Fostering self-change among problem drinkers: A proactive community intervention

Addictive Behaviors, Vol. 21, No. 6, pp. 817-833,19% Copyright 0 1996 Elsevier Science Ltd Printed in the USA. All rights reserved 0306-46031% $15.00 + .oO

Pergamon

PII s0306-4603(%)ooo39-1

IV. Alcohol Abuse: Nick Heather, Chair

FOSTERING SELF-CHANGE AMONG PROBLEM DRINKERS: A PROACTIVE COMMUNITY INTERVENTION LINDA C. SOBELL,“? JOHN A. CUNNINGHAM,t MARK B. SOBELL,*t SANGEETA AGRAWAL,t$ DOUGLAS R. GAVIN,t§ GLORIA I. LEO,? and KAREN N. SINGHtS *Nova Southeastern University, Ft. Lauderdale, Florida TAddiction Research Foundation, Toronto, Ontario, Canada $University of Toronto, $York University, Toronto Abstract-This paper describes the rationale and design for a recently implemented study involving a community-based intervention designed to foster self-change for individuals who otherwise would be unlikely to seek formal help or treatment for their alcohol problem. The study is based on research examining natural recovery processes with alcohol abusers and on clinical trials using a Guided Self-Change model of treatment with problem drinkers. Advertisements and mailed pamphlets are used to solicit individuals who wanted to change their drinking on their own using self-help materials. Respondents are screened and, if eligible, are randomly assigned to two conditions: Guided Self-Change (GSC) or Educational Materials Control (EMC) (projected N = 788). All subjects complete and mail in several brief assessment forms. Subjects in the GSC group receive advice and personalized feedback based on their assessment answers. Subjects in the EMC group receive educational pamphlets prepared for general medical and mental health settings. Subject characteristics and drinking-related history variables for the first 10% of the sample are presented. Subjects will be followed up at 12 months following the intervention.

For years, the alcohol field has been dominated by an almost exclusive focus on individuals who are severely dependent on alcohol (Sobell & Sobell, 1993b). However, epidemiological studies have demonstrated that severely dependent individuals constitute a very small portion of the population with alcohol problems (Cahalan, 1987; Institute of Medicine, 1990; Room, 1977). The emphasis on severe dependence has resulted in a myopic view of the disorder that characterized it as progressive, irreversible, and resolved only through treatment. However, viewing alcohol problems as lying along a continuum ranging from no problems to mild problems to severe problems has profound implications for how we view and treat individuals with alcohol problems. One implication is that there are multiple pathways to recovery, including some, such as natural recovery, that have largely been ignored by the addictions field. The study described in this paper represents a convergence of research examining natural recovery processes with alcohol abusers (Sobell, Sobell, & Toneatto, 1992; Sobell, Sobell, Toneatto, & Leo, 1993), and clinical trials using a Guided Self-Change (GSC; Sobell & Sobell, 1993a; Sobell, Sobell, & Gavin, 1995a) model of treatment with problem drinkers. The study involves a community-based intervention designed to foster self-change for individuals who otherwise would be unlikely to seek formal help or treatment for their alcohol problem. Subjects are being sought through advertisements asking for individuals who want to change their drinking on their own using The research presented in this paper was supported in part, by a grant (AA08593) from the National Institute on Alcohol Abuse and Alcoholism. Requests for reprints should be sent to L. Sobell, Nova Southeastern University, Center for Psychological Studies, 3301 College Ave., Fort Lauderdale, FL 33314, USA. 817

818

L. C. SOBELL

et al

free mail-out self-help materials. The intervention is designed to take account of three factors that have been found to be associated with problem drinkers who do not seek formal help or treatment: (a) the stigma or embarrassment of being in treatment for alcohol problems (reviewed in Cunningham, Sobell, Sobell, Agrawal, & Toneatto, 1993b); (b) a desire to “change on their own” (reviewed in Cunningham et al., 1993b); and (c) little belief by the general public that self-change is a viable pathway to recovery (Cunningham, Sobell, & Chow, 1992.1993a). The first part of this paper outlines the conceptual framework upon which this intervention is based. Then the design and methodology of the study are presented. Lastly, because recruitment into the trial began just recently, only subject characteristics and drinking-related history variables for those subjects recruited to date (about 10% of the total sample) are presented.

CONCEPTUAL THE

IJNDERPINNINGS INTERVENTION

OF

Natural recoveries Once considered a neglected area of study, in the last decade considerable attention has been given to research on natural recoveries from alcohol problems. Although for many years there was disagreement about the exact prevalence of natural recoveries from alcohol problems, there was little question that significant numbers of individuals recover in this manner. A sizable body of epidemiological and longitudinal studies of alcohol problems in the general population has now demonstrated that the prevalence of natural recoveries (also referred to as spontaneous remission, self-change, untreated remission, or spontaneous recovery) is greater than previously suggested (Fillmore, 1988). In fact, two Canadian population surveys have shown that self-change is the predominant (77.5% and 77.7%, respectively) pathway to recovery from alcohol problems (Sobell, Cunningham, & Sobell, 1996). A notable finding of most natural recovery studies is that such recoveries are especially prevalent for individuals mildly to moderately dependent on alcohol and drugs as opposed to those who are severely dependent (Biernacki, 1986; Fillmore, 1988; Sobell et al., 1996; Sobell et al., 1993; Waldorf, Reinarman, & Murphy, 1991). Decisional Balance Theory (cognitive appraisals/evaluations) As interest in the area of natural recoveries has grown, so has the search for knowledge about the processes antecedent and consequent to the self-change process. The few studies that have examined the processes associated with self-change all suggest that in many cases a cognitive appraisal process appears to facilitate the resolution of alcohol problems in the absence of treatment. For example, one study found that the majority of persons (57%) who recover without treatment engage in a cognitive appraisal process, which can be characterized as weighing the perceived costs and benefits of continuing to drink against those of reducing or stopping drinking and deciding that the adverse consequences of excessive drinking outweigh the benefits (Sobell et al., 1993). A cognitive appraisal process has been reported in other studies of naturally recovered alcohol abusers (Granfield & Cloud, 1996; Klingemann, 1991a, 1991b; Ludwig, 198.5; Tucker, Vuchinich, & Gladsjo, 1991), and also has been found to be associated with the long-term recoveries of treated alcohol abusers (Amodeo & Kurtz, 1990). Similar processes have also been reported for cocaine and heroin addicts who have recovered on their own (Biernacki, 1986; Waldorf et al., 1991; Toneatto et al., 1994).

