Attrition from conjoint alcoholism treatment: Do dropouts differ from completers?

Journal of Substance Abuse, 6, 249-265 (1994)

Attrition From Conjoint Alcoholism Treatment: Do Dropouts Differ From Completers? Elizabeth E. Epstein Barbara S. McCrady Kevin J. Miller Marc Steinberg Rutgers--The State University of New Jersey

This study addresses patient attrition in order to identify variables associated with retention in conjoint treatment for alcohol abuse and dependence. Subjects were 105 male alcoholics and their partners who participated in a randomized clinical trial of three approaches to conjoint treatment of alcoholism: (a) alcohol and behavioral marital therapy (ABMT); (b) ABMT plus Alcoholics Anonymous and Alanon (AA/ABMT); and (c) ABMT plus relapse prevention (RP/ABMT). Completers (n = 45) attended two assessment and 15-17 treatment sessions. Partial completers (n = 23) left treatment between the 5th and 15th treatment session. Thirty-seven dropouts left treatment between the first assessment session and the 5th treatment session; of these, 22 dropouts completed at least one treatment session (called early treatment dropouts). O f subjects who entered treatment, dropouts from early treatment were least compliant with treatment requirements in the first few sessions, less educated, and less committed to their relationship. Data indicate that therapists with more clinical experience were more likely to retain clients in treatment, regardless of treatment condition. T h e data do not reflect a linear relationship between most variables studied and a continuum of attrition status from assessment to completion of the program.

Patient attrition from outpatient treatment of alcohol use disorders has dropped only slightly since Baekeland and Lundwall's (1975) estimate of 5275% before the fifth session. Dropout rates have ranged from 27-62% before the fifth session, and 74-83% before the 2nd or 3rd month of treatment (Leigh, Ogborne, & Cleland', 1984; Noel, McCrady, Stout, & Fisher-Nelson, 1987; Rees, Beech, & Hore, 1984; Silberfeld & Glaser, 1979; Smart & Gray, 1978; Stark & Campbell, 1988). Attrition continues to be a major problem for the clinical utility of treatment This work was supported by Grant Number AA07070 from the National Institute on Alcohol Abuse and Alcoholism to Barbara S. McCrady. We would like to thank Linda Hirsch, Sandy Hoffmann, and Karen Lewis for their help in preparation of this article. Correspondence and requests for reprints should be sent to Elizabeth E. Epstein, Center of Alcohol Studies, Smithers Hall, Allison Road, Busch Campus, R u t g e r s - - T h e State University of New Jersey, Piscataway, NJ 08855-0969.

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programs and for the scientific validity of treatment outcome research. Clinically, treatment retention has been related to positive treatment outcome (Emrick, 1975). In treatment outcome studies, attrition can introduce systematic bias and thus affect both the external validity (generalizability) and internal validity (ability to draw conclusions) of the research. Given the important implications of treatment attrition, it is not surprising that many researchers have attempted to isolate client and treatment variables that predict treatment completion. Some characteristics that differentiate dropouts from completers have been reported consistently across more than one study, or are robust findings within a single study. Completers have more perceived severity of the alcohol problem (Rees et al., 1984), greater social stability and support (Baekeland, Lundwall, & Shanahan, 1973; Leigh et al., 1984), less time delay between initial contact with the patient and the first session (Leigh et al., 1984), less depression and more internal locus of control (O'Leary, Rohsenow, & Chaney, 1979), greater spouse or family involvement in treatment (Noel et al., 1987), more stable employment (Noel et al., 1987), and less cognitive impairment (Erwin & Hunter, 1984). In addition, clients who complete treatment are more likely to initiate contact with the treatment facility (Noel et al., 1987) and to receive medical interventions (Smart & Gray, 1978). Little consistency across studies (Pekarik & Zimmer, 1992) has been noted for many other variables, including a range of demographic, personality, symptom severity, psychopathology, and treatment factors. Inconsistent findings across attrition studies may be due to the lack of agreed upon definitions of early attrition (Pekarik & Zimmer, 1992; Stark & Campbell, 1988). Some studies use time (weeks or months) in treatment as a dependent variable, whereas others use number of sessions attended before dropout. Some consider any patient who left treatment any time prior to completion of the program a dropout; others divide the treatment program by number of weeks or sessions to create categories such as immediate or early dropouts versus long-term remainers or treatment completers. Siddall and Conway (1988) suggested that study-specific findings and common methodological failures, such as failure to deal with interactions among variables, may contribute to the inconsistency found among studies. Other possible reasons may be the wide range of variables examined across studies and the heterogeneity of treatments and patient characteristics. Additionally, very few studies to date (Keso & Salaspuro, 1990; Noel et al., 1987; Zweben, Pearlman, & Li, 1983) have examined attrition in populations randomly assigned to treatment conditions. Few studies (Noel et al., 1987; Zweben et al., 1983) have looked at attrition from conjoint treatment of alcoholism. Zweben et al. (1983) found that clients seen with their spouses for assessment and treatment were less likely to refuse or drop out of treatment than clients seen individually. Zweben et al. also reported that among couples who are seen in a short-term, communication-interactionbased conjoint therapy program, more social stability was associated with retention in treatment. Social stability was calculated as an index of various factors such as living arrangements and plans, family contact, employment transience, and legal status. In the other published study on attrition from couples therapy,

