Methodological approaches in the evaluation of alcoholism treatment: A critical review

Methodological approaches in the evaluation of alcoholism treatment: A critical review

PREVENTIVE MEDICINE 4, 464-481 (1975) Methodological Alcoholism Approaches in the Evaluation Treatment: A Critical Review of SUSAN J. MAY AND LE...

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PREVENTIVE

MEDICINE

4, 464-481 (1975)

Methodological Alcoholism

Approaches in the Evaluation Treatment: A Critical Review

of

SUSAN J. MAY AND LEWIS H. KULLER Department

of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pa.

A review of the evaluative literature in the area of treatment modalities for alcoholism demonstrates that there is little evidence to substantiate that treatment of any kind alters the natural history of the disease. Research aimed at the evaluation of alcoholism treatment modalities and/or programs has been mainly descriptive in nature. Only a few of the studies have utilized a valid study design including control groups, random sample selection, and objective measurements of behavioral change. The literature also demonstrates a lack of consensus as to what constitutes an effective outcome and an effective measurement of that outcome for the alcoholic patient. Each of the studies occurs in isolation, and only rarely does one investigator build his study on the results of other similar evaluations. If knowledge is to be gained as to the effectiveness of various modes of therapy for the alcoholic, researchers must be willing to share ideas and to evaluate with an adequate study design including the use of control groups, validated measurement tools, and simple statistical techniques.

Alcoholism, as both a medical and social problem, has received increasing interest from many segments of society over the past 10 years. Research into the causative factors of alcohol abuse and alcoholism have resulted in a number of theories, almost as numerous as the professional and scientific disciplines with which the research is associated. Theories of etiology include genetic (17), sociocultural (2), nutritional (23), psychological (1 l), and allergic (42). This plethora of theories as well as the impetus of large scale federal funding has resulted in numerous programs for the treatment of alcoholism. Within the framework of these programs, widely divergent modes of therapy are employed. Among the most common are (a) behavior therapy, (b) group and individual psychotherapy, (c) hypnotherapy, and (d) various forms of drug therapy (disulfiram, chlordiazepoxide, LSD) (38). Although a multiplicity of resources exists to aid the person with an alcohol problem in the United States, the incidence and prevalance of alcohol abuse continues to rise at an alarming rate (33). One major shortcoming of alcoholism programs is the lack of conclusive evidence to substantiate that treatment of any kind alters the natural history of the disease. Pittman stated in 1963 that “perhaps the greatest weakness of all alcoholism treatment programs is the lack of a critical evaluation of their success or failure with alcoholic patients. As yet the field of alcoholism has had no carefully controlled experiments which would attempt to compare the success and failure rates of treated and non-treated patients who had originally been in the same facility” (4). 464 Copyright @ 1975 by Academic Press, Inc. All rights of reproduction in any form reserved.

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Since that statement was made over 10 years ago, there have been some attempts to evaluate specific alcoholism treatment programs. However, little has been done to provide a broad-based scientific assessment of the treatment modalities presently in use. This paper will attempt to review the evaluative research pertinent to alcoholism treatment programs over the past 10 years. The review will cover three major areas: (a) studies designed to evaluate utilization and/or participation in alcoholism treatment programs, (b) studies designed to assess the effectiveness of a specific type of therapy on the alcoholic, and (c) proposed models for the assessment of outcome in the treatment of alcoholism. STUDIES DESIGNED TO EVALUATE UTILIZATION AND PARTICIPATION IN ALCOHOLISM TREATMENT PROGRAMS

Common to many alcoholism treatment programs is the patient who pleads for an appointment and then does not appear on the assigned day. Also common is the request for discharge, against medical advice, from a patient who only days before requested admission to a program designed to treat his or her problems associated with the use of alcohol. Before any attempt can be made to evaluate the results of treatment on the alcoholic patient, the characteristics of both those patients who enter treatment and those patients who complete the treatment once it is begun must be ascertained. However, only a few studies have directed themselves toward this end. Mayer et al. (24) investigated the characteristics of 193 patients who contacted the Peter Bent Brigham Hospital in 1962 as well as the differences between those who appeared for their initial appointment and those who did not. Results showed the alcoholic patients scheduled for an immediate intake (within 4 days) tended to keep their initial appointment. No differences between the groups were found in relationship to age, sex, race, religion, marital status, occupational status, income, or place of residence. Panepinto et al. (29), in a study of 340 alcoholics receiving drug therapy for the treatment of alcoholism, found that alcoholics with the underlying diagnosis of schizophrenia (as compared to those with diagnoses of personality disorders) had more program contacts and maintained longer treatment relationships with a therapist than any of the other alcoholics. Wilkinson et al. (39) used data from a biographical questionnaire and a battery of psychological tests to determine predictors of success of 132 alcoholics in completing a 90-day psychotherapeutic alcoholism treatment program. They concluded that “completers” and “drop outs” could not be differentiated by level of intelligence, specific vocational interests, and kind of value systems. “Completors,” as a group, showed more adequate personal adjustment (as measured by the MMPI and SAT) in areas such as marital status, job history, and drinking patterns. Finally, Mozdzierz et al. (28) examined the personality characteristic differences between alcoholics who leave treatment against medical advice and those who do not. In this study of 47 alcoholic veterans (22 AMA and 25 nonAMA), Mozdzierz found that AMA alcoholics tend to (a) deny their problems

