute intervention, rehabilitation, and maintenance) that are necessary to achieve and maintain sustained recovery. The acute intervention stage includes emergency treatment and detoxification, which are likely to be needed by persons with severe alcohol problems. It also includes the screening of individuals in various community settings to detect the presence of alcohol problems. Screening is intended mainly to detect persons with mild or moderate problems, but it will also detect persons with more severe problems who may have escaped notice. Not all individuals with severe alcohol problems will require detoxification as the first phase of the treatment episode; all will require acute intervention, even if it only screening. Rehabilitation describes the efforts involved in helping an individual change his or her drinking behavior. Rehabilitation comprises all activities designed to change directly the pattern of excessive consumption of beverage alcohol and prevent a return to the pattern. The rehabilitation stage may require that an individual learn new coping skills and develop new patterns of living and thinking (Johnson, 1980; Abrams and Niaura, 1987~. It can be further divided into two substages: primary care and extended care or stabilization. Primary care is a period in which the treatment is undertaken to initiate change in an individual's alcohol consumption, to uncover the root causes of the excessive drinking behavior, and to provide positive substitute behaviors. The extent of primary care will vary with the severity of impairment and can be categorized as a brief intervention or an intensive intervention. Extended care in the committee's scheme is defined as a period in which the person is involved in supportive activities to strengthen and consolidate the i

WHAT IS TREATMENT? 67 changes that were initiated during primary care. The primary care period tends to be of limited duration, whereas the extended care or stabilization period can be prolonged. Individuals will vary in the length of time they require for primary care or extended care, in part as a function of the degree of severity of their problem and their level of social competence. Each model of the treatment course that was reviewed earlier has attempted to provide for such substages using a variety of terms and descriptions for the settings in which primary care and extended care take place. Often, the setting and stage of treatment have been combined. Most frequently, there has been confusion between the stage of treatment and the setting for extended care (e.g., halfway house, domiciliary, nursing home). This confusion has resulted in a continuing problem in matching the needs of individuals for extended care with appropriate sources of funding because of the difficulty in specifying which funding source bears the responsibility for providing formal treatment and which is responsible for providing a supportive alcohol-free living environment while in each stage of treatment. This separation of responsibilities appears to have originated in the development of Twelve Step houses and early halfway houses (Booz-Allen and Hamilton, Inc., 1978~. A key element of the committee's proposed taxonomy is to separate the concept of extended care from the concept of residence or living situation and to recognize that, for some persons, extended care on an ambulatory (outpatient) basis is both necessary and possible (Edwards, 1987~. Another goal of the committee's taxonomy is to make a clear distinction between extended care and aftercare. In the committee's proposed scheme, extended care is part of the rehabilitation stage, and aftercare is part of the maintenance stage. Extended care or stabilization differs from what has been called aftercare in that formal contact with the treatment program is maintained while the intensity and frequency of the contacts are gradually reduced as part of an ongoing treatment plan. "Aftercare," on the other hand, has been used to describe the long-term efforts that help the individual maintain the changes made during formal treatment. Exactly what efforts fall under this rubric, however, is sometimes difficult to determine, in part because programs vary in their use of the term and because its meaning has shifted over the years. For example, in an early set of accreditation standards, aftercare was defined as "postdischarge services designed to help a patient maintain and improve on the gains made during treatment" (Joint Commission on the Accreditation of Hospitals, 1983~. Thus, initially, the term was applied to all of the services provided to individuals following discharge from inpatient treatment. Its general intent was to ease the transition between hospital and home and provide continuity of care beyond the inpatient phase of treatment. Such a transition was needed because, in the early days of development of the Minnesota model and of other similar approaches, persons in the majority of inpatient programs experienced an abrupt leap from total immersion in a highly structured, 24-hour _ r ~ ~ 1 alcohol-free milieu to an anercare plan Inal Ellen ~llc;U ~llly lU1 ull~-a-~& "~&,,,' meetings and referral to Alcoholics Anonymous. As with many of the terms used in the alcohol field, however, there was little consensus on what aftercare really was; as a result there has been some confusion among aftercare, the continued formal treatment which is required by many persons (what the committee refers to an extended care), and the ongoing support for avoiding relapse required by most, if not all, persons with alcohol problems. This confusion has been engendered by the idea that "treatments is limited to a 28-day inpatient stay, the primary care treatment duration often found in programs subscribing to the Minnesota model. Aftercare thus came to mean arrangements made for the person discharged from formal treatment for continued informal support from self-help groups, a program alumni group, or informal, nonscheduled contact with the treatment program. Today, however, given the high rate of relapse that was seen following the limited treatment offered by the

68 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS 28-day inpatient stay, the term aftercare has also come to mean continued formal treatment in a nonhospital setting following an initial hospital stay as an inpatient (in the committee's taxonomy, this is "extended cares). For example, Stuckey and Harrison offered the following descriptions: Formal aftercare should be a commitment and extend a minimum of 8 weeks after discharge. Many rehabilitation centers have extensive aftercare up to 2 years after discharge and others have patients return for week-long refresher periods during early sobriety. The debate over the length of formal aftercare revolves around developing an overreliance of the patient on the treatment center. (1982:871) The backbone of true aftercare support, however, is AA There was no epidemic of treatment centers until the AA support network was in place and effective throughout the country. Rehabilitation centers using AA aftercare uniformly report that better than 80% of their clients are not drinking at a point 2 years after treatment. (1982:873) And Filstead (1988a:182) noted, "last a practical matter, employee assistance programs are concerned not only with the intensive phase of treatment, be it outpatient, residential, or hospital based, but also with the aftercare or continuing-care phase that provides the supportive environment following residential intervention." Yet despite the efforts of many in the field, there is still no agreement on what constitutes appropriate aftercare or on the appropriate duration of such services (Vannicelli, 1978; Costello, 1980; Gilbert, 1988~. In addition, there has been a general shift away from viewing the specialized unit in the general hospital or psychiatric hospital as the most appropriate and most cost-effective setting for the long-term effort required to facilitate the significant behavioral changes required. For all psychiatric illnesses as well as for alcohol and drug problems, hospitals and residential treatment centers now tend to be viewed as the appropriate setting for short-term crisis intervention, problem resolution, and stabilization (primary cares); continuing treatment is seen as being more appropriate to less expensive residential or outpatient settings (nextended cares). In the face of continuing ambiguity surrounding the make-up of "aftercare," many in the field of alcohol problems have begun to use the concepts of continuing care, follow-up, and relapse prevention have begun to replace the concept of aftercare. The committee prefers these concepts to that of aftercare, which implies that treatment has ended with discharge from the primary rehabilitation stage in the inpatient setting. In particular, relapse prevention is an area of continuing treatment that is becoming more defined. Relapse prevention is the term now used to describe the more formal activities that are designed to prevent "slips," or "lapses," from leading to full-blown relapses-that is, a return to the individual's pattern of drinking before treatment (Marlatt, 1985; Gorski, 1986; IOM, 1989~. In developing the rationale for his self-managed relapse prevention program, Marlatt (1985) makes a distinction between the methods used to initiate abstinence or moderate use and the methods used to maintain abstinence or moderate use: "Once an alcoholic has stopped drinking, for example, RP [relapse prevention] methods can be applied toward the effective maintenance of abstinence regardless of the methods used to initiate abstinence (e.g., attending AA meetings, aversion therapy, voluntary cessation, or some other means)" (p. 4~. In its taxonomy of treatment, the committee has combined the activities known as relapse prevention, continuing care, and aftercare under the rubric "maintenance" as a more acceptable description of the third major stage of treatment. AR persons whit receive treatment for alcohol problems should be involved in maintenance activities following the

WHAT IS TREATMENT? 69 treatment for alcohol problems should be involved in mair~enar~ce acfivit~es following the completion of the formal treatment activities of the rehabilitation stage. The specific form, content, and duration of the maintenance stage should be determined by the ongoing follow-up reassessment that has been incorporated into the treatment process (see the discussion of outcome monitoring in Chapter 12~. By including an option for continued support in the maintenance stage, the committee's proposed framework recognizes the heterogeneity of alcohol problems and the differing needs of the individuals who experience them. For example, for some severely impaired individuals (e.g., the chronic public inebriate), domiciliary care in a long-term sheltered living environment is required whereas for only mildly impaired individuals, periodic follow-up visits with their physician may be all that is required. There have been relatively few studies of the treatment and recovery process that use such a continuum of stages, despite earlier calls for such research (Vannicelli, 1978; Costello, 1980; IOM, 1980; Costello and Hodde, 1981; Moberg et al., 1982; Moos et al., 1982~. As described in Section III, the committee considers the need for such an organizing scheme and the conduct of studies on the treatment process, through follow-up and reassessment, to be critical for future research and practice. Treatment Settings The term treatment setting is used in several different ways in the literature on the treatment of alcohol problems. Sometimes it is used to describe the organizational location in which treatment is provided (e.g., a health care facility, mental health center, private practitioner's office). Sometimes it is used to describe the underlying treatment philosophy (e.g., social setting detoxification, medical setting detoxification). At still other times it is used to describe a person's living arrangement while in treatment (e.g., inpatient, outpatient; hospital, prison, residential facility, group home, nursing home, day treatment center, halfway house). As noted by the Department of Health and Human Services (DHHS), the most common use of the term in research and program planning for the treatment of alcohol problems has been to describe the environment within which treatment takes place: ... .. Treatment can be delivered in two basic types of settings-inpatient and outpatient-although some settings represent a combination of the two. The major distinction is whether care involves overnight care in a residential facility. Inpatient care involves the provision of medical, social, and other supporting services for patients who require 24-hour supervision. Outpatient care is the provision of nonresidential evaluative and alcohol treatment services on both a scheduled and nonscheduled basis. The choice of treatment setting is related to a variety of factors, including the ability to pay, the severity of alcohol abuse and attendant problems, the ability to leave the home environment to be treated in inpatient settings, and the client's orientation toward help-seeking. The varied inpatient and outpatient settings thus often serve a distinctive client population. (USDHHS, 1986:72) DHHS's recent categorization of two basic treatment settings (inpatient and outpatient) is not fully consistent with prior usage or with the differentiation among settings used by the states in their planning and funding. It is also not fully consistent with the differentiation used by payers in their determination of the level of care that is appropriate for a given procedure (treatment modality) and for an individual's clinical status. For example, inpatient care has generally been further divided into 24-hour