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Noel et al. (1987) compared treatment refusers, early treatment dropouts, and treated subjects who participated in a random assignment study of levels of spouse involvement in conjoint therapy for alcoholic men. Treatment that most fully involved the spouse, and initial marital satisfaction and client-initiated contact were most strongly associated with completion of the program. The current study examines factors related to attrition in a sample of couples who participated in a highly spouse-involved treatment to see which pretreatment client characteristics, within-treatment client behaviors, and treatment factors were associated with continuance. The research reported here avoids certain problems of previous studies. First, the study examines attrition at several phases in the treatment protocol so that attrition status is not arbitrarily dichotomized. Second, the study was done in the context of a randomized trial testing three variants of a well-defined treatment modality: conjoint treatment for male alcoholics and their nonalcoholic partners. The study was designed to (a)examine the relationships between attrition and pretreatment individual client characteristics that are theoretically relevant to conjoint therapy of alcoholism; (b) examine the relationship between marital relationship variables and attrition from conjoint therapy of alcoholism; (c) see if compliance in early treatment predicts attrition; and (d) test the effects of treatment variables on attrition.

METHOD Subjects Subjects were 105 men with alcohol problems and their nonalcoholic spouses or female cohabitating partners. All couples sought conjoint alcoholism treatment within a clinical research study. Male subjects had a current alcohol problem, had consumed alcohol within the 60 days prior to their first contact with our clinic, and were in a stable, cohabitating relationship with a woman. Exclusion criteria were signs of psychosis or chronic organic brain syndrome, and physical dependence on drugs other than alcohol, assessed during a clinical interview. Couples were recruited through an outpatient addictions treatment program, advertising, employee assistance programs, and community agencies and physicians. O f the 220 persons who made a telephone inquiry about the study, 115 couples were appropriate and attended an in-person clinical assessment. O f these, 5 did not meet inclusion criteria (all for significant drug problems in addition to an alcohol problem), and 5 refused to participate further. O f the remaining 105 couples who gave informed consent, 7 (6.6%) dropped out after the first assessment session (clinical screen dropouts), and 8 (7.6% discontinued participation after the second research assessment session (baseline dropouts). Thus, 90 (86%) couples completed assessment and attended at least one treatment session. O f these, 22 couples (early treatment dropouts; 21% of the entire eligible sample) d r o p p e d out between the 1st and 5th treatment session. In summary, a total of 37 couples consented to the study but discontinued at a point prior to the 5th treatment session (35% of the entire eligible sample). Twenty-three (22%)

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Table 1. Number of Subjects and Dropouts at Different Phases of the Treatment Program Phase of Program

n

(%)

Clinical Screen Ineligible or uninterested Signed consent form Clinical screen dropouts Baseline Interview Baseline Dropouts Assigned to Treatment Early Treatment Dropouts (1-4 sessions) Total Dropouts Partial Completers (5-14 sessions) Completers (15-17 sessions)