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with interpersonal relationships, (b) feel hostile and suspicious, (c) be more defensive, (d) deny general psychological distress as well as discomfort and disturbance in somatic functioning, and disavow their dependency needs. The type of data that the aforementioned authors attempted to gather on program “noncompletors“ is of crucial importance. If one is to evaluate treatment success accurately, all persons introduced to the treatment must be considered. The next section of this paper will demonstrate that in most instances, only persons who successfully completed a program of therapy are included in evaluating the outcome of treatment. STUDIES DESIGNED TO ASSESS THE EFFECTIVENESS A SPECIFIC THERAPY OR PROGRAM

OF

There are two main schools of thought represented in the literature on the evaluation of alcoholism treatment programs. The first, and by far the most common, is that successful treatment outcome must be measured in terms of drinking behavior, with complete abstinence from alcohol as the ultimate goal. The second school of thought, which has gained increasing support in recent years, believes that the criterion of alcohol use as the sole evaluative measure of outcome is only a part of the picture. Proponents of this school further believe that total abstinence is much too restrictive a criterion and that treatment outcome of alcoholics should be evaluated along the broader dimensions of total life adjustment and adaptation. Despite the inconsistencies and incongruities within the field, there have been several attempts over the past 10 yr to evaluate alcoholism treatment programs and to assess the outcome of the alcoholic patient following treatment. Table 1 presents an overview of the types of therapies and programs that have been evaluated. Primary emphasis in evaluation over the last 10 years has been on the benefits of psychotherapy, the preferred method of alcoholism treatment since the early 1900’s. Of the 24 studies reviewed in this paper, 15 are primarily concerned with the effects of psychotherapy on the alcoholic patient (3,8,10,12,14-l 6, 18,21,22,25,26,30,32,40). Investigators comprising a second group have directed themselves to the study of the effects of various drug therapies on the recovering alcoholic person. Of this group, four such studies will be reviewed (1,5,34,36). The additional studies explored in this paper are concerned with the evaluation of less traditional modes of therapy for the alcoholic person, i.e., hypnosis (9,20) and behavior therapy (7,27,35). For a thorough discussion of the aversive conditioning aspects of behavior therapy, see the review of Davidson (7). Voegtlin and Lemere (37) published a review of all studies occurring between 1909 and 1941 that were concerned with the evaluation of treatment for the alcoholic. They concluded that from an examination of the literature alone, the medical profession is unable to form any sort of opinion as to the value of conventional psychotherapy in the treatment of alcoholism. Hill and Blane (19) reviewed 49 studies concerned with the evaluation of psychotherapy in the treatment of alcoholism. These authors supported Hill and Voegtlin in concluding that “we are still unable to form any conclusive opinion as to the value of psy-

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chotherapeutic methods in the treatment of alcoholism.” In response to the traditionally poor studies published with respect to the evaluation of treatment for the alcoholic, Hill and Blane formulated a list of criteria for valid evaluative research in the area of alcoholism treatment (19). Their criteria, basic to any specific endeavor, include the following: (a) in order to attribute change to a specific treatment, it is necessary to show that the change would not have occurred without the treatment-thus, the necessity for a control group; (b) in order to make treatment and control groups comparable, the method of subject selection used must assure random assignment of patients to various treatment conditions; (c) to study a change in behavior, it is necessary to select and define the behavior to be evaluated; this behavior must be relevant to the treatment program goals; (d) reliable methods and instruments for measuring change in behavior must be utilized, and (e) pretreatment as well as posttreatment measurements must be taken to insure measurements of behavioral change. Study Design- Use of Control Groups Since 1965 there has been an increasing trend toward prospective rather than retrospective evaluative research in the field of alcoholism. Only 8 of the 24 studies reviewed were completely retrospective in design (Table 2). However, of the 16 studies prospective in nature, only five (16,18,30,3 1,35) used a design free from inherent inadequacies. One major inadequacy becomes apparent in looking at the use of a control group (Table 1). In one-half, or 11, of the studies, there was no evidence to support the use of a control group of any kind. Although some of these 11 studies may have tacitly been using the patient as his own control, inadequacies in collection of pretreatment, treatment, and posttreatment data rendered the model invalid. Of the remaining 13 studies, three adequately used the patient as his own control, eight compared the results of two treatment groups that were each undergoing a different type of therapeutic intervention, and two (studies of drug intervention) used a nontreated control group. Not one of the 15 studies employing the traditional method of psychotherapy used a nontreated control group. As such, no attention was given to the influence of nontreatment variables such as spontaneous remission or decrease in drinking with age due to the sheer passage of time. This aspect may be of critical importance in studying the effectiveness of alcoholism treatment. In one of the two studies that used a nontreated control group, Charnoff demonstrated that the placebo group fared considerably better than any of the three treatment groups in terms of sobriety and/or freedom from intoxication (5). Another problem inherent in the study design was the randomization of patients. Of the 13 studies utilizing an adequate control group, only seven (5,9,10,14,30,35,40) attempted to randomize the patient into the two comparison groups, i.e.,, treated or nontreated (5,9) and treatment 1 or treatment 2 (10,14,30,35,40). Thus, one can see that in many cases even when the study employed adequate controls, the principles involved in randomization of subjects were frequently ignored.