A proactive community intervention

819

Alcohol abusers whose recoveries are associated with cognitive evaluations (as opposed to recoveries precipitated by discrete events) are of particular interest as these recoveries have implications for clients in treatment as well as for individuals who want to change their drinking but who would otherwise not seek treatment. If a cognitive appraisal process (e.g., generating a balance sheet evaluating the pros and cons of continuing to use and of not using) facilitates the resolution of alcohol problems, then outcomes for problem drinkers might be improved by their engaging in a cognitive appraisal of their alcohol use. The intent of such an exercise would be (a) to accentuate or make more salient the costs of the person’s drinking; (b) when possible, to lessen the perceived rewards of drinking; (c) to make apparent the benefits of change (i.e., recovery), and (d) to identify potential obstacles to change (e.g., costs of changing). Applying this approach, individuals formulate their drinking concerns as a payoff matrix or balance sheet of “pros” and “cons” for different courses of action. Over the years, Janis and Mann have used a decisional balance sheet procedure with some success to encourage behavior change with different populations (Colten & Janis, 1982; Hoyt & Janis, 1975; Janis & Mann, 1968; Mann, 1972). A decisional balance process has also been used with smokers (Velicer, DeClemente, Prochaska, & Brandenburg, 1985) and for weight loss (O’Connell & Velicer, 1988). Although the notion of performing a cognitive appraisal of one’s drinking has been discussed in the literature (Allsop & Saunders, 1989; Orford, 1986; Orford & Keddie, 1986; Saunders & Wilkinson, 1990), this has usually been in relation to preventing relapses to drinking. Decision theory (Janis & Mann, 1977) which has been put forth as an explanation for relapses (Allsop & Saunders, 1989; Orford, 1986; Saunders & Allsop, 1987), can also explain how alcohol abusers resolve their alcohol problems. Self-change approaches

Self-change approaches are usually part of brief interventions that help alcohol abusers analyze and guide their own behavior change. Factors associated with the development of self-change approaches (Sobell & Sobell, 1993a) include: (a) the need for outpatient treatments for persons whose alcohol problems are not severe; (b) demonstrations that for many individuals brief interventions are as beneficial as more intensive interventions (Bien, Miller, & Tonigan, 1993; Miller et al., 1995); and (c) an emphasis on self-control processes in the evolution of cognitive-behavior therapy (e.g., Mahoney & Lyddon, 1988; Thoresen & Mahoney, 1974). The success of brief self-change interventions for problem drinkers suggests that such individuals possess sufficient skills, before entering treatment, to function effectively. This, in turn, suggests that the major function of these treatments might be motivational-to catalyze individuals’ use of their own resources to bring about behavior change. A recent study provides some support for the idea that self-change approaches and minimal interventions might appeal to adult drinkers (Werch, 1990). In this study, over one quarter of all adult drinkers reported an interest in receiving aids to help them drink more moderately. Moreover, drinkers who were interested in receiving one or more self-help aids reported high levels of drinking and a greater motivation to limit their alcohol use. This study suggests that a considerable number of drinkers, especially heavier drinkers, would be receptive to aids to help them drink less. The applicability of brief self-change approaches to a community context was demonstrated in a recent study by Sitharthan, Kavanagh, and Sayer (1996). They evaluated a 4-month intervention delivered by correspondence for problem drinkers. This study compared a cognitive-behavioral therapy (CBT) intervention (Sitharthan & Ka-

820

L. C. SOBELL

et al.

vanagh, 1990) with a minimal intervention (MI) (e.g., educational material and suggestions to self-monitor drinking). After 4 months, the CBT group showed a significantly greater drop in alcohol consumption than the MI group; this difference was maintained at 12 months despite the MI group being given the CBT materials at 4 months. In a review of brief interventions, Heather concluded that “Evidence shows that brief interventions are effective and should be used for individuals who are not actively seeking help at specialist agencies. This justification is, again independent of level of seriousness, although most recipients of community-based interventions will obviously have problems of a less severe variety” (Heather, 1989, p. 366). Motivational Interventions Motivation has become a key issue in cognitive behavioral interventions with alcohol and other drug abusers. Miller and Rollnick (1991) view motivation as a state that is changeable and reflects various features of a person’s history and the presenting situation. As part of his general cognitive social learning theory of behavior Bandura also discusses variables that can affect motivation (Bandura, 1986). Goal choice is a good example of one such variable. In Bandura’s theory goals represent internal standards used by people to evaluate their own performance. He posits that under certain conditions (e.g., when goals are explicit, proximal, and viewed as attainable) people strive to make their performance match their goals (i.e., having goals increases motivation). He further hypothesized that “it is commitment under conditions of perceived choice that mobilizes self-evaluation in support of goal adherence” (Bandura, 1986, p. 478). In other words, clients will be more motivated to comply with a treatment strategy when they perceive themselves as having chosen to pursue that strategy. In a recent study of predictors of successful smoking cessation, the person’s motivational level was found to be the most important predictor variable (Richmond, Kehoe, & Webster, 1993a). The research literature suggests that treatments for not severely dependent alcohol and drug abusers should emphasize increasing and maintaining motivation to change. Such an emphasis is especially important because such individuals have not yet experienced severe consequences of their alcohol or drug use and, therefore, have less incentive to abandon the behavior. In their book on motivational interventions, Miller and Rollnick (1991) identified several ways that motivation can be enhanced: provision of advice; removal of barriers to change: allowing clients as much perceived choice as possible in the treatment process; decreasing the attractiveness of substance use; arranging external contingencies to encourage and support change; providing personal feedback about the effects of alcohol and drug use as a way of reinforcing progress in treatment; setting clear and feasible goals; and expressing a helping attitude. Problem drinkers, the underserved majority The report by the Institute of Medicine (1990) suggests that the ratio of problem drinkers to those seriously dependent on alcohol is about 4:l. While the exact ratio varies as a function of the definitions invoked, the important point is that the population of “problem drinkers” is not only quite large, but considerably larger than the population of persons who are severely dependent on alcohol (Kristenson, 1987; Room, 1980; Skinner, 1990; Sobell & Sobell, 1993a). For present purposes, problem drinkers can be considered to be persons who have identifiable alcohol problems, but who have not experienced severe consequences or serious alcohol withdrawal symptoms. The ratio of untreated to treated alcohol abusers ranges from a conservative estimate of 3:l to a liberal estimate of 13:l (Roizen, Cahalan, & Shanks, 1978; Sobell et al.,