115 10 105 7 98 8 90 22 37 23 45

100 6.7 93.3 7.6 85.7 21.1 35.2 21.9 42.9

couples (partial completers) left treatment between the 5th and 15th treatment session. Completers (n = 45, or 43%) attended both assessment sessions and 1517 treatment sessions. Table 1 summarizes subject flow. Table 2 describes the sample. The average age of the male subjects was 39.24, and of the partners was 37.44. Couples were cohabitating (married or nonmarried) for an average of 12.39 years. Average years of education for the sample was 13.39 for the client and 13.69 for the spouse. The sample was primarily Caucasian. Table 2. Descriptive Demographic Information for the Sample of 105 Alcoholic Men and Their Female Partners %

Age Client Partner Years Education Client Partner Years Together Couples Married Ethnicity Black Client Partner Caucasian Client Partner Latino Client Partner Native American Client Partner

88.6

5.7 5.7 92.0 93.0 0.9 0.0 0.9 0.9

M

SD

Range

39.24 37.44

10.67 10.63

24-73 21-73

13.39 13.69 12.39

2.37 2.02 11.75

8-20 12-19 7-51

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Procedure Assessment

Prospective clients or their spouses were interviewed briefly over the phone to determine initial appropriateness for the study. Appropriate couples were scheduled for a 2-hour clinical assessment interview. During this session, couples were further assessed for inclusion in the study, including a mental status exam to assess for organic brain syndrome. Also, drug use and signs of physical dependence were assessed by questions on quantity and frequency of legal and illicit drug use in the past 6 months, and on the client's and partner's reports of negative consequences related to this drug use. This information was used to make DSMHI-R (American Psychiatric Association, 1987) drug abuse and dependence diagnoses. More general questions were asked about lifetime use of illicit drugs. Couples were informed that the study included two assessment sessions, 15 weekly conjoint treatment sessions, and 18 months of follow-up. Subjects completed intake forms, the Michigan Alcoholism Screening Test (MAST; Selzer, 1971) and the SCL-90R (Derogatis, Lipman, & Covi, 1973). Informed consent was obtained. Subjects were given a packet of paper-and-pencil questionnaires to complete at home and were scheduled for a second research assessment session. During the research session, baseline data were gathered by a trained research assistant who assessed the man's drinking history and psychosocial functioning through structured interviews with both partners present so that the partner could give collateral information.

Treatment

After the baseline research interview, couples were randomly assigned to one of three treatment conditions: (a) alcohol behavioral marital therapy (ABMT, n = 30) in which the alcoholic and his partner attended each session and learned basic cognitive-behavioral skills for control of the alcohol problem and for improvement of the marital relationship; (b) Alcoholics Anonymous and Alanon involvement plus ABMT (AA/ABMT, n = 31) in which the therapist facilitated the couple's involvement with AA and Alanon, in addition to the standard ABMT treatment; and (c) relapse prevention plus ABMT (RP/ABMT, n = 29) in which a significant focus was put on relapse prevention during treatment and on a continuing treatment component (booster sessions at I; 3; 6; and 12 months) following the intgnsive treatment phase, in addition to the standard ABMT treatment. All three treatment conditions emphasized a goal of abstinence from alcohol. Therapists followed detailed protocols for each session, using conditionspecific treatment manuals developed by the second author. Each couple was assigned to a therapist for 15 weekly 90-min sessions. Two emergency sessions were allowable, so that the total possible number of treatment sessions was 17. The first few sessions were spent helping the alcoholic become abstinent; later sessions focused more on the marital relationship. Subjects were not compensated financially for participation in this study; however, treatment was provided on a sliding fee scale and no couple was refused treatment if they could not pay.