Group psychotherapy Outpatient

Inpatient

Individual psychotherapy Outpatient

Type of therapy evaluated

Willems et al., 1973

Knox, 1972

Bateman and Peterson, 1971

Gillis and Keet. 1969

Haberman, 1%6

Davies et al., 1956

Mayer and Myerson, 1971

Mayer and Myerson, 1970

Investigator and ye=

1 Population studied

96 male and female alcoholics volunteered for treatment 797 consecutive alcoholic admissions to hospital, male and female 521 consecutive male admissions and program completers in hospital program 54 male alcoholic veterans 69 male alcoholics (32-long term, 38--short term)

393 male and female alcoholics voluntarily sought treatment 393 male and female alcoholics volunteered for treatment 50 male and female alcoholics discharged from hospitalsall voluntary admissions

TABLE

Yes-two treatment groups

No

No

Patient used as own control

No

No

Each patient used as own control No

Use of control group

Alcoholics Anonymous

Behavior therapy

Hypnosis

Psychedelic therapy

Drug therapy

Inpatient vs outpatient

Inpatient

Mixed therapy Outpatient

Gallant et al., 1973

Jacobson and Silfverskiold, 1973 Mills et al., 1971 Cohen et al., 1972 Sobell and Sobell, 1973 Kish and Hermann

Edwards. 1966

Charnoff et al., 1963 Sereny and Fryatt, 1%6 Baekeland et al., 1971 Soskin, 1970

Male veteran alcoholics

74 male alcoholics Male alcoholics Male alcoholics 70 male alcoholics

82 male veteran alcoholics 40 male and female alcoholics

Male and female alcoholics 95 male and female alcoholics admitted to ARF clinic 232 male and female alcoholics

210 male chronic alcoholic offender

Schuckit and Winokur, 1972 Edwards, 1970

Fitzgerald et al., 1971

Pittman and Tate, 1969

105 male and female alcoholics volunteered for treatment Sample of 255 male and female alcoholics from 1006 hospital admissions 392 male and 139 female alcoholics admitted for treatment Hospitalized female (45) alcoholics 40 male alcoholics

Goldfried, 1%9

No

Yes-casecontrol Yes-two treatment groups Yes-two treatment groups Yes-comparison of two treatment groups No No Yes-four comparison groups

Yes-two treatment groups Yes-comparison of three treatment groups Yes-drug placebo No

No

Each patient used as own control Yes-two treatment groups

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MAY AND KULLER TABLE 2

Investigator and year

Length of treatment

Time of final follow-up

Prospective study design Charnoff et al., 1%3

Variable

Haberman, 1%6

20 weeks average

Edwards, 1966

Variable

Goldfried, 1%9 pittman and Tate, 1969 Edwards, 1970 Mayer and Myerson, 1970

10 days; experimental group variable Inpatients 8.9 weeks, outpatients 7.7 weeks. Variable with an average of four sessions

Soskin, 1970

26 days

Kish and Hermann, 1971 Mills et al., 1971 Schuckit and Winokur, 1972 Cohen et al., 1972 Jacobson and Silfverskiold, 1973 Willems et al., 1973 Gallant et al., 1973 Sobell and Sobell, 1973

8 weeks 2 weeks

5 weeks 5 sessions Variable 6 months average

3, 6, and 12 months after beginning of treatment 26 weeks after treatment Monthly for first 6 months after treatment and at 1 yr 4 and 8 months after beginning of treatment Discharge Every month after admission for 12 months At termination of treatment or 36 months after initiation of treatment, which ever comes first Immediately after treatment 3, 6, and 12 months after discharge During therapy 3 yr after treatment Immediately after treatment 6 months after treatment 1 and 2 yr after discharge iyrafter treatment Every 3 to 4 weeks for 2 yr

Retrospective study design Davies et al., 1956 Sereny and Fryatt, 1%6

2 to 3 months average Variable

Every 6 months for 2 yr 6 months after treatment

ALCOHOLISM TABLE Investigator and YW

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2 (Continued)

Length of treatment

Time of final follow-up

Retrospective study design Gillis and Keet, 1%9 Baekeland et al., 1971 Fitzgerald et al., 1971 Bateman and Peterson, 1971 Mayer and Myerson, 1971 Knox, 1972

6 months average 16 weeks average

Average of 4 sessions 54.5 days

Continuous monitoring after discharge During or immediately after therapy Yearly 4 yr after treatment 6 months after discharge Final treatment session 4 yr after treatment