A

821

proactive community intervention

1992). Many of the untreated are persons whose problems are not severe. Until very recently, most of the available services have been very intensive and targeted at the small percentage of individuals with severe alcohol problems, to the virtual exclusion of programs for problem drinkers. What the research literature tells us about this large population of problem drinkers is that they often respond well to nonintensive, brief self-change interventions aimed at helping them assert control over their behavior (Sobell & Sobell, 1993a). Because such services are unavailable in most communities, one possible explanation for the large number of untreated alcohol abusers may relate to the fact that few appropriate and appealing interventions are available for problem drinkers (Sobell & Sobell, 1993a). Summary

Because the vast majority of individuals with alcohol problems are unlikely to enter traditional alcohol treatment programs, one alternative is to “take the treatment” to them. There is a serious need for developing and evaluating alternative minimally intrusive interventions that appeal to problem drinkers. Efficient methods of fostering self-change in community settings would allow for widespread impact on alcohol problems and at a much lower cost than outpatient services. RESEARCH

DESIGN

AND

METHOD

Subjects

Eligible respondents have to be of legal drinking age (219 years of age in Ontario). Respondents who call in response to an advertisement or a pamphlet are screened for a history of previous treatment or formal help for alcohol problems. The definition of formal treatment is the one that was used to screen subjects in our natural recovery study with alcohol abusers (Sobell et al., 1992): any intervention by formally recognized programs or individuals whose main goal is to treat people who have alcohol problems, or any other treatment specifically addressing alcohol problems [e.g., alcohol treatment rehabilitation centers, outpatient, inpatient, public and private alcohol treatment facilities or programs providing services for alcohol abusers; use of anti-alcohol drugs-Antabuse. temposil; no more than two Alcoholic Anonymous (AA) meetings or similar self-help groups when attended by respondents to deal with their own drinking problem; professional counseling for alcohol problems; and treatmentoriented drinking driver courses]. Participation in alcohol-related treatment of any duration, even one session, is considered treatment because of the growing number of studies showing that brief interventions can be effective (Bien et al., 1993). Some types of warnings or advice are not considered as formal help or treatment, including nondiagnostic warnings or interventions by friends, relatives, and ministers; diagnostic warnings by physicians; and detoxification for alcohol withdrawals with no concurrent or subsequent treatment or counseling. Individuals with a prior treatment history are referred to an appropriate local treatment agency, if they desire. Excluding people with a history of prior treatment is intended to insure that more severely dependent alcohol abusers are not included in a brief intervention. Eligible respondents also have to report drinking on average 212 standard drinks (SDS; 1 SD = 13.6 g absolute alcohol) per week or having consumed at least 5 SDS on ~-5 days in the past year. Respondents who do not have a drinking problem according to these criteria (Addiction Research Foundation and Canadian Centre on Substance Abuse, 1993; National Institute on Alcohol Abuse and Alcoholism, 1992) are

822

L. C. SOBELL

et al

ineligible. Such individuals are sent educational materials if they so desire, and/or are offered a referral to an appropriate treatment agency. Potential subjects who respond to advertisements or mailed pamphlets and who meet the initial study criteria are sent a consent form and several brief baseline questionnaires assessing drinking and related behaviors. The assessment materials are mailed to subjects with instructions that completing the materials will help them to better evaluate their current drinking. Respondents are asked to sign the consent and return it with the assessment materials in a preaddressed, stamped envelope. Upon returning the consent and questionnaires. subjects who meet all remaining study criteria are randomly assigned to one of two groups: (a) Guided Self-Change (GSC; n = 394 projected. or (b) Educational Materials Control (EMC; II = 394 projected). For respondents in the GSC group, the materials are computer analyzed and results are sent back to respondents with instructions that they can use the personalized materials to guide their own change. Respondents in the EDMC group are not sent personalized feedback but instead receive two educational pamphlets. Subjects who fail to return their baseline questionnaires are sent a reminder letter to return their questionnaires. All respondents are told that the evaluation for most individuals consists of being contacted by mail and phone after 12 months to evaluate whether the materials were of any help and what their drinking was like over this 12-month period. They are also told that this 12-month evaluation will provide them with a pre-post program profile showing changes they have made in their drinking (the pre-post profile will be sent to all followed-up respondents after the follow-up). To address questions about the validity of alcohol abusers’ self-reports, a random sample of 10% of each group (40 per group) will be offered $100 for an in-person interview and provision of a collateral informant who will be asked independently to provide information about the respondent’s drinking and related behavior in the past year. This subsample of respondents will be breath tested before their interview using a portable breath tester. Assessment Measures The following questionnaires

are mailed

out to all respondents

at baseline.