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E.E. Epstein, B.S. McCrady, K.J. Miller, and M. Steinberg

Therapists Each therapist was trained to deliver all three treatment conditions to reduce the possibility of therapist by treatment bias. Clients were assigned based on availability of therapists. Therapists (7 women and 5 men) were two doctoral level clinical psychologists (first two authors), and 10 advanced graduate students in clinical psychology. All therapists had previous experience with treating substance abusers, and with cognitive-behavioral methods. All therapists underwent standardized training for the study, and participated in a weekly group supervision session. Procedures Regarding Attrition Missed appointments were followed up with a phone call from the therapist to the client to reschedule the session. If clients indicated that they no longer wanted treatment, they were encouraged to continue, or at least to come in again and discuss their reluctance to continue. In every case, therapists attempted to speak with both spouses. Variables and Measures All information was based on self-report of the subject by interview or paperand-pencil questionnaires. Partners were present during the assessment interviews and provided collateral information. When the client and spouse disagreed, they discussed the area of discrepancy until an agreement was reached. Pretreatment Client Characteristics

Demographics. Information about age, ethnicity, years married and/or living together as married, and education were gathered in a self-report intake form. Substance Use Severity and Pattern. The Alcohol Dependence Scale (ADS; Skinner & Allen, 1982) is a 25-item, self-report measure of symptoms and consequences of drinking in the last 12 months. Scores can range from 0-75; a higher score indicates greater severity of an alcohol problem. Internal consistency for this measure is .92. Age of onset of alcohol dependence or abuse was derived from the Composite International Diagnostic Interview Substance Abuse Module (CIDI-SAM; Robins et al., 1988). The CIDI-SAM is a structured interview that yields information regarding DSM-III-R (American Psychiatric Association, 1987) diagnoses, age of onset, and negative consequences from alcohol use. The earliest three alcohol-dependence diagnosis criteria were used to establish age of onset of problem drinking. The Time-Line Follow Back Interview (Sobell, Maisto, Sobell, Cooper, & Saunders, 1980) was administered to determine quantity and frequency of drinking and drinking pattern (binge, episodic, or daily) in the 6 months prior to and following treatment. Current and lifetime frequency and quantity of drug use was assessed at the initial clinical interview, as mentioned previously. Because subjects with moder-

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255

ate or severe drug problems were excluded from the study, drug use during treatment was not recorded. PsychologicalDistress. The S C L - 9 0 R (Derogatis et al., 1973) is a self-report measure of recent psychological distress, assessing nine dimensions of psychiatric symptomatology and one global severity score. Raw scores are converted into T scores. Marital Satisfaction and Commitment. The Dyadic Adjustment Scale (DAS; Spanier, 1976), is a 32-item, self-report measure that yields one global measure of marital satisfaction. Cronbach's alpha for this measure was reported to be .96 (Spanier, 1976). In addition to the global score, one individual item on the questionnaire was used separately in analyses. This item was a 6-point (0-5) Likerttype measure of degree of commitment to the relationship reported by the subject from My relationship can never succeed and there is no more that I can do to keep the relationship going (0) to I want desperately for my relationship to succeed and would go to almost any length to see that it does (5).

Early Treatment Compliance Daily Drinking Log. Drinking behavior in early treatment was measured by self-report daily drinking logs to track consumption of alcohol during treatment. Using a self-recording card, male subjects recorded the number and type of alcoholic drinks they consumed each day. Homework Record. Homework was assigned to each couple at each treatment session. Therapists recorded assignments given and completed in a homework record. Percentage of completed homework was calculated for the first 4 sessions attended. Percentages were used rather than absolute numbers because some subjects attended fewer than 4 sessions.

Treatment Variables Treatment Condition. Couples were randomly assigned to the ABMT, AA/ ABMT, or RP/ABMT treatment conditions. Randomization to treatment condition was successful. Subjects in the three conditions did not differ significantly on demographic variables such as age, education, and years living together, and on pretreatment severity of alcohol use and alcohol-related consequences.

Therapist Characteristics. Therapists' history of providing therapy ranged from 15 years of postdoctoral practice to a 1-year predoctoral practicum. Certain therapists had extensive experience as mental health aides, but only limited supervised therapy experience. Thus, a weighted sum was calculated to reflect therapists' prior clinical experience, which varied in length and quality. Clinical experience at different levels of training was rated differently, giving a weight of 1 to each post-bachelor clinical hour, 2 to each post-master's clinical hour, 3 to each psychology internship clinical hour, and 4 to each postdoctoral clinical

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E.E. Epstein, B.S. McCrady, K.J. Miller, and M. Steinberg

hour. Clinical hours were multiplied by the weights, then totaled, and divided by 100. The weighted scores ranged from 8 to 424 (M = 54.19, SD = 79.98). Other variables examined were therapists' gender and attrition rates in each therapist's caseload.