70 BROADENING THE BASE OF lllEATMENT FOR ALCOHOL PROBLEMS treatment and supervision in a hospital and in a freestanding facility such as a halfway house or recovery home (Armor et al., 1978; Research Triangle Institute, 1985~. In contrast to the DHHS structure, the first major national study of treatment for alcohol problems identified three types of settings: inpatient, intermediate, and outpatient (Armor et al., 1978~. These settings were used by NIAAA in its original monitoring system for federally funded alcohol treatment centers, which provided the data for the Armor study. The inpatient care or hospital setting included all facilities that were licensed as general or specialty hospitals. Common features of the hospital setting were the use of the medical model, removal from the environment that supported the excessive drinking, and a highly structured program offering a range of treatment modalities. The intermediate care setting grouped together all residential facilities (primarily halfway houses) that provided transitional living arrangements for severely impaired individuals who were moving from hospital inpatient care to independent living. The common feature of intermediate care facilities included staffing by nonprofessionals whose responsibility was to provide a supportive, alcohol-free communal living milieu; any continuing professional treatment was carried out elsewhere. The Armor team's study also acknowledged the existence of a graded series of nonhospital residential settings (i.e., residential care facilities, quarterway houses, halfway houses) that offered varying intensities of treatment and support. The introduction by NIAAA of the quarterway house concept, however, shifted the definition of the intermediate care setting from a supportive transitional living facility to an active treatment facility that provided primary care similar to that provided in hospital settings (Diesenhaus and Booth, 1977; Armor et al., 1978~. Once this shift occurred, intermediate care settings, many of which were still identified as halfway houses, were seen to be occupying three positions on the treatment continuum: (1) less expensive, social model primary rehabilitation settings (quarterway houses); (2) extended care or transitional living settings (halfway houses) for persons who did not need the level of nursing and medical care associated with hospitals or nursing homes but who required removal from a stressful environment during rehabilitation; and (3) extended care or transitional living settings (residential care) for persons who had completed primary treatment but who were not yet seen as ready to return to their original life situation or for persons who needed to reconstruct a new social reality (O'Briant et al., 1973; Armor et al., 1978~. These new functions were similar to those called for in the Uniform Act's definition of intermediate care. The outpatient care setting delineated by the Armor team included all facilities in which the person did not reside and received one to several hours of treatment per week. These facilities ranged from private practitioners' offices to community social services agencies to hospital outpatient clinics. Like intermediate care settings, outpatient care settings subserved three functions: primary treatment, extended care, and follow-up or aftercare. The definitional difficulties that plague other aspects of the alcohol problems field extend to treatment settings in that the definitions used in national planning and policymaking efforts have not been consistent. This problem is seen in the 1987 National Drug and Alcoholism Treatment Unit Survey (NDATUS) conducted by NIAAA In the 1987 survey the agency uses a different classification scheme to obtain data on treatment settings than that used in earlier surveys. For capturing data on individuals in treatment in its 1987 survey, NIAAA used the categories "Facility Location" and "lype of Care" to describe the treatment setting in which active clients were enrolled (USDDHS, 1987a). The two facility locations on the survey were (1) hospital inpatient and (2) nonhospital. The five types of care listed are (1) inpatient/residential social detoxification, (2) inpatient/residential medical detoxification, (3) inpatient/residential custodial/domiciliary care, (4) inpatient/residential rehabilitation/ recovery care, and (5) outpatient/nonresidential

WHAT IS TREATMENT? 71 rehabilitation/recovery care. In contrast, the 1982 NDATUS used hospital, quarterway house, halfway house, recovery home, other residential facility, outpatient facility, and correctional facility for its facility location classifications. Various states have tried to deal with these inconsistencies by developing their own definitions of treatment setting. For example, in 1978 the Colorado Alcohol and Drug Abuse Division introduced its Treatment Needs Model, which distinguished among four different settings in which the major treatment activity was to take place: (1) outpatient, (2) partial (day) care, (3) residential, and (4) hospital inpatient. Settings were primarily differentiated by (a) the amount of time per day that the individual was to spend in either treatment activities or under observation and control (restriction) by clinical staff (i.e., part time, which was indicated for outpatient and day-care settings, or full time, which was indicated for residential and inpatient facilities and (b) the relationship of the setting to a hospital. Hospital-based programs were to be used for patients whose conditions required a greater amount of nursing and medical care; they were differentiated from residential programs in terms of licensing requirements for physical structure, patient safety, staffing composition and ratios, and nature of medical control and supervision (Colorado Alcohol and Drug Abuse Division, 1978~. In medical care the term treatment setting has been most often used to describe the individual's status in treatment or enrollment in a particular level of care: hospital (inpatient care), nursing home (intermediate care), or outpatient clinic (ambulatory care). Both the halfway house and nursing home designations imply a convalescent as opposed to an active treatment role; however, in the treatment of alcohol problems, as in the treatment of psychiatric disabilities, persons who require noncomplicated detoxification or rehabilitation are ambulatory and do not need the full services of a hospital. Consequently, in recent years the field has seen the development and acceptance of the nonhospital, freestanding facility for providing residential detoxification and rehabilitation services as well as convalescent, supportive, and custodial services. The issue of medical control and supervision of the treatment process and of the setting in which the treatment takes place has been a critical factor in attempting to reconcile the dilemmas posed by the different requirements of the funding available for patients (Holder, 1987; Reynolds, 1988a,b). Health insurance mechanisms, whether public or private, require medical control; community services funds do not (Booz-Allen and Hamilton Tnc.. 19781. To broaden the extent and range of reimbursement for treatment, .' . . ~ .~ VIA 4~ ... lo_ +~;~h..~^nt Of a number of states have introduced new licensing standards lo HllOW 1Or [~llUUUl~111~llt At detoxification and rehabilitation services provided to ambulatory patients in nonhospital settings (DenHartog, 1982; Diesenhaus, 1982; Lawrence Johnson and Associates, Inc., 1983~. For example, Colorado developed its nonhospital community intensive residential treatment program licensure category for public- and private-sector programs (mixed medical-social setting models) as well as program standards for alcohol detoxification and rehabilitation units in licensed hospitals (medical model). Oregon adopted a similar program licensure category. Similar concerns about capturing third-party payer funds led California to develop its chemical dependency rehabilitation hospital licensure category for private-sector programs (modified medical model) and recovery home standards for public-sector programs (social model). In an attempt to develop a single national framework, NIAAA sponsored a project to develop guidelines for the classification of the essential characteristics of treatment settings in which services were provided (Chatham, 1984~. A major impetus for this effort was the desire to provide legitimization of reimbursement for treatment of alcohol problems by private and public health insurers in both the expanded traditional and the new nontraditional settings that had developed as a result of NIAAA's categorical grant programs (see Chapter 18~. There were also other reasons for developing such a classification: (1) to provide a common definition of treatment settings for information and

72 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS evaluation reporting systems; (2) to provide guidelines for state alcoholism authorities to use in their licensure activities; (3) to familiarize the general health planning community with the type and character of settings in which alcoholism services were provided; and (4) to acquaint the general public with the types of resources that might be available in their communities (Bast, 1984~. The classification system was modeled after the American Hospital Association's Classification of Health Care Institutions (American Hospital Association, 1974~. There has not been widespread adoption or use of the framework, however; thus, it does not appear to be serving the purposes for which it was intended. Nevertheless, in the review of treatment cost-effectiveness prepared for the committee by Holder and colleagues (1988:10), this framework was used as part of the basis for definitions of the general types of settings in which rehabilitative care can take place. These definitions are summarized below. Ir~patiem The provision of medical services and supportive services induding board, laundry, and housekeeping for patients who require 24-hour supervision in a hospital or other suitably equipped and licensed medical facility for the treatment of alcohol problems and other problems related to alcohol use. Residential The provision of 24-hour care or support, or both, for individuals who live on the premises of the program. Intermediate The provision of care or support, or both, in a partial (less than 24-hour) treatment or recovery setting for individuals who need more intensive care, treatment, and support than are available through outpatient settings or who can benefit from supportive social arrangements during the day. Outpatient The provision of nonresidential evaluative and treatment services on both a scheduled and nonscheduled basis. These definitions for rehabilitative care are quite similar to those used by several of the states. The definitions include the differentiation between the requirements of treatment in a hospital and in a freestanding facility. They also include, as the intermediate care setting, the partial care or day-care option that has become increasingly important in obtaining appropriate level of care placement. Although Holder and his colleagues note that acute care (detoxification) can also take place in a variety of settings, they do not attempt a similar differentiation of the settings in which rehabilitation can take place. He committee considers it possible to carry out any of the stages of treatment for alcohol problems in any of the settings, should the ir~dividual's clinical status merit that placement. There was similar recognition of the independence of the setting in which treatment took place and the treatment process itself in all the other models that were reviewed earlier (Glaser et al., 1978; Blume, 1983; Pattison, 1985~. In addition, the Funding Task Force of the North American Congress of Alcohol and Drug Problems clearly stated that all three stages or active treatment elements could take place in either a hospital, nonhospital, or nonresidential setting (Boche, 1975~. The various proposals suggest important commonalities that must be considered in developing a general framework for classifying treatment settings. The committee has chosen to use the same four categories proposed by Holder and colleagues (1988), with slightly modified definitions. These categories in turn define the levels of care, which the committee employs as its framework for describing the continuum of care: Irlpatient The provision of treatment for alcohol problems, comprising, as needed, medical services, nursing services, counseling, supportive services, board, laundry,