Sample Selection The nature of the population studied in each research paper appeared to be a product of the type of facility offering the therapeutic intervention rather than a product of any scientific endeavor to select a sample that might be representative of the population of alcoholics as a whole (Table 1). Eleven of the 24 studies utilized only male alcoholics, whereas only one study concerned itself with a totally female population. The majority of studies used consecutive voluntary admissions to their program as a study sample. Another common approach was to use program completers as a sample for follow-up. In most instances criteria for subject selection or population characteristics were not clearly specified in the research report. In only 12 of the 24 studies were even the demographic characteristics of the study group examined as a pretreatment variable (Table 3). In only two instances was the sampling procedure well enough defined prior to the study to assure random selection of patients (30,35). The inadequacies and/or sampling bias found in subject selection present inherent study difficulties: (a) inability to apply methods of random selection and control conditions, (b) inability to generalize findings to any group other than the original study group, and (c) inability to compare the results of any one study with the results of a second study in the same general area. Selection of Variables Measures The variables chosen for study in the alcoholic population differed greatly from one investigator to another. Also widely divergent was the time each variable was measured, i.e., during the pretreatment, treatment, and posttreatment periods. The time intervals for the collection of posttreatment data appeared in I Tables 3 and 4 present a summary of the variables measured by those investigators evaluating the effects of psychotherapy on the alcoholic. Investigators measuring the effects of other modes of therapy used similar variables.

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TABLE 3 Pretreatment variables measured Demographic characteristics

A.A. membership Criminal history

Source of referral Drinking history

Treatment history

Psychiatric diagnoses Interpersonal relationships Motivation for treatment General health Type of alcoholic Personality factors

Measurement tools used

Investigator and year

Haberman, 1966

Interview Strauss and Bacon S.S. Scale, interview Rating scale, interview Rating scale, interview Interview Rating scale Interview Interview Interview and records Interview Arrest records Interview Interview Interview and records Interview and records Interview Interview Records Interview Records Interview Interview Interview Interview Rating scale, interview Interview Interview Interview Interview Interview Interview Interview Interview Records Interview Who system Interview Records Rating scale, interview

Davies, et al., 1956 Goldfried, 1969 Gillis and Keet, 1969 Pittman and Tate, 1969 Edwards, 1970 Mayer and Myerson, 1970 Bateman and Peterson, 1971 Schuckit and Winokur, 1972 Willems ei al., 1973 Gallant et al., 1973 Sobell and Sobell, 1973 Bateman and Peterson, 1971 Schuckit and Winokur, 1972 Davies et al., 1956 Pittman and Tate, 1%9 Mayer and Myerson, 1970 Knox, 1972 Willems et al., 1973 Gallant et al., 1973 Gillis and Keet, 1969 Mayer and Myerson, 1970 Haberman, 1966 Davies, et al., 1956 Goldfried, 1%9 Gillis and Keet, 1969 Pittman and Tate, 1969 Mayer and Myerson, 1970 Bateman and Peterson, 1971 Schuckit and Winokur, 1972 Haberman, 1966 Davies, et al., 1956 Schuckit and Winokur, 1972 Knox, 1972 Willems et. al., 1973 Davies et al., 1956 Schuckit and Winokur, 1972 Knox, 1972

Interview Interview Interview Jellinek’s classification Jellinek’s classification Personality inventory

Gillis and Keet, 1969 Pittman and Tate, 1969 Mayer and Myerson, 1970 Edwards, 1970 Bateman and Peterson, 1971 Edwards, 1970

Gillis and Keet, 1969

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many cases to be based on individual preference rather than a sound evaluative design. These intervals ranged from immediate posttreatment to a 4-yr follow-up period (Table 2). Since many studies have shown that the percentage of abstainers decreased over time after treatment (10,12,40), the findings of those investigators who measured outcome immediately after treatment or in a period less than 1 yr after treatment have provided at best an overestimation of success in terms of sobriety status at outcome. The two most consistent sets of variables to be examined both before and after treatment in the majority of studies were demographic characteristics and drinking history/sobriety status. However, only 8 of the 15 studies attempting to determine the effects of psychotherapy on the alcoholic measured these same variables both before and after treatment (Tables 3 and 4). TABLE 4 Variables measured Treatment Therapist influence Professional status of therapist Drug administration Use of medical services Posttreatment variables Sobriety status

Demographic characteristics

General health Criminal behavior

Measurement tools used

Investigator and year

Observation and interview Records

Haberman, 1966 Mayer and Myerson, 1971

Records Records

Mayer and Myerson, 1971 Mayer and Myerson, 1971

Records

Mayer and Myerson, 1970

Interview Interview Interview Interview Interview and records Interview Rating scale Records Records Mailed questionnaire Interview and Records Records Interview Interview and records Mailed questionnaire

Haberman, 1966 Davies et al., 1956 Schuckit and Winokur, 1972 Goldfried, 1%9 Gillis and Keet, 1969 Pittman and Tate, 1969 Edwards, 1970 Mayer and Myerson, 1970 Mayer and Myerson, 1971 Bateman and Peterson, 1971 Fitzgerald ef al., 1971 Knox, 1972 Willems et al., 1973 Gallant et al., 1973 Kish and Hermann, 1971

Interview Interview and records Interview Records Interview Interview and records Interview Interview Records

Goldfried, 1969 Gillis and Keet, I%9 Pittman and Tate, 1969 Mayer and Myerson, 1970 Willems ef al., 1973 Gallant et al., 1973 Pittman and Tate, 1969 Pittman and Tate, 1969 Knox, 1972