Data Analysis For certain analyses that involved self-report paper-and-pencil questionnaires, 2 subjects' self-report data were deleted from analyses because 1 subject showed increasing evidence of intellectual dysfunction over time and the other was illiterate. Statistical analyses included analysis of variance (ANOVA) to examine continuous variables in relation to dropout status, and chi-square analyses where appropriate to examine categorical variables in relation to dropout status. Tukey studentized range tests were used to examine post hoc differences at the .05 alpha level. For variables with non-normal distributions, Kruskal-Wallis nonparametric tests were used (p values shown beneath Table 3). Because, as Table 3 indicates, the nonparametric results were similar to the parametric tests for all but one variable (mean drinks per drinking day, pretreatment), parametric results are discussed in the text. Multiple statistical tests increased the possibility of Type I errors. The Bonferroni-corrected p value for the study is .003, so that p values higher than .003 should be interpreted with caution. Multivariate analyses (discriminant function analysis and stepwise discriminant analysis) were done to test classification and relative predictive power of variables that were shown to be influential in the univariate analyses. RESULTS Pretreatment Client Characteristics Demographics ANOVAs comparing all five groups found trends toward significant differences on age, F(4, 98) -- 2.41, p < .055, and years married or living together, F(4, 100) = 2.21, p < .07. Specific mean comparisons showed that baseline dropouts and partial completers tended to be younger and married for fewer years than the other groups (see Table 3). Follow-up ANOVAs that included only subjects who actually entered treatment were done for education and years married as they were considered to be particularly relevant for treatment engagement in cognitive-behavioral conjoint therapy. We reasoned that the marital treatment, as opposed to assessment, might have a differential effect (in terms of treatment retention) on couples married longer. Education was examined separately for subjects who started treatment because there seemed to be variability in the response of subjects to more complex aspects of cognitive-behavioral treatment (e.g., functional analysis, problem-solving skills, etc.). Significant main effects were found for length of time married or living together, F(2, 87) = 3.43, p < .04, and education, F(2, 85) = 3.67, p < .03, for early treatment dropouts versus partial completers versus completers. Partial completers had been married or

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living together for fewer years than dropouts or completers. Subjects who remained in treatment longer had more years of education than those who discontinued treatment prematurely.

Pretreatment Alcohol Use: Severity and Pattern As sample sizes were relatively small and multivariate analyses of variance (MANOVAs) delete cases with any missing values, ANOVAs were performed in order to minimize numbers of deleted cases for the pretreatment severity analyses. There was a significant main effect for mean drinks per drinking day in the 6 months prior to treatment, F(3, 91) = 5.13, p < .003. Post hoc Tukey tests showed that subjects who dropped out after the baseline interview drank significantly more than early treatment dropouts and completers. The distribution for the baseline dropouts was unusual and the nonparametric tests showed a p value of .055. Drinking variables that did not significantly differentiate five attrition groups included: age of onset of alcohol problem, number of years of heavy drinking, percentage of possible alcohol-related negative consequences (as measured by the CIDI-SAM), ADS score, and percentage of drinking days in the 6 months preceding treatment. Psychiatric Distress The groups did not differ on the SCL-90R Global Severity Index. Marital Satisfaction and Commitment There was no relationship between overall marital satisfaction (measured by the DAS) and subject attrition, but an ANOVA that included all subjects to test the item measuring marital commitment was significant, F(3, 85) = 2.69, p < .05. A post hoc Tukey test showed that early treatment dropouts were less committed than partial completers. Compliance in Early Treatment Percentage of Homework Completed in Early Sessions The ANOVA for percentage of assigned treatment homework completed by the client was significant, F(2, 66) = 15.62, p < .0001. Post hoc tests showed that dropouts completed a lower percentage of assigned homework during the time they were in treatment than did partial completers and corrtpleters during the first 4 sessions of their treatment. Drinking During Early Treatment A MANOVA was done to test the relationship between attrition and drinking during early treatment (mean drinks per drinking day and the percentage of drinking days in Sessions 2-4). No significant differences were found between attrition and drinking behavior in early treatment.

