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A follow-up of alcoholics treated by behaviour therapy
Fkhav. Rcr. k Therapy, 1967. Vol. 5, pp. 89 to 94. Pergamon Press Ltd. Printed in England
A FOLLOW-UP OF ALCOHOLICS TREATED BY BEHAVIOUR THERAPY* B. GEQ. BLAKE Ontario Hospital, Whitby, Ontario, Canada
(Received
10 Uctobcr
1966)
Summary-Follow-up results at 6 and 12 months after discharge from hospital for alcoholics treated by behaviour therapy arc reported. Two groups are compared: a relaxation-aversion and an aversion-only group. At twelve months’ follow-up the indications am that the relaxation-aversion approach to treatment shows some slight advantage over treatment by electrical aversion conditioning alone in an unsekted sample of in-patient alcoholic admissions. The difference is not statistically significant. It is suggested that careful selection of subjects for each type of treat-t on the basis of individual differencea in neurotic drive shoutd further clarify the question.
INTRODUCTION A TECHNIQUE described as relaxation-aversion therapy, along with results at 6 and 12 months’ follow-up of cases treated by this method, was discussed in a previous paper (Blake, 1965). A control group of alcoholics treated by electrical aversion therapy alone, without the aid of progressive relaxation, has since been collected. This report presents the results obtained with this group and compares the outcome with that of the experimental (i.e. relaxation-aversion) sample at the same stages of follow-up. For the purpose of the study, alcoholism has been described as a learned habit of uncontrollable drinking which is used by an individual in an effort to reduce a disturbance in psychological homeostasis. The definition is underpinned by concepts in the reinforcement theory of learning (Kingham, 1958; Kepner, 1964; Dollard and Miller, 1950; Blake 1965, 1966a). The rationale behind such an approach as relaxation-aversion for the treatment of alcoholism has been discussed by writers such as Eysenck (1960), Metzner (1963) and Lazarus (1965). The methodological advantages of electrical techniques of conditioned aversion have been outlined by Me&ire and Vallancc (1964), Blake (1966b) and reviewed in detail by Rachman (1965). SUBJECTS The experimental and control groups contained 37 and 25 Ss respectively. The subjects in each sample were comparable as regards such variables as age, sex, socioeconomic class (by occupation), chronic&y, previous hospitalization for alcoholism, psychiatric diagnosis and intelligence. (Blake 1965, 1966a). l The research was carried out at the Crichton Royal Hospital, Dumfries, Scotland and was supported by a grant from the Medical Research Council.
89
90
B. CEO.
BLAKE
FOLLOW-UP For the purpose of comparison between groups, four outcome categories are defined: The abstinent category includes those individuals who are known to have been abstinent during the whole period of follow-up. Abstinence was assumed if the patient’s own report was supported by observations from individuals who were closely associated with him in one way or another: spouse, relative, G.P., employer, and others. The improved category includes those persons whose drinking was now of a social order (one case: the quantity and type of alcohol as well as his drinking environment being radically different from his former addictive drinking behaviour) and appeared to be in no danger of pathological escalation; or those whose drinking throughout the period of follow-up had been substantially reduced compared with their former level of drinking, with improvement in their general level of adjustment as recognized at the time of admission to hospital. Adjustment is evaluated against the criteria outlined by Knight (1941) and Blake (1965). The relapsed group includes those individuals who had reverted to their former level of drinking with no noticeable adjustment in other areas of social behaviour, or those who had at least one further period of hospitalization for alcoholism since discharge, but did not undergo further behaviour therapy. The fourth category includes those subjects who had opted out of treatment after it had started, those who were lost to follow-up, or those for whom no reliable information as to their drinking and general adjustment since discharge was available. Three subjects opted out of treatment during the course of the research: one male in the relaxation-aversion group and a male and a female in the aversion-only group. In order to accommodate the time-table of the research, the minimum follow-up period was set at 12 months. All 37 subjects in the experimental group and 22 of the 25 controls had completed the scheduled period of follow-up at the time of evaluating the results. Tables 1 to 4 give the breakdown of outcome for the two groups at 6 and 12 months’ respectively. abstinent, improved, relapsed and others.
