Prevention and Treatment of Alcohol Problems Research Opportunities (1990) / Chapter Skim
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9 Treatment Modalities: Process and Outcome
9 Treatment Modalities: Process and Outcome
Pages 169-214
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From page 169... ...
In an effort to close this gap, the sections below survey research focusing on a number of topics of interest: specific treatment approaches, traditional treatment programs, the intensity and duration of treatment, aftercare, and the treatment process itself. In the final section, the committee presents its conclusions and summarizes the opportunities for further progress in treatment research.
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From page 170... ...
Relapse prevention strategies have been incorporated into treatment programs. Principles underlying some of these strategies are described in Chapter 3.
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From page 171... ...
Fuller and Williford (1980) , in a urinalysis of a randomized clinical trial, reported that two groups of alcoholics who were given disulfiram showed significantly higher abstinence rates at 12 months, compared with those who were given no disulfiram Only one of the two medicated groups received a therapeutic dose, however, whereas the other was given only 1 milligram (mg)
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The following questions represent opportunities for research on antidipsotropic medications: . What motivational procedures most effectively increase compliance with antidipsotropic medications?
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It may be useful to combine such pharmacotherapy with psychological inte~ventions designed to enhance motivation and medication compliance. The following questions represent opportunities for research on effect-altering medications: .
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From page 174... ...
Other investigations, including a major Veterans Administration collaborative study, have found no therapeutic impact of lithium on the drinking outcomes of either depressed or nondepressed alcoholics (Peck et al., 1981; Pond et al., 1981; Powell et al., 1986; Dorus, 1988~. A variety of other psychotropic medications have been tested for their effects on drinking behavior and the desire to drink (Liskow and Goodwin, 1987~.
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From page 175... ...
Chemical aversion pairs alcohol with nausea and vomiting induced by emetic drugs. Aversion therapy is a mainstay of alcohol treatment in the Soviet Union and continues to be used in some U.S.
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Does the addition of chemical aversion therapy to an alcohol treatment program significantly improve long-term outcomes? · Does covert sensitization suppress urges to drink and have beneficial effects on long-term outcomes?
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From page 177... ...
Psychotherapy and Counseling Controlled treatment outcome studies prior to 1980 failed to yield persuasive evidence for the effectiveness of psychodynamic psychotherapy with alcoholics (Miller and Hester, 1980~. Recent controlled studies have not substantially altered this trend, although more promising results have been obtained in drug abuse populations (see Chapter 12~.
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From page 178... ...
Two studies reported very poor retention of treatment-relevant information by alcoholics (Sanchez-Craig and Walker, 1982; Becker and Jaffe, 1984~. The following questions represent opportunities for research on didactic approaches: · What contributions to treatment outcome are made by educational lectures within the context of a multimodal treatment program?
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From page 179... ...
Given its great importance in U.S. treatment programs, it is unfortunate that AA has not been the subject of more empirical research.
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. What role does mutual help group participation play in the context of multimodal treatment programs?
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From page 181... ...
~. Although recent studies provide support for the effectiveness of behavioral marital therapy current alcohol treatment programs include a much wider range of interventions for couples and families.
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From page 182... ...
New research is needed to explore the effects of conjoint therapies, not only on the drinking of the alcoholics but also on the adjustment of spouses, children, and other family members. The following questions represent opportunities for research on conjoint therapies: · What couples and family therapy approaches contribute significantly to favorable outcomes for treated alcoholics and their families?
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From page 183... ...
reported substantially higher one-and two-year abstinence rates among alcoholics given assertiveness training in addition to standard treatment procedures. A Norwegian study similarly found that inpatients given social skills training, relative to controls who received only standard hospital treatment, had thrice as many days of sobriety and employment in the subsequent year, sustained abstinence for longer periods, and experienced fewer than one-fourth as many days of institutionalization (Eriksen, Bjornstad, and Gotestam, 1986~.
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From page 184... ...
As discussed in the writings of Gorski (e.g., Gorski and Miller, 1982) , relapse prevention strategies have been popularized and integrated into the 12 step approach used by AA The approach's intended effect is that the addition of relapse prevention procedures to a treatment program will reduce the probability and rapidity of relapse.
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From page 185... ...
RESEARCH ON TRADITIONAL TREATMENT PROGRAMS In practice, alcoholism treatment programs in the United States typically offer a combination of modalities that includes detoxification and health care, AA groups, lectures and films, group therapy, individual counseling, recreational and occupational therapy, medication, and aftercare group meetings. Claims of high success rates are sometimes made for such programs.