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Treatment Variables Treatment Condition There was no relationship between treatment condition (ABMT vs. AA/ ABMT vs. RP/ABMT) and attrition status. Therapist Characteristics A chi-square analysis comparing attrition status for individual therapists' clients was nonsignificant. (Cell sizes were small, however, because there were 12 therapists; this minimized the chances of finding significance.) Level of clinical experience of the therapist differentiated attrition status, F(2, 87) = 3.48, p < .04: Completers had more experienced therapists than did dropouts or partial completers. One therapist had many more hours of clinical experience than the others and was an outlier in this regard so she was eliminated from the analyses. Results were still significant, F(2, 83) = 3.40, p < .04. Multivariate Analyses A discriminant function analysis was done for subjects who entered treatment to test classification of attrition status using variables shown to be influential in previous analyses. Years of education, years married or living together, percentage of homework done in early treatment, marital commitment, and therapist clinical experience together correctly classified 70% of the subjects who entered treatment. A stepwise discriminant analysis procedure was done for subjects who entered treatment to see which of the influential variables were most important in predicting attrition. Percentage of homework done (R 2 = .30), therapist's clinical e x p e r i e n c e (R 2 = .07), and years married or living together (R 2 = .07) were most predictive and together accounted for 44% of the variance in attrition.

DISCUSSION This study used a well-defined, well-controlled, manual-driven couples' treatment protocol as a vehicle through which to study treatment attrition. Extensive assessment, specific treatment conditions, and clear within-therapy tracking allowed us to examine many factors that may contribute to attrition, including pretreatment client'characteristics, marital satisfaction and commitment, compliance in early treatment, and treatment factors. T h e design of this study provides a unique opportunity to examine attrition rates from assessment separately from treatment. This is important for two reasons. First, as the literature on heterogeneity of the alcoholic population grows, assessment and diagnostic information may become more important in the treatment services arena, and may become a standardized first part of any treatment program. Thus, examination of factors related to attrition from this phase of "treatment" will become important in preventing attrition following assessment. Second, research on brief intervention for alcohol problems (Rotgers, 1993) is

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expanding and showing promise for attenuating the development of alcohol problems. Brief interventions may range from a few minutes of assessment and advice to 5 sessions of treatment. According to the brief intervention model, the two assessment sessions described in this study may merit consideration as treatment interventions, and attrition from this phase of "treatment" becomes important. In our sample, 25% of the 60 couples who left treatment before the 15th treatment session dropped out of the program at some point during the assessment period. Fifty-eight percent of the noncompleting sample dropped out of the program after attending the clinic a total of five times, or, after attending two assessment sessions and 3 actual treatment sessions. These rates suggest that couples who leave treatment are likely to do so early on; if they remain in treatment long enough to have two assessment sessions and 3 treatment sessions they are likely to complete the entire course of treatment.

Characteristics of Attrition Status Groups Table 4 summarizes pretreatment characteristics, compliance with treatment, and treatment differences among the five groups. Because certain analyses were done again using only subjects who entered treatment, the significance levels of these analyses are listed below Table 4. Subjects who dropped out of the program after the clinical assessment were among the oldest in the sample (p < .06) and were married for a relatively long time (p < .07; these two variables are, of course, related). Clinical screen dropouts, on demographic variables, look most like the group of subjects who completed all 15 sessions in terms of social stability. More information was available about the subjects who dropped out after the baseline research assessment. These subjects were among the least socially stable, with the most severe daily drinking habit. This group of baseline dropouts looked similar to the group of partial completers (i.e., those who began treatment but did not finish the entire protocol) on most of the pretreatment client characteristics measures. Thus, few variables in our sample suggest which clients will drop out during the assessment phase. In fact, clients who dropped out immediately after initial screening tended to be quite different than those who completed the entire assessment but did not begin treatment. Further research on attrition from assessment and brief treatment needs to be done. Once a client entered treatment, clients who completed varying amounts of treatment were quite distinguishable. Early treatment dropouts (subjects who began treatment but left before the 5th session) were relatively less educated, drank relatively few drinks per day, and were less committed to their marriage than the rest of the sample. Given that their alcohol-use history most closely matches the subjects who completed all treatments, it may be that these subjects are identifiable based on their level of marital distress, rather than severity of drinking history. Early in treatment these subjects are easy to identify based on their low degree of compliance with early homework assignments.