WHAT IS TREATMENT? 73 and housekeeping for persons who require 24-hour supervision in a hospital or other suitably equipped and licensed medical setting. Residential The provision of treatment for alcohol problems, comprising, as needed, medical services, nursing services, counseling, supportive services, board, laundry, and housekeeping for persons who require 24-hour supervision in a freestanding residential facility or other suitably equipped and licensed specialty setting. I~ermedi~e The provision of treatment for alcohol problems, comprising, as needed, medical services, nursing services, counseling, supportive services, board, laundry, and housekeeping for persons who require care or support, or both, in a partial (less than 24-hour) treatment or recovery setting. Such persons generally will be those who need more intensive care, treatment, and support than are available through outpatient settings or who can benefit from supportive social arrangements during the day in a suitably equipped and licensed specialty setting. Ouipat~em The provision of treatment for alcohol problems, comprising, as needed, medical services, nursing services, counseling, and supportive services for persons who can benefit from treatment available through ambulatory care settings while maintaining themselves in their usual living arrangements. Treatment Modalities The content of treatment is usually referred to as the technique, method, procedure, or modality. The specific activities that are used to relieve symptoms or to induce behavior change are referred to as modalities. Treatment modalities are additional elements of the continuum of care that are implemented within each of the philosophies, stages, and settings that have already been described. Many treatment modalities have been used to address alcohol problems, alone or in combination, including advice, psychotherapy, self-help groups, aversive counterconditioning, antianxiety medication, self-control training, stress management, massage therapy, antidipsotropic medication, physical exercise, vocational counseling, marital and family therapy, hypnosis, education about the effects of alcohol, milieu management, and social skills training. The committee has used three general categories-(1) pharmacological, (2) psychological, and (3) behavioral in the paragraphs below to organize its description of the variety of treatment modalities. More critical review of the effectiveness of the modalities appears in Appendix B. Pharmacological Treatment Modalities There have been a number of attempts to classify the different drugs used in the treatment of alcohol problems. The major distinctions have been in terms of (a) drugs used to counter or antagonize the acute effects of alcohol intoxication, (b) drugs used in the management of withdrawal (detoxification), and (c) drugs used in long-term treatment (rehabilitation and relapse prevention). Drugs used to manage intoxication At present there is no known compound that can counteract or antagonize the acute effects of alcohol intoxication. Such a drug would be useful in a variety of situations frequently encountered in hospital emergency rooms, ranging from the treatment of serious, life-threatening overdoses in comatose admissions to the calming of combative public inebriates (Noble, 1984; Jaffe and Ciraulo, 1985~. Previously, research has focused on finding a single all-purpose drug that could reverse alcohol-induced respiratory depression, reduce alcohol-induced cognitive and motor impairments, and lessen the subjective state of intoxication (Liskow and Goodwin, 1987~. There has been little success to date, but some agents appear promising, notably, zimelidine, ibuprofen, lithium, and the narcotic antagonist nalaxone.

74 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Drugs used to manage withdrawal Most persons who become intoxicated experience a mild form of withdrawal, which is usually self-limited. In mild withdrawal a person may experience irritability, anxiety, tremor of the hands, sweating, rapid heart beat, nausea, vomiting, diarrhea, and sleep disturbance. The onset of these withdrawal symptoms is within hours of the last drink. The peak experience of these symptoms comes one or two days after the cessation of drinking; most symptoms gradually disappear after three to seven days. A small percentage of persons will experience more severe withdrawal symptoms, with an estimated 1 to 3 percent experiencing seizures or delirium tremens (DTs), or both. DTs are characterized by profound confusion and disorientation, hyperactivity, and hallucinations. The onset of DTs typically occurs on the second or third day after drinking has stopped; DTs typically peak on the fourth day and gradually subside over another three to five days (Femino and Lewis, 1982; Jaffe and Ciraulo, 1985~. Seizures generally occur within the first 24 hours. The severity of the withdrawal syndrome varies greatly among individuals and is generally proportional to the duration of the preceding period of alcohol consumption, although other factors are involved in determining severity. Persons who have experienced withdrawal symptoms in the past are more likely to experience severe withdrawal than are persons who have not experienced such symptoms; in general, severity increases each time withdrawal occurs (Jaffe and Ciraulo, 1985~. In addition, other concurrent physical illnesses (e.g., trauma, pneumonia, gastritis) can increase the severity of withdrawal. Benzodiazepines, the most commonly prescribed antianxiety drugs, are considered the drugs of choice in the pharmacological management of alcohol withdrawal (Noble, 1984; Jaffe and Ciraulo, 1985; Liskow and Goodwin, 1987; Cushman, 1988~. These drugs are chosen in part because of the cross-tolerance between alcohol and the benzodiazepines (e.g., chloridiazepoxide, diazepam, fluorazepam, and orazepam). Two distinct approaches to detoxification have developed, which reflect different treatment orientations rather than the selective placement of individuals based on their clinical status and a knowledge of the effectiveness of various treatment modalities. The first approach, pharmacologically assisted detoxification, is identified with the medical model and is referred to as medical detoxification. The second approach is identified with the sociocultural model and is referred to either as nonmedical detoxification or social model detoxification. Currently, these are seen as rival rather than as complementary approaches (Klerman, 1989~. Although it has long been recognized that careful nursing, counseling, and supportive care alone can reduce the severity of withdrawal, advocates of the medical model continue to urge the use of drugs and other physical procedures to help control the withdrawal process (Whitfield et al., 1978; Jaffe and Ciraulo, 1985~. Their concern has been to have qualified medical care in an inpatient setting available to ensure the safety and comfort of the person should severe withdrawal develop. However, recent studies have used random assignment to demonstrate that pharmacologically assisted withdrawal can be safely carried out in an ambulatory setting (Alterman et al., 1988; Hayashida et al., 1989~. Medical detoxification also involves the use of other Physical procedures" in the treatment of withdrawal. Standard practice is to prescribe thiamine on admission and the use of multivitamins, given daily either orally or by injection (Jaffe and Ciraulo, 1985~. Social setting detoxification uses behavioral and environmental techniques (e.g., reassurance and reality orientation) to achieve the same ends. Although there is no single instrument in general use to predict the severity of withdrawal, there are several scales that have been employed in order to determine which orientation and which setting or level of care is necessary for a given individual. For example, the Selective Severity Assessment Scale has been suggested as promising (DenHartog, 1982~. The Clinical Institute Withdrawal Assessment for Alcohol is another

WHAT IS TREATMENT? 75 scale which has been used to measure symptoms of withdrawal and to monitor the severity of the withdrawal syndrome (e.g., Sellers and Naranjo, 1985~. Such scales could be helpful in placement decisions if all levels of care and both types of treatment orientation (medical and sociocultural) were available in each community. Drugs used during rehabilimior' and maintenance A wide variety of drugs has been used in the long-term treatment of alcohol problems. Although there are limited clinical data to demonstrate that any of the drug therapies are effective in preventing a return to drinking, drugs continue to be used for certain persons in certain situations, and research continues to pursue pharmacological agents that can be used to decrease the appetite to drink. Several categories of such drugs are discussed in the following paragraphs. Disulfiram (Antabuse) is described as the most commonly prescribed drug for the treatment of alcohol problems (Saxe et al., 1983; Schuckit, 1985~. The agent is identified as an alcohol-sensitizir~g drug, which is a medication that precipitates unpleasant symptoms if the person drinks. Disulfiram is the only such drug in regular use in the United States, although calcium carbide is used in Canada and Europe. Calcium carbide is a shorter acting drug of this kind and could be used as a complement to disulfiram in certain cases; however, it has not been approved for use in the United States. Another alcohol- sensitizing drug, metronidazole, has also been tried and discarded, primarily because of its side effects. Disulfiram was introduced as a pharmacological treatment for chronic alcoholism in 1948 with much enthusiasm, following the serendipitous discovery of its action by two researchers who became ill at a cocktail party. The disulfiram-ethanol reaction (DER) results from the blocking of the complete oxidation of alcohol to acetate, producing an accumulation of acetaldehyde. Disulfiram inhibits the enzyme aldehyde dehydrogenase, thereby causing a toxic reaction that consists of marked vasodilation and hypotension. The DER involves an initial sensation of heat and a bright red flushing; there is coughing and labored breathing. Nausea is common, and vomiting may occur if a large amount of alcohol has been consumed. There is also a painful feeling of apprehension. Initially, when the drug was introduced, the person was given a demonstration of the DER, but this practice was dropped in favor of an explanation and description of the results if the person were to drink while taking disulfiram. A DER can be experienced two to three days after discontinuation of the medication. In certain cases, a DER can occur up to two weeks after discontinuation. Standard practice is a starting dose of 500 mg daily for one to two weeks, and a maintenance dose of 250 mg daily. The medication is usually taken in the morning but may sometimes be taken at night if a sedative effect is present. Disulfiram is usually continued until the person has shown substantial personal, social, and vocational improvement; maintenance or relapse prevention may be required for years. When it was first introduced, disulfiram was routinely prescribed in many treatment programs to all persons who were admitted as part of the standard rehabilitation protocol. Because of its side effects and the potential of dangerous DERs in some individuals, questions about its relative effectiveness and safety have led to recommendations for its more selective use as an adjunct to other treatment modalities (Kwentus and Major, 1979; Noble, 1984; Schuckit, 1985; Forrest, 1985; Jaffe and Ciraulo, 1985; Liskow and Goodwin, 1987; Sellers, 1988~. The effective use of disulfiram requires a cooperative individual who will comply with the treatment regimen, taking the prescribed dose consistently. Because of this requirement, there has been research to determine whether an implant can be used; thus far, such efforts have not been successful, and compliance is achieved through monitoring (the ingestion of the medication observed by treatment personnel or a family member, checked by self-report in a weekly follow-up session, or investigated through urine testing). Various theories have been advanced for the action of disulfiram in preventing