TABLE
1. SIX
MONTHS'
FOLLOW-UP OF 37 CASESTREATED AVERSION THERAPY
cases
Total
Outcome
Male
Female
BY RELAXATION-
(?I,)
1.
Abstinent
14’
6
20
54
2.
Improved
2
I
3
8
3.
Relapsed
7
3
IO
27
4.
Others
4
4
II
Total
27
37
100
10
A ~oLu)w-UP T~L.E
2.
OF ALCOHOLICS TREATED BY BEHAVJOUR ‘J-JiERAPy
SIX MONTHS’ FOLLOW-UP OF 25 CASES TREATED BY EmaLAVERSION THERAPY ALONE
Outcome Male.
Total
(%I
12
48
3
12
Female
I.
Abstinent
9
2.
Improved
3
3.
Relapsed
4
I
5
20
4.
Others
4
I
5
20
Total
20
5
25
100
TABLE 3.
91
3 -
TWELVE MONTHS’ FOLLOW-UP OF 37 CASES TRBATELI BY J~ELA~ATIONAVERBION THERAPY
cases Outcome
Total Male
FCmalC
C%)
1.
Abstinent
I2
5
17*
46
2.
Improved
3
2
5*
13
3.
Relapsed
8
3
4.
Others
4
-
27
TOtal
IO
11
30
4
11
37
100
* Includes 3 subjects (1 male, 2 female) relapsed, readmitted for further relaxation-aversion and have been abstinent or improved for 12 months since last discharge.
TABLE
4.
TWELVE MONTHS FOLLOW-UP OP 22 CASES TUBATED BY ELEtXItICNAVERSION THERAPY AWNE
Outcome Male
I.
Abstinent
3
2.
Improved
6
3.
Relapsed
4
4.
Others
5
Total
18
* Includes one subject readmitted
Total
(%I
5
23
6.
27
6
27
5
23
22
100
Female
2 2 4
for booster treatment
during follow-up.
therapy
92
B. GEO.
BLAKE
The results at 12 months’ follow-up show that 59 per cent of the experimental sample compared with 50 per cent of the controls were classified as either abstinent or improved. The difference is not statistically significant; it does not, however, refute the hypothesis that in the treatment of alcoholism there is a need to extinguish the drive, fear or anxiety, that motivates the drinking while tackling simultaneously the habit of uncontrollable drinking by conditioned aversion therapy (Metzner, 1963; Blake, 1965). To test the hypothesis rigorously, it would be necessary to select subjects for the experimental sample on the basis of the presence, or absence, of accompanying neurotic anxiety. This procedure had not been adopted in the present study. Taking both groups together 59 subjects have completed a minimum of 12 months’ follow-up. Of these, 56 per cent (33) were classed as abstinent (22) or improved (11). Two male subjects died from heart disease during follow-up: the first, in the experimental group had been abstinent for 13 months; the second, in the control group, had been abstinent for 6 months prior to death. When these two subjects are excluded, the 36 S’s in the experimental sample had a mean period of follow-up of 2.25 years (range 18-37 months): those (24) in the control group had a mean period of follow-up of 1.5 years (range IO-29 months). For these periods 47 and 54 per cent of the experimental and control samples respectively were classified as abstinent or improved. DISCUSSION One of the basic requirements in evaluating the efficacy of any treatment programme is the use of control groups. To this end, a comparison of the results obtained in the study with published reports of other types of treatment for alcoholism, would offer some measure of the value and generality of the method. It has been noted, however (Walton, 1961; Pattison, 1966), that follow-up studies of the treatment of alcoholism have been so heterogeneous that few reliable conclusions can be drawn about either treatment results or methods. The point is illustrated by the observation that often different types of patients may be involved, uniform follow-up procedures are seldom adopted, and terms such as “sober”, may be inadequately defined. From this point of view, know“abstinent”, “improved”, ledge of the status of untreated alcoholics would be a more suitable basis for evaluating the worth of any treatment programme. Valiance (1965, in a two-year follow-up of 62 alcoholics in the psychiatric unit of a general hospital found who had had “first-aid management” that less than 5 per cent were abstinent and altogether about 25 per cent could be considered improved. Kendall and Staton (1965) in a study of 62 untreated alcoholics with a mean follow-up period of 6.7 years found that fewer untreated alcoholics (one case) became abstinent or returned to normal drinking and more died or committed suicide. From this point of view, the results obtained in this study may be taken as a demonstration of the utility of the method. It is planned to set-up a cross-cultural study to evaluate the method further. This work will be based on a North American sample who, in terms of the Registrar General’s classification, would fall into social classes (by occupation) 3, 4 and 5 compared with the subjects in the present study who belonged predominantly to social classes 1 and 2. At the same time the work will of necessity incorporate modifications arising from experience with the technique; considerations will also be given to recent developments in the field of behaviour therapy for the treatment of alcoholism; for example, work reported by Lazarus (1965), Miller et al. (1964), MacCulloch ef al. (1966). One proposal will be to extend the number
A FOLLOW-UP
OF ALCOHOLICS TREATED BY BEHAVIOUR THERAPY
93
of conditioning sessions per subject to 20, with 20 trials per session on a 50 per cent partial reinforcement schedule. It is anticipated that this procedure will reduce the percentage of patients who failed to demonstrate the conditioned response as measured by GSR. It was found that on the conditioning regime reported by Blake (1965) 28 per cent of a sample of 48 S’s failed to demonstrate conditioning (Blake, 1966). An apparatus for aversion conditioning to the smell of alcohol specifically has also been developed. Atttention will also be directed to the development and refinement of methods for measuring conditioning as well as progress in therapy. For, while modification in the conditioning procedure in the directions outlined above may reduce the percentage of nonresponders on GSR measures, it is likely that individuals respond autonomically differently to the same conditioning experience (Eysenck, 1962). In which case it will be important to investigate other autonomic functions, such as rate and depth of breathing, heart rate, EMG, as well as behavioural measures. As regards behavioural measures it is thought that techniques such as those reported by Feldman and MacCulloch (1965); Marks er al. (1965) or repertory grid techniques as developed by Bannister and Fransella (1966) and Fransella and Adams (1966) may repay investigation. wish to thank Dr. W. MCALUM, Consultant Psychiatrist at the Crichton Royal Hospital, in whose unit this work was carried out, and Mrs. J. PARISHfor her help in preparing the manuscript.
Acknowledgements-1
REFERENCES D. and FRANSELLA F. (1966) A grid test of schizophrenic thought disorder. Br. J. sot. clin. Psychol. 5, 95-102. BLAKEB. G. (1965) The application of behaviour therapy to the treatment of alcoholism. Behuv. Res. & IXerapy 3, 75-85. BLAKEB. G. (1966a) An evaluation of the conditioned aversion method of treating alcoholism and of individual differences in response to such treatment. Unpublished Ph.D. thesis, University of Edinburgh BLAKEB. G. (1966b) Alcoholism. Special techniques of therapy. Discovery 27, -7. J~_LARD J. and MILLERN. E. (1950) Personality und Psychotherapy. McGraw-Hill, New York. EY~ENCKH. J. (1960) Bekzviour Therapy and the Neuroses. Pergamon Press, Oxford. EYSENCKH. J. (1962) Conditioning and personality. Br. J. Psycho/. 53, 299-306. FELDMAN M. P. and MACCULLXH M. J. (1965) The application of anticipatory avoidance learning to the treatment of homosexuality. I: Theory, technique and preliminary results. Behov. Res. & Therupy 2. 165-184. FRANSELLA F. and ADMC~B. (1966) An illustration of the use of repertory grid technique in a clinical setting. Br. J. sot. clin. Psychol. 5, 5 l-62. KENDALLR. E. and STA~ONM. C. (1965) The fate of untreated alcoholics. Quurt. J. Stud. Alcohol 26, 685686. KEPNERE. (1964) Application of learning theory to the etiology and treatment of alcoholism. Quart. J. Stud. Alcohol 25, 279-291. KINOHAM R. J. (1958) Alcoholism and the reinforcement theory of learning. Quart. J. Srud. Alcohol 19, 320-330. KNIOM R. P. (1941) Evaluation of the result of psychoanalytic therapy. Am. 1. Psychiut. 