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Couples who left treatment after 5 therapy sessions but before the end of treatment (partial completers) looked more like baseline dropouts than like early treatment dropouts or treatment completers. They were the youngest group, relatively less educated, and had been living together fewer years. They also had relatively severe (in terms of drinks per day) drinking careers. This group reported strong relationship commitment. The completers were among the most socially stable (oldest and most educated subjects, married a relatively long time). Completers drank the least number of daily drinks pretreatment and were very compliant in early treatment. Variables Associated With Attrition From Marital Treatment of Alcoholism, and Treatment Implications Baseline Marital Satisfaction and Commitment Commitment to the marriage, rather than subjective report of happiness in the marriage, was related to attrition from marital therapy. In using conjoint alcoholism treatment with a broader population, it would be important to assess marital commitment routinely at the beginning of treatment and plan the treatment strategy accordingly to maximize chances of completion. Level of Education More highly educated people remained in treatment longer; it may be necessary to tailor the level of conceptual difficulty of the sometimes complicated cognitive behavioral therapy to the educational level of the client. These findings echo those of Kadden, Cooney, Getter, and Litt (1989) who found that skillstraining treatment for alcoholism was less effective for cognitively impaired patients than for others. Social Stability Our results partially replicate those of Zweben et al. (1983): Higher social stability is related to retention in couples treatment. Social stability is measured differently in our sample, however. Older, more educated couples who were married longer and were committed to their relationship were among the treatment completers. Compliance in Early Treatment Percentage of homework completed by the client in the early treatment sessions was strongly related to dropout status. Noncompliance with homework requirements in early treatment may be a marker for high risk of attrition. Therapists' Clinical Experience We cannot determine, through this design, if therapists' clinical experience was causative in retaining patients. However, assignment to therapists was done based on caseload availability and mutually convenient schedules, rather than using any systematic couple-therapist matching. More clinically experienced

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therapists were able to retain couples in treatment better than less experienced therapists. The therapist-patient relationship was more important in retaining patients than was the type of conjoint treatment delivered. The importance of the therapist-patient relationship in treatment success has been highlighted by others (Miller, Benefield, & Tonigan, 1993). Our findings suggest that conjoint treatment of alcohol problems appears to be delivered best by clinically experienced therapists, as this type of treatment is difficult (McCrady & Epstein, in press) for martial therapy novices. Alternatively, beginning therapists should be given extensive and close supervision when learning how to provide this type of therapy. D i r e c t i o n s for Future R e s e a r c h

Our data do not reflect a linear relationship between subject characteristics studied and the continuum of dropout-partial completer-completer. This may be why multiple regression-based analyses of prediction of dropout in other studies have not yielded consistent results; those analyses test a linear relationship between predictor variables and length of time in treatment, which is not an appropriate dependent variable to examine attrition, according to our findings. The results indicating that more clinically experienced therapists were able to retain couples longer in therapy merits further investigation. Treatment process research might be done, ideally in a randomized clinical trial of experienced versus less experienced clinicians, to examine differences in experienced therapists' (vs. less experienced therapists') behaviors during treatment. Our results on initial psychological distress as measured by the S C L - 9 0 R were were not statistically significant. Our assessment battery did not cover Axis I and II disorders; it was our clinical impression, however, that subjects who suffered from severe anxiety and those who demonstrated characterological problems, were less tolerant of demands made by the treatment program. Future research might include a structured diagnostic interview to examine effects of Axis I and II psychopathology more directly in conjoint treatment of alcohol problems. As a whole, rates of attrition in our study were lower than in many other studies of individual or group therapy. This replicates previous research (Noel et al., 1987; Zweben et al., 1983) showing that spouse-involved therapy is related to retention in alcohol tFeatment. Different dropout rates for high versus low marital commitment in our sample suggest that marital commitment may be a variable mediating compliance with conjoint alcoholism treatment. Finally, it should be noted that this study was done on male alcoholics. Very little is known about women's attrition from treatment for substance abuse, and should be studied in future research. REFERENCES

American PsychiatricAssociation. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author.

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