76 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS relapse, but a general consensus has not yet developed. The use of disulfiram appears to be most successful for those individuals who have decided to abstain and who need an external aid in carrying out this decision. Fuller and colleagues (1986) recently reported the results of a controlled, blinded multicenter study of the effectiveness of disulfiram treatment as it is used in clinical practice: in combination with counseling and given to patients to take at home (rather than ingested daily in the presence of a monitor). Male subjects were randomly assigned to one of three conditions: (1) counseling plus a daily 250 mg dose of disulfiram (the standard regimen in which the subject is exposed to both pharmacological action of disulfiram and the pharmacological threat of DER); (2) counseling plus a daily 1 mg dose of disulfiram (a placebo regimen to control for the pharmacological action of disulfiram while the subject is exposed to the psychological threat of DER); and (3) counseling plus a daily 50 mg dose of riboflavin (a regimen in which the subject is exposed to counseling while controlling for the psychological threat of DER as well as the pharmacological action of disulfiram). Fuller and coworkers (1986) did not find that disulfiram as it is customarily used with outpatients was any more effective than counseling alone in achieving continuous abstinence. Their results, as those of previous studies, did suggest that disulfiram may be useful for older, more socially stable men who have a history of relapses. The results also highlight the need to investigate in more detail the factors associated with compliance: these researchers found that those men who did comply with the prescribed treatment regimen in all three conditions were more likely to remain abstinent than those who did not comply. Another class of drugs, psychotropic medications, are also used in rehabilitation and relapse prevention and can be said to decrease drinking by improving associated psychopathology (i.e., anxiety, depression) (Noble, 1984; Jaffe and Ciraulo, 1985; Meyer, 1986; Liskow and Goodwin, 1987~. The current use of psychoactive medications to decrease anxiety or depression in persons with alcohol problems recognizes the heterogeneity that exists. Clinicians seek to identify those persons for whom excessive drinking is clearly associated with anxiety or depression and to find an appropriate drug that will decrease the target symptom (Jaffe and Ciraulo, 1985~. For example, araidepressara drugs have been extensively prescribed for persons with alcohol problems because depression is so often seen in the immediate postwithdrawal phase. The original justification for prescribing antidepressant drugs was based on clinical studies that showed that persons with severe alcohol problems were frequently depressed and that their depressions were similar to those seen in persons with primary affective disorders. The assumption was that the depression caused the excessive drinking and that eliminating the depression would eliminate the drinking. Critics contended that the depression was the consequence and not the cause of the excessive drinking and that when the drinking ended, the depression would lift. In many individuals, such depression clears without pharmacological intervention (Liskow and Goodwin, 1987~. Current practice is to recommend the use of antidepressant drugs only if a major depression is found to coexist with the chronic alcohol problem after a reasonable evaluation period of at least three weeks following detoxification (Gallant, 1987; Nace, 1987~. Tricyclic antidepressants (TCAs) are a family of drugs that show a high level of effectiveness in relieving symptoms of depression. Studies are continuing on three of the TCAs that have been used to treat persons with alcohol problems (amitrytyline, imipramine, and doxepin). These medications are sometimes recommended as treatments for persons who are assessed as having a severe depression that preceded their alcohol problems or who manifest persistent depression after the postdetoxification clearance period (Jaffe and Ciraulo, 1985; Liskow and Goodwin, 1987~. A critical factor in the use of TCAs is to ensure that an adequate dose has been prescribed and that there is compliance with the regimen. Earlier studies have been criticized for using therapeutically inadequate doses; Liskow and Goodwin (1987) suggest that, to be effective, TCAs should be given in higher

wHAr IS lllEATMENI? 77 doses than those used for depressed persons without alcohol problems. Monoamine oxidase inhibitors (MAOIs) constitute the second group of antidepressant drugs that have been used with some success to treat persons with both depressive and anxiety symptoms. There is less evidence regarding their effectiveness in persons with alcohol problems (Jaffe and Ciraulo, 1985~. Another drug, lithium, is the third major antidepressant that has been employed. Its original use was based on clinical experience and the etiologic theory that the underlying problem in difficulties with alcohol was a lack of impulse control similar to that found in hypomanic states. It has been used both experimentally and clinically to treat depression in persons with alcohol problems. Lithium is used to treat bipolar conditions (where there are mood swings between manic and depressed states) rather than unipolar depression (Gallant, 1987~; however, its AA ~ _ _ _ _ . _ _ ~ ~ ~~ ~ ~ trial (Dorus et al., 1989) found no difference in outcome for males with alcohol problems, with or without depression, who received lithium or an inactive placebo. As with the antidepressant drugs, experienced clinicians now recommend that amiamae~ drugs (anxiolytic agents) be administered to that subgroup of persons with alcohol problems who have a comorbid diagnosable anxiety disorder (Meyer, 1986~. The judicious prescription of antianxiety agents, primarily the benzodiazepines, is also recommended for persons who continue to experience anxiety symptoms (e.g., insomnia, nightmares, palpitations) in the immediate postwithdrawal phase, which can last for three weeks to six months (Jaffe and Ciraulo, 1985; Meyer, 1986; Gallant, 1987; Liskow and Goodwin, 1987~. One of the rationales for the use of antianxiety drugs is that they improve retention in ongoing treatment and relapse prevention efforts. Yet there has been a great deal of controversy regarding their use in long-term rehabilitation and relapse prevention because of their own dependence-producing properties (Jaffe and Ciraulo, 1985; Meyer, 1986; Gallant, 1987~. Newer anxiolytic agents that apparently do not produce dependence are currently under investigation; these agents include beta blockers, propranalol, and buspirone. In the search for a tranquilizing drug to be used in rehabilitation, the criteria have been (a) low abuse potential; (b) effectiveness in maintaining individuals in treatment; and (c) lack of potentiation (augmentation) of the effects of alcohol. Buspirone is one of a new class of anxiolytic agents that do not have sedative effects; it does not appear to create physical dependence or to potentiate the effects of alcohol. More studies are required to determine whether it can fulfill its early promise and whether it is truly nonaddictive. Drugs used to attenuate drinking behavior Much of the current research on pharmacological agents is focused on finding a drug that will directly reduce the desire or craving for alcohol. The physiological model, understandably, considers craving to be primarily physiological, although environmental and social cues are also seen as contributors to the inability of an individual to abstain from drinking and his or her vulnerability to relapse in given situations (Meyer, 1986; Liskow and Goodwin, 1987~. Each of the psychotropic medications, which are now reserved for treatment of so-called "dual-diagnosis patients-those individuals with alcohol problems and a concomitant psychiatric condition has been used and studied as much for its effectiveness in decreasing the desire to drink as for its effectiveness in reducing the associated anxiety or depressive symptoms (see Chapter 16~. Lithium in particular is regarded with interest because several studies have shown that lithium may block the euphoria felt when drinking and reduce the desire to drink (Judd et al., 1977; Noble, 1984; Liskow and Goodwin, 1987; Sellers, 1988~. More recently, interest has focused on those drugs-dopamine, serotonin, and gamma aminobutyric acid (GABA)-that affect the neurotransmitters that are assumed to play a role in the effects of alcohol on the central nervous system. The antidepressant serotonin uptake inhibitors (e.g., femeldine, fluoxetine, fluovramine) have been shown in preliminary studies to decrease alcohol consumption. The relevance of such drugs to effectiveness has not yet been demonstrated in controlled trials. A recent clinical , _ _ _ . .