98, 434 (Cited in WOLPE,1958). L-us A. A. (1965) Towards the understanding and effective treatment of alcoholism. S. Afr. med. J. 39, 736741. MACZCULUXH M. J., FELDMAN M. P., Oaroan 1. F. and MACCULLOCH M. L. (1966) Anticipatory avoidance learning in the treatment of alcoholism: a record of therapeutic failure. Behuv. Res. & Therupy 4, 187-196. MARKS I. M., RACHMANS. and GELDERM. G. (1965) Methods for assessment of aversion treatment in fetishism and masochism. Behav. Res. & 77wapy 3, 253-258. MCGUIRER. J. and VALLANCE M. (1964) Aversion therapy by electric shock : a simple technique. Br. Med. J. i, 151-153. METZNERR. (1963) Re-evaluation of Wolpe and Dollard/Miller. Behuv. Res. & 77terupy 1, 213-216. BANNISTER
94
B.GEO.BLAKE
MILLER E. C., DVORAK B. A. and TURNERD. W. (1964) A method of creating aversion to alcohol by refkx conditioning in a group setting. In (Ed. FRANKS C. M.) Conditioning Techniquer in Clinical Practice and Research. Springer, New York. P~mso~ E. M. (1966) A critique of alcoholism treatment concepts with special reference to abstinence. Quart J. Stud. Akohol27, 49-71. RACHMAN S. (1965) Aversion Therapy: chemical or electrical. Behov. Res. CGTherapy 2, 289-300. VALLANCE M. (1965) Alcoholism: A two year follow-up study. Br. J. Psychiar. 111, 348-356. WALTON H. (1961) Group methods in hospital organization and patient treatment as applied in the psychiatric treatment of alcoholism. AIn. 1. Psych&. 118, 410-418.
A FOLLOW-UP OF ALCOHOLICS TREATED BY BEHAVIOUR THERAPY* B. GEQ. BLAKE Ontario Hospital, Whitby, Ontario, Canada
(Received
10 Uctobcr
1966)
Summary-Follow-up results at 6 and 12 months after discharge from hospital for alcoholics treated by behaviour therapy arc reported. Two groups are compared: a relaxation-aversion and an aversion-only group. At twelve months’ follow-up the indications am that the relaxation-aversion approach to treatment shows some slight advantage over treatment by electrical aversion conditioning alone in an unsekted sample of in-patient alcoholic admissions. The difference is not statistically significant. It is suggested that careful selection of subjects for each type of treat-t on the basis of individual differencea in neurotic drive shoutd further clarify the question.
INTRODUCTION A TECHNIQUE described as relaxation-aversion therapy, along with results at 6 and 12 months’ follow-up of cases treated by this method, was discussed in a previous paper (Blake, 1965). A control group of alcoholics treated by electrical aversion therapy alone, without the aid of progressive relaxation, has since been collected. This report presents the results obtained with this group and compares the outcome with that of the experimental (i.e. relaxation-aversion) sample at the same stages of follow-up. For the purpose of the study, alcoholism has been described as a learned habit of uncontrollable drinking which is used by an individual in an effort to reduce a disturbance in psychological homeostasis. The definition is underpinned by concepts in the reinforcement theory of learning (Kingham, 1958; Kepner, 1964; Dollard and Miller, 1950; Blake 1965, 1966a). The rationale behind such an approach as relaxation-aversion for the treatment of alcoholism has been discussed by writers such as Eysenck (1960), Metzner (1963) and Lazarus (1965). The methodological advantages of electrical techniques of conditioned aversion have been outlined by Me&ire and Vallancc (1964), Blake (1966b) and reviewed in detail by Rachman (1965). SUBJECTS The experimental and control groups contained 37 and 25 Ss respectively. The subjects in each sample were comparable as regards such variables as age, sex, socioeconomic class (by occupation), chronic&y, previous hospitalization for alcoholism, psychiatric diagnosis and intelligence. (Blake 1965, 1966a). l The research was carried out at the Crichton Royal Hospital, Dumfries, Scotland and was supported by a grant from the Medical Research Council.