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Most of the variables of concern were measured on a pretreatment basis and related to sobriety status at the time of follow-up. However, some of the studies measured the outcome of sobriety without measuring any behavior at intake. Another shortcoming can be seen in the measurement of posttreatment variables. While all of the studies were concerned with drinking behavior at time of follow-up, many ignored the correlative social behavior of the individual alcoholic. Only a few studies concerned themselves with the influence of treatment variables on the alcoholics, and there were no studies concerned with the role of extraneous environmental variables on the recovering alcoholic. These differences in the selection and definition of criterion variables compound the difficulties previously encountered when one attempts to analyze the design and/or results of the various studies in a comparable manner. Measurement: Tools and Implementation From Tables 3 and 4 it can be seen easily that a variety of tools was used throughout the studies to measure both pretreatment and posttreatment variables. Most of the investigators devised their own interview and/or questionnaire schedule but failed to mention a pretest or other means of establishing the reliability or validity of their measurement tool. A minority of investigators made use of instruments that had been validated previously in other research, e.g., MMPI or the Zigler and Phillips Social Competency Scale. In no instance was the measurement tool used actually presented in the literature for the reader to review. Again, this lack of consistency in measurement makes comparability between studies an impossible task. Evaluation Outcomes As has been previously stated, the main variable of concern as a measure of successful outcome is the sobriety status of the individual after treatment. In addition to looking solely at sobriety status, many of the investigators attempted to correlate other social and psychological factors to drinking behavior (Tables 5 and 6.) The choice of factors viewed as relevant again varied from study to study. Where the choice of factors was constant from study to study, the interpretation of the correlation of that factor became a variant. For instance, length of drinking prior to treatment was found to be a significant variable in relationship to posttreatment sobriety by one group of investigators (32), and this same variable was found to be unrelated to posttreatment sobriety by other teams of researchers (3,8,14). However, noncomparability of findings would be expected in view of the variety of study designs, methods of sample selection, and measurement tools encountered in this review. In summary, research aimed at the evaluation of alcoholism treatment modalities and/or programs has been mainly descriptive in nature. Only a few of the studies have utilized a valid study design including objective measurements of behavioral change. Although the majority of the studies are prospective in nature

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TREATMENT 5

VARIABLES POSITIVELY CORRELATEDWITH INCREASEDSOBRIETYAFTER TREATMENT Summary of outcomes Duration of sobriety prior to intake Motivation for treatment Length of stay in treatment Source of referral Marital stability Prior A.A. attendance Vocational stability Adjunct use of antabuse Contact with community agencies Personal and social stability Physical health Adequate family resources Adequate therapist-patient relationship Age Length of drinking Insight upon admission

Investigator and year Haberman, 1966 Davies et al., 1956 Bateman and Peterson, 1971 Gillis and Keet, 1969 Haberman, 1966 Fitzgerald et al., 1971 Gillis and Keet, 1969 Goldfried, 1969 Haberman, 1966 Bateman and Peterson, 1971 Davies et al., 1956 Goldfried, 1%9 Bateman and Peterson, 1971 Haberman, 1966 Pittman and Tate, 1969 Mayer and Myerson, 1970 Mayer and Myerson, 1970 Mayer and Myerson, 1970 Mayer and Myerson, 1970 Bateman and Peterson, 1971 Schuckit and Winokur, 1971 Schuckit and Winokur, 1971 Willems et al., 1973

only, a small number of researchers employed a control group for comparative purposes. Another distressing shortcoming of evaluative research in this area is a lack of consensus as to what constitutes an effective outcome and an effective measurement of that outcome for the alcoholic patient. As a result, each study occurs in isolation, and only rarely does any one investigator build his study on the results of other similar evaluations reported in previous work. PROPOSED

MODELS FOR THE ASSESSMENT OF OUTCOME IN THE TREATMENT OF ALCOHOLISM

In response to the noncomparability of evaluative research in the area of alcoholism treatment, a few authors have recently devoted their time toward developing comparable outcome measures to be used in the determination of prognostic and follow-up variables relevant to improved posttreatment status. One test employed frequently in the study of alcoholics both at intake and follow-up has been the MMPI. Rohan and others have successfully used this inventory to measure changes due to treatment in hospitalized alcoholics. In 1972 Rohan proposed further use of the MMPI as a tool to delineate subclasses or types of alcoholics (3 1). A group of 40 male alcoholics hopitalized at a Veterans Administration hospital served as subjects for this study. All of the participants were given the

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MAY AND KULLER TABLE 6 VARIABLES NEGATIVELY CORRELATED WITH INCREASED SOBRIETY AFTER TREATMENT

Summary of outcomes Previous psychotherapy Criminal history Educational level Unstable vocational history Use of concurrent medical services History of delirium tremens Concurrent psychiatric diagnoses Isolation in living Social class Variables not correlated with increased sobriety after treatment 4% Marital status Sex Referral source Adjunct use of drug therapy Length of drinking Vocation Motivation Social class Personality factors