78 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS treatment, however, remains uncertain until more extensive clinical trials are carried out (Liskow and Goodwin, 1987; Sellers, 1988~. Similarly, positive results of preliminary studies with bromocriptine and apomorphine (dopamine antagonists) and homotaurine (a GABA receptor antagonist) require follow-up (Liskow and Goodwin, 1987~. Psychological Treatment Modalities There is, as noted at the beginning of this section, a wide variety of psychological treatments, both behavioral and psychodynamic, that have been used in the treatment of alcohol problems. Sometimes it is difficult to determine whether a specific approach is primarily behavioral or psychodynamic. Group therapy and marital and family therapy, for example, cannot truly be classified as either psychodynamic or behavioral because they are used by practitioners from each orientation. In fact, current practice is to combine different modalities and orientations to fashion multimodal treatment approaches. There are, however, certain specific modalities that for descriptive purposes are identified with one or the other model because of the rationale for their use and effect. Behavioral tmatmer~ modalities The first clinical use of techniques derived from learning theory to reduce alcohol consumption was by the Soviet physician Kantorovich more than 50 years ago. Kantorovich used electrical aversion, but the method was shown to be ineffective, and its use as a clinical procedure discontinued (Wilson et al., 1975; Nathan, 1984~. The major continuing use of behavioral methods over the intervening years was as chemical aversion, a technique initiated at the Shadel Sanatorium in Seattle (Lemere and Vogetlin, 1950~. The more widespread application of behavioral methods to a range of psychopathological disorders began in the early 1960s (Nathan, 1984~. These initial efforts reflected a comparatively simple view of the etiology of problem drinking as an attempt to reduce conditioned anxiety. The first, unidimensional learning theories about the cause of excessive drinking were primarily derived from animal laboratory studies (e.g., Conger, 1951, 1956) and clinical observations that alcohol eased high levels of anxiety in persons under treatment for alcohol problems. However, behavioral research with humans challenged the view that conditioned anxiety was the sole cause of excessive drinking (e.g., Nathan and O'Brien, 1971; Mello, 1972; Okulitch and Marlatt, 1972) and suggested that cognitive elements must also be considered. Indeed, contemporary behavioral theories see learning as occurring within a context that comprises sociocultural, genetic, and physiological etiologic factors. The newer conceptualizations of etiology that have been derived from social learning theory view problem drinking as multiply determined; equal attention must be paid to the determinants of drinking behavior and to the consequences of drinking because these consequences maintain the behavior (Marlatt and Donovan, 1982~. Behavior therapy for persons with alcohol problems starts with a detailed, comprehensive behavioral assessment that includes five critical elements (Nathan, 1984~: 4. 1. the target behavior itself its frequency, intensity, and pattern; 2. the antecedent events-the "setting" events for the individual's maladaptive behavior; the maintaining stimuli- the environmental factors that reinforce the target behaviors; the reinforcement hierarchy the range of factors in the environment that reinforce both target and nontarget behaviors; and the potential for remediation in the environment. Behavior therapies have sometimes been controversial because they have been associated with challenges to the premise that total abstinence should be the goal of treatment (e.g., Miller and Caddy, 1977; Sobell and Sobell, 1973, 1986/1987; Pendery et al., 1982~. The current expression of this position is that for some moderately impaired

WHAT IS TREATMENT? 79 persons, a goal of reduced consumption can be useful, whereas for more severely impaired persons a goal of abstinence is required (Nathan and McCrady, 1986; Sanchez-Craig and Wilkinson, 1986/1987; Skinner, 1985, 1988~. At present, this conclusion is based more on ideology than on scientific evidence. Nathan (1984) has classified behavioral treatments as (a) those using a single procedure that focuses on abusive drinking, (b) those focusing on antecedents and consequences, and (c) those using a broad spectrum approach, that is, a combination of specific procedures either simultaneously or sequentially. Some examples of specific procedures are presented below, although this discussion is by no means comprehensive or exhaustive. Chemical aversion remains the best-known behavioral treatment procedure that focuses on drinking behavior (Wilson, 1987~. In chemical aversion as currently practiced, a noxious stimulus (nausea induced by oral ingestion or intramuscular injection, or both, of an emetic drug) is paired with a drink of the person's favorite alcoholic beverage. Vomiting is induced to condition the individual to react adversely to the sight, smell, or taste of alcohol. Five aversion treatments are generally administered on alternate days during a 10- to 15-day hospitalization. Some persons develop adequate aversion in fewer than five treatments; others require additional treatments. Because aversion does not generalize to all alcoholic beverages, the individual receives a number of different beverages at some time during the treatment. Covert sensitization is a verbal aversion therapy (Cautela, 1977) that uses the person's imagination to repeatedly pair unpleasant, often nausea provoking events with the anticipated acts involved in drinking. The person visualizes the drinking sequence-ordering of a drink, touching the glass to the lips, drinking itself-all in his or her usual drinking environments. At the moment the person brings the glass to his lips, he is instructed to imagine an aversive stimulus, usually vomiting. He is asked to imagine that relief occurs when he turns away from the drink. Treatment involves repeated sessions (20 presentations per session over 6 to 12 months) with the person practicing twice a day and using the procedure whenever he or she feels the urge to drink. Stress management training has also been found to help persons with alcohol problems in staying sober, particularly when anxiety is a significant concomitant problem (Miller and Hester, 1986~. Biofeedback is one such technique. It uses an electronic apparatus to monitor physiological responses and to display them to the individual through visual or auditory feedback. The individual is trained to produce the feedback by practicing the desired response (usually the relaxation of muscle groups or meditation). The person learns to recognize the subjective states that indicate heightened muscle tension as measured in electromyographic (EMG) biofeedback or alpha waves as measured by the electroencephalograph (EEG). Subjects practice producing the desired response, using the visual or auditory feedback as cues and reinforcers. Biofeedback training has been found to contribute to reductions in drinking but only for individuals with high levels of anxiety. Other forms of stress management training that have been used in the treatment of alcohol problems have been progressive relaxation training, meditation, systematic desensitization, and exercise. A variety of behavioral social skills training procedures has been developed by those who believe that excessive drinking is caused by the inability to perform to one's own satisfaction in interpersonal situations (Oei and Jackson, 1980, 1982~. Individuals are taught in either group or social settings how to respond in typical social encounters; sessions focus on such specific skills as how to express and receive positive and negative feelings, how to initiate contact, and how to reply to criticism. The modeling of skills, role playing, and videotapes of role-playing situations are all techniques that have been used in this type of behavioral approach.

80 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Contingency management, another behavioral technique, attempts to formalize, through contracts, the naturally occurring contingencies, both positive and negative, reinforcing and punishing, that result from excessive drinking. This approach involves identifying the target behavior to be changed (i.e., drinking), identifying an appropriate reward or punishment to be administered for continued performance of the behavior to be changed, and dispensing rewarding or punishing events or activities contingent on a predetermined level of performance of the target behavior. The keys to developing effective contingency management are to (a) identify, through assessment, consequences that are meaningful to the person; (b) develop mutual agreement about the contingency, and (c) carefully and consistently carry out the contingency with all parties to the agreement (e.g., spouse, employer) performing their designated roles. Community reinforcement counseling is a contingency management approach that is designed to provide focused behavioral training to persons with chronic alcohol problems. The goal of the counseling is to improve longstanding vocational, interpersonal, and familial problems (Hunt and Azrin, 1973; Azrin et al., 1982; Nathan and Niaura, 1985; IOM 1989~. The reinforcers used in these studies were access to family, to jobs, and to friends, which were contingent on sobriety. Community reinforcement counseling is a broad-spectrum treatment strategy that includes the use of disulfiram; a regular reporting system to provide counselors with feedback from friends, family, and employers on the individual's drinking behavior or other problems; a source of continuing social support through a neighborhood Buddy, or peer advisor; and ongoing group counseling. In the 1980s new treatment procedures have been introduced that may be broadly described as relapse prevention strategies. These include Marlatt's cognitive-behavioral strategies (Marlatt and Gordon, 1985), Annis's (1986) self-efficacy approach, and Littman's (1986) "survivals model. The three models overlap, all relying heavily on cognitive therapy techniques to avert posttreatment relapse. In recent years, relapse prevention strategies have been widely publicized, and training has been offered to practitioners (Gorski and Miller, 1982; Gorski, 1986~. The addition of relapse prevention procedures to a treatment program is intended to reduce the probability and rapidity of relapse, although the techniques can be used for primary rehabilitation as well as relapse prevention. Annis's self-efficacy approach, a behavioral treatment strategy derived from Bandura's (1982, 1985) social learning theory of self-efficacy, is described below as an example of these techniques. The self-efficacy treatment strategy uses careful assessment of the situations in which the person drank heavily during the past year to determine which contexts present a high risk of return to excessive drinking. The approach also involves careful assessment of the person's confidence in his or her ability to handle conflictual or stressful situations without resorting to heavy drinking. The key assumption underlying this strategy is that it is not the drinking alone that leads to a return to chronic, excessive drinking; also of importance are the meaning of the act of drinking for the person, the alternative behaviors that the person has available for coping with the stressful drinking situation, and the strength of the individual's belief in his or her ability to handle the situation effectively without resorting to drinking. Treatment consists of developing a hierarchical series of performance-based homework assignments that the person can perform successfully, thereby experiencing a sense of mastery in what were formerly seen as problematic drinking situations. The therapist monitors the person's feelings of self-eff~cacy as each assignment is completed. A variety of techniques can be used, including rehearsal of the activity during the therapy sessions and joint performance of the task with a responsible friend or the therapist. During the treatment process, the person may also use an alcohol-sensitizing drug as additional protection (Annie and Davis, 1988~. Behavioral self-control training is another relapse prevention strategy that uses a set of self-management procedures designed to help individuals stop or reduce alcohol consumption (Sanchez-Craig and Wilkinson, 1986/1987; Sanchez-Craig et al., 1987;