89
90
B. CEO.
BLAKE
FOLLOW-UP For the purpose of comparison between groups, four outcome categories are defined: The abstinent category includes those individuals who are known to have been abstinent during the whole period of follow-up. Abstinence was assumed if the patient’s own report was supported by observations from individuals who were closely associated with him in one way or another: spouse, relative, G.P., employer, and others. The improved category includes those persons whose drinking was now of a social order (one case: the quantity and type of alcohol as well as his drinking environment being radically different from his former addictive drinking behaviour) and appeared to be in no danger of pathological escalation; or those whose drinking throughout the period of follow-up had been substantially reduced compared with their former level of drinking, with improvement in their general level of adjustment as recognized at the time of admission to hospital. Adjustment is evaluated against the criteria outlined by Knight (1941) and Blake (1965). The relapsed group includes those individuals who had reverted to their former level of drinking with no noticeable adjustment in other areas of social behaviour, or those who had at least one further period of hospitalization for alcoholism since discharge, but did not undergo further behaviour therapy. The fourth category includes those subjects who had opted out of treatment after it had started, those who were lost to follow-up, or those for whom no reliable information as to their drinking and general adjustment since discharge was available. Three subjects opted out of treatment during the course of the research: one male in the relaxation-aversion group and a male and a female in the aversion-only group. In order to accommodate the time-table of the research, the minimum follow-up period was set at 12 months. All 37 subjects in the experimental group and 22 of the 25 controls had completed the scheduled period of follow-up at the time of evaluating the results. Tables 1 to 4 give the breakdown of outcome for the two groups at 6 and 12 months’ respectively. abstinent, improved, relapsed and others.
TABLE
1. SIX
MONTHS'
FOLLOW-UP OF 37 CASESTREATED AVERSION THERAPY
cases
Total
Outcome
Male
Female
BY RELAXATION-
(?I,)
1.
Abstinent
14’
6
20
54
2.
Improved
2
I
3
8
3.
Relapsed
7
3
IO
27
4.
Others
4
4
II
Total
27
37
100
10
A ~oLu)w-UP T~L.E
2.
OF ALCOHOLICS TREATED BY BEHAVJOUR ‘J-JiERAPy
SIX MONTHS’ FOLLOW-UP OF 25 CASES TREATED BY EmaLAVERSION THERAPY ALONE
Outcome Male.
Total
(%I
12
48
3
12
Female
I.
Abstinent
9
2.
Improved
3
3.
Relapsed
4
I
5
20
4.
Others
4
I
5
20
Total
20
5
25
100
TABLE 3.
91
3 -
TWELVE MONTHS’ FOLLOW-UP OF 37 CASES TRBATELI BY J~ELA~ATIONAVERBION THERAPY
cases Outcome
Total Male
FCmalC
C%)
1.
Abstinent
I2
5
17*
46
2.
Improved
3
2
5*
13
3.
Relapsed
8
3
4.
Others
4
-
27
TOtal
IO
11
30
4
11
37
100
* Includes 3 subjects (1 male, 2 female) relapsed, readmitted for further relaxation-aversion and have been abstinent or improved for 12 months since last discharge.
TABLE
4.
TWELVE MONTHS FOLLOW-UP OP 22 CASES TUBATED BY ELEtXItICNAVERSION THERAPY AWNE
Outcome Male
I.
Abstinent
3
2.
Improved
6
3.
Relapsed
4
4.
Others
5
Total
18
* Includes one subject readmitted
Total
(%I
5
23
6.