Daily drinking 12 months preintervention. Potential respondents are asked to reconstruct their daily drinking over the past 12 months as best they can using a Timeline Followback (TLFB) calendar (Sobell & Sobell. 1992. lYY6a). Included with the TLFB calendar is a one-page set of instructions for self-administering the TLFB along with a standard drink conversion card. Alcohol Use Disorders Identification Test (AUDIT). The AUDIT is a l&item questionnaire that covers the domains of alcohol consumption, drinking behavior. and alcohol-related problems (Saunders. Aasland, Babor, De La Fuente, & Grant. lYY3). The AUDIT was designed to identify (a) hazardous drinkers (i.e., those whose drinking increases their risk of alcohol-related problems, although alcohol-associated harm may not yet have occurred); (b) harmful drinkers (who have had recent physical or mental harm from their drinking, but who are not alcohol-dependent): and (c) people with alcohol dependence. Brief assessment. A 4-page shortened version of the core assessment questionnaire used in the Guided Self-Change Unit (Sobell & Sobell. 1995) at the Addiction Research Foundation is used to collect demographic (e.g., education, gender, current em-

A proactive community intervention

823

ployment and marital status, age) and alcohol-related history data (e.g., years drinking problem, alcohol arrests, alcohol-related consequences, previous quit attempts, smoking history). Measures ofmotivation to change drinking. Although alternative motivational scales exist because assessment in a brief intervention should also be brief, this study is using a four-question scale that has been used with smokers (Richmond et al., 1993a). The question wordings were changed to inquire about drinking. A composite motivation score is obtained with a possible range of zero to 10 based on the sum of responses to the four questions: (a) “Would you like to reduce or quit drinking if you could do so easily?” No = 0; Yes = I); (b) “How seriously would you like to reduce or quit drinking altogether ?” (scale of 0 = not at all to 3 = very seriously); (c) “Do you intend to reduce or quit drinking in the next two weeks ?” (0 = definitely no to 3 = definitely yes); and (d) “What is the possibility that 12 months from now you will not have a problem with alcohol ?” (0 = definitely no to 3 = definitely yes). As in previous studies with outpatients, (Sobell, Sobell, & Leo, 1993; Sobell & Sobell, 1993a, 1995), all respondents are asked the following two questions: (a) “At this moment. how important is it that you change your current drinking?” (0 to 100; 0 = not important at all, 100 = the most important thing in my life); and (b) “At this moment, how confident are you that you will change your current drinking?” (0 to 100: 0 = I do not think I will change, 100 = I think I will definitely change). Brief Situational Confidence Profile (BSCP). The BSCP is a variation of the Situational Confidence Questionnaire (SCQ; Annis & Graham, 1988,1995) by which respondents indicate their ability to resist urges to drink heavily in eight types of situations. Identification of current areas of high-risk drinking is a hallmark of cognitive-behavioral treatment programs (Marlatt & Gordon, 1985; Sobell & Sobell, 1993a). Experimental Groups Guided self-change (GSC) group. Respondents in this group receive a motivational intervention using advice feedback materials. The advice feedback materials have been used in Guided Self-Change treatment of problem drinkers (Sobell, Sobell, Brown, & Cleland, 1995). Because many untreated problem drinkers do not view their drinking as serious enough to warrant seeking treatment (Hingson, Mangione, Meyers, & Scotch, 1982; Werch, 1990), the advice feedback materials are intended to foster self-change by getting drinkers to view their heavy drinking from a new perspective (e.g., risks to their health; heaviness of their drinking in relation to national survey data; amount of money spent on drinking). Further support for providing such feedback comes from a general population survey where most respondents said they first recognized a problem by the volume of their intake (Hingson et al., 1982). Two studies using advice feedback with smokers suggest that for problem drinkers similar advice related to their drinking might be an effective intervention. In one study subjects who received a leaflet on how to stop smoking along with individualized advice about their smoking habits had “a statistically significant increase in the rate of reported and maintained cessation” (Ledwith, 1984, p. 336) as compared to subjects who received only the leaflet or who received nothing. Another study with smokers (Curry, Wagner, & Grothaus, 1991; Curry, Louie, Grothaus, & Wagner, 1992) evaluated whether personalized feedback about their smoking behavior and health concerns would affect initial and sustained quitting. Personalized feedback appeared to

824

L. C. SOBELL

et al.

have its greatest impact in the early stages of change as subjects who received the feedback were about twice as likely to quit smoking compared to a control group and about three times as likely as two other groups that received monetary incentives. Although the change was sustained, it appears that the feedback increased the confidence only of the early quitters. Based on their assessment responses, each respondent in the GSC group is sent a 6-page personalized feedback summary titled “Where Does Your Drinking Fit In?” (see Appendix A). This summary includes: (a) information from their TLFB calendar (Sobell & Sobell, 1992, 1996a, 1996b) about their drinking in the past year. economic costs, and the estimated average number of calories consumed from alcohol per drinking day. Also included are two charts that allow respondents to evaluate the heaviness of their drinking in relation to national norms by gender and potential alcohol-related health consequences; (b) a scale showing the relative severity of their alcohol problem based on their AUDIT Score; (c) a list of their self-reported alcohol-related consequences; (d) a graph of their Brief Self-Confidence Profile (BSCP) showing areas of vulnerability in terms of resisting the urge to drink heavily in certain situations; and (e) a Decisional Balance Exercise evaluating the pros and cons of drinking (see Appendix B). This pamphlet tells respondents it will help them (1) think about the benefits and the costs of changing or continuing their current drinking, (2) understand factors that affect their drinking decisions, and (3) decide what they want to do about their current drinking. Educational materials control (EMC) group. Respondents in this group complete the same baseline questionnaires as those in the GSC group. However, no personalized feedback is provided until after their 12-month follow-up interview (i.e., after the follow-up interview all respondents receive a pre-post profile of their drinking and related behaviors). Similar to studies in the smoking field (reviewed in Curry, 1993), respondents in the EDMC group are given two informational pamphlets that discuss the nature of alcohol abuse and provide general advice on how to deal with alcohol problems, The first pamphlet, an informational brochure describing the nature of alcohol problems, has been used for 4 years on the Guided Self-Change Unit (Sobell & Sobell, 199.5) and by the Association for Advancement of Behavior Therapy. The second pamphlet “Drinkthink-How Much is Too Much’?” was developed by the Toronto Department of Public Health and is used by several local health and social services agencies. It has received very positive evaluations. Recruitment via advertisements and mail-out pamphlets. Many studies recruiting problem drinkers to treatment and recruiting naturally recovered subjects have used advertisements with carefully worded statements to attract such individuals. Affect-laden labels, such as alcoholics and alcohol abuser are specifically avoided. Instead the ads typically say things such as “Are you concerned about your drinking?” (Klingemann, 1991b; Miller & Hester, 1980; Miller, Taylor, & West, 1980; Pearlman, Zweben, & Li, 1989; Sobell et al., 1993,1995). To maximize the generalizability of findings to a broad segment of the population, in addition to print advertisements in newspapers and at subway stations, pamphlets are also being delivered to residences in Toronto (a large metropolitan city with 2 l/2 million people) using a random selection of postal codes. Consistent with minimizing stigma and maximizing responsiveness to ads, the mail-out pamphlet used in the present study states “Where Does Your Drinking Fit In?” The reverse side presents a pie chart which illustrates by gender the average number of