WHAT IS TREATMEN17 81 Sanchez-Craig, 1988~. Treatment using this modality involves self-observation of drinking behavior through self-monitoring and the setting of specific behavioral objectives based on an analysis of the functions served by drinking (roughly categorized as drinking to cope and drinking for pleasure). The self-monitoring of drinking behavior through the use of structured record keeping provides information both about the functions of drinking and situations of high risk. Self-monitoring also provides feedback about progress. For persons who use drinking for coping, treatment involves the establishment of alternative cognitive and behavioral responses. For persons who use drinking for pleasure, treatment involves the establishment of self-control skills to avoid intoxication and the development of alternative recreational skills. Reactivity to alcohol stimuli has been found to be predictive of relapse. A plausible but still experimental relapse prevention strategy is cue exposure, in which the goal is to diminish a drinker's responsivity to cues that may precipitate the desire to drink or relapse. Empirical support for the cue exposure approach is currently limited to case reports (Blakey and Baker, 1980) and evidence that cue exposure decreases the subjective desire to drink and reduces the individual's perceived difficulty of resisting relapse (Rankin et al., 1983~. Cue therapy consists of a series of treatment sessions in which the person is presented with the sight and smell of alcohol but consumption is strictly forbidden after the person has imagined himself in a high risk situation for drinking (e.g., having a fight with their spouse or attending a fraternity party). The person and therapist then review the feelings aroused by the alcohol and may practice responses that can lead to refusing a drink. Cue therapy is based on extinction theory: the cues lose their arousal value through repeated exposure without reinforcement. Psychodynamic modalities A simple yet helpful definition of psychotherapy is that it is "an interpersonal process designed to bring about modifications of feelings, [thoughts], attitudes, and behaviors which have proven troublesome to the person seeking help from a trained professional" (Strupp, 1978:3~. Contemporary psychotherapy is characterized by a variety of theoretical orientations (e.g., psychoanalytic, Gestalt, cognitive, rational-emotive). Very often the psychotherapy offered to a person with alcohol problems reflects the orientation and training of the therapist; there have been no real comparisons of the effectiveness of the different theoretical varieties of psychotherapy in treating persons with alcohol problems. What has emerged, however, is a set of principles or techniques that are recommended for use with persons experiencing alcohol problems (Zimberg et al., 1985; Nace, 1987~. As with the other modalities described, current practice is to include psychotherapy as a component in a multimodality approach. Psychotherapeutic principles are often embodied in the overall design of these multicomponent programs. Psychotherapy also varies in the format through which it is delivered: it can be offered in individual sessions, in groups of unrelated persons, and in groups of family members. In addition, types of psychotherapy vary in duration-the number of sessions and the period of time over which those sessions are spaced. Durations have ranged from short term (12 or fewer sessions) to long-term (up to 7 years) (Saxe et al., 1983~. There does not appear to be substantial evidence supporting the greater effectiveness of longer periods of time in the few studies that have considered this variable (IOM, 1989~. The various formats are discussed in the paragraphs below. In recent years individual dynamic psychotherapy has not been seen as a major contributor to the treatment of persons with alcohol problems. The lack of support for use of this approach comes from a history of failure in the use of psychoanalytically oriented methods, which viewed problem drinking as a symptom of underlying pathology and sought to resolve the underlying conflict through the use of interpretations and development of insight (Zimberg, 1985; Nace, 1987~. There are those, however, who feel that individual psychotherapy or counseling continues to play an important role in the treatment of

82 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS alcohol problems (Zimberg et al., 1985; Johnson, 1986~. Most psychotherapists and counselors focus on contemporary life problems and the drinking behavior rather than on historical, developmental issues. Supportive rather than uncovering therapy is the primary mode. Specific variations of the approach have developed based on clinical experience (Blume, 1983; Nace, 1987) in which the therapist is advised to take a more active role, to be both supportive and confrontative, and to be aware of the characteristic defense structure and ego disturbances of persons with alcohol problems. Individual psychotherapy generally is recommended only as part of a more comprehensive rehabilitation effort that can include alcohol education, referral to Alcoholics Anonymous, family intervention with referral to Al-Anon and Alateen, the prescription of disulfiram, and specific efforts (e.g., vocational training) to remove life problems that contribute to continued problem drinking. Unlike individual psychotherapy, group psychotherapy is among the most commonly used psychotherapeutic techniques for the treatment of alcohol problems (Blume, 1985~. Group therapy is used in most primary and extended care rehabilitation programs-indeed, has been required by some licensing authorities in keeping with the belief that it is the most effective and economical treatment modality available for alcohol problems. This belief, however, is based primarily on clinical experience and earlier studies, which did not involve sophisticated controls (Kansas, 1982; Brandsma and Pattison, 1985~. Group therapy as a distinct singular treatment is rare. As with individual psychotherapy, group therapy is offered in concert with alcohol education, referral to Alcoholics Anonymous, and additional supportive activities. Similarly to individual psychotherapy, groups tend to vary according to the orientation and training of the thera- pists or the ideology of the overall program of which they are a component. Consequently, variety is a prominent feature of group therapy for alcohol problems, and there is no standardization as to length of participation in the group, frequency of group meetings, length of group sessions, number of therapists, and style of group interaction. The advantages that are often cited for the use of group psychotherapy focus on the technique in which persons with alcohol problems share experiences surrounding alcohol use with others who have had similar experiences. In this approach, group members provide both support for the difficulties to be encountered in staying sober while confronting the behaviors that are assumed to be characteristic of such persons: denial, manipulativeness, and grandiosity. As a primary rehabilitation modality in either an inpatient or outpatient setting, group psychotherapy generally involves a daily (or three to five times a week) 1- to 1-l/2 hour session led by a staff member. When group therapy is used as an extended care or aftercare modality, groups may meet as frequently as three times a week and as infrequently as once a month. The optimal size for a group is generally considered to be 8 to 12 persons, although in practice groups vary from 4 to more than 20 persons. As with other kinds of group psychotherapy, the use of male and female cotherapists is seen as optimal for facilitating the group process. In addition to group psychotherapy, organized programs often use the principles of group dynamics in conducting other components of the overall treatment program. These components may include educational groups that present factual material about the physiological action of alcohol, the physical consequences of prolonged excessive drinking, the potential familial, social, legal, and vocational consequences, and the characteristics of this problem state. Educational groups vary in size and style. The most common format is large-group presentations of material through lectures, films, and videotapes, followed by a discussion period in which the goal is both to clarify and amplify the factual material and to correct misconceptions and emotional reactions. Such educational groups are the main component of many drinking driver programs in which format, content, number and length of sessions, and instructor qualifications are prescribed by state government regulations.

WHAT IS TREATMENTS 83 Activity groups are another type of group psychotherapy organized around a specific recreational event and used widely in organized programs. The objectives of activity group participation are to relearn social skills by interacting with other people in a sober context, to learn and practice alternative recreational activities that will eventually replace drinking, and to become familiar with community resources. Many organized programs also use community meetings or ward management meetings as Proun therapy vehicles. c' c7 v ~ ~ Over the past 25 years there has been an increase in the development of family-oriented theories about the causes and treatment of alcohol problems (Ablon, 1976, 1984; Kaufman, 1985~. To a certain extent these efforts to develop techniques specifically directed at families with alcohol problems arose out of the failure to achieve successful outcomes using psychoanalytically oriented individual psychotherapy (Baekeland et al., 1975; Edwards et al., 1977~. Marital and family treatments focus on both the drinking behavior of the identified individual with alcohol problems and the patterns of family interaction and communication. There is no one family therapy approach; rather, there is a variety of theories and interventions being used in clinical practice. Different schools of family therapy (e.g., structural, behavioral, interactional, psychodynamic) use different languages, strategies, and techniques. Some of the family intervention methods that have been utilized in the alcohol problems field include joint hospitalization of marital couples (although only one spouse has alcohol problems) (Steinglass, 1979a); group therapy for married couples in which one or both spouses has alcohol problems; intensive three- to seven-day family intervention programs as part of fixed-length Minnesota model primary rehabilitation programs (Laundergan and Williams, 1979~; day treatment for marital couples (McCrady et al., 1986~; Al-Anon; family education; and the involvement of the multigeneration family in a series of therapy sessions. A number of fixed-length inpatient rehabilitation programs have introduced a one week residential stay for family members who attend a highly structured program of lectures, films, discussion meetings, milieu therapy sessions, group therapy or counseling sessions, and family counseling sessions. Similar outpatient family programs have been introduced as part of fed-length outpatient rehabilitation programs, although it is more common for these programs to spread family participation out over the full course of the primary care period (e.g., involving family members in two sessions per week over a four-week course). There have been no comprehensive studies of the comparative effectiveness of these varied approaches (Kaufman, 1985; McCrady, 1988; IOM, 1989). One of the reasons difficulties arise in describing and studying family treatment approaches is that there is such a wide variety of family types (McCrady, 1988~. Some examples are married couples without children; nuclear families consisting of two parents and children living in the same household; remarried families consisting of two married adults with children from the current marriage or from the previous marriage, or both, who may or may not be living in the same household; multigenerational families living in the same household; single-parent families; cohabiting heterosexual couples; cohabiting same-sex couples; engaged or involved couples who do not live together; long-term roommates without sexual involvement; and adult offspring, either married or unmarried, who do not live in the family household but who are available and involved with the parents. Alcohol problems may be identified in any adult or child member of the family, and more than one family member may be experiencing problems with alcohol. Goals for family treatment also vary considerably. They may comprise facilitating a better outcome in terms of reduced consumption by the identified problem drinkers; enhancing the personal adjustment and functioning of all family members; enhancing family functioning, communication, and relationships; or all of these objectives. The goals that are chosen vary with the type of treatment provided and with the stage of treatment (McCrady, 1988~.