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From page 186... ...
These studies exemplify how reported success rates are significantly influenced by the stringency of outcome criteria. Reports of uncontrolled studies pose difficulties in interpretation.
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From page 187... ...
In addition, special populations that are seen in private treatment programs may not be found in public programs in which controlled research is more commonly conducted. Yet uncontrolled studies cannot substitute for properly controlled, randomized designs in determining the absolute and relative effectiveness of treatment programs and modalities.
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From page 188... ...
Reimbursement policies of health care insurers have often followed this maxim, paying preferentially for more intensive and expensive forms of alcohol treatment. Uncontrolled studies have long reported a positive correlation between length of stay in treatment and favorable outcome, and studies since 1980 have continued this trend (e.g., Finney, Moos, and Chan, 1981; McLellan et al., 1982)
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From page 189... ...
, and require further investigation. The following questions represent opportunities for research on the intensity and duration of treatment: · For what types of individuals is residential treatment differentially effective or more cost-effective than nonresidential alternatives?
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If so, for what types of individuals are there differential benefits? TREATMENT PROCESS RESEARCH Whereas outcome research provides data regarding the overall impact of therapeutic interventions, process research yields information about the active ingredients of treatment efficacy.
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~ The following questions represent opportunities for research on the mechanisms of treatment efficacy: · For a particular treatment approach (e.g., cognitive therapy, marital/family therapy, AA) , what are predicted to be the necessary and sufficient conditions for recovery to occur?
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The following questions represent opportunities for research on therapist characteristics: · What role do therapist characteristics (e.g., empathy, self-disclosure, optimism, confrontiveness) play in influencing client/patient dropout, motivation for change, and treatment outcome?
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· How great are differences in therapist effectiveness within specific treatment strategies?
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From page 194... ...
round no Olllerences between two treatment programs for DWI offenders and a home-study control group given a single 30-minute session and educational reading matter. With few exceptions (e.g., Brown, 1980)
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The following questions represent opportunities for research on motivation, compliance, and mandated treatment: . What interventions, therapist characteristics, or situational factors increase the probability that a problem drinker will enter, continue, and comply with treatment?
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Other currently or previously used treatment methods remain unproved. More than half of controlled clinical trials of alcohol treatment approaches have yielded negative results; that is, no significant differences in outcome among groups.
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From page 197... ...
A variety of specific alcohol treatment methods have been associated with increased improvement, relative to no treatment or alternative treatments, in controlled studies. Future research should continue to evaluate the effectiveness of alternative current and new treatment modalities.
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From page 198... ...
, but given the incremental new knowledge they yield, well-designed controlled clinical trials remain a- cost-effective investment of research funds. Contemporary quasi-experimental designs offer sound alternatives in instances in which controlled trials are not feasible.
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From page 199... ...
Graham et al. A controlled trial of relapse prevention procedures based on self-efficacy theory.
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From page 200... ...
Emetic and electric shock alcohol aversion therapy: Assessment of conditioning.
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An evaluation of three treatment programmed for alcoholism: An experimental study with sex and 18-month follow-ups.
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Longabaugh et al. Adherence in a behavioral alcohol treatment program.
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From page 203... ...
Counseling for Relapse Prevention. Independence, MO: Herald House-Independence Press, 1982.
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From page 204... ...
Hall. Relapse prevention and alcohol aftercare: Effects on drinking outcome, change process, and aftercare attendance.
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Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press, 1985.
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From page 206... ...
Covert sensitization: Alternative treatment approaches for alcoholics. Paper presented at the Second Congress of the International Society for Biomedical Research on Alcoholism, Santa Fe, 1984.
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Assessment of Chemical Aversion Therapy for Alcoholism. Washington DC: National Center for Health Care Technology, 1981.
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Replicable abstinence rates in an alcoholism treatment program.
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W Changing patients' health beliefs to improve compliance with alcoholism treatment: A controlled trial.
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Random assignment to abstinence and controlled drinking: Evaluation of a cognitive-behavioral treatment program for problem drinkers.
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From page 211... ...
Longabaugh et al. Marital therapy helps enhance the long-term effectiveness of alcohol treatment.
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From page 212... ...
Ellingstad et al.- Results of a longitudinal evaluation of court-mandated DWI treatment programs in Phoenix, Arizona.
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From page 213... ...
Li. A comparison of brief advice and conjoint therapy in the treatment of alcohol abuse: The results of the marital systems study.
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