A proactive community intervention

825

drinks consumed per week by Canadian adults (Health and Welfare Canada, 1990). The pamphlet also explains that a confidential self-guided change program is available by mail and without cost for individuals who would like to evaluate their current drinking. The print advertisements begin with the line “Thinking about Changing Your Drinking” and are briefer due to publication costs. The print ads also emphasize that self-change is possible, as over 75% of individuals change their drinking on their own (Sobell et al., 1996). Follow-up

One year following when subjects are sent their respective group materials they will be sent a 1Zmonth TLFB (Sobell & Sobell, 1992) calendar, the AUDIT, and the BSCP. Respondents will be asked to complete these questionnaires and mail them back in a preaddressed, stamped envelope. Other follow-up questions will be asked of all respondents by telephone (e.g., alcohol-related consequences, use of any alcoholrelated treatment or self-help in the past 12 months). Respondents will also be asked to rate the utility of the advice/feedback or educational materials they were sent (0 = no use at all to 5 = very useful, helped me a lot). Finally, all respondents will be asked if they would recommend a similar way of trying to change their drinking for others who have alcohol problems. As described earlier, 10% of the respondents will be randomly selected to be interviewed in person. They will receive $100 for the interview and will be breath tested before the interview to insure that they are alcohol free. They also will be asked to provide the name of a person who can be contacted to provide independent reports of the subjects’ drinking over the past year. Collaterals will be interviewed by phone. The collateral interview will cover the respondents’ drinking over the last 30 days of the 12-month follow-up interval, alcohol-related consequences, and any use of alcohol treatment. They will also be asked to evaluate how they perceive the respondents’ current drinking (no problem, minor problem, major problem). To address the problems of potential attrition at follow-up, at 4 and 8 months after being sent their respective group materials all respondents will be sent letter reminders that they will be followed up. They will also be asked to send an updated address if they move. RESULTS

Over the course of the first 3 months of the project, 335 individuals have personally responded to various media solicitations. Of these, 76.7% (n = 257) met the initial screening criteria. Of the 78 who were ineligible, 88.5% (n = 69) had received some type of treatment and the rest were excluded by the drinking criteria. Of the 257 eligible study respondents who were sent baseline screening questionnaires, to date 76 (about 10% of the projected final sample) respondents have completed all forms and been randomly assigned to one of the two groups. Because the follow-up phase of the study has not yet begun, only demographic and alcohol-related history variables are presented for subjects. As shown in Table I, respondents can generally be characterized as mildly dependent on alcohol. Like mildly dependent alcohol abusers who participate in brief interventions (Bien & Burge, 1990; Sobell & Sobell, 1995; Sobell et al., 1995a), these individuals have high social stability as reflected by their employment and marital status, and education. Very few have ever been arrested or hospitalized for alcohol-related problems despite reporting an average 11-year drinking problem history. Very few report morning drinking (15%)

826

L. C. SOBELL

et al.

and by definition none had received any alcohol-related treatment or help. Their mean (SD) AUDIT score (range: 0 to 40) was 19.2 (6.0). Their drinking was not extremely heavy, especially compared with studies of severely dependent alcohol abusers (Foy, Nunn, & Rychtarik, 1984: Ito, Donovan, & Hall, 1988; Kuchipudi, Hobein, Flickinger, & Iber, 1990). Collectively, subjects drank on 80.4% of all days during the preintervention year, and when they drank they averaged (SD) 5.9 (2.7) drinks per drinking day. Typical of other problem drinker populations (Sobell & Sobell, 1995; Sobell et al., 1995a), they reported several alcohol-related consequences [mean (SD) = 3.4 (2.2)]. Subjects were also asked to provide a subjective evaluation of the severity of their drinking problem over the previous year: 42.1% (n = 32) evaluated their problem as “Major” or “Very Major,” defined as having suffered at least one or more serious alcohol-related consequence. This figure stands in contrast to two studies of problem drinkers in treatment (Sobell & Sobell, 1995; Sobell et al.. 1995a), where 78% and 76%, respectively, evaluated their problem as “Major” to “Very Major.” There are two other notable differences between these subjects and most mildly dependent alcohol abusers in treatment studies. With a mean (SD) age of 50.4 (12.2) years, respondents are considerably older (about 10 years) than studies of problem drinkers. Second, unlike naturally recovered alcohol abusers who reported an average of 2.2 serious attempts to reduce or quit prior to their recovery (Sobell, Sobell, & Kozlowksi, 1995b), subjects in the present study reported considerably more serious attempts to quit or reduce their drinking [mean (SD) = 11.9 (14.2) median = 7, range: O-601. Finally, several questions addressed subjects’ commitment to changing their drinking. Using a brief 4-question scale that reflects readiness to change (0 = not committed to 10 = very committed) and that was used previously with smokers (Richmond, Mak-

Table

1. Demographic

and alcohol

history

variables

for subjects

(N = 76)

Variables % Male % Employed (full or self-employed) % Married/Widowed % Completed high school % Completed some university % White collar % White (ethnicity) Mean (SD) age Subjective evaluation of their drinking during past year % Not a problem % MinoriVery minor problem % Major/Very major problem % (n) Morning drinking Mean (SD) alcohol-related hospitalizations Mean (SD) alcohol-related arrests Mean (SD) years problem drinking Mean (SD) attempts to quit/reduce drinking Mean (SD) alcohol-related consequences % Who say they are serious about reducing/quitting drinking % Intend to quit/reduce drinking next two weeks % (n) Say they will not have an alcohol problem in 12 months % (n) Smoked (ever) % Ever smokers who stopped Mean (SD) AUDIT score Mean (SD) drinks/drinking day past year Mean (SD) % days drinking past year

71.1 52.6 59.2 75.0 34.2 52.6 94.7 so.4 (12.2) 2.6 55.3 42.1 14.5 0.1 0.4 10.7 11.9 3.4 100.0 76.3 55.3 71.1 53.7 19.2 5.9 80.4