27
6
27
5
23
22
100
Female
2 2 4
for booster treatment
during follow-up.
therapy
92
B. GEO.
BLAKE
The results at 12 months’ follow-up show that 59 per cent of the experimental sample compared with 50 per cent of the controls were classified as either abstinent or improved. The difference is not statistically significant; it does not, however, refute the hypothesis that in the treatment of alcoholism there is a need to extinguish the drive, fear or anxiety, that motivates the drinking while tackling simultaneously the habit of uncontrollable drinking by conditioned aversion therapy (Metzner, 1963; Blake, 1965). To test the hypothesis rigorously, it would be necessary to select subjects for the experimental sample on the basis of the presence, or absence, of accompanying neurotic anxiety. This procedure had not been adopted in the present study. Taking both groups together 59 subjects have completed a minimum of 12 months’ follow-up. Of these, 56 per cent (33) were classed as abstinent (22) or improved (11). Two male subjects died from heart disease during follow-up: the first, in the experimental group had been abstinent for 13 months; the second, in the control group, had been abstinent for 6 months prior to death. When these two subjects are excluded, the 36 S’s in the experimental sample had a mean period of follow-up of 2.25 years (range 18-37 months): those (24) in the control group had a mean period of follow-up of 1.5 years (range IO-29 months). For these periods 47 and 54 per cent of the experimental and control samples respectively were classified as abstinent or improved. DISCUSSION One of the basic requirements in evaluating the efficacy of any treatment programme is the use of control groups. To this end, a comparison of the results obtained in the study with published reports of other types of treatment for alcoholism, would offer some measure of the value and generality of the method. It has been noted, however (Walton, 1961; Pattison, 1966), that follow-up studies of the treatment of alcoholism have been so heterogeneous that few reliable conclusions can be drawn about either treatment results or methods. The point is illustrated by the observation that often different types of patients may be involved, uniform follow-up procedures are seldom adopted, and terms such as “sober”, may be inadequately defined. From this point of view, know“abstinent”, “improved”, ledge of the status of untreated alcoholics would be a more suitable basis for evaluating the worth of any treatment programme. Valiance (1965, in a two-year follow-up of 62 alcoholics in the psychiatric unit of a general hospital found who had had “first-aid management” that less than 5 per cent were abstinent and altogether about 25 per cent could be considered improved. Kendall and Staton (1965) in a study of 62 untreated alcoholics with a mean follow-up period of 6.7 years found that fewer untreated alcoholics (one case) became abstinent or returned to normal drinking and more died or committed suicide. From this point of view, the results obtained in this study may be taken as a demonstration of the utility of the method. It is planned to set-up a cross-cultural study to evaluate the method further. This work will be based on a North American sample who, in terms of the Registrar General’s classification, would fall into social classes (by occupation) 3, 4 and 5 compared with the subjects in the present study who belonged predominantly to social classes 1 and 2. At the same time the work will of necessity incorporate modifications arising from experience with the technique; considerations will also be given to recent developments in the field of behaviour therapy for the treatment of alcoholism; for example, work reported by Lazarus (1965), Miller et al. (1964), MacCulloch ef al. (1966). One proposal will be to extend the number
A FOLLOW-UP
OF ALCOHOLICS TREATED BY BEHAVIOUR THERAPY
93
of conditioning sessions per subject to 20, with 20 trials per session on a 50 per cent partial reinforcement schedule. It is anticipated that this procedure will reduce the percentage of patients who failed to demonstrate the conditioned response as measured by GSR. It was found that on the conditioning regime reported by Blake (1965) 28 per cent of a sample of 48 S’s failed to demonstrate conditioning (Blake, 1966). An apparatus for aversion conditioning to the smell of alcohol specifically has also been developed. Atttention will also be directed to the development and refinement of methods for measuring conditioning as well as progress in therapy. For, while modification in the conditioning procedure in the directions outlined above may reduce the percentage of nonresponders on GSR measures, it is likely that individuals respond autonomically differently to the same conditioning experience (Eysenck, 1962). In which case it will be important to investigate other autonomic functions, such as rate and depth of breathing, heart rate, EMG, as well as behavioural measures. As regards behavioural measures it is thought that techniques such as those reported by Feldman and MacCulloch (1965); Marks er al. (1965) or repertory grid techniques as developed by Bannister and Fransella (1966) and Fransella and Adams (1966) may repay investigation. wish to thank Dr. W. MCALUM, Consultant Psychiatrist at the Crichton Royal Hospital, in whose unit this work was carried out, and Mrs. J. PARISHfor her help in preparing the manuscript.