Investigator and year Haberman, 1966 Davies, et al., 1956 Goldfried, 1%9 Willems et al., 1973 Haberman, 1966 Willems et al., 1973 Mayer and Meyerson, 1971 Willems et al., 1973 Schuckit and Winokur, 1972 Willems et al., 1973 Willems et al., 1973 Davies et al., 1956 Bateman and Peterson, 1971 Gallant, et al., 1973 Davies et al., 1956 Davies et al., 1956 Mayer and Myerson, 1970 Knox, 1972 Davies et al., 1956 Mayer and Myerson, 1970 Bateman and Peterson, 1971 Davies et al., 1956 Mayer and Myerson, 1970 Davies et al., 1956 Bateman and Peterson, 1971 Edwards, 1970

MMPI upon admission to and discharge from the alcoholic rehabilitation program. Scale 4 of the MMPI was found to have predictive value in treatment outcome. The scoring on scale 4 delineated three subgroups of alcoholics: (a) high score (above 70) upon both admission and discharge, (b) low score (below 70) upon both admission and discharge, and (c) high score upon admission and low score upon discharge. The group scoring high during both periods of testing was found to be the most psychologically disturbed. Although these subjects did demonstrate some positive change during treatment as measured by the MMPI, it was believed that their posttreatment maladjustment patterns were likely to recur as in “structural psychopathy.” The men who scored low at both testings were felt to be the most “normal” of the three groups and to be among the greatest beneficiaries of the existing treatment program. The third group, scoring high on scale 4 upon admission but low upon discharge, were believed to belong to the “psychopathic reaction type.” These subjects were able to alter their defense mechanisms during treatment as they found themselves accepted and welcomed into the group.

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The authors believe that with further research the MMPI will provide a means of establishing subclasses within an alcoholic population, which, in turn, could generate different and more realistic treatment and treatment expectations for the individual alcoholic (31). Foster ef al. (13) undertook a short-term follow-up study of alcoholics for the purpose of developing an instrument to describe outcome dimensions for the evaluation of alcohol therapy programs. The 202 consecutive first admissions to the Alcoholism Division of the Fort Logan Mental Health Center in 1970 were selected for follow-up study. Upon initial contact with the Unit, these patients had been randomly assigned to one of three treatment programs. Plan I offered 2 weeks of individual inpatient care; Plan II was identical to Plan I except that the patient’s family and significant others were encouraged to participate; and Plan III was a program of outpatient therapy offered to the client in his home. The mean age of all patients was 43, 10% were women, and 5 1% were married. Follow-up data were obtained 3 months after treatment by interview at a location convenient for the patient. The patient was rated on a three-point scale in each of seven areas: (a) job performance, (b) adequacy of friendships and peer relationships, (c) degree of involvement in community activities, (d) indications of uncontrolled drinking, (e) involvement with personal problems, (f) problems in marriage and family, and (g) overall adjustment. An original questionnaire consisting of 63 items was used to collect the data. Of these 63 items, 29 were selected for a core factor analysis. Analyses were directed at identifying the first principal factor and determining the minimum replicable rank of the intercorrelation matrix and identification of the independent simple structure factors (use of the Varimax procedure). The principal factor underlying all positive outcomes was adaptation and adjustment. Persons scoring high along this dimension indicated abstinence from the use of alcohol and adjustment and success in their work and interpersonal and emotional stability. In addition to this principal factor, the authors found seven relatively independent measures indicative of treatment success. In order of importance these factors are (a) abstinence from alcohol, (b) interviewer rating of “observed improvement,” (c) job and/or social productivity, (d) self-claimed improvement and/or control of drinking problem, (e) decrease in sociopathy, (f) intrapersonal adjustment, and (g) social involvement. The authors believe that the success of alcoholism treatment can be measured along these dimensions of general adaptation and adjustment, with abstinence from alcohol used as only one criterion (13). A second type of categorization to measure treatment outcome in alcoholics was devised by Willems et al. (41). From prior observation of the alcoholic population, these authors found a number of variables to be of prognostic significance in treatment outcome. The investigators provide nine scales to measure outcome: (a) social adjustment, (b) employment/work record, (c) legal record, (d) record of previous treatment, (e) stress symptoms, (f) sobriety for the past 5 yr, (g) delirium tremens/al-

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cohol hallucinosis, (h) physical damage to body, and (i) insight. Within each of the given scales, various subcategories are weighed as criteria of success. The greater the individual patient’s score, the less good the prognosis. Reproducibility, i.e., intraobserver correlation, was found to be high on all scales. A correlation coefficient of 0.825 on the sobriety scale (scale 6) was the lowest. Final outcome assessment, depending on the patient’s score on the combined scales, can be made in four categories: (a) recovered, (b) improved, (c) unchanged, and (d) unknown (lost to follow-up). The authors believe that these measurements can be obtained only through interview with the patient and supplemental information from at least one secondary source (41). DISCUSSION