(0.5) (1 .O) (9.6) (14.2) (2.2)

(54) (6.0) (2.7)

A proactive

community

intervention

827

inson, Kehoe. Giugni. & Webster. 1993b), respondents’ mean (SD) scores [6.9 (1.3)] were reflective of a very high level of commitment to change. Lastly, on a scale from 0 (not importanr) to 100 (most inrpportant thing in my life) subjects’ mean (SD) importance rating of changing their drinking was 70.3 (23.5), slightly lower than for problem drinkers [mean (SD) = 79.8 (14.5)] entering brief treatment (Sobell & Sobell, 1995; Sobell et al., 1995a). Although this study was initiated only recently, it is clear that the current recruitment procedures are proving effective in attracting the attention of problem drinkers. It is also evident that many problem drinkers will comply with the request to provide assessment information (the actual percentage cannot be determined until the intake phase of the study is completed). On this basis, the evaluation phase of the study is expected to be highly informative both in terms of whether the personalized advice/feedback is successful in encouraging self-change, and also in terms of whether subjects who do not change seek referrals to treatment.

CONCLUSION

Because the vast majority of individuals with alcohol problems will never come to traditional treatment programs and because of the considerable cost to society of their drinking-related problems. alternative interventions need to be developed that are perceived as attractive and to be sought out rather than avoided. The intervention described in this paper was designed to have these characteristics. This intervention is consistent with an efficient approach to public health care where individuals are first provided with an intervention that is least intrusive on their lifestyle yet has a reasonable chance of success (Sobell & Sobell, 1993). Such an approach has the opportunity of reaching large numbers of individuals who are otherwise unwilling, not ready. or not motivated to access the formal health care system. If the intervention succeeds, it is reasonable to speculate that the change in respondents’ behavior will have occurred earlier than would otherwise be expected, and therefore that the anticipated costs of these respondents’ alcohol problems to society will be reduced. If the initial intervention does not work, then the level of care can be stepped up (i.e., more treatment or an alternative treatment). Moreover, if successful the intervention could be employed in a proactive recruitment of individuals in a variety of settings such as health care clinics, high schools and colleges, and military bases.

REFERENCES Addiction

Research Foundation and Canadian Centre on Substance Abuse. (1993). Modrrnrr drinking und paper presented at International Symposium on Moderate Drinking and Health. Toronto. Ontario. Canada. Allsop. S.. & Saunders. B. (1989). Relapse and alcohol problems. In M. Gossop (Ed.). Relapse nnd addicrive behavior (pp. 1140). New York:Tavistock/Routledge. Amodeo. M.. & Kurtz. N. (1990). Cognitive processes and abstinence in a treated alcoholic population. healrh,

Inrernationcrl

Jorrrnal

of the Addicriom.

25.983-1009.

Annis. H. M.. & Graham. J. M. (19X8). Sifrrational Confidence Qurstiomuirr (SCQ .?9): C/srr’.v Guide. Toronto: Addiction Research Foundation. Annis. H. M.. & Graham. J. M. (1995). Profile types on the Inventory of Drinking Situations: Implications for relapse prevention counseling. Psychology of Addictive Behm~iors. 9. 176-182. Bandura. A. (1986). Social foundoriom of thought and action: A social cognirive theory. Englewood Cliffs. NJ: Prentice-Hall. Bien. T. H.. 8i Burge. R. (1990). Smoking and drinking: A review of the hterature. Internnrional Journal of Addicrions.

25. 1429-1454.