84 BROADENING TEIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Another area of variability is the specific timing and nature of the family involvement in treatment. Family involvement can occur prior to treatment in attempts to "intervene" and persuade the drinker to enter treatment; it can also occur during treatment primarily to keep the drinker participating in treatment efforts and complying with specific requirements (e.g., taking prescribed medication) and to work on Family issues." Family members can also be involved in treatment when the drinker is not to help them cope with the situation and their own reactions and behaviors. There has been some question about the appropriate setting for the initiation of family involvement (McCrady, 1988~. For example, there are no data that suggest that family treatment is more effectively initiated on an inpatient basis, as is common practice. Indeed, two studies find little support for the effectiveness of family treatment on an inpatient basis (Steinglass, 1979a; McCrady et al., 1982~. Reviews of the limited research that has been done do support the belief that family involvement may increase the likelihood that a person with alcohol problems will enter and remain in treatment; the review also suggests that family involvement may increase the likelihood that the problem drinker will successfully reduce the quantity or frequency of drinking or remain abstinent after treatment (Steinglass, 1979b; McCrady, 1988~. McCrady (1988) concludes her review of the status of family treatment by suggesting that research data support superior outcomes for family-involved treatment, enough so that the modal approach should involve family members in carefully planned interventions. She suggests that the questions that now need to be addressed to guide future research and practice are the following: What family members should be involved at what stages in treatment, and what kinds of family treatment methods should be used? She also recommends that in planning treatment, Family should be defined broadly to comprise all those members of the person's immediate social environment who have a substantial emotional commitment to the individual, whether or not they are biological or legal relatives. Summary and Conclusions As a way to clarify the dimensions of treatment for alcohol problems, the committee has reviewed the many different definitions offered in previous studies, reviews, and planning documents. It has developed a definition of treatment that can encompass all efforts to reduce alcohol consumption by persons who experience problems surrounding such consumption, as well as the additional supportive services required to prevent relapse and a return to destructive alcohol use. The committee's definition incorporates those activities that are currently labeled intervention as well as those labeled treatment and rehabilitation: Treatment refers to the broad range of services, including identircafion,brief intervention, assessment, diagnosis, counseling, medicalservices, psychiatric services, psychological services, social services, and follow-up, for persons with alcoholproblems. The overallgoal of treatment is to reduce or eliminate the use of alcohol as a corztributir~g factor to physical, psychological, awl social dysfunction awl to arrest, retard, or reverse the progress of associated problems. This expanded definition reflects the committee's conclusion that efforts to treat alcohol problems in this country have in the recent past been too narrowly focused on those persons with the most severe problems. Its review of prior efforts has suggested a preliminary framework for identifying the elements of an expanded continuum of care that incorporates intervention (secondary prevention) activities as well as treatment and

WHAT IS TREATMENT? 85 rehabilitation (tertiary prevention) efforts and that can address the treatment needs of persons at each level of severity of alcohol problems. The committee's definition also reflects the professional judgment that the treatment of alcohol problems cannot be limited only to those direct activities designed to reduce alcohol consumption. Supportive services are required if relapse is to be avoided and continued sobriety and recovery is to be maintained by individuals who may have few personal and social resources and who are experiencing very severe physical, vocational, family, legal, or emotional problems surrounding their use of alcohol. The extent of the person's dysfunction in other key life areas (e.g., employment, physical health, emotional health, marital and family relations) should determine the breadth of the treatment response needed. Treatments for alcohol problems are diverse, in part because experts have different views about the causes of such problems. Three major views or models of the etiology of alcohol problems have been guiding treatment provision in recent years; these are the .. . . . . . . _

86 c,' ~, ~, BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS how well the framework can incorporate the elements of the original continuum of care, as defined in the Uniform Act, and the modifications that have been introduced in the many state and county jurisdictions that have developed a maturing system of local treatment services. As a result of its deliberations, the committee found that treatment for alcohol problems includes a broad range of activities that vary in content, duration, intensity, goals, setting. provider. and target population and that no single treatment approach or modality has been demonstrated to be superior to all others. The committee also found that although there is agreement that an organized continuum of care is required, there is no agreement on the definition of that continuum, on the definitions of the service elements, or even on what constitutes a single treatment episode for purposes of evaluating treatment appropriateness and success. The federal government, state and local governments, and other third-party payers, in their planning, funding, and regulatory efforts, use very different labels and definitions for the elements in the continuum of care, often confusing the orientation of the providers, the stage of treatment, the setting of treatment, and the modality or procedure used. It is only recently that research has begun to investigate these elements in a systematic fashion. Additional studies are needed to determine the effectiveness of the different modalities, alone and in combination. The committee sees a need to develop a consensually accepted system for describing the treatment episode. This system can then serve as the basis for defining the required continuum of care-the orientations, stages, settings, and modalities of treatment to be used in both research and program development. There have been a number of prior efforts to develop classifications of treatment programs for evaluating and funding treatment from a national perspective. These efforts have used such variables as treatment philosophy, settings, and modalities, but there has been no acceptance of a uniform classification. Consequently, there is no consistent definition of treatment in this country or of the elements of the continuum of care that are necessary to meet national objectives to reduce the prevalence of alcohol problems. The rich diversity of treatment options reviewed by the committee reflects the dynamic vitality of the field. The committee is encouraged by the evolution that has occurred and wishes to encourage that growth by assisting in the development of a comprehensive framework for evaluation and program development. REFERENCES Ablon, J. 1976. Family structure and behavior in alcoholism: A review of the literature. Pp. 205-242 in Social Pathology, Vol. 4 of The Biology of Alcoholism, B. Kissin and H. Begleiter, eds. New York: Plenum Press. Ablon, J. 1984. Family research and alcoholism. Pp. 383-396 in Recent Developments in Alcoholism, vol. 2, M. Galanter, ed. New York: Plenum Press. Abrams, D. B., and R. S. Niaura. 1987. Social learning theory. Pp. 131-178 in Psychological Theories of Drinking and Alcoholism, H. T. Blane and K E. Leonard, eds. New York: Guilford Press. Alterman, A. I., M. Hayashida, and C. P. O'Brien. 1988. Treatment response and safety of ambulatory medical detoxification. Journal of Studies on Alcohol 49:160-166. American Hospital Association. 1974. Classification of Health Care Institutions. Chicago: American Hospital Association. Anderson, D. J. 1981. Perspectives on Treatment: The Minnesota Experience. Center City, Minn.: Hazelden Foundation. Anderson, J. G., and F. S. Gilbert. 1989. Communication skills training with alcoholics for improving performance of two of the Alcoholics Anonymous recovery steps. Journal of Studies on Alcohol 50:361-367.

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.

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.

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.

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.

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.

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.

WHAT IS TREATMENT? 93 Marlatt, G. A., J. S. Baer, D. M. Donovan, and D. R. Kivlan. 1988. Addictive behaviors: Etiology and treatment. Annual Review of Psychology 39:223-252. McClellan, A. T., L. Luborsky, G. E. Woody, and C. P. O'Brien. 1980. An improved diagnostic instrument for substance abuse patients: The Addiction Severity Index. Journal of Nervous and Mental Disorders 168:26-33. McCrady, B. S. 1988. Executive summary: Criteria and issues to consider when deciding to intervene at the maritaVfamily level, the individual level, or both. Prepared for the IOM Committee to Identify Research Opportunities for the Prevention and Treatment of Alcohol-Related Problems. McCrady, B.S., J. Moreau, T. J. Paolina, and R. Longabaugh. 1982. Joint hospitalization and couples therapy for alcoholism: A four-year follow-up. Journal of Studies on Alcohol 43:1244-1250. McCrady, B.S., N. E. Noel, D. B. Abrams, R. L. Stout, H. F. Nelson, and W. M. Hay. 1986. Comparative effectiveness of three types of spouse involvement in outpatient behavioral alcoholism treatment. Journal of Studies on Alcohol 47:459467. Mello, N. K 1972. Behavioral studies of alcoholism. Pp. 219-292 in Physiology and Behavior. Vol. 2 of The Biology of Alcoholism, B. Kissin and H. Begleiter, eds. New York: Plenum Press. Meyer, R. E. 1986. Anxiolytics and the alcoholic patient. Journal of Studies on Alcohol 47:269-273. Miller, B., W. F Manov, and A. Wright. 1987. The community model approach: Los Angeles County's application of public health principles to alcohol problems. Presented at the American Public Health Association Meeting, New Orleans, Louisiana, October. Miller, W. R., and G.R. Caddy. 1977. Abstinence and controlled drinking in the treatment of problem drinkers. Journal of Studies on Alcohol 38:986-1003. Miller, W. R., and R. K Hester. 1986. Inpatient alcoholism treatment: Who benefits? American Psychologist 41:794 805. Moberg, D. P., W. K Krause, and P. K Klein. 1982. Posttreatment drinking behavior among inpatients from an industrial alcoholism program. International Journal of Addictions 17:549-567. Moos, R. H., and J. W. Finney. 198711988. Alcoholism program evaluations: The treatment domain. Drugs and Society 2(2):31-51. ~-lea- ~ Moos, R. H., R. C. Cronkhite, and J. W. Finney. 1982. A conceptual framework for alcoholism treatment evaluation. Pp. 1120-39 in Encyclopedic Handbook of Alcoholism. E.M. Pattison and E. Kaufman, eds. New York: Gardner Press. Mulford, H. 1979. Treating alcoholism versus accelerating the natural recovery process: A cost-benefit comparison. Journal of Studies on Alcohol 40:505-513. Mulford, H. 1988. Enhancing the natural control of drinking behavior: Catching up with common sense. Presented at the Conference on Evaluating Treatment Outcomes, University of California, San Diego, Extension Program on Alcohol Issues, February 5. Nace, E. P. 1987. The Treatment of Alcoholism. New York: Bruner/Mazel. Nathan, P. E. 1984. Contributions of learning theory to the diagnosis and treatment of alcoholism. Pp. 328-338 in Psychiatry Update. Vol. 3 of the American Psychiatric Association Annual Review, L. Grinspoon, ed. Washington D.C.: American Psychiatric Association. Nathan, P. E., and B. S. McCrady. 1986/1987. Bases for the use of abstinence as a goal in the treatment of alcohol abusers. Drugs and Society 1(2/3):109-131. Nathan, P. E., and R. S. Niaura. 1985. Behavioral assessment and treatment of alcoholism. Pp. 391455 in The Diagnosis and Treatment of Alcoholism, 2d ea., J. H. Mendelson and N. K Mello, eds. New York: McGraw-Hill. Nathan, P. E., and J. S. O'Brien. 1971. An experimental analysis of the behavior of alcoholics and nonalcoholics during prolonged problem drinking. Behavior Therapy 2:455476.