Although the studies reviewed in this paper are not inclusive of every published work over the past 10 years, they are representative of the type of research being pursued. One may note that sophistication in evaluative measurement has been improving over time, yet concurrent improvements in study design have been almost nonexistent. Most of the studies reviewed have been completely lacking in untreated control groups even though the proportion of alcoholic patients who recover without special therapy has been reported to be as high as 2 1% (38). Only 2 of the 24 studies reviewed used a nontreatment group for control purposes. Another eight of the studies used a second type of treatment group as a control for the treatment under study. Of the remaining studies, three used the patient as his own control, and eleven used no control at all. Of the studies using a nontreated group for control, the paper by Charnoff on the use of psychotherapeutic agents was the only study to randomize subjects (5). Only three of the studies using a second treatment group for controls randomized the study participants. Thus, for the large majority of studies in this area, the use of a proper control group, with randomization of alcoholics to be studied, has been ignored. A second weakness of the studies reviewed was the failure to obtain baseline data on the study population prior to intake. In only one-third of the investigations completed was this facet of the study design considered important. Thus, no matter how sophisticated the outcome measure, the validity of attributing successful outcome to therapeutic intervention must be questioned. Both the measurement of successful outcome and the reliability and/or validity of that measurement proved to be a great variate within the evaluative literature. Measurement tools in use ranged from standardized tests such as the MMPI to interviewer observation or self-reporting of the alcoholic. Outcome measures used as success criterion included (a) demographic characteristics, (b) social functioning, (c) specific personality traits, (d) behavioral characteristics, (e) change to “social drinking,” and (f) abstinence. Neither the measurement tools nor the success criteria were consistent from

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study to study. Mayer and Myerson’s paper (25) and that of Willems (40) appear to be the only studies, with the exception of a few studies using standardized psychological testing, where validity and/or reliability of the measurement tools were given consideration. None of the studies dealt with the appropriateness of its outcome criteria to the program or patient being studied. Another problem consistently ignored in all of the studies was the representativeness of their sample. Thus, in many instances, investigators assumed broader applicability to their findings than the data were able to support. Although there has been an increase in the emphasis toward evaluative work in the area of alcoholism treatment programs over the past 10 years, the type of research in this area has brought few, if any, answers as to the effectiveness of treatment for the alcoholic. Emphasis must be placed on a proper study design including the use of a nontreated group of control patients. Attention must be paid to the pretreatment characteristics of the population under study as well as the posttreatment characteristics. Researchers must be willing to share ideas and utilize validated measurement tools and simple statistical techniques. One investigator cannot answer the questions. It is only through many studies of a valid nature that one will begin to see if what has been believed for years is in fact true, i.e., that alcoholism treatment programs inherently help the alcoholic patient to a successful recovery. REFERENCES 1. Baekeland, F., Lundwall, L., Kissin, B., and Shanahan, T. Correlates of outcome in disulfiram treatment of alcoholism. .I. Nerv. Menr. Dis. 153, l-9 (1971). 2. Bales, R. F. Cultural differences in rates of alcoholism, in “Drinking and Intoxication” (McCarthy, Ed.), pp. 263-277. College and University Press, New Haven, 1959. 3. Bateman, N. I., and Peterson, D. M. Variables related to outcome of treatment for hospitalized alcoholics. Inr. J. Addict. 6, 215-224 (197 1). 4. Blum, E. M.. and Blum, R. H. “Alcoholism: Modem Psychological Approaches to Treatment,” Chap. XXI, p. 261. Jersey-Bass, Inc., San Francisco, 1969. 5. Chamoff, S. M., Kissin, B., and Reed, J. I. An evaluation of various psychotherapeutic agents in the long term treatment of chronic alcoholism: Results of a double blind study. Amer. J. Med. Sci.246, 78-85 (1963). 6. Cohen, M., Liebson, I. A., and Faillace, L. A. A technique for establishing controlled drinking in chronic alcoholics. Dis. Nerv. Syst. 33, 46-49 (1972).

7. Davidson, W. S. Studies of aversive conditioning for alcoholics: A critical review of theory and research methodology. Psych& Bull. 81, 571-581 (1974). 8. Davies, D. I-., Shepard, M., and Myers, E. The two-year prognosis of 50 alcohol addicts after treatment in hospital. Quart. J. Stud. Alcohol 17, 485-502 (1956) 9. Edwards, G. Hypnosis in treatment of alcohol addiction. Quart. J. Stud. Alcohol 27, 221-241 (1966).

10. Edwards, G. Alcoholism: The analysis of treatment, in “Alcohol and Alcoholism” (Popham, Ed.), pp. 173-178. University of Toronto Press, Toronto, 1970. 11. Finney, J. C., Smith, D. F., Skeeters, D. E., and Auvenshine, C. D. MMPI alcoholism scales. Quarf. J. Stud. Alcohol 32, 1055-1060 (1971). 12. Fitzgerald, B. J., Pasewark, R. A., and Clark, R. Four year follow-up of alcoholics treated at a rural state hospital. Quart. J. Stud. Alcohol 32, 636-642 (197 1). 13. Foster, FM., Horn, J. L., and Wanberg, K. W. Dimensions of treatment outcome. Quart. .I. Stud. Alcoho! 33, 1079-1098 (1972).