828

L. C. SOBELL

et al

Bien. T. H.. Miller. W. R.. & Tonigan. J. S. (lYY3). Brief interventions for alcohol problems: A review. Addiction, 88.315-336. Biernacki. P. (IY86). Pnrhrva,vs from heroin addictton rrco~~y bihorrr ~earment. Philadelphia: Temple University Press. Cahalan. D. (1987). Studying drinking problems rather than alcoholism. In M. Galanter (Ed.). Recmr devrlopmenr.s in nlcohotim. Vol. 5. (pp. 363-372). New York: Plenum. Colten. M. E.. & Janis. I. L. (1982). Effects of moderate self-disclosure and the balance-sheet procedure. In 1. L. Jams (Ed.). Cvrcnselirtfi o)t prr.sonal dcvi.\ions: Theory und resrarch OH helping in short-term r&lrionships (pp. 159-171). New Haven. CT Yale University Press. Cunningham. J. A.. Sobell. L. C.. Rr Chow. V. A. (1’392. June). The pubhc’s percepttons of the appropriateness of treatment outcomes. Paper presented at World Congress of Cognitive Therapy. Toronto, Ontario. Canada. Cunningham. J. A.. Sobell. L. C.. & Chow. V. M. C. (lYY3a). What’s in a label’? The effects of substance types and labels on treatment considerations and stigma.Jourrtcrl ofSr[lrlirs 011 Alcohol. 54.693AYY. Cunningham. J. A.. Sobell. L. C.. Sobell. M. B.. Agravval. S.. & Toneatto. T. (lYY3b). Barriers to treatment: Why alcohol and drug abusers delay or never seek treatment. Addictive Behaviors. 18.347-353. Curry. S.. Wagner. E. H.. & Grothaus. L. C. (lYY1). Evaluation of intrinsic and extrinsic mottvation interventions wsith a self-help smoking cessation program. foltrrtcrl of Consrtfringnnd Clinicul P.s~cholo~v. 59. 318324. Curry. S. J. (lYY3). Self-help interventions for smoking cessation. Jortrnrrl of Con.sultin,g and. Ctiniccd P.rychotogy. 61.790-803. Curry. S. J.. Louie. D.. Grothaus, L. C.. Bi Wagner. E. H. (1992). Written personalized feedback and confidence in smoking cessation. Psychotog~, of’Addicl~vr Brtlnvior,v, 6,175-1X0. Fillmore. K. M. (1988). Alcohol use across fhe /if<, course: A criricml review of 70 years of intermtional longitudinal rrsearch.Toronto, Ontario: Addiction Research Foundation. Foy. D. W.. Nunn. L. B.. & Rychtarik. R. G. (1984). Broad-spectrum behavioral treatment for chronic alcoholics: Effects of training controlled drinking skills. Joltrrrcrl of Cons~tlting and Clinical Prychalogy, 52. 218-230. Grantield. R.. & Cloud. W. (1996). The elephant that no one sees: Natural recovery among middle-class addicts. Journal of Drug lsstres. 26.4S-hl. Health and Welfare Canada. (1990). Nurional alcohol and other drugs survey (IMY): A highlight reporr. Ottawa: Health and Welfare Canada. Heather. N. (1YXY). Psychology and brief interventions. BuMI Joumat c?fAddicfion. 84.3.57-370. Hingson. R.. Mangi0ne.T.. Meyers. A.. & Scotch. N. (lY82). Seeking help for drinking problems: A study in the Boston metropolitan area. Joirrnal of S/drrs on Alcohol. 43.273-288. Hoyt. M. E. & Janis, I. L. (1975). Increasing adherence to a stressful decision via a motivational balancesheet procedure: A field experiment. Joitrncrl cJfPer.sonuliry a& Social Psychology. 31. X33-839. Institute of Medicme. (1990). Broadening the husr of tretrment for ulcohot problems. Washington. DC: National Academy Press. Ito. R. J.. Donovan. D. M.. & Hall, J. J. (lY8X). Relapse prevention in alcohol aftercare: Effects on drinking outcome. change process. and aftercare attendance. British Journal ofAdrlic/ion. 83.171-181. Janis. 1. L.. & Mann. L. (1968). A conflict-theory approach to attitude change and decision making. In A. G. Greenwald. T. C. Brock, & T. M. Ostrom (Eels.). Psychological fmrtzdnfions of rrrritudec (pp. 327-360). New York: Academic Press. Janis. I. L.. & Mann. L. (1977). neci.sio,l-f~?rrkinX’ A psychological unnlysis of conflicr. chorcr. and commitmenu. New York: Free Press. Klingemann. H. (199 1a): Coping a,rd maintc’nuucc trrtrrcgirs of sp~~mneous remitter.y from problem use of alcohol rrrtd heroin in S~,ir:rrtond. Paper prcscntcd at the 17th Annual Alcohol Epidemiological Symposmm. Sigtuna. Sweden. Klingemann. H. K.-H. (IYYlb). The motivation for change from problem alcohol and heroin use. Brirhh Journal ofAddiction, 86. 727-744. Kristenson. H. (1087). Alcohol dependence and problem drinking in urban middle aged men. Alcohol and AIcoholism. 1.601~06. Kuchipudi. V.. Hobein. K.. Flickmger. A., & Iber. F. L. (1YYO). Failure of a 2-hour motivattonal intervention to alter recurrent drinking behavior in alcoholics with gastrointestinal disease. Joctrnrrt of Srdies on Alcohol, 51. 35&360. Ledwith. F. (1984). Immediate and delayed effects of postal advice on stopping smoking. Hratrh Butterin. 42. 332-345. Ludwig. A. M. (1085). Cognitive processes associated with “spontaneous” recovery from alcoholism. Jortrnal of 9dir.s on Alcohol. 46.53-58. Mahoney. M. J.. & Lyddon. W. J. (198X). Recent developments in cognitive approaches to counseling and psychotherapy. The Cortnveting fsychotogisr. 16. lYth234. Mann. L. (1972). Use of a “balance sheet” procedure to improve the quality of personal decision making: A held experiment with college applicants. Jortrrrut of L’ocalioncd Brhovior. 2.29 l-300. Marlatt. G. A.. & Gordon, J. R. (1985). Retapsr prevvnlion. New York: Guilford Press.

A proactive community intervention

829

Miller, W. R., Brown, J. M., Simpson,T. L. et al. (1995). What works? A methodological analysis of the alcohol treatment outcome literature. In R. K. Hester & W. R. Miller (Eds), Handbook ofalcoholism treatment approaches: Effective alternatives (2nd ed.) (pp. 1244). Boston: Allyn and Bacon. Miller, W. R., & Hester, R. K. (1980). Treating the problem drinker: Modern approaches In W. R. Miller (Ed.), The addictive behaviors: Treatment of alcoholism, drug abuse, smoking and obesity (pp. 11-141). New York: Pergamon Press Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford. Miller, W. R.,Taylor, C. A., & West, J. C. (1980). Focused versus broad-spectrum behavior therapy for problem drinkers Journal of Consulting and Clinical Psychology, 48,590-601. National Institute on Alcohol Abuse and Alcoholism. (1992). Moderate drinking. In Alcohol Alert, PH 315 No. 16, pp.l-3. Rockville, MD: Author. O’Connell, D. O., & Velicer, W. F. (1988). A decisional balance measure and the stage of change model for weight loss International Journal of Addictions, 23,729-750. Orford, J. (1986). Critical conditions for change in the addictive behaviors. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change (pp. 91-108). New York: Plenum Press Orford, J., & Keddie, A. (1986). Abstinence or controlled drinking in clinical practice: A test of the dependence and persuasion hypotheses British Journal of Addiction, 81.495-504. Pearlman, S., Zweben, A., & Li, S. (1989). The comparability of solicited versus clinic subjects in alcohol treatment research. British Journal of Addiction, 84,523-532. Richmond, R. L., Kehoe, L. A., & Webster, I. W. (1993a). Multivariate models for predicting abstention following interventions to stop smoking by general practitionersAddicrion,88,1127-1135. Richmond, R. L., Makinson, R. J., Kehoe, L. A., Giugni, A. A., &Webster, 1. W. (1993b). One-year evaluation of three smoking cessation interventions administered by general practitioners. Addictive Behaviors, 18,187-199.