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.

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.

96 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS Skinner, H. A. 1988. Executive summary: Spectrum of drinkers and intervention responses. Prepared for the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse. Skinner, H. A., and S. Halt. 1987. The Alcohol Clinical Index Strategies for Identifying Patients with Alcohol Problems. Toronto: Addiction Research Foundation. Sobell, M. B., and L. C. Sobell. 1973. Individualized behavior therapy for alcoholics. Behavior Therapy 4:49-72. Sokolow, L., J. Welte, G. Hynes and J. Lyons. 1980. Treatment-related differences between male and female alcoholics. Journal of Addictions and Health 1. Steinglass, P. 1979a. An experimental treatment program for alcoholic couples. Journal of Studies on Alcohol 40:159-182. Steinglass, P. 1979b. Family therapy with alcoholics: A review. Pp. 147-186 in Family Therapy of Drug and Alcohol Abuse, E. Kaufman and P. Kaufman, eds. New York: Gardner Press. Strauss, A., L. Schatzman, D. Ehrlich, and M. Sabshin. 1964. Psychiatric Ideologies and Institutions. New York: Free Press. Strupp, H. H. 1978. Psychotherapy research and practice: An overview. Pp. 3-22 in Handbook of Psychotherapy and Behavior Change: An Empirical Analysis. 2d ea., S. Garfield and A. E. Bergin, eds. New York: John Wiley and Sons. Stuckey, R. F., and J. S. Harrison. 1982. The alcoholism rehabilitation center. Pp. 865-873 in Encyclopedic Handbook of Alcoholism, E. M. Pattison and E. Kaufman, eds. New York: Gardner Press. Trice, H. M., and J. A. Beyer. 1984. Work related outcomes of the constructive confrontation strategy in a job based alcoholism program. Journal of Studies on Alcohol 45:393404. U.S. Department of Health and Human Services (USDHHS). 1981. Fourth Special Report to the U.S. Congress on Alcohol and Health. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. U.S. Department of Health and Human Services (USDHHS). 1986. Toward a National Plan to Combat Alcohol Abuse and Alcoholism. Report submitted to the United States Congress. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. U.S. Department of Health and Human Seduces (USDHHS). 1987a. 1987 National Drug and Alcoholism Treatment Unit Sunrey: NDATUS Instruction Manual for States and Reporting Units. Rockville, Md.: National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism. U.S. Department of Health and Human Services (USDHHS). 1987. Sixth Special Report to the U.S. Congress on Alcohol and Health. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. U.S. Department of Health, Education, and Welfare (USDHEW). 1971. First Special Report to the U.S. Congress on Alcohol and Health. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism. Vaillant, G. E. 1983. The Natural History of Alcoholism: Causes, Patterns, and Paths to Recovery. Cambridge, Mass.: Harvard University Press. Vannicelli, M. 1978. Impact of aftercare in the treatment of alcoholics: A cross-legged panel analysis. Journal of Studies on Alcohol 39:1875-1886. Walker, R. D., D. M. Donovan, D. R. Kivlahan, and M. R. O'Leary. 1983. Length of stay, neuropsychological performance, and aftercare: Influences on alcohol treatment outcome. Journal of Consulting and Clinical Psychology 51:900-911. Wallerstein, R. S. 1956. Comparative study of treatment methods for chronic alcoholism: The alcoholism research project at Winter VA Hospital. American Journal of PsychiatIy 113:228-233. Wallerstein, R. S. 1957. Hospital Treatment of Alcoholism: A Comparative, Experimental Study. New York: Basic Books.

WHAT IS TREATMENT? 97 Walsh, D. C., R. W. Hingson, and D. M. Merrigan. 1986. A randomized trial comparing inpatient and outpatient alcoholism treatments in industry A first report. Presented at the Annual Meeting of the Alcohol Epidemiology Section of the International Council on Alcohol and Addictions, Dubrovnik, Yugoslavia, June. Weedman, R. D. 1987. Admission, Continued Stay and Discharge Criteria for Alcoholism and Drug Dependence Treatment Services. Irvine, Cali£: National Association of Addiction Treatment Providers. Weisman, M. N. 1988. Musings on the art of treatment. Alcohol Health and Research World 12:282-287. Weisner, C., and R. Room. 1984. Financing and ideology in alcohol treatment. Social Problems 32:167-184. Welte, J., G. Hynes, L. Sokolow, and J. Lyons. 1978. Alcoholism Treatment Effectiveness: An Outcome Study of New York State Operated Rehabilitation Units. Albany N.Y.: Research Institute on Alcoholism. Whitfield, C. L., G. Thompson, A. Lamb, V. Spencer, M. Pfeifer, and M. Browning-Ferrando. 1978. Detoxification of 1024 patients without psychoactive drugs. Journal of the American Medical Association 239:1409-1410. Williams, C. N., D. C. Lewis, J. Femino, L. Hall, K Blackburn-Kilduff, R. Rosen, and C. Samella. 1985. Overcoming barriers to identification and referral of alcoholics in a general hospital setting: one approach. Rhode Island Medical Journal 68:131-138. Wilson, G. T., R. Leaf, and P. E. Nathan. 1975. The aversive control of excessive drinking by chronic alcoholics in the laboratory. Journal of Applied Behavioral Analysis 8:13-26. Wilson, G.T. 1987. Chemical aversion conditioning as a treatment for alcoholism: A re-analysis. Behavioral Research and Therapy 25:503-515. Wright, ~ 1985. What is a social model program? Los Angeles County Office of Alcohol Programs, Department of Health Services, Los Angeles, Calif. Wright, A. 1986. A community model approach to alcohol-related problems. Los Angeles County Office of Alcohol Programs, Department of Health Services, Los Angeles, Calif. Yahr, H. T. 1988. A national comparison of public- and private-sector alcoholism treatment delivery system characteristics. Journal of Studies on Alcohol 49:233-239. Zimberg, S. 1974. Evaluation of alcoholism treatment in Harlem. Quarterly Journal of Studies on Alcohol 35:550-557. Zimberg, S. 1983. Comprehensive model of alcoholism treatment in a general hospital. Bulletin of the New York Academy of Medicine, 59(2~:222-229. Zimberg, S. 1985. Principles of alcoholism psychotherapy. Pp. 3-22 in Practical Approaches to Alcoholism Psychotherapy, S. Zimberg, J. Wallace, and S. B. Blume, eds. New York: Plenum Press. Zimberg, S., J. Wallace, and S. B. Blume, eds. 1985. Practical Approaches to Alcoholism Psychotherapy. New York: Plenum Press. Zucker, R. A., and E. S. Lisansky Gomberg. 1986. Etiology of alcoholism reconsidered: The case for a biopsychosocial process. American Psychologist 41:783-793. Zuska, J. J. 1978. Beginnings of the Navy program. Alcoholism: Clinical and Experimental Research 2:352-357.

Next: Chapter 4--Who provides treatment? »
Broadening the Base of Treatment for Alcohol Problems Get This Book
×
Buy Paperback | $160.00
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

In this congressionally mandated study, an expert committee of the Institute of Medicine takes a close look at where treatment for people with alcohol problems seems to be headed, and provides its best advice on how to get there. Careful consideration is given to how the creative growth of treatment can best be encouraged while keeping costs within reasonable limits. Particular attention is devoted to the importance of developing therapeutic approaches that are sensitive to the special needs of the many diverse groups represented among those who have developed problems related to their use of "man's oldest friend and oldest enemy." This book is the most comprehensive examination of alcohol treatment to date.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  6. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  7. ×

    View our suggested citation for this chapter.

    « Back Next »
  8. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!