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14. Gallant, D. M., Bishop, M. P., Mouledoux, A., Faulkner, M. A., Brisolara, A., and Swanson, W. A. The revolving-door alcoholic. Arch. Cm. Psychiatry 28, 633-635 (1973). 15. Gillis, L. S., and Keet, M. Prognostic factors and treatment results in hospitalized alcoholics. Quart. .I. Stud. Alcohol 30, 426-437 (1969). 16. Goldfried, M. R. Prediction of improvement in an alcoholism outpatient clinic. Quart. J. Stud. Alcohol 30, 129-139 (1969). 17. Goodwin, D. W., Schulsinger, F., Hermansen, L., Guze. S. B., and Winokur, G. Alcohol problems in adoptees raised apart from alcoholic biological parents. Arch. Cm. Psychiatry 28, 238-243 (1973). 18. Haberman, P. W. Factors related to increased sobriety in group psychotherapy with alcoholics. J. Clin. Psychol. 22, 229-235 (1966). 19. Hill, M. J., and Blane, H. T. Evaluation of psychotherapy with alcoholics: A critical review. Quart. J. Stud. Alcohol 28, 76-104 (1967). 20. Jacobson, N. O., and Silfverskiold, P. N. A controlled study of a hypnotic method in the treatment of alcoholism, with evaluation by objective criteria. Bit. J. Addict. 68, 25-32 (1973). 21. Kish, G. B., and Hermann, H. T. The Fort Meade alcoholism treatment program. Quart. J. Stud. Alcohol 32, 628-635 (1971). 22. Knox, W. J. Four-year follow-up of veterans treated on a small alcoholism treatment ward. Quart. J. Stud. Alcohol 33, 105-l 10 (1972). 23. Leevy, C. M., Valdellon, E., and Smith. F. Nutritional factors in alcoholism and its complications, in “Biological Bases of Alcoholism” (Yedy and Mardones, Eds.), pp. 364-382. WileyInterscience Inc., New York, 1971. 24. Mayer, J., Needham, M. A., and Myerson, D. J. Contact with initial attendance at an alcoholism clinic. Quart. J. Stud. Alcohol 26,480-485 (1965). 25. Mayer, J., and Myerson, D. J. Characteristics of outpatient alcoholics in relation to change in drinking, work and marital status during treatment. Quart. J. Stud. Alcohol 31, 889-897 (1970). 26. Mayer, J., and Myerson, D. J. Outpatient treatment of alcoholics. Quart. J. Stud. Alcohol 32, 620-627 (1971). 27. Mills, K. C., Sobell, M. B., and Schaefer, H. H. Training social drinking as an alternative to abstinence for alcoholics. Behav. Ther. 2, 18-27 (197 1). 28. Mozdzierz, G. J., Macchitelli, F. J., Conway, J. A., and Krauss, H. H. Personality characteristics differences between alcoholics who leave treatment against medical advice and those who don’t. J. Clin. Psychol. 29, 78-80 (1973). 29. Panepinto, W. C., Higgins, M. J., Keane-Dawes, W. Y., and Smith, D. Underlying psychiatric diagnoses as an indicator of participation in alcoholism therapy. Quart. J. Stud. Alcohol 31, 950-956 (1970). 30. Pittman, D. J., and Tate, R. L. A comparison of two treatment programs for alcoholics. Quart. J. Stud. Alcohol 30, 888-899 (1969). 31. Rohan, W. P. MMPI changes in hospitalized alcoholics. Quart. J. Stud. Alcohol 33, 65-76 (1972). 32. Schuckit, M. A., and Winokur, G. A short term follow-up of women alcoholics. Dis. Nerv. Syst. 33, 672-678 (1972). 33. A Second Special Report to the United States Congress on Alcohol and Health, June 1974. Publication of HEW 34. Sereny, G., and Fryatt, M. A follow-up evaluation of the treatment of chronic alcoholics. Can. Med. Assoc. J. 94, 8-12 (1966). 35. Sobell, M. B., and Sobell, L. C. Evidence of controlled drinking by former alcoholics: A second year evaluation of individualized behavior therapy. Paper presented at the 8 1st Annual Convention of the American Psychological Association, August 3 1, 1973. 36. Soskin, R. A. Personality and attitude change after two alcoholism treatment programs. Quart. J. Stud. Alcohol 31, 920-93 1 (1970). 37. Voegtlin, W. L., and Lemere, F. The treatment of alcohol addiction: A review of the literature. Quart. J. Stud. Alcohol 2, 7 17-803 (1942). 38. Wallgreen, H., and Barry, H. “Actions of Alcohol-Chronic and Clinical Aspects.” Elsevier Publishing Co., New York, 1970.

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39. Wilkinson, A. E., Prado, W. M., Williams, W. O., and Schnadt, F. W. Psychological test characteristics and length of stay in alcoholism treatment. Quart. J. Stud. Alcohol 32, 60-65 (1971). 40. Willems, P. J. A., Letemendia, F. J. J., and Arroyave, F. A two-year follow-up study comparing short with long stay inpatient treatment of alcoholics. Bit. J. Psychiarry 122, 637-648 (1973). 41. Willems, P. J. A., Letemendia, F. J. J., and Arroyave, F. A categorization for the assessment of prognosis and outcome in the treatment of alcoholism. &it. J. Psychiatry 122,649-654 ( 1973). 42. Williams, R. J. The etiology of alcoholism: A working hypothesis involving the interplay of hereditary and environmental factors. Quart. J. Stud. AIcohol7, 567-587 (1947).