Roizen, R., Cahalan, D., & Shanks, P. (1978). Spontaneous remission among untreated problem drinkers In D. B. Kandel (Ed.), Longitudinal research on drug use: Empirical findings and methodological issues (pp. 197-221). Washington, DC: Hemisphere. Room, R. (1977). Measurement and distribution of drinking patterns and problems in general populations In Cl. Edwards, M. M. Gross, M. Keller, J. Moser, & R. Room (Eds.), Alcohol-related disabilities (pp. 62-87). Geneva: World Health Organization. Room, R. (1980). Treatment-seeking populations in large realities. In G. Edwards & M. Grant (Eds), Alcoholism treatment in transition (pp. 205-224). London: Croom Helm. Saunders B., & Allsop, S (1987). Relapse: A psychological perspective. British Journal of Addiction,82,417-429. Saunders, B., & Wilkinson, C. (1990). Motivation and addiction behavior: A psychological perspective. Drug and Alcohol Review, 9,133142.

Saunders J. B., Aasland, 0. G., Babor, T. F., De La Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): Who collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction, 88.791-804. Sitharthan,T., & Kavanagh, D. J, (1990). Role of self-efficacy in predicting outcomes from a programme for controlled drinking. Drug and Alcohol Dependence, 27,87-94. Sitharthan, T., Kavanagh, D. J., & Sayer, G. (1996). Moderating drinking by correspondence: An evaluation of a new method of intervention. Addiction, 91,345-355. Skinner, H. A. (1990). Spectrum of drinkers and intervention opportunities. Canadian Medical Association Journal, 143.1054-1059.

Sobell, L. C., Cunningham, J. A., & Sobell, M. B. (1996). Recovery from alcohol problems with and without treatment: Prevalence in two population studies. American Journal of Public He&h, 86966972. Sobell, L. C., & Sobell, M. B. (1992). Timeline follow-back: A technique for assessing self-reported alcohol consumption. In R. Z. Litten & J. Allen (Eds), Measuring alcohol consumption: Psychosocial and biological methods (pp. 41-72). New Jersey: Humana Press. Sobell, L. C., & Sobell, M. B. (1995). Guided Self-Change clinical treatment manual. Toronto, Canada: Addiction Research Foundation. Sobell, L. C., & Sobell, M. B. (1996a). Alcohol Timeline Followback (TLFB) user’s manual. Toronto, Canada: Addiction Research Foundation. Sobell, L. C., & Sobell, M. B. (1996b). Timeline Followback (TLFB) for alcohol (Version 4.0b) (computer software). Toronto, Canada: Addiction Research Foundation. Sobell. L. C., Sobell, M. B., Brown, J., & Cleland, I? A. (1995, November). A randomized trial comparing group versus individual Guided Self-Change treatment for alcohol and drug abusers. Poster presented at the 29th Annual Meeting of the Association for Advancement of Behavior Therapy, Washington, D. C. Sobell, L. C., Sobell, M. B., & Leo, G. I. (1993, November). Spousal social support: A motivational intervention for alcohol abusers. Poster presented at the Annual Meeting of the Association for Advancement of Behavior Therapy, Atlanta, GA. Sobell, L. C., Sobell, M: B., & Toneatto,T (1992). Recovery from alcohol problems without treatment. In N. Heather, W. R. Miller, & J. Greeley (Eds), Self-control and the addictive behaviors (pp. 198242). New York: Maxwell Macmillan.

830

L. C. SOBELL

et al.

Sobell. L. C.. Sobell. M. B.. Toneatto, T.. & Leo. G. I. (1993). What triggers the resolution of alcohol problems without treatment? Alcoholism: Clinical und Experin~rntal Rrseurch. 17.217-224. Sobell. M. B.. & Sobell. L. C. (1993a). Problem drinkers: Guided self-change treatmmi. New York: Guilford Press. Sobell. M. B.. & Sobell, L. C. (1993b). Treatment for problem drinkers: A public health prioritv. In J. S. Baer, G. A. Marlatt. & R. J. McMahon (Eds.). Addictive behaviors across rhe lifespan: Prevent&n. treatment, and policy issues (pp. 1388157). Beverly Hills. CA: Sage. Sobell. M. B., & Sobell. L. C. (1995. July). Grorrp i’crsns individuul Guided Self-Change trecrlment for prohkm drinkers. Paper presented at the World Congress on Behavioural and Cognitive Therapies. Copenhagen, Denmark. Sobell. M. B.. Sobell. L. C., & Gavin. D. R. (199Sa). Portraying alcohol treatment outcomes: Different yardsticks of success. Behavior Therapy. 26.643469. Sobell. M. B.. Sobell, L. C., & Kozlowski, L. T. (lYY5b). Dural recoveries from alcohol and smoking problems. In J. B. Fertig & J. A. Allen (Eds.). Alcohol and ~ohacco: From basic science to clinical pruclice (pp. 207-224). NIAAA Research Monograph No. 30. Rockville. MD: National Institute on Alcohol Abuse and Alcoholism. Thoresen. C. E.. & Mahoney, M. J. (1974). Behavioral self-control. New York: Rinehart and Winston. Toneatt0.T.. Sobell. L. C., Rubel. E. et al. (1994. November). Comparing untreated recovery in cocaine and alcohol abusers. Poster presented at the 28th Annual Meeting of the Association for Advancement of Behavior Therapy, San Diego, CA. Tucker. J. A., Vuchinich, R. E.. & Gladsjo. J. A. (1991). Environmental influences on relapse in substance use disorders. International Journal of Addictions. 25. 1017-1050. Velicer, W. E. DeClemente, C. C., Prochaska. J. 0.. & Brandenburg. N. (lY85). Decisional balance measure for assessing and predicting smoking status. Journal of Personality and Social Psychology, 48. 12791289. Waldorf. D.. Reinarman. C., & Murphy S. (lYY1). Cocaine chunges: The experience of using and qrtitting. Philadelphia. PA: Temple University. Werch. C. E. (1990). Are drinkers interested in inexpensive approaches to reduce their alcohol use. Journal of Drug Edncarion. 20.67-7.5.

A proactive community intervention

APPENDIX

A

Personal Feedback Summary for Subjects in the Guided Self-Change Group

831

832

L. C. SOBELL

et al.

Copyright

0 L.C. Sobell and M.B. Sobell. Reprinted by permission.

833

A proactive community intervention APPENDIX

B:

Decisional Balance Exercise for Subjects in the Guided Self-Change Group

ECISIONAL ALANCING

c 0

i

Copyright 0 L.C. Sobell and M.B. Sobell Renrint~A

hv

nprmiszinn