Acknowledgements-1
REFERENCES D. and FRANSELLA F. (1966) A grid test of schizophrenic thought disorder. Br. J. sot. clin. Psychol. 5, 95-102. BLAKEB. G. (1965) The application of behaviour therapy to the treatment of alcoholism. Behuv. Res. & IXerapy 3, 75-85. BLAKEB. G. (1966a) An evaluation of the conditioned aversion method of treating alcoholism and of individual differences in response to such treatment. Unpublished Ph.D. thesis, University of Edinburgh BLAKEB. G. (1966b) Alcoholism. Special techniques of therapy. Discovery 27, -7. J~_LARD J. and MILLERN. E. (1950) Personality und Psychotherapy. McGraw-Hill, New York. EY~ENCKH. J. (1960) Bekzviour Therapy and the Neuroses. Pergamon Press, Oxford. EYSENCKH. J. (1962) Conditioning and personality. Br. J. Psycho/. 53, 299-306. FELDMAN M. P. and MACCULLXH M. J. (1965) The application of anticipatory avoidance learning to the treatment of homosexuality. I: Theory, technique and preliminary results. Behov. Res. & Therupy 2. 165-184. FRANSELLA F. and ADMC~B. (1966) An illustration of the use of repertory grid technique in a clinical setting. Br. J. sot. clin. Psychol. 5, 5 l-62. KENDALLR. E. and STA~ONM. C. (1965) The fate of untreated alcoholics. Quurt. J. Stud. Alcohol 26, 685686. KEPNERE. (1964) Application of learning theory to the etiology and treatment of alcoholism. Quart. J. Stud. Alcohol 25, 279-291. KINOHAM R. J. (1958) Alcoholism and the reinforcement theory of learning. Quart. J. Srud. Alcohol 19, 320-330. KNIOM R. P. (1941) Evaluation of the result of psychoanalytic therapy. Am. 1. Psychiut. 98, 434 (Cited in WOLPE,1958). L-us A. A. (1965) Towards the understanding and effective treatment of alcoholism. S. Afr. med. J. 39, 736741. MACZCULUXH M. J., FELDMAN M. P., Oaroan 1. F. and MACCULLOCH M. L. (1966) Anticipatory avoidance learning in the treatment of alcoholism: a record of therapeutic failure. Behuv. Res. & Therupy 4, 187-196. MARKS I. M., RACHMANS. and GELDERM. G. (1965) Methods for assessment of aversion treatment in fetishism and masochism. Behav. Res. & 77wapy 3, 253-258. MCGUIRER. J. and VALLANCE M. (1964) Aversion therapy by electric shock : a simple technique. Br. Med. J. i, 151-153. METZNERR. (1963) Re-evaluation of Wolpe and Dollard/Miller. Behuv. Res. & 77terupy 1, 213-216. BANNISTER
94
B.GEO.BLAKE
MILLER E. C., DVORAK B. A. and TURNERD. W. (1964) A method of creating aversion to alcohol by refkx conditioning in a group setting. In (Ed. FRANKS C. M.) Conditioning Techniquer in Clinical Practice and Research. Springer, New York. P~mso~ E. M. (1966) A critique of alcoholism treatment concepts with special reference to abstinence. Quart J. Stud. Akohol27, 49-71. RACHMAN S. (1965) Aversion Therapy: chemical or electrical. Behov. Res. CGTherapy 2, 289-300. VALLANCE M. (1965) Alcoholism: A two year follow-up study. Br. J. Psychiar. 111, 348-356. WALTON H. (1961) Group methods in hospital organization and patient treatment as applied in the psychiatric treatment of alcoholism. AIn. 1. Psych&. 118, 410-418.